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Cook D, Figurski J, Patel R, Burneo J, Langlands S, Keitz S. 6Ts teaching tips for evidence-based practitioners. EVIDENCE-BASED MEDICINE 2007; 12:100-1. [PMID: 17885149 DOI: 10.1136/ebm.12.4.100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
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Akl EA, Karmath G, Yosuico V, Kim SY, Barba M, Sperati F, Cook D, Schünemann HJ. Anticoagulation for thrombosis prophylaxis in cancer patients with central venous catheters. Cochrane Database Syst Rev 2007:CD006468. [PMID: 17636845 DOI: 10.1002/14651858.cd006468.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Central venous catheter (CVC) placement increases the risk of thrombosis in cancer patients. Thrombosis often necessitates the removal of the CVC, resulting in treatment delays and thrombosis related morbidity and mortality. OBJECTIVES To evaluate the efficacy and safety of anticoagulation in reducing venous thromboembolic (VTE) events in cancer patients with CVC. SEARCH STRATEGY A comprehensive search for studies of anticoagulation in cancer patients up to January 2006 was conducted in the following databases: The Cochrane Central Register of Controlled Trials ( CENTRAL), MEDLINE, EMBASE and ISI the Web of Science. SELECTION CRITERIA Randomized controlled trials (RCTs) comparing unfractionated heparin (UFH), low molecular weight heparin (LMWH), vitamin K antagonists (VKA), fondaparinux or ximelagatran to no intervention or placebo in cancer patients with a CVC or comparing two different anticoagulants. DATA COLLECTION AND ANALYSIS Data was extracted on methodological quality, patients, interventions and outcomes including all cause mortality (primary outcome), premature CVC removal, catheter-related infections, CVC site and non CVC site deep venous thrombosis (DVT), pulmonary embolism (PE), major and minor bleeding and thrombocytopenia. MAIN RESULTS Of 3986 identified citations nine RCTs were included in the meta-analysis including one published as an abstract and one focusing on paediatric patients not included in the meta-analysis. None of these RCTs tested fondaparinux or ximelagatran. The use of heparin in cancer patients with CVC was associated with a trend towards a reduction in symptomatic DVT (Relative Risk (RR) = 0.43; 95% Confidence Interval (CI): 0.18 to 1.06), but the data did not show any statistically significant effect on mortality (RR = 0.74; 95% CI: 0.40 to 1.36), infection (RR = 0.91; 95% CI: 0.36 to 2.28), major bleeding (RR = 0.68; 95% CI: 0.10 to 4.78) or thrombocytopenia (RR = 0.85; 95% CI: 0.49 to 1.46). The effect warfarin on symptomatic DVT was not statistically significant (RR = 0.62; 95% CI: 0.30 to 1.27). When studies assessing different types of anticoagulants were pooled, symptomatic DVT rates were significantly reduced (RR = 0.56; 95% CI: 0.34 to 0.92). AUTHORS' CONCLUSIONS Cancer patients with CVC considering anticoagulation, should consider the possible benefit of reduced incidence of thromboembolic complications with the burden and harms of anticoagulation. Future studies should be adequately powered and evaluate the effects of newer anticoagulants such as fondaparinux and ximelagatran in cancer patients with CVC.
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Muscedere JG, Heyland DK, Cook D. Venous thromboembolism in critical illness in a community intensive care unit. J Crit Care 2007; 22:285-9. [PMID: 18086398 DOI: 10.1016/j.jcrc.2007.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 01/11/2007] [Accepted: 02/23/2007] [Indexed: 10/23/2022]
Abstract
BACKGROUND Venous thromboembolism (VTE) can be a life-threatening complication of critical illness. Venous thromboembolism rates observed depend on the population studied, the screening modality used, and thromboprophylaxis prescribed. Few studies report on the rates of clinically diagnosed VTE in critically ill patients. The purpose of this study was to characterize the incidence of clinically diagnosed VTE, prophylactic strategies used, and diagnostic studies ordered in a critically ill population at a tertiary community intensive care unit (ICU), both during and after their ICU stay. METHODS We did a retrospective chart review of 600 consecutive critically ill patients admitted to a tertiary community ICU. RESULTS Fifty (8.3%) patients developed VTE over the course of their ICU and hospital stay (18 [3.0%] patients during their ICU stay and 32 [5.7% of 561 ICU survivors] patients after ICU discharge). By ICU admission diagnosis, most events occurred in neurosurgical patients, although this group comprised only 24.8% of the population. Across all subgroups, most VTE events occurred after ICU discharge. Intensive care unit patients received thromboprophylaxis 87.6% (95% confidence interval, 81.5-93.7) of the time spent in ICU. However, thromboprophylaxis was administered significantly less often after transfer to the ward compared with within the ICU (from 87.6% to 59.8%, P < .001). CONCLUSION The rates of clinically diagnosed VTE rates in critically ill patients are substantial. Venous thromboembolism occurs before, during, and after ICU discharge. Continued vigilance and thromboprophylaxis are warranted across the continuum of critical illness.
