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Koneshamoorthy A, Epa DS, O'Neal DN, Lee MH, Santamaria JD, MacIsaac RJ. Outcomes associated with a variable rate insulin infusion diabetic ketoacidosis protocol. J Diabetes Complications 2024; 38:108702. [PMID: 38387103 DOI: 10.1016/j.jdiacomp.2024.108702] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 01/30/2024] [Accepted: 02/13/2024] [Indexed: 02/24/2024]
Abstract
AIMS To relate adverse events with glucose correction rates in diabetic ketoacidosis (DKA) using variable rate intravenous insulin-infusions (VRIII). METHODS Retrospective, observational study in adults with DKA who received insulin infusions between 2012 and 2017 at St Vincent's Hospital, Melbourne. Early correction of hyperglycaemia (<10 mmol/L) was evaluated for association with hypoglycaemia (<4.0 mmol/L), hypokalaemia (potassium <3.3 mmol/L) and clinical outcomes via regression analysis. RESULTS The study involved 97 patients, with 93 % having type 1 diabetes. The mean age was 38 years, 47 % were women and 35 % were admitted to intensive care. Hypoglycaemia rates during 12 and 24 h of treatment were 6.2 % and 8.2 %, respectively with 58 % of patients recording their first BGL <10 mmol/L within 12 h and 88 % within 24 h. Ketone clearance time averaged at 15.6 h. Hyperglycaemia correction rates to <10 mmol/L were not different in those with/without hypoglycaemia at 12/24 h, in multivariate analysis including admission BGL. Hypokalaemia occurred in 40.2 % of patients and was associated with lower pH but not BGL correction rates. CONCLUSION The VRIII protocol achieved early hyperglycaemia correction and ketoacidosis reversal with low hypoglycaemia risk. However, high hypokalaemia rates suggest the need for aggressive potassium replacement, especially in markedly acidotic patients.
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Affiliation(s)
- Anojian Koneshamoorthy
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia.
| | - Dilan Seneviratne Epa
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia
| | - David N O'Neal
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia; University of Melbourne, Department of Medicine, Fitzroy, Victoria 3065, Australia; Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Parkville, Victoria 3052, Australia
| | - Melissa H Lee
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia
| | - John D Santamaria
- University of Melbourne, Department of Medicine, Fitzroy, Victoria 3065, Australia; Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia
| | - Richard J MacIsaac
- Department of Endocrinology & Diabetes, St Vincent's Hospital Melbourne, Fitzroy, Victoria 3065, Australia; University of Melbourne, Department of Medicine, Fitzroy, Victoria 3065, Australia; Australian Centre for Accelerating Diabetes Innovations, University of Melbourne, Parkville, Victoria 3052, Australia
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2
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Moran JL, Duke GJ, Santamaria JD, Linden A. Modelling of intensive care unit (ICU) length of stay as a quality measure: a problematic exercise. BMC Med Res Methodol 2023; 23:207. [PMID: 37710162 PMCID: PMC10500937 DOI: 10.1186/s12874-023-02028-x] [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: 12/24/2022] [Accepted: 09/01/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Intensive care unit (ICU) length of stay (LOS) and the risk adjusted equivalent (RALOS) have been used as quality metrics. The latter measures entail either ratio or difference formulations or ICU random effects (RE), which have not been previously compared. METHODS From calendar year 2016 data of an adult ICU registry-database (Australia & New Zealand Intensive Care Society (ANZICS) CORE), LOS predictive models were established using linear (LMM) and generalised linear (GLMM) mixed models. Model fixed effects quality-metric formulations were estimated as RALOSR for LMM (geometric mean derived from log(ICU LOS)) and GLMM (day) and observed minus expected ICU LOS (OMELOS from GLMM). Metric confidence intervals (95%CI) were estimated by bootstrapping; random effects (RE) were predicted for LMM and GLMM. Forest-plot displays of ranked quality-metric point-estimates (95%CI) were generated for ICU hospital classifications (metropolitan, private, rural/regional, and tertiary). Robust rank confidence sets (point estimate and 95%CI), both marginal (pertaining to a singular ICU) and simultaneous (pertaining to all ICU differences), were established. RESULTS The ICU cohort was of 94,361 patients from 125 ICUs (metropolitan 16.9%, private 32.8%, rural/regional 6.4%, tertiary 43.8%). Age (mean, SD) was 61.7 (17.5) years; 58.3% were male; APACHE III severity-of-illness score 54.6 (25.7); ICU annual patient volume 1192 (702) and ICU LOS 3.2 (4.9). There was no concordance of ICU ranked model predictions, GLMM versus LMM, nor for the quality metrics used, RALOSR, OMELOS and site-specific RE for each of the ICU hospital classifications. Furthermore, there was no concordance between ICU ranking confidence sets, marginal and simultaneous for models or quality metrics. CONCLUSIONS Inference regarding adjusted ICU LOS was dependent upon the statistical estimator and the quality index used to quantify any LOS differences across ICUs. That is, there was no "one best model"; thus, ICU "performance" is determined by model choice and any rankings thereupon should be circumspect.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.
| | - Graeme J Duke
- Department of Intensive Care, Eastern Health, Box Hill, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital (Melbourne), Fitzroy, Australia
| | - Ariel Linden
- Linden Consulting Group, LLC, San Francisco, CA, USA
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3
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Dixon B, Sharkey JM, Teo EJ, Grace SA, Savage JS, Udy A, Smith P, Hellerstedt J, Santamaria JD. Assessment of a Non-Invasive Brain Pulse Monitor to Measure Intra-Cranial Pressure Following Acute Brain Injury. Med Devices (Auckl) 2023; 16:15-26. [PMID: 36718229 PMCID: PMC9883992 DOI: 10.2147/mder.s398193] [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] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/13/2023] [Indexed: 01/26/2023]
Abstract
Background Intracranial pressure (ICP) monitoring requires placing a hole in the skull through which an invasive pressure monitor is inserted into the brain. This approach has risks for the patient and is expensive. We have developed a non-invasive brain pulse monitor that uses red light to detect a photoplethysmographic (PPG) signal arising from the blood vessels on the brain's cortical surface. The brain PPG and the invasive ICP waveform share morphological features which may allow measurement of the intracranial pressure. Methods We enrolled critically ill patients with an acute brain injury with invasive ICP monitoring to assess the new monitor. A total of 24 simultaneous invasive ICP and brain pulse monitor PPG measurements were undertaken in 12 patients over a range of ICP levels. Results The waveform morphologies were similar for the invasive ICP and brain pulse monitor PPG approach. Both methods demonstrated a progressive increase in the amplitude of P2 relative to P1 with increasing ICP levels. An automated algorithm was developed to assess the PPG morphological features in relation to the ICP level. A correlation was demonstrated between the brain pulse waveform morphology and ICP levels, R2=0.66, P < 0.001. Conclusion The brain pulse monitor's PPG waveform demonstrated morphological features were similar to the invasive ICP waveform over a range of ICP levels, these features may provide a method to measure ICP levels. Trial Registration ACTRN12620000828921.
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Affiliation(s)
- Barry Dixon
- Cyban Pty Ltd, Melbourne, VIC, Australia,Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia,Department of Medicine, University of Melbourne, Melbourne, Vic, Australia,Correspondence: Barry Dixon, Department of Critical Care Medicine, St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia, Tel +61 3 9231 4425, Email
| | | | - Elliot J Teo
- Cyban Pty Ltd, Melbourne, VIC, Australia,Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia
| | | | | | - Andrew Udy
- Department of Critical Care Medicine, The Alfred Hospital, Melbourne, Australia
| | - Paul Smith
- Department of Neurosurgery, St Vincent’s Hospital, Melbourne, Australia,University of Melbourne Medical School, Melbourne, Vic, Australia
| | | | - John D Santamaria
- Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia
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4
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van Haren FMP, Laffey JG, Artigas A, Page C, Schultz MJ, Cosgrave D, McNicholas B, Smoot TL, Nunes Q, Richardson A, Yoon HJ, van Loon LM, Ghosh A, Said S, Panwar R, Smith R, Santamaria JD, Dixon B. Can nebulised HepArin Reduce morTality and time to Extubation in Patients with COVID-19 Requiring invasive ventilation Meta-Trial (CHARTER-MT): Protocol and Statistical Analysis Plan for an investigator-initiated international meta-trial of prospective randomised clinical studies. Br J Clin Pharmacol 2022; 88:3272-3287. [PMID: 35106809 PMCID: PMC9303761 DOI: 10.1111/bcp.15253] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 01/06/2022] [Accepted: 01/22/2022] [Indexed: 12/15/2022] Open
Abstract
There is significant interest in the potential for nebulised unfractionated heparin (UFH) as a novel therapy for patients with COVID-19 induced acute hypoxaemic respiratory failure requiring invasive ventilation. The scientific and biological rationale for nebulised heparin stems from the evidence for extensive activation of coagulation resulting in pulmonary microvascular thrombosis in COVID-19 pneumonia. Nebulised delivery of heparin to the lung may limit alveolar fibrin deposition and thereby limit progression of lung injury. Importantly, laboratory studies show that heparin can directly inactivate the SARS-CoV-2 virus, thereby prevent its entry into and infection of mammalian cells. UFH has additional anti-inflammatory and mucolytic properties that may be useful in this context. METHODS AND INTERVENTION: The Can nebulised HepArin Reduce morTality and time to Extubation in Patients with COVID-19 Requiring invasive ventilation Meta-Trial (CHARTER-MT) is a collaborative prospective individual patient data analysis of on-going randomised controlled clinical trials across several countries in 5 continents, examining the effects of inhaled heparin in patients with COVID-19 requiring invasive ventilation on various endpoints. Each constituent study will randomise patients with COVID-19 induced respiratory failure requiring invasive ventilation. Patients are randomised to receive nebulised heparin or standard care (open label studies) or placebo (blinded placebo-controlled studies) while under invasive ventilation. Each participating study collect a pre-defined minimum dataset. The primary outcome for the meta-trial is the number of ventilator-free days up to day 28 day, defined as days alive and free from invasive ventilation. ETHICS AND DISSEMINATION: The meta-trial is registered at ClinicalTrials.gov ID NCT04545541. Each contributing study is individually registered and has received approval of the relevant ethics committee or institutional review board. Results of this study will be shared with the WHO, published in scientific journals, and presented at scientific meetings.
