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Tiruvoipati R, Kaul S, Gupta S, Haji K. VENT-AVOID Trial - Avoiding Acute Hypercapnic Respiratory Failure! Am J Respir Crit Care Med 2024. [PMID: 38608272 DOI: 10.1164/rccm.202403-0514le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/11/2024] [Indexed: 04/14/2024] [Imported: 04/14/2024] Open
Affiliation(s)
| | - Sameer Kaul
- Peninsula Health, 5644, Frankston, Victoria, Australia
| | - Sachin Gupta
- Frankston Hospital, 60087, Frankston, Victoria, Australia
- Monash University Faculty of Medicine Nursing and Health Sciences, 22457, Clayton, Victoria, Australia
| | - Kavi Haji
- Frankston Hospital, 60087, Frankston, Victoria, Australia
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Sivarajah J, Toolis M, Seminoff S, Smith J, Bhalla V, Paul E, Tiruvoipati R. Prognostic value of high-sensitivity cardiac troponin in non-cardiac surgical patients in intensive care units. Intern Emerg Med 2024; 19:201-209. [PMID: 38194002 PMCID: PMC10827830 DOI: 10.1007/s11739-023-03509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 12/06/2023] [Indexed: 01/10/2024] [Imported: 01/10/2024]
Abstract
Type II myocardial injury following surgical procedures is associated with adverse outcomes. The prognostic value of high-sensitivity cardiac troponin (hs-cTn) due to type II myocardial injury in surgical patients admitted to intensive care unit (ICU) remains unclear. The aim of this study was to assess prognostic value of hs-cTn in type II acute myocardial injury in non-cardiac surgical patients requiring post-operative ICU admission. Retrospective analysis of patients admitted to two level III ICUs following surgery and had hs-cTn measured on the day of ICU admission. Patients who had type I acute myocardial infarction (AMI) during their admission were excluded from the study. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ICU length of stay (LOS) and hospital LOS. A total of 420 patients were included. On univariable analysis, higher hs-cTn was associated with increased hospital mortality (14.6% vs 6.3%, p = 0.008), ICU LOS (41.1 h, vs 25 h, p = 0.004) and hospital LOS (253 h vs 193 h, p = 0.02). On multivariable analysis, hs-cTn was not independently associated with increased risk of hospital mortality. However, in patients who had elective surgery, hs-cTn was associated with increased risk (OR 1.048; 95% CI 1.004-1.094; p = 0.031) of hospital mortality with area under the receiver operating characteristic curve of 0.753 (95% CI 0.598-0.908). In elective surgical patients, hs-cTn was associated with increased risk of mortality. Larger multicentre studies are required to confirm this association that may assist in risk stratification of elective surgical patients requiring ICU admission.
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Affiliation(s)
- Jitain Sivarajah
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Michael Toolis
- Department of Intensive Care Medicine, Dandenong Hospital, 135 David Street, Dandenong, VIC, 3175, Australia
| | - Samantha Seminoff
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Jesse Smith
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Vikram Bhalla
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia
| | - Eldho Paul
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC, 3199, Australia.
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
- Peninsula Clinical School, Monash University, Faculty of Medicine, Nursing and Health Sciences, Frankston, Australia.
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Brown H, Donnan M, McCafferty J, Collyer T, Tiruvoipati R, Gupta S. Association between frailty and clinical outcomes in hospitalised patients requiring Code Blue activation. Intern Med J 2022; 52:1602-1608. [PMID: 33977608 DOI: 10.1111/imj.15352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/06/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Code Blues allow a rapid, hospital wide response to acutely deteriorating patients. The concept of frailty is being increasingly recognised as an important element in determining outcomes of critically ill patients. We hypothesised that increasing frailty would be associated with worse outcomes following a Code Blue. AIMS To investigate the association between increasing frailty and outcomes of Code Blues. METHODS Single-centre retrospective design of patients admitted to Frankston Hospital in Australia between 1 January 2013 and 31 December 2017 who triggered a Code Blue. Frailty evaluation was made based on electronic medical records as were the details and the outcomes of the Code Blue. The primary outcome measure was a composite of hospital mortality or Cerebral Performance Categories scale ≥3. Secondary outcomes included the immediate outcome of the Code Blue and hospital mortality. RESULTS One hundred and forty-eight of 911 screened patients were included in the final analysis. Seventy-three were deemed 'frail' and the remainder deemed 'fit'. Seventy-eight percent of frail patients reached the primary outcome, compared with 41% of fit patients (P < 0.001). Multivariable analysis demonstrated frailty to be associated with primary outcome (odds ratio = 2.87; 95% confidence interval (CI) 1.28-6.44; P = 0.01). A cardiac aetiology for the Code Blue was also associated with an increased odds of primary outcome (OR = 3.52; 95% CI 1.51-8.05; P = 0.004). CONCLUSIONS Frailty is independently associated with the composite outcome of hospital mortality or severe disability following a Code Blue. Frailty is an important tool in prognostication for these patients and might aid in discussions regarding treatment limitations.
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Affiliation(s)
- Hamish Brown
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
| | - Matthew Donnan
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
| | - Jonathan McCafferty
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
| | - Taya Collyer
- Academic Unit, Peninsula Health, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
| | - Sachin Gupta
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
- Monash University, Melbourne, Victoria, Australia
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Subramaniam A, Pilcher D, Tiruvoipati R, Wilson J, Mitchell H, Xu D, Bailey M. Timely goals of care documentation in patients with frailty in the COVID-19 era: a retrospective multi-site study. Intern Med J 2022; 52:935-943. [PMID: 34935268 DOI: 10.1111/imj.15671] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/09/2021] [Accepted: 12/15/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Older frail patients are more likely to have timely goals of care (GOC) documentation than non-frail patients. AIMS To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID-19 pandemic (2020), compared with the pre-COVID-19 era (2019) for older frail patients. METHODS Multi-site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC. RESULTS The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68-0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80-0.93). CONCLUSION Timely GOC documentation occurred less frequently in frail patients during the COVID-19 pandemic than in the pre-COVID-19 era.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
- Peninsula Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
- Peninsula Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John Wilson
- Department of Information Technology, Peninsula Health, Melbourne, Victoria, Australia
| | - Hayden Mitchell
- Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Dan Xu
- Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
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Subramaniam A, Ueno R, Tiruvoipati R, Srikanth V, Bailey M, Pilcher D. Comparison of the predictive ability of clinical frailty scale and hospital frailty risk score to determine long-term survival in critically ill patients: a multicentre retrospective cohort study. Crit Care 2022; 26:121. [PMID: 35505435 PMCID: PMC9063154 DOI: 10.1186/s13054-022-03987-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The Clinical Frailty Scale (CFS) is the most commonly used frailty measure in intensive care unit (ICU) patients. The hospital frailty risk score (HFRS) was recently proposed for the quantification of frailty. We aimed to compare the HFRS with the CFS in critically ill patients in predicting long-term survival up to one year following ICU admission. METHODS In this retrospective multicentre cohort study from 16 public ICUs in the state of Victoria, Australia between 1st January 2017 and 30th June 2018, ICU admission episodes listed in the Australian and New Zealand Intensive Care Society Adult Patient Database registry with a documented CFS, which had been linked with the Victorian Admitted Episode Dataset and the Victorian Death Index were examined. The HFRS was calculated for each patient using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes that represented pre-existing conditions at the time of index hospital admission. Descriptive methods, Cox proportional hazards and area under the receiver operating characteristic (AUROC) were used to investigate the association between each frailty score and long-term survival up to 1 year, after adjusting for confounders including sex and baseline severity of illness on admission to ICU (Australia New Zealand risk-of-death, ANZROD). RESULTS 7001 ICU patients with both frailty measures were analysed. The overall median (IQR) age was 63.7 (49.1-74.0) years; 59.5% (n = 4166) were male; the median (IQR) APACHE II score 14 (10-20). Almost half (46.7%, n = 3266) were mechanically ventilated. The hospital mortality was 9.5% (n = 642) and 1-year mortality was 14.4% (n = 1005). HFRS correlated weakly with CFS (Spearman's rho 0.13 (95% CI 0.10-0.15) and had a poor agreement (kappa = 0.12, 95% CI 0.10-0.15). Both frailty measures predicted 1-year survival after adjusting for confounders, CFS (HR 1.26, 95% CI 1.21-1.31) and HFRS (HR 1.08, 95% CI 1.02-1.15). The CFS had better discrimination of 1-year mortality than HFRS (AUROC 0.66 vs 0.63 p < 0.0001). CONCLUSION Both HFRS and CFS independently predicted up to 1-year survival following an ICU admission with moderate discrimination. The CFS was a better predictor of 1-year survival than the HFRS.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Peninsula Health, 2 Hastings Road, VIC, 3199, Frankston, Australia.
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Eastern Health, Box Hill, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Peninsula Health, 2 Hastings Road, VIC, 3199, Frankston, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Peninsula Clinical School, Monash University, Frankston, VIC, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Geriatric Medicine, Peninsula Health, Frankston, VIC, Australia
- National Centre for Healthy Ageing, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
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Collyer TA, Athanasopoulos G, Srikanth V, Tiruvoipati R, Matthews C, Mcinnes N, Menon S, Dowling J, Braun G, Krivitsky TA, Cooper H, Andrew NE. Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia. J Epidemiol Community Health 2022; 76:341-349. [PMID: 34782421 PMCID: PMC8595051 DOI: 10.1136/jech-2021-217010] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Accepted: 11/02/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Melbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020). METHODS We used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020. RESULTS ED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and <18 years. Presentations persisted at expected levels for urgent conditions, and ED triage categories 1 and 5, with clear reductions in categories 2-4. CONCLUSIONS Our analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne's lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.
