Management of atrial fibrillation in critically ill patients

Usefulness of lactate to albumin ratio for predicting in-hospital mortality in atrial fibrillation patients admitted to the intensive care unit: a retrospective analysis from MIMIC-IV database

BACKGROUND

High lactate to albumin ratio (LAR) has been reported to be associated to with poor prognosis in patients admitted to the intensive care unit (ICU). However, its role in predicting in-hospital mortality in AF patients admitted to ICU has not been explored.

METHODS

The Medical Information Mart for Intensive Care-IV (MIMIC-IV) database was used to retrieve information on patients who had been diagnosed with AF. X-tile software was utilized to determine the optimal cut-off LAR. Area under the receiver operating characteristic curves (AUC), calibration plots, and decision curve analysis (DCA) were conducted to assess the prediction performance of LAR for in-hospital mortality.

RESULTS

Finally, 8,287 AF patients were included and 1,543 death (18.6%) occurred. The optimal cut-off value of LAR is 0.5. Patients in lower LAR (< 0.5) group showed a better in-hospital survival compared to patients in higher LAR (≥ 0.5) group (HR: 2.67, 95%CI:2.39-2.97, P < 0.001). A nomogram for in-hospital mortality in patients with AF was constructed based on multivariate Cox analysis including age, CCI, β blockers usage, APSIII, hemoglobin and LAR. This nomogram exhibited excellent discrimination and calibration abilities in predicting in-hospital mortality for critically ill AF patients.

CONCLUSION

LAR, as a readily available biomarker, can predict in-hospital mortality in AF patients admitted to the ICU. The nomogram that combined LAR with other relevant variables performed exceptionally well in terms of predicting in-hospital mortality.

Recognition and management of hemorrhaging in combination with emerging enterogenic sepsis during a hepatectomy: a case report

BACKGROUND

Patients with hemorrhagic shock may develop emerging enterogenic sepsis due to damage to the intestinal mucosal barrier and translocation of intestinal bacteria and endotoxins caused by ischemic injury. Because of the dual effects of anesthesia state and hemorrhagic shock, perioperative emerging enterogenic sepsis is even more rare and insidious.

CASE PRESENTATION

We reported a case of 56-year-old man who underwent right hepatectomy for intrahepatic bile duct stones. Severe hemorrhage occurred during the procedure and the hemodynamics neither improved nor worsened after rehydration therapy and vasoactive drug administration. Based on the patient's history and clinical presentation, a possible enterogenic sepsis was considered. After anti-infective treatment and hormone supplementation, the patient's circulation improved significantly and he had an uneventful recovery.

CONCLUSION

The possibility of emerging enterogenic sepsis in hemorrhagic shock must always be taken into consideration. Familiarity with the risk factors and pathophysiological alterations of enterogenic sepsis is a prerequisite for early recognition and sound clinical decision making.

Triggers of Atrial Fibrillation in the Geriatric Medical Intensive Care Unit: An Observational Study

Background

Atrial fibrillation (AF) is a common arrhythmia in the non-cardiac intensive care unit (ICU). However, data concerning AF incidence and predictors in such populations are scarce and controversial. The study aimed to investigate the contributing factors of new-onset AF in elderly patients within the medical intensive care setting.

Methods

Patients admitted to ICU during a 6-month period were prospectively studied. Patients admitted for short period postoperative monitoring and patients with chronic or paroxysmal AF were excluded. The conditions involved as AF risk factors or "triggers" from demographic data, history, and echocardiography were recorded. Acute Physiology and Chronic Health Evaluation II score was calculated. Electrolytes including some trace elements (zinc, copper, and magnesium) were analyzed.

Results

The study included 142 patients (49% females). Mean age was 69.5 ± 7.3 years. AF was observed in 12%. Diagnosis of pneumonia (P < 0.001), low copper (P < 0.0001) and low zinc levels (P < 0.0001) was significantly associated with the occurrence of AF. By multivariate analysis, they remained statistically significant (odds ratio, 7.0; 95% confidence interval, 2.0 - 24.6; P < 0.01).

Conclusions

A significant fraction of ICU elderly patients manifests AF. The relevant factors contributing to AF incidence in the elderly are pneumonia and low zinc and low copper.

