Biomedical subjects

Thomas E Stewart

Publications and source records attributed to Thomas E Stewart.

At least 19 recordsLinked to original sources

PubMed2006

Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome.

RATIONALE: Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS). OBJECTIVES: To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge. METHODS: We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge. MEASUREMENTS: Clinical and functional outcomes, health care use, and direct medical costs. RESULTS: Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from emotional role and mental health, all other domains remained below that of the normal population. From ICU admission to 2 yr after ICU discharge, the largest portion of health care costs for a survivor of ARDS was the initial hospital stay, with ICU costs accounting for 76% of these costs. After the initial hospital stay, health care costs were related to hospital readmissions and inpatient rehabilitation. CONCLUSIONS: Survivors of ARDS continued to have functional impairment and compromised health-related quality of life 2 yr after discharge from the ICU. Health care use and costs after the initial hospitalization were driven by hospital readmissions and inpatient rehabilitation.

Adult↗

PubMed2006

New modalities of mechanical ventilation: high-frequency oscillatory ventilation and airway pressure release ventilation.

Management of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS) is largely supportive, with the use of mechanical ventilation being a central feature. Recent advances in the understanding of ALI/ARDS and mechanical ventilation have revealed that lung-protective ventilation strategies may attenuate ventilator-associated lung injury and improve patient morbidity/mortality. High-frequency oscillatory ventilation and airway pressure release ventilation are two novel alternative modes of ventilation that theoretically fulfill the principles of lung protection and may offer an advantage over conventional ventilation for ALI/ARDS.

Continuous Positive Airway Pressure↗

PubMed2006

Canadian survey of the use of sedatives, analgesics, and neuromuscular blocking agents in critically ill patients.

OBJECTIVES: To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ventilated adults, and to define clinical factors that influence these practices. DESIGN: Cross-sectional mail survey. PARTICIPANTS: Canadian critical care practitioners. MEASUREMENTS AND MAIN RESULTS: A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (>or=15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care-trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092). CONCLUSIONS: There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.

Adult↗

PubMed2006

Five percent albumin for adult burn shock resuscitation: lack of effect on daily multiple organ dysfunction score.

BACKGROUND: The effect of 5 percent human albumin on multiple organ dysfunction was investigated during the first 14 days of treatment to determine whether albumin resuscitation might benefit adult burn patients. STUDY DESIGN AND METHODS: Multicenter unblinded controlled trial with stratified block (two patients per block) randomization by center and mortality prediction at enrollment (high-risk stratum [predicted mortality, 50%-90%] and low-risk stratum [predicted mortality, <50%]). The primary outcome was the worst multiple organ dysfunction score (MODS), excluding the cardiovascular component, to Day 14. Eligible adults (>15 years) suffering from thermal injury not more than 12 hours before enrollment received fluid resuscitation with Ringer's lactate (n=23) or 5 percent human albumin plus Ringer's lactate (n=19) by protocol to achieve recommended (American Burn Association) resuscitation endpoints. RESULTS: Forty-two patients were randomly assigned. There were no significant differences (median [95% confidence intervals]) in age (36 [24-45] vs. 31 [25-39] years), burn size (39 [32-53] vs. 32 [26-34] total body surface area percentage), inhalation injury (n=12/19 vs. n=11/23), or baseline MODS (3 [1-5] vs. 1.5 [0-2]) between the treatment and control groups. In an intention-to-treat analysis, there was no significant difference between the treatment and control group in the lowest MODS from Day 0 to Day 14 (analysis of covariance, p=0.73). CONCLUSION: Treatment with 5 percent albumin from Day 0 to Day 14 does not decrease the burden of MODS in adult burn patients.

Adult↗

PubMed2006

Outcomes of interfacility critical care adult patient transport: a systematic review.

INTRODUCTION: We aimed to determine the adverse events and important prognostic factors associated with interfacility transport of intubated and mechanically ventilated adult patients. METHODS: We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined. RESULTS: Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies. CONCLUSION: Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.

Adult↗

PubMed2006

Morbidity and mortality of patients with invasive group A streptococcal infections admitted to the ICU.

