Blood Pressure Goals in Critically Ill Patients.

Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.

Perfusion-Dependent Focal Neurologic Deficits in a Critically Ill Heart Transplant Recipient: A Case of Tacrolimus-Associated Reversible Cerebral Vasospasm Syndrome?

TACROLIMUS, a mainstay of immunosuppression after orthotopic heart transplantation (OHT), is associated with a broad range of side effects. Vasoconstriction caused by tacrolimus has been proposed as a mechanism underlying common side effects such as hypertension and renal injury. Neurologic side effects attributed to tacrolimus include headaches, posterior reversible encephalopathy syndrome (PRES), or reversible cerebral vasospasm syndrome (RCVS). Six case reports have been published describing RCVS in the setting of tacrolimus administration after OHT. The authors report a case of perfusion-dependent focal neurologic deficits attributed to tacrolimus-induced RCVS in an OHT recipient.

Evaluation of saline versus gel as contact medium for ultrasonographic image quality.

OBJECTIVES: Evaluate the time taken to visualize the internal jugular vein and carotid arteries, and subjective image quality assessed on a 0-100 visual analogic scale, on an ultrasound model using either traditional ultrasound gel or normal saline. METHODS: Twenty-two anesthesiology residents and twenty anesthesiology faculty were blinded and randomized into four separate groups using gel and saline as a conduction medium, in different sequences. RESULTS: Subjective image quality was 12.2 ± 4.2 better with gel than with saline (P < 0.01). Image acquisition time did not differ significantly between the two mediums. There was no significant difference in subjective image quality or time to image acquisition between faculty and residents. CONCLUSIONS: Internal jugular vein and carotid artery identification time using ultrasonography were similar between gel and saline as conduction mediums. The difference in subjective image quality did not appear clinically relevant. Better image quality resulted in less time taken to identify the structures, as expected. We conclude that saline may be an effective alternative medium to gel for vessel imaging and access guidance. Further study in a clinical setting is warranted.