Goal-directed Therapy Research Articles

Unresponsive Low Mixed Venous Oxygen Saturation During Early Intensive Care Unit Stay is Associated With Increased Risk of Organ Dysfunction After Cardiac Surgery: A Single-Center Retrospective Study

The aim of the study was to determine if unresponsive mixed venous oxygen saturation (SvO2) values during early postoperative hours are associated with postoperative organ dysfunction. A single-center retrospective observational study. A university hospital. A total of 6,282 adult patients requiring cardiac surgery who underwent surgery in a University Hospital from 2007 to 2020. A pulmonary artery catheter was used to gather SvO2 samples after surgery at admission to the intensive care unit (ICU) and 4 hours later. For the analysis, patients were divided into 4 groups according to their SvO2 values. The rate of organ dysfunctions categorized according to the SOFA score was then studied among these subgroups. The crude mortality rate for the cohort at 1 year was 4.3%. Multiple organ dysfunction syndrome (MODS) was present in 33.0% of patients in the early postoperative phase. During the 4-hour initial treatment period, 43% of the 931 patients with low SvO2 on admission responded to goal-directed therapy to increase SvO2 >60%; whereas, in 57% of the 931 patients, the low SvO2 was sustained. According to the adjusted logistic regression analyses, the odds ratio for MODS (4.23 [95% CI 3.41-5.25]), renal- replacement therapy (4.97 [95% CI 3.28-7.52]), time on a ventilator (2.34 [95% CI 2.17-2.52]), and vasoactive-inotropic score >30 (3.62 [95% CI 2.96-4.43]) were the highest in the group with sustained low SvO2. Patients with SvO2 <60% at ICU admission and 4 hours later had the greatest risk of postoperative MODS. Responsiveness to a goal-directed therapy protocol targeting maintaining or increasing SvO2 ≥60% at and after ICU admission may be beneficial.

Abstract 14430: The Corcare Heart Function Optimization Protocol: A Structured Quality Improvement Intervention to Improve Goal Directed Targets for Patients With Reduced Ejection Fraction

Introduction: Reduced ejection fraction (REF) in patients is prevalent, utilizing substantial health care resources. Goal Directed Therapy (GDT) reduces hospitalization, morbidity, and mortality but use is suboptimal. Care in subspecialty clinics following discharge reduces readmission, but is not scaled for longitudinal care of the larger REF population. Canadian guidelines support integration of primary, specialist, and non-physician care in systems to improve outcomes. Hypothesis: A protocol-guided intervention will achieve high rates of GDT for REF patients in a community health care setting. Goal: To evaluate a pragmatic quality-of-care intervention to achieve GDT for REF patients and assess barriers to GDT. Methods: Patients referred for imaging and cardiology consultation at a community facility (Jan 1/15-Dec 31/22) were screened. Patients with LVEF &lt;41% on echocardiogram were included if their cardiologist consented to study protocol GDT and were enrolled at the next scheduled, usual care cardiologist visit. 2 project nurses confirmed patient status and assisted GDT management using medical directives at 9 protocol-specified visits between usual care visits over 32 weeks. The primary target was achieving GDT or maximally tolerated GDT (&gt;0 mg). A secondary endpoint, clinical inertia, was defined as not achieving GDT due to physician or patient choice. Results: 864 patients (13 cardiologists) participated: median age 71 (28-102) years, diabetes 25%, hypertension 60%, atrial fibrillation 22%. At intake: NYHA class ≥2 (60%), EF &lt;30% (45%), 30-35% (27%), 36-40% (29%), REF etiology ischemic (47%), non-ischemic (43%), mixed (10%). The majority achieved GDT in each class; inertia, not intolerance predominantly accounted for those who did not achieve GDT. Conclusion: This pragmatic community-based intervention achieved high rates of GDT that could improve longitudinal care for REF patients, and is potentially scalable and generalizable.

