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1.
Br J Anaesth ; 132(3): 491-506, 2024 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-38185564

RESUMO

BACKGROUND: We aimed to evaluate the comparative effectiveness and safety of various i.v. pharmacologic agents used for procedural sedation and analgesia (PSA) in the emergency department (ED) and ICU. We performed a systematic review and network meta-analysis to enable direct and indirect comparisons between available medications. METHODS: We searched Medline, EMBASE, Cochrane, and PubMed from inception to 2 March 2023 for RCTs comparing two or more procedural sedation and analgesia medications in all patients (adults and children >30 days of age) requiring emergent procedures in the ED or ICU. We focused on the outcomes of sedation recovery time, patient satisfaction, and adverse events (AEs). We performed frequentist random-effects model network meta-analysis and used the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach to rate certainty in estimates. RESULTS: We included 82 RCTs (8105 patients, 78 conducted in the ED and four in the ICU) of which 52 studies included adults, 23 included children, and seven included both. Compared with midazolam-opioids, recovery time was shorter with propofol (mean difference 16.3 min, 95% confidence interval [CI] 8.4-24.3 fewer minutes; high certainty), and patient satisfaction was better with ketamine-propofol (mean difference 1.5 points, 95% CI 0.3-2.6 points, high certainty). Regarding AEs, compared with midazolam-opioids, respiratory AEs were less frequent with ketamine (relative risk [RR] 0.55, 95% CI 0.32-0.96; high certainty), gastrointestinal AEs were more common with ketamine-midazolam (RR 3.08, 95% CI 1.15-8.27; high certainty), and neurological AEs were more common with ketamine-propofol (RR 3.68, 95% CI 1.08-12.53; high certainty). CONCLUSION: When considering procedural sedation and analgesia in the ED and ICU, compared with midazolam-opioids, sedation recovery time is shorter with propofol, patient satisfaction is better with ketamine-propofol, and respiratory adverse events are less common with ketamine.


Assuntos
Analgesia , Ketamina , Propofol , Adulto , Criança , Humanos , Propofol/efeitos adversos , Midazolam/efeitos adversos , Ketamina/efeitos adversos , Metanálise em Rede , Dor/tratamento farmacológico , Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência , Unidades de Terapia Intensiva , Sedação Consciente/efeitos adversos , Sedação Consciente/métodos , Ensaios Clínicos Controlados Aleatórios como Assunto
2.
Crit Care Med ; 52(5): 717-728, 2024 05 01.
Artigo em Inglês | MEDLINE | ID: mdl-38265271

RESUMO

OBJECTIVES: Recent reviews demonstrated discordant effects of ICU-based physical rehabilitation on physical function. These inconsistencies may be related to differences in treatment fidelity-the extent to which a protocol is delivered as planned. Before evaluating the association of fidelity with outcomes, we must first understand the extent of treatment fidelity reporting in ICU-based physical rehabilitation randomized controlled trials (RCTs). DATA SOURCES: Six electronic databases from inception to December 2022. STUDY SELECTION: We included RCTs enrolling adults or children admitted to the ICU, if greater than or equal to 50% were invasively mechanically ventilated greater than 24 hours, and underwent an ICU-based physical rehabilitation intervention, with no limitation to comparators or outcomes. DATA EXTRACTION: We screened and extracted data independently and in duplicate, with a third reviewer as needed. Extracted data included study characteristics, treatment descriptions, and the presence of National Institutes of Health Behaviour Change Consortium (NIH-BCC) treatment fidelity tool components. Treatment fidelity scores were calculated as the proportion of reported (numerator) out of total NIH-BCC components (denominator). We calculated scores across studies and by treatment group (intervention vs. comparator). We used linear regression to assess for a time trend in study treatment fidelity scores. DATA SYNTHESIS: Of 20,433 citations, 94 studies met inclusion criteria. Authors reported a median (first-third quartiles) of 19% (14-26%) of treatment fidelity components across studies. Intervention group scores were higher than comparator groups (24% [19-33%] vs. 14% [5-24%], p < 0.01). We found a mean increase in study treatment fidelity scores by 0.7% (0.3 points) per year. CONCLUSIONS: Only 19% of treatment fidelity components were reported across studies, with comparator groups more poorly reported. Future research could investigate ways to optimize treatment fidelity reporting and determine characteristics associated with treatment fidelity conduct in ICU-based physical rehabilitation RCTs.


Assuntos
Hospitalização , Unidades de Terapia Intensiva , Estados Unidos , Adulto , Criança , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto
3.
Can J Anaesth ; 71(1): 118-126, 2024 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-37884773

RESUMO

PURPOSE: We sought to understand the beliefs and practices of Canadian intensivists regarding their use of ketamine as a sedative in critically ill patients and to gauge their interest in a randomized controlled trial (RCT) examining its use in the intensive care unit (ICU). METHODS: We designed and validated an electronic self-administered survey examining the use of ketamine as a sedative infusion for ICU patients. We surveyed 400 physician members of the Canadian Critical Care Society (CCCS) via email between February and April 2022 and sent three reminders at two-week intervals. The survey was redistributed in January 2023 to improve the response rate. RESULTS: We received 87/400 (22%) completed questionnaires. Most respondents reported they rarely use ketamine as a continuous infusion for sedation or analgesia in the ICU (52/87, 58%). Physicians reported the following conditions would make them more likely to use ketamine: asthma exacerbation (73/87, 82%), tolerance to opioids (68/87, 77%), status epilepticus (44/87, 50%), and severe acute respiratory distress syndrome (33/87, 38%). Concern for side-effects that limited respondents' use of ketamine include adverse psychotropic effects (61/87, 69%) and delirium (47/87, 53%). The majority of respondents agreed there is need for an RCT to evaluate ketamine as a sedative infusion in the ICU (62/87, 71%). CONCLUSION: This survey of Canadian intensivists illustrates that use of ketamine as a continuous infusion for sedation is limited, and is at least partly driven by concerns of adverse psychotropic effects. Canadian physicians endorse the need for a trial investigating the safety and efficacy of ketamine as a sedative for critically ill patients.


