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Renger L, Dhanani J, Milford E, Tabah A, Shekar K, Ramanan M, Laupland KB. Cannabis use disorders and outcome of admission to intensive care: A retrospective multi-centre cohort study. J Crit Care 2024; 80:154504. [PMID: 38128218 DOI: 10.1016/j.jcrc.2023.154504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 12/08/2023] [Indexed: 12/23/2023]
Abstract
PURPOSE To identify factors associated with cannabinoid use among patients admitted to ICU and its impact on survival. METHODS A cohort of adult patients admitted to four public Australian ICUs was assembled. Individuals with mental and behavioural disorders related to cannabinoids were identified using ICD10-AM codes. RESULTS Of a cohort of 34,680 admissions among 28,689 adults, 292 (0.8%) had an associated diagnosis related to cannabinoids, of which 66% were classified as harmful use, 26% as dependence syndrome/withdrawal state, 4% as psychosis/delirium, and 4% as acute intoxication. Patients with cannabinoid-use disorders were more likely to be male (73%), tended to be younger (36 vs 62 years), with fewer comorbidities and lesser severity of disease. ICU LOS was longer for those with cannabinoid-use disorders (2 vs 1 days; p < 0.0001). Patients with cannabinoid-use disorders had lower 90-day case-fatality (6% vs. 10%; p = 0.034), however no significant effect on mortality was present after adjustment for severity of illness, age, and chronic comorbidities (p = 1.0). CONCLUSION Cannabinoid-use disorders were present in 0.8% of ICU admissions in our region and were associated with increased ICU length of stay. Further studies are needed to examine cannabinoids as contributors to and modifiers of critical illness.
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Affiliation(s)
- Laura Renger
- Department of Intensive Care Services, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia.
| | - Jayesh Dhanani
- Department of Intensive Care Services, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Elissa Milford
- Department of Intensive Care Services, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland Centre for Clinical Research, Brisbane, Queensland, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia
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Lin FF, Chen Y, Rattray M, Murray L, Jacobs K, Brailsford J, Free P, Garrett P, Tabah A, Ramanan M. Interventions to improve patient admission and discharge practices in adult intensive care units: A systematic review. Intensive Crit Care Nurs 2024:103688. [PMID: 38494383 DOI: 10.1016/j.iccn.2024.103688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 03/08/2024] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Abstract
OBJECTIVES To identify and synthesise interventions and implementation strategies to optimise patient flow, addressing admission delays, discharge delays, and after-hours discharges in adult intensive care units. METHODS This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Five electronic databases, including CINAHL, PubMed, Emcare, Scopus, and the Cochrane Library, were searched from 2007 to 2023 to identify articles describing interventions to enhance patient flow practices in adult intensive care units. The Critical Appraisal Skills Program (CASP) tool assessed the methodological quality of the included studies. All data was synthesised using a narrative approach. SETTING Adult intensive care units. RESULTS Eight studies met the inclusion criteria, mainly comprising quality improvement projects (n = 3) or before-and-after studies (n = 4). Intervention types included changing workflow processes, introducing decision support tools, publishing quality indicator data, utilising outreach nursing services, and promoting multidisciplinary communication. Various implementation strategies were used, including one-on-one training, in-person knowledge transfer, digital communication, and digital data synthesis and display. Most studies (n = 6) reported a significant improvement in at least one intensive care process-related outcome, although fewer studies specifically reported improvements in admission delays (0/0), discharge delays (1/2), and after-hours discharge (2/4). Two out of six studies reported significant improvements in patient-related outcomes after implementing the intervention. CONCLUSION Organisational-level strategies, such as protocols and alert systems, were frequently employed to improve patient flow within ICUs, while healthcare professional-level strategies to enhance communication were less commonly used. While most studies improved ICU processes, only half succeeded in significantly reducing discharge delays and/or after-hours discharges, and only a third reported improved patient outcomes, highlighting the need for more effective interventions. IMPLICATIONS FOR CLINICAL PRACTICE The findings of this review can guide the development of evidence-based, targeted, and tailored interventions aimed at improving patient and organisational outcomes.
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Affiliation(s)
- Frances Fengzhi Lin
- College of Nursing and Health Sciences, Flinders University, South Australia, Australia; Caring Futures Institute, Flinders University, South Australia, Australia; School of Health, University of the Sunshine Coast, Queensland, Australia.
| | - Yingyan Chen
- School of Health, University of the Sunshine Coast, Queensland, Australia
| | - Megan Rattray
- College of Medicine & Public Health, Flinders University, South Australia, Australia
| | - Lauren Murray
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Kylie Jacobs
- Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Jane Brailsford
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Patricia Free
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Peter Garrett
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Alexis Tabah
- Redcliffe Hospital, Redcliffe, Queensland, Australia
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Zampieri FG, Cavalcanti AB, Di Tanna GL, Damiani LP, Hammond NE, Machado FR, Micallef S, Myburgh J, Ramanan M, Venkatesh B, Rice TW, Semler MW, Young PJ, Finfer S. Balanced crystalloids versus saline for critically ill patients (BEST-Living): a systematic review and individual patient data meta-analysis. Lancet Respir Med 2024; 12:237-246. [PMID: 38043564 DOI: 10.1016/s2213-2600(23)00417-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/16/2023] [Accepted: 10/31/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND The effect of balanced crystalloids compared with that of saline in critically ill patients overall and in specific subgroups is unclear. We aimed to assess whether use of balanced solutions, compared with 0·9% sodium chloride (saline), decreased in-hospital mortality in adult patients in intensive care units (ICUs). METHODS For this systematic review and individual patient data meta-analysis, we searched PubMed, Embase, and CENTRAL databases from inception until March 1, 2022 (updated Sept 1, 2023) for individually randomised and cluster-randomised trials comparing balanced solutions with saline for adult patients in the ICU. Eligible trials were those that allocated patients to receive balanced solutions or saline for fluid resuscitation and maintenance fluids, or for maintenance fluids only; and administered the allocated fluid throughout ICU admission or, for trials using landmark mortality as their primary outcome, until the timepoint at which mortality was assessed (if ≥28 days). Authors of eligible trials were contacted to request individual patient data. Data obtained from eligible trials were merged, checked for accuracy, and centrally analysed by use of Bayesian regression models. The primary outcome was in-hospital mortality. Prespecified subgroups included patients with traumatic brain injury. This study was registered with PROSPERO (CRD42022299282). FINDINGS Our search identified 5219 records, yielding six eligible randomised controlled trials. Data obtained for 34 685 participants from the six trials, 17 407 assigned to receive balanced crystalloids and 17 278 to receive saline, were included in the analysis. The mean age of participants was 58·8 years (SD 17·5). Of 34 653 participants with available data, 14 579 (42·1%) were female and 20 074 (57·9%) were male. Among patients who provided consent to report in-hospital mortality, 2907 (16·8%) of 17 313 assigned balanced solutions and 2975 (17·3%) of 17 166 assigned saline died in hospital (odds ratio [OR] 0·962 [95% CrI 0·909 to 1·019], absolute difference -0·4 percentage points [-1·5 to 0·2]). The posterior probability that balanced solutions reduced mortality was 0·895. In patients with traumatic brain injury, 191 (19·1%) of 999 assigned balanced and 141 (14·7%) of 962 assigned saline died (OR 1·424 [1·100 to 1·818], absolute difference 3·2 percentage points [0·7 to 8·7]). The probability that balanced solutions increased mortality in patients with traumatic brain injury was 0·975. In an independent risk of bias assessment, two trials were deemed to be at low risk of bias and four at high risk of bias. INTERPRETATION The probability that using balanced solutions in the ICU reduces in-hospital mortality is high, although the certainty of the evidence was moderate and the absolute risk reduction was small. In patients with traumatic brain injury, using balanced solutions was associated with increased in-hospital mortality. FUNDING HCor (Brazil) and The George Institute for Global Health (Australia).
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil; Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Alexandre B Cavalcanti
- HCor Research Institute, São Paulo, Brazil; Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil
| | - Gian Luca Di Tanna
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Department of Business Economics, Health and Social Care, University of Applied Sciences and Arts of Southern Switzerland, Lugano, Switzerland
| | | | - Naomi E Hammond
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, NSW Australia
| | - Flavia R Machado
- Brazilian Research in Intensive Care Network-BRICNet, São Paulo, Brazil; Anesthaesiology, Pain and Intensive Care Department, Hospital São Paulo, Federal University of São Paulo, São Paulo, Brazil
| | - Sharon Micallef
- The George Institute for Global Health, Sydney, NSW, Australia
| | - John Myburgh
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; St George Hospital, Sydney, NSW, Australia
| | - Mahesh Ramanan
- The George Institute for Global Health, Sydney, NSW, Australia; Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Metro North Hospital and Health Services, Brisbane, QLD, Australia; School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Woolloongabba, QLD, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand; Medical Research Institute of New Zealand, Wellington, New Zealand; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia; Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Simon Finfer
- The George Institute for Global Health, Sydney, NSW, Australia; University of New South Wales, Sydney, NSW, Australia; School of Public Health, Imperial College London, London, UK.
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Ramanan M, Delaney A, Venkatesh B. Fluid therapy in diabetic ketoacidosis. Curr Opin Clin Nutr Metab Care 2024; 27:178-183. [PMID: 38126191 DOI: 10.1097/mco.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
PURPOSE OF REVIEW To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed. RECENT FINDINGS Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials. SUMMARY Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.
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Affiliation(s)
- Mahesh Ramanan
- Caboolture and The Prince Charles Hospitals, Metro North Hospital and Health Services, Brisbane, Queensland
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- James Mayne Academy of Critical Care, The University of Queensland, St Lucia, Queensland
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Royal North Shore Hospital, St Leonards, New South Wales
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, Sydney, New South Wales
- Wesley Hospital, Auchenflower, Queensland, Australia
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5
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Flaws D, Fraser JF, Laupland K, Lavana J, Patterson S, Tabah A, Tronstad O, Ramanan M. Time in ICU and post-intensive care syndrome: how long is long enough? Crit Care 2024; 28:34. [PMID: 38263124 PMCID: PMC10807116 DOI: 10.1186/s13054-024-04812-7] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/17/2024] [Indexed: 01/25/2024] Open
Abstract
BACKGROUND Our understanding of post-ICU recovery is influenced by which patients are selected to study and treat. Many studies currently list an ICU length of stay of at least 24, 48, or 72 h as an inclusion criterion. This may be driven by established evidence that prolonged time in an ICU bed and prolonged ventilation can complicate post-ICU rehabilitation. However, recovery after short ICU stays still needs to be explored. METHODS This is a secondary analysis from the tracking outcomes post-intensive care (TOPIC) study. One hundred and thirty-two participants were assessed 6-months post-ICU discharge using standardised and validated self-report tools for physical function, cognitive function, anxiety, depression and post-traumatic stress disorder (with clinically significant impairment on any tool being considered a complicated recovery). Routinely collected data relating to the ICU stay were retrospectively accessed, including length of stay and duration of mechanical ventilation. Patients with short ICU stays were intentionally included, with 77 (58%) participants having an ICU length of stay < 72 h. RESULTS Of 132 participants, 40 (30%) had at least one identified post-ICU impairment 6 months after leaving ICU, 22 (17%) of whom had an ICU length of stay < 72 h. CONCLUSION Many patients with an ICU length of stay < 72 h are reporting post-ICU impairment 6 months after leaving ICU. This is a population often excluded from studies and interventions. Future research should further explore post-ICU impairment among shorter stays.
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Affiliation(s)
- Dylan Flaws
- Department of Mental Health, Metro North Mental Health, Caboolture Hospital, Caboolture, QLD, Australia.
- Critical Care Research Group, Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia.
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Northside Medical School, University of Queensland, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Kevin Laupland
- School of Clinical Sciences, Queensland University of Technology, Brisbane, QLD, Australia
- Department of Intensive Care, Intensive Care Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Jayshree Lavana
- Department of Intensive Care, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sue Patterson
- Critical Care Research Group, Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Dentistry, University of Queensland, Brisbane, QLD, Australia
| | - Alexis Tabah
- Department of Intensive Care, Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia
- Department of Intensive Care, Intensive Care Unit, Caboolture Hospital, Brisbane, QLD, Australia
| | - Oystein Tronstad
- Critical Care Research Group, Adult Intensive Care Service, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of Intensive Care, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Physiotherapy Department, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Mahesh Ramanan
- Department of Intensive Care, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
- Department of Intensive Care, Intensive Care Unit, Caboolture Hospital, Brisbane, QLD, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
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6
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Marella P, Ramanan M, Shekar K, Tabah A, Laupland KB. Determinants of 90-day case fatality among older patients admitted to intensive care units: A retrospective cohort study. Aust Crit Care 2024; 37:18-24. [PMID: 37679215 DOI: 10.1016/j.aucc.2023.07.039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 07/18/2023] [Accepted: 07/25/2023] [Indexed: 09/09/2023] Open
Abstract
BACKGROUND A recent systematic review identified highly variable case-fatality rates among studies of older patients admitted to intensive care units (ICUs). However, structural and process determinants including patient resident status, tertiary ICU status, and treatment limitations were unavailable. OBJECTIVE The objective of this study was to evaluate the role of determinants such as resident status, tertiary ICU, and treatment limitations on 90-day case fatality among older ICU patients. METHODS A retrospective cohort of all Queensland residents aged 75 years and older admitted to four ICUs within the Metro North Hospital and Health Service was included. The impact of Metro North Hospital and Health Service resident status, tertiary ICU, treatment limitations, and other known determinants on 90-day all-cause case fatality (case-fatality) was assessed. RESULTS Of the 2144 eligible first admissions included, 1365 were residents, and 893 were nonelective admissions. The case-fatality rates were higher in residents (21% vs 12%, p < 0.001), nonelective admissions (32% vs 7%, p < 0.001), and non-tertiary ICU admissions (27% vs 16%, p < 0.001). The case fatality increased progressively with age, being highest (29.6%) in the >90 years age-group. Multivariable mixedeffects logistic regression modelling demonstrated that presence of treatment limitations was strongly associated with case fatality, but neither resident status nor the tertiary ICU was associated. CONCLUSION The presence of treatment limitations should be considered when evaluating variations in case fatality among cohorts of older ICU patients, in addition to variables with well-established association with case fatality such as comorbidities and illness severity.
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Affiliation(s)
- Prashanti Marella
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; Mater Clinical Unit, University of Queensland, Brisbane, Australia.
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kiran Shekar
- The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services, Queensland, Australia; Queensland University of Technology, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Queensland University of Technology, Brisbane, Queensland, Australia; Department of Intensive Care Services, Royal Brisbane and Womens Hospital, Brisbane, Queensland, Australia
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7
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Kumar A, Doola R, Zahumensky A, Shaikh A, Tabah A, Laupland KB, Ramanan M. Association between elevated lactate and clinical outcomes in adults with diabetic ketoacidosis. J Crit Care 2023; 78:154377. [PMID: 37478533 DOI: 10.1016/j.jcrc.2023.154377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Revised: 07/09/2023] [Accepted: 07/10/2023] [Indexed: 07/23/2023]
Abstract
PURPOSE To assess the occurrence of hyperlactatemia among patients admitted to the intensive care unit (ICU) with diabetic ketoacidosis (DKA), and effect on in-hospital mortality. MATERIALS AND METHODS A retrospective, multicentre, cohort study of adult patients admitted to ICU with a primary diagnosis of DKA in Australia and New Zealand, utilising a pre-existing dataset. The primary exposure variable was lactate, dichotomised into normolactatemia (lactate <2.0 mmol/L) and hyperlactatemia (lactate ≥ 2.0 mmol/L) groups. The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay (LOS), requirement for ventilation, renal replacement therapy (RRT) and inotropes. RESULTS The final dataset included 9061 patients. Hyperlactatemia was associated with in-hospital mortality (Odds Ratio [OR] 1.785 (95% CI 1.122-2.841, p = 0.014), hospital LOS (Geometric mean ratio [GMR] 1.063, 95% CI 1.025-1.103, p = 0.001), ICU LOS (GMR 1.057, 95% CI 1.026-1.09. p < 0.001), RRT (OR 2.198, 95% CI 1.449-3.334, p < 0.001) and inotropes (OR 1.578, 95% CI 1.311-1.899, p < 0.001). These associations persisted in Type 2 but not Type 1 diabetics. CONCLUSIONS Hyperlactatemia in patients admitted to ICU with DKA is associated with higher mortality, longer hospital and ICU LOS, and higher rates of mechanical ventilation, RRT and inotropes.
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Affiliation(s)
- Aashish Kumar
- Intensive Care Unit, Logan Hospital, Queensland, Brisbane, Australia
| | - Ra'eesa Doola
- Department of Nutrition and Dietetics, Princess Alexandra Hospital, Queensland, Brisbane, Australia; PA-Southside Clinical Unit, School of Clinical Medicine, The University of Queensland, Brisbane, Australia
| | - Amanda Zahumensky
- Intensive Care Unit, Caboolture Hospital, Queensland, Brisbane, Australia
| | - Arif Shaikh
- Intensive Care Unit, Caboolture Hospital, Queensland, Brisbane, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Queensland, Brisbane, Australia
| | - Kevin B Laupland
- Intensive Care Unit, Royal Brisbane and Women's Hospital, Queensland, Brisbane, Australia; Queensland University of Technology (QUT), Brisbane, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Queensland, Brisbane, Australia; Intensive Care Unit, The Prince Charles Hospital, Queensland, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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8
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White KC, Laupland KB, Tabah A, Ramanan M, Bellomo R. Details and the devil within: the case of sepsis associated AKI. Author's reply. Intensive Care Med 2023; 49:1426-1427. [PMID: 37689617 DOI: 10.1007/s00134-023-07209-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 08/21/2023] [Indexed: 09/11/2023]
Affiliation(s)
- Kyle C White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Queensland University of Technology (QUT), Brisbane, QLD, Australia.
