In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents—that are easily titratable—reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.
Background Acute kidney injury (AKI) is a common complication of cardiac surgery. Factors such as cardiopulmonary bypass, aortic cross-clamping and surgical stress may precipitate renal hypoperfusion and ischaemia, inflammation and oxidative stress are associated with development of AKI. Albumin’s pharmacological properties and widespread availability have the potential to mitigate these factors. However, the effect of albumin on cardiac surgery-associated AKI is unknown. Objective To evaluate the impact of postoperative 20% albumin infusion on kidney function after high-risk cardiac surgery. Methods We designed an open-label, multicentre, randomised controlled trial—the ALBICS study (ALBumin Infusion and acute kidney injury following Cardiac Surgery). A total of 590 patients undergoing high-risk cardiac surgery (combined procedure or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) will be enrolled into the study and randomly allocated to receive a postoperative 20% albumin infusion or standard care in a 1:1 ratio, stratified by centre and baseline renal function. The study fluid will be administered upon arrival in intensive care for 15 h. Patients will be followed up until 28 days after surgery or until discharge from the hospital. The primary outcome is the proportion of patients who develop AKI in both groups. Secondary outcomes to be measured are proportions of AKI stage II and III, 28-day mortality, mechanical ventilation time and length of stay in intensive care and hospital. Conclusion This trial aims to determine if a postoperative infusion of concentrated albumin reduces the risk of AKI following high-risk cardiac surgery. Trial registration Australian New Zealand Clinical Trials Registry ACTRN12619001355167. Registered on 03 October 2019—retrospectively registered. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378383.
A bstract Background Obesity is one of the major risk factors for cardiovascular and peripheral vascular diseases. However, the obesity paradox confers survival benefits in heart failure and cardiac surgery patients. Studies examining the outcomes of obese patients following cardiac arrest provided conflicting results. Objective To study the association between obesity and outcome in patients following cardiac arrest. Materials and methods We conducted a retrospective cohort study at a tertiary intensive care unit (ICU). Data were collected from medical records between January 1, 2018 and December 31, 2018, for all adult ICU patients who were admitted to our ICU following a cardiac arrest. Data collected included demographics, anthropometrics, and details of the cardiac arrest. The primary outcome was survival to hospital discharge. Secondary outcomes were duration of mechanical ventilation, ICU, and hospital length of stay. Results A total of 126 patients were admitted to the ICU following a cardiac arrest during the study period, of whom 14 patients were excluded due to missing body mass index (BMI) data. Seventy-six patients were non-obese (BMI <30) and 36 patients were obese (BMI ≥30). There was no difference in survival to hospital discharge between obese and non-obese patients (52.8 vs 59.2%, p = 0.52, OR = 0.77, 95% CI 0.35–1.71). Moreover, there was no difference between obese and non-obese patients in ICU length of stay (81.50 vs 76.0 hours, p = 0.42), hospital length of stay (9 vs 10 days, p = 0.63), and duration of mechanical ventilation (55 vs 43 hours, p = 0.30). In the logistical regression analysis, BMI was not associated with improved survival (OR = 0.97, 95% CI 0.92–1.03, p = 0.23). Conclusion For patients admitted to ICU following cardiac arrest, we could not show that obesity improves survival, length of stay, or duration of mechanical ventilation. How to cite this article Chavda MP, Pakavakis A, Ernest D. Does Obesity Influence the Outcome of the Patients Following a Cardiac Arrest? Indian J Crit Care Med 2020;24(11):1077–1080.
