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Salter B, DeBenedictis B, Spatafora L, Kapralik J, Luo C, Qiu S, Dawson L, Junek M, Pitre T, Jones A, Beauchamp M, Kruisselbrink R, Duong M, Costa AP, Tsang JL, Ho T. Hospitalised COVID-19 outcomes are predicted by hypoxaemia and pneumonia phenotype irrespective of the timing of their emergence. BMJ Open 2022; 12:e062453. [PMID: 36581424 PMCID: PMC9805826 DOI: 10.1136/bmjopen-2022-062453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
UNLABELLED Despite the known clinical importance of hypoxemia and pneumonia, there is a paucity of evidence for these variables with respect to risk of mortality and short-term outcomes among those hospitalised with COVID-19. OBJECTIVE Describe the prevalence and clinical course of patients hospitalised with COVID-19 based on oxygenation and pneumonia status at presentation and determine the incidence of emergent hypoxaemia or radiographic pneumonia during admission. METHODS A retrospective study was conducted using a Canadian regional registry. Patients were stratified according to hypoxaemia/pneumonia phenotype and prevalence. Clinical parameters were compared between phenotypes using χ2 and one-way Analysis of variance (ANOVA). Cox analysis estimated adjusted Hazard Ratios (HR) for associations between disease outcomes and phenotypes. RESULTS At emergency department (ED) admission, the prevalence of pneumonia and hypoxaemia was 43% and 50%, respectively, and when stratified to phenotypes: 28.2% hypoxaemia+/pneumonia+, 22.2% hypoxaemia+/pneumonia-, 14.5% hypoxaemia-/pneumonia+ and 35.1% hypoxaemia-/pneumonia-. Mortality was 31.1% in the hypoxaemia+/pneumonia- group and 26.3% in the hypoxaemia+/pneumonia+ group. Hypoxaemia with pneumonia and without pneumonia predicted higher probability of death. Hypoxaemia either <24 hours or ≥24 hours after hospitalisation predicted higher mortality and need for home oxygen compared with those without hypoxaemia. Patients with early hypoxaemia had higher probability of Intensive care unit (ICU) admission compared with those with late hypoxaemia. CONCLUSION Mortality in COVID-19 infection is predicted by hypoxaemia with or without pneumonia and was greatest in patients who initially presented with hypoxaemia. The emergence of hypoxaemia was predicted by radiographic pneumonia. Patients with early and emergent hypoxaemia had similar mortality but were less likely to be admitted to ICU. There may be delayed identification of hypoxaemia, which prevents timely escalation of care.
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Affiliation(s)
- Brittany Salter
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Laura Spatafora
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Jessica Kapralik
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Candice Luo
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Steven Qiu
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Laura Dawson
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Mats Junek
- Department of Rheumatology, McMaster University, Hamilton, Ontario, Canada
| | - Tyler Pitre
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Aaron Jones
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Marla Beauchamp
- School of Rehabilitation Science, McMaster University, Hamilton, Ontario, Canada
| | | | - MyLinh Duong
- Respirology, McMaster University, Hamilton, Ontario, Canada
| | | | - Jennifer Ly Tsang
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Medicine, Niagara Health System - Saint Catharines Site, Saint Catharines, Ontario, Canada
| | - Terence Ho
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Respirology, McMaster University, Hamilton, Ontario, Canada
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Ma Z, Camargo Penuela M, Law M, Joshi D, Chung HO, Lam JNH, Tsang JL. Impact of a multifaceted and multidisciplinary intervention on pain, agitation and delirium management in an intensive care unit: an experience of a Canadian community hospital in conducting a quality improvement project. BMJ Open Qual 2021; 10:bmjoq-2020-001305. [PMID: 34887298 PMCID: PMC8663072 DOI: 10.1136/bmjoq-2020-001305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 11/23/2021] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Clinical guidelines suggest that routine assessment, treatment, and prevention of pain, agitation, and delirium (PAD) is essential to improving patient outcomes as delirium is associated with increased mortality and morbidity. Despite the well-established improvements on patient outcomes, adherence to PAD guidelines is poor in community intensive care units (ICU). This quality improvement (QI) project aims to evaluate the impact of a multifaceted and multidisciplinary intervention on PAD management in a Canadian community ICU and to describe the experience of a Canadian community hospital in conducting a QI project. METHODS A ten-member PAD advisory committee was formed to develop and implement the intervention. The intervention consisted of a multidisciplinary rounds script, poster, interviews, visual reminders, educational modules, pamphlet and video. The 4-week intervention targeted nurses, family members, physicians, and the multidisciplinary team. An uncontrolled, before-and-after study methodology was used. Adherence to PAD assessment guidelines by nurses was measured over a 6-week pre-intervention and over a 6-week post-intervention periods. RESULTS Data on 430 and 406 patient-days (PD) were available for analysis during the pre- and post- intervention periods, respectively. The intervention did not improve the proportion of PD with guideline compliance to the assessment of pain (23.4% vs. 22.4%, p=0.80), agitation (42.9% vs. 38.9%, p=0.28), nor delirium (35.2% vs. 29.6%, p=0.10) by nurses. DISCUSSION The implementation of a multifaceted and multidisciplinary intervention on PAD assessment did not result in significant improvements in guideline adherence in a community ICU. Barriers to knowledge translation are apparent at multiple levels including the personal level (low completion rates on educational modules), interventional level (under-collection of data), and organisational level (coinciding with hospital accreditation education). Our next steps include reintroduction of education modules using organisation approved platforms, updating existing ICU policy, updating admission order sets, and conducting audit and feedback.
