Intensive physiotherapic respiratory care in critically ill patients with tracheostomy after cardiac surgery

Background. Patients following major cardiac surgery are increasingly elderly and present many comorbidities. For these reasons their post-operative phase is often burdened by several complications requiring a long stay in Critical Care and prolonged mechanical ventilation. Most of these patients, when transferred to our Intensive Cardiac Rehabilitation Unit, still have a percutaneous tracheostomy due to respiratory mechanical dysfunction. The aim of our work is to present new rehabilitative care strategies in such compromised patients. Methods and materials. We studied 27 elderly critically ill tracheostomized patients who were split into 2 Groups (A = 11 and B = 16). The Groups were homogeneous for age and for left ventricular ejection fraction. Group A received a standard treatment including cautious mobilisation and respiratory unspecific physiotherapy. Group B received an earlier and more aggressive treatment with a specific respiratory physiotherapy including Positive Expiration Pressure (PEP) directly connected to the tracheostomy cannula. A protocol for tracheostomy decannulation by assessment of the Peak Expiratory Flow during cough (PCEF≥ 180 L/min.) has been defined in order to verify the patients ability to develop a mechanically effective cough to obtain weaning from tracheostomy. Besides, in the patients of Group B, we carried out a screening of the swallowing dysfunction. Results. Four patients of Group A deceased while in Group B there were no deaths. Furthermore patients of Group B showed a statistically significant improvement of mobility and respiratory indexes. In Group B only one patient was discharged with tracheostomy cannula in site because he did not reach standard criteria for decannulation and his PCEF value was not satisfactory. This patient underwent percutaneous gastrostomy. Conclusions. A precocious and intensive rehabilitation, based on specific respiratory physiotherapy, significantly improves mobility and respiratory indexes of patients with tracheostomy. The PCEF and the swallowing deficit evaluation allows an earlier tracheostomy decannulation with lower risk of complications.

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Clinical Efficacy of Immediate Rehabilitation Training after Coronary Artery Intervention in Patients with AMI

Tobacco Regulatory Science ◽

10.18001/trs.7.5.1.79 ◽

2021 ◽

Vol 7 (5) ◽

pp. 3087-3092

Author(s):

Youlin Fu ◽

Zhongming Yang ◽

Chongrong Qiu

Keyword(s):

Coronary Artery ◽

Left Ventricular Ejection Fraction ◽

Ejection Fraction ◽

Daily Living ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Rehabilitation Training ◽

Group A ◽

Group B

This paper investigates the effect of rehabilitation training on the clinical outcome and prognosis of patients with acute myocardial infarction after coronary artery intervention. There was no significant difference in daily living ability score and left ventricular ejection fraction between group A before intervention (P>0.05). The score of daily living ability of group A was (76.58±3.27) significantly higher than that of group B after intervention (73.7). ±3.4) (P<0.05); left ventricular ejection fraction after intervention (55.75±4.4) was significantly higher than that of group B (52.41 ±4.19) (P<0.05); total satisfaction rate of patients in group A (93.02%) was significantly higher In group B (69.77%), the difference between the groups was statistically significant (P<0.05); the total incidence of adverse reactions and mortality in group A (11.63%, 2.33%) was significantly lower than that in group B (53.49%, 16.28%).), the difference was statistically significant (P < 0.05). In patients with acute myocardial infarction, after interventional coronary artery intervention, immediate intervention with rehabilitation training can improve left ventricular ejection fraction, improve daily living ability and nursing satisfaction, and reduce postoperative adverse reactions and death. Medical staff should be used reasonably in the clinic according to the actual situation of the patient.

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Effect of warm-up on left ventricular response to sudden strenuous exercise

Journal of Applied Physiology ◽

10.1152/jappl.1982.53.2.380 ◽

1982 ◽

Vol 53 (2) ◽

pp. 380-383 ◽

Cited By ~ 21

Author(s):

C. Foster ◽

D. S. Dymond ◽

J. Carpenter ◽

D. H. Schmidt

Keyword(s):

Blood Flow ◽

Ejection Fraction ◽

Myocardial Blood Flow ◽

Left Ventricular ◽

Strenuous Exercise ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

Warm Up ◽

Group A ◽

Group B

Sudden strenuous exercise (SSE) has been shown to produce ischemic electrocardiographic (ECG) responses, abnormalities of myocardial blood flow, and decreases in left ventricular ejection fraction. Prior exercise taken as warm-up has been shown to ameliorate the ECG and myocardial blood flow abnormalities induced by SSE. The purpose of this study was to determine whether warm-up would normalize the responses of the left ventricular ejection fraction to SSE. Twenty healthy male volunteers performed SSE (400-W bicycle exercise) either with (group A, n = 10) or without (group B, n = 10) warm-up. Ejection fraction was measured using first-pass radionuclide angiography under control conditions and during SSE. During SSE ejection fraction decreased from control values in both group A (70.5 +/- 6.3 to 64.8 +/- 8.2%) and group B (70.3 +/- 10.1 to 57.7 +/- 7.7%), although ejection fraction was significantly higher during SSE in group A. The results are consistent with the hypothesis that the abnormal responses to SSE are attributable to subendocardial ischemia secondary to a delay in autoregulation of myocardial blood flow. However, the decrease in ejection fraction during SSE even following warm-up suggests that the mechanism for the abnormal response to SSE is more complicated than previously hypothesized.

