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Critical care medicine 05/2013; 41(5):1381-1383. · 6.37 Impact Factor
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John Muscedere,
Marianna Ofner,
Anand Kumar,
Jennifer Long,
Francois Lamontagne,
Deborah Cook,
Allison McGeer,
Clarence Chant, John Marshall,
Philippe Jouvet,
Robert Fowler
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ABSTRACT: ABSTRACT PURPOSE: Although secondary infections are recognized as a cause of morbidity and mortality in seasonal influenza, their frequency, characteristics and associated clinical outcomes in Influenza A (H1N1)-related critical illness are unknown. METHODS: In a prospective cohort of adult patients admitted to Canadian Intensive Care Units (ICUs) with H1N1 infection, the frequency and associated clinical outcomes of prevalent (culture taken within 72 hours of ICU admission) and ICU-acquired (culture taken after 72 hours from ICU admission) positive bacterial cultures were determined. RESULTS: Among 681 patients the mean age was 47.9 years (standard deviation [SD] 15.1), APACHE II was 21.0 (9.9) and 573 (84.0%) were invasively mechanical ventilated (MV). Positive cultures were obtained in 259 (38.0 %): 77 (29.7%) prevalent; 115 (44.4%) ICU-acquired; 40 (15.4%) had both; culture date was unavailable in 27 (10.4%). The most common bacterial organisms isolated were coagulase negative staphylococci, Staphylococcus aureus, Pseudomonas sp. and Streptococcus pneumoniae. Antibiotics were prescribed in 661 (97.1%) with 3.8 (1.9) prescriptions per patient. Patients with any positive culture had longer days of MV [mean(SD); 15.2 (10.7) vs. 10.7 (9.0), p< 0.0001], ICU stay [median(IQR);18.2 (12.5) vs. 10.8 (9.0) days, p< 0.0001], hospitalization [median(IQR); 30.7 (20.7) vs. 19.2 (17.4) days, p< 0.0001] and a trend towards increased hospital mortality (25.1% vs. 19.9%, p = 0.15). Patients with ICU-acquired positive cultures had worse outcomes compared to those with positive prevalent cultures or who were culture negative. CONCLUSION: Culture-based evidence of secondary infections commonly complicates Influenza A(H1N1)-related critical illness and is associated with worse clinical outcomes despite nearly ubiquitous antibiotic administration.
Chest 02/2013; · 5.25 Impact Factor
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Deborah Cook,
Ellen McDonald,
Orla Smith,
Nicole Zytaruk,
Diane Heels-Ansdell,
Irene Watpool,
Tracy McArdle,
Andrea Matte,
France Clarke,
Shirley Vallance, [......],
Clive Woolfe,
Neil Orford,
Richard Hall,
Neill Kj Adhikari,
Marie-Claude Ferland, John Marshall,
Maureen Meade,
For The Protect Investigators,
On Behalf Of The Canadian Critical Care Trials Group,
The Australian And New Zealand Intensive Care Society Clinical Trials Group
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ABSTRACT: INTRODUCTION: Research on coenrolment practices and its impact are limited in the ICU setting. The objectives of this study were; 1) to describe patterns and predictors of coenrolment of patients in a thromboprophylaxis trial, and 2) to examine the consequences of coenrolment on clinical and trial outcomes. METHODS: In an observational analysis of an international thromboprophylaxis trial in 67 ICUs, we examined the coenrolment of critically ill medical-surgical patients into more than one study, and examined the clinical and trial outcomes among coenrolled and non-coenrolled patients. RESULTS: Among 3746 patients enrolled in the Prophylaxis for ThromboEmbolism in Critical Care Trial, 713 (19.0%) were coenrolled in at least one other study (53.6% in a randomized trial, 37.0% in an observational study, and 9.4% in both). Six factors independently associated with coenrolment (all p<0.001) were illness severity (odds ratio [OR] 1.35, 95% confidence interval [CI] 1.19-1.53 for each 10 point APACHE II score increase), substitute decision-makers providing consent, rather than patients (OR 3.31, 2.03-5.41), experience of persons inviting consent (OR 2.67, 1.74-4.11 for persons with >10 years experience compared to persons with none), center size (all ORs >10 for ICUs with >15 beds), affiliation with trials groups (OR 5.59, 3.49-8.95), and main trial rather than pilot phase (all ORs >8 for recruitment year beyond the pilot). Coenrolment did not influence clinical or trial outcomes or risk of adverse events. CONCLUSIONS: Coenrolment was strongly associated with features of the patients, research personnel, setting and study. Coenrolment had no impact on trial results, and appeared safe, acceptable and feasible. Transparent reporting, scholarly discourse, ethical analysis, and further research are needed on the complex topic of coenrolment during critical illness.
