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2.  Early sedation use in critically ill mechanically ventilated patients: when less is really more 
Critical Care  2014;18(6):600.
Over the last 10 years, there has been an explosion of literature surrounding sedation management for critically ill patients. The clinical target has moved away from an unconscious and immobile patient toward a goal of light or no sedation and early mobility. The move away from terms such as ‘sedation’ toward more patient-centered and symptom-based control of pain, anxiety, and agitation makes the management of critically ill patients more individualized and dynamic. Over-sedation has been associated with negative ICU outcomes, including longer durations of mechanical ventilation and lengths of stay, but few studies have been able to associate deep sedation with increased mortality.
doi:10.1186/s13054-014-0600-3
PMCID: PMC4331387  PMID: 25673278
3.  A ventilator strategy combining low tidal volume ventilation, recruitment maneuvers, and high positive end-expiratory pressure does not increase sedative, opioid, or neuromuscular blocker use in adults with acute respiratory distress syndrome and may improve patient comfort 
Background
The Lung Open Ventilation Study (LOV Study) compared a low tidal volume strategy with an experimental strategy combining low tidal volume, lung recruitment maneuvers, and higher plateau and positive end-expiratory pressures (PEEP) in adults with acute respiratory distress syndrome (ARDS). Herein, we compared sedative, opioid, and neuromuscular blocker (NMB) use among patients managed with the intervention and control strategies and clinicians' assessment of comfort in both groups.
Methods
This was an observational substudy of the LOV Study, a randomized trial conducted in 30 intensive care units in Canada, Australia, and Saudi Arabia. In 16 centers, we recorded daily doses of sedatives, opioids, and NMBs and surveyed bedside clinicians about their own comfort with the assigned ventilator strategy and their perceptions of patient comfort. We compared characteristics and outcomes of patients who did and did not receive NMBs.
Results
Study groups received similar sedative, opioid, and NMB dosing on days 1, 3, and 7. Patient comfort as assessed by clinicians was not different in the two groups: 93% perceived patients had no/minimal discomfort. In addition, 92% of clinicians were comfortable with the assigned ventilation strategy without significant differences between the two groups. When clinicians expressed discomfort, more expressed discomfort about PEEP levels in the intervention vs control group (2.9% vs 0.7%, P <0.0001), and more perceived patient discomfort among controls (6.0% vs 4.3%, P = 0.049). On multivariable analysis, the strongest associations with NMB use were higher plateau pressure (hazard ratio (HR) 1.15; 95% confidence interval (CI) 1.07 to 1.23; P = 0.0002) and higher daily sedative dose (HR 1.03; 95% CI 1.02 to 1.05; P <0.0001). Patients receiving NMBs had more barotrauma, longer durations of mechanical ventilation and hospital stay, and higher mortality.
Conclusions
In the LOV Study, high PEEP, low tidal volume ventilation did not increase sedative, opioid, or NMB doses in adults with ARDS, compared with a lower PEEP strategy, and appeared at least as comfortable for patients. NMB use may reflect worse lung injury, as these patients had more barotrauma, longer durations of ventilation, and higher mortality.
Trial registration
ClinicalTrials.gov Identifier NCT00182195
doi:10.1186/s13613-014-0033-9
PMCID: PMC4273695  PMID: 25593749
ARDS; Neuromuscular blocker; Sedation; Opioid; Mechanical ventilation; Clinician comfort
4.  Intensive care sedation: the past, present and the future 
Critical Care  2013;17(3):322.
Despite the universal prescription of sedative drugs in the intensive care unit (ICU), current practice is not guided by high-level evidence. Landmark sedation trials have made significant contributions to our understanding of the problems associated with ICU sedation and have promoted changes to current practice. We identified challenges and limitations of clinical trials which reduced the generalizability and the universal adoption of key interventions. We present an international perspective regarding current sedation practice and a blueprint for future research, which seeks to avoid known limitations and generate much-needed high-level evidence to better guide clinicians' management and therapeutic choices of sedative agents.
doi:10.1186/cc12679
PMCID: PMC3706847  PMID: 23758942
5.  Do heart and respiratory rate variability improve prediction of extubation outcomes in critically ill patients? 
Critical Care  2014;18(2):R65.
