Steven Reynolds

Causes of moral distress in the intensive care unit: A qualitative study

PURPOSEnThe purpose of the study is to examine the causes of moral distress in diverse members of the intensive care unit (ICU) team in both community and tertiary ICUs.nnnMATERIALS AND METHODSnWe used focus groups and coding of transcripts into themes and subthemes in 2 tertiary care ICUs and 1 community ICU.nnnRESULTSnBased on input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported causes of moral distress were concerns about the care provided by other health care workers, the amount of care provided (especially too much care at end of life), poor communication, inconsistent care plans, and issues around end of life decision making.nnnCONCLUSIONSnCauses of moral distress vary among ICU professional groups, but all are amenable to improvement.

Recall of ICU Stay in Patients Managed With a Sedation Protocol or a Sedation Protocol With Daily Interruption.

Objectives:To 1) describe factual, emotional, and delusional memories of ICU stay for patients enrolled in the SLEAP (Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol) trial; 2) compare characteristics of patients with and without ICU recall, and patients with and without delusional memories; and 3) determine factors associated with delusional memories 28 days after ICU discharge. Design:Prospective cohort. Setting:Sixteen North American medical and surgical ICUs. Patients:Critically ill, mechanically ventilated adults randomized in the SLEAP trial. Interventions:Post-ICU interviews on days 3, 28, and 90 using the validated ICU Memory Tool. Measurements and Main Results:Overall, 289 of 297 ICU survivors (97%) (146 protocolized sedation and 143 protocolized sedation plus daily interruption patients) were interviewed at least once. Because there were no differences in recall status or types of memories between the two sedation groups, we present the findings for all patients rather than by study group. On days 3, 28, and 90, 28%, 26%, and 36% of patients, respectively, reported no recall of being in the ICU (overall perception, self-reported) (p = 0.75). Mean daily doses of benzodiazepines and opioids were lower in patients with no ICU recall than those with recall (p < 0.0001 for both). Despite one third of patients reporting no recall of ICU stay on day 3, 97% and 90% reported at least one factual and one emotional memory from ICU, respectively. Emotional memories declined with time after ICU discharge, particularly panic and confusion. Delusional memories 28 days after discharge were common (70%) yet unrelated to delirium (p = 0.84), recall status (p = 0.15), total dose of benzodiazepine (p = 0.78), or opioid (p = 0.21). Delusional memories were less likely with longer duration of mechanical ventilation (odds ratio, 0.955; 95% CI, 0.91–1.00; p = 0.04). Conclusions:Recall of ICU stay and types of memories reported were not influenced by the trial sedation strategy. Lack of ICU recall and delusional memories were common after ICU discharge despite the use of sedation strategies that promoted wakefulness.

The Effect of Inadequate Initial Empiric Antimicrobial Treatment on Mortality in Critically Ill Patients with Bloodstream Infections: A Multi-Centre Retrospective Cohort Study

Hospital mortality rates are elevated in critically ill patients with bloodstream infections. Given that mortality may be even higher if appropriate treatment is delayed, we sought to determine the effect of inadequate initial empiric treatment on mortality in these patients. A retrospective cohort study was conducted across 13 intensive care units in Canada. We defined inadequate initial empiric treatment as not receiving at least one dose of an antimicrobial to which the causative pathogen(s) was susceptible within one day of initial blood culture. We evaluated the association between inadequate initial treatment and hospital mortality using a random effects multivariable logistic regression model. Among 1,190 patients (1,097 had bacteremia and 93 had candidemia), 476 (40%) died and 266 (22%) received inadequate initial treatment. Candidemic patients more often had inadequate initial empiric therapy (64.5% versus 18.8%), as well as longer delays to final culture results (4 vs 3 days) and appropriate therapy (2 vs 0 days). After adjustment, there was no detectable association between inadequate initial treatment and mortality among bacteremic patients (Odds Ratio (OR): 1.02, 95% Confidence Interval (CI) 0.70–1.48); however, candidemic patients receiving inadequate treatment had nearly three times the odds of death (OR: 2.89, 95% CI: 1.05–7.99). Inadequate initial empiric antimicrobial treatment was not associated with increased mortality in bacteremic patients, but was an important risk factor in the subgroup of candidemic patients. Further research is warranted to improve early diagnostic and risk prediction methods in candidemic patients.

