Systolic anterior motion (SAM) of the mitral valve refers to the unusual movement of the anterior and sometimes the posterior mitral valve leaflets toward the left ventricular outflow tract (LVOT) during systole. This phenomenon is most frequently associated with the asymmetric septal variant of hypertrophic cardiomyopathy (HCM), but it can also occur in conditions like acute myocardial infarction, diabetes mellitus, hypertensive heart disease, after mitral valve repair, and even in asymptomatic individuals during dobutamine stress tests. We present a case of transient SAM induced by a junctional rhythm along with high doses of dobutamine and nitroglycerin in an intensive care unit (ICU) setting. Transesophageal echocardiography (TEE) played a crucial role in detecting SAM and showed that transitioning from a junctional rhythm to a ventricular paced rhythm led to an improvement in the SAM condition.
Category Archives: issue
Comparative assessment of hemodynamic changes and outcomes in ventilator weaning
Introduction: Mechanical ventilation is fundamental for the management of critically ill patients. The mode of mechanical ventilation may impact the patient in different ways. This study aimed to assess the hemodynamic changes occurring when transitioning between Volume-Controlled Ventilation (VCV) to Variable Pressure Support (VPS) and VCV to Pressure Support (PS) by echocardiography. Also, a comparison between the spontaneous breathing modes in terms of outcomes, specifically, weaning of mechanical ventilation, days on a ventilator, hospital days, and survival, was conducted.
Methods: This prospective observational study was conducted on 40 mechanically ventilated patients who showed readiness for weaning from Mechanical ventilation. When transitioning between VCV and VPS in arm A and from VCV to PS in arm B, an echocardiographic assessment (transesophageal echocardiography and transthoracic echocardiography) was performed. Both modes were further compared in terms of weaning and the success of liberation from mechanical ventilation.
Results: By comparing both arms, there was a significant difference in velocity time integral (VTI) and stroke volume (SV) for TEE and TTE with p-values of 0.044, 0.022, and 0.05, 0.059, respectively. Also, the cardiac output (CO) showed a statistically significant difference between both arms with a p-value of 0.04. On the other side, there was no statistically significant difference between both arms in terms of ventilator days (p-value of 0.88), length of stay (p-value of 0.651), weaning trial success (p-value of 0.525), and survival rate (p-value of 0.525).
Conclusion: The study showed that VPS is a promising modality that can be used in place of PS as a weaning mode. It provides better patient comfort and a more physiological way of breath delivery. The study also concluded that TTE and TEE will show similar results in most patients and that both can be used interchangeably.
The challenge of antimicrobial resistance in intensive care setting
Antimicrobial resistance (AMR) is a growing global health crisis, also in the frame of One Health perspective (1). This problem represents a dramatic emergency in critical care settings like intensive care units (ICUs), where patients are most vulnerable, also because of persistent lack in the pharmaceutical pipeline for the development of new antibiotics (2-4). ICUs are the front line in managing patients with life-threatening conditions, such as severe infections, trauma, and organ failure. Therefore, ICUs present unique conditions – as patients are critically ill, immunocompromised, and often subjected to invasive procedures and extended hospital stays — provide an ideal environment for the emergence and spread of resistant pathogens. AMR poses significant challenges for healthcare providers in ICUs, where timely and effective antibiotic treatment is crucial, directly impacting on clinical outcomes, mortality rates and increased healthcare costs (5). [More]
Volume 11, Issue 2, April 2025
Characteristics and temporality of the ventilatory techniques in the management of acute respiratory distress syndrome: A scoping review
Introduction: Acute Respiratory Distress Syndrome (ARDS) is a critical condition characterised by acute respiratory failure due to increased alveolar-capillary membrane permeability. This leads to non-cardiogenic pulmonary oedema, hypoxemia, and impaired respiratory compliance, significantly impacting patients’ survival and quality of life. The management of ARDS involves various ventilatory and non-ventilatory therapies. Understanding the optimal timing and application of these therapies is crucial for improving patient outcomes.
Aim of the study: This scoping review aims to identify and synthesise the ventilatory techniques used in managing ARDS, focusing on their temporality and the interplay between different therapies. The study seeks to synthesize the available evidence and summarize current management strategies, highlighting areas for further research and improvement in ARDS care.
Material and Methods: A systematic search of PubMed, EBSCO, and ScienceDirect databases was conducted, following the Joanna Briggs Institute guidelines (2015), for articles published between 2013 and 2023. Studies involving adult patients (18 years or older) diagnosed with ARDS and receiving ventilatory support in the ICU were included. Exclusion criteria included other acute respiratory pathologies, clinically extreme obese patients, and patients with tracheostomy.
