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Previous studies suggested that ongoing treatment with renin-angiotensin-aldosterone system (RAAS) inhibitor drugs may alter the course of SARS-CoV-2 infection and promote the development of more severe forms of the disease. The authors conducted a comparative, observational study to retrospectively analyze data collected from 394 patients admitted to ICU due to SARS-CoV-2 pneumonia. The primary aim of the study was to establish an association between the use of RAAS inhibitor drugs and mortality in the ICU. The secondary aims of the study were to establish an association between the use of RAAS inhibitor drugs and clinical severity at ICU admission, the need for tracheal intubation, total days of mechanical ventilation, and the ICU length of stay. The authors found no statistically significant difference in ICU mortality between patients on RAAS inhibitor drugs at admission and those who were not (31.3% versus 26.2% mortality, p-value 0.3). However, the group of patients taking RAAS inhibitor drugs appeared to be more critical at ICU admission, and this difference became statistically significant in the subgroup of non-hypertensive patients. ICU mortality in the subgroup of non-hypertensive patients treated with RAAS inhibitor drugs also tended to be higher. Overexpression of the angiotensin-converting enzyme 2 (ACE2) in human cells, induced by RAAS inhibitor drugs, promotes viral entry-replication of SARS-CoV-2 and alters the basal balance of the RAAS, which may explain the findings observed in the present study. These phenomena may be amplified in non-hypertensive patients treated with RAAS inhibitor therapy.

Objective The present study investigates whether ScvO2 variations induced by passive leg raising (PLR) are able to predict fluid responsiveness (FR) in mechanically ventilated patients. Design A monocentric prospective clinical study. Setting An intensive care division in a tertiary hospital. Patients The inclusion criteria were elective postoperative cardiac surgery patients who were over 18 years old, deeply sedated, mechanically ventilated and needed volume expansion (VE). Fluid responders (R) were defined as patients who increased their left ventricular outflow tract velocity time integral (VTI) ≥15% after VE. Intervention In patients included in this study, continuous ScvO2 monitoring (CeVOX device, Pulsion Medical Systems) and VTI (transthoracic echocardiography) were measured simultaneously before and during a PLR test and before and after VE (with 500 ml of saline). Measurements and main results Thirty‐three consecutive patients were included in this study. In 15 patients with a positive PLR test (increase in VTI ≥15%), ScvO2 increased during PLR by 9 ± 4%. In the 18 patients with a negative PLR test, ScvO2 did not significantly change during PLR. VE increased ScvO2 by 9 ± 6% and 2 ± 4% in responders and nonresponders, respectively. If ScvO2 increased by >4% during the PLR test, then a positive VTI response (≥15%) was diagnosed with a sensitivity of 93% (68–99%) and a specificity of 94% (63–99%) (Area under the receiver operating characteristic curve 0.92 ± 0.58, p, ScvO2 variation induced by PLR is a reliable, minimally invasive parameter for predicting FR at the bedside of deeply sedated, mechanically ventilated, critically ill patients undergoing cardiac surgery.

Introduction Current knowledge on the use of extracorporeal membrane oxygenation (ECMO) in COVID‐19 remains limited to small series and registry data. In the present retrospective monocentric study, we report on our experience, our basic principles, and our results in establishing and managing ECMO in critically ill COVID‐19 patients. Methods A cohort study was conducted in patients with severe acute respiratory distress syndrome (ARDS) related to COVID‐19 pneumonia admitted to the ICU of the Geneva University Hospitals and supported by VV‐ECMO from March 14 to May 31. The VV‐ECMO implementation criteria were defined according to an institutional algorithm validated by the local crisis unit and the Swiss Society of Intensive Care Medicine. Results Out of 137 ARDS patients admitted to our ICU, 10 patients (age 57 ± 4 years, BMI 31.5 ± 5 kg/m2, and SAPS II score 56 ± 3) were put on VV‐ECMO. The mean duration of mechanical ventilation before ECMO and mean time under ECMO were 7 ± 3 days and 19 ± 11 days, respectively. The ICU and hospital length of stay were 26 ± 11 and 35 ± 10 days, respectively. The survival rate for patients on ECMO was 40%. The comparative analysis between survivors and non‐survivors highlighted that survivors had a significantly shorter mechanical ventilation duration before ECMO (4 ± 2 days vs. 9 ± 2 days, p = 0.01). All the patients who had more than 150 h of mechanical ventilation before the application of ECMO ultimately died. Conclusion The present results suggest that VV‐ECMO can be safely utilized in appropriately selected COVID‐19 patients with refractory hypoxemia. The main information for clinicians is that late VV‐ECMO therapy (i.e., beyond the seventh day of mechanical ventilation) seems futile., Time‐course of COVID‐19 pneumoniafrom the onset of symptoms to the decision to implement VV‐ECMO according to the results of this study. HFNO, high‐flow nasal oxygen; CPAP, continuous positive airway pressure