Abstract 19124: Systemic Sclerosis Masquerading as Heart Failure

Cardiac disease occurs in 80% of patients with systemic sclerosis (SS). Patients may present with various symptoms, including dyspnea, palpitations, chest pain, and heart failure. Of these, systolic heart failure has the rarest prevalence, estimated between 1-5% of patients. The mechanism behind myocardial damage is still unclear. Current literature supports a fibrotic process due to ischemic necrosis and reperfusion damage. There is a lack of representation of SS-related cardiac disease, but it is crucial to recognize it early for prompt intervention. A 62-year-old male with a history of diastolic dysfunction presented with acute hypoxic respiratory failure. A transthoracic echocardiogram demonstrated a new severely reduced systolic function at 20%. Angiogram demonstrated non-obstructive coronary artery disease. Further autoimmune workup revealed a significantly elevated ANA and highly positive RNA polymerase III antibody. The patient underwent a cardiac magnetic resonance imaging (MRI) scan, which showed evidence of inflammation with diffuse myocardial fibrosis concerning an infiltrative process. Subsequent cardiac positron emission tomography (PET) showed increased uptake in the basal portions of the septum and anterior wall for myocarditis. Given his autoimmune workup results and imaging, the patient was subsequently diagnosed with rapidly progressive cutaneous systemic sclerosis and associated non-ischemic cardiomyopathy. The patient was started on goal-directed medical therapy, including losartan, spironolactone, metoprolol, and empagliflozin. Additionally, he started on mycophenolate mofetil for immunosuppression. Roughly six months after discharge, his pulmonary function tests remain stable. His ejection fraction improved to 62%. Roughly one-third of systemic sclerosis-related deaths are due to cardiac involvement. Yet, most patients are asymptomatic during the early stages, with a variable phenotype later in disease progression. We report a case of a patient who developed systemic sclerosis-related myocarditis with an initial presentation of acute systolic heart failure. His cardiac dysfunction recovered from optimal goal-directed therapy and immunosuppression.

Abstract 16927: The Mother of All Pseudoaneurysms - A Rare Case

Introduction: Femoral artery pseudoaneurysms (FAP) are typically caused by percutaneous access during coronary and peripheral angiography. It occurs in 0.1 to 0.2% of diagnostic catheterization procedures and in 3.5% to 5.5% of interventional procedures. Cases of “Giant” femoral artery pseudoaneurysms have seldom documented in the past, however, our case is unique for two reasons:- Pseudoaneurysm presented 6 months after femoral arterial access, which is unusual.- This size of pseudo-aneurysm has yet to be documented. Case Description: 74-year-old male with history of diabetes mellitus type II and tobacco abuse presented with chest pain. He underwent cardiac catheterization via radial access, which confirmed severe multi-vessel disease with ejection fraction of 30%. Patient was started on goal-directed medical therapy with planned elective IABP-assisted coronary artery bypass grafting (CABG). On the day of surgery in anticipation of IABP, right femoral artery was accessed, however, intra-operative transesophageal echocardiography showed improvement of ejection fraction to 55%, which led to removal of the femoral sheath and application of a closure device. Six months later, patient presented with a large right groin mass. Computed tomography angiography confirmed a pseudoaneurysm anterior to the right common femoral artery, measuring 9.6 cm x 9.8 cm causing moderate stenosis of the superficial femoral artery. Peripheral arterial duplex ascertained the neck of pseudoaneurysm measuring 1.3 cm. Patient underwent emergent repair of the right femoral pseudoaneurysm, with thrombus removal. No further recurrence of pseudoaneurysm was noted. Discussion: Pseudoaneurysms may arise months after femoral arterial access. Any groin symptoms in patients who underwent percutaneous femoral arterial access warrant additional investigation. Further studies are needed to elucidate the factors that increase the risk of formation and rupture of pseudoaneurysms

