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Abstracts |
The King Award is presented annually by the Canadian Critical Care Society for the best oral presentation by a resident. This award is named after Dr Garner King, who was past Professor and Head of the Department of Medicine at the University of Alberta. Dr King trained many of the first generations of critical care physicians in Canada, and also many from abroad. He was the second president of the Canadian Critical Care Society (1978–1980).
Toronto Critical Care Medicine Symposium Toronto, Ontario October 26 – October 28, 2005
1st. prize and King Award
Name: Alexis F. Turgeon
Position: Clinical and Research Fellow
Professional Initials: MD MSc FRCPC
Department: Critical Care Medicine
Institution: University of Ottawa, The Ottawa Hospital - General Campus
Address: 501 Smyth Road, BOX 207
City: Ottawa
Province: Ontario
Country: Canada
Postal Code: K1H 8L6
E-mail: alexisturgeon{at}yahoo.ca
Co Authors Name: Brian Hutton, Dean Fergusson, Paul C. Hébert, Lauralyn McIntyre
Institution Affiliation: OHRI - Centre for Transfusion and Critical Care Research
EFFECT OF INTRAVENOUS IMMUNOGLOBULINS IN CRITICALLY ILL ADULTS WITH SEPSIS: A META-ANALYSIS
Alexis F. Turgeon MD MSc FRCPC, Brian Hutton MSc, Dean Fergusson MHA PhD, Paul C. Hébert MD MSc FRCPC, Lauralyn McIntyre MD MSc FRCPC, for the Centre for Transfusion and Critical Care Research and the Critical Care Medicine Program, University of Ottawa, Ottawa, Canada.
Introduction: Intravenous immunoglobulin therapy has been proposed as an adjuvant treatment in sepsis. However, the benefit of the therapy remains unclear and its use is not currently recommended. This systematic review evaluated the effect of polyclonal iv immunoglobulin therapy on mortality in critically ill adult patients with sepsis.
Methods: A systematic search strategy was applied to Medline (1966–September 2005) and the Cochrane Register of Controlled Trials (September 2005) to identify all randomized controlled trials of polyclonal iv immunoglobulin therapy with a placebo comparison or no intervention during the course of sepsis, severe sepsis or septic shock in critically ill adult patients. Abstracts and book chapters were included, and no restriction was placed on language of publication. The primary endpoint was all-cause mortality. Review of citations retrieved from the electronic search, methodological assessment and data extraction were independently performed by two investigators. References of all identified trials were reviewed for additional studies. Authors of trials were contacted to provide additional clinical data or information on methodology when unclear.
Results: Eighteen trials (n = 2,127) met eligibility criteria and were included in the analysis. Polyclonal iv immunoglobulin therapy was associated with an overall survival benefit of 32% (risk ratio [RR] = 0.68, 95% confidence interval [CI], 0.55–0.84) compared to placebo or no intervention. The benefit of the therapy improved when only published data and peer-reviewed trials were analyzed (RR = 0.66, 95% CI, 0.49–0.85), (13 trials, n = 1287) and when only trials designed with a placebo group were included (RR = 0.61, 95% CI, 0.40–0.93), (7 trials, n = 896). From the three high-quality trials (n = 701) including one large unpublished trial trending toward negative, pooled results showed a trend for a survival benefit (RR = 0.78, 95% CI, 0.43–1.40). No major side effect attributable to iv immunoglobulin therapy was reported in any of the trials.
Conclusion: We observed a survival benefit from all summary estimates of studies with the use of polyclonal iv immunoglobulin therapy in sepsis compared to placebo or no intervention. Despite most studies being conducted before the current standard of therapy for sepsis was established, it should be considered as a potential adjuvant therapy. However, polyclonal iv immunoglobulin therapy should be further studied in well-defined high-risk populations with the current standard of therapy before its systematic use is recommended.
Special Mention
Name: Stephanie Vandenberg
Position: Health Sciences Student
Department: Critical Care Medicine
Institution: Hospital for Sick Children
City: Toronto
Country: Canada
Telephone: 416-813-6504
E-mail: chris{at}sickkids.ca
Co Authors Name: James Hutchison, Christopher S. Parshuram
Institution Affiliation: Hospital for Sick Children
CROSS-SECTIONAL SURVEY OF LEVELS OF CARE AND RESPONSE MECHANISMS FOR EVOLVING CRITICAL ILLNESS IN NORTH AMERICAN PEDIATRIC HOSPITALS
Stephanie Vandenberg, James Hutchison, Christopher S. Parshuram
Objective: Cardiopulmonary arrest in children is frequently devastating, and may be preceded by recognizable clinical deterioration. We sought to describe the levels of care, the frequency of code blues (CB), and identification and response mechanisms for evolving critical illness in North American paediatric hospitals.