Type A lactic acidosis is a potentially life‐threatening complication in critically ill patients and is the hallmark of a shock state as a result of tissue hypoperfusion and dysoxia. Type B lactic acidosis results from mechanisms other than dysoxia and is a rare condition in patients with solid tumors or hematological malignancies. We present a case of a 60‐year‐old man with lactic acidosis who was found to have a Burkitt lymphoma related to a posttransplant lymphoproliferative disorder. Lactagenic cancers are characterized by increased aerobic glycolysis and excessive lactate formation, a phenomenon described by Warburg in 1923 that is correlated with cancer aggressiveness and poor survival. There is increased glucose utilization with the purpose of lactagenesis under fully oxygenated conditions, as lactate seems to be a potent signaling molecule for angiogenesis, immune escape, cell migration, metastasis and self‐sufficient metabolism, which are five essential steps of carcinogenesis. Type B lactic acidosis in association with malignancies carries an extremely poor prognosis. Currently, effective chemotherapy seems to be the only hope for survival., Lactagenic cancers are characterized by increased aerobic glycolysis and excessive lactate formation, a phenomenon described by Warburg in 1923 that is correlated with cancer aggressiveness and poor survival. Type B lactic acidosis in association with malignancies carries an extremely poor prognosis. Currently, effective chemotherapy seems to be the only hope for survival.

Stress hyperglycemia is a transient increase in blood glucose during acute physiological stress in the absence of glucose homeostasis dysfunction. Its's presence has been described in critically ill patients who are subject to many physiological insults. In this regard, hyperglycemia and impaired glucose tolerance are also frequent in patients who are admitted to the intensive care unit for heart failure and cardiogenic shock. The hyperglycemia observed at the beginning of these cardiac disorders appears to be related to a variety of stress mechanisms. The release of major stress and steroid hormones, catecholamine overload, and glucagon all participate in generating a state of insulin resistance with increased hepatic glucose output and glycogen breakdown. In fact, the observed pathophysiological response, which appears to regulate a stress situation, is harmful because it induces mitochondrial impairment, oxidative stress‐related injury to cells, endothelial damage, and dysfunction of several cellular channels. Paradigms are now being challenged by growing evidence of a phenomenon called glucotoxicity, providing an explanation for the benefits of lowering glucose levels with insulin therapy in these patients. In the present review, the authors present the data published on cardiac glucotoxicity and discuss the benefits of lowering plasma glucose to improve heart function and to positively affect the course of critical illness., A review of the pathophysiological and clinical evidence surrounding the impact of stress hyperglycemia and cardiac glucotoxicity on cardiac physiology.

Extracorporeal carbon dioxide removal (ECCO2R) is a low blood flow veno-venous extracorporeal membrane oxygenation technique that provides artificial blood CO2removal. Recently, a new ECCO2R system (PrismaLung), providing very low blood flow has been commercialized. The aim of this study is to report its use in severe chronic obstructive pulmonary disease (COPD) patients needing an ECCO2R therapy. Six severe COPD patients with acute exacerbation leading to refractory hypercapnic respiratory acidosis were treated with ECCO2R therapy. Two different systems were used: a PrismaLung system and a conventional ECCO2R device. The maximum blood flow provided by PrismaLung was significantly lower than that with the conventional ECCO2R system. In three patients initially treated with PrismaLung, there were no improvements in pH, PaCO2, or RR. Thus, the therapy was switched to a conventional ECCO2R system in these three patients, and three others were treated from the outset by the conventional ECCO2R system, providing significant improvement in pH, PaCO2, and RR. The present retrospective study describes the first use of PrismaLung in severe COPD patients with acute exacerbation. When compared with a higher blood flow ECCO2R system, our results show that this novel, very low-flow device is not able to remove sufficient CO2, normalize pH or decrease respiratory rate.

Understanding the respiratory mechanics of ARDS patients is crucial to avoid ventilator-induced lung injury (VILI), and this is much more challenging if not only lung compliance is altered but the whole compliance of the respiratory system is abnormal, as in obese patients. We face this problem daily in the ICU, and to optimize ventilation, we estimate respiratory mechanics using an oesophageal balloon. The balloon position is crucial to assess reliable values. In the present technical note, we describe the use of echocardiography to confirm the correct position of this instrument.

