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Rai S, Brace C, Ross P, Darvall J, Haines K, Mitchell I, van Haren F, Pilcher D. Characteristics and Outcomes of Very Elderly Patients Admitted to Intensive Care: A Retrospective Multicenter Cohort Analysis. Crit Care Med 2023; 51:1328-1338. [PMID: 37219961 PMCID: PMC10497207 DOI: 10.1097/ccm.0000000000005943] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Abstract
OBJECTIVES To characterize and compare trends in ICU admission, hospital outcomes, and resource utilization for critically ill very elderly patients (≥ 80 yr old) compared with the younger cohort (16-79 yr old). DESIGN A retrospective multicenter cohort study. SETTING One-hundred ninety-four ICUs contributing data to the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database between January 2006 and December 2018. PATIENTS Adult (≥ 16 yr) patients admitted to Australian and New Zealand ICUs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Very elderly patients with a mean ± sd age of 84.8 ± 3.7 years accounted for 14.8% (232,582/1,568,959) of all adult ICU admissions. They had higher comorbid disease burden and illness severity scores compared with the younger cohort. Hospital (15.4% vs 7.8%, p < 0.001) and ICU mortality (8.5% vs 5.2%, p < 0.001) were higher in the very elderly. They stayed fewer days in ICU, but longer in hospital and had more ICU readmissions. Among survivors, a lower proportion of very elderly was discharged home (65.2% vs 82.4%, p < 0.001), and a higher proportion was discharged to chronic care/nursing home facilities (20.1% vs 7.8%, p < 0.001). Although there was no change in the proportion of very elderly ICU admissions over the study period, they showed a greater decline in risk-adjusted mortality (6.3% [95% CI, 5.9%-6.7%] vs 4.0% [95% CI, 3.7%-4.2%] relative reduction per year, p < 0.001) compared with the younger cohort. The mortality of very elderly unplanned ICU admissions improved faster than the younger cohort ( p < 0.001), whereas improvements in mortality among elective surgical ICU admissions were similar in both groups ( p = 0.45). CONCLUSIONS The proportion of ICU admissions greater than or equal to 80 years old did not change over the 13-year study period. Although their mortality was higher, they showed improved survivorship over time, especially in the unplanned ICU admission subgroup. A higher proportion of survivors were discharged to chronic care facilities.
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Affiliation(s)
- Sumeet Rai
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, Canberra Health Services, Garran, Canberra, Australia
| | - Charlotte Brace
- Department of Anaesthesia, Auckland City District Health Board, Auckland, New Zealand
| | - Paul Ross
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, St. Kilda Rd, Prahran, Melbourne, Australia
| | - Jai Darvall
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, Australia
| | - Kimberley Haines
- Department of Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, Australia
- Department of Physiotherapy, Western Health, Melbourne, Australia
| | - Imogen Mitchell
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, Canberra Health Services, Garran, Canberra, Australia
| | - Frank van Haren
- School of Medicine and Psychology, College of Health and Medicine, Australian National University, Acton, Canberra, Australia
- Intensive Care Unit, St George Hospital, Sydney, Australia
| | - David Pilcher
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
- The Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, St. Kilda Rd, Prahran, Melbourne, Australia
- The Australian and New Zealand Intensive Care Society (ANZICS), Centre for Outcome and Resources Evaluation, Camberwell, Melbourne, Australia
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Pham T, Heunks L, Bellani G, Madotto F, Aragao I, Beduneau G, Goligher EC, Grasselli G, Laake JH, Mancebo J, Peñuelas O, Piquilloud L, Pesenti A, Wunsch H, van Haren F, Brochard L, Laffey JG, Acharya SP, Amin P, Arabi Y, Aragao I, Bauer P, Beduneau G, Beitler J, Berkius J, Bugedo G, Camporota L, Cerny V, Cho YJ, Clarkson K, Estenssoro E, Goligher E, Grasselli G, Gritsan A, Hashemian SM, Hermans G, Heunks LM, Jovanovic B, Kurahashi K, Laake JH, Matamis D, Moerer O, Molnar Z, Ozyilmaz E, Panka B, Papali A, Peñuelas Ó, Perbet S, Piquilloud L, Qiu H, Razek AA, Rittayamai N, Roldan R, Serpa Neto A, Szuldrzynski K, Talmor D, Tomescu D, Van Haren F, Villagomez A, Zeggwagh AA, Abe T, Aboshady A, Acampo-de Jong M, Acharya S, Adderley J, Adiguzel N, Agrawal VK, Aguilar G, Aguirre G, Aguirre-Bermeo H, Ahlström B, Akbas T, Akker M, Al Sadeh G, Alamri S, Algaba A, Ali M, Aliberti A, Allegue JM, Alvarez D, Amador J, Andersen FH, Ansari S, Apichatbutr Y, Apostolopoulou O, Arabi Y, Arellano D, Arica M, Arikan H, Arinaga K, Arnal JM, Asano K, Asín-Corrochano M, Avalos Cabrera JM, Avila Fuentes S, Aydemir S, Aygencel G, Azevedo L, Bacakoglu F, Badie J, Baedorf Kassis E, Bai G, Balaraj G, Ballico B, Banner-Goodspeed V, Banwarie P, Barbieri R, Baronia A, Barrett J, Barrot L, Barrueco-Francioni JE, Barry J, Bauer P, Bawangade H, Beavis S, Beck E, Beehre N, Belenguer Muncharaz A, Bellani G, Belliato M, Bellissima A, Beltramelli R, Ben Souissi A, Benitez-Cano A, Benlamin M, Benslama A, Bento L, Benvenuti D, Berkius J, Bernabe L, Bersten A, Berta G, Bertini P, Bertram-Ralph E, Besbes M, Bettini LR, Beuret P, Bewley J, Bezzi M, Bhakhtiani L, Bhandary R, Bhowmick K, Bihari S, Bissett B, Blythe D, Bocher S, Boedjawan N, Bojanowski CM, Boni E, Boraso S, Borelli M, Borello S, Borislavova M, Bosma KJ, Bottiroli M, Boyd O, Bozbay S, Briva A, Brochard L, Bruel C, Bruni A, Buehner U, Bugedo G, Bulpa P, Burt K, Buscot M, Buttera S, Cabrera J, Caccese R, Caironi P, Canchos Gutierrez I, Canedo N, Cani A, Cappellini I, Carazo J, Cardonnet LP, Carpio D, Carriedo D, Carrillo R, Carvalho J, Caser E, Castelli A, Castillo Quintero M, Castro H, Catorze N, Cengiz M, Cereijo E, Ceunen H, Chaintoutis C, Chang Y, Chaparro G, Chapman C, Chau S, Chavez CE, Chelazzi C, Chelly J, Chemouni F, Chen K, Chena A, Chiarandini P, Chilton P, Chiumello D, Cho YJ, Chou-Lie Y, Chudeau N, Cinel I, Cinnella G, Clark M, Clark T, Clarkson K, Clementi S, Coaguila L, Codecido AJ, Collins A, Colombo R, Conde J, Consales G, Cook T, Coppadoro A, Cornejo R, Cortegiani A, Coxo C, Cracchiolo AN, Crespo Ramirez M, Crova P, Cruz J, Cubattoli L, Çukurova Z, Curto F, Czempik P, D'Andrea R, da Silva Ramos F, Dangers L, Danguy des Déserts M, Danin PE, Dantas F, Daubin C, Dawei W, de Haro C, de Jesus Montelongo F, De Mendoza D, de Pablo R, De Pascale G, De Rosa S, Decavèle M, Declercq PL, Deicas A, del Carmen Campos Moreno M, Dellamonica J, Delmas B, Demirkiran O, Demirkiran H, Dendane T, di Mussi R, Diakaki C, Diaz A, Diaz W, Dikmen Y, Dimoula A, Doble P, Doha N, Domingos G, Dres M, Dries D, Duggal A, Duke G, Dunts P, Dybwik K, Dykyy M, Eckert P, Efe S, Elatrous S, Elay G, Elmaryul AS, Elsaadany M, Elsayed H, Elsayed S, Emery M, Ena S, Eng K, Englert JA, Erdogan E, Ergin Ozcan P, Eroglu E, Escobar M, Esen F, Esen Tekeli A, Esquivel A, Esquivel Gallegos H, Ezzouine H, Facchini A, Faheem M, Fanelli V, Farina MF, Fartoukh M, Fehrle L, Feng F, Feng Y, Fernandez I, Fernandez B, Fernandez-Rodriguez ML, Ferrando C, Ferreira da Silva MJ, Ferreruela M, Ferrier J, Flamm Zamorano MJ, Flood L, Floris L, Fluckiger M, Forteza C, Fortunato A, Frans E, Frattari A, Fredes S, Frenzel T, Fumagalli R, Furche MA, Fusari M, Fysh E, Galeas-Lopez JL, Galerneau LM, Garcia A, Garcia MF, Garcia E, Garcia Olivares P, Garlicki J, Garnero A, Garofalo E, Gautam P, Gazenkampf A, Gelinotte S, Gelormini D, Ghrenassia E, Giacomucci A, Giannoni R, Gigante A, Glober N, Gnesin P, Gollo Y, Gomaa D, Gomero Paredes R, Gomes R, Gomez RA, Gomez O, Gomez A, Gondim L, Gonzalez M, Gonzalez I, Gonzalez-Castro A, Gordillo Romero O, Gordo F, Gouin P, Graf Santos J, Grainne R, Grando M, Granov Grabovica S, Grasselli G, Grasso S, Grasso R, Grimmer L, Grissom C, Gritsan A, Gu Q, Guan XD, Guarracino F, Guasch N, Guatteri L, Gueret R, Guérin C, Guerot E, Guitard PG, Gül F, Gumus A, Gurjar M, Gutierrez P, Hachimi A, Hadzibegovic A, Hagan S, Hammel C, Han Song J, Hanlon G, Hashemian SM, Heines S, Henriksson J, Herbrecht JE, Heredia Orbegoso GO, Hermans G, Hermon A, Hernandez R, Hernandez C, Herrera L, Herrera-Gutierrez M, Heunks L, Hidalgo J, Hill D, Holmquist D, Homez M, Hongtao X, Hormis A, Horner D, Hornos MC, Hou M, House S, Housni B, Hugill K, Humphreys S, Humbert L, Hunter S, Hwa Young L, Iezzi N, Ilutovich S, Inal V, Innes R, Ioannides P, Iotti GA, Ippolito M, Irie H, Iriyama H, Itagaki T, Izura J, Izza S, Jabeen R, Jamaati H, Jamadarkhana S, Jamoussi A, Jankowski M, Jaramillo LA, Jeon K, Jeong Lee S, Jeswani D, Jha S, Jiang L, Jing C, Jochmans S, Johnstad BA, Jongmin L, Joret A, Jovanovic B, Junhasavasdikul D, Jurado MT, Kam E, Kamohara H, Kane C, Kara I, Karakurt S, Karnjanarachata C, Kataoka J, Katayama S, Kaushik S, Kelebek Girgin N, Kerr K, Kerslake I, Khairnar P, Khalid A, Khan A, Khanna AK, Khorasanee R, Kienhorst D, Kirakli C, Knafelj R, Kol MK, Kongpolprom N, Kopitko C, Korkmaz Ekren P, Kubisz-Pudelko A, Kulcsar Z, Kumasawa J, Kurahashi K, Kuriyama A, Kutchak F, Laake JH, Labarca E, Labat F, Laborda C, Laca Barrera MA, Lagache L, Landaverde Lopez A, Lanspa M, Lascari V, Le Meur M, Lee SH, Lee YJ, Lee J, Lee WY, Lee J, Legernaes T, Leiner T, Lemiale V, Leonor T, Lepper PM, Li D, Li H, Li O, Lima AR, Lind D, Litton E, Liu N, Liu L, Liu J, Llitjos JF, Llorente B, Lopez R, Lopez CE, Lopez Nava C, Lovazzano P, Lu M, Lucchese F, Lugano M, Lugo Goytia G, Luo H, Lynch C, Macheda S, Madrigal Robles VH, Maggiore SM, Magret Iglesias M, Malaga P, Mallapura Maheswarappa H, Malpartida G, Malyarchikov A, Mansson H, Manzano A, Marey I, Marin N, Marin MDC, Markman E, Martin F, Martin A, Martin Dal Gesso C, Martinez F, Martínez-Fidalgo C, Martin-Loeches I, Mas A, Masaaki S, Maseda E, Massa E, Mattsson A, Maugeri J, McCredie V, McCullough J, McGuinness S, McKown A, Medve L, Mei C, Mellado Artigas R, Mendes V, Mervat