Critical care clinics
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Critical care clinics · Jul 2014
ReviewHemodynamic Assessment in the Contemporary Intensive Care Unit: A Review of Circulatory Monitoring Devices.
The assessment of the circulating volume and efficiency of tissue perfusion is necessary in the management of critically ill patients. The controversy surrounding pulmonary artery catheterization has led to a new wave of minimally invasive hemodynamic monitoring technologies, including echocardiographic and Doppler imaging, pulse wave analysis, and bioimpedance. This article reviews the principles, advantages, and limitations of these technologies and the clinical contexts in which they may be clinically useful.
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Cardiogenic shock is the most common cause of in-hospital mortality for patients who have suffered a myocardial infarction. Mortality exceeds 50% and management is focused on a rapid diagnosis of cardiogenic shock, restoration of coronary blood flow through early revascularization, complication management, and maintenance of end-organ homeostasis. Besides revascularization, inotropes and vasodilators are potent medical therapies to assist the failing heart. Pulmonary arterial catheters are an important adjunctive tool to assess patient hemodynamics, but their use should be limited to select patients in cardiogenic shock.
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Patients admitted to the intensive care unit (ICU) are at increased risk for cardiac arrhythmias, the most common of which can be subdivided into tachyarrhythmias and bradyarrhythmias. These arrhythmias may be the primary reason for ICU admission or may occur in the critically ill patient. This article addresses the occurrence of arrhythmias in the critically ill patient, and discusses their pathophysiology, implications, recognition, and management.
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Critical care clinics · Jul 2014
ReviewLeft Ventricular Assist Device Management and Complications.
Patients on long-term left ventricular assist device (LVAD) support present unique challenges in the intensive care unit. It is crucial to know the status of end-organ perfusion, which may require invasive hemodynamic monitoring with a systemic arterial and pulmonary artery catheter. Depending on the indication for LVAD support (bridge to decision or cardiac transplantation vs destination therapy), it is important to readdress goals of care with the patient (if possible) and their family after major events have occurred that challenge the survival of the patient.
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In this review, cardiac arrest is discussed, with a focus on neuroprognostication and the emerging data, with regard to identifying more accurate predictors of neurologic outcomes in the era of therapeutic hypothermia. Topics discussed include recent controversies with regard to targeted temperature management in comatose survivors of cardiac arrest; neurologic complications associated with surgical disease and procedures, namely aortic dissection, infective endocarditis, left ventricular assist devices, and coronary artery bypass grafting; and the cause, pathogenesis, and management of neurogenic stunned myocardium.