Critical care (London, England) 01/2013; 17(1):R1. · 4.61 Impact Factor
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Emily Rimmer,
Anand Kumar,
Steve Doucette, John Marshall,
Sandra Dial,
David Gurka,
R Phillip Dellinger,
Satendra Sharma,
Charles Penner,
Andreas Kramer,
Kenneth Wood,
John Ronald,
Aseem Kumar,
Alexis F Turgeon,
Donald S Houston,
Ryan Zarychanski
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ABSTRACT: BACKGROUND:: Septic shock is a highly inflammatory and procoagulant state associated with significant mortality. In a single randomized controlled trial, recombinant human activated protein C (drotrecogin alfa) reduced mortality in patients with severe sepsis at high risk of death. Further clinical trials, including a recently completed trial in patients with septic shock, failed to reproduce these results. OBJECTIVE:: To evaluate the effectiveness of recombinant human activated protein C on mortality in a cohort of patients with septic shock and to explore possible reasons for inconsistent results in previous studies. DESIGN:: Retrospective, 2:1 propensity-matched, multicenter cohort study. SETTING:: Twenty-nine academic and community intensive care units in three countries. PATIENTS:: Seven thousand three hundred ninety-two adult patients diagnosed with septic shock, of which 349 received recombinant human activated protein C within 48 hrs of intensive care unit admission between 1997 and 2007. MEASUREMENTS AND MAIN RESULTS:: Our primary outcomes were mortality over 30 days and mortality stratified by Acute Physiology and Chronic Health Evaluation II quartile. Using a propensity-matched Cox proportional hazard model, we observed a 6.1% absolute reduction in 30-day mortality associated with the use of recombinant human activated protein C (108/311 [34.7%] vs. 254/622 [40.8%], hazard ratio 0.72, 95% confidence interval 0.52-1.00, p = .05) and noted consistent reductions in mortality among Acute Physiology and Chronic Health Evaluation II quartiles. A time to event analysis showed that the time to appropriate antimicrobials after documented hypotension decreased for each year of study (p = .003), a finding that was congruent with a decrease in annual mortality over the study period (odds ratio 0.96 per year [95% confidence interval 0.93-0.99], p = .003). CONCLUSIONS:: In this retrospective, propensity-matched, multicenter cohort study of patients with septic shock, early use of recombinant human activated protein C was associated with reduced mortality. Improvements in general quality of care such as speed of antimicrobial delivery leading to decreasing mortality of patients with septic shock may have contributed to the null results of the recently completed trial of recombinant human activated protein C in patients with septic shock.
