Heart & Lung - The Journal of Critical Care - Articles in Press

Management of recurrent pleural effusions with a tunneled catheter - Corrected Proof

Elizabeth McConnell Baker, Sheila Melander — 2009-12-11

Recurrent pulmonary effusions are commonly seen in patients with end-stage diseases. Traditional treatment modalities have required several days of hospitalization or frequent invasive procedures. Drainage with a tunneled pulmonary catheter can provide symptom palliation and resolution of the effusion without activity restriction or hospitalization.

Acquired noncompaction associated with coronary heart disease and myopathy - Corrected Proof

Josef Finsterer, Claudia Stöllberger, Elisabeth Bonner — 2009-12-11

In a 77-year-old man with a history of arterial hypertension, coronary heart disease, dilative cardiomyopathy, mitral and tricuspid insufficiency, arteriovenous block III, implantation of a pacemaker, atrial fibrillation, and heart failure, left ventricular hypertrabeculation (LVHT) was detected on transthoracic echocardiography during hospitalization for worsening heart failure. Revision of previous echocardiography did not show LVHT in any of the previous investigations why LVHT was interpreted as acquired. The additional presentation with bilateral ptosis, madarosis (absent eyelashes), bilateral hypoacusis, sore neck muscles, absent tendon reflexes, weakness for foot extension, ataxic stance, and recurrently elevated creatine kinase with normal troponin-T suggested a metabolic myopathy. Autopsy after death resulting from intractable heart failure, 17 months later, confirmed severe coronary heart disease and LVHT in the apex. The case confirms that LVHT may be acquired in single cases with neuromuscular disease and may represent an adaptive mechanism of an impaired myocardium.

Risk factors for late extubation after coronary artery bypass grafting - Corrected Proof

2009-12-11

Objective: To evaluate the independent risk factors for late extubation after coronary artery bypass grafting (CABG).Methods: Preoperative, intraoperative, and postoperative characteristics of patients undergoing isolated CABG between June 2005 and June 2008 at the Tongji Hospital were retrospectively analyzed. Elapsed time between CABG and extubation of more than 8hours was defined as late extubation.Results: The incidence of late extubation after CABG was 69.23% (288/416). Through univariate and logistic regression analysis, the independent risk factors for late extubation after CABG were older age (odds ratio [OR]=4.804), duration of cardiopulmonary bypass (OR=2.426), perioperative use of intra-aortic balloon pump (OR=1.451), preoperative arterial oxygen partial pressure (OR=.204), and postoperative hemoglobin level (OR=.793).Conclusion: Older age, prolonged cardiopulmonary bypass time, perioperative intra-aortic balloon pump requirement, low preoperative arterial oxygen partial pressure, and low postoperative hemoglobin level were identified as the 5 independent risk factors for late extubation after CABG.

Severe encephalopathy after ingestion of star fruit juice in a patient with chronic renal failure admitted to the intensive care unit - Corrected Proof

2009-12-11

Star fruit (Averrhoa carambola) is a popular tropical fruit that is usually consumed as fresh fruit or fruit juice. Consumption of star fruit by patients with chronic renal failure can lead to neurologic symptoms. The present report describes the clinical course, management, and outcome of a patient with chronic renal failure admitted to an intensive care unit after ingestion of star fruit juice 2 days before hospital admission. A case of nausea, vomiting, intractable hiccups, and severe encephalopathy along with mental confusion, disorientation, agitation, and seizures in a 53-year-old woman is presented. The patient's ventilatory pattern worsened, with development of dyspnea and tachypnea, which resulted in her transfer to an intensive care unit. Although hemodialysis was performed and the septic shock was adequately treated, the patient died on the fifth day after hospital admission. The susceptibility of patients with chronic renal failure to star fruit and the severity of intoxication are poorly known by intensivists. This case demonstrates that star fruit consumption should be considered as a cause of rapid deterioration in the renal function of patients with underlying chronic renal failure, potentially resulting in a fatal outcome.

