Palliative Sedation via Intraosseous Vascular Access: A Safe and Feasible Way to Obtain a Vascular Access End of Life.

Intraosseous (IO) access is normally reserved for emergencies and critical care conditions when venous cannulation is not possible. Nonetheless, we present a case of IO insertion to a 56-year-old man, tetraplegic for many years due to progressive spinal muscular atrophy and with refractory suffering. The IO access was used for palliative sedation with propofol in a home care setting. The patient died after 11 days of palliative care, of which the last 4 days were with palliative sedation using an IO cannula as a vascular access. No complications were noted from this route of administration. We advocate the use of IO access in the palliative care of terminal ill patients when a venous cannulation is not possible.

Patient-assessed short-term positive response to cardiac resynchronization therapy is an independent predictor of long-term mortality.

AIMS: Cardiac resynchronization therapy (CRT) has a well-documented positive effect on mortality and heart failure morbidity. The aim of this study was to assess the long-term survival and the predictive value of self-assessed functional status on the long-term prognosis of patients treated with CRT-pacemaker (CRT-P). METHODS AND RESULTS: Data were retrospectively collected from medical records of 446 consecutive patients implanted with CRT-P at a large-volume Swedish tertiary care centre. Primary outcome was all-cause mortality, predictive variables were assessed by log-rank test and univariate cox regression. Three hundred and nine patients had reliable information available on early improvement after implantation and were included in the multivariate analyses. The cohort was followed for a median of 79 months and was similar in baseline characteristics compared with major controlled trials. During follow-up 204 patients died, yearly mortality was 11.7%. Early improvement of self-assessed functional status was a strong independent predictor of survival [hazard ratio, HR 0.59, confidence interval (CI) 0.40-0.87, P = 0.007], together with well-known predictors; NYHA III-IV vs I-II (HR 1.66, CI 1.09-2.536, P = 0.018), age (HR 1.05, CI 1.03-1.08, P < 0.001), male gender (HR 2.0, CI 1.11-3.45, P = 0.021), and loop diuretic use (HR 4.41, CI 1.08-18.02). Patients with early improvement of self-assessed functional status had better 2-year and 5-year survival (P < 0.001). CONCLUSIONS: Real-life patient characteristics and predictors of outcome compare well with those in published prospective trials. Self-assessed functional status is a strong predictor of long-term survival, which may have implications for a more active follow-up of patients without spontaneous improvement.

Coronary sinus cannulation with a steerable catheter during biventricular device implantation.

OBJECTIVES: To determine whether a steerable catheter with electrogram guidance (CS-assist group) could facilitate access to the coronary sinus (CS) during cardiac resynchronization therapy (CRT) implantation. DESIGN: Consecutive patients who underwent CRT implantation were recruited prospectively into the CS-assist group (n = 81) and compared with those using conventional techniques without an electrogram guidance (conventional group, n = 101). RESULTS: The CS cannulation success rate was clearly greater in the CS-assist group (100%) than that in the conventional group (95%, p < 0.05), with significantly shorter mean procedure time (52.6 ± 20.6 min vs. 73.2 ± 40.9 min, p < 0.01) and fluoroscopy time (3.6 ± 3.2 min vs. 14.2 ± 20.4 min, p < 0.01). In the five CS cannulation failure cases, mean procedure time (144.0 ± 37.0 min) and fluoroscopy time (57.8 ± 24.8 min) were significantly longer than those in the other patients (61.2 ± 32.3 and 8.2 ± 13.6 min, respectively, n = 177, both p < 0.01). CONCLUSIONS: Using the steerable catheter with real-time electrogram guidance, location of and access to the CS is more rapid and successful, which may improve the success of the CRT implantation and may give significant time savings.

Prognostic impact of early ventricular fibrillation in patients with ST-elevation myocardial infarction treated with primary PCI.

AIMS: Current guidelines do not advocate implantation of cardioverter-defibrillators (ICD) for survivors of ventricular fibrillation (VF) during the first 48 hours of ST-elevation myocardial infarction (STEMI). However, contemporary studies in a real-life setting with long-term follow-up are lacking. We assessed the prognostic impact of early VF in a non-selected population of STEMI patients treated with primary percutaneous coronary intervention (PCI). METHODS AND RESULTS: Consecutive STEMI patients admitted to a Swedish tertiary care hospital during 2007-2009 were identified from the Register of Information and Knowledge about Swedish Heart Intensive Care Admissions (n=1718, age 66±12 years, 70% male). Patients with VF were identified from the register, and medical records were reviewed to determine the time point of VF. Patients surviving VF in the first 48 hours after symptom onset were compared with patients without VF for one-year mortality and a combined endpoint of death, resuscitated VF or appropriate ICD therapy. VF within 48 hours occurred in 7% of STEMI patients (n=121). In patients alive at 48 hours (n=1663), VF patients (n=101) had higher in-hospital mortality (12% vs. 2%, p<0.001). However, in VF patients discharged alive (n=89), mortality was low (1%) and combined endpoint rate (3%) did not differ compared with patients without VF (n=1538; 4% and 4% respectively). CONCLUSION: In a large non-selected population of STEMI patients treated with primary PCI, VF during the first 48 hours after STEMI is associated with increased in-hospital mortality but does not influence the long-term prognosis for those discharged alive.

Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators.

Patients with an implantable cardioverter defibrillator (ICD) have an ongoing risk of sudden incapacitation that might cause harm to others while driving a car. Driving restrictions vary across different countries in Europe. The most recent recommendations for driving of ICD patients in Europe were published in 1997 and focused mainly on patients implanted for secondary prevention. In recent years there has been a vast increase in the number of patients with an ICD and in the percentage of patients implanted for primary prevention. The EHRA task force on ICD and driving was formed to reassess the risk of driving for ICD patients based on the literature available. The recommendations are summarized in the following table and are further explained in the document, (Table see text). Driving restrictions are perceived as difficult for patients and their families, and have an immediate consequence for their lifestyle. To increase the adherence to the driving restrictions, adequate discharge of education and follow-up of patients and family are pivotal. The task force members hope this document may serve as an instrument for European and national regulatory authorities to formulate uniform driving regulations.

Consensus statement of the European Heart Rhythm Association: updated recommendations for driving by patients with implantable cardioverter defibrillators.

Patients with an implantable cardioverter defibrillator (ICD) have an ongoing risk of sudden incapacitation that might cause harm to others while driving a car. Driving restrictions vary across different countries in Europe. The most recent recommendations for driving of ICD patients in Europe were published in 1997 and focused mainly on patients implanted for secondary prevention. In recent years there has been a vast increase in the number of patients with an ICD and in the percentage of patients implanted for primary prevention. The EHRA task force on ICD and driving was formed to reassess the risk of driving for ICD patients based on the literature available. The recommendations are summarized in the following table and are further explained in the document. [table: see text] Driving restrictions are perceived as difficult for patients and their families, and have an immediate consequence for their lifestyle. To increase the adherence to the driving restrictions, adequate discharge of education and follow-up of patients and family are pivotal. The task force members hope this document may serve as an instrument for European and national regulatory authorities to formulate uniform driving regulations.