Cardiac injury in COVID-19 Helms, Julie; Combes, Alain; Aissaoui, Nadia
Intensive care medicine,
01/2022, Volume:
48, Issue:
1
Journal Article
Peer reviewed
Open access
Abstract OBJECTIVES Postoperative mediastinitis, a feared complication after cardiac surgery, is associated with high mortality, especially of critically ill patients. Candida species infections are ...rare and severe, with poorly known outcomes. We conducted a case–control study to describe the characteristics, management and outcomes of patients with postoperative Candida mediastinitis. METHODS This French, monocentre, retrospective study included all patients with postoperative Candida mediastinitis (January 2003–February 2020) requiring intensive care unit admission. Candida mediastinitis patients (henceforth cases) were matched 1:1 with postoperative bacterial mediastinitis (henceforth control), based on 3 factors during mediastinitis management: age >40 years, cardiac transplantation and invasive circulatory device used. The primary end point was the probability of survival within 1 year after intensive care unit (ICU) admission. RESULTS Forty cases were matched to 40 controls. The global male/female ratio was 2.1, with mean age at admission 47.9 ± 13.8 years. Candida species were: 67.5% albicans, 17.5% glabrata, 15% parapsilosis, 5.0% tropicalis, 2.5% krusei and 2.5% lusitaniae. The median duration of mechanical ventilation was 23, 68.8% of patients received renal replacement therapy and 62.5% extracorporeal membrane oxygenation support. The probability of survival within the first year after ICU admission was 40 ± 5.5% and was significantly lower for cases than for controls (43 ± 8% vs 80 ± 6.3%, respectively; Log-rank test: P < 0.0001). The multivariable Cox proportional hazards model retained only renal replacement therapy hazard ratio (HR) 3.7, 95% confidence interval (CI) 1.1–13.1; P = 0.04 and Candida mediastinitis (HR 2.4, 95% CI 1.1–5.6; P = 0.04) as independently associated with 1-year mortality. CONCLUSIONS Candida mediastinitis is a serious event after cardiac surgery and independently associated with 1-year mortality. Further studies are needed to determine whether deaths are directly attributable to Candida mediastinitis.
Acute pulmonary oedema (APE) is one of the most common causes of unscheduled hospital admissions among patients 65 years old or older 1, 2, with up to half being critically ill 2. APE is associated ...with a high mortality and rate of re-hospitalisation. Whilst in-hospital mortality ranges from 4 to 10%, the readmission rate for APE increases with time after discharge, ranging from 15% at 1 month to 45–50% at 6 months. One in three APE patients dies within 1 year 1, 2. In this document we outline 10 key questions ICU specialists should address when managing APE.
Rates of survival with functional recovery for both in-hospital and out-of-hospital cardiac arrest are notably low. Extracorporeal cardiopulmonary resuscitation (ECPR) is emerging as a modality to ...improve prognosis by augmenting perfusion to vital end-organs by utilizing extracorporeal membrane oxygenation (ECMO) during conventional CPR and stabilizing the patient for interventions aimed at reversing the aetiology of the arrest. Implementing this emergent procedure requires a substantial investment in resources, and even the most successful ECPR programs may nonetheless burden healthcare systems, clinicians, patients, and their families with unsalvageable patients supported by extracorporeal devices. Non-randomized and observational studies have repeatedly shown an association between ECPR and improved survival, versus conventional CPR, for in-hospital cardiac arrest in select patient populations. Recently, randomized controlled trials suggest benefit for ECPR over standard resuscitation, as well as the feasibility of performing such trials, in out-of-hospital cardiac arrest within highly coordinated healthcare delivery systems. Application of these data to clinical practice should be done cautiously, with outcomes likely to vary by the setting and system within which ECPR is initiated. ECPR introduces important ethical challenges, including whether it should be considered an extension of CPR, at what point it becomes sustained organ replacement therapy, and how to approach patients unable to recover or be bridged to heart replacement therapy. The economic impact of ECPR varies by health system, and has the potential to outstrip resources if used indiscriminately. Ideally, studies should include economic evaluations to inform health care systems about the cost-benefits of this therapy.
In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks ...and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.
Aim
To address the paucity of data on the characteristics, outcome and temporal trends in mortality of cardiogenic shock (CS) patients admitted to intensive care units (ICUs) we examined key ...features, variations in mortality from CS, and predictors of death in ICU patients over the past 15 years.
Methods and results
From the 1997–2012 database of the Collège des Utilisateurs de Bases de données en Réanimation (CUB‐Réa) that prospectively collects data from ICUs in the greater Paris area, we determined temporal trends in the incidence of CS, patient outcomes Crude and Simplified Acute Physiology Score (SAPS)‐II Standardized Mortality and predictors of in‐ICU mortality. Of the 316 905 ICU admissions, 19 416 (6.1%) exhibited CS, with incidence increasing from 4.1% to 7.7% (P < 0.001). Over time, the age of admitted patients decreased by 2.7 years 95% confidence interval (CI), −2.0 to −3.4 and SAPS‐II increased by 5.8% (95% CI 4.8–6.8) from 58.7 ± 25.3 to 64.5 ± 23.3 (P < 0.001). Crude in‐ICU mortality declined from 50% to 45% (−5.6%; 95% CI −7.7 to −3.5) as SAPS‐II Standardized ICU mortality rates decreased from 56.5% to 44.2% (P < 0.001). A more recent time‐period was an independent correlate of decreased mortality in multivariate analyses. The decrease in mortality rate was more marked in patients with decompensated heart failure, cardiac arrest, or acute myocardial infarction.
