-
François Lamontagne,
Hector Quiroz Martinez, Neill K J Adhikari,
Deborah J Cook,
Karen K Y Koo,
François Lauzier,
Alexis F Turgeon,
Michelle E Kho,
Karen E A Burns,
Clarence Chant,
Rob Fowler,
Ivor Douglas,
Yannick Poulin,
Karen Choong,
Niall D Ferguson,
Maureen O Meade
[show abstract]
[hide abstract]
ABSTRACT: OBJECTIVE: The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of corticosteroids in clinical practice. DESIGN: Self-administered paper survey. POPULATION: Intensivists in academic hospitals with clinical trial expertise in critical illness. MEASUREMENTS: We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids. MAIN RESULTS: Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressor-refractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroid-responsive illnesses (85%). CONCLUSIONS: Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.
Canadian Anaesthetists? Society Journal 04/2013; · 2.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: Neurologic disability is common after aneurysmal subarachnoid hemorrhage (aSAH). Our objective was to systematically review the prophylactic use of magnesium to improve neurologic outcomes in these patients. METHODS: We searched MEDLINE, EMBASE, CINAHL, and Cochrane Central Register of Controlled Trials to June 2012 for randomized and quasi-randomized controlled trials of intravenous magnesium in adults after aSAH, given before radiologic vasospasm or delayed cerebral ischemia (DCI) and compared with any control group. Two reviewers independently extracted data on study population, interventions, and outcomes (good neurologic outcome [primary outcome], cerebral infarction, DCI, radiographic vasospasm, mortality, adverse events). Analyses used random-effects models. RESULTS: Of 702 citations, 13 trials (n = 2401) met the selection criteria. Meta-analyses showed that magnesium did not increase the probability of good neurologic outcome (risk ratio [RR], 1.02; 95% confidence interval [CI], 0.97-1.07; P = .49; 12 trials, n = 2345) or decrease the risks of cerebral infarction (RR, 0.69; 95% CI, 0.46-1.05; P = .08; 5 trials, n = 572), radiographic vasospasm (RR, 0.86; 95% CI, 0.71-1.04; P = .13; 7 trials, n = 438), or mortality (RR, 0.98; 95% CI, 0.80-1.20; P = .86; 11 trials, n = 2092). Magnesium did reduce the risk of DCI (RR, 0.73; 95% CI, 0.56-0.96; P = .02; 10 trials, n = 1095). Data on adverse events were generally sparse. CONCLUSIONS: Despite decreasing the incidence of DCI in patients with aSAH, prophylactic intravenous magnesium does not improve neurologic outcome or decrease cerebral infarction, radiographic vasospasm, or mortality.
Journal of critical care 11/2012; · 2.13 Impact Factor
-
Ayodele Odutayo, Neill K J Adhikari,
James Barton,
Karen E A Burns,
Jan O Friedrich,
David Klein,
Stephen Lapinsky,
Sasha Litwin,
Aleksander Meret,
Rahim Moineddin,
Bonnie Richardson,
Robert Richardson,
Alina Zaltzman,
Michelle Hladunewich,
Ron Wald
[show abstract]
[hide abstract]
ABSTRACT: PURPOSE: We undertook this study to characterize the epidemiology of acute kidney injury (AKI) in Canadian critical care units. We aimed to identify predictors of mortality for patients diagnosed with AKI. METHODS: We conducted a prospective cohort study of consecutive patients admitted to critical care units at five Canadian hospitals over a 30-day period. Each patient was followed until hospital discharge or for a maximum of 30 days. The serum creatinine criteria for the Acute Kidney Injury Network (AKIN-SCr) system were used to identify, classify, and characterize patients who developed AKI. We used multivariable logistic regression to predict 30-day mortality among patients with AKI. RESULTS: We identified 603 patients, 161 (26.7%) of whom developed AKI. Compared to patients without AKI, those with AKI were more likely to die (29.2% vs 8.6%, P < 0.001). The risk of death increased with increasing AKIN-SCr stage (P < 0.001). In all, 19 patients (11.8% of those with AKI) commenced dialysis a median of one day (interquartile range, one to two days) after AKI diagnosis. At AKI diagnosis, the blood urea nitrogen (BUN) level (adjusted odds ratio [OR] 1.68, 95% confidence interval [CI] 1.01 to 2.79/10 mmol·L(-1)) and serum bicarbonate (adjusted OR 0.88, 95% CI 0.81 to 0.95/1 mmol·L(-1)) were associated with 30-day mortality and predicted death with an area under the receiver-operating characteristic curve of 0.79 (95% CI 0.71 to 0.86). CONCLUSIONS: Acute kidney injury is a common complication of critical illness in Canada. The development of even the mildest stage of AKI is associated with a substantially higher risk of death. At AKI diagnosis, routine clinical data may be helpful for predicting adverse outcomes.
