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van Zuylen ML, Siegelaar SE, Plummer MP, Deane AM, Hermanides J, Hulst AH. Perioperative management of long-acting glucagon-like peptide-1 (GLP-1) receptor agonists: concerns for delayed gastric emptying and pulmonary aspiration. Br J Anaesth 2024; 132:644-648. [PMID: 38290907 DOI: 10.1016/j.bja.2024.01.001] [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: 09/13/2023] [Revised: 12/31/2023] [Accepted: 01/04/2024] [Indexed: 02/01/2024] Open
Abstract
Prescriptions and use of glucagon-like peptide-1 (GLP-1) receptor agonists are increasing dramatically, as indications are expanding from the treatment of diabetes mellitus to weight loss for people with obesity. As GLP-1 receptor agonists delay gastric emptying, perioperative healthcare practitioners could be concerned about an increased risk for pulmonary aspiration during general anaesthesia. We summarise relevant medical literature and provide evidence-based recommendations for perioperative care for people taking GLP-1 receptor agonists. GLP-1 receptor agonists delay gastric emptying; however, ongoing treatment attenuates this effect. The risk of aspiration during general anaesthesia is unknown. However, we advise caution in patients who recently commenced on GLP-1 receptor agonists. After over 12 weeks of treatment, standard fasting times likely suffice to manage the risk of pulmonary aspiration for most otherwise low-risk patients.
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Affiliation(s)
- Mark L van Zuylen
- Amsterdam UMC Location University of Amsterdam, Department of Anaesthesiology, Amsterdam, The Netherlands; Amsterdam UMC Location University of Amsterdam, Department of Paediatric Intensive Care, Emma Children's Hospital, Amsterdam, The Netherlands.
| | - Sarah E Siegelaar
- Amsterdam UMC Location University of Amsterdam, Department of Endocrinology and Metabolism, Amsterdam, The Netherlands; Research Institute, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands.
| | - Mark P Plummer
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia.
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.
| | - Jeroen Hermanides
- Amsterdam UMC Location University of Amsterdam, Department of Anaesthesiology, Amsterdam, The Netherlands.
| | - Abraham H Hulst
- Amsterdam UMC Location University of Amsterdam, Department of Anaesthesiology, Amsterdam, The Netherlands; Research Institute, Amsterdam Gastroenterology Endocrinology and Metabolism, Amsterdam, the Netherlands.
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Wittholz K, Bongetti AJ, Fetterplace K, Caldow MK, Karahalios A, De Souza DP, Elahee Doomun SN, Rooyackers O, Koopman R, Lynch GS, Ali Abdelhamid Y, Deane AM. Plasma beta-hydroxy-beta-methylbutyrate availability after enteral administration during critical illness after trauma: An exploratory study. JPEN J Parenter Enteral Nutr 2024. [PMID: 38522007 DOI: 10.1002/jpen.2622] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 02/26/2024] [Accepted: 02/28/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND During critical illness skeletal muscle wasting occurs rapidly. Although beta-hydroxy-beta-methylbutyrate (HMB) is a potential treatment to attenuate this process, the plasma appearance and muscle concentration is uncertain. METHODS This was an exploratory study nested within a blinded, parallel group, randomized clinical trial in which critically ill patients after trauma received enteral HMB (3 g daily) or placebo. Plasma samples were collected at 0, 60, and 180 min after study supplement administration on day 1. Needle biopsies of the vastus lateralis muscle were collected (baseline and day 7 of the HMB treatment intervention period). An external standard curve was used to calculate HMB concentrations in plasma and muscle. RESULTS Data were available for 16 participants (male n = 12 (75%), median [interquartile range] age 50 [29-58] years) who received placebo and 18 participants (male n = 14 (78%), age 49 [34-55] years) who received HMB. Plasma HMB concentrations were similar at baseline but increased after HMB (T = 60 min: placebo 0.60 [0.44-1.31] µM; intervention 51.65 [22.76-64.72] µM). Paired muscle biopsies were collected from 11 participants (placebo n = 7, HMB n = 4). Muscle HMB concentrations were similar at baseline between groups (2.35 [2.17-2.95]; 2.07 [1.78-2.31] µM). For participants in the intervention group who had the repeat biopsy within 4 h of HMB administration, concentrations were greater (7.2 and 12.3 µM) than those who had the repeat biopsy >4 h after HMB (2.7 and 2.1 µM). CONCLUSION In this exploratory study, enteral HMB administration increased plasma HMB availability. The small sample size limits interpretation of the muscle HMB findings.
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Affiliation(s)
- Kym Wittholz
- Department of Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Amy J Bongetti
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Kate Fetterplace
- Department of Allied Health (Clinical Nutrition), Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
| | - Marissa K Caldow
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - David P De Souza
- Metabolomics Australia, Bio21 Institute, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Olav Rooyackers
- Division of Anesthesiology and Intensive Care, Department of Clinical Science, Technology and Intervention, Karolinska Institutet, Huddinge, Sweden
| | - René Koopman
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Gordon S Lynch
- Department of Anatomy and Physiology, Centre for Muscle Research, University of Melbourne, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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Wittholz K, Hinckfus C, Karahalios A, Panganiban H, Phillips N, Rotherham H, Rechnitzer T, Ali Abdelhamid Y, Deane AM, Fetterplace K. Association between protocol change to a higher-protein formula with lower energy targets and nutrient delivery in critically ill patients with COVID-19: A retrospective cohort study. JPEN J Parenter Enteral Nutr 2024. [PMID: 38477349 DOI: 10.1002/jpen.2620] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Guidelines recommend prioritizing protein provision while avoiding excessive energy delivery to critically ill patients with coronavirus disease 2019 (COVID-19), but there are no prospective studies evaluating such a targeted approach in this group. We aimed to evaluate the effect of a "higher-protein formula protocol" on protein, energy, and volume delivery when compared with standard nutrition protocol. METHODS This was a retrospective cohort study of adult patients with COVID-19 who received mechanical ventilation for >72 h and enteral nutrition. Before October 2021, the standard nutrition protocol for patients was 0.7 ml/kg/h ideal body weight (IBW) of a 63 g/L protein and 1250 kcal/L formula. From October 2021, we implemented a higher-protein formula protocol for patients with COVID-19. The initial prescription was 0.5 ml/kg/h IBW of a 100 g/L protein and 1260 kcal/L formula with greater emphasis on energy targets being directed by indirect calorimetry when possible. Measured outcomes included protein, energy, and volume delivered. RESULTS There were 114 participants (standard protocol, 48; higher-protein protocol, 66) with 1324 days of nutrition support. The median (95% CI) differences in protein, energy, and volume delivery between targeted and standard protocol periods were 0.08 g/kg/day (-0.02 to 0.18 g/kg/day), -1.71 kcal/kg/day (-3.64 to 0.21 kcal/kg/day) and -1.5 ml/kg/day (-2.9 to -0.1 ml/kg/day). Thirty-three patients (standard protocol, 7; higher-protein protocol, 26) had 44 indirect calorimetry assessments. There was no difference in measured energy expenditure over time (increased by 0.49 kcal/kg/day [-0.89 to 1.88 kcal/kg/day]). CONCLUSION Implementation of a higher-protein formula protocol to patients with COVID-19 modestly reduced volume administration without impacting protein and energy delivery.
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Affiliation(s)
- Kym Wittholz
- Department of Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Chloe Hinckfus
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Amalia Karahalios
- Centre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Haustine Panganiban
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Nadine Phillips
- Centre of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Hannah Rotherham
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Thomas Rechnitzer
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Kate Fetterplace
- Department of Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
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Vanstone MG, Krewulak K, Taneja S, Swinton M, Fiest K, Burns KEA, Debigare S, Dionne JC, Guyatt G, Marshall JC, Muscedere JG, Deane AM, Finfer S, Myburgh JA, Gouskos A, Rochwerg B, Ball I, Mele T, Niven DJ, English SW, Verhovsek M, Cook DJ. Patient-important upper gastrointestinal bleeding in the ICU: A mixed-methods study of patient and family perspectives. J Crit Care 2024; 81:154761. [PMID: 38447306 DOI: 10.1016/j.jcrc.2024.154761] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 02/23/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION The objective of this study was to create a definition of patient-important upper gastrointestinal bleeding during critical illness as an outcome for a randomized trial. DESIGN This was a sequential mixed-methods qualitative-dominant multi-center study with an instrument-building aim. In semi-structured individual interviews or focus groups we elicited views from survivors of critical illness and family members of patients in the intensive care unit (ICU) regarding which features indicate important gastrointestinal bleeding. Quantitative demographic characteristics were collected. We analyzed qualitative data using inductive content analysis to develop a definition for patient-important upper gastrointestinal bleeding. SETTING Canada and the United States. PARTICIPANTS 51 ICU survivors and family members of ICU patients. RESULTS Participants considered gastrointestinal bleeding to be important if it resulted in death, disability, or prolonged hospitalization. The following also signaled patient-important upper gastrointestinal bleeding: blood transfusion, vasopressors, endoscopy, CT-angiography, or surgery. Whether an intervention evinced concern depended on its effectiveness, side-effects, invasiveness and accessibility; contextual influences included participant familiarity and knowledge of interventions and trust in the clinical team. CONCLUSIONS Survivors of critical illness and family members described patient-important upper gastrointestinal bleeding differently than current definitions of clinically-important upper gastrointestinal bleeding.
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Affiliation(s)
- Meredith G Vanstone
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Karla Krewulak
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shipra Taneja
- Department of Family Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Kirsten Fiest
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Sylvie Debigare
- Patient and Family Partnership Committee, Commission Scolaire Central Québec, Canadian Critical Care Trials Group, Canada
| | - Joanna C Dionne
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - John C Marshall
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada; Department of Surgery, Unity Health Toronto, University of Toronto, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queens University, Kingston Health Sciences Center
| | - Adam M Deane
- Department of Critical Care, University of Melbourne, Melbourne Medical School, Victoria, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia; The George Institute for Global Health, School of Public Health, Imperial College London, London, England, United Kingdom
| | - John A Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee representative, FAST-NAWC Trial, University of Toronto, Canada
| | - Bram Rochwerg
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ian Ball
- Department of Medicine, Western University, London, Ontario, Canada.; Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Tina Mele
- Department of Critical Care Medicine, Western University, London, Ontario, Canada; Department of Surgery, Western University, London, Ontario, Canada
| | - Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Shane W English
- Department of Medicine (Critical Care), University of Ottawa, Ottawa, Ontario, Canada; Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Madeleine Verhovsek
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Health Research Methods, Evidence, and Impact, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada; Department of Critical Care, St. Joseph's Healthcare Hamilton.
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5
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Deane AM, Casaer MP. Editorial: The interaction between protein delivery and blood urea and ammonia during critical illness. Curr Opin Clin Nutr Metab Care 2024; 27:144-146. [PMID: 38320160 DOI: 10.1097/mco.0000000000001016] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Adam M Deane
- University of Melbourne, Melbourne Medical School, Department of Critical Care
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Leggett N, Emery K, Rollinson TC, Deane AM, French C, Manski-Nankervis JA, Eastwood G, Miles B, Witherspoon S, Stewart J, Merolli M, Ali Abdelhamid Y, Haines KJ. Clinician- and Patient-Identified Solutions to Reduce the Fragmentation of Post-ICU Care in Australia. Chest 2024:S0012-3692(24)00247-2. [PMID: 38382876 DOI: 10.1016/j.chest.2024.02.019] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 01/31/2024] [Accepted: 02/10/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Critical care survivors experience multiple care transitions, with no formal follow-up care pathway. RESEARCH QUESTION What are the potential solutions to improve the communication between treating teams and integration of care following an ICU admission, from the perspective of patients, their caregivers, intensivists, and general practitioners (GPs) from diverse socioeconomic areas? STUDY DESIGN AND METHODS This study included a qualitative design using semi-structured interviews with intensivists, GPs, and patients and caregivers. Framework analysis was used to analyze data and to identify solutions to improve the integration of care following hospital discharge. Patients were previously mechanically ventilated for > 24 h in the ICU and had access to a video-enabled device. Clinicians were recruited from hospital networks and a state-wide GP network. RESULTS Forty-six interviews with clinicians, patients, and caregivers were completed (15 intensivists, 8 GPs, 15 patients, and 8 caregivers). Three higher level feedback loops were identified that comprised 10 themes. Feedback loop 1 was an ICU and primary care collaboration. It included the following: (1) developing collaborative relationships between the ICU and primary care; (2) providing interprofessional education and resources to support primary care; and (3) improving role clarity for patient follow-up care. Feedback loop 2 was developing mechanisms for improved communication across the care continuum. It included: (4) timely, concise information-sharing with primary care on post-ICU recovery; (5) survivorship-focused information-sharing across the continuum of care; (6) empowering patients and caregivers in self-management; and (7) creation of a care coordinator role for survivors. Feedback loop 3 was learning from post-ICU outcomes to improve future care. It included: (8) developing comprehensive post-ICU care pathways; (9) enhancing support for patients following a hospital stay; and (10) integration of post-ICU outcomes within the ICU to improve clinician morale and understanding. INTERPRETATION Practical solutions to enhance the quality of survivorship for critical care survivors and their caregivers were identified. These themes are mapped to a novel conceptual model that includes key feedback loops for health system improvements and foci for future interventional trials to improve ICU survivorship outcomes.
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Affiliation(s)
- Nina Leggett
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia; Department of Critical Care, the University of Melbourne, Melbourne, VIC, Australia.
| | - Kate Emery
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia
| | - Thomas C Rollinson
- Department of Physiotherapy, the University of Melbourne, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia; Institute for Breathing and Sleep, Melbourne, VIC, Australia
| | - Adam M Deane
- Department of Intensive Care, Melbourne Health, Melbourne, VIC, Australia; Department of Critical Care, School of Medicine, the University of Melbourne, Melbourne, VIC, Australia
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, VIC, Australia
| | - Jo-Anne Manski-Nankervis
- Department of General Practice and Primary Care, Melbourne Medical School, The University of Melbourne, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Critical Care, Austin Health, Melbourne, VIC, Australia
| | - Briannah Miles
- Department of Intensive Care, Melbourne Health, Melbourne, VIC, Australia
| | | | - Jonathan Stewart
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Mark Merolli
- Centre for Digital Transformation of Health, the University of Melbourne, Melbourne, VIC, Australia; Department of Physiotherapy, School of Health Sciences, Faculty of Medicine, Dentistry, and Health Sciences, the University of Melbourne, Melbourne, VIC, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, School of Medicine, the University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Kimberley J Haines
- Department of Physiotherapy, Western Health, Melbourne, VIC, Australia; Department of Critical Care, School of Medicine, the University of Melbourne, Melbourne, VIC, Australia
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7
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Haines KJ, Hibbert E, Skinner EH, Leggett N, Holdsworth C, Ali Abdelhamid Y, Bates S, Bicknell E, Booth S, Carmody J, Deane AM, Emery K, Farley KJ, French C, Krol L, MacLeod-Smith B, Maher L, Paykel M, Iwashyna TJ. In-person peer support for critical care survivors: The ICU REcovery Solutions cO-Led through surVivor Engagement (ICURESOLVE) pilot randomised controlled trial. Aust Crit Care 2024:S1036-7314(24)00022-5. [PMID: 38360469 DOI: 10.1016/j.aucc.2024.01.006] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Peer support is a promising intervention to mitigate post-ICU disability, however there is a paucity of rigorously designed studies. OBJECTIVES The objective of this study was to establish feasibility of an in-person, co-designed, peer-support model. METHODS Prospective, randomised, adaptive, single-centre pilot trial with blinded outcome assessment, conducted at a university-affiliated hospital in Melbourne, Australia. Intensive care unit survivors (and their nominated caregiver, where survivor and caregiver are referred to as a dyad), >18 years of age, able to speak and understand English and participate in phone surveys, were eligible. Participants were randomised to the peer-support model (six sessions, fortnightly) or usual care (no follow-up or targeted information). Two sequential models were piloted: 1. Early (2-3 weeks post hospital discharge) 2. Later (4-6 weeks post hospital discharge). Primary outcome was feasibility of implementation measured by recruitment, intervention attendance, and outcome completion. Secondary outcomes included post-traumatic stress and social support. RESULTS Of the 231 eligible patients, 80 participants were recruited. In the early model we recruited 38 participants (28 patients, 10 carers; 18 singles, 10 dyads), with an average (standard deviation) age of 60 (18) years; 55 % were female. Twenty-two participants (58 %) were randomised to intervention. Participants in the early intervention model attended a median (interquartile range) of 0 (0-1) sessions (total 24 sessions), with 53% (n = 20) completing the main secondary outcome of interest (Impact of Event Scale) at the baseline and 37 % (n = 14) at the follow-up. For the later model we recruited 42 participants (32 patients, 10 carers; 22 singles, 10 dyads), with an average (standard deviation) age of 60.4 (15.4) years; 50 % were female. Twenty-one participants (50 %) were randomised to intervention. The later intervention model attended a median (interquartile range) of 1 (0-5) sessions (total: 44 sessions), with the main secondary outcome impact of events scale (IES-R) completed by 41 (98 %) participants at baseline and 29 (69 %) at follow-up. CONCLUSIONS In this pilot trial, a peer-support model that required in-person attendance delivered in a later posthospital phase of recovery appeared more feasible than an early model. Further research should investigate alternative modes of intervention delivery to improve feasibility (ACTRN12621000737831).
