Publications by authors named "Peter G Brindley"

100 Publications

Anti-N-methyl-d-aspartate receptor encephalitis: A primer for acute care healthcare professionals.

J Intensive Care Soc 2021 May 25;22(2):95-101. Epub 2020 Mar 25.

Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.

This primer summarizes the diagnosis, treatment, complications, and prognosis of anti-N-methyl-d-aspartate receptor encephalitis for healthcare professionals, especially those in acute care specialities. Anti-N-methyl-d-aspartate receptor encephalitis is an immune-mediated encephalitis that is classically paraneoplastic and associated with ovarian teratomas in young women. Other less common neoplastic triggers include testicular cancers, Hodgkin lymphoma, lung and breast cancers. It may also be triggered by infection, occurring as a para-infectious phenomenon, seen most commonly after herpes simplex-1 encephalitis. Presentation varies but typically consists of behavioural and cognitive manifestations, seizures, dysautonomia, movement disorders, central hypoventilation, and coma, necessitating intensive care unit admission. Diagnosis of anti-N-methyl-d-aspartate receptor encephalitis requires high clinical suspicion plus ancillary testing, the most sensitive being cerebrospinal fluid analysis for anti-N-methyl-d-aspartate receptor antibodies. Imaging in search of an ovarian teratoma should be exhaustive and tumours need to be surgically treated. Treatment should be expeditious with pulsed steroids and either plasma exchange or intravenous immunoglobulin. Second-line treatments include intravenous rituximab, cyclophosphamide, azathioprine, and intrathecal methotrexate. Most patients recover to be functionally independent, but the in-hospital course can be months long followed by extensive rehabilitation. Given the lengthy course of illness, we explain why education and debriefing are important for staff, and where families can obtain additional help.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1751143720914181DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8120570PMC
May 2021

Storm in a Teacup: The Physics of Everyday Life.

Authors:
Peter G Brindley

Anesth Analg 2020 Dec;131(6):e243

Department of Critical Care Medicine, Department of Anesthesiology and Pain Medicine, Dossetor Ethics Centre, University of Alberta, Edmonton, Alberta, Canada,

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000005176DOI Listing
December 2020

How to Change Your Mind: What the New Science of Psychedelics Teaches Us About Consciousness, Dying, Addiction, Depression, and Transcendence.

Authors:
Peter G Brindley

Anesth Analg 2021 Mar;132(3):e37-e38

Departments of Critical Care Medicine and Anesthesiology and Pain Medicine, Dosseter Ethics Centre, University of Alberta, Edmonton, Alberta, Canada,

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000005349DOI Listing
March 2021

The Violinist's Thumb: And Other Lost Tales of Love, War, and Genius as Written by Our Genetic Code.

Authors:
Peter G Brindley

Anesth Analg 2020 Nov;131(5):e213

Departments of Critical Care Medicine and Anesthesiology and Pain Medicine, Dossetor Ethics Centre, University of Alberta, Edmonton, Alberta, Canada,

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1213/ANE.0000000000005126DOI Listing
November 2020

Optic Nerve Sheath Diameter Ultrasound for Raised Intracranial Pressure: A Literature Review and Meta-analysis of its Diagnostic Accuracy.

J Ultrasound Med 2021 Apr 24. Epub 2021 Apr 24.

Department of Internal Medicine, University of South Carolina, School of Medicine, Columbia, South Carolina, USA.

Optic nerve sheath diameter (ONSD) ultrasound is becoming increasingly more popular for estimating raised intracranial pressure (ICP). We performed a systematic review and analysis of the diagnostic accuracy of ONSD when compared to the standard invasive ICP measurement.

Method: We performed a systematic search of PUBMED and EMBASE for studies including adult patients with suspected elevated ICP and comparing sonographic ONSD measurement to a standard invasive method. Quality of studies was assessed using the QUADAS-2 tool by two independent authors. We used a bivariate model of random effects to summarize pooled sensitivity, specificity, and diagnostic odds ratio (DOR). Heterogeneity was investigated by meta-regression and sub-group analyses.

Results: We included 18 prospective studies (16 studies including 619 patients for primary outcome). Only one study was of low quality, and there was no apparent publication bias. Pooled sensitivity was 0.9 [95% confidence intervals (CI): 0.85-0.94], specificity was 0.85 (95% CI: 0.8-0.89), and DOR was 46.7 (95% CI: 26.2-83.2) with partial evidence of heterogeneity. The Area-Under-the-Curve of the summary Receiver-Operator-Curve was 0.93 (95% CI: 0.91-0.95, P < .05). No covariates were significant in the meta-regression. Subgroup analysis of severe traumatic brain injury and parenchymal ICP found no heterogeneity. ICP and ONSD had a correlation coefficient of 0.7 (95% CI: 0.63-0.76, P < .05).

Conclusion: ONSD is a useful adjunct in ICP evaluation but is currently not a replacement for invasive methods where they are feasible.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jum.15732DOI Listing
April 2021

Delayed intensive care unit admission from the emergency department: impact on patient outcomes. A retrospective study.

Rev Bras Ter Intensiva 2021 Jan-Mar;33(1):125-137

Department of Critical Care, King Saud Medical City - Riyadh, Arábia Saudita.

