Critical care clinics
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Critical care clinics · Jan 2024
ReviewThe Changing Epidemiology of the Cardiac Intensive Care Unit.
Coronary care units (CCUs) were originally designed to monitor and treat peri-infarction ventricular arrhythmias but have evolved into highly specialized cardiac intensive care units (CICUs) that provide care to a patient population that is increasingly heterogeneous and complex. Paralleling broader epidemiologic trends, patients admitted to contemporary CICUs are older and have a greater burden of cardiovascular and non-cardiovascular comorbidities. Moreover, contemporary CICU patients have high illness severity and often present with acute noncardiac organ dysfunction. In addition to these shifting demographic patterns, there have been important epidemiologic changes in CICU technologies, multidisciplinary systems of care, and physician staffing and training.
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Critical care clinics · Jan 2024
ReviewDesign and Execution of Clinical Trials in the Cardiac Intensive Care Unit.
Clinical practice in the contemporary cardiac intensive care unit (CICU) has evolved significantly over the last several decades. With more frequent multisystem organ failure, increasing use of advanced respiratory support, and the advent of new mechanical circulatory support platforms, clinicians in the CICU are increasingly managing patients with complex comorbid disease in addition to their high-acuity cardiovascular illnesses. Here, the authors discuss challenges associated with traditional trial design in the CICU setting and review novel clinical trial designs that may facilitate better evidence generation in the CICU.
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Critical care clinics · Jan 2024
ReviewDiagnosis and Management of Pulmonary Hypertension and Right Ventricular Failure in the Cardiovascular Intensive Care Unit.
Pulmonary hypertension (PH) encompasses a broad range of conditions, including pulmonary artery hypertension, left-sided heart disease, and pulmonary and thromboembolic disorders. Successful diagnosis and management rely on an integrated clinical assessment of the patient's physiology and right heart function. Right ventricular (RV) heart failure is often a result of PH, but may result from varying abnormalities in preload, afterload, and intrinsic myocardial dysfunction, which require distinct management strategies. Consideration of an individual's hemodynamic phenotype and physiologic circumstances is paramount in management of PH and RV failure, particularly when there is clinical instability in the intensive care setting.
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Heart transplantation (HT) remains the best treatment of patients with severe heart failure who are deemed to be transplant candidates. The authors discuss postoperative management of the HT recipient by system, emphasizing areas where care might differ from other cardiac surgery patients. Working together, critical care physicians, heart transplant surgeons and cardiologists, advanced practice providers, pharmacists, transplant coordinators, nursing staff, physical therapists, occupational therapists, rehabilitation specialists, nutritionists, health psychologists, social workers, and the patient and their loved ones partner to increase the likelihood of a successful outcome.
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Critical care clinics · Jan 2024
ReviewManagement of Vasoplegic Shock in the Cardiovascular Intensive Care Unit after Cardiac Surgery.
Vasoplegic shock after cardiac surgery is characterized by hypotension, a high cardiac output, and vasodilation. Much of the understanding of this pathologic state is informed by the understanding of septic shock. ⋯ The need for vasopressors to sustain an adequate blood pressure as well as pharmacologic adjuncts to mitigate the inflammatory inciting process are necessary. The rationale behind vasopressor escalation and consideration of adjuncts are discussed.