Critical care medicine 08/2012; 40(11):2974-2981. · 6.37 Impact Factor
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Lauralyn McIntyre,
Dean A Fergusson,
Brian Rowe,
Deborah J Cook,
Yaseen Arabi,
Sean M Bagshaw,
Marcel Emond,
Simon Finfer,
Alison Fox-Robichaud,
Alasdair Gray, [......],
Paul Hebert,
Eddy Lang, John Marshall,
Ian Stiell,
Alan Tinmouth,
Joe Pagliarello,
Alexis Turgeon,
Timothy Walsh,
Andrew Worster,
Ryan Zarychanski
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ABSTRACT: Severe sepsis and septic shock are the most common reasons for admission to an intensive care unit; and the risk of death is substantial, estimated at approximately 40%. Evidence suggests that early resuscitation strategies that include the use of resuscitation fluids, antibiotics, blood, and inotropes reduce death. Although fluid resuscitation is an immediate life-saving intervention, a fundamental question that remains unanswered is whether the type of resuscitation fluid impacts survival when it is initiated very early in the course of septic shock. A randomized controlled trial published in 2008 confirmed that hydroxyethyl starch fluids cause acute renal failure defined by the requirement for renal replacement therapy. In contrast, a subgroup analysis from a randomized controlled trial suggests that 4% albumin fluid may reduce death from severe sepsis; however, these findings require confirmation in a large randomized trial. Our team is planning a pragmatic early septic shock fluid resuscitation trial that will compare the effectiveness of 5% albumin vs normal saline on 90-day mortality (PRECISE). In this article, we summarize the scientific rationale and inherent challenges associated with the conduct of PRECISE, the background work and planning elements that have been undertaken, and the PRECISE RCT protocol with rationale and justifications provided for the chosen population, the interventions, and the outcome measures.
Transfusion medicine reviews 01/2012; 26(4):333-341. · 3.61 Impact Factor
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Lauralyn A McIntyre,
Dean A Fergusson,
Deborah J Cook,
Brian H Rowe,
Sean M Bagshaw,
Dave Easton,
Marcel Emond,
Simon Finfer,
Alison Fox-Robichaud,
Claude Gaudert,
Robert Green,
Paul Hebert, John Marshall,
Nigel Rankin,
Ian Stiell,
Alan Tinmouth,
Joe Pagliarello,
Alexis F Turgeon,
Andrew Worster,
Ryan Zarychanski
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ABSTRACT: Randomized, controlled trials of fluid resuscitation in early septic shock face many logistic challenges. We describe the Fluid Resuscitation with 5% albumin versus Normal Saline in Early Septic Shock (PRECISE) pilot trial study design and report feasibility of patient recruitment.
Six Canadian academic centers enrolled adult patients with early suspected septic shock from the emergency department and intensive care unit department. Consent was deferred. Using concealed allocation, participants were randomized to either 5% albumin or 0.9% sodium chloride. Blinded fluid resuscitation started immediately and continued for 7 days in the intensive care unit. Target recruitment was established a priori at 2 patients per site per month.
Fifty-one patients were enrolled; 50 patients received study fluid. We recruited a median of 2.5 patients (interquartile range [IQR], 1.5-3.0) per site per month into the trial. Median age and Acute Physiology and Chronic Health Evaluation II scores were 64.5 (IQR, 55.0-78.0) and 25.0 (IQR, 20.0-29.0), respectively. Most patients (n = 37 [74.0%]) were enrolled from the emergency department for a median of 1.6 hours (IQR, 0.8-3.5 hours) from their first hypotensive event and received a median of 2.4 L (IQR, 1.5-3.0 L) of resuscitation fluid before inclusion. Consent was deferred for 44 patients (89.8%).
Patient recruitment into the PRECISE pilot trial met our prespecified feasibility targets, and the PRECISE team is planning the larger trial.
Journal of critical care 12/2011; 27(3):317.e1-6. · 2.13 Impact Factor
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ABSTRACT: Pandemic H1N1 influenza is projected to be unprecedented in its scope, causing acute critical illness among thousands of young otherwise healthy adults, who will need advanced life support. Rigorous, relevant, timely, and ethical clinical and health services research is crucial to improve their care and outcomes. Studies designed and conducted during a pandemic should be held to the same high methodologic and implementation standards as during other times. However, unique challenges arise with the need to conduct investigations as efficiently as possible, focused on the optimal outcome for the individual patient, while balancing the need for maximal societal benefit. We believe that clinical critical care research during a pandemic must be approached differently from research undertaken under nonemergent circumstances. We propose recommendations to clinical investigators and research ethics committees regarding clinical and health services research on pandemic-related critical illness. We also propose strategies such as expedited and centralized research ethics committee reviews and alternate consent models.
