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1.
Respir Physiol Neurobiol ; 298: 103844, 2022 04.
Article in English | MEDLINE | ID: covidwho-1620996

ABSTRACT

BACKGROUND: Use of high positive end-expiratory pressure (PEEP) and prone positioning is common in patients with COVID-19-induced acute respiratory failure. Few data clarify the hemodynamic effects of these interventions in this specific condition. We performed a physiologic study to assess the hemodynamic effects of PEEP and prone position during COVID-19 respiratory failure. METHODS: Nine adult patients mechanically ventilated due to COVID-19 infection and fulfilling moderate-to-severe ARDS criteria were studied. Respiratory mechanics, gas exchange, cardiac output, oxygen consumption, systemic and pulmonary pressures were recorded through pulmonary arterial catheterization at PEEP of 15 and 5 cmH2O, and after prone positioning. Recruitability was assessed through the recruitment-to-inflation ratio. RESULTS: High PEEP improved PaO2/FiO2 ratio in all patients (p = 0.004), and significantly decreased pulmonary shunt fraction (p = 0.012), regardless of lung recruitability. PEEP-induced increases in PaO2/FiO2 changes were strictly correlated with shunt fraction reduction (rho=-0.82, p = 0.01). From low to high PEEP, cardiac output decreased by 18 % (p = 0.05) and central venous pressure increased by 17 % (p = 0.015). As compared to supine position with low PEEP, prone positioning significantly decreased pulmonary shunt fraction (p = 0.03), increased PaO2/FiO2 (p = 0.03) and mixed venous oxygen saturation (p = 0.016), without affecting cardiac output. PaO2/FiO2 was improved by prone position also when compared to high PEEP (p = 0.03). CONCLUSIONS: In patients with moderate-to-severe ARDS due to COVID-19, PEEP and prone position improve arterial oxygenation. Changes in cardiac output contribute to the effects of PEEP but not of prone position, which appears the most effective intervention to improve oxygenation with no hemodynamic side effects.


Subject(s)
Blood Pressure/physiology , COVID-19/physiopathology , COVID-19/therapy , Heart Rate/physiology , Outcome and Process Assessment, Health Care , Oxygen Consumption/physiology , Positive-Pressure Respiration , Prone Position , Vascular Resistance/physiology , Aged , Aged, 80 and over , Female , Hemodynamic Monitoring , Humans , Intensive Care Units , Italy , Male , Middle Aged , Prone Position/physiology
2.
Prog Cardiovasc Dis ; 69: 47-53, 2021.
Article in English | MEDLINE | ID: covidwho-1536982

ABSTRACT

Heart failure (HF) is associated with considerable morbidity and mortality. The increasing prevalence of HF and inpatient HF hospitalization has a considerable burden on healthcare cost and utilization. The recognition that hemodynamic changes in pulmonary artery pressure (PAP) and left atrial pressure precede the signs and symptoms of HF has led to interest in hemodynamic guided HF therapy as an approach to allow earlier intervention during a heart failure decompensation. Remote patient monitoring (RPM) utilizing telecommunication, cardiac implantable electronic device parameters and implantable hemodynamic monitors (IHM) have largely failed to demonstrate favorable outcomes in multicenter trials. However, one positive randomized clinical trial testing the CardioMEMS device (followed by Food and Drug Administration approval) has generated renewed interest in PAP monitoring in the HF population to decrease hospitalization and improve quality of life. The COVID-19 pandemic has also stirred a resurgence in the utilization of telehealth to which RPM using IHM may be complementary. The cost effectiveness of these monitors continues to be a matter of debate. Future iterations of devices aim to be smaller, less burdensome for the patient, less dependent on patient compliance, and less cumbersome for health care providers with the integration of artificial intelligence coupled with sophisticated data management and interpretation tools. Currently, use of IHM may be considered in advanced heart failure patients with the support of structured programs.


