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Jeffcote T, Battistuzzo CR, Plummer MP, McNamara R, Anstey J, Bellapart J, Roach R, Chow A, Westerlund T, Delaney A, Bihari S, Bowen D, Weeden M, Trapani A, Reade M, Jeffree RL, Fitzgerald M, Gabbe BJ, O'Brien TJ, Nichol AD, Cooper DJ, Bellomo R, Udy A. PRECISION-TBI: a study protocol for a vanguard prospective cohort study to enhance understanding and management of moderate to severe traumatic brain injury in Australia. BMJ Open 2024; 14:e080614. [PMID: 38387978 PMCID: PMC10882309 DOI: 10.1136/bmjopen-2023-080614] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a heterogeneous condition in terms of pathophysiology and clinical course. Outcomes from moderate to severe TBI (msTBI) remain poor despite concerted research efforts. The heterogeneity of clinical management represents a barrier to progress in this area. PRECISION-TBI is a prospective, observational, cohort study that will establish a clinical research network across major neurotrauma centres in Australia. This network will enable the ongoing collection of injury and clinical management data from patients with msTBI, to quantify variations in processes of care between sites. It will also pilot high-frequency data collection and analysis techniques, novel clinical interventions, and comparative effectiveness methodology. METHODS AND ANALYSIS PRECISION-TBI will initially enrol 300 patients with msTBI with Glasgow Coma Scale (GCS) <13 requiring intensive care unit (ICU) admission for invasive neuromonitoring from 10 Australian neurotrauma centres. Demographic data and process of care data (eg, prehospital, emergency and surgical intervention variables) will be collected. Clinical data will include prehospital and emergency department vital signs, and ICU physiological variables in the form of high frequency neuromonitoring data. ICU treatment data will also be collected for specific aspects of msTBI care. Six-month extended Glasgow Outcome Scores (GOSE) will be collected as the key outcome. Statistical analysis will focus on measures of between and within-site variation. Reports documenting performance on selected key quality indicators will be provided to participating sites. ETHICS AND DISSEMINATION Ethics approval has been obtained from The Alfred Human Research Ethics Committee (Alfred Health, Melbourne, Australia). All eligible participants will be included in the study under a waiver of consent (hospital data collection) and opt-out (6 months follow-up). Brochures explaining the rationale of the study will be provided to all participants and/or an appropriate medical treatment decision-maker, who can act on the patient's behalf if they lack capacity. Study findings will be disseminated by peer-review publications. TRIAL REGISTRATION NUMBER NCT05855252.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Camila R Battistuzzo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Mark P Plummer
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - James Anstey
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Judith Bellapart
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Rebecca Roach
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Andrew Chow
- Department of Intensive Care Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Torgeir Westerlund
- Department of Intensive Care Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Anthony Delaney
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Shailesh Bihari
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - David Bowen
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Weeden
- Intensive Care Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Anthony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Michael Reade
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, Medical School, University of Queensland, Brisbane, Queensland, Australia
| | - Rosalind L Jeffree
- Faculty of Medicine, Medical School, University of Queensland, Brisbane, Queensland, Australia
- Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Perth, Western Australia, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, Western Australia, Australia
| | - Belinda J Gabbe
- Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Alistair D Nichol
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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Taylor JD, Bailey M, Cooper DJ, French C, Menon DK, Nichol AD, Pisică D, Udy A, Volovici V, Higgins AM. Association Between Early External Ventricular Drain Insertion and Functional Outcomes 6 Months Following Moderate-to-Severe Traumatic Brain Injury. J Neurotrauma 2024. [PMID: 38279804 DOI: 10.1089/neu.2023.0493] [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: 01/29/2024] Open
Abstract
Traumatic brain injury (TBI) is a leading global cause of morbidity and mortality. Intracranial hypertension following moderate-to-severe TBI (m-sTBI) is a potentially modifiable secondary cerebral insult and one of the central therapeutic targets of contemporary neurocritical care. External ventricular drain (EVD) insertion is a common therapeutic intervention used to control intracranial hypertension and attenuate secondary brain injury. However, the optimal timing of EVD insertion in the setting of m-sTBI is uncertain and practice variation is widespread. Therefore, we aimed to assess if there is an association between timing of EVD placement and functional neurological outcome at 6 months post m-sTBI. We pooled individual patient data for all relevant harmonizable variables from the Erythropoietin in Traumatic Brain Injury (EPO-TBI) and Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomized control trials, and the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) Core Study version 3.0 and Australia-Europe NeuroTrauma Effectiveness Research in TBI (Oz-ENTER) prospective observational studies to create a combined dataset. The Glasgow Coma Scale (GCS) score was used to define TBI severity and we included all patients admitted to an intensive care unit with a GCS ≤12, who were 15 years or older and underwent EVD placement within 7 days of injury. We used hierarchical multi-variable logistic regression models to study the association between EVD insertion within 24 h of injury (early) compared with EVD insertion more than 24 h after injury (late) and 6-month functional neurological outcome measured using the Glasgow Outcome Score Extended (GOSE). In total, 2536 patients were assessed. Of these, 502 (20%) underwent early EVD insertion and 145 (6%) underwent late EVD insertion. Following adjustment for the IMPACT (International Mission for Prognosis and Analysis of Clinical Trials in TBI) score extended (Core + CT), sex, injury severity score, study and treatment site, patients receiving a late EVD had higher odds of death or severe disability (GOSE 1-4) at 6 months follow-up than those receiving an early EVD adjusted odds ratio; 95% confidence interval, 2.14; 1.22-3.76; p = 0.008. Our study suggests that in patients with m-sTBI where an EVD is needed, early (≤ 24 h post-injury) insertion may result in better long-term functional outcomes. This finding supports future prospective investigation in this area.
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Affiliation(s)
- Jonathon D Taylor
- Department of Critical Care Medicine, Auckland City Hospital, Grafton, Auckland, New Zealand
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
| | - Craig French
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Western Health, Melbourne, Victoria, Australia
- Department of Intensive Care, University of Melbourne, Melbourne, Victoria, Australia
| | - David K Menon
- Division of Anesthesia, University of Cambridge, Addenbrooke's, Cambridge, United Kingdom
| | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
- University College Dublin Clinical Research Center, St. Vincent's University Hospital, Dublin, Ireland
| | - Dana Pisică
- Center for Medical Decision Making, Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
- Department of Neurosurgery, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Alfred, Melbourne, Victoria, Australia
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Center, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Aubron C, Chapalain X, Bailey M, Board J, Buhr H, Cartwright B, Dennis M, Hodgson C, Forrest P, McIlroy D, Murphy D, Murray L, Pellegrino V, Pilcher D, Sheldrake J, Tran H, Vallance S, Cooper DJ, McQuilten Z. Anti-Factor-Xa and Activated Partial Thromboplastin Time Concordance and Outcomes in Adults Undergoing Extracorporeal Membrane Oxygenation: A Secondary Analysis of the Pilot Low-Dose Heparin in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation Randomized Trial. Crit Care Explor 2023; 5:e0999. [PMID: 37954899 PMCID: PMC10635598 DOI: 10.1097/cce.0000000000000999] [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] [Indexed: 11/14/2023] Open
Abstract
OBJECTIVES To determine the concordance between activated partial thromboplastin time (aPTT) and anti-factor-Xa (anti-Xa) in adults undergoing extracorporeal membrane oxygenation (ECMO) and to identify the factors associated with discordant paired aPTT/anti-Xa. DESIGN Pre-planned secondary analysis of the Low-Dose Heparin in Critically Ill Patients Undergoing Extracorporeal Membrane Oxygenation pilot randomized unblinded, parallel-group controlled trial. SETTING Two ICUs in two university hospitals. PATIENTS Thirty-two critically ill patients who underwent ECMO and who had at least one paired aPTT and anti-Xa assay performed at the same time. INTERVENTIONS We analyzed the concordance between aPTT and anti-Xa and identified factors associated with discordant paired aPTT/anti-Xa based on their respective therapeutic ranges. We also compared biological parameters between heparin resistance episode and no heparin resistance. MEASUREMENTS AND MAIN RESULTS Of the 32 patients who were included in this study, 24 (75%) had at least one discordant paired aPTT/anti-Xa. Of the 581 paired aPTT/anti-Xa that were analyzed, 202 were discordant. The aPTT was relatively lower than anti-Xa in 66 cases (32.7%) or relatively higher than anti-Xa in 136 cases (67.3%). Thirty-three heparin resistance episodes were identified in six patients (19%). CONCLUSIONS In these critically ill patients undergoing ECMO, one third of paired aPTT/anti-Xa measures was discordant. Coagulopathy and heparin resistance might be the reasons for discordance. Our results support the potential importance of routinely monitoring both tests in this setting.
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Affiliation(s)
- Cécile Aubron
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Département de Médecine Intensive Réanimation, Centre Hospitalier Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Xavier Chapalain
- Département d'anesthésie réanimation, Centre Hospitalier Universitaire de Brest, site La Cavale Blanche, Université de Bretagne Occidentale, Brest, France
| | - Michael Bailey
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
| | - Jasmin Board
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Heidi Buhr
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Bruce Cartwright
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Mark Dennis
- Cardiology Department, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Carol Hodgson
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
| | - Paul Forrest
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - David McIlroy
- Department of Anaesthesia & Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Deirdre Murphy
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Lynne Murray
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
| | - Vincent Pellegrino
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Huyen Tran
- Clinical Haematology Department, Alfred Hospital, Melbourne, VIC, Australia
| | | | - D James Cooper
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Zoe McQuilten
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Monash University, Melbourne, VIC, Australia
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Cooper DJ, Travaglia I, Talcott WJ, Ghaly M, Miles BA, Frank D, Seetharamu N, Parashar B. Characteristics of Premature Radiotherapy Terminations in Patients with Oral Cavity and Laryngeal Carcinomas. Int J Radiat Oncol Biol Phys 2023; 117:e573-e574. [PMID: 37785748 DOI: 10.1016/j.ijrobp.2023.06.1907] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) Premature radiation therapy (RT) terminations in patients with head and neck cancer result in poor outcomes. However, the underlying factors that contribute to early RT termination are understudied, especially in the era of hypofractionated treatment. In this retrospective single institution study, we examined causes and clinical characteristics of premature terminations in oral cavity (OC) and laryngeal carcinomas. MATERIALS/METHODS We reviewed charts of 188 patients treated with RT ± systemic therapy for OC and laryngeal cancer from 2017-2022. Patients were typically prescribed standard 1.8-2.0 Gy fractionation regimens, though patients deemed unlikely to complete conventional RT upon initial evaluation were given SBRT. Premature termination was defined as completion of less than 95% prescribed RT. We collected pertinent demographic, clinicopathological data on this termination cohort, which was compared to a matched cohort of patients with RT completion. We used logistic regression analysis to examine factors predictive of premature termination. RESULTS Of the patients included in this analysis, 72.7% were prescribed adjuvant RT [9.1% OC, 45.5% larynx] vs. 27.3% primary RT [90.9% OC, 45.5% larynx]. 84.6% received conventional IMRT, while 15.4% received SBRT. 17 patients (9.0%) had premature RT (all IMRT) terminations- 9 OC and 8 laryngeal primaries. Mean age of those who had premature termination was 79.5 years (range: 70-98). 70.6% were male, 58.8% were white, and 23.5% were single/widowed. Majority received concurrent systemic therapy (58.8%), had AJCC (8th Ed.) Stage ≥ III (76.5%), Charlson-Comorbidity Index ≥6 (64.7%), ECOG score ≥2 (70.6%), smoked >10 pack-years (76.5%), and lived >10 miles from RT facility (58.8%). The most common documented reasons for premature termination were: subjective intolerance (29.4%), death (23.5%), objective RT toxicity (23.5%), and inpatient admission (17.6%). The mean time on treatment for IMRT was 27.8 days for termination cohort vs. 47.7 days for completion cohort. The percentage of patients reporting RT toxicity (CTCAE v5.0 mucositis, severe weight loss, oral infection, e.g.) was 88.2% for termination cohort vs. 29.6% for completion cohort. On regression analysis, ECOG score at the time of initiation of RT was independently associated with premature termination (OR: 2.438, 95% CI: 1.155-5.146, p = .019). CONCLUSION This retrospective analysis of patients undergoing RT for OC and laryngeal cancers at our tertiary care center demonstrated nearly 1 in 10 patients are at risk for premature termination. Poor performance status was independently associated with premature termination. There was a 100% completion rate in hypofractionated treatment with SBRT. Taken together, poor performance status may identify patients at risk for premature termination and thus identify good candidates for SBRT protocols.
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Affiliation(s)
- D J Cooper
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - I Travaglia
- Department of Pathology, Northwell Health, New Hyde Park, NY
| | - W J Talcott
- Zucker School of Medicine at Hofstra/Northwell, Lake Success, NY
| | - M Ghaly
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, NY
| | - B A Miles
- Department of Otolaryngology, Northwell Health, New York City, NY
| | - D Frank
- Northwell Health, Lake Success, NY
| | | | - B Parashar
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
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Chitti BS, Fraser M, Cooper DJ, Wint A, Seetharamu N, Ghaly M. Impact of Dosimetric Parameters on Local Control and Toxicity of Head and Neck SBRT. Int J Radiat Oncol Biol Phys 2023; 117:e572-e573. [PMID: 37785745 DOI: 10.1016/j.ijrobp.2023.06.1904] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) SBRT is potentially useful as a local therapy for head and neck cancer patients who require re-irradiation, as well as those who may not be candidates for surgical resection or a lengthy course of conventionally fractionated radiation therapy. The objective of this study was to assess rates of local control with SBRT, as well as the impact of mucosal dosimetric parameters on rates of grade 3 or higher toxicity in patients treated with head and neck SBRT. MATERIALS/METHODS We retrospectively reviewed patients within our institution who underwent SBRT for cancers of the oral cavity and oropharynx between 2013 and 2022. Primary endpoints were local control (LC) and grade 3 or higher toxicity potentially attributable to SBRT, based on CTCAE 5.0. We analyzed the following endpoints as potential predictors of toxicity: 1) ratio of total oral mucosal volume/oral mucosal volume outside of PTV, 2) mean dose to oral mucosa, and 3) maximum dose to oral mucosa. We conducted regression analysis to determine predictors of local failure and severe toxicity. We estimated local control using Kaplan-Meier analysis. RESULTS We treated 66 tumors in 60 patients with a median age of 71 years. 41 patients (68.3%) had oral cavity cancer and 19 (31.6%) had oropharynx cancer. 64 tumors (97.0%) were squamous cell carcinomas. 32 tumors (48.5%) were previously irradiated. Mean PTV volume was 55 cc (range: 39.4-74.1 ccs). Median prescribed radiation dose was 40 Gy given in 5 biweekly fractions. A total of 51 patients received systemic therapy (platinum-based chemotherapy in 52%, Cetuximab in 38%). 10 patients (16.7%) additionally received immunotherapy, constituting 56% of 18 patients treated from 2019-2022. Median pain score at presentation was 3/10. Oral pain non-significantly increased between 3 weeks and 3 months after starting treatment and subsequently returned to baseline after SBRT (P = 0.227). Local control was 68.5%, at a median follow up of 9.8 months. In oral cavity tumors, 1- and 2-year local control rates were 78.7% and 43.1% respectively. 1- and 2-year rates of LC were 78.9% and 50.2% in oropharynx tumors. Grade 3 or higher toxicities were present in 18 patients (30.0%), including osteonecrosis in 6 (10.0%) and ulceration or extensive tissue necrosis in 12 (20.0%). No significant relationship was present between mucosal surface radiation doses and acute oral mucosa toxicity. On regression analysis for both local control and grade 3 or higher toxicity, we did not find any significant association with prior radiation, disease site, age, or PTV volume. CONCLUSION SBRT provided comparable local control for tumors of the oropharynx and oral cavity, with slightly higher 2-year local control in tumors of the oropharynx, and comparable rates of toxicity. We appreciated increased use of immunotherapy in our study population from 2019 onwards. We did not find any relationships between dosimetric parameters and rates of grade 3 or higher toxicity, or local control, though our analysis is limited by a small sample size.
