1
|
Holton C, Shah S, Miller JO. New Right Ventricular Dysfunction in Pediatric Acute Respiratory Distress Syndrome on Venovenous Extracorporeal Membrane Oxygenation. ASAIO J 2024:00002480-990000000-00508. [PMID: 38896850 DOI: 10.1097/mat.0000000000002257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Abstract
The development of new right ventricular (RV) dysfunction after cannulation to venovenous (VV) extracorporeal membrane oxygenation (ECMO) and its association with worse outcomes is increasingly recognized in adult patients, however, no studies have evaluated this phenomenon in pediatric patients. We report results of a single-center retrospective cohort study at a large academic children's hospital. New RV systolic dysfunction was present in 48% (12/25) of pediatric patients on VV ECMO for acute respiratory distress syndrome (ARDS). There was no statistically significant difference in survival, duration of mechanical ventilation, or hospital length of stay between those with and without RV dysfunction. Over half (5/9, 56%) of survivors with RV dysfunction on ECMO had RV dilation or RV hypertrophy on post-ECMO echocardiograms, and in two patients the RV dysfunction persisted for months following decannulation. Cardiac catheterization and autopsy reports suggested that echocardiographic assessment of RV systolic function alone may not be sufficient to diagnose clinically relevant RV injury. This is the first study to report the prevalence of RV dysfunction on VV ECMO for pediatric ARDS. Future multicenter collaboration is needed to create a clinically relevant definition of pediatric "RV injury" and to further evaluate risk factors and outcomes of RV dysfunction.
Collapse
Affiliation(s)
- Caroline Holton
- From the Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
| | - Sanket Shah
- Division of Cardiology, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
| | - Jenna O Miller
- From the Division of Critical Care, Department of Pediatrics, University of Missouri-Kansas City and Children's Mercy Hospital, Kansas City, Missouri
| |
Collapse
|
2
|
Arora RC, Brown JK, Chatterjee S, Gan TJ, Singh G, Tong MZ. Perioperative management of the vulnerable and failing right ventricle. Perioper Med (Lond) 2024; 13:40. [PMID: 38750602 PMCID: PMC11097429 DOI: 10.1186/s13741-024-00397-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 05/05/2024] [Indexed: 05/18/2024] Open
Abstract
Under recognition combined with suboptimal management of right ventricular (RV) dysfunction and failure is associated with significant perioperative morbidity and mortality. The contemporary perioperative team must be prepared with an approach for early recognition and prompt treatment. In this review, a consensus-proposed scoring system is described to provide a pragmatic approach for expeditious decision-making for these complex patients with a vulnerable RV. Importantly, this proposed scoring system incorporates the context of the planned surgical intervention. Further, as the operating room (OR) represents a unique environment where patients are susceptible to numerous insults, a practical approach to anesthetic management and monitoring both in the OR and in the intensive care unit is detailed. Lastly, an escalating approach to the management of RV failure and options for mechanical circulatory support is provided.
Collapse
Affiliation(s)
- R C Arora
- Harrington Heart and Vascular Institute - University Hospitals, Cleveland, OH, USA.
- Department of Surgery, Case Western Reserve University, Cleveland, OH, USA.
| | - J K Brown
- Department of Anesthesiology and Perioperative Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - S Chatterjee
- Department of Surgery, Baylor College of Medicine, Houston, TX, USA
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, TX, USA
| | - T J Gan
- Division of Anesthesiology and Perioperative Medicine, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - G Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- Departments of Critical Care Medicine and Surgery, University of Alberta, Edmonton, AB, Canada
| | - M Z Tong
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
3
|
Alvarado-Socarras JL, Quintero-Lesmes DC, Martin DT, Vasquez R, Monsalve MM, Cristancho LM, Rojas LS, Martinez JL, Medina CR, Gomez CP. Maternal-Fetal Results of COVID-19-Infected Pregnant Women Treated with Extracorporeal Membrane Oxygenation: A Descriptive Report. Am J Perinatol 2024; 41:e2115-e2123. [PMID: 37216968 DOI: 10.1055/a-2097-1852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
OBJECTIVE COVID-19 infection may produce severe pneumonia, mainly in the adult population. Pregnant women with severe pneumonia are at high risk of developing complications, and conventional therapy sometimes fails to reverse hypoxemia. Therefore, extracorporeal membrane oxygenation (ECMO) is an option in cases with refractory hypoxemic respiratory failure. This study aims to evaluate the maternal-fetal risk factors, clinical characteristics, complications, and outcomes of 11 pregnant or peripartum patients with COVID-19 treated with ECMO. STUDY DESIGN This is a retrospective descriptive study of 11 pregnant women undergoing ECMO therapy during the COVID-19 pandemic. RESULTS In our cohort, four patients underwent ECMO during pregnancy (36.3%) and 7 during the postpartum period. Initially, they started on venovenous ECMO, and three patients were required to change modality due to clinical conditions. In total, 4/11 pregnant women (36.3%) died. We established two periods that differed in the implementation of a standardized care model for reducing associated morbidities and mortality. Neurological complications were responsible for most deaths. Regarding fetal outcomes at early-stage pregnancies on ECMO (4), we report three stillbirths (75%), and one newborn (twin pregnancy) survived and had a favorable evolution. CONCLUSION At later-stage pregnancies, all newborns survived, and we did not identify any vertical infection. ECMO therapy is an alternative for pregnant women with severe hypoxemic respiratory failure due to COVID-19, and may improve maternal and neonatal results. Regarding fetal outcomes, the gestational age played a definitive role. However, the main complications reported in our series and others are neurological. It is essential to develop novel, future interventions to prevent these complications.
Collapse
Affiliation(s)
| | - Doris C Quintero-Lesmes
- Research Center, Investigation Center, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Delia Theurel Martin
- Department of Pediatric-Neonatal Critical Care, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Raul Vasquez
- Department of Critical Care Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Mary Mendoza Monsalve
- ECMO Department, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Lizeth Mogollon Cristancho
- Department of Critical Care Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Leonardo Salazar Rojas
- ECMO Department, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Jenifer Leon Martinez
- Department of Radiology, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Carlos Riaño Medina
- Department of Perinatal Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Camilo Pizarro Gomez
- Department of Critical Care Medicine, Fundacion Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| |
Collapse
|
4
|
Dimarakis I, Aldea GS. Commentary: Extreme cardiorespiratory pathophysiology: Critical care evolution in response to a pandemic. J Thorac Cardiovasc Surg 2024; 167:1842-1844. [PMID: 36764913 PMCID: PMC9859641 DOI: 10.1016/j.jtcvs.2023.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 01/17/2023] [Indexed: 01/22/2023]
Affiliation(s)
- Ioannis Dimarakis
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash.
| | - Gabriel S Aldea
- Division of Cardiothoracic Surgery, Department of Surgery, University of Washington Medical Center, Seattle, Wash
| |
Collapse
|
5
|
Cain MT, Taylor LJ, Colborn K, Teman NR, Hoffman J, Mayer KP, Etchill EW, Sevin CM, Jaishankar S, Ramanan R, Enfield K, Zwischenberger JB, Jolley SE, Rove JY. Worse survival in patients with right ventricular dysfunction and COVID-19-associated acute respiratory distress requiring extracorporeal membrane oxygenation: A multicenter study from the ORACLE Group. J Thorac Cardiovasc Surg 2024; 167:1833-1841.e2. [PMID: 36717346 PMCID: PMC9767877 DOI: 10.1016/j.jtcvs.2022.12.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 12/08/2022] [Accepted: 12/16/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We sought to determine the impact of right ventricular dysfunction on the outcomes of mechanically ventilated patients with COVID-19 requiring veno-venous extracorporeal membrane oxygenation. METHODS Six academic centers conducted a retrospective analysis of mechanically ventilated patients with COVID-19 stratified by support with veno-venous extracorporeal membrane oxygenation during the first wave of the pandemic (March to August 2020). Echocardiograms performed for clinical indications were reviewed for right and left ventricular function. Baseline characteristics, hospitalization characteristics, and survival were compared. RESULTS The cohort included 424 mechanically ventilated patients with COVID-19, 126 of whom were cannulated for veno-venous extracorporeal membrane oxygenation. Right ventricular dysfunction was observed in 38.1% of patients who received extracorporeal membrane oxygenation and 27.4% of patients who did not receive extracorporeal membrane oxygenation with an echocardiogram. Biventricular dysfunction was observed in 5.5% of patients who received extracorporeal membrane oxygenation. Baseline patient characteristics were similar in both the extracorporeal membrane oxygenation and non-extracorporeal membrane oxygenation cohorts stratified by the presence of right ventricular dysfunction. In the extracorporeal membrane oxygenation cohort, right ventricular dysfunction was associated with increased inotrope use (66.7% vs 24.4%, P < .001), bleeding complications (77.1% vs 53.8%, P = .015), and worse survival independent of left ventricular dysfunction (39.6% vs 64.1%, P = .012). There was no significant difference in days ventilated before extracorporeal membrane oxygenation, length of hospital stay, hours on extracorporeal membrane oxygenation, duration of mechanical ventilation, vasopressor use, inhaled pulmonary vasodilator use, infectious complications, clotting complications, or stroke. The cohort without extracorporeal membrane oxygenation cohort demonstrated no statistically significant differences in in-hospital outcomes. CONCLUSIONS The presence of right ventricular dysfunction in patients with COVID-19-related acute respiratory distress syndrome supported with veno-venous extracorporeal membrane oxygenation was associated with increased in-hospital mortality. Additional studies are required to determine if mitigating right ventricular dysfunction in patients requiring veno-venous extracorporeal membrane oxygenation improves mortality.
Collapse
Affiliation(s)
- Michael T Cain
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Lauren J Taylor
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Kathryn Colborn
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Nicholas R Teman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Va
| | - Jordan Hoffman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Kirby P Mayer
- Department of Physical Therapy, College of Health Sciences, University of Kentucky, Lexington, Ky
| | - Eric W Etchill
- Division of Cardiothoracic Surgery, Department of Surgery, Johns Hopkins University, Baltimore, Md
| | - Carla M Sevin
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University, Nashville, Tenn
| | | | - Raj Ramanan
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pa
| | - Kyle Enfield
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Virginia, Charlottesville, Va
| | - Joseph B Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, University of Kentucky, Lexington, Ky
| | - Sarah E Jolley
- Division of Pulmonary Sciences and Critical Care, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, Colo
| | - Jessica Y Rove
- Division of Cardiothoracic Surgery, Department of Surgery, University of Colorado Anschutz Medical Campus, Aurora, Colo.
| |
Collapse
|
6
|
Bagate F, Masi P, Boukantar M, Radu C, Saiydoun G, Fiore A, Chiaroni PM, Teiger E, Folliguet T, Gallet R, Mekontso Dessap A. Refractory cor pulmonale under extracorporeal membrane oxygenation for acute respiratory distress syndrome: the role of conversion to veno-pulmonary arterial assist-a case series. Front Med (Lausanne) 2024; 11:1348077. [PMID: 38725464 PMCID: PMC11079173 DOI: 10.3389/fmed.2024.1348077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Accepted: 04/05/2024] [Indexed: 05/12/2024] Open
Abstract
Introduction Pulmonary vascular dysfunction during severe acute respiratory distress syndrome (ARDS) may lead to right ventricle (RV) dysfunction and acute cor pulmonale (ACP). The occurrence/persistence of ACP despite conventional extracorporeal membrane oxygenation (ECMO) is a challenging situation. We explored the usefulness of a specific dual-lumen cannula that bypasses the RV, and on which a veno-pulmonary arterial assist (V-P ECMO) was mounted, in ARDS patients. Methods We report a case-series of ARDS patients put on conventional veno-arterial or veno-venous ECMO and presented refractory ACP as an indication for a reconfiguration to V-P ECMO using the ProtekDuo cannula. The primary endpoint was the mitigation of RV and pulmonary vascular dysfunction as assessed by the change in end-diastolic RV/left ventricle (LV) surface ratio. Results Six patients had their conventional ECMO reconfigured to V-P ECMO to treat refractory ACP. There was a decrease in end-diastolic RV/LV surface ratio, as well as end-systolic LV eccentricity index, and lactatemia immediately after V-P ECMO initiation. The resolution of refractory ACP was immediately achieved in four of our six (66%) patients. The V-P ECMO was weaned after a median of 26 [8-93] days after implantation. All but one patient were discharged home. We detected one case of severe hemolysis with V-P ECMO and two suspected cases of right-sided infective endocarditis. Conclusion V-P ECMO is useful to mitigate RV overload and to improve hemodynamics in case of refractory ACP despite conventional ECMO.