Methods: A cross-sectional telephone survey of North American hospitals was performed. Included hospitals had > 50 acute care pediatric beds and > two wards. The survey was developed by two investigators (CP, SV), and was reviewed by the Canadian Critical Care Trials Group.
Results: Four hundred and sixty-four hospitals were contacted. Responses were received from 388 (84%) hospitals, and 398 respondents. All included hospitals had PICUs, 99 (55%) had HDUs, 101 (56%) had ECMO, and 69 (38%) used ECMO for refractory cardiopulmonary arrest. The size of the PICU was variably significant. All hospitals had CB teams; 175 (97%) had intermediate response mechanisms for children who were clinically deteriorating: 29 (17%) had formal medical emergency teams (MET), 92 (53%) consulted the PICU, and 14 (8%) used CB teams. Twenty-three (13%) hospitals reported they were developing a pediatric MET. Only one hospital used a formal early warning score to identify clinical deterioration.
Conclusion: Code blues occurrence was not infrequent and was treated by CB teams. Most hospitals (97%) had additional urgent-response mechanisms for children who were clinically deteriorating; 17% had a formal MET team, and 23 hospitals were developing MET teams. The size of the PICU was the only variable independently associated with CB frequency. While most hospitals had formal mechanisms to treat sick patients, the process of identification was unstructured and may not facilitate the optimal use of response teams.
Outstanding Resident Poster #1
Name: Eddy Fan
Position: Fellow
Professional Initials: MD, FRCPC
Department: Interdepartmental Division of Critical Care Medicine
Institution: University of Toronto
City: Toronto
Province: Ontario
Country: Canada
Postal Code: M5B 2R6
Telephone: 416-616-2345
E-mail: eddy_fan{at}yahoo.ca
Co Authors Name: Russell D. MacDonald,3,4,5 Neill K.J. Adhikari,1,5 Damon C. Scales,1,6 Randy S. Wax,1,2 Thomas E. Stewart,1,2,7 Niall D. Ferguson1,7
Institution Affiliation: Interdepartmental Division of Critical Care Medicine,1 University of Toronto, Toronto, Canada; Mount Sinai Hospital,2 Toronto, Canada; Division of Emergency Medicine,3 Department of Medicine, University of Toronto, Toronto, Canada; Ontario Air Ambulance Base Hospital Program,4 Toronto, Canada; Sunnybrook and Women’s College Health Sciences Centre,5 Toronto, Canada; St. Michael’s Hospital,6 Toronto, Canada; and the University Health Network,7 Toronto, Canada
OUTCOMES OF INTERFACILITY CRITICAL CARE ADULT PATIENT TRANSPORT: A SYSTEMATIC REVIEW
Russell D. MacDonald,3,4,5 Neill K.J. Adhikari,1,5 Damon C. Scales,1,6 Randy S. Wax,1,2 Thomas E. Stewart,1,2,7 Niall D. Ferguson1,7
Objective: To determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients.
Design: Systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until January 10, 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. Bibliographies of selected articles were also examined.
Results: Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (3 studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies.
Conclusions: Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, and/or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.
Name: François Marquis
Position: Staff Physician
Department: Critical Care Unit
Institution: Maisonneuve-Rosemont Hospital
Address: 5415 l’Assomption blvd
City: Montréal
Province: Québec
Country: Canada
Postal Code: H1T 2M4
Telephone: 514-252-3400 #4558
E-mail: f.marquis{at}sympatico.ca
Co Authors Name: Rahima Jamal, Isabelle Ayotte, Sébastien Ouimet, Yoanna Skrobik
Institution Affiliation: Maisonneuve-Rosemont Hospital
VALIDITY AND RELIABILITY OF BEDSIDE NURSING ASSESSMENTS OF PAIN, SEDATION AND DELIRIUM
François Marquis, Rahima Jamal, Isabelle Ayotte, Sébastien Ouimet, Yoanna Skrobik
Introduction: Critically ill patients should routinely be evaluated for the presence and intensity of pain, assessed as to their sedation level, and screened for delirium. However, assessing both pain and delirium in intensive care unit (ICU) patients is particularly challenging, given the confounding effect of sedation. The purpose of this study was to describe the validity and reliability of real-time practice-based nursing concurrent assessments of pain, sedation and delirium, in an ICU where these three assessments occur as part of routine nursing care.
Methods: Thirty randomly selected nurses were observed by one of two trained adjudicators for documentation and clinical bedside evaluation of pain, sedation level and delirium scoring. The scales were the numeric rating scale,1 the Richmond agitation and sedation scale2 and the intensive care delirium screening checklist3 score for the evaluation of delirium. Each feature was assessed as to documentation in the bedside nursing sheets; accurate use of a scale; and validity of use of the scale with a joint bedside examination of the patient.
