Intensive care management of right ventricular failure and pulmonary hypertension crises

COVID-19 Patients With Pulmonary Hypertension Hospitalized in the United States During the Early Pandemic: Analysis of In-Hospital Mortality, Clinical Outcomes, and Racial Disparities

Coronavirus Disease 2019 (COVID-19) has been linked to severe consequences among hospitalized patients diagnosed with pulmonary hypertension (PH), as evidenced by a limited number of studies. Our retrospective study employed the National Inpatient Sample (NIS) database to evaluate in-hospital mortality and various clinical outcomes in COVID-19 patients with and without PH. This study included all patients ages 18 years and above who were hospitalized in the United States from January 1,2020 to December 31, 2020 with a COVID-19 diagnosis. The patients were then divided into 2 cohorts based on their PH status. After multivariate adjustment, we discovered that COVID-19 patients with PH experienced considerably higher in-hospital mortality, longer hospital stays, and higher costs of hospitalization when compared to COVID-19 patients without PH. Moreover, we observed an increased dependence on invasive and noninvasive positive pressure ventilation among COVID-19 patients with PH, indicating more severe respiratory failure. Our findings suggest that COVID-19 patients with PH had a heightened risk of acute pulmonary embolism and myocardial infarction while hospitalized. Lastly, among COVID-19 patients with PH, Hispanic and Native American patients demonstrated a persistently higher risk of in-hospital mortality compared to other racial groups. To our knowledge, this is the most comprehensive study of outcomes for COVID-19 patients with PH. The observed inpatient mortality appears to be driven by in-hospital complications, particularly pulmonary embolism. Given the substantial mortality and complications associated with COVID-19 and PH, we advocate for SARS-CoV-2 vaccination and the implementation of aggressive nonpharmacological preventive measures.

Continuous Prostanoid Initiation in Severe Pulmonary Hypertension in the Pediatric Cardiac Intensive Care Unit

OBJECTIVE

Limited data exists regarding prostanoid (PGI2) use in critically ill patients with pulmonary hypertension. (PH) in the pediatric cardiac intensive care unit (CICU) setting.

MATERIALS AND METHODS

Single center, retrospective study of patients with diagnosis of PH who received continuous PGI2 and were admitted to CICU from January/2015 to April/2022. Data collected included patient demographics and clinical characteristics including diagnosis, etiology of PH, vasoactive and ventilatory support, length of stay, and survival. Type, initial, maximum, and final dose of PGI2 as well as hemodynamic data was obtained. Data reported as mean ± standard deviation. Significance taken p value < 0.05.

RESULTS

24 patients received PGI2 therapy at a mean age of 3.1 years, range (0-16.6 years). PGI2 was in the form of IV epoprostenol in 12 patients, IV treprostinil in 6, and SQ treprostinil in 6 patients. Mean initial dose was 2.79 ng/kg/min, max dose 18.75 ng/kg/min, and mean duration of therapy was 38.5 days. At PGI2 initiation, 21 (87.5%) were on vasoactive infusions, 19 (79.2%) mechanically ventilated (MV), and 6 (25%) were on extracorporeal membrane oxygenation (ECMO). The in-hospital mortality rate was 37.5% (n = 9). Patients MV and on ECMO support had higher risk of death (p = 0.04, and < 0.01, respectively).

CONCLUSION

PGI2 therapy was tolerated in approximately 50% of patients with the most common side effect being hypotension leading to discontinuation in 1/3rd of patients. Ongoing evaluation of the benefits of PGI2 for patients in the CICU setting will help better identify patient selection, type, and dosing of PGI2.

Cardiac dysfunction in severe pediatric acute respiratory distress syndrome: the right ventricle in search of the right therapy

Severe acute respiratory distress syndrome in children, or PARDS, carries a high risk of morbidity and mortality that is not fully explained by PARDS severity alone. Right ventricular (RV) dysfunction can be an insidious and often under-recognized complication of severe PARDS that may contribute to its untoward outcomes. Indeed, recent evidence suggest significantly worse outcomes in children who develop RV failure in their course of PARDS. However, in this narrative review, we highlight the dearth of evidence regarding the incidence of and risk factors for PARDS-associated RV dysfunction. While we wish to draw attention to the absence of available evidence that would inform recommendations around surveillance and treatment of RV dysfunction during severe PARDS, we leverage available evidence to glean insights into potentially helpful surveillance strategies and therapeutic approaches.

