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Search Results: 1 - 10 of 219734 matches for " Damon C. Scales "
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Ultrasound-guided tracheostomy - not for the many, but perhaps the few... or the one
Lorraine N Tremblay, Damon C Scales
Critical Care , 2011, DOI: 10.1186/cc10106
Abstract: The study by Rajajee and colleagues [1] published in the previous issue of Critical Care, 'Real-time ultrasound-guided percutaneous dilatational tracheostomy', is certainly thought provoking. Although both percutaneous tracheostomy and ultrasound for critically ill patients have been studied for decades, Rajajee and colleagues have added a new twist: they incorporate 'real-time' ultrasound in an effort to improve the safety of percutaneous tracheostomy in a heterogeneous case series of 13 patients, some of whom have problems known to make inserting a tracheostomy more challenging (for example, two patients under cervical spine precautions, and six obese patients, of whom four had unclear anatomy by palpation). Of importance, in this case series palpation and bronchoscopy were also used to determine anatomy (that is, ultrasound alone was not tested) and bronchoscopy was used to rule out injury to the posterior tracheal wall prior to passing the dilators. This small feasibility study does not allow us to draw any conclusions about the incremental benefits or harms of using 'real-time' ultrasound over standard approaches in higher-risk tracheostomy patients, as few patients were included and there was no comparison group. Furthermore, this pilot series does not prove that we should all fire up the ultrasound before performing our next tracheostomy, but it does reinforce several important messages.The first message is that neck ultrasound can provide useful additional information about variations in neck anatomy [2,3], which might lead to modifications of the planned surgical approach. As Figure 3 in the study nicely illustrates [1], ultrasound can be used to measure the distance from skin to trachea, allowing the choice of an appropriately sized tracheostomy tube (that is, regular or extended length), which certainly might be beneficial for patients with larger necks. However, it can be difficult to visualize the actual needle and its tract during an ultrasound-guided
Highlights from the Critical Care Canada Forum 2009 - 25 to 28 October 2009, Toronto, Ontario, Canada
Iain J McCullagh, Damon C Scales
Critical Care , 2010, DOI: 10.1186/cc8221
Abstract: The Critical Care Canada Forum 2009 featured several presentations describing the outcomes of critically ill patients with H1N1 virus infection from Australia, Mexico, and Canada.Dr Jamie Cooper (Melbourne, Australia), speaking on behalf of the Australia-New Zealand Intensive Care Influenza Investigators [2], described outcomes of 722 patients with confirmed H1N1 virus infection that were admitted to 187 intensive care units. Of these patients, most (92%) were younger than age 65, and large proportions were pregnant (9.1%) or had a body mass index >35 (28.6%). The overall mortality rate (as of September 2009) was 14.3% (95% confidence interval = 11.7 to 16.9%). Nitric oxide, inhaled prostacyclin, and prone positioning were used frequently to treat refractory hypoxemia. Outcomes of 68 patients from 15 centres who were treated with extracorporeal membrane oxygenation were also described [3]. Illness severity was predictably very high in this group, and the overall hospital mortality was 23% with most deaths due to haemorrhage.Dr Anand Kumar (Winnipeg, Canada) and Dr Rob Fowler (Toronto, Canada) presented data from the Canadian Experience [4]. Severe illness due to H1N1 infection (confirmed or probable) occurred in 168 patients during a 4-month period. Similar to the Australian-New Zealand experience, the cohort was young (mean age 32 years), and females, children, and the obese were disproportionally affected by severe illness requiring critical care. The overall mortality at 90 days was 17.3% (95% confidence interval = 12.0 to 24%). Notably, one-quarter of cases involved First Nations Canadians, Inuit, Métis, or aboriginals. Rescue therapies to treat refractory hypoxemia, including nitric oxide and high-frequency oscillation, were also commonly required in this group.Dr Guillermo Dominguez (Mexico City, Mexico) next presented outcomes of 58 critically ill patients with H1N1 infection in Mexico [5]. This cohort was one of the first to be affected by the pandemic, and
A Case for Osler
Catherine Chung,Martin C. Chang,Damon Scales
University of Toronto Medical Journal , 2001, DOI: 10.5015/utmj.v78i2.1027
Routine chest x-rays in intensive care units: a systematic review and meta-analysis
Anusoumya Ganapathy, Neill KJ Adhikari, Jamie Spiegelman, Damon C Scales
Critical Care , 2012, DOI: 10.1186/cc11321
