Peter Dodek

University of British Columbia - Vancouver, Vancouver, British Columbia, Canada

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Publications (201)994.72 Total impact

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    ABSTRACT: Very elderly persons admitted to ICUs are at high risk of death. To document life-sustaining interventions (mechanical ventilation, vasopressors, renal replacement therapy) provided in the ICU and outcomes of care. Multicenter, prospective cohort study. ICUs of 24 Canadian hospitals. Patients 80 years old or older admitted to the ICU. None. One thousand six hundred seventy-one patients were included. The average age of the cohort was 85 years (range, 80-100 yr). Median total length of stay in ICU was 4 days (interquartile range, 2-8 d) and in hospital was 17 days (interquartile range, 8-33 d). Of all patients included, 502 (30%) stayed in ICU for 7 days or more and 344 (21%) received some form of life-sustaining treatment for at least 7 days. ICU and hospital mortality were 22% and 35%, respectively. For nonsurvivors, the median time from ICU admission to death was 10 days (interquartile range, 3-20 d). Of those who died (n = 5 85), 289 (49%) died while receiving mechanical ventilation, vasopressors, or dialysis. The presence of frailty or advance directives had little impact on limiting use of life-sustaining treatments or shortening the time from admission to death. In this multicenter study, one third of very elderly ICU patients died in hospital, many after a prolonged ICU stay while continuing to receive aggressive life-sustaining interventions. These findings raise questions about the use of critical care at the end of life for the very elderly.
    Critical care medicine 04/2015; DOI:10.1097/CCM.0000000000001024 · 6.15 Impact Factor
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    ABSTRACT: Bacteremia is a leading cause of mortality and morbidity in critically ill adults. No previous randomized controlled trials have directly compared shorter versus longer durations of antimicrobial treatment in these patients. This is a multicenter pilot randomized controlled trial in critically ill patients with bacteremia. Eligible patients will be adults with a positive blood culture with pathogenic bacteria identified while in the intensive care unit. Eligible, consented patients will be randomized to either 7 days or 14 days of adequate antimicrobial treatment for the causative pathogen(s) detected on blood cultures. The diversity of pathogens and treatment regimens precludes blinding of patient and clinicians, but allocation concealment will be extended to day 7 and outcome adjudicators will be blinded. The primary outcome for the main trial will be 90-day mortality. The primary outcome for the pilot trial is feasibility defined by (i) rate of recruitment exceeding 1 patient per site per month and (ii) adherence to treatment duration protocol ≥ 90%. Secondary outcomes include intensive care unit, hospital and 90-day mortality rates, relapse rates of bacteremia, antibiotic-related side effects and adverse events, rates of Clostridium difficile infection, rates of secondary infection or colonization with antimicrobial resistant organisms, ICU and hospital lengths of stay, mechanical ventilation and vasopressor duration in intensive care unit, and procalcitonin levels on the day of randomization, and day 7, 10 and 14 after the index blood culture. The BALANCE pilot trial will inform the design and execution of the subsequent BALANCE main trial, which will evaluate shorter versus longer duration treatment for bacteremia in critically ill patients, and thereby provide an evidence basis for treatment duration decisions for these infections. The Pilot Trial was registered on 26 September 2014. NCT02261506 .
    Trials 04/2015; 16(1):173. DOI:10.1186/s13063-015-0688-z · 2.12 Impact Factor
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    ABSTRACT: Intensive Care Units (ICUs) provide life-supporting treatment; however, resources are limited, so demand may exceed supply in the event of pandemics, environmental disasters, or in the context of an aging population. We hypothesized that comprehensive national data on ICU resources would permit a better understanding of regional differences in system capacity. After the 2009-2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group surveyed all acute care hospitals in Canada to assess ICU capacity. Using a structured survey tool administered to physicians, respiratory therapists and nurses, we determined the number of ICU beds, ventilators, and the ability to provide specialized support for respiratory failure. We identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for critically ill patients. Twenty-two hospitals had an ICU that routinely cared for children; 15 had dedicated pediatric ICUs. Per 100,000 population, there was substantial variability in provincial capacity, with a mean of 0.9 hospitals with ICUs (provincial range 0.4-2.8), 10 ICU beds capable of providing mechanical ventilation (provincial range 6-19), and 15 invasive mechanical ventilators (provincial range 10-24). There was only moderate correlation between ventilation capacity and population size (coefficient of determination (R(2)) = 0.771). ICU resources vary widely across Canadian provinces, and during times of increased demand, may result in geographic differences in the ability to care for critically ill patients. These results highlight the need to evolve inter-jurisdictional resource sharing during periods of substantial increase in demand, and provide background data for the development of appropriate critical care capacity benchmarks.