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Affiliation(s)
- Frank M P van Haren
- Australian National University, Canberra, Australia.,University of New South Wales, Sydney, Australia.,Intensive Care Unit, St George Hospital, Sydney, Australia
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, and Regenerative Medicine Institute (REMEDI) at CÚRAM Centre for Research in Medical Devices, Biomedical Sciences Building, National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Ireland
| | - Antonio Artigas
- Critical Center, Corporació Sanitaria Parc Tauli, CIBER Enfermedades Respiratorias, Autonomous University of Barcelona, Sabadell, Spain
| | - Clive Page
- Sackler Institute of Pulmonary Pharmacology, King's College London, UK
| | - Marcus J Schultz
- Department of Intensive Care, Amsterdam University Medical Centre, Amsterdam, the Netherlands.,Nuffield Department of Medicine, Oxford University, Oxford, UK.,Mahidol-Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
| | - David Cosgrave
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Ireland
| | - Bairbre McNicholas
- Department of Anaesthesia, University Hospital Galway, Saolta Hospital Group, Ireland
| | | | - Quentin Nunes
- Institute of Systems, Molecular and Integrative Biology, University of Liverpool, Liverpool, United Kingdom
| | | | | | | | - Angajendra Ghosh
- Intensive Care Unit, The Northern Hospital, Melbourne, Australia
| | - Simone Said
- Intensive Care Unit, The Northern Hospital, Melbourne, Australia
| | | | - Roger Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
| | - Barry Dixon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia
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5
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Duke GJ, Moran JL, Bersten AD, Bihari S, Roodenburg O, Karnon J, Hirth S, Hakendorf P, Santamaria JD. Hospital-acquired complications: the relative importance of hospital- and patient-related factors. Med J Aust 2021; 216:242-247. [PMID: 34970736 DOI: 10.5694/mja2.51375] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 09/27/2021] [Accepted: 10/08/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To quantify the prevalence of hospital-acquired complications; to determine the relative influence of patient- and hospital-related factors on complication rates. DESIGN, PARTICIPANTS Retrospective analysis of administrative data (Integrated South Australian Activity Collection; Victorian Admitted Episodes Dataset) for multiple-day acute care episodes for adults in public hospitals. SETTING Thirty-eight major public hospitals in South Australia and Victoria, 2015-2018. MAIN OUTCOME MEASURES Hospital-acquired complication rates, overall and by complication class, by hospital and hospital type (tertiary referral, major metropolitan service, major regional service); variance in rates (intra-class correlation coefficient, ICC) at the patient, hospital, and hospital type levels as surrogate measures of their influence on rates. RESULTS Of 1 558 978 public hospital episodes (10 029 918 bed-days), 151 486 included a total of 214 286 hospital-acquired complications (9.72 [95% CI, 9.67-9.77] events per 100 episodes; 2.14 [95% CI, 2.13-2.15] events per 100 bed-days). Complication rates were highest in tertiary referral hospitals (12.7 [95% CI, 12.6-12.8] events per 100 episodes) and for episodes including intensive care components (37.1 [95% CI, 36.7-37.4] events per 100 episodes). For all complication classes, inter-hospital variation was determined more by patient factors (overall ICC, 0.55; 95% CI, 0.53-0.57) than by hospital factors (ICC, 0.04; 95% CI, 0.02-0.07) or hospital type (ICC, 0.01; 95% CI, 0.001-0.03). CONCLUSIONS Hospital-acquired complications were recorded for 9.7% of hospital episodes, but patient-related factors played a greater role in determining their prevalence than the treating hospital.
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Affiliation(s)
- Graeme J Duke
- Box Hill Hospital, Melbourne, VIC.,Eastern Health Clinical School, Monash University, Melbourne, VIC
| | | | | | | | - Owen Roodenburg
- Eastern Health Clinical School, Monash University, Melbourne, VIC.,Eastern Health, Melbourne, VIC
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Duke GJ, Shann F, Knott CI, Oberender F, Pilcher DV, Roodenburg O, Santamaria JD. Hospital-acquired complications in critically ill patients. CRIT CARE RESUSC 2021; 23:285-291. [PMID: 38046077 PMCID: PMC10692509 DOI: 10.51893/2021.3.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: The national hospital-acquired complications (HAC) system has been promoted as a method to identify health care errors that may be mitigated by clinical interventions. Objectives: To quantify the rate of HAC in multiday stay adults admitted to major hospitals. Design: Retrospective observational analysis of 5-year (July 2014 - June 2019) administrative dataset abstracted from medical records. Setting: All 47 hospitals with on-site intensive care units (ICUs) in the State of Victoria. Participants: All adults (aged ≥ 18 years) stratified into planned or unplanned, surgical or medical, ICU or other ward, and by hospital peer group (tertiary referral, metropolitan, regional). Main outcome measures: HAC rates in ICU compared with ward, and mixed-effects regression estimates of the association between HAC and i) risk of clinical deterioration, and ii) admission hospital site (intraclass correlation coefficient [ICC] > 0.3). Results: 211 120 adult ICU separations with mean hospital mortality of 7.3% (95% CI, 7.2-7.4%) reported 110 132 (42.6%) HAC events (commonly, delirium, infection, arrhythmia and respiratory failure) in 62 945 records (29.8%). Higher HAC rates were reported in elective (cardiac [50.3%] and non-cardiac [40.6%]) surgical subgroups compared with emergency medical subgroup (23.9%), and in tertiary (35.4%) compared with non-tertiary (22.7%) hospitals. HAC was strongly associated with on-admission patient characteristics (P < 0.001), but was weakly associated with hospital site (ICC, 0.08; 95% CI, 0.05-0.11). Conclusions: Critically ill patients have a high burden of HAC events, which appear to be associated with patient admission characteristics. HAC may an indicator of hospital admission complexity rather than hospital-acquired complications.
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Affiliation(s)
- Graeme J. Duke
- Intensive Care Service, Eastern Health, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
| | - Frank Shann
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Intensive Care Department, Royal Children’s Hospital, Melbourne, VIC, Australia
| | - Cameron I. Knott
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Intensive Care Department, Bendigo Health, Bendigo, VIC, Australia
- Intensive Care Department, Austin Health, Melbourne, VIC, Australia
| | - Felix Oberender
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Paediatric Intensive Care Department, Monash Children’s Hospital, Melbourne, VIC, Australia
| | - David V. Pilcher
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Intensive Care Department, Alfred Health, Melbourne, VIC, Australia
- Centre for Outcomes and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
| | - Owen Roodenburg
- Intensive Care Service, Eastern Health, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - John D. Santamaria
- INSIGHT Committee, Critical Care Clinical Network, Safer Care Victoria, Melbourne, VIC, Australia
- Critical Care Department, St Vincent’s Hospital Melbourne, Melbourne, VIC, Australia
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7
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Abstract
Background Mortality modelling in the critical care paradigm traditionally uses logistic regression, despite the availability of estimators commonly used in alternate disciplines. Little attention has been paid to covariate endogeneity and the status of non-randomized treatment assignment. Using a large registry database, various binary outcome modelling strategies and methods to account for covariate endogeneity were explored. Methods Patient mortality data was sourced from the Australian & New Zealand Intensive Society Adult Patient Database for 2016. Hospital mortality was modelled using logistic, probit and linear probability (LPM) models with intensive care (ICU) providers as fixed (FE) and random (RE) effects. Model comparison entailed indices of discrimination and calibration, information criteria (AIC and BIC) and binned residual analysis. Suspect covariate and ventilation treatment assignment endogeneity was identified by correlation between predictor variable and hospital mortality error terms, using the Stata™ “eprobit” estimator. Marginal effects were used to demonstrate effect estimate differences between probit and “eprobit” models. Results The cohort comprised 92,693 patients from 124 intensive care units (ICU) in calendar year 2016. Patients mean age was 61.8 (SD 17.5) years, 41.6% were female and APACHE III severity of illness score 54.5(25.6); 43.7% were ventilated. Of the models considered in predicting hospital mortality, logistic regression (with or without ICU FE) and RE logistic regression dominated, more so the latter using information criteria indices. The LPM suffered from many predictions outside the unit [0,1] interval and both poor discrimination and calibration. Error terms of hospital length of stay, an independent risk of death score and ventilation status were correlated with the mortality error term. Marked differences in the ventilation mortality marginal effect was demonstrated between the probit and the "eprobit" models which were scenario dependent. Endogeneity was not demonstrated for the APACHE III score. Conclusions Logistic regression accounting for provider effects was the preferred estimator for hospital mortality modelling. Endogeneity of covariates and treatment variables may be identified using appropriate modelling, but failure to do so yields problematic effect estimates. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01251-8.
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Affiliation(s)
- John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital (Melbourne), Fitzroy, Australia
| | - Graeme J Duke
- Intensive Services, Eastern Health, Box Hill, Australia
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8
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Fujii T, Udy AA, Nichol A, Bellomo R, Deane AM, El-Khawas K, Thummaporn N, Serpa Neto A, Bergin H, Short-Burchell R, Chen CM, Cheng KH, Cheng KC, Chia C, Chiang FF, Chou NK, Fazio T, Fu PK, Ge V, Hayashi Y, Holmes J, Hu TY, Huang SF, Iguchi N, Jones SL, Karumai T, Katayama S, Ku SC, Lai CL, Lee BJ, Liaw WJ, Ong CTW, Paxton L, Peppin C, Roodenburg O, Saito S, Santamaria JD, Shehabi Y, Tanaka A, Tiruvoipati R, Tsai HE, Wang AY, Wang CY, Yeh YC, Yu CJ, Yuan KC. Incidence and management of metabolic acidosis with sodium bicarbonate in the ICU: An international observational study. Crit Care 2021; 25:45. [PMID: 33531020 PMCID: PMC7851901 DOI: 10.1186/s13054-020-03431-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. METHOD This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH < 7.3 and a Base Excess < -4 mEq/L, within 24-h of ICU admission) were included. Screening continued until 10 patients who received and 10 patients who did not receive sodium bicarbonate in the first 24 h (early bicarbonate therapy) were included at each site. The primary outcome was ICU mortality, and the association between sodium bicarbonate and the clinical outcomes were assessed using regression analysis with generalized linear mixed model. RESULTS We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. CONCLUSIONS Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.