Collapse
Affiliation(s)
- François Bagate
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
| | - Paul Masi
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
| | - Madjid Boukantar
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
| | - Costin Radu
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Gabriel Saiydoun
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Antonio Fiore
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | | | - Emmanuel Teiger
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
| | - Thierry Folliguet
- APHP, Hôpitaux Universitaires Henri Mondor, Département de Chirurgie Cardiaque, Créteil, France
| | - Romain Gallet
- APHP, Hôpitaux Universitaires Henri Mondor, Service de Cardiologie, Créteil, France
- U955-IMRB, Equipe 03, Inserm, Univ Paris Est Créteil (UPEC), Ecole Nationale Vétérinaire d’Alfort (EnVA), Maisons-Alfort, France
| | - Armand Mekontso Dessap
- AP-HP, Hôpitaux Universitaires Henri Mondor, DHU A-TVB, Service de Médecine Intensive Réanimation, Créteil, France
- Université Paris Est Créteil, Faculté de Médecine, Groupe de recherche clinique CARMAS, Créteil, France
- INSERM U955, Institut Mondor de Recherche Biomédicale, Créteil, France
| |
Collapse
|
7
|
Santos A, Monge-García MI, Borges JB, Retamal J, Tusman G, Larsson A, Suarez-Sipmann F. Impact of respiratory cycle during mechanical ventilation on beat-to-beat right ventricle stroke volume estimation by pulmonary artery pulse wave analysis. Intensive Care Med Exp 2024; 12:34. [PMID: 38592650 PMCID: PMC11004097 DOI: 10.1186/s40635-024-00618-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 03/28/2024] [Indexed: 04/10/2024] Open
Abstract
BACKGROUND The same principle behind pulse wave analysis can be applied on the pulmonary artery (PA) pressure waveform to estimate right ventricle stroke volume (RVSV). However, the PA pressure waveform might be influenced by the direct transmission of the intrathoracic pressure changes throughout the respiratory cycle caused by mechanical ventilation (MV), potentially impacting the reliability of PA pulse wave analysis (PAPWA). We assessed a new method that minimizes the direct effect of the MV on continuous PA pressure measurements and enhances the reliability of PAPWA in tracking beat-to-beat RVSV. METHODS Continuous PA pressure and flow were simultaneously measured for 2-3 min in 5 pigs using a high-fidelity micro-tip catheter and a transonic flow sensor around the PA trunk, both pre and post an experimental ARDS model. RVSV was estimated by PAPWA indexes such as pulse pressure (SVPP), systolic area (SVSystAUC) and standard deviation (SVSD) beat-to-beat from both corrected and non-corrected PA signals. The reference RVSV was derived from the PA flow signal (SVref). RESULTS The reliability of PAPWA in tracking RVSV on a beat-to-beat basis was enhanced after accounting for the direct impact of intrathoracic pressure changes induced by MV throughout the respiratory cycle. This was evidenced by an increase in the correlation between SVref and RVSV estimated by PAPWA under healthy conditions: rho between SVref and non-corrected SVSD - 0.111 (0.342), corrected SVSD 0.876 (0.130), non-corrected SVSystAUC 0.543 (0.141) and corrected SVSystAUC 0.923 (0.050). Following ARDS, correlations were SVref and non-corrected SVSD - 0.033 (0.262), corrected SVSD 0.839 (0.077), non-corrected SVSystAUC 0.483 (0.114) and corrected SVSystAUC 0.928 (0.026). Correction also led to reduced limits of agreement between SVref and SVSD and SVSystAUC in the two evaluated conditions. CONCLUSIONS In our experimental model, we confirmed that correcting for mechanical ventilation induced changes during the respiratory cycle improves the performance of PAPWA for beat-to-beat estimation of RVSV compared to uncorrected measurements. This was demonstrated by a better correlation and agreement between the actual SV and the obtained from PAPWA.
Collapse
Affiliation(s)
- Arnoldo Santos
- Intensive Care Medicine Department. Hospital, Universitario Fundación Jiménez Díaz. IIS-FJD, Madrid, Spain.
- CIBER de Enfermedades Respiratorias CIBERES ISCIII, Madrid, Spain.
- Universidad Alfonso X El Sabio, Madrid, Spain.
| | - M Ignacio Monge-García
- Unidad de Cuidados Críticos, Hospital Universitario SAS de Jerez, Jerez de La Frontera, Spain
| | - João Batista Borges
- First Faculty of Medicine, Institute of Physiology, Charles University, Prague, Czechia
| | - Jaime Retamal
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gerardo Tusman
- Department of Anesthesia, Hospital Privado de Comunidad, Mar del Plata, Argentina
| | - Anders Larsson
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Fernando Suarez-Sipmann
- CIBER de Enfermedades Respiratorias CIBERES ISCIII, Madrid, Spain
- Department of Critical Care, Hospital Universitario de la Princesa, Madrid, Spain
| |
Collapse
|
8
|
Franchi F, Detti E, Fogagnolo A, Spadaro S, Cevenini G, Cataldo G, Addabbo T, Biuzzi C, Marianello D, Volta CA, Taccone FS, Scolletta S. Estimation of the transpulmonary pressure from the central venous pressure in mechanically ventilated patients. J Clin Monit Comput 2024:10.1007/s10877-024-01150-5. [PMID: 38512359 DOI: 10.1007/s10877-024-01150-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/05/2024] [Indexed: 03/23/2024]
Abstract
Transpulmonary pressure (PL) calculation requires esophageal pressure (PES) as a surrogate of pleural pressure (Ppl), but its calibration is a cumbersome technique. Central venous pressure (CVP) swings may reflect tidal variations in Ppl and could be used instead of PES, but the interpretation of CVP waveforms could be difficult due to superposition of heartbeat-induced pressure changes. Thus, we developed a digital filter able to remove the cardiac noise to obtain a filtered CVP (f-CVP). The aim of the study was to evaluate the accuracy of CVP and filtered CVP swings (ΔCVP and Δf-CVP, respectively) in estimating esophageal respiratory swings (ΔPES) and compare PL calculated with CVP, f-CVP and PES; then we tested the diagnostic accuracy of the f-CVP method to identify unsafe high PL levels, defined as PL>10 cmH2O. Twenty patients with acute respiratory failure (defined as PaO2/FiO2 ratio below 200 mmHg) treated with invasive mechanical ventilation and monitored with an esophageal balloon and central venous catheter were enrolled prospectively. For each patient a recording session at baseline was performed, repeated if a modification in ventilatory settings occurred. PES, CVP and airway pressure during an end-inspiratory and -expiratory pause were simultaneously recorded; CVP, f-CVP and PES waveforms were analyzed off-line and used to calculate transpulmonary pressure (PLCVP, PLf-CVP, PLPES, respectively). Δf-CVP correlated better than ΔCVP with ΔPES (r = 0.8, p = 0.001 vs. r = 0.08, p = 0.73), with a lower bias in Bland Altman analysis in favor of PLf-CVP (mean bias - 0.16, Limits of Agreement (LoA) -1.31, 0.98 cmH2O vs. mean bias - 0.79, LoA - 3.14, 1.55 cmH2O). Both PLf-CVP and PLCVP correlated well with PLPES (r = 0.98, p < 0.001 vs. r = 0.94, p < 0.001), again with a lower bias in Bland Altman analysis in favor of PLf-CVP (0.15, LoA - 0.95, 1.26 cmH2O vs. 0.80, LoA - 1.51, 3.12, cmH2O). PLf-CVP discriminated high PL value with an area under the receiver operating characteristic curve 0.99 (standard deviation, SD, 0.02) (AUC difference = 0.01 [-0.024; 0.05], p = 0.48). In mechanically ventilated patients with acute respiratory failure, the digital filtered CVP estimated ΔPES and PL obtained from digital filtered CVP represented a reliable value of standard PL measured with the esophageal method and could identify patients with non-protective ventilation settings.
Collapse
Affiliation(s)
- Federico Franchi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy.
| | - Emanuele Detti
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Alberto Fogagnolo
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Savino Spadaro
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Gabriele Cevenini
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Gennaro Cataldo
- Department of Medical Biotechnologies, University of Siena, 53100, Siena, Italy
| | - Tommaso Addabbo
- Department of Information Engineering and Mathematics, University of Siena, 53100, Siena, Italy
| | - Cesare Biuzzi
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Daniele Marianello
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| | - Carlo Alberto Volta
- Intensive Care Unit, Department of Translational Medicine and for Romagna, Azienda Ospedaliera Universitaria di Ferrara, University of Ferrara, 44121, Ferrara, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, 1070, Belgium
| | - Sabino Scolletta
- Department of Medicine, Surgery and Neurosciences, Anesthesia and Intensive Care Unit, University Hospital of Siena, Viale Bracci 10, Siena, 53100, Italy
| |
Collapse
|
9
|
Rubulotta F, Blanch Torra L, Naidoo KD, Aboumarie HS, Mathivha LR, Asiri AY, Sarlabous Uranga L, Soussi S. Mechanical Ventilation, Past, Present, and Future. Anesth Analg 2024; 138:308-325. [PMID: 38215710 DOI: 10.1213/ane.0000000000006701] [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: 01/14/2024]
Abstract
Mechanical ventilation (MV) has played a crucial role in the medical field, particularly in anesthesia and in critical care medicine (CCM) settings. MV has evolved significantly since its inception over 70 years ago and the future promises even more advanced technology. In the past, ventilation was provided manually, intermittently, and it was primarily used for resuscitation or as a last resort for patients with severe respiratory or cardiovascular failure. The earliest MV machines for prolonged ventilatory support and oxygenation were large and cumbersome. They required a significant amount of skills and expertise to operate. These early devices had limited capabilities, battery, power, safety features, alarms, and therefore these often caused harm to patients. Moreover, the physiology of MV was modified when mechanical ventilators moved from negative pressure to positive pressure mechanisms. Monitoring systems were also very limited and therefore the risks related to MV support were difficult to quantify, predict and timely detect for individual patients who were necessarily young with few comorbidities. Technology and devices designed to use tracheostomies versus endotracheal intubation evolved in the last century too and these are currently much more reliable. In the present, positive pressure MV is more sophisticated and widely used for extensive period of time. Modern ventilators use mostly positive pressure systems and are much smaller, more portable than their predecessors, and they are much easier to operate. They can also be programmed to provide different levels of support based on evolving physiological concepts allowing lung-protective ventilation. Monitoring systems are more sophisticated and knowledge related to the physiology of MV is improved. Patients are also more complex and elderly compared to the past. MV experts are informed about risks related to prolonged or aggressive ventilation modalities and settings. One of the most significant advances in MV has been protective lung ventilation, diaphragm protective ventilation including noninvasive ventilation (NIV). Health care professionals are familiar with the use of MV and in many countries, respiratory therapists have been trained for the exclusive purpose of providing safe and professional respiratory support to critically ill patients. Analgo-sedation drugs and techniques are improved, and more sedative drugs are available and this has an impact on recovery, weaning, and overall patients' outcome. Looking toward the future, MV is likely to continue to evolve and improve alongside monitoring techniques and sedatives. There is increasing precision in monitoring global "patient-ventilator" interactions: structure and analysis (asynchrony, desynchrony, etc). One area of development is the use of artificial intelligence (AI) in ventilator technology. AI can be used to monitor patients in real-time, and it can predict when a patient is likely to experience respiratory distress. This allows medical professionals to intervene before a crisis occurs, improving patient outcomes and reducing the need for emergency intervention. This specific area of development is intended as "personalized ventilation." It involves tailoring the ventilator settings to the individual patient, based on their physiology and the specific condition they are being treated for. This approach has the potential to improve patient outcomes by optimizing ventilation and reducing the risk of harm. In conclusion, MV has come a long way since its inception, and it continues to play a critical role in anesthesia and in CCM settings. Advances in technology have made MV safer, more effective, affordable, and more widely available. As technology continues to improve, more advanced and personalized MV will become available, leading to better patients' outcomes and quality of life for those in need.
