1
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Rollinson TC, McDonald LA, Rose J, Eastwood G, Costa-Pinto R, Modra L, Maeda A, Bacolas Z, Anstey J, Bates S, Bradley S, Dumbrell J, French C, Ghosh A, Haines K, Haydon T, Hodgson C, Holmes J, Leggett N, McGain F, Moore C, Nelson K, Presneill J, Rotherham H, Said S, Young M, Zhao P, Udy A, Chaba A, Bellomo R, Neto AS. Magnitude and time to peak oxygenation effect of prone positioning in ventilated adults with COVID-19 related acute hypoxemic respiratory failure. Acta Anaesthesiol Scand 2024; 68:361-371. [PMID: 37944557 DOI: 10.1111/aas.14356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 09/14/2023] [Accepted: 10/28/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Prone positioning may improve oxygenation in acute hypoxemic respiratory failure and was widely adopted in COVID-19 patients. However, the magnitude and timing of its peak oxygenation effect remain uncertain with the optimum dosage unknown. Therefore, we aimed to investigate the magnitude of the peak effect of prone positioning on the PaO2 :FiO2 ratio during prone and secondly, the time to peak oxygenation. METHODS Multi-centre, observational study of invasively ventilated adults with acute hypoxemic respiratory failure secondary to COVID-19 treated with prone positioning. Baseline characteristics, prone positioning and patient outcome data were collected. All arterial blood gas (ABG) data during supine, prone and after return to supine position were analysed. The magnitude of peak PaO2 :FiO2 ratio effect and time to peak PaO2 :FIO2 ratio effect was measured. RESULTS We studied 220 patients (mean age 54 years) and 548 prone episodes. Prone positioning was applied for a mean (±SD) 3 (±2) times and 16 (±3) hours per episode. Pre-proning PaO2 :FIO2 ratio was 137 (±49) for all prone episodes. During the first episode. the mean PaO2 :FIO2 ratio increased from 125 to a peak of 196 (p < .001). Peak effect was achieved during the first episode, after 9 (±5) hours in prone position and maintained until return to supine position. CONCLUSIONS In ventilated adults with COVID-19 acute hypoxemic respiratory failure, peak PaO2 :FIO2 ratio effect occurred during the first prone positioning episode and after 9 h. Subsequent episodes also improved oxygenation but with diminished effect on PaO2 :FIO2 ratio. This information can help guide the number and duration of prone positioning episodes.
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Affiliation(s)
- Thomas C Rollinson
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, The University of Melbourne, Melbourne, Victoria, Australia
- Institute for Breathing and Sleep, Melbourne, Victoria, Australia
| | - Luke A McDonald
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia
| | - Joleen Rose
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Lucy Modra
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
| | - Zoe Bacolas
- Department of Physiotherapy, Austin Health, Melbourne, Victoria, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Samantha Bates
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Scott Bradley
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
| | - Jodi Dumbrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Craig French
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Angaj Ghosh
- Department of Intensive Care, Northern Health, Melbourne, Victoria, Australia
| | - Kimberley Haines
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - Tim Haydon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Carol Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
| | - Jennifer Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Nina Leggett
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
- Department of Physiotherapy, Western Health, Melbourne, Victoria, Australia
| | - Forbes McGain
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Western Health, Melbourne, Victoria, Australia
| | - Cara Moore
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Kathleen Nelson
- Department of Physiotherapy, Alfred Health, Melbourne, Victoria, Australia
| | - Jeffrey Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Hannah Rotherham
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Simone Said
- Department of Intensive Care, Northern Health, Melbourne, Victoria, Australia
| | - Meredith Young
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Peinan Zhao
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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Jeffcote T, Battistuzzo CR, Plummer MP, McNamara R, Anstey J, Bellapart J, Roach R, Chow A, Westerlund T, Delaney A, Bihari S, Bowen D, Weeden M, Trapani A, Reade M, Jeffree RL, Fitzgerald M, Gabbe BJ, O'Brien TJ, Nichol AD, Cooper DJ, Bellomo R, Udy A. PRECISION-TBI: a study protocol for a vanguard prospective cohort study to enhance understanding and management of moderate to severe traumatic brain injury in Australia. BMJ Open 2024; 14:e080614. [PMID: 38387978 PMCID: PMC10882309 DOI: 10.1136/bmjopen-2023-080614] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 02/13/2024] [Indexed: 02/24/2024] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) is a heterogeneous condition in terms of pathophysiology and clinical course. Outcomes from moderate to severe TBI (msTBI) remain poor despite concerted research efforts. The heterogeneity of clinical management represents a barrier to progress in this area. PRECISION-TBI is a prospective, observational, cohort study that will establish a clinical research network across major neurotrauma centres in Australia. This network will enable the ongoing collection of injury and clinical management data from patients with msTBI, to quantify variations in processes of care between sites. It will also pilot high-frequency data collection and analysis techniques, novel clinical interventions, and comparative effectiveness methodology. METHODS AND ANALYSIS PRECISION-TBI will initially enrol 300 patients with msTBI with Glasgow Coma Scale (GCS) <13 requiring intensive care unit (ICU) admission for invasive neuromonitoring from 10 Australian neurotrauma centres. Demographic data and process of care data (eg, prehospital, emergency and surgical intervention variables) will be collected. Clinical data will include prehospital and emergency department vital signs, and ICU physiological variables in the form of high frequency neuromonitoring data. ICU treatment data will also be collected for specific aspects of msTBI care. Six-month extended Glasgow Outcome Scores (GOSE) will be collected as the key outcome. Statistical analysis will focus on measures of between and within-site variation. Reports documenting performance on selected key quality indicators will be provided to participating sites. ETHICS AND DISSEMINATION Ethics approval has been obtained from The Alfred Human Research Ethics Committee (Alfred Health, Melbourne, Australia). All eligible participants will be included in the study under a waiver of consent (hospital data collection) and opt-out (6 months follow-up). Brochures explaining the rationale of the study will be provided to all participants and/or an appropriate medical treatment decision-maker, who can act on the patient's behalf if they lack capacity. Study findings will be disseminated by peer-review publications. TRIAL REGISTRATION NUMBER NCT05855252.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Camila R Battistuzzo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Mark P Plummer
- Department of Intensive Care, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
| | - James Anstey
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Judith Bellapart
- Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Rebecca Roach
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Andrew Chow
- Department of Intensive Care Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Torgeir Westerlund
- Department of Intensive Care Medicine, John Hunter Hospital, Newcastle, New South Wales, Australia
| | - Anthony Delaney
- The George Institute for Global Health, Sydney, New South Wales, Australia
- Department of Intensive Care Medicine, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Shailesh Bihari
- Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - David Bowen
- Westmead Hospital, Sydney, New South Wales, Australia
| | - Mark Weeden
- Intensive Care Unit, St George Hospital, Sydney, New South Wales, Australia
| | - Anthony Trapani
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - Michael Reade
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
- Faculty of Medicine, Medical School, University of Queensland, Brisbane, Queensland, Australia
| | - Rosalind L Jeffree
- Faculty of Medicine, Medical School, University of Queensland, Brisbane, Queensland, Australia
- Neurosurgery, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University Faculty of Health Sciences, Perth, Western Australia, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, Western Australia, Australia
| | - Belinda J Gabbe
- Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Department of Neurology, Alfred Hospital, Melbourne, Victoria, Australia
- Department of Neuroscience, Monash University Central Clinical School, Melbourne, Victoria, Australia
| | - Alistair D Nichol
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care, The Alfred Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Victoria, Australia
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Rollinson TC, McDonald LA, Rose J, Eastwood G, Costa-Pinto R, Modra L, Maeda A, Bacolas Z, Anstey J, Bates S, Bradley S, Dumbrell J, French C, Ghosh A, Haines K, Haydon T, Hodgson CL, Holmes J, Leggett N, McGain F, Moore C, Nelson K, Presneill J, Rotherham H, Said S, Young M, Zhao P, Udy A, Neto AS, Chaba A, Bellomo R. Neuromuscular blockade and oxygenation changes during prone positioning in COVID-19. J Crit Care 2024; 79:154469. [PMID: 37992464 DOI: 10.1016/j.jcrc.2023.154469] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/25/2023] [Accepted: 11/09/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain. METHODS Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position. RESULTS We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO2 (P/F ratio) during the first prone episode with NMBs reached 208 ± 63 mmHg compared with 161 ± 66 mmHg without NMBs (Δmean = 47 ± 5 mmHg) for an absolute increase from baseline of 76 ± 56 mmHg versus 55 ± 56 mmHg (padj < 0.001). The mean P/F ratio on return to the supine position was 190 ± 63 mmHg in the NMB group versus 141 ± 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 ± 58 mmHg versus 34 ± 56 mmHg (padj < 0.001). CONCLUSION During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.
