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type=\u0022text\/css\u0022 rel=\u0022stylesheet\u0022 href=\u0022\/\/d282kpwvnogo5m.cloudfront.net\/sites\/default\/files\/advagg_css\/css__ce2QY63WIanKyr8eSq7eavr1XQRRmFD6ZSmwpyJi8lM__zXwFqpqmxrZOXXcd_TpBQpjuELbmIP9wBR5UuTDWAO4__YJWWMMdfCJuAFm5cUEp88OsodhO3ZA-2lzRfoBsSlk4.css\u0022 media=\u0022all\u0022 \/\u003E\n\u003Clink rel=\u0027stylesheet\u0027 type=\u0027text\/css\u0027 href=\u0027\/sites\/all\/modules\/contrib\/panels\/plugins\/layouts\/onecol\/onecol.css\u0027 \/\u003E\u003C\/head\u003E\u003Cbody\u003E\u003Cdiv class=\u0022panels-ajax-tab-panel panels-ajax-tab-panel-sageoa-tab-art\u0022\u003E\u003Cdiv class=\u0022panel-display panel-1col clearfix\u0022 \u003E\n  \u003Cdiv class=\u0022panel-panel panel-col\u0022\u003E\n    \u003Cdiv\u003E\u003Cdiv class=\u0022panel-pane pane-highwire-markup\u0022 \u003E\n  \n      \n  \n  \u003Cdiv class=\u0022pane-content\u0022\u003E\n    \u003Cdiv class=\u0022highwire-markup\u0022\u003E\u003Cdiv xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EKey issues in critical care for the acute care cardiologist were addressed by a panel of experts. Specific topics include the Berlin definition of acute respiratory distress syndrome, merging applications for extracorporeal support, intravenous fluid managementa, s well as emerging pathogens in sepsis.\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EBacterial Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EExclusive Article - For home page\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EPrevention \u0026amp; Screening\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EBacterial Infections\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECritical Care\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EMyocardial Infarction\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EExclusive Article - For home page\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EKey issues in critical care for the acute care cardiologist were addressed by a panel of experts. The Berlin definition of acute respiratory distress syndrome (ARDS) [Ranieri VM et al. \u003Cem\u003EJAMA\u003C\/em\u003E. 2012] was the topic discussed by Alexandre Mebazaa, MD, University Hospital St Louis-Lariboisi\u00e8re, Paris, France. The new definition is simplified when compared with the former definition established in 1994 at the American-European Consensus Conference, and it characterizes ARDS by its acute onset (defined as within 7 days of a known clinical insult or new or worsening respiratory symptoms), the presence of bilateral opacities consistent with pulmonary edema on chest imaging, and respiratory failure not fully explained by cardiac failure or fluid overload. There is no use of the term \u003Cem\u003Eacute lung injury\u003C\/em\u003E in the Berlin definition.\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe oxygenation severity scale was also simplified to include 3 categories of ARDS according to the measured PaO\u003Csub\u003E2\u003C\/sub\u003E: FiO\u003Csub\u003E2\u003C\/sub\u003E ratio (in mm Hg) with positive end-expiratory pressure \u2265 5 cm H\u003Csub\u003E2\u003C\/sub\u003EO: mild (200 to 300), moderate (100 to 200), and severe (\u2264 100). The severity scale correlates with mortality, noted Prof Mebazaa, with a mortality of 27% for mild ARDS, 32% for moderate, and 45% for severe.\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EChiara Lazzeri, MD, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy, spoke about emerging applications for extracorporeal support. The potential lifesaving indications for extracorporeal membrane oxygenation (ECMO) are expanding, as technological advances have improved ECMO circuits and made ECMO more widely available.\u003C\/p\u003E\u003Cp id=\u0022p-5\u0022\u003EConsiderations in the use of extracorporeal cardiopulmonary resuscitation (ECPR) are based on observational studies or those based on alternate designs, such as propensity score-matched analysis. Most of these analyses\u2014in patients with either in-hospital or out-of-hospital cardiac arrest\u2014demonstrated improved survival at discharge and up to 1 year, as well as improvement in the rate of survival with minimal neurologic impairment, in groups receiving either ECPR or cardiopulmonary resuscitation assisted with autopriming portable ECMO, as compared with patients receiving conventional cardiopulmonary resuscitation [Johnson NJ et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2014; Wang CH et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2014; Maekawa K et al. \u003Cem\u003ECrit Care Med.\u003C\/em\u003E 2013; Shin TG et al. \u003Cem\u003EInt J Cardiol\u003C\/em\u003E. 2013; Shin TG et al. \u003Cem\u003ECrit Care Med.\u003C\/em\u003E 2011; Chen YS et al. \u003Cem\u003ELancet\u003C\/em\u003E. 2008].