Hussein D. Kanji

Limited echocardiography–guided therapy in subacute shock is associated with change in management and improved outcomes

PURPOSE The purpose of the study was to compare the effect of limited echocardiography (LE)-guided therapy to standard management on 28-day mortality, intravenous fluid prescription, and inotropic dosing following early resuscitation for shock. MATERIALS AND METHODS Two hundred twenty critically ill patients with undifferentiated shock from a quaternary intensive care unit were included in the study. The LE group consisted of 110 consecutive patients prospectively studied over a 12-month period receiving LE-guided management. The standard management group consisted of 110 consecutive patients retrospectively studied with shock immediately prior to the LE intervention. RESULTS In the LE group, fluid restriction was recommended in 71 (65%) patients and initiation of dobutamine in 27 (25%). Fluid prescription during the first 24 hours was significantly lower in LE patients (49 [33-74] vs 66 [42-100] mL/kg, P = .01), whereas 55% more LE patients received dobutamine (22% vs 12%, P = .01). The LE patients had improved 28-day survival (66% vs 56%, P = .04), a reduction in stage 3 acute kidney injury (20% vs 39%), and more days alive and free of renal support (28 [9.7-28] vs 25 [5-28], P = .04). CONCLUSIONS Limited echocardiography-guided management following early resuscitation is associated with improved survival, less fluid, and increased inotropic prescription. A prospective randomized control trial is required to verify these results.

Sixty-four-slice computed tomographic scanner to clear traumatic cervical spine injury: systematic review of the literature.

PURPOSE Cervical spine (CS) injury in blunt trauma is a prevalent and devastating complication. Clearing CS injuries in obtunded patients is fraught with challenges, and no single imaging modality or algorithm is both safe and effective. Increased time in c-spine precautions is associated with greater patient morbidity including increased ventilator associated pneumonia, delirium and ulceration. We systemically reviewed the literature to assess the effectiveness of 64-slice computed tomographic (CT) scanners in clearing traumatic CS injuries. MATERIALS AND METHODS Studies were identified using MEDLINE and Embase, the references of identified studies, international experts on CS clearance and authors of primary studies. Three reviewers independently selected and extracted data from studies that reported on both CT and MRI in traumatic CS injury. RESULTS We included five studies involving a total of 3443 patients; however, heterogeneity and lack of sample size precluded quantitative summation of the results. Qualitative assessment showed that 64-Slice CT scan, when applied within a set protocol, performed favourably in clearing injury. CONCLUSIONS Data suggests that using 64-slice CT scans on obtunded trauma patients with grossly intact motor function, in the context of a defined clearance protocol with interpretation by an experienced radiologist, may be sufficient to safely clear significant CS injury. A prospective study comparing MRI and 64-slice CT scan clearance in this population is necessary to corroborate these conclusions.

Anticoagulation practices and the prevalence of major bleeding, thromboembolic events, and mortality in venoarterial extracorporeal membrane oxygenation: A systematic review and meta-analysis

Purpose: The purpose was to evaluate the safety of anticoagulation in venoarterial extracorporeal membrane oxygenation (VA‐ECMO). Design: We performed a systematic review and meta‐analysis using multiple electronic databases. Studies were from 1977 to September 27, 2016. We evaluated the effect of anticoagulation in VA‐ECMO on outcomes including major bleeding, thromboembolic events, and in‐hospital mortality using a random effects model meta‐analysis. Results: Twenty‐six studies (1496 patients) were included. Ten studies only had patients with postcardiotomy shock, 4 studies only included extracorporeal cardiopulmonary resuscitation patients, and 10 studies had a mixture of patients. Most studies (n = 17) were low quality with a Newcastle‐Ottawa Scale score ≤5. The summary prevalence of major bleeding was 27% (95% confidence interval [CI], 18%‐35%), with considerable between‐study heterogeneity (I2 = 91%). Major bleeding requiring reoperation was the most common bleeding event. The summary prevalence of thromboembolic events was 8% (95% CI, 4%‐13%; I2 = 83%). Limb ischemia, circuit‐related clotting, and stroke were the most commonly reported events. The summary prevalence for in‐hospital mortality was 59% (95% CI, 52%‐67%; I2 = 78%). Conclusions: The optimal targets and strategies for anticoagulation in VA‐ECMO are unclear. Evaluation of major bleeding and thromboembolic events is limited by study quality and between‐study heterogeneity. Clinical trials are needed to investigate the optimal anticoagulation strategy. HighlightsThe optimal strategy for anticoagulation is currently unknown for patients on venoarterial extracorporeal membrane oxygenation.We performed a systematic review and meta‐analysisMajor bleeding events were very common in all studies with a summary prevalence of 27%.Significant between‐study heterogeneity limits any recommendations for the optimal strategy of anticoagulationFurther clinical trials are needed to examine this question.