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Affiliation(s)
- Thomas C Rollinson
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, The University of Melbourne, Melbourne, VIC, Australia; Institute for Breathing and Sleep, Melbourne, VIC, Australia.
| | - Luke A McDonald
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Joleen Rose
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Rahul Costa-Pinto
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Lucy Modra
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
| | - Akinori Maeda
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Zoe Bacolas
- Department of Physiotherapy, Austin Health, Melbourne, VIC, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Samantha Bates
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Scott Bradley
- Department of Intensive Care, Alfred Health, VIC, Australia; Department of Physiotherapy, Alfred Health, VIC, Australia
| | - Jodi Dumbrell
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Craig French
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Angaj Ghosh
- Department of Intensive Care, Northern Health, VIC, Australia
| | - Kimberley Haines
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia; Department of Physiotherapy, Western Health, VIC, Australia
| | - Tim Haydon
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Carol L Hodgson
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Health, VIC, Australia; Department of Physiotherapy, Alfred Health, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Jennifer Holmes
- Department of Critical Care Medicine, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Nina Leggett
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia; Department of Physiotherapy, Western Health, VIC, Australia
| | - Forbes McGain
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Western Health, VIC, Australia
| | - Cara Moore
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | - Jeffrey Presneill
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Hannah Rotherham
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Simone Said
- Department of Intensive Care, Northern Health, VIC, Australia
| | - Meredith Young
- Department of Intensive Care, Alfred Health, VIC, Australia
| | - Peinan Zhao
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Andrew Udy
- Department of Intensive Care, Alfred Health, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Ary Serpa Neto
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Anis Chaba
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Health, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Data Analytics Research and Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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Jeffcote T, Weir T, Anstey J, Mcnamara R, Bellomo R, Udy A. The Impact of Sedative Choice on Intracranial and Systemic Physiology in Moderate to Severe Traumatic Brain Injury: A Scoping Review. J Neurosurg Anesthesiol 2023; 35:265-273. [PMID: 35142704 DOI: 10.1097/ana.0000000000000836] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 10/04/2021] [Accepted: 01/06/2022] [Indexed: 11/27/2022]
Abstract
Although sedative use is near-ubiquitous in the acute management of moderate to severe traumatic brain injury (m-sTBI), the evidence base for these agents is undefined. This review summarizes the evidence for analgosedative agent use in the intensive care unit management of m-sTBI. Clinical studies of sedative and analgosedative agents currently utilized in adult m-sTBI management (propofol, ketamine, benzodiazepines, opioids, and alpha-2 agonists) were identified and assessed for relevance and methodological quality. The primary outcome was the effect of the analgosedative agent on intracranial pressure (ICP). Secondary outcomes included intracranial hemodynamic and metabolic parameters, systemic hemodynamic parameters, measures of therapeutic intensity, and clinical outcomes. Of 594 articles identified, 61 met methodological review criteria, and 40 were included in the qualitative summary; of these, 33 were prospective studies, 18 were randomized controlled trials, and 8 were blinded. There was consistent evidence for the efficacy of sedative agents in the management of m-sTBI and raised ICP, but the overall quality of the evidence was poor, consisting of small studies (median sample size, 23.5) of variable methodological quality. Propofol and midazolam achieve the goals of sedation without notable differences in efficacy or safety, although high-dose propofol may disrupt cerebral autoregulation. Dexmedetomidine and propofol/ dexmedetomidine combination may cause clinically significant hypotension. Dexmedetomidine was effective to achieve a target sedation score. De novo opioid boluses were associated with increased ICP and reduced cerebral perfusion pressure. Ketamine bolus and infusions were not associated with increased ICP and may reduce the incidence of cortical spreading depolarization events. In conclusion, there is a paucity of high-quality evidence to inform the optimal use of analgosedative agents in the management of m-sTBI, inferring significant scope for further research.
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Affiliation(s)
- Toby Jeffcote
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Timothy Weir
- Department of Intensive Care Medicine, The Alfred Hospital
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
| | - Robert Mcnamara
- Department of Intensive Care, Royal Perth Hospital, Perth, WA, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The Austin Hospital
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne
- Department of Critical Care, University of Melbourne, Parkville
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
| | - Andrew Udy
- Department of Intensive Care Medicine, The Alfred Hospital
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Prahran, Vic
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McNamara R, Meka S, Anstey J, Fatovich D, Haseler L, Jeffcote T, Udy A, Bellomo R, Fitzgerald M. Development of Traumatic Brain Injury Associated Intracranial Hypertension Prediction Algorithms: A Narrative Review. J Neurotrauma 2023; 40:416-434. [PMID: 36205570 PMCID: PMC9986028 DOI: 10.1089/neu.2022.0201] [Citation(s) in RCA: 4] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Traumatic intracranial hypertension (tIH) is a common and potentially lethal complication of moderate to severe traumatic brain injury (m-sTBI). It often develops with little warning and is managed reactively with the tiered application of intracranial pressure (ICP)-lowering interventions administered in response to an ICP rising above a set threshold. For over 45 years, a variety of research groups have worked toward the development of technology to allow for the preemptive management of tIH in the hope of improving patient outcomes. In 2022, the first operationalizable tIH prediction system became a reality. With such a system, ICP lowering interventions could be administered prior to the rise in ICP, thus protecting the patient from potentially damaging tIH episodes and limiting the overall ICP burden experienced. In this review, we discuss related approaches to ICP forecasting and IH prediction algorithms, which collectively provide the foundation for the successful development of an operational tIH prediction system. We also discuss operationalization and the statistical assessment of tIH algorithms. This review will be of relevance to clinicians and researchers interested in development of this technology as well as those with a general interest in the bedside application of machine learning (ML) technology.
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Affiliation(s)
- Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- School of Medicine, Curtin University, Bentley, Western Australia, Australia
- Address correspondence to: Robert McNamara, BMBS, FCICM, Department of Intensive Care Medicine, Royal Perth Hospital, Perth, Western Australia, Australia 6001
| | - Shiv Meka
- Data Innovation Laboratory, Western Australian Department of Health, Perth, Western Australia, Australia
| | - James Anstey
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Daniel Fatovich
- Department of Emergency Medicine, Royal Perth Hospital, Perth, Western Australia, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, Western Australia, Australia
| | - Luke Haseler
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
| | - Toby Jeffcote
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
| | - Andrew Udy
- Department of Intensive Care, Alfred Health, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, Australia
- Data Analytics Research and Evaluation, Austin Hospital, Melbourne, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, Western Australia, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, Western Australia, Australia
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Wigmore G, Deane AM, Anstey J, Bailey M, Bihari S, Eastwood G, Ghanpur R, Maiden MJ, Presneill JJ, Raman J, Bellomo R. Study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-ll (HAS FLAIR-II) trial. CRIT CARE RESUSC 2022; 24:309-318. [PMID: 38047012 PMCID: PMC10692638 DOI: 10.51893/2022.4.oa1] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Background: Fluid bolus therapy with 20% albumin may shorten the duration of vasopressor therapy in patients after cardiac surgery. Objective: To describe the study protocol and statistical analysis plan for the 20% Human Albumin Solution Fluid Bolus Administration Therapy in Patients after Cardiac Surgery-II (HAS FLAIR-II) trial. Design, setting, participants and intervention: HAS FLAIR-II is a phase 2b, multicentre, parallel group, openlabel, randomised controlled trial that will be conducted at six Australian intensive care units. Patients requiring fluid bolus therapy after cardiac surgery will be randomly assigned in a 1:1 ratio to the intervention of fluid bolus therapy with 20% albumin or a comparator of fluid bolus therapy with a crystalloid solution. Main outcome measures: The primary outcome measure is the cumulative duration of vasopressor therapy. Secondary outcomes include vasopressor use, service utilisation, and mortality. All analyses will be conducted on an intention-to-treat basis. Results and conclusion: The study protocol and statistical analysis plan will guide the conduct and analysis of the HAS FLAIR-II trial, such that analytical and reporting biases are minimised. Trial registration: This trial has been registered with the Australian New Zealand Clinical Trials Registry (ACTRN No. 12620000137998).
