Trauma resident exposure in Canada and operative numbers (TraumaRECON): a national multicentre retrospective review of operative and nonoperative trauma teaching.

BACKGROUND: General surgeons play an important role in the provision of trauma care in Canada and the current extent of their trauma experience during training is unknown. We sought to quantify the operative and nonoperative educational experiences among Canadian general surgery trainees. METHODS: We conducted a multicentre retrospective study of major operative exposures experienced by general surgery residents, as identified using institutional trauma registries and subsequent chart-level review, for 2008-2018. We also conducted a site survey on trauma education and structure. RESULTS: We collected data on operative exposure for general surgery residents from 7 programs and survey data from 10 programs. Operations predominantly occurred after hours (73% after 1700 or on weekends) and general surgery residents were absent from a substantial proportion (25%) of relevant trauma operations. The structure of trauma education was heterogeneous among programs, with considerable site-specific variability in the involvement of surgical specialties in trauma care. During their training, graduating general surgery residents each experienced around 4 index trauma laparotomies, 1 splenectomy, 1 thoracotomy, and 0 neck explorations for trauma. CONCLUSION: General surgery residents who train in Canada receive variable and limited exposure to operative and nonoperative trauma care. These data can be used as a baseline to inform the application of competency-based medical education in trauma care for general surgery training in Canada.

Annexin A5 in Patients With Severe COVID-19 Disease: A Single-Center, Randomized, Double-Blind, Placebo-Controlled Feasibility Trial.

OBJECTIVES: To evaluate the study design and feasibility of drug administration and safety in a randomized clinical trial of recombinant human annexin A5 (SY-005), a constitutively expressed protein with anti-inflammatory, antiapoptotic, and anticoagulant properties, in patients with severe coronavirus disease 2019 (COVID-19). DESIGN: Double-blind, randomized clinical trial. SETTING: Two ICUs at an academic medical center. PATIENTS/SUBJECTS: Adults admitted to the ICU with a confirmed diagnosis of COVID-19 and requiring ventilatory or vasopressor support. INTERVENTIONS: SY-005, a recombinant human annexin A5, at 50 or 100 µg/kg IV every 12 hours for 7 days. MEASUREMENTS AND MAIN RESULTS: We enrolled 18 of the 55 eligible patients (33%) between April 21, 2021, and February 3, 2022. We administered 82% (196/238) of the anticipated doses of study medication and 86% (169/196) were given within 1 hour of the scheduled time. There were no drug-related serious adverse events. We captured 100% of the data that would be required for measuring clinical outcomes in a phase 2 or 3 trial. LIMITATIONS: The small sample size was a result of decreasing admissions of patients with COVID-19, which triggered a stopping rule for the trial. CONCLUSIONS: Although enrollment was low, administration of SY-005 to critically ill patients with COVID-19 every 12 hours for up to 7 days was feasible and safe. Further clinical trials of annexin A5 for the treatment of COVID-19 are warranted. Given reduction of severe COVID-19 disease, future studies should explore the safety and effectiveness of SY-005 use in non-COVID-related sepsis.

Child restraint systems: Understanding confidence in proper use and addressing the need for education.

Objective: To quantify the extent of proper local child restraint system (CRS) use and to better understand changes to the level of self-reported confidence with increased CRS installations. With the goal being to improve safety for children travelling in personal vehicles across London, ON and the region. Methods: Public CRS clinics were initiated by Injury Prevention staff after they obtained the Child Passenger Safety Technician certification. Additionally, an online survey was commissioned targeting Ontario parents who had installed at least one CRS in the last five years. Results: From September 2018 to September 2019, 96 comprehensive CRS checks were performed, with 29% of systems found to be installed correctly. Survey results showed a high level of reported confidence with CRS installation (N = 514, 70% female, 43% one child). Parents who had installed only one CRS reported higher confidence in their first install, compared to parents who had installed two or more systems. Conclusions: The error rate with CRS installation and use seen in London, Ontario and the region, is similar to that reported in previous research. Survey results showed high levels of self-reported confidence in CRS use, especially for parents who have installed only one CRS. There presents a need to better understand the root cause of the discrepancy between level of confidence and proper CRS use and to expand our understanding of CRS knowledge retention and transferability to subsequent systems.

When is a person dead? The Canadian public's understanding of death and death determination: a nationwide survey.

