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Burden of illness in venous thromboembolism in critical care: a multicenter observational study.

https://arctichealth.org/en/permalink/ahliterature171809
Source
J Crit Care. 2005 Dec;20(4):341-7
Publication Type
Article
Date
Dec-2005
Author
Rakesh Patel
Deborah J Cook
Maureen O Meade
Lauren E Griffith
Geeta Mehta
Graeme M Rocker
John C Marshall
Rick Hodder
Claudio M Martin
Daren K Heyland
Sharon Peters
John Muscedere
Mark Soth
Nicole Campbell
Gordon H Guyatt
Author Affiliation
Department of Medicine, University of Ottawa, Canada K1Y 4E9.
Source
J Crit Care. 2005 Dec;20(4):341-7
Date
Dec-2005
Language
English
Publication Type
Article
Keywords
Anticoagulants - therapeutic use
Canada - epidemiology
Female
Humans
Incidence
Intensive Care Units
Male
Middle Aged
Prevalence
Pulmonary Embolism - epidemiology - prevention & control - therapy
Retrospective Studies
Venous Thrombosis - epidemiology - prevention & control - therapy
Abstract
The frequency of clinically diagnosed venous thromboembolism (VTE) including deep venous thrombosis (DVT) and pulmonary embolism (PE) in medical-surgical critically ill patients is unclear. The objectives of this study were to estimate the prevalence and incidence of radiologically confirmed DVT and PE in medical-surgical intensive care unit (ICU) patients and to determine the impact of prophylaxis on the frequency of these events.
In a retrospective observational cohort study in 12 adult ICUs, we identified prevalent cases (diagnosed in the 24 hours preceding ICU admission up to 48 hours post-ICU admission) and incident cases (diagnosed 48 hours or more after ICU admission and up to 8 weeks after ICU discharge) of upper or lower limb DVT or PE. Deep venous thrombosis was diagnosed by compression ultrasound or venogram. Each DVT was classified as clinically suspected or not clinically suspected in that the latter was diagnosed by scheduled screening ultrasonography. Pulmonary embolism was diagnosed by ventilation-perfusion lung scan, computed tomography pulmonary angiography, echocardiography, electrocardiography, or autopsy.
Among 12,338 patients, 252 (2.0%) patients had radiologically confirmed DVT or PE and another 47 (0.4%) had possible DVT or PE. Prevalent DVTs were diagnosed in 0.4% (95% confidence interval [CI], 0.3%-0.5%) of patients and prevalent PEs were diagnosed in 0.4% (95% CI, 0.3%-0.6%). Incident DVTs were diagnosed in 1.0% (95% CI, 0.8%-1.2%) of patients, and incident PEs were diagnosed in 0.5% (95% CI, 0.4%-0.6%). Of patients with incident VTE, 65.8% of cases occurred despite receipt of thromboprophylaxis for at least 80% of their days in ICU. The median (interquartile range) ICU length of stay was similar for patients with DVT (7 [3-17]) and PE (5 [2-8]). For all patients with VTE, ICU mortality was 16.7% (95% CI, 12.0%-21.3%) and hospital mortality was 28.5% (95% CI, 22.8%-34.1%).
Venous thromboembolism appears to be an apparently infrequent, but likely underdiagnosed problem, occurring among patients receiving prophylaxis. Findings suggest the need for increased suspicion among clinicians, renewed efforts at thromboprophylaxis, and evaluation of superior prevention strategies.
PubMed ID
16310605 View in PubMed
Less detail

Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting.

https://arctichealth.org/en/permalink/ahliterature136993
Source
CMAJ. 2011 Feb 22;183(3):E195-214
Publication Type
Conference/Meeting Material
Article
Date
Feb-22-2011
Author
Sean P Keenan
Tasnim Sinuff
Karen E A Burns
John Muscedere
Jim Kutsogiannis
Sangeeta Mehta
Deborah J Cook
Najib Ayas
Neill K J Adhikari
Lori Hand
Damon C Scales
Rose Pagnotta
Lynda Lazosky
Graeme Rocker
Sandra Dial
Kevin Laupland
Kevin Sanders
Peter Dodek
Author Affiliation
sean_keenan@telus.net
Source
CMAJ. 2011 Feb 22;183(3):E195-214
Date
Feb-22-2011
Language
English
Publication Type
Conference/Meeting Material
Article
Keywords
Acute Disease - therapy
Canada
Continuous Positive Airway Pressure
Humans
Positive-Pressure Respiration
Notes
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Comment In: CMAJ. 2011 Feb 22;183(3):293-421324861
Comment In: Ann Intern Med. 2011 Jun 21;154(12):JC6-721690585
PubMed ID
21324867 View in PubMed
Less detail

Implementation of clinical practice guidelines for ventilator-associated pneumonia: a multicenter prospective study.

