Risk Of Circulatory Collapse Research Articles

Placement of bronchial occluder outside the tracheal tube in a patient combined with airway compression undergoing mediastinal tumors resection: a case report

BackgroundMediastinal tumors pose a challenging respiratory and circulatory management during anesthesia procedures, there is a risk of circulatory collapse or complete airway obstruction, which in severe cases can lead to cardiac arrest. We reported a case of anesthetic management using a bronchial blocker placed outside the tracheal tube. In this case report, the patient’s trachea was so severely compressed that the airway was extremely narrow, only 4 mm at its narrowest point. By reporting the anesthetic management of this patient, we intend to provide an unusual approach for airway management.Case presentationA 52-year-old male patient was admitted to the hospital due to cough and expectoration for one year. Additionally, the patient experienced chest tightness and asthma after physical activity. The enhanced computed tomography revealed there existed an irregular soft tissue mass in the right upper mediastinum, which significantly compressed the trachea and esophagus. The results of the mediastinal puncture pathology showed the presence of mesenchymal tumors. According to the results above, the patient was diagnosed with a mediastinal tumor and scheduled to undergo tumor resection under general anesthesia. We used a bronchial occluder outside the tracheal tube for general anesthesia. After surgery, the patient received thorough treatment and was subsequently discharged from the hospital.ConclusionIn patients with severe airway compression from a mediastinal tumor airway compression, positioning a bronchial occluder externally to the tracheal tube is an effective method of airway management. However, we still need more clinical practice to help the process become more standardized.

Catheter-directed therapies for high and intermediate-high risk patients with acute pulmonary embolism: Results from a multiparametric follow-up protocol

Introduction: Intermediate-high- and high-risk pulmonary embolism (PE) patients treated with anticoagulation alone are associated with a considerable risk of circulatory collapse, death, or long-term pulmonary hypertension. Pulmonary Embolism Response Teams (PERT) have been created to deliver PE patients a better care. Catheter-Directed Therapies (CDT), with mechanical thrombolysis and/or local fibrinolysis allow faster reperfusion and hemodynamic improvement without the systemic bleeding risk of systemic fibrinolysis. However, clinical evidence of its safety and benefits are lacking. Objectives: This analysis aims to describe the hemodynamics, morphological and perfusion improvement over time in intermediate-high- and high-risk acute PE patients submitted to CDT. Methods: Prospective registry of consecutive intermediate-high- and high-risk PE patients submitted to CDT (mechanical thrombolysis with Penumbra aspiration system and/or intrapulmonary local fibrinolysis with alteplase) in a single tertiary center. A multiparametric follow-up protocol was designed to evaluate echocardiographic, CT-scan, pulmonary angiogram, and right heart catheterization data at admission and at 3 months after CDT.

Catheter-directed therapies impact on intermediate-high- and high-risk pulmonary embolism patients

Abstract Introduction Intermediate-high- and high-risk pulmonary embolism (PE) patients treated with anticoagulation alone are associated with a considerable risk of circulatory collapse, death, or long-term pulmonary hypertension. Pulmonary Embolism Response Teams (PERT) have been created to deliver PE patients a better care. Catheter Directed Therapies (CDT), with mechanical thrombolysis and/or local fibrinolysis allow faster reperfusion and hemodynamic improvement without the systemic hemorrhagic effects of systemic fibrinolysis. The clinical evidence of its benefits is lacking. Objectives This analysis aims to describe the hemodynamics, morphological and perfusion improvement in intermediate-high- and high-risk acute PE patients submitted to CDT. Methods Prospective registry of consecutive intermediate-high- and high-risk PE patients submitted to CDT (mechanical thrombolysis with PenumbraÔ aspiration system and/or intrapulmonary local fibrinolysis with alteplase) in a single tertiary center. A multiparametric follow-up protocol was designed to evaluate echocardiographic, CT-scan, pulmonary angiogram, and right heart catheterization data at admission and at 3 months after CDT. The paired samples t-Test was used for the analysis of the variables. Results 26 PE patients (42.3% male, mean age 59 years old) were submitted to CDT (19% combined Penumbra and local fibrinolysis, 12% isolated Penumbra and 69% isolated local fibrinolysis). Baseline characteristics, laboratorial, imaging and procedure data are summarized in the figure 1. No major bleeding was seen during or after the procedure. 1 pulmonary artery dissection and 1 Penumbra burr partial avulsion occurred, both with conservative treatment with good result. 3 patients died during the follow-up (1 for oncologic disease, 1 for septic shock and 1 after discharge with undetermined cause). Of the remaining, 18 patients completed the 3-month follow-up protocol. At 3 months, a significant improvement was seen in the patients’ hemodynamics with 3.3mmHg mean drop of RA pressure (p 0.007), 16.1mmHg mean drop of systolic PA pressure (p <0.001), 8.0mmHg mean drop of mean PA pressure (p<0.001), 1.4L/min and 0.7L/min/m2 mean increases in cardiac output and index (p 0.003, p 0.001), and a tendency to a 0.8 Wood units decrease in the pulmonary vascular resistance (p 0.093). It was also seen an improvement in the perfusion defects with a mean drop of 7.9 points in the modified Miller index (p <0.001) and an improvement in the RV function with a mean decrease of 0.5 in the RV/LV ratio by CT-scan (p <0.001), a mean increase of 5.6mm in TAPSE (p <0.001) and a decrease of median NT-proBNP levels in 2866pg/ml (p <0.001). Conclusions In patients with intermediate-high- and high-risk PE, the use of CDT with mechanical thrombolysis and/or local fibrinolysis is safe and associated with improvement in hemodynamics, RV function and perfusion defects.Table 1.baseline characteristicsTable 2.results

