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Cater DT, Meyers BA, Mitra S, Bhattacharya S, Machado RF, Serrano R, Rowan CM, Gaston B, Vlachos P. NOVEL ECHOCARDIOGRAM ANALYSIS OF CARDIAC DYSFUNCTION IS ASSOCIATED WITH MORTALITY IN PEDIATRIC SEPSIS. Shock 2024; 62:26-31. [PMID: 38661156 DOI: 10.1097/shk.0000000000002359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
ABSTRACT Objectives: The objective of our study was to semiautomatically generate echocardiogram indices in pediatric sepsis using novel algorithms and determine which indices were associated with mortality. We hypothesized that strain and diastolic indices would be most associated with mortality. Design: Retrospective cohort study of children with sepsis from 2017 to 2022. Survivors and nonsurvivors were compared for echocardiogram indices. Multivariate Cox proportional hazard models were constructed for our primary outcome of in-hospital mortality. Linear regression was performed for secondary outcomes, which included multiple composite 28-day outcomes. Results: Of the 54 patients in the study, 9 (17%) died. Multiple echocardiogram indices of both right (RV) and left ventricles (LV) were associated with in-hospital mortality [RV GLS adjusted hazard ratio (aHR): 1.16 (1.03-1.29), P = 0.011; RV global longitudinal early diastolic strain rate (GLSre) aHR: 0.24 (0.07 to 0.75), P = 0.014; LV GLSre aHR: 0.33 (0.11-0.97), P = 0.044]. Impairment in GLS was associated with fewer ventilator-free days [RV GLS β-coefficient: -0.47 (-0.84 to -0.10), P = 0.013; LV GLS β-coefficient -0.62 (-1.07 to -0.17), P = 0.008], organ-support free days [RV GLS β-coefficient: -0.49 (-0.87 to -0.11), P = 0.013; LV GLS β-coefficient: -0.64 (-1.10 to -0.17), P = 0.008], and days free from ICU [RV GLS β-coefficient: -0.42 (-0.79 to -0.05), P = 0.026; LV GLS β-coefficient: -0.58 (-1.03 to -0.13), P = 0.012]. Systolic indices were not associated with mortality in this cohort. Conclusion: Our study demonstrates the feasibility of obtaining echocardiogram indices in a semiautomatic method using our algorithms. We showed that abnormal strain is associated with worse outcomes in a cohort of children with sepsis.
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Affiliation(s)
- Daniel T Cater
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis Indiana
| | - Brett A Meyers
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | - Shailee Mitra
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
| | | | - Roberto F Machado
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ryan Serrano
- Division of Pediatric Cardiology, Loma Linda University Children's Hospital and Medical Center, Loma Linda, California
| | - Courtney M Rowan
- Division of Critical Care, Department of Pediatrics, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis Indiana
| | - Benjamin Gaston
- Riley Hospital for Children and the Herman B. Wells Center for Pediatric Research, Indianapolis, Indiana
| | - Pavlos Vlachos
- School of Mechanical Engineering, Purdue University, West Lafayette, Indiana
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2
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Gerhardy B, Sivapathan S, Bowcock E, Orde S, Morgan L. Right Ventricular Dysfunction on Transthoracic Echocardiography and Long-Term Mortality in the Critically Unwell: A Systematic Review and Meta-Analysis. J Intensive Care Med 2024; 39:203-216. [PMID: 38056074 DOI: 10.1177/08850666231218713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
OBJECTIVE Right ventricular dysfunction (RVD) is common in the critically ill. To date studies exploring RVD sequelae have had heterogenous definitions and diagnostic methods, with limited follow-up. Additionally much literature has been pathology specific, limiting applicability to the general critically unwell patient. METHOD AND STUDY DESIGN We conducted a systematic review and meta-analysis to evaluate the impact of RVD diagnosed with transthoracic echocardiography (TTE) on long-term mortality in unselected critically unwell patients compared to those without RVD. A systematic search of EMBASE, Medline and Cochrane was performed from inception to March 2022. All RVD definitions using TTE were included. Patients were those admitted to a critical or intensive care unit, irrespective of disease processes. Long-term mortality was defined as all-cause mortality occurring at least 30 days after hospital admission. A priori subgroup analyses included disease specific and delayed mortality (death after hospital discharge/after the 30th day from hospital admission) in patients with RVD. A random effects model analysis was performed with the Dersimionian and Laird inverse variance method to generate effect estimates. RESULTS Of 5985 studies, 123 underwent full text review with 16 included (n = 3196). 1258 patients had RVD. 19 unique RVD criteria were identified. The odds ratio (OR) for long term mortality with RVD was 2.92 (95% CI 1.92-4.54, I2 76.4%) compared to no RVD. The direction and extent was similar for cardiac and COVID19 subgroups. Isolated RVD showed an increased risk of delayed mortality when compared to isolated left/biventricular dysfunction (OR 2.01, 95% CI 1.05-3.86, I2 46.8%). CONCLUSION RVD, irrespective of cause, is associated with increased long term mortality in the critically ill. Future studies should be aimed at understanding the pathophysiological mechanisms by which this occurs. Commonly used echocardiographic definitions of RVD show significant heterogeneity across studies, which contributes to uncertainty within this dataset.