Introduction
Prolonged ventilation and failed extubation are associated with increased harm and cost. The added value of heart and respiratory rate variability (HRV and RRV) during spontaneous breathing trials (SBTs) to predict extubation failure remains unknown.
Methods
We enrolled 721 patients in a multicenter (12 sites), prospective, observational study, evaluating clinical estimates of risk of extubation failure, physiologic measures recorded during SBTs, HRV and RRV recorded before and during the last SBT prior to extubation, and extubation outcomes. We excluded 287 patients because of protocol or technical violations, or poor data quality. Measures of variability (97 HRV, 82 RRV) were calculated from electrocardiogram and capnography waveforms followed by automated cleaning and variability analysis using Continuous Individualized Multiorgan Variability Analysis (CIMVA™) software. Repeated randomized subsampling with training, validation, and testing were used to derive and compare predictive models.
Results
Of 434 patients with high-quality data, 51 (12%) failed extubation. Two HRV and eight RRV measures showed statistically significant association with extubation failure (P <0.0041, 5% false discovery rate). An ensemble average of five univariate logistic regression models using RRV during SBT, yielding a probability of extubation failure (called WAVE score), demonstrated optimal predictive capacity. With repeated random subsampling and testing, the model showed mean receiver operating characteristic area under the curve (ROC AUC) of 0.69, higher than heart rate (0.51), rapid shallow breathing index (RBSI; 0.61) and respiratory rate (0.63). After deriving a WAVE model based on all data, training-set performance demonstrated that the model increased its predictive power when applied to patients conventionally considered high risk: a WAVE score >0.5 in patients with RSBI >105 and perceived high risk of failure yielded a fold increase in risk of extubation failure of 3.0 (95% confidence interval (CI) 1.2 to 5.2) and 3.5 (95% CI 1.9 to 5.4), respectively.
Conclusions
Altered HRV and RRV (during the SBT prior to extubation) are significantly associated with extubation failure. A predictive model using RRV during the last SBT provided optimal accuracy of prediction in all patients, with improved accuracy when combined with clinical impression or RSBI. This model requires a validation cohort to evaluate accuracy and generalizability.
Trial registration
ClinicalTrials.gov NCT01237886. Registered 13 October 2010.
doi:10.1186/cc13822
PMCID: PMC4057494  PMID: 24713049
6.  Predictors of physical restraint use in Canadian intensive care units 
Critical Care  2014;18(2):R46.
Introduction
Physical restraint (PR) use in the intensive care unit (ICU) has been associated with higher rates of self-extubation and prolonged ICU length of stay. Our objectives were to describe patterns and predictors of PR use.
Methods
We conducted a secondary analysis of a prospective observational study of analgosedation, antipsychotic, neuromuscular blocker, and PR practices in 51 Canadian ICUs. Data were collected prospectively for all mechanically ventilated adults admitted during a two-week period. We tested for patient, treatment, and hospital characteristics that were associated with PR use and number of days of use, using logistic and Poisson regression respectively.
Results
PR was used on 374 out of 711 (53%) patients, for a mean number of 4.1 (standard deviation (SD) 4.0) days. Treatment characteristics associated with PR were higher daily benzodiazepine dose (odds ratio (OR) 1.05, 95% confidence interval (CI) 1.00 to 1.11), higher daily opioid dose (OR 1.04, 95% CI 1.01 to 1.06), antipsychotic drugs (OR 3.09, 95% CI 1.74 to 5.48), agitation (Sedation-Agitation Scale (SAS) >4) (OR 3.73, 95% CI 1.50 to 9.29), and sedation administration method (continuous and bolus versus bolus only) (OR 3.09, 95% CI 1.74 to 5.48). Hospital characteristics associated with PR indicated patients were less likely to be restrained in ICUs from university-affiliated hospitals (OR 0.32, 95% CI 0.17 to 0.61). Mainly treatment characteristics were associated with more days of PR, including: higher daily benzodiazepine dose (incidence rate ratio (IRR) 1.07, 95% CI 1.01 to 1.13), daily sedation interruption (IRR 3.44, 95% CI 1.48 to 8.10), antipsychotic drugs (IRR 15.67, 95% CI 6.62 to 37.12), SAS <3 (IRR 2.62, 95% CI 1.08 to 6.35), and any adverse event including accidental device removal (IRR 8.27, 95% CI 2.07 to 33.08). Patient characteristics (age, gender, Acute Physiology and Chronic Health Evaluation II score, admission category, prior substance abuse, prior psychotropic medication, pre-existing psychiatric condition or dementia) were not associated with PR use or number of days used.