Curriculum Development and Evaluation of a Hemodynamic Critical Care Ultrasound: A Systematic Review of the Literature

Objective:The application of ultrasound to assess a patient’s cardiac function and volume status is becoming commonplace in the practice of critical care. These skills have been taught through varying curricula; however, no consensus on the optimal curriculum has been established. The purpose of this systematic review is to evaluate the literature regarding critical care ultrasound curriculum development and evaluation. Data Sources:Studies were identified using MEDLINE, Embase, CINAHL, PsycInfo, the Cochrane Center Register of Controlled Trials, and ERIC according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines through June 2014. Study Selection:Included studies were limited to those that described adult (age, > 16 yr) cardiac or hemodynamic critical care ultrasound curricula for physicians. Two reviewers independently screened studies based on predetermined exclusion criteria, and disagreements were resolved by a third reviewer. Data Extraction:Data were abstracted, and quality was assessed by two reviewers using the Newcastle-Ottawa Scale. Data abstracted from the studies included the learner population, examination type, duration, composition, and setting of the curriculum, means of evaluation, and outcomes. Data Synthesis:The search yielded 654 studies; of which, 15 met inclusion criteria. All curricula used a combination of didactic and hands-on components. The highest agreement between novice and experts, coupled with the most time-efficient application, was achieved when the study was limited to a basic qualitative approach for the assessment of global function or contractility and assessment of inferior vena cava collapsibility. The mode of delivery seemed most efficient when a hybrid method was used, including online instruction. Minimum scanning competency may be achieved with 30 scans although more rigorous study on this element is necessary. Conclusions:Assessment of cardiac function and volume assessment is becoming an essential skill in critical care medicine. Physicians can be taught bedside echocardiography in a time-effective manner with positive benefit to patients by applying a concise curriculum with limited content.

Early veno-venous extracorporeal membrane oxygenation is associated with lower mortality in patients who have severe hypoxemic respiratory failure: A retrospective multicenter cohort study

PURPOSE The purpose of the study is to compare outcomes in patients who had severe hypoxemic respiratory failure (Pao2/fraction of inspired oxygen <100) who received early veno-venous extracorporeal membrane oxygenation (ECMO) as an adjunct to mechanical ventilation, to those in patients who received conventional mechanical ventilation alone. MATERIALS AND METHODS This is a multicenter, retrospective unmatched and matched cohort study of patients admitted between April 2006 and December 2013. Generalized logistic mixed-effects models and Cox proportional hazards models were used to determine the association between treatment with ECMO that was started within 3 days of intensive care unit (ICU) admission and ICU and hospital mortality and length of stay, respectively. RESULTS A total of 2440 patients who had severe hypoxemic respiratory failure due to various etiologies were included, 46 who received early veno-venous ECMO and 2394 unmatched and 398 matched controls who received conventional ventilation alone. Compared to matched controls, ECMO was associated with a lower odds of ICU (odds ratio [95% confidence interval], 0.30 [0.13-0.67]) and inhospital death (odds ratio 0.30 [0.14-0.67]). In addition, ECMO was associated with longer times to discharge from ICU and hospital (hazard ratio, 0.42 [0.37-0.47] and 0.53 [0.38-0.73], respectively). CONCLUSIONS In this observational study, use of early ECMO compared to conventional mechanical ventilation alone in patients who had severe hypoxemic respiratory failure was associated with a lower risk of mortality and a longer length of stay.

Assessment of Paramedic Ultrasound Curricula: A Systematic Review.

OBJECTIVE Prehospital ultrasound is being applied in the field. The purpose of this systematic review is to describe evidence pertaining to ultrasound curricula for paramedics specifically, including content, duration, setting, design, evaluation, and application. METHODS Electronic searches of MEDLINE, Embase, CINAHL, and the Cochrane Center Register of Controlled Trials were conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Primary literature describing acute care ultrasound curricula for paramedics were included. Two authors independently extracted data and assessed quality using 2 validated tools. RESULTS Twelve studies with 187 paramedics were included. Curricula duration varied, with effective curricula teaching focused assessment with sonography for trauma (FAST) in 6 to 8 hours and pleural ultrasound in 25 minutes. FAST, pleural, and fracture-detection ultrasound are being applied in the field by paramedics; however, no literature exists describing application to detect cardiac standstill. Curricula combined didactic and hands-on components including simulation and evaluated competency using sensitivity and specificity of paramedic-performed ultrasound. CONCLUSIONS Paramedic ultrasound curricula in FAST and pleural ultrasound is feasible and time effective with successful application. Although fracture detection ultrasound is being used by the special operations forces, no comprehensive curriculum was described. Curricula designed to detect cardiac standstill have been too short, and successful application by paramedics has not been shown.

Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) for emergency cardiac support

Purpose: Veno‐arterial extracorporeal membrane oxygenation (VA‐ECMO) may provide benefit to patients in refractory cardiac arrest and cardiogenic shock. We aim to summarize our centers 6‐year experience with resuscitative VA‐ECMO. Materials and methods: A retrospective medical record review (April 2009 to 2015) was performed on consecutive non‐cardiotomy patients who were managed with VA‐ECMO due to refractory in‐ or out‐of‐hospital cardiac (IHCA/OHCA) arrest (E‐CPR) or refractory cardiogenic shock (E‐CS) with or without preceding cardiac arrest. Our primary outcome was survival to hospital discharge and good neurological status (Cerebral Performance Category 1–2). Results: There were a total of 22 patients who met inclusion criteria of whom 9 received E‐CPR (8 IHCA, 1 OHCA) and 13 received E‐CS. The median age for E‐CPR patients was 52 [IQR 45, 58] years, and 54 [IQR 38, 64] years for E‐CS patients. Cardiac arrest duration was 70.33 (SD 39.56) min for the E‐CPR patients, and 24.67 (SD 26.73) min for the 9 patients treated with E‐CS who had previously arrested. Initial cardiac arrest rhythms were pulseless electrical activity (39%), ventricular fibrillation (33%), or ventricular tachycardia (28%). A total of 18/22 patients were successfully weaned from VA‐ECMO (78%); 16 patients survived to hospital discharge (73%) with 15 in good neurological condition. Conclusion: The initiation of VA‐ECMO at our center for treatment of refractory cardiac arrest and cardiogenic shock yielded a high proportion of survivors and favorable neurological outcomes. HighlightsMean duration from start of CPR to initiation of VA‐ECMO was 103.73 min (±98.41).Successful weaning from VA‐ECMO in 78% of patientsSurvival rate with good neurological condition (CPC 1‐2) was 67%) for E‐CPR, 69% for E‐CS and 68% overall

Current and Future Status of Extracorporeal Cardiopulmonary Resuscitation for In-Hospital Cardiac Arrest

Numerous series, propensity-matched trials, and meta-analyses suggest that appropriate use of extracorporeal cardiopulmonary resuscitation (E-CPR) for in-hospital cardiac arrest (IHCA) can be lifesaving. Even with an antecedent cardiopulmonary resuscitation (CPR) duration in excess of 45 minutes, 30-day survival with favourable neurologic outcome using E-CPR is approximately 35%-45%. Survival may be related to age, duration of CPR, or etiology. Associated complications include sepsis, renal failure, limb and neurologic complications, hemorrhage, and thrombosis. However, methodological biases-including small sample size, selection bias, publication bias, and inability to control for confounders-in these series prevent definitive conclusions. As such, the 2015 American Heart Association Advanced Cardiac Life Support guidelines update recommended E-CPR as a Level of Evidence IIb recommendation in appropriate cases. The absence of high-quality evidence presents an opportunity for clinician/scientists to generate practice-defining data through collaborative investigation and prospective trials. A multidisciplinary dialogue is required to standardize the field and promote multicentre investigation of E-CPR with data sharing and the development of a foundation for high-quality trials. The objectives of this review are to (1) provide an overview of the strengths and limitations of currently available studies investigating the use of E-CPR in patients with IHCA and highlight knowledge gaps; (2) create a framework for the standardization of terminology, clinical practice, data collection, and investigation of E-CPR for patients with IHCA that will help ensure congruence in future work in this area; and (3) propose suggestions to guide future research by the cardiovascular community to advance this important field.

Safety and outcomes of mobile ECMO using a bicaval dual-stage venous catheter

There is little published data on the safety and effectiveness of mobile (inter-hospital) extracorporeal membrane oxygenation (ECMO) in adults, particularly focusing on the cannulation strategy. We sought to study the outcomes of patients cannulated with a bicaval dual lumen catheter needing mobile compared with conventional ECMO. Specifically, we evaluated the safety of using this cannulation strategy during initiation, in transport and overall performance. Multivariate adjustment was performed to report on adjusted 6 month survival as well as complications and performance from cannulation and the ECMO run. A total of 170 consecutive patients (44 mobile ECMO, 126 conventional ECMO) with severe hypoxemic respiratory failure were included in our cohort from 2010 to 2014. Improved in-hospital survival and adjusted lower 6 month mortality favored the mobile ECMO group (86% vs. 79%; odds ratio [OR] 0.24 [0.07–0.69]). Performance of ECMO and complications were similar between the two groups. There were no serious ECMO cannulation-related complications reported during cannulation and on transport. We conclude that the use of bicaval dual lumen catheters instituted with fluoroscopy guidance at referral sites is safe and should be considered in mobile ECMO patients. Furthermore, mobile ECMO is associated with an unexpected mortality benefit in severely hypoxemic patients. Further prospective study is needed to elucidate this finding.