ROLE OF MODIFIED EARLY WARNING SCORE IN EVALUATING MORTALITY IN POSTOPERATIVE PERIOD

Objectives: The intent of the study is to analyze the role of modified early warning score (MEWS) in the assessment of the need of early intervention and surgical intensive care unit (SICU) admission in patients undergoing elective and emergency major surgical procedures. Methods: This prospective study incorporated 150 patients who underwent emergency or elective major surgical procedures, with monitoring of physiological parameters in the post-operative period with implementation of MEWS. The MEWS score of 1–3: Escalation of monitoring done. MEWS of 4–5: Escalation of monitoring, urgent assessment by the surgical team, shift of patient to intensive care unit (ICU) if required. MEWS of ≥6: Shift of patient to ICU with emergency assessment by the surgical/medical/ICU team. Outcomes were (1) improvement in patients’ clinical condition after early goal-directed therapies (frequent monitoring, shifting to ICU), (2) discharged alive from the hospital, and (3) patient death. Results: In our study, all the patients with MEWS from 1 to 7 were discharged alive and all the patients with a score above ≥8 were succumbed to death suggesting MEWS score of ≥8 implicates the strict need for SICU admission and an increased mortality of the patient in the post-operative period. MEWS improved communication between nursing staff, junior doctors with surgical team to “flag-up” and prioritize patients. Conclusion: The MEWS is an important risk management tool that is simple to implement and effective in identifying the early deterioration of the patients, which can be used as a routine protocol in post-operative period and assessing the need of ICU for further interventions.

Osimertinib-induced biventricular cardiomyopathy with abnormal cardiac MRI findings: a case report

BackgroundOsimertinib is a third-generation epidermal growth factor receptor (EGFR) inhibitor that is currently the first-line treatment for metastatic EGFR-mutated non-small-cell lung cancer (NSCLC) due to its favorable efficacy and tolerability profile compared to previous generations of EGFR inhibitors. However, it can cause uncommon, yet serious, cardiovascular adverse effects.Case PresentationWe present the case of a 63-year-old man with EGFR-mutated NSCLC treated with osimertinib who developed new-onset non-ischemic cardiomyopathy with biventricular dysfunction and heart failure in the context of an enlarging pericardial effusion. For the first time, we demonstrate cardiac MR imaging findings associated with osimertinib-associated cardiomyopathy, including focal late gadolinium enhancement and myocardial edema. The patient’s biventricular function normalized after initiation of goal-directed medical therapy for heart failure and holding osimertinib. The patient was subsequently started on afatinib, a second-generation epidermal growth factor receptor-tyrosine kinase inhibitor (EGFR-TKI), without recurrence of cardiomyopathy.ConclusionsThis case highlights the need to better understand osimertinib-induced cardiotoxicity and strategies to optimize oncologic care in patients who develop severe cardiac toxicities from cancer therapy. It further underlines the importance of specialized multidisciplinary care of cancer patients who develop cardiotoxicities to optimize their oncologic outcomes.

Early Goal-Directed Therapy Using FloTrac/EV1000 Platform for Hemodynamic Optimization to Improve Perioperative Outcomes in Patients Undergoing Major Abdominal Surgery: A Randomized Controlled Trial

Objective: To compare the efficacy of early goal-directed therapy (EGDT) based on the FloTrac/EV1000 platform versus standard care to improve perioperative outcomes in patients undergoing major abdominal surgery. Materials and Methods: Forty patients undergoing major abdominal surgery were randomized to the Control or EGDT group. The Control group was managed to achieve a mean arterial pressure (MAP) of 65 to 90 mmHg, a central venous pressure of 8 to 12 mmHg, a urine output of 0.5 mL/kg/h or more, and an SpO₂ of more than 95%. The EGDT group was managed to achieve similar goals using information from the FloTrac/ EV1000 platform by receiving fluid to maintain stroke volume variation (SVV) of less than 13%, inotropic drugs to achieve a cardiac index (CI) of 2.2 to 4.0 L/min/m⁻², and/or vasoactive drugs to achieve a systemic vascular resistance index (SVRI) of 1,600 to 2,500 dynes·s/cm⁻⁵/m². Results: There were 20 patients in each group. The EGDT group received more colloid (p=0.035). The MAP and SVRI of both groups were comparable. The SVV of the Control group was higher (p=0.002), while the CI of the EGDT group was higher (p&lt;0.001). The EGDT group had a shorter intubated time and a shorter stay in the ICU, with a mean difference of –3.95 h (95% CI –7.85 to –0.05, p=0.047) and –14.75 h (95% CI –25.38 to –4.12, p=0.008), respectively. The EGDT group had shorter hospital stays, albeit without significance (p=0.273). No postoperative complication was detected. Conclusion: Implementation of EGDT using FloTrac/EV1000, compared to conventional care, in patients undergoing major abdominal surgery results in shorter intubated time and shorter stay in the ICU. The shorter hospital stay did not achieve statistical significance. Keywords: Early goal-directed therapy; Major abdominal surgery; Perioperative outcome; Intubation time; ICU stay; Hospital stay