Collapse
Affiliation(s)
- Francesca Rubulotta
- From the Department of Critical Care Medicine, McGill University, Montreal, Quebec, Canada
| | - Lluis Blanch Torra
- Department of Critical Care, Parc Taulí Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Kuban D Naidoo
- Division of Critical Care, University of Witwatersrand, Johannesburg, South Africa
| | - Hatem Soliman Aboumarie
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, Harefield Hospital, Royal Brompton and Harefield Hospitals, London, United Kingdom
- School of Cardiovascular and Metabolic Medicine and Sciences, King's College London, London, United Kingdom
| | - Lufuno R Mathivha
- Department of Anaesthetics, Critical Care and Mechanical Circulatory Support, The Chris Hani Baragwanath Academic Hospital, University of the Witwatersrand
| | - Abdulrahman Y Asiri
- Department of Internal Medicine and Critical Care, King Khalid University Medical City, Abha, Saudi Arabia
- Department of Critical Care Medicine, McGill University
| | - Leonardo Sarlabous Uranga
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, Spain
| | - Sabri Soussi
- Department of Anesthesia and Pain Management, University Health Network - Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto
- UMR-S 942, Cardiovascular Markers in Stress Conditions (MASCOT), Institut national de la santé et de la recherche médicale (INSERM), Université de Paris Cité, France
| |
Collapse
|
10
|
McGuigan PJ, Bowcock EM, Barrett NA, Blackwood B, Boyle AJ, Cadamy AJ, Camporota L, Conlon J, Cove ME, Gillies MA, McDowell C, McNamee JJ, O'Kane CM, Puxty A, Sim M, Parsons-Simmonds R, Szakmany T, Young N, Orde S, McAuley DF. The Effect of Lower Tidal Volume Ventilation Facilitated by Extracorporeal Carbon Dioxide Removal Compared With Conventional Lung Protective Ventilation on Cardiac Function. Crit Care Explor 2024; 6:e1028. [PMID: 38213419 PMCID: PMC10783412 DOI: 10.1097/cce.0000000000001028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2024] Open
Abstract
OBJECTIVES Lower tidal volume ventilation (targeting 3 mL/kg predicted body weight, PBW) facilitated by extracorporeal carbon dioxide removal (ECCO2R) has been investigated as a potential therapy for acute hypoxemic respiratory failure (AHRF) in the pRotective vEntilation with veno-venouS lung assisT in respiratory failure (REST) trial. We investigated the effect of this strategy on cardiac function, and in particular the right ventricle. DESIGN Substudy of the REST trial. SETTING Nine U.K. ICUs. PATIENTS Patients with AHRF (Pao2/Fio2 < 150 mm Hg [20 kPa]). INTERVENTION Transthoracic echocardiography and N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements were collected at baseline and postrandomization in patients randomized to ECCO2R or usual care. MEASUREMENTS The primary outcome measures were a difference in tricuspid annular plane systolic excursion (TAPSE) on postrandomization echocardiogram and difference in NT-proBNP postrandomization. RESULTS There were 21 patients included in the echocardiography cohort (ECCO2R, n = 13; usual care, n = 8). Patient characteristics were similar in both groups at baseline. Median (interquartile range) tidal volumes were lower in the ECCO2R group compared with the usual care group postrandomization; 3.6 (3.1-4.2) mL/kg PBW versus 5.2 (4.9-5.7) mL/kg PBW, respectively (p = 0.01). There was no difference in the primary outcome measure of mean (sd) TAPSE in the ECCO2R and usual care groups postrandomization; 21.3 (5.4) mm versus 20.1 (3.2) mm, respectively (p = 0.60). There were 75 patients included in the NT-proBNP cohort (ECCO2R, n = 36; usual care, n = 39). Patient characteristics were similar in both groups at baseline. Median (interquartile range [IQR]) tidal volumes were lower in the ECCO2R group than the usual care group postrandomization; 3.8 (3.3-4.2) mL/kg PBW versus 6.7 (5.8-8.1) mL/kg PBW, respectively (p < 0.0001). There was no difference in median (IQR) NT-proBNP postrandomization; 1121 (241-5370) pg/mL versus 1393 (723-4332) pg/mL in the ECCO2R and usual care groups, respectively (p = 0.30). CONCLUSIONS In patients with AHRF, a reduction in tidal volume facilitated by ECCO2R, did not modify cardiac function.
Collapse
Affiliation(s)
- Peter J McGuigan
- Royal Victoria Hospital, Belfast, United Kingdom
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Emma M Bowcock
- Nepean Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Nicholas A Barrett
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew J Boyle
- Royal Victoria Hospital, Belfast, United Kingdom
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Andrew J Cadamy
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
- School of Medicine, Dentistry, and Nursing, University of Glasgow, Glasgow, United Kingdom
| | - Luigi Camporota
- Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
- Centre for Human and Applied Physiological Sciences, King's College London, London, United Kingdom
| | - John Conlon
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | | | | | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Belfast, United Kingdom
| | | | - Cecilia M O'Kane
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| | - Alex Puxty
- Glasgow Royal Infirmary, Glasgow, United Kingdom
| | - Malcolm Sim
- Queen Elizabeth University Hospital, Glasgow, United Kingdom
| | | | - Tamas Szakmany
- Royal Gwent Hospital, Aneurin Bevan University Health Board, Newport, United Kingdom
- Department of Anaesthesia Intensive Care and Pain Medicine, Cardiff University, Cardiff, United Kingdom
| | - Neil Young
- Edinburgh Royal Infirmary, Edinburgh, United Kingdom
| | - Sam Orde
- Nepean Hospital, Sydney, Australia
- University of Sydney, Sydney, Australia
| | - Daniel F McAuley
- Royal Victoria Hospital, Belfast, United Kingdom
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, United Kingdom
| |
Collapse
|
11
|
Ferraz JFFM, Siuba MT, Krishnan S, Chatburn RL, Mireles-Cabodevila E, Duggal A. Physiologic Markers of Disease Severity in ARDS. Respir Care 2023; 68:1708-1718. [PMID: 37438051 PMCID: PMC10676265 DOI: 10.4187/respcare.11100] [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] [Received: 04/03/2023] [Accepted: 07/06/2023] [Indexed: 07/14/2023]
Abstract
Despite its significant limitations, the PaO2 /FIO2 remains the standard tool to classify disease severity in ARDS. Treatment decisions and research enrollment have depended on this parameter for over 50 years. In addition, several variables have been studied over the past few decades, incorporating other physiologic considerations such as ventilation efficiency, lung mechanics, and right-ventricular performance. This review describes the strengths and limitations of all relevant parameters, with the goal of helping us better understand disease severity and possible future treatment targets.
Collapse
Affiliation(s)
- Joao F F M Ferraz
- Department of Hospital Medicine, Community Care Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Sudhir Krishnan
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Robert L Chatburn
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Eduardo Mireles-Cabodevila
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio.
| |
Collapse
|
12
|
Evrard B, Woillard JB, Legras A, Bouaoud M, Gourraud M, Humeau A, Goudelin M, Vignon P. Diagnostic, prognostic and clinical value of left ventricular radial strain to identify paradoxical septal motion in ventilated patients with the acute respiratory distress syndrome: an observational prospective multicenter study. Crit Care 2023; 27:424. [PMID: 37919787 PMCID: PMC10623720 DOI: 10.1186/s13054-023-04716-y] [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] [Received: 09/01/2023] [Accepted: 10/31/2023] [Indexed: 11/04/2023] Open
Abstract
BACKGROUND Acute cor pulmonale (ACP) is prognostic in patients with acute respiratory distress syndrome (ARDS). Identification of paradoxical septal motion (PSM) using two-dimensional echocardiography is highly subjective. We sought to describe feature-engineered metrics derived from LV radial strain changes related to PSM in ARDS patients with ACP of various severity and to illustrate potential diagnostic and prognostic yield. METHODS This prospective bicentric study included patients under protective ventilation for ARDS related to COVID-19 who were assessed using transesophageal echocardiography (TEE). Transgastric short-axis view at mid-papillary level was used to visually grade septal motion, using two-dimensional imaging, solely and combined with LV radial strain: normal (grade 0), transient end-systolic septal flattening (grade 1), prolonged end-systolic septal flattening or reversed septal curvature (grade 2). Inter-observer variability was calculated. Feature engineering was performed to calculate the time-to-peak and area under the strain curve in 6 LV segments. In the subset of patients with serial TEE examinations, a multivariate Cox model analysis accounting for new-onset of PSM as a time-dependent variable was used to identify parameters associated with ICU mortality. RESULTS Overall, 310 TEE examinations performed in 182 patients were analyzed (age: 67 [60-72] years; men: 66%; SAPSII: 35 [29-40]). Two-dimensional assessment identified a grade 1 and grade 2 PSM in 100 (32%) and 48 (15%) examinations, respectively. Inter-rater reliability was weak using two-dimensional imaging alone (kappa = 0.49; 95% CI 0.40-0.58; p < 0.001) and increased with associated LV radial strain (kappa = 0.84, 95% CI 0.79-0.90, p < 0.001). The time-to-peak of mid-septal and mid-lateral segments occurred significantly later in systole and increased with the grade of PSM. Similarly, the area under the strain curve of these segments increased significantly with the grade of PSM, compared with mid-anterior or mid-inferior segments. Severe acute cor pulmonale with a grade 2 PSM was significantly associated with mortality. Requalification in an upper PSM grade using LV radial strain allowed to better identify patients at risk of death (HR: 6.27 [95% CI 2.28-17.2] vs. 2.80 [95% CI 1.11-7.09]). CONCLUSIONS In objectively depicting PSM and quantitatively assessing its severity, TEE LV radial strain appears as a valuable adjunct to conventional two-dimensional imaging.
Collapse
Affiliation(s)
- Bruno Evrard
- Medical-Surgical ICU, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 87042, Limoges Cedex, France.
| | - Jean-Baptiste Woillard
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
- Pharmacology & Transplantation, INSERM U1248, University of Limoges, Limoges, France
- Faculty of Medicine, University of Limoges, 87000, Limoges, France
- Department of Pharmacology, Toxicology and Pharmacovigilance, University Hospital of Limoges, Limoges, France
| | - Annick Legras
- Intensive Care Unit, Tours Teaching Hospital, Tours, France
| | | | - Maeva Gourraud
- Intensive Care Unit, Tours Teaching Hospital, Tours, France
| | - Antoine Humeau
- Pharmacology & Transplantation, INSERM U1248, University of Limoges, Limoges, France
| | - Marine Goudelin
- Medical-Surgical ICU, Dupuytren Teaching Hospital, 87000, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Philippe Vignon
- Medical-Surgical ICU, Dupuytren Teaching Hospital, 87000, Limoges, France
- Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
- Faculty of Medicine, University of Limoges, 87000, Limoges, France
| |
Collapse
|
13
|
Yusuff H, Chawla S, Sato R, Dugar S, Bangash MN, Antonini MV, Shelley B, Valchanov K, Roscoe A, Scott J, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Zochios V. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 2. J Cardiothorac Vasc Anesth 2023; 37:2318-2326. [PMID: 37625918 DOI: 10.1053/j.jvca.2023.07.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 07/05/2023] [Accepted: 07/17/2023] [Indexed: 08/27/2023]
Abstract
The right ventricle (RV) is intricately linked in the clinical presentation of critical illness; however, the basis of this is not well-understood and has not been studied as extensively as the left ventricle. There has been an increased awareness of the need to understand how the RV is affected in different critical illness states. In addition, the increased use of point-of-care echocardiography in the critical care setting has allowed for earlier identification and monitoring of the RV in a patient who is critically ill. The first part of this review describes and characterizes the RV in different perioperative states. This second part of the review discusses and analyzes the complex pathophysiologic relationships between the RV and different critical care states. There is a lack of a universal RV injury definition because it represents a range of abnormal RV biomechanics and phenotypes. The term "RV injury" (RVI) has been used to describe a spectrum of presentations, which includes diastolic dysfunction (early injury), when the RV retains the ability to compensate, to RV failure (late or advanced injury). Understanding the mechanisms leading to functional 'uncoupling' between the RV and the pulmonary circulation may enable perioperative physicians, intensivists, and researchers to identify clinical phenotypes of RVI. This, consequently, may provide the opportunity to test RV-centric hypotheses and potentially individualize therapies.
Collapse
Affiliation(s)
- Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom.
