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1.
Can J Anaesth ; 71(8): 1137-1144, 2024 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-38504038

RESUMO

PURPOSE: The ordering of routine blood test panels in advance is common in intensive care units (ICUs), with limited consideration of the pretest probability of finding abnormalities. This practice contributes to anemia, false positive results, and health care costs. We sought to understand practices and attitudes of Canadian adult intensivists regarding ordering of blood tests in critically ill patients. METHODS: We conducted a nationwide Canadian cross-sectional survey consisting of 15 questions assessing three domains (global perceptions, test ordering, daily practice), plus 11 demographic questions. The target sample was one intensivist per adult ICU in Canada. We summarized responses using descriptive statistics and present data as mean with standard deviation (SD) or count with percentage as appropriate. RESULTS: Over seven months, 80/131 (61%) physicians responded from 77 ICUs, 50% of which were from Ontario. Respondents had a mean (SD) clinical experience of 12 (9) years, and 61% worked in academic centres. When asked about their perceptions of how frequently unnecessary blood tests are ordered, 61% responded "sometimes" and 23% responded "almost always." Fifty-seven percent favoured ordering complete blood counts one day in advance. Only 24% of respondents believed that advanced blood test ordering frequently led to changes in management. The most common factors perceived to influence blood test ordering in the ICU were physician preferences, institutional patterns, and order sets. CONCLUSION: Most respondents to this survey perceived that unnecessary blood testing occurs in the ICU. The survey identified possible strategies to decrease the number of blood tests.


RéSUMé: OBJECTIF: La prescription à l'avance de tests sanguins de routine est courante dans les unités de soins intensifs (USI), avec une prise en compte limitée de la probabilité de découverte d'anomalies avant le test. Cette pratique contribue à l'anémie, aux résultats faussement positifs et aux coûts des soins de santé. Nous avons cherché à comprendre les pratiques et les attitudes des intensivistes pour adultes au Canada en ce qui concerne la prescription d'analyses sanguines chez la patientèle gravement malade. MéTHODE: Nous avons mené un sondage transversal à l'échelle nationale au Canada en posant 15 questions évaluant trois domaines (perceptions globales, commande de tests, pratique quotidienne), ainsi que 11 questions démographiques. L'échantillon cible était composé d'un·e intensiviste par unité de soins intensifs pour adultes au Canada. Nous avons résumé les réponses à l'aide de statistiques descriptives et présenté les données sous forme de moyennes avec écarts type (ET) ou de dénombrements avec pourcentages, selon le cas. RéSULTATS: Sur une période de sept mois, 80 médecins sur 131 (61%) ont répondu dans 77 unités de soins intensifs, dont 50% en Ontario. Les répondant·es avaient une expérience clinique moyenne (ET) de 12 (9) ans, et 61% travaillaient dans des centres universitaires. Lorsqu'on leur a demandé ce qu'ils ou elles pensaient de la fréquence à laquelle des tests sanguins inutiles étaient prescrits, 61% ont répondu « parfois ¼ et 23% ont répondu « presque toujours ¼. Cinquante-sept pour cent étaient en faveur de la réalisation d'une formule sanguine complète un jour à l'avance. Seulement 24% des personnes interrogées estimaient que la prescription de tests sanguins à l'avance entraînait fréquemment des changements dans la prise en charge. Les facteurs les plus souvent perçus comme influençant la prescription d'analyses sanguines à l'unité de soins intensifs étaient les préférences des médecins, les habitudes institutionnelles et les ensembles d'ordonnances. CONCLUSION: La plupart des répondant·es à ce sondage ont l'impression que des tests sanguins inutiles sont prescrits aux soins intensifs. L'enquête a permis d'identifier des stratégies possibles pour réduire le nombre de tests sanguins.


Assuntos
Unidades de Terapia Intensiva , Padrões de Prática Médica , Humanos , Canadá , Unidades de Terapia Intensiva/estatística & dados numéricos , Estudos Transversais , Padrões de Prática Médica/estatística & dados numéricos , Testes Hematológicos/estatística & dados numéricos , Atitude do Pessoal de Saúde , Adulto , Inquéritos e Questionários , Masculino , Procedimentos Desnecessários/estatística & dados numéricos , Estado Terminal , Feminino , Cuidados Críticos/estatística & dados numéricos
2.
Can J Anaesth ; 70(6): 1064-1074, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-37173564

