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Martinez-Perez S, van Waes JAR, Vernooij LM, Cuthbertson BH, Beattie WS, Wijeysundera DN, van Klei WA. Postoperative troponin surveillance to detect myocardial infarction: an observational cohort modelling study. Br J Anaesth 2024; 132:667-674. [PMID: 38233301 DOI: 10.1016/j.bja.2023.12.019] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 11/29/2023] [Accepted: 12/18/2023] [Indexed: 01/19/2024] Open
Abstract
BACKGROUND Clinical presentation of postoperative myocardial infarction (POMI) is often silent. Several international guidelines recommend routine troponin surveillance in patients at risk. We compared how these different guidelines select patients for surveillance after noncardiac surgery with our established risk stratification model. METHODS We used outcome data from two prospective studies: Measurement of Exercise Tolerance before Surgery (METS) and Troponin Elevation After Major non-cardiac Surgery (TEAMS). We compared the major American, Canadian, and European guideline recommendations for troponin surveillance with our established risk stratification model. For each guideline and model, we quantified the number of patients requiring monitoring, % POMI detected, sensitivity, specificity, diagnostic odds ratio, and number needed to screen (NNS). RESULTS METS and TEAMS contributed 2350 patients, of whom 319 (14%) had myocardial injury, 61 (2.5%) developed POMI, and 14 (0.6%) died. Our risk stratification model selected fewer patients for troponin monitoring (20%), compared with the Canadian (78%) and European (79%) guidelines. The sensitivity to detect POMI was highest with the Canadian and European guidelines (0.85; 95% confidence interval [CI] 0.74-0.92). Specificity was highest using the American guidelines (0.91; 95% CI 0.90-0.92). Our risk stratification model had the best diagnostic odds ratio (2.5; 95% CI 1.4-4.2) and a lower NNS (21 vs 35) compared with the guidelines. CONCLUSIONS Most postoperative myocardial infarctions were detected by the Canadian and European guidelines but at the cost of low specificity and a higher number of patients undergoing screening. Patient selection based on our risk stratification model was optimal.
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Affiliation(s)
- Selene Martinez-Perez
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada
| | - Judith A R van Waes
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lisette M Vernooij
- Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology, Intensive Care and Pain Medicine, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - W Scott Beattie
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesiology, St. Michael's Hospital, Toronto, ON, Canada
| | - Wilton A van Klei
- Department of Anesthesiology and Pain Management, Toronto General Hospital/University Health Network Toronto, Toronto, ON, Canada; Department of Anesthesiology, Intensive Care and Emergency Medicine, University Medical Center Utrecht, Utrecht, The Netherlands; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
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Amaral ACKB, Cuthbertson BH. The efficiency of computerised clinical decision support systems. Lancet 2024; 403:410-411. [PMID: 38262431 DOI: 10.1016/s0140-6736(23)02839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/20/2023] [Indexed: 01/25/2024]
Affiliation(s)
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centres, Toronto, ON M4G 2T9, Canada.
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Brown A, Ferrando-Vivas P, Popa M, de la Fuente GM, Pappachan J, Cuthbertson BH, Drikite L, Feltbower R, Gouliouris T, Sale I, Shulman R, Tume LN, Myburgh J, Woolfall K, Harrison DA, Mouncey PR, Rowan K, Pathan N. Use of selective gut decontamination in critically ill children: PICnIC a pilot RCT and mixed-methods study. Health Technol Assess 2024; 28:1-84. [PMID: 38421007 PMCID: PMC11017160 DOI: 10.3310/hdkv1008] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
Background Healthcare-associated infections are a major cause of morbidity and mortality in critically ill children. In adults, data suggest the use of selective decontamination of the digestive tract may reduce the incidence of healthcare-associated infections. Selective decontamination of the digestive tract has not been evaluated in the paediatric intensive care unit population. Objectives To determine the feasibility of conducting a multicentre, cluster-randomised controlled trial in critically ill children comparing selective decontamination of the digestive tract with standard infection control. Design Parallel-group pilot cluster-randomised controlled trial with an integrated mixed-methods study. Setting Six paediatric intensive care units in England. Participants Children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 hours were eligible for the PICnIC pilot cluster-randomised controlled trial. During the ecology periods, all children admitted to the paediatric intensive care units were eligible. Parents/legal guardians of recruited patients and healthcare professionals working in paediatric intensive care units were eligible for inclusion in the mixed-methods study. Interventions The interventions in the PICnIC pilot cluster-randomised controlled trial included administration of selective decontamination of the digestive tract as oro-pharyngeal paste and as a suspension given by enteric tube during the period of mechanical ventilation. Main outcome measures The decision as to whether a definitive cluster-randomised controlled trial is feasible is based on multiple outcomes, including (but not limited to): (1) willingness and ability to recruit eligible patients; (2) adherence to the selective decontamination of the digestive tract intervention; (3) acceptability of the definitive cluster-randomised controlled trial; (4) estimation of recruitment rate; and (5) understanding of potential clinical and ecological outcome measures. Results A total of 368 children (85% of all those who were eligible) were enrolled in the PICnIC pilot cluster-randomised controlled trial across six paediatric intensive care units: 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering selective decontamination of the digestive tract, the majority (98%) of children received at least one dose of selective decontamination of the digestive tract, and of these, 68% commenced within the first 6 hours. Consent for the collection of additional swabs was low (44%), though data completeness for potential outcomes, including microbiology data from routine clinical swab testing, was excellent. Recruited children were representative of the wider paediatric intensive care unit population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cluster-randomised controlled trial of 3 children/site/week, based on data from all UK paediatric intensive care units. The proposed trial, including consent and selective decontamination of the digestive tract, was acceptable to parents and staff with adaptations, including training to improve consent and communication, and adaptations to the administration protocol for the paste and ecology monitoring. Clinical outcomes that were considered important included duration of organ failure and hospital stay, healthcare-acquired infections and survival. Limitations The delivery of the pilot cluster-randomised controlled trial was disrupted by the COVID-19 pandemic, which led to slow set-up of sites, and a lack of face-to face training. Conclusions PICnIC's findings indicate that a definitive cluster-randomised controlled trial in selective decontamination of the digestive tract in paediatric intensive care units is feasible with the inclusion modifications, which would need to be included in a definitive cluster-randomised controlled trial to ensure that the efficiency of trial processes is maximised. Future work A definitive trial that incorporates the protocol adaptations and outcomes arising from this study is feasible and should be conducted. Trial registration This trial is registered as ISRCTN40310490. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/152/01) and is published in full in Health Technology Assessment; Vol. 28, No. 8. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Alanna Brown
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Mariana Popa
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | | | - John Pappachan
- Paediatric Intensive Care Unit, Southampton Children's Hospital, University of Southampton, Southampton, UK
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laura Drikite
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | | | - Theodore Gouliouris
- Clinical Microbiology and Public Health Laboratory, Addenbrooke's Hospital, Cambridge University Hospital NHS Foundation Trust, Cambridge, UK
| | | | - Robert Shulman
- Department of Pharmacy, University College London Hospitals NHS Foundation Trust, London, UK
| | - Lyvonne N Tume
- Intensive Care Unit, Alder Hey Children's NHS Foundation Trust Liverpool, Liverpool, UK
| | - John Myburgh
- George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Kerry Woolfall
- Department of Public Health, Policy and Systems, University of Liverpool, Liverpool, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, UK
| | - Nazima Pathan
- Department of Paediatrics, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
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Gorsky K, Cuninghame S, Jayaraj K, Slessarev M, Francoeur C, Withington DE, Chen J, Cuthbertson BH, Martin C, Chapman M, Ganesan SL, McKinnon N, Jerath A. Inhaled Volatiles for Status Asthmaticus, Epilepsy, and Difficult Sedation in Adult ICU and PICU: A Systematic Review. Crit Care Explor 2024; 6:e1050. [PMID: 38384587 PMCID: PMC10881088 DOI: 10.1097/cce.0000000000001050] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2024] Open
Abstract
OBJECTIVES Inhaled volatile anesthetics support management of status asthmaticus (SA), status epilepticus (SE), and difficult sedation (DS). This study aimed to evaluate the effectiveness, safety, and feasibility of using inhaled anesthetics for SA, SE, and DS in adult ICU and PICU patients. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. STUDY SELECTION Primary literature search that reported the use of inhaled anesthetics in ventilated patients with SA, SE, and DS from 1970 to 2021. DATA EXTRACTION Study data points were extracted by two authors independently. Quality assessment was performed using the Joanna Briggs Institute appraisal tool for case studies/series, Newcastle criteria for cohort/case-control studies, and risk-of-bias framework for clinical trials. DATA SYNTHESIS Primary outcome was volatile efficacy in improving predefined clinical or physiologic endpoints. Secondary outcomes were adverse events and delivery logistics. From 4281 screened studies, the number of included studies/patients across diagnoses and patient groups were: SA (adult: 38/121, pediatric: 28/142), SE (adult: 18/37, pediatric: 5/10), and DS (adult: 21/355, pediatric: 10/90). Quality of evidence was low, consisting mainly of case reports and series. Clinical and physiologic improvement was seen within 1-2 hours of initiating volatiles, with variable efficacy across diagnoses and patient groups: SA (adult: 89-95%, pediatric: 80-97%), SE (adults: 54-100%, pediatric: 60-100%), and DS (adults: 60-90%, pediatric: 62-90%). Most common adverse events were cardiovascular, that is, hypotension and arrhythmias. Inhaled sedatives were commonly delivered using anesthesia machines for SA/SE and miniature vaporizers for DS. Few (10%) of studies reported required non-ICU personnel, and only 16% had ICU volatile delivery protocol. CONCLUSIONS Volatile anesthetics may provide effective treatment in patients with SA, SE, and DS scenarios but the quality of evidence is low. Higher-quality powered prospective studies of the efficacy and safety of using volatile anesthetics to manage SA, SE, and DS patients are required. Education regarding inhaled anesthetics and the protocolization of their use is needed.
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Affiliation(s)
- Kevin Gorsky
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
| | - Sean Cuninghame
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Kesikan Jayaraj
- Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Marat Slessarev
- Department of Medicine, University of Western Ontario, London, ON, Canada
- Western Institute for Neuroscience, Western University, London, ON, Canada
| | - Conall Francoeur
- Department of Pediatrics, Laval University Faculty of Medicine, QC, Canada
| | - Davinia E Withington
- Department of Anesthesiology, McGill University Faculty of Medicine, Montreal, QC, Canada
| | - Jennifer Chen
- Department of Medical Biophysics, University of Western Ontario, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio Martin
- Department of Medicine, University of Western Ontario, London, ON, Canada
| | - Martin Chapman
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Saptharishi Lalgudi Ganesan
- Western Institute for Neuroscience, Western University, London, ON, Canada
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Nicole McKinnon
- Department of Critical Care Medicine, The Hospital for Sick Children, Toronto, ON, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Management, University of Toronto, Toronto, ON, Canada
- Cardiovascular Program, ICES, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
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5
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Prowle JR, Croal B, Abbott TEF, Cuthbertson BH, Wijeysundera DN. Cystatin C or creatinine for pre-operative assessment of kidney function and risk of post-operative acute kidney injury: a secondary analysis of the METS cohort study. Clin Kidney J 2024; 17:sfae004. [PMID: 38269033 PMCID: PMC10807905 DOI: 10.1093/ckj/sfae004] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Indexed: 01/26/2024] Open
Abstract
Background Post-operative acute kidney injury (PO-AKI) is a common surgical complication consistently associated with subsequent morbidity and mortality. Prior kidney dysfunction is a major risk factor for PO-AKI, however it is unclear whether serum creatinine, the conventional kidney function marker, is optimal in this population. Serum cystatin C is a kidney function marker less affected by body composition and might provide better prognostic information in surgical patients. Methods This was a pre-defined, secondary analysis of a multi-centre prospective cohort study of pre-operative functional capacity. Participants were aged ≥40 years, undergoing non-cardiac surgery. We assessed the association of pre-operative estimated glomerular filtration rate (eGFR) calculated using both serum creatinine and serum cystatin C with PO-AKI within 3 days after surgery, defined by KDIGO creatinine changes. The adjusted analysis accounted for established AKI risk factors. Results A total of 1347 participants were included (median age 65 years, interquartile range 56-71), of whom 775 (58%) were male. A total of 82/1347 (6%) patients developed PO-AKI. These patients were older, had higher prevalence of cardiovascular disease and related medication, were more likely to have intra-abdominal procedures, had more intraoperative transfusion, and were more likely to be dead at 1 year after surgery 6/82 (7.3%) vs 33/1265 (2.7%) (P = .038). Pre-operative eGFR was lower in AKI than non-AKI patients using both creatinine and cystatin C. When both measurements were considered in a single age- and sex-adjusted model, eGFR-Cysc was strongly associated with PO-AKI, with increasing risk of AKI as eGFR-Cysc decreased below 90, while eGFR-Cr was no longer significantly associated. Conclusions Data from over 1000 prospectively recruited surgical patients confirms pre-operative kidney function as major risk factor for PO-AKI. Of the kidney function markers available, compared with creatinine, cystatin C had greater strength of association with PO-AKI and merits further assessment in pre-operative assessment of surgical risk.