Canadian Anaesthetists? Society Journal 07/2012; 59(10):934-942. · 2.31 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Meta-analyses pooling continuous outcomes can use mean differences (MD), standardized MD (MD in pooled standard deviation units, SMD), or ratio of arithmetic means (RoM). Recently, ratio of geometric means using ad hoc (RoGM (ad hoc) ) or Taylor series (RoGM (Taylor) ) methods for estimating variances have been proposed as alternative effect measures for skewed continuous data. Skewed data are suggested for summary measures of clinical parameters restricted to positive values which have large coefficients of variation (CV). Our objective was to compare performance characteristics of RoGM (ad hoc) and RoGM (Taylor) to MD, SMD, and RoM. We used empiric data from systematic reviews reporting continuous outcomes and selected from each the meta-analysis with the most and at least 5 trials (Cochrane Database [2008, Issue 1]). We supplemented this with simulations conducted with representative parameters. Pooled results were calculated using each effect measure. Of the reviews, 232/5053 met the inclusion criteria. Empiric data and simulation showed that RoGM (ad hoc) exhibits more extreme treatment effects and greater heterogeneity than all other effect measures. Compared with MD, SMD, and RoM, RoGM (Taylor) exhibits similar treatment effects, more heterogeneity when CV ≤0.7, and less heterogeneity when CV > 0.7. In conclusion, RoGM (Taylor) may be considered for pooling continuous outcomes in meta-analysis when data are skewed, but RoGM (ad hoc) should not be used. However, clinicians' lack of familiarity with geometric means combined with acceptable performance characteristics of RoM in most situations suggests that RoM may be the preferable ratio method for pooling continuous outcomes in meta-analysis.
Statistics in Medicine 03/2012; 31(17):1857-86. · 1.88 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: There are minimal data available on critical care case-mix, care processes and outcomes in lower and middle income countries (LMICs). The objectives of this paper were to gather data in the Solomon Islands in order to gain a better understanding of common presentations of critical illness, available hospital resources, and what resources would be helpful in improving the care of these patients in the future.
This study used a mixed methods approach, including a cross sectional survey of respondents' opinions regarding critical care needs, ethnographic information and qualitative data.
The four most common conditions leading to critical illness in the Solomon Islands are malaria, diseases of the respiratory system including pneumonia and influenza, diabetes mellitus and tuberculosis. Complications of surgery and trauma less frequently result in critical illness. Respondents emphasised the need for basic critical care resources in LMICs, including equipment such as oximeters and oxygen concentrators; greater access to medications and blood products; laboratory services; staff education; and the need for at least one national critical care facility.
A large degree of critical illness in LMICs is likely due to inadequate resources for primary prevention and healthcare; however, for patients who fall through the net of prevention, there may be simple therapies and context-appropriate resources to mitigate the high burden of morbidity and mortality. Emphasis should be on the development and acquisition of simple and inexpensive tools rather than complicated equipment, to prevent critical care from unduly diverting resources away from other important parts of the health system.
BMC International Health and Human Rights 03/2012; 12:1. · 1.44 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Interest in the global burden of critical illness is growing, but comprehensive data to describe this burden and the resources available to provide care for critically ill patients are lacking.
