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Ling RR, Ueno R, Alamgeer M, Sundararajan K, Sundar R, Bailey M, Pilcher D, Subramaniam A. FRailty in Australian patients admitted to Intensive care unit after eLective CANCER-related SURGery: a retrospective multicentre cohort study (FRAIL-CANCER-SURG study). Br J Anaesth 2024; 132:695-706. [PMID: 38378383 DOI: 10.1016/j.bja.2024.01.020] [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: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/18/2024] [Indexed: 02/22/2024] Open
Abstract
BACKGROUND The association between frailty and short-term and long-term outcomes in patients receiving elective surgery for cancer remains unclear, particularly in those admitted to the ICU. METHODS In this multicentre retrospective cohort study, we included adults ≥16 yr old admitted to 158 ICUs in Australia from January 1, 2018 to March 31, 2022 after elective surgery for cancer. We investigated the association between frailty and survival time up to 4 yr (primary outcome), adjusting for a prespecified set of covariates. We analysed how this association changed in specific subgroups (age categories [<65, 65-80, ≥80 yr], and those who survived hospitalisation), and over time by splitting the survival information at monthly intervals. RESULTS We included 35,848 patients (median follow-up: 18.1 months [inter-quartile range: 8.3-31.1 months], 19,979 [56.1%] male, median age 69.0 yr [inter-quartile range: 58.8-76.0 yr]). Some 3502 (9.8%) patients were frail (defined as clinical frailty scale ≥5). Frailty was associated with lower survival (hazard ratio: 1.72, 95% confidence interval [CI]: 1.59-1.86 compared with clinical frailty scale ≤4); this was concordant across several sensitivity analyses. Frailty was most strongly associated with mortality early on in follow-up, up to 10 months (hazard ratio: 1.39, 95% CI: 1.03-1.86), but this association plateaued, and its predictive capacity subsequently diminished with time up until 4 yr (1.96, 95% CI: 0.73-5.28). Frailty was associated with similar effects when stratified based on age, and in those who survived hospitalisation. CONCLUSIONS Frailty was associated with poorer outcomes after an ICU admission after elective surgery for cancer, particularly in the short term. However, its predictive capacity with time diminished, suggesting a potential need for longitudinal reassessment to ensure appropriate prognostication in this population.
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Affiliation(s)
- Ryan R Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - Muhammad Alamgeer
- Department of Medicine/School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Department of Medical Oncology, Monash Health, Clayton, VIC, Australia; Centre for Cancer Research, Hudson Institute of Medical Research, Monash University, Clayton, VIC, Australia
| | - Krishnaswamy Sundararajan
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, SA, Australia; Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Raghav Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore; Department of Haematology-Oncology, National University Cancer Institute, National University Hospital, Singapore; Cancer and Stem Cell Biology Program, Duke-NUS Medical School, Singapore; The N.1 Institute for Health, National University of Singapore, Singapore; Singapore Gastric Cancer Consortium, Singapore
| | - Michael Bailey
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia
| | - David Pilcher
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Box Hill Hospital, Eastern Health, Box Hill, VIC, Australia; Department of Intensive Care, Peninsula Health, Frankston, VIC, Australia; Department of Intensive Care, Dandenong Hospital, Dandenong, VIC, Australia; Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
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Ling RR, Bonavia W, Ponnapa Reddy M, Pilcher D, Subramaniam A. Persistent Critical Illness and Long-Term Outcomes in Patients With COVID-19: A Multicenter Retrospective Cohort Study. Crit Care Explor 2024; 6:e1057. [PMID: 38425579 PMCID: PMC10904098 DOI: 10.1097/cce.0000000000001057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
OBJECTIVES A nontrivial number of patients in ICUs experience persistent critical illness (PerCI), a phenomenon in which features of the ICU course more consistently predict mortality than the initial indication for admission. We aimed to describe PerCI among patients with critical illness caused by COVID-19, and these patients' short- and long-term outcomes. DESIGN Multicenter retrospective cohort study. SETTING Australian and New Zealand Intensive Care Society Adult Patient Database of 114 Australian ICUs between January 1, 2020, and March 31, 2022. PATIENTS Patients 16 years old or older with COVID-19, and a documented ICU length of stay. EXPOSURE The presence of PerCI, defined as an ICU length of stay greater than or equal to 10 days. MEASUREMENTS We compared the survival time up to 2 years from ICU admission using time-varying robust-variance estimated Cox proportional hazards models. We further investigated the impact of PerCI in subgroups of patients, stratifying based on whether they survived their initial hospitalization. MAIN RESULTS We included 4961 patients in the final analysis, and 882 patients (17.8%) had PerCI. ICU mortality was 23.4% in patients with PerCI and 6.5% in those without PerCI. Patients with PerCI had lower 2-year (70.9% [95% CI, 67.9-73.9%] vs. 86.1% [95% CI, 85.0-87.1%]; p < 0.001) survival rates compared with patients without PerCI. Patients with PerCI had higher mortality (adjusted hazards ratio: 1.734; 95% CI, 1.388-2.168); this was consistent across several sensitivity analyses. When analyzed as a nonlinear predictor, the hazards of mortality were inconsistent up until 10 days, before plateauing. CONCLUSIONS In this multicenter retrospective observational study patients with PerCI tended to have poorer short-term and long-term outcomes. However, the hazards of mortality plateaued beyond the first 10 days of ICU stay. Further studies should investigate predictors of developing PerCI, to better prognosticate long-term outcomes.
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Affiliation(s)
- Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, National University Health System, Singapore
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - William Bonavia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Intensive Care, Frankston Hospital, Frankston, Victoria, Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care, Frankston Hospital, Frankston, Victoria, Australia
- Department of Intensive Care, North Canberra Hospital, Canberra, Australia
- Department of Anaesthesia and Pain Medicine, Nepean Hospital, Sydney, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
| | - Ashwin Subramaniam
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Frankston Hospital, Frankston, Victoria, Australia
- Department of Medicine, Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Intensive Care, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
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Padhi S, Shrestha P, Alamgeer M, Stevanovic A, Karikios D, Rajamani A, Subramaniam A. Oncology and intensive care doctors' perception of intensive care admission of cancer patients: A cross-sectional national survey. Aust Crit Care 2024:S1036-7314(24)00003-1. [PMID: 38350752 DOI: 10.1016/j.aucc.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Revised: 12/05/2023] [Accepted: 12/08/2023] [Indexed: 02/15/2024] Open
Abstract
INTRODUCTION Prognosis in oncology has improved with early diagnosis and novel therapies. However, critical illness continues to trigger clinical and ethical dilemmas for the treating oncology and intensive care unit (ICU) doctors. OBJECTIVES The objective of this study was to investigate the perceptions of oncology and ICU doctors in managing critically ill cancer patients. METHODS A cross-sectional web-based survey exploring the management of a fictitious acutely deteriorating case vignette with solid-organ malignancy. The survey weblink was distributed between May and July 2022 to all Australian oncology and ICU doctors via newsletters to the members of the Medical Oncology Group of Australia, the Australian and New Zealand Intensive Care Society, and the College of Intensive Care Medicine inviting them to participate. The weblink was active till August 2022. The six domains included patient prognostication, advanced care plan, collaborative management, legal/ethical/moral challenges, ICU referral, and protocol-based ICU admission. The outcomes were reported as the level of agreement between oncology and ICU doctors for each domain/question. RESULTS 184 responses (64 oncology and 120 ICU doctors) were analysed. Most respondents were specialists (78.1% [n = 50] oncology, 78.3% [n = 94] ICU doctors). Oncology doctors more commonly reported managing cancer patients with poor prognosis than ICU doctors (p < 0.001). Oncology doctors less commonly referred such patients for ICU admission (29.7% [n = 19] vs. 80.8% [n = 97], p < 0.001; odds ratio [OR] = 0.07; 95% confidence interval [CI]: 0.03-0.16) and infrequently encountered patients with prior goals of care (GOC) in medical emergency team escalations (40.6% [n = 26] vs. 86.7% [n = 104]; p < 0.001; OR = 0.06; 95% CI: 0.02-0.15; p < 0.001). Oncology doctors were less likely to discuss GOC during medical emergency team calls or within 24 h of ICU admission. More oncology doctors than ICU doctors thought that training rotation in the corresponding speciality group was beneficial (56.3% [n = 36] vs. 31.7% [n = 38]; p = 0.012; OR = 2.07; 95% CI: 1.02-4.23; p = 0.045). CONCLUSION Oncology doctors were less likely to encounter acute patient deterioration or establish timely GOC for such patients. Oncology doctors believed that an ICU rotation during their training may have helped manage challenging situations.
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Affiliation(s)
- Swarup Padhi
- Department of Intensive Care, Goulburn Valley Health, Shepparton, Victoria, Australia.
| | - Prajwol Shrestha
- Department of Medical Oncology, Calvary Mater Newcastle Hospital, NSW, Australia
| | - Muhammad Alamgeer
- Department of Medical Oncology, Monash Health, Clayton, Victoria, Australia; School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Australia; Centre for Cancer Research, Hudson Institute of Medical Research, Clayton, Australia
| | - Amanda Stevanovic
- Department of Medical Oncology, Nepean Clinical School and Nepean Hospital, Kingswood, NSW, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Deme Karikios
- Department of Medical Oncology, Nepean Clinical School and Nepean Hospital, Kingswood, NSW, Australia; Sydney Medical School, University of Sydney, NSW, Australia
| | - Arvind Rajamani
- Sydney Medical School, University of Sydney, NSW, Australia; Department of Intensive Care, Nepean Clinical School and Nepean Hospital, Kingswood, NSW, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia; Department of Intensive Care, Monash Health, Dandenong, Victoria, Australia; Peninsula Clinical School, Monash University, Frankston, Victoria, Australia; Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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Donnan MT, Bihari S, Subramaniam A, Dabscheck EJ, Riley B, Pilcher DV. The Long-Term Impact of Frailty After an Intensive Care Unit Admission Due to Chronic Obstructive Pulmonary Disease. Chronic Obstr Pulm Dis 2024; 11:83-94. [PMID: 37931590 PMCID: PMC10913924 DOI: 10.15326/jcopdf.2023.0453] [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] [Subscribe] [Scholar Register] [Accepted: 10/18/2023] [Indexed: 11/08/2023]
Abstract
Rationale Frailty is an increasingly recognized aspect of chronic obstructive pulmonary disease (COPD). The impact of frailty on long-term survival after admission to an intensive care unit (ICU) due to an exacerbation of COPD has not been described. Objective The objective was to quantify the impact of frailty on time to death up to 4 years after admission to the ICU in Australia and New Zealand for an exacerbation of COPD. Methods We performed a multicenter retrospective cohort study of adult patients admitted to 179 ICUs with a primary diagnosis of an exacerbation of COPD using the Australian and New Zealand Intensive Care Society Adult Patient Database from January 1, 2018, through December 31, 2020, in New Zealand, and March 31, 2022, in Australia. Frailty was measured using the clinical frailty scale (CFS). The primary outcome was survival up to 4 years after ICU admission. The secondary outcome was readmission to the ICU due to an exacerbation of COPD. Measurements and Main Results We examined 7126 patients of which 3859 (54.1%) were frail (CFS scores of 5-8). Mortality in not-frail individuals versus frail individuals at 1 and 4 years was 19.8% versus 40.4%, and 56.8% versus 77.3% respectively (both p<0.001). Frailty was independently associated with a shorter time to death (adjusted hazard ratio 1.66; 95% confidence interval 1.54-1.80).There was no difference in the proportion of survivors with or without frailty who were readmitted to the ICU during a subsequent hospitalization. Conclusions Frailty was independently associated with poorer long-term survival in patients admitted to the ICU with an exacerbation of COPD.
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Affiliation(s)
- Matthew T. Donnan
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
| | - Shailesh Bihari
- College of Medicine and Public Health, Flinders University, South Australia
- Department of Intensive and Critical Care, Finders Medical Centre, Adelaide, Australia
| | - Ashwin Subramaniam
- Intensive Care Unit, Peninsula Health, Melbourne, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eli J. Dabscheck
- Department of Respiratory Medicine, The Alfred Hospital, Melbourne, Australia
- Central Clinical School, Monash University, The Alfred Hospital, Melbourne, Australia
| | - Brooke Riley
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
| | - David V. Pilcher
- Department of Intensive Care, The Alfred Hospital, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- The Australian and New Zealand Intensive Care Society, Centre for Outcome and Resources Evaluation, Melbourne, Victoria, Australia
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Rajamani A, Subramaniam A, Lung B, Masters K, Gresham R, Whitehead C, Lowrey J, Seppelt I, Kumar H, Kumar J, Hassan A, Orde S, Bharadwaj PA, Arvind H, Huang S. Remi-fent 1-A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients. CRIT CARE RESUSC 2023; 25:216-222. [PMID: 38234321 PMCID: PMC10790007 DOI: 10.1016/j.ccrj.2023.10.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Objective To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients. Design Single-center, open-labelled, pRCT with blinded analysis. Setting Australian tertiary intensive care unit (ICU). Participants Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation >12 h, or study-drug hypersensitivity. Interventions Open-label fentanyl and remifentanil infusions per existing ICU protocols. Outcomes Primary outcomes were feasibility of recruiting ≥1 patient/week and >90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group. Results 208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p < 0.001); hypotension (n = 78 versus n = 53; p < 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01). Conclusions We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.
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Affiliation(s)
- Arvind Rajamani
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
- Department of Intensive Care Medicine, Nepean Hospital, Kingswood, NSW 2747, Australia
| | | | - Brian Lung
- Department of Anaesthesia, Nepean Hospital, Kingswood, NSW 2747, Australia
| | - Kristy Masters
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Rebecca Gresham
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Christina Whitehead
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Julie Lowrey
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Ian Seppelt
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
- Faculty of Medicine, University of Sydney, Australia
- Critical Care Division, The George Institute for Global Health, Sydney, Australia
| | - Hemant Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Jayashree Kumar
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Anwar Hassan
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | - Sam Orde
- Department of Intensive Care Medicine, Nepean Hospital, Derby Street, Kingswood, NSW 2747, Australia
| | | | | | - Stephen Huang
- Nepean Clinical School, University of Sydney, Derby Street, Kingswood, NSW 2747, Australia
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Alamgeer M, Ling RR, Ueno R, Sundararajan K, Sundar R, Pilcher D, Subramaniam A. Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study. Lancet Healthy Longev 2023; 4:e675-e684. [PMID: 38042160 DOI: 10.1016/s2666-7568(23)00209-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/28/2023] [Accepted: 09/28/2023] [Indexed: 12/04/2023] Open
Abstract
BACKGROUND Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU. METHODS In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age ≥16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or ≥65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups. FINDINGS Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32·1%) had frailty, and 11 662 (55·1%) were male, 9489 (44·8%) were female, and 23 (0·1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29·5% vs 10·9%; p<0·0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1·52 [95% CI 1·43-1·60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1·66 [1·51-1·83]) and aged 65 years or older (1·40 [1·38-1·56]), but its effects were larger in patients younger than 65 years (pinteraction<0·0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1·49 [1·40-1·59]). INTERPRETATION In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management. FUNDING None.
