Ventricular-arterial decoupling is associated with in-hospital adverse events in normotensive pulmonary embolism.

During acute pulmonary embolism (PE) a compensatory increase in right ventricular (RV) contractility is required to match increased afterload to maintain right ventricular-pulmonary arterial (RV-PA) coupling. The aim of this study was to assess the prognostic utility of RV-PA decoupling in acute PE. We assessed the association between measures of transthoracic echocardiography (TTE)-derived RV-PA coupling including tricuspid annular plane systolic excursion (TAPSE)/right ventricular systolic pressure (RVSP) and right ventricular fractional area change (FAC)/RVSP as well as stroke volume index (SVI)/RVSP (a measure of pulmonary artery capacitance) with adverse PE-related events (in-hospital PE-related mortality or cardiopulmonary decompensation) using logistic regression analysis. In 820 normotensive patients TTE-derived markers of RV-PA coupling were associated with PE-related adverse events. For each 0.1 mm/mmHg decrease in TAPSE/RVSP the odds of an adverse event increased by 2.5-fold [adjusted OR (aOR) 2.49, 95% confidence interval (CI) 1.46-4.24, p = 0.001], for every 0.1%/mmHg decrease in FAC/RVSP the odds of an adverse event increased by 1.4-fold (aOR 1.42, CI 1.09-1.86, p = 0.010), and for every 0.1 mL/mmHg m2 decrease in SVI/RVSP the odds of an event increased by 2.75-fold (aOR 2.78, CI 1.72-4.50, p < 0.001). In multivariable analysis, TAPSE/RVSP and SVI/RVSP were independent of other risk stratification methods including computed tomography-derived right ventricular dysfunction (RVD), the Bova score, and subjective assessment of TTE-derived RVD. In patients with normotensive acute PE, TTE-derived measures of RV-PA coupling are associated with adverse in-hospital PE-related events and provide incremental value in the risk assessment beyond computed tomography-derived RVD, the Bova score, or subjective TTE-derived RVD.

Sequential Organ Failure Assessment in H1N1 pandemic planning.

OBJECTIVE: The H1N1 pandemic has highlighted the importance of reliable and valid triage instruments. A Sequential Organ Failure Assessment score of >11 has been proposed to exclude patients from critical care resources quoting an associated mortality of >90%. We sought to assess the mortality associated with this Sequential Organ Failure Assessment threshold and the resource implications of such a triage protocol. DESIGN: Retrospective cohort. SETTING: Three multisystem intensive care units. PATIENTS: Consecutive patients admitted from January 2003 to December 2008. Subsequently, a comparison H1N1 cohort was assembled consisting of all patients admitted in 2009 with confirmed H1N1. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Sequential Organ Failure Assessment was collected daily by use of an electronic bedside clinical information system (n = 10,204 patients, 69,913 patient days). Mean admission Acute Physiology and Chronic Health Evaluation was 19.1. 13.4% of the cohort (9% of total patient days) had an initial Sequential Organ Failure Assessment of >11. Mortality in patients with an initial Sequential Organ Failure Assessment score of >11 was 59% (95% confidence interval: 56%, 62%). The mortality associated with an initial Sequential Organ Failure Assessment >11 across diagnostic categories varied from 29% for poisoning to 67% for neurologic patients. Hospital mortality exceeded 90% only when initial Sequential Organ Failure Assessment was >20 (0.2% of patients). H1N1 patients were younger, had a longer intensive care unit length of stay, and more commonly had a respiratory admission diagnosis than the nonH1N1 cohort. Hospital mortality in H1N1 patients with an initial Sequential Organ Failure Assessment score of >11 was 31% (95% confidence interval: 5%, 56%). CONCLUSIONS: A Sequential Organ Failure Assessment score of >11 was not associated with a hospital mortality of >90% at any time during intensive care unit stay. Only a small proportion of patients have the extreme initial Sequential Organ Failure Assessment values associated with a hospital mortality of >90% limiting the usefulness of Sequential Organ Failure Assessment as a triage instrument for pandemic planning. Application of a Sequential Organ Failure Assessment threshold of >11 to the recent H1N1 pandemic would have excluded patients with a markedly lower mortality than seen in a large regional cohort of intensive care unit patients.

Rapid prediction of adverse outcomes for acute normotensive pulmonary embolism: derivation of the Calgary Acute Pulmonary Embolism score.

