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Paddock K, Woolfall K, Kearney A, Pattison N, Frith L, Gamble C, Welters I, Trinder J, Young B. Learning from stakeholders to inform good practice guidance on consent to research in intensive care units: a mixed-methods study. BMJ Open 2022; 12:e066149. [PMID: 36375987 PMCID: PMC9664286 DOI: 10.1136/bmjopen-2022-066149] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Obtaining informed consent from patients in intensive care units (ICUs) prior to enrolment in a study is practically and ethically complex. Decisions about the participation of critically ill patients in research often involve substitute decision makers (SDMs), such as a patient's relatives or doctors. We explored the perspectives of different stakeholder groups towards these consent procedures. DESIGN AND METHODS Mixed-methods study comprising surveys completed by ICU patients, their relatives and healthcare practitioners in 14 English ICUs, followed by qualitative interviews with a subset of survey participants. Empirical bioethics informed the analysis and synthesis of the data. Survey data were analysed using descriptive statistics of Likert responses, and analysis of interview data was informed by thematic reflective approaches. RESULTS Analysis included 1409 survey responses (ICU patients n=333, relatives n=488, healthcare practitioners n=588) and 60 interviews (ICU patients n=13, relatives n=30, healthcare practitioners n=17). Most agreed with relatives acting as SDMs based on the perception that relatives often know the patient well enough to reflect their views. While the practice of doctors serving as SDMs was supported by most survey respondents, a quarter (25%) disagreed. Views were more positive at interview and shifted markedly depending on particularities of the study. Participants also wanted reassurance that patient care was prioritised over research recruitment. Findings lend support for adaptations to consent procedures, including collaborative decision-making to correct misunderstandings of the implications of research for that patient. This empirical evidence is used to develop good practice guidance that is to be published separately. CONCLUSIONS Participants largely supported existing consent procedures, but their perspectives on these consent procedures depended on their perceptions of what the research involved and the safeguards in place. Findings point to the importance of explaining clearly what safeguards are in place to protect the patient.
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Affiliation(s)
- Katie Paddock
- Department of Childhood, Youth and Education Studies, Manchester Metropolitan University, Manchester, UK
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Anna Kearney
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - Natalie Pattison
- East and North Hertfordshire National Health Service Trust, Hertfordshire, UK
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Lucy Frith
- Centre for Social Ethics and Policy, The University of Manchester, Manchester, UK
| | - Carrol Gamble
- Department of Biostatistics, University of Liverpool, Liverpool, UK
| | - Ingeborg Welters
- Department of Critical Care, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - John Trinder
- Ulster Hospital, Belfast, South Eastern Health & Social Services Trust, Belfast, Ireland
| | - Bridget Young
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
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Baekgaard J, Arleth T, Siersma V, Hinkelbein J, Yücetepe S, Klimek M, van Vledder MG, Van Lieshout EMM, Mikkelsen S, Zwisler ST, Andersen M, Fenger-Eriksen C, Isbye DL, Rasmussen LS, Steinmetz J. Comparing restrictive versus liberal oxygen strategies for trauma patients - the TRAUMOX2 trial: protocol for a randomised clinical trial. BMJ Open 2022; 12:e064047. [PMID: 36344005 PMCID: PMC9644337 DOI: 10.1136/bmjopen-2022-064047] [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: 11/09/2022] Open
Abstract
INTRODUCTION Supplemental oxygen is commonly used in trauma patients, although it may lead to hyperoxaemia that has been associated with pulmonary complications and increased mortality. The primary objective of this trial, TRAUMOX2, is to compare a restrictive versus liberal oxygen strategy the first 8 hours following trauma. METHODS AND ANALYSIS TRAUMOX2 is an investigator-initiated, international, parallel-grouped, superiority, outcome assessor-blinded and analyst-blinded, randomised, controlled, clinical trial.Adult patients with suspected major trauma are randomised to eight hours of a restrictive or liberal oxygen strategy. The restrictive group receives the lowest dosage of oxygen (>21%) that ensures an SpO2 of 94%. The liberal group receives 12-15 L O2/min or FiO2=0.6-1.0.The primary outcome is a composite of 30-day mortality and/or development of major respiratory complications (pneumonia and/or acute respiratory distress syndrome).With 710 participants in each arm, we will be able to detect a 33% risk reduction with a restrictive oxygen strategy if the incidence of our primary outcome is 15% in the liberal group. ETHICS AND DISSEMINATION TRAUMOX2 is carried out in accordance with the Helsinki II Declaration. It has been approved by the Danish Committee on Health Research Ethics for the Capital Region (H-21018062) and The Danish Medicines Agency, as well as the Dutch Medical Research Ethics Committee Erasmus MS (NL79921.078.21 and MEC-2021-0932). A website (www.traumox2.org) is available for updates and study results will be published in an international peer-reviewed scientific journal. TRIAL REGISTRATION NUMBERS EudraCT 2021-000556-19; NCT05146700.