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Affiliation(s)
- Tomoko Fujii
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia.
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan.
| | - Andrew A Udy
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Alistair Nichol
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
| | - Rinaldo Bellomo
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Centre for Integrated Critical Care, Melbourne Medical School, University of Melbourne, Melbourne, VIC, Australia
| | - Adam M Deane
- Melbourne Medical School, Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Khaled El-Khawas
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Naorungroj Thummaporn
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Hannah Bergin
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
| | - Robert Short-Burchell
- Intensive Care Unit, University Hospital Geelong, Barwon Health, Geelong, VIC, Australia
| | - Chin-Ming Chen
- Department of Intensive Care Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Kuang-Hua Cheng
- Department of Critical Care Medicine, Mackay Memorial Hospital Taipei Branch, Taipei, Taiwan
| | - Kuo-Chen Cheng
- Department of Intensive Care Medicine, Chi-Mei Medical Center, Tainan, Taiwan
| | - Clemente Chia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, VIC, Australia
| | - Feng-Fan Chiang
- Division of Internal & Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Nai-Kuan Chou
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Timothy Fazio
- Melbourne Medical School, Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
- Health Intelligence, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Pin-Kuei Fu
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Victor Ge
- Intensive Care Unit, Peninsula Health, Frankston, VIC, Australia
| | - Yoshiro Hayashi
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Jennifer Holmes
- Intensive Care Unit, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Ting-Yu Hu
- Department of Critical Care Medicine, Mackay Memorial Hospital Taipei Branch, Taipei, Taiwan
| | | | - Naoya Iguchi
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Sarah L Jones
- Intensive Care Unit, Royal Darwin Hospital, Darwin, NT, Australia
| | - Toshiyuki Karumai
- Department of Intensive Care Medicine, Kameda Medical Center, Chiba, Japan
| | - Shinshu Katayama
- Department of Anesthesiology and Intensive Care Medicine, Jichi Medical University School of Medicine, Tochigi, Japan
| | - Shih-Chi Ku
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Chao-Lun Lai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - Bor-Jen Lee
- Division of Internal & Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Wen-Jinn Liaw
- Chung-Shan Medical University Hospital, Taichung, Taiwan
| | - Chelsea T W Ong
- Intensive Care Services, Eastern Health, Box Hill, VIC, Australia
| | - Lisa Paxton
- Melbourne Medical School, Department of Medicine, The University of Melbourne, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Chloe Peppin
- Critical Care and Perioperative Services, Monash Health, Melbourne, VIC, Australia
| | - Owen Roodenburg
- Intensive Care Services, Eastern Health, Box Hill, VIC, Australia
| | - Shinjiro Saito
- Intensive Care Unit, Jikei University Hospital, Tokyo, Japan
| | - John D Santamaria
- Intensive Care Unit, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Yahya Shehabi
- Critical Care Research, Monash Health School of Clinical Sciences, Monash University, Clayton, VIC, Australia
| | - Aiko Tanaka
- Department of Anesthesiology and Intensive Care Medicine, Graduate School of Medicine, Osaka University, Osaka, Japan
| | - Ravindranath Tiruvoipati
- Department of Epidemiology and Preventive Medicine, Australian and New Zealand Intensive Care Research Centre, Monash University, 553 St Kilda Rd, Melbourne, VIC, 3004, Australia
- Intensive Care Unit, Peninsula Health, Frankston, VIC, Australia
| | - Hsiao-En Tsai
- Department of Internal Medicine, National Taiwan University Hospital Hsin-Chu Branch, Hsin-Chu, Taiwan
| | - An-Yi Wang
- Department of Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Yu Wang
- Division of Internal & Critical Care Medicine, Taichung Veterans General Hospital, Taichung, Taiwan
| | - Yu-Chang Yeh
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Internal Medicine, Park Branch, National Taiwan University Hospital Biomedical, Hsin-Chu, Taiwan
| | - Kuo-Ching Yuan
- Department of Critical Care Medicine, Taipei Medical University Hospital, Taipei, Taiwan
- Department of Emergency Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
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9
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Affiliation(s)
- Graeme J Duke
- Eastern Health Intensive Care Research, Box Hill Hospital, Box Hill, VIC 3128, Australia; Faculty of Medicine, Nursing, and Health Sciences, Monash University, Clayton, VIC, Australia.
| | - John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, SA, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - David V Pilcher
- Department of Intensive Care, Alfred Hospital, Prahran, VIC, Australia; Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Carlton, VIC, Australia
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10
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Duke GJ, Moran JL, Santamaria JD, Roodenburg O. Safety of the endotracheal tube for prolonged mechanical ventilation. J Crit Care 2020; 61:144-151. [PMID: 33161243 DOI: 10.1016/j.jcrc.2020.10.018] [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: 02/27/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 11/26/2022]
Abstract
RATIONALE The endotracheal tube (ETT) is the most common route for invasive mechanical ventilation (MV) yet controversy attends its long-term safety. OBJECTIVE Assess the safety of ETT compared with tracheostomy tube (TT) for MV support in the intensive care unit (ICU). METHODS Retrospective analysis of five year national dataset of 128,977 adults (age > 15-years) admitted for MV therapy with tracheostomy tube (TT; n = 4772) or without (ETT; n = 124,204), excluding those with neurological diagnoses or likely to require a surgical airway (n = 27,466), in 93 public health service ICUs across Australia, between July 2013-June 2018. MEASUREMENTS Hospital survival (including liberation from MV) for ETT Group compared with TT Group using a probit regression model adjusted for confounding using fixed, endogenous and non-random treatment assignment covariates, and their interactions; analysed and plotted as marginal effects by duration of MV. RESULTS Median duration of MV was 2 (IQR =1-4) days, predominantly via ETT (124,205; 96.3%), and 21,620 (16.7%) died. Temporal trend for ETT increased (OR = 1.06 per year, 95%CI =1.03-1.10) compared to TT, even for prolonged (>3 weeks) MV (38.1%). Higher risk-adjusted mortality was associated with longer duration of MV and after 9 days of MV with retention of ETT compared with TT - average (mortality) treatment effect 12.6% (95%CI =10.7-14.5). The latter was not significant after 30 days of MV. CONCLUSIONS The safety of ETT compared with TT beyond short-term MV (≤9-days) is uncertain and requires prospective evaluation with additional data.
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Affiliation(s)
- Graeme J Duke
- Department of Intensive Care Medicine, Eastern Health, Box Hill, Australia; Monash University, Clayton, Australia.
| | - John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital (Melbourne), Fitzroy, Australia
| | - Owen Roodenburg
- Department of Intensive Care Medicine, Eastern Health, Box Hill, Australia; Monash University, Clayton, Australia
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11
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Duke GJ, Moran JL, Santamaria JD, Pilcher DV. Sepsis in the new millennium - Are we improving? J Crit Care 2020; 56:273-280. [PMID: 32001425 DOI: 10.1016/j.jcrc.2020.01.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 01/13/2020] [Accepted: 01/13/2020] [Indexed: 01/27/2023]
Affiliation(s)
- Graeme J Duke
- Eastern Health Intensive Care Research, Box Hill Hospital, Box Hill, Victoria, Australia; Monash University, Clayton, Victoria, Australia.
| | - John L Moran
- Department of Intensive Care Medicine, The Queen Elizabeth Hospital, Woodville, South Australia, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital (Melbourne), Fitzroy, Victoria, Australia.
| | - David V Pilcher
- Department of Intensive Care, Alfred Hospital, Commercial Rd, Prahran, Victoria, Australia; The Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation, Carlton, Victoria, Australia.
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Darvall JN, Bellomo R, Paul E, Subramaniam A, Santamaria JD, Bagshaw SM, Rai S, Hubbard RE, Pilcher D. Frailty in very old critically ill patients in Australia and New Zealand: a population‐based cohort study. Med J Aust 2019; 211:318-323. [DOI: 10.5694/mja2.50329] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2019] [Accepted: 07/31/2019] [Indexed: 01/28/2023]
Affiliation(s)
- Jai N Darvall
- Royal Melbourne Hospital Melbourne VIC
- Centre for Integrated Critical CareUniversity of Melbourne Melbourne VIC
| | - Rinaldo Bellomo
- Centre for Integrated Critical CareUniversity of Melbourne Melbourne VIC
- Austin Hospital Melbourne VIC
| | | | - Ashwin Subramaniam
- Peninsula Health Melbourne VIC
- Peninsula Clinical SchoolMonash University Melbourne VIC
| | | | | | - Sumeet Rai
- ANU Medical SchoolAustralian National University Canberra ACT
- Canberra Hospital Canberra ACT
| | - Ruth E Hubbard
- Centre for Health Services ResearchUniversity of Queensland Brisbane QLD
| | - David Pilcher
- The Alfred Hospital Melbourne VIC
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society Melbourne VIC
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13
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Smith RJ, Reid DA, Santamaria JD. Frailty is associated with reduced prospect of discharge home after in‐hospital cardiac arrest. Intern Med J 2019; 49:978-985. [DOI: 10.1111/imj.14159] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 01/28/2023]
Affiliation(s)
- Roger J. Smith
- Department of Critical Care MedicineSt Vincent’s Hospital Melbourne Victoria Australia
| | - David A. Reid
- Department of Critical Care MedicineSt Vincent’s Hospital Melbourne Victoria Australia
| | - John D. Santamaria
- Department of Critical Care MedicineSt Vincent’s Hospital Melbourne Victoria Australia
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14
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Lee MH, Calder GL, Santamaria JD, MacIsaac RJ. Diabetic ketoacidosis in adult patients: an audit of factors influencing time to normalisation of metabolic parameters. Intern Med J 2018; 48:529-534. [PMID: 29316133 DOI: 10.1111/imj.13735] [Citation(s) in RCA: 16] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Revised: 12/19/2017] [Accepted: 12/21/2017] [Indexed: 01/07/2023]
Abstract
BACKGROUND Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS). AIMS To identify factors that predict a slower time to resolution of DKA in adults with diabetes. METHODS Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored. RESULTS Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P < 0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P < 0.001). CONCLUSIONS Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.