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Affiliation(s)
- Benjamin Gerhardy
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Respiratory Medicine, Nepean Hospital, Kingswood, NSW, Australia
| | - Shanthosh Sivapathan
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Emma Bowcock
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
| | - Lucy Morgan
- Nepean Clinical School, University of Sydney School of Medicine, Sydney, NSW, Australia
- Department of Respiratory Medicine, Nepean Hospital, Kingswood, NSW, Australia
- Department of Respiratory Medicine, Concord Repatriation Hospital, Concord, NSW, Australia
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3
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Lashin H, Olusanya O, Bhattacharyya S. Right ventricular function is associated with 28-day mortality in myocardial infarction complicated by cardiogenic shock: A retrospective observational study. J Intensive Care Soc 2022; 23:439-446. [PMID: 36751361 PMCID: PMC9679897 DOI: 10.1177/17511437211037927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Right ventricular (RV) function is increasingly being recognised as an important factor influencing outcomes in ST elevation myocardial infarction (STEMI) complicated by cardiogenic shock (CS). In this study, we investigated RV echocardiographic parameters' association with 28-day mortality in patients admitted to intensive care with STEMI complicated by CS with reduced left ventricle ejection fraction (LVEF). Method We performed a retrospective analysis of patients admitted to intensive care unit (ICU) in a single tertiary cardiac centre over a 34-month period with STEMI complicated by CS and LVEF < 40%. Clinical and echocardiographic data were collected and correlated with 28-day mortality. Results One-hundred patients were included with a mean age of 62.6 ±12.7 years and 78% were male. Mortality at 28 days was 37%. Respectively, 85%, 40% and 25% of patients required mechanical ventilation, mechanical circulatory support and renal replacement therapy. Tricuspid annulus peak systolic velocity (RV S') was significantly higher in survivors (12 ± 3.3 v 10 ± 3.5 cm/s, p = 0.03) and was an independent predictor of mortality (odds ratio 1.2, 95% confidence interval 1.1-1.4, p = 0.04). RV S' of 10.5 cm/s exhibited best sensitivity and specificity (64% and 65%, respectively; p = 0.02) for mortality. The Kaplan-Meier curve demonstrated 85% risk of 28-day mortality for RV S' < 10.5 cm/s v 53% for RV S' > 10.5 cm/s (p = 0.02). Conclusion RV function is associated 28-day mortality in patients admitted to ICU with STEMI complicated by CS with reduced LVEF. RV S' predicted mortality with good sensitivity and specificity.
