Abstract
Beta-blockers are a potential option to manage peri-operative atrial fibrillation. Landiolol is a new ultra-short beta-blocker with a half-life of only 4 minutes and very high beta-1 ...selectivity which has been used for treatment and prevention of atrial fibrillation in pulmonary surgery and gastro-intestinal surgery. Due to its limited negative inotropic effect and high beta-1 selectivity landiolol allows for control of heart rate with minimal impact on blood pressure. Landiolol is well tolerated by the respiratory system. Additional benefits are related to the regulation of the inflammatory response and blunting of the adrenergic pathway. There is a limited number of trials with total of 61 patients undergoing lung resection or oesophagectomy who developed post-operative atrial fibrillation and were treated with landiolol. The experience with landiolol for prevention is more documented than landiolol application for treatment of post-operative atrial fibrillation. There are 9 comparative studies with a total of 450 patients administered landiolol for prevention of post-operative atrial fibrillation. The use of low dosage (5-10mcg/kg/min) is usually sufficient to rapidly control heart rate which is associated with earlier and higher rate of conversion to sinus rhythm as compared to the controls. The excellent tolerance of landiolol at lower dosage (3-5mcg/kg/min) allows to initiate prophylactic use during surgery and postoperatively. Landiolol prophylaxis is associated with reduced incidence of post-operative atrial fibrillation without triggering adverse events related to a beta-blockade.
In atrial and ventricular tachyarrhythmias, reduced time for ventricular filling and loss of atrial contribution lead to a significant reduction in cardiac output, resulting in cardiogenic shock. ...This may also occur during catheter ablation in 11% of overall procedures and is associated with increased mortality. Managing cardiogenic shock and (supra) ventricular arrhythmias is particularly challenging. Inotropic support may exacerbate tachyarrhythmias or accelerate heart rate; antiarrhythmic drugs often come with negative inotropic effects, and electrical reconversions may risk worsening circulatory failure or even cardiac arrest. The drop in native cardiac output during an arrhythmic storm can be partly covered by the insertion of percutaneous mechanical circulatory support (MCS) devices guaranteeing end-organ perfusion. This provides physicians a time window of stability to investigate the underlying cause of arrhythmia and allow proper therapeutic interventions (e.g., percutaneous coronary intervention and catheter ablation). Temporary MCS can be used in the case of overt hemodynamic decompensation or as a “preemptive strategy” to avoid circulatory instability during interventional cardiology procedures in high-risk patients. Despite the increasing use of MCS in cardiogenic shock and during catheter ablation procedures, the recommendation level is still low, considering the lack of large observational studies and randomized clinical trials. Therefore, the evidence on the timing and the kinds of MCS devices has also scarcely been investigated. In the current review, we discuss the available evidence in the literature and gaps in knowledge on the use of MCS devices in the setting of ventricular arrhythmias and arrhythmic storms, including a specific focus on pathophysiology and related therapies.
Background
The role of chest drain (CD) location by bedside imaging methods in the diagnosis of pneumothorax has not been explored in a prospective study yet.
Methods
Covid-19 ARDS patients with ...pneumothorax were prospectively monitored with chest ultrasound (CUS) and antero-posterior X-ray (CR) performed after drainage in the safe triangle. CD foreshortening was estimated as a decrease of chest drain index (CDI = length of CD in chest taken from CR/depth of insertion on CD scale + 5 cm). The angle of inclination of the CD was measured between the horizontal line and the CD at the point where it enters pleural space on CR.
Results
Of the total 106 pneumothorax cases 80 patients had full lung expansion on CUS, the CD was located by CUS in 69 (86%), the CDI was 0.99 (0.88–1.06). 26 cases had a residual pneumothorax after drainage (24.5%), the CD was located by CUS in 31%, the CDI was 0.76 (0.6–0.93),
p
< 0.01. The risk ratio for a pneumothorax in a patient with not visible CD between the pleural layers on CUS and an associated low CDI on CR was 5.97,
p
˂0.0001. For the patients with a steep angle of inclination (> 50°) of the CD, the risk ratio for pneumothorax was not significant (
p
< 0.17). A continued air leak from the CD after drainage is related to the risk for a residual pneumothorax (RR 2.27,
p
= 0.003).
Conclusion
Absence of a CD on CUS post drainage, low CDI on CR and continuous air leak significantly associate with residual occult pneumothorax which may evade diagnosis on an antero-posterior CR.
To determine the relationship between the degree of tricuspid regurgitation (TR) and accuracy of cardiac output measurement by thermodilution in mechanically ventilated patients. DESIGN AND SETTING. ...Prospective observational study in a 20-bed general intensive care unit in the university hospital.