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Affiliation(s)
- Melissa H Lee
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Genevieve L Calder
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - John D Santamaria
- Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
| | - Richard J MacIsaac
- Department of Endocrinology and Diabetes, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia.,Department of Medicine, The University of Melbourne, Melbourne, Victoria, Australia
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15
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Smith RJ, Santamaria JD, Holmes JA, Faraone EE, Hurune PN, Reid DA. Use of resuscitation plans at a tertiary Australian hospital: room for improvement. Intern Med J 2018; 47:767-774. [PMID: 28422404 DOI: 10.1111/imj.13460] [Citation(s) in RCA: 5] [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: 01/24/2017] [Revised: 03/23/2017] [Accepted: 04/08/2017] [Indexed: 11/26/2022]
Abstract
BACKGROUND The 'Acute Resuscitation Plan' (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the 'Not for Cardiopulmonary Resuscitation (CPR)' form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. AIM To evaluate the introduction of the ARP. METHODS This study is a retrospective audit of the records of all admissions to the hospital from January to June 2014 (Not for CPR period) and January to June 2015 (ARP period). The main outcomes are the incidence of resuscitation plans, the proportion of ARP specifying consultation with the patient (or representative) and with senior medical staff, and the proportion of ARP among older patients and those with significant comorbidity. RESULTS Resuscitation plans were present for 453 of 23 325 (1.9%) admissions in the Not for CPR period versus 1801 of 24 037 (7.5%) in the ARP period (odds ratio (OR) 4.1, 95% confidence interval (CI) 3.7-4.5, P < 0.001). A total of 42% of ARP specified 'care of the dying' in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARP and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥90 years, 59% from aged care, 90% with metastatic cancer and 64% aged ≥80 years and with a Charlson comorbidity index ≥3. CONCLUSIONS More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process, and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Jennifer A Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Patricia N Hurune
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
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Smith RJ, Santamaria JD, Faraone EE, Holmes JA, Reid DA. Rapid response team diagnoses: frequencies and related hospital mortality. CRIT CARE RESUSC 2017; 19:71-80. [PMID: 28215135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
OBJECTIVES To describe the frequency and hospital mortality of problems (diagnoses) encountered by a rapid response team (RRT), and to identify the most common diagnoses for RRT triggers and for treating units. DESIGN For each RRT event in 2015 at a tertiary hospital for adults, we chose the diagnosis that best explained the RRT event from a pre-defined list after reviewing relevant test results and clinical notes. RESULTS There were 937 RRT events during 700 admissions and there were 58 different RRT diagnoses in 11 diagnosis groups. The largest groups were neurological and consciousness problems (22.9%), circulatory problems (19.0%) and breathing problems (16.0%). The most common diagnoses were rapid atrial fibrillation (7.6%) and oversedation or narcosis (4.8%). When SpO2 < 90% triggered RRT review, the leading diagnoses were complex respiratory failure (25.9%) and pneumonia (11.4%). When decreased conscious state triggered review, the main problems were neurological, but there were 39 different diagnoses among these cases. The main problems among orthopaedic cases were post-operative hypovolaemia (19.0%) and spinal anaesthetic-related or epidural analgesicrelated hypotension (15.2%). Hospital mortality was 101/700 (14.4%). Diagnoses with high mortality included gastrointestinal bleeding (4/17, 23.5%), complex respiratory failure (8/33, 24.2%), intracranial event (8/28, 28.6%), cardiogenic shock or acute heart failure (5/17, 29.4%), pneumonia (7/21, 33.3%), chest sepsis (5/11, 45.5%) and cardiac arrest (18/26, 69.2%). CONCLUSIONS The RRT activation trigger provides only a general indication of the diagnosis. Some problems appear preventable and could provide a focus for unit-based quality initiatives. The mortality of some diagnoses is substantial, and this may help in setting treatment goals, but more work is needed to understand the association of RRT diagnosis and outcome.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Jennifer A Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
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17
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Nota C, Santamaria JD, Reid D, Tobin AE. The impact of an education program and written guideline on adherence to low tidal volume ventilation. CRIT CARE RESUSC 2016; 18:174-180. [PMID: 27604331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND Low tidal volume ventilation reduces mortality in patients with acute lung injury (ALI) and may reduce the risk of ALI in ventilated patients. A previous audit of our ventilation practices showed poor adherence to low tidal volume ventilation, and we subsequently introduced written ventilation guidelines and an education program to change practice. OBJECTIVES To determine if adherence to low tidal volume ventilation (defined as mandatory tidal volumes of =?6.5 mL/ kg predicted body weight [PBW]) in ventilated patients was improved with a written guideline and staff education. DESIGN AND SETTING Retrospective analysis of recorded mandatory ventilator settings from the clinical information system of a tertiary referral intensive care unit from 1 January 2012 to 31 December 2015, involving analysis of mandatory ventilator settings in relation to PBW to determine adherence to guidelines, and interrupted time-series analysis to assess the impact of education. MAIN OUTCOME MEASURE Adherence to low tidal volume ventilation. RESULTS The mean tidal volume for the cohort was 7.4 mL/ kg (SD, 1.3 mL/kg) PBW, and 760 patients (26.9%) received an average tidal volume during mandatory ventilation of ≤6.5 mL/kg PBW. Interrupted time-series analysis showed improved adherence after education, with an increase in adherence of 29.4% (95% CI, 19.3%-39.5%) from baseline. Multivariate logistic analysis found height, weight and staff education, but not sex, were associated with adherence to low tidal volume ventilation. CONCLUSION Written protocols and education can influence clinician behaviour, with substantial improvements in adherence to low tidal volume ventilation. Efforts to improve adherence through ward-based education appear warranted and necessary. Adherence was strongly associated with patient height, which suggested that adherence was partly the result of chance rather than design.
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Affiliation(s)
- Celeste Nota
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - David Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Antony E Tobin
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
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18
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Dixon B, Smith R, Santamaria JD, Orford NR, Wakefield BJ, Ives K, McKenzie R, Zhang B, Yap CH. A trial of nebulised heparin to limit lung injury following cardiac surgery. Anaesth Intensive Care 2016; 44:28-33. [PMID: 26673586 DOI: 10.1177/0310057x1604400106] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Cardiac surgery with cardiopulmonary bypass triggers an acute inflammatory response in the lungs. This response gives rise to fibrin deposition in the microvasculature and alveoli of the lungs. Fibrin deposition in the microvasculature increases alveolar dead space, while fibrin deposition in alveoli causes shunting. We investigated whether prophylactic nebulised heparin could limit this form of lung injury. We undertook a single-centre double-blind randomised trial. Forty patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomised to prophylactic nebulised heparin (50,000 U) or placebo. The primary endpoint was the change in arterial oxygen levels over the operative period. Secondary endpoints included end-tidal CO₂, the alveolar dead space fraction and bleeding complications. We found nebulised heparin did not improve arterial oxygen levels. Nebulised heparin was, however, associated with a lower alveolar dead space fraction (P <0.05) and lower tidal volumes at the end of surgery (P <0.01). Nebulised heparin was not associated with bleeding complications. In conclusion, prophylactic nebulised heparin did not improve oxygenation, but was associated with evidence of better alveolar perfusion and CO₂elimination at the end of surgery.
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Affiliation(s)
- B Dixon
- Department of Critical Care, St.Vincent's Hospital, Melbourne, Victoria
| | - R Smith
- Department of Critical Care, St.Vincent's Hospital, Melbourne, Victoria
| | - J D Santamaria
- Department of Critical Care, St.Vincent's Hospital, Melbourne, Victoria
| | - N R Orford
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - B J Wakefield
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - K Ives
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - R McKenzie
- Department of Critical Care, Barwon Health University Hospital, Geelong, Victoria
| | - B Zhang
- Department of Cardiothoracic Surgery, Barwon Health University Hospital, Geelong, Victoria
| | - C H Yap
- Department of Epidemiology and Preventive Medicine, Monash University and School of Medicine, Deakin University, Melbourne, Victoria
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Iwashyna TJ, Hodgson CL, Pilcher D, Orford N, Santamaria JD, Bailey M, Bellomo R. Towards defining persistent critical illness and other varieties of chronic critical illness. CRIT CARE RESUSC 2015; 17:215-218. [PMID: 26282262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
We hypothesise that there exists a substantial and growing group of "persistently critically ill" patients who appear to be intensive care unit-dependent because of a cascade of critical illnesses rather than their original ICU admitting diagnosis. These persistently critically ill patients are those who remain in the ICU because of ongoing complications of care that continue after their reason for admission has been treated and is no longer active. We believe such patients can be distinguished from patients currently labelled as "chronic critical illness" or "prolonged mechanical ventilation". We further believe that their primary problem is not simply failure to wean from mechanical ventilation due to muscle weakness and impaired gas exchange. We outline a program of clinician consultation, epidemiological research, consensus conference and validation to develop a useful definition of persistent critical illness, with the aim of supporting investigations in preventing persistence, and improving the care of patients so affected.
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Affiliation(s)
- Theodore J Iwashyna
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Carol L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Neil Orford
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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20
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Santamaria JD, Duke GJ, Pilcher DV, Cooper DJ, Moran J, Bellomo R. The timing of discharge from the intensive care unit and subsequent mortality. A prospective, multicenter study. Am J Respir Crit Care Med 2015; 191:1033-9. [PMID: 25730675 DOI: 10.1164/rccm.201412-2208oc] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic. OBJECTIVES To determine factors independently associated with mortality after ICU discharge. METHODS This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010. MEASUREMENTS AND MAIN RESULTS We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49-74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3-25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00-18:00) and 1,672 (16.4%) after-hours (18:00-06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P < 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5-45.6). CONCLUSIONS In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.
