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Although aligning care with patient goals is fundamental to critical care, this process is often delayed and leads to conflict among patients, families, and intensive care unit (ICU) teams. Interprofessional collaboration within ICU teams is an opportunity to improve goal-aligned care, yet this collaboration is poorly understood. A better understanding of how ICU team members work together to provide goal-aligned care may identify new strategies for improvement.Transactive memory systems is a theory of group mind that explains how high-performing teams use a shared memory and collective cognition. We applied this theory to characterize the process of interprofessional collaboration within ICU teams and its relationship with goal-aligned care.We conducted a secondary analysis of focus group (n = 10) and semi-structured interview (n = 8) transcripts, gathered during a parent study at two academic medical centers on the process of ICU care delivery in acute respiratory failure. Participants (N = 70) included interprofessional ICU and palliative care team members, surrogates, and patient survivors. We used directed content analysis, applying transactive memory systems theory and its major components (specialization, coordination, credibility) to examine ICU team collaboration.Participants described each ICU profession as having a specialized role in aligning care with patient goals. Different professions have different opportunities to gather knowledge about patient goals and priorities, which results in dispersion of this knowledge among different team members. To share and use this dispersed knowledge, ICU teams rely on an informal coordination process and "side conversations." This process is a workaround for formal channels (e.g., health records, interprofessional rounds) that do not adequately convey knowledge about patient goals. This informal process does not occur if team members are discouraged from asserting their knowledge because of hierarchy or lack of psychological safety. Conversely, coordination succeeds when team members recognize each other as credible sources of valued knowledge.We found that ICU team members work together to align care with patient goals and priorities, using transactive memory systems. The successful function of these systems can be disrupted or promoted by ICU organizational and cultural factors, which are potential targets for efforts to increase goal-aligned care.

We aimed to determine the association between sepsis and long-term cardiovascular events. We conducted a systematic review of observational studies evaluating post-sepsis cardiovascular outcomes in adult sepsis survivors. MEDLINE, Embase, and the Cochrane Controlled Trials Register and Database of Systematic Reviews were searched from inception until April 21st, 2021. Two reviewers independently extracted individual study data and evaluated risk of bias. Random-effects models estimated the pooled crude cumulative incidence and adjusted hazard ratios (aHRs) of cardiovascular events compared to either non-septic hospital survivors or population controls. Primary outcomes included myocardial infarction, stroke, and congestive heart failure; outcomes were analysed at maximum reported follow-up (from 30 days to beyond 5 years post-discharge). Of 12,649 screened citations, 27 studies (25 cohort studies, 2 case-crossover studies) were included with a median of 4,289 (IQR 502–68,125) sepsis survivors and 18,399 (IQR 4,028–83,506) controls per study. The pooled cumulative incidence of myocardial infarction, stroke, and heart failure in sepsis survivors ranged from 3 to 9% at longest reported follow-up. Sepsis was associated with a higher long-term risk of myocardial infarction (aHR 1.77 [95% CI 1.26 to 2.48]; low certainty), stroke (aHR 1.67 [95% CI 1.37 to 2.05]; low certainty), and congestive heart failure (aHR 1.65 [95% CI 1.46 to 1.86]; very low certainty) compared to non-sepsis controls. Surviving sepsis may be associated with a long-term, excess hazard of late cardiovascular events which may persist for at least 5 years following hospital discharge.

Rationale: Patients with hematologic malignancies requiring mechanical ventilation have historically experienced poor outcomes.Objectives: We aimed to determine whether body composition characteris...

Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51-68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9-14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79-99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2-7). Mortality across those at severe malnutrition (NRI 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04-5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure.

Background: In-hospital transfers such as from the intensive care unit (ICU) to the general internal medicine (GIM) ward place patients at risk of adverse events. A structured handover tool may improve transitions from the ICU to the GIM ward. Objective: To develop, implement, and evaluate a customized user-designed transfer tool to improve transitions from the ICU to the GIM ward. Methods: This was a pre–post intervention study at a tertiary academic hospital. We developed and implemented a user-designed, structured, handwritten ICU-to-GIM transfer tool. The tool included active medical issues, functional status, medications and medication changes, consulting services, code status, and emergency contact information. Transfer tool users included GIM physicians, ICU physicians, and critical care rapid response team nurses. An implementation audit and mixed qualitative and quantitative analysis of pre–post survey responses was used to evaluate clinician satisfaction and the perceived quality of patient transfers. Results: The pre–post survey response rate was 51.8% (99/191). Respondents included GIM residents (58.5%), ICU rapid response team physicians and nurses (24.2%), and GIM attending physicians (17.2%). Less than half of clinicians (48.8%) reported that the preintervention transfer process was adequate. Clinicians who used the transfer tool reported that the transfer process was improved (93.3% vs. 48.8%, P = 0.03). Clinician-reported understanding of medication changes in the ICU increased (69.2% vs. 29.1%, P = 0.004), as did their ability to plan for a safe hospital discharge (69.2% vs. 31.0%, P = 0.01). However, only 64.2% of audited transfers used the tool. Frequently omitted sections included home medications (missing in 83.4% of audits), new medications (33.3%), and secondary diagnosis (33.3%). Thematic analysis of free-text responses identified areas for improvement including clarifying the course of ICU events and enhancing tool usability. Conclusion: A user-designed, structured, handwritten transfer tool may improve the perceived quality of patient transfers from the ICU to the GIM wards.