A bstract Background Traditional arterial blood gas (ABG) analysis may miss out on some metabolic acid–base disorders. We prospectively compared Stewart's approach in critically ill patients to traditional bicarbonate-anion gap-based methods (with and without correction for albumin) to diagnose acid–base disorders. Patients and methods Five hundred ABG samples from medical or surgical patients in the ICU were analyzed with traditional bicarbonate-anion gap-based methodology with and without correction for albumin and Stewart's biochemical approach. The primary outcome identification of additional metabolic disorders diagnosed with Stewart's approach in comparison to bicarbonate system-based approaches. We also looked at the correlation between the strong ion gap (SIG) and the albumin-corrected anion gap (acAnion Gap). Results Stewart's approach detected missed metabolic disorders in 58 (11.6%) blood gas results reported as “within normal limits” with the bicarbonate-uncorrected anion gap approach. In 50 (10%) of these ABGs, the acAnion Gap approach was able to diagnose the missed metabolic disorders. Thus, the albumin-corrected anion gap method had a similar diagnostic performance to Stewart's approach, as it missed additional disorders in only eight (1.6%) blood gases. Conclusion In this study, we found that the acAnion Gap approach was similar in diagnostic performance to Stewart's approach. We feel that the corrected anion gap approach can be safely used if a ready calculator for Stewart's approach is not available. How to cite this article Paliwal R, Pakavakis A, Divatia JV, Kulkarni AP. Utility of Stewart's Approach to Diagnose Missed Complex Acid–Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study. Indian J Crit Care Med 2022;26(1):23–32.
A 59-year-old man was diagnosed with a massive pulmonary embolism. Despite thrombolysis there were two episodes of cardiac arrest and following recovery of spontaneous circulation profound cardiorespiratory failure ensued. An extracorporeal membrane oxygenation retrieval team initiated veno-venous extracorporeal membrane oxygenation on site to facilitate transfer to the extracorporeal membrane oxygenation centre. An excellent outcome is reported in the short term. This represents one of the few published cases of veno-venous extracorporeal membrane oxygenation for a massive pulmonary embolism following thrombolysis.
requirements (p¼<0.01). When patients received an initial dietitian review on day 1 of admission, they were also more likely to achieve nutrition requirements (p¼<0.01). Documented reasons for delayed EN commencement or failure to achieve nutritional requirements were airway management, procedural requirements and waiting for dietitian review. Nursing care specific to EN management was poorly documented. Conclusion: EN commencement time and delivering target volumes are equally important in achieving nutritional requirements. Yet it continues to be challenging in the ICU environment. Barriers occur at both an individual and organisational level.
BackgroundAcute kidney injury (AKI) is a common complication of cardiac surgery. Factors such as cardiopulmonary bypass, aortic cross-clamping and surgical stress may precipitate renal hypoperfusion and ischaemia, inflammation, and oxidative stress are associated with development of AKI. Albumin’s pharmacological properties and widespread availability have the potential to mitigate these factors. However, the effect of albumin on cardiac surgery associated AKI is unknown.ObjectiveTo evaluate the impact of postoperative 20% albumin infusion on kidney function after high-risk cardiac surgery.MethodsWe designed an open label, multicentre, randomised controlled trial – the ALBICS study (ALBumin Infusion and acute kidney injury following Cardiac Surgery). A total of 590 patients undergoing high-risk cardiac surgery (combined procedure or estimated glomerular filtration rate (eGFR) <60mL/min/1.73m2) will be enrolled into the study and randomly allocated to receive a postoperative 20% albumin infusion or standard care in a 1:1 ratio, stratified by centre and baseline renal function. The study fluid will be administered upon arrival in intensive care for 16 hours. Patients will be followed up until 28 days after surgery or until discharge from the hospital. The primary outcome is the proportion of patients who develop AKI in both groups. Secondary outcomes to be measured are proportions of AKI stage II and III, 28-day mortality, mechanical ventilation time and length of stay in intensive care and hospital.ConclusionThis trial aims to determine if a postoperative infusion of concentrated albumin reduces the risk of AKI following high-risk cardiac surgery. Trial registrationAustralian New Zealand Clinical Trials Registry, ACTRN1261900135516703. Registered 03 October 2019 – retrospectively registered, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378383.
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