Prediction and validation of the duration of hemodialysis sessions for the treatment of acute ethylene glycol poisoning.

The duration of hemodialysis (HD) sessions for the treatment of acute ethylene glycol poisoning is dependent on concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. Ethylene glycol assays are not readily available, potentially leading to undue extension or premature termination of HD. We report a prediction model for the duration of high-efficiency HD sessions based retrospectively on a cohort study of 26 cases of acute ethylene glycol poisoning in 24 individuals treated by alcohol dehydrogenase competitive inhibitors, cofactors and HD. Two patients required HD for more than 14 days, and two died. In 19 cases, the mean ethylene glycol elimination half-life during high-efficiency HD was 165 minutes (95% confidence interval of 151-180 minutes). In a training set of 12 patients with acute ethylene glycol poisoning, using the 90th percentile half-life (195 minutes) and a target ethylene glycol concentration of 2 mmol/l (12.4 mg/dl) allowed all cases to reach a safe ethylene glycol under 3 mmol/l (18.6 mg/dl). The prediction model was then validated in a set of seven acute ethylene glycol poisonings. Thus, the HD session time in hours can be estimated using 4.7 x (Ln [the initial ethylene glycol concentration (mmol/l)/2]), provided that metabolic acidosis is corrected.

Association between e-alert implementation for detection of acute kidney injury and outcomes: a systematic review.

Background: Electronic alerts (e-alerts) for acute kidney injury (AKI) in hospitalized patients are increasingly being implemented; however, their impact on outcomes remains uncertain. Methods: We performed a systematic review. Electronic databases and grey literature were searched for original studies published between 1990 and 2016. Randomized, quasi-randomized, observational and before-and-after studies that included hospitalized patients, implemented e-alerts for AKI and described their impact on one of care processes, patient-centred outcomes or resource utilization measures were included. Results: Our search yielded six studies ( n = 10 165 patients). E-alerts were generally automated, triggered through electronic health records and not linked to clinical decision support. In pooled analysis, e-alerts did not improve mortality [odds ratio (OR) 1.05; 95% confidence intervals (CI), 0.84-1.31; n = 3 studies; n = 3425 patients; I 2 = 0%] or reduce renal replacement therapy (RRT) use (OR 1.20; 95% CI, 0.91-1.57; n = 2 studies; n = 3236 patients; I 2 = 0%). Isolated studies reported improvements in selected care processes. Pooled analysis found no significant differences in prescribed fluid therapy. Conclusions: In the available studies, e-alerts for AKI do not improve survival or reduce RRT utilization. The impact of e-alerts on processes of care was variable. Additional research is needed to understand those aspects of e-alerts that are most likely to improve care processes and outcomes.

Prediction and validation of hemodialysis duration in acute methanol poisoning.

The duration of hemodialysis (HD) in methanol poisoning (MP) is dependent on the methanol concentration, the operational parameters used during HD, and the presence and severity of metabolic acidosis. However, methanol assays are not easily available, potentially leading to undue extension or premature termination of treatment. Here we provide a prediction model for the duration of high-efficiency HD in MP. In a retrospective cohort study, we identified 71 episodes of MP in 55 individuals who were treated with alcohol dehydrogenase inhibition and HD. Four patients had residual visual abnormality at discharge and only one patient died. In 46 unique episodes of MP with high-efficiency HD the mean methanol elimination half-life (T1/2) during HD was 108 min in women, significantly different from the 129 min in men. In a training set of 28 patients with MP, using the 90th percentile of gender-specific elimination T1/2 (147 min in men and 141 min in women) and a target methanol concentration of 4 mmol/l allowed all cases to reach a safe methanol of under 6 mmol/l. The prediction model was confirmed in a validation set of 18 patients with MP. High-efficiency HD time in hours can be estimated using 3.390 × (Ln (MCi/4)) for women and 3.534 × (Ln (MCi/4)) for men, where MCi is the initial methanol concentration in mmol/l, provided that metabolic acidosis is corrected.

Treatment delays in patients undergoing primary percutaneous coronary intervention for ST elevation myocardial infarction at the Quebec Heart and Lung Institute.