Results: The reliability between adjudicators for the bedside evaluation of pain and sedation was 100%. The Cronbach’s 
score for the evaluation of delirium was 86.3% overall. Except for the agitation/slowing criteria (70.8%), reliability between adjudicators was over 80% for the other seven criteria of the delirium score. A majority of nurses (27/30) documented pain assessments and 20/30 followed recommended standards. Nurses relied on their own evaluation of the patient’s pain 25% of the time, without an objective patient-driven scale. Bedside pain evaluation comparing nurses to adjudicators showed perfect correlation. Sedation was often documented (28/30) correctly (27/30); at bedside assessment of sedation, the correlation (r2) with adjudicators was 0.85 (P < 0.0005, Cronbach’s of 0.960). A majority of nurses documented delirium scales (28/30); 18 of the 27 available scores showed proper scale use. Bedside assessments showed a r2 of 0.854 (P < 0.0005, Cronbach’s of 0.957). The daytime shift (mean ICU nursing experience: 11.5 years) had the best overall performance; the night shift was next (mean ICU nursing experience: 2.7 years) and the evening shift (mean ICU nursing experience: 6.3 years) the worst. The highest variability in nursing assessment performance occurred in delirium assessments of psychomotor agitation or slowing.
Conclusions: In a single centre ICU with mandated routine assessments, the evaluation of pain, sedation and delirium occurs over 90% of the time. Assessment quality varies based on type of assessment (with sedation being evaluated best, delirium next best, and pain least well). Daytime, night time, and evening nurses’ performance vary significantly, particularly with regard to delirium assessment.
References
1 Available from URL; http://www.rnao.org/bestpractices/PDF/BPG_Assessment_of_Pain_Summary.pdf
2 Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond agitation-sedation scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med 2002; 166:1338–44.
3 Bergeron N, Dubois MJ, Skrobik Y. Intensive care delirium checklist: evaluation of a new screening tool. Intensive Care Med 2001; 27:859–64.[Medline]
Name: Zarychanski, Ryan
Position: Critical Care Resident
Professional Initials: MD FRCPC
Department: Hematology and Critical Care
Institution: University of Manitoba
City: Winnipeg
Province: Manitoba
Country: Canada
Postal Code: R3E 0V9
E-mail:ryan{at}zarychanski.com
Co Authors name: Ryan Zarychanski, Harleena Gulati, Daniel Roberts, Satendra Sharma, Donald S. Houston, Anand Kumar
Institution Affiliation: Section of Critical Care Medicine,1 University of Manitoba; and Section of Hematology/Medical Oncology,2 University of Manitoba.
SYSTEMICALLY ADMINISTERED HEPARIN IS ASSOCIATED WITH INCREASED SURVIVAL IN PATIENTS DIAGNOSED WITH SEPTIC SHOCK
Ryan Zarychanski,1 Harleena Gulati,1 Daniel Roberts,1 Satendra Sharma,1 Donald S. Houston,2 Anand Kumar1
Background: Sepsis and septic shock represent a systemic inflammation state with substantial pro-coagulant elements. Unfractionated heparin (UFH) is a well known systemic anticoagulant that also possesses significant anti-inflammatory properties. Unfractionated heparin therapy has been shown to increase survival in experimental models of septic shock. The objective of this study was to evaluate the potential therapeutic benefit of UFH in a cohort of patients diagnosed with septic shock.
Methods: This retrospective case-matched cohort study involved 788 patients diagnosed with septic shock who were admitted to Winnipeg regional intensive care units (ICUs) from 1989–2004. The study group consisted of 394 patients who received systemic full dose anticoagulation with UFH within 48 hr of admission, and who lived at least 48 hr. Clinically relevant outcomes were compared to 394 matched control patients who received either no heparin or only prophylactic doses, and who survived a minimum of 48 hr in an ICU setting. Patients in each group were matched 1:1 for APACHE II score, site of infection, and time to effective antimicrobial therapy. The primary outcome variables were hospital mortality and 30 days survival. Secondary outcomes included, duration of vasopressor/inotrope therapy, duration of mechanical ventilation, and both hospital and ICU length of stay.
Results: Major baseline patient characteristics were similar in the study and control groups. Administration of therapeutic heparin was associated with a significant reduction in hospital mortality (42.6% vs 51.3%, P = 0.02). Intensive care unit mortality was similarly decreased. Cox proportional regression analysis demonstrated a sustained survival advantage among patients receiving therapeutic dose heparin over 30 days (heart rate 0.72 [95% confidence interval 0.59–0.88], P = 0.01).
Conclusion: Early administration of therapeutic dose UFH is associated with decreased mortality when administered to patients diagnosed with septic shock. These findings are both clinically significant, and economically important given the minimal cost of UFH.
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