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Affiliation(s)
- Taya A Collyer
- Peninsula Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston, Victoria, Australia
- National Centre for Healthy Aging, Frankston, Victoria, Australia
| | - George Athanasopoulos
- Department of Econometrics and Business Statistics, Monash University Faculty of Business and Economics, Caulfield East, Victoria, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston, Victoria, Australia
- National Centre for Healthy Aging, Frankston, Victoria, Australia
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Peninsula Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston, Victoria, Australia
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Chris Matthews
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Nicholas Mcinnes
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Shyaman Menon
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Jonathan Dowling
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Gary Braun
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Timur A Krivitsky
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Helen Cooper
- Peninsula Health, Frankston Hospital, Frankston, Victoria, Australia
| | - Nadine E Andrew
- Peninsula Clinical School, Monash University Faculty of Medicine, Nursing and Health Sciences, Frankston, Victoria, Australia
- National Centre for Healthy Aging, Frankston, Victoria, Australia
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Tiruvoipati R, Gupta S, Haji K. COVID-19 Is Not Comparable to H1N1 Influenza. Ann Am Thorac Soc 2022; 19:509-510. [PMID: 34818143 PMCID: PMC8937222 DOI: 10.1513/annalsats.202110-1097le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Affiliation(s)
- Ravindranath Tiruvoipati
- Penninsula HealthMelbourne, Victoria, Australia
- Peninsula Clinical School, Monash UniversityMelbourne, Victoria, Australia
- Corresponding author (e-mail: )
| | - Sachin Gupta
- Penninsula HealthMelbourne, Victoria, Australia
- Peninsula Clinical School, Monash UniversityMelbourne, Victoria, Australia
| | - Kavi Haji
- Penninsula HealthMelbourne, Victoria, Australia
- Monash UniversityMelbourne, Victoria, Australia
- University of MelbourneMelbourne, Victoria, Australia
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Tiruvoipati R, Serpa Neto A, Young M, Marhoon N, Wilson J, Gupta S, Pilcher D, Bailey M, Bellomo R. An Exploratory Analysis of the Association between Hypercapnia and Hospital Mortality in Critically Ill Patients with Sepsis. Ann Am Thorac Soc 2022; 19:245-254. [PMID: 34380007 DOI: 10.1513/annalsats.202102-104oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Rationale: Hypercapnia may affect the outcome of sepsis. Very few clinical studies conducted in noncritically ill patients have investigated the effects of hypercapnia and hypercapnic acidemia in the context of sepsis. The effect of hypercapnia in critically ill patients with sepsis remains inadequately studied. Objectives: To investigate the association of hypercapnia with hospital mortality in critically ill patients with sepsis. Methods: This is a retrospective study conducted in three tertiary public hospitals. Critically ill patients with sepsis from three intensive care units between January 2011 and May 2019 were included. Five cohorts (exposure of at least 24, 48, 72, 120, and 168 hours) were created to account for immortal time bias and informative censoring. The association between hypercapnia exposure and hospital mortality was assessed with multivariable models. Subgroup analyses compared ventilated versus nonventilated and pulmonary versus nonpulmonary sepsis patients. Results: We analyzed 84,819 arterial carbon dioxide pressure measurements in 3,153 patients (57.6% male; median age was 62.5 years). After adjustment for key confounders, both in mechanically ventilated and nonventilated patients and in patients with pulmonary or nonpulmonary sepsis, there was no independent association of hypercapnia with hospital mortality. In contrast, in ventilated patients, the presence of prolonged exposure to both hypercapnia and acidemia was associated with increased mortality (highest odds ratio of 16.5 for ⩾120 hours of potential exposure; P = 0.007). Conclusions: After adjustment, isolated hypercapnia was not associated with increased mortality in patients with sepsis, whereas prolonged hypercapnic acidemia was associated with increased risk of mortality. These hypothesis-generating observations suggest that as hypercapnia is not an independent risk factor for mortality, trials of permissive hypercapnia avoiding or minimizing acidemia in sepsis may be safe.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Marcus Young
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Nada Marhoon
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - John Wilson
- Peninsula Health Informatics, Frankston Hospital, Melbourne, Victoria, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, The Alfred Hospital, Melbourne, Victoria, Australia; and
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation, the University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Peninsula Clinical School, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
- Data Analytics Research and Evaluation, the University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
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Chan R, Ueno R, Afroz A, Billah B, Tiruvoipati R, Subramaniam A. Association between frailty and clinical outcomes in surgical patients admitted to intensive care units: a systematic review and meta-analysis. Br J Anaesth 2022; 128:258-271. [PMID: 34924178 DOI: 10.1016/j.bja.2021.11.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/10/2021] [Accepted: 11/03/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preoperative frailty may be a strong predictor of adverse postoperative outcomes. We investigated the association between frailty and clinical outcomes in surgical patients admitted to the ICU. METHODS PubMed, Embase, and Ovid MEDLINE were searched for relevant articles. We included full-text original English articles that used any frailty measure, reporting results of surgical adult patients (≥18 yr old) admitted to ICUs with mortality as the main outcome. Data on mortality, duration of mechanical ventilation, ICU and hospital length of stay, and discharge destination were extracted. The quality of included studies and risk of bias were assessed using the Newcastle Ottawa Scale. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS Thirteen observational studies met inclusion criteria. In total, 58 757 patients were included; 22 793 (39.4%) were frail. Frailty was associated with an increased risk of short-term (risk ratio [RR]=2.66; 95% confidence interval [CI]: 1.99-3.56) and long-term mortality (RR=2.66; 95% CI: 1.32-5.37). Frail patients had longer ICU length of stay (mean difference [MD]=1.5 days; 95% CI: 0.8-2.2) and hospital length of stay (MD=3.9 days; 95% CI: 1.4-6.5). Duration of mechanical ventilation was longer in frail patients (MD=22 h; 95% CI: 1.7-42.3) and they were more likely to be discharged to a healthcare facility (RR=2.34; 95% CI: 1.36-4.01). CONCLUSION Patients with frailty requiring postoperative ICU admission for elective and non-elective surgeries had increased risk of mortality, lengthier admissions, and increased likelihood of non-home discharge. Preoperative frailty assessments and risk stratification are essential in patient and clinician planning, and critical care resource utilisation. CLINICAL TRIAL REGISTRATION PROSPERO CRD42020210121.
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Affiliation(s)
- Rachel Chan
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Department of Anaesthesia and Pain Management, The Canberra Hospital, ACT, Australia.
| | - Ryo Ueno
- Department of Intensive Care, Eastern Health, Box Hill, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, VIC, Australia.
| | - Afsana Afroz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia; Monash University Peninsula Clinical School, VIC, Australia.
| | - Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia; Monash University Peninsula Clinical School, VIC, Australia.
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Tiruvoipati R, Peek G. Extracorporeal Carbon Dioxide Removal vs Standard Care Ventilation Effect on 90-Day Mortality in Patients With Acute Hypoxemic Respiratory Failure. JAMA 2022; 327:83-84. [PMID: 34982126 DOI: 10.1001/jama.2021.20996] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
| | - Giles Peek
- UF Health Congenital Heart Center, Gainesville, Florida
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11
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Subramaniam A, Tiruvoipati R, Zuberav A, Wengritzky R, Bowden C, Wang WC, Wadhwa V. Risk perception and emotional wellbeing in healthcare workers involved in rapid response calls during the COVID-19 pandemic: A substudy of a cross-sectional survey. Aust Crit Care 2022; 35:34-39. [PMID: 34654611 PMCID: PMC8437811 DOI: 10.1016/j.aucc.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Coronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. AIMS The primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. METHODS We undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. RESULTS Four hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. CONCLUSION(S) Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.
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Affiliation(s)
- Ashwin Subramaniam
- Frankston Hospital, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia; School of Public Health and Preventive Medicine, Monash UNiversity, Australia; The Bays Hospital, Mornington, Australia.
| | - Ravindranath Tiruvoipati
- Frankston Hospital, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia; Peninsula Private Hospital, Australia.
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12
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Subramaniam A, Tiruvoipati R, Green C, Srikanth V, Soh L, Yeoh AC, Hussain F, Bailey M, Pilcher D. Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients. Intern Med J 2021; 51:2078-2086. [PMID: 32892457 DOI: 10.1111/imj.15032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/21/2020] [Accepted: 08/17/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. AIMS To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. METHODS This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates. RESULTS Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender. CONCLUSION Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, The Bays Hospital, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Intensive Care, Peninsula Private Hospital, Victoria, Australia
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Frankston, Victoria, Australia
- Menzies Institute for Medical Research, Hobart, Tasmania, Australia
| | - Lionel Soh
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Monash Health, Clayton, Victoria, Australia
| | - Aun Chian Yeoh
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Monash Health, Clayton, Victoria, Australia
| | - Faisal Hussain
- Business Intelligence Unit, Peninsula Health, Frankston, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
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13
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Ge V, Subramaniam A, Banakh I, Wang WC, Tiruvoipati R. Management of sodium-glucose cotransporter 2 inhibitors during the perioperative period: A retrospective comparative study. J Perioper Pract 2021; 31:391-398. [PMID: 32894998 DOI: 10.1177/1750458920948693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Current guidelines recommend withholding sodium-glucose cotransporter 2 inhibitors perioperatively due to concerns of euglycaemic diabetic ketoacidosis. However, such guidelines are largely based on case reports and small case series, many extrapolated from non-surgical patients. The aim was to investigate whether withholding sodium-glucose cotransporter 2 inhibitors as per current perioperative guidelines was associated with a reduction in serious adverse events, including euglycaemic diabetic ketoacidosis. METHODS Instances of perioperative management of sodium-glucose cotransporter 2 inhibitors, over a four-year period were classified into two categories: those where sodium-glucose cotransporter 2 inhibitors were withheld as per guidelines and those where sodium-glucose cotransporter 2 inhibitors were administered in the perioperative period. The primary outcome was 'total major perioperative complications': a composite of serious adverse events including euglycaemic diabetic ketoacidosis, diabetic ketoacidosis, acute kidney injury, urosepsis and death. RESULTS Eighty-two instances in 64 patients were included. Withholding sodium-glucose cotransporter 2 inhibitors was associated with an increased incidence of total major perioperative complications and poorer glycaemic control postoperatively. Multivariable logistic regression analysis revealed that withholding sodium-glucose cotransporter 2 inhibitors perioperatively (OR = 13.15; 95% CI = 1.8-138.9) and preoperative urea (OR 1.85 (95% CI = 1.17-3.43) were independently associated with an increase in total major postoperative complications. CONCLUSION Withholding sodium-glucose cotransporter 2 inhibitors as per current guidelines was associated with an increase in postoperative complications and reduced glycaemic control.
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Affiliation(s)
- Victor Ge
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Iouri Banakh
- Department of Pharmacy, Peninsula Health, Melbourne, Australia
| | - Wei Chun Wang
- Cabrini Health and Monash Health, Melbourne, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Ponnapa Reddy M, Subramaniam A, Afroz A, Billah B, Lim ZJ, Zubarev A, Blecher G, Tiruvoipati R, Ramanathan K, Wong SN, Brodie D, Fan E, Shekar K. Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:e1001-e1014. [PMID: 33927120 PMCID: PMC8439644 DOI: 10.1097/ccm.0000000000005086] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes. DESIGN AND SETTING We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020. SUBJECTS AND INTERVENTION Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included. MEASUREMENTS AND MAIN RESULTS Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25-54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14-25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3-6%). Respiratory rate decreased post prone positioning (mean difference, -3.2 breaths/min; 95% CI, -4.6 to -1.9). Intubation and mortality rates were 24% (95% CI, 17-32%) and 13% (95% CI, 6-19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them. CONCLUSIONS Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.