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Affiliation(s)
- Hazem Lashin
- Adult Critical Care Unit, Barts
Heart Centre, St Bartholomew’s
Hospital, West Smithfield, London, UK,William Harvey Research Institute,
Barts and the London school of medicine and dentistry, Queen Mary University of
London, Charterhouse square, London, UK,Dr. Hazem Lashin, Adult Critical Care Unit,
Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, EC1A 7BE,
London, U K.
| | - Olusegun Olusanya
- Adult Critical Care Unit, Barts
Heart Centre, St Bartholomew’s
Hospital, West Smithfield, London, UK
| | - Sanjeev Bhattacharyya
- William Harvey Research Institute,
Barts and the London school of medicine and dentistry, Queen Mary University of
London, Charterhouse square, London, UK,Cardiology Department Barts Heart
Centre, St Bartholomew’s
Hospital, West Smithfield, London, UK
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4
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Lyhne MD, Kabrhel C, Giordano N, Andersen A, Nielsen-Kudsk JE, Zheng H, Dudzinski DM. The echocardiographic ratio tricuspid annular plane systolic excursion/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism. Eur Heart J Cardiovasc Imaging 2021; 22:285-294. [PMID: 33026070 DOI: 10.1093/ehjci/jeaa243] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2020] [Accepted: 08/07/2020] [Indexed: 12/22/2022] Open
Abstract
AIMS Right ventricular (RV) failure causes death from acute pulmonary embolism (PE), due to a mismatch between RV systolic function and increased RV afterload. We hypothesized that an echocardiographic ratio of this mismatch [RV systolic function by tricuspid annular plane systolic excursion (TAPSE) divided by pulmonary arterial systolic pressure (PASP)] would predict adverse outcomes better than each measurement individually, and would be useful for risk stratification in intermediate-risk PE. METHODS AND RESULTS This was a retrospective analysis of a single academic centre Pulmonary Embolism Response Team registry from 2012 to 2019. All patients with confirmed PE and a formal transthoracic echocardiogram performed within 2 days were included. All echocardiograms were analysed by an observer blinded to the outcome. The primary endpoint was a 7-day composite outcome of death or haemodynamic deterioration. Secondary outcomes were 7- and 30-day all-cause mortality. A total of 627 patients were included; 135 met the primary composite outcome. In univariate analysis, the TAPSE/PASP was associated with our primary outcome [odds ratio = 0.028, 95% confidence interval (CI) 0.010-0.087; P < 0.0001], which was significantly better than either TAPSE or PASP alone (P = 0.017 and P < 0.0001, respectively). A TAPSE/PASP cut-off value of 0.4 was identified as the optimal value for predicting adverse outcome in PE. TAPSE/PASP predicted both 7- and 30-day all-cause mortality, while TAPSE and PASP did not. CONCLUSION A combined echocardiographic ratio of RV function to afterload is superior in prediction of adverse outcome in acute intermediate-risk PE. This ratio may improve risk stratification and identification of the patients that will suffer short-term deterioration after intermediate-risk PE.
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Affiliation(s)
- Mads D Lyhne
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA.,Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark.,Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Christopher Kabrhel
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA
| | - Nicholas Giordano
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA
| | - Asger Andersen
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Jens Erik Nielsen-Kudsk
- Department of Cardiology, Aarhus University Hospital, Palle Juul Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Hui Zheng
- Biostatistics Center, Massachusetts General Hospital, 50 Staniford Street, Boston, MA 02114, USA
| | - David M Dudzinski
- Department of Emergency Medicine, Center for Vascular Emergencies, Massachusetts General Hospital, 0 Emerson Place, MA 02114, USA.,Department of Cardiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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5
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Flower L, Olusanya O, Madhivathanan PR. The use of critical care echocardiography in peri-arrest and cardiac arrest scenarios: Pros, cons and what the future holds. J Intensive Care Soc 2021; 22:230-240. [PMID: 34422106 PMCID: PMC8373287 DOI: 10.1177/1751143720936998] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023] Open
Abstract
Echocardiography is being increasingly deployed as a diagnostic and monitoring tool in the critically ill. This rise in popularity has led to its recommendation as a core competence in intensive care, with several training routes available. In the peri-arrest and cardiac arrest population, point of care focused echocardiography has the potential to transform patient care and improve outcomes. Be it via diagnosis of shock aetiology and reversibility or assessing response to treatment and prognostication. This narrative review discusses current and future applications of echocardiography in this patient group and provides a structure with which one can approach such patients.
