Fran Priestap

A prospective, observational registry of patients with severe sepsis: The Canadian Sepsis Treatment and Response Registry*

Objective:To determine the location of acquisition, timing, and outcomes associated with severe sepsis in community and teaching hospital critical care units. Design:Prospective, observational study. Setting:Twelve Canadian community and teaching hospital critical care units. Patients:All patients admitted between March 17, 2003, and November 30, 2004 to the study critical care units with at least a 24-hr length of stay or severe sepsis identified during the first 24 hrs. Interventions:Daily monitoring for severe sepsis. Measurements and Main Results:We recorded data describing characteristics of patients, infections, systemic responses, and organ dysfunction. Severe sepsis occurred in 1238 patients (overall rate, 19.0%; range, 8.2%–35.3%). Hospital mortality was 38.1% (95% confidence interval [CI]: 35.4–40.8). Median intensive care unit length of stay was 10.3 days (interquartile range: 5.5, 17.9). Variables associated with mortality in multivariable analysis included age (odds ratio [OR] by decade 1.50; 95% CI: 1.36–1.65), acquisition location of severe sepsis (with community as the reference—hospital [OR: 1.69; CI: 1.16–2.46], early intensive care unit [OR: 2.15; CI: 1.42–3.25], late intensive care unit [OR: 2.65; CI: 1.82–3.87]), late intensive care unit (OR: 2.65; CI: 1.82–3.87), any comorbidity (OR: 1.42; CI: 1.04–1.93), chronic renal failure (OR: 2.03; CI: 1.10–3.76), oliguria (OR: 1.34; CI: 1.02–1.76), thrombocytopenia (OR: 2.12; CI: 1.43–3.13), metabolic acidosis (OR: 1.54; CI: 1.13–2.10), Multiple Organ Dysfunction Score (OR: 1.15; CI: 1.09–1.21) and Acute Physiology and Chronic Health Evaluation II predicted risk (OR: 3.75; CI: 2.08–6.76). Conclusion:These data confirm that sepsis is common and has high mortality in general intensive care unit populations. Our results can inform healthcare system planning and clinical study designs. Modifiable variables associated with worse outcomes, such as nosocomial infection (hospital acquisition), and metabolic acidosis indicate potential targets for quality improvement initiatives that could decrease mortality and morbidity.

Variation in length of intensive care unit stay after cardiac arrest: where you are is as important as who you are.

Objective:To determine whether hospital site is independently associated with length of intensive care unit (ICU) stay in those patients who die in hospital after experiencing a cardiac arrest. Design:Retrospective cohort study. Setting:Thirty-one Canadian ICUs, all but one being members of the Critical Care Research Network. Patients:All patients admitted to these ICUs after resuscitation from a cardiac arrest. Interventions:None. Measurements and Main Results:Retrospective analysis of prospectively collected clinical data. Using gamma regression with ICU length of stay as the dependent variable, we found the following variables to be independently associated with ICU length of stay: age, gender, Acute Physiology and Chronic Health Evaluation II score, Glasgow Coma Scale score, hospital size, and hospital site. Conclusions:In this cohort of patients admitted to ICU after cardiac arrest, hospital site was strongly associated with ICU length of stay after controlling for patient-specific factors. Variation in processes of care among ICUs may point to opportunities for improvement.

Impact of intensive care unit discharge time on patient outcome

Objective:To determine the impact of nighttime intensive care unit (ICU) discharge on patient outcome. Design:Multiple-center, retrospective observational cohort study. Setting:Canadian hospitals. Patients:We used a prospectively collected dataset containing information on 79,090 consecutive admissions from 31 Canadian community and teaching hospitals. Interventions:None. Measurements and Main Results:Patients were categorized according to the time of ICU discharge into daytime (07:00–20:59) and nighttime (21:00–06:59). Admissions were excluded if the patients were a) ≤16 yrs of age (392); b) admitted following cardiac surgery (6,641); c) admitted following the initial admission for patients readmitted to the ICU within the same hospital stay (3,632); d) admitted due to a lack of available ward or specialty care beds (457); or c) transferred to another acute care facility (7,724). We found that 62,056 patients were discharged to the ward following the initial ICU admission. Of the 47,062 discharges eligible for analyses, 10.1% were discharged at night. The unadjusted odds of death for patients discharged from ICU at night was 1.35 (95% confidence interval, 1.23, 1.49), compared with patients discharged during the daytime. After adjustment for illness severity, source, case-mix, age, gender, and hospital size, the mortality risk was increased by 1.22-fold (95% confidence interval, 1.10, 1.36) for nighttime discharges. Multivariate regression analysis revealed that patients discharged from the ICU at night have a significantly shorter ICU length of stay than those discharged during the day (p < .001). Whereas hospital length of stay was similar for daytime and nighttime discharges who survived hospital stay, patients discharged at night who did not survive hospital stay had a significantly shorter hospital length of stay (p = .002). Conclusions:Patients discharged from the ICU at night have an increased risk of mortality compared with those discharged during the day.

