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Aims We sought to evaluate the clinical impact of a 6 month transthoracic echocardiography (TTE) teaching programme in a critical care unit. Methods An observational single centre study. Four critical care doctors, 2 fellows and 2 consultants were trained to use TTE. The study was conducted over 2 six month study periods; period 1 before echocardiography training and period 2 following echocardiography training. Results An increased number of TTE examinations were performed following echocardiography training, 47 TTE studies during period 1 and 144 TTE studies during period 2. The commonest indications for TTE examination were assessment of ventricular function, wall motion abnormalities and cardiac tamponade. The percentage of TTE studies leading to a change in clinical management were similar during both periods, 30% period 1 and 34% period 2. During period 2 the majority of TTE’s leading to management change were performed by critical care doctors who frequently manipulated vasoactive medications and administered fluid therapy. Conclusions A 6 month echocardiography training programme led to an increase number of TTE studies independently performed by critical care doctors with resultant clinical impact in one third of cases., Competing Interests: The authors have no conflict of interest in relation to the subject matter in this manuscript.

Cardiac surgery has been evolving to include minimally invasive, hybrid and transcatheter techniques. Increasing patient age and medical complexity means that critical care management needs to adapt and evolve. Recent advances have occurred in several areas, including ventilation, haemodynamics and mechanical circulatory support, bleeding and coagulation, acute kidney injury, and neurological management. This narrative review describes standard care, recent advances, and future areas of research in the critical care management of patients undergoing cardiac surgery.

Cardiac tamponade should be considered in a critically ill patient in whom the cause of haemodynamic shock is unclear. When considering tamponade, transthoracic echocardiography plays an essential role and is the initial investigation of choice. Diagnostic sensitivity of transthoracic echocardiography is dependent on image quality, and in some cases a transoesophageal approach may be required to confirm the diagnosis. Knowledge of the pathophysiology and echocardiographic features of cardiac tamponade are essential for the practicing Intensivist. This review presents an approach to the recognition, diagnosis, and treatment of cardiac tamponade in critically ill patients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

As increasing demand for organs is a challenge for transplant services worldwide it is essential to audit the process of organ donation. To address this, a national audit of potential organ donors was undertaken across hospitals with Intensive Care Units (N = 36). Questionnaires were returned on all patients (n = 2073) who died in these units from 1/9/07-31/8/08; 200 (10%) of these patients were considered for Brain Stem Testing (BST), 158 patients (79%) were diagnosed Brain Stem Dead (BSD) and 138 patients (87%) became potential donors. Consent for donation was given by 92 (69%) next of kin and 90 potential donors (65%) became organ donors. There was no evidence of a large number of potential organ donors being missed. Recommendations included completion of BSTs on all appropriate patients, development of support on BST, referral of all BSD patients to the Organ Procurement Service; enhanced co-ordination within hospitals and sustained information/education campaigns.

Erectile dysfunction (ED) occurs in varying degrees in an estimated 20 to 30 million American men and is associated with adverse effects on quality of life; particularly personal well-being, family and social interrelationships. Research into ED has focused primarily on the physiologic mechanisms of corpus cavernosum smooth muscle relaxation, and penile erection as the end result of smooth muscle relaxation. These processes are mediated by cholinergic, nonadrenergic, noncholinergic (NANC, e.g., nitric oxide), vasoactive intestinal peptide (VIP), and potentially calcitonin gene-related peptide (CGRP) containing nerves. Release of nitric oxide following sexual stimulation from non-adrenergic, non cholinergic nerves and vascular endothelium activates guanylyl cyclase and induces intracellular cGMP synthesis. In turn, cGMP results in lowering intracellular concentrations, inhibits contractility of the penile smooth muscle, and induces an erectile response. Phosphodiesterase type 5 (PDE 5) is the predominant enzyme responsible for cGMP hydrolysis in trabecular smooth muscle. Activation of PDE 5 terminates NO-induced, cGMP-mediated smooth muscle relaxation, and subsequent penile flaccidity. Sildenafil citrate is a potent PDE type 5 reversible and selective inhibitor which blocks cGMP hydrolysis effectively. FDA approval of sildenafil citrate as the first oral agent for ED in males has resulted in significant interest. We discuss the clinical and pharmacologic properties of sildenafil citrate as well as the urologic and cardiac implications.

