Guidelines recommend modified ultrafiltration (MUF) and cell washing for blood conservation after cardiopulmonary bypass (CPB), although information on outcomes is lacking. This research compared ...online MUF (ultrafiltration of the patient’s entire circulating volume) with off-line MUF (ultrafiltration of the residual CPB volume) and centrifugation (cell washing of the residual CPB volume).
This prospective cohort study enrolled 99 consecutive patients, grouped by method (group I, online MUF, n = 35; group II, off-line MUF, n = 30; group III, centrifugation, n = 34). Primary outcome was transfusion by 18 hours. Secondary outcomes were 18-hour hemoglobin levels, fluid balance (weight change), and biomarker levels indicating coagulation and organ function.
By 18 hours, 22.9%, 6.7%, and 14.7% of group I, II, and III patients, respectively, had undergone transfusion (P = .19). Percentage weight gain differed by group (group I, 5.7%; group II, 1.3%; group III, 4.5%; P < .0001). Baseline to 18-hour hemoglobin change also differed by group, with the group I increase significantly exceeding that of group II (P = .002) but not differing from group III (P = .36). After adjustment for European System for Cardiac Operative Risk Evaluation II (EuroSCORE), weight gain, and transfusion, only the group II to III difference remained significant (P = .002).
Online MUF does not appear to offer a reduction in blood transfusion over other methods. Although patients undergoing online MUF had greater improvement in baseline to 18-hour hemoglobin compared with patients undergoing off-line MUF, this benefit appeared attributable to fluid shifting. Off-line MUF was associated with the least frequent transfusions. Although online MUF does not appear to reduce blood transfusion, larger prospective randomized controlled studies are required for confirmation.
Painful experiences are common among hospitalized children. Long-term negative biopsychosocial consequences of undertreated pain are recognized.
The study benchmarks pain prevalence, assessment, and ...treatment as first steps to improve pain care in a Canadian tertiary hospital.
Single-day audits were undertaken on the pediatric ward (PW), pediatric emergency department (ED), and maternal services (MS). Participants (child or caregiver proxy) reported hospital pain experiences in the preceding 24 h; medical records were reviewed for assessment and treatment.
Among 84 participants, pain prevalence ranged from 75% to 88%; mean pain intensity ranged from 5.7 to 6.5/10. Prevalence of moderate to severe pain was 78% on PW, 65% in ED, and 55% on MS; needle pokes were the most frequent cause of worst pain. Documentation of pain assessment varied by setting (PW, 93%; ED, 13%; MS, 0%). Documented maximum pain scores were significantly lower compared to participant report (mean difference 4.5/10, SD 3.1, P < 0.0001). A total 29% (6/21) of infants with heel lance or injection received breastfeeding or sucrose, and 29% (7/24) of participants receiving other needle procedures had documented or reported topical lidocaine use. All participants on MS underwent needle procedures.
Pain is experienced commonly by infants and children in PW, ED, and MS. Pain assessment documentation is not routine and underestimates participant report. Evidence-based pain management strategies are underutilized. An institution-wide quality improvement approach is required to address pain care. Pain assessment and needle pain prevention and treatment should be prioritized in these pediatric acute care and newborn care settings.
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Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, UILJ, UKNU, UL, UM, UPUK
Long-term care (LTC) facilities require urgent, evidence-based care renewal. During 2020 three medical student-driven research projects aiming to study care satisfaction, patient care team dynamics, ...and advance care directive effectiveness in a local LTC facility required a marked shift in approach due to COVID-19 regulations.
All three projects were re-invented as rapid reviews from their initial designs intended to provide a baseline for quality improvement projects. English-limited PubMed searches for publications within the past 10 years were undertaken. Review articles were prioritized and supplemented by individual studies. Students reviewed the initial abstracts, reviewed them with a supervisor/mentor, assessed the articles for quality, and synthesized major themes.
A total of 52 publications were evaluated for the final synthesis of all three projects. Relevant information was retrieved for all three areas, suitable for local evaluation/intervention at micro, meso, and macro policy levels.
