Escalating and De-escalating Temporary Mechanical Circulatory Support in Cardiogenic Shock: A Scientific Statement From the American Heart Association.

The use of temporary mechanical circulatory support in cardiogenic shock has increased dramatically despite a lack of randomized controlled trials or evidence guiding clinical decision-making. Recommendations from professional societies on temporary mechanical circulatory support escalation and de-escalation are limited. This scientific statement provides pragmatic suggestions on temporary mechanical circulatory support device selection, escalation, and weaning strategies in patients with common cardiogenic shock causes such as acute decompensated heart failure and acute myocardial infarction. The goal of this scientific statement is to serve as a resource for clinicians making temporary mechanical circulatory support management decisions and to propose standardized approaches for their use until more robust randomized clinical data are available.

Invasive Management of Acute Myocardial Infarction Complicated by Cardiogenic Shock: A Scientific Statement From the American Heart Association.

Cardiogenic shock (CS) remains the most common cause of mortality in patients with acute myocardial infarction. The SHOCK trial (Should We Emergently Revascularize Occluded Coronaries for Cardiogenic Shock) demonstrated a survival benefit with early revascularization in patients with CS complicating acute myocardial infarction (AMICS) 20 years ago. After an initial improvement in mortality related to revascularization, mortality rates have plateaued. A recent Society of Coronary Angiography and Interventions classification scheme was developed to address the wide range of CS presentations. In addition, a recent scientific statement from the American Heart Association recommended the development of CS centers using standardized protocols for diagnosis and management of CS, including mechanical circulatory support devices (MCS). A number of CS programs have implemented various protocols for treating patients with AMICS, including the use of MCS, and have published promising results using such protocols. Despite this, practice patterns in the cardiac catheterization laboratory vary across health systems, and there are inconsistencies in the use or timing of MCS for AMICS. Furthermore, mortality benefit from MCS devices in AMICS has yet to be established in randomized clinical trials. In this article, we outline the best practices for the contemporary interventional management of AMICS, including coronary revascularization, the use of MCS, and special considerations such as the treatment of patients with AMICS with cardiac arrest.

Pain assessment in the intensive care unit: development and psychometric testing of the nonverbal pain assessment tool.

BACKGROUND: Few standardized tools measure pain in nonverbal patients in the intensive care unit (ICU). Evidence exists that patient behaviors provide important information about pain in those unable to report their pain. OBJECTIVE: The Nonverbal Pain Assessment Tool (NPAT), a behavioral pain assessment tool, was developed for the nonverbal adult patient in the ICU. Content and criterion validity and internal and interrater reliability were evaluated. METHODS: The validity of NPAT was assessed against the patients' self-reports of pain. Interrater reliability was tested by 5 teams of 2 nurses assessing pain in nonverbal adult patients in 4 different ICUs. RESULTS: The tool underwent 2 revisions and involved 270 patients. During the final evaluation, strong internal reliability (chronbach's α, .82; 95% confidence interval), moderately strong interrater reliability (concordance coefficient, .72; 95% confidence interval; and weighted κ statistic, .35), and moderately strong validity (concordance coefficient, .66; 95% confidence interval) were achieved. CONCLUSION: The NPAT was found to possess moderately strong validity and strong internal and interrater reliability. It is easy to use, and provides a standard approach to assessing pain in the nonverbal adult patient.

Current trends in cardiac transplantation.

More than 30 years of experience in cardiac transplantation have resulted in cardiac transplantation being the primary therapeutic choice for patients under 65 years of age who have advanced heart failure and who remain symptomatic despite maximal medical therapy. The success and widespread use of cardiac transplantation is attributed to more liberal guidelines in recipient and donor selection, effective immunosuppressive therapy, close monitoring for rejection, and effective management of rejection. This article presents the current status of recipient and donor selection, surgical techniques, postoperative care, immunosuppression strategies, and rejection monitoring and management. Challenges associated with allocation of organs continue.

Transcutaneous carbon dioxide monitoring.

Technologies now exist that measure carbon dioxide levels transcutaneously. Rapid assessment of patients who have depressed ventilation or suspected sepsis can improve treatment decisions including the need for admission to the ICU and pulmonary artery catheterization.

Thoracic aortic aneurysms.

Thoracic aortic aneurysm with dissection is the most common fatal condition involving the aorta. The prevalence of aortic aneurysms appears to be increasing, which may reflect improvements in imaging techniques as well as increased clinical awareness of the condition. Most thoracic aortic aneurysms are caused by atherosclerosis and its associated risk factors of hypertension, smoking, and hypercholesterolemia. The clinical presentation varies and may mimic other more common disease processes. Early recognition on the basis of a focused history, physical examination, appropriate diagnostic studies, and management is essential for good outcomes.