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Biomedical subjects

John W Drover

Publications and source records attributed to John W Drover.

11 recordsLinked to original sources
PubMed2005

Recent developments in percutaneous tracheostomy: improving techniques and expanding roles.

PURPOSE OF REVIEW: The purpose of this review is to provide an update of recent developments pertaining to the use of percutaneous tracheostomy. Percutaneous tracheostomy has been established as an alternative to open surgical tracheostomy, but many key questions about the optimal use of this procedure remain unanswered. RECENT FINDINGS: Issues in percutaneous tracheostomy that have been addressed in the recent literature include the optimal method, timing, use of percutaneous tracheostomy in emergencies, safety in high-risk populations, confirmation of tracheal puncture, and outcomes. SUMMARY: Recent literature suggests that percutaneous tracheostomy is safe to use in an expanding population of patients, including patients with airway compromise and thrombocytopenia. Several methods seem to be safe alternatives to that originally described. Capnography has arisen as an alternative to bronchoscopy for confirmation of tracheal puncture. Recent evidence highlights that although tracheostomy may improve short-term outcome, these critically ill patients have a significant long-term risk of poor outcome. This must be taken into consideration when this procedure is offered.

Emergency Medicine↗
PubMed2004

Minimum postoperative antibiotic duration in advanced appendicitis in children: a review.

The suitable duration of antibiotic use following appendectomy for advanced appendicitis in children is still debated. A systematic review was performed, including published experimental and observational data of antibiotic use in children who had undergone appendectomy for advanced appendicitis. Data were extracted and analyzed according to predefined criteria. Twenty-eight studies were selected that included 2,284 patients. There was no consistency among the protocols regarding length of antibiotic use, discharge criteria, or use of home antibiotics following discharge. Limiting duration of antibiotic use to 3 days did not appear to be associated with higher rates of intraabdominal abscess or wound infection. In the absence of higher-level evidence, shortening of antibiotic regimens following surgery for pediatric complicated appendicitis appears to be safe.

Anti-Bacterial Agents↗
PubMed2003

Translaryngeal tracheostomy: experience of 340 cases.

OBJECTIVE: To describe the authors' initial experience with a new and innovative dilational translaryngeal tracheostomy bedside technique. STUDY DESIGN: A prospective documentation of 340 patients who received an elective translaryngeal tracheostomy in a multidisciplinary, tertiary care intensive care unit during a 45-month period. RESULTS: All translaryngeal tracheostomy procedures but one were completed successfully; one was aborted because of bleeding from a thyroid vein. Minor perioperative complications occurred in 42% of patients, which caused no adverse effects. The most common complication was arterial desaturation occurring in 17% of patients; this was short-lived, and the lowest saturation was 79%. Blood loss was minimal (<5 mL) in all but one case, despite an elevated international normalized ratio (INR) and partial thromboplastin time in 42% and 41% of patients, respectively, and a low platelet count in 13% of patients. CONCLUSIONS: Translaryngeal tracheostomy is a safe and reliable technique and can also be used in patients with unstable cervical spines and bleeding diathesis. It has become the authors' procedure of choice for an elective bedside tracheostomy in the intensive care unit.

Documentation↗
PubMed2003

Prophylactic pancreatic enzymes to reduce feeding tube occlusions.

BACKGROUND: Small-bore, feeding tube occlusion is reported to be as high as 23% to 35%. Pancreatic enzyme solution has been used to dissolve internal clots in feeding tubes. This study examined the prophylactic use of pancreatic enzyme solution with continuous enteral feeding in critically ill patients. METHODS: This was a randomized, unblinded trial conducted in an intensive care unit at a tertiary care hospital. Feeding tubes were randomized to receive pancreatic enzyme solution every 4 hours or usual care. Pancreatic enzyme solution contained lipase 8,000 units, amylase 30,000 units, protease activity 30,000 units, sodium bicarbonate 300 mg, and 5 mL warm sterile water. RESULTS: Ninety-five feeding tubes were followed up in 101 patients. Ten feeding tubes (9.9%) developed primary occlusions. Analysis revealed 2/52 (4%) of the tubes in the enzyme arm had occlusions, whereas 8/49 (16%) of control tubes had occlusions (p = .04). Time to occlusion was significantly longer in the pancreatic enzyme arm (p = .02). CONCLUSIONS: The use of prophylactic pancreatic enzymes may reduce the incidence of feeding tube occlusions.

Journal Article↗
PubMed2002

Glutamine supplementation in serious illness: a systematic review of the evidence.

