Highlights from the Critical Care Canada Forum 2009 - 25 to 28 October 2009, Toronto, Ontario, Canada

The Critical Care Canada Forum was held in Toronto, Canada from October 25-28 2009. The conference, which focuses on the care of critically ill patients wherever the patients are located, was attended by 879 delegates and featured 197 separate presentations, including several as yet unpublished trials. The hot topic this year was planning for the impact of a worldwide outbreak of H1N1 influenza on critical care systems, but the conference also covered a broad range of critical care interventions including mechanical ventilation, sedation and analgesia, renal replacement therapy, and extracorporeal membrane oxygenation. Herein we summarize just a few of the many exciting clinical trials and plenary topics presented at the conference.


H1N1 pandemic
Th e Critical Care Canada Forum 2009 featured several presentations describing the outcomes of critically ill patients with H1N1 virus infection from Australia, Mexico, and Canada.
Dr Jamie Cooper (Melbourne, Australia), speaking on behalf of the Australia-New Zealand Intensive Care Infl uenza Investigators [2], described outcomes of 722 patients with confi rmed H1N1 virus infection that were admitted to 187 intensive care units. Of these patients, most (92%) were younger than age 65, and large proportions were pregnant (9.1%) or had a body mass index >35 (28.6%). Th e overall mortality rate (as of September 2009) was 14.3% (95% confi dence interval = 11.7 to 16.9%). Nitric oxide, inhaled prostacyclin, and prone positioning were used frequently to treat refractory hypoxemia. Outcomes of 68 patients from 15 centres who were treated with extracorporeal membrane oxygenation were also described [3]. Illness severity was predictably very high in this group, and the overall hospital mortality was 23% with most deaths due to haemorrhage.
Dr Anand Kumar (Winnipeg, Canada) and Dr Rob Fowler (Toronto, Canada) presented data from the Canadian Experience [4]. Severe illness due to H1N1 infection (confi rmed or probable) occurred in 168 patients during a 4-month period. Similar to the Australian-New Zealand experience, the cohort was young (mean age 32 years), and females, children, and the obese were disproportionally aff ected by severe illness requiring critical care. Th e overall mortality at 90 days was 17.3% (95% confi dence interval = 12.0 to 24%). Notably, onequarter of cases involved First Nations Canadians, Inuit, Métis, or aboriginals. Rescue therapies to treat refractory hypoxemia, including nitric oxide and high-frequency oscillation, were also commonly required in this group.
Dr Guillermo Dominguez (Mexico City, Mexico) next presented outcomes of 58 critically ill patients with H1N1 infection in Mexico [5]. Th is cohort was one of the fi rst to be aff ected by the pandemic, and mortality at 60 days was high (41.4%, 95% confi dence interval = 28.9 to 55.0%).
Together, these presentations highlighted the potential importance of early treatment with neuraminidase inhibitors. Following the session, 240 of the Critical Care Canada Forum delegates received the H1N1 vaccine through a team from the Toronto Public Health Department.

Renal replacement therapy
Dr Jamie Cooper (Melbourne, Australia) also presented the recently published RENAL study (Randomized Evaluation of Normal vs. Augmented Level of renal replace ment therapy in ICU) [6] on behalf of the Australian and New Zealand Intensive Care Society Clinical Trials Group and the George Institute for International Health. Th is study randomized 1,508 patients to receive either lower intensity (25 ml/kg body weight/ hour) or higher intensity (40 ml/kg body weight/hour) post-dilution continuous venovenous haemodiafi ltration. At 90 days, mortality in both groups was the same (44.7%) (odds ratio = 1.00, 95% confi dence interval = 0.81 to 1.23; P = 0.99). Higher rates of hypophosphataemia were observed in the higher intensity group. Dr Cooper concluded that the results of this study and the recently published Veterans Aff airs/National Institutes of Health Acute Renal Failure Trial Network study [7], which produced similar fi ndings, suggest that higher intensity renal replacement therapy does not lead to lower mortality for critically ill patients.

Intensive care unit follow-up programmes
Dr Brian Cuthbertson (Toronto, Canada) presented the PRaCTICaL study, a UK multicentre randomized controlled trial of intensive nurse-led intensive care unit follow-up programmes versus standard care [8]. Th e intervention included clinic visits and a self-directed physical rehabilitation programme. In total, 286 patients were included and 192 completed 1-year follow-up. Th ere was no evidence of a diff erence in the main outcome measurehealth-related quality of life measured using the Short Form 36 questionnaire at 12 months. During the discussion follow ing the presentation, it was suggested that future studies should consider focusing on diff erently timed or diff er ently structured programmes to improve long-term out comes of patients following intensive care unit discharge.

Industry and medicine
Dr Tom Stossel (Boston, USA) and Dr Allan Detsky (Toronto, Canada) engaged in an exciting debate about the pros and cons of allowing for-profi t companies to become involved in healthcare research, medical education, and clinical practice. Dr Stossel reminded delegates of the large number of new products and innovations that were introduced during the past 30 years that would probably not have been developed without signifi cant investment from industry. He also discussed the extent to which US government legislation now restricts the activities of industry in that country. In his response, Dr Detsky reasoned that there should always be a clear separation between funding for research and funding for marketing and promotion. He also argued that groups tasked with developing clinical guidelines should be discouraged from accepting funding from industry to reduce the potential for a confl ict of interest.

Conclusion
Th e above is just a small selection of the many fascinating clinical and basic science topics that were presented at this year's meeting, including rehabilitation and early mobilization after critical care, acute respiratory distress syndrome, cardiology problems in critical care, and transfusion medicine. Planning for next year's meeting is already under way and it promises to maintain the same very high standard of critical care education. Save the date: 6 to 10 November 2010.