Improving quality of withdrawal of life-sustaining measures in organ donation: a framework and implementation toolkit.

BACKGROUND: Donation after circulatory determination of death (DCD) is responsible for the largest increase in deceased donation over the past decade. When the Canadian DCD guideline was published in 2006, it included recommendations to create standard policies and procedures for withdrawal of life-sustaining measures (WLSM) as well as quality assurance frameworks for this practice. In 2016, the Canadian Critical Care Society produced a guideline for WLSM that requires modifications to facilitate implementation when DCD is part of the end-of-life care plan. METHODS: A pan-Canadian multidisciplinary collaborative was convened to examine the existing guideline framework and to create tools to put the existing guideline into practice in centres that practice DCD. RESULTS: A set of guiding principles for implementation of the guideline in DCD practice were produced using an iterative, consensus-based approach followed by development of four implementation tools and three quality assurance and audit tools. CONCLUSIONS: The tools developed will aid DCD centres in fulsomely adapting the Canadian Critical Care Society Withdrawal of Life-Sustaining Measures guideline.

RéSUMé: CONTEXTE : Au cours des dix dernières années, le don d'organe après un décès cardiocirculatoire (DDC) a été à l'origine de la plus importante augmentation de dons provenant d'individus décédés. Les lignes directrices canadiennes sur le DDC, publiées en 2006, recommandaient la création de politiques et de procédures standard pour l'interruption des traitements de maintien des fonctions vitales (TMFV) ainsi que celle de cadres d'assurance de la qualité pour cette pratique. En 2016, la Société canadienne de soins intensifs a publié des recommandations concernant les TMFV; ces recommandations nécessitent des modifications pour pouvoir être facilement mises en œuvre lorsque le DDC fait partie du plan de soins de fin de vie. MéTHODE : Un groupe collaboratif multidisciplinaire pancanadien s'est réuni afin d'examiner le cadre établi par les lignes directrices existantes et créer des outils pour mettre en œuvre ces recommandations dans les centres pratiquant le DDC. RéSULTATS : En utilisant une approche itérative et consensuelle, un ensemble de principes directeurs a été créé pour mettre en œuvre des directives concernant la pratique du DDC : quatre outils d'implantation et trois outils d'assurance de la qualité et d'audit ont été mis au point. CONCLUSION : Les outils créés aideront les centres de DDC à adapter de manière plus complète les Lignes directrices pour l'interruption des traitements de maintien des fonctions vitales de la Société canadienne de soins intensifs.

Managing new oral anticoagulants in the perioperative and intensive care unit setting.

Managing patients in the perioperative setting receiving novel oral anticoagulation agents for thromboprophylaxis or stroke prevention with atrial fibrillation is an important consideration for clinicians. The novel oral anticoagulation agents include direct Factor Xa inhibitors rivaroxaban and apixaban, and the direct thrombin inhibitor dabigatran. In elective surgery, discontinuing their use is important, but renal function must also be considered because elimination is highly dependent on renal elimination. If bleeding occurs in patients who have received these agents, common principles of bleeding management as with any anticoagulant (including the known principles for warfarin) should be considered. This review summarizes the available data regarding the management of bleeding with novel oral anticoagulation agents. Hemodialysis is a therapeutic option for dabigatran-related bleeding, while in vitro studies showed that prothrombin complex concentrates are reported to be useful for rivaroxaban-related bleeding. Additional clinical studies are needed to determine the best method for reversal of the novel oral anticoagulation agents when bleeding occurs.

Hematology Emergencies in Critically Ill Adults: Benign Hematology.

Hematologic conditions (malignant or benign) may progress to acute critical illness requiring prompt recognition and intensive management. This review outlines diagnostic considerations and approaches to management for intensivists of common benign hematologic emergencies, including the following: thrombotic thrombocytopenic purpura, atypical hemolytic uremic syndrome, disseminated intravascular coagulopathy, catastrophic antiphospholipid antibody syndrome, hemophagocytic lymphohistiocytosis, acute chest syndrome associated with sickle cell disease, and hyperhemolysis syndrome.

Hematology Emergencies in Adults With Critical Illness: Malignant Hematology.

As outcomes have improved across the hematologic malignancy population, candidacy for ICU admission has increased. This complex population may develop a variety of complications related to their treatment or underlying disease that can result in critical illness necessitating ICU support. This review highlights common causes of critical illness associated with hematologic malignancies, including the following: (1) neutropenic sepsis; (2) hyperleukocytosis and leukostasis across patients with acute myeloid leukemia; (3) complications of acute promyelocytic leukemia; (4) tumor lysis syndrome; and (5) critical care complications that can arise following hematopoietic stem cell transplantation.

Oncologic Emergencies: Traditional and Contemporary.