Background Intensive Care Unit (ICU) patients are known to lose muscle mass and function during ICU stay. Ultrasonography (US) application for the assessment of the skeletal muscle is a promising tool and might help detecting muscle changes and thus several dysfunctions during early stages of ICU stay. MUSiShock is a research project aiming to investigate structure and function of diaphragm and peripheral muscles using ultrasound techniques in septic shock patients, and to assess their relevance in several clinical outcomes such as the weaning process. Methods and design This is a research protocol from an observational prospective cohort study. We plan to assess eighty-four septic shock patients during their ICU stay at the following time-points: at 24 hours of ICU admission, then daily until day 5, then weekly, at extubation time and at ICU discharge. At each time-point, we will measure the quadriceps rectus femoris and diaphragm muscles, using innovative US muscle markers such as Shear-Wave Elastography (SWE). In parallel, the Medical Research Council (MRC) sum score for muscle testing and the Airway occlusion pressure (P0.1) will also be collected. We will describe the association between SWE assessment and other US markers for each muscle. The association between the changes in both diaphragm and rectus femoris US markers over time will be explored as well; finally, the analysis of a combined model of one diaphragm US marker and one limb muscle US marker to predict weaning success/failure will be tested. Discussion By using muscle ultrasound at both diaphragm and limb levels, MUSiShock aims to improve knowledge in the early detection of muscle dysfunction and weakness, and their relationship with muscle strength and MV weaning, in critically ill patients. A better anticipation of these short-term muscle structure and function outcomes may allow clinicians to rapidly implement measures to counteract it. Trial registration ClinicalTrials.gov, NCT04550143. Registered on 16 September 2020.

New generation devices for long-term mechanical circulatory support are centrifugal pumps having fully magnetically levitated rotors to reduce blood trauma. Recently, the novel HeartMate 3 was cleared for clinical application in Switzerland. In two Swiss University Hospitals part of the "Lausanne-Geneva Transplantation Network," 10 consecutive patients in end-stage heart failure received the HeartMate 3 (Thoratec Corporation, Pleasanton, CA). Device implantation criteria were persistent low output syndrome despite optimal medical treatment. The primary end-point of the study was survival or transplantation to 90 days on the device. Five patients (50%) were in Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) class 1 and 2 (two were under venoarterial extracorporeal membrane oxygenation [VA-ECMO]), and five were in class 3 and 4. The indication was bridge-to-transplant in seven patients, and destination therapy in three. Two patients (20%) received concomitant aortic valve surgery. Four patients (40%) required temporary right ventricle support (tRVAD) for a mean of 8 ± 1.5 days. Bleeding requiring surgical revision occurred in five (50%) patients, two during the tRVAD support. At the 90 day end-point, survival was 90%, one (10%) died due to respiratory failure. Three (30%) experienced critical illness polyneuropathy. Two had body temperature over 38.5°C for more than 7 days after implant, without infections. Two (20%) had late driveline infection. The pump allowed rapid improvement of patients' clinical conditions even in severely compromised patients. Postoperative bleeding occurred in the setting of anticoagulation. No hemolysis or pump thrombosis occurred. Fever occurred frequently but was not associated with mortality. Hemodynamic support was consistent over time without significant adverse events.

Even if the HeartMate 3

Measuring cardiac output (CO) is an integral part of the diagnostic and therapeutic strategy in critically ill patients. During the last decade, the single transpulmonary thermodilution (TPTD) technique was implemented in clinical practice. The purpose of this paper was to systematically review and critically assess the existing data concerning the reproducibility of CO measured using TPTD (COTPTD). A total of 16 studies were identified to potentially be included in our study because these studies had the required information that allowed for calculating the reproducibility of COTPTD measurements. 14 adult studies and 2 pediatric studies were analyzed. In total, 3432 averaged CO values in the adult population and 78 averaged CO values in the pediatric population were analyzed. The overall reproducibility of COTPTD measurements was 6.1 ± 2.0 % in the adult studies and 3.9 ± 2.9 % in the pediatric studies. An average of 3 boluses was necessary for obtaining a mean CO value. Achieving more than 3 boluses did not improve reproducibility; however, achieving less than 3 boluses significantly affects the reproducibility of this technique. The present results emphasize that TPTD is a highly reproducible technique for monitoring CO in critically ill patients, especially in the pediatric population. Our findings suggest that obtaining a mean of 3 measurements for determining CO values is recommended.

