Shock Management for Cardio-surgical ICU Patients - The Golden Hours.
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ABSTRACT:
SUBMITTER: Hauffe T
PROVIDER: S-EPMC5490875 | biostudies-other | 2015 Oct
REPOSITORIES: biostudies-other
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Project description:Shock in cardio-surgical intensive care unit (ICU) patients requires prompt identification of the underlying condition and timely therapeutic interventions. Management during the first 6 hours, also referred to as "the golden hours", is of paramount importance to reverse the shock state and improve the patient's outcome. The authors have previously described a state-of-the-art diagnostic work-up and discussed how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery during this phase. Ideally, shock can be reversed during this initial period. However, some patients might have developed multiple organ dysfunction, which persists beyond the first 6 hours despite the early haemodynamic treatment goals having been accomplished. This period, also referred to as "the silver days", is the focus of this review. The authors discuss how to reduce vasopressor load and how to minimise adrenergic stress by using alternative inotropes, extracorporeal life-support and short acting beta-blockers. The review incorporates data on fluid weaning, safe ventilation, daily interruption of sedation, delirium management and early rehabilitation. It includes practical recommendations in areas where the evidence is scarce or controversial. Although the focus is on cardio-surgery ICU patients, most of the considerations apply to critical ill patients in general.
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Project description:Postoperative atrial fibrillation (POAF) is one of the most frequent complications after cardiothoracic surgery and a predictor for postoperative mortality and prolonged ICU-stay. Current guidelines suggest the multi-channel inhibitor Vernakalant as a treatment option for rhythm control. However, rare cases of severe hypotension and cardiogenic shock following drug administration have been reported. To elucidate the impact of Vernakalant on hemodynamics, we included ten ICU patients developing POAF after elective cardiac surgery, all of them awake and breathing spontaneously, in this prospective trial. Patients received the recommended dosage of Vernakalant and were clinically observed and monitored (heart rate, invasive blood pressure, pulse oximetry, central venous pressure) in 1-minute-intervals for 20 minutes before- and 120 minutes after the first dose of Vernakalant. The median time from the end of surgery until occurrence of POAF amounted up to 52.8 [45.9-77.4] hours, it took 3.5 [1.2-10.1] hours from occurrence of POAF until the first application of Vernakalant. All patients received catecholamine support with epinephrine that was held steady and not dynamic throughout the observational phase. We noted stable hemodynamic conditions, with a trend towards a reduction in heart rate throughout the 120 minutes after drug administration. In 7 patients (70%), conversion to sustained sinus rhythm (SR) occurred within 8.0 minutes [6.0-9.0]. No serious adverse events (SAEs) were noted during the observation period. In this prospective trial in ICU-patients showing POAF after cardiac surgery, intravenous Vernakalant did not induce clinically relevant negative effects on patients' hemodynamics but resulted in conversion to sustained SR after a median of 8.0 minutes in 7 out of ten patients.
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Project description:The value of lung ultrasound (LU) in assessing extravascular lung water (EVLW) was demonstrated by comparing LU with gold-standard methods for EVLW assessment. However, few studies have analysed the value of B-Line score (BLS) in guiding fluid management during critical illness. The purpose of this trial was to evaluate if a BLS-guided fluid management strategy could improve fluid balance and short-term mortality in surgical intensive care unit (ICU) patients. We conducted a randomised, controlled trial within the ICUs of two university hospitals. Critically ill patients were randomised upon ICU admission in a 1:1 ratio to BLS-guided fluid management (active group) or standard care (control group). In the active group, BLS was monitored daily until ICU discharge or day 28 (whichever came first). On the basis of BLS, different targets for daily fluid balance were set with the aim of avoiding or correcting moderate/severe EVLW increase. The primary outcome was 28-day mortality. Over 24 months, 166 ICU patients were enrolled in the trial and included in the final analysis. Trial results showed that daily BLS monitoring did not lead to a different cumulative fluid balance in surgical ICU patients as compared to standard care. Consecutively, no difference in 28-day mortality between groups was found (10.5% vs. 15.6%, p = 0.34). However, at least 400 patients would have been necessary for conclusive results.
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Project description:Circulatory shock affects approximately one-third of all patients in the Intensive Care Unit (ICU) and it is correlated with high mortality. Septic shock (SS) and cardiogenic shock (CS) are two types of circulatory shock, with a different etiology. We aimed to assess in whole blood of CS and SS patients the transcriptomic alterations occurring over one week after ICU admission in order to identify the pathways that are modulated in circulatory shock irrespective of the etiology. We used Gene Set Enrichment Analysis (GSEA) to identify the biological processes and transcriptional regulators significantly enriched in both types of shock.
2020-01-08 | GSE131411 | GEO
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Project description:Early cholecystectomy within 72 hours has been shown to be superior to late or delayed cholecystectomy with regard to outcome and cost of treatment. Recently, immediate cholecystectomy within 24 hours of onset of symptom was proposed as standard procedure for the management of fit patients presenting with acute cholecystitis. We sort to find out if there are any differences in surgical outcomes between patients managed within 24 h and those managed 25-72 h following symptom begin for acute cholecystitis.A retrospective analysis was performed. The outcomes of patients undergoing laparoscopic cholecystectomy within 24 h were compared to those of patients managed 25-72 h following symptom onset for acute cholecystitis.35 patients managed 25-72 h following begin of symptoms were matched with 35 patients with similar baseline features, medical comorbidities and disease severity managed within 24 hours of symptom onset. There were no significant differences in the duration of surgery, postoperative complications, rate of conversion and length of hospital stay.Immediate laparoscopic cholecystectomy for acute cholecystitis within 24 hour of symptom onset is not superior to surgery 25-72 hour after symptoms begin. Laparoscopic cholecystectomy for acute cholecystitis therefore can be safely performed anytime within the golden 72 h.
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