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Deane AM, Hodgson CL, Young P, Little L, Singh V, Poole A, Young M, Mackle D, Lange K, Williams P, Peake SL, Chapman MJ, Iwashyna TJ. The rapid and accurate categorisation of critically ill patients (RACE) to identify outcomes of interest for longitudinal studies: a feasibility study. Anaesth Intensive Care 2017; 45:476-484. [PMID: 28673218 DOI: 10.1177/0310057x1704500411] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The capacity to measure the impact of an intervention on long-term functional outcomes might be improved if research methodology reflected our clinical approach, which is to individualise goals of care to what is achievable for each patient. The objective of this multicentre inception cohort study was to evaluate the feasibility of rapidly and accurately categorising patients, who were eligible for simulated enrolment into a clinical trial, into unique categories based on premorbid function. Once a patient met eligibility criteria a rapid 'baseline assessment' was conducted to categorise patients into one of eight specified groups. A subsequent 'gold standard' assessment was made by an independent blinded assessor once patients had recovered sufficiently to allow such an assessment to occur. Accuracy was predefined as agreement in >80% of assessments. One hundred and twenty-two patients received a baseline assessment and 104 (85%) were categorised to a unique category. One hundred and six patients survived to have a gold standard assessment performed, with 100 (94%) assigned to a unique category. Ninety-two patients had both a baseline and gold standard assessment, and these agreed in 65 (71%) patients. It was not feasible to rapidly and accurately categorise patients according to premorbid function.
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Affiliation(s)
| | | | | | | | - V Singh
- The Australian & New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University Melbourne, Victoria
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Kelly SJ, Moran JL, Williams PJ, Burns K, Rowland A, Miners JO, Peake SL. Haemodynamic effects of parenteral vs. enteral paracetamol in critically ill patients: a randomised controlled trial. Anaesthesia 2016; 71:1153-62. [DOI: 10.1111/anae.13562] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2016] [Indexed: 11/30/2022]
Affiliation(s)
- S. J. Kelly
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
| | - J. L. Moran
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
| | - P. J. Williams
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
- School of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
| | - K. Burns
- Department of Clinical Pharmacology; Flinders University; School of Medicine; Bedford Park South Australia Australia
| | - A. Rowland
- Department of Clinical Pharmacology; Flinders University; School of Medicine; Bedford Park South Australia Australia
| | - J. O. Miners
- Department of Clinical Pharmacology; Flinders University; School of Medicine; Bedford Park South Australia Australia
| | - S. L. Peake
- Department of Intensive Medicine; The Queen Elizabeth Hospital; Woodville South South Australia Australia
- School of Medicine; University of Adelaide; Adelaide South Australia Australia
- School of Epidemiology and Preventive Medicine; Monash University; Melbourne Victoria Australia
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Reid DB, Chapple LS, O'Connor SN, Bellomo R, Buhr H, Chapman MJ, Davies AR, Eastwood GM, Ferrie S, Lange K, McIntyre J, Needham DM, Peake SL, Rai S, Ridley EJ, Rodgers H, Deane AM. The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission. Anaesth Intensive Care 2016; 44:406-12. [PMID: 27246942 DOI: 10.1177/0310057x1604400309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.