OBJECTIVE: To describe the most common serious adverse effects and organ toxicities associated with emerging therapies for cancer that may necessitate admission to the ICU. DATA SOURCES AND STUDY SELECTION: PubMed and Medline search of relevant articles in English on the management of adverse effects of immunotherapy for cancer. DATA EXTRACTION AND DATA SYNTHESIS: Targeted immunotherapies including tyrosine kinase inhibitors, monoclonal antibodies, checkpoint inhibitors, and immune effector cell therapy have improved the outcome and quality of life of patients with cancer. However, severe and life-threatening side effects can occur. These toxicities include infusion or hypersensitivity reactions, cytokine release syndrome, pulmonary, cardiac, renal, hepatic, and neurologic toxicities, hemophagocytic lymphohistiocytosis, opportunistic infections, and endocrinopathies. Cytokine release syndrome is the most common serious toxicity after administration of monoclonal antibodies and immune effector cell therapies. Most of the adverse events from immunotherapy results from an exaggerated T-cell response directed against normal tissue, resulting in the generation of high levels of proinflammatory cytokines. Toxicities from targeted therapies are usually secondary to “on target toxicities”. Management is largely supportive and may include discontinuation of the specific agent corticosteroids and other immune-suppressing agents for severe (grade 3 or 4) immune-related adverse events like neurotoxicity and pneumonitis. CONCLUSIONS: The complexity of toxicities associated with modern targeted and immunotherapeutic agents for cancer require a multidisciplinary approach among ICU staff, oncologists, and organ specialists and adoption of standardized treatment protocols to ensure the best possible patient outcomes.

Background Vancomycin-resistant enterococci (VRE) are antibiotic-resistant organisms associated with both colonization and serious life-threatening infection in health care settings. Contamination of platelet concentrates (PCs) with Enterococcus can result in transfusion-transmitted infection. Case presentation This report describes the investigation of a septic transfusion case involving a 27-year-old male patient with relapsed acute leukemia who was transfused with a 5-day-old buffy coat PC pool and developed fever and rigors. Discussion Microbiology testing and pulse-field gel electrophoresis (PFGE) was done on patient blood cultures obtained from peripheral and central lines. Microbiology and molecular testing were also performed on the remaining posttransfusion PC pool, which was refrigerated for 24 hours before microbiology testing. Red blood cell (RBC) and plasma units associated with the implicated PCs were screened for microbial contamination. Patient blood cultures obtained from peripheral and central lines yielded vancomycin-resistant Enterococcus faecium. Gram stain of a sample from the platelet pool was negative but coagulase-negative Staphylococcus (CNST) and VRE were isolated on culture. Antibiotic sensitivity and PFGE profiles of several VRE isolates from the patient before and after transfusion, and the PC pool, revealed that all were closely related. Associated RBC and plasma components tested negative for microbial contamination. Conclusions Microbiological and molecular investigations showed a relationship between VRE isolated from the patient before and after transfusion, and therefore it is postulated that a patient-to-PC retrograde contamination (from either blood or skin) occurred. As the CNST isolated from the PC pool was not isolated from patient samples, its implication in the transfusion event is unknown.

PURPOSE: To determine how patients perceive their quality of life (QOL) six months following critical illness and to measure clinicians’ discriminative accuracy of predicting this outcome. MATERIALS AND METHODS: This prospective cohort study of intensive care unit (ICU) survivors asked patients to report their QOL strictly at six months compared to one month before their critical illness as better, the same, or worse. ICU physicians and nurses made six-month QOL predictions for these patients.. RESULTS: Of 162 critical illness survivors, 33% (n=53) of patients reported six-month QOL as better, 33% (n=54) the same, and 34% (n=55) worse. Abnormal cognition and inability to return to primary pastime or original place of residence (p

BackgroundOptimal end-of-life care requires identifying patients that are near the end of life. The extent to which attending physicians and trainee physicians agree on the prognoses of their patients is unknown. We investigated agreement between attending and trainee physician on the surprise question: “Would you be surprised if this patient died in the next 12 months?”, a question intended to assess mortality risk and unmet palliative care needs.MethodsThis was a multicentre prospective cohort study of general internal medicine patients at 7 tertiary academic hospitals in Ontario, Canada. General internal medicine attending and senior trainee physician dyads were asked the surprise question for each of the patients for whom they were responsible. Surprise question response agreement was quantified by Cohen’s kappa using Bayesian multilevel modeling to account for clustering by physician dyad. Mortality was recorded at 12 months.ResultsSurprise question responses encompassed 546 patients from 30 attending-trainee physician dyads on academic general internal medicine teams at 7 tertiary academic hospitals in Ontario, Canada. Patients had median age 75 years (IQR 60–85), 260 (48%) were female, and 138 (25%) were dependent for some or all activities of daily living. Trainee and attending physician responses agreed in 406 (75%) patients with adjusted Cohen’s kappa of 0.54 (95% credible interval 0.41 to 0.66). Vital status was confirmed for 417 (76%) patients of whom 160 (38% of 417) had died. Using a response of “No” to predict 12-month mortality had positive likelihood ratios of 1.84 (95% CrI 1.55 to 2.22, trainee physicians) and 1.51 (95% CrI 1.30 to 1.72, attending physicians), and negative likelihood ratios of 0.31 (95% CrI 0.17 to 0.48, trainee physicians) and 0.25 (95% CrI 0.10 to 0.46, attending physicians).ConclusionTrainee and attending physician responses to the surprise question agreed in 54% of cases after correcting for chance agreement. Physicians had similar discriminative accuracy; both groups had better accuracy predicting which patients would survive as opposed to which patients would die. Different opinions of a patient’s prognosis may contribute to confusion for patients and missed opportunities for engagement with palliative care services.

