Cause Of Circulatory Failure Research Articles

Temporary ventricular assist device support with a catheter-based axial pump: Changing the paradigm at a pediatric heart center

ObjectiveWe report the largest pediatric single-center experience with an Impella (Abiomed Inc) catheter-based axial pump support. MethodsWe conducted a retrospective cohort study of all patients with acute decompensated heart failure or cardiogenic shock requiring catheter-based axial pump support between October 2014 and February 2022. The primary outcome per individual encounter (hospital admission) was defined as bridge-to-recovery, bridge-to-durable ventricular assist device support, bridge-to-cardiac transplantation, or death at 6 months after catheter-based axial pump explantation. Adverse events were defined according to the Pediatric Interagency Registry for Mechanical Circulatory Support criteria. ResultsOur final study cohort included 37 encounters with 43 catheter-based axial pump implantations. A single catheter-based axial pump device was used for support in 33 encounters (89%), with 2 catheter-based axial pump devices used in 3 (8%) separate encounters and 3 catheter-based axial pump devices used in 1 (3%) encounter. The median [range] age, weight, and body surface area at implantation were 16.8 [6.9-42.8] years, 61.1 [23.1-123.8] kg, and 1.7 [0.8-2.5] m2, respectively. The predominant causes of circulatory failure were graft failure/rejection in 16 patients (43%), followed by cardiomyopathy in 7 patients (19%), arrhythmia refractory to medical therapies in 6 patients (16%), myocarditis/endocarditis in 4 patients (11%), and heart failure due to congenital heart disease in 4 patients (11%). Competing outcomes analysis showed a positive outcome with bridge-to-recovery in 58%, bridge-to-durable VAD support in 14%, and bridge-to-cardiac transplantation in 14% at 6 months. Fourteen percent of encounters resulted in death at 6 months. ConclusionsWe demonstrate that catheter-based axial pump support in children results in excellent 1- and 6-month survival with an acceptable adverse event profile.

A four-step model to aid teaching, clinical assessment and communication of circulatory disorders among junior clinicians

Conditions associated with circulatory disturbance are common causes of admission to the intensive care unit (ICU)1 as well as clinical deterioration after admission has occurred. Accordingly, it is important for ICU clinicians to have a thorough knowledge of the causes of circulatory failure and an approach to assessing them. Circulatory conditions are also a common cause of clinical deterioration in hospital ward.

Hemodynamic monitoring of ARDS by critical care echocardiography

Acute respiratory distress syndrome (ARDS) is a major cause of morbidity and mortality in intensive care units and affects about 10% of critically ill patients and almost 25% of mechanically ventilated patients. It is characterized by life-threatening impairment of pulmonary gas exchange, but in two-thirds of cases is associated with hemodynamic instability. Shock is the primary factor influencing mortality and is driven by sepsis in half of the cases and by a more specific mechanism of ARDS in the other half, which is pulmonary vascular dysfunction, i.e., pulmonary hypertension related to the inflammatory process in the lung, which is very sensitive to a respiratory strategy. ARDS-related right ventricular failure, which is also named acute cor pulmonale (ACP), occurs in 20–25% of patients in the area of lung protective ventilation. In this condition, critical care echocardiography (CCE) plays a central role in adequate hemodynamic assessment and management at the bedside because of its ability to yield information quickly on cardiac dimensions and function, respiratory variations of vena cava dimensions and changes in cardiac output in response to therapy. Added to clinical and laboratory data, with invasive blood pressure monitoring and a central venous catheter, such information can be used to define the cause of circulatory failure, to evaluate the benefit and risk balance of fluid expansion, and to consider a strategy for right ventricle protection. Moreover, in the most severe situations, CCE can also guide the establishment and good functioning of extracorporeal membrane oxygenation (ECMO). In this article, we illustrate and summarize the value of CCE in ARDS and give some physiological pointers to its appropriate use.

Diagnostic point-of-care ultrasound: applications in obstetric anaesthetic management.