Critical care medicine 12/2009; 38(4 Suppl):e138-42. · 6.37 Impact Factor
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Anand Kumar,
Ryan Zarychanski,
Ruxandra Pinto,
Deborah J Cook, John Marshall,
Jacques Lacroix,
Tom Stelfox,
Sean Bagshaw,
Karen Choong,
Francois Lamontagne, [......],
Jeffrey Singh,
Tim Karachi,
Kim Wiebe,
Kendiss Olafson,
Clare Ramsey,
Sat Sharma,
Peter Dodek,
Maureen Meade,
Richard Hall,
Robert A Fowler
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ABSTRACT: Between March and July 2009, the largest number of confirmed cases of 2009 influenza A(H1N1) infection occurred in North America.
To describe characteristics, treatment, and outcomes of critically ill patients in Canada with 2009 influenza A(H1N1) infection.
A prospective observational study of 168 critically ill patients with 2009 influenza A(H1N1) infection in 38 adult and pediatric intensive care units (ICUs) in Canada between April 16 and August 12, 2009.
The primary outcome measures were 28-day and 90-day mortality. Secondary outcomes included frequency and duration of mechanical ventilation and duration of ICU stay.
Critical illness occurred in 215 patients with confirmed (n = 162), probable (n = 6), or suspected (n = 47) community-acquired 2009 influenza A(H1N1) infection. Among the 168 patients with confirmed or probable 2009 influenza A(H1N1), the mean (SD) age was 32.3 (21.4) years; 113 were female (67.3%) and 50 were children (29.8%). Overall mortality among critically ill patients at 28 days was 14.3% (95% confidence interval, 9.5%-20.7%). There were 43 patients who were aboriginal Canadians (25.6%). The median time from symptom onset to hospital admission was 4 days (interquartile range [IQR], 2-7 days) and from hospitalization to ICU admission was 1 day (IQR, 0-2 days). Shock and nonpulmonary acute organ dysfunction was common (Sequential Organ Failure Assessment mean [SD] score of 6.8 [3.6] on day 1). Neuraminidase inhibitors were administered to 152 patients (90.5%). All patients were severely hypoxemic (mean [SD] ratio of Pao(2) to fraction of inspired oxygen [Fio(2)] of 147 [128] mm Hg) at ICU admission. Mechanical ventilation was received by 136 patients (81.0%). The median duration of ventilation was 12 days (IQR, 6-20 days) and ICU stay was 12 days (IQR, 5-20 days). Lung rescue therapies included neuromuscular blockade (28% of patients), inhaled nitric oxide (13.7%), high-frequency oscillatory ventilation (11.9%), extracorporeal membrane oxygenation (4.2%), and prone positioning ventilation (3.0%). Overall mortality among critically ill patients at 90 days was 17.3% (95% confidence interval, 12.0%-24.0%; n = 29).
Critical illness due to 2009 influenza A(H1N1) in Canada occurred rapidly after hospital admission, often in young adults, and was associated with severe hypoxemia, multisystem organ failure, a requirement for prolonged mechanical ventilation, and the frequent use of rescue therapies.
JAMA The Journal of the American Medical Association 10/2009; 302(17):1872-9. · 30.03 Impact Factor
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European Journal of Intensive Care Medicine 08/2009; 35(10):1655-8. · 5.17 Impact Factor
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Sean M Bagshaw,
Stephen Lapinsky,
Sandra Dial,
Yaseen Arabi,
Peter Dodek,
Gordon Wood,
Paul Ellis,
Jorge Guzman, John Marshall,
Joseph E Parrillo,
Yoanna Skrobik,
Anand Kumar
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ABSTRACT: To describe the incidence and outcomes associated with early acute kidney injury (AKI) in septic shock and explore the association between duration from hypotension onset to effective antimicrobial therapy and AKI.
Retrospective cohort study.
A total of 4,532 adult patients with septic shock from 1989 to 2005.
Intensive care units of 22 academic and community hospitals in Canada, the United States and Saudi Arabia.