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Mindelsohn Way, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Outram Road, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Centre Singapore, Singapore
| | - Jeffrey Scott
- Jackson Health System / Miami Transplant Institute, Miami, FL
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| |
Collapse
|
14
|
Zochios V, Shelley B, Antonini MV, Chawla S, Sato R, Dugar S, Valchanov K, Roscoe A, Scott J, Bangash MN, Akhtar W, Rosenberg A, Dimarakis I, Khorsandi M, Yusuff H. Mechanisms of Acute Right Ventricular Injury in Cardiothoracic Surgical and Critical Care Settings: Part 1. J Cardiothorac Vasc Anesth 2023; 37:2073-2086. [PMID: 37393133 DOI: 10.1053/j.jvca.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/21/2023] [Accepted: 06/07/2023] [Indexed: 07/03/2023]
Affiliation(s)
- Vasileios Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.
| | - Benjamin Shelley
- Department of Cardiothoracic Anesthesia and Intensive Care, Golden Jubilee National Hospital, Clydebank, United Kingdom; Anesthesia, Perioperative Medicine and Critical Care research group, University of Glasgow, Glasgow, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy; Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Ryota Sato
- Division of Critical Care Medicine, Department of Medicine, The Queen's Medical Center, Honolulu, HI
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Kamen Valchanov
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore
| | - Andrew Roscoe
- Department of Anesthesia and Perioperative Medicine, Singapore General Hospital, Singapore; Department of Anesthesiology, Singapore General Hospital, National Heart Center, Singapore
| | - Jeffrey Scott
- Jackson Health System, Miami Transplant Institute, Miami, FL
| | - Mansoor N Bangash
- Liver Intensive Care Unit, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom; Birmingham Liver Failure Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom; Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, College of Medical and Dental sciences, University of Birmingham, Birmingham, United Kingdom
| | - Waqas Akhtar
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Alex Rosenberg
- Royal Brompton and Harefield Hospitals, Part of Guys and St. Thomas's National Health System Foundation Trust, London, United Kingdom
| | - Ioannis Dimarakis
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Maziar Khorsandi
- Division of Cardiothoracic Surgery, University of Washington Medical Center, Seattle, WA
| | - Hakeem Yusuff
- Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom; Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| |
Collapse
|
15
|
Webb L, Burton L, Manchikalapati A, Prabhakaran P, Loberger JM, Richter RP. Cardiac dysfunction in severe pediatric acute respiratory distress syndrome: the right ventricle in search of the right therapy. Front Med (Lausanne) 2023; 10:1216538. [PMID: 37654664 PMCID: PMC10466806 DOI: 10.3389/fmed.2023.1216538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Accepted: 07/21/2023] [Indexed: 09/02/2023] Open
Abstract
Severe acute respiratory distress syndrome in children, or PARDS, carries a high risk of morbidity and mortality that is not fully explained by PARDS severity alone. Right ventricular (RV) dysfunction can be an insidious and often under-recognized complication of severe PARDS that may contribute to its untoward outcomes. Indeed, recent evidence suggest significantly worse outcomes in children who develop RV failure in their course of PARDS. However, in this narrative review, we highlight the dearth of evidence regarding the incidence of and risk factors for PARDS-associated RV dysfunction. While we wish to draw attention to the absence of available evidence that would inform recommendations around surveillance and treatment of RV dysfunction during severe PARDS, we leverage available evidence to glean insights into potentially helpful surveillance strategies and therapeutic approaches.
Collapse
Affiliation(s)
- Lece Webb
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Luke Burton
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Ananya Manchikalapati
- Division of Pediatric Critical Care, Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Priya Prabhakaran
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Jeremy M. Loberger
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Robert P. Richter
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL, United States
| |
Collapse
|
16
|
Owyang CG, Rippon B, Teran F, Brodie D, Araos J, Burkhoff D, Kim J, Tonna JE. Pulmonary Artery Pressures and Mortality during VA ECMO: An ELSO Registry Analysis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.08.08.23293859. [PMID: 37645725 PMCID: PMC10462237 DOI: 10.1101/2023.08.08.23293859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
Background Systemic hemodynamics and specific ventilator settings have been shown to predict survival during venoarterial extracorporeal membrane oxygenation (VA ECMO). While these factors are intertwined with right ventricular (RV) function, the independent relationship between RV function and survival during VA ECMO is unknown. Objectives To identify the relationship between RV function with mortality and duration of ECMO support. Methods Cardiac ECMO runs in adults from the Extracorporeal Life Support Organization (ELSO) Registry between 2010 and 2022 were queried. RV function was quantified via pulmonary artery pulse pressure (PAPP) for pre-ECMO and on-ECMO periods. A multivariable model was adjusted for Society for Cardiovascular Angiography and Interventions (SCAI) stage, age, gender, and concurrent clinical data (i.e., pulmonary vasodilators and systemic pulse pressure). The primary outcome was in-hospital mortality. Results A total of 4,442 ECMO runs met inclusion criteria and had documentation of hemodynamic and illness severity variables. The mortality rate was 55%; non-survivors were more likely to be older, have a worse SCAI stage, and have longer pre-ECMO endotracheal intubation times (P < 0.05 for all) than survivors. Improving PAPP from pre-ECMO to on-ECMO time (Δ PAPP) was associated with reduced mortality per 10 mm Hg increase (OR: 0.91 [95% CI: 0.86-0.96]; P=0.002). Increasing on-ECMO PAPP was associated with longer time on ECMO per 10 mm Hg (Beta: 15 [95% CI: 7.7-21]; P<0.001). Conclusions Early improvements in RV function from pre-ECMO values were associated with mortality reduction during cardiac ECMO. Incorporation of Δ PAPP into risk prediction models should be considered.
Collapse
Affiliation(s)
- Clark G. Owyang
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Brady Rippon
- Department of Population Health Sciences, Weill Cornell Medical College, New York, New York, USA
| | - Felipe Teran
- Department of Emergency Medicine, NewYork-Presbyterian Hospital/Weill Cornell Medical College, New York, New York, USA
| | - Daniel Brodie
- Department of Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Joaquin Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY, United States
| | | | - Jiwon Kim
- Division of Cardiology, Department of Medicine, Weill Cornell Medicine/New York Presbyterian Hospital, 525 East 68th Street, New York, NY, 10021, USA
| | - Joseph E. Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, UT, USA; Department of Emergency Medicine, University of Utah Health, Salt Lake City, UT, USA
| |
Collapse
|
17
|
Zainab A, Gooch M, Tuazon DM. Acute Respiratory Distress Syndrome in Patients with Cardiovascular Disease. Methodist Debakey Cardiovasc J 2023; 19:58-65. [PMID: 37547902 PMCID: PMC10402823 DOI: 10.14797/mdcvj.1244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 04/27/2023] [Indexed: 08/08/2023] Open
Abstract
Heart and lung interaction within the thoracic cavity is well known during inhalation and exhalation, both spontaneously and during mechanical ventilation. Disease and dysfunction of one organ affect the function of the other. A review of the cause-and-effect relationship between cardiovascular disease and acute respiratory distress syndrome (ARDS) is of significance, as the disease burden of both conditions has both a national and global impact on health care. This literature review examines the relationship between cardiovascular disease and ARDS over the past 25 years.
Collapse
Affiliation(s)
- Asma Zainab
- Methodist DeBakey Heart & Vascular Center, Houston Methodist, Houston, Texas, US
- Weill Cornell Medical College, New York, US
| | | | | |
Collapse
|
18
|
Huang S, Vieillard-Baron A, Evrard B, Prat G, Chew MS, Balik M, Clau-Terré F, De Backer D, Mekontso Dessap A, Orde S, Morelli A, Sanfilippo F, Charron C, Vignon P. Echocardiography phenotypes of right ventricular involvement in COVID-19 ARDS patients and ICU mortality: post-hoc (exploratory) analysis of repeated data from the ECHO-COVID study. Intensive Care Med 2023; 49:946-956. [PMID: 37436445 DOI: 10.1007/s00134-023-07147-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/18/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE Exploratory study to evaluate the association of different phenotypes of right ventricular (RV) involvement and mortality in the intensive care unit (ICU) in patients with acute respiratory distress syndrome (ARDS) due to coronavirus disease 2019 (COVID-19). METHODS Post-hoc analysis of longitudinal data from the multicenter ECHO-COVID observational study in ICU patients who underwent at least two echocardiography examinations. Echocardiography phenotypes were acute cor pulmonale (ACP, RV cavity dilatation with paradoxical septal motion), RV failure (RVF, RV cavity dilatation and systemic venous congestion), and RV dysfunction (tricuspid annular plane systolic excursion ≤ 16 mm). Accelerated failure time model and multistate model were used for analysis. RESULTS Of 281 patients who underwent 948 echocardiography studies during ICU stay, 189 (67%) were found to have at least 1 type of RV involvements during one or several examinations: ACP (105/281, 37.4%), RVF (140/256, 54.7%) and/or RV dysfunction (74/255, 29%). Patients with all examinations displaying ACP had survival time shortened by 0.479 [0.284-0.803] times when compared to patients with all examinations depicting no ACP (P = 0.005). RVF showed a trend towards shortened survival time by a factor of 0.642 [0.405-1.018] (P = 0.059), whereas the impact of RV dysfunction on survival time was inconclusive (P = 0.451). Multistate analysis showed that patients might transit in and out of RV involvement, and those who exhibited ACP in their last critical care echocardiography (CCE) examination had the highest risk of mortality (hazard ratio (HR) 3.25 [2.38-4.45], P < 0.001). CONCLUSION RV involvement is prevalent in patients ventilated for COVID-19 ARDS. Different phenotypes of RV involvement might lead to different ICU mortality, with ACP having the worst outcome.
Collapse
Affiliation(s)
- Stephen Huang
- Intensive Care Medicine, Nepean Hospital, NBMLHD, The University of Sydney, Sydney, Australia
| | - Antoine Vieillard-Baron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Bruno Evrard
- Medical-Surgical ICU, Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France
| | - Gwenaël Prat
- Service de Médecine Intensive Réanimation, CHU Cavale Blanche Brest, Brest, France
| | - Michelle S Chew
- Department of Anaesthesiology and Intensive Care, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Martin Balik
- Department of Anesthesiology and Intensive Care, General University Hospital and 1St Medical Faculty, Charles University, Prague, Czechia
| | - Fernando Clau-Terré
- Department of Anaesthesiology and Critical Care Medicine, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Daniel De Backer
- CHIREC Hospitals Université Libre de Bruxelles, Brussels, Belgium
| | - Armand Mekontso Dessap
- Service de Médecine Intensive Réanimation, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Inserm U955, Université Paris-Est Créteil, 94000, Créteil, France
| | - Sam Orde
- Intensive Care Medicine, Nepean Hospital, NBMLHD, The University of Sydney, Sydney, Australia
| | - Andrea Morelli
- Department Clinical Internal Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Viale del Policlinico, Rome, Italy
| | - Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Policlinico-Vittorio Emanuele University Hospital, Catania, Italy
| | - Cyril Charron
- Service de Médecine Intensive Réanimation, Assistance Publique-Hôpitaux de Paris, University Hospital Ambroise Paré, 92100, Boulogne-Billancourt, France
- INSERM UMR 1018, Clinical Epidemiology Team, CESP, Université de Paris Saclay, Villejuif, France
| | - Philippe Vignon
- Medical-Surgical ICU, Inserm CIC 1435, Dupuytren Teaching Hospital, 87000, Limoges, France.
