Early experience with critically ill patients with COVID-19 in Montreal.

PURPOSE: Montreal has been the epicentre of the coronavirus disease (COVID-19) pandemic in Canada. Given the regional disparities in incidence and mortality in the general population, we aimed to describe local characteristics, treatments, and outcomes of critically ill COVID-19 patients in Montreal. METHODS: A single-centre retrospective cohort of consecutive adult patients admitted to the intensive care unit (ICU) of Hôpital du Sacré-Coeur de Montréal with confirmed COVID-19 were included. RESULTS: Between 20 March and 13 May 2020, 75 patients were admitted, with a median [interquartile range (IQR)] age of 62 [53-72] yr and high rates of obesity (47%), hypertension (67%), and diabetes (37%). Healthcare-related infections were responsible for 35% of cases. The median [IQR] day 1 sequential organ failure assessment score was 6 [3-7]. Invasive mechanical ventilation (IMV) was used in 57% of patients for a median [IQR] of 11 [5-22] days. Patients receiving IMV were characterized by a moderately decreased median [IQR] partial pressure of oxygen:fraction of inspired oxygen (day 1 PaO2:FiO2 = 177 [138-276]; day 10 = 173 [147-227]) and compliance (day 1 = 48 [38-58] mL/cmH2O; day 10 = 34 [28-42] mL/cmH2O) and very elevated estimated dead space fraction (day 1 = 0.60 [0.53-0.67]; day 10 = 0.72 [0.69-0.79]). Overall hospital mortality was 25%, and 21% in the IMV patients. Mortality was 82% in patients ≥ 80 yr old. CONCLUSIONS: Characteristics and outcomes of critically ill patients with COVID-19 in Montreal were similar to those reported in the existing literature. We found an increased physiologic dead space, supporting the hypothesis that pulmonary vascular injury may be central to COVID-19-induced lung damage.

RéSUMé: OBJECTIF: Montréal a été l'épicentre de la pandémie du coronavirus (COVID-19) au Canada. Étant donné les disparités régionales dans l'incidence et la mortalité dans la population générale, nous avons tenté de décrire les caractéristiques locales, les traitements et le devenir des patients atteints de la COVID-19 en état critique à Montréal. MéTHODE: Notre étude de cohorte rétrospective monocentrique a inclus tous les patients adultes admis consécutivement à l'unité de soins intensifs de l'Hôpital du Sacré-Cœur de Montréal avec un diagnostic confirmé de COVID-19. RéSULTATS: Soixante-quinze patients ont été admis entre le 20 mars et le 13 mai 2020. Ceux-ci avaient un âge médian [écart interquartile (ÉIQ)] de 62 [53­72] ans et présentaient une incidence élevée d'obésité (47 %), d'hypertension (67 %) et de diabète (37 %). Les transmissions associées aux soins de santé étaient responsables de 35 % des cas. Au jour 1, le score SOFA (Sequential Organ Failure Assessment ­ évaluation séquentielle de défaillance des organes) médian [ÉIQ] était de 6 [3­7]. La ventilation mécanique invasive (VMI) a été utilisée chez 57 % des patients, pour une durée médiane [ÉIQ] de 11 [5­22] jours. Les patients ayant reçu une VMI étaient caractérisés par une médiane [ÉIQ] modérément réduite de la pression partielle de la fraction d'oxygène inspiré (jour 1 PaO2:FiO2 = 177 [138­276]; jour 10 = 173 [147­227]), de la compliance (jour 1 = 48 [38­58] mL/cmH2O; jour 10 = 34 [28­42] mL/cmH2O), ainsi que par une fraction d'espace mort estimé très élevée (jour 1 = 0,60 [0,53-0,67]; jour 10 = 0,72 [0,69-0,79]). La mortalité hospitalière était de 25 % globalement, et de 21 % chez les patients avec VMI. La mortalité a atteint 82 % chez les patients agés de ≥ 80 ans. CONCLUSION: Les caractéristiques et le devenir des patients en état critique atteints de la COVID-19 à Montréal étaient semblables à ceux rapportés dans la littérature existante. Nous avons observé un espace mort physiologique augmenté, ce qui appuie l'hypothèse que des lésions vasculaires pulmonaires seraient primordiales dans les lésions pulmonaires induites par la COVID-19.