Complications during pregnancy are not frequent, but may occur abruptly. Point-of-care ultrasound is a non-invasive, non-ionising diagnostic tool that is available at the bed-side when complications occur. This review covers the use of ultrasound in various clinical situations. Gastric ultrasound can identify stomach contents that put the woman at risk for pulmonary aspiration. In the future, this tool will probably be used routinely before induction of anaesthesia to determine the presence of stomach contents above a particular risk threshold. Difficult tracheal intubation, and the potential for 'can't intubate, can't oxygenate', is more frequent in pregnant women. Point-of-care ultrasound of the airway allows accurate identification of the cricothyroid membrane, permitting rapid and safer establishment of front-of-neck airway access. Combined cardiac and lung ultrasound candetermine the potential risk:benefit of fluid administration in the pregnant patient. Such prediction is of critical importance, given the tendency of pregnant women to develop pulmonary oedema. Combined echocardiography and lung ultrasound can be combined with ultrasound of the leg veins to differentiate between the various causes of acute respiratory failure, and guide treatment in this situation. Finally, as shown in the general population, multi-organ point-of-care ultrasound allows early diagnosis of the main causes of circulatory failure and cardiac arrest at the bed-side. As the importance of point-of-care ultrasound in critical patients is increasingly recognised, it is emerging as an important tool in the therapeutic armoury of obstetric anaesthetists.

PREVALENCE, PATTERN AND CLINICAL OUTCOME OF CIRCULATORY SHOCK IN CRITICALLY ILL PATIENTS IN MEDICAL ICU

ABSTRACT Background: To study the epidemiology of circulatory shock secondly to assess different pattern of circulatory shock among adult critically ill patients admitted to medical ICU of internal medicine department Zagazig University during the study period and finally to study the clinical outcome (morbidity and mortality) of different pattern of circulatory shock. Methods and subjects: The current Cross-sectional cohort study had been carried out on 694 patients with circulatory shock who were admitted in medical ICU with criteria of peripheral circulatory failure. The included patients were subdivided into three groups according to the provisional and definitive diagnosis of type of circulatory shock depending on CVP, echocardiography, cardiac output and laboratory investigations as follow: Group1: hypovolemic shock group ,Group 2: cardiogenic shock group and Group 3: septic shock group. All patients were subjected to thorough medical and clinical history taking and full clinical assessment. Blood samples were withdrawn for routine investigations (Complete blood count, Kidney function tests, Liver function tests, CRP, INR, Arterial blood gases (ABG), Mean saturation of central venous oxygen (ScvO2) and serum lactate. Shock severity was assessed by using APACHE IV score and SOFA score. Results : The frequency of circulatory shock patients is 13.9% per year. Hypovolemic shock was the major cause of circulatory failure in the studied population followed by septic shock and finally cardiogenic shock. The severity assessment parameters including APPACHE IV score , SOFA score, length of hospital stay and GCS were statically significant difference among the three studied groups, with significant increase in APPACHE IV score and SOFA score in cardiogenic group. APPACHE IV score and SOFA score were significant independent predictor of survival. The outcome measures of our populations during their ICU stay and after discharge to the medical words shows that mortality increase progressively with increase the length of ICU stay, there was significant difference in survival among the three groups, the most favorable outcome is hypovolemic group, and the worst was observed in the cardiogenic shock group. Conclusions: Circulatory shock is a life threatening condition associated with high mortality so early recognition and early intervention will decrease morbidity and mortality in critically ill patients. CVP, echocardiography and laboratory investigations especially serum lactate and SCVO2 are easy, reliable and available in all emergency departments. All can help in early diagnosis of type of circulatory shock. Calculation of APPACHE IV score and SOFA score were easy and reliable which potentially allow one to diagnose life-threatening condition and treat them before laboratory results are back. Key words: Circulatory Shock, medical ICU

Circulatory Failure and Lactic Acidosis Associated with Giant Saphenous Vein Graft Aneurysm

Context: Saphenous vein graft aneurysms may be a life-threatening condition. It may take 15-20 years to fully develop and is regarded as a relatively rare and late complication of coronary artery bypass grafting. Giant aneurysms may particularly cause mechanical complications due to neighboring structure compression. Simultaneous right atrial and ventricle compressions due to saphenous vein graft aneurysms as a cause of circulatory failure and lactic acidosis are rarely demonstrated in intensive care unit patients. Case report: We hereby report a case of a 74-year-old patient who was diagnosed with circulatory failure that developed into acute cardiac failure with obstructive shock. The patient had undergone coronary bypass grafting 20 years previously. Computed tomography angiography revealed a right-sided 6.7 × 7.1 cm paracardial aneurysm, originating from the venous graft, compressing the right atrium and ventricle inflow tract. Conclusions: We hypothesize that hemodynamic instability due to right ventricular inflow obstruction contributed to circulatory failure with consequently inadequate oxygen delivery and lactic acidosis. Despite immediate supportive treatment, the clinical condition deteriorated and a percutaneous intervention with a stent or surgical ligation with excision was not feasible thereafter. Saphenous vein graft aneurysms should be considered in patients with circulatory failure who have a history of coronary artery bypass grafting.