Impact of a disease-management program on symptom burden and health-related quality of life in patients with idiopathic pulmonary fibrosis and their care partners - Corrected Proof

2009-11-23

Background: Patients were recruited from the Dorothy P. and Richard P. Simmons Center for Interstitial Lung Disease, located within the University of Pittsburgh Medical Center. Idiopathic pulmonary fibrosis results in scarring of the lung and respiratory failure, and has a median survival of 3 to 5 years from the time of diagnosis. The purpose of this study was to determine whether patients with idiopathic pulmonary fibrosis and their care partners could be more optimally managed by a disease-management intervention entitled “Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management,” which nurses delivered using the format of a support group. We hypothesized that participation would improve perceptions of health-related quality of life (HRQoL) and decrease symptom burden.Methods: Subjects were 42 participants randomized to an experimental (10 patient/care partner dyads) or control (11 patient/care partner dyads) group. Experimental group participants attended the 6-week program, and controls received usual care. Before and after the program, all participants completed questionnaires designed to assess symptom burden and HRQoL. Patients and care partners in the intervention group were also interviewed in their home to elicit information on their experience after participating in the Program to Reduce Idiopathic Pulmonary Fibrosis Symptoms and Improve Management.Results: After the intervention, experimental group patients rated their HRQoL less positively (P = .038) and tended to report more anxiety (P = .077) compared with controls. Care partners rated their stress at a lower level (P = .018) compared with controls. Course evaluations were uniformly positive. Post-study qualitative interviews with experimental group participants suggested benefits not exemplified by these scores. Patient participants felt less isolated, were able to put their disease into perspective, and valued participating in research and helping others.Conclusion: Further exploration of the impact of disease-management interventions in patients with advanced lung disease and their care partners is needed using both qualitative and quantitative methodology. Disease-management interventions have the potential to positively affect patients with advanced lung disease and their care partners.

The feasibility and utility of the aid to cardiac triage intervention to improve nurses' cardiac triage decisions - Corrected Proof

Cynthia Arslanian-Engoren, Bonnie Hagerty, Cathy L. Antonakos, Kim A. Eagle — 2009-11-23

Background: Despite the benefits of prompt treatment of myocardial infarction, gender disparities exist in emergency department (ED) nurses' cardiac triage decisions.Objective: To determine the feasibility and utility of the aid to cardiac triage (ACT) intervention designed to improve ED nurses' cardiac triage decisions for women with myocardial infarction.Methods: A prospective, exploratory design was used. To determine feasibility, we evaluated the 1-hour time allocated for the intervention and ED nurses' participation rates. Twenty-three participants completed a utility questionnaire at the completion of the 1-hour intervention, and 18 participants completed the questionnaire 3 months post-intervention.Results: The ACT intervention was delivered within 30 to 40minutes, allowing 20minutes for questions and discussion. ED nurses viewed the ACT intervention as a useful, helpful, and practical tool for improving their cardiac triage decisions at both intervention completion and 3 months later.Conclusion: The evaluation supports the feasibility and utility of the ACT intervention.

Testing the psychometric properties of the Chinese version of the Heart Failure Learning Needs Inventory - Corrected Proof

Mingming Yu, Sek Ying Chair, Carmen W.H. Chan, Meili Liu — 2009-11-23

Objective: To translate the Heart Failure Learning Needs Inventory into Chinese and to evaluate its psychometric properties in the Chinese population with heart failure (HF).Methods: The study used a cross-sectional design. Instrument performance was measured on a convenience sample of 247 patients with HF recruited from the cardiac departments of 3 university-affiliated hospitals and repeated on 34 patients to examine the test–retest reliability.Results: One item of advanced directives was deleted from the Chinese version of the instrument because of its poor culture relevance. The Chinese version demonstrated acceptable internal consistency with a Cronbach's α of .96 for the total scale and .77 to .89 for the subscales. The item-to-total correlation ranging from .54 to .85 provided further evidence of the instrument's internal consistency. The content validity index was .86, indicating satisfactory content validity. The test–retest reliability was satisfactory with an intraclass correlation coefficient of .96 for the total scale and .61 to .91 for the subscales. There were no significant differences in the total scale and subscale scores over 10 days (P > .05). This finding further supported the stability of the instrument. Moreover, principle component analysis revealed 9 factors, explaining 60.89% of the variance. Means of the subscales were relatively lower than that of the western countries. Furthermore, the means of 2 subscales, general HF information and lifestyle modification, were different among patients with New York Heart Association classifications I and IV.Conclusion: The Chinese version of the Heart Failure Learning Needs Inventory is a reliable and valid instrument to measure the learning needs of patients with HF in Mainland China.

