RESUMEN
Small, portable hand-held ultrasound devices nowadays enable a widespread use of prehospital point-of-care ultrasound (pPOCUS), which has so far only been used hesitantly, especially in ground-based emergency services. Many critical or even life-threatening conditions or internal injuries can often be better diagnosed or ruled out using pPOCUS, which can enable faster and more suitable goal-directed treatment and hospital transport. This article critically discusses relevant data, clinical benefits, limitations and challenges to be overcome when using pPOCUS for the most important life-threatening situations and aims to call for intensifying training and the extensive use of pPOCUS.
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Servicios Médicos de Urgencia , Medicina de Emergencia , Sistemas de Atención de Punto , Ultrasonografía , Humanos , Servicios Médicos de Urgencia/métodos , Ultrasonografía/métodos , Ultrasonografía/instrumentación , Medicina de Emergencia/educación , Medicina de Emergencia/métodosRESUMEN
Extracorporeal membrane oxygenation (ECMO) is often the last resort for escalation of treatment in patients with severe acute respiratory distress syndrome (ARDS). The success of treatment is mainly determined by patient-specific factors, such as age, comorbidities, duration and invasiveness of the pre-existing ventilation treatment as well as the expertise of the treating ECMO center. In particular, the adjustment of mechanical ventilation during ongoing ECMO treatment remains controversial. Although a reduction of invasiveness of mechanical ventilation seems to be reasonable due to physiological considerations, no improvement in outcome has been demonstrated so far for the use of ultraprotective ventilation regimens.
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Oxigenación por Membrana Extracorpórea , Respiración Artificial , Síndrome de Dificultad Respiratoria , Oxigenación por Membrana Extracorpórea/métodos , Síndrome de Dificultad Respiratoria/terapia , Humanos , Respiración Artificial/métodosRESUMEN
Both in-hospital and out-of-hospital cardiac arrests are associated with a high mortality. In the past survival advantages for patients could be achieved by optimizing the chain of rescue and postresuscitation treatment; however, for patients with refractory cardiac arrest, there have so far been few promising treatment options. For selected patients with refractory cardiac arrest who do not achieve return of spontaneous circulation with conventional cardiopulmonary resuscitation (CPR), extracorporeal (e)CPR using venoarterial extracorporeal membrane oxygenation is an option to improve the probability of survival. This article describes the technical features, important aspects of treatment, and the current data situation on eCPR in patients with in-hospital or out-of-hospital cardiac arrest.
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Reanimación Cardiopulmonar , Oxigenación por Membrana Extracorpórea , Paro Cardíaco , Paro Cardíaco Extrahospitalario , Humanos , Reanimación Cardiopulmonar/métodos , Oxigenación por Membrana Extracorpórea/métodos , Paro Cardíaco/terapia , Paro Cardíaco Extrahospitalario/terapia , Paro Cardíaco Extrahospitalario/mortalidad , Tasa de SupervivenciaRESUMEN
Critical care cardiology (CCC) in the modern era is shaped by a multitude of innovative treatment options and an increasingly complex, ageing patient population. Generating high-quality evidence for novel interventions and devices in an intensive care setting is exceptionally challenging. As a result, formulating the best possible therapeutic approach continues to rely predominantly on expert opinion and local standard operating procedures. Fostering the full potential of CCC and the maturation of the next generation of decision-makers in this field calls for an updated training concept, that encompasses the extensive knowledge and skills required to care for critically ill cardiac patients while remaining adaptable to the trainee's individual career planning and existing educational programs. In the present manuscript, we suggest a standardized training phase in preparation of the first ICU rotation, propose a modular CCC core curriculum, and outline how training components could be conceptualized within three sub-specialization tracks for aspiring cardiac intensivists.
RESUMEN
Both in-hospital and out-of-hospital cardiac arrests are associated with a high mortality. In the past survival advantages for patients could be achieved by optimizing the chain of rescue and postresuscitation treatment; however, for patients with refractory cardiac arrest, there have so far been few promising treatment options. For selected patients with refractory cardiac arrest who do not achieve return of spontaneous circulation with conventional cardiopulmonary resuscitation (CPR), extracorporeal (e)CPR using venoarterial extracorporeal membrane oxygenation is an option to improve the probability of survival. This article describes the technical features, important aspects of treatment, and the current data situation on eCPR in patients with in-hospital or out-of-hospital cardiac arrest.
