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Category: CSICU

Authors: Schober A, Sterz F, Herkner H, Wallmueller C, Weiser C, Hubner P, Testori C.

Reference: Emerg Med J. 2017 May;34(5):277-281.

In refractory cardiac arrest, with cardiopulmonary resuscitation (CPR) for more than 30 min, chances of survival are small. Extracorporeal cardiopulmonary resuscitation (ECPR) is an option for certain patients with cardiac arrest. The aim of this study was to evaluate characteristics of patients selected for ECPR.
Anonymised data of adult patients suffering refractory cardiac arrest, transported with ongoing CPR to an ED of a tertiary care centre between 2002 and 2012 were analysed. Outcome measure was the selection for ECPR. Secondary outcome was 180 days survival in good neurological condition.
Overall, 239 patients fulfilled the inclusion criteria. ECPR was initiated in seven patients. Patients treated with ECPR were younger (46 vs 60 years; p=0.04), had shorter intervals before CPR was started (0 vs 1 min; p=0.013), faster admissions at the ED (38 vs 56 min; p=0.31) and lower blood glucose levels on admission (14 vs 21 mmol/L; p=0.018). Survival to discharge in good neurological condition was achieved in 14 (6%) of all patients. One patient in the ECPR group survived in excellent neurological condition. Age was independently associated with the selection for ECPR (OR 0.07; 95% CI 0.01 to 0.85; p=0.037).
Emergency extracorporeal life support was used for a highly selected group of patients in refractory cardiac arrest. Several parameters were associated with the decision, but only age was independently associated with the selection for ECPR. The patient selection resulting in a survival of one patient out of seven treated seems reasonable. Randomised controlled trials evaluating the age limit as selection criteria are urgently needed to confirm these findings.
© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.
Cardiac arrest; ECLS; ECPR; Extracorporeal life support; Resuscitation; Ventricular fibrillation

Authors: Dzierba AL, Abrams D, Brodie D

Reference: Crit Care. 2017 Mar 21;21(1):66

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from .

Authors: Docherty AB, Walsh TS

Reference: Crit Care. 2017 Mar 21;21(1):61

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from .

Authors: Giovanni Falsini, Simone Grotti, Italo Porto, Giulio Toccafondi, Aureliano Fraticelli, Paolo Angioli, Kenneth Ducci, Francesco Liistro, Maurizio Pieroni, Tamara Taddei, Serena Romanelli, Roberto Rossi, Leonardo Bolognese


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Delirium is a frequent in-hospital complication in elderly patients, and is associated with poor clinical outcome. Its clinical impact, however, has not yet been fully addressed in the setting of the cardiac intensive care unit (CICU). The present study is a prospective, two-centre registry aimed at assessing the incidence, prevalence and significance of delirium in elderly patients with acute cardiac diseases.

Between January 2014 and March 2015, all consecutive patients aged 65 years or older admitted to the CICU of our institutions were enrolled and followed for 6 months. Delirium was defined according to the confusion assessment method.

During the study period, 726 patients were screened for delirium. The mean age was 79.1±7.8 years. A total of 111 individuals (15.3%) were diagnosed with delirium; of them, 46 (41.4%) showed prevalent delirium (PD), while 65 (58.6%) developed incident delirium (ID). Patients 85 years or older showed a delirium rate of 52.3%. Hospital stay was longer in delirious versus non-delirious patients. Patients with delirium showed higher in-hospital, 30-day and 6-month mortality compared to non-delirious patients, irrespective of the onset time (overall, ID or PD). Six-month re-hospitalisation was significantly higher in overall delirium and the PD group, as compared to non-delirious patients. Kaplan–Meier analysis showed a significant reduction of 6-month survival in patients with delirium compared to those without, irrespective of delirium onset time (i.e. ID or PD). A positive confusion assessment method was an independent predictor of short and long-term mortality.

Delirium is a common complication in elderly CICU patients, and is associated with a longer and more complicated hospital stay and increased short and long-term mortality. Our findings suggest the usefulness of a protocol for the early identification of delirium in the CICU. NCT02004665

Keywords Delirium, cardiac intensive care unit, mortality, elderly, confusion assessment method

Authors: Ma RW, Huilgol RL, Granger E, Jackson A, Saling S, Dower A, Nivison-Smith I.