Abstract: We searched Medline and Embase (1948 to March 2011) for randomized and quasi-randomized controlled trials (RCTs) and before-after observational studies comparing a strategy of routine CXRs to a more restrictive approach with CXRs performed to investigate clinical changes among critically ill adults or children. In duplicate, we extracted data on the CXR strategy, study quality and clinical outcomes (ICU and hospital mortality; duration of mechanical ventilation and ICU and hospital stay).Nine studies (39,358 CXRs; 9,611 patients) were included in the meta-analysis. Three trials (N = 870) of moderate to good quality provided information on the safety of a restrictive routine CXR strategy; only one trial systematically assessed for missed findings. Pooled data from trials showed no evidence of effect of a restrictive approach on ICU mortality (risk ratio [RR] 1.04, 95% confidence interval [CI] 0.84 to 1.28, P = 0.72; two trials, N = 776), hospital mortality (RR 0.98, 95% CI 0.68 to 1.41, P = 0.91; two trials, N = 259), ICU length of stay (weighted mean difference [WMD] -0.86 days, 95% CI -2.38 to 0.66 days, P = 0.27; three trials, N = 870), hospital length of stay (WMD -2.50 days, 95% CI -6.62 to 1.61 days, P = 0.23; two trials, N = 259), or duration of mechanical ventilation (WMD -0.30 days, 95% CI -1.48 to 0.89 days, P = 0.62; three trials, N = 705). Adding data from six observational studies, one of which systematically screened for missed findings, gave similar results.This meta-analysis did not detect any harm associated with a restrictive chest radiograph strategy. However, confidence intervals were wide and harm was not rigorously assessed. Therefore, the safety of abandoning routine CXRs in patients admitted to the ICU remains uncertain.Physicians often order routine daily antero-posterior chest x-rays (CXRs) for patients in intensive care units (ICUs) due to concerns about the severity of cardiopulmonary illness and complexity of medical interventions [1] and
Critical Care Canada Forum 2008, 11–13 November 2008, Toronto, Ontario, Canada
M Elizabeth Wilcox, Iain J McCullagh, Damon C Scales
Critical Care , 2009, DOI: 10.1186/cc7683
Abstract: Dr Daniel Talmor (Boston, MA, USA) presented, for the first time, the results of a trial of positive end-expiratory pressure titration using esophageal pressure measurements (to estimate transpulmonary pressure) versus positive end-expiratory pressure titration according to the Acute Respiratory Distress Syndrome Network standard-of-care recommendations in patients with acute lung injury or acute respiratory distress syndrome [1]. The study reached its early stopping criterion and was terminated after enrolling only 61 patients; the ratio of the partial pressure of oxygen to the fraction of inspired oxygen at 72 hours was 88 mmHg higher in the esophageal-pressure-guided group (95% confidence interval, 78.1 to 98.3). A dynamic discussion subsequently ensued, during which several audience members applauded the use of physiology-guided mechanical ventilation, while others argued that a multicenter trial studying clinical endpoints meaningful to patients and clinicians should be conducted to confirm the anticipated benefits of positive end-expiratory pressure titration using esophageal probes.Later in the conference, Dr Luciano Gattinoni (Milano, Italy) eloquently described how secondary lung injury from barotrauma and volutrauma might be reduced by mechanical ventilation in the prone position [2,3]. Published trials, however, have not yet established an overall survival benefit [4-6], and two recent meta-analyses [7,8] did not support prone positioning in the routine management of acute lung injury and acute respiratory distress syndrome. Dr Gattinoni showed that if the results of all trials are pooled [4-6] there is a trend towards improved survival when the analyses are restricted to the most severe cases of acute respiratory distress syndrome (n = 150; prone 6-month mortality 45.3% versus supine 6-month mortality 58.1%, P = 0.057). Dr Gattinoni then presented unpublished results from his new clinical trial of prone positioning versus conventional (supine) mechanical
Documentation of best interest by intensivists: a retrospective study in an Ontario critical care unit
Mohana Ratnapalan, Andrew B Cooper, Damon C Scales, Ruxandra Pinto
BMC Medical Ethics , 2010, DOI: 10.1186/1472-6939-11-1
Abstract: Using a quality of communication instrument developed from a literature search and expert opinion, 2 investigators transcribed and analyzed 260 handwritten communications for 105 critically ill patients who died in the intensive care unit between January and June 2006. Cohen's kappa was calculated before analysis and then disagreements were resolved by consensus. We report results on a per-patient basis to represent documented communication as a process leading up to the time of death in the ICU. We report frequencies and percentages for discrete data, median (m) and interquartile range (IQR) for continuous data.Our cohort was elderly (m 72, IQR 58-81 years) and had high APACHE II scores predictive of a high probability of death (m 28, IQR 23-36). Length of stay in the intensive care unit prior to death was short (m 2, IQR 1-5 days), and withdrawal of life support preceded death for more than half (n 57, 54%). Brain