The optimal approach to titrate vasopressor therapy is unclear. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As ...data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines.
In a multicenter prospective cohort study of critically ill adults with severe hypotension, we recorded MAP and vasopressor doses hourly. We investigated variability across patients and centres using multivariable regression models and Analysis of variance (ANOVA), respectively.
We included data from 56 patients treated in 6 centers. The mean (standard deviation SD) age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were 64 (14) and 25 (8). Half (28 of 56) of the patients were at least 65 years old, and half had chronic hypertension. The patient-averaged MAP while receiving vasopressors was 75 mm Hg (6) and the median (1st quartile, 3rd quartile) duration of vasopressor therapy was 43 hours (23, 84). MAP achieved was not associated with history of underlying hypertension (p = 0.46) but did vary by center (p<0.001).
In this multicenter, prospective observational study, the patient-level average MAP while receiving vasopressors for severe hypotension was 75 mmHg, approximately 10 mmHg above current recommendations and stated practices. Moreover, our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but MAP achieved while receiving vasopressors varied by site.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract
Background
Appropriate training of health professionals has been recommended to increase organ donation rates. Some studies have shown insufficient knowledge among medical students. This ...survey aims to describe their knowledge and attitude toward organ donation (OD).
Method
We designed, pre-tested and conducted an online survey of all undergraduate medical students from Montreal, Laval and Sherbrooke universities in 2016–2017. Multivariate linear regression identified factors associated with a better knowledge score.
Results
Twenty-two percent (750/3344) of students completed the survey. Ninety-one percent of students adequately knew that neurological death is irreversible; 76% acknowledged that someone could be neurologically deceased while his heart is still beating; 69% were not aware of circulatory determination of death. For only one knowledge item, senior students had a better answer than junior students. Total knowledge score was associated with exposure to OD during medical studies and comfort in answering patients’ questions about OD (
p
< 0,001). Regarding attitude, 96% of respondents wished to become organ donors after death and 92% supported OD training during their medical training.
Conclusion
Despite a favourable attitude, medical students have limited knowledge of OD. Findings suggest the need for a formal curriculum about OD, as students expressed.
IntroductionVasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for ...vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60–65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years.Methods and analysisOVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation.Ethics and disseminationThis protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums.Trial registration numberNCT03431181.
Objective
The efficacy of systemic corticosteroids in many critical illnesses remains uncertain. Our primary objective was to survey intensivists in North America about their perceived use of ...corticosteroids in clinical practice.
Design
Self-administered paper survey.
Population
Intensivists in academic hospitals with clinical trial expertise in critical illness.
Measurements
We generated questionnaire items in focus groups and refined them after assessments of clinical sensibility and test-retest reliability and pilot testing. We administered the survey to experienced intensivists practicing in selected North American centres actively enrolling patients in the multicentre Oscillation for ARDS Treated Early (OSCILLATE) Trial (ISRCTN87124254). Respondents used a four-point scale to grade how frequently they would administer corticosteroids in 14 clinical settings. They also reported their opinions on 16 potential near-absolute indications or contraindications for the use of corticosteroids.
Main results
Our response rate was 82% (103/125). Respondents were general internists (50%), respirologists (22%), anesthesiologists (21%), and surgeons (7%) who practiced in mixed medical-surgical units. A majority of respondents reported almost always prescribing corticosteroids in the setting of significant bronchospasm in a mechanically ventilated patient (94%), recent corticosteroid use and low blood pressure (93%), and vasopressor-refractory septic shock (52%). Although more than half of respondents stated they would almost never prescribe corticosteroids in severe community-acquired pneumonia (81%), acute lung injury (ALI, 76%), acute respiratory distress syndrome (ARDS, 65%), and severe ARDS (51%), variability increased with severity of acute lung injury. Near-absolute indications selected by most respondents included known adrenal insufficiency (99%) and suspicion of cryptogenic organizing pneumonia (89%), connective tissue disease (85%), or other potentially corticosteroid-responsive illnesses (85%).
Conclusions
Respondents reported rarely prescribing corticosteroids for ALI, but accepted them for bronchospasm, suspected adrenal insufficiency due to previous corticosteroid use, and vasopressor-refractory septic shock. These competing indications will complicate the design and interpretation of any future large-scale trial of corticosteroids in critical illness.
In this trial of intravenous vitamin C in adult patients with sepsis, those who received a vitamin C infusion had a higher risk of death or persistent organ dysfunction at 28 days than those who ...received placebo.
Diverse 1,2- and 1,2,5-substituted pyrroles were efficiently prepared through a regioselective functionalization of 2-formylpyrrole (5a). This methodology was applied for the first total synthesis of ...pyrrolemarumine (4b), the aglycone of the corresponding natural pyrrole alkaloid 4"-O-α-L-rhamnopyranoside. The synthesis of 4b was achieved starting from 5a through a seven-step process in 28% overall yield.
Early cardiopulmonary resuscitation has been shown to increase survival. Nurse-initiated defibrillation could decrease delays before shock administration.