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Affiliation(s)
- Geoffrey Wigmore
- Department of Anaesthesia, Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
| | - Adam M. Deane
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - James Anstey
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne 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
| | - Shailesh Bihari
- Department of Intensive and Critical Care Medicine, Flinders Medical Centre, Adelaide, SA, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Rashmi Ghanpur
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Intensive care Unit, Warringal Private hospital, Melbourne, VIC, Australia
| | - Matthew J. Maiden
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
| | - Jeffrey J. Presneill
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne 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
| | - Jaishankar Raman
- University of Melbourne, Melbourne, VIC, Australia
- St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Deakin University, Melbourne, VIC, Australia
- University of Illinois at Urbana-Champaign, Urbana (IL), USA
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - For the HAS FLAIR-II trial investigators
- Department of Anaesthesia, Western Health, Melbourne, VIC, Australia
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Royal Melbourne 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
- Department of Intensive and Critical Care Medicine, Flinders Medical Centre, Adelaide, SA, Australia
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
- Intensive care Unit, Warringal Private hospital, Melbourne, VIC, Australia
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
- Intensive Care Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
- Intensive Care Unit, Barwon Health, Geelong, VIC, Australia
- University of Melbourne, Melbourne, VIC, Australia
- St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
- Deakin University, Melbourne, VIC, Australia
- University of Illinois at Urbana-Champaign, Urbana (IL), USA
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7
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Russo G, Harrois A, Anstey J, Van Der Jagt M, Taccone F, Udy A, Citerio G, Duranteau J, Ichai C, Badenes R, Prowle J, Ercole A, Oddo M, Schneider A, Wolf S, Helbok R, Nelson D, Cooper J. Early sedation in traumatic brain injury: a multicentre international observational study. CRIT CARE RESUSC 2022; 24:319-329. [PMID: 38047010 PMCID: PMC10692594 DOI: 10.51893/2022.4.oa2] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Objectives: We aimed to investigate the use of sedation in patients with severe traumatic brain injury (TBI), focusing on the choice of sedative agent, dose, duration, and their association with clinical outcomes. Design: Multinational, multicentre, retrospective observational study. Settings: 14 trauma centres in Europe, Australia and the United Kingdom. Participants: A total of 262 adult patients with severe TBI and intracranial pressure monitoring. Main outcome measures: We described how sedative agents were used in this population. The primary outcome was 60-day mortality according to the use of different sedative agents. Secondary outcomes included intensive care unit and hospital length of stay, and the Extended Glasgow Outcome Scale at hospital discharge. Results: Propofol and midazolam were the most commonly used sedatives. Propofol was more common than midazolam as first line therapy (35.4% v 25.6% respectively). Patients treated with propofol had similar Acute Physiology and Chronic Health Evaluation (APACHE) II and International Mission for Prognosis and Analysis of Clinical Trials in Traumatic Brain Injury (IMPACT) scores to patients treated with midazolam, but lower Injury Severity Score (ISS) (median, 26 [IQR, 22-38] v 34 [IQR, 26-44]; P = 0.001). The use of propofol was more common in heavier patients, and midazolam use was strongly associated with opioid co-administration (OR, 12.9; 95% CI, 3.47-47.95; P < 0.001). Sixty-day mortality and hospital mortality were predicted by a higher IMPACT score (P < 0.001) and a higher ISS (P < 0.001), but, after adjustment, were not related to the choice of sedative agent. Conclusions: Propofol was used more often than midazolam, and large doses were common for both sedatives. The first choice was highly variable, was affected by injury severity, and was not independently associated with 60-day mortality.
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Affiliation(s)
- Giovanni Russo
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Anatole Harrois
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kr emlin Bicêtre, France
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Mathieu Van Der Jagt
- Department of Intensive Care for Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
| | - Fabio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Andrew Udy
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Giuseppe Citerio
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerar do Hospital, ASST-Monza, Monza, Italy
| | - Jacques Duranteau
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kr emlin Bicêtre, France
| | - Carole Ichai
- Université Côte d’Azur, Center Hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2, Nice, France
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
| | - John Prowle
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
| | - Ari Ercole
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation T rust, Cambridge, United Kingdom
| | - Mauro Oddo
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Antoine Schneider
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
| | - Stefan Wolf
- Department of Neur osurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Berlin, Germany
| | - Raimund Helbok
- Department of Neur ology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - David Nelson
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
| | - Jamie Cooper
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - For the TBI Collaborative Investigators
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Anesthesia and Surgical Intensive Care, CHU de Bicetre, Le Kr emlin Bicêtre, France
- Department of Intensive Care for Adults, Erasmus MC-University Medical Center, Rotterdam, The Netherlands
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
- Intensive Care Unit, Alfred Hospital, Melbourne, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- School of Medicine and Surgery, University Milano Bicocca-Neurointensive Care, San Gerar do Hospital, ASST-Monza, Monza, Italy
- Université Côte d’Azur, Center Hospitalier Universitaire de Nice, Service de Réanimation polyvalente, Hôpital Pasteur 2, Nice, France
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, University of Valencia, Valencia, Spain
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom
- Neurosciences and Trauma Critical Care Unit, Cambridge University Hospitals NHS Foundation T rust, Cambridge, United Kingdom
- Department of Medical-Surgical Intensive Care Medicine, Faculty of Biology and Medicine, Center Hospitalier Universitaire, Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
- Department of Neur osurgery, Charité Universitätsmedizin Neuro Intensive Care Unit 102i, Berlin, Germany
- Department of Neur ology, Neurocritical Care Unit, Medical University of Innsbruck, Innsbruck, Austria
- Section for Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden
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8
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Anstey J, Jensen T, Lalani F, Conner SM. Teaching the Teachers: A Flexible, Cognitive-Focused Curriculum in Point-of-Care Ultrasound Education for Hospital Medicine Faculty. J Ultrasound Med 2022; 41:3103-3111. [PMID: 36063066 DOI: 10.1002/jum.16091] [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] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 07/08/2022] [Accepted: 08/10/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVES We aimed to decrease barriers to acquiring Point-of-Care Ultrasound (POCUS) knowledge among attending physicians and improve the safety of trainee POCUS use through a novel flexible and cognitive based curriculum. METHODS We developed three educational pathways using varied approaches to educational delivery: a novel and asynchronous cognitive curriculum to allow Educational Supervision, a hands-on pathway for Limited Practice, and a more robust pathway for Independent Practice and credentialing. RESULTS From November 2018 through June 2021, 102 of 116 hospitalists engaged in some portion of the curriculum. Twenty-four completed the Educational Supervision pathway, 31 completed the Limited Practice pathway, and 17 enrolled in the Independent Practice pathway with three achieving independent practice. Faculty who completed the Educational Supervision pathway had improved scores on a comprehensive POCUS knowledge assessment, 43.5% [95% Confidence Interval (CI) 38.2-48.8] versus 72.0% [95% CI 65.2-78.8], P < .001. Junior faculty were more likely to engage in the supervision pathway and senior faculty were more likely to complete an intensive course to complete the Limited Practice pathway. CONCLUSIONS A flexible, cognitive focused POCUS curriculum was effective in creating high levels of engagement, and a cognitive only curriculum resulted in significant improvement in hospitalists' POCUS knowledge without hands on training. Finally, we found that hospitalist engagement in the curriculum did not follow the lowest barrier to entry or time commitment and engagement varied by time in practice. Training faculty to independent practice remains a substantial challenge.
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Affiliation(s)
- James Anstey
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
- Department of Medicine, Division of Hospital Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Trevor Jensen
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
| | - Farhan Lalani
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
- Department of Medicine, Division of Hospital Medicine, University of Texas Southwestern, Dallas, Texas, USA
| | - Stephanie McCarty Conner
- Department of Medicine, Division of Hospital Medicine, University of California, San Francisco, California, USA
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9
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Poole AP, Finnis ME, Anstey J, Bellomo R, Bihari S, Birardar V, Doherty S, Eastwood G, Finfer S, French CJ, Heller S, Horowitz M, Kar P, Kruger PS, Maiden MJ, Mårtensson J, McArthur CJ, McGuinness SP, Secombe PJ, Tobin AE, Udy AA, Young PJ, Deane AM. The Effect of a Liberal Approach to Glucose Control in Critically Ill Patients with Type 2 Diabetes: A multicenter, parallel-group, open-label, randomized clinical trial. Am J Respir Crit Care Med 2022; 206:874-882. [PMID: 35608484 DOI: 10.1164/rccm.202202-0329oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale Blood glucose concentrations affect outcomes in critically ill patients but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objective To evaluate the effects of a 'liberal' approach to targeted blood glucose range during intensive care unit (ICU) admission. Methods This mutlicenter, parallel-group, open-label, randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dL and titrated to a target range of 180 to 252 mg/dL. In the comparator group insulin was commenced at a blood glucose >180 mg/dL and titrated to a target range of 108 to 180 mg/dL. The primary outcome was incident hypoglycemia (<72 mg/dL). Secondary outcomes included glucose metrics and clinical outcomes. Main Results At least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio: 0.21 (95% CI, 0.09 to 0.49); P<0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability and less relative hypoglycaemia (P<0.001 for all comparisons). By day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference 4.6 percentage points (95%CI, -3.9 to 13.2%); P=0.29). Conclusions A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registration available at www.anzctr.org.au, ID: ACTRN12616001135404.
