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1.  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
2.  Pressure and Volume Limited Ventilation for the Ventilatory Management of Patients with Acute Lung Injury: A Systematic Review and Meta-Analysis 
PLoS ONE  2011;6(1):e14623.
Background
Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) are life threatening clinical conditions seen in critically ill patients with diverse underlying illnesses. Lung injury may be perpetuated by ventilation strategies that do not limit lung volumes and airway pressures. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing pressure and volume-limited (PVL) ventilation strategies with more traditional mechanical ventilation in adults with ALI and ARDS.
Methods and Findings
We searched Medline, EMBASE, HEALTHSTAR and CENTRAL, related articles on PubMed™, conference proceedings and bibliographies of identified articles for randomized trials comparing PVL ventilation with traditional approaches to ventilation in critically ill adults with ALI and ARDS. Two reviewers independently selected trials, assessed trial quality, and abstracted data. We identified ten trials (n = 1,749) meeting study inclusion criteria. Tidal volumes achieved in control groups were at the lower end of the traditional range of 10–15 mL/kg. We found a clinically important but borderline statistically significant reduction in hospital mortality with PVL [relative risk (RR) 0.84; 95% CI 0.70, 1.00; p = 0.05]. This reduction in risk was attenuated (RR 0.90; 95% CI 0.74, 1.09, p = 0.27) in a sensitivity analysis which excluded 2 trials that combined PVL with open-lung strategies and stopped early for benefit. We found no effect of PVL on barotrauma; however, use of paralytic agents increased significantly with PVL (RR 1.37; 95% CI, 1.04, 1.82; p = 0.03).
Conclusions
This systematic review suggests that PVL strategies for mechanical ventilation in ALI and ARDS reduce mortality and are associated with increased use of paralytic agents.
doi:10.1371/journal.pone.0014623
PMCID: PMC3030554  PMID: 21298026
3.  Relaunching the Pro–Con section at Critical Care 
Critical Care  2008;12(2):140.
doi:10.1186/cc6867
PMCID: PMC2447602
4.  Long-term Psychological and Occupational Effects of Providing Hospital Healthcare during SARS Outbreak 
Emerging Infectious Diseases  2006;12(12):1924-1932.
TOC Summary Line: Healthcare workers in hospitals affected by SARS experience increased psychological stress 1–2 years after the outbreak.
Healthcare workers (HCWs) found the 2003 outbreak of severe acute respiratory syndrome (SARS) to be stressful, but the long-term impact is not known. From 13 to 26 months after the SARS outbreak, 769 HCWs at 9 Toronto hospitals that treated SARS patients and 4 Hamilton hospitals that did not treat SARS patients completed a survey of several adverse outcomes. Toronto HCWs reported significantly higher levels of burnout (p = 0.019), psychological distress (p<0.001), and posttraumatic stress (p<0.001). Toronto workers were more likely to have reduced patient contact and work hours and to report behavioral consequences of stress. Variance in adverse outcomes was explained by a protective effect of the perceived adequacy of training and support and by a provocative effect of maladaptive coping style and other individual factors. The results reinforce the value of effective staff support and training in preparation for future outbreaks.
doi:10.3201/eid1212.060584
PMCID: PMC3291360  PMID: 17326946
Severe Acute Respiratory Syndrome; Stress, Psychological; Health Personnel; Stress, Traumatic; Burnout, Professional, research
5.  Outcomes of interfacility critical care adult patient transport: a systematic review 
Critical Care  2005;10(1):R6.
Introduction
We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients.
Methods
We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined.
Results
Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies.
Conclusion
Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.
doi:10.1186/cc3924
PMCID: PMC1550794  PMID: 16356212
6.  Clinical review: Mechanical ventilation in severe asthma 
Critical Care  2005;9(6):581-587.