Analysis of the association between atrial fibrillation with in-hospital mortality in people admitted for community-acquired pneumonia through an observational, nation-wide, sex-stratified study

We aimed to analyze the influence of atrial fibrillation (AF) prior to hospital admission (“prevalent”) and AF diagnosed during hospital admission (“incident”) on in-hospital mortality (IHM) in women and men admitted for community-acquired pneumonia (CAP) in Spain (2016–2019). We used the Spanish Register of Specialized Care‐Basic Minimum Database. We analyzed 519,750 cases of CAP in people ≥ 18 years (213,631 women (41.1%)), out of which people with prevalent AF represented 23.75% (N = 123,440), whereas people with incident AF constituted 0.60% (N = 3154). Versus no AF, crude IHM was significantly higher for prevalent AF (15.24% vs. 11.40%, p < 0.001) and for incident AF (23.84% vs. 12.24%, p < 0.001). After propensity score marching, IHM in women and men with prevalent AF neared IHM in women and men with no AF (15.72% vs. 15.52%, p = 0.425; and 14.90% vs. 14.99%, p = 0.631, respectively), but IHM in women and men with incident AF was higher than IHM in women and men with no AF (24.37% vs. 13.36%, p < 0.001; and 23.94% vs. 14.04%, p < 0.001, respectively). Male sex was associated with a higher IHM in people with prevalent AF (OR 1.06; 95% CI 1.02–1–10), but not in people with incident AF (OR 0.93; 95% CI 0.77–1–13). AF diagnosed during hospital admission was associated with a higher IHM, irrespectively of sex.

The Influence of Atrial Fibrillation on In-Hospital Mortality in People with Hospital-Acquired Pneumonia: An Observational, Sex-Stratified Study

(1) Background: The study aimed to analyze the influence of atrial fibrillation (AF) prior to hospital admission (“prevalent”) and new-onset AF diagnosed during hospital admission (“incident”) on in-hospital mortality (IHM) in women and men who developed hospital-acquired pneumonia (HAP) in Spain (2016−2019). (2) Methods: We used the Spanish Register of Specialized Care-Basic Minimum Database. (3) Results: We analyzed 38,814 cases of HAP (34.6% women; 13.5% ventilator-associated). Prevalent AF was coded in 19.9% (n = 7742), and incident AF in 5.5% (n = 2136) of HAP. Crude IHM was significantly higher for prevalent AF (34.22% vs. 27.35%, p < 0.001) and for incident AF (35.81% vs. 28.31%, p < 0.001) compared to no AF. After propensity score matching, IHM among women and men with prevalent AF was higher than among women and men with no AF (among women, 32.89% vs. 30.11%, p = 0.021; among men, 35.05% vs. 32.46%, p = 0.008). Similarly, IHM among women and men with incident AF was higher than among women and men with no AF (among women, 36.23% vs. 29.90%, p = 0.013; among men, 35.62% vs. 30.47%; p = 0.003). Sex was associated with a higher IHM only in people with incident AF (for female, OR = 1.21; 95% CI: 1.01−1.57). (4) Conclusions: Both prevalent and incident AF were associated with higher IHM in people who developed HAP. Female sex was associated with a higher IHM in incident AF.

Echocardiography in a critical care unit: A contemporary review

INTRODUCTION

Echocardiography is a rapid, noninvasive, and complete cardiac assessment tool for patients with hemodynamic instability. This review provides an overview of the evidence for current practices in critical care units (CCUs), incorporating the use of echocardiography in different etiologies of shock.

AREAS COVERED

: Relevant articles were extracted after searching on databases by two reviewers and incorporated in this review in a narrative style.

EXPERT OPINION

: In an acute scenario, a basic echocardiographic study yields prompt diagnosis, allowing for the initiation of treatment. The most common pathologies in shocked patients are identified promptly using two-dimensional (2D) and M-mode echocardiography. A more comprehensive assessment can follow after patients have been stabilized. There are four types of shock: (i) cardiogenic shock, (ii) hypovolemic shock, (iii) obstructive shock, and (iv) septic shock. All of them can be readily identified by echocardiography. As echocardiography is increasingly being used in an intensive care setting, its applications and evidence base should be expanded by randomized controlled trials to demonstrate patient outcomes in critical care.

In-Hospital Mortality Among Critically Ill Patients With Atrial Fibrillation (AF) Versus Patients Without AF

Introduction

Atrial fibrillation (AF) is one of the most frequent arrhythmias observed in the intensive care unit (ICU). The present study assessed AF as an independent risk factor for mortality among patients in the ICU setting.

Methodology

A prospective cohort study was conducted at the medical ICU in a tertiary academic medical center from September 2020 to January 2021. All critically ill patients, irrespective of gender, who were admitted for at least two days in the ICU were eligible to partake in the study. Individuals in the cardiovascular surgical ICU and the trauma ICU were not eligible. Demographics, clinical history, the occurrence of AF, fluid input and output, echocardiography, drug history, and hospital mortality were recorded during the first week of admission. Patients were divided into two groups.