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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White KC, Laupland KB, Tabah A, Ramanan M, Bellomo R. Double the risk of death and other 'inconvenient truths' about oliguria. Author's reply. Intensive Care Med 2023; 49:1422-1423. [PMID: 37707579 DOI: 10.1007/s00134-023-07218-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/30/2023] [Indexed: 09/15/2023]
Affiliation(s)
- Kyle C White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Queensland University of Technology (QUT), Brisbane, QLD, Australia.
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
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10
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White KC, Laupland KB, Tabah A, Ramanan M, Bellomo R. Clinical implications of urine output-based sepsis-associated acute kidney injury. Author's reply. Intensive Care Med 2023; 49:1266-1267. [PMID: 37638978 DOI: 10.1007/s00134-023-07205-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 08/17/2023] [Indexed: 08/29/2023]
Affiliation(s)
- Kyle C White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Queensland University of Technology (QUT), Brisbane, QLD, Australia.
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Australia
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11
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White KC, Serpa-Neto A, Hurford R, Clement P, Laupland KB, See E, McCullough J, White H, Shekar K, Tabah A, Ramanan M, Garrett P, Attokaran AG, Luke S, Senthuran S, McIlroy P, Bellomo R. Sepsis-associated acute kidney injury in the intensive care unit: incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes. A multicenter, observational study. Intensive Care Med 2023; 49:1079-1089. [PMID: 37432520 PMCID: PMC10499944 DOI: 10.1007/s00134-023-07138-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 06/09/2023] [Indexed: 07/12/2023]
Abstract
PURPOSE The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to describe the epidemiology of SA-AKI. METHODS This is a retrospective cohort study carried out in 12 intensive care units (ICUs) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of SA-AKI based on the ADQI definition. RESULTS Out of 84,528 admissions, 13,451 met the SA-AKI criteria with its incidence peaking at 18% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with a median time to SA-AKI diagnosis of 1 day (interquartile range (IQR) 1-1) from ICU admission. At diagnosis, most SA-AKI patients (54%) had a stage 1 AKI, mostly due to the low urinary output (UO) criterion only (65%). Compared to diagnosis by creatinine alone, or by both UO and creatinine criteria, patients diagnosed by UO alone had lower renal replacement therapy (RRT) requirements (2.8% vs 18% vs 50%; p < 0.001), which was consistent across all stages of AKI. SA-AKI hospital mortality was 18% and SA-AKI was independently associated with increased mortality. In SA-AKI, diagnosis by low UO only, compared to creatinine alone or to both UO and creatinine criteria, carried an odds ratio of 0.34 (95% confidence interval (CI) 0.32-0.36) for mortality. CONCLUSION SA-AKI occurs in 1 in 6 ICU patients, is diagnosed on day 1 and carries significant morbidity and mortality risk with patients mostly admitted from home via the ED. However, most SA-AKI is stage 1 and mostly due to low UO, which carries much lower risk than diagnosis by other criteria.
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Affiliation(s)
- Kyle C White
- Intensive Care Unit, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia.
- Queensland University of Technology (QUT), Brisbane, QLD, Australia.
| | - Ary Serpa-Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Rod Hurford
- Intensive Care Unit, Princess Alexandra Hospital, 199 Ipswich Road, Woolloongabba, Brisbane, QLD, 4102, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Emily See
- School of Medicine, University of Melbourne, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
- Department of Nephrology, The Royal Melbourne Hospital, Parkville, Australia
- Department of Nephrology, The Royal Children's Hospital, Parkville, Australia
| | - James McCullough
- Intensive Care Unit, Gold Coast University Hospital, Southport, QLD, Australia
| | - Hayden White
- Intensive Care Unit, Logan Hospital, Logan, QLD, Australia
- School of Medicine and Dentistry, Griffith University, Mount Gravatt, QLD, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Intensive Care Unit, Redcliffe Hospital, Brisbane, QLD, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Peter Garrett
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Intensive Care Unit, Sunshine Coast University Hospital, Birtinya, QLD, Australia
| | - Antony G Attokaran
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Intensive Care Unit, Rockhampton Hospital, The Range, QLD, Australia
| | - Stephen Luke
- Intensive Care Services, Mackay Base Hospital, Mackay, QLD, Australia
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
| | - Siva Senthuran
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Intensive Care Unit, Townsville Hospital, Townsville, QLD, Australia
| | | | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, University of Melbourne, Melbourne, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
- Department of Intensive Care,, Royal Melbourne Hospital, Melbourne, Australia
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12
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Attokaran AG, Ramanan M, Hunt L, Chandra K, Sandha R, Watts S, Venkatesh B. Sodium chloride or plasmalyte-148 for patients presenting to emergency departments with diabetic ketoacidosis: A nested cohort study within a multicentre, cluster, crossover, randomised, controlled trial. Emerg Med Australas 2023; 35:657-663. [PMID: 36970972 DOI: 10.1111/1742-6723.14198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 02/15/2023] [Accepted: 02/21/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVE To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission. METHODS We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU. RESULTS Eighty-four patients were enrolled (SC n = 38, PL n = 46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01-7.21], PL: 7.17 [IQR 6.99-7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000-3200 mL; SC) and 2200 mL (IQR 2000-3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13-3.97, P = 0.71). CONCLUSION Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.
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Affiliation(s)
- Antony George Attokaran
- Rockhampton Hospital, Rockhampton, Queensland, Australia
- Rural Clinical School, The University of Queensland, Rockhampton, Queensland, Australia
| | - Mahesh Ramanan
- Caboolture Hospital, Caboolture, Queensland, Australia
- The Prince Charles Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, New South Wales, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Lisa Hunt
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kavita Chandra
- Sunshine Coast University Hospital, Birtinya, Queensland, Australia
| | - Rajbir Sandha
- Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Stacey Watts
- Caboolture Hospital, Caboolture, Queensland, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Princess Alexandra Hospital, Brisbane, Queensland, Australia
- Wesley Hospital, Brisbane, Queensland, Australia
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13
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Flaws D, Allen C, Baker S, Barnett A, Metcalf O, Pollock H, Ramanan M, Tabah A, Varker T. A protocol for a pilot randomised controlled trial of an Early Psychiatric Assessment, Referral, and Intervention Study (EPARIS) for intensive care patients. PLoS One 2023; 18:e0287470. [PMID: 37384627 PMCID: PMC10309621 DOI: 10.1371/journal.pone.0287470] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 06/02/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND Up to 80% of Intensive Care Unit patients experience physical, cognitive, and/or psychological complications post-discharge, known as 'Post Intensive Care Syndrome' (PICS). Early diagnosis and intervention are a priority, but while current post-intensive care follow-up processes endorse a multidisciplinary model, incorporating a psychiatric consultation has not been studied. METHODS A pilot, open-label randomised controlled trial was developed by a multidisciplinary team to evaluate the feasibility and acceptability of incorporating a psychiatric review into an existing post-ICU clinic. The study will run for 12 months and aim to recruit 30 participants. Inclusion criteria for participants: a) ICU admission greater than 48 hours, b) no cognitive impairment that prevents participation, c) ≥ 18 years old, d) residing in Australia, e) fluent in English, f) able to provide GP information, and g) likely to be contactable in 6 months. Patient recruitment will be at Redcliffe Hospital, Queensland, Australia, and will involve patients attending the Redcliffe post intensive care clinic. Participants will be allocated to intervention or control using block randomisation and allocation concealment. Participants allocated to the control arm will receive the standard cares provided by the clinic, which involves an unstructured interview about their ICU experience and a battery of surveys about their psychological, cognitive, and physical function. Those allocated to the intervention arm will receive these same cares as well as an appointment with a psychiatrist for a single session intervention. The psychiatric intervention will involve a comprehensive review, including comorbid disorders, substance use, suicidal ideation, psychosocial stressors, social/emotional supports. Psychoeducation and initial treatment will be provided as indicated and recommendations given to the patient and their GP about how to access ongoing care. In addition to surveys conducted as part of standard clinic cares, all participants will complete additional questionnaires about their history, hospital experience, mental and physical health as well as employment circumstances. All participants will be followed up 6 months after their appointment and will be invited to complete follow-up questionnaires about their mental and physical health, as well as health service use and employment circumstances. The trial has been registered with ANZCTR (ACTRN12622000894796). RESULTS To evaluate the feasibility and acceptability of the intervention to the patient population. Differences between groups will be assessed using an independent samples t-test. Resource requirements to administer the intervention will be evaluated by reporting the mean duration of the EPARIS assessment and approximate cost per patient to provide this service. To estimate the effect size of any treatment effects, changes in secondary outcome measures between baseline and 6 months will be compared between intervention and control groups using Analysis of Covariance regression. As this is a pilot, we will not use p-values or test a null hypothesis, but will give confidence intervals. CONCLUSIONS This protocol provides a pragmatic evaluation of the acceptability of introducing early psychiatric assessment into an existing post-ICU follow-up process, and if considered acceptable will inform future research into the efficacy and generalisability of the intervention. The strengths of EPARIS are the prospective, longitudinal design with a control population, and its use of validated post-ICU outcome measures.
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Affiliation(s)
- Dylan Flaws
- Critical Care Research Group, The Prince Charles Hospital, Queensland, Australia
- School of Clinical Sciences, Queensland University of Technology, Queensland, Australia
- Metro North Mental Health, Caboolture Hospital, Queensland, Australia
- Faculty of Medicine, University of Queensland, Queensland, Australia
| | - Chelsea Allen
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Queensland, Australia
| | - Stuart Baker
- Department of Intensive Care, Redcliffe Hospital, Queensland, Australia
| | - Adrian Barnett
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology, Queensland, Australia
| | - Olivia Metcalf
- Phoenix Australia, Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Victoria, Australia
| | - Hamish Pollock
- Department of Intensive Care, Redcliffe Hospital, Queensland, Australia
| | - Mahesh Ramanan
- Department of Intensive Care, Caboolture Hospital, Queensland, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia
- Mayne Academy of Critical Care, University of Queensland, Queensland, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, New South Wales, Australia
| | - Alexis Tabah
- School of Clinical Sciences, Queensland University of Technology, Queensland, Australia
- Faculty of Medicine, University of Queensland, Queensland, Australia
- Department of Intensive Care, Redcliffe Hospital, Queensland, Australia
| | - Tracey Varker
- Phoenix Australia, Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Victoria, Australia
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14
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Lin F, Craswell A, Murray L, Brailsford J, Cook K, Anagi S, Muir R, Garrett P, Pusapati R, Carlini J, Ramanan M. Establishing critical care nursing research priorities for three Australian regional public hospitals: A mixed method priority setting study. Intensive Crit Care Nurs 2023; 77:103440. [PMID: 37104948 DOI: 10.1016/j.iccn.2023.103440] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 04/04/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023]
Abstract
OBJECTIVE To determine key priorities for critical care nursing research in three Australian regional public hospitals, representing the shared priorities of healthcare professionals and patient representatives. METHODS A three phase priority setting study, including consensus methods (nominal group), survey, qualitative interviews and focus groups were conducted between May 2021 and March 2022. Healthcare professionals and patient representatives from critical care units in regional public hospitals in Australia participated. A patient representative contributed to research design and co-authored this paper. RESULTS In phase one, 29 research topics were generated. In phase two, during a nominal group ranking process, the top 5 priority areas for each site were identified. In the final phase, three themes from focus groups and interviews included patient flow through intensive care, patient care through intensive care journey and intensive care patient recovery. CONCLUSION Identifying context specific research priorities through a priority setting exercise provides insight into the topics that are important to healthcare professionals and to patients in critical care. The top research priorities for nursing research in critical care in regional Australian hospitals include patient flow, patient recovery, and evidence based patient care through the intensive care journey, such as delirium management, pain and sedation, and mobilisation. These shared priorities will be used to guide future nursing research in critical care over the next 3-5 years. IMPLICATIONS FOR CLINICAL PRACTICE The method we used in identifying the research priorities can be used by other researchers and clinicians; close collaboration among researchers and clinicians will be beneficial for practice improvement; and how we can be reassured that our practice is evidence based is worthy of attention.
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Affiliation(s)
- Frances Lin
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia; Sunshine Coast Health Institute, Sunshine Coast, Queensland, Australia.
| | - Alison Craswell
- School of Health, University of the Sunshine Coast, Sunshine Coast, Queensland, Australia; Sunshine Coast Health Institute, Sunshine Coast, Queensland, Australia; Caboolture Hospital, Metro North Hospital and Health Service, Caboolture, Queensland, Australia
| | - Lauren Murray
- Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Jane Brailsford
- Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Katrina Cook
- Caboolture Hospital, Metro North Hospital and Health Service, Caboolture, Queensland, Australia
| | - Shivaprasad Anagi
- Intensive Care Unit, Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Rachel Muir
- School of Nursing and Midwifery, Griffith University, Gold Coast, Queensland, Australia; Menzies Health Institute Queensland, Griffith University, Gold Coast, Queensland, Australia; Florence Nightingale Faculty of Nursing, Midwifery & Palliative Care, Kings College London, UK
| | - Peter Garrett
- Intensive Care Unit, Sunshine Coast University Hospital, Sunshine Coast, Queensland, Australia
| | - Raju Pusapati
- Intensive Care Unit, Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Joan Carlini
- Department of Marketing, Griffith University, Gold Coast, Queensland, Australia; Consumer Advisory Group, Gold Coast Health, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service, Caboolture, Queensland, Australia
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15
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Marella P, Laupland KB, Shekar K, Tabah A, Edwards F, Ramanan M. Institution-free days after critical illness: A multicenter retrospective study. J Crit Care 2023; 74:154253. [PMID: 36640478 DOI: 10.1016/j.jcrc.2023.154253] [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: 06/30/2022] [Revised: 12/31/2022] [Accepted: 01/03/2023] [Indexed: 01/15/2023]
Abstract
BACKGROUND Patient-centered outcomes beyond mortality such as institution-free days (IFD) are becoming increasingly relevant in critical care trials. METHODS We calculated IFD using three definitions which differed in the way death and censoring of after-hospital deaths were handled analysing data from adult patient databases admitted to four ICUs of North Brisbane, Australia. Differences in distribution of IFD using different definitions were explored with descriptive statistics and histograms. Six pre-specified variables (age, illness severity, comorbidities index, elective status, surgical/medical admission and treatment limitations) were assessed and reported as determinants of IFDs for the proposed definitions. RESULTS Data from 25,371 ICU admissions was analysed. The density distribution of IFD was bimodal with a peak at 0 days and a variable right-sided peak depending on the definition used. The mean IFD varied from 253 (standard deviation(SD) 151.3) to 295 (SD 116.2) depending on definition used. Multivariable zero-inflated negative binomial regression modelling showed that the six pre-specified variables had significant associations with IFD and their magnitude of effect varied with the definition used. CONCLUSIONS IFD is a simple, easily measurable patient-centered outcome that varies depending on the definition used. Patient input should be sought to define the optimum definition and clinical use of IFD.
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Affiliation(s)
- Prashanti Marella
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; Mater Clinical Unit, University of Queensland, Brisbane, Australia
| | - Kevin B Laupland
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Department of Intensive Care Services, Royal Brisbane and Womens hospital, Brisbane, Queensland, Australia
| | - Kiran Shekar
- The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Metro North Hospital and Health Services, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Services, Queensland, Australia; The Prince Charles Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia.
