Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study.

OBJECTIVES: Studies have suggested intrapulmonary shunts may contribute to hypoxemia in COVID-19 acute respiratory distress syndrome (ARDS) with worse associated outcomes. We evaluated the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia workup for shunt etiology and associations with mortality. DESIGN: Prospective, observational cohort study. SETTING: Four tertiary hospitals in Edmonton, Alberta, Canada. PATIENTS: Adult critically ill, mechanically ventilated, ICU patients admitted with COVID-19 or non-COVID (November 16, 2020, to September 1, 2021). INTERVENTIONS: Agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler ± transesophageal echocardiography assessed for R-L shunts presence. MEASUREMENTS AND MAIN RESULTS: Primary outcomes were shunt frequency and association with hospital mortality. Logistic regression analysis was used for adjustment. The study enrolled 226 patients (182 COVID-19 vs 42 non-COVID). Median age was 58 years (interquartile range [IQR], 47-67 yr) and Acute Physiology and Chronic Health Evaluation II scores of 30 (IQR, 21-36). In COVID-19 patients, the frequency of R-L shunt was 31 of 182 COVID patients (17.0%) versus 10 of 44 non-COVID patients (22.7%), with no difference detected in shunt rates (risk difference [RD], -5.7%; 95% CI, -18.4 to 7.0; p = 0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared with those without (54.8% vs 35.8%; RD, 19.0%; 95% CI, 0.1-37.9; p = 0.05). This did not persist at 90-day mortality nor after adjustment with regression. CONCLUSIONS: There was no evidence of increased R-L shunt rates in COVID-19 compared with non-COVID controls. R-L shunt was associated with increased in-hospital mortality for COVID-19 patients, but this did not persist at 90-day mortality or after adjusting using logistic regression.

Midodrine therapy for vasopressor dependent shock in the intensive care unit: a protocol for a systematic review and meta-analysis.

INTRODUCTION: Intensive care unit (ICU) lengths of stay are modified by ongoing need for haemodynamic support in critically ill patients. This is most commonly provided by intravenous vasopressor therapy. Midodrine has been used as an oral agent for haemodynamic support in patients with orthostatic hypotension or cirrhosis. However, its efficacy in treating shock in the ICU, particularly for patients weaning from intravenous vasopressors, remains uncertain. The objective of this systematic review is to determine the efficacy of midodrine in vasopressor dependent shock. METHODS AND ANALYSIS: We will search Ovid MEDLINE, Ovid Embase, CINAHL and Cochrane Library for observational trials and randomised controlled trials evaluating midodrine in critically ill patients from inception to 21 April 2022. We will also review unpublished data and relevant conference abstracts. Outcomes will include ICU length of stay, duration of intravenous vasopressor support, ICU mortality, hospital mortality, hospital length of stay and rates of ICU readmission. Data will be analysed in aggregate, where appropriate. We will evaluate risk of bias using the modified Cochrane tool and certainty of evidence using Grading of Recommendations, Assessment, Development and Evaluations methodology. We will perform trial sequential analysis for the outcome of ICU length of stay. ETHICS AND DISSEMINATION: Ethics approval is not required as primary data will not be collected. Findings of this review will be disseminated through peer-related publication and will inform future clinical trials. PROSPERO REGISTRATION NUMBER: CRD42021260375.

LIBERATE: a study protocol for midodrine for the early liberation from vasopressor support in the intensive care unit (LIBERATE): protocol for a randomized controlled trial.

