BACKGROUND: Wide interhospital variations exist in cardiovascular intensive care unit (CICU) admission practices and the use of critical care restricted therapies (CCRx), but little is known about the differences in patient acuity, CCRx utilization, and the associated outcomes within tertiary centers. METHODS: The Critical Care Cardiology Trials Network is a multicenter registry of tertiary and academic CICUs in the United States and Canada that captured consecutive admissions in 2-month periods between 2017 and 2022. This analysis included 17 843 admissions across 34 sites and compared interhospital tertiles of CCRx (eg, mechanical ventilation, mechanical circulatory support, continuous renal replacement therapy) utilization and its adjusted association with in-hospital survival using logistic regression. The Pratt index was used to quantify patient-related and institutional factors associated with CCRx variability. RESULTS: The median age of the study population was 66 (56–77) years and 37% were female. CCRx was provided to 62.2% (interhospital range of 21.3%–87.1%) of CICU patients. Admissions to CICUs with the highest tertile of CCRx utilization had a greater burden of comorbidities, had more diagnoses of ST–elevation myocardial infarction, cardiac arrest, or cardiogenic shock, and had higher Sequential Organ Failure Assessment scores. The unadjusted in-hospital mortality (median, 12.7%) was 9.6%, 11.1%, and 18.7% in low, intermediate, and high CCRx tertiles, respectively. No clinically meaningful differences in adjusted mortality were observed across tertiles when admissions were stratified by the provision of CCRx. Baseline patient-level variables and institutional differences accounted for 80% and 5.3% of the observed CCRx variability, respectively. CONCLUSIONS: In a large registry of tertiary and academic CICUs, there was a >4-fold interhospital variation in the provision of CCRx that was primarily driven by differences in patient acuity compared with institutional differences. No differences were observed in adjusted mortality between low, intermediate, and high CCRx utilization sites.
This state-of-the-art review describes the potential etiologies, pathophysiology, and management of mixed shock in the context of a proposed novel classification system. Cardiogenic-vasodilatory shock occurs when cardiogenic shock is complicated by inappropriate vasodilation, impairing compensatory mechanisms, and contributing to worsening shock. Vasodilatory-cardiogenic shock occurs when vasodilatory shock is complicated by myocardial dysfunction, resulting in low cardiac output. Primary mixed shock occurs when a systemic insult triggers both myocardial dysfunction and vasoplegia. Regardless of the etiology of mixed shock, the hemodynamic profile can be similar, and outcomes tend to be poor. Identification and treatment of both the initial and complicating disease processes is essential along with invasive hemodynamic monitoring given the evolving nature of mixed shock states. Hemodynamic support typically involves a combination of inotropes and vasopressors, with few data available to guide the use of mechanical circulatory support. Consensus definitions and novel treatment strategies are needed for this dangerous condition.
Introduction: Early mobility in critical illnesses, like acute decompensated heart failure, is essential to preserving muscle strength. However, patients on mechanical support devices such as a femoral-inserted intra-aortic balloon pump (f-IABP) have traditionally had limited mobility due to potential complications. Unfortunately, this commonly leads to prolonged ICU stay and an increased need for rehabilitation. Aim: This study evaluates the safety and feasibility of implementing a nurse-led verticalization protocol for patients with an f-IABP. Methods: A total of 36 patients with f-IABP successfully verticalized utilizing the Kreg Catalyst™ bed between May 1, 2022, to May 4, 2023, for one hour-long session. The cohort selection required patients to be ambulatory before f-IABP placement, hemodynamically stable, and free of arrhythmias within the last 24 hours. The study carefully monitored hemodynamic stability by comparing baseline averages to peak tolerated angle (PTA) data. Results: A total of 322 verticalization sessions were completed without significant complications and only nine minor complications. Minor complications included five sessions (1.55%), resulting in a catheter readjustment of over 3 centimeters. They averaged 9±7 verticalization sessions per patient, averaging 55±13 minutes. Were19/36 patients (53%) achieved a PTA greater than 70 degrees. Mean arterial pressure decreased by 4±7mmHg. Pulmonary artery systolic pressure decreased by 2±3mmHg, the cardiac index fell by 0.1± 0.5L/min/m 2 , and the heart rate increased by 4±5bpm. Of the 36 patients, 29 (81%) received heart transplants during their hospitalization and had an average post-operative ICU stay of 7 days and a total postoperative hospital stay of 18 days. Of the cohort study, 23 patients (64%) were discharged home with home health, ten patients (27%) were transferred to a rehabilitation center, two patients (5%) were transferred to an outside hospital, and one patient transitioned to comfort care. Conclusions: The result of the study indicates that it is safe and feasible to verticalize patients with f-IABP.
