Advances in critical care management of patients undergoing cardiac surgery.

Cardiac surgery has been evolving to include minimally invasive, hybrid and transcatheter techniques. Increasing patient age and medical complexity means that critical care management needs to adapt and evolve. Recent advances have occurred in several areas, including ventilation, haemodynamics and mechanical circulatory support, bleeding and coagulation, acute kidney injury, and neurological management. This narrative review describes standard care, recent advances, and future areas of research in the critical care management of patients undergoing cardiac surgery.

Echocardiographic approach to cardiac tamponade in critically ill patients.

Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients.

Transesophageal echocardiography in critically ill patients.

OBJECTIVE: To evaluate the safety and utility of transesophageal echocardiography performed by intensive care physicians in critically ill patients. DESIGN: Retrospective chart review. SETTING: A 24-bed multidisciplinary adult intensive care unit in a 692-bed tertiary referral teaching hospital. PATIENTS: Two hundred fifty-five intensive care patients. INTERVENTIONS: We studied 255 consecutive intensive care patients who underwent transesophageal echocardiography between January 1996 and January 2000. MEASUREMENTS AND MAIN RESULTS: Three hundred eight transesophageal echocardiography studies were successfully performed; the probe could not be passed in one patient with a cervical fracture. The indications included unexplained hypotension (40%), known or suspected endocarditis (27%), assessment of ventricular function (15%), pulmonary edema (5%), source of embolus (4%), assessment of aorta (4%), and other (5%). In 67% of hypotensive patients, transesophageal echocardiography revealed the cause of hemodynamic instability, leading to a management change and improvement in blood pressure in 31%. This included surgery in 22% without the need for additional tests. Overall, transesophageal echocardiography findings led to a significant change in management in 32% of all studies performed. One patient receiving continuous positive airways pressure suffered pulmonary aspiration during tracheal intubation before transesophageal echocardiography, two patients had hypotension associated with sedative medication, and there was one case of oropharyngeal bleeding after probe insertion. CONCLUSION: Transesophageal echocardiography when performed by intensive care physicians is a safe procedure and provides useful information for the evaluation and management of critically ill patients.