Objectives:Antibiotics are commonly used in intensive care units (ICUs), yet differences in antibiotic use across ICUs are unknown. Herein, we studied antibiotic use across ICUs and examined factors that contributed to variation.Methods:We conducted a retrospective cohort study using data from Ontario’s Critical Care Information System (CCIS), which included 201 adult ICUs and 2,013,397 patient days from January 2012 to June 2016. Antibiotic use was measured in days of therapy (DOT) per 1,000 patient days. ICU factors included ability to provide ventilator support (level 3) or not (level 2), ICU type (medical-surgical or other), and academic status. Patient factors included severity of illness using multiple-organ dysfunction score (MODS), ventilatory support, and central venous catheter (CVC) use. We analyzed the effect of these factors on variation in antibiotic use.Results:Overall, 269,351 patients (56%) received antibiotics during their ICU stay. The mean antibiotic use was 624 (range 3–1460) DOT per 1,000 patient days. Antibiotic use was significantly higher in medical-surgical ICUs compared to other ICUs (697 vs 410 DOT per 1,000 patient days; P < .0001) and in level 3 ICUs compared to level 2 ICUs (751 vs 513 DOT per 1,000 patient days; P < .0001). Higher antibiotic use was associated with higher severity of illness and intensity of treatment. ICU and patient factors explained 47% of the variation in antibiotic use across ICUs.Conclusions:Antibiotic use varies widely across ICUs, which is partially associated with ICUs and patient characteristics. These differences highlight the importance of antimicrobial stewardship to ensure appropriate use of antibiotics in ICU patients.

Background: Tumour lysis syndrome (TLS) occurs when lysis of malignant cells causes electrolyte disturbances and potentially organ dysfunction. Guidelines recommending preventive therapy according to TLS risk are based on low-quality evidence.Objectives: The primary objective was to characterize utilization of TLS preventive strategies through comprehensive description of current practice. Secondary objectives were to determine TLS incidence, to compare use of preventive strategies among intermediate- and high-risk patients, and to describe TLS treatment strategies.Methods: This retrospective chart review examined data for patients with newly diagnosed hematologic malignancy who were admitted to an oncology centre and/or affiliated intensive care unit between October 2015 and September 2016 in Toronto, Ontario, Canada. Results: Fifty-eight patients (29 at intermediate risk, 29 at high risk) were eligible for inclusion. Use of preventive allopurinol, IV bicarbonate, and furosemide was similar between groups. Rasburicase was more frequently used for high-risk patients (3% [1/29] of intermediate-risk patients versus 36% [9/25] of high-risk patients; p = 0.003). In 4 (14%) of the intermediate-risk patients and 2 (8%) of the high-risk patients, TLS developed during the admission. TLS was observed in 10% (1/10) of patients who received preventive rasburicase and 11% (5/44) of those who did not (p > 0.99), and in 9% (4/45) of patients who received preventive IV bicarbonate and 25% (2/8) of those who did not (p = 0.22). Treatment strategies included rasburicase, IV bicarbonate, furosemide, and renal replacement therapy.Conclusions: In this retrospective chart review, rasburicase was more commonly used for high-risk patients, whereas the use of other agents was similar between risk groups. This pattern of use is inconsistent with guidelines, which recommend that all high-risk patients receive rasburicase. There was no difference in TLS incidence between patients who did and did not receive preventive rasburicase or IV bicarbonate. Further prospective studies are needed to inform management of patients with malignancies who are at intermediate or high risk of TLS.RÉSUMÉContexte : Le syndrome de lyse tumorale (SLT) se produit lorsque la lyse de cellules malignes provoque des perturbations électrolytiques et la dysfonction potentielle d’un organe. Les lignes directrices préconisant une thérapie préventive basée sur le risque de SLT se fondent sur des éléments de preuve de piètre qualité.Objectifs : L’objectif principal consistait à décrire l’adoption des stratégies de prévention du SLT en décrivant précisément la pratique actuelle. Les objectifs secondaires consistaient, quant à eux, à déterminer l’incidence du SLT, à comparer l’utilisation des stratégies de prévention pour les patients présentant un risque élevé et moyen et à décrire les stratégies de traitement du SLT.Méthodes : Cet examen rétrospectif a permis d’examiner les données de patients ayant récemment reçu un diagnostic d’hémopathie maligne et ayant été admis dans un centre d’oncologie ou une unité de soins intensifs affiliée, entre octobre 2015 et septembre 2016 à Toronto (Ontario), au Canada.Résultats : Cinquante-huit patients (29 présentant un risque moyen et 29 un risque élevé) étaient admissibles. L’utilisation d’allopurinol à titre préventif, de bicarbonate par voie intraveineuse et de furosémide était similaire d’un groupe à l’autre. Le rasburicase était plus fréquemment utilisé pour les patients présentant un risque élevé (3 % [1/29] de patients présentant un risque moyen contre 36 % [9/25] de patients présentant un risque élevé; p = 0.003). Quatre (14 %) patients présentant un risque moyen et deux (8 %) présentant un risque élevé ont développé un SLT pendant l’admission. Le SLT a été observé chez 10 % (1/10) des patients ayant reçu du rasburicase à titre préventif et chez 11 % (5/44) des patients qui n’en avaient pas reçu (p > 0,99); il a aussi été observé chez 9 % (4/45) des patients ayant reçu du bicarbonate par voie intraveineuse à titre préventif et chez 25 % (2/8) des patients qui n’en avaient pas reçu (p = 0.22). Les stratégies de traitement comprenaient le rasburicase, le bicarbonate par voie intraveineuse, le furosémide et la thérapie de remplacement rénal.Conclusions : Dans cet examen rétrospectif des dossiers, l’usage du rasburicase était plus fréquent pour les patients présentant un risque élevé, tandis que celui d’autres agents était similaire entre les groupes à risque. Ce schéma d’utilisation n’est pas conforme aux lignes directrices, qui recommandent que tous les patients présentant un risque élevé reçoivent du rasburicase. Aucune différence n’est apparue dans l’incidence du SLT parmi les patients ayant reçu du rasburicase ou du bicarbonate par voie intraveineuse à titre préventif et parmi ceux qui n’en avaient pas reçu. Davantage d’études prospectives sont nécessaires pour mieux connaitre la gestion des patients à haut risque ou ceux qui présentent des risques moyens de SLT, mais qui ont des malignités.