\u003C\/p\u003E\u003Cp id=\u0022p-6\u0022\u003EThe success of ECMO support depends on the selection of patients, ECMO team expertise, and ECMO postresuscitation care, said Prof Lazzeri. Factors associated with successful extracorporeal resuscitation for cardiac arrest include patient age (16 to 70 years), witnessed arrest, \u0026lt; 15-minute duration from collapse to emergency medical services arrival, and ventricular fibrillation or ventricular tachycardia as the initial rhythm [Johnson NJ et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2014; Wang CH et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2014]. Postresuscitation care that included early reperfusion when coronary arteries are occluded [Kagawa E et al. \u003Cem\u003ECirculation\u003C\/em\u003E. 2012], therapeutic hypothermia, mechanical chest compression, and establishment of an intra-arterial balloon pump [Sakamoto T et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2014; Stub et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2014; Belohlavek J et al. \u003Cem\u003EJ Transl Med.\u003C\/em\u003E 2012] correlated with better outcomes.\u003C\/p\u003E\u003Cp id=\u0022p-7\u0022\u003EECMO could be the first option for resuscitation in settings where ECPR is available, Prof Lazzeri said; therefore, ECMO networks have been proposed as a means to extend mechanical circulatory support assistance, even to primary care centers. ECMO is being explored in refractory cardiogenic shock [Beurtheret S et al. \u003Cem\u003EEur Heart J.\u003C\/em\u003E 2013; Tsao NW et al. \u003Cem\u003EJ Crit Care\u003C\/em\u003E. 2012] and massive pulmonary embolism [Wu MY et al. \u003Cem\u003EResuscitation\u003C\/em\u003E. 2013].\u003C\/p\u003E\u003Cp id=\u0022p-8\u0022\u003EKirsten M\u00f8ller, PhD, Rigshospitalet, Copenhagen, Denmark, discussed emerging pathogens in sepsis, noting the increasing prevalence of infections due to Gram-positive organisms and fungi. Emerging pathogens include methicillin-resistant \u003Cem\u003EStaphylococcus aureus\u003C\/em\u003E, extended-spectrum beta-lactamase-producing Gram-negative bacteria, vancomycin-resistant \u003Cem\u003EEnterococcus faecium\u003C\/em\u003E, multidrug-resistant \u003Cem\u003EAcinetobacter baumannii\u003C\/em\u003E, and \u003Cem\u003EClostridium difficile\u003C\/em\u003E.\u003C\/p\u003E\u003Cp id=\u0022p-9\u0022\u003EEarly adequate antimicrobial coverage in septic shock is key to a successful outcome (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E), she said, as institution of antimicrobials within 30 minutes is associated with a mortality rate of \u0026lt; 20%, while delayed antimicrobial therapy (\u0026gt; 36 hours) is almost always fatal [Nobre V et al. \u003Cem\u003ECurr Opin Crit Care\u003C\/em\u003E. 2007; Kumar A et al. \u003Cem\u003ECrit Care Med.\u003C\/em\u003E 2006]. Early goal-directed therapy - which involves adjusting cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand\u2014may improve overall survival. Early goal-directed therapy was associated with an improvement in 28-day mortality by 42% when compared with standard therapy [Rivers E et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2001].\u003C\/p\u003E\u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/28\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Impact of Early Adequate Antimicrobials in Septic Shock\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-1719814385\u0022 data-figure-caption=\u0022Impact of Early Adequate Antimicrobials in Septic Shock\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/28\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/28\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/14\/42\/28\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/15365\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n            \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003EImpact of Early Adequate Antimicrobials in Septic Shock\u003C\/p\u003E\n         \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced from Nobre V et al. Prompt antibiotic administration and goal-directed hemodynamic support in patients with severe sepsis and septic shock. \u003Cem\u003ECurr Opin Crit Care\u003C\/em\u003E. 2007;13:586\u2013591. As adapted from Kumar A et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in human septic shock. \u003Cem\u003ECrit Care Med.\u003C\/em\u003E 2006;34:1589\u20131596. Used with permission from Lippincott Williams \u0026amp; Wilkins.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cp id=\u0022p-11\u0022\u003ENorepinephrine is the sympathomimetic of choice in septic shock based on a review of studies comparing it with dopamine [de Backer D et al. \u003Cem\u003ECrit Care Med.