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Affiliation(s)
- Zechen Ma
- Niagara Regional Campus, McMaster University Michael G DeGroote School of Medicine, St. Catharines, Ontario, Canada
| | - Mercedes Camargo Penuela
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada.,Department of Health Science, Brock University, Saint Catharines, Ontario, Canada
| | - Madelyn Law
- Department of Health Science, Brock University, Saint Catharines, Ontario, Canada
| | - Divya Joshi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Han-Oh Chung
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada.,Medicine/Critical Care, McMaster University Department of Medicine, Hamilton, Ontario, Canada
| | - Joyce Nga Hei Lam
- Niagara Health System-Saint Catharines Site, Saint Catharines, Ontario, Canada
| | - Jennifer Ly Tsang
- Medicine/Critical Care, McMaster University Department of Medicine, Hamilton, Ontario, Canada .,Medicine/Critical Care, Niagara Health, St. Catharines, Ontario, Canada
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Honarmand K, Um KJ, Belley-Côté EP, Alhazzani W, Farley C, Fernando SM, Fiest K, Grey D, Hajdini E, Herridge M, Hrymak C, Møller MH, Kanji S, Lamontagne F, Lauzier F, Mehta S, Paunovic B, Singal R, Tsang JL, Wynne C, Rochwerg B. Canadian Critical Care Society clinical practice guideline: The use of vasopressin and vasopressin analogues in critically ill adults with distributive shock. Can J Anaesth 2020; 67:369-376. [PMID: 31797234 DOI: 10.1007/s12630-019-01546-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 09/30/2019] [Accepted: 10/04/2019] [Indexed: 12/18/2022] Open
Abstract
PURPOSE Hemodynamic management of adults with distributive shock often includes the use of catecholamine-based vasoconstricting medications. It is unclear whether adding vasopressin or vasopressin analogues to catecholamine therapy is beneficial in the management of patients with distributive shock. The purpose of this guideline was to develop an evidence-based recommendation regarding the addition of vasopressin to catecholamine vasopressors in the management of adults with distributive shock. METHODS We summarized the evidence informing this recommendation by updating a recently published meta-analysis. Then, a multidisciplinary panel from the Canadian Critical Care Society developed the recommendation using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. RESULTS The updated systematic review identified 25 randomized controlled trials including a total of 3,737 patients with distributive shock. Compared with catecholamine therapy alone, the addition of vasopressin or its analogues was associated with a reduced risk of mortality (relative risk [RR], 0.91; 95% confidence interval [CI], 0.85 to 0.99; low certainty), reduced risk of atrial fibrillation (RR, 0.77; 95% CI, 0.67 to 0.88; high certainty), and increased risk of digital ischemia (RR, 2.56; 95% CI, 1.24 to 5.25; moderate certainty). CONCLUSIONS After considering certainty in the evidence, values and preferences, cost, and other factors, the expert guideline panel suggests using vasopressin or vasopressin analogues in addition to catecholamines over catecholamine vasopressors alone for the management of distributive shock (conditional recommendation, low certainty evidence).