RéSUMé: OBJECTIF: Nous avons cherché à comprendre les croyances et les pratiques des intensivistes pratiquant au Canada concernant leur utilisation de la kétamine comme sédatif chez la patientèle gravement malade et à évaluer leur intérêt pour une étude randomisée contrôlée (ERC) examinant son utilisation à l'unité de soins intensifs (USI). MéTHODE: Nous avons mis au point et validé un sondage électronique auto-administré examinant l'utilisation de la kétamine comme perfusion sédative pour les patient·es aux soins intensifs. Nous avons envoyé le sondage à 400 médecins membres de la Société canadienne de soins intensifs (SCCC) par courriel entre février et avril 2022 et envoyé trois rappels à intervalles de deux semaines. Le sondage a été redistribué en janvier 2023 afin d'améliorer le taux de réponse. RéSULTATS: Nous avons reçu 87 questionnaires remplis sur 400 (22 %). La plupart des personnes répondantes ont déclaré qu'elles utilisaient rarement la kétamine en perfusion continue pour la sédation ou l'analgésie à l'USI (52/87, 58 %). Les médecins ont déclaré que les conditions suivantes les rendraient plus susceptibles d'utiliser de la kétamine : une exacerbation de l'asthme (73/87, 82 %), une tolérance aux opioïdes (68/87, 77 %), un état de mal épileptique (44/87, 50 %) et un syndrome de détresse respiratoire aigu (33/87, 38 %). Les inquiétudes quant aux effets secondaires qui ont limité l'utilisation de la kétamine par les répondant·es comprennent les effets psychotropes indésirables (61/87, 69 %) et le delirium (47/87, 53 %). La majorité des personnes répondantes étaient d'accord qu'une ERC est nécessaire pour évaluer la kétamine en tant que perfusion sédative à l'USI (62/87, 71 %). CONCLUSION: Cette enquête menée auprès d'intensivistes au Canada montre que l'utilisation de la kétamine comme perfusion continue pour la sédation est limitée, au moins en partie en raison d'inquiétudes liées aux effets psychotropes indésirables. Les médecins pratiquant au Canada reconnaissent la nécessité d'une étude sur l'innocuité et l'efficacité de la kétamine comme sédatif pour la patientèle gravement malade.


Assuntos
Ketamina , Humanos , Ketamina/efeitos adversos , Estado Terminal , Canadá , Unidades de Terapia Intensiva , Hipnóticos e Sedativos , Inquéritos e Questionários
4.
JAMA Netw Open ; 4(12): e2136263, 2021 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-34889948

RESUMO

Importance: The COVID-19 pandemic created the need for rapid and urgent guidance for clinicians to manage COVID-19 among patients and prevent transmission. Objective: To appraise the quality of clinical practice guidelines (CPGs) using the National Academy of Medicine (NAM) criteria. Evidence Review: A search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials to December 14, 2020, and a search of related articles to February 28, 2021, that included CPGs developed by societies or by government or nongovernment organizations that reported pharmacologic treatments of hospitalized patients with COVID-19. Teams of 2 reviewers independently abstracted data and assessed CPG quality using the 15-item National Guideline Clearinghouse Extent of Adherence to Trustworthy Standards (NEATS) instrument. Findings: Thirty-two CPGs were included in the review. Of these, 25 (78.1%) were developed by professional societies and emanated from a single World Health Organization (WHO) region. Overall, the CPGs were of low quality. Only 7 CPGs (21.9%) reported funding sources, and 12 (37.5%) reported conflicts of interest. Only 5 CPGs (15.6%) included a methodologist, described a search strategy or study selection process, or synthesized the evidence. Although 14 CPGs (43.8%) made recommendations or suggestions for or against treatments, they infrequently rated confidence in the quality of the evidence (6 of 32 [18.8%]), described potential benefits and harms (6 of 32 [18.8%]), or graded the strength of the recommendations (5 of 32 [15.6%]). External review, patient or public perspectives, or a process for updating were rare. High-quality CPGs included a methodologist and multidisciplinary collaborations involving investigators from 2 or more WHO regions. Conclusions and Relevance: In this review, few COVID-19 CPGs met NAM standards for trustworthy guidelines. Approaches that prioritize engagement of a methodologist and multidisciplinary collaborators from at least 2 WHO regions may lead to the production of fewer, high-quality CPGs that are poised for updates as new evidence emerges. Trial Registration: PROSPERO Identifier: CRD42021245239.


