Category Archives: Circulation

New developments that every intensivist should know about…..

Cardiology

Prof S Price

COVID-19

2020 Acute Coronary Syndromes (ACS) in Patients Presenting without Persistent ST-Segment Elevation (Management of) Guidelines

  • Rapid rule in/rule out algorithms now recommended to use ESC 0h/1h algorithm ( or 1h/2h algorithm (second best option) if a hs-cTn test with a validated algorithm is available
  • If elective non-invasive/invasive imaging is needed after the rule-out of MI, invasive angiography is the best option in those with a very high clinical likelihood of UA. Stress testing with imaging or CCTA is best in those with low-to-modest clinical risk.
  • Rhythm monitoring for up to 24 h or to PCI (whichever comes first) is recommended for those at low risk for arrhythmias and monitoring >24h if at increased risk
  • Early routine invasive approach within 24 hours for NSTEMI based on hs-cTn measurements, GRACE score >140, dynamic/new STT changes.

Clinical application of the 4th Universal Definition of Myocardial Infarction

Temporary circulatory support for cardiogenic shock

Pulmonology

EJ Nossent

Potential therapies

Pirfenidone for idiopathic pulmonary fibrosis: analysis of pooled data from three multinational phase 3 trials

Efficacy and Safety of Nintedanib in Idiopathic Pulmonary Fibrosis

Nintedanib for Systemic Sclerosis–Associated Interstitial Lung Disease

Nintedanib in Progressive Fibrosing Interstitial Lung Diseases

Take home message

  • ILD is not one disease
  • Acute excacerbation in every type of ILD
  • The landscape is changing; finally…
  • Position antifibrotic therapy fibrotic ILD not clear yet; immunosuppressants.

From the disease lung fibrosis to criteria, towards phenotyping, towards personalized medicine.

Neurology

Prof S Koch

COVID-19

Conclusion

EID risk is increasing due to climate change and loss of biodiversity
-> we need to adress this now

Neurological manifestation of Covid-19 occur in ~ 36%

Cerebrovasculare Manifestions occur in ~ 5% of Covid-19 patients based on
–pathological coagulation or hyperinflammation
–includes younger patients or patients with typical riskfactors
–leads to more severe outcome
-> check carefully coagulation parameters and risk factors

Altered conscious state is seen in ~ 65% of Covid-19 ICU patients
–based on encephalopathy or seizures
-> EEG monitoring, MRI

Anaesthesiology

S Loer

Optimizing preoperative fluid therapy Encourage use of clear carbohydrate drinks up until 2 h prior to surgery!

  • Less catabolism
  • Less postoperative nausea and vomiting
  • Less insulin resistance
  • Less perioperative anxiety

Intraoperative fluids

Impact of intraoperative goal-directed fluid therapy on major morbidity and mortality after transthoracic oesophagectomy: a multicentre, randomised controlled trial

Perioperative goal-directed therapy: what’s the best study design to investigate its impact on patient outcome?

Anesthesia-induced immune modulation

Post-op delirium

Postoperative delirium: perioperative assessment, risk reduction, and management

Post-op pain

Can we predict defibrillation success during cardiac arrest?

Ristagno Giuseppe, Milan

  • Coarse VF responds well to defibrillation; intermediate and fine VF – not as well
  • Defibrillation failure approaches ~75% during CPR
  • Current shockable algorithm considers all shockable situations the same and uses the time approach (Shock –> 2 min CPR –> Shock)
  • Recurrent VF /Resistant VF–> multiple defib attempts –> worse myocardial dysfunction post ROSC. Improving defib success will reduce the number of attempts and the post ROSC myocardial dysfunction
  • ECG waveform analysis during CPR can be used to individualize defibrillation attempts to improve success
  • AMplitude Spectrum Area (AMSA), one such technique, gives the area under the amplitude and frequency curve obtained from rhythm analysis during CPR
  • Higher the AMSA –> higher are the chances of successful defibrillation
  • With good chest compressions AMSA improves over time –> improved defibrillation success
  • AMSA >15.5 predicts defibrillation success and <6.5 predicts failure

  • Immediate vs delayed Defib in shockable rhythm – no superiority of one approach over the other (Cochrane meta-analysis – 2014)
  • AMSA trial ongoing. Analysis of data from the first 30 patients – quite promising (see screen shot below)
  • This might change the way we defibrillate in future!

Assessing and optimizing respiratory drive at the bedside

Irene Telias, Canada

Respiratory drive is the output of respiratory centers that control the magnitude of inspiratory effort

Why assess respiratory drive?

  • Derangements are frequent
  • Can have adverse consequences on diaphragm/lungs/ sleep

Respiratory control is complex

  • Chemoreflex – pH, pCO2 and pO2 via central and peripheral chemoreceptors control the output of the respiratory center
  • Multiple factors modify the drive in ICU patients (inflammation, metabolic demands, mechanical ventilation etc)

Monitoring

  • Respiratory center cannot be monitored directly. Respiratory drive is a surrogate
  • Measures of respiratory drive can be used to estimate inspiratory effort and vice versa

Techniques

  • Electrical activity of the diaphragm (EAdi)
  • Mechanical activation of diaphragm (Diaphragm Ultrasound)
  • Esophageal or gastric pressure measurement
  • P0.1 or Pocc
  • P0.1 specific for respiratory drive
  • Respiratory rate is not a good measure of the drive (except when it is <17 or >30 in ICU patients)

How is it done?

  • Majority of vents do it
  • P0.1 is the drop in airway pressure in the first 100 msec; Pocc is the drop in airway pressure during an end expiratory occlusion maneuver
  • P0.1 – Surrogate of respiratory drive, validated

High Respiratory drive

  • P0.1 > 3.5 – 4 cmH2O– High respiratory drive
  • Identify modifiable factors (adjust flow and tidal volume, reduce dead space, treat infection, pain etc)
  • PEEP and FiO2 adjustment
  • Sedation and analgesia

Low respiratory drive

  • 1 <1 cmH20
  • Typically, in patients recovering from respiratory failure – usually on high levels of PS – causes apnea and disrupted sleep
  • Reduce PS or use other modes