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Affiliation(s)
- Muhammad Alamgeer
- Department of Medicine, School of Clinical Sciences, Monash University, Clayton, VIC, Australia; Department of Medical Oncology, Monash Health, Clayton, VIC, Australia.
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Eastern Health, Box Hill, VIC, Australia
| | - Krishnaswamy Sundararajan
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, SA, Australia; University of Adelaide, Adelaide, SA, Australia
| | - Raghav Sundar
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
| | - Ashwin Subramaniam
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Peninsula Health, Frankston, VIC, Australia; Department of Intensive Care, Dandenong Hospital, Dandenong, VIC, Australia; Peninsula Clinical School, Monash University, Frankston, VIC, Australia
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Subramaniam A, Ling RR, Ridley EJ, Pilcher DV. The impact of body mass index on long-term survival after ICU admission due to COVID-19: A retrospective multicentre study. CRIT CARE RESUSC 2023; 25:182-192. [PMID: 38234325 PMCID: PMC10790021 DOI: 10.1016/j.ccrj.2023.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 01/19/2024]
Abstract
Objective The impact of obesity on long-term survival after intensive care unit (ICU) admission with severe coronavirus disease 2019 (COVID-19) is unclear. We aimed to quantify the impact of obesity on time to death up to two years in patients admitted to Australian and New Zealand ICUs. Design Retrospective multicentre study. Setting 92 ICUs between 1st January 2020 through to 31st December 2020 in New Zealand and 31st March 2022 in Australia with COVID-19, reported in the Australian and New Zealand Intensive Care Society adult patient database. Participants All patients with documented height and weight to estimate the body mass index (BMI) were included. Obesity was classified patients according to the World Health Organization recommendations. Interventions and main outcome measures The primary outcome was survival time up to two years after ICU admission. The effect of obesity on time to death was assessed using a Cox proportional hazards model. Confounders were acute illness severity, sex, frailty, hospital type and jurisdiction for all patients. Results We examined 2,931 patients; the median BMI was 30.2 (IQR 25.6-36.0) kg/m2. Patients with a BMI ≥30 kg/m2 were younger (median [IQR] age 57.7 [46.2-69.0] vs. 63.0 [50.0-73.6]; p < 0.001) than those with a BMI <30 kg/m2. Most patients (76.6%; 2,244/2,931) were discharged alive after ICU admission. The mortality at two years was highest for BMI categories <18.5 kg/m2 (35.4%) and 18.5-24.9 kg/m2 (31.1%), while lowest for BMI ≥40 kg/m2 (14.5%). After adjusting for confounders and with BMI 18.5-24.9 kg/m2 category as a reference, only the BMI ≥40 kg/m2 category patients had improved survival up to 2 years (hazard ratio = 0.51; 95%CI: 0.34-0.76). Conclusions The obesity paradox appears to exist beyond hospital discharge in critically ill patients with COVID-19 admitted in Australian and New Zealand ICUs. A BMI ≥40 kg/m2 was associated with a higher survival time of up to two years.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Dandenong Hospital, Monash Health, Dandenong, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Emma J. Ridley
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Nutrition and Dietetics, Alfred Hospital, Melbourne, Victoria, Australia
| | - David V. Pilcher
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
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Tiruvoipati R, Ludski J, Gupta S, Subramaniam A, Ponnapa Reddy M, Paul E, Haji K. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+ device. Eur J Med Res 2023; 28:291. [PMID: 37596670 PMCID: PMC10436516 DOI: 10.1186/s40001-023-01269-2] [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: 06/02/2023] [Accepted: 08/05/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Several extracorporeal carbon dioxide removal (ECCO2R) devices are currently in use with variable efficacy and safety profiles. PrismaLung+ is an ECCO2R device that was recently introduced into clinical practice. It is a minimally invasive, low flow device that provides partial respiratory support with or without renal replacement therapy. Our aim was to describe the clinical characteristics, efficacy, and safety of PrismaLung+ in patients with acute hypercapnic respiratory failure. METHODS All adult patients who required ECCO2R with PrismaLung+ for hypercapnic respiratory failure in our intensive care unit (ICU) during a 6-month period between March and September 2022 were included. RESULTS Ten patients were included. The median age was 55.5 (IQR 41-68) years, with 8 (80%) male patients. Six patients had acute respiratory distress syndrome (ARDS), and two patients each had exacerbations of asthma and chronic obstructive pulmonary disease (COPD). All patients were receiving invasive mechanical ventilation at the time of initiation of ECCO2R. The median duration of ECCO2R was 71 h (IQR 57-219). A significant improvement in pH and PaCO2 was noted within 30 min of initiation of ECCO2R. Nine patients (90%) survived to weaning of ECCO2R, eight (80%) survived to ICU discharge and seven (70%) survived to hospital discharge. The median duration of ICU and hospital stays were 14.5 (IQR 8-30) and 17 (IQR 11-38) days, respectively. There were no patient-related complications with the use of ECCO2R. A total of 18 circuits were used in ten patients (median 2 per patient; IQR 1-2). Circuit thrombosis was noted in five circuits (28%) prior to reaching the expected circuit life with no adverse clinical consequences. CONCLUSION(S) PrismaLung+ rapidly improved PaCO2 and pH with a good clinical safety profile. Circuit thrombosis was the only complication. This data provides insight into the safety and efficacy of PrismaLung+ that could be useful for centres aspiring to introduce ECCO2R into their clinical practice.
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Affiliation(s)
- Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia.
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia.
| | - Jarryd Ludski
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
| | - Sachin Gupta
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Department of Intensive Care Medicine, Dandenong Hospital, Dandenong, Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Intensive Care, Calvary Hospital, Canberra, ACT, Australia
| | - Eldho Paul
- ANZIC-RC, School of Public Health and Preventive Medicine, Monash University, 553 St Kilda Road, Melbourne, VIC, 3004, Australia
- Alfred Hospital, Melbourne, VIC, Australia
| | - Kavi Haji
- Department of Intensive Care Medicine, Frankston Hospital, Peninsula Health, Frankston, VIC, 3199, Australia
- Division of Medicine, Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Surgery, University of Melbourne, Melbourne, VIC, Australia
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9
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Yoder AK, Farooqi AS, Wernz C, Subramaniam A, Ravi V, Goepfert R, Sturgis EM, Mitra D, Bishop AJ, Guadagnolo BA. Outcomes after definitive treatment for cutaneous angiosarcomas of the face and scalp: Reevaluating the role of surgery and radiation therapy. Head Neck 2023. [PMID: 37272774 DOI: 10.1002/hed.27418] [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] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 05/12/2023] [Accepted: 05/15/2023] [Indexed: 06/06/2023] Open
Abstract
INTRODUCTION We investigated outcomes and prognostic factors for patients treated for cutaneous angiosarcoma (CA). METHODS We conducted a retrospective review of patients treated for CA of the face and scalp from 1962 to 2019. All received definitive treatment with surgery, radiation (RT), or a combination (S-XRT). The Kaplan-Meier method was used to estimate outcomes. Multivariable analyses were conducted using the Cox proportional hazards model. RESULTS For the 143 patients evaluated median follow-up was 33 months. Five-year LC was 51% and worse in patients with tumors >5 cm, multifocal tumors, those treated pre-2000, and with single modality therapy (SMT). These remained associated with worse LC on multivariable analysis. The 5-year disease-specific survival (DSS) for the cohort was 56%. Tumor size >5 cm, non-scalp primary site, treatment pre-2000, and SMT were associated with worse DSS. CONCLUSION Large or multifocal tumors are negative prognostic factors in patients with head and neck CA. S-XRT improved outcomes.
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Affiliation(s)
- A K Yoder
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - A S Farooqi
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - C Wernz
- Baylor College of Medicine, Houston, Texas, USA
| | - A Subramaniam
- Department of Sarcoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - V Ravi
- Department of Sarcoma Medical Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - R Goepfert
- Department of Head and Neck Surgery, MD Anderson Cancer Center, Houston, Texas, USA
| | - E M Sturgis
- Department of Otolaryngology-Head and Neck Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - D Mitra
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - A J Bishop
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
| | - B A Guadagnolo
- Department of Radiation Oncology, MD Anderson Cancer Center, Houston, Texas, USA
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10
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Zaman FY, Subramaniam A, Afroz A, Samoon Z, Gough D, Arulananda S, Alamgeer M. Circulating Tumour DNA (ctDNA) as a Predictor of Clinical Outcome in Non-Small Cell Lung Cancer Undergoing Targeted Therapies: A Systematic Review and Meta-Analysis. Cancers (Basel) 2023; 15:cancers15092425. [PMID: 37173891 PMCID: PMC10177293 DOI: 10.3390/cancers15092425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2023] [Revised: 04/16/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023] Open
Abstract
BACKGROUND Liquid biopsy (LB) analysis using (ctDNA)/cell-free DNA (cfDNA) is an emerging alternative to tissue profiling in (NSCLC). LB is used to guide treatment decisions, detect resistance mechanisms, and predicts responses, and, therefore, outcomes. This systematic review and meta-analysis evaluated the impact of LB quantification on clinical outcomes in molecularly altered advanced NSCLC undergoing targeted therapies. METHODS We searched Embase, MEDLINE, PubMed, and Cochrane Database, between 1 January 2020 and 31 August 2022. The primary outcome was progression-free survival (PFS). Secondary outcomes included overall survival (OS), objective response rate (ORR), sensitivity, and specificity. Age stratification was performed based on the mean age of the individual study population. The quality of studies was assessed using the Newcastle-Ottawa Scale (NOS). RESULTS A total of 27 studies (3419 patients) were included in the analysis. Association of baseline ctDNA with PFS was reported in 11 studies (1359 patients), while that of dynamic changes with PFS was reported in 16 studies (1659 patients). Baseline ctDNA-negative patients had a trend towards improved PFS (pooled hazard ratio [pHR] = 1.35; 95%CI: 0.83-1.87; p < 0.001; I2 = 96%) than ctDNA-positive patients. Early reduction/clearance of ctDNA levels after treatment was related to improved PFS (pHR = 2.71; 95%CI: 1.85-3.65; I2 = 89.4%) compared to those with no reduction/persistence in ctDNA levels. The sensitivity analysis based on study quality (NOS) demonstrated improved PFS only for good [pHR = 1.95; 95%CI: 1.52-2.38] and fair [pHR = 1.99; 95%CI: 1.09-2.89] quality studies, but not for poor quality studies. There was, however, a high level of heterogeneity (I2 = 89.4%) along with significant publication bias in our analysis. CONCLUSIONS This large systematic review, despite heterogeneity, found that baseline negative ctDNA levels and early reduction in ctDNA following treatment could be strong prognostic markers for PFS and OS in patients undergoing targeted therapies for advanced NSCLC. Future randomised clinical trials should incorporate serial ctDNA monitoring to further establish the clinical utility in advanced NSCLC management.
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Affiliation(s)
- Farzana Y Zaman
- Department of Medical Oncology, Monash Health, Clayton 3168, Australia
| | - Ashwin Subramaniam
- School of Public Health and Preventive Medicine, Monash University, Clayton 3168, Australia
- Department of Intensive Care, Peninsula Health, Frankston 3199, Australia
- Peninsula Clinical School, Monash University, Frankston 3199, Australia
| | - Afsana Afroz
- School of Public Health and Preventive Medicine, Monash University, Clayton 3168, Australia
| | - Zarka Samoon
- Department of Medical Oncology, Monash Health, Clayton 3168, Australia
| | - Daniel Gough
- Centre for Cancer Research, Hudson Institute of Medical Research, Clayton 3168, Australia
- Department of Molecular and Translational Science, Monash University, Clayton 3168, Australia
| | - Surein Arulananda
- Department of Medical Oncology, Monash Health, Clayton 3168, Australia
- Centre for Cancer Research, Hudson Institute of Medical Research, Clayton 3168, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton 3168, Australia
| | - Muhammad Alamgeer
- Department of Medical Oncology, Monash Health, Clayton 3168, Australia
- Centre for Cancer Research, Hudson Institute of Medical Research, Clayton 3168, Australia
- School of Clinical Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton 3168, Australia
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11
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Reddy MP, Subramaniam A, Chua C, Ling RR, Anstey C, Ramanathan K, Slutsky AS, Shekar K. Respiratory system mechanics, gas exchange, and outcomes in mechanically ventilated patients with COVID-19-related acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med 2022; 10:1178-1188. [PMID: 36335956 PMCID: PMC9708089 DOI: 10.1016/s2213-2600(22)00393-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 07/28/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022]
Abstract
The association of respiratory mechanics, particularly respiratory system static compliance (CRS), with severity of hypoxaemia in patients with COVID-19-related acute respiratory distress syndrome (ARDS) has been widely debated, with some studies reporting distinct ARDS phenotypes based on CRS. Ascertaining whether such phenotypes exist is important, because they might indicate the need for ventilation strategies that differ from those used in patients with ARDS due to other causes. In a systematic review and meta-analysis of studies published between Dec 1, 2019, and March 14, 2022, we evaluated respiratory system mechanics, ventilator parameters, gas exchange parameters, and clinical outcomes in patients with COVID-19-related ARDS. Among 11 356 patients in 37 studies, mean reported CRS, measured close to the time of endotracheal intubation, was 35·8 mL/cm H2O (95% CI 33·9-37·8; I2=96·9%, τ2=32·6). Pooled mean CRS was normally distributed. Increasing ARDS severity (assessed by PaO2/FiO2 ratio as mild, moderate, or severe) was associated with decreasing CRS. We found no evidence for distinct CRS-based clinical phenotypes in patients with COVID-19-related ARDS, and we therefore conclude that no change in conventional lung-protective ventilation strategies is warranted. Future studies should explore the personalisation of mechanical ventilation strategies according to factors including respiratory system mechanics and haemodynamic status in patients with ARDS.