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Affiliation(s)
- B S Chitti
- Northwell Health Cancer Institute, Lake Success, NY
| | - M Fraser
- Northwell Health Cancer Institute, Lake Success, NY
| | - D J Cooper
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - A Wint
- Northwell Health Cancer Institute, Lake Success, NY
| | | | - M Ghaly
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, NY
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Gui B, Nosrati JD, Cooper DJ, Wuu YR, Tchelebi L, Herman JM. The Association of Chemoradiation Induced Lymphopenia with Racial Disparity and Its Prognostic Impact on Survival for Anal Cancer. Int J Radiat Oncol Biol Phys 2023; 117:e299-e300. [PMID: 37785093 DOI: 10.1016/j.ijrobp.2023.06.2313] [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: 10/04/2023]
Abstract
PURPOSE/OBJECTIVE(S) While the association between chemoradiation induced lymphopenia (CIL) and poor overall survival (OS) is established in multiple solid malignancies, it has not been studied in anal cancer. Racial and socioeconomic disparities as potential predictors of lymphopenia have not been reported. We hypothesize that race and socioeconomic status is associated with increased incidence of severe CIL, which can predict worse overall survival for patients with anal cancer. MATERIALS/METHODS A cohort of 75 patients treated with definitive chemoradiation (CRT) for squamous cell anal cancer from January 2014 to December 2020 was reviewed. Total lymphocyte counts (TLC) at baseline and TLC nadir at 1 month post-CRT were analyzed. Logistic regression was used to identify associations between race, gender, ethnicity, median household income by zip code, marital status, baseline hematopoietic cell counts, and post-CRT Grade 3+ lymphopenia (TLC <0.5k/μL). Kaplan-Meier method and Cox regression model were used to perform survival analysis. RESULTS Of the 75 patients identified, mean age was 66.9 years and median follow-up time was 37.1 months. There were 63 females, 53 non-Hispanic whites, 22 minorities (12 Blacks, 9 Hispanics, 1 Asians) Radiation dose ranged from 41.4 Gray to 56 Gray. At 1 month post CRT, 85.3% developed lymphopenia (G1 9.3%, G2 26.7%, G3 37.3%, G4 12.0%). On multivariate logistic regression, non-white race demonstrated a trend to have more Grade 3+ lymphopenia (OR = 3.5, p = 0.07). On univariate Cox regression, poorer overall survival was associated with race (HR 3.7, p = 0.04), baseline white blood count (HR 1.3, p = 0.04), baseline hemoglobin (HR 0.6, p = 0.04), and post-CRT Grade 3+ lymphopenia (HR 5.8, p = 0.03). On multivariate Cox regression, only post-CRT Grade 3+ lymphopenia was associated with worse OS (HR 7.5, p = 0.049). 5-year OS significantly differed between patients with and without post-CRT Grade 3+ lymphopenia (62.3% vs 94.7%, P = 0.01). CONCLUSION Lymphopenia is commonly observed after chemoradiation for anal cancer. Racial disparity is associated with severe lymphopenia induced by chemoradiation, which is a robust predictor of poor survival in anal cancer. More attention to lymphopenia induced by chemoradiation for anal cancer is needed, particularly in racial minorities.
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Affiliation(s)
- B Gui
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - J D Nosrati
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY; Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
| | - D J Cooper
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - Y R Wuu
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, NY; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY
| | - L Tchelebi
- Department of Radiation Medicine, Northwell Health Cancer Institute, Lake Success, NY
| | - J M Herman
- Department of Radiation Medicine, Northwell Health Cancer Institute, New Hyde Park, NY
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Jackson AIR, Boney O, Pearse RM, Kurz A, Cooper DJ, van Klei WA, Cabrini L, Miller TE, Moonesinghe SR, Myles PS, Grocott MPW. Systematic reviews and consensus definitions for the Standardised Endpoints in Perioperative Medicine (StEP) initiative: mortality, morbidity, and organ failure. Br J Anaesth 2023; 130:404-411. [PMID: 36697275 DOI: 10.1016/j.bja.2022.12.012] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 11/30/2022] [Accepted: 12/09/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Mortality, morbidity, and organ failure are important and common serious harms after surgery. However, there are many candidate measures to describe these outcome domains. Definitions of these measures are highly variable, and validity is often unclear. As part of the International Standardised Endpoints in Perioperative Medicine (StEP) initiative, this study aimed to derive a set of standardised and valid measures of mortality, morbidity, and organ failure for use in perioperative clinical trials. METHODS Three domains of endpoints (mortality, morbidity, and organ failure) were explored through systematic literature review and a three-stage Delphi consensus process using methods consistently applied across the StEP initiative. Reliability, feasibility, and patient-centredness were assessed in round 3 of the consensus process. RESULTS A high level of consensus was achieved for two mortality time points, 30-day and 1-yr mortality, and these two measures are recommended. No organ failure endpoints achieved threshold criteria for consensus recommendation. The Clavien-Dindo classification of complications achieved threshold criteria for consensus in round 2 of the Delphi process but did not achieve the threshold criteria in round 3 where it scored equivalently to the Post Operative Morbidity Survey. Clavien-Dindo therefore received conditional endorsement as the most widely used measure. No composite measures of organ failure achieved an acceptable level of consensus. CONCLUSIONS Both 30-day and 1-yr mortality measures are recommended. No measure is recommended for organ failure. One measure (Clavien-Dindo) is conditionally endorsed for postoperative morbidity, but our findings suggest that no single endpoint offers a reliable and valid measure to describe perioperative morbidity that is not dependent on the quality of deli-vered care. Further refinement of current measures, or development of novel measures, of postoperative morbidity might improve consensus in this area.
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Affiliation(s)
- Alexander I R Jackson
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Oliver Boney
- Surgical Outcomes Research Centre, University College Hospital, London, UK; Health Services Research Centre, National Institute of Academic Anaesthesia, Royal College of Anaesthetists, London, UK
| | - Rupert M Pearse
- Faculty of Medicine & Dentistry, Queen Mary University of London, UK
| | - Andrea Kurz
- Departments of General Anesthesiology and Outcomes Research, Cleveland Clinic, Cleveland, OH, USA
| | - D James Cooper
- Australia New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Wilton A van Klei
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network Toronto, Canada; Department of Anesthesiology and Pain Medicine, Temerty Faculty of Medicine, University of Toronto, Toronto, ON, USA; Department of Anesthesiology and Intensive Care Medicine, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Luca Cabrini
- Department of Biology and Life Sciences, ASST Sette Laghi, Insubria University, Varese, Italy
| | - Timothy E Miller
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA
| | - S Ramani Moonesinghe
- Centre for Peri-Operative Medicine, Research Department for Targeted Intervention, University College London, London, UK; University College London/University College London Hospitals National Institute Health Research Biomedical Research Centre, London, UK; Department for Anaesthesia and Perioperative Medicine, University College London Hospitals, London, UK
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, The Alfred Hospital, Melbourne, VIC, Australia; Department of Anaesthesiology and Perioperative Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael P W Grocott
- Perioperative and Critical Care Theme, NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK; Integrative Physiology and Critical Illness Group, Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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8
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Levkovich BJ, Orosz J, Bingham G, Cooper DJ, Dooley M, Kirkpatrick C, Jones DA. Medication-related Medical Emergency Team activations: a case review study of frequency and preventability. BMJ Qual Saf 2023; 32:214-224. [PMID: 35790383 DOI: 10.1136/bmjqs-2021-014185] [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: 08/31/2021] [Accepted: 06/08/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Despite recognition of clinical deterioration and medication-related harm as patient safety risks, the frequency of medication-related Rapid Response System activations is undefined. We aimed to estimate the incidence and preventability of medication-related Medical Emergency Team (MET) activations and describe the associated adverse medication events. METHODS A case review study of consecutive MET activations at two acute, academic teaching hospitals in Melbourne, Australia with mature Rapid Response Systems was conducted. All MET activations during a 3-week study period were assessed for a medication cause including identification of the contributing adverse medication event and its preventability, using validated tools and recognised classification systems. RESULTS There were 9439 admissions and 628 MET activations during the study period. Of these, 146 (23.2%) MET activations were medication related: an incidence of 15.5 medication-related MET activation per 1000 admissions. Medication-related MET activations occurred a median of 46.6 hours earlier (IQR 22-165) in an admission than non-medication-related activations (p=0.001). Furthermore, this group also had more repeat MET activations during their admission (p=0.021, OR=1.68, 95% CI 1.09 to 2.59). A total of 92 of 146 (63%) medication-related MET activations were potentially preventable. Tachycardia due to omission of beta-blocking agents (10.9%, n=10 of 92) and hypotension due to cumulative toxicity (9.8%, n=9 of 92) or inappropriate use (10.9%, n=10 of 92) of antihypertensives were the most common adverse medication events leading to potentially preventable medication-related MET activations. CONCLUSIONS Medications contributed to almost a quarter of MET activations, often early in a patient's admission. One in seven MET activations were due to potentially preventable adverse medication events. The most common of these were omission of beta-blockers and clinically inappropriate antihypertensive use. Strategies to prevent these events would increase patient safety and reduce burden on the MET.
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Affiliation(s)
- Bianca J Levkovich
- Centre for Medicines Use and Safety, Monash University, Clayton, Victoria, Australia
- Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Judit Orosz
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | | | - D James Cooper
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
- Australia and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia
| | - Michael Dooley
- Centre for Medicines Use and Safety, Monash University, Clayton, Victoria, Australia
- Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - Carl Kirkpatrick
- Centre for Medicines Use and Safety, Monash University, Clayton, Victoria, Australia
| | - Daryl A Jones
- Australia and New Zealand Intensive Care Research Centre, Monash University, Clayton, Victoria, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
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9
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Rezoagli E, Petrosino M, Rebora P, Menon DK, Mondello S, Cooper DJ, Maas AIR, Wiegers EJA, Galimberti S, Citerio G. High arterial oxygen levels and supplemental oxygen administration in traumatic brain injury: insights from CENTER-TBI and OzENTER-TBI. Intensive Care Med 2022; 48:1709-1725. [PMID: 36264365 PMCID: PMC9705485 DOI: 10.1007/s00134-022-06884-x] [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: 06/21/2022] [Accepted: 08/17/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The effect of high arterial oxygen levels and supplemental oxygen administration on outcomes in traumatic brain injury (TBI) is debated, and data from large cohorts of TBI patients are limited. We investigated whether exposure to high blood oxygen levels and high oxygen supplementation is independently associated with outcomes in TBI patients admitted to the intensive care unit (ICU) and undergoing mechanical ventilation. METHODS This is a secondary analysis of two multicenter, prospective, observational, cohort studies performed in Europe and Australia. In TBI patients admitted to ICU, we describe the arterial partial pressure of oxygen (PaO2) and the oxygen inspired fraction (FiO2). We explored the association between high PaO2 and FiO2 levels within the first week with clinical outcomes. Furthermore, in the CENTER-TBI cohort, we investigate whether PaO2 and FiO2 levels may have differential relationships with outcome in the presence of varying levels of brain injury severity (as quantified by levels of glial fibrillary acidic protein (GFAP) in blood samples obtained within 24 h of injury). RESULTS The analysis included 1084 patients (11,577 measurements) in the CENTER-TBI cohort, of whom 55% had an unfavorable outcome, and 26% died at a 6-month follow-up. Median PaO2 ranged from 93 to 166 mmHg. Exposure to higher PaO2 and FiO2 in the first seven days after ICU admission was independently associated with a higher mortality rate. A trend of a higher mortality rate was partially confirmed in the OzENTER-TBI cohort (n = 159). GFAP was independently associated with mortality and functional neurologic outcome at follow-up, but it did not modulate the outcome impact of high PaO2 levels, which remained independently associated with 6-month mortality. CONCLUSIONS In two large prospective multicenter cohorts of critically ill patients with TBI, levels of PaO2 and FiO2 varied widely across centers during the first seven days after ICU admission. Exposure to high arterial blood oxygen or high supplemental oxygen was independently associated with 6-month mortality in the CENTER-TBI cohort, and the severity of brain injury did not modulate this relationship. Due to the limited sample size, the findings were not wholly validated in the external OzENTER-TBI cohort. We cannot exclude the possibility that the worse outcomes associated with higher PaO2 were due to use of higher FiO2 in patients with more severe injury or physiological compromise. Further, these findings may not apply to patients in whom FiO2 and PaO2 are titrated to brain tissue oxygen monitoring (PbtO2) levels. However, at minimum, these findings support the need for caution with oxygen therapy in TBI, particularly since titration of supplemental oxygen is immediately applicable at the bedside.
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Affiliation(s)
- Emanuele Rezoagli
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo University Hospital, Extracorporeal Membrane Oxygenation (ECMO) Center, Azienda Socio-Sanitaria Territoriale (ASST) di Monza, Monza, Italy
| | - Matteo Petrosino
- Department of Medicine and Surgery, Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Paola Rebora
- Department of Medicine and Surgery, Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Hills Road, Box 93, Cambridge, CB2 0QQ, UK
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - D James Cooper
- Intensive Care Department, Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Andrew I R Maas
- Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Stefania Galimberti
- Department of Medicine and Surgery, Bicocca Bioinformatics Biostatistics and Bioimaging B4 Center, University of Milano - Bicocca, Monza, Italy
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy. .,NeuroIntensive Care Unit, Neuroscience Department, Hospital San Gerardo, ASST Monza, Monza, Italy.
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10
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Hodgson CL, Higgins AM, Bailey MJ, Anderson S, Bernard S, Fulcher BJ, Koe D, Linke NJ, Board JV, Brodie D, Buhr H, Burrell AJC, Cooper DJ, Fan E, Fraser JF, Gattas DJ, Hopper IK, Huckson S, Litton E, McGuinness SP, Nair P, Orford N, Parke RL, Pellegrino VA, Pilcher DV, Sheldrake J, Reddi BAJ, Stub D, Trapani TV, Udy AA, Serpa Neto A. Incidence of death or disability at 6 months after extracorporeal membrane oxygenation in Australia: a prospective, multicentre, registry-embedded cohort study. Lancet Respir Med 2022; 10:1038-1048. [PMID: 36174613 DOI: 10.1016/s2213-2600(22)00248-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment. METHODS This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov, NCT03793257. FINDINGS Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] -32% [95% CI -49 to -15]; p<0·001) but not VA-ECMO (VA-ECMO vs eCPR -8% [-22 to 6]; p=0·27). INTERPRETATION In our study, only a third of patients were alive without moderate-to-severe disability at 6 months after initiation of ECMO. The finding that disability was common across all areas of functioning points to the need for long-term, multidisciplinary care and support for surviving patients who have had ECMO. Further studies are needed to understand the 180-day and longer-term prognosis of patients with different diagnoses receiving different modes of ECMO, which could have important implications for the selection of patients for ECMO and management strategies in the ICU. FUNDING The National Health and Medical Research Council of Australia.
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Michael J Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Shannah Anderson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Stephen Bernard
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Bentley J Fulcher
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Denise Koe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Natalie J Linke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Jasmin V Board
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons, NY, USA; New York-Presbyterian Hospital, New York, NY, USA
| | - Heidi Buhr
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - John F Fraser
- School of Medicine, University of Queensland, St Lucia, QLD, Australia; Critical Care Research Group, Adult Intensive Care Society, Prince Charles Hospital, Chermside, QLD, Australia
| | - David J Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, NSW, Australia
| | - Ingrid K Hopper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Sue Huckson
- Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, WA, Australia
| | - Shay P McGuinness
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Medical Research Institute of New Zealand, Wellington, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Priya Nair
- Intensive Care Unit, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Neil Orford
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, University Hospital Geelong, Geelong, VIC, Australia; School of Medicine, Deakin University, Geelong Waurn Ponds, VIC, Australia
| | - Rachael L Parke
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Medical Research Institute of New Zealand, Wellington, New Zealand; Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | | | - David V Pilcher
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Jayne Sheldrake
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | | | - Dion Stub
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Tony V Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Parkville, VIC, Australia; Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia; Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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11
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Begum H, Neto AS, Alliegro P, Broadley T, Trapani T, Campbell LT, Cheng AC, Cheung W, Cooper DJ, Erickson SJ, French CJ, Litton E, McAllister R, Nichol A, Palermo A, Plummer MP, Rotherham H, Ramanan M, Reddi B, Reynolds C, Webb SAR, Udy AA, Burrell A. People in intensive care with COVID-19: demographic and clinical features during the first, second, and third pandemic waves in Australia. Med J Aust 2022; 217:352-360. [PMID: 35686307 PMCID: PMC9347520 DOI: 10.5694/mja2.51590] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare the demographic and clinical features, management, and outcomes for patients admitted with COVID-19 to intensive care units (ICUs) during the first, second, and third waves of the pandemic in Australia. DESIGN, SETTING, AND PARTICIPANTS People aged 16 years or more admitted with polymerase chain reaction-confirmed COVID-19 to the 78 Australian ICUs participating in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia project during the first (27 February - 30 June 2020), second (1 July 2020 - 25 June 2021), and third COVID-19 waves (26 June - 1 November 2021). MAIN OUTCOME MEASURES Primary outcome: in-hospital mortality. SECONDARY OUTCOMES ICU mortality; ICU and hospital lengths of stay; supportive and disease-specific therapies. RESULTS 2493 people (1535 men, 62%) were admitted to 59 ICUs: 214 during the first (9%), 296 during the second (12%), and 1983 during the third wave (80%). The median age was 64 (IQR, 54-72) years during the first wave, 58 (IQR, 49-68) years during the second, and 54 (IQR, 41-65) years during the third. The proportion without co-existing illnesses was largest during the third wave (41%; first wave, 32%; second wave, 29%). The proportion of ICU beds occupied by patients with COVID-19 was 2.8% (95% CI, 2.7-2.9%) during the first, 4.6% (95% CI, 4.3-5.1%) during the second, and 19.1% (95% CI, 17.9-20.2%) during the third wave. Non-invasive (42% v 15%) and prone ventilation strategies (63% v 15%) were used more frequently during the third wave than during the first two waves. Thirty patients (14%) died in hospital during the first wave, 35 (12%) during the second, and 281 (17%) during the third. After adjusting for age, illness severity, and other covariates, the risk of in-hospital mortality was similar for the first and second waves, but 9.60 (95% CI, 3.52-16.7) percentage points higher during the third than the first wave. CONCLUSION The demographic characteristics of patients in intensive care with COVID-19 and the treatments they received during the third pandemic wave differed from those of the first two waves. Adjusted in-hospital mortality was highest during the third wave.