STUDY OBJECTIVES: To describe the clinical features and outcome of patients with invasive group A streptococcal (GAS) infections admitted to the ICU. DESIGN: Prospective, population-based surveillance for invasive GAS infections was conducted in Ontario from January 1992 until June 2002. All 62 patients meeting clinical and/or histopathologic criteria for invasive GAS who were admitted to the ICUs of four university-affiliated hospitals in Toronto, Canada were included. Demographic and clinical information were obtained retrospectively by chart review. ICU morbidity data included the occurrence of organ dysfunction (renal, hepatic, coagulation, ARDS), treatment, and interventions such as hemodialysis and mechanical ventilation. MEASUREMENTS AND RESULTS: ARDS developed in 34%, renal dysfunction developed in 55%, hepatic dysfunction developed in 64%, and coagulopathy developed in 69% of patients. A total of 56% of patients were treated with IV polyspecific IgG (IVIG), 81% were intubated and placed on mechanical ventilation, and 21% required renal replacement therapy. The median durations of ICU and hospital stay were 5.3 days and 15.0 days, respectively. The overall mortality was 40%. Mortality correlated directly with acute physiology and chronic health evaluation II score and the number of dysfunctional organs. Survivors were younger, had lower severity of illness scores, fewer dysfunctional organs, and were less likely to have shock or to receive treatment with vasopressors, mechanical ventilation, or pulmonary artery catheters. There was no association between the use of IVIG, surgical intervention, or clindamycin, and survival. Variables independently associated with mortality on multivariable analysis were the presence of coagulopathy (p = 0.0005) and liver dysfunction (p = 0.0123). CONCLUSIONS: Patients with invasive GAS infection admitted to the ICU have a high mortality rate. In this group of patients, coagulopathy and liver failure were independently associated with mortality. We did not observe any association between the use of IVIG, surgical intervention, or clindamycin, and survival.

APACHE↗

PubMed2005

Ventilatory management of acute lung injury and acute respiratory distress syndrome.

CONTEXT: The acute lung injury and acute respiratory distress syndrome are critical illnesses associated with significant morbidity and mortality. Mechanical ventilation is the cornerstone of supportive therapy. However, despite several important advances, the optimal strategy for ventilation and adjunctive therapies for patients with acute lung injury and acute respiratory distress syndrome is still evolving. EVIDENCE ACQUISITION: To identify reports of invasive ventilatory and adjunctive therapies in adult patients with acute lung injury and acute respiratory distress syndrome, we performed a systematic English-language literature search of MEDLINE (1966-2005) using the Medical Subject Heading respiratory distress syndrome, adult, and related text words, with emphasis on randomized controlled trials and meta-analyses. EMBASE and the Cochrane Central Register of Controlled Trials were similarly searched. The search yielded 1357 potential articles of which 53 were relevant to the study objectives and considered in this review. EVIDENCE SYNTHESIS: There is strong evidence to support the use of volume- and pressure-limited lung-protective ventilation in adult patients with acute lung injury and acute respiratory distress syndrome. The benefit of increased levels of positive end-expiratory pressure and recruitment maneuvers is uncertain and is being further evaluated in ongoing trials. Existing randomized controlled trials of alternative ventilation modes, such as high-frequency oscillation and adjunctive therapies, including inhaled nitric oxide and prone positioning demonstrate no significant survival advantage. However, they may have a role as rescue therapy for patients with acute respiratory distress syndrome with refractory life-threatening hypoxemia. CONCLUSIONS: Volume- and pressure-limited ventilation strategies should be used in managing adult acute lung injury and acute respiratory distress syndrome patients. Further research is needed to identify barriers to widespread adoption of this strategy, as well as the role of alternative ventilation modes and adjunctive therapies.

Humans↗

PubMed2005

Clinical review: Mechanical ventilation in severe asthma.

Respiratory failure from severe asthma is a potentially reversible, life-threatening condition. Poor outcome in this setting is frequently a result of the development of gas-trapping. This condition can arise in any mechanically ventilated patient, but those with severe airflow limitation have a predisposition. It is important that clinicians managing these types of patients understand that the use of mechanical ventilation can lead to or worsen gas-trapping. In this review we discuss the development of this complication during mechanical ventilation, techniques to measure it and strategies to limit its severity. We hope that by understanding such concepts clinicians will be able to reduce further the poor outcomes occasionally related to severe asthma.