death criteria were present for 18 patients (17%). Although intensivists' communications were timely (median 17 h from admission to critical care), the person consenting on behalf of the incapable patient was explicitly documented for only 10% of patients. Life support strategies at the time of communication were noted in 45% of charts, and options for their future use were presented in 88%. Considerations relevant to determining the patient's best interest in relation to the treatment plan were not well documented. While explicit survival estimates were noted in 50% of charts, physicians infrequently documented their own predictions of the patient's functional status (20%), anticipated need for chronic care (0%), or post ICU quality of life (3%). Similarly, documentation of the patient's own perspectives on these ranged from 2-18%.Intensivists' documentation of their communication with substitute decision makers frequently outlined the proposed plan of treatment, but often lacked evidence of discussion relevant to whether the treatment plan was expected
Intensive care outcomes in bone marrow transplant recipients: a population-based cohort analysis
Damon C Scales, Deva Thiruchelvam, Alexander Kiss, William J Sibbald, Donald A Redelmeier
Critical Care , 2008, DOI: 10.1186/cc6923
Abstract: We conducted a population-based cohort analysis of all adult bone marrow transplant recipients who received subsequent ICU care in Ontario, Canada from 1 January 1992 to 31 March 2002. The primary endpoint was mortality at 1 year.A total of 2,653 patients received bone marrow transplantation; 504 of which received ICU care during a subsequent hospitalization. Patients receiving any major procedure during their ICU stay had higher 1-year mortality than those patients who received no ICU procedure (87% versus 44%, P < 0.0001). Death rates at 1 year were highest for those receiving mechanical ventilation (87%), pulmonary artery catheterization (91%), or hemodialysis (94%). In combination, the strongest independent predictors of death at 1 year were mechanical ventilation (odds ratio, 7.4; 95% confidence interval, 4.8 to 11.4) and hemodialysis (odds ratio, 8.7; 95% confidence interval, 2.1 to 36.7), yet no combination of procedures uniformly predicted 100% mortality.The prognosis of bone marrow transplant recipients receiving ICU care during subsequent hospitalizations is very poor but should not be considered futile.Bone marrow transplantation is a heroic element of therapy for leukemia, lymphoma, and some other devastating diseases. The procedure sometimes yields improved long-term survival, yet it can entail significant morbidity during the initial recovery [1-3]. About 40% of patients receive intensive care unit (ICU) treatment with the initial transplant [4]. The specific reasons for ICU admission frequently involve pulmonary, hepatic, or neurological dysfunction [5-8]. In addition to monitoring techniques such as continuous blood pressure recording, ICU care often involves complicated treatment including mechanical ventilation, renal replacement therapy, and continuous medication infusions.The utility of expensive ICU treatments for bone marrow transplant recipients is uncertain (Additional File 1). Two studies recruited patients prospectively [9,10], whereas most
Prophylactic anticoagulation to prevent venous thromboembolism in traumatic intracranial hemorrhage: a decision analysis
Damon C Scales, Jay Riva-Cambrin, Dave Wells, Valerie Athaide, John T Granton, Allan S Detsky
Critical Care , 2010, DOI: 10.1186/cc8980
Abstract: The decision node involved the choice to administer or to withhold low molecular weight heparin (LMWH) anticoagulation prophylaxis at 24 hours. Advantages of withholding therapy were decreased risk of ICH progression (death, disabling neurologic deficit, non-disabling neurologic deficit), and decreased risk of systemic bleeding complications (death, massive bleed). The associated disadvantage was greater risk of developing DVT/PE or death. Probabilities for each outcome were derived from natural history studies and randomized controlled trials when available. Utilities were obtained from accepted databases and previous studies.The expected value associated with withholding anticoagulation prophylaxis was similar (0.90) to that associated with the LMWH strategy (0.89). Only two threshold values were encountered in one-way sensitivity analyses. If the effectiveness of LMWH at preventing DVT exceeded 80% (range from literature 33% to 82%) our model favoured this therapy. Similarly, our model favoured use of LMWH if this therapy increased the risk of ICH progression by no more than 5% above the baseline risk.Our model showed no clear advantage to providing or withholding anticoagulant prophylaxis for DVT/PE prevention at 24 hours after traumatic brain injury associated with ICH. Therefore randomized controlled trials are justifiable and needed to guide clinicians.It is estimated that more than 1.5 million people in the United States sustain traumatic head injury each year [1]. Radiologic evidence of intracranial hemorrhage at the time of presentation is present in up to 45% of cases and is associated with a markedly poorer prognosis [2,3]. Traumatic intracranial hemorrhage encompasses cerebral contusion, subdural hematoma, subarachnoid hemorrhage, epidural hematoma and intracerebral hemorrhage. These are characterized by a relatively high risk of bleeding progression, especially within the first 24 hours [2,4-6].Traumatic intracranial hemorrhage is also associated with