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Affiliation(s)
- Kimberley J Haines
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia.
| | - Elizabeth Hibbert
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | | | - Nina Leggett
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Clare Holdsworth
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Department of Intensive Care, Melbourne Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Samantha Bates
- Department of Intensive Care, Western Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Erin Bicknell
- Department of Physiotherapy, Melbourne Health, Melbourne, Australia
| | - Sarah Booth
- Department of Social Work, Western Health, Melbourne, Australia
| | - Jacki Carmody
- Department of Psychology, Western Health, Melbourne, Australia
| | - Adam M Deane
- Department of Intensive Care, Melbourne Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Kate Emery
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - K J Farley
- Department of Intensive Care, Western Health, Melbourne, Australia
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, Australia; Department of Critical Care, Melbourne Medical School, The University of Melbourne, Australia
| | - Lauren Krol
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | | | - Lynne Maher
- Ko Awatea, Health System Innovation and Improvement, Counties Manukau Health, Auckland, New Zealand
| | - Melanie Paykel
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - Theodore J Iwashyna
- Pulmonary and Critical Care Medicine, School of Medicine, John Hopkins University, Baltimore, MD, United States
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8
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Panganiban HP, Nguyen CD, Abdelhamid YA, Ankravs M, Karahalios E, Macisaac C, Rechnitzer T, Sharrock L, Tran-Duy A, Fazio T, Deane AM. Feasibility of Embedding a Randomised Clinical Trial (RCT) into an Electronic Medical Record (EMR) for Patients Admitted to an Intensive Care Unit (ICU). Stud Health Technol Inform 2024; 310:1420-1421. [PMID: 38269676 DOI: 10.3233/shti231224] [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] [Indexed: 01/26/2024]
Abstract
To establish the feasibility of embedding an RCT into EMR in the ICU, we evaluated the route of phosphate replacement. The EMR screened 207 patients who met the inclusion criteria from 20 April 2022 to 30 June 2022. 162 patients were randomised and 145 patients allocated to treatment. Our study showed that it was feasible to embed screening, randomisation, and treatment allocation for an RCT within an EMR in the ICU.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Adam M Deane
- The Royal Melbourne Hospital
- University of Melbourne
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9
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Leisman DE, Handisides DR, Chawla LS, Albertson TE, Busse LW, Boldt DW, Deane AM, Gong MN, Ham KR, Khanna AK, Ostermann M, McCurdy MT, Thompson BT, Tumlin JS, Adams CD, Hodges TN, Bellomo R. Angiotensin II treatment is associated with improved oxygenation in ARDS patients with refractory vasodilatory shock. Ann Intensive Care 2023; 13:128. [PMID: 38103056 PMCID: PMC10725390 DOI: 10.1186/s13613-023-01227-5] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 12/10/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND The physiological effects of renin-angiotensin system modulation in acute respiratory distress syndrome (ARDS) remain controversial and have not been investigated in randomized trials. We sought to determine whether angiotensin-II treatment is associated with improved oxygenation in shock-associated ARDS. METHODS Post-hoc subgroup analysis of the Angiotensin Therapy for High Output Shock (ATHOS-3) trial. We studied patients who met modified Berlin ARDS criteria at enrollment. The primary outcome was PaO2/FiO2-ratio (P:F) at 48-h adjusted for baseline P:F. Secondary outcomes included oxygenation index, ventilatory ratio, PEEP, minute-ventilation, hemodynamic measures, patients alive and ventilator-free by day-7, and mortality. RESULTS Of 81 ARDS patients, 34 (42%) and 47 (58%) were randomized to angiotensin-II or placebo, respectively. In angiotensin-II patients, mean P:F increased from 155 mmHg (SD: 69) at baseline to 265 mmHg (SD: 160) at hour-48 compared with no change with placebo (148 mmHg (SD: 63) at baseline versus 164 mmHg (SD: 74) at hour-48)(baseline-adjusted difference: + 98.4 mmHg [95%CI 35.2-161.5], p = 0.0028). Similarly, oxygenation index decreased by - 6.0 cmH2O/mmHg at hour-48 with angiotensin-II versus - 0.4 cmH2O/mmHg with placebo (baseline-adjusted difference: -4.8 cmH2O/mmHg, [95%CI - 8.6 to - 1.1], p = 0.0273). There was no difference in PEEP, minute ventilation, or ventilatory ratio. Twenty-two (64.7%) angiotensin-II patients had sustained hemodynamic response to treatment at hour-3 versus 17 (36.2%) placebo patients (absolute risk-difference: 28.5% [95%CI 6.5-47.0%], p = 0.0120). At day-7, 7/34 (20.6%) angiotensin-II patients were alive and ventilator-free versus 5/47(10.6%) placebo patients. Day-28 mortality was 55.9% in the angiotensin-II group versus 68.1% in the placebo group. CONCLUSIONS In post-hoc analysis of the ATHOS-3 trial, angiotensin-II was associated with improved oxygenation versus placebo among patients with ARDS and catecholamine-refractory vasodilatory shock. These findings provide a physiologic rationale for trials of angiotensin-II as treatment for ARDS with vasodilatory shock. TRIAL REGISTRATION ClinicalTrials.Gov Identifier: NCT02338843 (Registered January 14th 2015).
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Affiliation(s)
- Daniel E Leisman
- Department of Medicine, Massachusetts General Hospital, 55 Fruit St., GRB 7-730, Boston, MA, 02114, USA.
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.
| | | | - Lakhmir S Chawla
- Department of Medicine, Veterans Affairs Medical Center, San Diego, CA, USA
| | - Timothy E Albertson
- Departments of Medicine, Emergency Medicine and Anesthesiology, School of Medicine, UC Davis, Sacramento, CA, USA
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - David W Boldt
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Adam M Deane
- Department of Medicine and Radiology, Royal Melbourne Hospital, The University of Melbourne, Melbourne Medical School, Parkville, Australia
| | - Michelle N Gong
- Division of Critical Care Medicine, Division of Pulmonary Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Kealy R Ham
- Department of Critical Care, Mayo Clinic, Phoenix, AZ, USA
| | - Ashish K Khanna
- Department of Anesthesiology, Section On Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative (POIC), Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | - Michael T McCurdy
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - James S Tumlin
- Renal Division, Department of Medicine, Emory University Medical Center, Emory University, Atlanta, GA, USA
| | | | | | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Australia
- Department of Intensive Care Medicine, Austin Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcome and Resource Evaluation (CORE), Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
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10
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Turner N, Farrow B, Betrie AH, Finnis ME, Lankadeva YR, Sharman J, Tan P, Abdelhamid YA, Deane AM, Plummer MP. Cerebrospinal fluid and plasma ascorbate concentrations following subarachnoid haemorrhage. CRIT CARE RESUSC 2023; 25:175-181. [PMID: 38234324 PMCID: PMC10790009 DOI: 10.1016/j.ccrj.2023.10.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/26/2023] [Accepted: 10/08/2023] [Indexed: 01/19/2024]
Abstract
Background Ascorbate, the biologically active form of vitamin C, is the primary neural anti-oxidant. Ascorbate concentrations have never been quantified following aneurysmal subarachnoid haemorrhage (aSAH). Objective To quantify plasma and cerebrospinal fluid (CSF) ascorbate concentrations in patients following SAH. Design Setting Participants Main Outcome Measures Cohort study in which plasma and CSF ascorbate concentrations were measured longitudinally in 12 aSAH patients admitted to a quaternary referral intensive care unit and compared to one-off samples obtained from 20 pregnant women prior to delivery in a co-located obstetric hospital. Data are median [interquartile range] or median (95 % confidence intervals). Results Forty-eight plasma samples were obtained from the 12 aSAH patients (eight females, age 62 [53-68] years). Eight participants with extra-ventricular drains provided 31 paired CSF-plasma samples. Single plasma and CSF samples were obtained from 20 pregnant women (age 35 [31-37] years). Initial plasma and CSF ascorbate concentrations post aSAH were less than half those in pregnant controls (plasma: aSAH: 31 [25-39] μmol/L vs. comparator: 64 [59-77] μmol/L; P < 0.001 and CSF: 116 [80-142] μmol/L vs. 252 [240-288] μmol/L; P < 0.001). Post aSAH there was a gradual reduction in the CSF:plasma ascorbate ratio from ∼4:1 to ∼1:1. Six (50 %) patients developed vasospasm and CSF ascorbate concentrations were lower in these patients (vasospasm: 61 (25, 97) vs. no vasospasm: 110 (96, 125) μmol/L; P = 0.01). Conclusion Post aSAH there is a marked reduction in CSF ascorbate concentration that is most prominent in those who develop vasospasm.
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Affiliation(s)
- Natasha Turner
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Brodie Farrow
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Ashenafi H. Betrie
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria 3052, Australia
- Translational Neurodegeneration Laboratory, Florey Institute of Neuroscience and Mental Health, Health, Melbourne, Victoria 3052, Australia
| | - Mark E. Finnis
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria 3010, Australia
- Intensive Care Unit Research, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
| | - Yugeesh R. Lankadeva
- Pre-clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, Melbourne, Victoria 3052, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Jeremy Sharman
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
| | - Patrick Tan
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria 3010, Australia
- Department of Anaesthesia, The Royal Women's Hospital, Grattan Street & Flemington Road, Melbourne, Victoria 3052, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria 3050, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria 3010, Australia
| | - Mark P. Plummer
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Victoria 3010, Australia
- Intensive Care Unit Research, Royal Adelaide Hospital, Adelaide, South Australia 5000, Australia
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11
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Deane AM, Alhazzani W, Guyatt G, Finfer S, Marshall JC, Myburgh J, Zytaruk N, Hardie M, Saunders L, Knowles S, Lauzier F, Chapman MJ, English S, Muscedere J, Arabi Y, Ostermann M, Venkatesh B, Young P, Thabane L, Billot L, Heels-Ansdell D, Al-Fares AA, Hammond NE, Hall R, Rajbhandari D, Poole A, Johnson D, Iqbal M, Reis G, Xie F, Cook DJ. REVISE: Re- Evaluating the Inhibition of Stress Erosions in the ICU: a randomised trial protocol. BMJ Open 2023; 13:e075588. [PMID: 37968012 PMCID: PMC10660838 DOI: 10.1136/bmjopen-2023-075588] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 05/12/2023] [Accepted: 10/23/2023] [Indexed: 11/17/2023] Open
Abstract
INTRODUCTION The Re-Evaluating the Inhibition of Stress Erosions (REVISE) Trial aims to determine the impact of the proton pump inhibitor pantoprazole compared with placebo on clinically important upper gastrointestinal (GI) bleeding in the intensive care unit (ICU), 90-day mortality and other endpoints in critically ill adults. The objective of this report is to describe the rationale, methodology, ethics and management of REVISE. METHODS AND ANALYSIS REVISE is an international, randomised, concealed, stratified, blinded parallel-group individual patient trial being conducted in ICUs in Canada, Australia, Saudi Arabia, UK, US, Kuwait, Pakistan and Brazil. Patients≥18 years old expected to remain invasively mechanically ventilated beyond the calendar day after enrolment are being randomised to either 40 mg pantoprazole intravenously or an identical placebo daily while mechanically ventilated in the ICU. The primary efficacy outcome is clinically important upper GI bleeding within 90 days of randomisation. The primary safety outcome is 90-day all-cause mortality. Secondary outcomes include rates of ventilator-associated pneumonia, Clostridioides difficile infection, new renal replacement therapy, ICU and hospital mortality, and patient-important GI bleeding. Tertiary outcomes are total red blood cells transfused, peak serum creatinine level in the ICU, and duration of mechanical ventilation, ICU and hospital stay. The sample size is 4800 patients; one interim analysis was conducted after 2400 patients had complete 90-day follow-up; the Data Monitoring Committee recommended continuing the trial. ETHICS AND DISSEMINATION All participating centres receive research ethics approval before initiation by hospital, region or country, including, but not limited to - Australia: Northern Sydney Local Health District Human Research Ethics Committee and Mater Misericordiae Ltd Human Research Ethics Committee; Brazil: Comissão Nacional de Ética em Pesquisa; Canada: Hamilton Integrated Research Ethics Board; Kuwait: Ministry of Health Standing Committee for Coordination of Health and Medical Research; Pakistan: Maroof Institutional Review Board; Saudi Arabia: Ministry of National Guard Health Affairs Institutional Review Board: United Kingdom: Hampshire B Research Ethics Committee; United States: Institutional Review Board of the Nebraska Medical Centre. The results of this trial will inform clinical practice and guidelines worldwide. TRIAL REGISTRATION NUMBER NCT03374800.
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Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Waleed Alhazzani
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Simon Finfer
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - John C Marshall
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - John Myburgh
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Nicole Zytaruk
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Miranda Hardie
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Lois Saunders
- Research Institute, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Serena Knowles
- Critical Care Program, The George Institute for Global Health, Sydney, New South Wales, Australia
| | - Francois Lauzier
- Departments of Anesthesiology, Medicine & Critical Care Medicine, Centre de Recherche du CHU de Québec - Université Laval, Laval, Quebec, Canada
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Shane English
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - John Muscedere
- Department of Critical Care Medicine, Queens University, Kingston, Ontario, Canada
| | - Yaseen Arabi
- Intensive Care Department, King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, UK
| | | | - Paul Young
- Intensive Care Department, Wellington Hospital, London, UK
| | - Lehana Thabane
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Diane Heels-Ansdell
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Abdulrahman A Al-Fares
- Departments of Anesthesia, Critical Care Medicine and Pain Medicine, Al-Amiri Hospital, Kuwait City, Kuwait
| | - Naomi E Hammond
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - R Hall
- Departments of Anesthesia, Critical Care and Pharmacology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Dorrilyn Rajbhandari
- Critical Care Medicine, The George Institute for Global Health, Newtown, New South Wales, Australia
| | - Alexis Poole
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Daniel Johnson
- Departments of Critical Care and Anesthesia, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Mobeen Iqbal
- Intensive Care Department, Maroof International Hospital, Islamabad, Pakistan
| | - Gilmar Reis
- Cardresearch-Cardiologia Assistencial e de Pesquisa LTDA, Pontifical Catholic University of Minas Gerais, Belo Horizonte, Brazil
| | - Feng Xie
- Department of Health Research Methods, Evidence & Impact, Mcmaster University, Hamilton, Ontario, Canada
| | - Deborah J Cook
- Departments of Medicine and Health Research Methods, Evidence & Impact, McMaster University, Hamilton, Ontario, Canada
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12
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Wittholz K, Fetterplace K, Karahalios A, Ali Abdelhamid Y, Beach L, Read D, Koopman R, Presneill JJ, Deane AM. Beta-hydroxy-beta-methylbutyrate supplementation and functional outcomes in multitrauma patients: A pilot randomized controlled trial. JPEN J Parenter Enteral Nutr 2023; 47:983-992. [PMID: 37357015 DOI: 10.1002/jpen.2527] [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] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/21/2023] [Accepted: 05/24/2023] [Indexed: 06/27/2023]
Abstract
BACKGROUND Beta-hydroxy-beta-methylbutyrate (HMB) is a nutrition supplement that may attenuate muscle wasting from critical illness. This trial aimed to determine feasibility of administering a blinded nutrition supplement in the intensive care unit (ICU) and continuing it after ICU discharge. METHODS Single-center, parallel-group, blinded, placebo-controlled, randomized feasibility trial. After traumatic injury necessitating admission to ICU, participants were randomized to receive an enteral study supplement of 3 g of HMB (intervention) or placebo daily for 28 days or until hospital discharge. Primary outcome was feasibility of administering the study supplement, quantified as protocol adherence. Secondary outcomes included change in quadriceps muscle thickness, measured weekly until day 28 or hospital discharge by using ultrasound and analyzed by using a linear mixed model. RESULTS Fifty randomized participants (intervention, n = 26; placebo, n = 24) showed comparable baseline characteristics. Participants received 862 (84.3%) of the 1022 prescribed supplements during hospitalization with 543 (62.8%) delivered via an enteral feeding tube. The median (IQR) number of study supplements successfully administered per participant was 19.5 (13.0-24.0) in the intervention group and 16.5 (8.5-23.5) in the placebo group. Marked loss of quadriceps muscle thickness occurred in both groups, with the point estimate favoring attenuated muscle loss with the intervention, albeit with wide CIs (mean intervention difference after 28 days, 0.26 cm [95% CI, -0.13 to 0.64]). CONCLUSION A blinded, placebo-controlled, randomized clinical trial of daily enteral HMB supplementation for up to 28 days in hospital is feasible. Any effect of HMB supplementation to attenuate muscle wasting after traumatic injury remains uncertain.
