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New Westminster, Canada

Reynolds S.C.,Royal Columbian Hospital | Reynolds S.C.,University of British Columbia | Shorr A.F.,Washington Hospital Center | Muscedere J.,Queens University | And 4 more authors.
Critical Care Medicine | Year: 2012

OBJECTIVE: The utility of procalcitonin for the diagnosis of infection in the critical care setting has been extensively investigated with conflicting results. Herein, we report procalcitonin values relative to baseline patient characteristics, presence of shock, intensive care unit time course, infectious status, and Gram stain of infecting organism. DESIGN: Prospective, multicenter, observational study of critically ill patients admitted to intensive care unit for >24 hrs. SETTING: Three tertiary care intensive care units. PATIENTS: All consenting patients admitted to three mixed medical-surgical intensive care units. Patients who had elective surgery, overdoses, and who were expected to stay <24 hrs were excluded. INTERVENTIONS: Patients were followed prospectively to ascertain the presence of prevalent (present at admission) or incident (developed during admission) infections and clinical outcomes. Procalcitonin levels were measured daily for 10 days and were analyzed as a function of the underlying patient characteristics, presence of shock, time of infection, and pathogen isolated. MAIN RESULTS: Five hundred ninety-eight patients were enrolled. Medical and surgical infected cohorts had similar baseline procalcitonin values (3.0 [0.7-15.3] vs. 3.7 [0.6-9.8], p =.68) and peak procalcitonin (4.5 [1.0-22.9] vs. 5.0 [0.9-16.0], p =.91). Infected patients were sicker than their noninfected counterparts (Acute Physiology and Chronic Health Evaluation II 22.9 vs. 19.3, p <.001); those with infection at admission had a trend toward higher peak procalcitonin values than did those whose infection developed in the intensive care unit (4.9 vs. 1.4, p =.06). The presence of shock was significantly associated with elevations in procalcitonin in cohorts who were and were not infected (both groups p <.003 on days 1-5). CONCLUSIONS: Procalcitonin dynamics were similar between surgical and medical cohorts. Shock had an association with higher procalcitonin values independent of the presence of infection. Trends in differences in procalcitonin values were seen in patients who had incident vs. prevalent infections. Copyright © 2012 by the Society of Critical Care Medicine and Lippincott Williams and Wilkins. Source

Burns K.E.A.,University of Toronto | Burns K.E.A.,Li Ka Shing Knowledge Institute | Meade M.O.,McMaster University | Lessard M.R.,Laval University | And 6 more authors.
American Journal of Respiratory and Critical Care Medicine | Year: 2013

Rationale: Automated weaning has not been compared with a paper-based weaning protocol in North America. Objectives: We conducted a pilot randomized trial comparing automated weaning with protocolized weaning in critically ill adults to evaluate clinician compliance and acceptance of the weaning and sedation protocols, recruitment, and impact on outcomes. Methods: From August 2007 to October 2009, we enrolled critically ill adults requiring more than 24 hours of mechanical ventilation and at least partial reversal of the condition precipitating respiratory failure at nine Canadian intensive care units. We randomized patients who tolerated at least 30 minutes of pressure support and either failed or were not yet ready to undergo a spontaneous breathing trial to automated or protocolized weaning. Both groups used pressure support, included spontaneous breathing trials, used a common positive end-expiratory pressure-FIO2 chart, sedation protocol, and criteria for extubation, reintubation, and noninvasive ventilation. Measurements and Main Results: We recruited 92 patients (49 automated, 43 protocolized) over 26 months. Adherence to assigned weaning protocols and extreme sedation scale scores fell within pre-specified thresholds. Combined physician-respiratory therapist and nurse acceptance scores of the study weaning and sedation protocols, respectively, were not significantly different. Automated weaning patients had significantly shorter median times to first successful spontaneous breathing trial (1.0 vs. 4.0 d; P < 0.0001), extubation (3.0 vs. 4.0 d; P = 0.02), and successful extubation (4.0 vs. 5.0 d; P = 0.01), and underwent fewer tracheostomies and episodes of protracted ventilation. Conclusions: Compared with a standardized protocol, automated weaning was associated with promising outcomes that warrant further investigation. Minor protocol modifications may increase compliance, facilitate recruitment, and enhance feasibility. Clinical trial registered with www.controlled-trials.com (ISRCTN43760151) Copyright © 2013 by the American Thoracic Society. Source

