Cardiovascular System in the Critically Ill Patient

2019 ◽  
pp. 26-34
Author(s):  
Juan G. Ripoll Sanz ◽  
Norlalak Jiramethee ◽  
Jose L. Diaz-Gomez
Keyword(s):  
Cardiac Output ◽  
Cardiovascular System ◽  
Critically Ill ◽  
Fluid Responsiveness ◽  
Critically Ill Patients ◽  
Integrated System ◽  
Critically Ill Patient ◽  
Cardiovascular Disorders ◽  
Output Control ◽  
System 2

This chapter provides an overview of fundamental pathophysiologic concepts for the diagnosis and management of cardiovascular disorders in critically ill patients. Three major topics are presented: 1) the importance of vascular–cardiac pump coupling as an integrated system, 2) practical considerations of ventricular dysfunction, and 3) systemic vessels as a crucial factor for cardiac output control and fluid responsiveness.

scholarly journals Impact of Renal Replacement Therapy on Mortality in Critically Ill Patients—The Nephrologist’s View within an Interdisciplinary Intensive Care Team

2021 ◽  
Vol 10 (15) ◽  
pp. 3379
Author(s):  
Matthias Klingele ◽  
Lea Baerens
Keyword(s):  
Intensive Care ◽  
Renal Replacement Therapy ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Positive Impact ◽  
Kidney Injury ◽  
Care Team ◽  
Critically Ill Patient ◽  
Late Start

Acute kidney injury (AKI) is a common complication in critically ill patients with an incidence of up to 50% in intensive care patients. The mortality of patients with AKI requiring dialysis in the intensive care unit is up to 50%, especially in the context of sepsis. Different approaches have been undertaken to reduce this high mortality by changing modalities and techniques of renal replacement therapy: an early versus a late start of dialysis, high versus low dialysate flows, intermittent versus continuous dialysis, anticoagulation with citrate or heparin, the use of adsorber or special filters in case of sepsis. Although in smaller studies some of these approaches seemed to have a positive impact on the reduction of mortality, in larger studies these effects could not been reproduced. This raises the question of whether there exists any impact of renal replacement therapy on mortality in critically ill patients—beyond an undeniable impact on uremia, hyperkalemia and/or hypervolemia. Indeed, this is one of the essential challenges of a nephrologist within an interdisciplinary intensive care team: according to the individual situation of a critically ill patient the main indication of dialysis has to be identified and all parameters of dialysis have to be individually chosen with respect to the patient’s situation and targeting the main dialysis indication. Such an interdisciplinary and individual approach would probably be able to reduce mortality in critically ill patients with dialysis requiring AKI.

scholarly journals Feasibility of cardiac output measurements in critically ill patients by medical students

2020 ◽  
Vol 12 (1) ◽  
Author(s):  
Geert Koster ◽  
Thomas Kaufmann ◽  
Bart Hiemstra ◽  
Renske Wiersema ◽  
Madelon E. Vos ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Critical Care ◽  
Medical Students ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Left Ventricular ◽  
Percentage Error ◽  
Poor Agreement ◽  
Cardiac Output Measurements

Abstract Background Critical care ultrasonography (CCUS) is increasingly applied also in the intensive care unit (ICU) and performed by non-experts, including even medical students. There is limited data on the training efforts necessary for novices to attain images of sufficient quality. There is no data on medical students performing CCUS for the measurement of cardiac output (CO), a hemodynamic variable of importance for daily critical care. Objective The aim of this study was to explore the agreement of cardiac output measurements as well as the quality of images obtained by medical students in critically ill patients compared to the measurements obtained by experts in these images. Methods In a prospective observational cohort study, all acutely admitted adults with an expected ICU stay over 24 h were included. CCUS was performed by students within 24 h of admission. CCUS included the images required to measure the CO, i.e., the left ventricular outflow tract (LVOT) diameter and the velocity time integral (VTI) in the LVOT. Echocardiography experts were involved in the evaluation of the quality of images obtained and the quality of the CO measurements. Results There was an opportunity for a CCUS attempt in 1155 of the 1212 eligible patients (95%) and in 1075 of the 1212 patients (89%) CCUS examination was performed by medical students. In 871 out of 1075 patients (81%) medical students measured CO. Experts measured CO in 783 patients (73%). In 760 patients (71%) CO was measured by both which allowed for comparison; bias of CO was 0.0 L min−1 with limits of agreement of − 2.6 L min−1 to 2.7 L min−1. The percentage error was 50%, reflecting poor agreement of the CO measurement by students compared with the experts CO measurement. Conclusions Medical students seem capable of obtaining sufficient quality CCUS images for CO measurement in the majority of critically ill patients. Measurements of CO by medical students, however, had poor agreement with expert measurements. Experts remain indispensable for reliable CO measurements. Trial registration Clinicaltrials.gov; http://www.clinicaltrials.gov; registration number NCT02912624