Early veno-venous extracorporeal membrane oxygenation is associated with lower mortality in patients who have severe hypoxemic respiratory failure: A retrospective multicenter cohort study

PURPOSEnThe purpose of the study is to compare outcomes in patients who had severe hypoxemic respiratory failure (Pao2/fraction of inspired oxygen <100) who received early veno-venous extracorporeal membrane oxygenation (ECMO) as an adjunct to mechanical ventilation, to those in patients who received conventional mechanical ventilation alone.nnnMATERIALS AND METHODSnThis is a multicenter, retrospective unmatched and matched cohort study of patients admitted between April 2006 and December 2013. Generalized logistic mixed-effects models and Cox proportional hazards models were used to determine the association between treatment with ECMO that was started within 3 days of intensive care unit (ICU) admission and ICU and hospital mortality and length of stay, respectively.nnnRESULTSnA total of 2440 patients who had severe hypoxemic respiratory failure due to various etiologies were included, 46 who received early veno-venous ECMO and 2394 unmatched and 398 matched controls who received conventional ventilation alone. Compared to matched controls, ECMO was associated with a lower odds of ICU (odds ratio [95% confidence interval], 0.30 [0.13-0.67]) and inhospital death (odds ratio 0.30 [0.14-0.67]). In addition, ECMO was associated with longer times to discharge from ICU and hospital (hazard ratio, 0.42 [0.37-0.47] and 0.53 [0.38-0.73], respectively).nnnCONCLUSIONSnIn this observational study, use of early ECMO compared to conventional mechanical ventilation alone in patients who had severe hypoxemic respiratory failure was associated with a lower risk of mortality and a longer length of stay.

Bacteremia Antibiotic Length Actually Needed for Clinical Effectiveness (BALANCE): study protocol for a pilot randomized controlled trial.

BackgroundBacteremia is a leading cause of mortality and morbidity in critically ill adults. No previous randomized controlled trials have directly compared shorter versus longer durations of antimicrobial treatment in these patients.Methods/DesignThis is a multicenter pilot randomized controlled trial in critically ill patients with bacteremia. Eligible patients will be adults with a positive blood culture with pathogenic bacteria identified while in the intensive care unit. Eligible, consented patients will be randomized to either 7xa0days or 14xa0days of adequate antimicrobial treatment for the causative pathogen(s) detected on blood cultures. The diversity of pathogens and treatment regimens precludes blinding of patient and clinicians, but allocation concealment will be extended to day 7 and outcome adjudicators will be blinded. The primary outcome for the main trial will be 90-day mortality. The primary outcome for the pilot trial is feasibility defined by (i) rate of recruitment exceeding 1 patient per site per month and (ii) adherence to treatment duration protocolu2009≥u200990%. Secondary outcomes include intensive care unit, hospital and 90-day mortality rates, relapse rates of bacteremia, antibiotic-related side effects and adverse events, rates of Clostridium difficile infection, rates of secondary infection or colonization with antimicrobial resistant organisms, ICU and hospital lengths of stay, mechanical ventilation and vasopressor duration in intensive care unit, and procalcitonin levels on the day of randomization, and day 7, 10 and 14 after the index blood culture.DiscussionThe BALANCE pilot trial will inform the design and execution of the subsequent BALANCE main trial, which will evaluate shorter versus longer duration treatment for bacteremia in critically ill patients, and thereby provide an evidence basis for treatment duration decisions for these infections.Trial registrationThe Pilot Trial was registered on 26 September 2014. Trial registration number: NCT02261506.