Asthma↗

PubMed2005

Clinical review: SARS - lessons in disaster management.

Disaster management plans have traditionally been required to manage major traumatic events that create a large number of victims. Infectious diseases, whether they be natural (e.g. SARS [severe acute respiratory syndrome] and influenza) or the result of bioterrorism, have the potential to create a large influx of critically ill into our already strained hospital systems. With proper planning, hospitals, health care workers and our health care systems can be better prepared to deal with such an eventuality. This review explores the Toronto critical care experience of coping in the SARS outbreak disaster. Our health care system and, in particular, our critical care system were unprepared for this event, and as a result the impact that SARS had was worse than it could have been. Nonetheless, we were able to organize a response rapidly during the outbreak. By describing our successes and failures, we hope to help others to learn and avoid the problems we encountered as they develop their own disaster management plans in anticipation of similar future situations.

Communicable Disease Control↗

PubMed2005

Development of a clinical definition for acute respiratory distress syndrome using the Delphi technique.

PURPOSE: The objective of this study is to describe the implementation of formal consensus techniques in the development of a clinical definition for acute respiratory distress syndrome. MATERIALS AND METHODS: A Delphi consensus process was conducted using e-mail. Sixteen panelists who were both researchers and opinion leaders were systematically recruited. The Delphi technique was performed over 4 rounds on the background of an explicit definition framework. Item generation was performed in round 1, item reduction in rounds 2 and 3, and definition evaluation in round 4. Explicit consensus thresholds were used throughout. RESULTS: Of the 16 panelists, 11 actually participated in developing a definition that met a priori consensus rules on the third iteration. New incorporations in the Delphi definition include the use of a standardized oxygenation assessment and the documentation of either a predisposing factor or decreased thoracic compliance. The panelists rated the Delphi definition as acceptable to highly acceptable (median score, 6; range, 5-7 on a 7-point Likert scale). CONCLUSIONS: We conclude that it is feasible to consider using formal consensus in the development of future definitions of acute respiratory distress syndrome. Testing of sensibility, reliability, and validity are needed for this preliminary definition; these test results should be incorporated into future iterations of this definition.

Delphi Technique↗

PubMed2005

Airway pressures, tidal volumes, and mortality in patients with acute respiratory distress syndrome.

OBJECTIVE: To determine the usual practice for setting tidal volume and other ventilatory parameters in patients with acute respiratory distress syndrome (ARDS) in the late 1990s and to determine the independent effects of these practices on intensive care unit mortality. DESIGN: Subanalysis of a prospective observational study. Multivariable logistic regression was used to analyze the effects of ventilatory management on mortality. SETTING: A total of 361 intensive care units in 20 countries in March 1998. PATIENTS: A total of 467 mechanically ventilated patients with ARDS. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The mean tidal volume used in the first week of ARDS was 8.8 mL/kg measured body weight, and there was great variability in these tidal volumes (sd = 2.0). Tidal volumes were significantly lower in patients with (n = 265) than without (n = 202) a recorded plateau pressure (8.6 vs. 9.1 mL/kg, p = .01). The overall intensive care unit mortality rate was 60.2%. In addition to the strong influence of organ failures and higher levels of inspired oxygen, late-onset ARDS (onset after >48 hrs of mechanical ventilation; odds ratio, 2.09) was independently associated with mortality. In addition, lower levels of positive end-expiratory pressure were independently associated with higher mortality (odds ratio, 0.91; 1 cm of H2O increments). Neither inspiratory pressures nor tidal volumes were independently associated with mortality, and there was no evidence of increased mortality with the use of lower inspiratory pressures. CONCLUSIONS: This descriptive study demonstrated considerable interpatient variability in tidal volumes during the study period. In addition to traditional prognostic indicators, timing of ARDS onset and the use of low levels of positive end-expiratory pressure or no positive end-expiratory pressure during the first week may adversely influence outcome in ARDS patients.

Adult↗

PubMed2005

Severe acute respiratory syndrome and critical care medicine: the Toronto experience.