MKE, Michaux I, Mikhaeil M, Milagros O, Milet I, Millan MT, Minwei Z, Mirabella L, Mishra S, Mistraletti G, Mochizuki K, Moerer O, Moghal A, Mojoli F, Molin A, Molnar Z, Montiel R, Montini L, Monza G, Mora Aznar M, Morakul S, Morales M, Moreno Torres D, Morocho Tutillo DR, Motherway C, Mouhssine D, Mouloudi E, Muñoz T, Munoz de Cabo C, Mustafa M, Muthuchellappan R, Muthukrishnan M, Muttini S, Nagata I, Nahar D, Nakanishi M, Nakayama I, Namendys-Silva SA, Nanchal R, Nandakumar S, Nasi A, Nasir K, Navalesi P, Naz Aslam T, Nga Phan T, Nichol A, Niiyama S, Nikolakopoulou S, Nikolic E, Nitta K, Noc M, Nonas S, Nseir S, Nur Soyturk A, Obata Y, Oeckler R, Oguchi M, Ohshimo S, Oikonomou M, Ojados A, Oliveira MT, Oliveira Filho W, Oliveri C, Olmos A, Omura K, Orlandi MC, Orsenigo F, Ortiz-Ruiz De Gordoa L, Ota K, Ovalle Olmos R, Öveges N, Oziemski P, Ozkan Kuscu O, Özyilmaz E, Pachas Alvarado F, Pagella G, Palaniswamy V, Palazon Sanchez EL, Palmese S, Pan G, Pan W, Panka B, Papanikolaou M, Papavasilopoulou T, Parekh A, Parke R, Parrilla FJ, Parrilla D, Pasha T, Pasin L, Patão L, Patel M, Patel G, Pati BK, Patil J, Pattnaik S, Paul D, Pavesi M, Pavlotsky VA, Paz G, Paz E, Pecci E, Pellegrini C, Peña Padilla AG, Perchiazzi G, Pereira T, Pereira V, Perez M, Perez Calvo C, Perez Cheng M, Perez Maita R, Pérez-Araos R, Perez-Teran P, Perez-Torres D, Perkins G, Persona P, Petnak T, Petrova M, Pham T, Philippart F, Picetti E, Pierucci E, Piervincenzi E, Pinciroli R, Pintado MC, Piquilloud L, Piraino T, Piras S, Piras C, Pirompanich P, Pisani L, Platas E, Plotnikow G, Porras W, Porta V, Portilla M, Portugal J, Povoa P, Prat G, Pratto R, Preda G, Prieto I, Prol-Silva E, Pugh R, Qi Y, Qian C, Qin T, Qiu H, Qu H, Quintana T, Quispe Sierra R, Quispe Soto R, Rabbani R, Rabee M, Rabie A, Rahe Pereira MA, Rai A, Raj Ashok S, Rajab M, Ramdhani N, Ramey E, Ranieri M, Rathod D, Ray B, Redwanul Huq SM, Regli A, Reina R, Resano Sarmiento N, Reynaud F, Rialp G, Ricart P, Rice T, Richardson A, Rieder M, Rinket M, Rios F, Rios F, Risso Vazquez A, Rittayamai N, Riva I, Rivette M, Roca O, Roche-Campo F, Rodriguez C, Rodriguez G, Rodriguez Gonzalez D, Rodriguez Tucto XY, Rogers A, Romano ME, Rørtveit L, Rose A, Roux D, Rouze A, Rubatto Birri PN, Ruilan W, Ruiz Robledo A, Ruiz-Aguilar AL, Sadahiro T, Saez I, Sagardia J, Saha R, Saha R, Saiphoklang N, Saito S, Salem M, Sales G, Salgado P, Samavedam S, Sami Mebazaa M, Samuelsson L, San Juan Roman N, Sanchez P, Sanchez-Ballesteros J, Sandoval Y, Sani E, Santos M, Santos C, Sanui M, Saravanabavan L, Sari S, Sarkany A, Sauneuf B, Savioli M, Sazak H, Scano R, Schneider F, Schortgen F, Schultz MJ, Schwarz GL, Seçkin Yücesoy F, Seely A, Seiler F, Seker Tekdos Y, Seok Chan K, Serano L, Serednicki W, Serpa Neto A, Setten M, Shah A, Shah B, Shang Y, Shanmugasundaram P, Shapovalov K, Shebl E, Shiga T, Shime N, Shin P, Short J, Shuhua C, Siddiqui S, Silesky Jimenez JI, Silva D, Silva Sales B, Simons K, Sjøbø BÅ, Slessor D, Smiechowicz J, Smischney N, Smith P, Smith T, Smith M, Snape S, Snyman L, Soetens F, Sook Hong K, Sosa Medellin MÁ, Soto G, Souloy X, Sousa E, Sovatzis S, Sozutek D, Spadaro S, Spagnoli M, Spångfors M, Spittle N, Spivey M, Stapleton A, Stefanovic B, Stephenson L, Stevenson E, Strand K, Strano MT, Straus S, Sun C, Sun R, Sundaram V, SunPark T, Surlemont E, Sutherasan Y, Szabo Z, Szuldrzynski K, Tainter C, Takaba A, Tallott M, Tamasato T, Tang Z, Tangsujaritvijit V, Taniguchi L, Taniguchi D, Tarantino F, Teerapuncharoen K, Temprano S, Terragni P, Terzi N, Thakur A, Theerawit P, Thille AW, Thomas M, Thungtitigul P, Thyrault M, Tilouch N, Timenetsky K, Tirapu J, Todeschini M, Tomas R, Tomaszewski C, Tonetti T, Tonnelier A, Trinder J, Trongtrakul K, Truwit J, Tsuei B, Tulaimat A, Turan S, Turkoglu M, Tyagi S, Ubeda A, Vagginelli F, Valenti MF, Vallverdu I, Van Axel A, van den Hul I, van der Hoeven H, Van Der Meer N, Van Haren F, Vanhoof M, Vargas-Ordoñez M, Vaschetto R, Vascotto E, Vatsik M, Vaz A, Vazquez-Sanchez A, Ventura S, Vermeijden JW, Vidal A, Vieira J, Vilela Costa Pinto B, Villagomez A, Villagra A, Villegas Succar C, Vinorum OG, Vitale G, Vj R, Vochin A, Voiriot G, Volta CA, von Seth M, Wajdi M, Walsh D, Wang S, Wardi G, Ween-Velken NC, Wei BL, Weller D, Welsh D, Welters I, Wert M, Whiteley S, Wilby E, Williams E, Williams K, Wilson A, Wojtas J, Won Huh J, Wrathall D, Wright C, Wu JF, Xi G, Xing ZJ, Xu H, Yamamoto K, Yan J, Yáñez J, Yang X, Yates E, Yazicioglu Mocin O, Ye Z, Yildirim F, Yoshida N, Yoshido HHL, Young Lee B, Yu R, Yu G, Yu T, Yuan B, Yuangtrakul N, Yumoto T, Yun X, Zakalik G, Zaki A, Zalba-Etayo B, Zambon M, Zang B, Zani G, Zarka J, Zerbi SM, Zerman A, Zetterquist H, Zhang J, Zhang H, Zhang W, Zhang G, Zhang W, Zhao H, Zheng J, Zhu B, Zumaran R. Weaning from mechanical ventilation in intensive care units across 50 countries (WEAN SAFE): a multicentre, prospective, observational cohort study. Lancet Respir Med 2023; 11:465-476. [PMID: 36693401 DOI: 10.1016/s2213-2600(22)00449-0] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 11/07/2022] [Accepted: 11/10/2022] [Indexed: 01/23/2023]
Abstract
BACKGROUND Current management practices and outcomes in weaning from invasive mechanical ventilation are poorly understood. We aimed to describe the epidemiology, management, timings, risk for failure, and outcomes of weaning in patients requiring at least 2 days of invasive mechanical ventilation. METHODS WEAN SAFE was an international, multicentre, prospective, observational cohort study done in 481 intensive care units in 50 countries. Eligible participants were older than 16 years, admitted to a participating intensive care unit, and receiving mechanical ventilation for 2 calendar days or longer. We defined weaning initiation as the first attempt to separate a patient from the ventilator, successful weaning as no reintubation or death within 7 days of extubation, and weaning eligibility criteria based on positive end-expiratory pressure, fractional concentration of oxygen in inspired air, and vasopressors. The primary outcome was the proportion of patients successfully weaned at 90 days. Key secondary outcomes included weaning duration, timing of weaning events, factors associated with weaning delay and weaning failure, and hospital outcomes. This study is registered with ClinicalTrials.gov, NCT03255109. FINDINGS Between Oct 4, 2017, and June 25, 2018, 10 232 patients were screened for eligibility, of whom 5869 were enrolled. 4523 (77·1%) patients underwent at least one separation attempt and 3817 (65·0%) patients were successfully weaned from ventilation at day 90. 237 (4·0%) patients were transferred before any separation attempt, 153 (2·6%) were transferred after at least one separation attempt and not successfully weaned, and 1662 (28·3%) died while invasively ventilated. The median time from fulfilling weaning eligibility criteria to first separation attempt was 1 day (IQR 0-4), and 1013 (22·4%) patients had a delay in initiating first separation of 5 or more days. Of the 4523 (77·1%) patients with separation attempts, 2927 (64·7%) had a short wean (≤1 day), 457 (10·1%) had intermediate weaning (2-6 days), 433 (9·6%) required prolonged weaning (≥7 days), and 706 (15·6%) had weaning failure. Higher sedation scores were independently associated with delayed initiation of weaning. Delayed initiation of weaning and higher sedation scores were independently associated with weaning failure. 1742 (31·8%) of 5479 patients died in the intensive care unit and 2095 (38·3%) of 5465 patients died in hospital. INTERPRETATION In critically ill patients receiving at least 2 days of invasive mechanical ventilation, only 65% were weaned at 90 days. A better understanding of factors that delay the weaning process, such as delays in weaning initiation or excessive sedation levels, might improve weaning success rates. FUNDING European Society of Intensive Care Medicine, European Respiratory Society.
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Affiliation(s)
- Tài Pham
- Service de Médecine Intensive-Réanimation, AP-HP, Hôpital de Bicêtre, DMU CORREVE, FHU SEPSIS, Groupe de Recherche CARMAS, Hôpitaux Universitaires Paris-Saclay, Le Kremlin-Bicêtre, France; Université Paris-Saclay, UVSQ, Université Paris-Sud, Inserm U1018, Equipe d'Epidémiologie Respiratoire Intégrative, CESP, 94807, Villejuif, France
| | - Leo Heunks
- Department of Intensive Care Medicine, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Fabiana Madotto
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Irene Aragao
- Department of Intensive Care Medicine, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Gaëtan Beduneau
- Normandie University, UNIROUEN, UR 3830, CHU Rouen, Department of Medical Intensive Care, F-76000 Rouen, France
| | - Ewan C Goligher
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Medicine, Division of Respirology, Toronto General Hospital Research Institute University Health Network, Toronto, Canada
| | - Giacomo Grasselli
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Jon Henrik Laake
- Department of Anaesthesiology and Department of Research and Development, Division of Critical Care and Emergencies, Oslo University Hospital, Oslo, Norway
| | - Jordi Mancebo
- Department of Intensive Care Medicine, Hospital Universitari Sant Pau, Barcelona, Spain
| | - Oscar Peñuelas
- Intensive Care Unit, Hospital Universitario de Getafe, Madrid, Spain; Centro de Investigación Biomédica en Red, CIBER de Enfermedades Respiratorias, CIBERES, Madrid, Spain
| | - Lise Piquilloud
- Adult Intensive Care Unit, University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Antonio Pesenti
- Department of Anaesthesia, Intensive Care and Emergency, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Frank van Haren
- College of Health and Medicine, Australian National University, Canberra, ACT, Australia; Intensive Care Unit, St George Hospital, Sydney, NSW, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospitals, Galway, Ireland; School of Medicine, Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, National University of Ireland Galway, Galway, Ireland.