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Affiliation(s)
- Alexis P Poole
- The University of Adelaide Discipline of Acute Care Medicine, 242032, Adelaide, South Australia, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Adelaide, Australia.,Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Mark E Finnis
- Royal Adelaide Hospital, Department of Critical Care Services, Adelaide, South Australia, Australia.,University of Adelaide, Discipline of Acute Care Medicine, Adelaide, South Australia, Australia
| | - James Anstey
- Saint Vincent's Hospital Melbourne, 60078, Department of Intensive Care, Fitzroy, Victoria, Australia
| | | | - Shailesh Bihari
- Flinders Medical Centre and Flinders University, Department of Intensive Care Medicine, Bedford park, South Australia, Australia
| | - Vishwanath Birardar
- The University of Adelaide Discipline of Acute Care Medicine, 242032, Adelaide, South Australia, Australia.,Lyell McEwin Hospital, 3187, Intensive Care Unit, Elizabeth Vale, South Australia, Australia
| | - Sarah Doherty
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Glenn Eastwood
- Austin hospital, Intensive care unit, Heidelgerg, Victoria, Australia
| | - Simon Finfer
- University of Sydney, Intensive Care, St. Leonards, New South Wales, Australia
| | - Craig J French
- Western Health, Victoria, Intensive Care Unit, Melbourne, Victoria, Australia
| | - Simon Heller
- Clinical Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, United Kingdom of Great Britain and Northern Ireland
| | - Michael Horowitz
- The University of Adelaide Adelaide Medical School, 110466, Centre of Research Excellence in Translating Nutritional Science to Good Health, Adelaide, South Australia, Australia
| | - Palash Kar
- The University of Adelaide Discipline of Acute Care Medicine, 242032, Adelaide, South Australia, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Peter S Kruger
- Princess Alexandra Hospital, Intensive Care Unit, Brisbane, Queensland, Australia.,University of Queensland, Critical Care, Endocrinology and Metabolism Research Unit, Brisbane, Queensland, Australia
| | - Matthew J Maiden
- Royal Adelaide Hospital, Intensive Care Unit, Adelaide, South Australia, Australia.,University of Adelaide, Discipline of Acute Care Medicine, Adelaide, South Australia, Australia
| | - Johan Mårtensson
- Karolinska Institutet Department of Physiology and Pharmacology, 111126, Stockholm, Sweden.,Karolinska University Hospital, 59562, Perioperative Medicine and Intensive Care, Stockholm, Sweden
| | | | - Shay P McGuinness
- Auckland District Health Board, Cardiothoracic and Vascular ICU, Aucklanad, New Zealand
| | - Paul J Secombe
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia.,Department of Intensive Care, Alice Springs Hospital, Alice Springs, Australia
| | - Antony E Tobin
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, Victoria, Australia.,Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
| | - Andrew A Udy
- Monash University, School of Public Health and Preventive Medicine, Melbourne, Victoria, Australia
| | - Paul J Young
- Wellington Hospital, Intensive Care Unit, Wellington, New Zealand.,Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Adam M Deane
- The University of Melbourne, 2281, Centre for Integrated Critical Care , Melbourne, Victoria, Australia.,Royal Melbourne Hospital, 90134, Intensive Care Unit, Melbourne, Victoria, Australia.,Royal Melbourne Hospital, 90134, Department of Medicine, Melbourne, Victoria, Australia;
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10
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McNamara R, Meka S, Anstey J, Fatovich D, Haseler L, Fitzgerald M, Udy A. The Monitoring with Advanced Sensors, Transmission and E-Resuscitation in Traumatic Brain Injury (MASTER-TBI) collaborative: bringing data science to the ICU bedside. CRIT CARE RESUSC 2022; 24:39-42. [PMID: 38046840 PMCID: PMC10692591 DOI: 10.51893/2022.1.oa5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: With the adoption of multimodal neuromonitoring techniques, a large amount of high resolution neurophysiological data is generated during the treatment of patients with moderate to severe traumatic brain injury (m-sTBI) that is available for further analysis. The Monitoring with Advanced Sensors, Transmission and E-Resuscitation in Traumatic Brain Injury (MASTER-TBI) collaborative was formed in 2020 to facilitate analysis of these data. Objective: The MASTER-TBI collaborative curates m-sTBI patient data for the purposes of comparative effectiveness research, machine learning algorithm development, and neuropathophysiological phenomena analysis. Design, setting and participants: The MASTER-TBI collaborative is a multicentre longitudinal cohort study which utilises a novel hybrid cloud platform and other data science-informed techniques to collect and analyse data from patients with m-sTBI in whom both intracranial pressure monitoring and ICM+ (Cambridge Enterprise, Cambridge, UK) neuromonitoring software are utilised. MASTER-TBI enrols patients with m-sTBI from three participating Australian trauma intensive care units (ICUs). Main outcome measures: Captured outcome measures available for analysis include pathophysiological events (intracranial hypertension, cerebral perfusion pressure variations etc), surgical interventions, ICU and hospital length of stay, patient discharge status, and, where available, Glasgow Outcome Score-Extended (GOS-E) at 6 months. Results and conclusion: MASTER-TBI continues to develop data science-informed systems and techniques to maximise the use of captured high resolution m-sTBI patient neuromonitoring data. The highly innovative systems provide a world-class platform which aims to enhance the search for improved m-sTBI care and outcomes. This article provides an overview of the MASTER-TBI project's developed systems and techniques as well as a rationale for the approaches taken.
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Affiliation(s)
- Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA, Australia
- School of Medicine, Curtin University, Perth, WA, Australia
| | - Shiv Meka
- Data Innovation Laboratory, Western Australian Department of Health, Perth, WA, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Daniel Fatovich
- Emergency Medicine, Royal Perth Hospital, University of Western Australia, Perth, WA, Australia
- Centre for Clinical Research in Emergency Medicine, Harry Perkins Institute of Medical Research, Perth, WA, Australia
| | - Luke Haseler
- Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Perth, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Perth, WA, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash, University, Melbourne, VIC, Australia
- Department of Intensive Care, Alfred Health, Melbourne, VIC, Australia
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11
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Abstract
BACKGROUND Machine learning (ML) has captured the attention of many clinicians who may not have formal training in this area but are otherwise increasingly exposed to ML literature that may be relevant to their clinical specialties. ML papers that follow an outcomes-based research format can be assessed using clinical research appraisal frameworks such as PICO (Population, Intervention, Comparison, Outcome). However, the PICO frameworks strain when applied to ML papers that create new ML models, which are akin to diagnostic tests. There is a need for a new framework to help assess such papers. OBJECTIVE We propose a new framework to help clinicians systematically read and evaluate medical ML papers whose aim is to create a new ML model: ML-PICO (Machine Learning, Population, Identification, Crosscheck, Outcomes). We describe how the ML-PICO framework can be applied toward appraising literature describing ML models for health care. CONCLUSION The relevance of ML to practitioners of clinical medicine is steadily increasing with a growing body of literature. Therefore, it is increasingly important for clinicians to be familiar with how to assess and best utilize these tools. In this paper we have described a practical framework on how to read ML papers that create a new ML model (or diagnostic test): ML-PICO. We hope that this can be used by clinicians to better evaluate the quality and utility of ML papers.
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Affiliation(s)
- Xinran Liu
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, United States.,University of California, San Francisco, San Francisco, California, United States
| | - James Anstey
- Division of Hospital Medicine, University of California, San Francisco, San Francisco, California, United States
| | - Ron Li
- Division of Hospital Medicine, Stanford University, Stanford, California, United States
| | - Chethan Sarabu
- doc.ai, Palo Alto, California, United States.,Department of Pediatrics, Stanford University, Stanford, California, United States
| | - Reiri Sono
- University of California, San Francisco, San Francisco, California, United States
| | - Atul J Butte
- Bakar Computational Health Sciences Institute, University of California, San Francisco, San Francisco, California, United States
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12
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Darvall JN, Bellomo R, Bailey M, Anstey J, Pilcher D. Long-term Survival of Critically Ill Patients Stratified According to Pandemic Triage Categories: A Retrospective Cohort Study. Chest 2021; 160:538-548. [PMID: 33711333 PMCID: PMC7941020 DOI: 10.1016/j.chest.2021.03.002] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Background The COVID-19 pandemic has led to unprecedented demand for ICUs, with the need to triage admissions along with the development of ICU triage criteria. However, how these criteria relate to outcomes in patients already admitted to the ICU is unknown, as is the incremental ICU capacity that triage of these patients might create given existing admission practices. Research Question What is the short- and long-term survival of low- vs high-priority patients for ICU admission according to current pandemic triage criteria? Study Design and Methods This study analyzed prospectively collected registry data (2007-2018) in 23 ICUs in Victoria, Australia, with probabilistic linkage with death registries. After excluding elective surgery, admissions were stratified according to existing ICU triage protocol prioritization as low (age ≥ 85 years, or severe chronic illness, or Sequential Organ Failure Assessment [SOFA] score = 0 or ≥ 12), medium (SOFA score = 8-11) or high (SOFA score = 1-7) priority. The primary outcome was long-term survival. Secondary outcomes were in-hospital mortality, ICU length of stay (LOS) and bed-day usage. Results This study examined 126,687 ICU admissions. After 5 years of follow-up, 1,093 of 3,296 (33%; 95% CI, 32-34) of “low-priority” patients aged ≥ 85 years or with severe chronic illness and 86 of 332 (26%; 95% CI, 24-28) with a SOFA score ≥ 12 were still alive. Sixty-three of 290 (22%; 95% CI, 17-27) of patients in these groups followed up for 10 years were still alive. Together, low-priority patients accounted for 27% of all ICU bed-days and had lower in-hospital mortality (22%) than the high-priority patients (28%). Among nonsurvivors, low-priority admissions had shorter ICU LOS than medium- or high-priority admissions. Interpretation Current SOFA score or age or severe comorbidity-based ICU pandemic triage protocols exclude patients with a close to 80% hospital survival, a > 30% five-year survival, and 27% of ICU bed-day use. These findings imply the need for stronger evidence-based ICU triage protocols.
