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- Arnaud, Alexis P, et al.
(författare)
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SARS-CoV-2 infection and venous thromboembolism after surgery : an international prospective cohort study
- 2022
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Ingår i: Anaesthesia. - : Wiley. - 0003-2409 .- 1365-2044. ; 77:1, s. 28-39
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Tidskriftsartikel (refereegranskat)abstract
- SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality (5.4 (95%CI 4.3-6.7)). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.
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| 2. |
- Aslam, Tayyba N., et al.
(författare)
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A survey of preferences for respiratory support in the intensive care unit for patients with acute hypoxaemic respiratory failure
- 2023
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Ingår i: Acta Anaesthesiologica Scandinavica. - : WILEY. - 0001-5172 .- 1399-6576. ; 67:10, s. 1383-1394
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundWhen caring for mechanically ventilated adults with acute hypoxaemic respiratory failure (AHRF), clinicians are faced with an uncertain choice between ventilator modes allowing for spontaneous breaths or ventilation fully controlled by the ventilator. The preferences of clinicians managing such patients, and what motivates their choice of ventilator mode, are largely unknown. To better understand how clinicians preferences may impact the choice of ventilatory support for patients with AHRF, we issued a survey to an international network of intensive care unit (ICU) researchers.MethodsWe distributed an online survey with 32 broadly similar and interlinked questions on how clinicians prioritise spontaneous or controlled ventilation in invasively ventilated patients with AHRF of different severity, and which factors determine their choice.ResultsThe survey was distributed to 1337 recipients in 12 countries. Of these, 415 (31%) completed the survey either fully (52%) or partially (48%). Most respondents were identified as medical specialists (87%) or physicians in training (11%). Modes allowing for spontaneous ventilation were considered preferable in mild AHRF, with controlled ventilation considered as progressively more important in moderate and severe AHRF. Among respondents there was strong support (90%) for a randomised clinical trial comparing spontaneous with controlled ventilation in patients with moderate AHRF.ConclusionsThe responses from this international survey suggest that there is clinical equipoise for the preferred ventilator mode in patients with AHRF of moderate severity. We found strong support for a randomised trial comparing modes of ventilation in patients with moderate AHRF.
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| 6. |
- Chew, Michelle S, 1969-
(författare)
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Right ventricular function
- 2020
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Ingår i: Oxford Textbook of Advanced Critical Care Echocardiography. - : Oxford University Press. - 9780198749288
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Bokkapitel (övrigt vetenskapligt/konstnärligt)abstract
- The right ventricle (RV) has historically been given less importance than the left. There are important anatomical differences, including several intracardiac structures that may complicate echocardiographic assessments. The right heart is sensitive to changes in pressure and its function is affected by common interventions in critical care such as fluid loading and positive pressure ventilation. Right and left ventricular functions are inextricably linked, and both systolic and diastolic ventricular interdependence occur. The echocardiographic examination of the RV includes an assessment of size and dimensions, systolic and diastolic function, estimation of intracardiac and pulmonary pressures. These should be interpreted in the context of the clinical interventions that the patient was subjected to at the time of imaging, as well as left ventricular function. RV failure is associated with poorer outcomes in several disease states including congestive cardiac failure and acute myocardial infarction. In critically ill patients, acute respiratory distress syndrome (ARDS) has significant implications for right heart function, where there is a necessary balance between respiratory mechanics and haemodynamics.
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| 7. |
- Chew, Michelle S, 1969-
(författare)
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Sedation and analgesia
- 2022
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Ingår i: The Very Old Critically Ill Patients. - Cham : Springer. - 9783030941321 - 9783030941338 ; , s. 319-333
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Bokkapitel (refereegranskat)abstract
- The main objective of this chapter is to obtain an understanding of the interaction between pain, sedation, and delirium. Specifically, the reader should be able to identify the unique challenges for their management taking into account that the very old are a particularly vulnerable group with often conflicting treatment priorities. This chapter will discuss implications for short- and long-term ICU outcomes including mortality, time on mechanical ventilation, and increased ICU and hospital lengths of stay, as well long-term cognitive impairment. Finally, the reader should be able to formulate a plan for sedation, pain, and delirium management for the very old ICU patient using ABCDEF principles.
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| 8. |
- Chew, Michelle S, 1969-
(författare)
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Septic shock
- 2020
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Ingår i: Oxford Textbook of Advanced Critical Care Echocardiography. - : Oxford University Press. - 9780198749288
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Bokkapitel (övrigt vetenskapligt/konstnärligt)abstract
- Failure or dysfunction of the cardiovascular system is the defining feature of septic shock. While there is now evidence for the central role of the heart in the pathophysiology of septic shock, it is important to remember that it is only one component of the cardiovascular system. Thus, it is often impossible to distinguish between the direct effects of sepsis on the heart and its responses to other changes in the cardiovascular system. Systolic, diastolic, left, and right heart functions are variably affected and are not mutually exclusive. They may be associated with rises in cardiac troponins and may be associated with underlying cardiovascular disease. Current evidence suggests left ventricular systolic dysfunction (assessed as reduced ejection fraction) is not associated with increased mortality, while diastolic dysfunction seems to be more predictive. Right heart failure occurs commonly, even with lung-protective ventilation strategies. Echocardiography is currently the only bedside technique providing comprehensive information regarding heart function during sepsis. In combination with information obtained with pulmonary arterial catheterization, it may be used to monitor the effects of fluid loading, mechanical ventilation, and vasopressor/inotropic therapy in the patient with septic shock. Future areas of research include (1) the development of a universal definition for septic cardiomyopathy; (2) investigating methods for distinguishing sepsis-specific changes from underlying disease; (3) investigating the relationship between cardiac biomarkers and echocardiographic changes; (4) investigating new echocardiographic markers of systolic and diastolic function; (5) integration of lung-protective mechanical ventilation and haemodynamic management strategies guided by echocardiographic findings.
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| 10. |
- De Backer, Daniel, et al.
(författare)
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How can assessing hemodynamics help to assess volume status?
- 2022
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Ingår i: Intensive Care Medicine. - : SPRINGER. - 0342-4642 .- 1432-1238. ; 48, s. 11482-1494
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Forskningsöversikt (refereegranskat)abstract
- In critically ill patients, fluid infusion is aimed at increasing cardiac output and tissue perfusion. However, it may contribute to fluid overload which may be harmful. Thus, volume status, risks and potential efficacy of fluid administration and/or removal should be carefully evaluated, and monitoring techniques help for this purpose. Central venous pressure is a marker of right ventricular preload. Very low values indicate hypovolemia, while extremely high values suggest fluid harmfulness. The pulmonary artery catheter enables a comprehensive assessment of the hemodynamic profile and is particularly useful for indicating the risk of pulmonary oedema through the pulmonary artery occlusion pressure. Besides cardiac output and preload, transpulmonary thermodilution measures extravascular lung water, which reflects the extent of lung flooding and assesses the risk of fluid infusion. Echocardiography estimates the volume status through intravascular volumes and pressures. Finally, lung ultrasound estimates lung edema. Guided by these variables, the decision to infuse fluid should first consider specific triggers, such as signs of tissue hypoperfusion. Second, benefits and risks of fluid infusion should be weighted. Thereafter, fluid responsiveness should be assessed. Monitoring techniques help for this purpose, especially by providing real time and precise measurements of cardiac output. When decided, fluid resuscitation should be performed through fluid challenges, the effects of which should be assessed through critical endpoints including cardiac output. This comprehensive evaluation of the risk, benefits and efficacy of fluid infusion helps to individualize fluid management, which should be preferred over a fixed restrictive or liberal strategy.
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