Intensive Care Network Podcasts

Survival in patients with advanced heart failure (AHF) has improved over the last 2 decades. An increasing number of patients however, are dying with progressive heart failure over the same duration. Optimal utilization of medical therapies and devices like implantable defibrillators and biventricular pacemakers are the likely reasons patients are surviving longer albeit with progressive HF.   Evolution in mechanical circulatory support (MCS) devices has occurred over the same period, such that they can now be rapidly instituted providing support for pump failure, often percutaneously, with timely restitution of physiologic and metabolic derangements with fewer complications.    MCS devices can be classified as Short term and Long term. Short term devices such as Intraaortic balloon pumps (IABP), Impella ®, TandemHeart® or Venoarterial extracorporeal membrane oxygenation (VA – ECMO) using a Cardiohelp® device, are usually employed as ‘Bridge to Recovery’(BTR) or Bridge to Decision’(BTD), usually in acu

When is an arrhythmia important? Can you tell, or should you always refer to a cardiologist? What are the best management strategies for common arrhythmias and are there any potential problems to be aware of? What about the “do not miss” diagnoses?    Arrhythmias are common in critically unwell patients, and may represent primary cardiac pathology, or the cardiac response to underlying pathology. Estimates for the incidence of arrhythmias in patients in the intensive care unit (ICU) vary widely. Atrial fibrillation is the most common arrhythmia in the ICU, and management varies according to patient instability, underlying comorbidities and conditions, with important features that may favour a rate-control strategy over cardioversion, or a pharmacologic cardioversion over an electrical cardioversion. Atrial tachycardias are less common, but may have important consequences, and be difficult to manage in the intensive care patient. Ventricular arrhythmias are often immediately life threatening, and may requ

Patients admitted to the intensive care unit (ICU) are at increased risk for cardiac arrhythmias. They may be the reason for admission or resulting from the underlying condition. Treating exacerbating and contributing factors is the first step in management, however in certain cases may not be sufficient. Further the diagnosis of the arrhythmia may difficult from the ECG. An invasive cardiac electrophysiology study (EPS) can be helpful in establishing the diagnosis and can be combined with catheter ablation to eliminate the substrate. The field of cardiac electrophysiology is rapidly developing with technological advances providing insights into the mechanism of certain arrhythmias and expanding the therapeutic potential. This presentation will provide an overview of recent developments and insights into the management of common arrhythmias on the ICU.   

The intent of this presentation is to provide an update of coronary assessment and management for the adult intensivist. Discussion points will include:   1. An assessment of coronary severity, using established methods, in particular fractional flow reserve (FFR),   2. Which stent- highlight the evolution of the stent to the current generation and what is evolving,  3. How to keep the stent open with current concepts of antiplatelet therapy and how this impacts the critically ill patient   4. What to consider if the ECG is abnormal, but the coronaries are not flow limiting obstruction- an occasional dilemma in the critically ill patient and finally   5.  Discussion around a contemporary study regarding cardiogenic shock and coronary ischemia.  

Debate: Who should care for GUCH? Presenters: Dr Susanna Price & Dr Peta Alexander. Moderator: Dr Bennett Sheridan

GUCH - A growing problem by Dr Susanna Price.

Congenital Heart Disease (CHD) in infants presents as inadequate systemic or pulmonary blood flow, or heart failure from intra-cardiac shunts. Approaches to surgical intervention comprise primary repair, early palliation with subsequent repair or definitive palliation.  CHD palliation evolved in the pre-cardiopulmonary bypass era. In 1938 a patent ductus arteriosus was ligated, in 1944 pulmonary blood flow was established via subclavian artery to pulmonary artery anastomosis (Blalock, Taussig and Thomas), and in 1952 pulmonary artery banding was employed to protect pulmonary vasculature. In the 1950s-60s symptomatic infants underwent these palliative procedures with reparative intra-cardiac interventions delayed due to perceived risk. In the late 1960s emerging publications shifted the focus to early primary repair.   An exponential increase in the complexity of surgical repairs over the past 50 years have built on early innovation, exemplified by management of transposition of the great arteries. Surgical ap

Inotropic agents are commonly used in critically ill patients to support myocardia contractility either in the setting of cardiac surgery or ischemia or in the setting of sepsis associated myocardial dysfunction. The most commonly used agents are beta-agonist drugs (dobutamine), mixed beta and alpha agents (adrenaline and dopamine), phosphodiesterase inhibitors (inodilators) such as milrinone or enoximone or calcium sensitizers (levosimendan). Such agents are currently used according to clinician and/or unit preference based on tradition, mentorship, belief, inductive physiological reasoning, familiarity, understanding of pharmacokinetic and pharmacodynamics properties, side effects, and cost. No randomized controlled trials exist to support the notion that treatment targeted to similar physiological outcomes (ie cardiac index or MVO2) with one drug versus another would yield a different clinical outcome. More recently, however, two double-blind RCTs have compared adjunctive inotropic therapy with levosimenda