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Affiliation(s)
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research CentreMelbourneVIC
| | | | | | - Tony Trapani
- Monash UniversityMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Lewis T Campbell
- Royal Darwin HospitalDarwinNT
- Menzies School of Health ResearchDarwinNT
| | | | | | - D James Cooper
- Monash UniversityMelbourneVIC
- Australian and New Zealand Intensive Care Research CentreMelbourneVIC
- Alfred HealthMelbourneVIC
| | | | | | | | | | | | | | | | | | - Mahesh Ramanan
- Prince Charles HospitalBrisbaneQLD
- Caboolture HospitalCabooltureQLD
| | | | | | | | - Andrew A Udy
- Monash UniversityMelbourneVIC
- Australian and New Zealand Intensive Care Research CentreMelbourneVIC
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12
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Hodgson CL, Higgins AM, Bailey M, Barrett J, Bellomo R, Cooper DJ, Gabbe BJ, Iwashyna T, Linke N, Myles PS, Paton M, Philpot S, Shulman M, Young M, Serpa Neto A. Comparison of 6-month outcomes of sepsis versus non-sepsis critically ill patients receiving mechanical ventilation. Crit Care 2022; 26:174. [PMID: 35698201 PMCID: PMC9189265 DOI: 10.1186/s13054-022-04041-w] [Citation(s) in RCA: 6] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Accepted: 05/26/2022] [Indexed: 12/29/2022] Open
Abstract
Background Data on long-term outcomes after sepsis-associated critical illness have mostly come from small cohort studies, with no information about the incidence of new disability. We investigated whether sepsis-associated critical illness was independently associated with new disability at 6 months after ICU admission compared with other types of critical illness. Methods We conducted a secondary analysis of a multicenter, prospective cohort study in six metropolitan intensive care units in Australia. Adult patients were eligible if they had been admitted to the ICU and received more than 24 h of mechanical ventilation. There was no intervention. Results The primary outcome was new disability measured with the WHO Disability Assessment Schedule 2.0 (WHODAS) 12 level score compared between baseline and 6 months. Between enrollment and follow-up at 6 months, 222/888 (25%) patients died, 100 (35.5%) with sepsis and 122 (20.1%) without sepsis (P < 0.001). Among survivors, there was no difference for the incidence of new disability at 6 months with or without sepsis, 42/106 (39.6%) and 106/300 (35.3%) (RD, 0.00 (− 10.29 to 10.40), P = 0.995), respectively. In addition, there was no difference in the severity of disability, health-related quality of life, anxiety and depression, post-traumatic stress, return to work, financial distress or cognitive function. Conclusions Compared to mechanically ventilated patients of similar acuity and length of stay without sepsis, patients with sepsis admitted to ICU have an increased risk of death, but survivors have a similar risk of new disability at 6 months. Trial registration NCT03226912, registered July 24, 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-04041-w.
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia. .,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia.
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Jonathon Barrett
- Intensive Care Unit, Epworth Healthcare, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Theodore Iwashyna
- Division of Pulmonary and Critical Care, Department of Medicine, University of Michigan, Ann Arbor, USA.,Centre for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Natalie Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - Michelle Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Physiotherapy, Monash Health, Melbourne, VIC, Australia
| | - Steve Philpot
- Intensive Care Unit, Cabrini Health, Melbourne, VIC, Australia
| | - Mark Shulman
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - Meredith Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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13
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Fitzgerald M, Ponsford J, Lannin NA, O'Brien TJ, Cameron P, Cooper DJ, Rushworth N, Gabbe B. AUS-TBI: The Australian Health Informatics Approach to Predict Outcomes and Monitor Intervention Efficacy after Moderate-to-Severe Traumatic Brain Injury. Neurotrauma Rep 2022; 3:217-223. [PMID: 35919508 PMCID: PMC9279124 DOI: 10.1089/neur.2022.0002] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Predicting and optimizing outcomes after traumatic brain injury (TBI) remains a major challenge because of the breadth of injury characteristics and complexity of brain responses. AUS-TBI is a new Australian Government–funded initiative that aims to improve personalized care and treatment for children and adults who have sustained a TBI. The AUS-TBI team aims to address a number of key knowledge gaps, by designing an approach to bring together data describing psychosocial modulators, social determinants, clinical parameters, imaging data, biomarker profiles, and rehabilitation outcomes in order to assess the influence that they have on long-term outcome. Data management systems will be designed to track a broad range of suitable potential indicators and outcomes, which will be organized to facilitate secure data collection, linkage, storage, curation, management, and analysis. It is believed that these objectives are achievable because of our consortium of highly committed national and international leaders, expert committees, and partner organizations in TBI and health informatics. It is anticipated that the resulting large-scale data resource will facilitate personalization, prediction, and improvement of outcomes post-TBI.
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Affiliation(s)
- Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Nedlands, Western Australia, Australia
- Perron Institute for Neurological and Translational Science, Nedlands, Western Australia, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia
- Monash Epworth Rehabilitation Research Centre–Epworth Healthcare, Richmond, Victoria, Australia
| | - Natasha A. Lannin
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terence J. O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Peter Cameron
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre Recovery Program (ANZIC-RC), Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Nick Rushworth
- Brain Injury Australia, Sydney, New South Wales, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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14
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Hodgson CL, Higgins AM, Bailey MJ, Mather AM, Beach L, Bellomo R, Bissett B, Boden IJ, Bradley S, Burrell A, Cooper DJ, Fulcher BJ, Haines KJ, Hodgson IT, Hopkins J, Jones AYM, Lane S, Lawrence D, van der Lee L, Liacos J, Linke NJ, Gomes LM, Nickels M, Ntoumenopoulos G, Myles PS, Patman S, Paton M, Pound G, Rai S, Rix A, Rollinson TC, Tipping CJ, Thomas P, Trapani T, Udy AA, Whitehead C, Anderson S, Neto AS. Comparison of 6-Month Outcomes of Survivors of COVID-19 versus Non-COVID-19 Critical Illness. Am J Respir Crit Care Med 2022; 205:1159-1168. [PMID: 35258437 PMCID: PMC9872799 DOI: 10.1164/rccm.202110-2335oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [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] [Indexed: 01/27/2023] Open
Abstract
Rationale: The outcomes of survivors of critical illness due to coronavirus disease (COVID-19) compared with non-COVID-19 are yet to be established. Objectives: We aimed to investigate new disability at 6 months in mechanically ventilated patients admitted to Australian ICUs with COVID-19 compared with non-COVID-19. Methods: We included critically ill patients with COVID-19 and non-COVID-19 from two prospective observational studies. Patients were eligible if they were adult (age ⩾ 8 yr) and received ⩾24 hours of mechanical ventilation. In addition, patients with COVID-19 were eligible with a positive laboratory PCR test for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Measurements and Main Results: Demographic, intervention, and hospital outcome data were obtained from electronic medical records. Survivors were contacted by telephone for functional outcomes with trained outcome assessors using the World Health Organization Disability Assessment Schedule 2.0. Between March 6, 2020, and April 21, 2021, 120 critically ill patients with COVID-19, and between August 2017 and January 2019, 199 critically ill patients without COVID-19, fulfilled the inclusion criteria. Patients with COVID-19 were older (median [interquartile range], 62 [55-71] vs. 58 [44-69] yr; P = 0.019) with a lower Acute Physiology and Chronic Health Evaluation II score (17 [13-20] vs. 19 [15-23]; P = 0.011). Although duration of ventilation was longer in patients with COVID-19 than in those without COVID-19 (12 [5-19] vs. 4.8 [2.3-8.8] d; P < 0.001), 180-day mortality was similar between the groups (39/120 [32.5%] vs. 70/199 [35.2%]; P = 0.715). The incidence of death or new disability at 180 days was similar (58/93 [62.4%] vs. 99/150 [66/0%]; P = 0.583). Conclusions: At 6 months, there was no difference in new disability for patients requiring mechanical ventilation for acute respiratory failure due to COVID-19 compared with non-COVID-19. Clinical trial registered with www.clinicaltrials.gov (NCT04401254).
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Affiliation(s)
- Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and,Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Michael J. Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Anne M. Mather
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Lisa Beach
- Department of Physiotherapy (Allied Health), the Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Critical Care, School of Medicine, and,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, University of Canberra, Canberra, Australian Capital Territory, Australia;,Physiotherapy Department, Canberra Hospital, Canberra, Australian Capital Territory, Australia
| | - Ianthe J. Boden
- Physiotherapy Department, Launceston General Hospital, Launceston, Tasmania, Australia;,School of Medicine, University of Tasmania, Tasmania, Australia
| | - Scott Bradley
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and
| | - Bentley J. Fulcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Kimberley J. Haines
- Department of Critical Care, School of Medicine, and,Physiotherapy Department, Western Health, Melbourne, Victoria, Australia
| | - Isabelle T. Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Jack Hopkins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Alice Y. M. Jones
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Stuart Lane
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Intensive Care Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Drew Lawrence
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | | | - Jennifer Liacos
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Natalie J. Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Lonni Marques Gomes
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Marc Nickels
- Physiotherapy Department, Princess Alexandra Hospital, Metro South Health, Queensland, Australia
| | | | - Paul S. Myles
- Department of Anaesthesiology and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Shane Patman
- Faculty of Medicine, Nursing and Midwifery, Health Sciences, and Physiotherapy, the University of Notre Dame Australia, Perth, Western Australia, Australia
| | - Michelle Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Physiotherapy, Monash Health, Melbourne, Victoria, Australia
| | - Gemma Pound
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Physiotherapy Department, St. Vincent’s Hospital, Melbourne, Victoria, Australia
| | - Sumeet Rai
- Canberra Health Services, Canberra, Australian Capital Territory, Australia;,Medical School, Australia National University, Canberra, Australian Capital Territory, Australia
| | - Alana Rix
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Thomas C. Rollinson
- Medical School, Australia National University, Canberra, Australian Capital Territory, Australia;,Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Victoria, Australia
| | - Claire J. Tipping
- Department of Physiotherapy, the Alfred, Melbourne, Victoria, Australia
| | - Peter Thomas
- Department of Physiotherapy, The University of Melbourne, Victoria, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Intensive Care and Hyperbaric Medicine and
| | - Christina Whitehead
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Intensive Care Medicine, Nepean Hospital, Kingswood, New South Wales, Australia
| | - Shannah Anderson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine,,Department of Critical Care, School of Medicine, and,Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia;,Department of Physiotherapy, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia; and
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15
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Gantner D, Wiegers E, Bragge P, Finfer S, Delaney A, van Essen T, Peul WC, Maas A, Cooper DJ. Decompressive craniectomy practice following traumatic brain injury, in comparison with randomized trials. J Neurotrauma 2022; 39:860-869. [PMID: 35243877 DOI: 10.1089/neu.2021.0312] [Citation(s) in RCA: 6] [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] [Indexed: 11/12/2022] Open
Abstract
High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized CENTER-TBI and OzENTER-TBI Core study datasets. These include patients admitted to ICUs in Europe, the United Kingdom and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI, and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8.9%) of those matching DECRA enrolment, and in 30/224 (13.4%) of those matching RESCUEicp. Of patients who underwent DC 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to be potentially harmful, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown.
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Affiliation(s)
- Dashiell Gantner
- Monash University, 2541, Australian and New Zealand Intensive Care Research Centre, 553 St Kilda Rd, Melbourne, Victoria, Australia, 3004.,Alfred Health, 5392, Department of Intensive Care, 55 Commercial Rd, Melbourne, Victoria, Australia, 3004;
| | - Eveline Wiegers
- Erasmus University Rotterdam, 6984, Department of Public Health, Kortenaerstraat 22, J, Rotterdam, Zuid-Holland, Netherlands, 3012VD;
| | - Peter Bragge
- National Trauma Research Institute, 89 Commercial Road, Prahran, Melbourne, Victoria, Australia, 3004;
| | - Simon Finfer
- Royal North Shore Hospital, Intensive Care Unit, Pacific Highway, Sydney, New South Wales, Australia, 2076;
| | - Anthony Delaney
- The George Institute for Global Health, 211065, Newtown, New South Wales, Australia;
| | | | - Wilco C Peul
- Leiden University Medical Center, 4501, Neurosurgery, LUMC, Albinusdreef 2, Leiden, Holland, Netherlands, 2300 RC.,Medical Centre Haaglanden, 2901, Neurosurgery, Den Haag, Netherlands, 2501 CK;
| | - Andrew Maas
- University Hospital Antwerp, Neurosurgery, Wilrijkstraat 10, Edegem, Belgium, 2650.,Netherlands;
| | - D James Cooper
- The Alfred, Intensive Care, Commercial Road, Melbourne, Victoria, Australia, 3004.,Monash University, ANZIC-RC, Level 6, The Alfred Centre, 99 Commercial Road, Melbourne, Victoria, Australia, 3004;
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16
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Hodgson CL, Higgins AM, Bailey MJ, Mather AM, Beach L, Bellomo R, Bissett B, Boden IJ, Bradley S, Burrell A, Cooper DJ, Fulcher BJ, Haines KJ, Hopkins J, Jones AYM, Lane S, Lawrence D, van der Lee L, Liacos J, Linke NJ, Gomes LM, Nickels M, Ntoumenopoulos G, Myles PS, Patman S, Paton M, Pound G, Rai S, Rix A, Rollinson TC, Sivasuthan J, Tipping CJ, Thomas P, Trapani T, Udy AA, Whitehead C, Hodgson IT, Anderson S, Neto AS. The impact of COVID-19 critical illness on new disability, functional outcomes and return to work at 6 months: a prospective cohort study. Crit Care 2021; 25:382. [PMID: 34749756 PMCID: PMC8575157 DOI: 10.1186/s13054-021-03794-0] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Accepted: 10/13/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND There are few reports of new functional impairment following critical illness from COVID-19. We aimed to describe the incidence of death or new disability, functional impairment and changes in health-related quality of life of patients after COVID-19 critical illness at 6 months. METHODS In a nationally representative, multicenter, prospective cohort study of COVID-19 critical illness, we determined the prevalence of death or new disability at 6 months, the primary outcome. We measured mortality, new disability and return to work with changes in the World Health Organization Disability Assessment Schedule 2.0 12L (WHODAS) and health status with the EQ5D-5LTM. RESULTS Of 274 eligible patients, 212 were enrolled from 30 hospitals. The median age was 61 (51-70) years, and 124 (58.5%) patients were male. At 6 months, 43/160 (26.9%) patients died and 42/108 (38.9%) responding survivors reported new disability. Compared to pre-illness, the WHODAS percentage score worsened (mean difference (MD), 10.40% [95% CI 7.06-13.77]; p < 0.001). Thirteen (11.4%) survivors had not returned to work due to poor health. There was a decrease in the EQ-5D-5LTM utility score (MD, - 0.19 [- 0.28 to - 0.10]; p < 0.001). At 6 months, 82 of 115 (71.3%) patients reported persistent symptoms. The independent predictors of death or new disability were higher severity of illness and increased frailty. CONCLUSIONS At six months after COVID-19 critical illness, death and new disability was substantial. Over a third of survivors had new disability, which was widespread across all areas of functioning. Clinical trial registration NCT04401254 May 26, 2020.
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia.
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia.
- Department of Critical Care, School of Medicine, University of Melbourne, Victoria, Australia.
