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Search Results: 1 - 10 of 3101 matches for " Gordon Rubenfeld "
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Looking beyond 28-day all-cause mortality
Gordon Rubenfeld
Critical Care , 2002, DOI: 10.1186/cc1513
Abstract: In this issue of Critical Care, Dale Rublee and colleagues look beyond 28-day all-cause mortality, assessing the effects of antithrombin III on quality of life in sepsis survivors [1]. Although many of us would like to think that the battle has been won when a patient leaves the intensive care unit (ICU) after severe sepsis or acute respiratory distress syndrome (ARDS), a growing body of literature indicates that survivors of intensive care have an increased risk of death and have a significantly impaired quality of life after they leave the ICU. There are several possible mechanisms for these long-term effects, and many patients may be affected by several of them. Survival may be impaired simply because people with severe co-morbid diseases are most likely to get critically ill. Alternatively, critical illness may leave patients immunosuppressed and at risk for further complications that lead to early death. Hypoxemia, septic encephalopathy, and sedative medication may cause cognitive dysfunction [2]. Critical illness neuromyopathy, steroids, and bedrest may cause profound weakness [3]. The trauma of critical illness and false memories may cause post-traumatic stress disorder and depression [4]. Financial burdens continue well after hospital discharge [5]. Tracheostomy scars, striae from anasarca, decubitus ulcers, and digits lost to ischemia may affect patients' self image.The study by Rublee and colleagues [1] is an analysis of secondary endpoints in the Kybersept (antithrombin III) trial that failed to show a statistically significant effect on 28-day mortality [6]. They compared the Karnofsky performance scale and six domains of a visual analogue scale of quality of life: mobility, physical activity, communications–speech, alertness, energy, and overall quality of life. The authors performed at least 63 statistical comparisons across variables, time points, and populations to identify several situations in which antithrombin III seemed to have a statistically s
Morbid Obesity: Peri-operative Management
Abhijit Duggal, Gordon Rubenfeld
Critical Care , 2010, DOI: 10.1186/cc9265
Abstract: In this second edition, the 25 chapters are arranged in five general sections. The text is well illustrated and competently organized. The authors come from varied clinical backgrounds and include anesthesiologists, surgeons, and intensivists. Each chapter is well researched and appropriately referenced and deals with all aspects of care of bariatric surgical patients.The authors start with a discussion of specific challenges of the pathophysiology in the bariatric population and then move on to preparation and pre-operative management, intra-operative management, and post-operative care of bariatric surgery patients. The text has minimal repetition and flows very well from one section to the next. New features in this edition include chapters on the pathophysiology of pneumoperitoneum, post-operative rhabdomyolysis, informed consent, and bariatric surgery in adolescents.The chapters on positioning, monitoring, airway management, drug dosing, ventilatory strategies, comorbidities, and post-operative care all include information that would be extremely relevant to the practice of both anesthetists and intensivists. Some chapters (for example, the ones dealing with informed consent, renal dysfunction, and cortical electrical activity monitoring) were informative but did not seem to provide obesity-specific information. Although intensivists and anesthetists are not responsible for operative decisions, the authors could have provided greater detail about the selection of bariatric procedures and their associated outcomes and benefits.The book is an excellent resource for anesthetists, surgeons, and intensivists who wish to develop skills to recognize potential complications and provide quality peri-operative care to obese patients. This book will also be valuable to nursing staff, dieticians, and managers involved in the care of morbidly obese patients and will be a useful addition to the reference collection of institutions planning to develop or improve their bariatr
Year in review 2005: Critical Care – resource management
André Amaral, Gordon D Rubenfeld
Critical Care , 2006, DOI: 10.1186/cc4953
Abstract: During 2005 Critical Care published several original papers dealing with resource management. These papers focused mainly on sepsis and inflammation, with particular interest in the pathogenesis of the syndrome (especially the coagulation cascade and inflammatory aspects), analysis of prognostic indexes and markers, resuscitation and resource use in critical care.The importance of coagulation in sepsis has been the focus of attention by investigators for a few years [1]. Only recently has a compound, activated protein C (aPC), been shown effective and been approved for clinical use [2]. Because other natural anticoagulants have not been shown to be effective [3,4], however, the question remains whether the anticoagulant characteristics of aPC are indeed responsible for the survival benefit, or whether certain anti-inflammatory or fibrinolytic