OCOSO2: study protocol for a single-blinded, multicentre, randomised controlled trial assessing a central venous oxygen saturation-based goal-directed therapy to reduce postoperative complications in high-risk patients after elective major surgery

BackgroundFluid loading-based goal-directed therapy is a cornerstone of anaesthesia management in major surgery. Its widespread application has contributed to a significant improvement in perioperative morbidity and mortality. In theory, only hypovolemic patients should receive fluid therapy. However, to achieve such a diagnosis, a surrogate marker of cardiac output adequacy must be used. Current methods of fluid loading-based goal-directed therapy do not assess cardiac output adequacy. Nowadays, new devices make it possible to continuously monitor central venous oxygen saturation (ScvO2) and therefore, to assess the adequacy of perioperative cardiac output during surgery. In major surgery, ScvO2-based goal-directed therapy can be used to enhance fluid therapy and improve patient outcomes.MethodsWe designed a prospective, randomised, single-blinded, multicentre controlled superiority study with a 1:1 allocation ratio. Patients to be included will be high-risk major surgery patients (> 50 years old, ASA score > 2, major intra-abdominal or intra-thoracic surgery > 90 min). Patients in the control group will undergo standard fluid loading-based goal-directed therapy, as recommended by the guidelines. Patients in the intervention group will have ScvO2-based goal-directed therapy and receive fluid loading only if fluid responsiveness and cardiac output inadequacy are present. The primary outcome will be the Comprehensive Complication Index on day five postoperatively.DiscussionThis study is the first to address the issue of cardiac output adequacy in goal-directed therapy. Our hypothesis is that cardiac output optimisation during major surgery achieved by continuous monitoring of the ScvO2 to guide fluid therapy will result in a reduction of postoperative complications as compared with current goal-directed fluid therapy practices.Trial registrationClinicalTrials.gov. NCT03828565. Registered on February 4, 2019.

The effect of goal-directed hemodynamic therapy on clinical outcomes in patients undergoing radical cystectomy: a randomized controlled trial

BackgroundThis study investigated the effects of intraoperative goal-directed hemodynamic therapy (GDHT) on postoperative outcomes in patients undergoing open radical cystectomy.MethodsThis prospective, single-center, randomized controlled trial included 82 patients scheduled for open radical cystectomy between September 2018 and November 2021. The GDHT group (n = 39) received the stroke volume index- and cardiac index-based hemodynamic management using advanced hemodynamic monitoring, while the control group (n = 36) received the standard care under the discretion of attending anesthesiologists during surgery. The primary outcome was the incidence of a composite of in-hospital postoperative complications during hospital stays.ResultsA total of 75 patients were included in the final analysis. There was no significant difference in the incidence of in-hospital postoperative complications (28/39 [71.8%] vs. 30/36 [83.3%], risk difference [95% CI], -0.12 [-0.30 to 0.07], P = 0.359) between the groups. The amounts of intraoperative fluid administered were similar between the groups (2700 [2175–3250] vs. 2900 [1950–3700] ml, median difference [95% CI] -200 [-875 to 825], P = 0.714). The secondary outcomes, including the incidence of seven major postoperative complications, duration of hospital stay, duration of intensive care unit stay, and grade of complications, were comparable between the two groups. Trends in postoperative estimated glomerular filtration rate, serum creatinine, and C-reactive protein did not differ significantly between the two groups.ConclusionsIntraoperative GDHT did not reduce the incidence of postoperative in-hospital complications during the hospital stay in patients who underwent open radical cystectomy.Trial registrationThis study was registered at http://www.clinicaltrials.gov (Registration number: NCT03505112; date of registration: 23/04/2018).