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Reanimación Cardiopulmonar , Oxigenación por Membrana Extracorpórea , Paro Cardíaco Extrahospitalario , Humanos , Reanimación Cardiopulmonar/efectos adversos , Paro Cardíaco Extrahospitalario/terapia , HospitalesRESUMEN
Hemostatic disorders are common during extracorporeal membrane oxygenation (ECMO)-therapy. This includes both bleeding and thrombotic complications. Particularly bleeding is often associated with fatal outcome. The early identification of hemorrhagic diathesis and the diagnosis of the underlying pathology are essential. A distinction into device-, disease-, and drug-related disorders appears reasonable. However, both correct diagnosis and therapy can be challenging and sometimes counterintuitive. Since bleeding seems to be more frequent and dangerous compared to thrombosis, the understanding of coagulation disorders and minimizing anticoagulation has been focused in recent years. Due to progress in membrane coating and configuration of modern ECMO circuits it is even possible to perform ECMO without any anticoagulation in well selected cases. It became apparent that routine laboratory tests are likely to miss severe coagulation disorders during ECMO-therapy. Better understanding can also help to individualize anticoagulation in patients and hence preventing complications. Acquired von Willebrand syndrome, platelet dysfunction, waste coagulopathy as well as silent hemolysis should be taken into account when bleeding or thromboembolic complications appear. Recognizing impaired intrinsic fibrinolysis may favour intensified anticoagulation even in patients exhibiting signs of bleeding. Drug monitoring with standard coagulation tests, viscoelastic tests and anti-Xa-levels as wells as screening for disorders of primary hemostasis should be implemented in clinical routine to guide physicians through complex anticoagulative therapy. The patient's coagulative status should be interpreted taking the underlying disease and current therapy into account in order to enable a personalized approach to hemostasis in patients treated with ECMO.
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Anticoagulantes , Oxigenación por Membrana Extracorpórea , Hemorragia , Trombosis , Humanos , Oxigenación por Membrana Extracorpórea/efectos adversos , Hemorragia/etiología , Hemorragia/terapia , Anticoagulantes/uso terapéutico , Coagulación SanguíneaRESUMEN
Dimethylarginine dimethylaminohydrolase 1 (DDAH1) protects against cardiovascular disease by metabolising the risk factor asymmetric dimethylarginine (ADMA). However, the question whether the second DDAH isoform, DDAH2, directly metabolises ADMA has remained unanswered. Consequently, it is still unclear if DDAH2 may be a potential target for ADMA-lowering therapies or if drug development efforts should focus on DDAH2's known physiological functions in mitochondrial fission, angiogenesis, vascular remodelling, insulin secretion, and immune responses. Here, an international consortium of research groups set out to address this question using in silico, in vitro, cell culture, and murine models. The findings uniformly demonstrate that DDAH2 is incapable of metabolising ADMA, thus resolving a 20-year controversy and providing a starting point for the investigation of alternative, ADMA-independent functions of DDAH2.
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Amidohidrolasas , Arginina , Ratones , Animales , Amidohidrolasas/metabolismo , Arginina/metabolismo , Óxido Nítrico/metabolismoRESUMEN
Bleeding events in patients under direct oral anticoagulation (DOAC) can be life-threating but are commonly not related to drug overdose. However, a relevant DOAC plasma concentration impairs the hemostasis and should therefore be ruled out immediately after hospital admission. The effect of DOAC is typically not visible in standard coagulation tests such as activated partial thrombin time or thromboplastin time. Specific anti-Xa or anti-IIa assays allow a specific drug monitoring, but they are too time-consuming in critical bleeding events and typically not available 24 h/7 d in routine care. Recent advantages in point-of-care (POC) testing might improve patient care by early exclusion of relevant DOAC levels, but sufficient validation is still lacking. POC urine analysis help to exclude DOAC in emergency patients, but does not provide a quantitative information about plasma concentration. POC viscoelastic testing (VET) can determine the DOAC effect on clotting time and helps further to reveal other concomitant bleeding disorders in emergency, e.g., factor deficiency or hyperfibrinolysis. If a relevant plasma concentration of the DOAC is assumed or was proven by either laboratory assays or POC testing, restoration of factor IIa or factor IIa activity is key for effective hemostasis. Limited evidence suggests that specific reversals for DOAC, e.g., idarucizumab for dabigatran and andexanet alfa for apixaban or rivaroxaban, might be superior to increasing thrombin generation by administration of prothrombin complex concentrates. To determinate, if DOAC reversal is indicated or not, time from last intake, anti-Xa/dTT values or results from POC tests can be considered. This experts' opinion provides a feasible decision algorithm for clinical practice.