    Critical care (London, England) 04/2015; 19(1):133. DOI:10.1186/s13054-015-0852-6
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    ABSTRACT: Little is known about the perspectives and experiences of family members of very elderly patients who are admitted to the intensive care unit. To describe family members' perspectives about care provided to very elderly critically ill patients. Multicenter, prospective, cohort study. In total, 535 family members of patients aged 80 years or older admitted to 22 intensive care units for more than 24 h. Family members reported that the "patient be comfortable and suffer as little as possible" was their most important value and "the belief that life should be preserved at all costs" was their least important value considered in making treatment decisions. Most family members (57.9%) preferred that life support be used for their family member, whereas 24.1% preferred comfort measures only, and 14.4% were unsure of their treatment preferences. Only 57.3% reported that a doctor had talked to them about treatment options for the patient. Overall, 29.7% of patients received life-sustaining treatments for more than 7 days and 50.3% of these died in hospital. Families were most satisfied with the skill and competency of nurses and least satisfied with being included and supported in the decision-making process and with their sense of control over the patient's care. There is incongruity between family values and preferences for end-of-life care and actual care received for very elderly patients who are admitted to the intensive care unit. Deficiencies in communication and decision-making may be associated with prolonged use of life-sustaining treatments in very elderly critically ill patients, many of whom ultimately die. © The Author(s) 2015.
    Palliative Medicine 02/2015; DOI:10.1177/0269216314566060 · 2.85 Impact Factor
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    ABSTRACT: The goal of end-of-life (EOL) communication and decision-making is to create a shared understanding about a person's values and treatment preferences that will lead to a plan of care that is consistent with these values and preferences. Improvements in communication and decision-making at the EOL have been identified as a high priority from a patient and family point of view. The purpose of this study was to develop quality indicators related to EOL communication and decision-making. We convened a multidisciplinary panel of experts to develop definitions, a conceptual framework of EOL communication and decision-making, and quality indicators using a modified Delphi method. We generated a list of potential items based on literature review and input from panel members. Panel members rated the items using a 7-point Likert scale (1=very little importance to 7=extremely important) over four rounds of review until consensus was achieved. Twenty-four of the 28 panel members participated in all four rounds of the Delphi process. The final list of quality indicators comprised 34 items, divided into the four categories of our conceptual framework: Advance care planning (eight items), Goals of care discussions (13 items), Documentation (five items), and Organization/System aspects (eight items). Eleven items were rated "extremely important" (median score). All items had a median score of 5 (moderately important) or greater. We have developed definitions, a conceptual framework, and quality indicators that researchers and health care decision-makers can use to evaluate and improve the quality of EOL communication and decision-making. Copyright © 2015 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.
    Journal of Pain and Symptom Management 01/2015; DOI:10.1016/j.jpainsymman.2014.12.007 · 2.74 Impact Factor
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    ABSTRACT: Venous thromboembolism (VTE) is a common complication of critical illness with important clinical consequences. The Prophylaxis for ThromboEmbolism in Critical Care Trial (PROTECT) is a multicenter, blinded, randomized controlled trial comparing the effectiveness of the two most common pharmocoprevention strategies, unfractionated heparin (UFH) and low molecular weight heparin (LMWH) dalteparin, in medical-surgical patients in the intensive care unit (ICU). E-PROTECT is a prospective and concurrent economic evaluation of the PROTECT trial. The primary objective of E-PROTECT is to identify and quantify the total (direct and indirect, variable and fixed) costs associated with the management of critically ill patients participating in the PROTECT trial, and, to combine costs and outcome results to determine the incremental cost-effectiveness of LMWH versus UFH, from the acute healthcare system perspective, over a data-rich time horizon of ICU admission and hospital admission. We derive baseline characteristics and probabilities of in-ICU and in-hospital events from all enrolled patients. Total costs are derived from centers, proportional to the numbers of patients enrolled in each country. Direct costs include medication, physician and other personnel costs, diagnostic radiology and laboratory testing, operative and non-operative procedures, costs associated with bleeding, transfusions and treatment-related complications. Indirect costs include ICU and hospital ward overhead costs. Outcomes are the ratio of incremental costs per incremental effects of LMWH versus UFH during hospitalization; incremental cost to prevent a thrombosis at any site (primary outcome); incremental cost to prevent a pulmonary embolism, deep vein thrombosis, major bleeding event or episode of heparin-induced thrombocytopenia (secondary outcomes) and incremental cost per life-year gained (tertiary outcome). Pre-specified subgroups and sensitivity analyses will be performed and confidence intervals for the estimates of incremental cost-effectiveness will be obtained using bootstrapping. This economic evaluation employs a prospective costing methodology concurrent with a randomized controlled blinded clinical trial, with a pre-specified analytic plan, outcome measures, subgroup and sensitivity analyses. This economic evaluation has received only peer-reviewed funding and funders will not play a role in the generation, analysis or decision to submit the manuscripts for publication.Trial registration: Identifier: NCT00182143. Date of registration: 10 September 2005.