\u003C\/em\u003E 2012]. Blood glucose should be kept \u0026lt; 10 mmol\/L, but intensive control to 4.5 to 6.0 mmol\/L is no better and is sometimes significantly worse than conventional control on outcomes [Finfer S et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2009]. A transfusion hemoglobin threshold of 7 g\/dL is safe in septic shock when compared with 9 g\/dL, producing similar rates of mortality and ischemic events at 90 days in a recently published trial [Hoist LB et al. \u003Cem\u003EN Engl J Med.\u003C\/em\u003E 2014].\u003C\/p\u003E\u003Cp id=\u0022p-12\u0022\u003EIntravenous (IV) fluid management plays a fundamental role in the acute cardiac care of hospitalized patients, playing a vital role in establishing and maintaining cellular homeostasis, said Antonello Gavazzi, MD, Ospedali Riuniti di Bergamo, Bergamo, Italy. When used appropriately, IV fluid therapy can improve outcomes. Management of fluid should be accomplished per volume status at clinical stage of disease: rescue, optimization, stabilization, and de-escalation [Hoste EA et al. \u003Cem\u003EBr J Anaesth\u003C\/em\u003E. 2014]. In the rescue stage, fluid bolus should be administered to correct hypotensive status. During the optimization stage, continuous infusion of fluid should be carried out to maintain homeostasis, replace losses, or prevent organ injury. In the stabilization stage, fluid should be maintained only if oral intake is inadequate. During de-escalation, IV fluid should be avoided if oral intake of fluid is possible.\u003C\/p\u003E\u003Cp id=\u0022p-13\u0022\u003EInappropriate use of IV fluid therapy may result in high levels of morbidity, prolongation of hospitalization, and excess mortality. Inappropriate use ranges from inadequate rehydration to excessive fluid infusion, leading to tissue hypoperfusion or tissue edema and severe electrolyte derangements.\u003C\/p\u003E\u003Cp id=\u0022p-14\u0022\u003EA multiparametric approach should be used for the assessment of fluid status, aiming to individualize fluid management.\u003C\/p\u003E\u003Cul class=\u0022list-unord \u0022 id=\u0022list-1\u0022\u003E\u003Cli id=\u0022list-item-1\u0022\u003E\n            \u003Cp id=\u0022p-15\u0022\u003EA chest radiograph can identify signs of lung congestion, such as upper-zone vessel enlargement, high vascular pedicle width, septal lines, pulmonary edema, and pleural effusions.\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-2\u0022\u003E\n            \u003Cp id=\u0022p-16\u0022\u003ERight ventricular and left ventricular (LV) filling pressure hemodynamics can be measured with a Swan-Ganz catheter, along with cardiac output and vascular resistance.\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-3\u0022\u003E\n            \u003Cp id=\u0022p-17\u0022\u003ENoninvasive ultrasonography can calculate the dimensions of the inferior vena cava and its variation to respiration and ventilation, as another method to estimate right atrial filling pressures and preload.\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-4\u0022\u003E\n            \u003Cp id=\u0022p-18\u0022\u003ENatriuretic peptides maybe measured; levels of B-type natriuretic peptide (BNP) are related to LV filling pressure. BNP levels can be monitored to determine response to fluid management.\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-5\u0022\u003E\n            \u003Cp id=\u0022p-19\u0022\u003ECarbohydrate antigen 125 is a biomarker that correlates with hemodynamic variables, fluid congestion, diastolic function, BNP, filling pressures, left atrial volume, and pleural fluids and can be modified with fluid management.\u003C\/p\u003E\n         \u003C\/li\u003E\u003Cli id=\u0022list-item-6\u0022\u003E\n            \u003Cp id=\u0022p-20\u0022\u003EBioimpedance vector analysis is a noninvasive technique to estimate body mass and water composition by bioelectrical impedance measurements, resistance, and reactance. Bioimpedance vector analysis can assess the hydration state in normal, hyperhydrated, and dehydrated patients by drawing a hydragram.\u003C\/p\u003E\n         \u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-21\u0022\u003EIn conclusion, the knowledge, skills, tools, and data to support the critical care cardiologist continue to evolve, as does the critical care management of the intensive cardiovascular (CV) care unit patient population. The CV intensive care unit of the 21st century is not the one that your senior colleagues trained in and staffed. Programs of CV intensive care unit fellowship training are being established in many tertiary and quaternary hospitals to support the needs of acute care cardiologists and their patients.\u003C\/p\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2014 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/14\/42\/28.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nzlwcd\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nzlwcd\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}