We examined 27 patients (not undergoing cardiac surgery): 8 with no or 1st degree TR, 9 with 2nd degree, and 10 with 3rd degree TR.
All patients were measured twice using simultaneously transesophageal echocardiography and pulmonary artery catheter for cardiac output.
Continuous Doppler measurements were taken in the left ventricular outflow tract at the level of the aortic valve. Cardiac output was calculated by multiplying the velocity-time integral by aortic valve area and heart rate. Simultaneous pulmonary artery catheter measurements were taken averaging the results of the three 10-cc boluses of iced saline. The difference between the methods was 0.5+/-1.1 l/min (mean +/-2 SD) in patients with no or 1st degree TR (r=0.96), 0.8+/-2.0 l/min in those with 2nd degree TR (r=0.92), and 1.9+/-2.3 l/min in those with 3rd degree TR (r=0.69).
A high degree of TR is associated with underestimation of cardiac output measured by thermodilution.
We report an unusual case of fatal air embolism into the superior mesenteric artery in a patient, who underwent replacement of the ascending aorta for aortic dissection type A. CT performed twice on ...the first postoperative day showed abundant air in the superior mesenteric artery and its branches (but not in the portal-venous system) indicating air embolism with no signs of bowel necrosis. On the second postoperative day, the patient underwent extensive bowel resection due to bowel ischemia and died on the third postoperative day on MODS/SIRS.
Abstract Purpose To determine bioenergetic gain of 2 different citrate anticoagulated continuous hemodiafiltration (CVVHDF) modalities and a heparin modality. Materials and Methods We compared the ...bio-energetic gain of citrate, glucose and lactate between 29 patients receiving 2.2% acid-citrate-dextrose with calcium-containing lactate-buffered solutions (ACD/Caplus /lactate), 34 on 4% trisodium citrate with calcium-free low-bicarbonate buffered fluids (TSC/Camin /bicarbonate), and 18 on heparin with lactate buffering (Hep/lactate). Results While delivered CVVHDF dose was about 2000 mL/h, total bioenergetic gain was 262kJ/h (IQR 230-284) with ACD/Caplus /lactate, 20 kJ/h (8-25) with TSC/Camin /bicarbonate ( P < .01) and 60 kJ/h (52-76) with Hep/lactate. Median patient delivery of citrate was 31.2 mmol/h (25-34.7) in ACD/Caplus /lactate versus 14.8 mmol/h (12.4-19.1) in TSC/Camin /bicarbonate groups ( P < .01). Median delivery of glucose was 36.8 mmol/h (29.9-43) in ACD/Caplus /lactate, and of lactate 52.5 mmol/h (49.2-59.1) in ACD/Caplus /lactate and 56.1 mmol/h (49.6-64.2) in Hep/lactate groups. The higher energy delivery with ACD/Caplus /lactate was partially due to the higher blood flow used in this modality and the calcium-containing dialysate. Conclusions The bioenergetic gain of CVVHDF comes from glucose (in ACD), lactate and citrate. The amount substantially differs between modalities despite a similar CVVHDF dose and is unacceptably high when using ACD with calcium-containing lactate-buffered solutions and a higher blood flow. When calculating nutritional needs, we should account for the energy delivered by CVVHDF.
Purpose
Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are ...often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies.
Methods
The PRICE panel identified lists of clinical and echocardiographic parameters (the “items”) deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts’ opinion into account.
Results
A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed.
Conclusion
The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.
Purpose
Exploratory study to evaluate the association of different phenotypes of right ventricular (RV) involvement and mortality in the intensive care unit (ICU) in patients with acute respiratory ...distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19).
Methods
Post-hoc analysis of longitudinal data from the multicenter ECHO-COVID observational study in ICU patients who underwent at least two echocardiography examinations. Echocardiography phenotypes were acute cor pulmonale (ACP, RV cavity dilatation with paradoxical septal motion), RV failure (RVF, RV cavity dilatation and systemic venous congestion), and RV dysfunction (tricuspid annular plane systolic excursion ≤ 16 mm). Accelerated failure time model and multistate model were used for analysis.
Results
Of 281 patients who underwent 948 echocardiography studies during ICU stay, 189 (67%) were found to have at least 1 type of RV involvements during one or several examinations: ACP (105/281, 37.4%), RVF (140/256, 54.7%) and/or RV dysfunction (74/255, 29%). Patients with all examinations displaying ACP had survival time shortened by 0.479 0.284–0.803 times when compared to patients with all examinations depicting no ACP (
P
= 0.005). RVF showed a trend towards shortened survival time by a factor of 0.642 0.405–1.018 (
P
= 0.059), whereas the impact of RV dysfunction on survival time was inconclusive (
P
= 0.451). Multistate analysis showed that patients might transit in and out of RV involvement, and those who exhibited ACP in their last critical care echocardiography (CCE) examination had the highest risk of mortality (hazard ratio (HR) 3.25 2.38–4.45,
P
< 0.001).