The ART of Antiretroviral Therapy in Critically Ill Patients With HIV

2018 ◽  
Vol 34 (11-12) ◽  
pp. 897-909 ◽  
Author(s):  
Tyler Finocchio ◽  
William Coolidge ◽  
Thomas Johnson
Keyword(s):  
Intensive Care ◽  
Antiretroviral Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Care Setting ◽  
Critically Ill Patient ◽  
Intensive Care Setting ◽  
Antiretroviral Medications ◽  
Immunodeficiency Virus ◽  
Inflammatory Syndrome

The management of patients with human immunodeficiency virus (HIV) can be a complicated specialty within itself, made even more complex when there are so many unanswered questions regarding the care of critically ill patients with HIV. The lack of consensus on the use of antiretroviral medications in the critically ill patient population has contributed to an ongoing clinical debate among intensivists. This review focuses on the pharmacological complications of antiretroviral therapy (ART) in the intensive care setting, specifically the initiation of ART in patients newly diagnosed with HIV, immune reconstitution inflammatory syndrome (IRIS), continuation of ART in those who were on a complete regimen prior to intensive care unit admission, barriers of drug delivery alternatives, and drug-drug interactions.

scholarly journals T3 as predictor of mortality in any cause non-critically ill patient

2021 ◽  
Author(s):  
Erika Biegelmeyer ◽  
Iury Scanagata ◽  
Laura Alves ◽  
Murilo Reveilleau ◽  
Fernando Pereira Schwengber ◽  
...  
Keyword(s):  
Hospital Mortality ◽  
Clinical Outcomes ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Critically Ill Patient ◽  
Total Serum ◽  
Population Total ◽  
Low T3 ◽  
Serum T3 ◽  
Overall Mortality

Background: Low T3 syndrome refers to a set of thyroid hormone metabolism alterations present in disease state. A correlation between low T3 and poor clinical outcomes in the intensive care unit is more established. Nonetheless, studies on non-critically ill patients are few and controversial. Objective: To evaluate the prevalence and predictive value of low T3 levels on 30 days- and six month-term mortality in non-critically ill patients. Secondary outcomes evaluated length of hospital stay, overall mortality, and hospital readmission. Design: Prospective cohort study. Methods: 345 consecutive patients from Internal medicine ward of a tertiary hospital in southern Brazil included from October 2018 to April 2019 and followed for 6 months. Levels of total serum T3 were measured weekly, from admission to discharge, and correlated with 30-day hospital mortality. Results: Prevalence of low T3 was 36.6%. Low T3 levels were associated with higher 30-days hospital mortality (15.1% versus 4.1%, p<0.001) and higher 6-months overall mortality (31.7% versus 13.2%, p<0.001). Total serum T3 at admission was an independent predictor of 30-days hospital mortality. Conclusion: Low T3 levels are a prevalent condition among non-critically ill patients and this condition is associated with poor clinical outcomes in this population. Total serum T3 levels, alone or in association with other predictive scores, were demonstrated to be an easy and valuable tool for risk stratification, and should be further employed in this setting.