PURPOSE: We aimed to describe the Canadian public's understanding and perception of how death is determined in Canada, their level of interest in learning about death and death determination, and their preferred strategies for informing the public. METHODS: We conducted a nationwide cross-sectional survey of a representative sample of the Canadian public. The survey presented two scenarios of a man who met current criteria for neurologic death determination (scenario 1) and a man who met current criteria for circulatory death determination (scenario 2). Survey questions evaluated understanding of how death is determined, acceptance of death determination by neurologic and circulatory criteria, and interest and preferred strategies in learning more about the topic. RESULTS: Among 2,000 respondents (50.8% women; n = 1,015), nearly 67.2% believed that the man in scenario 1 was dead (n = 1,344) and 81.2% (n = 1,623) believed that the man in scenario 2 was dead. Respondents who believed that the man was not dead or were unsure endorsed several factors that may increase their agreement with the determination of death, including requiring more information about how death was determined, seeing the results of brain imaging/tests, and a third doctor's opinion. Predictors of disbelief that the man in scenario 1 is dead were younger age, being uncomfortable with the topic of death, and subscribing to a religion. Predictors of disbelief that the man in scenario 2 is dead were younger age, residing in Quebec (compared with Ontario), having a high school education, and subscribing to a religion. Most respondents (63.3%) indicated interest in learning more about death and death determination. Most respondents preferred to receive information about death and death determination from their health care professional (50.9%) and written information provided by their health care professional (42.7%). CONCLUSION: Among the Canadian public, the understanding of neurologic and circulatory death determination is variable. More uncertainty exists with death determination by neurologic criteria than with circulatory criteria. Nevertheless, there is a high level of general interest in learning more about how death is determined in Canada. These findings provide important opportunities for further public engagement.

RéSUME: OBJECTIF: Notre objectif était de décrire la compréhension et la perception du public canadien quant à la façon dont le décès est déterminé au Canada, son niveau d'intérêt à en apprendre davantage sur le décès et la détermination du décès, et ses stratégies préférées pour informer le public. MéTHODE: Nous avons réalisé un sondage transversal national auprès d'un échantillon représentatif de la population canadienne. L'enquête a présenté deux scénarios : un homme qui répondait aux critères actuels de détermination d'un décès neurologique (scénario 1) et un homme qui répondait aux critères actuels de détermination d'un décès cardiocirculatoire (scénario 2). Les questions de l'enquête évaluaient la compréhension de la façon dont le décès est déterminé, l'acceptation de la détermination du décès selon des critères neurologiques et circulatoires, et l'intérêt et les stratégies préférées pour en apprendre davantage sur le sujet. RéSULTATS: Parmi les 2000 répondants (50,8 % de femmes; n = 1015), près de 67,2 % ont estimé que l'homme du scénario 1 était décédé (n = 1344) et 81,2 % (n = 1623) ont estimé que l'homme du scénario 2 était décédé. Les répondants qui croyaient que l'homme n'était pas décédé ou qui n'étaient pas sûrs ont acquiescé à plusieurs facteurs qui pourraient accroître leur accord avec la détermination du décès, y compris le besoin de plus de renseignements sur la façon dont le décès a été déterminé, la consultation des résultats d'imagerie et des tests cérébraux et l'opinion d'un troisième médecin. Les prédicteurs de non-conviction que l'homme dans le scénario 1 était décédé étaient le fait d'être plus jeune, le fait d'être mal à l'aise avec le sujet de la mort et la croyance en une religion. Les prédicteurs de non-conviction à l'égard du décès de l'homme dans le scénario 2 étaient le fait d'être plus jeune, d'être résident du Québec (comparativement à l'Ontario), d'avoir complété des études secondaires et la croyance en une religion. La plupart des répondants (63,3 %) ont indiqué qu'ils souhaiteraient en apprendre davantage sur le décès et la détermination du décès. La plupart des répondants préféraient recevoir de l'information sur le décès et la détermination du décès de leur professionnel de la santé (50,9 %) et de l'information écrite fournie par leur professionnel de la santé (42,7 %). CONCLUSION: Parmi le public canadien, la compréhension de la détermination du décès neurologique et cardiocirculatoire est variable. Il existe plus d'incertitude en matière de détermination du décès selon des critères neurologiques que selon des critères cardiocirculatoires. Néanmoins, il existe un grand intérêt général à en apprendre davantage sur la façon dont le décès est déterminé au Canada. Ces résultats offrent d'importantes possibilités de participation accrue du public à l'avenir.

Efficacy of high dose tranexamic acid (TXA) for hemorrhage: A systematic review and meta-analysis.

BACKGROUND: Standard dose (≤ 1 g) tranexamic acid (TXA) has established mortality benefit in trauma patients. The role of high dose IV TXA (≥2 g or ≥30 mg/kg as a single bolus) has been evaluated in the surgical setting, however, it has not been studied in trauma. We reviewed the available evidence of high dose IV TXA in any setting with the goal of informing its use in the adult trauma population. METHODS: We searched MEDLINE, EMBASE and unpublished sources from inception until July 27, 2022 for studies that compared standard dose with high dose IV TXA in adults (≥ 16 years of age) with hemorrhage. Screening and data abstraction was done independently and in duplicate. We pooled trial data using a random effects model and considered randomized controlled trials (RCTs) and observational cohort studies separately. We assessed the individual study risk of bias using the Cochrane Risk of Bias for RCTs and the Newcastle-Ottawa Scale for observational cohort studies. The overall certainty of evidence was assessed using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation). RESULTS: We included 20 studies with a combined total of 12,523 patients. Based on pooled RCT data, and as compared to standard dose TXA, high dose IV TXA probably decreases transfusion requirements (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.76 to 0.97, moderate certainty) but with possibly no effect on blood loss (mean difference [MD] 43.31 ml less, 95% CI 135.53 to 48.90 ml less, low certainty), and an uncertain effect on thromboembolic events (OR 1.33, 95% CI 0.86 to 2.04, very low certainty) and mortality (OR 0.70, 95% CI 0.37 to 1.32, very low certainty). CONCLUSION: When compared to standard dose, high dose IV TXA probably reduces transfusion requirements with an uncertain effect on thromboembolic events and mortality. LEVEL OF EVIDENCE: Systematic review and meta-analysis, level IV.