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Affiliation(s)
- Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Calvary Hospital, Canberra, ACT, Australia,Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia,Correspondence to: Dr Mallikarjuna Ponnapa Reddy, Department of Intensive Care Medicine, Calvary Hospital, Canberra ACT 2617, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Clayton, VIC, Australia,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia,Peninsula Clinical School, Monash University, Clayton, VIC, Australia
| | - Clara Chua
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Ryan Ruiyang Ling
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Christopher Anstey
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine University of Queensland, Brisbane, QLD, Australia,School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Kollengode Ramanathan
- Department of Surgery, National University of Singapore, Singapore,Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore
| | - Arthur S Slutsky
- Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada,Department of Medicine and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Kiran Shekar
- Prince Charles Hospital Northside Clinical Unit, Faculty of Medicine University of Queensland, Brisbane, QLD, Australia,Department of Intensive Care Medicine, Bond University, Gold Coast, QLD, Australia,Adult Intensive Care Services and Critical Care Research Group, the Prince Charles Hospital, Brisbane, QLD, Australia,Department of Intensive Care Medicine, Queensland University of Technology, Brisbane, QLD, Australia
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12
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Ponnapa Reddy MR, Kadam U, Lee JDY, Chua C, Wang W, McPhail T, Lee J, Yarwood N, Majumdar M, Subramaniam A. Family satisfaction with intensive care unit communication during the COVID-19 pandemic: a prospective multicentre Australian study Family Satisfaction - COVID ICU. Intern Med J 2022; 53:481-491. [PMID: 36346289 PMCID: PMC9877714 DOI: 10.1111/imj.15964] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 10/25/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND Virtual communication has become common practice during the coronavirus disease 2019 (COVID-19) pandemic because of visitation restrictions. AIMS The authors aimed to evaluate overall family satisfaction with the intensive care unit (FS-ICU) care involving virtual communication strategies during the COVID-19 pandemic period. METHODS In this prospective multicentre study involving three metropolitan hospitals in Melbourne, Australia, the next of kin (NOK) of all eligible ICU patients between 1 July 2020 and 31 October 2020 were requested to complete an adapted version of the FS-ICU 24-questionnaire. Group comparisons were analysed and calculated for family satisfaction scores: ICU/care (satisfaction with care), FS-ICU/dm (satisfaction with information/decision-making) and FS-ICU/total (overall satisfaction with the ICU). The essential predictors that influence family satisfaction were identified using quantitative and qualitative analyses. RESULTS Seventy-three of the 227 patients' NOK who initially agreed completed the FS-ICU questionnaire (response rate 32.2%). The mean FS-ICU/total was 63.9 (standard deviation [SD], 30.8). The mean score for satisfaction with FS-ICU/dm was lower than the FS-ICU/care (62.1 [SD, 30.3) vs 65.4 (SD, 31.4); P < 0.001]. There was no difference in mean FS-ICU/total scores between survivors (n = 65; 89%) and non-survivors (n = 8, 11%). Higher patient Acute Physiology and Chronic Health Evaluation III score, female NOK and the patient dying in the ICU were independent predictors for FS-ICU/total score, while a telephone call at least once a day by an ICU doctor was related to family satisfaction for FS-ICU/dm. CONCLUSIONS There was low overall family satisfaction with ICU care and virtual communication strategies adopted during the COVID-19 pandemic. Efforts should be targeted for improving factors with virtual communication that cause low family satisfaction during the COVID-19 pandemic.
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Affiliation(s)
- Mallikarjuna Reddy Ponnapa Reddy
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia,Department of Intensive Care MedicineCalvary Public HospitalBruceAustralian Capital TerritoryAustralia
| | - Umesh Kadam
- Department of Intensive Care MedicineWerribee Mercy HospitalWerribeeVictoriaAustralia,Department of Intensive Care MedicineMonash Health Casey HospitalBerwickVictoriaAustralia,Department of Intensive Care MedicineEpworth Hospital GeelongWaurn PondsVictoriaAustralia
| | - John Dong Young Lee
- Department of Intensive Care MedicineMonash Health Casey HospitalBerwickVictoriaAustralia
| | - Clara Chua
- Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Wei Wang
- School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Tomecka McPhail
- Department of Social WorkWerribee Mercy HospitalWerribeeVictoriaAustralia
| | - Jodie Lee
- Department of Social WorkMonash Health Casey HospitalBerwickVictoriaAustralia
| | - Naomi Yarwood
- Department of Intensive Care MedicineEpworth Hospital GeelongWaurn PondsVictoriaAustralia
| | - Mainak Majumdar
- Department of Intensive Care MedicineWerribee Mercy HospitalWerribeeVictoriaAustralia
| | - Ashwin Subramaniam
- Department of Intensive Care MedicineFrankston HospitalFrankstonVictoriaAustralia,Department of Intensive Care MedicineEpworth Hospital GeelongWaurn PondsVictoriaAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia,School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
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13
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Yoder A, Farooqi A, Wernz C, Subramaniam A, Zheng J, Ravi V, Goepfert R, Sturgis E, Mitra D, Bishop A, Guadagnolo B. Outcomes after Definitive Treatment for Cutaneous Angiosarcomas of the Face and Scalp: Re-Evaluating the Role of Combined Modality Treatment. Int J Radiat Oncol Biol Phys 2022. [DOI: 10.1016/j.ijrobp.2022.07.1821] [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: 11/27/2022]
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14
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Subramaniam A, Liu S, Lochhead L, Appelbaum LG. A systematic review of transcranial direct current stimulation on eye movements and associated psychological function. Rev Neurosci 2022; 34:349-364. [PMID: 36310385 DOI: 10.1515/revneuro-2022-0082] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Accepted: 09/07/2022] [Indexed: 11/05/2022]
Abstract
Abstract
The last decades have seen a rise in the use of transcranial direct current stimulation (tDCS) approaches to modulate brain activity and associated behavior. Concurrently, eye tracking (ET) technology has improved to allow more precise quantitative measurement of gaze behavior, offering a window into the mechanisms of vision and cognition. When combined, tDCS and ET provide a powerful system to probe brain function and measure the impact on visual function, leading to an increasing number of studies that utilize these techniques together. The current pre-registered, systematic review seeks to describe the literature that integrates these approaches with the goal of changing brain activity with tDCS and measuring associated changes in eye movements with ET. The literature search identified 26 articles that combined ET and tDCS in a probe-and-measure model and are systematically reviewed here. All studies implemented controlled interventional designs to address topics related to oculomotor control, cognitive processing, emotion regulation, or cravings in healthy volunteers and patient populations. Across these studies, active stimulation typically led to changes in the number, duration, and timing of fixations compared to control stimulation. Notably, half the studies addressed emotion regulation, each showing hypothesized effects of tDCS on ET metrics, while tDCS targeting the frontal cortex was widely used and also generally produced expected modulation of ET. This review reveals promising evidence of the impact of tDCS on eye movements and associated psychological function, offering a framework for effective designs with recommendations for future studies.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
| | - Sicong Liu
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
- Annenberg School of Communication, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Liam Lochhead
- Department of Psychiatry, University of California, San Diego, CA 92093, USA
| | - Lawrence Gregory Appelbaum
- Department of Psychiatry and Behavioral Sciences, Duke University, Durham, NC 27710, USA
- Department of Psychiatry, University of California, San Diego, CA 92093, USA
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15
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Mitchell PD, Buckley C, Subramaniam A, Crowther S, Donnelly SC. Elevated serum ACE levels in patients with post-acute COVID-19 syndrome. QJM 2022; 115:651-652. [PMID: 35588264 PMCID: PMC9384078 DOI: 10.1093/qjmed/hcac119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 03/21/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- P D Mitchell
- From the Department of Medicine, Tallaght University Hospital & Trinity College Dublin, Dublin, Ireland
- Address correspondence to Dr P.D. Mitchell, Department of Medicine, Trinity Centre, Tallaght University Hospital, Belgard Square North, Tallaght, Dublin 24, Ireland.
| | - C Buckley
- From the Department of Medicine, Tallaght University Hospital & Trinity College Dublin, Dublin, Ireland
| | - A Subramaniam
- From the Department of Medicine, Tallaght University Hospital & Trinity College Dublin, Dublin, Ireland
| | - S Crowther
- From the Department of Medicine, Tallaght University Hospital & Trinity College Dublin, Dublin, Ireland
| | - S C Donnelly
- From the Department of Medicine, Tallaght University Hospital & Trinity College Dublin, Dublin, Ireland
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16
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Subramaniam A, Shekar K, Anstey C, Tiruvoipati R, Pilcher D. Impact of frailty on clinical outcomes in patients with and without COVID-19 pneumonitis admitted to intensive care units in Australia and New Zealand: a retrospective registry data analysis. Crit Care 2022; 26:301. [PMID: 36192763 PMCID: PMC9527725 DOI: 10.1186/s13054-022-04177-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 09/21/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND It is unclear if the impact of frailty on mortality differs between patients with viral pneumonitis due to COVID-19 or other causes. We aimed to determine if a difference exists between patients with and without COVID-19 pneumonitis. METHODS This multicentre, retrospective, cohort study using the Australian and New Zealand Intensive Care Society Adult Patient Database included patients aged ≥ 16 years admitted to 153 ICUs between 01/012020 and 12/31/2021 with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome, and Clinical Frailty Scale (CFS). The primary outcome was hospital mortality. RESULTS A total of 4620 patients were studied, and 3077 (66.6%) had COVID-19. The patients with COVID-19 were younger (median [IQR] 57.0 [44.7-68.3] vs. 66.1 [52.0-76.2]; p < 0.001) and less frail (median [IQR] CFS 3 [2-4] vs. 4 [3-5]; p < 0.001) than non-COVID-19 patients. The overall hospital mortality was similar between the patients with and without COVID-19 (14.7% vs. 14.9%; p = 0.82). Frailty alone as a predictor of mortality showed only moderate discrimination in differentiating survivors from those who died but was similar between patients with and without COVID-19 (AUROC 0.68 vs. 0.66; p = 0.42). Increasing frailty scores were associated with hospital mortality, after adjusting for Australian and New Zealand Risk of Death score and sex. However, the effect of frailty was similar in patients with and without COVID-19 (OR = 1.29; 95% CI: 1.19-1.41 vs. OR = 1.24; 95% CI: 1.11-1.37). CONCLUSION The presence of frailty was an independent risk factor for mortality. However, the impact of frailty on outcomes was similar in COVID-19 patients compared to other causes of viral pneumonitis.
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Affiliation(s)
- Ashwin Subramaniam
- grid.466993.70000 0004 0436 2893Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC 3199 Australia ,grid.1002.30000 0004 1936 7857Peninsula Clinical School, Monash University, Frankston, VIC Australia ,grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia
| | - Kiran Shekar
- grid.415184.d0000 0004 0614 0266Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, QLD Australia ,grid.1003.20000 0000 9320 7537University of Queensland, Brisbane, QLD Australia ,grid.1033.10000 0004 0405 3820Queensland University of Technology Brisbane and Bond University, Gold Coast, QLD Australia
| | - Christopher Anstey
- grid.1022.10000 0004 0437 5432Griffith University, Gold Coast, QLD Australia
| | - Ravindranath Tiruvoipati
- grid.466993.70000 0004 0436 2893Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC 3199 Australia ,grid.1002.30000 0004 1936 7857Peninsula Clinical School, Monash University, Frankston, VIC Australia
| | - David Pilcher
- grid.1002.30000 0004 1936 7857Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC Australia ,grid.1623.60000 0004 0432 511XDepartment of Intensive Care, Alfred Hospital, Melbourne, VIC Australia ,grid.489411.10000 0004 5905 1670Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC Australia
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17
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Subramaniam A, Tiruvoipati R, Pilcher D, Bailey M. Treatment limitations and clinical outcomes in critically ill frail patients with and without COVID-19 pneumonitis. J Am Geriatr Soc 2022; 71:145-156. [PMID: 36151970 PMCID: PMC9539196 DOI: 10.1111/jgs.18044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/21/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID-19 pneumonitis in those admitted to Australian and New Zealand ICUs. METHODS This registry-based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID-19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations. RESULTS 884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID-19. There were more male patients in COVID-19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE-III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%-CI 1.39-2.14), age (OR = 1.05; 95%-CI 1.04-1.06), and presence of chronic respiratory condition (OR = 1.58; 95%-CI 1.10-2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID-19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%-CI 0.98-1.96). CONCLUSIONS The proportion of treatment limitations was similar in patients with frailty with or without COVID-19 pneumonitis at ICU admission.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive CarePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Ravindranath Tiruvoipati
- Department of Intensive CarePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia,Centre for Outcome and Resource EvaluationAustralian and New Zealand Intensive Care SocietyMelbourneVictoriaAustralia,Department of Intensive CareAlfred HospitalMelbourneVictoriaAustralia
| | - Michael Bailey
- Centre for Outcome and Resource EvaluationAustralian and New Zealand Intensive Care SocietyMelbourneVictoriaAustralia
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18
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Alamgeer M, Coleman A, McDowell L, Giddings C, Safdar A, Sigston E, Wang Y, Subramaniam A. Treatment outcomes of standard (high dose) cisplatin and non-standard chemotherapy for locally advanced head and neck cancer. Cancer Rep (Hoboken) 2022; 6:e1674. [PMID: 35792145 PMCID: PMC9875652 DOI: 10.1002/cnr2.1674] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2022] [Revised: 06/09/2022] [Accepted: 06/21/2022] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION Concurrent chemoradiotherapy with high-dose (HD) cisplatin is the standard treatment for locally advanced head and neck squamous cell carcinoma (LA-HNSCC). Due to the higher treatment-related adverse effects with standard therapy, alternative regimens (non-standard therapy), namely, lower dose weekly cisplatin, carboplatin/paclitaxel, or cetuximab are considered. There is, however, no consensus on non-standard regimens. We aimed to investigate the efficacy and safety profile of these regimens. METHODS This single centre retrospective cohort study included all consecutive adult patients with newly diagnosed LA-HNSCC treated with either standard or non-standard regimens between January 2016 and April 2021. The primary outcome was 2-year failure-free survival (FFS). The secondary outcomes included acute toxicities, hospitalisation rates, dose modifications, treatment failure rates (TFR), and overall survival. RESULTS About 235 patients were included in the final analysis; median age was 61 years (IQR 55-67), and 87% were male. Most had oropharyngeal tumours (85.5%) and p16-positivity was frequent (80%). About 56% received non-standard regimens: weekly cisplatin = 79 and non-cisplatin = 48. These patients had higher Charlson Comorbidity Index (CCI; p < .001) and lower European Cooperative Oncology Group (ECOG)-0 (p = .003). There was no difference in 2-year FFS (hazard ratio [HR] = 1.16; 95% confidence interval - [CI] 0.65-2.05), hospitalisation and grade-3 toxicity rates between the two regimens. Nausea and vomiting were lower in the non-standard regimen (3.0% vs. 16%, p < .001). Dose reductions, adjusted for age, sex, and CCI, were less likely in the non-standard regimen (OR = 2.36; 95%-CI: 1.01-5.49, p = .007). CONCLUSIONS We demonstrated similar efficacy of lower dose weekly cisplatin and carboplatin/paclitaxel regimens and better safety profile of weekly cisplatin compared to standard HD cisplatin regimens for LA-HNSCC. Multicenter randomised control trials are required in HD cisplatin-ineligible patients.