    Trials 12/2014; 15(1):502. DOI:10.1186/1745-6215-15-502 · 2.12 Impact Factor
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    ABSTRACT: The aim of this study was to determine the attributable length of stay and mortality due to bleeding as a complication of therapeutic anticoagulation in intensive care unit (ICU) patients. Charts of patients from 7 ICUs in British Columbia were screened daily for the occurrence of major bleeding while receiving therapeutic heparin. To determine attributable length of stay and mortality, a matched and unmatched cohort design as well as multivariate analysis were used. We included only patients who were started on anticoagulation on or after day 2 in the ICU. Between 2006 and 2009, a total of 868 patients were started on therapeutic anticoagulation and 139 bled. One hundred five patients who bled were matched to 261 controls. In the matched analysis after adjustment for potential confounders, each bleeding event was associated with an increase in ICU length of stay (hazard ratio for ICU discharge, 0.47; 95% confidence interval, 0.38-0.57; attributable ICU length of stay of 13.8 days). Hospital length of stay was also significantly increased. In the entire cohort analysis, bleeding was also associated with increased ICU length of stay (hazard ratio, 0.59; confidence interval, 0.48-0.72; attributable stay of 6.1 days) and increased hospital length of stay. In both analyses, bleeding was not associated with hospital mortality. Major bleeding while receiving anticoagulation is associated with a substantial increase in ICU and hospital length of stay.
    Journal of Patient Safety 12/2014; DOI:10.1097/PTS.0000000000000149 · 0.88 Impact Factor
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    ABSTRACT: Delirium is common during critical illness and associated with adverse outcomes. We compared characteristics and outcomes of delirious and nondelirious patients enrolled in a multicenter trial comparing protocolized sedation with protocolized sedation plus daily sedation interruption. Randomized trial. Sixteen North American medical and surgical ICUs. Four hundred thirty critically ill, mechanically ventilated adults. All patients had hourly titration of opioid and benzodiazepine infusions using a validated sedation scale. For patients in the interruption group, infusions were resumed, if indicated, at half of previous doses. Delirium screening occurred daily; positive screening was defined as an Intensive Care Delirium Screening Checklist score of 4 or more at any time. Delirium was diagnosed in 226 of 420 assessed patients (53.8%). Coma was identified in 32.7% of delirious compared with 22.7% of nondelirious patients (p = 0.03). The median time to onset of delirium was 3.5 days (interquartile range, 2-7), and the median duration of delirium was 2 days (interquartile range, 1-4). Delirious patients were more likely to be male (61.1% vs 46.6%; p = 0.005), have a surgical/trauma diagnosis (21.2% vs 11.0%; p = 0.030), and history of tobacco (31.5% vs 16.2%; p = 0.002) or alcohol use (34.6% vs 20.9%; p = 0.009). Patients with positive delirium screening had longer duration of ventilation (13 vs 7 d; p < 0.001), ICU stay (12 vs 8 d; p < 0.0001), and hospital stay (24 vs 15 d; p < 0.0001). Delirious patients were more likely to be physically restrained (86.3% vs 76.7%; p = 0.014) and undergo tracheostomy (34.6% vs 15.5%; p < 0.0001). Antecedent factors independently associated with delirium onset were restraint use (hazard ratio, 1.87; 95% CI, 1.33-2.63; p = 0.0003), antipsychotic administration (hazard ratio, 1.67; 95% CI, 1.005-2.767; p = 0.047), and midazolam dose (hazard ratio, 0.998; 95% CI, 0.997-1.0; p = 0.049). There was no difference in delirium prevalence or duration between the interruption and control groups. In mechanically ventilated adults, delirium was common and associated with longer duration of ventilation and hospitalization. Physical restraint was most strongly associated with delirium.