Objective: To review the current status of echocardiography in critically ill patients with special reference to the advantages and disadvantages of the transthoracic and transoesophageal approaches., Data Sources: A review of articles published in peer reviewed journals from 1976-1999 and identified through a MEDLINE search on echocardiography., Summary of Review: Echocardiography is a rapidly evolving field which is relatively new to intensivists. Both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) are extremely useful in managing critically ill patients. In intensive care practice echocardiograpy is used to evaluate clinical syndromes such as unexplained hypotension, search for source of sepsis or source of emboli, as well as haemodynamic assessment and monitoring. TOE although somewhat invasive, provides superb images which often assist in both diagnosis and improved treatment., Conclusions: Echocardiography often provides useful information in critically ill patients. Intensivists should familiarise themselves with this new technology and if possible become skilled practitioners of this exciting technique. The care of critically ill patients will benefit from its widespread use.

Objective: To review the current status of echocardiography in critically ill patients with special reference to the advantages and disadvantages of the transthoracic and transoesophageal approaches., Data Sources: A review of articles published in peer reviewed journals from 1976-1999 and identified through a MEDLINE search on echocardiography., Summary of Review: Echocardiography uses the reflection of high frequency sound waves at tissue boundaries to construct a two-dimensional image of cardiac structures. Two-dimensional echo-cardiography is the cornerstone of cardiac ultrasound, although Doppler techniques (pulsed wave, continuous wave, and colour flow) form an integral part of every modern echocardiographic study. The Doppler effect is based on changes in sound frequency that occur when a sound source moves towards or away from an observer. Blood flow velocities measured by Doppler can be used to estimate pressure, valve area and stroke volume. The standard imaging positions of the probe are either outside the thorax (i.e. transthoraracic echocardiography or TTE) or inside the oesophagus (i.e. transoesophageal echo-cardiography or TOE) both of which provide information that can be helpful in managing critically ill patients., Conclusions: Echocardiography is a rapidly developing technology. Cardiac structures can be imaged in 'real time'. Image quality continues to improve. The use of transoesophageal probe positioning has also widened the potential of this bedside technique in critically ill patients.

Objectives: The aim of this study was to assess the effect of angiotensin-converting enzyme (ACE) inhibition with enalapril on forearm endothelial function in subjects with type II diabetes mellitus., Background: Endothelial function is depressed in the presence of conventional risk factors for atherosclerosis, and various therapies, such as lipid-lowering therapy in hypercholesterolemia, can improve endothelial-mediated vasodilation. ACE inhibition has improved such function in several conditions including type I diabetes, but there is no evidence for a beneficial effect in type II diabetes., Methods: The influence of enalapril (10 mg twice daily for 4 weeks) on endothelium-dependent and -independent vasodilator function was determined in 10 type II diabetic subjects using a double-blinded placebo-controlled crossover protocol. Forearm blood flow was measured using strain-gage plethysmography and graded intrabrachial infusion of acetylcholine (ACh), N(G)-monomethyl-L-arginine (LNMMA) and sodium nitroprusside (SNP)., Results: Enalapril increased the response to the endothelium-dependent vasodilator, ACh (p < 0.02) and the vasoconstrictor response to the nitric oxide (NO) synthase inhibitor, LNMMA (p < 0.002). No difference was evident in the response to SNP., Conclusions: In type II diabetic subjects without evidence of vascular disease, the ACE inhibitor enalapril improved stimulated and basal NO-dependent endothelial function. The study extends the spectrum of beneficial effects demonstrated to result from ACE inhibition in diabetes.