In total, 64.4% of patients with septic shock developed early AKI (i.e., within 24 h after onset of hypotension). By RIFLE criteria, 16.3% had risk, 29.4% had injury and 18.7% had failure. AKI patients were older, more likely female, with more co-morbid disease and greater severity of illness. Of 3,373 patients (74.4%) with hypotension prior to receiving effective antimicrobial therapy, the median (IQR) time from hypotension onset to antimicrobial therapy was 5.5 h (2.0-13.3). Patients with AKI were more likely to have longer delays to receiving antimicrobial therapy compared to those with no AKI [6.0 (2.3-15.3) h for AKI vs. 4.3 (1.5-10.8) h for no AKI, P < 0.0001). A longer duration to antimicrobial therapy was also associated an increase in odds of AKI [odds ratio (OR) 1.14, 95% CI 1.10-1.20, P < 0.001, per hour (log-transformed) delay]. AKI was associated with significantly higher odds of death in both ICU (OR 1.73, 95% CI 1.60-1.9, P < 0.0001) and hospital (OR 1.62, 95% CI, 1.5-1.7, P < 0.0001). By Cox proportional hazards analysis, including propensity score-adjustment, each RIFLE category was independently associated with a greater hazard ratio for death (risk 1.31; injury 1.45; failure 1.56).
Early AKI is common in septic shock. Delays to appropriate antimicrobial therapy may contribute to significant increases in the incidence of AKI. Survival was considerably lower for septic shock associated with early AKI, with increasing severity of AKI, and with increasing delays to appropriate antimicrobial therapy.
European Journal of Intensive Care Medicine 01/2009; 35(5):871-81. · 5.17 Impact Factor
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James Douketis,
Deborah Cook,
Maureen Meade,
Gordon Guyatt,
William Geerts,
Yoanna Skrobik,
Martin Albert,
John Granton,
Paul Hébert,
Guiseppe Pagliarello, John Marshall,
Robert Fowler,
Andreas Freitag,
Christian Rabbat,
David Anderson,
Nicole Zytaruk,
Diane Heels-Ansdell,
Mark Crowther
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ABSTRACT: Use of low-molecular-weight heparins is avoided in patients with renal insufficiency because of concerns about an excessive anticoagulant effect and increased bleeding risk. To challenge this premise, we evaluated if deep vein thrombosis (DVT) prophylaxis with dalteparin sodium confers an excessive anticoagulant effect in critically ill patients with severe renal insufficiency.
We conducted a multicenter, single-arm clinical trial of DVT prophylaxis with dalteparin sodium, 5000 IU once daily in critically ill patients with a creatinine clearance lower than 30 mL/min (to convert to milliliters per second, multiply by 0.0167). Bioaccumulation was defined by a trough anti-Xa level higher than 0.40 IU/mL, measured twice weekly. The pharmacodynamic properties of dalteparin were assessed by serial anti-Xa levels measured on days 3, 10, and 17.
We enrolled 156 patients with a mean (SD) creatinine clearance of 18.9 (6.5) mL/min; 18 were excluded because they died or were discharged before testing (n = 3) or had prevalent DVT (n = 15). Of 138 patients included, the median (interquartile range [IQR]) duration of dalteparin exposure was 7 (4-12) days. In 120 patients who had at least 1 trough anti-Xa level (427 total measurements), no patient had bioaccumulation (0%; 95% confidence interval [CI]: 0%-3.0%); the median (IQR) trough anti-Xa level was undetectable (<0.10 IU/mL [<0.10 to <0.10 IU/mL]). Based on serial measurements, peak anti-Xa levels were 0.29 to 0.34 IU/mL and trough levels were lower than 0.06 IU/mL. Deep vein thrombosis occurred in 7 of 138 patients (5.1%; 95% CI, 2.5%-10.1%); major bleeding occurred in 10 patients (7.2%; 95% CI, 4.0%-12.8%), all with trough anti-Xa levels of 0.18 IU/mL or lower.
In critically ill patients with severe renal insufficiency, DVT prophylaxis with dalteparin sodium, 5000 IU once daily, is not associated with an excessive anticoagulant effect due to drug bioaccumulation and is unlikely to contribute to bleeding.
clinicaltrials.gov Identifier: NCT00138099.