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael J Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Victoria, Australia
| | - Anne M Mather
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lisa Beach
- Department of Physiotherapy (Allied Health), The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, School of Medicine, University of Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia
| | - Bernie Bissett
- Discipline of Physiotherapy, University of Canberra, Canberra, Australia
- Physiotherapy Department, Canberra Hospital, Canberra, Australia
| | - Ianthe J Boden
- Physiotherapy Department, Launceston General Hospital, Launceston, Tasmania, Australia
- Launceston Clinical School, University of Tasmania, Tasmania, Australia
| | - Scott Bradley
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
| | - Aidan Burrell
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Bentley J Fulcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kimberley J Haines
- Physiotherapy Department, Western Health, Melbourne, Victoria, Australia
| | - Jack Hopkins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alice Y M Jones
- School of Health and Rehabilitation Sciences, University of Queensland, Brisbane, Queensland, Australia
| | - Stuart Lane
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Medicine Nepean Hospital, New South Wales, Australia
| | - Drew Lawrence
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
| | | | - Jennifer Liacos
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
| | - Natalie J Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lonni Marques Gomes
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Marc Nickels
- Physiotherapy Department, Princess Alexandra Hospital, Metro South Health, Queensland, Australia
| | | | - Paul S Myles
- Department of Anaesthesiology and Perioperative Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Shane Patman
- Faculty of Medicine, Nursing and Midwifery, Health Sciences and Physiotherapy, The University of Notre Dame Australia, Perth, Western Australia, Australia
| | - Michelle Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Physiotherapy, Monash Health, Melbourne, Victoria, Australia
| | - Gemma Pound
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Physiotherapy Department, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Sumeet Rai
- Canberra Health Services, Canberra, Australia
- Medical School, Australia National University, Canberra, Australia
| | - Alana Rix
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
| | - Thomas C Rollinson
- Department of Physiotherapy, Division of Allied Health, Austin Health, Melbourne, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
| | - Janani Sivasuthan
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Claire J Tipping
- Department of Physiotherapy, The Alfred, Melbourne, Victoria, Australia
| | - Peter Thomas
- Department of Physiotherapy, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Christina Whitehead
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Medicine Nepean Hospital, New South Wales, Australia
| | - Isabelle T Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Shannah Anderson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Physiotherapy (Allied Health), The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation (DARE) Centre, Austin Hospital, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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17
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Burrell AJ, Neto AS, Broadley T, Trapani T, Begum H, Campbell LT, Cheng AC, Cheung W, Cooper DJ, Erickson SJ, French CJ, Kaldor JM, Litton E, Murthy S, McAllister RE, Nichol AD, Palermo A, Plummer MP, Ramanan M, Reddi BA, Reynolds C, Webb SA, Udy AA. Comparison of baseline characteristics, treatment and celinical outcomes of critically ill COVID-19 patients admitted in the first and second waves in Australia. CRIT CARE RESUSC 2021; 23:308-319. [PMID: 38046076 PMCID: PMC10692524 DOI: 10.51893/2021.3.oa8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To report longitudinal differences in baseline characteristics, treatment, and outcomes in patients with coronavirus disease 2019 (COVID-19) admitted to intensive care units (ICUs) between the first and second waves of COVID-19 in Australia. Design, setting and participants: SPRINT-SARI Australia is a multicentre, inception cohort study enrolling adult patients with COVID-19 admitted to participating ICUs. The first wave of COVID-19 was from 27 February to 30 June 2020, and the second wave was from 1 July to 22 October 2020. Results: A total of 461 patients were recruited in 53 ICUs across Australia; a higher number were admitted to the ICU during the second wave compared with the first: 255 (55.3%) versus 206 (44.7%). Patients admitted to the ICU in the second wave were younger (58.0 v 64.0 years; P = 0.001) and less commonly male (68.9% v 60.0%; P = 0.045), although Acute Physiology and Chronic Health Evaluation (APACHE) II scores were similar (14 v 14; P = 0.998). High flow oxygen use (75.2% v 43.4%; P < 0.001) and non-invasive ventilation (16.5% v 7.1%; P = 0.002) were more common in the second wave, as was steroid use (95.0% v 30.3%; P < 0.001). ICU length of stay was shorter (6.0 v 8.4 days; P = 0.003). In-hospital mortality was similar (12.2% v 14.6%; P = 0.452), but observed mortality decreased over time and patients were more likely to be discharged alive earlier in their ICU admission (hazard ratio, 1.43; 95% CI, 1.13-1.79; P = 0.002). Conclusion: During the second wave of COVID-19 in Australia, ICU length of stay and observed mortality decreased over time. Multiple factors were associated with this, including changes in clinical management, the adoption of new evidence-based treatments, and changes in patient demographic characteristics but not illness severity.
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Affiliation(s)
- Aidan J.C. Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tessa Broadley
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Husna Begum
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Lewis T. Campbell
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
| | - Allen C. Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, VIC, Australia
| | - Winston Cheung
- Department of Intensive Care Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Craig J. French
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Western Health, Melbourne, VIC, Australia
| | - John M. Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
- Department of Intensive Care Medicine, St John of God Hospital Subiaco, Perth, WA, Australia
| | - Srinivas Murthy
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Alistair D. Nichol
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Mark P. Plummer
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia
| | - Benjamin A.J. Reddi
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Claire Reynolds
- Intensive Care Unit, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Steve A. Webb
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, St John of God Hospital Subiaco, Perth, WA, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
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18
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Wiegers EJA, Trapani T, Gabbe BJ, Gantner D, Lecky F, Maas AIR, Menon DK, Murray L, Rosenfeld JV, Vallance S, Lingsma HF, Steyerberg EW, Cooper DJ. Characteristics, management and outcomes of patients with severe traumatic brain injury in Victoria, Australia compared to United Kingdom and Europe: A comparison between two harmonised prospective cohort studies. Injury 2021; 52:2576-2587. [PMID: 33910683 DOI: 10.1016/j.injury.2021.04.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/18/2021] [Accepted: 04/07/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE The aim of this manuscript is to compare characteristics, management, and outcomes of patients with severe Traumatic Brain Injury (TBI) between Australia, the United Kingdom (UK) and Europe. METHODS We enrolled patients with severe TBI in Victoria, Australia (OzENTER-TBI), in the UK and Europe (CENTER-TBI) from 2015 to 2017. Main outcome measures were mortality and unfavourable outcome (Glasgow Outcome Scale Extended <5) 6 months after injury. Expected outcomes were compared according to the IMPACT-CT prognostic model, with observed to expected (O/E) ratios and 95% confidence intervals. RESULTS We included 107 patients from Australia, 171 from UK, and 596 from Europe. Compared to the UK and Europe, patients in Australia were younger (median 32 vs 44 vs 44 years), a larger proportion had secondary brain insults including hypotension (30% vs 17% vs 21%) and a larger proportion received ICP monitoring (75% vs 74% vs 58%). Hospital length of stay was shorter in Australia than in the UK (median: 17 vs 23 vs 16 days), and a higher proportion of patients were discharged to a rehabilitation unit in Australia than in the UK and Europe (64% vs 26% vs 28%). Mortality overall was lower than expected (27% vs 35%, O/E ratio 0.77 [95% CI: 0.64 - 0.87]. O/E ratios were comparable between regions for mortality in Australia 0.86 [95% CI: 0.49-1.23] vs UK 0.82 [0.51-1.15] vs Europe 0.76 [0.60-0.87]). Unfavourable outcome rates overall were in line with historic expectations (O/E ratio 1.32 [0.96-1.68] vs 1.13 [0.84-1.42] vs 0.96 [0.85-1.09]). CONCLUSIONS There are major differences in case-mix between Australia, UK, and Europe; Australian patients are younger and have a higher rate of secondary brain insults. Despite some differences in management and discharge policies, mortality was less than expected overall, and did not differ between regions. Functional outcomes were similar between regions, but worse than expected, emphasizing the need to improve treatment for patients with severe TBI.
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Affiliation(s)
- Eveline J A Wiegers
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands; School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Tony Trapani
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Belinda J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Health Data Research UK, Swansea University, United Kingdom
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, Alfred Hospital, Melbourne, Australia
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK; Emergency Department, Salford Royal Hospital, Salford, UK
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, Alfred Hospital, Melbourne, Australia; Department of Surgery, Monash University, Melbourne, Australia
| | - Shirley Vallance
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, the Netherlands; Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, The Netherlands
| | - D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Department, Alfred Hospital, Melbourne, Australia
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Cooper DJ, Rosenfeld JV, Murray L, Arabi YM, Davies AR, Ponsford J, Seppelt I, Reilly P, Wiegers E, Wolfe R. Patient Outcomes at Twelve Months after Early Decompressive Craniectomy for Diffuse Traumatic Brain Injury in the Randomized DECRA Clinical Trial. J Neurotrauma 2021; 37:810-816. [PMID: 32027212 PMCID: PMC7071071 DOI: 10.1089/neu.2019.6869] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Functional outcomes at 12 months were a secondary outcome of the randomized DECRA trial of early decompressive craniectomy for severe diffuse traumatic brain injury (TBI) and refractory intracranial hypertension. In the DECRA trial, patients were randomly allocated 1:1 to either early decompressive craniectomy or intensive medical therapies (standard care). We conducted planned secondary analyses of the DECRA trial outcomes at 6 and 12 months, including all 155 patients. We measured functional outcome using the Glasgow Outcome Scale-Extended (GOS-E). We used ordered logistic regression, and dichotomized the GOS-E using logistic regression, to assess outcomes in patients overall and in survivors. We adjusted analyses for injury severity using the International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT) model. At 12 months, the odds ratio (OR) for worse functional outcomes in the craniectomy group (OR 1.68; 95% confidence interval [CI]: 0.96-2.93; p = 0.07) was no longer significant. Unfavorable functional outcomes after craniectomy were 11% higher (59% compared with 48%), but were not significantly different from standard care (OR 1.58; 95% CI: 0.84-2.99; p = 0.16). Among survivors after craniectomy, there were fewer good (OR 0.33; 95% CI: 0.12-0.91; p = 0.03) and more vegetative (OR 5.12; 95% CI: 1.04-25.2; p = 0.04) outcomes. Similar outcomes in survivors were found at 6 months after injury. Vegetative (OR 5.85; 95% CI: 1.21-28.30; p = 0.03) and severely disabled outcomes (OR 2.49; 95% CI: 1.21-5.11; p = 0.01) were increased. Twelve months after severe diffuse TBI and early refractory intracranial hypertension, decompressive craniectomy did not improve outcomes and increased vegetative survivors.
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Affiliation(s)
- D James Cooper
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Victoria, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Lynnette Murray
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Yaseen M Arabi
- Department of Intensive Care, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
| | - Andrew R Davies
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jennie Ponsford
- School of Psychological Sciences, Monash University, Melbourne, Victoria, Australia.,Monash-Epworth Rehabilitation Research Center, Melbourne, Victoria, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Sydney, New South Wales, Australia
| | - Peter Reilly
- Neurosurgery Department, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Eveline Wiegers
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Public Health, Erasmus University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Rory Wolfe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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20
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Saadah NH, Wood EM, Bailey MJ, Cooper DJ, French CJ, Haysom HE, Sparrow RL, Wellard CJ, McQuilten ZK. Age of red blood cells is not associated with in-hospital mortality in massively transfused patients. J Trauma Acute Care Surg 2021; 91:279-286. [PMID: 34108423 DOI: 10.1097/ta.0000000000003192] [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] [Indexed: 11/25/2022]
Abstract
BACKGROUND Studies comparing mortality following massive transfusion (MT) with fresher versus longer-stored red blood cells (RBCs) have focused on trauma patients. The Australian and New Zealand Massive Transfusion Registry collects data on all adult MT cases (≥5 RBCs within 4 hours, any bleeding context, ≥18 years) at participating hospitals. METHODS Years 2007 to 2018 data from 29 hospitals were analyzed to quantify the association between mortality and RBC storage time in adult MT cases. We ran three logistic regression models separately on each of seven bleeding contexts, with in-hospital mortality as the outcome and, in turn, (1) mean storage time (STmean) quartiles, (2) proportion of RBCs ≥30 days old (propOLD), and (3) scalar age of blood index as predictors. RESULTS A total of 8,685 adult MT cases involving transfusion of 126,622 RBCs were analyzed with Australian and New Zealand data analyzed separately. Mean storage times for these cases were (by quartile in ascending order) as follows: Australia, 12.5 days (range, 3.1-15.5 days), 17.7 (15.5-19.9), 22.3 (19.9-24.9), and 29.8 (24.9-41.7); New Zealand, 11.3 days (3.6-13.7), 15.3 (13.7-16.8), 18.7 (16.8-20.7), and 24.5 (20.7-35.6). The odds ratios comparing in-hospital mortality for each quartile with that of the control first quartile (freshest blood), proportion of longer-stored (≥30 days) RBCs, and scalar age of blood index were not statistically significant across all bleeding contexts. CONCLUSION We find no correlation between in-hospital mortality and storage time of transfused RBCs in a large cohort of adult MT patients representing all bleeding contexts. These results are consistent with those of recent large multicenter trials. LEVEL OF EVIDENCE Epidemiologic, level III; Therapeutic, level IV.
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Affiliation(s)
- Nicholas H Saadah
- From the Transfusion Research Unit (N.H.S., E.M.W., H.E.H., R.L.S., C.J.W., Z.K.M.), Public Health and Preventive Medicine, Monash University; Department of Haematology (E.M.W., Z.K.M.), Monash Health; Australian and New Zealand Intensive Care Research Centre (M.J.B., D.J.C., C.J.F., Z.K.M.), Public Health and Preventive Medicine, Monash University; and Department of Intensive Care (C.J.F., Z.K.M.), Western Health, Melbourne, Australia
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21
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Higgins AM, Neto AS, Bailey M, Barrett J, Bellomo R, Cooper DJ, Gabbe BJ, Linke N, Myles PS, Paton M, Philpot S, Shulman M, Young M, Hodgson CL. Predictors of death and new disability after critical illness: a multicentre prospective cohort study. Intensive Care Med 2021; 47:772-781. [PMID: 34089063 DOI: 10.1007/s00134-021-06438-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Accepted: 05/15/2021] [Indexed: 11/24/2022]
Abstract
PURPOSE This study aimed to determine the prevalence and predictors of death or new disability following critical illness. METHODS Prospective, multicentre cohort study conducted in six metropolitan intensive care units (ICU). Participants were adults admitted to the ICU who received more than 24 h of mechanical ventilation. The primary outcome was death or new disability at 6 months, with new disability defined by a 10% increase in the WHODAS 2.0. RESULTS Of 628 patients with the primary outcome available (median age of 62 [49-71] years, 379 [61.0%] had a medical admission and 370 (58.9%) died or developed new disability by 6 months. Independent predictors of death or new disability included age [OR 1.02 (1.01-1.03), P = 0.001], higher severity of illness (APACHE III) [OR 1.02 (1.01-1.03), P < 0.001] and admission diagnosis. Compared to patients with a surgical admission diagnosis, patients with a cardiac arrest [OR (95% CI) 4.06 (1.89-8.68), P < 0.001], sepsis [OR (95% CI) 2.43 (1.32-4.47), P = 0.004], or trauma [OR (95% CI) 6.24 (3.07-12.71), P < 0.001] diagnosis had higher odds of death or new disability, while patients with a lung transplant [OR (95% CI) 0.21 (0.07-0.58), P = 0.003] diagnosis had lower odds. A model including these three variables had good calibration (Brier score 0.20) and acceptable discriminative power with an area under the receiver operating characteristic curve of 0.76 (95% CI 0.72-0.80). CONCLUSION Less than half of all patients mechanically ventilated for more than 24 h were alive and free of new disability at 6 months after admission to ICU. A model including age, illness severity and admission diagnosis has acceptable discriminative ability to predict death or new disability at 6 months.
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Affiliation(s)
- A M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - A Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - M Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - J Barrett
- Intensive Care Unit, Epworth Healthcare, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - R Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - D J Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - B J Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - N Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
| | - P S Myles
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - M Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.,Department of Physiotherapy, Monash Health, Melbourne, VIC, Australia
| | - S Philpot
- Intensive Care Unit, Cabrini Health, Melbourne, VIC, Australia
| | - M Shulman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - M Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - C L Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia. .,Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia.
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22
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Ridley EJ, Davies AR, Bernard S, McArthur C, Murray L, Paul E, Trapani A, Cooper DJ. Measured energy expenditure in mildly hypothermic critically ill patients with traumatic brain injury: A sub-study of a randomized controlled trial. Clin Nutr 2021; 40:3875-3882. [PMID: 34130035 DOI: 10.1016/j.clnu.2021.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 04/26/2021] [Accepted: 05/17/2021] [Indexed: 01/03/2023]
Abstract
BACKGROUND & AIMS Prophylactic hypothermia, often used in critically ill patients with traumatic brain injury, reduces energy expenditure and may affect energy delivered by nutrition therapy. The primary objective of this study was to measure energy expenditure in hypothermic patients over the first 3 days after traumatic brain injury (TBI). Secondary objectives included comparison of measured energy expenditure and nutrition delivery to day 7. METHODS A prospective sub-study of a randomized controlled trial conducted in patients with severe TBI, investigating prophylactic hypothermia (33-35 °C) as a neuroprotective therapy. In two centers, indirect calorimetry was initiated within 24 h of randomization and repeated up to twice daily to day 7. Data are presented as n (%), mean (standard deviation (SD)), median [interquartile range (IQR)], and mean difference (95% confidence interval (CI)). RESULTS Forty patients were included (20 in each group), with 17 patients in the hypothermic and 16 in the normothermic group having an indirect calorimetry measurement in the first 3 days. Over the first 3 days, the mean temperature in the hypothermic and normothermic groups was 33.5 (0.6) ºC (n = 17) and 37 (0.5) ºC (n = 16), p < 0.0001, and the mean measured energy expenditure, was 21 (5) and 27 (4) kcal/kg, p = 0.002, representing a mean difference of 5 (95% CI: 2-8) kcal/kg. Energy expenditure was 20% (95% CI: 9.5-29%) less in hypothermia patients compared to normothermia patients. Hypothermia patients also had higher gastric residual volumes across the 7 day study period (438 (237) mls vs 184 (103) mls, p < 0.0001) and higher use of metoclopramide and erythromycin as prokinetics. Despite enteral nutrition intolerance, hypothermia patients received 93% of measured energy expenditure over 7 days. CONCLUSION In TBI patients, energy expenditure was 20% less when receiving prophylactic hypothermia compared to normothermia. Greater gastric residual volumes, use of prokinetics and energy delivery that approximated measured energy expenditure was also observed in hypothermia patients. TRIAL REGISTRY NUMBER POLAR-RCT: clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235. This sub-study was not registered separately.