- Réanimation Polyvalente, CHU Dupuytren, 2 Ave. Martin Luther King, 87042, Limoges Cedex, France.
| |
Collapse
|
19
|
Chawla S, Sato R, Duggal A, Alwakeel M, Hasegawa D, Alayan D, Collier P, Sanfilippo F, Lanspa M, Dugar S. Correlation between tissue Doppler-derived left ventricular systolic velocity (S') and left ventricle ejection fraction in sepsis and septic shock: a retrospective cohort study. J Intensive Care 2023; 11:28. [PMID: 37400918 DOI: 10.1186/s40560-023-00678-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Tissue Doppler-derived left ventricular systolic velocity (mitral S') has shown excellent correlation to left ventricular ejection fraction (LVEF) in non-critically patients. However, their correlation in septic patients remains poorly understood and its impact on mortality is undetermined. We investigated the relationship between mitral S' and LVEF in a large cohort of critically-ill septic patients. METHODS We conducted a retrospective cohort study between 01/2011 and 12/2020. All adult patients (≥ 18 years) who were admitted to the medical intensive care unit (MICU) with sepsis and septic shock that underwent a transthoracic echocardiogram (TTE) within 72 h were included. Pearson correlation test was used to assess correlation between average mitral S' and LVEF. Pearson correlation was used to assess correlation between average mitral S' and LVEF. We also assessed the association between mitral S', LVEF and 28-day mortality. RESULTS 2519 patients met the inclusion criteria. The study population included 1216 (48.3%) males with a median age of 64 (IQR: 53-73), and a median APACHE III score of 85 (IQR: 67, 108). The median septal, lateral, and average mitral S' were 8 cm/s (IQR): 6.0, 10.0], 9 cm/s (IQR: 6.0, 10.0), and 8.5 cm/s (IQR: 6.5, 10.5), respectively. Mitral S' was noted to have moderate correlation with LVEF (r = 0.46). In multivariable logistic regression analysis, average mitral S' was associated with an increase in both 28-day ICU and in-hospital mortality with odds ratio (OR) 1.04 (95% CI 1.01-1.08, p = 0.02) and OR 1.04 (95% CI 1.01-1.07, p = 0.02), respectively. CONCLUSIONS Even though mitral S' and LVEF may be related, they are not exchangeable and were only found to have moderate correlation in this study. LVEF is U-shaped, while mitral S' has a linear relation with 28-day ICU mortality. An increase in average mitral S' was associated with higher 28-day mortality.
Collapse
Affiliation(s)
- Sanchit Chawla
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
- Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA
| | - Mahmoud Alwakeel
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Daisuke Hasegawa
- Department of Internal Medicine, Mount Sinai Beth Israel, New York, NY, USA
| | - Dina Alayan
- Department of Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Patrick Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Filippo Sanfilippo
- Anaesthesiology and Intensive Care, University of Catania, Catania, Italy
- Policlinico-San Marco University Hospital, Catania, Italy
| | - Michael Lanspa
- Critical Care Echocardiography Service, Intermountain Medical Center, Murray, UT, USA
- Division of Pulmonary and Critical Care Medicine, University of Utah, Salt Lake City, UT, USA
| | - Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
- Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH, USA.
| |
Collapse
|
20
|
Zhu P, Zhu J, Tong S, She X, Qi Z, Xu Q, Shi Z, Si L, Hou M, Gan G, Pan C. Clinical characteristics of patients with a risk of pulmonary artery hypertension secondary to ARDS in a high-altitude area. BMJ Open Respir Res 2023; 10:e001475. [PMID: 37524522 PMCID: PMC10391833 DOI: 10.1136/bmjresp-2022-001475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 07/14/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND Hypoxaemia plays an important role in the development of pulmonary artery hypertension (PAH). Patients with acute respiratory distress syndrome (ARDS) in a high-altitude area have different pathophysiological characteristics from those patients in the plains. The goal of our study was to explore the clinical characteristics of PAH secondary to ARDS in a high-altitude area. METHODS This was a prospective study conducted in the affiliated Hospital of Qinghai University. Two investigators independently assessed pulmonary artery pressure (PAP) and right ventricular function by transthoracic echocardiography. Basic information and clinical data of the patients who were enrolled were collected. A multivariable logistic regression model was used to evaluate the risk factors for PAH secondary to ARDS in the high-altitude area. RESULTS The incidence of PAH secondary to ARDS within 48 hours in the high-altitude area was 44.19%. Partial pressure of oxygen/fraction of inspired oxygen <165.13 mm Hg was an independent risk factor for PAH secondary to ARDS in the high-altitude area. Compared with the normal PAP group, the right ventricular basal dimensions were significantly larger and the right ventricular tricuspid annular plane systolic excursion was lower in the PAH group (right ventricular basal dimensions: 45.47±2.60 vs 40.67±6.12 mm, p=0.019; tricuspid annular plane systolic excursion (TAPSE): 1.82±0.40 vs 2.09±0.32 cm, p=0.021). The ratio of TAPSE to systolic PAP was lower in the PAH group (0.03±0.01 vs 0.08±0.03 cm/mm Hg, p<0.001). CONCLUSIONS The incidence of PAH in patients with ARDS in our study is high. PAH secondary to ARDS in a high-altitude area could cause right ventricular dysfunction. TRIAL REGISTRATION NUMBER NCT05166759.
Collapse
Affiliation(s)
- Peng Zhu
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Jing Zhu
- Department of Cardiology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Shijun Tong
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Xiaobin She
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Zhenyuan Qi
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Qianjin Xu
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Zhongshan Shi
- Department of Critical Care Medicine, People's Hospital of Golmud City, Golmud, Qinghai, China
| | - Lining Si
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Ming Hou
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Guifen Gan
- Department of Critical Care Medicine, Qinghai University Affiliated Hospital, Xining, Qinghai, China
| | - Chun Pan
- Department of Critical Care Medicine, Health Management Center, University of Electronic Science and Technology of China Sichuan Provincial People's Hospital, Chengdu, Sichuan, China
| |
Collapse
|
21
|
Estoos EM, Jocham KP, Zhang C, Benson LM, Milas A, Zakhary B. Optimal positive end-expiratory pressure reduces right ventricular dysfunction in COVID-19 patients on venovenous extracorporeal membrane oxygenation: A retrospective single-center study. J Crit Care 2023; 75:154274. [PMID: 36764115 PMCID: PMC9908009 DOI: 10.1016/j.jcrc.2023.154274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023]
Abstract
While mechanical ventilation practices on venovenous extracorporeal membrane oxygenation (VV ECMO) are variable, most institutions utilize a lung rest strategy utilizing relatively low positive end-expiratory pressure (PEEP). The effect of PEEP titration using esophageal manometry during VV ECMO on pulmonary and cardiac function is unknown. This was a retrospective study of 69 patients initiated on VV ECMO between March 2020 through November 2021. Patients underwent standard PEEP (typically 10 cm H2O) or optimal PEEP (PEEP titrated to an end-expiratory transpulmonary pressure 0-3 cm H2O) throughout the ECMO run. The optimal PEEP strategy had higher levels of applied PEEP (17.9 vs. 10.8 cm H2O on day 2 of ECMO), decreased incidence of hemodynamically significant RV dysfunction (4.55% vs. 44.0%, p = 0.0001), and higher survival to decannulation (72.7% vs. 44.0%, p = 0.022). Survival to discharge did not reach statistical significance (27% vs. 11%, p = 0.211). In univariate logistic regression analysis, optimal PEEP was associated with less hemodynamically significant RV dysfunction with an odds ratio (OR) of 0.06 (95% confidence interval [CI] = 0.01-0.27, p = 0.0008) and increased survival to decannulation with an OR of 3.39 (95% CI 1.23-9.79), p = 0.02), though other confounding factors may have contributed.
Collapse
Affiliation(s)
- Ethan M. Estoos
- Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, United States of America,Corresponding author
| | - Kevin P. Jocham
- Department of Internal Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Chengda Zhang
- Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Lauren M. Benson
- Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Anamaria Milas
- Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, United States of America
| | - Bishoy Zakhary
- Department of Pulmonary and Critical Care Medicine, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Portland, OR 97239, United States of America
| |
Collapse
|
22
|
Bansal M, Mehta A, Machanahalli Balakrishna A, Kalyan Sundaram A, Kanwar A, Singh M, Vallabhajosyula S. RIGHT VENTRICULAR DYSFUNCTION IN SEPSIS: AN UPDATED NARRATIVE REVIEW. Shock 2023; 59:829-837. [PMID: 36943772 DOI: 10.1097/shk.0000000000002120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
ABSTRACT Sepsis is a multisystem disease process, which constitutes a significant public health challenge and is associated with high morbidity and mortality. Among other systems, sepsis is known to affect the cardiovascular system, which may manifest as myocardial injury, arrhythmias, refractory shock, and/or septic cardiomyopathy. Septic cardiomyopathy is defined as the reversible systolic and/or diastolic dysfunction of one or both ventricles. Left ventricle dysfunction has been extensively studied in the past, and its prognostic role in patients with sepsis is well documented. However, there is relatively scarce literature on right ventricle (RV) dysfunction and its role. Given the importance of timely detection of septic cardiomyopathy and its bearing on prognosis of patients, the role of RV dysfunction has come into renewed focus. Hence, through this review, we sought to describe the pathophysiology of RV dysfunction in sepsis and what have we learnt so far about its multifactorial nature. We also elucidate the roles of different biomarkers for its detection and prognosis, along with appropriate management of such patient population.
Collapse
Affiliation(s)
- Mridul Bansal
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Aryan Mehta
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | | | - Arvind Kalyan Sundaram
- Section of Cardiovascular Medicine, Department of Medicine, UMass Chan-Baystate Medical Center, Springfield, Massachusetts
| | | | - Mandeep Singh
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | | |
Collapse
|
23
|
Wong IMJ, Ferguson ND, Urner M. Invasive mechanical ventilation. Intensive Care Med 2023; 49:669-672. [PMID: 37115258 DOI: 10.1007/s00134-023-07079-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Accepted: 04/13/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Irene M J Wong
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Departments of Medicine and Physiology, University of Toronto, Toronto, Canada.
- Division of Respirology and Critical Care Medicine, Department of Medicine, University Health Network, Toronto, Canada.
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
- Toronto General Research Institute, Toronto, Canada.
- Toronto General Hospital, 585 University Avenue, MaRS-9012, Toronto, ON, M5G 2N2, Canada.
| | - Martin Urner
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, Canada
| |
Collapse
|
24
|
Zochios V, Yusuff H, Antonini MV, Schmidt M, Shekar K. Veno-Pulmonary Arterial Extracorporeal Membrane Oxygenation in Severe Acute Respiratory Distress Syndrome: Should We Consider Mechanical Support of the Pulmonary Circulation From the Outset? ASAIO J 2023; 69:511-518. [PMID: 37000676 DOI: 10.1097/mat.0000000000001930] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
Affiliation(s)
- Vasileios Zochios
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Hakeem Yusuff
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
- Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital, AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Modena, Italy
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition 75651, Paris Cedex 13, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, Queensland, Australia
- Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, Queensland, Australia
| |
Collapse
|
25
|
Kołodziejczak MM, Sierakowska K, Tkachenko Y, Kowalski P. Artificial Intelligence in the Intensive Care Unit: Present and Future in the COVID-19 Era. J Pers Med 2023; 13:891. [PMID: 37373880 DOI: 10.3390/jpm13060891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 05/18/2023] [Accepted: 05/22/2023] [Indexed: 06/29/2023] Open
Abstract
The development of artificial intelligence (AI) allows for the construction of technologies capable of implementing functions that represent the human mind, senses, and problem-solving skills, leading to automation, rapid data analysis, and acceleration of tasks. These solutions has been initially implemented in medical fields relying on image analysis; however, technological development and interdisciplinary collaboration allows for the introduction of AI-based enhancements to further medical specialties. During the COVID-19 pandemic, novel technologies established on big data analysis experienced a rapid expansion. Yet, despite the possibilities of advancements with these AI technologies, there are number of shortcomings that need to be resolved to assert the highest and the safest level of performance, especially in the setting of the intensive care unit (ICU). Within the ICU, numerous factors and data affect clinical decision making and work management that could be managed by AI-based technologies. Early detection of a patient's deterioration, identification of unknown prognostic parameters, or even improvement of work organization are a few of many areas where patients and medical personnel can benefit from solutions developed with AI.
Collapse
Affiliation(s)
- Michalina Marta Kołodziejczak
- Department of Anesthesiology and Intensive Care, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, Antoni Jurasz University Hospital No.1, 85-094 Bydgoszcz, Poland
| | - Katarzyna Sierakowska
- Department of Anesthesiology and Intensive Care, Collegium Medicum Bydgoszcz, Nicolaus Copernicus University Torun, Antoni Jurasz University Hospital No.1, 85-094 Bydgoszcz, Poland
| | - Yurii Tkachenko
- Department of Anesthesiology and Intensive Care, Władysław Biegański Regional Specialized Hospital, 86-300 Grudziadz, Poland
| | - Piotr Kowalski
- Department of Anesthesiology and Intensive Care, Władysław Biegański Regional Specialized Hospital, 86-300 Grudziadz, Poland
| |
Collapse
|
26
|
Brown TN, Brogan TV. Right ventricular dysfunction in patients with acute respiratory distress syndrome receiving venovenous extracorporeal membrane oxygenation. Front Cardiovasc Med 2023; 10:1027300. [PMID: 37265572 PMCID: PMC10229794 DOI: 10.3389/fcvm.2023.1027300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 04/10/2023] [Indexed: 06/03/2023] Open
Abstract
Acute respiratory distress syndrome is characterized by non-cardiogenic pulmonary edema, decreased pulmonary compliance, and abnormalities in gas exchange, especially hypoxemia. Patients with acute respiratory distress syndrome (ARDS) who receive support with venovenous (V-V) extracorporeal membrane oxygenation (ECMO) usually have severe lung disease. Many patients with ARDS have associated pulmonary vascular injury which can result in elevated pulmonary vascular resistance and right heart dysfunction. Since V-V ECMO relies upon preserved cardiac function, right heart failure has important implications for patient evaluation, management, and outcomes. Worsening right heart function complicates ARDS and disease processes. Given the increasing use of ECMO to support patients with ARDS, an understanding of right ventricular-ECMO and cardiopulmonary interactions is essential for the clinician. A narrative review of the manifestations of right heart dysfunction, as well as diagnosis and management strategies for the patient with ARDS on ECMO, is provided.
