Pub Date : 2019-09-17DOI: 10.21037/jeccm.2019.08.08
M. W. Bettink, M. Arbous, N. Raat, E. Mik
Safeguarding an adequate oxygen transport to organs and tissues is a prime goal in the care for critically ill patients. Over the last two decades it has become clear that in certain pathophysiological circumstances macrocirculatory derailment is followed, or accompanied, by microcirculatory dysfunction. Resuscitation strategies to restore and optimize blood flow to organs are based on the idea that restoring oxygen supply will re-establish aerobic metabolism and lead to “healthy parenchymal cells”. However, mitochondrial damage and subsequent dysfunction, or cellular adaptation to hypoxia, might attenuate or even counterbalance the positive effects of resuscitation on the cellular level. In this short review we will address mitochondrial function and adaptation, causes of mitochondrial dysfunction, the concept of cytopathic hypoxia, (loss of) hemodynamic coherence and ways to assess aspects of mitochondrial function in patients. Mitochondria are the primary consumers of oxygen and the ultimate destination of approximately 98% of oxygen reaching our tissue cells. Most of the oxygen is used for energy production by oxidative phosphorylation, but a small amount is used for generating reactive oxygen species and heat generation. While adenosine triphosphate (ATP) production is the best-known function of mitochondria, they also play key roles in calcium homeostasis and cell-death mechanisms. Oxidative phosphorylation has a very high affinity for oxygen and functions well at very low oxygen levels. However, cellular respiration does adapt to changes in oxygen availability at physiological levels, a mechanism known as “oxygen conformance”. Oxygen conformance, mitochondrial damage by certain hits (e.g., toxins and medication), mitochondrial dysfunction and autonomic metabolic reprogramming are factors that could contribute to what is known as “cytopathic hypoxia”. This concept describes insufficient oxygen metabolism in cells despite sufficient oxygen delivery in sepsis. Altered cellular oxygen utilization and thus reduced oxygen demand could in itself cause decreased microcirculatory blood flow, making microcirculatory dysfunction in sepsis under some circumstances a possible epiphenomenon. Resuscitation and forced restoration of microcirculatory flow could lead to relative hyperoxia, and be counterproductive by increasing reactive oxygen production and intervening with protective adaptation mechanisms. The complex pathophysiology of a critically ill patient, especially in severe sepsis and septic shock, requires a multilevel approach. In understanding the interplay between macrocirculation, microcirculation, and parenchymal cells the mitochondria are key players that should not be overlooked. Progress is being made in technologies to assess aspects of mitochondrial function at the bedside, for example direct measurement of mitochondrial oxygen tension and oxygen consumption.
{"title":"Mind the mitochondria!","authors":"M. W. Bettink, M. Arbous, N. Raat, E. Mik","doi":"10.21037/jeccm.2019.08.08","DOIUrl":"https://doi.org/10.21037/jeccm.2019.08.08","url":null,"abstract":"Safeguarding an adequate oxygen transport to organs and tissues is a prime goal in the care for critically ill patients. Over the last two decades it has become clear that in certain pathophysiological circumstances macrocirculatory derailment is followed, or accompanied, by microcirculatory dysfunction. Resuscitation strategies to restore and optimize blood flow to organs are based on the idea that restoring oxygen supply will re-establish aerobic metabolism and lead to “healthy parenchymal cells”. However, mitochondrial damage and subsequent dysfunction, or cellular adaptation to hypoxia, might attenuate or even counterbalance the positive effects of resuscitation on the cellular level. In this short review we will address mitochondrial function and adaptation, causes of mitochondrial dysfunction, the concept of cytopathic hypoxia, (loss of) hemodynamic coherence and ways to assess aspects of mitochondrial function in patients. Mitochondria are the primary consumers of oxygen and the ultimate destination of approximately 98% of oxygen reaching our tissue cells. Most of the oxygen is used for energy production by oxidative phosphorylation, but a small amount is used for generating reactive oxygen species and heat generation. While adenosine triphosphate (ATP) production is the best-known function of mitochondria, they also play key roles in calcium homeostasis and cell-death mechanisms. Oxidative phosphorylation has a very high affinity for oxygen and functions well at very low oxygen levels. However, cellular respiration does adapt to changes in oxygen availability at physiological levels, a mechanism known as “oxygen conformance”. Oxygen conformance, mitochondrial damage by certain hits (e.g., toxins and medication), mitochondrial dysfunction and autonomic metabolic reprogramming are factors that could contribute to what is known as “cytopathic hypoxia”. This concept describes insufficient oxygen metabolism in cells despite sufficient oxygen delivery in sepsis. Altered cellular oxygen utilization and thus reduced oxygen demand could in itself cause decreased microcirculatory blood flow, making microcirculatory dysfunction in sepsis under some circumstances a possible epiphenomenon. Resuscitation and forced restoration of microcirculatory flow could lead to relative hyperoxia, and be counterproductive by increasing reactive oxygen production and intervening with protective adaptation mechanisms. The complex pathophysiology of a critically ill patient, especially in severe sepsis and septic shock, requires a multilevel approach. In understanding the interplay between macrocirculation, microcirculation, and parenchymal cells the mitochondria are key players that should not be overlooked. Progress is being made in technologies to assess aspects of mitochondrial function at the bedside, for example direct measurement of mitochondrial oxygen tension and oxygen consumption.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.08.08","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43578326","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-17DOI: 10.21037/jeccm.2019.08.02
