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Therapeutic Approaches in Acute Heart Failure
Published in Andreas P. Kalogeropoulos, Hal A. Skopicki, Javed Butler, Heart Failure, 2023
Getu Teressa, Rachel A. Bright, Andreas P. Kalogeropoulos
Clinical trajectory monitoring assesses resolution of signs and symptoms of congestion, adequate perfusion, end-organ function recovery, and maintenance of acceptable vital signs. Assessing improvement in dyspnea, orthopnea, crackles, and jugular venous pressure (JVP) are important indicators of treatment trajectory as they indirectly reflect left-sided filling pressure. The presence of rales or fine crackles usually indicates higher filling pressures than the baseline and can be present before detection of pulmonary edema radiographically. However, these findings can be often absent in chronic HF patients owing to compensation of the pulmonary lymphatic system. JVP measures right-sided filling pressure and can serve as a surrogate for left-sided filling pressures. However, other processes may lead to disproportionately higher right-sided filling pressure than left-sided filling pressure. In the case of uncertainty in assessing intracardiac filling pressures clinically, invasive hemodynamic monitoring can be considered to guide therapy in the setting of respiratory distress or clinical evidence of impaired perfusion (ACCF/AHA class I, Level C). However, pulmonary artery catheterization does not reduce mortality or length of hospitalization, and in fact may increase adverse events.86 Therefore, routine use of invasive hemodynamic monitoring is not recommended.82
Therapy of acute myocardial infarction
Published in Wilbert S. Aronow, Jerome L. Fleg, Michael W. Rich, Tresch and Aronow’s Cardiovascular Disease in the Elderly, 2019
Joshua M. Stolker, Michael W. Rich
The causes of cardiogenic shock complicating acute MI are similar to the causes of HF and hypotension. Since a minority of patients survive cardiogenic shock in the absence of a treatable underlying disorder, immediate evaluation for a potentially correctable problem is critical. Emergent echocardiography should be performed to assess overall left ventricular function and to rule out valvular lesions, pericardial disease, and septal or ventricular free wall perforation (16). Pulmonary artery catheterization is occasionally indicated to facilitate diagnosis and for guiding therapy. Cardiac catheterization may be necessary in some cases if the diagnosis remains in doubt, as a prelude to PCI or corrective surgery, or to assess for stent thrombosis or related occlusion of a recent PCI or bypass graft.
Iatrogenic tracheobronchial and chest injury
Published in Philippe Camus, Edward C Rosenow, Drug-induced and Iatrogenic Respiratory Disease, 2010
Marios Froudarakis, Demosthenes Makris, Demosthenes Bouros
A large survey of pulmonary artery catheterization in 6245 patients revealed a low incidence of morbidity associated with the procedure.77 The incidence rate of intrapulmonary haemorrhage was 0.064 per cent, of minor pulmonary infarcts 0.064 per cent, perforation of right ventricle in one patient 0.016 per cent, and death from uncontrollable pulmonary haemorrhage in another patient (0.016 per cent). Patients who undergo cardiac surgery or patients with pulmonary hypertension are at increased risk to present these complications. Anticoagulation may compound the risk.
Our current understanding of and approach to the management of lung cancer with pulmonary hypertension
Published in Expert Review of Respiratory Medicine, 2021
Gaelle Dauriat, Jerome LePavec, Pauline Pradere, Laurent Savale, Dominique Fabre, Elie Fadel
Before surgery, patients with PH should be referred to an expert center for an assessment of the severity of the hemodynamic impairments. Targeted PH treatment should be optimized to achieve the best possible hemodynamic conditions at the time of surgery [98]. Stress, pain, mechanical ventilation, and inflammation in response to the surgical trauma can result in a further PVR increase, which may increase the risk of right heart failure [99]. Right cardiac function is particularly at-risk during anesthesia induction, the initiation of positive-pressure ventilation, the initiation of single-lung ventilation, and clamping of the pulmonary artery. Transesophageal echocardiography (TEE) and pulmonary artery catheterization or continuous hemodynamic monitoring may also be useful intraoperatively. TEE offers a continuous assessment of the left-ventricular end-diastolic area in the trans-gastric short-axis view, identification of myocardial ischemia by segmental evaluation of left ventricular wall thickening, monitoring of sPAP and tricuspid regurgitation, and continuous monitoring of cardiac output.
The use of bronchoscopy in critically ill patients: considerations and complications
Published in Expert Review of Respiratory Medicine, 2018
Critically ill patients are often vulnerable to cardiovascular and hemodynamic compromise, especially in the presence of severe hypoxemia. Close monitoring of oxygen saturation, pulse rate, electrocardiography (ECG) and blood pressure is the key for early recognition and timely intervention. After initiation of FB, heart rate and cardiac output are usually transiently increased [16]. In a study performed in mechanically ventilated patients, approximately 20% of patients experienced hemodynamic instability, which was associated with preexisting cardiovascular comorbidity [21]. Papazian et al. evaluated the hemodynamic effects of FB and BAL with pulmonary artery catheterization in patients who were hemodynamically unstable [17]. The patients were receiving PEEP of at least 10 cmH2O and intravenous vasoactive and/or inotropic support. Mean arterial and mean pulmonary artery pressure were both increased, whereas mixed venous oxygen saturation was decreased, from baseline during FB.
Intramuscular dimethyl trisulfide: efficacy in a large swine model of acute severe cyanide toxicity
Published in Clinical Toxicology, 2019
Tara B. Hendry-Hofer, Alyssa E. Witeof, Dennean S. Lippner, Patrick C. Ng, Sari B. Mahon, Matthew Brenner, Gary A. Rockwood, Vikhyat S. Bebarta
Adolescent female Yorkshire swine (Sus scrofa) (Oak Hill Genetics, Ewing, IL) weighing 45–55 kg were used for this study. Anesthesia was induced with IM administration of 10–20 mg/kg ketamine (MWI, Boise, ID) and isoflurane (MWI, Boise, ID) via nosecone. Animals were intubated with a cuffed 8.0 mm endotracheal tube (Teleflex, Morrisville, NC), and peripheral venous access obtained. Sedation was maintained using the Drager Fabius GS anesthesia machine (Drager, Houston, TX) with 1–3% isoflurane and 0.4 FIO2. Tidal volume was set at 8 ml/kg and a respiratory rate of 16–20 breaths per minute, adjusting the minute volume to maintain an end-tidal CO2 of 45–55 mmHg. A 7.5 ml/kg bolus of 0.9% saline (B. Braun, Bethlehem, PA) was given prior to central line placement. The external jugular and femoral artery were visualized using the M9 ultrasound system (Mindray, Mahwah, NJ) and central venous and arterial access were obtained. The Drager Infinity Delta monitor (Drager, Houston, Tx) was used to monitor and record respiratory parameters, pulse oximetry, body temperature, invasive blood pressure, and electrocardiogram (ECG) throughout the experiment. Invasive hemodynamic variables were measured via pulmonary artery catheterization using an eight-French Swan Ganz CCOmbo catheter and the Edwards Vigilance II monitor (Edwards Lifesciences, Irvine, CA). Once vascular access was obtained a one-time bolus of heparin (100 units/kg) was given and isoflurane was weaned to 0.8–1% and 0.21 FiO2 until the animal was breathing spontaneously, without mechanical ventilation. Sedation was maintained with isoflurane throughout the experimental procedures to minimize pain and discomfort.