Objective: To study the impact of delayed admission by more than 4 hours on the outcomes of critically ill patients.

Methods: This was a retrospective observational study in which adult patients admitted directly from the emergency department to the intensive care unit were divided into two groups: Timely Admission if they were admitted within 4 hours and Delayed Admission if admission was delayed for more than 4 hours. Intensive care unit length of stay and hospital/intensive care unit mortality were compared between the groups. Propensity score matching was performed to correct for imbalances. Logistic regression analysis was used to explore delayed admission as an independent risk factor for intensive care unit mortality.

Results: During the study period, 1,887 patients were admitted directly from the emergency department to the intensive care unit, with 42% being delayed admissions. Delayed patients had significantly longer intensive care unit lengths of stay and higher intensive care unit and hospital mortality. These results were persistent after propensity score matching of the groups. Delayed admission was an independent risk factor for intensive care unit mortality (OR = 2.6; 95%CI 1.9 - 3.5; p < 0.001). The association of delay and intensive care unit mortality emerged after a delay of 2 hours and was highest after a delay of 4 hours.

Conclusion: Delayed admission to the intensive care unit from the emergency department is an independent risk factor for intensive care unit mortality, with the strongest association being after a delay of 4 hours.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5935/0103-507X.20210014DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8075331PMC
March 2020

Therapeutic plasma exchange in patients with life-threatening COVID-19: a randomised controlled clinical trial.

Int J Antimicrob Agents 2021 May 7;57(5):106334. Epub 2021 Apr 7.

Research & Innovation Centre, King Saud Medical City, Riyadh, Saudi Arabia; Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, GA, USA. Electronic address:

Assessment of efficacy of therapeutic plasma exchange (TPE) following life-threatening COVID-19. This was an open-label, randomised clinical trial of ICU patients with life-threatening COVID-19 (positive RT-qPCR plus ARDS, sepsis, organ failure, hyperinflammation). Study was terminated after 87/120 patients enrolled. Standard treatment plus TPE (n = 43) versus standard treatment (n = 44), and stratified by PaO/FiO ratio (>150 vs. ≤150), were compared. Primary outcomes were 35-day mortality and TPE safety. Secondary outcomes were association between TPE and mortality, improvement in SOFA score, change in inflammatory biomarkers, days on mechanical ventilation (MV), and ICU length of stay (LOS). Eighty-seven patients [median age 49 (IQR 34-63) years; 82.8% male] were randomised (44 standard care; 43 standard care plus TPE). Days on MV (P = 0.007) and ICU LOS (P = 0.02) were lower in the TPE group. 35-Day mortality was non-significantly lower in the TPE group (20.9% vs. 34.1%; Kaplan-Meier, P = 0.582). TPE was associated with increased lymphocytes and ADAMTS-13 activity and decreased serum lactate, lactate dehydrogenase, ferritin, d-dimers and interleukin-6. Multivariable regression analysis provided several predictors of 35-day mortality: PaO/FiO ratio (HR, 0.98, 95% CI 0.96-1.00; P = 0.02]; ADAMTS-13 activity (HR, 0.89, 95% CI 0.82-0.98; P = 0.01); pulmonary embolism (HR, 3.57, 95% CI 1.43-8.92; P = 0.007). Post-hoc analysis revealed a significant reduction in SOFA score for TPE patients (P < 0.05). In critically-ill COVID-19 patients, addition of TPE to standard ICU therapy was associated with faster clinical recovery and no increased 35-day mortality.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.ijantimicag.2021.106334DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8024223PMC
May 2021

COVID-19 with spontaneous pneumothorax, pneumomediastinum, and subcutaneous emphysema in the intensive care unit: Two case reports.

J Infect Public Health 2021 Mar 29;14(3):290-292. Epub 2020 Dec 29.

Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; Critical Care Department. Keck School of Medicine, University of Southern California, Los Angeles, CA, USA. Electronic address:

Real-Time-reverse-transcription-Polymerase-Chain-Reaction from nasopharyngeal swabs and chest computed tomography (CT) depicting typically bilateral ground-glass opacities with a peripheral and/or posterior distribution are mandatory in the diagnosis of COVID-19. COVID-19 pneumonia may present though with atypical features such as pleural and pericardial effusions, lymphadenopathy, cavitations, and CT halo sign. In these two case-reports, COVID-19 presented as pneumothorax, pneumomediastinum and subcutaneous emphysema in critically ill patients. These disorders may require treatment or can be even self-limiting. Clinicians should be aware of their potential effects on the cardiorespiratory status of critically ill COVID-19 patients. Finally, pneumothorax can be promptly diagnosed by means of lung ultrasound. Although operator dependent, lung ultrasound is a useful bedside diagnostic tool that could alleviate the risk of cross-infection related to COVID-19 patient transport.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jiph.2020.12.019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7771902PMC
March 2021

Prone mechanical cardiopulmonary resuscitation (CPR): Optimal supine chest compression metrics can be achieved in the prone position.

Resuscitation 2021 02 7;159:172-173. Epub 2020 Dec 7.

Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.resuscitation.2020.11.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721356PMC
February 2021

Peripheral neuropathy in severe COVID-19 resolved with therapeutic plasma exchange.

Clin Case Rep 2020 Oct 7. Epub 2020 Oct 7.

