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Biomedical subjects

G Pagliarello

Publications and source records attributed to G Pagliarello.

At least 19 recordsLinked to original sources
PubMed2001

Is a low transfusion threshold safe in critically ill patients with cardiovascular diseases?

OBJECTIVE: To compare a restrictive red blood cell transfusion strategy with a more liberal strategy in volume-resuscitated critically ill patients with cardiovascular disease. SETTING: Twenty-two academic and three community critical care units across Canada. STUDY DESIGN: Randomized controlled clinical trial. STUDY POPULATION: Three hundred fifty-seven critically ill patients with cardiovascular diseases from the Transfusion Requirements in Critical Care trial who had a hemoglobin concentration of <90 g/L within 72 hrs of admission to the intensive care unit. INTERVENTIONS: Patients were randomized to a restrictive strategy to receive allogeneic red blood cell transfusions at a hemoglobin concentration of 70 g/L (and maintained between 70 and 90 g/L) or a liberal strategy to receive red blood cells at 100 g/L (and maintained between 100 and 120 g/L). RESULTS: Baseline characteristics in the restrictive (n = 160) and the liberal group (n = 197) were comparable, except for the use of cardiac and anesthetic drugs (p <.02). Average hemoglobin concentrations (85 +/- 6.2 vs. 103 +/- 6.7 g/L; p <.01) and red blood cell units transfused (2.4 +/- 4.1 vs. 5.2 +/- 5.0 red blood cell units; p <.01) were significantly lower in the restrictive compared with the liberal group. Overall, all mortality rates were similar in both study groups, including 30-day (23% vs. 23%; p = 1.00), 60-day, hospital, and intensive care unit rates. Changes in multiple organ dysfunction from baseline scores were significantly less in the restrictive transfusion group overall (0.2 +/- 4.2 vs. 1.3 +/- 4.4; p =.02). In the 257 patients with severe ischemic heart disease, there were no statistically significant differences in all survival measures, but this is the only subgroup where the restrictive group had lower but nonsignificant absolute survival rates compared with the patients in the liberal group. CONCLUSION: A restrictive red blood cell transfusion strategy generally appears to be safe in most critically ill patients with cardiovascular disease, with the possible exception of patients with acute myocardial infarcts and unstable angina.

APACHE↗
PubMed2000

Use of abdominal computed tomography in blunt trauma: do we scan too much?

OBJECTIVES: To determine what proportion of abdominal computed tomography (CT) scans ordered after blunt trauma are positive and the applicability and accuracy of existing clinical prediction rules for obtaining a CT scan of the abdomen in this setting. SETTING: A leading trauma hospital, affiliated with the University of Ottawa. DESIGN: A retrospective cohort study. PATIENTS AND METHODS: All patients with blunt trauma admitted to hospital over a 1-year period having an Injury Severity Score (ISS) greater than 12 who underwent CT of the abdomen during the initial assessment. Recorded data included age, sex, Glasgow Coma Scale (GCS) score, ISS, type of injuries, number of abdominal CT scans ordered, and scan results. Two clinical prediction rules were found in the literature that identify patients likely to have intra-abdominal injuries. These rules were applied retrospectively to the cohort. The predicted proportion of positive CT scans was compared with the observed proportion, and the sensitivity, specificity, and accuracy were estimated. RESULTS: Of the 297 patients entered in the study, 109 underwent abdominal CT. The median age was 32 years, 71% were male and the median ISS was 24. In only 36.7% (40 of 109) of scans were findings suggestive of intra-abdominal injuries. Application of one of the clinical prediction rules gave a sensitivity of 93.8% and specificity of 25.5% but excluded 23% of patients because of a GCS score less than 11. The second prediction rule tested could be applied to all patients and was highly sensitive (92.5%) and specific (100.0%). CONCLUSIONS: The assessment of the abdomen in blunt trauma remains a challenge. Accuracy in predicting positive scans in equivocal cases is poor. Retrospective application of an existing clinical prediction rule was found to be highly accurate in identifying patients with positive CT findings. Prospective use of such a rule could reduce the number of CT scans ordered without missing significant injuries.