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16
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Tabah A, Buetti N, Staiquly Q, Ruckly S, Akova M, Aslan AT, Leone M, Conway Morris A, Bassetti M, Arvaniti K, Lipman J, Ferrer R, Qiu H, Paiva JA, Povoa P, De Bus L, De Waele J, Zand F, Gurjar M, Alsisi A, Abidi K, Bracht H, Hayashi Y, Jeon K, Elhadi M, Barbier F, Timsit JF, Pollock H, Margetts B, Young M, Bhadange N, Tyler S, Ledtischke A, Finnis M, Ledtischke A, Finnis M, Dwivedi J, Saxena M, Biradar V, Soar N, Sarode V, Brewster D, Regli A, Weeda E, Ahmed S, Fourie C, Laupland K, Ramanan M, Walsham J, Meyer J, Litton E, Palermo AM, Yap T, Eroglu E, Attokaran AG, Jaramillo C, Nafees KMK, Rashid NAHA, Walid HAMI, Mon T, Moorthi PD, Sudhirchandra S, Sridharan DD, Haibo Q, Jianfeng X, Wei-Hua L, Zhen W, Qian C, Luo J, Chen X, Wang H, Zhao P, Zhao J, Wusi Q, Mingmin C, Xu L, Yin C, Wang R, Wang J, Yin Y, Zhang M, Ye J, Hu C, Zhou S, Huang M, Yan J, Wang Y, Qin B, Ye L, Weifeng X, Peije L, Geng N, Hayashi Y, Karumai T, Yamasaki M, Hashimoto S, Hosokawa K, Makino J, Matsuyoshi T, Kuriyama A, Shigemitsu H, Mishima Y, Nagashima M, Yoshida H, Fujitani S, Omori K, Rinka H, Saito H, Atobe K, Kato H, Takaki S, Hasan MS, Jamaluddin MFH, Pheng LS, Visvalingam S, Liew MT, Wong SLD, Fong KK, Rahman HBA, Noor ZM, Tong LK, Azman AH, Mazlan MZ, Ali S, Jeon K, Lee SM, Park S, Park SY, Lim SY, Goh QY, Ng SY, Lie SA, Kwa ALH, Goh KJ, Li AY, Ong CYM, Lim JY, Quah JL, Ng K, Ng LXL, Yeh YC, Chou NK, Cia CT, Hu TY, Kuo LK, Ku SC, Wongsurakiat P, Apichatbutr Y, Chiewroongroj S, Nadeem R, Houfi AE, Alsisi A, Elhadidy A, Barsoum M, Osman N, Mostafa T, Elbahnasawy M, Saber A, Aldhalia A, Elmandouh O, Elsayed A, Elbadawy MA, Awad AK, Hemead HM, Zand F, Ouhadian M, Borsi SH, Mehraban Z, Kashipazha D, Ahmadi F, Savaie M, Soltani F, Rashidi M, Baghbanian R, Javaherforoosh F, Amiri F, Kiani A, Zargar MA, Mahmoodpoor A, Aalinezhad F, Dabiri G, Sabetian G, Sarshad H, Masjedi M, Tajvidi R, Tabatabaei SMN, Ahmed AK, Singer P, Kagan I, Rigler M, Belman D, Levin P, Harara B, Diab A, Abilama F, Ibrahim R, Fares A, Buimsaedah A, Gamra M, Aqeelah A, AliAli AM, Homaidan AGS, Almiqlash B, Bilkhayr H, Bouhuwaish A, Taher AS, Abdulwahed E, Abousnina FA, Hdada AK, Jobran R, Hasan HB, Hasan RSB, Serghini I, Seddiki R, Boukatta B, Kanjaa N, Mouhssine D, Wajdi MA, Dendane T, Zeggwagh AA, Housni B, Younes O, Hachimi A, Ghannam A, Belkhadir Z, Amro S, Jayyab MA, Hssain AA, Elbuzidi A, Karic E, Lance M, Nissar S, Sallam H, Elrabi O, Almekhlafi GA, Awad M, Aljabbary A, Chaaban MK, Abu-Sayf N, Al-Jadaan M, Bakr L, Bouaziz M, Turki O, Sellami W, Centeno P, Morvillo LN, Acevedo JO, Lopez PM, Fernández R, Segura M, Aparicio DM, Alonzo MI, Nuccetelli Y, Montefiore P, Reyes LF, Reyes LF, Ñamendys-Silva SA, Romero-Gonzalez JP, Hermosillo M, Castillo RA, Leal JNP, Aguilar CG, Herrera MOG, Villafuerte MVE, Lomeli-Teran M, Dominguez-Cherit JG, Davalos-Alvarez A, Ñamendys-Silva SA, Sánchez-Hurtado L, Tejeda-Huezo B, Perez-Nieto OR, Tomas ED, De Bus L, De Waele J, Hollevoet I, Denys W, Bourgeois M, Vanderhaeghen SFM, Mesland JB, Henin P, Haentjens L, Biston P, Noel C, Layos N, Misset B, De Schryver N, Serck N, Wittebole X, De Waele E, Opdenacker G, Kovacevic P, Zlojutro B, Custovic A, Filipovic-Grcic I, Radonic R, Brajkovic AV, Persec J, Sakan S, Nikolic M, Lasic H, Leone M, Arbelot C, Timsit JF, Patrier J, Zappela N, Montravers P, Dulac T, Castanera J, Auchabie J, Le Meur A, Marchalot A, Beuzelin M, Massri A, Guesdon C, Escudier E, Mateu P, Rosman J, Leroy O, Alfandari S, Nica A, Souweine B, Coupez E, Duburcq T, Kipnis E, Bortolotti P, Le Souhaitier M, Mira JP, Garcon P, Duprey M, Thyrault M, Paulet R, Philippart F, Tran M, Bruel C, Weiss E, Janny S, Foucrier A, Perrigault PF, Djanikian F, Barbier F, Gainnier M, Bourenne J, Louis G, Smonig R, Argaud L, Baudry T, Dessap AM, Razazi K, Kalfon P, Badre G, Larcher R, Lefrant JY, Roger C, Sarton B, Silva S, Demeret S, Le Guennec L, Siami S, Aparicio C, Voiriot G, Fartoukh M, Dahyot-Fizelier C, Imzi N, Klouche K, Bracht H, Hoheisen S, Bloos F, Thomas-Rueddel D, Petros S, Pasieka B, Dubler S, Schmidt K, Gottschalk A, Wempe C, Lepper P, Metz C, Viderman D, Ymbetzhanov Y, Mugazov M, Bazhykayeva Y, Kaligozhin Z, Babashev B, Merenkov Y, Temirov T, Arvaniti K, Smyrniotis D, Psallida V, Fildisis G, Soulountsi V, Kaimakamis E, Iasonidou C, Papoti S, Renta F, Vasileiou M, Romanou V, Koutsoukou V, Matei MK, Moldovan L, Karaiskos I, Paskalis H, Marmanidou K, Papanikolaou M, Kampolis C, Oikonomou M, Kogkopoulos E, Nikolaou C, Sakkalis A, Chatzis M, Georgopoulou M, Efthymiou A, Chantziara V, Sakagianni A, Athanasa Z, Papageorgiou E, Ali F, Dimopoulos G, Almiroudi MP, Malliotakis P, Marouli D, Theodorou V, Retselas I, Kouroulas V, Papathanakos G, Montrucchio G, Sales G, De Pascale G, Montini LM, Carelli S, Vargas J, Di Gravio V, Giacobbe DR, Gratarola A, Porcile E, Mirabella M, Daroui I, Lodi G, Zuccaro F, Schlevenin MG, Pelosi P, Battaglini D, Cortegiani A, Ippolito M, Bellina D, Di Guardo A, Pelagalli L, Covotta M, Rocco M, Fiorelli S, Cotoia A, Rizzo AC, Mikstacki A, Tamowicz B, Komorowska IK, Szczesniak A, Bojko J, Kotkowska A, Walczak-Wieteska P, Wasowska D, Nowakowski T, Broda H, Peichota M, Pietraszek-Grzywaczewska I, Martin-Loeches I, Bisanti A, Cartoze N, Pereira T, Guimarães N, Alves M, Marques AJP, Pinto AR, Krystopchuk A, Teresa A, de Figueiredo AMP, Botelho I, Duarte T, Costa V, Cunha RP, Molinos E, da Costa T, Ledo S, Queiró J, Pascoalinho D, Nunes C, Moura JP, Pereira É, Mendes AC, Valeanu L, Bubenek-Turconi S, Grintescu IM, Cobilinschi C, Filipescu DC, Predoi CE, Tomescu D, Popescu M, Marcu A, Grigoras I, Lungu O, Gritsan A, Anderzhanova A, Meleshkina Y, Magomedov M, Zubareva N, Tribulev M, Gaigolnik D, Eremenko A, Vistovskaya N, Chukina M, Belskiy V, Furman M, Rocca RF, Martinez M, Casares V, Vera P, Flores M, Amerigo JA, Arnillas MPG, Bermudez RM, Armestar F, Catalan B, Roig R, Raguer L, Quesada MD, Santos ED, Gomà G, Ubeda A, Salgado DM, Espina LF, Prieto EG, Asensio DM, Rodriguez DM, Maseda E, De La Rica AS, Ayestaran JI, Novo M, Blasco-Navalpotro MA, Gallego AO, Sjövall F, Spahic D, Svensson CJ, Haney M, Edin A, Åkerlund J, De Geer L, Prazak J, Jakob S, Pagani J, Abed-Maillard S, Akova M, Aslan AT, Timuroglu A, Kocagoz S, Kusoglu H, Mehtap S, Ceyhun S, Altintas ND, Talan L, Kayaaslan B, Kalem AK, Kurt I, Telli M, Ozturk B, Erol Ç, Demiray EKD, Çolak S, Akbas T, Gundogan K, Sari A, Agalar C, Çolak O, Baykam NN, Akdogan OO, Yilmaz M, Tunay B, Cakmak R, Saltoglu N, Karaali R, Koksal I, Aksoy F, Eroglu A, Saracoglu KT, Bilir Y, Guzeldag S, Ersoz G, Evik G, Sungurtekin H, Ozgen C, Erdoğan C, Gürbüz Y, Altin N, Bayindir Y, Ersoy Y, Goksu S, Akyol A, Batirel A, Aktas SC, Morris AC, Routledge M, Morris AC, Ercole A, Antcliffe D, Rojo R, Tizard K, Faulkner M, Cowton A, Kent M, Raj A, Zormpa A, Tinaslanidis G, Khade R, Torlinski T, Mulhi R, Goyal S, Bajaj M, Soltan M, Yonan A, Dolan R, Johnson A, Macfie C, Lennard J, Templeton M, Arias SS, Franke U, Hugill K, Angell H, Parcell BJ, Cobb K, Cole S, Smith T, Graham C, Cerman J, Keegan A, Ritzema J, Sanderson A, Roshdy A, Szakmany T, Baumer T, Longbottom R, Hall D, Tatham K, Loftus S, Husain A, Black E, Jhanji S, Baikady RR, Mcguigan P, Mckee R, Kannan S, Antrolikar S, Marsden N, Torre VD, Banach D, Zaki A, Jackson M, Chikungwa M, Attwood B, Patel J, Tilley RE, Humphreys MSK, Renaud PJ, Sokhan A, Burma Y, Sligl W, Baig N, McCoshen L, Kutsogiannis DJ, Sligl W, Thompson P, Hewer T, Rabbani R, Huq SMR, Hasan R, Islam MM, Gurjar M, Baronia A, Kothari N, Sharma A, Karmakar S, Sharma P, Nimbolkar J, Samdani P, Vaidyanathan R, Rubina NA, Jain N, Pahuja M, Singh R, Shekhar S, Muzaffar SN, Ozair A, Siddiqui SS, Bose P, Datta A, Rathod D, Patel M, Renuka MK, Baby SK, Dsilva C, Chandran J, Ghosh P, Mukherjee S, Sheshala K, Misra KC, Yakubu SY, Ugwu EM, Olatosi JO, Desalu I, Asiyanbi G, Oladimeji M, Idowu O, Adeola F, Mc Cree M, Karar AAA, Saidahmed E, Hamid HKS. Epidemiology and outcomes of hospital-acquired bloodstream infections in intensive care unit patients: the EUROBACT-2 international cohort study. Intensive Care Med 2023; 49:178-190. [PMID: 36764959 PMCID: PMC9916499 DOI: 10.1007/s00134-022-06944-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/23/2022] [Indexed: 02/12/2023]
Abstract
PURPOSE In the critically ill, hospital-acquired bloodstream infections (HA-BSI) are associated with significant mortality. Granular data are required for optimizing management, and developing guidelines and clinical trials. METHODS We carried out a prospective international cohort study of adult patients (≥ 18 years of age) with HA-BSI treated in intensive care units (ICUs) between June 2019 and February 2021. RESULTS 2600 patients from 333 ICUs in 52 countries were included. 78% HA-BSI were ICU-acquired. Median Sequential Organ Failure Assessment (SOFA) score was 8 [IQR 5; 11] at HA-BSI diagnosis. Most frequent sources of infection included pneumonia (26.7%) and intravascular catheters (26.4%). Most frequent pathogens were Gram-negative bacteria (59.0%), predominantly Klebsiella spp. (27.9%), Acinetobacter spp. (20.3%), Escherichia coli (15.8%), and Pseudomonas spp. (14.3%). Carbapenem resistance was present in 37.8%, 84.6%, 7.4%, and 33.2%, respectively. Difficult-to-treat resistance (DTR) was present in 23.5% and pan-drug resistance in 1.5%. Antimicrobial therapy was deemed adequate within 24 h for 51.5%. Antimicrobial resistance was associated with longer delays to adequate antimicrobial therapy. Source control was needed in 52.5% but not achieved in 18.2%. Mortality was 37.1%, and only 16.1% had been discharged alive from hospital by day-28. CONCLUSIONS HA-BSI was frequently caused by Gram-negative, carbapenem-resistant and DTR pathogens. Antimicrobial resistance led to delays in adequate antimicrobial therapy. Mortality was high, and at day-28 only a minority of the patients were discharged alive from the hospital. Prevention of antimicrobial resistance and focusing on adequate antimicrobial therapy and source control are important to optimize patient management and outcomes.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Brisbane, Australia. .,Queensland Critical Care Research Network (QCCRN), Brisbane, QLD, Australia. .,Queensland University of Technology, Brisbane, QLD, Australia. .,Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.
| | - Niccolò Buetti
- Infection Control Program and WHO Collaborating Centre on Patient Safety, Geneva University Hospitals and Faculty of Medicine, Geneva, Switzerland.,Université de Paris, INSERM, IAME UMR 1137, 75018, Paris, France
| | | | - Stéphane Ruckly
- Université de Paris, INSERM, IAME UMR 1137, 75018, Paris, France.,ICUREsearch, Biometry, 38600, Fontaine, France
| | - Murat Akova
- Department of Infectious Diseases, Hacettepe University School of Medicine, Ankara, Turkey
| | - Abdullah Tarik Aslan
- Department of Internal Medicine, Hacettepe University School of Medicine, Ankara, Turkey
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Hospital Nord, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Marseille, France
| | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Hills Road, Cambridge, CB2 0QQ, UK.,Division of Immunology, Department of Pathology, University of Cambridge, Tennis Court Road, Cambridge, Cb2 1QP, UK.,JVF Intensive Care Unit, Addenbrooke's Hospital, Cambridge, Hills Road, Cambridge, CB2 0QQ, UK
| | - Matteo Bassetti
- Infectious Diseases Clinic, Department of Health Sciences, University of Genoa and Ospedale Policlinico San Martino, Genoa, Italy
| | - Kostoula Arvaniti
- Intensive Care Unit, Papageorgiou University Affiliated Hospital, Thessaloníki, Greece
| | - Jeffrey Lipman
- Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia.,Nimes University Hospital, University of Montpellier, Nimes, France.,Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Herston, Australia
| | - Ricard Ferrer
- Intensive Care Department, SODIR-VHIR Research Group, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Haibo Qiu
- Jiangsu Provincial Key Laboratory of Critical Care Medicine, Department of Critical Care Medicine, Nanjing Zhongda Hospital, Southeast University, Nanjing, 210009, China
| | - José-Artur Paiva
- Intensive Care Medicine Department, Centro Hospitalar Universitário Sao Joao, Porto, Portugal.,Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal.,Infection and Sepsis ID Group, Porto, Portugal
| | - Pedro Povoa
- NOVA Medical School, New University of Lisbon, Lisbon, Portugal.,Center for Clinical Epidemiology and Research Unit of Clinical Epidemiology, OUH Odense University Hospital, Odense, Denmark.,Polyvalent Intensive Care Unit, Hospital de São Francisco Xavier, CHLO, Lisbon, Portugal
| | - Liesbet De Bus
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jan De Waele
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium.,Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Farid Zand
- Anesthesiology and Critical Care Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mohan Gurjar
- Department of Critical Care Medicine, Sanjay Gandhi Post Graduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Adel Alsisi
- ICU Department, Prime Hospital, Dubai, United Arab Emirates.,Critical Care Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Khalid Abidi
- Medical ICU, Ibn Sina University Hospital, Faculty of Medicine and Pharmacy, Mohammed V University, Rabat, Morocco
| | - Hendrik Bracht
- Central Interdisciplinary Emergency Medicine, University Hospital Ulm, Ulm, Germany
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda General Hospital, Kamogawa, Japan
| | - Kyeongman Jeon
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - François Barbier
- Service de Médecine Intensive-Réanimation, Centre Hospitalier Régional d'Orléans, 14, avenue de L'Hôpital, 45100, Orléans, France
| | - Jean-François Timsit
- Université Paris-Cité, INSERM, IAME UMR 1137, 75018, Paris, France.,Medical and Infectious Diseases Intensive Care Unit, AP-HP, Bichat-Claude Bernard University Hospital, 46 Omdurman maternity hospitalrue Henri Huchard, 75877, Paris Cedex, France
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Song C, Dennis M, Burns B, Dyson S, Forrest P, Ramanan M, Levinson D, Moylan E. Improving access to extracorporeal membrane oxygenation for out of hospital cardiac arrest: pre-hospital ECPR and alternate delivery strategies. Scand J Trauma Resusc Emerg Med 2022; 30:77. [PMID: 36566221 DOI: 10.1186/s13049-022-01064-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/19/2022] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND The use of extracorporeal membrane oxygenation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) patients is usually implemented in-hospital. As survival in ECPR patients is critically time-dependent, alternative models in ECPR delivery could improve equity of access. OBJECTIVES To identify the best strategy of ECPR delivery to provide optimal patient access, to examine the time-sensitivity of ECPR on predicted survival and to model potential survival benefits from different delivery strategies of ECPR. METHODS We used transport accessibility frameworks supported by comprehensive travel time data, population density data and empirical cardiac arrest time points to quantify the patient catchment areas of the existing in-hospital ECPR service and two alternative ECPR strategies: rendezvous strategy and pre-hospital ECPR in Sydney, Australia. Published survival rates at different time points to ECMO flow were applied to predict the potential survival benefit. RESULTS With an in-hospital ECPR strategy for refractory OHCA, five hospitals in Sydney (Australia) had an effective catchment of 811,091 potential patients. This increases to 2,175,096 under a rendezvous strategy and 3,851,727 under the optimal pre-hospital strategy. Assuming earlier provision of ECMO flow, expected survival for eligible arrests will increase by nearly 6% with the rendezvous strategy and approximately 26% with pre-hospital ECPR when compared to the existing in-hospital strategy. CONCLUSION In-hospital ECPR provides the least equitable access to ECPR. Rendezvous and pre-hospital ECPR models substantially increased the catchment of eligible OHCA patients. Traffic and spatial modelling may provide a mechanism to design appropriate ECPR service delivery strategies and should be tested through clinical trials.