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Affiliation(s)
- Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Calvary Hospital, ACT, Australia
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Afsana Afroz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Zheng Jie Lim
- Department of Intensive Care Medicine, Ballarat Health Services, Ballarat, VIC, Australia
| | - Alexandr Zubarev
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
| | - Gabriel Blecher
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
- Department of Emergency, Monash Health, Clayton, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Kollengode Ramanathan
- Department of Intensive Care Medicine, Calvary Hospital, ACT, Australia
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, Ballarat Health Services, Ballarat, VIC, Australia
- Department of Emergency, Monash Health, Clayton, VIC, Australia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Hospital, Singapore
- Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
- Department of Medicine, Columbia University College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Suei Nee Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Kiran Shekar
- Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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15
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Subramaniam A, Zuberav A, Wengritzky R, Bowden C, Tiruvoipati R, Wang WC, Wadhwa V. 'Code-95' rapid response calls for patients under airborne precautions in the COVID-19-era: a cross-sectional survey of healthcare worker perceptions. Intern Med J 2021; 51:494-505. [PMID: 33890372 PMCID: PMC8251212 DOI: 10.1111/imj.15145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID-19 infection were pre-warned with the announcement of 'Code-95' with calls. AIM To assess healthcare worker (HCW) perspectives on pre-warning rapid response calls (RRC) with 'Code-95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID-19 infection. METHODS Design: prospective cross-sectional single-centre survey of HCW over a 3-week period. SETTING tertiary public hospital. PARTICIPANTS HCW caring for deteriorating or aggressive patients. MAIN OUTCOME MEASURES the primary outcome was to assess HCW perspectives in attending Code-95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities. RESULTS A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code-95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection-control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code-95 calls. CONCLUSIONS Most surveyed HCW supported Code-95 announcements pre-warning them of potential COVID-19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code-95 system to pre-warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive CareFrankston HospitalFrankstonVictoriaAustralia
- Department of Intensive CareThe Bays HospitalFrankstonVictoriaAustralia
- Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
- Peninsula HealthMonash UniversityMelbourneVictoriaAustralia
| | - Alexandr Zuberav
- Department of Intensive CareFrankston HospitalFrankstonVictoriaAustralia
| | | | | | - Ravindranath Tiruvoipati
- Department of Intensive CareThe Bays HospitalFrankstonVictoriaAustralia
- Department of Intensive CarePeninsula Private HospitalLangwarrinVictoriaAustralia
| | - Wei Chun Wang
- Peninsula HealthMonash UniversityMelbourneVictoriaAustralia
- Department of BiostatisticsCabrini HealthMelbourneVictoriaAustralia
| | - Vikas Wadhwa
- Department of Intensive CareFrankston HospitalFrankstonVictoriaAustralia
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16
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Gupta S, Balachandran M, Bolton G, Pratt N, Molloy J, Paul E, Tiruvoipati R. Comparison of clinical outcomes between nurse practitioner and registrar-led medical emergency teams: a propensity-matched analysis. Crit Care 2021; 25:117. [PMID: 33752731 PMCID: PMC7986296 DOI: 10.1186/s13054-021-03534-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/05/2021] [Indexed: 02/08/2023] Open
Abstract
OBJECTIVE Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls. METHODS The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group. RESULTS A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p = 0.015). CONCLUSION Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.
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Affiliation(s)
- Sachin Gupta
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | | | - Gaby Bolton
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
| | - Naomi Pratt
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
| | - Jo Molloy
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
| | - Eldho Paul
- ANZIC-RC, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia.
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia.
- ANZIC-RC, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, 3199, Australia.
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Nasa P, Azoulay E, Khanna AK, Jain R, Gupta S, Javeri Y, Juneja D, Rangappa P, Sundararajan K, Alhazzani W, Antonelli M, Arabi YM, Bakker J, Brochard LJ, Deane AM, Du B, Einav S, Esteban A, Gajic O, Galvagno SM, Guérin C, Jaber S, Khilnani GC, Koh Y, Lascarrou JB, Machado FR, Malbrain MLNG, Mancebo J, McCurdy MT, McGrath BA, Mehta S, Mekontso-Dessap A, Mer M, Nurok M, Park PK, Pelosi P, Peter JV, Phua J, Pilcher DV, Piquilloud L, Schellongowski P, Schultz MJ, Shankar-Hari M, Singh S, Sorbello M, Tiruvoipati R, Udy AA, Welte T, Myatra SN. Expert consensus statements for the management of COVID-19-related acute respiratory failure using a Delphi method. Crit Care 2021; 25:106. [PMID: 33726819 PMCID: PMC7962430 DOI: 10.1186/s13054-021-03491-y] [Citation(s) in RCA: 109] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 02/04/2021] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. METHODS Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p < 0·05 was considered as unstable). RESULTS Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16-24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. CONCLUSION Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. TRIAL REGISTRATION The study was registered with Clinical trials.gov Identifier: NCT04534569.
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Affiliation(s)
- Prashant Nasa
- Critical Care Medicine, NMC Speciality Hospital, Dubai, United Arab Emirates
| | - Elie Azoulay
- Saint-Louis teaching hospital - APHP - and University of Paris, Paris, France
| | - Ashish K Khanna
- Wake Forest University School of Medicine, Winston-Salem, NC and Outcomes Research Consortium , Cleveland, USA
| | - Ravi Jain
- Mahatma Gandhi Medical College and Hospital, Jaipur, India
| | - Sachin Gupta
- Narayana Super Speciality Hospital, Gurugram, India
| | - Yash Javeri
- Regency Super Speciality Hospital, Lucknow, India
| | | | | | | | | | | | - Yaseen M Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Centre, Riyadh, Saudi Arabia
| | - Jan Bakker
- New York University School of Medicine and Columbia University College of Physicians & Surgeons, New York, USA
- Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Laurent J Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, and University of Toronto, Toronto, Canada
| | - Adam M Deane
- Royal Melbourne Hospital and The University of Melbourne, Melbourne, Australia
| | - Bin Du
- Peking Union Medical College Hospital, Peking, China
| | - Sharon Einav
- The Shaare Zedek Medical Center, Jerusalem, Israel
| | - Andrés Esteban
- Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | | | | | - Claude Guérin
- University de Lyon, Lyon, France
- Institut Mondor de Recherches Biomédicales, Medecine Intensive Réanimation Hôpital Edouard Herriot Lyon, and Medecine Intensive Réanimation Hôpital Edouard Herriot Lyon, Créteil, France
| | - Samir Jaber
- Montpellier University Hospital, Montpellier, France
- Hôpital Saint-Éloi, CHU de Montpellier, Phy Med Exp, Université de Montpellier, Montpellier, France
| | | | - Younsuck Koh
- Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | | | - Manu L N G Malbrain
- International Fluid Academy, Lovenjoel, Belgium
- Faculty of Engineering, Department of Electronics and Informatics, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | | | | | - Brendan A McGrath
- Manchester University NHS Foundation Trust, Manchester, UK
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology Medicine and Health, University of Manchester, Academic Health Sciences Centre, Manchester, UK
| | - Sangeeta Mehta
- Sinai Health and the University of Toronto, Toronto, Canada
| | - Armand Mekontso-Dessap
- Assistance Publique - Hôpitaux de Paris, Hôpitaux Universitaires Henri-Mondor, Service de Medicine Intensive Réanimation, and Univ Paris Est Créteil, CARMAS, Créteil, France
| | - Mervyn Mer
- Charlotte Maxeke Johannesburg Academic Hospital and Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Michael Nurok
- Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, USA
| | | | - Paolo Pelosi
- San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences , Genoa, Italy
- Department of Surgical Sciences and Integrated Sciences, University of Genoa , Genoa, Italy
| | | | - Jason Phua
- Alexandra Hospital and National University Hospital, Singapore, Singapore
| | | | - Lise Piquilloud
- Lausanne University Hospital and Lausanne University, Lausanne, Switzerland
| | | | - Marcus J Schultz
- Amsterdam University Medical Center, Amsterdam, The Netherlands
- Mahidol University, Bangkok, Thailand
- University of Oxford, Oxford, UK
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, London, UK
- King's College London, London, UK
| | - Suveer Singh
- Royal Brompton Hospital and Chelsea and Westminster Hospital, Imperial College, London, UK
| | | | | | | | - Tobias Welte
- Department of Respiratory Medicine, German Centre of Lung Research, Hannover, Germany
| | - Sheila N Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Dr. Ernest Borges Road, Parel, Mumbai, India.
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18
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Haji K, Muthu S, Banakh I, Tiruvoipati R. Prolonged encephalopathy and associated nonconvulsive seizures from suspected pregabalin and tapentadol: Two case reports and review of literature. Clin Case Rep 2021; 9:1362-1366. [PMID: 33768845 PMCID: PMC7981720 DOI: 10.1002/ccr3.3772] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Revised: 05/17/2020] [Accepted: 10/20/2020] [Indexed: 02/05/2023] Open
Abstract
A combination of pregabalin and tapentadol may be associated with prolonged encephalopathy.
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Affiliation(s)
- Kavi Haji
- Department of Intensive Care MedicineFrankston HospitalFrankstonVic.Australia
- School of Public HealthFaculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVic.Australia
- Faculty of SurgeryUniversity of MelbourneMelbourneVic.Australia
| | - Sachin Muthu
- Department of Intensive Care MedicineFrankston HospitalFrankstonVic.Australia
| | - Iouri Banakh
- Department of PharmacyFrankston HospitalFrankstonVic.Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care MedicineFrankston HospitalFrankstonVic.Australia
- School of Public HealthFaculty of Medicine, Nursing and Health SciencesMonash UniversityMelbourneVic.Australia
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19
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Fujii T, Udy AA, Nichol A, Bellomo R, Deane AM, El-Khawas K, Thummaporn N, Serpa Neto A, Bergin H, Short-Burchell R, Chen CM, Cheng KH, Cheng KC, Chia C, Chiang FF, Chou NK, Fazio T, Fu PK, Ge V, Hayashi Y, Holmes J, Hu TY, Huang SF, Iguchi N, Jones SL, Karumai T, Katayama S, Ku SC, Lai CL, Lee BJ, Liaw WJ, Ong CTW, Paxton L, Peppin C, Roodenburg O, Saito S, Santamaria JD, Shehabi Y, Tanaka A, Tiruvoipati R, Tsai HE, Wang AY, Wang CY, Yeh YC, Yu CJ, Yuan KC. Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study. Crit Care 2021; 25:45. [PMID: 33531020 PMCID: PMC7851901 DOI: 10.1186/s13054-020-03431-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. METHOD This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. RESULTS We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. CONCLUSIONS Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.
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Affiliation(s)
- Tomoko Fujii
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan.
