Cardiogenic shock (CS) occurs in ≈5% to 8% of patients hospitalized with ST-elevation myocardial infarction (STEMI). Recent research has suggested that the peripheral vasculature and neurohormonal and cytokine systems play a role in the pathogenesis and persistence of CS. Early revascularization for CS improves survival substantially. New mechanical approaches to treatment are available, and clinical trials are feasible even in this high-risk population. Most importantly, hospital survivors have an excellent chance for long-term survival with good quality of life. This review will outline the causes, pathophysiology, and treatment of CS with a focus on CS complicating myocardial infarction (MI.) The case will be made for viewing CS as a serious disorder with a high early death rate, but one that is treatable and that, if approached aggressively, can result in full recovery.

CS is a state of end-organ hypoperfusion due to cardiac failure. The definition of CS includes hemodynamic parameters: persistent hypotension (systolic blood pressure 18 mm Hg or right ventricular [RV] end-diastolic pressure >10 to 15 mm Hg). The diagnosis is usually made with the help of pulmonary artery (PA) catheterization; however, Doppler echocardiography may also be used to confirm elevation of LV filling pressures.1 Hypoperfusion may be manifest clinically by cool extremities, decreased urine output, and/or alteration in mental status. Hemodynamic abnormalities form a spectrum that ranges from mild hypoperfusion to profound shock, and the short-term outcome is directly related to the severity of hemodynamic derangement.

MI with LV failure remains …

Cardiogenic Shock Current Concepts and Improving Outcomes

Importance Blood transfusion is one of the most frequently used therapies worldwide and is associated with benefits, risks, and costs. Objective To develop a set of evidence-based recommendations for patient blood management (PBM) and for research. Evidence Review The scientific committee developed 17 Population/Intervention/Comparison/Outcome (PICO) questions for red blood cell (RBC) transfusion in adult patients in 3 areas: preoperative anemia (3 questions), RBC transfusion thresholds (11 questions), and implementation of PBM programs (3 questions). These questions guided the literature search in 4 biomedical databases (MEDLINE, EMBASE, Cochrane Library, Transfusion Evidence Library), searched from inception to January 2018. Meta-analyses were conducted with the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology and the Evidence-to-Decision framework by 3 panels including clinical and scientific experts, nurses, patient representatives, and methodologists, to develop clinical recommendations during a consensus conference in Frankfurt/Main, Germany, in April 2018. Findings From 17 607 literature citations associated with the 17 PICO questions, 145 studies, including 63 randomized clinical trials with 23 143 patients and 82 observational studies with more than 4 million patients, were analyzed. For preoperative anemia, 4 clinical and 3 research recommendations were developed, including the strong recommendation to detect and manage anemia sufficiently early before major elective surgery. For RBC transfusion thresholds, 4 clinical and 6 research recommendations were developed, including 2 strong clinical recommendations for critically ill but clinically stable intensive care patients with or without septic shock (recommended threshold for RBC transfusion, hemoglobin concentration Conclusions and Relevance The 2018 PBM International Consensus Conference defined the current status of the PBM evidence base for practice and research purposes and established 10 clinical recommendations and 12 research recommendations for preoperative anemia, RBC transfusion thresholds for adults, and implementation of PBM programs. The relative paucity of strong evidence to answer many of the PICO questions supports the need for additional research and an international consensus for accepted definitions and hemoglobin thresholds, as well as clinically meaningful end points for multicenter trials.

Patient Blood Management: Recommendations From the 2018 Frankfurt Consensus Conference

Low-intensity ultrasound neuromodulation: An overview of mechanisms and emerging human applications.

Background: Restrictive cardiomyopathy (RCM) is rare in childhood, but has a grave prognosis. The cause of disease in most cases is unknown. Objective: To determine the prevalence of sarcomere protein gene mutations in children with idiopathic RCM. Methods: Twelve patients (9 female, mean age 5.1 years) with idiopathic RCM referred between 1991 and August 2006 underwent detailed clinical and genetic evaluation. Nine had received cardiac transplants at the time of the study. The entire coding sequences of the genes encoding eight cardiac sarcomere proteins and desmin were screened for mutations. Familial evaluation was performed on first-degree relatives. Results: Four patients (33%) had a family history of cardiomyopathy: RCM (n = 2); dilated cardiomyopathy (n = 1) and left ventricular non-compaction (n = 1). Sarcomere protein gene mutations were identified in four patients (33%): 2 in the cardiac troponin I gene (TNNI3) and 1 each in the troponin T (TNNT2) and α-cardiac actin (ACTC) genes. Two were de novo mutations and 3 were new mutations. All mutations occurred in functionally important and conserved regions of the genes. Conclusions: Sarcomere protein gene mutations are an important cause of idiopathic RCM in childhood. We describe the first mutation in ACTC in familial RCM. The identification of RCM in a child should prompt consideration of sarcomere protein disease as a possible cause and warrants clinical evaluation of the family.

