Showing papers by "Margaret S. Herridge published in 2007"

Weaning from mechanical ventilation

Abstract: Weaning covers the entire process of liberating the patient from mechanical support and from the endotracheal tube. Many controversial questions remain concerning the best methods for conducting this process. An International Consensus Conference was held in April 2005 to provide recommendations regarding the management of this process. An 11-member international jury answered five pre-defined questions. 1) What is known about the epidemiology of weaning problems? 2) What is the pathophysiology of weaning failure? 3) What is the usual process of initial weaning from the ventilator? 4) Is there a role for different ventilator modes in more difficult weaning? 5) How should patients with prolonged weaning failure be managed? The main recommendations were as follows. 1) Patients should be categorised into three groups based on the difficulty and duration of the weaning process. 2) Weaning should be considered as early as possible. 3) A spontaneous breathing trial is the major diagnostic test to determine whether patients can be successfully extubated. 4) The initial trial should last 30 min and consist of either T-tube breathing or low levels of pressure support. 5) Pressure support or assist-control ventilation modes should be favoured in patients failing an initial trial/trials. 6) Noninvasive ventilation techniques should be considered in selected patients to shorten the duration of intubation but should not be routinely used as a tool for extubation failure.

One-year outcomes and health care utilization in survivors of severe acute respiratory syndrome.

Abstract: Background Severe Acute Respiratory Syndrome (SARS) became a global epidemic in 2003. Comprehensive information on 1-year outcomes and health care utilization is lacking. Research conducted during the SARS outbreak may help inform research planning for future public health emergencies. The objective of this study was to evaluate the 1-year outcomes in survivors of SARS and their family caregivers. Method The study was prospective and observational. We evaluated 117 SARS survivors from Toronto, Ontario. Patients were interviewed and underwent physical examination, pulmonary function testing, chest radiography, a 6-minute-walk test, quality-of-life measures, and self-report of health care utilization. At 1 year, informal caregivers were identified for a survey on caregiver burden. Results The enrolled survivors of SARS were young (median age, 42 years), and most were women (67%) and health care workers (65%). At 1 year after hospital discharge, pulmonary function measures were in the normal range, but 18% of patients had a significant reduction in distance walked in 6 minutes. The Medical Outcomes Study 36-Item Short Form Health Survey (SF-36) domains were 0.3 to 1.0 SD below normal at 1 year. Of the patients, 17% had not returned to work by 1 year. Fifty-one patients required 668 visits to psychiatry or psychology practitioners. During the SARS epidemic, informal caregivers reported a decline of 1.6 SD below normal on the mental component score of the SF-36. Conclusions Most SARS survivors had good physical recovery from their illness, but some patients and their caregivers reported a significant reduction in mental health 1 year later. Strategies to ameliorate the psychological burden of an epidemic on the patient and family caregiver should be considered as part of future pandemic planning.

Neuromuscular function in survivors of the acute respiratory distress syndrome.

Abstract: Contexte : Les survivants du syndrome de detresse respiratoire aigue (SDRA) se plaignent d'une faiblesse generalisee et d'une diminution de la tolerance a l'effort plus de deux ans apres leur conge de l'unite de soins intensifs. Il est possible que des complications neuromusculaires persistantes du SDRA contribuent a l'invalidite fonctionnelle observee chez ces patients. Methodes : Seize survivants du SDRA ont subi une evaluation neurologique complete et un electrodiagnostic standardise, 6 a 24 mois apres leur sortie de l'unite de soins intensifs. Quatre de ces patients ont consenti a subir une biopsie musculaire ouverte. Resultats : Sept des seize patients avaient des mononeuropathies compressives focales qui etaient significatives au point de vue clinique. L'electrodiagnostic n'a pas revele de changements attribuables a une polyneuropathie ou a une myopathie reliee a une maladie grave. Les quatre biopsies musculaires etaient anormales et, bien que les anomalies anatomopathologiques n'etaient pas specifiques au point de vue structural, la presence d'une myopathie acquise demeure possible. Quatre patients se plaignaient de troubles sensitifs mixtes persistants, mais leur evaluation electrodiagnostique etait normale. Conclusions : La frequence elevee des mononeuropathies demontre qu'il faut etre vigilant en ce qui concerne les soins quotidiens a l'unite de soins intensifs. Nos constatations suggerent egalement que la faiblesse et la diminution de la tolerance a l'effort chez les survivants du SDRA pourraient etre reliees aux effets combines de neuropathies compressives et de changements structuraux generalises presents de longue date au niveau des muscles, et que l'invalidite fonctionnelle prolongee a une base organique chez ces patients.

Review of retention strategies in longitudinal studies and application to follow-up of ICU survivors

Abstract: Objective To review the literature on retention strategies in follow-up studies and their relevance to critical care and to comment on the Toronto experience with the acute respiratory distress syndrome (ARDS) and severe acute respiratory syndrome (SARS) follow-up studies.

Long-term outcomes after critical illness: past, present, future.

Abstract: Introduction This issue of Current Opinion in Critical Care challenges us to reflect on where we have come in our understanding of outcomes and to renew our commitment to future research. We now understand that nerve, muscle and brain dysfunction represent the major, and often irreversible, morbidities sustained from an episode of critical illness. We still understand, however, so little about the pathogenesis of these lesions. This highlights the need for more focused longitudinal studies to better characterize inherent and extrinsic risk factors, risk modifiers and the basic science of muscle, nerve and brain injury. As well, recent literature has highlighted the enormous burden on professional caregivers during and after an episode of critical illness and our need to evaluate process of care issues and organizational structure to preserve this precious and finite human resource to further optimize outcomes. There are now enormous numbers of survivors of critical illness and we must discuss strategies to elevate the profile of ICU patients and family caregivers to align public health policy and planning with these burgeoning needs. Finally, we need to design and test future interventions for patients and family caregivers to achieve the best possible outcomes for our ICU survivors and their families. These are significant, but not insurmountable challenges, as evidenced by our acquisition of important new knowledge over the past several years.

Physical consequences of critical illness

Abstract: Patients who survive critical illness are at risk of permanent physical and functional deficits which decrease the health-related quality of life. The reasons for physical morbidity include the nature of and treatment for the inciting critical illness, new decrements in organ function and worsening of pre-existing organ dysfunction, and prolonged physical immobility and long intensive care unit stay.