Evaluation of prognostic scale Thrombolysis In Myocardial Infarction and Killip. An ST-elevation myocardial infarction new scale.

BACKGROUND: Prognostic systems are complex. So it is necessary to find tools, which are easy to use and have good calibration and discrimination. OBJECTIVES: The objective of this study is to evaluate the usefulness of Killip, Thrombolysis In Myocardial Infarction (TIMI), and age to develop a new prognostic scale for patients with ST-elevation myocardial infarction (STEMI). METHODS: The study population included all patients with STEMI consecutively admitted to the Intensive Care Unit of Carlos Haya Hospital, Malaga, Spain. Top variables included are Killip and TIMI, hospital mortality, intensive care unit stay, treatment received, and care times intervals. RESULTS: The results are 806 patients; 75.6% men; age 63.11 ± 12.83 years old; TIMI, 3.57 ± 2.38; Killip I, 81.4%; and hospital mortality, 11.3%. Mortality increased in relation to age, TIMI, and Killip (P < .001). Receiver operating characteristic (ROC) area for TIMI is 0.832 (0.786-0.878) and Killip, 0.757 (0.698-0.822). Thrombolysis In Myocardial Infarction classification was associated with Killip and age by multiple linear regression. Patients were stratified into 5 groups according to Killip and age: Killip I and younger than 65 years (n = 369; mortality, 1.4%; odds ratio [OR], 1), Killip I and 65 to 75 years old (n = 173; mortality, 6.9%; OR, 5.43 [1.88-15.66]), Killip I and older than 75 years (n = 112; mortality, 18.9%; OR, 13.03 [4.69-36.21]), Killip II to III (n = 129; mortality, 31%; OR, 22.72 [12.55-85.29]), Killip IV (n = 20; mortality, 80%; OR, 291.2 [71.32-1189]). ROC area is 0.84 (0.798-0.883). We created a scale with scores based on the ß coefficient of logistical regression. CONCLUSIONS: The TIMI scale discriminated hospital mortality correctly for STEMI. It performed better than Killip alone and similar to a simple model that included age and Killip. The 2-variable model consists of a simple scale with 5 categories.

Mechanical circulatory support in cardiogenic shock patients.

Cardiogenic shock (CS) is a highly complex clinical condition that requires a management strategy focused on early resolution of the underlying cause and the provision of circulatory support. In cases of refractory CS, mechanical circulatory support (MCS) is employed to replace the failed cardiocirculatory system, thereby preventing the development of multiorgan failure. There are various types of MCS, and patients with CS typically require devices that are either short-term (< 15 days) or intermediate-term (15-30 days). When choosing the device the underlying cause of CS, as well as the presence or absence of concomitant conditions such as failed ventricle, respiratory failure, and the intended purpose of the support should be taken into consideration. Patients with MCS require the comprehensive care indicated in complex critically ill patients with multiorgan dysfunction, with an emphasis on device monitoring and control. Different complications may arise during support management, and its withdrawal must be protocolized.

Role of ultrasound in the critical ill patient with ECMO.

Ultrasound is an essential diagnostic tool in critically ill patients with extracorporeal membrane oxygenation (ECMO). With it, we can make an anatomical and functional (cardiac, pulmonary and vascular) evaluation which allows us to execute an adequate configuration, guides implantation, helps clinical monitorization and detects complications, facilitates withdrawal and complete post-implant evaluation. In patients with ECMO as respiratory support (veno-venous), thoracic ultrasound allows monitoring pulmonary illness evolution and echocardiography the evaluation of biventricular function, especially right ventricle function, and cardiac output to optimize oxygen transport. In ECMO as circulatory support (veno-arterial), echocardiography is the guide of hemodynamic monitoring, allows detecting the most frequent complications and helps the weaning. In ECMO teams, for a proper management of these patients, there must be trained intensivists with advanced knowledge on this technique.

Papel de la ecografía en el paciente crítico con ECMO / Role of ultrasound in the critical ill patient with ECMO

La ecografía es un instrumento diagnóstico fundamental en el paciente crítico con membrana de oxigenación extracorpórea (ECMO). Con ella podemos hacer una evaluación anatómica y funcional (cardiaca, pulmonar y vascular) para plantear una adecuada configuración; además, guía su implante, ayuda en la monitorización clínica y la detección de complicaciones, facilita su retirada y completa la evaluación postimplante. En los pacientes con ECMO como soporte respiratorio (veno-venosa), la ecografía torácica permite monitorizar la evolución de la enfermedad pulmonar y la ecocardiografía la evaluación de la función biventricular, especialmente la derecha, y el gasto cardiaco para optimizar el transporte de oxígeno. En la ECMO como soporte circulatorio (veno-arterial), la ecocardiografía supone la guía de la monitorización hemodinámica, permite detectar las principales complicaciones y ayuda al destete del dispositivo. En los equipos ECMO, para un adecuado manejo de estos pacientes, debe haber intensivistas entrenados y con conocimientos avanzados sobre esta técnica. (AU)

Ultrasound is an essential diagnostic tool in critically ill patients with extracorporeal membrane oxygenation (ECMO). With it, we can make an anatomical and functional (cardiac, pulmonary and vascular) evaluation which allows us to execute an adequate configuration, guides implantation, helps clinical monitorization and detects complications, facilitates withdrawal and complete post-implant evaluation. In patients with ECMO as respiratory support (veno-venous), thoracic ultrasound allows monitoring pulmonary illness evolution and echocardiography the evaluation of biventricular function, especially right ventricle function, and cardiac output to optimize oxygen transport. In ECMO as circulatory support (veno-arterial), echocardiography is the guide of hemodynamic monitoring, allows detecting the most frequent complications and helps the weaning. In ECMO teams, for a proper management of these patients, there must be trained intensivists with advanced knowledge on this technique. (AU)

APACHE-II score and Killip class for patients with acute myocardial infarction.

OBJECTIVE: To analyse the influence on the prognosis of intensive care unit (ICU) patients with acute myocardial infarction (AMI): prognostic index score, Killip class, AMI site, thrombolysis and other variables that might improve prognostic capacity and functioning of the APACHE-II index. DESIGN: Cohort study using prospectively gathered ARIAM project data. SETTING: ICUs from 129 Spanish hospitals. PATIENTS: ICU-admitted AMI patients in ARIAM database during 4-year period were retrospectively studied. MEASUREMENTS AND MAIN RESULTS: The sample comprised 6,458 patients, 76.8% males, age 64.97 +/- 12.56 years, APACHE-II score 9.49 +/- 7.03 points and ICU mortality 8.9%. Mortality was higher for females (p < 0.001), anterior AMI site (p < 0.001), previous AMI (p < 0.001), delay-to-hospital arrival >180 min (p = 0.003) and non-receipt of thrombolysis (p = 0.015). ICU mortality was related to age (p < 0.001) and APACHE-II score (p < 0.001). In multivariate analysis, it was related to APACHE-II (OR 1.16), age (OR 1.05), gender (OR 1.64), previous AMI (OR 1.57), anterior AMI (OR 2.05) and delay >180 min (OR 1.37). Killip class, gathered in 1,893 patients, was significantly associated with ICU mortality, and two predictive models were constructed for this group using multivariate analysis. Area under ROC curve was 0.94 in one (Killip class, age, gender, APACHE-II) versus 0.92 in the other (same variables without APACHE-II). CONCLUSIONS: APACHE-II score and Killip class are useful for assessing the severity of patients with AMI and are complementary. Each can be used with a few commonly gathered clinical variables to construct prognostic models to assess severity. Their joint application yields a model with excellent discrimination capacity.