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Affiliation(s)
- Changle Song
- School of Civil Engineering, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Mark Dennis
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Cardiology, Royal Prince Alfred Hospital, Sydney, Australia
| | - Brian Burns
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,NSW Ambulance, Sydney, Australia
| | | | - Paul Forrest
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia
| | - Mahesh Ramanan
- Prince Charles Hospital, Brisbane, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, Australia
| | - David Levinson
- School of Civil Engineering, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Emily Moylan
- School of Civil Engineering, The University of Sydney, Sydney, NSW, 2006, Australia.
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18
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Shah V, Ahuja A, Kumar A, Anstey C, Thang C, Guo L, Shekar K, Ramanan M. Outcomes of Prolonged ICU Stay for Patients Undergoing Cardiac Surgery in Australia and New Zealand. J Cardiothorac Vasc Anesth 2022; 36:4313-4319. [PMID: 36207199 DOI: 10.1053/j.jvca.2022.08.026] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/28/2022] [Accepted: 08/29/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the effect of intensive care unit (ICU) length of stay (LOS) on hospital mortality and non-home discharge for patients undergoing cardiac surgery over a 16-year period in Australia and New Zealand. DESIGN A retrospective, multicenter cohort study covering the period January 1, 2004 to December 31, 2019. SETTING One hundred one hospitals in Australia and New Zealand that submitted data to the Australia New Zealand Intensive Care Society Adult Patient Database. PARTICIPANTS Adult patients (aged >18) who underwent coronary artery bypass grafting, valve surgery, or combined valve + coronary artery surgery. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The authors analyzed 252,948 cardiac surgical patients from 101 hospitals, with a median age of 68.3 years (IQR 60-75.5), of whom 74.2% (187,632 of 252,948) were male patients. A U-shaped relationship was observed between ICU LOS and hospital mortality, with significantly elevated mortality at short (<20 hours) and long (>5 days) ICU LOS, which persisted after adjustment for illness severity and across clinically important subgroups (odds ratio for mortality with ICU LOS >5 days = 3.21, 95% CI 2.88-3.58, p < 0.001). CONCLUSIONS Prolonged duration of ICU LOS after cardiac surgery is associated with increased hospital mortality in a U-shaped relationship. An ICU LOS >5 days should be considered a meaningful definition for prolonged ICU stay after cardiac surgery.
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Affiliation(s)
- Vikram Shah
- Intensive Care Unit, Sunshine Coast University Hospital, Queensland, Australia
| | - Abhilasha Ahuja
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Logan, Queensland, Australia; School of Medicine, Griffith University, Queensland, Australia
| | - Chris Anstey
- School of Medicine, Griffith University, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Christopher Thang
- School of Medicine, Griffith University, Queensland, Australia; Department of Anaesthesia, Sunshine Coast University Hospital, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Linda Guo
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Kiran Shekar
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia; Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia; Critical Care Division, George Institute for Global Health, Level 5, Newtown, New South Wales, Australia; School of Medicine, University of Queensland, Herston, Queensland, Australia.
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19
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Ramanan M, Kumar A, Billot L, Myburgh J, Venkatesh B. Recruitment characteristics of randomised trials in critical care: A systematic review. Clin Trials 2022; 19:673-680. [PMID: 36068946 DOI: 10.1177/17407745221123248] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND/AIMS To summarise the temporal trends of recruitment and methodological characteristics of critical care randomised controlled trials with the primary outcome of mortality. METHODS PubMed was searched for articles meeting inclusion and exclusion criteria. Randomised controlled trials, with primary outcome of mortality, of adult and paediatric critical care patients treated in an intensive care unit, were included. Neonatal intensive care unit trials, non-English publications and conference proceedings or abstracts without full-length publications were excluded. Duplicate literature search, article selection and quality assessment were performed by two reviewers with disputes resolved through discussion. Data were extracted into a custom-designed Research Electronic Data Capture database. RESULTS The search identified 67,199 records of which 230 were included. The annual number of critical care randomised controlled trials published increased gradually over a 30-year period from 0 in 1990 to 19 in 2014 with stabilisation at 8-11 between 2015 and 2020. Twenty-seven percent of randomised controlled trials were low risk in all categories using the Cochrane Risk of Bias tool. Methodological characteristics such as registration on clinical trials registries and data safety monitoring committee presence significantly (p < 0.001) increased over time. The median recruitment was 376 patients (interquartile range 125-895) with significant increase (p = 0.002) from 62 (interquartile range: 33-486) in 1991 to 725 (interquartile range: 537-2600) in 2020. This was accompanied by an increase in recruitment times. Thus overall, recruitment rates did not increase. Early cessation occurred in 23% (54/230) of randomised controlled trials with no temporal trend. CONCLUSION The number, size and some methodological qualities of critical randomised controlled trials with primary outcome of mortality have increased over time, but rates of recruitment and early cessation have been unchanged.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD, Australia.,School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Meadowbrook, QLD, Australia
| | - Laurent Billot
- Statistics Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Balasubramanian Venkatesh
- School of Medicine, University of Queensland, Brisbane, QLD, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia.,Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia.,Intensive Care Unit, Wesley Hospital, Auchenflower, QLD, Australia
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20
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Begum H, Neto AS, Alliegro P, Broadley T, Trapani T, Campbell LT, Cheng AC, Cheung W, Cooper DJ, Erickson SJ, French CJ, Litton E, McAllister R, Nichol A, Palermo A, Plummer MP, Rotherham H, Ramanan M, Reddi B, Reynolds C, Webb SAR, Udy AA, Burrell A. People in intensive care with COVID-19: demographic and clinical features during the first, second, and third pandemic waves in Australia. Med J Aust 2022; 217:352-360. [PMID: 35686307 PMCID: PMC9347520 DOI: 10.5694/mja2.51590] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 03/21/2022] [Accepted: 03/24/2022] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To compare the demographic and clinical features, management, and outcomes for patients admitted with COVID-19 to intensive care units (ICUs) during the first, second, and third waves of the pandemic in Australia. DESIGN, SETTING, AND PARTICIPANTS People aged 16 years or more admitted with polymerase chain reaction-confirmed COVID-19 to the 78 Australian ICUs participating in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia project during the first (27 February - 30 June 2020), second (1 July 2020 - 25 June 2021), and third COVID-19 waves (26 June - 1 November 2021). MAIN OUTCOME MEASURES Primary outcome: in-hospital mortality. SECONDARY OUTCOMES ICU mortality; ICU and hospital lengths of stay; supportive and disease-specific therapies. RESULTS 2493 people (1535 men, 62%) were admitted to 59 ICUs: 214 during the first (9%), 296 during the second (12%), and 1983 during the third wave (80%). The median age was 64 (IQR, 54-72) years during the first wave, 58 (IQR, 49-68) years during the second, and 54 (IQR, 41-65) years during the third. The proportion without co-existing illnesses was largest during the third wave (41%; first wave, 32%; second wave, 29%). The proportion of ICU beds occupied by patients with COVID-19 was 2.8% (95% CI, 2.7-2.9%) during the first, 4.6% (95% CI, 4.3-5.1%) during the second, and 19.1% (95% CI, 17.9-20.2%) during the third wave. Non-invasive (42% v 15%) and prone ventilation strategies (63% v 15%) were used more frequently during the third wave than during the first two waves. Thirty patients (14%) died in hospital during the first wave, 35 (12%) during the second, and 281 (17%) during the third. After adjusting for age, illness severity, and other covariates, the risk of in-hospital mortality was similar for the first and second waves, but 9.60 (95% CI, 3.52-16.7) percentage points higher during the third than the first wave. CONCLUSION The demographic characteristics of patients in intensive care with COVID-19 and the treatments they received during the third pandemic wave differed from those of the first two waves. Adjusted in-hospital mortality was highest during the third wave.
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Affiliation(s)
| | - Ary S Neto
- Australian and New Zealand Intensive Care Research CentreMelbourneVIC
| | | | | | - Tony Trapani
- Monash UniversityMelbourneVIC
- Alfred HealthMelbourneVIC
| | - Lewis T Campbell
- Royal Darwin HospitalDarwinNT
- Menzies School of Health ResearchDarwinNT
| | | | | | - D James Cooper
- Monash UniversityMelbourneVIC
- Australian and New Zealand Intensive Care Research CentreMelbourneVIC
- Alfred HealthMelbourneVIC
| | | | | | | | | | | | | | | | | | - Mahesh Ramanan
- Prince Charles HospitalBrisbaneQLD
- Caboolture HospitalCabooltureQLD
| | | | | | | | - Andrew A Udy
- Monash UniversityMelbourneVIC
- Australian and New Zealand Intensive Care Research CentreMelbourneVIC
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21
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White K, Tabah A, Ramanan M, Shekar K, Edwards F, Laupland KB. 90-day Case-Fatality in Critically ill Patients with Chronic Liver Disease Influenced by Presence of Portal Hypertension, Results from a Multicentre Retrospective Cohort Study. J Intensive Care Med 2022; 38:5-10. [PMID: 35892180 DOI: 10.1177/08850666221100408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Critical illness in patients with chronic liver disease (CLD) is increasing in occurrence, and by virtue of its adverse effect on prognosis, its presence may influence the decision to offer admission to intensive care units (ICU). Our objective was to examine the determinants and outcome of patients with CLD admitted to ICU. METHODS A retrospective cohort of patients admitted to four adult ICUs in Queensland, Australia from 2017 to 2019. Patients with mild or moderate-severe CLD were defined by the absence and presence of portal hypertension, respectively, and were was determined using granular ICU and state-wide administrative databases. The primary outcome was 90-day all cause case-fatality. RESULTS We included 3836 patients in the analysis, of which, 60 (2%) had mild liver disease and 132 (3%) had moderate-severe liver disease . Patients with CLD had higher incidence of other co-morbidities with the median adjusted-Charlson co-morbidity index (CCI) was 1 (interquartile range; IQR 0-3) for no CLD, 2 (IQR 1.5-4) for mild CLD, and 3 (IQR 2-5) for moderate-severe CLD. Case-fatality rates at 90 days was 17% for no CLD, 25% for mild CLD, and 41% for moderate-severe CLD. Among those with mild and moderate-severe CLD, an increased co-morbidity burden as measured by an adjusted CCI score of low (0-3), medium (4-5), high (6-7) and very high (>7) resulted in increasing case-fatality rates of 24-40%, 11-28.5%, 33-62%, and 50% respectively. Moderate-severe CLD, but not mild CLD, was independently associated with increased case-fatality at 90 days (Odds Ratio 1.58; 95% confidence interval 1.01-2.48; p = 0.004) after adjusting for medical co-morbidities and severity of illness using logistic regression analysis. CONCLUSIONS Although patients with moderate-severe CLD have an increased risk for 90-day case-fatality, patients with mild CLD are not at higher risk for death following ICU admission.
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Affiliation(s)
- Kyle White
- Intensive Care Unit, 1966Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, 60077Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, 60075Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Felicity Edwards
- 1969Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B Laupland
- 1969Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,550021Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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22
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Tabah A, Ramanan M, Bailey RL, Chavan S, Baker S, Huckson S, Pilcher D, Litton E. Family visitation policies, facilities, and support in Australia and New Zealand intensive care units: A multicentre, registry-linked survey. Aust Crit Care 2022; 35:375-382. [PMID: 34353725 DOI: 10.1016/j.aucc.2021.06.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 06/18/2021] [Accepted: 06/20/2021] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVE The objective of this study was to describe family visitation policies, facilities, and support in Australia and New Zealand (ANZ) intensive care units (ICUs). METHODS A survey was distributed to all Australian and New Zealand ICUs reporting to the Australian and New Zealand Intensive Care Society Centre for Outcomes and Resources Evaluation Critical Care Resources (CCR) Registry in 2018. Data were obtained from the survey and from data reported to the CCR Registry. For this study, open visiting (OV) was defined as allowing visitors for more than 14 h per day. SETTING AND PARTICIPANTS This study included all Australian and New Zealand ICUs reporting to CCR in 2018. MAIN OUTCOME MEASURES The main outcome measures were family access to the ICU and visiting hours, characteristics of the ICU waiting area, and information provided to and collected from the relatives. FINDINGS Fifty-six percent (95/170) of ICUs contributing to CCR responded, representing 44% of ANZ ICUs and a range of rural, metropolitan, tertiary, and private ICUs. Visiting hours ranged from 1.5 to 24 h per day, with 68 (72%) respondent ICUs reporting an OV policy, of which 64 (67%) ICUs were open to visitors 24 h a day. A waiting room was part of the ICU for 77 (81%) respondent ICUs, 74 (78%) reported a separate dedicated room for family meetings, and 83 (87%) reported available social worker services. Most ICUs reported facilities for sleeping within or near the hospital. An information booklet was provided by 64 (67%) ICUs. Only six (6%) ICUs required personal protective equipment for all visitors, and 76 (80%) required personal protective equipment for patients with airborne precautions. CONCLUSIONS In 2018, the majority of ANZ ICUs reported liberal visiting policies, with substantial facilities and family support.
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Affiliation(s)
- Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, 4020, Redcliffe, Queensland, Australia; Faculty of Medicine, University of Queensland, 4029, Brisbane, Queensland, Australia.
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, 4029, Brisbane, Queensland, Australia; Intensive Care Units, Caboolture and Prince Charles Hospitals, Queensland, Australia; The George Institute for Global Health, Sydney, New South Wales, Australia; University of New South Wales, Sydney, New South Wales, Australia.
| | - Rachel L Bailey
- Intensive Care Outreach, Caboolture Hospital, Caboolture, Queensland, Australia.
| | - Shaila Chavan
- ANZICS Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia.
| | - Stuart Baker
- Intensive Care Unit, Redcliffe Hospital, 4020, Redcliffe, Queensland, Australia; Faculty of Medicine, University of Queensland, 4029, Brisbane, Queensland, Australia.
| | - Sue Huckson
- ANZICS Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia.
| | - David Pilcher
- ANZICS Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; Department of Intensive Care, The Alfred Hospital, Prahran, Victoria, Australia; The Australian and New Zealand Intensive Care - Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Edward Litton
- ANZICS Centre for Outcome and Resource Evaluation, Camberwell, Victoria, Australia; Intensive Care Unit, St John of God Hospital, Perth, Western Australia, Australia; School of Medicine, University of Western Australia, Perth, Western Australia, Australia.
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23
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Hammond NE, Zampieri FG, Di Tanna GL, Garside T, Adigbli D, Cavalcanti AB, Machado FR, Micallef S, Myburgh J, Ramanan M, Rice TW, Semler MW, Young PJ, Venkatesh B, Finfer S, Delaney A. Balanced Crystalloids versus Saline in Critically Ill Adults - A Systematic Review with Meta-Analysis. NEJM Evid 2022; 1:EVIDoa2100010. [PMID: 38319180 DOI: 10.1056/evidoa2100010] [Citation(s) in RCA: 56] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Balanced Crystalloids and Saline in Critical IllnessThis article presents a frequentist (showing no significant difference) and Bayesian (in which the posterior probability that balanced crystalloids reduced mortality was 89.5%) systematic review of randomized clinical trials comparing balanced crystalloids with saline in critically ill adults with the primary outcome of 90-day mortality.
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Affiliation(s)
- Naomi E Hammond
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Fernando G Zampieri
- HCor Research Institute, São Paulo
- D'Or Research and Education Institute, São Paulo
| | - Gian Luca Di Tanna
- BioStatistics and Data Science Division, Meta-Research and Evidence Synthesis, The George Institute for Global Health, University of New South Wales, Sydney
| | - Tessa Garside
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | - Derick Adigbli
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
| | | | - Flavia R Machado
- Anesthesiology, Pain, and Intensive Care Department, Federal University of São Paulo, São Paulo
| | - Sharon Micallef
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Department of Intensive Care, St. George Hospital, Sydney
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, Queensland, Australia
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville
| | - Paul J Young
- Department of Intensive Care, Wellington Regional Hospital, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Queensland, Australia
| | - Simon Finfer
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- School of Public Health, The George Institute for Global Health, Imperial College, London
| | - Anthony Delaney
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney
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24
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Abstract
This systematic review examines geographical representation of low- and middle-income countries in randomized clinical trials for COVID-19 compared with high-income countries.