Assuntos
Tratamento Farmacológico da COVID-19 , Atenção à Saúde/normas , Hospitalização , Pandemias , Guias de Prática Clínica como Assunto/normas , Academias e Institutos , Humanos , SARS-CoV-2 , Sociedades Médicas , Confiança
5.
Pediatr Crit Care Med ; 22(9): e480-e491, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-33710073

RESUMO

OBJECTIVE: To synthesize the available evidence examining the efficacy and safety of levetiracetam compared with phenytoin or fosphenytoin in benzodiazepine-refractory pediatric status epilepticus. DATA SOURCES: We searched (from inception until April 27, 2020) Ovid MEDLINE, EMBASE, Web of Science, and Cochrane Central Register of Controlled Trials. STUDY SELECTION: Two reviewers, independently and in duplicate, screened citations and manuscripts for eligible randomized controlled trials. DATA EXTRACTION AND SYNTHESIS: Independently and in duplicate, we performed data abstraction, risk of bias assessment, and certainty assessment using Grading of Recommendations, Assessment, Development, and Evaluation. We performed meta-analyses using random-effect models or, if insufficient data, presented findings narratively. RESULTS: We identified seven randomized controlled trials (n = 1,575). Pooled analysis demonstrated low certainty evidence for no difference of levetiracetam on time to seizure cessation (mean difference, -3.11 min; 95% CI, -6.67 to 0.45), early seizure cessation (relative risk, 1.09, 95% CI, 0.95-1.26), or late seizure cessation (relative risk, 1.05; 95% CI, 0.93-1.18). Adverse event outcomes were limited by low event numbers. We found low certainty evidence for less respiratory depression with levetiracetam (relative risk, 0.28; 95% CI, 0.12-0.69). CONCLUSIONS: The efficacy of levetiracetam is comparable with phenytoin or fosphenytoin in children with benzodiazepine-refractory status epilepticus (low certainty evidence). Levetiracetam may cause less respiratory depression. Clinicians and guideline developers should weigh safety profiles when choosing between these agents.


Assuntos
Fenitoína , Estado Epiléptico , Anticonvulsivantes/efeitos adversos , Criança , Humanos , Levetiracetam/uso terapêutico , Fenitoína/efeitos adversos , Fenitoína/análogos & derivados , Estado Epiléptico/tratamento farmacológico
7.
CMAJ Open ; 8(3): E522-E529, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32873580

RESUMO

BACKGROUND: Optimal drug therapy in children relies on the availability of pediatric-specific information. We aimed to describe the current status of pediatric pharmacotherapy data in monographs of new drugs approved by Health Canada. METHODS: In this descriptive analysis, we reviewed the quality and quantity of monographs of new drugs approved by Health Canada between Jan. 1, 2007, and Dec. 31, 2016. We excluded drugs withdrawn from the Canadian market and drugs with primary indications irrelevant to pediatrics. We determined the percentage of included drug monographs that listed pediatric-specific information. RESULTS: During this study period, Health Canada approved 281 drugs, 270 of which met our inclusion criteria. Pediatric-specific information and indication were present in 127 (47.1%) and 75 (27.8%) of the drug monographs, respectively. Of all pediatric age groups, neonates had the lowest number of indications listed in the product monographs (7, 2.6%). Only 9 (60%) oral drugs indicated for children 6 years of age or younger were available in child-friendly, age-appropriate dosage forms. INTERPRETATION: Most of the new drugs approved by Health Canada do not contain pediatric or neonatal indications in their product monographs, and therefore, are used "off-label." Regulatory mechanisms are required to promote both neonatal and pediatric drug development and submission of available pediatric data by manufacturers to Health Canada.


Assuntos
Formas de Dosagem , Aprovação de Drogas/métodos , Desenvolvimento de Medicamentos/métodos , Tratamento Farmacológico/métodos , Pediatria/métodos , Canadá , Criança , Pré-Escolar , Indústria Farmacêutica , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Uso Off-Label
8.
Pediatr Crit Care Med ; 21(12): 1035-1041, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32590828

RESUMO

OBJECTIVES: To examine the gender distribution of authorship of pediatric critical care randomized control trials. DATA SOURCES: The 415 randomized control trials in pediatric critical care published before 2019. STUDY SELECTION: We included all randomized control trials enrolling children in a PICU. We used PICUtrials.net, which uses comprehensive search strategies of multiple databases, to identify published randomized control trials. DATA EXTRACTION: We manually extracted the name and profession of each listed author from each publication and classified each author as male or female based on their name. RESULTS: We included 2,146 authors and were able to classify 1,888 (88%) as men or women. Overall, 38% of authors were women, this varied with the authorship position: 37% of first, 38% of middle, and 25% of last authors were women (p < 0.001). The three most common professions were physician (63%), nonclinician (11%), and nurse (6%)-of which 30%, 45%, and 97%, respectively, were women. The percentage of female authorship overall has increased from 28% in 1985-1989 to 39% in 2015-2018 (p for trend = 0.004). There were no significant differences in the characteristics of randomized control trials published with a female first or last author versus those with both male first and last authors with respect to the median number of children randomized (60 vs. 50; p = 0.41), multicentred trials (17% vs. 24%; p = 0.12), trials at low risk of bias (50% vs. 66%; p = 0.26), reporting any funding (55% vs. 51%; p = 0.66), or median number of citations per year (1.5 vs. 2.4; p = 0.09). CONCLUSIONS: Although increasing over time, the percentage of researchers publishing pediatric critical care randomized control trials who are women still lags behind the percentage clinicians who are women. Trials that female researchers publish are similar in characteristics and impact as male researchers. Further work should identify barriers to gender diversity and potential solutions in pediatric critical care research.


