Purpose
The aim of this study was to characterize differences in directives to limit treatments and discontinue invasive mechanical ventilation (IMV) in elderly (65–80 years) and very elderly (> ...80 years) intensive care unit (ICU) patients.
Methods
We prospectively described new written orders to limit treatments, IMV discontinuation strategies direct extubation, direct tracheostomy, spontaneous breathing trial (SBT), noninvasive ventilation (NIV) use, and associations between initial failed SBT and outcomes in 142 ICUs from 6 regions (Canada, India, United Kingdom, Europe, Australia/New Zealand, United States).
Results
We evaluated 788 (586 elderly; 202 very elderly) patients. Very elderly (vs. elderly) patients had similar withdrawal orders but significantly more withholding orders, especially cardiopulmonary resuscitation and dialysis, after ICU admission 67 (33.2%) vs. 128 (21.9%); p = 0.002. Orders to withhold reintubation were written sooner in very elderly (vs. elderly) patients 4 (2–8) vs. 7 (4–13) days, p = 0.02. Very elderly and elderly patients had similar rates of direct extubation 39 (19.3%) vs. 113 (19.3%), direct tracheostomy 10 (5%) vs. 40 (6.8%), initial SBT 105 (52%) vs. 302 (51.5%) and initial successful SBT 84 (80%) vs. 245 (81.1%). Very elderly patients experienced similar ICU outcomes (mortality, length of stay, duration of ventilation) but higher hospital mortality 26 (12.9%) vs. 38 (6.5%). Direct tracheostomy and initial failed SBT were associated with worse outcomes. Regional differences existed in withholding orders at ICU admission and in withholding and withdrawal orders after ICU admission.
Conclusions
Very elderly (vs. elderly) patients had more orders to withhold treatments after ICU admission and higher hospital mortality, but similar ICU outcomes and IMV discontinuation. Significant regional differences existed in withholding and withdrawal practices.
Background
Noninvasive positive‐pressure ventilation (NPPV) provides ventilatory support without the need for an invasive airway. Interest has emerged in using NPPV to facilitate earlier removal of ...an endotracheal tube and to decrease complications associated with prolonged intubation.
Objectives
We evaluated studies in which invasively ventilated adults with respiratory failure of any cause (chronic obstructive pulmonary disease (COPD), non‐COPD, postoperative, nonoperative) were weaned by means of early extubation followed by immediate application of NPPV or continued IPPV weaning. The primary objective was to determine whether the noninvasive positive‐pressure ventilation (NPPV) strategy reduced all‐cause mortality compared with invasive positive‐pressure ventilation (IPPV) weaning. Secondary objectives were to ascertain differences between strategies in proportions of weaning failure and ventilator‐associated pneumonia (VAP), intensive care unit (ICU) and hospital length of stay (LOS), total duration of mechanical ventilation, duration of mechanical support related to weaning, duration of endotracheal mechanical ventilation (ETMV), frequency of adverse events (related to weaning) and overall quality of life. We planned sensitivity and subgroup analyses to assess (1) the influence on mortality and VAP of excluding quasi‐randomized trials, and (2) effects on mortality and weaning failure associated with different causes of respiratory failure (COPD vs. mixed populations).
Search methods
We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library, Issue 5, 2013), MEDLINE (January 1966 to May 2013), EMBASE (January 1980 to May 2013), proceedings from four conferences, trial registration websites and personal files; we contacted authors to identify trials comparing NPPV versus conventional IPPV weaning.
Selection criteria
Randomized and quasi‐randomized trials comparing early extubation with immediate application of NPPV versus IPPV weaning in intubated adults with respiratory failure.
Data collection and analysis
Two review authors independently assessed trial quality and ed data according to prespecified criteria. Sensitivity and subgroup analyses assessed (1) the impact of excluding quasi‐randomized trials, and (2) the effects on selected outcomes noted with different causes of respiratory failure.
Main results
We identified 16 trials, predominantly of moderate to good quality, involving 994 participants, most with chronic obstructive pulmonary disease (COPD). Compared with IPPV weaning, NPPV weaning significantly decreased mortality. The benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD (risk ratio (RR) 0.36, 95% confidence interval (CI) 0.24 to 0.56) versus mixed populations (RR 0.81, 95% CI 0.47 to 1.40). NPPV significantly reduced weaning failure (RR 0.63, 95% CI 0.42 to 0.96) and ventilator‐associated pneumonia (RR 0.25, 95% CI 0.15 to 0.43); shortened length of stay in an intensive care unit (mean difference (MD) ‐5.59 days, 95% CI ‐7.90 to ‐3.28) and in hospital (MD ‐6.04 days, 95% CI ‐9.22 to ‐2.87); and decreased the total duration of ventilation (MD ‐5.64 days, 95% CI ‐9.50 to ‐1.77) and the duration of endotracheal mechanical ventilation (MD ‐ 7.44 days, 95% CI ‐10.34 to ‐4.55) amidst significant heterogeneity. Noninvasive weaning also significantly reduced tracheostomy (RR 0.19, 95% CI 0.08 to 0.47) and reintubation (RR 0.65, 95% CI 0.44 to 0.97) rates. Noninvasive weaning had no effect on the duration of ventilation related to weaning. Exclusion of a single quasi‐randomized trial did not alter these results. Subgroup analyses suggest that the benefits for mortality were significantly greater in trials enrolling exclusively participants with COPD versus mixed populations.
Authors' conclusions
Summary estimates from 16 trials of moderate to good quality that included predominantly participants with COPD suggest that a weaning strategy that includes NPPV may reduce rates of mortality and ventilator‐associated pneumonia without increasing the risk of weaning failure or reintubation.
OBJECTIVES:Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable ...across centers. We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care.
DESIGN, SETTING, AND PARTICIPANTS:We conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers.
