A Comparison of Long-Term Outcomes in Patients Managed With Venovenous Extracorporeal Membrane Oxygenation in the First and Second Waves of the COVID-19 Pandemic in the United Kingdom.

OBJECTIVES: Early studies of venovenous extracorporeal membrane oxygenation (ECMO) in COVID-19 have revealed similar outcomes to historical cohorts. Changes in the disease and treatments have led to differences in the patients supported on venovenous ECMO in the first and second waves. We aimed to compare these two groups in both the acute and follow-up phase. DESIGN: Retrospective single-center cohort study comparing mortality at censoring date (November 30, 2021) and decannulation, patient characteristics, complications and lung function and quality of life (QOL-by European Quality of Life 5 Dimensions 3 Level Version) at first follow-up in patients supported on venovenous ECMO between wave 1 and wave 2 of the COVID-19 pandemic. SETTING: Critical care department of a severe acute respiratory failure service. PATIENTS: Patients supported on ECMO for COVID-19 between wave 1 (March 17, 2020, to August 31, 2020) and wave 2 (January 9, 2020, to May 25, 2021). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: One hundred twenty-three patients were included in our analysis. Survival at censoring date (χ 2 , 6.35; p = 0.012) and decannulation (90.4% vs 70.0%; p < 0.001) was significantly lower in the second wave, while duration of ECMO run was longer (12.0 d [18.0-30.0 d] vs 29.5 d [15.5-58.3 d]; p = 0.005). Wave 2 patients had longer application of noninvasive ventilation (NIV) prior to ECMO and a higher frequency of barotrauma. Patient age and NIV use were independently associated with increased mortality (odds ratio 1.07 [1.01-1.14]; p = 0.025 and 3.37 [1.12-12.60]; p = 0.043, respectively). QOL and lung function apart from transfer coefficient of carbon monoxide corrected for hemoglobin was similar at follow-up across the waves. CONCLUSIONS: Most patients with COVID-19 supported on ECMO in both waves survived in the short and longer term. At follow-up patients had similar lung function and QOL across the two waves. This suggests that ECMO has an ongoing role in the management of a carefully selected group of patients with COVID-19.

General anesthesia versus sedation for implantation of a biventricular pacing device for cardiac resynchronization therapy.

OBJECTIVE: Heart failure carries significant risk for major noncardiac surgery. Whether this risk is transferable to minor surgery is less well-documented. Thus, the aim of this study was to assess the outcome of a contemporary cohort of heart failure patients undergoing cardiac resynchronization therapy (CRT) device insertion under general anesthesia or sedation. DESIGN: Retrospective observational study. SETTING: Tertiary cardiac specialist hospital. PARTICIPANTS: Heart failure patients. INTERVENTIONS: CRT insertion under general anesthesia or sedation. MEASUREMENTS AND MAIN RESULTS: Anesthesia, heart failure, and outcome data were collected on a consecutive series of patients having CRT device insertion between 2002 and 2010. A total of 242 patients were managed by the anesthesia department during the study period. After exclusion criteria were applied, data for 183 patients were analyzed. Immediate perioperative (<24 hours) mortality was zero; 30-day mortality of 138 patients was 2.2%. One patient (0.5%) required unplanned intensive care admission. A comparison was made between the sedation (n = 76) group and the general anesthesia (GA) group (n = 107). When compared with the sedation group, the GA group had more intraoperative hypotension (26.2% versus 4.0%, p<0.00001). There was no difference between the GA and sedation groups with regard to 30-day mortality (1.4% versus 3.1%, p = 0.57), unplanned intensive care admission (0% versus 1.3%, p = 0.42), and length of stay in days (3 versus 3, p = 0.82). CONCLUSION: The authors found that patients with heart failure undergoing CRT insertion with concurrent general anesthesia or sedation had minimal immediate perioperative risk and that there was no difference in postoperative outcome between general anesthesia and sedation.

Factors associated with long-term outcomes in adult congenital heart disease patients with infective endocarditis: a 16-year tertiary single-centre experience.

OBJECTIVES: Studies concerning factors associated with long-term outcomes in adult congenital heart disease (ACHD) patients after infective endocarditis (IE) are scarce, while IE-related mortality in these patients remains a burden. We evaluated the factors associated with long-term survival in ACHD patients admitted for IE. METHODS: We performed a retrospective single-centre study of all ACHD patients admitted for IE to a tertiary cardiothoracic centre between 1999 and 2015. Underlying ACHD, detailed echocardiographic and clinical data, surgical treatment and long-term follow-up were analysed. RESULTS: We identified 151 ACHD patients admitted due to 176 episodes IE with 30-day, 6-month and 1-, 5- and 10-year survival of 95.4%, 92.7%, 92.7%, 84.7% and 75.6%, respectively. In a multivariable analysis, adjusted estimated probability of death was consistently higher after an IE episode among patients with complex as compared to simple/moderate ACHD: 10.6% vs 2.4% at 30 days, 15.0% vs 3.4% at 6 months and 1 year, 30.4% vs 7.8% at 5 years and 44.9% vs 13.1% at 10 years. Risk of death was higher among patients with prosthetic valve in comparison with those without (risk ratios 1.73-1.92). Surgical treatment was required in 76 (43.2%) episodes with 30-day mortality of 3.9%. Risk of death appeared to be lower than in the conservatively treated subgroup (risk ratios 0.71-0.78). CONCLUSIONS: We demonstrated satisfactory long-term survival in ACHD patients who were treated for IE in a tertiary cardiothoracic centre. Early mortality tended to be lower in the surgically treated subgroup. Factors negatively associated with long-term survival were complex ACHD and presence of prosthetic valve.