BACKGROUND: Acute pulmonary embolism (PE) has a wide spectrum of outcomes, but the best method to risk-stratify normotensive patients for adverse outcomes remains unclear. METHODS: A multicentre retrospective cohort study of acute PE patients admitted from emergency departments in Calgary, Canada, between 2012 and 2017 was used to develop a refined acute PE risk score. The composite primary outcome of in-hospital PE-related death or haemodynamic decompensation. The model was internally validated using bootstrapping and the prognostic value of the derived risk score was compared to the Bova score. RESULTS: Of 2067 patients with normotensive acute PE, the primary outcome (haemodynamic decompensation or PE-related death) occurred in 32 (1.5%) patients. In simplified Pulmonary Embolism Severity Index high-risk patients (n=1498, 78%), a multivariable model used to predict the primary outcome retained computed tomography (CT) right-left ventricular diameter ratio ≥1.5, systolic blood pressure 90-100 mmHg, central pulmonary artery clot and heart rate ≥100 beats·min-1 with a C-statistic of 0.89 (95% CI 0.82-0.93). Three risk groups were derived using a weighted score (score, prevalence, primary outcome event rate): group 1 (0-3, 73.8%, 0.34%), group 2 (4-6, 17.6%, 5.8%), group 3 (7-9, 8.7%, 12.8%) with a C-statistic 0.85 (95% CI 0.78-0.91). In comparison the prevalence (primary outcome) by Bova risk stages (n=1179) were stage I 49.8% (0.2%); stage II 31.9% (2.7%); and stage III 18.4% (7.8%) with a C-statistic 0.80 (95% CI 0.74-0.86). CONCLUSIONS: A simple four-variable risk score using clinical data immediately available after CT diagnosis of acute PE predicts in-hospital adverse outcomes. External validation of the Calgary Acute Pulmonary Embolism score is required.

Thrombolysis of Postoperative Acute Pulmonary Embolism with a Thrombus in Transit.

Right heart thrombus in transit clot (RHTT) associated with a pulmonary thromboembolism (PTE) is a rare but potentially fatal diagnosis. Early diagnosis and immediate intervention are crucial. This report describes the case of a healthy, physically active 32-year-old female who presented 19 days postoperatively, following an anterior cruciate ligament reconstruction and partial lateral meniscectomy with a saddle PE, RHTT, and right ventricular (RV) strain. The patient received half of the standard dose of intravenous tissue plasminogen activator (TPA) in combination with anticoagulation and survived. Case reports of RHTT will inform future studies designed to evaluate whether and when thrombolysis should be administered.

Identifying What Is Known About Improving Operating Room to Intensive Care Handovers: A Scoping Review.

The purpose is to provide a descriptive overview of relevant material exploring improvement of handovers from the operating room (OR) to intensive care unit (ICU). An online search (MEDLINE, Cochrane, EMBASE, CINAHL, and Joanna Briggs), including gray literature and relevant reference lists, was completed. In all, 4574 unique citations were screened and 155 full-text reviews performed; 65 articles were included in the final analysis. The majority of articles discuss an ideal structure for handover (n = 63; 97%); 43 (66%) articles mentioned strategies for implementing such an approach. Only 21 (32%) explicitly described formal quality improvement (QI) methods. Few explored project sustainability and impact of a structured handover on patient safety outcomes (n = 15, 23%). Published literature suggests that there is a significant gap in evidence of measured patient outcomes from standardization of OR to ICU handover processes. Identifying formal QI strategies used to sustain standardized handover processes will allow accurate measurement of patient outcomes.

Effect of critical care medicine fellows on patient outcome in the intensive care unit.

BACKGROUND: The impact that physician trainees have on patient outcomes in academic adult medical/surgical intensive care units (ICUs) has not been adequately assessed. METHOD: All admissions to adult ICUs within the Calgary Health Region over a three-year period when a critical care medicine fellow (CCMF) was on service were compared to when an attending physician was alone on service. Primary outcomes were ICU and in-hospital mortality and length of stay (LOS). RESULTS: CCMFs and attending physicians admitted 3,341 patients, while attending physicians alone admitted 3,224 patients. There was no difference in ICU or in-hospital mortality between the two groups; regression analysis determined CCMFs did not affect patient LOS. CONCLUSION: In teaching hospitals with adult mixed medical/surgical ICUs, CCMFs do not have an effect on patient outcome or LOS. Improved patient outcomes at academic institutions previously attributed to the presence of CCMFs may instead be due to institution and patient-related factors.