Results

Patients with AF had significantly higher in-hospital mortality, 27 (73%), and longer hospital stays (11.61 ± 7.01) as compared to patients who did not suffer from AF (p<0.0001). The mean length of stay in ICU was 10.32 ± 5.92 and the duration of mechanical ventilation was 7.05 ± 6.16 days in the AF group which was significantly higher than patients who did not have AF (p<0.0001). No significant difference was found in mortality rate between new-onset and recurrent AF among the patients; albeit the latter was higher (60% vs 81.8%, p=0.142).

Conclusion

The present study indicated that AF was a predictor of mortality hence, associated with poor patient prognosis. The occurrence of AF was associated with high in-hospital mortality and longer hospital stay. Further large-scale studies should be conducted to explore other socio-demographic and clinical risk factors.

Risk prediction of clinical adverse outcomes with machine learning in a cohort of critically ill patients with atrial fibrillation

Critically ill patients affected by atrial fibrillation are at high risk of adverse events: however, the actual risk stratification models for haemorrhagic and thrombotic events are not validated in a critical care setting. With this paper we aimed to identify, adopting topological data analysis, the risk factors for therapeutic failure (in-hospital death or intensive care unit transfer), the in-hospital occurrence of stroke/TIA and major bleeding in a cohort of critically ill patients with pre-existing atrial fibrillation admitted to a stepdown unit; to engineer newer prediction models based on machine learning in the same cohort. We selected all medical patients admitted for critical illness and a history of pre-existing atrial fibrillation in the timeframe 01/01/2002–03/08/2007. All data regarding patients’ medical history, comorbidities, drugs adopted, vital parameters and outcomes (therapeutic failure, stroke/TIA and major bleeding) were acquired from electronic medical records. Risk factors for each outcome were analyzed adopting topological data analysis. Machine learning was used to generate three different predictive models. We were able to identify specific risk factors and to engineer dedicated clinical prediction models for therapeutic failure (AUC: 0.974, 95%CI: 0.934–0.975), stroke/TIA (AUC: 0.931, 95%CI: 0.896–0.940; Brier score: 0.13) and major bleeding (AUC: 0.930:0.911–0.939; Brier score: 0.09) in critically-ill patients, which were able to predict accurately their respective clinical outcomes. Topological data analysis and machine learning techniques represent a concrete viewpoint for the physician to predict the risk at the patients’ level, aiding the selection of the best therapeutic strategy in critically ill patients affected by pre-existing atrial fibrillation.

Impact of patient characteristics on the efficacy and safety of landiolol in patients with sepsis-related tachyarrhythmia: Subanalysis of the J-Land 3S randomised controlled study

BACKGROUND

The J-Land 3S trial demonstrated that landiolol is effective and tolerated for treating sepsis-related tachyarrhythmias. Patient characteristics (e.g. baseline heart rate [HR], type of tachyarrhythmia, and concomitant disorders) may impact the outcomes of landiolol therapy. We performed subanalyses of J-Land 3S to evaluate the impact of patient characteristics on the efficacy and safety of landiolol for treating sepsis-related tachyarrhythmia.

METHODS

Patients (≥20 years old; N = 151) hospitalised with sepsis at 54 participating hospitals in Japan with HR ≥100 beats/min for ≥10 min accompanied by diagnosis of tachyarrhythmia were randomised 1:1 to conventional sepsis therapy alone (control group) or conventional sepsis therapy plus landiolol (landiolol group). The efficacy and safety of landiolol were assessed in prespecified analyses of patients divided into subgroups by baseline characteristics and in post hoc, multivariate analyses with adjustment for age and HR at baseline.

FINDINGS

The percentage of patients with HR of 60-94 beats/min at 24 h after randomisation (primary endpoint) was greater in the landiolol group in most subgroups in univariate unadjusted analyses and in multivariate logistic regression. The incidence of new-onset arrhythmia by 168 h and mortality by 28 days were also lower in the landiolol group in most subgroups in univariate and multivariate Cox proportional hazards models. No subgroups showed a markedly higher incidence of adverse events in univariate or multivariate logistic regression analyses.

INTERPRETATION

These results of the J-Land 3S study suggest that the efficacy and safety of landiolol are generally unaffected by key patient characteristics.

FUNDING

Ono Pharmaceutical Co., Ltd.

Anticoagulation strategies in critical care for the treatment of atrial fibrillation: a protocol for a systematic review and meta-analysis

INTRODUCTION

Atrial fibrillation (AF) is the most common cardiac arrhythmia in critically ill patients and is associated with an increased risk of thromboembolic events and mortality. Oral anticoagulation for thromboembolism prophylaxis is a key component of managing AF in the general population and is recommended by National Institute for Health and Care Excellence guidelines. However, assessment tools used to aid decision making about anticoagulation have not yet been validated in the critical care setting. There is a paucity of data assessing the impact of anticoagulation strategies on clinical outcomes in critically ill patients with AF. We present a protocol for a systematic review and meta-analysis to evaluate the effectiveness of anticoagulation strategies for AF used specifically in critical care.