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Douketis J, Cook D, Zytaruk N, Heels-Ansdell D, Anderson D, Geerts W, Meade M, Guyatt G, Crowther M. DALTEPARIN THROMBOPROPHYLAXIS IN CRITICALLY ILL PATIENTS WITH SEVERE RENAL INSUFFICIENCY: THE DIRECT STUDY. J Thromb Haemost 2007. [DOI: 10.1111/j.1538-7836.2007.tb00774.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Brozek J, McDonald E, Clarke F, Gosse C, Jaeschke R, Cook D. Pneumonia observational incidence and treatment: a multidisciplinary process improvement study. Am J Crit Care 2007; 16:214-9. [PMID: 17460312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
BACKGROUND Little information is available on the types, causes, and treatment of pneumonia in intensive care unit patients in usual clinical practice. OBJECTIVE To characterize treatment of patients with presumed pneumonia in a tertiary care intensive care unit and to identify potential areas for improvement in care. METHODS In a prospective, cohort study, the sample consisted of all consecutive patients treated in an intensive care unit during a 3-month period. For patients with presumed pneumonia, data were collected on incidence of pneumonia, diagnostic investigations, microbial isolates, and antibiotics prescribed. RESULTS Of 194 admissions, 73 patients were treated for pneumonia: 47 had community-acquired pneumonia; 12 had hospital-acquired pneumonia; 12 had ventilator-associated pneumonia, both early (7) and late (5); and 2 had intensive care unit-acquired pneumonia. Approximately 71% of patients had microbiological tests performed. Among 54 microbial isolates, 51.9% were gram-positive bacteria, 31.5% were gram-negative bacteria, and 9.3% were Candida species. The most commonly used antimicrobials were quinolones (54 of 192 prescriptions) and cephalosporins (33); each patient received a median of 3 antibiotics. CONCLUSIONS Most cases of pneumonia were community acquired. The most common causative organisms were gram-positive cocci. Four quality improvement strategies were rationalization of antibiotic use during rounds, nurses' reporting of culture results, review of antibiotic appropriateness by a pharmacist, and redesign of the clinical information system.
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Cook D, Rocker G. A communication strategy and brochure reduced the burden of bereavement on relatives of patients dying in the intensive care unit. ACP JOURNAL CLUB 2007; 146:69. [PMID: 17474678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
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Brożek J, McDonald E, Clarke F, Gosse C, Jaeschke R, Cook D. Pneumonia Observational Incidence and Treatment: A Multidisciplinary Process Improvement Study. Am J Crit Care 2007. [DOI: 10.4037/ajcc2007.16.3.214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background Little information is available on the types, causes, and treatment of pneumonia in intensive care unit patients in usual clinical practice.
Objective To characterize treatment of patients with presumed pneumonia in a tertiary care intensive care unit and to identify potential areas for improvement in care.
Methods In a prospective, cohort study, the sample consisted of all consecutive patients treated in an intensive care unit during a 3-month period. For patients with presumed pneumonia, data were collected on incidence of pneumonia, diagnostic investigations, microbial isolates, and antibiotics prescribed.
Results Of 194 admissions, 73 patients were treated for pneumonia: 47 had community-acquired pneumonia; 12 had hospital-acquired pneumonia; 12 had ventilator-associated pneumonia, both early (7) and late (5); and 2 had intensive care unit–acquired pneumonia. Approximately 71% of patients had microbiological tests performed. Among 54 microbial isolates, 51.9% were gram-positive bacteria, 31.5% were gram-negative bacteria, and 9.3% were Candida species. The most commonly used antimicrobials were quinolones (54 of 192 prescriptions) and cephalosporins (33); each patient received a median of 3 antibiotics.
Conclusions Most cases of pneumonia were community acquired. The most common causative organisms were gram-positive cocci. Four quality improvement strategies were rationalization of antibiotic use during rounds, nurses’ reporting of culture results, review of antibiotic appropriateness by a pharmacist, and redesign of the clinical information system.
