RESUMO
Over the last several decades, the cardiac intensive care unit (CICU) has seen an increase in the complexity of the patient population and etiologies requiring CICU admission. Currently, respiratory failure is the most common reason for admission to the contemporary CICU. As a result, noninvasive ventilation (NIV), including noninvasive positive-pressure ventilation and high-flow nasal cannula, has been increasingly utilized in the management of patients admitted to the CICU. In this review, we detail the different NIV modalities and summarize the evidence supporting their use in conditions frequently encountered in the CICU. We describe the unique pathophysiologic interactions between positive pressure ventilation and left and/or right ventricular dysfunction. Additionally, we discuss the evidence and strategies for utilization of NIV as a method to reduce extubation failure in patients who required invasive mechanical ventilation. Lastly, we examine unique considerations for managing respiratory failure in certain, high-risk patient populations such as those with right ventricular failure, severe valvular disease, and adult congenital heart disease. Overall, it is critical for clinicians who practice in the CICU to be experts with the application, risks, benefits, and modalities of NIV in cardiac patients with respiratory failure.
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Background: Family-centered rounds (FCR) reduce the risk of psychological comorbidities of family members and improve the quality of communication between providers and families. Materials and methods: We conducted a pilot quality improvement study analyzing family perceptions of virtual FCR. Family members of previously admitted cardiac ICU patients who participated in at least one session of virtual FCR between April 2020 and June 2021 at Massachusetts General Hospital were surveyed post-ICU discharge. Results: During the study, 82 family members enrolled and participated in virtual FCR with 29 completing the post-admission telephone survey. Many cardiac ICU patients were male (n = 53), and a majority were discharged home (43%) with the patient's wives being the most common respondents to the questionnaire (n = 18). Across all questions in the survey, more than 75% of the respondents perceived the highest level of care in trust, communication, relationship, and compassion with their provider. Participants perceived the highest level of care in trust (96%), explanation (88%), as well as care and understanding (89%). Conclusions: Family members of cardiac ICU patients positively rated the quality of communication and perceived a high level of trust and communication between their providers on the virtual format.
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Unidades de Terapia Intensiva , Visitas de Preceptoria , Humanos , Masculino , Feminino , Família/psicologia , Comunicação , Relações Profissional-FamíliaRESUMO
OBJECTIVE: The objective of this study was to identify undertreated subgroups of patients with heart failure who would benefit from better perioperative optimization. SUMMARY OF BACKGROUND DATA: Patients with heart failure have increased risks of postoperative cardiac complications after noncardiac surgery. METHODS: In this analysis of hospital registry data of 130,677 patients undergoing noncardiac surgery, the exposure was preoperative history of heart failure. The outcome, cardiac complications, was defined as a composite of myocardial infarction, cardiac arrest, acute heart failure, and mortality within 30 postoperative days. RESULTS: History of heart failure (n = 10,256; 7.9%) was associated with increased risk of cardiac complications [8.1% vs 1.1%; adjusted odds ratio, 2.28 (95% CI, 2.02-2.56); P < 0.001). Patients with heart failure and who carried a lower risk profile had increased risks of postoperative cardiac complications secondary to heart failure [adjusted absolute risk difference, 1.7% (95% CI, 1.4%-2.0%, lower risk); P < 0.001 vs 0.5% (95% CI, -0.6% to 1.6%, higher risk); P = 0.38]. Patients with heart failure and lower risk received a lower level of health care utilization preoperatively, and less frequently received anti-heart failure medications (59% vs 72% and 61% vs 82%; both P < 0.001). These preventive therapies significantly decreased the risk of cardiac complications in patients with heart failure. CONCLUSIONS: In patients with heart failure who have a lower preoperative risk profile, clinicians often make insufficient attempts to optimize their clinical condition preoperatively. Preoperative preventive treatment reduces the risk of postoperative cardiac complications in these lower-risk patients with heart failure.