Peak body temperature predicts mortality in critically ill patients without cerebral damage - Corrected Proof

2009-10-19

Objectives: We investigated whether mortality in intensive care unit (ICU) patients without cerebral damage is associated with fever manifestation and characteristics.Methods: Patients admitted to a medical-surgical ICU between October 2005 and July 2006 were prospectively studied. Exclusion criteria were acute brain injury, intracerebral/subarachnoid hemorrhage, ischemic stroke, and brain surgery. An ear-based or axillary thermometer was used to measure body temperature. The association between fever (ear-based temperature, >38.3°C), fever characteristics, and ICU mortality was evaluated using univariate and multivariate analysis.Results: Two hundred and thirty-nine patients were enrolled. Fever was not associated with ICU mortality after adjustment for confounding patient factors. A significant dose-response increase of ICU mortality according to 1°C increments of peak body temperature was demonstrated, whereas peak body temperature was an independent predictor of ICU mortality.Conclusion: These findings imply that, although fever is not generally associated with mortality in patients without cerebral damage, it can be harmful and should be suppressed when it becomes very high. Rigorous clinical trials are needed to help establish antipyretic therapy guidelines.

Successful treatment of saphenous venous graft thrombus by tirofiban infusion - Corrected Proof

2009-10-16

A 60-year old man with a history of coronary-artery bypass grafting presented with symptoms of acute coronary syndrome. Coronary angiography revealed a huge intraluminal thrombus in the saphenous vein graft to the second obtuse marginal branch of the left circumflex artery. A glycoprotein IIb/IIIa inhibitor (tirofiban) was administered intravenously. Two days later, thrombus dissolution and Thrombolysis In Myocardial Infarction (TIMI) grade 3 flow were evident on repeat coronary angiography. Glycoprotein IIb/IIIa inhibitors may be useful in a thrombus-laden saphenous-vein graft.

Fever of unknown origin (FUO) due to a solitary cavitary lung lesion: The deadly ferritin-laced doughnut - Corrected Proof

Burke A. Cunha, Francisco M. Pherez, Douglas S. Katz — 2009-10-16

Fever of unknown origin (FUO) is the clinical designation for patients who have fevers >101F that have persisted for >3 weeks that remain undiagnosed, after an intensive ambulatory/in-hospital workup. Fevers of unknown origin may be due to wide variety of infectious, neoplastic, or rheumatic/inflammatory disorders. The most common causes of FUOs in elderly patients are infectious and neoplastic diseases. With FUOs, the clinical presentation and routine laboratory tests are usually sufficient to narrow differential diagnostic possibilities. We present a case of an elderly Italian woman who presented with an FUO and a solitary, thick-walled cavitary lesion on chest x-ray (CXR). The infectious disease differential diagnosis of her FUO included lung abscess, M. tuberculosis (TB), systemic mycoses, and echinococcal-cyst (or hydatid-cyst) disease. The malignancy and neoplastic differential diagnosis included bronchogenic carcinoma, lymphoma, and metastatic carcinoma. Her nonspecific laboratory tests indicated a highly elevated erythrocyte sedimentation rate (ESR) >100 mm/hour, chronic thrombocytosis, relative lymphopenia, and highly elevated serum ferritin levels. Excluding highly elevated serum ferritin levels, the differential diagnosis of her FUO with a solitary, thick-walled cavitary lesion was lung abscess vs. tuberculosis. However, her highly elevated serum ferritin levels proved to be the critical diagnostic clue in predicting the diagnosis of squamous-cell carcinoma. We conclude that serum ferritin levels are an important part of the laboratory workup. As with other nonspecific laboratory tests, the diagnostic significance of highly elevated ferritin levels depends associated clinical features in the clinical presentation.

