Michael B. Butler

Spatial Information Infrastructure for Integrated Coastal and Ocean Management in Canada

Access to current, comprehensive, and reliable spatial information is necessary for informed decision making in integrated coastal and ocean management. This need is being met through development of a marine spatial information infrastructure that encompasses both technological and institutional responses. This article traces Canadas experience in developing a marine spatial information infrastructure over the last 30 years starting with the compilation of coastal atlases, through the development of geographic information systems, to remote data acquisition instruments and Web mapping portals. Because of the plethora of initiatives, it has been essential to be selected and limit the number and choice of examples. The institutional response has lagged behind that of technological innovation and hinges on understanding users’ needs and decision support drivers, sustainability of institutional and individual champions, and, above all, cooperation and collaboration among the broad community of practice.

Postintubation hypotension in intensive care unit patients: A multicenter cohort study.

PURPOSE To determine the incidence of postintubation hypotension (PIH) and associated outcomes in critically ill patients requiring endotracheal intubation. MATERIALS AND METHODS Medical records were reviewed for 479 consecutive critically ill adult patients who required intubation by an intensive care unit (ICU) service at 1 of 4 academic tertiary care hospitals. The primary outcome measure was the incidence of PIH. Secondary outcome measures included mortality, ICU length of stay, requirement for renal replacement therapy, and a composite end point consisting of overall mortality, ICU length of stay greater than 14 days, duration of mechanical ventilation longer than 7 days, and renal replacement therapy requirement. RESULTS Overall, the incidence of PIH among ICU patients requiring intubation was 46% (218/479 patients). On univariate analysis, patients who developed PIH had increased ICU mortality (37% PIH vs 28% no PIH, P = .049) and overall mortality (39% PIH vs 30% no PIH, P = .045). After adjusting for important risk factors, development of PIH was associated with the composite end point of major morbidity and mortality (odds ratio, 2.00; 95% confidence interval, 1.30-3.07; P = .0017). CONCLUSIONS The development of PIH is common in ICU patients requiring emergency airway control and is associated with poor patient outcomes.

End-tidal capnometry during emergency department procedural sedation and analgesia: a randomized, controlled study.

BACKGROUND This prospective, randomized trial was undertaken to evaluate the utility of adding end-tidal capnometry (ETC) to pulse oximetry (PO) in patients undergoing procedural sedation and analgesia (PSA) in the emergency department (ED). METHODS The patients were randomized to monitoring with or without ETC in addition to the current standard of care. Primary endpoints included respiratory adverse events, with secondary endpoints of level of sedation, hypotension, other PSA-related adverse events and patient satisfaction. RESULTS Of 986 patients, 501 were randomized to usual care and 485 to additional ETC monitoring. In this series, 48% of the patients were female, with a mean age of 46 years. Orthopedic manipulations (71%), cardioversion (12%) and abscess incision and drainage (12%) were the most common procedures, and propofol and fentanyl were the sedative/analgesic combination used for most patients. There was no difference in patients experiencing de-saturation (SaO2<90%) between the two groups; however, patients in the ETC group were more likely to require airway repositioning (12.9% vs. 9.3%, P=0.003). Hypotension (SBP<100 mmHg or <85 mmHg if baseline <100 mmHg) was observed in 16 (3.3%) patients in the ETC group and 7 (1.4%) in the control group (P=0.048). CONCLUSIONS The addition of ETC does not appear to change any clinically significant outcomes. We found an increased incidence of the use of airway repositioning maneuvers and hypotension in cases where ETC was used. We do not believe that ETC should be recommended as a standard of care for the monitoring of patients undergoing PSA.

Increased mortality in trauma patients who develop postintubation hypotension

BACKGROUND Post-intubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. METHODS Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, co-morbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. RESULTS Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161/444) in our study population. In-hospital mortality occurred in 29.8% (48/161) of patients in the PIH group, compared to 15.9% (45/283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio [AOR] = 3.45, 95% CI 1.42-8.36) and in-hospital (AOR = 1.83, 95% CI 1.01-3.31). CONCLUSIONS In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. LEVEL OF EVIDENCE Level III, Prognostic and Epidemiological.BACKGROUND Postintubation hypotension (PIH) is common and associated with poor outcomes in critically ill patient populations requiring emergency endotracheal intubation (ETI). The importance of PIH in the trauma population remains unclear. The objective of this study was to determine the prevalence of PIH in trauma patients and assess the association of PIH with patient outcomes. METHODS Retrospective case series of adult (≥16 years) patients who were intubated on arrival at a tertiary trauma center in Halifax, Nova Scotia, Canada, between 2000 and 2015. Data were collected from the Nova Scotia Trauma Registry and patient chart, and included demographics, comorbidities, trauma characteristics, intubation time, as well as all fluids, medications, adverse events, interventions, and vital signs during the 15 minutes before/after ETI. We evaluated the prevalence of PIH and created a logistic regression model to determine likelihood of mortality in the PIH and non-PIH groups after controlling for patient and provider characteristics. RESULTS Overall, 477 patients required ETI on assessment by the trauma service, of which 444 patients met eligibility criteria and were included in the analysis. The prevalence of PIH was 36.3% (161 of 444) in our study population. In-hospital mortality occurred in 29.8% (48 of 161) of patients in the PIH group, compared with 15.9% (45 of 283) of patients in the non-PIH group (p = 0.001). Development of PIH was associated with increased mortality in the emergency department (adjusted odds ratio, 3.45; 95% confidence interval, 1.42–8.36) and in-hospital (adjusted odds ratio, 1.83; 95% confidence interval, 1.01–3.31). CONCLUSION In our study of trauma patients requiring ETI, development of PIH was common (36.3%) and associated with increased mortality. Intubation practices in critically ill trauma patients is an important patient safety issue that requires further investigation. LEVEL OF EVIDENCE Prognostic and epidemiological, level III; Level IV, Therapeutic.