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Affiliation(s)
- Muhammad Alamgeer
- Department of Medical OncologyMonash HealthClaytonVictoriaAustralia,Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Andrew Coleman
- Department of Radiation OncologyPeter MacCallum Cancer CentreParkvilleVictoriaAustralia
| | - Lachlan McDowell
- Department of Radiation OncologyPeter MacCallum Cancer CentreParkvilleVictoriaAustralia
| | - Charles Giddings
- Department of Otolaryngology, Head and Neck SurgeryMonash HealthClaytonVictoriaAustralia,Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Adnan Safdar
- Department of Otolaryngology, Head and Neck SurgeryMonash HealthClaytonVictoriaAustralia
| | - Elizabeth Sigston
- Department of Otolaryngology, Head and Neck SurgeryMonash HealthClaytonVictoriaAustralia,Department of Surgery, School of Clinical Sciences at Monash Health, Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia
| | - Yang Wang
- Department of Medical OncologyMonash HealthClaytonVictoriaAustralia
| | - Ashwin Subramaniam
- Faculty of Medicine, Nursing and Health SciencesMonash UniversityClaytonVictoriaAustralia,Department of Intensive Care MedicinePeninsula HealthFrankstonVictoriaAustralia,Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia,Australian and New Zealand Intensive Care Research Centre (ANZIC‐RC), School of Public Health and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
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19
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Subramaniam A, Lim ZJ, Ponnapa Reddy M, Mitchell H, Shekar K. SARS-CoV-2 transmission risk to healthcare workers performing tracheostomies: a systematic review. ANZ J Surg 2022; 92:1614-1625. [PMID: 35655401 PMCID: PMC9347596 DOI: 10.1111/ans.17814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 05/10/2022] [Accepted: 05/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Tracheostomy is a commonly performed procedure in patients with coronavirus disease 2019 (COVID-19) receiving mechanical ventilation (MV). This review aims to investigate the occurrence of SARS-CoV-2 transmission from patients to healthcare workers (HCWs) when tracheostomies are performed. METHODS This systematic review used the preferred reporting items for systematic reviews and meta-analysis framework. Studies reporting SARS-CoV-2 infection in HCWs involved in tracheostomy procedures were included. RESULTS Sixty-nine studies (between 01/11/2019 and 16/01/2022) reporting 3117 tracheostomy events were included, 45.9% (1430/3117) were performed surgically. The mean time from MV initiation to tracheostomy was 16.7 ± 7.9 days. Location of tracheostomy, personal protective equipment used, and anaesthesia technique varied between studies. The mean procedure duration was 14.1 ± 7.5 minutes; was statistically longer for percutaneous tracheostomies compared with surgical tracheostomies (mean duration 17.5 ± 7.0 versus 15.5 ± 5.6 minutes, p = 0.02). Across 5 out of 69 studies that reported 311 tracheostomies, 34 HCWs tested positive for SARS-CoV-2 and 23/34 (67.6%) were associated with percutaneous tracheostomies. CONCLUSIONS In this systematic review we found that SARS-CoV-2 transmission to HCWs performing or assisting with a tracheostomy procedure appeared to be low, with all reported transmissions occurring in 2020, prior to vaccinations and more recent strains of SARS-CoV-2. Transmissions may be higher with percutaneous tracheostomies. However, an accurate estimation of infection risk was not possible in the absence of the actual number of HCWs exposed to the risk during the procedure and the inability to control for multiple confounders related to variable timing, technique, and infection control practices.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care MedicinePeninsula HealthMelbourneVictoria
- Monash University, Peninsula Clinical SchoolMelbourneVictoriaAustralia
- Australian and New Zealand Intensive Care Research Centre (ANZIC RC), Department of Epidemiology and Preventive MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Zheng Jie Lim
- Department of AnaesthesiaAustin HospitalHeidelbergVictoriaAustralia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care MedicinePeninsula HealthMelbourneVictoria
- Department of Intensive Care MedicineCalvary HospitalCanberraAustralian Capital TerritoryAustralia
| | - Hayden Mitchell
- Department of MedicinePeninsula HealthFrankstonVictoriaAustralia
| | - Kiran Shekar
- Adult Intensive Care ServicesThe Prince Charles HospitalBrisbaneQueenslandAustralia
- School of MedicineUniversity of QueenslandBrisbaneQueenslandAustralia
- Institute of Health and Biomedical innovationUniversity of Technology BrisbaneBrisbaneQueenslandAustralia
- School of MedicineBond UniversityGold CoastQueenslandAustralia
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20
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Perez W, Luedecke A, Becker D, Cribbs M, Subramaniam A, Sinkey R. Increased nuchal translucency in fetus with neonatal dilated cardiomyopathy and MAP3K7 genetic variant. Ultrasound Obstet Gynecol 2022; 60:141-142. [PMID: 34687574 DOI: 10.1002/uog.24800] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 10/11/2021] [Accepted: 10/15/2021] [Indexed: 06/13/2023]
Affiliation(s)
- W Perez
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for Women's Reproductive Health, Birmingham, AL, USA
| | - A Luedecke
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Department of Genetics, University of Alabama at Birmingham, AL, USA
| | - D Becker
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for Women's Reproductive Health, Birmingham, AL, USA
| | - M Cribbs
- Department of Medicine, Division of Cardiovascular Disease, University of Alabama at Birmingham, AL, USA
| | - A Subramaniam
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for Women's Reproductive Health, Birmingham, AL, USA
| | - R Sinkey
- Department of Obstetrics & Gynecology, University of Alabama at Birmingham, Birmingham, AL, USA
- Center for Women's Reproductive Health, Birmingham, AL, USA
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21
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Johnston C, Subramaniam A, Orosz J, Burrell A, Neto AS, Young M, Bailey M, Pilcher D, Udy A, Jones D. Intensive care admissions following rapid response team reviews in patients with COVID-19 in Australia. CRIT CARE RESUSC 2022; 24:106-115. [PMID: 38045596 PMCID: PMC10692595 DOI: 10.51893/2022.2.oa1] [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
Objectives: To evaluate the epidemiology of rapid response team (RRT) reviews that led to intensive care unit (ICU) admissions, and to evaluate the frequency of in-hospital cardiac arrests (IHCAs) among ICU patients with confirmed coronavirus disease 2019 (COVID-19) in Australia. Design: Multicentre, retrospective cohort study. Setting: 48 public and private ICUs in Australia. Participants: All adults (aged ≥ 16 years) with confirmed COVID-19 admitted to participating ICUs between 25 January and 31 October 2020, as part of SPRINT-SARI (Short PeRiod IncideNce sTudy of Severe Acute Respiratory Infection) Australia, which were linked with ICUs contributing to the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD). Main outcome measures and results: Of the 413 critically ill patients with COVID-19 who were analysed, 48.2% (199/413) were admitted from the ward and 30.5% (126/413) were admitted to the ICU following an RRT review. Patients admitted following an RRT review had higher Acute Physiology and Chronic Health Evaluation (APACHE) scores, fewer days from symptom onset to hospitalisation (median, 5.4 [interquartile range (IQR), 3.2-7.6] v 7.1 days [IQR, 4.1-9.8]; P < 0.001) and longer hospitalisations (median, 18 [IQR, 11-33] v 13 days [IQR, 7-24]; P < 0.001) compared with those not admitted via an RRT review. Admissions following RRT review comprised 60.3% (120/199) of all ward-based admissions. Overall, IHCA occurred in 1.9% (8/413) of ICU patients with COVID-19, and most IHCAs (6/8, 75%) occurred during ICU admission. There were no differences in IHCA rates or in ICU or hospital mortality rates based on whether a patient had a prior RRT review or not. Conclusions: This study found that RRT reviews were a common way for deteriorating ward patients with COVID-19 to be admitted to the ICU, and that IHCA was rare among ICU patients with COVID-19.
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Affiliation(s)
- Craig Johnston
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Ashwin Subramaniam
- Intensive Care Unit, Frankston Hospital, Melbourne, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Judit Orosz
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Aidan Burrell
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Meredith Young
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - David Pilcher
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
- ANZICS Centre for Outcome and Resource Evaluation (CORE), Melbourne, VIC, Australia
| | - Andrew Udy
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
| | - Daryl Jones
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventative Medicine, Monash University, Melbourne, VIC, Australia
- Intensive Care Unit, Austin Hospital, Melbourne, VIC, Australia
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22
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Subramaniam A, Pilcher D, Tiruvoipati R, Wilson J, Mitchell H, Xu D, Bailey M. Timely goals of care documentation in patients with frailty in the COVID-19 era: a retrospective multi-site study. Intern Med J 2022; 52:935-943. [PMID: 34935268 DOI: 10.1111/imj.15671] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Revised: 11/09/2021] [Accepted: 12/15/2021] [Indexed: 02/05/2023]
Abstract
BACKGROUND Older frail patients are more likely to have timely goals of care (GOC) documentation than non-frail patients. AIMS To investigate whether timely documentation of GOC within 72 h differed in the context of the COVID-19 pandemic (2020), compared with the pre-COVID-19 era (2019) for older frail patients. METHODS Multi-site retrospective cohort study was conducted in two public hospitals where all consecutive frail adult patients aged ≥65 years were admitted under medical units for at least 24 h between 1 March 31 and October in 2019 and between 1 March and 31 October 2020 were included. The GOC was derived from electronic records. Frailty status was derived from hospital coding data using hospital frailty risk score (frail ≥5). The primary outcome was the documentation of GOC within 72 h of hospital admission. Secondary outcomes included hospital mortality, rapid response call, intensive care unit admission, prolonged hospital length of stay (≥10 days) and time to the documentation of GOC. RESULTS The study population comprised 2021 frail patients admitted in 2019 and 1849 admitted in 2020, aged 81.2 and 90.9 years respectively. The proportion of patients with timely GOC was lower in 2020, than 2019 (48.3% (893/1849) vs 54.9% (1109/2021); P = 0.021). After adjusting for confounding factors, patients in 2020 were less likely to receive timely GOC (odds ratio = 0.77; 95% confidence interval (CI) 0.68-0.88). Overall time to GOC documentation was longer in 2020 (hazard ratio = 0.86; 95% CI 0.80-0.93). CONCLUSION Timely GOC documentation occurred less frequently in frail patients during the COVID-19 pandemic than in the pre-COVID-19 era.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
- Peninsula Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Melbourne, Victoria, Australia
- Peninsula Clinical School, Monash University, Melbourne, Victoria, Australia
| | - John Wilson
- Department of Information Technology, Peninsula Health, Melbourne, Victoria, Australia
| | - Hayden Mitchell
- Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Dan Xu
- Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
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23
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Subramaniam A, Ueno R, Tiruvoipati R, Darvall J, Srikanth V, Bailey M, Pilcher D, Bellomo R. Defining ICD-10 surrogate variables to estimate the modified frailty index: a Delphi-based approach. BMC Geriatr 2022; 22:422. [PMID: 35562684 PMCID: PMC9107186 DOI: 10.1186/s12877-022-03063-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 04/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There are currently no validated globally and freely available tools to estimate the modified frailty index (mFI). The widely available and non-proprietary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding could be used as a surrogate for the mFI. We aimed to establish an appropriate set of the ICD-10 codes for comorbidities to be used to estimate the eleven-variable mFI. METHODS A three-stage, web-based, Delphi consensus-building process among a panel of intensivists and geriatricians using iterative rounds of an online survey, was conducted between March and July 2021. The consensus was set a priori at 75% overall agreement. Additionally, we assessed if survey responses differed between intensivists and geriatricians. Finally, we ascertained the level of agreement. RESULTS A total of 21 clinicians participated in all 3 Delphi surveys. Most (86%, 18/21) had more than 5-years' experience as specialists. The agreement proportionately increased with every Delphi survey. After the third survey, the panel had reached 75% consensus in 87.5% (112/128) of ICD-10 codes. The initially included 128 ICD-10 variables were narrowed down to 54 at the end of the 3 surveys. The inter-rater agreements between intensivists and geriatricians were moderate for surveys 1 and 3 (κ = 0.728, κ = 0.780) respectively, and strong for survey 2 (κ = 0.811). CONCLUSIONS This quantitative Delphi survey of a panel of experienced intensivists and geriatricians achieved consensus for appropriate ICD-10 codes to estimate the mFI. Future studies should focus on validating the mFI estimated from these ICD-10 codes. TRIAL REGISTRATION Not applicable.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia. .,Peninsula Clinical School, Monash University, Frankston, Victoria, Australia. .,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Eastern Health, Box Hill, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia.,Peninsula Clinical School, Monash University, Frankston, Victoria, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jai Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia.,Department of Geriatric Medicine, Peninsula Health, Frankston, Victoria, Australia.,National Centre for Healthy Ageing, Melbourne, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia.,Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
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24
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Subramaniam A, Ueno R, Tiruvoipati R, Srikanth V, Bailey M, Pilcher D. Comparison of the predictive ability of clinical frailty scale and hospital frailty risk score to determine long-term survival in critically ill patients: a multicentre retrospective cohort study. Crit Care 2022; 26:121. [PMID: 35505435 PMCID: PMC9063154 DOI: 10.1186/s13054-022-03987-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 04/09/2022] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The Clinical Frailty Scale (CFS) is the most commonly used frailty measure in intensive care unit (ICU) patients. The hospital frailty risk score (HFRS) was recently proposed for the quantification of frailty. We aimed to compare the HFRS with the CFS in critically ill patients in predicting long-term survival up to one year following ICU admission. METHODS In this retrospective multicentre cohort study from 16 public ICUs in the state of Victoria, Australia between 1st January 2017 and 30th June 2018, ICU admission episodes listed in the Australian and New Zealand Intensive Care Society Adult Patient Database registry with a documented CFS, which had been linked with the Victorian Admitted Episode Dataset and the Victorian Death Index were examined. The HFRS was calculated for each patient using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes that represented pre-existing conditions at the time of index hospital admission. Descriptive methods, Cox proportional hazards and area under the receiver operating characteristic (AUROC) were used to investigate the association between each frailty score and long-term survival up to 1 year, after adjusting for confounders including sex and baseline severity of illness on admission to ICU (Australia New Zealand risk-of-death, ANZROD). RESULTS 7001 ICU patients with both frailty measures were analysed. The overall median (IQR) age was 63.7 (49.1-74.0) years; 59.5% (n = 4166) were male; the median (IQR) APACHE II score 14 (10-20). Almost half (46.7%, n = 3266) were mechanically ventilated. The hospital mortality was 9.5% (n = 642) and 1-year mortality was 14.4% (n = 1005). HFRS correlated weakly with CFS (Spearman's rho 0.13 (95% CI 0.10-0.15) and had a poor agreement (kappa = 0.12, 95% CI 0.10-0.15). Both frailty measures predicted 1-year survival after adjusting for confounders, CFS (HR 1.26, 95% CI 1.21-1.31) and HFRS (HR 1.08, 95% CI 1.02-1.15). The CFS had better discrimination of 1-year mortality than HFRS (AUROC 0.66 vs 0.63 p < 0.0001). CONCLUSION Both HFRS and CFS independently predicted up to 1-year survival following an ICU admission with moderate discrimination. The CFS was a better predictor of 1-year survival than the HFRS.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Peninsula Health, 2 Hastings Road, VIC, 3199, Frankston, Australia.