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Affiliation(s)
- Kym Wittholz
- Department of Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Kate Fetterplace
- Department of Allied Health (Clinical Nutrition), The Royal Melbourne Hospital, Melbourne, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Amalia Karahalios
- Center of Epidemiology and Biostatistics, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Lisa Beach
- Department of Allied Health (Physiotherapy), The Royal Melbourne Hospital, Melbourne, Australia
| | - David Read
- Department of Trauma and General Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | - René Koopman
- Department of Anatomy and Physiology, Center for Muscle Research, The University of Melbourne, Melbourne, Australia
| | - Jeffrey J Presneill
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Australia
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13
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Summers MJ, Chapple LAS, Bellomo R, Chapman MJ, Ferrie S, Finnis ME, French C, Hurford S, Kakho N, Karahalios A, Maiden MJ, O'Connor SN, Peake SL, Presneill JJ, Ridley EJ, Tran-Duy A, Williams PJ, Young PJ, Zaloumis S, Deane AM. Study protocol for TARGET protein: The effect of augmented administration of enteral protein to critically ill adults on clinical outcomes: A cluster randomised, cross-sectional, double cross-over, clinical trial. CRIT CARE RESUSC 2023; 25:147-154. [PMID: 37876373 PMCID: PMC10581259 DOI: 10.1016/j.ccrj.2023.08.001] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Background It is unknown whether increasing dietary protein to 1.2-2.0 g/kg/day as recommended in international guidelines compared to current practice improves outcomes in intensive care unit (ICU) patients. The TARGET Protein trial will evaluate this. Objective To describe the study protocol for the TARGET Protein trial. Design setting and participants TARGET Protein is a cluster randomised, cross-sectional, double cross-over, pragmatic clinical trial undertaken in eight ICUs in Australia and New Zealand. Each ICU will be randomised to use one of two trial enteral formulae for three months before crossing over to the other formula, which is then repeated, with enrolment continuing at each ICU for 12 months. All patients aged ≥16 years in their index ICU admission commencing enteral nutrition will be eligible for inclusion. Eligible patients will receive the trial enteral formula to which their ICU is allocated. The two trial enteral formulae are isocaloric with a difference in protein dose: intervention 100g/1000 ml and comparator 63g/1000 ml. Staggered recruitment commenced in May 2022. Main outcomes measures The primary outcome is days free of the index hospital and alive at day 90. Secondary outcomes include days free of the index hospital at day 90 in survivors, alive at day 90, duration of invasive ventilation, ICU and hospital length of stay, incidence of tracheostomy insertion, renal replacement therapy, and discharge destination. Conclusion TARGET Protein aims to determine whether augmented enteral protein delivery reduces days free of the index hospital and alive at day 90. Trial registration Australian New Zealand Clinical Trials Registry (ACTRN12621001484831).
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Affiliation(s)
- Matthew J. Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Craig French
- Intensive Care Unit, Sunshine Hospital, Melbourne, Victoria, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Nima Kakho
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
| | - Amalia Karahalios
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Matthew J. Maiden
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Stephanie N. O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Sandra L. Peake
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Jeffrey J. Presneill
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Dietetics and Nutrition, Alfred Hospital, Melbourne, Victoria, Australia
| | - An Tran-Duy
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
| | - Patricia J. Williams
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
| | - Paul J. Young
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Sophie Zaloumis
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
| | - TARGET Protein Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Austin Health, Heidelberg, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- Intensive Care Unit, Sunshine Hospital, Melbourne, Victoria, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, University Hospital Geelong, Geelong, Victoria, Australia
- Intensive Care Unit, The Queen Elizabeth Hospital, Woodville South, South Australia, Australia
- Dietetics and Nutrition, Alfred Hospital, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Melbourne, Victoria, Australia
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Melbourne, Victoria, Australia
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14
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Young PJ, Hodgson CL, Mackle D, Mather AM, Beasley R, Bellomo R, Bernard S, Brickell K, Deane AM, Eastwood G, Finfer S, Higgins AM, Hunt A, Lawrence C, Linke NJ, Litton E, McDonald CF, Moore J, Nichol AD, Olatunji S, Parke RL, Peake S, Secombe P, Seppelt IM, Turner A, Trapani T, Udy A, Kasza J. Protocol summary and statistical analysis plan for the low oxygen intervention for cardiac arrest injury limitation (LOGICAL) trial. CRIT CARE RESUSC 2023; 25:140-146. [PMID: 37876368 PMCID: PMC10581260 DOI: 10.1016/j.ccrj.2023.06.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Background The effect of conservative vs. liberal oxygen therapy on outcomes of intensive care unit (ICU) patients with hypoxic ischaemic encephalopathy (HIE) is uncertain and will be evaluated in the Low Oxygen Intervention for Cardiac Arrest injury Limitation (LOGICAL) trial. Objective The objective of this study was to summarise the protocol and statistical analysis plans for the LOGICAL trial. Design setting and participants LOGICAL is a randomised clinical trial in adults in the ICU who are comatose with suspected HIE (i.e., those who have not obeyed commands following return of spontaneous circulation after a cardiac arrest where there is clinical concern about possible brain damage). The LOGICAL trial will include 1400 participants and is being conducted as a substudy of the Mega Randomised registry trial comparing conservative vs. liberal oxygenation targets in adults receiving unplanned invasive mechanical ventilation in the ICU (Mega-ROX). Main outcome measures The primary outcome is survival with favourable neurological function at 180 days after randomisation as measured with the Extended Glasgow Outcome Scale (GOS-E). A favourable neurological outcome will be defined as a GOS-E score of lower moderate disability or better (i.e. a GOS-E score of 5-8). Secondary outcomes include survival time, day 180 mortality, duration of invasive mechanical ventilation, ICU length of stay, hospital length of stay, the proportion of patients discharged home, quality of life assessed at day 180 using the EQ-5D-5L, and cognitive function assessed at day 180 using the Montreal Cognitive Assessment (MoCA-blind). Conclusions The LOGICAL trial will provide reliable data on the impact of conservative vs. liberal oxygen therapy in ICU patients with suspected HIE following resuscitation from a cardiac arrest. Prepublication of the LOGICAL protocol and statistical analysis plan prior to trial conclusion will reduce the potential for outcome-reporting or analysis bias. Trial registration Australian and New Zealand Clinical Trials Registry (ACTRN12621000518864).
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Affiliation(s)
- Paul J. Young
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
| | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Anne M. Mather
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Department of Intensive Care & Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Victorian Heart Hospital, Melbourne, Victoria, Australia
| | - Kathy Brickell
- University College Dublin Clinical Research Centre at St Vincents University Hospital, Dublin, Ireland
| | - Adam M. Deane
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University College London, London, United Kingdom
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Anna Hunt
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Cassie Lawrence
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Natalie J. Linke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Edward Litton
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, Australia
| | - Christine F. McDonald
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
- Faculty of Medicine, University of Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - James Moore
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Alistair D. Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care & Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- University College Dublin Clinical Research Centre at St Vincent's University Hospital, Dublin, Ireland
| | - Shaanti Olatunji
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Rachael L. Parke
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Sandra Peake
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
| | - Paul Secombe
- Intensive Care Unit, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
| | - Ian M. Seppelt
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Intensive Care Unit, Nepean Hospital, Sydney, New South Wales, Australia
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care & Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - for the LOGICAL management committee, the Australian and New Zealand Intensive Care Society Clinical Trials Group, and the Irish Critical Care Trials Group
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care & Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Victorian Heart Hospital, Melbourne, Victoria, Australia
- University College Dublin Clinical Research Centre at St Vincents University Hospital, Dublin, Ireland
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Faculty of Medicine, University College London, London, United Kingdom
- School of Medicine, University of Western Australia, Perth, Western Australia, Australia
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, Australia
- Department of Respiratory and Sleep Medicine, Austin Health, Melbourne, Victoria, Australia
- Faculty of Medicine, University of Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
- University College Dublin Clinical Research Centre at St Vincent's University Hospital, Dublin, Ireland
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia, Australia
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Alice Springs Hospital, Alice Springs, Northern Territory, Australia
- Intensive Care Unit, Nepean Hospital, Sydney, New South Wales, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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15
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Collie JTB, Jiang A, Abdelhamid YA, Ankravs M, Bellomo R, Byrne KM, Clancy A, Finnis ME, Greaves R, Tascone B, Deane AM. Relationship of blood thiamine pyrophosphate to plasma phosphate and the response to enteral nutrition plus co-administration of intravenous thiamine during critical illness. J Hum Nutr Diet 2023; 36:1214-1224. [PMID: 36919646 DOI: 10.1111/jhn.13162] [Citation(s) in RCA: 2] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 02/06/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Hypovitamin B1 occurs frequently during critical illness but is challenging to predict or rapidly diagnose. The aim of this study was to evaluate whether plasma phosphate concentrations predict hypovitamin B1, enteral nutrition prevents hypovitamin B1 and intravenous thiamine supplementation achieves supraphysiological concentrations in critically ill patients. METHODS Thirty-two enterally fed critically ill patients, with a plasma phosphate concentration ≤0.65 mmol/L, formed a nested cohort within a larger randomised clinical trial. Patients were assigned to receive intravenous thiamine (200 mg) twice daily, and controls were not administered intravenous thiamine. Thiamine pyrophosphate concentrations were measured at four time points (pre- and post-infusion and 4- and 6-h post-infusion) on days 1 and 3 in those allocated to thiamine and once in the control group. RESULTS Baseline thiamine pyrophosphate concentrations were similar (intervention 88 [67, 93] vs. control 89 [62, 110] nmol/L, p = 0.49). Eight (25%) patients had hypovitamin B1 (intervention 3 vs. control 5), with two patients in the control group remaining insufficient at day 3. There was no association between baseline phosphate and thiamine pyrophosphate concentrations. Intravenous thiamine achieved supraphysiological concentrations 6 h post first infusion, with concentrations increasing to day 3. In the control group, thiamine pyrophosphate concentrations were not statistically different between baseline and day 3 (mean change: 8.6 [-6.0, 23.1] nmol/L, p = 0.25). CONCLUSIONS Phosphate concentrations did not predict hypovitamin B1, which was observed in 25% of the participants. Enteral nutrition alone prevented the development of new hypovitamin B1. Administration of a single 200-mg dose of intravenous thiamine achieved supraphysiological concentrations of thiamine pyrophosphate, with repeated dosing sustaining this effect.
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Affiliation(s)
- Jake T B Collie
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Agilent Technologies, Melbourne, Victoria, Australia
| | - Alice Jiang
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Melissa Ankravs
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Kathleen M Byrne
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Annabelle Clancy
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Mark E Finnis
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ronda Greaves
- School of Health and Biomedical Sciences, RMIT University, Melbourne, Victoria, Australia
- Department of Biochemical Genetics, Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
- Department of Paediatrics, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
| | - Brianna Tascone
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Victoria, Australia
- Department of intensive care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
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16
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Reintam Blaser A, Bachmann KF, Deane AM. Gastrointestinal function in critically ill patients. Curr Opin Clin Nutr Metab Care 2023:00075197-990000000-00089. [PMID: 37389469 DOI: 10.1097/mco.0000000000000955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
PURPOSE OF REVIEW To summarize recent evidence regarding the diagnosis of acute gastrointestinal dysfunction and enteral feeding intolerance, and relationship of these to development of multiple organ dysfunction syndrome, during critical illness. RECENT FINDINGS Novel gastric feeding tubes that attenuate gastroesophageal regurgitation or facilitate continuous monitoring of gastric motility have been developed. The definition of enteral feeding intolerance remains controversial, which may be resolved using a consensus process. A novel scoring system for gastrointestinal dysfunction (GIDS - GastroIntestinal Dysfunction Score) was recently developed but it is not yet validated or tested to evaluate the effect of any interventions. Studies of biomarkers to identify gastrointestinal dysfunction have yet to yield a suitable biomarker for daily clinical use. SUMMARY The assessment of gastrointestinal function in critically ill patients continues to rely on complex daily clinical assessment. Scoring systems, consensus definitions and novel technology appear the most promising tools and interventions to improve patient care.
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Affiliation(s)
- Annika Reintam Blaser
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Lucerne Cantonal Hospital, Lucerne
| | - Kaspar F Bachmann
- Department of Anaesthesiology and Intensive Care, University of Tartu, Tartu, Estonia
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
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17
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van Gassel RJJ, Bels JLM, Tartaglia K, van Bussel BCT, van Kuijk SMJ, Deane AM, Puthucheary Z, Weijs PJM, Vloet L, Beishuizen B, De Bie Dekker A, Fraipont V, Lamote S, Ledoux D, Scheeren C, De Waele E, van Zanten ARH, Mesotten D, van de Poll MCG. The impact of high versus standard enteral protein provision on functional recovery following intensive care admission (PRECISE trial): study protocol for a randomized controlled, quadruple blinded, multicenter, parallel group trial in mechanically ventilated patients. Trials 2023; 24:416. [PMID: 37337234 DOI: 10.1186/s13063-023-07380-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 05/16/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Critically ill patients are subject to severe skeletal muscle wasting during intensive care unit (ICU) stay, resulting in impaired short- and long-term functional outcomes and health-related quality of life. Increased protein provision may improve functional outcomes in ICU patients by attenuating skeletal muscle breakdown. Supporting evidence is limited however and results in great variety in recommended protein targets. METHODS The PRECISe trial is an investigator-initiated, bi-national, multi-center, quadruple-blinded randomized controlled trial with a parallel group design. In 935 patients, we will compare provision of isocaloric enteral nutrition with either a standard or high protein content, providing 1.3 or 2.0 g of protein/kg/day, respectively, when fed on target. All unplanned ICU admissions with initiation of invasive mechanical ventilation within 24 h of admission and an expected stay on ventilator support of at least 3 days are eligible. The study is designed to assess the effect of the intervention on functional recovery at 1, 3, and 6 months following ICU admission, including health-related quality of life, measures of muscle strength, physical function, and mental health. The primary endpoint of the trial is health-related quality of life as measured by the Euro-QoL-5D-5-level questionnaire Health Utility Score. Overall between-group differences will be assessed over the three time points using linear mixed-effects models. DISCUSSION The PRECISe trial will evaluate the effect of protein on functional recovery including both patient-centered and muscle-related outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04633421 . Registered on November 18, 2020. First patient in (FPI) on November 19, 2020. Expected last patient last visit (LPLV) in October 2023.
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Affiliation(s)
- Rob J J van Gassel
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Julia L M Bels
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands.