Challenges to obtaining population-based global estimates of critical illness and resources to treat it include the syndrome-based definitions of critical illness, incorrect equating of 'critical illness' with 'admission to an intensive care unit', lack of reliable case ascertainment in administrative data, and short prodrome and high mortality of critical illness, limiting the number of prevalent cases. Modeling techniques will be required to estimate the burden of critical illness and disparities in access to critical care using existing data sources. Demand for critical care is likely to increase, related to urbanization, an aging demographic, and the ongoing wars, disasters, and pandemics, whereas economic crises will likely decrease the ability to pay for it.
Major unexplored research and public health questions remain unanswered regarding the worldwide burden of critical illness, variation in resources available for treatment, and strategies to prevent and treat critical illness that are broadly effective and feasible.
Current opinion in critical care 12/2011; 17(6):620-5. · 2.67 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Survivors of ARDS report depressive symptoms and memory complaints, the prevalence of which after 5 years is unknown.
We administered instruments assessing symptoms of depression (Beck Depression Inventory II [BDI-II]) and memory complaints (Memory Assessment Clinics Self-Rating Scale [MAC-S]) to 64 survivors of ARDS from four university-affiliated ICUs 5 years after ICU discharge. We compared BDI-II scores to quality of life (Medical Outcomes Study 36-Item Short Form [SF-36]) mental health domains (role emotional, mental health, mental component summary), compared BDI-II and MAC-S scores to earlier scores (median, 22 months postdischarge), and examined return to work.
Forty-three (67.2%), 46 (71.9%), and 38 (59.4%) patients fully completed the BDI-II, MAC-S ability subscale, and MAC-S frequency of occurrence subscale, respectively. Responders were young (median, 48 years; first-third quartile [Q1-Q3], 39-61 years) with high illness severity. The median BDI-II score was 10 (Q1-Q3, 3-18); eight of 43 (18.6%) had moderate to severe depressive symptoms compared with 14 of 43 (32.6%) earlier (P = .15, n = 38 with paired data). Median MAC-S ability and MAC-S frequency scores were 81 (Q1-Q3, 57-92) and 91.5 (Q1-Q3, 76-105), respectively, similar to earlier scores (P = .67 and P = .64, respectively); 0% to 4.3% scored > 2 SDs below population norms. Higher BDI-II score was predicted by higher earlier BDI-II score, slower recovery of organ function, and longer duration of mechanical ventilation and ICU stay. Higher MAC-S score was predicted by higher earlier MAC-S score. SF-36 mental health domain scores were very stable (P = .57-.83). BDI-II and SF-36 mental health domains were negatively correlated (Spearman coefficient, -0.50 to -0.82). Most patients returned to work regardless of depressive symptoms (minimal to mild, 31 of 35 [88.6%]; moderate to severe, five of eight [62.5%]; P = .12).
Compared with ∼ 2 years postdischarge from the ICU, depressive symptoms and memory complaints were similar at 5 years. Mental health domains of the SF-36 may not be sensitive to small changes in mood symptoms.
Chest 12/2011; 140(6):1484-93. · 5.25 Impact Factor
-
Neill K J Adhikari,
Abdel Bashir,
François Lamontagne,
Sangeeta Mehta,
Niall D Ferguson,
Qi Zhou,
Lori Hand,
Kasia Czarnecka,
Deborah J Cook,
John T Granton,
Jan O Friedrich,
Andreas Freitag,
Irene Watpool,
Maureen O Meade
[show abstract]
[hide abstract]
ABSTRACT: High-frequency oscillation is used for adults with acute lung injury/acute respiratory distress syndrome. Given the uncertain benefits, our objective was to describe contemporary patient selection, high-frequency oscillation utilization, and outcomes.
Utilization review.
Ten academic centers (Ontario, Canada; January 1, 2005-January 31, 2007).
We included 190 consecutive adults treated with high-frequency oscillation and retrospectively abstracted data on patient demographics, gas exchange, hemodynamics, settings during conventional ventilation and high-frequency oscillation, adjunctive therapies, and outcomes. We used logistic regression to explore associations with oxygenation response and hemodynamic and ventilatory complications (2 hrs after high-frequency oscillation initiation) and mortality. Continuous data are reported as mean (sd) or median (quartile 1, quartile 3).
None.
