Small-Volume Blood Collection Tubes to Reduce Transfusions in Intensive Care: The STRATUS Randomized Clinical Trial.

Importance: Blood collection for laboratory testing in intensive care unit (ICU) patients is a modifiable contributor to anemia and red blood cell (RBC) transfusion. Most blood withdrawn is not required for analysis and is discarded. Objective: To determine whether transitioning from standard-volume to small-volume vacuum tubes for blood collection in ICUs reduces RBC transfusion without compromising laboratory testing procedures. Design, Setting, and Participants: Stepped-wedge cluster randomized trial in 25 adult medical-surgical ICUs in Canada (February 5, 2019 to January 21, 2021). Interventions: ICUs were randomized to transition from standard-volume (n = 10 940) to small-volume tubes (n = 10 261) for laboratory testing. Main Outcomes and Measures: The primary outcome was RBC transfusion (units per patient per ICU stay). Secondary outcomes were patients receiving at least 1 RBC transfusion, hemoglobin decrease during ICU stay (adjusted for RBC transfusion), specimens with insufficient volume for testing, length of stay in the ICU and hospital, and mortality in the ICU and hospital. The primary analysis included patients admitted for 48 hours or more, excluding those admitted during a 5.5-month COVID-19-related trial hiatus. Results: In the primary analysis of 21 201 patients (mean age, 63.5 years; 39.9% female), which excluded 6210 patients admitted during the early COVID-19 pandemic, there was no significant difference in RBC units per patient per ICU stay (relative risk [RR], 0.91 [95% CI, 0.79 to 1.05]; P = .19; absolute reduction of 7.24 RBC units/100 patients per ICU stay [95% CI, -3.28 to 19.44]). In a prespecified secondary analysis (n = 27 411 patients), RBC units per patient per ICU stay decreased after transition from standard-volume to small-volume tubes (RR, 0.88 [95% CI, 0.77 to 1.00]; P = .04; absolute reduction of 9.84 RBC units/100 patients per ICU stay [95% CI, 0.24 to 20.76]). Median decrease in transfusion-adjusted hemoglobin was not statistically different in the primary population (mean difference, 0.10 g/dL [95% CI, -0.04 to 0.23]) and lower in the secondary population (mean difference, 0.17 g/dL [95% CI, 0.05 to 0.29]). Specimens with insufficient quantity for analysis were rare (≤0.03%) before and after transition. Conclusions and Relevance: Use of small-volume blood collection tubes in the ICU may decrease RBC transfusions without affecting laboratory analysis. Trial Registration: ClinicalTrials.gov Identifier: NCT03578419.

Toward an all-inclusive trauma system in Central South Ontario: development of the Trauma-System Performance Improvement and Knowledge Exchange (T-SPIKE) project.

Background: There is currently no integrated data system to capture the true burden of injury and its management within Ontario's regional trauma networks (RTNs), largely owing to difficulties in identifying these patients across the multiple health care provider records. Our project represents an iterative effort to create the ability to chart the course of care for all injured patients within the Central South RTN. Methods: Through broad stakeholder engagement of major health care provider organizations within the Central South RTN, we obtained research ethics board approval and established data-sharing agreements with multiple agencies. We tested identification of trauma cases from Jan. 1 to Dec. 31, 2017, and methods to link patient records between the various echelons of care to identify barriers to linkage and opportunities for administrative solutions. Results: During 2017, potential trauma cases were identified within ground paramedic services (23 107 records), air medical transport services (196 records), referring hospitals (7194 records) and the lead trauma hospital trauma registry (1134 records). Linkage rates for medical records between services ranged from 49% to 92%. Conclusion: We successfully conceptualized and provided a preliminary demonstration of an initiative to collect, collate and accurately link primary data from acute trauma care providers for certain patients injured within the Central South RTN. Administration-level changes to the capture and management of trauma data represent the greatest opportunity for improvement.