BACKGROUND: Current guidelines for ST elevation myocardial infarction (STEMI) recommend performing primary percutaneous coronary intervention (PCI) within 90 min of hospital arrival. However, recent data suggest that in a real-world setting, median door-to-balloon (DTB) time is closer to 180 min for transfer patients, with less than 5% of patients being treated within 90 min. A retrospective observational study was conducted to assess time to treatment in patients undergoing primary PCI at the Quebec Heart and Lung Institute (QHLI). METHODS: Consecutive lytic-eligible patients undergoing primary PCI at the QHLI for STEMI between April 2004 and March 2005 were included in the present analysis. The primary evaluation was DTB time measured from arrival at the first hospital to first balloon inflation. Clinical outcomes were in-hospital death, reinfarction and bleeding. DTB times and hospital outcomes of patients transferred from referring hospitals were compared with those of patients presenting directly to the QHLI. RESULTS: During the study period, 203 lytic-eligible patients were treated with primary PCI. Sixty-nine patients presented directly to the QHLI and 134 were transferred from other hospitals. Six transfer patients were excluded because of missing time variables. The median DTB time was 114 min in transfer patients, compared with 87 min in patients presenting directly to the QHLI (P<0.001). DTB time was less than 90 min in 24% of the transfer population compared with 55% of patients presenting directly to the QHLI (P<0.001). In patients referred from hospitals within a radius of 30 km from the QHLI (n=100), median DTB time was 106 min with 30% receiving PCI within 90 min. In these patients, estimated PCI-related delay was 74 min. For patients presenting to hospitals beyond 30 km (n=28), median DTB time was 142 min with 4% receiving reperfusion within 90 min. In these patients, estimated PCI-related delay was 110 min. Median DTB time for patients presenting during off hours at the QHLI was 92 min compared with 79 min for patients presenting during regular business hours (P=0.02). In patients transferred from other hospitals, median DTB time was 118 min during off hours and 108 min during normal business hours (P=0.07). CONCLUSIONS: A DTB time of less than 90 min can be achieved in the majority of patients presenting directly to a primary PCI centre. However, for patients presenting to community hospitals, transfer for primary PCI is often associated with delayed revascularization. The present study highlights the need for careful patient selection when deciding between on-site thrombolytic therapy and transfer for primary PCI for STEMI patients presenting to hospitals without PCI facilities.

Association Between Cytomegalovirus Reactivation and Clinical Outcomes in Immunocompetent Critically Ill Patients: A Systematic Review and Meta-Analysis.

BACKGROUND: The aim of our systematic review was to investigate the association between cytomegalovirus (CMV) reactivation and outcomes in immunocompetent critically ill patients. METHODS: We searched electronic databases and gray literature for original studies and abstracts published between 1990 and October 2016. The review was limited to studies including critically ill immunocompetent patients. Cytomegalovirus reactivation was defined as positive polymerase chain reaction, pp65 antigenemia, or viral culture from blood or bronchoalveolar lavage. Selected patient-centered outcomes included mortality, duration of mechanical ventilation, need for renal replacement therapy (RRT), and nosocomial infections. Health resource utilization outcomes included intensive care unit and hospital lengths of stay. RESULTS: Twenty-two studies were included. In our primary analysis, CMV reactivation was associated with increased ICU mortality (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.87-3.47), overall mortality (OR, 2.02; 95% CI, 1.60-2.56), duration of mechanical ventilation (mean difference 6.60 days; 95% CI, 3.09-10.12), nosocomial infections (OR, 3.20; 95% CI, 2.05-4.98), need for RRT (OR, 2.37; 95% CI, 1.31-4.31), and ICU length of stay (mean difference 8.18 days; 95% CI, 6.14-10.22). In addition, numerous sensitivity analyses were performed. CONCLUSIONS: In this meta-analysis, CMV reactivation was associated with worse clinical outcomes and greater health resource utilization in critically ill patients. However, it remains unclear whether CMV reactivation plays a causal role or if it is a surrogate for more severe illness.

Quality indicators of continuous renal replacement therapy (CRRT) care in critically ill patients: a systematic review.

OBJECTIVES: Renal replacement therapy is increasingly utilized in the intensive care unit (ICU), of which continuous renal replacement therapy (CRRT) is most common. Despite CRRT being a relatively invasive and resource intensive technology, there remains wide practice variation in its application. This systematic review appraised the evidence for quality indicators (QIs) of CRRT care in critically ill patients. DESIGN: A comprehensive search strategy was developed and performed in five citation databases (Medline, Embase, CINAHL, Cochrane Library, and PubMed) and select grey literature sources. Two reviewers independently screened, selected, and extracted data using standardized forms. Each retrieved citation was appraised for quality using the Newcastle-Ottawa Scale (NOS) and Cochrane risk of bias tool. Data were summarized narratively. MEASUREMENTS AND MAIN RESULTS: Our search yielded 8374 citations, of which 133 fulfilled eligibility. This included 97 cohort studies, 24 randomized controlled trials, 10 case-control studies, and 2 retrospective medical audits. The quality of retrieved studies was generally good. In total, 18 QIs were identified that were mentioned in 238 instances. Identified QIs were classified as related to structure (n = 4, 22.2 %), care processes (n = 9, 50.0 %), and outcomes (n = 5, 27.8 %). The most commonly mentioned QIs focused on filter lifespan (n = 98), small solute clearance (n = 46), bleeding (n = 30), delivered dose (n = 19), and treatment interruption (n = 5). Across studies, the definitions used for QIs evaluating similar constructs varied considerably. When identified, QIs were most commonly described as important (n = 144, 48.3 %), scientifically acceptable (n = 32, 10.7 %), and useable and/or feasible (n = 17, 5.7 %) by their primary study authors. CONCLUSIONS: We identified numerous potential QIs of CRRT care, characterized by heterogeneous definitions, varying quality of derivation, and limited evaluation. Further study is needed to prioritize a concise inventory of QIs to measure, improve, and benchmark CRRT care for critically ill patients. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42015015530.

