Showing papers by "Deborah J. Cook published in 2007"

Effect of nitric oxide on oxygenation and mortality in acute lung injury: systematic review and meta-analysis

Abstract: Objective To review the literature on the use of inhaled nitric oxide to treat acute lung injury/acute respiratory distress syndrome (ALI/ARDS) and to summarise the effects of nitric oxide, compared with placebo or usual care without nitric oxide, in adults and children with ALI or ARDS. Design Systematic review and meta-analysis. Data sources Medline, CINAHL, Embase, and CENTRAL (to October 2006), proceedings from four conferences, and additional information from authors of 10 trials. Review methods Two reviewers independently selected parallel group randomised controlled trials comparing nitric oxide with control and extracted data related to study methods, clinical and physiological outcomes, and adverse events. Main outcome measures Mortality, duration of ventilation, oxygenation, pulmonary arterial pressure, adverse events. Results 12 trials randomly assigning 1237 patients met inclusion criteria. Overall methodological quality was good. Using random effects models, we found no significant effect of nitric oxide on hospital mortality (risk ratio 1.10, 95% confidence interval 0.94 to 1.30), duration of ventilation, or ventilator-free days. On day one of treatment, nitric oxide increased the ratio of partial pressure of oxygen to fraction of inspired oxygen (PaO 2 /FiO 2 ratio) (13%, 4% to 23%) and decreased the oxygenation index (14%, 2% to 25%). Some evidence suggested that improvements in oxygenation persisted until day four. There was no effect on mean pulmonary arterial pressure. Patients receiving nitric oxide had an increased risk of developing renal dysfunction (1.50, 1.11 to 2.02). Conclusions Nitric oxide is associated with limited improvement in oxygenation in patients with ALI or ARDS but confers no mortality benefit and may cause harm. We do not recommend its routine use in these severely ill patients.

Oral decontamination for prevention of pneumonia in mechanically ventilated adults: systematic review and meta-analysis

Abstract: Objective To evaluate the effect of oral decontamination on the incidence of ventilator associated pneumonia and mortality in mechanically ventilated adults. Design Systematic review and meta-analysis. Data sources Medline, Embase, CINAHL, the Cochrane Library, trials registers, reference lists, conference proceedings, and investigators in the specialty. Review methods Two independent reviewers screened studies for inclusion, assessed trial quality, and extracted data. Eligible trials were randomised controlled trials enrolling mechanically ventilated adults that compared the effects of daily oral application of antibiotics or antiseptics with no prophylaxis. Results 11 trials totalling 3242 patients met the inclusion criteria. Among four trials with 1098 patients, oral application of antibiotics did not significantly reduce the incidence of ventilator associated pneumonia (relative risk 0.69, 95% confidence interval 0.41 to 1.18). In seven trials with 2144 patients, however, oral application of antiseptics significantly reduced the incidence of ventilator associated pneumonia (0.56, 0.39 to 0.81). When the results of the 11 trials were pooled, rates of ventilator associated pneumonia were lower among patients receiving either method of oral decontamination (0.61, 0.45 to 0.82). Mortality was not influenced by prophylaxis with either antibiotics (0.94, 0.73 to 1.21) or antiseptics (0.96, 0.69 to 1.33) nor was duration of mechanical ventilation or stay in the intensive care unit. Conclusions Oral decontamination of mechanically ventilated adults using antiseptics is associated with a lower risk of ventilator associated pneumonia. Neither antiseptic nor antibiotic oral decontamination reduced mortality or duration of mechanical ventilation or stay in the intensive care unit.

Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy.

Abstract: Objective:Although noninvasive positive pressure ventilation (NPPV) is a widely accepted treatment for some patients with acute respiratory failure, the use of NPPV in patients who have decided to forego endotracheal intubation is controversial. Therefore, the Society of Critical Care Medicine charg

Facilitating clinician adherence to guidelines in the intensive care unit: A multicenter, qualitative study.