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Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia; Nutrition Department, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - Stephen Bernard
- Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia
| | - Colin McArthur
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Lynne Murray
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - Antony Trapani
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, St Kilda Road, Melbourne, 3004, Australia; Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, 3004, Australia
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23
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Levkovich BJ, Jones DA, Bingham G, Orosz J, Dooley MJ, Cooper DJ, Kirkpatrick CM. Evaluation of medical emergency team medication management practices in acute hospitals: A multicentre study. Aust Crit Care 2021; 35:59-65. [PMID: 33902988 DOI: 10.1016/j.aucc.2021.02.008] [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: 10/24/2020] [Revised: 01/24/2021] [Accepted: 02/16/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Medical emergency teams use medications to rescue deteriorating patients. Medication management is the system of steps and processes, including prescribing, distribution, administration, and monitoring, to achieve the best outcomes from medication use. Systems or standards for medication management by medical emergency teams have not been defined. OBJECTIVES The aim of the study was to propose potential solutions to improve medical emergency team medication management by evaluating medication supply and related medication management practices during medical emergency team activations and understanding clinicians' perceptions about medical emergency team medication management in acute hospitals. METHODS A prospective multicentre audit of intensive care unit-equipped hospitals in Victoria, Australia, was conducted. After advertisement and invitation via scheduled email newsletters to hospitals, a representative of the medical emergency team from each hospital self-administered an online audit tool during December 2019 and January 2020. Audit data were analysed descriptively, and perceptions were analysed using content analysis. RESULTS Responses were received from 32 of the 44 (72.7%) eligible hospitals. At 17 of the 32 (53.1%) hospitals, arrest trolleys provided medications for medical emergency team activations, in addition to arrest calls. At 15 of the 32 (46.9%) hospitals, separate, dedicated medical emergency team medication supplies were used to care for deteriorating patients. Dedicated medical emergency team supplies contained a median of 20 (range = 8-37) medications, predominantly cardiovascular (median = 8, mode = 7, range = 4-16) and neurological medications (median and mode = 6, range = 0-11). Variation was observed in all storage and other supply-related medication management practices studied. The four most frequent categories of clinicians' perceptions described systematic challenges with availability of the right medication in the right place at the right time. CONCLUSIONS Current supply and related medication management practices and clinicians' perceptions demonstrated further development is necessary for medication management to meet the needs of medical emergency team clinicians and their patients.
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Affiliation(s)
- Bianca J Levkovich
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy, Alfred Health, Melbourne, Victoria, Australia; Safer Care Victoria, Melbourne, Victoria, Australia; Australia New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Daryl A Jones
- Australia New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Gordon Bingham
- Nursing Services, Alfred Health, Melbourne, Victoria, Australia
| | - Judit Orosz
- Intensive Care Unit, Austin Hospital, Heidelberg, Victoria, Australia
| | - Michael J Dooley
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia; Pharmacy, Alfred Health, Melbourne, Victoria, Australia
| | - D James Cooper
- Australia New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia; Intensive Care Unit, The Alfred, Melbourne, Victoria, Australia
| | - Carl M Kirkpatrick
- Centre for Medicines Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Parkville, Victoria, Australia
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Higgins AM, Neto AS, Bailey M, Barrett J, Bellomo R, Cooper DJ, Gabbe B, Linke N, Myles PS, Paton M, Philpot S, Shulman M, Young M, Hodgson CL. The psychometric properties and minimal clinically important difference for disability assessment using WHODAS 2.0 in critically ill patients. CRIT CARE RESUSC 2021; 23:103-112. [PMID: 38046389 PMCID: PMC10692530 DOI: 10.51893/2021.1.oa10] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives: The 12-item World Health Organization Disability Assessment Schedule 2.0 (WHODAS 2.0) provides a standardised method for measuring health and disability. This study aimed to determine its reliability, validity and responsiveness and to establish the minimum clinically important difference (MCID) in critically ill patients. Design: Prospective, multicentre cohort study. Setting: Intensive care units of six metropolitan hospitals. Participants: Adults mechanically ventilated for > 24 hours. Main outcome measures: Reliability was assessed by measuring internal consistency. Construct validity was assessed by comparing WHODAS 2.0 scores at 6 months with the EuroQoL visual analogue scale (EQ VAS) and Lawton Instrumental Activities of Daily Living (IADL) scale scores. Responsiveness was evaluated by assessing change over time, effect sizes, and percentage of patients showing no change. The MCID was calculated using both anchor and distribution-based methods with triangulation of results. Main results: A baseline and 6-month WHODAS 2.0 score were available for 448 patients. The WHODAS 2.0 demonstrated good correlation between items with no evidence of item redundancy. Cronbach α coefficient was 0.91 and average split-half coefficient was 0.91. There was a moderate correlation between the WHODAS 2.0 and the EQ VAS scores (r = -0.72; P < 0.001) and between the WHODAS 2.0 and the Lawton IADL scores (r = -0.66; P < 0.001) at 6 months. The effect sizes for change in the WHODAS 2.0 score from baseline to 3 months and from 3 to 6 months were low. Ceiling effects were not present and floor effects were present at baseline only. The final MCID estimate was 10%. Conclusion: The 12-item WHODAS 2.0 is a reliable, valid and responsive measure of disability in critically ill patients. A change in the total WHODAS 2.0 score of 10% represents the MCID.
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Affiliation(s)
- Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Jonathan Barrett
- Intensive Care Unit, Epworth Healthcare, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Belinda Gabbe
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Natalie Linke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Paul S. Myles
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - Michelle Paton
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Physiotherapy, Monash Health, Melbourne, VIC, Australia
| | - Steve Philpot
- Intensive Care Unit, Cabrini Health, Melbourne, VIC, Australia
| | - Mark Shulman
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Anaesthesiology and Perioperative Medicine, The Alfred, Melbourne, VIC, Australia
| | - Meredith Young
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Carol L. Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
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25
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Kow CY, Harley B, Li C, Romo P, Gkolia P, Lu KY, Bell C, Jithoo R, Tee J, Cooper DJ, Rosenfeld JV, Lewis PM, Udy A, Hunn M. Escalating Mean Arterial Pressure in Severe Traumatic Brain Injury: A Prospective, Observational Study. J Neurotrauma 2021; 38:1995-2002. [PMID: 33280492 DOI: 10.1089/neu.2020.7289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To investigate cerebral autoregulatory status in patients with severe traumatic brain injury (TBI), guidelines now suggest active manipulation of mean arterial pressure (MAP). There is a paucity of data, however, describing the effect on intracranial pressure (ICP) when MAP is raised. Consecutive patients with TBI requiring ICP monitoring were enrolled from November 2019 to April 2020. The MAP and ICP were recorded continuously, and clinical annotations were made whenever intravenous vasopressors were commenced or adjusted to defend cerebral perfusion pressure (CPP) targets. A significant change in MAP burden was defined as MAP >100min.mm Hg over 15 min. The primary outcome was the change in ICP burden over the same 15-min period. Bedside and clinical parameters were then compared between these groups. Twenty-eight patients were enrolled, providing 212 clinical events, of which 60 were deemed significant. Over the first 15 min, 65% were associated with a net negative ICP burden. A greater reduction in ICP burden was observed with events occurring in patients without a history of hypotension at scene (p = 0.016), after three days post-injury (p = 0.0018), and where the pressure-reactivity index (PRx) was <0.25 (p = 0.0005) or the ICP amplitude to CPP correlation coefficient (RAC) was <-0.10 (p = 0.0036) at the initiation of vasopressor changes. The ICP burden in the first 15 min was highly correlated with the next 15-min period. In patients with severe TBI requiring ICP monitoring, increasing MAP to pursue a CPP target was followed by a net negative ICP burden in approximately two-thirds of events. These data suggest a MAP challenge may be a useful adjunct in managing intracranial hypertension.
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Affiliation(s)
- Chien Yew Kow
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Benjamin Harley
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Charles Li
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Phillip Romo
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Panagiota Gkolia
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Kuan-Ying Lu
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Catherine Bell
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Rondhir Jithoo
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jin Tee
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, and Monash University, Clayton, Victoria, Australia
| | - Philip M Lewis
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Electrical and Computer Systems Engineering, Monash University, Clayton, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Hunn
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
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26
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James RH, Doyle CP, Cooper DJ. Descriptive record of the activity of military critical care transfer teams deployed to London in April 2020 to undertake transfer of patients with COVID-19. BMJ Mil Health 2020; 169:e74-e77. [PMID: 33372109 DOI: 10.1136/bmjmilitary-2020-001619] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/12/2020] [Accepted: 11/21/2020] [Indexed: 11/03/2022]
Abstract
In the face of the COVID-19 outbreak, military healthcare teams were deployed to London to assist the London Ambulance Service t transfer ventilated patients between medical facilities. This paper describes the preparation and activity of these military teams, records the lessons identified (LI) and reviews the complications encountered'. The teams each had two members. A consultant or registrar in emergency medicine (EM) and pre-hospitalemergency medicine (PHEM)E or anaesthesia and an emergency nurse or paramedic. Following a period of training, the teams undertook 52 transfers over a 14-day period. LI centred around minimising both interruption to ventilation and risk of aerosolisation of infectious particles and thus the risk of transmission of COVID-19 to the treating clinicians. Three patient-related complications (6% of all transfers) were identified. This was the first occasion on which the Defence Medical Services (DMS) were the main focus of a large-scale clinical military aid to the civil authorities. It demonstrated that DMS personnel have the flexibility to deliver a novel effect and the ability to seamlessly and rapidly integrate with a civilian organisation. It highlighted some clinical lessons that may be useful for future prehospital emergency care taskings where patients may have a transmissible respiratory pathogen. It also showed that clinicians from different backgrounds are able to safely undertake secondary transfer of ventilated patients. This approacmay enhance flexibility in future operational patient care pathways.
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Affiliation(s)
- Robert Hywel James
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Birmingham, UK .,Emergency Department, Derriford Hospital, Plymouth, UK.,Devon Air Ambulance, Exeter, Devon, UK
| | - C P Doyle
- London Ambulance Service NHS Trust, London, UK.,London's Air Ambulance, London, UK
| | - D J Cooper
- Emergency Department, Royal Stoke University Hospital, Stoke-on-Trent, Staffordshire, UK.,Royal Centre for Defence Medicine, Birmingham, Birmingham, UK
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27
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Burrell AJ, Pellegrini B, Salimi F, Begum H, Broadley T, Campbell LT, Cheng AC, Cheung W, Cooper DJ, Earnest A, Erickson SJ, French CJ, Kaldor JM, Litton E, Murthy S, McAllister RE, Nichol AD, Palermo A, Plummer MP, Ramanan M, Reddi BA, Reynolds C, Trapani T, Webb SA, Udy AA. Outcomes for patients with COVID-19 admitted to Australian intensive care units during the first four months of the pandemic. Med J Aust 2020; 214:23-30. [PMID: 33325070 DOI: 10.5694/mja2.50883] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [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: 06/27/2020] [Accepted: 09/15/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe the characteristics and outcomes of patients with COVID-19 admitted to intensive care units (ICUs) during the initial months of the pandemic in Australia. DESIGN, SETTING Prospective, observational cohort study in 77 ICUs across Australia. PARTICIPANTS Patients admitted to participating ICUs with laboratory-confirmed COVID-19 during 27 February - 30 June 2020. MAIN OUTCOME MEASURES ICU mortality and resource use (ICU length of stay, peak bed occupancy). RESULTS The median age of the 204 patients with COVID-19 admitted to intensive care was 63.5 years (IQR, 53-72 years); 140 were men (69%). The most frequent comorbid conditions were obesity (40% of patients), diabetes (28%), hypertension treated with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (24%), and chronic cardiac disease (20%); 73 patients (36%) reported no comorbidity. The most frequent source of infection was overseas travel (114 patients, 56%). Median peak ICU bed occupancy was 14% (IQR, 9-16%). Invasive ventilation was provided for 119 patients (58%). Median length of ICU stay was greater for invasively ventilated patients than for non-ventilated patients (16 days; IQR, 9-28 days v 3 days; IQR, 2-5 days), as was ICU mortality (26 deaths, 22%; 95% CI, 15-31% v four deaths, 5%; 95% CI, 1-12%). Higher Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores on ICU day 1 (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.09-1.21) and chronic cardiac disease (aHR, 3.38; 95% CI, 1.46-7.83) were each associated with higher ICU mortality. CONCLUSION Until the end of June 2020, mortality among patients with COVID-19 who required invasive ventilation in Australian ICUs was lower and their ICU stay longer than reported overseas. Our findings highlight the importance of ensuring adequate local ICU capacity, particularly as the pandemic has not yet ended.
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Affiliation(s)
- Aidan Jc Burrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Breanna Pellegrini
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | - Farhad Salimi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | - Husna Begum
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Tessa Broadley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Lewis T Campbell
- Royal Darwin Hospital, Darwin, NT.,Menzies School of Health Research, Darwin, NT
| | - Allen C Cheng
- The Alfred Hospital, Melbourne, VIC.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | | | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | | | - Craig J French
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,Western Health, Melbourne, VIC
| | - John M Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA.,St John of God Health Care, Perth, WA
| | | | | | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Annamaria Palermo
- Fiona Stanley Hospital, Perth, WA.,St John of God Health Care, Perth, WA
| | | | | | - Benjamin Aj Reddi
- Royal Adelaide Hospital, Adelaide, SA.,The University of Adelaide, Adelaide, SA
| | | | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,St John of God Health Care, Perth, WA
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
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28
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Quine EJ, Murray L, Trapani T, Cooper DJ. Thromboelastography to Assess Coagulopathy in Traumatic Brain Injury Patients Undergoing Therapeutic Hypothermia. Ther Hypothermia Temp Manag 2020; 11:53-57. [PMID: 32833584 DOI: 10.1089/ther.2020.0025] [Citation(s) in RCA: 2] [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: 11/12/2022] Open
Abstract
Therapeutic hypothermia has been a treatment option for patients with severe traumatic brain injury (TBI) for many years. There has, however, been uncertainty whether hypothermia in this context also increased clinical bleeding risk, perhaps due to platelet dysfunction. Standard coagulation tests do not allow accurate assessment of in vivo coagulation. We studied specific coagulation abnormalities in patients undergoing therapeutic hypothermia for severe TBI using bedside thromboelastography (TEG).We studied 20 patients with severe blunt TBI from a single tertiary ICU who were enrolled in the prophylactic hypothermia to lessen traumatic brain injury (POLAR) trial. Ten patients had been randomized to hypothermia, and 10 were controls receiving normothermic standard care. TEG was undertaken during and after therapeutic hypothermia, and at the same time points in controls. Coagulation profiles were then compared between the hypothermic and control patients, and also between hypothermia and later normothermia in the study patients. Patients were primarily young (mean age 34 years) and male (85%). Measures of injury severity, including Glasgow coma score and injury severity scale, were not different between groups. Using TEG, the median alpha angle was reduced in hypothermic patients compared with controls (69.2° vs. 72.0°, p = 0.02), although both were within the normal range. LY30 was also reduced (0.0% vs. 0.5%, p < 0.01). Both differences persisted when hypothermic patients were compared with themselves during later normothermia. Therapeutic hypothermia during severe TBI causes a small decrease in the rate of clot formation. However, this decrease is within the normal range, and is unlikely to be clinically significant.
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Affiliation(s)
- Edward J Quine
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Lynnette Murray
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.,Department of Intensive Care, Alfred Health, Melbourne, Australia
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29
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Maiden MJ, Cameron PA, Rosenfeld JV, Cooper DJ, McLellan S, Gabbe BJ. Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study. Am J Respir Crit Care Med 2020; 201:167-177. [PMID: 31657946 DOI: 10.1164/rccm.201903-0673oc] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [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: 12/11/2022] Open
Abstract
Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.