FRI194 Pheochromocytoma Presenting As Catecholamine-Induced Cardiomyopathy: A Case Report

Abstract Disclosure: M. Tsikala Vafea: None. D. Lee: None. Introduction: Pheochromocytoma (PCC) is a rare catecholamine-secreting neuroendocrine tumor presenting with the classic triad of episodic headache, sweating and tachycardia. Catecholamine-induced cardiomyopathy (CICMP) can occur as a complication of PCC in 7-11% of patients. It presents more commonly as dilated cardiomyopathy and inverted Takotsubo cardiomyopathy but also as hypertrophic or unspecified cardiomyopathy. Following appropriate pharmacologic treatment and resection of PCC, these cardiac complications usually resolve. Case report: 36 year old man with history of hypertension presented to the hospital with worsening orthopnea and cough. Following antibiotic treatment failure for suspected pneumonia, he was re-admitted with hemoptysis, tachycardia, hypoxia, and hypertensive emergency. Troponin and brain natriuretic peptide were found to be elevated. CT chest and abdomen showed pulmonary nodules and a large left adrenal mass measuring 9.6x9.3x9.4 cm, concerning for metastatic PCC. He was subsequently started on doxazosin. Transthoracic echo showed bi-atrial enlargement, diffuse severe left ventricle hypokinesis, reduced ejection fraction 25% and diastolic dysfunction. Stress cardiac MRI showed non-ischemic cardiomyopathy, corroborating the diagnosis of CICMP. After achieving adequate alpha-adrenergic blockade, he was started on goal-direct medical therapy consisting of valsartan, metoprolol and empagliflozin. His pulmonary nodular opacities improved on repeat imaging, congruent with pulmonary edema rather than metastases. Plasma and 24-hour urine metanephrines (2,964 pg/mL and 23,310 mcg/24 hr, respectively) and normetanephrines (9,266 pg/mL and 33,927 mcg/24 hr, respectively), as well as dopamine (493 pg/mL), epinephrine (3,205 pg/mL) and norepinephrine (above reportable range of 4,800 pg/mL) eventually came back significantly elevated, confirming his diagnosis of PCC. A month after presentation, he underwent left adrenalectomy, which revealed an 11 cm composite PCC ganglioneuroma. One-month postoperatively, urine metanephrines and normetanephrines were normal but his ejection fraction remained unchanged. Discussion: CICMP should be considered in patients presenting with acute heart failure and an incidental adrenal mass to avoid delays in treatment. Acute pulmonary edema may resemble pulmonary nodules on CT, so interpretation of these findings should correlate with the clinical presentation. Timely initiation of alpha-adrenergic blockade upon suspicion of PCC is crucial as it can significantly improve hemodynamics, and biochemical markers take time to result. 96% of CICMP cases improve after resection of PCC within a variable time frame ranging from one week to several months. Our patient’s CICMP had not improved one month after his adrenalectomy, but it remains to be seen whether he eventually recovers his cardiac function. Presentation: Friday, June 16, 2023

The effects of perioperative goal-directed therapy on acute kidney injury after cardiac surgery in the early period

Background: This study aims to investigate the effects of goaldirected fluid therapy on the development of acute kidney injury in the perioperative period in patients undergoing cardiopulmonary bypass. Methods: Between November 2019 and May 2021, a total of 60 patients (46 males, 14 females; mean age: 62.5±9.6 years; range, 44 to 76 years) who were scheduled for elective coronary artery bypass grafting or valve surgery under cardiopulmonary bypass were included in the study. The patients were divided into two groups as the study group (Group S, n=30) and control group (Group C, n=30). The patients in Group C were treated with standard therapy, while the patients in Group S were treated with goal-directed fluid therapy. The Kidney Disease: Improving Global Outcomes (KDIGO) classification and renal biomarkers were used for the evaluation of acute kidney injury. Results: Acute kidney injury rates were similar in both groups (30%). Postoperative fluid requirement, intra-, and postoperative erythrocyte suspension requirements were significantly lower in Group S than Group C (p=0.002, p=0.02, and p=0.002, respectively). Cystatin-C was lower in Group S (p&lt;0.002). The kidney injury molecule-1, glomerular filtration rate, and creatinine levels were similar in both groups. The length of hospital stay was longer in Group C than Group S (p&lt;0.001). Conclusion: Although goal-directed fluid therapy does not change the incidence of acute kidney injury in patients undergoing cardiac surgery, it can significantly decrease Cystatin-C levels. Goal-directed fluid therapy can also decrease fluid and erythrocyte requirements with shorter length of hospital stay.