Rapid reviews of issue-specific, long-term care literature are low resource avenues towards coordinated care improvement. They may also serve as rapid means for regular policy updates while providing next-generation care providers with improved LTC perspectives.
Abstract Purpose The study sought to assess the feasibility of performing adult abdominal examinations using a telerobotic ultrasound system in which radiologists or sonographers can control fine ...movements of a transducer and all ultrasound settings from a remote location. Methods Eighteen patients prospectively underwent a conventional sonography examination (using EPIQ 5 Philips or LOGIQ E9 GE Healthcare) followed by a telerobotic sonography examination (using the MELODY System AdEchoTech and SonixTablet BK Ultrasound) according to a standardized abdominal imaging protocol. For telerobotic examinations, patients were scanned remotely by a sonographer 2.75 km away. Conventional examinations were read independently from telerobotic examinations. Image quality and acceptability to patients and sonographers was assessed. Results Ninety-two percent of organs visualized on conventional examinations were sufficiently visualized on telerobotic examinations. Five pathological findings were identified on both telerobotic and conventional examinations, 3 findings were identified using only conventional sonography, and 2 findings were identified using only telerobotic sonography. A paired sample t test showed no significant difference between the 2 modalities in measurements of the liver, spleen, and diameter of the proximal aorta; however, telerobotic assessments overestimated distal aorta and common bile duct diameters and underestimated kidney lengths ( P values < .05). All patients responded that they would be willing to have another telerobotic examination. Conclusions A telerobotic ultrasound system is feasible for performing abdominal ultrasound examinations at a distant location with minimal training and setup requirements and a moderate learning curve. Telerobotic sonography (robotic telesonography) may open up the possibility of remote ultrasound clinics for communities that lack skilled sonographers and radiologists, thereby improving access to care.
Obesity rates are increasing worldwide, particularly in North America. The impact of obesity on the outcome of critically ill patients is unclear.
A prospective observational cohort study of ...consecutive patients admitted to a tertiary critical care unit in Canada between January 10, 2008 and March 31, 2009 was conducted. Exclusion criteria were age <18 years, admission <24 h, planned cardiac surgery, pregnancy, significant ascites, unclosed surgical abdomen and brain death on admission. Height, weight and abdominal circumference were measured at the time of intensive care unit (ICU) admission. Coprimary end points were ICU mortality and a composite of ICU mortality, reintubation, ventilator-associated pneumonia, line sepsis and ICU readmission. Subjects were stratified as obese or nonobese, using two separate metrics: body mass index (BMI) ≥ 30 kg/m(2) and a novel measurement of 75th percentile for waist-to-height ratio (WHR).
Among 449 subjects with a BMI ≥ 18.5 kg/m(2), both BMI and WHR were available for comparative analysis in 348 (77.5%). Neither measure of obesity was associated with the primary end points. BMI ≥ 3 0 kg/m(2) was associated with a lower odds of six-month mortality than the BMI <30 kg/m(2) group (adjusted OR 0.59 95% CI 0.36 to 0.97; P=0.04) but longer intubation times (adjusted RR 1.56 95% CI 1.17 to 2.07; P=0.003) and longer ICU length of stay (adjusted RR 1.67 95% CI 1.21 to 2.31; P=0.002). Conversely, measurement of 75th percentile for WHR was associated only with decreased ICU readmission (OR 0.23 95% CI 0.07 to 0.79; P=0.02).
Obesity was not necessarily associated with worse outcomes in critically ill patients.