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Gedge E, Giacomini M, Cook D. Withholding and withdrawing life support in critical care settings: ethical issues concerning consent. JOURNAL OF MEDICAL ETHICS 2007; 33:215-8. [PMID: 17400619 PMCID: PMC2652778 DOI: 10.1136/jme.2006.017038] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
The right to refuse medical intervention is well established, but it remains unclear how best to respect and exercise this right in life support. Contemporary ethical guidelines for critical care give ambiguous advice, largely because they focus on the moral equivalence of withdrawing and withholding care without confronting the very real differences regarding who is aware and informed of intervention options and how patient values are communicated and enacted. In withholding care, doctors typically withhold information about interventions judged too futile to offer. They thus retain greater decision-making burden (and power) and face weaker obligations to secure consent from patients or proxies. In withdrawing care, there is a clearer imperative for the doctor to include patients (or proxies) in decisions, share information and secure consent, even when continued life support is deemed futile. How decisions to withhold and withdraw life support differ ethically in their implications for positive versus negative interpretations of patient autonomy, imperatives for consent, definitions of futility and the subjective evaluation of (and submission to) benefits and burdens of life support in critical care settings are explored. Professional reflection is required to respond to trends favouring a more positive interpretation of patient autonomy in the context of life support decisions in critical care. Both the bioethics and critical care communities should investigate the possibilities and limits of growing pressure for doctors to disclose their reasoning or seek patient consent when decisions to withhold life support are made.
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Cook D, Rocker G, Giacomini M, Sinuff T, Heyland D. Understanding and changing attitudes toward withdrawal and withholding of life support in the intensive care unit. Crit Care Med 2007; 34:S317-23. [PMID: 17057593 DOI: 10.1097/01.ccm.0000237042.11330.a9] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
A careful examination of our attitudes toward end-of-life care is critical to our understanding of where change is needed to improve patient outcomes. The objectives of our narrative review are 1) to review why the intensive care unit setting presents particular challenges for the delivery of optimal end-of-life care, 2) to outline how four different research methods can provide insights into our understanding of attitudes about withdrawal of life support, and 3) to suggest seven different approaches to changing prevailing attitudes toward withdrawal of life support in the intensive care unit. To better understand attitudes about end-of-life care in general and withdrawal of life support in particular, we reviewed four different sources of data: 1) decision support tools, 2) qualitative research, 3) surveys, and 4) observational studies. Understanding these attitudes offers valuable insights about strategies that may help to improve the care of dying patients and their families. There are several ways to change attitudes; the approaches we reviewed are 1) promoting social change professionally, 2) legitimizing end-of-life research, 3) determining what families of dying patients need, 4) initiating quality improvement locally, 5) evaluating the benefits and harms of new initiatives, 6) modeling quality end-of-life care for future clinicians, and 7) using narratives. Attitudes toward end-of-life care are influenced by many factors and change slowly. Our attitudes have social and personal origins; they are grounded in values that are collective and community based. Different research methods provide insights into attitudes toward death in the intensive care unit and withdrawal of life support in particular. Understanding these attitudes may offer valuable insights about strategies that should help improve the care for dying patients and their families.
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McMullin J, Brozek J, McDonald E, Clarke F, Jaeschke R, Heels-Ansdell D, Leppert R, Foss A, Cook D. Lowering of glucose in critical care: a randomized pilot trial. J Crit Care 2007; 22:112-8; discussion 118-9. [PMID: 17548021 DOI: 10.1016/j.jcrc.2006.08.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2006] [Revised: 06/28/2006] [Accepted: 08/01/2006] [Indexed: 01/08/2023]
Abstract
BACKGROUND Similar to cardiac surgery patients, medical-surgical critically ill patients may benefit from intensive insulin therapy. The objectives of this pilot trial were to evaluate the feasibility of a randomized trial of intensive insulin therapy with respect to (a) achieving target glucose values in the 2 ranges of 5 to 7 and 8 to 10 mmol/L and (b) uncovering problems with the protocol in anticipation of a larger trial. SETTING The trial was conducted in a 15-bed medical-surgical university-affiliated intensive care unit (ICU). METHODS We included patients older than 18 years, expected to be in ICU for more than 72 hours, with a glucose value of more than 10 mmol/L within 48 hours of ICU admission. Exclusion criteria were diabetic ketoacidosis, severe hepatic failure or hepatic resection, pancreatitis, glucose of less than 2.2 mmol/L on admission to hospital, insulin infusion on admission to ICU, planned withdrawal of life support, and inability