Background: Organ congestion is a mediator of adverse outcomes in critically ill patients. Point-Of-Care ultrasound (POCUS) is widely available and could enable clinicians to detect signs of venous congestion at the bedside. The aim of this study was to develop several grading system prototypes using POCUS and to determine their respective ability to predict acute kidney injury (AKI) after cardiac surgery. This is a post-hoc analysis of a single-center prospective study in 145 patients undergoing cardiac surgery for which repeated daily measurements of hepatic, portal, intra-renal vein Doppler and inferior vena cava (IVC) ultrasound were performed during the first 72 h after surgery. Five prototypes of venous excess ultrasound (VExUS) grading system combining multiple ultrasound markers were developed. Results: The association between each score and AKI was assessed using time-dependant Cox models as well as conventional performance measures of diagnostic testing. A total of 706 ultrasound assessments were analyzed. We found that defining severe venous congestion as the presence of severe flow abnormalities in multiple Doppler patterns with a dilated IVC (≥ 2 cm) showed the strongest association with the development of subsequent AKI compared with other combinations (HR: 3.69 CI 1.65-8.24 p = 0.001). The association remained significant after adjustment for baseline risk of AKI and vasopressor/inotropic support (HR: 2.82 CI 1.21-6.55 p = 0.02). Furthermore, this severe VExUS grade offered a useful positive likelihood ratio (+LR: 6.37 CI 2.19-18.50) when detected at ICU admission, which outperformed central venous pressure measurements. Conclusions: The combination of multiple POCUS markers may identify clinically significant venous congestion.

Background Acute kidney injury ( AKI ) after cardiac surgery is associated with adverse outcomes. Venous congestion can impair kidney function, but few tools are available to assess its impact at the bedside. The objective of this study was to determine whether portal flow pulsatility and alterations in intrarenal venous flow assessed by Point‐Of‐Care ultrasound are associated with AKI after cardiac surgery. Methods and Results This single‐center prospective cohort study recruited patients undergoing cardiac surgery with cardiopulmonary bypass. Hepatic and renal Doppler ultrasound assessments were performed before surgery, at the intensive care unit admission, and daily for 3 days after surgery. The primary statistical analysis was performed using proportional hazards model for time‐dependent variables. Among the 145 patients included, 49 patients (33.8%) developed AKI after cardiac surgery. The detection of portal flow pulsatility was associated with an increased risk of AKI (hazard ratio: 2.09, confidence interval, 1.11–3.94, P=0.02), as were severe alterations of intrarenal venous flow (hazard ratio: 2.81, confidence interval, 1.42–5.56, P =0.003). These associations remained significant in multivariable models. The addition of these markers to preoperative risk factors and central venous pressure measurement at intensive care unit admission improved the prediction of AKI . (Continuous net reclassification improvement: 0.364, confidence interval, 0.081–0.652 for portal Doppler and net reclassification improvement: 0.343, confidence interval, 0.081–0.628 for intrarenal Doppler) Conclusions Portal flow pulsatility and intrarenal flow alterations are markers of venous congestion and are independently associated with AKI after cardiac surgery. These tools might offer valuable information to develop strategies aimed at treating or preventing congestive cardiorenal syndrome after cardiac surgery. Clinical Trial Registration URL : https://www.clinicaltrials.gov . Unique identifier: NCT 02831907.

Nurses should involve, if willing, FC to participate in activities that optimise patient well-being FC to use recognized delirium management strategies like reorientation and reassurance.

On March 11, 2020, the World Health Organization declared that COVID-19 was a pandemic. 1 At that time, only 118,000 cases had been reported globally, 90% of which had occurred in 4 countries. 1 Since then, the world landscape has changed dramatically. As of March 31, 2020, there are now nearly 800,000 cases, with truly global involvement. 2 Countries that were previously unaffected are currently experiencing mounting rates of the novel coronavirus infection with associated increases in COVID-19erelated deaths. At present, Canada has more than 8000 cases of COVID-19, with considerable variation in