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Incidence and Associated Risk Factors of Contrast Induced Nephropathy in Diabetes and Non Diabetic Patients

Journal of National Institute of Neurosciences Bangladesh ◽

10.3329/jninb.v3i1.36269 ◽

2018 ◽

Vol 3 (1) ◽

pp. 29-36

Author(s):

Mohammed Rashed Anwar ◽

KAM Mahbub Hasan ◽

Asraful Hoque ◽

Babrul Alam ◽

Dilip Kumar Debnath ◽

...

Keyword(s):

Risk Factors ◽

Serum Creatinine ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Diabetic Patients ◽

Contrast Induced Nephropathy ◽

Diabetes Group ◽

Ventricular Ejection Fraction ◽

Group A ◽

Group B

Background: Contrast-induced nephropathy (CIN) is the third leading cause of hospital-acquired acute renal failure.Objective: The purpose of the present study was to compare the incidence and associated risk factors of contrast induced nephropathy in diabetes and non-diabetic patients.Methodology: This was cross-sectional study performed in the Department of Nephrology at National Institute of Kidney Diseases and Urology, Sher-E-Bangla Nagar, Dhaka and Department of Cardiology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from January 2016 to July 2016. Contrast induced nephropathy (CIN) is defined as increase in serum creatinine of ≥25% from baseline value and/ or an absolute increase of ≥0.5 mg/dl in serum creatinine from baseline. Patients were divided in to two groups Group A (Patients with Diabetes mellitus) and Group B (Patients without Diabetes mellitus). To identify independent characteristics associated with CIN, multivariable logistic regression analysis was used through SPSS version 23. Results of this model were presented as Odds Ratio (OR). P value was calculated to see the significance of various risk factors in diabetes and non-diabetes patients.Results: The difference in baseline creatinine serum creatinine was found statistically significant (P<0.001). In group A 57 patients (50.9%) had eGFR <60ml/min/1.73m2, 55 patients (49.1%) had eGFR ≥60ml/min. The difference in estimated GFR was found statistically significant (P<0.001). Left ventricular ejection fraction <40% was present in 6 (5.4%), 7 (5.1%) in group A and B respectively, ≥40% in 106 (94.6%), 131 (94.9%) in group A and B respectively. CIN developed in 21 (18.80%) patients in group A and 2 (1.4%) patients in group B (CIN was defined by increased in serum creatinine ≥25% of baseline or ≥44μmol/L). All belonged to group A, 16 (19%) of the diabetic patients out of 86 developed CIN. Diabetic patients who had eGFR <60ml/min (n=30), 13 (43.3%) developed CIN. Among all patients (n=250), 23 developed CIN. Overall incidence was 9.2%.Conclusion: CIN was significant developed in diabetes group than non diabetes. Left ventricular ejection fraction and total volume of contrast media used was significantly higher in diabetes group than non-diabetes group B patients.Journal of National Institute of Neurosciences Bangladesh, 2017;3(1): 29-36

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614 Implantable cardiac monitors predict arrhythmic events in post-infarction patients with mildly reduced left ventricular ejection fraction

European Heart Journal Supplements ◽

10.1093/eurheartj/suab127.036 ◽

2021 ◽

Vol 23 (Supplement_G) ◽

Author(s):

Vincenzo Riverso ◽

Antonio Curcio ◽

Alessia Tempestini ◽

Emilia De Luca ◽

Sabrina La Bella ◽

...