Rationale: Understanding long-term outcomes of critically ill patients may inform shared decision-making in the intensive care unit (ICU).Objectives: To quantify 6-month functional outcomes of general ICU patients, and develop a multivariable model comprising factors present during the first ICU day to predict which patients will return to their baseline function 6 months later.Methods: We conducted a prospective cohort study in three medical ICUs and two surgical ICUs in three hospitals. We enrolled patients who spent at least 3 days in the ICU and received mechanical ventilation for more than 48 hours and/or vasoactive infusions for more than 24 hours.Results: We measured 6-month outcomes including survival, return to original place of residence, and physical and cognitive function. Of 303 enrolled patients, 299 (98.7%) had complete follow-up at 6 months. Among the 169 patients (56.5%) who survived to 6 months, 82.8% returned home, 81.9% were able to toilet, 71.3% were able to ambulate 10 stairs, and 62...

To describe techniques to facilitate safe intubation in critically ill patients.Despite advances in the treatment of critically ill patients, endotracheal intubation remains a high-risk procedure associated with complications that can lead to appreciable morbidity and mortality. In addition to the usual anatomical factors that can predict a difficult intubation, incorporating pathophysiological considerations and crisis resource management may enhance safety and mitigate risk. Enhancing preoxygenation with high-flow oxygen or noninvasive ventilation, the early use of intravenous fluids and/or vasopressors to prevent hypotension and videolaryngoscopy for first pass success are all promising additions to airway management.Facilitating intubation by either sedation with paralysis or allowing patients to continue to breathe spontaneously are reasonable options for airway management. These approaches have potential advantages and disadvantages.Recognizing the unique challenges of endotracheal intubation in critically ill patients is paramount in limiting further deterioration during this high-risk procedure. A safe approach to intubation focuses on recognizing risk factors that predict challenges in achieving an optimal view of the glottis, maintaining optimal oxygenation, and minimizing the risks and benefits of sedation/induction strategies that are meant to facilitate intubation and avoid clinical deterioration.

Consider the hypothetical case of a 75-year-old patient admitted to the intensive care unit (ICU) for acute hypoxic respiratory failure due to pneumonia and systolic heart failure. Although she suffers from a potentially treatable infection, her advanced age and chronic illness increase her risk of experiencing a poor outcome. Her family feels conflicted about whether the use of mechanical ventilation would be acceptable given what they understand about her values and preferences. In the ICU setting, clinicians, patients, and surrogate decision-makers frequently face challenges of prognostic uncertainty as well as uncertainty regarding patients' goals and values. Time-limited trials (TLTs) of life-sustaining treatments in the ICU have been proposed as one strategy to help facilitate goal-concordant care in the midst of a complex and high-stakes decision-making environment. TLTs represent an agreement between clinicians and patients or surrogate decision-makers to employ a therapy for an agreed-upon time period, with a plan for subsequent reassessment of the patient's progress according to previously-established criteria for improvement or decline. Herein, we review the concept of TLTs in intensive care, and explore their potential benefits, barriers, and challenges. Research demonstrates that, in practice, TLTs are conducted infrequently and often incompletely, and are challenged by system-level factors that diminish their effectiveness. The promise of TLTs in intensive care warrants continued research efforts, including implementation studies to improve adoption and fidelity, observational research to determine optimal timeframes for TLTs, and interventional trials to determine if TLTs ultimately improve the delivery of goal-concordant care in the ICU.

BackgroundCritical care intensity is known to vary across regions and centers, yet the mechanisms remain unidentified. Physician behaviors have been implicated in the variability of intensive care near the end of life, but physician characteristics that may underlie this association have not been determined.PurposeWe sought to identify behavioral attributes that vary among intensivists to generate hypotheses for mechanisms of intensivist-attributable variation in critical care delivery.MethodsWe administered a questionnaire to intensivists who participated in a prior cohort study in which intensivists made prognostic estimates. We evaluated the degree to which scores on six attribute measures varied across intensivists. Measures were selected for their relevance to preference-sensitive critical care: a modified End-of-Life Preferences (EOLP) scale, Life Orientation Test-Revised (LOT-R), Jefferson Scale of Empathy (JSE), Physicians' Reactions to Uncertainty (PRU) scale, Collett-Lester Fear of Death (CLFOD) scale, and a test of omission bias. We conducted regression analyses assessing relationships between intensivists' attribute scores and their prognostic accuracy, as physicians' prognostic accuracy may influence preference-sensitive decisions.Results20 of 25 eligible intensivists (80%) completed the questionnaire. Intensivists' scores on the EOLP, LOT-R, PRU, CLFOD, and omission bias measures varied considerably, while their responses on the JSE scale did not. There were no consistent associations between attribute scores and prognostic accuracy.ConclusionsIntensivists vary in feasibly measurable attributes relevant to preference-sensitive critical care delivery. These attributes represent candidates for future research aimed at identifying mechanisms of clinician-attributable variation in critical care and developing effective interventions to reduce undue variation.

Objectives Chimeric antigen receptor T-cell therapy, a type of immune effector therapy for cancer, has demonstrated encouraging results in clinical trials for the treatment of patients with refractory hematologic malignancies. Nevertheless, there are toxicities specific to these treatments that, if not recognized and treated appropriately, can lead to multiple organ failure and death. This article is a comprehensive review of the available literature and provides, from a critical care perspective, recommendations by experienced intensivists in the care of critically ill adult chimeric antigen receptor T-cell patients. Data sources PubMed and Medline search of articles published from 2006 to date. Study selection Clinical studies, reviews, or guidelines were selected and reviewed by the authors. Data extraction Not available. Data synthesis Not available. Conclusions Until modifications in chimeric antigen receptor T-cell therapy decrease their toxicities, the intensivist will play a leading role in the management of critically ill chimeric antigen receptor T-cell patients. As this novel immunotherapeutic approach becomes widely available, all critical care clinicians need to be familiar with the recognition and management of complications associated with this treatment.