The recognition and management of oncologic emergencies are becoming increasingly relevant in the intensive care unit, particularly in the era of novel biologic therapies. Early recognition and multidisciplinary collaboration are essential to improving patient outcomes. This article discusses aspects of diagnosis and management for important malignancy-associated emergencies.

Impact of Gender on Clinical Evaluation of Trainees in the Intensive Care Unit.

Background: Gender disparities in medical education are increasingly demonstrated, including in trainee assessment. Objective: This study aimed to evaluate whether gender differences exist in trainees' evaluation during intensive care unit (ICU) rotations, which has not been previously studied. Methods: We reviewed the in-training evaluation reports (ITERs) for trainees rotating through five academic ICUs at the University of Toronto over a 10-year period (2007-2017). We compared the mean global score for the rotation and the mean score for seven training subdomains between men and women trainees. All scores were reported on a scale of 1 (unsatisfactory) to 5 (outstanding). Results: Over the 10-year period, there were 3,203 ITERS overall, representing 1,207 women and 1,996 men trainees. The mean overall score was lower for women than for men trainees: 4.26 (standard deviation [SD], 0.58) for women and 4.30 (SD, 0.60) for men (P = 0.04). This difference was driven by anesthesia trainees, in whom the mean overall score was 4.21 for women and 4.37 for men (P < 0.001), with men trainees scoring consistently higher across all seven training subdomains. Within surgical, internal medicine, and critical care residents, there were no differences between men and women in the overall score or the scores across any of the seven subdomains. Across all ITERS, women were less likely than men to receive an overall rating of 5 (outstanding) for the ICU rotation (33% women vs. 37% men; odds ratio, 0.83; 95% confidence interval, 0.71-0.96). Conclusion: Overall, quantitative evaluation scores between women and men trainees in the ICU are relatively similar. Within anesthesia trainees, scores for men were consistently higher across all domains of evaluation, a finding that requires further investigation.

Perspectives on Advance Care Planning for Patients with Hematologic Malignancy: An International Clinician Questionnaire.

Rationale: Critical illness is common in patients with hematologic malignancy (HM). Advance care planning (ACP) can allow these patients to express their care preferences before life-threatening illnesses. Objectives: To evaluate physicians' perspectives surrounding ACP in patients with HM. Methods: We administered a survey to intensivists and hematologic oncologists who care for patients with HM across Canada and the United Kingdom. Potential respondents were identified from institutions that have a hematologic-oncology program. The survey was disseminated electronically. Results: A total of 111 physicians completed the survey, with a response rate of 19% (39% across those who opened the e-mail); 52% of respondents were intensivists, and 48% of respondents were hematologic oncologists. Of the responses, 15.5% of physicians reported that ACP happens routinely at their institution, whereas 8.3% of physicians stated that code status is routinely discussed. ACP discussions were most commonly reported at the onset of critical illness (84.3% of respondents), during disease recurrence (52.9% of respondents), or during the transition to a strictly palliative approach (54.9% of respondents). Commonly cited barriers to ACP centered on physicians' concern about the reaction of the patient or family. Conclusions: This study emphasizes the need for earlier and more frequent ACP discussions in this high-risk population with a variety of barriers identified.

Fulminant Guillain-Barré syndrome in a patient with systemic lupus erythematosus.

A 45-year-old man with a history of systemic lupus erythematosus presented with progressive weakness and areflexia. Electromyogram revealed reduced motor and sensory amplitudes without demyelinating features. He was clinically diagnosed with the acute motor and sensory axonal neuropathy variant of Guillain-Barré syndrome. Despite intravenous immunoglobulin therapy, he deteriorated with loss of all voluntary motor function and cranial nerve reflexes. Concomitant investigations revealed class V lupus nephritis. Therapy was initiated with plasma exchange, glucocorticoids and further immunosuppression, with gradual neurological recovery. We present the first documented case of fulminant Guillain-Barré syndrome as a neuropsychiatric manifestation of systemic lupus erythematosus, highlighting how immune-mediated polyneuropathy via diffuse deafferentation may mimic the outward appearance of brain death. While glucocorticoids are not indicated in idiopathic Guillain-Barré, when this neurological disorder is a consequence of systemic lupus erythematosus, immunomodulatory treatment should be initiated to prevent neurological deterioration.

The influence of various patient characteristics on D-dimer concentration in critically ill patients and its role as a prognostic indicator in the intensive care unit setting.

This study examines the relationship between D-dimer concentration and patient age, gender, race, and renal function, and the role of D-dimer concentration as a predictor of in-hospital mortality, in a critically ill patient population. The results demonstrate there is a correlation between increased D-dimer concentration and renal impairment in critically ill patients, with patients in renal failure having the highest D-dimer concentrations. Peak D-dimer levels were higher among female patients than in male patients, but there was no association between peak D-dimer levels and other patient characteristics. D-dimer concentration was also not predictive of in-hospital mortality.