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Affiliation(s)
- John D Santamaria
- 1 Intensive Care Unit, St. Vincent's Hospital (Melbourne), Fitzroy, Australia
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21
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Santamaria JD, Tobin AE, Reid DA. Do we practise low tidal-volume ventilation in the intensive care unit? a 14-year audit. CRIT CARE RESUSC 2015; 17:108-112. [PMID: 26017128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
BACKGROUND Low tidal volume ventilation (LTVV) has been shown to reduce mortality of patients with acute lung injury (ALI) but uptake by clinicians has been low. Recent studies have shown that LTVV results in survival benefit at 24 months after discharge and, importantly, benefits patients without ALI. OBJECTIVE To determine adherence to LTVV in patients on mechanical ventilation (MV). DESIGN, SETTING AND PARTICIPANTS Retrospective analysis of ventilator settings recorded within the clinical information system of a 15-bed general ICU in a tertiary referral hospital, between 1 January 2000 and 31 May 2013. METHODS Analysis of mandatory MV with volume or pressure control. MAIN OUTCOME MEASURES Adherence to LTVV (_6.5 mL/ kg predicted body weight [PBW]). RESULTS We studied 4923 patients with a median age of 66 years (interquartile range [IQR], 57-74 years), and a median Acute Physiology and Chronic Health Evaluation II score of 16 (IQR, 13-19). Included were 3486 men (70.8%), and 3386 (66.8%) had undergone cardiac surgery. There were 249 450 ventilator measurements, with a median per patient of 75 measurements (IQR, 17-255 measurements). The median tidal volume was 8.15 mL/kg PBW (IQR, 7.15- 9.34 mL/kg PBW) for an adherence of 13.4%. Independent factors associated with adherence were sex, high inspiratory pressures, high positive end expiratory pressure and low PaO2/FiO2 ratio. CONCLUSION Adherence to LTVV in a general cohort of ICU patients was low, but it was better in patients with more severe lung disease. Overestimation of PBW may have contributed to our findings. Regular auditing of LTVV adherence might be considered a clinical indicator of good MV practice.
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Affiliation(s)
- John D Santamaria
- Intensive Care Unit, St Vincent's Hospital, Melbourne, VIC, Australia.
| | - Antony E Tobin
- Intensive Care Unit, St Vincent's Hospital, Melbourne, VIC, Australia
| | - David A Reid
- Intensive Care Unit, St Vincent's Hospital, Melbourne, VIC, Australia
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Smith RJ, Santamaria JD, Faraone EE, Holmes JA, Reid DA, Tobin AE. The duration of hospitalization before review by the rapid response team: A retrospective cohort study. J Crit Care 2015; 30:692-7. [PMID: 25981444 DOI: 10.1016/j.jcrc.2015.04.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Revised: 04/01/2015] [Accepted: 04/04/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Jennifer A Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
| | - Antony E Tobin
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Australia.
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Suzuki S, Eastwood GM, Bailey M, Gattas D, Kruger P, Saxena M, Santamaria JD, Bellomo R. Paracetamol therapy and outcome of critically ill patients: a multicenter retrospective observational study. Crit Care 2015; 19:162. [PMID: 25879463 PMCID: PMC4411740 DOI: 10.1186/s13054-015-0865-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Accepted: 03/09/2015] [Indexed: 12/13/2022]
Abstract
Introduction In this study, we aimed to examine the association between paracetamol administration in the intensive care unit (ICU) and mortality in critically ill patients. Methods We conducted a multicenter retrospective observational study in four ICUs. We obtained information on paracetamol use, body temperature, demographic, clinical and outcome data from each hospital’s clinical information system and admissions and discharges database. We performed statistical analysis to assess the association between paracetamol administration and hospital mortality. Results We studied 15,818 patients with 691,348 temperature measurements at 4 ICUs. Of these patients, 10,046 (64%) received at least 1 g of paracetamol. Patients who received paracetamol had lower in-hospital mortality (10% vs. 20%, P <0.001), and survivors were more likely to have received paracetamol (66% vs. 46%; P <0.001). However, patients treated with paracetamol were also more likely to be admitted to the ICU after surgery (70% vs. 51%; P <0.001) and/or after elective surgery (55% vs. 37%; P <0.001). In multivariate logistic regression analysis including a propensity score for paracetamol treatment, we found a significant and independent association between the use of paracetamol and reduced in-hospital mortality (adjusted odds ratio =0.60 (95% confidence interval (CI), 0.53 to 0.68), P <0.001). Cox proportional hazards analysis showed that patients who received paracetamol also had a significantly longer time to death (adjusted hazard ratio =0.51 (95% CI, 0.46 to 0.56), P <0.001). The association between paracetamol and decreased mortality and/or time to death was broadly consistent across surgical and medical patients. It remained present after adjusting for paracetamol administration as a time-dependent variable. However, when such time-dependent analysis was performed, the association of paracetamol with outcome lost statistical significance in the presence of fever and suspected infection and in patients in the lower tertiles of Acute Physiology and Chronic Health Evaluation II scores. Conclusions Paracetamol administration is common in the ICU and appears to be independently associated with reduced in-hospital mortality and time to death after adjustment for multiple potential confounders and propensity score. This association, however, was modified by the presence of fever, suspected infection and lesser illness severity and may represent the effect of indication bias. Electronic supplementary material The online version of this article (doi:10.1186/s13054-015-0865-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Satoshi Suzuki
- Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia. .,Okayama University Hospital, 700-0082 Okayama Prefecture, Okayama 1-1-1, Japan.
| | - Glenn M Eastwood
- Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia.
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Alfred Centre, 53 Commercial Rd, Melbourne, Victoria 3004, Australia.
| | - David Gattas
- Royal Prince Alfred Hospital, Missenden Rd, Camperdown, NSW 2050, Australia.
| | - Peter Kruger
- Princess Alexandra Hospital, 237 Ipswich Rd, Wooloongabba, QLD 4102, Australia.
| | - Manoj Saxena
- St George Hospital, Gray St, Kogarah, NSW 2217, Australia.
| | - John D Santamaria
- St Vincent's Hospital, 59 Victoria Parade, Fitzroy, Victoria 3065, Australia.
| | - Rinaldo Bellomo
- Austin Hospital, 145 Studley Rd, Heidelberg, Victoria 3084, Australia. .,Australian and New Zealand Intensive Care Research Centre, Alfred Centre, 53 Commercial Rd, Melbourne, Victoria 3004, Australia.
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Mok K, Smith RJ, Reid DA, Santamaria JD. Changing clinical guidelines from delayed to early aperient administration for enterally fed intensive care patients was associated with increased diarrhoea: a before-and-after, intention-to-treat evaluation. Aust Crit Care 2015; 28:208-13. [PMID: 25773579 DOI: 10.1016/j.aucc.2015.02.002] [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] [Received: 10/06/2014] [Revised: 02/19/2015] [Accepted: 02/21/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The 14-bed intensive care unit of a tertiary referral hospital adopted a guideline to start docusate sodium with sennosides when enteral nutrition was started. This replaced a guideline to start aperients after 24h of enteral nutrition if no bowel action had occurred. We sought to determine the effect of this change on the incidence of diarrhoea and constipation in intensive care. METHODS Retrospective audit of the medical records of consecutive adult patients admitted to intensive care and given enteral nutrition, excluding those with a primary gastrointestinal system diagnosis, between Jan-Aug 2011 (the delayed group, n=175) and Jan-Aug 2012 (the early group, n=175). The early aperient guideline was implemented during Sep-Dec 2011. RESULTS The early and delayed groups were similar in age (median 62 years vs. 64 years; P=0.17), sex (males 65% vs. 63%; P=0.91), and postoperative cases (31% vs. 33%; P=0.82) and had similar proportions who received mechanical ventilation (95% vs. 95%; P=1.00), an inotrope or vasopressor (63% vs. 70%; P=0.17), renal replacement therapy (8% vs. 10%; P=0.71), opiates (77% vs. 80%; P=0.60), antibiotics (89% vs. 91%; P=0.72) and metoclopramide (46% vs. 55%; P=0.11). A significantly larger proportion of the early group received an aperient (54% vs. 29%, P<0.001) and experienced diarrhoea (38% vs. 27%, P=0.04), but the groups had similar proportions affected by constipation (42% vs. 43%, P=0.91). CONCLUSIONS Changing guidelines from delayed to early aperient administration was associated with an increase in the incidence of diarrhoea but was not associated with the incidence of constipation. These findings do not support changing guidelines from delayed to early aperient administration.
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Affiliation(s)
- Kammy Mok
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia
| | - Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia.
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital Melbourne, Australia
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Duke GJ, Pilcher DV, Shann F, Santamaria JD, Oberender F, Bailey MJ. ANZROD, COPE 4 and PIM 3: caveat emptor. CRIT CARE RESUSC 2014; 16:155-157. [PMID: 25161015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Affiliation(s)
- G J Duke
- Intensive Care Department, Eastern Health, Melbourne, VIC, Australia.
| | - D V Pilcher
- The Alfred Hospital, Melbourne, VIC, Australia
| | - F Shann
- Intensive Care Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - J D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - F Oberender
- Intensive Care Department, Royal Children's Hospital, Melbourne, VIC, Australia
| | - M J Bailey
- Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
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Smith RJ, Santamaria JD, Reid DA, Faraone EE. The mortality associated with review by the rapid response team for non-arrest deterioration: a cohort study of acute hospital adult patients. CRIT CARE RESUSC 2014; 16:119-126. [PMID: 24888282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To compare the admission characteristics, discharge destination and mortality of patients reviewed by the rapid response team (RRT) for deterioration with those of other hospital patients; and to determine the association between RRT review for deterioration and mortality. DESIGN, SETTING AND PATIENTS Acute admissions of adult patients to a tertiary hospital between 1 January 2008 and 31 December 2011 were identified from administrative data. Data for each patient's first admission were merged with RRT data on the first RRT event of each admission, if any. RRT events involving cardiac arrest were classified as arrest events and all others as deterioration events. RESULTS Of 43 385 patients in the cohort, 1117 (2.57%) had RRT review for deterioration and 91 (0.21%) for cardiac arrest. Deterioration events occurred a median of 3.23 days after admission. Advanced treatments were instituted in 38.59% of deterioration events, and a new not-for resuscitation order for 5.55%. Compared with those not reviewed by the RRT, patients in the deterioration group were older (median, 70 v 60 years, P < 0.001) and had a higher Charlson comorbidity index (median, 1 v 0, P < 0.001). They also more often died in hospital (18.80% v 1.42%, P < 0.001) or were discharged to another hospital (37.51% v 13.39%, P < 0.001) and more often died in the 90 days after admission (24.44% v 3.48%, P < 0.001). Their adjusted odds ratio of death in the 90 days after admission was 5.85 (95% CI, 4.97-6.89, P < 0.001). CONCLUSION Patients reviewed for deterioration were older and had greater comorbidity than patients the RRT was not called to review. RRT review for deterioration was an independent risk factor for mortality.
