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Objectives Since 2016, Canada has allowed for euthanasia based on strict criteria under federal medical assistance in dying legislation. The purpose of this study was to determine how Canadian intensivists perceive medical assistance in dying and whether they believe their approach to withdrawal of life-sustaining therapies has changed following introduction of medical assistance in dying. Design Electronic survey. Setting Participants were recruited from 11 PICU programs and 14 adult ICU programs across Canada. All program leaders for whom contact information was available were approached for participation. Participants We invited intensivists and critical care trainees employed between December 2019 and May 2020 to participate using a snowball sampling technique in which department leaders distributed study information. All responses were anonymous. Quantitative data were analyzed using descriptive statistics. Categorical variables were analyzed using Pearson chi-square test. Interventions Not applicable. Measurements and main results We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. Most were from academic centers (81%, n = 121). Of respondents, 86% (n = 130) were familiar with medical assistance in dying legislation, 71% in favor, 14% conflicted, and 11% opposed. Only 5% (n = 8) thought it had influenced their approach to withdrawal of life-sustaining therapies. Half of participants had no standardized protocol for withdrawal of life-sustaining therapies in their unit, and 41% (n = 62) had observed medications given in disproportionately high doses during withdrawal of life-sustaining therapies, with 13% having personally administered such doses. Most (80%, n = 120) had experienced explicit requests from families to hasten death, and almost half (47%, n = 70) believed it was ethically permissible to intentionally hasten death following withdrawal of life-sustaining therapies. Conclusions Most Canadian intensivists surveyed do not think that medical assistance in dying has changed their approach to end of life in the ICU. A significant minority are ethically conflicted about the current approach to assisted dying/euthanasia in Canada. Almost half believe it is ethical to intentionally hasten death during withdrawal of life-sustaining therapies if death is expected.

Hyperammonemia syndrome (HS) is a rare post-transplant complication associated with high morbidity and mortality. Its incidence appears to be higher in lung transplant recipients and its pathophysiology is not well understood. In addition to underlying metabolic abnormalities, it is postulated that HS may be associated with Ureaplasma or Mycoplasma spp. lung infections. Management of this condition is not standardized and may include preemptive antimicrobials, renal replacement, nitrogen scavenging, and bowel decontamination therapies, as well as dietary modifications.In this case series, we describe seven HS cases, five of whom had metabolic deficiencies ruled out. In addition, a literature review was performed by searching PubMed following PRISMA-P guidelines. Articles containing the terms "hyperammonemia" and "lung" were reviewed from 1 January 1997 to 31 October 2021.All HS cases described in our center had positive airway samples for Mycoplasmataceae, neurologic abnormalities and high ammonia levels post-transplant. Mortality in our group (57%) was similar to that published in previous cases. The literature review supported that HS is an early complication post-transplant, associated with Ureaplasma spp. and Mycoplasma hominis infections and of worse prognosis in patients presenting cerebral edema and seizures.This review highlights the need for rapid testing for Ureaplasma spp. and M. hominis after lung transplant, as well as the necessity for future studies to explore potential therapies that may improve outcomes in these patients.

Since 2016, Canada has permitted medical assistance in dying (MAID). Our aims were to understand how Canadian intensivists view MAID and the impact of MAID on end-of-life care in the ICU.This was a descriptive qualitative study of responses from a 41-item questionnaire. We recruited intensivists and trainees from 11 pediatric ICU programs and 14 adult ICU programs across Canada between December 2019 and May 2020. Two qualitative researchers inductively coded responses and then conducted preliminary thematic analysis. Themes were subsequently refined through group discussion.We obtained 150 complete questionnaires (33% response rate), of which 50% were adult practitioners and 50% pediatric. We identified six main themes including: intensivists have a wide range of opinions on MAID; MAID has not changed ICU practice; and moral distress has a diverse impact on practice. Physicians also discussed the role of provider intent and the importance of treating withdrawal of life-sustaining treatments (WLST) as a process to protect patients, families, and providers.Canadian intensivists hold a wide range of opinions on MAID, but most agree it has not changed ICU practice. Importantly, intensivists also hold differing views on the relevance of physician intent in medical ethics.