A Pilot Randomized Trial Comparing Weaning From Mechanical Ventilation on Pressure Support Versus Proportional Assist Ventilation.

Objectives:Despite protocols incorporating spontaneous breathing trials, 31% of ICU patients experience difficult or prolonged weaning from mechanical ventilation. Nonfatiguing modes such as pressure support ventilation are recommended. Proportional assist ventilation provides assistance in proportion to patient effort, which may optimize weaning. However, it is not known how proportional assist ventilation performs relative to pressure support ventilation over a prolonged period in the complex ICU setting. The purpose of this study was to compare the physiologic and clinical performance (failure rate), safety, and feasibility of protocols using daily spontaneous breathing trial plus pressure support ventilation versus proportional assist ventilation until ventilation discontinuation. Design:Single-center, unblinded pilot randomized controlled trial. Setting:Medical-surgical ICU of a tertiary-care hospital. Patients:Adult patients intubated greater than 36 hours were randomized if they met eligibility criteria for partial ventilatory support, tolerated pressure support ventilation greater than or equal to 30 minutes, and either failed or did not meet criteria for a spontaneous breathing trial. Interventions:Patients were randomized to the pressure support ventilation or proportional assist ventilation protocol (PAV+, Puritan Bennett 840; Covidien, Boulder, CO). Both protocols used progressive decreases in level of assistance as tolerated, coupled with daily assessment for spontaneous breathing trials. Measurements and Main Results:Of 54 patients randomized, outcome data are available for 50 patients; 27 were randomized to receive proportional assist ventilation and 23 to receive pressure support ventilation. There were no adverse events linked to the study interventions, and protocol violations were infrequent. Recruitment was slower than projected (1.3 patients per month). The median (interquartile range) time from randomization to successful extubation was 3.9 days (2.8–8.4 d) on proportional assist ventilation versus 4.9 days (2.9–26.3 d) on pressure support ventilation (p = 0.39). Time to live ICU discharge was 7.3 days (5.2–11.4 d) on proportional assist ventilation versus 12.4 days (7.5–30.8 d) on pressure support ventilation (p = 0.03). Conclusion:This pilot study demonstrates the utility, safety, and feasibility of the weaning protocols and provides important information to guide the design of a future randomized controlled trial comparing weaning from mechanical ventilation on pressure support ventilation versus proportional assist ventilation.

The introduction of basic critical care echocardiography reduces the use of diagnostic echocardiography in the intensive care unit

BACKGROUND Basic critical care echocardiography (CCE) is routinely used by intensive care unit (ICU) providers to rapidly address key hemodynamic questions for the critically ill. By comparison, diagnostic echocardiography (DE) uses a comprehensive examination with more traditional workflow and sophisticated techniques. Despite these differences, both are frequently used to answer similar questions in ICU. This overlap raises questions of duplicate testing and redundancy of hospital resources. We therefore evaluated the effect of the introduction of basic CCE over the use of DE in Victoria Hospital, a tertiary care ICU in London Ontario, Canada. METHODS The monthly mean ratios of basic CCE and DE studies to patient care days (PCD) were plotted and general linear models were used to test for trends over time. Student t test was used to compare the mean DE/PCD before and after the introduction of basic CCE. The ratio of management actions for basic CCE studies was described. Outcome measures were compared using Pearson χ(2) test of association or the Wilcoxon rank sum test. RESULTS Over the 2-year study period, 1264 basic CCE studies were performed. Over this time, the ratio of CCE/PCD increased significantly (P<.001), whereas the ratio of DE/PCD decreased significantly (P=.004). When comparing the pre- and post-CCE periods, the mean DE/PCD decreased significantly from 5.27% to 4.51% (P=.01). There was no adverse change in ICU outcomes before and after the introduction of basic CCE. Mortality rates (pre- and post-CCE) were 23.69% and 24.61% (P=.48); median length of stay was 4.18 and 3.53 days (P<.001); and ventilated patient day rate was 64.96% and 64.93% (P>.9). There was a significant increase in vasoactive/inotropic drugs from a 20.47% vasoactive/inotropic drug/patient day rate to 21.99% (P<.001). Of all basic CCE studies, 61% led to a specific management action, including ordering a DE in 10.7% of cases. CONCLUSION In a hospital with a significant increase in basic CCE use, an associated significant decrease in DE use was observed with no increase in adverse outcomes. The significant increase in basic CCE use resulted in a change of management in most cases including the request for DE in a minority of cases.