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Cardiopatias , Insuficiência Cardíaca , Infarto do Miocárdio , Humanos , Estudos Retrospectivos , Complicações Pós-Operatórias , Fatores de RiscoRESUMO
OBJECTIVES: In acute pulmonary embolism (PE), the right ventricle (RV) may dilate compromising left ventricular (LV) size, thereby increasing RV/LV ratio. End-diastolic RV/LV ratio is often used in PE risk stratification, though the cause of death is RV systolic failure. We aimed to confirm our pre-clinical observations of higher RV/LV ratio in systole compared to diastole in human patients with PE. METHODS: We blinded and independently analyzed echocardiograms from 606 patients with PE, evaluated by a Pulmonary Embolism Response Team. We measured RV/LV ratios in end-systole and end-diastole and fractional area change (FAC). Our primary outcome was a composite of 7-day clinical deterioration, treatment escalation or death. Secondary outcomes were 7-day and 30-day all-cause mortality. RESULTS: RV/LV ratio was higher in systole compared to diastole (median 1.010 [.812-1.256] vs. .975 [.843-1.149], p < .0001). RV/LV in systole and diastole were correlated (slope = 1.30 [95% CI 1.25-1.35], p < .0001 vs. slope = 1). RV/LV ratios in both systole and diastole were associated with the primary composite outcome but not with all-cause mortality. CONCLUSION: The RV/LV ratio is higher when measured in systole versus in diastole in patients with acute PE. The two approaches had similar associations with clinical outcomes, that is, it appears reasonable to measure RV/LV ratio in diastole.
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Insuficiência Cardíaca , Embolia Pulmonar , Humanos , Ventrículos do Coração/diagnóstico por imagem , Diástole , Sístole , Embolia Pulmonar/diagnóstico por imagem , Ecocardiografia , Doença AgudaRESUMO
Human infection by the novel viral pathogen SARS-CoV-2 results in a clinical syndrome termed Coronavirus Disease 2019 (COVID-19). Although the majority of COVID-19 cases are self-limiting, a substantial minority of patients develop disease severe enough to require intensive care. Features of critical illness associated with COVID-19 include hypoxemic respiratory failure, acute respiratory distress syndrome (ARDS), shock, and multiple organ dysfunction syndrome (MODS). In most (but not all) respects critically ill patients with COVID-19 resemble critically ill patients with ARDS due to other causes and are optimally managed with standard, evidence-based critical care protocols. However, there is naturally an intense interest in developing specific therapies for severe COVID-19. Here we synthesize the rapidly expanding literature around the pathophysiology, clinical presentation, and management of COVID-19 with a focus on those points most relevant for intensivists tasked with caring for these patients. We specifically highlight evidence-based approaches that we believe should guide the identification, triage, respiratory support, and general ICU care of critically ill patients infected with SARS-CoV-2. In addition, in light of the pressing need and growing enthusiasm for targeted COVID-19 therapies, we review the biological basis, plausibility, and clinical evidence underlying these novel treatment approaches.
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COVID-19/terapia , Cuidados Críticos/métodos , Estado Terminal/terapia , Adulto , COVID-19/complicações , COVID-19/fisiopatologia , Prática Clínica Baseada em Evidências/métodos , Humanos , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/terapiaRESUMO
Staphylococcus aureus prosthetic valve endocarditis (PVE) remains among the most morbid bacterial infections, with mortality estimates ranging from 40% to 80%. The proportion of PVE cases due to methicillin-resistant Staphylococcus aureus (MRSA) has grown in recent decades, to account for more than 15% of cases of S. aureus PVE and 6% of all cases of PVE. Because no large studies or clinical trials for PVE have been published, most guidelines on the diagnosis and management of MRSA PVE rely upon expert opinion and data from animal models or related conditions (e.g., coagulase-negative Staphylococcus infection). We performed a review of the literature on MRSA PVE to summarize data on pathogenic mechanisms and updates in epidemiology and therapeutic management and to inform diagnostic strategies and priority areas where additional clinical and laboratory data will be particularly useful to guide therapy. Major updates discussed in this review include novel diagnostics, indications for surgical management, the utility of aminoglycosides in medical therapy, and a review of newer antistaphylococcal agents used for the management of MRSA PVE.