    Critical Care Medicine 12/2014; 43(3). DOI:10.1097/CCM.0000000000000727 · 6.15 Impact Factor
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    ABSTRACT: To identify risk factors for failure of anticoagulant thromboprophylaxis in critically ill patients in the ICU. Multivariable regression analysis of thrombosis predictors from a randomized thromboprophylaxis trial. Sixty-seven medical-surgical ICUs in six countries. Three thousand seven hundred forty-six medical-surgical critically ill patients. All patients received anticoagulant thromboprophylaxis with low-molecular-weight heparin or unfractionated heparin at standard doses. Independent predictors for venous thromboembolism, proximal leg deep vein thrombosis, and pulmonary embolism developing during critical illness were assessed. A total of 289 patients (7.7%) developed venous thromboembolism. Predictors of thromboprophylaxis failure as measured by development of venous thromboembolism included a personal or family history of venous thromboembolism (hazard ratio, 1.64; 95% CI, 1.03-2.59; p = 0.04) and body mass index (hazard ratio, 1.18 per 10-point increase; 95% CI, 1.04-1.35; p = 0.01). Increasing body mass index was also a predictor for developing proximal leg deep vein thrombosis (hazard ratio, 1.25; 95% CI, 1.06-1.46; p = 0.007), which occurred in 182 patients (4.9%). Pulmonary embolism occurred in 47 patients (1.3%) and was associated with body mass index (hazard ratio, 1.37; 95% CI, 1.02-1.83; p = 0.035) and vasopressor use (hazard ratio, 1.84; 95% CI, 1.01-3.35; p = 0.046). Low-molecular-weight heparin (in comparison to unfractionated heparin) thromboprophylaxis lowered pulmonary embolism risk (hazard ratio, 0.51; 95% CI, 0.27-0.95; p = 0.034) while statin use in the preceding week lowered the risk of proximal leg deep vein thrombosis (hazard ratio, 0.46; 95% CI, 0.27-0.77; p = 0.004). Failure of standard thromboprophylaxis using low-molecular-weight heparin or unfractionated heparin is more likely in ICU patients with elevated body mass index, those with a personal or family history of venous thromboembolism, and those receiving vasopressors. Alternate management or incremental risk reduction strategies may be needed in such patients.
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    ABSTRACT: Because of previously documented health care disparities, we hypothesized that English-speaking Latino parents/caregivers would be less satisfied with care and decision making than English-speaking non-Latino white (NLW) parents/caregivers. An intensive care unit (ICU) family satisfaction survey, Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version), was completed by English-speaking parents/caregivers of children in a cardiothoracic ICU at a university-affiliated children's hospital in 2011. English-speaking NLW and Latino parents/caregivers of patients, younger than 18 years, admitted to the ICU were approached to participate on hospital day 3 or 4 if they were at the bedside for greater than or equal to 2 days. Analysis of variance, χ(2), and Student t tests were used. Cronbach αs were calculated. Fifty parents/caregivers completed the survey in each group. Latino parents/caregivers were younger, more often mothers born outside the United States, more likely to have government insurance or no insurance, and had less education and income. There were no differences between the groups' mean overall satisfaction scores (92.6 ± 8.3 and 93.0 ± 7.1, respectively; P = .80). The Family Satisfaction in the Intensive Care Unit Survey (pediatric, 24 question version) showed high internal consistency reliability (α = .95 and .91 for NLW and Latino groups, respectively). No disparities in ICU satisfaction with care and decision making between English-speaking NLW and Latino parents/caregivers were found. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Critical Care 12/2014; 30(2). DOI:10.1016/j.jcrc.2014.11.009 · 2.19 Impact Factor
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    ABSTRACT: Many healthcare workers are concerned about the provision of nonbeneficial treatment in the acute care setting. We sought to explore the perceptions of acute care practitioners to determine whether they perceived nonbeneficial treatment to be a problem, to generate an acceptable definition of nonbeneficial treatment, to learn about their perceptions of the impact and causes of nonbeneficial treatment, and the ways that they feel could reduce or resolve nonbeneficial treatment.
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    ABSTRACT: The guideline-recommended elements to include in discussions about goals of care with patients with serious illness are mostly based on expert opinion. We sought to identify which elements are most important to patients and their families.
