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We read with great enthusiasm the recently published article, “Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal,” by Fatima et al.
We applaud the authors’ in-depth evaluation of a sequence of ultrasound images to assess for abnormal pathologies as sources of hypoxia and hypotension in the perioperative setting. The algorithm assesses for the presence or absence of critical pathology such as obstruction, extravascular blood, and pneumothorax. Their protocol includes a comprehensive cardiac evaluation in addition to obtaining imaging of the inferior vena cava, the pleura/lung, and the peritoneum. The authors argued that as opposed to other algorithms, theirs more comprehensively incorporates symptomatology and the underlying pathophysiology.
However, the SALVATION algorithm is not new. First introduced in 2006 and published in 2008 by Weingart et al., the “Rapid Ultrasound for Shock and Hypotension (RUSH)” examination uses the same series and sequence of ultrasound windows.
The RUSH examination includes an evaluation of the heart, inferior vena cava, peritoneal cavity, aorta, and lungs and is meant to help determine the cause of shock in an undifferentiated patient. The examination is indicated in a symptomatic, critically ill patient (typically manifesting the clinical symptoms and signs of hypoxia, hypotension, or both), with its primary purpose being the rapid identification of life-threatening pathology. Treatment then can be directed as indicated.
Figure 1 demonstrates how the SALVATION examination mirrors the RUSH examination with regard to probe positioning and sequence of evaluation. Weingart et al. originally described the following steps: assessment of the heart to evaluate for pericardial tamponade, right ventricular enlargement, and global LV function; inferior vena cava view allowing for rapid assessment of relative hypovolemia or presence of obstructive pathology; the FAST examination to search for intraabdominal free fluid; axial views of the aorta to help rule out abdominal aortic aneurysms; and finally, a pulmonary ultrasound to rule out tension pneumothorax as a cause of hypotension and/or hypoxia.
Stickles et al., in their systematic review, demonstrated that the RUSH examination performed better when used to rule in causes of shock (as opposed to excluding specific diagnoses) and accurately ruled out obstructive shock.
Although we commend the authors on developing a comprehensive ultrasound protocol, we advise against just reinventing the wheel. The authors listed in their limitations the lack of objective metrics to determine efficacy, achievement of competency, and transferability. We would argue these aspects already have been determined for the RUSH protocol. Creating a new, yet very similar, protocol risks generating confusion and can make adoption more difficult. A more useful discussion, in our opinion, would be to study the role of an established protocol like RUSH in the operating room and perioperative environment. If found to be beneficial, it then can be promoted for adoption by more members of the medical community.
Conflict of Interest
Dr. Weingart and his colleagues are credited with creating the RUSH protocol. There are no other conflicts of interest for the authors.
Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A practical echo-guided approach proposal.
Despite the valuable use of modern applications of perioperative ultrasound across multiple disciplines, there have been limitations to its implementation, restricting its impact on patient-based clinical outcomes. Point-of-care ultrasound evaluation of hypoxia and hypotension is an important tool to assess the underlying undifferentiated etiologies in a timely manner. However, there is a lack of consensus on the formal role of ultrasound during evaluation of perioperative hypoxia or hypotension.
We read with interest the communication by Weingart et al.1 in response to the article “Simplified Algorithm for Evaluation of Perioperative Hypoxia and Hypotension (SALVATION): A Practical Echo-guided Approach Proposal.”2 We are thankful to the authors for their review, insightful remarks, and thorough attention to our article. Emergency medicine physicians were the earliest adopters of point-of-care ultrasound (POCUS), paving the way for diversification and adoption of this technology across multiple specialties.