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Sheehan JR, Calpin P, Kernan M, Kelly C, Casey S, Murphy D, Alvarez-Iglesias A, Giacomini C, Cody C, Curley G, McGeary S, Hanley C, McNicholas B, van Haren F, Laffey JG, Cosgrave D. The CHARTER-Ireland trial: can nebulised heparin reduce acute lung injury in patients with SARS-CoV-2 requiring advanced respiratory support in Ireland: a study protocol and statistical analysis plan for a randomised control trial. Trials 2022; 23:774. [PMID: 36104785 PMCID: PMC9471050 DOI: 10.1186/s13063-022-06518-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/06/2022] [Indexed: 11/10/2022] Open
Abstract
Background COVID-19 pneumonia is associated with the development of acute respiratory distress syndrome (ARDS) displaying some typical histological features. These include diffuse alveolar damage with extensive pulmonary coagulation activation. This results in fibrin deposition in the microvasculature, leading to the formation of hyaline membranes in the air sacs. Well-conducted clinical trials have found that nebulised heparin limits pulmonary fibrin deposition, attenuates progression of ARDS, hastens recovery and is safe in non-COVID ARDS. Unfractionated heparin also inactivates the SARS-CoV-2 virus and prevents entry into mammalian cells. Nebulisation of heparin may therefore limit fibrin-mediated lung injury and inhibit pulmonary infection by SARS-CoV-2. Based on these findings, we designed the CHARTER-Ireland Study, a phase 1b/2a randomised controlled study of nebulised heparin in patients requiring advanced respiratory support for COVID-19 pneumonia. Methods This is a multi-centre, phase 1b/IIa, randomised, parallel-group, open-label study. The study will randomise 40 SARs-CoV-2-positive patients receiving advanced respiratory support in a critical care area. Randomisation will be via 1:1 allocation to usual care plus nebulised unfractionated heparin 6 hourly to day 10 while receiving advanced respiratory support or usual care only. The study aims to evaluate whether unfractionated heparin will decrease the procoagulant response associated with ARDS up to day 10. The study will also assess safety and tolerability of nebulised heparin as defined by number of severe adverse events; oxygen index and respiratory oxygenation index of intubated and unintubated, respectively; ventilatory ratio; and plasma concentration of interleukin (IL)-1β, IL6, IL-8, IL-10 and soluble tumour necrosis factor receptor 1, C-reactive protein, procalcitonin, ferritin, fibrinogen and lactate dehydrogenase as well as the ratios of IL-1β/IL-10 and IL-6/IL-10. These parameters will be assessed on days 1, 3, 5 and 10; time to separation from advanced respiratory support, time to discharge from the intensive care unit and number tracheostomised to day 28; and survival to days 28 and 60 and to hospital discharge, censored at day 60. Some clinical outcome data from our study will be included in the international meta-trials, CHARTER and INHALE-HEP. Discussion This trial aims to provide evidence of potential therapeutic benefit while establishing safety of nebulised heparin in the management of ARDS associated with SARs-CoV-2 infection. Trial registration ClinicalTrials.govNCT04511923. Registered on 13 August 2020. Protocol version 8, 22/12/2021 Protocol identifier: NUIG-2020-003 EudraCT registration number: 2020-003349-12 9 October 2020 Supplementary Information The online version contains supplementary material available at 10.1186/s13063-022-06518-z.
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van Haren F, van den Heuvel S, Ligtenberg M, Vissers K, Steegers M. Diagnostic tools should be used for the diagnosis of chemotherapy induced peripheral neuropathy in breast cancer patients receiving taxanes. Cancer Rep (Hoboken) 2021; 5:e1577. [PMID: 34687287 PMCID: PMC9575489 DOI: 10.1002/cnr2.1577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/10/2021] [Accepted: 10/12/2021] [Indexed: 12/03/2022] Open
Abstract
Background Though the incidence, characteristics, and pathogenesis of chemotherapy induced peripheral neuropathy (CIPN) by taxane based chemotherapy were extensively studied, diagnostic guidelines extent only recently. Aim To observationally investigate whether specific tests can be used to predict and monitor CIPN severity. Methods Fourteen female breast cancer patients receiving paclitaxel or docetaxel were evaluated using the McGill Pain Questionnaire (MPQ), National Cancer Institute Common Toxicity Criteria (NCI‐CTC) grading, clinical total neuropathy score (TNSc), quantitative sensory testing (QST) of pressure pain threshold (PPT), and numeric rating scale (NRS) scores and stocking and glove distribution testing (SGDT), at the start (T0), midst (T1), and end (T2) of their treatment and after 3 months (T3). Results At T3, patients scored NCI‐CTC neuropathy grade 1 (14.3%), 2 (64.3%), and 3 (14.3%) respectively. Fifty percentage scored at least grade 1 at T0, with complaints not caused by CIPN. Pain, if present, was denominated “tingling” and “cold” in the MPQ. Median TNSc score increased from T0 (2.43) to T1 (4.71) to T2 (5.50) to T3 (5.57), as did pinprick and cold sensation disturbances in SGDT. PPT and associated NRS remained unchanged. TNSc and SGDT at T1 could not predict the NCI‐CTC grade at T3. Conclusion NCI‐CTC, TNSc, and stocking and glove distribution testing can be used in the early diagnosis and monitoring of CIPN, with false‐positive findings at baseline. Final NCI‐CTC grades could not be predicted.
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Affiliation(s)
- Frank van Haren
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Sandra van den Heuvel
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Mandy Ligtenberg
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
| | - Monique Steegers
- Department of Anesthesiology, Pain and Palliative Medicine, Radboudumc, Nijmegen, The Netherlands
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Sakr Y, Midega T, Antoniazzi J, Solé-Violán J, Bauer PR, Ostermann M, Pellis T, Szakmany T, Zacharowski K, Ñamendys-Silva SA, Pham T, Ferrer R, Taccone FS, van Haren F, Brochard L. Do ventilatory parameters influence outcome in patients with severe acute respiratory infection? Secondary analysis of an international, multicentre14-day inception cohort study. J Crit Care 2021; 66:78-85. [PMID: 34461380 PMCID: PMC8394083 DOI: 10.1016/j.jcrc.2021.08.008] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Revised: 07/13/2021] [Accepted: 08/16/2021] [Indexed: 11/06/2022]
Abstract
Purpose To investigate the possible association between ventilatory settings on the first day of invasive mechanical ventilation (IMV) and mortality in patients admitted to the intensive care unit (ICU) with severe acute respiratory infection (SARI). Materials and methods In this pre-planned sub-study of a prospective, multicentre observational study, 441 patients with SARI who received controlled IMV during the ICU stay were included in the analysis. Results ICU and hospital mortality rates were 23.1 and 28.1%, respectively. In multivariable analysis, tidal volume and respiratory rate on the first day of IMV were not associated with an increased risk of death; however, higher driving pressure (DP: odds ratio (OR) 1.05; 95% confidence interval (CI): 1.01–1.1, p = 0.011), plateau pressure (Pplat) (OR 1.08; 95% CI: 1.04–1.13, p < 0.001) and positive end-expiratory pressure (PEEP) (OR 1.13; 95% CI: 1.03–1.24, p = 0.006) were independently associated with in-hospital mortality. In subgroup analysis, in hypoxemic patients and in patients with acute respiratory distress syndrome (ARDS), higher DP, Pplat, and PEEP were associated with increased risk of in-hospital death. Conclusions In patients with SARI receiving IMV, higher DP, Pplat and PEEP, and not tidal volume, were associated with a higher risk of in-hospital death, especially in those with hypoxemia or ARDS.
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Affiliation(s)
- Yasser Sakr
- Department of Anaesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany.
| | - Thais Midega
- Department of Anaesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany; Department of intensive care, Instituto de Assistência Médicaao Servidor Público Estadual, São Paulo, Brazil
| | - Julia Antoniazzi
- Department of Anaesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany; Intensive Care Unit at Hospital das Clínicas da Faculdade de Medicina de Ribeirão Preto, Brazil
| | - Jordi Solé-Violán
- Intensive Care Medicine Department, Hospital Universitario Dr Negrín, Las Palmas de Gran Canaria, Spain
| | - Philippe R Bauer
- Mayo Clinic, Division of Pulmonary and Critical Care Medicine, Saint Mary's Hospital, Rochester, USA
| | | | - Tommaso Pellis
- Department of Anaesthesia and Intensive Care, AAS 5 Friuli Occidentale Pordenone Hospital, Pordenone, Italy
| | - Tamas Szakmany
- Department of Anaesthesia, Intensive Care, and Pain Medicine, Division of Population Medicine, Cardiff University, UK
| | - Kai Zacharowski
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Silvio A Ñamendys-Silva
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, Instituto Nacional de Ciencias Medicas y Nutricion Salvador Zubiran, & Hospital Medica Sur, Mexico City, Mexico
| | - Tài Pham
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre, Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
| | - Ricard Ferrer
- Intensive Care Department, Valld'Hebron University Hospital, Shock, Organ Dysfunction and Resuscitation Research Group, Valld'Hebron Research Institute, Barcelona, Spain
| | - Fabio S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Frank van Haren
- Intensive Care Unit, the Canberra Hospital, Canberra, Australia
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada; Keenan Research Centre, Li KaShing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada
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Dunlop WA, Secombe PJ, Agostino J, van Haren F. Characteristics and outcomes of Aboriginal and Torres Strait Islander patients with dialysis-dependent kidney disease in Australian Intensive Care Units. Intern Med J 2020; 52:458-467. [PMID: 33012108 DOI: 10.1111/imj.15077] [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: 06/01/2020] [Revised: 09/04/2020] [Accepted: 09/27/2020] [Indexed: 11/05/2022]
Abstract
BACKGROUND In Australia, 531 people per million population have dialysis-dependent Chronic Kidney Disease (CKD5D). The incidence is four times higher for Aboriginal and Torres Strait Islander (Indigenous) people compared to non-Indigenous Australians. CKD5D increases the risk of hospitalisation, admission to the Intensive Care Unit (ICU) and mortality compared to patients without CKD5D. There is limited literature describing short-term outcomes of patients with CKD5D who are admitted to ICU, comparing Indigenous and non-Indigenous patients. AIMS This registry-based retrospective cohort analysis compared demographic and clinical data between Indigenous and non-Indigenous patients with CKD5D and tested whether Indigenous status predicted short-term outcomes independently of other contributing factors. Adjusted hospital mortality was the primary outcome measure. METHODS Data were from the Australian and New Zealand Intensive Care Society's Centre for Outcome and Resource Evaluation Adult Patient Database. Australian ICU admissions between 2010 and 2017 were included. Data from 173 ICUs (2,136 beds) include 1,051,697 ICU admissions of which 23,793 had a pre-existing diagnosis of CKD5D. RESULTS Indigenous patients comprised 11.9% of CKD5D patients in ICU. CKD5D was prevalent among 4.9% of Indigenous and 2.9% of non-Indigenous ICU admissions. Indigenous patients were 13.5 years younger, had fewer comorbidities and lower crude mortality despite equivalent calculated mortality risk. After adjusting for age, remoteness and severity of illness, Indigenous status did not predict mortality. CONCLUSIONS Socioeconomic disadvantage contributes to earlier development of CKD5D and the over representation in ICU of Indigenous people. Mortality is equivalent once correcting for confounders, but addressing inequality requires strengthening preventative care. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Paul J Secombe
- Intensive Care Unit, Central Australia Health Service, Alice Springs, NT
| | - Jason Agostino
- Medical School, Australian National University, Canberra, ACT
| | - Frank van Haren
- Medical School, Australian National University, Canberra, ACT.,Intensive Care Unit, Canberra Hospital, Canberra, ACT.,Faculty of Health, University of Canberra, Canberra, ACT
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Young PJ, Bagshaw SM, Forbes AB, Nichol AD, Wright SE, Bellomo R, Haren FV, Litton E, Webb SA. Opportunities and challenges of clustering, crossing over, and using registry data in the PEPTIC trial. CRIT CARE RESUSC 2020. [DOI: 10.51893/2020.2.ed2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The Proton Pump Inhibitors (PPIs) versus Histamine-2 Receptor Blockers (H2RBs) for Ulcer Prophylaxis Therapy in the Intensive Care Unit (ICU) (PEPTIC) trial is the largest randomised clinical trial ever conducted in the field of intensive care medicine. The potential clinical implications of the trial have been the subject of a previous editorial. Here we focus on the implications of the study for clinical trial science and on the opportunities the study provides for exploratory analyses that will potentially shed further light on the relative safety and efficacy of using PPIs or H2RBs for stress ulcer prophylaxis in the critically ill.