Subject(s)
Arterial Pressure , Atrial Function, Left , Atrial Pressure , Heart Failure/diagnosis , Hemodynamic Monitoring/instrumentation , Pulmonary Artery/physiopathology , Remote Sensing Technology/instrumentation , Telemedicine/instrumentation , Algorithms , COVID-19 , Diffusion of Innovation , Equipment Design , Heart Failure/physiopathology , Heart Failure/therapy , Humans , Predictive Value of Tests , Prognosis , Reproducibility of Results , Signal Processing, Computer-Assisted
3.
Sensors (Basel) ; 21(7)2021 Mar 27.
Article in English | MEDLINE | ID: covidwho-1308416

ABSTRACT

The CardioMEMS pulmonary artery (PA) monitoring system placed in the left lower lobe pulmonary artery is capable of measuring pulmonary artery pressure remotely as a surrogate of intracardiac filling pressures and volume status. The technique is safe and reliable. By using remote PA monitoring for proactive medical interventions, there is a growing body of clinical evidence for a substantial, robust reduction in HF hospitalizations in various populations (clinical trial setting, post-marketing studies and real-world experiences). This review summarizes the clinical evidence, outlines future perspectives, and aims for remote patient care in heart failure using CardioMEMS.


Subject(s)
Heart Failure , Hemodynamic Monitoring , Chronic Disease , Heart Failure/diagnosis , Heart Failure/therapy , Humans , Pulmonary Artery
4.
J Intensive Care Med ; 36(5): 511-523, 2021 May.
Article in English | MEDLINE | ID: covidwho-1029763

ABSTRACT

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to "collateral damage" in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.


Subject(s)
Acute-On-Chronic Liver Failure , COVID-19 , Critical Care , Echocardiography/methods , Liver Cirrhosis , Point-of-Care Systems , Remote Consultation , Shock , Acute-On-Chronic Liver Failure/etiology , Acute-On-Chronic Liver Failure/physiopathology , Acute-On-Chronic Liver Failure/therapy , COVID-19/epidemiology , COVID-19/prevention & control , Cardiology/trends , Critical Care/methods , Critical Care/organization & administration , Critical Illness/therapy , Delayed Diagnosis/prevention & control , Hemodynamic Monitoring/instrumentation , Hemodynamic Monitoring/methods , Humans , Infection Control , Liver Cirrhosis/complications , Liver Cirrhosis/physiopathology , Liver Cirrhosis/therapy , Organizational Innovation , Remote Consultation/instrumentation , Remote Consultation/methods , Remote Consultation/organization & administration , SARS-CoV-2 , Shock/diagnosis , Shock/etiology , Shock/therapy
5.
Curr Heart Fail Rep ; 18(1): 12-22, 2021 02.
Article in English | MEDLINE | ID: covidwho-1014219

ABSTRACT

PURPOSE OF REVIEW: Wireless hemodynamic monitoring in heart failure patients allows for volume assessment without the need for physical exam. Data obtained from these devices is used to assist patient management and avoid heart failure hospitalizations. In this review, we outline the various devices, mechanisms they utilize, and effects on heart failure patients. RECENT FINDINGS: New applications of these devices to specific populations may expand the pool of patients that may benefit. In the COVID-19 pandemic with a growing emphasis on virtual visits, remote monitoring can add vital ancillary data. Wireless hemodynamic monitoring with a pulmonary artery pressure sensor is a highly effective and safe method to assess for worsening intracardiac pressures that may predict heart failure events, giving lead time that is valuable to keep patients optimized. Implantation of this device has been found to improve outcomes in heart failure patients regardless of preserved or reduced ejection fraction.