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Endocardite Bacteriana/epidemiologia , Próteses Valvulares Cardíacas/microbiologia , Staphylococcus aureus Resistente à Meticilina/isolamento & purificação , Infecções Relacionadas à Prótese/epidemiologia , Infecções Estafilocócicas/epidemiologia , Antibacterianos/uso terapêutico , Gerenciamento Clínico , Sinergismo Farmacológico , Quimioterapia Combinada , Diagnóstico Precoce , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/tratamento farmacológico , Endocardite Bacteriana/microbiologia , Humanos , Staphylococcus aureus Resistente à Meticilina/efeitos dos fármacos , Infecções Relacionadas à Prótese/diagnóstico , Infecções Relacionadas à Prótese/tratamento farmacológico , Infecções Estafilocócicas/diagnóstico , Infecções Estafilocócicas/tratamento farmacológicoAssuntos
Síndrome de Ehlers-Danlos/diagnóstico , Dissecção Aórtica/etiologia , Anti-Hipertensivos/uso terapêutico , Infarto Cerebral/etiologia , Colágeno Tipo III/genética , Angiografia por Tomografia Computadorizada , Diagnóstico Diferencial , Síndrome de Ehlers-Danlos/complicações , Síndrome de Ehlers-Danlos/genética , Síndrome de Ehlers-Danlos/terapia , Cefaleia/etiologia , Humanos , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Mutação , Cervicalgia/etiologiaRESUMO
BACKGROUND: Appropriate use criteria (AUC) represent an important mechanism by which to promote the rational utilization of healthcare resources. No study to date has been conducted assessing the applicability of current AUC to transthoracic echocardiograms (TTEs) performed in a cardiac intensive care unit (CICU). We analyzed 2 years of consecutive TTEs performed in a CICU at a quaternary-care academic medical center, hypothesizing that current AUC may not adequately describe the role of TTE in a modern CICU. METHODS: Indications for TTEs were independently classified by two investigators in accordance with 2011 AUC. If investigators were unable to assign an AUC classification to a given study, it was deemed to be unclassifiable. Disagreements between investigators were resolved by consensus. Cases in which consensus could not be reached underwent definitive adjudication by a third investigator. RESULTS: Of the 826 TTEs, 619 TTEs were classified as appropriate (74.9%, CI 71.8%-77.9%), 12 as uncertain (1.5%, CI 0.75%-2.5%), 21 as rarely appropriate (2.5%, CI 1.6%-3.9%), and 174 were unable to be classified (21.1%, CI 18.3%-24.0%). The most common unclassifiable indication was "initial evaluation of cardiac structure or function after cardiac arrest of unknown etiology" (n = 101). CONCLUSION: Current AUC for TTEs may not adequately address the complexity of clinical cases encountered in the CICU. In our study of 826 consecutive TTEs, 21.1% were unable to be classified, reflecting the difficulty in applying AUC to this unique clinical environment. Further studies are therefore needed to better delineate the appropriateness of TTEs performed in the CICU.
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Cuidados Críticos/métodos , Cuidados Críticos/estatística & dados numéricos , Ecocardiografia/métodos , Ecocardiografia/estatística & dados numéricos , Fidelidade a Diretrizes/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Centros Médicos Acadêmicos , Idoso , Cardiologia/métodos , Cardiologia/estatística & dados numéricos , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Estudos RetrospectivosAssuntos
Betacoronavirus , Infecções por Coronavirus/diagnóstico , Pericardite/etiologia , Pneumonia Viral/diagnóstico , Síndrome do Desconforto Respiratório/etiologia , Insuficiência Respiratória/etiologia , Idoso , Fibrilação Atrial/etiologia , COVID-19 , Teste para COVID-19 , Técnicas de Laboratório Clínico , Angiografia Coronária , Infecções por Coronavirus/complicações , Diagnóstico Diferencial , Eletrocardiografia , Humanos , Hipóxia/etiologia , Pulmão/diagnóstico por imagem , Masculino , Pandemias , Pericardite/diagnóstico , Pneumonia Viral/complicações , SARS-CoV-2 , Tomografia Computadorizada por Raios X , Troponina T/sangueAssuntos
Neoplasias de Cabeça e Pescoço/secundário , Pescoço/diagnóstico por imagem , Teratoma/diagnóstico , Adulto , Assistência ao Convalescente , Desfibriladores Implantáveis , Diagnóstico Diferencial , Edema/etiologia , Neoplasias de Cabeça e Pescoço/complicações , Neoplasias de Cabeça e Pescoço/diagnóstico , Neoplasias de Cabeça e Pescoço/patologia , Humanos , Masculino , Cervicalgia/etiologia , Radiografia Torácica , Teratoma/complicações , Teratoma/patologia , Teratoma/secundário , Neoplasias Testiculares/terapia , Tomografia Computadorizada por Raios X , Ultrassonografia , Conduta ExpectanteRESUMO
A 31-year-old woman with substance-use disorder was admitted to this hospital because of fevers and chest pain. CT of the chest revealed multiple thick-walled nodular opacities throughout both lungs. Diagnostic tests were performed, and management decisions were made.
