IMPORTANCE Supplementing potassium in an effort to maintain high-normal serum concentrations is a widespread strategy used to prevent atrial fibrillation after cardiac surgery (AFACS), but is not evidence-based, carries risks, and is costly. OBJECTIVE To determine whether a lower serum potassium concentration trigger for supplementation is noninferior to a high-normal trigger. DESIGN, SETTING, AND PARTICIPANTS This open-label, noninferiority, randomized clinical trial was conducted at 23 cardiac surgical centers in the United Kingdom and Germany. Between October 20, 2020, and November 16, 2023, patients with no history of atrial dysrhythmias scheduled for isolated coronary artery bypass grafting (CABG) surgery were enrolled. The last study patient was discharged from the hospital on December 11, 2023. INTERVENTIONS Patients were randomly assigned to a strategy of tight or relaxed potassium control (only supplementing if serum potassium concentration fell below 4.5 mEq/L or 3.6 mEq/L, respectively). Patients wore an ambulatory heart rhythm monitor, which was analyzed by a core laboratory masked to treatment assignment. MAIN OUTCOMES AND MEASURES The prespecified primary end point was clinically detected and electrocardiographically confirmed new-onset AFACS in the first 120 hours after CABG surgery or until hospital discharge, whichever occurred first. All primary outcome events were validated by an event validation committee, which was masked to treatment assignment. Noninferiority of relaxed potassium control was defined as a risk difference for new-onset AFACS with associated upper bound of a 1-sided 97.5% CI of less than 10%. Secondary outcomes included other heart rhythm–related events, clinical outcomes, and cost related to the intervention. RESULTS A total of 1690 patients (mean age, 65 years; 256 [15%] females) were randomized. The primary end point occurred in 26.2% of patients (n = 219) in the tight group and 27.8% of patients (n = 231) in the relaxed group, which is a risk difference of 1.7% (95% CI, −2.6% to 5.9%). There was no difference between the groups in the incidence of at least 1 AFACS episode detected by any means or by ambulatory heart rhythm monitor alone, non-AFACS dysrhythmias, in-patient mortality, or length of stay. Per-patient cost for purchasing and administering potassium was significantly lower in the relaxed group (mean difference, $111.89 [95% CI, $103.60-$120.19]; P <.001). CONCLUSIONS AND RELEVANCE For AFACS prophylaxis, supplementation only when serum potassium concentration fell below 3.6 mEq/L was noninferior to the current widespread practice of supplementing potassium to maintain a serum potassium concentration greater than or equal to 4.5 mEq/L. The lower threshold of supplementation was not associated with any increase in dysrhythmias or adverse clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04053816
Targeted temperature management is recommended after out-of-hospital cardiac arrest and may be achieved using a variety of cooling devices. This study was conducted to explore the performance and outcomes for intravascular versus surface devices for targeted temperature management after out-of-hospital cardiac arrest. A retrospective analysis of data from the Targeted Temperature Management trial. N = 934. A total of 240 patients (26%) managed with intravascular versus 694 (74%) with surface devices. Devices were assessed for speed and precision during the induction, maintenance and rewarming phases in addition to adverse events. All-cause mortality, as well as a composite of poor neurological function or death, as evaluated by the Cerebral Performance Category and modified Rankin scale were analysed. For patients managed at 33 °C there was no difference between intravascular and surface groups in the median time taken to achieve target temperature (210 [interquartile range (IQR) 180] minutes vs. 240 [IQR 180] minutes, p = 0.58), maximum rate of cooling (1.0 [0.7] vs. 1.0 [0.9] °C/hr, p = 0.44), the number of patients who reached target temperature (within 4 hours (65% vs. 60%, p = 0.30); or ever (100% vs. 97%, p = 0.47), or episodes of overcooling (8% vs. 34%, p = 0.15). In the maintenance phase, cumulative temperature deviation (median 3.2 [IQR 5.0] °C hr vs. 9.3 [IQR 8.0] °C hr, p = <0.001), number of patients ever out of range (57.0% vs. 91.5%, p = 0.006) and median time out of range (1 [IQR 4.0] hours vs. 8.0 [IQR 9.0] hours, p = <0.001) were all significantly greater in the surface group although there was no difference in the occurrence of pyrexia. Adverse events were not different between intravascular and surface groups. There was no statistically significant difference in mortality (intravascular 46.3% vs. surface 50.0%; p = 0.32), Cerebral Performance Category scale 3–5 (49.0% vs. 54.3%; p = 0.18) or modified Rankin scale 4–6 (49.0% vs. 53.0%; p = 0.48). Intravascular and surface cooling was equally effective during induction of mild hypothermia. However, surface cooling was associated with less precision during the maintenance phase. There was no difference in adverse events, mortality or poor neurological outcomes between patients treated with intravascular and surface cooling devices. TTM trial ClinicalTrials.gov number https://clinicaltrials.gov/ct2/show/NCT01020916 NCT01020916; 25 November 2009
This review summarizes key research papers published in the fields of cardiology and intensive care during 2006 in Critical Care and, where relevant, in other journals within the field. The papers have been grouped into categories: haemodynamic monitoring, vascular access in intensive care, microvascular assessment and manipulation, and impact of metabolic acidosis on outcome.
Historically patients who presented following an Out of Hospital Cardiac Arrest (OHCA) of presumed cardiac origin had dismal survival data with concerns that survivors would have poor neurological outcomes. In recent years there has been increased focus on prehospital care and coordinated care once patients arrive in hospital, including urgent percutaneous coronary intervention (PCI) and targeted temperature management (TTM). In our unit we have a multi-disciplinary heart attack team (HAT) in place that specialises in treating this challenging patient population by delivering the patients directly to our cardiac catheter laboratories and then to intensive care where they have TTM in addition to standard intensive care.
Methods
This is a retrospective observational study looking at the outcome of consecutive OHCA patients who were managed by the HAT and presented to our institution over a period of 1 year. The HAT was formally introduced in July 2011. We focused on survival, neurological status on hospital discharge using the cerebral performance scores (CPC), length of stay (LOS) in cardiothoracic ITU (CTITU) and in hospital and activity in the coronary catheter lab notably door to balloon times (DBT) for PCI. Data were derived from hospital notes, electronic records and ambulance sheets.
Results
A total of 53 patients presented directly to our institution following an OHCA of presumed cardiac origin. The mean age was 61 years (SD 14 years) with 75.5% male. 36 patients (67.9%) survived to hospital discharge with a mean age 59 years (SD 15 years) and 73% male. 30 patients had ST elevation or LBBB on their presenting ECG. 30 patients (83.3%) were discharged with no significant neurological impairment, CPC 1 and 2. 6 patients were discharged with neurological impairment, CPC3; there were no patients in CPC4. The median LOS on CTITU was 4 days (IQR 6.5 days) and for the survivors the median LOS was 5 days (IQR 7.4 days). The hospital LOS for all patients was 11 days (IQR 13.4 days) with the median LOS in hospital for survivors 16 days (IQR 13.5 days). 49 patients (92.5%) had urgent angiography with 29 patients proceeding to successful PCI (59.2%) and 5 patients (10.2%) referred for CABG with three vessel disease. The median DBT for these patients was 49 min (IQR 31 min), with the survivors having a median DBT 46 min (IQR 30 min). 7 patients (19.4%) were discharged from hospital with an ICD.
Conclusions
The survival of OHCA patients presenting to our cardiac unit compares favourably with published data. We believe these outcomes are a result of our successful heart attack team which enables us to deliver high rate of urgent coronary intervention and aggressive intensive care therapy including targeted temperature management.
