The variable impact of the overdose crisis on organ donation among five Canadian provinces: a retrospective study.

BACKGROUND: While most overdose deaths in Canada occur in the community, some patients are resuscitated, admitted to intensive care units having sustained severe anoxic brain injury, and have the potential to be organ donors. The purpose of this study was to determine the impact of the overdose crisis on organ donation in selected Canadian provinces. METHODS: We obtained data on the total number of organ donors and those dying because of overdose in five Canadian provinces from 2014 to 2018. We also obtained data for January-June 2019 for four of five provinces (Quebec excepted). We accessed federal and provincial data on the number of overdose deaths and compared the proportion of organ donors who died of an overdose both over time and between provinces. The number of organ transplants resulting from donors dying of an overdose from three provinces was also determined. RESULTS: From 2014 to 2017, there was a 35% increase (554 to 747) in total deceased organ donors but a 294% increase (31 to 122) in organ donors dying of an overdose. While the proportion of organ donors dying from an overdose increased overall, this varied from 35% (42 of 121) in British Columbia to < 5% in both Quebec (9 of 182) and Nova Scotia (< 2 of 16). There were 1,043 organ transplants resulting from organ donors dying of overdose in BC, Ontario and Alberta although only 2.5-3.5% (297 of 10,858) of those dying of an overdose became organ donors. CONCLUSIONS: There has been an increase in organ donors dying from drug overdose in Canada. Regional variation mirrors differences in total opiate-related death.

RéSUMé: CONTEXTE: Bien que la plupart des décès par surdose au Canada surviennent dans la collectivité, certains patients sont réanimés et admis dans des unités de soins intensifs après avoir subi de graves lésions cérébrales anoxiques, et peuvent devenir des donneurs d'organes. L'objectif de cette étude était de déterminer l'impact de la crise des surdoses sur le don d'organes dans certaines provinces canadiennes. MéTHODE: Nous avons obtenu des données concernant le nombre total de donneurs d'organes et de personnes décédées d'une surdose dans cinq provinces canadiennes de 2014 à 2018. Nous avons également obtenu des données pour la période de janvier à juin 2019 pour quatre des cinq provinces (à l'exception du Québec). Nous avons consulté les données fédérales et provinciales sur le nombre de décès par surdose et comparé la proportion de donneurs d'organes décédés d'une surdose au fil du temps et entre les provinces. Le nombre de greffes d'organes provenant de donneurs décédés par surdose dans trois provinces a également été déterminé. RéSULTATS: Entre 2014 et 2017, il y a eu une augmentation de 35 % (de 554 à 747) du nombre total de donneurs d'organes décédés, mais une augmentation de 294 % (de 31 à 122) du nombre de donneurs d'organes décédés d'une surdose. Bien que la proportion de donneurs d'organes décédés d'une surdose ait augmenté dans l'ensemble, cette proportion variait de 35 % (42 sur 121) en Colombie-Britannique à < 5 % au Québec (9 sur 182) et en Nouvelle-Écosse (< 2 sur 16). Il y a eu 1043 greffes d'organes provenant de donneurs décédés par surdose en Colombie-Britannique, en Ontario et en Alberta, bien que seulement 2,5 à 3,5 % (297 sur 10 858) des personnes décédées d'une surdose soient devenues donneurs d'organes. CONCLUSION: Il y a eu une augmentation du nombre de donneurs d'organes décédés d'une surdose de drogue au Canada. La variation régionale reflète les différences dans le nombre total de décès liés aux opiacés.

Does teaching crisis resource management skills improve resuscitation performance in pediatric residents?*.