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Affiliation(s)
- John R Prowle
- Critical Care and Peri-operative Medicine Research Group, William Harvey Research Institute, Faculty of Medicine, Queen Mary University of London, London, UK
- Adult Critical Care Unit, Barts Health NHS Trust, London, UK
| | - Bernard Croal
- NHS Grampian-Clinical Biochemistry, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, UK
| | - Thomas E F Abbott
- Critical Care and Peri-operative Medicine Research Group, William Harvey Research Institute, Faculty of Medicine, Queen Mary University of London, London, UK
- Adult Critical Care Unit, Barts Health NHS Trust, London, UK
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON,Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
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Kaas-Hansen BS, Kjaer MBN, Møller MH, Jensen AKG, Larsen ME, Cuthbertson BH, Perner A, Granholm A. Health-related quality of life trajectories in critical illness: Protocol for a Monte Carlo simulation study. Acta Anaesthesiol Scand 2024; 68:122-129. [PMID: 37650374 DOI: 10.1111/aas.14324] [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] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/12/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Health-related quality of life (HRQoL) is a patient-centred outcome increasingly used as a secondary outcome in critical care research. It may cover several important dimensions of clinical status in intensive care unit (ICU) patients that arguably elude other more easily quantified outcomes such as mortality. Poor associations with harder outcomes, conflicting data on HRQoL in critically ill compared to the background population, and paradoxical effects on HRQoL and mortality complicate the current operationalisation in critical care trials. This protocol outlines a simulation study that will gauge if the areas under the HRQoL trajectories could be a viable alternative. METHODS We will gauge the behaviour of the proposed HRQoL operationalisation through Monte Carlo simulations, under clinical scenarios that reflect a broad critical care population eligible for inclusion in a large pragmatic trial. We will simulate 15,360 clinical scenarios based on a full factorial design with the following seven simulation parameters: number of patients per arm, relative mortality reduction in the interventional arm, acceleration of HRQoL improvement in the interventional arm, the relative improvement in final HRQoL in the interventional arm, dampening effect of mortality on HRQoL values at discharge from the ICU, proportion of so-called mortality benefiters in the interventional arm and mortality trajectory shape. For each clinical scenario, we will simulate 100,000 two-arm trials with 1:1 randomisation. HRQoL will be sampled fortnightly after ICU discharge. Outcomes will include HRQoL in survivors and all patients at the end of follow-up; mean areas under the HRQoL trajectories in both arms; and mean difference between areas under the HRQoL trajectories and single-sampled HRQoLs at the end of follow-up. DISCUSSION In the outlined simulation study, we aim to assess whether the area under the HRQoL trajectory curve could be a candidate for reconciling the seemingly paradoxical effects on improved mortality and reduced HRQoL while remaining sensitive to early or accelerated improvement in patient outcomes. The resultant insights will inform subsequent methodological work on prudent collection and statistical analysis of such data from real critically ill patients.
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Affiliation(s)
- Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Section of Biostatistics, Deparment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | | | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Deparment of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Mia Esta Larsen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Brian H Cuthbertson
- Department of Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
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Pathan N, Woolfall K, Popa M, de la Fuente GM, Ferrando-Vivas P, Brown A, Gouliouris T, Tume LN, Shulman R, Cuthbertson BH, Sale I, Feltbower RG, Myburgh J, Pappachan J, Harrison D, Mouncey P, Rowan K. Selective digestive tract decontamination to prevent healthcare associated infections in critically ill children: the PICNIC multicentre randomised pilot clinical trial. Sci Rep 2023; 13:21668. [PMID: 38066012 PMCID: PMC10709430 DOI: 10.1038/s41598-023-46232-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 10/30/2023] [Indexed: 12/18/2023] Open
Abstract
Healthcare-associated infections (HCAIs) are a major cause of morbidity and mortality in critically ill children. Data from adult studies suggest Selective Decontamination of the Digestive tract (SDD) may reduce the incidence of HCAIs and improve survival. There are no data from randomised clinical trials in the paediatric setting. An open label, parallel group pilot cRCT and mixed-methods perspectives study was conducted in six paediatric intensive care units (PICUs) in England. Participants were children (> 37 weeks corrected gestational age, up to 16 years) requiring mechanical ventilation expected to last for at least 48 h. Sites undertook standard care for a period of 9 weeks and were randomised into 3 sites which continued standard care and 3 where SDD was incorporated into infection control practice for eligible children. Interviews and focus groups were conducted for parents and staff working in PICU. 434 children fulfilled eligibility criteria, of whom 368 (85%) were enrolled. This included 207 in the baseline phase (Period One) and 161 in the intervention period (Period Two). In sites delivering SDD, the majority (98%) of children received at least one dose of SDD and of these, 68% commenced within the first 6 h. Whilst admission swabs were collected in 91% of enrolled children, consent for the collection of additional swabs was low (44%). Recruited children were representative of the wider PICU population. Overall, 3.6 children/site/week were recruited compared with the potential recruitment rate for a definitive cRCT of 3 children/site/week, based on data from all UK PICUs. Parents (n = 65) and staff (n = 44) were supportive of the aims of the study, suggesting adaptations for a larger definitive trial including formulation and administration of SDD paste, approaches to consent and ecology monitoring. Stakeholders identified preferred clinical outcomes, focusing on complications of critical illness and quality-of-life. A definitive cRCT in SDD to prevent HCAIs in critically ill children is feasible but should include adaptations to ecology monitoring along with the dosing schedule and packaging into a paediatric specific format. A definitive study is supported by the findings with adaptations to ecology monitoring and SDD administration.Trial Registration: ISRCTN40310490 Registered 30/10/2020.
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Affiliation(s)
- Nazima Pathan
- University of Cambridge, Cambridge, UK.
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK.
| | | | | | | | | | - Alanna Brown
- Intensive Care National Audit and Research Centre, London, UK
- University College London, London, UK
| | | | | | | | | | | | | | - John Myburgh
- The George Institute for Global Health, Sydney, Australia
| | | | - David Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - Paul Mouncey
- Intensive Care National Audit and Research Centre, London, UK
| | - Kathryn Rowan
- Intensive Care National Audit and Research Centre, London, UK
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8
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Daza JF, Wijeysundera HC, Diep C, Ladha KS, Cuthbertson BH, Wijeysundera DN. Healthcare Costs of New Functional Impairment in the Year after Noncardiac Surgery. Anesthesiology 2023; 139:902-904. [PMID: 37874043 DOI: 10.1097/aln.0000000000004674] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2023]
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9
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Cuninghame S, Jerath A, Gorsky K, Sivajohan A, Francoeur C, Withington D, Burry L, Cuthbertson BH, Orser B, Martin C, Owen AM, Slessarev M. Corrigendum to 'Effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults: a systematic review and meta-analysis' (Br J Anaesth 2023; 131: 314-27). Br J Anaesth 2023; 131:788. [PMID: 37596182 DOI: 10.1016/j.bja.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023] Open
Affiliation(s)
- Sean Cuninghame
- Department of Medicine, Western University, London, ON, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Schulich Heart Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Kevin Gorsky
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Asaanth Sivajohan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Conall Francoeur
- Centre de Recherche CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Davinia Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Schulich Heart Program, Sunnybrook Research Institute, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Beverley Orser
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio Martin
- Department of Medicine, Western University, London, ON, Canada
| | - Adrian M Owen
- Western Institute for Neuroscience, Department of Psychology and Department of Physiology and Pharmacology, Western University, London, ON, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada.
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10
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Alfitian J, Riedel B, Ismail H, Ho KM, Xie S, Zimmer P, Kammerer T, Wijeysundera DN, Cuthbertson BH, Schier R. Sex-related differences in functional capacity and its implications in risk stratification before major non-cardiac surgery: a post hoc analysis of the international METS study. EClinicalMedicine 2023; 64:102223. [PMID: 37811489 PMCID: PMC10556582 DOI: 10.1016/j.eclinm.2023.102223] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/24/2023] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Background Poor functional capacity has been identified as an important modifiable risk factor for postoperative complications. Cardiopulmonary exercise testing (CPET) provides objective parameters of functional capacity (e.g., oxygen consumption at peak exercise, peak VO2), with significant prognostication for postoperative complications. However, sex-specific thresholds for functional capacity to predict surgical risk are yet to be established. Therefore, we performed a post hoc analysis of the international, multicentre, prospective observational METS (Measurement of Exercise Tolerance before Surgery) study to evaluate if sex-specific thresholds of peak VO2 improve risk prediction of postoperative complications. Methods We undertook a post hoc analysis (HREC/71824/PMCC) of the METS study, which was performed between March 2013 and March 2016. We investigated whether sex-specific differences exist for CPET-derived parameters and associated thresholds for predicting postoperative complications in this large cohort of patients that had major non-cardiac surgery (n = 1266). Logistic regression models were analyzed for the association of low peak VO2 with moderate-to-severe in-hospital postoperative complications. Optimal sex-specific peak VO2 thresholds were obtained by maximizing the Youden index of receiver operating characteristic (ROC) curves. Finally, multivariable logistic regression models tested the resulting sex-specific thresholds against the established non-sex-specific peak VO2 threshold (14 mL kg-1 min-1) adjusted for clinically relevant features such as comorbidities and surgical complexity. Models were evaluated by bootstrapping optimism-corrected area under the ROC curve and the net reclassification improvement index (NRI). Findings Female patients (n = 480) had a lower mean (SD) peak VO2 than males (16.7 (4.9) mL kg-1 min-1 versus 21.2 (6.5) mL kg-1 min-1, p < 0.001) and a lower postoperative complication rate (10.4% versus 15.3%; p = 0.018) than males (n = 786). The optimal peak VO2 threshold for predicting postoperative complications was 12.4 mL kg-1 min-1 for females and 22.3 mL kg-1 min-1 for males, respectively. In the multivariable regression model, low non-sex-specific peak VO2 did not independently predict postoperative complications. In contrast, low sex-specific peak VO2 was an independent predictor of postoperative complications (OR 2.29; 95% CI: 1.60, 3.30; p < 0.001). The optimism-corrected AUC-ROC of the sex-specific model was higher compared with the non-sex-specific model (0.73 versus 0.7; DeLong's test: p = 0.021). The sex-specific model classified 39% of the patients more correctly than the baseline model (NRI = 0.39; 95% CI: 0.24, 0.55). In contrast, the non-sex-specific model only classified 9% of the patients more correctly when compared against the baseline model (NRI = 0.09; 95% CI: -0.04, 0.22). Interpretation Our data report sex-specific differences in preoperative CPET-derived functional capacity parameters. Sex-specific peak VO2 thresholds identify patients at increased risk for postoperative complications with a higher discriminatory ability than a sex-unspecific threshold. As such, sex-specific threshold values should be considered in preoperative CPET to potentially improve risk stratification and to guide surgical decision-making, including eligibility for surgery, preoperative optimization strategies (prehabilitation) or seeking non-surgical options. Funding There was no funding for the present study. The original METS study was funded by Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Affiliation(s)
- Jonas Alfitian
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Bernhard Riedel
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
| | - Hilmy Ismail
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
| | - Kwok M. Ho
- University of Western Australia and Murdoch University, Australia
| | - Sophia Xie
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
| | - Philipp Zimmer
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
| | - Tobias Kammerer
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
| | - Duminda N. Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
| | - Brian H. Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Robert Schier
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
| | - the METS Study Investigators
- University of Cologne, Faculty of Medicine and University Hospital Cologne, Department for Anesthesiology and Intensive Care Medicine, Germany
- Department of Anaesthesia, Perioperative Medicine and Pain Medicine, Peter MacCallum Cancer Centre, Australia
- The Department of Critical Care, University of Melbourne, Melbourne, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Australia
- University of Western Australia and Murdoch University, Australia
- Peter MacCallum Cancer Centre, Centre for Biostatistics and Clinical Trials, Australia
- Division of Performance and Health, Institute for Sport and Sport Science, TU Dortmund University, Germany
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St. Michael’s Hospital, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University of Marburg, Campus Fulda, Germany
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Trivedi V, Ladha KS, Jivraj NK, Saskin R, Thorpe KE, Wijeysundera DN, Cuthbertson BH. Association between preoperative cardiac risk assessment and health care costs in major noncardiac surgery: a multicentre health economic analysis. Can J Anaesth 2023; 70:1340-1349. [PMID: 37430180 DOI: 10.1007/s12630-023-02519-x] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 02/08/2023] [Accepted: 02/09/2023] [Indexed: 07/12/2023] Open
Abstract
PURPOSE Patients with impaired functional capacity who undergo major surgery are at increased risk of postoperative morbidity including complications and increased length of stay. These outcomes have been associated with increased hospital and health system costs. We aimed to assess whether common preoperative risk indices are associated with postoperative cost. METHODS We conducted a health economic analysis focused on the subset of Measurement of Exercise Tolerance before Surgery (METS) study participants in Ontario, Canada. Participants were scheduled for major elective noncardiac surgery and underwent several preoperative assessments of cardiac risk, including physicians' subjective assessment, Duke Activity Status Index (DASI) questionnaire, peak oxygen consumption, and N-terminal pro-B-type natriuretic peptide concentration. Using linked health administrative data, postoperative costs were calculated for both one year and in-hospital. Using multiple regression models, we tested for association between the preoperative measures of cardiac risk and postoperative costs. RESULTS Our study included 487 patients (mean [standard deviation] age 68 [11] yr and 47.0% female) who underwent noncardiac surgery between 13 June 2013 and 8 March 2016. Overall, the median [interquartile range] cost incurred within one year postoperatively was CAD 27,587 [13,902-32,590], of which CAD 12,928 [10,253-12,810] were incurred in-hospital and CAD 14,497 [10,917-15,017] were incurred by 30 days. None of the four preoperative measures of cardiac risk assessment were associated with costs incurred in hospital or at one year postoperatively. This lack of strong association persisted in sensitivity analyses considering type of surgical procedure, burden of preoperative cost, and when costs were categorized as quantiles. CONCLUSION In patients undergoing major noncardiac surgery, common measures of functional capacity are not consistently associated with total postoperative cost. Until further data exist that differ from this analysis, clinicians and health care funders should not assume that preoperative measures of cardiac risk are associated with annual health care or hospital costs for such surgeries.
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Affiliation(s)
- Vatsal Trivedi
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute for Better Health, Trillium Health Partners, Mississauga, ON, Canada
| | - Karim S Ladha
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Naheed K Jivraj
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Refik Saskin
- Institute for Clinical Evaluative Sciences, Toronto, ON, Canada
| | - Kevin E Thorpe
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Toronto, ON, M4N 3M5, Canada.