Introduction: Extracorporeal cardiopulmonary resuscitation (ECPR) can treat cardiac arrest refractory to conventional therapy. Many institutions are interested in developing their own ECPR program. However, there are challenges in logistics and implementation. Hypothesis: Development of an ECPR team and identification of UPMC Presbyterian as a receiving center will increase recognition of potential ECPR candidates. Methods: We developed an infrastructure of Emergency Medical Services (EMS), Medic Command, and an in-hospital ECPR team. We identified inclusion criteria for patients with an out of hospital cardiac arrest (OHCA) likely to have a reversible arrest etiology and developed them into a simple checklist. These criteria were: witnessed arrest with bystander CPR, shockable rhythm, and ages 18 to 60. We trained local EMS crews to screen patients and review the checklist with a Command Physician prior to transport to our hospital. Results: From October 2015 to March 31 st 2018, there were 1165 dispatches for OHCA, of which 664 (57%) were treated and transported to the hospital and 120 to our institution. Of these, five patients underwent ECPR. Of the remaining cases, 64 (53%) had nonshockable rhythms, 48 (40%) were unwitnessed arrests, 50 (42%) were over age 60 and the remaining 20 (17%) had no documented reasons for exclusion. Prehospital CPR duration was 26 [IQR 25-40] min. Four patients (80%) underwent mechanical CPR with LUCAS device. Time from arrest to arrive on scene was 5 [IQR 4-6] min and time call MD command was 13 [IQR 7-21] min. Time to transport was 20 [IQR 19-21] min. Time from arrest to initiation of ECMO was 63 [IQR 59-69] min. Conclusions: ECPR is a relatively infrequent occurrence. Implementation challenges include prompt identification of patients with reversible OHCA causes, preferential transport to an ECPR capable facility and changing the focus of EMS in these select patients from a “stay and play” to a “load and go” mentality.
Introduction: Patients undergoing heart transplant evaluation wait in the hospital for weeks. The intra-aortic balloon pump (IABP) is commonly used as a bridge to heart transplants. However, patients with a femoral-inserted IABP may face mobility limitations. Goal: To address this issue, the Cardiac Intensive Care Unit (CICU) implemented a modified Ramsey protocol aimed at ambulating patients with IABP. Goals: The goal was to improve patient health outcomes. The project aims to ambulate patients with f-IABP in Cardiac Intensive Care Unit (CICU) to prevent functional decline due to bed rest. Methods: The provider prescribed all IABP patients in the CICU ambulation. Before ambulation, patients who met the criteria were verticalized, utilizing the KREG Catalyst™ bed at 70 degrees for at least 45 minutes three times/day. After tolerating the verticalization at 70 degrees, nurses and physical therapists will assist the patient in stepping off the bed for at least 45 minutes 2 before ambulating around the unit. Results: A total of 14 patients were ambulated, of which twelve were male and two were female. The mean aged is 59 years, ranging from 30 to 72 years. The participants underwent an average of 15 ambulation sessions, with the minimum being one session and the maximum being 52 sessions. During these sessions, the participants covered an average total distance of 9619.29 feet, ranging from a minimum of 70 feet to a maximum of 36250 feet. The participants spent an average of 4061.86 seconds ambulating, with a minimum duration of one minute and a maximum of 30 minutes. The average catheter migration was 0.2229 centimeters upon implementation of the intervention. The findings show no significant adverse events with implementing this protocol. Conclusions: By implementing this protocol, healthcare professionals can enhance patient care and optimize post-heart transplant length of stay.