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands.
| | | | - Bas C T van Bussel
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Zudin Puthucheary
- William Harvey Research Institute, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, London, UK
- Adult Critical Care Unit, Royal London Hospital, London, UK
| | - Peter J M Weijs
- Department of Nutrition and Dietetics, Faculty of Sports and Nutrition, Amsterdam University of Applied Sciences, Amsterdam, the Netherlands
- Department of Nutrition and Dietetics, Amsterdam University Medical Center, Vrije Universiteit, Amsterdam, the Netherlands
| | - Lilian Vloet
- Research Department of Emergency and Critical Care, HAN University of Applied Science, School of Health Studies, Nijmegen, the Netherlands
- IQ Healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Bert Beishuizen
- Department of Intensive Care Medicine, Medisch Spectrum Twente, Enschede, the Netherlands
| | | | - Vincent Fraipont
- Service of Intensive Care Medicine, Citadelle Hospital, Liège, Belgium
| | - Stoffel Lamote
- Department of Intensive Care Medicine, AZ Groeninge, Kortrijk, Belgium
| | - Didier Ledoux
- Sensation & Perception Research Group, GIGA Consciousness, University of Liège, Liège, Belgium
- Intensive Care Units, University Hospital of Liège, Liège, Belgium
| | - Clarissa Scheeren
- Department of Intensive Care Medicine, Zuyderland Medisch Centrum, Heerlen/Sittard, the Netherlands
| | - Elisabeth De Waele
- Departement of Nutrition, Universitair Ziekenhuis Brussel, Jette, Belgium
| | | | - Dieter Mesotten
- Department of Intensive Care Medicine, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, UHasselt, Diepenbeek, Belgium
| | - Marcel C G van de Poll
- Department of Intensive Care Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
- NUTRIM School for Nutrition and Translational Research in Metabolism, Maastricht University, Maastricht, the Netherlands
- Department of Surgery, Maastricht University Medical Center, Maastricht, The Netherlands
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18
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Showler L, Ali Abdelhamid Y, Goldin J, Deane AM. Sleep during and following critical illness: A narrative review. World J Crit Care Med 2023; 12:92-115. [PMID: 37397589 PMCID: PMC10308338 DOI: 10.5492/wjccm.v12.i3.92] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 02/13/2023] [Accepted: 03/22/2023] [Indexed: 06/08/2023] Open
Abstract
Sleep is a complex process influenced by biological and environmental factors. Disturbances of sleep quantity and quality occur frequently in the critically ill and remain prevalent in survivors for at least 12 mo. Sleep disturbances are associated with adverse outcomes across multiple organ systems but are most strongly linked to delirium and cognitive impairment. This review will outline the predisposing and precipitating factors for sleep disturbance, categorised into patient, environmental and treatment-related factors. The objective and subjective methodologies used to quantify sleep during critical illness will be reviewed. While polysomnography remains the gold-standard, its use in the critical care setting still presents many barriers. Other methodologies are needed to better understand the pathophysiology, epidemiology and treatment of sleep disturbance in this population. Subjective outcome measures, including the Richards-Campbell Sleep Questionnaire, are still required for trials involving a greater number of patients and provide valuable insight into patients’ experiences of disturbed sleep. Finally, sleep optimisation strategies are reviewed, including intervention bundles, ambient noise and light reduction, quiet time, and the use of ear plugs and eye masks. While drugs to improve sleep are frequently prescribed to patients in the ICU, evidence supporting their effectiveness is lacking.
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Affiliation(s)
- Laurie Showler
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Jeremy Goldin
- Sleep and Respiratory Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
| | - Adam M Deane
- Intensive Care Medicine, The Royal Melbourne Hospital, Parkville 3050, Victoria, Australia
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Northcott MH, Johnston G, Presneill JJ, Fazio TN, Adamson N, Ankravs MJ, Hackenberger L, Ali Abdelhamid Y, MacIsaac CM, Deane AM. Aggression, violence and threatening behaviour during critical illness. CRIT CARE RESUSC 2023; 25:65-70. [PMID: 37876598 PMCID: PMC10581280 DOI: 10.1016/j.ccrj.2023.05.002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective This article aims to quantify prevalence of patient aggression or threatened/actual violence during critical illness. Design This is a retrospective cohort study. Setting This study was conducted in single adult trauma intensive care unit (ICU). Participants Patients aged 18 years or over, admitted between January 2015 and December 2020, who triggered a "Code Grey" response due to aggression or threatened/actual violence. Main outcome measure The primary outcome was prevalence of Code Grey events. Secondary outcomes included unadjusted and adjusted (logistic mixed model) effects of patient demographics, diagnoses and severity of illness on Code Grey events. Results There were 16175 ICU admissions relating to 14085 patients and 807 Code Grey events involving 379 (2.7%) patients. The observed count of events increased progressively from 2015 (n = 77) to 2020 (n = 204). For patients with a Code Grey, the median count of events was 3 (range 1-33). Independent predictors of at least one ICU Code Grey event included male sex (OR 2.5; 95% CI 1.8 to 3.4), young age (most elevated odds ratio in patients 20-30 years), admission from the emergency department (OR 2.8, 95% CI 2.1 to 3.6) and a trauma diagnosis (OR 1.4, 95% CI 1.1 to 1.9). Code Grey patients had longer admissions with a reduced risk of death. Conclusions The prevalence of Code Grey events in ICU appears to be increasing. Patients may have repeated events. Younger male patients admitted to ICU via the emergency department with a trauma or medical diagnosis are at greatest risk of a Code Grey event.
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Affiliation(s)
| | - Gemma Johnston
- Department of Anaesthesia, Royal Melbourne Hospital, Australia
| | - Jeffrey J. Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Australia
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Australia
| | - Timothy N. Fazio
- Business Intelligence Unit, Royal Melbourne Hospital, Australia
- Department of Medicine, Melbourne Medical School, University of Melbourne, Australia
| | | | - Melissa J. Ankravs
- Intensive Care Unit, Royal Melbourne Hospital, Australia
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Australia
- Department of Pharmacy, Royal Melbourne Hospital, Australia
| | | | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Australia
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Australia
| | - Christopher M. MacIsaac
- Intensive Care Unit, Royal Melbourne Hospital, Australia
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Australia
- Department of Critical Care Medicine, Melbourne Medical School, University of Melbourne, Australia
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20
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Dimopoulos S, Leggett NE, Deane AM, Haines KJ, Abdelhamid YA. Models of intensive care unit follow-up care and feasibility of intervention delivery: A systematic review. Aust Crit Care 2023:S1036-7314(23)00060-7. [PMID: 37263902 DOI: 10.1016/j.aucc.2023.04.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/23/2023] [Accepted: 04/24/2023] [Indexed: 06/03/2023] Open
Abstract
BACKGROUND The optimal model of outpatient intensive care unit (ICU) follow-up care remains uncertain, and there is limited evidence of benefit. RESEARCH QUESTION The objective of this research is to describe existing models of outpatient ICU follow-up care, quantify participant recruitment and retention, and describe facilitators of patient engagement. STUDY DESIGN & METHODS A systematic search of the MEDLINE and EMBASE databases was undertaken in June 2021. Two independent reviewers screened titles, abstracts, and full texts against eligibility criteria. Studies of adults with any outpatient ICU follow-up were included. Studies were excluded if published before 1990, not published in English, or of paediatric patients. Quantitative data were extracted using predefined data fields. Key themes were extracted from qualitative studies. Risk of bias was assessed. RESULTS A total of 531 studies were screened. Forty-seven studies (32 quantitative and 15 qualitative studies) with a total of 5998 participants were included. Of 33 quantitative study interventions, the most frequently reported model of care was in-person hospital-based interventions (n = 27), with 10 hybrid (part in-hospital, part remote) interventions. Literature was limited for interventions without hospital attendance (n = 6), including telehealth and diaries. The median ranges of rates of recruitment, rates of intervention delivery, and retention to outcome assessment for hospital-based interventions were 51.5% [24-94%], 61.9% [8-100%], and 52% [8.1-82%], respectively. Rates were higher for interventions without hospital attendance: 82.6% [60-100%], 68.5% [59-89%], and 75% [54-100%]. Facilitators of engagement included patient-perceived value of follow-up, continuity of care, intervention accessibility and flexibility, and follow-up design. Studies had a moderate risk of bias. INTERPRETATION Models of post-ICU care without in-person attendance at the index hospital potentially have higher rates of recruitment, intervention delivery success, and increased participant retention when compared to hospital-based interventions. PROSPERO REGISTRATION CRD42021260279.
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Affiliation(s)
| | - Nina E Leggett
- Department of Physiotherapy, Western Health, Victoria, Australia; Department of Critical Care, School of Medicine, The University of Melbourne, Victoria, Australia
| | - Adam M Deane
- Intensive Care Unit, The Royal Melbourne Hospital, Victoria, Australia; Department of Critical Care, School of Medicine, The University of Melbourne, Victoria, Australia
| | - Kimberley J Haines
- Department of Physiotherapy, Western Health, Victoria, Australia; Department of Critical Care, School of Medicine, The University of Melbourne, Victoria, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, The Royal Melbourne Hospital, Victoria, Australia; Department of Critical Care, School of Medicine, The University of Melbourne, Victoria, Australia.
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Cook DJ, Swinton M, Krewulak KD, Fiest K, Dionne J, Debigare S, Guyatt G, Taneja S, Alhazzani W, Burns KEA, Marshall JC, Muscedere J, Gouskos A, Finfer S, Deane AM, Myburgh J, Rochwerg B, Ball I, Mele T, Niven D, English S, Verhovsek M, Vanstone M. What counts as patient-important upper gastrointestinal bleeding in the ICU? A mixed-methods study protocol of patient and family perspectives. BMJ Open 2023; 13:e070966. [PMID: 37208143 DOI: 10.1136/bmjopen-2022-070966] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Clinically important upper gastrointestinal bleeding is conventionally defined as bleeding accompanied by haemodynamic changes, requiring red blood cell transfusions or other invasive interventions. However, it is unclear if this clinical definition reflects patient values and preferences. This protocol describes a study to elicit views from patients and families regarding features, tests, and treatments for upper gastrointestinal bleeding that are important to them. METHODS AND ANALYSIS This is a sequential mixed-methods qualitative-dominant multi-centre study with an instrument-building aim. We developed orientation tools and educational materials in partnership with patients and family members, including a slide deck and executive summary. We will invite intensive care unit (ICU) survivors and family members of former ICU patients to participate. Following a virtual interactive presentation, participants will share their perspectives in an interview or focus group. Qualitative data will be analysed using inductive qualitative content analysis, wherein codes will be derived directly from the data rather than using preconceived categories. Concurrent data collection and analysis will occur. Quantitative data will include self-reported demographic characteristics. This study will synthesise the values and perspectives of patients and family members to create a new trial outcome for a randomised trial of stress ulcer prophylaxis. This study is planned for May 2022 to August 2023. The pilot work was completed in Spring 2021. ETHICS AND DISSEMINATION This study has ethics approval from McMaster University and the University of Calgary. Findings will be disseminated via manuscript and through incorporation as a secondary trial outcome on stress ulcer prophylaxis. TRIAL REGISTRATION NUMBER NCT05506150.
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Affiliation(s)
- Deborah J Cook
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Marilyn Swinton
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Karla D Krewulak
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Kirsten Fiest
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Joanna Dionne
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Sylvie Debigare
- Patient and Family Partnership Committee, Canadian Critical Care Trials Group, Montreal, Quebec, Canada
| | - Gordon Guyatt
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shipra Taneja
- Family Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Waleed Alhazzani
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, St. Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Karen E A Burns
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John C Marshall
- Surgery and Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Muscedere
- Critical Care Medicine, Kingston Health Sciences Center, Queens University, Kingston, Ontario, Canada
| | - Audrey Gouskos
- Patient and Family Advisory Committee and Steering Committee Representative, Toronto, Ontario, Canada
| | - Simon Finfer
- Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- The George Institute for Global Health, School of Public Health, Imperial College London, London, UK
| | - Adam M Deane
- Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - John Myburgh
- Critical Care, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Bram Rochwerg
- Medicine, McMaster University, Hamilton, Ontario, Canada
- Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
- Critical Care, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Ian Ball
- Medicine and Epidemiology and Biostatistics, Western University, London, Ontario, Canada
| | - Tina Mele
- Surgery and Critical Care Medicine, Western University, London, Ontario, Canada
| | - Daniel Niven
- Critical Care Medicine, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Shane English
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Division of Critical Care, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
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Wieruszewski PM, Bellomo R, Busse LW, Ham KR, Zarbock A, Khanna AK, Deane AM, Ostermann M, Wunderink RG, Boldt DW, Kroll S, Greenfeld CR, Hodges T, Chow JH. Initiating angiotensin II at lower vasopressor doses in vasodilatory shock: an exploratory post-hoc analysis of the ATHOS-3 clinical trial. Crit Care 2023; 27:175. [PMID: 37147690 PMCID: PMC10163684 DOI: 10.1186/s13054-023-04446-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 04/17/2023] [Indexed: 05/07/2023] Open
Abstract
BACKGROUND High dose vasopressors portend poor outcome in vasodilatory shock. We aimed to evaluate the impact of baseline vasopressor dose on outcomes in patients treated with angiotensin II (AT II). METHODS Exploratory post-hoc analysis of the Angiotensin II for the Treatment of High-Output Shock (ATHOS-3) trial data. The ATHOS-3 trial randomized 321 patients with vasodilatory shock, who remained hypotensive (mean arterial pressure of 55-70 mmHg) despite receiving standard of care vasopressor support at a norepinephrine-equivalent dose (NED) > 0.2 µg/kg/min, to receive AT II or placebo, both in addition to standard of care vasopressors. Patients were grouped into low (≤ 0.25 µg/kg/min; n = 104) or high (> 0.25 µg/kg/min; n = 217) NED at the time of study drug initiation. The primary outcome was the difference in 28-day survival between the AT II and placebo subgroups in those with a baseline NED ≤ 0.25 µg/kg/min at the time of study drug initiation. RESULTS Of 321 patients, the median baseline NED in the low-NED subgroup was similar in the AT II (n = 56) and placebo (n = 48) groups (median of each arm 0.21 µg/kg/min, p = 0.45). In the high-NED subgroup, the median baseline NEDs were also similar (0.47 µg/kg/min AT II group, n = 107 vs. 0.45 µg/kg/min placebo group, n = 110, p = 0.75). After adjusting for severity of illness, those randomized to AT II in the low-NED subgroup were half as likely to die at 28-days compared to placebo (HR 0.509; 95% CI 0.274-0.945, p = 0.03). No differences in 28-day survival between AT II and placebo groups were found in the high-NED subgroup (HR 0.933; 95% CI 0.644-1.350, p = 0.71). Serious adverse events were less frequent in the low-NED AT II subgroup compared to the placebo low-NED subgroup, though differences were not statistically significant, and were comparable in the high-NED subgroups. CONCLUSIONS This exploratory post-hoc analysis of phase 3 clinical trial data suggests a potential benefit of AT II introduction at lower doses of other vasopressor agents. These data may inform design of a prospective trial. TRIAL REGISTRATION The ATHOS-3 trial was registered in the clinicaltrials.gov repository (no. NCT02338843). Registered 14 January 2015.
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Affiliation(s)
| | - Rinaldo Bellomo
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Laurence W Busse
- Department of Medicine, Emory University, Atlanta, GA, USA
- Emory Critical Care Center, Emory Healthcare, Atlanta, GA, USA
| | - Kealy R Ham
- Department of Critical Care Medicine, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, University Münster, Munster, Germany
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
- Perioperative Outcomes and Informatics Collaborative, Winston-Salem, NC, USA
- Outcomes Research Consortium, Cleveland, OH, USA
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK
| | - Richard G Wunderink
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - David W Boldt
- Department of Anesthesiology and Critical Care Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Stew Kroll
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | | | - Tony Hodges
- La Jolla Pharmaceutical Company, Waltham, MA, USA
| | - Jonathan H Chow
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, 2700 M St. NW, 7Th Floor, Room 709, Washington, DC, 20037, USA.
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23
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Sharrock L, Ankravs MJ, Deane AM, Rechnitzer T, Wallis SC, Roberts JA, Bellomo R. Clearance of Piperacillin-Tazobactam and Vancomycin During Continuous Renal Replacement With Regional Citrate Anticoagulation. Ther Drug Monit 2023; 45:265-268. [PMID: 35994070 DOI: 10.1097/ftd.0000000000001028] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/19/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The use of regional citrate anticoagulation during continuous venovenous hemodiafiltration (CVVHDF) has increased worldwide. However, data on its effect on the pharmacokinetics of antibiotics are limited. In this study, the authors aimed to measure the clearance of piperacillin-tazobactam and vancomycin in patients receiving CVVHDF with regional citrate anticoagulation. METHODS This study measured piperacillin-tazobactam and vancomycin concentrations in patients receiving CVVHDF with regional citrate anticoagulation. Dosing regimens were independently selected by intensivists. Arterial blood and effluent fluid samples were obtained over a single dosing interval and analyzed using ultra-high-performance liquid chromatography with tandem mass spectrometry. RESULTS Seventeen sampling intervals in 15 patients (9 receiving piperacillin-tazobactam only, 4 receiving vancomycin only, and 2 receiving both) were used. The median overall clearance for piperacillin was 35.2 mL/min [interquartile range (IQR): 32.2-38.6], 70 mL/min (IQR: 62.7-76.2) for tazobactam, and 29.5 mL/min (IQR: 26.2-32) for vancomycin. CONCLUSIONS This is the first study to quantify the pharmacokinetics of vancomycin and piperacillin-tazobactam in patients receiving CVVHDF with regional citrate anticoagulation. These results indicate high clearance and provide key information to guide optimal dosing.