Quality improvement in the ICU. A Canadian perspective.

This article will provide an overview of the quality improvement initiatives of the Department of Critical Care Medicine, Calgary Health Region. The Department has a Quality Council that is responsible for its quality improvement activities. The FOCUS-PDSA model is used for various projects including the development of guidelines and protocols. The Department has also participated in two collaboratives which use the Improvement Model methodology. It has 7 projects completed with 10 projects currently underway.

Is regional citrate superior to systemic heparin anticoagulation for continuous renal replacement therapy? A prospective observational study in an adult regional critical care system.

PURPOSE: Continuous renal replacement therapy (CRRT) is commonly used in the care of critically ill patients although the optimal means of anticoagulation is not well defined. We report our regional CRRT protocol that was developed using the principles of quality improvement and compare the effect of regional citrate with systemic heparin anticoagulation on filter life span. MATERIALS AND METHODS: Prospective observational cohort study in a Canadian adult regional critical care system. A standardized protocol for CRRT has been implemented at all adult intensive care units in the Calgary Health Region since August 1999. All patients with acute renal failure treated with CRRT during October 1, 2002, to September 30, 2003, were identified and followed up prospectively until hospital discharge or death. RESULTS: Eighty-seven patients with acute renal failure requiring CRRT were identified, 54 were initially treated with citrate, 29 with heparin, and 4 with saline flushes. Citrate and heparin were used in 212 (66%) and 97 (30%) of filters for 8776 and 2651 hours of CRRT, respectively. Overall median (interquartile range) filter life span with citrate was significantly greater than heparin (40 [14-72] vs 20 [5-44] hours, P < .001). The median time to spontaneous filter failure was significantly greater with citrate compared with heparin (>72 vs 33 hours, P < .001). Citrate anticoagulation resulted in greater completion of scheduled filter life span (59% vs 10%, P > .001). Citrate anticoagulation was well tolerated with no patient requiring elective discontinuation for hypernatremia, metabolic alkalosis, or hypocalcemia. CONCLUSIONS: Regional citrate anticoagulation was associated with prolonged filter survival and increased completion of scheduled filter life span compared with heparin. These data support small studies suggesting that citrate is a superior anticoagulant for CRRT and suggest the need for a future definitive randomized controlled trial.

Dialysis Disequilibrium Syndrome: brain death following hemodialysis for metabolic acidosis and acute renal failure--a case report.

BACKGROUND: Dialysis disequilibrium syndrome (DDS) is the clinical phenomenon of acute neurologic symptoms attributed to cerebral edema that occurs during or following intermittent hemodialysis (HD). We describe a case of DDS-induced cerebral edema that resulted in irreversible brain injury and death following acute HD and review the relevant literature of the association of DDS and HD. CASE PRESENTATION: A 22-year-old male with obstructive uropathy presented to hospital with severe sepsis syndrome secondary to pneumonia. Laboratory investigations included a pH of 6.95, PaCO2 10 mmHg, HCO3 2 mmol/L, serum sodium 132 mmol/L, serum osmolality 330 mosmol/kg, and urea 130 mg/dL (46.7 mmol/L). Diagnostic imaging demonstrated multifocal pneumonia, bilateral hydronephrosis and bladder wall thickening. During HD the patient became progressively obtunded. Repeat laboratory investigations showed pH 7.36, HCO3 19 mmol/L, potassium 1.8 mmol/L, and urea 38.4 mg/dL (13.7 mmol/L) (urea-reduction-ratio 71%). Following HD, spontaneous movements were absent with no pupillary or brainstem reflexes. Head CT-scan showed diffuse cerebral edema with effacement of basal cisterns and generalized loss of gray-white differentiation. Brain death was declared. CONCLUSIONS: Death is a rare consequence of DDS in adults following HD. Several features may have predisposed this patient to DDS including: central nervous system adaptations from chronic kidney disease with efficient serum urea removal and correction of serum hyperosmolality; severe cerebral intracellular acidosis; relative hypercapnea; and post-HD hemodynamic instability with compounded cerebral ischemia.

Identifying intensive care unit discharge planning tools: protocol for a scoping review.