Idiopathic restrictive cardiomyopathy in children is caused by mutations in cardiac sarcomere protein genes

https://link.springer.com/content/pdf/10.1007/s13311-018-00691-3.pdf

Focused Ultrasound for Neuromodulation.

Ultrasound scanning is now utilized in all aspects of anaesthesia, critical care, and pain management. Typical applications include determination of left ventricular function and cardiac output, assessment of haemodynamic instability, assistance with difficult venous access, and facilitation of accurate neural block. – 3 One aspect of competency in ultrasound imaging includes an understanding of how images can be displayed optimally. This article discusses three main aspects of the physics of diagnostic ultrasound, that is to say, spatial resolution, temporal resolution, and contrast resolution; it utilizes examples from perioperative echocardiography to illustrate these principles.

Resolution in ultrasound imaging

Preoperative Anemia and Outcomes in Cardiovascular Surgery: Systematic Review and Meta-Analysis

OBJECTIVES Preoperative anaemia is a strong predictor of blood transfusion requirements and must be assessed for appropriate optimization before elective surgery. Iron therapy is a transfusion-sparing approach effective for increasing haemoglobin concentrations. However, its role in elective cardiac surgery and the optimal route of administration remain unknown. This single-centre, non-blinded, randomized, controlled trial compared the effectiveness of intravenous ferric carboxymaltose therapy with oral iron for anaemic patients undergoing elective cardiac surgery. METHODS Fifty anaemic patients scheduled for elective cardiac surgery were randomized to receive either oral or intravenous iron therapy 3-8 weeks preoperatively. Changes in haemoglobin concentration were measured. Blood transfusion and postoperative outcome data were collected. RESULTS Preoperative median increases in haemoglobin were 1.0 g/l (interquartile range -3.25 to 7.25 g/l) and 3.0 g/l (interquartile range -1.25 to 6.25 g/l) for patients receiving intravenous and oral iron, respectively (P = 0.42). The median first 12-h blood loss was significantly higher in the intravenous group (655 ml; interquartile range 162-1540 ml) compared to the oral group (313 ml; interquartile range 150-1750 ml; P < 0.007). Median increments in serum ferritin were superior for the intravenous group (median difference 313 µg/l; interquartile range 228-496) compared to the oral group (median difference 5.5 µg/l; interquartile range -1.4 to 19.4; P < 0.001). CONCLUSIONS Increases in ferritin after intravenous iron administration were significantly greater than those after oral iron administration. There was no significant difference in haemoglobin increments between groups. Despite significantly higher intraoperative blood loss in the group receiving intravenous iron, blood transfusion requirements for both groups were not statistically different. CLINICAL TRIAL REGISTRATION ISRCTN22158788.

Intravenous iron does not effectively correct preoperative anaemia in cardiac surgery: a pilot randomized controlled trial.

† facilitating surgery, for example, lobectomy, pneumonectomy, pleurectomy, decortication, bullectomy, diaphragmatic hernia repair, pericardial window, and oesophagectomy; † preventing cross-contamination of the contralateral lung, for example, endobronchial haemorrhage, abscess with empyema, bronchiectasis, and lavage; † controlling distribution of ventilation, for example, bronchopleural fistula.

Hypoxaemia during one-lung anaesthesia

ObjectiveTo assess the effects of preoperative anemia on outcomes of cardiac surgery and to explore the trend in mortality over an 8-year period.MethodsDuring the study period (2005–2012), all 1170 patients undergoing elective or urgent cardiac surgery and classed as anemic were included. A matched group of non-anemic 1170 patients was used as a control group. Postoperative outcomes were compared between the 2 groups. The association between preoperative anemia and postoperative outcomes was analyzed using a logistic regression model.ResultsCompared with patients without anemia, the need for airway support (15% vs. 12%, p = 0.05), renal replacement therapy (13% vs. 8%, p  7 days) hospital stay (odds ratio = 1.21, confidence interval: 0.97–1.51, p...

Alexander Ng

Papers

Resolution in ultrasound imaging

Preoperative Anemia and Outcomes in Cardiovascular Surgery: Systematic Review and Meta-Analysis

Intravenous iron does not effectively correct preoperative anaemia in cardiac surgery: a pilot randomized controlled trial.

Hypoxaemia during one-lung anaesthesia

Anemia in cardiac surgery: next target for mortality and morbidity improvement?