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Affiliation(s)
- Kimia Honarmand
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Kevin John Um
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - Waleed Alhazzani
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
- Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Chris Farley
- Hamilton Health Sciences Centre, Hamilton, ON, Canada
| | - Shannon M Fernando
- Division of Critical Care, Department of Medicine and Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Donna Grey
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Edita Hajdini
- School of Nursing, McMaster University, Hamilton, ON, Canada
| | - Margaret Herridge
- Department of Medicine, Toronto General Hospital/University Health Network, and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Carmen Hrymak
- Section of Critical Care, Department of Medicine, and Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
- Centre for Research in Intensive Care, Copenhagen, Denmark
| | - Salmaan Kanji
- Department of Pharmacy, The Ottawa Hospital and Clinical Epidemiology Program, The Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - François Lamontagne
- Department of Medicine, Université de Sherbrooke and Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - François Lauzier
- Department of Medicine and Department of Anesthesiology & Critical Care and Trauma - Emergency - Critical Care Medicine, Population Health and Optimal Health Practices Research Unit, CHU de Québec, Université Laval Research Centre, Université Laval, Quebec, QC, Canada
| | - Sangeeta Mehta
- Department of Medicine, Sinai Health System and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Bojan Paunovic
- Department of Internal Medicine, Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Rohit Singal
- CVT Associates, Vancouver Island Health Authority, Victoria, BC, Canada
| | - Jennifer Ly Tsang
- Department of Medicine, McMaster University, Hamilton, ON, Canada
- Department of Medicine, Niagara Health, Niagara, ON, Canada
| | | | - Bram Rochwerg
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, McMaster University, Hamilton, ON, Canada.
- Department of Medicine, Faculty of Health Sciences, Juravinski Hospital, 711 Concession Street, Hamilton, ON, L8V 1C3, Canada.
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Tan CM, Camargo M, Miller F, Ross K, Maximous R, Yung P, Marshall C, Fleming D, Law M, Tsang JL. Impact of a nurse engagement intervention on pain, agitation and delirium assessment in a community intensive care unit. BMJ Open Qual 2019; 8:e000421. [PMID: 31428703 PMCID: PMC6683107 DOI: 10.1136/bmjoq-2018-000421] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Revised: 04/06/2019] [Accepted: 07/06/2019] [Indexed: 11/25/2022] Open
Abstract
Background In 2013, the Society of Critical Care Medicine published a revised version of the ICU Pain, Agitation, and Delirium (PAD) guidelines. Immobility and sleep were subsequently added in 2018. Despite the well-established advantages of implementing these guidelines, adoption and adherence remain suboptimal. This is especially true in community settings, where PAD assessment is performed less often, and the implementation of PAD guidelines has not yet been studied. The purpose of this prospective interventional study is to evaluate the effect of a multifaceted nurse engagement intervention on PAD assessment in a community intensive care unit (ICU). Methods All patients admitted to our community ICU for over 24 hours were included. A 20-week baseline audit was performed, followed by the intervention, and a 20-week postintervention audit. The intervention consisted of a survey, focus groups and education sessions. Primary outcomes included rates of daily PAD assessment using validated tools. Results There were improvements in the number of patients with at least one assessment per day of pain (67.5% vs 59.3%, p=0.04), agitation (93.1% vs 78.7%, p<0.001) and delirium (54.2% vs 39.4%, p<0.001), and the number of patients with target Richmond Agitation-Sedation Scale ordered (63.1% vs 46.8%, p=0.002). There was a decrease in the rate of physical restraint use (10.0% vs 30.9%, p<0.001) and no change in self-extubation rate (0.9% vs 2.5%, p=0.2). Conclusion The implementation of a multifaceted nurse engagement intervention has the potential to improve rates of PAD assessment in community ICUs. Screening rates in our ICU remain suboptimal despite these improvements. We plan to implement multidisciplinary interventions targeting physicians, nurses and families to close the observed care gap.
