JapanesepeoplehaveanoutofhospitalcardiacarrestduetoCVDseveryyearandt - PDF document

1 Japanesepeoplehaveanout-of-hospitalcardi
Japanesepeoplehaveanout-of-hospitalcardiacarrestduetoCVDseveryyearandtheoveralllife-savingrateisstilllow[6].SincetheCVDscontainmanyfatalemergencydiseases,coronarycareunit(CCU)wasestablishedasafacilityresponsibleforintensivecareintheacutephaseinordertoimprovetheoutcomeoftheCVDs.ProgressfromthecoronarycareunittothecardiovascularintensivecareunitThedevelopmentofCCUinthemid-twentiethcenturywasamajoradvanceincardiologypractice[7].CCUwasdevelopedinthe1960swhenitbecameclearthatclosemonitoringbyspeciallytrainedstaff,cardiopulmo-naryresuscitation(CPR),andmedicalinterventionscanreducemortalityduetoCVDcomplicationssuchascardiogenicshockandfatalarrhythmias.CCU,whichwasinitiallyestablishedasaseparateunitfortheearlydetectionandtreatmentofarrhythmiascomplicatingAMI,currentlyprovidesthesettingforthemonitoringandtreatmentofawidevarietyofcriticalCVDstates.Therefore,theCCUhascometobecalledtheCICU.Theroleofcardiovascularintensivecarehasevolvedwiththerapidprogressofdiagnosticandthera-peuticstrategiesinthepracticeofclinicalcardiology[7].Thetechnologicaldevelopmentsofclinicalcardiology,suchasinvasivehemodynamicmonitoringandintracor-onaryinterventionalproceduresanddevices,haveresultedinevolutionofintensivecareforCVDs.Subsequently,se-vereCVDpatientsadmittedtoCICUareincreasingyearbyyear.Figure1displaysmyconceptaboutcardiovascularin-tensivecare.IntheeraofCCU,themaintargetpatientswereacutemyocardialinfarction(AMI).Percutaneouscoronaryintervention(PCI)anddefibrillationwereim-portanttreatments.Subsequently,asthetargetpatientsspreadtoheartfailure,shock,out-of-hospitalcardiacarrest,etc.,theneedforcardiovascularintensivecarein-cludingrespiratorymanagementandbloodpurificationtherapyincreased.FeaturesofcardiovascularintensivecareTheCICUisahospitalwardspecializedinthecareofpatientswithsevereheartdiseases,suchasAMI,cardio-myopathy,andarrhythmias.Thosepatientsoftencom-plainofheartfailureandcardiogenicshock.Therefore,thesevereCVDpatientsneedcontinuousmonitoringandintensivecare.ThemainfeatureofCICUistheavailabilityofthecontinuousmonitoringofthecardiacrhythmbyelectro-cardiography(ECG).Thisallowsearlyinterventionwithmedication,cardioversion,ordefibrillation,improvingtheprognosisofthesevereCVDpatients.Furthermore,car-diovascularintensivecareneedstohavevariouskindsofdiagnosticmedicalequipmentasshowninTable1.Also,therapeuticequipmentnecessaryforcardiovascularinten-sivecareisshowninTable2.Inadditiontocirculationmanagement,systemicmanagementisrequiredintheCICU.So,itisnecessarytoprepareaventilatorandabloodpurificationdeviceaswellastheauxiliarycirculationdevices,suchasintra-aorticballoonpump(IABP)andper-cutaneouscardiopulmonarysupportsystem(PCPS)intheCICU.Recently,itisalsoindispensabletoprovidetheequipmentforperformingtargetedtemperaturemanage-mentforthepatientsresuscitatedfromcardiogenicout-of-hospitalcardiacarrest(OHCA)[8].Adedicatedmedicalstaffisrequiredforcardiovascu-larintensivecareinordertoperformbestpatientman-agement.InJapan,cardiologistscertifiedbytheJapanCirculationSocietyareassignedtoCICU.Inaddition,nursesandtechnicianswhoaretrainedonprofessionalcareofCVDpatientsarealsoassigned.Inordertopro-videthebestpatientmanagement,teammedicalcarethroughcooperationofmedicalstaffintheCICUisin-dispensable.TheCICUphysicianstaffneedstheabilitytoevaluateelectrocardiogramsandcardiacfunctionsbyechocardiography. Fig.1Evolvedroleofthecardiovascularintensivecare