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Affiliation(s)
- Lucy Sharrock
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Pharmacy Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Melissa J Ankravs
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Pharmacy Department, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Thomas Rechnitzer
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Steven C Wallis
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Jason A Roberts
- University of Queensland Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Departments of Pharmacy and Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Division of Anaesthesiology, Critical Care, Emergency and Pain Medicine, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - Rinaldo Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia; and
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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Wigmore G, Deane AM, Anstey J, Bailey M, Bihari S, Eastwood G, Ghanpur R, Maiden MJ, Presneill JJ, Raman J, Bellomo R. Study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-ll (HAS FLAIR-II) trial. CRIT CARE RESUSC 2022; 24:309-318. [PMID: 38047012 PMCID: PMC10692638 DOI: 10.51893/2022.4.oa1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Background: Fluid bolus therapy with 20% albumin may shorten the duration of vasopressor therapy in patients after cardiac surgery. Objective: To describe the study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-II (HAS FLAIR-II) trial. Design, setting, participants and intervention: HAS FLAIR-II is a phase 2b, multicentre, parallel group, openlabel, randomised controlled trial that will be conducted at six Australian intensive care units. Patients requiring fluid bolus therapy after cardiac surgery will be randomly assigned in a 1:1 ratio to the intervention of fluid bolus therapy with 20% albumin or a comparator of fluid bolus therapy with a crystalloid solution. Main outcome measures: The primary outcome measure is the cumulative duration of vasopressor therapy. Secondary outcomes include vasopressor use, service utilisation, and mortality. All analyses will be conducted on an intention-to-treat basis. Results and conclusion: The study protocol and statistical analysis plan will guide the conduct and analysis of the HAS FLAIR-II trial, such that analytical and reporting biases are minimised. Trial registration: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN No. 12620000137998).
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Affiliation(s)
- Geoffrey Wigmore
- Department of Anaesthesia, Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Adam M. Deane
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - James Anstey
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Shailesh Bihari
- Department of Intensive and Critical Care Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rashmi Ghanpur
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Intensive care Unit, Warringal Private hospital, Melbourne, VIC, Australia
| | - Matthew J. Maiden
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
| | - Jeffrey J. Presneill
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Jaishankar Raman
- University of Melbourne, Melbourne, VIC, Australia
- St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Deakin University, Melbourne, VIC, Australia
- University of Illinois at Urbana-Champaign, Urbana (IL), USA
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - For the HAS FLAIR-II trial investigators
- Department of Anaesthesia, Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive and Critical Care Medicine, Flinders Medical Centre, Adelaide, SA, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Intensive care Unit, Warringal Private hospital, Melbourne, VIC, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Deakin University, Melbourne, VIC, Australia
- University of Illinois at Urbana-Champaign, Urbana (IL), USA
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25
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Kaul N, Nation J, Laing J, Nicolo J, Deane AM, Udy AA, Kwan P, O'Brien TJ. Modified low ratio ketogenic therapy in the treatment of adults with super-refractory status epilepticus. JPEN J Parenter Enteral Nutr 2022; 46:1819-1827. [PMID: 35285036 PMCID: PMC9790306 DOI: 10.1002/jpen.2373] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Revised: 02/14/2022] [Accepted: 03/06/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Induction of ketosis by manipulation of nutrition intake has been proposed as an adjunctive treatment for super-refractory status epilepticus (SRSE). However, the classical 4:1 ketogenic ratio may not meet the nutrition needs, specifically protein for critically ill adults. The aim of this study was to analyze the outcomes of adults with SRSE who received a lower ketogenic ratio of 2:1 grams of fat to non-fat grams, including 20%-30% of energy from medium chain triglycerides. METHODS We reviewed patients aged ≥18 years with SRSE treated with ketogenic therapy between July 2015 and December 2020 at two quaternary teaching hospitals in Melbourne, Australia. Data collected from medical records included patient demographics, nutrition prescription, clinical outcomes, and ketogenic therapy-related complications. The primary outcome of the study was to assess tolerability of ketogenic therapy. RESULTS Twelve patients (female = 7) were treated with ketogenic therapy for SRSE. Patients received between 4 and 8 antiseizure medications and 1-5 anesthetic agents prior to commencement of ketogenic therapy. Blood beta-hydroxybutyrate concentrations were variable (median = 0.5 mmol/L, range: 0.0-6.1 mmol/L). SRSE resolved in 10 cases (83%) after a median of 9 days (range: 2-21 days) following commencement of ketogenic therapy. Ketogenic therapy-associated complications were reported in five patients, leading to cessation in two patients. CONCLUSION Despite the challenge in maintaining ketosis during critical illness, low ratio 2:1 ketogenic therapy incorporating medium chain triglycerides is tolerable for adults with SRSE. Further studies are required to determine the optimal timing, nutrition prescription and duration of ketogenic therapy for SRSE treatment.
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Affiliation(s)
- Neha Kaul
- Department of Nutrition and DieteticsAlfred HospitalMelbourneVictoriaAustralia,Department of Allied Health (Clinical Nutrition)Royal Melbourne HospitalParkvilleVictoriaAustralia,Departments of Neurosciences and NeurologyAlfred Hospital and Monash UniversityMelbourneVictoriaAustralia,Department of Medicine, Royal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia
| | - Judy Nation
- Department of Medicine, Royal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia
| | - Joshua Laing
- Departments of Neurosciences and NeurologyAlfred Hospital and Monash UniversityMelbourneVictoriaAustralia
| | - John‐Paul Nicolo
- Departments of Neurosciences and NeurologyAlfred Hospital and Monash UniversityMelbourneVictoriaAustralia,Department of NeurologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Adam M. Deane
- Department of Medicine, Royal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia,Intensive Care UnitRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Andrew A. Udy
- Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research CentreMonash UniversityMelbourneVictoriaAustralia,Department of Intensive Care and Hyperbaric MedicineAlfred HospitalMelbourneVictoriaAustralia
| | - Patrick Kwan
- Departments of Neurosciences and NeurologyAlfred Hospital and Monash UniversityMelbourneVictoriaAustralia,Department of Medicine, Royal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia,Department of NeurologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
| | - Terence J. O'Brien
- Departments of Neurosciences and NeurologyAlfred Hospital and Monash UniversityMelbourneVictoriaAustralia,Department of Medicine, Royal Melbourne HospitalUniversity of MelbourneParkvilleVictoriaAustralia,Department of NeurologyRoyal Melbourne HospitalParkvilleVictoriaAustralia
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Karri R, Chen YPP, Burrell AJC, Penny-Dimri JC, Broadley T, Trapani T, Deane AM, Udy AA, Plummer MP. Machine learning predicts the short-term requirement for invasive ventilation among Australian critically ill COVID-19 patients. PLoS One 2022; 17:e0276509. [PMID: 36288359 PMCID: PMC9604987 DOI: 10.1371/journal.pone.0276509] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/21/2021] [Accepted: 10/07/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE(S) To use machine learning (ML) to predict short-term requirements for invasive ventilation in patients with COVID-19 admitted to Australian intensive care units (ICUs). DESIGN A machine learning study within a national ICU COVID-19 registry in Australia. PARTICIPANTS Adult patients who were spontaneously breathing and admitted to participating ICUs with laboratory-confirmed COVID-19 from 20 February 2020 to 7 March 2021. Patients intubated on day one of their ICU admission were excluded. MAIN OUTCOME MEASURES Six machine learning models predicted the requirement for invasive ventilation by day three of ICU admission from variables recorded on the first calendar day of ICU admission; (1) random forest classifier (RF), (2) decision tree classifier (DT), (3) logistic regression (LR), (4) K neighbours classifier (KNN), (5) support vector machine (SVM), and (6) gradient boosted machine (GBM). Cross-validation was used to assess the area under the receiver operating characteristic curve (AUC), sensitivity, and specificity of machine learning models. RESULTS 300 ICU admissions collected from 53 ICUs across Australia were included. The median [IQR] age of patients was 59 [50-69] years, 109 (36%) were female and 60 (20%) required invasive ventilation on day two or three. Random forest and Gradient boosted machine were the best performing algorithms, achieving mean (SD) AUCs of 0.69 (0.06) and 0.68 (0.07), and mean sensitivities of 77 (19%) and 81 (17%), respectively. CONCLUSION Machine learning can be used to predict subsequent ventilation in patients with COVID-19 who were spontaneously breathing and admitted to Australian ICUs.
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Affiliation(s)
- Roshan Karri
- Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Yi-Ping Phoebe Chen
- Faculty of Science, Technology and Engineering, La Trobe University, Melbourne, Victoria, Australia
| | - Aidan J. C. Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | | | - Tessa Broadley
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark P. Plummer
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Critical Care, Melbourne Medical School, Melbourne, Victoria, Australia
- * E-mail:
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27
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Jalleh RJ, Xie C, Deane AM, Plummer MP, Jones KL, Horowitz M, Kar P. One-hour plasma glucose level after a 75 g oral glucose load and its relationship to gastric emptying in survivors of critical illness and stress hyperglycaemia. CRIT CARE RESUSC 2022; 24:268-271. [PMID: 38046216 PMCID: PMC10692590 DOI: 10.51893/2022.3.oa6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: A 1-hour plasma glucose level ≥ 8.6 mmol/L in a 75 g oral glucose tolerance test has been strongly associated with increased morbidity and mortality in outpatients without diabetes. Our primary aim was to evaluate the 1-hour plasma glucose level in a 75 g glucose tolerance test in survivors of critical illness with stress hyperglycaemia at 3 months after intensive care unit (ICU) discharge, with the secondary aims to evaluate the 2-hour plasma glucose level, glycated haemoglobin (HbA1c), and gastric emptying. Design:Post hoc analysis of a single-centre, prospective cohort study. Setting: Single-centre, tertiary referral, mixed medical-surgical ICU. Participants: Consecutively admitted patients aged ≥ 18 years who developed stress hyperglycaemia and survived to hospital discharge were eligible. Interventions: Participants returned at 3 months after ICU discharge and underwent a 75 g oral glucose tolerance test. Main outcome measures: One- and 2-hour post load plasma glucose level, HbA1c, and assessment of gastric emptying via an isotope breath test. Results: Thirty-five patients (12 females; mean age, 58.5 years [SD, 10.5]; mean HbA1c, 37.4 mmol/mol [SD, 7.0]) attended the followup. In 32/35 patients (91%) the 1-hour post load plasma glucose level was ≥ 8.6 mmol/L. There was a positive correlation between the plasma glucose level at 1 hour (r2 = 0.21; P = 0.006), but no correlation between the 2-hour glucose level (r2 = 0.006; P = 0.63) and gastric emptying. Conclusion: Glucose intolerance, when defined as 1-hour glucose level ≥ 8.6 mmol/L following a 75 g oral glucose load, persists at 3 months in most survivors of stress hyperglycaemia and is dependent on the rate of gastric emptying. Longitudinal studies to characterise mechanisms underlying dysglycaemia and progression to diabetes in individuals with stress hyperglycaemia are indicated.
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Affiliation(s)
- Ryan J. Jalleh
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia
| | - Cong Xie
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark P. Plummer
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Karen L. Jones
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Adelaide Medical School, The University of Adelaide, Adelaide, SA, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, SA, Australia
| | - Palash Kar
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
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Plummer MP, Hermanides J, Deane AM. Is it time to personalise glucose targets during critical illness? Curr Opin Clin Nutr Metab Care 2022; 25:364-369. [PMID: 35787592 DOI: 10.1097/mco.0000000000000846] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW Dysglycaemia complicates most critical care admissions and is associated with harm, yet glucose targets, particularly in those with preexisting diabetes, remain controversial. This review will summarise advances in the literature regarding personalised glucose targets in the critically ill. RECENT FINDINGS Observational data suggest that the degree of chronic hyperglycaemia in critically ill patients with diabetes attenuates the relationship between mortality and several metrics of dysglycaemia, including blood glucose on admission, and mean blood glucose, glycaemic variability and hypoglycaemia in the intensive care unit. The interaction between acute and chronic hyperglycaemia has recently been quantified with novel metrics of relative glycaemia including the glycaemic gap and stress hyperglycaemia ratio. Small pilot studies provided preliminary data that higher blood glucose thresholds in critically ill patients with chronic hyperglycaemia may reduce complications of intravenous insulin therapy as assessed with biomakers. Although personalising glycaemic targets based on preexisting metabolic state is an appealing concept, the recently published CONTROLLING trial did not identify a mortality benefit with individualised glucose targets, and the effect of personalised glucose targets on patient-centred outcomes remains unknown. SUMMARY There is inadequate data to support adoption of personalised glucose targets into care of critically ill patients. However, there is a strong rationale empowering future trials utilising such an approach for patients with chronic hyperglycaemia.
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Affiliation(s)
- Mark P Plummer
- Department of Intensive Care, Royal Adelaide Hospital
- Faculty of Health and Medical Sciences, University of Adelaide, Adelaide
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
| | - Jeroen Hermanides
- Department of Anesthesiology, Amsterdam UMC location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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29
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Showler L, Rait L, Chan M, Tondello M, George A, Tascone B, Presneill JJ, MacIsaac CM, Abdelhamid YA, Deane AM. Communication with bereaved family members after death in the ICU: the CATHARTIC randomised clinical trial. CRIT CARE RESUSC 2022; 24:116-127. [PMID: 38045592 PMCID: PMC10692614 DOI: 10.51893/2022.2.oa2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: It is uncertain whether psychological distress in the family members of patients who die during an intensive care unit (ICU) admission may be improved by bereavement interventions. In this trial, relatives' symptoms of anxiety and depression after 6 months were measured when allocated to three commonly used bereavement follow-up strategies. Design: Single-centre, randomised, three parallel-group trial. Setting: A tertiary ICU in Australia. Participants: Relatives of patients who died in the ICU. Interventions: Relatives received bereavement follow-up 4 weeks after the death using a condolence letter, short telephone call or no contact. Main outcome measures: The primary outcome was the total Hospital Anxiety and Depression Scale (HADS-T) score. Secondary outcomes estimated anxiety, depression, complicated grief, post-traumatic stress, and satisfaction with ICU care. Results: Seventy-one relatives participated (24 had no contact, 19 were contacted by letter and 28 by telephone 4 weeks after the death). The mean HADS-T score for no contact was 16.1 (95% CI, 12.4-19.8). Receipt of a letter was associated with a mean HADS-T increase of 1.4 (4.0 decrease to 6.8 increase), and a condolence call was accompanied by a mean decrease of 1.6 (6.6 decrease to 3.4 increase; P > 0.5). Non-significant differences were observed for all secondary outcomes. Conclusions: Anxiety and depression at 6 months in the relatives of patients who died in the ICU was not meaningfully alleviated by receipt of either a condolence letter or telephone call. Trial registration: Australia New Zealand Clinical Trials Registry (ACTRN12619000917134).
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Affiliation(s)
- Laurie Showler
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Louise Rait
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Michael Chan
- Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark Tondello
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Alastair George
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Brianna Tascone
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeffrey J. Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Christopher M. MacIsaac
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Yasmine Ali Abdelhamid
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Adam M. Deane
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
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Young PJ, Mackle D, Hodgson C, Bellomo R, Bailey M, Beasley R, Deane AM, Eastwood G, Finfer S, Freebairn R, King V, Linke N, Litton E, McArthur C, McGuinness S, Panwar R. Conservative or liberal oxygen therapy for mechanically ventilated adults with acute brain pathologies: A post-hoc subgroup analysis. J Crit Care 2022; 71:154079. [PMID: 35660843 DOI: 10.1016/j.jcrc.2022.154079] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 04/10/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To compare the effect of conservative vs. liberal oxygen therapy in mechanically ventilated adults in the intensive care unit (ICU) with non-hypoxic ischemic encephalopathy (HIE) acute brain pathologies. MATERIALS AND METHODS Post-hoc analysis of data from 217 patients with non-HIE acute brain pathologies included in the ICU Randomized Trial Comparing Two Approaches to OXygen therapy (ICU-ROX). RESULTS Patients allocated to conservative oxygen spent less time with oxygen saturation ≥ 97% (50.5 [interquartile range (IQR), 18.5-119] vs. 82 h [IQR, 38-164], absolute difference, -31.5 h; 95%CI, -59.6 to -3.4). At 180 days, 38 of 110 conservative oxygen patients (34.5%) and 28 of 104 liberal oxygen patients (26.9%) had died (absolute difference, 7.6 percentage points; 95%CI, -4.7 to 19.9 percentage points; P = 0.23; interaction P = 0.02 for non-HIE acute brain pathologies vs. HIE; interaction P = 0.53 for non-HIE acute brain pathologies vs. non-neurological conditions). CONCLUSIONS In this post-hoc analysis, patients admitted to the ICU with non-HIE acute brain pathologies treated with conservative oxygen therapy did not have significantly lower mortality than those treated with liberal oxygen. A trial with adequate statistical power is needed to determine whether our day 180 mortality point estimate of treatment effect favoring liberal oxygen therapy indicates a true effect.