Conclusions
PR was used in half of the patients in these 51 ICUs. Treatment characteristics predominantly predicted PR use, as opposed to patient or hospital/ICU characteristics. Use of sedative, analgesic, and antipsychotic drugs, agitation, heavy sedation, and occurrence of an adverse event predicted PR use or number of days used.
doi:10.1186/cc13789
PMCID: PMC4075126  PMID: 24661688
7.  Cardiac ischemia in patients with septic shock randomized to vasopressin or norepinephrine 
Critical Care  2013;17(3):R117.
Introduction
Cardiac troponins are sensitive and specific biomarkers of myocardial necrosis. We evaluated troponin, CK, and ECG abnormalities in patients with septic shock and compared the effect of vasopressin (VP) versus norepinephrine (NE) on troponin, CK, and ECGs.
Methods
This was a prospective substudy of a randomized trial. Adults with septic shock randomly received, blinded, a low-dose infusion of VP (0.01 to 0.03 U/min) or NE (5 to 15 μg/min) in addition to open-label vasopressors, titrated to maintain a mean blood pressure of 65 to 75 mm Hg. Troponin I/T, CK, and CK-MB were measured, and 12-lead ECGs were recorded before study drug, and 6 hours, 2 days, and 4 days after study-drug initiation. Two physician readers, blinded to patient data and drug, independently interpreted ECGs.
Results
We enrolled 121 patients (median age, 63.9 years (interquartile range (IQR), 51.1 to 75.3), mean APACHE II 28.6 (SD 7.7)): 65 in the VP group and 56 in the NE group. At the four time points, 26%, 36%, 32%, and 21% of patients had troponin elevations, respectively. Baseline characteristics and outcomes were similar between patients with positive versus negative troponin levels. Troponin and CK levels and rates of ischemic ECG changes were similar in the VP and the NE groups. In multivariable analysis, only APACHE II was associated with 28-day mortality (OR, 1.07; 95% CI, 1.01 to 1.14; P = 0.033).
Conclusions
Troponin elevation is common in adults with septic shock. We observed no significant differences in troponin, CK, and ECGs in patients treated with vasopressin and norepinephrine. Troponin elevation was not an independent predictor of mortality.
Trial registration
Controlled-trials.com ISRCTN94845869
doi:10.1186/cc12789
PMCID: PMC4057204  PMID: 23786655
Septic shock; myocardial ischemia; vasopressin; norepinephrine; troponin; electrocardiogram
8.  Sleep, anxiety and fatigue in family members of patients admitted to the intensive care unit: a questionnaire study 
Critical Care  2013;17(3):R91.
Introduction
Family members of critically ill patients often experience increased incidence of physical and mental health issues. One of the first ways family members suffer is by losing sleep. The purpose of this study is to understand sleep quality, levels of fatigue and anxiety, and factors contributing to poor sleep in adult family members of critically ill patients.
Methods
A questionnaire was designed to evaluate sleep, fatigue and anxiety during the intensive care unit (ICU) admission. We incorporated three validated instruments: General Sleep Disturbance Scale (GSDS), Beck Anxiety Index (BAI) and Lee Fatigue Scale (NRS-F). Adult family members of patients in ICU for more than 24 hours were approached for questionnaire completion. Patient demographics were recorded.