OBJECTIVE: The effect of teaching crisis resource management skills on the resuscitation performance of pediatric residents is unknown. The primary objective of this pilot study was to determine if teaching crisis resource management to residents leads to improved clinical and crisis resource management performance in simulated pediatric resuscitation scenarios. DESIGN: A prospective, randomized control pilot study. SETTING: Simulation facility at tertiary pediatric hospital. SUBJECTS: Junior pediatric residents. INTERVENTIONS: Junior pediatric residents were randomized to 1 hour of crisis resource management instruction or no additional training. MEASUREMENTS AND MAIN RESULTS: Time to predetermined resuscitation tasks was noted in simulated resuscitation scenarios immediately after intervention and again 3 months post intervention. Crisis resource management skills were evaluated using the Ottawa Global Rating Scale. Fifteen junior residents participated in the study, of which seven in the intervention group. The intervention crisis resource management group placed monitor leads 24.6 seconds earlier (p = 0.02), placed an IV 47.1 seconds sooner (p = 0.04), called for help 50.4 seconds faster (p = 0.03), and checked for a pulse after noticing a rhythm change 84.9 seconds quicker (p = 0.01). There was no statistically significant difference in time to initiation of cardiopulmonary resuscitation (p = 0.264). The intervention group had overall crisis resource management performance scores 1.15 points higher (Ottawa Global Rating Scale [out of 7]) (p = 0.02). Three months later, these differences between the groups persisted. CONCLUSIONS: A 1-hour crisis resource management teaching session improved time to critical initial steps of pediatric resuscitation and crisis resource management performance as measured by the Ottawa Global Rating Scale. The control group did not develop these crisis resource management skills over 3 months of standard training indicating that obtaining these skills requires specific education. Larger studies of crisis resource education are required.

A case of sodium chlorite toxicity managed with concurrent renal replacement therapy and red cell exchange.

INTRODUCTION: Sodium chlorite is a powerful oxidizing agent with multiple commercial applications. We report the presentation and management of a single case of human toxicity of sodium chlorite. CASE REPORT: A 65-year-old man presented to hospital after accidentally ingesting a small amount of a sodium chlorite solution. His principal manifestations were mild methemoglobinemia, severe oxidative hemolysis, disseminated intravascular coagulation, and anuric acute kidney injury. He was managed with intermittent hemodialysis, followed by continuous venovenous hemofiltration for management of acute kidney injury and in an effort to remove free plasma chlorite. Concurrently, he underwent two red cell exchanges, as well as a plasma exchange, to reduce the burden of red cells affected by chlorite. These interventions resulted in the cessation of hemolysis with stabilization of serum hemoglobin and platelets. The patient survived and subsequently recovered normal renal function. DISCUSSION: This is only the second case of sodium chlorite intoxication reported in the medical literature and the first to report the use of renal replacement therapy in combination with red cell exchange in its management.

Pilot study comparing sepsis management with and without electronic clinical practice guidelines in an academic emergency department.

BACKGROUND: Sepsis is a potentially life-threatening condition that requires urgent management in an Emergency Department (ED). Evidence-based guidelines for managing sepsis have been developed; however, their integration into routine practice is often incomplete. Care maps may help clinicians meet guideline targets more often. OBJECTIVES: To determine if electronic clinical practice guidelines (eCPGs) improve management of patients with severe sepsis and septic shock (SS/SS). METHODS: The impact of an eCPG on the management of patients presenting with SS/SS over a 3-year period at a tertiary care ED was evaluated using retrospective case-control design and chart review methods. Cases and controls, matched by age and sex, were chosen from an electronic database using physician sepsis diagnoses. Data were compared using McNemar tests or paired t-tests, as appropriate. RESULTS: Overall, 51 cases and controls were evaluated; the average age was 62 years, and 60% were male. eCPG patients were more likely to have a central venous pressure and central venous oxygen saturation measured; however, lactate measurement, blood cultures, and other investigations were similarly ordered (all p > 0.05). The administration of antibiotics within 3 h (63% vs. 41%; p = 0.03) and vasopressors (45% vs. 20%; p = 0.02) was more common in the eCPG group; however, use of corticosteroids and other interventions did not differ between the groups. Overall, survival was high and similar between groups. CONCLUSION: A sepsis eCPG experienced variable use; however, physicians using the eCPG achieved more quality-of-care targets for SS/SS. Strategies to increase the utilization of eCPGs in Emergency Medicine seem warranted.

Canadian Association of Emergency Physicians sepsis treatment checklist: optimizing sepsis care in Canadian emergency departments.