Assuntos
Autoria , Editoração , Criança , Cuidados Críticos , Feminino , Humanos , Masculino , Pesquisadores
10.
Can J Hosp Pharm ; 73(2): 125-132, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32362669

RESUMO

BACKGROUND: Providing safe and effective sedation to critically ill children is challenging. The assessment, prevention, and treatment of symptoms of iatrogenic withdrawal are critical aspects of sedation practice. OBJECTIVE: To describe the use of sedative medications in critically ill children at McMaster Children's Hospital. METHODS: This retrospective observational study included children admitted over a 12-month period who survived their illness and who received sedation and at least 48 h of invasive ventilation. We collected data from the time of admission to the pediatric intensive care unit to 3 days after discontinuation of sedation. RESULTS: We included 67 children. The median age was 1.6 (interquartile range [IQR] 0.2-6.2) years, and respiratory illnesses were the most common reason for admission (41 [61%]). The children received invasive ventilation for a median of 7 (IQR 4-11) days and sedation for a median of 12 (IQR 6-20) days. Sixty-six children (99%) received an opioid, and all received a benzodiazepine, with median cumulative doses of 14 (IQR 5-27) mg/kg morphine equivalents and 15 (IQR 6-32) mg/kg midazolam equivalents. Dexmedetomidine was given to 31 children (46%), for a median of 8 (IQR 4-12) days. Most children (67%) received sedation after extubation (median duration 7 [IQR 4-14] days). In addition, 32 children (48%) continued to receive sedative medications after transfer to the ward, for a median of 6 (IQR 4-13) days. Forty-two children (63%) had at least one Withdrawal Assessment Tool-1 (WAT-1) score indicative of iatrogenic withdrawal. Children who experienced withdrawal were exposed to more opioids and more benzodiazepines, both per day and overall, and for longer periods. CONCLUSIONS: The children in this study were exposed to multiple sedatives, and many continued to receive these medications for an extended period after discontinuation of mechanical ventilation. Iatrogenic withdrawal was common and represents an important opportunity to improve children's recovery after critical illness.


CONTEXTE: Il est difficile d'offrir une sédation sûre et efficace aux enfants gravement malades. L'évaluation, la prévention et le traitement des symptômes du sevrage iatrogène sont des aspects critiques de la pratique de la sédation. OBJECTIF: Décrire l'usage de sédatifs pour les enfants gravement malades à l'Hôpital pour enfants McMaster. MÉTHODES: Cette étude observationnelle rétrospective comprenait des enfants admis sur une période de 12 mois, ayant survécu à leur maladie et ayant reçu une sédation ainsi qu'une ventilation effractive d'au moins 48 h. Nous avons recueilli des données à partir du moment de leur admission à l'unité de soins pédiatriques intensifs et jusqu'à trois jours après l'arrêt de la sédation. RÉSULTATS: Nous avons inclus 67 enfants. L'âge moyen était 1,6 an (écart interquartile [IQR] 0,2­6,2), et les maladies respiratoires étaient la raison la plus fréquente (41 [61 %]). Les enfants ont reçu une ventilation effractive pendant 7 jours en moyenne (IQR 4­11) et une sédation pendant 12 jours en moyenne (IQR 6­20). Soixante-six (99 %) enfants ont reçu un opiacé et ils ont tous reçu une benzodiazépine, avec des doses moyennes cumulées équivalentes à 14 mg/kg (IQR 5­27) de morphine et des doses moyennes cumulées équivalentes à 15 (IQR 6­32) mg/kg de midazolam. Trente et un (46 %) enfants ont reçu de la dexmédétomidine pendant huit jours en moyenne (IQR 4­12). La plupart (67 %) des enfants ont reçu une sédation après l'extubation (durée moyenne 7 [IQR 4­14] jours). De plus, 32 (48 %) enfants ont continué de recevoir des sédatifs après leur transfert dans leur chambre, et cela pendant six jours en moyenne (IQR 4­13). Les scores de quarante-deux (63 %) des enfants obtenus grâce à l'Outil d'évaluation du sevrage, version 1 [WAT-1], révèlent un sevrage iatrogène. Les enfants ayant ressenti des symptômes de sevrage ont été exposés à davantage d'opiacés et de benzodiazépines, aussi bien chaque jour que de manière globale, mais également pendant des périodes prolongées. CONCLUSIONS: Les enfants de cette étude ont été exposés à plusieurs sédatifs et bon nombre d'entre eux ont continué à recevoir ces médicaments pendant une période prolongée après l'arrêt de la ventilation mécanique. Le sevrage iatrogène se pratiquait couramment; il s'agit d'une belle occasion d'améliorer la convalescence des enfants après une maladie grave.

11.
Pediatr Crit Care Med ; 21(1): 12-20, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31577694

RESUMO

OBJECTIVES: Clinical research is a collaborative enterprise; researchers benefit from the expertise, experience, and resources of their collaborators. We sought to describe the extent and patterns of collaboration among pediatric critical care trialists, and to identify the most influential individuals, centers, and countries. DESIGN: Social network analysis of coauthorship. DATA SOURCES: Publications of pediatric critical care randomized controlled trials (1986-2018). DATA EXTRACTION: We manually extracted the names of all authors and their affiliations. We used productivity (number of randomized controlled trials), influence (number of citations), and four measures of prominence in the social network (degree, betweenness, closeness, and eigenvector centrality) to identify the most influential individuals. MEASUREMENTS AND MAIN RESULTS: From 415 randomized controlled trials in pediatric critical care, we identified 2,176 trialists from 377 centers in 43 countries. The coauthorship network is highly disconnected and dominated by a single large cluster of trialists publishing 142 (34%) of the randomized controlled trials. However, 119 (29%) of the randomized controlled trials were published by 28 smaller clusters-a median (interquartile range) of 3 (2-4) randomized controlled trials each. The remaining 154 (37%) randomized controlled trials were coauthored by researchers publishing a single randomized controlled trial each. This overall structure has remained constant with the publication of new randomized controlled trials over 33 years. The most influential trialists and centers varied according to the metric we used; only one trialist and three centers ranked in the top 10 for all measures of influence. Thirty-five of the 40 trialists (88%) ranking in the top 10 of any of the measures were from the United States, the United Kingdom, and Canada. CONCLUSIONS: Pediatric critical care has made considerable progress in the number of trialists and randomized controlled trials, but the research enterprise remains highly clustered and fragmented, particularly geographically. Efforts to further increase the quantity and quality of research in the field should include steps to increase the level and range of collaboration.