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12
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Cuninghame S, Jerath A, Gorsky K, Sivajohan A, Francoeur C, Withington D, Burry L, Cuthbertson BH, Orser BA, Martin C, Owen AM, Slessarev M. Effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults: a systematic review and meta-analysis. Br J Anaesth 2023; 131:314-327. [PMID: 37344338 DOI: 10.1016/j.bja.2023.05.004] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 04/17/2023] [Accepted: 05/04/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Sedation of critically ill patients with inhaled anaesthetics may reduce lung inflammation, time to extubation, and ICU length of stay compared with intravenous (i.v.) sedatives. However, the impact of inhaled anaesthetics on cognitive and psychiatric outcomes in this population is unclear. In this systematic review, we aimed to summarise the effect of inhaled anaesthetics on cognitive and psychiatric outcomes in critically ill adults. METHODS We searched MEDLINE, EMBASE, and PsycINFO for case series, retrospective, and prospective studies in critically ill adults sedated with inhaled anaesthetics. Outcomes included delirium, psychomotor and neurological recovery, long-term cognitive dysfunction, ICU memories, anxiety, depression, post-traumatic stress disorder (PTSD), and instruments used for assessment. RESULTS Thirteen studies were included in distinct populations of post-cardiac arrest survivors (n=4), postoperative noncardiac patients (n=3), postoperative cardiac patients (n=2), and mixed medical-surgical patients (n=4). Eight studies reported delirium incidence, two neurological recovery, and two ICU memories. One study reported on psychomotor recovery, long-term cognitive dysfunction, anxiety, depression, and PTSD. A meta-analysis of five trials found no difference in delirium incidence between inhaled and i.v. sedatives (relative risk 0.95 [95% confidence interval: 0.59-1.54]). Compared with i.v. sedatives, inhaled anaesthetics were associated with fewer hallucinations and faster psychomotor recovery but no differences in other outcomes. There was heterogeneity in the instruments used and timing of these assessments. CONCLUSIONS Based on the limited evidence available, there is no difference in cognitive and psychiatric outcomes between adults exposed to volatile sedation or intravenous sedation in the ICU. Future studies should incorporate outcome assessment with validated tools during and after hospital stay. SYSTEMATIC REVIEW PROTOCOL PROSPERO CRD42021236455.
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Affiliation(s)
- Sean Cuninghame
- Department of Medicine, Western University, London, ON, Canada
| | - Angela Jerath
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Schulich Heart Program, Sunnybrook Research Institute, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Kevin Gorsky
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Asaanth Sivajohan
- Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Conall Francoeur
- Centre de Recherche CHU de Québec-Université Laval, Quebec City, QC, Canada
| | - Davinia Withington
- Department of Anesthesia, Montreal Children's Hospital, Montreal, QC, Canada; Department of Anesthesia, McGill University, Montreal, QC, Canada
| | - Lisa Burry
- Departments of Pharmacy and Medicine, Mount Sinai Hospital, Toronto, ON, Canada; Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute for Health Policy, Management and Evaluation, University of Toronto, ON, Canada
| | - Beverley A Orser
- Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Department of Anesthesia, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Claudio Martin
- Department of Medicine, Western University, London, ON, Canada
| | - Adrian M Owen
- Western Institute for Neuroscience, Western University, London, ON, Canada; Department of Psychology and Department of Physiology and Pharmacology, Western University, London, Canada
| | - Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada; Western Institute for Neuroscience, Western University, London, ON, Canada.
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13
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Mills CS, Cuthbertson BH, Michou E. What's new in reducing the impact of tracheostomy on communication and swallowing in the ICU. Intensive Care Med 2023; 49:860-863. [PMID: 37079084 PMCID: PMC10353948 DOI: 10.1007/s00134-023-07064-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/29/2023] [Indexed: 04/21/2023]
Affiliation(s)
- Claire S Mills
- Speech and Language Therapy Department, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
- University Department of Anaesthesiology and Pain Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Emilia Michou
- Speech and Language Therapy Department, School of Health Rehabilitation Sciences, University of Patras, Patras, Greece
- Centre for Gastrointestinal Sciences, The University of Manchester, Manchester, UK
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14
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Cuthbertson BH. The Faltering Evidence Base for Early Rehabilitation. Am J Respir Crit Care Med 2023; 208:7-8. [PMID: 37159943 PMCID: PMC10870848 DOI: 10.1164/rccm.202304-0701ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023] Open
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15
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Premraj L, Camarda C, White N, Godoy DA, Cuthbertson BH, Rocco PRM, Pelosi P, Robba C, Suarez JI, Cho SM, Battaglini D. Tracheostomy timing and outcome in critically ill patients with stroke: a meta-analysis and meta-regression. Crit Care 2023; 27:132. [PMID: 37005666 PMCID: PMC10068163 DOI: 10.1186/s13054-023-04417-6] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 03/27/2023] [Indexed: 04/04/2023] Open
Abstract
BACKGROUND Stroke patients requiring mechanical ventilation often have a poor prognosis. The optimal timing of tracheostomy and its impact on mortality in stroke patients remains uncertain. We performed a systematic review and meta-analysis of tracheostomy timing and its association with reported all-cause overall mortality. Secondary outcomes were the effect of tracheostomy timing on neurological outcome (modified Rankin Scale, mRS), hospital length of stay (LOS), and intensive care unit (ICU) LOS. METHODS We searched 5 databases for entries related to acute stroke and tracheostomy from inception to 25 November 2022. We adhered to PRISMA guidance for reporting systematic reviews and meta-analyses. Selected studies included (1) ICU-admitted patients who had stroke (either acute ischaemic stroke, AIS or intracerebral haemorrhage, ICH) and received a tracheostomy (with known timing) during their stay and (2) > 20 tracheotomised. Studies primarily reporting sub-arachnoid haemorrhage (SAH) were excluded. Where this was not possible, adjusted meta-analysis and meta-regression with study-level moderators were performed. Tracheostomy timing was analysed continuously and categorically, where early (< 5 days from initiation of mechanical ventilation to tracheostomy) and late (> 10 days) timing was defined per the protocol of SETPOINT2, the largest and most recent randomised controlled trial on tracheostomy timing in stroke patients. RESULTS Thirteen studies involving 17,346 patients (mean age = 59.8 years, female 44%) met the inclusion criteria. ICH, AIS, and SAH comprised 83%, 12%, and 5% of known strokes, respectively. The mean time to tracheostomy was 9.7 days. Overall reported all-cause mortality (adjusted for follow-up) was 15.7%. One in five patients had good neurological outcome (mRS 0-3; median follow-up duration was 180 days). Overall, patients were ventilated for approximately 12 days and had an ICU LOS of 16 days and a hospital LOS of 28 days. A meta-regression analysis using tracheostomy time as a continuous variable showed no statistically significant association between tracheostomy timing and mortality (β = - 0.3, 95% CI = - 2.3 to 1.74, p = 0.8). Early tracheostomy conferred no mortality benefit when compared to late tracheostomy (7.8% vs. 16.4%, p = 0.7). Tracheostomy timing was not associated with secondary outcomes (good neurological outcome, ICU LOS and hospital LOS). CONCLUSIONS In this meta-analysis of over 17,000 critically ill stroke patients, the timing of tracheostomy was not associated with mortality, neurological outcomes, or ICU/hospital LOS. TRIAL REGISTRATION PROSPERO-CRD42022351732 registered on 17th of August 2022.
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Affiliation(s)
- Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia
| | | | - Nicole White
- Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health and Social Work, Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Daniel Agustin Godoy
- Neurointensive Care Unit, Critical Care Department, Sanatorio Pasteur, Chacabuco 675, 4700, Catamarca, Argentina
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
- University Department of Anaesthesiology in Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Jose I Suarez
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Department of Neurology, Neurosurgery, Anaesthesiology and Critical Care Medicine and Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
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16
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Rose L, Istanboulian L, Amaral ACKB, Burry L, Cox CE, Cuthbertson BH, Iwashyna TJ, Dale CM, Fraser I. Co-designed and consensus based development of a quality improvement checklist of patient and family-centered actionable processes of care for adults with persistent critical illness. J Crit Care 2022; 72:154153. [PMID: 36174432 DOI: 10.1016/j.jcrc.2022.154153] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/15/2022] [Accepted: 09/06/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Few quality improvement tools specific to patients with persistent or chronic critical illness exist to aid delivery of high-quality care. Using experience-based co-design methods, we sought consensus from key stakeholders on the most important actionable processes of care for inclusion in a quality improvement checklist. METHODS Item generation methods: systematic review, semi-structured interviews (ICU survivors and family) members, touchpoint video creation, and semi-structured interviews (ICU clinicians). Consensus methods: modified online Delphi and a virtual meeting using nominal group technique methods. RESULTS We enrolled 138 ICU interprofessional team, patients, and family members. We obtained consensus on a quality improvement checklist comprising 11 core domains: patient and family involvement in decision-making; patient communication; physical comfort and complication prevention; promoting self-care and normalcy; ventilator weaning; physical therapy; swallowing; pharmacotherapy; psychological issues; delirium; and appropriate referrals. An additional 27 actionable processes are contained within 6 core domains that provide more specific direction on the actionable process to be targeted. CONCLUSIONS Using a highly collaborative and methodologically rigorous process, we generated a quality improvement checklist of actionable processes to improve patient and family-centred care considered important by key stakeholders. Future research is needed to understand optimal implementation strategies and impact on outcomes and experience.
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Affiliation(s)
- Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.
| | - Laura Istanboulian
- Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto, Toronto East Health Network, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada
| | - Lisa Burry
- Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada; Mount Sinai Hospital, Sinai Health System, Toronto, ON, Canada
| | | | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada; Sunnybrook Research Institute, Toronto, Canada; University Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Theodore J Iwashyna
- University of Michigan, Ann Arbor, VA Health System, United States of America
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada; Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Ian Fraser
- Provincial Centre of Weaning Excellence, Michael Garron Hospital, Toronto East Health Network, Toronto, Canada
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Myburgh JA, Seppelt IM, Goodman F, Billot L, Correa M, Davis JS, Gordon AC, Hammond NE, Iredell J, Li Q, Micallef S, Miller J, Mysore J, Taylor C, Young PJ, Cuthbertson BH, Finfer SR. Effect of Selective Decontamination of the Digestive Tract on Hospital Mortality in Critically Ill Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA 2022; 328:1911-1921. [PMID: 36286097 PMCID: PMC9607966 DOI: 10.1001/jama.2022.17927] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Whether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain. OBJECTIVE To determine whether SDD reduces in-hospital mortality in critically ill adults. DESIGN, SETTING, AND PARTICIPANTS A cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021. INTERVENTIONS ICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care. MAIN OUTCOMES AND MEASURES The primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs. RESULTS Of 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, -1.7% [95% CI, -4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, -11.0%; 95% CI, -14.7% to -7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, -1.95%; 95% CI, -3.5% to -0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, -0.24%; 95% CI, -0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (-3.3% vs -1.59%; mean difference, -1.71% [1-sided 97.5% CI, -∞ to 4.31%] and 0.88% vs 0.55%; mean difference, -0.32% [1-sided 97.5% CI, -∞ to 5.47%]) in the first and second periods, respectively. CONCLUSIONS AND RELEVANCE Among critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02389036.
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Affiliation(s)
| | - John A Myburgh
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- St George Hospital, Sydney, Australia
| | - Ian M Seppelt
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of Sydney, Australia
- Nepean Hospital, Sydney, Australia
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Fiona Goodman
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Laurent Billot
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - Maryam Correa
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Joshua S Davis
- John Hunter Hospital, Newcastle, Australia
- School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
- Menzies School of Heath Research, Newcastle, Australia
| | - Anthony C Gordon
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, Imperial College London, London, England
| | - Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Royal North Shore Hospital, Sydney, Australia
| | - Jon Iredell
- Faculty of Medicine, University of Sydney, Australia
- Centre for Infectious Disease and Microbiology Westmeath Institute of Medical Research, Sydney, Australia
| | - Qiang Li
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Jennene Miller
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- St George Hospital, Sydney, Australia
- Liverpool Hospital, Sydney, Australia
| | - Jayanthi Mysore
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Colman Taylor
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Paul J Young
- Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Brian H Cuthbertson
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Simon R Finfer
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
- Faculty of Medicine, University of New South Wales, Sydney, Australia
- Faculty of Medicine, Imperial College London, London, England
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18
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Daza JF, Cuthbertson BH, Myles PS, Shulman MA, Wijeysundera DN, Wijeysundera DN, Pearse RM, Myles PS, Abbott TEF, Shulman MA, Torres E, Ambosta A, Melo M, Mamdani M, Thorpe KE, Wallace S, Farrington C, Croal BL, Granton JT, Oh P, Thompson B, Hillis G, Beattie WS, Wijeysundera HC, Ellis M, Borg B, Kerridge RK, Douglas J, Brannan J, Pretto J, Godsall MG, Beauchamp N, Allen S, Kennedy A, Wright E, Malherbe J, Ismail H, Riedel B, Melville A, Sivakumar H, Murmane A, Kenchington K, Kirabiyik Y, Gurunathan U, Stonell C, Brunello K, Steele K, Tronstad O, Masel P, Dent A, Smith E, Bodger A, Abolfathi M, Sivalingam P, Hall A, Painter TW, Macklin S, Elliott A, Carrera AM, Terblanche NCS, Pitt S, Samuels J, Wilde C, Leslie K, MacCormick A, Bramley D, Southcott AM, Grant J, Taylor H, Bates S, Towns M, Tippett A, Marshall F, McCartney CJL, Choi S, Somascanthan P, Flores K, Karkouti K, Clarke HA, Jerath A, McCluskey SA, Wasowicz M, Day L, Pazmino-Canizares J, Belliard R, Lee L, Dobson K, Stanbrook M, Hagen K, Campbell D, Short T, Van Der Westhuizen J, Higgie K, Lindsay H, Jang R, Wong C, McAllister D, Ali M, Kumar J, Waymouth E, Kim C, Dimech J, Lorimer M, Tai J, Miller R, Sara R, Collingwood A, Olliff S, Gabriel S, Houston H, Dalley P, Hurford S, Hunt A, Andrews L, Navarra L, Jason-Smith A, Thompson H, McMillan N, Back G. Measurement properties of the WHO Disability Assessment Schedule 2.0 for evaluating functional status after inpatient surgery. Br J Surg 2022; 109:968-976. [PMID: 35929065 DOI: 10.1093/bjs/znac263] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Revised: 05/17/2022] [Accepted: 07/08/2022] [Indexed: 11/12/2022]
Abstract
BACKGROUND Expert recommendations propose the WHO Disability Assessment Schedule (WHODAS) 2.0 as a core outcome measure in surgical studies, yet data on its long-term measurement properties remain limited. These were evaluated in a secondary analysis of the Measurement of Exercise Tolerance before Surgery (METS) prospective cohort. METHODS Participants were adults (40 years of age or older) who underwent inpatient non-cardiac surgery. The 12-item WHODAS and EQ-5DTM-3L questionnaires were administered preoperatively (in person) and 1 year postoperatively (by telephone). Responsiveness was characterized using standardized response means (SRMs) and correlation coefficients between change scores. Construct validity was evaluated using correlation coefficients between 1-year scores and comparisons of WHODAS scores across clinically relevant subgroups. RESULTS The analysis included 546 patients. There was moderate correlation between changes in WHODAS and various EQ-5DTM subscales. The strongest correlation was between changes in WHODAS and changes in the functional domains of the EQ-5D-3L-for example, mobility (Spearman's rho 0.40, 95 per cent confidence interval [c.i.] 0.32 to 0.48) and usual activities (rho 0.45, 95 per cent c.i. 0.30 to 0.52). When compared across quartiles of EQ-5D index change, median WHODAS scores followed expected patterns of change. In subgroups with expected functional status changes, the WHODAS SRMs ranged from 'small' to 'large' in the expected directions of change. At 1 year, the WHODAS demonstrated convergence with the EQ-5D-3L functional domains, and good discrimination between patients with expected differences in functional status. CONCLUSION The WHODAS questionnaire has construct validity and responsiveness as a measure of functional status at 1 year after major surgery.