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Affiliation(s)
- Roger J Smith
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia.
| | - John D Santamaria
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - David A Reid
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Espedito E Faraone
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
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Duke GJ, Barker A, Knott CI, Santamaria JD. Outcomes of older people receiving intensive care in Victoria. Med J Aust 2014; 200:323-6. [PMID: 24702089 DOI: 10.5694/mja13.10132] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Accepted: 10/25/2013] [Indexed: 11/17/2022]
Abstract
UNLABELLED OBJECTIVE To assess trends in service use and outcome of critically ill older people (aged ≥ 65 years) admitted to an intensive care unit (ICU). DESIGN, PATIENTS AND SETTING Retrospective cohort analysis of administrative data on older patients discharged from ICUs at all 23 adult public hospitals with onsite ICUs in Victoria between 1 July 1999 and 30 June 2011. Subgroups examined included those aged ≥ 80 years, major diagnosis categories, and those receiving mechanical ventilation. MAIN OUTCOME MEASURES Resource use and hospital survival; also length of stay (LOS) and discharge destination trends. RESULTS Over 12 years, 108,171 people aged ≥ 65 years were admitted to ICUs; of these, 49,912 (46.1%) received mechanical ventilation and 17,772 (16.4%) died. Despite an increase in the older age population (2.5% per annum) and acute care admissions (7.3% per annum) over the period studied, there was a net reversal in prevalence trends for ICU admissions (- 1.7% per annum; P = 0.04) and admissions of patients requiring mechanical ventilation (- 1.6% per annum) in the 8 years since 2004. Annual risk-adjusted mortality fell (odds ratio, 0.97 per year; 95% CI, 0.96-0.97 per year; P < 0.001) without prolongation of hospital or ICU LOS (P = 0.49) or discharge to residential aged care (RAC). Similar trends were noted in all a priori subgroups. CONCLUSIONS Improved hospital survival without an increase in demand for ICU admission or RAC or an increase in LOS suggests there has been improvement in the care of the older age population.
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Affiliation(s)
| | - Anna Barker
- Centre of Research Execllence in Patient Safety, Monash University, Melbourne, VIC, Australia
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Duke GJ, Barker A, Rasekaba T, Hutchinson A, Santamaria JD. A brief review of recent trends in Victorian intensive care, 2000-2011. CRIT CARE RESUSC 2014; 16:24-28. [PMID: 24588432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND Review of resource use and patient outcomes of intensive care unit services over time provides insights into service delivery and safety. OBJECTIVE To examine temporal trends in resource consumption and risk-adjusted mortality of adult ICU patients in Victoria. DESIGN, PARTICIPANTS AND SETTING Retrospective cohort study of 214 619 adult ICU admissions recorded from 23 major hospitals over 12 years from 1 July 1999 to 30 June 2011. OUTCOMES Primary outcomes were population rates of ICU admission and mechanical ventilation (MV), ICU and hospital length of stay, and hospital survival. Secondary outcomes included average ICU and MV bed numbers. Administrative data were derived from the Victorian Admitted Episodes Dataset and the Australian Bureau of Statistics. The Critical Care Outcome Prediction Equation informed estimates for risk-adjusted mortality. Temporal mortality trends were evaluated for outcome estimates and hierarchical logisticregression trends were evaluated for risk-adjusted mortality. RESULTS Of ICU admissions, 104 103 (48.5%) were patients who received MV, and 87.6% ICU admissions were adults who survived to hospital discharge. There was a decline in the risk-adjusted mortality (odds ratio, 0.967 per year; 95% CI, 0.963-0.971; P<0.001). Similar results were found in 17 hospitals (74%) and in nine of 10 major diagnostic subgroups. There was an increase of 5.2 occupied ICU beds per year (range, ?4.2 ICU beds per year; P=0.002). Despite ICU admissions being a minority cohort (2.5% of public hospital admissions) this group used 8.6% of hospital bed-days and attracted 19.5% of funding. CONCLUSIONS There was an increase in ICU resource availability and evidence of improvement in hospital survival, suggesting improved quality of care. These evaluation methods may be useful in monitoring statewide capacity, service delivery and patient safety.
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Affiliation(s)
- Graeme J Duke
- Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia.
| | - Anna Barker
- Centre of Research Excellence in Patient Safety, Monash University, Melbourne, VIC, Australia
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Jelinek MV, Santamaria JD, Best JD, Thompson DR, Tonkin AM, Vale MJ. Reversing social disadvantage in secondary prevention of coronary heart disease. Int J Cardiol 2014; 171:346-50. [DOI: 10.1016/j.ijcard.2013.12.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 11/04/2013] [Accepted: 12/12/2013] [Indexed: 11/28/2022]
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Santamaria JD, Tobin AE, Anstey MH, Smith RJ, Reid DA. Do outlier inpatients experience more emergency calls in hospital? An observational cohort study. Med J Aust 2014; 200:45-8. [DOI: 10.5694/mja12.11680] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 09/05/2013] [Indexed: 11/17/2022]
Affiliation(s)
| | - Antony E Tobin
- Intensive Care Unit, St Vincent's Hospital, Melbourne, VIC
| | - Matthew H Anstey
- Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Mass, USA
| | - Roger J Smith
- Intensive Care Unit, St Vincent's Hospital, Melbourne, VIC
| | - David A Reid
- Intensive Care Unit, St Vincent's Hospital, Melbourne, VIC
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Dixon B, Reid D, Collins M, Newcomb AE, Rosalion A, Yap CH, Santamaria JD, Campbell DJ. The operating surgeon is an independent predictor of chest tube drainage following cardiac surgery. J Cardiothorac Vasc Anesth 2014; 28:242-6. [PMID: 24439890 DOI: 10.1053/j.jvca.2013.09.010] [Citation(s) in RCA: 30] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Bleeding into the chest is a major cause of blood transfusion and adverse outcomes following cardiac surgery. The authors investigated predictors of bleeding following cardiac surgery to identify potentially correctable factors. DESIGN Data were retrieved from the medical records of patients undergoing cardiac surgery over the period of 2002 to 2008. Multivariate analysis was used to identify the independent predictors of chest tube drainage. SETTING Tertiary hospital. PARTICIPANTS Two thousand five hundred seventy-five patients. INTERVENTIONS Cardiac surgery. RESULTS The individual operating surgeon was independently associated with the extent of chest tube drainage. Other independent factors included internal mammary artery grafting, cardiopulmonary bypass time, urgency of surgery, tricuspid valve surgery, redo surgery, left ventricular impairment, male gender, lower body mass index and higher preoperative hemoglobin levels. Both a history of diabetes and administration of aprotinin were associated with reduced levels of chest tube drainage. CONCLUSIONS The individual operating surgeon was an independent predictor of the extent of chest tube drainage. Attention to surgeon-specific factors offers the possibility of reduced bleeding, fewer transfusions, and improved patient outcomes.
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Affiliation(s)
- Barry Dixon
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia.
| | - David Reid
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Marnie Collins
- Department of Statistics, Peter MacCallum Hospital, Melbourne, Australia
| | - Andrew E Newcomb
- Department of Cardiothoracic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Alexander Rosalion
- Department of Cardiothoracic Surgery, St. Vincent's Hospital, Melbourne, Australia
| | - Cheng-Hon Yap
- Department of Cardiothoracic Surgery, Geelong Hospital, Melbourne, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - John D Santamaria
- Department of Intensive Care, St. Vincent's Hospital, Melbourne, Australia
| | - Duncan J Campbell
- St. Vincent's Institute of Medical Research, St. Vincent's Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, St. Vincent's Hospital, Melbourne, Australia
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Dixon B, Smith R, Campbell DJ, Tobin A, Newcomb AE, Rosalion A, Opeskin K, Carter H, Scott DA, Santamaria JD. The Effect of Etanercept on Lung Leukocyte Margination and Fibrin Deposition after Cardiac Surgery. Am J Respir Crit Care Med 2013; 188:751-4. [DOI: 10.1164/rccm.201301-0120le] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Duke GJ, Barker A, Rasekaba T, Hutchinson A, Santamaria JD. Development and validation of the critical care outcome prediction equation, version 4. CRIT CARE RESUSC 2013; 15:191-197. [PMID: 23944205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
OBJECTIVE To revise and validate the accuracy of the critical care outcome prediction equation (COPE) model, version 4. DESIGN, PARTICIPANTS AND SETTING Observational cohort analysis of 214 616 adult consecutive intensive care unit admissions recorded from 23 ICUs over 12 years. Data derived from the Victorian Admitted Episode Database (VAED) were used to identify treatment-independent risk factors consistently associated with hospital mortality. A revised version of the COPE-4 model using a random intercept hierarchical logistic regression model was developed in a sample of 35 878 (16.7%) consecutive ICU separations. MAIN OUTCOME MEASURES Accuracy was tested by comparing observed and predicted mortality in the remaining 178 741 (83.3%) records and in 23 institutional cohorts. Stability was assessed using the standardised mortality ratio, Hosmer-Lemeshow H10 statistic, calibration plot and Brier score. RESULTS The COPE-4 model had satisfactory overall discrimination with an area under receiver operating characteristic curve of 0.82 for both datasets. The development and validation datasets demonstrated good overall calibration with H10 statistics of 13.38 (P = 0.10) and 14.84 (P = 0.06) and calibration plot slopes of 0.99 and 1.034, respectively. Discrimination was satisfactory in all 23 hospitals and one or more calibration criteria were achieved in 19 hospitals (83%). CONCLUSIONS COPE-4 model prediction of hospital mortality for ICU admissions has satisfactory performance for use as a risk-adjustment tool in Victoria. Model refinement may further improve its performance.
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Affiliation(s)
- Graeme J Duke
- Box Hill Hospital, Eastern Health, Melbourne, VIC, Australia.