BackgroundHealth technology reassessment (HTR) is a process to manage existing health technologies to ensure ongoing optimal use. A model to guide HTR was developed; however, there is limited practical experience. This paper addresses this knowledge gap through the completion of a multi-phase HTR of red blood cell (RBC) transfusion practices in the intensive care unit (ICU).ObjectiveThe HTR consisted of three phases and here we report on the final phase: the development, implementation, and evaluation of behavior change interventions aimed at addressing inappropriate RBC transfusions in an ICU.MethodsThe interventions, comprised of group education and audit and feedback, were co-designed and implemented with clinical leaders. The intervention was evaluated through a controlled before-and-after pilot feasibility study. The primary outcome was the proportion of potentially inappropriate RBC transfusions (i.e., with a pre-transfusion hemoglobin of 70 g/L or more).ResultsThere was marked variability in the monthly proportion of potentially inappropriate RBC transfusions. Relative to the pre-intervention phase, there was no significant difference in the proportion of potentially inappropriate RBC transfusions post-intervention. Lessons from this work include the importance of early and meaningful engagement of clinical leaders; tailoring the intervention modalities; and, efficient access to data through an electronic clinical information system.ConclusionsIt was feasible to design, implement, and evaluate a tailored, multi-modal behavior change intervention in this small-scale pilot study. However, early evaluation of the intervention revealed no change in technology use leading to reflection on the important question of how the HTR model needs to be improved.

To evaluate the feasibility of intraoperative continuous renal replacement therapy (IoCRRT) during liver transplantation (LT), in terms of recruitment, protocol adherence, and ascertainment of follow-up. In this pilot randomized open-label controlled trial in adults receiving LT with a Model for End-Stage Liver Disease (MELD) score ≥ 25 and preoperative acute kidney injury (RIFLE - RISK or higher) and/or estimated glomerular filtration rate < 60 mL·min−1·1.73 m−2, patients were randomized to receive IoCRRT or standard of care (SOC). Primary endpoints were feasibility and adverse events. Primary analysis was intention-to-treat (n = 32) and secondary analysis was per-protocol (n = 28). The trial was stopped early because of slow patient accrual and inadequate funding. Sixty patients were enrolled and 32 (53%) were randomized (n = 15 IoCRRT; n = 17 SOC). Mean (standard deviation) MELD was 36 (8), 81% (n = 26) had cirrhosis; 69% (n = 22) received preoperative RRT; 66% (n = 21) received LT from the intensive care unit. Four patients (n = 2 IoCRRT, n = 2 SOC) did not receive LT post-randomization. Seven patients (41%) allocated to SOC crossed over intraoperatively to IoCRRT. Three patients were lost to follow-up at one year. No adverse events occurred related to IoCRRT. There were no differences in survival at one year (IoCRRT, 71% [n = 10/14] vs SOC, 93% [n = 14/15]; risk ratio, 0.77; 95% confidence interval, 0.54 to 1.1). In the per-protocol analysis (n = 28 received IoCRRT after randomization - n = 20 IoCRRT, n = 8 SOC), one-year survival was 92% and perioperative complications were similar between groups. Only one patient was receiving dialysis one year after LT. In this pilot randomized trial, IoCRRT was feasible and safe with no difference in complications. Crossover rates were high. Despite high preoperative severity of illness, one-year survival was excellent. These data can inform the design of a larger multicentre trial. www.clinicalTrials.gov (NCT01575015); registered 12 April, 2012.

Hyperammonemia syndrome (HS) is a rare complication with high mortality described after lung transplantation. Its pathophysiology is still unclear, but previous studies, including murine models, have linked the identification of Mycoplasmataceae in airway specimens with HS occurrence. This study explores the association between Mycoplasmataceae polymerase chain reaction (PCR) positivity, ammonia levels, HS, and mortality post-lung transplant. Adults who underwent lung transplantation between July 2017 and August 2019 had prospective surveillance testing for Mycoplasma and Ureaplasma using PCR on post-operative bronchoscopy samples. One hundred and fifty-nine patients underwent lung transplantation during the study period. Mean age was 54 (±13) years; baseline diseases were predominantly pulmonary fibrosis (37.7%) and chronic obstructive pulmonary disease (35.8%). Mycoplasma and/or Ureaplasma airway positivity was found in 42 (26.4%) of tested patients, represented mostly by M. salivarium (26/43; 60.4%), U. parvum (7/43; 16.2%), and U. urealyticum (5/43; 11.6%). Median peak ammonia levels were higher in those with Ureaplasma colonization compared to uncolonized patients (p = .04), however, only three patients developed HS. Recipient airway Ureaplasma positivity was independently associated with younger (aOR 0.94, 95% CI 0.88-0.99, p = .04) and female donors (aOR 4.29; 95% CI 1.01-18.2, p = .05).