Introduction Delirium is highly prevalent in the intensive care unit (ICU) and is associated with adverse clinical outcomes. At this time, there is no drug that effectively prevents delirium in critically ill patients. Alterations in melatonin secretion and metabolism may contribute to the development of delirium. Administration of exogenous melatonin has been shown to prevent delirium in non-critically ill surgical and medical patients. This trial will demonstrate the feasibility of a planned multicentre, randomised controlled trial to test the hypothesis that melatonin can prevent delirium in critically ill patients compared with placebo. Methods and analysis This feasibility trial is a randomised, 3-arm, placebo-controlled study of melatonin (2 vs 0.5 mg vs placebo, administered for a maximum of 14 days) for the prevention of delirium in critically ill patients. A total of 69 patients aged 18 years and older with an expected ICU length of stay >48 hours will be recruited from 3 Canadian ICUs. The primary outcome is protocol adherence (ie, overall proportion of study drug doses administered in the prescribed administration window). Secondary outcomes include pharmacokinetic parameters, incidence, time to onset, duration of delirium, number of delirium-free days, adverse events, self-reported sleep quality, rest-activity cycles measured by wrist actigraphy, duration of mechanical ventilation, ICU length of stay and mortality. Data will be analysed using an intention-to-treat approach. Ethics and dissemination The study has been approved by Health Canada and the research ethics board of each study site. Trial results will be presented at international conferences and published in a peer-reviewed journal. Trial registration number NCT02615340: Pre-results.

Importance Physicians often rely on surrogate decision-makers (SDMs) to make important decisions on behalf of critically ill patients during times of incapacity. It is uncertain whether targeted interventions to improve surrogate decision-making in the intensive care unit (ICU) reduce nonbeneficial treatment and improve SDM comprehension, satisfaction, and psychological morbidity. Objective To perform a systematic review and meta-analysis of randomized clinical trials (RCTs) to determine the association of such interventions with patient- and family-centered outcomes and resource use. Data Sources A search was conducted of MEDLINE, Embase, and other relevant databases for potentially relevant studies from inception through May 30, 2018. Study Selection Randomized clinical trials studying interventions that were targeted at SDMs or family members of critically ill adults in the ICU were included. Key search terms includedsurrogateorsubstitute decision-maker,critically ill,randomized controlled trials, and their respective related terms. Data Extraction and Synthesis This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Two independent, blinded reviewers independently screened citations and extracted data. Random effects models with inverse variance weighting were used to pool outcomes data when possible and otherwise present findings qualitatively. Main Outcomes and Measures Outcomes of interest were divided into 3 categories: (1) patient-related clinical outcomes (mortality, length of stay [LOS], duration of life-sustaining therapies), (2) SDM and family-related outcomes (comprehension, major change in goals of care, incident psychological comorbidities [posttraumatic stress disorder, anxiety, depression], and satisfaction with care), and (3) use of resources (cost of care and health care resource use). Results Of 3735 studies screened, 13 RCTs were included, comprising a total of 10 453 patients. Interventions were categorized as health care professional led (n = 6), ethics consultation (n = 3), palliative care consultation (n = 2), and media (n = 1 pamphlet and 1 video). No association with mortality was observed (risk ratio, 1.03; 95% CI, 0.98-1.08;P = .22). Intensive care unit LOS was significantly shorter among patients who died (mean difference, −2.11 days; 95% CI, −4.16 to −0.07;P = .04), but not in the overall population (mean difference, –0.79 days; 95% CI, −2.33 to 0.76 days;P = .32). There was no consistent difference in SDM-related outcomes, including satisfaction with care or perceived quality of care (n = 6 studies) and incident psychological comorbidities (depression: ratio of means, −0.11; 95% CI, −0.29 to 0.08;P = .26; anxiety: ratio of means, −0.08; 95% CI, −0.25 to 0.08;P = .31; or posttraumatic stress disorder: ratio of means: −0.04; 95% CI, −0.21 to 0.13;P = .65). Among 6 trials reporting effects on health care resource use, only 1 nurse-led intervention observed a significant reduction in costs ($75 850 control vs $51 060 intervention;P = .04). Conclusions and Relevance Systematic interventions aimed at improving surrogate decision-making for critically ill adults may reduce ICU LOS among patients who die in the ICU, without influencing overall mortality. Better understanding of the complex processes related to surrogate decision-making is needed.

Recognizing patients in whom endotracheal intubation is likely to be difficult can help alert physicians to the need for assistance from a clinician with airway training and having advanced airway management equipment available.To identify risk factors and physical findings that predict difficult intubation.The databases of MEDLINE and EMBASE were searched from 1946 to June 2018 and from 1947 to June 2018, respectively, and the reference lists from the retrieved articles and previous reviews were searched for additional studies.Sixty-two studies with high (level 1-3) methodological quality that evaluated the accuracy of clinical findings for identifying difficult intubation were reviewed.Two authors independently abstracted data. Bivariate random-effects meta-analyses were used to calculate summary positive likelihood ratios across studies or univariate random-effects models when bivariate models failed to converge.Among the 62 high-quality studies involving 33 559 patients, 10% (95% CI, 8.2%-12%) of patients were difficult to intubate. The physical examination findings that best predicted a difficult intubation included a grade of class 3 on the upper lip bite test (lower incisors cannot extend to reach the upper lip; positive likelihood ratio, 14 [95% CI, 8.9-22]; specificity, 0.96 [95% CI, 0.93-0.97]), shorter hyomental distance (range of3-5.5 cm; positive likelihood ratio, 6.4 [95% CI, 4.1-10]; specificity, 0.97 [95% CI, 0.94-0.98]), retrognathia (mandible measuring9 cm from the angle of the jaw to the tip of the chin or subjectively short; positive likelihood ratio, 6.0 [95% CI, 3.1-11]; specificity, 0.98 [95% CI, 0.90-1.0]), and a combination of physical findings based on the Wilson score (positive likelihood ratio, 9.1 [95% CI, 5.1-16]; specificity, 0.95 [95% CI, 0.90-0.98]). The widely used modified Mallampati score (≥3) had a positive likelihood ratio of 4.1 (95% CI, 3.0-5.6; specificity, 0.87 [95% CI, 0.81-0.91]).Although several simple clinical findings are useful for predicting a higher likelihood of difficult endotracheal intubation, no clinical finding reliably excludes a difficult intubation. An abnormal upper lip bite test, which is easily assessed by clinicians, raises the probability of difficult intubation from 10% to greater than 60% for the average-risk patient.