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
- Peninsula Clinical School, Monash University, Frankston, VIC, Australia.
| | - Ryo Ueno
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care, Eastern Health, Box Hill, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Peninsula Health, 2 Hastings Road, VIC, 3199, Frankston, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Peninsula Clinical School, Monash University, Frankston, VIC, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Monash University, Frankston, VIC, Australia
- Department of Geriatric Medicine, Peninsula Health, Frankston, VIC, Australia
- National Centre for Healthy Ageing, Melbourne, Australia
| | - Michael Bailey
- 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
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia
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25
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Subramaniam A, Wengritzky R, Skinner S, Shekar K. Colorectal Surgery in Critically Unwell Patients: A Multidisciplinary Approach. Clin Colon Rectal Surg 2022; 35:244-260. [PMID: 35966378 PMCID: PMC9374534 DOI: 10.1055/s-0041-1740045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
A proportion of patients require critical care support following elective or urgent colorectal procedures. Similarly, critically ill patients in intensive care units may also need colorectal surgery on occasions. This patient population is increasing in some jurisdictions given an aging population and increasing societal expectations. As such, this population often includes elderly, frail patients or patients with significant comorbidities. Careful stratification of operative risks including the need for prolonged intensive care support should be part of the consenting process. In high-risk patients, especially in setting of unplanned surgery, treatment goals should be clearly defined, and appropriate ceiling of care should be established to minimize care that is not in the best interest of the patient. In this article we describe approaches to critically unwell patients requiring colorectal surgery and how a multidisciplinary approach with proactive intensive care involvement can help achieve the best outcomes for these patients.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia,Department of Intensive Care, The Bays Healthcare, Mornington, Victoria, Australia,Address for correspondence Ashwin Subramaniam, MBBS, MMed, FRACP, FCICM Intensive Care Specialist, Frankston HospitalVictoriaAustralia
| | - Robert Wengritzky
- Department of Anaesthesia, Peninsula Health, Frankston, Victoria, Australia
| | - Stewart Skinner
- Department of Surgery, Peninsula Health, Frankston, Victoria, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia,Queensland University of Technology, University of Queensland, Brisbane, Queensland, Australia
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Chan R, Ueno R, Afroz A, Billah B, Tiruvoipati R, Subramaniam A. Association between frailty and clinical outcomes in surgical patients admitted to intensive care units: a systematic review and meta-analysis. Br J Anaesth 2022; 128:258-271. [PMID: 34924178 DOI: 10.1016/j.bja.2021.11.018] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 10/10/2021] [Accepted: 11/03/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Preoperative frailty may be a strong predictor of adverse postoperative outcomes. We investigated the association between frailty and clinical outcomes in surgical patients admitted to the ICU. METHODS PubMed, Embase, and Ovid MEDLINE were searched for relevant articles. We included full-text original English articles that used any frailty measure, reporting results of surgical adult patients (≥18 yr old) admitted to ICUs with mortality as the main outcome. Data on mortality, duration of mechanical ventilation, ICU and hospital length of stay, and discharge destination were extracted. The quality of included studies and risk of bias were assessed using the Newcastle Ottawa Scale. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS Thirteen observational studies met inclusion criteria. In total, 58 757 patients were included; 22 793 (39.4%) were frail. Frailty was associated with an increased risk of short-term (risk ratio [RR]=2.66; 95% confidence interval [CI]: 1.99-3.56) and long-term mortality (RR=2.66; 95% CI: 1.32-5.37). Frail patients had longer ICU length of stay (mean difference [MD]=1.5 days; 95% CI: 0.8-2.2) and hospital length of stay (MD=3.9 days; 95% CI: 1.4-6.5). Duration of mechanical ventilation was longer in frail patients (MD=22 h; 95% CI: 1.7-42.3) and they were more likely to be discharged to a healthcare facility (RR=2.34; 95% CI: 1.36-4.01). CONCLUSION Patients with frailty requiring postoperative ICU admission for elective and non-elective surgeries had increased risk of mortality, lengthier admissions, and increased likelihood of non-home discharge. Preoperative frailty assessments and risk stratification are essential in patient and clinician planning, and critical care resource utilisation. CLINICAL TRIAL REGISTRATION PROSPERO CRD42020210121.
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Affiliation(s)
- Rachel Chan
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Department of Anaesthesia and Pain Management, The Canberra Hospital, ACT, Australia.
| | - Ryo Ueno
- Department of Intensive Care, Eastern Health, Box Hill, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, VIC, Australia.
| | - Afsana Afroz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia; Monash University Peninsula Clinical School, VIC, Australia.
| | - Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia; Monash University Peninsula Clinical School, VIC, Australia.
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Subramaniam A, Shekar K, Afroz A, Ashwin S, Billah B, Brown H, Kundi H, Lim ZJ, Ponnapa Reddy M, Curtis JR. Frailty and mortality associations in patients with
COVID
‐19: A Systematic Review and Meta‐analysis. Intern Med J 2022; 52:724-739. [PMID: 35066970 PMCID: PMC9314619 DOI: 10.1111/imj.15698] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 01/04/2022] [Accepted: 01/17/2022] [Indexed: 01/08/2023]
Abstract
Background Observational data during the pandemic have demonstrated mixed associations between frailty and mortality. Aim To examine associations between frailty and short‐term mortality in patients hospitalised with coronavirus disease 2019 (COVID‐19). Methods In this systematic review and meta‐analysis, we searched PubMed, Embase and the COVID‐19 living systematic review from 1 December 2019 to 15 July 2021. Studies reporting mortality and frailty scores in hospitalised patients with COVID‐19 (age ≥18 years) were included. Data on patient demographics, short‐term mortality (in hospital or within 30 days), intensive care unit (ICU) admission and need for invasive mechanical ventilation (IMV) were extracted. The quality of studies was assessed using the Newcastle−Ottawa Scale. Results Twenty‐five studies reporting 34 628 patients were included. Overall, 26.2% (n = 9061) died. Patients who died were older (76.7 ± 9.6 vs 69.2 ± 13.4), more likely male (risk ratio (RR) = 1.08; 95% confidence interval (CI): 1.06–1.11) and had more comorbidities. Fifty‐eight percent of patients were frail. Adjusting for age, there was no difference in short‐term mortality between frail and non‐frail patients (RR = 1.04; 95% CI: 0.84–1.28). The non‐frail patients were commonly admitted to ICU (27.2% (4256/15639) vs 29.1% (3567/12274); P = 0.011) and had a higher mortality risk (RR = 1.63; 95% CI: 1.30–2.03) than frail patients. Among patients receiving IMV, there was no difference in mortality between frail and non‐frail (RR = 1.62; 95% CI 0.93–2.77). Conclusion This systematic review did not demonstrate an independent association between frailty status and short‐term mortality in patients with COVID‐19. Patients with frailty were less commonly admitted to ICU and non‐frail patients were more likely to receive IMV and had higher mortality risk. This finding may be related to allocation decisions for patients with frailty amidst the pandemic.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine Peninsula Health Frankston Victoria Australia
- Monash University, Peninsula Clinical School Frankston Victoria Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital Brisbane Queensland Australia
- University of Queensland, Brisbane; Queensland University of Technology Brisbane and Bond University Gold Coast Queensland Australia
| | - Afsana Afroz
- Centre for Integrated Critical Care, Department of Medicine and Radiology Melbourne Medical School Melbourne Victoria Australia
| | - Sushma Ashwin
- Department of Health Economics School of Health and social development, Deakin University Melbourne Victoria Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine Monash University Melbourne Victoria Australia
| | - Hamish Brown
- Department of Intensive Care Medicine Peninsula Health Frankston Victoria Australia
| | - Harun Kundi
- Department of Cardiology Ankara City Hospital Ankara Turkey
| | - Zheng Jie Lim
- Department of Anaesthesiology, Austin Health Heidelberg Victoria Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine Peninsula Health Frankston Victoria Australia
- Department of Intensive Care Medicine, Calvary Hospital Canberra Australian Capital Territory Australia
| | - J Randall Curtis
- Cambia Palliative Care Centre of Excellence University of Washington Seattle Washington United States of America
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine University of Washington Seattle Washington United States of America
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Parikh T, Al-Bassam W, Shehabi Y, Pakavakis A, Subramaniam A. Current practice, education, and recommendations for training of central line insertion for trainees and fellows in adult ICUs across Australia and New Zealand. Intern Med J 2022; 53:723-730. [PMID: 35014135 DOI: 10.1111/imj.15692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Revised: 12/21/2021] [Accepted: 12/30/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND The objective of this study was to explore variability in existing training and accreditation processes for Central venous access device (CVAD) insertion among different ICUs, current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. METHODS A prospective cross-sectional web-based survey was sent via email and CICM e-Newsletter to intensivists and directors of intensive care units (ICUs) across ANZ. All responses were tabulated, post-hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarized. RESULTS 115 responses were received from various public and private ICUs from all states of ANZ. 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICUs, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools, and ultrasound training to improve training and assessment. 35% of the participants inserted 0 to 5 CVADs and more than half of the intensivists had inserted <10 CVADs in one-year period. Two-thirds of the respondents recommended inserting between 6 to 20 CVADs each year to maintain competence. CONCLUSION The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion amongst intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICUs. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Tapan Parikh
- Department of Intensive care, Monash Medical Centre, Frankston, Victoria, Australia
| | - Wisam Al-Bassam
- Department of Intensive care, Monash Medical Centre, Frankston, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Yahya Shehabi
- Department of Intensive care, Monash Medical Centre, Frankston, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Adrian Pakavakis
- Department of Intensive care, Monash Medical Centre, Frankston, Victoria, Australia.,Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
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Subramaniam A, Tiruvoipati R, Zuberav A, Wengritzky R, Bowden C, Wang WC, Wadhwa V. Risk perception and emotional wellbeing in healthcare workers involved in rapid response calls during the COVID-19 pandemic: A substudy of a cross-sectional survey. Aust Crit Care 2022; 35:34-39. [PMID: 34654611 PMCID: PMC8437811 DOI: 10.1016/j.aucc.2021.08.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/12/2021] [Accepted: 08/22/2021] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Coronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. AIMS The primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. METHODS We undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. RESULTS Four hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. CONCLUSION(S) Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.
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Affiliation(s)
- Ashwin Subramaniam
- Frankston Hospital, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia; School of Public Health and Preventive Medicine, Monash UNiversity, Australia; The Bays Hospital, Mornington, Australia.
| | - Ravindranath Tiruvoipati
- Frankston Hospital, Peninsula Health, Australia; Peninsula Clinical School, Monash University, Australia; Peninsula Private Hospital, Australia.
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Al-Bassam W, Parikh T, Neto AS, Idrees Y, Kubicki MA, Hodgson CL, Subramaniam A, Reddy MP, Gullapalli N, Michel C, Matthewman MC, Naughton J, Pereira J, Shehabi Y, Bellomo R. Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation. CRIT CARE RESUSC 2021; 23:394-402. [PMID: 38046681 PMCID: PMC10692625 DOI: 10.51893/2021.4.oa4] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described. Objective: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation. Design, setting and participants: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days. Main outcome measures: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation. Results: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH2O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0-9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0-8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support. Conclusions: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management.
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Affiliation(s)
- Wisam Al-Bassam
- Department of Intensive Care, Monash Medical Centre, Melbourne, VIC, Australia
| | - Tapan Parikh
- Department of Intensive Care, Monash Medical Centre, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Data Analytics Research and Evaluation Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
| | - Yamamah Idrees
- Department of Intensive Care, Ballarat Base Hospital, Ballarat, VIC, Australia
| | - Mark A. Kubicki
- Department of Intensive Care, Ballarat Base Hospital, Ballarat, VIC, Australia
| | - Carol L. Hodgson
- Department of Intensive Care, The Alfred, Melbourne, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Melbourne, VIC, Australia
| | | | - Navya Gullapalli
- School of Medicine, Monash University, Melbourne, VIC, Australia
| | - Claire Michel
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | | | - Jack Naughton
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Jason Pereira
- Department of Intensive Care, The Alfred, Melbourne, VIC, Australia
| | - Yahya Shehabi
- Department of Intensive Care, Monash Medical Centre, Melbourne, VIC, Australia
- Department of Surgery, Monash University, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, Austin Hospital and University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
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Subramaniam A, Tiruvoipati R, Green C, Srikanth V, Soh L, Yeoh AC, Hussain F, Bailey M, Pilcher D. Frailty status, timely goals of care documentation and clinical outcomes in older hospitalised medical patients. Intern Med J 2021; 51:2078-2086. [PMID: 32892457 DOI: 10.1111/imj.15032] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 07/21/2020] [Accepted: 08/17/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care (GOC) documentation is vital to avoid futile/unwarranted interventions in the event of deterioration. AIMS To investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. METHODS This was a single-centre retrospective study of all medical patients aged ≥80 years admitted to the acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using the Hospital Frailty Risk Score (HFRS) derived from hospital coding data. Primary outcome compared proportions of timely GOC within 72-h between frail (HFRS ≥ 5) and non-frail (HFRS < 5) patients. Exploratory secondary outcomes included in-hospital mortality, rapid response calls (RRC), prolonged length of stay (LOS) and 28-day readmission rates. RESULTS Of the 1118 admitted patients, 529 (47.3%) were frail. Timely GOC occurred in 50% (559/1118), more commonly in frail patients (283/529, 53.5%) than non-frail patients (276/589, 46.9%), P = 0.027. Frailty was positively associated with timely GOC independent of age and gender (odds ratio = 1.28; 95% confidence interval = 1.01-163; P = 0.041). In univariable analyses, timely GOC was associated with greater in-hospital mortality, RRC, and hospital LOS in both frail and non-frail patients (all P < 0.05) and greater 28-day readmissions only among frail patients (P = 0.028). Multivariable regression demonstrated that timely GOC was associated only with in-hospital mortality in both frail and non-frail patients, independent of age and gender. CONCLUSION Older frail hospitalised patients were more likely to have timely GOC than older non-frail patients. Timely GOC in such patients may avoid burdensome treatments.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, The Bays Hospital, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Intensive Care, Peninsula Private Hospital, Victoria, Australia
| | - Cameron Green
- Department of Intensive Care, Peninsula Health, Frankston, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Frankston, Victoria, Australia
- Menzies Institute for Medical Research, Hobart, Tasmania, Australia
| | - Lionel Soh
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Monash Health, Clayton, Victoria, Australia
| | - Aun Chian Yeoh
- Department of Medicine, Peninsula Health, Frankston, Victoria, Australia
- Department of Intensive Care, Monash Health, Clayton, Victoria, Australia
| | - Faisal Hussain
- Business Intelligence Unit, Peninsula Health, Frankston, Victoria, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Hospital, Melbourne, Victoria, Australia
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Ottewill C, Mulpeter R, Lee J, Shrestha G, O’Sullivan D, Subramaniam A, Hogan B, Varghese C. Therapeutic anti-coagulation in COVID-19 and the potential enhanced risk of retroperitoneal hematoma. QJM 2021; 114:508-510. [PMID: 33742677 PMCID: PMC8083784 DOI: 10.1093/qjmed/hcab059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 02/17/2021] [Indexed: 11/14/2022] Open
Affiliation(s)
- C Ottewill
- Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
- Address correspondence to Dr C. Ottewill, Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland.