Collapse
Affiliation(s)
- Tyler N. Brown
- Pediatric Critical Care Medicine, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, United States
| | - Thomas V. Brogan
- Department of Pediatrics, University of Washington School of Medicine, Seattle Children’s Hospital, Seattle, Washington, United States
| |
Collapse
|
27
|
Kamenshchikov NO, Duong N, Berra L. Nitric Oxide in Cardiac Surgery: A Review Article. Biomedicines 2023; 11:biomedicines11041085. [PMID: 37189703 DOI: 10.3390/biomedicines11041085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 03/26/2023] [Accepted: 03/29/2023] [Indexed: 05/17/2023] Open
Abstract
Perioperative organ injury remains a medical, social and economic problem in cardiac surgery. Patients with postoperative organ dysfunction have increases in morbidity, length of stay, long-term mortality, treatment costs and rehabilitation time. Currently, there are no pharmaceutical technologies or non-pharmacological interventions that can mitigate the continuum of multiple organ dysfunction and improve the outcomes of cardiac surgery. It is essential to identify agents that trigger or mediate an organ-protective phenotype during cardiac surgery. The authors highlight nitric oxide (NO) ability to act as an agent for perioperative protection of organs and tissues, especially in the heart-kidney axis. NO has been delivered in clinical practice at an acceptable cost, and the side effects of its use are known, predictable, reversible and relatively rare. This review presents basic data, physiological research and literature on the clinical application of NO in cardiac surgery. Results support the use of NO as a safe and promising approach in perioperative patient management. Further clinical research is required to define the role of NO as an adjunct therapy that can improve outcomes in cardiac surgery. Clinicians also have to identify cohorts of responders for perioperative NO therapy and the optimal modes for this technology.
Collapse
Affiliation(s)
- Nikolay O Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
| | - Nicolette Duong
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
- Respiratory Care Service, Patient Care Services, Massachusetts General Hospital, Boston, MA 02114, USA
| |
Collapse
|
28
|
Chotalia M, Ali M, Alderman JE, Bansal S, Patel JM, Bangash MN, Parekh D. Cardiovascular Subphenotypes in Acute Respiratory Distress Syndrome. Crit Care Med 2023; 51:460-470. [PMID: 36728428 DOI: 10.1097/ccm.0000000000005751] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVES To use clustering methods on transthoracic echocardiography (TTE) findings and hemodynamic parameters to characterize circulatory failure subphenotypes and potentially elucidate underlying mechanisms in patients with acute respiratory distress syndrome (ARDS) and to describe their association with mortality compared with current definitions of right ventricular dysfunction (RVD). DESIGN Retrospective, single-center cohort study. SETTING University Hospital ICU, Birmingham, United Kingdom. PATIENTS ICU patients that received TTE within 7 days of ARDS onset between April 2016 and December 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Latent class analysis (LCA) of TTE/hemodynamic parameters was performed in 801 patients, 62 years old (interquartile range, 50-72 yr old), 63% male, and 40% 90-day mortality rate. Four cardiovascular subphenotypes were identified: class 1 (43%; mostly normal left and right ventricular [LV/RV] function), class 2 (24%; mostly dilated RV with preserved systolic function), class 3 (13%, mostly dilated RV with impaired systolic function), and class 4 (21%; mostly high cardiac output, with hyperdynamic LV function). The four subphenotypes differed in their characteristics and outcomes, with 90-day mortality rates of 19%, 40%, 78%, and 59% in classes 1-4, respectively ( p < 0.0001). Following multivariable logistic regression analysis, class 3 had the highest odds ratio (OR) for mortality (OR, 6.9; 95% CI, 4.0-11.8) compared with other RVD definitions. Different three-variable models had high diagnostic accuracy in identifying each of these latent subphenotypes. CONCLUSIONS LCA of TTE parameters identified four cardiovascular subphenotypes in ARDS that more closely aligned with circulatory failure mechanisms and mortality than current RVD definitions.
Collapse
Affiliation(s)
- Minesh Chotalia
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Muzzammil Ali
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Joseph E Alderman
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Sukh Bansal
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Jaimin M Patel
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Mansoor N Bangash
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| | - Dhruv Parekh
- Birmingham Acute Care Research Group, University of Birmingham, Birmingham, United Kingdom
- Department of Anaesthetics and Critical Care, Queen Elizabeth Hospital Birmingham, Birmingham, United Kingdom
| |
Collapse
|
29
|
Ganeriwal S, Alves Dos Anjos G, Schleicher M, Hockstein MA, Tonelli AR, Duggal A, Siuba MT. Right ventricle-specific therapies in acute respiratory distress syndrome: a scoping review. Crit Care 2023; 27:104. [PMID: 36907888 PMCID: PMC10008150 DOI: 10.1186/s13054-023-04395-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 03/06/2023] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVE To summarize knowledge and identify gaps in evidence regarding treatment of right ventricular dysfunction (RVD) in acute respiratory distress syndrome (ARDS). DATA SOURCES We conducted a comprehensive search of MEDLINE, Embase, CINAHL, Web of Science, and the Cochrane Central Register of Controlled Trials. STUDY SELECTION Studies were included if they reported effects of treatments on right ventricular function, whether or not the intent was to modify right ventricular function. DATA EXTRACTION Data extraction was performed independently and in duplicate by two authors. Data items included the study design, patient population, type of intervention, comparison group, and RV-specific outcomes. DATA SYNTHESIS Of 1,430 studies screened, 51 studies reporting on 1,526 patients were included. By frequency, the included studies examined the following interventions: ventilator settings (29.4%), inhaled medications (33.3%), extracorporeal life support (13.7%), intravenous or oral medications (13.7%), and prone positioning (9.8%). The majority of the studies were non-randomized experimental studies (53%), with the next most common being case reports (16%). Only 5.9% of studies were RCTs. In total, 27% of studies were conducted with the goal of modifying RV function. CONCLUSIONS Given the prevalence of RVD in ARDS and its association with mortality, the dearth of research on this topic is concerning. This review highlights the need for prospective trials aimed at treating RV dysfunction in ARDS.
Collapse
Affiliation(s)
- Simran Ganeriwal
- Department of Internal Medicine, Community Care Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Mary Schleicher
- The Cleveland Clinic Floyd D. Loop Alumni Library, Cleveland Clinic, Cleveland, OH, USA
| | - Maxwell A Hockstein
- Departments of Emergency Medicine and Critical Care, MedStar Washington Hospital Center, Washington, DC, USA
| | - Adriano R Tonelli
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Department of Pulmonary Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Matthew T Siuba
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
| |
Collapse
|
30
|
Abstract
Aerosolized prostacyclins are frequently used in patients with severe acute respiratory distress syndrome and refractory hypoxia. Previous studies have shown improvement in oxygenation with use of pulmonary vasodilators such as iloprost and epoprostenol; however, there is no head-to-head comparison between these agents. OBJECTIVES To compare the effects of inhaled epoprostenol and inhaled iloprost in critically ill patients with refractory hypoxia. DESIGN SETTING AND PARTICIPANTS We performed a retrospective cohort analysis of patients admitted to the ICUs at the University of Oklahoma Health Sciences Center between 2015 and 2018. Adult patients who received aerosolized epoprostenol or iloprost for more than 4 hours were included in the analysis. MAIN OUTCOMES AND MEASURES The primary endpoint measured was to compare the change in Pao2/Fio2 ratio between patients treated with iloprost compared with epoprostenol. Secondary outcomes measured were 90-day in-hospital mortality and improvement in vasopressor requirements. RESULTS A total of 126 patients were included in the study, 95 of whom received iloprost (75%) and 31 patients (25%) received epoprostenol. There were significant improvements in Pao2/Fio2 ratio in both the iloprost and epoprostenol group. Patients in the epoprostenol group appeared to have a higher 90-day mortality compared with the iloprost group. However, our study was not powered to detect a mortality difference and this finding likely represents a sicker population in the epoprostenol group and prescription bias. The use of iloprost was associated with higher vasopressor requirements in the first 12 hours of administration, an association was not observed in the epoprostenol group. CONCLUSIONS AND RELEVANCE In this retrospective cohort analysis, use of both pulmonary vasodilators was associated with similar improvement in gas exchange. The mortality difference observed likely represents difference in severity of illness. Further studies are needed to corroborate these findings.
Collapse
|
31
|
Right Ventricular Injury Increases Mortality in Patients With Acute Respiratory Distress Syndrome on Veno-Venous Extracorporeal Membrane Oxygenation: A Systematic Review and Meta-Analysis. ASAIO J 2023; 69:e14-e22. [PMID: 36375040 DOI: 10.1097/mat.0000000000001854] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Right ventricular injury (RVI) in the context of acute respiratory distress syndrome (ARDS) is well recognized as an important determinant risk factor of mortality. Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is part of the algorithm for the management of patients with severe ARDS and severely impaired gas exchange. Although VV-ECMO may theoretically protect the RV it is uncertain to what degree RVI persists despite VV-ECMO support, and whether it continues to influence mortality after ECMO initiation. The aim of this systematic review and meta-analysis was to investigate the impact of RVI on mortality in this context, testing the hypothesis that RVI worsens mortality in this cohort. We performed a systematic search that identified seven studies commenting on RVI and mortality in patients with ARDS receiving VV-ECMO. The presence of RVI was associated with greater mortality overall (odds ratios [OR]: 2.72; 95% confidence intervals [CI]: 1.52-4.85; p < 0.00) and across three subgroups (RV dilatational measures: OR: 3.51; 95% CI: 1.51-8.14; p < 0.01, RV functional measures: OR: 1.84; 95% CI: 0.99-3.42; p = 0.05, RV measurements post-ECMO initiation: OR: 1.94; 95% CI: 1.01-3.72; p < 0.05). Prospective studies are needed to investigate the causal relationship between RVI and mortality in this patient group and the best management strategies to reduce mortality.
Collapse
|
32
|
Acute right ventricular injury phenotyping in ARDS. Intensive Care Med 2023; 49:99-102. [PMID: 36219228 PMCID: PMC9552138 DOI: 10.1007/s00134-022-06904-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/28/2022] [Indexed: 01/24/2023]
|
33
|
Vos ME, Cox EGM, Schagen MR, Hiemstra B, Wong A, Koeze J, van der Horst ICC, Wiersema R. Right ventricular strain measurements in critically ill patients: an observational SICS sub-study. Ann Intensive Care 2022; 12:92. [PMID: 36190597 PMCID: PMC9530097 DOI: 10.1186/s13613-022-01064-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Accepted: 09/16/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Right ventricular (RV) dysfunction is common in critically ill patients and is associated with poor outcomes. RV function is usually evaluated by Tricuspid Annular Plane Systolic Excursion (TAPSE) which can be obtained using critical care echocardiography (CCE). Myocardial deformation imaging, measuring strain, is suitable for advanced RV function assessment and has widely been studied in cardiology. However, it is relatively new for the Intensive Care Unit (ICU) and little is known about RV strain in critically ill patients. Therefore, the objectives of this study were to evaluate the feasibility of RV strain in critically ill patients using tissue-Doppler imaging (TDI) and explore the association between RV strain and conventional CCE measurements representing RV function. METHODS This is a single-center sub-study of two prospective observational cohorts (Simple Intensive Care Studies (SICS)-I and SICS-II). All acutely admitted adults with an expected ICU stay over 24 h were included. CCE was performed within 24 h of ICU admission. In patients in which CCE was performed, TAPSE, peak systolic velocity at the tricuspid annulus (RV s') and TDI images were obtained. RV free wall longitudinal strain (RVFWSL) and RV global four-chamber longitudinal strain (RV4CSL) were measured during offline analysis. RESULTS A total of 171 patients were included. Feasibility of RVFWSL and RV4CSL was, respectively, 62% and 56% in our population; however, when measurements were performed, intra- and inter-rater reliability based on the intraclass correlation coefficient were good to excellent. RV dysfunction based on TAPSE or RV s' was found in 56 patients (33%) and 24 patients (14%) had RV dysfunction based on RVFWSL or RV4CSL. In 14 patients (8%), RVFWSL, RV4CSL, or both were reduced, despite conventional RV function measurements being preserved. These patients had significantly higher severity of illness scores. Sensitivity analysis with fractional area change showed similar results. CONCLUSIONS TDI RV strain imaging in critically ill patients is challenging; however, good-to-excellent reproducibility was shown when measurements were adequately obtained. Future studies are needed to elucidate the diagnostic and prognostic value of RV strain in critically ill patients, especially to outweigh the difficulty and effort of imaging against the clinical value.