In the ICU, the main challenges with obese patients are to take into account the pulmonary pathophysiological characteristics when choosing the best management options.

The present pilot study investigated whether respiratory variation in subclavian vein (SCV) diameters correlates with fluid responsiveness in mechanically ventilated patients. Monocentric, prospective clinical study on fluid responsiveness in adult sedated, mechanically ventilated ICU patient, monitored with the PiCCO™ system (Pulsion Medical System, Germany), and requiring a fluid challenge (FC). A 10-min fluid bolus of 500 mL of 0.9% saline was administered. Cardiac output (CO) and dynamic parameters [stroke volume variation (SVV) and pulse pressure variation (PPV)] measured by transpulmonary thermodilution and pulse contour analysis (PiCCO™) as well as classical hemodynamic parameters were recorded at baseline and after FC. Fluid responsiveness was described as an increase in CO of ≥ 15%. Ultrasound measurements obtained in the subclavian long-axis view were used to calculate the SCVvariability index. A cut-off value for SCV variation for the prediction of fluid responsiveness was determined using receiver operating curve (ROC) analysis. Nine of 20 FCs (45%) induced an increase in CO of ≥ 15%. At baseline, the SCVvariability index was greater in responders than in non-responders (34.0 ± 21.4 vs. 9.0 ± 5.5; p = 0.0005). Diagnostic performance for the SCVvariability index revealed a cut-off value of 14 with a sensitivity of 100% [Confidence interval (CI) 95% (90; 100)] and a specificity of 82% [CI 95% (48; 98)] for the prediction of fluid responsiveness. Other parameters, such as SVV and PPV, could not predict fluid responsiveness. The correlation coefficient between CO variation and the SCVvariability index was 0.73 (p

Survival after cardiac arrest depends on prompt and effective cardiopulmonary resuscitation (CPR). Resuscitative teams are more frequently using mechanical chest compression devices, as documented in physiologic and experimental data, suggesting that these devices are more effective than manual CPR. A 41-year-old male patient presented with an ST-elevation myocardial infarction with cardiac arrest. The patient was immediately resuscitated by manual chest compressions; CPR was continued with a mechanical chest compression device (LUCAS 2). The patient had experienced a 15-minute period of "low-flow" without "no-flow" episode. After a discussion with the heart team, we decided that the patient was a candidate for extracorporeal membrane oxygenation (ECMO) therapy. During the ECMO implantation, we noticed that while performing transesophageal echocardiography, chest compressions were ineffective with the machine. After the ECMO implantation, we observed myocardial damage in the right-sided heart cavities. The present case report illustrates the likelihood that the mechanical chest compression device has limitations that might contribute to inadequate CPR. Therefore, rescuers should consider the efficacy of their chest compression through a continuous hemodynamic monitoring during CPR.

The ever-increasing use of immune checkpoint inhibitors in cancer is leading to a high incidence of autoimmune side effects. This report discusses an autoimmune fulminant myocarditis in an elderly patient with metastatic pulmonary adenocarcinoma in whom the most advanced invasive heart failure therapies were used successfully. She was treated with nivolumab. This case illustrates a severe cardiovascular complication of immunotherapy and highlights to cardiologists the importance of aggressive treatments in patients with metastatic cancers whose prognosis has improved dramatically.

Extracorporeal life support (ECLS) is increasingly used worldwide in patients with life-threatening hemodynamic or respiratory conditions. The femoral venoarterial cannulation, whether percutaneous or surgical, is the simplest and quickest method; however, a number of vascular complications may occur. We present two cases in which, despite a well-placed reperfusion cannula in the superior femoral artery, apparent limb ischemia of the cannulated limb developed rapidly after ECLS implantation and was suspected to be caused by arterial vasospasm. Both cases were successfully managed with the injection of a vasodilator cocktail of verapamil, nitroglycerin, and lidocaine directly in the reperfusion cannula.

Background Parameters allowing for outcome discrimination of extracorporeal membrane oxygenation (ECMO) therapy in acute coronary syndromes (ACS) complicated by refractory cardiogenic shock (CS) and/or cardio-respiratory arrest (CA) remain elusive. We aimed at evaluating the potential prognostic roles of blood and procedural parameters associated with 30-day mortality following ECMO. Methods and results A group of 29 patients with ACS complicated by CS and/or CA, who underwent ECMO at a single center, was retrospectively analyzed. Eighteen patients (62%) died at 30-day follow up. "Survivors" and "non-survivors" had similar demographics, clinical and biochemical characteristics at admission, except for blood lactate peak in the first 24h that was increased in non-survivors. Procedural characteristics of percutaneous coronary intervention (PCI) and ECMO were comparable in either group. The peak of blood lactate concentration predicted 30-day mortality independently of age, sex and ECMO duration. The cutoff value, determined by receiver operating characteristic (ROC) curve analysis, was found at 11mmol/l. Conclusions The peak of serum lactate under ECMO in the first 24h predicted 30-day mortality in patients with ACS complicated with CS and CA.