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Affiliation(s)
- D B Reid
- Intensive Care Registrar, Royal Adelaide Hospital, Adelaide, South Australia
| | - L S Chapple
- Department of Anaesthesia, Princess Alexandra Hospital, Brisbane, Queensland
| | - S N O'Connor
- Research Manager, Intensive Care Unit, Department of Critical Care Services, Royal Adelaide Hospital, Adelaide, South Australia
| | - R Bellomo
- Intensive Care Consultant, Austin Hospital, Melbourne, Victoria
| | - H Buhr
- Research Manager, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - M J Chapman
- Director of Research, Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
| | - A R Davies
- Research Fellow, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - G M Eastwood
- Research Manager, Department of Intensive Care, Austin Hospital, Melbourne, Victoria
| | - S Ferrie
- Critical Care Dietitian, Intensive Care Service, Royal Prince Alfred Hospital, Sydney, New South Wales
| | - K Lange
- Biostatistician, Discipline of Medicine, University of Adelaide, Adelaide, South Australia
| | - J McIntyre
- Research Coordinator, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - D M Needham
- Medical Director, Outcomes After Critical Illness and Surgery Group, Johns Hopkins University, Baltimore, USA
| | - S L Peake
- Senior Intensive Care Clinician, Discipline of Acute Care Medicine, University of Adelaide, Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Adelaide, South Australia
| | - S Rai
- Intensive Care Specialist, The Canberra Hospital, Canberra, Australian Capital Territory
| | - E J Ridley
- Nutrition Program Manager, Department of Epidemiology and Preventative Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria
| | - H Rodgers
- Research Coordinator, The Canberra Hospital, Canberra, Australian Capital Territory
| | - A M Deane
- Department of Intensive Care Medicine, Royal Adelaide Hospital, Discipline of Acute Care Medicine, University of Adelaide, Adelaide, South Australia
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Angus DC, Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, Delaney A, Harrison DA, Holdgate A, Howe B, Huang DT, Iwashyna T, Kellum JA, Peake SL, Pike F, Reade MC, Rowan KM, Singer M, Webb SAR, Weissfeld LA, Yealy DM, Young JD. A systematic review and meta-analysis of early goal-directed therapy for septic shock: the ARISE, ProCESS and ProMISe Investigators. Intensive Care Med 2015; 41:1549-60. [PMID: 25952825 DOI: 10.1007/s00134-015-3822-1] [Citation(s) in RCA: 248] [Impact Index Per Article: 27.6] [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: 03/25/2015] [Accepted: 04/10/2015] [Indexed: 01/06/2023]
Abstract
PURPOSE To determine whether early goal-directed therapy (EGDT) reduces mortality compared with other resuscitation strategies for patients presenting to the emergency department (ED) with septic shock. METHODS Using a search strategy of PubMed, EmBase and CENTRAL, we selected all relevant randomised clinical trials published from January 2000 to January 2015. We translated non-English papers and contacted authors as necessary. Our primary analysis generated a pooled odds ratio (OR) from a fixed-effect model. Sensitivity analyses explored the effect of including non-ED studies, adjusting for study quality, and conducting a random-effects model. Secondary outcomes included organ support and hospital and ICU length of stay. RESULTS From 2395 initially eligible abstracts, five randomised clinical trials (n = 4735 patients) met all criteria and generally scored high for quality except for lack of blinding. There was no effect on the primary mortality outcome (EGDT: 23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI 0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled estimate of 90-day mortality from the three recent multicentre studies (n = 4063) also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25 [95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P < 0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) = 71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82 to 1.07); P = 0.33]. CONCLUSION EGDT is not superior to usual care for ED patients with septic shock but is associated with increased utilisation of ICU resources.