BACKGROUND: Transitions of care between providers are vulnerable periods in healthcare delivery that expose patients to preventable errors and adverse events. Patient discharge from the intensive care unit (ICU) to a medical or surgical hospital ward is one of the most challenging and high risk transitions of care. Approximately 1 in 12 patients discharged will be readmitted to ICU or die before leaving the hospital. Many more patients are exposed to unnecessary healthcare, adverse events and/or are disappointed with the quality of their care. Our objective is to conduct a scoping review by systematically searching the literature to identify ICU discharge planning tools and their supporting evidence-base including barriers and facilitators to their use. METHODS AND ANALYSIS: Systematic searching of the published health literature will be conducted to identify the existing ICU discharge planning tools and supporting evidence. Literature (research and non-research) reporting on the tools used to facilitate decision making and/or communication at ICU discharge with patients of any age will be included. Outcomes will include adverse events and provider and patient/family-reported outcomes. Two investigators will independently review the abstracts (screen 1) to identify those meeting the inclusion criteria and then independently assess the full text articles (screen 2) to determine if they meet the inclusion criteria. Data collection will include information on citations and identified tools. A quality assessment will be performed on original research studies. A descriptive summary will be developed for each tool. ETHICS AND DISSEMINATION: Our scoping review will synthesise the literature for ICU discharge planning tools and identify the opportunities for knowledge to action and gaps in evidence where primary evidence is necessary. This will serve as the foundational element in a multistep research programme to standardise and improve the quality of care provided to patients during ICU discharge. Ethics approval is not required for this study.

Time series analysis of use patterns for common invasive technologies in critically ill patients.

PURPOSE: Critically ill patients are frequently managed with invasive technologies as part of their medical care. Little is known about use patterns. We examined use trends for invasive technologies used in critically ill patients. MATERIALS AND METHODS: Using time series analysis and data on 26 989 patients from 3 medical-surgical intensive care units (ICUs) (n = 18 224) and 1 surgical ICU (n = 8765) between January 1, 1999, and January 1, 2007, we measured changes in the proportion of patients receiving the 4 most frequently used invasive technologies used in critically ill patients. RESULTS: The 4 most common invasive technologies used in critically ill patients during the study period were arterial lines (71%), endotracheal intubations (61%), central venous catheters (51%), and pulmonary artery catheters (18%). The proportion of ICU patients who received pulmonary artery catheters decreased from 25% in 1999 to 8% in 2006 (P < .001). Use of central venous catheters increased from 39% to 46% (P < .001). After adjusting for baseline characteristics, patients admitted in 2006 were 4 times less likely to receive a pulmonary artery catheter (odds ratio, 0.28; 95% confidence interval, 0.24-0.33), but 42% (odds ratio, 1.42; 95% confidence interval, 1.27-1.58) more likely to receive a central venous catheter than patients admitted in 1999. No significant changes were observed for intubations and arterial lines. CONCLUSIONS: The use of invasive technologies in critically ill patients is changing and may have important implications for resource use, clinician education, and patient care. Initiatives should be considered for ensuring clinician competency during technology transitions.

Benchmarking performance in organ donation programs: dependence on demographics and mortality rates.

PURPOSE: Donors whose diagnosis of death is based upon neurologic criteria are the primary source of organs for human transplantation. The current measure of effectiveness of organ donation programs is the crude statistic, donors per million population (DPMP). This statistic represents the number of available donors, divided by the potential donor population. Comparisons between transplantation programs are done using the DPMP statistic. We sought to determine if variance in organ donation rates, reported as DPMP could be accounted for by differences in population demographics, specifically age and gender-specific mortality rates. METHODS: We obtained the population distribution and deaths for the year 2000 for the Calgary Health Region (CHR) and the country of Spain. Expected deaths were then calculated by standardizing the sample, based upon weighted averages of age, gender and cause-specific mortality rates. RESULTS: In 2000, Spain reported a crude organ donation rate of 33.9 DPMP. Standardizing the observed deaths in Spain using the CHR population distribution and calculating expected deaths based on the CHR rates, resulted in an adjusted rate of 19.2 DPMP (P < 0.05). CONCLUSIONS: These results bring into question the reliability of using crude DPMP as a measure of organ and tissue donation program performance. Alternative measures of benchmarking performance in organ donation programs should be considered.

Tension pneumothorax secondary to colonic perforation during diagnostic colonoscopy: report of a case.