Transfer status may not be associated with worse outcomes in elderly trauma patients.

PURPOSE: To compare outcomes of elderly patients who arrive directly to a lead trauma centre to those who are transferred from a peripheral hospital. METHODS: This study used a retrospective cohort design and data obtained from the local trauma registry. The study population was patients 65 years and older who presented with an Injury Severity Score (ISS) of 12 or greater, or for whom the trauma team was activated, over a 10-year period. Patients were excluded from the study if they arrived direct from the scene and died within 3 hours of arrival, they were found to have no injuries, or they were directly admitted more than 2 days from the time of injury. Following the use of multiple imputation, multivariable logistic regression analysis was used to evaluate the relationship between in-hospital mortality and directness of transport, while adjusting for potentially confounding variables. RESULTS: Of the 1619 patients included in the analyses over half (54.2%) were transported directly from the scene of injury to the lead trauma hospital (LTH). The remaining 45.8% initially presented to a non-tertiary hospital and were later transferred to the LTH. Crude mortality was 18.7% in the direct group and 14.0% in the transfer group (p = 0.015). The unadjusted odds of death for patients arriving to LTH by referral was 0.71 (95% confidence interval, 0.54, 0.93), compared to patients arriving to the LTH directly. After adjustment for age, ISS, presence of severe head injury, Charlson Comorbidity Index, shock, initial GCS, and ICU admission from the emergency department, the mortality risk did not differ significantly for transferred patients compared to those arriving directly (OR = 0.77 (95% confidence interval, 0.54, 1.09). CONCLUSION: There was no significant difference in in-hospital mortality between elderly patients transported directly to the trauma centre and those who were transferred from peripheral hospitals.

Intravenous lidocaine for the management of traumatic rib fractures: A double-blind randomized controlled trial (INITIATE program of research).

BACKGROUND: Traumatic rib fractures (TRFs) are common with a 10% incidence in all trauma patients and are associated with significant morbidity and mortality. Adequate analgesia is paramount for preventing pulmonary complications and death. Evidence exists for intravenous (IV) lidocaine's effectiveness and safety in postoperative thoracic and abdominal surgery, and we hypothesized that it would be effective in patients with TRFs. METHODS: We conducted a single-center, double-blind, randomized control trial comparing IV lidocaine plus usual analgesics to placebo infusion plus usual analgesics for 72 hours to 96 hours. Participants were adult trauma patients diagnosed with two or more TRFs requiring hospital admission. The primary outcome was mean pain score at rest and with movement, as measured on the visual analog scale. Secondary outcomes included patient satisfaction and opioid requirements (standardized total morphine equivalents). The study was powered to detect a 20% reduction in pain scores, which has been deemed clinically meaningful. RESULTS: Thirty-six patients were enrolled and randomized to IV lidocaine or placebo. Comparison of the mean visual analog scale pain scores demonstrated significant pain reduction with movement in the lidocaine group compared with placebo (7.05 ± 1.72 vs. 8.22 ± 1.28, p = 0.042). Although pain scores at rest were reduced in the lidocaine group, this difference was not statistically significant (3.37 ± 2.00 vs. 3.82 ± 1.97; p = 0.519). Patient satisfaction was higher in the lidocaine group than the placebo group, although this did not reach statistical significance (8.3; interquartile range [IQR], 7.0-9.6 vs. 6.3; IQR, 5.2-7.1; p = 0.105). Total morphine equivalents were lower in the lidocaine group than the placebo group, but this difference did not reach statistical significance (167; IQR, 60-340 vs. 290; IQR 148-390; p = 0.194). CONCLUSION: These results demonstrate that lidocaine has a beneficial analgesic effect in patients with TRFs. Future work is needed to evaluate lidocaine's ability to reduce patient important consequences of inadequate analgesia. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level II.

Personal, professional, and psychological impact of the COVID-19 pandemic on hospital workers: A cross-sectional survey.

OBJECTIVES: We aimed to evaluate the personal, professional, and psychological impact of the COVID-19 pandemic on hospital workers and their perceptions about mitigating strategies. DESIGN: Cross-sectional web-based survey consisting of (1) a survey of the personal and professional impact of the COVID-19 pandemic and potential mitigation strategies, and (2) two validated psychological instruments (Kessler Psychological Distress Scale [K10] and Impact of Events Scale Revised [IES-R]). Regression analyses were conducted to identify the predictors of workplace stress, psychological distress, and post-traumatic stress. SETTING AND PARTICIPANTS: Hospital workers employed at 4 teaching and 8 non-teaching hospitals in Ontario, Canada during the COVID-19 pandemic. RESULTS: Among 1875 respondents (84% female, 49% frontline workers), 72% feared falling ill, 64% felt their job placed them at great risk of COVID-19 exposure, and 48% felt little control over the risk of infection. Respondents perceived that others avoided them (61%), reported increased workplace stress (80%), workload (66%) and responsibilities (59%), and 44% considered leaving their job. The psychological questionnaires revealed that 25% had at least some psychological distress on the K10, 50% had IES-R scores suggesting clinical concern for post-traumatic stress, and 38% fulfilled criteria for at least one psychological diagnosis. Female gender and feeling at increased risk due to PPE predicted all adverse psychological outcomes. Respondents favoured clear hospital communication (59%), knowing their voice is heard (55%), expressions of appreciation from leadership (55%), having COVID-19 protocols (52%), and food and beverages provided by the hospital (50%). CONCLUSIONS: Hospital work during the COVID-19 pandemic has had important personal, professional, and psychological impacts. Respondents identified opportunities to better address information, training, and support needs.

