AHA Statement Takes Aim at Complications in Cardiac ICUs

Keeping up with noncardiovascular comorbid conditions among patients in cardiac intensive care units (CICUs)—and understanding how best to prevent complications—is a challenge for cardiologists. In a scientific statement from the American Heart Association (AHA), researchers say a checklist may help.

While it is possible to extrapolate from the general critical-care literature to some extent, the purpose of the new statement specific for cardiac ICU patients is to consolidate what is applicable, and to highlight knowledge gaps unique to the population and their underlying diseases and medications, the chair of the writing group told TCTMD.

“Patients within the CICU are becoming increasingly complex, and therefore we need to be proactive in terms of preventing their noncardiac complications,” said Christopher B. Fordyce, MD, MSc (University of British Columbia, Vancouver, Canada). “The purpose of this is really to help inform and provide a framework for cardiologists or cardiovascular practitioners to help take care of these patients.”

The scientific statement was published online October 29, 2020, ahead of print in Circulation.

Need for a Daily Checklist

The statement reviews the current state of the evidence and guidance on preventing healthcare-associated infections that overlap in general ICU and CICU patients. These include catheter-associated urinary tract infections, central line-associated bloodstream infections, ventilator-associated pneumonia, and multidrug-resistant pathogens. At the heart of all of them is meticulous hand hygiene and cleaning and disinfecting protocols.

Borrowing from general ICU management protocols, the writing committee also reviews how the elements of the ABCDEF bundle (assessment and management of pain; spontaneous awakening and breathing trials; analgesia and sedation choice; delirium monitoring, prevention, and treatment; early mobilization and exercise; family engagement and empowerment) can be tailored for the cardiac ICU.

Fordyce and colleagues support the use of a daily bedside checklist during patient rounds to encourage standardization of preventive therapies. The checklist contains eight sections that incorporate a range of assessment and monitoring elements for pain and delirium screening; targeted light sedation and minimization of multiple sedatives; extubation success; early mobilization; GI bleeding; hyperglycemia; medication review; imaging; palliative care; and multidisciplinary specialist involvement, where appropriate.

Fordyce said he hopes clinicians will find the checklist useful. “We would also like to hopefully, in the future, study how the checklist changes practice or how it influences care,” he added.

More specific recommendations from the writing committee include:

• Limiting antipsychotic treatment in those with hyperactive delirium and minimizing the use of QTc-prolonging antipsychotic medications.
• Selective use of adjuvant nonpharmacological pain relief such as music, massage, heat, or ice.
• Avoiding the femoral access site for central venous catheters.
• Being familiar with the potential hemodynamic benefits and complications of positive pressure ventilation in subsets of patients with acute and chronic CV disease.
• Considering trophic enteral feeding in patients with compensated or resolving shock, and those undergoing therapeutic temperature management.
• Avoiding parenteral nutrition except in those unable to meet > 60% of caloric requirements after 7 to 10 days on enteral feeding.

Gaps and Unknowns, Including COVID-19

In an online commentary, David A. Morrow, MD, MPH (Brigham and Women’s Hospital and Harvard Medical School, Boston, MA), notes that the writing committee acknowledges multiple times in the statement that there is a lack of data specific to the cardiac ICU to guide evidence-based practice. Despite this, he says the statement provides “a comprehensive set of suggestions for current best practices to prevent complications in the CICU.”

Fordyce and colleagues say high-quality, randomized data and quality-improvement efforts are needed in a number of areas “to better define the epidemiology of critical illness-related complications in the CICU patient population and to evaluate existing and novel therapies with rigorous multicenter clinical trials and large prospective registries.”

Although the statement was developed prior to the ongoing global pandemic of COVID-19, Fordyce told TCTMD that the virus has made it even more important to follow established standards of practice so everyone is on the same page, and patients and providers are properly protected.

“We know from COVID that if you don't have an approach, if you're not ready to deal with COVID and suspected COVID patients in your hospital, have testing available, and ensure that staff are properly protected, it's just chaos,” he said. “The pandemic has demonstrated just how important it is to have protocols and a framework in place.”