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Affiliation(s)
- Jai N Darvall
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Data Analytics Research & Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - David Pilcher
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Department of Intensive Care, Alfred Hospital, Melbourne, VIC, Australia; Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC, Australia
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13
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Yi G, Deane AM, Ankravs M, Sharrock L, Anstey J, Abdelhamid YA. A fixed dose approach to thrombosis chemoprophylaxis may be inadequate in heavier critically ill patients. CRIT CARE RESUSC 2021; 23:94-102. [PMID: 38046388 PMCID: PMC10692573 DOI: 10.51893/2021.1.oa9] [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: Overweight patients are at greater risk of venous thromboembolism. We aimed to describe prescribing patterns of thrombosis chemoprophylaxis in critically ill patients weighing ≥ 100 kg and quantify the effectiveness of these regimens using the surrogate biomarker of plasma anti-Xa level. Design, setting and patients: A prospective single-centre cohort study was conducted over a 6-month period. Patients weighing ≥ 100 kg who were prescribed enoxaparin for chemoprophylaxis and expected to remain in the intensive care unit for > 48 hours were eligible. Anti-Xa levels were measured once a patient had received at least three consecutive doses of enoxaparin. Peak levels were measured 4-6 hours after the third dose and trough levels were measured before the fourth dose. Anti-Xa levels were compared with established target ranges for peak and trough anti-Xa levels (0.2-0.5 IU/mL and > 0.1 IU/mL, respectively). Results: Eighty-eight patients met the eligibility criteria, and anti-Xa levels for 42 patients were obtained. Fixed dose chemoprophylaxis approaches varied considerably, with 40 mg once daily (54/88 [61%]) and 40 mg twice daily (20/88 [23%]) being the most frequently prescribed regimens. No patient had a peak anti-Xa level > 0.5 IU/mL. When comparing 40 mg once daily versus twice daily, the once daily regimen had lower median trough levels (0.01 IU/mL [interquartile range (IQR), 0.00-0.04] v 0.09 IU/mL [IQR, 0.05-0.13]; P < 0.001) and greater proportions of patients with levels below the established range (< 0.1 IU/mL) (15/16 [95%] v 7/14 [50%]; P = 0.002) and levels that were undetectable (0.00 IU/mL) (8/16 [50%] v 1/14 [7%]; P = 0.01). Conclusions: At a single centre, thrombosis chemoprophylaxis prescribing patterns for heavier critically ill patients varied considerably. Current fixed dose approaches may be inadequate in this cohort.
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Affiliation(s)
- George Yi
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Adam M. Deane
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
| | - Melissa Ankravs
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
- Pharmacy Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Lucy Sharrock
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Pharmacy Department, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
| | - Yasmine Ali Abdelhamid
- Intensive Care Unit, Royal Melbourne Hospital, Melbourne, VIC, Australia
- The University of Melbourne, Melbourne Medical School, Department of Critical Care, Melbourne, VIC, Australia
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14
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Litton E, Atkinson H, Anstey J, Anstey M, Campbell LT, Forbes A, Hahn R, Hooper K, Kasza J, Knapp S, McGain F, Ngyuen N, Pilcher D, Reddi B, Reid C, Robinson S, Thompson K, Webb S, Young P. Optimising a targeted test reduction intervention for patients admitted to the intensive care unit: The Targeted Intensive Care Test Ordering Cluster Trial intervention. Aust Crit Care 2021; 34:419-426. [PMID: 33526330 DOI: 10.1016/j.aucc.2020.11.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Revised: 11/03/2020] [Accepted: 11/15/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Approaches to routine diagnostic testing in the intensive care unit include time-scheduled testing and targeted testing. Blood tests and chest radiographs requested on a routine, time-scheduled basis may reduce the risk of missing important findings. Targeted testing, considering individual patient needs, may reduce unnecessary testing, wasted clinician time, and costs. However, existing evidence of targeted testing interventions is generally of low quality, and the optimal testing approach is uncertain. OBJECTIVES The aim of the study was to describe the development of an intervention to reduce unnecessary diagnostic test ordering by clinicians working in intensive care, with the aim of informing the design of a pivotal clinical trial. METHODS The Capability, Opportunity, Motivation-Behaviour model was used as a theoretical framework for change. The intervention components were informed by systematically identifying, assessing, and classifying targeted testing interventions in behavioural terms. Feedback from intensive care clinicians and patients was sought using surveys and a consumer reference group. RESULTS The mean percentage of routine tests considered unnecessary by 201 intensive care clinicians was 33 (standard deviation = 16). When presented with a statement of the pros and cons for targeted versus liberal testing (n = 154), 93 (60%) consumer survey respondents preferred a more liberal approach, 33 (21%) preferred a more restrictive approach, and 28 (18%) were unsure. There were 24 behavioural interventions identified and incorporated into the final intervention. This had five major components: (i) a management committee to acquire, disseminate, and coordinate intervention-related information, (ii) a targeted testing guideline for sites, (iii) educational material for sites, (iv) site medical and nursing champions, and (v) site audit and feedback. CONCLUSIONS Although surveyed intensive care clinicians report substantial unnecessary routine diagnostic testing, on the basis of currently available evidence, consumers prefer a more liberal approach. This feedback, and a framework to identify behavioural interventions, has been used to inform the design of a proposed targeted testing clinical trial.
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Affiliation(s)
- Edward Litton
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia.
| | - Helen Atkinson
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - James Anstey
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Matthew Anstey
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Lewis T Campbell
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Andrew Forbes
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Rebecca Hahn
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Katherine Hooper
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Jessica Kasza
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Sharon Knapp
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Forbes McGain
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Nhi Ngyuen
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - David Pilcher
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Benjamin Reddi
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Chris Reid
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Suzanne Robinson
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Kelly Thompson
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Steve Webb
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
| | - Paul Young
- Intensive Care Unit, Fiona Stanley Hospital, Robin Warren Drive, Murdoch, Western Australia, 6150, Australia
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15
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Udy AA, Finnis M, Cohen J, Delaney A, Anstey J, Anstey M, Barge D, Bhardwa V, Board J, Brinkerhoff G, Fitzgerald E, Flower O, Healey PM, Hunt A, Lawrence C, Mehrtens J, Newby L, Pearson D, Raith EP, Robertson Y, Schweikert S, Starr T, Tallott M, van der Poll A, Young P, Bellomo R, Cooper DJ. Erratum to “Six-month mortality and functional outcomes in aneurysmal sub-arachnoid haemorrhage patients admitted to intensive care units in Australia and New Zealand: A prospective cohort study” [J. Clin. Neurosci. 80 (2020) 92–99]. J Clin Neurosci 2020; 82:192. [DOI: 10.1016/j.jocn.2020.11.018] [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: 11/30/2022]
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16
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Affiliation(s)
- Fernando G Zampieri
- HCor Research Institute, Rua Abílio Soares 250, 12th floor, São Paulo, Brazil.
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, VIC, Australia
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17
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Hu X, Li X, Boggett S, Yang Y, Chun-Ting W, Anstey J, Royse A, Royse C. Routine Intraoperative Inhaled Milrinone and Iloprost Reduces Inotrope Use in Patients Undergoing Cardiac Surgery: A Retrospective Cohort Pilot Study. Anesth Analg 2020; 131:527-536. [PMID: 32371741 DOI: 10.1213/ane.0000000000004793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Catecholamine inotropes are frequently used after cardiopulmonary bypass (CPB) but may have undesirable effects. The aim was to identify whether the routine use of inhaled pulmonary vasodilators might reduce the requirement for inotrope drugs after cardiac surgery. METHODS Retrospective cohort study of sequential patients undergoing cardiac surgery at the Royal Melbourne Hospital performed by a single surgeon and anesthesia care team, within 14 months before and after routine implementation of inhaled pulmonary vasodilators, August 2017. Milrinone 4 mg and iloprost 20 µg were inhaled using a vibrating mesh nebulizer (Aerogen) before initiation of CPB and at chest closure. Other aspects of clinical management were unaltered over the time period. Two investigators blinded to each other extracted data from electronic and written medical records. The primary outcome was any use of inotropes in the perioperative period; a Fisher exact test was used to analyze any differences between the 2 groups. Demographic data, hemodynamic data, and use of inotropes and vasopressors were collected from induction of anesthesia to 36 hours postoperative in the intensive care unit (ICU). Hospital and ICU length of stay, cost, and complications were collected. RESULTS Any use of inotropes was significantly lower with inhaled pulmonary dilators (62.5% vs 86.8%, odds ratio [95% confidence interval {CI}], 0.253 (0.083-0.764); P = .011), including intraoperative inotrope use (37.5% vs 86.8%, odds ratio [95% CI], 0.091 (0.03-0.275); P < .001). ICU length of stay was significantly lower with inhaled pulmonary dilators (45 hours, interquartile range [IQR], 27-65 vs 50 hours, IQR, 45-74; P = .026). There were no significant differences among major postoperative complications or costs between groups. CONCLUSIONS Routine use of inhaled milrinone 4 mg and iloprost 20 µg before and after CPB is associated with reduced postoperative inotrope use.
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Affiliation(s)
- Xiaobo Hu
- From the Department of Intensive Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China.,Department of Intensive Care Medicine, Western Health, Melbourne, Victoria, Australia.,Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Xiaoqiang Li
- Department of Anaesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Stuart Boggett
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Yang Yang
- Department of Intensive Care Medicine, Western Health, Melbourne, Victoria, Australia.,Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia
| | - Wang Chun-Ting
- From the Department of Intensive Care Medicine, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, China
| | - James Anstey
- Department of Intensive Care Medicine, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Alistair Royse
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Departments of Surgery
| | - Colin Royse
- Department of Surgery, University of Melbourne, Melbourne, Victoria, Australia.,Anesthesia and Pain Management, Royal Melbourne Hospital, Parkville, Victoria, Australia.,Outcomes Research Consortium, Cleveland Clinic, Cleveland, Ohio
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18
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Poole AP, Finnis ME, Anstey J, Bellomo R, Bihari S, Biradar V, Doherty S, Eastwood G, Finfer S, French CJ, Ghosh A, Heller S, Horowitz M, Kar P, Kruger PS, Maiden MJ, Mårtensson J, McArthur CJ, McGuinness SP, Secombe PJ, Tobin AE, Udy AA, Young PJ, Deane AM. Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial. CRIT CARE RESUSC 2020; 22:133-141. [PMID: 32389105 PMCID: PMC10692470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes. OBJECTIVE To detail the protocol, analysis and reporting plans for a randomised clinical trial - the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial - which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0-14.0 mmol/L) or usual care (target 6.0-10.0 mmol/L). MAIN OUTCOME MEASURES The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes. RESULTS AND CONCLUSION The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised. TRIAL REGISTRATION This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.
