Vascular Access and Complications in Critical Illness.

Chapter 41 - Prognosis of neurologic complications in critical illness

In Brief Despite the diagnostic and therapeutic advances that have occurred in medical practice over the past 3 decades, critically ill patients all too frequently develop complications that can result in increased morbidity, mortality, and cost of care. Among the most commonly encountered complications are venous thromboembolic disease (VTE), ventilator-associated pneumonia (VAP), catheter-associated infections (CAI), and stress-related mucosal disease (SRMD). Fortunately, clinicians have effective prophylactic strategies to prevent these complications in high-risk critically ill patients. Essential aspects of management for the critically ill patient should include knowledge of the risk factors for development, skill in recognition, and awareness of prevention strategies for the common complications of critical illness. In practical terms, the major obstacle has been failure to implement effective prophylactic strategies early enough in the “at-risk population” to achieve the beneficial effects on outcome. The best educational plan appears to be targeting the medical students and house staff, along with the intensive care unit nurses, pharmacists, and respiratory therapists. It is hoped that through education and the development of management protocols, morbidity and mortality will be improved for the critically ill patient. Complications of critical illness have been an all-too-frequent occurrence, despite recent advances in technology and medical care. It has become clear that the key to successful management of the critically ill patient requires the incorporation of effective therapeutic management, along with the use of appropriate prophylactic strategies. Those patients who have increased risk for these complications should be identified early, and appropriate prophylactic management strategies should be instituted. This paper emphasizes prophylactic recommendations and guidelines, along with the evidence upon which these recommendations are based.

Sedation Scales in the ICU

BackgroundCritical illness polyneuropathy (CIP) is a common neuromuscular complication in critically ill patients and is associated with increased morbidity, prolonged mechanical ventilation, and delayed recovery. This study aims to identify clinical factors associated with the development or progression of CIP in critically ill patients admitted to a tertiary care center in Lebanon.MethodologyThis prospective cohort study included 70 adult patients (≥18 years) admitted to the intensive care unit (ICU) at the American University of Beirut Medical Center. Baseline demographics, medical history, and clinical data were collected upon admission. Nerve conduction studies (NCS) were conducted on day zero and repeated on day seven of ICU stay. Hospital course details, new medications, and complications were recorded throughout the observation period. Categorical variables were analyzed using the chi-squared test, while continuous variables were compared using the Mann-Whitney U test. A p-value <0.05 was considered statistically significant.ResultsOf the 70 patients enrolled, 46 were excluded due to inability to complete the follow-up NCS, primarily because of ICU stays shorter than seven days. The final analysis included 24 patients, among whom nine (37.5%) developed new or progressive CIP by day seven. Among all clinical variables analyzed, only thyroid dysfunction showed a statistically significant association with CIP development (p = 0.026). Notably, 32% of patients with CIP had underlying hypothyroidism or hyperthyroidism. Other commonly suspected factors, including corticosteroid use, beta-blocker therapy, and sepsis, were not statistically significant in this cohort.ConclusionsThyroid dysfunction was significantly associated with the development of CIP in critically ill patients in this study. These findings suggest that thyroid status may play a previously underrecognized role in the pathogenesis of CIP and highlight the potential value of routine thyroid screening in ICU patients. Further research involving larger, multicenter cohorts is warranted to validate these results and investigate the mechanisms linking thyroid dysfunction to neuromuscular complications in critical illness.