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Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Barwon Health, Geelong, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Peter A Cameron
- Emergency and Trauma Centre.,School of Public Health and Preventive Medicine and
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, and.,Department of Surgery, Monash University, Melbourne, Australia.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and
| | - D James Cooper
- Intensive Care Unit, The Alfred Hospital, Prahran, Australia.,School of Public Health and Preventive Medicine and
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine and.,Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
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30
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Hodgson CL, Cooper DJ, Arabi Y, King V, Bersten A, Bihari S, Brickell K, Davies A, Fahey C, Fraser J, McGuinness S, Murray L, Parke R, Paul E, Tuxen D, Vallance S, Young M, Nichol A. Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial. Am J Respir Crit Care Med 2020; 200:1363-1372. [PMID: 31356105 DOI: 10.1164/rccm.201901-0109oc] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Rationale: Open lung ventilation strategies have been recommended in patients with acute respiratory distress syndrome (ARDS).Objectives: To determine whether a maximal lung recruitment strategy reduces ventilator-free days in patients with ARDS.Methods: A phase II, multicenter randomized controlled trial in adults with moderate to severe ARDS. Patients received maximal lung recruitment, titrated positive end expiratory pressure and further Vt limitation, or control "protective" ventilation.Measurements and Main Results: The primary outcome was ventilator-free days at Day 28. Secondary outcomes included mortality, barotrauma, new use of hypoxemic adjuvant therapies, and ICU and hospital stay. Enrollment halted October 2, 2017, after publication of ART (Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial), when 115 of a planned 340 patients had been randomized (57% male; mean age, 53.6 yr). At 28 days after randomization, there was no difference between the maximal lung recruitment and control ventilation strategies in ventilator-free days (median, 16 d [interquartile range (IQR), 0-21 d], n = 57, vs. 14.5 d [IQR, 0-21.5 d], n = 56; P = 0.95), mortality (24.6% [n = 14/56] vs. 26.8% [n = 15/56]; P = 0.79), or the rate of barotrauma (5.2% [n = 3/57] vs. 10.7% [n = 6/56]; P = 0.32). However, the intervention group showed reduced use of new hypoxemic adjuvant therapies (i.e., inhaled nitric oxide, extracorporeal membrane oxygenation, prone; median change from baseline 0 [IQR, 0-1] vs. 1 [IQR, 0-1]; P = 0.004) and increased rates of new cardiac arrhythmia (n = 17 [29%] vs. n = 7 [13%]; P = 0.03).Conclusions: Compared with control ventilation, maximal lung recruitment did not reduce the duration of ventilation-free days or mortality and was associated with increased cardiovascular adverse events but lower use of hypoxemic adjuvant therapies.Clinical trial registered with www.clinicaltrials.gov (NCT01667146).
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Affiliation(s)
- Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,Intensive Care Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Yaseen Arabi
- King Saud bin Abdulaziz University for Health Sciences and.,King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Victoria King
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Bersten
- Intensive Care Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Shailesh Bihari
- Intensive Care Department, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Kathy Brickell
- University College Dublin Clinical Research Centre, St. Vincent's University Hospital, Dublin, Ireland
| | - Andrew Davies
- Intensive Care Department, Frankston Hospital, Frankston, Victoria, Australia
| | - Ciara Fahey
- University College Dublin Clinical Research Centre, St. Vincent's University Hospital, Dublin, Ireland
| | - John Fraser
- Intensive Care Department, Prince Charles Hospital, Chermside, Queensland, Australia
| | - Shay McGuinness
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand; and
| | - Lynne Murray
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand; and
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - David Tuxen
- Intensive Care Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Shirley Vallance
- Intensive Care Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Meredith Young
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia.,University College Dublin Clinical Research Centre, St. Vincent's University Hospital, Dublin, Ireland.,Intensive Care Department, Alfred Hospital, Melbourne, Victoria, Australia
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31
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Affiliation(s)
- Zoe K McQuilten
- Transfusion Research Unit, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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32
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Harrois A, Anstey JR, Taccone FS, Udy AA, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle JR, Ercole A, Oddo M, Schneider A, van der Jagt M, Wolf S, Helbok R, Nelson DW, Skrifvars MB, Cooper DJ, Bellomo R. Correction to: Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study. Ann Intensive Care 2019; 9:136. [PMID: 31802308 PMCID: PMC6892991 DOI: 10.1186/s13613-019-0610-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- A Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia. .,Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France.
| | - J R Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - F S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - A A Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - G Citerio
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - J Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - C Ichai
- Université Côte d'Azur, Centre hospitalier Universitaire de Nice, Service de Réanimation Polyvalente, Hôpital Pasteur 2, Nice, France
| | - R Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - J R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - A Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - A Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - M van der Jagt
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - S Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - R Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - D W Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - M B Skrifvars
- Division of Intensive Care, Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - D J Cooper
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - R Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,School of Medicine, University of Melbourne, Melbourne, Australia
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33
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Harrois A, Anstey JR, Taccone FS, Udy AA, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle JR, Ercole A, Oddo M, Schneider A, van der Jagt M, Wolf S, Helbok R, Nelson DW, Skrifvars MB, Cooper DJ, Bellomo R. Serum sodium and intracranial pressure changes after desmopressin therapy in severe traumatic brain injury patients: a multi-centre cohort study. Ann Intensive Care 2019; 9:99. [PMID: 31486921 PMCID: PMC6728106 DOI: 10.1186/s13613-019-0574-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2019] [Accepted: 08/26/2019] [Indexed: 12/24/2022] Open
Abstract
Background In traumatic brain injury (TBI) patients desmopressin administration may induce rapid decreases in serum sodium and increase intracranial pressure (ICP). Aim In an international multi-centre study, we aimed to report changes in serum sodium and ICP after desmopressin administration in TBI patients. Methods We obtained data from 14 neurotrauma ICUs in Europe, Australia and UK for severe TBI patients (GCS ≤ 8) requiring ICP monitoring. We identified patients who received any desmopressin and recorded daily dose, 6-hourly serum sodium, and 6-hourly ICP. Results We studied 262 severe TBI patients. Of these, 39 patients (14.9%) received desmopressin. Median length of treatment with desmopressin was 1 [1–3] day and daily intravenous dose varied between centres from 0.125 to 10 mcg. The median hourly rate of decrease in serum sodium was low (− 0.1 [− 0.2 to 0.0] mmol/L/h) with a median period of decrease of 36 h. The proportion of 6-h periods in which the rate of natremia correction exceeded 0.5 mmol/L/h or 1 mmol/L/h was low, at 8% and 3%, respectively, and ICPs remained stable. After adjusting for IMPACT score and injury severity score, desmopressin administration was independently associated with increased 60-day mortality [HR of 1.83 (1.05–3.24) (p = 0.03)]. Conclusions In severe TBI, desmopressin administration, potentially representing instances of diabetes insipidus is common and is independently associated with increased mortality. Desmopressin doses vary markedly among ICUs; however, the associated decrease in natremia rarely exceeds recommended rates and median ICP values remain unchanged. These findings support the notion that desmopressin therapy is safe.
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Affiliation(s)
- A Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia. .,Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France.
| | - J R Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - F S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - A A Udy
- Intensive Care Unit, The Alfred Hospital, Melbourne, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - G Citerio
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerardo Hospital, ASST-Monza, Monza, Italy
| | - J Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, APHP, Université Paris Sud, 78 Rue du Général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - C Ichai
- Université Côte d'Azur, Centre hospitalier Universitaire de Nice, Service de Réanimation Polyvalente, Hôpital Pasteur 2, Nice, France
| | - R Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - J R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - A Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - M Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - A Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Centre Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - M van der Jagt
- Department of Intensive Care, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - S Wolf
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - R Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - D W Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - M B Skrifvars
- Division of Intensive Care, Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - D J Cooper
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - R Bellomo
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Health, Melbourne, VIC, Australia.,School of Medicine, University of Melbourne, Melbourne, Australia
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Freeman AI, Widdowson S, Murphy C, Cooper DJ. Economic assessment of aerated constructed treatment wetlands using whole life costing. Water Sci Technol 2019; 80:75-85. [PMID: 31461424 DOI: 10.2166/wst.2019.246] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
There is increasing pressure on water treatment practitioners to demonstrate and deliver best value and sustainability for the end user. The aim of this paper is to evaluate the sustainability and economics, using whole life costing, of wastewater treatment technologies used in small community wastewater treatment works (WwTW) of <2,000 population equivalent (PE). Three comparable wastewater treatment technologies - a saturated vertical flow (SVF) aerated wetland, a submerged aerated filter (SAF) and a rotating biological contactor (RBC) - were compared using whole life cost (WLC) assessment. The study demonstrates that the CAPEX of a technology or asset is only a small proportion of the WLC throughout its operational life. For example, the CAPEX of the SVF aerated wetland scenario presented here is up to 74% (mean = 66 ± 6%) less than the cumulative WLC throughout a 40-year operational time scale, which demonstrates that when comparing technology economics, the most cost-effective solution is one that considers both CAPEX and OPEX. The WLC assessment results indicate that over 40 years, the SVF aerated wetland and RBC technologies have comparable net present value (NPV) WLCs which are significantly below those identified for submerged aerated filter systems (SAF) for treatment of wastewater from communities of <1,000PE. For systems designed to treat wastewater from communities of >1,000PE, the SVF aerated wetland was more economical over 40 years, followed by the RBC and then the SAF. The aerated wetland technology can therefore potentially deliver long-term cost benefits and reduced payback periods compared to alternative treatment technologies for treating wastewater from small communities.
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Affiliation(s)
- A I Freeman
- ARM Group Limited, Rydal House, Colton Rd, Rugeley, Staffordshire, WS15 3HF, United Kingdom E-mail:
| | - S Widdowson
- ARM Group Limited, Rydal House, Colton Rd, Rugeley, Staffordshire, WS15 3HF, United Kingdom E-mail:
| | - C Murphy
- ARM Group Limited, Rydal House, Colton Rd, Rugeley, Staffordshire, WS15 3HF, United Kingdom E-mail:
| | - D J Cooper
- ARM Group Limited, Rydal House, Colton Rd, Rugeley, Staffordshire, WS15 3HF, United Kingdom E-mail:
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Burrell AJC, Bennett V, Serra AL, Pellegrino VA, Romero L, Fan E, Brodie D, Cooper DJ, Kaye DM, Fraser JF, Hodgson CL. Venoarterial extracorporeal membrane oxygenation: A systematic review of selection criteria, outcome measures and definitions of complications. J Crit Care 2019; 53:32-37. [PMID: 31181462 DOI: 10.1016/j.jcrc.2019.05.011] [Citation(s) in RCA: 15] [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: 11/10/2018] [Revised: 04/28/2019] [Accepted: 05/22/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE The purpose of this study was to systematically investigate the reporting of selection criteria and outcome measures, and to examine definitions of complications used in venoarterial extracorporeal membrane oxygenation studies (V-A ECMO). MATERIALS AND METHODS Medline, EMBASE and the Cochrane central register were searched for V-A ECMO studies from January 2005 to July 2017. Studies with ≤99 patients or without patient centered outcomes were excluded. Two reviewers independently assessed search results and undertook data extraction. RESULTS Forty-six studies met the inclusion criteria, and all were retrospective, observational studies. Inconsistent reporting of selection criteria, ECMO management and outcome measures was common. In-hospital mortality was the most common primary outcome (41% of studies), followed by 30-day mortality (11%). Bleeding was the most frequent complication reported, most commonly defined as "bleeding requiring transfusion" (median ≥ 2 Units/day). Significant variation in reporting and definitions was also evident for vascular, neurological renal and infectious complications. CONCLUSION This systematic review provides clinicians with the most commonly reported selection criteria, outcome measures and complications used in ECMO practice. However non-standardized definitions and inconsistent reporting limits their ability to inform practice. New consensus driven definitions of complications and patient centred outcomes are urgently needed.
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Affiliation(s)
- Aidan J C Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Victoria Bennett
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.
| | - Alexis L Serra
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - Vincent A Pellegrino
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Lorena Romero
- The Ian Potter Library, The Alfred Hospital, Melbourne, Australia.
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management, and Evaluation, University of Toronto, Toronto, Canada.
| | - Daniel Brodie
- Division of Pulmonary, Allergy, and Critical Care, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, USA.
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - David M Kaye
- Baker IDI Heart and Diabetes Research Institute, Melbourne, Australia.
| | - John F Fraser
- Critical Care Research Group Adult Intensive Care Service, The Prince Charles Hospital and University of Queensland, Brisbane, Australia
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
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Knott RJ, Harris A, Higgins A, Nichol A, French C, Little L, Haddad S, Presneill J, Arabi Y, Bailey M, Cooper DJ, Duranteau J, Huet O, Mak A, McArthur C, Pettilä V, Skrifvars MB, Vallance S, Varma D, Wills J, Bellomo R. Cost-Effectiveness of Erythropoietin in Traumatic Brain Injury: A Multinational Trial-Based Economic Analysis. J Neurotrauma 2019; 36:2541-2548. [PMID: 30907230 DOI: 10.1089/neu.2018.6229] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [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: 12/26/2022] Open
Abstract
The EPO-TBI multi-national randomized controlled trial found that erythropoietin (EPO), when compared to placebo, did not affect 6-month neurological outcome, but reduced illness severity-adjusted mortality in patients with traumatic brain injury (TBI), making the cost-effectiveness of EPO in TBI uncertain. The current study uses patient-level data from the EPO-TBI trial to evaluate the cost-effectiveness of EPO in patients with moderate or severe TBI from the healthcare payers' perspective. We addressed the issue of transferability in multi-national trials by estimating costs and effects for specific geographical regions of the study (Australia/New Zealand, Europe, and Saudi Arabia). Unadjusted mean quality-adjusted life-years (QALYs; 95% confidence interval [CI]) at 6 months were 0.027 (0.020-0.034; p < 0.001) higher in the EPO group, with an adjusted QALY increment of 0.014 (0.000-0.028; p = 0.04). Mean unadjusted costs (95% CI) were $US5668 (-9191 to -2144; p = 0.002) lower in the treatment group; controlling for baseline IMPACT-TBI score and regional heterogeneity reduced this difference to $2377 (-12,446 to 7693; p = 0.64). For a willingness-to-pay threshold of $US50,000 per QALY, 71.8% of replications were considered cost-effective. Therefore, we did not find evidence that EPO was significantly cost-effective in the treatment of moderate or severe TBI at 6-month follow-up.
