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Signa Vitae

A Journal In Intensive Care And Emergency Medicine

Author: Signavitae (Page 2 of 89)

Will Focus do?

Abstract

Ultrasound is an elegant method which provides insight into the patient. Focused cardiac ultrasound (FoCUS) includes a basic approach to the heart and inferior vena cava (IVC) by ultrasound. By only using the eye-balling method attending physicians can obtain important information for a better understanding of a patient’s pathophysiology. Obtained data can be used immediately and integrated together with other clinical data, which helps physicians in their decision-making process.

Key words: focused cardiac ultrasound, point of care ultrasound, physicians performed ultrasound, hemodynamic monitoring, shock, cardiac arrest

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Acute heart failure and cardiogenic shock

Introduction

Cardiovascular disease accounts for one quarter of all deaths, and once cancer mortality is excluded, cardiac disease alone accounts for more deaths than all other causes put together. Heart failure (defined as the inability of the heart to pump enough blood to meet the demands of the body) is common, being the primary cause of hospital admission in >1million patients per year in the USA, with 25% readmitted within 1 month, and a 10-20% mortality at 6 months after discharge. In newly diagnosed patients there is a >20% mortality at one year, rising to 50% at two years and >66% at ten years – proving as malignant as many common cancers. The underlying causes include coronary artery disease, hypertension, valve dysfunction, cardiomyopathies (inherited and acquired), congenital heart disease, arrhythmia, toxins (either ‘recreational’ – cocaine and alcohol, or therapeutic – some chemotherapeutic agents), pulmonary embolism and sepsis. Acute heart failure (AHF) may be a new diagnosis in patients with no history of cardiac disease, or occur as a result of acute decompensation in patients with known heart failure. It is the leading cause of hospital admission in people >65 years in the UK. European-wide, approximately 50% of these patients will be readmitted within 12 months, and 30% deceased at the 1-year follow-up.

Key words: cardiogenic shock, heart failure, mechanical circulatory support

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Palliative care in heart failure

Abstract

Chronic heart failure is a progressive disease with serious symptoms, which reduce patient functionality and increasingly interfere with basic daily activities. Therefore, palliative care should be incorporated relatively early in the management of the disease as supportive treatment. With its progression, the role of palliation becomes more and more important. Principles of palliative care in heart patients cannot be simply transferred from the oncology. The prognosis in patients with chronic heart failure is less reliable than in oncology. Furthermore, in cardiac patients, active treatment of the heart failure is preserved or even intensified in the advanced stage of the disease, because it can control the severity of the symptoms.

Nevertheless, when ICU treatment in the terminal stage is recognized and confirmed as futile, the duty of intensivist is to provide care so that the patient can die with preserved dignity and without any additional harm.

Key words: palliative care, heart failure

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Ethical dilemmas in delivery room and NICU

Abstract

Primigravida in 23/24 weeks of twin pregnancy after IVF/ET with chorioamnionitis and visible amniotic membranes of first twin was admitted to our hospital demanding caesarean section. Ethical Committee declined patient’s request, and within 20 minutes vaginal delivery occur. The first twin’s fetal weight was 610g with a 1-minute Apgar score of 3 and a 5-minute score of 4. The neonate was immediately resuscitated, intubated and required mechanical ventilation with Surfactant endotracheal administration. On the first postpartal day an ultrasound examination detected a grade 3 intraventricular haemorrhage (IVH) with clot dissolving and convulsions in clinical status. The newborn was hyperglycaemic with confirmed perinatal infection and a grade 1 necrotic enterocolitis (NEC). Regarding persistent ductus arteriosus indomethacin was administered. During the NICU stay porencephalic cysts and hydrocephalus arose without visible brain tissue. On the 75th postpartal day cardiorespiratory insufficiency occurred with lethal outcome. The second twin’s fetal weight was 680g with a 1-minute Apgar score of 2 and a 5-minute Apgar score of 3. The baby was born with bradycardia and had a few gasps. The neonate was immediately resuscitated, intubated and high-frequency mechanically ventilated. Surfactant was administered endotracheally. An ultrasound detected grade 3 IVH. Lethal outcome appeared on first postpartal day. In the second case there was a premature delivery of neonates of 23 weeks gestational age, BW 749g. The parents were not interested in resuscitation, and the baby showed weak signs of life. The issue of whether or not to intubate arose. Therefore, a dilemma appeared – to reanimate in such conditions, or not? To use an aggressive approach in the NICU, or not? There were ethical dilemmas within the medical personnel regarding resuscitation in such conditions considering the presented clinical and laboratory findings from the first postpartal day. Comfort care is probably the best option, but without medico-legal regulations this is impossible.

Key words: extremely low gestational age infants, ethical dilemmas, resuscitation, delivery room, NICU (Neonatal Intensive Care Unit)

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Noninvasive versus invasive haemodynamic monitoring – the use of transoesophageal doppler monitoring in patients undergoing elective cardiac bypass grafting surgery – our experience at University hospital centre Zagreb

Introduction

Insight into a patient’s hemodynamic status is very important to keep circulatory homeostasis as physiological as possible, especially during the perioperative period. A cardiac surgery setting is challenging for all parties involved – the anaesthesiologist, the surgeon and, of course, the patient.

The pulmonary artery catheter (PAC), popularly called the “Swan Ganz” catheter, in honour of its inceptors, has been the gold-standard of hemodynamic status insight since 1970. (1-3) However, novel hemodynamic monitors have been emerging over the last 20 or so years, which are less invasive than the PAC – even a PAC obituary was already written in 2013, which states PAC’s cousin, the continuous cardiac output PAC, as the sole surviving family member. (4)

One such monitor is the transoesophageal Doppler (in this case Deltex CardioQ™ ODM; Oesophageal Doppler Monitor, Deltex Medical, Chichester, UK). The premise is to place an ultrasonic probe into the oesophagus, at a depth that corresponds to the level of thoracic vertebrae 5 and 6 (Th5-Th6), that is 40-45cm from the nasal septum, or 35-40cm from the incisors (the probe can be placed trans-nasally or trans-orally). The tip of the probe is ideally angled at 45° towards the descending aorta (the desired position is achieved by gently rotating the probe while in the oesophagus to obtain the characteristic signal on the monitor), and blood velocity is obtained by means of continuous-wave Doppler signal emission and reception (velocity is calculated via a frequency shift equation), which is then presented as a continuous velocity/time graphical interpretation on a proprietary monitor screen. (5) Flow is calculated by using an equation for the descending aorta cross-sectional area (CSA), derived from demographic nomograms, and equals to a product of descending aorta blood velocity and descending aorta CSA. (6) Inherent transoesophageal Doppler hemodynamic variables, such as flow time (FT), peak velocity (PV), stroke distance (SD), flow time to peak (FTp) and mean acceleration (MA) are all derived from the Doppler probe measured descending aorta blood velocity using proprietary equations and algorithms. (7)

This study was done to compare hemodynamic measurements obtained via thermodilution (PAC) and a transoesophageal Doppler probe (TEDP) in patients who underwent elective cardiac bypass grafting surgery.

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