Keyword(s):

Remote Monitoring ◽

Cardiac Dysfunction ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Ventricular Ejection Fraction ◽

St Segment ◽

Group A ◽

Group B

Abstract Aims Complications of acute myocardial infarction (MI) can be life-threatening leading to sudden cardiac death. While guidelines recommend prompt revascularization and prolonged intensive care hospitalization, predictors of major adverse cardiovascular outcomes are yet poorly understood. The role of implantable cardioverter-defibrillators, even in cases of non-sustained arrhythmias is still debated. To date, it is unknown how to follow-up patients with mild cardiac dysfunction after MI. Implantable cardiac monitors (ICMs) can be helpful for stratifying patients in the early discharge period, and remote monitoring might speed up arrhythmia recognition and treatment. We investigated the role of remote monitoring of ICMs to detect arrhythmic events in post-MI patients without overt cardiac dysfunction. Methods and results We enrolled 13 patients (9 males; 69.8 years) after either ST-segment (N = 7) or non-ST-segment elevation (N = 6) MI with a left ventricular ejection fraction (LVEF) >35%, admitted to our coronary care unit for urgent revascularization between September 2019 and September 2021. Twelve patients underwent percutaneous myocardial revascularization, whereas one was treated with medical therapy only. All patients received an ICM during hospitalization according to echo and EKG parameters. We considered LVEF ≤ 40% as sole risk factor or LVEF between 40% and 50% in addition to either PQ length prolongation, or QRS widening, or pathologic heart rate variability, or non-sustained ventricular tachycardia/paroxysmal advanced second degree atrioventricular block. Patients with multiple revascularization procedures and several hospital admissions were excluded. Implanted ICM were frequently monitored both remotely and in-office when required. During follow-up, brady- and tachy-arrhythmias were recorded in four patients (30.8%). The remote monitoring of the ICM documented new-onset atrial fibrillation, high-degree atrioventricular block, severe bradycardia, and sustained ventricular tachycardia. Three patients required hospitalization and upgrade of the implanted device with pacemakers and cardioverter/defibrillator. For arrhythmic risk stratification, patients were divided into two subgroups; group A included patients with LVEF 40% associated with heart rate > 60 b.p.m., PQ length >160 ms and QRS width >86 ms (N = 4); group B included patients with EF 41%/50%, PQ length <159 and QRS width <85 ms (N = 10). First group experienced more advanced rhythm disorders than group B (P < 0.05). Device implantation was significantly higher in group A (P < 0.05%). Conclusions OFF-label implementation of ICMs coupled with remote device monitoring may be effective for early detection of serious adverse cardiac rhythm alterations in patients after MI and LVEF higher than 35%. Further monitoring is ongoing for assessing the occurrence of multiple arrhythmias or their increased occurrence.

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P497Arrhythmic burden in patients with filamin C (FLNC) truncating variant associated cardiomyopathy

EP Europace ◽

10.1093/europace/euaa162.181 ◽

2020 ◽

Vol 22 (Supplement_1) ◽

Author(s):

A Zupan Meznar ◽

D Zizek ◽

U D Breskvar Kac ◽

K Writzl ◽

M Jan ◽

...

Keyword(s):

Left Ventricular ◽

Left Ventricular Ejection ◽

Optimal Timing ◽

Icd Implantation ◽

Ventricular Ejection Fraction ◽

Number Of Patients ◽

Group A ◽

Group B ◽

Current Guidelines

Abstract Background Truncating variants in FLNC gene are associated with an overlapping phenotype of arrhythmogenic and dilated cardiomyopathy. There are reports of high arrhythmia propensity with sudden cardiac death (SCD) often being the first symptom of the disease. It has been suggested that the current European guidelines primary prevention (PP) recommendation about implantable cardioverter-defibrillator (ICD) implantation might not be applicable in these patients and that earlier intervention should be considered. Purpose We sought to investigate the arrhythmic burden in FLNC truncation carriers in our centre. Methods Adult FLNC truncation carriers diagnosed in our centre between the years 2018 and 2019 were included in the study. We retrospectively analysed clinical data, and ICD follow-up reports in the cohort. Patients implanted with an ICD were divided in 3 groups: group A (secondary prevention ICD implantation), group B (PP indication according to the current guidelines – left ventricular ejection fraction (LVEF) below 35%) and group C (early PP– FLNC truncation carrier, LVEF < 50% and late gadolinium enhancement on cardiac magnetic resonance). We report the number of patients experiencing SCD and the number of appropriate and inappropriate ICD therapies per group. Results Twenty-four adult patients from 3 different families with three distinct FLNC truncating variants were identified. Ten (42%) were male; the average age was 45 ± 14 years. There were 3 (13%) SCDs in one family (2 male and one female, 29-42 years old) and two (8%) aborted SCDs in the remaining two families (one male and one female, 66 and 51 years old). Altogether eleven (46%) patients were implanted with an ICD. There were three patients in group A (2 aborted SCDs and 1 sustained ventricular tachycardia (VT)), two patients in group B and six patients in group C. Average ICD follow-up times were 42, 48 and 6 months for groups A, B and C, respectively. Eight appropriate ICD therapies occurred in 3 patients (27%). In group A, there were four sustained VT episodes successfully converted with an anti-tachycardia pacing (ATP) in two patients (67%); the average time to first therapy was 33 months. In group B, there was one appropriate shock for ventricular fibrillation (VF), and three sustained VT episodes in one patient (50%), time to first therapy was 60 months. After six months follow-up, there were no appropriate therapies registered in group C. Two patients (18%) experienced inappropriate shocks due to sinus tachycardia, one in group A and one in group C. Conclusion One-fifth of FLNC truncation carriers in our cohort experienced SCD. When patients received an ICD according to the current guidelines, majority experienced appropriate ICD therapy. Further clinical studies with longer follow-up will be needed to define appropriate risk stratification and optimal timing for prophylactic ICD intervention in these patients.

