Bedside Cardiac Pocus in Emergency Setting: A Practice Review

Pregnancy Arrhythmias: Management in the Emergency Department and Critical Care

Pregnancy is closely associated with an elevated risk of arrhythmias, constituting the predominant cardiovascular complication during this period. Pregnancy may induce the exacerbation of previously controlled arrhythmias and, in some instances, arrhythmias may present for the first time in pregnancy. The most important proarrhythmic mechanisms during pregnancy are the atrial and ventricular stretching, coupled with increased sympathetic activity. Notably, arrhythmias, particularly those originating in the ventricles, heighten the likelihood of syncope, increasing the potential for sudden cardiac death. The effective management of arrhythmias during the peripartum period requires a comprehensive, multidisciplinary approach from the prepartum to the postpartum period. The administration of antiarrhythmic drugs during pregnancy necessitates meticulous attention to potential alterations in pharmacokinetics attributable to maternal physiological changes, as well as the potential for fetal adverse effects. Electric cardioversion is a safe and effective intervention during pregnancy and should be performed immediately in patients with hemodynamic instability. This review discusses the pathophysiology of arrythmias in pregnancy and their management.

Practical Review of Mechanical Ventilation in Adults and Children in The Operating Room and Emergency Department

BACKGROUND

During general anesthesia, mechanical ventilation can cause pulmonary damage through mechanism of ventilator-induced lung injury which is a major cause of postoperative pulmonary complications, which varies between 5 and 33% and increases significantly the 30-day mortality of the surgical patient.

OBJECTIVE

The aim of this review is to analyze different variables which played key role in safe application of mechanical ventilation in the operating room and emergency setting.

METHOD

Also, we wanted to analyze different types of population that underwent intraoperative mechanical ventilation like obese patients, pediatric and adult population and different strategies such as one lung ventilation and ventilation in trendelemburg position. The peer-reviewed articles analyzed were selected according to PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) from Pubmed/Medline, Ovid/Wiley and Cochrane Library, combining key terms such as: "pulmonary post-operative complications", "protective ventilation", "alveolar recruitment maneuvers", "respiratory compliance", "intraoperative paediatric ventilation", "best peep", "types of ventilation". Among the 230 papers identified, 150 articles were selected, after title - abstract examination and removing the duplicates, resulting in 94 articles related to mechanical ventilation in operating room and emergency setting that were analyzed.

RESULTS

Careful preoperative patient's evaluation and protective ventilation (i.e. use of low tidal volumes, adequate PEEP and alveolar recruitment maneuvers) has been shown to be effective not only in limiting alveolar de-recruitment, alveolar overdistension and lung damage, but also in reducing the onset of pulmonary post-operative complications (PPCs).

CONCLUSION

Mechanical ventilation is like "Janus Bi-front" because it is essential for surgical procedures, for the care of critical care patients and in life-threatening conditions but it can be harmful to the patient if continued for a long time and where an excessive dose of oxygen is administered into the lungs. Low tidal volume is associated with minor rate of PPCs and other complications and every complication can increase length of Stay, adding cost to NHS between 1580 € and 1650 € per day in Europe and currently the prevention of PPCS is only weapon that we possess.

Alterations of Left Ventricular Function Persisting during Post-Acute COVID-19 in Subjects without Previously Diagnosed Cardiovascular Pathology

(1) Background: Coronavirus infection (Covid-19) has emerged as a severe medical condition, associated with high pulmonary morbidity and often with cardiovascular (CV) complications. This study aims to evidence the persistence of left ventricular (LV) systolic function (LV-SF) alterations and diastolic dysfunction (DD) in COVID-19 patients without history of cardiovascular (CV) diseases by transthoracic echocardiography (TTE). (2) Methods: 125 patients, aged under 55 years, hospitalized during the first outbreak of Covid-19 for moderate pneumonia, underwent a comprehensive cardiologic examination and TTE at 6-10 weeks after discharge. Their initial in-hospital laboratory data and thorax computer tomography (TCT) were accessed from the electronic database of the hospital. (3) Results: with TTE, we documented alterations of LV-SF and DD in 8.8% of patients and in 16.8% only patterns of DD, statistically correlated with the initial levels of creatin-kinase (CK-MB) and inflammatory factors. Multivariate regression analysis evidenced that CK-MB levels, age, and body mass index (BMI) are responsible for 65% of LV-SF decrease. (4) Conclusions: Alterations of LV-SF and DD are frequent in post-acute COVID-19 infection and are responsible for the persistence of symptoms. Elevated myocardial necrosis markers during the acute phase seem to predict subsequent alteration of cardiac performance.