Abbreviated Injury Scale↗
PubMed1999

A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group.

BACKGROUND: To determine whether a restrictive strategy of red-cell transfusion and a liberal strategy produced equivalent results in critically ill patients, we compared the rates of death from all causes at 30 days and the severity of organ dysfunction. METHODS: We enrolled 838 critically ill patients with euvolemia after initial treatment who had hemoglobin concentrations of less than 9.0 g per deciliter within 72 hours after admission to the intensive care unit and randomly assigned 418 patients to a restrictive strategy of transfusion, in which red cells were transfused if the hemoglobin concentration dropped below 7.0 g per deciliter and hemoglobin concentrations were maintained at 7.0 to 9.0 g per deciliter, and 420 patients to a liberal strategy, in which transfusions were given when the hemoglobin concentration fell below 10.0 g per deciliter and hemoglobin concentrations were maintained at 10.0 to 12.0 g per deciliter. RESULTS: Overall, 30-day mortality was similar in the two groups (18.7 percent vs. 23.3 percent, P= 0.11). However, the rates were significantly lower with the restrictive transfusion strategy among patients who were less acutely ill -- those with an Acute Physiology and Chronic Health Evaluation II score of < or =20 (8.7 percent in the restrictive-strategy group and 16.1 percent in the liberal-strategy group; P=0.03) -- and among patients who were less than 55 years of age (5.7 percent and 13.0 percent, respectively; P=0.02), but not among patients with clinically significant cardiac disease (20.5 percent and 22.9 percent, respectively; P=0.69). The mortality rate during hospitalization was significantly lower in the restrictive-strategy group (22.3 percent vs. 28.1 percent, P=0.05). CONCLUSIONS: A restrictive strategy of red-cell transfusion is at least as effective as and possibly superior to a liberal transfusion strategy in critically ill patients, with the possible exception of patients with acute myocardial infarction and unstable angina.

APACHE↗
PubMed1999

Variation in red cell transfusion practice in the intensive care unit: a multicentre cohort study.

OBJECTIVES: To determine the degree of interinstitutional transfusion practice variation and reasons why red cells are administered in critically ill patients. STUDY DESIGN: Multicentre cohort study combined with a cross-sectional survey of physicians requesting red cell transfusions for patients in the cohort. STUDY POPULATION: The cohort included 5298 consecutive patients admitted to six tertiary level intensive care units in addition to administering a survey to 223 physicians requesting red cell transfusions in these units. MEASUREMENTS: Haemoglobin concentrations were collected, along with the number and reasons for red cell transfusions plus demographic, diagnostic, disease severity (APACHE II score), intensive care unit (ICU) mortality and lengths of stay in the ICU. RESULTS: Twenty five per cent of the critically ill patients in the cohort study received red cell transfusions. The overall number of transfusions per patient-day in the ICU averaged 0.95 +/- 1.39 and ranged from 0.82 +/- 1.69 to 1.08 +/- 1.27 between institutions (P < 0.001). Independent predictors of transfusion thresholds (pre-transfusion haemoglobin concentrations) included patient age, admission APACHE II score and the institution (P < 0.0001). A very significant institution effect (P < 0.0001) persisted even after multivariate adjustments for age, APACHE II score and within four diagnostic categories (cardiovascular disease, respiratory failure, major surgery and trauma) (P < 0.0001). The evaluation of transfusion practice using the bedside survey documented that 35% (202 of 576) of pre-transfusion haemoglobin concentrations were in the range of 95-105 g/l and 80% of the orders were for two packed cell units. The most frequent reasons for administering red cells were acute bleeding (35%) and the augmentation of O2 delivery (25%). CONCLUSIONS: There is significant institutional variation in critical care transfusion practice, many intensivists adhering to a 100g/l threshold, and opting to administer multiple units despite published guidelines to the contrary. There is a need for prospective studies to define optimal practice in the critically ill.

Journal Article↗
PubMed1998

A Canadian survey of transfusion practices in critically ill patients. Transfusion Requirements in Critical Care Investigators and the Canadian Critical Care Trials Group.