Collapse
Affiliation(s)
- Madelon E Vos
- University Medical Center Groningen, Department of Anaesthesiology, University of Groningen, Groningen, The Netherlands.
| | - Eline G M Cox
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - Maaike R Schagen
- Erasmus Medical Center, Department of Internal Medicine, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Bart Hiemstra
- Department of Anaesthesiology, Location VU Medical Center, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Adrian Wong
- Department of Critical Care, King's College Hospital, London, UK
| | - Jacqueline Koeze
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University of Maastricht, University Medical Center Maastricht, Maastricht, The Netherlands
| | - Renske Wiersema
- University Medical Center Groningen, Department of Critical Care, University of Groningen, Groningen, The Netherlands.,Department of Cardiology, Erasmus University Rotterdam, Erasmus Medical Center, Rotterdam, the Netherlands
| | | |
Collapse
|
34
|
Abstract
PURPOSE OF REVIEW Right ventricular (RV) failure is increasingly recognized as a major cause of morbidity and mortality. When RV failure is refractory to medical therapy, escalation to right-sided mechanical circulatory support (MCS) should be considered. In this review, we begin by recapitulating the hemodynamics of RV failure, then we delve into current and future right-sided MCS devices and describe their hemodynamic profiles. RECENT FINDINGS The field of temporary right-sided MCS continues to expand, with evolving strategies and new devices actively under development. All right-sided MCS devices bypass the RV, with each bypass configuration conferring a unique hemodynamic profile. Devices that aspirate blood directly from the RV, as opposed to the RA or the IVC, have more favorable hemodynamics and more effective RV unloading. There has been a growing interest in single-access MCS devices which do not restrict patient mobility. Additionally, a first-of-its-kind percutaneous, pulsatile, right-sided MCS device (PERKAT RV) is currently undergoing investigation in humans. Prompt recognition of refractory RV failure and deployment of right-sided MCS can improve outcomes. The field of right-sided MCS is rapidly evolving, with ongoing efforts dedicated towards developing novel temporary devices that are single access, allow for patient mobility, and directly unload the RV, as well as more durable devices.
Collapse
|
35
|
Zapata L, Suárez-Montero J, Flores-Orella M, Morales-Alarcón E, Segarra A, Santos-Rodríguez J. Acute cor pulmonale in patients with acute respiratory distress syndrome due to COVID-19. MEDICINA INTENSIVA (ENGLISH EDITION) 2022; 46:645-647. [PMID: 36088263 PMCID: PMC9449780 DOI: 10.1016/j.medine.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 11/29/2021] [Accepted: 12/28/2021] [Indexed: 11/24/2022]
|
36
|
Relation of Ischemic Heart Disease to Outcomes in Patients With Acute Respiratory Distress Syndrome. Am J Cardiol 2022; 176:24-29. [PMID: 35606175 DOI: 10.1016/j.amjcard.2022.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Revised: 03/29/2022] [Accepted: 04/05/2022] [Indexed: 11/21/2022]
Abstract
Patients with ischemic heart disease (IHD) are often excluded from acute respiratory distress syndrome (ARDS) clinical trials. As a result, little is known about the impact of IHD in this population. We sought to assess the association between IHD and clinical outcomes in patients with ARDS. Participants from 4 ARDS randomized controlled trials with shared study criteria, definitions, and end points were included. Using multivariable logistic regression, we assessed for the association between IHD and a primary outcome of 60-day mortality. Secondary outcomes included 90-day mortality, 28-day ventilator-free days, and 28-day organ failure. Among 1,909 patients, 102 had a history of IHD (5.4%). Patients with IHD were more likely to be older and male (p <0.05). Noncardiac co-morbidities, severity of illness, and other markers of ARDS severity were not statistically different (all, p >0.05). Patients with IHD had a higher 60-day (39.2% vs 23.3%, p <0.001) and 90-day (40.2% vs 24.0%, p <0.001) mortality, and experienced more frequent renal (45.1% vs 32.0%, p = 0.006) and hepatic (35.3% vs 25.2%, p = 0.023) failure. After multivariable adjustment, 60-day (odds ratio [OR] 1.76; 95% confidence interval [CI]: 1.07 to 2.89, p = 0.025) and 90-day (OR 1.74; 95% CI: 1.06 to 2.85, p = 0.028) mortality remained higher. IHD was associated with 10% fewer ventilator-free days (incidence rate ratio 0.90; 95% CI: 0.85 to 0.96, p = 0.001). In conclusion, co-morbid IHD was associated with higher mortality and fewer ventilator-free days in patients with ARDS. Future studies are needed to identify predictors of mortality and improve treatment paradigms in this critically ill subgroup of patients.
Collapse
|
37
|
Zochios V, Brodie D, Shekar K, Schultz MJ, Parhar KKS. Invasive mechanical ventilation in patients with acute respiratory distress syndrome receiving extracorporeal support: a narrative review of strategies to mitigate lung injury. Anaesthesia 2022; 77:1137-1151. [PMID: 35864561 DOI: 10.1111/anae.15806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/28/2022]
Abstract
Veno-venous extracorporeal membrane oxygenation is indicated in patients with acute respiratory distress syndrome and severely impaired gas exchange despite evidence-based lung protective ventilation, prone positioning and other parts of the standard algorithm for treating such patients. Extracorporeal support can facilitate ultra-lung-protective ventilation, meaning even lower volumes and pressures than standard lung-protective ventilation, by directly removing carbon dioxide in patients needing injurious ventilator settings to maintain sufficient gas exchange. Injurious ventilation results in ventilator-induced lung injury, which is one of the main determinants of mortality in acute respiratory distress syndrome. Marked reductions in the intensity of ventilation to the lowest tolerable levels under extracorporeal support may be achieved and could thereby potentially mitigate ventilator-induced lung injury and theoretically patient self-inflicted lung injury in spontaneously breathing patients with high respiratory drive. However, the benefits of this strategy may be counterbalanced by the use of continuous deep sedation and even neuromuscular blocking drugs, which may impair physical rehabilitation and impact long-term outcomes. There are currently a lack of large-scale prospective data to inform optimal invasive ventilation practices and how to best apply a holistic approach to patients receiving veno-venous extracorporeal membrane oxygenation, while minimising ventilator-induced and patient self-inflicted lung injury. We aimed to review the literature relating to invasive ventilation strategies in patients with acute respiratory distress syndrome receiving extracorporeal support and discuss personalised ventilation approaches and the potential role of adjunctive therapies in facilitating lung protection.
Collapse
Affiliation(s)
- V Zochios
- Department of Cardiothoracic Critical Care Medicine and ECMO, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, UK.,Department of Cardiovascular Sciences, University of Leicester, UK
| | - D Brodie
- Columbia University College of Physicians and Surgeons, New York, NY, USA.,Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA
| | - K Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.,Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia.,Faculty of Medicine, University of Queensland, Brisbane and Bond University, Goldcoast, QLD, Australia
| | - M J Schultz
- Department of Intensive Care, Amsterdam University Medical Centres, Amsterdam, the Netherlands.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Department of Medical Affairs, Hamilton Medical AG, Bonaduz, Switzerland
| | - K K S Parhar
- Department of Critical Care Medicine, University of Calgary and Alberta Health Services, Calgary, AB, Canada
| |
Collapse
|
38
|
Crager SE, Humphreys C. Right Ventricular Failure and Pulmonary Hypertension. Emerg Med Clin North Am 2022; 40:519-537. [DOI: 10.1016/j.emc.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
|
39
|
Sun K, Cedarbaum E, Hill C, Win S, Parikh NI, Hsue PY, Durstenfeld MS. Association of Right Ventricular Dilation and Dysfunction on Echocardiogram with In-Hospital Mortality Among Patients Hospitalized with COVID-19 Compared with Other Acute Respiratory Illness. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.06.29.22277073. [PMID: 35794892 PMCID: PMC9258295 DOI: 10.1101/2022.06.29.22277073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Although right ventricular (RV) dysfunction is associated with mortality in acute COVID-19, the role of RV dilation is uncertain. The prognostic significance of RV dilation and dysfunction among hospitalized patients with acute COVID-19 compared to other respiratory illnesses. METHODS We conducted a retrospective cohort study to examine 225 consecutive adults admitted for acute COVID-19 and 6,150 control adults admitted for influenza, pneumonia or ARDS who had a clinical echocardiogram performed. We used logistic regression models to assess associations between RV parameters and in-hospital mortality adjusted for confounders. RESULTS Among those with COVID-19, 48/225 (21.3%) died during the index hospitalization compared to 727/6150 (11.8%) with other respiratory illness (p=0.001). Independent of COVID-19, mild and moderate to severe RV dilation were associated with 1.4 and 2.0 times higher risk of inpatient mortality, respectively (95%CI 1.17 to 1.69; p=0.0003; 95%CI 1.62 to 2.47; p<0.0001, respectively). Similarly, mild and moderate RV dysfunction were associated with 1.4 and 1.7 times higher risk of inpatient mortality (95%CI 1.10 to 1.77; p=0.007; 95%CI 1.17 to 2.42; p=0.005, respectively). Relative to normal RV size and non-COVID-19 acute respiratory illness, mild and moderate RV dilation were associated with 1.4 times and 2.0 times higher risk among those without COVID-19 and 1.9 times higher and 3.0 times higher risk among those with COVID-19, with similar findings for RV dysfunction. Having both RV dilation and dysfunction or RV dilation alone were associated with 1.7 times higher risk while RV dysfunction alone was associated with 1.4 times higher risk compared to normal RV size and function. CONCLUSIONS RV dilation and dysfunction are associated with increased risk of inpatient mortality among those with COVID-19 and other respiratory illnesses. Abnormal RV findings may identify those at higher risk of short-term mortality from acute respiratory illness including COVID-19 beyond other risk markers.
Collapse
|
40
|
Giustiniano E, Palma S, Meco M, Ripani U, Nisi F. Echocardiography in Prone Positioned Critically Ill Patients: A Wealth of Information from a Single View. Diagnostics (Basel) 2022; 12:diagnostics12061460. [PMID: 35741270 PMCID: PMC9221662 DOI: 10.3390/diagnostics12061460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/07/2022] [Accepted: 06/10/2022] [Indexed: 02/05/2023] Open
Abstract
In critically ill patients, standard transthoracic echocardiography (TTE) generally does not facilitate good image quality during mechanical ventilation. We propose a prone-TTE in prone positioned patients, which allows clinicians to obtain a complete apical four-chamber (A-4-C) view. A basic cardiac assessment can be performed in order to evaluate right ventricle function and left ventricle performance, even measuring objective parameters, i.e., tricuspid annular plane systolic excursion (TAPSE); pulmonary artery systolic pressure (PAP), from the tricuspid regurgitation peak Doppler velocity; RV end-diastolic diameter and its ratio to left ventricular end-diastolic diameter; the S’ wave peak velocity with tissue Doppler imaging; the ejection fraction (EF); the mitral annular plane systolic excursion (MAPSE); diastolic function evaluation by the mitral valve; and annular Doppler velocities. Furthermore, by tilting the probe, we can obtain the apical-five-chamber (A-5-C) view, which facilitates the analysis of blood flow at the level of the output tract of the left ventricle (LVOT) and then the estimation of stroke volume. Useful applications of this technique are hemodynamic assessment, titration of fluids, vasoactive drugs therapy, and evaluation of the impact of prone positioning on right ventricle performance and right pulmonary resistances. We believe that considerable information can be drawn from a single view and hope this may be helpful to emergency and critical care clinicians whenever invasive hemodynamic monitoring tools are not available or are simply inconvenient due to clinical reasons.