Adult congenital heart disease: intensive care management and outcome prediction.

OBJECTIVE: Improved patient survival and increasingly complex surgery have expanded the requirement for specialist care for patients with adult congenital heart disease (ACHD). Despite the recent publications of management guidelines for ACHD, data concerning optimal patterns of care in the peri-operative/critical care period of this challenging population are sparse. The aims of the current study were to therefore to determine the pattern of intensive care unit (ICU) management, resource utilisation and predictors of mortality in critically ill ACHD patients. DESIGN, SETTING AND PATIENTS: Data were collected prospectively for patients with ACHD stratified for complexity of disease admitted to the ICU of a tertiary cardiothoracic centre (1997-2002). Multivariate analysis of pre-operative indices as predictors of mortality was performed. Of 342 ACHD admissions (total mortality 4.4%, simple 0%, moderate/complex 10.6%), the requirement for specialist investigations and interventions was high, reflected in ICU admission costs per patient (simple $5391+/-130, moderate $13218+/-261, complex $30074+/-689). Standard severity of illness scoring systems did not accurately predict mortality; however, abnormal pre-operative thyroid function (p=0.0048), creatinine (p=0.0032) and bilirubin (p=0.0021) were highly predictive of mortality. CONCLUSIONS: Peri-operative mortality in patients with ACHD is low overall but varies with disease complexity. Such patients have a high requirement for specialist ICU investigation/intervention. Although standard severity of illness scoring is unhelpful, simple pre-operative parameters may predict peri-operative mortality. These findings reflect the requirement for specialist care, and have implications for planning service provision, training and operative consent in ACHD patients.

Attenuation of nerve growth factor-induced visceral hyperalgesia via cannabinoid CB(1) and CB(2)-like receptors.

Cannabinoids have previously been shown to possess analgesic properties in a model of visceral hyperalgesia in which the neurotrophin, nerve growth factor (NGF), plays a pivotal role. The purpose of this study was to investigate the antihyperalgesic effects of two cannabinoids in NGF-evoked visceral hyperalgesia in order to test the hypothesis that endocannabinoids may modulate the NGF-driven elements of inflammatory hyperalgesia. Intra-vesical installation of NGF replicates many features of visceral hyperalgesia, including a bladder hyper-reflexia and increased expression of the immediate early gene c fos in the spinal cord. We investigated the action of anandamide and palmitoylethanolamide (PEA) on these parameters. Both anandamide (at a dose of 25 mg/kg) and PEA (at a dose of 2.5 mg/kg) attenuated the bladder hyper-reflexia induced by intra-vesical NGF. The use of cannabinoid CB1 receptor (SR141617A) and CB2 receptor (SR144528) antagonists suggested that the effect of anandamide was mediated by both CB1 and CB2 cannabinoid receptors whilst the action of PEA was via CB2 (or CB2-like) receptors only. Furthermore, anandamide (25 mg/kg) and PEA (2.5 mg/kg) reduced intra-vesical NGF-evoked spinal cord Fos expression at the appropriate level (L6) by 35 and 43%, respectively. However, neither CB1 nor CB2 receptor antagonists altered the action of anandamide. PEA-induced reduction in Fos expression was abrogated by SR144528. These data add to the growing evidence of a therapeutic potential for cannabinoids, and support the hypothesis that the endogenous cannabinoid system modulates the NGF-mediated components of inflammatory processes.

Arvanil-induced inhibition of spasticity and persistent pain: evidence for therapeutic sites of action different from the vanilloid VR1 receptor and cannabinoid CB(1)/CB(2) receptors.

Activation of cannabinoid receptors causes inhibition of spasticity, in a mouse model of multiple sclerosis, and of persistent pain, in the rat formalin test. The endocannabinoid anandamide inhibits spasticity and persistent pain. It not only binds to cannabinoid receptors but is also a full agonist at vanilloid receptors of type 1 (VR1). We found here that vanilloid VR1 receptor agonists (capsaicin and N-N'-(3-methoxy-4-aminoethoxy-benzyl)-(4-tert-butyl-benzyl)-urea [SDZ-249-665]) exhibit a small, albeit significant, inhibition of spasticity that can be attenuated by the vanilloid VR1 receptor antagonist, capsazepine. Arvanil, a structural "hybrid" between capsaicin and anandamide, was a potent inhibitor of spasticity at doses (e.g. 0.01 mg/kg i.v.) where capsaicin and cannabinoid CB(1) receptor agonists were ineffective. The anti-spastic effect of arvanil was unchanged in cannabinoid CB(1) receptor gene-deficient mice or in wildtype mice in the presence of both cannabinoid and vanilloid receptor antagonists. Likewise, arvanil (0.1-0.25 mg/kg) exhibited a potent analgesic effect in the formalin test, which was not reversed by cannabinoid and vanilloid receptor antagonists. These findings suggest that activation by arvanil of sites of action different from cannabinoid CB(1)/CB(2) receptors and vanilloid VR1 receptors leads to anti-spastic/analgesic effects that might be exploited therapeutically.