OBJECTIVES: To characterize the contemporary red cell transfusion practice in the critically ill and to define clinical factors that influence these practices. DESIGN: Scenario-based national survey. STUDY POPULATION: Canadian critical care practitioners. MEASUREMENTS AND MAIN RESULTS: We evaluated transfusion thresholds before transfusion and the number of red cell units ordered, under the given conditions. Of 254 Canadian critical care physicians, 193 (76%) responded to the survey. The primary specialty of most respondents was internal medicine (56%). Internal medicine respondents were in practice for an average of 8.4 +/- 5.7 (SD) yrs, and worked most often in combined medical/surgical intensive care units. Baseline hemoglobin transfusion thresholds averaged from 8.3 +/- 1.0 g/dL in a scenario involving a young stable trauma victim to 9.5 +/- 1.0 g/dL for an older patient after gastrointestinal bleeding. Transfusion thresholds differed significantly (p< .0001) between all four separate scenarios. With the exception of congestive heart failure (p> .05), all clinical factors (including age, Acute Physiology and Chronic Health Evaluation II score, preoperative status, hypoxemia, shock, lactic acidosis, coronary ischemia, and chronic anemia) significantly (p< .0001) modified the transfusion thresholds. A statistically significant (p< .01) difference in baseline transfusion thresholds was noted across four major regions (with a maximum of five academic centers per region) of the country. Low physician numbers in two of the regions did not allow for further investigation of regional variations. CONCLUSIONS: There is significant variation in critical care transfusion practice, with many intensivists adhering to a 10.0-g/dL threshold, while other physicians described a much more restrictive approach to red cell transfusion. Also, many physicians opted to administer multiple units, despite published guidelines to the contrary. Additionally, the administration of red cells was strongly influenced by a number of clinical factors, many unique to intensive care unit patients. There is a need for prospective studies to define optimal practice in the critically ill.

Adult↗
PubMed1997

Does transfusion practice affect mortality in critically ill patients? Transfusion Requirements in Critical Care (TRICC) Investigators and the Canadian Critical Care Trials Group.

In 4,470 critically ill patients, we examined the impact of transfusion practice on mortality rates. As compared with survivors, patients who died in intensive care units (ICU) had lower hemoglobin values (95 +/- 26 versus 104 +/- 23 g/L, p < 0.0001) and were transfused red cells more frequently (42.6% versus 28.0%, p < 0.0001). In patients with cardiac disease, there was a trend toward an increased mortality when hemoglobin values were < 95 g/L (55% versus 42%, p = 0.09) as compared with anemic patients with other diagnoses. Patients with anemia, a high APACHE II score (> 20), and a cardiac diagnosis had a significantly lower mortality rate when given 1 to 3 or 4 to 6 units of allogeneic red cells (55% [no transfusions] versus 35% [1 to 3 units] or 32% [4 to 6 units], respectively, p = 0.01). Adjusted odds ratio (OR) predicting survival were 0.61 (95% CI; 0.37 to 1.00, p = 0.026) after 1 to 3 units and 0.49 (95% CI; 0.23 to 1.03, p = 0.03) after 4 to 6 units compared with nontransfused anemic patients. In the subgroup with cardiac disease, increasing hemoglobin values in anemic patients was associated with improved survival (OR = 0.80 for each 10 g/L increase, p = 0.012). We conclude that anemia increases the risk of death in critically ill patients with cardiac disease. Blood transfusions appear to decrease this risk.

APACHE↗
PubMed1995

Transfusion requirements in critical care. A pilot study. Canadian Critical Care Trials Group.