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Affiliation(s)
- Julian F Daza
- Division of General Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada.,Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Brian H Cuthbertson
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Mark A Shulman
- Department of Anaesthesiology and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, Victoria, Australia
| | - Duminda N Wijeysundera
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
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19
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Dale CM, Rose L, Carbone S, Pinto R, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Scales DC, Cuthbertson BH. Effect of oral chlorhexidine de-adoption and implementation of an oral care bundle on mortality for mechanically ventilated patients in the intensive care unit (CHORAL): a multi-center stepped wedge cluster-randomized controlled trial. Intensive Care Med 2021; 47:1295-1302. [PMID: 34609548 PMCID: PMC8490143 DOI: 10.1007/s00134-021-06475-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [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: 02/19/2021] [Accepted: 07/05/2021] [Indexed: 11/29/2022]
Abstract
Purpose Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients. Methods A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors. Results A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio [aOR], 1.13; 95% confidence interval [CI] 0.82 to 1.54; P = 0.46). Time to IVACs (adjusted hazard ratio [aHR], 1.06; 95% CI 0.44 to 2.57; P = 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23; P = 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10; P = 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17; P = 0.02) improved in the intervention period. Conclusion Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06475-2.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Louise Rose
- Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, 57 Waterloo Road, Room 1.1.3, London, SE1 8WA, UK.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, 155 College Street, Suite 130, Toronto, ON, M5T 1P8, Canada.,Department of Critical Care, St. Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Pharmacy, Mount Sinai Hospital, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Krembil Research Institute, 399 Bathurst Street, Toronto, ON, M5T 2S8, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Interdepartmental Division of Critical Care Medicine, Faculty of Medicine, University of Toronto, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada. .,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
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20
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris I, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Lee N, Cook JA. Placebo comparator group selection and use in surgical trials: the ASPIRE project including expert workshop. Health Technol Assess 2021; 25:1-52. [PMID: 34505829 PMCID: PMC8450778 DOI: 10.3310/hta25530] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The use of placebo comparisons for randomised trials assessing the efficacy of surgical interventions is increasingly being considered. However, a placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. OBJECTIVES To provide a summary of knowledge on placebo controls in surgical trials and to summarise any recommendations for designers, evaluators and funders of placebo-controlled surgical trials. DESIGN To carry out a state-of-the-art workshop and produce a corresponding report involving key stakeholders throughout. SETTING A workshop to discuss and summarise the existing knowledge and to develop the new guidelines. RESULTS To assess what a placebo control entails and to assess the understanding of this tool in the context of surgery is considered, along with when placebo controls in surgery are acceptable (and when they are desirable). We have considered ethics arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be carried out and interpreted. The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with a high risk of bias, particularly because of the placebo effect. CONCLUSIONS The use of placebo controls is justified in randomised controlled trials of surgical interventions provided that there is a strong scientific and ethics rationale. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. An outline for best practice was produced in the form of the Applying Surgical Placebo in Randomised Evaluations (ASPIRE) guidelines for those considering the use of a placebo control in a surgical randomised controlled trial. LIMITATIONS Although the workshop participants involved international members, the majority of participants were from the UK. Therefore, although every attempt was made to make the recommendations applicable to all health systems, the guidelines may, unconsciously, be particularly applicable to clinical practice in the UK NHS. FUTURE WORK Future work should evaluate the use of the ASPIRE guidelines in making decisions about the use of a placebo-controlled surgical trial. In addition, further work is required on the appropriate nomenclature to adopt in this space. FUNDING Funded by the Medical Research Council UK and the National Institute for Health Research as part of the Medical Research Council-National Institute for Health Research Methodology Research programme.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Jane M Blazeby
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Charles Weijer
- Departments of Medicine, Epidemiology and Biostatistics, and Philosophy, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, University of Birmingham, Queen Elizabeth Hospital Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Ian Harris
- Faculty of Medicine, South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Orthopedics, Clinical Epidemiology Unit, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research, NIHR Bristol and Weston Biomedical Research Centre, Population Health Sciences, University of Bristol, Bristol, UK
| | - Amar Rangan
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- Department of Health Sciences, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Barnaby C Reeves
- Clinical Trials Evaluation Unit Bristol Medical School, University of Bristol, Bristol Royal Infirmary, Bristol, UK
| | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, University of Oxford, John Radcliffe Hospital, Oxford, UK
| | | | - Naomi Lee
- Editorial Department, The Lancet, London, UK
| | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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21
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Ladha KS, Cuthbertson BH, Abbott TEF, Pearse RM, Wijeysundera DN. Functional decline after major elective non-cardiac surgery: a multicentre prospective cohort study. Anaesthesia 2021; 76:1593-1599. [PMID: 34254670 DOI: 10.1111/anae.15537] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/04/2021] [Indexed: 11/28/2022]
Abstract
Self-reported postoperative functional recovery is an important patient-centred outcome that is rarely measured or considered in research and decision-making. We conducted a secondary analysis of the measurement of exercise tolerance before surgery (METS) study for associations of peri-operative variables with functional decline after major non-cardiac surgery. Patients who were at least 40 years old, had or were at risk of, coronary artery disease and who were scheduled for non-cardiac surgery were recruited. Primary outcome was a reduction in mobility, self-care or ability to conduct usual activities (EuroQol 5 dimension) from before surgery to 30 days and 1 year after surgery. A decline in at least one function was reported by 523/1309 (40%) participants at 30 days and 320/1309 (24%) participants at 1 year. Participants who reported higher pre-operative Duke Activity Status indices more often reported functional decline 30 days after surgery and less often reported functional decline 1 year after surgery. The odds ratios (95%CI) of functional decline 30 days and 1 year after surgery with moderate or severe postoperative complications were 1.46 (1.02-2.09), p = 0.037 and 1.44 (0.98-2.13), p = 0.066. Discrimination of participants who reported functional decline 30 days and 1 year after surgery were poor (c-statistic 0.61 and 0.63, respectively). In summary, one quarter of participants reported functional decline up to one postoperative year.
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Affiliation(s)
- K S Ladha
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,University of Toronto, Toronto, ON, Canada
| | - B H Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - T E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - R M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - D N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
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22
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Cuthbertson BH, Goddard SL, Lorencatto F, Koo E, Rose L, Fan E, Kho ME, Needham DM, Rubenfeld GD, Francis JJ. Barriers and Facilitators to Early Rehabilitation in the ICU: A Theory Driven Delphi Study. Crit Care Med 2021; 48:e1171-e1178. [PMID: 33003076 DOI: 10.1097/ccm.0000000000004580] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES There is conflicting evidence for the effectiveness of early rehabilitation in the intensive care and marked variation in rates of implementation in practice. We aimed to identify barriers and facilitators to early rehabilitation in mechanically ventilated patients and their relevance to practice, as perceived by key ICU clinicians across North America. DESIGN A Delphi study using the Theoretical Domains Framework, consisting of an initial qualitative round and subsequent quantitative rounds, was conducted to gather clinician agreement and perceived importance of barriers and facilitators to early rehabilitation. The survey included questions on the range of individual, sociocultural, and broader organizational influence on behaviors. SETTING Clinical practice in North America. SUBJECTS Four clinician groups (intensive care physicians, nurses, therapists, and respiratory therapists). INTERVENTIONS A three-round Delphi study. MEASUREMENTS AND MAIN RESULTS Fifty of 74 (67%) of invited clinicians completed the study. Agreement and consensus with Delphi survey items were high in both rounds within and between professional groups. Agreement was highest for items related to the domain "Beliefs about Consequences" (e.g., mortality reduction) and lowest for items related to the domain "Behavioral Regulation" (e.g., team discussion of barriers). Beliefs expressed about improved mortality and improvements in a variety of other long-term outcomes were not consistent with the current evidence base. Individual agreement scores changed very little from Round 2 to Round 3 of the Delphi, suggesting stability of beliefs and existing consensus. CONCLUSIONS This study identified a wide range of beliefs about early rehabilitation that may influence provider behavior and the success and appropriateness of further implementation. The apparent inconsistency between the optimism of stakeholders regarding mortality reductions and a low level of implementation reported elsewhere represent the most major challenge to future implementation success. Other foci for future implementation work include planning, barriers, feedback, and education of staff.
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Affiliation(s)
- Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Centre for Behaviour Change, University College London, London, United Kingdom.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.,Provincial Centre for Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada.,School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada.,Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD.,School of Health Sciences, City University of London, London, United Kingdom
| | - Shannon L Goddard
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Fabiana Lorencatto
- Centre for Behaviour Change, University College London, London, United Kingdom
| | - Ellen Koo
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Louise Rose
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, United Kingdom.,Provincial Centre for Weaning Excellence, Toronto East General Hospital, Toronto, ON, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Michelle E Kho
- School of Rehabilitation Science, McMaster University, Hamilton, ON, Canada
| | - Dale M Needham
- Division of Pulmonary and Critical Care Medicine, Department of Physical Medicine and Rehabilitation, Johns Hopkins University, Baltimore, MD
| | - Gordon D Rubenfeld
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jill J Francis
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,School of Health Sciences, City University of London, London, United Kingdom
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23
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Tillmann BW, Fu L, Hill AD, Scales DC, Fowler RA, Cuthbertson BH, Wunsch H. Acute healthcare resource utilization by age: A cohort study. PLoS One 2021; 16:e0251877. [PMID: 34010313 PMCID: PMC8133481 DOI: 10.1371/journal.pone.0251877] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 05/05/2021] [Indexed: 11/29/2022] Open
Abstract
Background Granular data related to the likelihood of individuals of different ages accessing acute and critical care services over time is lacking. Methods We used population-based, administrative data from Ontario to identify residents of specific ages (20, 30, 40, etc. to 100) on January 1st every year from 1995–2019. We assessed rates of emergency department (ED) visits (2003–19), hospitalizations, intensive care unit (ICU) admissions (2003–19), and mechanical ventilation. Findings Overall the 25-year study period, ED were the most common acute healthcare encounter with 100-year-olds having the lowest rate (138.7/1,000) and 90-year-olds the highest (378.5/1,000). Rates of hospitalization ranged from 24.2/1,000 for those age 20 up to 224.9/1,000 for those age 90. Rates of ICU admission and mechanical ventilation were lowest for those age 20 (1.0 and 0.4/1,000), more than tripled by age 50 (3.3 and 1.7/1,000) and peaked at age 80 (20.3 and 10.1/1,000). Over time rates of ED visits increased (164.3 /1,000 in 2003 vs 199.1 /1,000 in 2019) as did rates of invasive mechanical ventilation (2.0/1,000 in 1995 vs 2.9/1,000 in 2019), whereas rates of ICU admission remained stable (4.8/1,000 in 2003 vs 4.9/1,000 in 2019) and hospitalization declined (66.8/1,000 in 1995 vs 51.5/1,000 in 2019). Age stratified analysis demonstrated that rates of ED presentation increased for those age 70 and younger while hospitalization decreased for all age groups; ICU admission and mechanical ventilation rates changed variably by age, with increasing rates demonstrated primarily among people under the age of 50. Interpretation Rates of hospitalizations have decreased over time across all age groups, whereas rates of ED presentation, ICU admissions, and mechanical ventilation have increased, primarily driven by younger adults. These findings suggest that although the delivery of healthcare may be moving away from inpatient medicine, there is a growing population of young adults requiring significant healthcare resources.
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Affiliation(s)
- Bourke W. Tillmann
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- * E-mail:
| | - Longdi Fu
- ICES, University of Toronto, Toronto, Ontario, Canada
| | - Andrea D. Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Damon C. Scales
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Ontario, Canada
| | - Robert A. Fowler
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Brian H. Cuthbertson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- ICES, University of Toronto, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
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Ramos RJ, Ladha KS, Cuthbertson BH, Shulman MA, Myles PS, Wijeysundera DN. Association of six-minute walk test distance with postoperative complications in non-cardiac surgery: a secondary analysis of a multicentre prospective cohort study. Can J Anaesth 2021; 68:514-529. [PMID: 33442834 PMCID: PMC7932965 DOI: 10.1007/s12630-020-01909-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The six-minute walk test (6MWT) is a simple and valid test for assessing cardiopulmonary fitness. Nevertheless, the relationship between preoperative 6MWT distance and postoperative complications is uncertain. We conducted a secondary analysis of the 6MWT nested cohort substudy of the Measurement of Exercise Tolerance before Surgery study to determine if 6MWT distance predicts postoperative complications or death. METHODS This analysis included 545 adults (≥ 40 yr) who were at elevated cardiac risk and had elective inpatient non-cardiac surgery at 15 hospitals in Canada, Australia, and New Zealand. Each participant performed a preoperative 6MWT and was followed for 30 days after surgery. The primary outcome was moderate or severe in-hospital complications. The secondary outcome was 30-day death or myocardial injury. Multivariable logistic regression modelling was used to characterize the adjusted association of 6MWT distance with these outcomes. RESULTS Seven participants (1%) terminated their 6MWT sessions early because of lower limb pain, dyspnea, or dizziness. Eighty-one (15%) participants experienced moderate or severe complications and 69 (13%) experienced 30-day myocardial injury or death. Decreased 6MWT distance was associated with increased odds of moderate or severe complications (adjusted odds ratio, 1.32 per 100 m decrease; 95% confidence interval, 1.01 to 1.73; P = 0.045). There was no association of 6MWT distance with myocardial injury or 30-day death (non-linear association; P = 0.49). CONCLUSION Preoperative 6MWT distance had a modest association with moderate or severe complications after inpatient non-cardiac surgery. Further studies are needed to determine the optimal role of the 6MWT as an objective exercise test for informing preoperative risk stratification.
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Affiliation(s)
- Ryan J Ramos
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Karim S Ladha
- Department of Anesthesia, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centres, Toronto, ON, Canada
| | - Mark A Shulman
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Duminda N Wijeysundera
- Department of Anesthesia, St Michael's Hospital, 30 Bond Street, Toronto, ON, M5B 1W8, Canada.
