Long-Term Survival and Health-Related Quality of Life in Adults After Extra Corporeal Membrane Oxygenation.

BACKGROUND: The study aims to determine long-term survival, health-related quality of life (HRQoL) and functional and physical outcomes of adult extra corporeal membrane oxygenation (ECMO) patients as there are limited and conflicting data in this area. METHODS: All patients receiving ECMO from April 2009 until June 2014 at The Prince Charles Hospital, Brisbane had Kaplan Meier survival calculated. Quality of life (QoL) was assessed using the Short Form Health Survey (SF-36v2), EQ5D-5L, The Frenchay Activities Index (FAI) and a return to work survey. From December 2011, these measures and 6-minute walk distance (6MWD) were assessed at hospital discharge and 12 months post-discharge. RESULTS: Seventy-seven (77) patients (45 veno-arterial and 32 veno-venous) received ECMO of whom 47/77 (61%) survived to hospital discharge. There were no deaths recorded in those discharged alive from the intensive care unit at median follow-up time 1,011days (range 227-2,014 days). Mean SF-36 scores (n=33) and EQ5D were assessed at a median of 606days after hospital discharge. SF-36 scores were significantly (p<0.05) worse than age-matched norms in all domains except vitality, bodily pain and mental health. Thirteen (13) (39%) participants had persistent problems with mobility and usual activity as measured by EQ5D. At 12 months post-ECMO, 6MWD was 531(IQR:397.3-626.8)m; 72% (IQR:53.2-77.6%) predicted but had improved by 223m (p=0.002) when compared to baseline. Nineteen (19) of 20 participants who had been employed pre-ECMO had returned to work. CONCLUSIONS: All ECMO patients discharged from hospital were alive at follow-up. Despite improvements in physical measures and HRQoL, long-term functional deficits persist when compared to that of aged- and sex-matched norms.

Percutaneous management of aortic stenosis in high-risk patients.

As the population ages, the prevalence of aortic stenosis is increasing. There is an unmet clinical need for the treatment of aortic stenosis in high-risk patients, who are often older, frail and have multiple comorbidities. Percutaneous aortic valve replacement (PAVR) is a new and innovative technique for the management of high-risk patients with aortic stenosis. There are currently two devices under evaluation in clinical trials in Australia: the CoreValve ReValving System and the Edwards SAPIEN valve. These devices are generally deployed retrogradely, mainly transfemorally or via the subclavian artery or, less commonly, transapically. Initial experience has been encouraging, with good short-term outcomes. However, there is a lack of long-term data. PAVR is presently only advocated for high-risk older patients with symptomatic aortic stenosis. Where PAVR lies in the treatment algorithm for aortic stenosis will be determined by randomised controlled trials, but for now it offers a genuine treatment alternative for high-risk patients.

Nurse-determined assessment of cardiac output. Comparing a non-invasive cardiac output device and pulmonary artery catheter: a prospective observational study.

BACKGROUND: The accurate measurement of Cardiac output (CO) is vital in guiding the treatment of critically ill patients. Invasive or minimally invasive measurement of CO is not without inherent risks to the patient. Skilled Intensive Care Unit (ICU) nursing staff are in an ideal position to assess changes in CO following therapeutic measures. The USCOM (Ultrasonic Cardiac Output Monitor) device is a non-invasive CO monitor whose clinical utility and ease of use requires testing. OBJECTIVES: To compare cardiac output measurement using a non-invasive ultrasonic device (USCOM) operated by a non-echocardiograhically trained ICU Registered Nurse (RN), with the conventional pulmonary artery catheter (PAC) using both thermodilution and Fick methods. DESIGN: Prospective observational study. SETTING AND PARTICIPANTS: Between April 2006 and March 2007, we evaluated 30 spontaneously breathing patients requiring PAC for assessment of heart failure and/or pulmonary hypertension at a tertiary level cardiothoracic hospital. METHODS: SCOM CO was compared with thermodilution measurements via PAC and CO estimated using a modified Fick equation. This catheter was inserted by a medical officer, and all USCOM measurements by a senior ICU nurse. Mean values, bias and precision, and mean percentage difference between measures were determined to compare methods. The Intra-Class Correlation statistic was also used to assess agreement. The USCOM time to measure was recorded to assess the learning curve for USCOM use performed by an ICU RN and a line of best fit demonstrated to describe the operator learning curve. RESULTS: In 24 of 30 (80%) patients studied, CO measures were obtained. In 6 of 30 (20%) patients, an adequate USCOM signal was not achieved. The mean difference (+/-standard deviation) between USCOM and PAC, USCOM and Fick, and Fick and PAC CO were small, -0.34+/-0.52 L/min, -0.33+/-0.90 L/min and -0.25+/-0.63 L/min respectively across a range of outputs from 2.6L/min to 7.2L/min. The percent limits of agreement (LOA) for all measures were -34.6% to 17.8% for USCOM and PAC, -49.8% to 34.1% for USCOM and Fick and -36.4% to 23.7% for PAC and Fick. Signal acquisition time reduced on average by 0.6 min per measure to less than 10 min at the end of the study. CONCLUSIONS: In 80% of our cohort, USCOM, PAC and Fick measures of CO all showed clinically acceptable agreement and the learning curve for operation of the non-invasive USCOM device by an ICU RN was found to be satisfactorily short. Further work is required in patients receiving positive pressure ventilation.

Takotsubo cardiomyopathy associated with sepsis due to Streptococcus pneumoniae pneumonia.

A 65-year-old woman was transferred from another hospital with a diagnosis of acute myocardial infarction associated with shock. An initial electrocardiogram (ECG) showed ST-segment elevation in leads V1-V6. A transoesophageal echocardiogram showed akinesis of the distal anterior septum and apical regions and hyperkinesis of the basal segments, with an ejection fraction of 20%- 25%. The coronary angiogram showed trivial coronary disease. By Day 6 of admission, the ECG showed normal left ventricle size and systolic function, with an ejection fraction of 65% and no regional abnormalities of wall motion. Sputum examination subsequently revealed typical Streptococcus pneumoniae. Our case demonstrates for the first time an association between sepsis and takotsubo cardiomyopathy. We analyse the possible role of sepsis and the systemic inflammatory response syndrome caused by severe infection as the initial causative mechanism of this syndrome.