METHODS AND ANALYSIS

We will conduct a systematic review of the literature by searching MEDLINE, EMBASE, CENTRAL and PubMed databases for articles published from January 1990 to October 2019. Studies reporting anticoagulation strategies for AF in adults (>18 years) admitted to a general critical care setting will be assessed for inclusion. Outcomes of interest will include (1) percentage of patients started on anticoagulation in critical care for AF, (2) incidence of thromboembolism, (3) incidence of bleeding events, (4) intensive care unit (ICU) mortality, (5) hospital mortality, (6) ICU length of stay and (7) hospital length of stay. We will conduct a meta-analysis of trials. Risk of bias will be assessed using the Cochrane Risk of Bias tool for randomised trials or the Newcastle-Ottawa Risk of Bias assessment tool for non-randomised studies. This protocol and subsequent systematic review will be reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.

ETHICS AND DISSEMINATION

This proposed systematic review will include data extracted from published studies; therefore, ethical approval is not required. The results of this review will be published in clinical specialty journals and presented at international meetings and conferences.

TRIAL REGISTRATION NUMBER

CRD42020158237.

Novel rate control strategy with landiolol in patients with cardiac dysfunction and atrial fibrillation

While patients with acute heart failure often have tachycardia with atrial fibrillation, there have been no established medical tools that control tachycardia safely and definitely. Digoxin has been recommended as a first choice in the former guidelines, but it takes time to affect and has a risk of adverse events particularly for those with chronic kidney disease. Landiolol is a recently innovated ultra‐short‐acting beta‐blocker with 251‐fold β1/β2 selectivity, which was originally indicated only to control peri‐operative supra‐ventricular tachyarrhythmia by 2013 in Japan. We aimed to review how to use landiolol in patients with cardiac dysfunction and tachycardia due to atrial fibrillation. We reviewed recently conducted randomized control trials using landiolol, recently updated guidelines, as well as current practical use of landiolol. Japan landiolol vs. Digoxin (J‐Land) study demonstrated that landiolol was more effective to control tachycardia than digoxin in atrial fibrillation patients with left ventricular dysfunction in 2013. Given the result, the revised Japanese heart failure guideline recommends landiolol for rate control during atrial fibrillation in acute heart failure patients as Class IIa with evidence level B. Currently in Japan, landiolol is used for rate control, even in patients with advanced heart failure receiving continuous infusion of inotropes. The clinical use of landiolol in patients with cardiac dysfunction and tachycardia due to atrial fibrillation is increasing. Further studies are warranted to investigate the implication of faster and safer rate control using landiolol.

Efficacy and safety of 1C class antiarrhythmic agent (propafenone) for supraventricular arrhythmias in septic shock compared to amiodarone: protocol of a prospective randomised double-blind study

INTRODUCTION

Supraventricular arrhythmias contribute to haemodynamic compromise in septic shock. A retrospective study generated the hypothesis that propafenone could be more effective than amiodarone in achieving and maintaining sinus rhythm (SR). Certain echocardiographic parameters may predict a successful cardioversion and help in the decision on rhythm or rate control strategy.

METHODS AND ANALYSIS

The trial includes septic shock patients with new-onset arrhythmia, but without severe impairment of the left ventricular ejection fraction. After baseline echocardiography, the patient is randomised to receive a bolus and maintenance dose of either amiodarone or propafenone. The primary outcome is the proportion of patients that have achieved rhythm control at 24 hours after the start of the infusion. The secondary outcomes are the percentages of patients that needed rescue treatments (DC cardioversion or unblinding and crossover of the antiarrhythmics), the recurrence of arrhythmias, intensive care unit mortality, 28-day and 1-year mortality. In the posthoc analysis, we separately assess subgroups of patients with pulmonary hypertension and right ventricular dysfunction. In the exploratory part of the study, we assess whether the presence of a transmitral diastolic A wave and its higher velocity-time integral is predictive for the sustainability of mechanical SR and whether the indexed left atrial endsystolic volume is predictive of recurrent arrhythmia. Considering that the restoration of SR within 24 hours occurred in 74% of the amiodarone-treated patients and in 89% of the patients treated with propafenone, we plan to include 200 patients to have an 80% chance to demonstrate the superiority of propafenone at p=0.05.

ETHICS AND DISSEMINATION

The trial is recruiting patients according to its second protocol version approved by the University Hospital Ethical Board on the 6 October 2017 (No. 1691/16S-IV). The results will be disseminated through peer reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT03029169.