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Diagnosis and management of dysphagia in patients with tracheostomy tube after cardiac surgery: an early screening protocol

Monaldi Archives for Chest Disease ◽

10.4081/monaldi.2010.270 ◽

2015 ◽

Vol 74 (2) ◽

Author(s):

Naika Scalabrino ◽

Laura Crespi ◽

Monica Bosco ◽

Emanuele Troisi ◽

Gaia Vezzaro ◽

...

Keyword(s):

Cardiac Surgery ◽

Tracheostomy Tube ◽

Left Ventricular ◽

Oral Feeding ◽

Left Ventricular Ejection ◽

Blue Dye ◽

Early Assessment ◽

Ventricular Ejection Fraction ◽

Swallowing Dysfunction ◽

Swallowing Rehabilitation

SCOPE. Patients with tracheostomy tube after major cardiac surgery undergoing Cardiac Rehabilitation Program often present swallowing disorders that need a specific evaluation. This study aimed at validating the usefulness of a swallowing screen protocol in order to obtain an early assessment of dysphagia and to prevent aspiration, malnutrition and dehydration risks. MATERIALS AND METHODS. The protocol has been applied to 38 consecutive patients with tracheostomy tube after cardiac surgery between September 2007 and December 2009. The average age of patients was 73 ± 6 years; the average value of left ventricular ejection fraction was 41 ± 4%. The protocol included a water swallowing test and a specific swallowing test with blue dye. During tests, the presence of signs of swallowing dysfunction was evaluated and oxygen saturation levels were monitored. RESULTS. Out of 38 patients, 2 did not show any swallowing deficits; 18 showed deficits in the water swallowing test even though they presented a preserved swallowing function during specific swallowing test. All these 20 patients (53%), before discharge, restarted an oral feeding and obtained an adequate body mass index and effective coughing, so they were soon decannulated. Twelve patients (31%) showed deficits during the water swallowing test, confirmed by the specific swallowing test with blue dye: the tracheostomy tube was not removed and a specific program of swallowing rehabilitation was performed. Before discharge all patients restarted an oral feeding, recovered an effective coughing and were decannulated. Six patients (16%), because of persistent dysphagia, underwent percutaneous endoscopic gastrostomy. None of these 38 patients developed ab ingestis pneumonia, dehydration or malnutrition. CONCLUSIONS. An early assessment of swallowing in patients with tracheostomy tube after cardiac surgery allows the selection of patients with higher aspiration risk, preventing possible severe complications.

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Current use of inotropes in circulatory shock

Annals of Intensive Care ◽

10.1186/s13613-021-00806-8 ◽

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.

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Specific diseases: valvular heart disease

ESC CardioMed ◽

10.1093/med/9780198784906.003.0641 ◽

2018 ◽

pp. 2666-2667

Author(s):

Bernard Iung ◽

Luc A. Pierard

Keyword(s):

Cardiac Surgery ◽

Aortic Stenosis ◽

Perioperative Complications ◽

Left Ventricular ◽

Valvular Disease ◽

Left Ventricular Ejection ◽

Mechanical Prosthesis ◽

Ventricular Ejection Fraction ◽

Asymptomatic Patients ◽

Mitral Commissurotomy

The evaluation of the risk of non-cardiac surgery in patients with valvular disease should take into account the type, severity, and tolerance of valvular disease, and the risk inherent to non-cardiac surgery. Aortic stenosis carries the highest risk of perioperative complications. Except for emergency non-cardiac surgery, an intervention on the aortic valve is indicated firstly in case of severe symptomatic aortic stenosis. In asymptomatic patients, low- and intermediate-risk non-cardiac surgery can be performed, while the strategy should be individualized for high-risk non-cardiac surgery. Balloon aortic valvuloplasty may be used as a bridge if non-cardiac surgery is urgent. Percutaneous mitral commissurotomy should be considered in symptomatic patients with severe mitral stenosis. In patients with severe aortic or mitral regurgitation, the risk of non-cardiac surgery is low if they are asymptomatic with preserved left ventricular ejection fraction. In patients with a mechanical prosthesis, perioperative anticoagulant therapy should be adapted to the haemorrhagic risk of intervention and to the patient- and prosthesis-related thromboembolic risk.

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