Assuntos
Bibliometria , Pesquisa Biomédica/métodos , Cuidados Críticos , Ensaios Clínicos Controlados Aleatórios como Assunto , Autoria , Canadá , Criança , Humanos , Pediatria , Editoração , Pesquisadores , Rede Social , Reino Unido , Estados Unidos
12.
Pediatr Crit Care Med ; 21(2): e107-e113, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31821206

RESUMO

OBJECTIVE: To describe current stress ulcer prophylaxis practice in Canadian PICUs. DESIGN: Multicenter cohort study. We defined stress ulcer prophylaxis as the use of a proton-pump inhibitor, histamine-2 receptor antagonist, or sucralfate within the first 2 PICU days among children who had not been on these medications at home and had no evidence of gastrointestinal bleeding. SETTING: Seven PICUs in Canada. PATIENTS: Three hundred seventy-eight children requiring mechanical ventilation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Children were ventilated for a median (interquartile range) of 2 days (1-6 d) and stayed in the PICU for a median (interquartile range) of 4 days (2-10 d). The median (interquartile range) age was 1.3 years (0.3-6.7 yr). Seventy percent of all children received acid suppression during their PICU stay. One hundred sixty-seven (54%) of the 309 children eligible for stress ulcer prophylaxis received it. Histamine-2 receptor antagonists were the most frequently used class (66%), followed by proton-pump inhibitors (47%) and sucralfate (4%), and 20% received more than one class. Stress ulcer prophylaxis was continued on the PICU transfer orders for 34% of these children. Children who received prophylaxis were older and had a higher Pediatric Risk of Mortality III score, more often received nonsteroidal anti-inflammatory drugs and systemic corticosteroids and received less enteral nutrition. In multivariate analysis, age and invasive mechanical ventilation were independently associated with an increased likelihood of receiving stress ulcer prophylaxis and receiving feeds was independently associated with a decreased likelihood of receiving stress ulcer prophylaxis. Gastrointestinal bleeding was reported in 21 (6%) of 378 children; three (0.8%) were clinically important. Eighteen percent were treated for a new respiratory tract infection, and 1% developed Clostridium difficile-associated diarrhea. CONCLUSIONS: Stress ulcer prophylaxis is common in Canadian PICUs. Clinically important gastrointestinal bleeding and C. difficile-associated diarrhea are rare, and the utility of routine prophylaxis should be examined.


Assuntos
Antiulcerosos/uso terapêutico , Estado Terminal , Úlcera Péptica/prevenção & controle , Estresse Fisiológico , Canadá , Criança , Pré-Escolar , Estudos de Coortes , Diarreia/epidemiologia , Nutrição Enteral , Feminino , Hemorragia Gastrointestinal/epidemiologia , Hemorragia Gastrointestinal/prevenção & controle , Antagonistas dos Receptores H2 da Histamina/uso terapêutico , Humanos , Lactente , Unidades de Terapia Intensiva Pediátrica , Masculino , Inibidores da Bomba de Prótons/uso terapêutico , Respiração Artificial , Sucralfato/uso terapêutico
13.
Crit Care Med ; 47(12): e1014-e1021, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31738741

RESUMO

OBJECTIVES: Occupational therapists have specialized expertise to enable people to perform meaningful "occupations" that support health, well-being, and participation in life roles. Given the physical, cognitive, and psychologic disability experienced by ICU survivors, occupational therapists could play an important role in their recovery. We conducted a scoping review to determine the state of knowledge of interventions delivered by occupational therapists in adult ICU patients. DATA SOURCES: Eight electronic databases from inception to 05/2018. STUDY SELECTION: We included reports of adult patients receiving direct patient care from an occupational therapist in the ICU, all study designs, and quantitative and qualitative traditions. DATA EXTRACTION: Independently in duplicate, interprofessional team members screened titles, abstracts, and full texts and extracted report and intervention characteristics. From original research articles, we also extracted study design, number of patients, and primary outcomes. We resolved disagreements by consensus. DATA SYNTHESIS: Of 50,700 citations, 221 reports met inclusion criteria, 74 (79%) published after 2010, and 125 (56%) appeared in critical care journals. The three most commonly reported types of interventions were mobility (81%), physical rehabilitation (61%), and activities of daily living (31%). We identified 46 unique original research studies of occupational therapy interventions; the most common study research design was before-after studies (33%). CONCLUSIONS: The role of occupational therapists in ICU rehabilitation is not currently well established. Current interventions in the ICU are dominated by physical rehabilitation with a growing role in communication and delirium prevention and care. Given the diverse needs of ICU patients and the scope of occupational therapy, there could be an opportunities for occupational therapists to expand their role and spearhead original research investigating an enriched breadth of ICU interventions.


