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After practicing labour law for ten years, she joined the Yukon government's treaty negotiation team with special responsibility for the self-government and dispute resolution tables. She worked in Ontario on tax policy and reported to the Deputy Minister of Health as a special consultant on health care reform.
She has deep tribunal experience. Her practice consists of serving clients as an arbitrator and mediator and sole tribunal judge. Lane served as a Director of Coast Capital Savings for nine years and has extensive Board experience in the charitable sector. Lane holds the Chartered Mediator and Chartered Arbitrator designations. Lane was appointed as board chair on December 31, , for a two-year term ending December 31, Prior to his move to the Maritimes in , Dr.
Yoon completed all of his medical training at the University of Alberta and was an academic emergency physician based at the University of Alberta Hospital for 13 years. Serum lactate is not a direct measure of tissue perfusion [ 31 ]. Increases in the serum lactate level may represent tissue hypoxia, accelerated aerobic glycolysis driven by excess beta-adrenergic stimulation, or other causes e. Regardless of the source, increased lactate levels are associated with worse outcomes [ 32 ].
Because lactate is a standard laboratory test with prescribed techniques for its measurement, it may serve as a more objective surrogate for tissue perfusion as compared with physical examination or urine output.
Five randomized controlled trials patients have evaluated lactate-guided resuscitation of patients with septic shock [ 33 , 34 , 35 , 36 , 37 ]. A significant reduction in mortality was seen in lactate-guided resuscitation compared to resuscitation without lactate monitoring RR 0. Two other meta-analyses of the patients who were enrolled in these trials demonstrate moderate evidence for reduction in mortality when an early lactate clearance strategy was used, compared with either usual care nonspecified or with a Scvo 2 normalization strategy [ 38 , 39 ].
We recommend that hospitals and hospital systems have a performance improvement program for sepsis, including sepsis screening for acutely ill, high-risk patients BPS.
Rationale Performance improvement efforts for sepsis are associated with improved patient outcomes [ 40 ]. Sepsis performance improvement programs should optimally have multiprofessional representation physicians, nurses, affiliate providers, pharmacists, respiratory therapists, dietitians, administrators with stakeholders from all key disciplines represented in their development and implementation.
Successful programs should include protocol development and implementation, targeted metrics to be evaluated, data collection, and ongoing feedback to facilitate continuous performance improvement [ 41 ].
In addition to traditional continuing education efforts to introduce guidelines into clinical practice, knowledge translation efforts can be valuable in promoting the use of high-quality evidence in changing behavior [ 42 ]. Sepsis performance improvement programs can be aimed at earlier recognition of sepsis via a formal screening effort and improved management of patients once they are identified as being septic.
Because lack of recognition prevents timely therapy, sepsis screening is associated with earlier treatment [ 43 , 44 ]. Notably, sepsis screening has been associated with decreased mortality in several studies [ 20 , 45 ].
The implementation of a core set of recommendations bundle has been a cornerstone of sepsis performance improvement programs aimed at improving management [ 46 ].
Note that the SSC bundles have been developed separately from the guidelines in conjunction with an educational and improvement partnership with the Institute for Healthcare Improvement [ 46 ]. The SSC bundles that are based on previous guidelines have been adopted by the U. To align with emerging evidence and U. While specifics vary widely among different programs, a common theme is the drive toward improvement in compliance with sepsis bundles and practice guidelines such as SSC [ 8 ].
A meta-analysis of 50 observational studies demonstrated that performance improvement programs were associated with a significant increase in compliance with the SSC bundles and a reduction in mortality OR 0. The largest study to date examined the relationship between compliance with the SSC bundles based on the guidelines and mortality.
A total of 29, patients in hospitals in the United States, Europe, and South America were examined over a 7. Lower mortality was observed in hospitals with higher compliance. Overall hospital mortality decreased 0. This benefit has also been shown across a wide geographic spectrum. This recommendation met the prespecified criteria for a BPS. The specifics of performance improvement methods varied markedly between studies; thus, no single approach to performance improvement could be recommended ESM 5.
We recommend that appropriate routine microbiologic cultures including blood be obtained before starting antimicrobial therapy in patients with suspected sepsis or septic shock if doing so results in no substantial delay in the start of antimicrobials BPS. Remarks Appropriate routine microbiologic cultures always include at least two sets of blood cultures aerobic and anaerobic. Rationale Sterilization of cultures can occur within minutes to hours after the first dose of an appropriate antimicrobial [ 49 , 50 ].
Obtaining cultures prior to the administration of antimicrobials significantly increases the yield of cultures, making identification of a pathogen more likely. Isolation of an infecting organism s allows for de-escalation of antimicrobial therapy first at the point of identification and then again when susceptibilities are obtained.
De-escalation of antimicrobial therapy is a mainstay of antibiotic stewardship programs and is associated with less resistant microorganisms, fewer side effects, and lower costs [ 51 ]. Several retrospective studies have suggested that obtaining cultures prior to antimicrobial therapy is associated with improved outcome [ 52 , 53 ].
Similarly, de-escalation has also been associated with improved survival in several observational studies [ 54 , 55 ]. The desire to obtain cultures prior to initiating antimicrobial therapy must be balanced against the mortality risk of delaying a key therapy in critically ill patients with suspected sepsis or septic shock who are at significant risk of death [ 56 , 57 ].
We recommend that blood cultures be obtained prior to initiating antimicrobial therapy if cultures can be obtained in a timely manner. Therefore, in patients with suspected sepsis or septic shock, appropriate routine microbiologic cultures should be obtained before initiation of antimicrobial therapy from all sites considered to be potential sources of infection if it results in no substantial delay in the start of antimicrobials.