Lung Disease and the Lightest of Metals

716 Vascular access options in coronary angiogram procedures: Randomized controlled trial of a patient decision aid

Vascular access related complications are the most common complications from catheter based EP procedures and have been reported to occur in 1-13% of cases. We prospectively assessed vascular complications in a large series of consecutive patients undergoing catheter based electrophysiologic (EP) procedures with ultrasound (US) guided vascular access versus conventional access. Consecutive patients undergoing catheter ablation procedures at VCU medical center were included. US guided access was obtained in all cases starting June 2015 (US group) while modified Seldinger technique without US guidance (non-US group) was used in cases prior to this date. All vascular complications were recorded for a 30-day period after the procedure. A total of 689 patients underwent 720 procedures. Ablations for ventricular tachyarrhythmias (ventricular tachycardia: VT, premature ventricular contractions: PVCs) accounted for 89 (12%) cases; atrial fibrillation (AF) ablations accounted for 328 procedures (46%) and other catheter based procedures accounted for 42% of cases. A significantly higher incidence of complications was noted in the non-US group compared with the US group (19 [5.3%] vs. 4 [1.1%], respectively, P = 0.002). Major complications were also higher among the non-US group (9 [2.5%] vs. 2 [0.6%], P = 0.03). Increasing age (P = 0.04) and non-US guided vascular access (P = 0.002) were associated with a higher risk of vascular access complications. In a large series of patients undergoing catheter based EP procedures for cardiac arrhythmias, US guided vascular access was associated with a significantly decreased 30-day risk of vascular complications.

Neuromuscular weakness acquired in the intensive care unit (ICU) causes significant impairment in critically ill patients. The spectrum of critical illness neuromuscular disease includes critical illness myopathy, critical illness polyneuropathy or both, and occurs in approximately one-third of patients admitted to the ICU and those who are ventilated for at least 7 days. Recognized risk factors include sepsis, systemic inflammatory response syndrome, multi-organ failure, neuromuscular blocking agents and corticosteroids, however the absence of predisposing factors should not preclude critical illness neuromuscular disease. A 23-year-old male suffered a cervical spine injury and was admitted to the ICU. Two weeks post admission, he lost all power in his upper limbs, neck and face. Nerve conduction studies and needle electromyography were performed 4 weeks and 3 months after the injury, suggesting that myopathy was the likely cause of weakness. The definitive diagnosis of critical illness myopathy was based on muscle biopsy demonstrating myosin filament loss. Evaluation of new-onset weakness in ICU patients is essential to distinguish neurological causes from complications of critical illness. Signs and symptoms of critical illness neuromuscular disease must be identified early to encourage recovery, promote rehabilitation, and reduce morbidity and mortality.