Socioeconomic Status and Medical Assistance in Dying: A Regional Descriptive Study.

Objective: Concerns that medical assistance in dying (MAiD) may harm vulnerable groups unable to access medical treatments and social supports have arisen since the legalization of MAiD on June 17, 2016; however, there is little research on the topic. The purpose of this study is to investigate the socioeconomic status (SES) of patients who request MAiD at the London Health Sciences Centre (LHSC). Methods: A retrospective analysis of patients from the LHSC MAiD database between June 6, 2016 and December 20, 2019 was conducted. Patients were linked to income data from the 2016 Canadian Census, and their corresponding income quintile was a proxy for SES. Geographic information system (GIS) mapping software was used to visualize the distribution of income and MAiD requests. Results: 39.4% of the LHSC catchment area was classified as low SES. Two hundred thirty-seven (58.1%) MAiD requests came from low SES patients and 171 (41.9%) requests came from high SES patients. Two hundred fifty-nine (63.5%) patients who requested a MAiD assessment did not receive MAiD following their request. Of the 237 lower SES patients, 150 (63.3% [95% CI 57.2-69.3]) did not receive MAiD. Of the 171 higher SES patients, 109 (63.7% [95% CI 56.5-70.9]) did not receive MAiD. Conclusion: A disproportionate number of requests for a MAiD assessment at LHSC came from lower SES patients; however, similar proportions of patients who requested MAiD from each SES group received aid in dying. Future research should explore why a disproportionately high number of low SES patients request MAiD at LHSC.

The impact of the COVID-19 pandemic on intensive care unit workers: a nationwide survey.

PURPOSE: To evaluate the impact of the COVID-19 pandemic on Canadian intensive care unit (ICU) workers. METHODS: Between June and August 2020, we distributed a cross-sectional online survey of ICU workers evaluating the impact of the pandemic, coping strategies, symptoms of post-traumatic stress disorder (PTSD; Impact of Events Scale-Revised), and psychological distress, anxiety, and depression (Kessler Psychological Distress Scale). We performed regression analyses to determine the predictors of psychological symptoms. RESULTS: We analyzed responses from 455 ICU workers (80% women; 67% from Ontario; 279 nurses, 69 physicians, and 107 other healthcare professionals). Respondents felt that their job put them at great risk of exposure (60%), were concerned about transmitting COVID-19 to family members (76%), felt more stressed at work (67%), and considered leaving their job (37%). Overall, 25% had probable PTSD and 18% had minimal or greater psychological distress. Nurses were more likely to report PTSD symptoms (33%) and psychological distress (23%) than physicians (5% for both) and other health disciplines professionals (19% and 14%). Variables associated with PTSD and psychological distress included female sex (beta-coefficient [B], 1.59; 95% confidence interval [CI], 1.20 to 2.10 and B, 3.79; 95% CI, 1.79 to 5.78, respectively; P < 0.001 for differences in scores across groups) and perceived increased risk due to PPE shortage or inadequate PPE training (B, 1.87; 95% CI, 1.51 to 2.31 and B, 4.88; 95% CI, 3.34 to 6.43, respectively). Coping strategies included talking to friends/family/colleagues (80%), learning about COVID-19 (78%), and physical exercise (68%). Over half endorsed the following workplace strategies as valuable: hospital-provided scrubs, clear communication and protocols by hospitals, knowing their voice is heard, subsidized parking, and gestures of appreciation from leadership. CONCLUSIONS: This survey study shows that ICU workers have been impacted by the COVID-19 pandemic with high levels of stress and psychological burden. Respondents endorsed communication, protocols, and appreciation from leadership as helpful mitigating strategies.