Heyland D.K.,Queens University | Heyland D.K.,Clinical Evaluation Research Unit | Johnson A.P.,Queens University | Reynolds S.C.,Royal Columbian Hospital | And 3 more authors.
Critical Care Medicine | Year: 2011

Objective: Procalcitonin may be associated with reduced antibiotic usage compared to usual care. However, individual randomized controlled trials testing this hypothesis were too small to rule out harm, and the full cost-benefit of this strategy has not been evaluated. The purpose of this analysis was to evaluate the effect of a procalcitonin-guided antibiotic strategy on clinical and economic outcomes. Interventions: The use of procalcitonin-guided antibiotic therapy. Methods and Main Results: We searched computerized databases, reference lists of pertinent articles, and personal files. We included randomized controlled trials conducted in the intensive care unit that compared a procalcitonin-guided strategy to usual care and reported on antibiotic utilization and clinically important outcomes. Results were qualitatively and quantitatively summarized. On the basis of no effect in hospital mortality or hospital length of stay, a cost or cost-minimization analysis was conducted using the costs of procalcitonin testing and antibiotic acquisition and administration. Costs were determined from the literature and are reported in 2009 Canadian dollars. Five articles met the inclusion criteria. Procalcitonin-guided strategies were associated with a significant reduction in antibiotic use (weighted mean difference -2.14 days, 95% confidence interval -2.51 to -1.78, p < .00001). No effect was seen of a procalcitonin-guided strategy on hospital mortality (risk ratio 1.06, 95% confidence interval 0.86-1.30, p = .59; risk difference 0.01, 95% confidence interval -0.04 to +0.07, p = .61) and intensive care unit and hospital lengths of stay. The cost model revealed that, for the base case scenario (daily price of procalcitonin Can$49.42, 6 days of procalcitonin measurement, and 2-day difference in antibiotic treatment between procalcitonin-guided therapy and usual care), the point at which the cost of testing equals the cost of antibiotics saved is when daily antibiotics cost Can$148.26 (ranging between Can$59.30 and Can$296.52 on the basis of different assumptions in sensitivity analyses). Conclusions: Procalcitonin-guided antibiotic therapy is associated with a reduction in antibiotic usage that, under certain assumptions, may reduce overall costs of care. However, the overall estimate cannot rule out a 7% increase in hospital mortality. Copyright © 2011 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins. Source

Lund A.,Royal Columbian Hospital | Turris S.A.,University of British Columbia | Bowles R.,Justice Institute of British Columbia
Prehospital and Disaster Medicine | Year: 2014

Mass gatherings (MG) impact their host and surrounding communities and with inadequate planning, may impair baseline emergency health services. Mass gatherings do not occur in a vacuum; they have both consumptive and disruptive effects that extend beyond the event itself. Mass gatherings occur in real geographic locations that include not only the event site, but also the surrounding neighborhoods and communities. In addition, the impact of small, medium, or large special events may be felt for days, or even months, prior to and following the actual events. Current MG reports tend to focus on the events themselves during published event dates and may underestimate the full impact of a given MG on its host community. In order to account for, and mitigate, the full effects of MGs on community health services, researchers would benefit from a common model of community impact. Using an operations lens, two concepts are presented, the vortex and the ripple, as metaphors and a theoretical model for exploring the broader impact of MGs on host communities. Special events and MGs impact host communities by drawing upon resources (vortex) and by disrupting normal, baseline services (ripple). These effects are felt with diminishing impact as one moves geographically further from the event center, and can be felt before, during, and after the event dates. Well executed medical and safety plans for events with appropriate, comprehensive risk assessments and stakeholder engagement have the best chance of ameliorating the potential negative impact of MGs on communities. Copyright © World Association for Disaster and Emergency Medicine 2014. Source

Chan A.W.,Royal Columbian Hospital | Chan A.W.,University of British Columbia
Journal of Invasive Cardiology | Year: 2010

Carotid stenosis is often present in patients who need cardiac surgery and is predictive of post-operative stroke. A strategy of combined carotid endarterectomy and cardiac surgery had been adopted in the past. Staged carotid artery stenting prior to cardiac surgery is a less invasive alternative and seems to be associated with a lower incidence of stroke and myocardial infarction as compared to the combined surgical approach. This article provides a systemic review of the management of patients with concomitant carotid and cardiac disease requiring cardiac surgical procedure, and will discuss some management issues related to carotid stenting in this group of patients. Based on the available data, it is perhaps time to revise our practice guidelines by replacing the combined surgical strategy with the staged carotid stenting and cardiac surgery approach. Source

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