RESUMEN
This article reviews noteworthy investigations and society recommendations published in 2023 relevant to the care of critically ill cardiothoracic surgical patients. We reviewed 3,214 articles to identify 18 publications that add to the existing literature across a variety of topics including resuscitation, nutrition, antibiotic management, extracorporeal membrane oxygenation (ECMO), neurologic care following cardiac arrest, coagulopathy and transfusion, steroids in pulmonary infections, and updated guidelines in the management of acute respiratory distress syndrome (ARDS).
Asunto(s)
Cuidados Críticos , Oxigenación por Membrana Extracorpórea , Humanos , Cuidados Críticos/métodos , Oxigenación por Membrana Extracorpórea/métodos , Enfermedad Crítica , Síndrome de Dificultad Respiratoria/terapia , Procedimientos Quirúrgicos Cardíacos/métodosRESUMEN
Since their initial approval by the Food and Drug Administration in 2016, leadless pacemakers have become increasingly prevalent. This growth has been driven by an improved adverse effect profile when compared to traditional pacemakers, including lower rates of infection, as well as eliminated risk of pocket hematoma and lead complications. More recently, technology enabling leadless synchronized atrioventricular pacing in patients with atrioventricular block has vastly expanded the indications for these devices. Anesthesiologists will increasingly be relied upon to safely care for patients with leadless pacemakers undergoing non-electrophysiology procedures and surgery. This article provides an overview of the technology, evidence base, current indications, and unique perioperative considerations for leadless pacemakers.
Asunto(s)
Marcapaso Artificial , Humanos , Marcapaso Artificial/efectos adversos , Estimulación Cardíaca Artificial/efectos adversos , Estimulación Cardíaca Artificial/métodos , Arritmias Cardíacas/terapia , Arritmias Cardíacas/etiología , Diseño de EquipoRESUMEN
The past year in critical care medicine was notable for ongoing sequelae of the COVID-19 pandemic, including nationwide shortages and critical care demand in many regions in excess of usual operating capacity. Despite these challenges, evidence-based medicine and investigations into the optimal management of the critically ill continued to be at the forefront. This article is a collection of studies published in 2022 which are specifically relevant to cardiothoracic critical care. These noteworthy publications add to the existing literature across a broad spectrum of topics, from optimal timing of mechanical circulatory support (MCS), delirium prevention, updates in nutrition guidelines, alternative defibrillation techniques, novel ventilator management, and observing the downstream psychological impact of extracorporeal membrane oxygenation (ECMO) therapy.
Asunto(s)
COVID-19 , Oxigenación por Membrana Extracorpórea , Humanos , Pandemias , COVID-19/terapia , Cuidados Críticos/métodos , Oxigenación por Membrana Extracorpórea/métodos , Progresión de la Enfermedad , Enfermedad Crítica/terapiaRESUMEN
This year marked a number of milestones in critical care. As vaccines for the SARS-CoV-2 virus became widely available and were confirmed to be exceptionally effective against severe illness and hospitalization, we were then faced with new variants and the resource-intense responses necessary to combat them. Despite challenges new and old, we have persevered and continued to provide excellent care to our patients while pushing the boundaries of clinical research. This article is a collection of studies published in 2021 relevant to critical care, with a specific focus on cardiothoracic critical care. To ignore the impact of the COVID-19 pandemic would do a disservice to our colleagues, many of whom have made incredible breakthroughs in novel therapies to the coronavirus, and yet we present additional themes of delirium, acute kidney injury, lung transplant, advances in ECMO as well as biomarkers of sepsis.
Asunto(s)
COVID-19 , Pandemias , COVID-19/terapia , Vacunas contra la COVID-19 , Cuidados Críticos , Humanos , SARS-CoV-2Asunto(s)
Oxigenación por Membrana Extracorpórea , Síndrome de Dificultad Respiratoria , Oxigenación por Membrana Extracorpórea/efectos adversos , Humanos , Hipoxia/diagnóstico , Hipoxia/etiología , Hipoxia/terapia , Síndrome de Dificultad Respiratoria/etiología , Síndrome de Dificultad Respiratoria/terapiaRESUMEN
This year will be forever marked by the drastic changes COVID-19 wrought on our personal and professional lives. New roles and challenges in critical care have forced us to be constantly nimble and flexible in how we approach medicine. The strain of these challenges is apparent throughout the health care community and our society as a whole. Despite this adversity, 2020 will also be remembered for fantastic advances in research. This article is a collection of influential and exciting studies published in 2020 encompassing a broad swath of critical care with a focus on cardiothoracic critical care. Themes include examinations of early extracorporeal membrane oxygenation support for out-of-hospital cardiac arrest patients, the impact of sedation and other risk factors on perioperative mortality, a novel fluid resuscitation strategy following cardiac surgery, and advances in the fields of heart and lung transplantation as well as how they were affected by COVID-19. Given that many cardiothoracic intensivists were redeployed to the care of SARS-CoV-2 patients, we also discuss important advances in therapeutics for the virus.