to obtain informed consent. Patients underwent concealed random allocation to a target glucose range of 5 to 7 or 8 to 10 mmol/L using pretested algorithms of insulin infusions. Dedicated glucometer measurement of arterial glucose values was calibrated daily to values measured in the laboratory. RESULTS We enrolled 20 patients with a mean (SD) Acute Physiology and Chronic Health Evaluation (APACHE) II score of 32 (10.2); 14 were insulin-dependent pre-ICU, and all were medical admissions. Mean glucose values were different in the 2 groups (7.1 +/- 2.6 vs 9.4 +/- 2.1 mmol/L, P < .001). Although the intensive insulin therapy group had more glucose measurements performed than the control group, a similar proportion of values were within the target range (682 [42.4%] of 1607 values in the 5- to 7-mmol/L range; 250 [38.7%] of 660 values in the 8- to 10-mmol/L range, P = .35). Glucose values of less than 2.5 mmol/L developed 7 times in 5 patients, 4 of whom were in the intensive insulin therapy group; however, no adverse consequences were documented. As expected, there were no differences in clinically important outcomes. CONCLUSIONS In this pilot trial of ICU patients with high illness severity, glucose values were in the 2 target ranges only 40% of the time, using well-accepted initiation and maintenance insulin infusion algorithms. A large randomized trial of glycemic control is feasible in this population to examine clinically important outcomes, but will require refined insulin algorithms and more comprehensive behavior change strategies to achieve target values.
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Heyland DK, Dhaliwal R, Day AG, Muscedere J, Drover J, Suchner U, Cook D. REducing Deaths due to OXidative Stress (The REDOXS Study): Rationale and study design for a randomized trial of glutamine and antioxidant supplementation in critically-ill patients. Proc Nutr Soc 2007; 65:250-63. [PMID: 16923310 DOI: 10.1079/pns2006505] [Citation(s) in RCA: 117] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Critically-ill patients experience an extent of hyperinflammation, cellular immune dysfunction, oxidative stress and mitochondrial dysfunction. Supplementation with key nutrients, such as glutamine and antioxidants, is most likely to have a favourable effect on these physiological derangements, leading to an improvement in clinical outcomes. The results of two meta-analyses suggest that glutamine and antioxidants may be associated with improved survival. The purpose of the present paper is to report the background rationale and study protocol for the evaluation of the effect of high-dose glutamine and antioxidant supplementation on mortality in a large-scale randomized trial in 1200 mechanically-ventilated, critically-ill patients. Patients admitted to an intensive care unit (ICU) with clinical evidence of severe organ dysfunction will be randomized to one of four treatments in a 2 x 2 factorial design: (1) glutamine; (2) antioxidant therapy; (3) glutamine and antioxidant therapy; (4) placebo. The primary outcome for this study is 28 d mortality. The secondary outcomes are duration of stay in ICU, adjudicated diagnosis of infection, multiple organ dysfunction, duration of mechanical ventilation, length of stay in hospital and health-related quality of life at 3 and 6 months. A novel design feature is the combined use of parenteral and enteral study nutrients dissociated from the nutrition support. The therapeutic strategies tested in the randomized trial may lead to less morbidity and improved survival in critically-ill patients. The trial will be conducted in approximately twenty tertiary-care ICU in Canada and the first results are expected in 2009.
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Heyland D, Dodek P, Muscedere J, Day A, Cook D. A randomized trial of combination therapy versus monotherapy for the empiric treatment of suspected ventilator-associated pneumonia. Crit Care 2007. [PMCID: PMC4095149 DOI: 10.1186/cc5255] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Ruest A, Cook D. Oral decontamination with chlorhexidine reduced ventilator-associated pneumonia in high-risk patients. ACP JOURNAL CLUB 2006; 145:68. [PMID: 17080980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Cheung AM, Tansey CM, Tomlinson G, Diaz-Granados N, Matté A, Barr A, Mehta S, Mazer CD, Guest CB, Stewart TE, Al-Saidi F, Cooper AB, Cook D, Slutsky AS, Herridge MS. Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med 2006; 174:538-44. [PMID: 16763220 DOI: 10.1164/rccm.200505-693oc] [Citation(s) in RCA: 311] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS). OBJECTIVES To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge. METHODS We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge. MEASUREMENTS Clinical and functional outcomes, health care use, and direct medical costs. RESULTS Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from emotional role and mental health, all other domains remained below that of the normal population. From ICU admission to 2 yr after ICU discharge, the largest portion of health care costs for a survivor of ARDS was the initial hospital stay, with ICU costs accounting for 76% of these costs. After the initial hospital stay, health care costs were related to hospital readmissions and inpatient rehabilitation. CONCLUSIONS Survivors of ARDS continued to have functional impairment and compromised health-related quality of life 2 yr after discharge from the ICU. Health care use and costs after the initial hospitalization were driven by hospital readmissions and inpatient rehabilitation.