Debkumar Chowdhury
Background: The incidence of hip fractures is increasing as the population ages with current estimates of 101,000 per year by the year 2020 in the United Kingdom. Pain has both a physiological and a psychological component to it. Early and effective analgesia has been proven to benefit patients and possibly lead to earlier return to baseline function. Through the years fascia iliaca blocks (FIBs) have been used as an adjunct management for analgesic relief in neck of femur fractures Methods: We carried out a preliminary study to assess the use of stickers to document various measures of pain management. There was patchy uptake of the aforementioned stickers, we subsequently reverted back to the use of our pre-existing hip fracture proforma for documentation of pain scores. There were two main parameters measured in our study in our Emergency Department in our District General Hospital. The first parameter was the time to reassessment from initial assessment. The second parameter was assessing the effectiveness of FIBs and the associated pain scores. In total we had 42 patients included in our study over a 6-month period with 25 patients undergoing FIBs. Results: The average time to reassessment was noted to be 72 min. In patients that underwent FIBs there was a 41.8% improvement in pain scores. From the study we noted that 9 patients refused to have the FIB (21.4%). From the 25 patients that underwent FIB, it was noted that 11 patients had no improvement of their pain scores from the pain score at reassessment (44%). However, it is worth noting the longer acting nature of the FIB provides patients with pain relief for longer periods especially if there is a delay to theatre. Conclusions: FIBs provide an effective adjunct to analgesia. We identified various measures that could be implemented for better analgesic control in patients with neck of femur fractures. We hope to undertake studies with larger number of patients to better assess the effectiveness of FIBs.
{"title":"Comparing the effectiveness of fascia iliaca block with standard analgesia in neck of femur fractures in a district general hospital emergency department—a prospective study with review of literature","authors":"Debkumar Chowdhury","doi":"10.21037/jeccm.2019.08.02","DOIUrl":"https://doi.org/10.21037/jeccm.2019.08.02","url":null,"abstract":"Background: The incidence of hip fractures is increasing as the population ages with current estimates of 101,000 per year by the year 2020 in the United Kingdom. Pain has both a physiological and a psychological component to it. Early and effective analgesia has been proven to benefit patients and possibly lead to earlier return to baseline function. Through the years fascia iliaca blocks (FIBs) have been used as an adjunct management for analgesic relief in neck of femur fractures \u0000 Methods: We carried out a preliminary study to assess the use of stickers to document various measures of pain management. There was patchy uptake of the aforementioned stickers, we subsequently reverted back to the use of our pre-existing hip fracture proforma for documentation of pain scores. There were two main parameters measured in our study in our Emergency Department in our District General Hospital. The first parameter was the time to reassessment from initial assessment. The second parameter was assessing the effectiveness of FIBs and the associated pain scores. In total we had 42 patients included in our study over a 6-month period with 25 patients undergoing FIBs. Results: The average time to reassessment was noted to be 72 min. In patients that underwent FIBs there was a 41.8% improvement in pain scores. From the study we noted that 9 patients refused to have the FIB (21.4%). From the 25 patients that underwent FIB, it was noted that 11 patients had no improvement of their pain scores from the pain score at reassessment (44%). However, it is worth noting the longer acting nature of the FIB provides patients with pain relief for longer periods especially if there is a delay to theatre. \u0000 Conclusions: FIBs provide an effective adjunct to analgesia. We identified various measures that could be implemented for better analgesic control in patients with neck of femur fractures. We hope to undertake studies with larger number of patients to better assess the effectiveness of FIBs.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.08.02","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49570710","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-16DOI: 10.21037/jeccm.2019.09.01
G. Poulakou, S. Lagou, S. Papadatos, I. Anagnostopoulos, M. Papatheodoridi, G. Dimopoulos