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Young PJ, Bagshaw SM, Forbes AB, Nichol AD, Wright SE, Bellomo R, van Haren F, Litton E, Webb SA. Opportunities and challenges of clustering, crossing over, and using registry data in the PEPTIC trial. CRIT CARE RESUSC 2020; 22:105-109. [PMID: 32389102 PMCID: PMC10692457] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta Hospital, Alberta, Canada
| | - Andrew B Forbes
- Biostatistics Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | | | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Steve A Webb
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
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Deane AM, Little L, Bellomo R, Chapman MJ, Davies AR, Ferrie S, Horowitz M, Hurford S, Lange K, Litton E, Mackle D, O'Connor S, Parker J, Peake SL, Presneill JJ, Ridley EJ, Singh V, van Haren F, Williams P, Young P, Iwashyna TJ. Outcomes Six Months after Delivering 100% or 70% of Enteral Calorie Requirements during Critical Illness (TARGET). A Randomized Controlled Trial. Am J Respir Crit Care Med 2020; 201:814-822. [PMID: 31904995 DOI: 10.1164/rccm.201909-1810oc] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: The long-term effects of delivering approximately 100% of recommended calorie intake via the enteral route during critical illness compared with a lesser amount of calories are unknown.Objectives: Our hypotheses were that achieving approximately 100% of recommended calorie intake during critical illness would increase quality-of-life scores, return to work, and key life activities and reduce death and disability 6 months later.Methods: We conducted a multicenter, blinded, parallel group, randomized clinical trial, with 3,957 mechanically ventilated critically ill adults allocated to energy-dense (1.5 kcal/ml) or routine (1.0 kcal/ml) enteral nutrition.Measurements and Main Results: Participants assigned energy-dense nutrition received more calories (percent recommended energy intake, mean [SD]; energy-dense: 103% [28] vs. usual: 69% [18]). Mortality at Day 180 was similar (560/1,895 [29.6%] vs. 539/1,920 [28.1%]; relative risk 1.05 [95% confidence interval, 0.95-1.16]). At a median (interquartile range) of 185 (182-193) days after randomization, 2,492 survivors were surveyed and reported similar quality of life (EuroQol five dimensions five-level quality-of-life questionnaire visual analog scale, median [interquartile range]: 75 [60-85]; group difference: 0 [95% confidence interval, 0-0]). Similar numbers of participants returned to work with no difference in hours worked or effectiveness at work (n = 818). There was no observed difference in disability (n = 1,208) or participation in key life activities (n = 705).Conclusions: The delivery of approximately 100% compared with 70% of recommended calorie intake during critical illness does not improve quality of life or functional outcomes or increase the number of survivors 6 months later.
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Affiliation(s)
- Adam M Deane
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital and
| | - Lorraine Little
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Centre for Integrated Critical Care, Melbourne Medical School, The University of Melbourne, Parkville, Australia
| | | | - Andrew R Davies
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Suzie Ferrie
- Department of Nutrition and Dietetics, Royal Prince Alfred Hospital, Camperdown, Australia
| | - Michael Horowitz
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | - Sally Hurford
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Kylie Lange
- Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide Medical School, University of Adelaide, Adelaide, Australia
| | | | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | - Jeffrey J Presneill
- Department of Medicine and Radiology, Melbourne Medical School, Royal Melbourne Hospital and
| | - Emma J Ridley
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Vanessa Singh
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Frank van Haren
- Medical School, Australian National University, Canberra, Australia; and
| | | | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Theodore J Iwashyna
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan
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Madotto F, Rezoagli E, Pham T, Schmidt M, McNicholas B, Protti A, Panwar R, Bellani G, Fan E, van Haren F, Brochard L, Laffey JG. Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome: insights from the LUNG SAFE study. Crit Care 2020; 24:125. [PMID: 32234077 PMCID: PMC7110678 DOI: 10.1186/s13054-020-2826-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 12/06/2019] [Accepted: 03/06/2020] [Indexed: 12/23/2022]
Abstract
Background Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. Methods In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 ≥ 0.60 during hyperoxemia). Results Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55–100 mmHg) patients (P = 0.47). Conclusions Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. Trial registration LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073
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Affiliation(s)
- Fabiana Madotto
- Research Center on Public Health, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Scientific Institute for Research, Hospitalization and Health Care, IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
| | - Emanuele Rezoagli
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland
| | - Tài Pham
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Canada.,Department of Critical Care Medicine, St Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Marcello Schmidt
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Bairbre McNicholas
- Nephrology, School of Medicine, National University of Ireland Galway, Galway, Ireland
| | - Alessandro Protti
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milan), Italy.,Humanits clinical and research center - IRCCS, Rozzano (Milan), Italy
| | - Rakshit Panwar
- Intensive Care Unit, John Hunter Hospital, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, University of Newcastle, Newcastle, Australia
| | - Giacomo Bellani
- Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Eddy Fan
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada.,Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada.,Department of Medicine, University Health Network and Sinai Health System, Toronto, Canada
| | - Frank van Haren
- Intensive Care Unit, The Canberra Hospital and Australian National University, Canberra, Australia
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Canada.,Department of Critical Care Medicine, St Michael's Hospital, Toronto, Canada.,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, National University of Ireland Galway, Galway, Ireland. .,Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland. .,Keenan Research Centre for Biomedical Science, St Michael's Hospital, Toronto, Canada.
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11
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Secombe P, Woodman R, Chan S, Pilcher D, van Haren F. Epidemiology and outcomes of obese critically ill patients in Australia and New Zealand. CRIT CARE RESUSC 2020; 22:35-44. [PMID: 32102641 PMCID: PMC10692468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE The apparent survival benefit of being overweight or obese in critically ill patients (the obesity paradox) remains controversial. Our aim is to report on the epidemiology and outcomes of obesity within a large heterogenous critically ill adult population. DESIGN Retrospective observational cohort study. SETTING Intensive care units (ICUs) in Australia and New Zealand. PARTICIPANTS Critically ill patients who had both height and weight recorded between 2010 and 2018. OUTCOME MEASURES Hospital mortality in each of five body mass index (BMI) strata. Subgroups analysed included diagnostic category, gender, age, ventilation status and length of stay. RESULTS Data were available for 381 855 patients, 68% of whom were overweight or obese. Increasing level of obesity was associated with lower unadjusted hospital mortality: underweight (11.9%), normal weight (7.7%), overweight (6.4%), class I obesity (5.4%), and class II obesity (5.3%). After adjustment, mortality was lowest for patients with class I obesity (adjusted odds ratio, 0.78; 95% CI, 0.74- 0.82). Adverse outcomes with class II obesity were only seen in patients with cardiovascular and cardiac surgery ICU admission diagnoses, where mortality risk rose with progressively higher BMIs. CONCLUSION We describe the epidemiology of obesity within a critically ill Australian and New Zealand population and confirm that some level of obesity is associated with lower mortality, both overall and across a range of diagnostic categories and important subgroups. Further research should focus on potential confounders such as nutritional status and the appropriateness of BMI in isolation as an anthropometric measure in critically ill patients.
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Affiliation(s)
- Paul Secombe
- Intensive Care Unit, Alice Springs Hospital, Alice Springs, NT, Australia.
| | - Richard Woodman
- Centre for Epidemiology and Biostatistics, Flinders University, Adelaide, SA, Australia
| | - Sean Chan
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia
| | - David Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia
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12
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van Haren F, van den Heuvel S, Radema S, van Erp N, van den Bersselaar L, Vissers K, Steegers M. Intravenous lidocaine affects oxaliplatin pharmacokinetics in simultaneous infusion. J Oncol Pharm Pract 2020; 26:1850-1856. [PMID: 32075507 DOI: 10.1177/1078155220905011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Oxaliplatin is a chemotherapeutic agent used to treat malignancies of the gastrointestinal tract. Neuropathy is a frequent dose-limiting side-effect of oxaliplatin therapy, without preventive or curative strategies. Concomitant administration of intravenous lidocaine could be a promising treatment. However, the effect of intravenous lidocaine on oxaliplatin pharmacokinetics was never studied before. We evaluated the effect of lidocaine on the area under the curve and Cmax of oxaliplatin as a part of a larger study addressing the prevention and treatment of oxaliplatin induced peripheral neuropathy with lidocaine. METHODS In this prospective cross-over trial, patients received an oxaliplatin cycle with and without lidocaine (bolus 1.5 mg kg-1 followed by 1.5 mg kg-1 h-1 in 3 h). Levels of oxaliplatin, measured as ultrafiltrable platinum were determined at 10 min after cessation of oxaliplatin infusion and hourly thereafter. Outcomes are the difference in area under the curve of oxaliplatin (primary) and the difference in the Cmax of oxaliplatin (secondary). RESULTS No difference in the %Δ area under the curve of oxaliplatin (-2.40 ± 7.66, 90% CI +10.50 to -15.31) was found. However, %Δ Cmax of oxaliplatin (-28.72 ± 6.01, 90% CI -18.59 to -38.85) was lower to a statistically significant extent in the chemotherapy cycle with lidocaine. No (serious) adverse events were reported. CONCLUSIONS Lidocaine does not affect the area under the curve of oxaliplatin, which is the most important parameter in drug interaction studies and for oxaliplatin treatment effect. The lower Cmax in the chemotherapeutic cycle with lidocaine is significant and remarkable, but with an unknown exact mechanism or clinical significance, making further research desirable.
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Affiliation(s)
- Frank van Haren
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Sandra van den Heuvel
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Sandra Radema
- Department of Medical Oncology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Nielka van Erp
- Department of Pharmacology, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Luuk van den Bersselaar
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Kris Vissers
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Monique Steegers
- Department of Anesthesiology Pain and Palliative Medicine, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
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13
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Young PJ, Bagshaw SM, Forbes AB, Nichol AD, Wright SE, Bailey M, Bellomo R, Beasley R, Brickell K, Eastwood GM, Gattas DJ, van Haren F, Litton E, Mackle DM, McArthur CJ, McGuinness SP, Mouncey PR, Navarra L, Opgenorth D, Pilcher D, Saxena MK, Webb SA, Wiley D, Rowan KM. Effect of Stress Ulcer Prophylaxis With Proton Pump Inhibitors vs Histamine-2 Receptor Blockers on In-Hospital Mortality Among ICU Patients Receiving Invasive Mechanical Ventilation: The PEPTIC Randomized Clinical Trial. JAMA 2020; 323:616-626. [PMID: 31950977 PMCID: PMC7029750 DOI: 10.1001/jama.2019.22190] [Citation(s) in RCA: 106] [Impact Index Per Article: 26.5] [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: 12/18/2022]
Abstract
IMPORTANCE Proton pump inhibitors (PPIs) or histamine-2 receptor blockers (H2RBs) are often prescribed for patients as stress ulcer prophylaxis drugs in the intensive care unit (ICU). The comparative effect of these drugs on mortality is unknown. OBJECTIVE To compare in-hospital mortality rates using PPIs vs H2RBs for stress ulcer prophylaxis. DESIGN, SETTING, AND PARTICIPANTS Cluster crossover randomized clinical trial conducted at 50 ICUs in 5 countries between August 2016 and January 2019. Patients requiring invasive mechanical ventilation within 24 hours of ICU admission were followed up for 90 days at the hospital. INTERVENTIONS Two stress ulcer prophylaxis strategies were compared (preferential use with PPIs vs preferential use with H2RBs). Each ICU used each strategy sequentially for 6 months in random order; 25 ICUs were randomized to the sequence with use of PPIs and then use of H2RBs and 25 ICUs were randomized to the sequence with use of H2RBs and then use of PPIs (13 436 patients randomized by site to PPIs and 13 392 randomized by site to H2RBs). MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality within 90 days during index hospitalization. Secondary outcomes were clinically important upper gastrointestinal bleeding, Clostridioides difficile infection, and ICU and hospital lengths of stay. RESULTS Among 26 982 patients who were randomized, 154 opted out, and 26 828 were analyzed (mean [SD] age, 58 [17.0] years; 9691 [36.1%] were women). There were 26 771 patients (99.2%) included in the mortality analysis; 2459 of 13 415 patients (18.3%) in the PPI group died at the hospital by day 90 and 2333 of 13 356 patients (17.5%) in the H2RB group died at the hospital by day 90 (risk ratio, 1.05 [95% CI, 1.00 to 1.10]; absolute risk difference, 0.93 percentage points [95% CI, -0.01 to 1.88] percentage points; P = .054). An estimated 4.1% of patients randomized by ICU site to PPIs actually received H2RBs and an estimated 20.1% of patients randomized by ICU site to H2RBs actually received PPIs. Clinically important upper gastrointestinal bleeding occurred in 1.3% of the PPI group and 1.8% of the H2RB group (risk ratio, 0.73 [95% CI, 0.57 to 0.92]; absolute risk difference, -0.51 percentage points [95% CI, -0.90 to -0.12 percentage points]; P = .009). Rates of Clostridioides difficile infection and ICU and hospital lengths of stay were not significantly different by treatment group. One adverse event (an allergic reaction) was reported in 1 patient in the PPI group. CONCLUSIONS AND RELEVANCE Among ICU patients requiring mechanical ventilation, a strategy of stress ulcer prophylaxis with use of proton pump inhibitors vs histamine-2 receptor blockers resulted in hospital mortality rates of 18.3% vs 17.5%, respectively, a difference that did not reach the significance threshold. However, study interpretation may be limited by crossover in the use of the assigned medication. TRIAL REGISTRATION anzctr.org.au Identifier: ACTRN12616000481471.