Archives of internal medicine 09/2008; 168(16):1805-12. · 11.46 Impact Factor
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ABSTRACT: A multidisciplinary research program on levels of care was conducted in 15 adult intensive care units in North America, Europe, and Australia. The program addressed advance directives for cardiopulmonary resuscitation, provision of advanced life support, and clinicians' discomfort with evolving treatment plans. The results indicated that the factors that determined the establishment of directives for advance life support differed from the factors that informed a decision to limit or withdraw support after admission to an intensive care unit. In addition, clinicians' prognoses were imprecise and often an underestimation of the probability of short-term survival. Finally, some degree of discomfort was common in care providers in the intensive care unit, most often because they thought interventions were excessive and not compatible with an acceptable future quality of life. The provision of advanced life support mandates explicit decision making about how life-support measures should be used.
American Journal of Critical Care 06/2006; 15(3):269-79. · 1.66 Impact Factor
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Lauren Griffith,
Deborah Cook,
Steven Hanna,
Graeme Rocker,
Peter Sjokvist,
Peter Dodek, John Marshall,
Mitchell Levy,
Joseph Varon,
Simon Finfer,
Roman Jaeschke,
Lisa Buckingham,
Gordon Guyatt
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ABSTRACT: To examine the incidence and predictors of clinician discomfort with life support plans for ICU patients.
Prospective cohort in 13 medical-surgical ICUs in four countries.
657 mechanically ventilated adults expected to stay in ICU at least 72 h.
Daily we documented the life support plan for mechanical ventilation, inotropes and dialysis, and clinician comfort with these plans. If uncomfortable, clinicians stated whether the plan was too technologically intense (the provision of too many life support modalities or the provision of any modality for too long) or not intense enough, and why. At least one clinician was uncomfortable at least once for 283 (43.1%) patients, primarily because plans were too technologically intense rather than not intense enough (93.9% vs. 6.1%). Predictors of discomfort because plans were too intense were: patient age, medical admission, APACHE II score, poor prior functional status, organ dysfunction, dialysis in ICU, plan to withhold dialysis, plan to withhold mechanical ventilation, first week in the ICU, clinician, and city.
Clinician discomfort with life support perceived as too technologically intense is common, experienced mostly by nurses, variable across centers, and is more likely for older, severely ill medical patients, those with acute renal failure, and patients lacking plans to forgo reintubation and ventilation. Acknowledging the sources of discomfort could improve communication and decision making.
Intensive Care Medicine 10/2004; 30(9):1783-90. · 5.40 Impact Factor
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Graeme Rocker,
Deborah Cook,
Peter Sjokvist,
Bruce Weaver,
Simon Finfer,
Ellen McDonald, John Marshall,
Anne Kirby,
Mitchell Levy,
Peter Dodek,
Daren Heyland,
Gordon Guyatt
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ABSTRACT: Predicting outcomes for critically ill patients is an important aspect of discussions with families in the intensive care unit. Our objective was to evaluate clinical intensive care unit survival predictions and their consequences for mechanically ventilated patients.
Prospective cohort study.
Fifteen tertiary care centers.
Consecutive mechanically ventilated patients > or = 18 yrs of age with expected intensive care unit stay > or = 72 hrs.
We recorded baseline characteristics at intensive care unit admission. Daily we measured multiple organ dysfunction score (MODS), use of advanced life support, patient preferences for life support, and intensivist and bedside intensive care unit nurse estimated probability of intensive care unit survival.