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Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand; Intensive Care Unit, Wellington Hospital, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia.
| | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia; Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Adam M Deane
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia; Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Glenn Eastwood
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia; University of Melbourne, Parkville, Victoria, Australia
| | - Simon Finfer
- Critical Care Division and Trauma, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia; School of Public Health, Imperial College London, London, England, UK
| | - Ross Freebairn
- Intensive Care Unit, Hawkes Bay Hospital, Hastings, New Zealand
| | - Victoria King
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Natalie Linke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand; Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Shay McGuinness
- Medical Research Institute of New Zealand, Wellington, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, New Lambton Heights, New South Wales, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
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Poole AP, Finnis ME, Anstey J, Bellomo R, Bihari S, Birardar V, Doherty S, Eastwood G, Finfer S, French CJ, Heller S, Horowitz M, Kar P, Kruger PS, Maiden MJ, Mårtensson J, McArthur CJ, McGuinness SP, Secombe PJ, Tobin AE, Udy AA, Young PJ, Deane AM. The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A multicenter, parallel-group, open-label, randomized clinical trial. Am J Respir Crit Care Med 2022; 206:874-882. [PMID: 35608484 DOI: 10.1164/rccm.202202-0329oc] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Blood glucose concentrations affect outcomes in critically ill patients but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objective To evaluate the effects of a 'liberal' approach to targeted blood glucose range during intensive care unit (ICU) admission. Methods This mutlicenter, parallel-group, open-label, randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dL and titrated to a target range of 180 to 252 mg/dL. In the comparator group insulin was commenced at a blood glucose >180 mg/dL and titrated to a target range of 108 to 180 mg/dL. The primary outcome was incident hypoglycemia (<72 mg/dL). Secondary outcomes included glucose metrics and clinical outcomes. Main Results At least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio: 0.21 (95% CI, 0.09 to 0.49); P<0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability and less relative hypoglycaemia (P<0.001 for all comparisons). By day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference 4.6 percentage points (95%CI, -3.9 to 13.2%); P=0.29). Conclusions A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registration available at www.anzctr.org.au, ID: ACTRN12616001135404.
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Affiliation(s)
- Alexis P Poole
- The University of Adelaide Discipline of Acute Care Medicine, 242032, Adelaide, South Australia, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Adelaide, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark E Finnis
- Royal Adelaide Hospital, Department of Critical Care Services, Adelaide, South Australia, Australia.,University of Adelaide, Discipline of Acute Care Medicine, Adelaide, South Australia, Australia
| | - James Anstey
- Saint Vincent's Hospital Melbourne, 60078, Department of Intensive Care, Fitzroy, Victoria, Australia
| | | | - Shailesh Bihari
- Flinders Medical Centre and Flinders University, Department of Intensive Care Medicine, Bedford park, South Australia, Australia
| | - Vishwanath Birardar
- The University of Adelaide Discipline of Acute Care Medicine, 242032, Adelaide, South Australia, Australia.,Lyell McEwin Hospital, 3187, Intensive Care Unit, Elizabeth Vale, South Australia, Australia
| | - Sarah Doherty
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Austin hospital, Intensive care unit, Heidelgerg, Victoria, Australia
| | - Simon Finfer
- University of Sydney, Intensive Care, St. Leonards, New South Wales, Australia
| | - Craig J French
- Western Health, Victoria, Intensive Care Unit, Melbourne, Victoria, Australia
| | - Simon Heller
- Clinical Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Michael Horowitz
- The University of Adelaide Adelaide Medical School, 110466, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia
| | - Palash Kar
- The University of Adelaide Discipline of Acute Care Medicine, 242032, Adelaide, South Australia, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter S Kruger
- Princess Alexandra Hospital, Intensive Care Unit, Brisbane, Queensland, Australia.,University of Queensland, Critical Care, Endocrinology and Metabolism Research Unit, Brisbane, Queensland, Australia
| | - Matthew J Maiden
- Royal Adelaide Hospital, Intensive Care Unit, Adelaide, South Australia, Australia.,University of Adelaide, Discipline of Acute Care Medicine, Adelaide, South Australia, Australia
| | - Johan Mårtensson
- Karolinska Institutet Department of Physiology and Pharmacology, 111126, Stockholm, Sweden.,Karolinska University Hospital, 59562, Perioperative Medicine and Intensive Care, Stockholm, Sweden
| | | | - Shay P McGuinness
- Auckland District Health Board, Cardiothoracic and Vascular ICU, Aucklanad, New Zealand
| | - Paul J Secombe
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care, Alice Springs Hospital, Alice Springs, Australia
| | - Antony E Tobin
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, Victoria, Australia.,Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Paul J Young
- Wellington Hospital, Intensive Care Unit, Wellington, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Adam M Deane
- The University of Melbourne, 2281, Centre for Integrated Critical Care , Melbourne, Victoria, Australia.,Royal Melbourne Hospital, 90134, Intensive Care Unit, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, 90134, Department of Medicine, Melbourne, Victoria, Australia;
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32
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Chapple LAS, Kouw IWK, Summers MJ, Weinel LM, Gluck S, Raith E, Slobodian P, Soenen S, Deane AM, van Loon LJC, Chapman MJ. Muscle Protein Synthesis Following Protein Administration in Critical Illness. Am J Respir Crit Care Med 2022; 206:740-749. [PMID: 35584344 DOI: 10.1164/rccm.202112-2780oc] [Citation(s) in RCA: 35] [Impact Index Per Article: 17.5] [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: 11/16/2022] Open
Abstract
Rationale Dietary protein may attenuate the muscle atrophy experienced by patients in the Intensive Care Unit (ICU), yet protein handling is poorly understood. Objective To quantify protein digestion and amino acid absorption, and fasting and postprandial myofibrillar protein synthesis during critical illness. Methods Fifteen mechanically ventilated adults (12M; age 50±17y, Body Mass Index (BMI) 27±5kg·m-2) and 10 healthy controls (6M; 54±23y, BMI 27±4kg·m-2) received a primed intravenous L-[ring-2H5]-phenylalanine, L-[3,5-2H2]-tyrosine, and L-[1-13C]-leucine infusion over 9.5h, and a duodenal bolus of intrinsically-labelled (L-[1-13C]-phenylalanine and L-[1-13C]-leucine) intact milk protein (20g protein) over 60min. Arterial blood and muscle samples were taken at baseline (fasting) and for 6h following duodenal protein administration. Data are mean±SD; analysed with 2-way repeated measures ANOVA and independent samples t-test. Measurements and main results Fasting myofibrillar protein synthesis rates did not differ between ICU patients and healthy controls (0.023±0.013 vs 0.034±0.016%/h; P=0.077). Following protein administration, plasma amino acid availability did not differ between groups (ICU patients 54.2±9.1 vs healthy controls 61.8±13.1%; P=0.12), and myofibrillar protein synthesis rates increased in both groups (0.028±0.010 vs 0.043±0.018 %/h, main time effect P=0.046, P-interaction=0.584) with lower rates in ICU patients compared to healthy controls (main group effect P=0.001). Incorporation of protein-derived phenylalanine into myofibrillar protein was ~60% lower in ICU patients (0.007±0.007 vs 0.017±0.009 mole % excess (MPE); P=0.007). Conclusion The capacity for critically ill patients to use ingested protein for muscle protein synthesis is markedly blunted despite relatively normal protein digestion and amino acid absorption.
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Affiliation(s)
- Lee-Anne S Chapple
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia;
| | - Imre W K Kouw
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Maastricht University Medical Centre+, 199236, Department of Human Biology, NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht, Limburg, Netherlands
| | - Matthew J Summers
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Luke M Weinel
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Samuel Gluck
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Eamon Raith
- Royal Adelaide Hospital, 1062, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia
| | - Peter Slobodian
- Central Adelaide Local Health Network, 375072, Pharmacy, Adelaide, South Australia, Australia
| | - Stijn Soenen
- The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia.,Bond University Faculty of Health Sciences and Medicine, 104559, Gold Coast, Queensland, Australia
| | - Adam M Deane
- The University of Melbourne, 2281, Melbourne Medical School, Department of Critical Care, Melbourne, Victoria, Australia
| | - Luc J C van Loon
- NUTRIM School of Nutrition and Translational Research in Metabolism, Maastricht University Medical Centre+, Department of Human Biology, Maastricht, Netherlands
| | - Marianne J Chapman
- Royal Adelaide Hospital, Intensive Care Unit, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Adelaide Medical School, Adelaide, South Australia, Australia.,The University of Adelaide, 1066, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia
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33
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Ridley EJ, Bailey M, Chapman M, Chapple LAS, Deane AM, Hodgson C, King VL, Marshall A, Miller EG, McGuinness SP, Parke R, Udy AA. Protocol summary and statistical analysis plan for Intensive Nutrition Therapy compar Ed to usual care i N cri Tically ill adults (INTENT): a phase II randomised controlled trial. BMJ Open 2022; 12:e050153. [PMID: 35260448 PMCID: PMC8905937 DOI: 10.1136/bmjopen-2021-050153] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
INTRODUCTION It is plausible that a longer duration of nutrition intervention may have a greater impact on clinical and patient-centred outcomes. The Intensive Nutrition care Therapy comparEd to usual care iN criTically ill adults (INTENT) trial will determine if a whole hospital nutrition intervention is feasible and will deliver more total energy compared with usual care in critically ill patients with at least one organ system failure. METHODS AND ANALYSIS This study is a prospective, multicentre, unblinded, parallel-group, phase II randomised controlled trial (RCT) conducted in 23 hospitals in Australia and New Zealand. Mechanically ventilated critically ill adult patients with at least one organ failure who have been in intensive care unit (ICU) for 72-120 hours and meet all of the inclusion and none of the exclusion criteria will be randomised to receive either intensive or usual nutrition care. INTENT started recruitment in October 2018 and a sample size of 240 participants is anticipated to be recruited in 2022. The study period is from randomisation to hospital discharge or study day 28, whichever occurs first, and the primary outcome is daily energy delivery from nutrition therapy. Secondary outcomes include daily energy and protein delivery during ICU and in the post-ICU period, duration of ventilation, ventilator-free days, total bloodstream infection rate and length of hospital stay. All other outcomes are considered tertiary and results will be analysed on an intention-to-treat basis. ETHICS AND DISSEMINATION Ethics approval has been received in Australia (Alfred Hospital Ethics Committee (HREC/18/Alfred/101) and Human Research Ethics Committee of the Northern Territory Department of Health (2019-3372)) and New Zealand (Northern A Health and Disability Ethics Committee (18/NTA/222). Results will be disseminated in an international peer-reviewed journal(s), at scientific meetings and via social media. TRIAL REGISTRATION NUMBER NCT03292237.
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Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Nutrition Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Medicine and Radiology, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Marianne Chapman
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Adam M Deane
- Department of Medicine and Radiology, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Victoria L King
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Marshall
- Acute and Complex Care, Gold Coast Hospital and Health Service, Southport, Queensland, Australia
- Menzies Health Institute Queensland, Griffith University, Gold Coast Campus, Southport, Queensland, Australia
| | - Eliza G Miller
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - S P McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- School of Nursing, The University of Auckland, Auckland, New Zealand
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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34
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Affiliation(s)
- Adam M Deane
- University of Melbourne, Melbourne Medical School, Department of Critical Care
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Michael P Casaer
- Clinical Department and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
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Wittholz K, Fetterplace K, Ali Abdelhamid Y, Presneill JJ, Beach L, Thomson B, Read D, Koopman R, Deane AM. β-Hydroxy-β-methylbutyrate (HMB) supplementation and functional outcomes in multi-trauma patients: a study protocol for a pilot randomised clinical trial (BOOST trial). Pilot Feasibility Stud 2022; 8:21. [PMID: 35101139 PMCID: PMC8802472 DOI: 10.1186/s40814-022-00990-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/20/2022] [Indexed: 11/25/2022] Open
Abstract
Background There are no therapies proven to diminish the muscle wasting that occurs in patients after major trauma who are admitted to the intensive care unit (ICU). β-Hydroxy-β-methylbutyrate (HMB) is a nutrition intervention that may attenuate muscle loss and, thereby, improve recovery. The primary aim of this study is to determine the feasibility of a blinded randomised clinical trial of HMB supplementation to patients after major trauma who are admitted to the ICU. Secondary aims are to establish estimates for the impact of HMB when compared to placebo on muscle mass and nutrition-related patient outcomes. Methods This prospective, single-centre, blinded, randomised, placebo-controlled, parallel-group, feasibility trial with allocation concealment will recruit 50 participants over 18 months. After informed consent, participants will be randomised [1:1] to receive either the intervention (three grams of HMB dissolved in either 150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed) or placebo (150 ml of orange juice for those allowed oral intake or 150 ml of water for those being enterally fed). The intervention will be commenced in ICU, continued after ICU discharge and ceased at hospital discharge or day 28 post randomisation, whichever occurs first. The primary outcome is the feasibility of administering the intervention. Secondary outcomes include change in muscle thickness using ultrasound and other nutritional and patient-centred outcomes. Discussion This study aims to determine the feasibility of administering HMB to critically ill multi-trauma patients throughout ICU admission until hospital discharge. Results will inform design of a larger randomised clinical trial. Trial registration The protocol is registered with Australian New Zealand Clinical Trials Registry (ANZCTR) ANZCTR: 12620001305910. UTN: U1111-1259-5534.
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36
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Tio SY, Williams E, Worth LJ, Deane AM, Bond K, Slavin MA, Sasadeusz J. Invasive pulmonary aspergillosis in critically ill patients with COVID-19 in Australia: implications for screening and treatment. Intern Med J 2021; 51:2129-2132. [PMID: 34939293 DOI: 10.1111/imj.15602] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 10/15/2021] [Accepted: 10/15/2021] [Indexed: 12/15/2022]
Abstract
We report four cases of invasive pulmonary aspergillus co-infection in patients with coronavirus disease 2019 (COVID-19) infection and acute respiratory distress syndrome requiring intensive care unit (ICU) admission. Aspergillus fumigatus and Aspergillus terreus were isolated, with early infection onset following ICU admission. Clinicians should be aware of invasive pulmonary aspergillosis in ICU patients with COVID-19 infection, particularly those receiving dexamethasone. We propose screening of these high-risk patients with twice-weekly fungal culture from tracheal aspirate and, if feasible, Aspergillus polymerase chain reaction. Diagnosis is challenging and antifungal treatment should be considered in critically ill patients who have new or worsening pulmonary changes on chest imaging and mycological evidence of infection.
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Affiliation(s)
- Shio Yen Tio
- Victorian Infectious Diseases Service (VIDS), The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Eloise Williams
- Department of Microbiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Leon J Worth
- Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Adam M Deane
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia
| | - Katherine Bond
- Department of Microbiology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Monica A Slavin
- Victorian Infectious Diseases Service (VIDS), The Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Infectious Diseases, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia.,National Centre for Infections in Cancer, Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Victoria, Australia
| | - Joe Sasadeusz
- Victorian Infectious Diseases Service (VIDS), The Royal Melbourne Hospital, Melbourne, Victoria, Australia
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37
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Murthy TA, Bellomo R, Chapman MJ, Deane AM, Ferrie S, Finnis ME, Hurford S, O’Connor SN, Peake SL, Summers MJ, Williams PJ, Young PJ, Chapple LAS. Protein delivery in mechanically ventilated adults in Australia and New Zealand: current practice. CRIT CARE RESUSC 2021; 23:386-393. [PMID: 38046685 PMCID: PMC10692581 DOI: 10.51893/2021.4.oa3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To quantify current protein prescription and delivery in critically ill adults in Australia and New Zealand and compare it with international guidelines. Design: Prospective, multicentre, observational study. Setting: Five intensive care units (ICUs) across Australia and New Zealand. Participants: Mechanically ventilated adults who were anticipated to receive enteral nutrition for ≥ 24 hours. Main outcome measures: Baseline demographic and nutrition data in ICU, including assessment of requirements, prescription and delivery of enteral nutrition, parenteral nutrition and protein supplementation, were collected. The primary outcome was enteral nutrition protein delivery (g/kg ideal body weight [IBW] per day). Data are reported as mean ± standard deviation or n (%). Results: 120 patients were studied (sex, 60% male; mean age, 59 ± 16 years; mean admission APACHE II score, 20 ± 8). Enteral nutrition was delivered on 88%, parenteral nutrition on 6.8%, and protein supplements on 0.3% of 1156 study days. For the 73% (88/120) of patients who had a nutritional assessment, the mean estimated protein requirements were 99 ± 22 g/day (1.46 ± 0.55 g/kg IBW per day). The mean daily protein delivery was 54 ± 23 g (0.85 ± 0.35 g/kg IBW per day) from enteral nutrition and 56 ± 23 g (0.88 ± 0.35 g/kg IBW per day) from all sources (enteral nutrition, parenteral nutrition, protein supplements). Protein delivery was ≥ 1.2 g/kg IBW per day on 29% of the total study days per patient. Conclusions: Protein delivery as a part of current usual care to critically ill adults in Australia and New Zealand remains below that recommended in international guidelines.