PB1046 Early Goal-Directed Hemostatic Therapy (EGDHT) for Severe Acute Bleeding Management in the Intensive Care Unit

PB1046 Early Goal-Directed Hemostatic Therapy (EGDHT) for Severe Acute Bleeding Management in the Intensive Care Unit

Impact of fluid and haemodynamic management in cytoreductive surgery with hyperthermic intraperitoneal chemotherapy on postoperative outcomes - A systematic review.

Cytoreduction surgery (CRS) with hyperthermic intraperitoneal chemotherapy (HIPEC) is an extensive surgery associated with significant fluid shift and blood loss. The haemodynamic management and fluid therapy protocol may impact postoperative outcomes. This systematic review was conducted to find the effect of haemodynamic monitoring and perioperative fluid therapy in CRS-HIPEC on postoperative outcomes. We searched PubMed, Scopus and Google Scholar. All studies published between 2010 and 2022 involving CRS-HIPEC surgeries that compared the effect of fluid therapy and haemodynamic monitoring on postoperative outcomes were included. Keywords for database searches included a combination of Medical Subject Headings terms and plain text related to the CRS-HIPEC procedure. The risk of bias and the certainty assessment were done by Risk of Bias-2 and the methodological index for non-randomised studies. The review included 16 published studies out of 388 articles. The studies were heterogeneous concerning the design type and parameter measures. The studies with goal-directed fluid therapy protocol had a duration of intensive care unit (ICU) stay that varied from 1 to 20 days, while mortality varied from 0% to 9.5%. The choice of fluid, crystalloid versus colloid, remains inconclusive. The studies that compared crystalloids and colloids for perioperative fluid management did not show a difference in clinical outcomes. The interpretation of the available literature is challenging because the definitions of various fluid regimens and haemodynamic goals are not uniform among studies. An individualised approach to perioperative fluid therapy and a justified dynamic index cut-off for haemodynamic monitoring seem reasonable for CRS-HIPEC procedures.

Diagnostic Criteria of Takotsubo Cardiomyopathy in the Clinical Setting: A Case Report

Introduction Takotsubo cardiomyopathy (TTS) is a rare condition related to stress featuring apical hypokinesis. Current guidelines suggest that the exclusion of other causal factors like myocarditis is required to diagnose TTS. However, we propose that the existing diagnostic criteria for TTS, particularly, required exclusion of myocarditis, adds to the challenge of making this diagnosis in the clinical setting. Hereby, we present a case with basal hypokinesis that could have been attributed to a conjunction of reverse Takotsubo syndrome (rTTS) with viral or toxic myocarditis. Case Presentation: A 29-year-old female complained of acute persistent chest pain, palpitations, and vomiting after smoking marijuana. She was tachycardic without hemodynamic instability or hypoxia. Electrocardiogram showed sinus tachycardia. Troponin peaked at 16.1 ng/ml. Urine drug screen was positive for amphetamines. Echocardiogram and catheterization showed left ventricular reduced ejection fraction (25-30%) with basal hypokinesia and apical hyperkinesis, suggestive of reversed Takotsubo cardiomyopathy. Cardiac magnetic resonance (CMR) also showed delayed contrast enhancement suggestive of myocarditis. Viral panel noted positive Coxsackie B titer on day 7 of hospitalization. She was treated with goal-directed medical therapy and repeat echocardiogram 6 days after showed normalized left ventricular systolic function. Discussion: Guidelines recommend the use of clinical history, inflammatory markers, and CMR to exclude infectious myocarditis before diagnosing rTTS. The clinical scenario in this case presented evidence of a catecholamine-related substance exposure known to trigger takotsubo cardiomyopathy and of an elevated Coxsackie B titer. The CMR showed features explainable by myocarditis and partially by rTTS. This case highlights the complexity of diagnosing TTS or rTTS with infective myocarditis as exclusion criteria. While imaging, history, and labs play a vital role, a lack of complete understanding about the pathophysiology of this disease as well as existing diagnostic criteria complicate the ability to make this diagnosis in the clinical setting.

The impact of brain tissue oxygenation monitoring on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended in patients with moderate to severe traumatic brain injury: A systematic review.