Interventional Nephrology: Core Curriculum 2009

Survivorship after critical illness is associated with significant disability, psychological issues, and cognitive dysfunction, collectively termed post-intensive care syndrome. To date, minimal research has been published exploring the survivorship journey, disability, and recovery, in Aotearoa New Zealand. A constructivist grounded theory methodology explored the memories, experiences, and transition from critical illness to recovery with eleven survivors of critical illness. Interviews took place between six and nine months after hospital discharge. Themes and categories were developed from initial line coding followed by axial and selective coding. Data analysis and data collection were conducted simultaneously. Constant comparison was used through memos and field notes until data saturation was reached. The findings from this study describe a survivorship journey through tangible phases of illness interspersed with cascading events, hazy memories, and transitions. In the intensive care unit, the sequelae and complications of critical illness are synonymous with the aftershocks of an earthquake. Physical weakness, psychological distress, amnesia, and delirium are commonly encountered. These complications contribute to the development of post-intensive care syndrome. These aftershocks are experienced for weeks to months after returning home. The grounded theory derived from this study is that of transition through the disaster of critical illness, a journey that is analogous to the core phases of an earthquake. Participants had little help from the healthcare system and were highly dependent on families and friends for protection, care, and support. Whilst systematic follow-up is recommended and often available overseas, it is sparse in Aotearoa New Zealand. Information, reassurance, and psychological support within a culturally appropriate follow-up service setting is needed to support survivors. Te Reo Māori Translation Te hīkoi ki te ora mā roto i ngā māuiui tino tārūrū i Aotearoa: He rangahau whakamahi ariā hou Ngā Ariā Matua Ko te hoa haere o te hīkoi ki te ora i muri i ngā māuiui tino tārūrū ko te hauātanga tūturu, ngā raru ā-hinengaro, te turingonge hirikapo, ēnei katoa ka kīa ko te mate i muri i te noho i te wāhanga whāomoomo. Tae mai ki tēnei wā, he iti noa ngā rangahau kua whakaputaina ki te ao e tūhura nei i te hīkoi ki te ora, te hauātanga, me te whakamātūtū i Aotearoa. I tūhura tētahi tikanga rangahau ariā hou waihanga ara i ngā mahara, i ngā wheako me te whakawhitinga mai i te māuiui tārūrū ki te ora, o ētahi mōrehu tekau mā tahi o te māuiui tino tārūrū. I tū ngā uiui nei e ono marama, e iwa marama rānei, i muri i te putanga atu i te hōhipera. I whakawhanaketia ngā tāhuhu me ngā kāwai mai i ngā waehere whakatāhuhu tuatahi, me ngā waehere tūhonohono, waehere tīpako hoki, i muri. I kawea ngātahitia te tātari raraunga me te kohinga raraunga. I whakatairitea pūpututia ngā mahi, nā ngā tuhinga karere poto, me ngā tuhipoka i te wāhi mahi, taea noatia te pūrenatanga raraunga. Hei whakamārama ngā kitenga o tēnei rangahau i tētahi hīkoi ki te ora mā ētahi wā o te māuiui, ngā tūponotanga mahi, ngā mahara āhua rehu, me ngā whitinga ki tētahi āhua hou. I roto i te wāhanga whāomoomo, he āhua ōrite ngā mahi i pā i muri, me ngā raru o te tārūrū māuiui, ki ngā rū iti ka pā i muri i tētahi rū nui, ko te ngoikore o te tinana tērā, ko te āmaimai hinengaro tērā, ko te wareware tērā, ko te ngutungutu ahi hoki tērā, ēnei katoa ka tau ki runga i te tangata, i te mutunga ka pā te āhua o mate i muri i te noho i te wāhanga whāomoomo. I haere tonu ēnei rū iti i muri i ētahi wiki, i muri hoki i ētahi marama, i muri mai i te hokinga atu ki te kāinga. Ko te ariā hou i takea mai i tēnei rangahau ko te whakawhiti mai i te aituā o te māuiui tārūrū, tētahi haere āhua ōrite ki ngā tūponotanga i muri i tētahi rū. Kāore i tino nui ngā āwhina o te pūnaha hauora ki te hunga whai wāhi, ā, i riro kē nā ngā whānau me ngā hoa rātou i tautiaki, i taurima, i tautoko. Ahakoa e tūtohutia ana ngā mahi tautiaki i te tūroro i ngā rā o muri me te mōhio, e wātea ana i tāwāhi, he tūāporoporo noa i Aotearoa. E hiahiatia ana he mōhiotanga, ngā kupu atawhai, me te tautoko inenga hinengaro i roto i tētahi tautuhitanga ratonga tōtika ā-ahurea, hei tautoko i ngā mōrehu.

BackgroundAcute kidney injury (AKI) is a serious complication of critical illness with both attributed morbidity and mortality at short-term and long-term. The incidence of AKI reported in critically ill patients varies substantially with the population evaluated and the definitions used. We aimed to assess which of the AKI definitions (RIFLE, AKIN or KDIGO) with or without urine output criteria recognizes AKI most frequently and quickest. Additionally, we conducted a review on the comparison of incidence proportions of varying AKI definitions in populations of critically ill patients.MethodsWe included all patients with index admissions to our intensive care unit (ICU) from January 1st, 2014 until June 11th, 2014 to determine the incidence and onset of AKI by RIFLE, AKIN and KDIGO during the first 7 days of ICU admission. We conducted a sensitive search using PubMed evaluating the comparison of RIFLE, AKIN and KDIGO in critically ill patientsResultsAKI incidence proportions were 15, 21 and 20% respectively using serum creatinine criteria of RIFLE, AKIN and KDIGO. Adding urine output criteria increased AKI incidence proportions to 35, 38 and 38% using RIFLE, AKIN and KDIGO definitions. Urine output criteria detected AKI in patients without AKI at ICU admission in a median of 13 h (IQR 7–22 h; using RIFLE definition) after admission compared to a median of 24 h using serum creatinine criteria (IQR24-48 h). In the literature a large heterogeneity exists in patients included, AKI definition used, reference or baseline serum creatinine used, and whether urine output in the staging of AKI is used.ConclusionAKIN and KDIGO criteria detect more patients with AKI compared to RIFLE criteria. Addition of urine output criteria detect patients with AKI 11 h earlier than serum creatinine criteria and may double AKI incidences in critically ill patients. This could explain the large heterogeneity observed in literature.