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Parshuram CS, Kirpalani H, Mehta S, Granton J, Cook D. In-house, overnight physician staffing: a cross-sectional survey of Canadian adult and pediatric intensive care units. Crit Care Med 2006; 34:1674-8. [PMID: 16625115 DOI: 10.1097/01.ccm.0000218808.13189.e7] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Physician staffing is an important determinant of patient outcomes following intensive care unit (ICU) admission. We conducted a national survey of in-house after-hours physician staffing in Canadian ICUs. DESIGN : Cross-sectional survey. SETTING Canadian adult and pediatric ICUs. PARTICIPANTS ICU directors. INTERVENTIONS ICU directors of Canadian adult and pediatric ICUs were surveyed to describe overnight staffing by interns, residents, critical care medicine trainees, clinical assistants, and ICU physicians in their ICUs. MEASUREMENTS AND MAIN RESULTS Data were collected regarding hospital and ICU demographics and ICU staffing. For ICUs with in-house overnight physicians, we documented physician experience, shift duration, and clinical responsibilities outside the ICU. We identified 98 Canadian ICU directors, of whom 88 (90%) responded. Dedicated in-house physician coverage overnight was reported in 53 (60%) ICUs, including 13 (15%) in which ICU staff physicians stayed in-house overnight. Compared with ICUs without in-house physicians, those with in-house physicians had more ICU beds (15 vs. 8.5, p=.0001) and fewer ICU staff physicians (5 vs. 7, p=.03). For the 271 physicians who provide overnight staffing, the median level of postgraduate experience was 3 yrs (range, <1 yr, >10 yrs); 129 (48%) had <3 months of ICU experience. Most shifts (83%) were >20 hrs long. CONCLUSIONS In-house overnight physician staffing in Canadian ICUs varies widely. Only a minority of ICUs comply with the 2003 Society of Critical Care Medicine guidelines for adult ICUs recommending continuous in-house staffing by ICU staff physicians. The duration of most ICU shifts raises concern about workload-associated fatigue and medical error. The impact of current nighttime staffing requires further evaluation with respect to patient outcomes.
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Cook D, Rocker G, Marshall J, Griffith L, McDonald E, Guyatt G. Levels of care in the intensive care unit: a research program. Am J Crit Care 2006; 15:269-79. [PMID: 16632769] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
A multidisciplinary research program on levels of care was conducted in 15 adult intensive care units in North America, Europe, and Australia. The program addressed advance directives for cardiopulmonary resuscitation, provision of advanced life support, and clinicians' discomfort with evolving treatment plans. The results indicated that the factors that determined the establishment of directives for advance life support differed from the factors that informed a decision to limit or withdraw support after admission to an intensive care unit. In addition, clinicians' prognoses were imprecise and often an underestimation of the probability of short-term survival. Finally, some degree of discomfort was common in care providers in the intensive care unit, most often because they thought interventions were excessive and not compatible with an acceptable future quality of life. The provision of advanced life support mandates explicit decision making about how life-support measures should be used.
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Cook D, Rocker G, Marshall J, Griffith L, McDonald E, Guyatt G. Levels of Care in the Intensive Care Unit: A Research Program. Am J Crit Care 2006. [DOI: 10.4037/ajcc2006.15.3.269] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
A multidisciplinary research program on levels of care was conducted in 15 adult intensive care units in North America, Europe, and Australia. The program addressed advance directives for cardiopulmonary resuscitation, provision of advanced life support, and clinicians’ discomfort with evolving treatment plans. The results indicated that the factors that determined the establishment of directives for advance life support differed from the factors that informed a decision to limit or withdraw support after admission to an intensive care unit. In addition, clinicians’ prognoses were imprecise and often an underestimation of the probability of short-term survival. Finally, some degree of discomfort was common in care providers in the intensive care unit, most often because they thought interventions were excessive and not compatible with an acceptable future quality of life. The provision of advanced life support mandates explicit decision making about how life-support measures should be used.
