Peripartum Cardiomyopathy: Current Options for Treatment and Cardiovascular Support.

Peripartum cardiomyopathy is a rare form of acute heart failure but the major cause of all deaths in pregnant patients with heart failure. Improved survival rates in recent years, however, emphasize the importance of early recognition and initiation of heart failure treatment. This article, therefore, attempts to raise awareness among cardiac and obstetric anesthesiologists as well as intensivists of this often fatal diagnosis. This review summarizes theories of the pathophysiology and outcome of peripartum cardiomyopathy. Based on the most recent literature, it further outlines diagnostic criteria and treatment options including medical management, mechanical circulatory support devices, and heart transplantation. Earlier recognition of this rare condition and a new generation of mechanical circulatory devices has contributed to the improved outcome. More frequently, patients in cardiogenic shock who fail medical management are successfully bridged to recovery on extracorporeal circulatory devices or survive with a long-lasting implantable ventricular assist device. The outcome of transplanted patients with peripartum cardiomyopathy, however, is worse compared to other recipients of heart transplants and warrants further investigation in the future.

The Association of Preoperative Hematocrit and Transfusion with Mortality in Patients Undergoing Elective Non-cardiac Surgery.

BACKGROUND: Patients with anemia frequently undergo surgery, as it is unclear at what threshold clinicians should consider delaying surgery for preoperative anemia optimization. The primary objective of this study was to determine whether there is an association of varying degrees of anemia and transfusion with 30-day mortality. METHODS: This is a retrospective cohort study using the American College of Surgeons National Surgical Quality Improvement Program database from 2011 to 2013. Cohorts were analyzed based on preoperative hematocrit range-patients with: (1) no anemia, (2) hematocrit ≥33% and <36% in females or <39% in males, (3) hematocrit ≥30% and <33%, (4) hematocrit ≥27% and <30%, (5) hematocrit ≥24% and <27%, and (6) hematocrit ≥21% and less than 24%. Multivariable logistic regression was used to analyze the association of anemia and transfusion with 30-day in-hospital mortality. RESULTS: The odds for 30-day mortality increased incrementally as the hematocrit ranges decreased, in which preoperative hematocrit between 21 and 24% had the highest odds for this outcome (odds ratio [OR] 6.50, p < 0.0001) compared to the reference group (no anemia). The use of transfusion increased the odds of mortality even further (OR 5.57, p < 0.0001). Among patients that received an intra-/postoperative transfusion, preoperative anemia was not predictive of mortality. CONCLUSIONS: Healthcare providers making preoperative clinical decisions for patients undergoing elective surgery should consider the degree of preoperative anemia and likelihood of perioperative transfusion.

Severity of Acute Kidney Injury in the Post-Lung Transplant Patient Is Associated With Higher Healthcare Resources and Cost.

OBJECTIVE: Perioperative risk factors and the clinical impact of acute kidney injury (AKI) and failure after lung transplantation are not well described. The incidences of AKI and acute renal failure (ARF), potential perioperative contributors to their development, and postdischarge healthcare needs were evaluated. DESIGN: Retrospective. SETTING: University hospital. PARTICIPANTS: Patients undergoing lung transplantation between January 1, 2011 and December 31, 2015. MEASURED DATA: The incidences of AKI and ARF, as defined using the Risk, Injury, Failure, Loss, End-Stage Renal Disease criteria, were measured. Perioperative events were analyzed to identify risk factors for renal compromise. A comparison of ventilator days, intensive care unit (ICU) and hospital lengths of stay (LOS), 1-year readmissions, and emergency department visits was performed among AKI, ARF, and uninjured patients. MEASUREMENTS AND MAIN RESULTS: Ninety-seven patients underwent lung transplantation; 22 patients developed AKI and 35 patients developed ARF. Patients with ARF had significantly longer ICU LOS (12 days v 4 days, p < 0.001); ventilator days (4.5 days v 1 day, p < 0.001); and hospital LOS (22.5 days v 14 days, p < 0.001) compared with uninjured patients. Patients with AKI also had significantly longer ICU and hospital LOS. Patients with ARF had significantly more emergency department visits and hospital readmissions (2 v 1 readmissions, p = 0.002) compared with uninjured patients. A univariable analysis suggested that prolonged surgical time, intraoperative vasopressor use, and cardiopulmonary bypass use were associated with the highest increased risk for AKI. Intraoperative vasopressor use and cardiopulmonary bypass mean arterial pressure <60 mmHg were identified as independent risk factors by multivariable analysis for AKI. CONCLUSION: The severity of AKI was associated with an increase in the use of healthcare resources after surgery and discharge. Certain risk factors appeared modifiable and may reduce the incidence of AKI and ARF.

Hemodynamic Consequence of Hand Ventilation Versus Machine Ventilation During Transport After Cardiac Surgery.

