17 Jan 10
Posted in Heart failure/Cardiogenic shock at 1:01 by Laci
By CTorgersen, C Schmittinger, S Wagner, H Ulmer, J Takala, S Jakob and M Dünser
Critical Care 2009, 13:R157
Despite the key role of hemodynamic goals, there are few data addressing the question as to which hemodynamic variables are associated with outcome or should be targeted in cardiogenic shock patients. The aim of this study was to investigate the association between hemodynamic variables and cardiogenic shock mortality.
Methods
Medical records and the patient data management system of a multidisciplinary intensive care unit (ICU) were reviewed for patients admitted because of cardiogenic shock. In all patients, the hourly variable time integral of hemodynamic variables during the first 24 hours after ICU admission was calculated. If hemodynamic variables were associated with 28-day mortality, the hourly variable time integral of drops below clinically relevant threshold levels was computed. Regression models and receiver operator characteristic analyses were calculated. All statistical models were adjusted for age, admission year, mean catecholamine doses and the Simplified Acute Physiology Score II (excluding hemodynamic counts) in order to account for the influence of age, changes in therapies during the observation period, the severity of cardiovascular failure and the severity of the underlying disease on 28-day mortality.
Results
One-hundred and nineteen patients were included. Cardiac index (CI) (P = 0.01) and cardiac power index (CPI) (P = 0.03) were the only hemodynamic variables separately associated with mortality. The hourly time integral of CI drops <3, 2.75 (both P = 0.02) and 2.5 (P = 0.03) L/min/m2 was associated with death but not that of CI drops <2 L/min/m2 or lower thresholds (all P > 0.05). The hourly time integral of CPI drops <0.5-0.8 W/m2 (all P = 0.04) was associated with 28-day mortality but not that of CPI drops <0.4 W/m2 or lower thresholds (all P > 0.05).
Conclusions
During the first 24 hours after intensive care unit admission, CI and CPI are the most important hemodynamic variables separately associated with 28-day mortality in patients with cardiogenic shock. A CI of 3 L/min/m2 and a CPI of 0.8 W/m2 were most predictive of 28-day mortality. Since our results must be considered hypothesis-generating, randomized controlled trials are required to evaluate whether targeting these levels as early resuscitation endpoints can improve mortality in cardiogenic shock.
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Posted in Heart failure/Cardiogenic shock at 0:59 by Laci
By M Yilmaz and A Mebazaa
Critical Care 2009, 13:1013
Cardiogenic shock is a lethal condition. Physicians are searching for hemodynamic markers which could help risk-stratification of patients in this picture. Torgersen and coworkers present an hourly time integral of the cardiac power index and cardiac index drops to predict outcomes in the setting of cardiogenic shock. Continuous monitoring of hemodynamic markers may have a role in prediction of outcomes.
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15 Jan 10
Posted in ECMO, Mechanical ventilation at 1:40 by Laci
By T Muller, A Philipp, A Luchner, C Karagiannidis, T Bein, M Hilker, L Rupprecht, J Langgartner, M Zimmermann et al
Critical Care 2009, 13:R205
Mortality of severe acute respiratory distress syndrome in adults is still unacceptably high. Extracorporeal membrane oxygenation (ECMO) could represent an important treatment option, if complications were reduced by new technical developments.
Methods
Efficiency, side effects and outcome of treatment with a new miniaturized device for veno-venous extracorporeal gas transfer were analysed in 60 consecutive patients with life-threatening respiratory failure.
Results
A rapid increase of PaO2/FiO2 from 64 (48-86) mmHg to 120 (84-171) mmHg and a decrease of PaCO2 from 63 (50-80) mmHg to 33 (29-39) mmHg were observed after start of the extracorporeal support (p<0.001). Gas exchange capacity of the device averaged 155 (116-182) mL/min for oxygen and 210 (164-251) mL/min for carbon dioxide. Ventilatory parameters were reduced to a highly protective mode, allowing a fast reduction of tidal volume from 495 (401-570) mL to 336 (292-404) mL (p < 0.001) and of peak inspiratory pressure from 36 (32-40) cmH2O to 31 (28-35) cmH2O (p < 0.001). Transfusion requirements averaged 0.8 (0.4-1.8) units of red blood cells per day. 62% of patients were weaned from the extracorporeal system, and 45% survived to discharge.
Conclusions
Veno-venous extracorporeal membrane oxygenation with a new miniaturized device supports gas transfer effectively, allows for highly protective ventilation and is very reliable. Modern ECMO technology extends treatment opportunities in severe lung failure.
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Posted in Admission to ICU, Critical Care at 0:48 by Laci
By J-L Vincent, S Opal and J Marshall
Crit Care Med 2010;38:283-287
Severity scores such as Acute Physiology and Chronic Health Evaluation II have been advocated as entry criteria for clinical trials and in clinical decision-making. We present ten reasons why we believe this approach is not appropriate and may even be detrimental.
Data sources
Available relevant literature from authors’ personal databases and personal knowledge of past and future clinical trial development.
Data synthesis
Severity scores were not designed for use in individual patients or for therapeutic decision-making for specific interventions. Difficulties with the time window needed to calculate these scores and the need to administer therapies early further limit their use in this context. The complex nature of the scores makes it difficult to use them at the bedside and there is considerable interobserver variability in score calculation. Inclusion of chronic health and age points in severity scores may prevent younger, previously healthy patients, with similar acute physiological dysfunction and therefore total lower severity scores, from trial inclusion or from receiving therapies that may be beneficial.
Conclusions
We believe severity of illness scores are poor surrogates for risk stratification and should not be used as a criterion for patient enrollment into clinical trials or as the basis for individual treatment decisions.
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