Postintubation Hypotension in General Anesthesia: A Retrospective Analysis

Background: Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department endotracheal intubations. Study objective was to determine the incidence of PIH and its impact on outcomes following tracheal intubation in a general anesthesia population. Methods: Structured chart audit of adult patients intubated for a vascular surgery procedure at a tertiary care center over a 3-year period. Outcomes included in-hospital mortality, extended intensive care unit length of stay (ICU LOS), and requirement for postoperative (postop) hemodialysis or mechanical ventilation. Results: Incidence of PIH was 60% (837 of 1395). Patients who developed PIH had increased mortality (8.8% PIH vs 5.2% no-PIH; P = .014), extended ICU LOS (7.9% PIH vs 2.0% no-PIH; P < .001), and postop mechanical ventilation requirement (20.7% PIH vs 3.8% no-PIH; P < .001). When controlling for confounding factors, PIH was associated with extended ICU LOS (odds ratio [OR] 2.55, 95% confidence interval [CI] 1.01-6.62, P = .049), postop ventilation (OR 2.43, 95% CI 1.27-4.74, P = .008), and a composite end point (OR 1.72, 95% CI 1.02-2.92, P = .043). Conclusions: Development of PIH occurs in 60% of patients undergoing intubation for vascular surgery and was associated with adverse outcomes including extended ICU LOS and postop ventilation requirement.

Effect of Hydroxyethyl Starch on Outcomes in High-Risk Vascular Surgery Patients: A Retrospective Analysis

OBJECTIVE To assess the effect of using hydroxyethyl starch (HES) for intraoperative fluid therapy on outcomes in high-risk vascular surgery patients. DESIGN Retrospective case series. SETTING Single-center academic hospital. PARTICIPANTS The study included 1,395 adult vascular surgery patients with peripheral vascular disease. INTERVENTIONS Retrospective review of hospital databases. MEASUREMENTS AND MAIN RESULTS Outcomes were compared between patients who were intraoperatively administered HES (Voluven [Fresenius Kabi, Bad Homburg, Germany] or Pentaspan [Bristol-Myers Squibb Canada, Montreal, Quebec, Canada]) versus patients who received only crystalloids during their procedure. Logistic regression was used to assess for association between these groups and mortality (in-hospital, 30-day), intensive care unit admission, hemodialysis requirement, vasopressor requirement, and ventilator requirement. Overall, 796 patients had complete fluid records and were included in the analysis. After adjustment for potential confounders, receiving an HES solution was associated with increased likelihood of 30-day mortality (odds ratio [OR] 2.11, 95% confidence interval [CI] 1.05-3.80), postoperative requirement for hemodialysis (OR 6.17, 95% CI 1.09-35.10), intensive care unit admission (OR 3.52, 95% CI 2.15-5.74), and mechanical ventilation (OR 3.16, 95% CI 1.84-5.41). CONCLUSIONS Intraoperative administration of HES was associated with an increased likelihood of adverse outcomes compared with use of crystalloids alone.

Resuscitation Prior to Emergency Endotracheal Intubation: Results of a National Survey

Introduction Respiratory failure is a common problem in emergency medicine (EM) and critical care medicine (CCM). However, little is known about the resuscitation of critically ill patients prior to emergency endotracheal intubation (EETI). Our aim was to describe the resuscitation practices of EM and CCM physicians prior to EETI. Methods A cross-sectional survey was developed and tested for content validity and retest reliability by members of the Canadian Critical Care Trials Group. The questionnaire was distributed to all EM and CCM physician members of three national organizations. Using three clinical scenarios (trauma, pneumonia, congestive heart failure), we assessed physician preferences for use and types of fluid and vasopressor medication in pre-EETI resuscitation of critically ill patients. Results In total, 1,758 physicians were surveyed (response rate 50.2%, 882/1,758). Overall, physicians would perform pre-EETI resuscitation using either fluids or vasopressors in 54% (1,193/2,203) of cases. Most physicians would “always/often” administer intravenous fluid pre-EETI in the three clinical scenarios (81%, 1,484/1,830). Crystalloids were the most common fluid physicians would “always/often” administer in congestive heart failure (EM 43%; CCM 44%), pneumonia (EM 97%; CCM 95%) and trauma (EM 96%; CCM 96%). Pre-EETI resuscitation using vasopressors was uncommon (4.9%). Training in CCM was associated with performing pre-EETI resuscitation (odds ratio, 2.20; 95% CI, [1.44–3.36], p<0.001). Conclusion Pre-EETI resuscitation is common among Canadian EM and CCM physicians. Most physicians use crystalloids pre-EETI as a resuscitation fluid, while few would give vasopressors. Physicians with CCM training were more likely to perform pre-EETI resuscitation.