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Anticoagulantes , Trastornos de la Coagulación Sanguínea , Humanos , Anticoagulantes/efectos adversos , Hemorragia/inducido químicamente , Rivaroxabán/efectos adversos , Pruebas de Coagulación Sanguínea , Dabigatrán , Trastornos de la Coagulación Sanguínea/tratamiento farmacológico , Administración OralRESUMEN
BACKGROUND: In reconstructive surgery, loss of a microvascular free flap due to perfusion disorders, especially thrombosis, is a serious complication. In recent years, viscoelastic testing (VET) has become increasingly important in point-of-care (POC) anticoagulation monitoring. This paper describes a protocol for enhanced anticoagulation monitoring during maxillofacial flap surgery. OBJECTIVE: The aim of the study will be to evaluate, in a controlled setting, the predictive value of POC devices for the type of flap perfusion disorders due to thrombosis or bleeding. VET, Platelet monitoring (PM) and standard laboratory tests (SLT) are comparatively examined. METHODS/DESIGN: This study is an investigator-initiated prospective trial in 100 patients undergoing maxillofacial surgery. Patients who undergo reconstructive surgery using microvascular-free flaps will be consecutively enrolled in the study. All patients provide blood samples for VET, PM and SLT at defined time points. The primary outcome is defined as free flap loss during the hospital stay. Statistical analyses will be performed using t-tests, including the Bonferroni adjustment for multiple comparisons. DISCUSSION: This study will help clarify whether VET can improve individualized patient care in reconstruction surgery. A better understanding of coagulation in relation to flap perfusion disorders may allow real-time adaption of antithrombotic strategies and potentially prevent flap complications.
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Point of care (POC) devices are increasingly used in the ICU and in anesthesia. Besides POC-devices for blood gas analysis, several devices are available for coagulation measurements. Although basic principles for thromboelastographic measurements are not novel, some promising developments were made during the last decade improving both user-friendliness and measurement reliability. For instance, POC measurements of activated clotting time (ACT) for heparin monitoring is still regarded as standard-of-care in cardiac interventions and surgery. In the field of anesthesia and intensive care medicine, POC-devices for thromboelastographic and platelet aggregation measurements are widely used. Their impact in case of bleeding and patient blood management for cardiothoracic and trauma surgery is well known. Moreover, there are promising concepts for anticoagulation monitoring including new oral anticoagulant drugs. Coagulation POC-devices may also identify patients at specific risk for thromboembolic events quickly. On the other hand, benefits of POC-devices need to be balanced against limitations, which include technical restrictions and operator related errors, mainly affecting reproducibility and interpretation of results. Therefore, it is recommendable to consider results of POC-coagulation testing in comparison to standard laboratory tests (SLT). Nevertheless, in urgent or emergency situations POC results enable fast decision making to optimize patient care.
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Anestesiología , Sistemas de Atención de Punto , Coagulación Sanguínea , Cuidados Críticos , Humanos , Reproducibilidad de los ResultadosRESUMEN
Acute respiratory distress syndrome (ARDS) is a common disease entity in critical care medicine and is still associated with a high mortality. Because of the heterogeneous character of ARDS, animal models are an insturment to study pathology in relatively standardized conditions. Rodent models can bridge the gap from in vitro investigations to large animal and clinical trials by facilitating large sample sizes under physiological conditions at comparatively low costs. One of the most commonly used rodent models of acute lung inflammation and ARDS is administration of lipopolysaccharide (LPS), either into the airways (direct, pulmonary insult) or systemically (indirect, extra-pulmonary insult). This narrative review discusses the dynamics of important pathophysiological pathways contributing to the physiological response to LPS-induced injury. Pathophysiological pathways of LPS-induced lung injury are not only influenced by the type of the primary insult (e.g., pulmonary or extra-pulmonary) and presence of additional stimuli (e.g., mechanical ventilation), but also by time. As such, findings in animal models of LPS-induced lung injury may depend on the time point at which samples are obtained and physiological data are captured. This review summarizes the current evidence and highlights uncertainties on the molecular dynamics of LPS-induced lung injury in rodent models, encouraging researchers to take accurate timing of LPS-induced injury into account when designing experimental trials.