RéSUMé: OBJECTIF: Évaluer l'impact de la pandémie de COVID-19 sur les travailleurs canadiens des unités de soins intensifs (USI). MéTHODE: Entre juin et août 2020, nous avons fait parvenir un sondage transversal en ligne aux travailleurs des soins intensifs pour évaluer l'impact de la pandémie, les stratégies d'adaptation et les symptômes de stress post-traumatique (SPT; Échelle révisée de l'impact de l'événement - IES-R), ainsi que la détresse psychologique, l'anxiété et la dépression (Échelle de détresse psychologique de Kessler). Nous avons réalisé des analyses de régression pour déterminer les prédicteurs de symptômes psychologiques. RéSULTATS: Nous avons analysé les réponses de 455 travailleurs des soins intensifs (80 % de femmes; 67 % de l'Ontario; 279 infirmières/infirmiers, 69 médecins et 107 autres professionnels de la santé). Les répondants ont estimé que leur emploi les plaçait face à un risque élevé d'exposition (60 %), craignaient de transmettre la COVID-19 aux membres de leur famille (76 %), se sentaient plus stressés au travail (67 %) et avaient envisagé de quitter leur emploi (37 %). Dans l'ensemble, 25 % souffraient probablement d'un SPT et 18 % présentaient une détresse psychologique minimale ou supérieure. Les infirmières et infirmiers étaient plus susceptibles de rapporter des symptômes de SPT (33 %) et de détresse psychologique (23 %) que les médecins (5 % pour les deux) et les professionnels de la santé des autres disciplines (19 % et 14 %). Les variables associées à un SPT et à la détresse psychologique comprenaient le sexe féminin (coefficient bêta [B], 1,59; intervalle de confiance [IC] à 95 %, 1,20 à 2,10 et B, 3,79; IC 95 %, 1,79 à 5,78, respectivement; P < 0,001 pour les différences de scores entre les groupes) et la perception d'un risque accru en raison des pénuries d'EPI ou d'une formation inadéquate en EPI (B, 1,87; IC 95 %, 1,51 à 2,31 et B, 4,88; IC 95 %, 3,34 à 6,43, respectivement). Les stratégies d'adaptation comprenaient le fait de parler aux amis, à la famille ou aux collègues (80 %), l'acquisition de connaissances concernant la COVID-19 (78 %) et l'exercice physique (68 %). Plus de la moitié ont estimé que les stratégies de travail suivantes étaient utiles : des uniformes fournis par les hôpitaux, une communication et des protocoles clairs de la part des hôpitaux, le fait de savoir que leur voix est entendue, un stationnement subventionné et des gestes d'appréciation de la part des dirigeants. CONCLUSION: Cette étude montre que les travailleurs des soins intensifs ont été touchés par la pandémie de COVID-19 avec des niveaux élevés de stress et de fardeau psychologique. Les répondants ont déclaré que la communication, les protocoles et les gestes d'appréciation de la direction constituaient des stratégies d'atténuation utiles.

Drug use in Canadian patients with trauma after cannabis legalization.

Background: The federal Cannabis Act came into force on Oct. 17, 2018, in Canada, making Canada only the second country in the world to legalize the cultivation, acquisition, possession and consumption of cannabis and its by-products. This provided a unique opportunity to evaluate the impact of this legislation on drug-related trauma. Methods: We performed a prospective observational study on the use of cannabis and other illicit drugs in the trauma population at a lead Canadian trauma centre in London, Ontario, in the 3 months before (July 1 to Sept. 30, 2018) and 3 months after (Nov. 1, 2018, to Jan. 31, 2019) the legalization of cannabis in Canada. We defined cannabis use as a positive cannabinoid screen result at the time of assessment by the trauma team. We also screened for opioids, amphetamines and cocaine. Results: A total of 210 patients were assessed by our trauma service between July 1 and Sept. 30, 2018, and 141 patients were assessed between Nov. 1, 2018, and Jan. 31, 2019. Motor vehicle collisions were the most common cause of trauma both before (101 [48.1%]) and after (67 [47.5%]) legalization. The mean Injury Severity Score was 17.6 (standard deviation [SD] 13.0) and 19.7 (SD 14.8), respectively. Drug screens were done in 88 patients (41.9%) assessed before legalization and 99 patients (70.2%) assessed after legalization. There was no difference in the rate of positive cannabinoid screen results before and after legalization (22 [25%] v. 22 [22%]). There was a trend toward higher rates of positive cannabinoid screen results (2/10 [20%] v. 5/8 [62%]) and positive toxicology screen results (5/10 [50%] v. 6/8 [75%]) after legalization among patients with penetrating trauma, but our sample was too small to achieve statistical significance. Conclusion: We found no difference in the rates of positive cannabinoid screen results among patients assessed at our trauma centre in the 3 months before and the 3 months after legalization of cannabis; however, there was a trend toward an increase in the rates of positive results of toxicology screens and cannabinoid screens among those with penetrating trauma. These preliminary single-centre data showing no increased rates of cannabis use in patients with trauma after legalization are reassuring.