The 851 patients were aged 61.2 (+/- 17.6, mean + SD) yrs with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.7 (+/- 8.6). Three hundred and four patients (35.7%) died in the intensive care unit, and 341 (40.1%) were assessed by a physician at least once to have a < 10% intensive care unit survival probability. Independent predictors of intensive care unit mortality were baseline APACHE II score (hazard ratio, 1.16; 95% confidence interval, 1.08-1.24, for a 5-point increase) and daily factors such as MODS (hazard ratio, 2.50; 95% confidence interval, 2.06-3.04, for a 5-point increase), use of inotropes or vasopressors (hazard ratio, 2.14; 95% confidence interval, 1.66-2.77), dialysis (hazard ratio, 0.51; 95% confidence interval, 0.35-0.75), patient preference to limit life support (hazard ratio, 10.22; 95% confidence interval, 7.38-14.16), and physician but not nurse prediction of < 10% survival. The impact of physician estimates of < 10% intensive care unit survival was greater for patients without vs. those with preferences to limit life support (p < .001) and for patients with less vs. more severe organ dysfunction (p < .001). Mechanical ventilation, inotropes or vasopressors, and dialysis were withdrawn more often when physicians predicted < 10% probability of intensive care unit survival (all ps < .001).
Physician estimates of intensive care unit survival < 10% are associated with subsequent life support limitation and more powerfully predict intensive care unit mortality than illness severity, evolving or resolving organ dysfunction, and use of inotropes or vasopressors.
Critical Care Medicine 05/2004; 32(5):1149-54. · 6.33 Impact Factor
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Gordon Guyatt,
Deborah Cook,
Bruce Weaver,
Graeme Rocker,
Peter Dodek,
Peter Sjokvist,
Cindy Hamielec,
Serge Puksa, John Marshall,
Debra Foster,
Mitchell Levy,
Joseph Varon,
Kevin Thorpe,
Malcolm Fisher,
Stephen Walter
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ABSTRACT: Perceptions about functional and employment status before admission to the intensive care unit (ICU) may influence how patients and clinicians make decisions about cardiopulmonary resuscitation.
To examine the relationship between cardiopulmonary resuscitation directives established within 24 hours of admission to the ICU and clinical perceptions of premorbid functional and employment status.
Prospective observational study in 15 university-affiliated centers in Canada, the United States, Australia, and Sweden. Patients: A total of 1,008 ICU patients aged 18 years or older expected to stay in the ICU at least 72 hours. Measurements: By using multinomial logistic regression, we examined the relationship between functional status and employment status perceived by the ICU team 1 month before ICU admission (the independent variables) and resuscitation status (the dependent variable). Each patient had either an explicit resuscitation directive (to resuscitate or not to resuscitate), or an implicit resuscitation directive to resuscitate.
On average, patients were 61.7 years (+/-17.4 y) old with an Acute Physiology and Chronic Health Evaluation (APACHE) II score of 21.5 (+/-8.7); 846 (83.9%) were ventilated mechanically within 48 hours and 345 (34.2%) died in the ICU. Most patients (793, 78.7%) had no explicit resuscitation directive; 98 (9.7%) had an explicit plan to resuscitate, whereas 117 (11.6%) had an explicit plan of do-not-resuscitate. Of 1,008 patients, 98 (9.7%) were severely functionally limited, 217 (21.5%) were somewhat limited, 628 (62.3%) were totally independent, and 65 (6.4%) had unknown functional status 1 month before ICU admission. Severe functional status impairment was associated moderately with an explicit plan to resuscitate (odds ratio, 2.2 relative to no explicit directive) and associated strongly with an explicit do-not-resuscitate plan (odds ratio, 6.2 relative to no explicit directive, P value on the difference =.011). This relationship was not influenced by age, sex, APACHE II score, medical or surgical status, admission diagnosis, employment status, or city. However, severe functional status was associated strongly and significantly with an explicit do-not-resuscitate directive among those who could not participate in decision making (odds ratio, 8.2; 95% confidence interval, 4.5-15.0), and more weakly associated in those who could participate (odds ratio, 1.7; 95% confidence interval, 0.3-8.6). Being unemployed was associated with an increased odds of an explicit resuscitation directive versus no explicit directive (odds ratio, 5.5; 95% confidence interval, 2.2-13.4).
Functional status impairment perceived by the ICU team is associated clearly with do-not-resuscitate directives in patients unable to participate in decision making. However, the association appears much weaker in patients able to participate in decision making. Patients' perceived employment status also may influence resuscitation decisions. Our results emphasize the challenges of ensuring that crucial resuscitation decisions are not affected adversely by patients' inability to participate in decisions, and by their functional and employment status.