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Affiliation(s)
- Rachel J Knott
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia
| | - Anthony Harris
- Centre for Health Economics, Monash Business School, Monash University, Melbourne, Victoria, Australia
| | - Alisa Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,The Alfred, Melbourne, Victoria, Australia.,University College Dublin-Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
| | - Craig French
- Western Health, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Samir Haddad
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Kingdom of Saudi Arabia
| | - Jeffrey Presneill
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,The Alfred, Melbourne, Victoria, Australia.,University of Queensland and Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Yaseen Arabi
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center Riyadh, Kingdom of Saudi Arabia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,The Alfred, Melbourne, Victoria, Australia
| | - Jacques Duranteau
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Assistance Publique des Hopitaux de Paris, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Paris, France
| | - Olivier Huet
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Anaesthesiology and Intensive Care Medicine, CHU La Cavale Blanche, Brest, France
| | - Anne Mak
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,The Alfred, Melbourne, Victoria, Australia
| | - Colin McArthur
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Auckland City Hospital, Auckland, New Zealand
| | - Ville Pettilä
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Shirley Vallance
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,The Alfred, Melbourne, Victoria, Australia
| | | | - Judy Wills
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,The Alfred, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Western Health, Melbourne, Victoria, Australia.,University of Melbourne, Melbourne, Victoria, Australia.,Austin Hospital, Melbourne, Victoria, Australia
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37
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Affiliation(s)
- D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
| | - Colin McArthur
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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Myles PS, Smith JA, Kasza J, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, McGuinness S, Byrne K, Chan MT, Landoni G, Wallace S, Forbes A, Myles P, Smith J, Cooper DJ, Silbert B, McNeil J, Marasco S, Esmore D, Krum H, Tonkin A, Buxton B, Heritier S, Merry A, Liew D, McNeil J, Forbes A, Cooper D, Wallace S, Meehan A, Myles P, Wallace S, Galagher W, Farrington C, Ditoro A, Wutzlhofer L, Story D, Peyton P, Baulch S, Sidiropoulos S, Potgieter D, Baker R, Pesudovs B, O'Loughlin J Wells E, Coutts P, Bolsin S, Osborne C, Ives K, Smith J, Hulley A, Christie-Taylor G, Painter T, Lang S, Mackay H, Cokis C, March S, Bannon P, Wong C, Turner L, Scott D, Silbert B, Said S, Corcoran P, Painter T, de Prinse L, Bussières J, Gagné N, Lamy A, Semelhago L, Chan M, Underwood M, Choi G, Fung B, Landoni G, Lembo R, Monaco F, Simeone F, Marianello D, Alvaro G, De Vuono G, van Dijk D, Dieleman J, Numan S, McGuinness S, Parke R, Raudkivi P, Gilder E, Byrne K, Dunning J, Termaat J, Mans G, Jayarajah M, Alderton J, Waugh D, Platt M, Pai A, Sevillano A, Lal A, Sinclair C, Kunst G, Knighton A, Cubas G, Saravanan P, Millner R, Vasudevan V, Patteril M, Lopez E, Basu R, Lu J. Tranexamic acid in coronary artery surgery: One-year results of the Aspirin and Tranexamic Acid for Coronary Artery Surgery (ATACAS) trial. J Thorac Cardiovasc Surg 2019; 157:644-652.e9. [DOI: 10.1016/j.jtcvs.2018.09.113] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 09/13/2018] [Accepted: 09/27/2018] [Indexed: 11/30/2022]
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Cooper DJ, Nichol AD, Bailey M, Bernard S, Cameron PA, Pili-Floury S, Forbes A, Gantner D, Higgins AM, Huet O, Kasza J, Murray L, Newby L, Presneill JJ, Rashford S, Rosenfeld JV, Stephenson M, Vallance S, Varma D, Webb SAR, Trapani T, McArthur C. Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial. JAMA 2018; 320:2211-2220. [PMID: 30357266 PMCID: PMC6583488 DOI: 10.1001/jama.2018.17075] [Citation(s) in RCA: 156] [Impact Index Per Article: 26.0] [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: 12/12/2022]
Abstract
IMPORTANCE After severe traumatic brain injury, induction of prophylactic hypothermia has been suggested to be neuroprotective and improve long-term neurologic outcomes. OBJECTIVE To determine the effectiveness of early prophylactic hypothermia compared with normothermic management of patients after severe traumatic brain injury. DESIGN, SETTING, AND PARTICIPANTS The Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury-Randomized Clinical Trial (POLAR-RCT) was a multicenter randomized trial in 6 countries that recruited 511 patients both out-of-hospital and in emergency departments after severe traumatic brain injury. The first patient was enrolled on December 5, 2010, and the last on November 10, 2017. The final date of follow-up was May 15, 2018. INTERVENTIONS There were 266 patients randomized to the prophylactic hypothermia group and 245 to normothermic management. Prophylactic hypothermia targeted the early induction of hypothermia (33°C-35°C) for at least 72 hours and up to 7 days if intracranial pressures were elevated, followed by gradual rewarming. Normothermia targeted 37°C, using surface-cooling wraps when required. Temperature was managed in both groups for 7 days. All other care was at the discretion of the treating physician. MAIN OUTCOMES AND MEASURES The primary outcome was favorable neurologic outcomes or independent living (Glasgow Outcome Scale-Extended score, 5-8 [scale range, 1-8]) obtained by blinded assessors 6 months after injury. RESULTS Among 511 patients who were randomized, 500 provided ongoing consent (mean age, 34.5 years [SD, 13.4]; 402 men [80.2%]) and 466 completed the primary outcome evaluation. Hypothermia was initiated rapidly after injury (median, 1.8 hours [IQR, 1.0-2.7 hours]) and rewarming occurred slowly (median, 22.5 hours [IQR, 16-27 hours]). Favorable outcomes (Glasgow Outcome Scale-Extended score, 5-8) at 6 months occurred in 117 patients (48.8%) in the hypothermia group and 111 (49.1%) in the normothermia group (risk difference, 0.4% [95% CI, -9.4% to 8.7%]; relative risk with hypothermia, 0.99 [95% CI, 0.82-1.19]; P = .94). In the hypothermia and normothermia groups, the rates of pneumonia were 55.0% vs 51.3%, respectively, and rates of increased intracranial bleeding were 18.1% vs 15.4%, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe traumatic brain injury, early prophylactic hypothermia compared with normothermia did not improve neurologic outcomes at 6 months. These findings do not support the use of early prophylactic hypothermia for patients with severe traumatic brain injury. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235.
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Affiliation(s)
- D. James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Departments of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Alistair D. Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Departments of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Irish Critical Care Clinical Trials Network, University College Dublin-Clinical Research Centre at St Vincent’s University Hospital, Dublin, Ireland
- Department of Anaesthesia and Intensive Care Medicine, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Stephen Bernard
- Departments of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Peter A. Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre of Excellence in Traumatic Brain Injury Research, Monash University, Melbourne, Victoria, Australia
- Emergency Medicine, Hamad Medical Corporation, Dhueta, Qatar
- Emergency and Trauma Centre, Alfred Hospital, Melbourne, Victoria, Australia
| | - Sébastien Pili-Floury
- Service de Réanimation Chirurgicale, Pôle d'Anesthésie et Réanimation Chirurgicale, Centre Hospitalier Universitaire de Besancon, Besançon, France
| | - Andrew Forbes
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Dashiell Gantner
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Departments of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre of Excellence in Traumatic Brain Injury Research, Monash University, Melbourne, Victoria, Australia
| | - Alisa M. Higgins
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Olivier Huet
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Anaesthesia and Intensive Care Medicine, Hôpital de La Cavale Blanche, CHRU de Brest, Brest, France
- UFR de médecine et des sciences de la santé, Université de Bretagne Occidenta, Brest, France
| | - Jessica Kasza
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lynne Murray
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Lynette Newby
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Jeffrey J. Presneill
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Medicine, University of Melbourne, Melbourne, Victoria, Australia
| | | | - Jeffrey V. Rosenfeld
- Neurosurgery, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland
| | - Michael Stephenson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Ambulance Victoria, Melbourne, Victoria, Australia
| | - Shirley Vallance
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Departments of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Dinesh Varma
- Department of Surgery, Monash University, Melbourne, Victoria, Australia
- Radiology, Alfred Hospital, Melbourne, Victoria, Australia
| | - Steven A. R. Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, Royal Perth Hospital, Perth, Western Australia, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Departments of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Colin McArthur
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
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40
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Myles PS, Smith JA, Kasza J, Silbert B, Jayarajah M, Painter T, Cooper DJ, Marasco S, McNeil J, Bussières JS, McGuinness S, Chan MTV, Wallace S, Forbes A. Aspirin in coronary artery surgery: 1-year results of the Aspirin and Tranexamic Acid for Coronary Artery Surgery trial. J Thorac Cardiovasc Surg 2018; 157:633-640. [PMID: 30401528 DOI: 10.1016/j.jtcvs.2018.08.114] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 07/07/2018] [Accepted: 08/21/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Aspirin may reduce the risk of vascular graft thrombosis after cardiovascular surgery. We previously reported the 30-day results of a trial evaluating aspirin use before coronary artery surgery. Here we report the 1-year outcomes evaluating late thrombotic events and disability-free survival. METHODS Using a factorial design, we randomly assigned patients undergoing coronary artery surgery to receive aspirin or placebo and tranexamic acid or placebo. The results of the aspirin comparison are reported here. The primary 1-year outcome was death or severe disability, the latter defined as living with a modified Katz activities of daily living score < 8. Secondary outcomes included a composite of myocardial infarction, stroke and death from any cause through to 1 year after surgery. RESULTS Patients were randomly assigned to aspirin (1059 patients) or placebo (1068 patients). The rate of death or severe disability was 4.1% in the aspirin group and 3.5% in the placebo group (relative risk, 1.17; 95% confidence interval, 0.76-1.81; P = .48). There was no significant difference in the rates of myocardial infarction (P = .11), stroke (P = .086), or death (P = .24), or a composite of these cardiovascular end points (P = .68). With the exception of those with a low European System for Cardiac Operative Risk Evaluation score (P = .03), there were no interaction effects on these outcomes with tranexamic acid (all tests of interaction P > .10). CONCLUSIONS In patients undergoing coronary artery surgery, preoperative aspirin did not reduce death or severe disability, or thrombotic events through to 1 year after surgery.
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Affiliation(s)
- Paul S Myles
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia.
| | - Julian A Smith
- Monash University, Melbourne, Australia; Monash Medical Centre, Clayton, Australia
| | | | | | | | - Thomas Painter
- Royal Adelaide Hospital and Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - D James Cooper
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | - Silvana Marasco
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
| | | | - Jean S Bussières
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Quebec, Canada
| | | | | | - Sophie Wallace
- Alfred Hospital, Melbourne, Australia; Monash University, Melbourne, Australia
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Cohen AT, Phillips MJ, Edmondson RA, Skinner JA, Das SK, Cooper DJ, Thomas EM, Melissari E, Kakkar VV. A Dose Ranging Study to Evaluate Dermatan Sulphate in Preventing Deep Vein Thrombosis following Total Hip Arthroplasty. Thromb Haemost 2018. [DOI: 10.1055/s-0038-1648963] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
SummaryDermatan sulphate catalyses thrombin inhibition by heparin cofactor II; it has a lower haemorrhagic to antithrombotic ratio than that of heparin in animal models. Consecutive patients aged forty years or more, electively undergoing total hip replacement under general anaesthesia, were randomly allocated to one of three dosage regimens of dermatan sulphate (MF701, Mediolanum Farmaceutici) given intramuscularly. These were 200 mg once daily (n = 50), 200 mg twice daily (n = 52) and 300 mg twice daily (n = 51), administered from twenty-four hours pre-operatively until the tenth postoperative day. The overall incidence of DVT assessed by bilateral venography was 53%, 51% and 34% respectively (Chi-square test for trend p = 0.06). The incidence of major proximal DVT was 10.6%, 8.5% and 2.1% respectively. Pulmonary embolism (PE) and bleeding were assessed in all 153 patients. There was one case of PE in each dose group. The incidence of bleeding episodes, volume of blood lost and blood transfusion requirements were low and showed no increase with increasing dose. The patients were followed up 4-8 weeks after discharge.We conclude that the two lower doses were subtherapeutic in this population, however dermatan sulphate given 300 mg twice daily, proved to be efficacious with an incidence of proximal major DVT of 2.1% and a low incidence of bleeding complications. A trial of dermatan sulphate 300 mg twice daily compared to standard prophylactic agents is needed.
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Affiliation(s)
- A T Cohen
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - M J Phillips
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - R A Edmondson
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - J A Skinner
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - S K Das
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - D J Cooper
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - E M Thomas
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - E Melissari
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
| | - V V Kakkar
- The Thrombosis Research Institute, Emmanuel Kaye Building, London, UK
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Ridley EJ, Parke RL, Davies AR, Bailey M, Hodgson C, Deane AM, McGuinness S, Cooper DJ. What Happens to Nutrition Intake in the Post-Intensive Care Unit Hospitalization Period? An Observational Cohort Study in Critically Ill Adults. JPEN J Parenter Enteral Nutr 2018; 43:88-95. [PMID: 29924393 DOI: 10.1002/jpen.1196] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 04/01/2018] [Accepted: 04/12/2018] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little is currently known about nutrition intake and energy requirements in the post-intensive care unit (ICU) hospitalization period in critically ill patients. We aimed to describe energy and protein intake, and determine the feasibility of measuring energy expenditure during the post-ICU hospitalization period in critically ill adults. METHODS This is a nested cohort study within a randomized controlled trial in critically ill patients. After discharge from ICU, energy and protein intake was quantified periodically and indirect calorimetry attempted. Data are presented as n (%), mean (SD), and median (interquartile range [IQR]). RESULTS Thirty-two patients were studied in the post-ICU hospitalization period, and 12 had indirect calorimetry. Mean age and BMI was 56 (18) years and 30 (8) kg/m2 , respectively, 75% were male, and the median estimated energy and protein requirement were 2000 [1650-2550] kcal and 112 [84-129] g, respectively. Oral nutrition either alone (n = 124 days, 55%) or in combination with enteral nutrition (n = 96 days, 42%) was the predominant mode. Over 227 total days in the post-ICU hospitalization period, a median [IQR] of 1238 [869-1813] kcal and 60 [35-89.5] g of protein was received from nutrition therapy. In the 12 patients who had indirect calorimetry, the median measured daily energy requirement was 1982 [1843-2345] kcal and daily energy deficit was -95 [-1050 to 347] kcal compared with the measured energy requirement. CONCLUSIONS Energy and protein intake in the post-ICU hospitalization period was less than estimated and measured energy requirements. Oral nutrition provided alone was the most common mode of nutrition therapy.
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Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Nutrition Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Rachael L Parke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, New Zealand
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Physiotherapy Department, Alfred Health, Melbourne, Victoria, Australia
| | - Adam M Deane
- Intensive Care Unit, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
- Faculty of Medical and Health Sciences, University of Auckland, Grafton, Auckland, New Zealand
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Melbourne, Victoria, Australia
- Intensive Care Unit, The Alfred Hospital, Melbourne, Victoria, Australia
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Presneill J, Gantner D, Nichol A, McArthur C, Forbes A, Kasza J, Trapani T, Murray L, Bernard S, Cameron P, Capellier G, Huet O, Newby L, Rashford S, Rosenfeld JV, Smith T, Stephenson M, Varma D, Vallance S, Walker T, Webb S, James Cooper D. Statistical analysis plan for the POLAR-RCT: The Prophylactic hypOthermia trial to Lessen trAumatic bRain injury-Randomised Controlled Trial. Trials 2018; 19:259. [PMID: 29703266 PMCID: PMC5923032 DOI: 10.1186/s13063-018-2610-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Accepted: 03/27/2018] [Indexed: 01/10/2023] Open
Abstract
Background The Prophylactic hypOthermia to Lessen trAumatic bRain injury-Randomised Controlled Trial (POLAR-RCT) will evaluate whether early and sustained prophylactic hypothermia delivered to patients with severe traumatic brain injury improves patient-centred outcomes. Methods The POLAR-RCT is a multicentre, randomised, parallel group, phase III trial of early, prophylactic cooling in critically ill patients with severe traumatic brain injury, conducted in Australia, New Zealand, France, Switzerland, Saudi Arabia and Qatar. A total of 511 patients aged 18–60 years have been enrolled with severe acute traumatic brain injury. The trial intervention of early and sustained prophylactic hypothermia to 33 °C for 72 h will be compared to standard normothermia maintained at a core temperature of 37 °C. The primary outcome is the proportion of favourable neurological outcomes, comprising good recovery or moderate disability, observed at six months following randomisation utilising a midpoint dichotomisation of the Extended Glasgow Outcome Scale (GOSE). Secondary outcomes, also assessed at six months following randomisation, include the probability of an equal or greater GOSE level, mortality, the proportions of patients with haemorrhage or infection, as well as assessment of quality of life and health economic outcomes. The planned sample size will allow 80% power to detect a 30% relative risk increase from 50% to 65% (equivalent to a 15% absolute risk increase) in favourable neurological outcome at a two-sided alpha of 0.05. Discussion Consistent with international guidelines, a detailed and prospective analysis plan has been developed for the POLAR-RCT. This plan specifies the statistical models for evaluation of primary and secondary outcomes, as well as defining covariates for adjusted analyses and methods for exploratory analyses. Application of this statistical analysis plan to the forthcoming POLAR-RCT trial will facilitate unbiased analyses of these important clinical data. Trial registration ClinicalTrials.gov, NCT00987688 (first posted 1 October 2009); Australian New Zealand Clinical Trials Registry, ACTRN12609000764235. Registered on 3 September 2009. Electronic supplementary material The online version of this article (10.1186/s13063-018-2610-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeffrey Presneill
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia.,Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Dashiell Gantner
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Department of Intensive Care, The Alfred, Melbourne, Australia
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Department of Intensive Care, The Alfred, Melbourne, Australia.,Department of Anaesthesia and Intensive Care Medicine, St Vincent's University Hospital, Dublin, Ireland.,School of Medicine and Medical Sciences, University College, Dublin, Ireland
| | - Colin McArthur
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Andrew Forbes
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia
| | - Jessica Kasza
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Department of Intensive Care, The Alfred, Melbourne, Australia
| | - Lynnette Murray
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia
| | - Stephen Bernard
- Department of Intensive Care, The Alfred, Melbourne, Australia.,Ambulance Victoria, Melbourne, Australia
| | - Peter Cameron
- Centre of Excellence in Traumatic Brain Injury Research, The Alfred, Monash University, Melbourne, Australia.,Emergency Medicine, Hamad Medical Corporation, Doha, Qatar.,Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Gilles Capellier
- Réanimation médicale CHRU Jean Minjoz, Besançon, France.,Université de Franche - Comte, 1 Rue Claude Goudimel, Besançon, 25030, France
| | - Olivier Huet
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Department of Anaesthesia and Intensive Care Medicine, Hôpital de La Cavale Blanche, CHRU de Brest, Brest, France.,UFR de médecine et des sciences de la santé, Université de Bretagne Occidental, Brest, France
| | - Lynette Newby
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | | | - Jeffrey V Rosenfeld
- Department of Surgery, Monash University, Melbourne, Australia.,Department of Neurosurgery, The Alfred Hospital, Melbourne, Australia.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of The Health Sciences (USUHS), Bethesda, MD, USA
| | - Tony Smith
- St John New Zealand, Auckland, New Zealand.,Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Michael Stephenson
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Ambulance Victoria, Melbourne, Australia
| | - Dinesh Varma
- Department of Radiology, The Alfred Hospital, Melbourne, Australia.,Department of Surgery, Monash University, Melbourne, Australia
| | - Shirley Vallance
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Department of Intensive Care, The Alfred, Melbourne, Australia
| | | | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia.,Intensive Care Unit, Royal Perth Hospital, Perth, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, School of Public Health and Preventive Medicine, 99 Commercial Road, Melbourne, 3004, Australia. .,Department of Intensive Care, The Alfred, Melbourne, Australia.