    Canadian Medical Association Journal 11/2014; 186(18). DOI:10.1503/cmaj.140673 · 5.81 Impact Factor
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    ABSTRACT: Venous thromboembolism (VTE) is a common complication of acute illness, and its prevention is a ubiquitous aspect of inpatient care. A multicenter blinded, randomized trial compared the effectiveness of the most common pharmocoprevention strategies, unfractionated heparin (UFH) and the low-molecular-weight heparin (LMWH) dalteparin, finding no difference in the primary end point of leg deep-vein thrombosis but a reduced rate of pulmonary embolus and heparin-induced thrombocytopenia among critically ill medical-surgical patients who received dalteparin.
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    ABSTRACT: Within a multicenter randomized trial comparing protocolized sedation with protocolized sedation plus daily interruption (DI), we sought perspectives of intensive care unit (ICU) clinicians regarding each strategy. At 5 ICUs, we administered a questionnaire daily to nurses and physicians, asking whether they liked using the assigned strategy, reasons for their responses, and concerns regarding DI. A total of 301 questionnaires were completed, for 31 patients (15 protocol only and 16 DI); 117 (59 physicians and 58 nurses) were the first questionnaire completed by that health care provider for that patient and were included in analyses. Most respondents liked using the assigned strategy (81% protocol only and 81% DI); more physicians than nurses liked DI (100% vs 61%; P < .001). Most common reasons for liking the assigned sedation strategy were better neurologic assessment (70% DI), ease of use (58% protocol only), and improved patient outcomes (51% protocol only and 44% DI). Only 19% of clinicians disliked the assigned sedation strategy (equal numbers for protocol only and DI). Respondents' concerns during DI were respiratory compromise (61%), pain (48%), agitation (45%), and device removal (26%). More questionnaires from nurses than physicians expressed concerns about DI. Most respondents liked both sedation strategies. Nurses and physicians had different preferences and rationales for liking or disliking each strategy. Copyright © 2014 Elsevier Inc. All rights reserved.
    Journal of Critical Care 10/2014; 30(2). DOI:10.1016/j.jcrc.2014.10.021 · 2.19 Impact Factor
  • Peter M Dodek
    American Journal of Respiratory and Critical Care Medicine 09/2014; 190(6):601-603. DOI:10.1164/rccm.201401-0132ED · 11.99 Impact Factor
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    ABSTRACT: The aims of this study are to assess adherence to the Brain Trauma Foundation (BTF) cerebral perfusion pressure (CPP) guidelines and to determine if adherence is associated with mortality in patients who have a severe traumatic brain injury.
    Journal of Critical Care 07/2014; 30(1). DOI:10.1016/j.jcrc.2014.07.026 · 2.19 Impact Factor
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    ABSTRACT: Objective: Fluids and vasoactive agents are both used to treat septic shock, but little is known about how they interact or the optimal way to administer them. We sought to determine how hospital mortality was influenced by combined use of these two treatments. Design: Retrospective evaluation using multivariable logistic regression to evaluate the association between hospital mortality and categorical variables representing initiation of vasoactive agents and volumes of IV fluids given 0-1, 1-6, and 6-24 hours after onset, including interactions and adjusting for potential confounders. Setting: ICUs of 24 hospitals in 3 countries. Patients: Two thousand eight hundred forty-nine patients who survived more than 24 hours after after onset of septic shock, admitted between 1989 and 2007. Interventions: None. Measurements and Main Results: Fluids and vasoactive agents had strong, interacting associations with mortality (p < 0.0001). Mortality was lowest when vasoactive agents were begun 1-6 hours after onset, with more than 1 L of fluids in the initial hour after shock onset, more than 2.4 L from hours 1-6, and 1.6-3.5 L from 6 to 24 hours. The lowest mortality rates were associated with starting vasoactive agents 1-6 hours after onset. Conclusions: The focus during the first hour of resuscitation for septic shock should be aggressive fluid administration, only thereafter starting vasoactive agents, while continuing aggressive fluid administration. Starting vasoactive agents in the initial hour may be detrimental, and not all of that association is due to less fluids being given with such early initiation of vasoactive agents.
    Critical Care Medicine 07/2014; 42(10). DOI:10.1097/CCM.0000000000000520 · 6.15 Impact Factor
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    ABSTRACT: Given conflicting data and current guidelines, low-dose corticosteroids are often used in the treatment of septic shock. To evaluate the therapeutic benefit of early low-dose corticosteroid in patients with septic shock.