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Giacomini M, Cook D, DeJean D, Shaw R, Gedge E. Decision tools for life support: a review and policy analysis. Crit Care Med 2006; 34:864-70. [PMID: 16521283 DOI: 10.1097/01.ccm.0000201904.92483.c6] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To identify, describe, and compare published documents intended to guide decisions about the administration, withholding, or withdrawal of life support in critical care. DESIGN Review article. SETTING AND SOURCES: Publicly available, English-language guidelines or decision tools for life support, identified through systematic literature search. MEASUREMENTS AND MAIN RESULTS Forty-nine documents were included and coded for authorship, source, development methodology, format, and positions taken on 12 common life-support issues. Sources were independent academics (n=21, 43%), professional organizations (n=19, 44%), and provider organizations. Eighteen documents (37%) described no development method. Twenty-three (47%) were produced collectively (e.g., by committees or consensus conference), 7 (14%) mentioned a literature review, and 2 (4%) were based upon the author's professional experience. Tools differed in format and focus; we characterize three types as decision schemas (involving clinical practice algorithms; n=7, 14%), decision guides (reviewing legal or professional positions; n=29, 59%), and decision counsels (more discursive and focusing typically on ethical issues; n=13, 27%). Tools addressed 12 common life-support issues: advance directives (67%), resource considerations (51%), ICU discharge criteria (27%), ICU admission criteria (16%), whether withholding differs from withdrawing life support (59%), whether nutrition and hydration decisions are different from decisions about other types of life support (61%), euthanasia (49%), double effect (47%), brain death (35%), special considerations for patients in a persistent vegetative state (51%), potential organ donors (12%), and pregnant patients (10%). Positions on these key life-support issues varied. CONCLUSIONS Published tools for guiding life-support decisions vary widely in their genesis, authorship, format, focus, and practicality. They also differ in their attention to, and positions on, key life-support dilemmas. Future research on decision tools should focus on how users interpret and apply the messages in these tools and their impacts on practice, quality of care, participant experiences, and outcomes.
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Vincent JL, Fink MP, Marini JJ, Pinsky MR, Sibbald WJ, Singer M, Suter PM, Cook D, Pepe PE, Evans T. Intensive Care and Emergency Medicine. Chest 2006; 129:1061-7. [PMID: 16608959 DOI: 10.1378/chest.129.4.1061] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Over the last quarter of a century, intensive care medicine has developed into an established hospital specialty with its own unique identity and characteristics. Significant advances have occurred, mostly in a succession of small steps rather than any dramatic leap, with many being linked to advances in health care across other disciplines. In addition, many changes have resulted from the scientific identification of the detrimental effects of certain traditional practices once thought to be therapeutic. Here, in an attempt to learn from the past and offer guidance for future progress, we detail some of the key changes in various aspects of intensive care medicine including respiratory, cardiovascular, metabolic, and nutritional care, as well as sepsis, polytrauma, organization, and management.
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Cook D, Douketis J, Crowther MA, Anderson DR. The diagnosis of deep venous thrombosis and pulmonary embolism in medical-surgical intensive care unit patients. J Crit Care 2006; 20:314-9. [PMID: 16310601 DOI: 10.1016/j.jcrc.2005.09.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Revised: 09/02/2005] [Accepted: 09/08/2005] [Indexed: 11/29/2022]
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Cook D, Crowther MA, Douketis J. Thromboprophylaxis in medical-surgical intensive care unit patients. J Crit Care 2006; 20:320-3. [PMID: 16310602 DOI: 10.1016/j.jcrc.2005.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Revised: 08/29/2005] [Accepted: 09/08/2005] [Indexed: 10/25/2022]
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McMullin J, Cook D, Griffith L, McDonald E, Clarke F, Guyatt G, Gibson J, Crowther M. Minimizing errors of omission: Behavioural rEenforcement of Heparin to Avert Venous Emboli: The BEHAVE Study*. Crit Care Med 2006; 34:694-9. [PMID: 16505655 DOI: 10.1097/01.ccm.0000201886.84135.cb] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation. DESIGN Prospective longitudinal observational study. SETTING Medical-surgical intensive care unit. PARTICIPANTS Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit. INTERVENTIONS Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period. MEASUREMENTS AND MAIN RESULTS Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001). CONCLUSIONS After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.
