Citations

Background: Little is known about the epidemiology and prognostic significance of acid-base disturbances in the cardiovascular intensive care unit (CICU). This study examines the association of acid-base status at admission with in-hospital mortality among CICU patients. Methods: We conducted a retrospective analysis of adults admitted to the Mayo Clinic CICU from 2007-2018 who had available blood gas data, utilizing laboratory values obtained closest to the time of CICU admission. Arterial pH, serum bicarbonate, base excess, and partial pressure of carbon dioxide (PaCO 2 ) were examined as predictors of in-hospital mortality. Logistic regression models were used to assess associations, with adjustment for demographics, comorbidities, illness severity, and interventions. A composite acidosis score (CAS, range 0–5), incorporating predefined cut-offs for arterial pH, base excess, and anion gap was calculated to quantify acid-base disturbance severity. Results: A total of 3,229 patients were included for analysis. Of all acid-base variables, acidemia (pH<7.35) emerged as the strongest predictor of in-hospital mortality (adjusted odds ratio [aOR] 1.60, 95% confidence interval [CI] 1.29-1.98, p <0.003). Metabolic acidosis (HCO 3 <20 mEq/L) aOR 1.55, 95% CI 1.24-1.95, p <0.001) and respiratory acidosis (PaCO 2 >45 mmHg, aOR 1.44, 95% CI 1.14-1.81, p =0.002) were associated with worse adjusted in-hospital mortality, whereas alkalemia, metabolic alkalosis, and respiratory alkalosis were not (Fig. 1A-C). After adjustment, lower pH and more negative base excess were associated with higher in-hospital mortality (both p <0.001), whereas HCO 3 and PaCO 2 were not ( p =0.053&p=0.051, respectively; Fig. 2). Patients with combined metabolic and respiratory acidosis had the highest in-hospital mortality (56.3%), followed by patients with isolated or compensated metabolic acidosis (Fig.1D). Patients with severe acidosis (CAS>1) had higher mortality (aOR 2.34, 95% CI 1.88–2.90; p<0.001, Fig. 3AB). In-hospital mortality rose with increasing CAS (aOR 1.36 per point higher, 95% CI 1.26–1.47; p<0.001), with consistent effects across admission diagnoses (Fig. 3C). Conclusions: Acidemia, especially in the context of combined metabolic and respiratory acidosis, strongly predicts in-hospital mortality in the CICU. Incorporating combined acid-base disorders into risk stratification scores may facilitate earlier recognition and prevent progression of hemometabolic shock, thereby improving prognosis.

Abstract Psychological distress, moral injury, and burnout are prevalent among intensive care unit (ICU) professionals, impacting individual well-being, team dynamics, and patient safety. Structured peer support programmes, delivered by trained colleagues rather than mental health professionals, could be implemented as low-threshold, scalable interventions to promote psychological safety and resilience. This review outlines five foundational pillars for implementing peer support in the ICU, including formal programme design, training, inclusivity, confidentiality, and continuous evaluation. It also addresses practical strategies to overcome cultural and institutional barriers, such as stigma, time constraints, and hierarchical norms. Drawing on current evidence and recent unpublished survey data from North American critical care cardiologists, the article provides a practical framework for integrating peer support into ICU culture. Peer support represents a complementary approach to formal mental health services and offers tangible benefits for clinician well-being, retention, and quality of care.

Abstract Aims The Society for Cardiovascular Angiography and Interventions (SCAI) Classification provides risk stratification of patients with acute myocardial infarction complicated by cardiogenic shock (AMI-CS). This sub-study of the ECLS-SHOCK trial investigates the prognostic impact of SCAI stages in AMI-CS and the influence of SCAI stages on the effect of extracorporeal life support (ECLS) therapy in AMI-CS patients. Methods Patients with AMI-CS enrolled in the multicentre, randomized ECLS-SHOCK trial were included. The outcomes, treatment effect and safety of ECLS were stratified according to SCAI stage at admission using a post-hoc classification. Results From a total of 417 patients enrolled in the ECLS-SHOCK trial between June 2019 and November 2022, 51.6% (n = 215), 13.4% (n = 56) and 35.0% (n = 146) presented in SCAI Stages C, D and E, respectively. SCAI stages were associated with the risk of 30 day all-cause mortality (C vs. D vs. E: 32.6% vs. 67.9% vs. 64.4%, P &lt; 0.001), with rates of renal replacement therapy at 30 days (C vs. D vs. E: 7.0% vs. 19.6% vs. 13.7%, P = 0.03) and with poor neurological outcomes (C vs. D vs. E: 17.2% vs. 44.4% vs. 36.5%, P &lt; 0.001). No interaction was observed between SCAI stage and the treatment effect of ELCS on 30 day all-cause mortality (ELCS vs. control SCAI C: 32.7% vs. 32.4%; SCAI D: 68.4% vs. 66.7%; SCAI E: 59.7% vs. 68.4%, P for interaction = 0.65). Conclusions In AMI-CS patients included in the ECLS-SHOCK trial, SCAI stages at admission were predictive for mortality and for the incidence of safety events. The efficacy of ECLS treatment was not affected by SCAI stage.

