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Signa Vitae

Journal of Anaesthesia, Intensive Care and Emergency Medicine

Intensive care management of patients with left ventricular assist device


Mechanical circulatory support devices, especially left ventricular assist devices (LVADs) represent an important treatment modality for patients with end-stage heart failure (HF). In a 1-year period (from January to December 2017) in our intensive care unit (ICU) we had a total of 8 patients with LVAD implantation. LVADs are devices with unique physiology which restore tissue circulation by increasing blood supply, nevertheless, they can be challenging to manage and are associated with significant complications.

Keywords: Critical Care, Heart-Assist Devices, Heart Failure, Hemodynamics, Hemodynamic Monitoring, Cardiac surgery, Postoperative Complications

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Impact of prehospital rapid sequence intubation and mechanical ventilation on prehospital vital signs and outcome in trauma patients


Introduction. Medications during rapid sequence intubation (RSI) have known detrimental side effects. Prehospital mechanical ventilation after successful endotracheal intubation also increases mortality due to hyperventilation and positive pressure ventilation. The aim of this retrospective analysis was to determine the impact of RSI on prehospital hemodynamic parameters and prehospital ventilation status on mortality rate and functional outcome in trauma patients.

Methods. Charts of 73 trauma patients, who underwent prehospital RSI over a 12-year period, were retrospectively reviewed. Prehospital vital signs, before and after RSI, were compared. Patients were divided, according to ventilation status, into three groups based on initial PaCO2: hypocarbic/hyperventilated (PaCO2<35mmHg), normocarbic/normoventilated (PaCO2 35-45 mmHg) and hypercarbic/hypoventilated (PaCO2>45mmHg).

Results. Seventy-three patients were enrolled in the retrospective analysis. There was a significant difference in respiratory rate (p=0.046), arterial oxygen saturation (p<0.001), mean arterial pressure (p<0.001) and Glasgow Coma Scale (GCS) (p<0.001) before and after RSI. GCS at discharge (p=0.003) and arterial oxygen saturation (p=0.05) were significantly higher in the normoventilated group. There was no significant difference in survival to hospital discharge among compared groups.

Conclusion. Our retrospective analysis suggests that prehospital RSI has no detrimental hemodynamic side effects and that normoventilation leads to a favorable neurological outcome.

Key words: intubation, prehospital, mechanical ventilation, trauma, hemodynamics

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The effects of post-intubation hypertension in severe traumatic brain injury


Introduction. The effect of post-intubation hypertension in severe traumatic brain injury (TBI) patients remains uncertain. We aimed to determine the relationship between post-intubation hypertension (mean arterial pressure (MAP) > 110mmHg) and outcomes in severe TBI.

Methods. In this retrospective cohort study, adults who presented with isolated TBI and a MAP ≥ 70mmHg were assessed. Data were retrieved from our institutional trauma registry and the admission list of our neurosurgical intensive care unit (ICU).

Results. We enrolled 126 patients, 81 of whom had a MAP ≤ 110 mmHg after intubation and were assigned to group 1; 45 patients who had a MAP > 110 mmHg were assigned to group 2. Only age (P = 0.008), heart rate (HR; P = 0.036), and MAP before intubation (P < 0.001) were significantly different between groups. We found no significant intergroup differences in mortality (35.8 vs. 35.6%, P = 1.000) or in the motor function of survivors at discharge (P = 0.333). The length of ventilator-dependent (median: 2.0 vs. 5.0 days; P = 0.003) and ICU stays (median: 4.5 vs. 10.0 days; P = 0.005) were significantly longer in group 2. Post-intubation hypertension remained significantly associated with longer ICU stay (≥ 7 days) and poor neurologic outcome (motor < 4 at discharge) after adjusting for other variables (post-intubation MAP >110 mmHg, P < 0.034, OR 3.119, 95% CI 1.087-8.953).

Conclusion. Post-intubation hypertension was associated with longer ventilator-dependent and ICU stays in patients with severe TBI.

Key words: endotracheal intubation, hemodynamics, blood pressure, mean arterial pressure, intracranial hemorrhage.

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Preoperative management of hypoplastic left heart syndrome


Pediatricians are frequently involved in the care of cyanotic newborns in the labor and delivery room, as well as in the well baby nursery. Causes of hypoxia and cyanosis in the term newborn can be found within all physiological systems. Congenital heart structural diseases account for the largest diagnostic category. There have been significant advances during the past years in the diagnosis and treatment of neonates with critical congenital heart disease, especially in the field of pre- and post-operative intensive care.

The term hypoplastic left heart syndrome (HLHS) describes a spectrum of cardiac structural abnormalities characterized by marked hypoplasia of the left ventricle and ascending aorta. Prenatal diagnosis, initial resuscitation and optimal preoperative management are key elements that allow the best opportunity for low mortality and normal neurodevelopment in affected newborns.  Preoperatively, the goal is to achieve adequate systemic oxygen delivery. Patency of the ductus arteriosus (DA) is critical for survival until surgery. Blood flow to the pulmonary and systemic circulations should be nearly balanced (goal Qp/Qs ratio of 1).  The immediate therapy for all infants with HLHS is an intravenous infusion of prostaglandin E1 (PGE1) in order to manipulate the DA and maintain ductal patency. Oxygen saturations of 75% to 85% by pulse oximetry suggest an adequate balance between systemic and pulmonary blood flow.  Judicious use of inotropic support is initiated if evidence of low cardiac output is detected. Diuretics may be necessary to help alleviate the increased volume load on the right ventricle. The goal of respiratory management is to increase pulmonary vascular resistance and decrease systemic vascular resistance.  Infants with HLHS who are born with a severely restricted or no inter-atrial communication, a rare occurrence, have profound hypoxemia.  The severe restriction of blood flow across the atrial septum results in a life-threatening situation and these patients, which present with severe cyanosis and hemodynamic instability, require urgent postnatal cardiac catheterization to relieve the septal obstruction and improve oxygenation. Special attention should be paid to the prevention of brain injury and poor neurodevelopmental outcome.

Care for infants with HLHS is complex, and often multiple specialists are involved. Despite an increase in the number of newborns with complex congenital heart disease and a growing percentage of patients with single-ventricle physiology, it is possible to care for this particular group of patients and achieve acceptable mortality risks, even in centres with no pediatric cardiac surgery facilities, if good preoperative management protocols are followed.

Key words: congenital heart disease, newborn, intensive care, hemodynamics, PGE1, ductus arteriosus


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Mediastinal tube placement in a premature infant with cardiorespiratory derangement due to ventilator associated pneumomediastinum


While mediastinal free air in the ventilated newborn is usually benign, tension pneumomediastinum can lead to further cardiorespiratory compromise due to the compression of mediastinal structures, including the heart and large blood vessels. The authors present a case of life-threatening pneumomediastinum in a ventilated preterm leading to abrupt onset of cardiorespiratory failure. An 8 French (Fr) drainage catheter was placed in the anterior mediastinum using the 2nd right intercostal space as an insertion site, with prompt hemodynamic improvement. A brief description of the drainage technique and a literature review is presented.

Key words: hemodynamics, mechanical ventilation, pneumomediastinum, pneumothorax, thoracocentesis

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