Abstract: Objective:To determine perceived facilitators and barriers to guideline implementation and clinician adherence to guidelines in the intensive care unit (ICU).Design:Multicenter qualitative study in three university-affiliated ICUs in Canada.Methods:We conducted individual semistructured interviews o

Bleeding during critical illness: a prospective cohort study using a new measurement tool.

Abstract: Purpose: To estimate the incidence, severity, duration and consequences of bleeding during critical illness, and to test the performance characteristics of a new bleeding assessment tool. Methods: Clinical bleeding assessments were performed prospectively on 100 consecutive patients admitted to a medical-surgical intensive care unit (ICU) using a novel bleeding measurement tool called HEmorrhage MEasurement (HEME). Bleeding assessments were done daily in duplicate and independently by blinded, trained assessors. Inter-rater agreement and construct validity of the HEME tool were calculated using φ. Risk factors for major bleeding were identified using a multivariable Cox proportional hazards model. Results: Overall, 90% of patients experienced a total of 480 bleeds of which 94.8% were minor and 5.2% were major. Inter-rater reliability of the HEME tool was excellent (φ = 0.98, 95% CI: 0.96 to 0.99). A decrease in platelet count and a prolongation of partial thromboplastin time were independent risk factors for major bleeding but neither were renal failure nor prophylactic anticoagulation. Patients with major bleeding received more blood transfusions and had longer ICU stays compared to patients with minor or no bleeding. Conclusions: Bleeding, although primarily minor, occurred in the majority of ICU patients. One of five patients experienced a major bleed which was associated with abnormal coagulation tests but not with prophylactic anticoagulants. These baseline bleeding rates can inform the design of future clinical trials in critical care that use bleeding as an outcome and HEME is a useful tool to measure bleeding in critically ill patients.

A systematic review of studies comparing health outcomes in Canada and the United States.

Abstract: Background: Differences in medical care in the United States compared with Canada, including greater reliance on private funding and for-profit delivery, as well as markedly higher expenditures, may result in different health outcomes. Objectives: To systematically review studies comparing health outcomes in the United States and Canada among patients treated for similar underlying medical conditions. Methods: We identified studies comparing health outcomes of patients in Canada and the United States by searching multiple bibliographic databases and resources. We masked study results before determining study eligibility. We abstracted study characteristics, including methodological quality and generalizability. Results: We identified 38 studies comparing populations of patients in Canada and the United States. Studies addressed diverse problems, including cancer, coronary artery disease, chronic medical illnesses and surgical procedures. Of 10 studies that included extensive statistical adjustment and enrolled broad populations, 5 favoured Canada, 2 favoured the United States, and 3 showed equivalent or mixed results. Of 28 studies that failed one of these criteria, 9 favoured Canada, 3 favoured the United States, and 16 showed equivalent or mixed results. Overall, results for mortality favoured Canada (relative risk 0.95, 95% confidence interval 0.92–0.98, p = 0.002) but were very heterogeneous, and we failed to find convincing explanations for this heterogeneity. The only condition in which results consistently favoured one country was end-stage renal disease, in which Canadian patients fared better. Interpretation: Available studies suggest that health outcomes may be superior in patients cared for in Canada versus the United States, but differences are not consistent.

Trials and Tribulations of Systematic Reviews and Meta-Analyses

Abstract: Systematic reviews can help practitioners keep abreast of the medical literature by summarizing large bodies of evidence and helping to explain differences among studies on the same question. A systematic review involves the application of scientific strategies, in ways that limit bias, to the assembly, critical appraisal, and synthesis of all relevant studies that address a specific clinical question. A meta-analysis is a type of systematic review that uses statistical methods to combine and summarize the results of several primary studies. Because the review process itself (like any other type of research) is subject to bias, a useful review requires rigorous methods that are clearly reported. Used increasingly to inform medical decision making, plan future research agendas, and establish clinical policy, systematic reviews may strengthen the link between best research evidence and optimal health care. In this article, we discuss key steps in how to critically appraise and how to conduct a systematic review or meta-analysis.