    Critical Care Medicine 07/2014; 42(11). DOI:10.1097/CCM.0000000000000518 · 6.15 Impact Factor
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    ABSTRACT: Background Sleep deprivation leads to reduced vigilance and potentially impairs work performance. Nurses may work long shifts that may contribute to sleep deprivation. Objective To assess how nurses' sleep patterns are affected by work schedules and other factors. Methods Between October 2009 and June 2010, a total of 20 critical care nurses completed daily sleep and activity logs and a demographic survey and wore an actigraph to objectively measure sleep time for 14 days. Results In a multivariate model with controls for repeated measures, mean sleep time between consecutive work shifts was short: 6.79 hours between 2 day shifts and 5.68 hours between 2 night shifts (P =.01). Sleep time was much greater between days when no shifts were worked (8.53 hours), consistent with catch-up sleep during these times. Every minute of 1-way commuting time was associated with a reduction of sleep time by 0.84 minutes. Conclusion Critical care nurses obtain reduced amounts of sleep between consecutive work shifts, particularly between consecutive night shifts. Whether this degree of sleep deprivation adversely affects patients' safety needs further study.
    American Journal of Critical Care 07/2014; 23(4):290-5. DOI:10.4037/ajcc2014876 · 1.60 Impact Factor
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    ABSTRACT: Controversies regarding the process and timing of the determination of death for controlled organ donation after circulatory death persist. This study assessed the feasibility of conducting a prospective, observational study of continuous monitoring of vital signs for 30 minutes after the clinical determination of death in five Canadian ICUs. Waveform data were analyzed. Prospective observational cohort study. One pediatric and four adult Canadian ICUs. One month of age or older, admitted to the ICU, and for whom a consensual decision to withdraw life-sustaining therapies had been made, with an anticipation of imminent death. None. Invasive arterial blood pressure, electrocardiogram, and oxygen saturation plethysmography activity were recorded and reviewed for 30 minutes after declaration of death. Feasibility was assessed (recruitment, consent rate, protocol compliance, and staff satisfaction). Of 188 subjects screened over 16 months, 41 subjects were enrolled (87% consent rate). Data collection was complete for 30 subjects (73% protocol compliance). In four subjects, arterial blood pressure resumed following cessation of activity. The longest period of cessation of arterial blood pressure before resumption was 89 seconds. The duration of resumed activity ranged from 1 to 172 seconds. No cases of sustained resumption of arterial blood pressure activity were recorded, and no instances of clinical autoresuscitation were reported. In nearly all patients (27 of 30), electrocardiogram activity continued after the disappearance of arterial blood pressure. This is the first observational study to prospectively collect waveform data for 30 minutes after the declaration of death. A future larger study may support initial data suggesting that circulatory function does not resume after more than 89 seconds of absence. Furthermore, persistence of cardiac electrical activity with the documented absence of circulation may not be relevant to declaration of death.
    Critical care medicine 05/2014; 42(11). DOI:10.1097/CCM.0000000000000417 · 6.15 Impact Factor

Publication Stats

7k Citations
994.72 Total Impact Points


  • 1991–2015
    • University of British Columbia - Vancouver
      • • Division of Critical Care Medicine
      • • Centre for Health Evaluation & Outcome Sciences
      Vancouver, British Columbia, Canada
  • 1988–2015
    • St. Paul's Hospital
      Saskatoon, Saskatchewan, Canada
  • 2008–2014
    • Providence Health Care
      Vancouver, British Columbia, Canada
  • 2007–2012
    • University of Toronto
      • Division of Critical Care Medicine
      Toronto, Ontario, Canada
  • 2004–2011
    • Dalhousie University
      • Department of Medicine
      Halifax, Nova Scotia, Canada
  • 2009
    • Health Sciences Centre Winnipeg
      Winnipeg, Manitoba, Canada
  • 2002–2009
    • Queen's University
      • • Department of Oncology
      • • Department of Medicine
      Kingston, Ontario, Canada
  • 2004–2007
    • Royal Columbian Hospital
      نيو ويستمينيستر، كولومبيا البريطانية, British Columbia, Canada
  • 2003–2006
    • McMaster University
      • Department of Medicine
      Hamilton, Ontario, Canada
  • 2002–2003
    • Kingston General Hospital
      Kingston, Ontario, Canada
  • 1999
    • University of Victoria
      • School of Health Information Science
      Victoria, British Columbia, Canada
  • 1990
    • University of California, Los Angeles
      Los Ángeles, California, United States