Abstract Purpose The purpose of the study was to compare the effect of limited echocardiography (LE)–guided therapy to standard management on 28-day mortality, intravenous fluid prescription, and ...inotropic dosing following early resuscitation for shock. Materials and methods Two hundred twenty critically ill patients with undifferentiated shock from a quaternary intensive care unit were included in the study. The LE group consisted of 110 consecutive patients prospectively studied over a 12-month period receiving LE-guided management. The standard management group consisted of 110 consecutive patients retrospectively studied with shock immediately prior to the LE intervention. Results In the LE group, fluid restriction was recommended in 71 (65%) patients and initiation of dobutamine in 27 (25%). Fluid prescription during the first 24 hours was significantly lower in LE patients (49 33-74 vs 66 42-100 mL/kg, P = .01), whereas 55% more LE patients received dobutamine (22% vs 12%, P = .01). The LE patients had improved 28-day survival (66% vs 56%, P = .04), a reduction in stage 3 acute kidney injury (20% vs 39%), and more days alive and free of renal support (28 9.7-28 vs 25 5-28, P = .04). Conclusions Limited echocardiography–guided management following early resuscitation is associated with improved survival, less fluid, and increased inotropic prescription. A prospective randomized control trial is required to verify these results.
Abstract Objective Several risk-scoring systems have been developed to predict surgical mortality and complications in cardiac surgical patients, but none of the current systems include factors ...related to the intraoperative period. The purpose of this study was to develop a score that incorporates both preoperative and intraoperative factors so that it could be used for patients admitted to a cardiac surgical intensive care unit (ICU) immediately after surgery. Method Preoperative and intraoperative data from 30,350 patients in four hospitals were used to build a multiple logistic regression model estimating 30-day mortality after cardiac surgery. Sixty percent of the patients were used as a derivation group and forty percent as a validation group. Results Mortality occurred in 2.6% of patients (n = 790). Preoperative factors identified in the model were age, female sex, emergency status, pulmonary hypertension, peripheral vascular disease, renal dysfunction, diabetes, peptic ulcer disease, history of alcohol abuse, and refusal of blood products. Intraoperative risk factors included the need for an intra-aortic balloon pump, ventricular assist device or extracorporeal membrane oxygenation leaving the operating room, presence of any intraoperative complication reported by the surgeon, the use of inotropes, high-dose vasopressors, red blood cell transfusion, and cardiopulmonary bypass time. When used after surgery at ICU admission, the model had C-statistics of 0.86 in both derivation and validation sets to estimate the 30-day mortality. Conclusions Preoperative and intraoperative variables can be used on admission to a cardiac surgical ICU to estimate 30-day mortality. The score could be used for risk stratification after cardiac surgery and evaluation of performance of cardiac surgical ICUs.
Abstract Purpose The purpose of the study is to compare outcomes in patients who had severe hypoxemic respiratory failure (Pa o2 /fraction of inspired oxygen < 100) who received early veno-venous ...extracorporeal membrane oxygenation (ECMO) as an adjunct to mechanical ventilation, to those in patients who received conventional mechanical ventilation alone. Materials and methods This is a multicenter, retrospective unmatched and matched cohort study of patients admitted between April 2006 and December 2013. Generalized logistic mixed-effects models and Cox proportional hazards models were used to determine the association between treatment with ECMO that was started within 3 days of intensive care unit (ICU) admission and ICU and hospital mortality and length of stay, respectively. Results A total of 2440 patients who had severe hypoxemic respiratory failure due to various etiologies were included, 46 who received early veno-venous ECMO and 2394 unmatched and 398 matched controls who received conventional ventilation alone. Compared to matched controls, ECMO was associated with a lower odds of ICU (odds ratio 95% confidence interval, 0.30 0.13-0.67) and inhospital death (odds ratio 0.30 0.14-0.67). In addition, ECMO was associated with longer times to discharge from ICU and hospital (hazard ratio, 0.42 0.37-0.47 and 0.53 0.38-0.73, respectively). Conclusions In this observational study, use of early ECMO compared to conventional mechanical ventilation alone in patients who had severe hypoxemic respiratory failure was associated with a lower risk of mortality and a longer length of stay.
In keeping with standard practice for shock, all patients had received at least 20 mL/kg intravenous fluids and continued to require vasopressors at the time of the intervention. Because of the rapid ...time-line associated with resuscitation, we chose a single limited echocardiogram to influence clinical decision making rather than repeated measures. ...it is apparent that a single limited echocardiogram performed to guide fluid therapy following the initial (12-24 hours) acute resuscitation should provide the greatest impact, with diminishing yield beyond this stage.
Abstract Background Patients undergoing surgical coronary revascularization typically recover in an intensive care unit where many aspects of patient care are protocolized despite absence of ...widespread evidence-based guidelines on perioperative management. It was hypothesized that the postoperative management strategies varied significantly among units. Methods We surveyed 31 Canadian cardiac surgical intensive care units to obtain their postoperative standing orders. Management strategies after coronary bypass surgery were compared to identify areas of variability in the care of frequent clinical scenarios. Results In all, 28 units (90%) responded, and 26 sites (84%) reported using at least 1 formal postoperative protocol. All but 1 of the responding units (96%) have specific orders for coronary artery bypass graft patients. Orders for allogeneic red blood cell transfusion threshold, postoperative extubation pathway, analgesia, and atrial fibrillation management were present in 40%, 74%, 60%, and 57% of the responding units, respectively. A protocolized trigger to notify the surgeon was specified for bleeding and hypotension in 75% and 35% of the centres, respectively. A standing order for aspirin administration was used in 91% of the centres, and statin administration was mentioned in 41%. Despite the frequent use of protocols in postoperative care, the content of the protocol varied significantly from centre to centre. Conclusion The majority of Canadian centres use at least 1 formal protocol for the care of the postoperative coronary revascularization patient. There is, however, significant variability in these management protocols. Future studies should examine whether implementation of standardized protocols improves outcomes and what treatment strategies are optimal in postoperative cardiac surgical patients.
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