Fresh frozen plasma transfusion in critically ill patients.

Abstract: Objectives:Although guidelines for fresh frozen plasma (FFP) use have been published, many transfusions are considered inappropriate. Current guidelines suggest few circumstances in which FFP transfusion to critically ill patients is warranted. The objectives of this study were to evaluate the consi

A survey of Canadian intensivists' resuscitation practices in early septic shock.

Abstract: Recent evidence suggests that early, aggressive resuscitation in patients with septic shock reduces mortality. The objective of this survey was to characterize reported resuscitation practices of Canadian physicians caring for adult critically ill patients with early septic shock. A scenario-based self-administered national survey was sent out to Canadian critical care physicians. One hypothetical scenario was developed to obtain information on several aspects of resuscitation in early septic shock, including monitoring and resuscitation end-points, fluid administration, red blood cell transfusion triggers, and use of inotropes. The sampling frame was physician members of Canadian national and provincial critical care societies. The survey response rate was 232 out of 355 (65.3%). Medicine was the most common primary specialty (60.0%), most respondents had practiced for 6 to 10 years (30.0%), and 82.0% were male. The following monitoring devices/parameters were reported as used/measured 'often' or 'always' by at least 89% of respondents: oxygen saturation (100%), Foley catheters (100%), arterial blood pressure lines (96.6%), telemetry (94.3%), and central venous pressure (89.2%). Continuous monitoring of central venous oxygen saturation was employed 'often' or 'always' by 9.8% of respondents. The two most commonly cited resuscitation end-points were urine output (96.5%) and blood pressure (91.8%). Over half of respondents used normal saline (84.5%), Ringers lactate (52.2%), and pentastarch (51.3%) 'often' or 'always' for early fluid resuscitation. In contrast, 5% and 25% albumin solutions were cited as used 'often' or 'always' by 3.9% and 1.3% of respondents, respectively. Compared with internists, surgeons and anesthesiologists (odds ratio (95% confidence interval): 9.8 (2.9 to 32.7) and 3.8 (1.7 to 8.7), respectively) reported greater use of Ringers lactate. In the setting of a low central venous oxygen saturation, 52.5% of respondents reported use of inotropic support 'often' or 'always'. Only 7.6% of physicians stated they would use a red blood cell transfusion trigger of 100 g/l to optimize oxygen delivery further. Our survey results suggest that there is substantial practice variation in the resuscitation of adult patients with early septic shock. More randomized trials are needed to determine the optimal approach.

Antibiotic management of suspected nosocomial ICU-acquired infection: does prolonged empiric therapy improve outcome?

Abstract: To characterize empiric antibiotic use in patients with suspected nosocomial ICU-acquired infections (NI), and determine the impact of prolonged therapy in the absence of infection. Multicenter prospective cohort, with eight medical-surgical ICUs in North America and Europe. 195 patients with suspected NI. The diagnosis of NI was adjudicated by a blinded Clinical Evaluation Committee using retrospective review of clinical, radiological, and culture data. Empiric antibiotics were prescribed for 143 of 195 (73.3%) patients with suspected NI; only 39 of 195 (20.0%) were adjudicated as being infected. Infection rates were similar in patients who did (26 of 143, 18.2%), or did not (13 of 52, 25.0%) receive empiric therapy ( p = 0.3). Empiric antibiotics were continued for more than 4 days in 56 of 95 (59.0%) patients without adjudicated NI. Factors associated with continued empiric therapy were increased age ( p = 0.02), ongoing SIRS ( p = 0.03), and hospital ( p = 0.004). Patients without NI who received empiric antibiotics for longer than 4 days had increased 28-day mortality (18 of 56, 32.1%), compared with those whose antibiotics were discontinued (3 of 39, 7.7%; OR = 5.7, 95% CI 1.5–20.9, p = 0.005). When the influence of age, admission diagnosis, vasopressor use, and multiple organ dysfunction was controlled by multivariable analysis, prolonged empiric therapy was not independently associated with mortality (OR = 3.8, 95% CI 0.9–15.5, p = 0.07). Empiric antibiotics were initiated four times more often than NI was confirmed, and frequently continued in the absence of infection. We found no evidence that prolonged use of empiric antibiotics improved outcome for ICU patients, but rather a suggestion that the practice may be harmful.