Reference: ANZ J Surg. 2016 Dec;86(12):1002-1006

Extracorporeal membrane oxygenation (ECMO) provides support to patients with severe but reversible cardiac or pulmonary failure. Vascular complications of ECMO are well recognized.
We performed a retrospective review of 70 patients (mean age 48 years; 15-85) who received peripheral veno-arterial ECMO from 2004 to 2010 in a single centre. For statistical analysis, chi-squared test and multivariate binary logistic regression analysis were used to assess for association between response variables (i.e. limb ischaemia, ECMO site bleeding and deep vein thrombosis (DVT)) and possible predictive variables.
There were 14 (20%) cases of acute limb ischaemia with no statistically significant relationship between acute limb ischaemia and independent variables. Thirty-three patients received distal limb cannulas (47%). There was no statistically significant association between limb ischaemia and presence of distal limb cannula (P = 0.8). Multivariate binary logistic regression analysis identified insertion by cutdown as a predictor of lower probability of insertion site bleeding (n = 12, odds ratio 0.24, P = 0.04). Seven cases of DVT were identified; multivariate binary logistic regression analysis identified insertion by cutdown (odds ratio 0.08, P = 0.03) and days of ECMO less than five (odds ratio 0.08, P = 0.04) as predictive factors for reduced rates of DVT.
Ischaemic complications of ECMO are common and occur despite the presence of a distal limb-perfusing cannula; however in our study the distal limb cannula was a limb-salvaging intervention in six patients. Prolonged time on ECMO is a risk factor for DVT, and a high index of suspicion must be maintained. Percutaneous insertion was associated with higher rates of bleeding and DVT.
© 2016 Royal Australasian College of Surgeons.

Authors: Pinho C, Cruz S, Santos A, Abelha FJ.

Reference: J Clin Anesth. 2016 Sep;33:507-13.

The aim of this study was to determine the incidence of postoperative delirium (POD) and the presence of previous conditions related to its development.
Prospective observational study.
The study was performed in adult patients (n=221) scheduled for elective surgery and admitted to the postanesthesia care unit (PACU).
The presence of POD was assessed by the Nursing Delirium Screening Scale at discharge from the PACU and 24hours after surgery. Descriptive analyses were carried out, and statistical comparisons were performed with Mann-Whitney U, χ(2), or Fisher exact test. Logistic regression analysis was used for evaluation of independent determinants of POD.
POD was found in 25 patients (11%). Patients who developed POD were older (median age, 69 vs 57years; P


Reference: PUBLIC RELEASE: 16-MAR-2017

Sophia Antipolis, 16 March 2017: Delirium is associated with a five-fold increase in mortality in acute cardiac patients, according to research published today in European Heart Journal: Acute Cardiovascular Care.1 Delirium was common and affected over half of acute cardiac patients aged 85 years and older.

Delirium is a clinical syndrome caused by a disturbance in the normal functioning of the brain. Delirious patients are less aware of, and responsive to, their environment. They can be disorientated, incoherent, and in a dream-like state, with hallucinations, disordered speech and memory disturbances.

Delirium affects at least one in ten hospitalised patients and is more common in the elderly. These patients have worse long-term prognosis and more complications during their hospital stay.

“Among hospitalised patients, those admitted to an intensive care unit are more likely to develop delirium and there are strategies to limit its consequences,” said lead author Dr Giovanni Falsini, interventional cardiologist, San Donato Hospital, Arezzo, Italy. “Less is known about delirium and its significance in patients admitted to cardiac intensive care units. This study investigated the incidence and clinical impact of delirium in patients with acute cardiac diseases.”

The study included all patients aged 65 years and older admitted to two cardiac intensive care units during a period of 15 months. Only non-intubated patients were enrolled. Validated score systems and questionnaires were used to detect and diagnose the presence of delirium at admission or during the hospital stay.

Delirious patients were closely followed by nursing and medical staff who used a flowchart for delirium treatment. This included treating pain and anxiety, and discontinuing medications known to cause delirium. Patient survival at six months was determined by telephone call.

The investigators found that delirium was a frequent condition among elderly patients with acute cardiac diseases. The study population consisted of 726 patients with an average age of 79 years, of whom 15% had delirium (at admission or during the hospital stay). More than half (52%) of patients aged 85 years and older were delirious.

Patients with delirium had a worse prognosis, with a five-fold increase in both in-hospital and 30-day mortality and a two-fold increase in six-month mortality. Delirium was not only a strong and independent factor in predicting mortality, but was also associated with longer hospital stay and more frequent rehospitalisations during follow-up.

“Delirium is a common and serious condition in acute cardiac patients,” said Dr Falsini. “They stay in hospital longer, return to hospital more often, and are more likely to die in the short- and long-term.”

Dr Falsini said elderly patients may be at higher risk because they usually have pre-existing issues that can predispose to delirium such as dementia, visual and hearing impairments, depression, use of psychoactive drugs, infections, or electrolyte disturbances.

He said: “The more complex and frail the patient is, the higher the rate of delirium and subsequent worse outcomes. It is unknown whether delirium can be treated to improve prognosis in critically ill patients, or whether it is a marker of organ dysfunction or systemic disease and an early sign that complications are likely. Monitoring delirium has been linked with reduced in-hospital mortality in mechanically ventilated patients and it is possible that similar benefit might occur in acute non-intubated patients.”

Dr Falsini concluded: “Delirium is common, serious, costly and under-recognised. A protocol is needed to identify and treat delirium in high-risk settings, like cardiac intensive care units.”

Authors: Heller A, Dollerschell J, Burk J, Haines H, Kozinn J.