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Kaukonen KM, Bailey M, Pilcher D, Cooper DJ, Bellomo R. The systemic inflammatory response syndrome criteria and their differential association with mortality. J Crit Care 2018; 46:29-36. [PMID: 29660669 DOI: 10.1016/j.jcrc.2018.04.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/31/2018] [Accepted: 04/03/2018] [Indexed: 11/19/2022]
Abstract
PURPOSE Despite the recent Sepsis-3 consensus, the Systemic Inflammatory Response Syndrome (SIRS) criteria continue to be assessed and recommended. Such use implies equivalence and interchangeability of criteria. Thus, we aimed to test whether such criteria are indeed equivalent and interchangeable. MATERIALS AND METHODS From 2000 to 2015, we identified patients with infection, organ failure, and at least one SIRS criterion in 179 Intensive Care Units in Australia and New. Zealand. We studied the association of different SIRS criteria with hospital mortality. RESULTS Among 131,016 patients with infection and organ failure, mortality increased from 10.6% for the respiratory rate criterion to 15.8% for the heart rate criterion (P<0.01); from 10.1% for the high leukocyte count criterion to 20.0% for a low count and from 10.1% for a high temperature to 14.4% for a low temperature criterion. With any two SIRS criteria, hospital mortality varied from 11.5% to 30.8% depending on the combination of criteria. This difference remained unchanged after adjustments and was consistent over time. CONCLUSIONS Different individual and combinations of SIRS criteria were associated with marked differences in hospital mortality. These differences remained unchanged after adjustment and over time and imply that individual SIRS criteria are not equivalent or interchangeable.
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Affiliation(s)
- Kirsi-Maija Kaukonen
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Finland.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia; ANZICS Centre for Outcome and Resource Evaluation CORE, Melbourne, Australia.
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Department of Intensive Care, The Alfred Hospital, Melbourne, Australia.
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia; Intensive Care Unit, Austin Health, Heidelberg, Australia.
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45
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Beck B, Gantner D, Cameron PA, Braaf S, Saxena M, Cooper DJ, Gabbe BJ. Temporal Trends in Functional Outcomes after Severe Traumatic Brain Injury: 2006-2015. J Neurotrauma 2018; 35:1021-1029. [PMID: 29256832 DOI: 10.1089/neu.2017.5287] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Severe traumatic brain injury (TBI) is associated with poor outcomes; however, little is known about whether these outcomes are improving over time. This study examined temporal trends in functional outcomes of severe TBI at six months post-injury. We conducted a retrospective cohort study (January 1, 2006 to December 31, 2015) of hospitalized adult (≥16 years) patients with severe TBI using data from the population-based Victorian State Trauma Registry. The primary outcome was the Glasgow Outcome Scale-Extended (GOS-E) at six months post-injury, dichotomized as upper severe disability or worse (GOS-E ≤4, termed "unfavorable outcome") and lower moderate disability or better (GOS-E ≥5; termed "favorable outcome"). Multivariable logistic regression was used to investigate temporal trends in functional outcomes at six months post-injury. Of the 1966 patients with severe TBI who were followed up at six months post-injury (median age, 42 years (interquartile range [IQR]: 25-68); male, 73%), a majority of patients had an unfavorable outcome (GOS-E ≤4; n = 1372, 70%). After adjusting for confounders, there was no change in functional outcomes over time (adjusted odds ratio [AOR] = 1.02, 95% confidence interval [CI]: 0.98,1.06; p = 0.35). Similarly, there was no change in the adjusted odds of death (GOS-E = 1) at six months post-injury (AOR = 1.04, 95% CI: 1.00,1.08; p = 0.08). Using a population-wide, high quality, comprehensive registry, we demonstrated no change in death or functional outcomes after severe TBI between 2006 and 2015 in a mature trauma system. There is a clear need to identify targeted improvements in the treatment of these patients with the aim of reducing in-hospital death and improving long-term outcomes.
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Affiliation(s)
- Ben Beck
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia
| | - Dashiell Gantner
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,3 Department of Intensive Care and Hyperbaric Medicine, The Alfred , Melbourne, Victoria, Australia
| | - Peter A Cameron
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,4 Emergency and Trauma Centre, The Alfred Hospital , Melbourne, Victoria, Australia
| | - Sandra Braaf
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia
| | - Manoj Saxena
- 5 Intensive Care Unit, St George Hospital , Sydney, New South Wales, Australia .,6 Critical Care & Trauma Division, The George Institute for Global Health , University of New South Wales, Sydney, New South Wales, Australia
| | - D James Cooper
- 2 Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,3 Department of Intensive Care and Hyperbaric Medicine, The Alfred , Melbourne, Victoria, Australia
| | - Belinda J Gabbe
- 1 Department of Epidemiology and Preventive Medicine, Monash University , Melbourne, Victoria, Australia .,7 Farr Institute, Swansea University Medical School, Swansea University , Swansea, United Kingdom
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46
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Aubron C, Kandane-Rathnayake RK, Andrianopoulos N, Westbrook A, Engelbrecht S, Ozolins I, Bailey M, Murray L, Cooper DJ, Wood EM, McQuilten ZK. Day or overnight transfusion in critically ill patients: does it matter? Vox Sang 2018; 113:275-282. [PMID: 29392786 DOI: 10.1111/vox.12635] [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: 07/19/2017] [Revised: 12/02/2017] [Accepted: 01/04/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVES The timing of blood administration in critically ill patients is first driven by patients' needs. This study aimed to define the epidemiology and significance of overnight transfusion in critically ill patients. MATERIALS AND METHODS This is a post hoc analysis of a prospective multicentre observational study including 874 critically ill patients receiving red blood cells, platelets, fresh frozen plasma (FFP) or cryoprecipitate. Characteristics of patients receiving blood only during the day (8 am up until 8 pm) were compared to those receiving blood only overnight (8 pm up until 8 am). Characteristics of transfusion were compared, and factors independently associated with major bleeding were analysed. RESULTS The 287 patients transfused during the day only had similar severity and mortality to the 258 receiving blood products overnight only. Although bleeding-related admission diagnoses were similar, major bleeding was the indication for transfusion in 12% of patients transfused in daytime only versus 30% of patients transfused at night only (P < 0·001). Similar total amount of blood products were transfused at day and night (2856 versus 2927); however, patients were more likely to receive FFP and cryoprecipitate at night compared with daytime. Overnight transfusion was independently associated with increased odds of major bleeding (odds ratio, 3·16, 95% confidence interval, 2·00-5·01). CONCLUSION Transfusion occurs evenly across day and night in ICU; nonetheless, there are differences in type of blood products administered that reflect differences in indication. Critically ill patients were more likely to receive blood for major bleeding at night irrespective of admission diagnosis.
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Affiliation(s)
- C Aubron
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Médecine Intensive Réanimation, Brest University Hospital - Université de Bretagne Occidentale, Brest, France
| | - R K Kandane-Rathnayake
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - N Andrianopoulos
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - A Westbrook
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - S Engelbrecht
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - I Ozolins
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - M Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - L Murray
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - D J Cooper
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - E M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Z K McQuilten
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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47
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Ridley EJ, Davies AR, Parke R, Bailey M, McArthur C, Gillanders L, Cooper DJ, McGuinness S. Supplemental parenteral nutrition versus usual care in critically ill adults: a pilot randomized controlled study. Crit Care 2018; 22:12. [PMID: 29361959 PMCID: PMC5781264 DOI: 10.1186/s13054-018-1939-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/21/2017] [Accepted: 01/02/2018] [Indexed: 12/29/2022]
Abstract
Background In the critically ill, energy delivery from enteral nutrition (EN) is often less than the estimated energy requirement. Parenteral nutrition (PN) as a supplement to EN may increase energy delivery. We aimed to determine if an individually titrated supplemental PN strategy commenced 48–72 hours following ICU admission and continued for up to 7 days would increase energy delivery to critically ill adults compared to usual care EN delivery. Methods This study was a prospective, parallel group, phase II pilot trial conducted in six intensive care units in Australia and New Zealand. Mechanically ventilated adults with at least one organ failure and EN delivery below 80% of estimated energy requirement in the previous 24 hours received either a supplemental PN strategy (intervention group) or usual care EN delivery. EN in the usual care group could be supplemented with PN if EN remained insufficient after usual methods to optimise delivery were attempted. Results There were 100 patients included in the study and 99 analysed. Overall, 71% of the study population were male, with a mean (SD) age of 59 (17) years, Acute Physiology and Chronic Health Evaluation II score of 18.2 (6.7) and body mass index of 29.6 (5.8) kg/m2. Significantly greater energy (mean (SD) 1712 (511) calories vs. 1130 (601) calories, p < 0.0001) and proportion of estimated energy requirement (mean (SD) 83 (25) % vs. 53 (29) %, p < 0.0001) from EN and/or PN was delivered to the intervention group compared to usual care. Delivery of protein and proportion of estimated protein requirements were also greater in the intervention group (mean (SD) 86 (25) g, 86 (23) %) compared to usual care (mean (SD) 53 (29) g, 51 (25) %, p < 0.0001). Antibiotic use, ICU and hospital length of stay, mortality and functional outcomes were similar between the two groups. Conclusions This individually titrated supplemental PN strategy applied over 7 days significantly increased energy delivery when compared to usual care delivery. Clinical and functional outcomes were similar between the two patient groups. Trial registration Clinical Trial registry details: NCT01847534 (First registered 22 April 2013, last updated 31 July 2016) Electronic supplementary material The online version of this article (10.1186/s13054-018-1939-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia. .,Nutrition Department, Alfred Health, Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Rachael Parke
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia
| | - Colin McArthur
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| | - Lyn Gillanders
- The Department of Critical Care Medicine, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Nutrition and Dietetics, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Faculty of Medical and Health Sciences, University of Auckland, Park Road, Grafton, Auckland, New Zealand
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Intensive Care Unit, The Alfred Hospital, Commercial Road, Melbourne, VIC, 3004, Australia
| | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventative Medicine, Monash University, Level 3, 553 St Kilda Road, Melbourne, 3004, Australia.,Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
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48
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Skrifvars MB, French C, Bailey M, Presneill J, Nichol A, Little L, Durantea J, Huet O, Haddad S, Arabi Y, McArthur C, Cooper DJ, Bellomo R, for the EPO-TBI Investigators and t. Cause and Timing of Death and Subgroup Differential Effects of Erythropoietin in the EPO-TBI Study. J Neurotrauma 2018; 35:333-340. [DOI: 10.1089/neu.2017.5135] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Markus B. Skrifvars
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University and Helsinki University Hospital, Helsinki, Finland
| | - Craig French
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
- North West Academic Centre, University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeffrey Presneill
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- St Vincent's University Hospital, Dublin, Ireland
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jacques Durantea
- Département d'Anesthésie-Réanimation, Hôpital de Bicêtre, Assistance Publique des Hopitaux de Paris, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Paris, France
| | - Olivier Huet
- Department of Anaesthesiology and Intensive Care Medicine, CHU La Cavale Blanche, Brest, France
| | - Samir Haddad
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Yaseen Arabi
- King Saud Bin Abdulaziz University for Health Sciences and King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
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Cooper DJ, McQuilten ZK, Nichol A, Ady B, Aubron C, Bailey M, Bellomo R, Gantner D, Irving DO, Kaukonen KM, McArthur C, Murray L, Pettilä V, French C. Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults. N Engl J Med 2017; 377:1858-1867. [PMID: 28952891 DOI: 10.1056/nejmoa1707572] [Citation(s) in RCA: 122] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND It is uncertain whether the duration of red-cell storage affects mortality after transfusion among critically ill adults. METHODS In an international, multicenter, randomized, double-blind trial, we assigned critically ill adults to receive either the freshest available, compatible, allogeneic red cells (short-term storage group) or standard-issue (oldest available), compatible, allogeneic red cells (long-term storage group). The primary outcome was 90-day mortality. RESULTS From November 2012 through December 2016, at 59 centers in five countries, 4994 patients underwent randomization and 4919 (98.5%) were included in the primary analysis. Among the 2457 patients in the short-term storage group, the mean storage duration was 11.8 days. Among the 2462 patients in the long-term storage group, the mean storage duration was 22.4 days. At 90 days, there were 610 deaths (24.8%) in the short-term storage group and 594 (24.1%) in the long-term storage group (absolute risk difference, 0.7 percentage points; 95% confidence interval [CI], -1.7 to 3.1; P=0.57). At 180 days, the absolute risk difference was 0.4 percentage points (95% CI, -2.1 to 3.0; P=0.75). Most of the prespecified secondary measures showed no significant between-group differences in outcome. CONCLUSIONS The age of transfused red cells did not affect 90-day mortality among critically ill adults. (Funded by the Australian National Health and Medical Research Council and others; TRANSFUSE Australian and New Zealand Clinical Trials Registry number, ACTRN12612000453886 ; ClinicalTrials.gov number, NCT01638416 .).
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Affiliation(s)
- D James Cooper
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Zoe K McQuilten
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Alistair Nichol
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Bridget Ady
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Cécile Aubron
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Michael Bailey
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Rinaldo Bellomo
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Dashiell Gantner
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - David O Irving
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Kirsi-Maija Kaukonen
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Colin McArthur
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Lynne Murray
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Ville Pettilä
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
| | - Craig French
- From the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (D.J.C., Z.K.M., A.N., B.A., C.A., M.B., R.B., D.G., K.-M.K., L.M., C.F.), the Department of Intensive Care, Alfred Hospital (D.J.C., A.N., D.G.), the Department of Haematology, Monash Health (Z.K.M.), the Department of Intensive Care, Austin Hospital (R.B.), the University of Melbourne (R.B., C.F.), Research and Development, Australian Red Cross Blood Service (D.O.I.), and the Department of Intensive Care, Western Health (C.F.) - all in Melbourne, VIC, Australia; Irish Critical Care Clinical Trials Network, University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin (A.N.); the Département de Médecine Intensive Réanimation, Brest University Hospital, Brest, France (C.A.); the Department of Anesthesiology (K.-M.K.) and the Division of Intensive Care, Department of Anesthesiology (V.P.), Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki; and the Medical Research Institute of New Zealand and the Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand (C.M.)
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McQuilten ZK, Bailey M, Cameron PA, Stanworth SJ, Venardos K, Wood EM, Cooper DJ. Fibrinogen concentration and use of fibrinogen supplementation with cryoprecipitate in patients with critical bleeding receiving massive transfusion: a bi-national cohort study. Br J Haematol 2017; 179:131-141. [PMID: 28653339 DOI: 10.1111/bjh.14804] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [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: 01/31/2017] [Accepted: 05/01/2017] [Indexed: 02/06/2023]
Abstract
We aimed to compare hypofibrinogenaemia prevalence in major bleeding patients across all clinical contexts, fibrinogen supplementation practice, and explore the relationship between fibrinogen concentrations and mortality. This cohort study included all adult patients from 20 hospitals across Australia and New Zealand who received massive transfusion between April 2011 and October 2015. Of 3566 patients, 2829 (79%) had fibrinogen concentration recorded, with a median first and lowest concentration of 2·0 g/l (interquartile range [IQR] 1·5-2·7) and 1·8 g/l (IQR 1·3-2·4), respectively. Liver transplant (1·7 g/l, IQR 1·2-2·1), trauma (1·8, IQR 1·3-2·5) and vascular surgery (1·9 g/l, IQR 1·4-2·5) had lower concentrations. Total median fibrinogen dose administered from all products was 7·3 g (IQR 3·3-13·0). Overall, 1732 (61%) received cryoprecipitate and 9 (<1%) fibrinogen concentrate. Time to cryoprecipitate issue in those with initial fibrinogen concentration <1 g/l was 2·5 h (IQR 1·2-4·3 h). After adjustment, initial fibrinogen concentration had a U-shaped association with in-hospital mortality [adjusted odds ratios: fibrinogen <1 g/l, 2·31 (95% confidence interval (CI) 1·48-3·60); 1-1·9 g/l, 1·29 (95% CI 0·99-1·67) and >4 g/l, 2·03 (95% CI 1·35-3·04), 2-4 g/l reference category]. The findings indicate areas for practice improvement including timely administration of cryoprecipitate, which is the most common source of concentrated fibrinogen in Australia and New Zealand.
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Affiliation(s)
- Zoe K McQuilten
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Peter A Cameron
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Simon J Stanworth
- NHS Blood and Transplant/Oxford University Hospitals NHS Trust, John Radcliffe Hospital, and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Kylie Venardos
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Erica M Wood
- Transfusion Research Unit, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,Monash Health, Melbourne, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
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