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Radiation-induced pulmonary fibrosis is a common severe long-time complication of radiation therapy for tumors of the thorax. Current therapeutic options used in the clinic include only supportive managements strategies, such as anti-inflammatory treatment using steroids, their efficacy, however, is far from being satisfactory. Recent studies have demonstrated that the development of lung fibrosis is a dynamic and complex process, involving the release of reactive oxygen species, activation of Toll-like receptors, recruitment of inflammatory cells, excessive production of nitric oxide and production of collagen by activated myofibroblasts. In this review we summarized the current state of knowledge on the pathophysiological processes leading to the development of lung fibrosis and we also discussed the possible treatment options.
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Reducing ventilator-associated lung injury by individualized mechanical ventilation (MV) in patients with Acute Respiratory Distress Syndrome (ARDS) remains a matter of research. We randomly assigned 27 pigs with acid aspiration-induced ARDS to three different MV protocols for 24 h, targeting different magnitudes of collapse and tidal recruitment (collapse&TR): the ARDS-network (ARDSnet) group with low positive end-expiratory pressure (PEEP) protocol (permissive collapse&TR); the Open Lung Concept (OLC) group, PaO2/FiO2 >400 mmHg, indicating collapse&TR <10%; and the minimized collapse&TR monitored by Electrical Impedance Tomography (EIT) group, standard deviation of regional ventilation delay, SDRVD. We analyzed cardiorespiratory parameters, computed tomography (CT), EIT, and post-mortem histology. Mean PEEP over post-randomization measurements was significantly lower in the ARDSnet group at 6.8 ± 1.0 cmH2O compared to the EIT (21.1 ± 2.6 cmH2O) and OLC (18.7 ± 3.2 cmH2O) groups (general linear model (GLM) p < 0.001). Collapse&TR and SDRVD, averaged over all post-randomization measurements, were significantly lower in the EIT and OLC groups than in the ARDSnet group (collapse p < 0.001, TR p = 0.006, SDRVD p < 0.004). Global histological diffuse alveolar damage (DAD) scores in the ARDSnet group (10.1 ± 4.3) exceeded those in the EIT (8.4 ± 3.7) and OLC groups (6.3 ± 3.3) (p = 0.16). Sub-scores for edema and inflammation differed significantly (ANOVA p < 0.05). In a clinically realistic model of early ARDS with recruitable and nonrecruitable collapse, mechanical ventilation involving recruitment and high-PEEP reduced collapse&TR and resulted in improved hemodynamic and physiological conditions with a tendency to reduced histologic lung damage.
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PURPOSE OF REVIEW: The aim of the present review was to concisely summarize recent studies and current knowledge about effects of red blood cell storage injury in trauma patients. RECENT FINDINGS: Despite a pathophysiological rationale for older packed red blood cells (PRBCs) being associated with adverse events in the host organism, recent large clinical trials failed to show negative effects of transfusion with older PRBCs on clinically relevant outcomes in mixed patient population. However, there is a lack of well-designed randomized controlled trials focusing on the effects of storage lesion of PRBCs in trauma patients. SUMMARY: In the absence of specific evidence for trauma patients, we recommend to continue with a conservative transfusion regime and standard of care blood banking practice of using older PRBCs first.
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Conservación de la Sangre/efectos adversos , Transfusión de Eritrocitos/efectos adversos , Eritrocitos/fisiología , Reacción a la Transfusión/prevención & control , Heridas y Lesiones/terapia , Bancos de Sangre , Conservación de la Sangre/métodos , Ensayos Clínicos como Asunto , Cuidados Críticos/métodos , Cuidados Críticos/normas , Enfermedad Crítica/terapia , Transfusión de Eritrocitos/normas , Humanos , Nivel de Atención , Factores de Tiempo , Reacción a la Transfusión/etiología , Resultado del TratamientoRESUMEN
Transportation of a patient between medical facilities without interruption of the medical treatment can be a challenging task. This review aims to define the term "interhospital transport" and give a general overview of the steps for organizing a transfer. Furthermore we discuss the team qualification, equipment standards and how to manage adverse events before and during transport by means of patient triage. The advanced interhospital transport of the critically ill patient can be defined as follows: "transportation of a patient between medical facilities without interruption of the medical treatment and monitoring due to the underlying disease by means of specific medical, technical equipment and knowledge with the objective of improved patient care." Several organizational steps come along with patients transfer: the hospital of origin has to identify transfer-eligible patients and be willing to release the patient. It has to identify a destination hospital and negotiate the transfer; the patient has to be transportable, the patient/relatives must agree; the transporting unit has to have the infrastructure and acknowledge to transport the patient; the insurance company or the family has to guarantee for the additional costs. Relocation team members need a specific training that focus on typical critical events that happen during transport. Technical equipment (ventilator, stretcher, monitor, defibrillator, external pacemaker, blood-gas analyzer) facilitates smooth patient transition from one facility to a distant one. The use of checklists is associated with a reduction of incidents during the transport.