Acute heart failure (AHF) is defined as rapid onset of new or worsening signs and symptoms of heart failure. It represents a life-threatening condition requiring treatment for fluid overload and hemodynamic compromise. Presentation may be initial diagnosis with symptoms and signs of AHF or acute decompensation of pre-existing cardiomyopathy. Hemodynamic instability results from disorders of the myocardium, valves, conduction system or pericardium, in isolation or combination. Potentially treatable causes, e.g. acute coronary syndromes, must be diagnosed and managed early for restoration of function.   Physiological changes associated with AHF result in reduced cardiac output and end-organ hypoperfusion. Once potentially treatable causes are managed, stratification of patients by clinical presentation guides further therapeutic intervention. AHF patients can be categorized as either ‘wet’ or ‘dry’ by clinical fluid status assessment, and either ‘cold’ or ‘warm’ according to perfusion status. In combination, th

In non-cardiac ICU patients, the two major causes of acute myocardial dysfunction are sepsis-related cardiac depression (SRCD) and stress-related cardiomyopathy, the most common cause being the former. The main mechanisms responsible for SRCD include release of cardiac-depressant substances such as pro-inflammatory cytokines, hyporesponsiveness of beta-adrenergic receptors, decreased sensitivity of the myofilament to Ca++, and excessive production of perioxynitrite. Echocardiography is the best method to diagnose SRCD. If a cut-off value of 45% left ventricular ejection fraction is used to define SRCD, the occurrence of SRCD is 60% in septic shock patients (40% on the day of admission and in 20% the two following days). Recent advances in ultrasonography such as speckle-tracking (measuring the longitudinal systolic strain) may allow detecting cardiac abnormalities that are not detected by conventional echocardiography. Even when the SRCD is diagnosed, an important issue is to decide to treat it since left ven

Ventricular pump function is often compromised during critical illness and for a variety of reasons. The most common cause of a limited cardiac output in acutely ill patients is right ventricular (RV) dysfunction. Exacerbations of chronic obstructive lung disease or the use of high end-expiratory pressure sin acute lung injury to support arterial oxygenation can result in acute elevations of pulmonary arterial pressure impeding RV ejection, causing RV dilation, decreased left ventricular (LV) diastolic compliance. All these effects limit cardiac output and LV stroke volume. Importantly, the treatment is to sustain mean arterial pressure greater than pulmonary artery pressure to prevent RV ischemia and balance RV fluid status to avoid both over-distention (acute cor pulmonale) and under-filling. This delicate fluid balance is greatly facilitated by the immediate and repeated use of bedside echocardiography. Attempts to minimize lung over distention should be a primary focus of therapy.  If one focuses only on

Over 65,000 people are diagnosed with heart failure every year in Australia. Heart failure is implicated in the deaths of 61,000 individuals per year. Although the need for cardiovascular support is common in patients in the Intensive Care Unit (ICU) with about 60% of ventilated patients requiring some form of inotropic or vasopressor support, a primary diagnosis of acute heart failure on admission to ICU is much less common. There are about 3000 ICU admissions per year primarily due to cardiogenic shock, cardiomyopathy or congestive heart failure in Australia and New Zealand. This represents 2% of all ICU admissions. Only a minority of these patients have a prior history of significant cardiac disease. The mortality of these three conditions are 40%, 17% and 14% respectively. Since the early 2000’s there has been a progressive decline in risk adjusted mortality of all patients admitted to ANZ ICUs. However, the decline in mortality for patients with acute heart failure has lagged behind other diagnoses. This

Shree Basu and Ahmed Osman discuss paediatric traumatic brain injury. They cover initial management, prevention of secondary injury, what is different in paediatrics compared to adults and the latest evidence. From www.IntensiveCareNetwork.com

Shree Basu is joined by Marino Festa to discuss sepsis. They cover epidemiology, challenges in diagnosing sepsis, SEPSIS 3 guidelines and what it means in paediatrics, and some clinical tips on the assessment and management of children with sepsis. Here's a useful articleon the prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. From www.IntensiveCareNetwork.com

My own experience by Ms Claire Kerr. Ms Kerr is a nurse who also spent significant amounts of time in hospital as an adolescent. Claire outlines her own experience in the hospital system and the things that made a difference for her.

In this episode Shree Basu and Ahmed Osman discuss the shocked neonate - both the initial management when they present and the subsequent PICU management. From IntensiveCareNetwork.com

Prehospital Damage Control Resuscitation by Ann Weaver

In this episode Shree Basu and Ahmed Osman discuss the tricky issues surrounding management of paeds CICU patients with a single ventricle. From IntensiveCareNetwork.com

Shree Basu and Lily Foster are paediatric intensive care trainees. They discuss post operative management in paediatric cardiac intensive care following surgery for congenital heart disease.