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Affiliation(s)
- Carolyn M Tan
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Mercedes Camargo
- Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada.,Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Franziska Miller
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Katie Ross
- Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Ramez Maximous
- Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Priscilla Yung
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Carl Marshall
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada
| | - Dimitra Fleming
- Pharmacy, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada
| | - Madelyn Law
- Department of Health Sciences, Brock University, St. Catharines, Ontario, Canada
| | - Jennifer Ly Tsang
- Niagara Regional Campus, Michael G. DeGroote School of Medicine, McMaster University, St. Catharines, Ontario, Canada.,Medicine, Niagara Health-Saint Catharines Site, St. Catharines, Ontario, Canada.,Department of Medicine, McMaster University, Hamilton, Ontario, Canada
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Charbonney E, Tsang JL, Wassermann J, Adhikari NK. Acute refractory hypoxemia after chest trauma reversed by high-frequency oscillatory ventilation: a case report. J Med Case Rep 2013; 7:186. [PMID: 23855954 PMCID: PMC3726508 DOI: 10.1186/1752-1947-7-186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2012] [Accepted: 03/26/2013] [Indexed: 11/24/2022] Open
Abstract
Introduction Polytrauma often results in significant hypoxemia secondary to direct lung contusion or indirectly through atelectasis, systemic inflammatory response, large volume fluid resuscitation and blood product transfusion. In addition to causing hypoxemia, atelectasis and acute lung injury can lead to right ventricular failure through an acute increase in pulmonary vascular resistance. Mechanical ventilation is often applied, accompanied with recruitment maneuvers and positive end-expiratory pressure in order to recruit alveoli and reverse atelectasis, while preventing excessive alveolar damage. This strategy should lead to the reversal of the hypoxemic condition and the detrimental heart–lung interaction that may occur. However, as described in this case report, hemodynamic instability and intractable alveolar atelectasis sometimes do not respond to conventional ventilation strategies. Case presentation We describe the case of a 21-year-old Caucasian man with severe chest trauma requiring surgical interventions, who developed refractory hypoxemia and overt right ventricular failure. After multiple failed attempts of recruitment using conventional ventilation, the patient was ventilated with high-frequency oscillatory ventilation. This mode of ventilation allowed the reversal of the hemodynamic effects of severe hypoxemia and of the acute cor pulmonale. We use this case report to describe the physiological advantages of high-frequency oscillatory ventilation in patients with chest trauma, and formulate the arguments to explain the positive effect observed in our patient. Conclusions High-frequency oscillatory ventilation can be used in the context of a blunt chest trauma accompanied by severe hypoxemia due to atelectasis. The positive effect is due to its capacity to recruit the collapsed alveoli and, as a result, the relief of increased pulmonary vascular resistance and subsequently the reversal of acute cor pulmonale. This approach may represent an alternative in case of failure of the conventional ventilation strategy.
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Affiliation(s)
- Emmanuel Charbonney
- Centre de Santé et de Services Sociaux de Trois-Rivières, 1991 Boul, du Carmel, Trois-Rivières, QC G8Z 3R9, Canada.
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Tsang JL, Parodo JC, Marshall JC. Regulation of apoptosis and priming of neutrophil oxidative burst by diisopropyl fluorophosphate. J Inflamm (Lond) 2010; 7:32. [PMID: 20609247 PMCID: PMC2913997 DOI: 10.1186/1476-9255-7-32] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/23/2009] [Accepted: 07/07/2010] [Indexed: 12/25/2022]
Abstract
BACKGROUND Diisopropyl fluorophosphate (DFP) is a serine protease inhibitor that is widely used as an inhibitor of endogenous proteases in in vitro neutrophil studies. Its effects on neutrophil function are unclear. We sought to determine the biological effects of DFP on human neutrophil apoptosis and oxidative burst. METHODS We isolated neutrophils from healthy volunteers, incubated them with DFP (2.5 mM), and evaluated neutrophil elastase (NE) activity, neutrophil degranulation, apoptosis as reflected in hypodiploid DNA formation and exteriorization of phosphatidylserine (PS), processing and activity of caspases-3 and -8, oxidative burst activity and hydrogen peroxide release. RESULTS Consistent with its activity as a serine protease inhibitor, DFP significantly inhibited NE activity but not the degranulation of azurophilic granules. DFP inhibited constitutive neutrophil apoptosis as reflected in DNA fragmentation, and the processing and activity of caspases-3 and -8. DFP also inhibited priming of neutrophils for oxidative burst activity and hydrogen peroxide release. However, DFP enhanced the exteriorization of PS in a dose-dependent manner. CONCLUSION We conclude that DFP exerts significant effects on neutrophil inflammatory function that may confound the interpretation of studies that use it for its antiprotease activity. We further conclude that endogenous proteases play a role in the biology of constitutive neutrophil apoptosis.
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Affiliation(s)
- Jennifer Ly Tsang
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Canada.
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