Patients (60.0% male; mean age, 52; sd 17) had predominantly acute lung injury/acute respiratory distress syndrome (89.8%) and were severely ill (mean Acute Physiology and Chronic Health Evaluation II score, 28; sd, 9) and hypoxemic (mean Pao2/Fio2, 80; sd, 42). High-frequency oscillation was started a median of 2 (1, 8) days after intubation and continued for a median of 3 (2, 7) days. During high-frequency oscillation, adjunctive treatments (neuromuscular blockade, 75.6%; recruitment maneuvers, 49.5%; nitric oxide, 34.0%; steroids, 63.1%) and new barotrauma or chest tube placement (23.5%) were common. Ten patients (5.3%) had technical complications; five required a new ventilator. Reasons for stopping high-frequency oscillation included death or withdrawal of life support (39.1%), significant improvement in respiratory failure (37.6%), and inadequate improvement (23.3%). One hundred and twenty-eight of 189 patients died in hospital. Most (62.5%) had a positive oxygenation response after 2 hrs of high-frequency oscillation (mean absolute increase in PaO₂/FiO₂, 22 [SD, 54]; 95% confidence interval of mean 14-31). A minority had lower PaO₂/FiO₂ (32.5%) or a hemodynamic (27.5%) or ventilatory (30.5%) complication. Older age, Acute Physiology and Chronic Health Evaluation II score, and Paco2 before high-frequency oscillation were independently associated with mortality.
Most patients treated with high-frequency oscillation have acute respiratory distress syndrome and severe hypoxemia that modestly improves 2 hrs after high-frequency oscillation application. However, oxygenation worsens in some patients, complications are common, and mortality is high.
Critical care medicine 07/2011; 39(12):2631-44. · 6.37 Impact Factor
-
Edward Etchells, Neill K J Adhikari,
Robert Wu,
Mark Cheung,
Sherman Quan,
Richard Mraz,
Brian Wong,
Ruxandra Pinto,
Rajin Mehta,
Dante Morra,
Robert Fowler,
William Sibbald,
Howard Abrams,
Peter G Rossos
[show abstract]
[hide abstract]
ABSTRACT: For patients with critical laboratory abnormalities, timely clinical alerts with decision support could improve management and reduce adverse events.
The authors developed a real-time clinical alerting system for critical laboratory abnormalities. The system sent alerts to physicians as text messages to a smartphone or alphanumeric pager. Decision support was available via smartphone or hospital intranet. The authors evaluated the system in a prospective controlled stepped-wedge study with blinded outcome assessment in general internal medicine units at two academic hospitals. The outcomes were the proportion of potential clinical actions that were actually completed in response to the alert, and adverse events (worsening of condition or complications related to treatment of the condition).
The authors evaluated 498 laboratory conditions on 271 patients. Overall, only 50% of potential clinical actions were carried out, and there were adverse clinical events within 48 h for 36% of the laboratory conditions. The median (IQR) proportion of potential clinical actions that were actually completed was 50% (33-75%) with alerting system on and 50% (33-100%) with alerting system off (p=0.94, Wilcoxon rank sum test). When the alerting system was on (n=164 alerts) there were 67 adverse events within 48 h of the alerts (42%). When the alerting system was off (n=334 alerts), there were 112 adverse events within 48 h (33%; difference: 9% higher with alerting system on, p=0.06).
The provision of real-time clinical alerts and decision support for critical laboratory abnormalities did not improve clinical management or decrease adverse events.
BMJ quality & safety 07/2011; 20(11):924-30.
-
[show abstract]
[hide abstract]
ABSTRACT: Meta-analyses of continuous outcomes typically use mean differences (MDs) or standardized mean differences (SMDs) (MD in pooled standard deviation units). Ratio of means (RoM) is an alternative effect measure that performs comparably in simulation. We compared treatment effects and heterogeneity for RoM, MD, and SMD using empiric data.
From the Cochrane Database (2008, issue 1), we included systematic reviews reporting continuous outcomes, selected the meta-analysis with the most (and ≥five) trials, and calculated MD (where possible), SMD, and RoM. For each pair of effect measures, we compared P-values separately for treatment effect and heterogeneity and assessed asymmetry of discordant pairs (statistically significant result for only one of two measures).
