Outcomes and clinical practice in patients with COVID-19 admitted to the intensive care unit in Montréal, Canada: a descriptive analysis.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic is responsible for millions of infections worldwide, and a substantial number of these patients will be admitted to the intensive care unit (ICU). Our objective was to describe the characteristics, outcomes and management of critically ill patients with COVID-19 pneumonia at a single designated pandemic centre in Montréal, Canada. METHODS: A descriptive analysis was performed on consecutive critically ill patients with COVID-19 pneumonia admitted to the ICU at the Jewish General Hospital, a designated pandemic centre in Montréal, between Mar. 5 and May 21, 2020. Complete follow-up data corresponding to death or discharge from hospital health records were included to Aug. 4, 2020. We summarized baseline characteristics, management and outcomes, including mortality. RESULTS: A total of 106 patients were included in this study. Twenty-one patients (19.8%) died during their hospital stay, and the ICU mortality was 17.0% (18/106); all patients were discharged home or died, except for 4 patients (2 awaiting a rehabilitation bed and 2 awaiting long-term care). Twelve of 65 patients (18.5%) requiring mechanical ventilation died. Prone positioning was used in 29 patients (27.4%), including in 10 patients who were spontaneously breathing; no patient was placed on extracorporeal membrane oxygenation. High-flow nasal cannula was used in 51 patients (48.1%). Acute kidney injury was the most common complication, seen in 20 patients (18.9%), and 12 patients (11.3%) required renal replacement therapy. A total of 53 patients (50.0%) received corticosteroids. INTERPRETATION: Our cohort of critically ill patients with COVID-19 had lower mortality than that previously described in other jurisdictions. These findings may help guide critical care decision-making in similar health care systems in further COVID-19 surges.

Sengstaken-Blakemore tube for non-variceal distal esophageal bleeding refractory to endoscopic treatment: a case report & review of the literature.

Non-variceal upper-gastrointestinal bleeding (NVUGIB) refractory to therapeutic endoscopy is a challenging situation. The following details a novel use for the Sengstaken-Blakemore tube in a case of severe ulcerative esophagitis after failure of conventional medical and endoscopic treatment. A 77-year-old man with a history of peptic ulcer disease developed massive hematemesis during a hospital admission. Initial gastroscopy revealed an adherent blood clot occupying the distal esophagus, extending to the gastric cardia and proximal fundus. Epinephrine was injected into and surrounding the clot; however, following the endoscopy the patient was hemodynamically unstable, requiring aggressive resuscitation. Repeat gastroscopy, following saline lavage, revealed active bleeding within severely ulcerated esophageal mucosa, immediately proximal to the gastro-esophageal (GE) junction. Despite apparent hemostasis following injection of epinephrine and electrocautery, the patient displayed clinical signs of continued bleeding. Furthermore, surgical and radiological interventions were precluded by the patient's hemodynamic instability. In an attempt to tamponade blood supply to the GE junction, a Sengstaken-Blakemore tube was inserted and placed under tension. Successful hemostasis was subsequently achieved and the patient remained stable. This is the first case to describe use of a Sengstaken-Blakemore tube in severe ulcerative esophagitis refractory to standard endoscopic management.

Survival from in-hospital cardiac arrest on the Internal Medicine clinical teaching unit.

BACKGROUND: There is a paucity of data on patient outcomes following in-hospital cardiac arrest (IHCA) on the Internal Medicine clinical teaching unit (CTU). Accurate outcome data enhances discussions between patients, surrogates, and physicians, and assists in their management. METHODS: We performed a retrospective cohort study of consecutive "Code Blue" calls on 2 medical CTUs in a Canadian tertiary centre from January 1, 2003 to June 30, 2007. The medical records of identified patients were screened for eligibility and patient-specific and arrest-specific data were collected for eligible events. Primary outcome was survival to hospital discharge. RESULTS: Our cohort comprised 83 patients; including 54 (65.1%) men with a mean age of 75 years (range, 38-97). Infection (34.9%) was the principal reason for admission and over half of patients had 3 or more comorbid illnesses. Forty-three (51.8%) of the IHCA events were witnessed. In all, 39 (90.7%) of the witnessed and 36 (90%) of the unwitnessed arrests were pulseless electrical activity (PEA) or asystole (P = not significant). Return of spontaneous circulation occurred in 29 patients (34.9%) and 2 (2.4%) survived to hospital discharge. No patients survived to discharge after unwitnessed arrest. CONCLUSIONS: IHCA in Internal Medicine CTU patients is characterized by a high rate of PEA/asystole and a minimal chance of survival to hospital discharge. Moreover, no patient with an unwitnessed arrest survived to hospital discharge. While these findings require confirmation in a larger study, they merit consideration in the context of code status discussions, particularly with respect to the response to unwitnessed arrests.

Is weaning failure caused by low-frequency fatigue of the diaphragm?

Because patients who fail a trial of weaning from mechanical ventilation experience a marked increase in respiratory load, we hypothesized that these patients develop diaphragmatic fatigue. Accordingly, we measured twitch transdiaphragmatic pressure using phrenic nerve stimulation in 11 weaning failure and 8 weaning success patients. Measurements were made before and 30 minutes after spontaneous breathing trials that lasted up to 60 minutes. Twitch transdiaphragmatic pressure was 8.9 +/- 2.2 cm H2O before the trials and 9.4 +/- 2.4 cm H2O after their completion in the weaning failure patients (p = 0.17); the corresponding values in the weaning success patients were 10.3 +/- 1.5 and 11.2 +/- 1.8 cm H2O (p = 0.18). Despite greater load (p = 0.04) and diaphragmatic effort (p = 0.01), the weaning failure patients did not develop low-frequency fatigue probably because of greater recruitment of rib cage and expiratory muscles (p = 0.004) and because clinical signs of distress mandating the reinstitution of mechanical ventilation arose before the development of fatigue. Twitch pressure revealed considerable diaphragmatic weakness in many weaning failure patients. In conclusion, in contrast to our hypothesis, weaning failure was not accompanied by low-frequency fatigue of the diaphragm, although many weaning failure patients displayed diaphragmatic weakness.