Subject(s)
COVID-19/epidemiology , Heart Failure/diagnosis , Heart Failure/therapy , Hemodynamic Monitoring/instrumentation , Pulmonary Artery , Hemodynamic Monitoring/methods , Humans , Quality of Life , Randomized Controlled Trials as Topic , User-Computer Interface
6.
Anaesthesiol Intensive Ther ; 52(5): 409-417, 2020.
Article in English | MEDLINE | ID: covidwho-983605

ABSTRACT

The SARS-CoV-2-related disease has an undoubted impact on the healthcare system. In the treatment of severe COVID-19 cases, the main focus is on respiratory failure. However, available data suggest an important contribution of haemodynamic impairment in the course of this disease. SARS-CoV-2 may affect the circulatory system in various ways that are universal for septic conditions. Nonetheless, unique features of this pathogen, e.g. direct insult leading to myocarditis and renin-angiotensin-aldosterone axis dysregulation, must be taken into account. Although current recommendations on COVID-19 resemble previous septic shock guidelines, special attention to haemodynamic monitoring and treatment is necessary. Regarding treatment, one must take into account the potential profound hypovolaemia of severe COVID-19 patients. Pharmacological cardiovascular support should follow existing guidelines and practice. Interesting concepts of decatecholaminisation and the effect of vasopressors on pulmonary circulation are also presented in this review on COVID-19-related haemodynamic failure.


Subject(s)
COVID-19/physiopathology , COVID-19/therapy , Hemodynamics , COVID-19/complications , Cardiovascular Diseases/etiology , Cardiovascular Diseases/therapy , Critical Care , Hemodynamic Monitoring , Humans
8.
Anaesth Crit Care Pain Med ; 39(5): 563-569, 2020 10.
Article in English | MEDLINE | ID: covidwho-696277

ABSTRACT

PURPOSE: To survey haemodynamic monitoring and management practices in intensive care patients with the coronavirus disease 2019 (COVID-19). METHODS: A questionnaire was shared on social networks or via email by the authors and by Anaesthesia and/or Critical Care societies from France, Switzerland, Belgium, Brazil, and Portugal. Intensivists and anaesthetists involved in COVID-19 ICU care were invited to answer 14 questions about haemodynamic monitoring and management. RESULTS: Globally, 1000 questionnaires were available for analysis. Responses came mainly from Europe (n = 460) and America (n = 434). According to a majority of respondents, COVID-19 ICU patients frequently or very frequently received continuous vasopressor support (56%) and had an echocardiography performed (54%). Echocardiography revealed a normal cardiac function, a hyperdynamic state (43%), hypovolaemia (22%), a left ventricular dysfunction (21%) and a right ventricular dilation (20%). Fluid responsiveness was frequently assessed (84%), mainly using echo (62%), and cardiac output was measured in 69%, mostly with echo as well (53%). Venous oxygen saturation was frequently measured (79%), mostly from a CVC blood sample (94%). Tissue perfusion was assessed biologically (93%) and clinically (63%). Pulmonary oedema was detected and quantified mainly using echo (67%) and chest X-ray (61%). CONCLUSION: Our survey confirms that vasopressor support is not uncommon in COVID-19 ICU patients and suggests that different haemodynamic phenotypes may be observed. Ultrasounds were used by many respondents, to assess cardiac function but also to predict fluid responsiveness and quantify pulmonary oedema. Although we observed regional differences, current international guidelines were followed by most respondents.


Subject(s)
Betacoronavirus , Coronavirus Infections/therapy , Critical Care/methods , Health Care Surveys , Hemodynamic Monitoring , Pandemics , Pneumonia, Viral/therapy , Africa/epidemiology , Americas/epidemiology , Asia/epidemiology , Australia/epidemiology , COVID-19 , Cardiotonic Agents/therapeutic use , Coronavirus Infections/complications , Coronavirus Infections/epidemiology , Coronavirus Infections/physiopathology , Disease Management , Echocardiography/statistics & numerical data , Europe/epidemiology , Fluid Therapy , Hemodynamics/drug effects , Humans , Oxygen/blood , Pneumonia, Viral/complications , Pneumonia, Viral/epidemiology , Pneumonia, Viral/physiopathology , Procedures and Techniques Utilization , Pulmonary Edema/etiology , Pulmonary Edema/physiopathology , SARS-CoV-2 , Shock/etiology , Shock/physiopathology , Vasoconstrictor Agents/therapeutic use
9.
Heart Fail Rev ; 26(1): 1-10, 2021 01.
Article in English | MEDLINE | ID: covidwho-680074