| | - Andrew A Udy
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Alistair Nichol
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Adam M Deane
- Melbourne Medical School, Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Khaled El-Khawas
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Naorungroj Thummaporn
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Hannah Bergin
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
| | - Robert Short-Burchell
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Chin-Ming Chen
- Department of Intensive Care Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Kuang-Hua Cheng
- Department of Critical Care Medicine, Mackay Memorial Hospital Taipei Branch, Taipei, Taiwan
| | - Kuo-Chen Cheng
- Department of Intensive Care Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Clemente Chia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Feng-Fan Chiang
- Division of Internal & Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Nai-Kuan Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Timothy Fazio
- Melbourne Medical School, Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
- Health Intelligence, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Pin-Kuei Fu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Victor Ge
- Intensive Care Unit, Peninsula Health, Frankston, VIC, Australia
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Jennifer Holmes
- Intensive Care Unit, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Ting-Yu Hu
- Department of Critical Care Medicine, Mackay Memorial Hospital Taipei Branch, Taipei, Taiwan
| | | | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Sarah L Jones
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
| | - Toshiyuki Karumai
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Shinshu Katayama
- Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shih-Chi Ku
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Bor-Jen Lee
- Division of Internal & Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Jinn Liaw
- Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Chelsea T W Ong
- Intensive Care Services, Eastern Health, Box Hill, VIC, Australia
| | - Lisa Paxton
- Melbourne Medical School, Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Chloe Peppin
- Critical Care and Perioperative Services, Monash Health, Melbourne, VIC, Australia
| | - Owen Roodenburg
- Intensive Care Services, Eastern Health, Box Hill, VIC, Australia
| | - Shinjiro Saito
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - John D Santamaria
- Intensive Care Unit, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Yahya Shehabi
- Critical Care Research, Monash Health School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ravindranath Tiruvoipati
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Intensive Care Unit, Peninsula Health, Frankston, VIC, Australia
| | - Hsiao-En Tsai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - An-Yi Wang
- Department of Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yu Wang
- Division of Internal & Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, Park Branch, National Taiwan University Hospital Biomedical, Hsin-Chu, Taiwan
| | - Kuo-Ching Yuan
- Department of Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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20
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Burrell AJC, Serpa Neto A, Trapani T, Broadley T, French C, Udy AA. Rapid Translation of COVID-19 Preprint Data into Critical Care Practice. Am J Respir Crit Care Med 2021; 203:368-371. [PMID: 33270550 PMCID: PMC7874320 DOI: 10.1164/rccm.202009-3661le] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Aidan J C Burrell
- Monash University Melbourne, Victoria, Australia
- The Alfred Hospital Melbourne, Victoria, Australia and
| | | | - Tony Trapani
- Monash University Melbourne, Victoria, Australia
| | | | - Craig French
- Monash University Melbourne, Victoria, Australia
- Western Health Melbourne, Victoria, Australia
| | - Andrew A Udy
- Monash University Melbourne, Victoria, Australia
- The Alfred Hospital Melbourne, Victoria, Australia and
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21
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Garcia SC, Toolis M, Ubels M, Mollah T, Paul E, Pandey A, Thia B, Wong T, Tiruvoipati R. Comparison of clinical characteristics and outcomes between alcohol-induced and gallstone-induced acute pancreatitis: An Australian retrospective observational study. SAGE Open Med 2021; 9:20503121211030837. [PMID: 34290866 PMCID: PMC8274077 DOI: 10.1177/20503121211030837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/18/2021] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To compare the characteristics and outcomes of patients presenting to hospital with alcohol-induced and gallstone-induced acute pancreatitis. METHODS Retrospective study of all patients with alcohol-induced or gallstone-induced pancreatitis during the period 1 June 2012 to 31 May 2016. The primary outcome measure was hospital mortality. Secondary outcome measures included hospital length of stay, requirements for intensive care unit admission, intensive care unit mortality, mechanical ventilation, renal replacement therapy, requirement of inotropes and total parenteral nutrition. RESULTS A total of 642 consecutive patients (49% alcohol; 51% gallstone) were included. No statistically significant differences were found between alcohol-induced and gallstone-induced acute pancreatitis with respect to hospital mortality, requirement for intensive care unit admission, intensive care unit mortality and requirement for mechanical ventilation, renal replacement therapy, inotropes or total parenteral nutrition. There was significant difference in hospital length of stay (3.07 versus 4.84; p < 0.0001). On multivariable regression analysis, Bedside Index of Severity in Acute Pancreatitis score (estimate: 0.393; standard error: 0.058; p < 0.0001) and admission haematocrit (estimate: 0.025; standard error: 0.008; p = 0.002) were found to be independently associated with prolonged hospital length of stay. CONCLUSION Hospital mortality did not differ between patients with alcohol-induced and gallstone-induced acute pancreatitis. The duration of hospital stay was longer with gallstone-induced pancreatitis. Bedside Index of Severity in Acute Pancreatitis score and admission haematocrit were independently associated with hospital length of stay.
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Affiliation(s)
| | - Michael Toolis
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
| | - Max Ubels
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
| | - Taha Mollah
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
| | - Eldho Paul
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ashish Pandey
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
| | - Brandon Thia
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
| | - Tricia Wong
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Ravindranath Tiruvoipati, Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road, Frankston, VIC 3199, Australia.
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22
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Forster GM, Bihari S, Tiruvoipati R, Bailey M, Pilcher D. The Association between Discharge Delay from Intensive Care and Patient Outcomes. Am J Respir Crit Care Med 2020; 202:1399-1406. [PMID: 32649212 DOI: 10.1164/rccm.201912-2418oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Rationale: ICU discharge delay occurs when a patient is considered ready to be discharged but remains in the ICU. The effect of discharge delay on patient outcomes is uncertain.Objectives: To investigate the association between discharge delay and patient outcomes including hospital mortality, readmission to ICU, and length of hospital stay after ICU discharge.Methods: Data were accessed from the Australian and New Zealand Intensive Care Society Adult Patient Database between 2011 and 2019. Descriptive analyses and hierarchical logistic and Cox proportional hazards regression were used to examine association between discharge delay and adjusted outcomes. Patients were stratified and analyzed by categories of mortality risk at ICU admission.Measurements and Main Results: The study included 1,014,540 patients from 190 ICUs: 756,131 (75%) were discharged within 6 hours of being deemed ready, with 137,042 (13%) discharged in the next 6 hours; 17,656 (2%) were delayed 48-72 hours; 31,389 (3.1%) died in hospital; and 45,899 (4.5%) patients were readmitted to ICU. Risk-adjusted mortality declined with increasing discharge delay and was lowest at 48-72 hours (adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.94). The effect was seen in patients with predicted risk of death on admission to ICU of greater than 5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.70-0.84). There was a progressive reduction in adjusted odds of readmission with increasing discharge delay.Conclusions: Increasing discharge delay in ICUs is associated with reduced likelihood of mortality and ICU readmission in high-risk patients. Consideration should be given to delay the discharge of patients with high risk of death on ICU admission.
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Affiliation(s)
- Gareth Mitchell Forster
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Shailesh Bihari
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
- College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences and
| | - Michael Bailey
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; and
| | - David Pilcher
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; and
- Department of Intensive Care, The Alfred Hospital, Commercial Road, Prahran, Melbourne, Victoria, Australia
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23
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Tiruvoipati R, Gupta S, Pilcher D, Bailey M. Management of hypercapnia in critically ill mechanically ventilated patients-A narrative review of literature. J Intensive Care Soc 2020; 21:327-333. [PMID: 34093735 PMCID: PMC8142102 DOI: 10.1177/1751143720915666] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
The use of lower tidal volume ventilation was shown to improve survival in mechanically ventilated patients with acute lung injury. In some patients this strategy may cause hypercapnic acidosis. A significant body of recent clinical data suggest that hypercapnic acidosis is associated with adverse clinical outcomes including increased hospital mortality. We aimed to review the available treatment options that may be used to manage acute hypercapnic acidosis that may be seen with low tidal volume ventilation. The databases of MEDLINE and EMBASE were searched. Studies including animals or tissues were excluded. We also searched bibliographic references of relevant studies, irrespective of study design with the intention of finding relevant studies to be included in this review. The possible options to treat hypercapnia included optimising the use of low tidal volume mechanical ventilation to enhance carbon dioxide elimination. These include techniques to reduce dead space ventilation, and physiological dead space, use of buffers, airway pressure release ventilation and prone positon ventilation. In patients where hypercapnic acidosis could not be managed with lung protective mechanical ventilation, extracorporeal techniques may be used. Newer, minimally invasive low volume venovenous extracorporeal devices are currently being investigated for managing hypercapnia associated with low and ultra-low volume mechanical ventilation.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
- ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Ravindranath Tiruvoipati, Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria 3199, Australia.
| | - Sachin Gupta
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - David Pilcher
- ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- The ANZICS Centre for Outcome and Resource Evaluation (ANZICS CORE), Melbourne, Australia
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - Michael Bailey
- ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- The ANZICS Centre for Outcome and Resource Evaluation (ANZICS CORE), Melbourne, Australia
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24
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Abstract
Good quality sleep is considered to be essential for healthy living and recovering from illness. It would be logical to think that good quality sleep is most required when a patient is critically ill in an intensive care unit (ICU). Several studies have demonstrated poor quality of sleep while the patients are in ICU. Subjective tools such as questionnaires while simple are unreliable to accurately assess sleep quality. Relatively few studies have used standardized polysomnography. The use of novel biological markers of sleep such as serum brain-derived neurotrophic factor concentrations may help in conjunction with polysomnography to assess sleep quality in critically ill patients. Attempts to improve sleep included nonpharmacological interventions including the use of earplugs, eye sleep masks, and pharmacological agents including ketamine, propofol, dexmedetomidine, and benzodiazepines. The evidence for these interventions remains unclear. Further research is needed to assess quality of sleep and improve the sleep quality in intensive care settings.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Ravindranath Tiruvoipati, Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria 3199, Australia.
| | - Juan Mulder
- Department of Respiratory and Sleep Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
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25
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Abstract
Vanishing bile duct syndrome (VBDS) refers to a group of acquired disorders associated with progressive destruction and disappearance of the intrahepatic bile ducts. We report a case of meropenem-induced VBDS in a patient who had undergone surgical repair of a ruptured abdominal aortic aneurysm. Meropenem was used to treat Serratia marcescens isolated from blood, urine, sputum, and wound swab cultures. The patient developed severe mixed liver injury with no obstruction noted in radiological imaging. Because of the patient's increasing serum bilirubin level, VBDS was suspected and the meropenem was therefore changed to ciprofloxacin on postoperative day 18. Although the bilirubin level decreased, meropenem was restarted 3 days later because of clinical concerns regarding worsening fever and sepsis. Restarting meropenem was associated with an immediate increase in the serum bilirubin level. This further increase in bilirubin after reintroduction of meropenem strongly suggested meropenem-induced VBDS. The antibiotic therapy was changed from meropenem to ciprofloxacin and metronidazole, leading to a dramatic decrease in the bilirubin level to normal within a few weeks. In patients receiving meropenem, VBDS as a cause of deranged liver function and cholestasis should be considered after ruling out mechanical and other probable causes of liver injury.
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Affiliation(s)
- Alexandr Zubarev
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC 3800, Australia
| | - Matthew Li
- Department of Pharmacy, Frankston Hospital, Frankston, VIC 3199, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC 3800, Australia
- Ravindranath Tiruvoipati, Department of Intensive Care Medicine, Frankston Hospital, 2 Hastings Road (PO Box 52), Frankston, Victoria 3199, Australia. E-mail:
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC 3199, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, VIC 3800, Australia
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Tiruvoipati R, Botha J. Fighting a pandemic with mechanical ventilators. Intern Med J 2020; 50:1019-1020. [PMID: 32881219 PMCID: PMC7436369 DOI: 10.1111/imj.14951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 06/14/2020] [Accepted: 06/14/2020] [Indexed: 02/05/2023]
Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
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27
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Subramaniam A, Tiruvoipati R, Lodge M, Moran C, Srikanth V. Frailty in the older person undergoing elective surgery: a trigger for enhanced multidisciplinary management - a narrative review. ANZ J Surg 2020; 90:222-229. [PMID: 31916659 DOI: 10.1111/ans.15633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The ageing of our society has led to increasing numbers of older people requiring elective surgical procedures. Preoperative frailty is a strong predictor of adverse post-operative outcomes. This review aims to summarize the evidence for interventions aimed at improving outcomes in frail older people who may undergo elective surgery. METHODS Articles published on perioperative management of frailty between 1 January 1970 and 31 May 2019 were searched using PubMed and EMBASE. RESULTS We identified very few studies investigating such interventions, such as comprehensive geriatric assessment, prehabilitation (alone or as a multicomponent strategy) and other multicomponent interventions. Administration of a comprehensive geriatric assessment was shown to be associated with reduced mortality, fewer complications and shorter length of hospital stay, and may be best targeted towards those who are identified as frail for resource efficiency. Multicomponent interventions including prehabilitation may be associated with improved outcomes, but the evidence base for these needs to be strengthened. CONCLUSION Establishing multidisciplinary collaborative services to provide person-centred models of care should be considered for older people presenting for elective surgery, particularly in those with greater preoperative frailty. Further large-scale studies should focus on implementing and evaluating such multicomponent models of care.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital and The Bays Hospital, Melbourne, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Frankston Hospital and Peninsula Private Hospital, Melbourne, Victoria, Australia
| | - Margot Lodge
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Aged Care, Caulfield Hospital, Alfred Health, Melbourne, Victoria, Australia
| | - Christopher Moran
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Aged Care, Caulfield Hospital, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Acute Care of the Elderly, Menzies Institute for Medical Research, Hobart, Tasmania, Australia
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Abstract
OBJECTIVE To describe the characteristics of patients presenting to an Emergency Department (ED) following overdoses; to identify risk factors for intensive care unit (ICU) admission among these patients; and to identify the rate of mortality and repeat overdose presentations over four years. METHODS Adult patients presenting to ED following drug overdose during 2014 were included. Data were collected from medical notes and hospital databases. RESULTS During the study period, 654 patients presented to ED 800 times following overdose. Seventy-eight (9.8%) resulted in ICU admission, and 59 (7.4%) required intubation; 57.2% had no history of overdose presentations, and 72.9% involved patients with known psychiatric illness. Overdose of atypical antipsychotics (AAP), age and history of prior overdose independently predicted ICU admission. A third of patients (n = 196, 30%) had subsequent presentations to ED following overdose, in the four years from their index presentation, with an all-cause four-year mortality of 3.4% (n = 22). CONCLUSION A history of overdose, use of AAP and older age were risk factors for ICU admission following ED presentations. Over a third of patients had repeat overdose presentation in the four-year follow-up with a mortality of 3.4%.