Results
The study population consisted of 94 respondents, (49.1 ± 12.9 years, 52.7% male); 43.6% were children and 21.3% were spouses of ICU patients. Sleep quality was rated as poor/very poor by 43.5% of respondents, and good/very good by 15.2%. The most common factors contributing to poor sleep were anxiety (43.6%), tension (28.7%) and fear (24.5%). Respondents' most common suggestions to improve sleep were more information regarding the patient's health (24.5%) and relaxation techniques (21.3%). Mean GSDS score was 38.2 ± 19.3, with 58.1% of respondents experiencing moderate to severe sleep disturbance. Mean BAI was 12.3 ± 10.2, with 20.7% of respondents experiencing moderate to severe anxiety. Mean NRS-F was 3.8 ± 2.5, with 57.6% of respondents experiencing moderate to high fatigue. Family members who spent one or more nights in the hospital had significantly higher GSDS, BAI and NRS-F scores. The patient's Acute Physiology and Chronic Health Evaluation (APACHE) II score at survey completion correlated significantly with family members' GSDS, BAI and NRS-F.
Conclusion
The majority of family members of ICU patients experience moderate to severe sleep disturbance and fatigue, and mild anxiety.
doi:10.1186/cc12736
PMCID: PMC3706908  PMID: 23705988
sleep, fatigue; anxiety; family members; intensive care unit; questionnaire study
9.  An antimicrobial stewardship program improves antimicrobial treatment by culture site and the quality of antimicrobial prescribing in critically ill patients 
Critical Care  2012;16(6):R216.
Introduction
Increasing antimicrobial costs, reduced development of novel antimicrobials, and growing antimicrobial resistance necessitate judicious use of available agents. Antimicrobial stewardship programs (ASPs) may improve antimicrobial use in intensive care units (ICUs). Our objective was to determine whether the introduction of an ASP in an ICU altered the decision to treat cultures from sterile sites compared with nonsterile sites (which may represent colonization or contamination). We also sought to determine whether ASP education improved documentation of antimicrobial use, including an explicit statement of antimicrobial regimen, indication, duration, and de-escalation.
Methods
We retrospectively analyzed consecutive patients with positive bacterial cultures admitted to a 16-bed medical-surgical ICU over 2-month periods before and after ASP introduction (April through May 2008 and 2009, respectively). We evaluated the antimicrobial treatment of positive sterile- versus nonsterile-site cultures, specified a priori. We reviewed patient charts for clinician documentation of three specific details regarding antimicrobials: an explicit statement of antimicrobial regimen/indication, duration, and de-escalation. We also analyzed cost and defined daily doses (DDDs) (a World Health Organization (WHO) standardized metric of use) before and after ASP.
Results
Patient demographic data between the pre-ASP (n = 139) and post-ASP (n = 130) periods were similar. No difference was found in the percentage of positive cultures from sterile sites between the pre-ASP period and post-ASP period (44.9% versus 40.2%; P = 0.401). A significant increase was noted in the treatment of sterile-site cultures after ASP (64% versus 83%; P = 0.01) and a reduction in the treatment of nonsterile-site cultures (71% versus 46%; P = 0.0002). These differences were statistically significant when treatment decisions were analyzed both at an individual patient level and at an individual culture level. Increased explicit antimicrobial regimen documentation was observed after ASP (26% versus 71%; P < 0.0001). Also observed were increases in formally documented stop dates (53% versus 71%; P < 0.0001), regimen de-escalation (15% versus 23%; P = 0.026), and an overall reduction in cost and mean DDDs after ASP implementation.
Conclusions
Introduction of an ASP in the ICU was associated with improved microbiologically targeted therapy based on sterile or nonsterile cultures and improved documentation of antimicrobial use in the medical record.
doi:10.1186/cc11854
PMCID: PMC3672592  PMID: 23127353
10.  Permissive underfeeding versus target enteral feeding in adult critically ill patients (PermiT Trial): a study protocol of a multicenter randomized controlled trial 
Trials  2012;13:191.
Background
Nutritional support is an essential part of the management of critically ill patients. However, optimal caloric intake has not been systematically evaluated. We aim to compare two strategies of enteral feeding: permissive underfeeding versus target feeding.