Two hundred thirty-two of 5,053 reviews were included. Measures demonstrated similar treatment effects, with ≤6% discordant pairs and no asymmetry. A 0.5 SMD increase corresponded to 22 (95% confidence interval: 19, 24)% increase using RoM. There was less heterogeneity in RoM vs. MD (n=143, P=0.007), SMD vs. RoM (n=232, P=0.005), and SMD vs. MD (n=143, P=0.004). Comparing discordant pairs, fewer meta-analyses showed significant heterogeneity with SMD vs. RoM (P=0.04), consistent with the known bias of SMD.
Empiric data from diverse meta-analyses demonstrate similar treatment effects and no large differences in heterogeneity of RoM compared with difference-based methods.
Journal of clinical epidemiology 05/2011; 64(5):556-64. · 2.96 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Reliance on third party consent for patients without decision-making capacity presents unique challenges for critical care research. We compared the attitudes and beliefs of Canadian research ethics boards (REBs) and intensive care unit researchers toward the use of various consent models for a low-risk randomized controlled trial.
Self-administered, scenario-based survey.
Sixty-two percent of eligible REBs (n = 83) and 78% of eligible researchers (n = 124) completed the questionnaire. The REBs were less comfortable endorsing alternative consent models when a substitute decision maker was unavailable, including consent provided by (a) the intensivist involved with the trial (2.0% vs 15.3%; P = .014), (b) the intensivist not involved with the trial (10.0% vs 36.7%; P = .001), (c) 2 physicians (the intensivist and another consultant, neither of whom is involved with the trial) (18.0% vs 54.1%; P < .001), and (d) 2 physicians involved neither with the trial nor the patient's care (10.2% vs 52.0%; P < .001). In similar circumstances, REBs were less comfortable approving both deferred (8.0% vs 43.3%; P < .001) and waived (4.1% vs 22.4%; P = .005) consent.
In this survey of scenarios involving low-risk critical care research, REBs were significantly more conservative in approving alternative consent models compared with investigators.
Journal of critical care 03/2011; 26(5):533.e11-22. · 2.13 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Medication-prescribing errors with adverse drug events impose substantial harms on patients and health systems. Medication errors resulting in preventable adverse drug events most commonly occur at the ordering stage. Electronic prescribing may prevent such errors but its impact has not been rigorously evaluated.
We conducted a pragmatic cluster randomized controlled trial in academic hospital ambulatory clinics to evaluate the effects of a commercially available electronic prescribing software system on total prescription error ratio. Secondary outcomes included the number of callbacks for clarification from community pharmacies to physicians' clinics.
Twenty-six physicians used the electronic prescribing system, writing 1980 prescriptions during 44 intervention weeks when the electronic prescribing system was available (7.6% of these were electronic, the remainder handwritten) and 973 prescriptions during 22 control weeks while the system was switched off (1.4% electronic, prescribed in the previous intervention week, but issued with delay). The total prescription error rate was 118/1980 (6.0%) in intervention weeks and 57/973 (5.9%) in control weeks (P = 0.91). During the intervention period more callbacks requesting clarification were made to clinic administrators (n = 83, 1.89 per week) than during control weeks (n = 32, 1.45 per week; P < 0.001).
Implementation of the electronic prescribing system had no impact on total prescription error, and increased the callback rate. In spite of intensive user support, few prescriptions in intervention weeks were made using the electronic system. Given the costs, training requirements, workflow redesigns and regulatory hurdles, additional evaluations of outpatient prescribing on clinically important outcomes are needed.
Journal of Evaluation in Clinical Practice 03/2011; 18(4):761-7. · 1.23 Impact Factor
-
Francois Lamontagne,
Deborah J Cook, Neill K J Adhikari,
Matthias Briel,
Mark Duffett,
Michelle E Kho,
Karen E A Burns,
Gordon Guyatt,
Alexis F Turgeon,
Qi Zhou,
Maureen O Meade
[show abstract]
[hide abstract]
ABSTRACT: Patients with septic shock often receive intravenous vasopressor infusions, with little evidence available to guide their titration. We surveyed Canadian intensivists to document self-reported vasopressor titration strategies for patients with septic shock.