Risk factors for mortality in patients admitted to intensive care units with pneumonia

BackgroundDespite the high mortality in patients with pneumonia admitted to an ICU, data on risk factors for death remain limited.MethodsIn this secondary analysis of PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial), we focused on the patients admitted to ICU with a primary diagnosis of pneumonia. The primary outcome for this study was 90-day hospital mortality and the secondary outcome was 90-day ICU mortality. Cox regression model was conducted to examine the relationship between baseline and time-dependent variables and hospital and ICU mortality.ResultsSix hundred sixty seven patients admitted with pneumonia (43.8xa0% females) were included in our analysis, with a mean age of 60.7xa0years and mean APACHE II score of 21.3. During follow-up, 111 patients (16.6xa0%) died in ICU and in total, 149 (22.3xa0%) died in hospital. Multivariable analysis demonstrated significant independent risk factors for hospital mortality including male sex (hazard ratio (HR)u2009=u20091.5, 95xa0% confidence interval (CI): 1.1 - 2.2, p-valueu2009=u20090.021), higher APACHE II score (HRu2009=u20091.2, 95xa0% CI: 1.1 - 1.4, p-valueu2009<u20090.001 for per-5 point increase), chronic heart failure (HRu2009=u20092.9, 95xa0% CI: 1.6 - 5.4, p-valueu2009=u20090.001), and dialysis (time-dependent effect: HRu2009=u20092.7, 95xa0% CI: 1.3 - 5.7, p-valueu2009=u20090.008). Higher APACHE II score (HRu2009=u20091.2, 95xa0% CI: 1.1 - 1.4, p-valueu2009=u20090.002 for per-5 point increase) and chronic heart failure (HRu2009=u20092.6, 95xa0% CI: 1.3 – 5.0, p-valueu2009=u20090.004) were significantly related to risk of death in the ICU.ConclusionIn this study using data from a multicenter thromboprophylaxis trial, we found that male sex, higher APACHE II score on admission, chronic heart failure, and dialysis were independently associated with risk of hospital mortality in patients admitted to ICU with pneumonia. While high illness severity score, presence of a serious comorbidity (heart failure) and need for an advanced life support (dialysis) are not unexpected risk factors of mortality, male sex might necessitate further exploration. More studies are warranted to clarify the effect of these risk factors on survival in critically ill patients admitted to ICU with pneumonia.Trial registrationClinicalTrials.gov Identifier: NCT00182143.

Determinants of Antibiotic Tailoring in Pediatric Intensive Care: A National Survey*

Objectives: To describe the criteria that currently guide empiric antibiotic treatment in children admitted to Canadian PICUs. Design: Cross-sectional survey. Setting: Canadian PICUs. Subjects: Pediatric intensivists and pediatric infectious diseases specialists. Interventions: None. Measurements and Main Results: We used focus groups and literature review to design the survey questions and its four clinical scenarios (sepsis, pneumonia, meningitis, and intra-abdominal infections). We analyzed our results using descriptive statistics and multivariate linear regression. Our response rate was 60% for pediatric intensivists (62/103) and 36% for pediatric infectious diseases specialists (37/103). Variables related to patient characteristics, disease severity, pathogens, and clinical, laboratory, and radiologic infection markers were associated with longer courses of antibiotics, with median increment ranging from 1.75 to 7.75 days. The presence of positive viral polymerase chain reaction result was the only variable constantly associated with a reduction in antibiotic use (median decrease from, –3.25 to –8.25 d). Importantly, 67–92% of respondents would still use a full course of antibiotics despite positive viral polymerase chain reaction result and marked clinical improvement for patients with suspected sepsis, pneumonia, and intra-abdominal infection. Clinical experience was associated with shorter courses of antibiotics for meningitis and sepsis (–1.3 d [95% CI, –2.4 to –0.2] and –1.8 d [95% CI, –2.8 to –0.7] per 10 extra years of clinical experience, respectively). Finally, site and specialty also influenced antibiotic practices. Conclusions: Decisions about antibiotic management for PICU patients are complex and involve the assessment of several different variables. With the exception of a positive viral polymerase chain reaction, our findings suggest that physicians rarely consider reducing the duration of antibiotics despite clinical improvement. In contrast, they will prolong the duration when faced with a nonreassuring characteristic. The development of objective and evidence-based criteria to guide antibiotic therapy in critically ill children is crucial to ensure the rational use of these agents in PICUs.

