Implications of High Sensitivity Troponin Levels After Lung Transplantation.

Trends in high-sensitivity cardiac troponin I (hs-cTnI) after lung transplant (LT) and its clinical value are not well stablished. This study aimed to determine kinetics of hs-cTnI after LT, factors impacting hs-cTnI and clinical outcomes. LT recipients from 2015 to 2017 at Toronto General Hospital were included. Hs-cTnI levels were collected at 0-24 h, 24-48 h and 48-72 h after LT. The primary outcome was invasive mechanical ventilation (IMV) >3 days. 206 patients received a LT (median age 58, 35.4% women; 79.6% double LT). All patients but one fulfilled the criteria for postoperative myocardial infarction (median peak hs-cTnI = 4,820 ng/mL). Peak hs-cTnI correlated with right ventricular dysfunction, >1 red blood cell transfusions, bilateral LT, use of EVLP, kidney function at admission and time on CPB or VA-ECMO. IMV>3 days occurred in 91 (44.2%) patients, and peak hs-cTnI was higher in these patients (3,823 vs. 6,429 ng/mL, p < 0.001 after adjustment). Peak hs-cTnI was higher among patients with had atrial arrhythmias or died during admission. No patients underwent revascularization. In summary, peak hs-TnI is determined by recipient comorbidities and perioperative factors, and not by coronary artery disease. Hs-cTnI captures patients at higher risk for prolonged IMV, atrial arrhythmias and in-hospital death.

Improve Communicating Uncertainty in Intensive Care Unit With Patient and Family (ICU-PF).

Communicating uncertainty with patients and families in the intensive care unit is challenging and requires time and skill to convey the information. This proposal aims to provide a structured path for identifying and communicating uncertainty with patients and families in the unit. The focus is to improve the quality of care and timely communication to meet the expectations and needs of families and patients. The project focuses on the first 24 hours of intensive care unit admission to improve communication of uncertainty. By utilizing the Plan-Do-Study-Act cycle, the workflow uses a screening tool to identify uncertainty and communicate using evidence-based recommendations and the mnemonic VALUE (Value family statements, Acknowledge emotions, Listen, Understand the patient as a person, Elicit questions) as the standard of care. The workflow can be incorporated during the routine rounds as part of the A-F liberation bundle. The outcome is to improve patient and family satisfaction scores using a validated Family Satisfaction with Care in the Intensive Care Unit (FS-ICU 24) questionnaire to achieve a score of 75 or more, which correlates with very good. Challenges and limitations are discussed in the proposal.

Cardiovascular Collapse in COVID-19 Infection: The Role of Venoarterial Extracorporeal Membrane Oxygenation (VA-ECMO).

Coronavirus Disease 2019 (COVID-19) has been associated with cardiovascular complications, including acute cardiac injury, heart failure, and cardiogenic shock (CS). The role of venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the event of COVID-19-associated cardiovascular collapse has not been established. We reviewed the existing literature surrounding the role of VA-ECMO in the treatment of coronavirus-related cardiovascular collapse. COVID-19 is associated with a higher incidence of cardiovascular complications compared with previous coronavirus outbreaks (Severe Acute Respiratory Syndrome Coronavirus and Middle East Respiratory Syndrome Coronavirus). We found only 1 case report from China in which COVID-19-associated fulminant myocarditis and CS were successfully rescued using VA-ECMO as a bridge to recovery. We identified potential clinical scenarios (cardiac injury, myocardial infarction with and without obstructive coronary artery disease, viral myocarditis, and decompensated heart failure) leading to CS and risk factors for poor/uncertain benefit (age, sepsis, mixed/predominantly vasodilatory shock, prothrombotic state or coagulopathy, severe acute respiratory distress syndrome, multiorgan failure, or high-risk prognostic scores) specific to using VA-ECMO as a bridge to recovery in COVID-19 infection. Additional considerations and proposed recommendations specific to the COVID-19 pandemic were formulated with guidance from published data and expert consensus. A small subset of patients with cardiovascular complications from COVID-19 infection may progress to refractory CS. While accepting that resource scarcity may be the overwhelming concern for healthcare systems during this pandemic, VA-ECMO can be considered in highly selected cases of refractory CS and echocardiographic evidence of biventricular failure. The decision to initiate this therapy should take into consideration the availability of resources, perceived benefit, and risks of transmitting disease.

La maladie à coronavirus 2019 (COVID-19) est associée à des complications cardiovasculaires, y compris des lésions cardiaques aiguës, l'insuffisance cardiaque et le choc cardiogénique (CC). Le rôle de l'oxygénation par membrane extracorporelle (ECMO pour extracorporeal membrane oxygenation) veino-artérielle dans les cas de collapsus cardiovasculaire associé à la COVID-19 n'a pas été établi. Nous avons passé en revue la documentation existante abordant le rôle de l'ECMO veino-artérielle dans le traitement du collapsus cardiovasculaire lié au coronavirus. La COVID-19 est associée à une incidence plus élevée de complications cardiovasculaires comparativement aux éclosions antérieures d'infections à coronavirus (syndrome respiratoire aigu sévère et syndrome respiratoire du Moyen-Orient). Nous n'avons trouvé qu'un seul cas (signalé en Chine) de myocardite fulminante et de CC associés à la COVID-19 où l'ECMO veino-artérielle a permis d'assurer la survie du patient dans l'attente d'une récupération de la fonction cardiaque. Nous avons ciblé divers scénarios cliniques (lésion cardiaque, infarctus du myocarde avec ou sans coronaropathie obstructive, myocardite virale et insuffisance cardiaque décompensée) susceptibles d'aboutir à un CC et cerné des facteurs de risque de bienfaits faibles ou incertains (âge, septicémie, choc vasodilatateur mixte ou prédominant, état prothrombotique ou coagulopathie, syndrome de détresse respiratoire aiguë sévère, défaillance multiviscérale ou scores pronostiques à haut risque) cadrant spécifiquement avec l'utilisation de l'ECMO veino-artérielle dans l'attente d'une récupération de la fonction cardiaque chez le patient atteint de COVID-19. D'autres considérations et recommandations visant spécifiquement la pandémie de COVID-19 ont été énoncées à la lumière des données publiées et d'un consensus d'experts. Au sein d'un petit sous-groupe de patients atteints de COVID-19, les complications cardiovasculaires de l'infection peuvent évoluer vers un CC réfractaire. Tout en acceptant que la pénurie de ressources puisse être la principale préoccupation des systèmes de santé pendant cette pandémie, on peut envisager de recourir à l'ECMO veino-artérielle dans des cas soigneusement sélectionnés de CC réfractaire et en présence de preuves échocardiographiques d'insuffisance biventriculaire. La décision d'instaurer ce traitement doit tenir compte de la disponibilité des ressources, des avantages perçus et des risques de transmission de la maladie.