Journal of Critical Care 10/2003; 18(3):133-41. · 2.13 Impact Factor
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Deborah Cook,
Graeme Rocker, John Marshall,
Peter Sjokvist,
Peter Dodek,
Lauren Griffith,
Andreas Freitag,
Joseph Varon,
Christine Bradley,
Mitchell Levy,
Simon Finfer,
Cindy Hamielec,
Joseph McMullin,
Bruce Weaver,
Stephen Walter,
Gordon Guyatt
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ABSTRACT: In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians' decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation.
We studied adults who were receiving mechanical ventilation in 15 intensive care units, recording base-line physiological characteristics, daily Multiple Organ Dysfunction Scores, the patient's decision-making ability, the type of life support administered, the use of do-not-resuscitate orders, the physician's prediction of the patient's status, and the physician's perceptions of the patient's preferences about the use of life support. We examined the relation between these factors and withdrawal of mechanical ventilation, using Cox proportional-hazards regression analysis.
Of 851 patients who were receiving mechanical ventilation, 539 (63.3 percent) were successfully weaned, 146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn. The need for inotropes or vasopressors was associated with withdrawal of the ventilator (hazard ratio, 1.78; 95 percent confidence interval, 1.20 to 2.66; P=0.004), as were the physician's prediction that the patient's likelihood of survival in the intensive care unit was less than 10 percent (hazard ratio, 3.49; 95 percent confidence interval, 1.39 to 8.79; P=0.002), the physician's prediction that future cognitive function would be severely impaired (hazard ratio, 2.51; 95 percent confidence interval, 1.28 to 4.94; P=0.04), and the physician's perception that the patient did not want life support used (hazard ratio, 4.19; 95 percent confidence interval, 2.57 to 6.81; P<0.001).
Rather than age or the severity of the illness and organ dysfunction, the strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physician's predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.
New England Journal of Medicine 10/2003; 349(12):1123-32. · 53.30 Impact Factor
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ABSTRACT: Objective: To evaluate the incidence and risk factors for clinically important upper gastrointestinal bleeding in critically ill patients requiring mechanical ventilation.
Design: In duplicate, blinded adjudicators determined the presence of clinically important gastrointestinal bleeding using a priori criteria, evaluating relevant clinical, laboratory, and diagnostic data. Cox proportional hazards regression analyses were used to examine baseline and time-dependent risk factors for bleeding.
Setting: Sixteen university-affiliated intensive care units (ICUs) in Canada.
Patients: A total of 1,077 critically ill ICU patients ventilated for at least 48 hrs.
Interventions: Patients were randomized to stress ulcer prophylaxis with intravenous ranitidine or nasogastric sucralfate; otherwise, management was at the discretion of the ICU team.
Measurements and Main Results: Demographic data included patient characteristics, Acute Physiology and Chronic Health Evaluation II score, and multiple organ dysfunction (MOD) score. Each day in the ICU, physiologic measurements including MOD score, feeding, and other treatment variables were recorded. The significant risk factors for upper gastrointestinal bleeding in the univariable analyses were low platelet count, maximum serum creatinine, maximum MOD score, maximum pulmonary component of the MOD score, maximum hepatic component of the MOD score, maximum renal component of the MOD score, enteral nutrition, and stress ulcer prophylaxis with ranitidine. The only independent predictors of bleeding in the multivariable analysis were maximum serum creatinine (relative risk = 1.16 [95% confidence interval = 1.02-1.32]), enteral nutrition (relative risk = 0.30 [95% confidence interval = 0.13-0.67]), and ranitidine administration (relative risk = 0.39 [95% confidence interval = 0.17-0.83]).
Conclusions: In critically ill ventilated patients, renal failure was independently associated with an increased risk of clinically important gastrointestinal bleeding, whereas enteral nutrition and stress ulcer prophylaxis with ranitidine conferred significantly lower bleeding rates.
Critical Care Medicine 11/1999; 27(12):2812-2817. · 6.33 Impact Factor