Neonatal circulatory failure due to acute hypertensive crisis : clinical and echocardiographic clues : cardiovascular topics

Circulatory failure due to acute arterial hypertension in the neonatal period is rare. This study was undertaken to assess the clinical and echocardiographic manifestations of circulatory failure resulting from acute neonatal hypertensive crisis. Neonatal and cardiology databases from 2007 to 2010 were reviewed. An established diagnosis of circulatory failure due to neonatal hypertension before the age of 14 days was required for inclusion. Six patients were identified. Five patients presented with circulatory failure due to an acute hypertensive crisis. The median age at presentation was 8.5 days (range: 6.0-11.0) with a median body weight of 3.58 kg (range: 0.86-4.70). Echocardiography demonstrated mild left ventricular dysfunction [median shortening fraction (SF) 25%, range 10-30] and mild aortic regurgitation in 83% (5/6) of patients. One patient with left ventricular dysfunction (SF = 17%) had a large apical thrombus. Two patients were hypotensive, and hypertension only became evident after restoration of cardiac output. Administration of intravenous milrinone was successful, with rapid improvement of the clinical condition. Left ventricular function normalised in all survivors. Early neonatal circulatory collapse due to arterial hypertension is a rare but potentially life-threatening condition. At presentation, hypotension, especially in the presence of a dysfunctional left ventricle, does not exclude a hypertensive crisis being the cause of circulatory failure. The echocardiographic presence of mild aortic regurgitation combined with left ventricular hypocontractility in a structurally normal heart should alert the physician to the presence of underlying hypertension.

Vascular reactivity and membrane potential in survivors and non-survivors with peritonitis-induced septic shock

Background: Vascular hyporeactivity and hyperpolarization are important causes of circulatory failure in septic shock. However, there is no data on the differences in vascular reactivity and resting membrane potential for survivors and non-survivors of sepsis. Thus, the aim of this study was to examine and compare the changes in vascular reactivity and resting membrane potential for survivors and non-survivors following cecal ligation and puncture (CLP)-induced sepsis. Methods: Wistar rats were subjected to CLP or a sham operation after the carotid artery and vein were cannulated. The changes in hemodynamics, biochemical variables, aortic isometric tension, smooth muscle membrane potential, and aortic superoxide levels were monitored during the experimental period. Results: The CLP surgery caused circulatory failure, multiple organ dysfunction syndrome (MODS), vascular hyporeactivity to norepinephrine (NE), and vascular hyperpolarization. Compared with survivors, non-survivors showed more severe organ dysfunction and a lower increase in aortic superoxide levels at 9 h. In addition, non-survivors displayed lower decreases in vascular reactivity to NE and resting membrane potential in the aortas compared to those of the survivors. Conclusions: These results demonstrate signifi cant differences in vascular reactivity and resting membrane potential for survivors and non-survivors after CLP-induced sepsis. However, vascular hyporeactivity and hyperpolarization only partially contributed to the early death of septic animals, while early death in our study was most likely due to organ dysfunction (i.e. MODS) in this CLP-induced sepsis model.

Plasma Substitutes Therapy in Pediatrics

Hypovolemia is the most common cause of circulatory failure in children and may lead to critical tissue perfusion and eventually multiple-organ failure. Administration of fluids to maintain or restore intravascular volume represents a common intervention after hemorrhagic shock occurring during surgical procedures or in patients with trauma. Notwithstanding, there is uncertainty whether the type of fluid may significantly influence the outcome, especially in pediatrics. Both human albumin and crystalloids are usually administered: the advantages of crystalloids include low cost, lack of effect on coagulation, no risk of anaphylactic reaction or transmission of infectious agents. However, large amount of crystalloid infusion has been correlated with pulmonary oedema, bilateral pleural effusions, intestinal intussusception, excessive bowel edema, impairing closure of surgical wounds and peripheral edema. Moreover, intravascular volume expansion obtained by crystalloids is known to be significantly shorter and less efficacious than colloids. Among synthetic colloids, gelatins have been used for many years in children, also in early infancy, to treat intravascular fluid deficits. Hydroxyethylstarch (HES) preparations have been introduced recently, becoming very popular for vascular loading both in adults and children. However, the number of pediatric studies aimed at evaluating HES efficacy and tolerance is limited. Given the ongoing controversies on the use of colloids in childhood, this review will focus on the pharmacodynamics of synthetic and non synthetic colloids for the treatment of critical blood loss in pediatrics.