Assuntos
Cuidados Críticos/métodos , Unidades de Terapia Intensiva , Terapia Ocupacional , Humanos
14.
Pediatr Crit Care Med ; 20(6): e274-e282, 2019 06.
Artigo em Inglês | MEDLINE | ID: mdl-30946294

RESUMO

OBJECTIVES: Characterize current practices for PICU-based rehabilitation, and physician perceptions and attitudes, barriers, resources, and outcome assessment in contemporary PICU settings. DESIGN: International, self-administered, quantitative, cross-sectional survey. SETTING: Online survey distributed from March 2017 to April 2017. PATIENTS OR SUBJECTS: Pediatric critical care physicians who subscribed to email distribution lists of the Pediatric Acute Lung Injury and Sepsis Investigators, the Pediatric Neurocritical Care Research Group, or the Prevalence of Acute Critical Neurological Disease in Children: A Global Epidemiological Assessment study group, and visitors to the World Federation of Pediatric Intensive and Critical Care Societies website. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 170 subjects who began the survey, 148 completed it. Of those who completed the optional respondent information, most reported working in an academic medical setting and were located in the United States. The main findings were 1) a large majority of PICU physicians reported working in institutions with no guidelines for PICU-based rehabilitation, but expressed interest in developing and implementing such guidelines; 2) despite this lack of guidelines, an overwhelming majority of respondents reported that their current practices would involve consultation of multiple rehabilitation services for each case example provided; 3) PICU physicians believed that additional research evidence is needed to determine efficacy and optimal implementation of PICU-based rehabilitation; 4) PICU physicians reported significant barriers to implementation of PICU-based rehabilitation across centers; and 5) low routine assessment of long-term functional outcomes of PICU patients, although some centers have developed multidisciplinary follow-up programs. CONCLUSIONS: Physicians lack PICU-based rehabilitation guidelines despite great interest and current practices involving a high degree of PICU-based rehabilitation consultation. Data are needed to identify best practices and necessary resources in the delivery of ICU-based multidisciplinary rehabilitation and long-term functional outcomes assessment to optimize recovery of children and families affected by critical illness.


Assuntos
Atitude do Pessoal de Saúde , Unidades de Terapia Intensiva Pediátrica/organização & administração , Médicos/psicologia , Reabilitação/organização & administração , Cuidados Críticos , Estudos Transversais , Humanos , Guias de Prática Clínica como Assunto , Reabilitação/normas , Estados Unidos
15.
Pediatr Crit Care Med ; 19(11): e595-e602, 2018 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-30074981

RESUMO

OBJECTIVES: Clinical research is a complex scientific and social enterprise. Our objective was to identify strategies that pediatric critical care trialists consider acceptable, feasible, and effective to improve the design and conduct randomized controlled trials in pediatric critical care. DESIGN: Qualitative descriptive study using semistructured individual interviews. SUBJECTS: We interviewed 26 pediatric critical care researchers from seven countries who have published a randomized controlled trial (2005-2015). We used purposive sampling to achieve diversity regarding researcher characteristics and randomized controlled trial characteristics. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Most participants (24 [92%]) were from high-income countries, eight (31%) had published more than one randomized controlled trial, 17 (65%) had published a multicenter randomized controlled trial, and eight (31%) had published a multinational randomized controlled trial. An important theme was "building communities"-groups of individuals with similar interests, shared experiences, and common values, bound by professional and personal relationships. Participants described a sense of community as a source of motivation and encouragement and as a means to larger, more rigorous trials, increasing researcher and clinician engagement and maintaining enthusiasm. Strategies to build communities stressed in-person interactions (both professional and social), capable leadership, and trust. Another important theme was "getting started." Participants highlighted the importance of formal research training and high-quality experiential learning through collaboration on other's projects, guided by effective mentorship. Also important was "working within the system"-ensuring academic credit for a range of contributions, not only for the principal investigator role. The longitudinal notion of "building on success" was also underscored as a cross-cutting theme. CONCLUSIONS: Coordinated, deliberate actions to build community and ensure key training and practical experiences for new investigators may strengthen the research enterprise in pediatric critical care. These strategies, potentially in combination with other novel approaches, may vitalize clinical research in this field.


Assuntos
Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Pesquisadores , Criança , Cuidados Críticos , Estado Terminal , Humanos , Entrevistas como Assunto , Pediatria , Pesquisa Qualitativa , Melhoria de Qualidade
16.
Pediatr Crit Care Med ; 19(2): e105-e111, 2018 02.
Artigo em Inglês | MEDLINE | ID: mdl-29394234

RESUMO

OBJECTIVES: To identify, in addition to survival, preferred outcome measures of PICU family care providers and PICU healthcare professionals for interventional trials enrolling critically ill children, and to describe general attitudes of family care providers and healthcare professionals regarding research in the PICU. DESIGN: Cross-sectional survey examining subject experience with clinical research and personal preferences for outcome measures for a hypothetical interventional clinical trial. SETTING: PICUs within four academic children's hospitals in the United States and Canada. SUBJECTS: Two cohorts including family members of critically ill children in PICUs (family care providers) and multidisciplinary staff working in the PICUs (healthcare professionals). INTERVENTIONS: Administration of a short, deidentified survey. MEASUREMENTS: Demographic data were collated for the two subject groups. Participants were queried regarding their attitudes related to research conducted in the PICU. In addition to survival, each group was asked to identify their three most important outcomes for an investigation examining whether or not an intervention helps seriously ill children recover. MAIN RESULTS: Demographics for family care providers (n = 40) and healthcare professionals (n = 53) were similarly distributed. Female respondents (79.8%) predominated. Participants (98.9%) ascertained the importance of conducting research in the PICU, but significant challenges associated with this goal in the high stress PICU environment. Both quality of life and functioning after leaving the hospital were chosen as the most preferred outcome measure, with 77.5% of family care providers and 84.9% of healthcare professionals indicating this choice. Duration of organ dysfunction was identified by 70.0% of family care providers and 40.7% of healthcare professionals as the second most preferred outcome measure. CONCLUSIONS: In addition to survival, long-term quality of life/functional status and duration of organ dysfunction represent important interventional trial outcome measures for both families of critically ill children, as well as the multidisciplinary team who provides critical care.


