In patients treated for endocarditis, multiple risk factors for AKI were identified. Prospective studies are needed to evaluate these variables for causation of AKI in patients treated for endocarditis.
Background: Intravenous sedation and analgesia are important therapies during mechanical ventilation (MV). However, daily interruption of these medications is associated with improved outcomes in mechanically ventilated patients. We tested a clinical pathway for the use of sedation and analgesia during MV in a cardiac intensive care unit (CICU). Methods and results:We evaluated all mechanically ventilated patients in a CICU during two phases: phase 1 prior to pathway implementation (PRE) and phase 2 post-pathway implementation (POST). A total of 198 patients (98 PRE and 100 POST) and 1012 days of intubation (574 PRE and 434 POST) were included in this analysis. We found an increase in the frequency of daily interruptions of sedation post-implementation (49.3% PRE and 58.4% POST, p=0.0041). There was a significant decrease in the mean duration of MV in the POST vs PRE periods (5.0±2.3 vs 6.1±2.8 days, p=0.015). There was also a significant decrease in total neuroimaging studies (9 vs 49, p=0.001) and a trend toward a decrease in tracheostomies (3.0% vs 6.1% , p=0.33). Mean CICU length of stay (LOS) and hospital LOS respectively were 10.4 days and 16.8 days PRE and 10.4 days and 17.9 days POST (p=0.99 and p=0.55). Mortality did not differ (PRE 36.7% vs POST 32.0% p=0.55). Conclusions: Implementation of a pragmatic pathway for sedation and analgesia in a CICU was associated with an increase in the daily interruption of sedation and a corresponding decrease in the duration of MV days and the need for neuroimaging.
Background: The concurrent use of therapeutic hypothermia (TH) following cardiac arrest and mechanical circulatory support (MCS) for cardiogenic shock is becoming increasingly common. Little is known however, about the combined use of TH and MCS for patients after ROSC following a cardiac arrest who remain in cardiogenic shock. Therefore we describe the experience with concomitant use of TH and MCS from a large academic tertiary care center in Boston. Methods: Baseline characteristics and clinical outcomes at hospital discharge were reported for patients undergoing TH following cardiac arrest who also received MCS for cardiogenic shock. MCS included Intra-aortic balloon pump (IABP) two percutaneous ventricular assist devices (Impella, and TandemHeart), and extracorporeal membrane oxygenation (ECMO). Clinical outcomes included mortality as well as cerebral performance category (CPC) at hospital discharge. Results: There were a total of 14 patients who underwent concomitant TH and MCS following a cardiac arrest. Baseline characteristics and clinical outcomes are noted in the Figure. 9 patients underwent placement of IABP, 2 patients an Impella pump, 2 patients a TandemHeart, and 1 patient ECMO. All 14 cardiac arrests were due to cardiovascular etiologies; 9 of 14 had STEMI. 9 of 14 patients had an initial shockable rhythm. Mean age was 56 years (+/- 19), mean downtime was 35 minutes (+/- 24). All patients were vasopressor dependent. Bleeding events are noted in the table. 8 patients survived to hospital discharge, all with good neurologic outcome. These rates were comparable to the survival rates and neurologic outcomes among 82 patients who underwent TH post cardiac arrest (from cardiovascular etiologies) without concomitant MCS (Figure). Conclusion: Based on our experience from a large academic tertiary care center, concomitant use of TH and MCS is both safe and feasible with an encouraging rate of cardiac and neurologic recovery.