Patients with cirrhosis and concomitant coronary/valvular heart disease present a clinical dilemma. The therapeutic outcome of major cardiac surgery is significantly poorer in patients with cirrhosis compared with patients without cirrhosis. To address this, we aimed to identify associations between the severity of cirrhosis and post-cardiac surgical outcomes. A historical cohort analysis of patients undergoing cardiac surgery at the University of Alberta Hospital from January 2004 to December 2014 was used to identify and propensity score-match 60 patients with cirrhosis to 310 patients without cirrhosis. The relationships between cirrhosis and i) mortality, ii) postoperative complications, and iii) requirement of healthcare resources were evaluated. Ten-year mortality was significantly higher in cirrhotic patients compared with propensity score-matched non-cirrhotic patients (40% vs 20%; relative risk [RR], 2.0; 95% confidence interval [CI], 1.3 to 2.9; P = 0.001). Cirrhotic patients had more complications (63% vs 48%; RR, 1.3; 95% CI, 1.05 to 1.7; P = 0.02), longer median [interquartile range (IQR)] intensive care unit stays (5 [3–11] vs 2 [1–4] days; P < 0.001), time on mechanical ventilation (median [IQR] 2 [1–5] vs 1 [0.5–1.2] days; P < 0.001) and more frequently required renal replacement therapy (15% vs 6%; RR, 2.5; 95% CI, 1.2 to 5.2; P = 0.02) postoperatively. After adjusting for other covariates, presence of cirrhosis (adjusted odds ratio, 2.2; 95% CI, 1.1 to 4.1) and intraoperative transfusion (adjusted odds ratio, 3.2; 95% CI, 1.6 to 6.3) were independently associated with increased mortality. Despite having low median model for end-stage liver disease scores, this small series of cirrhotic patients undergoing cardiac surgery had significantly higher mortality rates and required more organ support postoperatively than propensity score-matched non-cirrhotic patients. Impact de la cirrhose chez les patients subissant une chirurgie cardiaque : une etude de cohorte observationnelle et retrospective

Summary Background The optimal means of pre-operative risk stratification in patients with atrial fibrillation (AF) is uncertain. Objective To examine the accuracy of AF thromboembolic risk models (the CHADS2, CHA2DS2-VASc, and R2CHADS2 scores) for predicting 30-day stroke and/or all-cause mortality after non-cardiac surgery in patients with preoperative AF, and to compare these risk scores with the Revised Cardiac Risk Index (RCRI). Patients/Methods A multicentre (8 countries, 2007–2011) prospective cohort study of patients ≥ 45 years of age undergoing inpatient non-cardiac surgery, who were followed until 30 days after surgery. We calculated c-statistics for each risk prediction model and net reclassification improvements (NRIs) compared with the RCRI. Results The 961 patients with preoperative AF were at higher risk of any cardiovascular event in the 30 days postoperatively compared with the 13 001 patients without AF: 26.6% vs. 9.0%; adjusted odds ratio, 1.58; 95% confidence interval [CI], 1.33–1.88. All thromboembolic risk scores predicted postoperative death just as well as the RCRI (with c-indices between 0.67 and 0.72). Compared with the RCRI (which had a c-index of 0.64 for 30-day stroke/death), the CHADS2 (c-index, 0.67; NRI, 0.31; 95% CI, 0.02–0.61) significantly improved postoperative stroke/mortality risk prediction, largely due to improved discrimination of patients who did not subsequently have an event. Conclusions In AF patients, the three thromboembolic risk scores performed similarly to the RCRI in predicting death within 30 days and the CHADS2 score was the best predictor of postoperative stroke/death regardless of type of surgery.