BACKGROUND: Intravenous (IV) vasopressors to support hemodynamics are a primary indication for intensive care unit (ICU) admission. Utilization of oral vasopressor therapy may offer an alternative to IV vasopressor therapy in the ICU, thus decreasing the need for ICU admission. Oral vasopressors, such as midodrine, have been used for hemodynamic support in non-critically ill patients, but their evaluation in critically ill patients to potentially spare IV vasopressor therapy has been limited. METHODS: The LIBERATE study will be a multicenter, parallel-group, blinded, randomized placebo-controlled trial. It will recruit adult (i.e., age ≥ 18 years) critically ill patients receiving stable or decreasing doses of IV vasopressors. Eligible patients will be randomized to receive either midodrine 10 mg administered enterally every 8 h or placebo until 24 h post-discontinuation of IV vasopressors. The primary outcome will be ICU length of stay. Secondary outcomes include all-cause mortality at 90 days, hospital length of stay, length of IV vasopressor support, re-initiation of IV vasopressors, rates of ICU readmission, and occurrence of AEs. Health economic outcomes including ICU, hospital and healthcare costs, and cost-effectiveness will be evaluated. Pre-planned subgroup analyses include age, sex, frailty, severity of illness, etiology of shock, and comorbid conditions. DISCUSSION: LIBERATE will rigorously evaluate the effect of oral midodrine on duration of ICU stay and IV vasopressor support in critically ill patients. TRIAL REGISTRATION: ClinicalTrials.gov NCT05058612 . Registered on September 28, 2021.

Critical care ultrasound training: a survey exploring the "education gap" between potential and reality in Canada.

BACKGROUND: Critical care ultrasound (CCUS) is now a core competency for Canadian critical care medicine (CCM) physicians, but little is known about what education is delivered, how competence is assessed, and what challenges exist. We evaluated the Canadian CCUS education landscape and compared it against published recommendations. METHODS: A 23-item survey was developed and incorporated a literature review, national recommendations, and expert input. It was sent in the spring of 2019 to all 13 Canadian Adult CCM training programs via their respective program directors. Three months were allowed for data collection and descriptive statistics were compiled. RESULTS: Eleven of 13 (85%) programs responded, of which only 7/11 (64%) followed national recommendations. Curricula differed, as did how education was delivered: 8/11 (72%) used hands-on training; 7/11 (64%) used educational rounds; 5/11 (45%) used image interpretation sessions, and 5/11 (45%) used scan-based feedback. All 11 employed academic half-days, but only 7/11 (64%) used experience gained during clinical service. Only 2/11 (18%) delivered multiday courses, and 2/11 (18%) had mandatory ultrasound rotations. Most programs had only 1 or 2 local CCUS expert-champions, and only 4/11 (36%) assessed learner competency. Common barriers included educators receiving insufficient time and/or support. CONCLUSIONS: Our national survey is the first in Canada to explore CCUS education in critical care. It suggests that while CCUS education is rapidly developing, gaps persist. These include variation in curriculum and delivery, insufficient access to experts, and support for educators.

A 58-Year-Old Man With Episodic Hypercapnic Respiratory Failure.

CASE PRESENTATION: A 58-year-old man presented to the ED with a 1-week history of progressive weight loss, generalized weakness, unsteadiness, and dizziness. In hospital, he experienced a witnessed episode of loss of consciousness with no observable respirations that lasted for 15 minutes. His arterial blood gas demonstrated hypercapnic respiratory failure, and he required mask ventilation and vasoactive medications. Similar episodes occurred several more times over the course of the night that required the patient to be intubated. The paroxysmal episodes persisted necessitating continued invasive ventilatory support and admission to the ICU. The episodes occurred in both awake and asleep states and required the ventilator settings to dictate a minimum rate, but minimal ventilatory support otherwise. Further history revealed other symptomatic complaints of vertigo, dysphagia, and hypophonia that had progressed over a 2-month period. The patient's medical history was pertinent for a diagnosis of prostatic carcinoma 3 years previously that was found to be castrate resistant. He had metastases to his hip, ribs, and thoracic spine. Previous treatments had included bicalutamide, docetaxel, and abiraterone; he was receiving leuprolide therapy on presentation.

Outcomes among critically ill adults with influenza infection.