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Affiliation(s)
- Alexis P Poole
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia.
| | - Mark E Finnis
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Shailesh Bihari
- Department of Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, SA, Australia
| | - Vishwanath Biradar
- Department of Intensive Care, Lyell McEwin Hospital, Adelaide, SA, Australia
| | - Sarah Doherty
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Glenn Eastwood
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia
| | - Simon Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
| | - Craig J French
- Department of Intensive Care, Western Health, Melbourne, VIC, Australia
| | - Angaj Ghosh
- Intensive Care Unit, Northern Health, Melbourne, VIC, Australia
| | - Simon Heller
- Clinical Diabetes, Endocrinology and Metabolism, University of Sheffield, Sheffield, United Kingdom
| | - Michael Horowitz
- Endocrine and Metabolic Unit, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Peter S Kruger
- Department of Intensive Care, Princess Alexandra Hospital, Brisbane, QLD, Australia
| | - Matthew J Maiden
- Discipline of Acute Care Medicine, University of Adelaide, Adelaide, SA, Australia
| | - Johan Mårtensson
- Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Solna, Sweden
| | - Colin J McArthur
- Department of Critical Care Medicine, Auckland District Health Board, Auckland, New Zealand
| | - Shay P McGuinness
- Cardiothoracic and Vascular Intensive Care and High Dependency Unit, Auckland District Health Board, Auckland, New Zealand
| | - Paul J Secombe
- Department of Intensive Care, Alice Springs Hospital, Alice Springs, NT, Australia
| | - Antony E Tobin
- Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, VIC, Australia
| | - Andrew A Udy
- Department of Intensive Care, The Alfred Hospital, Melbourne, VIC, Australia
| | - Paul J Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.
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19
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Poole AP, Finnis ME, Anstey J, Bellomo R, Bihari S, Biradar V, Doherty S, Eastwood G, Finfer S, French CJ, Ghosh A, Heller S, Horowitz M, Kar P, Kruger PS, Maiden MJ, Mårtensson J, McArthur CJ, McGuinness SP, Secombe PJ, Tobin AE, Udy AA, Young PJ, Deane AM. Study protocol and statistical analysis plan for the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial. CRIT CARE RESUSC 2020. [DOI: 10.51893/2020.2.oa3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes. OBJECTIVE: To detail the protocol, analysis and reporting plans for a randomised clinical trial — the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial — which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION: A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0–14.0 mmol/L) or usual care (target 6.0–10.0 mmol/L). MAIN OUTCOME MEASURES: The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes. RESULTS AND CONCLUSION: The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised. TRIAL REGISTRATION: This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.
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20
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Costello C, Basseal JM, Yang Y, Anstey J, Yastrebov K. Prevention of pathogen transmission during ultrasound use in the Intensive Care Unit: Recommendations from the College of Intensive Care Medicine Ultrasound Special Interest Group (USIG). Australas J Ultrasound Med 2020; 23:103-110. [PMID: 34760589 PMCID: PMC8411769 DOI: 10.1002/ajum.12205] [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] [Indexed: 12/15/2022] Open
Abstract
ICU ultrasonography constitutes important part of modern car patient care. Current standards and practice of infection control and prevention are inadequate. This purpose of this document is to adapt and expand the 2017 Australasian Society for Ultrasound in Medicine (ASUM) and the Australasian College for Infection Prevention Control (ACIPC) guidelines on minimum standards for reprocessing/cleaning of ultrasound transducers to the specifics of intensive care medicine and provide advice to the ICU practitioners and health care administrators. It considers the medical, administrative, financial and practical controversies surrounding implementation, and addresses emerging issues of care for patients with confirmed or suspected Corona Virus Disease 2019 (COVID-19).
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Affiliation(s)
| | - Jocelyne M Basseal
- Discipline of Infectious Diseases & ImmunologyFaculty of Health and MedicineThe University of SydneySydneyNew South WalesAustralia
| | - Yang Yang
- Department of SurgeryUniversity of MelbourneAustralia Monash UniversityEastern Clinical SchoolMelbourneVictoriaAustralia
| | - James Anstey
- Royal Melbourne HospitalParkvilleVictoriaAustralia
| | - Konstantin Yastrebov
- St George HospitalPrince of Wales HospitalUniversity of New South WalesSydneyNew South WalesAustralia
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21
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Yang Y, Anstey J, Yastrebov K, Nanjayya VB, Orde S, Nalos M, Costello C, Ryan NPG. COVID-US: A simplified approach to cardiopulmonary ultrasound in suspected and confirmed COVID-19 patients in surge crisis. Australas J Ultrasound Med 2020; 23:96-102. [PMID: 32514320 PMCID: PMC7267540 DOI: 10.1002/ajum.12209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 04/15/2020] [Accepted: 04/16/2020] [Indexed: 01/12/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (COVID-19) pandemic has placed an unprecedented challenge on healthcare systems across the globe. Rapid assessment of the cardiorespiratory function to monitor disease progression and guide treatment is essential. Therefore, we have designed the COVID-US: a simplified cardiopulmonary ultrasound approach to use in suspected and confirmed COVID-19 patients, to aid front-line health workers in their decision-making in a surge crisis.
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Affiliation(s)
- Yang Yang
- Intensive Care UnitWestern Health160 Gordon StFootscray3011VictoriaAustralia
- Intensive Care UnitBox Hill Hospital,Eastern clinical school, Monash University8 Arnold StBox Hill3128VictoriaAustralia
| | - James Anstey
- Intensive Care UnitRoyal Melbourne Hospital300 Grattan Street (corner of Royal Parade)Parkville3050.VictoriaAustralia
| | - Konstantin Yastrebov
- Intensive Care UnitPrinces of Wales Hospital320-346 Barker StRandwick2031New South WalesAustralia
- University of New South WalesSydney2052New South WalesAustralia
| | | | - Sam Orde
- Intensive Care UnitNepean HospitalKingswood, Penrith2747New South WalesAustralia
| | - Marek Nalos
- Intensive Care MedicineNepean HospitalKingswood, Penrith2747New South WalesAustralia
| | - Cartan Costello
- Intensive Care UnitWollongong HospitalWollongongNew South WalesAustralia
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22
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Anstey J, Lucas BP. Worry Loves Company, but Unnecessary Consultations May Harm the Patients We Comanage. J Hosp Med 2020; 15:60-61. [PMID: 31869302 PMCID: PMC6932593 DOI: 10.12788/jhm.3304] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/09/2019] [Accepted: 08/09/2019] [Indexed: 11/20/2022]
Affiliation(s)
- James Anstey
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, California
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
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23
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de Tymowski C, Pallado S, Anstey J, Depret F, Moreno N, Benyamina M, Cupaciu A, Jully M, Oueslati H, Fratani A, Coutrot M, Chaussard M, Guillemet L, Dudoignon E, Mimoun M, Chaouat M, Mebazaa A, Legrand M, Soussi S. Early hypoalbuminemia is associated with 28-day mortality in severely burned patients: A retrospective cohort study. Burns 2019; 46:630-638. [PMID: 31629616 DOI: 10.1016/j.burns.2019.09.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 09/06/2019] [Accepted: 09/20/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Hypoalbuminemia is a frequent condition in the first 24 h after a severe burn injury and is associated with worse outcomes. METHODOLOGY We investigated the relation between very early hypoalbuminemia (<6 h after admission) and clinical outcome in a retrospective cohort admitted to our unit for severe burn injuries between 2012 and 2017. RESULTS 73 severely burned patients were included, with a delay of admission of 3 (2-4) h. In a context of early exogenous supply of albumin, admission and 4H Albuminemia (Alb4 h) were significantly lower in deceased patients (respectively, 34 (29-37) vs 27 (23-30) g/l; p = 0.009 and 27 (24-32) vs 21 (17-27) g/l; p = 0.022) whereas albuminemia ≥6 h were not. The best threshold value of Alb4 h to discriminate 28-day mortality was 23 g/l. Patients with an Alb4 h < 23 g/l had a higher 28-day mortality than patients with an Alb4 h ≥ 23 g/l (42% vs 11%; p = 0.003); adjusted OR = 4.47 (95% CI 1.15-17.36); p = 0.03. CONCLUSION In severely burned patients receiving early albumin supply, early hypoalbuminemia is associated with higher mortality whereas later albuminemia (≥6 h) is not. Exploration of whether early albumin infusion (8-12 h post injury) may alter clinical outcome is warranted.
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Affiliation(s)
- Christian de Tymowski
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; INSERM U1149, Centre de Recherche sur l'Inflammation CRI, Paris, France; Laboratoire d'Excellence (Labex) Inflammex, ComUE Sorbonne Paris Cité, Paris, France.
| | - Simon Pallado
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France.