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Endocardite Bacteriana/diagnóstico por imagem , Doenças das Valvas Cardíacas/diagnóstico por imagem , Dependência de Heroína/complicações , Abuso de Substâncias por Via Intravenosa/complicações , Valva Tricúspide/diagnóstico por imagem , Adulto , Dor no Peito/etiologia , Diagnóstico Diferencial , Dispneia/etiologia , Ecocardiografia Doppler em Cores , Ecocardiografia Transesofagiana , Endocardite Bacteriana/complicações , Feminino , Febre/etiologia , Doenças das Valvas Cardíacas/complicações , Hepatite C/complicações , Dependência de Heroína/tratamento farmacológico , Dependência de Heroína/reabilitação , Humanos , Pulmão/diagnóstico por imagem , Pulmão/patologia , Relações Médico-Paciente , Embolia Pulmonar/diagnóstico , Radiografia , Abuso de Substâncias por Via Intravenosa/reabilitaçãoAssuntos
Pneumopatias Parasitárias/diagnóstico , Pulmão/diagnóstico por imagem , Eosinofilia Pulmonar/diagnóstico , Animais , Cardiomiopatia Hipertrófica Familiar/complicações , Tosse/etiologia , Diagnóstico Diferencial , Eletrocardiografia , Filariose Linfática/diagnóstico , Eosinofilia/diagnóstico , Humanos , Pneumopatias Fúngicas/diagnóstico , Pneumopatias Parasitárias/complicações , Masculino , Microfilárias , Pessoa de Meia-Idade , Eosinofilia Pulmonar/complicações , Radiografia Torácica , Avaliação de SintomasRESUMO
OBJECTIVES: Evaluate the characteristics of U.S. physicians who are board certified in cardiology and critical care medicine ("dual-boarded cardiologists"). DESIGN: Retrospective cross-sectional study using a comprehensive database of licensed U.S. physicians linked to Medicare claims. SETTING: The United States. SUBJECTS: Dual-boarded cardiologists. MEASUREMENTS AND MAIN RESULTS: We used a comprehensive physician database to identify all physicians who were board certified in cardiology and critical care medicine before July 2015. We assessed physicians' characteristics and compared dual-boarded cardiologists with and without active board certification in critical care medicine and estimated the maximum proportion of 2014 Medicare Cardiac ICU admissions treated by dual-boarded cardiologists. Among 473 dual-boarded cardiologists, 16 (3.4%) were women; 468 (99%) and 85 (18%) maintained active board certification in cardiology and critical care medicine, respectively. Overall, 98 dual-boarded cardiologists (21%) submitted 1,215 total claims for critical care services in 2014. Compared to dual-boarded cardiologists without active board certification in critical care medicine, those with active certification had more publications (median publications: 6.5 vs 3.0; p = 0.002), were more likely to be professors (22.3% vs 9.5%; p = 0.003), and were more likely to bill Medicare for critical care services (29% vs 17.8%; p = 0.002). We estimated that no more than 0.47% of all 2014 Medicare Cardiac ICU admissions were treated by a dual-boarded cardiologist. CONCLUSIONS: Dual-boarded cardiologists appear to deliver a small proportion of all Cardiac ICU services received by Medicare beneficiaries. Optimizing the modern Cardiac ICU workforce will require greater efforts to promote and support the training of dual-boarded cardiologists.