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Affiliation(s)
- Josefine Baekgaard
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Tobias Arleth
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
| | - Volkert Siersma
- The Research Unit for General Practice and Section of General Practice, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Sirin Yücetepe
- Department of Anaesthesiology and Intensive Care Medicine, Faculty of Medicine, University Hospital Cologne, Cologne, Nordrhein-Westfalen, Germany
| | - Markus Klimek
- Department of Anaesthesiology, University Medical Centre Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, Netherlands
| | - Mark G van Vledder
- Trauma Research Unit Department of Surgery, University Medical Centre Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, Netherlands
| | - Esther M M Van Lieshout
- Trauma Research Unit Department of Surgery, University Medical Centre Rotterdam, Erasmus MC, Rotterdam, Zuid-Holland, Netherlands
| | - Søren Mikkelsen
- The Prehospital Research Unit, University of Southern Denmark, Odense, Syddanmark, Denmark
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Syddanmark, Denmark
| | - Stine Thorhauge Zwisler
- The Prehospital Research Unit, University of Southern Denmark, Odense, Syddanmark, Denmark
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Syddanmark, Denmark
| | - Mikkel Andersen
- Department of Anaesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Dan L Isbye
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Lars S Rasmussen
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Jacob Steinmetz
- Department of Anaesthesia and Trauma Centre, Centre of Head and Orthopaedics, University of Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
- Danish Air Ambulance, Aarhus, Denmark
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Sivajohan A, Krause SC, Hegazy A, Slessarev M. Protocol for a systematic review on effective patient positioning for rapid sequence intubation. BMJ Open 2022; 12:e062988. [PMID: 36332945 PMCID: PMC9639087 DOI: 10.1136/bmjopen-2022-062988] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Rapid sequence intubation (RSI) is an advanced airway technique to perform endotracheal intubation in patients at high risk of aspiration. Although RSI is recognised as a life-saving technique and performed by many physicians in various settings (emergency departments, intensive care units), there is still a lack of consensus on various features of the procedure, most notably patient positioning. Previously, experts have commented on the unique drawbacks and benefits of various positions and studies have been published comparing patient positions and how it can affect endotracheal intubation in the context of RSI. The purpose of this systematic review is to compile the existing evidence to understand and compare how different patient positions can potentially affect the success of RSI. METHODS AND ANALYSIS We will use MEDLINE, EMBASE and the Cochrane Library to source studies from 1946 to 2021 that evaluate the impact of patient positioning on endotracheal intubation in the context of RSI. We will include randomised control trials, case-control studies, prospective/retrospective cohort studies and mannequin simulation studies for consideration in this systematic review. Subsequently, we will generate a Preferred Reporting Items for Systematic Reviews and Meta-Analyses flow diagram to display how we selected our final studies for inclusion in the review. Two independent reviewers will complete the study screening, selection and extraction, with a third reviewer available to address any conflicts. The reviewers will extract this data in accordance with our outcomes of interest and display it in a table format to highlight patient-relevant outcomes and difficulty airway management outcomes. We will use the Risk of Bias tool and the Newcastle-Ottawa Scale to assess included studies for bias. ETHICS AND DISSEMINATION This systematic review does not require ethics approval, as all patient-centred data will be reported from published studies. PROSPERO REGISTRATION NUMBER CRD42022289773.
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Affiliation(s)
| | - Sarah Ct Krause
- Schulich School of Medicine and Dentistry, London, Ontario, Canada
| | - Ahmed Hegazy
- Department of Anaesthesia and Perioperative Medicine, University of Western Ontario, London, Ontario, Canada
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Kovács EH, Rottler M, Dembrovszky F, Ocskay K, Szabó L, Hegyi P, Molnár Z, Tánczos K. Investigating the association between IL-6 antagonist therapy and blood coagulation in critically ill patients with COVID-19: a protocol for a prospective, observational, multicentre study. BMJ Open 2022; 12:e063856. [PMID: 36332964 PMCID: PMC9638747 DOI: 10.1136/bmjopen-2022-063856] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Hypercoagulation is one the main features of COVID-19. It is induced by the hyperinflammatory response that shifts the balance of haemostasis towards pro-coagulation. Interleukin-6 (IL-6) antagonist therapy has been recommended in certain subgroups of critically ill patients with COVID-19 to modulate inflammatory response. The interaction between immune response and haemostasis is well recognised. Therefore, our objective is to evaluate whether the modulation of the inflammatory response by IL-6 antagonist inflicts any changes in whole blood coagulation as assessed by viscoelastic methods in critically ill patients with COVID-19. METHODS AND ANALYSIS In this prospective observational study, we are going to collect data on inflammatory parameters and blood coagulation using the ClotPro® device. The primary outcome is the change of the fibrinolytic system measured by the Lysis Time and Lysis onset time before and after immunomodulation therapy. Data will be collected before the IL-6 antagonist administration at baseline (T0) then after 24, 48 hours, then on day 5 and 7 (T1-4, respectively). Secondary outcomes include changes in other parameters related to inflammation, blood coagulation and biomarkers of endothelial injury. ETHICS AND DISSEMINATION Ethical approval was given by the Medical Research Council of Hungary (1405-3/2022/EÜG). All participants provided written consent. The results of the study will be disseminated through peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT05218369; Clinicaltrials.gov.
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Affiliation(s)
- Emőke Henrietta Kovács
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
| | - Máté Rottler
- Szent György University Teaching Hospital of Fejér County, Székesfehérvár, Hungary
| | - Fanni Dembrovszky
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Klementina Ocskay
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - László Szabó
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Péter Hegyi
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Division of Pancreatic Diseases, Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Zsolt Molnár
- Centre for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Department of Anaesthesiology and Intensive Therapy, Poznan University of Medical Sciences, Poznan, Poland
| | - Krisztián Tánczos
- Department of Anaesthesiology and Intensive Therapy, Semmelweis University, Budapest, Hungary
- Soproni Erzsébet Teaching Hospital and Rehabilitation Institute, Sopron, Hungary
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