The elderly population is increasing in the developed world, therefore elderlies account for a considerable proportion of intensive care unit (ICU) admissions. A precise threshold for “elderly” is a matter of debate. The process of ageing is associated with physiological and functional alterations of the human body and organs that render elderly people vulnerable to infections. As a result of dysfunction of specific parts of immune response called immunosenescence, elderly patients may be threatened by severe infections. Chronic low-grade inflammation, termed inflammaging, is another contributor. In addition to these, comorbidities associated with increasing age, such as diabetes mellitus and immunosuppressive conditions pose an additive risk for infections and in some studies they were associated with increased mortality. Epidemiology of ICU infections may differ in elderlies, compared to other adults. Infections tend to be less microbiologically confirmed and site of infection may be obscure on presentation. The identified pathogens are frequently Gram-negative and particularly Enterobacteriaceae exhibiting a multidrug-resistant (MDR) phenotype. Multiple antibiotic prescriptions in this age-group, specific comorbidities (such as bronchiectasis or chronic obstructive pulmonary disease), residence in long term care facilities and frequent hospitalisations, are among others recognized risk factors for MDR infections. Data from two large European databases show that intra-abdominal infections are predominant among ICU infections in the elderly and Candida spp infections rank second, after Enterobacteriaceae. Age may pose important implications in treatment decisions. Organ derangements, physiological changes caused by increasing age and multiple concomitant medications call clinicians for vigilance about adverse events and toxicity. Despite all the above, elderlies in the ICU did not exhibit worse outcomes compared to younger counterparts in a straightforward manner. Studies however are heterogenous and most of them are single centers. As age is a continuous process, only analysis performed in subgroups of 65–74 (young-old elderlies), 75–84 (old elderlies) and >85 (old-old or oldest old elderlies) provides a better depiction of ICU outcomes. Most studies have shown a worse ICU outcome for the group of oldest-old elderlies, compared with young adults and elderlies in the range of 65 to 84 years of age. These data indicate that age per se may not represent a barrier in decisions concerning ICU admission and triage has to be done on an individual basis. However, epidemiological particularities of this age group should be taken into account in the selection of early and appropriate antimicrobial treatment, which will optimize patients’ outcomes.
{"title":"Infections in elderly intensive care unit patients","authors":"G. Poulakou, S. Lagou, S. Papadatos, I. Anagnostopoulos, M. Papatheodoridi, G. Dimopoulos","doi":"10.21037/jeccm.2019.09.01","DOIUrl":"https://doi.org/10.21037/jeccm.2019.09.01","url":null,"abstract":"The elderly population is increasing in the developed world, therefore elderlies account for a considerable proportion of intensive care unit (ICU) admissions. A precise threshold for “elderly” is a matter of debate. The process of ageing is associated with physiological and functional alterations of the human body and organs that render elderly people vulnerable to infections. As a result of dysfunction of specific parts of immune response called immunosenescence, elderly patients may be threatened by severe infections. Chronic low-grade inflammation, termed inflammaging, is another contributor. In addition to these, comorbidities associated with increasing age, such as diabetes mellitus and immunosuppressive conditions pose an additive risk for infections and in some studies they were associated with increased mortality. Epidemiology of ICU infections may differ in elderlies, compared to other adults. Infections tend to be less microbiologically confirmed and site of infection may be obscure on presentation. The identified pathogens are frequently Gram-negative and particularly Enterobacteriaceae exhibiting a multidrug-resistant (MDR) phenotype. Multiple antibiotic prescriptions in this age-group, specific comorbidities (such as bronchiectasis or chronic obstructive pulmonary disease), residence in long term care facilities and frequent hospitalisations, are among others recognized risk factors for MDR infections. Data from two large European databases show that intra-abdominal infections are predominant among ICU infections in the elderly and Candida spp infections rank second, after Enterobacteriaceae. Age may pose important implications in treatment decisions. Organ derangements, physiological changes caused by increasing age and multiple concomitant medications call clinicians for vigilance about adverse events and toxicity. Despite all the above, elderlies in the ICU did not exhibit worse outcomes compared to younger counterparts in a straightforward manner. Studies however are heterogenous and most of them are single centers. As age is a continuous process, only analysis performed in subgroups of 65–74 (young-old elderlies), 75–84 (old elderlies) and >85 (old-old or oldest old elderlies) provides a better depiction of ICU outcomes. Most studies have shown a worse ICU outcome for the group of oldest-old elderlies, compared with young adults and elderlies in the range of 65 to 84 years of age. These data indicate that age per se may not represent a barrier in decisions concerning ICU admission and triage has to be done on an individual basis. However, epidemiological particularities of this age group should be taken into account in the selection of early and appropriate antimicrobial treatment, which will optimize patients’ outcomes.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-16","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.09.01","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48160548","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-10DOI: 10.21037/jeccm.2019.08.07
Ilonka N. de Keijzer, T. Kaufmann, T. Scheeren