We sought to compare the inferior vena cava diameter measured by transthoracic echocardiography and by transesophageal echocardiography in human and animals. Transthoracic echocardiography yielded lower inferior vena cava diameter values than transesophageal echocardiography. Adult and pediatric intensivists should pay attention to the risk of false measurement of the inferior vena cava anterior-posterior diameter that may be due to compression of the inferior vena cava by the sonographic probe when the subxiphoid view is used.

Purpose: Monitoring using transpulmonary thermodilution (TPTD) via a single thermal indicator technique allows measurement of cardiac output, extravascular lung water (EVLW) and volumetric vari- ables. Methods and results: This report describes two cases of sys- temic-venous circulation shunt generating early recirculation of thermal indicator with overestimation of EVLW. Conclusion: In the case of recirculation of thermal indicator, the observed overestimated EVLW in absence of gas exchanges abnormal- ity could be an indicator suggesting the search for a circulatory shunt.

The authors describe clinical cases of two patients admitted to intensive care unit following severe Plasmodium falciparum malaria. Patients' sublingual microcirculation was monitored by on-line Sidestream dark-field imaging before and after treatment with erythrocytapheresis. Before treatment, microcirculatory flow alterations were obvious. Therapy produced a rapid decrease in infected red blood cells with a significant improvement in microcirculatory flows, capillary perfusion and patients' outcome. The present cases emphasize the relevance of microcirculation monitoring in patients with capillary perfusion alterations resulting from severe malaria. As far as we know, this is the first observations of an improvement of capillary perfusion after erythrocytapheresis.

Massive acute pulmonary embolism (MAPE) represents a significant risk for morbidity and mortality. The potential for sudden and fatal deterioration highlights the need for a prompt diagnosis and appropriate intervention. Using two cases reports, we describe two different modes of successful ECMO implantation (VA-ECMO vs. VV-ECMO) for MAPE leading to cardiac arrest. A 27-year-old patient with a severe trauma presented with a MAPE leading to cardiac arrest. In this case, which had absolute contraindications of thrombolysis, a VA-ECMO was successfully implanted. Additionally, a 56-year-old patient presented with a MAPE leading to cardiac arrest. Although intravenous thrombolysis allowed for hemodynamic stabilization, the patient remained severely hypoxemic with RV dilation. A VV-ECMO was successfully implemented, leading to a rapid improvement in both oxygenation and RV function. ECMO can provide lifesaving hemodynamic and respiratory support in critically ill patients with a MAPE who are too unstable to tolerate other interventions or have failed other therapies. An important determinant of success in the use of ECMO for MAPE is the return of adequate RV function, which allows physicians to appropriately identify which type of ECMO to implant.

Background Although heart transplantation is a successful therapy for patients suffering from end-stage heart failure, the therapeutic is limited by the lack of organs. Donor cardiac arrest is a classic hindrance to heart retrieval as it raises issues on post-transplant outcomes. Case presentation The present case reports a successful heart transplantation after prolonged donor cardiac arrest (total lowflow time of 95 minutes) due to anaphylactic shock necessitating extracorporeal life support. We further provide an overview of the current evidence and outcomes of heart transplantation in cases of donor cardiac arrest. Conclusion Providing that donor and recipient criteria are respected, donor cardiac arrest does not seem to be an adverse predictor in heart transplantation. Electronic supplementary material The online version of this article (doi:10.1186/s13019-015-0393-8) contains supplementary material, which is available to authorized users.

Rationale: Drug-induced valvular heart disease (DI-VHD) remains an under-recognized entity. Patient concerns: This report describes a heart valve replacement which was complicated by intractable systemic pulmonary arterial hypertension in a 61-year-old female with severe restrictive mitral and aortic disease. The diagnosis of valvular disease was preceded by a history of unexplained respiratory distress. The patient had been exposed to benfluorex for 6.5 years. Diagnoses: The diagnostic procedure documented specific drug-induced valvular fibrosis. Interventions: Surgical mitral and aortic valve replacement was performed. Outcomes: Heart valve replacement was postoperatively complicated by unanticipated disproportionate pulmonary hypertension. This issue was fatal despite intensive care including prolonged extracorporeal life support. Lessons: Benfluorex is a fenfluramine derivative which has been marketed between 1976 and 2009. Although norfenfluramine is the common active and toxic metabolite of all fenfluramine derivatives, the valvular and pulmonary arterial toxicity of benfluorex was much less known than that of fenfluramine and dexfenfluramine. The vast majority of benfluorex-induced valvular heart disease remains misdiagnosed as hypothetical rheumatic fever due to similarities between both etiologies. Better recognition of DI-VHD is likely to improve patient outcome.