OBJECTIVE: To evaluate the effects of a restrictive and a liberal red blood cell (RBC) transfusion strategy on mortality and morbidity in critically ill patients. STUDY DESIGN: Multicenter, prospective, randomized clinical trial. PATIENT POPULATION: Sixty-nine normovolemic critically ill patients admitted to one of five tertiary level intensive care units with hemoglobin values less than 90 g/L within 72 hours of admission. INTERVENTIONS: Patients were randomly allocated to one of two RBC transfusion strategies. Hemoglobin values were maintained between 100 and 120 g/L in the liberal transfusion group and between 70 and 90 g/L in the restrictive group. RESULTS: Primary diagnosis and mean +/- SD age (58.6 +/- 15 vs 59.0 +/- 21 years and Acute Physiology and Chronic Health Evaluation II score (20 +/- 6.2 vs 21 +/- 7.2) were similar in the restrictive and liberal groups, respectively. Daily hemoglobin values averaged 90 g/L in the restrictive group vs 109 g/L in the liberal group (P < .001). The restrictive group received 2.5 U per patient compared with 4.8 U per patient in the liberal group. This represents a 48% relative decrease (P < .001) in RBC units transfused per patient. The 30-day mortality rate was 24% in the restrictive group compared with 25% in the liberal group; the 95% confidence interval around the absolute difference was -19% to 21%. Similar observations were noted for intensive care unit mortality (P = .76) and 120-day mortality (P > .99). In addition, survival analysis comparing time until death in both groups did not reveal any significant difference (P = .93) between groups. Organ dysfunction scores were also similar (P = .44). CONCLUSION: In this small randomized trial, neither mortality nor the development of organ dysfunction was affected by the transfusion strategy, which suggests that a more restrictive approach to the transfusion of RBCs may be safe in critically ill patients. However, the study lacked power to detect small but clinically significant differences. Therefore, further investigations of RBC transfusion strategies are warranted.

APACHE↗
PubMed1993

The pulmonary artery (Swan-Ganz) catheter. Evaluation of a hemodynamic monitoring device in critical care medicine.

The pulmonary artery catheter (PAC) is an invasive hemodynamic monitoring device that is used extensively in critical care units. This technological advance allows the critical care physician and nurse to closely monitor physiological functions at the bedside. There have been no formal evaluations of the impact of this device on patient care. Reviews and observational studies have yielded different conclusions regarding risks and benefits to patients. This has resulted in much editorial comment expressing divergent opinions on the value of the PAC, but there has been no scientific evidence to guide practice and no apparent effect on the use of these devices. The PAC and other medical monitoring devices must be evaluated with respect to their impact on patient care.

Catheterization, Swan-Ganz↗
PubMed1992

Traumatic rupture of the thoracic aorta: diagnosis on fibreoptic bronchoscopy.

The diagnosis of thoracic aortic rupture can be difficult, especially in the presence of other life-threatening injuries. We present a case in which the presence of major intraabdominal trauma shifted clinical attention away from the mediastinum. During bronchoscopy, which was performed to investigate high intraoperative airway pressures, unexpected tracheal and carinal compression were discovered. Thoracic aortography revealed aortic rupture distal to the left subclavian artery. Successful repair was subsequently achieved.

Aged↗
PubMed1992

Traumatic injury to the diaphragm: timely diagnosis and treatment.

Traumatic injury to the diaphragm is a relatively uncommon injury with potential for considerable morbidity if the diagnosis is delayed or missed. This review of cases of traumatic diaphragmatic injury was undertaken in order to emphasize methods and timing of diagnosis and treatment. From 1986 through 1990, 43 cases of traumatic diaphragmatic injury were admitted to the trauma unit at Sunnybrook Health Sciences Centre, for an incidence of 2% of all new multiple trauma admissions. All patients were evaluated and treated by a dedicated trauma team. The left hemidiaphragm was injured in 32 patients, the right hemidiaphragm was injured in eight cases, and the injury was bilateral in three patients. Thirty-four patients had blunt trauma. The mean Injury Severity Score for all patients was 32. The diagnosis of diaphragmatic injury was made radiologically in 21 cases and at surgery in 22 cases. The diagnosis in all cases with penetrating trauma was made at the time of surgery. The interval between injury and definitive surgery was less than 12 hours in 39 of 43 patients. The diagnosis of diaphragmatic injury was delayed by more than 12 hours in only one patient. The other three patients were diagnosed soon after injury but their definitive surgery was delayed for other reasons. Surgical repair of the diaphragm was performed via laparotomy in 40 of 43 cases. Only one patient was repaired in a delayed fashion by thoracotomy for thoracic complications. A clear contrast can be drawn between blunt injuries and penetrating trauma.(ABSTRACT TRUNCATED AT 250 WORDS)

Diaphragm↗
PubMed1992

The Integrated Trauma Program: a model for cooperative trauma triage.