Improved Survival in Hepatocellular Carcinoma Patients with Cardiac Arrhythmia by Amiodarone Treatment through Autophagy

Hepatocellular carcinoma (HCC) is a primary malignancy of the liver. In basic studies, the regulation of autophagy has offered promising results for HCC treatment. This study aimed to address the question of whether amiodarone can improve survival rates in HCC patients associated with autophagy. Using datasets from the National Health Insurance Research Database, we enrolled patients over 18 years of age that had been diagnosed with HCC between January 1997 and December 2010. Amiodarone and non-amiodarone users were matched at a 1:1 frequency, according to all variables. Additionally, HepG2 cells treated with amiodarone were evaluated by cell viability and autophagic change. Autophagic signaling was examined by immunoblotting and tissue array immunohistochemistry. Of the 10,946 patients diagnosed with HCC, each cohort included 221 patients after 1:1 propensity score matching. The median survival was 36.70 months for the amiodarone users, and 24.48 months for the non-amiodarone users. After adjusting for age, gender, comorbidities and treatment, amiodarone users had a significantly lower risk of mortality. Amiodarone users also demonstrated an improved 3-year survival rate. Furthermore, amiodarone treatment-induced autophagy in HepG2 cells was demonstrated by autophagosome formation associated with increasing LC3B-II, P62, and Beclin-1 expression. Autophagic flux also increased following amiodarone treatment with bafilomycin A1. SiRNA of LC3B knocked down endogenous LC3B formation and restored HepG2 cell viability. This study provides epidemiologic evidence that amiodarone via autophagic degradation machinery may offer survival benefits for HCC patients with a history of arrhythmia. Further randomized, blinded, and placebo-controlled trials are warranted for patients with HCC.

Clinical effects of intravenous to oral amiodarone transition strategies in critically ill adult patients

WHAT IS KNOWN AND OBJECTIVE

There is limited guidance on how to transition critically ill patients from intravenous (IV) to oral (PO) amiodarone. The objective of this study was to assess the impact of IV and PO amiodarone overlap on short-term tachyarrhythmia recurrence and adverse hemodynamic outcomes in the intensive care unit.

METHODS

This is a retrospective, single-center analysis of critically ill adults who were treated with IV amiodarone for a supraventricular arrhythmia with rapid ventricular rate (RVR) and transitioned to PO amiodarone while inpatient. Patients were excluded if rate control was not achieved prior to the PO transition. Receipt of concomitant IV and PO therapy for ≤2 hours was considered no overlap (NOV) and >2 hours was considered overlap (OV). Tachyarrhythmia recurrence and adverse hemodynamic events were compared between groups.

RESULTS

A total of 90 patients (45 NOV, 45 OV) were included in the analysis. The median overlap duration was 0.1 (-1.3 to 1.2) hours in the NOV arm and 4 (2.6-6.1) hours in the OV arm. Recurrence of RVR occurred in 9 (20%) patients in each arm (P = 1.0). The median time from IV discontinuation to return of tachyarrhythmia was 10.5 hours. There were no significant differences in amiodarone dosing, electrolyte abnormalities, volume status or concomitant cardiac medications at the time of IV to PO transition. Hypotension occurred in 13% and 20% (P = 0.369) and bradycardia in 9% and 13% (P = 0.502) of patients in the NOV and OV arms, respectively.

WHAT IS NEW AND CONCLUSION

Providing IV and PO overlap of amiodarone for a median of 4 hours did not decrease the rate of early tachyarrhythmia recurrence. Future studies are warranted to evaluate the impact of alternative amiodarone dosing strategies on breakthrough tachyarrhythmia.

How to manage various arrhythmias and sudden cardiac death in the cardiovascular intensive care

In the clinical practice of cardiovascular critical care, we often observe a variety of arrhythmias in the patients either with (secondary) or without (idiopathic) underlying heart diseases. In this manuscript, the clinical background and management of various arrhythmias treated in the CCU/ICU will be reviewed. The mechanism and background of lethal ventricular tachyarrhythmias vary as time elapses after the onset of MI that should be carefully considered to select a most suitable therapy. In the category of non-ischemic cardiomyopathy, several diseases are known to be complicated by the various ventricular tachyarrhythmias with some specific mechanisms. According to the large-scale registry data, the most common arrhythmia is atrioventricular block. It is essential for the decision of permanent pacemaker indication to rule out the presence of transient causes such as ischemia and electrolyte abnormalities. The prevalence of atrial fibrillation (AF) is very high in the patients with heart failure (HF) and myocardial infarction (MI). AF and HF have a reciprocal causal relationship; thus, both are associated with the poor prognosis. Paroxysmal AF occurs in 5 to 20% during the acute phase of MI and triggered by several specific factors including pump failure, atrial ischemia, and autonomic instability. After the total management of patients with various arrhythmias and basic heart diseases, the risk of sudden cardiac death should be stratified for each patient to assess the individual need for preventive therapies. Finally, it is recommended that the modalities of the treatment and prophylaxis should be selected on a case-by-case basis in the scene of critical care.