Method/Design
This is an international multi-center randomized controlled trial in critically ill medical- surgical adult patients. Using a centralized allocation, 862 patients will be randomized to permissive underfeeding or target feeding. Patients in the permissive group receive 50% (acceptable range is 40% to 60%) of the calculated caloric requirement, while those in the targeted group receive 100% (acceptable range 70% to 100%) of the calculated caloric requirement. The primary outcome is 90-day all-cause mortality. Secondary outcomes include ICU and hospital mortality, 28-day, and 180-day mortality as well as health care-associated infections, organ failure, and length of stay in the ICU and hospital. The trial has 80% power to detect an 8% absolute reduction in 90-day mortality assuming a baseline risk of death of 25% at an alpha level of 0.05.
Discussion
Patient recruitment started in November 2009 and is currently active in five centers. The Data Monitoring Committee advised continuation of the trial after the first interim analysis. The study is expected to finish by November 2013.
Trial registration
Current Controlled Trials ISRCTN68144998
doi:10.1186/1745-6215-13-191
PMCID: PMC3517534  PMID: 23057605
Enteral nutrition; Intensive Care Units; Caloric restriction; Infections; Insulin; Mortality
11.  Partial Ventilatory Support Modalities in Acute Lung Injury and Acute Respiratory Distress Syndrome—A Systematic Review 
PLoS ONE  2012;7(8):e40190.
Purpose
The efficacy of partial ventilatory support modes that allow spontaneous breathing in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is unclear. The objective of this scoping review was to assess the effects of partial ventilatory support on mortality, duration of mechanical ventilation, and both hospital and intensive care unit (ICU) lengths of stay (LOS) for patients with ALI and ARDS; the secondary objective was to describe physiologic effects on hemodynamics, respiratory system and other organ function.
Methods
MEDLINE (1966–2009), Cochrane, and EmBase (1980–2009) databases were searched using common ventilator modes as keywords and reference lists from retrieved manuscripts hand searched for additional studies. Two researchers independently reviewed and graded the studies using a modified Oxford Centre for Evidence-Based Medicine grading system. Studies in adult ALI/ARDS patients were included for primary objectives and pre-clinical studies for supporting evidence.
Results
Two randomized controlled trials (RCTs) were identified, in addition to six prospective cohort studies, one retrospective cohort study, one case control study, 41 clinical physiologic studies and 28 pre-clinical studies. No study was powered to assess mortality, one RCT showed shorter ICU length of stay, and the other demonstrated more ventilator free days. Beneficial effects of preserved spontaneous breathing were mainly physiological effects demonstrated as improvement of gas exchange, hemodynamics and non-pulmonary organ perfusion and function.
Conclusions
The use of partial ventilatory support modalities is often feasible in patients with ALI/ARDS, and may be associated with short-term physiological benefits without appreciable impact on clinically important outcomes.
doi:10.1371/journal.pone.0040190
PMCID: PMC3420868  PMID: 22916094
12.  Errors Associated with IV Infusions in Critical Care 
Background
All medication errors are serious, but those associated with the IV route of administration often result in the most severe outcomes. According to the literature, IV medications are associated with 54% of potential adverse events, and 56% of medication errors.
Objectives
To determine the type and frequency of errors associated with prescribing, documenting, and administering IV infusions, and to also determine if a correlation exists between the incidence of errors and either the time of day (day versus night) or the day of the week (weekday versus weekend) in an academic medicosurgical intensive care unit without computerized order entry or documentation.
Methods
As part of a quality improvement initiative, a prospective, observational audit was conducted for all IV infusions administered to critically ill patients during 40 randomly selected shifts over a 7-month period in 2007. For each IV infusion, data were collected from 3 sources: direct observation of administration of the medication to the patient, the medication administration record, and the patient’s medical chart. The primary outcome was the occurrence of any infusion-related errors, defined as any errors of omission or commission in the context of IV medication therapy that harmed or could have harmed the patient.