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Enfermedad Crítica , Transferencia de Pacientes/organización & administración , HumanosAsunto(s)
Respiración Artificial/tendencias , Síndrome de Dificultad Respiratoria/terapia , Cuidados Críticos/métodos , Oxigenación por Membrana Extracorpórea/tendencias , Predicción , Humanos , Respiración Artificial/efectos adversos , Síndrome de Dificultad Respiratoria/fisiopatología , Factores de Riesgo , Volumen de Ventilación Pulmonar/fisiología , Lesión Pulmonar Inducida por Ventilación Mecánica/prevención & controlRESUMEN
Parenchymal strain is a key determinant of lung injury produced by mechanical ventilation. However, imaging estimates of volumetric tidal strain (ε = regional tidal volume/reference volume) present substantial conceptual differences in reference volume computation and consideration of tidally recruited lung. We compared current and new methods to estimate tidal volumetric strains with computed tomography, and quantified the effect of tidal volume (VT) and positive end-expiratory pressure (PEEP) on strain estimates. Eight supine pigs were ventilated with VT = 6 and 12 ml/kg and PEEP = 0, 6, and 12 cmH2O. End-expiratory and end-inspiratory scans were analyzed in eight regions of interest along the ventral-dorsal axis. Regional reference volumes were computed at end-expiration (with/without correction of regional VT for intratidal recruitment) and at resting lung volume (PEEP = 0) corrected for intratidal and PEEP-derived recruitment. All strain estimates demonstrated vertical heterogeneity with the largest tidal strains in middependent regions (P < 0.01). Maximal strains for distinct estimates occurred at different lung regions and were differently affected by VT-PEEP conditions. Values consistent with lung injury and inflammation were reached regionally, even when global measurements were below critical levels. Strains increased with VT and were larger in middependent than in nondependent lung regions. PEEP reduced tidal-strain estimates referenced to end-expiratory lung volumes, although it did not affect strains referenced to resting lung volume. These estimates of tidal strains in normal lungs point to middependent lung regions as those at risk for ventilator-induced lung injury. The different conditions and topography at which maximal strain estimates occur allow for testing the importance of each estimate for lung injury.
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Pulmón/fisiología , Volumen de Ventilación Pulmonar/fisiología , Animales , Inflamación/fisiopatología , Respiración con Presión Positiva/métodos , Respiración Artificial/métodos , Porcinos , Tomografía Computarizada por Rayos X/métodos , Lesión Pulmonar Inducida por Ventilación Mecánica/fisiopatologíaRESUMEN
In the last 20 years, survival among patients with acute respiratory distress syndrome (ARDS) has increased substantially with advances in lung-protective ventilation and resuscitation. Building on this success, personalizing mechanical ventilation to patient-specific physiology for enhanced lung protection will be a top research priority for the years ahead. However, the ARDS research agenda must be broader in scope. Further understanding of the heterogeneous biology, from molecular to mechanical, underlying early ARDS pathogenesis is essential to inform therapeutic discovery and tailor treatment and prevention strategies to the individual patient. The ARDSne(x)t research agenda for the next 20 years calls for bringing personalized medicine to ARDS, asking simultaneously both whether a treatment affords clinically meaningful benefit and for whom. This expanded scope necessitates standard acquisition of highly granular biological, physiological, and clinical data across studies to identify biologically distinct subgroups that may respond differently to a given intervention. Clinical trials will need to consider enrichment strategies and incorporate long-term functional outcomes. Tremendous investment in research infrastructure and global collaboration will be vital to fulfilling this agenda.