Hydrogen sulfide is produced endogenously by a variety of enzymes involved in cysteine metabolism.Clinical data indicate that endogenous levels of hydrogen sulfide are diminished in various forms of cardiovascular diseases.The aim of the current study was to investigate the effects of hydrogen sulfide supplementation on cardiac function during reperfusion in a clinically relevant experimental model of cardiopulmonary bypass.Twelve anesthetized dogs underwent hypothermic cardiopulmonary bypass.After 60 minutes of hypothermic cardiac arrest, reperfusion was started after application of either saline vehicle (control, n = 6), or the sodium sulfide infusion (1 mg/kg/hour, n = 6).Biventricular hemodynamic variables were measured by combined pressure-volume-conductance catheters.Coronary and pulmonary blood flow, vasodilator responses to acetylcholine and sodiumnitroprusside and pulmonary function were also determined.Administration of sodium sulfide led to a significantly better recovery of left and right ventricular systolic function (P < 0.05) after 60 minutes of reperfusion.Coronary blood flow was also significantly higher in the sodium sulfide-treated group (P < 0.05).Sodium sulfide treatment improved coronary blood flow, and preserved the acetylcholine-induced increases in coronary and pulmonary blood (P < 0.05).Myocardial ATP levels were markedly improved in the sulfide-treated group.Thus, supplementation of sulfide improves the recovery of myocardial and endothelial function and energetic status after hypothermic cardiac arrest during cardiopulmonary bypass.These beneficial effects occurred without any detectable adverse hemodynamic or cardiovascular effects of sulfide at the dose used in the current study.
Dysglycemia and glycemic variability are associated with poor outcomes in critically ill patients. Targeted temperature management alters blood glucose homeostasis. We investigated the association between blood glucose concentrations and glycemic variability and the neurologic outcomes of patients randomized to targeted temperature management at 33°C or 36°C after cardiac arrest.Post hoc analysis of the multicenter TTM-trial. Primary outcome of this analysis was neurologic outcome after 6 months, referred to as "Cerebral Performance Category."Thirty-six sites in Europe and Australia.All 939 patients with out-of-hospital cardiac arrest of presumed cardiac cause that had been included in the TTM-trial.Targeted temperature management at 33°C or 36°C.Nonparametric tests as well as multiple logistic regression and mixed effects logistic regression models were used. Median glucose concentrations on hospital admission differed significantly between Cerebral Performance Category outcomes (p < 0.0001). Hyper- and hypoglycemia were associated with poor neurologic outcome (p = 0.001 and p = 0.054). In the multiple logistic regression models, the median glycemic level was an independent predictor of poor Cerebral Performance Category (Cerebral Performance Category, 3-5) with an odds ratio (OR) of 1.13 in the adjusted model (p = 0.008; 95% CI, 1.03-1.24). It was also a predictor in the mixed model, which served as a sensitivity analysis to adjust for the multiple time points. The proportion of hyperglycemia was higher in the 33°C group compared with the 36°C group.Higher blood glucose levels at admission and during the first 36 hours, and higher glycemic variability, were associated with poor neurologic outcome and death. More patients in the 33°C treatment arm had hyperglycemia.
Dynamic testing of muscle tissue oxygenation (StO2) with near-infrared spectroscopy and vascular occlusion (VOT) has been used to study pathophysiological states, but there is a paucity of data for standardised techniques in normal subjects. Three-minute VOT is frequently described. We have collected StO2 data for this technique and compared them with a shorter 2-minute test.
