Simple interventions--significant impact.
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Consumer Behavior↗
Biomedical subjects
William J Sibbald
Publications and source records attributed to William J Sibbald.
Attitudes regarding organ donation from non-heart-beating donors.
PURPOSE: To determine the attitudes toward organ donation from non-heart-beating cadaver donors in a sample of the general public and health care workers. MATERIALS AND METHODS: A moderator-administered questionnaire was completed by members of the general public, recruited randomly from a professional consumer research group's database, and health care workers recruited from the same database, family practice clinics, and local hospitals. Two primary scenarios were tested: (1) patient in coma, not going to survive intensive care unit (ICU), and (2) patient lapsing in and out of consciousness, lifetime institutional care. RESULTS: Sixty members of the general public and 68 health care workers completed the questionnaire. The majority of both groups were aware life support could be withdrawn in Scenario 1, however, significantly fewer were aware life support could also be withdrawn in Scenario 2 (83% general public vs 34% general public, P <.001 and 94% health care workers vs 78% health care workers, P =.012). Uncertainty in prognosis was cited as the primary concern. The issue of organ donation was directly linked with withdrawal of life support. The majority of both groups believed that organ donation would be permissible if further life support were deemed to be not in the patient's best interest because of poor short-term prognosis (94% health care workers and 98% general public for Scenario 1 and 87% health care workers and 81% general public for Scenario 2). The greatest difficulty arose in defining futility of care. Expected quality of life, patient's and family's values, opinions, and religious beliefs were felt to be most important in determining decisions regarding futility and withdrawal of life support. Physician beliefs and values were felt to influence decisions more than they should. CONCLUSIONS: Both the general public and health care workers support the use of non-heart-beating cadaver donors once a decision has been made to withdraw life support. However, both groups raised concerns regarding how the decision to withdraw life support is made.
Attitude of Health Personnel↗
Changing physician behavior: a review of patient safety in critical care medicine.
The publication of the Agency for Healthcare Research and Quality (AHRQ) report in July 2001 entitled "Making Health Care Safer: A Critical Analysis of Patient Safety Practices," represents a significant perceptual change in health care ideology. It can be argued that this compilation recognizes not only that medical errors occur in the health care system, but also that there are significant learning opportunities that may arise in the identification of these errors that are otherwise known as medical misadventures. The report concluded and outlined a series of 11 highly rated practices whose usage are associated with increased safety. The AHRQ report also articulated that there is a need to investigate methods used to align medical practice with evidence regarding patient safety. In other words, after the identification of the 11 priority safety practices, it is thus important to determine the most effective methods to change physician behavior toward these practices that will intuitively result in increased safety performance. Five different educational-based strategies have been identified as techniques to change physician behavior: (1) Academic Detailing, (2) Audit and Feedback, (3) Local Opinion Leaders, (4) Reminder Systems, and (5) Printed Material. This article reviews these strategies in the context of critical care medicine and offers some opinions regarding setting the future research agenda in this investigative field.
Critical Care↗
Randomized, controlled clinical trials in sepsis: has methodological quality improved over time?
OBJECTIVE: To systematically evaluate the methodological quality of randomized clinical trials and to determine whether randomized clinical trials of sepsis improved in methodological quality over time. DATA SOURCES: Computerized MEDLINE search of articles published in any language from 1966 to 1998 combined with a manual search of bibliographies of published articles and communication with known experts in the field. STUDY SELECTION: All randomized clinical trials of sepsis, severe sepsis, and septic shock performed in adults and published as full articles. DATA EXTRACTION: Abstracts of all retrieved records were reviewed and the inclusion criteria were applied. All selected articles were classified into (a) trials designed to detect differences in mortality as the primary end point, or (b) trials focusing on surrogate outcome measures (i.e., physiological or biochemical parameters). All retrieved trials were then graded for methodological quality using an objective grading scheme developed specifically for this study. The data selection and extraction process was carried out independently by two of the authors; any disagreement was resolved by discussion. DATA SYNTHESIS: Seventy-four randomized clinical trials involving septic patients qualified for inclusion in this study (40 reporting mortality outcomes, 34 reporting other surrogate outcomes). Trials reporting mortality as the primary outcome had significantly higher quality scores compared with trials reporting surrogate outcome measures (29.6 +/- 1.0 vs. 24.3 +/- 0.8, p =.0006). From 1976 to 1998, trial methodology improved significantly over time (an average of 0.36 points per year, p =.021). Mortality outcome trials improved an average of 0.58 points per year (p =.0011) whereas surrogate outcome trials did not demonstrate an improvement in methodological quality over time (p =.249). CONCLUSION: The methodological limitations identified in this article can help to target further improvement in trial design to enhance the validity of findings from future randomized clinical trials of sepsis.