Venoarterial Extracorporeal Membrane Oxygenation Support for Severe Pericardial Decompression Syndrome: A Case Report.

OBJECTIVES: We report a case of a man with tamponade decompression syndrome following pericardial drainage. DATA SOURCES: ICU - Montreal Heart Institute. STUDY SELECTION: Case report. DATA EXTRACTION: Clinical and surgical records. DATA SYNTHESIS: None. CONCLUSIONS: Our case adds further concerns in supporting a patient with tamponade decompression syndrome, including mechanical circulatory support, due to the reversible nature of this condition.

Simulation as a Tool to Ensure Competency and Quality of Care in the Cardiac Critical Care Unit.

Cardiac critical care units are high-risk clinical environments. Medical emergencies are frequent and require the intervention of a cohesive, efficient, and well trained interprofessional team. In modern clinical practice there is increased emphasis on safety but also increased lack of acceptance of medical errors and as a consequence, increased litigation. In the past decade, simulation-based learning has arisen as an effective and safe means to learn and practice acute care setting skills. It has been used and studied in different contexts including procedural skills training, crisis resource management and team training, patient and family member communication skills, and health care system quality improvement. Simulation-based education is a relatively recent teaching strategy and evidence of its efficacy continues to grow. Nevertheless, many influential medical societies are now promoting a simulation-based approach for cardiovascular training and continuing medical education. In this article we review the simulation literature in the intensive care unit and evaluate its integration in coronary care units and postoperative cardiovascular intensive care units. We also provide resources for educators and clinicians who wish to implement simulation workshops in these settings.

Prelicensure Simulation-Enhanced Interprofessional Education: A Critical Review of the Research Literature.

STATEMENT: This review explores the state of prelicensure interprofessional education (IPE) using simulation-based education (SBE) by examining studies that use SBE for prelicensure IPE through a critical review of the research literature. We focus particularly on studies that included experiential SBE with reported measures and formal IPE with prelicensure participants from at least 2 health care professions. Fifty-four studies met criteria. We explore these studies, providing a compilation of information (e.g., educational, simulation, and research methods used; outcome measures reported; and demographics of learner groups), identifying themes that may affect learning, as well as surfacing challenges and gaps in the field. The quality and rigor of the existing literature is inadequate to confidently determine factors that affect learning through simulation-enhanced IPE. We suggest that more rigorous research criteria be included in future studies and a list of reporting items be provided, where future publications can enhance knowledge to guide best practice in simulation-enhanced IPE.

Acute Kidney Injury and Renal Recovery with the Use of Aminoglycosides: A Large Retrospective Study.

BACKGROUND: Recent acute kidney injury (AKI) guidelines, based on studies performed a decade ago, recommend avoiding aminoglycosides (AGs) in patients at risk of AKI. Whether present patient characteristics and management have changed this risk is uncertain. We determined the current incidence, risk factors and outcomes of AG-AKI. METHODS: We retrospectively identified adult patients who received gentamicin or tobramycin for ≥5 days in 2 large university-affiliated centers, excluding critically ill and dialysis patients. We assessed the incidence of Risk, Injury, Failure, Loss and End-stage kidney disease criteria of AKI risk and then matched each AKI to 2 controls of same age and gender to determine factors associated with AG-AKI and its recovery, defined by a creatinine within 150% of baseline by 21 days. RESULTS: Since 2001, the frequency of AG administration and dosing declined, but the incidence of AG-AKI remained constant. Of the 562 patients who received AG for ≥5 days, 65 (12%) developed AG-AKI after 11 (IQR 8-15) days, with 56, 29 and 15% having stages 1, 2 and 3 AKI, respectively. We matched these to 130 controls. In this nested case-control study, independent AKI risk factors were vancomycin coadministration, high AG trough levels and heart failure. AG-AKI compared to AG exposure without AKI was associated with greater mortality. Renal recovery occurred in 51% of the AKI patients and was less likely with heart failure and higher AKI severity. CONCLUSION: AG administration has recently decreased but the risk of AKI remained unchanged and half of the patients did not recover. Vancomycin coadministration, high AG trough levels and heart failure independently predicted AKI.