Qualitative study of pain of patients with chronic obstructive pulmonary disease - Corrected Proof

2009-10-16

Objective: This study evaluated the pain experiences of patients with chronic obstructive pulmonary disease (COPD).Sample: We studied 16 patients with severe COPD.Design: A semistructured interview was performed to obtain information on patients' experiences with pain and the impact of pain on quality of life (QOL). Data were analyzed using the methodology of Kvale.Results: Three main themes emerged: incomprehensible and unbearable pain; locked in my body and shut out from the world; and the vicious COPD circle. Patients reported moderate to severe pain located primarily in the shoulders, neck, upper arms, and chest. Patients reported a number of severe symptoms occurring simultaneously, and negatively affecting each other. Vicious circles of pain, breathlessness, sleep disturbance, and anxiety were described as exerting negative effects on patients' QOL.Conclusion: Unrelieved pain appears to be a significant problem in patients with COPD. Research is warranted to determine if pain is clustered with other symptoms, and how these symptoms affect the clinical management of COPD.

Clinical characteristics, ballooning pattern, and long-term prognosis of transient left ventricular ballooning syndrome - Corrected Proof

2009-10-05

Objective: Although patients with transient left ventricular ballooning syndrome (TLVBS), also known as Takotsubo cardiomyopathy, improve rapidly and recover left ventricular systolic function, the long-term prognosis is not well-known. This study investigated the clinical features of TLVBS, and its in-hospital and long-term (in-hospital plus postdischarge) mortality.Methods and Results: We evaluated 87 patients diagnosed with TLVBS. The median follow-up was 42 months (interquartile range, 19 to 72 months). During follow-up, no recurrences were reported, but 20 (23%) patients died. Two nonsurvivors (2%) were suspected of dying from sudden cardiac death. The in-hospital total mortality rate was 9%, but the in-hospital cardiac mortality rate was 0%. Most deaths were associated with underlying noncardiac diseases. Baseline characteristics were mostly similar between survivors and nonsurvivors. However, nonsurvivors were older, and more likely to be smokers compared with survivors. Underlying noncardiac diseases were the only independent predictors of long-term mortality (hazard ratio, 3.954; 95% confidence interval, 1.369 to 11.422; P=.011). There were no significant differences in long-term mortality, according to the preceding stress events or ballooning patterns.Conclusions: Although a substantial number of patients with TLVBS die, the long-term cardiac mortality is low. The severity of heart failure owing to TLVBS may influence in-hospital mortality, whereas underlying noncardiac diseases have a more significant correlation with the long-term prognosis than does TLVBS itself.

Acute transient phlebitis during eptifibatide intravenous injection: Case report - Corrected Proof

Emile Hay, Yossef Blaer, Vladimir Shlyakhover, Amos Katz, Jamal Jafari — 2009-10-05

We present a 56-year-old man who developed acute transient phlebitis of the right cephalic vein during an intravenous injection of eptifibatide (Integrilin, Schering Plough, Kenilworth, NJ). The eptifibatide injections were discontinued, and signs of phlebitis disappeared within minutes. The patient's course was uneventful, and he was discharged home after 8 days. As far as we know, this is the first report of acute transient phlebitis during intravenous eptifibatide injections in the English-language medical literature.

Caregiving for patients requiring left ventricular assistance device support - Corrected Proof

Kathy Baker, Maureen Flattery, Jeanne Salyer, Kathryn H. Haugh, Megan Maltby — 2009-10-05

Background: The responsibility of caregiving for patients requiring left ventricular assistance device (LVAD) support may be significant. However, little is known about their experience. Data from the Interagency Registry for Mechanically Assisted Circulatory Support (2006-2009) reported that 1722 patients had received LVADs as a bridge to transplantation, recovery, or destination therapy. The use of this advanced technology in the management of endstage heart failure is expected to continue, suggesting increased involvement of family members and significant others. The purpose of this qualitative study was to describe the experiences of caregivers of patients who received LVAD therapy as a bridge to transplantation.Methods: Semistructured interviews allowed participants to describe their experiences as caregivers. Interviews were audiotape-recorded and transcribed verbatim. An analysis was conducted using Sandelowski's three-step process for the analysis of phenomenological data: data dwelling, open coding, and data reduction.Results: Participants (n=5 women and 1 man; age, 51 years; range=44 to 66 years; duration of caregiving, 183.9 days; range, 26 to 372 days; relationship to patient: spouse=3, parent=1, significant other=1, and friend=1) were designated caregivers of patients discharged home with an LVAD. Two themes emerged: sacrifice and moving beyond. Caregivers sacrificed relationships with friends and family, jobs and livelihood, health, and peace of mind in their roles as caregivers. “Moving beyond” reflected coping and adaptation to the sacrifices of being a caregiver.Conclusions: Experiences described by caregivers suggest that they successfully incorporated the role of caregiver for patients with a complex therapeutic regimen into their daily lives. The specific findings should guide healthcare professionals in their efforts to support caregivers.