Assuntos
Atitude do Pessoal de Saúde , Pesquisa Biomédica/estatística & dados numéricos , Cuidados Críticos/estatística & dados numéricos , Estado Terminal/terapia , Avaliação de Resultados em Cuidados de Saúde/estatística & dados numéricos , Adulto , Canadá , Ensaios Clínicos como Assunto , Estudos Transversais , Família , Feminino , Pessoal de Saúde/estatística & dados numéricos , Hospitais Pediátricos , Humanos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Qualidade de Vida , Taxa de Sobrevida , Estados Unidos , Adulto Jovem
17.
Can J Hosp Pharm ; 70(4): 288-293, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28894313

RESUMO

BACKGROUND: Stress ulcer prophylaxis is commonly used in pediatric critical care, to prevent upper gastrointestinal bleeding. The most frequently used agents are histamine-2 receptor antagonists (H2RAs) and proton pump inhibitors (PPIs). The risk-benefit ratio for stress ulcer prophylaxis is uncertain, because data from randomized clinical trials (RCTs) on the effectiveness and harms of prophylaxis in children are limited. OBJECTIVE: To describe the views of Canadian pediatric intensivists about a future RCT of stress ulcer prophylaxis. METHODS: We conducted an online survey of Canadian pediatric critical care physicians. We e-mailed information about the study and a link to a 10-item survey to 111 potential respondents, with 2 reminders for nonrespondents. We assessed the relationship between respondents' characteristics and their views about the need for and potential participation in a trial using logistic regression and assessed regional differences using the χ2 test. RESULTS: The 68 physicians who replied (61% of potential respondents) had a median of 12 (interquartile range 5-20) years of experience. Forty-four (65%) of the respondents stated that a large, rigorous RCT of stress ulcer prophylaxis in children is needed, and 94% (62 of 66) indicated that it should include a placebo group. The 3 most common designs suggested were a 3-arm trial comparing PPI, H2RA, and placebo (56% [37 of 66 respondents to this question]) and 2-arm trials comparing PPI with placebo (15% [n = 10]) and H2RA with placebo (8% [n = 5]). The 5 patient groups that respondents most commonly stated should be excluded (because they should not receive placebo) were children receiving acid suppression at home (66% [42 of 64 respondents to this question]) or corticosteroids (59% [n = 38]), those with severe coagulopathy or receiving extracorporeal membrane oxygenation (both 36% [n = 23]), and those with burns (31% [n = 20]). Most respondents indicated a willingness to participate in an RCT (64% [42 of 66 respondents to this question]), whereas some (29% [n = 19]) indicated that participation would depend on trial design or funding; only 8% (n = 5) were disinclined to participate. CONCLUSIONS: There is considerable interest in a placebo-controlled RCT of stress ulcer prophylaxis among pediatric critical care physicians in Canada, but consensus on key elements of the trial design is needed.


CONTEXTE: La prophylaxie de l'ulcère de stress est fréquemment employée en soins intensifs pédiatriques afin de prévenir les saignements du tractus gastro-intestinal supérieur. Les agents les plus souvent employés sont les antagonistes des récepteurs H2 de l'histamine (anti-H2) et les inhibiteurs de la pompe à protons (IPP). Le rapport bénéfice-risque pour la prophylaxie de l'ulcère de stress est incertain, car les données provenant d'essais cliniques à répartition aléatoire (ECRA) sur l'efficacité et les dangers de la prophylaxie chez l'enfant sont peu nombreuses. OBJECTIF: Décrire les points de vue des pédiatres intensivistes canadiens à propos d'un futur ECRA sur la prophylaxie de l'ulcère de stress. MÉTHODES: Nous avons réalisé un sondage en ligne auprès de médecins canadiens en soins intensifs pédiatriques. Nous avons envoyé par courriel de l'information sur l'étude, dont un lien menant au sondage en dix points, à 111 répondants potentiels et deux rappels à ceux n'ayant pas répondu d'emblée. Nous avons évalué, au moyen d'un modèle de régression logistique, les points de vue des répondants à propos de la nécessité d'un essai et de leur participation potentielle à celui-ci en fonction de leurs caractéristiques individuelles et, à l'aide d'un test de χ2, les différences régionales. RÉSULTATS: Les 68 médecins (61 % des répondants potentiels) qui ont répondu avaient une médiane de 12 (écart interquartile de 5 à 20) années d'expérience. Quarante-quatre (65 %) des répondants indiquaient qu'il serait nécessaire de procéder à un important et rigoureux ECRA sur la prophylaxie de l'ulcère de stress chez l'enfant et 94 % (62 des 66 répondants) indiquaient que l'étude devrait comprendre un groupe placebo. Les trois plans expérimentaux les plus souvent suggérés étaient : un essai à trois groupes comparant les IPP, les anti-H2 et le placebo (56 % [37 des 66 répondants à cette question]), un essai à deux groupes comparant les IPP au placebo (15 % [n = 10]) et un essai à deux groupes comparant les anti-H2 au placebo (8 % [n = 5]). Les cinq groupes de patients que les répondants indiquaient le plus souvent comme ceux devant être exclus (parce qu'ils ne devraient pas recevoir de placebo) étaient : les enfants recevant un traitement de suppression de la sécrétion d'acide à la maison (66% [42 des 64 répondants à cette question]), ceux traités à l'aide de corticoïdes (59 % [n = 38]), ceux atteints d'une coagulopathie grave ou ceux traités par oxygénation extracorporelle sur oxygénateur à membrane (36 % chacun [n = 23]) et ceux souffrant de brûlures (31% [n = 20]). La plupart des répondants ont indiqué être prêts à participer à un ECRA (64% [42 des 66 répondants à cette question]), alors que certains (29 % [n = 19]) ont indiqué que leur participation dépendrait du plan de l'étude ou de son financement; seulement 8% (n = 5) n'étaient pas enclins à participer. CONCLUSIONS: On constate parmi les médecins canadiens en soins intensifs pédiatriques un intérêt marqué pour la tenue d'un ECRA comparatif contre placebo sur la prophylaxie de l'ulcère de stress, mais il est d'abord nécessaire d'obtenir un consensus sur les éléments clés du plan expérimental.

