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J McMullin

Publications and source records attributed to J McMullin.

6 recordsLinked to original sources
PubMed2006

Minimizing errors of omission: behavioural reenforcement of heparin to avert venous emboli: the BEHAVE study.

OBJECTIVE: To improve patient safety by increasing heparin thromboprophylaxis for medical-surgical intensive care unit patients using a multiple-method approach to evidence-based guideline development and implementation. DESIGN: Prospective longitudinal observational study. SETTING: Medical-surgical intensive care unit. PARTICIPANTS: Multidisciplinary clinicians caring for critically ill patients in a 15-bed medical-surgical closed intensive care unit. INTERVENTIONS: Phase 1 was a 3-month baseline period during which we documented anticoagulation and mechanical thromboprophylaxis. Phase 2 was a 1-yr period in which we implemented a thromboprophylaxis guideline using a) interactive multidisciplinary educational in-services; b) verbal reminders to the intensive care unit team; c) computerized daily nurse recording of thromboprophylaxis; d) weekly graphic feedback to individual intensivists on guideline adherence; and e) publicly displayed graphic feedback on group performance. Phase 3 was a 3-month follow-up period 10 months later, during which we documented thromboprophylaxis. Computerized daily nurse recording of thromboprophylaxis continued in this period. MEASUREMENTS AND MAIN RESULTS: Intensive care unit and hospital mortality rates were similar across phases, although patients in phase 2 had higher Acute Physiology and Chronic Health Evaluation II scores than patients in phases 1 and 3. The proportion (median % [interquartile range]) of intensive care unit patient-days of heparin thromboprophylaxis in phases 1, 2, and 3 was 60.0 (0, 100), 90.9 (50, 100), and 100.0 (60, 100), respectively (p=.01). The proportion (median % [interquartile range]) of days during which heparin thromboprophylaxis was omitted in error in phases 1, 2, and 3 was 20 (0, 53.8), 0 (0, 6.3), and 0 (0, 0), respectively (p<.001). CONCLUSIONS: After development and implementation of an evidence-based thromboprophylaxis guideline, we found significantly more patients receiving heparin thromboprophylaxis. Guideline adherence was maintained 1 yr later. Further research is needed on which are the most effective strategies to implement patient safety initiatives in the intensive care unit.

Aged↗
PubMed2001

Prevention and diagnosis of venous thromboembolism in critically ill patients: a Canadian survey.

BACKGROUND: Venous thromboembolism (VTE) confers considerable morbidity and mortality in hospitalized patients, although few studies have focused on the critically ill population. The objective of this study was to understand current approaches to the prevention and diagnosis of deep venous thrombosis (DVT) and pulmonary embolism (PE) among patients in the intensive care unit (ICU). DESIGN: Mailed self-administered survey of ICU Directors in Canadian university affiliated hospitals. RESULTS: Of 29 ICU Directors approached, 29 (100%) participated, representing 44 ICUs and 681 ICU beds across Canada. VTE prophylaxis is primarily determined by individual ICU clinicians (20/29, 69.0%) or with a hematology consultation for challenging patients (9/29, 31.0%). Decisions are usually made on a case-by-case basis (18/29, 62.1%) rather than by preprinted orders (5/29, 17.2%), institutional policies (6/29, 20.7%) or formal practice guidelines (2/29, 6.9%). Unfractionated heparin is the predominant VTE prophylactic strategy (29/29, 100.0%) whereas low molecular weight heparin is used less often, primarily for trauma and orthopedic patients. Use of pneumatic compression devices and thromboembolic stockings is variable. Systematic screening for DVT with lower limb ultrasound once or twice weekly was reported by some ICU Directors (7/29, 24.1%) for specific populations. Ultrasound is the most common diagnostic test for DVT; the reference standard of venography is rarely used. Spiral computed tomography chest scans and ventilation-perfusion scans are used more often than pulmonary angiograms for the diagnosis of PE. ICU Directors recommend further studies in the critically ill population to determine the test properties and risk:benefit ratio of VTE investigations, and the most cost-effective methods of prophylaxis in medical-surgical ICU patients. INTERPRETATION: Unfractionated subcutaneous heparin is the predominant VTE prophylaxis strategy for critically ill patients, although low molecular weight heparin is prescribed for trauma and orthopedic patients. DVT is most often diagnosed by lower limb ultrasound; however, several different tests are used to diagnose PE. Fundamental research in critically ill patients is needed to help make practice evidence-based.

Anticoagulants↗
PubMed1995

A case study with delayed renal graft function as a consequence of severe secondary hyperparathyroidism.

A 36-year-old Arab man had been treated with hemodialysis for 6 years. During that time he received no treatment with phosphate binders or 1,25-dihydroxy-vitamin D3. He thus developed a severe form of secondary hyperparathyroidism and presented with bone disease, pseudoclubbing of the fingers, and soft-tissue calcification. He was transplanted with a kidney from a living donor, but there was no immediate onset in renal function. A biopsy showed crystal deposition that was thought to be due to his secondary hyperparathyroidism. Four weeks after the renal transplantation with still no evidence of a functioning graft, a parathyroidectomy was performed. A few days later, graft function recovered, and the amount of the crystals in the kidney decreased. There is strong evidence that the severe secondary hyperparathyroidism prevented the onset of renal function. It is concluded that crystal deposition with graft dysfunction should be an absolute indication for parathyroidectomy.

Adult↗
PubMed1978

Ioglycamide (Biligram) studies in man--relation between plasma concentration and billary excretion.

Plasma ioglycamide concentration was linearly related to the rate of intravenous infusion over a dose range of from 1 to 4 mg per kg per min. The relation between plasma and biliary concentration of ioglycamide was studied in 15 anicteric patients with a T-tube in situ. Peak biliary concentrations and excretory rates of ioglycamide were seen when the plasma concentration was greater than 1500 micrograms per ml. The mean biliary transport maximum (Tm) for ioglycamide in man was 31.6 mg/min (range 22.0-40.4). The results suggest that near optimal concentrations of iodine in the bile duct can be obtained during intravenous cholangiography if ioglycamide is infused for one hour at a rate of about 4 mg per kg per min.

Bile↗
PubMed1978

Ioglycamide (Biligram) studies in man--plasma binding, renal and biliary excretion studies in jaundiced and anicteric patients.

When five patients with varying degrees of hepatic impairment and a T-tube in situ were given intravenous ioglycamide at a rate of 2 mg/kg/min for two hours the mean biliary excretion in the first two hours was only 3.2% of the administered dose. In contrast, in five T-tube patients with relatively normal liver function the mean biliary excretion over the same time interval was 20.6%. The mean plasma concentration of ioglycamide achieved at the end of a two-hour intravenous infusion at 2 mg/kg/min was 1427 +/- 187 microgram/ml in six anicteric patients and 1262 +/- 82 in six jaundiced patients. Despite these very similar plasma levels the 24-hour urinary excretion of ioglycamide was 42.3 +/- 3.8% of the administered dose in the patients with jaundice compared with only 18.1 +/- 2.4% in the anicteric group. These differences probably reflect the fact that the percentage of unbound contrast agent in the plasma of the jaundiced group (11.9 +/- 1.9%) was significantly higher than that of the anicteric group (6.4 +/- 0.9%). It is suggested that bilirubin and possibly other substances in the plasma are competing with ioglycamide for binding sites on albumin. These factors need to be borne in mind when performing intravenous cholangiograms on jaundiced patients.

Aged↗