Predictors of Poor Outcomes in Critically Ill Adults with Hematologic Malignancy

Background. Patients with hematologic malignancy (HM) often require intensive care unit (ICU) admission due to organ failure through disease progression or treatment-related complications. Objective. To determine mortality and prognostic variables in adult patients with HM who were admitted to ICU. Methods. Structured chart review of all adult patients (age ≥ 18 years) with HM admitted to ICU of a Canadian tertiary care hospital between 2004 and 2014. Outcome measures included mortality (ICU, 30-day, 60-day, and 12-month). Logistic regression was performed to determine predictors of mortality. Results. Overall, there were 206 cases of HM admitted to the ICU during the study (mean age: 51.3 ± 13.6 years; 60% male). Median stay was 3 days, with 14.1% requiring prolonged ICU admission. ICU mortality was 45.6% and increased to 59.2% at 30 days, 62.6% at 60 days, and 74.3% at 12 months. Predictors of increased ICU mortality included mechanical ventilation requirement and vasopressor therapy requirement, while admission to ICU postoperatively and having myeloma were associated with decreased mortality. Conclusions. Patients admitted to ICU with HM have high mortality (45.6%), which increased to 74.3% at 1 year. Analysis of multiple variables identified critical illness, postsurgical admission, and myeloma as predictors of patient outcomes.

Adverse events and outcomes of procedural sedation and analgesia in major trauma patients

Context: Trauma patients requiring procedural sedation and analgesia (PSA) may have increased risk of adverse events (AEs) and poor outcomes. Aims: To determine the incidence of AEs in adult major trauma patients who received PSA and to evaluate their postprocedural outcomes. Settings and Design: Retrospective analysis of adult patients (age >16) who received PSA between 2006 and 2014 at a Canadian academic tertiary care center. Materials and Methods: We compared the incidence of PSA-related AEs in trauma patients with nontrauma patients. Postprocedural outcomes including Intensive Care Unit admission, length of hospital stay, and mortality were compared between trauma patients who did or did not receive PSA. Statistical Analysis Used: Descriptive statistics and multivariable logistic regression. Results: Overall, 4324 patients received PSA during their procedure, of which 101 were trauma patients (107 procedures). The majority (77%) of these 101 trauma patients were male, relatively healthy (78% with American Society of Anesthesiologists Physical Status [ASA-PS] 1), and most (85%) of the 107 procedures were orthopedic manipulations. PSA-related AEs were experienced by 45.5% of the trauma group and 45.9% of the nontrauma group. In the trauma group, the most common AEs were tachypnea (23%) and hypotension (20%). After controlling for age, gender, and ASA-PS, trauma patients were more likely than nontrauma patients to develop hypotension (odds ratio 1.79; 95% confidence interval 1.11-2.89). Conclusion: Although trauma patients were more likely than nontrauma patients to develop hypotension during PSA, their outcomes were not worse compared to trauma patients who did not have PSA.

Hemoglobin thresholds and red blood cell transfusion in adult patients with moderate or severe traumatic brain injuries: A retrospective cohort study.

Purpose: We aimed to evaluate the association between transfusion practices and clinical outcomes in patients with traumatic brain injury. Material and methods: We conducted a retrospective cohort study of adult patients with moderate or severe traumatic brain injury admitted to the intensive care unit (ICU) of a level I trauma center between 2009 and 2013. The associations between hemoglobin (Hb) level, red blood cell (RBC) transfusion and clinical outcomes were estimated using robust Poisson models and proportional hazard models with time‐dependent variables, adjusted for confounders. Results: We included 215 patients. Sixty‐six patients (30.7%) were transfused during ICU stay. The median pre‐transfusion Hb among transfused patients was 81 g/L (IQR 67–100), while median nadir Hb among non‐transfused patients was 110 g/L (IQR 93–123). Poor outcomes were significantly more frequent in patients who were transfused (mortality risk ratio [RR]: 2.15 [95% CI 1.37–3.38] and hazard ratio: 3.06 [95% CI 1.57–5.97]; neurological complications RR: 3.40 [95% CI 1.35–8.56]; trauma complications RR: 1.65 [95% CI 1.31–2.08]; ICU length of stay geometric mean ratio: 1.42 [95% CI 1.06–1.92]). Conclusions: During ICU stay, transfused patients tended to have lower Hb levels and worse outcomes than patients who did not receive RBCs, after adjustment for confounders. HIGHLIGHTSOne third of ICU patients with TBI receive a RBC transfusion.TBI patients that are transfused in the ICU have lower Hb levels over their ICU stay.RBC seems associated with unfavourable outcomes in TBI patients.