Contexte: La Loi fédérale sur le cannabis est entrée en vigueur ici le 17 octobre 2018, faisant du Canada le second pays à légaliser la culture, l'acquisition, la possession et la consommation du cannabis et de ses produits dérivés. Cette situation fournit une occasion unique d'évaluer l'impact de cette loi sur les traumatismes liés aux drogues. Méthodes: Nous avons procédé à une étude d'observation prospective sur la consommation du cannabis et d'autres drogues illicites chez une population de victimes de traumatismes dans un grand centre canadien de traumatologie de London, en Ontario, au cours des 3 mois précédant (1er juillet au 30 septembre 2018) et des 3 mois suivant (1er novembre 2018 au 31 janvier 2019) la légalisation du cannabis au Canada. La consommation de cannabis était confirmée par l'obtention de résultats positifs aux tests de dépistage des cannabinoïdes demandés par l'équipe de traumatologie. Nous avons aussi effectué un dépistage des opioïdes, des amphétamines et de la cocaïne. Résultats: En tout, notre service de traumatologie a vu 210 patients entre le 1er juillet et le 30 septembre 2018, et 141 entre le 1er novembre 2018 et le 31 janvier 2019. Les accidents de la route ont été la plus fréquente cause de traumatisme avant (101 [48,1 %]) et après (67 [47,5 %]) la légalisation. L'indice moyen de gravité des blessures a été de 17,6 (écart-type [É.-T.] 13,0) et 19,7 (É.-T. 14,8), respectivement. Un dépistage de drogues a été effectué chez 88 patients (41,9 %) vus avant la légalisation et chez 99 patients (70,2 %) vus après la légalisation. On n'a observé aucune différence quant aux taux de résultats positifs aux tests de dépistage des cannabinoïdes enregistrés avant et après la légalisation (22 [25 %] c. 22 [22 %]). Les taux de résultats positifs aux tests de dépistage des cannabinoïdes (2/10 [20 %] c. 5/8 [62 %]) et aux tests toxicologiques (5/10 [50 %] c. 6/8 [75 %]) ont eu tendance à être plus élevés après la légalisation chez les patients victimes de traumatismes pénétrants, mais notre échantillon était trop petit pour atteindre une portée statistique. Conclusion: Nous n'avons observé aucune différence quant aux taux de résultats positifs au dépistage des cannabinoïdes au cours des 3 mois précédant et suivant la légalisation du cannabis; par contre, les taux de résultats positifs aux tests de dépistage des drogues et du cannabis ont eu tendance à être plus élevés chez les victimes de traumatismes pénétrants. Ces données préliminaires provenant d'un seul centre qui ne montrent pas d'augmentation des taux de consommation de cannabis chez les polytraumatisés sont rassurantes.

A retrospective observational study of daytime and nighttime transfers from the intensive care unit: through the lens of critical care response teams.

PURPOSE: To evaluate the impact of nighttime compared with daytime transfers from the intensive care unit (ICU) on mortality in a hospital with a critical care response team (CCRT). METHODS: We performed a retrospective observational study of ICU patients transferred between January 2011 and July 2013 who received CCRT follow-up. The transferred patients were divided into cohorts of daytime and nighttime transfers. A multivariable logistic regression model was used to identify independent predictors of mortality after ICU transfer. RESULTS: There were 1,857 patients included in the study. With the exception of Multiple Organ Dysfunction Score on admission, transfers to a step-down unit, and lower urine output, there were no differences in the baseline characteristics, clinical events identified by CCRTs, and the number of CCRT interventions performed between daytime and nighttime transfers. Patients transferred at night were at higher risk of death in the univariate analysis but not in the multivariate analysis. Independent predictors of mortality included older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.002 to 1.04), transfer to a medical service (OR, 1.96; 95% CI, 1.11 to 3.43), CCRT identification of hypoxemic respiratory failure (OR, 5.86; 95% CI, 3.11 to 11.04), decreased level of consciousness (OR, 3.14; 95% CI, 1.23 to 8.02), hypotension (OR, 3.69; 95% CI, 1.36 to 10.01), and longer CCRT duration of follow-up (OR, 1.02; 95% CI, 1.004 to 1.03). CONCLUSIONS: Nighttime transfer from the ICU was not an independent predictor of mortality. We identified unique predictors of mortality, including clinical events that CCRTs identified in patients immediately after ICU transfer. Future studies are required to validate these predictors of mortality in transferred ICU patients.

RéSUMé: OBJECTIF: Évaluer l'impact sur la mortalité des transferts de nuit par rapport aux transferts de jour de l'unité de soins intensifs (USI) dans un hôpital disposant d'une équipe d'intervention en soins intensifs (EISI). MéTHODE: Nous avons réalisé une étude observationnelle rétrospective des patients de l'USI transférés entre janvier 2011 et juillet 2013 suivis par l'EISI. Les patients transférés ont été divisés en cohortes de transferts de jour et de nuit. Un modèle de régression logistique multivariée a été utilisé pour identifier les prédicteurs indépendants de mortalité après un transfert de l'USI. RéSULTATS: L'étude a inclus 1857 patients. À l'exception du Score de défaillance multiviscérale, des transferts à une unité de soins intermédiaires et de la réduction du débit d'urine, aucune différence n'a été notée dans les caractéristiques de base, les événements cliniques identifiés par l'EISI et le nombre d'interventions de l'EISI effectuées entre les transferts de jour et de nuit. Les patients transférés la nuit étaient plus à risque de décès dans l'analyse univariée, mais pas dans l'analyse multivariée. Les prédicteurs indépendants de mortalité comprenaient un âge avancé (rapport de cotes [RC], 1,02; intervalle de confiance [IC] 95 %, 1,002 à 1,04), le transfert à un service médical (RC, 1,96; IC 95 %, 1,11 à 3,43), l'identification par l'EISI d'une insuffisance respiratoire hypoxémique (RC, 5,86; IC 95 %, 3,11 à 11,04), la diminution du niveau de conscience (RC, 3,14; IC 95%, 1,23 à 8,02), l'hypotension (RC, 3,69; IC 95%, 1,36 à 10,01), et une durée plus longue de suivi par l'EISI (RC, 1,02; IC 95 %, 1,004 à 1,03). CONCLUSION: Le transfert nocturne de l'USI n'est pas un prédicteur indépendant de mortalité. Nous avons identifié des prédicteurs particuliers de mortalité, notamment les événements cliniques identifiés par l'EISI chez les patients immédiatement après leur transfert de l'USI. Des études futures sont nécessaires pour valider ces prédicteurs de mortalité chez les patients transférés des soins intensifs.