Effect of Cardiopulmonary Bypass on Thrombin Generation and Protein C Pathway

OBJECTIVE The purpose of this study was to evaluate the mechanisms of cardiopulmonary bypass (CPB)-induced dysregulation between thrombin and its regulatory anticoagulant activated protein C (APC). DESIGN A prospective observational cohort study. SETTING A tertiary care university hospital and associated research laboratory. PATIENTS Twenty patients undergoing elective coronary artery bypass surgery with (n = 10) or without CPB (n = 10). INTERVENTIONS Blood samples were collected at 7 time points: preinduction; after heparin; 1 hour after the institution of CPB (or the completion of distal anastomoses in off-CPB group); after protamine; and at 0, 4, and 18 hours in the Intensive care unit (ICU). Samples were analyzed for prothrombin fragments (F1+2), thrombin-antithrombin complexes, protein C (PC), APC, soluble thrombomodulin (sTM), and soluble endothelial protein C receptor (sEPCR). MEASUREMENTS AND MAIN RESULTS F1+2 levels increased significantly 1 hour after the initiation of CPB in comparison with baseline (2.7 ± 0.5 v 0.5 ± 0.2 nmol/L, p < 0.001) (mean ± standard deviation) and remained elevated until 4 hours after ICU admission (p < 0.001). In contrast, APC levels did not show any significant changes over time in either group. sEPCR, sTM, and PC levels did not change during CPB although sEPCR decreased significantly after the termination of CPB compared with baseline in the CPB group. CONCLUSIONS Exposure to CPB is associated with a distinct thrombin surge that continues postoperatively for 4 hours. The impaired ability to generate APC reflects a complex process that is not associated with increased levels of sEPCR and thrombomodulin during CPB. Further studies are required to evaluate the regulation of the host APC response in cardiac surgery.

Factors Associated With the Increasing Rates of Discharges Directly Home From Intensive Care Units—A Direct From ICU Sent Home Study:

Objectives: To evaluate the relationship between rates of discharge directly to home (DDH) from the intensive care unit (ICU) and bed availability (ward and ICU). Also to identify patient characteristics that make them candidates for safe DDH and describe transfer delay impact on length of stay (LOS). Methods: Retrospective cohort study of all adult patients who survived their stay in our medical–surgical–trauma ICU between April 2003 and March 2015. Results: Median age was 49 years (interquartile range [IQR]: 33.5-60.4), and the majority of the patients were males (54.8%). Median number of preexisting comorbidities was 5 (IQR: 2-7) diagnoses. Discharge directly to home increased from 28 (3.1% of all survivors) patients in 2003 to 120 (12.5%) patients in 2014. The mean annual rate of DDH was between 11% and 12% over the last 6 years. Approximately 62% (n = 397) of patients waited longer than 4 hours for a ward bed, with a median delay of 2.0 days (IQR: 0.5-4.7) before being DDH. There was an inverse correlation between ICU occupancy and DDH rates (rP = −.55, P < .0001, 95% confidence interval [CI] = −0.36 to −0.69, R2 = .29). There was no correlation with ward occupancy and DDH rates (rs = −.055, P = .64, 95% CI = −0.25 to 0.21). Conclusions: The DDH rates have been increasing over time at our institution and were inversely correlated with ICU bed occupancy but were not associated with ward occupancy. The DDH patients are young, have few comorbidities on admission, and few discharge diagnoses, which are usually reversible single system problems with low disease burden. Transfers to the ward are delayed in a majority of cases, leading to increased ICU LOS and likely increased overall hospital LOS as well.