Adult↗
Increasing P(50) does not improve DO(2CRIT) or systemic VO(2) in severe anemia.
Reducing the hemolobin (Hb)-O(2) binding affinity facilitates O(2) unloading from Hb, potentially increasing tissue mitochondrial O(2) availability. We hypothesized that a reduction of Hb-O(2) affinity would increase O(2) extraction when tissues are O(2) supply dependent, reducing the threshold of critical O(2) delivery (DO(2 CRIT)). We investigated the effects of increased O(2) tension at which Hb is 50% saturated (P(50)) on systemic O(2) uptake (VO(2) (SYS)), DO(2 CRIT), lactate production, and acid-base balance during isovolemic hemodilution in conscious rats. After infusion of RSR13, an allosteric modifier of Hb, P(50) increased from 36.6 +/- 0.3 to 48.3 +/- 0.6 but remained unchanged at 35.4 +/- 0.8 mmHg after saline (control, CON). Arterial O(2) saturations were equivalent between RSR13 and saline groups, but venous PO(2) was higher and venous O(2) saturation was lower after RSR13. Convective O(2) delivery progressively declined during hemodilution reaching the DO(2 CRIT) at 3.4 +/- 0.8 ml x min(-1) x 100 g(-1) (CON) and 3.6 +/- 0.6 ml x min(-1) x 100 g(-1) (RSR13). At Hb of 8.1 g/l VO(2) (SYS) started to decrease (CON: 1.9 +/- 0.1; RSR13: 1.8 +/- 0.2 ml x min(-1) x 100 g(-1)) and fell to 0.8 +/- 0.2 (CON) and 0.7 +/- 0.2 ml x min(-1). 100 g(-1) (RSR13). Arterial lactate was lower in RSR13-treated than in control animals when animals were O(2) supply dependent. The decrease in base excess, arterial pH, and bicarbonate during O(2) supply dependence was significantly less after RSR13 than after saline. These findings demonstrate that during O(2) supply dependence caused by severe anemia, reducing Hb-O(2) binding affinity does not affect VO(2) (SYS) or DO(2 CRIT) but appears to have beneficial effects on oxidative metabolism and acid base balance.
Acid-Base Equilibrium↗
Effect of a maldistribution of microvascular blood flow on capillary O(2) extraction in sepsis.
Inherent in the remote organ injury caused by sepsis is a profound maldistribution of microvascular blood flow. Using a 24-h rat cecal ligation and perforation model of sepsis, we studied O(2) transport in individual capillaries of the extensor digitorum longus (EDL) skeletal muscle. We hypothesized that erythrocyte O(2) saturation (SO(2)) levels within normally flowing capillaries would provide evidence of either a mitochondrial failure (increased SO(2)) or an O(2) transport derangement (decreased SO(2)). Using a spectrophotometric functional imaging system, we found that sepsis caused 1) an increase in stopped flow capillaries (from 10 to 38%, P < 0.05), 2) an increase in the proportion of fast-flow to normal-flow capillaries (P < 0.05), and 3) a decrease in capillary venular-end SO(2) levels from 58.4 +/- 20.0 to 38.5 +/- 21.2%, whereas capillary arteriolar-end SO(2) levels remained unchanged compared with the sham group. Capillary O(2) extraction increased threefold (P < 0.05) and was directly related to the degree of stopped flow in the EDL. Thus impaired O(2) transport in early stage sepsis is likely the result of a microcirculatory dysfunction.
Animals↗