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Affiliation(s)
- Mahesh Ramanan
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Steven Y. C. Tong
- Department of Infectious Diseases, The University of Melbourne at the Peter Doherty Institute for Infection and Immunity, Melbourne, Australia
| | | | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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25
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Guo L, Ryan B, Leditschke IA, Haines KJ, Cook K, Eriksson L, Olusanya O, Selak T, Shekar K, Ramanan M. Impact of unacceptable behaviour between healthcare workers on clinical performance and patient outcomes: a systematic review. BMJ Qual Saf 2022; 31:679-687. [DOI: 10.1136/bmjqs-2021-013955] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 12/26/2021] [Indexed: 12/12/2022]
Abstract
BackgroundRecent studies suggest that displays of unacceptable behaviour, including bullying, discrimination and harassment, between healthcare workers (HCWs) may impair job performance, and in turn, increase the frequency of medical errors, adverse events and healthcare-related complications. The objective of this systematic review was to summarise the current evidence of the impact of unacceptable behaviour occurring between HCWs on clinical performance and patient outcomes.MethodsWe searched MEDLINE, Embase, PsycINFO and CINAHL from 1 January 1990 to 31 March 2021. The search results were screened by two independent reviewers and studies were included if they were original research that assessed the effects of unacceptable behaviour on clinical performance, quality of care, workplace productivity or patient outcomes. Risk of bias was assessed using tools relevant to the study design and the data were synthesised without meta-analysis.ResultsFrom the 2559 screened studies, 36 studies were included: 22 survey-based studies, 4 qualitative studies, 3 mixed-methods studies, 4 simulation-based randomised controlled trials (RCTs) and 3 other study designs. Most survey-based studies were low quality and demonstrated that HCWs perceived a relationship between unacceptable behaviour and worse clinical performance and patient outcomes. This was supported by a smaller number of higher quality retrospective studies and RCTs. Two of four RCTs produced negative results, possibly reflecting inadequate power or study design limitations. No study demonstrated any beneficial effect of unacceptable behaviour on the study outcomes.ConclusionsDespite the mixed quality of evidence and some inconsistencies in the strengths of associations reported, the overall weight of evidence shows that unacceptable behaviour negatively affects the clinical performance of HCWs, quality of care, workplace productivity and patient outcomes. Future research should focus on the evaluation and implementation of interventions that reduce the frequency of these behaviours.
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26
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Abstract
OBJECTIVE To determine the proportion of patients surviving their cardiac surgery who experienced non-home discharge (NHD) over a 16-year period in Australia and New Zealand (ANZ). DESIGN Retrospective, multicentre, cross-sectional study over the time period 01 January 2004 to 31 December 2019. SETTING Adult patients who underwent cardiac surgery from the Australia New Zealand Intensive Care Society Adult Patient Database (APD). PARTICIPANTS Adult patients (age 18 and above) who underwent index coronary artery bypass grafting, cardiac valve surgery or combined valve/coronary surgery. EXPOSURE The primary exposure variable was the calendar year during the which the index surgery was performed. OUTCOME The primary outcome was NHD after the index surgery. NHD included discharge to locations such as nursing home, chronic care facility, rehabilitation and palliative care. RESULTS We analysed 252 924 index cardiac surgical admissions from 101 discrete sites with a median age of 68 years (IQR 60-76), of which 74.2% (187 662 out of 252 920) were males. Of these, 4302 (1.7%) patients died in hospital and 213 011 (84.2%) were discharged home, 18 010 (7.1%) were transferred to another hospital and 17 601 (7%) experienced NHD. In Australia, 14 457 (6.4%) of patients progressed to NHD, compared with 3144 (11.7%) in New Zealand. The rate of NHD increased significantly over time (adjusted OR per year=1.06, 95% CI, 1.06 to 1.07, p<0.001). Increasing age, female sex, non-elective surgery, surgery type and Acute Physiology and Chronic Health Evaluation III Score were all associated with significant increase in NHD. CONCLUSIONS There was significant increase in NHD after cardiac surgery over time in ANZ. This has significant clinical relevance for informed consent discussions between healthcare providers and patients, and for healthcare services planning.
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Affiliation(s)
- Mahesh Ramanan
- ICU, Caboolture Hospital, Caboolture, Queensland, Australia
- Critical Care Division, George Institute for Global Health, Sydney, New South Wales, Australia
- School of Medicine, The University of Queensland School of Medicine, Herston, Queensland, Australia
| | - Aashish Kumar
- ICU, Logan Hospital, Loganholme, Queensland, Australia
| | - Chris Anstey
- School of Medicine, The University of Queensland School of Medicine, Herston, Queensland, Australia
- Sunshine Coast Clinical School, Griffith University School of Medicine, Birtinya, Queensland, Australia
| | - Kiran Shekar
- School of Medicine, The University of Queensland School of Medicine, Herston, Queensland, Australia
- Critical Care Research Group, The Prince Charles Hospital, Chermside, Queensland, Australia
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27
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Laupland KB, Shekar K, Tabah A, Clement P, Edwards F, Ramanan M. Excess Burden of Critical Illness Related to Inflammatory Bowel Disease. Intern Med J 2021; 53:812-818. [PMID: 34932276 DOI: 10.1111/imj.15672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 12/13/2021] [Accepted: 12/13/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Although inflammatory bowel disease (IBD) is associated with major morbidity and mortality, few studies have evaluated its associated burden of critical illness. AIMS We sought to examine the epidemiology and outcome of ICU admission among patients with IBD in north Brisbane, Australia. METHODS A population-based cohort design was utilized. All admissions to ICUs serving the Metro North Hospital and Health Service among adult residents during 2017-2019 were included. Data were obtained from ICU clinical information systems with linkages to statewide admissions and death registries. RESULTS Among 9,011 ICU admissions, 101 (1.1%) were among patients with IBD of which 57 (0.6%) and 44 (0.5%) had UC and CD, respectively. The incidence of ICU admission was 379, 1,336, 1,514, and 1,429 per 100,000 annually among those without IBD, CD, UC and IBD, respectively. Patients with IBD were at excess risk for admission across all age groups with women at highest risk under age 50 and men thereafter. The all cause 90-day case-fatality rates following ICU admission were not significantly different among patient groups and were 18%, 12%, 15%, and 12% for CD, UC, IBD, and non-IBD, respectively. However, as compared to non-IBD patients, those with CD (151.8 vs. 39.4 per 100,000; RR 3.85; 95% CI, 1.25-9.02; p=0.013); UC (159.4 vs 39.4 per 100,000; RR 4.05; 95% CI, 1.48-8.84; p=0.005), and IBD 155.6 vs 39.4 per 100,000; RR 3.95; 95% CI, 1.96-7.10; p=0.002) were at significantly higher risk for mortality. CONCLUSIONS Patients with IBD suffer a major burden of critical illness. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
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28
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Laupland KB, Ramanan M, Shekar K, Kirrane M, Clement P, Young P, Edwards F, Bushell R, Tabah A. Is intensive care unit mortality a valid survival outcome measure related to critical illness? Anaesth Crit Care Pain Med 2021; 41:100996. [PMID: 34902631 DOI: 10.1016/j.accpm.2021.100996] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 09/01/2021] [Accepted: 10/12/2021] [Indexed: 11/01/2022]
Abstract
RATIONALE Use of death as an outcome of intensive care unit (ICU) admission may be biased by differential discharge decisions. OBJECTIVE To determine the validity of ICU survival status as an outcome measure of all cause case-fatality. METHODS A retrospective cohort of first admissions among adults to four ICUs in North Brisbane, Australia was assembled. Death in ICU (censored at discharge or 30 days) was compared with 30-day overall case-fatality. RESULTS The 30-day overall case-fatality was 8.1% (2436/29,939). One thousand six hundred and thirty-one deaths occurred within the ICU stay and 576 subsequent during hospital post-ICU discharge within 30-days; ICU and hospital case-fatality rates were 5.4% and 7.4%, respectively. An additional 229 patients died after hospital separation within 30 days of ICU admission of which 110 (48.0%) were transferred to another acute care hospital, 80 (34.9%) discharged home, and 39 (17.0%) transferred to an aged care/chronic care/rehabilitation facility. Patients who died after ICU discharge were older, had higher APACHE III scores, were more likely to be elective surgical patients, and were less likely to be out of state residents or managed in a tertiary referral hospital. Limiting determination of case-fatality to ICU information alone would correctly detect 95% (780/821) of all-cause mortality at day 3, 90% (1093/1213) at day 5, 75% (1524/2019) at day 15, 72% (1592/2244) at day 21, and 67% (1631/2436) at day 30 of follow-up. CONCLUSIONS Use of ICU case-fatality significantly underestimates the true burden and biases assessment of determinants of critical illness-related mortality in our region.
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Affiliation(s)
- Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Marianne Kirrane
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Patrick Young
- Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Rachel Bushell
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
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29
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Ramanan M, Burrell A, Paul E, Trapani T, Broadley T, McGloughlin S, French C, Udy A. Nosocomial infections amongst critically ill COVID-19 patients in Australia. J Clin Virol Plus 2021; 1:100054. [PMID: 35262030 PMCID: PMC8582097 DOI: 10.1016/j.jcvp.2021.100054] [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: 07/11/2021] [Revised: 11/02/2021] [Accepted: 11/08/2021] [Indexed: 11/23/2022] Open
Abstract
Purpose To determine the frequency of nosocomial infections including hospital-acquired pneumonia (HAP) and bloodstream infection (BSI), amongst critically ill patients with COVID-19 infection in Australian ICUs and to evaluate associations with mortality and length of stay (LOS). Methods The effect of nosocomial infections on hospital mortality was evaluated using hierarchical logistic regression models to adjust for illness severity and mechanical ventilation. Results There were 490 patients admitted to 55 ICUs during the study period. Adjusted odds ratio (OR) for hospital mortality was 1.61 (95% confidence interval (CI) 0.61-4.27, p = 0.3) when considering BSI, and 1.76 (95% CI 0.73-4.21, p = 0.2) for HAP. The average adjusted ICU LOS was significantly longer for patients with BSI (geometric mean 9.0 days vs 6.3 days, p = 0.04) and HAP (geometric mean 13.9 days vs 6.0 days p<0.001). Conclusion Nosocomial infection rates amongst patients with COVID-19 were low and their development was associated with a significantly longer ICU LOS.
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Affiliation(s)
- Mahesh Ramanan
- Caboolture Hospital, 120 McKean Street, Caboolture, Queensland, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, 1 King Street, Newtown, New South Wales, 2042, Australia
- School of Medicine, University of Queensland, St. Lucia, Queensland, 4072, Australia
| | - Aidan Burrell
- Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, Victoria, Australia
| | - Eldho Paul
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, Victoria, Australia
| | - Tony Trapani
- Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, Victoria, Australia
| | - Tessa Broadley
- Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, Victoria, Australia
| | - Steve McGloughlin
- Department of Epidemiology and Preventative Medicine, School of Public Health, Monash University, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, Victoria, Australia
| | - Craig French
- Western Health, Furlong Road, St Albans, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, 553St Kilda Road, Melbourne, Victoria, Australia
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Sin JCK, Laupland KB, Ramanan M, Tabah A. Response to the letter: Renal status in the association between hyperphosphatemia and mortality. J Crit Care 2021; 67:217-218. [PMID: 34690035 DOI: 10.1016/j.jcrc.2021.10.002] [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] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 10/07/2021] [Indexed: 11/27/2022]
Affiliation(s)
- Jeremy Cheuk Kin Sin
- Department of Anaesthesia and Perioperative Medicine, Sunshine Coast University Hospital, Birtinya, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture and The Prince Charles Hospitals, Brisbane, Queensland, Australia; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia.
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Ramanan M, Shorr A, Lipman J. Ventriculitis: Infection or Inflammation. Antibiotics (Basel) 2021; 10:antibiotics10101246. [PMID: 34680826 PMCID: PMC8532926 DOI: 10.3390/antibiotics10101246] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/07/2021] [Accepted: 10/11/2021] [Indexed: 11/16/2022] Open
Abstract
Ventriculitis, or infection of the cerebrospinal fluid, in the presence of external ventricular drains (EVD), is an important complication and associated with substantial mortality, morbidity, and healthcare costs. Further, the conditions that require the insertion of an EVD, such as neurotrauma and subarachnoid hemorrhage, are themselves associated with inflammation of the cerebrospinal fluid. Phenotypically, patients with inflammation of the cerebrospinal fluid can present with very similar symptoms, signs, and laboratory findings to those with infection. This review examines various controversies relating to the definitions, diagnosis, challenges of differentiating infection from inflammation, prevention, and treatment of ventriculitis in patients with EVDs.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD 4510, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Chermside, QLD 4032, Australia
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Newtown, NSW 1466, Australia
- Correspondence:
| | - Andrew Shorr
- Washington Hospital Center, Medical Intensive Care Unit, Washington, DC 20010, USA;
| | - Jeffrey Lipman
- School of Medicine, The University of Queensland, Brisbane, QLD 4072, Australia;
- Jamieson Trauma Institute and Intensive Care Services, Royal Brisbane and Women’s Hospital, Herston, QLD 4029, Australia
- Nimes University Hospital, University of Montpellier, 30029 Nimes, France
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Ramanan M, Attokaran A, Murray L, Bhadange N, Stewart D, Rajendran G, Pusapati R, Petty M, Garrett P, Kruger P, Peake S, Billot L, Venkatesh B. Sodium chloride or Plasmalyte-148 evaluation in severe diabetic ketoacidosis (SCOPE-DKA): a cluster, crossover, randomized, controlled trial. Intensive Care Med 2021; 47:1248-1257. [PMID: 34609547 DOI: 10.1007/s00134-021-06480-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 07/09/2021] [Indexed: 12/17/2022]
Abstract
PURPOSE To determine whether treatment with Plasmalyte-148 (PL) compared to sodium chloride 0.9% (SC) results in faster resolution of diabetic ketoacidosis (DKA) and whether the acetate in PL potentiates ketosis. METHODS We conducted a cluster, crossover, open-label, randomized, controlled Phase 2 trial at seven hospitals in adults admitted to intensive care unit (ICU) with severe DKA with hospital randomised to PL or SC as fluid therapy. The primary outcome, DKA resolution, was defined as a change in base excess to ≥ - 3 mEq/L at 48 h. RESULTS Ninety-three patients were enrolled with 90 patients included in the modified-intention-to-treat population (PL n = 48, SC n = 42). At 48 h, mean fluid administration was 6798 ± 4850 ml vs 6574 ± 3123 ml, median anion gap 6 mEq/L (IQR 5-7) vs 7 mEq/L (IQR 5-7) and median blood ketones 0.3 mmol/L (IQR 0.1-0.5) vs 0.3 (IQR 0.1-0.5) in the PL and SC groups. DKA resolution at 48 h occurred in 96% (PL) and 86% (SC) of patients; odds ratio 3.93 (95% CI 0.73-21.16, p = 0.111). At 24 h, DKA resolution occurred in 69% (PL) and 36% (SC) of patients; odds ratio 4.24 (95% CI 1.68-10.72, p = 0.002). The median ICU and hospital lengths of stay were 49 h (IQR 23-72) vs 55 h (IQR 41-80) and 81 h (IQR 58-137) vs 98 h (IQR 65-195) in the PL and SC groups. CONCLUSION Plasmalyte-148, compared to sodium chloride 0.9%, may lead to faster resolution of metabolic acidosis in patients with DKA without an increase in ketosis. These findings need confirmation in a large, Phase 3 trial.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, McKean Street, Caboolture, QLD, 4510, Australia. .,Adult Intensive Care Services, The Prince Charles Hospital, Rode Road, Chermside, QLD, 4032, Australia. .,The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia. .,School of Medicine, University of Queensland, Sir Fred Schonell Drive, St Lucia, QLD, 4072, Australia.
| | - Antony Attokaran
- Intensive Care Unit, Rockhampton Hospital, Canning Street, Rockhampton, QLD, 4700, Australia
| | - Lauren Murray
- Intensive Care Unit, Sunshine Coast University Hospital, Doherty Street, Birtinya, QLD, 4575, Australia
| | - Neeraj Bhadange
- Intensive Care Unit, Ipswich Hospital, Chelmsford Avenue, Ipswich, QLD, 4305, Australia
| | - David Stewart
- Intensive Care Unit, Queen Elizabeth-2 Jubilee Hospital, Kessels Road, Coopers Plains, QLD, 4108, Australia
| | - Gokulnath Rajendran
- Intensive Care Unit, Mackay Base Hospital, Bridge Road, Mackay, QLD, 4741, Australia
| | - Raju Pusapati
- Intensive Care Unit, Hervey Bay Hospital, Urraween Road, Pialba, QLD, 4655, Australia
| | - Melissa Petty
- Intensive Care Unit, Caboolture Hospital, McKean Street, Caboolture, QLD, 4510, Australia
| | - Peter Garrett
- Intensive Care Unit, Sunshine Coast University Hospital, Doherty Street, Birtinya, QLD, 4575, Australia
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Ipswich Road, Woolloongabba, QLD, 4102, Australia
| | - Sandra Peake
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville Road, Woodville South, South Australia, 5011, Australia
| | - Laurent Billot
- The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales, Level 5/1 King Street, Newtown, NSW, 2042, Australia.,Intensive Care Unit, Wesley and Princess Alexandra Hospitals, Woolloongabba, QLD, Australia
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Ramanan M, Roberts S, McCullough JPA, Naidoo R, Rapchuk I, Matebele M, Tabah A, Kruger P, Smith J, Shekar K. Fluid resuscitation after cardiac surgery in the intensive care unit: A bi-national survey of clinician practice. (The FRACS-ICU clinician survey). Ann Card Anaesth 2021; 24:441-446. [PMID: 34747751 PMCID: PMC8617391 DOI: 10.4103/aca.aca_190_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 08/29/2020] [Accepted: 09/06/2020] [Indexed: 11/04/2022] Open
Abstract
Context and Aims To describe current fluid and vasopressor practices after cardiac surgery in Australia and New Zealand cardiothoracic intensive care units (ICU). Design and Setting This web-based survey was conducted in cardiothoracic ICUs in Australia and New Zealand. Methods Intensivists, cardiac surgeons, and anesthetists were contacted to complete the online survey that asked questions regarding first and second choice fluids and vasopressors and the tools and factors that influenced these choices. Results There were 96 respondents including 51 intensivists, 27 anesthetists, and 18 cardiac surgeons. Balanced crystalloids were the most preferred fluids (70%) followed by 4% albumin (18%) overall and among intensivists and anesthetists; however, cardiac surgeons (41%) preferred 4% albumin as their first choice. The most preferred second choice was 4% albumin (74%). Among vasopressors, noradrenaline was the preferred first choice (93%) and vasopressin the preferred second choice (80%). 53% initiated blood transfusion at a hemoglobin threshold of 70 g/L. Clinical acumen and mean arterial pressure were the most commonly used modalities in determining the need for fluids. Conclusions There is practice variation in preference for fluids used in cardiac surgical patients in Australia and New Zealand; however, balanced crystalloids and 4% albumin were the most popular choices. In contrast, there is broad agreement with the use of noradrenaline and vasopressin as first and second-line vasopressors. These data will inform the design of future studies that aim to investigate hemodynamic management post cardiac surgery.