Abstract #1408136: The Calm Before the Storm: Cardiogenic Shock in Graves’ Disease

This case highlights the endocrine and cardiopulmonary physiology of thyroid storm in a patient with comorbid rapid atrial fibrillation, severe heart failure with reduced ejection fraction and resultant cardiogenic shock in order to raise awareness regarding the risk of circulatory collapse, as well as the value of bedside ultrasound in management. A 42-year-old man presented to our hospital with 2 months of worsening dyspnea and lower extremity edema, 2 years of diarrhea and 50-pound weight loss followed by weight gain. He was hypertensive and in rapid atrial fibrillation (HR 180/min). A diltiazem drip was initiated, but he continued to be tachycardic (HR 120/min). Bedside point-of-care ultrasound (POCUS) was concerning for a severe cardiomyopathy. Chest x-ray demonstrated pulmonary edema. Labs demonstrated TSH < 0.01 mcIUnit/mL, free T4 2.9 mcg/dL (0.7-1.5 mcg/dL), and free T3 12.1 pg/mL (1.6-3.9 pg/mL). He met criteria highly suggestive of thyroid storm by the Burch-Wartofsky Point Scale, scoring 70 points, so management became focused on this. The diltiazem drip was discontinued in favor of an intravenous metoprolol challenge. Soon thereafter, his heart rate decreased to 80 bpm with low-normal mean arterial pressures. He developed acute hypoxemic respiratory failure with cool, cyanotic extremities. He was placed on non-invasive positive pressure ventilation with norepinephrine and dobutamine for treatment of cardiogenic shock secondary to thyroid storm. Hydrocortisone and propylthiouracil were administered. Echocardiogram showed severe left ventricular global hypokinesis with ejection fraction of 15%. As vasopressors were weaned, he underwent cautious diuresis. A short course of propranolol was started, which was subsequently switched to metoprolol tartrate. Thyrotropin receptor and thyroperoxidase antibodies were elevated. Thyroid ultrasound suggested autoimmune thyroiditis. He was transitioned to methimazole and discharged home. Thyroid storm patients are at risk of circulatory collapse after treatment with rate-control agents, especially in the presence of systolic dysfunction. In one study, underlying hyperthyroidism was unknown in 32% of patients admitted to the ICU for thyroid storm, and ICU mortality rates were 17%. Thyroid hormone sensitizes the myocardium to adrenergic input by upregulating adrenergic receptors, resulting in baseline tachycardia to maintain cardiac output and subsequent high-output heart failure.

Total pericardiectomy for uremic pericarditis.

AbstractBetween 1973 and 1975, 19 patients were treated for uremic pericarditis. The clinical presentation of the condition varied, with some patients having minimal symptoms (chest pain, fever) and others sustaining circulatory collapse. Pericardial friction rub, elevated central venous pressure, and paradoxical pulse were the most common physical findings. Serial chest radiography, echocardiography, and cardiac scan were most useful in establishing the diagnosis. Three patients had cardiac catheterization and angiography. Pericardiectomy was the initial procedure performed in 13 of 19 patients, and there was no operative mortality or recurrence of pericarditis. Four patients initially had a pericardial window created rather than a pericardiectomy. Two had recurrence of symptoms and one required later total pericardiectomy. Two patients underwent initial tube pericardiostomy. Both died after recurrent tamponade. Total pericardiectomy appears to be the treatment of choice for uremic pericarditis and the only form of therapy which is definitive. The risk of circulatory collapse from tamponade warrants early operative intervention in this critically ill group of patients.