Respiratory failure from severe asthma is a potentially reversible, life-threatening condition. Poor outcome in this setting is frequently a result of the development of gas-trapping. This condition can arise in any mechanically ventilated patient, but those with severe airflow limitation have a predisposition. It is important that clinicians managing these types of patients understand that the use of mechanical ventilation can lead to or worsen gas-trapping. In this review we discuss the development of this complication during mechanical ventilation, techniques to measure it and strategies to limit its severity. We hope that by understanding such concepts clinicians will be able to reduce further the poor outcomes occasionally related to severe asthma.
doi:10.1186/cc3733
PMCID: PMC1414026  PMID: 16356242
7.  Clinical review: SARS – lessons in disaster management 
Critical Care  2005;9(4):384-389.
Disaster management plans have traditionally been required to manage major traumatic events that create a large number of victims. Infectious diseases, whether they be natural (e.g. SARS [severe acute respiratory syndrome] and influenza) or the result of bioterrorism, have the potential to create a large influx of critically ill into our already strained hospital systems. With proper planning, hospitals, health care workers and our health care systems can be better prepared to deal with such an eventuality. This review explores the Toronto critical care experience of coping in the SARS outbreak disaster. Our health care system and, in particular, our critical care system were unprepared for this event, and as a result the impact that SARS had was worse than it could have been. Nonetheless, we were able to organize a response rapidly during the outbreak. By describing our successes and failures, we hope to help others to learn and avoid the problems we encountered as they develop their own disaster management plans in anticipation of similar future situations.
doi:10.1186/cc3041
PMCID: PMC1269424  PMID: 16137388
8.  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
9.  Albumin in critical care: SAFE, but worth its salt? 
Critical Care  2004;8(5):297-299.
Intravascular fluid therapy is a common critical care intervention. However, the optimal type of resuscitation fluid, crystalloid or colloid, remains controversial. Despite the many theoretical benefits of human albumin administration in critically ill patients, there has been little evidence to support its widespread clinical use. Previous systematic reviews have led to conflicting results regarding the safety and efficacy of albumin. The recently reported Saline versus Albumin Evaluation study has provided conclusive evidence that 4% albumin is as safe as saline for resuscitation, although no overall benefit of albumin use was seen. Subgroup analysis of the albumin-treated group revealed a trend towards decreased mortality in patients with septic shock, and a trend towards increased mortality in trauma patients, especially those with traumatic brain injury. The results of these subgroups, as well as the use of higher albumin concentrations and other synthetic colloids (dextrans, starches), require rigorous evaluation in clinical trials. Finally, the Saline versus Albumin Evaluation trial represents a methodological milestone in critical care medicine, due to its size, its efficient trial design, and its logistical coordination. Future studies are still required, however, to establish a therapeutic niche for albumin and other colloids.
doi:10.1186/cc2943
PMCID: PMC1065031  PMID: 15469582
albumins; colloids; critical care; crystalloids; fluid therapy
10.  Critical care procedure logging using handheld computers 
Critical Care  2004;8(5):R336-R342.
Introduction
We conducted this study to evaluate the feasibility of implementing an internet-linked handheld computer procedure logging system in a critical care training program.
Methods
Subspecialty trainees in the Interdepartmental Division of Critical Care at the University of Toronto received and were trained in the use of Palm handheld computers loaded with a customized program for logging critical care procedures. The procedures were entered into the handheld device using checkboxes and drop-down lists, and data were uploaded to a central database via the internet. To evaluate the feasibility of this system, we tracked the utilization of this data collection system. Benefits and disadvantages were assessed through surveys.
Results
All 11 trainees successfully uploaded data to the central database, but only six (55%) continued to upload data on a regular basis. The most common reason cited for not using the system pertained to initial technical problems with data uploading. From 1 July 2002 to 30 June 2003, a total of 914 procedures were logged. Significant variability was noted in the number of procedures logged by individual trainees (range 13–242). The database generated by regular users provided potentially useful information to the training program director regarding the scope and location of procedural training among the different rotations and hospitals.