properties may also come into play. This issue was investigated in a small case-control study that could demonstrate a decrease in thrombin generation, as reflected by decreased levels of thrombin-antithrombin and pro-thrombin fragments 1 and 2 after aPC administration [5]. The inflammatory mediators and parameters of fibrinolysis did not change, however, which suggests that the main action of aPC may be anticoagulation, not fibrinolysis or inhibition of inflammation. One must therefore argue not only about the importance of coagulation in sepsis, but also how it is inhibited, because the targets on the coagulation cascade of natural anticoagulants are different: tissue factor pathway inhibitor seems to be an 'all or none' mediator, specifically involved in initiating the coagulation cascade [6]. It would therefore probably be useful if it could be administered before coagulation was initiated.Antithrombin III, on the other hand, works on later events in the cascade [7] and also benefits from specific interactions with endothelial glycosaminoglycans that may already be dysfunctional in sepsis [8]. Another report, however, showe
Pro/con clinical debate: The use of prone positioning in the management of patients with acute respiratory distress syndrome
John J Marini, Gordon Rubenfeld
Critical Care , 2002, DOI: 10.1186/cc1447
Abstract: A 29-year-old obese man is involved in a motor vehicle accident and has a pulmonary contusion that results in severe acute respiratory distress syndrome (ARDS). He is mechanically ventilated with volume cycle ventilation (tidal volume, 6 ml/kg ideal body weight), a positive end-expiratory pressure of 18 cmH2O, and a fractional inspired oxygen concentration of 0.8. His injuries are minimal and do not prevent him from being moved. Given your concerns about his oxygenation, you wonder whether there might be a benefit to prone positioning.John J MariniCritically ill patients are frequently immobilized in the supine position for days to weeks with periodic 15–30° lateral positioning. Supine positioning allows access to vital structures, facilitates catheter placement, allows the patient to face caregivers and family, and avoids potential pressure-related complications, such as ocular injury, jugular vein compression, and skin ulceration at points of increased pressure (for instance, the nose, chin, or knees).Maintaining a supine position may also be mandated by the underlying condition (such as anterior burns or massive ventral trauma). In nature, however, an unrelieved supine orientation is never encountered for extended periods; postural variation is innate. Moreover, if one horizontal orientation is to be preferred, there are five reasons for choosing the prone position in preference to the supine position.Firstly, sinus and airway anatomy affords more efficient secretion drainage when prone. Secondly, the lung fits into the prone thorax with less distortion. This improved fit results from the repositioned diaphragm and heart; the heart compresses the dorsal lung when supine and rests on the sternum when prone [1].Thirdly, the supine position predisposes to airway closure in the dorsal regions that receive the majority of blood flow [2]. Regional ventilation-to-perfusion relationships are more uniform in the prone position, especially in patients with ARDS. Increased
Attending to the lightness of numbers: toward the understanding of critical care epidemiology
Valdelis N Okamoto, Gordon D Rubenfeld
Critical Care , 2004, DOI: 10.1186/cc2952
Abstract: A lot of epidemiology is simple division. Divide the number of new cases of a disease by the number of people at risk of developing it and you have its incidence. Divide the incidence of the disease in people exposed by the incidence in those unexposed and you have the relative risk. The standardized mortality ratio (SMR) is just the observed number of deaths divided by the number of deaths predicted by a reference population.In critical care, we spend a lot of time thinking about the epidemiology of the numerator – the patients with critical illness who are admitted to an intensive care unit (ICU). Although this is no trivial matter, there is great difficulty in deciding which patients have which critical illness syndromes; far less attention has been paid to the denominator. These are the patients who are not critically ill and patients with critical illness who are not admitted to the ICU. Most of the epidemiological studies in critical care do not express their results in terms of population burden of critical illness – in other words, they fail to account for the population at risk, namely the denominator. Some studies do a superb job of evaluating the numerator (careful examination of patients in an ICU with the disease under study) but, because they studied patients at selected institutions, the population denominator, and hence the incidence, cannot be determined [1,2]. Other studies have used the entire United States population as the denominator but use a numerator extrapolated from relatively limited observations [3,4]. We therefore do not have very good population data on the burden of critical illness or the burden of intensive care needs.In critical care epidemiology, denominators have not been fully understood because they are difficult to estimate. ICUs are at the apex of a complex health care system and receive patients from many sources. The geographic population at risk for illness that should be used as a denominator to generate disease incidence