| | - R Mulpeter
- Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - J Lee
- Department of Radiology, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - G Shrestha
- Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - D O’Sullivan
- Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - A Subramaniam
- Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - B Hogan
- Department of Radiology, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
| | - C Varghese
- Department of Respiratory Medicine, Tallaght University Hospital, Tallaght, Dublin 24, Ireland
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Bishop A, Zheng J, Subramaniam A, Ghia A, Wang C, Patel S, Guadagnolo B, Mitra D, Farooqi A, Kim B, Guha-Thakurta N, Li J, Ravi V. High Terminal Hemorrhage Risk From Cardiac Angiosarcoma Brain Metastases Warrants Frequent Brain Imaging and Early Intervention. Int J Radiat Oncol Biol Phys 2021. [DOI: 10.1016/j.ijrobp.2021.07.972] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Ge V, Subramaniam A, Banakh I, Wang WC, Tiruvoipati R. Management of sodium-glucose cotransporter 2 inhibitors during the perioperative period: A retrospective comparative study. J Perioper Pract 2021; 31:391-398. [PMID: 32894998 DOI: 10.1177/1750458920948693] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE Current guidelines recommend withholding sodium-glucose cotransporter 2 inhibitors perioperatively due to concerns of euglycaemic diabetic ketoacidosis. However, such guidelines are largely based on case reports and small case series, many extrapolated from non-surgical patients. The aim was to investigate whether withholding sodium-glucose cotransporter 2 inhibitors as per current perioperative guidelines was associated with a reduction in serious adverse events, including euglycaemic diabetic ketoacidosis. METHODS Instances of perioperative management of sodium-glucose cotransporter 2 inhibitors, over a four-year period were classified into two categories: those where sodium-glucose cotransporter 2 inhibitors were withheld as per guidelines and those where sodium-glucose cotransporter 2 inhibitors were administered in the perioperative period. The primary outcome was 'total major perioperative complications': a composite of serious adverse events including euglycaemic diabetic ketoacidosis, diabetic ketoacidosis, acute kidney injury, urosepsis and death. RESULTS Eighty-two instances in 64 patients were included. Withholding sodium-glucose cotransporter 2 inhibitors was associated with an increased incidence of total major perioperative complications and poorer glycaemic control postoperatively. Multivariable logistic regression analysis revealed that withholding sodium-glucose cotransporter 2 inhibitors perioperatively (OR = 13.15; 95% CI = 1.8-138.9) and preoperative urea (OR 1.85 (95% CI = 1.17-3.43) were independently associated with an increase in total major postoperative complications. CONCLUSION Withholding sodium-glucose cotransporter 2 inhibitors as per current guidelines was associated with an increase in postoperative complications and reduced glycaemic control.
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Affiliation(s)
- Victor Ge
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
| | - Iouri Banakh
- Department of Pharmacy, Peninsula Health, Melbourne, Australia
| | - Wei Chun Wang
- Cabrini Health and Monash Health, Melbourne, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Melbourne, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Australia
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Ponnapa Reddy M, Subramaniam A, Afroz A, Billah B, Lim ZJ, Zubarev A, Blecher G, Tiruvoipati R, Ramanathan K, Wong SN, Brodie D, Fan E, Shekar K. Prone Positioning of Nonintubated Patients With Coronavirus Disease 2019-A Systematic Review and Meta-Analysis. Crit Care Med 2021; 49:e1001-e1014. [PMID: 33927120 PMCID: PMC8439644 DOI: 10.1097/ccm.0000000000005086] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019-related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes. DESIGN AND SETTING We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020. SUBJECTS AND INTERVENTION Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included. MEASUREMENTS AND MAIN RESULTS Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25-54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14-25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3-6%). Respiratory rate decreased post prone positioning (mean difference, -3.2 breaths/min; 95% CI, -4.6 to -1.9). Intubation and mortality rates were 24% (95% CI, 17-32%) and 13% (95% CI, 6-19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them. CONCLUSIONS Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.
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Affiliation(s)
- Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Calvary Hospital, ACT, Australia
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Afsana Afroz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Zheng Jie Lim
- Department of Intensive Care Medicine, Ballarat Health Services, Ballarat, VIC, Australia
| | - Alexandr Zubarev
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
| | - Gabriel Blecher
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
- Department of Emergency, Monash Health, Clayton, VIC, Australia
| | - Ravindranath Tiruvoipati
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
| | - Kollengode Ramanathan
- Department of Intensive Care Medicine, Calvary Hospital, ACT, Australia
- Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care Medicine, Ballarat Health Services, Ballarat, VIC, Australia
- Department of Emergency, Monash Health, Clayton, VIC, Australia
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- National University Hospital, Singapore
- Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
- Department of Medicine, Columbia University College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Suei Nee Wong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Daniel Brodie
- Department of Medicine, Columbia University College of Physicians and Surgeons, and Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Kiran Shekar
- Faculty of Medicine, Bond University, Gold Coast, QLD, Australia
- Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, QLD, Australia
- Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane; Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
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Subramaniam A, Lim ZJ, Ponnapa Reddy M, Shekar K. Systematic review and meta-analysis of the characteristics and outcomes of readmitted COVID-19 survivors. Intern Med J 2021; 51:1773-1780. [PMID: 34487424 PMCID: PMC8652871 DOI: 10.1111/imj.15350] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 05/06/2021] [Indexed: 12/29/2022]
Abstract
The objective of the present study is to investigate the incidence, characteristics and outcomes of patients who were readmitted to hospital emergency departments or required re‐hospitalisation following an index hospitalisation with a diagnosis of COVID‐19. A systematic review of PubMed, EMBASE and pre‐print websites was conducted between 1 January and 31 December 2020. Studies reporting on the incidence, characteristics and outcomes of patients with COVID‐19 who represent or require hospital admission were included. Two authors independently performed study selection and data extraction. Study quality was assessed with the Newcastle‐Ottawa Scale. Discrepancies were resolved by consensus or through an independent third reviewer. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews guidelines. Six studies reporting on 547 readmitted patients were included. The overall incidence was 4.4%, most common in males (57.2%), and due to respiratory distress or prolonged COVID‐19. Readmitted patients had a shorter initial hospital length of stay (LOS) compared with those with a single hospitalisation (8.1 ± 10.6 vs 13.9 ± 10.2 days). The mean time to readmission was 7.6 ± 6.0 days; the mean LOS on re‐hospitalisation was 6.3 ± 5.6 days. Hypertension (odds ratio (OR) = 2.08; 95% confidence interval (CI) 1.69–2.55; P < 0.001; I2 = 0%), diabetes mellitus (OR = 1.77; 95% CI 1.38–2.27; P < 0.001; I2 = 0%) and chronic renal failure (OR = 2.37; 95% CI 1.09–5.14; P < 0.001; I2 = 0%) were more common in these patients. Intensive care admission rates were similar between the two groups; 12.8% (22/172) of readmitted patients died. In summary, readmitted patients following an index hospitalisation for COVID‐19 were more commonly males with multiple comorbidities. Shorter initial hospital LOS and unresolved primary illness may have contributed to readmission.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care, The Bays Hospital, Melbourne, Victoria, Australia
| | - Zheng Jie Lim
- Department of Anaesthesiology, Austin Health, Melbourne, Victoria, Australia
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Peninsula Health, Frankston Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care, The Bays Hospital, Melbourne, Victoria, Australia.,Department of Intensive Care Medicine, Calvary Hospital, Canberra, Australian Capital Territory, Australia
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.,Department of Intensive Care, University of Queensland, Brisbane, Queensland, Australia.,Queensland University of Technology Brisbane and Bond University, Gold Coast, Queensland, Australia
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Subramaniam A, Ponnapa Reddy M, Kadam U, Zubarev A, Lim Z, Anstey C, Bihari S, Haji J, Luo J, Mitra S, Ramanathan K, Rajamani A, Rubulotta F, Svensk E, Shekar K. Development and validation of a tool to appraise guidelines on SARS-CoV-2 infection control strategies in healthcare workers. Aust Crit Care 2021; 35:415-423. [PMID: 34404579 PMCID: PMC8266544 DOI: 10.1016/j.aucc.2021.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2021] [Revised: 06/17/2021] [Accepted: 06/24/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Clinical guidelines on infection control strategies in healthcare workers (HCWs) play an important role in protecting them during the severe acute respiratory syndrome coronavirus 2 pandemic. Poorly constructed guidelines that are incomprehensive and/or ambiguous may compromise HCWs' safety. OBJECTIVE The objective of this study was to develop and validate a tool to appraise guidelines on infection control strategies in HCWs based on the guidelines published early in the coronavirus disease 2019 pandemic. DESIGN, SETTING, AND OUTCOMES A three-stage, web-based, Delphi consensus-building process among a panel of diverse HCWs and healthcare managers was performed. The tool was validated by appraising 40 international, specialty-specific, and procedure-specific guidelines along with national guidelines from countries with a wide range of gross national income. RESULTS Overall consensus (≥75%) was reached at the end of three rounds for all six domains included in the tool. The Delphi panel recommended an ideal infection control guideline should encompass six domains: general characteristics (domain 1), engineering recommendations (domain 2), personal protective equipment (PPE) use (domain 3), and administrative aspects (domain 4-6) of infection control. The appraisal tool performed well across the six domains, and the inter-rater agreement was excellent for the 40 guidelines. All included guidelines performed relatively better in domains 1-3 than in domains 4-6, and this was more evident in guidelines originating from lower income countries. CONCLUSION The guideline appraisal tool was robust and easy to use. Engineering recommendations aspects of infection control, administrative measures that promote optimal PPE use, and HCW wellbeing were generally lacking in assessed guidelines. This tool may enable health systems to adopt high-quality HCW infection control guidelines during the severe acute respiratory syndrome coronavirus 2 pandemic and may also provide a framework for future guideline development.
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Affiliation(s)
- Ashwin Subramaniam
- Frankston Hospital, Frankston, VIC Australia; The Bays Hospital, Mornington, VIC Australia; Monash University, Frankston, VIC Australia.
| | - Mallikarjuna Ponnapa Reddy
- Frankston Hospital, Frankston, VIC Australia; The Bays Hospital, Mornington, VIC Australia; Calvary Public Hospital, ACT, Canberra, Australia.
| | - Umesh Kadam
- Werribee Mercy Hospital, Werribee, VIC, Australia; Casey Monash Hospital, Berwick, VIC, Australia.
| | | | - Zheng Lim
- Austin Health VIC, Heidelburg, Australia.
| | - Chris Anstey
- Griffith University, University of Queensland, Qld Australia.
| | - Shailesh Bihari
- Flinders University and Flinders Medical Center, SA, Australia.
| | | | | | | | - Kollengode Ramanathan
- National University Hospital, Singapore; Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | - Arvind Rajamani
- University of Sydney, Nepean Clinical School and Nepean Hospital, Kingswood, NSW, Australia.
| | | | - Erik Svensk
- Anesthesia and Intensive Care Unit, Sundsvall Hospital, Sundsvall, Sweden.
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland; University of Queensland, Brisbane, Qld, Australia; Bond University, Gold Coast, Qld, Australia.
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Subramaniam A, Zuberav A, Wengritzky R, Bowden C, Tiruvoipati R, Wang WC, Wadhwa V. 'Code-95' rapid response calls for patients under airborne precautions in the COVID-19-era: a cross-sectional survey of healthcare worker perceptions. Intern Med J 2021; 51:494-505. [PMID: 33890372 PMCID: PMC8251212 DOI: 10.1111/imj.15145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 11/30/2020] [Accepted: 12/02/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID-19 infection were pre-warned with the announcement of 'Code-95' with calls. AIM To assess healthcare worker (HCW) perspectives on pre-warning rapid response calls (RRC) with 'Code-95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID-19 infection. METHODS Design: prospective cross-sectional single-centre survey of HCW over a 3-week period. SETTING tertiary public hospital. PARTICIPANTS HCW caring for deteriorating or aggressive patients. MAIN OUTCOME MEASURES the primary outcome was to assess HCW perspectives in attending Code-95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities. RESULTS A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code-95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection-control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code-95 calls. CONCLUSIONS Most surveyed HCW supported Code-95 announcements pre-warning them of potential COVID-19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code-95 system to pre-warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive CareFrankston HospitalFrankstonVictoriaAustralia
- Department of Intensive CareThe Bays HospitalFrankstonVictoriaAustralia
- Peninsula Clinical SchoolMonash UniversityFrankstonVictoriaAustralia
- Peninsula HealthMonash UniversityMelbourneVictoriaAustralia
| | - Alexandr Zuberav
- Department of Intensive CareFrankston HospitalFrankstonVictoriaAustralia
| | | | | | - Ravindranath Tiruvoipati
- Department of Intensive CareThe Bays HospitalFrankstonVictoriaAustralia
- Department of Intensive CarePeninsula Private HospitalLangwarrinVictoriaAustralia
| | - Wei Chun Wang
- Peninsula HealthMonash UniversityMelbourneVictoriaAustralia
- Department of BiostatisticsCabrini HealthMelbourneVictoriaAustralia
| | - Vikas Wadhwa
- Department of Intensive CareFrankston HospitalFrankstonVictoriaAustralia
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Subramaniam A, Alamgeer M. Estimating the impact of COVID-19-induced coagulopathy. Ann Acad Med Singap 2021; 50:294-296. [PMID: 33990816 DOI: 10.47102/annals-acadmedsg.2021113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
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Liu S, Donaldson R, Subramaniam A, Palmer H, Champion CD, Cox ML, Appelbaum LG. Developing expert gaze pattern in laparoscopic surgery requires more than behavioral training. J Eye Mov Res 2021; 14. [PMID: 33828818 PMCID: PMC8019143 DOI: 10.16910/jemr.14.2.2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Expertise in laparoscopic surgery is realized through both manual dexterity and efficient eye
movement patterns, creating opportunities to use gaze information in the educational process.
