CJEM Articles: David D. Sweet

Displaying 1-4 of 4 results

  • Prevalence of advance directives among elderly patients attending an urban Canadian emergency department
    March 2012 14 2
    David D. Sweet, Erin Fukushima, Ginjeet Gina K. Gill, Riyad B. Abu-Laban

     Introduction:
    To date, there has been minimal research on advance directives (ADs) among elderly patients in Canadian emergency departments (EDs). The purpose of this study was to determine the prevalence of ADs among elderly patients visiting an urban ED. We also explored whether there were factors associated with the existence of an AD and possible barriers to having one.
    Methods:
    This prospective study ran between October and December 2008. Individuals over the age of 70 who presented to the ED between 7 am and 7 pm, 7 days a week, were considered for enrolment. Exclusion criteria included previous enrolment and inability to provide informed consent. A team of nurses who specialize in assessment of geriatric patients administered a study instrument consisting of 28 questions. Topics included demographics, level of education, medical information, and knowledge of and attitudes toward ADs.
    Results:
    The results from 280 participants, with an average age of 80.6 years, were analyzed. Thirty-five percent of participants reported that they knew what an AD was; 19.3% of participants said they had an AD, but only 5.6% brought it to the hospital; 50.7% were interested in further information regarding ADs; and 67.9% of participants felt that it was important for physicians to know their wishes about life support.
    Conclusion:
    Knowledge of ADs among elderly patients visiting an urban Canadian ED is limited and is likely a significant factor precluding wider prevalence of ADs. There is interest in further discussion about ADs in this population group.

  • Effect of an emergency department sepsis protocol on the care of septic patients admitted to the intensive care unit
    September 2010 12 5
    David D. Sweet, MD, MD; Dean Chittock, MD; Dharmvir Jaswal, MD; Jen Rachel, MD; Matt Bouchard, MD; Praveena Sivapalan, MD; Winnie Fu, MSc

    Objective: We sought to determine whether the implementation of a sepsis protocol in a Canadian emergency department (ED) improves care for the subset of patients admitted to the intensive care unit (ICU).
    Methods: After implementing a sepsis protocol in our ED we used an ICU database and chart review to compare various time-dependent end points and outcomes between a historical control year and the first year after implementation. We re-viewed the charts of all patients admitted to the ICU within 24 hours of ED admission with a primary or other diagnosis of sepsis, severe sepsis or septic shock, who met criteria for early goal-directed therapy within the first 6 hours of their ED stay.
    Results: We compared 29 patients from the control year with 30 patients from the year after implementation of our sepsis protocol. We found that patients treated during the postintervention year had improvements in time to antibiotics (4.2 v. 1.0 h, difference = –3.2 h, 95% CI –4.8 to –2.0), time to central line placement (above the diaphragm) (11.6 v. 3.2 h, difference = –8.4 h, 95% CI –12.1 to –4.7), time to arterial line placement (7.5 v. 2.3 h, difference = –5.2 h, 95% CI –7.4 to –3.0), and achievement of central venous pressure and central venous oxygen saturation goals (11.1 v. 5.1 h, difference = –6.0 h, 95% CI –11.03 to –1.71, and 13.1 v. 5.5 h,  difference = –7.6 h, 95% CI –11.97 to –3.16, respectively). There were no statistically significant differences in ICU length of stay, hospital length of stay or mortality (31.0% v. 20.0%, difference = –11.0%, 95% CI–33.1% to 11.1%).
    Conclusion: Implementation of an ED sepsis protocol im-proves care for patients with severe sepsis and septic shock.

  • Profound metabolic acidosis from pyroglutamic acidemia: an underappreciated cause of high anion gap metabolic acidosis
    September 2010 12 5
    David D. Sweet, Jan Jaap Bijlsma, Thomas J. Green

    The workup of the emergency patient with a raised anion gap metabolic acidosis includes assessment of the components of “MUDPILES” (methanol; uremia; diabetic ketoacidosis; paraldehyde; isoniazid, iron or inborn errors of metabolism; lactic acid; ethylene glycol; salicylates). This approach is usually sufficient for the majority of cases in the emergency department; however, there are many other etiologies not addressed in this mnemonic. Organic acids including 5-oxoproline (pyroglutamic acid) are rare but important causes of anion gap metabolic acidosis. We present the case of a patient with profound metabolic acidosis with raised anion gap, due to pyroglutamic acid in the setting of malnutrition and chronic ingestion of acetaminophen.

  • Purulent pericarditis in a patient with rheumatoid arthritis treated with etanercept and methotrexate
    January 2007 9 1
    Bruce Morrison, David D. Sweet, George Isac, John Fenwick, Vinay Dhingra

    Purulent pericarditis is rarely seen in this post-antibiotic era. We report a case of spontaneous purulent pericarditis in a patient with rheumatoid arthritis being treated with etanercept, a tumour necrosis factor-alpha (TNF-α) antagonist, and methotrexate, an immunosuppressant. Both are disease-modifying anti-rheumatic drugs. We discuss the pathophysiology of purulent pericarditis and the recent literature on the infectious complications of TNF-α antagonists.