https://arctichealth.org/en/permalink/ahliterature118301
Source
Crit Care Med. 2013 Jan;41(1):15-23
Publication Type
Article
Date
Jan-2013
Author
Tasnim Sinuff
John Muscedere
Deborah J Cook
Peter M Dodek
William Anderson
Sean P Keenan
Gordon Wood
Richard Tan
Marilyn T Haupt
Michael Miletin
Redouane Bouali
Xuran Jiang
Andrew G Day
Janet Overvelde
Daren K Heyland
Author Affiliation
Sunnybrook Research Institute, Sunnybrook Health Sciences Center and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada. taz.sinuff@sunnybrook.ca
Source
Crit Care Med. 2013 Jan;41(1):15-23
Date
Jan-2013
Language
English
Publication Type
Article
Keywords
Canada
Female
Guideline Adherence
Humans
Inservice training
Male
Middle Aged
Outcome Assessment (Health Care)
Pneumonia, Ventilator-Associated - diagnosis - prevention & control - therapy
Practice Guidelines as Topic
Prospective Studies
Translational Medical Research
United States
Abstract
Ventilator-associated pneumonia is an important cause of morbidity and mortality in critically ill patients. Evidence-based clinical practice guidelines for the prevention, diagnosis, and treatment of ventilator-associated pneumonia may improve outcomes, but optimal methods to ensure implementation of guidelines in the intensive care unit are unclear. Hence, we determined the effect of educational sessions augmented with reminders, and led by local opinion leaders, as strategies to implement evidence-based ventilator-associated pneumonia guidelines on guideline concordance and ventilator-associated pneumonia rates.
Two-year prospective, multicenter, time-series study conducted between June 2007 and December 2009.
Eleven ICUs (ten in Canada, one in the United States); five academic and six community ICUs.
At each site, 30 adult patients mechanically ventilated >48 hrs were enrolled during four data collection periods (baseline, 6, 15, and 24 months).
Guideline recommendations for the prevention, diagnosis, and treatment of ventilator-associated pneumonia were implemented using a multifaceted intervention (education, reminders, local opinion leaders, and implementation teams) directed toward the entire multidisciplinary ICU team. Clinician exposure to the intervention was assessed at 6, 15, and 24 months after the introduction of this intervention.
The main outcome measure was aggregate concordance with the 14 ventilator-associated pneumonia guideline recommendations. One thousand three hundred twenty patients were enrolled (330 in each study period). Clinician exposure to the multifaceted intervention was high and increased during the study: 86.7%, 93.3%, 95.8%, (p
Notes
Comment In: Crit Care Med. 2013 Jan;41(1):329-3123269134
PubMed ID
23222254 View in PubMed
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The occurrence and impact of bacterial organisms complicating critical care illness associated with 2009 influenza A(H1N1) infection.

https://arctichealth.org/en/permalink/ahliterature116488
Source
Chest. 2013 Jul;144(1):39-47
Publication Type
Article
Date
Jul-2013
Author
John Muscedere
Marianna Ofner
Anand Kumar
Jennifer Long
Francois Lamontagne
Deborah Cook
Allison McGeer
Clarence Chant
John Marshall
Philippe Jouvet
Robert Fowler
Author Affiliation
Department of Medicine, Queen's University, Kingston, ON, Canada. muscedej@kgh.kari.net
Source
Chest. 2013 Jul;144(1):39-47
Date
Jul-2013
Language
English
Publication Type
Article
Keywords
Adult
Canada
Cohort Studies
Critical Illness - epidemiology
Female
Humans
Incidence
Influenza A Virus, H1N1 Subtype
Influenza, Human - complications
Intensive Care Units
Length of Stay
Male
Middle Aged
Prognosis
Prospective Studies
Pseudomonas Infections - diagnosis - epidemiology
Respiration, Artificial
Staphylococcal Infections - diagnosis - epidemiology
Streptococcal Infections - diagnosis - epidemiology
Abstract
Although secondary infections are recognized as a cause of morbidity and mortality in seasonal influenza, their frequency, characteristics, and associated clinical outcomes in 2009 influenza A(H1N1) (A[H1N1])-related critical illness are unknown.
In a prospective cohort of adult patients admitted to Canadian ICUs with influenza A(H1N1) infection, the frequency and associated clinical outcomes of prevalent (culture taken within 72 h of ICU admission) and ICU-acquired (culture taken after 72 h from ICU admission) positive bacterial cultures were determined.
Among 681 patients, the mean age was 47.9 years (SD, 15.1), APACHE (Acute Physiology and Chronic Health Examination) II score was 21.0 (9.9), and 573 patients (84.0%) were invasively mechanically ventilated. Positive cultures were obtained in 259 patients (38.0%): 77 (29.7%) had prevalent, 115 (44.4%) had ICU-acquired, and 40 (15.4%) had both; culture date was unavailable in 27 (10.4%). The most common bacterial organisms isolated were coagulase-negative staphylococci, Staphylococcus aureus, Pseudomonas species, and Streptococcus pneumoniae. Antibiotics were prescribed in 661 (97.1%), with 3.8 (1.9) prescriptions per patient. Patients with any positive culture had longer days of mechanical ventilation (mean [SD], 15.2 [10.7] vs 10.7 [9.0]; P
PubMed ID
23392627 View in PubMed
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Persistent organ dysfunction plus death: a novel, composite outcome measure for critical care trials.