Traumatic brain injuries (TBIs) are one of the leading causes of death or long-term disability around the world. As a result of improvements in supportive care, patients are surviving more severe insults with more pronounced dependency on their families, hospitals, and long-term care facilities. The introduction of brain tissue oxygenation (PbtO2) monitoring aims to recognize episodes of reduced cerebral perfusion with and without associated increased intracranial pressure (ICP). The aim of this review is to determine the impact of PbtO2 on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended (GOS/GOSE) in patients with moderate to severe TBI. Systematic review with narrative and meta-analysis. All original research in which adult patients undergoing PbtO2 were compared with a control group of traditional ICP/cerebral perfusion pressure (CPP) monitoring. Both randomized controlled trials and observational studies were included in this review. Databases were searched in September 2022. The primary outcome of the review was the impact of PbtO2 monitoring on GOS/GOSE, while secondary outcomes were mortality and length of stay (LOS) in the intensive care unit (ICU). Seven studies with a combined number of 770 patients were included in the review. These patients were adults ≥16 years of age. Only two of the studies included found a statistically significant association between PbtO2 monitoring and improved long-term neurological outcomes in patients with TBI (p = .01, p < .01). A meta-analysis of the secondary outcomes identified an associated reduction of mortality in favour of the group treated with PbtO2 monitoring (p < .0001). Results from studies examining LOS in ICU have demonstrated an associated increase of LOS in ICU in patients treated with PbtO2-guided therapy. From the studies included in this review, only two found a statistically significant association between PbtO2 monitoring and long-term outcomes. It is unclear whether PbtO2 goal-directed therapy has a positive impact on the long-term neurological functions and mortality of patients suffering from TBI. A multicentre randomized controlled trial may provide further evidence, but not necessarily conclusive. Further research is warranted to determine the efficacy of the introduction of this new monitoring system to guide local policy change.

Heart Failure: Recent Advances and Breakthroughs

Heart failure (HF) is a common clinical condition encountered in various healthcare settings with a vast socioeconomic impact. Recent advancements in pharmacotherapy have led to the evolution of novel therapeutic agents with a decrease in hospitalization and mortality rates in HF with reduced left ventricular ejection fraction (HFrEF). Lately, the introduction of artificial intelligence (AI) to construct decision-making models for the early detection of HF has played a vital role in optimizing cardiovascular disease outcomes. In this review, we examine the newer therapies and evidence behind goal-directed medical therapy (GDMT) for managing HF. We also explore the application of AI and machine learning (ML) in HF, including early diagnosis and risk stratification for HFrEF.

Bone but not Bone: Systemic Calcinosis Presenting as Lumbar Facet Pseudohypertrophy with Neurogenic Claudication

Systemic sclerosis affects 14-21 per million persons annually and can present with calcinosis-deposition in the skin and subcutaneous tissues. In rare circumstances, paraspinal depositions are also seen, which can cause neural element compression requiring surgical intervention. Here we present the case of a 61-year-old woman with systemic sclerosis on goal-directed therapy who presented with neurogenic pseudoclaudication and imaging suggesting severe joint hypertrophy. The case illustrates that calcinosis in scleroderma can cause facet joint pseudohypertrophy that is difficult to distinguish from true hypertrophy on imaging. Such pseudohypertrophy is often refractory to medical therapy, necessitating surgical intervention. Last, owing to the fluid nature of the calcinotic fluid, decompression is often easier than would be expected based on preoperative imaging alone.

