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1.
Ann Am Thorac Soc ; 15(4): 494-502, 2018 04.
Artículo en Inglés | MEDLINE | ID: mdl-29509509

RESUMEN

RATIONALE: Randomized trials and meta-analyses have informed several aspects of weaning. Results are rarely replicated in practice, as evidence is applied in intensive care units that differ from the settings in which it was generated. OBJECTIVES: We aimed to: 1) describe weaning practice variation (identifying weaning candidates, conducting spontaneous breathing trials, using ventilator modes, and other aspects of care during weaning); 2) characterize regional differences in weaning practices; and 3) identify factors associated with practice variation. METHODS: We conducted a cross-sectional, self-administered, international postal survey of adult intensivist members of regional critical care societies from six geographic regions, including Canada, India, the United Kingdom, Europe, Australia/New Zealand, and the United States. We worked with societies to randomly select potential respondents from membership lists and administer questionnaires with the goal of obtaining 200 responses per region. RESULTS: We analyzed 1,144 questionnaires (Canada, 156; India, 136; United Kingdom, 219; Europe, 260; Australia/New Zealand, 196; United States, 177). Across regions, most respondents screened patients once daily to identify spontaneous breathing trials candidates (regional range, 70.0%-95.6%) and less often screened twice daily (range, 12.2%-33.1%) or more than twice daily (range, 1.6%-18.2%). To wean patients, most respondents used pressure support alone (range, 31.0%-71.7%) or with spontaneous breathing trials (range, 35.7%-68.1%). To conduct spontaneous breathing trials, respondents predominantly used pressure support with positive end-expiratory pressure (range, 56.5%-72.3%) and T-piece (8.9%-59.5%). Across regions, we found important variation in screening frequency, spontaneous breathing trials techniques; ventilator modes, written directives to guide care, noninvasive ventilation; and the roles played by available personnel in various aspects of weaning. CONCLUSIONS: Our findings document the presence and extent of practice variation in ventilator weaning on an international scale, and highlight the multidisciplinary and collaborative nature of weaning.


Asunto(s)
Enfermedad Crítica , Intubación Intratraqueal/métodos , Respiración Artificial/métodos , Desconexión del Ventilador/métodos , Adulto , Estudios Transversales , Encuestas de Atención de la Salud , Humanos , Internacionalidad , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/terapia , Resultado del Tratamiento , Desconexión del Ventilador/tendencias
2.
Can J Anaesth ; 59(10): 934-42, 2012 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-22843289

RESUMEN

PURPOSE: We undertook this study to characterize the epidemiology of acute kidney injury (AKI) in Canadian critical care units. We aimed to identify predictors of mortality for patients diagnosed with AKI. METHODS: We conducted a prospective cohort study of consecutive patients admitted to critical care units at five Canadian hospitals over a 30-day period. Each patient was followed until hospital discharge or for a maximum of 30 days. The serum creatinine criteria for the Acute Kidney Injury Network (AKIN-SCr) system were used to identify, classify, and characterize patients who developed AKI. We used multivariable logistic regression to predict 30-day mortality among patients with AKI. RESULTS: We identified 603 patients, 161 (26.7%) of whom developed AKI. Compared to patients without AKI, those with AKI were more likely to die (29.2% vs 8.6%, P < 0.001). The risk of death increased with increasing AKIN-SCr stage (P < 0.001). In all, 19 patients (11.8% of those with AKI) commenced dialysis a median of one day (interquartile range, one to two days) after AKI diagnosis. At AKI diagnosis, the blood urea nitrogen (BUN) level (adjusted odds ratio [OR] 1.68, 95% confidence interval [CI] 1.01 to 2.79/10 mmol·L(-1)) and serum bicarbonate (adjusted OR 0.88, 95% CI 0.81 to 0.95/1 mmol·L(-1)) were associated with 30-day mortality and predicted death with an area under the receiver-operating characteristic curve of 0.79 (95% CI 0.71 to 0.86). CONCLUSIONS: Acute kidney injury is a common complication of critical illness in Canada. The development of even the mildest stage of AKI is associated with a substantially higher risk of death. At AKI diagnosis, routine clinical data may be helpful for predicting adverse outcomes.


Asunto(s)
Lesión Renal Aguda/epidemiología , Unidades de Cuidados Intensivos , Diálisis Renal/métodos , Lesión Renal Aguda/mortalidad , Lesión Renal Aguda/terapia , Adulto , Anciano , Anciano de 80 o más Años , Canadá/epidemiología , Estudios de Cohortes , Creatinina/sangre , Femenino , Estudios de Seguimiento , Hospitales/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Estudios Prospectivos , Curva ROC , Análisis de Supervivencia , Factores de Tiempo , Resultado del Tratamiento
3.
Can J Anaesth ; 56(8): 567-76, 2009 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-19582533

RESUMEN

PURPOSE: To determine the stated practices of clinicians in weaning critically ill adults from invasive ventilation. METHODS: We conducted a cross-sectional, self-administered postal survey of Critical Care physicians and respiratory therapists (RTs) in leadership roles at Canadian teaching hospitals. We identified respondents using electronic mail and telephone correspondence. We used rigorous survey methodology to develop, test, and administer the questionnaire. RESULTS: One hundred ten of 162 (67.9%) clinicians returned the survey with 99 respondents (55 physicians and 44 RTs) completing it either in-part or in-full. Approximately 95% of respondents acknowledged ever performing spontaneous breathing trials (SBTs) in clinical practice. Of these, 95.6% and 32% of respondents reported conducting daily and twice-daily screening to identify SBT candidates, at least sometimes. The three most common techniques to conduct SBTs included; pressure support (PS) with positive end-expiratory pressure (70.8%), continuous positive airway pressure (35.7%), and use of a T-piece (25.0%). PS ventilation was the weaning strategy used most frequently before SBTs. Most respondents (57.1%) considered continuous infusion of sedative-hypnotics to be a relative contraindication to tracheal extubation. However, concurrent administration of low dose vasopressors, inotropes, and analgesic boluses, or continuous analgesic infusions were considered acceptable amongst 60.8%, 73.2%, 78.4% and 58.8% of respondents, respectively. We did not observe regional variation in whether clinicians ever perform SBTs, the ventilatory modes used prior to an SBT nor in the use of PS and SBTs during the weaning process. CONCLUSIONS: Pressure support and SBTs are common features of weaning in Canadian teaching hospitals. Compared to the published literature, our survey suggests that weaning practices have evolved over time and that practice variation may be greater on an international level compared to a national level.


Asunto(s)
Enfermedad Crítica , Intubación Intratraqueal/métodos , Respiración Artificial/métodos , Desconexión del Ventilador/métodos , Adulto , Canadá , Estudios Transversales , Encuestas de Atención de la Salud , Hospitales de Enseñanza , Humanos , Respiración Artificial/estadística & datos numéricos , Insuficiencia Respiratoria/terapia , Resultado del Tratamiento , Desconexión del Ventilador/tendencias
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