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.
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25
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Santa Mina D, Sellers D, Au D, Alibhai SMH, Clarke H, Cuthbertson BH, Darling G, El Danab A, Govindarajan A, Ladha K, Matthew AG, McCluskey S, Ng KA, Quereshy F, Karkouti K, Randall IM. A Pragmatic Non-Randomized Trial of Prehabilitation Prior to Cancer Surgery: Study Protocol and COVID-19-Related Adaptations. Front Oncol 2021; 11:629207. [PMID: 33777780 PMCID: PMC7987917 DOI: 10.3389/fonc.2021.629207] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 11/13/2020] [Accepted: 01/29/2021] [Indexed: 12/13/2022] Open
Abstract
Background Experimental data highlight the potential benefits and health system cost savings related to surgical prehabilitation; however, adequately powered randomized controlled trial (RCT) data remain nascent. Emerging prehabilitation services may be informed by early RCT data but can be limited in informing real-world program development. Pragmatic trials emphasize external validity and generalizability to understand and advise intervention development and implementation in clinical settings. This paper presents the methodology of a pragmatic prehabilitation trial to complement emerging phase III clinical trials and inform implementation strategies. Methods This is a pilot pragmatic clinical trial conducted in a large academic hospital in Toronto, Ontario, Canada to assess feasibility of clinical implementation and derive estimates of effectiveness. Feasibility data include program referral rates, enrolment and attrition, intervention adherence and safety, participant satisfaction, and barriers and facilitators to programming. The study aims to receive 150 eligible referrals for adult, English-speaking, preoperative oncology patients with an identified indication for prehabilitation (e.g., frailty, deconditioning, malnutrition, psychological distress). Study participants undergo a baseline assessment and shared-decision making regarding the intervention setting: either facility-based prehabilitation or home-based prehabilitation. In both scenarios, participants receive an individualized exercise prescription, stress-reduction psychological support, nutrition counseling, and protein supplementation, and if appropriate, smoking cessation program referrals. Secondary objectives include estimating intervention effects at the week prior to surgery and 30 and 90 days postoperatively. Outcomes include surgical complications, postoperative length of stay, mortality, hospital readmissions, physical fitness, psychological well-being, and quality of life. Data from participants who decline the intervention but consent for research-related access to health records will serve as comparators. The COVID-19 pandemic required the introduction of a 'virtual program' using only telephone or internet-based communication for screening, assessments, or intervention was introduced. Conclusion This pragmatic trial will provide evidence on the feasibility and viability of prehabilitation services delivered under usual clinical conditions. Study amendments due to the COVID-19 pandemic are presented as strategies to maintain prehabilitation research and services to potentially mitigate the consequences of extended surgery wait times.
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Affiliation(s)
- Daniel Santa Mina
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada.,Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Daniel Sellers
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Darren Au
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Shabbir M H Alibhai
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Division of General Internal Medicine and Geriatrics, University Health Network, Toronto, ON, Canada
| | - Hance Clarke
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Gail Darling
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Alaa El Danab
- Clinical Nutrition, Princess Margaret Cancer Centre, University Health Network, Toronto, ON, Canada
| | - Anand Govindarajan
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgery, Sinai Health System, Toronto, ON, Canada
| | - Karim Ladha
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada
| | - Andrew G Matthew
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Stuart McCluskey
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Karen A Ng
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Geriatrics, Sinai Health System, Toronto, ON, Canada
| | - Fayez Quereshy
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Surgical Oncology, Princess Margaret Cancer Centre, Toronto, ON, Canada
| | - Keyvan Karkouti
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Ian M Randall
- Faculty of Medicine, University of Toronto, Toronto, ON, Canada.,Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
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26
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Wunsch H, Hill AD, Bosch N, Adhikari NKJ, Rubenfeld G, Walkey A, Ferreyro BL, Tillmann BW, Amaral ACKB, Scales DC, Fan E, Cuthbertson BH, Fowler RA. Comparison of 2 Triage Scoring Guidelines for Allocation of Mechanical Ventilators. JAMA Netw Open 2020; 3:e2029250. [PMID: 33315112 PMCID: PMC7737087 DOI: 10.1001/jamanetworkopen.2020.29250] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
IMPORTANCE In the current setting of the coronavirus disease 2019 pandemic, there is concern for the possible need for triage criteria for ventilator allocation; to our knowledge, the implications of using specific criteria have never been assessed. OBJECTIVE To determine which and how many admissions to intensive care units are identified as having the lowest priority for ventilator allocation using 2 distinct sets of proposed triage criteria. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study conducted in spring 2020 used data collected from US hospitals and reported in the Philips eICU Collaborative Research Database. Adult admissions (N = 40 439) to 291 intensive care units from 2014 to 2015 who received mechanical ventilation and were not elective surgery patients were included. EXPOSURES New York State triage criteria and original triage criteria proposed by White and Lo. MAIN OUTCOMES AND MEASURES Sequential Organ Failure Assessment (SOFA) scores were calculated for admissions. The proportion of patients who met initial criteria for the lowest level of priority for mechanical ventilation using each set of criteria and their characteristics and outcomes were assessed. Agreement was compared between the 2 sets of triage criteria, recognizing differences in stated criteria aims. RESULTS Among 40 439 intensive care unit admissions of patients who received mechanical ventilation, the mean (SD) age was 62.6 (16.6) years, 54.9% were male, and the mean (SD) SOFA score was 4.5 (3.7). Using the New York State triage criteria, 8.9% (95% CI, 8.7%-9.2%) were in the lowest priority category; these lowest priority admissions had a mean (SD) age of 62.9 (16.6) years, used a median (interquartile range) of 57.3 (20.1-133.5) ventilator hours each, and had a hospital survival rate of 38.6% (95% CI, 37.0%-40.2%). Using the White and Lo triage criteria, 4.3% (95% CI, 4.1%-4.5%) were in the lowest priority category; these admissions had a mean (SD) age of 68.6 (13.2) years, used a median (interquartile range) of 61.7 (24.3-142.8) ventilator hours each, and had a hospital survival rate of 56.2% (95% CI, 53.8%-58.7%). Only 655 admissions (1.6%) were in the lowest priority category for both guidelines, with the κ statistic for agreement equal to 0.20 (95% CI, 0.18-0.21). CONCLUSIONS AND RELEVANCE Use of 2 initially proposed ventilator triage guidelines identified approximately 1 in every 10 to 25 admissions as having the lowest priority for ventilator allocation, with little agreement. Clinical assessment of different potential criteria for triage decisions in critically ill populations is important to ensure valid and equitable allocation of resources.
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Affiliation(s)
- Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, Columbia University, New York, New York
| | - Andrea D. Hill
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Nicholas Bosch
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Neill K. J. Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gordon Rubenfeld
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Allan Walkey
- Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Bruno L. Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Bourke W. Tillmann
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andre C. K. B. Amaral
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Damon C. Scales
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute of St Michael’s Hospital, Toronto, Ontario, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- University Health Network and Sinai Health System, Toronto, Ontario, Canada
| | - Brian H. Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Robert A. Fowler
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Sunnybrook Research Institute, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
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27
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May SM, Abbott TEF, Del Arroyo AG, Reyes A, Martir G, Stephens RCM, Brealey D, Cuthbertson BH, Wijeysundera DN, Pearse RM, Ackland GL. MicroRNA signatures of perioperative myocardial injury after elective noncardiac surgery: a prospective observational mechanistic cohort study. Br J Anaesth 2020; 125:661-671. [PMID: 32718726 PMCID: PMC7678162 DOI: 10.1016/j.bja.2020.05.066] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/08/2020] [Accepted: 05/31/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Elevated plasma or serum troponin, indicating perioperative myocardial injury (PMI), is common after noncardiac surgery. However, underlying mechanisms remain unclear. Acute coronary syndrome (ACS) is associated with the early appearance of circulating microRNAs, which regulate post-translational gene expression. We hypothesised that if PMI and ACS share pathophysiological mechanisms, common microRNA signatures should be evident. METHODS We performed a nested case control study of samples obtained before and after noncardiac surgery from patients enrolled in two prospective observational studies of PMI (postoperative troponin I/T>99th centile). In cohort one, serum microRNAs were compared between patients with or without PMI, matched for age, gender, and comorbidity. Real-time polymerase chain reaction quantified (qRT-PCR) relative microRNA expression (cycle quantification [Cq] threshold <37) before and after surgery for microRNA signatures associated with ACS, blinded to PMI. In cohort two, we analysed (EdgeR) microRNA from plasma extracellular vesicles using next-generation sequencing (Illumina HiSeq 500). microRNA-messenger RNA-function pathway analysis was performed (DIANA miRPath v3.0/TopGO). RESULTS MicroRNAs were detectable in all 59 patients (median age 67 yr [61-75]; 42% male), who had similar clinical characteristics independent of developing PMI. In cohort one, serum microRNA expression increased after surgery (mean fold-change) hsa-miR-1-3p: 3.99 (95% confidence interval [CI: 1.95-8.19]; hsa-miR-133-3p: 5.67 [95% CI: 2.94-10.91]; P<0.001). These changes were not associated with PMI. Bioinformatic analysis of differentially expressed microRNAs from cohorts one (n=48) and two (n=11) identified pathways associated with adrenergic stress and calcium dysregulation, rather than ischaemia. CONCLUSIONS Circulating microRNAs associated with cardiac ischaemia were universally elevated in patients after surgery, independent of development of myocardial injury.
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Affiliation(s)
- Shaun M May
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Tom E F Abbott
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Ana G Del Arroyo
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Anna Reyes
- University College London NHS Hospitals Trust, London, UK
| | - Gladys Martir
- University College London NHS Hospitals Trust, London, UK
| | | | - David Brealey
- University College London NHS Hospitals Trust, London, UK
| | - Brian H Cuthbertson
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Science Centre, Toronto, ON, Canada
| | - Duminda N Wijeysundera
- Department of Anaesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Rupert M Pearse
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Gareth L Ackland
- Translational Medicine & Therapeutics, William Harvey Research Institute, Queen Mary University of London, London, UK.
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Affiliation(s)
- Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Center, 2075 Bayview Avenue, Toronto, Canada.
- Inter-Departmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada.
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.
| | - Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
- Tory Trauma Program, Sunnybrook Health Sciences Center, Toronto, Canada
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29
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Vijayaraghavan BKT, Willaert X, Cuthbertson BH. Cost-effectiveness analysis should be mandatory in clinical-effectiveness research. CMAJ 2020; 191:E1140. [PMID: 31615824 DOI: 10.1503/cmaj.73298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
| | - Xavier Willaert
- Consultant, Department of Critical Care Medicine, ZOL, Genk, Belgium
| | - Brian H Cuthbertson
- Professor of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ont
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30
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Beard DJ, Campbell MK, Blazeby JM, Carr AJ, Weijer C, Cuthbertson BH, Buchbinder R, Pinkney T, Bishop FL, Pugh J, Cousins S, Harris IA, Lohmander LS, Blencowe N, Gillies K, Probst P, Brennan C, Cook A, Farrar-Hockley D, Savulescu J, Huxtable R, Rangan A, Tracey I, Brocklehurst P, Ferreira ML, Nicholl J, Reeves BC, Hamdy F, Rowley SC, Cook JA. Considerations and methods for placebo controls in surgical trials (ASPIRE guidelines). Lancet 2020; 395:828-838. [PMID: 32145797 DOI: 10.1016/s0140-6736(19)33137-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Revised: 11/13/2019] [Accepted: 12/06/2019] [Indexed: 01/09/2023]
Abstract
Placebo comparisons are increasingly being considered for randomised trials assessing the efficacy of surgical interventions. The aim of this Review is to provide a summary of knowledge on placebo controls in surgical trials. A placebo control is a complex type of comparison group in the surgical setting and, although powerful, presents many challenges. This Review outlines what a placebo control entails and present understanding of this tool in the context of surgery. We consider when placebo controls in surgery are acceptable (and when they are desirable) in terms of ethical arguments and regulatory requirements, how a placebo control should be designed, how to identify and mitigate risk for participants in these trials, and how such trials should be done and interpreted. Use of placebo controls is justified in randomised controlled trials of surgical interventions provided there is a strong scientific and ethical rationale. Surgical placebos might be most appropriate when there is poor evidence for the efficacy of the procedure and a justified concern that results of a trial would be associated with high risk of bias, particularly because of the placebo effect. Feasibility work is recommended to optimise the design and implementation of randomised controlled trials. This Review forms an outline for best practice and provides guidance, in the form of the Applying Surgical Placebo in Randomised Evaluations (known as ASPIRE) checklist, for those considering the use of a placebo control in a surgical randomised controlled trial.
