Acute and critically ill peripartum cardiomyopathy and 'bridge to' therapeutic options: a single center experience with intra-aortic balloon pump, extra corporeal membrane oxygenation and continuous-flow left ventricular assist devices

Introduction: Peripartum cardiomyopathy (PPCM) patients refractory to medical therapy and intra-aortic balloon pump (IABP) counterpulsation or in whom weaning from these therapies is impossible, are candidates for a left ventricular assist device (LVAD) as a bridge to recovery or transplant. Continuous-flow LVADs are smaller, have a better long-term durability and are associated with better outcomes. Extra corporeal membrane oxygenation (ECMO) can be used as a temporary support in patients with refractory cardiogenic shock. The aim of this study was to evaluate the efficacy and safety of mechanical support in acute and critically ill PPCM patients. Methods: This was a retrospective search of the patient database of the Ghent University hospital (2000 to 2010). Results: Six PPCM-patients were treated with mechanical support. Three patients presented in the postpartum period and three patients at the end of pregnancy. All were treated with IABP, the duration of IABP support ranged from 1 to 13 days. An ECMO was inserted in one patient who presented with cardiogenic shock, multiple organ dysfunction syndrome and a stillborn baby. Two patients showed partial recovery and could be weaned off the IABP. Four patients were implanted with a continuous-flow LVAD (HeartMate II(R), Thoratec Inc.), including the ECMO-patient. Three LVAD patients were successfully transplanted 78, 126 and 360 days after LVAD implant; one patient is still on the transplant waiting list. We observed one peripheral thrombotic complication due to IABP and five early bleeding complications in three LVAD patients. One patient died suddenly two years after transplantation. Conclusions: In PPCM with refractory heart failure IABP was safe and efficient as a bridge to recovery or as a bridge to LVAD. ECMO provided temporary support as a bridge to LVAD, while the newer continuous-flow LVADs offered a safe bridge to transplant

Outcome in patients perceived as receiving excessive care across different ethical climates: a prospective study in 68 intensive care units in Europe and the USA

Purpose: Whether the quality of the ethical climate in the intensive care unit (ICU) improves the identification of patients receiving excessive care and affects patient outcomes is unknown. Methods: In this prospective observational study, perceptions of excessive care (PECs) by clinicians working in 68 ICUs in Europe and the USA were collected daily during a 28-day period. The quality of the ethical climate in the ICUs was assessed via a validated questionnaire. We compared the combined endpoint (death, not at home or poor quality of life at 1 year) of patients with PECs and the time from PECs until written treatment-limitation decisions (TLDs) and death across the four climates defined via cluster analysis. Results: Of the 4747 eligible clinicians, 2992 (63%) evaluated the ethical climate in their ICU. Of the 321 and 623 patients not admitted for monitoring only in ICUs with a good (n = 12, 18%) and poor (n = 24, 35%) climate, 36 (11%) and 74 (12%), respectively were identified with PECs by at least two clinicians. Of the 35 and 71 identified patients with an available combined endpoint, 100% (95% CI 90.0–1.00) and 85.9% (75.4–92.0) (P = 0.02) attained that endpoint. The risk of death (HR 1.88, 95% CI 1.20–2.92) or receiving a written TLD (HR 2.32, CI 1.11–4.85) in patients with PECs by at least two clinicians was higher in ICUs with a good climate than in those with a poor one. The differences between ICUs with an average climate, with (n = 12, 18%) or without (n = 20, 29%) nursing involvement at the end of life, and ICUs with a poor climate were less obvious but still in favour of the former. Conclusion: Enhancing the quality of the ethical climate in the ICU may improve both the identification of patients receiving excessive care and the decision-making process at the end of life

Surgical decompression for abdominal compartment syndrome after emergency cardiac surgery