To better understand how expert gaze behaviors are acquired through deliberate practice
of technical skills, three surgeons were assessed and five novices were trained and assessed
in a 5-visit protocol on the Fundamentals of Laparoscopic Surgery peg transfer task.
The task was adjusted to have a fixed action sequence to allow recordings of dwell durations
based on pre-defined areas of interest (AOIs). Trained novices were shown to reach more
than 98% (M = 98.62%, SD = 1.06%) of their behavioral learning plateaus, leading to equivalent
behavioral performance to that of surgeons. Despite this equivalence in behavioral
performance, surgeons continued to show significantly shorter dwell durations at visual targets
of current actions and longer dwell durations at future steps in the action sequence than
trained novices (ps ≤ .03, Cohen’s ds > 2). This study demonstrates that, while novices can
train to match surgeons on behavioral performance, their gaze pattern is still less efficient
than that of surgeons, motivating surgical training programs to involve eye tracking technology
in their design and evaluation.
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Gullapalli N, Lim ZJ, Ramanathan K, Bihari S, Haji J, Shekar K, Wong WT, Rajamani A, Subramaniam A. Personal protective equipment preparedness in intensive care units during the coronavirus disease 2019 pandemic: An Asia-Pacific follow-up survey. Aust Crit Care 2021; 35:5-12. [PMID: 33965312 PMCID: PMC8769656 DOI: 10.1016/j.aucc.2021.02.007] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 12/14/2022] Open
Abstract
Background Personal-protective equipment (PPE)-preparedness, defined as adherence to guidelines, healthcare worker (HCW) training, procuring PPE stocks and responding appropriately to suspected cases, is crucial to prevent HCW-infections. Objectives To perform a follow-up survey to assess changes in PPE-preparedness across six Asia-Pacific countries during the COVID-19 pandemic. Methods A prospective follow-up cross-sectional, web-based survey was conducted between 10/08/2020 to 01/09/ 2020, five months after the initial Phase 1 survey. The survey was sent to the same 231 intensivists across the six Asia-Pacific countries (Australia, Hong Kong, India, New Zealand, Philippines, and Singapore) that participated in Phase 1. The main outcome measure was to identify any changes in PPE-preparedness between Phases 1 and 2. Findings Phase 2 had responses from 132 ICUs (57%). Compared to Phase 1 respondents reported increased use of PPE-based practices such as powered air-purifying respirator (40.2% vs. 6.1%), N95-masks at all times (86.4% vs. 53.7%) and double-gloving (87.9% vs. 42.9%). The reported awareness of PPE stocks (85.6% vs. 51.9%), mandatory showering policies following PPE-breach (31.1% vs. 6.9%) and safety perception amongst HCWs (60.6% vs. 28.4%) improved significantly during Phase 2. Despite reported statistically similar adoption rate of the buddy system in both phases (42.4% vs. 37.2%), there was a reported reduction in donning/doffing training in Phase 2 (44.3% vs. 60.2%). There were no reported differences HCW training in other areas, such as tracheal intubation, intra-hospital transport and safe waste disposal, between the 2 phases. Conclusions Overall reported PPE-preparedness improved between the two survey periods, particularly in PPE use, PPE inventory and HCW perceptions of safety. However, the uptake of HCW training and implementation of low-cost safety measures continued to be low and the awareness of PPE breach management policies were suboptimal. Therefore, the key areas for improvement should focus on regular HCW training, implementing low-cost buddy-system and increasing awareness of PPE-breach management protocols.
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Affiliation(s)
| | - Zheng Jie Lim
- Ballarat Health Services, Ballarat, Victoria, Australia.
| | | | - Shailesh Bihari
- Flinders University and Flinders Medical Center, Bedford Park, SA, 5042, Australia.
| | | | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia; Bond University, Gold Coast, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia.
| | | | - Arvind Rajamani
- University of Sydney, Nepean Clinical School and Nepean Hospital, Kingswood, NSW, Australia.
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Rajamani A, Subramaniam A, Shekar K, Haji J, Luo J, Bihari S, Wong WT, Gullapalli N, Renner M, Alcancia CM, Ramanathan K. Personal protective equipment preparedness in Asia-Pacific intensive care units during the coronavirus disease 2019 pandemic: A multinational survey. Aust Crit Care 2021; 34:135-141. [PMID: 33214027 PMCID: PMC7522707 DOI: 10.1016/j.aucc.2020.09.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/09/2020] [Accepted: 09/13/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND There has been a surge in coronavirus disease 2019 admissions to intensive care units (ICUs) in Asia-Pacific countries. Because ICU healthcare workers are exposed to aerosol-generating procedures, ensuring optimal personal protective equipment (PPE) preparedness is important. OBJECTIVE The aim of the study was to evaluate PPE preparedness across ICUs in six Asia-Pacific countries during the initial phase of the coronavirus disease 2019 pandemic, which is defined by the World Health Organization as guideline adherence, training healthcare workers, procuring stocks, and responding appropriately to suspected cases. METHODS A cross-sectional Web-based survey was circulated to 633 level II/III ICUs of Australia, New Zealand (NZ), Singapore, Hong Kong (HK), India, and the Philippines. FINDINGS Two hundred sixty-three intensivists responded, representing 231 individual ICUs eligible for analysis. Response rates were 68-100% in all countries except India, where it was 24%. Ninety-seven percent of ICUs either conformed to or exceeded World Health Organization recommendations for PPE practice. Fifty-nine percent ICUs used airborne precautions irrespective of aerosol generation procedures. There were variations in negative-pressure room use (highest in HK/Singapore), training (best in NZ), and PPE stock awareness (best in HK/Singapore/NZ). High-flow nasal oxygenation and noninvasive ventilation were not options in most HK (66.7% and 83.3%, respectively) and Singapore ICUs (50% and 80%, respectively), but were considered in other countries to a greater extent. Thirty-eight percent ICUs reported not having specialised airway teams. Showering and "buddy systems" were underused. Clinical waste disposal training was suboptimal (38%). CONCLUSIONS Many ICUs in the Asia-Pacific reported suboptimal PPE preparedness in several domains, particularly related to PPE training, practice, and stock awareness, which requires remediation. Adoption of low-cost approaches such as buddy systems should be encouraged. The complete avoidance of high-flow nasal oxygenation reported by several intensivists needs reconsideration. Consideration must be given to standardise PPE guidelines to minimise practice variations. Urgent research to evaluate PPE preparedness and severe acute respiratory syndrome coronavirus 2 transmission is required.
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Affiliation(s)
- Arvind Rajamani
- University of Sydney, Nepean Clinical School, Australia; Nepean Hospital, Kingswood, NSW, Australia.
| | - Ashwin Subramaniam
- Frankston Hospital, Frankston, VIC, Australia; Adjunct Senior Lecturer, Monash University, Australia.
| | - Kiran Shekar
- Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia; Critical Care Research Group and Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Australia; University of Queensland, Brisbane, Queensland, Australia; Australia and Bond University, Gold Coast, Queensland, Australia.
| | | | | | - Shailesh Bihari
- Flinders University and Flinders Medical Center, Bedford Park, SA, 5042, Australia.
| | | | - Navya Gullapalli
- Monash University, Clayton, VIC, Australia; Dunedin Hospital, SDHB, New Zealand.
| | - Markus Renner
- Dunedin Hospital, SDHB, New Zealand; Otago University, New Zealand.
| | - Claudia Maria Alcancia
- Makati Medical Center, Philippines; Cardiothoracic Intensive Care Unit, National University Hospital (Clinical Fellow), Singapore.
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Lim ZJ, Subramaniam A, Ponnapa Reddy M, Blecher G, Kadam U, Afroz A, Billah B, Ashwin S, Kubicki M, Bilotta F, Curtis JR, Rubulotta F. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis. Am J Respir Crit Care Med 2021; 203:54-66. [PMID: 33119402 PMCID: PMC7781141 DOI: 10.1164/rccm.202006-2405oc] [Citation(s) in RCA: 218] [Impact Index Per Article: 72.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Rationale: Initial reports of case fatality rates (CFRs) among adults with coronavirus disease (COVID-19) receiving invasive mechanical ventilation (IMV) are highly variable.Objectives: To examine the CFR of patients with COVID-19 receiving IMV.Methods: Two authors independently searched PubMed, Embase, medRxiv, bioRxiv, the COVID-19 living systematic review, and national registry databases. The primary outcome was the "reported CFR" for patients with confirmed COVID-19 requiring IMV. "Definitive hospital CFR" for patients with outcomes at hospital discharge was also investigated. Finally, CFR was analyzed by patient age, geographic region, and study quality on the basis of the Newcastle-Ottawa Scale.Measurements and Results: Sixty-nine studies were included, describing 57,420 adult patients with COVID-19 who received IMV. Overall reported CFR was estimated as 45% (95% confidence interval [CI], 39-52%). Fifty-four of 69 studies stated whether hospital outcomes were available but provided a definitive hospital outcome on only 13,120 (22.8%) of the total IMV patient population. Among studies in which age-stratified CFR was available, pooled CFR estimates ranged from 47.9% (95% CI, 46.4-49.4%) in younger patients (age ≤40 yr) to 84.4% (95% CI, 83.3-85.4%) in older patients (age >80 yr). CFR was also higher in early COVID-19 epicenters. Overall heterogeneity is high (I2 >90%), with nonsignificant Egger's regression test suggesting no publication bias.Conclusions: Almost half of patients with COVID-19 receiving IMV died based on the reported CFR, but variable CFR reporting methods resulted in a wide range of CFRs between studies. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources. Reporting of definitive outcomes on all patients would facilitate comparisons between studies.Systematic review registered with PROSPERO (CRD42020186997).
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Affiliation(s)
- Zheng Jie Lim
- Department of Intensive Care Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
- Faculty of Medicine, Nursing and Health Sciences
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia
- School of Clinical Sciences at Monash Health, and
| | - Gabriel Blecher
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Clayton, Victoria, Australia
- Department of Intensive Care Medicine, Calvary Hospital Canberra, Canberra, Australia
| | - Umesh Kadam
- Emergency Department, Monash Health, Clayton, Victoria, Australia
- Department of Intensive Care Medicine, Monash Health Casey Hospital, Casey, Victoria, Australia
| | - Afsana Afroz
- Department of Intensive Care Medicine, Werribee Mercy Hospital, Werribee, Victoria, Australia
- Center for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, Victoria, Australia
| | - Baki Billah
- Department of Intensive Care Medicine, Werribee Mercy Hospital, Werribee, Victoria, Australia
| | - Sushma Ashwin
- Department of Health Economics, School of Health and Social Development, Deakin University, Melbourne, Victoria, Australia
| | - Mark Kubicki
- Department of Intensive Care Medicine, Ballarat Health Services, Ballarat, Victoria, Australia
| | - Federico Bilotta
- Department of Neuroanaesthesia and Neurocritical Care, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - J. Randall Curtis
- Cambia Palliative Care Center of Excellence and
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Washington, Seattle, Washington; and
| | - Francesca Rubulotta
- Department of Intensive Care Medicine, Charing Cross Hospital Imperial College National Health Service Trust, London, United Kingdom
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Lim ZJ, Ponnapa Reddy M, Afroz A, Billah B, Shekar K, Subramaniam A. Incidence and outcome of out-of-hospital cardiac arrests in the COVID-19 era: A systematic review and meta-analysis. Resuscitation 2020; 157:248-258. [PMID: 33137418 PMCID: PMC7603976 DOI: 10.1016/j.resuscitation.2020.10.025] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/18/2020] [Accepted: 10/19/2020] [Indexed: 12/29/2022]
Abstract
Background The impact of COVID-19 on pre-hospital and hospital services and hence on the prevalence and outcomes of out-of-hospital cardiac arrests (OHCA) remain unclear. The review aimed to evaluate the influence of the COVID-19 pandemic on the incidence, process, and outcomes of OHCA. Methods A systematic review of PubMed, EMBASE, and pre-print websites was performed. Studies reporting comparative data on OHCA within the same jurisdiction, before and during the COVID-19 pandemic were included. Study quality was assessed based on the Newcastle-Ottawa Scale. Results Ten studies reporting data from 35,379 OHCA events were included. There was a 120% increase in OHCA events since the pandemic. Time from OHCA to ambulance arrival was longer during the pandemic (p = 0.036). While mortality (OR = 0.67, 95%-CI 0.49−0.91) and supraglottic airway use (OR = 0.36, 95%-CI 0.27−0.46) was higher during the pandemic, automated external defibrillator use (OR = 1.78 95%-CI 1.06–2.98), return of spontaneous circulation (OR = 1.63, 95%CI 1.18-2.26) and intubation (OR = 1.87, 95%-CI 1.12-–3.13) was more common before the pandemic. More patients survived to hospital admission (OR = 1.75, 95%-CI 1.42–2.17) and discharge (OR = 1.65, 95%-CI 1.28–2.12) before the pandemic. Bystander CPR (OR = 1.18, 95%-CI 0.95-1.46), unwitnessed OHCA (OR = 0.84, 95%-CI 0.66–1.07), paramedic-resuscitation attempts (OR = 1.19 95%-CI 1.00–1.42) and mechanical CPR device use (OR = 1.57 95%-CI 0.55–4.55) did not defer significantly. Conclusions The incidence and mortality following OHCA was higher during the COVID-19 pandemic. There were significant variations in resuscitation practices during the pandemic. Research to define optimal processes of pre-hospital care during a pandemic is urgently required. Review registration PROSPERO (CRD42020203371).
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Affiliation(s)
- Zheng Jie Lim
- Department of Anaesthesia and Intensive Care Medicine, Ballarat Health Services, Ballarat, Victoria, Australia.
| | - Mallikarjuna Ponnapa Reddy
- Department of Intensive Care Medicine, Calvary Hospital, Canberra, Australian Capital Territory, Australia
| | - Afsana Afroz
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Baki Billah
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Kiran Shekar
- Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, Australia; University of Queensland, Brisbane, Queensland University of Technology Brisbane and Bond University, Gold Coast, Queensland, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
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Ajjampur K, Subramaniam A. The importance of early use of beta blockers and gastric decontamination in caffeine overdose: A case report. Aust Crit Care 2020; 34:395-400. [PMID: 33131980 DOI: 10.1016/j.aucc.2020.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 09/13/2020] [Accepted: 09/18/2020] [Indexed: 11/16/2022] Open
Abstract
Caffeine is a common stimulant consumed daily worldwide and available in a wide variety of over-the-counter formulations. It is a mild central nervous system stimulant when used in recommended doses. However, it can be fatal if taken as an intentional or accidental overdose. We report a case of a 48-year-old lady with depression and post-traumatic stress disorder who consumed a significant overdose of caffeine, triggered by the stress that she had contracted coronavirus disease 19. This led to significant cardiovascular and central nervous system toxicity. The condition was identified early and managed appropriately with early β-blockers and gastric decontamination, which saved her life. There are few studies with regard to such modalities on treatment for caffeine overdose; our patient responded rapidly and favourably to the treatment. Why should an emergency physician be aware of this? Caffeine overdose is uncommon but one that clinicians should be aware of. Early identification and intervention with β-adrenergic antagonists and activated charcoal is paramount in caffeine toxicity.