Conclusion
RV involvement is prevalent in patients ventilated for COVID-19 ARDS. Different phenotypes of RV involvement might lead to different ICU mortality, with ACP having the worst outcome.
IMPORTANCE: Out-of-hospital cardiac arrest (OHCA) has poor outcome. Whether intra-arrest transport, extracorporeal cardiopulmonary resuscitation (ECPR), and immediate invasive assessment and ...treatment (invasive strategy) is beneficial in this setting remains uncertain. OBJECTIVE: To determine whether an early invasive approach in adults with refractory OHCA improves neurologically favorable survival. DESIGN, SETTING, AND PARTICIPANTS: Single-center, randomized clinical trial in Prague, Czech Republic, of adults with a witnessed OHCA of presumed cardiac origin without return of spontaneous circulation. A total of 256 participants, of a planned sample size of 285, were enrolled between March 2013 and October 2020. Patients were observed until death or day 180 (last patient follow-up ended on March 30, 2021). INTERVENTIONS: In the invasive strategy group (n = 124), mechanical compression was initiated, followed by intra-arrest transport to a cardiac center for ECPR and immediate invasive assessment and treatment. Regular advanced cardiac life support was continued on-site in the standard strategy group (n = 132). MAIN OUTCOMES AND MEASURES: The primary outcome was survival with a good neurologic outcome (defined as Cerebral Performance Category CPC 1-2) at 180 days after randomization. Secondary outcomes included neurologic recovery at 30 days (defined as CPC 1-2 at any time within the first 30 days) and cardiac recovery at 30 days (defined as no need for pharmacological or mechanical cardiac support for at least 24 hours). RESULTS: The trial was stopped at the recommendation of the data and safety monitoring board when prespecified criteria for futility were met. Among 256 patients (median age, 58 years; 44 17% women), 256 (100%) completed the trial. In the main analysis, 39 patients (31.5%) in the invasive strategy group and 29 (22.0%) in the standard strategy group survived to 180 days with good neurologic outcome (odds ratio OR, 1.63 95% CI, 0.93 to 2.85; difference, 9.5% 95% CI, −1.3% to 20.1%; P = .09). At 30 days, neurologic recovery had occurred in 38 patients (30.6%) in the invasive strategy group and in 24 (18.2%) in the standard strategy group (OR, 1.99 95% CI, 1.11 to 3.57; difference, 12.4% 95% CI, 1.9% to 22.7%; P = .02), and cardiac recovery had occurred in 54 (43.5%) and 45 (34.1%) patients, respectively (OR, 1.49 95% CI, 0.91 to 2.47; difference, 9.4% 95% CI, −2.5% to 21%; P = .12). Bleeding occurred more frequently in the invasive strategy vs standard strategy group (31% vs 15%, respectively). CONCLUSIONS AND RELEVANCE: Among patients with refractory out-of-hospital cardiac arrest, the bundle of early intra-arrest transport, ECPR, and invasive assessment and treatment did not significantly improve survival with neurologically favorable outcome at 180 days compared with standard resuscitation. However, the trial was possibly underpowered to detect a clinically relevant difference. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01511666
The amount of information on the web is continually growing. Orientation within accessible information is becoming more and more difficult for the user. Therefore, there is a need to personalize the ...presented information and make it comply with the user’s expectations. Adaptation is often discussed within the field of web technologies. Intensive research within the field of adaptive systems has been carried out in the last two decades. Several models have been proposed for the description of adaptive hypermedia architecture. However, there is still a lack of generality in the architecture, which makes collaboration and content reusability difficult, even impossible. Most of the contemporary approaches use ad-hoc solutions and there is a need of a general formal model to simplify development of adaptive systems and enable data interchange among them. In our work, we aim to propose such a model, its formal description and the methodology for developing systems based on this model as a contribution to the current state of research in the field of hypermedia systems.The main contributions of the thesis are the following:1. New formal adaptivity model utilizing semantic web technologies for user modeling in adaptive hypermedia systems.2. Multidimensional user model architecture supporting effective reasoning and data exchange.3. Design of data exchange format based on XML and RDF.4. Methodology for effective adaptive systems development.5. Framework support for adaptive systems implementation in Java programming language and its experimental verification.
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