Intrapulmonary and Intracardiac Shunts in Adult COVID-19 Versus Non-COVID Acute Respiratory Distress Syndrome ICU Patients Using Echocardiography and Contrast Bubble Studies (COVID-Shunt Study): A Prospective, Observational Cohort Study.

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.

Critical care ultrasound training: a survey exploring the "education gap" between potential and reality in Canada.

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.

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

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.

RéSUMé: OBJECTIF: Les experts recommandent que les intensivistes soient habiles en échographie aux soins intensifs. Les sondages publiés révèlent que de nombreux établissements ne possèdent pas de stratégie réfléchie ni de curriculum formalisé en échographie, tout en souffrant d'un manque d'implication du corps professoral et des résidents. Les aptitudes ne sont donc pas uniformes. C'est pourquoi nous avons réalisé une évaluation des besoins afin de mettre au point un curriculum interprofessionnel standardisé en échographie aux soins intensifs qui servira de fondation vers une maîtrise des aptitudes de bases universelles. MéTHODE: Nous avons réalisé une étude en méthodes mixtes auprès de résidents, de patrons et d'infirmiers et infirmières praticiens en soins intensifs travaillant dans cinq unités de soins intensifs médico-chirurgicaux universitaires et communautaires à Edmonton, en Alberta. Nous avons formé des groupes de réflexion qualitatifs puis avons réalisé des sondages quantitatifs afin d'explorer, d'approfondir et d'intégrer nos résultats dans un cadre de curriculum. RéSULTATS: Des groupes de réflexion composés de 19 praticiens interprofessionnels ont identifié des thèmes majeurs, notamment les avantages perçus, les obstacles à l'apprentissage, les priorités, les risques perçus, les caractéristiques d'un enseignement efficace, l'assurance d'un succès à long terme et l'acquisition des compétences. Les sous-thèmes ont mis en lumière une attrition rapide des compétences après des ateliers d'un ou deux jours, le manque d'enseignants compétents, le manque de formation longitudinale, et le besoin de mentorat sur le lieu de travail. Trente-cinq praticiens (35/70; 50 %) ont répondu au sondage. Les formations antérieures incluaient des ateliers (16/35; 46 %) et de l'auto-apprentissage (11/35; 31 %). Onze pourcent (4/35) des répondants ont fait part d'inquiétudes concernant les erreurs potentielles dans la performance de l'échographie aux soins intensifs. Le sondage a permis de raffiner les ressources, le contenu, la livraison et l'évaluation. L'intégration des résultats qualitatifs et quantitatifs a permis de réaliser un cadre exhaustif de curriculum. CONCLUSION: En nous appuyant sur les recommandations publiées, notre évaluation des besoins a identifié des priorités supplémentaires pour encadrer une formation d'échographie destinée aux soins intensifs. Plus spécifiquement, il existe une perte perçue des compétences à la suite d'ateliers courts et il manque de stratégies pour soutenir l'apprentissage. En palliant ces manques, il pourrait être possible de réduire le fossé entre les recommandations nationales et les besoins en première ligne.

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

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 (r = 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 (r = 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.