The Society of Thoracic Surgeons Task Force on Resuscitation After Cardiac Surgery provides this professional society perspective on resuscitation in patients who arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation and includes information from existing guidelines, from the International Liaison Committee on Resuscitation, from our own structured literature reviews on issues particular to cardiac surgery, and from an international survey on resuscitation hosted by CTSNet. In gathering evidence for this consensus paper, searches were conducted using the MEDLINE keywords "cardiac surgery," "resuscitation," "guideline," "thoracic surgery," "cardiac arrest," and "cardiac massage." Weight was given to clinical studies in humans, although some case studies, mannequin simulations of potential protocols, and animal models were also considered. Consensus was reached using a modified Delphi method consisting of two rounds of voting until 75% agreement on appropriate wording and strength of the opinions was reached. The Society of Thoracic Surgeons Workforce on Critical Care was enlisted in this process to provide a wider variety of experiences and backgrounds in an effort to reinforce the opinions provided. We start with the premise that external massage is ineffective for an arrest due to tamponade or hypovolemia (bleeding), and therefore these subsets of patients will receive inadequate cerebral perfusion during cardiac arrest in the absence of resternotomy. Because these two situations are common causes for an arrest after cardiac surgery, the inability to provide effective external cardiopulmonary resuscitation highlights the importance of early emergency resternotomy within 5 minutes. In addition, because internal massage is more effective than external massage, it should be used preferentially if other quickly reversible causes are not found. We present a protocol for the cardiac arrest situation that includes the following recommendations: (1) successful treatment of a patient who arrests after cardiac surgery is a multidisciplinary activity with at least six key roles that should be allocated and rehearsed as a team on a regular basis; (2) patients who arrest with ventricular fibrillation should immediately receive three sequential attempts at defibrillation before external cardiac massage, and if this fails, emergency resternotomy should be performed; (3) patients with asystole or extreme bradycardia should undergo an attempt to pace if wires are available before external cardiac massage, then optionally external pacing followed by emergency resternotomy; and (4) pulseless electrical activity should receive prompt resternotomy after quickly reversible causes are excluded. Finally, we recommend that full doses of epinephrine should not be routinely given owing to the danger of extreme hypertension if a reversible cause is rapidly resolved. Protocols are given for excluding reversible airway and breathing complications, for left ventricular assist device eme...

Cardiac rehabilitation programs across Canada have suspended inperson services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. Virtual cardiac rehabilitation (VCR) offers an alternate mechanism of care delivery, capable of providing similar patient outcomes and safety profiles compared with centre-based programs. To minimize care gaps, all centres should consider developing and implementing a VCR program. The process of this rapid implementation, however, can be daunting. Centres should initially focus on the collation, utilization, and R ESUM E Cardiac rehabilitation (CR) programs across Canada have suspended in-person, centre-based cardiac rehabilitation (CBCR) services as a result of large-scale physical distancing recommendations designed to flatten the COVID-19 pandemic curve. CBCR has unequivocally demonstrated reductions in hospital readmissions, secondary events, and mortality in patients with cardiovascular disease. 1 Significant

Delirium is an acute syndrome that involves fluctuating changes in attention and cognition. Although delirium is the most common neurologic complication after cardiac operation, data about its impact on long-term outcomes are lacking. The purpose of this systematic review was to examine the effect of postoperative delirium (PoD) on long-term outcomes, including morbidity, probability of death, cognitive decline, institutionalization, and health-related quality of life (HRQoL) in patients undergoing cardiac operation. After performing this systematic review we determined that PoD after cardiac operation is associated with an increased risk of probability of death and readmission to the hospital and a decrease in cognitive function, overall function, and HRQoL.

Background: Right ventricular failure after cardiac surgery is associated with morbidity and mortality. Right ventricular dysfunction results in hepatic venous congestion, which impacts the portal circulation. We aimed to determine whether an increased portal flow pulsatility fraction was associated with right ventricular dysfunction in cardiac surgery patients. We also aimed to describe the haemodynamic factors and postoperative complications associated with an increased portal pulsatility in this setting. Methods: We conducted a prospective single-centre cohort study, recruiting adults undergoing cardiac surgery. Portal flow was assessed before, during, and after surgery by Doppler ultrasound. A detailed haemodynamic and echocardiographic assessment was performed at the same time points. Results: A total of 115 patients were included. Both systolic and diastolic right ventricular dysfunction were associated with a higher portal pulsatility fraction (P¼0.008 and <0.001, respectively). A positive association was present between portal pulsatility fraction and measurements representative of venous pressure (central venous pressure, inferior vena cava diameter). A post-procedural portal pulsatility fraction !50% measured in the operating room was present in 21 (18.3%) patients and was associated with an increased risk of major complications (odds ratio¼5.83, confidence interval, 2.04e16.68, P¼0.001). The addition of portal flow assessment to a predictive model including EuroSCORE II and systolic right ventricular dysfunction improved prediction of postoperative complications. Conclusions: High portal flow pulsatility fraction is associated with right ventricular dysfunction, signs of venous congestion and decreased perfusion, and an increased risk of major complications. Portal vein Doppler ultrasound appears to be promising for risk assessment in the perioperative period. Clinical trials registration: NCT02658006.