Table1DiagnosticequipmentnecessaryforcardiovascularintensivecareBedsidemonitoringsystem:ECG,bloodpressure,respiratoryratePulseoximeter(SpO2)ThermometerTwelve-leadelectrocardiographyCardiacultrasounddeviceCardiacoutputmeasurementsystem:Swan-GanzcatheterPortableX-rayimagingequipmentDopplerbloodflowmeterBloodg

2 asanalyzerKasaokaJournalofIntensiveCare
asanalyzerKasaokaJournalofIntensiveCare (2017) 5:72 Page2of5 Inrecentyears,cardiologistshavebeenrequirednotonlycirculationmanagementbutalsosystemicintensivecarepracticessuchasrespiratorymanagementandinfu-sionmanagement.CooperationbetweencardiologistsandintensivecarespecialistsisalsoimportanttocopewithCVDpatientswithvariouscomplications,suchasrespiratoryfailure,renalfailure,andsepsis.IbelievethatsystemizedtrainingrelatedtogeneralintensivecareisnecessarysothatCICUstaffcanmastertheuseofdiagnosticandtherapeuticmedicalequipmentsshowninTables1and2.IntheUSA,coronarycareunitsareusuallysubsetsofintensivecareunits(ICU)dedicatedtothecareofcritic-allyillcardiacpatients.Theseunitsareusuallypresentinhospitalsthatroutinelyengageincardiothoracicsur-gery.Itisreportedthatnoncardiovasculardisease-relatedacuityhassignificantlyincreasedintheCICUandmaybeinfluencingmortality[9].Recently,itisreportedthatlessonslearnedfromad-vancesincardiovascularintensivecarecanbebroadlyappliedtoaddresstheurgentneedtoimproveoutcomesandefficiencyinavarietyofhealthcaresettings[10].TheCICUisahigh-riskenvironmentthatadmitscom-plexpatientssufferingfromacuteconditionsthatcanbecomelife-threateningatanymoment.Itisreportedthatsimulation-basedteachingprogramyieldsmanyben-efitsforcardiacintensivecareunits,allowingprofessionalstoacquirenotonlyproceduralskillsspecifictotheprac-ticebutalsoconfidenceandcompetenceasmembersofanefficientandskilledresuscitationteam[11].MonitoringoftheheartandvascularsystemThemostimportantmonitorincardiovascularintensivecareisanelectrocardiogramthatevaluatesthecardiacrhythmoftheCVDpatients.Inaddition,hemodynamicmonitoringofinvasivearterialpressureandpulmonaryarterypressuremayberequiredintheCVDpatientscomplicatedwithcardiogenicshockoracuteheartfail-ure.Hemodynamicevaluationisanimportantfactorintheseverityassessmentofthosepatients.ForCICUmed-icalstaff,itisnecessaryforoptimalpatientcaretoselecteffectivemeansfromvarioushemodynamictoolsandtoadjusttheusageaccordingtotheclinicalsituation[12].Sincetheintroductioninthe1970s,pulmonaryarterycatheterhasbeencommonlyutilizedforhemodynamicmonitoringinthecriticallyillpatient,especiallyintheadultpopulation[13].Thestandardpulmonaryarterycatheter,asdevelopedbyDrs.SwanandGanz,hasfourlumensalongitslength,andtheselumensallowfortheassessmentofhemodynamicdatainvariousplacesalongtheright-sidedcirculation[14].Dataavailableincluderightatriumpressure,rightventriclepressure,pulmonaryarterypressure,andpulmonarycapillarywedgepressure.Usingthesevariablesandmeasuredvaluesofheartrate,systemicarterialpressure,andcardiacoutput,numeroushemodynamicvariablescanbecalculated,includingpul-monaryandsystemicvascularresistance.Cardiacoutputismostcommonlymeasuredwiththepulmonaryarterycatheterusingthethermodilutiontechnique.Advantagesofthethermodilutionmethodincludeitsvalidatedreli-abilityanditseaseofuseatthebedsideofCCU.Furthermore,cardiacoutputcanbemeasuredwithnewtechnology,whichisestimatedbyanalysisofthepulsecontourfromanarterialwaveform,sincethesys-tolicportionofthewaveformreflectsstrokevolume(SV)[12].Inrecentyears,thesedeviceshavebeenusedforhemodynamicmonitoringintheCICU.Althoughtheuseofinvasivehemodynamicmonitoringhasdeclinedinrecentyears,itispossibletoobtainuse-fulinformationforassessingthepathologyandseverityoftheCVDsanddeterminingthetreatmentpolicyforthecriticallyillpatients.Targetedtemperaturemanagementforthepatientswithout-of-hospitalcardiacarrestintheCICUInpatientssurvivingout-of-hospitalcardiacarrest,tar-getedtemperaturemanagement(TTM),previouslyknownasmildtherapeutichypothermia,hasbeenreportedtosignificantlyimprovelong-termneurologicaloutcomeandmayprovetobeoneofthemostimportantclinicalad-vancementsintheresuscitationscience

3 [8].Clinicalbenefitoftherapeutichypother
[8].Clinicalbenefitoftherapeutichypothermiainpatientswithpost-cardiacarrestsyndrome(PCAS)hasbeendem-onstratedbytworandomizedcontroltrialssince2002[15,16].However,theterm“therapeutichypothermia”hasbeenreplacedwith“targetedtemperatureman-agement(TTM)”since2011afterthemeetingoffivemajorprofessionalphysiciansocieties[17].Subsequently,alargemulticenterstudycomparingTTMbetween33and36°Cdidnotshowtheadvantageof33°Cabove36°C[18].Therefore,itisproposedthatTTMtreatmentshouldbeadministeredtoOHCApatientswithashockableinitialrhythm.TheOHCApatientswithventricularfibrillation(VF)arethemainindicationsforTTM. Table2TherapeuticequipmentnecessaryforcardiovascularintensivecareDefibrillatorCardiacpacemakerNoninvasiveventilationsystemMechanicalventilatorBloodpurificationdeviceIntra-aorticballoonpumpPercutaneouscardiopulmonaryassistdeviceTemperaturemanagementsystemKasaokaJournalofIntensiveCare (2017) 5:72 Page3of5 Therefore,itisnecessarytoestablishasystemtoper-formtheTTMforresuscitatedpatientsadmittedtoCICU.DoctorsandnurseswhoworkatCICUarerequiredtohaveknowledgeandskillsonTTM.Cardiacarrest,asuddenstopineffectivebloodflow,oftenhappensoutsidethehospital.Itisdifficultformanypatientswhoexperienceout-of-hospitalcardiacarreststosurvive.Themostcommoncauseofcardiacarrestisheartattack,andthemosteffectivetreatmentforcardiacarrestisimmediatecardiopulmonaryresusci-tation(CPR)anddefibrillationbyanyonewhocandotheseprocedures.Theterm,“ChainofSurvival”isguide-linestohelppeoplesurvivecardiacarrest[19].Thefiveguidelinesintheadultout-of-hospitalChainofSur-vivalthatarerecommendedbytheAmericanHeartAssociation(AHA)are:1.Recognitionofcardiacarrestandactivationoftheemergencyresponsesystem2.Earlycardiopulmonaryresuscitationwithanemphasisonchestcompressions3.Rapiddefibrillation4.Basicandadvancedemergencymedicalservices5.Advancedlifesupportandpost-cardiacarrestcareRecently,itisreportedthattheproportionofOHCApatientswithafavorableneurologicaloutcomeimprovedsignificantlyaftertheimplementationofthefifthlink[20].TTMisincludedinthetreatmentforpost-cardiacarrestsyndrome(PCAS)whichisonthefifthchain.TTMcanbeinducedandmaintainedwithbasicmeanssuchasicepacks,fans,coldairblankets,andinfusionofcoldfluidsorwithcostlyadvancedsystemssuchassurfacecoolingpadsorendovascularcatheters[21].Recently,amulticenterstudycomparingtheeffectsofsurfacecoolingandendovascularcoolingwasconducted[22].Endovascularcoolingappearstobemoreefficientinrapidlyreachingandbettercontrollingthetargetedtemperaturewithadecreasedworkloadfornursesdur-ingtheTTMperiod.However,endovascularcoolingwasnotsignificantlysuperiortobasicsurfacecoolingintermsoffavorableoutcome.CICUmedicalstaffneedstobecomeproficientinusingvariousdevicesforbodytemperaturemanagement.ManagementofcardiogenicshockintheCICUCardiogenicshockisaconditioninwhichinsufficientorganperfusionoccursduetodecreasedcardiacoutput[23].Causesofcardiogenicshockincludesevereheartdis-easessuchasAMI,fulminantmyocarditis,andcardiomy-opathy.Thislife-threateningemergencyconditionrequiresintensivemonitoringwithaggressivehemodynamicsup-port.Inordertosurvivepatientswithcardiogenicshock,resuscitationtreatmentmustbeperformedbeforeirrevers-ibledamagetoimportantorgansoccurs.Thekeytogoodoutcomeinpatientswithcardiogenicshockisasystematicapproach,withrapiddiagnosisandrapidstartofpharmacologicaltreatmenttomaintainbloodpressureandcardiacoutputaswellastreatmentfortheunderlyingdisease.Pulmonaryarterycatheterisausefulmethodforevaluatingthehemodynamicsofshockpatients.AllshockpatientsrequireadmissiontogeneralICUorCICU.Amultidisciplinarycardiogenicshockteamisrecommendedtoguidetherapidandefficientuseoftheseavailabletreatments[23].Allpatientswithcardio-genicshockrequireclosehemodyna

4 micmonitoring,vol-umesupporttoensureadeq
micmonitoring,vol-umesupporttoensureadequatesufficientpreload,andventilatorysupportsuchastrachealintubationandmech-anicalventilation[24].InmechanicalcirculatorysupportsuchasIABP,PCPSshouldbeconsideredforpatientswithshockrefractorytoconventionalmedicaltherapy[23].Cardiogenicshockisaclinicalconditionwithhighmortalityrate.Furtherimprovementofcardiovascularintensivecareisexpectedtoimprovethelife-savingrateofcardiogenicshock.ConclusionsCardiovascularintensivecareunit(CICU)isahospitalwardthatspecializesinthecareofpatientswhohaveexperiencedischemicheartdiseaseaswellasotherse-vereheartdisease.Furthermore,thepatientsintheCICUoftenhavevariouscomplicationssuchasrespira-toryfailureandrenalfailure.Therefore,medicalstaffswhoworkatCICUarerequiredtohavetheabilitytopracticesystemicintensivecare.AbbreviationsAHA:AmericanHeartAssociation;AMI:Acutemyocardialinfarction;CAD:Coronaryarterydisease;CCU:Coronarycareunit;CICU:Cardiovascularintensivecareunit;CPR:Cardiopulmonaryresuscitation;CVD:Cardiovasculardisease;ECG:Electrocardiography;IABP:Intra-aorticballoonpump;ICU:Intensivecareunit;OHCA:Out-of-hospitalcardiacarrest;PCAS:Post-cardiacarrestsyndrome;PCI:Percutaneouscoronaryintervention;PCPS:Percutaneouscardiopulmonarysupportsystem;SV:Strokevolume;TTM:TargetedtemperaturemanagementAcknowledgementsNotapplicable.FundingNotapplicable.AvailabilityofdataandmaterialsNotapplicable.EthicsapprovalandconsenttoparticipateNotapplicable.ConsentforpublicationNotapplicable.CompetinginterestsTheauthordeclaresthathehasnocompetinginterests.KasaokaJournalofIntensiveCare (2017) 5:72 Page4of5 Publisher’sNoteSpringerNatureremainsneutralwithregardtojurisdictionalclaimsinpublishedmapsandinstitutionalaffiliations.Received:5September2017Accepted:12December2017 References1.BowryAD,LeweyJ,DuganiSB,ChoudhryNK.Theburdenofcardiovasculardiseaseinlow-andmiddle-incomecountries:epidemiologyandmanagement.CanJCardiol.2015;31:1151–9.2.GidwaniUK,KiniAS.Fromthecoronarycareunittothecardiovascularintensivecareunit:theevolutionofcardiaccriticalcare.CardiolClin.2013;31:485–92.3.GBD2015MortalityandCausesofDeath,Collaborators.Global,regional,andnationallifeexpectancy,all-causemortality,andcause-specificmortalityfor249causesofdeath,1980-2015:asystematicanalysisfortheGlobalBurdenofDiseaseStudy2015.Lancet.2016;388:1459–544.4.McGillHC,McMahanCA,GiddingSS.Preventingheartdiseaseinthe21stcentury:implicationsofthePathobiologicalDeterminantsofAtherosclerosisinYouth(PDAY)study.Circulation.2008;117:1216–27.5.GoAS,MozaffarianD,RogerVL,etal.Heartdiseaseandstrokestatistics—2013update:areportfromtheAmericanHeartAssociation.Circulation.2013;127:e6–e245.6.KitamuraT,KiyoharaK,SakaiT,etal.Public-accessdefibrillationandout-of-hospitalcardiacarrestinJapan.NEnglJMed.2016;375:1649–59.7.WalkerDM,WestNE,RaySG.Britishcardiovascularsocietyworkinggrouponacutecardiaccare.Fromcoronarycareunittoacutecardiaccareunit:theevolvingroleofspecialistcardiaccare.Heart.2012;98:350–2.8.FukudaT.Targetedtemperaturemanagementforadultout-of-hospitalcardiacarrest:currentconceptsandclinicalapplications.JIntensiveCare.2016;4:30.9.KatzJN,ShahBR,VolzEM,etal.Evolutionofthecoronarycareunit:clinicalcharacteristicsandtemporaltrendsinhealthcaredeliveryandoutcomes.CritCareMed.2010;38:375–81.10.LoughranJ,PuthawalaT,SuttonBS,etal.Thecardiovascularintensivecareunit—anevolvingmodelforhealthcaredelivery.JIntensiveCareMed.2017;32:116–23.11.BrunetteV,Thibodeau-JarryN.Simulationasatooltoensurecompetencyandqualityofcareinthecardiaccriticalcareunit.CanJCardiol.2017;33:119–27.12.StevenM,HollenbergMD.Hemodynamicmonitoring.Chest.2013;143:1480–8.13.TsangR.Hemodynamicmonitoringinthecardiacintensivecareunit.CongenitHeartDis.2013;8:568–75.14.SwanHJ,GanzW,F

5 orresterJ,etal.Catheterizationoftheheart
orresterJ,etal.Catheterizationoftheheartinmanwithuseofaflow-directedballoon-tippedcatheter.NEnglJMed.1970;283:447–51.15.HypothermiaafterCardiacArrestStudyGroup.Mildtherapeutichypothermiatoimprovetheneurologicoutcomeaftercardiacarrest.NEnglJMed.2002;346:549–56.16.BernardSA,GrayTW,BuistMD,etal.Treatmentofcomatosesurvivorsofout-of-hospitalcardiacarrestwithinducedhypothermia.NEnglJMed.2002;346:557–63.17.NunnallyME,JaeschkeR,BellinganGJ,etal.Targetedtemperaturemanagementincriticalcare:areportandrecommendationsfromfiveprofessionalsocieties.CritCareMed.2011;39:1113–25.18.NielsenN,WetterslevJ,CronbergT,TrialInvestigatorsTTM,etal.Targetedtemperaturemanagementat33°Cversus36°Caftercardiacarrest.NEnglJMed.2013;369:2197–206.19.HazinskiMF,NolanJP,AickinR,etal.Part1:ExecutiveSummary2015InternationalConsensusonCardiopulmonaryResuscitationandEmergencyCardiovascularCareSciencewithTreatmentRecommendations.Circulation.2015;132(suppl1):S2–S39.20.TagamiT,HirataK,TakeshigeT,etal.Implementationofthefifthlinkofthechainofsurvivalconceptforout-of-hospitalcardiacarrest.Circulation.2012;126:589–97.21.PoldermanKH,HeroldI.Therapeutichypothermiaandcontrollednormothermiaintheintensivecareunit:practicalconsiderations,sideeffects,andcoolingmethods.CritCareMed.2009;37:1101–20.22.DeyeN,CariouA,GirardieP,etal.Endovascularversusexternaltargetedtemperaturemanagementforpatientswithout-of-hospitalcardiacarrest.Circulation.2015;132:182–93.23.DollJA,OhmanEM,PatelMR,etal.Ateam-basedapproachtopatientsincardiogenicshock.CatheterCardiovascInterv.2016;88:424–33.24.SzymanskiFM,FilipiakKJ.Cardiogenicshock—diagnosticandtherapeuticoptionsinthelightofnewscientificdata.AnaesthesiologyIntensiveTherapy.2014;46:301–6. • We accept pre-submission inquiries  Our selector tool helps you to Þnd the most relevant journal We provide round the clock customer support  Convenient online submission Thorough peer review Inclusion in PubMed and all major indexing services  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submit Submit your next manuscript to BioMed Central and we will help you at every step: KasaokaJournalofIntensiveCare (2017) 5:72 Page5of5 REVIEWOpenAccess Evolvedroleofthecardiovascularintensivecareunit(CICU)ShunjiKasaokaAbstractCardiovascularintensivecarereferstospecialsystemicmanagementforthepatientswithseverecardiovasculardisease(CVD),whichconsistsofheartdiseaseandvasculardisease.CVDisoneoftheleadingcausesofdeathintheworld.InordertopreventdeathduetoCVDs,anintensivecareunitforsevereCVDpatients,so-calledcardiovascularintensivecareunit(CICU),hasbeendevelopedinmanygeneralhospitals.Thetechnologicaldevelopmentsofclinicalcardiology,suchasinvasivehemodynamicmonitoringandintracoronaryinterventionalproceduresanddevices,haveresultedinevolutionofintensivecareforCVDs.Subsequently,severeCVDpatientsadmittedtoCICUareincreasingyearbyyear.DedicatedmedicalstaffisrequiredforCICUinordertoperformbest Correspondence:kasaoka@kuh.kumamoto-u.ac.jpDepartmentofEmergencyandGeneralMedicine,KumamotoUniversityHospital,1-1-1Honjo,Chuo-ku,Kumamoto860-8556,Japan ©TheAuthor(s).2017OpenAccessThisarticleisdistributedunderthetermsoftheCreativeCommonsAttribution4.0InternationalLicense(http://creativecommons.org/licenses/by/4.0/),whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedyougiveappropriatecredittotheoriginalauthor(s)andthesource,providealinktotheCreativeCommonslicense,andindicateifchangesweremade.TheCreativeCommonsPublicDomainDedicationwaiver(http://creativecommons.org/publicdomain/zero/1.0/)appliestothedatamadeavailableinthisarticle,unlessotherwisestated.KasaokaJournalofIntensiveCare (2017) 5:72 DOI10.1186/s40560-017-0271