A study by Maizel and colleagues [1] in a recent issue of Critical Care shows that a resident skilled at inserting a central venous catheter (CVC) via the ultrasound-guided (UG) technique may face difficulties inserting a CVC via the anatomical landmark (LM) technique. Because several studies have demonstrated significantly increased safety, effectiveness, and efficiency of UG vascular access, as compared with cannulation by anatomical LMs, the UG technique became the more broadly recommended procedure [2-4]. However, as residents are trained only in this technique, they are no longer able to perform the LM technique, even when ultrasound is not available or applicable. In fact, we recently had a patient with extensive subcutaneous emphysema requiring veno-venous extracorporeal membrane oxygenation. Percutaneous cannula implantation, usually performed under ultrasound guidance, has been inserted using the LM technique. Because of emphysema, no visualization of veins was possible (Figure 1). Figure 1 Ultrasound images of the neck for the internal jugular vein location during vascular access puncture (A) with and (B) without subcutaneous emphysema. An impossible ultrasound guidance (A) and a possible ultrasound guidance (B) are shown. Despite international recommendations, it seems to be essential to avoid the UG one-way dogmatic approach and continue to train our young colleagues to insert the CVC via a conventional technique because in certain situations in which ultrasound guidance cannot be used, cannulation remains vital for the patient. Thus, if the clinical situation is favorable (anatomy and coagulation are normal, and the patient is not overweight), young doctors could make a puncture test according to the LM technique. The UG technique would be automatically performed in case of failure of the first and single puncture. In this way, the LM technique will continue to be taught so that all doctors can insert catheters in situations when ultrasound is not usable.

Background. The aim of this survey was to describe, in a situation of growing availability of monitoring devices and parameters, the practices in haemodynamic monitoring at the bedside.Methods. We conducted a Web-based survey in Swiss adult ICUs (2009-2010). The questionnaire explored the kind of monitoring used and how the fluid management was addressed.Results. Our survey included 71% of Swiss ICUs. Echocardiography (95%), pulmonary artery catheter (PAC: 85%), and transpulmonary thermodilution (TPTD) (82%) were the most commonly used. TPTD and PAC were frequently both available, although TPTD was the preferred technique. Echocardiography was widely available (95%) but seems to be rarely performed by intensivists themselves. Guidelines for the management of fluid infusion were available in 45% of ICUs. For the prediction of fluid responsiveness, intensivists rely preferentially on dynamic indices or echocardiographic parameters, but static parameters, such as central venous pressure or pulmonary artery occlusion pressure, were still used.Conclusions. In most Swiss ICUs, multiple haemodynamic monitoring devices are available, although TPTD is most commonly used. Despite the usefulness of echocardiography and its large availability, it is not widely performed by Swiss intensivists themselves. Regarding fluid management, several parameters are used without a clear consensus for the optimal method.

Various pacemakers can now track diverse hemodynamic parameters that are useful in the management of patients with heart failure. Among these indicators, pulmonary fluid status can be monitored. To the best of our knowledge, this is the first case describing an agreement between a simultaneous detection of an increase in lung water by transthoracic impedance monitoring (OptiVolTM (Medtronic, Inc., Minneapolis, MN), and the transpulmonary thermodilution method (PiCCOTM, Pulsion Medical Systems, Munich, Germany) in a patient with acute pulmonary oedema. The present case suggests that transthoracic impedance monitoring could be a useful tool to guide therapy in critically ill patients with implanted devices and lung fluid congestion

Mild therapeutic hypothermia is now recognized as standard therapy in patients resuscitated from out-of-hospital cardiac arrest (OHCA), and is recommended in comatose patients suffering from cardiac arrest related to ventricular fibrillation (VF) [1]. In these patients, maintaining an adequate tissue oxygen delivery (DO2) is crucial. However, during hypothermia, clinical signs of hypoperfusion such as cold, clammy skin and delayed capillary refill are not reliable and monitoring devices must, therefore, be used to measure or estimate the cardiac index (CI). However, there are no recommendations regarding the target value of CI in the hypothermic patient. In this article, the authors attempt to provide clinicians with some rationale to guide their therapy for the management of CI in patients treated with mild therapeutic hypothermia.