Contexte: On ne dispose actuellement d'aucun système intégré de gestion des données pour évaluer le fardeau réel des traumatismes et de leur gestion dans les réseaux régionaux de traumatologie (RRT) en Ontario, en bonne partie en raison de la difficulté d'identifier les cas parmi la multiplicité des dossiers d'intervenants médicaux. Notre projet représente un effort itératif pour créer la capacité de cartographier le parcours de soin de tous les polytraumatisés du RRT de la région Centre-Sud. Méthodes: Grâce à l'engagement général des intervenants des grandes organisations de santé du RRT de la région Centre-Sud, nous avons obtenu l'approbation d'un comité d'éthique de la recherche et conclu des accords de partage des données avec plusieurs agences. Nous avons testé l'identification des cas de traumatologie du 1er janvier au 31 décembre 2017 et les méthodes de liaison des dossiers de patients entre les divers échelons de soin pour identifier les obstacles à la liaison et leurs solutions administratives possibles. Résultats: Au cours de 2017, les cas de traumatologie potentiels ont été identifiés auprès des services ambulanciers terrestres (23 107 dossiers), des services de transport médical aérien (196 dossiers), des hôpitaux référents (7194 dossiers) et du registre hospitalier principal de traumatologie (1134 dossiers). Les taux de liaison entre les différents services pour les dossiers médicaux variaient de 49 % à 92 %. Conclusion: Nous avons conceptualisé et présenté avec succès la démonstration préliminaire d'un projet visant à recueillir, colliger et relier avec justesse les données primaires des intervenants en traumatologie aiguë pour certains patients blessés du RRT du Centre-Sud. Des changements administratifs centrés sur la saisie et la gestion des données de traumatologie représentent la meilleure voie vers une amélioration.

The TRAAGIC score: early predictors of inpatient mortality in adult trauma patients

Background: Scoring systems are important in prognostication and decision-making in the management of trauma patients. However, they often include an extensive list of factors not easily recalled by clinicians on admission. Additionally, multivariable analyses examining predictors of mortality in these patients is lacking. This study aimed to develop and validate a mortality prediction score for adult trauma inpatients. The intention was to create a scoring tool that could be easily remembered and implemented by clinicians. Methods: This is a retrospective analysis of 5175 adult trauma patients treated at a level 1 trauma centre in Hamilton, Ontario, from 2002 to 2013. For derivation of the score, logistic regression was applied to data collected from 2002 to 2006 to identify potential predictors. Variables with p ≤ 0.10 identified from univariable analysis were entered in the multivariable logistic regression. Statistical significance was set at a value of 0.05. The prediction performance of the score was then assessed and validated on data for trauma patients treated from 2007 to 2013. The discrimination ability and calibration of the validation model were assessed. Frequencies, odds ratios with 95% confidence intervals (CIs) and C-statistics were reported. Results: The TRAAGIC prediction score (transfusion, age, airway, hyperglycemia, international normalized ratio, creatinine) showed a C-index of 0.85 (95% CI 0.83­0.87) in the derivation cohort. The TRAAGIC score had high discrimination and good calibration when applied to the validation cohort. Conclusion: The TRAAGIC score is an easily remembered and straightforward toolthat can reasonably predict inpatient mortality for adult trauma patients.

Contexte: Les systèmes de classification sont importants pour le pronostic et le processus décisionnel relatifs à la prise en charge des patients de traumatologie. Par contre, ces systèmes incluent souvent une longue liste de facteurs dont les cliniciens peuvent difficilement se rappeler quand un patient est admis. De plus, on déplore l'absence d'analyses multivariées sur les prédicteurs de mortalité chez ces patients. La présente étude visait à concevoir et valider un score de prédiction de la mortalité pour les polytraumatisés adultes hospitalisés. L'intention était de créer pour les médecins un outil de classification facile à retenir et simple à utiliser. Méthodes: Il s'agit d'une analyse rétrospective de 5175 polytraumatisés adultes traités dans un centre de traumatologie de niveau 1 de Hamilton, en Ontario, de 2002 à 2013. Le score est dérivé de l'analyse de régression logistique appliquée aux données recueillies de 2002 à 2006 pour dégager les prédicteurs potentiels. Les variables identifiées à partir d'analyses univariées dont p ≤ 0,10 ont été incluses dans l'analyse de régression logistique multivariée. La portée statistique a été fixée à 0,05. Le rendement prédictif du score a alors été évalué et validé pour les polytraumatisés traités de 2007 à 2013. On a évalué le pouvoir discriminant et l'étalonnage du modèle de validation, et on a fait état des fréquences, des rapports des cotes avec intervalles de confiance (IC) de 95 % et de la statistique C. Résultats: Le score de prédiction TRAAGIC (transfusion, âge, voies aériennes, hyperglycémie, ratio international normalisé, créatinine) a produit un indice de concordance de 0,85 (IC de 95 % 0,83­0,87) dans la cohorte de dérivation. Le score TRAAGIC s'est révélé doté d'un important pouvoir discriminant et d'un bon étalonnage lorsqu'on l'a appliqué à la cohorte de validation. Conclusion: Le score TRAAGIC est un outil facile à retenir et simple à utiliser qui permet de prédire raisonnablement le risque de mortalité chez les polytraumatisés adultes hospitalisés.