Fluid administration in the perioperative period is daily clinical practice for all anesthesiologists. The goal of fluid administration is to increase cardiac output in order to ultimately improve oxygen delivery to the tissues. Fluid therapy can be given as maintenance or as replacement fluid therapy. For both of these therapies balanced crystalloids belong to the first line of treatment. Colloids are used for fluid replacement as well, but are given for more specific indications such as hypovolemia as a consequence of blood loss. Fluids, as any other intravenous drug, have indications, contra-indications, and potential side-effects. No conclusive evidence exists over the way and amount of fluids that should be administered, and several strategies have been developed, e.g., restrictive or liberal fluid therapy or perioperative goal-directed therapy (PGDT). Restrictive fluid therapy uses limited amounts of fluid compared to liberal fluid therapy, however no clear definitions of restricted or liberal fluid therapy are available. PGDT uses hemodynamic variables to assess fluid responsiveness and to guide fluid therapy in order to optimize the hemodynamic status of the patient. Future directions in fluid administration are to use personalized hemodynamic target values and to use PGDT in closed-loop systems. Most important, fluids should be administered with the same caution that is used with any intravenous drug.
{"title":"Which type of fluid to use perioperatively?","authors":"Ilonka N. de Keijzer, T. Kaufmann, T. Scheeren","doi":"10.21037/jeccm.2019.08.07","DOIUrl":"https://doi.org/10.21037/jeccm.2019.08.07","url":null,"abstract":"Fluid administration in the perioperative period is daily clinical practice for all anesthesiologists. The goal of fluid administration is to increase cardiac output in order to ultimately improve oxygen delivery to the tissues. Fluid therapy can be given as maintenance or as replacement fluid therapy. For both of these therapies balanced crystalloids belong to the first line of treatment. Colloids are used for fluid replacement as well, but are given for more specific indications such as hypovolemia as a consequence of blood loss. Fluids, as any other intravenous drug, have indications, contra-indications, and potential side-effects. No conclusive evidence exists over the way and amount of fluids that should be administered, and several strategies have been developed, e.g., restrictive or liberal fluid therapy or perioperative goal-directed therapy (PGDT). Restrictive fluid therapy uses limited amounts of fluid compared to liberal fluid therapy, however no clear definitions of restricted or liberal fluid therapy are available. PGDT uses hemodynamic variables to assess fluid responsiveness and to guide fluid therapy in order to optimize the hemodynamic status of the patient. Future directions in fluid administration are to use personalized hemodynamic target values and to use PGDT in closed-loop systems. Most important, fluids should be administered with the same caution that is used with any intravenous drug.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-10","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.08.07","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42572540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-09DOI: 10.21037/jeccm.2019.08.03
M. Miller, C. Perlick
Injury is the leading cause of death and disability in children and young adults from ages 1–24 (1). Blunt trauma accounts for over 90% of traumatic mechanisms of injury in children. with blunt abdominal trauma accounting for approximately 10–15% of all blunt mechanisms (2-4).
{"title":"Pediatric solid organ injury management: the role of initial hematocrit in lean times","authors":"M. Miller, C. Perlick","doi":"10.21037/jeccm.2019.08.03","DOIUrl":"https://doi.org/10.21037/jeccm.2019.08.03","url":null,"abstract":"Injury is the leading cause of death and disability in children and young adults from ages 1–24 (1). Blunt trauma accounts for over 90% of traumatic mechanisms of injury in children. with blunt abdominal trauma accounting for approximately 10–15% of all blunt mechanisms (2-4).","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.08.03","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45448186","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01Epub Date: 2019-09-20DOI: 10.21037/jeccm.2019.09.02
Jennifer N Ervin
Little is known about specific expectations family members and other types of surrogates have regarding clinician interaction. The objective of this study is to describe communication expectations regarding clinician engagement when surrogates represent patients who are too critically ill to advocate on their own behalf. As part of a larger study, a panel of 44 former patients and surrogate decision makers of a 20-bed medical intensive care unit (ICU) housed within a large academic hospital in the Midwestern United States responded to an online survey. Findings suggest that participants held different expectations for different intensive care providers in that 98% expected to talk to an attending physician within 48 hours of their loved one being admitted to the ICU, while 88% expected to have spoken with a registered nurse, and 74% with a respiratory therapist. Only half expected to have talked with a resident or fellow, and a third to a social worker. Regarding communication frequency, 95% of participants expected to interact with the care team at least once a day, and 74% preferred for contact to be initiated by clinicians. Together this suggests that expectations for surrogate-clinician communication more closely aligned with current guidelines for family-centered care than they are with actual practice.
