Showing papers by "Deborah J. Cook published in 2010"
TL;DR: Evaluating the association of higher vs lower PEEP with patient-important outcomes in adults with acute lung injury or ARDS who are receiving ventilation with low tidal volumes found that higher levels were associated with improved survival among the subgroup of patients with ARDS, but lower levels were not associated withImproved hospital survival.
Abstract: Context Trials comparing higher vs lower levels of positive end-expiratory pressure (PEEP) in adults with acute lung injury or acute respiratory distress syndrome (ARDS) have been underpowered to detect small but potentially important effects on mortality or to explore subgroup differences. Objectives To evaluate the association of higher vs lower PEEP with patient-important outcomes in adults with acute lung injury or ARDS who are receiving ventilation with low tidal volumes and to investigate whether these associations differ across prespecified subgroups. Data Sources Search of MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (1996-January 2010) plus a hand search of conference proceedings (2004-January 2010). Study Selection Two reviewers independently screened articles to identify studies randomly assigning adults with acute lung injury or ARDS to treatment with higher vs lower PEEP (with low tidal volume ventilation) and also reporting mortality. Data Extraction Data from 2299 individual patients in 3 trials were analyzed using uniform outcome definitions. Prespecified effect modifiers were tested using multivariable hierarchical regression, adjusting for important prognostic factors and clustering effects. Results There were 374 hospital deaths in 1136 patients (32.9%) assigned to treatment with higher PEEP and 409 hospital deaths in 1163 patients (35.2%) assigned to lower PEEP (adjusted relative risk [RR], 0.94; 95% confidence interval [CI], 0.86-1.04; P = .25). Treatment effects varied with the presence or absence of ARDS, defined by a value of 200 mm Hg or less for the ratio of partial pressure of oxygen to fraction of inspired oxygen concentration (P = .02 for interaction). In patients with ARDS (n = 1892), there were 324 hospital deaths (34.1%) in the higher PEEP group and 368 (39.1%) in the lower PEEP group (adjusted RR, 0.90; 95% CI, 0.81-1.00; P = .049); in patients without ARDS (n = 404), there were 50 hospital deaths (27.2%) in the higher PEEP group and 44 (19.4%) in the lower PEEP group (adjusted RR, 1.37; 95% CI, 0.98-1.92; P = .07). Rates of pneumothorax and vasopressor use were similar. Conclusions Treatment with higher vs lower levels of PEEP was not associated with improved hospital survival. However, higher levels were associated with improved survival among the subgroup of patients with ARDS.
1,268 citations
TL;DR: Although colloid solutions are more expensive and may possibly be harmful in some patients, they were administered to more patients and during more resuscitation episodes than crystalloids were and choice of fluid varies markedly between countries.
Abstract: Recent evidence suggests that choice of fluid used for resuscitation may influence mortality in critically ill patients. We conducted a cross-sectional study in 391 intensive care units across 25 countries to describe the types of fluids administered during resuscitation episodes. We used generalized estimating equations to examine the association between patient, prescriber and geographic factors and the type of fluid administered (classified as crystalloid, colloid or blood products). During the 24-hour study period, 1,955 of 5,274 (37.1%) patients received resuscitation fluid during 4,488 resuscitation episodes. The main indications for administering crystalloid or colloid were impaired perfusion (1,526/3,419 (44.6%) of episodes), or to correct abnormal vital signs (1,189/3,419 (34.8%)). Overall, colloid was administered to more patients (1,234 (23.4%) versus 782 (14.8%)) and during more episodes (2,173 (48.4%) versus 1,468 (32.7%)) than crystalloid. After adjusting for patient and prescriber characteristics, practice varied significantly between countries with country being a strong independent determinant of the type of fluid prescribed. Compared to Canada where crystalloid, colloid and blood products were administered in 35.5%, 40.6% and 28.3% of resuscitation episodes respectively, odds ratios for the prescription of crystalloid in China, Great Britain and New Zealand were 0.46 (95% confidence interval (CI) 0.30 to 0.69), 0.18 (0.10 to 0.32) and 3.43 (1.71 to 6.84) respectively; odds ratios for the prescription of colloid in China, Great Britain and New Zealand were 1.72 (1.20 to 2.47), 4.72 (2.99 to 7.44) and 0.39 (0.21 to 0.74) respectively. In contrast, choice of fluid was not influenced by measures of illness severity (for example, Acute Physiology and Chronic Health Evaluation (APACHE) II score). Administration of resuscitation fluid is a common intervention in intensive care units and choice of fluid varies markedly between countries. Although colloid solutions are more expensive and may possibly be harmful in some patients, they were administered to more patients and during more resuscitation episodes than crystalloids were.