Critical Care Department King Saud Medical City Riyadh Saudi Arabia.

Peripheral neuropathies including Guillain-Barré syndrome may be linked to life-threatening COVID-19. Plasma exchange is a safe rescue therapy in severe COVID-19 with associated neurological manifestations and thromboinflammation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/ccr3.3397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7675564PMC
October 2020

Continuous renal replacement therapy with the addition of CytoSorb cartridge in critically ill patients with COVID-19 plus acute kidney injury: A case-series.

Artif Organs 2021 May 26;45(5):E101-E112. Epub 2020 Dec 26.

Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia.

Our aim was to investigate continuous renal replacement therapy (CRRT) with CytoSorb cartridge for patients with life-threatening COVID-19 plus acute kidney injury (AKI), sepsis, acute respiratory distress syndrome (ARDS), and cytokine release syndrome (CRS). Of 492 COVID-19 patients admitted to our intensive care unit (ICU), 50 had AKI necessitating CRRT (10.16%) and were enrolled in the study. Upon ICU admission, all had AKI, ARDS, septic shock, and CRS. In addition to CRRT with CytoSorb, all received ARDS-net ventilation, prone positioning, plus empiric ribavirin, interferon beta-1b, antibiotics, hydrocortisone, and prophylactic anticoagulation. We retrospectively analyzed inflammatory biomarkers, oxygenation, organ function, duration of mechanical ventilation, ICU length-of-stay, and mortality on day-28 post-ICU admission. Patients were 49.64 ± 8.90 years old (78% male) with body mass index of 26.70 ± 2.76 kg/m . On ICU admission, mean Acute Physiology and Chronic Health Evaluation (APACHE) II was 22.52 ± 1.1. Sequential Organ Function Assessment (SOFA) score was 9.36 ± 2.068 and the ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen (PaO /FiO ) was 117.46 ± 36.92. Duration of mechanical ventilation was 17.38 ± 7.39 days, ICU length-of-stay was 20.70 ± 8.83 days, and mortality 28 days post-ICU admission was 30%. Nonsurvivors had higher levels of inflammatory biomarkers, and more unresolved shock, ARDS, AKI, and pulmonary emboli (8% vs. 4%, P < .05) compared to survivors. After 2 ± 1 CRRT sessions with CytoSorb, survivors had decreased SOFA scores, lactate dehydrogenase, ferritin, D-dimers, C-reactive protein, and interleukin-6; and increased PaO /FiO ratios, and lymphocyte counts (all P < .05). Receiver-operator-curve analysis showed that posttherapy values of interleukin-6 (cutoff point >620 pg/mL) predicted in-hospital mortality for critically ill COVID-19 patients (area-under-the-curve: 0.87, 95% CI: 0.81-0.93; P = .001). No side effects of therapy were recorded. In this retrospective case-series, CRRT with the CytoSorb cartridge provided a safe rescue therapy in life-threatening COVID-19 with associated AKI, ARDS, sepsis, and hyperinflammation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/aor.13864DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7753655PMC
May 2021

Residual Lung Injury in Patients Recovering From COVID-19 Critical Illness: A Prospective Longitudinal Point-of-Care Lung Ultrasound Study.

J Ultrasound Med 2020 Nov 13. Epub 2020 Nov 13.

Department of Emergency Medicine, St. Francis Hospital, Columbus, Georgia, USA.

Scarce data exist regarding the natural history of lung lesions detected on ultrasound in those who survive severe COVID-19 pneumonia.

Objective: We performed a prospective analysis of point-of-care ultrasound (POCUS) findings in critically ill COVID-19 patients during and after hospitalization.

Methods: We enrolled 171 COVID-19 intensive care unit patients. POCUS of the lungs was performed with phased array (2-4 MHz), convex (2-6 MHz) and linear (10-15 MHz) transducers, scanning 12 lung areas. Chest computed tomography angiography was performed to exclude suspected pulmonary embolism. Survivors were clinically and sonographically evaluated during a 4 month period for evidence of residual lung injury. Chest computed tomography angiography and echocardiography were used to exclude pulmonary hypertension (PH) and chest high-resolution-computed-tomography to exclude interstitial lung disease (ILD) in symptomatic survivors.

Results: Cox regression analysis showed that lymphocytopenia (hazard ratio [HR]: 0.88, 95% confidence intervals [CI]: 0.68-0.96, p = 0.048), increased lactate (HR: 1.17, 95% CI: 0.94-1.46, p = 0.049), and D-dimers (HR: 1.21, 95% CI: 1.03-1.44, p = 0.03) were mortality predictors. Non-survivors had increased incidence of pulmonary abnormalities (B-lines, pleural line irregularities, and consolidations) compared to survivors (p < 0.05). During follow-up, POCUS with clinical and laboratory parameters integrated in the semi-quantitative Riyadh-Residual-Lung-Injury scale had sensitivity of 0.82 (95% CI: 0.76-0.89) and specificity of 0.91 (95% CI: 0.94-0.95) in predicting ILD. The prevalence of PH and ILD (non-specific-interstitial-pneumonia) was 7% and 11.8%, respectively.

Conclusion: POCUS showed ability to monitor the evolution of severe COVID-19 pneumonia after hospital discharge, supporting its integration in clinical predictive models of residual lung injury.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jum.15563DOI Listing
November 2020

Development of a critical care ultrasound curriculum using a mixed-methods needs assessment and engagement of frontline healthcare professionals.