Results
It was determined that up to 21 separate errors might occur in association with a single dose of an IV medication. In total, 1882 IV infusions were evaluated, and 5641 errors were identified. Omissions or discrepancies related to documentation accounted for 92.7% of all errors. The most common errors identified via each of the 3 data sources were incomplete labelling of IV tubing (1779 or 31.5% of all errors), omission of infusion diluent from the medication administration record (474 or 8.4% of all errors), and discrepancy between the medication order as recorded in the patient’s chart and the IV medication that was being infused (105 or 1.9% of all errors).
Conclusions
Strict definitions of errors and direct observation methods allowed identification of errors at every step of the medication administration process that was evaluated. Documentation discrepancies were the most prevalent type of errors in this paper-based system.
PMCID: PMC3282194  PMID: 22479108
IV infusion; continuous infusion; errors; intensive care unit; critical care; perfusion i.v.; perfusion continue; erreurs; unité de soins intensifs; soins aux malades en phase critique
14.  Open the lung with high-frequency oscillation ventilation or conventional mechanical ventilation? It may not matter! 
Critical Care  2010;14(6):1010.
The 'open lung' approach has been proposed as a reasonable ventilation strategy to mitigate ventilator-induced lung injury (VILI) and possibly reduce acute respiratory distress syndrome (ARDS)-related mortality. However, several randomized clinical trials have failed to show any significant clinical benefit of a ventilation strategy applying higher positive end-expiratory pressure (PEEP) and low tidal volume.
Dispute regarding the optimal levels of PEEP in ARDS patients represents the substrate for a translational research effort from the bedside to the bench, driving animal studies aimed at elucidating which ventilation strategies reduce biotrauma, considered one of the most important driving forces of VILI and ARDS-related multi-organ failure and mortality. Inappropriate values for end-inspiratory or end-expiratory pressure have clear potential to damage a lung predisposed to VILI. In the heterogeneous environment of the ARDS 'baby lung', lung recruitment and the avoidance of tidal overstretch with high-frequency oscillation ventilation or conventional mechanical ventilation, guided by respiratory mechanics, appears to reduce VILI.
doi:10.1186/cc9343
PMCID: PMC3220010  PMID: 21156085
15.  Bench-to-bedside review: High-frequency oscillatory ventilation in adults with acute respiratory distress syndrome 
Critical Care  2006;10(6):240.
Mechanical ventilation is the cornerstone of therapy for patients with acute respiratory distress syndrome (ARDS). Paradoxically, mechanical ventilation can exacerbate lung damage – a phenomenon known as ventilator-induced lung injury. While new ventilation strategies have reduced the mortality rate in patients with ARDS, this mortality rate still remains high. High-frequency oscillatory ventilation (HFOV) is an unconventional form of ventilation that may improve oxygenation in patients with ARDS, while limiting further lung injury associated with high ventilatory pressures and volumes delivered during conventional ventilation. HFOV has been used for almost two decades in the neonatal population, but there is more limited experience with HFOV in the adult population. In adults, the majority of the published literature is in the form of small observational studies in which HFOV was used as 'rescue' therapy for patients with very severe ARDS who were failing conventional ventilation. Two prospective randomized controlled trials, however, while showing no mortality benefit, have suggested that HFOV, compared with conventional ventilation, is a safe and effective ventilation strategy for adults with ARDS. Several studies suggest that HFOV may improve outcomes if used early in the course of ARDS, or if used in certain populations. This review will summarize the evidence supporting the use of HFOV in adults with ARDS.
doi:10.1186/cc5096
PMCID: PMC1794464  PMID: 17184554
16.  Prospective evaluation of an internet-linked handheld computer critical care knowledge access system 
Critical Care  2004;8(6):R414-R421.
Introduction
Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs.
Methods
Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators.
Results
Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3–126.8), with medical software accessed less often (median 9/month, IQR 3.7–13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15–40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources (P = 0.018). Benefits and barriers to use of this technology were identified.
Conclusion
An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.
doi:10.1186/cc2967
PMCID: PMC1065064  PMID: 15566586
clinical; computer; critical care; decision support systems; handheld; internet; point-of-care systems; practice guidelines; simulation
17.  Bench-to-bedside review: Recruitment and recruiting maneuvers 
Critical Care  2004;9(1):60-65.