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Affiliation(s)
| | - Ashwin Subramaniam
- Peninsula Health, Frankston, Victoria, Australia; Monash University, Peninsula Clinical School, Australia.
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Subramaniam A, Haji JY, Kumar P, Ramanathan K, Rajamani A. Noninvasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey. Indian J Crit Care Med 2020; 24:926-931. [PMID: 33281316 PMCID: PMC7689117 DOI: 10.5005/jp-journals-10071-23640] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND About 5% of hospitalized coronavirus disease 2019 (COVID-19) patients will need intensive care unit (ICU) admission for hypoxemic respiratory failure requiring oxygen support. The choice between early mechanical ventilation and noninvasive oxygen therapies, such as, high-flow nasal oxygen (HFNO) and/or noninvasive positive-pressure ventilation (NPPV) has to balance the contradictory priorities of protecting healthcare workers by minimizing aerosol-generation and optimizing resource management. This survey over two timeframes aimed to explore the controversial issue of location and noninvasive oxygen therapy in non-intubated ICU patients using a clinical vignette. MATERIALS AND METHODS An online survey was designed, piloted, and distributed electronically to Indian intensivists/anesthetists, from private hospitals, government hospitals, and medical college hospitals (the latter two referred to as first-responder hospitals), who are directly responsible for admitting/managing patients in ICU. RESULTS Of the 204 responses (125/481 in phase 1 and 79/320 in phase 2), 183 responses were included. Respondents from first-responder hospitals were more willing to manage non-intubated hypoxemic patients in neutral pressure rooms, while respondents from private hospitals preferred negative-pressure rooms (p < 0.001). In both the phases, private hospital doctors were less comfortable to use any form of noninvasive oxygen therapies in neutral-pressure rooms compared to first-responder hospitals (low-flow oxygen therapy: 72 vs 50%, p < 0.01; HFNO: 47 vs 24%, p < 0.01 and NPPV: 38 vs 28%, p = 0.20). INTERPRETATION Variations existed in practices among first-responder and private intensivists/anesthetists. The resource optimal private hospital intensivists/anesthetists were less comfortable using noninvasive oxygen therapies in managing COVID-19 patients. This may reflect differential resource availability necessitating resolution at national, state, and local levels. HOW TO CITE THIS ARTICLE Subramaniam A, Haji JY, Kumar P, Ramanathan K, Rajamani A. Noninvasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey. Indian J Crit Care Med 2020;24(10):926-931.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, Frankston, VIC Monash University, VIC, Frankston, Australia
| | - Jumana Y Haji
- Department of Anesthesia and Critical Care, Aster CMI Hospital, Bengaluru, Karnataka, India
- Jumana Y Haji, Department of Anesthesia and Critical Care, Aster CMI Hospital, Bengaluru, Karnataka, India, Phone: +91 9686521100, e-mail:
| | - Prashant Kumar
- Department of Critical Care Medicine, Kailash Hospital Neuro Institute KHNI, Noida, Uttar Pradesh, India
| | | | - Arvind Rajamani
- Department of Intensive Care, University of Sydney, Nepean Clinical School and Nepean Hospital, Kingswood, New South Wales, Australia
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Haji JY, Subramaniam A, Kumar P, Ramanathan K, Rajamani A. State of Personal Protective Equipment Practice in Indian Intensive Care Units amidst COVID-19 Pandemic: A Nationwide Survey. Indian J Crit Care Med 2020; 24:809-816. [PMID: 33132565 PMCID: PMC7584819 DOI: 10.5005/jp-journals-10071-23550] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Optimal personal protective equipment (PPE) preparedness is key to minimize healthcare workers (HCW) infection with COVID-19. This two-phase survey evaluated PPE preparedness (adherence to Ministry of Health India (MoH) PPE-recommendations; HCW-training; PPE-inventory; PPE-breach management) in Indian intensive care units (ICU). MATERIALS AND METHODS The phase 1 survey was distributed electronically to intensivists from 481 Indian hospitals between March 25, 2020, and April 06, 2020, as part of a multinational survey. Phase 2 was repeated in 320 Indian hospitals between April 20, 2020, and April 30, 2020. RESULTS Response rate was 25% from 22 states. PPE practice varied between states and between private, government, and medical colleges. Between phase 1 and phase 2, all aspects of PPE training improved: donning/doffing 43% vs 66%, respectively; p value <0.01); safe waste disposal practices (38% vs 52%; p value = 0.09); intubation training (18% vs 31%; p value = 0.05); and transport (18% vs 31%; p value = 0.05). Perception of confidence for adequate PPE-training improved from 39 to 53% (p value = 0.26). In all, 47 to 60% ICUs adhered to MoH recommendations. Wearing N95-masks at all times increased from 47 to 60% (p value = 0.89). Very few ICUs provided quantitative/qualitative N95 masks fit testing (12% vs 29%; p value <0.01). Low-cost practices like "buddy-system" for donning-doffing (27% vs 44%; p value = 0.02) and showering after PPE breach (10% vs 8%; p value = 0.63) were underutilized. There was reluctance to PPE reuse. In all, 71% were unaware/diffident about PPE inventory. CONCLUSION Despite interstate variability, most ICUs conformed to MoH recommendations. This survey conducted during initial pandemic phase demonstrated improved PPE preparedness uniformly across India with scope for further improvement. We suggest implementation of quality improvement measures to improve pandemic preparedness and minimize HCW infection rates, focused on regular PPE training, buddy system, and PPE-breach management. HOW TO CITE THIS ARTICLE Haji JY, Subramaniam A, Kumar P, Ramanathan K, Rajamani A. State of Personal Protective Equipment Practice in Indian Intensive Care Units amidst COVID-19 Pandemic: A Nationwide Survey. Indian J Crit Care Med 2020;24(9):809-816.
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Affiliation(s)
- Jumana Yusuf Haji
- Department of Anesthesia and Critical Care, Aster CMI Hospital, Bengaluru, Karnataka, India
| | - Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital, VIC Monash University VIC, Frankston, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Prashant Kumar
- Department of Critical Care Medicine, Kailash Hospital Neuro Institute, Noida, Uttar Pradesh, India
| | | | - Arvind Rajamani
- Department of Intensive Care, University of Sydney, Nepean Clinical School and Nepean Hospital, Kingswood, NSW, Australia
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Khalil V, Blackley S, Subramaniam A. Evaluation of a pharmacist-led shared decision-making in atrial fibrillation and patients' satisfaction-a before and after pilot study. Ir J Med Sci 2020; 190:819-824. [PMID: 32808181 DOI: 10.1007/s11845-020-02343-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chronic complex diseases like atrial fibrillation have potential long-term economical and personal consequences. Shared decision-making principles may promote therapeutic compliance, satisfaction and outcomes. Pharmacists, as patient-advocates, play a key role in guiding them through complex clinical decisions about their chronic disease management and anticoagulation choices. AIM To evaluate the impact of pharmacist-led shared decision making on patients' satisfaction and appropriateness of their anticoagulation therapy in newly diagnosed atrial fibrillation patients. METHODS A prospective 2-phase before and after single-centre study was conducted in an Australian hospital. Phase 1 provided usual care, and patients' satisfaction and appropriateness of their anticoagulation therapy were evaluated. Phase-2 assessed the impact on satisfaction and appropriateness of anticoagulant therapy following pharmacist-led interventions of shared decision making to promote patients' involvement. RESULTS Patients with pharmacist-led shared decision making reported higher degree of appropriateness of anticoagulation therapy and satisfaction (36% vs 92%, P < 0.001; 25% vs 68, P < 0.001), respectively. Additionally, patients who had a pharmacist input during their hospital stay received guideline-recommended anticoagulant therapy and reported satisfaction with their management was also higher in stage 2 (21% vs 65%, p < 0.001). CONCLUSION The study highlights pharmacist-led shared decision making in atrial fibrillation that contributes to patient satisfaction and appropriateness of therapy.
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Affiliation(s)
- Viviane Khalil
- Peninsula Health, Frankston, Victoria, 3199, Australia. .,Monash University, Clayton , Vic 3800, Australia.
| | | | - Ashwin Subramaniam
- Peninsula Health, Frankston, Victoria, 3199, Australia.,Monash University, Clayton , Vic 3800, Australia.,The Bays Hospital, Vale St, Mornington, 3931, Australia
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Rajamani A, Huang S, Subramaniam A, Thomson M, Luo J, Simpson A, McLean A, Aneman A, Madapusi TV, Lakshmanan R, Flynn G, Poojara L, Gatward J, Pusapati R, Howard A, Odlum D. Evaluating the influence of data collector training for predictive risk of death models: an observational study. BMJ Qual Saf 2020; 30:202-207. [PMID: 32229628 DOI: 10.1136/bmjqs-2020-010965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Revised: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Severity-of-illness scoring systems are widely used for quality assurance and research. Although validated by trained data collectors, there is little data on the accuracy of real-world data collection practices. OBJECTIVE To evaluate the influence of formal data collection training on the accuracy of scoring system data in intensive care units (ICUs). STUDY DESIGN AND METHODS Quality assurance audit conducted using survey methodology principles. Between June and December 2018, an electronic document with details of three fictitious ICU patients was emailed to staff from 19 Australian ICUs who voluntarily submitted data on a web-based data entry form. Their entries were used to generate severity-of-illness scores and risks of death (RoDs) for four scoring systems. The primary outcome was the variation of severity-of-illness scores and RoDs from a reference standard. RESULTS 50/83 staff (60.3%) submitted data. Using Bayesian multilevel analysis, severity-of-illness scores and RoDs were found to be significantly higher for untrained staff. The mean (95% high-density interval) overestimation in RoD due to training effect for patients 1, 2 and 3, respectively, were 0.24 (0.16, 0.31), 0.19 (0.09, 0.29) and 0.24 (0.1, 0.38) respectively (Bayesian factor >300, decisive evidence). Both groups (trained and untrained) had wide coefficients of variation up to 38.1%, indicating wide variability. Untrained staff made more errors in interpreting scoring system definitions. INTERPRETATION In a fictitious patient dataset, data collection staff without formal training significantly overestimated the severity-of-illness scores and RoDs compared with trained staff. Both groups exhibited wide variability. Strategies to improve practice may include providing adequate training for all data collection staff, refresher training for previously trained staff and auditing the raw data submitted by individual ICUs. The results of this simulated study need revalidation on real patients.
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Affiliation(s)
- Arvind Rajamani
- Department of Intensive Care Medicine, The University of Sydney Nepean Clinical School, Kingswood, New South Wales, Australia
| | - Stephen Huang
- Department of Intensive Care Medicine, The University of Sydney Nepean Clinical School, Kingswood, New South Wales, Australia
| | - Ashwin Subramaniam
- Department of Intensive Care Medicine, Peninsula Clinical School, Monash University, Frankston, Victoria, Australia
| | | | - Jinghang Luo
- Nepean Hospital, Penrith, New South Wales, Australia
| | | | - Anthony McLean
- Department of Intensive Care Medicine, The University of Sydney Nepean Clinical School, Kingswood, New South Wales, Australia
| | - Anders Aneman
- Liverpool Hospital, Liverpool, New South Wales, Australia
| | | | | | - Gordon Flynn
- Prince of Wales Hospital and Community Health Services, Randwick, New South Wales, Australia
| | - Latesh Poojara
- Blacktown Hospital, Blacktown, New South Wales, Australia
| | - Jonathan Gatward
- The University of Sydney Northern Clinical School, Saint Leonards, New South Wales, Australia
| | - Raju Pusapati
- Hervey Bay Hospital, Hervey Bay, Queensland, Australia
| | - Adam Howard
- Royal Perth Hospital, Perth, Western Australia, Australia
| | - Debbie Odlum
- Nepean Hospital, Penrith, New South Wales, Australia
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Subramaniam A, Tiruvoipati R, Lodge M, Moran C, Srikanth V. Frailty in the older person undergoing elective surgery: a trigger for enhanced multidisciplinary management - a narrative review. ANZ J Surg 2020; 90:222-229. [PMID: 31916659 DOI: 10.1111/ans.15633] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 07/10/2019] [Revised: 11/17/2019] [Accepted: 11/19/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND The ageing of our society has led to increasing numbers of older people requiring elective surgical procedures. Preoperative frailty is a strong predictor of adverse post-operative outcomes. This review aims to summarize the evidence for interventions aimed at improving outcomes in frail older people who may undergo elective surgery. METHODS Articles published on perioperative management of frailty between 1 January 1970 and 31 May 2019 were searched using PubMed and EMBASE. RESULTS We identified very few studies investigating such interventions, such as comprehensive geriatric assessment, prehabilitation (alone or as a multicomponent strategy) and other multicomponent interventions. Administration of a comprehensive geriatric assessment was shown to be associated with reduced mortality, fewer complications and shorter length of hospital stay, and may be best targeted towards those who are identified as frail for resource efficiency. Multicomponent interventions including prehabilitation may be associated with improved outcomes, but the evidence base for these needs to be strengthened. CONCLUSION Establishing multidisciplinary collaborative services to provide person-centred models of care should be considered for older people presenting for elective surgery, particularly in those with greater preoperative frailty. Further large-scale studies should focus on implementing and evaluating such multicomponent models of care.
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Affiliation(s)
- Ashwin Subramaniam
- Department of Intensive Care, Frankston Hospital and The Bays Hospital, Melbourne, Victoria, Australia
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Ravindranath Tiruvoipati
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Frankston Hospital and Peninsula Private Hospital, Melbourne, Victoria, Australia
| | - Margot Lodge
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Aged Care, Caulfield Hospital, Alfred Health, Melbourne, Victoria, Australia
| | - Christopher Moran
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Aged Care, Caulfield Hospital, Alfred Health, Melbourne, Victoria, Australia
- Department of Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Melbourne, Victoria, Australia
| | - Velandai Srikanth
- Peninsula Clinical School, Central Clinical School, Monash University, Melbourne, Victoria, Australia
- Department of Geriatric Medicine, Peninsula Health, Melbourne, Victoria, Australia
- Acute Care of the Elderly, Menzies Institute for Medical Research, Hobart, Tasmania, Australia
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