Anticoagulation for thrombosis prophylaxis in cancer patients with central venous catheters.

Abstract: BACKGROUND Central venous catheter (CVC) placement increases the risk of thrombosis in cancer patients. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis related morbidity and mortality. OBJECTIVES To evaluate the efficacy and safety of anticoagulation in reducing venous thromboembolic (VTE) events in cancer patients with CVC. SEARCH STRATEGY A comprehensive search for studies of anticoagulation in cancer patients up to January 2006 was conducted in the following databases: The Cochrane Central Register of Controlled Trials ( CENTRAL), MEDLINE, EMBASE and ISI the Web of Science. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), fondaparinux or ximelagatran to no intervention or placebo in cancer patients with a CVC or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS Data was extracted on methodological quality, patients, interventions and outcomes including all cause mortality (primary outcome), premature CVC removal, catheter-related infections, CVC site and non CVC site deep venous thrombosis (DVT), pulmonary embolism (PE), major and minor bleeding and thrombocytopenia. MAIN RESULTS Of 3986 identified citations nine RCTs were included in the meta-analysis including one published as an abstract and one focusing on paediatric patients not included in the meta-analysis. None of these RCTs tested fondaparinux or ximelagatran. The use of heparin in cancer patients with CVC was associated with a trend towards a reduction in symptomatic DVT (Relative Risk (RR) = 0.43; 95% Confidence Interval (CI): 0.18 to 1.06), but the data did not show any statistically significant effect on mortality (RR = 0.74; 95% CI: 0.40 to 1.36), infection (RR = 0.91; 95% CI: 0.36 to 2.28), major bleeding (RR = 0.68; 95% CI: 0.10 to 4.78) or thrombocytopenia (RR = 0.85; 95% CI: 0.49 to 1.46). The effect warfarin on symptomatic DVT was not statistically significant (RR = 0.62; 95% CI: 0.30 to 1.27). When studies assessing different types of anticoagulants were pooled, symptomatic DVT rates were significantly reduced (RR = 0.56; 95% CI: 0.34 to 0.92). AUTHORS' CONCLUSIONS Cancer patients with CVC considering anticoagulation, should consider the possible benefit of reduced incidence of thromboembolic complications with the burden and harms of anticoagulation. Future studies should be adequately powered and evaluate the effects of newer anticoagulants such as fondaparinux and ximelagatran in cancer patients with CVC.

Withholding and withdrawing life support in critical care settings: ethical issues concerning consent

Abstract: The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged too futile to offer. They thus retain greater decision-making burden (and power) and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients (or proxies) in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of (and submission to) benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made.

Surfactant therapy for acute respiratory failure in children: a systematic review and meta-analysis

Abstract: Introduction Exogenous surfactant is used to treat acute respiratory failure in children, although the benefits and harms in this setting are not clear. The objective of the present systematic review is to assess the effect of exogenous pulmonary surfactant on all-cause mortality in children mechanically ventilated for acute respiratory failure.

Practice guidelines as multipurpose tools: a qualitative study of noninvasive ventilation.