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Affiliation(s)
- Mark Savage
- Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Australia
| | - Ross Kung
- Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Australia; and Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Brandon Thia
- Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Australia
| | - Dinushka Perera
- Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Australia; and Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
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Das A, Anstey M, Bass F, Blythe D, Buhr H, Campbell L, Davda A, Delaney A, Gattas D, Green C, Ferrier J, Hammond N, Palermo A, Pellicano S, Phillips M, Regli A, Roberts B, Ross-King M, Sarode V, Simpson S, Spiller S, Sullivan K, Tiruvoipati R, Haren FV, Waterson S, Yaw LK, Litton E. Internet health information use by surrogate decision makers of patients admitted to the intensive care unit: a multicentre survey. CRIT CARE RESUSC 2019; 21:305-10. [PMID: 31778639 DOI: pmid/31778639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To investigate the use, understanding, trust and influence of the internet and other sources of health information used by the next of kin (NOK) of patients admitted to the intensive care unit (ICU). DESIGN Multicentre structured survey. SETTING The ICUs of 13 public and private Australian hospitals. PARTICIPANTS NOK who self-identified as the primary surrogate decision maker for a patient admitted to the ICU. MAIN OUTCOME MEASURES The frequency, understanding, trust and influence of online sources of health information, and the quality of health websites visited using the Health on the Net Foundation Code of Conduct (HONcode) for medical and health websites. RESULTS There were 473 survey responses. The median ICU admission days and number of ICU visits by the NOK at the time of completing the survey was 3 (IQR, 2-6 days) and 4 (IQR, 2-7), respectively. The most commonly reported sources of health information used very frequently were the ICU nurse (55.6%), ICU doctor (38.7%), family (23.3%), hospital doctor (21.4%), and the internet (11.3%). Compared with the 243 NOK (51.6%) not using the internet, NOK using the internet were less likely to report complete understanding (odds ratio [OR], 0.57; 95% CI, 0.38-0.88), trust (OR, 0.34; 95% CI, 0.19-0.59), or influence (OR, 0.58; 95% CI, 0.38-0.88) associated with the ICU doctor. Overall, the quality of the 40 different reported websites accessed was moderately high. CONCLUSIONS A substantial proportion of ICU NOK report using the internet as a source of health information. Internet use is associated with lower reported understanding, trust and influence of the ICU doctor.
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Affiliation(s)
| | | | - Frances Bass
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - David Blythe
- Intensive Care Unit, Armadale Hospital, Perth, WA, Australia
| | - Heidi Buhr
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Lewis Campbell
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
| | - Ashish Davda
- St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | - Anthony Delaney
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - David Gattas
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, VIC, Australia
| | - Janet Ferrier
- Intensive Care Unit, St John of God Subiaco Hospital, Perth, WA, Australia
| | - Naomi Hammond
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | | | | | | | | | | | - Michelle Ross-King
- St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | | | | | - Shakira Spiller
- Division of Critical Care, Canberra Hospital, Canberra, ACT, Australia
| | - Kirsty Sullivan
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | | | - Frank van Haren
- Division of Critical Care, Canberra Hospital, Canberra, ACT, Australia
| | - Sharon Waterson
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
| | - Lai Kin Yaw
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
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Toolis M, Tiruvoipati R, Botha J, Green C, Subramaniam A. A practice survey of airway management in Australian and New Zealand intensive care units. CRIT CARE RESUSC 2019; 21:139-147. [PMID: 31142245 DOI: pmid/31142245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To characterise intubation practices in Australian and New Zealand intensive care units (ICUs) and investigate clinician support for establishing airway management guidelines in Australian and New Zealand ICUs. DESIGN An online survey was designed, piloted and distributed to members of the mailing list of the Australian and New Zealand Intensive Care Society (ANZICS), with medical members invited to participate. Respondents were excluded if their primary practice was in paediatric ICUs. MAIN OUTCOME MEASURES Data collected included the respondents' demographics and airway management practices and whether respondents supported the formulation of Australian and New Zealand intubation guidelines for critically ill patients in ICU and mandatory airway management training for Fellows of the College of Intensive Care Medicine of Australia and New Zealand (CICM). RESULTS Over a quarter of ANZICS medical members completed the survey (203/756, 27%), of which 166 (22%) were included in the analysis. The majority of respondents were male (80%), consultant intensivists (80%), and from tertiary centres (59%). Seventeen per cent worked concurrently in ICU and anaesthesia, and 52% had not completed formal airway training within the previous 3 years. Propofol was the preferred induction agent (67%) and rocuronium was the preferred neuromuscular blocking agent (58%). Videolaryngoscopy was immediately available in 97% of the ICUs and used first-line by 43% of respondents. Sixty-one per cent of respondents were in favour of the development of Australian and New Zealand ICU airway management guidelines, and 80% agreed that airway management training should be mandatory for CICM Fellows. CONCLUSION Variation of practices in intubation was noted in the participants. Approximately 61% of respondents supported the development of Australian and New Zealand ICU airway management guidelines, and 80% supported mandatory airway management training.
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Affiliation(s)
| | | | - John Botha
- Frankston Hospital, Melbourne, VIC, Australia
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Gupta S, Tiruvoipati R, Wang WC, Green C, Botha J. How do intensivists treat their patients, their loved ones and themselves? Results of a survey of intensivists facing an evolving hypothetical clinical scenario. N Z Med J 2019; 132:13-22. [PMID: 31095540 DOI: pmid/31095540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
AIM Prognostication and decisions regarding ineffectiveness of treatment remain challenging for clinicians and are some of the most difficult yet understudied aspects of clinical medicine. We sought to explore what management intensivists would advocate for a patient, for themselves or for a loved one at different points in an evolving hypothetical clinical scenario of a critically ill patient admitted to the intensive care unit (ICU). METHOD An online survey was constructed and was circulated to fellows of the College of Intensive Care Medicine (CICM) of Australia and New Zealand. Participants were presented with an evolving hypothetical clinical scenario of a patient admitted to ICU following out-of-hospital cardiac arrest (OHCA) at four time-points (day 3,7,14 and 28) during their conceptual ICU stay. RESULTS One hundred and twenty-six CICM fellows participated. Survey responses revealed significant differences in the proportion of respondents that would advocate for aggressive treatment, conservative management or withdrawal of treatment for themselves compared to patients; for a family member as compared to a patient at several time points. CONCLUSIONS The management that intensivists would advocate for patients differs from the management that they would advocate for their loved ones and themselves.
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Affiliation(s)
- Sachin Gupta
- Intensivist, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia; School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
| | - Ravindranath Tiruvoipati
- Intensivist, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia; School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
| | - Wei Chun Wang
- Statistician, Peninsula Clinical School, Monash University, Australia
| | - Cameron Green
- Research Coordinator, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia
| | - John Botha
- Director of Intensive Care Medicine, Department of Intensive Care Medicine, Frankston Hospital (Peninsula Health), Melbourne, Australia; School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia
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Banakh I, Kung R, Gupta S, Matthiesson K, Tiruvoipati R. Euglycemic diabetic ketoacidosis in association with dapagliflozin use after gastric sleeve surgery in a patient with type II diabetes mellitus. Clin Case Rep 2019; 7:1087-1090. [PMID: 31110751 PMCID: PMC6509932 DOI: 10.1002/ccr3.2147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 02/11/2019] [Accepted: 03/18/2019] [Indexed: 02/05/2023] Open
Abstract
Sodium-glucose cotransporter 2 inhibitors (SGLT2Is) can be associated with euglycemic diabetic ketoacidosis (eDKA). Severe metabolic acidosis with extreme electrolyte abnormalities can occur with nonsignificant blood glucose elevations in SGLT2I-treated patients. Additional risk factors for eDKA include prolonged fasting, major illness, large weight loss, and reductions in insulin doses.
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Affiliation(s)
- Iouri Banakh
- Pharmacy DepartmentFrankston HospitalFrankstonVictoriaAustralia
| | - Ross Kung
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia
| | - Sachin Gupta
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia
- School of Public Health, Faculty of Medicine, Nursing and Health SciencesMonash UniversityFrankstonVictoriaAustralia
| | - Kati Matthiesson
- Victorian Diabetes and Endocrine NetworkMalvernVictoriaAustralia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia
- School of Public Health, Faculty of Medicine, Nursing and Health SciencesMonash UniversityFrankstonVictoriaAustralia
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Abstract
OBJECTIVES To investigate the ability of available delirium risk assessment tools to identify patients at risk of delirium in an Australian tertiary ICU. DESIGN Prospective observational study. SETTING An Australian tertiary ICU. PATIENTS All patients admitted to the study ICU between May 8, 2017, and December 31, 2017, were assessed bid for delirium throughout their ICU stay using the Confusion Assessment Method for ICU. Patients were included in this study if they remained in ICU for over 24 hours and were excluded if they were delirious on ICU admission, or if they were unable to be assessed using the Confusion Assessment Method for ICU during their ICU stay. Delirium risk was calculated for each patient using the prediction of delirium in ICU patients, early prediction of delirium in ICU patients, and Lanzhou models. Data required for delirium predictor models were obtained retrospectively from patients medical records. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 803 ICU admissions during the study period, of which 455 met inclusion criteria. 35.2% (n = 160) were Confusion Assessment Method for ICU positive during their ICU admission. Delirious patients had significantly higher Acute Physiology and Chronic Health Evaluation III scores (median, 72 vs 54; p < 0.001), longer ICU (median, 4.8 vs 1.8 d; p < 0.001) and hospital stay (16.0 vs 8.16 d; p < 0.001), greater requirement of invasive mechanical ventilation (70% vs 21.4%; p < 0.001), and increased ICU mortality (6.3% vs 2.4%; p = 0.037). All models included in this study displayed moderate to good discriminative ability. Area under the receiver operating curve for the prediction of delirium in ICU patients was 0.79 (95% CI, 0.75-0.83); recalibrated prediction of delirium in ICU patients was 0.79 (95% CI, 0.75-0.83); early prediction of delirium in ICU patients was 0.72 (95% CI, 0.67-0.77); and the Lanzhou model was 0.77 (95% CI, 0.72-0.81). CONCLUSIONS The predictive models evaluated in this study demonstrated moderate to good discriminative ability to predict ICU patients' risk of developing delirium. Models calculated at 24-hours post-ICU admission appear to be more accurate but may have limited utility in practice.