Mottling as a prognosis marker in cardiogenic shock

AimsImpact of skin mottling has been poorly studied in patients admitted for cardiogenic shock. This study aimed to address this issue and identify determinants of 30-day and 1-year mortality in a large cardiogenic shock cohort of all etiologies.Methods and resultsFRENSHOCK is a prospective multicenter observational registry conducted in French critical care units between April and October, 2016. Among the 772 enrolled patients (mean age 65.7 ± 14.9 years; 71.5% male), 660 had skin mottling assessed at admission (85.5%) with almost 39% of patients in cardiogenic shock presenting mottling. The need for invasive respiratory support was significantly higher in patients with mottling (50.2% vs. 30.1%, p < 0.001) and likewise for the need for renal replacement therapy (19.9% vs. 12.4%, p = 0.09). However, the need for mechanical circulatory support was similar in both groups. Patients with mottling at admission presented a higher length of stay (19 vs. 16 days, p = 0.033), a higher 30-day mortality rate (31% vs. 23.3%, p = 0.031), and also showed significantly higher mortality at 1-year (54% vs. 42%, p = 0.003). The subgroup of patients in whom mottling appeared during the first 24 h after admission had the worst prognosis at 30 days.ConclusionSkin mottling at admission in patients with cardiogenic shock was statistically associated with prolonged length of stay and poor outcomes. As a perfusion-targeted resuscitation parameter, mottling is a simple, clinical-based approach and may thus help to improve and guide immediate goal-directed therapy to improve cardiogenic shock patients’ outcomes.Graphical

Management of Sepsis and Septic Shock: What Have We Learned in the Last Two Decades?

Sepsis is a clinical syndrome encompassing physiologic and biological abnormalities caused by a dysregulated host response to infection. Sepsis progression into septic shock is associated with a dramatic increase in mortality, hence the importance of early identification and treatment. Over the last two decades, the definition of sepsis has evolved to improve early sepsis recognition and screening, standardize the terms used to describe sepsis and highlight its association with organ dysfunction and higher mortality. The early 2000s witnessed the birth of early goal-directed therapy (EGDT), which showed a dramatic reduction in mortality leading to its wide adoption, and the surviving sepsis campaign (SSC), which has been instrumental in developing and updating sepsis guidelines over the last 20 years. Outside of early fluid resuscitation and antibiotic therapy, sepsis management has transitioned to a less aggressive approach over the last few years, shying away from routine mixed venous oxygen saturation and central venous pressure monitoring and excessive fluids resuscitation, inotropes use, and red blood cell transfusions. Peripheral vasopressor use was deemed safe and is rising, and resuscitation with balanced crystalloids and a restrictive fluid strategy was explored. This review will address some of sepsis management's most important yet controversial components and summarize the available evidence from the last two decades.

Pulse Pressure Variance (PPV)-Guided Fluid Management in Adult Patients Undergoing Supratentorial Tumor Surgeries: A Randomized Controlled Trial.

Objective Appropriate fluid management in neurosurgery is critical due to the risk of secondary brain injury. Determination of volume status is challenging with static variables being unreliable. Goal-directed fluid therapy with dynamic variables allows reliable determination of fluid responsiveness and promises better outcomes. We aimed to compare the intraoperative fluid requirement between conventional central venous pressure (CVP)-guided and pulse pressure variance (PPV)-guided fluid management in supratentorial tumor surgeries. Materials and Methods This prospective, randomized, double-blind, single-center trial was conducted with 72 adults undergoing supratentorial tumor surgery in a supine position. Patients were divided into two groups of 36 patients each receiving CVP- and PPV-guided fluid therapy. The CVP-guided group received boluses to target CVP greater than 8 mm Hg along with hourly replacement of intraoperative losses and maintenance fluids. The PPV-guided group received boluses to target PPV less than 13% in addition to maintenance fluids. Total intraoperative fluids administered and the incidence of hypotension was recorded along with the brain relaxation score. Postoperatively, serum lactate levels, periorbital and conjunctival edema, as well as postoperative nausea and vomiting were assessed. Statistical Analyses All statistical analyses were performed with Statistical Package for Social Sciences, version-20 (SPSS-20, IBM, Chicago, Illinois, United States). To compare the means between the two groups (CVP vs. PPV), independent samples t -test was used for normal distribution data and Mann-Whitney U test for nonnormal distribution data. The chi-square test or Fischer's exact test was used for categorical variables. Results The CVP group received significantly more intraoperative fluids than the PPV group (4,340 ± 1,010 vs. 3,540 ± 740 mL, p < 0.01). Incidence of hypotension was lower in the PPV group (4 [11.1%] vs. 0 [0%], p = 0.04). Brain relaxation scores, serum lactate levels, periorbital and conjunctival edema, and incidence of postoperative nausea and vomiting were comparable between the groups. Conclusion The requirement for intraoperative fluids was less in PPV-guided fluid management with better hemodynamic stability, adequate brain conditions, and no compromise of perfusion.