347 citations
TL;DR: Vasopressin may reduce progression to renal failure and mortality in patients at risk of kidney injury who have septic shock and the interaction of treatment group and RIFLE category was significant in predicting mortality.
Abstract: To compare the effects of vasopressin versus norepinephrine infusion on the outcome of kidney injury in septic shock Post-hoc analysis of the multi-center double-blind randomized controlled trial of vasopressin versus norepinephrine in adult patients who had septic shock (VASST) Seven hundred seventy-eight patients were randomized to receive a blinded infusion of either low-dose vasopressin (001–003 U/min) or norepinephrine infusion (5–15 μg/min) in addition to open-label vasopressors and were included in the outcome analysis All vasopressors were titrated and weaned to maintain a target blood pressure RIFLE criteria for acute kidney injury were used to compare the effects of vasopressin versus norepinephrine In view of multiple simultaneous comparisons, a p value of 001 was considered statistically significant Kidney injury was present in 464 patients (596%) at study entry In patients in the RIFLE “Risk” category (n = 106), vasopressin as compared with norepinephrine was associated with a trend to a lower rate of progression to renal “Failure” or “Loss” categories (208 vs 396%, respectively, p = 003), and a lower rate of use of renal replacement therapy (170 vs 377%, p = 002) Mortality rates in the “Risk” category patients treated with vasopressin compared to norepinephrine were 308 versus 547%, p = 001, but this did not reach significance in a multiple logistic regression analysis (OR = 033, 99% CI 010–109, p = 002) The interaction of treatment group and RIFLE category was significant in predicting mortality Vasopressin may reduce progression to renal failure and mortality in patients at risk of kidney injury who have septic shock
208 citations
TL;DR: End-of-life care in Canada may be improved by providing better psychological and spiritual support, better planning of care and enhanced relationships with physicians, especially in aspects related to communication and decision-making.
Abstract: We used these comprehensive ratings of importance to develop and validate a novel questionnaire to measure satisfaction with endof-life care. 10 Using this questionnaire, we formally evaluated the care received at the end of life in several Canadian centres. By targeting initiatives for change at gaps in quality, we can address the highest priorities for improving end-of-life care in Canada. Our objective was to identify high-priority areas for improvement in the care of patients with advanced, life-limiting diseases and in the perceived quality of that care by their families. We identified these areas by focusing on care-related issues that had been rated as important by patients and their family members but were rated low on the questionnaire measuring satisfaction with end-of-life care.
136 citations
TL;DR: It is concluded that HIT is uncommon in critically ill patients and that the 4Ts score is worthy of further evaluation in this patient population.
112 citations
TL;DR: Low-dose corticosteroids administered within 14 days of disease onset may reduce all-cause mortality in patients with acute lung injury, acute respiratory distress syndrome, and severe pneumonia, however, the overall quality of the evidence precludes definitive conclusions regarding the use of cortICosteroids in this population.
99 citations
TL;DR: The CANHELP Questionnaire is a valid and internally consistent instrument to measure satisfaction with end-of-life care and good correlations between the overall satisfaction score and global rating of satisfaction were observed.
Abstract: The purpose of this study was to further validate a novel instrument to measure satisfaction with end-of-life care, called the Canadian Health Care Evaluation Project (CANHELP) questionnaire. Data were collected by a cross-sectional survey of patients who had advanced, life-limiting illnesses and their family caregivers, and who completed CANHELP, a global rating of satisfaction, and a quality of life questionnaire. We conducted factor analysis, assessed internal consistency using Cronbach's alpha, and evaluated construct validity by describing the correlation amongst CANHELP, global rating of satisfaction and the quality of life questionnaire scores. There were 361 patient and 193 family questionnaires available for analysis. In the factor analysis, we identified six easily interpretable factors which explained 55.4% and 60.2% of the variance for the patient and caregiver questionnaire, respectively. For the patient version, the subscales derived from these factors were Relationship with Doctors, Illness Management, Communication, Decision-Making, Role of the Family, and Your Well-being. For the family questionnaire, the factors were Relationship with Doctors, Characteristics of Doctors and Nurses, Illness Management, Communication and Decision-Making, Your Involvement, and Your Well-being. Each subscale for each questionnaire had acceptable to excellent internal consistency (Cronbach's alpha ranged from 0.69-0.94). We observed good correlations between the CANHELP overall satisfaction score and global rating of satisfaction (correlation coefficient 0.49 and 0.63 for patient and family, respectively) which was greater than the correlations between CANHELP and the quality of life instruments. We conclude that the CANHELP Questionnaire is a valid and internally consistent instrument to measure satisfaction with end-of-life care.