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Affiliation(s)
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington
- Intensive Care Unit, Wellington Hospital, Wellington, New Zealand
| | - Sean M Bagshaw
- Department of Critical Care Medicine, University of Alberta Hospital, Edmonton, Canada
| | | | - Alistair D Nichol
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- University College Dublin-Clinical Research Centre, St Vincent's Hospital, Dublin, Ireland
| | - Stephen E Wright
- Intensive Care Unit, Freeman Hospital, Newcastle upon Tyne, England
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
- Intensive Care Unit, Austin Hospital, Heidelberg, Australia
| | | | - Kathy Brickell
- University College Dublin-Clinical Research Centre, St Vincent's Hospital, Dublin, Ireland
| | | | - David J Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, Camperdown, Australia
- George Institute for Global Health, University of New South Wales, Sydney, Australia
| | | | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Murdoch, Australia
| | | | - Colin J McArthur
- Medical Research Institute of New Zealand, Wellington
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Shay P McGuinness
- Medical Research Institute of New Zealand, Wellington
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, England
| | | | - Dawn Opgenorth
- Department of Critical Care Medicine, University of Alberta Hospital, Edmonton, Canada
| | - David Pilcher
- Intensive Care Unit, Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Camberwell, Australia
| | - Manoj K Saxena
- George Institute for Global Health, University of New South Wales, Sydney, Australia
- Intensive Care Unit, Bankstown Hospital, Bankstown, Australia
| | - Steve A Webb
- Intensive Care Unit, Royal Perth Hospital, Perth, Australia
| | - Daisy Wiley
- Intensive Care National Audit and Research Centre, London, England
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, England
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14
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Abstract
Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation.
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Affiliation(s)
- Paul E Marik
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA, USA
| | - Liam Byrne
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Garran, ACT, Australia.,Australian National University Medical School, Canberra Hospital, Garran, ACT, Australia
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15
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Das A, Anstey M, Bass F, Blythe D, Buhr H, Campbell L, Davda A, Delaney A, Gattas D, Green C, Ferrier J, Hammond N, Palermo A, Pellicano S, Phillips M, Regli A, Roberts B, Ross-King M, Sarode V, Simpson S, Spiller S, Sullivan K, Tiruvoipati R, Haren FV, Waterson S, Yaw LK, Litton E. Internet health information use by surrogate decision makers of patients admitted to the intensive care unit: a multicentre survey. CRIT CARE RESUSC 2019; 21:305-10. [PMID: 31778639 DOI: pmid/31778639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVES To investigate the use, understanding, trust and influence of the internet and other sources of health information used by the next of kin (NOK) of patients admitted to the intensive care unit (ICU). DESIGN Multicentre structured survey. SETTING The ICUs of 13 public and private Australian hospitals. PARTICIPANTS NOK who self-identified as the primary surrogate decision maker for a patient admitted to the ICU. MAIN OUTCOME MEASURES The frequency, understanding, trust and influence of online sources of health information, and the quality of health websites visited using the Health on the Net Foundation Code of Conduct (HONcode) for medical and health websites. RESULTS There were 473 survey responses. The median ICU admission days and number of ICU visits by the NOK at the time of completing the survey was 3 (IQR, 2-6 days) and 4 (IQR, 2-7), respectively. The most commonly reported sources of health information used very frequently were the ICU nurse (55.6%), ICU doctor (38.7%), family (23.3%), hospital doctor (21.4%), and the internet (11.3%). Compared with the 243 NOK (51.6%) not using the internet, NOK using the internet were less likely to report complete understanding (odds ratio [OR], 0.57; 95% CI, 0.38-0.88), trust (OR, 0.34; 95% CI, 0.19-0.59), or influence (OR, 0.58; 95% CI, 0.38-0.88) associated with the ICU doctor. Overall, the quality of the 40 different reported websites accessed was moderately high. CONCLUSIONS A substantial proportion of ICU NOK report using the internet as a source of health information. Internet use is associated with lower reported understanding, trust and influence of the ICU doctor.
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Affiliation(s)
| | | | - Frances Bass
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - David Blythe
- Intensive Care Unit, Armadale Hospital, Perth, WA, Australia
| | - Heidi Buhr
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Lewis Campbell
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
| | - Ashish Davda
- St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | - Anthony Delaney
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | - David Gattas
- Intensive Care Service, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Cameron Green
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, VIC, Australia
| | - Janet Ferrier
- Intensive Care Unit, St John of God Subiaco Hospital, Perth, WA, Australia
| | - Naomi Hammond
- Malcom Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW, Australia
| | | | | | | | | | | | - Michelle Ross-King
- St John of God Midland Public and Private Hospitals, Perth, WA, Australia
| | | | | | - Shakira Spiller
- Division of Critical Care, Canberra Hospital, Canberra, ACT, Australia
| | - Kirsty Sullivan
- Department of Intensive Care Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | | | - Frank van Haren
- Division of Critical Care, Canberra Hospital, Canberra, ACT, Australia
| | - Sharon Waterson
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
| | - Lai Kin Yaw
- Intensive Care Unit, Royal Perth Hospital, Perth, WA, Australia
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16
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Rai S, Anthony L, Needham DM, Georgousopoulou EN, Sudheer B, Brown R, Mitchell I, van Haren F. Barriers to rehabilitation after critical illness: a survey of multidisciplinary healthcare professionals caring for ICU survivors in an acute care hospital. Aust Crit Care 2019; 33:264-271. [PMID: 31402265 DOI: 10.1016/j.aucc.2019.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [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: 12/03/2018] [Revised: 04/04/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND There is scant literature on the barriers to rehabilitation for patients discharged from the intensive care unit (ICU) to acute care wards. OBJECTIVES The objective of this study was to assess ward-based rehabilitation practices and barriers and assess knowledge and perceptions of ward clinicians regarding health concerns of ICU survivors. METHODS, DESIGN, SETTING, AND PARTICIPANTS This was a single-centre survey of multidisciplinary healthcare professionals caring for ICU survivors in an Australian tertiary teaching hospital. MAIN OUTCOME MEASURES The main outcome measures were knowledge of post-intensive care syndrome (PICS) amongst ward clinicians, perceptions of ongoing health concerns with current rehabilitation practices, and barriers to inpatient rehabilitation for ICU survivors. RESULTS The overall survey response rate was 35% (198/573 potential staff). Most respondents (66%, 126/190) were unfamiliar with the term PICS. A majority of the respondents perceived new-onset physical weakness, sleep disturbances, and delirium as common health concerns amongst ICU survivors on acute care wards. There were multifaceted barriers to patient mobilisation, with inadequate multidisciplinary staffing, lack of medical order for mobilisation, and inadequate physical space near the bed as common institutional barriers and patient frailty and cardiovascular instability as the commonly perceived patient-related barriers. A majority of the surveyed ward clinicians (66%, 115/173) would value education on health concerns of ICU survivors to provide better patient care. CONCLUSION There are multiple potentially modifiable barriers to the ongoing rehabilitation of ICU survivors in an acute care hospital. Addressing these barriers may have benefits for the ongoing care of ICU survivors.
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Affiliation(s)
- Sumeet Rai
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; Australian National University Medical School, Canberra, Australia.
| | - Lakmali Anthony
- Australian National University Medical School, Canberra, Australia
| | - Dale M Needham
- Critical Care Physical Medicine and Rehabilitation Program, John Hopkins Hospital, Baltimore, MD, USA; John Hopkins University School of Medicine and School of Nursing, Baltimore, MD, USA
| | | | - Bindu Sudheer
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; Australian Catholic University, Watson, Canberra, Australia
| | - Rhonda Brown
- Research School of Psychology, Australian National University, Canberra, Australia
| | - Imogen Mitchell
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; Australian National University Medical School, Canberra, Australia
| | - Frank van Haren
- Canberra Hospital Intensive Care Unit, Garran, Canberra, Australia; University of Canberra, Bruce, Canberra, Australia
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17
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Holloway JAC, Ranse K, Currie M, Jamieson M, van Haren F. An Integrative Review of the Physical Examination Performed on Deceased Potential Organ and Tissue Donors. Prog Transplant 2019. [DOI: 10.1177/1526924818817029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Physical examination of the deceased potential donor is used in conjunction with information obtained from the family and donor’s General Practitioner. The findings of these assessments are used to determine the degree of risk their organs and tissues could pose to a recipient. Objective: To review the international practices of performing the physical examination on deceased potential organ and tissue donors. Method: A systematic search of the databases PubMed, CINAHL, Embase, and MedLine and grey literature was conducted. The search was limited to English-language articles, published between 2000 and 2017. Results: The integrative review included 14 of 1223 articles identified. We found that, although a physical examination is considered a routine component of international donor screening practices and standards, supportive evidence for this is lacking. A systematic head to toe approach to the physical examination is consistently advocated, but guidance on the components and processes of such an examination is limited. The literature demonstrates some commonalities regarding what constitutes a high-risk finding, but there is some variation in its completeness, and information on how many donors are declined because of such findings was found in only 1 article. The training and education of staff were considered essential to enable an accurate and thorough physical examination, yet details of constituents of education and training programs were sparse. Conclusion: More research is needed into the components of the physical examination that potentially would reduce risk to recipients. A review of current practice may identify opportunities for practice improvement, education, and training.
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Affiliation(s)
| | - Kristen Ranse
- School of Nursing & Midwifery, Griffith University, Queensland, Australia
| | - Marian Currie
- Faculty of Health, University of Canberra, Canberra, Australia
| | - Maggie Jamieson
- Faculty of Health, University of Canberra, Canberra, Australia
| | - Frank van Haren
- Faculty of Health, University of Canberra, Canberra, Australia
- Australian National University, Canberra, Australia
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18
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Rai S, Brown R, van Haren F, Neeman T, Rajamani A, Sundararajan K, Mitchell I. Long-term follow-up for Psychological stRess in Intensive CarE (PRICE) survivors: study protocol for a multicentre, prospective observational cohort study in Australian intensive care units. BMJ Open 2019; 9:e023310. [PMID: 30782702 PMCID: PMC6352815 DOI: 10.1136/bmjopen-2018-023310] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION There are little published data on the long-term psychological outcomes in intensive care unit (ICU) survivors and their family members in Australian ICUs. In addition, there is scant literature evaluating the effects of psychological morbidity in intensive care survivors on their family members. The aims of this study are to describe and compare the long-term psychological outcomes of intubated and non-intubated ICU survivors and their family members in an Australian ICU setting. METHODS AND ANALYSIS This will be a prospective observational cohort study across four ICUs in Australia. The study aims to recruit 150 (75 intubated and 75 non-intubated) adult ICU survivors and 150 family members of the survivors from 2015 to 2018. Long-term psychological outcomes and effects on health-related quality of life (HRQoL) will be evaluated at 3 and 12 months follow-up using validated and published screening tools. The primary objective is to compare the prevalence of affective symptoms in intubated and non-intubated survivors of intensive care and their families and its effects on HRQoL. The secondary objective is to explore dyadic relations of psychological outcomes in patients and their family members. ETHICS AND DISSEMINATION The study has been approved by the relevant human research ethics committees (HREC) of Australian Capital Territory (ACT) Health (ETH.11.14.315), New South Wales (HREC/16/HNE/64), South Australia (HREC/15/RAH/346). The results of this study will be published in a peer-reviewed medical journal and presented to the local intensive care community and other stakeholders. TRIAL REGISTRATION NUMBER ACTRN12615000880549; Pre-results.
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Affiliation(s)
- Sumeet Rai
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Rhonda Brown
- Research School of Psychology, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Faculty of Health, University of Canberra, Canberra, Australian Capital Territory, Australia
| | - Teresa Neeman
- Statistical Consulting Unit, Australian National University, Canberra, Australian Capital Territory, Australia
| | - Arvind Rajamani
- Intensive Care Unit, Nepean Hospital, Penrith, New South Wales, Australia
- Discipline of Critical Care, Nepean Clinical School, University of Sydney, Sydney, New South Wales, Australia
| | - Krishnaswamy Sundararajan
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia, Australia
| | - Imogen Mitchell
- Intensive Care Unit, Canberra Hospital, Canberra, Australian Capital Territory, Australia
- Medical School, Australian National University, Canberra, Australian Capital Territory, Australia
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19
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Kengen R, Thoonen E, Daveson K, Loong B, Rodgers H, Beckingham W, Kennedy K, Suwandarathne R, van Haren F. Chlorhexidine washing in intensive care does not reduce bloodstream infections, blood culture contamination and drug-resistant microorganism acquisition: an interrupted time series analysis. CRIT CARE RESUSC 2018; 20:231-240. [PMID: 30153786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND Health care-associated infections are a major cause of morbidity and mortality in intensive care patients. The effect of daily washing with chlorhexidine on these infections is controversial. METHODS Single-centre, retrospective, open-label, sequential period, interrupted time series (ITS) analysis in a 31-bed tertiary referral mixed intensive care unit (ICU), comparing daily washing with water and soap (from January 2011 to August 2013) with chlorhexidine washing (from November 2013 to December 2015), after the introduction of a unit-level policy of chlorhexidine washing. All patients in the ICU were included in the study, except: if they were under 18 years of age, if their ICU stay was less than 24 hours (to ensure that all studied patients had at least one exposure to the daily wash intervention), or if patients had a known allergy to chlorhexidine. Outcome measures included: clinically significant positive blood cultures attributable to the ICU stay; contaminated blood cultures; newly acquired multidrug-resistant microorganisms (MDRO) such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE) or multidrug-resistant gram-negative (MRGN) isolates attributable to ICU from clinical and screening cultures; and newly acquired Clostridium difficile infections (CDIs). Incidence rates of these outcomes were calculated per 1000 patient days. MDRO acquisition rates were corrected for background hospital period prevalence rates of MDRO. RESULTS A total of 6634 patients were included in the study. ITS analysis showed no significant level or slope changes in any of the outcome measures after implementation of chlorhexidine washing. The incidence rate of clinically significant positive blood cultures during the chlorhexidine period compared with the water and soap period was 3.6 v 4.7 (P =0.37); blood culture contamination rates were 11.8 v 9.5 (P =0.56); incidence rates of new ICU-associated MDRO acquisitions were 3.22 v 3.69 (P =0.27); incidence rates of new CDI were 2.01 v 0.79 (P =0.16). Outcomes after adjustment for known and potential confounders were similar. CONCLUSIONS In this real-world, long term ICU study, implementation of a unit-level policy of daily washing with chlorhexidine impregnated cloths was not associated with a reduction in the rates of ICU-associated clinically significant positive blood cultures, blood culture contamination, newly acquired MDRO isolates, and CDIs.