Results: 437 articles were identified through the database search, of which 23 met the inclusion criteria and were included in the final review. Most articles were published between 2015-2019 (43.5%), originated from the USA (34.78%), and employed observational study designs (73.91%). The included studies reported on patients aged between 23 and 79 years, with intrapulmonary causes being the most common aetiology for ARDS. Various ventilatory strategies were identified, including conventional oxygen therapy, high-flow nasal cannula (HFNC), non-invasive ventilation (NIV), invasive ventilation (IMV), and combined approaches. Temporality was reported in 35% of the articles, but none of them as their primary focus.
Conclusions: The review highlights the diversity of ventilatory techniques employed in ARDS management and the importance of individualizing treatment strategies based on patient response and disease severity. The temporality of these interventions remains a crucial aspect, requiring further investigation to establish clearer guidelines for optimizing the timing and sequence of ventilatory support in ARDS. The findings underscore the need for future research to focus on patient-centred outcomes and the long-term implications of ARDS management, including quality of life and functional status.
A brief report on the association of preoperative hematological indices and acute deep vein thrombosis following total hip arthroplasty for osteoarthritis
Introduction: Total hip arthroplasty (THA) is a standard orthopedic procedure. Deep vein thrombosis (DVT) and pulmonary embolism are potential life-threatening postoperative complications.
Aim of the study: This study aimed to assess the prognostic value of systemic inflammatory indices [monocyte-to-lymphocyte ratio (MLR), neutrophil-to-lymphocyte ratio (NLR), platelets-to-lymphocyte ratio (PLR), systemic inflammatory index (SII), systemic inflammation response index (SIRI), and aggregate index of systemic inflammation (AISI)] and their potential association with acute postoperative DVT.
Materials and methods: We designed a multicentric, retrospective, observational cohort study, including adult patients undergoing elective HTA. Patients were divided into two groups, the DVT and non-DVT groups. We investigated the development of acute DVT early, and at 4 weeks after surgery and also registered length of hospital stay and mortality. All demographic data and laboratory data, hematological indices were extracted from patients files.
Results: 199 patients were included. Of those, 12 (6.03%) developed DVT and 187 (93.97%) did not. There was no statistically significant difference between patient age, gender, BMI, smoking status or comorbidities. No difference was founds between the two groups regarding median values of MLR (0.31 vs 0.27, p=0.12), NLR (3.16 vs 2.42, p=0.27), PLR (163.39 vs 123.01, p=0.27), SII (660.26 vs 568.52, p=0.33), SIRI (67.5 vs 65.26, p=0.89) and AISI (302.35 vs 290.48, p=0.85). Length of hospital stay was not significantly different (median 9 days in the DVT group vs 7 days in the non-DVT group, p=0.38), but mortality was significantly higher in the DVT group (3 deaths vs none in the non-DVT group, p<0.001).
Conclusion: MLR, NLR, PRL, SII, SIRI and AISI were not associated with the development of acute DVT following HTA in our study population.
Ability to identify patient-ventilator asynchronies in intensive care unit professionals: A multicenter cross-sectional analytical study
Introduction: Patient-ventilator asynchrony (PVA) is frequent in intensive care. Its presence is associated with prolonged days of mechanical ventilation and may lead to increased mortality in the intensive care unit (ICU) and hospital. Little is known about the ability of Colombian intensive care professionals to identify asynchronies, and the factors associated with their correct identification are not apparent.
Aim of the study: To describe the ability of Colombian intensive care professionals to identify patient-ventilator asynchronies (PVA) using waveform analysis. In addition, to define the characteristics associated with correctly detecting PVA.
Material and methods: We conducted a multicenter, cross-sectional, national survey-based study between January and August 2024. Colombian physiotherapists, respiratory therapists, nurses and intensive care physicians from 24 departments participated in the study. An online survey was used. They were asked to identify six different PVAs presented as videos. The videos were displayed using pressure/time and flow/time waveform of a Puritan Bennett 840 ventilator.
Results: We recruited 900 participants, 60% female, most of whom were physiotherapists (53%). Most professionals had specialty training in critical care (42%), and 32% reported having specific PVA training. Double triggering was the most frequently identified PVA (75%). However, only 3.67% of participants recognized all six PVAs. According to multiple logistic regression analysis, working in a mixed unit (OR 2.59; 95% CI 1.19 – 5.54), caring for neonates (OR 5.19; 95% CI 1.77 – 15.20), and having specific training (OR 2.38; 95% CI 1.16 – 4.76) increases the chance of correctly recognizing all PVAs.
Conclusion: In Colombia, a low percentage of professionals recognize all PVAs. Having specific training in this topic, working in mixed ICUs and neonatal intensive care was significantly associated with identifying all PVAs.
Latent class analysis for identification of sub-phenotypes predicting prognosis in hospitalized out-of-hospital cardiac arrest
Aim of the study: To determine which out-of-hospital cardiac arrest (OHCA) patients should receive advanced treatment is extremely challenging. The objective was to identify sub-phenotypes predicting the prognoses of adult OHCA patients by latent class analysis (LCA) using data up to just after admission.
