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.

IntroductionIntensive 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 analysisWe 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 We will also review unpublished data and relevant conference abstracts.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 disseminationEthics 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 numberCRD42021260375.

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.

Importance: Studies have suggested intra-pulmonary shunts may contribute to hypoxemia in COVID-19 ARDS and may be associated with worse outcomes. Objective: To evaluate the presence of right-to-left (R-L) shunts in COVID-19 and non-COVID ARDS patients using a comprehensive hypoxemia work-up for shunt etiology and associations with mortality. Design, Setting, Participants: We conducted a multi-centre (4 Canadian hospitals), prospective, observational cohort study of adult critically ill, mechanically ventilated, ICU patients admitted for ARDS from both COVID-19 or non-COVID (November 16, 2020-September 1, 2021). Intervention: Contrast-enhanced agitated-saline bubble studies with transthoracic echocardiography/transcranial Doppler (TTE/TCD) ± transesophageal echocardiography (TEE) assessed for the presence of R-L shunts. Main Outcomes and Measures: Primary outcomes were shunt incidence and association with hospital mortality. Logistic regression analysis was used to determine association of shunt presence/absence with covariables. Results: The study enrolled 226 patients (182 COVID-19 vs. 42 non-COVID). Median age was 58 years (interquartile range [IQR]: 47-67) and APACHE II scores of 30 (IQR: 21-36). In COVID-19 patients, the incidence of R-L shunt was 31/182 patients (17.0%; intra-pulmonary: 61.3%; intra-cardiac: 38.7%) versus 10/44 (22.7%) non-COVID patients. No evidence of difference was detected between the COVID-19 and non-COVID-19 shunt rates (risk difference [RD]: -5.7%, 95% CI: -18.4-7.0, p=0.38). In the COVID-19 group, hospital mortality was higher for those with R-L shunt compared to those without (54.8% vs 35.8%, RD: 19.0%, 95% CI 0.1-37.9, p=0.05). But this did not persist at 90-day mortality, nor after regression adjustments for age and illness severity. Conclusions: There was no evidence of increased R-L shunt rates in COVID-19 compared to non-COVID controls. Right-to-left 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.

Background: Influenza infection is a major cause of mortality in critical care units. Methods: Data 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: One hundred thirty patients with confirmed influenza infection had a mean age of 56 (±16) years; 72 (55%) were male. Mean Acute Physiology and Chronic Health Evaluation (APACHE II) score was 22 (±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: Among critically ill influenza patients, antiviral therapy was independently associated with survival. CRRT, higher severity of illness, and influenza A infection were associated with mortality.

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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

BackgroundBeginning with the guidance of central line insertion, point-of-care ultrasound (POCUS) has evolved into a more inclusive skill set to aid in the examination and management of the acutely ill patient. Published evidence, including original literature and consensus recommendations support an array of applications in the multi-disciplinary arena of acute care medicine. In parallel, we have seen multiple professional societies’ call for more POCUS training in residency. While POCUS has been received with enthusiasm in acute care medicine, there are a number of challenges to ensuring trainees can competently perform POCUS in the acute care environment. There is inconsistent evidence to support optimum practices in curriculum design, implementation, assessment, and evaluation. To help explore this gap, we are conducting a systematic review and meta-analysis of current evidence regarding POCUS curricula.MethodsWe will search electronic databases: MEDLINE, Embase, Cochrane Library, CINAHL, Ovid ERIC, Science Citation Index, and Conference Proceedings Citation Index. Further, we will search the ClinicalTrials.gov register, hand search key proceedings and check references from relevant systematic reviews. Title, abstract and full text screening for inclusion of eligible papers will be performed in duplicate, in accordance with the PRISMA statement. Included publications will be evaluated for internal validity using the Medical Education Research Study Quality Instrument (MERSQI) scale for educational studies. Data abstraction will be conducted using standardized forms with focus on learner population, number of participants, setting, POCUS application, methods of instruction, duration of intervention, methods of assessment, and program evaluation. Further to this, emphasis will be placed on validity arguments of assessment tools using Kane’s framework. Primary analysis will be qualitative in nature. When possible, homogenous studies will be pooled for quantitative meta-analysis.DiscussionOur systematic review will summarize the current evidence base for POCUS curriculum implementation, evaluation and assessment validity for acute care applications. We anticipate that our review will fill a critical knowledge gap, providing a sound platform for future evidence-based curriculum development.Systematic Review RegistrationOur systematic review was registered with the International prospective register of systematic reviews (PROSPERO) on September 19, 2018 with registration number: CRD42018105973.