We report a case of tension pneumothorax, which occurred secondary to colonic perforation during a colonoscopy. The patient was a 77-year-old woman in whom acute respiratory decompensation developed suddenly during a diagnostic colonoscopy for iron deficiency anemia. We diagnosed bilateral pneumothoraces, tension pneumothorax, pneumomediastinum, pneumoperitoneum, and emphysema of the face, neck, and chest. At laparotomy, a posterior colonic perforation was identified at the site of an ileocolic anastomosis performed 3 years earlier. We performed a primary repair and the patient was discharged from hospital 12 days later. Although diagnostic colonoscopy-induced intestinal perforation is rare, it is the most common and serious complication associated with this procedure. Occasionally, air spreads from the retroperitoneum into continuous tissue planes and decompresses into the adjacent structures. To our knowledge, this is the first report of two unique manifestations of diagnostic colonoscopy-induced intestinal perforation: tension pneumothorax and perforation at the site of a previous anastomosis. Both of these conditions should be considered in the event of acute respiratory failure in the endoscopy suite.

Ventilator-associated pneumonia in severe traumatic brain injury.

INTRODUCTION: Pneumonia is an important cause of morbidity following severe traumatic brain injury (TBI). However, previous studies have been limited by inclusion of specific patient subgroups or by selection bias. The primary objective of this study was to describe the incidence, risk factors for, and outcome of ventilator-associated pneumonia in an unselected population-based cohort of patients with severe TBI. An additional goal was to define the relationship of ventilator-associated pneumonia (VAP) with nonneurological organ dysfunction. METHODS: A prospective, observational cohort study was performed at Foothills Medical Centre, the sole adult tertiary-care trauma center servicing southern Alberta. All patients with severe TBI requiring ventilation for more than 48 hours between May 1, 2000 and December 30, 2002 were included. RESULTS: A total of 60 patients (45%) acquired VAP for an incidence density of 42.7/1000 ventilator days. Patients with polytrauma were at higher risk (risk ratio 1.7, 95% confidence interval, 0.9-3.1) for development of VAP than those with isolated head injury. Development of VAP was associated with a significantly greater degree of nonneurological organ system dysfunction. Although VAP was not associated with increased hospital mortality, patients who developed VAP had a longer duration of mechanical ventilation (15 versus 8 days, p < 0.0001), longer intensive care unit (17 versus 9 days, p < 0.0001) and hospital (60 versus 28 days, p = 0.003) lengths of stay, and more often required tracheostomy (35 versus 18%, p = 0.003). CONCLUSIONS: VAP occurs frequently and is associated with significant morbidity in patients with severe TBI.

Study of clinical course of organ dysfunction in intensive care.

OBJECTIVE: Multiple organ dysfunction is a common cause of death in intensive care units. We describe the daily course of multiple organ dysfunction measured by the Sequential Organ Failure Assessment score in a population-based cohort of critically ill patients. DESIGN: Prospective cohort study. SETTING: Adult multisystem intensive care units in the Calgary Health Region. PATIENTS: A total of 1,436 patients admitted from May 1, 2000 to April 30, 2001. MEASUREMENTS: Temporal change in Sequential Organ Failure Assessment score. INTERVENTIONS: None; observational study. MAIN RESULTS: The mean age was 58 yrs (range, 14-100). The mean +/- sd intensive care unit admission Acute Physiology and Chronic Health Evaluation II score was 25 +/- 9. The median intensive care unit length of stay was 4 days (interquartile range, 2-8), and the median hospital length of stay was 15 days (interquartile range, 7-32). A total of 20.5% of patients were infected at admission, and 26.0% were immediately postoperative. Intensive care unit mortality was 27.0%, and hospital mortality was 35.1%. The daily Sequential Organ Failure Assessment score was significantly higher in nonsurvivors than survivors. A population-averaged model determined a mean rate of change of Sequential Organ Failure Assessment score to be -0.29 per day (95% confidence interval, -0.32 to -0.25) for survivors and -0.03 per day (95% confidence interval, -0.08 to 0.03) for nonsurvivors (overall regression, p <.0001). Patients with infection had higher admission Sequential Organ Failure Assessment scores compared with patients without infection (difference, 1.8; p <.001), but a similar rate of daily change. CONCLUSIONS: Multiple organ dysfunction, does not follow a course of progressive and sequential failure. Evidence of differential daily change should further inform the use of organ failure scores as surrogate outcomes in clinical trials.