We identified Canadian intensivists caring for adult patients by merging membership lists of 3 Canadian critical care associations. We invited respondents to complete a scenario-based questionnaire to understand triggers for vasopressor use, target blood pressure values, and the influence of chronic comorbidities and acute illnesses on vasopressor prescription.
Sixty-three percent of eligible intensivists completed our survey. Most respondents (82.6%) would frequently or always administer vasopressor therapy for isolated hypotension but not for other isolated signs of organ failure (such as elevated serum lactate or low urine output). Respondents defined low blood pressure using mean arterial pressure (83.7%) and aimed for higher values when resuscitating a patient with multiple organ failure. Chronic comorbidities and acute concurrent illnesses had variable effects on stated vasopressor prescription. Norepinephrine (94.8%) was the preferred first-line vasopressor.
Self-reported vasopressor use for the treatment of septic shock is relatively uniform among Canadian intensivists; however, practice is variable in patients with chronic comorbidities or acute concurrent illnesses.
Journal of critical care 03/2011; 26(5):532.e1-7. · 2.13 Impact Factor
-
Sean P Keenan,
Tasnim Sinuff,
Karen E A Burns,
John Muscedere,
Jim Kutsogiannis,
Sangeeta Mehta,
Deborah J Cook,
Najib Ayas, Neill K J Adhikari,
Lori Hand,
Damon C Scales,
Rose Pagnotta,
Lynda Lazosky,
Graeme Rocker,
Sandra Dial,
Kevin Laupland,
Kevin Sanders,
Peter Dodek
Canadian Medical Association Journal 02/2011; 183(3):E195-214. · 8.22 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS.
We searched Medline, EMBASE, HEALTHSTAR and CENTRAL, related articles on PubMed™, conference proceedings and bibliographies of identified articles for randomized trials comparing PVL ventilation with traditional approaches to ventilation in critically ill adults with ALI and ARDS. Two reviewers independently selected trials, assessed trial quality, and abstracted data. We identified ten trials (n = 1,749) meeting study inclusion criteria. Tidal volumes achieved in control groups were at the lower end of the traditional range of 10-15 mL/kg. We found a clinically important but borderline statistically significant reduction in hospital mortality with PVL [relative risk (RR) 0.84; 95% CI 0.70, 1.00; p = 0.05]. This reduction in risk was attenuated (RR 0.90; 95% CI 0.74, 1.09, p = 0.27) in a sensitivity analysis which excluded 2 trials that combined PVL with open-lung strategies and stopped early for benefit. We found no effect of PVL on barotrauma; however, use of paralytic agents increased significantly with PVL (RR 1.37; 95% CI, 1.04, 1.82; p = 0.03).
This systematic review suggests that PVL strategies for mechanical ventilation in ALI and ARDS reduce mortality and are associated with increased use of paralytic agents.
PLoS ONE 01/2011; 6(1):e14623. · 4.09 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: Evidence-based practices improve intensive care unit (ICU) outcomes, but eligible patients may not receive them. Community hospitals treat most critically ill patients but may have few resources dedicated to quality improvement.
To determine the effectiveness of a multicenter quality improvement program to increase delivery of 6 evidence-based ICU practices.
Pragmatic cluster-randomized trial among 15 community hospital ICUs in Ontario, Canada. A total of 9269 admissions occurred during the trial (November 2005 to October 2006) and 7141 admissions during a decay-monitoring period (December 2006 to August 2007).
We implemented a videoconference-based forum including audit and feedback, expert-led educational sessions, and dissemination of algorithms to sequentially improve delivery of 6 practices. We randomized ICUs into 2 groups. Each group received this intervention, targeting a new practice every 4 months, while acting as control for the other group, in which a different practice was targeted in the same period. MAIN MEASURE OUTCOMES: The primary outcome was the summary ratio of odds ratios (ORs) for improvement in adoption (determined by daily data collection) of all 6 practices during the trial in intervention vs control ICUs.