Can J Anaesth 2021 Jan 21;68(1):71-80. Epub 2020 Oct 21.

Department of Medicine, University of Alberta, Edmonton, AB, Canada.

Purpose: Experts recommend that critical care medicine (CCM) practitioners should be adept at critical care ultrasound (CCUS). Published surveys highlight that many institutions have no deliberate strategy, no formalized curriculum, and insufficient engagement of CCM faculty and trainees. Consequently, proficiency is non-uniform. Accordingly, we performed a needs assessment to develop an inter-professional standardized CCUS curriculum as a foundation towards universal basic fluency.

Methods: Mixed-methods study of CCM trainees, attendings, and nurse practitioners working across five academic and community medical-surgical intensive care units in Edmonton, Alberta. We used qualitative focus groups followed by quantitative surveys to explore, refine, and integrate results into a curriculum framework.

Results: Focus groups with 19 inter-professional practitioners identified major themes including perceived benefits, learning limitations, priorities, perceived risks, characteristics of effective instruction, ensuring long-term success, and achieving competency. Sub-themes highlighted rapid attrition of skill following one- to two-day workshops, lack of skilled faculty, lack of longitudinal training, and the need for site-based mentorship. Thirty-five practitioners (35/70: 50%) completed the survey. Prior training included workshops (16/35; 46%) and self-teaching (11/35; 31%). Eleven percent (4/35) described concerns about potential errors in CCUS performance. The survey helped to refine resources, content, delivery, and assessment. Integration of qualitative and quantitative findings produced a comprehensive curriculum framework.

Conclusion: Building on published recommendations, our needs assessment identified additional priorities for a CCUS curriculum framework. Specifically, there is a perceived loss of skills following short workshops and insufficient strategies to sustain learning. Addressing these deficits could narrow the gap between national recommendations and frontline needs.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12630-020-01829-8DOI Listing
January 2021

Helmet Continuous Positive Airway Pressure in the Treatment of COVID-19 Patients with Acute Respiratory Failure could be an Effective Strategy: A Feasibility Study.

J Epidemiol Glob Health 2020 Sep;10(3):201-203

Senior Infectious Diseases Consultant & Director Research & Innovation Center, King Saud Medical City, Ministry of Health, Riyadh, Saudi Arabia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.2991/jegh.k.200817.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7509101PMC
September 2020

Reverse takotsubo cardiomyopathy in fulminant COVID-19 associated with cytokine release syndrome and resolution following therapeutic plasma exchange: a case-report.

BMC Cardiovasc Disord 2020 08 26;20(1):389. Epub 2020 Aug 26.

Critical Care Department, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia.

Background: Fulminant (life-threatening) COVID-19 can be associated with acute respiratory failure (ARF), multi-system organ failure and cytokine release syndrome (CRS). We present a rare case of fulminant COVID-19 associated with reverse-takotsubo-cardiomyopathy (RTCC) that improved with therapeutic plasma exchange (TPE).

Case Presentation: A 40 year old previous healthy male presented in the emergency room with 4 days of dry cough, chest pain, myalgias and fatigue. He progressed to ARF requiring high-flow-nasal-cannula (flow: 60 L/minute, fraction of inspired oxygen: 40%). Real-Time-Polymerase-Chain-Reaction (RT-PCR) assay confirmed COVID-19 and chest X-ray showed interstitial infiltrates. Biochemistry suggested CRS: increased C-reactive protein, lactate dehydrogenase, ferritin and interleukin-6. Renal function was normal but lactate levels were elevated. Electrocardiogram demonstrated non-specific changes and troponin-I levels were slightly elevated. Echocardiography revealed left ventricular (LV) basal and midventricular akinesia with apex sparing (LV ejection fraction: 30%) and depressed cardiac output (2.8 L/min) consistent with a rare variant of stress-related cardiomyopathy: RTCC. His ratio of partial arterial pressure of oxygen to fractional inspired concentration of oxygen was < 120. He was admitted to the intensive care unit (ICU) for mechanical ventilation and vasopressors, plus antivirals (lopinavir/ritonavir), and prophylactic anticoagulation. Infusion of milrinone failed to improve his cardiogenic shock (day-1). Thus, rescue TPE was performed using the Spectra Optia™ Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA) without protective antibodies. Over 5 days he received daily TPE (each lasting 4 hours). His lactate levels, oxygenation, and LV function normalized and he was weaned off vasopressors. His inflammation markers improved, and he was extubated on day-7. RT-PCR was negative on day-17. He was discharged to home isolation in good condition.

Conclusion: Stress-cardiomyopathy may complicate the course of fulminant COVID-19 with associated CRS. If inotropic therapy fails, TPE without protective antibodies may help rescue the critically ill patient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12872-020-01665-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7447602PMC
August 2020

Prospective Longitudinal Evaluation of Point-of-Care Lung Ultrasound in Critically Ill Patients With Severe COVID-19 Pneumonia.

J Ultrasound Med 2021 Mar 14;40(3):443-456. Epub 2020 Aug 14.

Department of Medicine, University of South Carolina School of Medicine, Columbia, South Carolina, USA.