19.
Artigo em Inglês | MEDLINE | ID: mdl-28533916

RESUMO

BACKGROUND: Despite sparse pediatric data on effectiveness, the majority of critically ill children receive medications to prevent gastrointestinal (GI) bleeding. Stress ulcer prophylaxis may have unintended consequences-increasing the risk of nosocomial infections-which may be more serious and common than the bleeding which these drugs are prescribed to prevent. Randomized controlled trials (RCTs) in pediatric critical care are exceptionally challenging to complete, thus a rigorous pilot RCT is crucial. The objective of this pilot RCT is to assess the feasibility of a large multicentre RCT of stress ulcer prophylaxis with pantoprazole to prevent upper GI bleeding vs. placebo. METHODS: A multi-centre blinded pilot RCT of 120 children in six Canadian PICUs. Children expected to require mechanical ventilation for more than 48 h will be randomized to receive intravenous pantoprazole 1 mg/kg or identical placebo once daily until they no longer need mechanical ventilation. We have four feasibility outcomes and will consider the trial successful if we achieve:Effective screening: If >80% of eligible patients are approached for consent.Timely enrollment: if >80% of participants receive their first dose of the assigned study drug within 1 day of becoming eligible.Participant accrual: If the average monthly enrolment is two or more participants per centre per month.Protocol adherence: if >90% of doses are administered according to the protocol. DISCUSSION: There are many uncertainties about the risks and benefits of stress ulcer prophylaxis. In an era of widespread use-where clinicians prescribe prophylaxis to the more severely ill-a large, rigorous RCT is required. A trial to determine if a strategy of withholding stress ulcer prophylaxis is not inferior to a strategy of routine stress ulcer prophylaxis will be challenging. A carefully designed and implemented pilot trial is essential. TRIAL REGISTRATION: ClinicalTrials.gov:NCT02929563 (Registered October 3, 2016).

20.
Crit Care ; 21(1): 75, 2017 Feb 25.
Artigo em Inglês | MEDLINE | ID: mdl-28330506

RESUMO

BACKGROUND: This systematic review and meta-analysis investigates the efficacy and safety of clonidine as a sedative in critically ill patients requiring invasive mechanical ventilation. METHODS: We performed a comprehensive search of MEDLINE, EMBASE, CINAHL and the Cochrane trial registry. We identified RCTs that compared clonidine to any non-clonidine regimen in critically ill patients, excluding neonates, requiring mechanical ventilation. The GRADE method was used to assess certainty of evidence. RESULTS: We included eight RCTs (n = 642 patients). In seven of the trials clonidine was used for adjunctive rather than stand-alone sedation. There was no difference in the duration of mechanical ventilation (mean difference (MD) 0.05 days, 95% confidence interval (CI) = -0.65 to 0.75, I 2 = 86%, moderate certainty), ICU mortality (relative risk (RR) 0.98, 95% CI = 0.51 to 1.90, I 2 = 0%, low certainty), or ICU length of stay (MD 0.04 days, 95% CI = -0.46 to 0.53, I 2 = 16%, moderate certainty), with clonidine. There was a significant reduction in the total dose of narcotics (standard mean difference (SMD) -0.26, 95% CI = -0.50 to -0.02, I 2 = 0%, moderate certainty) with clonidine use. Clonidine was associated with increased incidence of clinically significant hypotension (RR 3.11, 95% CI = 1.64 to 5.87, I 2 = 0%, moderate certainty). CONCLUSIONS: Until further RCTs are performed, data remains insufficient to support the routine use of clonidine as a sedative in the mechanically ventilated population. Clonidine may act as a narcotic-sparing agent, albeit with an increased risk of clinically significant hypotension.


Assuntos
Clonidina/farmacologia , Estado Terminal/terapia , Hipnóticos e Sedativos/farmacologia , Clonidina/uso terapêutico , Humanos , Hipnóticos e Sedativos/uso terapêutico , Hipotensão/etiologia , Unidades de Terapia Intensiva/organização & administração , Tempo de Internação , Respiração Artificial/métodos
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