Landiolol for rate control management of atrial fibrillation in patients with cardiac dysfunction

Atrial fibrillation (AFib) is frequently associated with heart failure. Guidelines for AFib management have been recently updated and include an algorithm for acute heart rate control based on left ventricular ejection fraction and haemodynamics. Landiolol is an injectable ultra-short beta-blocker with very high beta-1 selectivity, listed in Japanese Guidelines for AFib management as potential option for rate control of patient with heart failure. Landiolol is now available in Europe with indication of controlling heart rate in AFib and supraventricular tachycardia. This review discusses existing clinical data in Japan and perspectives of landiolol use for acute rate control of AFib patients with cardiac dysfunction.

Current practice in the management of new-onset atrial fibrillation in critically ill patients: a UK-wide survey

BACKGROUND

New-onset atrial fibrillation (AF) is the most common arrhythmia in critically ill patients. Although evidence base and expert consensus opinion for management have been summarised in several international guidelines, no specific considerations for critically ill patients have been included. We aimed to establish current practice of management of critically ill patients with new-onset AF.

METHODS

We designed a short user-friendly online questionnaire. All members of the Intensive Care Society were invited via email containing a link to the questionnaire, which comprised 21 questions. The online survey was conducted between November 2016 and December 2016.

RESULTS

The response rate was 397/3152 (12.6%). The majority of respondents (81.1%) worked in mixed Intensive Care Units and were consultants (71.8%). Most respondents (39.5%) would start intervention on patients with fast new-onset AF and stable blood pressure at a heart rate between 120 and 139 beats/min. However, 34.8% of participants would treat all patients who developed new-onset fast AF. Amiodarone and beta-blockers (80.9% and 11.6% of answers) were the most commonly used anti-arrhythmics. A total of 63.8% of respondents do not regularly anti-coagulate critically ill patients with new-onset fast AF, while 30.8% anti-coagulate within 72 hours. A total of 68.0% of survey respondents do not routinely use stroke risk scores in critically ill patients with new-onset AF. A total of 85.4% of participants would consider taking part in a clinical trial investigating treatment of new-onset fast AF in the critically ill.

DISCUSSION

Our results suggest a considerable disparity between contemporary practice of management of new-onset AF in critical illness and treatment recommendations for the general patient population suffering from AF, particularly with regard to anti-arrhythmics and anti-coagulation used. Amongst intensivists, there is a substantial interest in research for management of new-onset AF in critically ill patients.

Comparison of Two Central Venous Pressure Control Strategies to Prevent Atrial Fibrillation After Coronary Artery Bypass Grafting

BACKGROUND:

Atrial fibrillation (AF) takes place in 10-40% of patients undergoing coronary artery bypass grafting (CABG), and increases cardiovascular mortality. Enlargement of atrial chambers is associated with increased AF incidence, so patients with higher central venous pressure (CVP) are expected to have larger atrial distension, which increases AF incidence.

OBJECTIVE:

To compare post-CABG AF incidence, following two CVP control strategies.

METHODS:

Interventional, randomized, controlled clinical study. The sample comprised 140 patients undergoing CABG between 2011 and 2015. They were randomized into two groups, G15 and G20, with CVP maintained ≤ 15 cmH2O and ≤ 20 cmH2O, respectively.

RESULTS:

70 patients were included in each group. The AF incidence in G15 was 8.57%, and in G20, 22.86%, with absolute risk reduction of 14.28%, and number needed to treat (NNT) of 7 (p = 0.03). Mortality (G15 = 5.71%; G20 = 11.42%; p = 0.07), hospital length of stay (G15 = 7.14 days; G20 = 8.21 days; p = 0.36), number of grafts (median: G15 = 3, G2 = 2; p = 0.22) and cardiopulmonary bypass use (G15 = 67.10%; G20 = 55.70%; p = 0.22) were statistically similar. Age (p = 0.04) and hospital length of stay (p = 0.001) were significantly higher in patients who developed AF in both groups.

CONCLUSION:

Keeping CVP low in the first 72 post-CABG hours reduces the relative risk of AF, and may be useful to prevent AF after CABG.

FUNDAMENTO:

A fibrilação atrial (FA) ocorre em 10-40% dos pacientes submetidos a cirurgia de revascularização miocárdica (RM), e eleva a mortalidade cardiovascular. Como o aumento dos átrios está associado ao aumento da incidência de FA, espera-se que pacientes com pressão venosa central (PVC) mais alta tenham maior distensão atrial, o que eleva a incidência dessa arritmia.