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Affiliation(s)
- Roel Kengen
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia.
| | - Elcke Thoonen
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia
| | - Kathryn Daveson
- Infectious Diseases and Microbiology, Canberra Hospital, Woden, ACT, Australia
| | - Bronwyn Loong
- Research School of Finance, Actuarial Studies and Applied Statistics, Australian National University, Canberra, ACT, Australia
| | - Helen Rodgers
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia
| | - Wendy Beckingham
- Infection Prevention and Control, Canberra Hospital, Woden, ACT, Australia
| | - Karina Kennedy
- Infectious Diseases and Microbiology, Canberra Hospital, Woden, ACT, Australia
| | | | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Woden, ACT, Australia
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20
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Young PJ, Bagshaw SM, Forbes A, Nichol A, Wright SE, Bellomo R, Bailey MJ, Beasley RW, Eastwood GM, Festa M, Gattas D, van Haren F, Litton E, Mouncey PR, Navarra L, Pilcher D, Mackle DM, McArthur CJ, McGuinness SP, Saxena MK, Webb S, Rowan KM. A cluster randomised, crossover, registry-embedded clinical trial of proton pump inhibitors versus histamine-2 receptor blockers for ulcer prophylaxis therapy in the intensive care unit (PEPTIC study): study protocol. CRIT CARE RESUSC 2018; 20:182-189. [PMID: 30153780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
BACKGROUND The balance of risks and benefits with using proton pump inhibitors (PPIs) versus histamine-2 receptor blockers (H2RB) for stress ulcer prophylaxis in patients who are invasively ventilated in the intensive care unit (ICU) is uncertain. OBJECTIVE To describe the study protocol and statistical analysis plan for the Proton Pump Inhibitors versus Histamine-2 Receptor Blockers for Ulcer Prophylaxis Therapy in the Intensive Care Unit (PEPTIC) study. DESIGN, SETTING AND PARTICIPANTS Protocol for a prospective, multicentre, randomised, open-label, cluster crossover, registry-embedded trial to be conducted in 50 ICUs in Australia, Canada, Ireland, New Zealand and the United Kingdom. The PEPTIC study will compare two approaches to stress ulcer prophylaxis in mechanically ventilated adults implemented at the level of the ICU. One approach is to use PPIs as the default therapy and the other approach is to use H2RBs as the default therapy when stress ulcer prophylaxis is prescribed. Each ICU, by random allocation, will use one approach for 6 months and will then switch to the opposite approach for the next 6 months. The PEPTIC study began recruitment in August 2016 and will complete recruitment in January 2019. MAIN OUTCOME MEASURES The primary end point will be in-hospital mortality. Secondary outcomes include clinically significant upper gastrointestinal bleeding, Clostridium difficile infection, ICU length of stay and hospital length of stay. RESULTS AND CONCLUSIONS The PEPTIC study will compare the effect on in-hospital mortality of implementing, at the level of the ICU, the use of PPI as the preferred agent for stress ulcer prophylaxis in mechanically ventilated adults in the ICU with using H2RB as the preferred agent. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Registry (ANZCTRN 12616000481471).
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Affiliation(s)
- Paul J Young
- Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand.
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Andrew Forbes
- Biostatistics Unit, Department of Epidemiology and Preventive Medicine at Monash University, Melbourne, Vic, Australia
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Stephen E Wright
- Department of Perioperative and Critical Care, Freeman Hospital, Newcastle upon Tyne, United Kingdom
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Michael J Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | | | | | - Marino Festa
- Intensive Care Unit, Children's Hospital at Westmead, Sydney, NSW, Australia
| | - David Gattas
- Intensive Care Unit, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Leanlove Navarra
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Diane M Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Colin J McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Manoj K Saxena
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Steve Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, United Kingdom
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21
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Litton E, McCann M, van Haren F. Predicting Intensive Care Unit Length of Stay After Cardiac Surgery. J Cardiothorac Vasc Anesth 2018; 32:2683-2684. [PMID: 29752055 DOI: 10.1053/j.jvca.2018.04.010] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Edward Litton
- Fiona Stanley Hospital, Perth, WA, Australia; St John of God Hospital, Subiaco, Perth, WA, Australia
| | | | - Frank van Haren
- Canberra Hospital, Canberra, Australia; Australian National University, Medical School, Canberra, Australia
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22
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Abstract
The administration of intravenous fluid to critically ill patients is one of the most common, but also one of the most fiercely debated, interventions in intensive care medicine. Even though many thousands of patients have been enrolled in large trials of alternative fluid strategies, consensus remains elusive and practice is widely variable. Critically ill patients are significantly heterogeneous, making a one size fits all approach unlikely to be successful.New data from basic, animal, and clinical research suggest that fluid resuscitation could be associated with significant harm. There are several important limitations and concerns regarding fluid bolus therapy as it is currently being used in clinical practice. These include, but are not limited to: the lack of an agreed definition; limited and short-lived physiological effects; no evidence of an effect on relevant patient outcomes; and the potential to contribute to fluid overload, specifically when fluid responsiveness is not assessed and when targets and safety limits are not used.Fluid administration in critically ill patients requires clinicians to integrate abnormal physiological parameters into a clinical decision-making model that also incorporates the likely diagnosis and the likely risk or benefit in the specific patient's context. Personalised fluid resuscitation requires careful attention to the mnemonic CIT TAIT: context, indication, targets, timing, amount of fluid, infusion strategy, and type of fluid.The research agenda should focus on experimental and clinical studies to: improve our understanding of the physiological effects of fluid infusion, e.g. on the glycocalyx; evaluate new types of fluids; evaluate novel fluid minimisation protocols; study the effects of a no-fluid strategy for selected patients and scenarios; and compare fluid therapy with other interventions. The adaptive platform trial design may provide us with the tools to evaluate these types of interventions in the intrinsically heterogeneous intensive care unit population, accounting for the explicit assumption that treatment effects may be heterogeneous.
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Affiliation(s)
- Frank van Haren
- University of Canberra, Canberra, Australia. .,Australian National University, Canberra, Australia. .,Intensive Care Unit, Canberra Hospital, Canberra, Australia.
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23
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Vellinga NAR, Boerma EC, Koopmans M, Donati A, Dubin A, Shapiro NI, Pearse RM, van der Voort PHJ, Dondorp AM, Bafi T, Fries M, Akarsu-Ayazoglu T, Pranskunas A, Hollenberg S, Balestra G, van Iterson M, Sadaka F, Minto G, Aypar U, Hurtado FJ, Martinelli G, Payen D, van Haren F, Holley A, Gomez H, Mehta RL, Rodriguez AH, Ruiz C, Canales HS, Duranteau J, Spronk PE, Jhanji S, Hubble S, Chierego M, Jung C, Martin D, Sorbara C, Bakker J, Ince C. Mildly elevated lactate levels are associated with microcirculatory flow abnormalities and increased mortality: a microSOAP post hoc analysis. Crit Care 2017; 21:255. [PMID: 29047411 PMCID: PMC5646128 DOI: 10.1186/s13054-017-1842-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [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: 09/08/2016] [Accepted: 09/15/2017] [Indexed: 01/08/2023]
Abstract
Background Mildly elevated lactate levels (i.e., 1–2 mmol/L) are increasingly recognized as a prognostic finding in critically ill patients. One of several possible underlying mechanisms, microcirculatory dysfunction, can be assessed at the bedside using sublingual direct in vivo microscopy. We aimed to evaluate the association between relative hyperlactatemia, microcirculatory flow, and outcome. Methods This study was a predefined subanalysis of a multicenter international point prevalence study on microcirculatory flow abnormalities, the Microcirculatory Shock Occurrence in Acutely ill Patients (microSOAP). Microcirculatory flow abnormalities were assessed with sidestream dark-field imaging. Abnormal microcirculatory flow was defined as a microvascular flow index (MFI) < 2.6. MFI is a semiquantitative score ranging from 0 (no flow) to 3 (continuous flow). Associations between microcirculatory flow abnormalities, single-spot lactate measurements, and outcome were analyzed. Results In 338 of 501 patients, lactate levels were available. For this substudy, all 257 patients with lactate levels ≤ 2 mmol/L (median [IQR] 1.04 [0.80–1.40] mmol/L) were included. Crude ICU mortality increased with each lactate quartile. In a multivariable analysis, a lactate level > 1.5 mmol/L was independently associated with a MFI < 2.6 (OR 2.5, 95% CI 1.1–5.7, P = 0.027). Conclusions In a heterogeneous ICU population, a single-spot mildly elevated lactate level (even within the reference range) was independently associated with increased mortality and microvascular flow abnormalities. In vivo microscopy of the microcirculation may be helpful in discriminating between flow- and non-flow-related causes of mildly elevated lactate levels. Trial registration ClinicalTrials.gov, NCT01179243. Registered on August 3, 2010. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1842-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Namkje A R Vellinga
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands. .,Department of Intensive Care, Medical Center Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands.