BACKGROUND: The 2003 global outbreak of severe acute respiratory syndrome (SARS) provided numerous challenges to the delivery of critical care. The Toronto critical care community has learned important lessons from SARS, which will help in preparation for future disease outbreaks. OBJECTIVES: The objectives of this study were to review the epidemiology and clinical characteristics of the Toronto SARS outbreak, the challenges SARS provided to the delivery of critical care, and how we would like to be better organized for a similar challenge in the future. FINDINGS: SARS manifests clinically as atypical pneumonia and ranges in severity from minor nonspecific symptoms to adult respiratory distress syndrome (ARDS). Approximately 20% of patients with SARS will become critically ill and require admission to the intensive care unit. ARDS develops in the majority of these patients. Mortality from ARDS in SARS is high, and outcome is associated with the presence of comorbid disease and the severity of illness at presentation. The influx of critically ill patients and the transmission of SARS to front line workers created a tremendous strain on Toronto's healthcare system. From a critical care perspective, the most important limitation in the response to SARS was the absence of a coordinated leadership and communication infrastructure. Other challenges encountered during SARS include the following: closure of intensive care unit beds and loss of staff through quarantine and illness, implementing novel infection control protocols, educating staff, conducting research to learn about SARS, system planning, and maintaining staff morale during this very difficult period. CONCLUSIONS: Communication and leadership strategies were key components in the critical care response to SARS. Ideally, centers should have systems in place to allow for the rapid expansion and modification of critical care services in the event of a disease outbreak. Other critical care communities should consider their crisis response strategies in advance of similar events.

Canada↗

PubMed2005

Combining high-frequency oscillatory ventilation and recruitment maneuvers in adults with early acute respiratory distress syndrome: the Treatment with Oscillation and an Open Lung Strategy (TOOLS) Trial pilot study.

OBJECTIVE: To determine the safety, feasibility, and lung-recruitment efficacy of an explicit ventilation protocol combining high-frequency oscillatory ventilation and recruitment maneuvers. DESIGN: Prospective, multiple-center, single-intervention pilot study. SETTING: Four university-affiliated intensive care units. PATIENTS: Twenty-five patients with early acute respiratory distress syndrome and severe oxygenation failure. INTERVENTIONS: Patients were transitioned from standardized conventional ventilation to high-frequency oscillatory ventilation beginning with an initial cycle of up to three sustained inflation recruitment maneuvers (40 cm H2O x 40 secs), followed by a decremental titration of Fio2 and then mean airway pressure. Recruitment maneuvers were repeated for hypoxemia and routinely at least twice daily if the Fio2 was >0.4. A specific protocol was used for weaning high-frequency oscillatory ventilation, for transitioning to conventional ventilation, and for judging intolerance of conventional ventilation whereby patients should be put back on high-frequency oscillatory ventilation. MEASUREMENTS AND MAIN RESULTS: Patients (median [interquartile range] Acute Physiology and Chronic Health Evaluation II, 24 [19-32]; age, 50 [41-64]) were enrolled after 13 (range, 6-51) hrs of conventional ventilation. Following the initial cycle of recruitment, the mean (+/-sd) Pao2/Fio2 increased significantly compared with standardized conventional ventilation (200 +/- 117 vs. 92 +/- 36 mm Hg, p < .001). After a mean of 12 hrs of high-frequency oscillatory ventilation, the mean Fio2 was significantly reduced compared with prestudy levels (0.5 +/- 0.2 vs. 0.9 +/- 0.1, p < .001). A median of seven (four to 11) recruitment maneuvers was performed per patient over the study period, with only eight of 244 (3.3%) being aborted. Six of 19 patients transitioned to conventional ventilation (32%) were deemed intolerant and were switched back to high-frequency oscillatory ventilation. Protocol adherence was excellent with documented rates >90%. CONCLUSIONS: The combination of high-frequency oscillatory ventilation and recruitment maneuvers resulted in rapid and sustained improvement in oxygenation, likely through lung recruitment. This explicit high-frequency oscillatory ventilation protocol appears well tolerated, feasible, and physiologically sound.

Adult↗

PubMed2005

Clinical use of high-frequency oscillatory ventilation in adult patients with acute respiratory distress syndrome.