OBJETIVO:

Comparar a incidência de FA em pós-operatório de RM, seguindo duas estratégias de controle de PVC.

MÉTODOS:

Estudo clínico randomizado controlado intervencionista. A amostra foi composta por 140 pacientes submetidos a RM entre 2011 e 2015. Os pacientes foram randomizados em dois grupos, G15 e G20, mantidos com PVC máxima de 15 cmH2O e 20 cmH2O, respectivamente.

RESULTADOS:

Foram incluídos 70 pacientes em cada grupo. A incidência da arritmia em G15 foi de 8,57% e, no G20, de 22,86%, com redução de risco absoluto de 14,28% e número necessário para tratar (NNT) de 7 (p = 0,03). Mortalidade (G15 = 5,71%; G20 = 11,42%; p = 0,07), tempo de internamento (G15 = 7,14 dias; G20 = 8,21 dias; p = 0,36), número de enxertos (medianas: G15 = 3, G2 = 2; p = 0,22) e uso de circulação extracorpórea (G15 = 67,10%; G20 = 55,70%; p = 0,22) mostraram-se estatisticamente semelhantes. A idade (p = 0,04) e o tempo de internamento (p = 0,001) foram significativamente maiores nos pacientes que desenvolveram FA nos dois grupos.

CONCLUSÃO:

Manter a PVC com valores mais baixos nas primeiras 72h após a cirurgia de RM reduz o risco relativo de FA e pode ser uma ferramenta útil na prevenção da FA após RM.

Variable use of amiodarone is associated with a greater risk of recurrence of atrial fibrillation in the critically ill

Background

Atrial fibrillation is a common rhythm disturbance in the general medical-surgical intensive care unit. Amiodarone is a popular drug in this setting but evidence to inform clinical practice remains scarce. We aimed to identify whether variation in the clinical use of amiodarone was associated with recurrent atrial fibrillation.

Methods

This was a retrospective audit of 177 critically ill patients who developed new-onset atrial fibrillation after admission to a tertiary level medical-surgical trauma intensive care unit. Patterns of amiodarone prescription (including dosage schedule and duration) were assessed in relation to recurrence of atrial fibrillation during the intensive care unit stay. Known recurrence risk factors, such as inotrope administration, cardiac disease indices, Charlson Comorbidity Index, magnesium concentrations, fluid balance, and potassium concentrations, were also included in adjusted analysis using forward stepwise logistic regression modelling.

Results

The cohort had a median (interquartile range) age of 69 years (60–75), Acute Physiology and Chronic Health Evalution II score of 22 (17–28) and Charlson Comorbidity Index of 2 (1–4). A bolus dose of amiodarone followed by infusion (P = 0.02), in addition to continuing amiodarone infusion through to discharge from the intensive care unit (P < 0.001), were associated with less recurrent dysrhythmia. Recurrence after successful treatment was associated with ceasing amiodarone while an inotrope infusion continued (P < 0.001), and was more common in patients with a prior history of congestive cardiac failure (P = 0.04), and a diagnosis of systemic inflammatory response syndrome (P = 0.02).

Conclusions

Amiodarone should be administered as a bolus dose followed immediately with an infusion when treating atrial fibrillation in the medical-surgical intensive care unit. Consideration should be given to continuing amiodarone infusions in patients on inotropes until they are ceased.

Microfluidic Bioprinting of Heterogeneous 3D Tissue Constructs Using Low-Viscosity Bioink

A novel bioink and a dispensing technique for 3D tissue-engineering applications are presented. The technique incorporates a coaxial extrusion needle using a low-viscosity cell-laden bioink to produce highly defined 3D biostructures. The extrusion system is then coupled to a microfluidic device to control the bioink arrangement deposition, demonstrating the versatility of the bioprinting technique. This low-viscosity cell-responsive bioink promotes cell migration and alignment within each fiber organizing the encapsulated cells.

Optimizing atrial fibrillation management: from ICU and beyond

Atrial fibrillation (AF) that newly occurs during critical illness presents challenges for both short- and long-term management. During critical illness, patients with new-onset AF are clinically evaluated for hemodynamic instability owing to the arrhythmia as well as for potentially reversible arrhythmia triggers. Hemodynamically significant AF that persists during critical illness may be treated with heart rate or rhythm control strategies. Recent evidence suggests that patients in whom AF develops during acute illness (eg, sepsis, postoperatively) have high long-term risks for AF recurrence and for AF-associated complications, such as stroke, heart failure, and death. Therefore, we suggest increased efforts to improve communication of AF events between inpatient and outpatient providers and to reassess patients who had experienced new-onset AF during critical illness after they transition to the post-ICU setting. We describe various strategies for the assessment and long-term management of patients with new-onset AF during critical illness.