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Affiliation(s)
- David J Beard
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK.
| | - Marion K Campbell
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, UK
| | - Jane M Blazeby
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Andrew J Carr
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Charles Weijer
- Rotman Institute of Philosophy, Western Interdisciplinary Research Building, Western University, London, ON, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Rachelle Buchbinder
- Cabrini-Monash Department of Clinical Epidemiology, Cabrini Institute and Monash University, Melbourne, VIC, Australia
| | - Thomas Pinkney
- Academic Department of Surgery, Heritage Building, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, UK
| | - Felicity L Bishop
- Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK
| | - Jonathan Pugh
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Sian Cousins
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Ian A Harris
- Ingham Institute for Applied Medical Research, South Western Sydney Clinical School, The University of New South Wales, Sydney, NSW, Australia
| | - L Stefan Lohmander
- Department of Clinical Sciences Lund, Department of Orthopaedics Lund, Lund University, Lund, Sweden
| | - Natalie Blencowe
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Katie Gillies
- Health Services Research Unit, Health Sciences Building, University of Aberdeen, Aberdeen, UK
| | - Pascal Probst
- Department of General, Visceral and Transplantation Surgery, University of Heidelberg, Heidelberg, Germany
| | | | - Andrew Cook
- Wessex Institute, University of Southampton, Southampton, UK; University Hospital Southampton National Health Service Foundation Trust, Southampton, UK
| | | | - Julian Savulescu
- The Oxford Uehiro Centre for Practical Ethics, University of Oxford, Oxford, UK
| | - Richard Huxtable
- Centre for Surgical Research Population Health Sciences, Beacon House, University of Bristol, Bristol
| | - Amar Rangan
- Department of Health Sciences, Seebohm Rowntree Building, University of York, York, UK
| | - Irene Tracey
- Nuffield Department of Clinical Neurosciences, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Peter Brocklehurst
- Birmingham Clinical Trials Unit, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Manuela L Ferreira
- Faculty of Medicine and Health, Institute of Bone and Joint Research, Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Jon Nicholl
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Freddie Hamdy
- Nuffield Department of Surgical Sciences, John Radcliffe Hospital, University of Oxford, Oxford, UK; Old Road Campus Research Building, University of Oxford, Oxford, UK
| | | | - Jonathan A Cook
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Botnar Research Centre, University of Oxford, Oxford, UK
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Wittekamp BHJ, Oostdijk EAN, Cuthbertson BH, Brun-Buisson C, Bonten MJM. Selective decontamination of the digestive tract (SDD) in critically ill patients: a narrative review. Intensive Care Med 2019; 46:343-349. [PMID: 31820032 PMCID: PMC7042187 DOI: 10.1007/s00134-019-05883-9] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Accepted: 11/26/2019] [Indexed: 01/06/2023]
Abstract
Selective decontamination of the digestive tract (SDD) is an infection prevention measure for intensive care unit (ICU) patients that was proposed more than 30 years ago, and that is currently considered standard of care in the Netherlands, but only used sporadically in ICUs in other countries. In this narrative review, we first describe the rationale of the individual components of SDD and then review the evidence base for patient-centered outcomes, where we distinguish ICUs with low prevalence of antibiotic resistance from ICUs with moderate–high prevalence of resistance. In settings with low prevalence of antibiotic resistance, SDD has been associated with improved patient outcome in three cluster-randomized studies. These benefits were not confirmed in a large international cluster-randomized study in settings with moderate-to-high prevalence of antibiotic resistance. There is no evidence that SDD increases antibiotic resistance. We end with future directions for research.
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Affiliation(s)
- Bastiaan H J Wittekamp
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - Evelien A N Oostdijk
- Department of Intensive Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, University Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - Christian Brun-Buisson
- Biostatistics, Biomathematics, Pharmacoepidemiology and Infectious Diseases (B2PHI), Inserm UVSQ, Institut Pasteur, Paris, France
| | - Marc J M Bonten
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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32
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Ackland GL, Abbott TEF, Minto G, Clark M, Owen T, Prabhu P, May SM, Reynolds JA, Cuthbertson BH, Wijeysundera D, Pearse RM. Correction: Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies. PLoS One 2019; 14:e0226379. [PMID: 31805170 PMCID: PMC6894770 DOI: 10.1371/journal.pone.0226379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Angriman F, Ferreyro BL, Donaldson L, Cuthbertson BH, Ferguson ND, Bollen CW, Bachman TE, Lamontagne F, Adhikari NKJ. The harm of high-frequency oscillatory ventilation (HFOV) in ARDS is not related to a high baseline risk of acute cor pulmonale or short-term changes in hemodynamics. Intensive Care Med 2019; 46:132-134. [PMID: 31664500 PMCID: PMC7223916 DOI: 10.1007/s00134-019-05806-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Federico Angriman
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Bruno L Ferreyro
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada
| | - Lachlan Donaldson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Niall D Ferguson
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Department of Medicine, Sinai Health System and University Health Network, Toronto, Canada.,Research Institute, Toronto General Hospital, Toronto, Canada
| | - Casper W Bollen
- Pediatric Intensive Care Unit, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Thomas E Bachman
- Department of Biomedical Technology, School of Biomedical Engineering, Czech Technical University in Prague, Prague, Czech Republic
| | | | - Neill K J Adhikari
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada. .,Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
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Dale CM, Rose L, Carbone S, Smith OM, Burry L, Fan E, Amaral ACKB, McCredie VA, Pinto R, Quiñonez CR, Sutherland S, Scales DC, Cuthbertson BH. Protocol for a multi-centered, stepped wedge, cluster randomized controlled trial of the de-adoption of oral chlorhexidine prophylaxis and implementation of an oral care bundle for mechanically ventilated critically ill patients: the CHORAL study. Trials 2019; 20:603. [PMID: 31651364 PMCID: PMC6814100 DOI: 10.1186/s13063-019-3673-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 03/12/2019] [Accepted: 08/21/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Routine application of chlorhexidine oral rinse is recommended to reduce risk of ventilator-associated pneumonia (VAP) in mechanically ventilated patients. Recent reappraisal of the evidence from two meta-analyses suggests chlorhexidine may cause excess mortality in non-cardiac surgery patients and does not reduce VAP. Mechanisms for possible excess mortality are unclear. The CHORAL study will evaluate the impact of de-adopting chlorhexidine and implementing an oral care bundle (excluding chlorhexidine) on mortality, infection-related ventilator-associated complications (IVACs), and oral health status. METHODS The CHORAL study is a stepped wedge, cluster randomized controlled trial in six academic intensive care units (ICUs) in Toronto, Canada. Clusters (ICU) will be randomly allocated to six sequential steps over a 14-month period to de-adopt oral chlorhexidine and implement a standardized oral care bundle (oral assessment, tooth brushing, moisturization, and secretion removal). On study commencement, all clusters begin with a control period in which the standard of care is oral chlorhexidine. Clusters then begin crossover from control to intervention every 2 months according to the randomization schedule. Participants include all mechanically ventilated adults eligible to receive the standardized oral care bundle. The primary outcome is ICU mortality; secondary outcomes are IVACs and oral health status. We will determine demographics, antibiotic usage, mortality, and IVAC rates from a validated local ICU clinical registry. With six clusters and 50 ventilated patients on average each month per cluster, we estimate that 4200 patients provide 80% power after accounting for intracluster correlation to detect an absolute reduction in mortality of 5.5%. We will analyze our primary outcome of mortality using a generalized linear mixed model adjusting for time to account for secular trends. We will conduct a process evaluation to determine intervention fidelity and to inform interpretation of the trial results. DISCUSSION The CHORAL study will inform understanding of the effectiveness of de-adoption of oral chlorhexidine and implementation of a standardized oral care bundle for decreasing ICU mortality and IVAC rates while improving oral health status. Our process evaluation will inform clinicians and decision makers about intervention delivery to support future de-adoption if justified by trial results. TRIAL REGISTRATION ClinicalTrials.gov, NCT03382730 . Registered on December 26, 2017.
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Affiliation(s)
- Craig M Dale
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Centre, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada
| | - Louise Rose
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College, London, UK
| | - Sarah Carbone
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada
| | - Orla M Smith
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.,Department of Critical Care, St. Michael's Hospital, Toronto, Canada.,Li Ka Shing Knowledge Institute, Toronto, Canada
| | - Lisa Burry
- Department of Pharmacy, Mount Sinai Hospital, Toronto, Canada.,Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Victoria A McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network, Toronto, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | | | - Susan Sutherland
- Department of Dentistry, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Damon C Scales
- Sunnybrook Research Institute, Toronto, Canada.,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Sunnybrook Research Institute, Toronto, Canada. .,Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
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35
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Mooney JF, Croal BL, Cassidy S, Lee VW, Chow CK, Cuthbertson BH, Hillis GS. Relative value of cystatin C and creatinine-based estimates of glomerular filtration rate in predicting long-term mortality after cardiac surgery: a cohort study. BMJ Open 2019; 9:e029379. [PMID: 31530601 PMCID: PMC6756440 DOI: 10.1136/bmjopen-2019-029379] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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: 12/12/2022] Open
Abstract
OBJECTIVE Renal dysfunction predicts an increased risk of both early and long-term mortality after cardiac surgery. Cystatin C enables glomerular filtration rate (GFR) to be estimated accurately and may be superior in this regard to creatinine-based estimates. We hypothesised, therefore, that cystatin C and derived estimates of GFR would independently predict long-term survival after cardiac surgery and would be superior in this respect to traditional estimates of GFR. The current study tests this hypothesis in a large and well-characterised cohort of patients. DESIGN A prospective cohort study. SETTING Regional cardiothoracic centre in Northeast Scotland. PARTICIPANTS 1010 patients undergoing non-emergent cardiac surgery between 2004 and 2007. Serum creatinine and cystatin C levels were measured preoperatively and demographic and clinical variables were recorded. PRIMARY OUTCOME MEASURE All-cause mortality, established from the National Records of Scotland. RESULTS The median duration of follow-up after surgery was 9.7 years (IQR 8.9-10.6 years), during which 297 participants died. Preoperative creatinine and cystatin C levels and estimates of GFR derived from these were all strong predictors of death using Cox regression and remained independently predictive after adjustment for the logistic European System for Cardiac Operative Risk Evaluation, a well-validated clinical risk score and a range of other clinical predictors. Cystatin C-based measures were superior to creatinine-based estimates of GFR. CONCLUSIONS Cystatin C and creatinine derived eGFR are powerful and independent predictors of long-term mortality following cardiac surgery. Estimates of GFR derived from cystatin C convey superior prognostic information to conventional creatinine-based estimates, but the observed differences are modest.
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Affiliation(s)
- John F Mooney
- Cardiovascular Division, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Bernard L Croal
- Department of Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Sean Cassidy
- Department of Biochemistry, Aberdeen Royal Infirmary, Aberdeen, UK
| | - Vincent W Lee
- Westmead Institute for Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Clara K Chow
- Cardiovascular Division, The George Institute for Global Health, Sydney, New South Wales, Australia
- Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
- Westmead Applied Research Centre, Westmead Hospital, Sydney, New South Wales, Australia
| | - Brian H Cuthbertson
- Critical Care Medicine, Sunnnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Graham S Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Faculty of Health and Medical Sciences, University of Western Australia, Perth, Western Australia, Australia
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36
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Ackland GL, Abbott TEF, Minto G, Clark M, Owen T, Prabhu P, May SM, Reynolds JA, Cuthbertson BH, Wijesundera D, Pearse RM. Heart rate recovery and morbidity after noncardiac surgery: Planned secondary analysis of two prospective, multi-centre, blinded observational studies. PLoS One 2019; 14:e0221277. [PMID: 31433825 PMCID: PMC6703687 DOI: 10.1371/journal.pone.0221277] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 08/02/2019] [Indexed: 12/02/2022] Open
Abstract
Background Impaired cardiac vagal function, quantified preoperatively as slower heart rate recovery (HRR) after exercise, is independently associated with perioperative myocardial injury. Parasympathetic (vagal) dysfunction may also promote (extra-cardiac) multi-organ dysfunction, although perioperative data are lacking. Assuming that cardiac vagal activity, and therefore heart rate recovery response, is a marker of brainstem parasympathetic dysfunction, we hypothesized that impaired HRR would be associated with a higher incidence of morbidity after noncardiac surgery. Methods In two prospective, blinded, observational cohort studies, we established the definition of impaired vagal function in terms of the HRR threshold that is associated with perioperative myocardial injury (HRR ≤ 12 beats min-1 (bpm), 60 seconds after cessation of cardiopulmonary exercise testing. The primary outcome of this secondary analysis was all-cause morbidity three and five days after surgery, defined using the Post-Operative Morbidity Survey. Secondary outcomes of this analysis were type of morbidity and time to become morbidity-free. Logistic regression and Cox regression tested for the association between HRR and morbidity. Results are presented as odds/hazard ratios [OR or HR; (95% confidence intervals). Results 882/1941 (45.4%) patients had HRR≤12bpm. All-cause morbidity within 5 days of surgery was more common in 585/822 (71.2%) patients with HRR≤12bpm, compared to 718/1119 (64.2%) patients with HRR>12bpm (OR:1.38 (1.14–1.67); p = 0.001). HRR≤12bpm was associated with more frequent episodes of pulmonary (OR:1.31 (1.05–1.62);p = 0.02)), infective (OR:1.38 (1.10–1.72); p = 0.006), renal (OR:1.91 (1.30–2.79); p = 0.02)), cardiovascular (OR:1.39 (1.15–1.69); p<0.001)), neurological (OR:1.73 (1.11–2.70); p = 0.02)) and pain morbidity (OR:1.38 (1.14–1.68); p = 0.001) within 5 days of surgery. Conclusions Multi-organ dysfunction is more common in surgical patients with cardiac vagal dysfunction, defined as HRR ≤ 12 bpm after preoperative cardiopulmonary exercise testing. Clinical trial registry ISRCTN88456378.
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Affiliation(s)
- Gareth L. Ackland
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
- * E-mail:
| | - Tom E. F. Abbott
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Gary Minto
- Department of Anaesthesia, Derriford Hospital, Plymouth Hospitals NHS Trust; Peninsula Schools of Medicine and Dentistry, Plymouth University, Plymouth, United Kingdom
| | - Martin Clark
- Department of Anaesthesia, Royal Bournemouth Hospital, Bournemouth, United Kingdom
| | - Thomas Owen
- Department of Anaesthesia, Royal Preston Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, United Kingdom
| | - Pradeep Prabhu
- Department of Anaesthesia, Royal Surrey County Hospital, Guildford, United Kingdom
| | - Shaun M. May
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Joseph A. Reynolds
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
| | - Brian H. Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Duminda Wijesundera
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
- Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Rupert M. Pearse
- William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Abbott TEF, Pearse RM, Beattie WS, Phull M, Beilstein C, Raj A, Grocott MPW, Cuthbertson BH, Wijeysundera D, Ackland GL. Chronotropic incompetence and myocardial injury after noncardiac surgery: planned secondary analysis of a prospective observational international cohort study. Br J Anaesth 2019; 123:17-26. [PMID: 31029407 PMCID: PMC6676775 DOI: 10.1016/j.bja.2019.03.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 02/12/2019] [Accepted: 03/03/2019] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Physiological measures of heart failure are common in surgical patients, despite the absence of a diagnosis. Heart rate (HR) increases during exercise are frequently blunted in heart failure (termed chronotropic incompetence), which primarily reflects beta-adrenoreceptor dysfunction. We examined whether chronotropic incompetence was associated with myocardial injury after noncardiac surgery. METHODS This was a predefined analysis of an international cohort study where participants aged ≥40 yr underwent symptom-limited cardiopulmonary exercise testing before noncardiac surgery. Chronotropic incompetence was defined as the ratio of increase in HR during exercise to age-predicted maximal increase in HR <0.6. The primary outcome was myocardial injury within 3 days after surgery, defined by high-sensitivity troponin assays >99th centile. Explanatory variables were biomarkers for heart failure (ventilatory efficiency slope [minute ventilation/carbon dioxide production] ≥34; peak oxygen consumption ≤14 ml kg-1 min-1; HR recovery ≤6 beats min-1 decrease 1 min post-exercise; preoperative N-terminal pro-B-type natriuretic peptide [NT pro-BNP] >300 pg ml-1). Myocardial injury was compared in the presence or absence of sympathetic (i.e. chronotropic incompetence) or parasympathetic (i.e. impaired HR recovery after exercise) thresholds indicative of dysfunction. Data are presented as odds ratios (ORs) (95% confidence intervals). RESULTS Chronotropic incompetence occurred in 396/1325 (29.9%) participants; only 16/1325 (1.2%) had a heart failure diagnosis. Myocardial injury was sustained by 162/1325 (12.2%) patients. Raised preoperative NT pro-BNP was more common when chronotropic incompetence was <0.6 (OR: 1.57 [1.11-2.23]; P=0.011). Chronotropic incompetence was not significantly associated with myocardial injury (OR: 1.05 [0.74-1.50]; P=0.78), independent of rate-limiting therapy. HR recovery <12 beats min-1 decrease after exercise was associated with myocardial injury in the presence (OR: 1.62 [1.05-2.51]; P=0.03) or absence (OR: 1.60 [1.06-2.39]; P=0.02) of chronotropic incompetence. CONCLUSIONS Chronotropic incompetence is common in surgical patients. In contrast to parasympathetic dysfunction which was associated with myocardial injury, preoperative chronotropic incompetence (suggestive of sympathetic dysfunction) was not associated with postoperative myocardial injury.
