RESUMEN
BACKGROUND: Conventionally, in the pre-percutaneous intervention era, free wall rupture is reported to be a major concern for using steroids in myocardial infarction (MI) patients. Therefore, the aim of this study was to evaluate the safety of the use of steroids in critically ill post-MI patients in terms of hospital course and short-term (up to 180-day) mortality. METHODS: We included patients admitted to CCU diagnosed with MI, undergone revascularization, critically ill, and requiring mechanical ventilator (MV) support. The hospital course and short-term (up to 180-day) mortality were independently compared between steroid and non-steroid cohorts and propensity-matched non-steroid cohorts. RESULTS: A total of 312 patients were included, out of which steroids were used in 93 (29.8%) patients during their management. On periodic bedside echocardiography, no free wall rupture was documented in the steroid or non-steroid cohort. When compared steroids with a propensity-matched non-steroid cohort, MV duration >24 h was 66.7% vs. 59.1%; p = 0.288, major bleeding was 6.5% vs. 3.2%; p = 0.305, need for renal replacement therapy was 9.7% vs. 8.6%; p = 0.799, in-hospital mortality was 35.5% vs. 23.7%; p = 0.077, and 180-day mortality was 48.4% vs. 41.9%; p = 0.377, respectively. The hazard ratio was 1.22 [95% CI: 0.80 to 1.88] compared to the propensity-matched non-steroid cohort. The ejection fraction (%) was found to be the independent predictor of 180-day mortality with an adjusted odds ratio of 0.92 [95% CI: 0.86 to 0.98]. CONCLUSIONS: In conclusion, using steroids is safe in post-MI patients with no significant increase in short-term mortality risk.
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Infarto del Miocardio , Esteroides , Humanos , Infarto del Miocardio/mortalidad , Masculino , Femenino , Persona de Mediana Edad , Anciano , Esteroides/uso terapéutico , Esteroides/efectos adversos , Enfermedad Crítica/mortalidad , Mortalidad HospitalariaRESUMEN
BACKGROUND: This clinical audit aims to evaluate the clinical data regarding the management and outcomes of acute myocardial infarction (AMI) patients requiring mechanical ventilator (MV) support, along with identifying factors associated with prolonged MV support and 180-day mortality. MATERIALS AND METHODS: In this study, we audited clinical data regarding management, in-hospital and short-term outcomes of adult patients with AMI required MV support. Patients with prolonged MV duration (>24h) and/or 180-day mortality were compared with their counterparts, and associated factors were identified. The binary logistic and Cox regression analyses were performed to determine the predictors of prolonged MV duration and 180-day mortality. RESULTS: In a sample of 312 patients, 72.8% were male, and the mean age was 60.3±11.5 years. The median MV duration was 24 [24-48] hours, with 48.7% prolonged MV duration. The admission albumin level was found to be the independent predictor of prolonged MV duration with an adjusted OR of 0.42 [0.22-0.82]. Overall 7.4% were re-intubated, 6.7% needed renal replacement therapy, 17.6% required intra-aortic balloon pump (IABP) placement, and 16.7% required temporary pacemaker placement. The survival rate was 80.4% at the time of hospital discharge, 74.7% at 30-day, 71.2% at 90-day, and 68.6% at 180-day follow-up. Age, prolonged MV duration, and ejection fraction were found to be the independent predictors of cumulative 180-day mortality with adjusted HR of 1.04 [1.02-1.07], 1.02 [1.01-1.03], and 0.95 [0.92-0.98], respectively. CONCLUSIONS: Prolonged ventilator duration has significant prognostic implications; hence, tailored early recognition of high-risk patients needing more aggressive care can improve the outcomes.
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Sistema Cardiovascular , Infarto del Miocardio , Adulto , Humanos , Masculino , Persona de Mediana Edad , Anciano , Femenino , Respiración Artificial , Pakistán , Infarto del Miocardio/terapia , HospitalesRESUMEN
BACKGROUND: We hypothesize that a change in lung ultrasound score (LUS) can assist in the early diagnosis of weaning-induced respiratory failure (RF). The objective of this study was to determine the utility of LUS in weaning patients with mitral regurgitation (MR) from mechanical ventilation (MV). METHODS: This prospective observational study included patients with acute coronary syndrome (ACS) who required invasive MV after angiography/angioplasty. Echocardiography was performed and MR was recorded. When the patient was considered ready for extubation, a spontaneous breathing trial (SBT) was performed and pre- and post-SBT LUS was calculated. Patients who successfully passed the SBT were extubated and followed up for 48 hours for the signs of RF and outcomes. RESULTS: We enrolled 215 patients, out of which MR occurred in 51(23.7%) patients. On post-SBT lung ultrasound, patients with MR were more likely to have B2 lines compared to those without MR; 15.7% vs. 3.7%; p=0.002 and mean LUS was significantly higher for patients with MR as compared to patients without MR; 2.75±3.21 vs. 1.37± 2.02; p<0.001. Post-extubation RF and mean CCU stay were significantly higher in MR patients, 49.0% (25) vs. 32.3% (53); p=0.030 and 3.53±1.54 days vs. 2.41±1.1 days; p<0.001 respectively. However, re-intubation and coronary care unit (CCU) mortality rate were not significantly different between patients with and without MR; 7.8% (4/51) vs. 3.7% (6/164); p=0.215, and 5.9% (3/51) vs. 3% (5/164); p=0.35 respectively. CONCLUSIONS: Bedside LU is a convenient tool to detect changes in cardiopulmonary interactions during weaning for patients with MR post-ACS.