Post-intensive care syndrome (PICS), defined as new or worsening impairment in cognition, mental health, or physical function after critical illness, is an important development in survivors. Although studies to date have focused on the frequency of these impairments, fundamental questions remain unanswered regarding the survivor experience and the impact of the critical illness event on survivor resilience and recovery.To examine the association between resilience and neuropsychological and physical function and to contextualize these findings within the survivors' recovery experience.We conducted a mixed-methods pilot investigation of resilience among 43 survivors from two medical intensive care units (ICUs) within an academic health-care system. We interviewed survivors to identify barriers to and facilitators of recovery in the ICU, on the medical ward, and at home, using qualitative methods. We used a telephone battery of standardized tests to examine resilience, neuropsychological and physical function, and quality of life. We examined PICS in two ways. First, we identified how frequently survivors were impaired in one or more domains 6-12 months postdischarge. Second, we identified how frequently survivors reported that neuropsychological or physical function was worse.Resilience was low in 28% of survivors, normal in 63% of survivors, and high in 9% of survivors. Resilience was inversely correlated with self-reported executive dysfunction, symptoms of anxiety, depression, and post-traumatic stress disorder, difficulty with self-care, and pain (P 0.05). PICS was present in 36 survivors (83.7%; 95% confidence interval, 69.3-93.2%), whereas 23 survivors (53.5%; 95% confidence interval, 37.6-68.8%) reported worsening of neuropsychological or physical function after critical illness. We identified challenges along the recovery path of ICU survivors, finding that physical limitations and functional dependence were the most frequent challenges experienced in the ICU, medical ward, and on return to home. Spiritual and family support facilitated recovery.Resilience was inversely correlated with neuropsychological impairment, pain, and difficulty with self-care. PICS was present in most survivors of critical illness, and 54% reported neuropsychological or physical function to be worse, yet resilience was normal or high in most survivors. Survivors experienced many challenges during recovery, while spiritual and family support facilitated recovery.

Toxoplasma gondii is a ubiquitous intracellular parasite that can cause disseminated infection following reactivation in immunocompromised hosts. We describe a 58-year-old man who died of refractory shock because of disseminated toxoplasmosis. The diagnosis was only made postmortem on autopsy. We discuss the importance of considering toxoplasmosis on the differential diagnosis in high-risk patients, and review the role of screening and chemoprophylaxis in preventing infection.

A 52-year-old woman experienced the sudden onset of bilateral arm tingling and numbness, and noted that the words on her computer screen appeared “mixed up.” She improved over the next 24 hours, but then difficulty swallowing and slurred speech developed, progressing over the next three days to no speech.

Ultrasound measurements of diaphragm thickness (T di) and thickening (TFdi) may be useful to monitor diaphragm activity and detect diaphragm atrophy in mechanically ventilated patients. We aimed to establish the reproducibility of measurements in ventilated patients and determine whether passive inflation by the ventilator might cause thickening apart from inspiratory effort.Five observers measured T di and TFdi in 96 mechanically ventilated patients. The probe site was marked in 66 of the 96 patients. TFdi was measured at peak and end-inspiration (airway occluded and diaphragm relaxed) in nine healthy volunteers inhaling to varying lung volumes. The association with diaphragm electrical activity was quantified.Right hemidiaphragm thickness was obtained on 95 % of attempts; left hemidiaphragm measurements could not be obtained consistently. Right hemidiaphragm thickness measurements were highly reproducible (mean ± SD 2.4 ± 0.8 mm, repeatability coefficient 0.2 mm, reproducibility coefficient 0.4 mm), particularly after marking the location of the probe. TFdi measurements were only moderately reproducible (median 11 %, IQR 3-17 %, repeatability coefficient 17 %, reproducibility coefficient 16 %). TFdi and diaphragm electrical activity were positively correlated, r² = 0.32, p0.01). At inspiratory volumes below 50 % of inspiratory capacity, passive inflation did not cause diaphragm thickening. TFdi was considerably lower in patients on either partially assisted or controlled ventilation compared to healthy subjects (median 11 vs. 35 %, p0.001).Ultrasound measurements of right hemidiaphragm thickness are feasible and highly reproducible in ventilated patients. At clinically relevant inspiratory volumes, diaphragm thickening reflects muscular contraction and not passive inflation. This technique can be reliably employed to monitor diaphragm thickness, activity, and function during mechanical ventilation.

In patients with acute respiratory distress syndrome (ARDS), extracorporeal life support (ECLS) has been utilized to support gas exchange and mitigate ventilator-induced lung injury (VILI). The optimal ventilation settings while on ECLS are unknown. The purpose of this systematic review is to describe the ventilation practices in patients with ARDS who require ECLS.We electronically searched MEDLINE, EMBASE, CENTRAL, AMED, and HAPI (inception to January 2015). Studies included were randomized controlled trials, observational studies, or case series (≥4 patients) of ARDS patients undergoing ECLS. Our review focused on studies describing ventilation practices employed during ECLS for ARDS.Forty-nine studies (2,042 patients) met our inclusion criteria. Prior to initiation of ECLS, at least one parameter consistent with injurious ventilation [tidal volume8 mL/kg predicted body weight (PBW), peak pressure35 cmH2O (or plateau pressure30 cmH2O), or FiO2 ≥0.8] was noted in 90% of studies. After initiation of ECLS, studies reported median [interquartile range (IQR)] reductions in: tidal volume [2.4 mL/kg PBW (2.2-2.9)], plateau pressure [4.3 cmH2O (3.5-5.8)], positive end-expiratory pressure (PEEP) [0.20 cmH2O (0-3.0)], and FiO2 [0.40 (0.30-0.60)]. Median (IQR) overall mortality was 41 % (31-51%).Reduction in the intensity of mechanical ventilation in patients with ARDS supported by ECLS is common, suggesting that clinicians may be focused on reducing VILI after ECLS initiation. Future investigations should focus on establishing the optimal ventilatory strategy for patients with ARDS who require ECLS.

In patients with severe, acute respiratory failure undergoing venovenous extracorporeal membrane oxygenation (VV-ECMO), the optimal strategy for mechanical ventilation is unclear.Our objective was to describe ventilation practices used in centers registered with the Extracorporeal Life Support Organization (ELSO).We conducted an international cross-sectional survey of medical directors and ECMO program coordinators from all ELSO-registered centers. The survey was distributed using a commercial website that collected information on center characteristics, the presence of a mechanical ventilator protocol, ventilator settings, and weaning practices. E-mails were sent out to medical directors or coordinators at each ELSO center and their responses were pooled for analysis.We analyzed 141 (50%) individual responses from the 283 centers contacted across 28 countries. Only 27% of centers reported having an explicit mechanical ventilation protocol for ECMO patients. The majority of these centers (77%) reported "lung rest" to be the primary goal of mechanical ventilation, whereas 9% reported "lung recruitment" to be their ventilation strategy. A tidal volume of 6 ml/kg or less was targeted by 76% of respondents, and 58% targeted a positive end-expiratory pressure of 6-10 cm H2O while ventilating patients on VV-ECMO. Centers prioritized weaning VV-ECMO before mechanical ventilation.Although ventilation practices in patients supported by VV-ECMO vary across ELSO centers internationally, the majority of centers used a strategy that targeted lung-protective thresholds and prioritized weaning VV-ECMO over mechanical ventilation.

BACKGROUND: Chest radiography is an important component of the evaluation of patients with complaints referable to the chest. We sought to investigate the clinical utility of one particular finding on the lateral chest radiograph (CXR), namely, radioopacity obscuring the normal superior to inferior progression of vertebral radiolucency. A review of the literature yielded little published evidence to characterize the clinical utility of this finding to date. METHODS: We retrospectively identified 370 patients from a hospital database who underwent both computed tomography (CT) imaging of the chest and lateral chest radiography within 24 hours. We calculated the sensitivity, specificity, and likelihood ratios (LRs) associated with the presence or absence of an abnormal opacity overlying the vertebral column on lateral chest radiography using CT imaging of the chest as the reference standard. We also estimated interobserver and intraobserver reliability of this finding. RESULTS: Abnormal opacity overlying the vertebral column had a sensitivity of 86.9% (95% confidence interval [CI], 82.5%-90.3%) and specificity of 70.4% (95% CI, 59.7%-79.2%) for relevant CT-documented lower lobe and associated structural pathology. The associated summary positive LR (LR+) was 2.9 (95% CI, 2.1-4.1) and summary negative LR (LR−) was 0.19 (95% CI, 0.13-0.26). Kappa statistics were indicative of moderate intraobserver and interobserver agreement. CONCLUSIONS: The presence of abnormal opacity overlying the vertebral column on lateral chest radiography increases the probability of lower lobe and associated structural pathology somewhat. The absence of this finding decreased the probability of such pathology to a greater degree. Thus, this finding is useful in differentiating those patients with pathology from those without. Journal of Hospital Medicine 2009;4:E15–E19. © 2009 Society of Hospital Medicine.

Society has a vested interest in supporting and promoting health care research. Physicians, among other clinical professionals, have an important role to play. In recent years, many have decried the lack of opportunities for physicians to perform research.[1][1] Encouraging medical students and

We aimed to determine internal medicine residents' perceptions of the adequacy of their training to serve as in-hospital cardiac arrest team leaders, given the responsibility of managing acutely critically ill patients and with recent evidence suggesting that the quality of cardiopulmonary resuscitation provided in teaching hospitals is suboptimal.Cross-sectional postal survey.Canadian internal medicine training programs.Internal medicine residents attending Canadian English-speaking medical schools.A survey was mailed to internal medicine residents asking questions relating to four domains: adequacy of training, perception of preparedness, adequacy of supervision and feedback, and effectiveness of additional training tools.Of the 654 residents who were sent the survey, 289 residents (44.2%) responded. Almost half of the respondents (49.3%) felt inadequately trained to lead cardiac arrest teams. Many (50.9%) felt that the advanced cardiac life support course did not provide the necessary training for team leadership. A substantial number of respondents (40%) reported receiving no additional cardiac arrest training beyond the advanced cardiac life support course. Only 52.1% of respondents felt prepared to lead a cardiac arrest team, with 55.3% worrying that they made errors. Few respondents reported receiving supervision during weekdays (14.2%) or evenings and weekends (1.4%). Very few respondents reported receiving postevent debriefing (5.9%) or any performance feedback (1.3%). Level of training and receiving performance feedback were associated with perception of adequacy of training (r(2) = .085, p.001). Respondents felt that additional training involving full-scale simulation, leadership skills training, and postevent debriefing would be most effective in increasing their skills and confidence.The results suggest that residents perceive deficits in their training and supervision to care for critically ill patients as cardiac arrest team leaders. This raises sufficient concern to prompt teaching hospitals and medical schools to consider including more appropriate supervision, feedback, and further education for residents in their role as cardiac arrest team leaders.