Septic shock caused by Plesiomonas shigelloides in a patient with sickle beta-zero thalassemia - Corrected Proof

2009-09-14

Abstract: Invasive infection and extraintestinal complications are rarely caused by Plesiomonas shigelloides, a waterborne bacterium belonging to the Vibrionaceae family. We report a case of a 16-year-old female patient with sickle beta-zero thalassemia who survived septic shock caused by P. shigelloides associated with secondary acute respiratory distress syndrome and disseminated intravascular coagulation. Treatment with a carbapenem was successful, and the patient recovered without any sequelae. The previous reports of P. shigelloides sepsis are cited, and possible pathogenic mechanisms are discussed.

Anemia and blood transfusion practices in the critically ill: A prospective cohort review - Corrected Proof

Jissy Thomas, Louise Jensen, Susan Nahirniak, R.T. Noel Gibney — 2009-09-14

Background: Nearly 75% of critically ill patients develop anemia in the intensive care unit (ICU). Anemia can be treated with red blood cell (RBC) transfusions, although evidence suggests that lower hemoglobin levels are tolerated in the critically ill. Despite such recommendations, variation exists in clinical practice.Methods: A prospective cohort was assessed for anemia and RBC transfusion practices in 100 consecutive adults admitted to our General Systems ICU.Results: The prevalence of anemia in this cohort was 98%. Mean blood loss via phlebotomy was 25±10.3 mL per patient per day. The RBC transfusion rate for the ICU stay was 40%, increasing to 70% in patients whose ICU stay was >7 days. The mean pretransfusion level of hemoglobin was 7.35±0.47 mg/dL for the total cohort, and 8.2±0.65 mg/dL for those with a history of cardiovascular disease.Conclusion: Anemia was common in this critically ill cohort, with hemoglobin levels continuing to drop with ICU stay. Pretransfusion hemoglobin levels were lower than reported by others, yet the RBC transfusion rate was comparable. There was no association between anemia and phlebotomy practices in our ICU.

Differences in social support and illness perceptions among South Asian and Caucasian patients with coronary artery disease - Corrected Proof

Keerat Grewal, Donna E. Stewart, Sherry L. Grace — 2009-09-04

Objective: Social support and illness perceptions may affect recovery from a cardiac event or procedure. Previous research has found that patients of South Asian origin with coronary artery disease (CAD) have lower levels of social support and may perceive different causes of their condition. The purpose of this study was to quantitatively investigate differences in social support and illness perceptions between Caucasian and South Asian patients with CAD.Methods: A total of 562 inpatients with CAD (53 [9%] South Asian) were recruited from 2 hospitals. The Medical Outcomes Study social support scale and Illness Perception Questionnaire were administered to examine ethnocultural differences in total social support and subscales, and in illness perceptions subscales, including causes of illness.Results: South Asian participants had significantly lower levels of tangible (P=.001) and emotional/informational support (P < .001) compared with Caucasian participants. South Asians were less likely than Caucasians to believe they have personal control over their illness (P < .001). Trends were observed, with South Asian participants being more likely to attribute their condition to stress/worry (P=.04) and poor medical care in the past (P=.02) and less likely to attribute their illness to aging (P=.03) compared with Caucasian participants.Conclusion: Lower levels of social support among South Asians in Canada may have negative effects on recovery and prognosis. Our results support qualitative findings suggesting South Asians perceive their illness to be a result of fate or related to stress. Future studies should investigate interventions targeted at modifying illness perceptions among this group in an attempt to improve risk-reducing behavior and secondary prevention use.

Acute Streptococcus agalactiae endocarditis: Outcomes of early surgical treatment - Corrected Proof

2009-08-26

Abstract: The incidence of Streptococcus agalactiae is widely recognized as increasing in nonpregnant adults. This report describes a retrospective case series of S. agalactiae endocarditis at the Heart Institute of Sao Paulo, Brazil, between 2000 and 2006. Early diagnosis and valve surgery seem to have contributed to improved patient outcomes.