Abstract: Objective:Although practice guidelines for noninvasive ventilation (NIV) for patients with acute respiratory failure (ARF) have the potential to improve processes of care and patient outcomes, clinicians' views about life support technology guidelines are not well understood. The objective was to un

Clinical practice guidelines in the intensive care unit: a survey of Canadian clinicians’ attitudes

Abstract: To understand clinicians’ perceptions regarding practice guidelines in Canadian intensive care units (ICUs) to inform guideline development and implementation strategies We developed a self-administered survey instrument and assessed its clinical sensibility and reliability The survey was mailed to ICU physicians and nurses in Canada to determine local ICU guideline development and use, and to compare physicians’ and nurses’ attitudes and preferences towards guidelines The survey was completed by 516% (565/1095) of potential respondents Although less than half reported a formal guideline development committee in their ICU, 810% reported that guidelines were developed at their institutions Of clinicians who used guidelines in the ICU, 702% of nurses and 426% of physicians reported using them frequently or always Professional society guidelines (with or without local modification) were reportedly used in most ICUs, but physicians were more confident than nurses of their validity (P < 0001) Physicians considered endorsement of guidelines by a colleague more relevant for enhancing guideline use than did nurses (P < 0001) Nurses considered low risk of the guideline and whether the guideline is consistent with their practice (P < 0001) to be more relevant to guideline uptake than did physicians (P < 0001) Lack of agreement with recommendations was a more important barrier to use of guidelines for physicians than for nurses (P < 0001) Many Canadian institutions locally develop guidelines, and many ICU physicians and nurses report using them Planning implementation strategies according to clinician preferences may increase guideline use The nature of the differences in attitudes towards guidelines between nurses and physicians, and their impact on clinician adherence to guidelines requires further exploration

Interrater Reliability of APACHE II Scores for Medical-Surgical Intensive Care Patients: A Prospective Blinded Study

Abstract: BACKGROUND Despite widespread use of the Acute Physiology and Chronic Health Evaluation II (APACHE II), its interrater reliability has not been well studied. OBJECTIVE To determine interrater reliability of APACHE II scores among 1 intensive care nurse and 2 research clerks. METHODS In a prospective, blinded, observational study, 3 raters collected APACHE II scores on 37 consecutive patients in a medical-surgical intensive care unit. One research clerk was blinded to the study's start date to minimize observer bias. The nurse and the other research clerk were blinded to each other's scores and did not communicate with the first research clerk about the study. The data analyst was blinded to the identity and source of all 3 raters' scores. Intraclass correlation coefficients and 95% confidence intervals were assessed. RESULTS Mean (standard deviation) APACHE II scores were 21.8 (9.2) for the nurse, 20.4 (7.7) for research clerk 1, and 20.5 (8.1) for research clerk 2. Among the 3 raters, the intraclass correlation coefficient (95% confidence interval) was 0.90 (0.84, 0.94) for the APACHE II total score. Within APACHE II score components, the highest reliability was for age (0.98 [0.97, 0.99]), with lower reliabilities for the Chronic Health Index (0.64 [0.50, 0.80]) and the verbal component of the Glasgow Coma Scale (0.40 [0.20, 0.60]). Results were similar between pairs of raters. CONCLUSIONS Use of trained nonmedical personnel to collect illness severity scores for clinical, research, and administrative purposes is reasonable. This method could be used to assess reliability of other illness severity scores.

Resuscitating patients with early severe sepsis: a Canadian multicentre observational study.