Collapse
Affiliation(s)
- Enrico Giustiniano
- Department of Anesthesia, Intensive Care Unit and Pain Therapy, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy; (E.G.); (S.P.)
| | - Sergio Palma
- Department of Anesthesia, Intensive Care Unit and Pain Therapy, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy; (E.G.); (S.P.)
| | - Massimo Meco
- Department of Anesthesia and Intensive Care, Humanitas Gavazzeni Clinics, Via Mauro Gavazzeni, 21, 24125 Bergamo, Italy;
| | - Umberto Ripani
- Division of Clinic Anaesthesia, Department of Emergency Hospital Riuniti, Conca Street 71, 60126 Ancona, Italy;
| | - Fulvio Nisi
- Department of Anesthesia, Intensive Care Unit and Pain Therapy, IRCCS Humanitas Clinical and Research Center, 20089 Milan, Italy; (E.G.); (S.P.)
- Correspondence: ; Tel.: +39-02-8224-4115; Fax: +39-02-8224-4190
| |
Collapse
|
41
|
Elfsmark L, Ågren L, Akfur C, Jonasson S. Ammonia exposure by intratracheal instillation causes severe and deteriorating lung injury and vascular effects in mice. Inhal Toxicol 2022; 34:145-158. [PMID: 35452355 DOI: 10.1080/08958378.2022.2064566] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Ammonia (NH3) is a corrosive alkaline gas that can cause life-threatening injuries by inhalation. The aim was to establish a disease model for NH3-induced injuries similar to acute lung injury (ALI) described in exposed humans and investigate the progression of lung damage, respiratory dysfunction and evaluate biomarkers for ALI and inflammation over time. METHODS Female BALB/c mice were exposed to an NH3 dose of 91.0 mg/kg·bw using intratracheal instillation and the pathological changes were followed for up to 7 days. RESULTS NH3 instillation resulted in the loss of body weight along with a significant increase in pro-inflammatory mediators in both bronchoalveolar lavage fluid (e.g. IL-1β, IL-6, KC, MMP-9, SP-D) and blood (e.g. IL-6, Fibrinogen, PAI-1, PF4/CXCL4, SP-D), neutrophilic lung inflammation, alveolar damage, increased peripheral airway resistance and methacholine-induced airway hyperresponsiveness compared to controls at 20 h. On day 7 after exposure, deteriorating pathological changes such as increased macrophage lung infiltration, heart weights, lung hemorrhages and coagulation abnormalities (elevated plasma levels of PAI-1, fibrinogen, endothelin and thrombomodulin) were observed but no increase in lung collagen. Some of the analyzed blood biomarkers (e.g. RAGE, IL-1β) were unaffected despite severe ALI and may not be significant for NH3-induced damages. CONCLUSIONS NH3 induces severe acute lung injuries that deteriorate over time and biomarkers in lungs and blood that are similar to those found in humans. Therefore, this model has potential use for developing diagnostic tools for NH3-induced ALI and for finding new therapeutic treatments, since no specific antidote has been identified yet.
Collapse
Affiliation(s)
- Linda Elfsmark
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | - Lina Ågren
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | - Christine Akfur
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| | - Sofia Jonasson
- Swedish Defence Research Agency, CBRN Defence and Security, Umeå, Sweden
| |
Collapse
|
42
|
Zochios V, Yusuff H, Conway H, Lau G, Schmidt M. The Right Ventricle During Veno-Venous Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome: Can We Protect the Injured Ventricle? ASAIO J 2022; 68:456-460. [PMID: 35349520 DOI: 10.1097/mat.0000000000001655] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Affiliation(s)
- Vasileios Zochios
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Hakeem Yusuff
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
- University of Leicester, Leicester, United Kingdom
| | - Hannah Conway
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Gary Lau
- From the Department of Cardiothoracic Critical Care Medicine and ECMO Unit, Glenfield Hospital, University Hospitals of Leicester National Health Service Trust, Leicester, United Kingdom
| | - Matthieu Schmidt
- Sorbonne Université, GRC 30, RESPIRE, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris Cedex 13, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, Assistance Publique-Hôpitaux de Paris (APHP), Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France
| |
Collapse
|
43
|
Chotalia M, Ali M, Alderman JE, Patel JM, Parekh D, Bangash MN. Cardiovascular subphenotypes in patients with COVID-19 pneumonitis whose lungs are mechanically ventilated: a single-centre retrospective observational study. Anaesthesia 2022; 77:763-771. [PMID: 35243617 PMCID: PMC9314994 DOI: 10.1111/anae.15700] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/04/2022] [Indexed: 12/26/2022]
Abstract
Unsupervised clustering methods of transthoracic echocardiography variables have not been used to characterise circulatory failure mechanisms in patients with COVID‐19 pneumonitis. We conducted a retrospective, single‐centre cohort study in ICU patients with COVID‐19 pneumonitis whose lungs were mechanically ventilated and who underwent transthoracic echocardiography between March 2020 and May 2021. We performed latent class analysis of echocardiographic and haemodynamic variables. We characterised the identified subphenotypes by comparing their clinical parameters, treatment responses and 90‐day mortality rates. We included 305 patients with a median (IQR [range]) age 59 (49–66 [16–83]) y. Of these, 219 (72%) were male, 199 (65%) had moderate acute respiratory distress syndrome and 113 (37%) did not survive more than 90 days. Latent class analysis identified three cardiovascular subphenotypes: class 1 (52%; normal right ventricular function); class 2 (31%; right ventricular dilation with mostly preserved systolic function); and class 3 (17%; right ventricular dilation with systolic impairment). The three subphenotypes differed in their clinical characteristics and response to prone ventilation and outcomes, with 90‐day mortality rates of 22%, 42% and 73%, respectively (p < 0.001). We conclude that the identified subphenotypes aligned with right ventricular pathophysiology rather than the accepted definitions of right ventricular dysfunction, and these identified classifications were associated with clinical outcomes.
Collapse
Affiliation(s)
- M Chotalia
- Department of Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital, Birmingham, UK
| | - M Ali
- Department of Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital, UK
| | - J E Alderman
- Department of Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital, UK
| | - J M Patel
- Department of Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital, UK
| | - D Parekh
- Department of Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital, UK
| | - M N Bangash
- Department of Anaesthesia and Critical Care Medicine, Queen Elizabeth Hospital, UK
| |
Collapse
|
44
|
Slobod D, Assanangkornchai N, Alhazza M, Mettasittigorn P, Magder S. Right Ventricular Loading by Lung Inflation During Controlled Mechanical Ventilation. Am J Respir Crit Care Med 2022; 205:1311-1319. [PMID: 35213296 DOI: 10.1164/rccm.202111-2483oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE The inspiratory rise in transpulmonary pressure during mechanical ventilation increases right ventricular (RV) afterload. One mechanism is that when alveolar pressure (Palv) exceeds left atrial pressure, West zone 1 or 2 (non-zone 3) conditions develop and Palv becomes the downstream pressure opposing RV ejection. The tidal volume (VT) at which this impact on the RV becomes hemodynamically evident is not well established. OBJECTIVES To determine the magnitude of RV afterload and prevalence of significant non-zone 3 conditions during inspiration across the range of VT currently prescribed in clinical practice. METHODS In post-operative passively ventilated cardiac surgery patients, we measured right atrial, RV, pulmonary artery, pulmonary artery occlusion (Ppao), plateau (Pplat), and esophageal (Peso) pressures during short periods of controlled ventilation with VT increments ranging between 2-12 ml/kg PBW. The inspiratory increase in RV afterload was evaluated hemodynamically and echocardiographically. The prevalence of non-zone 3 conditions was determined using 2 definitions based on changes in Peso, Ppao and Pplat. RESULTS Fifty-one patients were studied. There was a linear relationship between VT, driving pressure and transpulmonary pressure and the inspiratory increase in the RV isovolumetric contraction pressure. Echocardiographically, increasing VT was associated with a greater inspiratory increase in markers of afterload and a decrease in stroke volume. Non-zone 3 conditions were present in >50% of subjects at a VT ≥ 6 ml/kg PBW. CONCLUSIONS In the range of VT currently prescribed, RV afterload increases with increasing VT. A mechanical ventilation strategy that limits VT and driving pressure is cardio-protective.
Collapse
Affiliation(s)
| | - Nawaporn Assanangkornchai
- McGill University, Montreal, Quebec, Canada.,Prince of Songkla University, 26686, Hat Yai, Songkhla, Thailand
| | - Manal Alhazza
- Guelph General Hospital, 60386, Guelph, Ontario, Canada
| | - Pattra Mettasittigorn
- Thammasat University Hospital, 176056, Anesthesiology, Khlong Nueng, Pathum Thani, Thailand
| | - Sheldon Magder
- Royal Victoria Hospital, 55980, Montreal, Quebec, Canada;
| |
Collapse
|
45
|
Kamenshchikov NO, Berra L, Carroll RW. Therapeutic Effects of Inhaled Nitric Oxide Therapy in COVID-19 Patients. Biomedicines 2022; 10:biomedicines10020369. [PMID: 35203578 PMCID: PMC8962307 DOI: 10.3390/biomedicines10020369] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 01/08/2023] Open
Abstract
The global COVID-19 pandemic has become the largest public health challenge of recent years. The incidence of COVID-19-related acute hypoxemic respiratory failure (AHRF) occurs in up to 15% of hospitalized patients. Antiviral drugs currently available to clinicians have little to no effect on mortality, length of in-hospital stay, the need for mechanical ventilation, or long-term effects. Inhaled nitric oxide (iNO) administration is a promising new non-standard approach to directly treat viral burden while enhancing oxygenation. Along with its putative antiviral affect in COVID-19 patients, iNO can reduce inflammatory cell-mediated lung injury by inhibiting neutrophil activation, lowering pulmonary vascular resistance and decreasing edema in the alveolar spaces, collectively enhancing ventilation/perfusion matching. This narrative review article presents recent literature on the iNO therapy use for COVID-19 patients. The authors suggest that early administration of the iNO therapy may be a safe and promising approach for the treatment of COVID-19 patients. The authors also discuss unconventional approaches to treatment, continuous versus intermittent high-dose iNO therapy, timing of initiation of therapy (early versus late), and novel delivery systems. Future laboratory and clinical research is required to define the role of iNO as an adjunct therapy against bacterial, viral, and fungal infections.
Collapse
Affiliation(s)
- Nikolay O. Kamenshchikov
- Cardiology Research Institute, Tomsk National Research Medical Center, Russian Academy of Sciences, 634012 Tomsk, Russia
- Correspondence:
| | - Lorenzo Berra
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA 02114, USA;
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
| | - Ryan W. Carroll
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA;
- Division of Pediatric Critical Care Medicine, Massachusetts General Hospital, Boston, MA 02114, USA
| |
Collapse
|
46
|
Cor pulmonale agudo en pacientes con síndrome de distrés respiratorio agudo secundario a COVID-19. Med Intensiva 2022; 46:645-647. [PMID: 35079192 PMCID: PMC8776495 DOI: 10.1016/j.medin.2021.12.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
47
|
Dugar S, Sato R, Zochios V, Duggal A, Vallabhajosyula S. Defining Right Ventricular Dysfunction in Acute Respiratory Distress Syndrome. J Cardiothorac Vasc Anesth 2021; 36:632-634. [PMID: 34583852 DOI: 10.1053/j.jvca.2021.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 08/28/2021] [Accepted: 09/01/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Siddharth Dugar
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH.
| | - Ryota Sato
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH
| | - Vasileios Zochios
- Department of Critical Care Medicine and ECMO unit, University Hospitals of Leicester National Health Service Trust, Glenfield Hospital, Leicester, United Kingdom
| | - Abhijit Duggal
- Department of Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, OH; Cleveland Clinic Lerner College of Medicine, Case Western University Reserve University, Cleveland, OH
| | - Saraschandra Vallabhajosyula
- Section of Cardiovascular Medicine, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, NC
| | | |
Collapse
|