Impact of cytomegalovirus reactivation on clinical outcomes in immunocompetent critically ill patients: protocol for a systematic review and meta-analysis.

BACKGROUND: Cytomegalovirus (CMV) reactivation in critically ill patients is a well-recognized phenomenon with an incidence as high as 71 %. A number of studies have investigated the association between CMV reactivation and outcomes in critically ill patients with conflicting results. We propose to conduct a systematic review and meta-analysis to determine the impact of CMV reactivation on patient-centered outcomes and measures of health resource utilization in immunocompetent critically ill patients. METHODS: In consultation with a research librarian, a search strategy will be developed and electronic databases (i.e., Ovid MEDLINE, Ovid EMBASE, and the Cochrane Library including the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials (CENTRAL)) will be searched for original studies. Selected grey literature sources will be hand-searched. Search themes will include cytomegalovirus, intensive care unit, and sepsis. Citation screening, selection, quality assessment, and data abstraction will be performed in duplicate. Pooled effect estimates of the impact of CMV reactivation on selected patient-centered outcomes and measures of health resource utilization will be described. DISCUSSION: This systematic review aims to explore the impact of CMV reactivation on patient-centered outcomes and health resource utilization in immunocompetent critically ill patients. Our results will help to better define the burden of disease associated with CMV reactivation. Indeed, evidence to date suggests increased mortality in this patient population. However, the relationship between CMV reactivation and health resource utilization remains less clear. Based on our results, future study on the impact of CMV treatment or prophylaxis on outcomes (including those other than mortality) may be warranted. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016035446.

Impact of e-alert for detection of acute kidney injury on processes of care and outcomes: protocol for a systematic review and meta-analysis.

INTRODUCTION: Acute kidney injury (AKI) is a common complication in hospitalised patients. It imposes significant risk for major morbidity and mortality. Moreover, patients suffering an episode of AKI consume considerable health resources. Recently, a number of studies have evaluated the implementation of automated electronic alerts (e-alerts) configured from electronic medical records (EMR) and clinical information systems (CIS) to warn healthcare providers of early or impending AKI in hospitalised patients. The impact of e-alerts on care processes, patient outcomes and health resource use, however, remains uncertain. METHODS AND ANALYSIS: We will perform a systematic review to describe and appraise e-alerts for AKI, and evaluate their impact on processes of care, clinical outcomes and health services use. In consultation with a research librarian, a search strategy will be developed and electronic databases (ie, MEDLINE, EMBASE, CINAHL, Cochrane Library and Inspec via Engineering Village) searched. Selected grey literature sources will also be searched. Search themes will focus on e-alerts and AKI. Citation screening, selection, quality assessment and data abstraction will be performed in duplicate. The primary analysis will be narrative; however, where feasible, pooled analysis will be performed. Each e-alert will be described according to trigger, type of alert, target recipient and degree of intrusiveness. Pooled effect estimates will be described, where applicable. ETHICS AND DISSEMINATION: Our systematic review will synthesise the literature on the value of e-alerts to detect AKI, and their impact on processes, patient-centred outcomes and resource use, and also identify key knowledge gaps and barriers to implementation. This is a fundamental step in a broader research programme aimed to understand the ideal structure of e-alerts, target population and methods for implementation, to derive benefit. Research ethics approval is not required for this review. SYSTEMATIC REVIEW REGISTRATION NUMBER: CRD42016033033.

Impact of thrombus aspiration on angiographic and clinical outcomes in patients with ST-elevation myocardial infarction.