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Melbourne, Australia.
| | - François Depret
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
| | - Nabilla Moreno
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Biochemistry laboratory, Paris, France.
| | - Mourad Benyamina
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France.
| | - Alexandru Cupaciu
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Marion Jully
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Haikel Oueslati
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Alexandre Fratani
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maxime Coutrot
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maité Chaussard
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Lucie Guillemet
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Emmanuel Dudoignon
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France
| | - Maurice Mimoun
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Plastic Surgery and Burn Unit, Paris, France
| | - Marc Chaouat
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Hôpitaux de Paris (AP-HP), Groupe Hospitalier St Louis-Lariboisière, Plastic Surgery and Burn Unit, Paris, France
| | - Alexandre Mebazaa
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
| | - Matthieu Legrand
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
| | - Sabri Soussi
- Hôpitaux de Paris (AP-HP), Groupe Hospitalier St-Louis-Lariboisière, Department of Anesthesiology and Critical Care and Burn Unit, Paris, France; University Paris Diderot, Paris, France; Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Lariboisière Hospital, Paris, France.
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Hay T, Deane AM, Rechnitzer T, Fetterplace K, Reilly R, Ankravs M, Bailey M, Fazio T, Anstey J, D’Costa R, Presneill JJ, MacIsaac CM, Bellomo R. The hospital-based evaluation of laxative prophylaxis in ICU (HELP-ICU): A pilot cluster-crossover randomized clinical trial. J Crit Care 2019; 52:86-91. [DOI: 10.1016/j.jcrc.2019.04.010] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2019] [Revised: 04/04/2019] [Accepted: 04/05/2019] [Indexed: 12/19/2022]
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Wigmore G, Anstey J, Deane A, Bellomo R. HAS FLAIR Investigators Reply to Fluid Resuscitation After Cardiac Surgery: The Quest for the Ideal Fluid. J Cardiothorac Vasc Anesth 2019; 33:3218-3219. [PMID: 31358439 DOI: 10.1053/j.jvca.2019.06.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 06/16/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Geoffrey Wigmore
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Adam Deane
- University of Melbourne, Department of Medicine, Royal Melbourne Hospital, Parkville, Australia
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, The Alfred Centre, Melbourne, Victoria, Australia; Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
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26
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Affiliation(s)
- James Anstey
- Division of Hospital Medicine, Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Brian P Lucas
- Medicine Service, White River Junction VA Medical Center, White River Junction, Vermont
- Geisel School of Medicine at Dartmouth College, Hanover, New Hampshire
- The Dartmouth Institute for Health Policy & Clinical Practice, Hanover, New Hampshire
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27
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Al-Bassam W, Dade F, Bailey M, Eastwood G, Osawa E, Eyeington C, Anstey J, Yi G, Ralph J, Kakho N, Kurup V, Licari E, King EC, Knott C, Chimunda T, Smith J, Subramaniam A, Reddy M, Green C, Parkin G, Shehabi Y, Bellomo R. "Likely overassistance" during invasive pressure support ventilation in patients in the intensive care unit: a multicentre prospective observational study. CRIT CARE RESUSC 2019; 21:18-24. [PMID: 30857508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVE To evaluate the prevalence of "likely overassistance" (categorised by respiratory rate [RR] ≤ 17 breaths/min or rapid shallow breathing index [RSBI] ≤ 37 breaths/min/L) during invasive pressure support ventilation (PSV), and the additional prevalence of fixed ventilator settings. DESIGN Multicentre prospective observational study of invasive PSV practice in six general Victorian intensive care units with blinding of staff members to data collection. PATIENTS At each hospital, investigators collected data between 11 am and 2 pm on all invasive PSV-treated patients on 60 sequential days, excluding weekends and public holidays, between 22 February and 30 August 2017. Each patient was included for maximum of 3 days. MAIN RESULTS We studied 231 patients, with a total of 379 observations episodes over the study period. There were 131 patients (56.7%) with at least one episode of RR ≤ 17 breaths/min; 146 patients (63.2%) with at least one episode of RSBI ≤ 37 breaths/min/L, and 85 patients (36.8%) with at least one episode of combined RR ≤ 17 breaths/min and RSBI ≤ 37 breaths/min/L. Moreover, the total number of observations with "likely overassistance" (RR ≤ 17 or RSBI ≤ 37 breaths/min/L) was 178 (47%) and 204 (53.8%), respectively; while for both combined criteria, it was 154 (40.6%). We also found that 10 cmH2O pressure support was delivered on 210 of the observations (55.4%) and adjusted in less than 25% of observations. Finally, less than half (179 observations) of all PSV-delivered tidal volumes (VT) were at the recommended value of 6-8 mL/kg predicted body weight (PBW) and more than 20% (79 observations) were at ≥ 10 mL/kg PBW. CONCLUSION In a cohort of Victorian hospitals in Australia, during invasive PSV, "likely overassistance" was common, and the pressure support level was delivered in a standardised and unadjusted manner at 10 cmH2O, resulting in the frequent delivery of potentially injurious VT.
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Affiliation(s)
| | - Fabien Dade
- Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Michael Bailey
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | | | | | | | - James Anstey
- Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - George Yi
- Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Jolene Ralph
- Royal Melbourne Hospital, Melbourne, VIC, Australia
| | | | | | | | | | | | | | | | | | | | | | | | | | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
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28
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Dudoignon E, Alanio A, Anstey J, Depret F, Coutrot M, Fratani A, Jully M, Cupaciu A, Chaussard M, Oueslati H, Ferry A, Benyamina M, de Tymowski C, Boccara D, Serror K, Chaouat M, Mimoun M, Lafaurie M, Denis B, Gits-Muselli M, Bretagne S, Mebazaa A, Legrand M, Soussi S. Outcome and potentially modifiable risk factors for candidemia in critically ill burns patients: A matched cohort study. Mycoses 2018; 62:237-246. [PMID: 30478963 DOI: 10.1111/myc.12872] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Revised: 10/26/2018] [Accepted: 11/20/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with extensive burns are at risk of developing candidemia. OBJECTIVES To identify potentially modifiable risk factors and outcomes of candidemia in critically ill burns patients. PATIENTS AND METHODS Retrospective matched cohort study including adult burns patients. Patients who developed candidemia were matched with burns patients with Candida spp colonisation and sepsis or septic shock without candidemia in a ratio of 1:3 (same severity scores and colonisation index). Univariate and multiple regression analyses were performed. RESULTS Of 130 severely burned patients with Candida spp colonisation and at least one episode of sepsis or septic shock, 14 were diagnosed with candidemia. In the candidemia group, patients had a median (IQR) total burns surface area (TBSA) of 57 (38-68)%, SAPSII of 43 (36-58) and ABSI of 11 (8-13). Multiple regression analysis showed that only duration of prior antibiotic therapy was independently associated with candidemia. ICU mortality was higher in the candidemia group (71% vs 35% [P = 0.02]). The log-rank test for 28-day mortality comparing patients with candidemia treated with an empirical strategy vs a curative strategy did not reach significance (P = 0.056). CONCLUSIONS Burns patients having received recent antibiotherapy have a higher risk of candidemia. Antifungal strategies did not influence outcome in this series.
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Affiliation(s)
- Emmanuel Dudoignon
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Alexandre Alanio
- Parasitology and Mycology laboratory, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France.,Molecular mycology unit, Institut Pasteur, CNRS, UMR2000, Paris, France
| | - James Anstey
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | - François Depret
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France
| | - Maxime Coutrot
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France
| | - Alexandre Fratani
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Marion Jully
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Alexandru Cupaciu
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Maïté Chaussard
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Haikel Oueslati
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Axelle Ferry
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Mourad Benyamina
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Christian de Tymowski
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - David Boccara
- Plastic Surgery and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Kevin Serror
- Plastic Surgery and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Marc Chaouat
- Plastic Surgery and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Maurice Mimoun
- Plastic Surgery and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Matthieu Lafaurie
- Department of Infectious Diseases, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Blandine Denis
- Department of Infectious Diseases, AP-HP, Hôpital Saint-Louis, Paris, France
| | - Maud Gits-Muselli
- Parasitology and Mycology laboratory, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France.,Molecular mycology unit, Institut Pasteur, CNRS, UMR2000, Paris, France
| | - Stephane Bretagne
- Parasitology and Mycology laboratory, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France.,Molecular mycology unit, Institut Pasteur, CNRS, UMR2000, Paris, France
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Hôpital Lariboisière, F-CRIN INI-CRCT network, Univ Paris Diderot, Paris, France
| | - Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France.,Université Paris Diderot, Paris, France.,Institut National de la Santé et de la Recherche Médicale (INSERM), UMR INSERM 942, Hôpital Lariboisière, F-CRIN INI-CRCT network, Univ Paris Diderot, Paris, France
| | - Sabri Soussi
- Department of Anesthesiology and Critical Care and Burn Unit, AP-HP, Hôpital Saint-Louis, Paris, France
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Poole AP, Anstey J, Bellomo R, Biradar V, Deane AM, Finfer SR, Finnis ME, French CJ, Kar P, Kruger PS, Maiden MJ, Mårtensson J, McArthur CJ, McGuinness SP, Secombe PJ, Tobin AE, Udy AA, Eastwood GM. Opinions and practices of blood glucose control in critically ill patients with pre-existing type 2 diabetes in Australian and New Zealand intensive care units. Aust Crit Care 2018; 32:361-365. [PMID: 30348487 DOI: 10.1016/j.aucc.2018.09.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 09/05/2018] [Accepted: 09/05/2018] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Approximately 9000 patients with type-2 diabetes mellitus (T2DM) are admitted to an intensive care unit (ICU) in Australia and New Zealand annually. For these patients, recent exploratory data suggest that targeting a more liberal blood glucose range during ICU admission may be safe and potentially beneficial. However, the current approach to blood glucose management of patients with T2DM in Australia and New Zealand ICUs is not well described, and there is uncertainty about clinician equipoise for trials of liberal glycaemic control in these patients. AIM The aim is to describe self-reported blood glucose management in patients with T2DM by intensivists working in Australian and New Zealand ICUs and to establish whether equipoise exists for a trial of liberal versus standard glycaemic control in such patients. METHOD An online questionnaire of Australia and New Zealand intensivists conducted in July-September 2016. RESULTS Seventy-one intensivists responded. Forty-five (63%) used a basic nomogram to titrate insulin. Sixty-six (93%) reported that insulin was commenced at blood glucose concentrations >10 mmol/L and titrated to achieve a blood glucose concentration between 6.0 and 10.0 mmol/L. A majority of respondents (75%) indicated that there was insufficient evidence to define optimal blood glucose targets in patients with T2DM, and 59 (83%) were prepared to enrol such patients in a clinical trial to evaluate a more liberal approach. CONCLUSION A majority of respondents were uncertain about the optimal blood glucose target range for patients with T2DM and would enrol such patients in a comparative trial of conventional versus liberal blood glucose control.