Asunto(s)
COVID-19 , Procedimientos Quirúrgicos Cardíacos/métodos , Enfermedades Cardiovasculares/terapia , Cuidados Críticos/métodos , Oxigenación por Membrana Extracorpórea/métodos , Trasplante de Corazón , Humanos , Trasplante de Pulmón , Paro Cardíaco Extrahospitalario/terapia , Factores de RiesgoAsunto(s)
Betacoronavirus , Enfermedades Cardiovasculares , Infecciones por Coronavirus , Pandemias , Neumonía Viral , COVID-19 , Humanos , SARS-CoV-2RESUMEN
Mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) is a fatal disorder characterized by progressive gastrointestinal dysmotility, peripheral neuropathy, leukoencephalopathy, skeletal myopathy, ophthalmoparesis, and ptosis. MNGIE stems from deficient thymidine phosphorylase activity (TP) leading to toxic elevations of plasma thymidine. Hematopoietic stem cell transplant (HSCT) restores TP activity and halts disease progression but has high transplant-related morbidity and mortality. Liver transplant (LT) was reported to restore TP activity in two adult MNGIE patients. We report successful LT in four additional MNGIE patients, including a pediatric patient. Our patients were diagnosed between ages 14 months and 36 years with elevated thymidine levels and biallelic pathogenic variants in TYMP. Two patients presented with progressive gastrointestinal dysmotility, and three demonstrated progressive peripheral neuropathy with two suffering limitations in ambulation. Two patients, including the child, had liver dysfunction and cirrhosis. Following LT, thymidine levels nearly normalized in all four patients and remained low for the duration of follow-up. Disease symptoms stabilized in all patients, with some manifesting improvements, including intestinal function. No patient died, and LT appeared to have a more favorable safety profile than HSCT, especially when liver disease is present. Follow-up studies will need to document the long-term impact of this new approach on disease outcome. Take Home Message: Liver transplantation is effective in stabilizing symptoms and nearly normalizing thymidine levels in patients with mitochondrial neurogastrointestinal encephalomyopathy (MNGIE) and may have an improved safety profile over hematopoietic stem cell transplant.
Asunto(s)
Trasplante de Hígado/métodos , Mitocondrias/metabolismo , Encefalomiopatías Mitocondriales/terapia , Timidina Fosforilasa/genética , Adolescente , Adulto , Trastornos de la Motilidad Esofágica/genética , Femenino , Trasplante de Células Madre Hematopoyéticas/mortalidad , Humanos , Lactante , Trasplante de Hígado/mortalidad , Imagen por Resonancia Magnética , Masculino , Mitocondrias/enzimología , Mitocondrias/patología , Encefalomiopatías Mitocondriales/diagnóstico por imagen , Encefalomiopatías Mitocondriales/genética , Encefalomiopatías Mitocondriales/fisiopatología , Enfermedades del Sistema Nervioso Periférico/genética , Timidina/sangre , Secuenciación del ExomaRESUMEN
Liver transplantation is a complex procedure performed on critically ill patients with multiple comorbidities, which requires the anesthesiologist to be facile with complex hemodynamics and physiology, vascular access procedures, and advanced monitoring. Over the past decade, there has been a continuing debate whether or not liver transplant anesthesia is a general or specialist practice. Yet, as significant data have come out in support of dedicated liver transplant anesthesia teams, there is not a guarantee of liver transplant exposure in domestic residencies. In addition, there are no standards for what competencies are required for an individual seeking fellowship training in liver transplant anesthesia. Using the Accreditation Council for Graduate Medical Education guidelines for residency training as a model, the Society for the Advancement of Transplant Anesthesia Fellowship Committee in conjunction with the Liver Transplant Anesthesia Fellowship Task Force has developed the first proposed standardized core competencies and milestones for fellowship training in liver transplant anesthesiology.
Asunto(s)
Anestesiólogos/educación , Anestesiología/educación , Becas/normas , Trasplante de Hígado/métodos , Acreditación , Anestesia/métodos , Anestesiólogos/normas , Anestesiología/normas , Competencia Clínica , Educación de Postgrado en Medicina/métodos , Humanos , Sociedades MédicasRESUMEN
A 40-year-old male with alcoholic cirrhosis and end-stage renal disease presented for simultaneous liver and kidney transplantation. Hemodialysis was utilized intraoperatively during liver transplantation. During the procedure, the patient developed refractory hypotension and ultimately received hydroxocobalamin for vasoplegia. Shortly after administration, the hemodialysis machine ceased working after a "blood leak" alarm developed. Without the ability to continue intraoperative dialysis, the kidney transplantation portion of his surgery was postponed. The patient was transferred to the intensive care unit, where he underwent continuous renal replacement therapy overnight, and his kidney transplant proceeded the following morning.
Asunto(s)
Hidroxocobalamina/administración & dosificación , Diálisis Renal , Vasoplejía/tratamiento farmacológico , Adulto , Humanos , Fallo Renal Crónico/cirugía , Trasplante de Riñón , Cirrosis Hepática Alcohólica/cirugía , Trasplante de Hígado , MasculinoRESUMEN
Postoperative pulmonary complications following cardiac and thoracic surgery are common and associated with significant morbidity and mortality. Noninvasive ventilation has emerged as a successful and well-validated strategy to treat various acute medical conditions. More recently, noninvasive ventilation has been studied in selective surgical patient populations with the goal of preventing postoperative complications and treating acute respiratory failure. In this clinical review, we will briefly examine the incidence of pulmonary complications following cardiothoracic surgery and the physiology and mechanics of acute respiratory failure and noninvasive ventilation. We then present a systematic review of the indications, patient selection, and current literature investigating the specific use of noninvasive ventilation in this population.