BACKGROUND: Primary percutaneous coronary intervention (PCI) in ST-elevation myocardial infarction (STEMI) may be limited by thrombus embolization. Export aspiration catheter (EAC) is a thrombectomy device which may enhance angiographic results, but its impact on clinical outcomes is unclear. This trial objective was to assess the impact of EAC on angiographic and clinical outcomes in patients with STEMI. METHODS: All STEMI patients undergoing primary or rescue PCI in a tertiary care center were included. Patients were divided in two groups according to the use of the EAC. Patients were followed up prospectively for death, reinfarction, revascularization, or stroke. Thrombolysis In Myocardial Infarction (TIMI) flow in the culprit vessel was assessed before and after PCI. RESULTS: Included in the analysis were 535 patients. EAC was used in 165 patients before angioplasty (Group 1) and 370 patients underwent PCI without thrombus aspiration (Group 2). More patients in Group 1 had initial TIMI flow 0-1 compared to Group 2 (88% vs. 62%, P<.001). Proportion of patients with a final TIMI flow 3 was the same in both groups (89.1% vs. 87.6% for Groups 1 and 2, respectively; P=.67). An analysis restricted to patients with initial TIMI flow 0-1 yielded similar results. No difference in clinical outcomes was observed between the two groups (P=.70). CONCLUSIONS: Selective use of the EAC based on the judgment of operators results in excellent angiographic and clinical results. Further clinical investigation is needed to definitely answer whether thromboaspiration needs to be performed in all STEMI patients undergoing primary PCI.

ECG-guided immediate intervention at the time of primary PCI to reduce door-to-balloon time in ST-elevation myocardial infarction patients.

BACKGROUND: In ST-segment elevation acute myocardial infarction (STEMI) patients undergoing primary percutaneous coronary intervention (PCI), all efforts must be made to improve door-to-balloon (DTB) times. This study was designed to assess the impact of electrocardiographic-guided immediate intervention (EGII) without performing a complete coronary evaluation on DTB times and clinical outcomes of STEMI patients treated with primary PCI. METHODS: Consecutive STEMI patients undergoing primary PCI at Laval Hospital between May 2006 and August 2007 were considered for inclusion. Patients with thrombolysis in myocardial infarction (TIMI) 2-3 flow in the culprit vessel on initial angiography and patients with previous coronary bypass surgery were excluded from the analysis. The primary evaluation was DTB time. Clinical outcomes consisted of cardiac death, reinfarction, revascularization or stroke. RESULTS: Two hundred seventy-nine (279) patients were included in the present analysis. Eighty-seven (87) patients underwent EGII (Group 1) and 192 underwent PCI after a complete angiographic diagnostic evaluation (Group 2). Median catheterization laboratory DTB was 21 minutes in Group 1 and 25.5 minutes in Group 2 (p < 0.0001). The median DTB time was 80 minutes for patients in Group 1, compared to 90 minutes for patients in Group 2 (p = 0.01). More patients in Group 1 received timely reperfusion (DTB < 90 min) than patients in Group 2 (63% vs. 49%; p = 0.04). There was a trend towards reduced mortality in Group 1 compared to Group 2 (p = 0.11, unadjusted). CONCLUSION: A strategy of EGII reduces DTB times with a possible impact on clinical outcomes in STEMI patients undergoing primary PCI.

Impact of fractional flow reserve measurement on the clinical management of patients with coronary artery disease evaluated with noninvasive stress tests prior to cardiac catheterization.

PURPOSE: Fractional flow reserve (FFR) is often performed to assess the severity of coronary artery stenoses. However, the usefulness of measuring FFR when a noninvasive test has been obtained prior to coronary angiography has not been studied. METHODS AND MATERIALS: We retrospectively reviewed 122 patients who underwent noninvasive stress test with cardiac imaging (SPECT or stress echocardiography) prior to FFR assessment of a coronary lesion. The usefulness of FFR measurement was determined. FFR was judged useful if decision to revascularize the patient reflected the result of FFR rather than the result of the stress test. RESULTS: A total of 136 lesions were evaluated. Of these, 66 were associated with a positive noninvasive test and 70 had no ischemia present in the territory of the evaluated vessel. When FFR was negative (> or =0.75) and the test positive (57 lesions), revascularization was deferred in 55. When FFR was positive (<0.75) and the functional test negative (8 lesions), revascularization was performed in 8. FFR measurement changed the clinical decision to revascularize the patient in 55 (83%) of the 66 lesions with ischemia documented on noninvasive tests compared to 8 (11%) of the 70 lesions without ischemia (P<.0001). CONCLUSION: FFR can be helpful in patients with coronary artery disease even when noninvasive testing is performed prior to coronary angiography. In this study, FFR measurement had the greatest impact in the evaluation of lesions with documented ischemia on noninvasive tests. In these patients, appropriate use of FFR based on the operator's judgment can prevent unnecessary revascularizations of intermediate lesions.