OBJECTIVES: The hemodynamic consequences of ventilation of intubated patients during transport either by hand or using a transport ventilator have not been reported in patients after cardiac surgery. The authors hypothesized that bag-mask ventilation would alter end-tidal CO2 during transport and hemodynamic parameters in patients post-cardiac surgery. DESIGN: A prospective, randomized trial. SETTING: A university-affiliated tertiary care hospital. PARTICIPANTS: Cardiac surgery patients. INTERVENTIONS: Thirty-six patients were randomized to hand ventilation or machine ventilation. Hemodynamic variables including blood pressure, heart rate, peripheral saturation of oxygen, and end-tidal carbon dioxide (ETCO2) were measured in these patients prior to transport, every 2 minutes during transport and upon arrival in the intensive care unit (ICU). Pulmonary artery pressure (PA) pressures were measured at origin and at destination. MEASUREMENTS AND MAIN RESULTS: Outcomes were changes from baseline in end-tidal CO2, hemodynamic changes from baseline and pulmonary artery pressure changes from origin to destination. The average transport time between the 2 groups was not different: 5 minutes for patients ventilated by hand and 5.47 minutes for patients ventilated with a transport ventilator (p = 0.369 by 2-sided t-test). The difference in all measured changes in ETCO2 between hand-ventilated and machine-ventilated patients during transport was 2.74 mmHg (p = 0.013). The difference between operating room and ICU ETCO2 from each cohort was 1.31 mmHg (p = 0.067). The difference in PAmean measured at origin and destination was 0.783 mmHg (p = 0.622). All other hemodynamic variables were not different during transport. CONCLUSIONS: Hand ventilation during transport was associated with greater change from baseline of ETCO2 compared to machine ventilation during transport after cardiac surgery, but this did not translate into any difference in hemodynamic changes upon arrival in ICU. A hemodynamic benefit of machine transport ventilation to cardiac patients was not demonstrated.

Surgical Site Infection in Thoracic Surgery Is Not Associated With Perioperative Hypothermia.

INTRODUCTION: The Surgical Care Improvement Project (SCIP) added the SCIP-Inf-10 measure to mandate that all surgical patients have perioperative temperature management to reduce surgical site infection. While the basis of this measure originated in colorectal surgery, we hypothesized that this would also apply to thoracic surgery patients. METHODS: This was a retrospective single-center pilot study reviewing two years of thoracic surgery cases for the incidence and duration of hypothermia during the operation and surgical site infection occurring within 30 days. Hypothermia was defined as a core temperature of < 36° C.  Results: A total of 317 patients were included in the study. Sixty-two percent of patients were identified as hypothermic. The average intraoperative temperature was 35.4°C ± 0.8°C in the hypothermic group and 36.4°C ± 0.3°C in the normothermic group. There were four surgical site infections in the study with three cases from the <36°C group (p = 1). There was no difference in average post-anesthesia care unit length of stay between the groups. The average hospital length of stay was 5.5 ± 5.2 days for the hypothermic group and 8.6 ± 12.8 days for the normothermic group (p=0.0024). CONCLUSION: Perioperative hypothermia was common in thoracic surgery and did not have a negative impact on surgical site infection.

The impact of a daily "medication time out" in the Intensive Care Unit.

OBJECTIVE: Medical errors play a large role in preventable harms within our health care system. Medications administered in the ICU can be numerous, complex and subject to daily changes. We describe a method to identify medication errors with the potential to improve patient safety. DESIGN: A quality improvement intervention featuring a daily medication time out for each patient was performed during rounds. SETTING: A 12-bed Cardiac Surgical ICU at a single academic institution with approximately 180 beds. INTERVENTION: After each patient encounter, the current medication list for the patient was read aloud from the electronic medical record, and the team would determine if any were erroneous or missing. Medication changes were recorded and graded post-hoc according to perceived significance. RESULTS: This intervention resulted in 285 medication changes in 347 patient encounters. 179 of the 347 encounters (51.6%) resulted in at least one change. Of the changes observed, 40.4% were categorized as trivial, 50.5% as minor and 9.1% were considered to have significant potential impact on patient care. The average time spent per patient for this intervention was 1.24 (SD 0.65) minutes. CONCLUSIONS: A daily medication time out should be considered as an additional mechanism for patient safety in the ICU.

Emergency department visits among patients with left ventricular assist devices.