Overall, adoption of the targeted practices was greater in intervention ICUs than in controls (summary ratio of ORs, 2.79; 95% confidence interval [CI], 1.00-7.74). Improved delivery in intervention ICUs was greatest for semirecumbent positioning to prevent ventilator-associated pneumonia (90.0% of patient-days in last month vs 50.0% in first month; OR, 6.35; 95% CI, 1.85-21.79) and precautions to prevent catheter-related bloodstream infection (70.0% of patients receiving central lines vs 10.6%; OR, 30.06; 95% CI, 11.00-82.17). Adoption of other practices, many with high baseline adherence, changed little.
In a collaborative network of community ICUs, a multifaceted quality improvement intervention improved adoption of care practices.
clinicaltrials.gov Identifier: NCT00332982.
JAMA The Journal of the American Medical Association 01/2011; 305(4):363-72. · 30.03 Impact Factor
-
Critical care medicine 12/2010; 38(12):2424-5. · 6.37 Impact Factor
-
Robert A Fowler,
Lori-Anne Noyahr,
J Daryl Thornton,
Ruxandra Pinto,
Jeremy M Kahn, Neill K J Adhikari,
Peter M Dodek,
Nadia A Khan,
Tom Kalb,
Andrea Hill,
James M O'Brien,
David Evans,
J Randall Curtis
[show abstract]
[hide abstract]
ABSTRACT: One in three Americans under 65 years of age does not have health insurance during some portion of each year. Patients who are critically ill and lack health insurance may be at particularly high risk of morbidity and mortality due to the high cost of intensive care.
To systematically review the medical and nonmedical literature to determine whether differences in critical care access, delivery, and outcomes are associated with health insurance status.
Nine electronic databases (inception to 11 April 2008) were independently screened and abstracted in duplicate.
From 5,508 citations, 29 observational studies met eligibility criteria. Among the general U.S. population, patients who were uninsured were less likely to receive critical care services than those with insurance (odds ratio [OR], 0.56; 95% confidence interval [CI], 0.55-0.56). Once admitted to the intensive care unit, patients who were uninsured had 8.5% (95% CI, 6.0-11.1) fewer procedures, were more likely to experience hospital discharge delays (OR 4.51; 95% CI, 1.46-13.93), and were more likely to have life support withdrawn (OR 2.80; 95% CI, 1.12-7.02). Lack of insurance may confer an independent risk of death for patients who are critically ill (OR 1.16; 95% CI, 1.01-1.33). Patients in managed care systems had 14.3% (95% CI, 11.5-17.2) fewer procedures in intensive care, but were also less likely to receive "potentially ineffective" care. Differences in unmeasured confounding factors may contribute to these findings.
Patients in the United States who are critically ill and do not have health insurance receive fewer critical care services and may experience worse clinical outcomes. Improving preexisting health care coverage, as opposed to solely delivering more critical care services, may be one mechanism to reduce such disparities.
American Journal of Respiratory and Critical Care Medicine 05/2010; 181(9):1003-11. · 11.08 Impact Factor
-
Sachin Sud,
Jan O Friedrich,
Paolo Taccone,
Federico Polli, Neill K J Adhikari,
Roberto Latini,
Antonio Pesenti,
Claude Guérin,
Jordi Mancebo,
Martha A Q Curley,
Rafael Fernandez,
Ming-Cheng Chan,
Pascal Beuret,
Gregor Voggenreiter,
Maneesh Sud,
Gianni Tognoni,
Luciano Gattinoni
[show abstract]
[hide abstract]
ABSTRACT: Prone position ventilation for acute hypoxemic respiratory failure (AHRF) improves oxygenation but not survival, except possibly when AHRF is severe.
To determine effects of prone versus supine ventilation in AHRF and severe hypoxemia [partial pressure of arterial oxygen (PaO(2))/inspired fraction of oxygen (FiO(2)) <100 mmHg] compared with moderate hypoxemia (100 mmHg < or = PaO(2)/FiO(2) < or = 300 mmHg).
Systematic review and meta-analysis.
Electronic databases (to November 2009) and conference proceedings.