{"title":"Communication expectations of critically ill patients and their families.","authors":"Jennifer N Ervin","doi":"10.21037/jeccm.2019.09.02","DOIUrl":"https://doi.org/10.21037/jeccm.2019.09.02","url":null,"abstract":"<p><p>Little is known about specific expectations family members and other types of surrogates have regarding clinician interaction. The objective of this study is to describe communication expectations regarding clinician engagement when surrogates represent patients who are too critically ill to advocate on their own behalf. As part of a larger study, a panel of 44 former patients and surrogate decision makers of a 20-bed medical intensive care unit (ICU) housed within a large academic hospital in the Midwestern United States responded to an online survey. Findings suggest that participants held different expectations for different intensive care providers in that 98% expected to talk to an attending physician within 48 hours of their loved one being admitted to the ICU, while 88% expected to have spoken with a registered nurse, and 74% with a respiratory therapist. Only half expected to have talked with a resident or fellow, and a third to a social worker. Regarding communication frequency, 95% of participants expected to interact with the care team at least once a day, and 74% preferred for contact to be initiated by clinicians. Together this suggests that expectations for surrogate-clinician communication more closely aligned with current guidelines for family-centered care than they are with actual practice.</p>","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.09.02","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"39054107","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-08-27DOI: 10.21037/jeccm.2019.07.04
Mathieu Godement, A. Vieillard-Baron
Acute respiratory distress syndrome (ARDS) is a major cause of morbidity and mortality in intensive care units and affects about 10% of critically ill patients and almost 25% of mechanically ventilated patients. It is characterized by life-threatening impairment of pulmonary gas exchange, but in two-thirds of cases is associated with hemodynamic instability. Shock is the primary factor influencing mortality and is driven by sepsis in half of the cases and by a more specific mechanism of ARDS in the other half, which is pulmonary vascular dysfunction, i.e., pulmonary hypertension related to the inflammatory process in the lung, which is very sensitive to a respiratory strategy. ARDS-related right ventricular failure, which is also named acute cor pulmonale (ACP), occurs in 20–25% of patients in the area of lung protective ventilation. In this condition, critical care echocardiography (CCE) plays a central role in adequate hemodynamic assessment and management at the bedside because of its ability to yield information quickly on cardiac dimensions and function, respiratory variations of vena cava dimensions and changes in cardiac output in response to therapy. Added to clinical and laboratory data, with invasive blood pressure monitoring and a central venous catheter, such information can be used to define the cause of circulatory failure, to evaluate the benefit and risk balance of fluid expansion, and to consider a strategy for right ventricle protection. Moreover, in the most severe situations, CCE can also guide the establishment and good functioning of extracorporeal membrane oxygenation (ECMO). In this article, we illustrate and summarize the value of CCE in ARDS and give some physiological pointers to its appropriate use.