Abdominal compartment syndrome typically occurs in patients after abdominal surgical procedures or trauma. Abdominal compartment syndrome is also increasingly described in conditions not related to abdominal operations, such as fluid resuscitation or burns. We report two patients who required surgical abdominal decompression for abdominal compartment syndrome that developed early after emergency coronary artery bypass graft surgery. No intraabdominal abnormalities were found at operation. Both patients had a protracted clinical course, but they survived and were discharged from the hospital

Polyurethane cuffed endotracheal tubes to prevent early postoperative pneumonia after cardiac surgery: A pilot study

ObjectivePatients receiving mechanical ventilation through an endotracheal tube are at increased risk for pneumonia. Because microaspiration of contaminated supraglottic secretions past the endotracheal tube cuff is considered to be central in the pathogenesis of ventilator-associated and postoperative pneumonia, better sealing of the upper trachea by the endotracheal tube cuff could possibly reduce this risk. We therefore postulated that use of a polyurethane cuffed tube would prevent early postoperative pneumonia through this mechanism in a population of cardiac surgical patients.MethodsIn a prospective, single-blind, randomized study, patients scheduled for cardiac surgery were allocated to intubation with a polyurethane cuffed endotracheal tube or the routinely used polyvinyl chloride cuffed endotracheal tube. Patients were scheduled for routine or emergency cardiac surgery and admitted to an 8-bed cardiac surgical intensive care unit of a tertiary care hospital.ResultsA total of 134 patients were available for analysis (67 in each group). Whereas mortality was not different between the groups, the incidence of early postoperative pneumonia and empirical prescription of antibiotic therapy were significantly lower in the polyurethane group than in the polyvinyl chloride group (23% vs 42%, P < .03). Intensive care unit and hospital stays were not significantly different between the two study subsets (3 ± 5 days vs 3 ± 4 days and 16 ± 9 vs 17±11 days, respectively). In a multivariate regression analysis, preoperative serum creatinine levels (odds ratio 1.85, confidence interval 1.02–3.37, P = .04) and perioperative transfusion (odds ratio 1.50, confidence interval 1.08–3.37, P = .015) were independently associated with increased risk of early postoperative pneumonia, whereas use of a polyurethane endotracheal tube was protective (odds ratio 0.31, confidence interval 0.13–0.77, P = .01).ConclusionPolyurethane cuffed endotracheal tubes can reduce the frequency of early postoperative pneumonia in cardiac surgical patients

Critically ill children treated with beta-lactam antibiotics : how to identify patients at risk for suboptimal exposure and clinical failure?

Background and aims In critically ill children, severely altered pharmacokinetics often result in subtherapeutic antibiotic concentrations. However, it remains unclear how to recognize those patients most at risk for suboptimal exposure and outcome data are lacking. This study aimed to identify risk factors for target non-attainment and clinical failure in critically ill children treated with beta-lactam antibiotics. Methods This observational cohort study included critically ill children aged 1 month to 15 years, treated intravenously with amoxicillin-clavulanic acid, piperacillin-tazobactam or meropenem. Steady-state trough plasma concentrations were considered therapeutic if ≤ MIC of the (suspected) pathogen. Risk factors for subtherapeutic concentrations and clinical failure were identified by logistic regression analysis. Clinical failure was defined as insufficient lessening of signs and symptoms and the need for alternate antimicrobial therapy. Results 382 trough concentrations were obtained from 157 patients (median age 1.25 years, Q1 0.4; Q3 4.2). Subtherapeutic concentrations were measured in 75.0%, 97.9% and 61.2% of patients treated with amoxicillin-clavulanic acid, piperacillin-tazobactam and meropenem, respectively. eGFR (p <0.001) and the absence of vasopressor treatment (p=0.026) were found as independent predictors of target non-attainment, whilst log transformed CRP was significantly related to clinical outcome (p=0.049). An association between antibiotic concentrations and clinical failure (22.9%) was not observed. Conclusions Subtherapeutic β-lactam antibiotic concentrations are common in critically ill children and correlate with renal function. Commonly used eGFR equations are helpful in daily practice to identify patients who require higher doses. Future studies should focus on dose optimization and evaluation of its effect on clinical outcome