Objectives: To perform a prospective longitudinal analysis of lung ultrasound findings in critically ill patients with coronavirus disease 2019 (COVID-19).

Methods: Eighty-nine intensive care unit (ICU) patients with confirmed COVID-19 were prospectively enrolled and tracked. Point-of-care ultrasound (POCUS) examinations were performed with phased array, convex, and linear transducers using portable machines. The thorax was scanned in 12 lung areas: anterior, lateral, and posterior (superior/inferior) bilaterally. Lower limbs were scanned for deep venous thrombosis and chest computed tomographic angiography was performed to exclude suspected pulmonary embolism (PE). Follow-up POCUS was performed weekly and before hospital discharge.

Results: Patients were predominantly male (84.2%), with a median age of 43 years. The median duration of mechanical ventilation was 17 (interquartile range, 10-22) days; the ICU length of stay was 22 (interquartile range, 20.2-25.2) days; and the 28-day mortality rate was 28.1%. On ICU admission, POCUS detected bilateral irregular pleural lines (78.6%) with accompanying confluent and separate B-lines (100%), variable consolidations (61.7%), and pleural and cardiac effusions (22.4% and 13.4%, respectively). These findings appeared to signify a late stage of COVID-19 pneumonia. Deep venous thrombosis was identified in 16.8% of patients, whereas chest computed tomographic angiography confirmed PE in 24.7% of patients. Five to six weeks after ICU admission, follow-up POCUS examinations detected significantly lower rates (P < .05) of lung abnormalities in survivors.

Conclusions: Point-of-care ultrasound depicted B-lines, pleural line irregularities, and variable consolidations. Lung ultrasound findings were significantly decreased by ICU discharge, suggesting persistent but slow resolution of at least some COVID-19 lung lesions. Although POCUS identified deep venous thrombosis in less than 20% of patients at the bedside, nearly one-fourth of all patients were found to have computed tomography-proven PE.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/jum.15417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7436430PMC
March 2021

Therapeutic plasma exchange in adult critically ill patients with life-threatening SARS-CoV-2 disease: A pilot study.

J Crit Care 2020 12 31;60:328-333. Epub 2020 Jul 31.

Critical Care Department, King Saud Medical City, Riyadh, Saudi Arabia; Department of Internal Medicine, South Carolina University, School of Medicine, Columbia, SC, USA; Critical Care Department, Keck Medical School, USC, LA, CA, USA. Electronic address:

Purpose: We investigated the effect of therapeutic plasma exchange (TPE) on life-threatening COVID-19; presenting as acute respiratory distress syndrome (ARDS) plus multi-system organ failure and cytokine release syndrome (CRS).

Materials And Methods: We prospectively enrolled ten consecutive adult intensive care unit (ICU) subjects [7 males; median age: 51 interquartile range (IQR): 45.1-55.9 years old] with life-threatening COVID-19 infection. All had ARDS [PaO2/FiO2 ratio: 110 (IQR): 95.5-135.5], septic shock, CRS and deteriorated within 24 h of ICU admission despite fluid resuscitation, antibiotics, hydroxychloroquine, ARDS-net and prone position mechanical ventilation. All received 5-7 TPE sessions (dosed as 1.0 to 1.5 plasma volumes).

Results: All of the following significantly normalized (p < 0.05) following the TPE completion, when compared to baseline: Sequential Organ Function Assessment score, PaO2/FiO2 ratio, levels of lymphocytes, total bilirubin, lactate dehydrogenase, ferritin, C-reactive protein and interleukin-6. No adverse effects from TPE were observed. Acute kidney injury and pulmonary embolism were observed in 10% and 20% of patients, respectively. The duration of mechanical ventilation was 9 (IQR: 7 to 12) days, the ICU length of stay was 15 (IQR: 13.2 to 19.6) days and the mortality on day-28 was 10%.

Conclusion: TPE demonstrates a potential survival benefit and low risk in life-threatening COVID-19, albeit in a small pilot study.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcrc.2020.07.001DOI Listing
December 2020

Prone cardiopulmonary resuscitation: A scoping and expanded grey literature review for the COVID-19 pandemic.

Resuscitation 2020 10 21;155:103-111. Epub 2020 Jul 21.

Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Canada.

Aim: To identify and summarize the available science on prone resuscitation. To determine the value of undertaking a systematic review on this topic; and to identify knowledge gaps to aid future research, education and guidelines.

Methods: This review was guided by specific methodological framework and reporting items (PRISMA-ScR). We included studies, cases and grey literature regarding prone position and CPR/cardiac arrest. The databases searched were MEDLINE, Embase, CINAHL, Cochrane CENTRAL, Cochrane Database of Systematic Reviews, Scopus and Google Scholar. Expanded grey literature searching included internet search engine, targeted websites and social media.

Results: Of 453 identified studies, 24 (5%) studies met our inclusion criteria. There were four prone resuscitation-relevant studies examining: blood and tidal volumes generated by prone compressions; prone compression quality metrics on a manikin; and chest computed tomography scans for compression landmarking. Twenty case reports/series described the resuscitation of 25 prone patients. Prone compression quality was assessed by invasive blood pressure monitoring, exhaled carbon dioxide and pulse palpation. Recommended compression location was zero-to-two vertebral segments below the scapulae. Twenty of 25 cases (80%) survived prone resuscitation, although few cases reported long term outcome (neurological status at hospital discharge). Seven cases described full neurological recovery.

