University Hospital Dubrava, Zagreb, Croatia, March 8th – 9th 2018
Objective. The aims of this study were to analyze the risk factors for and types of new-onset arrhythmias in ICU (Intensive care unit), and to evaluate their impact on patient outcomes.
Methods. We studied 1051 patients who were admitted to the two general ICUs between December 2013 and February 2016. These patients were divided into two groups: patients with new-onset arrhythmias and patients without new-onset arrhythmias. We compared the risk factors, types and prognoses of new-onset arrhythmias between these two groups.
Results. New-onset arrhythmias were observed in 20.84% (n=219) of 1051 patients. The main risk factors leading to arrhythmias included age, emergency operation, past cardiovascular disease, patients with multiple systemic diseases, acute respiratory distress syndrome, severe sepsis/septic shock, acute renal dysfunction, cardiovascular disease, electrolyte disturbance, patients on ventilators, patients on vasopressors and higher Acute Physiology and Chronic Health Evaluation II scores (APACHE II score) on ICU admission. Multivariate logistic regression revealed that age, emergency operation, severe sepsis/septic shock, cardiovascular disease, electrolyte disturbance, patients on ventilators and those with higher APACHE II scores on ICU admission, were all significantly associated with new-onset arrhythmias. Arial fibrillation was the most frequent arrhythmia. ICU mortality in patients with new-onset arrhythmias was 22.37% (49 out of 219) compared with 3.61% (30 out of 832) in patients without new-onset arrhythmias (p<0.001). Among surviving patients, ICU stay for those with new-onset arrhythmias was longer than those without new-onset arrhythmias (median stay of 10 days versus 5 days, p<0.001).
Conclusion. We found a high prevalence of new-onset arrhythmias in ICU patients. Arrhythmia, especially atrial fibrillation, was a common complication in ICU patients and was associated with increasing length of ICU stay and higher mortality.
Key words: arrhythmia, intensive care unit, critical illness, mortality
In cardiac surgery patients, intracoronary (IC) administration of levosimendan can provide optimal drug spread, enabling effective manifestation of favorable drug effects and avoiding potentially harmful systemic hypotension. This could be beneficial in acute coronary syndromes (ACS) with decreased left ventricular ejection fraction (LVEF). We present ten cases of IC administration of levosimendan in ACS manifested as ST segment elevation myocardial infarction, non-ST segment elevation myocardial infarction or unstable angina pectoris. All patients underwent coronary artery bypass graft (CABG) surgery, performed as an “off-pump” or “on-pump”/“off-clamp” procedure (latter one with the use of cardiopulmonary bypass on the beating heart). Levosimendan was administered as an IC bolus (125-250 μg) in each coronary artery graft (2-3 grafts). Intravenous (IV) levosimendan infusion continued (0.1-0.2 μg·kg-1·min-1) after graft placements (24-48 h), with IV infusion of norepinephrine (0.1 mg·ml-1), if needed. Cardiac function was assessed using LVEF (%) (Teicholz), thermodilution cardiac index (CI) (ml·m-2), and systemic vascular resistance (SVR) (dynes·sec·cm-5).
Nonparametric Wilcoxon signed-ranks test [presented as median (MED) with interquartile range (IQR)] indicated a significant difference between preoperative vs. immediate postoperative CI, SVR, and LVEF in all cases [2.2 (1.9-2.5) vs. 3.1 (2.9-3.4) ml·m-2, 1173.0 (1062.7-1278.2) vs. 882.5 (763.5-993.0) dynes·sec·cm-5, 44.5 (36.0-46.7) vs. 53.5 (45.7-59.2) %, respectively] (P=0.005), i.e. IC administration of levosimendan was associated with prompt improvement of intraoperative hemodynamics and cardiac contractility. IC administration of levosimendan may be a promising alternative method for improving decreased cardiac function in acute cardiac ischemia, besides necessary surgical revascularization.
Key words: levosimendan, intracoronary, acute coronary syndromes, CABG surgery
Objective. To examine the success of stabilisation and the short term outcomes from the routine use of nasal high flow (nHF) on an unselected cohort of babies in the delivery room (DR).
Design. Retrospective single-centre study
Setting. Single-centre neonatal intensive care unit (NICU)
Patients. Infants born at < 32 weeks gestation
Interventions. Stabilisation and transfer to NICU of an unselected cohort of babies using nHF
Main outcome measures. Success of stabilisation defined by successful transfer on nHF and clinical measures of stability at admission to NICU, including oxygen requirement, admission temperature, surfactant requirement, short term outcomes and whether infants were sustained on nHF by 72 hours of age.
Results. There were 133 eligible babies. 54 were commenced on nHF in the DR (Group A), 47 were stabilised by face mask CPAP (continuous positive airway pressure) (Group B), 26 were intubated (Group C); 6 required only minimal respiratory support (Group D). Median maturity varied between the groups (Group A 27+5 weeks, Group B 30 weeks, Group C 26+2 weeks, Group D 31+5). 72% of Group A and 75% of Group B remained on nHF for 72 hours (P=0.82). Fewer babies received surfactant in Group A versus Group B (29% vs 35%; P=0.67), however groups were not matched for maturity differences and Group A were significantly less mature and of lower birthweight (both P<0.001). Group A were significantly more likely to be in air at admission than Group B (P=0.03).
Conclusion. Preterm babies can be successfully stabilised and sustained on nHF. The use of nHF for immediate stabilisation appears to be effective and, in this study, led to significantly more babies being in air on admission to the NICU compared to face mask CPAP stabilisation.
Key words: nasal High Flow cannula, delivery room, stabilisation, premature
Heart rate variability (HRV) has been associated with a variety of clinical situations. However, few studies have examined the association between HRV and acute poisoning. Organophosphate (OP) and carbamate inhibit esterase enzymes, particularly acetylcholinesterase, resulting in an accumulation of acetylcholine and thereby promoting excessive activation of corresponding receptors. Because diagnosis and treatment of OP and carbamate poisoning greatly depend on the severity of cholinergic symptoms, and because HRV reflects autonomic status, some HRV parameters may be of value in diagnosing OP and carbamate poisoning among patients visiting the emergency department.
Patients who visited the emergency department of the study hospital between September 2008 and May 2010 with the chief complaint of acute poisoning or overdose were included. Cases that involved ingestion of OP or carbamate insecticides were classified as poisoning by cholinesterase inhibitors and compared with other cases of poisoning or overdose. The time-domain analysis included descriptive statistics of R-R intervals and instantaneous heart rates. The frequency-domain analysis used fast Fourier transformation. A Poincaré plot, which is a scatterplot of R-R intervals against the preceding R-R interval, was used for the nonlinear analysis.
Very-low-frequency (VLF) power and the ratio of low-frequency-to-high-frequency power (LF/HF) were the most effective parameters for distinguishing cholinesterase inhibitor poisoning among cases of acute poisoning, with areas under the receiver-operating characteristic curve of 0.76 and 0.87, respectively. Cholinesterase inhibitor poisoning was a significant factor determining VLF power and the LF/HF ratio after adjusting for possible confounding variables, including age over 40, gender, and tracheal intubation.
Frequency-domain parameters of HRV, such as VLF power and the LF/HF ratio, might be considered as potential diagnostic methods to distinguish cholinesterase inhibitor poisoning from other cases of intoxication in the early stages of emergency care.
Key words: electrocardiography, organophosphates, carbamates, poisoning