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Affiliation(s)
- Luke Flower
- Department of Anaesthesia, University College London Hospitals NHS Trust, London, UK
| | - Olusegun Olusanya
- Department of Critical Care, Barts Heart Centre, Barts Health NHS Trust, London, UK
| | - Pradeep R Madhivathanan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
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6
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Škulec R, Parizek T, Stadlerova B, Bilska M, Cerny V. Subcostal TAPSE measured by anatomical M-mode: prospective reliability clinical study in critically ill patients. Minerva Anestesiol 2021; 87:1200-1208. [PMID: 33982987 DOI: 10.23736/s0375-9393.21.15464-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Tricuspid annular plane systolic excursion (TAPSE), evaluated from a four-chamber apical view, is an echocardiographic parameter for the detection of right ventricular systolic dysfunction (RVD). We decided to assess the reliability of TAPSE measured from subcostal view (sTAPSE) by anatomical M-mode imaging (AMM) for evaluation of right ventricular systolic function and prediction of RVD in the critically ill patients by comparison with other echocardiographic parameters. METHODS We conducted an observational, prospective clinical study in 100 patients hospitalized in the intensive care unit. TAPSE, doppler tissue imaging-derived tricuspid lateral annular systolic velocity (DTI-S´ wave), two-dimensional fraction area change (2D FAC) and DTI-right ventricular index of myocardial performance (DTI-RIMP) were measured by transthoracic echocardiography. A subcostal four-chamber view was recorded for sTAPSE measurement. For that purpose, the cursor of AMM was aligned along the direction of the tricuspid lateral annulus movement and the amplitude of the movement was measured. RESULTS In a group of patients aged 64±16 years with a 31% prevalence of RVD we identified strong correlation between TAPSE and sTAPSE (r=0.963, P<0.001). sTAPSE correlated well with other measures of right ventricular systolic function (DTI-S´ wave: r=0.765; 2D FAC: r=0.701; DTI-RIMP: r=-0.661, P<0.001, respectively). The value of sTAPSE ≤15 mm predicted the presence of RVD defined by TAPSE with a sensitivity of 94.7% and specificity of 100.0%. CONCLUSIONS The sTAPSE measured by AMM in a population of critically ill patients has been found to be a reliable parameter of right ventricular systolic function and predicted RVD with high reliability.
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Affiliation(s)
- Roman Škulec
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital Usti nad Labem, J.E. Purkinje University, Usti nad Labem, Czech Republic - .,Faculty of Health Studies, J.E. Purkinje University, Usti nad Labem, Czech Republic - .,Department of Anesthesiology and Intensive Care, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Charles University, Hradec Kralove, Czech Republic - .,Emergency Medical Service of the Central Bohemian Region, Kladno, Czech Republic -
| | - Tomas Parizek
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital Usti nad Labem, J.E. Purkinje University, Usti nad Labem, Czech Republic.,Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.,Usti and Labem Region Emergency Medical Services, Usti and Labem, Czech Republic
| | - Barbora Stadlerova
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital Usti nad Labem, J.E. Purkinje University, Usti nad Labem, Czech Republic.,Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic
| | - Marcela Bilska
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital Usti nad Labem, J.E. Purkinje University, Usti nad Labem, Czech Republic.,Faculty of Medicine in Hradec Kralove, Charles University, Hradec Kralove, Czech Republic.,Usti and Labem Region Emergency Medical Services, Usti and Labem, Czech Republic
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital Usti nad Labem, J.E. Purkinje University, Usti nad Labem, Czech Republic.,Department of Research and Development, Charles University in Prague, Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove, Hradec Kralove, Czech Republic.,Department of Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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7
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Hockstein MA, Haycock K, Wiepking M, Lentz S, Dugar S, Siuba M. Transthoracic Right Heart Echocardiography for the Intensivist. J Intensive Care Med 2021; 36:1098-1109. [PMID: 33853435 DOI: 10.1177/08850666211003475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND The impact of critical illness on the right ventricle (RV) can be profound and RV dysfunction is associated with mortality. Intensivists are becoming more facile with bedside echocardiography, however, pedagogy has largely focused on left ventricular function. Here we review measurements of right heart function by way of echocardiographic modalities and list clinical scenarios where the RV dysfunction is a salient feature. MAIN RV dysfunction is heterogeneously defined across many domains and its diagnosis is not always clinically apparent. The RV is affected by conditions commonly seen in the ICU such as acute respiratory distress syndrome, pulmonary embolism, RV ischemia, and pulmonary hypertension. Basic ultrasonographic modalities such as 2D imaging, M-mode, tissue Doppler, pulsed-wave Doppler, and continuous Doppler provide clinicians with metrics to assess RV function and response to therapy. CONCLUSION The right ventricle is impacted by various critical illnesses with substantial mortality and mortality. Focused bedside echocardiographic exams with attention to the right heart may provide intensivists insight into RV function and provide guidance for patient management.