Diarrhea during critical illness: a multicenter cohort study.

PURPOSE: To study the incidence, predictors, and outcomes of diarrhea during the stay in the intensive care unit (ICU). METHODS: Prospective cohort of consecutive adults in the ICU for > 24 h during a 10-week period across 12 intensive care units (ICUs) internationally. The explored outcomes were: (1) incidence of diarrhea, (2) Clostridioides difficile-associated diarrhea (CDAD); (3) ICU and hospital length of stay (LOS) and mortality in patients with diarrhea. We fit generalized linear models to evaluate the predictors, management, morbidity and mortality associated with diarrhea. RESULTS: Among 1109 patients aged 61.4 (17.5) [mean (standard deviation)] years, 981(88.5%) were medical and 645 (58.2%) were mechanically ventilated. The incidence was 73.8% (818 patients, 73.8%, 95% confidence interval [CI] 71.1-76.6) using the definition of the World Health Organisation (WHO). Incidence varied across definitions (Bristol 53.5%, 95% CI 50.4-56.7; Bliss 37.7%, 95% CI 34.9-40.4). Of 99 patients with diarrhea undergoing CDAD testing, 23 tested positive (2.2% incidence, 95% CI 1.5-3.4). Independent predictors included enteral nutrition (RR 1.23, 95% CI 1.16-1.31, p < 0.001), antibiotic days (RR 1.02, 95% CI 1.02-1.03, p < 0.001), and suppositories (RR 1.14 95% CI 1.06-1.22, p < 0.001). Opiates decreased diarrhea risk (RR 0.76, 95% CI 0.68-0.86, p < 0.001). Diarrhea prompted management modifications (altered enteral nutrition or medications: RR 10.25, 95% CI 5.14-20.45, p < 0.001) or other consequences (fecal management device or CDAD testing: RR 6.16, 95% CI 3.4-11.17, p < 0.001). Diarrhea was associated with a longer time to discharge for ICU or hospital stay, but was not associated with hospital mortality. CONCLUSION: Diarrhea is common, has several predictors, and prompts changes in patient care, is associated with longer time to discharge but not mortality.

Academic and Community ICUs Participating in a Critical Care Randomized Trial: A Comparison of Patient Characteristics and Trial Metrics.

Clinical research in Canada is conducted primarily in "academic" hospitals, whereas most clinical care is provided in "community" hospitals. The objective of this nested observational study was to compare patient characteristics, outcomes, process-of-care variables, and trial metrics for patients enrolled in a large randomized controlled trial who were admitted to academic and community hospitals in Canada. DESIGN: We conducted a preplanned observational study nested within the Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT, a randomized controlled trial comparing probiotics to placebo in mechanically ventilated patients) Research Program. SETTING: ICUs. PATIENTS: Mechanically ventilated patients. MEASUREMENTS: We compared patient characteristics, interventions, outcomes, and trial metrics between patients enrolled in PROSPECT from academic and community hospitals. MAIN RESULTS: Participating centers included 34 (82.9%) academic and seven (17.1%) community hospitals, which enrolled 2,203 (86.2%) and 352 (13.8%) patients, respectively. Compared with academic hospitals, patients enrolled in community hospitals were older (mean [sd] 62.7 yr [14.9 yr] vs 59.5 yr [16.4 yr]; p = 0.044), had longer ICU stays (median [interquartile range {IQR}], 13 d [8-23 d] vs 11 d [7-8 d]; p = 0.012) and higher mortality (percentage, [95% CI] in the ICU, 30.4% [25.8-35.4%]vs 20.5% [18.9-11.3%]; p = 0.002) and hospital (40.6% [35.6-45.8%] vs 26.1% [24.3-27.9%]; p < 0.001). Trial metrics, including informed consent rate (85.9% vs 76.3%; p = 0.149), mean (sd) monthly enrolment rate (2.1 [1.4] vs 1.1 [0.7]; p = 0.119), and protocol adherence (90.6% vs 91.6%; p = 0.207), were similar between community and academic ICUs. CONCLUSIONS: Community hospitals can conduct high-quality research, with similar trial metrics to academic hospitals. Patient characteristics differed between community and academic hospitals, highlighting the need for broader engagement of community hospitals in clinical research to ensure generalizability of study results.