Abstract: Fluid resuscitation is a key factor in restoring hemodynamic stability and tissue perfusion in patients with severe sepsis. We sought to examine associations of the quantity and type of fluid administered in the first six hours after identification of severe sepsis and hospital mortality, intensive care unit (ICU) mortality, and organ failure. A retrospective, multicentre cohort study was undertaken at five Canadian tertiary care ICUs. We identified patients with severe sepsis admitted to the ICU between July 1, 2000, and June 30, 2002, using both administrative and clinical databases. Patients were included if they were hypotensive, had an infectious source, and at least two systemic inflammatory response syndrome criteria. We recorded total quantity and type of fluid administered for the first six hours after severe sepsis was identified. The first episode of hypotension defined the starting point for collection of fluid data. Multivariable regression analyses were performed to examine associations between quantity and type of fluid administered and hospital/ICU mortality, and organ failure. Of 2,026 potentially eligible patient charts identified, 496 patients met eligibility criteria. The mean age and Acute Physiology and Chronic Health Evaluation score (APACHE II) were 61.8 ± 16.5 yr and 29.0 ± 8.0, respectively. No associations between quantity or type of fluid administered and hospital mortality or ICU mortality were identified, and there were no statistically significant associations between quantity or type of fluid administered and organ failure. However, more fluid resuscitation was associated with an increased risk of cardiovascular failure [odds ratio (OR) and 95% confidence interval (CI)] for 2-4 L 1.67 (1.03-2.70) and > 4 L 2.34 (1.23-4.44) and a reduced risk of renal failure [OR, 95% CI for 2-4 L 0.48 (0.28-0.83) and > 4 L 0.45 (0.22-0.92)] in the first 24 hr of severe sepsis. Administration of colloid and crystalloid fluid as compared to crystalloid fluid alone was associated with a lower risk of renal failure [OR, 95% CI 0.45 (0.26 to 0.76)]. An association between hospital mortality and quantity or type of fluid administered in the first six hours after the diagnosis of severe sepsis was not identifiable. These findings should be considered as hypothesis-generating and warrant confirmation or refutation by randomized controlled trials. La reanimation liquidienne est un facteur crucial pour restaurer la stabilite hemodynamique et la perfusion tissulaire chez les patients en septicemie severe. Nous avons cherche a examiner les liens entre la quantite et le type de liquide administre durant les six premieres heures suivant le diagnostic d’une septicemie severe et la mortalite hospitaliere, la mortalite aux soins intensifs et la defaillance systemique. Une etude de cohorte retrospective et multi-centrique a ete entreprise dans cinq unites de soins intensifs de soins tertiaires au Canada. Nous avons identifie les patients atteints de septicemie severe admis aux soins intensifs entre le 1er juillet 2000 et le 30 juin 2002, en se fondant sur des bases de donnees administratives et cliniques. Les criteres d’inclusion comprenaient: l’hypotension, la presence d’une source infectieuse, et au minimum deux criteres du syndrome de reponse inflammatoire systemique. Nous avons enregistre la quantite totale et le type de liquide administre durant les six premieres heures suivant le diagnostic d’une septicemie severe. Le premier episode d’hypotension a defini le point de depart pour la recolte des donnees concernant les liquides administres. Des analyses de regression multivariees ont ete menees afin d’examiner les liens entre la quantite et le type de liquide administre et la mortalite a l’hopital/aux soins intensifs, ainsi que la defaillance systemique. Parmi les 2 026 dossiers de patients potentiellement eligibles, 496 patients ont presente les criteres d’admissibilite. L’âge moyen et le score APACHE II (Acute Physiology and Chronic Health Evaluation) etaient de 61,8 ± 16,5 ans et 29,0 ± 8,0, respective-ment. Aucun lien entre la quantite ou le type de liquide administre et la mortalite a l’hopital ou aux soins intensifs n’a ete identifie, et nous n’avons pas trouve de liens statistiquement significatifs entre la quantite ou le type de liquide administre et la defaillance systemi-que. Toutefois, davantage de reanimation liquidienne a ete associee a un risque accru de defaillance cardiovasculaire [rapport de cote (OR) et intervalle de confiance (CI) de 95 %] pour 2-4 L 1,67 (1,03-2,70) et> 4L 2,34 (1,23-4,44) ainsi qu’un risque reduit de defaillance renale [OR, CI 95 % pour 2-4 L 0,48 (0,28-0,83) et> 4L 0,45 (0,22-0,92)] durant les premieres 24 h de septice-mie severe. L’administration simultanee de colloide et cristalloide, comparativement a du cristalloide seul, a ete associee a un risque moindre de defaillance renale [OR, CI 95 % 0,45 (0,26 a 0,76)]. Aucune association entre la mortalite a l’hopital et la quantite ou le type de liquide administre durant les six premieres heures suivant le diagnostic d’une septicemie severe n’a pu etre identifiee. Ces donnees devraient etre considerees comme generatrices d’hypotheses et exigent leur confirmation ou, au contraire, leur refutation, par des etudes randomisees controlees.