Material and Methods: We conducted a retrospective observational study using multicentre OHCA registry from 95 Japanese hospitals including adult non-traumatic hospitalized OHCA. The primary outcome was 30-day favourable neurological outcome. Our LCA used clinically relevant variables up to just after admission and the optimal class number was determined from clinical importance and Bayesian information criterion. The associations between sub-phenotypes and outcomes were analysed using univariate logistic regression analysis with odds ratios (ORs) and 95% confidence intervals (CIs).
Results: Our LCA included 2,162 patients and identified four sub-phenotypes. The base excess on hospital arrival had the highest discriminative power. Thirty-day favourable neurological outcomes were observed in 526 patients (24.3%), including 284 (53.8%) in Group 1, 179 (21.2%) in Group 2, 26 (11.4%) in Group 3, and 37 (6.6%) in Group 4. Prehospital return of spontaneous circulation (ROSC) was achieved in 1,009 patients (46.7%), including 379 (81.8%) in Group 1, 340 (40.3%) in Group 2, 115 (50.4%) in Group 3, and 175 (31.1%) in Group 4. Univariate logistic regression analysis for primary outcome using Group 4 as reference revealed ORs (95% CI) of 16.5 (11.4–24.1) in Group 1, 3.83 (2.64–5.56) in Group 2, and 1.83 (1.08–3.10) in Group 3.
Conclusions: Our LCA classified OHCA into four sub-phenotypes showing significant differences for prognosis. In cases who achieved prehospital ROSC, it might be meaningful to continue advanced therapeutic interventions.
Use of prone position in spontaneous breathing in patients with COVID-19
Objective: To investigate if awake prone position (PP) reduces the rate of endotracheal intubation and mortality in patients with COVID-19 admitted to the intensive care unit (ICU).
Methods: This was a retrospective cohort study of 726 patients who were admitted to the ICU with acute hypoxic respiratory failure secondary to COVID-19. The protocol of the institution recommended the use of awake PP in patients with nasal catheter with an oxygen flow ≥ 5 L/min and SpO2 ≤ 90% or a high-flow nasal catheter (HFNC) with FiO2 ≥ 50% and SpO2 ≤ 90%. The following data were collected: age, comorbidities, SAPS-3 score, onset of symptoms, the degree of pulmonary involvement, duration of invasive and noninvasive MV, HFNC therapy, nitric oxide therapy, hemodialysis and PP while spontaneously breathing.
Results: There was a higher mortality rate in the supine position group (27.1%) than in the awake PP group (13.9%). There was no significant difference in the time on MV or number of patients on MV (p>0.05). The variables with p < 0.05 in the bivariate analysis were entered into the Cox regression model. The model was adjusted for awake PP, sex, age, SAPS-3 score, onset of symptoms, the degree of pulmonary involvement, chronic arterial disease, and noninvasive ventilation. The only variable associated with lower mortality over time was awake PP (hazard ratio: 0.55; 95% confidence interval: 0.33-0.92).
Conclusion: Awake prone position has been shown to be a safe and effective therapy that reduced mortality but not the risk of intubation in patients with COVID-19.
The effect of antiseizure medication on mortality in spontaneous aneurysmal subarachnoid hemorrhage
Background: Spontaneous aneurysmal subarachnoid hemorrhage (aSAH) is a major cause of morbidity and mortality in the United States. The efficacy of early antiseizure medication (ASM) is debated. Recent literature reports seizure rates ranging from 7.8% to 15.2% following spontaneous aSAH. Current guidelines recommend use of early ASM in patients with “high-risk features,” but whether early ASM use decreases the rate of death associated with aSAH remains unclear. This study assessed whether early administration of early ASM impacts mortality rates after spontaneous aSAH.
Methods: We conducted a retrospective cohort study using a publicly available dataset from the Massachusetts Institute of Technology, Medical Information Mart for Intensive Care-III (MIMIC) database of all patients over the age of 18 with spontaneous aSAH resulting in an intensive care unit (ICU) admission to a major United States trauma center from 2001 to 2012. The primary exposure was receiving early ASM and primary outcome of death within 7 days. Different regression models were created to explore the association between early ASM administration within 24 hours of admission and a composite outcome of seizure and/or death within 7 days of admission. Secondary outcomes included 30-day and one-year mortality.
Results: Of 253 patients with spontaneous aSAH, 148 received early ASM within 24 hours. Patients who did receive early ASM were less likely to die within 7 days of admission (adjusted odd ratio, [aOR]: 0.26 95% CI 0.10 to 0.68; P=0.006) but were more likely to have a seizure (aOR: 7.63 95% CI 2.07 to 28.17; P=0.002).
Conclusion: Early ASM administration was associated with lower rates of death and composite death/seizure within 7 days of admission among patients who presented to an ICU with spontaneous aSAH. These findings suggest broader use of early ASM in patients who present with spontaneous aSAH may improve early mortality.