OBJECTIVE: To examine the relationship between glutamine supplementation and hospital length of stay, complication rates, and mortality in patients undergoing surgery and experiencing critical illness. DATA SOURCES: Computerized search of electronic databases and search of personal files, abstract proceedings, relevant journals, and review of reference lists. STUDY SELECTION: We reviewed 550 titles, abstracts, and articles. Primary studies were included if they were randomized trials of critically ill or surgical patients that evaluated the effect of glutamine vs. standard care on clinical outcomes. DATA EXTRACTION We abstracted relevant data on the methodology and outcomes of primary studies in duplicate, independently. DATA SYNTHESIS There were 14 randomized trials comparing the use of glutamine supplementation in surgical and critically ill patients. When the results of these trials were aggregated, with respect to mortality, glutamine supplementation was associated with a risk ratio (RR) of 0.78 (95% confidence interval [CI], 0.58-1.04). Glutamine supplementation was also associated with a lower rate of infectious complications (RR, 0.81; 95% CI, 0.64-1.00) and a shorter hospital stay (-2.6 days; 95% CI, -4.5 to -0.7). We examined several -specified subgroups. Although there were no statistically significant subgroup differences detected, there were some important trends. With respect to mortality, the treatment benefit was observed in studies of parenteral glutamine (RR, 0.71; 95% CI, 0.51-0.99) and high-dose glutamine (RR, 0.73; 95% CI, 0.53-1.00) compared with studies of enteral glutamine (RR, 1.08; 95% CI, 0.57-2.01) and low-dose glutamine (RR, 1.02; 95% CI, 0.52-2.00). With respect to hospital length of stay, all of the treatment benefit was observed in surgical patients (-3.5 days; 95% CI, -5.3 to -1.7) compared with critically ill patients (0.9 days; 95% CI, -4.9 to 6.8). CONCLUSION: In surgical patients, glutamine supplementation may be associated with a reduction in infectious complication rates and shorter hospital stay without any adverse effect on mortality. In critically ill patients, glutamine supplementation may be associated with a reduction in complication and mortality rates. The greatest benefit was observed in patients receiving high-dose, parenteral glutamine.

Critical Care↗
PubMedDate not supplied

Optimizing the benefits and minimizing the risks of enteral nutrition in the critically ill: role of small bowel feeding.

BACKGROUND: Strategies that maximize the delivery of enteral nutrition while minimizing the associated risks have the potential to improve the outcomes of critically ill patients. By delivering enteral feeds in the small bowel, beyond the pylorus, the frequency of regurgitation and the risk of aspiration is thought to be decreased while at the same time, nutrient delivery is maximized. The purpose of this paper is to systematically review those studies that compare gastric with small bowel feeding. METHODS: We searched computerized bibliographic databases, personal files, and relevant reference lists to identify eligible studies. Only randomized, clinical trials of critically ill patients that compared small bowel and gastric feedings were included in this review. In an independent fashion, relevant data on the methodology and outcomes of primary studies were abstracted in duplicate. RESULTS: There were 10 studies that met the inclusion criteria for this review. In 1 study, small bowel feeding was associated with a reduction in gastroesophageal regurgitation and a trend toward reduced pulmonary aspiration. Several studies document that small bowel feeding was associated with an increase in protein and calories delivered and a shorter time to target dose of nutrition. Compared with gastric feeding, when the results of 7 randomized trials were aggregated statistically, small bowel feeding was associated with a reduction in pneumonia (relative risk, 0.76; 95% confidence intervals, 0.59, 0.99). There was no difference in mortality rates between the 2 groups. CONCLUSIONS: Small bowel feeding may be associated with a reduction in gastroesophageal regurgitation, an increase in nutrient delivery, a shorter time to achieve desired target nutrition, and a lower rate of ventilator-associated pneumonia.

Critical Illness↗
PubMedDate not supplied

Nutrition support in the critical care setting: current practice in canadian ICUs--opportunities for improvement?

BACKGROUND: The purpose of this project was to describe current nutrition support practice in the critical care setting and to identify interventions to target for quality improvement initiatives. METHODS: We conducted a cross-sectional national survey of dietitians working in intensive care units (ICUs) across Canada to document various aspects of nutrition support practice. RESULTS: Of the 79 dietitians sent study materials, 66 responded (83%). Sixteen of 66 sites (24.2%) reported the presence of a nutrition support team, and 35 of 66 (53%) used a standard enteral feeding protocol. Dietitians retrospectively abstracted data from charts of all patients in the ICU on April 18, 2001. Of 702 patients, 313 (44.6%) received enteral nutrition only, 50 (7.1%) received parenteral nutrition only, 60 (8.5%) received both, and 279 (39.7%) received no form of nutrition support. Enteral nutrition was initiated on 1.6 days (median) after admission to ICU; 10.7% of patients were initiated on day 1. Of those receiving any form of nutrition support, on average, patients received 58% of their prescribed amounts of calories and protein over the first 12 days in the ICU. Of all days on enteral feeds, patients received feeds into the small bowel on 381 of 2321 (16.4%) days. The mean head of the bed elevation for all patients was 30 degrees. Controlling for differences in patient characteristics, site factors contributing the most successful application of nutrition support included the amount of funded dietitians per ICU bed, size of ICU, and the fact that the ICU was located in an academic setting. CONCLUSIONS: A significant number of critically ill patients did not receive any form of nutrition support for the study period. Those that did receive nutrition support did not meet their prescribed energy or protein needs, especially earlier in the course of their illness. Significant opportunities to improve provision of nutrition support to critically ill patients exist.