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Affiliation(s)
- Cameron Green
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
| | - William Bonavia
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
| | - Candice Toh
- Department of Cardiology, Peninsula Health, Frankston, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
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Sheikh M, Tiruvoipati R, Hurley JC. Non-invasive ventilation of patients with acute asthma. Intern Med J 2019; 49:262-264. [PMID: 30754082 DOI: 10.1111/imj.14208] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/01/2018] [Accepted: 07/12/2018] [Indexed: 02/05/2023]
Abstract
A retrospective observational study of 21 patients admitted to the Intensive Care Unit (ICU) of Frankston Hospital with acute asthma between 2011 and 2014 was undertaken. We report the outcomes for three groups of patients; those that did (n = 7) or did not (n = 6) receive initial therapy with non-invasive ventilation (NIV) together with those that received invasive ventilation (n = 8). Patients successfully managed with NIV alone experienced a shorter ICU and hospital stay versus those who required invasive ventilation.
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Affiliation(s)
- Muhammad Sheikh
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Victoria, Australia
- Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - James C Hurley
- Internal Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
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Tiruvoipati R, Pilcher D, Bailey M. What is the Association With Dissociation?-Reply. JAMA Neurol 2018; 75:1572-1573. [PMID: 30383101 DOI: 10.1001/jamaneurol.2018.3237] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, Victoria, Australia
- Department of Intensive Care, The Alfred Hospital, Prahran, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Melbourne, Victoria, Australia
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36
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Ge V, Banakh I, Tiruvoipati R, Haji K. Bleomycin-induced pulmonary toxicity and treatment with infliximab: A case report. Clin Case Rep 2018; 6:2011-2014. [PMID: 30349718 PMCID: PMC6186889 DOI: 10.1002/ccr3.1790] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 08/08/2018] [Indexed: 02/05/2023] Open
Abstract
Given the current understanding of bleomycin-induced pneumonitis (BIP), the use of tumor necrosis factor alpha (TNF-α) inhibitors such as infliximab for late-stage disease appears to be of limited benefit. Further research regarding prevention and management of advanced BIP is required.
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Affiliation(s)
- Victor Ge
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia
| | - Iouri Banakh
- Pharmacy DepartmentFrankston HospitalFrankstonVictoriaAustralia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia
- School of Public HealthFaculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Kavi Haji
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia
- School of Public HealthFaculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
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Tiruvoipati R, Pilcher D, Botha J, Buscher H, Simister R, Bailey M. Association of Hypercapnia and Hypercapnic Acidosis With Clinical Outcomes in Mechanically Ventilated Patients With Cerebral Injury. JAMA Neurol 2018; 75:818-826. [PMID: 29554187 PMCID: PMC5885161 DOI: 10.1001/jamaneurol.2018.0123] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
IMPORTANCE Clinical studies investigating the effects of hypercapnia and hypercapnic acidosis in acute cerebral injury are limited. The studies performed so far have mainly focused on the outcomes in relation to the changes in partial pressure of carbon dioxide and pH in isolation and have not evaluated the effects of partial pressure of carbon dioxide and pH in conjunction. OBJECTIVE To review the association of compensated hypercapnia and hypercapnic acidosis during the first 24 hours of intensive care unit admission on hospital mortality in adult mechanically ventilated patients with cerebral injury. DESIGN, SETTING, AND PARTICIPANTS Multicenter, binational retrospective review of patients with cerebral injury (traumatic brain injury, cardiac arrest, and stroke) admitted to 167 intensive care units in Australia and New Zealand between January 2000 and December 2015. Patients were classified into 3 groups based on combination of arterial pH and arterial carbon dioxide (normocapnia and normal pH, compensated hypercapnia, and hypercapnic acidosis) during the first 24 hours of intensive care unit stay. MAIN OUTCOMES AND MEASURES Hospital mortality. RESULTS A total of 30 742 patients (mean age, 55 years; 21 827 men [71%]) were included. Unadjusted hospital mortality rates were highest in patients with hypercapnic acidosis. Multivariable logistic regression analysis and Cox proportional hazards analysis in 3 diagnostic categories showed increased odds of hospital mortality (cardiac arrest odds ratio [OR], 1.51; 95% CI, 1.34-1.71; stroke OR, 1.43; 95% CI, 1.27-1.6; and traumatic brain injury OR, 1.22; 95% CI, 1.06-1.42; P <.001) and hazard ratios (HR) (cardiac arrest HR, 1.23; 95% CI, 1.14-1.34; stroke HR, 1.3; 95% CI, 1.21-1.4; traumatic brain injury HR, 1.13; 95% CI, 1-1.27), in patients with hypercapnic acidosis compared with normocapnia and normal pH. There was no difference in mortality between patients who had compensated hypercapnia compared with patients who had normocapnia and normal pH. In patients with hypercapnic acidosis, the adjusted OR of hospital mortality increased with increasing partial pressure of carbon dioxide, while no such increase was noted in patients with compensated hypercapnia. CONCLUSIONS AND RELEVANCE Hypercapnic acidosis was associated with increased risk of hospital mortality in patients with cerebral injury. Hypercapnia, when compensated to normal pH during the first 24 hours of intensive care unit admission, may not be harmful in mechanically ventilated patients with cerebral injury.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
- Australian and New Zealand Intensive Care Research Center, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Center, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Sydney, Australia
- Department of Intensive Care, The Alfred Hospital, Prahran, Victoria, Australia
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria, Australia
| | - Hergen Buscher
- Department of Intensive Care Medicine, St Vincent’s Hospital, Sydney, Australia
- University of New South Wales, Australia, Sydney, Australia
| | - Robert Simister
- Institute of Neurology, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Center, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne Victoria, Australia
- The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Sydney, Australia
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Bishop EJ, Tiruvoipati R, Metcalfe J, Marshall C, Botha J, Kelley PG. The outcome of patients with severe and severe-complicated Clostridium difficile infection treated with tigecycline combination therapy: a retrospective observational study. Intern Med J 2018; 48:651-660. [PMID: 29363242 DOI: 10.1111/imj.13742] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 12/29/2017] [Accepted: 01/08/2018] [Indexed: 02/05/2023]
Abstract
BACKGROUND Tigecycline is a third-line therapy for severe Clostridium difficile infection (CDI) in Australasian guidelines. Differences in strain types make it difficult to extrapolate international tigecycline efficacy data with combination or monotherapy to Australian practice, where experience is limited. AIM To evaluate the efficacy and adverse effects associated with tigecycline combination therapy for severe and severe-complicated CDI in an Australian healthcare setting. METHODS This was a retrospective observational study at a metropolitan university-affiliated hospital. All patients between February 2013 and October 2016 treated with adjunctive intravenous tigecycline for >48 h for severe or severe-complicated CDI were included. Tigecycline was given in addition to oral vancomycin ± intravenous metronidazole. The primary outcome was all-cause mortality at 30 days from start of tigecycline combination therapy. Secondary outcomes included clinical cure, colectomy, adverse events and recurrence rates. RESULTS Thirteen patients with median age of 61 years had severe (n = 9) or severe-complicated (n = 4) CDI at tigecycline commencement. In 92% of patients, tigecycline started within 48 h after in-hospital CDI treatment, for median duration of 9 days. All-cause mortality at 30 days was 8% with no mortality in severe CDI and 25% (1/4) in patients with severe-complicated fulminant CDI, comparing favourably with historical rates of 9-38% and 30-80% in similar respective groups. Clinical cure was achieved in 77% of cases. There were no colectomies and one attributable tigecycline adverse reaction. CONCLUSIONS Tigecycline appears safe and effective as a part of combination therapy in severe CDI, and may be given earlier and for shorter durations than in current guidelines.
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Affiliation(s)
- Emma J Bishop
- Department of Infectious Diseases, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Julie Metcalfe
- Department of Infectious Diseases, Melbourne, Victoria, Australia
| | | | - John Botha
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Peter G Kelley
- Department of Infectious Diseases, Melbourne, Victoria, Australia
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Tiruvoipati R, Gupta S, Pilcher D, Bailey M. Hypercapnia and hypercapnic acidosis in sepsis: harmful, beneficial or unclear? CRIT CARE RESUSC 2018; 20:94-100. [PMID: 29852847 DOI: pmid/29852847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Mortality related to sepsis among critically ill patients remains high. Recent literature suggests that hypercapnia may affect the pathophysiology of sepsis. The effects of hypercapnia on sepsis are largely related to the direct effect of hypercapnic acidosis on immune function and, as a consequence, of increased cardiac output that subsequently leads to improved tissue oxygenation. Appropriate management of hypercapnia may aid in improving the outcomes of sepsis. Our aim was to review the effects of compensated hypercapnia and hypercapnic acidosis on sepsis, with a specific focus on critically ill patients. Hypercapnic acidosis has been extensively studied in various in vivo animal models of sepsis and ex vivo studies. Published data from animal experimental studies suggest that the effects of hypercapnic acidosis are variable, with benefit shown in some settings of sepsis and harm in others. The effects may also vary at different time points during the course of sepsis. There are very few clinical studies investigating the effects of hypercapnia in prevention of sepsis and in established sepsis. It appears from these very limited clinical data that hypercapnia may be associated with adverse outcomes. There are no clinical studies investigating clinical outcomes of hypercapnic acidosis or compensated hypercapnia in sepsis and septic shock in critical care settings, thus extrapolation of the experimental results to guide critical care practice is difficult. Clinical studies are needed, especially in critically ill patients, to define the effects of compensated hypercapnia and hypercapnic acidosis that may aid clinicians to improve the outcomes in sepsis.
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Affiliation(s)
| | - Sachin Gupta
- Department of Intensive Care medicine, Frankston Hospital, Frankston, Vic, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
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Subramaniam A, Green C, Omair M, Soh L, Yeoh AC, Tiruvoipati R. Cost implications of avoidable rapid response call activations in older patients. N Z Med J 2018; 131:38-52. [PMID: 29565935 DOI: pmid/29565935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Rapid response calls (RRCs) are designed to appropriately manage clinical deterioration. However, not all RRCs are appropriate due to medical futility or the patient's wishes. Incidence and costs associated with avoidable-RRC (ARRC) remain underexplored. AIMS The aim of this study was to describe the incidence and costs of ARRC activations in older patients. METHODS We retrospectively reviewed RRCs in patients aged ≥80 years over six months. We defined ARRC as RRC activations despite clear documentation confirming not for further RRCs. Data on investigations, equipment and management of each ARRC were analysed. We then micro-costed each ARRC using standard references. RESULTS Ten percent (25/255) of RRCs were ARRC (mean age 85.6 years) with most patients (88%) admitted under medical teams. Median duration of ARRC was 22 minutes (IQR 7-38 minutes). Palliative care services were underutilised (40%). Most patients (94.4%) died soon after ARRC. The costs for investigations, equipment and management was AUD $2,267.01, opportunity costs were AUD $3,861.55, with a grand total cost of AUD $6,128.56. CONCLUSION ARRC, noted in 10% of RRCs, are associated with increased time and financial costs. Further research is required to better understand ARRC triggers to reduce the burden of ARRC on patients, carers and hospital staff.