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Affiliation(s)
- Tom E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - W Scott Beattie
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada
| | - Mandeep Phull
- Department of Intensive Care Medicine, Queens Hospital, Romford, UK
| | - Christian Beilstein
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, Bern, Switzerland
| | - Ashok Raj
- Department of Intensive Care Medicine, Croydon University Hospital, Croydon, UK
| | - Michael P W Grocott
- Critical Care Research Group, NIHR Southampton Biomedical Research Centre, University Hospital Southampton, University of Southampton, Southampton, UK
| | - Brian H Cuthbertson
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Duminda Wijeysundera
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada
| | - Gareth L Ackland
- William Harvey Research Institute, Queen Mary University of London, London, UK.
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Haun de Oliveira O, Pinto R, DasGupta T, Sirtartchouck L, Rashleigh L, Cross N, Srikandarajah A, Sukumaran J, Wunsch H, Cuthbertson BH. Assessment of need for lower level acuity critical care services at a tertiary acute care hospital in Canada: A prospective cohort study. J Crit Care 2019; 53:91-97. [PMID: 31202164 DOI: 10.1016/j.jcrc.2019.06.004] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/11/2019] [Accepted: 06/03/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE Critical care beds are commonly described in three levels (highest level 3, lowest level 1). We aimed to describe the actual level of care for patients assigned to level 2 in a tertiary hospital with inadequate level 1 bed capacity. MATERIALS AND METHODS Prospective cohort study with daily assessment of level of care. The primary outcome was the proportion of patients who could be triaged to level 1 for the entirety of their ICU stay. Secondary outcomes included the percentage of patients who could receive level 1 care on any given day. RESULTS 289 patients originally classified as level 2 were assessed for the primary, and 335 for the secondary outcomes. 14.9% could be level 1 for their entire ICU stay. 20.6%, once appropriate for level 1, remained in that level for the rest of their ICU stay. 23.6% of the assessments were suitable for level 1 on any given day. CONCLUSION In a single centre, 14.9% of level 2 patients could have been cared for in a lower acuity bed for the entirety of their ICU stay. We believe this methodology is reproducible and can help resource allocation with regard to the high demand for critical care beds.
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Affiliation(s)
- Olivia Haun de Oliveira
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada
| | - Ruxandra Pinto
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada
| | - Tracey DasGupta
- Interprofessional Practice Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D404b, Toronto, ON M4N3M5, Canada
| | - Leda Sirtartchouck
- Interprofessional Practice Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D404b, Toronto, ON M4N3M5, Canada
| | - Laura Rashleigh
- Interprofessional Practice Department, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D404b, Toronto, ON M4N3M5, Canada
| | - Nicole Cross
- Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D503c, Toronto, ON M4N3M5, Canada
| | - Aruchana Srikandarajah
- Tory Trauma Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D503c, Toronto, ON M4N3M5, Canada
| | - Jaya Sukumaran
- Schulich Heart Program, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D408, Toronto, ON M4N3M5, Canada
| | - Hannah Wunsch
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada; Department of Anesthesia and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue, Room D108, Toronto, ON M4N3M5, Canada.
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Wijeysundera DN, Cuthbertson BH, Pearse RM, Myles PS. Functional capacity and preoperative risk evaluation - Authors' reply. Lancet 2019; 393:1593-1594. [PMID: 31007196 DOI: 10.1016/s0140-6736(18)33070-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada; Department of Anesthesia, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Brian H Cuthbertson
- Department of Anesthesia, Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON M4N 3M5, Canada.
| | | | - Paul S Myles
- The Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
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40
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Spronk PE, Cuthbertson BH. Decontamination Strategies for Critically Ill Patients. JAMA 2019; 321:1409. [PMID: 30964521 DOI: 10.1001/jama.2019.0448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Peter E Spronk
- Department of Intensive Care, Gelre Hospitals, Apeldoorn, the Netherlands
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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41
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Abbott TEF, Pearse RM, Cuthbertson BH, Wijeysundera DN, Ackland GL. Cardiac vagal dysfunction and myocardial injury after non-cardiac surgery: a planned secondary analysis of the measurement of Exercise Tolerance before surgery study. Br J Anaesth 2018; 122:188-197. [PMID: 30686304 PMCID: PMC6354047 DOI: 10.1016/j.bja.2018.10.060] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 08/22/2018] [Revised: 10/19/2018] [Accepted: 10/20/2018] [Indexed: 12/14/2022] Open
Abstract
Background The aetiology of perioperative myocardial injury is poorly understood and not clearly linked to pre-existing cardiovascular disease. We hypothesised that loss of cardioprotective vagal tone [defined by impaired heart rate recovery ≤12 beats min−1 (HRR ≤12) 1 min after cessation of preoperative cardiopulmonary exercise testing] was associated with perioperative myocardial injury. Methods We conducted a pre-defined, secondary analysis of a multi-centre prospective cohort study of preoperative cardiopulmonary exercise testing. Participants were aged ≥40 yr undergoing non-cardiac surgery. The exposure was impaired HRR (HRR≤12). The primary outcome was postoperative myocardial injury, defined by serum troponin concentration within 72 h after surgery. The analysis accounted for established markers of cardiac risk [Revised Cardiac Risk Index (RCRI), N-terminal pro-brain natriuretic peptide (NT pro-BNP)]. Results A total of 1326 participants were included [mean age (standard deviation), 64 (10) yr], of whom 816 (61.5%) were male. HRR≤12 occurred in 548 patients (41.3%). Myocardial injury was more frequent amongst patients with HRR≤12 [85/548 (15.5%) vs HRR>12: 83/778 (10.7%); odds ratio (OR), 1.50 (1.08–2.08); P=0.016, adjusted for RCRI). HRR declined progressively in patients with increasing numbers of RCRI factors. Patients with ≥3 RCRI factors were more likely to have HRR≤12 [26/36 (72.2%) vs 0 factors: 167/419 (39.9%); OR, 3.92 (1.84–8.34); P<0.001]. NT pro-BNP greater than a standard prognostic threshold (>300 pg ml−1) was more frequent in patients with HRR≤12 [96/529 (18.1%) vs HRR>12 59/745 (7.9%); OR, 2.58 (1.82–3.64); P<0.001]. Conclusions Impaired HRR is associated with an increased risk of perioperative cardiac injury. These data suggest a mechanistic role for cardiac vagal dysfunction in promoting perioperative myocardial injury.
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Affiliation(s)
- T E F Abbott
- William Harvey Research Institute, Queen Mary University of London, London, UK; University College London Hospital, London, UK
| | - R M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK
| | - B H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; University of Toronto, Toronto, ON, Canada
| | - D N Wijeysundera
- University of Toronto, Toronto, ON, Canada; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, ON, Canada; Toronto General Hospital, Toronto, ON, Canada
| | - G L Ackland
- William Harvey Research Institute, Queen Mary University of London, London, UK; Barts Health NHS Trust, London, UK.
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42
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Cuthbertson BH. Selective decontamination of the digestive tract in critical care: a teenage angst or coming of age issue? Crit Care 2018; 22:296. [PMID: 30428901 PMCID: PMC6236953 DOI: 10.1186/s13054-018-2227-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 10/10/2018] [Indexed: 01/04/2023]
Abstract
Selective decontamination of the digestive tract (SDD) has been with us since the early days of our specialty, and in some ways it marks our progression and maturation. How we have dealt with SDD to date ranges from “thorn in our side” to “elephant in the room”. With high quality multi-national studies underway, how we deal with these results will mark our final maturation to adulthood as a specialty.
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Affiliation(s)
- Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, M4N 3M5, Canada.
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Wijeysundera DN, Pearse RM, Shulman MA, Abbott TEF, Torres E, Ambosta A, Croal BL, Granton JT, Thorpe KE, Grocott MPW, Farrington C, Myles PS, Cuthbertson BH. Assessment of functional capacity before major non-cardiac surgery: an international, prospective cohort study. Lancet 2018; 391:2631-2640. [PMID: 30070222 DOI: 10.1016/s0140-6736(18)31131-0] [Citation(s) in RCA: 241] [Impact Index Per Article: 40.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 04/04/2018] [Accepted: 05/15/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Functional capacity is an important component of risk assessment for major surgery. Doctors' clinical subjective assessment of patients' functional capacity has uncertain accuracy. We did a study to compare preoperative subjective assessment with alternative markers of fitness (cardiopulmonary exercise testing [CPET], scores on the Duke Activity Status Index [DASI] questionnaire, and serum N-terminal pro-B-type natriuretic peptide [NT pro-BNP] concentrations) for predicting death or complications after major elective non-cardiac surgery. METHODS We did a multicentre, international, prospective cohort study at 25 hospitals: five in Canada, seven in the UK, ten in Australia, and three in New Zealand. We recruited adults aged at least 40 years who were scheduled for major non-cardiac surgery and deemed to have one or more risk factors for cardiac complications (eg, a history of heart failure, stroke, or diabetes) or coronary artery disease. Functional capacity was subjectively assessed in units of metabolic equivalents of tasks by the responsible anaesthesiologists in the preoperative assessment clinic, graded as poor (<4), moderate (4-10), or good (>10). All participants also completed the DASI questionnaire, underwent CPET to measure peak oxygen consumption, and had blood tests for measurement of NT pro-BNP concentrations. After surgery, patients had daily electrocardiograms and blood tests to measure troponin and creatinine concentrations until the third postoperative day or hospital discharge. The primary outcome was death or myocardial infarction within 30 days after surgery, assessed in all participants who underwent both CPET and surgery. Prognostic accuracy was assessed using logistic regression, receiver-operating-characteristic curves, and net risk reclassification. FINDINGS Between March 1, 2013, and March 25, 2016, we included 1401 patients in the study. 28 (2%) of 1401 patients died or had a myocardial infarction within 30 days of surgery. Subjective assessment had 19·2% sensitivity (95% CI 14·2-25) and 94·7% specificity (93·2-95·9) for identifying the inability to attain four metabolic equivalents during CPET. Only DASI scores were associated with predicting the primary outcome (adjusted odds ratio 0·96, 95% CI 0·83-0·99; p=0·03). INTERPRETATION Subjectively assessed functional capacity should not be used for preoperative risk evaluation. Clinicians could instead consider a measure such as DASI for cardiac risk assessment. FUNDING Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Ministry of Health and Long-Term Care, Ontario Ministry of Research, Innovation and Science, UK National Institute of Academic Anaesthesia, UK Clinical Research Collaboration, Australian and New Zealand College of Anaesthetists, and Monash University.
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Affiliation(s)
- Duminda N Wijeysundera
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | | | - Mark A Shulman
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | | | - Elizabeth Torres
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
| | - Althea Ambosta
- Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada
| | | | - John T Granton
- Department of Medicine, University Health Network, Toronto, ON, Canada; Department of Medicine, University of Toronto, Toronto, ON, Canada; Department of Medicine, Sinai Health System, Toronto, ON, Canada
| | - Kevin E Thorpe
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Applied Health Research Centre, St Michael's Hospital, Toronto, ON, Canada; Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Michael P W Grocott
- University Hospital Southampton, Southampton, UK; University of Southampton, Southampton, UK
| | - Catherine Farrington
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Paul S Myles
- Alfred Hospital, Melbourne, VIC, Australia; Monash University, Melbourne, VIC, Australia
| | - Brian H Cuthbertson
- Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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Rose L, Istanboulian L, Smith OM, Silencieux S, Cuthbertson BH, Amaral ACKB, Fraser I, Grey J, Dale C. Feasibility of the electrolarynx for enabling communication in the chronically critically ill: The EECCHO study. J Crit Care 2018; 47:109-113. [PMID: 29945066 DOI: 10.1016/j.jcrc.2018.06.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 05/29/2018] [Accepted: 06/10/2018] [Indexed: 10/14/2022]
Abstract
PURPOSE To assess feasibility of producing intelligible and comprehensible speech with an electrolarynx; measure anxiety, communication ease, and satisfaction before/after electrolarynx training; and identify barriers/facilitators. METHODS We included tracheostomized adults from 3 units following commands, reading English, and mouthing words. On enrolment, we measured anxiety, ease, and satisfaction with communication. We gave electrolarynx instruction for ≤5 days then 2 independent raters assessed intelligibility, sentence comprehensibility (9-point difficulty scale), and Electrolarynx Effectiveness Score (EES), and re-evaluated anxiety, communication ease, and satisfaction. Interviews explored barriers/facilitators. MEASUREMENTS AND MAIN RESULTS We recruited 24 participants (Jan2015-Dec2016). Mean (SD) intelligibility was 45%(18%) words correct: 57%(21%) when facing. Mean comprehension difficulty was 6.4(2.0) overall, indicating moderate difficulty (5.5(2.5) scored visualizing). Mean EES was 2.9(1.0) (3 = improved lip-reading through recognizable sounds). Anxiety decreased from median 3.8 to 2.0 (P = .007). Communication was rated easier (median 15 vs 12, P = .04) whereas satisfaction remained similar (P = .06). Facilitators included device friendliness, patient independence, and word intelligibility. Barriers were patient weakness, difficulty positioning the device, and limited sentence as opposed to word intelligibility. CONCLUSION The electrolarynx may aid intelligible speech for some tracheostomized patients if the communication partner can visualize the users face, and reduce anxiety and make patient perceived communication easier.