Beyond ethical dilemmas: improving the quality of end-of-life care in the intensive care unit
Gordon D Rubenfeld, J Randall Curtis
Critical Care , 2002, DOI: 10.1186/cc1866
Abstract: The consensus guidelines developed by Hawryluck and coworkers [1] provide a nice summary of the current principles that guide palliative care in the intensive care unit (ICU). Although recommendations in that article can be found in a variety of published guidelines on end-of-life care in the ICU [2,3,4,5], this Delphi-based consensus study provides useful additions. The Intent section in Table 4 of the report by Hawryluck and coworkers [1] is particularly helpful to clinicians trying to understand the practical implications of the 'principle of double effect'. Specific examples of charting tools or protocols based on these general concepts would be a useful addition to the general principles presented in the article. The distinction between the compassionate withdrawal of life-sustaining treatments and euthanasia is made forcefully and repeatedly by the authors. Suggestions to incorporate support for the ICU staff is an important, and often overlooked, addition.Unfortunately, more is needed than consensus on general principles. Studies from the past 10 years indicate that important problems persist with end-of-life care in the ICU, despite agreement on the general principles in that report. Patients die in ICUs in pain, receiving care that they and their families did not request. Objective prognostic data and advance directives have had little impact on patient care [6,7]. Clinicians' decisions regarding the use of life-sustaining treatments are driven by their personal biases, including training, age, religiosity, and specialization, rather than patient factors [8,9]. Nurses are profoundly frustrated by the care provided to dying patients in the ICU [10,11].These clinical problems concern ethical issues, but they will not be solved by consensus on ethics based guidelines because they are not caused by ethical discord. In fact, there is every reason to expect that solutions for improving end-of-life care in the ICU will look a lot like solutions for improving outco
Clinical review: Fresh frozen plasma in massive bleedings - more questions than answers
Bartolomeu Nascimento, Jeannie Callum, Gordon Rubenfeld, Joao Neto, Yulia Lin, Sandro Rizoli
Critical Care , 2010, DOI: 10.1186/cc8205
Abstract: Fresh frozen plasma (FFP) is a blood product that has been available since 1941 [1]. Initially used as a volume expander, it is currently indicated for the management and prevention of bleeding in coagulopathic patients [1-3]. The evidence on FFP transfusion is scant and of limited quality [4].Estimates state that 25 to 30% of all critical care patients receive FFP transfusions [5,6]. Despite its commonality, only 37% of the physicians in a recent study correctly responded to basic questions about FFP, including the volume of one unit [7]. An audit on transfusion practices suggested that one-half of all FFP transfused to critical care patients is inappropriate [5].Massive haemorrhage is among the most challenging issues in critical care, affecting trauma patients, surgical patients, obstetric patients and gastrointestinal patients [3,8,9]. In trauma, a recent series of retrospective clinical studies suggests that early and aggressive use of FFP at a 1:1 ratio with red blood cells (RBC) improves survival in cases of massive haemorrhage [10-19]. Because bleeding is directly responsible for 40% of all trauma-related deaths, this strategy - also known as haemostatic damage control or formula-driven resuscitation - has received substantial attention worldwide. This early formula-driven haemostatic resuscitation proposes transfusion of FFP at a near 1:1 ratio with RBC, thus addressing coagulopathy from the beginning of the resuscitation and potentially reducing mortality. Nevertheless, this strategy requires immediate access to large volumes of thawed universal donor FFP, which is challenging to implement.Despite conflict with existing guidelines, early formula-driven haemostatic resuscitation use is expanding and is gradually being used in nontraumatic bleedings in critical care [20]. Both the existing guidelines and early formula-driven haemostatic resuscitation are supported by limited evidence, generating controversies and challeng ing clinical decisions in critical c
The effect of an intensive care unit staffing model on tidal volume in patients with acute lung injury
Colin R Cooke, Timothy R Watkins, Jeremy M Kahn, Miriam M Treggiari, Ellen Caldwell, Leonard D Hudson, Gordon D Rubenfeld
Critical Care , 2008, DOI: 10.1186/cc7105
Abstract: We conducted a secondary analysis of a prospective population-based cohort of 759 patients with ALI who were alive and ventilated on day three of ALI, and were cared for in 23 intensive care units (ICUs) in King County, Washington.We compared day three tidal volume (VT) in open versus closed ICUs adjusting for potential patient and ICU confounders. In 13 closed model ICUs, 429 (63%) patients were cared for. Adjusted mean VT (mL/Kg predicted body weight (PBW) or measured body weight if height not recorded) for patients in closed ICUs was 1.40 mL/Kg PBW (95% confidence interval (CI) = 0.57 to 2.24 mL/Kg PBW) lower than patients in open model ICUs. Patients in closed ICUs were more likely (odds ratio (OR) = 2.23, 95% CI = 1.09 to 4.56) to receive lower VT (≤ 6.5 mL/Kg PBW) and were less likely (OR = 0.30, 95% CI = 0.17 to 0.55) to receive a potentially injurious VT (≥ 12 mL/Kg PBW) compared with patients cared for in open ICUs, independent of other covariates. The effect of closed ICUs on hospital mortality was not changed after accounting for delivered VT.Patients with ALI cared for in closed model ICUs are more likely to receive lower VT and less likely to receive higher VT, but there were no other differences in measured processes of care. Moreover, the difference in delivered VT did not completely account for the improved mortality observed in closed model ICUs.Over the past decade there has been a growing body of literature demonstrating an association between high-intensity physician staffing in the intensive care unit (ICU) and improved patient outcomes [1-7], although this association is not without controversy [8]. In 2001 the Society of Critical Care Medicine published the recommendations of two task forces convened to determine the 'best' ICU practice model and to define the role and practice of an intensivist. Based on available evidence, the report recommended that care in the ICU "...should be led by a full-time critical care-trained physician who is avai
Perceived barriers to the regionalization of adult critical care in the United States: a qualitative preliminary study
Jeremy M Kahn, Rebecca J Asch, Theodore J Iwashyna, Gordon D Rubenfeld, Derek C Angus, David A Asch
BMC Health Services Research , 2008, DOI: 10.1186/1472-6963-8-239
Abstract: We performed a qualitative study using semi-structured interviews of critical care stakeholders in the United States, including physicians, nurses and hospital administrators. Stakeholders were identified from a stratified-random sample of United States general medical and surgical hospitals. Key barriers and potential solutions were identified by performing content analysis of the interview transcriptions.We interviewed 30 stakeholders from 24 different hospitals, representing a broad range of hospital locations and sizes. Key barriers to regionalization included personal and economic strain on families, loss of autonomy on the part of referring physicians and hospitals, loss of revenue on the part of referring physicians and hospitals, the potential to worsen outcomes at small hospitals by limiting services, and the potential to overwhelm large hospitals. Improving communication between destination and source hospitals, provider education, instituting voluntary objective criteria to become a designated referral center, and mechanisms to feed back patients and revenue to source hospitals were identified as potential solutions to some of these barriers.Regionalization efforts will be met with significant conceptual and structural barriers. These data provide a foundation for future research and can be used to inform policy decisions regarding the design and implementation of a regionalized system of critical care.The presence of a trained critical care physician and a multidisciplinary care team is associated with improved patient outcomes in the intensive care unit (ICU) [1-3]. Given the ortage of ICU clinicians, however, only a small minority of ICUs in the United States are organized in this manner [4]. The situation is expected to worsen as the population ages and demand for critical care rises [5]. To address this crisis some have called for a regionalized approach to critical care [6-8]. Under a regionalized scenario, high-risk patients would be routinely tran
Emergency department length of stay for patients requiring mechanical ventilation: a prospective observational study
Louise Rose, Sara Gray, Karen Burns, Clare Atzema, Alex Kiss, Andrew Worster, Damon C. Scales, Gordon Rubenfeld, Jacques Lee
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine , 2012, DOI: 10.1186/1757-7241-20-30
Abstract: Prospective observational study of ED LOS for all patients receiving mechanical ventilation at four metropolitan EDs in Toronto, Canada over two six-month periods in 2009 and 2010.We identified 618 mechanically ventilated patients which represented 0.5% (95% CI 0.4%–0.5%) of all ED visits. Of these, 484 (78.3%) received invasive ventilation, 118 (19.1%) received NIV; 16 received both during the ED stay. Median Kaplan-Meier estimated duration of ED stay for all patients was 6.4?h (IQR 2.8–14.6). Patients with trauma diagnoses had a shorter median (IQR) LOS, 2.5?h (1.3–5.1), compared to ventilated patients with non-trauma diagnoses, 8.5?h (3.3–14.0) (p <0.001). Patients requiring NIV had a longer ED stay (16.6?h, 8.2–27.9) compared to those receiving invasive ventilation exclusively (4.6?h, 2.2–11.1) and patients receiving both (15.4?h, 6.4–32.6) (p <0.001). Longer ED LOS was associated with ED site and lower priority triage scores. Shorter ED LOS was associated with intubation at another ED prior to transfer.While patients requiring mechanical ventilation represent a small proportion of overall ED visits these critically ill patients frequently experienced prolonged ED stay especially those treated with NIV, assigned lower priority triage scores at ED presentation, and non-trauma patients.
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