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Insuficiencia de la Válvula Mitral , Insuficiencia Respiratoria , Humanos , Insuficiencia de la Válvula Mitral/diagnóstico por imagen , Insuficiencia de la Válvula Mitral/etiología , Desconexión del Ventilador , Respiración Artificial , Pulmón/diagnóstico por imagen , AngioplastiaRESUMEN
BACKGROUND: The Rapid Shallow Breathing Index (RSBI) has been hypothesized to have discriminating power for categorizing patients at higher risk of post-extubation respiratory failure (RF). Hence aim of this study was to determine the predictive value of RSBI for post-extubation RF in patients after acute myocardial infarction (AMI). METHODS: Consecutive, intubated patients admitted post-revascularization were included. RSBI and lung ultrasound score (LUS) were measured and post-extubation RF within 48 hours was recorded. RESULTS: RF was observed in 36.3% (78/215) patients. For the prediction of RF, RSBI and LUS had area under the curve of 0.670 and 0.635, respectively. The sensitivity, specificity, negative predictive value, and positive predictive value of RSBI >50.5 were 75.6%, 54.7%, 79.8%, and 48.8% respectively, while, the accuracy measures for the combination of RSBI with LUS >1.5 were 44.9%, 84.7%, 73.0%, and 62.5% respectively. CONCLUSIONS: Combined RSBI and LUS measured during spontaneous breathing trial in patients after an AMI, have high predictive abilities for identifying post-extubation RF.
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Infarto del Miocardio , Insuficiencia Respiratoria , Humanos , Extubación Traqueal , Estudios Prospectivos , Insuficiencia Respiratoria/diagnóstico por imagen , Insuficiencia Respiratoria/etiología , Insuficiencia Respiratoria/terapia , Pulmón , Infarto del Miocardio/complicaciones , Infarto del Miocardio/diagnóstico por imagen , Respiración ArtificialRESUMEN
Background Preventing end-organ failure in patients with shock requires rapid and easily accessible measurements of fluid responsiveness. Unlike septic shock, not all patients in cardiogenic shock are preload responsive. We conducted this study to determine the discriminant power of changes in end-tidal carbon dioxide (ETCO2), systolic blood pressure (SBP), inferior vena cava (IVC) collapsibility index (IVC-CI), and venous to arterial carbon dioxide (Pv-aCO2) gap after a fluid challenge and compared it to increases in cardiac output. Methodology In a prospective, quasi-experimental design, mechanically ventilated patients in cardiogenic shock were assessed for fluid responsiveness by comparing improvement in cardiac output (velocity time integral) with changes in ETCO2, heart rate, SBP, Pv-aCO2 gap, IVC-CI after a fluid challenge (a crystalloid bolus or passive leg raise). Results Out of 60 patients, with mean age 61.3 ± 14.8 years, mean acute physiology and chronic health evaluation (APACHE) score -14.82 ± 7.49, and median ejection fraction (EF) 25% (25-35), 36.7% (22) had non ST-segment elevation myocardial infarction (NSTEMI) and 60% (36) were ST-segment elevation myocardial infarction (STEMI). ETCO2 was the best predictor of fluid responsiveness; area under the curve (AUC) 0.705 (95% confidence interval (CI) 0.57-0.83), p=0.007, followed by reduction in Pv-aCO2 gap; AUC 0.598 (95% CI; 0.45-0.74), p= 0.202. Changes in SBP, mean arterial pressure (MAP), IVC-CI weren't significant; 0.431 (p=0.367), 0.437 (p=0.410), 0.569 (p=0.367) respectively. The discriminant value identified for ETCO2 was more than equal to 2 mmHg, with sensitivity 58.6%, specificity 80.7%, positive predictive value 73.9% [95% CI; 56.5% to 86.1%], negative predictive value 69.7% [95% CI; 56.7% to 76.9%]. Conclusions Change in ETCO2 is a useful bedside test to predict fluid responsiveness in cardiogenic shock.