73 citations
TL;DR: The prevalence, incidence, risk factors, clinical consequences, prophylaxis against venous thromboembolism in critically ill patients, and compliance with thromboprophylaxis are described.
Abstract: Critically ill patients in the medical-surgical intensive care unit are at high risk for deep venous thrombosis and pulmonary embolism, which comprise venous thromboembolism. Herein, we describe the prevalence, incidence, risk factors, clinical consequences, prophylaxis against venous thromboembolism in critically ill patients, and compliance with thromboprophylaxis. We focus primarily on medical-surgical intensive care unit patients, who represent the largest subgroup of critically ill patients. Despite the large and growing number of critically ill patients in our aging society, their high risk for venous thromboembolism, and the morbidity and mortality associated with this complication of critical illness, relatively few rigorous studies are available. Large, well-designed, randomized trials of thromboprophylaxis, powered to detect differences in patient-important outcomes, are required to advance our understanding and care of these vulnerable patients. Furthermore, because thromboprophylaxis is a common error of omission in hospitalized patients, redoubled efforts are needed to ensure that it is used in practice.
69 citations
TL;DR: Assessment of the etiology of cardiac troponin elevation among patients admitted to the intensive care unit (ICU) and whether etiology affects mortality and length of stay found patients with elevated Troponin had worse outcomes compared with patients without trop onin elevation, and tropon in elevation not due to MI was predictive of increased hospital mortality.
59 citations
51 citations
TL;DR: Recommendations are proposed to clinical investigators and research ethics committees regarding clinical and health services research on pandemic-related critical illness, and strategies such as expedited and centralized research ethics committee reviews and alternate consent models are proposed.
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
TL;DR: This work assesses literature reviews of therapeutic interventions for sepsis that include animal experiments for explicit appraisals of the risk of bias and clinical relevance and proposes a framework to enhance these features in future reviews of preclinical research.
Abstract: Objective:Certain methodologic features of animal experiments such as random assignment have been found to reduce the risk of bias. Because animal research sometimes informs clinical practice, explicit acknowledgment of the risk of bias and clinical relevance cultivates realistic expectations on the
TL;DR: In this paper, the roles and responsibilities of physicians, substitute decision makers, and the judicial system when decisions must be made on behalf of incapable persons, and a framework for conflict resolution during end-of-life decision-making for physicians practicing in Canada are provided.
Abstract: Background: End-of-life decisions regarding the administration, withdrawal or withholding of life-sustaining therapy in the critical care setting can be challenging. Disagreements between health care providers and family members occur, especially when families believe strongly in preserving life, and physicians are resistant to providing medically “futile” care. Such disagreements can cause tension and moral distress among families and clinicians.
Purpose: To outline the roles and responsibilities of physicians, substitute decision makers, and the judicial system when decisions must be made on behalf of incapable persons, and to provide a framework for conflict resolution during end-of-life decision-making for physicians practicing in Canada.
Source: We used a case-based example to illustrate our objectives. We employed a comprehensive approach to understanding end-of-life decision making that included: 1) a search for relevant literature; 2) a review of provincial college policies; 3) a review of provincial legislation on consent; 4) a consultation with two bioethicists and 5) a consultation with two legal experts in health law.
Principal Findings: In Canada, laws about substitute decision-making for health care are primarily provincial or territorial. Thus, laws and policies from professional regulatory bodies on end-of-life care vary across the country. We tabulated the provincial college policies on end-of-life care and the provincial legislation on consent and advance directives, and constructed a 10-step approach to conflict resolution.
Conclusion: Knowledge of underlying ethical principles, understanding of professional duties, and adoption of a process for mediation and conflict resolution are essential to ensuring that physicians and institutions act responsibly in maintaining a patients’ best interests in the context of family-centred care.
TL;DR: The future of clinical critical care nutrition research is promising, with more trials of increasing sample size being conducted and robust trial methodology, transparent reporting, and the development of research networks will help to further advance this important field.