In patients with acute respiratory distress syndrome (ARDS), the lung comprises areas of aeration and areas of alveolar collapse, the latter producing intrapulmonary shunt and hypoxemia. The currently suggested strategy of ventilation with low lung volumes can aggravate lung collapse and potentially produce lung injury through shear stress at the interface between aerated and collapsed lung, and as a result of repetitive opening and closing of alveoli. An 'open lung strategy' focused on alveolar patency has therefore been recommended. While positive end-expiratory pressure prevents alveolar collapse, recruitment maneuvers can be used to achieve alveolar recruitment. Various recruitment maneuvers exist, including sustained inflation to high pressures, intermittent sighs, and stepwise increases in positive end-expiratory pressure or peak inspiratory pressure. In animal studies, recruitment maneuvers clearly reverse the derecruitment associated with low tidal volume ventilation, improve gas exchange, and reduce lung injury. Data regarding the use of recruitment maneuvers in patients with ARDS show mixed results, with increased efficacy in those with short duration of ARDS, good compliance of the chest wall, and in extrapulmonary ARDS. In this review we discuss the pathophysiologic basis for the use of recruitment maneuvers and recent evidence, as well as the practical application of the technique.
doi:10.1186/cc2934
PMCID: PMC1065091  PMID: 15693985
acute respiratory distress syndrome; artificial respiration; atelectasis; mechanical ventilation; positive end-expiratory pressure
18.  Jeff Mann's EM Guidemaps 
Critical Care  2004;8(6):516.
doi:10.1186/cc2891
PMCID: PMC4082219
emergency medicine; guidemaps
19.  Handheld Computing in Medicine 
Handheld computers have become a valuable and popular tool in various fields of medicine. A systematic review of articles was undertaken to summarize the current literature regarding the use of handheld devices in medicine. A variety of articles were identified, and relevant information for various medical fields was summarized. The literature search covered general information about handheld devices, the use of these devices to access medical literature, electronic pharmacopoeias, patient tracking, medical education, research, business management, e-prescribing, patient confidentiality, and costs as well as specialty-specific uses for personal digital assistants (PDAs).
The authors concluded that only a small number of articles provide evidence-based information about the use of PDAs in medicine. The majority of articles provide descriptive information, which is nevertheless of value. This article aims to increase the awareness among physicians about the potential roles for handheld computers in medicine and to encourage the further evaluation of their use.
doi:10.1197/jamia.M1180
PMCID: PMC150367  PMID: 12595403
20.  Web reports: critically appraising online resources 
Critical Care  2002;6(6):462.
The Internet is an invaluable resource for critical care clinicians. However, the search for useful Internet resources can be frustrating and time-consuming. In this issue, Critical Care launches a new section entitled 'Web Reports', which will regularly provide critical appraisal of Internet resources that may be of interest to critical care health care workers.
doi:10.1186/cc1830
PMCID: PMC153439
critical care; Internet; online resources
21.  Pro/con clinical debate: Is high-frequency oscillatory ventilation useful in the management of adult patients with respiratory failure? 
Critical Care  2002;6(3):183-185.
In neonatal and pediatric intensive care units, high-frequency oscillatory ventilation (HFOV) has become an increasingly common therapy. This may not have been the case if researchers had not persisted in investigating the therapy after early disappointing clinical trials. Devices capable of providing this therapy to adults have become commercially available relatively recently. However, there are many questions that need to be answered regarding HFOV in adults: Is HFOV in adults superior to conventional mechanical ventilation? Who is the ideal candidate for HFOV? When should it be applied? What is the best technique with which to apply it? When should a patient on HFOV be converted back to conventional ventilation? What is the safety and efficacy of the device? As outlined in the following debate, there are several compelling arguments for and against the use of HFOV at this point in adults.
PMCID: PMC137439  PMID: 12133172
acute respiratory failure; critical illness; high-frequency oscillatory ventilation; mechanical ventilation
22.  Practising evidence-based medicine: the design and implementation of a multidisciplinary team-driven extubation protocol 
Critical Care  2001;5(6):349-354.