Three-Dimensional Transesophageal Echocardiography as an Alternative to Multidetector Computed Tomography in Aortic Annular Diameter Measurements for Transcatheter Aortic Valve Implantation

Simple Summary

Patients who have multiple associated comorbidities and need to change the aortic valve may have a contraindication to open-heart surgery, the alternative being transcatheter aortic valve implantation, which requires very precise measurements of the aortic annulus to determine the dimensions of the prostheses. Ultrasonographic imaging techniques, such as transesophageal echocardiography, are constantly evolving. The aim of our study was to compare the three-dimensional transesophageal echocardiography and multi-detector computer tomography methods, with the former being an alternative for patients who cannot undergo computer tomography because of a major contraindication. We have demonstrated that there were small differences between aortic annular measurements using multi-detector computer tomography (2.25 ± 0.19 cm) and three-dimensional transesophageal echocardiography (2.25 ± 0.15 cm). Thus, three-dimensional transesophageal echocardiography can be the solution for aortic annular measurements used to select the correct prosthesis for the transcatheter aortic valve implantation procedure in patients who cannot undergo computer tomography.

Abstract

Background and objectives: Transcatheter aortic valve implantation (TAVI) is a therapeutic choice for high surgical risk patients, serving as an alternative to open-heart surgery. Correct measurement of the aortic annulus, which leads to the selection of a suitable prosthesis and accurate outcome prediction, is essential for the success of TAVI. The objective of this study is to evaluate the accuracy of novel imaging te chniques in measuring the aortic annulus by comparing multi-detector computer tomography (MDCT) and three-dimensional transesophageal echocardiography (3D TEE) for the selection of the optimal prosthesis. Materials and Methods: Measurements of the aortic annulus have been performed on 25 patients using MDCT and TEE, and the correlation and agreement levels between the two measuring techniques were analyzed. MDCT measurements were used for the sizing of the prostheses. Results: MDCT and TEE measurements of aortic annular diameters were significantly correlated, with a mean difference of 0.001 cm. Conclusions: 3D TEE measurements have been in good agreement with MDCT and, therefore, 3D TEE can be used as an alternative in cases where MDCT is contraindicated or not available.

Risk Management and Treatment of Coagulation Disorders Related to COVID-19 Infection

Coronavirus disease 2019 (COVID-19) is an emerging infectious disease. Bilateral pneumonia, acute respiratory failure, systemic inflammation, endothelial dysfunction and coagulation activation are key features of severe COVID-19. Fibrinogen and D-dimer levels are typically increased. The risk for venous thromboembolism is markedly increased, especially in patients in the intensive care unit despite prophylactic dose anticoagulation. Pulmonary microvascular thrombosis has also been described and the risk for arterial thrombotic diseases also appears to be increased while bleeding is less common than thrombosis, but it can occur. Evaluation for venous thromboembolism may be challenging because symptoms of pulmonary embolism overlap with COVID-19, and imaging studies may not be feasible in all cases. The threshold for evaluation or diagnosis of thromboembolism should be low given the high frequency of these events. Management and treatment are new challenges due to the paucity of high-quality evidence regarding efficacy and safety of different approaches to prevent or treat thromboembolic complications of the disease. All inpatients should receive thromboprophylaxis unless contraindicated. Some institutional protocols provide more aggressive anticoagulation with intermediate or even therapeutic dose anticoagulation for COVID-19 patients admitted to ICU. Therapeutic dose anticoagulation is always appropriate to treat deep venous thrombosis or pulmonary embolism, unless contraindicated. This article reviews evaluation and management of coagulation abnormalities in individuals with COVID-19.