Conclusion: This scoping review did not identify sufficient evidence to justify a systematic review or modified resuscitation guidelines. It remains reasonable to initiate resuscitation in the prone position if turning the patient supine would lead to delays or risk to providers or patients. Prone resuscitation quality can be judged using end-tidal CO, and arterial pressure tracing, with patients turned supine if insufficient.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.resuscitation.2020.07.010DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7373011PMC
October 2020

Temporizing Life-Threatening Abdominal-Pelvic Hemorrhage Using Proprietary Devices, Manual Pressure, or a Single Knee: An Integrative Review of Proximal External Aortic Compression and Even "Knee BOA".

J Spec Oper Med 2020 ;20(2):110-114

Introduction: Abdominal-pelvic hemorrhage (i.e., originates below the diaphragm and above the inguinal ligaments) is a major cause of death. It has diverse etiology but is typically associated with gunshot or stab wounds, high force or velocity blunt trauma, aortic rupture, and peripartum bleeds. Because there are few immediately deployable, temporizing measures, and the standard approaches such as direct pressure, hemostatics, and tourniquets are less reliable than they are with compressible extremity injuries, risk for death resulting from abdominal-pelvic hemorrhage is high. This review concerns the exciting potential of proximal external aortic compression (PEAC) as a temporizing technique for life-threatening lower abdominal-pelvic hemorrhage. PEAC can be accomplished by means of a device, two locked arms (manual), or a single knee (genicular) to press over the midline supra-umbilical abdomen. The goal is to compress the descending aorta and slow or halt downstream hemorrhage while not delaying more definitive measures such as hemostatic packing, tourniquets, endovascular balloons, and ultimately operative repair.

Methods: Clinical review of the Ovid MEDLINE, In-Process, & Other Non-Indexed, and Google Scholar databases was performed for the period ranging from 1946 to 3 May 2019 for studies that included the following search terms: [proximal] external aortic compression OR vena cava compression AND (abdomen or pelvis) OR (hemorrhage) OR (emergency or trauma). In addition, references from included studies were assessed.

Conclusion: Sixteen studies met the inclusion criteria. Evidence was grouped and summarized from the specialties of trauma, aortic surgery, and obstetrics to help prehospital responders and guide much-needed additional research, with the goal of decreasing the high risk for death after life-threatening abdominal-pelvic hemorrhage.
View Article and Find Full Text PDF

Download full-text PDF

Source
July 2020

A pilot study of therapeutic plasma exchange for serious SARS CoV-2 disease (COVID-19): A structured summary of a randomized controlled trial study protocol.

Trials 2020 Jun 8;21(1):506. Epub 2020 Jun 8.

Critical Care Department, King Saud Medical City, Riyadh, Kingdom of Saudi Arabia.

Objectives: To evaluate the safety of therapeutic plasma exchange (TPE) in adult patients with serious/life-threatening COVID-19 requiring intensive care unit (ICU) admission, and associated 28-day mortality. Serious and life threatening COVID-19 are defined as per published literature (please, refer to the full protocol, Additional file 1). The rationale is that TPE can remove interleukins-3, 6, 8, 10, interferon-gamma and tumor necrosis factor-alpha. Thus, it may reduce the cytokine release syndrome associated with fulminant COVID-19 disease.

Trial Design: Pilot, interventional, open-label, randomized controlled multicenter trial.

Participants: Inclusion criteria are: 1) age ≥ 18 years old; 2) intubation and intensive care unit (ICU) admission; 3) serious and/or life-threatening COVID-19 (please, refer to the full protocol, Additional file 1). SARS-CoV-2 infection is confirmed by Real-Time-Polymerase-Chain-Reaction (RT-PCR) assays using QuantiNova Probe RT-PCR kit (Qiagen) in a Light-Cycler 480 real-time PCR system (Roche, Basel, Switzerland). Exclusion criteria are: 1) previous allergic reaction to plasma exchange or its ingredients (i.e., sodium citrate), 2) two consecutive negative RT-PCR tests for SARS-CoV-2 at least 24 hours apart, 3) mild COVID-19 not requiring ICU admission and 4) terminally ill patients receiving palliative care. The primary site will be King Saud Medical City (KSMC), Riyadh, Kingdom of Saudi Arabia (KSA). Also, the study will run in ICUs (Ministry of Health Cluster 1; Riyadh) and other centers in KSA pending their institutional review board (IRB) approval.

Interventions And Comparator: The intervention group will receive TPE, plus empiric treatment for COVID-19. TPE is administered using the Spectra Optia TM Apheresis System equipped with the Depuro D2000 Adsorption Cartridge (Terumo BCT Inc., USA). The first dose is 1.5 plasma volumes, followed by one plasma volume on alternate days or daily for five to seven total treatments. Spectra Optia TM Apheresis System operates with acid-citrate dextrose anticoagulant (ACDA) as per Kidney Disease Improving Global Outcomes (KDIGO) 2019 guidelines. Plasma is replaced with albumin 5% or fresh frozen plasma in patients with coagulopathy (prothrombin time >37 seconds; international normalized ratio >3; activated partial thromboplastin time >100 or fibrinogen level <100 mg/d). TPE sessions are performed daily over four hours and laboratory markers measured daily. The comparators are controls not receiving TPE but usual empiric treatment for COVID-19 as per institutional, national and international recommendations. Both groups will receive standard ICU supportive care.