{"title":"Hemodynamic monitoring of ARDS by critical care echocardiography","authors":"Mathieu Godement, A. Vieillard-Baron","doi":"10.21037/jeccm.2019.07.04","DOIUrl":"https://doi.org/10.21037/jeccm.2019.07.04","url":null,"abstract":"Acute respiratory distress syndrome (ARDS) is a major cause of morbidity and mortality in intensive care units and affects about 10% of critically ill patients and almost 25% of mechanically ventilated patients. It is characterized by life-threatening impairment of pulmonary gas exchange, but in two-thirds of cases is associated with hemodynamic instability. Shock is the primary factor influencing mortality and is driven by sepsis in half of the cases and by a more specific mechanism of ARDS in the other half, which is pulmonary vascular dysfunction, i.e., pulmonary hypertension related to the inflammatory process in the lung, which is very sensitive to a respiratory strategy. ARDS-related right ventricular failure, which is also named acute cor pulmonale (ACP), occurs in 20–25% of patients in the area of lung protective ventilation. In this condition, critical care echocardiography (CCE) plays a central role in adequate hemodynamic assessment and management at the bedside because of its ability to yield information quickly on cardiac dimensions and function, respiratory variations of vena cava dimensions and changes in cardiac output in response to therapy. Added to clinical and laboratory data, with invasive blood pressure monitoring and a central venous catheter, such information can be used to define the cause of circulatory failure, to evaluate the benefit and risk balance of fluid expansion, and to consider a strategy for right ventricle protection. Moreover, in the most severe situations, CCE can also guide the establishment and good functioning of extracorporeal membrane oxygenation (ECMO). In this article, we illustrate and summarize the value of CCE in ARDS and give some physiological pointers to its appropriate use.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-08-27","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/jeccm.2019.07.04","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"68337389","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-07-30DOI: 10.21037/JECCM.2019.07.02
G. Karlis, T. Xanthos, Anastasia Kotanido
Despite the fact that the principles of treating emergencies and acute diseases have been well described as far back as ancient times (1), emergency medicine (EM) as a recognized medical specialty has a life of less than 20 years. Indeed, according to the European Society of Emergency Medicine (EUSEM) website, in 2001 the United Kingdom and Ireland first recognized in Europe the specialty under the heading “Accident and Emergency Medicine”. Despite the remarkable progress in EM during the last decade, there are still huge diversities regarding the curriculum, the training, and the setting of the emergency departments (ED) around Europe. Some European countries have developed EM as a stand-alone specialty, others as a supra-specialty while a few have EDs that function with physicians from several specialties, such as internal medicine, cardiology, general surgery, anesthesiology, pediatrics etc.
{"title":"Emergency medicine and intensive care medicine: the missing link","authors":"G. Karlis, T. Xanthos, Anastasia Kotanido","doi":"10.21037/JECCM.2019.07.02","DOIUrl":"https://doi.org/10.21037/JECCM.2019.07.02","url":null,"abstract":"Despite the fact that the principles of treating emergencies and acute diseases have been well described as far back as ancient times (1), emergency medicine (EM) as a recognized medical specialty has a life of less than 20 years. Indeed, according to the European Society of Emergency Medicine (EUSEM) website, in 2001 the United Kingdom and Ireland first recognized in Europe the specialty under the heading “Accident and Emergency Medicine”. Despite the remarkable progress in EM during the last decade, there are still huge diversities regarding the curriculum, the training, and the setting of the emergency departments (ED) around Europe. Some European countries have developed EM as a stand-alone specialty, others as a supra-specialty while a few have EDs that function with physicians from several specialties, such as internal medicine, cardiology, general surgery, anesthesiology, pediatrics etc.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-07-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47534569","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-07-22DOI: 10.21037/JECCM.2019.07.01
C. Colebourn
This article provides an overview to the development and current position occupied by critical care echocardiography (CCE) in clinical practice in the UK. We discuss the key clinical and political drivers to the development of the subspecialty and give a detailed outline of the available levels and processes of accreditation in the UK. Discussion of clinical situations from our own practice is used to throw light on how the technique can contribute to clinical practice and how to introduce and maintain quality within that practice.
{"title":"Field guide to critical care echocardiography: the UK view","authors":"C. Colebourn","doi":"10.21037/JECCM.2019.07.01","DOIUrl":"https://doi.org/10.21037/JECCM.2019.07.01","url":null,"abstract":"This article provides an overview to the development and current position occupied by critical care echocardiography (CCE) in clinical practice in the UK. We discuss the key clinical and political drivers to the development of the subspecialty and give a detailed outline of the available levels and processes of accreditation in the UK. Discussion of clinical situations from our own practice is used to throw light on how the technique can contribute to clinical practice and how to introduce and maintain quality within that practice.","PeriodicalId":73727,"journal":{"name":"Journal of emergency and critical care medicine (Hong Kong, China)","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-07-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://sci-hub-pdf.com/10.21037/JECCM.2019.07.01","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44024549","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-06-28DOI: 10.21037/JECCM.2019.06.03
I. Kugasia, M. Ijaz, A. Khan
Malpositioning of central venous catheters (CVC) is a common complication and easily identified on a chest X-ray (CXR). However, positioning of CVC in the pleural space without causing pneumothorax is extremely rare and difficult to identify on a single view CXR. Pleural placement of CVC can be suspected by: either presence of pneumothorax post insertion or being able to flush ports of the CVC but without blood return.
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