A survey of Canadian intensivists' resuscitation practices in early septic shock.

INTRODUCTION: Recent evidence suggests that early, aggressive resuscitation in patients with septic shock reduces mortality. The objective of this survey was to characterize reported resuscitation practices of Canadian physicians caring for adult critically ill patients with early septic shock. METHODS: A scenario-based self-administered national survey was sent out to Canadian critical care physicians. One hypothetical scenario was developed to obtain information on several aspects of resuscitation in early septic shock, including monitoring and resuscitation end-points, fluid administration, red blood cell transfusion triggers, and use of inotropes. The sampling frame was physician members of Canadian national and provincial critical care societies. RESULTS: The survey response rate was 232 out of 355 (65.3%). Medicine was the most common primary specialty (60.0%), most respondents had practiced for 6 to 10 years (30.0%), and 82.0% were male. The following monitoring devices/parameters were reported as used/measured 'often' or 'always' by at least 89% of respondents: oxygen saturation (100%), Foley catheters (100%), arterial blood pressure lines (96.6%), telemetry (94.3%), and central venous pressure (89.2%). Continuous monitoring of central venous oxygen saturation was employed 'often' or 'always' by 9.8% of respondents. The two most commonly cited resuscitation end-points were urine output (96.5%) and blood pressure (91.8%). Over half of respondents used normal saline (84.5%), Ringers lactate (52.2%), and pentastarch (51.3%) 'often' or 'always' for early fluid resuscitation. In contrast, 5% and 25% albumin solutions were cited as used 'often' or 'always' by 3.9% and 1.3% of respondents, respectively. Compared with internists, surgeons and anesthesiologists (odds ratio (95% confidence interval): 9.8 (2.9 to 32.7) and 3.8 (1.7 to 8.7), respectively) reported greater use of Ringers lactate. In the setting of a low central venous oxygen saturation, 52.5% of respondents reported use of inotropic support 'often' or 'always'. Only 7.6% of physicians stated they would use a red blood cell transfusion trigger of 100 g/l to optimize oxygen delivery further. CONCLUSION: Our survey results suggest that there is substantial practice variation in the resuscitation of adult patients with early septic shock. More randomized trials are needed to determine the optimal approach.

Red blood cell transfusion practices amongst Canadian anesthesiologists: a survey.

PURPOSE: To assess red blood cell transfusion practices among Canadian anesthesiologists. METHODS: A survey depicting three realistic clinical scenarios of elective surgical procedures with different risks of bleeding was administered to all Canadian practicing members (n = 2,100) of the Canadian Anesthesiologists' Society. Respondents were requested to choose hemoglobin thresholds for which they would transfuse red blood cells under various conditions within each scenario. RESULTS: We obtained a response rate of 47% (719/1,512). Transfusion thresholds differed significantly between baseline scenarios. A threshold above 70 g x L(-1) was chosen by 48% of respondents in the general surgery scenario compared to 56% in the orthopedic surgery scenario and 79% in the vascular surgery scenario (P < 0.001). A history of coronary artery disease was associated with a transfusion threshold >or= 100 g x L(-1) in a significant proportion of respondents ranging from 20% in the orthopedic surgery scenario to 31% in the general surgery scenario and to 49% in the vascular surgery scenario (P < 0.001). Conversely, changing the patient's age from 60 to 20 yr resulted in the adoption of a transfusion threshold 30% of respondents in two scenarios (P < 0.001). The year of respondent graduation was strongly associated with these findings. CONCLUSION: There was significant variation in transfusion practices among Canadian anesthesiologists. The type of surgical procedure, patient's age and a history of coronary artery disease influenced reported transfusion threshold. Practice variation in specific subgroups would support the need for further research to identify optimal transfusion thresholds.

The societal unit cost of allogenic red blood cells and red blood cell transfusion in Canada.

BACKGROUND: There is a dearth of information about the cost of allogenic red blood cells (RBCs) and RBC transfusion in Canada in the aftermath of the Canadian blood system reorganization and the introduction of various safety measures. The unit cost of allogenic RBCs and RBC transfusion in Canada in 1994 was estimated at 152.17 US dollars. The objective of this study was to determine the unit cost of allogenic RBC transfusion in Canada from a societal perspective. STUDY DESIGN AND METHODS: A cost-structure analysis using the cost information from 2001 through 2002 was used. Costs of blood collection, production, distribution, delivery (hospital transfusion service processing and patient administration), transfusion reaction management, and opportunity cost of donor's time were included in the analysis. Canadian Blood Services and Héma-Québec supplied the data for collection, production, and distribution stages. Delivery and transfusion reaction costs were collected from eight hospitals across six Canadian provinces. In-patient costs were assessed for the intensive care unit, emergency, general medicine ward, and operating room. RESULTS: The aggregate mean societal unit cost of RBCs transfused on an inpatient basis in 2002 was 264.81 US dollars (95% confidence interval [CI], 256.29 dollars-275.65 dollars). The mean cost of blood collection, production, and distribution was 202.74 US dollars (95% CI, 199.63 dollars-204.31 dollars), the mean opportunity cost of donor time was 18.21 US dollars (95% CI, 17.11 dollars-21.63 dollars), the mean cost of hospital transfusion service processing was 16.65 US dollars (95% CI, 13.50 dollars-19.79 dollars), of RBC transfusion was 26.92 US dollars (95% CI, 25.33 dollars-28.52 dollars), and of transfusion reaction management was 0.29 US dollars(95% CI, 0.22 dollars-0.36 dollars). There were substantial variations in hospital transfusion service processing and RBC transfusion costs across hospitals. CONCLUSION: The societal unit cost of RBC transfusion has doubled since 1994 to 1995. Further increases in unit costs would be expected as additional safety measures are introduced. This will have important financial implications for treating patient populations that require a high level of RBC transfusions.