The hemodynamic effects of pre-transplant vaccination against COVID-19 among heart transplant candidates hospitalized for advanced heart failure remains unknown. A retrospective chart review was conducted at a high-volume transplant center from January through December 2021. 22 COVID-19 vaccination events occurred among patients hospitalized for decompensated heart failure while awaiting transplantation. Primary outcomes included inotrope and vasopressor dosages. Secondary outcomes included vital signs, pulmonary artery catheter measurements, diuretic dosages, and renal function. Data were extracted 24 h before through 72 h after vaccination. One of 22 vaccination events was associated with hemodynamic changes requiring increased inotropic and vasopressor support post-vaccination. In all other cases, transient hemodynamic changes occurred without need for escalated therapy. COVID-19 vaccination can be administered safely to most critically ill patients with advanced heart failure including those awaiting transplantation. All patients should be monitored closely as some may be susceptible to significant hemodynamic changes.
Introduction: Patients resuscitated from cardiac arrest (CA) often require vasopressors for hemodynamic support and frequently have cardiac dysfunction identified on transthoracic echocardiography (TTE). The association between TTE parameters and vasopressor requirements is not well-described. Hypothesis: Echocardiographic findings early after resuscitation from CA will predict vasopressor requirements. Methods: Prospective registry of patients resuscitated from CA underwent TTE within 24 hours after CA. We determined 2D measurements, LVEF, spectral Doppler of mitral inflow (E) and LV outflow and systolic and early diastolic (e’) tissue Doppler of the mitral annulus. Using Pearson correlation coefficients, we examined the association between TTE parameters and number of vasopressor drugs, cumulative vasopressor index (CVI) and Sequential Organ Failure Assessment (SOFA) score. Mean values of TTE parameters were compared in patients with high and low cardiovascular SOFA subscores using t-tests. Results: Among the 55 patients, LV end-diastolic diameter (LVEDD, r = -0.498 to -0.569, p = 0.0001 to 0.0003), LV end-systolic diameter (LVESD, r = -0.392 to -0.463, p = 0.0008 to 0.0053) and LV relative wall thickness (RWT, r = 0.452 to 0.503, p = 0.0002 to 0.0011) correlated significantly with admission and peak 24 hour number of vasopressor drugs and CVI. LVEDD (r = -0.324, p = 0.0229), LVESD (r = -0.290, p = 0.0431), RWT (0.429, p = 0.0021) and septal e’ velocity (r = -0.344, p = 0.037) correlated with admission SOFA score. Other TTE parameters including LVEF did not correlate with vasopressor requirements or SOFA score. Patients with cardiovascular SOFA subscore = 4 had lower LVEDD (4.16cm vs. 5.0cm, p = 0.0008), lower LVESD (3.07cm vs. 4.03cm, p = 0.0008), higher RWT (0.48 vs. 0.65, p = 0.0026) and lower E/e’ ratio (10.84 vs. 18.91, p = 0.0169) compared with patients with cardiovascular SOFA subscore < 4. Conclusions: A smaller, thicker LV cavity by echocardiography at 24 hours after CA is associated with higher vasopressor requirements and more severe organ failure. Patients who required more vasopressor support had smaller, thicker LV cavities and a lower E/e’ ratio. LV systolic dysfunction was not a significant predictor of vasopressor requirements.
Cardiogenic shock (CS) can be complicated by severe valvular heart disease (VHD). We analyzed cardiac intensive care unit (CICU) admissions by VHD status. The Critical Care Cardiology Trials Network is a multicenter network of tertiary CICUs. Centers contributed data from consecutive admissions during 2-month annual snapshots from 2017 to 2023. CS admissions were classified as having CS attributed to VHD, CS with non-causative VHD, or CS without severe VHD. Demographics and therapies were compared. Unadjusted and adjusted odds ratios for in-hospital mortality were calculated. We analyzed 5,242 admissions with CS (4.1% attributed to VHD, 18.8% with non-causative VHD, 77.1% without severe VHD). Mitral regurgitation (32.1%) and aortic stenosis (27.9%) were the most common pathologies in CS attributed to VHD. Admissions with CS attributed to VHD more commonly had LVEF≥40% on admission (present in 62.8%, 22.6%, and 15.1%, respectively; p<0.001). Valve intervention was performed in 32.1% of those with CS attributed to VHD. Unadjusted in-hospital mortality in admissions with CS attributed to VHD was 40.0%, compared to 33.4% and 30.3% in the other groups. VHD is the underlying cause of CS in a minority of CICU admissions but is associated with a high in-hospital mortality.