Time required to initiate outbreak and pandemic observational research

Purpose Observational research focused upon emerging infectious diseases such as Ebola virus, Middle East respiratory syndrome, and Zika virus has been challenging to quickly initiate. We aimed to determine the duration of start‐up procedures and barriers encountered for an observational study focused upon such infectious outbreaks. Materials and methods At 1 pediatric and 5 adult intensive care units, we measured durations from protocol receipt to a variety of outbreak research milestones, including research ethics board (REB) approval, data sharing agreement (DSA) execution, and patient study screening initiation. Results The median (interquartile range) time from site receipt of the protocol to REB submission was 73 (30‐126) days; to REB approval, 158 (42‐188) days; to DSA completion, 276 (186‐312) days; and to study screening initiation, 293 (269‐391) days. The median time from REB submission to REB approval was 43 (13‐85) days. The median time for all start‐up procedures was 335 (188‐335) days. Conclusions There is a lengthy start‐up period required for outbreak‐focused research. Completing DSAs was the most time‐consuming step. A reactive approach to newly emerging threats such as Ebola virus, Middle East respiratory syndrome, and Zika virus will likely not allow sufficient time to initiate research before most outbreaks are advanced. HighlightsStart‐up period required for observational studies focused on outbreak surveillance is time consuming.The median time for all start‐up procedures was 335 (188‐335) days.Completing data sharing agreements was the most time‐consuming step, taking 9 months on average.There is a need to have a nationally and internationally coordinated approach, with context‐appropriate, tiered case report forms and preparatory work—protocol and case report form generation, data sharing agreements, and REB submissions—completed during the pre‐ and interoutbreak periods.A reactive approach to newly emerging threats will likely not allow sufficient time to initiate research before most outbreaks are advanced or completed.

Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study

Background Moral distress is common among personnel in the intensive care unit, but the consequences of this distress are not well characterized. Objective To examine the consequences of moral distress in personnel in community and tertiary intensive care units in Vancouver, Canada. Methods Data for this study were obtained from focus groups and analysis of transcripts by themes and subthemes in 2 tertiary care intensive care units and 1 community intensive care unit. Results According to input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported emotion associated with moral distress was frustration. Negative impact on patient care due to moral distress was reported 26 times, whereas positive impact on patient care was reported 11 times and no impact on patient care was reported 10 times. Having thoughts about quitting working in the ICU was reported 16 times, and having no thoughts about quitting was reported 14 times. Conclusion In response to moral distress, health care providers experience negative emotional consequences, patient care is perceived to be negatively affected, and nurses and other health care professionals are prone to consider quitting working in the intensive care unit.

Dexmedetomidine as a procedural sedative for percutaneous tracheotomy: case report and systematic literature review.

Purpose. To describe the successful use of dexmedetomidine as the primary procedural sedative for a percutaneous tracheotomy procedure and to systematically present the supporting literature. Materials and Methods. A Case report of our experience and systematic literature search. PubMed, Embase, and Google Scholar were searched without restriction using the key words dexmedetomidine, percutaneous tracheotomy, and tracheotomy procedure. All relevant published references were retrieved irrespective of their methodological quality. Results. In total, only 3 relevant references were found. These include one small placebo controlled randomized trial and 2 case reports. The randomized, placebo controlled trial enrolled patients already sedated on midazolam and included 64 total patients. The 2 other case reports both described the use of dexmedetomidine as the primary procedural sedative. All of the cases reported the successful completion of the percutaneous tracheotomy without any major complication, but none reported the subjective patient experience. Conclusion. Based on the available published literature and our experience, we suggest that dexmedetomidine be considered for use as the primary procedural sedative for percutaneous tracheotomy procedure. Dexmedetomidines ability to provide adequate sedation and amnesia, without blunting the respiratory drive and protective reflexes of the patient, may make it an optimal agent in specific cases.