ABSTRACT

Heart failure is a common disease state that can be encountered at different stages in the course of a COVID-19 patient presentation. New or existing heart failure in the setting of COVID-19 can present a set of unique challenges that can complicate presentation, management, and prognosis. A careful understanding of the hemodynamic and diagnostic implications is essential for appropriate triage and management of these patients. Abnormal cardiac biomarkers are common in COVID-19 and can stem from a variety of mechanisms that involve the viral entry itself through the ACE2 receptors, direct cardiac injury, increased thrombotic activity, stress cardiomyopathy, and among others. The cytokine storm observed in this pandemic can be a culprit in many of the observed mechanisms and presentations. A correct understanding of the two-way interaction between heart failure medications and the infection as well as the proposed COVID-19 medications and heart failure can result in optimal management. Guideline-directed medical therapy for heart failure should not be interrupted for theoretical concerns but rather based on tolerance and clinical presentation. Initiating specific cardiac or heart failure medications to prevent the infection or mitigate the disease is also not an evidence-based practice at this time. Heart failure patients on advanced therapies including those with heart transplantation will particularly benefit from involving the advanced heart failure team members in the overall management if they contract the virus.


Subject(s)
COVID-19/drug therapy , COVID-19/epidemiology , Heart Failure/epidemiology , Heart Failure/therapy , COVID-19/physiopathology , Comorbidity , Disease Progression , Heart Failure/physiopathology , Heart Transplantation , Heart-Assist Devices , Hemodynamic Monitoring , Hemodynamics , Humans , Immunosuppression Therapy , SARS-CoV-2 , Self Care , Telemedicine
10.
Rev Assoc Med Bras (1992) ; 66(4): 521-527, 2020. tab
Article in English | WHO COVID, LILACS (Americas) | ID: covidwho-613692

ABSTRACT

SUMMARY Severe acute respiratory syndrome coronavirus 2 (Sars-CoV-2 infection) is a new challenge for all countries, and children are predisposed to acquire this disease. Some studies have demonstrated more severe diseases in adults, but critically ill pediatric patients have been described in all ages. Pulmonary involvement is the major feature, and ventilatory support is common in critical cases. Nevertheless, other very important therapeutic approaches must be considered. In this article, we reviewed extensively all recent medical literature to point out the main clinical attitudes to support these pediatric patients during their period in respiratory support. Radiologic findings, fluid therapy, hemodynamic support, use of inotropic/vasopressors, nutritional therapy, antiviral therapy, corticosteroids, antithrombotic therapy, and immunoglobulins are analyzed to guide all professionals during hospitalization. We emphasize the importance of a multi-professional approach for adequate recovery.


RESUMO A síndrome respiratória aguda grave (SRAG) pelo novo coronavirus (SARS-CoV-2) é um novo desafio para todos os países e crianças estão predispostas a adquirir a doença. Alguns estudos demonstraram quadros mais graves em adultos, mas crianças criticamente doentes foram descritas em todas as idades. O envolvimento pulmonar é a principal característica e a necessidade de suporte ventilatório é comum nos casos mais graves. Entretanto, outras abordagens terapêuticas importantes devem ser consideradas. Nesse artigo revisamos extensamente a literature médica até o momento a fim de citar os principais recursos terapêuticos para o manejo dos pacientes pediátricos durante o período de suporte ventilatório. Achados radiológicos, terapia fluídica, terapia antiviral, o uso de corticosteroides, terapia antitrombótica e o uso de imunoglobulinas foram analisados a fim de guiar os profissionais durante o período de hospitalização desses pacientes. Nós reforçamos a importância de uma abordagem multiprofissional para recuperação adequada.


Subject(s)
Humans , Child , Adolescent , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Coronavirus Infections/therapy , General Practice/methods , Physical Therapy Modalities , Critical Illness , Coronavirus Infections , Nutrition Therapy/methods , Pandemics , Fluid Therapy/methods , Betacoronavirus , Hemodynamic Monitoring/methods
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