Retrievable inferior vena cava filter for primary prophylaxis of pulmonary embolism in at-risk trauma patients: A feasibility trial.

OBJECTIVE: To determine if insertion of rIVCF for PE prophylaxis in high risk trauma patients could result in a clinically meaningful reduction (>24 h) in time that patients are left unprotected from PEs SUMMARY AND BACKGROUND DATA: Trauma patients are at high risk for the development of pulmonary embolism (PE). Early pharmacologic PE prophylaxis is ideal, however many patients are unable to receive prophylaxis due to concomitant injuries. Current guidelines are conflicting on the role of prophylactic retrievable inferior vena cava filters (rIVCF) for PE prevention in this patient population, and robust data to guide clinicians is lacking. METHODS: In this single center, randomized control trial of adult (age > 18 years) trauma patients at high risk for PE by EAST criteria and unable to receive pharmacologic prophylaxis for at least 72 h, we randomized 42 patients to receive a rIVCF or to not have a rIVCF placed. Our primary endpoints were time left unprotected to PE development and feasibility. RESULTS: The median patient age was 53 years, with a median Injury Severity Score of 33. Randomization to rIVCF reduced the time left unprotected to PE (Control: 78.2 h [53.6-104]; rIVCF: 25.5 h [9.8-44.6], p = 0.0001). Two pulmonary embolisms occurred in the control group, and one in the rIVCF group. Seven deaths occurred in the control group, and 8 in the rIVCF group. CONCLUSION: This feasibility study demonstrates a clinically meaningful reduction in time left unprotected to PE. Further investigations powered to demonstrate a reduction in PE incidence are required. LEVEL OF EVIDENCE: Level 1 Evidence randomized controlled trial.

The Use of Central Venous to Arterial Carbon Dioxide Tension Gap for Outcome Prediction in Critically Ill Patients: A Systematic Review and Meta-Analysis.

OBJECTIVES: In this systematic review and meta-analysis, we assessed whether a high CO2 gap predicts mortality in adult critically ill patients with circulatory shock. DATA SOURCES: A systematic search of MEDLINE and EMBASE electronic databases from inception to October 2019. STUDY SELECTION: Studies from adult (age ≥ 18 yr) ICU patients with shock reporting CO2 gap and outcomes of interest. Case reports and conference abstracts were excluded. DATA EXTRACTION: Data extraction and study quality assessment were performed independently in duplicate. DATA SYNTHESIS: We used the Newcastle-Ottawa Scale to assess methodological study quality. Effect sizes were pooled using a random-effects model. The primary outcome was mortality (28 d and hospital). Secondary outcomes were ICU length of stay, hospital length of stay, duration of mechanical ventilation, use of renal replacement therapy, use of vasopressors and inotropes, and association with cardiac index, lactate, and central venous oxygen saturation. CONCLUSIONS: We included 21 studies (n = 2,155 patients) from medical (n = 925), cardiovascular (n = 685), surgical (n = 483), and mixed (n = 62) ICUs. A high CO2 gap was associated with increased mortality (odds ratio, 2.22; 95% CI, 1.30-3.82; p = 0.004) in patients with shock, but only those from medical and surgical ICUs. A high CO2 gap was associated with higher lactate levels (mean difference 0.44 mmol/L; 95% CI, 0.20-0.68 mmol/L; p = 0.0004), lower cardiac index (mean difference, -0.76 L/min/m; 95% CI, -1.04 to -0.49 L/min/m; p = 0.00001), and central venous oxygen saturation (mean difference, -5.07; 95% CI, -7.78 to -2.37; p = 0.0002). A high CO2 gap was not associated with longer ICU or hospital length of stays, requirement for renal replacement therapy, longer duration of mechanical ventilation, or higher vasopressors and inotropes use. Future studies should evaluate whether resuscitation aimed at closing the CO2 gap improves mortality in shock.

External validation of a prognostic model for intensive care unit mortality: a retrospective study using the Ontario Critical Care Information System.