Ultrasound measurements of diaphragm thickness (T di) and thickening (TFdi) may be useful to monitor diaphragm activity and detect diaphragm atrophy in mechanically ventilated patients. We aimed to establish the reproducibility of measurements in ventilated patients and determine whether passive inflation by the ventilator might cause thickening apart from inspiratory effort. Five observers measured T di and TFdi in 96 mechanically ventilated patients. The probe site was marked in 66 of the 96 patients. TFdi was measured at peak and end-inspiration (airway occluded and diaphragm relaxed) in nine healthy volunteers inhaling to varying lung volumes. The association with diaphragm electrical activity was quantified. Right hemidiaphragm thickness was obtained on 95 % of attempts; left hemidiaphragm measurements could not be obtained consistently. Right hemidiaphragm thickness measurements were highly reproducible (mean ± SD 2.4 ± 0.8 mm, repeatability coefficient 0.2 mm, reproducibility coefficient 0.4 mm), particularly after marking the location of the probe. TFdi measurements were only moderately reproducible (median 11 %, IQR 3–17 %, repeatability coefficient 17 %, reproducibility coefficient 16 %). TFdi and diaphragm electrical activity were positively correlated, r 2 = 0.32, p

ContextIn assessing the patient with headache, clinicians are often faced with 2 important questions: Is this headache a migraine? Does this patient require neuroimaging? The diagnosis of migraine can direct therapy, and information obtained from the history and physical examination is used by physicians to determine which patients require neuroimaging.ObjectiveTo determine the usefulness of the history and physical examination that distinguish patients with migraine from those with other headache types and that identify those patients who should undergo neuroimaging.Data Sources and Study SelectionA systematic review was performed using articles from MEDLINE (1966-November 2005) that assessed the performance characteristics of screening questions in diagnosing migraine (with the International Headache Society diagnostic criteria as a gold standard) and addressed the accuracy of the clinical examination in predicting the presence of underlying intracranial pathology (with computed tomography/magnetic resonance imaging as the reference standard).Data ExtractionTwo authors independently reviewed each study to determine eligibility, abstract data, and classify methodological quality using predetermined criteria. Disagreement was resolved by consensus with a third author.Data SynthesisFour studies of screening questions for migraine (n = 1745 patients) and 11 neuroimaging studies (n = 3725 patients) met inclusion criteria. All 4 of the migraine studies illustrated high sensitivity and specificity if 3 or 4 criteria were met. The best predictors can be summarized by the mnemonic POUNDing (Pulsating, duration of 4-72 hOurs, Unilateral, Nausea, Disabling). If 4 of the 5 criteria are met, the likelihood ratio (LR) for definite or possible migraine is 24 (95% confidence interval [CI], 1.5-388); if 3 are met, the LR is 3.5 (95% CI, 1.3-9.2), and if 2 or fewer are met, the LR is 0.41 (95% CI, 0.32-0.52). For the neuroimaging question, several clinical features were found on pooled analysis to predict the presence of a serious intracranial abnormality: cluster-type headache (LR, 10.7; 95% CI, 2.2-52); abnormal findings on neurologic examination (LR, 5.3; 95% CI, 2.4-12); undefined headache (ie, not cluster-, migraine-, or tension-type) (LR, 3.8; 95% CI, 2.0-7.1); headache with aura (LR, 3.2; 95% CI, 1.6-6.6); headache aggravated by exertion or a valsalva-like maneuver (LR, 2.3; 95% CI, 1.4-3.8); and headache with vomiting (LR, 1.8; 95% CI, 1.2-2.6). No clinical features were useful in ruling out significant pathologic conditions.ConclusionsThe presence of 4 simple historical features can accurately diagnose migraine. Several individual clinical features were found to be associated with a significant intracranial abnormality, and patients with these features should undergo neuroimaging.

Laheij RJ, Sturkenboom MC, Hassing RJ, Dieleman J, Stricker BH, Jansen JB. Risk of community-acquired pneumonia and use of gastric acid-suppressive drugs. JAMA 2004;292(16):1955-60 Background: Dyspepsia is responsible for 7% of visits to family practitioners,[1][1] and millions of Canadians have

The relationship between isovolumic left ventricular (LV) relaxation and LV filling pressures remains incompletely explored. If there is a relationship between the rate of early diastolic LV relaxation and LV end-diastolic pressure, this would have important implications concerning both our understanding and, potentially, our treatment of LV diastolic dysfunction.To examine the baseline hemodynamic correlates of LV end-diastolic pressure in patients with both normal and abnormal LV function.The relationships between LV end-diastolic pressure, a variety of hemodynamic parameters (tau, the rate of LV isovolumic relaxation, LV peak positive+dP/dt, LV peak systolic pressure and heart rate), measures of LV end-systolic and end-diastolic volume, and age were determined using regression analysis techniques in 104 patients with normal LV systolic function and 90 patients with an LV ejection fraction of less than 40%.Univariate analysis demonstrated a correlation between tau and LV end-diastolic pressure (r=0.743, P0.001). There were significant univariate relationships between a number of other hemodynamic variables and LV end-diastolic pressure. A multiple regression model demonstrated that tau made the most important contribution to a model where LV end-diastolic pressure is the dependent variable. LV peak systolic pressure and heart rate also made significant contributions to the model. In 33 of these patients, when LV end-diastolic pressure was reduced using an inferior vena cava occlusion balloon, tau did not change. The acute administration of clonidine (n=11) caused an increase in LV end-diastolic pressure that was closely correlated with an observed increase in tau (r=0.843, P0.001).These observations suggest that the rate of LV isovolumic relaxation is a predictor of LV end-diastolic pressure.