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Affiliation(s)
- Mahesh Ramanan
- Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia
| | - Shaun Roberts
- Department of Anaesthesia, Princess Alexandra Hospital, Queensland, Australia
| | | | - Rishendran Naidoo
- Cardiothoracic Surgery, The Prince Charles Hospital, Queensland, Australia
| | - Ivan Rapchuk
- Department of Anaesthesia, The Prince Charles Hospital, Queensland, Australia
| | - Mbakise Matebele
- Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Queensland, Australia
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Queensland, Australia
| | - Julian Smith
- Cardiothoracic Surgery, Monash Medical Centre, Victoria, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Queensland, Australia
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Stolz A, Efendy R, Apte Y, Craswell A, Lin F, Ramanan M. Safety and efficacy of peripheral versus centrally administered vasopressor infusion: A single-centre retrospective observational study. Aust Crit Care 2021; 35:506-511. [PMID: 34600834 DOI: 10.1016/j.aucc.2021.08.005] [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] [Received: 12/07/2020] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Shock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. METHODS This is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. RESULTS We identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44-77), and Group 3, the highest (86, interquartile range = 57-101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. CONCLUSIONS Administration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.
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Affiliation(s)
- Annaliese Stolz
- Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia
| | | | - Yogesh Apte
- Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia.
| | | | - Frances Lin
- University of the Sunshine Coast, Sunshine Coast Health Institute, Queensland, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia; ICU, The Prince Charles Hospital, Australia; The George Institute & University of NSW, Australia
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Burrell AJ, Neto AS, Broadley T, Trapani T, Begum H, Campbell LT, Cheng AC, Cheung W, Cooper DJ, Erickson SJ, French CJ, Kaldor JM, Litton E, Murthy S, McAllister RE, Nichol AD, Palermo A, Plummer MP, Ramanan M, Reddi BA, Reynolds C, Webb SA, Udy AA. Comparison of baseline characteristics, treatment and celinical outcomes of critically ill COVID-19 patients admitted in the first and second waves in Australia. CRIT CARE RESUSC 2021; 23:308-319. [PMID: 38046076 PMCID: PMC10692524 DOI: 10.51893/2021.3.oa8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To report longitudinal differences in baseline characteristics, treatment, and outcomes in patients with coronavirus disease 2019 (COVID-19) admitted to intensive care units (ICUs) between the first and second waves of COVID-19 in Australia. Design, setting and participants: SPRINT-SARI Australia is a multicentre, inception cohort study enrolling adult patients with COVID-19 admitted to participating ICUs. The first wave of COVID-19 was from 27 February to 30 June 2020, and the second wave was from 1 July to 22 October 2020. Results: A total of 461 patients were recruited in 53 ICUs across Australia; a higher number were admitted to the ICU during the second wave compared with the first: 255 (55.3%) versus 206 (44.7%). Patients admitted to the ICU in the second wave were younger (58.0 v 64.0 years; P = 0.001) and less commonly male (68.9% v 60.0%; P = 0.045), although Acute Physiology and Chronic Health Evaluation (APACHE) II scores were similar (14 v 14; P = 0.998). High flow oxygen use (75.2% v 43.4%; P < 0.001) and non-invasive ventilation (16.5% v 7.1%; P = 0.002) were more common in the second wave, as was steroid use (95.0% v 30.3%; P < 0.001). ICU length of stay was shorter (6.0 v 8.4 days; P = 0.003). In-hospital mortality was similar (12.2% v 14.6%; P = 0.452), but observed mortality decreased over time and patients were more likely to be discharged alive earlier in their ICU admission (hazard ratio, 1.43; 95% CI, 1.13-1.79; P = 0.002). Conclusion: During the second wave of COVID-19 in Australia, ICU length of stay and observed mortality decreased over time. Multiple factors were associated with this, including changes in clinical management, the adoption of new evidence-based treatments, and changes in patient demographic characteristics but not illness severity.
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Affiliation(s)
- Aidan J.C. Burrell
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tessa Broadley
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Husna Begum
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Lewis T. Campbell
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
- Menzies School of Health Research, Darwin, NT, Australia
| | - Allen C. Cheng
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, VIC, Australia
| | - Winston Cheung
- Department of Intensive Care Medicine, Concord Repatriation General Hospital, Sydney, NSW, Australia
| | - D. James Cooper
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Craig J. French
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Western Health, Melbourne, VIC, Australia
| | - John M. Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW, Australia
| | - Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Perth, WA, Australia
- Department of Intensive Care Medicine, St John of God Hospital Subiaco, Perth, WA, Australia
| | - Srinivas Murthy
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | | | - Alistair D. Nichol
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Mark P. Plummer
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Caboolture, QLD, Australia
| | - Benjamin A.J. Reddi
- Royal Adelaide Hospital, Adelaide, SA, Australia
- University of Adelaide, Adelaide, SA, Australia
| | - Claire Reynolds
- Intensive Care Unit, St Vincent’s Health Network, Sydney, NSW, Australia
| | - Steve A. Webb
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, St John of God Hospital Subiaco, Perth, WA, Australia
| | - Andrew A. Udy
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
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Ramanan M, Billot L, Rajbhandari D, Myburgh J, Venkatesh B. An evaluation of factors that may influence clinicians' decisions not to enroll eligible patients into randomized trials in critical care. PLoS One 2021; 16:e0255361. [PMID: 34314449 PMCID: PMC8315530 DOI: 10.1371/journal.pone.0255361] [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] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 07/14/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To determine the association between intensive care unit (ICU) characteristics and clinicians' decision to decline eligible patients for randomization into a multicentered pragmatic comparative-effectiveness controlled trial. METHODS Screening logs from the Adjunctive Glucocorticoid Therapy in Septic Shock Trial (ADRENAL) and site-level data from the College of Intensive Care Medicine and Australia New Zealand Intensive Care Society were examined. The effects of ICU characteristics such as tertiary academic status, research coordinator availability, number of admissions, and ICU affiliations on clinicians declining to randomize eligible patients were calculated using mixed effects logistic regression modelling. RESULTS There were 21,818 patients screened for inclusion in the ADRENAL trial at 69 sites across five countries, out of which 5,501 were eligible, 3,800 were randomized and 659 eligible patients were declined for randomization by the treating clinician. The proportion of eligible patients declined by clinicians at individual ICUs ranged from 0 to41%. In the multivariable model, none of the ICU characteristics were significantly associated with higher clinician decline rate. CONCLUSIONS Neither tertiary academic status, nor other site-level variables were significantly associated with increased rate of clinicians declining eligible patients.
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Affiliation(s)
- Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
| | - Laurent Billot
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dorrilyn Rajbhandari
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - John Myburgh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Balasubramanian Venkatesh
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
- School of Medicine, University of Queensland, St Lucia, Queensland, Australia
- Intensive Care Unit, Wesley Hospital, Auchenflower, Queensland, Australia
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
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Thang C, Marella P, Kumar A, Matebele M, Ramanan M. Early Albumin Exposure After Cardiac Surgery. J Cardiothorac Vasc Anesth 2021; 36:1310-1317. [PMID: 34344597 DOI: 10.1053/j.jvca.2021.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 06/22/2021] [Accepted: 07/05/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES To determine whether the early use of albumin after cardiac surgery in the first 24 hours in the intensive care unit (ICU) is associated with reduced mortality. DESIGN A single-center nonrandomized retrospective cohort study using the Medical Information Mart in Intensive Care IV database. SETTING A single cardiothoracic ICU in the United States during a period between 2008 to 2019. PARTICIPANTS Patients undergoing valvular and/or cardiac bypass graft surgeries. INTERVENTIONS Albumin administered during the first 24 hours of the ICU admission. MEASUREMENTS AND MAIN RESULTS A total of 8,136 patients were included in this study, of whom 4,444 (54.6%) received albumin at any stage during the first 24 hours of ICU admission, and 69 (1.6%) of those patients died. The patient population exposed to albumin had higher comorbidities and illness severity compared to the no-albumin group. Patients exposed to albumin during the first 24 hours of ICU admission had a statistically significant reduction in mortality (odds ratio [OR], 0.68; 95% confidence interval [CI], 0.48-0.97, p < 0.05) after adjustment for age, the Oxford Acute Severity of Illness Score, and the Charlson comorbidity index. A sensitivity analysis of patients who received albumin at any stage during ICU admission showed increased mortality (OR, 1.93; 95% CI, 1.26-3.07, p < 0.01). Patients exposed to albumin had a significant increase in adjusted ICU length of stay (LOS) (geometric mean ratio 1.09; 95% CI, 1.05-1.10, p = < 0.001) and hospital LOS (geometric mean ratio 1.08; 95% CI, 1.05-1.10, p < 0.001). CONCLUSIONS Exposure to albumin in the first 24 hours after cardiac surgery is associated with a reduction in adjusted hospital mortality and an increase in both hospital and ICU lengths of stay.
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Affiliation(s)
- Christopher Thang
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia; School of Medicine, Griffith University, Gold Coast, Australia; Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service, Brisbane, Australia.
| | - Prashanti Marella
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service, Brisbane, Australia; Mater Clinical Unit, University of Queensland, Brisbane, Australia
| | - Aashish Kumar
- Intensive Care Unit, Logan Hospital, Metro South Hospital and Health Service, Brisbane, Australia
| | - Mbakise Matebele
- Faculty of Medicine, University of Queensland, Brisbane, Australia; School of Medicine, Griffith University, Gold Coast, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Caboolture Hospital, Metro North Hospital and Health Service, Brisbane, Australia; Faculty of Medicine, University of Queensland, Brisbane, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Australia; Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, Australia
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Sin JCK, Laupland KB, Ramanan M, Tabah A. Phosphate abnormalities and outcomes among admissions to the intensive care unit: A retrospective multicentre cohort study. J Crit Care 2021; 64:154-159. [PMID: 33906104 DOI: 10.1016/j.jcrc.2021.03.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 03/01/2021] [Accepted: 03/24/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE We investigated the effect of serum phosphate abnormalities at intensive care unit (ICU) admission on risk of death and length of stay in critically ill patients. MATERIALS AND METHODS A retrospective cohort of patients admitted to three adult ICUs in Queensland, Australia from April 2014 to 2019 was studied. Hypophosphataemia, normophosphataemia and hyperphosphataemia were defined as serum phosphate level of <0.8, 0.8-1.5 and >1.5 mmol/L respectively. Univariable and logistic regression analyses were performed to investigate the association between the phosphate groups and the risk of death. MEASUREMENTS AND MAIN RESULTS We included 13,155 patients in the analysis, of which 1424 (10.8%) patients had hypophosphataemia and 2544 (19.3%) hyperphosphataemia. The mean admission phosphate level was 1.25 (SD, ±0.43) mmol/L. Both hypophosphatemia (OR 1.29; 95% CI, 1.02-1.64; p = 0.034) and hyperphosphataemia (OR 1.39; 95% CI, 1.15-1.68; p = 0.001) at admission were independently associated with increased risk of death after adjusting for covariables using logistic regression analysis. CONCLUSION Hypophosphatemia and hyperphosphatemia were both independently associated with an increased case fatality rate and ICU length of stay in a large multicentre ICU cohort.
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Affiliation(s)
- Jeremy Cheuk Kin Sin
- Department of Anaesthesia, Redcliffe Hospital, Redcliffe, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture and the Prince Charles Hospitals, Brisbane, Queensland, Australia; The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia.
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Laupland KB, Ramanan M, Shekar K, Edwards F, Clement P, Tabah A. Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia. PLoS One 2021; 16:e0249840. [PMID: 33831072 PMCID: PMC8031082 DOI: 10.1371/journal.pone.0249840] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/25/2021] [Indexed: 12/03/2022] Open
Abstract
Background Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality. Objective To describe the long-term survival and examine determinants of death among patients with prolonged ICU admission. Methods A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics. Results During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14–20, 21–27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14–20, 21–27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214–1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model. Conclusions Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.
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Affiliation(s)
- Kevin B. Laupland
- Department of Intensive Care Services, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- * E-mail:
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Felicity Edwards
- Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
- Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia
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Flaws DF, Barnett A, Fraser J, Latu J, Ramanan M, Tabah A, Tippett V, Tronstad O, Patterson S. A protocol for tracking outcomes post intensive care. Nurs Crit Care 2021; 27:341-347. [PMID: 33609311 DOI: 10.1111/nicc.12613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 02/08/2021] [Accepted: 02/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Critically ill patients are more likely to survive intensive care than ever before due to advances in treatment. However, a proportion subsequently experiences post-intensive care syndrome (PICS) incurring substantial personal, social, and economic costs. PICS is a debilitating set of physical, psychological, and cognitive sequelae but the size and characteristics of the affected population have been difficult to describe, impeding progress in intensive care rehabilitation. AIMS AND OBJECTIVES The aim of this protocol is to describe recovery after admission to intensive care unit (ICU) and the predictors, correlates, and patient-reported outcomes for those experiencing PICS. The study will support the development of screening, diagnostic, and outcome measures to improve post-ICU recovery. DESIGN A prospective, multi-site observational study in three ICUs in Brisbane, Australia. Following consent, data will be collected from clinical records and using validated self-report instruments from 300 patients, followed up at 6 weeks and 6 months post ICU discharge. METHODS TOPIC is a prospective, multi-site observational study using self-report and clinical data on risk factors, including comorbidities, and outcomes. Data will be collected with consent from hospital records and participants 6 weeks and 6months post ICU discharge. RESULTS The main outcome measures will be self-reported physical, cognitive, and psychological function 6 weeks and 6 months post-ICU discharge. RELEVANCE TO CLINICAL PRACTICE This protocol provides a methodological framework to measure recovery and understand PICS. Data analysis will describe characteristics associated with recovery and PICS. The subsequent prediction and screening tools developed then aim to improve the effectiveness of post-ICU prevention and rehabilitation through more targeted screening and prediction and found a program of research developing a more tailored approach to PICS.
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Affiliation(s)
- Dylan F Flaws
- Department of Mental Health, Metro North Mental Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Adrian Barnett
- School of Public Health and Social Work, Queensland University of Technology, Brisbane, Queensland, Australia
| | - John Fraser
- Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Jiville Latu
- Department of Intensive Care, Intensive Care Unit, Redcliffe Hospital, Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Department of Intensive Care, Intensive Care Unit, Caboolture Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Alexis Tabah
- Department of Intensive Care, Intensive Care Unit, Redcliffe Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Vivienne Tippett
- School of Clinical Sciences, Queensland University of Technology, Brisbane, Queensland, Australia
| | - Oystein Tronstad
- Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Physiotherapy Department, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Sue Patterson
- Department of Mental Health, Metro North Mental Health, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, Critical Care Research Group, Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Dentistry, University of Queensland, Brisbane, Queensland, Australia
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41
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Kirrane MD, Shrapnel S, Ramanan M, Clement P, Fraser JF, Laupland KB, Sullivan CM, Shekar K. Intensive care digital health response to emerging infectious disease outbreaks such as COVID-19. Anaesth Intensive Care 2021; 49:105-111. [PMID: 33504171 DOI: 10.1177/0310057x20975777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The COVID-19 pandemic has required intensive care units to rapidly adjust and adapt their existing practices. Although there has a focus on expanding critical care infrastructure, equipment and workforce, plans have not emphasised the need to increase digital capabilities. The objective of this report was to recognise key areas of digital health related to the COVID-19 response. We identified and explored six focus areas relevant to intensive care, including using digital solutions to increase critical care capacity, developing surge capacity within an electronic health record, maintenance and downtime planning, training considerations and the role of data analytics. This article forms the basis of a framework for the intensive care digital health response to COVID-19 and other emerging infectious disease outbreaks.