Background Multiple questionnaires have been used to predict the diagnosis of OSA. Such models typically have multiple questions requiring cumulative scoring for interpretation. We wanted to ...determine whether a simple two-part questionnaire has predictive value in the pretest clinical evaluation for OSA. Methods A questionnaire consisting of two questions—(1) Does your bed partner ever poke or elbow you because you are snoring? and (2) Does your bed partner ever poke or elbow you because you have stopped breathing?—was prospectively administered to patients evaluated in a sleep disorders clinic prior to undergoing polysomnography. Age, sex, BMI, and Epworth Sleepiness Scale data were collected. Results Among the 128 patients who had a polysomnogram, answering “yes” to being awakened for snoring increased the OR of an apnea-hypopnea index ≥ 5/h 3.9 times compared with “no.” Answering “yes” to being awakened for apneic spells was associated with an OR of 5.8 for an apnea-hypopnea index ≥ 5/h compared with “no.” These associations did not differ by sex, BMI, Epworth Sleepiness Scale or answering “yes” to the other question. Subjects > 50 years old with OSA were less likely to report a positive elbow sign and had a significantly lower OR for being awakened for apneic spells than those < 50 years old. The sensitivity and specificity of being awakened for apneic spells was 65% and 76%, respectively, with a positive predictive value of 90%. Subgroup analysis revealed that in men with a BMI > 31 a positive elbow sign had a specificity of 96.6% for a diagnosis of OSA. Conclusions Among patients referred to a sleep disorders clinic, a positive response to being elbowed/poked for apneic spells significantly improves the pretest prediction of OSA.
Abstract
Increased family physician workloads have strained primary care. The objective of this study was to describe the frequency and types of quality concerns identified among Saskatchewan’s ...family physicians, changes in these concerns over time, associated physician characteristics, and recommendations made for improvement. In this repeated cross-sectional study (1997–2020), we examined family physician assessment reports from the Saskatchewan Practice Enhancement Program, a mandatory practice review strategy, for quality concerns on three outcomes: care, medical record, and facility. We recorded demographic and practice characteristics, the presence or absence of quality concerns, and the type of recommendations made. Concern incidence was calculated both overall and across subperiods, and three outcome-specific multiple logistic regression models were developed. Recommendations made were quantified, and their nature was evaluated using thematic analysis. Among 824 assessments, 20.8% identified concerns, with a statistically significant increase in 2015–20 over earlier years (14.2% versus 43.4%, P < .001). Corresponding proportions also significantly increased within each quality outcome (6.0%–37.1%, P < .001 for care concerns; 12.7%–19.6%, P = .03 for medical record concerns; 3.9%–21.0%, P < .001 for facility concerns). We found statistically significant adjusted associations between care concerns and both urban location odds ratio (OR): 2.2; 95% confidence interval (CI): 1.30, 3.8 and international medical training (OR: 2.4; 95% CI: 1.34, 4.2); facility concerns and solo practice (OR: 2.5 95% CI: 1.10, 5.7); and medical record concerns and male gender (OR: 1.88; 95% CI: 1.09, 3.3), solo practice (OR: 1.67; 95% CI: 1.01, 2.7), and increased age. Reflecting a statistically significant interaction found between age as a continuous covariate and time period, older physicians were more likely to have a medical record concern in later years (OR: 1.072; 95% CI: 1.026, 1.120) compared to earlier ones (OR: 1.021; 95% CI: 1.001, 1.043). Among physicians where a concern was identified, recommendations most frequently pertained to documentation (91.2%), chronic disease management (78.2%), cumulative patient profiles (62.9%), laboratory investigations (53.5%), medications (51.8%), and emergency preparedness (51.2%). A concerning and increasing proportion of family physicians have quality gaps, with identifiable factors and recurring recommendations. These findings provide direction for strategic support development.
Summary
Background
Positive‐pressure ventilation during transport of intubated patients is generally delivered via a hand‐pressurized device. Of these devices, self‐inflating resuscitators (SIR) and ...flow‐inflating resuscitators (FIR) constitute the two major types used. Selection of a particular device for transport, however, remains largely an institutional practice.
Objective
To evaluate the hypothesis that transport ventilation goals of intubated pediatric patients are better achieved using an FIR compared to an SIR.