Conclusion
A handheld computer procedure logging system can be effectively used in a critical care training program. However, user acceptance was not uniform, and continued training and support are required to increase user acceptance. Such a procedure database may provide valuable information that may be used to optimize trainees' educational experience and to document clinical training experience for licensing and accreditation.
doi:10.1186/cc2921
PMCID: PMC1065023  PMID: 15469577
critical care; handheld computers; internet; procedure logging; training program
11.  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
12.  Communication in the Toronto critical care community: important lessons learned during SARS 
Critical Care  2003;7(6):405-406.
The SARS outbreak in 2003 pushed Toronto's health care system to its limits. Staffing shortages, transmission of SARS within the ICU, and the influx of critically ill SARS patients were some unique challenges to the delivery of critical care. Communication strategies were a key component in the critical care response to SARS. Regular teleconference calls, web-based training and education, and the rapid coordination of research studies were some of the initiatives developed within the Toronto critical care community during the SARS outbreak. Other critical care communities should consider their communication strategies in advance of similar events.
PMCID: PMC374381  PMID: 14624673
communication; critical care; disease outbreaks; SARS
14.  Clinical review: High-frequency oscillatory ventilation in adults – a review of the literature and practical applications 
Critical Care  2003;7(5):385-390.
It has recently been shown that strategies aimed at preventing ventilator-induced lung injury, such as ventilating with low tidal volumes, can reduce mortality in patients with acute respiratory distress syndrome (ARDS). High-frequency oscillatory ventilation (HFOV) seems ideally suited as a lung-protective strategy for these patients. HFOV provides both active inspiration and expiration at frequencies generally between 3 and 10 Hz in adults. The amount of gas that enters and exits the lung with each oscillation is frequently below the anatomic dead space. Despite this, gas exchange occurs and potential adverse effects of conventional ventilation, such as overdistension and the repetitive opening and closing of collapsed lung units, are arguably mitigated. Although many investigators have studied the merits of HFOV in neonates and in pediatric populations, evidence for its use in adults with ARDS is limited. A recent multicenter, randomized, controlled trial has shown that HFOV, when used early in ARDS, is at least equivalent to conventional ventilation and may have beneficial effects on mortality. The present article reviews the principles and practical aspects of HFOV, and the current evidence for its application in adults with ARDS.
doi:10.1186/cc2182
PMCID: PMC270711  PMID: 12974971
acute lung injury; acute respiratory distress syndrome; high-frequency oscillatory ventilation; mechanical ventilation; ventilator-induced lung injury
15.  Surgical procedure logging with use of a hand-held computer 
Canadian Journal of Surgery  2002;45(5):345-350.
Objective
To evaluate the feasibility of incorporating hand-held computing technology in a surgical residency program, by means of hand-held devices for surgical procedure logging linked through the Internet to a central database.
Setting
Division of General Surgery, University of Toronto.
Design
A survey of general surgery residents.
Methods
The 69 residents in the general surgery training program received hand-held computers with preinstalled medical programs and a program designed for surgical procedure logging. Procedural data were uploaded via the Internet to a central database. Survey data were collected regarding previous computer use as well as previous procedure logging methods.
Main outcome measure
Utilization of the procedure logging system.
Results
After a 5-month pilot period, 38% of surgical residents were using the procedure-logging program successfully and on a regular basis. Program use was higher among more junior trainees. Analysis of the database provided valuable information on individual trainees, hospital programs and supervising surgeons, data that would assist in program development.
Conclusions
Hand-held devices can be implemented in a large division of general surgery to provide a reference database and a procedure-logging platform. However, user acceptance is not uniform and continued training and support are necessary to increase acceptance. The procedure database provides important information for optimizing trainees’ educational experience.
PMCID: PMC3684636  PMID: 12387537
16.  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
17.  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

Results 1-17 (17)