Background: Influenza infection is a major cause of mortality in critical care units. Methods: ata on critically ill adult patients with influenza infection from 2014 to 2019 were retrospectively collected, including mortality and critical care resource utilization. Independent predictors of mortality were identified using Cox regression. Results: ne hundred thirty patients with confirmed influenza infection had a mean age of 56 (SD 16) years; 72 (55%) were male. Mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 22 (SD 9). One hundred eight (83%) patients had influenza A (46% H1N1pdm09, 33% H3N2); 21 (16%) had influenza B. Fifty-five (42%) patients had bacterial co-infection. Only 5 (4%) had fungal co-infection. One hundred eight (83%) patients required mechanical ventilation; 94 (72%), vasopressor support; 26 (20%), continuous renal replacement therapy (CRRT); and 11 (9%), extracorporeal membrane oxygenation. One hundred twenty one (93%) patients received antiviral therapy (median 5 d). Thirty-day mortality was 23%. Patients who received antiviral treatment were more likely to survive with an adjusted hazard ratio (aHR) of 0.15 (95% CI 0.04 to 0.51, p = 0.003). Other independent predictors of mortality were the need for CRRT (aHR 2.48, 95% CI 1.14 to 5.43, p = 0.023), higher APACHE II score (aHR 1.08, 95% CI 1.02 to 1.14, p = 0.011), and influenza A (aHR 7.10, 95% CI 1.37 to 36.8, p = 0.020) compared with influenza B infection. Conclusions: mong critically ill influenza patients, antiviral therapy was independently associated with survival. CRRT, higher severity of illness, and influenza A infection were associated with mortality.

Historique: L'infection par l'influenza est une cause majeure de décès en soins intensifs. Méthodologie: Les chercheurs ont procédé à la collecte rétrospective des données sur des patients adultes gravement malades à cause d'une infection par l'influenza entre 2014 et 2019, y compris la mortalité et l'utilisation des ressources en soins intensifs. Ils ont établi les prédicteurs indépendants de mortalité au moyen de la régression de Cox. Résultats: Les 130 patients atteints d'une infection confirmée par l'influenza avaient un âge moyen de 56 ans (±16), et 72 (55 %) étaient de sexe masculin. Le score APACHE II (acronyme anglais d'évaluation de la physiologie aiguë et de la santé chronique) s'élevait à 22 (±9). Au total, 108 patients (83 %) étaient atteints de la grippe de type A (46 % H1N1pdm09, 33 % H3N2) et 21 (16 %), de la grippe de type B. De plus, 55 patients (42 %) étaient atteints d'une co-infection bactérienne, et seulement cinq (4 %), d'une co-infection fongique. Par ailleurs, 108 patients (83 %) ont eu besoin de ventilation mécanique, 94 (72 %), d'un soutien vasopresseur; 26 (20 %), d'une thérapie continue de remplacement rénal (TCRR) et 11 (9 %), d'une oxygénation extracorporelle. Au total, 121 patients (93 %) ont reçu une antivirothérapie (pendant une période médiane de cinq jours). La mortalité au bout de 30 jours s'élevait à 23 %. Les patients qui avaient reçu une antivirothérapie étaient plus susceptibles de survivre, selon un risque relatif ajusté (RRa) de 0,15 (IC à 95 % : 0,04 à 0,51, p = 0,003). Il y avait d'autres prédicteurs indépendants de mortalité : la nécessité de recourir à une TCRR (RRa 2,48, IC à 95 % : 1,14 à 5,43, p = 0,023), un score APACHE II élevé (RRa 1,08, IC à 95 % : 1,02 à 1,14, p = 0,011) et l'infection par l'influenza de type A (RRa 7,10, IC à 95 % : 1,37 à 36,8, p = 0,020) plutôt que par l'influenza de type B. Conclusions: Chez les patients gravement malades atteints de l'influenza, l'antivirothérapie était associée de manière indépendante à la survie. La TCRR, la plus grande gravité de la maladie et l'infection par l'influenza de type A étaient liées à la mortalité.