The Integrated Trauma Program (ITP) is the cooperative trauma triage service of the University of Toronto trauma and burn hospitals and the Ontario Ministry of Health. It provides physicians in referring hospitals direct access to a trauma team leader (TTL) in one of several trauma centers through a single phone number. Three adult trauma centers, one pediatric trauma center, and one burn center, all affiliated with the University of Toronto, participate in this program. This article describes the system during the first two years of operation. From July 1989 to June 1991, 1530 requests for patient transfers from a total of 97 hospitals were processed. Of these transfer requests, 77% were accepted by the TTL to a trauma service as multiple trauma cases, 16% were accepted directly to a surgical service without involving the trauma team, 4% were refused by the TTL as inappropriate referrals, and 3% of requests were cancelled by the referring physician. The transfer requests are distributed to a specific trauma center by request of the referring physician (10%), according to a rotation (70%), or as selected by the ITP (20%) when the scheduled hospital is not readily available. Closure of all adult trauma centers occurred on 43 occasions. During these closures, 48 patients bypassed the Toronto trauma centers and were transferred to other cities. The ITP office also keeps an ongoing data base of patients transferred. The mechanism of injury in the majority of cases is vehicular crashes. The mean Injury Severity Score is 24 for adults and 17 for children.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1991

Blunt liver trauma at sunnybrook Medical Centre: a 13 year experience.

Between June 1, 1976 and June 30, 1989 The Regional Trauma Unit at Sunnybrook Medical Centre in Toronto, Ontario, Canada received 3730 patients. Of these 335 (9%) sustained a liver injury, 95% being due to blunt trauma. Open peritoneal lavage was performed on 80% of liver trauma patients (267/335), 99% being true positive. A laparotomy was performed on 97% of patients (324/335). Major surgical treatment was required in 132 patients (41%) and minor treatment in 192 patients (59%). The remaining 11 patients were treated conservatively (n = 3) or died during resuscitation (n = 8). Morbidity directly related to the liver injury was seen in 29 of 249 surviving patients (11%) although overall morbidity was 27% (67/249). Reoperation was required in 6% (14/249) with abscess or hematoma accounting for 11 of 14 operations. The overall mortality rate was 26% (86/335). Eighty two percent of patients (n = 276) had a grade I, II or III liver trauma according to Moore's classification with a mortality of 12% (n = 32). The remaining 18% of patients (n = 59) had a grade IV or V liver trauma with a mortality of 44% (n = 26). Of the 86 deaths, head injury accounted for 48 (56% of deaths); liver hemorrhage for 17 (20%), liver sepsis for 1 (1%) and other causes for 20 deaths (23%). Thus death due to the liver injury itself (hemorrhage and sepsis) occurred in 18 out of 335 patients (5% overall). Head injury accounted for the death of 48 out of 335 patients (14% overall). Over the past 13 years a trend has occurred at our institution whereby we are seeing less liver trauma in our population of multiply injured patients from 12% (1976-1983) down to 7% (1985-1989); with a gradual decline in overall mortality from 32% (1976-1983) to 19% (1985-1989), whereas the percentage of deaths due to head injuries and liver injury have increased.

Cause of Death↗
PubMed1991

Mechanism of injury influences the pattern of injuries sustained by patients involved in vehicular trauma.

The authors examined the patterns of injury and death rates of patients involved in vehicle-related accidents who were admitted to the Regional Trauma Unit of Sunnybrook Health Science Centre in Toronto. Information was collected prospectively over a 36-month period. The subjects were placed in one of three mechanism-of-injury categories: four-wheel passenger vehicles, motorcycles and pedestrians. The patterns of injury were classified as primarily to the craniofacial and neck area, the torso, the extremities or to multiple regions. There were 815 patients who were involved in vehicle-related crashes and who suffered moderate to severe injuries (at least one region scoring more than 3 on the abbreviated injury scale). The death rate was 13% overall but was 21% in the group receiving multiple injuries. By mechanism of injury the death rates were: pedestrian group 20%, motorcycle group 18% and passenger-vehicle group 11% (p less than 0.01, chi 2 analysis). There was no difference in the mean injury severity score among the mechanism of injury groups. A higher proportion of the passenger-vehicle group sustained isolated craniofacial and torso injuries, and the pedestrian and motorcycle groups sustained more extremity injuries (p less than 0.001, chi 2 analysis). The results reveal a clear association between mechanism of injury and the patterns of injury observed.