Main Outcomes: Primary study end-point is 28-day mortality and safety of TPE in serious and/or life-threatening COVID-19. Safety will be evaluated by the documentation of any pertinent adverse and/or serious adverse effects related to TPE as per institutional, national and international (Food and Drug Administration) guidelines. Secondary outcomes are: i) improvement in Sequential Organ Function Assessment (SOFA) score ; ii) changes in inflammatory markers: serum C-reactive protein, lactate dehydrogenase, ferritin, d-dimers and interleukin-6; iii) days on mechanical ventilation and ICU length of stay.

Randomization: Eligible consented patients are randomized (1:1 allocation) after stratification by ICU center and two PaO2/FIO2 ratio categories (> 150 and ≤ 150). Randomization occurs in variable block sizes of four to eight patients. A web-based randomization service, randomize.net, is used to allocate patients to their respective strata prior to the intervention or control therapy.

Blinding (masking): Given the visibility of TPE machinery, the intervention will be unblinded; hence, no enrollment concealment will be expedited. The lack of allocation concealment will be mitigated by several measures (please, refer to the full protocol, Additional file 1).

Numbers To Be Randomized (sample Size): This pilot randomized trial aims to recruit a convenience sample of patients with serious and/or life-threatening COVID-19. Therefore, at least 20 patients are to be randomized to each group per participating center. We are hoping to consent and randomize approximately 60 patients in each group over a 3 to 6 months period giving a total of 120 participants.

Trial Status: The protocol version 1 was approved 29/04/2020. Recruitment is ongoing, and began on 01/05/2020. We estimate completion by 29/10/2020.

Trial Registration: Registered at ISRCTN on 18/05/2020 (ISRCTN21363594; doi.10.1186/ ISRCTN21363594).

Full Protocol: The full protocol is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest of expediting dissemination of this material, the familiar formatting has been eliminated; this letter serves as a summary of the key elements of the full protocol.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13063-020-04454-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276972PMC
June 2020

Prone CPR: A novel and cost-free solution to ensuring adequate chest compressions.

Resuscitation 2020 07 20;152:93-94. Epub 2020 May 20.

Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.resuscitation.2020.05.018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7238993PMC
July 2020

Feel Better, Work Better: The COVID-19 Perspective.

Can J Cardiol 2020 06 16;36(6):789-791. Epub 2020 Apr 16.

Canadian Forces Health Services Group, Department of National Defence, Government of Canada, Edmonton, Alberta, and Ottawa, Ontario, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.cjca.2020.04.012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7161513PMC
June 2020

Fidelity in surgical simulation: further lessons from the S.T.A.R.T.T. course

Can J Surg 2020 03 27;63(2):E161-E163. Epub 2020 Mar 27.

From the Department of Surgery, Section of General Surgery, University of Manitoba, Winnipeg, Man. (Johnson, Gillman); and the Department of Critical Care Medicine, Anesthesiology, University of Alberta, Edmonton, Alta. (Brindley).

Summary: Simulation has become a popular and ubiquitous medical education tool. In response to learner demands, and because of technological advancement, there is a trend toward increasing the realism of simulation. However, there is a paucity of evidence regarding what degree of fidelity is needed to deliver optimal simulation-based medical education. Feedback from the Simulated Trauma And Resuscitation Team Training (S.T.A.R.T.T.) course suggests that higherfidelity simulation is viewed as highly valuable to learners. Research is needed in order to guide the growing demand for higher-fidelity simulation in our medical training curricula and in order to justify or mitigate the associated costs and logistical challenges.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1503/cjs.017818DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7828954PMC
March 2020

Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go.

Am J Respir Crit Care Med 2020 04;201(7):775-788

Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada.

Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: ) preintubation assessment for potential difficulty (e.g., MACOCHA score); ) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and ) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1164/rccm.201908-1636CIDOI Listing
April 2020

Burnout Syndrome in UK Intensive Care Unit staff: Data from all three Burnout Syndrome domains and across professional groups, genders and ages.

J Intensive Care Soc 2019 Nov 11;20(4):363-369. Epub 2019 Jul 11.

Department of Critical Care, Northwick Park Hospital, London, UK.

Introduction: This is the first comprehensive evaluation of Burnout Syndrome across the UK Intensive Care Unit workforce and in all three Burnout Syndrome domains: Emotional Exhaustion, Depersonalisation and lack of Personal Accomplishment.

Methods: A questionnaire was emailed to UK Intensive Care Society members, incorporating the 22-item Maslach Burnout Inventory Human Services Survey for medical personnel. Burnout Syndrome domain scores were stratified by 'risk'. Associations with gender, profession and age-group were explored.

Results: In total, 996 multi-disciplinary responses were analysed. For Emotional Exhaustion, females scored higher and nurses scored higher than doctors. For Depersonalisation, males and younger respondents scored higher.