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Affiliation(s)
- Marianne D Kirrane
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Digital Metro North, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Sally Shrapnel
- Australian Research Council Centre of Excellence for Engineered Quantum Systems, University of Queensland, Brisbane, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Australia.,Intensive Care Unit, Caboolture Hospital, Caboolture, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Division, University of New South Wales, Sydney, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - John F Fraser
- Faculty of Medicine, University of Queensland, Brisbane, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Health Sciences and Medicine, Bond University, Robina, Australia
| | - Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - Clair M Sullivan
- Digital Metro North, Metro North Hospital and Health Service, Brisbane, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Australia.,Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.,Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.,Faculty of Health Sciences and Medicine, Bond University, Robina, Australia.,Faculty of Health, Queensland University of Technology, Brisbane, Australia
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42
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Apte Y, Jacobs K, Shewdin S, Murray A, Tung L, Ramanan M, Massey D. Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019. Aust Crit Care 2021; 34:176-181. [PMID: 33487546 PMCID: PMC7825921 DOI: 10.1016/j.aucc.2020.08.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2020] [Revised: 08/07/2020] [Accepted: 08/08/2020] [Indexed: 01/21/2023] Open
Abstract
Background Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases. Objectives The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland. Methods A Plan–Do–Study–Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients. Results A description of the methods used to promote a complex change strategy is provided in this article. Conclusions In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.
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Affiliation(s)
- Yogesh Apte
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia.
| | - Kylie Jacobs
- Intensive Care Unit, Redcliffe Hospital, Australia; University of Queensland, Australia
| | - Shaun Shewdin
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia
| | - Andrew Murray
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia
| | - Luke Tung
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia
| | - Mahesh Ramanan
- Intensive Care Unit, Redcliffe Hospital, Australia; Intensive Care Unit, Caboolture Hospital, Australia; University of Queensland, Australia; Intensive Care Unit, Prince Charles Hospital, Australia; The George Institute for Global Health, Australia; University of New South Wales, Australia
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Ippolito M, Ramanan M, Bellina D, Catalisano G, Iozzo P, Di Guardo A, Moscarelli A, Grasselli G, Giarratano A, Bassetti M, Tabah A, Cortegiani A. Personal protective equipment use by healthcare workers in intensive care unit during the early phase of COVID-19 pandemic in Italy: a secondary analysis of the PPE-SAFE survey. Ther Adv Infect Dis 2021; 8:2049936121998562. [PMID: 33717482 PMCID: PMC7922607 DOI: 10.1177/2049936121998562] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 02/01/2021] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Italy was the first Western country to be heavily affected by COVID-19. Healthcare workers (HCWs) were exposed to a high risk of occupational infection, partially due to insufficient personal protective equipment (PPE) supplies. This study aimed to describe the practices, availability, training, confidence in PPE use and the adverse effects due to extended PPE use, as reported by HCWs in Italy. We also aimed to provide a comparison between Italian data and those from other countries. METHODS This study was a secondary analysis of a previously published international study, the PPE-SAFE Survey, conducted in April 2020. Data were analysed from the original study database. RESULTS We analysed the responses from 380 healthcare workers based in Italy, out of the 2711 respondents to the international survey. Among the Italian respondents, FFP2 and FFP3 respirators or equivalent were the most used masks for routine tasks (respectively 188/380, 50%; and 163/380, 43%). The median time of wearing PPE without taking a break was 5 h [interquartile range (IQR) 4-6], with statistically significant difference from other countries [median 4 h (IQR 2-5) p < 0.0001]. In Italy, 249 out of 380 (65%) HCWs had never performed a formal fit test for a N95 mask or equivalent and 91/380 (24%) never had a partner for donning and doffing procedures. Most of the respondents (299/380, 79%) had received formal training in PPE use at any time. CONCLUSION Most of the surveyed Italian HCWs reported working at above usual capacity, long shifts with PPE without breaks and routine use in intensive care unit of aerosol protection (e.g. FFP2/FFP3), hazmat suits and face shields/visors. The correct adherence to safety procedures (e.g. donning/doffing in pairs, performing fit test) has substantial scope for improvement in the future.
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Affiliation(s)
- Mariachiara Ippolito
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia,
Italy
| | - Mahesh Ramanan
- Intensive Care Units, Caboolture and Prince
Charles Hospitals, School of Medicine, University of Queensland, The George
Institute for Global Health, University of New South Wales, Sydney,
Queensland, Australia
| | - Davide Bellina
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia,
Italy
| | - Giulia Catalisano
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia,
Italy
| | - Pasquale Iozzo
- Department of Anaesthesia, Intensive Care and
Emergency, Policlinico Paolo Giaccone, University of Palermo, Palermo,
Sicilia, Italy
| | - Andrea Di Guardo
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia,
Italy
| | - Alessandra Moscarelli
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia,
Italy
| | - Giacomo Grasselli
- Dipartimento di Anestesia, Rianimazione ed
Emergenza-Urgenza, Fondazione IRCCS Ca’ Granda Ospedale Maggiore
Policlinico, Milan, Lombardia, Italy
| | - Antonino Giarratano
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Palermo, Sicilia,
Italy
- Department of Anaesthesia, Intensive Care and
Emergency, Policlinico Paolo Giaccone, Palermo, Italy
| | - Matteo Bassetti
- Infectious Diseases Clinic of the San
Martino-IST University Hospital, University of Genoa, Genova, Liguria,
Italy
| | - Alexis Tabah
- Intensive Care Unit, Faculty of Medicine,
Redcliffe Hospital, University of Queensland, Saint Lucia, Queensland,
Australia
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral
Science (Di.Chir.On.S.), University of Palermo, Italy. Departement of
Anaesthesia, Intensive Care and Emergency, Policlinico Paolo Giaccone, Via
del Vespro 129, 90127, Palermo, Italy
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Ramanan M, Gill D, Doan T, Bosley E, Rashford S, Dennis M, Shekar K. Assessing need for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest using Power BI for data visualisation. Emerg Med Australas 2020; 33:685-690. [PMID: 33345465 DOI: 10.1111/1742-6723.13704] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 11/22/2020] [Accepted: 12/05/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To estimate the number of patients in refractory out-of-hospital cardiac arrest (OHCA) potentially suitable for transport to an extracorporeal cardiopulmonary resuscitation (ECPR)-capable hospital in Brisbane, Queensland, Australia, based on outcome predictors for ECPR, ambulance geolocation and patient data. METHODS A retrospective cohort study was performed using data from all patients in OHCA attended by Queensland Ambulance Service between 1 January 2014 and 31 December 2018. The number of refractory arrest patients who could potentially be transferred to an ECPR-capable centre within 45 min of the time of arrest was modelled using theoretical on-scene treatment times. RESULTS Of 25 518 ambulance-attended OHCA in Queensland during the study period, 540 (2%) patients met criteria of refractory arrest for study inclusion. Further age and arrest rhythm criteria for transport to an ECPR-capable hospital were met in 253 (47%) study patients, an average of 51 patients per year. In 2018, 72 patients met study criteria for transport to an ECPR-capable centre. Based on theoretical on-scene treatment times of 12 and 20 min, in 2018 only 14 (19%) and 11 (15%) patients respectively would potentially arrive at an ECPR-capable hospital within accepted timeframes for ECPR. CONCLUSIONS Retrospective data collected from existing ambulance databases can be used to model patient suitability for ECPR. Relatively few patients with refractory OHCA in Queensland, Australia, could be attended and transported to an ECPR-capable centre within clinically acceptable timeframes. Further studies of the transport logistics and economic implications of providing ECPR services for OHCA are required to better inform decisions around this intervention.
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Affiliation(s)
- Mahesh Ramanan
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia.,The George Institute for Global Health, The University of New South Wales, Sydney, New South Wales, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Denzil Gill
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Tan Doan
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | - Emma Bosley
- Queensland Ambulance Service, Brisbane, Queensland, Australia
| | | | - Mark Dennis
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Critical Care Research Group and Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Brisbane, Queensland, Australia.,School of Medicine, Bond University, Gold Coast, Queensland, Australia
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Burrell AJ, Pellegrini B, Salimi F, Begum H, Broadley T, Campbell LT, Cheng AC, Cheung W, Cooper DJ, Earnest A, Erickson SJ, French CJ, Kaldor JM, Litton E, Murthy S, McAllister RE, Nichol AD, Palermo A, Plummer MP, Ramanan M, Reddi BA, Reynolds C, Trapani T, Webb SA, Udy AA. Outcomes for patients with COVID-19 admitted to Australian intensive care units during the first four months of the pandemic. Med J Aust 2020; 214:23-30. [PMID: 33325070 DOI: 10.5694/mja2.50883] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/15/2020] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To describe the characteristics and outcomes of patients with COVID-19 admitted to intensive care units (ICUs) during the initial months of the pandemic in Australia. DESIGN, SETTING Prospective, observational cohort study in 77 ICUs across Australia. PARTICIPANTS Patients admitted to participating ICUs with laboratory-confirmed COVID-19 during 27 February - 30 June 2020. MAIN OUTCOME MEASURES ICU mortality and resource use (ICU length of stay, peak bed occupancy). RESULTS The median age of the 204 patients with COVID-19 admitted to intensive care was 63.5 years (IQR, 53-72 years); 140 were men (69%). The most frequent comorbid conditions were obesity (40% of patients), diabetes (28%), hypertension treated with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (24%), and chronic cardiac disease (20%); 73 patients (36%) reported no comorbidity. The most frequent source of infection was overseas travel (114 patients, 56%). Median peak ICU bed occupancy was 14% (IQR, 9-16%). Invasive ventilation was provided for 119 patients (58%). Median length of ICU stay was greater for invasively ventilated patients than for non-ventilated patients (16 days; IQR, 9-28 days v 3 days; IQR, 2-5 days), as was ICU mortality (26 deaths, 22%; 95% CI, 15-31% v four deaths, 5%; 95% CI, 1-12%). Higher Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores on ICU day 1 (adjusted hazard ratio [aHR], 1.15; 95% CI, 1.09-1.21) and chronic cardiac disease (aHR, 3.38; 95% CI, 1.46-7.83) were each associated with higher ICU mortality. CONCLUSION Until the end of June 2020, mortality among patients with COVID-19 who required invasive ventilation in Australian ICUs was lower and their ICU stay longer than reported overseas. Our findings highlight the importance of ensuring adequate local ICU capacity, particularly as the pandemic has not yet ended.
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Affiliation(s)
- Aidan Jc Burrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Breanna Pellegrini
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | - Farhad Salimi
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | - Husna Begum
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Tessa Broadley
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Lewis T Campbell
- Royal Darwin Hospital, Darwin, NT.,Menzies School of Health Research, Darwin, NT
| | - Allen C Cheng
- The Alfred Hospital, Melbourne, VIC.,School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | | | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Arul Earnest
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
| | | | - Craig J French
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,Western Health, Melbourne, VIC
| | - John M Kaldor
- The Kirby Institute, University of New South Wales, Sydney, NSW
| | - Edward Litton
- Fiona Stanley Hospital, Perth, WA.,St John of God Health Care, Perth, WA
| | | | | | - Alistair D Nichol
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Annamaria Palermo
- Fiona Stanley Hospital, Perth, WA.,St John of God Health Care, Perth, WA
| | | | | | - Benjamin Aj Reddi
- Royal Adelaide Hospital, Adelaide, SA.,The University of Adelaide, Adelaide, SA
| | | | - Tony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,St John of God Health Care, Perth, WA
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC.,The Alfred Hospital, Melbourne, VIC
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Ramanan M, Burrell A, Udy A. Should critically ill patients with COVID-19 be managed in high-volume ICUs? CRIT CARE RESUSC 2020; 22:394-396. [PMID: 38046875 PMCID: PMC10692549 DOI: 10.51893/2020.4.l1] [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] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Mahesh Ramanan
- Intensive Care Units, Caboolture Hospital and The Prince Charles Hospital, Metro North Hospitals and Health Services, Brisbane, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Aidan Burrell
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and, New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and, New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
| | - For the SPRINT-SARI Australia Investigators
- Intensive Care Units, Caboolture Hospital and The Prince Charles Hospital, Metro North Hospitals and Health Services, Brisbane, QLD, Australia
- Critical Care Division, The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- School of Medicine, University of Queensland, Brisbane, QLD, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
- Australian and, New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
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47
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Laupland KB, Tabah A, Jacobs N, Ramanan M. Determinants of serum magnesium abnormalities and outcome among admissions to the intensive care unit. Anaesth Crit Care Pain Med 2020; 39:793-797. [PMID: 33059107 DOI: 10.1016/j.accpm.2020.07.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 11/28/2022]
Abstract
Serum magnesium is a frequently measured and treated electrolyte. However, few studies have examined magnesium level abnormalities and outcome in critically ill patients. Our objective was to determine the epidemiology and outcome of magnesium abnormalities among patients admitted to intensive care units (ICU). A retrospective cohort including adult patients admitted to three ICUs in southeast Queensland was assembled. Magnesium levels < 0.7, 0.7-1.0, and > 1.0 mmol/L were classified as low, normal, and high, respectively. Among 14,101 patients, the median age was 59.3 (interquartile range; IQR, 45.1-70.5), 7493 (56.4%) were male, and the median APACHE III score was 48 (IQR, 34-66). At admission, 3357 (23.8%) patients were classified as having hypomagnesemia, 1682 (11.9%) hypermagnesemia, 165 (1.2%) mixed, and 8897 (63.1%) as normal. Patients with magnesium abnormalities were more likely to be underweight and to have higher APACHE III scores. The overall 30-day case fatality was 8.2% (1155/14,101). Compared to those with normal levels, patients with hypermagnesemia at admission were at two-fold increased crude risk for death (relative risk; RR, 2.09; 95% confidence interval; CI, 1.83-2.39; p < 0.0001). After controlling for confounding variables in logistic regression analysis, neither admission hypo- nor hypermagnesemia was associated with death. However, development of ICU acquired hypermagnesemia among those with normal (odds ratio; OR, 1.34; 95% CI, 1.02-1.77; p = 0.034) and low (OR, 1.67; 95% CI, 1.15-2.41; p = 0.006) admission magnesium levels increased the risk for death. Magnesium abnormalities are common among patients managed in ICUs. The determinants of ICU-acquired hypermagnesemia and its adverse effect on outcome warrants further investigation.