https://arctichealth.org/en/permalink/ahliterature136041
Source
Crit Care. 2011;15(2):R98
Publication Type
Article
Date
2011
Author
Daren K Heyland
John Muscedere
John Drover
Xuran Jiang
Andrew G Day
Author Affiliation
Department of Medicine, Queen's University, 76 Stuart Street, Kingston, ON K7L 2V7, Canada. dkh2@queensu.ca
Source
Crit Care. 2011;15(2):R98
Date
2011
Language
English
Publication Type
Article
Keywords
Aged
Canada - epidemiology
Critical Care - methods
Europe - epidemiology
Female
Follow-Up Studies
Hospital Mortality
Humans
Intensive Care Units - statistics & numerical data
Male
Middle Aged
Multiple Organ Failure - epidemiology - mortality
Outcome Assessment (Health Care) - methods
Prospective Studies
United States - epidemiology
Abstract
Due to resource limitations, few critical care interventions have been rigorously evaluated with adequately powered randomized clinical trials (RCTs). There is a need to improve the efficiency of RCTs in critical care so that more definitive high quality RCTs can be completed with the available resources. The objective of this study was to validate and demonstrate the utility of a novel composite outcome measure, persistent organ dysfunction (POD) plus death, for clinical trials of critically ill patients.
We performed a secondary analysis of a dataset from a prospective randomized trial involving 38 intensive care units (ICUs) in Canada, Europe, and the United States. We define POD as the persistence of organ dysfunction requiring supportive technologies during the convalescent phase of critical illness and it is present when a patient has an ongoing requirement for vasopressors, dialysis, or mechanical ventilation at the outcome assessments time points. In 600 patients enrolled in a randomized trial of nutrition therapy and followed prospectively for six months, we evaluated the prevalence of POD and its association with outcome.
At 28 days, 2.3% of patients had circulatory failure, 13.7% had renal failure, 8.7% had respiratory failure, and 27.2% had died, for an overall prevalence of POD + death = 46.0%. Of survivors at Day 28, those with POD, compared to those without POD, had a higher mortality rate in the six-month follow-up period, had longer ICU and hospital stays, and a reduced quality of life at three months. Given these rates of POD + death and using a two-sided Chi-squared test at alpha = 0.05, we would require 616 patients per arm to detect a 25% relative risk reduction (RRR) in mortality, but only 286 per arm to detect the same RRR in POD + mortality.
POD + death may be a valid composite outcome measure and compared to mortality endpoints, may reduce the sample size requirements of clinical trials of critically ill patients. Further validation in larger clinical trials is required.
Notes
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PubMed ID
21418560 View in PubMed
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The safety of targeted antibiotic therapy for ventilator-associated pneumonia: a multicenter observational study.

https://arctichealth.org/en/permalink/ahliterature158164
Source
J Crit Care. 2008 Mar;23(1):82-90
Publication Type
Article
Date
Mar-2008
Author
Ari R Joffe
John Muscedere
John C Marshall
Yinghua Su
Daren K Heyland
Author Affiliation
Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada T6G 2B7.
Source
J Crit Care. 2008 Mar;23(1):82-90
Date
Mar-2008
Language
English
Publication Type
Article
Keywords
Anti-Bacterial Agents - therapeutic use
Bronchoalveolar Lavage Fluid - microbiology
Bronchoscopy
Canada
Chi-Square Distribution
Female
Humans
Intensive Care Units
Male
Middle Aged
Pneumonia, Ventilator-Associated - drug therapy - microbiology
Sputum - microbiology
Statistics, nonparametric
Suction
Treatment Outcome
United States
Abstract
The aim of this study was to determine the safety of targeted antibiotic therapy (TT) in ventilator-associated pneumonia (VAP).
This was a secondary analysis from a multicenter trial of 740 patients with suspected VAP randomized to bronchoscopy or endotracheal aspirate cultures; all received empirical broad-spectrum antibiotics. Patients were grouped by whether they received TT, defined as tailoring or discontinuing antibiotics in response to enrolment culture results.
For patients with a positive culture (n = 412), baseline demographics, clinical progression of infection and multiple organ dysfunction scores (MODS), and mortality were similar for those on TT (n = 320) or those who did not receive TT (NoTT) (n = 92). The TT group had more days alive and off broad-spectrum antibiotics (14.5 vs 13.2, P = .04). In patients with a negative culture (n = 327), those on TT (n = 230) had similar baseline demographics, less frequent final adjudicated diagnosis of VAP (63.0% vs 76.3%, P = .02), and less severe clinical progression of infection and MODS compared with NoTT (n = 97). The TT group had more days alive and off broad-spectrum antibiotics (15.9 vs 13.1, P
PubMed ID
18359425 View in PubMed
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