Two authors independently selected and extracted data from parallel-group randomized controlled trials comparing prone with supine ventilation in mechanically ventilated adults or children with AHRF. Trialists provided subgroup data. The primary outcome was hospital mortality in patients with AHRF and PaO(2)/FiO(2) <100 mmHg. Meta-analyses used study-level random-effects models.
Ten trials (N = 1,867 patients) met inclusion criteria; most patients had acute lung injury. Methodological quality was relatively high. Prone ventilation reduced mortality in patients with PaO(2)/FiO(2) <100 mmHg [risk ratio (RR) 0.84, 95% confidence interval (CI) 0.74-0.96; p = 0.01; seven trials, N = 555] but not in patients with PaO(2)/FiO(2) > or =100 mmHg (RR 1.07, 95% CI 0.93-1.22; p = 0.36; seven trials, N = 1,169). Risk ratios differed significantly between subgroups (interaction p = 0.012). Post hoc analysis demonstrated statistically significant improved mortality in the more hypoxemic subgroup and significant differences between subgroups using a range of PaO(2)/FiO(2) thresholds up to approximately 140 mmHg. Prone ventilation improved oxygenation by 27-39% over the first 3 days of therapy but increased the risks of pressure ulcers (RR 1.29, 95% CI 1.16-1.44), endotracheal tube obstruction (RR 1.58, 95% CI 1.24-2.01), and chest tube dislodgement (RR 3.14, 95% CI 1.02-9.69). There was no statistical between-trial heterogeneity for most clinical outcomes.
Prone ventilation reduces mortality in patients with severe hypoxemia. Given associated risks, this approach should not be routine in all patients with AHRF, but may be considered for severely hypoxemic patients.
European Journal of Intensive Care Medicine 04/2010; 36(4):585-99. · 5.17 Impact Factor
-
[show abstract]
[hide abstract]
ABSTRACT: To determine the effect of renal replacement therapy dose on mortality and dialysis dependence in patients with acute kidney injury.
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to October 2009; PubMed "Related Articles;" bibliographies of included trials; and additional information from trial authors.
Randomized and quasi-randomized, controlled trials in adults with acute kidney injury prescribed highvs. standard-dose continuous renal replacement therapy (> or =30 mL/kg/hr vs. <30 mL/kg/hr), intermittent hemodialysis, or sustained low-efficiency dialysis (daily vs. alternate day, or by target biochemistry).
Three authors independently selected studies and extracted data on outcomes and study quality. Meta-analyses used random-effects models.
Of 5416 citations, 12 trials (n = 3999) met inclusion criteria. Modalities included continuous renal replacement therapy (7 trials), intermittent hemodialysis (3 trials), sustained low-efficiency dialysis (1 trial), and all three (1 trial). Study quality was moderate-high. Meta-analyses found no effect of high-dose renal replacement therapy on mortality (risk ratio, 0.89; 95% confidence interval, 0.77-1.03; 12 trials; n = 3954) or dialysis dependence among survivors (risk ratio, 1.15; 95% confidence interval, 0.92-1.44; 8 trials with events; n = 1743). The effect on mortality was similar (all interaction p values were nonsignificant) in patients with sepsis (risk ratio, 1.02; 95% confidence interval, 0.85-1.23; 9 trials; n = 1786) vs. without sepsis (risk ratio, 0.89; 95% confidence interval, 0.75-1.05; 8 trials; n = 1955), treated exclusively with continuous renal replacement therapy (risk ratio, 0.87; 95% confidence interval, 0.71-1.06; 7 trials; n = 2462) vs. other modalities alone or in combination (risk ratio, 0.92; 95% confidence interval, 0.70 -1.21; 5 trials; n = 1492), and in trials with low (risk ratio, 0.96; 95% confidence interval, 0.85-1.09; 6 trials; n = 3475) vs. higher (risk ratio, 0.76; 95% confidence interval, 0.53-1.09; 6 trials; n = 479) risk of bias.
High-dose renal replacement therapy in acute kidney injury does not improve patient survival or recovery of renal function overall or in important patient subgroups, including those with sepsis.
Critical care medicine 03/2010; 38(5):1360-9. · 6.37 Impact Factor
