Articles: outcome.
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There has been an increase in the use of central venous catheters for temporary hemodialysis access. In this report, we describe a case series of 12 patients on hemodialysis who developed intracardiac clots associated with the use of central venous catheters, their outcomes and review the literature on this syndrome. ⋯ Right atrial thrombi may occur in hemodialysis patients who use central venous catheters for dialysis access. These clots are frequently found in the right atrium or right atrial-superior vena caval junction. Ten of 12 patients (83%), had catheter-associated bacteremia, but the precise relationship between bacteremia and intracardiac clots is unclear. Chronic anticoagulation for 6 months lead to resolution of these clots in more than 50% of patients in our series.
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Cardiogenic shock has long been a difficult problem for clinicians. The most common cause is left ventricular pump failure after myocardial infarction, but other important causes include mechanical complications of infarction, right ventricular dysfunction, prolonged cardiopulmonary bypass, valvular disease, and cardiomyopathy. Cardiogenic shock is the leading cause of in-hospital death after myocardial infarction. ⋯ Improved understanding of the pathophysiology of cardiogenic shock has led to renewed emphasis on the notion that stunned or hibernating myocardium may recover function with hemodynamic support and restoration of flow. This concept has underscored the importance of expeditious initiation of supportive measures to maintain blood pressure and cardiac output, including both medications and intraaortic balloon counterpulsation. Finally, the theory that coronary revascularization would be beneficial by reversing the vicious cycle in which ischemia causes myocardial dysfunction, which in turn worsens ischemia, which had been supported by an extensive body of observational and registry studies, has now been strongly buttressed by the results of two randomized, controlled trials, both of which show improved mortality with early revascularization for cardiogenic shock in the setting of acute infarction.
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Interact Cardiovasc Thorac Surg · Dec 2004
Does the use of topical tranexamic acid in cardiac surgery reduce the incidence of post-operative mediastinal bleeding?
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the use of topical tranexamic acid reduces the incidence of post-operative mediastinal bleeding. ⋯ We conclude that, only 1 RCT exists to answer this question, which demonstrated a clinically small benefit in favour of topical tranexamic acid in low risk patients. Further RCTs should be performed prior to any further use of topical tranexamic acid as a strategy to reduce post-operative bleeding.
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Semin Respir Crit Care Med · Dec 2004
Corticosteroid therapy in patients with severe sepsis and septic shock.
Corticosteroids have been considered for decades for the treatment of severe sepsis and septic shock, based on their pivotal role in the stress response and their hemodynamic and antiinflammatory effects. Whereas short-term therapy with high doses of corticosteroids (up to 42 g hydrocortisone equivalent for 1-2 days) has been ineffective or potentially harmful, prolonged therapy with lower doses (200-300 mg hydrocortisone for 5-7 days or longer) in septic shock has recently revealed beneficial effects in several randomized, controlled trials. Assuming relative adrenal insufficiency (RAI) and peripheral cortisol resistance, treatment with low-dose hydrocortisone improved shock reversal, reduced inflammation, and improved outcome. ⋯ In addition the role of fludrocortisone is uncertain. Nevertheless, based on current data, low-dose hydrocortisone therapy should definitely be considered in vasopressor-dependent septic shock. This review will address some critical points.
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Spontaneous intracranial hypotension (SIH) is a postural headache syndrome unrelated to dural puncture. Because of the increasing failure of epidural blood patch (EBP) to relieve headache in SIH, we retrospectively investigated the epidemiological features and treatment outcomes in 55 cases of SIH. The study population was stratified by age and sex; continuous variables were compared for differences by t-tests; categorical variables were compared by Chi-squared analysis or Fisher exact tests. ⋯ EBP failures were more common in patients aged 40 and younger than in older patients (P = 0.003). Postural headache from SIH was not uniformly responsive to EBP, and had significant comorbidities, especially in men. The management of postural headache in SIH by other techniques to restore brain position and cerebrospinal fluid dynamics should be investigated.