PURPOSE: To externally validate an intensive care unit (ICU) mortality prediction model that was created using the Ontario Critical Care Information System (CCIS), which includes the Multiple Organ Dysfunction Score (MODS). METHODS: We applied the Transparent Reporting of a multivariable prediction model for Individual Prognosis Or Diagnosis (TRIPOD) recommendations to a prospective longitudinal cohort of patients discharged between 1 July 2015 and 31 December 31 2016 from 90 adult level-3 critical care units in Ontario. We used multivariable logistic regression with measures of discrimination, calibration-in-the-large, calibration slope, and flexible calibration plots to compare prediction model performance of the entire data set and for each ICU subtype. RESULTS: Among 121,201 CCIS records with ICU mortality of 11.3%, the C-statistic for the validation data set was 0.805. The C-statistic ranged from 0.775 to 0.846 among the ICU subtypes. After intercept recalibration to adjust the baseline risk, the mean predicted risk of death matched actual ICU mortality. The calibration slope was close to 1 with all CCIS data and ICU subtypes of cardiovascular and community hospitals with low ventilation rates. Calibration slopes significantly less than 1 were found for ICUs in teaching hospitals and community hospitals with high ventilation rates whereas coronary care units had a calibration slope significantly higher than 1. Calibration plots revealed over-prediction in high risk groups to a varying degree across all cohorts. CONCLUSIONS: A risk prediction model primarily based on the MODS shows reproducibility and transportability after intercept recalibration. Risk adjusting models that use existing and feasible data collection can support performance measurement at the individual ICU level.

RéSUMé: OBJECTIF: Nous souhaitions faire une validation externe d'un modèle de prédiction de la mortalité aux unités de soins intensifs (USI) créé en utilisant le Système d'information sur les soins aux malades en phase critique (SISMPC) de l'Ontario, qui comporte le Score de défaillance multisystémique (MODS). MéTHODE: Nous avons appliqué les recommandations de communication transparente d'un modèle de prédiction multivarié pour le pronostic ou le diagnostic individuel TRIPOD à une cohorte longitudinale prospective de patients. Ces patients devaient avoir reçu leur congé entre le 1er juillet 2015 et le 31 décembre 2016 de 90 unités de soins intensifs de niveau 3 pour adultes en Ontario. Nous avons utilisé une méthode de régression logistique multivariée accompagnée de mesures de discrimination, d'étalonnage global, de pentes d'étalonnage et de graphiques d'étalonnage afin de comparer la performance du modèle de prédiction pour l'ensemble des données dans son intégralité et pour chaque sous-type d'USI. RéSULTATS: Parmi les 121 201 dossiers du SISMPC présentant une mortalité à l'USI de 11,3 %, la statistique C pour l'ensemble de données de validation était 0,805. La statistique C allait de 0,775 à 0,846 parmi les sous-types d'USI. Après réétalonnage de l'ordonnée afin d'ajuster le risque de base, le risque prédit moyen de décès correspondait à la mortalité réelle à l'USI. La pente d'étalonnage était proche de 1 pour toutes les données du SISMPC et tous les sous-types d'USI des hôpitaux cardiovasculaires et communautaires ayant de faibles taux de patients ventilés. Des pentes d'étalonnage significativement inférieures à 1 ont été observées pour les USI dans les hôpitaux universitaires et les hôpitaux communautaires ayant des taux de patients ventilés élevés, alors que les unités de soins coronariens présentaient une pente d'étalonnage significativement supérieure à 1. Les courbes d'étalonnage ont révélé une sur-prédiction dans les groupes à risque élevé à des degrés variables dans toutes les cohortes. CONCLUSION: Un modèle de prédiction du risque se fondant principalement sur le score MODS a montré sa reproductibilité et son applicabilité après réétalonnage de l'ordonnée. Les modèles d'ajustement du risque qui s'appuient sur des collectes de données existantes et réalisables peuvent aider à mesurer la performance au niveau de l'USI individuelle.

Natural History of Cognitive Impairment in Critical Illness Survivors. A Systematic Review.

Long-term cognitive impairment is common among ICU survivors, but its natural history remains unclear. In this systematic review, we report the frequency of cognitive impairment in ICU survivors across various time points after ICU discharge that were extracted from 46 of the 3,350 screened records. Prior studies used a range of cognitive instruments, including subjective assessments (10 studies), single or screening cognitive test such as Mini-Mental State Examination or Trail Making Tests A and B (23 studies), and comprehensive cognitive batteries (26 studies). The mean prevalence of cognitive impairment was higher with objective rather than subjective assessments (54% [95% confidence interval (CI), 51-57%] vs. 35% [95% CI, 29-41%] at 3 months after ICU discharge) and when comprehensive cognitive batteries rather than Mini-Mental State Examination were used (ICU discharge: 61% [95% CI, 38-100%] vs. 36% [95% CI, 15-63%]; 12 months after ICU discharge: 43% [95% CI, 10-78%] vs. 18% [95% CI, 10-20%]). Patients with acute respiratory distress syndrome had higher prevalence of cognitive impairment than mixed ICU patients at ICU discharge (82% [95% CI, 78-86%] vs. 48% [95% CI, 44-52%]). Although some studies repeated tests at more than one time point, the time intervals between tests were arbitrary and dictated by operational limitations of individual studies or chosen cognitive instruments. In summary, the prevalence and temporal trajectory of ICU-related cognitive impairment varies depending on the type of cognitive instrument used and the etiology of critical illness. Future studies should use modern comprehensive batteries to better delineate the natural history of cognitive recovery across ICU patient subgroups and determine which acute illness and treatment factors are associated with better recovery trajectories.