Natural Products for the Treatment of Pulmonary Hypertension: Mechanism, Progress, and Future Opportunities

Pulmonary hypertension (PH) is a lethal disease due to the remodeling of pulmonary vessels. Its pathophysiological characteristics include increased pulmonary arterial pressure and pulmonary vascular resistance, leading to right heart failure and death. The pathological mechanism of PH is complex and includes inflammation, oxidative stress, vasoconstriction/diastolic imbalance, genetic factors, and ion channel abnormalities. Currently, many clinical drugs for the treatment of PH mainly play their role by relaxing pulmonary arteries, and the treatment effect is limited. Recent studies have shown that various natural products have unique therapeutic advantages for PH with complex pathological mechanisms owing to their multitarget characteristics and low toxicity. This review summarizes the main natural products and their pharmacological mechanisms in PH treatment to provide a useful reference for future research and development of new anti-PH drugs and their mechanisms.

Outcomes and Prognostic Factors of Pulmonary Hypertension Patients Undergoing Emergent Endotracheal Intubation

Background: Emergent endotracheal intubations (ETI) in pulmonary hypertension (PH) patients are associated with increased mortality. Post-intubation interventions that could increase survivability in this population have not been explored. We evaluate early clinical characteristics and complications following emergent endotracheal intubation and seek predictors of adverse outcomes during this post-intubation period. Methods: Retrospective cohort analysis of adult patients with groups 1 and 3 PH who underwent emergent intubation between 2005-2021 in medical and liver transplant ICUs at a tertiary medical center. PH patients were compared to non-PH patients, matched by Charlson Comorbidity Index. Primary outcomes were 24-h post-intubation and inpatient mortalities. Various 24-h post-intubation secondary outcomes were compared between PH and control cohorts. Results: We identified 48 PH and 110 non-PH patients. Pulmonary hypertension was not associated with increased 24-h mortality (OR 1.32, 95%CI 0.35-4.94, P = .18), but was associated with inpatient mortality (OR 4.03, 95%CI 1.29-12.5, P = .016) after intubation. Within 24 h post-intubation, PH patients experienced more frequent acute kidney injury (43.5% vs. 19.8%, P = .006) and required higher norepinephrine dosing equivalents (6.90 [0.13-10.6] mcg/kg/min, vs. 0.20 [0.10-2.03] mcg/kg/min, P = .037). Additionally, the median P/F ratio (PaO₂/FiO₂) was lower in PH patients (96.3 [58.9-201] vs. 233 [146-346] in non-PH, P = .001). Finally, a post-intubation increase in PaCO₂ was associated with mortality in the PH cohort (post-intubation change in PaCO₂ +5.14 ± 16.1 in non-survivors vs. -18.7 ± 28.0 in survivors, P = .007). Conclusions: Pulmonary hypertension was associated with worse outcomes after emergent endotracheal intubation than similar patients without PH. More importantly, our data suggest that the first 24 hours following intubation in the PH group represent a particularly vulnerable period that may determine long-term outcomes. Early post-intubation interventions may be key to improving survival in this population.

Antibiotics and ECMO in the Adult Population—Persistent Challenges and Practical Guides

Extracorporeal membrane oxygenation (ECMO) is an emerging treatment modality associated with a high frequency of antibiotic use. However, several covariables emerge during ECMO implementation, potentially jeopardizing the success of antimicrobial therapy. These variables include but are not limited to: the increased volume of distribution, altered clearance, and adsorption into circuit components, in addition to complex interactions of antibiotics in critical care illness. Furthermore, ECMO complicates the assessment of antibiotic effectiveness as fever, or other signs may not be easily detected, the immunogenicity of the circuit affects procalcitonin levels and other inflammatory markers while disrupting the immune system. We provided a review of pharmacokinetics and pharmacodynamics during ECMO, emphasizing practical application and review of patient-, illness-, and ECMO hardware-related factors.