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Affiliation(s)
| | | | | | - Lionel Soh
- Department of Medicine, Frankston Hospital, Australia
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Botha J, Green C, Carney I, Haji K, Gupta S, Tiruvoipati R. Proportional assist ventilation versus pressure support ventilation in weaning ventilation: a pilot randomised controlled trial. CRIT CARE RESUSC 2018; 20:33-40. [PMID: 29458319 DOI: pmid/29458319] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Proportional assist ventilation with load-adjustable gain factors (PAV+) is a mode of ventilation that provides assistance in proportion to patient effort. This may have physiological and clinical advantages when compared with pressure support ventilation (PSV). Our objective was to compare these two modes in patients being weaned from mechanical ventilation. DESIGN Prospective randomised controlled trial comparing PSV with PAV+. SETTING University-affiliated, tertiary referral intensive care unit (ICU). PARTICIPANTS Mechanically ventilated patients on a controlled mode of ventilation for at least 24 hours, who were anticipated to be spontaneously ventilated for at least 48 hours after randomisation. INTERVENTIONS Nil. MAIN OUTCOME MEASURES The primary outcome was time to successful liberation from the ventilator after the commencement of a spontaneous mode of ventilation. Secondary outcomes were requirement of rescue (mandatory) ventilation, requirement of sedative drugs, requirement for tracheostomy, re-intubation within 48 hours of extubation, ICU length of stay (LOS), hospital LOS, and ICU and hospital mortality. RESULTS 50 patients were randomised to either PSV (n = 25) or PAV+ (n = 25). There was no significant difference between the PAV+ and PSV groups in time to successful weaning (84.3 v 135.9 hours, respectively; P = 0.536). Four patients randomised to PAV+ were crossed over to PSV during weaning. There was no significant difference between groups for rescue ventilation, reintubation within 48 hours, tracheostomy, sedatives and analgesics prescribed, and ICU and hospital LOS. ICU mortality was higher in the PSV group (25% v 4 %; P = 0.002). CONCLUSIONS Both modes of ventilation were comparable in time to liberation from the ventilator.
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Affiliation(s)
- John Botha
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia.
| | - Cameron Green
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Ian Carney
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
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Molloy J, Pratt N, Tiruvoipati R, Green C, Plummer V. Relationship between diurnal patterns in Rapid Response Call activation and patient outcome. Aust Crit Care 2018; 31:42-46. [PMID: 28274779 DOI: 10.1016/j.aucc.2017.01.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 01/28/2017] [Accepted: 01/30/2017] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The Rapid Response Call (RRC) is a system designed to escalate care to a specialised team in response to the detection of patient deterioration. To date, there have been few studies which have explored the relationship between time of day of RRC and patient outcome. OBJECTIVE To examine the relationship between the time of RRC activations and patient outcome. METHOD All adult inpatients with a RRC in non-critical care wards of a metropolitan Australian hospital in 2012 were retrospectively reviewed. RRCs occurring between 18:00-07:59 were defined as 'out of hours'. RESULTS There were 892 RRC during the study period. RRCs out of hours were associated with a higher rate of ICU admissions immediately after the RRC (19.4% vs. 12.3%, p<0.001). Patients experiencing an out-of-hours RRC were more likely to have an in-hospital cardiopulmonary arrest (OR=1.7, p<0.04). In-hospital mortality rate was significantly higher for patients with out-of-hours RRCs (35.5% vs. 25.0%, p=0.014). After adjusting for confounders out-of-hours RRC were independently associated with increased need for ICU admissions and in-hospital mortality. CONCLUSION The diurnal timing of RRCs appears to have significant implications for patient mortality and morbidity, patient outcomes are worse if RRC occurs out of hours. This finding has implications for staffing and resource allocation.
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Affiliation(s)
- Joanne Molloy
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia.
| | - Naomi Pratt
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia.
| | - Ravindranath Tiruvoipati
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia; Monash University, Peninsula Campus, McMahons Road, Frankston, VIC 3199, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Victoria 3800, Australia.
| | - Cameron Green
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia.
| | - Virginia Plummer
- Peninsula Health, 2 Hastings Road (PO Box 52), Frankston, VIC 3199, Australia; Monash University, Peninsula Campus, McMahons Road, Frankston, VIC 3199, Australia.
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Brown H, Dodic S, Goh SS, Green C, Wang WC, Kaul S, Tiruvoipati R. Factors associated with hospital mortality in critically ill patients with exacerbation of COPD. Int J Chron Obstruct Pulmon Dis 2018; 13:2361-2366. [PMID: 30122916 PMCID: PMC6080864 DOI: 10.2147/copd.s168983] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
INTRODUCTION COPD is a leading cause of morbidity and mortality worldwide. Patients with COPD often require admission to intensive care units (ICU) during an acute exacerbation. OBJECTIVE This study aimed to identify the factors independently associated with hospital mortality in patients requiring ICU admission for acute exacerbation of COPD. METHODS Patients admitted to the ICU of Frankston Hospital between January 2005 and June 2016 with an admission diagnosis of COPD were retrospectively identified from ICU databases. Patients' comorbidities, arterial blood gas results, and in-patient interventions were retrieved from their medical records. Outcomes analyzed included hospital and ICU length of stay (LOS) and mortality. RESULTS A total of 305 patients were included. Mean age was 67.4 years. A total of 77% of patients required non-invasive ventilation; and 38.7% required invasive mechanical ventilation (IMV) for a median of 127.2 hours (SD =179.5). Mean ICU LOS was 4.5 days (SD =5.96), and hospital LOS was 11.6 days (SD =13). In-hospital mortality was 18.7%. Multivariate analysis revealed that patient age (odds ratio [OR] =1.06; 95% CI: 1.031-1.096), ICU LOS (OR =1.26; 95% CI: 1.017-1.571), Acute Physiology and Chronic Health Evaluation-II score (OR =1.07; 95% CI: 1.012-1.123), and requirement for IMV (OR =4.09; 95% CI: 1.791-9.324) to be significantly associated with in-hospital mortality. CONCLUSION Patient age, requirement for IMV, and illness severity were associated with poor patient outcomes.
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Affiliation(s)
- Hamish Brown
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia,
| | - Stefan Dodic
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia,
| | - Sheen Sern Goh
- Department of Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, VIC, Australia,
| | - Wei C Wang
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia,
| | - Sameer Kaul
- Department of Respiratory Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | - Ravindranath Tiruvoipati
- Faculty of Medicine, Nursing, and Health Sciences, Monash University, Melbourne, VIC, Australia,
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, VIC, Australia,
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Hampson J, Green C, Stewart J, Armitstead L, Degan G, Aubrey A, Paul E, Tiruvoipati R. Impact of the introduction of an endotracheal tube attachment device on the incidence and severity of oral pressure injuries in the intensive care unit: a retrospective observational study. BMC Nurs 2018; 17:4. [PMID: 29449786 PMCID: PMC5806388 DOI: 10.1186/s12912-018-0274-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 01/28/2018] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Endotracheal tube (ETT) fasteners such as the AnchorFast™ claim to assist with the prevention of oral pressure injuries in intubated patients, however evidence to support their clinical efficacy is limited. This retrospective observational study aimed to investigate the impact of the introduction of the AnchorFast™ device on the incidence of oral pressure injuries in mechanically ventilated patients. METHODS Data was collected from patient case notes and clinical incident reports for October 2010 to June 2013 (pre-AnchorFast) and July 2013 to March 2016 (post-AnchorFast). Incidence and location of oral pressure injuries associated with securing device, and compliance with institutional policies related to reducing oral pressure injuries were recorded. RESULTS Incidence of oral pressure injuries increased from 1.53/100 intubated patients in the pre-AnchorFast period to 3.73/100 intubated patients in the post-AnchorFast period (IRR = 2.43, 95%CI = 1.35-4.38; p = 0.003). Across both study periods, patients with an ETT secured using AnchorFast™ had significantly increased risk of oral pressure injuries (IRR = 2.03, 95%CI = 1.17-3.51; p = 0.02). There was also a significant difference in location of pressure injuries sustained with ETTs secured using cloth tapes (53.6% in corner of the mouth) vs. AnchorFast™ (75% on the lips) (p = 0.008). Among patients with oral pressure injuries, compliance with institutional policies relating to the prevention of pressure injuries was significantly greater after the introduction of the AnchorFast™ (9.1% vs 64.5%, p = 0.004). CONCLUSIONS The incidence of oral pressure injuries increased significantly following the introduction of the AnchorFast™ device. Further research is required to establish the reasons for this observed increase to and identify ways to reduce the risk of pressure injuries with ETT securement devices.
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Affiliation(s)
- Jaye Hampson
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
| | - Cameron Green
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
| | - Joanne Stewart
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
| | - Lauren Armitstead
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
| | - Gemma Degan
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
| | - Andrea Aubrey
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
| | - Eldho Paul
- 0000 0004 1936 7857grid.1002.3Department of Epidemiology and Preventive Medicine, School of Public health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC Australia
- 0000 0004 0432 511Xgrid.1623.6Clinical Haematology Department, The Alfred Hospital, Melbourne, Victoria 3181 Australia
| | - Ravindranath Tiruvoipati
- 0000 0004 0436 2893grid.466993.7Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, 2 Hastings road, Frankston, VIC 3199 Australia
- 0000 0004 1936 7857grid.1002.3Department of Epidemiology and Preventive Medicine, School of Public health and Preventive Medicine, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC Australia
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Gupta S, Green C, Subramaniam A, Zhen LD, Low E, Tiruvoipati R. The impact of delayed rapid response call activation on patient outcomes. J Crit Care 2017; 41:86-90. [PMID: 28500920 DOI: 10.1016/j.jcrc.2017.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2017] [Revised: 04/18/2017] [Accepted: 05/03/2017] [Indexed: 02/08/2023]
Abstract
PURPOSE To investigate the impact of delay in rapid response call (RRC) activation on Hospital mortality. MATERIALS AND METHODS This study was conducted in a university affiliated hospital providing medical, surgical, mental health, maternity, and pediatric services. RRCs were considered delayed if RRC activation was delayed by ≥15min. The primary outcome measure was in-hospital mortality. Secondary outcomes included hospital length of stay (LOS), requirement of ICU admission, as well as requirement of mechanical ventilation and ICU LOS for patients requiring ICU admission. RESULTS A total of 826 RRCs occurred in 629 patient admissions. A quarter of all RRCs were delayed by ≥15min, with a median delay of 1h and 20min. Patients with a delayed RRC had significantly higher in-hospital mortality (34.7% vs. 21.2%; p=0.001,) and significantly longer hospitalizations (11.6 vs. 8.4days; p=0.036). After adjusting for confounders, RRC activation was independently associated with increased in-hospital mortality (OR=1.79; 95% CI=1.17-2.72: p=0.007). CONCLUSIONS A delay of ≥15min was associated with significantly increased in-hospital mortality and longer hospitalization. The factors contributing to the observed increase in mortality with delayed RRCs require further exploration.
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Affiliation(s)
- Sachin Gupta
- Department of Intensive Care Medicine, Peninsula Health, Victoria, Australia; Faculty of Medicine, Nursing, and Health Sciences, Monash University, Victoria, Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Peninsula Health, Victoria, Australia.