| | - E Christiaan Boerma
- Department of Intensive Care, Medical Center Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands
| | - Matty Koopmans
- Department of Intensive Care, Medical Center Leeuwarden, P.O. Box 888, 8901 BR, Leeuwarden, The Netherlands
| | - Abele Donati
- Department of Biomedical Science and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Arnaldo Dubin
- Sanatorio Otamendi y Miroli, Servicio de Terapia Intensiva, Azcuénaga 870, Buenos Aires, Argentina
| | - Nathan I Shapiro
- Department of Emergency Medicine and Center for Vascular Biology Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Rupert M Pearse
- Barts and The London School of Medicine and Dentistry, London, UK
| | | | - Arjen M Dondorp
- Faculty of Tropical Medicine, Mahidol University, Bangkok, Thailand
| | - Tony Bafi
- Dor e Terapia Intensiva, Universidade Federal de São Paolo, São Paolo, Brasil
| | - Michael Fries
- Department of Anesthesia and Surgical Intensive Care, St. Vincenz Krankenhaus, Limburg, Germany
| | - Tulin Akarsu-Ayazoglu
- S.B. Medeniyet University Göztepe Education and Research Hospital Kadıköy, Istanbul, Turkey
| | - Andrius Pranskunas
- Intensive Care Department, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | | | - Gianmarco Balestra
- Medical Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Mat van Iterson
- Department of Anesthesiology, Intensive Care and Pain Management, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Farid Sadaka
- Critical Care Medicine/Neurocritical Care, Mercy Hospital St. Louis, St. Louis University Hospital, St. Louis, MO, USA
| | - Gary Minto
- Derriford Hospital, Plymouth University Peninsula School of Medicine, Plymouth, UK
| | - Ulku Aypar
- Intensive Care Unit, Hacettepe University, Ankara, Turkey
| | - F Javier Hurtado
- Intensive Care Unit, Hospital Español-State Health Administration Service, School of Medicine, University of the Republic, Montevideo, Uruguay
| | - Giampaolo Martinelli
- Department of Perioperative Medicine, Barts Heart Centre, St. Bartholomew's Hospital, London, UK
| | - Didier Payen
- Department of Anesthesiology, Critical Care and Mobile Emergency and Resuscitation Service (SMUR), Hôpital Lariboisière Assistance Publique - Hôpitaux de Paris (AP-HP)/Université Paris 7 Diderot, Paris, France
| | | | - Anthony Holley
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Australia
| | - Hernando Gomez
- Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ravindra L Mehta
- School of Medicine, University of California, San Diego, San Diego, CA, USA
| | | | - Carolina Ruiz
- Departamento de Medicina Intensiva, Escuela de Medicina, Facultad de Medicina, Universidad Católica de Chile, Santiago, Chile
| | | | - Jacques Duranteau
- Departement d'Anesthesie-Reanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre Assistance Publique - Hôpitaux de Paris (AP-HP), Le Kremlin-Bicêtre, Paris, France
| | - Peter E Spronk
- Intensive Care Unit, Gelre Ziekenhuizen, Apeldoorn, The Netherlands
| | - Shaman Jhanji
- Intensive Care Unit, The Royal Marsden Hospital, London, UK
| | - Sheena Hubble
- Intensive Care Unit, Royal Devon and Exeter Hospital, Exeter, UK
| | | | - Christian Jung
- Department of Cardiology, Universitätsherzzentrum Thüringen, Clinic of Internal Medicine I, Friedrich Schiller University Jena, Jena, Germany.,Division of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Düsseldorf, Düsseldorf, Germany
| | - Daniel Martin
- Intensive Care Unit, Royal Free Hospital, London, UK
| | - Carlo Sorbara
- Dipartimento di Anestesia, Rianimazione e Terapia Intensiva, Azienda Unità Locale Socio Sanitaria 9 (ULSS 9) Veneto, Treviso, Italy
| | - Jan Bakker
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Can Ince
- Department of Intensive Care Adults, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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24
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Bellani G, Laffey JG, Pham T, Madotto F, Fan E, Brochard L, Esteban A, Gattinoni L, Bumbasirevic V, Piquilloud L, van Haren F, Larsson A, McAuley DF, Bauer PR, Arabi YM, Ranieri M, Antonelli M, Rubenfeld GD, Thompson BT, Wrigge H, Slutsky AS, Pesenti A. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am J Respir Crit Care Med 2017; 195:67-77. [PMID: 27753501 DOI: 10.1164/rccm.201606-1306oc] [Citation(s) in RCA: 351] [Impact Index Per Article: 50.1] [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: 12/14/2022] Open
Abstract
RATIONALE Noninvasive ventilation (NIV) is increasingly used in patients with acute respiratory distress syndrome (ARDS). The evidence supporting NIV use in patients with ARDS remains relatively sparse. OBJECTIVES To determine whether, during NIV, the categorization of ARDS severity based on the PaO2/FiO2 Berlin criteria is useful. METHODS The LUNG SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) study described the management of patients with ARDS. This substudy examines the current practice of NIV use in ARDS, the utility of the PaO2/FiO2 ratio in classifying patients receiving NIV, and the impact of NIV on outcome. MEASUREMENTS AND MAIN RESULTS Of 2,813 patients with ARDS, 436 (15.5%) were managed with NIV on Days 1 and 2 following fulfillment of diagnostic criteria. Classification of ARDS severity based on PaO2/FiO2 ratio was associated with an increase in intensity of ventilatory support, NIV failure, and intensive care unit (ICU) mortality. NIV failure occurred in 22.2% of mild, 42.3% of moderate, and 47.1% of patients with severe ARDS. Hospital mortality in patients with NIV success and failure was 16.1% and 45.4%, respectively. NIV use was independently associated with increased ICU (hazard ratio, 1.446 [95% confidence interval, 1.159-1.805]), but not hospital, mortality. In a propensity matched analysis, ICU mortality was higher in NIV than invasively ventilated patients with a PaO2/FiO2 lower than 150 mm Hg. CONCLUSIONS NIV was used in 15% of patients with ARDS, irrespective of severity category. NIV seems to be associated with higher ICU mortality in patients with a PaO2/FiO2 lower than 150 mm Hg. Clinical trial registered with www.clinicaltrials.gov (NCT 02010073).
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Affiliation(s)
- Giacomo Bellani
- 1 Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,2 Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- 3 Department of Anesthesia.,4 Department of Critical Care Medicine, and.,5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,6 Department of Anesthesia.,7 Department of Physiology.,8 Interdepartmental Division of Critical Care Medicine
| | - Tài Pham
- 9 Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Unité de Réanimation Médico-Chirurgicale, Pôle Thorax Voies Aériennes, Groupe Hospitalier des Hôpitaux Universitaires de l'Est Parisien, Paris, France.,10 Unité Mixte de Recherche 1153, Inserm, Sorbonne Paris Cité, Epidémiologie Clinique et Statistiques, pour la Recherche en Santé Team, Université Paris Diderot, Paris, France.,11 Sorbonne Universités, Université Pierre et Marie Curie, Paris 06, France
| | - Fabiana Madotto
- 12 Research Centre on Public Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Eddy Fan
- 8 Interdepartmental Division of Critical Care Medicine.,13 Institute of Health Policy, Management and Evaluation, and.,14 Department of Medicine, University of Toronto, Toronto, Canada.,15 Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Laurent Brochard
- 4 Department of Critical Care Medicine, and.,8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada.,15 Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Andres Esteban
- 16 Hospital Universitario de Getafe, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Luciano Gattinoni
- 17 Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Vesna Bumbasirevic
- 18 School of Medicine, University of Belgrade, Belgrade, Serbia.,19 Department of Anesthesia and Intensive Care, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Lise Piquilloud
- 20 Adult Intensive Care and Burn Unit, University Hospital of Lausanne, Lausanne, Switzerland.,21 Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Frank van Haren
- 22 Intensive Care Unit, The Canberra Hospital, Canberra, Australia.,23 Australian National University, Canberra, Australia
| | - Anders Larsson
- 24 Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- 25 Centre for Experimental Medicine, Queen's University of Belfast, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, United Kingdom.,26 Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Philippe R Bauer
- 27 Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yaseen M Arabi
- 28 King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,29 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marco Ranieri
- 30 Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Sapienza Università di Roma, Roma, Italy
| | - Massimo Antonelli
- 31 Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Gordon D Rubenfeld
- 8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada.,32 Sunnybrook Health Sciences Center, Toronto, Canada
| | - B Taylor Thompson
- 33 Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hermann Wrigge
- 34 Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Arthur S Slutsky
- 5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada
| | - Antonio Pesenti
- 35 Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione Istituto di ricovero e Cura a Carattere Scientifico Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy; and.,36 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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25
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Laffey JG, Madotto F, Bellani G, Pham T, Fan E, Brochard L, Amin P, Arabi Y, Bajwa EK, Bruhn A, Cerny V, Clarkson K, Heunks L, Kurahashi K, Laake JH, Lorente JA, McNamee L, Nin N, Palo JE, Piquilloud L, Qiu H, Jiménez JIS, Esteban A, McAuley DF, van Haren F, Ranieri M, Rubenfeld G, Wrigge H, Slutsky AS, Pesenti A. Geo-economic variations in epidemiology, patterns of care, and outcomes in patients with acute respiratory distress syndrome: insights from the LUNG SAFE prospective cohort study. Lancet Respir Med 2017. [PMID: 28624388 DOI: 10.1016/s2213-2600(17)30213-8] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND Little information is available about the geo-economic variations in demographics, management, and outcomes of patients with acute respiratory distress syndrome (ARDS). We aimed to characterise the effect of these geo-economic variations in patients enrolled in the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE). METHODS LUNG SAFE was done during 4 consecutive weeks in winter, 2014, in a convenience sample of 459 intensive-care units in 50 countries across six continents. Inclusion criteria were admission to a participating intensive-care unit (including transfers) within the enrolment window and receipt of invasive or non-invasive ventilation. One of the trial's secondary aims was to characterise variations in the demographics, management, and outcome of patients with ARDS. We used the 2016 World Bank countries classification to define three major geo-economic groupings, namely European high-income countries (Europe-High), high-income countries in the rest of the world (rWORLD-High), and middle-income countries (Middle). We compared patient outcomes across these three groupings. LUNG SAFE is registered with ClinicalTrials.gov, number NCT02010073. FINDINGS Of the 2813 patients enrolled in LUNG SAFE who fulfilled ARDS criteria on day 1 or 2, 1521 (54%) were recruited from Europe-High, 746 (27%) from rWORLD-High, and 546 (19%) from Middle countries. We noted significant geographical variations in demographics, risk factors for ARDS, and comorbid diseases. The proportion of patients with severe ARDS or with ratios of the partial pressure of arterial oxygen (PaO2) to the fractional concentration of oxygen in inspired air (FiO2) less than 150 was significantly lower in rWORLD-High countries than in the two other regions. Use of prone positioning and neuromuscular blockade was significantly more common in Europe-High countries than in the other two regions. Adjusted duration of invasive mechanical ventilation and length of stay in the intensive-care unit were significantly shorter in patients in rWORLD-High countries than in Europe-High or Middle countries. High gross national income per person was associated with increased survival in ARDS; hospital survival was significantly lower in Middle countries than in Europe-High or rWORLD-High countries. INTERPRETATION Important geo-economic differences exist in the severity, clinician recognition, and management of ARDS, and in patients' outcomes. Income per person and outcomes in ARDS are independently associated. FUNDING European Society of Intensive Care Medicine, St Michael's Hospital, University of Milan-Bicocca.
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Affiliation(s)
- John G Laffey
- Department of Anesthesia, St Michael's Hospital, Toronto, ON, Canada; Department of Critical Care Medicine, St Michael's Hospital, Toronto, ON, Canada; Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Department of Anesthesia, University of Toronto, Toronto, ON, Canada; Department of Physiology, University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
| | - Fabiana Madotto
- Research Center on Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Giacomo Bellani
- Research Center on Public Health, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy; Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - Tài Pham
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Sorbonne Universités, UPMC Université Paris 06, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada; Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, ON, Canada
| | - Laurent Brochard
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Pravin Amin
- Department of Critical Care Medicine, Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | - Yaseen Arabi
- Intensive Care Department, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia; Respiratory Services, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia; King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Ednan K Bajwa
- Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Alejandro Bruhn
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Vladimir Cerny
- Department of Anesthesiology, Perioperative Medicine and Intensive Care, J E Purkinje University, Masaryk Hospital, Usti nad Labem, Czech Republic; Department of Research and Development, and Department of Anesthesiology and Intensive Care, Charles University in Prague, Prague, Czech Republic; Faculty of Medicine in Hradec Kralove, Hradec Kralove, Czech Republic
| | - Kevin Clarkson
- Department of Anaesthesia, Galway University Hospitals and National University of Ireland, Galway, Galway, Ireland
| | - Leo Heunks
- Department of Intensive Care, VU University Medical Centre Amsterdam, Netherlands
| | - Kiyoyasu Kurahashi
- Department of Anesthesiology and Intensive Care Medicine, School of Medicine, International University of Health and Welfare, Narita, Japan
| | - Jon Henrik Laake
- Division of Critical Care, Department of Anaesthesiology, Rikshospitalet Medical Centre, Oslo University Hospital, Oslo, Norway
| | - Jose A Lorente
- CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain
| | - Lia McNamee
- Centre for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland, UK; Wellcome-Wolfson Institute for Experimental Medicine, Belfast, Northern Ireland, UK; Regional Intensive Care Unit, Royal Victoria Hospital A&E, Grosvenor Road, Belfast, Northern Ireland, UK
| | - Nicolas Nin
- CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain; Hospital Español, Montevideo, Uruguay
| | - Jose Emmanuel Palo
- Section of Adult Critical Care, Department of Medicine, The Medical City, Pasig, Philippines
| | - Lise Piquilloud
- Adult Intensive Care and Burn Unit, University Hospital of Lausanne, Lausanne, Switzerland; Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Haibo Qiu
- Department of Critical Care Medicine, Nanjing Zhongda Hospital, School of Medicine, Southeast University, Nanjing 210009, China
| | - Juan Ignacio Silesky Jiménez
- Department of Intensive Care, Hospital San Juan de Dios, and Department of Intensive Care, Hospital CIMA San Jose, Council of Critical Medicine, University of Costa Rica, San Pedro Montes de Oca, Costa Rica
| | - Andres Esteban
- CIBER de Enfermedades Respiratorias, Hospital Universitario de Getafe, Universidad Europea, Madrid, Spain; Hospital Español, Montevideo, Uruguay
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland, UK; Wellcome-Wolfson Institute for Experimental Medicine, Belfast, Northern Ireland, UK; Regional Intensive Care Unit, Royal Victoria Hospital A&E, Grosvenor Road, Belfast, Northern Ireland, UK
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, Canberra, ACT, Australia; Australian National University, Canberra, ACT, Australia
| | - Marco Ranieri
- Sapienza Università di Roma, Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Rome, Italy
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Program in Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Center, Toronto, ON, Canada
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione IRCCS Cà Granda-Ospedale Maggiore Policlinico and Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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Reade MC, Eastwood GM, Bellomo R, Bailey M, Bersten A, Cheung B, Davies A, Delaney A, Ghosh A, van Haren F, Harley N, Knight D, McGuiness S, Mulder J, O'Donoghue S, Simpson N, Young P. Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial. JAMA 2016; 315:1460-8. [PMID: 26975647 DOI: 10.1001/jama.2016.2707] [Citation(s) in RCA: 220] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Effective therapy has not been established for patients with agitated delirium receiving mechanical ventilation. OBJECTIVE To determine the effectiveness of dexmedetomidine when added to standard care in patients with agitated delirium receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS The Dexmedetomidine to Lessen ICU Agitation (DahLIA) study was a double-blind, placebo-controlled, parallel-group randomized clinical trial involving 74 adult patients in whom extubation was considered inappropriate because of the severity of agitation and delirium. The study was conducted at 15 intensive care units in Australia and New Zealand from May 2011 until December 2013. Patients with advanced dementia or traumatic brain injury were excluded. INTERVENTIONS Bedside nursing staff administered dexmedetomidine (or placebo) initially at a rate of 0.5 µg/kg/h and then titrated to rates between 0 and 1.5 µg/kg/h to achieve physician-prescribed sedation goals. The study drug or placebo was continued until no longer required or up to 7 days. All other care was at the discretion of the treating physician. MAIN OUTCOMES AND MEASURES Ventilator-free hours in the 7 days following randomization. There were 21 reported secondary outcomes that were defined a priori. RESULTS Of the 74 randomized patients (median age, 57 years; 18 [24%] women), 2 withdrew consent later and 1 was found to have been randomized incorrectly, leaving 39 patients in the dexmedetomidine group and 32 patients in the placebo group for analysis. Dexmedetomidine increased ventilator-free hours at 7 days compared with placebo (median, 144.8 hours vs 127.5 hours, respectively; median difference between groups, 17.0 hours [95% CI, 4.0 to 33.2 hours]; P = .01). Among the 21 a priori secondary outcomes, none were significantly worse with dexmedetomidine, and several showed statistically significant benefit, including reduced time to extubation (median, 21.9 hours vs 44.3 hours with placebo; median difference between groups, 19.5 hours [95% CI, 5.3 to 31.1 hours]; P < .001) and accelerated resolution of delirium (median, 23.3 hours vs 40.0 hours; median difference between groups, 16.0 hours [95% CI, 3.0 to 28.0 hours]; P = .01). Using hierarchical Cox modeling to adjust for imbalanced baseline characteristics, allocation to dexmedetomidine was significantly associated with earlier extubation (hazard ratio, 0.47 [95% CI, 0.27-0.82]; P = .007). CONCLUSIONS AND RELEVANCE Among patients with agitated delirium receiving mechanical ventilation in the intensive care unit, the addition of dexmedetomidine to standard care compared with standard care alone (placebo) resulted in more ventilator-free hours at 7 days. The findings support the use of dexmedetomidine in patients such as these. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01151865.