The safety of percutaneous tracheostomy in patients with coagulopathy or thrombocytopenia.

Abstract: The safety and complications of percutaneous tracheostomy (PT) without bronchoscopic guidance in a group of ICU patients with thrombocytopenia platelet count of or = 1.5 or systemic heparinization), was studied. During the study period (May 2004-June 2005), 190 percutaneous tracheostomies were performed. Of these there were 11 (6%) patients with prolonged INR, 7 (4%) patients with thrombocytopenia and 14 (7%) patients on systemic heparin. There was no evidence of bleeding in patients with prolonged INR. A minor bleeding developed in only one patient with thrombocytopenia, and in two patients receiving systemic heparin. The PT was aborted for one patient with thrombocytopenia and slight increase of INR (1.3) due to major bleeding in spite of transfusion of both platelets and FFP. Our data suggest the incidence of bleeding is low in patients with coagulopathy and or thrombocytopenia-undergoing PT without bronchoscopic guidance.

Empiric antimicrobial therapy in critical illness: results of a surgical infection society survey.

Abstract: Background: Antibiotics are prescribed commonly in the intensive care unit (ICU). Often, therapy is initiated empirically; practice patterns are not well characterized. We documented approaches to ...

Targeting anemia with erythropoietin during critical illness

Abstract: The overall goals of clinical research in the intensive care unit (ICU) are to improve clinical outcomes through enhanced understanding of how critical illness develops and how such illness is best prevented, diagnosed, treated, or palliated. Several “normal” physiological measurements and laboratory values have been abandoned as therapeutic targets during critical illness, since in some randomized trials, attempts to normalize these measurements and values have shown either harm or no benefit with respect to clinical outcomes. One such target is the hemoglobin concentration. Anemia is commonly acquired in the ICU owing to hemodilution, blood loss, reduced red-cell production, and enhanced . . .

Pneumonia Observational Incidence and Treatment: A Multidisciplinary Process Improvement Study

Abstract: Background Little information is available on the types, causes, and treatment of pneumonia in intensive care unit patients in usual clinical practice. Objective To characterize treatment of patients with presumed pneumonia in a tertiary care intensive care unit and to identify potential areas for improvement in care. Methods In a prospective, cohort study, the sample consisted of all consecutive patients treated in an intensive care unit during a 3-month period. For patients with presumed pneumonia, data were collected on incidence of pneumonia, diagnostic investigations, microbial isolates, and antibiotics prescribed. Results Of 194 admissions, 73 patients were treated for pneumonia: 47 had community-acquired pneumonia; 12 had hospital-acquired pneumonia; 12 had ventilator-associated pneumonia, both early (7) and late (5); and 2 had intensive care unit-acquired pneumonia. Approximately 71% of patients had microbiological tests performed. Among 54 microbial isolates, 51.9% were gram-positive bacteria, 31.5% were gram-negative bacteria, and 9.3% were Candida species. The most commonly used antimicrobials were quinolones (54 of 192 prescriptions) and cephalosporins (33); each patient received a median of 3 antibiotics. Conclusions Most cases of pneumonia were community acquired. The most common causative organisms were gram-positive cocci. Four quality improvement strategies were rationalization of antibiotic use during rounds, nurses' reporting of culture results, review of antibiotic appropriateness by a pharmacist, and redesign of the clinical information system.

A communication strategy and brochure reduced the burden of bereavement on relatives of patients dying in the intensive care unit.

Abstract: Source Citation Lautrette A, Darmon M, Megarbane B, et al. A communication strategy and brochure for relatives of patients dying in the ICU. N Engl J Med. 2007;356:469-78. 17267907