Tako Tsubo cardiomyopathy in a patient with multiple trauma

Tako Tsubo cardiomyopathy has been described in a variety of stress situations, including several critical illness settings. We report the first case of this syndrome in a patient with multiple trauma. Tako Tsubo is an unusual cause of circulatory failure in such patients, to be distinguished from myocardial contusion and myocardial infarction. Prolonged ST segment elevation on EKG, minor troponin release, and transient left ventricular apical ballooning on transthoracic echocardiography are among the features to be recognized. Full recovery occurs spontaneously within several weeks.

Enfant polytraumatisé

Trauma is the leading cause of both morbidity and mortality in the paediatric population. Early and aggressive management may improve survival and functional outcome. In children with multiple traumas, optimal care includes adequate initial assessment, aggressive resuscitation and conservative surgical management as often as possible. Acute respiratory failure is frequent in trauma paediatric patients and endotracheal intubation should be performed without delay. Haemorrhage is the leading cause of circulatory failure. Resuscitative fluids and vasoactive drugs, if needed, are given before possible surgical control of haemorrhage. Since severe head trauma is preponderant in this population, one of the major goals of initial critical care management is aimed at preventing secondary brain damage, especially hypoxia and hypotension. Improvement in diagnosis imaging represents a crucial advance in paediatric trauma care, with ultrasonography used as first line investigation, and CT scanning as the gold standard in stabilised and adequately monitored children. This effective management should decrease mortality and morbidity of severe trauma.

Enfant polytraumatisé

Trauma is the leading cause of both morbidity and mortality in the paediatric population. An early and aggressive management might improve survival and functional outcome. Optimal paediatric trauma patient care includes adequate initial assessment, aggressive resuscitation and conservative surgical management as often as possible. Acute respiratory failure is frequent in trauma paediatric patient and endotracheal intubation should be performed without delay. Haemorrhage is the leading cause of circulatory failure. Resuscitative fluids and vasoactive drugs, if needed, are given before possible surgical control of haemorrhage. Since severe head trauma is preponderant in this population, one of the major goals of initial critical care management is aimed at preventing secondary brain damage, especially hypoxia and hypotension. Improvement in diagnosis imaging represents a crucial advance in paediatric trauma care, with ultrasonography used as the first line investigation, and CT scan as the gold standard in stabilised and adequately monitored children. This effective management should decrease mortality and morbidity of severe trauma.

Transesophageal echocardiographic evaluation of left ventricular function

Left ventricular function is a main cause of circulatory failure peri-operatively and in critically ill patients in general. Of patients presenting for non-cardiac surgery, 15% are at risk for, or have, cardiac disease and this number increases with age, and in patients presenting for surgery in the later stages of chronic diseases such as diabetes or arterial hypertension [1]. Peri-operative morbidity and mortality in this patient population can be decreased only by using intensive monitoring and by early recognition and correction of abnormalities [2]. Cardiovascular function is a primary determinant of prognosis in critically ill patients and cardiovascular indices have proven to be valuable parameters of illness severity and prognosis [3].

Oxygen transport and hemodynamics during retrograde whole-body perfusion

The changes in oxygen transport and hemodynamics during retrograde whole-body extracorporeal perfusion (retro-ECC) were studied in six mongrel dogs. Oxygen consumption during retro-ECC, in which the blood flow rate was set at 25% and 50% of the flow during antegrade extracorporeal perfusion (ante-ECC), respectively, was relatively high compared with that during ante-ECC. These changes were caused by an increase in the oxygen extraction ratio to 71.5% +/- 8.2% and 51.2% +/- 12.4% during retro-ECC/25% and retro-ECC/50%, respectively. Thus, tissue perfusion was apparently well maintained by retrograde perfusion on the basis of the oxygen transport data. However, central venous pressure increased markedly to 29.5 +/- 11.6 mmHg and 56.2 +/- 24.5 mmHg during retro-ECC/25% and retro-ECC/50%, respectively, because of massive venous congestion caused by insufficient arterial return of perfused blood. The great venous compliance and increased systemic vascular resistance were the main causes of circulatory failure during retro-ECC. The risk of serious complications owing to the venous congestion must be considered during retrograde perfusion, especially during the clinical application of retrograde cerebral perfusion.