Sex and gender are fundamental health determinants and their role as modifiers of treatment response is increasingly recognized. Norepinephrine is a cornerstone of septic shock management and its use is based on the highest level of evidence compared to dopamine. The related 2021 Surviving Sepsis Campaign (SCC) recommendation is presumably applicable to both females and males; however, a sex- and gender-based analysis is lacking, thus not allowing generalizable conclusions. This paper was aimed at exploring whether sex- and gender-disaggregated data are available in the evidence supporting this recommendation. For all the studies underpinning it, four pairs of authors, including a woman and a man, extracted data concerning sex and gender, according to the Sex and Gender Equity in Research guidelines. Nine manuscripts were included with an overall population of 2126 patients, of which 43.2% were females. No sex analysis was performed and gender was never reported. In conclusion, the present manuscript highlighted that the clinical studies underlying the SCC recommendation of NE administration in septic shock have neglected the likely role of sex and gender as modifiers of treatment response, thus missing the opportunity of sex- and gender-specific guidelines.

Even if hypothermia is described as one of the main causes of cardiac arrest, in medical literature, it is not often mentioned as a main cause of shock. Nevertheless, it is known to contribute to shock development, maintenance, and worsening of its prognosis by lowering cardiac performance and blood pressure; this is particularly relevant in sepsis. Diagnosing hypothermia can be challenging, especially in patients not suffering an obvious environmental exposure. Digital medical thermometers cannot accurately estimate hypothermia, so when suspected, the placement of an esophageal thermometer is indicated. Below 32°C, the electrocardiogram (ECG) often shows a characteristic elevation of the J point called the Osborne wave (OW). We present a case of a patient with mixed shock in which this electrocardiographic disturbance allowed for an early suspicion of hypothermia, enabling prompt initiation of adequate treatment.

Differentiating epileptic seizures from manifestations of intracranial pressure (ICP) fluctuations can be challenging in patients with a ventriculoperitoneal shunt (VPS). We report a case of intermittent VPS malfunction presenting with focal motor events initially misdiagnosed as refractory status epilepticus. A 27-year-old man with childhood-onset hydrocephalus treated with a right VPS and a previous history of focal epilepsy-managed with levetiracetam, perampanel, and lacosamide-presented with increased seizure frequency and intermittent headaches. Initial treatment included continuous infusions of valproate, lacosamide, and levetiracetam under the presumption of status epilepticus. However, prolonged (15-hour) video-EEG monitoring during the clinical events showed diffuse delta activity with suppression of the background rhythm rather than ictal discharges. These EEG changes coincided with episodes of arterial hypertension, profound bradycardia (as low as 20 bpm), and papilledema on funduscopic examination. Revision of the shunt system resulted in complete resolution of symptoms and withdrawal of antiseizure medications. Extended video-EEG monitoring can be a useful tool to distinguish epileptic seizures from paroxysmal manifestations of paroxysmal intracranial hypertension due to VPS malfunction.

Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of assisted reproduction. The hyperstimulated ovaries release vasoactive substances that can increase capillary permeability, resulting in volume shift to the extravascular space and leading to hypovolemia, ascites and, in complicated cases, pleural and pericardial effusions, kidney and liver failure, shock. Point Of Care UltraSound (POCUS) can help the emergency physician to detect many of these complications, as well as guide their treatment. In this case report we present a patient at low risk for OHSS who recently underwent a successful in vitro fertilization, coming to the emergency department with an unusual complication of OHSS (an isolated pleural effusion), that has been safely and promptly diagnosed and treated in the emergency room with the help of POCUS, without any unnecessary exposition to ionizing radiations.

Ovarian hyperstimulation syndrome (OHSS) is a well-known complication of assisted reproduction. The hyperstimulated ovaries release vasoactive substances that can increase capillary permeability, resulting in volume shift to the extravascular space and leading to hypovolemia, ascites and, in complicated cases, pleural and pericardial effusions, kidney and liver failure, shock. Point Of Care UltraSound (POCUS) can help the emergency physician to detect many of these complications, as well as guide their treatment. In this case report we present a patient at low risk for OHSS who recently underwent a successful in vitro fertilization, coming to the emergency department with an unusual complication of OHSS (an isolated pleural effusion), that has been safely and promptly diagnosed and treated in the emergency room with the help of POCUS, without any unnecessary exposition to ionizing radiations.