OBJECTIVE: High-frequency oscillatory ventilation (HFOV) is an emerging ventilatory strategy for adults that has been used successfully in the neonatal and pediatric population. This modality utilizes high mean airway pressures to maintain an open lung and low tidal volumes at a high frequency that allow for adequate ventilation while at the same time preventing alveolar overdistension. With the current understanding that excessive lung stretch and inadequate end-expiratory ventilatory volume may be injurious to the lungs, HFOV seems to be the ideal lung-protective ventilatory mode. During the past 8 yrs, there have been increasing numbers of studies describing its use in adult patients with acute respiratory distress syndrome. This article aims to review the published studies of HFOV in adults with acute respiratory distress syndrome with regard to its safety and efficacy. DATA SOURCE: To assist us with our review, we did a search of MEDLINE (from 1966 to present) and EMBASE (1980 to present) databases to identify adult, clinical, English-language, research articles related to HFOV use. In addition, we reviewed relevant animal and mechanical ventilation studies. We did not perform a formal systematic review. DATA SYNTHESIS: The application of HFOV was mainly reported as a rescue ventilatory mode in adult patients with acute respiratory distress syndrome who were thought to have failed conventional ventilation. In these patients, HFOV has consistently been shown to improve oxygenation without obvious increases in complications measured. There was only one randomized, controlled trial comparing HFOV with conventional ventilation. This study showed that there was a nonsignificant trend toward a lower mortality rate in the HFOV group. In addition, HFOV was as effective and safe as conventional ventilation. Although there are limitations, multiple studies have shown that earlier initiation of HFOV in patients with severe acute respiratory distress syndrome may also be associated with a lower mortality. CONCLUSIONS: HFOV seems to be safe and effective for adults with severe acute respiratory distress syndrome who have failed conventional ventilation. Further research is needed to determine the ideal patients, timing, and optimal technique with which to provide HFOV. When considering HFOV as an early, lung-protective mode of ventilation, there is still a need to perform an adequately powered, randomized, controlled trial comparing it with the best available form of conventional ventilation. However, we believe that such a trial should wait until we have a better understanding of HFOV in adults.

Adult↗

PubMed2005

Acute respiratory distress syndrome: underrecognition by clinicians and diagnostic accuracy of three clinical definitions.

OBJECTIVE: To determine and compare the diagnostic accuracy of three clinical definitions of acute respiratory distress syndrome (ARDS): (1) the American-European consensus conference definition; (2) the lung injury score; and (3) a recently developed Delphi definition. A second objective was to determine the accuracy of clinical diagnoses of ARDS made in daily practice. DESIGN: Independent comparison of autopsy findings with the daily status of clinical definitions, constructed with data abstracted retrospectively from medical records. SETTING: Tertiary intensive care unit. PATIENTS: One hundred thirty-eight patients from the period 1995 through 2001 who were autopsied after being mechanically ventilated. INTERVENTIONS: Clinical ARDS diagnoses were determined daily without knowledge of autopsy results. Charts were reviewed for any mention of ARDS in the clinical notes. Autopsies were reviewed independently by two pathologists for the presence of diffuse alveolar damage. The sensitivity and specificity of the definitions were determined with use of diffuse alveolar damage at autopsy as the reference standard. MEASUREMENTS AND MAIN RESULTS: Diffuse alveolar damage at autopsy was documented in 42 of 138 cases (30.4%). Only 20 of these 42 patients (47.6%) had any mention of ARDS in their chart. Sensitivities and specificities (95% confidence intervals) were as follows: American-European definition, 0.83 (0.72-0.95), 0.51 (0.41-0.61); lung injury score, 0.74 (0.61-0.87), 0.77 (0.69-0.86); and Delphi definition, 0.69 (0.55-0.83), 0.82 (0.75-0.90). Specificity was significantly higher for both the lung injury score and Delphi definition than for the American-European definition (p < .001 for both), whereas comparisons of sensitivity, which was higher for the American-European definition, were not significantly different (p = .34 and p = .07, respectively). CONCLUSIONS: Acute respiratory distress syndrome appears underrecognized by clinicians in patients who die with this syndrome. In this population, the specificities of existing clinical definitions vary considerably, which may be problematic for clinical trials.