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298
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Kotsakis A, Cook D, Griffith L, Anton N, Massicotte P, MacFarland K, Farrell R, Hutchison J. Clinically important venous thromboembolism in pediatric critical care: a Canadian survey. J Crit Care 2005; 20:373-80. [PMID: 16310610 DOI: 10.1016/j.jcrc.2005.09.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2005] [Revised: 09/08/2005] [Accepted: 09/08/2005] [Indexed: 01/12/2023]
Abstract
PURPOSE Pediatric venous thromboembolism (VTE) is becoming an increasingly recognized morbidity associated with critical illness. The objective of this survey is to identify the patient factors and radiological features that pediatric intensivists consider more or less likely to make a venous thrombosis (VTE) clinically important in their patients. MATERIALS AND METHODS Our definition of clinically important VTE was a VTE likely to result in short- or long-term morbidity or mortality if left untreated. We asked respondents to rate the likelihood that patient factors and radiological features make a venous thrombosis clinically important using a 5-point scale (1 = much less likely to 5 = much more likely). RESULTS The 38 (58.5%) of 65 pediatric intensivists responding rated 4 patient factors as most likely to make a VTE clinically important: clinical suspicion of pulmonary embolism (mean score, 4.8), symptoms (mean, 4.5), detection by physical exam (mean, 4.4), and the presence of an acute or chronic cardiopulmonary comorbidity that might limit a patient's ability to tolerate pulmonary embolism (mean, 4.3). Of the radiological features, the 2 considered most important were VTE involving the vena cava extending into the right atrium (mean, 5) and central veins (mean, 4.5). CONCLUSIONS When labeling a VTE as clinically important, pediatric intensivists rely on several specific patient factors and thrombus characteristics.
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299
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Tomasko MG, Archinal B, Becker T, Bézard B, Bushroe M, Combes M, Cook D, Coustenis A, de Bergh C, Dafoe LE, Doose L, Douté S, Eibl A, Engel S, Gliem F, Grieger B, Holso K, Howington-Kraus E, Karkoschka E, Keller HU, Kirk R, Kramm R, Küppers M, Lanagan P, Lellouch E, Lemmon M, Lunine J, McFarlane E, Moores J, Prout GM, Rizk B, Rosiek M, Rueffer P, Schröder SE, Schmitt B, See C, Smith P, Soderblom L, Thomas N, West R. Rain, winds and haze during the Huygens probe's descent to Titan's surface. Nature 2005; 438:765-78. [PMID: 16319829 DOI: 10.1038/nature04126] [Citation(s) in RCA: 466] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2005] [Accepted: 08/08/2005] [Indexed: 11/09/2022]
Abstract
The irreversible conversion of methane into higher hydrocarbons in Titan's stratosphere implies a surface or subsurface methane reservoir. Recent measurements from the cameras aboard the Cassini orbiter fail to see a global reservoir, but the methane and smog in Titan's atmosphere impedes the search for hydrocarbons on the surface. Here we report spectra and high-resolution images obtained by the Huygens Probe Descent Imager/Spectral Radiometer instrument in Titan's atmosphere. Although these images do not show liquid hydrocarbon pools on the surface, they do reveal the traces of once flowing liquid. Surprisingly like Earth, the brighter highland regions show complex systems draining into flat, dark lowlands. Images taken after landing are of a dry riverbed. The infrared reflectance spectrum measured for the surface is unlike any other in the Solar System; there is a red slope in the optical range that is consistent with an organic material such as tholins, and absorption from water ice is seen. However, a blue slope in the near-infrared suggests another, unknown constituent. The number density of haze particles increases by a factor of just a few from an altitude of 150 km to the surface, with no clear space below the tropopause. The methane relative humidity near the surface is 50 per cent.