'Tamponade' following cardiac surgery: terminology and echocardiography may both mislead.

OBJECTIVE: Echocardiography is widely considered the gold standard for the diagnosis of tamponade. While a relatively common complication of cardiac surgery in adults, determining whether haemodynamics are compromised by a pericardial collection early post-operatively can be difficult. The aim of the current study was to determine the nature and magnitude of the diagnostic challenge posed by cardiac tamponade following cardiac surgery. We therefore examined the accuracy of echocardiography in the diagnosis of tamponade in this patient group. METHODS: From January 2000 to January 2002, 2297 adult patients underwent cardiac surgery in a tertiary referral cardiothoracic centre. A retrospective analysis of prospectively collected data, from all patients diagnosed with post-operative bleeding and/or tamponade was performed. Data included demographics, surgery, anticoagulation/anti-platelet medication, clinical/echocardiographic features of tamponade and surgical findings at re-exploration. RESULTS: The diagnosis of 'tamponade' was confirmed at re-exploration in 148 patients. When it occurred early (<72 h) following cardiac surgery trans-thoracic echocardiography failed to visualise the majority of collections (60%), necessitating trans-esophageal echocardiography. Effusions were small (160+/-17 ml) and localised (92%), showing no echocardiographic features of classical tamponade (79%). Where patients developed tamponade late (>72 h) following cardiac surgery, clinical features were atypical, effusions larger (640+/-71 ml, P<0.0001)) and global (77%). Classical echocardiographic features of tamponade were usually present (70%) and readily visualised using trans-thoracic echocardiography. CONCLUSIONS: Haemodynamically significant pericardial collections occurring early following cardiac surgery rarely cause classical clinical or echocardiographic features of tamponade. Recognition of this as a separate diagnostic entity is necessary to ensure appropriate surgical intervention is not delayed.

Using audit to improve provision of analgesia for insertion of permanent pacemakers in children.

Pain has an adverse effect on the patient experience in hospital. The authors' institution used audit to improve the use of analgesia in the paediatric population. The audit cycle was repeated five times. Using education and training the institution was able to improve analgesia provision. A significant reduction in the number of children receiving no analgesia was demonstrated. In addition no further adverse event forms were submitted. Using audit can be an effective way to improve delivery of quality care.

Ventilator management in the cardiac intensive care unit.

Patients admitted to the Cardiac Intensive Care Unit (CICU) are of increasing complexity and often require ventilatory support. A deep understanding of respiratory physiology and the interactions between the cardiovascular and respiratory systems is essential. Ventilatory support should be tailored to the specific patient condition, ensuring effective minute ventilation, reducing work of breathing and minimizing adverse hemodynamic effects. The weaning process can stress the cardiovascular system and cardiac failure is a common cause of failure to wean. Identification of patients likely to fail and prompt pre-emptive intervention is crucial for successful weaning and avoiding complications related to prolonged mechanical ventilation.

Recombinant human erythropoietin use in a critically ill Jehovah's witness after cardiac surgery.

UNLABELLED: Complex cardiac surgery often requires blood transfusion. Some patients refuse transfusion, even when it is potentially life-threatening to do so. Although recombinant human erythropoietin (rhEPO) has been used to reduce the need for blood transfusion, it has been considered ineffective in critically ill patients. The time course of hematological responses in a Jehovah's Witness patient with acute renal failure and severe cardiac disease suggests that a trial of rhEPO should be considered for salvage therapy in critically ill patients. IMPLICATIONS: The authors describe successful treatment of life-threatening anemia using recombinant human erythropoietin in a critically ill Jehovah's Witness patient after cardiac surgery.

Sedation, anaesthesia and monitoring for bronchoscopy.

Management of the airway for paediatric bronchoscopy requires joint planning and constant communication between the bronchoscopist and the anaesthetist. At all times maintenance of an effective airway must be the first priority. All sedative drugs compromise the patency of the airway to some extent in addition to effective ventilation by the patient. Thus, a specific individual must be dedicated to ensure adequacy of airway and ventilation throughout the procedure. Since sedation and anaesthesia are merely two points on a continuum of reduced central nervous system activation, an anaesthetist most appropriately performs this role. There is a range of drugs that may be utilised to induce sedation and a variety of airway adjuncts, which will be described. Any individual using them should be familiar with their advantages and disadvantages and be capable of managing any predictable or unusual complications.