Patient, Family, and Physician Satisfaction With Planning for Direct Discharge to Home From Intensive Care Units: Direct From ICU Sent Home Study

Background: In the new era of decreasing hospital bed availability, there is an increasing rate of direct discharge to home (DDH) from intensive care units (ICUs), despite sparse literature informing this practice. Objectives: To evaluate patient, family, and ICU attending physician satisfaction with planning for DDH from the ICU and intensivists’ current DDH practices and perceptions. Methods: Prospective cohort study, using convenience sampling, of adult patients undergoing DDH from an ICU between February 2016 and February 2017 using a modified FS-ICU 24 satisfaction survey completed by patients, family members, and attending physicians at the time of patient discharge to home from the ICU. Results: Seventy-two percent of patients, 37% of family members, and 100% of ICU physicians recruited completed the survey. A majority of patients (89%) and families (78%) were satisfied or very satisfied with DDH. Only 6% of patients and 8% of families were dissatisfied to very dissatisfied with DDH. Conversely, ICU physician satisfaction varied, with only 5% being very comfortable with DDH and the majority (50%) only somewhat comfortable. Twenty percent of staff consultants were uncomfortable to very uncomfortable with the practice of DDH. Thirty-one percent of staff physician respondents felt that patient and family discomfort would be barriers to DDH. Compared to physicians and other allied health professionals, nurses were identified as the most helpful members of the health-care team in preparation for DDH by 98% of patients and 92% of family members. The DDH rates have increased for the past 12 years in our ICUs but declined during the study period (February 2016 to February 2017). Conclusions: Patients and family members are satisfied with the practice of DDH from ICU, although ICU physician satisfaction is more variable. Physician comfort may be improved by data informing which patients may be safely DDH from the ICU.

Lessons learned and new directions regarding Discharge Direct from Adult Intensive Care Units Sent Home (DISH): A narrative review

Purpose To perform a narrative review of the literature regarding the discharge of patients directly to home (DDH) from the intensive care unit, and to identify patient characteristics and clinical outcomes associated with this practice. Methods We searched MEDLINE and EMBASE from 1946 to present. We also manually searched the references of relevant articles. A two-step review process with three independent reviewers was used to identify relevant articles based on predetermined inclusion/exclusion criteria. Results Four studies were included in the final review. Two studies were retrospective and two studies were prospective that shared data from the same patient cohort. All were single center studies. Two of the four studies outlined clinical outcomes associated with DDH. Conclusions This study highlights the relative dearth in the literature regarding the increasingly common practice of DDH, underscores the importance of further studies in this area, and identifies future important foci of research.

Anesthesiologist and Emergency Medicine Physician Attitudes and Knowledge Regarding Etomidate for Intubation

Purpose: The use of etomidate as an induction agent for critically ill patients is controversial. While its favorable hemodynamic profile is enviable, etomidate has been shown to cause transient adrenal suppression. The clinical consequences of transient adrenal suppression are poorly understood. Anecdotally, some clinicians advocate strongly for etomidate, while others feel it can cause significant harm. To better understand the current clinical environment with respect to single-dose etomidate use in critically ill patients, Canadian anesthesiologists and Canadian emergency medicine (EM) physicians were questioned regarding their opinions, knowledge, and preferences about etomidate use as an induction agent. Methods: Invitations to participate with the electronic survey were sent to 100 Canadian EM physicians and 260 Canadian anesthesiologists. The survey had 4 general parts: demographics, familiarity with the current literature, choice of induction agent given various clinical scenarios, and opinions on the controversy. The Pearson γ2 test was used to detect whether significant differences exist between physician groups. Results: Ninety three anesthesiologists and 42 EM physicians responded for response rates of 36% and 42%. There were no self-reported differences in knowledge about etomidate properties between EM physicians and anesthesiologists. There were significant differences in etomidate use between EM physicians and anesthesiologists in general rapid sequence intubation, noncritically ill patients, and those with undifferentiated hypotension. Both EM physicians and anesthesiologists describe the current etomidate controversy as significant and not adequately resolved. Conclusion: There is no significant difference in self-reported etomidate knowledge between anesthesiologists and EM physicians; however, significant practice pattern differences exist with EM physicians using etomidate more often. Broad agreement supports future research to investigate etomidate’s impact in critically ill patients.