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Affiliation(s)
- Louise Rose
- Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, 2075 Bayview Ave, Toronto M4N 3M5, Canada; University of Toronto, 155 College St, Toronto M5T 1P8, Canada; Michael Garron Hospital, 825 Coxwell Ave, Toronto M4C 3E7, Canada; Kings College London, 57 Waterloo Bridge Rd, London.
| | | | - Orla M Smith
- St. Michael's Hospital, 30 Bond St, Toronto M5B 1W8, Canada; Li Ka Shing Knowledge Institute, 209 Victoria St., Toronto M5B 1T8, Canada
| | | | - Brian H Cuthbertson
- Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, 2075 Bayview Ave, Toronto M4N 3M5, Canada; University of Toronto, 155 College St, Toronto M5T 1P8, Canada
| | - Andre Carlos Kajdacsy-Balla Amaral
- Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, 2075 Bayview Ave, Toronto M4N 3M5, Canada; University of Toronto, 155 College St, Toronto M5T 1P8, Canada
| | - Ian Fraser
- University of Toronto, 155 College St, Toronto M5T 1P8, Canada; Michael Garron Hospital, 825 Coxwell Ave, Toronto M4C 3E7, Canada
| | - Joanne Grey
- Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, 2075 Bayview Ave, Toronto M4N 3M5, Canada
| | - Craig Dale
- Sunnybrook Health Sciences Centre and Sunnybrook Research Institute, 2075 Bayview Ave, Toronto M4N 3M5, Canada; University of Toronto, 155 College St, Toronto M5T 1P8, Canada
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Bean S, Shin P, Henry B, Cuthbertson BH. Second Medical Opinions in End-of-Life Disputes in Critical Care: An Ethics-Based Approach. ACTA ACUST UNITED AC 2018; 20:23-26. [PMID: 28837010 DOI: 10.12927/hcq.2017.25223] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Requests for a second medical opinion (SMO) by patients or substitute decision-makers (SDMs) can arise during end-of-life disputes in critical care. Such disagreements between patients or SDMs and physicians often pertain to specific elements of the decision-making process related to withholding or withdrawing of life-sustaining treatments. When these disputes occur in the critical care setting in Canada, practicalities and policy barriers prevent an SDM from obtaining an SMO without support from healthcare providers; moreover, in a majority of these cases the SDM will require the facilitation of a physician who is often the same individual with whom they are in conflict. Institutional and a national society's policy statements propose SMOs as an important component of a conflict resolution process for end-of-life disputes (Bosslet et al. 2015; Singer et al. 2001). However, these policies do not provide specific guidance to physicians on how to fairly consider SMO requests. Given the vulnerable position of patients and their SDMs in the critical care context and in order to promote fairness, physicians should apply consistent standards in deciding whether to facilitate a request for an SMO. To guide physicians' decision-making and inform future policy development, we propose three ethical principles for considering SDM requests for an SMO in critical care at the end of life.
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Affiliation(s)
- Sally Bean
- Policy advisor and director of the Ethics Centre, Sunnybrook Health Sciences; a member of the University of Toronto Joint Centre for Bioethics; an adjunct lecturer at Dalla Lana School of Public Health; an adjunct lecturer at the Institute of Health Policy Management & Evaluation and an associate member at the School of Graduate Studies
| | - Phil Shin
- Chief of medicine and medical director of critical care at North York General Hospital
| | - Blair Henry
- Senior ethicist at both Sunnybrook Health Sciences Centre and North York General Hospital and an assistant professor in the Department of Family and Community Medicine at the University of Toronto
| | - Brian H Cuthbertson
- Chief, Department of Critical Care Medicine at Sunnybrook Health Sciences Centre; a senior scientist with the Evaluative Clinical Sciences, Trauma, Emergency & Critical Care Research Program at Sunnybrook Research Institute; faculty in the Institute of Health Policy, Management and Evaluation, University of Toronto; and a professor in the Department of Anesthesia at the University of Toronto
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Affiliation(s)
- Brian H Cuthbertson
- 1 Department of Critical Care Medicine Sunnybrook Health Sciences Centre Toronto, Ontario, Canada and.,2 Department of Anesthesia University of Toronto Toronto, Ontario, Canada
| | - Hannah Wunsch
- 1 Department of Critical Care Medicine Sunnybrook Health Sciences Centre Toronto, Ontario, Canada and.,2 Department of Anesthesia University of Toronto Toronto, Ontario, Canada
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Affiliation(s)
- Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada.
| | - Shannon Goddard
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
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Murthy S, Pathan N, Cuthbertson BH. Selective digestive decontamination in critically ill children: A survey of Canadian providers. J Crit Care 2017; 39:169-171. [PMID: 28267670 DOI: 10.1016/j.jcrc.2017.02.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 02/13/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Selective digestive decontamination of the digestive tract involves the routine administration of oral, gastric, and intravenous antibiotics to mechanically ventilated children to prevent hospital-acquired infections. It has a strong evidence base in adults, with limited pediatric evidence. Current utilization of this intervention among pediatric physicians in North America is unknown. METHODS An electronic survey administered to pediatric critical care and pediatric infectious disease providers in Canada. Participants were surveyed on current institutional practices, their current knowledge of the evidence base, and perceptions of the risks and benefits of the intervention. Descriptive statistics were utilized. RESULTS 50 out of 143 (35%) surveyed responded. No hospital in Canada routinely performs SDD and the majority of respondents (74%) have neutral opinions on the subject of SDD. There was concern for increasing antibiotic resistance (43%) and some disagreement with the intravenous component of SDD (46%). The majority of respondents stated a need for pediatric-specific evidence before integrating SDD into their practice, even if further, large adult RCTs were performed. CONCLUSION Among surveyed providers, there is little knowledge and no use of selective digestive decontamination for the prevention of hospital-acquired infections. Before interventional studies are performed in pediatric practice, there is a need for study of facilitators, barriers and acceptability of SDD in practice.
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Herridge MS, Chu LM, Matte A, Tomlinson G, Chan L, Thomas C, Friedrich JO, Mehta S, Lamontagne F, Levasseur M, Ferguson ND, Adhikari NKJ, Rudkowski JC, Meggison H, Skrobik Y, Flannery J, Bayley M, Batt J, Santos CD, Abbey SE, Tan A, Lo V, Mathur S, Parotto M, Morris D, Flockhart L, Fan E, Lee CM, Wilcox ME, Ayas N, Choong K, Fowler R, Scales DC, Sinuff T, Cuthbertson BH, Rose L, Robles P, Burns S, Cypel M, Singer L, Chaparro C, Chow CW, Keshavjee S, Brochard L, Hebert P, Slutsky AS, Marshall JC, Cook D, Cameron JI. The RECOVER Program: Disability Risk Groups and 1-Year Outcome after 7 or More Days of Mechanical Ventilation. Am J Respir Crit Care Med 2016; 194:831-844. [PMID: 26974173 DOI: 10.1164/rccm.201512-2343oc] [Citation(s) in RCA: 230] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
RATIONALE Disability risk groups and 1-year outcome after greater than or equal to 7 days of mechanical ventilation (MV) in medical/surgical intensive care unit (ICU) patients are unknown and may inform education, prognostication, rehabilitation, and study design. OBJECTIVES To stratify patients for post-ICU disability and recovery to 1 year after critical illness. METHODS We evaluated a multicenter cohort of 391 medical/surgical ICU patients who received greater than or equal to 1 week of MV at 7 days and 3, 6, and 12 months after ICU discharge. Disability risk groups were identified using recursive partitioning modeling. MEASUREMENTS AND MAIN RESULTS The 7-day post-ICU Functional Independence Measure (FIM) determined the recovery trajectory to 1-year after ICU discharge and was an independent risk factor for 1-year mortality. The 7-day post-ICU FIM was predicted by age and ICU length of stay. By 2 weeks of MV, ICU patients could be stratified into four disability groups characterized by increasing risk for post ICU disability, ICU and post-ICU healthcare use, and disposition. Patients less than 42 years with ICU length of stay less than 2 weeks had the best function and fewest deaths at 1 year compared with patients greater than 66 years with ICU length of stay greater than 2 weeks who sustained the worst disability and 40% 1-year mortality. Depressive symptoms (17%) and post-traumatic stress disorder (18%) persisted at 1 year. CONCLUSIONS ICU survivors of greater than or equal to 1 week of MV may be stratified into four disability groups based on age and ICU length of stay. These groups determine 1-year recovery and healthcare use and are independent of admitting diagnosis and illness severity. Clinical trial registered with www.clinicaltrials.gov (NCT 00896220).
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Affiliation(s)
- Margaret S Herridge
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,4 Institute of Medical Science.,5 Toronto General Research Institute.,3 Interdepartmental Division of Critical Care Medicine
| | | | | | - George Tomlinson
- 1 Department of Medicine.,6 Institute of Health Policy, Management and Evaluation.,7 Dalla Lana School of Public Health.,8 Department of Medicine
| | | | | | - Jan O Friedrich
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Sangeeta Mehta
- 3 Interdepartmental Division of Critical Care Medicine.,12 Department of Medicine and Anesthesia, Mount Sinai Hospital, Toronto, Canada
| | - Francois Lamontagne
- 13 Centre de Recherche du CHU de Sherbrooke, Sherbrooke, Canada.,14 Ecole de Réadaptation, Institut Universitaire de Gériatrie de Sherbrooke, University of Sherbrooke, Sherbrooke, Canada
| | - Melanie Levasseur
- 14 Ecole de Réadaptation, Institut Universitaire de Gériatrie de Sherbrooke, University of Sherbrooke, Sherbrooke, Canada
| | - Niall D Ferguson
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,4 Institute of Medical Science.,5 Toronto General Research Institute.,3 Interdepartmental Division of Critical Care Medicine
| | - Neill K J Adhikari
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Jill C Rudkowski
- 16 Department of General Internal Medicine and.,17 Department of Critical Care, St. Joseph's Healthcare
| | - Hilary Meggison
- 18 Department of Critical Care, University of Ottawa, Ottawa, Canada
| | - Yoanna Skrobik
- 19 Department of Medicine and.,20 Division of Critical Care, Maisonneuve Rosemont Hospital, University of Montreal, Montreal, Canada
| | - John Flannery
- 21 Toronto Rehabilitation Institute.,22 Interdepartmental Division of Physiatry
| | - Mark Bayley
- 21 Toronto Rehabilitation Institute.,22 Interdepartmental Division of Physiatry
| | - Jane Batt
- 9 Department of Medicine.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Claudia Dos Santos
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Susan E Abbey
- 1 Department of Medicine.,23 Department of Psychiatry, and
| | - Adrienne Tan
- 1 Department of Medicine.,23 Department of Psychiatry, and
| | - Vincent Lo
- 2 Medical-Surgical Intensive Care.,24 Department of Physical Therapy
| | - Sunita Mathur
- 24 Department of Physical Therapy.,25 Rehabilitation Science Institution, and
| | - Matteo Parotto
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,3 Interdepartmental Division of Critical Care Medicine
| | | | | | - Eddy Fan
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,4 Institute of Medical Science.,5 Toronto General Research Institute.,3 Interdepartmental Division of Critical Care Medicine
| | - Christie M Lee
- 3 Interdepartmental Division of Critical Care Medicine.,12 Department of Medicine and Anesthesia, Mount Sinai Hospital, Toronto, Canada
| | - M Elizabeth Wilcox
- 1 Department of Medicine.,2 Medical-Surgical Intensive Care.,3 Interdepartmental Division of Critical Care Medicine
| | - Najib Ayas
- 26 Department of Medicine, St. Paul's Hospital, British Columbia, Vancouver, Canada
| | - Karen Choong
- 27 Department of Clinical Epidemiology and Biostatistics, and
| | - Robert Fowler
- 3 Interdepartmental Division of Critical Care Medicine.,6 Institute of Health Policy, Management and Evaluation.,7 Dalla Lana School of Public Health.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Damon C Scales
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Tasnim Sinuff
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Brian H Cuthbertson
- 3 Interdepartmental Division of Critical Care Medicine.,15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Louise Rose
- 15 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Priscila Robles
- 5 Toronto General Research Institute.,24 Department of Physical Therapy.,25 Rehabilitation Science Institution, and
| | | | - Marcelo Cypel
- 4 Institute of Medical Science.,5 Toronto General Research Institute.,28 Division of Thoracic Surgery and Lung Transplant, University Health Network, Toronto, Canada
| | - Lianne Singer
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute
| | - Cecelia Chaparro
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute.,28 Division of Thoracic Surgery and Lung Transplant, University Health Network, Toronto, Canada
| | - Chung-Wai Chow
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute
| | - Shaf Keshavjee
- 1 Department of Medicine.,4 Institute of Medical Science.,5 Toronto General Research Institute.,28 Division of Thoracic Surgery and Lung Transplant, University Health Network, Toronto, Canada
| | - Laurent Brochard
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Paul Hebert
- 29 Centre de recherche du Centre hospitalier de l'Université de Montreal, Montreal, Canada; and.,30 Department of Medicine of the Université de Montréal, Centre hospitalier de l'Université de Montréal, Montreal, Canada
| | - Arthur S Slutsky
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - John C Marshall
- 3 Interdepartmental Division of Critical Care Medicine.,9 Department of Medicine.,10 Division of Critical Care Medicine, and.,11 Keenan Research Center at the Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada
| | - Deborah Cook
- 27 Department of Clinical Epidemiology and Biostatistics, and.,31 Department of Medicine and Pediatrics, McMaster University, Hamilton, Canada
| | - Jill I Cameron
- 32 Department of Occupational Science and Occupational Therapy, University of Toronto, Toronto, Canada
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Hodgson C, Cuthbertson BH. Improving outcomes after critical illness: harder than we thought! Intensive Care Med 2016; 42:1772-1774. [PMID: 27686350 DOI: 10.1007/s00134-016-4526-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 08/23/2016] [Indexed: 01/12/2023]
Affiliation(s)
| | - Brian H Cuthbertson
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and University of Toronto, 2075 Bayview Avenue, D-wing, 1st floor room D1 08, Toronto, ON, M4N 3M5, Canada.
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