Critical pathways in cardiology
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The consequences of type-2 diabetes can be devastating and include a high risk for incident stroke. Fortunately, appropriate and timely treatment of diabetes may avert future complications and improve clinical outcomes. However, it would appear that up to 25% of the general population in the United States with diabetes may be undiagnosed, thereby exposing these individuals to the relentlessly progressive and unmitigated effects of diabetes on the systemic vasculature, with resultant major end-organ damage. ⋯ The inpatient setting could represent a window of opportunity to screen and appropriately manage patients hospitalized with recent symptomatic cerebral ischemia who harbor undiagnosed diabetes. Preliminary data suggest that up to 10% of hospitalized ischemic stroke and transient ischemic attack patients may have undiagnosed diabetes or prediabetes. Aiming to enhance in-hospital stroke care and improve target biomarker control, the SWift Evaluation and Early Treatment to Favorably Impact Inconspicuous glucose eXcess (SWEET-FIX) program, is being implemented at the University of California, Los Angeles Medial Center to systematically screen ischemic stroke and transient ischemic attack patients for undiagnosed diabetes or prediabetes, then implement evidence-based drug and behavioral goals prior to hospital discharge.
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Permanent neurologic impairment following cardiac arrest is often severely debilitating, even after successful resuscitation. Therapeutic hypothermia decreases anoxic brain injury and subsequent cognitive deficits. ⋯ To address the multifacets of therapeutic hypothermia, we assembled a multidisciplinary task force including members from various specialties to create an evidence-based guideline with transparency across disciplines and consistency of care. We describe our institutional guidelines for the initiation and management of induced hypothermia in patients successfully resuscitated from a cardiac arrest.
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Management of pain and sedation therapy is a vital component of optimizing patient outcomes; however, the ideal pharmacotherapy regimen has not been identified in the postoperative cardiac surgery population. We sought to evaluate efficacy and safety outcomes between postoperative mechanically ventilated cardiac surgery patients receiving dexmedetomidine versus propofol therapy upon arrival to the intensive care unit (ICU). We conducted a single center, descriptive study of clinical practice at a 20-bed cardiac surgery ICU in a tertiary academic medical center. ⋯ Hypotension (17 [61%] vs. 9 [32%]; P = 0.04), morphine use (11 [39.3%] vs. 1 [3.6%]; P = 0.002), and nonsteroidal anti-inflammatory use (7 [25%] vs. 1 [3.6%]; P = 0.05) occurred more during dexmedetomidine therapy versus propofol. Dexmedetomidine therapy resulted in a higher incidence of hypotension and analgesic consumption compared with propofol-based sedation therapy. Further evaluation is needed to assess differences in clinical outcomes of propofol and dexmedetomidine-based therapy in mechanically ventilated cardiac surgery patients.
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Primary percutaneous coronary intervention (PPCI) is the preferred method of reperfusion for ST-segment elevation myocardial infarction (STEMI), if it can be performed in a timely manner by an experienced interventional cardiologist at a high volume STEMI Receiving Center. However, an estimated 50% of STEMI patients present to STEMI Referral Centers without PPCI capability. ⋯ Nonetheless, transfer of STEMI patients for PPCI has not been used extensively in the United States and is associated with markedly prolonged transfer times. This study demonstrates that rapid transfer of STEMI patients from community hospitals without PPCI capability to a STEMI Receiving Center is both safe and feasible using a standardized protocol with an integrated transfer system.
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Comparative Study
Evaluation of a clinical decision support system for glucose control: impact of protocol modifications on compliance and achievement of glycemic targets.
Treating hyperglycemia may improve patient outcome, but is a clinical challenge. Three variations of a computerized insulin protocol were compared with regard to protocol compliance and achievement of glucose target levels. In group 1, the existing protocol was applied, in group 2 the protocol was modified to account for decreasing glucose values; group 3 had a higher threshold for initiating insulin, wider glucose target ranges, and included instructions to regulate glucose around mealtimes. ⋯ Average glucose levels increased in group 3 due to a higher threshold for starting insulin and a wider target range: 70% (group 1), 66% (group 2), and 61% (group 3) had an average glucose of <8 mmol/L (P < 0.001). Also, we observed a decreasing trend in incidence of hypoglycemia and reporting of noncompliance. Further improvements in glucose measurement technology and protocols are needed to optimally treat hyperglycemia in the Intensive Cardiac Care Unit.