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Affiliation(s)
- Kevin B Laupland
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia; Queensland University of Technology (QUT), Brisbane, Queensland, Australia.
| | - Alexis Tabah
- Intensive Care Unit, Redcliffe Hospital, Redcliffe, Queensland, Australia; Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Nicole Jacobs
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia; Intensive Care Unit, Caboolture Hospital, Caboolture, Queensland, Australia
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020. [PMID: 32876697 DOI: 10.1001/jama.2020.1702221] [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] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Angus DC, Derde L, Al-Beidh F, Annane D, Arabi Y, Beane A, van Bentum-Puijk W, Berry L, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Buzgau A, Cheng AC, de Jong M, Detry M, Estcourt L, Fitzgerald M, Goossens H, Green C, Haniffa R, Higgins AM, Horvat C, Hullegie SJ, Kruger P, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, Marshall J, McAuley D, McGlothin A, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Parker J, Rowan K, Sanil A, Santos M, Saunders C, Seymour C, Turner A, van de Veerdonk F, Venkatesh B, Zarychanski R, Berry S, Lewis RJ, McArthur C, Webb SA, Gordon AC, Al-Beidh F, Angus D, Annane D, Arabi Y, van Bentum-Puijk W, Berry S, Beane A, Bhimani Z, Bonten M, Bradbury C, Brunkhorst F, Buxton M, Cheng A, De Jong M, Derde L, Estcourt L, Goossens H, Gordon A, Green C, Haniffa R, Lamontagne F, Lawler P, Litton E, Marshall J, McArthur C, McAuley D, McGuinness S, McVerry B, Montgomery S, Mouncey P, Murthy S, Nichol A, Parke R, Rowan K, Seymour C, Turner A, van de Veerdonk F, Webb S, Zarychanski R, Campbell L, Forbes A, Gattas D, Heritier S, Higgins L, Kruger P, Peake S, Presneill J, Seppelt I, Trapani T, Young P, Bagshaw S, Daneman N, Ferguson N, Misak C, Santos M, Hullegie S, Pletz M, Rohde G, Rowan K, Alexander B, Basile K, Girard T, Horvat C, Huang D, Linstrum K, Vates J, Beasley R, Fowler R, McGloughlin S, Morpeth S, Paterson D, Venkatesh B, Uyeki T, Baillie K, Duffy E, Fowler R, Hills T, Orr K, Patanwala A, Tong S, Netea M, Bihari S, Carrier M, Fergusson D, Goligher E, Haidar G, Hunt B, Kumar A, Laffan M, Lawless P, Lother S, McCallum P, Middeldopr S, McQuilten Z, Neal M, Pasi J, Schutgens R, Stanworth S, Turgeon A, Weissman A, Adhikari N, Anstey M, Brant E, de Man A, Lamonagne F, Masse MH, Udy A, Arnold D, Begin P, Charlewood R, Chasse M, Coyne M, Cooper J, Daly J, Gosbell I, Harvala-Simmonds H, Hills T, MacLennan S, Menon D, McDyer J, Pridee N, Roberts D, Shankar-Hari M, Thomas H, Tinmouth A, Triulzi D, Walsh T, Wood E, Calfee C, O’Kane C, Shyamsundar M, Sinha P, Thompson T, Young I, Bihari S, Hodgson C, Laffey J, McAuley D, Orford N, Neto A, Detry M, Fitzgerald M, Lewis R, McGlothlin A, Sanil A, Saunders C, Berry L, Lorenzi E, Miller E, Singh V, Zammit C, van Bentum Puijk W, Bouwman W, Mangindaan Y, Parker L, Peters S, Rietveld I, Raymakers K, Ganpat R, Brillinger N, Markgraf R, Ainscough K, Brickell K, Anjum A, Lane JB, Richards-Belle A, Saull M, Wiley D, Bion J, Connor J, Gates S, Manax V, van der Poll T, Reynolds J, van Beurden M, Effelaar E, Schotsman J, Boyd C, Harland C, Shearer A, Wren J, Clermont G, Garrard W, Kalchthaler K, King A, Ricketts D, Malakoutis S, Marroquin O, Music E, Quinn K, Cate H, Pearson K, Collins J, Hanson J, Williams P, Jackson S, Asghar A, Dyas S, Sutu M, Murphy S, Williamson D, Mguni N, Potter A, Porter D, Goodwin J, Rook C, Harrison S, Williams H, Campbell H, Lomme K, Williamson J, Sheffield J, van’t Hoff W, McCracken P, Young M, Board J, Mart E, Knott C, Smith J, Boschert C, Affleck J, Ramanan M, D’Souza R, Pateman K, Shakih A, Cheung W, Kol M, Wong H, Shah A, Wagh A, Simpson J, Duke G, Chan P, Cartner B, Hunter S, Laver R, Shrestha T, Regli A, Pellicano A, McCullough J, Tallott M, Kumar N, Panwar R, Brinkerhoff G, Koppen C, Cazzola F, Brain M, Mineall S, Fischer R, Biradar V, Soar N, White H, Estensen K, Morrison L, Smith J, Cooper M, Health M, Shehabi Y, Al-Bassam W, Hulley A, Whitehead C, Lowrey J, Gresha R, Walsham J, Meyer J, Harward M, Venz E, Williams P, Kurenda C, Smith K, Smith M, Garcia R, Barge D, Byrne D, Byrne K, Driscoll A, Fortune L, Janin P, Yarad E, Hammond N, Bass F, Ashelford A, Waterson S, Wedd S, McNamara R, Buhr H, Coles J, Schweikert S, Wibrow B, Rauniyar R, Myers E, Fysh E, Dawda A, Mevavala B, Litton E, Ferrier J, Nair P, Buscher H, Reynolds C, Santamaria J, Barbazza L, Homes J, Smith R, Murray L, Brailsford J, Forbes L, Maguire T, Mariappa V, Smith J, Simpson S, Maiden M, Bone A, Horton M, Salerno T, Sterba M, Geng W, Depuydt P, De Waele J, De Bus L, Fierens J, Bracke S, Reeve B, Dechert W, Chassé M, Carrier FM, Boumahni D, Benettaib F, Ghamraoui A, Bellemare D, Cloutier È, Francoeur C, Lamontagne F, D’Aragon F, Carbonneau E, Leblond J, Vazquez-Grande G, Marten N, Wilson M, Albert M, Serri K, Cavayas A, Duplaix M, Williams V, Rochwerg B, Karachi T, Oczkowski S, Centofanti J, Millen T, Duan E, Tsang J, Patterson L, English S, Watpool I, Porteous R, Miezitis S, McIntyre L, Brochard L, Burns K, Sandhu G, Khalid I, Binnie A, Powell E, McMillan A, Luk T, Aref N, Andric Z, Cviljevic S, Đimoti R, Zapalac M, Mirković G, Baršić B, Kutleša M, Kotarski V, Vujaklija Brajković A, Babel J, Sever H, Dragija L, Kušan I, Vaara S, Pettilä L, Heinonen J, Kuitunen A, Karlsson S, Vahtera A, Kiiski H, Ristimäki S, Azaiz A, Charron C, Godement M, Geri G, Vieillard-Baron A, Pourcine F, Monchi M, Luis D, Mercier R, Sagnier A, Verrier N, Caplin C, Siami S, Aparicio C, Vautier S, Jeblaoui A, Fartoukh M, Courtin L, Labbe V, Leparco C, Muller G, Nay MA, Kamel T, Benzekri D, Jacquier S, Mercier E, Chartier D, Salmon C, Dequin P, Schneider F, Morel G, L’Hotellier S, Badie J, Berdaguer FD, Malfroy S, Mezher C, Bourgoin C, Megarbane B, Voicu S, Deye N, Malissin I, Sutterlin L, Guitton C, Darreau C, Landais M, Chudeau N, Robert A, Moine P, Heming N, Maxime V, Bossard I, Nicholier TB, Colin G, Zinzoni V, Maquigneau N, Finn A, Kreß G, Hoff U, Friedrich Hinrichs C, Nee J, Pletz M, Hagel S, Ankert J, Kolanos S, Bloos F, Petros S, Pasieka B, Kunz K, Appelt P, Schütze B, Kluge S, Nierhaus A, Jarczak D, Roedl K, Weismann D, Frey A, Klinikum Neukölln V, Reill L, Distler M, Maselli A, Bélteczki J, Magyar I, Fazekas Á, Kovács S, Szőke V, Szigligeti G, Leszkoven J, Collins D, Breen P, Frohlich S, Whelan R, McNicholas B, Scully M, Casey S, Kernan M, Doran P, O’Dywer M, Smyth M, Hayes L, Hoiting O, Peters M, Rengers E, Evers M, Prinssen A, Bosch Ziekenhuis J, Simons K, Rozendaal W, Polderman F, de Jager P, Moviat M, Paling A, Salet A, Rademaker E, Peters AL, de Jonge E, Wigbers J, Guilder E, Butler M, Cowdrey KA, Newby L, Chen Y, Simmonds C, McConnochie R, Ritzema Carter J, Henderson S, Van Der Heyden K, Mehrtens J, Williams T, Kazemi A, Song R, Lai V, Girijadevi D, Everitt R, Russell R, Hacking D, Buehner U, Williams E, Browne T, Grimwade K, Goodson J, Keet O, Callender O, Martynoga R, Trask K, Butler A, Schischka L, Young C, Lesona E, Olatunji S, Robertson Y, José N, Amaro dos Santos Catorze T, de Lima Pereira TNA, Neves Pessoa LM, Castro Ferreira RM, Pereira Sousa Bastos JM, Aysel Florescu S, Stanciu D, Zaharia MF, Kosa AG, Codreanu D, Marabi Y, Al Qasim E, Moneer Hagazy M, Al Swaidan L, Arishi H, Muñoz-Bermúdez R, Marin-Corral J, Salazar Degracia A, Parrilla Gómez F, Mateo López MI, Rodriguez Fernandez J, Cárcel Fernández S, Carmona Flores R, León López R, de la Fuente Martos C, Allan A, Polgarova P, Farahi N, McWilliam S, Hawcutt D, Rad L, O’Malley L, Whitbread J, Kelsall O, Wild L, Thrush J, Wood H, Austin K, Donnelly A, Kelly M, O’Kane S, McClintock D, Warnock M, Johnston P, Gallagher LJ, Mc Goldrick C, Mc Master M, Strzelecka A, Jha R, Kalogirou M, Ellis C, Krishnamurthy V, Deelchand V, Silversides J, McGuigan P, Ward K, O’Neill A, Finn S, Phillips B, Mullan D, Oritz-Ruiz de Gordoa L, Thomas M, Sweet K, Grimmer L, Johnson R, Pinnell J, Robinson M, Gledhill L, Wood T, Morgan M, Cole J, Hill H, Davies M, Antcliffe D, Templeton M, Rojo R, Coghlan P, Smee J, Mackay E, Cort J, Whileman A, Spencer T, Spittle N, Kasipandian V, Patel A, Allibone S, Genetu RM, Ramali M, Ghosh A, Bamford P, London E, Cawley K, Faulkner M, Jeffrey H, Smith T, Brewer C, Gregory J, Limb J, Cowton A, O’Brien J, Nikitas N, Wells C, Lankester L, Pulletz M, Williams P, Birch J, Wiseman S, Horton S, Alegria A, Turki S, Elsefi T, Crisp N, Allen L, McCullagh I, Robinson P, Hays C, Babio-Galan M, Stevenson H, Khare D, Pinder M, Selvamoni S, Gopinath A, Pugh R, Menzies D, Mackay C, Allan E, Davies G, Puxty K, McCue C, Cathcart S, Hickey N, Ireland J, Yusuff H, Isgro G, Brightling C, Bourne M, Craner M, Watters M, Prout R, Davies L, Pegler S, Kyeremeh L, Arbane G, Wilson K, Gomm L, Francia F, Brett S, Sousa Arias S, Elin Hall R, Budd J, Small C, Birch J, Collins E, Henning J, Bonner S, Hugill K, Cirstea E, Wilkinson D, Karlikowski M, Sutherland H, Wilhelmsen E, Woods J, North J, Sundaran D, Hollos L, Coburn S, Walsh J, Turns M, Hopkins P, Smith J, Noble H, Depante MT, Clarey E, Laha S, Verlander M, Williams A, Huckle A, Hall A, Cooke J, Gardiner-Hill C, Maloney C, Qureshi H, Flint N, Nicholson S, Southin S, Nicholson A, Borgatta B, Turner-Bone I, Reddy A, Wilding L, Chamara Warnapura L, Agno Sathianathan R, Golden D, Hart C, Jones J, Bannard-Smith J, Henry J, Birchall K, Pomeroy F, Quayle R, Makowski A, Misztal B, Ahmed I, KyereDiabour T, Naiker K, Stewart R, Mwaura E, Mew L, Wren L, Willams F, Innes R, Doble P, Hutter J, Shovelton C, Plumb B, Szakmany T, Hamlyn V, Hawkins N, Lewis S, Dell A, Gopal S, Ganguly S, Smallwood A, Harris N, Metherell S, Lazaro JM, Newman T, Fletcher S, Nortje J, Fottrell-Gould D, Randell G, Zaman M, Elmahi E, Jones A, Hall K, Mills G, Ryalls K, Bowler H, Sall J, Bourne R, Borrill Z, Duncan T, Lamb T, Shaw J, Fox C, Moreno Cuesta J, Xavier K, Purohit D, Elhassan M, Bakthavatsalam D, Rowland M, Hutton P, Bashyal A, Davidson N, Hird C, Chhablani M, Phalod G, Kirkby A, Archer S, Netherton K, Reschreiter H, Camsooksai J, Patch S, Jenkins S, Pogson D, Rose S, Daly Z, Brimfield L, Claridge H, Parekh D, Bergin C, Bates M, Dasgin J, McGhee C, Sim M, Hay SK, Henderson S, Phull MK, Zaidi A, Pogreban T, Rosaroso LP, Harvey D, Lowe B, Meredith M, Ryan L, Hormis A, Walker R, Collier D, Kimpton S, Oakley S, Rooney K, Rodden N, Hughes E, Thomson N, McGlynn D, Walden A, Jacques N, Coles H, Tilney E, Vowell E, Schuster-Bruce M, Pitts S, Miln R, Purandare L, Vamplew L, Spivey M, Bean S, Burt K, Moore L, Day C, Gibson C, Gordon E, Zitter L, Keenan S, Baker E, Cherian S, Cutler S, Roynon-Reed A, Harrington K, Raithatha A, Bauchmuller K, Ahmad N, Grecu I, Trodd D, Martin J, Wrey Brown C, Arias AM, Craven T, Hope D, Singleton J, Clark S, Rae N, Welters I, Hamilton DO, Williams K, Waugh V, Shaw D, Puthucheary Z, Martin T, Santos F, Uddin R, Somerville A, Tatham KC, Jhanji S, Black E, Dela Rosa A, Howle R, Tully R, Drummond A, Dearden J, Philbin J, Munt S, Vuylsteke A, Chan C, Victor S, Matsa R, Gellamucho M, Creagh-Brown B, Tooley J, Montague L, De Beaux F, Bullman L, Kersiake I, Demetriou C, Mitchard S, Ramos L, White K, Donnison P, Johns M, Casey R, Mattocks L, Salisbury S, Dark P, Claxton A, McLachlan D, Slevin K, Lee S, Hulme J, Joseph S, Kinney F, Senya HJ, Oborska A, Kayani A, Hadebe B, Orath Prabakaran R, Nichols L, Thomas M, Worner R, Faulkner B, Gendall E, Hayes K, Hamilton-Davies C, Chan C, Mfuko C, Abbass H, Mandadapu V, Leaver S, Forton D, Patel K, Paramasivam E, Powell M, Gould R, Wilby E, Howcroft C, Banach D, Fernández de Pinedo Artaraz Z, Cabreros L, White I, Croft M, Holland N, Pereira R, Zaki A, Johnson D, Jackson M, Garrard H, Juhaz V, Roy A, Rostron A, Woods L, Cornell S, Pillai S, Harford R, Rees T, Ivatt H, Sundara Raman A, Davey M, Lee K, Barber R, Chablani M, Brohi F, Jagannathan V, Clark M, Purvis S, Wetherill B, Dushianthan A, Cusack R, de Courcy-Golder K, Smith S, Jackson S, Attwood B, Parsons P, Page V, Zhao XB, Oza D, Rhodes J, Anderson T, Morris S, Xia Le Tai C, Thomas A, Keen A, Digby S, Cowley N, Wild L, Southern D, Reddy H, Campbell A, Watkins C, Smuts S, Touma O, Barnes N, Alexander P, Felton T, Ferguson S, Sellers K, Bradley-Potts J, Yates D, Birkinshaw I, Kell K, Marshall N, Carr-Knott L, Summers C. Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial. JAMA 2020; 324:1317-1329. [PMID: 32876697 PMCID: PMC7489418 DOI: 10.1001/jama.2020.17022] [Citation(s) in RCA: 537] [Impact Index Per Article: 134.3] [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: 01/27/2023]
Abstract
IMPORTANCE Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited. OBJECTIVE To determine whether hydrocortisone improves outcome for patients with severe COVID-19. DESIGN, SETTING, AND PARTICIPANTS An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020. INTERVENTIONS The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108). MAIN OUTCOMES AND MEASURES The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%). RESULTS After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively. CONCLUSIONS AND RELEVANCE Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Derek C Angus
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Farah Al-Beidh
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital (AP-HP), Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, King Abdulaziz Medical City, Riyadh, Saudi Arabia
| | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, United Kingdom
| | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | - Marc Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Charlotte Bradbury
- Bristol Royal Informatory, Bristol, United Kingdom
- University of Bristol, Bristol, United Kingdom
| | - Frank Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care (CSCC), Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Adrian Buzgau
- Helix, Monash University, Melbourne, Victoria, Australia
| | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Menno de Jong
- Department of Medical Microbiology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | | | - Lise Estcourt
- NHS Blood and Transplant, Bristol, United Kingdom
- Transfusion Medicine, Medical Sciences Division, University of Oxford, Oxford, United Kingdom
| | | | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Christopher Horvat
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Sebastiaan J Hullegie
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Peter Kruger
- Intensive Care Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
| | | | - John Marshall
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, United Kingdom
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Bryan McVerry
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephanie Montgomery
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | - Srinivas Murthy
- University of British Columbia School of Medicine, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- The Health Research Council of New Zealand, Wellington, New Zealand
- Medical Research Institute of New Zealand, Wellington, New Zealand
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane Parker
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kathryn Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre (ICNARC), London, United Kingdom
| | | | - Marlene Santos
- Li Ka Shing Knowledge Institute, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Christopher Seymour
- The Clinical Research Investigation and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- The UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Anne Turner
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Balasubramanian Venkatesh
- Southside Clinical Unit, Princess Alexandra Hospital, Brisbane, Queensland, Australia
- The George Institute for Global Health, Sydney, Australia
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Manitoba, Canada
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at University of California, Los Angeles
| | - Colin McArthur
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Steven A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- School of Medicine and Pharmacology, University of Western Australia, Crawley, Western Australia, Australia
- St John of God Hospital, Subiaco, Western Australia, Australia
| | - Anthony C Gordon
- Division of Anaesthetics, Pain Medicine and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, United Kingdom
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Ramanan M, Stolz A, Rooplalsingh R, Billot L, Myburgh J, Venkatesh B. An evaluation of the quality and impact of the global research response to the COVID-19 pandemic. Med J Aust 2020; 213:380-380.e1. [PMID: 32946592 PMCID: PMC7536958 DOI: 10.5694/mja2.50790] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Mahesh Ramanan
- Prince Charles Hospital, Brisbane, QLD.,Caboolture Hospital, Caboolture, QLD
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