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Affiliation(s)
- D C Angus
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, USA
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Reade MC, Huang DT, Bell D, Coats TJ, Cross AM, Peake SL, Singer M, Yealy DM, Angus DC. Severe sepsis: international and specialty variations in initial management. Crit Care 2008. [PMCID: PMC4088786 DOI: 10.1186/cc6636] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Moran JL, Peake SL, Solomon P. Learning new lessons or repeating old mistakes? CRIT CARE RESUSC 2002; 4:257-60. [PMID: 16573437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Moran JL, Peake SL, Solomon P. Hypothermia as therapy in cerebral injury. CRIT CARE RESUSC 2002; 4:86-92. [PMID: 16573410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Moran JL, Peake SL. Early enteral nutrition support improves outcome: hypothesis or fact? CRIT CARE RESUSC 2002; 4:15-7. [PMID: 16573397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Moran JL, Peake SL. Further reflections on clinical trials in critical care. CRIT CARE RESUSC 2001; 3:226-9. [PMID: 16573510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Moran JL, Peake SL, Solomon PJ. Reporting of clinical trials using group sequential methods. CRIT CARE RESUSC 2001; 3:146-7. [PMID: 16573493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
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Abstract
OBJECTIVE To investigate the effects of adjunctive therapy with parenteral N-acetyl-L-cysteine in patients with newly diagnosed septic shock. DESIGN Prospective, randomized, double-blind, placebo-controlled study. SETTING Multidisciplinary intensive care unit at a university teaching hospital. PATIENTS Twenty patients (N-acetyl-L-cysteine group [n = 10], placebo group [n = 10]), 15 male and five female, of mean age 64 +/- 15 (SD) yrs and Acute Physiology and Chronic health Evaluation (APACHE) II score 33 +/- 6, with septic shock within 24 hrs of diagnosis. INTERVENTIONS After a 2-hr stabilization period (time-zero minus 2 hrs to time-zero), patients received either N-acetyl-L-cysteine in 5% dextrose (150 mg/kg in 100 mL over 15 mins, followed by 50 mg/kg in 250 mL over 4 hrs, and then 100 mg/kg/24 hrs in 500 mL for 44 hrs; N-acetyl-L-cysteine group) or the equivalent volume of 5% dextrose (placebo group). MEASUREMENTS AND MAIN RESULTS Hemodynamic and oxygen transport indices were measured at time-zero minus 2 hrs and time-zero, and at multiple time points thereafter until completion of the trial infusion (time-zero plus 48 hrs). A daily Organ Failure Score was recorded for 14 days. Treatment group demographics and hemodynamic variables did not differ significantly between the two groups at time-zero. Mean (SD), pooled mean arterial pressure (MAP), and cardiac index were 75 +/- 15 mm Hg and 3.9 +/- 1.2 L/min/m2, respectively. Over the next 48 hrs, in the N-acetyl-L-cysteine group, there was a progressive decrease, relative to both time-zero and the placebo group, in MAP, cardiac index, and left ventricular stroke work index (p < .01, repeated-measures analysis of variance). Percentage reductions in these values relative to the placebo group at 48 hrs were 23%, 18%, and 43%, respectively Oxygen transport indices, arterial blood gas analyses, Pao2/Fio2 ratio, and shunt did not differ over time between the groups. There was no difference in either daily Organ Failure Score over time (p > .01, repeated-measures analysis of variance) or hospital mortality rate (90% N-acetyl-L-cysteine group, 50% placebo group) (p > .1, logistic regression) between the two groups. CONCLUSION Adjunctive therapy with N-acetyl-L-cysteine in newly diagnosed septic shock was associated with a depression in cardiovascular performance, as indicated by progressive reductions in cardiac index, left ventricular stroke work index, and MAP.