Background
Evidence from recent literature shows that protocol-directed extubation is a useful approach to liberate patients from mechanical ventilation (MV). However, research evidence does not necessarily provide guidance on how to implement changes in individual intensive care units (ICUs). We conducted the present study to determine whether such an evidence-based strategy can be implemented safely and effectively using a multidisciplinary team (MDT) approach.
Method
We designed a MDT-driven extubation protocol. Multiple meetings were held to encourage constructive criticism of the design by attending physicians, nurses and respiratory care practitioners (RCPs), in order to define a protocol that was evidence based and acceptable to all clinical staff involved in the process of extubation. It was subsequently implemented and evaluated in our medical/ surgical ICU. Outcomes included response of the MDT to the initiative, duration of MV and stay in the ICU, as well as reintubation rate.
Results
The MDT responded favourably to the design and implementation of this MDT-driven extubation protocol, because it provided greater autonomy to the staff. Outcomes reported in the literature and in the historical control group were compared with those in the protocol group, and indicated similar durations of MV and ICU stay, as well as reintubation rates. No adverse events were documented.
Conclusion
An MDT approach to protocol-directed extubation can be implemented safely and effectively in a multidisciplinary ICU. Such an effort is viewed favourably by the entire team and is useful in enhancing team building.
PMCID: PMC83857  PMID: 11737924
extubation protocol; mechanical ventilation; multidisciplinary team; spontaneous breathing trial; weaning
23.  Utility of routine chest radiographs in a medical–surgical intensive care unit: a quality assurance survey 
Critical Care  2001;5(5):271-275.
Objective
To determine the utility of routine chest radiographs (CXRs) in clinical decision-making in the intensive care unit (ICU).
Design
A prospective evaluation of CXRs performed in the ICU for a period of 6 months. A questionnaire was completed for each CXR performed, addressing the indication for the radiograph, whether it changed the patient's management, and how it did so.
Setting
A 14-bed medical–surgical ICU in a university-affiliated, tertiary care hospital.
Patients
A total of 645 CXRs were analyzed in 97 medical patients and 205 CXRs were analyzed in 101 surgical patients.
Results
Of the 645 CXRs performed in the medical patients, 127 (19.7%) led to one or more management changes. In the 66 surgical patients with an ICU stay <48 hours, 15.4% of routine CXRs changed management. In 35 surgical patients with an ICU stay ≥ 48 hours, 26% of the 100 routine films changed management. In both the medical and surgical patients, the majority of changes were related to an adjustment of a medical device.
Conclusions
Routine CXRs have some value in guiding management decisions in the ICU. Daily CXRs may not, however, be necessary for all patients.
PMCID: PMC83854  PMID: 11737902
chest radiograph; intensive care unit; quality assurance; routine radiography
24.  Handheld computers in critical care 
Critical Care  2001;5(4):227-231.
Background
Computing technology has the potential to improve health care management but is often underutilized. Handheld computers are versatile and relatively inexpensive, bringing the benefits of computers to the bedside. We evaluated the role of this technology for managing patient data and accessing medical reference information, in an academic intensive-care unit (ICU).
Methods
Palm III series handheld devices were given to the ICU team, each installed with medical reference information, schedules, and contact numbers. Users underwent a 1-hour training session introducing the hardware and software. Various patient data management applications were assessed during the study period. Qualitative assessment of the benefits, drawbacks, and suggestions was performed by an independent company, using focus groups. An objective comparison between a paper and electronic handheld textbook was achieved using clinical scenario tests.
Results
During the 6-month study period, the 20 physicians and 6 paramedical staff who used the handheld devices found them convenient and functional but suggested more comprehensive training and improved search facilities. Comparison of the handheld computer with the conventional paper text revealed equivalence. Access to computerized patient information improved communication, particularly with regard to long-stay patients, but changes to the software and the process were suggested.
Conclusions
The introduction of this technology was well received despite differences in users' familiarity with the devices. Handheld computers have potential in the ICU, but systems need to be developed specifically for the critical-care environment.
PMCID: PMC37409  PMID: 11511337
computer communication networks; medical informatics; medical technology; microcomputers; point-of-care technology

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