27 Aug 12

Management of atrial fibrillation in the acute setting

Posted in Arrhythmia, Critical Care at 1:04 by Laci

By J Chenoweth, D Diercks
Curr Op Crit Care 2012;18: 333–340

The review aims to describe the scope of the problem and potential therapeutic intervention for the management and risk stratification of patients with atrial fibrillation in the emergency department and acute care setting.

Recent findings
Atrial fibrillation is the most common arrhythmia prompting admission to the hospital. Management strategies include determining the trigger of the arrhythmia, rate control, and potential cardioversion. In the acute care setting the treatment is often dependent on the timing of the onset of arrhythmia. In those patients presenting with symptoms of less than 48 h of duration management may consist of rate control, pharmacologic, or electrical cardioversion. Recent studies suggest no difference in long-term outcomes with rate and rhythm control. In patients with symptoms greater that 48 h rate control is the initial option with potential for cardioversion as an outpatient. There are recent advances in ablation that provide additional options to patients with paroxysmal atrial fibrillation. An essential component of the treatment strategy for these patients is risk stratification for stroke and the initiation of long-term anticoagulation in appropriate patients.

Management of atrial fibrillation is guided by underlying causes of the atrial fibrillation and duration of symptoms.

09 May 12

Guidelines for the management of aneurysmal subarachnoid hemorrhage

Posted in Brain injury, Critical Care, Stroke. SAH at 9:55 by Laci

By E. Connolly Jr, A. Rabinstein, J. R. Carhuapoma, C. P. Derdeyn, J Dion, et al on behalf of the American Heart Association Stroke Council, Council on Cardiovascular Radiology and Intervention, Council on Cardiovascular Nursing, Council on Cardiovascular Surgery and Anesthesia, and Council on Clinical Cardiology

Stroke 2012; published online before print

The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of aneurysmal subarachnoid hemorrhage (aSAH).

A formal literature search of MEDLINE (November 1, 2006, through May 1, 2010) was performed. Data were synthesized with the use of evidence tables. Writing group members met by teleconference to discuss data-derived recommendations. The American Heart Association Stroke Council’s Levels of Evidence grading algorithm was used to grade each recommendation. The guideline draft was reviewed by 7 expert peer reviewers and by the members of the Stroke Council Leadership and Manuscript Oversight Committees. It is intended that this guideline be fully updated every 3 years.

Evidence-based guidelines are presented for the care of patients presenting with aSAH. The focus of the guideline was subdivided into incidence, risk factors, prevention, natural history and outcome, diagnosis, prevention of rebleeding, surgical and endovascular repair of ruptured aneurysms, systems of care, anesthetic management during repair, management of vasospasm and delayed cerebral ischemia, management of hydrocephalus, management of seizures, and management of medical complications.

aSAH is a serious medical condition in which outcome can be dramatically impacted by early, aggressive, expert care. The guidelines offer a framework for goal-directed treatment of the patient with aSAH.

23 Mar 12

Intensive care unit bed availability and outcomes for hospitalized patients with sudden clinical deterioration

Posted in Admission to ICU, Critical Care at 1:43 by Laci

By H T Stelfox,B R Hemmelgarn, S M Bagshaw, S Gao, C J Doig, C Nijssen-Jordan, B Manns

Arch Int Med 2012;172:467-474

Intensive care unit (ICU) beds, a scarce resource, may require prioritization of admissions when demand exceeds supply. We evaluated the effect of ICU bed availability on processes and outcomes of care for hospitalized patients with sudden clinical deterioration.

We identified consecutive hospitalized adults in Calgary, Alberta, Canada, with sudden clinical deterioration triggering medical emergency team activation between January 1, 2007, and December 31, 2009. We compared ICU admission rates (within 2 hours of medical emergency team activation), patient goals of care (resuscitative, medical, and comfort), and hospital mortality according to the number of ICU beds available (0, 1, 2, or >2), adjusting for patient, physician, and hospital characteristics (using data from clinical and administrative databases).

The cohort consisted of 3494 patients. Reduced ICU bed availability was associated with a decreased likelihood of patient admission within 2 hours of medical emergency team activation (P = .03) and with an increased likelihood of change in patient goals of care (P < .01). Patients with sudden clinical deterioration when zero ICU beds were available were 33.0% (95% CI, –5.1% to 57.3%) less likely to be admitted to the ICU and 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than 2 ICU beds were available. Hospital mortality did not vary significantly by ICU bed availability (P = .82).

Among hospitalized patients with sudden clinical deterioration, we noted a significant association between the number of ICU beds available and ICU admission and patient goals of care but not hospital mortality.

04 May 10

Diagnosis and management of hyponatraemia in hospitalised patients

Posted in Anesthesia, Critical Care at 0:10 by Laci

By P Reddy, A Mooradian

Int J Clin Pract  2009;63:1494-1508

Hyponatraemia is a commonly encountered electrolyte abnormality in hospitalised patients and is associated with significant morbidity and mortality. The fact that most cases of hyponatraemia are the result of water imbalance rather than sodium imbalance underscores the role of antidiuretic hormone (ADH) in the pathophysiology. Hyponatraemia can be classified according to the measured plasma osmolality as isotonic, hypertonic or hypotonic. Hyponatraemia with a normal plasma osmolality usually indicates pseudohyponatraemia, while hyponatraemia because of a high plasma osmolality is typically caused by hyperglycaemia. After excluding isotonic and hypertonic causes, hypotonic hyponatraemia is further classified according to the volume status of the patient as hypovolaemic, hypervolaemic or euvolaemic. Hypovolaemic hyponatraemia is accompanied by extracellular fluid (ECF) volume deficit, while hypervolaemic hyponatraemia manifests with ECF volume expansion. The syndrome of inappropriate ADH (SIADH) should be suspected in any patient with euvolaemic hyponatraemia with a urine osmolality above 100 mOsm/kg and urine sodium concentration above 40 mEq/l. In the management of any hyponatraemia regardless of the patient’s volume status, it is advised to restrict free water and hypotonic fluid intake. Hypertonic saline and vasopressin antagonists can be used to correct symptomatic hyponatraemia. The rate of correction is dependent upon the duration, degree of hyponatraemia and the presence or absence of symptoms. Symptomatic acute hyponatraemia (< 48 h) is a medical emergency requiring rapid correction to prevent the worsening of brain oedema. In asymptomatic patients with chronic hyponatraemia (> 48 h or unknown duration), fluid restriction and close monitoring alone are sufficient, while a slow correction by 0.5 mEq/l/h may be attempted in symptomatic patients. Excessive rapid correction should be avoided in both acute and chronic hyponatraemia, because it can lead to irreversible neurological complications including central osmotic demyelination.

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