This may include blood, cerebrospinal fluid, urine, wounds, respiratory secretions, and other body fluids, but does not normally include samples that require an invasive procedure such as bronchoscopy or open surgery. The decision regarding which sites to culture requires careful consideration from the treatment team.
If history or clinical examination clearly indicates a specific anatomic site of infection, cultures of other sites apart from blood are generally unnecessary.
Two or more sets aerobic and anaerobic of blood cultures are recommended before initiation of any new antimicrobial in all patients with suspected sepsis [ 59 ]. All necessary blood cultures may be drawn together on the same occasion.
Blood culture yield has not been shown to be improved with sequential draws or timing to temperature spikes [ 60 , 61 ]. Details on appropriate methods to draw and transport blood culture samples are enumerated in other guidelines [ 61 , 62 ].
This is done to assist in the diagnosis of a potential catheter-related bloodstream infection. Data are inconsistent regarding the utility of differential time to blood culture positivity i. It is important to note that drawing blood cultures from an intravascular catheter in case of possible infection of the device does not eliminate the option of removing the catheter particular nontunneled catheters immediately afterward. In patients without a suspicion of catheter-associated infection and in whom another clinical infection site is suspected, at least one blood culture of the two or more that are required should be obtained peripherally.
However, no recommendation can be made as to where additional blood cultures should be drawn.
Options include: a all cultures drawn peripherally via venipuncture, b cultures drawn through each separate intravascular device but not through multiple lumens of the same intravascular catheter, or c cultures drawn through multiple lumens in an intravascular device [ 66 , 67 , 68 , 69 , 70 ].
In the near future, molecular diagnostic methods may offer the potential to diagnose infections more quickly and more accurately than current techniques. However, varying technologies have been described, clinical experience remains limited, and additional validation is needed before recommending these methods as an adjunct to or replacement for standard blood culture techniques [ 71 , 72 , 73 ].
In addition, susceptibility testing is likely to require isolation and direct testing of viable pathogens for the foreseeable future. Rationale The rapidity of administration is central to the beneficial effect of appropriate antimicrobials.
In the presence of sepsis or septic shock, each hour delay in administration of appropriate antimicrobials is associated with a measurable increase in mortality [ 57 , 74 ]. Further, several studies show an adverse effect on secondary end points e.
Despite a meta-analysis of mostly poor-quality studies that failed to demonstrate a benefit of rapid antimicrobial therapy, the largest and highest-quality studies support giving appropriate antimicrobials as soon as possible in patients with sepsis with or without septic shock [ 57 , 74 , 79 , 80 , 81 ].
The majority of studies within the meta-analysis were of low quality due to a number of deficiencies, including small study size, using an initial index time of an arbitrary time point such as emergency department arrival, and indexing of outcome to delay in time to the first antimicrobial regardless of activity against the putative pathogen [ 82 , 83 ]. Other negative studies not included in this meta-analysis are compromised by equating bacteremia with sepsis as currently defined to include organ failure and septic shock [ 84 , 85 , 86 , 87 ].
Many of these studies are also compromised by indexing delays to easily accessible but nonphysiologic variables such as time of initial blood culture draw an event likely to be highly variable in timing occurrence.
The feasibility of achieving this target consistently, however, has not been adequately assessed. A number of patient and organizational factors appear to influence antimicrobial delays [ 88 ]. Accelerating appropriate antimicrobial delivery institutionally starts with an assessment of causes of delays [ 89 ].
These can include an unacceptably high frequency of failure to recognize the potential existence of sepsis or septic shock and of inappropriate empiric antimicrobial initiation e. In addition, unrecognized or underappreciated administrative or logistic factors often easily remedied may be found. Improving communication among medical, pharmacy, and nursing staff can also be highly beneficial.
Most issues can be addressed by quality improvement initiatives, including defined order sets. If antimicrobial agents cannot be mixed and delivered promptly from the pharmacy, establishing a supply of premixed drugs for urgent situations is an appropriate strategy for ensuring prompt administration. Many antimicrobials will not remain stable if premixed in a solution. This issue must be taken into consideration in institutions that rely on premixed solutions for rapid antimicrobial availability.
In addition, cross-sex hormones testosterone and estrogen are associated with dangerous health risks including but not limited to cardiac disease, high blood pressure, blood clots, stroke, diabetes, and cancer. Rates of suicide are nearly twenty times greater among adults who use cross-sex hormones and undergo sex reassignment surgery, even in Sweden which is among the most LGBTQ — affirming countries.
Conditioning children into believing a lifetime of chemical and surgical impersonation of the opposite sex is normal and healthful is child abuse. Michelle A. Cretella, M. The College is unaware of any medical literature that documents a gender dysphoric child seeking puberty blocking hormones who is not significantly distressed by the thought of passing through the normal and healthful process of puberty. In natal males, persistence has ranged from 2.
There is an obvious self-fulfilling nature to encouraging young GD children to impersonate the opposite sex and then institute pubertal suppression.
If a boy who questions whether or not he is a boy who is meant to grow into a man is treated as a girl, then has his natural pubertal progression to manhood suppressed, have we not set in motion an inevitable outcome? All of his same sex peers develop into young men, his opposite sex friends develop into young women, but he remains a pre-pubertal boy. He will be left psychosocially isolated and alone. He will be left with the psychological impression that something is wrong.
Moreover, neuroscience reveals that the pre-frontal cortex of the brain which is responsible for judgment and risk assessment is not mature until the mid-twenties. Never has it been more scientifically clear that children and adolescents are incapable of making informed decisions regarding permanent, irreversible and life-altering medical interventions. For this reason, the College maintains it is abusive to promote this ideology, first and foremost for the well-being of the gender dysphoric children themselves, and secondly, for all of their non-gender-discordant peers, many of whom will subsequently question their own gender identity, and face violations of their right to bodily privacy and safety.