scholarly journals Current use of inotropes in circulatory shock

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
Thomas W. L. Scheeren ◽  
Jan Bakker ◽  
Thomas Kaufmann ◽  
Djillali Annane ◽  
Pierre Asfar ◽  
...  
Keyword(s):  
Cardiac Output ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Clinical Signs ◽  
Left Ventricular ◽  
Additional Treatment ◽  
Circulatory Shock ◽  
Left Ventricular Ejection ◽  
First Line ◽  
Ventricular Ejection Fraction

Abstract Background Treatment decisions on critically ill patients with circulatory shock lack consensus. In an international survey, we aimed to evaluate the indications, current practice, and therapeutic goals of inotrope therapy in the treatment of patients with circulatory shock. Methods From November 2016 to April 2017, an anonymous web-based survey on the use of cardiovascular drugs was accessible to members of the European Society of Intensive Care Medicine (ESICM). A total of 14 questions focused on the profile of respondents, the triggering factors, first-line choice, dosing, timing, targets, additional treatment strategy, and suggested effect of inotropes. In addition, a group of 42 international ESICM experts was asked to formulate recommendations for the use of inotropes based on 11 questions. Results A total of 839 physicians from 82 countries responded. Dobutamine was the first-line inotrope in critically ill patients with acute heart failure for 84% of respondents. Two-thirds of respondents (66%) stated to use inotropes when there were persistent clinical signs of hypoperfusion or persistent hyperlactatemia despite a supposed adequate use of fluids and vasopressors, with (44%) or without (22%) the context of low left ventricular ejection fraction. Nearly half (44%) of respondents stated an adequate cardiac output as target for inotropic treatment. The experts agreed on 11 strong recommendations, all of which were based on excellent (> 90%) or good (81–90%) agreement. Recommendations include the indications for inotropes (septic and cardiogenic shock), the choice of drugs (dobutamine, not dopamine), the triggers (low cardiac output and clinical signs of hypoperfusion) and targets (adequate cardiac output) and stopping criteria (adverse effects and clinical improvement). Conclusion Inotrope use in critically ill patients is quite heterogeneous as self-reported by individual caregivers. Eleven strong recommendations on the indications, choice, triggers and targets for the use of inotropes are given by international experts. Future studies should focus on consistent indications for inotrope use and implementation into a guideline for circulatory shock that encompasses individualized targets and outcomes.

scholarly journals Znacaj profilakse akutne mukozne lezije kod pacijenata u jedinici intenzivnog lecenja

2007 ◽  
Vol 54 (1) ◽  
pp. 47-50 ◽  
Author(s):  
N.M. Popovic
Keyword(s):  
Critically Ill ◽  
Critically Ill Patients ◽  
Direct Consequence ◽  
Severe Trauma ◽  
Mucosal Lesion ◽  
Critically Ill Patient ◽  
Multiple Risk Factors ◽  
Massive Gastrointestinal Bleeding ◽  
Mucosal Lesions ◽  
Clinically Significant

At least three-quarters of critically ill patients develop mucosal lesion as a direct consequence of stress within the first 24 hours following the admission to intensive care unit. These mucosal lesions occur as superficial or deep mucosal lesions which can lead to massive gastrointestinal bleeding and it can put at risk the life of critically ill patient. There are multiple risk factors for the occurence of mucosal lesion such as: respiratory failure requiring mechanical ventilation, sepsis, hypotension, burns, severe trauma, neurotrauma, ileus, coagulopathy, renal and hepatic failure, myocardial infarction etc. The incidence of silent (ocult) bleeding in critically ill patients is almost 100%, but only about 5% of patients have clinically apparent (overt) hemorrhage and 1-2% have clinically significant bleeding which requires blood transfusions. In patients who are at the greatest risk of developing mucosal lesion, prophylactic treatment ought to be started immediately in order to achieve pH4 with adequate perfusion and coagulation. Today several groups of medications are used for the prevention of mucosal gastrointestinal lesion and they include: antacids, sucralfate, hisamine-2 receptor antagonists and proton pump inhibitors.

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