Shock Management for Cardio-surgical Intensive Care Unit Patient: The Silver Days

Shock in cardio-surgical intensive care unit (ICU) patients requires prompt identification of the underlying condition and timely therapeutic interventions. Management during the first 6 hours, also referred to as "the golden hours", is of paramount importance to reverse the shock state and improve the patient's outcome. The authors have previously described a state-of-the-art diagnostic work-up and discussed how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery during this phase. Ideally, shock can be reversed during this initial period. However, some patients might have developed multiple organ dysfunction, which persists beyond the first 6 hours despite the early haemodynamic treatment goals having been accomplished. This period, also referred to as "the silver days", is the focus of this review. The authors discuss how to reduce vasopressor load and how to minimise adrenergic stress by using alternative inotropes, extracorporeal life-support and short acting beta-blockers. The review incorporates data on fluid weaning, safe ventilation, daily interruption of sedation, delirium management and early rehabilitation. It includes practical recommendations in areas where the evidence is scarce or controversial. Although the focus is on cardio-surgery ICU patients, most of the considerations apply to critical ill patients in general.

Shock Management for Cardio-surgical ICU Patients - The Golden Hours

Postoperative shock following cardiac surgery is a serious condition with a high morbidity and mortality. There are four types of shock: cardiogenic, hypovolemic, obstructive and distributive and these can occur alone or in combination. Early identification of the underlying diseases and understanding of the mechanisms at play are key for successful management of shock. Prompt resuscitation measures are necessary to reverse the shock state and avoid permanent organ dysfunction or death. In this review, the authors focus on the management during the first 6 hours of shock (the 'golden hours'). They discuss how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery. The review incorporates the findings of recent trials on early goal-directed therapy and includes practical recommendations in areas in which the evidence is scare or controversial. While the review focuses on cardio-surgical patients, the suggested treatment algorithms might be usefully expanded to other critically ill patients with shock arising from other causes.

[Treatment of atrial fibrillation in intensive care units and emergency departments]

BACKGROUND

Atrial fibrillation is the most common arrhythmia in patients hospitalized in intensive care units and emergency departments and is associated with an increased morbidity and mortality. In critically ill patients, atrial fibrillation can cause hemodynamic instability and cardiogenic shock. The mechanisms and the management of atrial fibrillation are significantly different in critically ill patients compared to outpatients.

DIAGNOSIS AND TREATMENT

The initial management includes the evaluation of the hemodynamic consequences of new-onset atrial fibrillation and the optimization of reversible causes. In patients with hemodynamic instability the rapid restoration of an adequate perfusion pressure is the initial goal. Often, a rapid conversion in sinus rhythm is required to achieve hemodynamic stabilization. Electrical cardioversion, if possible performed after pretreatment with an antiarrhythmic drug to increase the success rate, frequently plays a central role in the conversion to sinus rhythm of hemodynamically unstable patients. Stable patients are initially treated with a short-acting intravenous β-blocker to achieve heart rate control. A conversion to sinus rhythm may be achieved pharmacologically with vernakalant, an atrial-specific multichannel blocker.

EVALUATION

All patients with atrial fibrillation lasting more than 48 h should be evaluated for anticoagulation in order to reduce cardio-embolic complications. After recovering from the acute illness, atrial fibrillation persists only in a minority of patients.

Suitability, efficacy, and safety of vernakalant for new onset atrial fibrillation in critically ill patients

Objectives. This study investigates the suitability, safety, and efficacy of vernakalant in critically ill patients with new onset atrial fibrillation (AF) after cardiac surgery. Methods. Patients were screened for inclusion and exclusion criteria according to the manufacturers' recommendations. Included patients were treated with 3 mg/kg of vernakalant over 10 min and, if unsuccessful, a second dose of 2 mg/kg. Blood pressure was measured continuously for 2 hours after treatment. Results. Of the 191 patients screened, 159 (83%) were excluded, most importantly due to hemodynamic instability (59%). Vernakalant was administered to 32 (17% of the screened) patients. Within 6 hours, 17 (53%) patients converted to sinus rhythm. Blood pressure did not decrease significantly 10, 30, 60, and 120 minutes after the vernakalant infusion. However, 11 patients (34%) experienced a transient decrease in mean arterial blood pressure <60 mmHg. Other adverse events included nausea (n = 1) and bradycardia (n = 2). Conclusions. Applying the strict inclusion and exclusion criteria provided by the manufacturer, only a minority of postoperative ICU patients with new onset AF qualified for vernakalant. Half of the treated patients converted to sinus rhythm. The drug was well tolerated, but close heart rate and blood pressure monitoring remains recommended.