Rob Fowler

Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia : Prevention

BACKGROUNDnVentilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients.nnnPURPOSEnTo develop evidence-based guidelines for the prevention of VAP.nnnDATA SOURCESnMEDLINE, EMBASE, CINAHL, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials.nnnSTUDY SELECTIONnThe authors systematically searched for all relevant randomized, controlled trials and systematic reviews on the topic of prevention of VAP in adults that were published from 1980 to October 1, 2006.nnnDATA EXTRACTIONnIndependently and in duplicate, the panel scored the internal validity of each trial. Effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. Scores for the safety, feasibility, and economic issues were assigned based on consensus of the guideline panel.nnnLEVELS OF EVIDENCEnThe following statements were used: recommend, consider, do not recommend, and no recommendation due to insufficient or conflicting evidence.nnnDATA SYNTHESISnTo prevent VAP: We recommend: that the orotracheal route of intubation should be used for intubation; a new ventilator circuit for each patient; circuit changes if the circuit becomes soiled or damaged, but no scheduled changes; change of heat and moisture exchangers every 5 to 7 days or as clinically indicated; the use of a closed endotracheal suctioning system changed for each patient and as clinically indicated; subglottic secretion drainage in patients expected to be mechanically ventilated for more than 72 hours; head of bed elevation to 45 degrees (when impossible, as near to 45 degrees as possible should be considered). Consider: the use of rotating beds; oral antiseptic rinses. We do not recommend: use of bacterial filters; the use of iseganan We make no recommendations regarding: the use of a systematic search for sinusitis; type of airway humidification; timing of tracheostomy; prone positioning; aerosolized antibiotics; intranasal mupirocin; topical and/or intravenous antibiotics.nnnCONCLUSIONnThere are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection.

Comprehensive evidence-based clinical practice guidelines for ventilator-associated pneumonia: Diagnosis and treatment

BACKGROUNDnVentilator-associated pneumonia (VAP) is an important cause of morbidity and mortality in ventilated critically ill patients. Despite a large amount of research evidence, the optimal diagnostic and treatment strategies for VAP remain controversial.nnnPURPOSEnThe aim of this study was to develop evidence-based clinical practice guidelines for the diagnosis and treatment of VAP. Data sources include Medline, EMBASE, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews and Register of Controlled Trials.nnnSTUDY SELECTIONnThe authors systematically searched for all relevant randomized controlled trials and systematic reviews on the diagnosis and treatment of VAP in mechanically ventilated adults that were published from 1980 to October 1, 2006.nnnDATA EXTRACTIONnIndependently and in duplicate, the panel critically appraised each published trial. The effect size, confidence intervals, and homogeneity of the results were scored using predefined definitions. The full guideline development panel arrived at a consensus for scores on safety, feasibility, and economic issues.nnnLEVELS OF EVIDENCEnBased on the scores for each topic, the following statements of recommendation were used: recommend, consider, do not recommend, and no recommendation because of insufficient or conflicting evidence.nnnDATA SYNTHESISnFor the diagnosis of VAP in immunocompetent patients, we recommend that endotracheal aspirates with nonquantitative cultures be used as the initial diagnostic strategy. When there is a suspicion of VAP, we recommend empiric antimicrobial therapy (in contrast to delayed or culture directed therapy) and appropriate single agent antimicrobial therapy for each potential pathogen as empiric therapy for VAP. Choice of antibiotics should be based on patient factors and local resistance patterns. We recommend that an antibiotic discontinuation strategy be used in patients who are treated of suspected VAP. For patients who receive adequate initial antibiotic therapy, we recommend 8 days of antibiotic therapy. We do not recommend nebulized endotracheal tobramycin or intratracheal instillation of tobramycin for the treatment of VAP.nnnCONCLUSIONnWe present evidence-based recommendations for the diagnosis and treatment of VAP. Implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP.

Hospital Incidence and Outcomes of the Acute Respiratory Distress Syndrome Using the Kigali Modification of the Berlin Definition.

RATIONALEnEstimates of the incidence of the acute respiratory distress syndrome (ARDS) in high- and middle-income countries vary from 10.1 to 86.2 per 100,000 person-years in the general population. The epidemiology of ARDS has not been reported for a low-income country at the level of the population, hospital, or intensive care unit (ICU). The Berlin definition may not allow identification of ARDS in resource-constrained settings.nnnOBJECTIVESnTo estimate the incidence and outcomes of ARDS at a Rwandan referral hospital using the Kigali modification of the Berlin definition: without requirement for positive end-expiratory pressure, hypoxia cutoff of SpO2/FiO2 less than or equal to 315, and bilateral opacities on lung ultrasound or chest radiograph.nnnMETHODSnWe screened every adult patient for hypoxia at a public referral hospital in Rwanda for 6 weeks. For every patient with hypoxia, we collected data on demographics and ARDS risk factors, performed lung ultrasonography, and evaluated chest radiography when available.nnnMEASUREMENTS AND MAIN RESULTSnForty-two (4.0%) of 1,046 hospital admissions met criteria for ARDS. Using various prespecified cutoffs for the SpO2/FiO2 ratio resulted in almost identical hospital incidence values. Median age for patients with ARDS was 37 years, and infection was the most common risk factor (44.1%). Only 30.9% of patients with ARDS were admitted to an ICU, and hospital mortality was 50.0%. Using traditional Berlin criteria, no patients would have met criteria for ARDS.nnnCONCLUSIONSnARDS seems to be a common and fatal syndrome in a hospital in Rwanda, with few patients admitted to an ICU. The Berlin definition is likely to underestimate the impact of ARDS in low-income countries, where resources to meet the definition requirements are lacking. Although the Kigali modification requires validation before widespread use, we hope this study stimulates further work in refining an ARDS definition that can be consistently used in all settings.

The Health Care Cost of Dying: A Population-Based Retrospective Cohort Study of the Last Year of Life in Ontario, Canada

Background Coordinated and appropriate health care across sectors is an ongoing challenge, especially at the end-of-life. Population-level data on end-of-life health care use and cost, however, are seldom reported across a comprehensive array of sectors. Such data will identify the level of care being provided and areas where care can be optimized. Methods This retrospective cohort study identified all deaths in Ontario from April 1, 2010 to March 31, 2013. Using population-based health administrative databases, we examined health care use and cost in the last year of life. Results Among 264,755 decedents, the average health care cost in the last year of life was

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53,661 (Quartile 1-Quartile 3:

Long-term outcomes and healthcare utilization following critical illness – a population-based study

19,568-

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66,875). The total captured annual cost of

Clinical research ethics for critically ill patients: A pandemic proposal

4.7 billion represents approximately 10% of all government-funded health care. Inpatient care, incurred by 75% of decedents, contributed 42.9% of total costs (

Antibiotic treatment duration for bloodstream infections in critically ill patients: a national survey of Canadian infectious diseases and critical care specialists

30,872 per user). Physician services, medications/devices, laboratories, and emergency rooms combined to less than 20% of total cost. About one-quarter used long-term-care and 60% used home care (

Admission of the very elderly to the intensive care unit: family members' perspectives on clinical decision-making from a multicenter cohort study.

34,381 and