INTERVENTION:None.
MEASUREMENTS:The main outcome measure was physicians’ perceptions of prognosis and recommendations on the level of care.
MAIN RESULTS:Our response rate was 64% (455/712). Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%). In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and one-third disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies.
CONCLUSIONS:A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.
BACKGROUND:Pilot trials are important to ensure that large randomized trials are rigorous, feasible, and economically justifiable. The objective of this review is to highlight the importance of ...randomized pilot trials and to describe key features of their design and interpretation using examples from critical care.
METHODS:We searched MEDLINE (1997–2007) and contacted experts to identify pilot randomized trials to exemplify and summarize their key methodologic features including objectives, sample size determination, outcomes, analysis, and reporting.
RESULTS:Pilot trials can have distinct and broad objectives. Investigators can predefine explicit criteria for determining their success. Surrogate outcome analyses are common in pilot trials, yet are usually underpowered to detect meaningful differences in clinically important end points and thus, should be cautiously interpreted. Pilot trials can facilitate successful conduct of large clinical trials by informing study design and streamlining protocol implementation.
RECOMMENDATIONS:We recommend that investigators define suitable objectives, determine sample size estimates, and select outcomes that will address their specific pilot trial objectives. Clinical effects documented in pilot trials should be reported with caution to avoid undue enthusiasm or pessimism about unstable estimates. Further methodologic work is required to identify optimal pilot trial design, indexing, and reporting.
OBJECTIVES:To characterize the perceived utilization of sedative, analgesic, and neuromuscular blocking agents, the use of sedation scales, algorithms, and daily sedative interruption in mechanically ...ventilated adults, and to define clinical factors that influence these practices.
DESIGN:Cross-sectional mail survey.
PARTICIPANTS:Canadian critical care practitioners.
MEASUREMENTS AND MAIN RESULTS:A total of 273 of 448 eligible physicians (60%) responded. Respondents were well distributed with regard to age, years of practice, specialist certification, size of intensive care unit and hospital, and location of practice. Twenty-nine percent responded that a protocol/care pathway/guideline for the use of sedatives or analgesics is currently in use in their intensive care unit. Daily interruption of continuous infusions of sedatives or analgesics is practiced by 40% of intensivists. A sedation scoring system is used by 49% of respondents. Of these, 67% use the Ramsay scale, 10% use the Sedation-Agitation Scale, 9% use the Glasgow Coma Scale, and 8% use the Motor Activity Assessment Scale. Only 3.7% of intensivists use a delirium scoring system in their intensive care units. Only 22% of respondents currently have a protocol for the use of neuromuscular blocking agents in their intensive care unit, and 84% of respondents use peripheral nerve stimulation for monitoring. In patients receiving neuromuscular blocking agents for >24 hrs, 63.7% of respondents discontinue the neuromuscular blocking agent daily. Intensivists working in university-affiliated hospitals are more likely to employ a sedation protocol and scale (p < .0001), as are intensivists working in larger intensive care units (≥15 beds, p < .01). Intensivists with anesthesiology training (and no formal critical care training) are more likely to use a protocol and sedation scale, and critical care–trained intensivists are more likely to use daily interruption. Younger physicians (<40 yrs) are more likely to practice daily interruption (p = .0092).
CONCLUSIONS:There is significant variation in critical care sedation, analgesia, and neuromuscular blockade practice. Given the potential effect of practices regarding these medications on patient outcome, future research and educational efforts related to evidence-based protocols for the use of these agents in mechanically ventilated patients might be worthwhile.
In 2006, the Canadian Council for Donation and Transplantation produced the first Canadian recommendations for organ donor management, the result of a 2004 forum in collaboration with the Canadian ...Critical Care Society, the Canadian Association of Transplantation and the Canadian Society of Transplantation. The 2006 guideline had an influence on organ donation recommendations internationally; however, it had not been updated to incorporate emerging evidence in organ donor management and critical care medicine and the many advances in guideline development methodology. Here, Ball et al discuss the existing Canadian recommendations for the medical management of neurologically deceased adult and pediatric potential donors for the purposes of single- or multi-organ recovery for transplantation.
Objective
The objectives of this study were to systematically identify and describe guidelines for the care of neurologically deceased donors and to evaluate their methodological quality, with the ...aim of informing and supporting the new Canadian guidelines for the management of organ donors.
Methodology
Following a systematic search, we included any document endorsed by an organ donation organization, a professional society, or a government, that aims to direct the medical management of adult, neurologically deceased, multi-organ donors. We extracted recommendations pertaining to six domains: the autonomic storm, hemodynamic instability, hormone supplementation, ventilation, blood product transfusions, and general intensive care unit (ICU) care. Methodological quality of the guidelines was assessed by the validated AGREE-II tool.
Main findings
This review includes 27 clinical practice guidelines representing 26 countries published between 1993 and 2019. Using the AGREE-II validated tool for the evaluation of guidelines’ quality, documents generally scored well on their scope and clarity of presentation. Nevertheless, quality was limited in terms of the scientific rigor of guideline development. Recommendations varied substantially across the domains of managing the autonomic storm, subsequent management of hemodynamic instability, hormone therapy, mechanical ventilation, blood product transfusion, and general ICU care. We found consistent recommendations for low tidal volume ventilation subsequent to the publication of a landmark clinical trial.
Conclusion
Highly inconsistent recommendations for deceased donor care summarized in this review likely reflect the relatively slow emergence of high-quality clinical research in this field, as well as a late uptake of recent validated guideline methodology. Even in this context of few randomized-controlled trials, our group supported the need for new Canadian guidelines for the management of organ donors that follow rigorous recognized methodology and grading of the evidence.
Trial registration
PROSPERO (CRD42018084012); registered 25 February 2016.
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