OBJECTIVE: The Canadian Association of Emergency Physicians (CAEP) sepsis guidelines created by the CAEP Critical Care Practice Committee (C4) and published in the Canadian Journal of Emergency Medicine (CJEM) form the most definitive publication on Canadian emergency department (ED) sepsis care to date. Our intention was to identify which of the care items in this document are specifically necessary in the ED and then to provide these items in a tiered checklist that can be used by any Canadian ED practitioner. METHODS: Practice points from the CJEM sepsis publication were identified to create a practice point list. Members of C4 then used a Delphi technique consensus process over May to October 2009 via e-mail to create a tiered checklist of sepsis care items that can or could be completed in a Canadian ED when caring for the septic shock patient. This checklist was then assessed for use by a survey of ED practitioners from varying backgrounds (rural ED, community ED, tertiary ED) from July to October 2010. RESULTS: Twenty sepsis care items were identified in the CAEP sepsis guidelines. Fifteen items were felt to be necessary for ED care. Two levels of checklists were then created that can be used in a Canadian ED. Most ED physicians in community and tertiary care centres could complete all parts of the level I sepsis checklist. Rural centres often struggle with the ability to obtain lactate values and central venous access. Many items of the level II sepsis checklist could not be completed outside the tertiary care centre ED. CONCLUSION: Sepsis care continues to be an integral and major part of the ED domain. Practice points for sepsis care that require specialized monitoring and invasive techniques are often limited to larger tertiary care EDs and, although heavily emphasized by many medical bodies, cannot be reasonably expected in all centres. When the resources of a centre limit patient care, transfer may be required.

The role of serum lactate in the acute care setting.

Acute care services are increasingly faced with the double burden of high patient acuity and limited resources. Early identification of patients who are sick or who have the potential to deteriorate rapidly is crucial so that these resources may be allocated to those in greatest need. Traditional measures of illness and end points of resuscitation, such as vital signs, often fail to identify occult hypoperfusion with certain disease processes associated with high morbidity and mortality. Thus, biochemical markers that may predict illness earlier are becoming more relevant. We present a review of the evidence behind use of the serum lactate level in this setting.

Gonococcal septic shock, acute respiratory distress syndrome, and multisystem organ failure: a case report.

We describe the first reported case of gonococcal septic shock with associated acute respiratory distress syndrome and multisystem organ failure, in which the patient made a full recovery, and add to the paucity of descriptive literature on gonococcal sepsis. The case was a 36-year-old previously healthy Aboriginal female from northern Canada. Treatment included fluid resuscitation, vasoactive drugs, mechanical ventilation, antimicrobial therapy, corticosteroid replacement, activated protein C, and general supportive care. In addition to being the first reported case of gonococcal septic shock with associated acute respiratory distress syndrome and multisystem organ failure in which the patient made a full clinical recovery this is also the first case of gonococcal septic shock treated with activated protein C; an association between its use and the favorable outcome is postulated, but cannot be confirmed.

Canadian Association of Emergency Physicians Sepsis Guidelines: the optimal management of severe sepsis in Canadian emergency departments.

INTRODUCTION: Optimal management of severe sepsis in the ED has evolved rapidly. The purpose of these guidelines is to review key management principles for Canadian emergency physicians, utilizing an evidence-based grading system. METHODS: Key areas in the management of septic patents were determined by members of the CAEP Critical Care Interest Group (C4). Members of C4 were assigned a question to be answered after literature review, based on the Oxford grading system. After completion, each section underwent a secondary review by another member of C4. A tertiary review was conducted by additional external experts, and modifications were determined by consensus. Grading was based on peer-reviewed publications only, and where evidence was insufficient to address an important topic, a "practice point" was provided based on group opinion. RESULTS: The project was initiated in 2005 and completed in December 2007. Key areas which were reviewed include the definition of sepsis, the use of invasive procedures, fluid resuscitation, vasopressor/inotrope use, the importance of culture acquisitionin the ED, antimicrobial therapy and source control. Other areas reviewed included the use of corticosteroids, activated protein C, transfusions and mechanical ventilation. CONCLUSION: Early sepsis management in the ED is paramount for optimal patient outcomes. The CAEP Critical Care Interest Group Sepsis Position Statement provides a framework to improve the ED care of this patient population.