Abstract: Background: The purpose of this methodological review is to quantify and qualify critical care nutrition randomized controlled trials (RCTs) that inform our practice, to evaluate their strengths and limitations, and to recommend strategies for improving the design of future trials in this area. Methods: The literature was systematically reviewed to find all RCTs published between 1980 and December 2008 that evaluated nutrition interventions in critical care. Data were abstracted on the nature and quality of included RCTs. Results: A total of 207 RCTs met the inclusion criteria. Of these, 170 (82.1%) were single-center, and 37 (17.9%) were multicenter. The largest number of trials evaluated intensive insulin therapy (n = 25), arginine-supplemented diets (n = 22), and supplemental parenteral glutamine (n = 17). The first RCTs were published in 1983 (n = 2), and the mean sample size was 39.0. In 2008, there were 26 RCTs, each enrolling an average of 237.1 patients. Excluding 2 cluster RCTs, 62 of 205 (30.2%)...
TL;DR: More research is needed on PE in medical-surgical ICU patients including issues on the epidemiologic aspects of PE and treatment of PE (including pharmacologic and nonpharmacologic approaches, determinants of treatment variation, and predictors of PE outcome adjusted for treatment).
Abstract: Pulmonary embolism (PE) is the most dangerous complication of venous thrombosis. Objectively confirmed PE is a potentially life-threatening complication of critical illness. In medical-surgical critically ill patients, signs and symptoms are nonspecific, the clinical pretest probability may be low, and diagnostic tests may not be done or may yield ambiguous results. Therefore, PE is often undiagnosed and untreated; autopsy findings indicate that PE is common in intensive care unit (ICU) decedents. PE may delay weaning from mechanical ventilation, increase the length of stay in ICU and hospital, and increase the risk of death. More research is needed on PE in medical-surgical ICU patients including issues on the epidemiologic aspects of PE (including risk factors and attributable morbidity and mortality) and treatment of PE (including pharmacologic and nonpharmacologic approaches, determinants of treatment variation, and predictors of PE outcome adjusted for treatment).
TL;DR: It is demonstrated that perioperative ASA usage as reported by surgeons is variable, identifying the need for, and community interest in, a large peri operative ASA trial.
Abstract: Purpose: Major cardiovascular complications associated with noncardiac surgery represent a substantial population health problem for which there are no established efficacious and safe prophylactic interventions. Acetyl-salicylic acid (ASA) represents a promising intervention. The objective of this study was to determine surgeons’ perioperative usage of ASA, and if they would enrol their patients in a perioperative ASA randomized controlled trial (RCT).
Methods: Cross-sectional survey of all practicing Canadian general, orthopedic, and vascular surgeons. Our mailed, self-administered survey asked surgeons to consider only their patients who were at risk of a major perioperative cardiovascular complication.
Results: The response rate was 906/1854 (49%). For patients taking ASA chronically, there was marked variability regarding ASA continuation prior to surgery amongst the general and orthopedic surgeons, whereas 76% of vascular surgeons continued ASA in 81-100% of their patients. For patients not taking ASA chronically, approaches to starting ASA prior to surgery were variable amongst the vascular surgeons, whereas 70% of general and 82% of orthopaedic surgeons did not start ASA. For patients taking ASA chronically, 73% of general surgeons, 70% of orthopaedic surgeons, and 36% of vascular surgeons would allow at least 40% of their patients to participate in a perioperative RCT comparing stopping versus continuing ASA. For patients not taking ASA chronically, most general (76%), orthopaedic (67%), and vascular (51%) surgeons would allow at least 40% of their patients to participate in a perioperative RCT comparing starting ASA versus placebo.
Conclusion: This national survey demonstrates that perioperative ASA usage as reported by surgeons is variable, identifying the need for, and community interest in, a large perioperative ASA trial.
TL;DR: Trials comparing higher versus lower levels of positive end-expiratory pressure (PEEP) in adults with acute lung injury or acute respiratory distress syndrome were underpowered to detect small but important effects on mortality, overall or in any subgroups.
Abstract: Trials comparing higher versus lower levels of positive end-expiratory pressure (PEEP) in adults with acute lung injury or acute respiratory distress syndrome (ARDS) were underpowered to detect small but important effects on mortality, overall or in any subgroups.
01 May 2010
01 May 2010
01 May 2010