Critical care 16(3), R98 (2012). doi:10.1186/cc11366, Published by BioMed Central Ltd, London

Introduction We wanted to determine the number of cold bolus injections that are necessary for achieving an acceptable level of precision for measuring cardiac index (CI), indexed global end-diastolic volume (GEDVi) and indexed extravascular lung water (EVLWi) by transpulmonary thermodilution. Methods We included 91 hemodynamically stable patients (age 59 (25% to 75% interquartile range: 39 to 79) years, simplified acute physiologic score (SAPS)II 59 (53 to 65), 56% under norepinephrine) who were monitored by a PiCCO2 device. We performed five successive cold saline (15 mL, 6°C) injections and recorded the measurements of CI, GEDVi and EVLWi. Results Considering five boluses, the coefficient of variation (CV, calculated as standard deviation divided by the mean of the five measurements) was 7 (5 to 11)%, 7 (5 to 12)% and 7 (6 to 12)% for CI, GEDVi and EVLWi, respectively. If the results of two bolus injections were averaged, the precision (2 × CV/√ number of boluses) was 10 (7 to 15)%, 10 (7 to 17)% and 8 (7 to 14)% for CI, GEDVi and EVLWi, respectively. If the results of three bolus injections were averaged, the precision dropped below 10%, that is, the cut-off that is generally considered as acceptable (8 (6 to 12)%, 8 (6 to 14)% and 8 (7 to 14)% for CI, GEDVi and EVLWi, respectively). If two injections were performed, the least significant change, that is, the minimal change in value that could be trusted to be significant, was 14 (10 to 21)%, 14 (10 to 24)% and 14 (11 to 23)% for CI, GEDVi and EVLWi, respectively. If three injections were performed, the least significant change was 12 (8 to 17)%, 12 (8 to 19)% and 12 (9 to 19)% for CI, GEDVi and EVLWi, respectively, that is, below the 15% cut-off that is usually considered as clinically relevant. Conclusions These results support the injection of at least three cold boluses for obtaining an acceptable precision when transpulmonary thermodilution is used for measuring CI, GEDVi and EVLWi.

Introduction Hemodynamic resuscitation should be aimed at achieving not only adequate cardiac output but also sufficient mean arterial pressure (MAP) to guarantee adequate tissue perfusion pressure. Since the arterial pressure response to volume expansion (VE) depends on arterial tone, knowing whether a patient is preload-dependent provides only a partial solution to the problem. The objective of this study was to assess the ability of a functional evaluation of arterial tone by dynamic arterial elastance (Eadyn), defined as the pulse pressure variation (PPV) to stroke volume variation (SVV) ratio, to predict the hemodynamic response in MAP to fluid administration in hypotensive, preload-dependent patients with acute circulatory failure. Methods We performed a prospective clinical study in an adult medical/surgical intensive care unit in a tertiary care teaching hospital, including 25 patients with controlled mechanical ventilation who were monitored with the Vigileo® monitor, for whom the decision to give fluids was made because of the presence of acute circulatory failure, including arterial hypotension (MAP ≤65 mmHg or systolic arterial pressure 0.89 predicted a MAP increase after fluid administration with a sensitivity of 93.75% (95% CI, 69.8%-99.8%) and a specificity of 100% (95% CI, 66.4%-100%). Conclusions Functional assessment of arterial tone by Eadyn, measured as the PVV to SVV ratio, predicted arterial pressure response after volume loading in hypotensive, preload-dependent patients under controlled mechanical ventilation.

Definition of the hemodynamic response to volume expansion (VE) could be useful in shocked critically ill patients in absence of cardiac index (CI) measurements. The aim of this study is to evaluate whether central venous oxygen saturation variations (ΔScvO(2)) after VE could be an alternative to classify responders (R) and nonresponders (NR) to volume therapy.A total of 30 patients requiring VE were included in this prospective cohort study, all equipped with radial arterial line and pulmonary artery catheters. CI, mixed venous oxygen saturation (SvO(2)) and ScvO(2) were measured before and after VE. CI, SvO(2), and ScvO(2) changes after volume were analyzed using linear regression. Receiver operating characteristics curve analysis was used to test their ability to distinguish R and NR.ΔScvO(2) and SvO(2) variations after VE (ΔSvO(2)) were significantly correlated with CI changes (ΔCI) after VE (r = 0.67 and r = 0.49, p0.001, respectively). A ΔScvO(2) threshold value of 4% allowed the definition of R and NR patients with 86% sensitivity (95%CI; 57-98%) and 81% specificity (95%CI; 54-96%).ScvO2 variations after VE was able to categorize VE efficiently and could be suggested as an alternative marker to define fluid responsiveness in absence of invasive CI measurement.