Outcomes of interfacility critical care adult patient transport: a systematic review
Eddy Fan, Russell D MacDonald, Neill KJ Adhikari, Damon C Scales, Randy S Wax, Thomas E Stewart, Niall D Ferguson
Critical Care , 2005, DOI: 10.1186/cc3924
Abstract: We performed a systematic review of MEDLINE, CENTRAL, EMBASE, CINAHL, HEALTHSTAR, and Web of Science (from inception until 10 January 2005) for all clinical studies describing the incidence and predictors of adverse events in intubated and mechanically ventilated adult patients undergoing interfacility transport. The bibliographies of selected articles were also examined.Five studies (245 patients) met the inclusion criteria. All were case-series and two were prospective in design. Due to the paucity of studies and significant heterogeneity in study population, outcome events, and results, we synthesized data in a qualitative manner. Pre-transport severity of illness was reported in only one study. The most common indication for transport was a need for investigations and/or specialist care (three studies, 220 patients). Transport modalities included air (fixed or rotor wing; 66% of patients) and ground (31%) ambulance, and commercial aircraft (3%). Transport teams included a physician in three studies (220 patients). Death during transfer was rare (n = 1). No other adverse events or significant therapeutic interventions during transport were reported. One study reported a 19% (28/145) incidence of respiratory alkalosis on arrival and another study documented a 30% overall intensive care unit mortality, while no adverse events or outcomes were reported after arrival in the three other studies.Insufficient data exist to draw firm conclusions regarding the mortality, morbidity, or risk factors associated with the interfacility transport of intubated and mechanically ventilated adult patients. Further study is required to define the risks and benefits of interfacility transfer in this patient population. Such information is important for the planning and allocation of resources related to transporting critically ill adults.Regionalization of care and the requirement for specialized resources result in the frequent need for interfacility transport of critically ill pati
An innovative telemedicine knowledge translation program to improve quality of care in intensive care units: protocol for a cluster randomized pragmatic trial
Damon C Scales, Katie Dainty, Brigette Hales, Ruxandra Pinto, Robert A Fowler, Neill KJ Adhikari, Merrick Zwarenstein
Implementation Science , 2009, DOI: 10.1186/1748-5908-4-5
Abstract: We will conduct a pragmatic cluster randomized active control trial in 15 community ICUs and one academic ICU in Ontario, Canada. The intervention is a multifaceted videoconferenced educational and problem-solving forum to organize knowledge translation strategies, including comparative audit and feedback, educational sessions from content experts, and dissemination of algorithms. Fifteen individual ICUs (clusters) will be randomized to receive quality improvement interventions targeting one of the best practices during each of six study phases. Each phase lasts four months during the first study year and three months during the second. At the end of each study phase, ICUs are assigned to an intervention for a best practice not yet received according to a random schedule. The primary analysis will use patient-level process-of-care data to measure the intervention's effect on rates of adoption and adherence of each best practice in the targeted ICU clusters versus controls.This study design evaluates a new system for knowledge translation and quality improvement across six common ICU problems. All participating ICUs receive quality improvement initiatives during every study phase, improving buy-in. This study design could be considered for other quality improvement interventions and in other care settings.This trial is registered with http://www.clinicaltrials.gov webcite (ID #: NCT00332982)The demand for intensive care is increasing because of an aging population and the introduction of new life-sustaining technologies[1]. This care is expensive and the necessary resources are limited [2-4]. Despite advances in critical care delivery, mortality remains high[5,6]. It is thus imperative that eligible patients receive interventions which improve outcomes or decrease intensive care unit (ICU) length of stay[7]. Delays between demonstration of effectiveness and the widespread use of such critical care evidence-based 'best practices'[8,9] constitute errors of omission and
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