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Affiliation(s)
- Tejaswini Arunachala Murthy
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Health, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Marianne J. Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
| | - Adam M. Deane
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Suzie Ferrie
- Department of Nutrition & Dietetics, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark E. Finnis
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Stephanie N. O’Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Sandra L. Peake
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine,Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Matthew J. Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Patricia J. Williams
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine,Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Paul J. Young
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Lee-anne S. Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council of Australia, Centre for Research Excellence in Translating Nutritional Science to Good Health, University of Adelaide, Adelaide, SA, Australia
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38
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Doola R, Deane AM, Barrett HL, Okano S, Tolcher DM, Gregory K, Coombes JS, Schalkwijk C, Todd AS, Forbes JM, Sturgess DJ. The impact of a modified carbohydrate formula, and its constituents, on glycaemic control and inflammatory markers: A nested mechanistic sub-study. J Hum Nutr Diet 2021; 35:455-465. [PMID: 34743379 DOI: 10.1111/jhn.12959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 10/11/2021] [Indexed: 12/25/2022]
Abstract
BACKGROUND Hyperglycaemia occurs frequently in the critically ill. Dietary intake of advanced glycation end-products (AGEs), specifically Nε-(carboxymethyl)lysine (CML), may exacerbate hyperglycaemia through perturbation of insulin sensitivity. The present study aimed to determine whether the use of nutritional formulae, with varying AGE loads, affects the amount of insulin administered and inflammation. METHODS Exclusively tube fed patients (n = 35) were randomised to receive Nutrison Protein Plus Multifibre®, Diason® or Glucerna Select®. Insulin administration was standardised according to protocol based on blood glucose (<10 mmol L-1 ). Samples were obtained at randomisation and 48 h later. AGEs in nutritional formula, plasma and urine were measured using mass spectrometry. Plasma inflammatory markers were measured using an enzyme-linked immunosorbent assay and multiplex bead-based assays. RESULTS AGE concentrations of CML in nutritional formulae were greatest with delivery of Nutrison Protein Plus® (mean [SD]; 6335 pmol mol-1 [2436]) compared to Diason® (4836 pmol mol-1 [1849]) and Glucerna Select® (4493 pmol mol-1 [1829 pmol mol-1 ]) despite patients receiving similar amounts of energy (median [interquartile range]; 12 MJ [8.2-13.7 MJ], 11.5 MJ [8.3-14.5 MJ], 11.5 MJ [8.3-14.5 MJ]). More insulin was administered with Nutrison Protein Plus® (2.47 units h-1 [95% confidence interval (CI) = 1.57-3.37 units h-1 ]) compared to Diason® (1.06 units h-1 [95% CI = 0.24-1.89 units h-1 ]) or Glucerna Select® (1.11 units h-1 [95% CI = 0.25-1.97 units h-1 ]; p = 0.04). Blood glucose concentrations were similar. There were associations between greater insulin administration and reductions in circulating interleukin-6 (r = -0.46, p < 0.01), tumour necrosis factor-α (r = -0.44, p < 0.05), high sensitivity C-reactive protein (r = -0.42, p < 0.05) and soluble receptor for advanced glycation end-products (r = -0.45, p < 0.01) concentrations. CONCLUSIONS The administration of greater AGE load in nutritional formula potentially increases the amount of insulin required to maintain blood glucose within a normal range during critical illness. There was an inverse relationship between exogenous insulin and plasma inflammatory markers.
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Affiliation(s)
- Ra'eesa Doola
- Princess Alexandra Hospital, Mater Research Institute, The University of Queensland, Brisbane, QLD, Australia
| | - Adam M Deane
- The Royal Melbourne Hospital, The University of Melbourne and Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - Helen L Barrett
- Mater Health Services, Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - Satomi Okano
- Mater Research Institute - Statistics Unit, QIMR Berghofer Medical Research Institute, Brisbane, QLD, Australia
| | - Debbie M Tolcher
- System Planning Branch, Strategy Policy and Planning Division, Brisbane, QLD, Australia
| | - Kye Gregory
- SHECC IMT, Queensland Health, Brisbane, QLD, Australia
| | - Jeff S Coombes
- School of Human Movement and Nutrition Sciences, Faculty of Health and Behavioural Sciences, The University of Queensland, Brisbane, QLD, Australia
| | - Casper Schalkwijk
- Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Maastricht University Medical Centre, Netherlands, The Netherlands
| | - Alwyn S Todd
- Mater Research Institute - The University of Queensland and Menzies Health Institute Brisbane, Griffith University, Brisbane, QLD, Australia
| | - Josephine M Forbes
- Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
| | - David J Sturgess
- Mater Research Institute - The University of Queensland, Brisbane, QLD, Australia
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39
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Krinsley JS, Deane AM, Gunst J. The goal of personalized glucose control in the critically ill remains elusive. Intensive Care Med 2021; 47:1319-1321. [PMID: 34533593 DOI: 10.1007/s00134-021-06530-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 09/05/2021] [Indexed: 11/28/2022]
Affiliation(s)
- James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital and Columbia Vagelos College of Physicians and Surgeons, Stamford, CT, USA.
| | - Adam M Deane
- Department of Critical Care, The University of Melbourne, Melbourne Medical School, Parkville, VIC, Australia
| | - Jan Gunst
- Department of Cellular and Molecular Medicine, Clinical Division and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium
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40
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Finlay LDB, Conway Morris A, Deane AM, Wood AJT. Neutrophil kinetics and function after major trauma: A systematic review. World J Crit Care Med 2021; 10:260-277. [PMID: 34616661 PMCID: PMC8462018 DOI: 10.5492/wjccm.v10.i5.260] [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] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2021] [Revised: 05/18/2021] [Accepted: 07/27/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Immune dysfunction following major traumatic injury is complex and strongly associated with significant morbidity and mortality through the development of multiple organ dysfunction syndrome (MODS), persistent inflammation, immunosuppression, and catabolism syndrome and sepsis. Neutrophils are thought to be a pivotal mediator in the development of immune dysfunction.
AIM To provide a review with a systematic approach of the recent literature describing neutrophil kinetics and functional changes after major trauma in humans and discuss hypotheses as to the mechanisms of the observed neutrophil dysfunction in this setting.
METHODS Medline, Embase and PubMed were searched on January 15, 2021. Papers were screened by two reviewers and those included had their reference list hand searched for additional papers of interest. Inclusion criteria were adults > 18 years old, with an injury severity score > 12 requiring admission to an intensive care unit. Papers that analysed major trauma patients as a subgroup were included.
RESULTS Of 107 papers screened, 48 were included in the review. Data were heterogeneous and most studies had a moderate to significant risk of bias owing to their observational nature and small sample sizes. Key findings included a persistently elevated neutrophil count, stereotyped alterations in cell-surface markers of activation, and the elaboration of heterogeneous and immunosuppressive populations of cells in the circulation. Some of these changes correlate with clinical outcomes such as MODS and secondary infection. Neutrophil phenotype remains a promising avenue for the development of predictive markers for immune dysfunction.
CONCLUSION Understanding of neutrophil phenotypes after traumatic injury is expanding. A greater emphasis on incorporating functional and clinically significant markers, greater uniformity in study design and assessment of extravasated neutrophils may facilitate risk stratification in patients affected by major trauma.
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Affiliation(s)
- Liam DB Finlay
- Melbourne Medical School, University of Melbourne, Melbourne 3052, Victoria, Australia
| | - Andrew Conway Morris
- Department of Medicine, University of Cambridge, Cambridge 01223, United Kingdom
| | - Adam M Deane
- Centre for Integrated Critical Care, University of Melbourne, Parkville 3052, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville 3052, Victoria, Australia
| | - Alexander JT Wood
- Centre for Integrated Critical Care, University of Melbourne, Parkville 3052, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Parkville 3052, Victoria, Australia
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41
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Collie JT, Hudson EP, Deane AM, Bellomo R, Greaves RF. A Stabilizing Agent, PCA/DTPA, Improves Plasma Storage Life for the Chromsystems Vitamin C Assay up to Six Months. Ann Lab Med 2021; 41:414-418. [PMID: 33536361 PMCID: PMC7884199 DOI: 10.3343/alm.2021.41.4.414] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 09/14/2020] [Accepted: 01/12/2021] [Indexed: 11/25/2022] Open
Abstract
The commonly used Chromsystems vitamin C (ascorbate) assay (Munich, Germany) has a sample storage life of five days at -20°C. Stabilizing agents have been successfully used to increase longevity; however, their suitability with this commercial assay is unclear. We investigated the compatibility of a stabilizing agent, perchloric acid/diethylenetriaminepentaacetic acid (PCA/DTPA), with the Chromsystems assay. Plasma was stored at -80°C, with or without PCA/DTPA. Storage up to six months was assessed through baseline and repeat analyses, stability was assessed by comparing paired non-stabilized and PCA/DTPA-stabilized plasma, and performance was assessed using allowable performance specifications of an external quality assurance program. Ascorbate concentration was significantly lower in non-stabilized plasma than in paired PCA/DTPA-stabilized plasma, with a proportional difference of 11% (P=0.01). All storage analysis results were within the allowable performance specifications. Storage at -80°C prevented plasma ascorbate oxidation; however, substantial oxidation occurred during sample processing. In conclusion, PCA/DTPA significantly reduces ascorbate oxidation, and PCA/DTPA-stabilized ascorbate plasma is compatible with the Chromsystems assay and stable for up to six months, when stored at -80°C.
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Affiliation(s)
- Jake Tb Collie
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.,Royal College of Pathologists Quality Assurance Programs Vitamins Advisory Committee, Sydney, New South Wales, Australia
| | - Elizabeth P Hudson
- Dubbo Hospital, Western NSW Local Health District, Dubbo, New South Wales, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Australia
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, The University of Melbourne, Melbourne, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Australia
| | - Ronda F Greaves
- School of Health and Biomedical Sciences, RMIT University, Bundoora, Victoria, Australia.,Royal College of Pathologists Quality Assurance Programs Vitamins Advisory Committee, Sydney, New South Wales, Australia.,Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Paediatrics, University of Melbourne, Melbourne, VIC, Australia
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42
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Wong C, Ho J, Ankravs MJ, Sharrock L, Kee K, Goldin J, MacIsaac C, Presneill JJ, Ali Abdelhamid Y, Deane AM. Administration of pharmacological sleep aids prior to, during and following critical illness. Intern Med J 2021; 52:1962-1970. [PMID: 34392601 DOI: 10.1111/imj.15492] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/22/2021] [Accepted: 08/01/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Sleep in the intensive care unit (ICU) is frequently disturbed and this may have a detrimental effect on recovery. AIMS To determine use of pharmacological sleep aids in critically ill patients prior to, during and after ICU admission. METHODS We conducted a single-centre period prevalence study of all adult patients admitted to a university-associated adult medical-surgical Intensive Care Unit (ICU) for more than two nights in a three-month period ending September 2019. The major outcome of interest was the proportion of ICU patients who had a pharmacological sleep aid administered prior to, during and after ICU admission. Associations of selected patient variables with sleep aid prescription in the ICU were summarized both as unadjusted univariable comparisons, and as adjusted effect estimates returned by a multivariable logistic regression model. RESULTS During the study period, 370 patients met all eligibility criteria. A pharmacological sleep aid was identified prior to hospital admission in 34 patients (9%) and in 62 patients (17%) during ICU admission. Of the 340 ICU survivors, 292 remained in the same hospital. Of these, 96 (33%) received a pharmacological sleep aid at least once during their post-ICU general hospital ward stay. Pre-hospital sleep aid use, male sex, longer ICU admission and higher APACHE III scores were associated with sleep aid prescription in the ICU. CONCLUSIONS Pharmacological sleep aids are administered frequently in the ICU with administration increasing substantially after ICU discharge. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Cliff Wong
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Jankin Ho
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Melissa J Ankravs
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria.,Pharmacy Department, Royal Melbourne, United States
| | - Lucy Sharrock
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria.,Pharmacy Department, Royal Melbourne Hospital, Parkville, Victoria
| | - Kirk Kee
- Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Victoria
| | - Jeremy Goldin
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria.,Department of Respiratory and Sleep Medicine, Royal Melbourne Hospital, Parkville, Victoria
| | - Christopher MacIsaac
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Victoria.,Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria
| | - Jeffrey J Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria.,Department of Medicine, University of Melbourne, Parkville, Victoria
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria.,Centre for Integrated Critical Care, University of Melbourne, Parkville, Victoria
| | - Adam M Deane
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria.,The University of Melbourne, Melbourne Medical School, Department of Critical Care, Parkville, Victoria
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43
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Gluck S, Andrawos A, Summers MJ, Lange J, Chapman MJ, Finnis ME, Deane AM. The use of smartphone-derived location data to evaluate participation following critical illness: A pilot observational cohort study. Aust Crit Care 2021; 35:225-232. [PMID: 34373172 DOI: 10.1016/j.aucc.2021.05.007] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 05/03/2021] [Accepted: 05/23/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Disability is common following critical illness, impacting the quality of life of survivors, and is difficult to measure. 'Participation' can be quantified as involvement in life outside of their home requiring movement from their home to other locations. Participation restriction is a key element of disability, and following critical illness, participation may be diminished. It may be possible to quantify this change using pre-existing smartphone data. OBJECTIVES The feasibility of extracting location data from smartphones of survivors of intensive care unit (ICU) admission and assessing participation, using location-based outcomes, during recovery from critical illness was evaluated. METHODS Fifty consecutively admitted, consenting adult survivors of non-elective admission to ICU of greater than 48-h duration were recruited to a prospective observational cohort study where they were followed up at 3 and 6 months following discharge. The feasibility of extracting location data from survivors' smartphones and creating location-derived outcomes assessing participation was investigated over three 28-d study periods: pre-ICU admission and at 3 and 6 months following discharge. The following were calculated: time spent at home; the number of destinations visited; linear distance travelled; and two 'activity spaces', a minimum convex polygon and standard deviation ellipse. RESULTS Results are median [interquartile range] or n (%). The number of successful extractions was 9/50 (18%), 12/39 (31%), and 13/33 (39%); the percentage of time spent at home was 61 [56-68]%, 77 [66-87]%, and 67 [58-77]% (P = 0.16); the number of destinations visited was 34 [18-64], 38 [22-63], and 65 [46-88] (P = 0.02); linear distance travelled was 367 [56-788], 251 [114-323], and 747 [326-933] km over 28 d (P = 0.02), pre-ICU admission and at 3 and 6 months following ICU discharge, respectively. Activity spaces were successfully created. CONCLUSION Limited smartphone ownership, missing data, and time-consuming data extraction limit current implementation of mass extraction of location data from patients' smartphones to aid prognostication or measure outcomes. The number of journeys taken and the linear distance travelled increased between 3 and 6 months, suggesting participation may improve over time.
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Affiliation(s)
- Samuel Gluck
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Alice Andrawos
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Matthew J Summers
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia.
| | - Jarrod Lange
- Hugo Centre for Population and Housing, University of Adelaide, Napier Building, North Terrace, Adelaide, SA 5000, Australia.
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Mark E Finnis
- Discipline of Acute Care Medicine, The University of Adelaide, AHMS, North Terrace, Adelaide, SA 5000, Australia; 4G751 Intensive Care Unit Research Department, The Royal Adelaide Hospital, Port Rd, Adelaide, SA 5000, Australia.
| | - Adam M Deane
- Intensive Care Unit, The Royal Melbourne Hospital, 300 Grattan St, Parkville, Melbourne, VIC 3010, Australia; The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, Australia, VIC 3050.