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Affiliation(s)
- Michael C Reade
- Burns, Trauma, and Critical Care Research Centre, University of Queensland and Joint Health Command, Australian Defence Force, Brisbane, Australia
| | | | - Rinaldo Bellomo
- School of Medicine, University of Melbourne and Austin Hospital, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | | | | | | | | | - David Knight
- Christchurch Hospital, Christchurch, New Zealand
| | | | | | | | | | - Paul Young
- Wellington Hospital, Wellington, New Zealand18Medical Research Institute of New Zealand, Wellington
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Bellani G, Laffey JG, Pham T, Fan E, Brochard L, Esteban A, Gattinoni L, van Haren F, Larsson A, McAuley DF, Ranieri M, Rubenfeld G, Thompson BT, Wrigge H, Slutsky AS, Pesenti A. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. JAMA 2016; 315:788-800. [PMID: 26903337 DOI: 10.1001/jama.2016.0291] [Citation(s) in RCA: 3000] [Impact Index Per Article: 375.0] [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: 12/20/2022]
Abstract
IMPORTANCE Limited information exists about the epidemiology, recognition, management, and outcomes of patients with the acute respiratory distress syndrome (ARDS). OBJECTIVES To evaluate intensive care unit (ICU) incidence and outcome of ARDS and to assess clinician recognition, ventilation management, and use of adjuncts-for example prone positioning-in routine clinical practice for patients fulfilling the ARDS Berlin Definition. DESIGN, SETTING, AND PARTICIPANTS The Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE) was an international, multicenter, prospective cohort study of patients undergoing invasive or noninvasive ventilation, conducted during 4 consecutive weeks in the winter of 2014 in a convenience sample of 459 ICUs from 50 countries across 5 continents. EXPOSURES Acute respiratory distress syndrome. MAIN OUTCOMES AND MEASURES The primary outcome was ICU incidence of ARDS. Secondary outcomes included assessment of clinician recognition of ARDS, the application of ventilatory management, the use of adjunctive interventions in routine clinical practice, and clinical outcomes from ARDS. RESULTS Of 29,144 patients admitted to participating ICUs, 3022 (10.4%) fulfilled ARDS criteria. Of these, 2377 patients developed ARDS in the first 48 hours and whose respiratory failure was managed with invasive mechanical ventilation. The period prevalence of mild ARDS was 30.0% (95% CI, 28.2%-31.9%); of moderate ARDS, 46.6% (95% CI, 44.5%-48.6%); and of severe ARDS, 23.4% (95% CI, 21.7%-25.2%). ARDS represented 0.42 cases per ICU bed over 4 weeks and represented 10.4% (95% CI, 10.0%-10.7%) of ICU admissions and 23.4% of patients requiring mechanical ventilation. Clinical recognition of ARDS ranged from 51.3% (95% CI, 47.5%-55.0%) in mild to 78.5% (95% CI, 74.8%-81.8%) in severe ARDS. Less than two-thirds of patients with ARDS received a tidal volume 8 of mL/kg or less of predicted body weight. Plateau pressure was measured in 40.1% (95% CI, 38.2-42.1), whereas 82.6% (95% CI, 81.0%-84.1%) received a positive end-expository pressure (PEEP) of less than 12 cm H2O. Prone positioning was used in 16.3% (95% CI, 13.7%-19.2%) of patients with severe ARDS. Clinician recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockade, and prone positioning. Hospital mortality was 34.9% (95% CI, 31.4%-38.5%) for those with mild, 40.3% (95% CI, 37.4%-43.3%) for those with moderate, and 46.1% (95% CI, 41.9%-50.4%) for those with severe ARDS. CONCLUSIONS AND RELEVANCE Among ICUs in 50 countries, the period prevalence of ARDS was 10.4% of ICU admissions. This syndrome appeared to be underrecognized and undertreated and associated with a high mortality rate. These findings indicate the potential for improvement in the management of patients with ARDS. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02010073.
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Affiliation(s)
- Giacomo Bellani
- School of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy2Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- Departments of Anesthesia and Critical Care Medicine, Keenan Research Centre for Biomedical Science, St Michael's Hospital4Departments of Anesthesia, Physiology and Interdepartmental division of Critical Care Medicine, University of Toronto, Canada
| | - Tài Pham
- AP-HP, Hôpital Tenon, Unité de Réanimation médico-chirurgicale, Pôle Thorax Voies aériennes, Groupe hospitalier des Hôpitaux Universitaires de l'Est Parisien, Paris, France6UMR 1153, Inserm, Sorbonne Paris Cité, ECSTRA Team, Université Paris Diderot, Pari
| | - Eddy Fan
- Department of Medicine, University Health Network and Mount Sinai Hospital9Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada
| | - Laurent Brochard
- Keenan Research Centre, Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Canada11Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - Andres Esteban
- Hospital Universitario de Getafe, CIBER de Enfermedades Respiratorias, Madrid, Spain
| | - Luciano Gattinoni
- Istituto di Anestesia e Rianimazione, Università degli Studi di Milano, Ospedale Maggiore, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
| | - Frank van Haren
- Intensive Care Unit, Canberra Hospital, and Australian National University, Canberra, Australia
| | - Anders Larsson
- Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- Centre for Experimental Medicine, Queen's University of Belfast, Belfast, Northern Ireland17Wellcome-Wolfson Institute for Experimental Medicine, Belfast, Northern Ireland18Regional Intensive Care Unit, Royal Victoria Hospital, Grosvenor Road, Belfast, No
| | - Marco Ranieri
- SAPIENZA Università di ROMA, Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Viale del Policlinico 155, 00161 Roma, Italy
| | - Gordon Rubenfeld
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada21Program in Trauma, Emergency and Critical Care, Sunnybrook Health Sciences Center, Toronto, Canada
| | - B Taylor Thompson
- Division of Pulmonary and Critical Care Unit, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Liebigstr. 20, D-04103 Leipzig, Germany
| | - Arthur S Slutsky
- Keenan Research Center at the Li Ka Shing Knowledge Institute of St Michael's Hospital, the Interdepartmental Division of Critical Care Medicine, and the Department of Medicine, University of Toronto, Toronto, Canada
| | - Antonio Pesenti
- Istituto di Anestesia e Rianimazione, Università degli Studi di Milano, Ospedale Maggiore, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy
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Young P, Saxena M, Bellomo R, Freebairn R, Hammond N, van Haren F, Holliday M, Henderson S, Mackle D, McArthur C, McGuinness S, Myburgh J, Weatherall M, Webb S, Beasley R. Acetaminophen for Fever in Critically Ill Patients with Suspected Infection. N Engl J Med 2015; 373:2215-24. [PMID: 26436473 DOI: 10.1056/nejmoa1508375] [Citation(s) in RCA: 130] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Acetaminophen is a common therapy for fever in patients in the intensive care unit (ICU) who have probable infection, but its effects are unknown. METHODS We randomly assigned 700 ICU patients with fever (body temperature, ≥38°C) and known or suspected infection to receive either 1 g of intravenous acetaminophen or placebo every 6 hours until ICU discharge, resolution of fever, cessation of antimicrobial therapy, or death. The primary outcome was ICU-free days (days alive and free from the need for intensive care) from randomization to day 28. RESULTS The number of ICU-free days to day 28 did not differ significantly between the acetaminophen group and the placebo group: 23 days (interquartile range, 13 to 25) among patients assigned to acetaminophen and 22 days (interquartile range, 12 to 25) among patients assigned to placebo (Hodges-Lehmann estimate of absolute difference, 0 days; 96.2% confidence interval [CI], 0 to 1; P=0.07). A total of 55 of 345 patients in the acetaminophen group (15.9%) and 57 of 344 patients in the placebo group (16.6%) had died by day 90 (relative risk, 0.96; 95% CI, 0.66 to 1.39; P=0.84). CONCLUSIONS Early administration of acetaminophen to treat fever due to probable infection did not affect the number of ICU-free days. (Funded by the Health Research Council of New Zealand and others; HEAT Australian New Zealand Clinical Trials Registry number, ACTRN12612000513819.).
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Affiliation(s)
- Paul Young
- From the Intensive Care Unit, Wellington Regional Hospital (P.Y., D.M.), Medical Research Institute of New Zealand (P.Y., R.F., M.H., S.H., D.M., C.M., S.M., R. Beasley), and Wellington School of Medicine, University of Otago (M.W.), Wellington, Intensive Care Unit, Hawke's Bay Hospital, Hastings (R.F.), Intensive Care Unit, Christchurch Hospital, Christchurch (S.H.), and the Department of Critical Care Medicine (C.M.) and Cardiothoracic and Vascular Intensive Care Unit (S.M.), Auckland City Hospital, Auckland - all in New Zealand; and the Critical Care and Trauma Division, George Institute for Global Health, Sydney (M.S., N.H., J.M.), Intensive Care Unit, St. George Hospital, Kogarah (M.S., J.M.), Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St. Leonards (N.H.), and Faculty of Medicine, St. George Clinical School, University of New South Wales, Kensington (J.M.), NSW, Intensive Care Unit, Austin Hospital (R. Bellomo), the Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University (R. Bellomo), and Faculty of Medicine, University of Melbourne (R. Bellomo), Melbourne, VIC, the Intensive Care Unit, Canberra Hospital, Canberra, ACT (F.H.), and the Intensive Care Unit, Royal Perth Hospital, Perth (S.W.), and the School of Medicine and Pharmacology, University of Western Australia, Crawley (S.W.), WA - all in Australia
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Haren FV, Cohen J, McKee A, Mitchell I, Pinder M, Seppelt I. Infection control in times of Ebola: how well are we training the next generation of intensivists in Australia and New Zealand? CRIT CARE RESUSC 2015; 17:65-66. [PMID: 26017121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Affiliation(s)
- Frank van Haren
- Intensive Care Unit, The Canberra Hospital, Canberra, ACT, Australia.
| | - Jeremy Cohen
- Intensive Care Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Andrew McKee
- Cardiovascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
| | - Imogen Mitchell
- Intensive Care Unit, The Canberra Hospital, Canberra, ACT, Australia
| | - Mary Pinder
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia
| | - Ian Seppelt
- Intensive Care Unit, Nepean Hospital, Penrith, NSW, Australia
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