Background Patients with cardiohepatic syndrome are at higher risk of adverse outcomes in the cardiac intensive care unit. We hypothesized that cardiohepatic syndrome phenotypes would exhibit differences in their clinical and transthoracic echocardiogram hemodynamic profiles, portending a higher risk of mortality. Methods We included unique CICU patients with an admission diagnosis of heart failure from 2007 to 2018 with available data for 1 or more admission liver function tests. Echocardiographic variables were extracted from patients who had a transthoracic echocardiogram within 1 day of admission. We assigned patients to 1 of 4 mutually exclusive cardiohepatic syndrome phenotype groups: normal, hepatocellular, cholestasis, and combined. Results We included 3992 CICU patients; 2483 had an available transthoracic echocardiogram. Patients with cholestasis had more right ventricular systolic dysfunction and congestion, whereas those with hepatocellular injury had more left ventricular systolic dysfunction and poor forward flow; hemodynamics and biventricular function were worst in the combined group. In‐hospital mortality occurred in 14.6% and was higher for patients with cholestasis or hepatocellular injury, especially those with greater extent/severity and worse biventricular function or poor hemodynamics. After adjustment, only the group with hepatocellular injury (adjusted odds ratio [OR], 1.35 [95% CI, 1.04–1.75], P =0.03) and the combined group (adjusted OR, 1.75 [95% CI, 1.30–2.34], P <0.001) remained at higher risk. One‐year mortality was highest in the combined group (adjusted hazard ratio [HR], 1.29 [95% CI, 1.10–1.51], P =0.002). Conclusions Cardiohepatic syndrome phenotypes are associated with distinct echocardiographic profiles. Patients with the combined cardiohepatic syndrome phenotype were at highest risk of mortality, particularly if this was combined with poor cardiac function.

OBJECTIVES: To investigate whether severe hyperoxia predisposes to end-organ complications and whether these complications contribute to in-hospital mortality among cardiogenic shock (CS) patients supported in venoarterial extracorporeal membrane oxygenation (VA-ECMO). DESIGN: Adult patients with CS from the Extracorporeal Life Support Organization Registry between 2010 and 2023 were categorized into normoxia (Pao 2 60–150 mm Hg), mild hyperoxia (Pao 2 151–300 mm Hg), and severe hyperoxia (Pao 2 > 300 mm Hg) based on their Pao 2 at 24 hours. The primary outcome was in-hospital mortality. End-organ complications were analyzed using multivariate logistic regression models, and causal mediation analysis was performed to estimate the direct and indirect effects of hyperoxia on mortality. SETTING: Multicenter, multinational prospective cohort study. PATIENTS: Adults with CS supported on VA-ECMO. INTERVENTIONS: Partial pressure of oxygen at 24 hours after VA-ECMO cannulation. MEASUREMENTS/MAIN RESULTS: A total of 10,541 patients were included (normoxia: 48.4%, mild hyperoxia: 30.0%, severe hyperoxia: 21.5%). There was higher in-hospital mortality in patients with severe hyperoxia (71.7%, adjusted OR [aOR]: 2.17; 95% CI, 1.19–2.50) and mild hyperoxia (63.8%, aOR: 1.34; 95% CI, 1.19–1.50) compared normoxia (52.7%; referent group). Severe hyperoxia was associated with more end-organ complications, which incrementally predicted higher mortality (aOR: 1.42; 95% CI, 1.25–1.61). Mediation analysis demonstrated that hyperoxia primary exerted a direct effect on mortality (86%), with contributions from neurologic (3.1%), hepatic (3.9%), renal (3.5%), and bleeding (2.3%) complications. CONCLUSIONS: Severe hyperoxia in patients with CS receiving VA-ECMO is associated with increased mortality and more end-organ complications. However, most of the effect of severe hyperoxia on mortality occurs via direct effects, independent of end-organ complications. These findings highlight the potential direct toxicity of hyperoxia and underscore the need for strategies to optimize oxygen delivery in this critically ill population.

Abstract Background Effusive-constrictive pericarditis (ECP) is a condition where acute pericarditis causes a pericardial effusion and stiffening of the pericardium, which can result in haemodynamic instability due to compression of right-sided cardiac chambers. Here, we present a patient with cardiac tamponade followed by ECP complicating treatment of acute myocardial infarction/cardiogenic shock supported with a percutaneous left ventricular assist device (PVAD). Case summary A 65-year-old male presented with an anterior ST-elevation myocardial infarction and cardiogenic shock. The left anterior descending artery was stented, and a PVAD was placed. The patient was haemodynamically unstable, and the PVAD had frequent suction alarms at higher flow rates. Pulsus paradoxus was noted on the arterial line tracing. Echocardiography showed a large pericardial effusion, which was drained with improvement in cardiac output. However, the patient soon worsened again with continued PVAD suction alarms, and this time echocardiography demonstrated constrictive physiology. The patient was treated with anti-inflammatory medications with improvement in haemodynamics. The PVAD was able to be weaned, and the patient was discharged in stable condition. Discussion Effusive-constrictive pericarditis is a syndrome exhibiting the physiology of both cardiac tamponade and constrictive pericarditis. Effusive-constrictive pericarditis should be considered in patients whose haemodynamics do not improve after pericardiocentesis. This patient had a PVAD placed, which relies on left ventricular preload to increase cardiac output. The numerous suction alarms encountered during this patient’s intensive care unit course were likely due to ECP decreasing preload.

ABSTRACT Cardiogenic shock (CS) remains a high morbidity and mortality condition worldwide frequently complicating acute myocardial infarction (AMI) and decompensated heart failure (HF). Within the management of CS, mechanical circulatory support (MCS) devices play a critical role in maintaining hemodynamic stability, preserving end‐organ perfusion and bridging patients through to recovery, implantation of durable support or transplantation. Despite their use, optimal timing of initiation, as well as patient and device selection remain unclear. This review explores the current landscape of MCS devices, surrounding evidence and key distinctions between devices. With increasing acknowledgment for the heterogeneity of CS, understanding the strengths and limitations of each device remains crucial to improving outcomes in this high‐risk population.