Background: Myocardial injury after noncardiac surgery (MINS) was defined as prognostically relevant myocardial injury due to ischemia that occurs during or within 30 days after noncardiac surgery. The study’s four objectives were to determine the diagnostic criteria, characteristics, predictors, and 30-day outcomes of MINS. Methods: In this international, prospective cohort study of 15,065 patients aged 45 yr or older who underwent in-patient noncardiac surgery, troponin T was measured during the first 3 postoperative days. Patients with a troponin T level of 0.04 ng/ml or greater (elevated “abnormal” laboratory threshold) were assessed for ischemic features (i.e., ischemic symptoms and electrocardiography findings). Patients adjudicated as having a nonischemic troponin elevation (e.g., sepsis) were excluded. To establish diagnostic criteria for MINS, the authors used Cox regression analyses in which the dependent variable was 30-day mortality (260 deaths) and independent variables included preoperative variables, perioperative complications, and potential MINS diagnostic criteria. Results: An elevated troponin after noncardiac surgery, irrespective of the presence of an ischemic feature, independently predicted 30-day mortality. Therefore, the authors’ diagnostic criterion for MINS was a peak troponin T level of 0.03 ng/ml or greater judged due to myocardial ischemia. MINS was an independent predictor of 30-day mortality (adjusted hazard ratio, 3.87; 95% CI, 2.96–5.08) and had the highest population-attributable risk (34.0%, 95% CI, 26.6–41.5) of the perioperative complications. Twelve hundred patients (8.0%) suffered MINS, and 58.2% of these patients would not have fulfilled the universal definition of myocardial infarction. Only 15.8% of patients with MINS experienced an ischemic symptom. Conclusion: Among adults undergoing noncardiac surgery, MINS is common and associated with substantial mortality.

Purpose There is a shortage of organ donors in Canada. The number of potential organ donors that are not referred to organ procurement organizations in Canada is unknown.

Acute kidney injury (AKI) is common in liver failure prior to orthotopic liver transplantation (OLT) and may complicate the intraoperative course. We describe the logistics of intraoperative continuous renal replacement therapy (CRRT) during OLT and the associated clinical outcomes. We performed a retrospective review of adult patients (age > 18 years) receiving intraoperative CRRT during OLT at the University of Alberta Hospital between January 1, 1996 and December 31, 2005. Demographic, detailed clinical, and perioperative data, physiologic and laboratory measures, details of renal replacement therapy (RRT) provided, and data on renal recovery and survival were ascertained. Of 636 OLTs, 41 (6.4%) received intraoperative CRRT. The most common indications for OLT in these patients were hepatitis C (34.2%) and alcoholic (29.3%) cirrhosis. The median [interquartile range (IQR)] Model for End-Stage Liver Disease score was 38 (31-43), and 90.2% were classified as Child-Pugh class C. Preoperatively, 70% were in the intensive care unit, 58.5% were mechanically ventilated, and 48.7% required vasopressor support. The median (IQR) duration of intraoperative CRRT was 258 (189-390) minutes, representing 57% of the total operative time. Filter circuit clotting occurred in 40% but was not associated with a shorter CRRT duration (P = 0.41). No other complications were described. CRRT allowed an even or negative intraoperative fluid balance in 92.7%. CRRT was continued in 78% after OLT for a median (IQR) of 5 (3-11) days. Of these, 24 (75%) were transitioned to intermittent hemodialysis for a median (IQR) of 15 (4-39) days. Survival was 97.6% at 1 month and 75.6% at 1 year. Renal recovery to RRT independence occurred in 100% of survivors by 1 year; however, the mean (standard deviation) estimated glomerular filtration rate (eGFR) was 54.7 (19.1) mL/minute/m2, with 62.1% having an eGFR < 60 mL/minute/m2. In conclusion, our data suggest that intraoperative CRRT during OLT is achievable and safe. Intraoperative CRRT may be a valuable adjuvant therapy for those with preoperative AKI. Additional investigations are warranted. Liver Transpl 15:73–78, 2009. © 2008 AASLD.