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300
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Abbott B, Abbott R, Adhikari R, Agresti J, Ajith P, Allen B, Allen J, Amin R, Anderson SB, Anderson WG, Araya M, Armandula H, Ashley M, Aulbert C, Babak S, Balasubramanian R, Ballmer S, Barish BC, Barker C, Barker D, Barton MA, Bayer K, Belczynski K, Betzwieser J, Bhawal B, Bilenko IA, Billingsley G, Black E, Blackburn K, Blackburn L, Bland B, Bogue L, Bork R, Bose S, Brady PR, Braginsky VB, Brau JE, Brown DA, Buonanno A, Busby D, Butler WE, Cadonati L, Cagnoli G, Camp JB, Cannizzo J, Cannon K, Cardenas L, Carter K, Casey MM, Charlton P, Chatterji S, Chen Y, Chin D, Christensen N, Cokelaer T, Colacino CN, Coldwell R, Cook D, Corbitt T, Coyne D, Creighton JDE, Creighton TD, Dalrymple J, D'Ambrosio E, Danzmann K, Davies G, DeBra D, Dergachev V, Desai S, DeSalvo R, Dhurandar S, Díaz M, Di Credico A, Drever RWP, Dupuis RJ, Ehrens P, Etzel T, Evans M, Evans T, Fairhurst S, Finn LS, Franzen KY, Frey RE, Fritschel P, Frolov VV, Fyffe M, Ganezer KS, Garofoli J, Gholami I, Giaime JA, Goda K, Goggin L, González G, Gray C, Gretarsson AM, Grimmett D, Grote H, Grunewald S, Guenther M, Gustafson R, Hamilton WO, Hanna C, Hanson J, Hardham C, Harry G, Heefner J, Heng IS, Hewitson M, Hindman N, Hoang P, Hough J, Hua W, Ito M, Itoh Y, Ivanov A, Johnson B, Johnson WW, Jones DI, Jones G, Jones L, Kalogera V, Katsavounidis E, Kawabe K, Kawamura S, Kells W, Khan A, Kim C, King P, Klimenko S, Koranda S, Kozak D, Krishnan B, Landry M, Lantz B, Lazzarini A, Lei M, Leonor I, Libbrecht K, Lindquist P, Liu S, Lormand M, Lubinski M, Lück H, Luna M, Machenschalk B, MacInnis M, Mageswaran M, Mailand K, Malec M, Mandic V, Marka S, Maros E, Mason K, Matone L, Mavalvala N, McCarthy R, McClelland DE, McHugh M, McNabb JWC, Melissinos A, Mendell G, Mercer RA, Meshkov S, Messaritaki E, Messenger C, Mikhailov E, Mitra S, Mitrofanov VP, Mitselmakher G, Mittleman R, Miyakawa O, Mohanty S, Moreno G, Mossavi K, Mueller G, Mukherjee S, Myers E, Myers J, Nash T, Nocera F, Noel JS, O'Reilly B, O'Shaughnessy R, Ottaway DJ, Overmier H, Owen BJ, Pan Y, Papa MA, Parameshwaraiah V, Parameswariah C, Pedraza M, Penn S, Pitkin M, Prix R, Quetschke V, Raab F, Radkins H, Rahkola R, Rakhmanov M, Rawlins K, Ray-Majumder S, Re V, Regimbau T, Reitze DH, Riesen R, Riles K, Rivera B, Robertson DI, Robertson NA, Robinson C, Roddy S, Rodriguez A, Rollins J, Romano JD, Romie J, Rowan S, Rüdiger A, Ruet L, Russell P, Ryan K, Sandberg V, Sanders GH, Sannibale V, Sarin P, Sathyaprakash BS, Saulson PR, Savage R, Sazonov A, Schilling R, Schofield R, Schutz BF, Schwinberg P, Scott SM, Seader SE, Searle AC, Sears B, Sellers D, Sengupta AS, Shawhan P, Shoemaker DH, Sibley A, Siemens X, Sigg D, Sintes AM, Smith J, Smith MR, Spjeld O, Strain KA, Strom DM, Stuver A, Summerscales T, Sung M, Sutton PJ, Tanner DB, Taylor R, Thorne KA, Thorne KS, Tokmakov KV, Torres C, Torrie C, Traylor G, Tyler W, Ugolini D, Ungarelli C, Vallisneri M, van Putten M, Vass S, Vecchio A, Veitch J, Vorvick C, Vyachanin SP, Wallace L, Ward H, Ward R, Watts K, Webber D, Weiland U, Weinstein A, Weiss R, Wen S, Wette K, Whelan JT, Whitcomb SE, Whiting BF, Wiley S, Wilkinson C, Willems PA, Willke B, Wilson A, Winkler W, Wise S, Wiseman AG, Woan G, Woods D, Wooley R, Worden J, Yakushin I, Yamamoto H, Yoshida S, Zanolin M, Zhang L, Zotov N, Zucker M, Zweizig J. Upper limits on a stochastic background of gravitational waves. PHYSICAL REVIEW LETTERS 2005; 95:221101. [PMID: 16384203 DOI: 10.1103/physrevlett.95.221101] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2005] [Indexed: 05/05/2023]
Abstract
The Laser Interferometer Gravitational-Wave Observatory has performed a third science run with much improved sensitivities of all three interferometers. We present an analysis of approximately 200 hours of data acquired during this run, used to search for a stochastic background of gravitational radiation. We place upper bounds on the energy density stored as gravitational radiation for three different spectral power laws. For the flat spectrum, our limit of omega0 < 8.4 x 10(-4) in the 69-156 Hz band is approximately 10(5) times lower than the previous result in this frequency range.
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