Accidents, Traffic↗
PubMed1990

The relative influence of alcohol and seatbelt usage on severity of injury from motor vehicle crashes.

Seatbelt usage has been consistently documented to decrease mortality and injury severity from motor vehicle crashes (MVC); however, conflicting results are available comparing mortality and injury severity, and blood alcohol positivity. Prospective testing on all MVC admissions showed that 51.5% of the non-belted, and 22% of the shoulder-belted drivers had a positive blood alcohol content (p less than 0.001). A comparison of belted and non-belted MVC drivers revealed a significantly higher mean length of stay (LOS) (p less than 0.05) and Injury Severity Score (ISS) (p less than 0.01) for the non-belted drivers. A comparison of groups positive and negative for blood alcohol revealed no significant differences in LOS or ISS, suggesting that these parameters are related to seatbelt use and not alcohol consumption.

Accidents, Traffic↗
PubMed1988

Physician-accompanied transport of surgical intensive care patients.

During a one-year period, 107 critically ill adult patients were transferred by a physician-accompanied transport system (PATS). Most patients required both tracheal intubation (82 per cent) and mechanical ventilation (71 per cent), while continuous vasopressor support was required in 27 per cent of transfers. Patients were classified as either potential organ donors (n = 21) or nondonor patients (n = 86). Nondonor patients had a mean time of patient transfer documented from the initial telephone contact to final arrival of the patient in the ICU of 345 +/- 221 min (range 65-1350 min); the mean time the patients were out-of-hospital was 73 +/- 58 min (range 5-330 min); the average distance travelled by the patient and PATS was 342 +/- 692 km (range 1-4000 km). Ultimate nonsurvivors of ICU admission (36 per cent) had shorter out-of-hospital times, shorter travel distances, and increased interventional support, as assessed by the Therapeutic Intervention Scoring System applied over the telephone and prior to departure at the referring hospital. Significant interventions were undertaken by PATS in 23 per cent of the nondonor patients prior to departure. During the transport process, there was at least a seven per cent morbidity (arrhythmia, hypotension, and vehicular difficulties) and a 0.9 mortality rate. We conclude that PATS offered significant advantages to this patient population through its ability to maintain acceptable morbidity and mortality rates while transferring patients over long distances and for prolonged periods of time.

Adolescent↗
PubMed1988

Liver blood flow after major hepatic resection.

The factors involved in liver regeneration are poorly understood, but it has been suggested that blood flow plays a role. This paper documents the changes in liver blood flow (LBF) that occur after major hepatic resection. Eight patients, ranging in age from 37 to 76 years, underwent liver resection. Liver blood flow was measured preoperatively and on days 1, 4 and 7 postoperatively by low-dose galactose clearance. There was a significant (p less than 0.01) fall in LBF on day 1 compared with the baseline value, followed by a significant (p less than 0.01) rise from the baseline value by day 4. By day 7, LBF had returned to baseline levels and was significantly (p less than 0.01) lower than on day 4. These changes in LBF may be related to the stimulus for liver regeneration and increased functional demands during the early regenerative phase.

Adult↗
PubMed1988

Mead Johnson Critical Care Symposium for the Practising Surgeon. 1. Transport of critically ill adult patients.

Interhospital transportation of critically ill patients over long distances is common in the tiered health care systems of North America. The authors describe their 1-year experience with a physician-assisted transport system, operating out of the surgical intensive care unit at the Toronto General Hospital. The application of a well-known severity of illness measure (therapeutic intervention scoring system) allowed them to correlate severity of illness, as assessed over the telephone before patient transfer, with eventual outcome after admission to the surgical intensive care unit. Their analysis of 107 critically ill patients transported by this system led them to conclude that the system is reliable and is associated with acceptable morbidity and mortality.

Adolescent↗