Reference: Anaesthesiol Intensive Ther. 2016;48(4):211-214

In the past decade, the rate and utilization of veno-venous extracorporeal membrane oxygenation (VV-ECMO) has increased dramatically. A single catheter technique has recently come into favour for providing VV-ECMO. Although it has been shown that intensivists can safely place these catheters, the safety of decannulation by intensivists has not been reported in the literature.
We describe a technique for safely decannulating the Avalon Elite VV-ECMO catheter at the bedside and assess the safety of this technique, as compared with the standard technique of decannulation in the operating room by a surgeon.
This was a retrospective cohort design conducted at a tertiary care cardiovascular intensive care unit at an academic medical centre. All patients who underwent VV-ECMO from 2009 to 2014 were included in the study except for those who had been decannulated for withdrawal of care. Complication rates from decannulation were compared between patients who were decannulated by surgeons in the operating room and those decannulated by intensivists in the intensive care unit (ICU).
Twenty-eight patients were included in this study, of whom twenty-three patients (82%) were decannulated by intensivists, board certified in Critical Care Medicine through the American Board of Anesthesiology, while five (18%) the patients were decannulated by a surgeon. There was no significant difference in the complications rates between the surgeons (0) and intensivists (1) (P = 1.00). There were no major complications requiring operative intervention associated with decannulation identified in this study.
It is safe for intensivists to decannulate the Avalon Elite VV-ECMO cannula in the ICU using our purse-string suture technique. Performing these decannulations at the bedside compared to operating room may have positive clinical ramifications that include improved patient safety, timely patient care and reduced operating room costs.
ECMO; decannulation; extracorporeal membrane oxygenation; intensive care unit; safety

Authors: Al Tmimi L, Van de Velde M, Meyns B, Meuris B, Sergeant P, Milisen K, Pottel H, Poesen K, Rex S.

Reference: Clin Chem Lab Med. 2016 Oct 1;54(10):1671-80.

To investigate the predictive value of S100 (biochemical marker of neuroglial injury) for the occurrence of postoperative delirium (POD) in patients undergoing off-pump coronary artery bypass (OPCAB)-surgery.
We enrolled 92 patients older than 18 years undergoing elective OPCAB-surgery. Serum-levels of S100 were determined at baseline (BL), end of surgery (EOS) and on the first postoperative day (PD1). Postoperatively, all-patients were evaluated daily until PD5 for the presence of POD using the confusion assessment method (CAM) or the confusion assessment method for the intensive care unit (CAM-ICU) for patients in the intensive care unit (ICU).
The overall incidence of POD was 21%. S100-values on PD1 significantly predicted the occurrence of POD during the later hospital stay [area under the curve (AUC)=0.724 (95% confidence interval (CI): 0.619-0.814); p=0.0001] with an optimal cut-off level of 123 pg mL-1 (sensitivity 100%, specificity 44%). Below this value, the absence of POD was predicted correctly in 43.66% of patients without POD [negative predictive value (NPV) of 100% (95%CI: 88.8%-100.0%) - positive predictive value of 29.8% (95%CI: 18.4%-43.4%) and likelihood ratio (LR) of the negative result of 0.0].

Authors: Dennis M, McCanny P, D'Souza M, Forrest P, Burns B, Lowe DA, Gattas D, Scott S, Bannon P, Granger E, Pye R, Totaro R; Sydney ECMO Research Interest Group.

Reference: Int J Cardiol. 2016 Dec 6. pii: S0167-5273(16)33093-5.

To describe the ECPR experience of two Australian ECMO centres, with regards to survival and neurological outcome, their predictors and complications.

Retrospective observational study of prospectively collected data on all patients who underwent extracorporeal cardiopulmonary resuscitation (ECPR) at two academic ECMO referral centres in Sydney, Australia.

Measurements and main results
Thirty-seven patients underwent ECPR, 25 (68%) were for in-hospital cardiac arrests. Median age was 54 (IQR 47–58), 27 (73%) were male. Initial rhythm was ventricular fibrillation or pulseless ventricular tachycardia in 20 patients (54%), pulseless electrical activity (n = 14, 38%), and asystole (n = 3, 8%). 27 (73%) arrests were witnessed and 30 (81%) patients received bystander CPR. Median time from arrest to initiation of ECMO flow was 45 min (IQR 30–70), and the median time on ECMO was 3 days (IQR 1–6). Angiography was performed in 54% of patients, and 27% required subsequent coronary intervention (stenting or balloon angioplasty 24%). A total of 13 patients (35%) survived to hospital discharge (IHCA 33% vs. OHCA 37%). All survivors were discharged with favourable neurological outcome (Cerebral Performance Category 1 or 2). Pre-ECMO lactate level was predictive of mortality OR 1.35 (1.06–1.73, p = 0.016).

In selected patients with refractory cardiac arrest, ECPR may provide temporary support as a bridge to intervention or recovery. We report favourable survival and neurological outcomes in one third of patients and pre-ECMO lactate levels predictive of mortality. Further studies are required to determine optimum selection criteria for ECPR.