Continuous-flow left ventricular assist devices (LVADs) are increasingly implanted to support patients with end-stage heart failure. These patients are at high risk for complications, many of which necessitate emergency care. While rehospitalization rates have been described, there is little data regarding emergency department (ED) visits. We hypothesize that ED visits are frequent and often require admission after LVAD implantation. We performed a retrospective review of patients in our health-care system followed by the advanced heart failure service for LVAD management after implantation between January 2011 and July 2015. We accounted for all ED visits in our system through February 2016, 7 months after the last implantation included. Clinically relevant demographic variables and ED visit details were recorded and analyzed to describe this population. We identified 81 patients with complete data, among whom there were 283 visits (3.49 visits/patient), occurring at a rate of approximately 7.3 ED visits per patient per year alive with LVAD. The most common reason for an ED visit is a complication related to bleeding (18% of visits), followed by chest pain (14%) and dizziness or syncope (13%). Thirty-six percent of patients were discharged from the ED without hospital admission. A growing populace with implanted LVADs represents an important population within emergency medicine. They are at risk for significant complications and frequently present to the ED. While many of these visits may be managed without hospital admission, this specialized patient group represents a potential area for improvement in provider education.

Preoperative Functional Status Is Associated With Unplanned Intubations Following Thyroidectomies.

BACKGROUND: Unplanned postoperative intubation is an important event that may influence the outcome of thyroid- and parathyroidectomies. We performed a focused study on the association of preoperative functional status with unplanned intubation outcomes in these relatively common surgeries. METHODS: Utilizing data from the National Surgical Quality Improvement Program database from 2007 to 2013, a propensity score-matched retrospective cohort study was performed assessing this outcome in the functionally independent versus dependent groups. Kaplan-Meier survival analysis and a Cox proportional hazards model were performed to assess the difference. RESULTS: There were a total of 98,035 thyroid- and parathyroidectomies identified from the National Surgical Quality Improvement Program from 2007 to 2013. After propensity score matching, there were 1,862 and 931 cases in the independent and dependent group, respectively. There were 11 versus 33 per 1,000 persons in the independent and dependent group, respectively, who experienced an unplanned intubation within 30 d following surgery (P < .001). The dependent group showed worse intubation-free survival over 30 d (P < .001). There were no differences in this outcome during postoperative days 0-1 (P = .17). Dependent functional status was statistically significantly associated with unplanned intubations up to 30 d postoperatively (hazard ratio 2.4, 95% CI 1.4-4.18, P = .002). CONCLUSIONS: Preoperative functional status is a good marker for identifying patients at risk for re-intubation after thyroid- and parathyroidectomy.

Should High-Frequency Ventilation in the Adult Be Abandoned?

High-frequency oscillatory ventilation (HFOV) can improve ventilation-perfusion matching without excessive alveolar tidal stretching or collapse-reopening phenomenon. This is an attractive feature in the ventilation of patients with ARDS. However, two recent large multi-center trials of HFOV failed to show benefits in this patient population. The following review addresses whether, in view of these trails, HFOV should be abandoned in the adult population?

Measuring intensive care unit performance after sustainable growth rate reform: An example with the National Quality Forum metrics.

BACKGROUND: Performance measurement is essential for quality improvement and is inevitable in the shift to value-based payment. The National Quality Forum is an important clearinghouse for national performance measures in health care in the United States. AIM: We reviewed the National Quality Forum library of performance measures to highlight measures that are relevant to critical care medicine, and we describe gaps and opportunities for the future of performance measurement in critical care medicine. CONCLUSION: Crafting performance measures that address core aspects of critical care will be challenging, as current outcome and performance measures have problems with validity. Future quality measures will likely focus on interdisciplinary measures across the continuum of patient care.

Importance of calcium-binding site 2 in simian virus 40 infection.

The exposure of molecular signals for simian virus 40 (SV40) cell entry and nuclear entry has been postulated to involve calcium coordination at two sites on the capsid made of Vp1. The role of calcium-binding site 2 in SV40 infection was examined by analyzing four single mutants of site 2, the Glu160Lys, Glu160Arg, Glu157Lys (E157K), and Glu157Arg mutants, and an E157K-E330K combination mutant. The last three mutants were nonviable. All mutants replicated viral DNA normally, and all except the last two produced particles containing all three capsid proteins and viral DNA. The defect of the site 1-site 2 E157K-E330K double mutant implies that at least one of the sites is required for particle assembly in vivo. The nonviable E157K particles, about 10% larger in diameter than the wild type, were able to enter cells but did not lead to T-antigen expression. Cell-internalized E157K DNA effectively coimmunoprecipitated with anti-Vp1 antibody, but little of the DNA did so with anti-Vp3 antibody, and none was detected in anti-importin immunoprecipitate. Yet, a substantial amount of Vp3 was present in anti-Vp1 immune complexes, suggesting that internalized E157K particles are ineffective at exposing Vp3. Our data show that E157K mutant infection is blocked at a stage prior to the interaction of the Vp3 nuclear localization signal with importins, consistent with a role for calcium-binding site 2 in postentry steps leading to the nuclear import of the infecting SV40.