Adolescent↗
PubMedDate not supplied

Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients.

OBJECTIVE: This study was conducted to develop evidence-based clinical practice guidelines for nutrition support (ie, enteral and parenteral nutrition) in mechanically ventilated critically ill adults. OPTIONS: The following interventions were systematically reviewed for inclusion in the guidelines: enteral nutrition (EN) versus parenteral nutrition (PN), early versus late EN, dose of EN, composition of EN (protein, carbohydrates, lipids, immune-enhancing additives), strategies to optimize delivery of EN and minimize risks (ie, rate of advancement, checking residuals, use of bedside algorithms, motility agents, small bowel versus gastric feedings, elevation of the head of the bed, closed delivery systems, probiotics, bolus administration), enteral nutrition in combination with supplemental PN, use of PN versus standard care in patients with an intact gastrointestinal tract, dose of PN and composition of PN (protein, carbohydrates, IV lipids, additives, vitamins, trace elements, immune enhancing substances), and the use of intensive insulin therapy. OUTCOMES: The outcomes considered were mortality (intensive care unit [ICU], hospital, and long-term), length of stay (ICU and hospital), quality of life, and specific complications. EVIDENCE: We systematically searched MEDLINE and CINAHL (cumulative index to nursing and allied health), EMBASE, and the Cochrane Library for randomized controlled trials and meta-analyses of randomized controlled trials that evaluated any form of nutrition support in critically ill adults. We also searched reference lists and personal files, considering all articles published or unpublished available by August 2002. Each included study was critically appraised in duplicate using a standard scoring system. VALUES: For each intervention, we considered the validity of the randomized trials or meta-analyses, the effect size and its associated confidence intervals, the homogeneity of trial results, safety, feasibility, and the economic consequences. The context for discussion was mechanically ventilated patients in Canadian ICUs. BENEFITS, HARMS, AND COSTS: The major potential benefit from implementing these guidelines is improved clinical outcomes of critically ill patients (reduced mortality and ICU stay). Potential harms of implementing these guidelines include increased complications and costs related to the suggested interventions. SUMMARIES OF EVIDENCE AND RECOMMENDATIONS: When considering nutrition support in critically ill patients, we strongly recommend that EN be used in preference to PN. We recommend the use of a standard, polymeric enteral formula that is initiated within 24 to 48 hours after admission to ICU, that patients be cared for in the semirecumbent position, and that arginine-containing enteral products not be used. Strategies to optimize delivery of EN (starting at the target rate, use of a feeding protocol using a higher threshold of gastric residuals volumes, use of motility agents, and use of small bowel feeding) and minimize the risks of EN (elevation of the head of the bed) should be considered. Use of products with fish oils, borage oils, and antioxidants should be considered for patients with acute respiratory distress syndrome. A glutamine-enriched formula should be considered for patients with severe burns and trauma. When initiating EN, we strongly recommend that PN not be used in combination with EN. When PN is used, we recommend that it be supplemented with glutamine, where available. Strategies that maximize the benefit and minimize the risks of PN (hypocaloric dose, withholding lipids, and the use of intensive insulin therapy to achieve tight glycemic control) should be considered. There are insufficient data to generate recommendations in the following areas: use of indirect calorimetry; optimal pH of EN; supplementation with trace elements, antioxidants, or fiber; optimal mix of fats and carbohydrates; use of closed feeding systems; continuous versus bolus feedings; use of probiotics; type of lipids; and mode of lipid delivery. VALIDATION: This guideline was peer-reviewed and endorsed by official representatives of the Canadian Critical Care Society, Canadian Critical Care Trials Group, Dietitians of Canada, Canadian Association of Critical Care Nurses, and the Canadian Society for Clinical Nutrition. SPONSORS: This guideline is a joint venture of the Canadian Critical Care Society, the Canadian Critical Trials Group, the Canadian Society for Clinical Nutrition, and Dietitians of Canada. The Canadian Critical Care Society and the Institute of Nutrition, Metabolism, and Diabetes of the Canadian Institutes of Health Research provided funding for development of this guideline.

Canada↗