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Affiliation(s)
- S L Peake
- Intensive Care Unit, Queen Elizabeth Hospital, Woodville, Australia
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Moran JL, Gallagher J, Peake SL, Cunningham DN, Salagaras M, Leppard P. Parenteral magnesium sulfate versus amiodarone in the therapy of atrial tachyarrhythmias: a prospective, randomized study. Crit Care Med 1995; 23:1816-24. [PMID: 7587256 DOI: 10.1097/00003246-199511000-00005] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE To compare the efficacy of parenteral magnesium sulfate vs. amiodarone in the therapy of atrial tachyarrhythmias in critically ill patients. DESIGN Prospective, randomized study. SETTING Multidisciplinary intensive care unit (ICU) at a university teaching hospital. PATIENTS Forty-two patients, 21 medical and 21 surgical, of mean (SD) age 67 +/- 15 yrs and mean Acute Physiology and Chronic Health Evaluation II score of 22 +/- 6, with atrial tachyarrhythmias (ventricular response rate of > or = 120 beats/min) sustained for > or = 1 hr. INTERVENTIONS After correction of the plasma potassium concentration to > or = 4.0 mmol/L, patients were randomly allocated to treatment with either a) magnesium sulfate 0.037 g/kg (37 mg/kg) bolus followed by 0.025 g/kg/hr (25 mg/kg/hr); or b) amiodarone 5 mg/kg bolus and 10 mg/kg/24-hr infusion. Therapeutic plasma magnesium concentration in the magnesium sulfate group was 1.4 to 2.0 mmol/L. Therapeutic end point was conversion to sinus rhythm over 24 hrs. MEASUREMENTS AND MAIN RESULTS At study entry (time 0), initial mean ventricular response rate and systolic blood pressure were 151 +/- 16 (SD) beats/min and 127 +/- 30 mm Hg in the magnesium sulfate group vs. 153 +/- 23 beats/min and 123 +/- 23 mm Hg in the amiodarone group, respectively (p = .8 and .65). Plasma magnesium (time 0) was 0.84 +/- 0.20 vs. 1.02 +/- 0.22 mmol/L in the magnesium and amiodarone group, respectively (p = .1). Eight patients had chronic dysrhythmias (magnesium 3, amiodarone 5). Excluding the two patient deaths (amiodarone group, time 0 + 12 to 24 hrs), no significant change in systolic blood pressure subsequently occurred in either group. In the magnesium group, mean plasma magnesium concentrations were 1.48 +/- 0.36, 1.82 +/- 0.41, 2.16 +/- 0.45, and 1.92 +/- 0.49 mmol/L at time 0 + 1, 4, 12 and 24 hrs, respectively. By logistic regression, the probability of conversion to sinus rhythm was significantly better for magnesium than for amiodarone at time 0 + 4 (0.6 vs. 0.44), 12 (0.72 vs. 0.5), and 24 (0.78 vs. 0.5) hrs. In patients not converting to sinus rhythm, a significant decrease in ventricular response rate occurred at time 0 + to 0.5 hrs (mean decrease 19 beats/min, p = .0001), but there was no specific treatment effect between the magnesium and the amiodarone groups; thereafter, there was no significant reduction in ventricular response rate over time in either group. CONCLUSIONS Intravenous magnesium sulfate is superior to amiodarone in the conversion of acute atrial tachyarrhythmias, while initial slowing of ventricular response rate in nonconverters appears equally efficacious with both agents.
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Affiliation(s)
- J L Moran
- Queen Elizabeth Hospital, Woodville, South Australia
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Affiliation(s)
- B L Duffy
- Department of Anaesthesia and Resuscitation, Queen Elizabeth Hospital, Woodville, South Australia
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Peake SL, Pavia JA, Bihari DJ, Chambers JB. An uncommon cause of acute right ventricular failure and high mixed venous oxygen saturation. Intensive Care Med 1992; 18:368-70. [PMID: 1469164 DOI: 10.1007/bf01694367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Ruptured sinus of Valsalva aneurysms are rare. We report a case in which the usual clinical manifestations were not present and the patient was initially treated as an acute pulmonary embolus. Despite three negative echocardiograms an intra-cardiac shunt was suspected because of a persistently elevated mixed venous oxygen saturation. Cardiac catheterisation confirmed the diagnosis. Surgical repair was performed and post operative recovery was uneventful.
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Affiliation(s)
- S L Peake
- Department of Intensive Care, Guy's Hospital, London, UK
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Abstract
Real-time renal ultrasonographic scans were obtained of 204 subjects, comprising 159 pregnant and 45 control subjects. A classification of hydronephrosis based on calyceal diameters was established, and the overall incidence of hydronephrosis was found to be 90% on the right side and 67% on the left side. Calyceal diameters for both kidneys were found to increase gradually throughout pregnancy, the right more rapidly than the left. Neither parity nor a history of urinary tract problems was found to be relevant to the degree of dilatation.
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