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Affiliation(s)
- Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, 8405MedStar Washington Hospital Center, Washington, DC, USA
| | - Korbin Haycock
- Department of Emergency Medicine, 4608Loma Linda University Medical Center, Loma Linda, CA, USA
| | - Matthew Wiepking
- Department of Emergency Medicine and Surgery, 12223University of Southern California-Keck School of Medicine, Los Angeles, CA, USA
| | - Skyler Lentz
- Division of Emergency Medicine and Pulmonary Disease & Critical Care Medicine, Department of Surgery and Medicine, Larner College of 12352Medicine-University of Vermont, Burlington, VT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Matthew Siuba
- Department of Critical Care Medicine, Respiratory Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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The contemporary pulmonary artery catheter. Part 2: measurements, limitations, and clinical applications. J Clin Monit Comput 2021; 36:17-31. [PMID: 33646499 PMCID: PMC7917533 DOI: 10.1007/s10877-021-00673-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 02/08/2021] [Indexed: 12/25/2022]
Abstract
Nowadays, the classical pulmonary artery catheter (PAC) has an almost 50-year-old history of its clinical use for hemodynamic monitoring. In recent years, the PAC evolved from a device that enabled intermittent cardiac output measurements in combination with static pressures to a monitoring tool that provides continuous data on cardiac output, oxygen supply and-demand balance, as well as right ventricular performance. In this review, which consists of two parts, we will introduce the difference between intermittent pulmonary artery thermodilution using bolus injections, and the contemporary PAC enabling continuous measurements by using a thermal filament which heats up the blood. In this second part, we will discuss in detail the measurements of the contemporary PAC, including continuous cardiac output measurement, right ventricular ejection fraction, end-diastolic volume index, and mixed venous oxygen saturation. Limitations of all of these measurements are highlighted as well. We conclude that thorough understanding of measurements obtained from the PAC is the first step in successful application of the PAC in daily clinical practice.
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Flower L, Madhivathanan PR, Andorka M, Olusanya O, Roshdy A, Sanfilippo F. Getting the most from the subcostal view: The rescue window for intensivists. J Crit Care 2020; 63:202-210. [PMID: 32958350 DOI: 10.1016/j.jcrc.2020.09.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 08/30/2020] [Accepted: 09/01/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Luke Flower
- Department of Anaesthesia, University College London Hospitals NHS Trust, London, United Kingdom.
| | - Pradeep R Madhivathanan
- Department of Anaesthesia and Intensive Care, Royal Papworth Hospital NHS Foundation Trust, Cambridge, United Kingdom
| | - Matyas Andorka
- Department of Critical Care, Surrey and Sussex Healthcare NHS Trust, London, United Kingdom
| | - Olusegun Olusanya
- Department of Critical Care, Barts Heart Centre, Barts Health NHS Trust, London, United Kingdom
| | - Ashraf Roshdy
- Department of Critical Care, Whipps Cross University Hospital, Barts Health NHS Trust, London, United Kingdom; Critical Care Medicine department, Alexandria University, Alexandria, Egypt
| | - Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, AOU Policlinico-Vittorio Emanuele, University of Catania, Catania, Italy
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