An observational study was conducted in a ...university hospital in Quebec (Canada) in late 2017. A standardized simulated scenario of a cardiac arrest after ventricular fibrillation was used.
It took, on average, 12 seconds for the nurses to call for medical assistance, and 28.8 seconds to initiate chest compressions. Most nurses could recognize ventricular fibrillation and that manual defibrillation was immediately required (91%).
Further research could help assess translation of skills from simulation scenarios to clinical context and should evaluate whether nurse-initiated defibrillation improves patient outcomes.
•A simulated cardiac arrest scenario after ventricular fibrillation was used.•It took 12 seconds for intensive care unit (ICU) nurses' to call for help after ventricular fibrillation onset.•Cardiopulmonary resuscitation maneuvers were initiated after 28.8 seconds following cardiac arrest.•ICU nurses' with more critical care experience call “code blue” sooner.•High-fidelity simulation can be used to assess ICU nurses' cardiopulmonary resuscitation skills.
Arthrobotrys musiformis is a nematophagous fungus with potential for the biological control of Haemonchus contortus larvae. This study aimed to identify and demonstrate the proteolytic activity of ...extracellular products from A musiformis cultured in a liquid medium against H contortus infective larvae. A musiformis was cultured on a solid medium and further grown in a liquid medium, which was then processed through ion exchange and hydrophobic interaction chromatography. The proteolytic activity of the purified fraction was assayed with either gelatin or bovine serum albumin as substrate. Optimum proteolytic activity was observed at pH 8 and a temperature of 37°C. Results obtained with specific inhibitors suggest the enzyme belongs to the serine-dependent protease family. The purified fraction concentrate from A musiformis was tested against H contortus infective larvae. A time-dependent effect was observed with 77 per cent immobility after 48 hours incubation, with alteration of the sheath. It is concluded that A musiformis is a potential candidate for biological control because of its resistant structures and also because of its excretion of extracellular products such as proteases. The present study contributes to the identification of one of the in vitro mechanisms of action of Amusiformis, namely the extracellular production of proteases against H contortus infective larvae. More investigations should be undertaken into how these products could be used to decrease the nematode population in sheep flocks under field conditions, thereby improving animal health while simultaneously diminishing the human and environmental impact of chemical-based drugs.
Background: High-quality cardiopulmonary resuscitation (CPR) is essential to survival and relies on well trained professionals. However, few studies have investigated intensive care unit nurses' CPR ...knowledge and attitudes relevant to intra hospital cardiac arrest. There is a dearth of tools to measure such knowledge and attitudes. Aim: To develop, validate and assess the psychometric properties of a survey related to CPR knowledge and attitudes. Method: The development and validation was based on Burns et al. (2008) method. Face and content validity, as well as reliability were respectively assessed with an expert panel (n=4), a pretest (n=9) and a testing phase (n=82). Test-retest analysis and Cronbachs alpha were used to assess reliability. Results: The NCRS contains 23 items, separated in five sections: tachydysrhythmia identification, CPR, defibrillation, attitudes and characteristics. Preliminary psychometric properties were judged as good; Cohens kappa, Spearmans correlation coefficient and Cronbachs alpha were respectively k=.814, p=.807 and a=0.645. Conclusion: The NCRS is the first survey available in French to assess knowledge and attitudes related to CPR. It will help researchers and managers to determine performance gaps regarding knowledge and attitudes towards tachydysrhythmia identification, CPR and defibrillation. Key words: survey, CPR, intensive care unit, knowledge
Background: Cardiac arrest is a frequent and potentially lethal complication during a hospitalisation. Intensive care unit (ICU) nurses' knowledge, skills, and attitudes about ACLS procedures have ...been hypothesized to be a key determinant in patient survival. However, these three characteristics of ICU nurses, as well as their determinants, have not been studied extensively. Aim: To evaluate ICU nurses' knowledge, skills, and attitudes regarding three resuscitation procedures (i.e., identification of ventricular tachydysrhythmias, cardiopulmonary resuscitation and defibrillation), and 2) to examine the associations between ICU nurses' demographic and professional characteristics and their knowledge, skills, and attitudes about these resuscitation procedures. Method: A descriptive-correlational study, based on a cross-sectional survey, was conducted in a university hospital in Quebec (Canada) in 2017. The survey was based on the French version of the Nurses Cardiopulmonary Resuscitation Survey (NCRS), previously developed and validated by the same researchers. Survey data were analyzed descriptively, and correlations were used to identify potential determinants of ICU nurses' knowledge, skills, and attitudes regarding resuscitation procedures. Results: In total, 82 nurses completed the survey, a 40.4% response rate. Most of respondents properly identified ventricular tachydysrhythmias (89%, n=73) and 66% (n=54) had good knowledge of CPR and defibrillation (score > 8/10). Nurses with higher NCRS scores reported being more confident in initiating manual defibrillation. ACLS-trained nurses had better chest compression knowledge. Conclusion: ICU nurses have good knowledge of CPR and defibrillation. Proper identification of shockable and non-shockable rhythms, as well as associated interventions should be fundamental aspects of training programs. Key words: intensive care, nursing, CPR, defibrillation, survey
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