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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Page 2 of 17

Geriatric patients in the ICU

Abstract

The proportion of patients older than 80 years admitted to the ICU is constantly increasing. Despite well-known admission criteria, older patients are frequently not referred and are admitted to the ICU. The emergency ward and ICU management of acute medical conditions should not depend on age only, but should be tailored to the individual patient in line with standards of care. After the successful treatment of acute illness, elderly people should receive complex and prolonged physical, social and psychological rehabilitation. Nevertheless, we must be able to recognize the point of futile treatment and provide proper palliative care. Less traumatised procedures that are better tolerated are preferred in the management of specific medical conditions in geriatric patients. General preventive programs promoting healthy lifestyles have been developed, but these must be implemented by a majority of older people. Medical science should promote adequate education of all professionals who are involved in the treatment of geriatric patients; societies should provide equal access to health-care in developed countries and countries in transition.

Key words: intensive care unit, outcome, survival, elderly, treatment intensity

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Humanizing critical care

Abstract

Sleep is important for human neurocognitive, emotional and physical health. Increasing evidence shows that the intensive care unit environment is disruptive to sleep patterns. Such disruption is unpleasant to patients, but mounting evidence suggests that it may also worsen outcome. However, improvements in the patient experience are readily obtained through simple measures such as the use of eyepads and earplugs. Early data suggest that such interventions are not only kind, but may impact on patient outcomes such as delirium rates.

Key words: sleep, light, noise, sound, eyepad, earplug

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Septic cardiomyopathy : pathophysiology and prognosis

Abstract

Septic cardiomyopathy is a separate clinical entity clearly distinct from myocarditis on histological grounds. Physiologically it characteristically presents, unlike other types of heart failure, with normal or increased cardiac output with normal or low preload pressures & a reduced systemic vascular resistance. Speckle tracking echocardiography is now the diagnostic tool of choice for detecting subtle changes in myocardial dysfunction

Ventricular contractility is invariably reduced to some degree in septic shock but, if severe ventricular dysfunction with low blood pressure and a falling cardiac output develops, mortality is twice that of septic shock without cardiac organ failure. However if the patient survives the episode of sepsis, septic cardiomyopathy is largely reversible since the changes are predominantly functional rather than structural although it is as yet uncertain if this applies when contraction band necrosis has developed as a result of the use of high doses of vasopressors.

Key words: sepsis, septic shock, septic cardiomyopathy, sepsis induced cardiomyopathy, ventricular contractility, speckle tracking echocardiography, ventricular re-synchronisation

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Percutaneous mechanical support in acute coronary syndromes

Abstract

Despite advances in interventional cardiology, persistently disappointing outcomes in patients with cardiogenic shock complicating myocardial infarction, together with the lack of evidence the that intra-aortic balloon pump improves outcomes in this patient population have led to a re-evaluation of other types of mechanical circulatory support. The increase in extracorporeal membrane oxygenation (ECMO) prompted by the H1N1 pandemic led to an increase in experience in using this technique in critically ill adult patients, and its use is now expanding in both respiratory and cardiac failure. Despite enthusiasm for the technique, high-quality evidence is lacking for its benefit. Nonetheless, ECMO and other types of percutaneous mechanical circulatory support do provide critical care clinicians with new supportive therapies that may prove to benefit patients, both from the high level of support that can be offered, and also minimising the use of potentially toxic inotropic agents.

Key words: cardiogenic shock, heart failure, mechanical circulatory support, extracorporeal membrane oxygenation, ECMO, myocardial infarction, acute coronary syndromes

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Dual antiplatelet therapy: short or long after acute coronary syndrome?

What the guidelines say

According to the latest ESC guidelines for the treatment of acute coronary syndrome (ACS) patients (1) treatment recommendations are as follows:

Aspirin (acetylsalicylic acid) is recommended for all ACS patients without contraindications. The initial oral loading dose (LD) is 150–300 mg in aspirin-naive patients, the maintenance dose (MD) is 75–100 mg/day. Aspirin is usually combined with a P2Y12-inhibitor, whereby prasugrel (60 mg LD or ticagrelor are preferred over clopidogrel unless these stronger antiplatelet agents are not available or contraindications exist. The recommended duration for dual antiplatelet therapy (DAPT) after ACS is 12 months, independent of the initial treatment strategy, which is either conservative medical treatment only, percutaneous coronary intervention (PCI), or bypass surgery, respectively. (1, 2)

Key Words: clopidogrel, prasugrel, ticagrelor, dual antiplatelet therapy

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