Conclusion: Approximately one-third of Intensive Care Unit team-members are at 'high-risk' for Burnout Syndrome, though there are important differences according to domain, gender, age-group and profession. This data may encourage a more nuanced understanding of Burnout Syndrome and more personalised strategies for our heterogeneous workforce.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1751143719860391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820232PMC
November 2019

Psychological 'burnout' in healthcare professionals: Updating our understanding, and not making it worse.

J Intensive Care Soc 2019 Nov 9;20(4):358-362. Epub 2019 May 9.

Critical Care, University of Toronto, ON, Canada.

Many healthcare professionals and professional societies are demanding action to counter 'burnout', especially in the acute care medical specialties. This review is intended to empower this laudable 'call to arms', while also validating concerns that have been raised about how we typically define, measure and counter this important issue. This review aims to advance the discussion, dispel common misconceptions, add important nuance, and identify common ground. We also encourage the ideas contained within the military term 'occupational stress injury', which include a cultural shift away from blame and stigmatization, and towards shared responsibility and empathy. We also outline why mandatory testing can be troublesome and why interventions should be tailored to individuals. While the need for immediate action may seem self-evident, we wish to mitigate the real possibility that good intentions could make a perilous situation worse. 'Burnout' matters, but how individuals and organizations go forward matters even more.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1751143719842794DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6820226PMC
November 2019

The MacGyver bias and attraction of homemade devices in healthcare.

Can J Anaesth 2019 Jul 12;66(7):757-761. Epub 2019 Apr 12.

Univesity of Manitoba, Winnipeg, MB, Canada.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s12630-019-01361-4DOI Listing
July 2019

Evaluating Extravascular Lung Water in Sepsis: Three Lung-Ultrasound Techniques Compared against Transpulmonary Thermodilution.

Indian J Crit Care Med 2018 Sep;22(9):650-655

Department of Medicine, Phramongkutklao Hospital, Bangkok, Thailand.

Background: Excessive extravascular lung water (EVLW) is associated with increased morbidity and mortality. We compared three lung-ultrasound (L-US) techniques against the reference-standard transpulmonary thermodilution (TPTD) technique to access EVLW.

Materials And Methods: This was a prospective, single-blind, cross-sectional study. Forty-four septic patients were enrolled. EVLW index was measured by the TPTD method, and an index of ≥10 mL/kg was considered diagnostic of pulmonary edema. EVLW index was then compared to three established bedside L-US protocols that evaluate sonographic B-lines: (1) a 28-zone protocol (total B-line score [TBS]) (2) a scanning 8-region examination, and (3) a 4-point examination.

Results: Eighty-nine comparisons were obtained. A statistically significant positive correlation was found between L-US TBS and an EVLW index ≥10 mL/kg ( = 0.668,P < 0.001). The 28-zone protocol score ≥39 has a sensitivity of 81.6% and a specificity of 76.5% to define EVLW index ≥10 mL/kg. In contrast, the positive 4-point examination and scanning 8-regions showed low sensitivity (23.7% and 50.0%, respectively) but high specificity (96.1% and 88.2%, respectively). Ten patients with a total of 21 comparisons met criteria for acute respiratory distress syndrome (ARDS). In this subgroup, only the TBS had statistically significant positive correlation to EVLW ( = 0.488,P = 0.025).

Conclusion: L-US is feasible in patients with severe sepsis. In addition, L-US 28-zone protocol demonstrated high specificity and better sensitivity than abbreviated 4- and 8-zone protocols. In ARDS, the L-US 28-zone protocol was more accurate than the 4- and 8-zone protocols in predicting EVLW. Consideration of limitations of the latter protocols may prevent clinicians from reaching premature conclusions regarding the prediction of EVLW.

Trial Registration: ISRCTN11419081. Registered 4 February 2015 retrospectively.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.4103/ijccm.IJCCM_256_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6161581PMC
September 2018

Proximal External Aortic Compression for Life-Threatening Abdominal-Pelvic and Junctional Hemorrhage: An Ultrasonographic Study in Adult Volunteers.

Prehosp Emerg Care 2019 Jul-Aug;23(4):538-542. Epub 2018 Nov 2.

: Following life-threatening junctional trauma, the goal is to limit blood loss while expediting transfer to operative rescue. Unfortunately, life-threatening abdominal-pelvic or junctional hemorrhage is often not amenable to direct compression and few temporizing strategies are available beyond hemostatic dressings, hypotensive resuscitation, and balanced transfusion. : In this study, we evaluated proximal external aortic compression to arrest blood flow in healthy adult men. : This was a simulation trial of proximal external aortic compression, for life-threatening abdominal-pelvic and junctional hemorrhage, in a convenience sample of healthy adult male volunteers. The primary end points were cessation of femoral blood flow as assessed by pulse wave Doppler ultrasound at the right femoral artery, caudal to the inguinal ligament. Secondary end points were discomfort and negative sequelae. : Aortic blood flow was arrested in 12 volunteers. Median time to blood flow cessation was 12.5 seconds. Median reported discomfort was 5 out of 10. No complications or negative sequelae were reported. : This trial suggests that it may be reasonable to attempt temporization of major abdominal-pelvic and junctional hemorrhage using bimanual proximal external aortic compression. In the absence of immediate alternatives for this dangerous and vexing injury pattern, there appear to be few downsides to prehospital proximal external aortic compression while concomitantly expediting definite care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1080/10903127.2018.1532477DOI Listing
January 2020