Methods
This randomized crossover simulation study compared the performance of SIR and FIR among anesthesia providers in a pediatric transport scenario. Subjects hand‐ventilated a test lung while simultaneously maneuvering a stretcher bed to simulate patient transport. Hand ventilation was carried out using a Jackson–Rees circuit (FIR) and a Laerdal pediatric silicone resuscitator (SIR). The primary outcome was the proportion of total breaths delivered within the predefined target PIP/PEEP range (30+/− 3, 10+/− 3 cm H2O). Secondary outcomes included proportion of total breaths delivered with operationally defined unacceptable breath variables (PIP > 35 cm H2O or PEEP < 5 cm H2O).
Results
Overall, participants were four times more likely to deliver target breaths and one‐third less likely to deliver unacceptable breaths using the FIR compared to the SIR. When comparing device performance, a 44% increase in the proportions of target breaths and a 40.4% decrease in unacceptable breaths using the FIR were observed (P < 0.0001 for both).
Conclusions
Hand ventilation during patient transport is superior using the FIR compared to the SIR to achieve target ventilatory goals and avoid unacceptable ventilatory cycles.
Abstract Purpose Placement of arm ports, or totally implanted venous access devices, is a common practice in our interventional radiology suite. We implant a miniaturized port in the upper arm for ...the provision of long-term chemotherapy. We hypothesized that there was general satisfaction with these arm ports and they have a minimal negative impact on quality of life. In this study we aimed to assess our hypotheses. Methods We surveyed subjects, who having previously received an arm port for chemotherapy to treat a malignancy, attended the interventional room for its removal. The survey assessed the port's effect on lifestyle, the degree of device-related pain, the acceptance of the port, and the willingness to have another port in the future. Results Survey responses from 77 subjects were reviewed. On a scale of 1 (most negative) to 10 (most positive), respondents indicated that the port system was a very positive enhancement to their treatment (satisfaction = 9.2 ± 2.0 and positivity = 8.8 ± 2.2). The port had little impact on daily activities. The mean score for the likelihood of choosing to have another port placed if additional treatment was required was 9.1 ± 2.1. Discussion The arm port in this study did not negatively impact subject satisfaction and quality of life for this cohort. Most subjects rated the device utility highly and felt that the port was a positive enhancement to their treatment, one that they would possibly utilise again in future, if need be.
Evidence suggests that phenobarbital can be used to treat alcohol withdrawal syndrome as monotherapy; however, the therapeutic cornerstone remains benzodiazepines. To date, studies comparing the two ...treatment modalities in the emergency department (ED) are few. We sought to determine whether phenobarbital versus benzodiazepine monotherapy impacts ED length of stay and need for admission among adult presentations at a single regional hospital. In June 2019, a treatment algorithm offering both phenobarbital and diazepam pathways was introduced at the Battlefords Union Hospital ED, an 11-bed unit treating 27 000 patients annually in North Battleford, Saskatchewan, Canada. A subsequent retrospective observational study evaluated all adult alcohol withdrawal syndrome presentations between June 2019 and January 2021. Medical records were reviewed for visit date, age, sex, comorbidities, psychosocial factors, Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scores, secondary diagnoses, time of day, protocol adherence, attending physician, length of stay, disposition, and ED return. Descriptive statistics, log-rank testing, simple regression, and multiple regression were used in analysis. Of the 184 presentations, 30.4% were treated with phenobarbital. Median length of stay for phenobarbital versus benzodiazepine therapy was 4.4 h and 4.4 h, respectively (p = 0.21). Of the phenobarbital presentations, 9.4% were hospitalized versus 17.1% of the benzodiazepine presentations (p = 0.20). When adjusted for confounders, phenobarbital-treated presentations were 71.3% less likely to be admitted (p = 0.03). This research suggests that phenobarbital performs similarly to benzodiazepines regarding alcohol withdrawal ED length of stay and may result in reduced hospitalizations.
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•Versus diazepam, phenobarbital decreases admissions for alcohol withdrawal.•Emergency length of stay does not differ between diazepam and phenobarbital.•Phenobarbital is effective monotherapy in treating acute alcohol withdrawal.
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