Conclusions
Patients with CS represent a greater proportion of patients admitted to ICUs over the past 15 years, having become younger but more critically ill. Although their mortality has decreased, suggesting improved overall patient management, it remains particularly high, warranting further research specifically focused on this population.
Background Management of right ventricular (RV) failure after left ventricular assist device (LVAD) implantation is not evidence based. Temporary circulatory assistance has recently been reported to ...be of value for managing postoperative RV failure after LVAD implantation, but only in small series of patients or isolated case reports. We report here our experience with the use of temporary right ventricular assist devices (RVADs) in LVAD recipients. Methods Forty-five of the 488 (9%) patients undergoing LVAD implantation between 2001 and 2011 at the Clinic for Thoracic and Cardiovascular Surgery in Bad Oeynhausen had RV failure requiring temporary RVAD. We analyzed preoperative data, complications, mortality at 6 months, and risk factors of death. Results The LVAD patients receiving temporary RVAD were younger than the 443 recipients of LVAD alone. They were more likely to have mechanical ventilation and haemofiltration and their Michigan right ventricular risk score was higher. The LVAD patients with temporary RVAD had a higher mortality at 6 months: 53%, versus 25% for patients receiving LVAD only ( P < .001). The univariate risk factors for death were high blood urea nitrogen and C-reactive protein concentrations, preoperative mechanical ventilation, preoperative hemofiltration, destination therapy, the use of temporary RVAD, and the development of RV failure. Multivariate analyses did not identify predictors of death. Conclusions The development of RV failure in LVAD recipients is a serious problem associated with high mortality. Temporary RV mechanical support is an acceptable way to manage postoperative RV failure in these severely ill LVAD recipients.
The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as a salvage therapy in cardiogenic shock is becoming of current practice. While VA-ECMO is potentially a life-saving technique, ...results are sometimes mitigated, emphasising the need for selecting the right indication in the right patient. This relies upon a clear definition of the individual therapeutic project, including the potential for recovery as well as the possible complications associated with VA-ECMO. To maximise the benefits of VA-ECMO, the basics of extracorporeal circulation should be perfectly understood since VA-ECMO can sometimes be detrimental. Hence, to be successful, VA-ECMO should be used by teams with sufficient experience and initiated after a thorough multidisciplinary discussion considering patient's medical history, pathology as well the anticipated evolution of the disease.
There is an extensive body of literature focused on sepsis-induced myocardial dysfunction, but results are conflicting and no objective definition of septic cardiomyopathy (SCM) has been established. ...SCM may be defined as a sepsis-associated acute syndrome of non-ischemic cardiac dysfunction with systolic and/or diastolic left ventricular (LV) dysfunction and/or right ventricular dysfunction. Physicians should consider this diagnosis in patients with sepsis-associated organ dysfunction, and particularly in cases of septic shock that require vasopressors. Echocardiography is currently the gold standard for diagnosis of SCM. Left ventricular ejection fraction is the most common parameter used to describe LV function in the literature, but its dependence on loading conditions, particularly afterload, limits its use as a measure of intrinsic myocardial contractility. Therefore, repeated echocardiography evaluation is mandatory. Evaluation of global longitudinal strain (GLS) may be more sensitive and specific for SCM than LV ejection fraction (LVEF). Standard management includes etiological treatment, adapted fluid resuscitation, use of vasopressors, and monitoring. Use of inotropes remains uncertain, and heart rate control could be an option in some patients.
Abstract
The use of veno-arterial extracorporeal membrane oxygenation (VA ECMO) for the treatment of refractory cardiogenic shock has increased significantly. Nevertheless, early weaning may be ...advisable to reduce the potential for severe complications. Only a few studies focusing on ECMO weaning predictors are currently available. Our objective was to evaluate factors that may help predict failure during VA ECMO weaning. We included 57 patients on VA ECMO support previously considered suitable for weaning based on specific criteria. Clinical, haemato-chemical and echocardiographic assessment was considered before and after a “weaning test” (ECMO flow < 2 L/min for at least 60 min). ECMO removal was left to the discretion of the medical team blinded to the results. Weaning failure was defined as a patient who died or required a new VA ECMO, heart transplant or LVAD 30 days after ECMO removal. Thirty-six patients (63.2%) were successfully weaned off VA ECMO, of whom 31 (54.4%) after the first weaning test. In case of first test failure, 3 out of 7 patients could be weaned after a 2nd test and 3 out of 4 patients after a 3rd test. Pre-existing ischemic heart disease (OR 9.6 1.1–83), pre-test left ventricular ejection fraction (LVEF) ≤ 25% and/or post-test LVEF ≤ 40% (OR 11 0.98–115), post-test systolic blood pressure ≤ 120 mmHg (OR 33 3–385), or length of ECMO support > 7 days (OR 24 2–269) were predictors of weaning failure. The VA ECMO weaning test failed in less than 40% of patients considered suitable for weaning. Clinical and echocardiographic criteria, which are easily accessible by a non-expert intensivist, may help increase the probability of successful weaning.
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