To review and discuss the epidemiology, contributing factors, and approach to clinical management of disorders of sodium and water balance in hospitalized patients.An electronic search of the MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases and a search of the bibliographies of all relevant studies and review articles for recent reports on hyponatremia and hypernatremia with a focus on critically ill patients.Disorders of sodium and water balance are exceedingly common in hospitalized patients, particularly those with critical illness and are often iatrogenic. These disorders are broadly categorized as hypo-osmolar or hyper-osmolar, depending on the balance (i.e., excess or deficit) of total body water relative to total body sodium content and are classically recognized as either hyponatremia or hypernatremia. These disorders may represent a surrogate for increased neurohormonal activation, organ dysfunction, worsening severity of illness, or progression of underlying chronic disease. Hyponatremic disorders may be caused by appropriately elevated (volume depletion) or inappropriately elevated (SIADH) arginine vasopressin levels, appropriately suppressed arginine vasopressin levels (kidney dysfunction), or alterations in plasma osmolality (drugs or body cavity irrigation with hypotonic solutions). Hypernatremia is most commonly due to unreplaced hypotonic water depletion (impaired mental status and/or access to free water), but it may also be caused by transient water shift into cells (from convulsive seizures) and iatrogenic sodium loading (from salt intake or administration of hypertonic solutions).In hospitalized patients, hyponatremia and hypernatremia are often iatrogenic and may contribute to serious morbidity and increased risk of death. These disorders require timely recognition and can often be reversed with appropriate intervention and treatment of underlying predisposing factors.

Acute kidney injury (AKI) is commonly and increasingly encountered in patients with critical illness. Fluid therapy is the cornerstone for the prevention and management of critically ill patients with AKI. New data have emerged that have raised concern that specific types of fluid (i.e. hydroxyethylstarch) may either contribute to or exacerbate AKI. Additional data have accumulated to indicate that the unnecessary accumulation of fluid and volume overload can negatively impact clinical outcomes. This finding may be further compounded in patients with oliguric AKI where solute and free water elimination are impaired. Diuretic therapy in AKI remains controversial. However, diuretic use is common, despite a paucity of evidence to show improved clinical outcomes. There are few therapeutic interventions proven to impact the clinical course and outcome of critically ill patients with established AKI. Current management strategies center largely on supportive care, with rapid resuscitation, removal of the stimulus contributing to AKI, judicious avoidance of complications, and allowing time for recovery. In this review, we explore recent insights on intravenous fluid therapy, volume overload, and diuretic therapy in the context of the critically ill patients with AKI.

We present a case of spontaneous subluxation of the Temporo-mandibular joint (TMJ) induced by succinylcholine, to compare our experience with previous cases reported in the literature, and to review the pathophysiology, preoperative screening, and intraoperative management of TMJ instability.A 39-yr-old female with primary hyperparathyroidism and a normal airway examination presented for elective parathyroidectomy. Following induction of anesthesia and the administration of succinylcholine prior to jaw manipulation, her mouth could not be opened, and we suspected spontaneous subluxation of the TMJ. We secured the airway with the use of a Trachlight and, subsequently, reduced the joint. Postoperatively, a history of mild TMJ-related symptoms was elicited.Instability of the TMJ is not uncommon, and has several implications for airway management, highlighting the importance of preoperative screening. Limited mouth opening, due to spontaneous subluxation of the TMJ following succinylcholine-induced muscle relaxation in the absence of airway manipulation, has only twice been reported in the literature. This report highlights how tracheal intubation may be accomplished using the Trachlight, in order to secure the airway prior to reduction of the subluxed joint.

Question Does vasodilatation in symptomatic patients with severe aortic stenosis and congestive heart failure improve cardiac index?