Aged↗

PubMed2004

Clinical issues and research in respiratory failure from severe acute respiratory syndrome.

The National Heart, Lung, and Blood Institute, along with the Centers for Disease Control and Prevention and the National Institute of Allergy and Infectious Diseases, convened a panel to develop recommendations for treatment, prevention, and research for respiratory failure from severe acute respiratory syndrome (SARS) and other newly emerging infections. The clinical and pathological features of acute lung injury (ALI) from SARS appear indistinguishable from ALI from other causes. The mainstay of treatments for ALI remains supportive. Patients with ALI from SARS who require mechanical ventilation should receive a lung protective, low tidal volume strategy. Adjuvant treatments recommended include prevention of venous thromboembolism, stress ulcer prophylaxis, and semirecumbent positioning during ventilation. Based on previous experience in Canada, infection control resources and protocols were recommended. Leadership structure, communication, training, and morale are an essential aspect of SARS management. A multicenter, placebo-controlled trial of corticosteroids for late SARS is justified because of widespread clinical use and uncertainties about relative risks and benefits. Studies of combined pathophysiologic endpoints were recommended, with mortality as a secondary endpoint. The group recommended preparation for studies, including protocols, ethical considerations, Web-based registries, and data entry systems.

Adrenal Cortex Hormones↗

PubMed2004

Prospective evaluation of an internet-linked handheld computer critical care knowledge access system.

INTRODUCTION: Critical care physicians may benefit from immediate access to medical reference material. We evaluated the feasibility and potential benefits of a handheld computer based knowledge access system linking a central academic intensive care unit (ICU) to multiple community-based ICUs. METHODS: Four community hospital ICUs with 17 physicians participated in this prospective interventional study. Following training in the use of an internet-linked, updateable handheld computer knowledge access system, the physicians used the handheld devices in their clinical environment for a 12-month intervention period. Feasibility of the system was evaluated by tracking use of the handheld computer and by conducting surveys and focus group discussions. Before and after the intervention period, participants underwent simulated patient care scenarios designed to evaluate the information sources they accessed, as well as the speed and quality of their decision making. Participants generated admission orders during each scenario, which were scored by blinded evaluators. RESULTS: Ten physicians (59%) used the system regularly, predominantly for nonmedical applications (median 32.8/month, interquartile range [IQR] 28.3-126.8), with medical software accessed less often (median 9/month, IQR 3.7-13.7). Eight out of 13 physicians (62%) who completed the final scenarios chose to use the handheld computer for information access. The median time to access information on the handheld handheld computer was 19 s (IQR 15-40 s). This group exhibited a significant improvement in admission order score as compared with those who used other resources (P = 0.018). Benefits and barriers to use of this technology were identified. CONCLUSION: An updateable handheld computer system is feasible as a means of point-of-care access to medical reference material and may improve clinical decision making. However, during the study, acceptance of the system was variable. Improved training and new technology may overcome some of the barriers we identified.

Academic Medical Centers↗

PubMed2004

Albumin in critical care: SAFE, but worth its salt?

Intravascular fluid therapy is a common critical care intervention. However, the optimal type of resuscitation fluid, crystalloid or colloid, remains controversial. Despite the many theoretical benefits of human albumin administration in critically ill patients, there has been little evidence to support its widespread clinical use. Previous systematic reviews have led to conflicting results regarding the safety and efficacy of albumin. The recently reported Saline versus Albumin Evaluation study has provided conclusive evidence that 4% albumin is as safe as saline for resuscitation, although no overall benefit of albumin use was seen. Subgroup analysis of the albumin-treated group revealed a trend towards decreased mortality in patients with septic shock, and a trend towards increased mortality in trauma patients, especially those with traumatic brain injury. The results of these subgroups, as well as the use of higher albumin concentrations and other synthetic colloids (dextrans, starches), require rigorous evaluation in clinical trials. Finally, the Saline versus Albumin Evaluation trial represents a methodological milestone in critical care medicine, due to its size, its efficient trial design, and its logistical coordination. Future studies are still required, however, to establish a therapeutic niche for albumin and other colloids.

Clinical Trials as Topic↗