Bolus arginine supplementation affects neither muscle blood flow nor muscle protein synthesis in young men at rest or after resistance exercise.

The aim of this study was to investigate the ergogenic potential of arginine on NO synthesis, muscle blood flow, and skeletal muscle protein synthesis (MPS). Eight healthy young men (22.1 ± 2.6 y, 1.79 ± 0.06 m, 76.6 ± 6.2 kg; mean ± SD) participated in 2 trials where they performed a bout of unilateral leg resistance exercise and ingested a drink containing either 10 g essential amino acids with 10 g l-arginine (ARG) or an isonitrogenous control (CON). Femoral artery blood flow of both the nonexercised and exercised leg was measured continuously using pulsed-wave Doppler ultrasound, while rates of mixed and myofibrillar MPS were determined using a primed continuous infusion of L-[ring-(13)C(6)] or L-[ring-(2)H(5)]phenylalanine. The plasma arginine concentration increased 300% during the ARG trial but not during the CON trial (P < 0.001). Plasma nitrate, nitrite, and endothelin-1, all markers of NO synthesis, did not change during either the ARG or CON trial. Plasma growth hormone increased to a greater degree after exercise in the ARG trial than CON trial (P < 0.05). Femoral artery blood flow increased 270% above basal in the exercised leg (P < 0.001) but not in the nonexercised leg, with no differences between the ARG and CON trials. Mixed and myofibrillar MPS were both greater in the exercised leg compared with the nonexercised leg (P < 0.001), but did not differ between the ARG and CON treatments. We conclude that an oral bolus (10 g) of arginine does not increase NO synthesis or muscle blood flow. Furthermore, arginine does not enhance mixed or myofibrillar MPS either at rest or after resistance exercise beyond that achieved by feeding alone.

Minimal whey protein with carbohydrate stimulates muscle protein synthesis following resistance exercise in trained young men.

Whey protein is a supplemental protein source often used by athletes, particularly those aiming to gain muscle mass; however, direct evidence for its efficacy in stimulating muscle protein synthesis (MPS) is lacking. We aimed to determine the impact of consuming whey protein on skeletal muscle protein turnover in the post-exercise period. Eight healthy resistance-trained young men (age=21+/-1 .0 years; BMI=26.8+/-0.9 kg/m2 (means+/-SE)) participated in a double-blind randomized crossover trial in which they performed a unilateral leg resistance exercise workout (EX: 4 sets of knee extensions and 4 sets of leg press; 8-10 repetitions/set; 80% of maximal), such that one leg was not exercised and acted as a rested (RE) comparator. After exercise, subjects consumed either an isoenergetic whey protein plus carbohydrate beverage (WHEY: 10 g protein and 21 g fructose) or a carbohydrate-only beverage (CHO: 21 g fructose and 10 g maltodextran). Subjects received pulse-tracer injections of L-[ring-2H5]phenylalanine and L-[15N]phenylalanine to measure MPS. Exercise stimulated a rise in MPS in the WHEY-EX and CHO-EX legs, which were greater than MPS in the WHEY-RE leg and the CHO-RE leg (all p<0.05), respectively. The rate of MPS in the WHEY-EX leg was greater than in the CHO-EX leg (p<0.001). We conclude that a small dose (10 g) of whey protein with carbohydrate (21 g) can stimulate a rise in MPS after resistance exercise in trained young men that would be supportive of a positive net protein balance, which, over time, would lead to hypertrophy.