Critical care management of patients with lymphatic conduction disorders

Objectives: Bleeding and vascular complications are currently the main adverse events associated with balloon aortic valvuloplasty (BAV). We assessed the hypothesis that BAV performed without heparin may be associated with lower complication rates. Methods We conducted a retrospective analysis of all consecutive patients who had undergone BAV in our center between 2008 and 2011. We evaluated 3 groups: patients included between 2008 and 2009 when BAV was performed with large sheaths (10 to 12 French) and injection of unfractionated heparin (UH) (50IU/kg bolus IV) (group 1); patients included after 2009, for whom smaller size sheaths (8 or 9 French) were used, were divided into 2 groups: group 2 (with UH bolus) and group 3 (without UH bolus). We collected all major in-hospital adverse events, bleeding (≥ BARC 3), vascular access complications (including pseudoanerysm or arterio venous fistula) and acute limb ischemia. Results Overall, 140 patients were included in this study. The 3 groups had similar median age (84 years) and preceding lower extremity artery disease (overall n= 36, 27%, p=0.79). Vascular access and bleeding complications were observed in 16 patients (11.4%) and were lower in group 3 compared to group 1 and group 2 (table 1). The use of heparin was associated with an increased risk of vascular access and bleeding complications [relative risk (IC) 2.85 (1.28 to 9.13] whereas absence of heparin did not increase ischemic complications as acute limb ischemia (p=0.82), stroke (1 patient in group 2) or other major in- hospital adverse events (p=0.5). Vascular and bleeding complications were comparable among patients who received heparin with no influence of the used sheath’ s size (table 1). In conclusion, we showed in this study that balloon aortic valvuloplasty performed without heparin is safe and leads to a dramatic reduction of vascular and bleeding events. Although randomization was not used, this marked difference is difficult to explain by confounding factors. .

Coronavirus disease 2019 is an epidemic disease throughout the world. The management of vascular access during the epidemic is currently unknown. In this multicenter cross-sectional study, we collected vascular access data from hemodialysis patients treated at 44 hospitals in Hubei from 22 January to 10 March 2020. We estimated the management of vascular access during the coronavirus disease 2019 outbreak. Of the 9231 hemodialysis patients included, 5387 patients (58.4%) were men and 2959 patients (32.1%) were older than 65 years. Arteriovenous fistula was the predominant type of vascular access, accounting for 76.5%; 496 patients (5.4%) developed vascular access complications; catheter flow reduction was the most common vascular access complication, and stenosis was the predominant complication among those with arteriovenous access. Overall, 280 vascular access sites were placed in patients newly diagnosed with uremia, of whom 260 (92.8%) underwent catheter insertion; 149 rescue procedures were carried out to treat the vascular access complications, which consisted of 132 catheters, 7 percutaneous transluminal angioplasties, 6 arteriovenous fistula repairs, and 4 arteriovenous fistulas. Occlusion of the arteriovenous access had the highest rescue rate (92.7%), while many other vascular access complications remained untreated; 69 and 142 patients were diagnosed with confirmed and suspected coronavirus disease 2019, respectively. A total of 146 patients died, of whom 29 patients (19.9%) died due to vascular access complications. Catheter flow reduction and stenosis of arteriovenous access were the major vascular access complications. Most of the vascular access sites established were catheters, and many of the vascular access complications remained untreated.

Effect of Adding a Pediatric Vascular Access Team Component to a Pediatric Peripheral Vascular Access Algorithm