RESUMO

PURPOSE: The under-representation of Black people within critical care research limits the generalizability of randomized controlled trials (RCTs). This meta-epidemiologic study investigated the proportionate representation of Black people enrolled at USA and Canadian study sites from high impact critical care RCTs. SOURCE: We searched for critical care RCTs published in general medicine and intensive care unit (ICU) journals between 1 January 2016 and 31 December 2020. We included RCTs that enrolled critically ill adults at USA or Canadian sites and provided race-based demographic data by study site. We compared study-based racial demographics with site-level city-based demographics and pooled representation of Black people across studies, cities, and centres using a random effects model. We used meta-regression to explore the impact of the following variables on Black representation in critical care RCTs: country, drug intervention, consent model, number of centres, funding, study site city, and year of publication. PRINCIPAL FINDINGS: We included 21 eligible RCTs. Of these, 17 enrolled at only USA sites, two at only Canadian sites, and two at both USA and Canadian sites. Black people were under-represented in critical care RCTs by 6% compared with population-based city demographics (95% confidence interval, 1 to 11). Using meta-regression, after controlling for pertinent variables, the country of the study site was the only significant source of heterogeneity (P = 0.02). CONCLUSION: Black people are under-represented in critical care RCTs compared with site-level city-based demographics. Interventions are required to ensure adequate Black representation in critical care RCTs at both USA and Canadian study sites. Further research is needed to investigate the factors contributing to Black under-representation in critical care RCTs.


RéSUMé: OBJECTIF: La sous-représentation des personnes noires dans la recherche en soins intensifs limite la généralisabilité des études randomisées contrôlées (ERC). Cette étude méta-épidémiologique a examiné la représentation proportionnelle des personnes noires inscrites aux sites américains et canadiens d'ERC à fort impact réalisées en soins intensifs. SOURCES: Nous avons recherché des ERC en soins intensifs publiées dans des revues de médecine générale et de soins intensifs (USI) entre le 1er janvier 2016 et le 31 décembre 2020. Nous avons inclus des ERC qui ont recruté des adultes gravement malades dans des sites américains ou canadiens et fourni des données démographiques basées sur la race par site d'étude. Nous avons comparé les données démographiques raciales de chaque étude aux données démographiques de la ville du site d'étude et regroupé la représentation des personnes noires dans les études, les villes et les centres en utilisant un modèle à effets aléatoires. Nous avons utilisé la méta-régression pour explorer l'impact des variables suivantes sur la représentation des personnes noires dans les ERC en soins intensifs : pays, intervention médicamenteuse, modèle de consentement, nombre de centres, financement, ville du site d'étude et année de publication. CONSTATATIONS PRINCIPALES: Nous avons inclus 21 ERC éligibles. De ce nombre, 17 ont recruté des patient·es uniquement dans des sites américains, deux dans des sites canadiens seulement et deux aux États-Unis et au Canada. Les personnes noires étaient sous-représentées dans les ERC en soins intensifs de 6 % par rapport à la population démographique des villes (intervalle de confiance à 95 %, 1 à 11). En utilisant la méta-régression, après avoir tenu compte des variables pertinentes, le pays du site d'étude était la seule source significative d'hétérogénéité (P = 0,02). CONCLUSION: Les personnes noires sont sous-représentées dans les ERC en soins intensifs par rapport aux données démographiques des villes. Des interventions sont nécessaires pour assurer une représentation adéquate des personnes noires dans les ERC en soins intensifs dans les sites d'étude américains et canadiens. D'autres recherches sont nécessaires pour étudier les facteurs contribuant à la sous-représentation des personnes noires dans les ERC en soins intensifs.


Assuntos
Cuidados Críticos , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto , Humanos , População Negra , Canadá , Estados Unidos
3.
Can J Anaesth ; 66(6): 648-657, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-31037586