endovascular surgery ◼ mortality ◼ outcomes E lective repair of thoracic aortic aneurysms is a prophylactic procedure performed when the risk of aneurysm rupture is judged to outweigh perioperative risk.It has been demonstrated that mortality because of any cause in the 5 years after repair in frail surgical candidates is high, despite the fact that perioperative mortality is relatively favorable and aortic-related death is reduced. 1,2atient selection, therefore, is vital if survival gains are to be achieved through elective repair of thoracic aneurysms.Preoperative factors are known to affect life expectancy after surgery, but the effect of perioperative complications on subsequent survival has not been reported.Patients undergoing elective thoracic aneurysm repair for thoracic aortic aneurysm from the updated MOTHER (Medtronic Thoracic Endovascular Registry) were studied, which comprises 7 clinical trials and 1 institutional series. 3Subjects with aneurysmal chronic aortic dissection were excluded.Perioperative complications were classified as neurological, cardiac, renal, respiratory, or access vessel-related.For all clinical trials, adverse events were reported via the trial data-collection process and were adjudicated by a review panel according to trial protocol.For the St George's Vascular Institute cohort, all adverse events were reviewed by 2 experienced clinicians and classified after discussion.The 30-day mortality rates associated with each were calculated, which represented the failure to rescue rate, and Kaplan-Meier analysis was performed to determine the effect of having each complication on long-term survival.The cumulative effect of multiple complications was studied, and a cutoff that split the group into those at high or low risk of all-cause mortality was established.Institutional Review Board approval was obtained separately for all constituent studies.Informed consent was given for all commercial registries but was not required for the institutional case series because it was determined to be a retrospective study by the Institutional Review Board.Of the 635 patients included in the study from the MOTHER registry, 38.5% had ≥1 complication, and 14.6% had >1.Mean follow-up was 3.7 years with a range of 0 to 10.4 years.Neurological complications occurred in 10.5% of patients, respiratory in 11.4%, cardiac in 8.5%, renal in 6.1%, and access complications in 21.7%.All classes of complications were associated with increased mortality within the first 30 days and during the 5-year follow-up period (log-rank P<0.001) in categories except access-related, which was P=0.012.Early mortality rates were 7.2%, 15.5%, 21.4%, and 25% for those with 1, 2, 3, and 4 complications, respectively.There was a sequential reduction in 5-year survival among patients experiencing cumulative complications (Figure).Those who had ≥2 complications had significantly worse late survival than others patients, with an estimated mean survival of 3.2 (95% confidence interval, 2.6-3.9)versus 7.2 (95% confidence interval, 6.6-6.8)years in those who did not (log-rank P<0.001).Survival was reduced even when patients dying ≤90 days of surgery are removed from the survival analysis.Cox's regression modeling demonstrated that renal (odds ratio, 2.1; 95% confidence interval, 1.5-3.0)
Critically ill patients with coronavirus disease 2019 (COVID-19) are at risk of invasive pulmonary aspergillosis. The clinical manifestations of a superimposed fungal infection in those patients are difficult to underpin. This is compounded by the non-specific radiological findings associated with this infection and the challenges associated with performing bronchoscopy in COVID-19 patients. We would like to present two COVID-19 cases who developed secondary Aspergillus pulmonary infection in the intensive care unit as shown by respiratory cultures, serum galactomannan and radiological images. Despite advanced intensive care and use of antifungal agents, both patients died eventually. This report illustrates the negative impact of secondary Aspergillosis and calls for the need of increased awareness of COVID19-associated pulmonary aspergillosis.
Thermal injury to the oesophagus is an important cause of life-threatening complication after ablation for atrial fibrillation (AF). Thermal protection of the oesophageal lumen by infusing cold liquid reduces thermal injury to a limited extent. We tested the ability of a more powerful method of oesophageal temperature control to reduce the incidence of thermal injury.A single-centre, prospective, double-blinded randomized trial was used to investigate the ability of the ensoETM device to protect the oesophagus from thermal injury. This device was compared in a 1:1 randomization with a control group of standard practice utilizing a single-point temperature probe. In the protected group, the device maintained the luminal temperature at 4°C during radiofrequency (RF) ablation for AF under general anaesthesia. Endoscopic examination was performed at 7 days post-ablation and oesophageal injury was scored. The patient and the endoscopist were blinded to the randomization. We recruited 188 patients, of whom 120 underwent endoscopy. Thermal injury to the mucosa was significantly more common in the control group than in those receiving oesophageal protection (12/60 vs. 2/60; P = 0.008), with a trend toward reduction in gastroparesis (6/60 vs. 2/60, P = 0.27). There was no difference between groups in the duration of RF or in the force applied (P value range= 0.2-0.9). Procedure duration and fluoroscopy duration were similar (P = 0.97, P = 0.91, respectively).Thermal protection of the oesophagus significantly reduces ablation-related thermal injury compared with standard care. This method of oesophageal protection is safe and does not compromise the efficacy or efficiency of the ablation procedure.
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