Microcirculation represents a complex system devoted to provide optimal tissue substrates and oxygen. Therefore, pathophysiological and technological knowledge developments tailored for capillary circulation analysis should generate major advances for critically ill patients' management. In the future, microcirculatory monitoring in several critical care situations will allow recognition of macro-microcirculatory decoupling, and, hopefully, it will promote the use of treatments aimed at preserving tissue oxygenation and substrate delivery.

The number of women with complex cyanotic heart disease reaching childbearing age is continuously increasing. For anesthesiologists, management of this ‘new’ obstetric population is particularly challenging. We report the case of a parturient with a palliated double-outlet right ventricle, who underwent a cesarean section at 34 weeks with low-dose sequential combined spinal-epidural anesthesia with patient-controlled epidural postoperative analgesia. Anesthetic considerations and specific limitations of invasive monitoring are discussed, along with a review of recent literature on maternal and neonatal complications associated with pregnancies in women with cyanotic congenital heart disease.

rnold Chiari malformations (ACM) are a groupof congenital anomalies with herniation of thecerebellum through the foramen magnum anddownward displacement of the lower pons and me-dulla (1). Type I ACM, which presents typically inadulthood, relates to cerebellar and cervical spinalcord involvement and can be associated with syringo-myelia (2). The most common clinical manifestationsare headaches, pain in the neck and upper extremities,ataxia, nystagmus, vertigo, upper extremity atrophy,and eventually bulbar symptoms and respiratory im-pairment with inspiratory stridor, reflecting tenthnerve palsy (3). Seizures have also recently been asso-ciated with type I ACM (4). Patients are more likely tobe symptomatic if the tonsillar herniation is largerthan 5 mm (5) and are invariably symptomatic if it ismore than 12 mm (6) on sagittal magnetic resonanceimaging (MRI). Increased intracranial pressure (ICP)has been reported (2) in type I ACM with syringomy-elia. It has been suggested that increased brain turgorin these patients may occur, which could interferewith cerebrospinal fluid (CSF) absorption resulting inincreased ICP (7).Type II ACM, which presents in infancy, is associ-ated with myelomeningocele. Symptoms include stri-dor, episodic apnea, depressed or absent gag reflex,nystagmus, and spastic upper extremity weakness. Aventriculoperitoneal shunt is often placed to treat hy-drocephalus while repairing the myelomeningocele.Type III ACM involves caudad displacement of thecerebellum and brainstem into a high cervical myelo-meningocele, and type IV consists of cerebellarhypoplasia without herniation.There are no firm recommendations regarding an-esthetic management of parturients with ACM. Fear ofherniation should probably not be of concern for pa-tients having had surgical decompression; however,few reports of neuraxial anesthesia for Cesarean de-livery have been published. We describe the success-ful use of spinal anesthesia for Cesarean delivery in apatient with a surgically corrected type I ACM.

This review article analyzes, through a nonsystematic approach, the pathophysiology of acute pancreatitis (AP) with a focus on the effects of thoracic epidural analgesia (TEA) on the disease. The benefit-risk balance is also discussed. AP has an overall mortality of 1 %, increasing to 30 % in its severe form. The systemic inflammation induces a strong activation of the sympathetic system, with a decrease in the blood flow supply to the gastrointestinal system that can lead to the development of pancreatic necrosis. The current treatment for severe AP is symptomatic and tries to correct the systemic inflammatory response syndrome or the multiorgan dysfunction. Besides the removal of gallstones in biliary pancreatitis, no satisfactory causal treatment exists. TEA is widely used, mainly for its analgesic effect. TEA also induces a targeted sympathectomy in the anesthetized region, which results in splanchnic vasodilatation and an improvement in local microcirculation. Increasing evidence shows benefits of TEA in animal AP: improved splanchnic and pancreatic perfusion, improved pancreatic microcirculation, reduced liver damage, and significantly reduced mortality. Until now, only few clinical studies have been performed on the use of TEA during AP with few available data regarding the effect of TEA on the splanchnic perfusion. Increasing evidence suggests that TEA is a safe procedure and could appear as a new treatment approach for human AP, based on the significant benefits observed in animal studies and safety of use for human. Further clinical studies are required to confirm the clinical benefits observed in animal studies.