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Tobin AE, Santamaria JD. Medical emergency teams are associated with reduced mortality across a major metropolitan health network after two years service: a retrospective study using government administrative data. Crit Care 2012; 16:R210. [PMID: 23107123 PMCID: PMC3682314 DOI: 10.1186/cc11843] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 10/23/2012] [Indexed: 11/15/2022]
Abstract
Introduction Medical emergency teams (MET) are implemented to ensure prompt clinical review of patients with deteriorating physiology with the intention of averting further deterioration, cardiac arrest and death. We sought to determine if MET implementation has led to reductions in hospital mortality across a large metropolitan health network utilising routine administrative data submitted by hospitals to the Department of Health Victoria. Methods The Victorian admissions episodes data set (VAED) contains data on all individual hospital separations in the State of Victoria, Australia. After gaining institutional ethics approval, we extracted data on all acute admissions to metropolitan hospitals for which we had information on the presence and timing of a MET system. Using logistic regression we determined whether there was an effect of MET implementation on mortality controlling for age, gender, Charlson comorbidity diagnostic groupings, emergency admission, same day admission, ICU admission, mechanical ventilation, year, indigenous ethnicity, liaison nurse service and hospital designation. Results 5911533 individual admissions and 73,599 associated deaths from July 1999 to June 2010 were included in the analysis. 52.2% were male and median age was 57(42-72 IQR). Mortality rates for MET and non-MET periods were 3.92 (3.88-3.95 95%CI) and 4.56 (4.51-4.61 95%CI) deaths per 1000 patient days with a rate ratio after adjustment for year of 0.88 (0.86-0.89 95%CI) P < 0.001. In a multivariable logistic regression, mortality was associated with a MET team being active in the hospital for more than 2 years. The odds ratio for mortality in hospitals where a MET system had been in place for greater than 4 years duration was 0.90 (0.88-0.92). Mortality during the first 2 years of a MET system being in place was not statistically different from pre-MET periods. Conclusions Utilising routinely collected administrative data we demonstrated that the presence of a hospital MET system for greater than 2 years was associated with an independent reduction in hospital mortality across a major metropolitan health network. Mortality benefits after the introduction of a MET system take time to become apparent.
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Jelinek MV, Santamaria JD, Thompson DR, Vale MJ. ‘FIT FOR PURPOSE’. The COACH program improves lifestyle and biomedical cardiac risk factors: Table 1. Heart 2012; 98:1608. [DOI: 10.1136/heartjnl-2012-302723] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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van Tonder FC, Sutherland T, Smith RJ, Chock JME, Santamaria JD. Medical emergencies in the imaging department of a university hospital: event and imaging characteristics. Resuscitation 2012; 84:21-4. [PMID: 22705833 DOI: 10.1016/j.resuscitation.2012.05.020] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2011] [Revised: 03/28/2012] [Accepted: 05/24/2012] [Indexed: 11/30/2022]
Abstract
We aimed to describe the characteristics of medical emergencies that occurred in the medical imaging department (MID) of a university hospital in Melbourne, Australia. A database of 'Respond Medical Emergency Team (MET)' and 'Respond Blue' calls was retrospectively examined for the period June 2003 to November 2010 in relation to events that occurred in the MID. The hospital medical imaging database was also examined in relation to these events and, where necessary, patients' notes were reviewed. Ethics approval was granted by the hospital ethics review board. There were 124 medical emergency calls in the MID during the study period, 28% Respond Blue and 72% Respond MET. Of these 124 calls, 26% occurred outside of usual work hours and 12% involved cardiac arrest. The most common reasons for the emergency calls were seizures (14%) and altered conscious state (13%). Contrast anaphylaxis precipitated the emergency in 4% of cases. In 83% of cases the emergency calls were for patients attending the MID for diagnostic imaging, the remainder being for a procedure. Of the scheduled imaging techniques, 45% were for computed tomography. The scheduled imaging was abandoned due to the emergency in 12% of cases. When performed, imaging informed patient management in 34% of cases in diagnostic imaging and in all cases in the context of image-guided procedures. Medical emergency calls in the MID often occurred outside usual work hours and were attributed to a range of medical problems. The emergencies occurred in relation to all imaging techniques and imaging informed patient management in many cases.
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Affiliation(s)
- F C van Tonder
- St. Vincent's Hospital (Melbourne), Medical Imaging Department, Melbourne, VIC, Australia.
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Dixon B, Santamaria JD, Reid D, Collins M, Rechnitzer T, Newcomb AE, Nixon I, Yii M, Rosalion A, Campbell DJ. The association of blood transfusion with mortality after cardiac surgery: cause or confounding? (CME). Transfusion 2012; 53:19-27. [DOI: 10.1111/j.1537-2995.2012.03697.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Smith RJ, Hickey BB, Santamaria JD. Automated external defibrillators and in-hospital cardiac arrest: Patient survival and device performance at an Australian teaching hospital. Resuscitation 2011; 82:1537-42. [DOI: 10.1016/j.resuscitation.2011.06.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2011] [Accepted: 06/21/2011] [Indexed: 10/18/2022]
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Pettilä V, Westbrook AJ, Nichol AD, Bailey MJ, Wood EM, Syres G, Phillips LE, Street A, French C, Murray L, Orford N, Santamaria JD, Bellomo R, Cooper DJ. Age of red blood cells and mortality in the critically ill. Crit Care 2011; 15:R116. [PMID: 21496231 PMCID: PMC3219399 DOI: 10.1186/cc10142] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Revised: 03/29/2011] [Accepted: 04/15/2011] [Indexed: 11/24/2022]
Abstract
Introduction In critically ill patients, it is uncertain whether exposure to older red blood cells (RBCs) may contribute to mortality. We therefore aimed to evaluate the association between the age of RBCs and outcome in a large unselected cohort of critically ill patients in Australia and New Zealand. We hypothesized that exposure to even a single unit of older RBCs may be associated with an increased risk of death. Methods We conducted a prospective, multicenter observational study in 47 ICUs during a 5-week period between August 2008 and September 2008. We included 757 critically ill adult patients receiving at least one unit of RBCs. To test our hypothesis we compared hospital mortality according to quartiles of exposure to maximum age of RBCs without and with adjustment for possible confounding factors. Results Compared with other quartiles (mean maximum red cell age 22.7 days; mortality 121/568 (21.3%)), patients treated with exposure to the lowest quartile of oldest RBCs (mean maximum red cell age 7.7 days; hospital mortality 25/189 (13.2%)) had an unadjusted absolute risk reduction in hospital mortality of 8.1% (95% confidence interval = 2.2 to 14.0%). After adjustment for Acute Physiology and Chronic Health Evaluation III score, other blood component transfusions, number of RBC transfusions, pretransfusion hemoglobin concentration, and cardiac surgery, the odds ratio for hospital mortality for patients exposed to the older three quartiles compared with the lowest quartile was 2.01 (95% confidence interval = 1.07 to 3.77). Conclusions In critically ill patients, in Australia and New Zealand, exposure to older RBCs is independently associated with an increased risk of death.
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Affiliation(s)
- Ville Pettilä
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Commercial Road, Melbourne 3004, Victoria, Australia.
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Dixon B, Opeskin K, Stamaratis G, Nixon I, Yi M, Newcomb AE, Rosalion A, Zhang Y, Santamaria JD, Campbell DJ. Pre-operative heparin reduces pulmonary microvascular fibrin deposition following cardiac surgery. Thromb Res 2011; 127:e27-30. [PMID: 20923713 DOI: 10.1016/j.thromres.2010.08.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2010] [Revised: 08/26/2010] [Accepted: 08/27/2010] [Indexed: 12/18/2022]
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Dixon B, Nixon I, Kenny J, Newcomb AE, Rosalion A, Opeskin K, Stamaratis G, Silbert BS, Said S, Santamaria JD, Campbell DJ. Aprotinin, but not tranexamic acid, is associated with increased pulmonary microvascular fibrin deposition after cardiac surgery. Thromb Res 2011; 127:272-4. [DOI: 10.1016/j.thromres.2010.11.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2010] [Revised: 11/15/2010] [Accepted: 11/15/2010] [Indexed: 10/18/2022]
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Dixon B, Santamaria JD. Blood transfusion after coronary artery bypass graft surgery. JAMA 2011; 305:149-50; author reply 150. [PMID: 21224455 DOI: 10.1001/jama.2010.1956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Smith RJ, Reid DA, Delaney EF, Santamaria JD. Fluid therapy using a balanced crystalloid solution and acid-base stability after cardiac surgery. CRIT CARE RESUSC 2010; 12:235-241. [PMID: 21143083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
OBJECTIVE To evaluate the effect of fluid therapy using Accusol (Baxter Healthcare, McGaw Park, Ill, USA), a crystalloid solution containing sodium bicarbonate and other electrolytes and having a strong ion difference of 35 mEq/L, on acid-base stability after cardiac surgery. DESIGN Retrospective per-protocol comparison. SETTING Intensive care unit of St Vincent's Hospital, a teaching hospital in Melbourne, Australia. PARTICIPANTS Consecutive adult patients admitted in daytime hours after elective on-pump coronary artery bypass graft surgery between May and October 2008 constituted the "pre-Accusol group" (n=40), and those admitted between May and October 2009 and who were treated with Accusol constituted the "Accusol group" (n=51). MAIN OUTCOME MEASURES The fluids and their component electrolytes administered; change in standard base excess (SBE) between the time of intensive care admission and 04:00 h the next day. RESULTS The Accusol group received a median Accusol dose of 1.86 mL/kg/h (interquartile range, 1.51-2.20 mL/ kg/h), which accounted for 38% (SD, 10%) of the total volume of fluid administered. The change in SBE was +0.03mmol/L (95% CI, -0.57 to 0.64 mmol/L; P = 0.91) in the Accusol group compared with -2.05mmol/L (95% CI, -2.64 to -1.45; P < 0.01) in the pre-Accusol group. The strong ion difference of the electrolytes administered as components of fluid therapies was higher in the Accusol group by 55.5mEq (95% CI, 40.0 to 71.0mEq; P < 0.01). Only 8% of the Accusol group received albumin compared with 48% of the pre-Accusol group (P < 0.01). CONCLUSIONS SBE was more stable in patients treated with Accusol. Further studies are needed to determine whether use of solutions such as Accusol influences important patient outcomes.
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Affiliation(s)
- Roger J Smith
- Intensive Care, St Vincent's Hospital, Melbourne, VIC.