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Victoria, Australia; Faculty of Medicine, Nursing, and Health Sciences, Monash University, Victoria, Australia; Department of Medicine, Peninsula Health, Victoria, Australia
| | - Lim Dee Zhen
- Department of Medicine, Peninsula Health, Victoria, Australia
| | - Elizabeth Low
- Department of Medicine, Peninsula Health, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Victoria, Australia; Faculty of Medicine, Nursing, and Health Sciences, Monash University, Victoria, Australia.
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Abstract
OBJECTIVE Approximately 20% of patients admitted to hospital with drug overdose will require intensive care unit (ICU) admission. An understanding of the characteristics of these patients may assist with their management and identify those patients at risk of multiple hospital presentations due to drug overdose. Our aim was to examine the characteristics of patients admitted to ICU following drug overdoses and identify the predictors of multiple hospital presentations due to drug overdose. METHODS Patients admitted to a metropolitan ICU over a three-year period following drug overdoses were identified using ICU patient databases, and their medical records. RESULTS There were 254 admissions due to drug overdoses. The majority of overdoses were intentional (82.7%) and included multiple agents (68.1%). Two-thirds of patients had psychiatric diagnosis, and 54% had documented history of substance use disorders. In-hospital mortality was 2.8%. Over half of patients admitted had documented history of prior hospital presentation due to overdoses. Personality disorder and schizophrenia were independent predictors of multiple hospital presentations due to overdoses. CONCLUSION Personality disorders or schizophrenia were independent predictors of patients with multiple overdose presentations. Preventative strategies focusing on these patients may reduce the incidence of their hospital presentations and ICU admissions.
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Affiliation(s)
- Vinit Athavale
- Senior registrar, Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia
| | - Cameron Green
- Research co-ordinator, Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia
| | - Kai Zheong Lim
- Medical student, Department of Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia
| | - Caroline Wong
- Medical student, Department of Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia
| | - Ravindranath Tiruvoipati
- Consultant in intensive care medicine, Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, and; Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
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Tiruvoipati R, Pilcher D, Buscher H, Botha J, Bailey M. Effects of Hypercapnia and Hypercapnic Acidosis on Hospital Mortality in Mechanically Ventilated Patients. Crit Care Med 2017; 45:e649-e656. [PMID: 28406813 DOI: 10.1097/ccm.0000000000002332] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Lung-protective ventilation is used to prevent further lung injury in patients on invasive mechanical ventilation. However, lung-protective ventilation can cause hypercapnia and hypercapnic acidosis. There are no large clinical studies evaluating the effects of hypercapnia and hypercapnic acidosis in patients requiring mechanical ventilation. DESIGN Multicenter, binational, retrospective study aimed to assess the impact of compensated hypercapnia and hypercapnic acidosis in patients receiving mechanical ventilation. SETTINGS Data were extracted from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database over a 14-year period where 171 ICUs contributed deidentified data. PATIENTS Patients were classified into three groups based on a combination of pH and carbon dioxide levels (normocapnia and normal pH, compensated hypercapnia [normal pH with elevated carbon dioxide], and hypercapnic acidosis) during the first 24 hours of ICU stay. Logistic regression analysis was used to identify the independent association of hypercapnia and hypercapnic acidosis with hospital mortality. INTERVENTIONS Nil. MEASUREMENTS AND MAIN RESULTS A total of 252,812 patients (normocapnia and normal pH, 110,104; compensated hypercapnia, 20,463; and hypercapnic acidosis, 122,245) were included in analysis. Patients with compensated hypercapnia and hypercapnic acidosis had higher Acute Physiology and Chronic Health Evaluation III scores (49.2 vs 53.2 vs 68.6; p < 0.01). The mortality was higher in hypercapnic acidosis patients when compared with other groups, with the lowest mortality in patients with normocapnia and normal pH. After adjusting for severity of illness, the adjusted odds ratio for hospital mortality was higher in hypercapnic acidosis patients (odds ratio, 1.74; 95% CI, 1.62-1.88) and compensated hypercapnia (odds ratio, 1.18; 95% CI, 1.10-1.26) when compared with patients with normocapnia and normal pH (p < 0.001). In patients with hypercapnic acidosis, the mortality increased with increasing PCO2 until 65 mm Hg after which the mortality plateaued. CONCLUSIONS Hypercapnic acidosis during the first 24 hours of intensive care admission is more strongly associated with increased hospital mortality than compensated hypercapnia or normocapnia.
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Affiliation(s)
- Ravindranath Tiruvoipati
- 1Department of Intensive Care Medicine, Frankston Hospital, Frankston, VIC, Australia.2Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.3ANZIC-RC, Department of Epidemiology & Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, VIC, Australia.4Department of Intensive Care Medicine, St Vincent's Hospital, Sydney, NSW, Australia.5University of New South Wales, Kensington, NSW, Australia
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Reaper S, Green C, Gupta S, Tiruvoipati R. Inter-rater reliability of the Reaper Oral Mucosa Pressure Injury Scale (ROMPIS): A novel scale for the assessment of the severity of pressure injuries to the mouth and oral mucosa. Aust Crit Care 2017; 30:167-171. [PMID: 27401598 DOI: 10.1016/j.aucc.2016.06.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Revised: 05/13/2016] [Accepted: 06/25/2016] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Patients who are intubated in the ICU are at risk of developing pressure injuries to the mouth and lips from endotracheal tubes. Clear documentation is important for pressure wound care; however, no validated instruments currently exist for the staging of pressure injuries to the oral mucosa. Instruments designed for the assessment of pressure injuries to other bodily regions are anatomically unsuited to the lips and mouth. OBJECTIVES This study aimed to develop and then assess the reliability of a novel scale for the assessment of pressure injuries to the mouth and oral mucosa. METHODS The Reaper Oral Mucosa Pressure Injury Scale (ROMPIS) was developed in consultation with ICU nurses, clinical nurse educators, Intensivists, and experts in pressure wound management. ICU nurses and portfolio-holders in pressure wound care from Peninsula Health (Victoria, Australia) were invited to use the ROMPIS to stage 19 de-identified clinical photographs of oral pressure injuries via secure online survey. Inter-rater reliability (IRR) was calculated using Krippendorff's alpha (α). RESULTS Among ICU nurses (n=52), IRR of the ROMPIS was α=0.307; improving to α=0.463 when considering only responses where injuries were deemed to be stageable using the ROMPIS (i.e. excluding responses where respondents considered an injury to be unstageable). Among a cohort of experts in pressure wound care (n=8), IRR was α=0.306; or α=0.443 excluding responses indicating that wounds were unstageable. CONCLUSIONS An instrument for the assessment and monitoring of pressure injuries to the mouth and lips has practical implications for patient care. This preliminary study indicates that the ROMPIS instrument has potential to be used clinically for this purpose; however, the performance of this scale may be somewhat reliant on the confidence or experience of the ICU nurse utilising it. Further validation is required.
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Affiliation(s)
- Sue Reaper
- Department of Intensive Care, Peninsula Health, Australia
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Australia.
| | - Sachin Gupta
- Department of Intensive Care, Peninsula Health, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
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Stewart JA, Green C, Stewart J, Tiruvoipati R. Factors influencing quality of sleep among non-mechanically ventilated patients in the Intensive Care Unit. Aust Crit Care 2017; 30:85-90. [PMID: 26970918 DOI: 10.1016/j.aucc.2016.02.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Revised: 01/15/2016] [Accepted: 02/22/2016] [Indexed: 02/08/2023] Open
Abstract
AIM To investigate the self-reported quality of sleep of non-mechanically ventilated patients admitted to an ICU, and to identify barriers to sleep in this setting. METHOD Patients admitted to the ICU of Frankston Hospital over a two month period who had spent at least one night in the ICU, and had not received mechanical ventilation were surveyed as they were discharged from the ICU. This survey required patients to rate the quality of their sleep in the ICU and at home immediately prior to hospitalisation on a 10cm visual analogue scale; and to identify perceived barriers to sleep in the ICU and at home prior to hospitalisation. RESULTS 56 respondents were surveyed during the study period. Median age was 74 years (range=18-92 years); median ICU length of stay was 1 day (range=1-7 days). Overall, respondents rated their quality of sleep in ICU (median=4.9/10) as significantly worse than at home immediately prior to ICU admission (median=7.15/10; Z=-3.02, p<0.002); however 44% of respondents rated their quality of sleep in ICU as better, or no worse, than at home immediately prior to hospitalisation. Sub-group analysis revealed that among patients with reduced quality of sleep (<5/10) prior to hospitalisation, 71.4% rated their quality of sleep in ICU as better, or no worse, than at home prior to hospitalisation, with no significant difference between sleep quality ratings in ICU and at home (p=0.341). Respondents identified the following as barriers to sleep in the ICU: noise levels overnight (53.6%); discomfort (33.9%); pain (32.1%); being awoken for procedures (32%); being attached to medical devices (28.6%); stress/anxiety (26.8%); and light levels (23.2%). CONCLUSION Pre-hospitalisation sleep quality appears to be an important influence on sleep in ICU. Many barriers to sleep in the ICU identified by respondents are potentially modifiable.
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Affiliation(s)
- John A Stewart
- Department of Intensive Care, Peninsula Health, Australia
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Australia.
| | - Joanne Stewart
- Department of Intensive Care, Peninsula Health, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Australia
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Tiruvoipati R, Botha J, Fletcher J, Gangopadhyay H, Majumdar M, Vij S, Paul E, Pilcher D. Intensive care discharge delay is associated with increased hospital length of stay: A multicentre prospective observational study. PLoS One 2017; 12:e0181827. [PMID: 28750010 PMCID: PMC5531506 DOI: 10.1371/journal.pone.0181827] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 07/08/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Some patients experience a delayed discharge from the intensive care unit (ICU) where the intended and actual discharge times do not coincide. The clinical implications of this remain unclear. OBJECTIVE To determine the incidence and duration of delayed ICU discharge, identify the reasons for delay and evaluate the clinical consequences. METHODS Prospective multi-centre observational study involving five ICUs over a 3-month period. Delay in discharge was defined as >6 hours from the planned discharge time. The primary outcome measure was hospital length stay after ICU discharge decision. Secondary outcome measures included ICU discharge after-hours, incidence of delirium, survival to hospital discharge, discharge destination, the incidence of ICU acquired infections, revocation of ICU discharge decision, unplanned readmissions to ICU within 72 hours, review of patients admitting team after ICU discharge decision. RESULTS A total of 955 out of 1118 patients discharged were included in analysis. 49.9% of the patients discharge was delayed. The most common reason (74%) for delay in discharge was non-availability of ward bed. The median duration of the delay was 24 hours. On univariable analysis, the duration of hospital stay from the time of ICU discharge decision was significantly higher in patients who had ICU discharge delay (Median days-5 vs 6; p = 0.003). After-hours discharge was higher in patients whose discharge was delayed (34% Vs 10%; p<0.001). There was no statistically significant difference in the other secondary outcomes analysed. Multivariable analysis adjusting for known confounders revealed delayed ICU discharge was independently associated with increased hospital length of stay. CONCLUSION Half of all ICU patients experienced a delay in ICU discharge. Delayed discharge was associated with increased hospital length of stay.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
- * E-mail:
| | - John Botha
- Department of Intensive Care Medicine, Frankston Hospital, Frankston, Victoria, Australia
- School of Public Health, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | | | | | | | - Sanjiv Vij
- Dandenong Hospital, Dandenong, Victoria, Australia
| | - Eldho Paul
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Clinical Haematology Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - David Pilcher
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care Medicine, Alfred Hospital, Melbourne, Victoria, Australia
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