RESUMO

PURPOSE: Elevated cardiac troponin concentrations in people with critical illness are associated with an increased risk of death. We aimed to assess the feasibility of a larger study to ascertain the utility of cardiac troponin as a prognostic tool for mortality in critically ill patients. METHODS: Patients admitted to participating intensive care units during the one-month enrolment period were eligible. We excluded cardiac surgical patients and patients who were admitted and either died or were discharged within 12 hr. In enrolled patients, we measured high-sensitivity cardiac troponin I (hs-cTnI) and obtained electrocardiograms to ascertain the incidence of myocardial infarction (MI) and isolated troponin elevation. Our feasibility objectives were to measure recruitment rate, the proportion of patients who consented under a deferred consent model, and time required for data collection and study procedures. RESULTS: Over a four-week enrolment period, 280 patients were enrolled using a deferred consent model. We obtained subsequent consent from 81% of patients. Study procedures and data collection required 1.7 hr per participant. Overall, 86 (38%) suffered a MI, 23 (10%) had an isolated hs-cTnI elevation, and 117 (52%) had no hs-cTnI elevation. The crude hospital mortality rate was 10% without an hs-cTnI elevation, 29% with an isolated hs-cTnl elevation (relative risk [RR]) 2.2; 95% confidence interval [CI], 1.0 to 6.0) and 29% with an MI (RR, 2.6; 95% CI, 1.4 to 5.1). CONCLUSION: Myocardial injury with elevated hs-cTnI concentrations and MIs occur frequently during critical illness. This pilot study has established the feasibility of conducting a large-scale investigation addressing this issue.


Assuntos
Eletrocardiografia , Infarto do Miocárdio/diagnóstico , Troponina I/sangue , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estado Terminal , Estudos de Viabilidade , Feminino , Mortalidade Hospitalar , Humanos , Incidência , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/sangue , Infarto do Miocárdio/epidemiologia , Projetos Piloto , Prognóstico , Estudos Prospectivos
4.
J Intensive Care Med ; 33(8): 475-480, 2018 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-29991343

RESUMO

BACKGROUND: Informed consent is a hallmark of ethical clinical research. An inherent challenge in critical care research is obtaining consent when patients lack decision-making capacity. One solution is deferred consent, which is often used for studies that are low risk or involve emergency interventions. Our objective was to describe a deferred consent model in a low-risk critical care study. METHODS: Prognostic Value of Elevated Troponins in Critical Illness Study was a prospective, pilot observational study of critically ill patients in 3 intensive care units, involving serial electrocardiograms and cardiac biomarkers. Newly admitted patients were enrolled over 1 month. When possible, informed consent was obtained a priori from the patient or substitute decision maker (SDM); otherwise, consent was deferred until the patient regained consent capacity or until their SDM was available. Logistic regression analysis was used to determine the association between patient's sex, Acute Physiology and Chronic Health Evaluation II score, study center, person providing consent (patient vs SDM), method of consent (telephone vs in person), and the provision or not of informed consent. RESULTS: The overall consent rate was 80.1% (213 of 266 persons approached). Of the 53 persons declining consent, 37 (69.8%) agreed to the use of data collected up until that point. Over half of all consent encounters were with patients rather than SDMs. Median interval delay between enrollment and the consent encounter was 1 day. On multivariate analysis, the only variable associated with consent was male sex of the patient (odds ratio for males 2.59, confidence interval: 1.19-5.63). CONCLUSION: Deferred consent facilitates implementation of time-sensitive research protocols until a consent encounter is possible. As a feasible alternative to exclusive a priori consent, the deferred consent model can be useful in low-risk studies in critically ill patients.


Assuntos
Cuidados Críticos/legislação & jurisprudência , Tomada de Decisões , Traumatismos Cardíacos/diagnóstico , Consentimento Livre e Esclarecido , Unidades de Terapia Intensiva/legislação & jurisprudência , Idoso , Cuidados Críticos/psicologia , Estado Terminal , Estudos de Viabilidade , Feminino , Humanos , Modelos Logísticos , Masculino , Competência Mental , Pessoa de Meia-Idade , Projetos Piloto , Estudos Prospectivos , Fatores de Tempo
5.
J Am Coll Cardiol ; 78(1): 66-76, 2021 07 06.
Artigo em Inglês | MEDLINE | ID: mdl-34210416

RESUMO

The lymphatic system is an integral part of the circulatory system and plays an important role in the volume homeostasis of the human body. The complex anatomy and physiology paired with a lack of simple diagnostic tools to study the lymphatic system have led to an underappreciation of the contribution of the lymphatic system to acute and chronic heart failure (HF). Herein, we discuss the physiological role of the lymphatic system in volume management and the evidence demonstrating the dysregulation of the lymphatic system in HF. Further, we discuss the opportunity to target the lymphatic system in the management of HF and different potential approaches to accessing the lymphatic system.


Assuntos
Insuficiência Cardíaca , Sistema Linfático/fisiopatologia , Gerenciamento Clínico , Deslocamentos de Líquidos Corporais/fisiologia , Insuficiência Cardíaca/fisiopatologia , Insuficiência Cardíaca/terapia , Humanos
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