Introduction:The rate of severe bleeding and thrombotic complications on ECLS remains high (20-40%) and leads to poor outcomes. Platelet dysfunction on ECLS has been described, but it is seldom considered in goal directed hemostasis management. TEG® with platelet mapping (TEG-PM) measures functional aspects of clot formation and the percent of Platelet Inhibition (PI) on specific platelet surface receptors. Data provided by TEG-PM might enhance our ability to titrate goal-directed hemostasis management, thereby minimizing bleeding complications. Our primary objectives were 1) to determine the frequency and magnitude of PI in children on ECLS, and 2) to determine if PI is independently associated with severe bleeding or mortality in children requiring ECLS. Methods: An IRB approved retrospective chart review was performed of children from birth to 18 years, who required ECLS from 9/30/2011-12/31/2012. Data collected included demographics, coagulation tests, TEG®-PM, the number and type of blood products transfused, the number and type of medications given within 24 hours prior to each TEG sample, the number and severity of bleeding and thrombotic complications. Severe bleeding was defined as intracranial, pulmonary or gastrointestinal bleeding. The magnitude of PI was defined as the median (IQR) of all values measured per patient. To assess the frequency of PI, a threshold of > 50 % PI was considered significant. We separately evaluated adenosine diphosphate (ADP) and arachidonic acid (AA) receptor inhibition. Data are presented as median (IQR). results: In 24 patients, we reviewed 54 TEG®-PM samples. The median number of TEG samples analyzed per patient was 2 (1-3), age was 9 months (0.9-73), heparin dose was 40 U/kg/hr (30-50) and duration on ECLS was 8 days (6-10). Severe bleeding occurred in 42 % (10/24) patients and thrombotic complications in 16 % (4/24). ICU mortality was 54 %( 13/24). We found > 50 % ADP-PI in 92 % (22/24) patients and 80 % (46/54) TEG®-PM samples. We found > 50 % AA-PI in 75 % (18/24) patients and 47 % (25/53) TEG®-PM samples. In the 54 samples analyzed, the magnitude of ADP-PI was 84 % (50-97) and AA-PI was 51% (11-72). The magnitude of AA-PI was higher in the severe bleeding group 59 % (34-77) compared to the non-bleeding group 36.6 % (4-61), (p=0.045). Upon logistic regression no variables were independently associated with severe bleeding. None of patients had received direct platelet inhibitors such as aspirin and dipyridamole. The patients had received known platelet inhibitors including: H2 Blockers 66% (16/24), inhaled Nitric Oxide (iNO) 50 % (12/24) and milrinone 42 %( 10/24) within 24 hours prior to the TEG sample reviewed. Use of these medications was not associated with increased ADP-PI, as the magnitude of ADP-PI was similar for patients received H2 blockers 84 %( 36-97) and those did not on H2 Blockers 85 % (52-97), (p =0.93); those on iNO 97 % (60-96) and not on iNO 73 % (46-97), (p=0.54); those on milrinone 74 % (44-96) and not on milrinone 86 % (53-98), (p =0.23). These a...
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Background: The known anticoagulant effects of hypothermia poses challenges when considering therapeutic hypothermia (TH) after cardiac arrest, including the risk of bleeding and the safety of giving concomitant antiplatelet and anticoagulation therapy. We therefore examined antithrombotic use and the risk of bleeding in patients receiving TH. Methods: In a large tertiary academic center in Boston, we examined the incidence of bleeding in patients evaluated for TH. Antiplatelet therapy and anticoagulation (oral or parenteral) prior to arrest and during the hospitalization were recorded. Results: TH was initiated in 190 patients and completed in 150. Among 40 patients in which TH was stopped early, bleeding was cited as a reason in 5 (though in 3 cases bleeding was documented at time of TH initiation). Of the 150 ‘completers’, 16 (10.6%) bled during TH. Bleeding was present at the time of TH initiation in 8/16 patients. Bleeding sites were most commonly GI 56.3% and vascular access 25% with no cases of intracranial bleeding. Presenting rhythm, survival, neurological outcomes and inpatient administration of antiplatelet and anticoagulation medications were similar between the bleeding and non-bleeding groups. Though there was no significant hematocrit change in the two groups, more patients with bleeding received red blood cell (RBC) transfusions (56.3% vs 2.2%) and received more RBC units (5.4±5.4 vs 1.3±0.5 p=0.054). Of the 15 patients on mechanical circulatory support, only 4 had a bleeding event during TH. Conclusion: There were no significant differences between the bleeding and non-bleeding groups during TH in terms of concomitant antithrombotic agents or neurologic recovery/survival. These findings suggest that the incidence of bleeding in TH is acceptable and that it is safe to treat patients with antithrombotics and mechanical circulatory devices as clinically indicated.
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