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44
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Deane AM, Jiang A, Tascone B, Clancy A, Finnis ME, Collie JT, Greaves R, Byrne KM, Fujii T, Douglas JS, Nichol A, Udy AA, Young M, Russo G, Fetterplace K, Maiden MJ, Plummer MP, Yanase F, Bellomo R, Ali Abdelhamid Y. A multicenter randomized clinical trial of pharmacological vitamin B1 administration to critically ill patients who develop hypophosphatemia during enteral nutrition (The THIAMINE 4 HYPOPHOSPHATEMIA trial). Clin Nutr 2021; 40:5047-5052. [PMID: 34388414 DOI: 10.1016/j.clnu.2021.07.024] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/02/2021] [Accepted: 07/17/2021] [Indexed: 01/11/2023]
Abstract
BACKGROUND Hypophosphatemia may be a useful biomarker to identify thiamine deficiency in critically ill enterally-fed patients. The objective was to determine whether intravenous thiamine affects blood lactate, biochemical and clinical outcomes in this group. METHOD This randomized clinical trial was conducted across 5 Intensive Care Units. Ninety critically ill adult patients with a serum phosphate ≤0.65 mmol/L within 72 h of commencing enteral nutrition were randomized to intravenous thiamine (200 mg every 12 h for up to 14 doses) or usual care (control). The primary outcome was blood lactate over time and data are median [IQR] unless specified. RESULTS Baseline variables were well balanced (thiamine: lactate 1.2 [1.0, 1.6] mmol/L, phosphate 0.56 [0.44, 0.64] mmol/L vs. control: lactate 1.0 [0.8, 1.3], phosphate 0.54 [0.44, 0.61]). Patients randomized to the intervention received a median of 11 [7.5, 13.5] doses for a total of 2200 [1500, 2700] mg of thiamine. Blood lactate over the entire 7 days of treatment was similar between groups (mean difference = -0.1 (95 % CI -0.2 to 0.1) mmol/L; P = 0.55). The percentage change from lactate pre-randomization to T = 24 h was not statistically different (thiamine: -32 (-39, -26) vs. control: -24 (-31, -16) percent, P = 0.09). Clinical outcomes were not statistically different (days of vasopressor administration: thiamine 2 [1, 4] vs. control 2 [0, 5.5] days; P = 0.37, and deaths 9 (21 %) vs. 5 (11 %); P = 0.25). CONCLUSIONS In critically ill enterally-fed patients who developed hypophosphatemia, intravenous thiamine did not cause measurable differences in blood lactate or clinical outcomes. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ACTRN12619000121167).
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Affiliation(s)
- Adam M Deane
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia.
| | - Alice Jiang
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Brianna Tascone
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Annabelle Clancy
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Mark E Finnis
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; The University of Adelaide, Discipline of Acute Care Medicine, Adelaide, Australia
| | - Jake T Collie
- RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia
| | - Ronda Greaves
- RMIT University, School of Health and Biomedical Sciences, Melbourne, Australia; Victorian Clinical Genetics Services, Murdoch Children's Research Institute, Melbourne, Australia
| | - Kathleen M Byrne
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Tomoko Fujii
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - James S Douglas
- Department of Intensive Care, Western Health, Melbourne, Australia
| | - Alistair Nichol
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Andrew A Udy
- Monash University, Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Meredith Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Australia
| | - Giovanni Russo
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Kate Fetterplace
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Matthew J Maiden
- The University of Adelaide, Discipline of Acute Care Medicine, Adelaide, Australia; Intensive Care Unit, Barwon Health, Geelong, Australia
| | - Mark P Plummer
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Rinaldo Bellomo
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Australia
| | - Yasmine Ali Abdelhamid
- The University of Melbourne, Department of Critical Care, Melbourne Medical School, Melbourne, Australia; Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
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45
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Bowtell MK, Ankravs MJ, Fazio T, Presneill JJ, MacIsaac C, Spence M, Bennet L, Plummer MP, Abdelhamid YA, Deane AM. A microcosting analysis of ICU expenditure in the interval between brain death and organ donation. CRIT CARE RESUSC 2021; 23:211-214. [PMID: 38045518 PMCID: PMC10692508 DOI: 10.51893/2021.2.oa8] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: The cost of providing care in an intensive care unit (ICU) after brain death to facilitate organ donation is unknown. The objective of this study was to estimate expenditure for the care delivered in the ICU between the diagnosis of brain death and subsequent organ donation. Design: Cohort study of direct and indirect costs using bottom-up and top-down microcosting techniques. Setting: Single adult ICU in Australia. Participants: All patients who met criteria for brain death and proceeded to organ donation during a 13-month period between 1 January 2018 and 31 January 2019. Main outcome measures: A comprehensive cost estimate for care provided in the ICU from determination of brain death to transfer to theatre for organ donation. Results: Forty-five patients with brain death became organ donors during the study period. The mean duration of postdeath care in the ICU was 37.9 hours (standard deviation [SD], 16.5) at a mean total cost of $7520 (SD, $3136) per donor. ICU staff salaries were the greatest contributor to total costs, accounting for a median proportion of 0.72 of total expenditure (interquartile range, 0.68-0.75). Conclusions: Substantial costs are incurred in ICU for the provision of patient care in the interval between brain death and organ donation.
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Affiliation(s)
- Meghan K. Bowtell
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Melissa J. Ankravs
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Timothy Fazio
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Health Intelligence Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jeffrey J. Presneill
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Christopher MacIsaac
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Michelle Spence
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Linda Bennet
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark P. Plummer
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Melbourne, VIC, Australia
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46
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Rait LI, Yeo NY, Abdelhamid YA, Showler L, Finnis ME, Deane AM. The impact of bereavement support on psychological distress in family members: a systematic review and meta-analysis. CRIT CARE RESUSC 2021; 23:225-233. [PMID: 38045512 PMCID: PMC10692582 DOI: 10.51893/2021.2.sr1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Persistent psychological distress occurs frequently in family members of patients who die in an intensive care unit (ICU). Objective: To determine the effectiveness of bereavement interventions in reducing persisting psychological distress in bereaved family members after death in an adult ICU. Design: Systematic review and meta-analysis of studies that assessed the effect of bereavement interventions on persisting psychological distress in bereaved family members of ICU patients. Data sources: MEDLINE and APA PsycInfo databases were searched until April 2020. Review methods: Two of us independently screened titles and abstracts of identified studies, and then completed full text evaluation of selected studies. We assessed risk of bias using version 2 of the Cochrane risk-of-bias tool for randomised trials and the Newcastle-Ottawa Scale, which is designed to assess the quality of non-randomised studies in meta-analyses. We also used random effects meta-analysis to assess the effect of various interventions on total Hospital Anxiety and Depression Scale (HADS) scores. Results: From 664 citations, five studies were included - three multicentre randomised clinical trials and two single centre observational studies. Three studies tested the intervention of written bereavement support materials and two studies used narration of family members' experiences in the ICU. All studies reported HADS scores. Scores for Impact of Event Scale, Impact of Event Scale-Revised and Inventory of Complicated Grief were measured in some but not all studies. There was no effect of an intervention on HADS scores (weighted mean difference, -0.79 [95% confidence interval, -3.81 to 2.23]; I2 = 65.8%). Conclusions: Owing to limited data, and clinical and statistical heterogeneity, there is considerable uncertainty regarding whether bereavement support strategies reduce, increase or have no effect on psychological distress in bereaved family members.
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Affiliation(s)
- Louise I. Rait
- Department of Critical Care, Melbourne Medical School,University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Nikki Y. Yeo
- Queen Elizabeth Hospital, Adelaide, SA, Australia
| | - Yasmine Ali Abdelhamid
- Department of Critical Care, Melbourne Medical School,University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Laurie Showler
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mark E. Finnis
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Adam M. Deane
- Department of Critical Care, Melbourne Medical School,University of Melbourne, Melbourne, VIC, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
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47
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Tu JSY, Reeve J, Deane AM, Plummer MP. Pharmacological Management of Paroxysmal Sympathetic Hyperactivity: A Scoping Review. J Neurotrauma 2021; 38:2221-2237. [PMID: 33823679 DOI: 10.1089/neu.2020.7597] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Paroxysmal sympathetic hyperactivity (PSH) occurs in ∼10% of patients following acute severe brain injury. While PSH is associated with worse outcomes, there are no clinical practice guidelines to inform treatment. We aimed to systematically review the literature on the pharmacological management of PSH. MEDLINE, Embase, and Cochrane library databases were searched from inception to August 2020. Eligible studies met the following criteria: 1) randomized controlled trials, non-randomized controlled trials (case control or controlled cohort), observational studies, case series, and case reports; 2) study population of adult and pediatric patients; 3) exposure to an acute neurological insult complicated by PSH (or historic synonym); 4) description of pharmacological treatment of PSH. Our search retrieved 2729 citations with 83 articles assessed for inclusion. After full text extraction, 56 manuscripts inclusive of 459 patients met eligibility criteria. We identified 31 case reports, 15 case series (152 patients), seven retrospective case control or cohort studies (212 patients), and three prospective observational studies (52 patients). Traumatic brain injury was the most common precipitating insult (407 patients), followed by hypoxic encephalopathy (72 patients) and intracranial hemorrhage (10 patients). There were 48 drugs from 22 classes prescribed for the management of PSH. The most frequently prescribed agents were benzodiazepines, β-blockers, opioids, α-2 agonists, and baclofen. However, route and dose of drug and subsequent outcome were inconsistently reported, such that no summary was possible. While a wide variety of drugs have been reported to treat PSH, there is a lack of even moderate-quality evidence to inform clinical decision making.
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Affiliation(s)
| | - Jake Reeve
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Australia
| | - Mark P Plummer
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia.,Center for Integrated Critical Care, University of Melbourne, Melbourne, Australia
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48
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Chapple LAS, Summers MJ, Weinel LM, Abdelhamid YA, Kar P, Hatzinikolas S, Calnan D, Bills M, Lange K, Poole A, O'Connor SN, Horowitz M, Jones KL, Deane AM, Chapman MJ. Effects of Standard vs Energy-Dense Formulae on Gastric Retention, Energy Delivery, and Glycemia in Critically Ill Patients. JPEN J Parenter Enteral Nutr 2021; 45:710-719. [PMID: 33543797 DOI: 10.1002/jpen.2065] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 11/20/2020] [Accepted: 12/14/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Energy-dense formulae are often provided to critically ill patients with enteral feed intolerance with the aim of increasing energy delivery, yet the effect on gastric emptying is unknown. The rate of gastric emptying of a standard compared with an energy-dense formula was quantified in critically ill patients. METHODS Mechanically ventilated adults were randomized to receive radiolabeled intragastric infusions of 200 mL standard (1 kcal/mL) or 100 mL energy-dense (2 kcal/mL) enteral formulae on consecutive days in this noninferiority, blinded, crossover trial. The primary outcome was scintigraphic measurement of gastric retention (percentage at 120 minutes). Other measures included area under the curve (AUC) for gastric retention and intestinal energy delivery (calculated from gastric retention of formulae over time), blood glucose (peak and AUC), and intestinal glucose absorption (using 3-O-methyl-D-gluco-pyranose [3-OMG] concentrations). Comparisons were undertaken using paired mixed-effects models. Data presented are mean ± SE. RESULTS Eighteen patients were studied (male/female, 14:4; age, 55.2 ± 5.3 years). Gastric retention at 120 minutes was greater with the energy-dense formula (standard, 17.0 ± 5.9 vs energy-dense, 32.5 ± 7.1; difference, 12.7% [90% confidence interval, 0.8%-30.1%]). Energy delivery (AUC120 , 13,038 ± 1119 vs 9763 ± 1346 kcal/120 minutes; P = 0.057), glucose control (peak glucose, 10.1 ± 0.3 vs 9.7 ± 0.3 mmol/L, P = 0.362; and glucose AUC120 8.7 ± 0.3 vs 8.5 ± 0.3 mmol/L.120 minutes, P = 0.661), and absorption (3-OMG AUC120 , 38.5 ± 4.0 vs 35.7 ± 4.0 mmol/L.120 minutes; P = .508) were not improved with the energy-dense formula. CONCLUSION In critical illness, administration of an energy-dense formula does not reduce gastric retention, increase energy delivery to the small intestine, or improve glucose absorption or glucose control; instead, there is a signal for delayed gastric emptying.
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Affiliation(s)
- Lee-Anne S Chapple
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Matthew J Summers
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Luke M Weinel
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Department of Medicine and Radiology, The University of Melbourne, Melbourne Medical School,Royal Melbourne Hospital, Parkville, Australia
| | - Palash Kar
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Seva Hatzinikolas
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Deborah Calnan
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Madison Bills
- Department of Nuclear Medicine, PET and Bone Densitometry, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Kylie Lange
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Alexis Poole
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Stephanie N O'Connor
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Karen L Jones
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
| | - Adam M Deane
- Department of Medicine and Radiology, The University of Melbourne, Melbourne Medical School,Royal Melbourne Hospital, Parkville, Australia
| | - Marianne J Chapman
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, The University of Adelaide, Adelaide, South Australia, Australia
- Centre of Research Excellence in Translating Nutritional Science to Good Health, The University of Adelaide, Adelaide, South Australia, Australia
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49
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Deane AM, Chapman MJ. Technology to inform the delivery of enteral nutrition in the intensive care unit. JPEN J Parenter Enteral Nutr 2021; 46:754-756. [PMID: 33928654 DOI: 10.1002/jpen.2137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Adam M Deane
- Department of Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Victoria, Australia
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, Faculty of Health Sciences, The University of Adelaide, Adelaide, South Australia, Australia
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50
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Ali Abdelhamid Y, Bernjak A, Phillips LK, Summers MJ, Weinel LM, Lange K, Chow E, Kar P, Horowitz M, Heller S, Deane AM. Nocturnal Hypoglycemia in Patients With Diabetes Discharged From ICUs: A Prospective Two-Center Cohort Study. Crit Care Med 2021; 49:636-649. [PMID: 33591015 DOI: 10.1097/ccm.0000000000004810] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 02/07/2023]
Abstract
OBJECTIVES There is very limited information about glycemic control after discharge from the ICU. The aims of this study were to evaluate the prevalence of hypoglycemia in ICU survivors with type-2 diabetes and determine whether hypoglycemia is associated with cardiac arrhythmias. DESIGN Prospective, observational, two-center study. Participants underwent up to 5 days of simultaneous blinded continuous interstitial glucose monitoring and ambulatory 12-lead electrocardiogram monitoring immediately after ICU discharge during ward-based care. Frequency of arrhythmias, heart rate variability, and cardiac repolarization markers were compared between hypoglycemia (interstitial glucose ≤ 3.5 mmol/L) and euglycemia (5-10 mmol/L) matched for time of day. SETTING Mixed medical-surgical ICUs in two geographically distinct university-affiliated hospitals. PATIENTS Patients with type-2 diabetes who were discharged from ICU after greater than or equal to 24 hours with greater than or equal to one organ failure and were prescribed subcutaneous insulin were eligible. MEASUREMENTS AND MAIN RESULTS Thirty-one participants (mean ± sd, age 65 ± 13 yr, glycated hemoglobin 64 ± 22 mmol/mol) were monitored for 101 ± 32 hours post-ICU (total 3,117 hr). Hypoglycemia occurred in 12 participants (39%; 95% CI, 22-56%) and was predominantly nocturnal (40/51 hr) and asymptomatic (25/29 episodes). Participants experiencing hypoglycemia had 2.4 ± 0.7 discrete episodes lasting 45 minutes (interquartile range, 25-140 min). Glucose nadir was less than or equal to 2.2 mmol/L in 34% of episodes. The longest episode of nocturnal hypoglycemia was 585 minutes with glucose nadir less than 2.2 mmol/L. Simultaneous electrocardiogram and continuous interstitial glucose monitoring recordings were obtained during 44 hours of hypoglycemia and 991 hours of euglycemia. Hypoglycemia was associated with greater risk of bradycardia but did not affect atrial or ventricular ectopics, heart rate variability, or cardiac repolarization. CONCLUSIONS In ICU survivors with insulin-treated type-2 diabetes, hypoglycemia occurs frequently and is predominantly nocturnal, asymptomatic, and prolonged.
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Affiliation(s)
- Yasmine Ali Abdelhamid
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Division of Critical Care and Investigative Services, Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Alan Bernjak
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
- INSIGNEO Institute for in silico Medicine, University of Sheffield, Sheffield, United Kingdom
| | - Liza K Phillips
- Discipline of Medicine, Department of Medical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council Centre of Research Excellence in Translating Nutritional Science to Good Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Endocrine and Metabolic Service, Medical Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Matthew J Summers
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Luke M Weinel
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Kylie Lange
- Discipline of Medicine, Department of Medical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council Centre of Research Excellence in Translating Nutritional Science to Good Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
| | - Elaine Chow
- Department of Medicine and Therapeutics, Chinese University of Hong Kong, Shatin, Hong Kong
| | - Palash Kar
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Critical Care Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Michael Horowitz
- Discipline of Medicine, Department of Medical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- National Health and Medical Research Council Centre of Research Excellence in Translating Nutritional Science to Good Health, Faculty of Health and Medical Sciences, University of Adelaide, Adelaide, SA, Australia
- Endocrine and Metabolic Service, Medical Services, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Simon Heller
- Department of Oncology and Metabolism, University of Sheffield, Sheffield, United Kingdom
- Sheffield Teaching Hospitals Foundation Trust, Sheffield, United Kingdom
| | - Adam M Deane
- Discipline of Acute Care Medicine, Department of Surgical Specialties, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Division of Critical Care and Investigative Services, Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Medicine and Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
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