Background There is limited epidemiologic data on patients with acute myelogenous (myeloid) leukemia (AML) requiring life-sustaining therapies in the intensive care unit (ICU). Our objectives were to describe the clinical characteristics and outcomes in critically ill AML patients. Methods This was a retrospective case-control study. Cases were defined as adult patients with a primary diagnosis of AML admitted to ICU at the University of Alberta Hospital between January 1st 2002 and June 30th 2008. Each case was matched by age, sex, and illness severity (ICU only) to two control groups: hospitalized AML controls, and non-AML ICU controls. Data were extracted on demographics, course of hospitalization, and clinical outcomes. Results In total, 45 AML patients with available data were admitted to ICU. Mean (SD) age was 54.8 (13.1) years and 28.9% were female. Primary diagnoses were sepsis (32.6%) and respiratory failure (37.3%). Mean (SD) APACHE II score was 30.3 (10.3), SOFA score 12.6 (4.0) with 62.2% receiving mechanical ventilation, 55.6% vasoactive therapy, and 26.7% renal replacement therapy. Crude in-hospital, 90-day and 1-year mortality was 44.4%, 51.1% and 71.1%, respectively. AML cases had significantly higher adjusted-hazards of death (HR 2.23; 95% CI, 1.38-3.60, p = 0.001) compared to both non-AML ICU controls (HR 1.69; 95% CI, 1.11-2.58, p = 0.02) and hospitalized AML controls (OR 1.0, reference variable). Factors associated with ICU mortality by univariate analysis included older age, AML subtype, higher baseline SOFA score, no change or an increase in early SOFA score, shock, vasoactive therapy and mechanical ventilation. Active chemotherapy in ICU was associated with lower mortality. Conclusions AML patients may represent a minority of all critically ill admissions; however, are not uncommonly supported in ICU. These AML patients are characterized by high illness severity, multi-organ dysfunction, and high treatment intensity and have a higher risk of death when compared with matched hospitalized AML or non-AML ICU controls. The absence of early improvement in organ failure may be a useful predictor for mortality for AML patients admitted to ICU.

To the Editor, Patients with a mediastinal mass are at risk of respiratory impairment, especially when general anesthesia is induced. Circulatory collapse may also occur because of a decrease in venous return. These effects might be accentuated when the physiologic changes of pregnancy are present. We report the case of a parturient with a mediastinal mass who presented for Cesarean delivery. The patient has provided written consent for publication of this report. A 24-yr-old G2P1 female at 39 weeks gestation presented for a repeat elective Cesarean delivery. At initial evaluation, she was dyspneic with pulsus paradoxus and a loud murmur. A transthoracic echocardiogram showed elevated right ventricular (RV) and pulmonary artery (PA) pressures, a left ventricular ejection fraction [ 65%, and a pericardial effusion requiring urgent ultrasound-guided pericardiocentesis. A chest x-ray showed a widened mediastinum with tracheal and bronchial shift. A computed tomography scan (Figure) confirmed the presence of an anterior-superior mediastinal mass (14 x 11 x 12 cm) encasing the aorta and the PA, with obliteration of the superior vena cava (SVC) and mass effect on the trachea and bronchus. The mediastinal mass was thought to be most consistent with a lymphoma. Plans were made for the patient to be transferred to the local heart institute following a five-day course of methylprednisolone 500 mg iv daily to shrink the mass. At the heart institute, she was scheduled to undergo Cesarean delivery with cardiopulmonary bypass (CPB) backup. Two days after admission, the patient went into spontaneous labour and was transported to the heart institute for urgent Cesarean delivery. An epidural anesthetic was deemed the safest option, allowing for spontaneous ventilation, thereby avoiding collapse of the mediastinal mass and a potentially difficult obstetrical airway. Left radial arterial and upper extremity intravenous catheters were in place, and a large-bore intravenous catheter was placed in the lower extremity. After insertion of an epidural catheter at the L2-L3 interspace, the patient was placed in a left lateral position with a 45 horizontal tilt. The catheter was then injected with 2% lidocaine 12 mL and 8.4% bicarbonate 1 mL. The cardiac surgeon placed left femoral CPB guidewires, a right femoral arterial line, and a Cordis venous line in preparation for CPB if needed. A vigorous baby boy was delivered. Throughout the procedure, 2L of crystalloid was infused, and phenylephrine was titrated at 100-500 lg min to maintain a mean arterial pressure within 10% of baseline. After delivery, an oxytocin infusion was started, with the addition of norepinephrine 0.010.15 lg kg min to maintain hemodynamic stability. A. L. Roze des Ordons, MD J. Lee, MD L. Scheelar, MD B. Achen, MD J. Taam, MD Department of Anesthesia and Pain Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada