key: cord-0007054-mvo6mdx5
authors: nan
title: CCCF 2017 Abstracts
date: 2018-06-01
journal: Can J Anaesth
DOI: 10.1007/s12630-018-1162-7
sha: 90d648169e0f96d187024217ab52be5d49d5c9b5
doc_id: 7054
cord_uid: mvo6mdx5

nan

, 2016, 20 team members (nurses, respiratory therapists, research assistants and research fellows) went across assigned areas of SMH to collect the data. Filled CRFs were later validated and the missing data completed. We also followed up patients for 90-day hospital outcome. Results: We screened 423 patients (ED n=38, Wards n=318, ICU n=72). Twentyone percent of the patients were on O 2 , with the highest prevalence in the ICU (42, 58%). The most common reason for O 2 use was congestive heart failure (19%) followed by pre/post-operative order, neurological conditions and pulmonary diseases. The most commonly used device was nasal prongs (54%) followed by invasive mechanical ventilators (26%). The number of patients requiring urgent consultation from the critical-care response team was only 4 out of 90 and the number of patients developing new ARDS within 7 days was 2 out of 90. At day 90, 12% of the patients had died in the hospital and 9% was still admitted. Hyper-oxygenation was common, affecting 42% of the patients. The prevalence was higher in the ICU (52% VS 37% in the wards). The median [IQR] of SpO 2 for overall patients was 97% [94-99%]. The devices causing high incidence of hyperoxygenation were tracheostomy mask (4/4), followed by mechanical ventilators (17/23; 74%) . There was no statistically significant difference between the FiO 2 set on the ventilators for those who were hyper-oxygenated and normo-oxygenated (0.40 [0.38-0.50] VS 0.40 [0.34-0.46] respectively). A secondary chart analysis indicated that ICU patients who were labelled as hyper-oxygenated spent 80% of the 24h hyper-oxygenated. Conclusion: Hyper-oxygenation is a common problem in patients receiving O 2 . The prevalence is higher in the ICU despite having more rigorous monitoring. Instability of the patients with fluctuation of the SpO 2 may influence the clinicians' decision to set higher target of SpO 2 to be on the safe side. The next phase of WHARF study will use a questionnaire to explore attitudes and decision makings of the clinicians facing various case scenario regarding O 2 management. Introduction: Patient eligibility for research in the intensive care unit (ICU) can occur at any time of day or week. Deferred consent, consent from the patient or substitute decision-maker (SDM) after research has commenced, is a common alteration in the ICU when conducting observational research or studying low risk, time-sensitive interventions or transient phenomenon (1) . Utilization of a deferred approach can overcome challenges experienced as a result of patient incapacity and SDM availability. SDMs and patients have endorsed deferred consent as an acceptable mechanism for research consent in the ICU (2, 3) . Herein we describe time to deferred consent from SDMs in an observational study of diaphragm activity in mechanically ventilated patients. Objectives: To describe consent outcomes, including timing, in an observational study of diaphragm activity in mechanically ventilated patients in the ICU. Methods: DIVIP, Assessing Diaphragm Muscle Inactivity in Mechanically Ventilated ICU Patients, is an observational study which involves serial recording of electrical activity of the diaphragm and daily diaphragm ultrasound (NCT02434016) for up to 5 days. The first ultrasound must be performed within 24 hours of mechanical ventilation. The Research Ethics Board at St. Michael's Hospital approved the use of a deferred consent model for patient enrollment in the study and for the conduct of the first ultrasound. The research team has up to 5 days after enrollment to assess the patient for capacity and/or identify and contact an SDM (in-person or by phone) for consent for continued participation and the completion of up to 5 ultrasounds. Data from our local screening log was reviewed to identify outcomes and timing of our deferred consent approach. Results: From April 2016 to the end of July 2017, we enrolled 29 patients into the study. Deferred consent was obtained from SDMs in 15 patients (52%). Most consents (11/15 ; 73%) occurred within 24 hours, allowing us to obtain the maximum number of ultrasounds in these patients. Consent for continued participation could not be obtained for 14 patients with the most common cause being no identifiable SDM (6/14; 43%), followed by patient extubation prior to consent (29%). In only one patient was the absence of consent the result of a designated SDM not being reachable within the 5-day study window. Considering all patients with an identified SDM, consent rates of 81% (13/16) and 94% (15/16) were possible with time windows of 48 hours and 5 days respectively.

A deferred consent model supported patient enrollment in our observational study. For patients with identifiable SDMs, a less restrictive window to make contact permitted SDM involvement in the majority of consents. Our experience in utilizing a deferred consent approach has informed the design of consent approaches in other studies by our group and may be useful to others conducting low risk, time-sensitive research in the ICU.

Chen, Jennifer 1 ; Tamasi, Tanya 2 ; McIntyre, Chris 2,3 ; Ball, Ian 2,4 ; Slessarev, Marat 2, 3 1 Departments of Pathology, 2 Medicine, 3 Medical Biophysics and 4 Epidemiology and Biostatistics, University of Western Ontario, London ON Introduction: Sepsis is a common syndrome associated with high ICU mortality and long-term complications. Despite advances in our understanding of sepsis pathophysiology, specific therapies are still lacking. Passive exercise is one potential therapy that may improve survival and long-term outcomes via the modulation of skeletal muscle blood flow (1) and distal organ perfusion (2) . However, the effect of passive exercise on organ perfusion in septic patients has never been measured. Furthermore, the dose of passive exercise required to affect distal organ perfusion will likely vary among septic patients given the heterogeneity of their baseline comorbidities, exercise tolerance, and illness severity. We developed a model of graded passive exercise that can be used to study global hemodynamics, brain and heart perfusion in septic patients, and tested its feasibility and safety in a cohort of healthy adults. Objectives: To assess the effect of a graded passive exercise model on global hemodynamics, cerebral blood flow and cardiac function in a cohort of healthy volunteers, and to test the feasibility and safety of this model prior to its application in septic patients. Methods: We passively exercised 11 healthy volunteers using an in-bed cycle ergometer. After collecting resting baseline data, we increased the ergometer cadence from 5 rotations per minute (RPM) to 55 RPM in 10 RPM intervals each lasting 5 minutes. During each interval, we recorded continuous global hemodynamics and cerebral blood flow using the Finapres® NOVA and transcranial doppler (TCD), respectively. We also measured regional and global left ventricular (LV) function at each cadence level using speckle tracking analysis, a sensitive technique to detect changes in regional and global LV contractility. Results: Graded passive exercise has no effect on global hemodynamics, except for a 7% increase in mean arterial pressure (MAP). There were no changes in cerebral blood flow or cardiac function. The graded passive exercise model was well tolerated by all participants. Conclusion: In healthy adults, our model of graded passive exercise is feasible, safe and has no clinically significant impact on global hemodynamics, cerebral blood flow or cardiac function. This model can now be safely applied to septic patients. 

The role of the newly formed National Platform Research Coordinator (NPRC) is to support the research and academic activities of the Canadian Critical Care Trials Group (CCCTG). The NPRC is responsible for supporting CCCTG members in 4 key domains including a) core documentation resources; b) research support; c) research training and mentoring; and d) patient and family engagement in critical care. Objective: We sought to evaluate the relative importance of activities in these 4 domains to the members of the CCCTG. This assessment will provide insight to the NPRC and the CCCTG regarding how best to support the learning needs of the multi-professional CCCTG members. Methods: We developed a 14 item questionnaire to rate the importance of key academic activities within the aforementioned 4 domains on a scale from 1 (not important at all) to 10 (extremely important). We provided participants the opportunity to comment on additional activities not included in the questionnaire. We collected respondents' demographic data including professional affiliation(s), role within the CCCTG, and length of time in that role. Before administering the questionnaire, we pilot tested it with 6 CCCTG members and assessed its clinical sensibility. Along with the electronic version distributed via SurveyMonkey®, we administered a paper version of the questionnaire at the 2017 Winter CCCTG scientific meeting. All responses were anonymous and questionnaire completion was voluntary. The need for a full Research Ethics Board (REB) application was waived by the Hamilton Health Sciences REB. Results: From January 2017 to July 2017, the questionnaire was distributed to 458 CCCTG members. 141 (30.8%) CCCTG members completed the questionnaire. Of the 141 respondents, 47.5% were MDs, 39.7% RCs, and 12.8% other allied health care professionals. Approximately one third of the respondents were in the first five years of their profession (38.3%) and another third for more than 15 years (31.9%). The topic of greatest importance in the 'core documentation' domain was 'maintenance of standardized operating procedures (SOPs)' (7.9/10). The research support domain, which prioritized 'Clinical Trials Ontario' and 'REB support', received the lowest rankings (6.1-6.5/10). However, multiple respondents noted the requirement for increased REB support for members outside of Ontario. The highest-ranked activity in the 'training and mentoring' domain was 'workshops pertaining to screening and consent' (7.4/10) . RNs ranked 'Good Clinical Practice and regulatory training', as well as 'manuscript/abstract writing/preparation', 0.5 points above the total averages. Junior professionals ranked 'finding a good mentor' higher by 0.7 average points than those who had been in their profession for more than 15 years. In the domain of 'patient and family engagement', 'preparing for multisite trials' tied for the top-rating survey-wide response along with SOP maintenance (7.9/10).

Respondents also felt strongly about 'engaging new members' (7.6/10) and 1 3 20 

Al Saied, Ghiath 1 ; AlMaani, Mohammed 1 ; Alhawdar, Taher 1 ; Alzahrani, Saud 1 ; Abdullah Almotairi 1 1 Section of Critical Care Medicine, King Fahad Medical City, Riyadh, Saudi Arabia Introduction: Cancer is one of the leading causes of morbidity and mortality worldwide. Some will require unplanned ICU care. The characteristics and outcomes of these patients are sometimes not well defined to treating ICU physicians, leading to inconsistent prognostication and therapeutic decisions. Some of these patients are allowed to receive advanced care despite poor prognosis leading to futile treatment and eventual mortality. However, outcome of ICU care in cancer patients have improved, which calls for a more refined triaging of cancer patients to ICU. Studies that describe the characteristics and outcomes of cancer patients is lacking in our population. Objectives: To describe the characteristics of patients with hematological and solid cancers who require ICU admission and to review their outcomes. Methods: We retrospectively collected data from patients with hematological and solid cancers admitted to a large academic ICU unit over a six year period (2011) (2012) (2013) (2014) (2015) (2016) . We excluded patients admitted electively for elective post-oncological surgery care. Logistic regression analyses will be conducted to examine the association between ICU mortality and the following covariates: Age, ICU length of stay (LOS), APACHE score, prior cancer therapy within three months, need of mechanical ventilation (MV), need of renal replacement therapy (RRT), and presence of febrile neutropenia. Survival at 30 and 90 days will be measured.

Stepwise selection procedure will be used to develop the multivariate logistic model. Kaplan-Meier survival curves will be plotted for both study groups and compared using log-rank test. Two-Tailed p-value of 0.05 will be considered significant. Results: There were a total of 473 admissions to ICU of patients with cancer. 221 admissions were hematological malignancies and 252 admissions were those with solid tumours. Average LOS in ICU was 9.9 days. Mean age was 51.2 years, whereas mean APACHE scores were 22.4 for hematological and 21.4 for solid tumours. 33.4% of patients had received cancer therapy within 3 months. 74.3% needed MV, and 15% needed RRT. 26 .8% were admitted with febrile neutropenia. Overall survival was 40.4% at 30 days, with 37.1% of hematological and 43.3% of solid tumour patients surviving 30 days. Survival decreases at 90 days to 25.6% overall, with similar numbers for hematological and solid tumours (26.2 and 25% respectively). Conclusion: Outcome of ICU patients with cancer is worse than the average ICU patient but these patients should not be denied ICU aggressive therapy solely based on their cancer status. More refined prognostication models should be constructed to help clinicians caring for oncology patients determine the utility of ICU admission once a need arises. Introduction: Critical care medicine is expensive. It is estimated that almost 1% of the gross domestic product is spent on critical care alone. 1 Additionally, intensive care unit (ICU) costs are expected to rise as usage escalates due to an aging population and the increasing severity of illness among hospitalized patients. 2, 3 It has been well described in the literature that a small proportion patients account for a disproportionate amount of health care spending. [4] [5] [6] [7] [8] [9] [10] Longitudinal data has shown that only a minority of these patients remain in the high-cost group over time, 15, 22 rendering reactive strategies less useful. Identifying these patients up front may present an opportunity for focused intervention to reduce spending, albeit there is a paucity of literature describing these patients in the ICU setting. To date, we are only aware of a single retrospective study reported in the ICU literature. 11 A better understanding of the cost pattern predictors may help anticipate resource demands and provide an opportunity to mitigate costs. Objectives: To describe the characteristics, cost patterns, and outcomes for highcost patients in the ICU. Methods: This was a retrospective observational cohort study conducted at two medical/surgical ICUs in a tertiary care academic centre. Included patients were critically ill admissions aged 18 years or older. This was a cost comparison study. Patients were divided into cost groups with the highest 10 th percentile being compared to the 90 th percentile regarding their characteristics, cost patterns and outcomes. Results: A total of 7849 patients (8449 encounters) were included, with 7063 in the low-cost group and 786 patients in the high-cost group. The high-cost group had a mean age of 60.7 years. The high-cost group had a longer length of stay with a mean duration of 32.6 days in the ICU. The median direct cost per patient in the high-cost group was $148327 (IQR 114007 -224610), and the top 10% of patients amounted to 49% of direct costs. Non-survivors were more likely to have a premorbid diagnosis of congestive heart failure, OR 1.84 (95% CI 1.27 -2.68), chronic obstructive pulmonary disease, OR 2.32 (95% CI 1.64 -3.28), or to be admitted after a procedural complication, OR 2.93 (95% CI 1.24 -6.90). Despite the difference in cost, the in-hospital mortality rate was 27.8% in the highcost group, compared to 29.5% in the low-cost group (p = .341). Only 10.7% of the high-cost group were ultimately dispositioned home, compared to 29.4% in the lowcost group (p < .0001), and 33.6% of patients were transferred to long term care facilities. Conclusions: In summary, in a population of high-cost ICU patients, we found that 1 3 22 the top 10% of patients are responsible for half of the total cost. Among these, only a minimal proportion are sent home. Premorbid chronic obstructive pulmonary disease and patients admitted from procedure complications independently predicted high-cost status among non-survivors and may represent a population where cost strategies could be further explored. 

The alpha 2 agonist clonidine may be used as an adjunct for ICU sedation and analgesia to decrease traditional sedative and opioid requirements. However, clonidine can cause hypotension and bradycardia. Objectives 1) To describe clonidine dosing regimens used for sedation in a mixed medical surgical ICU, as well as associated adverse events (i.e., hypotension, bradycardia, rebound withdrawal), and 2) to determine if clonidine has sparing effects on traditional drugs used for pain, sedation and agitation. Methods We conducted a retrospective chart review of all critically ill adult patients that received at least one dose of clonidine for sedation between 2011-2016. We categorized patients as low dose (LD ≤ 0.4 mg/day) or high dose (HD > 0.4 mg/day) based on the maximum total daily clonidine dose for the analysis.

Of the 166 patients that met inclusion criteria, 78 (47%) received HD. The median duration of clonidine was 5 days (2, 8) ; therapy was discontinued without weaning for 115 (69%) patients. Hypotension was the most prevalent adverse effect amongst all patients (19.6 % with SBP < 90 mmHg and 44.6% with MAP < 65 within the first 72 hours). However, there were no significant differences between dose groups in observed rates of hypotension. Incidence of withdrawal symptoms were higher for LD compared to the HD within 25-48 hours post-clonidine discontinuation, (28% vs. 13% for rebound hypertension, p = 0.017 and 49% vs. 31% for rebound tachycardia, p = 0.022). There was a greater reduction in mean daily opioid dose for HD versus LD (mean -218.8 mcg vs. -42.5 mcg of fentanyl equivalents, p = 0.049). The decrease in sedative and non-sedative usage post-clonidine initiation was not significant. Antipsychotic dose increased for HD compared to LD (5.7 mg olanzapine equivalents vs 0 mg, p = 0.04). Conclusions We found clonidine daily doses were titrated beyond 0.4 mg/day in nearly half of patients; therapy was abruptly stopped for two-thirds of patients. Incorporating a tapered approach may minimize withdrawal symptoms postclonidine cessation. Hypotension was the most prevalent adverse event but no difference based on daily dose. Titrated clonidine decreased patients' opioid but not sedative requirements.

Background: REVISE is a randomized, blinded, placebo-controlled trial examining the effect of intravenous (IV) pantoprazole compared to placebo (0.9% sodium chloride; normal saline [NS]) on rates of upper gastrointestinal bleeding, pneumonia and Clostridium difficile infection in the ICU. Pantoprazole is chemically stable, retaining its potency at 0.8mg/ml when mixed in NS for up to 28 days in the fridge (2-8°C) 1, 2 . However, some studies evaluating pantoprazole in solution have observed a change in colour over time, which may affect the integrity of blinding in a clinical trial. We previously documented colour stability for 5 days 3 . The objective of this study was to extend these observations to 10 days by evaluating any change in colour under refrigerated conditions (2-8°C) for 2 different pantoprazole parenteral formulations currently marketed in Canada. Methods: Under sterile conditions (laminar flow hood), Pharmacy Research Personnel prepared 5 sample minibags for each of the 2 parenteral pantoprazole products (10 x 50mL) (Table) . The final concentration of pantoprazole was 40mg/50mL (0.8mg/mL). Each mini-bag was labeled and stored protected from light and refrigerated at 2-8°Celcius. A continuous temperature measurement device was in the refrigerator throughout the testing period, recording the minimum and maximum temperature daily for 10 consecutive days. On each of the 10 study days, one 50mL minibag of each product formulation was selected. Using a transparent 10 ml syringe, 5 x 10 mL of reconstituted pantoprazole was withdrawn from the minibag, and compared with 10 mL of NS in an identical syringe (placebo). Syringes were placed on bright white paper for 20 minutes (the duration of typical study drug administration) under room light at room temperature, and daily photos were taken. The same 2 research coordinators performed all assessments. In duplicate but independently, they inspected the syringes, comparing each pantoprazole-containing syringe with the placebo syringe, seeking any colour change. This was repeated for a total of 10 days.

Pantoprazole Methods: Structured postmortem components of the 3 Wishes Project were a) ICU staff and project team sympathy cards for each family; b) elicitation and/or implementation of some postmortem wishes; and c) interviews with family members and clinicians of each decedent to learn about their perspectives on the project, which we conducted days to weeks postmortem. Unstructured postmortem components were a) letters from family members to ICU staff and project team; b) unplanned return visits by families to debrief on terminal events, counseling requests (psychological or spiritual), reconnecting with ICU staff or project team, c) reflective notes from 5 project team members and d) hospital memorial services. The experiences of patients, family members, and clinicians were examined through analysis of interviews with 86 family members and 150 clinicians (100% participation). The interviews with family members were conducted in-person (53, 61.6%), by phone (31, 36.0%) or email (2, 2.3%) and analyzed using conventional content analysis. Results: For 100 patient-family dyads, 452 wishes were implemented [314 (69.5%) antemortem and 138 (30.5%) postmortem]. Postmortem wishes included mementos and tributes to the patient, ongoing family support, observances, and acknowledgements. Offerings were from the ICU staff or project team to patients and families (e.g., dream catcher); or from the families to the ICU staff (e.g., baked goods), project team (e.g., patient's art work), future patients (e.g., room decorations) or families (e.g., frames for word clouds); or from the community to current (e.g., birthday cake) or future patients (e.g., knitted blankets). The 3 Wishes Project facilitated family re-engagement with ICU, hospital and project staff, through scheduled, structured components of the project, and also through spontaneous postmortem communications and visits. While some family members found it difficult being back in the hospital, all described the returning experience as meaningful during the grieving process. Conclusions: Whether offered formally or informally, with or without therapeutic intent, continued connections with family members of deceased patients appear to be valued, supported by ICU clinicians and welcomed by families in grief. Introduction: Intermittent renal replacement therapy is associated with dialysisinduced acute myocardial injury, in both chronic 1 and acute 2 treatments. Continuous Renal Replacement Therapy (CRRT) is often favoured in critically ill patients with acute kidney injury (AKI), hypotension or shock. Lower ultrafiltration rates, characteristic of CRRT, reduce systemic hemodynamic stress and may be cardioprotective. We assessed the impact of CRRT on the development of acute segmental myocardial injury, in critically ill patients requiring dialysis for AKI. Objectives: To assess the impact of CRRT on global and segmental left-ventricular function in critical ill patients requring dialysis for AKI. Out hypothesis was that CRRT, with its charecteristically lower ultrafiltration rates, would not induce cardiac stunning (i.e. will be cardioprotective). Methods: We used 2D-echo and speckle tracking analysis software (EchoPAC, GE Healthcare) to measure global and segmental left-ventricular myocardial longitudinal strain in 12 critically ill patients presenting with AKI. Measurements were made at baseline immediately prior to and 4, 8 and 24 hours after initiation of CRRT. Results: Measurements were completed in 11 patients. 10/11 patients developed new regional wall motion abnormalities, with 8 developing these as early as 4 hours after CRRT start. The number of affected segments varied from 1 to 11 (out of 12). Of 11 patients, 7 (58%) died in the ICU, with 5 of those dying within 2 days of CRRT initiation. Conclusions: Our results show that CRRT is associated with new regional myocardial injury. This injury was associated with high mortality. These results are concerning with respect to the presumed safety of CRRT (compared to other dialysis modalities) in critically ill patients. Further direct comparison of CRRT with other dialysis modalities is warranted to assess the potential for relative cardioprotection. Introduction: Up to 12% of the 800 000 patients who undergo mechanical ventilation in the United States every year require tracheostomies. A recent systematic review conducted by Hosokawa et al showed that early tracheostomy was associated with better outcomes: more ventilator-free days, shorter ICU stays, less sedation and reduced long-term mortality. However, no cost-analysis on the timing of early tracheostomies have been conducted. Objectives: To conduct a cost-analysis on the timing of tracheostomy in mechanically ventilated patients Methods: We collected individual length of hospital stay and length of ICU stay data from the studies included in the systematic review from Hosokawa et al. We also searched for any recent randomized control trials on the topic that were published after this review. Average daily hospital and ICU costs per patients were obtained from a cost model by Kahn et al. We estimated hospital and ICU costs by multiplying LOS with respective average daily cost per patient. We calculated difference in costs by subtracting hospital costs, ICU costs and total direct variable costs from early tracheotomy to late tracheotomy. 95% confidence intervals were estimated using bootstrap re-sampling procedures with 1000 iterations. Results: The average weighted cost of ICU stay in patients with an early tracheostomy was $ 5 063 less when compared to patients with late tracheostomy (95% CI: 355 -9770, I 2 = 89.8%). This was calculated using a random effects model. A sensitivity analysis shows consistent cost reductions even with longer LOS in the early tracheostomy group. Subgroup analysis revealed that very early tracheostomies (less than 4 days) cost on average $4492 USD less than late tracheostomies (95% CI: -1309 -10294, I 2 = 94.1%) and that early tracheostomies (less than 10 days but greater than 4) cost on average $6385 USD less than late tracheostomies (95% CI: -4396 -17165, I 2 = 70.0%) Conclusion: This study shows that early tracheostomy can significantly reduce direct variable and likely total costs in the intensive care unit based on length of stay alone. This is in addition to the already shown benefits of early tracheostomy in terms of ventilator dependent days, reduced length of stays, decreased pain, and improved communication. Further prospective studies on this topic are needed to definitely prove the cost-effectiveness of early tracheostomy in the critically ill population. Introduction: Survivors of critical illness are at risk of developing long-term physical disability. Early rehabilitation interventions, such as in-bed cycling, may improve functional outcomes. Before embarking on a large randomized controlled trial (RCT) with mechanically ventilated patients, assessment of the feasibility of routine physiotherapy (PT) interventions plus early in-bed cycling (Cycling) versus routine PT alone (Routine) and development of monitoring strategies throughout the hospital stay are of key importance. Given the complex clinical environment, the vulnerability of critically ill patients, and the novelty of an intervention that is rare in present practice, the CYCLE Pilot RCT (NCT02377830) was designed to determine the feasibility of a future large trial. Objective: To itemize and characterize trial preparation and execution activities during the CYCLE Pilot RCT in participating Intensive Care Units (ICU) and the study Methods Centre. Methods: In 7 Canadian sites, we retrospectively reviewed timelines to study initiation (e.g., research ethics board (REB) approval, first enrolment), site activities (e.g., start-up visits, protocol education, intervention delivery, outcomes measurement), and additional preparatory activities by the Methods Centre. Data sources included regulatory and Methods Centre documentation (e.g., approvals, communications, meeting agendas, coordinator notes). We report descriptive statistics as counts and proportions, and medians and quartiles (Q1-Q3). Attendees reported completing more CCUS exams per week immediately postcourse and at long term follow-up, compared to pre-course, but the number of exams per week showed trends toward decline at long term follow-up, compared to post-course. Thirty-seven respondents (63.8%) reported they did not log their CCUS exams, but 79.3% would use one if they were provided a convenient option.

In considering ways to support CCUS skills post-course, attendees ranked possible solutions as follows: ongoing access to modules (75.9%), virtual attendance to ultrasound image review sessions at an academic hospital ICU (69%), ultrasound image review/quality assurance (65.5%), video conference with course faculty (39.7%). Conclusions: In our examination of participant outcomes following CCUS course attendance, we found that despite CCUS uptake increasing, the absence of ongoing supervision and mentorship imposes a problematic barrier for participants seeking proficiency with the modality. Based on survey results, significant opportunity for and interest in post-course educational support exists. Given limited access to expert support, efforts should focus on delivering virtual support via video conferenced access to course faculty, case review and quality assurance of images. Introduction: Current guidelines suggest that non-benzodiazepine sedatives are the preferred sedative agents in mechanically ventilated adults in the intensive care unit (ICU). Among those agents, it is uncertain whether dexmedetomidine is better than propofol for sedation in patients after cardiac surgery. Objective: We undertook a systematic review and meta-analysis of randomized controlled trials (RCTs) to examine the efficacy and safety of dexmedetomidine, compared to propofol, in adult patients after cardiac surgery. Methods: Two reviewers independently searched PubMed, Embase, OVID Medline, and the Cochrane Library up to January 31st, 2017. The same reviewers completed abstract screening, study selection, data abstraction, and risk of bias assessment using the Cochrane Collaboration's tool for assessing risk of bias. We used the GRADE approach to assess the quality of evidence. We included RCTs that enrolled adult post-cardiac surgery patients, comparing dexmedetomidine to propofol, and reported any of the following outcomes: delirium, duration of mechanical ventilation, ICU length of stay, opioid requirements, and mortality. We pooled the estimate of effects across studies using a random-effects model. The results were summarized as risk ratio (RR) for binary outcomes, and mean difference (MD) for continuous outcomes. There were no statistically significant differences in ICU length of stay, mortality, or incidence of atrial fibrillation between dexmedetomidine and propofol sedation regimens.

Conclusions: Moderate quality evidence revealed that dexmedetomidine reduces postoperative delirium, shortens the duration of mechanical ventilation, and lowers opioid requirements after cardiac surgery, but may increase the incidence of bradycardia and hypotension compared with propofol. 

Introduction: Pediatric diabetic ketoacidosis (DKA) is a common, life-threatening, metabolic emergency that can complicate type one diabetes mellitus (DM1). Many aspects of DKA emergency treatment are not supported by high-level evidence and few randomized controlled trials (RCTs) have been done in this population. Studying time-sensitive emergency interventions can be challenging due to the need to rapidly identify and enrol potential participants. We conducted a pilot study to explore feasibility considerations and inform planning of a future RCT. Objectives: Our primary objectives were to determine the feasibility of an RCT of children with DM1 and DKA based on: 1. Timely identification of eligible participants by the research team, 2. Ability to obtain consent for data collection. We also sought to evaluate a variety of study process feasibility metrics and to characterize current DKA treatment practices. 

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The presence of a bronchoscope through the endotracheal tube (ETT) increases peak inspiratory airway pressures. This is thought to be caused by an increase in airway resistance [1] [2] [3] . This may reduce minute-ventilation (MV) as ventilation stops being delivered once the ventilator inspiratory pressure limit is reached. Increasing inspiratory pressure limit during fiberoptic bronchoscopy (FOB) is a strategy used to help maintain MV. However, it is unclear if such strategy results in gas trapping and increased transpulmonary pressures. In the clinical setting, plateau pressures (Pplat) are commonly used to estimate transpulmonary pressures. Based on bench testing data, increasing inspiratory pressure limit preserve the MV with limited impact on Pplat in most circumstances 4, 5 . Whether increasing inspiratory pressure limit result in increased Pplat remains to be assessed in the clinical setting. Objectives: The aim of this study was to evaluate the impact of FOB on Pplat in patients ventilated in volume-controlled mode. We hypothesized that increasing inspiratory pressure limit during FOB would not significantly affect Pplat. Methods: We conducted a prospective cohort study of mechanically ventilated patients in the ICU of a tertiary center teaching hospital of both medical and surgical patients (CHU de Québec -Université Laval / Hôtel-Dieu de Québec). The study was approved by the local Research Ethic Board. The inclusion criteria were age ≥ 18 years and mechanically ventilated in a volume-controlled mode through an endotracheal or tracheotomy tube. The exclusion criterias were prior inclusion in the study, refusal by the treating physician, unavailability of the research team and Pplat ≥ 30 cm H2O before FOB. As standardized in our unit, the inspiratory pressure limit was increased up to 80 cmH2O during FOB. No other intervention was made. The primary outcome was variation of Pplat from baseline during FOB. We stratified by ETT size (≤7.5 or ≥ 8.0) as ETT tube size was found to affect MV and Pplat in our physiological bench study.To detect a minimally clinically significant difference of 3 cm H2O from baseline Pplat, and a difference of 5 cm H2O between ETT groups, a total of 36 patients were enrolled (18 in each ETT group). We assumed a standard deviation of 5 cmH2O around Pplat, a power of 80% and an alpha level of 0.05.The secondary outcomes were variations in peak airway pressure and PEEP, desaturations and clinical adverse events. All analysis will be conducted using SAS 9.4. Results: 34 patients have been included in the study as of April 2017. We expect to complete the study by May 2017. Results of our analysis will be presented. Conclusion: Our study questions the optimal ventilator settings to safely perform FOB in critically ill mechanically ventilated patients. It will provide evidence on whether Pplat increases or not when inspiratory pressure limit is increased. If Pplat increases, this would justify further investigation of its clinical consequences. It could also introduce the importance to monitor Pplat during FOB. If Pplat does not increase, this would support the hypothesis of increased peak airway pressures 1 3 43 induced mainly by increased airway resistance. This would support the practice to increase inspiratory pressure limit as a safe and simple measure to optimize MV during FOB. Introduction: Sepsis is challenging to identify, particularly in those patients that present in the early stages of infection (early presenters). Early recognition reduces the time to treatment, which ultimately saves lives. In 2016, new Sepsis-3 criteria, specifically qSOFA (quick Sepsis-related Organ Failure Assessment) were identified. It is unknown how frontline Registered Nurses (RNs) working in the Emergency Department (ED) are operationalizing these new criteria. Objective: We sought to understand how RNs in the ED use the new Sepsis-3 criteria and their clinical experience to identify patients with suspected infection or sepsis, requiring timely treatment. Methods: To understand RNs' operationalization of sepsis, including the new Sepsis-3 criteria, a 7-item survey was developed and distributed to all RNs at the Hamilton General Hospital; an urban tertiary-care ED. During phase 1 the questionnaire was piloted with a convenience sample of 7 RNs in which feedback was obtained on sentence structure to 6 questions. Phase 2 tested for clinical sensibility of the questionnaire, a convenience sample of 7 respondents provided feedback using a 5-point Likert scale. The clinical sensibility testing covered several domains: appropriateness, redundancy, and survey completion time. We invited feedback on education around the new Sepsis-3 criteria and preferred learning strategy. Phase 3 included distribution of the final survey using paper versions and electronically via SurveyMonkey®. Respondents were asked to provide demographic data: sex, education, and clinical experience. Results: The survey was distributed to 79 ED RNs, of which 50 (63%) completed the survey. The average time to completion was 3.8 minutes. Respondents identified hypotension (64.0%), heart rate (58.0%), and temperature (54.0%) as the best characteristics to identify patients with suspected sepsis. Using a Likert scale, 48 (96%) respondents scored an average of 4.3 out of 5 for their level of confidence with early recognition of patients with sepsis. Despite the new Sepsis-3 criteria published 1 year ago, 33 (66.0%) respondents were not familiar with qSOFA, 13 (26.0%) were aware it existed but had not been educated on it, 4 (8.0%) were familiar with the criteria but relied on other variables to identify septic patients, and none claimed to have thorough understanding of the qSOFA criterion for sepsis. The majority (82%) of respondents agreed that the Sepsis-3 criteria is effective in identifying patients with potential sepsis, and a medical directive should be available for RNs to identify and initiate treatment of septic patients or those at risk. Conclusion: We have identified a knowledge gap in nursing understanding of the new Sepsis-3 criteria. In this cohort of ED nurses, hypotension was identified as the number one indicator for sepsis patients, thus matching 1 of the 3-qSOFA criteria. Respondents identified an interest in learning about Sepsis-3 and qSOFA via a variety of educational modes. Furthermore, ED nurses support the use of a medical directive in suspected septic patients. A larger study of Emergency Department nurses to yield further information and impact on practice is recommended. Background: Reducing hospital harm is an important patient safety goal. Unexpected ICU admissions from the ward are high morbidity, high cost events that are important to examine to improve patient safety. The objective of this study is to describe opportunities to improve care by characterizing the cause and timeline of unexpected ICU admissions from the ward in an academic, integrated, healthcare system. Methods: We conducted a retrospective study of a consecutive cohort of patients admitted to eight general medical and surgical wards at two academic hospitals from January to June 2014. A team of trained reviewers abstracted charts for demographic data, co-morbid status, ward admission diagnosis, ICU admission diagnosis, ICU and hospital length of stay, unexpected ICU transfer, and death. Patients unexpectedly admitted to the ICU from the ward were included in the analysis. Patients admitted for routine post-operative monitoring were excluded unless the reason for surgery was unexpected. Two reviewers coded the diagnoses independently, met to compare coding and reviewed discrepancies as a team until agreement was reached. We described the cause and timeline of unexpected ICU admissions from the ward and compared the diagnosis leading to ICU admission with the diagnosis at ward admission. Results: We analyzed 164 unexpected ICU admissions from 7130 total ward admissions. There were 23.0 unexpected ICU admissions / 1000 ward admissions. The three most common diagnostic conditions associated with unexpected ICU admission from the ward were, infection (22.6%), respiratory failure (18.3%), and CHF (9.1%). 71.5% of infections associated with ICU admissions were not noted at the time of ward admission. We found that 50.6% of unexpected ICU admissions occurred within 3 days of ward admission, and 82.9% of ICU admissions occurred within 8 days. Conclusion: Common reasons for unexpected ICU admission from the ward are infection, respiratory failure and CHF. The majority of infections leading to ICU admission are diagnosed after hospitalization. Unexpected ICU admissions typically occur within a week of hospitalization with half occurring within the first 3 days of hospitalization. Strategies to reduce the risk of unexpected ICU admission should focus on early prevention and management of infection, respiratory failure and CHF. Healthcare Hamilton ICU, a 21-bed medical-surgical tertiary care unit. Patients and families were invited to participate after a decision was made to withdraw advanced life support or after the intensivist estimated that the probability of dying in the ICU was > 95%. Patients were excluded if they were in the ICU for less than <12 hours. A project team member or bedside clinician elicited and implemented at least 3 wishes of the patient, family or clinicians that honoured the patient and family. From the original 5 wish categories, in triplicate, 3 investigators interpreted and reclassified 1376 wishes into a new taxonomy of 12 categories (connections, providing food and beverage, humanizing the environment, humanizing the patient, music, family care, rituals and spiritual support, preparations and final arrangements, word clouds, keepsakes and tributes, organ donation and paying it forward). We calculated the percentage of each wish category and analyzed the distribution of wish categories annually. Introduction: Physician's estimate of the prognosis of patients' is essential to shared decision making in the intensive care unit (ICU). The variables influencing these judgments are not well understood. Objectives: The aim of this study is to determine which individual physician and patient characteristics influence physician´s predictions of patient's mortality at 6 months. Additionally, we explored which of these factors are associated with the confidence of the predictions. Methods: Secondary analysis of a prospective cohort study that evaluated how well ICU physicians predicted patients' long-term outcomes. Recruitment occurred from October 2013 to May 2014 in 5 ICUs in the University of Pennsylvania. Patients were included if they required mechanical ventilation > 48 hours, vasopressors >24 hours, or both. ICU attending physicians were asked to predict whether patients were expected to live or die in 6-months, and to report their confidence in these predictions. Using univariate and multivariable logistic regression, we assessed the association between baseline physician and patient characteristics with study outcomes: 6-month mortality prediction (yes/no) and confidence of the prediction (yes/no). We graphically explored the linear association between continuous predictors and outcomes. We calculated c statistics for each logistic regression model and goodness of fit was measured using Hosmer Lemeshow. Results: Of 340 eligible patients, 303 were enrolled. Forty-seven physicians contributed at least one prediction per patient. Patient's median age was 62 years old (IQR 53-71) and 57% (N=157) were male. Physicians median age was 41 (IQR 38-53) and 80% (N=37) were male. Mortality at 6 months was predicted for 33% (N=99), of which 43% (N=130) died. The final multivariable model (Table 2 ) explaining physicians' predictions of mortality included patient's age (OR 1.03; 95%CI 1.01-1.05), the presence of malignancy (OR 2.70; 1.54-4.74); medical (vs. surgical patients) (OR 5.87; 95%CI 2.70-12.7) and patient's APACHE score (OR 1.02; 95%CI 1.01-1.02). This model deemed good discrimination (C statistic=0.77; 95% CI 0.72-0.83) and calibration (difference between expected and observed p value=0.87). The same variables were also associated with patient's actual mortality at 6 months (Table 3 ). Physician's age (OR 0.93; 95% CI 0.90-0.96), physician's male gender (OR 0.53; 95% CI 0.32-0.88) and years since graduation (OR 0.94; 95% CI 0.91-0.97) were associated lower confidence of the prediction (Table 3) . A higher APACHE score was also associated with lower confidence (OR 0.99; 95% CI 0.98-0.99). Conclusion: Physician and patient factors are associated with predictions of mortality and patient's actual mortality at 6 months. These include patient age, presence of malignancy, being a medical patient and severity of illness. Physician age, being male, years of experience and severity of illness were inversely associated with confidence in these predictions. This information should be considered when physicians reflect on how they make predictions for critically ill patients. Introduction: Long-term cognitive dysfunction is common in ICU survivors (1). Its temporal course remains unclear, impeding identification of appropriate time windows for therapeutic target discovery and interventions. This is partly due to lack of neurocognitive tests that are comprehensive, easy to administer and do not require presence of trained personnel. Cambridge Brain Sciences (CBS) is a validated web-based neurocognitive test battery previously used in large cohort studies, can be self-administered by patients, and allows testing frequencies not feasible with standard paper-based methods, making it an attractive method for objectively quantifying ICU-related cognitive dysfunction. However, CBS has never been evaluated in ICU patients. Objectives: To determine the feasibility of using web-based neurocognitive battery for assessment of cognitive function in ICU survivors. Methods: We recruited adult (age ≥ 18 years), non-delirious patients who were intubated for a minimum of 24 hours from two ICUs in London, Ontario. Patients with a documented history of dementia or neurological diseases were excluded. Demographic and clinical variables were recorded from medical records. Patients completed at least one CBS battery in the ICU, or shortly after discharge from ICU. Patients were considered impaired on a cognitive test if they scored > 2 standard deviations (SD) below the healthy population norms corrected for age and sex. Feasibility issues associated with web-based cognitive testing in ICU patients were recorded. Results: Of 44 patients approached, 21 underwent cognitive testing and 18 (6 females) were included in the analysis, with 15 of these completing the full 12-test battery. Median age was 62 years (SD 13.2), NEMS score 18 (SD 5.6), and ICU length of stay 5 days (SD 5.0). Twelve patients were tested in the ICU and 6 were tested within 1-4 days of transfer to ward. Fifteen of 18 patients were impaired on at least one test, with the median impairment of 2 tests (range 0-8). Feasibility issues with CBS included: unclear test interface (difficulty focusing on the appropriate part of computer monitor); patient fatigue due to battery length (with 3 of 18 completing partial battery only); complex test instructions; lack of progress feedback; test sounds disturbing other patients in shared rooms; and patient inexperience with using a computer mouse. Conclusion: Web-based cognitive testing is feasible in ICU patients. Feasibility issues need to be addressed in order to optimize this form of testing in ICU survivors. Our results will inform modification of a web-based battery for ICU needs, and help with the design of future observational studies. Introduction: Frailty is an increasingly recognized phenomenon in the healthcare of older-adults. Patient mobility is an important and well-recognized marker of clinical frailty 1 . Early mobilization in the intensive care unit (ICU) improves patient outcomes 2, 3 . Changes in mobility of individuals who are acutely unwell is under studied and has important implications on recovery and prognosis. Objectives: To investigate patient mobility as a clinical predictor in a critically ill older-adult patient population. Specifically, to investigate whether severity of illness at time of ICU admission is predictive of mobility performance and to assess whether changes in patient mobility correlate with in-hospital mortality. Methods: A single center prospective cohort study involving critically ill patients aged 65 and older admitted to the QEII's medical-surgical ICU. APACHE II scores were calculated at time of ICU admission to stratify critical illness severity. Physiotherapists integrated the HABAM into routine daily mobility assessments in the ICU. Additional items relevant to mobility in the ICU were added to the HABAM based on interdisciplinary team consensus -creating a modified CritCare-HABAM. Patient descriptive and changes in patient mobility up to four days in ICU were analyzed against in-hospital mortality using univariate regression analysis. Changes in patient mobility were also analyzed according to admission APACHE II score. This represents the first participants enrolled and completed hospitalization. Enrolment is ongoing. Results: A total of 38 patients were recruited and 34 were mobilized at least two days in ICU. Average APACHE II score was 23.3 (SD 6.57). Ten participants (26%) died in hospital. The CritCare-HABAM predicted in hospital mortality if there was a failure to improve in any of the three mobility domains or two-out-of-three domains (p=0.023 and p=0.039, respectively) whereas if there was failure to improve in any of the three mobility domains of the HABAM, there was a trend for significance (p=0.059). Neither increased severity of critical illness (APACHE II > 23) nor frailty (Clinical Frailty Scale > 4) were associated with decreased mobility performance (p=0.19).

The HABAM can be used in the ICU and changes in mobility predict in hospital death.

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The debate over what maintenance intravenous (IV) solution is the most appropriate for children has been ongoing for decades (1) . Hypotonic fluids were the preferred choice for hospitalized pediatric patients (2) . However, recent evidence has demonstrated that hypotonic fluids increase the risk of iatrogenic hyponatremia, its associated morbidities, and mortality (3) (4) (5) (6) . In contrast, isotonic fluids reduce the risk of hyponatremia (3) (4) (5) (6) and are thus the currently recommended fluid of choice for maintenance IV fluids in children. However, it is unclear whether this has translated into clinical practice. Further, isotonic fluids may be associated with hyperchloremic metabolic acidosis (HCMA), which itself may be associated with increased morbidity and mortality (7) (8) (9) (10) (11) (12) . Objectives: In critically ill pediatric patients admitted to the Pediatric Intensive Care Units (PICU), we sought to evaluate: 1 IV maintenance fluid prescription practice patterns 2 The incidence of iatrogenic hyperchloremia and HCMA, as well as associated morbidities 3 Predictors of HCMA in critically ill children

Children's Hospitals. All patients aged under 18 years admitted between January 1st, 2015 -January 31st, 2016, who received at least 50% of their maintenance fluid requirements parenterally, were included. The primary outcome was IV maintenance fluid prescription practices in the first 72 hours of admission. Secondary outcomes included the incidence of iatrogenic hyperchloremia and of HCMA in the first 72 hours of admission, predictors of iatrogenic HCMA, and the association between HCMA and clinical outcomes. We calculated that a sample size of 700 patients would enable us to achieve our primary and secondary outcomes. Descriptive analyses were used to present demographic data and the primary outcome, and regression analyses were used to evaluate the predictors of HCMA. Results: Of 771 patients admitted between January 1 st , 2015 -January 31 st , 2016, 541 were eligible. The median age was 69 months and 56% were males. 400 (74%) were medical patients and 141 (26%) were surgical patients. Normal Saline was the most commonly prescribed solution for IV maintenance over the first 72h of admission, followed by Ringer's Lactate, and hypotonic solutions (Figure 1 ; 74.1%, 23.4%, and 2.5%, respectively). Ringer's Lactate prescriptions increased while normal saline prescriptions decreased over time, in parallel to the daily prevalence of hyperchloremia. The incidence of hyperchloremia and HCMA over the first 72h of admission was 93.8% and 34.9%, respectively. Ongoing analyses will determine predictors of HCMA and their potential association with adverse events. Conclusion: Isotonic solutions comprised the overwhelming majority of IV maintenance fluid prescriptions, while balanced salt solutions are not used in these centers. Ringer's lactate use increased over the first 72h in response to increasing hyperchloremia. Iatrogenic hyperchloremia and HCMA appears to be extremely common in PICUs, observed here at a rate much higher than that reported in critically ill adults. The results of this study will provide a rationale to evaluate what type of isotonic solutions may be more appropriate in critically ill children, in order to minimize IV fluid associated morbidities. (1), however the relationship between physical function at ICU discharge and more proximal outcomes is unknown. The Physical Function ICU Test-scored (PFIT-s) is a reliable and valid measure of function in patients with critical illness. It includes 4 items (shoulder and knee extensor strength, amount of assistance required to stand, stepping cadence), and scores range from 0 to 10, with higher scores reflecting better function.(2, 3) While studies from Australia(4) and the United States(5) identified positive relationships between higher PFIT-s scores and better hospital discharge disposition, the generalizability of these findings in Canada are unknown.

Objectives: To predict the relationship between PFIT-s scores at ICU discharge and outcomes at hospital discharge in a cohort of Canadian ICU survivors.

Methods: This is a secondary analysis of 2 studies from the CYCLE Research Program: TryCYCLE (NCT01885442), a single-centre, 33-patient prospective cohort study of early in-bed cycling (6) , and CYCLE Pilot (NCT02377830), a 7-centre, 66 patient RCT of early in-bed cycling and routine physiotherapy interventions versus routine physiotherapy interventions alone (7) . Both of these studies included adult patients within the first 4 days of mechanical ventilation and first 7 days of ICU admission who could ambulate independently pre-hospital with or without a gait aid, and had no other exclusions. At ICU discharge, trained physiotherapists collected the PFIT-s. We prospectively identified whether ICU survivors with PFIT scores met any of 3 conditions comprising a composite outcome of poor health status at hospital discharge: 1) mortality, 2) readmission to ICU, or 3) discharge requiring paid assistance (e.g., home care, rehabilitation, assisted living, etc. 40%. This analysis underscores the prognostic value of physical functional disability after ICU discharge and its potential use predicting poor health status at hospital discharge. These findings may be useful in the evaluation of rehabilitation interventions designed to optimize patients' function and independence after hospitalization. Introduction: Viral bronchiolitis is one of the most prevalent causes of illness requiring hospitalization among children worldwide 1 and one of the most common reasons for admission to pediatric intensive care. It has been hypothesized that coinfection with bacteria results in more severe clinical outcomes. However, the effects of bacterial colonization, affecting upwards of 15% of healthy children 2 , on critically ill patients with bronchiolitis have yet to be proven. Current clinical management consists primarily of supportive therapies with the role of antibiotics remaining controversial. 3 Objectives/Methods: A retrospective review of all critically ill children admitted to the BC Children's Hospital Pediatric Intensive Care Unit (PICU) from 2014-2017 with a diagnosis of bronchiolitis was performed. Routine testing in this timeframe consisted of complete pathogen testing, including PCR for Streptococcus pneumoniae. Analyses were performed to determine the impact of bacterial colonization and antibiotic use on a primary outcome of PICU length-of-stay, with secondary outcomes of hospital stay and duration of ventilation. Results: There were 92 patients with complete pathogen testing performed during the assessed timeframe. A comparison between children with detected Streptococcus pneumoniae (n=22) and those without (n=70) revealed no significant (p=0.20) differences in severity of illness on presentation as per PRISM III scores (mean=3.0). Patients colonized with S. pneumoniae had significantly shorter PICU stays (p=0.002), hospital stays (p=0.0001) and duration of non-invasive ventilation (p=0.002). Multivariate analyses reveals that these effects on length of PICU stay and duration of ventilation do not persist after controlling for antibiotic use, presence of radiographic consolidation, age, and severity of illness (p=0.15, p=0.32). The relationship between colonization and duration of hospital stay persists after controlling for these variables (p=0.008). Conclusions: Children with viral bronchiolitis colonized with S. pneumoniae appear to have shorter hospital stays but similar length of PICU stays and duration of ventilation compared to children who are not colonized. Consistent with current literature 4 , the results of this study suggest bacterial colonization is not associated with increased severity of presenting illness or negative clinical outcomes. Introduction: Critically ill patients that require intubation are at high risk of hypoxia and cardiovascular instability. One in 4 major adverse airway events occur in the intensive care unit or emergency department. Timely and effective communication among team members is crucial during this high-risk procedure. Evidence from military and pre-hospital medicine has shown that standardized checklists limit human error and improve team communication and patient safety. The aim of this project was to implement the use of a team time-out with the communication of an intubation plan and team member concerns and increase the use of these tools to up to 80% in ICU intubations.

The study was conducted in medical-surgical intensive care units at two academic hospitals in Toronto. We identified current deficits in team communication by engaging stakeholders involved in intubations. We surveyed ICU nurses, physicians, and respiratory therapists to understand the perception of team efficacy in communication, equipment preparation, and patient safety and monitoring. We also audited ICU intubations to identify whether intubation plan, airway assessment, team concerns, and team member roles were verbalized prior to conducting the procedure. We used the survey and audit data to design and implement a preintubation communication tool. The implementation process involved 1) education sessions with physicians, respiratory therapists, and nurses, and 2) printed reminders in the ICU and intubation equipment cart. Results: Three main deficits in pre-intubation communication were identified. In the observed intubations, only 40% included team time outs, 70% had intubation plans verbalized, and 50% had team member concerns addressed. Fewer than 50% of survey respondents felt that any of these areas were consistently communicated during intubations. The final communication tool contained 6 components: 1) team time out, 2) indication for intubation, 3) team member roles, 4) equipment readiness, 5) intubation plan, and 6) final concerns. A post implementation audit and stakeholder survey is in progress. Conclusion: Intubation in critically ill patients is a high-risk procedure. Our assessment of current intubation practice identifies deficits in team communication that have potential impact on team member preparation and patient safety. We have implemented a bedside tool consisting of six key items. Educational sessions were provided to staff to understand and use the tool. We will be surveying the staff about usefulness of the tool and we are currently considering venues for further dissemination like inter-professional rounds, in situ simulation.

Gomaa, Abdul-Rahman 1 ; Wilkinson, Jonathan 1 1 Northampton General Hospital, Northampton, Northamptonshire, UK Introduction: Intravenous (IV) fluids are some of the most commonly prescribed day-to-day drugs. They have their indications, benefits, side-effects and complications. Evidence suggests that such prescriptions are rarely ever done correctly despite the presence of clear guidelines [1, 2] . This is thought to be due to lack of knowledge and experience, placing patients at increased risk of harm, also incurring unnecessary costs to the hospital. Objective: To ensure that all IV fluid prescriptions are safe, appropriate and adhere to NICE guidance by August 2017. Methods: Review and improve the prescribing process of "IV fluid prescribing" via three simultaneous approaches (figure 1). Teaching sessions were delivered to all junior doctors in order to improve knowledge and awareness of appropriate IV fluid prescribing and promote familiarity with the current NICE IV fluid guidelines. This included a 'feature session' at our local hospital Grand Round. A point-of-care aide-memoire containing a summary of the information needed for correct prescription was designed and printed. This complimented the teaching sessions and supported good clinical practice. Using serial Plan-Do-Study-Act (PDSA) cycles, a novel "IV fluid bundle" (figure 2) was developed, fine-tuned and trialled on five wards, (three surgical, two medical). The aim of the bundle was to ensure that patients were clinically reviewed in order to assess their volaemic status in order that appropriate IV fluids could then be selected and prescribed safely. Results: The impact of these interventions was assessed on the trial wards via a weekly point prevalence audit of the IV fluid bundles for the duration of the trial. Parameters looked at were: incidence of deranged U&E's, incidence of AKI and the number of days between the latest U&E's and the patient's IV fluid prescription. With only a 50% uptake we were able to significantly improve outcomes. Of all of the patients on the IV fluid bundle, 100% had a documented review of both fluid status and balance. The incidence of deranged U&E's decreased from 48% to 35%. Incidence of AKI decreased 14% to 10%. The average number of days between the latest U&E's and a fluid prescription decreased from 2.2 days to 1.0 day. Conclusion: Prescribing IV fluids is a complex task. It is an area of clinical practice that requires significant improvement both locally and nationally. The project included carefully structured interventions geared towards tackling the confounding issues (education, awareness and organisational systems) identified from previous audits and process mapping. Changing prescribing habits is an extremely challenging goal for many reasons. The introduction of a change that incorporates something clear and simple has a minimal effect on compliance. The design of a simple IV fluid bundle ensured minimal interference. Since commencing the project, we have seen an improvement in the knowledge base around IV fluid safety. We have also noticed a clear improvement in the prescription of IV fluids in our trust. Even though only a small representative sample of wards were selected for the fluid bundle trial, feedback was highly positive and reports were that the bundle was a help, not a hindrance. We anticipate that further improvements will be achieved once the bundle has been incorporated into the hospital's electronic prescribing system eliminating confusion 1 3

Sampaio, Tatiana Z.A.L. 1 Introduction: Sedation and analgesia are used to manage ventilated pediatric patients comfortably and safely. However, over-sedation can cause complications including prolonged mechanical ventilation [1] and Iatrogenic Withdrawal Syndrome (IWS). [2] Under-sedation puts patients at risk for unplanned extubation and agitation [3] . The use of standardized sedation and analgesia assessments can reduce under and over-sedation. [4] In our center, the protocol for sedation and analgesia titration relies on set targets for: State Behavioral Scale (SBS) [5] and Comfort B scale (CBS) [6] , respectively. The way targets are ordered and met will affect quality of care. This project was part of a large initiative to decrease IWS incidence in our unit. Objectives: (1) To determine the frequency of over-sedation, under-sedation and pain in pediatric patients intubated for longer than 5 days (2) to identify how the targets for SBS and CBS are ordered and how frequently.

Methods: This quality assurance project utilized data from a retrospective chart review that included patients intubated and ventilated for 5 or more days aged from birth to 18 years old from February 2015 to January 2016. Patients with a tracheostomy, ECMO, hemodialysis, and patients that died before sedation wean were excluded. Presence of under-sedation (US) was defined by SBS>0, presence of over-sedation (OS) was defined as SBS<-1 and presence of pain as CBS > 17 [4] . The targets for sedation and analgesia were collected daily and categorized as first order set, second order set, third order set and fourth order set. Results: 45 patients were included. The median age was 23 months (IQR 3.5-138), 40% of patients had a respiratory illness, 42% had a pre-existing condition, their PELOD-2 [7] score median was 5 (IQR: 4, 7). All but 1 patient experienced OS in some point of their time ventilated. Only 4 patients did not experience US or pain during the days that they were ventilated. Figure 1 shows the percentage of patients that experienced over-sedation or under-sedation per days after intubation. A total of 454 ventilation days were analyzed in this chart review 252 (55.5%) there was documented over-sedation,181(39.9%) under-sedation and 165 (36.3%) pain. 93.3% of patients had at least one set of SBS and MCS targets ordered, 77.8% in the first day of admission, and 60% had targets orders reviewed once. Table 1 attached is showing the targets of SBS and CBS ordered ranging from-1 to -2 and 8 to 14 respectively. Conclusions: This study showed that patients in our institution were frequently over-sedated, reflecting targets that were ordered in lower ranges than those recommended by literature [4] , which enabled over-sedation. MD orders of sedation and analgesia were identified as a root cause for over-sedation and consequently IWS. Simple and easy changes in documentation and daily bedside safety checklist were established in order to optimize use of sedation and analgesia and decrease complications related to over and under-sedation. 

We performed an electronic search using MEDLINE, EMBASE, CINAHL, the Cochrane Library, PROSPERO and the Joanna Briggs Institute EBP databases (Jan 1980 to Sept 2016) using keywords and MeSH terms to identify Englishlanguage publications describing the use of invasive or non-invasive MV in pregnant women. We excluded case reports and case series reporting less than 5 women published earlier than 2002 due to publication of evidence of the benefit of lung protective ventilation. Reference lists of included articles were manually searched. Two authors independently performed title and full text screening, and data extraction. Results: We retrieved 5034 studies and included 74 articles for data extraction and analysis. We found 44 case reports, 29 case series, and one case control study describing a median of 1 (IQR 1-10.75) women per study (total 924 women). Acute respiratory distress syndrome was the most common reason for ventilation (46 studies, 62%), most commonly due to influenza (26/46 studies, 57%)). Other frequent indications were status asthmaticus, pneumonia, and pulmonary edema. Overall maternal mortality was 21%. Non-invasive ventilation (NIV) (bi-level and continuous positive pressure ventilation) was used in 19 studies (24%) for 127 women. NIV failure, defined as need to provide invasive MV was required for 58/127 women (46%). Invasive ventilation was provided to 842 women in 70 studies (95%). Ventilator parameters were specified in 62% of studies. Most frequently reported modes were volume (184 women) and pressure control ventilation (11 women). Nonconventional modes such as airway pressure release ventilation were also used (7 women). When described, tidal volumes ranged from 5 to 10 ml/kg; positive endexpiratory pressure (PEEP) from 5 to 32cm H 2 O. Few descriptions of inspiratory peak or plateau airway pressures were provided. Adjunctive respiratory therapies were described in 43 studies (58%). Most frequently used were neuromuscular blocking agents (44 women); tracheostomy (33 women); venovenous extracorporeal membrane oxygenation (32 women); inhaled vasodilators (20 women); prone positioning (19 women); and high frequency oscillatory ventilation (11 women). Other therapies infrequently described were recruitment maneuvers and tracheal gas insufflation. A total of 323 deliveries were described including 134 (41%) during MV of which 106 (79%) were delivered by caesarean section. The impact of delivery on respiratory function was rarely reported. , are among the most susceptible to harm, and also account for significant resource utilization. Given this, a strategy to optimize health care provider performance is required. Performance scorecards have been utilized by healthcare institutions for the purposes of monitoring clinical performance and driving quality improvement. Unfortunately, most scorecards use overall outcomes that are hard to attribute to an individual. Furthermore, individuals will often tailor their practice to optimize scorecard variables (so-called "gaming"), instead of patient-centred care. While scorecards have been introduced in CCM to monitor safety, there is no widely-accepted or standardized scorecard that has been utilized for overall CCM performance. Objectives: We aim to improve quality of care, patient safety, and patient and family experience in CCM practice through the utilization of a standardized, repeatable and multidimensional performance scorecard, designed to provide a continuous review of ICU physician and nurse practice, as well as departmental metrics.

This will be a mixed-methods, controlled before and after study to assess the impact of a multidisciplinary clinical quality scorecard (specifically designed for CCM). Scorecard metrics were developed through expert consensus and existing literature. Attempts have been made to address "gaming" actions by incorporating multiple, opposing measures (so-called "Balanced Composites"). The study will include 19 attending CCM physicians and approximately 300 CCM nurses. Patient data for scorecard compilation is collected daily from patient bedside flow sheets. Pre-intervention baseline data will be collected for 6 months for each participant. After this, each participant will meet with the Department Head or Nursing Coordinator, at which time they will receive their individualized scorecard measures. Following a 3-month washout period, postintervention data will be collected for 6 months. The primary outcome will be change in performance metrics (including mortality, ICU length of stay, sedation, pain management, mobility, etc) following the provision of scorecard feedback to subjects. A cost analysis will also be performed. The qualitative portion will include interviews with participants once the intervention phase has been completed. Interviews will be analyzed in order to identify recurrent themes and subthemes, for the purposes of driving scorecard improvement.

The study protocol has been approved by the local research ethics board. Publication of the study results is anticipated in 2018 or 2019. If this intervention is found to improve patient and unit-directed outcomes, with evidence of cost-effectiveness, it would support the utilization of such a scorecard as a quality standard in CCM.

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Tremblay, Jan-Alexis, MD Introduction: In patients with acute right ventricular (RV) failure, decreasing RV afterload by administering inhaled vasodilators represents an interesting therapeutic approach, which has for now only been described in conjunction with endotracheal intubation [1] [2] [3] [4] , whereas positive pressure mechanical ventilation and sedation can both be hemodynamically deleterious in such patients 5 .

Objectives: We aimed to assess the hemodynamic effects of non-invasively administering inhaled nitric oxide (iNO) in critically ill patients with acute RV failure, as well as demonstrate the feasibility and explore the safety profile of this approach. Methods: This is a retrospective cohort study in which we evaluated the clinical course of all hemodynamically unstable patients with RV failure in whom iNO was initiated without intubation and mechanical ventilation in the intensive care unit (ICU) of our two centers between 2013 and 2017. The primary outcome was modifications in RV function parameters after starting iNO, and secondary outcomes included ICU length of stay, mortality, and occurrence of specific side effects (acute kidney injury as per the RIFLE 6 definition, significant bleeding prompting clinical intervention and persistent headache in the patient or nursing staff). Results: 18 patients were included in the analysis, 12 (67%) received iNO after cardiac surgery (mean EuroscoreII 19 ± 14) and 6 (33%) received iNO in a nonsurgical context. Median [Q1; Q3] iNO concentration was 20 [20; 20] ((systolic PAP -diastolic PAP)/CVP) increased from 1.45 to 2.24 (P=0.002), as did the indexed cardiac output from 2.0 to 2.6 l/min/m 2 (P=0.004). These rapid hemodynamic changes were not associated with significant modifications of vasopressor and inotrope doses. ICU mortality was 27.78% and median ICU length of stay was 7 [5; 9] days. Two significant bleeding episodes and one acute kidney injury occurred during iNO therapy but none was felt to be attributable to iNO. No headache was reported by the patients or nursing staff. Conclusion: Non-invasively administered iNO was associated with favourable hemodynamic effects in ICU patients with acute RV failure. This is the first report regarding such a therapeutic approach for these clinically challenging patients. Our results suggest the safety and feasibility of this therapy for which further prospective study is warranted. Introduction: Thoraco abdominal aneurysm repair is a complex vascular surgery with high post-operative morbidity and mortality. The patient in this case report was diagnosed as a case of thoraco-abdominal anuerysm on CT angiogram. Case report:

A 56 year old gentleman, ASA IV, presented for repair of De Bakey type III, dissected thoraco-abdominal aortic aneurysm. preoperative investigations were normal. Anaesthesia was induced with Midazolem, Etomidate, Fentanyl and Rocuronium after applying the standard monitoring. Before induction lumbar drain was inserted and the transduced pressure was 13 mm Hg. a left radial arterial line was placed. A left sided double lumen tube of size 37 was tried initially but due to compression of left main bronchus by the aneurysm the tube was placed on the right side .After two attempts an ETT size 8.5 was passed with a bronchial blocker. central venous and swans ganz catheter were inserted. One lung ventilation was established. Anaesthesia was maintained with 40% oxygen and Isoflurane (0.9-1.3). A total of 1000 micrograms of fentanyl was administered throughout the case. A TEE probe was placed for monitoring of left ventricular function. The patient was heparinized; common femoral artery and vein were cannulated and then cooled to 20⁰C. In the process. The aneurysm was then opened longitudinally. A 28mm Vascutek Dacron was anastomosed end to end. The operative findings revealed a very large dissecting aneurysm starting flush with left subclavian artery. The CSF pressure was continuously monitored during the procedure and CSF was passively drained when the pressure exceeds 13 mm Hg. During the case 10-20 mls of CSF was drained to maintain the pressure between 9-13 mm Hg. The patient was then shifted to CICU where he kept ventilated. He was then weaned from ventilator and extubated on fourth post op day but was reintubated on sixth post op day for drowsiness due to raised serum ammonia levels. Gradually the GCS restored to 10/10. Afterwards the patient had sepsis, acute kidney injury and ventilator associated pneumonia. Blood cultures were positive for carbapenem resistant Klebsiella pneumoniae. Tracheal cultures revealed acinetobacter. Antibiotics were started after taking ID on board. Tracheostomy with insertion of PEG was performed for prolong ventilation. Finally the patient was weaned off from ventilator and discharged home after approximately two and a half months. Conclusion: We presented a patient who underwent extent II TAAA repair, using permissive hypothermia, LHB, CSF drainage, and cold crystalloid renal perfusion. This technique offers the potential benefit of providing protection against brain, cardiac, renal, visceral, and spinal dysfunction without having to use adjuncts such as LHB, CSF drainage, selective perfusion of renal and visceral arteries, regional spinal cooling, or sequential aortic clamping.

Mailman, Jonathan F. 1 Table 1) A team of pharmacists shared ICU coverage in 77% of cases. Within those teams, 30% of staff have advanced training with either a Postbaccalaureate Doctor of Pharmacy (PharmD) or Masters degree, and 39% of organizations require an entry-to-practice degree and some on-the-job training as a minimum to practice in Critical Care. Advanced-degree training found more commonly in Vancouver and Toronto, where the Faculties of Pharmacy have offered PharmD degrees for more than a decade. Patient care rounds are completed in a standardized fashion in 55% of centres, with another 11% of centers reporting a similar format determined by the Attending Physicians. (Table 2 ) Within rounds, the Pharmacist has an allotted time to present in 52% of critical care units, with the remainder either expected to support and comment on presentations from other members of the team or as agreed upon with the Attending Physician. Clinical Pharmacists provide 8 hour/day coverage in 92% of centres, five days a week in 84%, with 4 hours (range 3-8) devoted to rounding. During rounds, pharmacists describe their contribution as most commonly reviewing current medications; adjusting medication dosing for organ dysfunction; reviewing antimicrobial therapy; providing therapeutic drug monitoring; and ensuring appropriate prophylaxis for stress ulcers, venous thromboembolism, and ventilator associated pneumonia. Pharmacists report using a checklist 33% of the time to prepare for rounds. A standardized patient monitoring form is used at 55% of sites and 80% of pharmacist documentation occurs outside the legal record on pharmacy documentation records. Pharmacists indicate that the majority of their suggestions/interventions on rounds are included in the Physician's Progress notes in 87% of centres. Supplementation of the physician progress notes occurs in 56% of centres when the Pharmacist determines greater detail is required or if the pharmacist's recommendation is discordant with the decision from rounds. Conclusion: Pharmacists' practice in critical care is variable in Canada. Higher credentialing is found in areas where a post baccalaureate PharmD program has been in existence for greater than 10 years. Documentation of interventions largely 1 3 90 occurs within the physicians progress note and the majority of pharmacist documentation occurs outside of the legal record. 

Pleural drainage is sometimes proposed as a means of facilitating weaning from mechanical ventilation, but the mechanism of benefit from this procedure is unclear [1, 2] . Experimental data and prior observations in nonmechanically ventilated patients suggest that draining effusions may improve diaphragm mechanics [3, 4] but this hypothesis has not been tested in mechanically ventilated patients. We undertook to determine whether pleural drainage enhances diaphragmatic pressure generation in mechanically ventilated patients. Methods: We enrolled mechanically ventilated patients with large pleural effusions on chest radiograph who had been selected by the medical team to undergo pleural drainage. An esophageal catheter was placed to record esophageal (Pes) and transdiaphragmatic pressure (Pdi) and diaphragm electrical activity (Edi). Pressures and Edi were recorded while subjects were placed on a CPAP trial with zero airway pressure (for up to 10 minutes as tolerated) before and after pleural drainage. Changes in Pes were corrected for swings in gastric pressure (Pga) due to expiratory abdominal muscle activity. The primary outcome was neuromuscular coupling (NMC) of the diaphragm, defined as the ratio of Pdi to Edi [5] . We also examined changes in NMC of the respiratory system (Pes/Edi), neuroventilatory coupling (NVC, tidal volume Vt/Edi), dynamic compliance (Cdyn = Vt/P L , transpulmonary pressure), and respiratory timing parameters. Results: Four patients were enrolled, Three of four subjects could not complete the 10-minute CPAP trial prior to drainage (median 6.6 minutes). All subjects underwent pleural drainage (volume drained 400cc-1510cc). Immediately following pleural drainage, all subjects completed the 10-minute CPAP trial without distress. Venous CO 2 tensions were unchanged before and after drainage. Diaphragm NMC increased following drainage ( Figure 1A, p<0.001) , although the improvement was observed in 3 of 4 patients (NMC increased by 17% to 50%). Respiratory NMC increased in all subjects ( Figure 1B, p<0 .001, range 19%-87%). Increases in NMC were accompanied by decreases in end-expiratory Pes, though one subject exhibited a paradoxical increase in end-expiratory Pes. Cdyn improved in 2 of 4 subjects ( Figure 1C ). These combined changes in NMC and Cdyn gave rise to significant improvements in NVC ( Figure 1D , p<0.001, range 13%-77%). One subject exhibited a significant (57%) decrease in respiratory rate after drainage without changes in venous PCO 2 . Conclusion: We observed significant improvements in diaphragm NMC, respiratory NMC, and CPAP trial tolerance following pleural drainage, consistent with the hypothesis that pleural effusions impede weaning from ventilation by impairing diaphragm mechanics. These findings suggest that pleural drainage may provide the greatest benefit to patients with reduced maximal inspiratory pressuregenerating capacity. Background/Aim: Bacterial pneumonia and septic shock are associated with substantial morbidity and mortality. Classification and Regression Tree (CART) methodology allows the development of predictive models using binary splits and offers an intuitive method for predicting outcome using processes familiar to clinicians. We aimed to improve determinations of prognosis at the time of admission for pneumonia and septic shock using CART model analysis. Methods: CART models were applied to all pneumonia-associated septic shock patients between 1996 and 2015 (n=4222) from the international, multicenter CATSS database. The association between patient and practice-related factors (time delay to appropriate antimicrobial therapy, severity of illness) and in-hospital mortality were evaluated. The accuracy in prediction of outcome (AC), sensitivity (SN), specificity (SP), and area under receiver-operating curve (AUROC) of the final model were evaluated in training (n=2111) and testing (n=2111) sets. Results: In the overall cohort (n=4222, mean age 62 years, 61% male), overall mortality at hospital discharge was 51%. Sixty-three percent (n=2652) were culture positive (tracheal aspirate/sputum or blood), 21% (n=876) had co-existent bacteremia and 35% (n=1075) had nosocomial infections. Of culture positive patients, the most common pathogens were staphylococcus sp. (n=702/2652, 27%), streptococcus sp. (n=658, 25%), pseudomonas sp. (n=267, 10%), Escherichia coli (n=225, 8.5%), Klebsiella sp. (n=183, 6.9%) and Haemophilus influenzae (n=118, 4.4%). On ICU admission, mean (SD) APACHEII was 26(8) and lactate 4.1 (3.9) mmol/L. While in ICU, 89% (n=3760) required mechanical ventilation and 11% (n=464) required new renal replacement therapy. Of 3048 patients who received appropriate antimicrobial therapy after the development of hypotension (shock), the mean delay to therapy was 10.9 hours. In the training set (n=2111) a new CART model (see Figure 1 ) using APACHEII ≥ 28, lactate ≥ 6.3 mmol/L, age > 65 and delay to appropriate antimicrobial therapy ≥ 6.6 hours yielded predictive AC 73%, SP 75%, SN 71% and AUROC 0.75. In the testing set (n=2111), the CART model offered predictive AC 69%, SP 72%, SN 65%, AUROC 0.72. of which were hospital/institute specific, and six provincial. There was no significant difference between mean time for applications that went through a hospital compared to provincial REB (46.56 days (SD: 29.72) vs 20.67 days (SD: 20.05), p =0.1). Eight sites required local privacy office reviews prior to study start day, for purposes of data sharing agreements. In most cases, this was completed concurrently during the time of clinical trial agreements and research ethics, but caused a delay in the startup of one site. Provincial privacy reviews were required for data sharing agreements with three organ donation organizations. We have completed two privacy reviews, which took an average of 113 days. Although this process did not cause a delay in implementing the study, it has hindered Canada-DONATE from collecting recipient data in one province. This application is still ongoing after 646 days. Lastly, the clinical trial agreements took on average 115 days (SD: 45.24) from when the site first received a template copy until the contract was fully executed. The variability in regulatory processes across sites is likely due to 1) unique requirements at the site level (e.g. internal privacy office), 2) provincial legislation, 3) the need for REB approval for both donors and recipients and 4) the perception that donation and transplantation should be keep separated. Conclusion: Research in organ donor care has unique regulatory and ethical barriers. Current research frameworks should be adapted to fit this reality and must take into consideration provincial legislation.

Introduction: Sleep disruption in ICU patients is common and may be associated with adverse outcomes including impaired healing response and delirium (1 The results of studies that reported the proportion of patients affected by a risk factor were combined and will be presented in aggregate.

We screened 1329 titles and abstracts and identified 13 studies that reported premorbid risk factors ( Figure 1 ) and 36 studies that reported ICU-acquired risk factors (Figure 2 ) for sleep disruption in ICU patients.

A compendium of all of the risk factors identified and their frequencies was developed. Among premorbid variables, poor sleep quality at home and use of sleep aids prior to admission were found to be risk factors for sleep disruption in ICU patients. Premorbid medical conditions showed no association with sleep disruption. During the ICU stay, the most frequently reported symptom-related risk factors included pain and psychological stress. The environmental risk factors most frequently reported to disrupt sleep in ICU were nursing care, environmental noise, and lights. Among disease-related variables, disease severity was inconsistently found to be a risk factor. Pharmacological risk factors reported included use of any sedative agent, benzodiazepines, propofol, morphine, midazolam, and steroids. Among these, steroid use was a risk factor for sleep disruption while the results were conflicting for other agents. There were conflicting data with respect to mechanical ventilation (MV) as a risk factor for sleep disruption. MV-induced central sleep apnea and patient-ventilator asynchrony were risk factors associated with sleep disruption. Conclusion: This review provides a systematic analysis of all premorbid and ICUacquired factors associated with sleep disruption in ICU patients. Establishing an inventory of the premorbid risk factors associated with sleep disruption in ICU will allow clinicians to identify those patients who are at highest risk, allowing for a more timely interventions to prevent sleep disruption and its sequelae in ICU patients. Identifying ICU-acquired risk factors for sleep disruption is crucial in the establishment of evidence-based local protocols that aim to reduce the burden of 1 3

sleep disruption in ICU patients, informs future research on this prevalent problem, and provides a framework for establishing guidelines for the prevention and treatment of sleep disruption in ICU patients.

Kyeremanteng, Kwadwo Introduction: Up to 87% of Canadian deaths occur in hospitals -of that proportion, up to 25% of hospitals deaths occur in the special care units, such as the intensive care unit (ICU). Patients admitted to the ICU are often suffering from critical or incurable conditions that require close observations and acute medical attention. It is therefore conceivable that ICU patients and their families are likely to be the individuals under the most physical and psychological distress and would benefit most from end-of-life care (EOLC) and palliative care (PC). Recently, hospitals have started integrating palliative care in the ICU (ICU-PC), and it has shown to improve patients' symptom management and overall quality of life. ICU-PC models have also shown to reduce patients' stays in the ICU, which ultimately reduced the resource consumption of the ICU by over $300,000. Despite the numerous advantages, very few Canadian hospitals have adopted the use of ICU-PC.

The proposed project will be one of the first studies to explore the barriers towards integrating palliative care into a Canadian ICU and the impact of the integration. The project will also evaluate the perceived quality of the end of life care (EOLC) provided at participating institutions. Through this study, we also seek the feasibility of launching a national study to determine and create a nationally accepted ICU-PC model.

Method: This is a mixed method survey designed to assess the needs and barriers for ICU-PC integration. Surveys will be administered to evaluate barriers against ICU-PC integration, best ways to approach the integration, perception of the quality of the EOLC provided. Through a needs assessment, we will also investigate how the EOLC can be improved.

Assessment of perceived quality of EOLC A) Healthcare professionals will be asked to identify potential barriers or hesitations that they have towards an ICU-PC integration in a survey.

B) Perceived quality of EOLC will be measured in a survey through seven domains: 1) patient-and family-centered decision making; 2) communication within the team and with patients and families; 3) continuity of care; 4) symptom management and comfort care; 5) emotional and practical support for patients and families; 6) spiritual support; and 7) emotional and organizational support for ICU staff. Conclusion: This has not been elucidated at the time of submission, as the survey is just being distributed. Results will be available for presentation at the conference.

Lopez Soto, C . We found marked heterogeneity in the timing of radiological examinations and timing and method of neurological assessments. Conclusions: CT and MRI are useful for predicting poor neurological outcome after cardiac arrest. Low GWR on CT scan has the highest specificity and lowest falsepositive rate, but also lowest sensitivity. Future research should directly compare these tests and their additive value to clinical examination. Introduction: Cerebral autoregulation (CA) protects the brain from ischemic or hyperemic injuries via modulation of cerebral blood flow (CBF). CA may be impaired in critically ill patients, possibly contributing to high incidence of delirium and longterm cognitive impairment in this population. Prior studies showed both normal and impaired CA in critically ill patients, but both static and dynamic measures are often done at over a limited observation period potentially missing the changes in CA status over the course of a typical ICU day. In this study, we monitored CA over 8 continuous hours in a cohort of critically ill patients using Mx, the moving correlation coefficient between CBF and mean arterial pressure (MAP). Objectives: To assess the status of CA over 8 hours of continuous observation in a cohort of critically ill patients admitted with sepsis or cardiac arrest. Methods: We recorded middle cerebral artery blood flow velocity (MCAv) using transcranial Doppler and MAP over 8 hours in a cohort of mechanically ventilated patients. We then examined the data offline and removed sections with poor MCAv or MAP signal, as well as any artefacts (e.g. movement resulting in loss of Doppler signal), and calculated Mx as the moving correlation coefficient between remaining MCAv and MAP data using 300 second intervals. We plotted Mx data vs. time for each patient to determine the status of CA. Mx value > 0.3 was used as a cut-off to determine impaired autoregulation. Results: We completed these measurements in 12 patients (8 septic, 9 male). The Mx vs. time profile varied considerably within and between patients. All patients displayed multiple transient spontaneous excursion of Mx above 0.3, suggesting a temporary loss of CA capacity. The frequency and duration of these excursions varied between patients. Excursions lasting more than 20 minutes were observed in only 6 patients, potentially rendering them vulnerable to ischemic or hyperemic injuries. Conclusions: In our cohort, all patients experienced multiple episodes of impaired CA of varying frequency and duration, with half of them losing CA for an extended and potentially dangerous time period. Further research is needed to determine whether the frequency and/or duration of the observed excursions correlate with delirium or long-term cognitive impairment. [1] [2] [3] [4] [5] and frequent patient preference to avoid unnecessary prolongation of life [6] [7] [8] . While our recent report demonstrated the substantial costs of ICU admission in this population [9] , costs of care in this group extend beyond the ICU have not been reported with respect to recovery of baseline functionality. Objectives: The objectives of this study were to determine the in-patient costs (ICU and non-ICU) for the very elderly admitted to ICU in Canada and report the overall cost incurred per survivor with recovery of baseline physical function.

The data source for this study was a multicentre, prospective, observational cohort of patients aged 80 years or older admitted to 22 Canadian ICUs from 2009 to 2013 [2, 3] . A subset of consenting individuals comprised a longitudinal cohort followed over 12 months. Costs were calculated from ICU and hospital length of stay for each patient and unit costs of for admission from Canadian academic hospital. Physical recovery at 12 months was defined as a Short Form-36 physical function score of at least 10 and no lower than 10 points below their pre-admission score [3] . Costs were expressed (in Canadian Dollars) as mean cost per patient per hospitalization, as well as total cost consumed per survivor and per survivor with recovery of baseline physical function. Results: In total, 1,671 patients were included; 610 were enrolled in the longitudinal cohort. The average age was 85 years; median length of stay was 4 days in ICU and 17 days in hospital; hospital mortality was 35% (585/1,671). Of the 505 evaluable patients in the longitudinal cohort at 12 months, 24% (123/505) had survived with recovery of their physical function. The average cost of in-patient care per patient was $34,070±73,347. Total cost incurred was $52,423 per survivor to discharge and $163,108 per survivor with recovery of physical function at 12 months. Conclusion: Very elderly patients admitted to ICU represent a group with very high total costs of hospitalization per functional survivor. In a resource-limited healthcare system, these figures are crucial for informing clinical decisions and policymaking, and reinforce the importance of early goals of care discussion to avoid both undesired and potentially non-beneficial interventions that carry substantial costs. Introduction: Previously, increased cerebral perfusion pressure (CPP) > 70mmHg has been associated with the onset of acute respiratory distress (ARDS) after traumatic brain injury (TBI). Recently, the concept of individualized perfusion targets using real time autoregulation assessment has emerged and at times, requires CPP titration > 70mmHg. Given historical concerns with increased incidence of ARDS, the association between ARDS and increased CPP requires further research. Objectives: To investigate the relationship between increased cerebral perfusion pressure in traumatic brain injury patients who develop acute respiratory distress syndrome versus those who do not. Methods: We conducted a single center retrospective cohort study investigating the association of increased CPP in patients who developed ARDS versus those who did not. We collected demographic data pertaining to age, gender, GCS motor score, Rotterdam CT score and mechanism of injury. We also collected physiologic data for CPP, intracranial pressure, ventilation parameters, cumulative fluid balance and delta pressure. Finally, we collected outcomes measures pertaining to duration of ventilation, length of ICU admission, length of hospitalzation and six month neurological outcome. Results: We conducted a retrospective analysis of 113 patients with severe TBI who underwent multimodal neuromonitoring. The mean age was 39 years (SD 17) and 26 / 113 (23%) were female gender. The median motor score was 3 (IQR 1 -4). The median Rotterdam score was 3 (IQR 3 -4). Sixteen patients (14%) developed ARDS according to the Berlin definition. There was no difference in the mean CPP during the first 7 days of admission between patients who developed ARDS (74mmHg SD 18 vs. 73mmHg SD 18, p=0.86) versus those who did not. There were no differences with respect to duration of mechanical ventilation, ICU length of stay, hospitalization or neurological outcome in both groups.

In our cohort of severe TBI patients who underwent invasive neuromonitoring, we did not observe an association between increased CPP in patients who developed ARDS versus those who did not. Introduction: Acute increases in muscle echodensity (sonographic signal attenuation or 'greyness') reflect muscle injury in athletes, patients in chronic muscular disease states, and muscle inflammation in critically ill patients. Diaphragm structure and function are known to deteriorate during mechanical ventilation, but changes in diaphragm echodensity have not been described to date. Objectives: We set out to establish the reproducibility of a technique for quantifying diaphragm echodensity in mechanically ventilated patients and to characterize the trajectory of diaphragm echodensity according to clinical outcome and diaphragm function. Methods: Thickness and echodensity of the right hemidiaphragm were measured on a daily basis for up to 14 days of mechanical ventilation. Maximal diaphragm thickening was measured on or before day 7 of ventilation. Echodensity was also measured in 10 healthy subjects. Three different ultrasound devices were employed for the study (Phillips Sparq, Mindray, Fujifilm Sonosite) but the same device and same gain level was employed for all measurements in each subject. Echodensity was quantified using gray scale histogram analysis of the diaphragm region traced out on images (ImageJ, NIH, Bethesda MD). The median grayscale value (range 0-255) was log-transformed to yield a normal distribution of echodensity values. Intraobserver repeatability on multiple images obtained on the same day was assessed in 30 patients. The evolution of diaphragm echodensity over time relative to each patient's baseline value was compared according to initial change in diaphragm thickness, maximal thickening fraction, and duration of mechanical ventilation. Results: A total of 176 echodensity measurements were obtained in 37 mechanically ventilated patients (mean 3.57, SD 0.61). Intra-observer repeatability for echodensity measurements on sequential images was acceptable (limits of agreement ±0.36, ±12%). Echodensity values varied according to ultrasound gain but not according to ultrasound device or imaging depth. Mean echodensity at baseline in mechanically ventilated patients was not significantly different from healthy subjects (Figure 1 , p=0.20); although in 41% of mechanically ventilated patients echodensity exceeded the 95 th percentile in healthy subjects (3.8) . Baseline echodensity was unrelated to age, sex, severity of illness, organ dysfunction, chronic comorbidity, or sepsis. The early evolution of echodensity differed according to patient outcomes. In patients who required less than 7 days of ventilation, echodensity tended to decrease during the first 4 days of the study, whereas it tended to increase in patients who required more than 7 days (Figure 2A) . Similarly, echodensity tended to decrease in patients who exhibited higher maximal thickening fraction after 1 week of ventilation whereas it tended to increase in patients who exhibited impaired maximal thickening fraction ( Figure 2B ). The evolution of diaphragm echodensity was unrelated to changes in diaphragm thickness over time ( Figure 2C ) or to variations in SOFA score and sepsis. Echodensity tended to increase over time at increasing inspiratory effort levels (diaphragm thickening > 30%, p=0.02). Conclusions: Diaphragm echodensity can be measured with reasonable precision in mechanically ventilated patients. Increases in echodensity during the early course of ventilation are associated with poor clinical outcomes. Echodensity may be a useful biomarker of diaphragm injury. 

In the technologic ICU setting, clinicians may inadvertently forget the "lives lived" of their patients before hospitalization, and have difficulty humanizing their patients. Initiated by 2 bedside nurses to improve the sense of humanity in a critical care encounter, the Footprints Project was developed to share a patient's personal information during critical illness. The project includes a Footprints Form completed by family members to capture personal information about patients, some of which is transcribed onto a Footprints Whiteboard by the bedside in each patient's room. This mixed-methods multi-phase project aims to facilitate more holistic patient-centered critical care. The objective of this qualitative phase was to understand the impact of the Footprints Project on the experience of clinicians working in the ICU. Methods: With 35 ICU clinicians, we conducted 10 semi-structured interviews (10 clinicians) and 5 focus groups (25 clinicians) 18 months after the Footprints Project was implemented. Focus groups and interviews were digitally recorded, transcribed verbatim and anonymized. Transcripts were analyzed by 4 team members using conventional content analysis. Codes were developed through periodic consensus meetings and organized into categories and themes once coding was completed. Results: Our sample included 13 bedsides nurses, 1 charge nurse, 4 physiotherapists, 2 respiratory therapists, 2 chaplains, 1 unit clerk and 12 physicians (5 fellows, 4 residents and 3 intensivists). Clinicians described using information found on the Footprints Form and Whiteboard as a 'conversation-starter' for talking with patients and families, and as an aid for difficult discussions about prognosis. Main themes identified in this qualitative analysis included: Enhancing Initial Communication, Informing Clinical Interventions, Promoting Interprofessional Collaboration, Facilitating Meaningful Relationships with Patients and Families, and Fostering Culture Change within the ICU. Clinicians reported using the Footprints Form and Whiteboard for diverse purposes, with several beneficial consequences. Sentiments about the untapped potential for the Footprints Project encouraged its more intentional use as a communication tool for both families and clinicians. Conclusions: The Footprints Project is a non-digital initiative in the fast-paced ICU which influences clinicians in a myriad of ways, helping them to connect with patients and families, and colleagues, while having a positive influence on the culture of the ICU. Introduction: Frailty denotes the loss of functional reserve capacity and is prevalent in approximately 30% of patients admitted to the Intensive Care Unit (ICU). Frailty is a multidimensional construct with important prognostic implications, but may be difficult to capture and measure in critically ill patients. The 9-point judgement-based Clinical Frailty Scale (CFS) is a validated clinical tool that has been used in many settings to screen for frailty. The CFS may be a useful risk stratification instrument that can help to predict the chance of adverse outcomes for critically ill patients. In 2 ICU studies, frailty has been associated with an increased risk of mortality, increased length of hospital stay and adverse hospital outcomes. Objectives: The objective of this study was to evaluate the prognostic value of CFS scores generated by research coordinators (RC) via chart review for critically ill patients. We used the CFS as a dichotomous variable, whereby frail was defined as a CFS score > 5 and non-frail was defined as a CFS score <5. Methods: In a prospective 2-center cohort study, we enrolled patients ≥18 years of age admitted to 2 ICUs in Hamilton, Canada for <24h. The RC generated CFS scores using 3 steps: 1) chart review, 2) family interview (if possible), and 3) patient interview (if possible). Subsequently, based on all accumulated data, the RC generated an overall impression captured in a Final CFS. Length of stay and vital status for both ICU and hospital discharge were recorded for all patients. Results: Of 336 patients screened, 150 patients were enrolled. 70 patients (46.7%) were identified as having pre-hospital frailty based on the initial chart review. The mean age of the frail cohort was significantly greater than those who were not frail (68.0 ± 11.8 v. 60.1 ±17.2, p=0.002). Both frail and non-frail patients had similar mean acute physiology and chronic health evaluation (APACHE) II scores (22.5 ± 7.7 v. 20.4 ± 6.9, p=0.09). In the frail cohort, 50% (n=35) of the patients were female, compared to 31% in the non-frail cohort (n=25). Frailty was not associated with a significantly increased length of ICU stay (1.01 days, p=0.58) or hospital stay (3.60 days, p=0.24) using median regression analyses. Frailty was associated with a trend toward increased risk of ICU mortality (hazard ratio (HR) 1.29, 95% CI: 0.60-2.78, p=0.51) and in hospital mortality (HR 1.12, 95% CI: 0.58-2.17, p=0.073), after adjusting for APACHE II score, use of mechanical ventilation and inotropes.

Although not statistically significant, frail patients had a higher risk of ICU and hospital mortality compared to their non-frail counterparts, after adjusting for illness severity. These preliminary data suggest that CFS scores used in an ICU setting may provide useful information that could help to guide conversations with families of critically ill patients, as well as being useful for clinical ICU research. Introduction: The ICU management of subarachnoid hemorrhage (SAH) is challenging, due in part to the severity of the underlying insult, competing systemic injuries, and unpredictable clinical course. Even with specialist management in dedicated critical care settings, morbidity and mortality from this condition remains high. Complex care decisions in SAH management may be simplified with the use of standardized management protocols (SMPs), which provide clinicians with an algorithm to guide patient care. However, despite their postulated benefit, it is currently unknown if SMPs are associated with improved clinical outcomes in patients with SAH. Objectives: We conducted a systematic review to determine whether the use of SMPs is associated with improved outcomes in patients admitted to the ICU with non-traumatic SAH. Primary outcomes included mortality at 6 months or greater and neurologic outcome at hospital discharge and follow-up. Secondary outcomes included length of stay in hospital, duration of mechanical ventilation, rates of aneurysm rebleeding and vasospasm, and healthcare costs. We additionally assessed the quality of the published literature in this domain with a validated grading tool. Methods: We developed comprehensive search strategies for MEDLINE, EMBASE, WoS, CINAHL, and CENTRAL to identify studies for inclusion. We also scanned the gray literature and reviewed published abstracts from relevant conference proceedings to locate further potential material. Our search yielded 9,585 articles, of which 9,151 were excluded by title and abstract screening. 404 studies were reviewed in full, and 15 observational studies were selected for final inclusion. Information on study design, baseline characteristics, and patient outcomes was extracted from each article into a pre-piloted data collection form and aggregated for analysis. Study quality was assessed according to a modified version of the Newcastle Ottawa Scale (NOS). Results: Most studies presented either a descriptive pathway or a flow diagram, with the majority of SMPs addressing the ICU management of delayed cerebral ischemia and corresponding vasospam. Of the 15 studies, 9 did not include a control group. 5 of these studies assessed functional outcomes but did not report them according to a recognized performance scale. 3 studies did not specify when they measured one or more of their primary outcomes. A total of 6 studies assessed SMP-related outcomes against a control group; 5 of these 6 studies showed statistically significant (p<0.05) improvements in one or more primary or secondary outcomes in the protocol-managed group. Only 2 studies reported level of adherence to the SMP. Overall study quality varied significantly based on NOS grading. Meta-analysis of the data was not possible given the dearth of studies meeting our inclusion criteria. Additionally, we noted significant sources of heterogeneity (variation in study design, non-standardized outcome reporting, and

Deferred consent in a minimal-risk study involving critically ill subarachnoid hemorrhage patients

Patients' preferences for enrolment into critical-care trials

Surrogate decision makers' attitudes towards research decision making for critically ill patients

The evolving threat of antimicrobial resistance -Options for action

The rising problem of antimicrobial resistance in the intensive care unit

Scopingreviews: Time for clarity in definition, methods and reporting

Effectiveness of education and an antibiotic control program in a tertiary care hospital in Thailand

Antibiotic resistance-the need for global solutions

A multicenter risk index for atrial fibrillation after cardiac surgery

Critical care medicine beds, use, occupancy, and costs in the United States: A methodollogical review

Trends in 1-year survival of people admitted to hospital in Ontario

How Do Sicker Canadians with Chronic Disease Rate the Health Care System?

The concentration of health care expenditures, revisited

Medical Savings Accounts: Will they reduce costs?

Long-term trends in the concentration of medicare spending

Rapid-Response Teams

Rethinking Rapid Response Teams

The Growth of Rapid Response Systems

Effectiveness of the Medical Emergency Team; the Importance of Dose

Extended stability of pantoprazole for injection in 0.9% sodium chloride or 5% dextrose at 4°C and 23°C

Stability of pantoprazole sodium in glass vials, polyvinyl chloride minibags and polypropylene syringes

Cook D for the REVISE Investigators and the CCCTG.Colour Stability Testing in Pantoprazole Formulations. Can Crit Care Forum Abstract Book

Incidence, risk factors, and outcome of ventilatorassociated pneumonia

The effect of pneumonia on mortality among patients hospitalized for acute stroke

Excess ICU mortality attributable to ventilator-associated pneumonia: the role of early vs. late onset

Risk factors for earlyonset, ventilator associated pneumonia in critical care patients: selected multiresistant versus nonresistant bacteria

The effect of late-onset ventilatorassociated pneumonia in determining patient mortality

Pneumonia caused by oxacillin-resistant Staphylococcus aureus treated with glycopeptides

Prologue to a Multi-Centre RCT of Early In-Bed Cycling in the ICU *Childerhose

France 2 ; Cook

Rudkowski Jill 4 ; Obrovac, Kristy 4 ; Millen

Tim 5,6 ; Rochwerg, Bram 5,6

Ellen 5 ; Fox-Robichaud

Canadian recommendations for critical care ultrasound training and competency

ICU sedation after coronary artery bypass graft surgery: dexmedetomidine-based versus propofol-based sedation regimens

Dexmedetomidine and the reduction of postoperative delirium after cardiac surgery

The Effects of Flexible Bronchoscopy on Mechanical Ventilation in a Pediatric Lung Model

The third international consensus definitions for sepsis and septic shock (sepsis-3)

Discriminative Accuracy of Physician and Nurse Predictions for Survival and Functional Outcomes 6 Months After an ICU Admission

Prognostication during physician-family discussions about limiting life support in intensive care units*. Critical Care Medicine

Six-Month Morbidity and Mortality among ICU Patients Receiving Life-Sustaining Therapy: A Prospective Cohort Study

Mortality predictions in the intensive care unit: Comparing physicians with scoring systems*. Critical Care Medicine

Medical futility: Predicting outcome of intensive care unit patients by nurses and doctors-A prospective comparative study*. Critical Care Medicine

A Global Clinical Measure of Fitness and Frailty in Elderly People

Effectiveness and Safety of the Awakening and Breathing Coordination, Delirium Monitoring/Management, and Early Exercise/Mobility (ABCDE) Bundle

The effects of active mobilisation and rehabilitation in ICU on mortality and function: a systematic review

Hyperchloremia in Critically ill Pediatric Patients, the HyCCiP Study Bulfon, A. 1 ; Stef

5 ; Zheng, K. 6

Investigators RP, the Canadian Critical Care Trials G. The RECOVER Program: Disability Risk Groups & One Year Outcome after >/= 7 Days of Mechanical Ventilation

A physical function test for use in the intensive care unit: validity, responsiveness, and predictive utility of the physical function ICU test (scored)

Development of a physical function outcome measure (PFIT) and a pilot exercise training protocol for use in intensive care

Functional outcomes in ICU -what should we be using? -an observational study

The physical function intensive care test: implementation in survivors of critical illness

TryCYCLE: A Prospective Study of the Safety and Feasibility of Early In-Bed Cycling in Mechanically Ventilated Patients

CYCLE pilot: a protocol for a pilot randomised study of early cycle ergometry versus routine physiotherapy in mechanically ventilated patients

Inappropriate prescribing of intravenous fluid in adult inpatients-a literature review of current practice and research

Intravenous fluid therapy in adults in hospital Clinical guideline

Risk Factors Associated With Iatrogenic Opioid and Benzodiazepine Withdrawal in Critically Ill Pediatric Patients: A Systematic Review and Conceptual Model

Defining Sedation-Related Adverse Events in the Pediatric Intensive Care Unit Defining Sedation-Related Adverse Events in the Pediatric Intensive Care

IV Maintenance Fluids at McMaster Children's Hospital: A Survey of Physicians References 1. Intravenous fluid prescription practices among pediatric residents in

The impact of the National Patient Safety Agency intravenous fluid alert on iatrogenic hyponatraemia in children

Isotonic vs Hypotonic Intravenous Fluids for Hospitalized Children JAMA

Pregnant and postpartum admissions to the intensive care unit: a systematic review

Clinical review: Ventilatory strategies for obstetric, brain-injured and obese patients

Inhaled nitric oxide for pulmonary hypertension after heart transplantation

Randomized, double-blind trial of inhaled nitric oxide in LVAD recipients with pulmonary hypertension. The Annals of thoracic surgery

A multicentre randomized-controlled trial of inhaled milrinone in high-risk cardiac surgical patients

Inhaled Nitric Oxide Augments Left Ventricular Assist Device Capacity by Ameliorating Secondary Right Ventricular Failure

Contemporary management of acute right ventricular failure: a statement from the Heart Failure Association and the Working Group on Pulmonary Circulation and Right Ventricular Function of the European Society of Cardiology

Palevsky P and Acute Dialysis Quality Initiative w. Acute renal failure -definition, outcome measures, animal models, fluid therapy and information technology needs

Importance of relative pulmonary hypertension in cardiac surgery: the mean systemic-to-pulmonary artery pressure ratio

Pulmonary Hypertension an Independent Risk Factor for Death in Intensive Care Unit: Correlation of Hemodynamic Factors with Mortality

The pulmonary artery pulsatility index identifies severe right ventricular dysfunction in acute inferior myocardial infarction

Pulmonary artery pulsatility index predicts right ventricular failure after left ventricular assist device implantation. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation

Morbidity and mortality after extent II thoracoabdominal aortic aneurysm repair. The Annals of thoracic surgery

Cerebrospinal fluid drainage for thoracic and thoracoabdominal aortic aneurysm surgery. The Cochrane Library

Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: the role of intrathecal papaverine. The Journal of thoracic and cardiovascular surgery

Open surgical repair of 2286 thoracoabdominal aortic aneurysms. The Annals of thoracic surgery

Complications of spinal fluid drainage in thoracic and thoracoabdominal aortic aneurysm surgery in 724 patients treated from 1987 to 2013

Optimal endorgan protection for thoracic and thoracoabdominal aortic aneurysm repair using deep hypothermic circulatory arrest. The Annals of thoracic surgery

Thirty-day mortality statistics underestimate the risk of repair of thoracoabdominal aortic aneurysms: a statewide experience

Pulmonary complications after descending thoracic and thoracoabdominal aortic aneurysm repair: predictors, prevention, and treatment. The Annals of thoracic surgery

Paraplegia after extensive thoracic and thoracoabdominal aortic aneurysm repair: does critical spinal cord ischemia occur postoperatively? The Journal of thoracic and cardiovascular surgery

Operative outcomes after open repair of descending thoracic aortic aneurysms in the era of endovascular surgery. The Annals of thoracic surgery

Utility and Safety of Draining Pleural Effusions in Mechanically Ventilated Patients: a Systematic Review and Meta-analysis

Utility of Draining Pleural Effusions in Mechanically Ventilated Patients

Mechanics of the Canine Diaphragm in Pleural Effusion

A. Mechanism of Relief of Dyspnea after Thoracentesis in Patients with Large Pleural Effusions

Monitoring of the Respiratory Muscles in the Critically Ill

Acute kidney injury due to rhabdomyolysis and renal replacement therapy: a critical review

Bench-to-bedside review: Rhabdomyolysis-an overview for clinicians

Rhabdomyolysis: An Evaluation of 475

Hospitalized Patients

Rhabdomyolysis: a review of the literature

Prognostic value, kinetics and effect of CVVHDF on serum of the myoglobin and creatine kinase in critically ill patients with rhabdomyolysis

Biochemical investigation of suspected rhabdomyolysis

Elevation of blood creatine kinase and selected blood parameters after exercise in thoroughbred racehorses (Equus caballus L.)

Rhabdomyolosis and its pathogenesis

Serum myoglobin level as diagnostic test in patients with acute myocardial infarction

Management of Crush-Related Injuries after Disasters

Use of myoglobin as a marker and predictor in myoglobinuric acute kidney injury

American College of Critical Care Medicine (ACCM) of the Society of Critical Care Medicine (SCCM): Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit

Dying in Canada; Is it an institutionalized, technologically supported experience?

Impact of a proactive approach to improve end of life care in a medical ICU

Symptom distress, interventions, and outcomes of intensive care unit cancer patients referred to a palliative care consult team

Proactive palliative are in the medical intensive care unit: effects of length of stay for selected high-risk patients

The Impact of Palliative Care Consultation in the ICU on Length of Stay: A Systematic Review and Cost Evaluation

Critical Care Peer Workgroup of the Promoting Excellence in End-of-Life Care Project. End-of-life care for the critically ill: A national intensive care unit survey

Improving Palliative Care in the ICU (IPAL-ICU) Project Advisory Board. Choosing and using screening criteria for palliative care consultation in the ICU: a report from the Improving Palliative Care in the ICU (IPAL-ICU) Advisory Board

Foundation Critical Care End-Of-Life Peer Workgroup Members. Quality indicators for end-of-life care in the intensive References

The Very Elderly Admitted to ICU: A Quality Finish?

Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study

Decision-making process, outcome, and 1-year quality of life of octogenarians referred for intensive care unit admission

On the benefit of intensive care for very old patients

Long-term survival, quality of life, and qualityadjusted life-years among critically ill elderly patients

What matters most in end-of-life care: perceptions of seriously ill patients and their family members

The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments

Failure to engage hospitalized elderly patients and their families in advance care planning

Cost analysis of the very elderly admitted to intensive care units

Traumatic brain injury

Monitoring and interpretation of intracranial pressure

Management of cerebral perfusion pressure after traumatic brain injury

Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition

Prevention of secondary ischemic insults after severe head injury

Impact of acute lung injury and acute respiratory distress syndrome after traumatic brain injury in the United States

The acute respiratory distress syndrome following isolated severe traumatic brain injury

Monitoring of cerebrovascular autoregulation: facts, myths, and missing links

Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care : a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive

Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE): explanation and elaboration

Prediction of Outcome in Traumatic Brain Injury with Computed Tomographic Characteristics: A Comparison between the Computed Tomographic Classification and Combinations of Computed Tomographic Predictors

Acute respiratory distress syndrome: the Berlin Definition

Specialist neurocritical care and outcome from head injury

Use of ICM+ Software for tracking "Optimal" CPP Values in Real Time

The incidence of ARDS and associated mortality in severe TBI using the Berlin definition

Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury

Driving pressure and survival in the acute respiratory distress syndrome

Effect of driving pressure on mortality in ARDS patients during lung protective mechanical ventilation in two randomized controlled trials

Association between ventilatory settings and development of acute respiratory distress syndrome in mechanically ventilated patients due to brain injury

Acute Lung Injury Is an Independent Risk Factor for Brain Hypoxia After Severe Traumatic Brain Injury

Pro/con debate: should PaCO2 be tightly controlled in all patients with acute brain injuries? Crit Care

Cerebral hemodynamic effects of acute hyperoxia and hyperventilation after severe traumatic brain injury

Regulation of Cerebral Autoregulation by Carbon Dioxide

Intracranial pressure changes in braininjured patients requiring positive end-expiratory pressure ventilation

Intracranial pressure responses to PEEP in headinjured patients

Effects of positive end-expiratory pressure on intracranial pressure and cerebral perfusion pressure

Effects of PEEP on the intracranial system of patients with head injury and subarachnoid hemorrhage: the role of respiratory system compliance

Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury

Critical thresholds for cerebrovascular reactivity after traumatic brain injury

The Third International Consensus Definitions for Sepsis and Septic Shock

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock

Opportunities for Emergency Medical Services care of sepsis

Evolution of Diaphragm Thickness during Mechanical Ventilation: Impact of Inspiratory Effort

Qualitative Ultrasound in Acute Critical Illness Muscle Wasting

Interobserver Reliability of Quantitative Muscle Sonographic Analysis in the Critically Ill Population

The Prognostic Value of Chart Review-Based Clinical Frailty Scale Scores in the Intensive Care Unit Takaoka A, Alyson A 1

Intensive Care Unit, Juravinski Hospital ,Hamilton, Canada; 4 Occupational Therapy

Guidelines for diagnosis, treatment, and prevention of clostridium difficult infections

Clinical practice guidelines for clostridium difficile infection in adults: 2010 update by the Society for Healthcare Epidemiology of America (SHEA) and the Infectious Diseases Society of America (IDSA)

European Society of Clinical Microbiology and Infectious Diseases (ESCMID): treatment guidance document for clostridium difficile infection (CDI)

This systematic review describes various MV strategies used in critically ill pregnant women. There is limited evidence that MV strategies used in the general ICU population are well suited to pregnancy. Existing data are insufficient to make recommendations on how MV should be modified for the critically ill pregnant woman.Parenchymal ICP catheter use, n(%) 26 Introduction: Ventilator-associated respiratory tract infections are a cause of morbidity and mortality in children with a tracheostomy. In addition, they cause greater exposition to broad-spectrum antibiotics. The use of inhaled antibiotics as a preventive measure to reduce ventilator-associated infections has not been studied in children with a tracheostomy. Objectives: To determine if the use of preventive inhaled antibiotics in this population reduces the risk of acquired respiratory tract infections and reduces exposition to broad-spectrum antibiotics. Methods: A retrospective study was performed by reviewing charts of all patients aged between 0 to 18 years old with a tracheostomy, hospitalised at the CHU Sainte Justine between January 2004 and November 2016 and treated with inhaled antibiotics as a preventive measure. The primary outcome was exposition to broadspectrum antibiotics in the 3-month period before and after the beginning of the preventive treatment with inhaled antibiotics. Adverse effects were also evaluated. Results: Six patients (median age: 10.0 months, interquartile: 8.3-11.0) were included in our analysis. One of them received colimycin, 3 received tobramycin and 2 were treated with both alternately. The median time of treatment was 74 days (69-161). Patients were exposed to broad spectrum antibiotics during 18 days (5-31) in the 3 months preceding the treatment versus 2 days (0-3) in the 3 months following the treatment initiation, p= 0,115 (Wilcoxon). The number of respiratory tract infections went from 2 (1-3) to 1 (0-1) during the same periods, p=0,066. Adverse effects most commonly reported were cough (n=2) and increased respiratory secretions post-inhalation (n=4). No new colonisation with antibiotics-resistant bacteria was observed in the 12 following months. Conclusion: Although limited by the small sample size, these results support the design of future studies to evaluate the potential clinical impact of preventive inhaled antibiotics in children with a tracheostomy. (9, 22) . Prior to CDI, 110 (99.1%) patients received at least one antibiotic for a median of 11 days (7, 18) ; 108 (97.3%) received proton pump inhibitors and 14 (12.6%) received histamine-2 receptor antagonists. ICU and hospital mortality were 21.6% (n=24) and 33.3% (n=37), respectively. ICU and hospital lengths of stay were 16 days (10,31) and 39 days (24,77), respectively. CDI recurred in 20 patients (18.0%). Hospital mortality for patients with non-severe vs severe CDI according to these 3 illness severity criteria were: ACG: 23.0% (14/61) vs. 46.0 %, (23/50), p=0.01; SHEA/IDSA: 19.0% (8/42) vs 42.0% (29/69), p=0.01; and ESCMID: 26.6% (17/64) vs 42.6% (20/47), p=0.08 (Table 1) . Conclusions: In this 3-center study, almost all patients with ICU-acquired CDI received invasive mechanical ventilation, antibiotics and proton pump inhibitors. ACG and SHEA/IDSA severity criteria may be useful for stratifying patients with ICU-acquired CDI based on the risk of death in hospital.