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Dixon B, Schultz MJ, Hofstra JJ, Campbell DJ, Santamaria JD. Nebulized heparin reduces levels of pulmonary coagulation activation in acute lung injury. Crit Care 2010; 14:445. [PMID: 21067553 PMCID: PMC3219269 DOI: 10.1186/cc9269] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Dixon B, Schultz MJ, Smith R, Fink JB, Santamaria JD, Campbell DJ. Nebulized heparin is associated with fewer days of mechanical ventilation in critically ill patients: a randomized controlled trial. Crit Care 2010; 14:R180. [PMID: 20937093 PMCID: PMC3219284 DOI: 10.1186/cc9286] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 10/11/2010] [Indexed: 01/29/2023]
Abstract
Introduction Prolonged mechanical ventilation has the potential to aggravate or initiate pulmonary inflammation and cause lung damage through fibrin deposition. Heparin may reduce pulmonary inflammation and fibrin deposition. We therefore assessed whether nebulized heparin improved lung function in patients expected to require prolonged mechanical ventilation. Methods Fifty patients expected to require mechanical ventilation for more than 48 hours were enrolled in a double-blind randomized placebo-controlled trial of nebulized heparin (25,000 U) or placebo (normal saline) 4 or 6 hourly, depending on patient height. The study drug was continued while the patient remained ventilated to a maximum of 14 days from randomization. Results Nebulized heparin was not associated with a significant improvement in the primary end-point, the average daily partial pressure of oxygen to inspired fraction of oxygen ratio while mechanically ventilated, but was associated with improvement in the secondary end-point, ventilator-free days amongst survivors at day 28 (22.6 ± 4.0 versus 18.0 ± 7.1, treatment difference 4.6 days, 95% CI 0.9 to 8.3, P = 0.02). Heparin administration was not associated with any increase in adverse events. Conclusions Nebulized heparin was associated with fewer days of mechanical ventilation in critically ill patients expected to require prolonged mechanical ventilation. Further trials are required to confirm these findings. Trial registration The Australian Clinical Trials Registry (ACTR-12608000121369).
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Affiliation(s)
- Barry Dixon
- Department of Intensive Care, St, Vincent's Hospital, 41 Victoria Parade, Fitzroy, Melbourne, Victoria, 3065, Australia.
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Smith RJ, Hickey BB, Santamaria JD. Automated external defibrillators and survival after in-hospital cardiac arrest: early experience at an Australian teaching hospital. CRIT CARE RESUSC 2009; 11:261-265. [PMID: 20001874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To evaluate the effect of the introduction of automated external defibrillators (AEDs) on survival after inhospital cardiac arrest. DESIGN, SETTING AND PARTICIPANTS Before-and-after study that compared patients during the 2 years before (8 November 2005 to 7 November 2007) and the year after (8 November 2007 to 7 November 2008) the deployment of AEDs to the non-critical care areas of a university teaching hospital. MAIN OUTCOME MEASURES Return of spontaneous circulation (ROSC) and survival to hospital discharge. RESULTS 55 in-hospital cardiac arrests occurred in the 2-year pre-AED period and 31 in the 1-year AED period. Patients had similar baseline characteristics in the pre-AED and AED periods including witnessed arrest (53% v 48%), arrest in an acute inpatient ward (78% v 90%), and initial arrest rhythm of pulseless ventricular tachycardia or ventricular fibrillation (18% v 16%). The proportions of patients with ROSC were similar in the pre-AED and AED periods (42% v 55%), as were the proportions who survived to hospital discharge (22% v 29%). In the AED period, the relative risk of ROSC was 1.31 (95% CI, 0.84- 2.04) and the relative risk of survival to hospital discharge was 1.33 (95% CI, 0.63-2.80). CONCLUSIONS ROSC and survival to hospital discharge did not change significantly after deployment of AEDs. The existence of a timely and robust resuscitation response with relatively good baseline outcomes, and the low proportion of initial shockable arrest rhythms may have limited the capacity of AEDs to improve survival.
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Duke GJ, Buist MD, Pilcher D, Scheinkestel CD, Santamaria JD, Gutteridge GA, Cranswick PJ, Ernest D, French C, Botha JA. Interventions to circumvent intensive care access block: a retrospective 2-year study across metropolitan Melbourne. Med J Aust 2009; 190:375-8. [PMID: 19351312 DOI: 10.5694/j.1326-5377.2009.tb02452.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 02/17/2009] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To measure the prevalence of interventions used to circumvent intensive care access block and to estimate the attributable mortality and additional hospital bed-days associated with them. DESIGN AND SETTING Retrospective observational study of 11 adult public hospital intensive care units (ICUs) in Melbourne, Victoria, July 2004 - June 2006. MAIN OUTCOME MEASURES Prevalence of five interventions in response to access block; attributable fatalities and/or increased length of stay associated with each. RESULTS 21 896 ICU admissions and 3039 inhospital deaths (13.9%) were screened. All hospitals reported ICU access block. There were 6787 interventions for access block (mean, 9.3/day) -- 4070 (18.6% of admissions) instances of after-hours step-down from an ICU to a low-acuity ward; 1115 (5.1%) delays in an emergency department > 8 hours; 895 (4.1%) postponed major surgeries; 487 (2.2%) interhospital transfers; and 220 (1.0%) instances of premature cessation of intensive care. Based on published risk estimates, these interventions may have resulted in 91.1 (95% CI, 34.7-147.2) attributable deaths and 4368 (95% CI, 333-10 050) additional hospital bed-days each year. CONCLUSIONS Intensive care access block is frequent, and measures to circumvent it increase mortality and length of stay. Further study of the health and financial implications of access block are warranted.
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Affiliation(s)
- Graeme J Duke
- Critical Care Department, Northern Hospital, Melbourne, VIC, Australia.
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Smith R, Hickey B, Holmes J, Santamaria JD. Six months experience with automated external defibrillators (AEDs) in a university teaching hospital. Aust Crit Care 2009. [DOI: 10.1016/j.aucc.2008.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Dixon B, Santamaria JD, Campbell DJ. A phase 1 trial of nebulised heparin in acute lung injury. Crit Care 2008; 12:R64. [PMID: 18460218 PMCID: PMC2481447 DOI: 10.1186/cc6894] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2008] [Revised: 04/02/2008] [Accepted: 05/06/2008] [Indexed: 01/11/2023]
Abstract
Introduction Animal studies of acute lung injury (ALI) suggest nebulised heparin may limit damage from fibrin deposition in the alveolar space and microcirculation. No human studies have been undertaken to date. We assessed the feasibility, safety and potential anticoagulant effects of administration of nebulised heparin to patients with ALI. Methods An open label phase 1 trial of four escalating doses of nebulised heparin was performed. A total of 16 ventilated patients with ALI were studied. The first group was administered a total of 50,000 U/day, the second group 100,000 U/day, the third group 200,000 U/day and the fourth group 400,000 U/day. Assessments of lung function included the PaO2/FiO2 ratio, lung compliance and the alveolar dead space fraction. Monitoring of anticoagulation included the activated partial thromboplastin time (APTT) and the thrombin clotting time. Bronchoalveolar lavage fluid was collected and the prothrombin fragment and tissue plasminogen activator levels were assessed. Analysis of variance was used to compare the effects of dose. Results No serious adverse events occurred for any dose. The changes over time for the PaO2/FiO2 ratio, lung compliance and the alveolar dead space fraction levels were similar for all doses. A trend to increased APTT and thrombin clotting time levels was present with higher doses (P = 0.09 and P = 0.1, respectively). For the highest dose, the APTT reached 64 seconds; following cessation of nebulised heparin, the APTT fell to 39 seconds (P = 0.06). In bronchoalveolar lavage samples a trend to reduced prothrombin fragment levels was present with higher doses (P = 0.1), while tissue plasminogen activator levels were similar for all doses. Conclusion Administration of nebulised heparin to mechanically ventilated patients with ALI is feasible. Nebulised heparin was not associated with any serious adverse events, and at higher doses it increased APTT levels. Larger trials are required to further investigate the safety and efficacy of nebulised heparin. In these trials due consideration must be given to systemic anticoagulant effects. Trial registration Australian Clinical trials registry ACTRN12606000388516.
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Affiliation(s)
- Barry Dixon
- Department of Intensive Care, St Vincent's Hospital, 41 Victoria Parade, Melbourne 3065, Australia.
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Tobin AE, Santamaria JD. An intensivist-led tracheostomy review team is associated with shorter decannulation time and length of stay: a prospective cohort study. Crit Care 2008; 12:R48. [PMID: 18402705 PMCID: PMC2447599 DOI: 10.1186/cc6864] [Citation(s) in RCA: 81] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2007] [Revised: 02/20/2008] [Accepted: 04/11/2008] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Without specific strategies to address tracheostomy care on the wards, patients discharged from the intensive care unit (ICU) with a tracheostomy may receive suboptimal care. We formed an intensivist-led multidisciplinary team to oversee ward management of such patients. To evaluate the service, we compared outcomes for the first 3 years of the service with those in the year preceding the service. METHODS Data were prospectively collected over the course of 3 years on ICU patients not under the care of the ear, nose, and throat unit who were discharged to the ward with a tracheostomy and compared with outcomes in the year preceding the introduction of the service. Principal outcomes were decannulation time, length of stay after ICU discharge, and stay of less than 43 days (upper trim point for the disease-related group [DRG] for tracheostomy). Analysis included trend by year and multivariable analysis using a Cox proportional hazards model. P values of less than 0.05 were assumed to indicate statistical significance. As this was a quality assurance project, ethics approval was not required. RESULTS Two hundred eighty patients were discharged with a tracheostomy over the course of a 4-year period: 41 in 2003, 60 in 2004, 95 in 2005, and 84 in 2006. Mean age was 61.8 (13.1) years, 176 (62.9%) were male, and mean APACHE (Acute Physiology and Chronic Health Evaluation) II score was 20.4 (6.4). Length of stay after ICU decreased over time (30 [13 to 52] versus 19 [10 to 34] days; P < 0.05 for trend), and a higher proportion of decannulated patients were discharged under the upper DRG trim point of 43 days (48% versus 66%; P < 0.05). Time to decannulation after ICU discharge decreased (14 [7 to 31] versus 7 [3 to 17] days; P < 0.01 for trend). Multivariate analysis showed that the hazard for decannulation increased by 24% (3% to 49%) per year. CONCLUSION An intensivist-led tracheostomy team is associated with shorter decannulation time and length of stay which may result in financial savings for institutions.
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Affiliation(s)
- Antony E Tobin
- Intensive Care Unit, St, Vincent's Hospital Melbourne, PO Box 2900, Fitzroy VIC 3065, Australia.
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