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Affiliation(s)
- Alexis P Poole
- Discipline of Acute Care Medicine, University of Adelaide, Australia; Department of Intensive Care, Royal Adelaide Hospital, Australia.
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, Australia
| | | | | | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, Australia
| | - Simon R Finfer
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Mark E Finnis
- Department of Intensive Care, Royal Adelaide Hospital, Australia
| | | | - Palash Kar
- Discipline of Acute Care Medicine, University of Adelaide, Australia; Department of Intensive Care, Royal Adelaide Hospital, Australia
| | - Peter S Kruger
- Department of Intensive Care, Princess Alexandra Hospital, Australia; School of Medicine, University of Queensland, Australia
| | | | | | - Colin J McArthur
- Department of Critical Care Medicine, Auckland District Health Board, Australia
| | - Shay P McGuinness
- Cardiothoracic and Vascular Intensive Care and High Dependency Unit, Auckland District Health Board, Australia
| | - Paul J Secombe
- Department of Intensive Care, Alice Springs Hospital, Australia
| | - Antony E Tobin
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Australia
| | - Andrew A Udy
- Department of Intensive Care, The Alfred Hospital, Australia
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30
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McNamara R, Deane AM, Anstey J, Bellomo R. Understanding the rationale for parenteral ascorbate (vitamin C) during an acute inflammatory reaction: a biochemical perspective. CRIT CARE RESUSC 2018; 20:174-179. [PMID: 30153778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Robert McNamara
- Department of Intensive Care, Royal Perth Hospital, University of Western Australia, Perth, WA, Australia.
| | - Adam M Deane
- Department of Intensive Care, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
| | - James Anstey
- Department of Intensive Care, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Royal Melbourne Hospital, University of Melbourne, Melbourne, Vic, Australia
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31
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Brunner L, Schaller N, Anstey J, Sillmann J, Steiner AK. Dependence of Present and Future European Temperature Extremes on the Location of Atmospheric Blocking. Geophys Res Lett 2018; 45:6311-6320. [PMID: 30364102 PMCID: PMC6190735 DOI: 10.1029/2018gl077837] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/30/2018] [Accepted: 05/31/2018] [Indexed: 05/18/2023]
Abstract
The impact of atmospheric blocking on European heat waves (HWs) and cold spells (CSs) is investigated for present and future conditions . A 50-member ensemble of the second generation Canadian Earth System Model is used to quantify the role of internal variability in the response to blocking. We find that the present blocking-extreme temperature link is well represented compared to ERA-Interim, despite a significant underestimation of blocking frequency in most ensemble members. Our results show a strong correlation of blocking with northern European HWs in summer, spring, and fall. However, we also find a strong anticorrelation between blocking and HW occurrence in southern Europe in all seasons. Blocking increases the CS frequency particularly in southern Europe in fall, winter, and spring but reduces it in summer. For the future we find that blocking will continue to play an important role in the development of both CSs and HWs in all seasons.
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Affiliation(s)
- Lukas Brunner
- Wegener Center for Climate and
Global ChangeUniversity of GrazGrazAustria
- FWF‐DK Climate
ChangeUniversity of GrazGrazAustria
- Now at Institute for Atmospheric and Climate Science, ETH
ZurichZurichSwitzerland
| | | | - James Anstey
- Canadian Centre for Climate
Modelling and Analysis, Environment and Climate Change CanadaUniversity of VictoriaVictoriaBritish ColumbiaCanada
| | - Jana Sillmann
- Center for International Climate
Research (CICERO)OsloNorway
| | - Andrea K. Steiner
- Wegener Center for Climate and
Global ChangeUniversity of GrazGrazAustria
- FWF‐DK Climate
ChangeUniversity of GrazGrazAustria
- Institute for Geophysics,
Astrophysics, and Meteorology, Institute of PhysicsUniversity of GrazGrazAustria
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32
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Fedi M, Shen SH, Campbell B, Dutschmann M, O’brien T, Anstey J, MacIsaac C. 101 Dispelling the curse: improvement of ventilatory drive in central alveolar hypoventilation syndrome after medullary infarction. J Neurol Neurosurg Psychiatry 2018. [DOI: 10.1136/jnnp-2018-anzan.100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
IntroductionCentral alveolar hypoventilation syndrome (CAHS) is a rare complication of stroke affecting the medullary respiratory centre. CAHS is characterised by impaired ventilatory response to CO2 leading to hypoventilation, hyper-capnoea and coma. Experimental studies have linked this syndrome to areas in the dorsal and ventrolateral medulla. CAHS is associated with long-term invasive ventilatory support, high mortality and morbidity. It is unclear whether sensitivity to CO2 can improve after the initial ischaemic medullary insult.CaseA 78 year old woman presenting with CAHS secondary to a unilateral left posterior inferior cerebellar artery infarction. MRI images confirmed that dorsal and ventrolateral medullary areas were affected. The patient was intubated initially for hyper-capnoeic respiratory failure and required a tracheostomy for ongoing respiratory support. To assess progress of respiratory recovery, we measured the patient’s ventilatory response to PaCO2 at 5, 7, and 14 days of admission. Parameters recorded included PaO2, ETCO2, PaCO2, pH, respiratory rate, and minute ventilation. During this time the patient underwent progressive periods of unsupported ventilation with close monitoring. Statistical correlation between respiratory rate and CO2 was measured by Pearson’s correlation coefficient (R). Her RR initially did not increase with PaCO2 during spontaneous ventilation (R=0.2604 p=0.077). Apnoeic episodes were frequent up to 41 episodes per 30 min of observation lasting up to 30 s. On day 7(R=0.7203 p<0.05) and up to day 14 (R=0.6295 p<0.05), there was a progressive statistically significant improvement in positive correlation between PCO2 and respiratory rate. This was associated with a reduction in apnoeic episodes possibly reflecting a recovery in ventilatory drive.ConclusionThis is the first detailed report demonstrating spontaneous recovery in CO2 responsiveness in the setting of CAHS secondary to unilateral medullary stroke. Plasticity of structures such as the retro-trapezoid nucleus are likely to play a role in recovery of CO2 sensitivity.References. Harper, et al. Functional neuroanatomy and sleep-disordered breathing: implications for autonomic regulation. Anatomical record2012;295(9):1385–95.. Mishina, et al. Efficacy of tracheostomy for central alveolar hypoventilation syndrome caused by lateral medullary infarction. Journal of Nippon Medical School2014;81(4):276–84.
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33
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Simonis FD, Barbas CSV, Artigas-Raventós A, Canet J, Determann RM, Anstey J, Hedenstierna G, Hemmes SNT, Hermans G, Hiesmayr M, Hollmann MW, Jaber S, Martin-Loeches I, Mills GH, Pearse RM, Putensen C, Schmid W, Severgnini P, Smith R, Treschan TA, Tschernko EM, Vidal Melo MF, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ, Neto AS. Potentially modifiable respiratory variables contributing to outcome in ICU patients without ARDS: a secondary analysis of PRoVENT. Ann Intensive Care 2018; 8:39. [PMID: 29564726 PMCID: PMC5862714 DOI: 10.1186/s13613-018-0385-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [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] [Received: 10/30/2017] [Accepted: 03/12/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND The majority of critically ill patients do not suffer from acute respiratory distress syndrome (ARDS). To improve the treatment of these patients, we aimed to identify potentially modifiable factors associated with outcome of these patients. METHODS The PRoVENT was an international, multicenter, prospective cohort study of consecutive patients under invasive mechanical ventilatory support. A predefined secondary analysis was to examine factors associated with mortality. The primary endpoint was all-cause in-hospital mortality. RESULTS 935 Patients were included. In-hospital mortality was 21%. Compared to patients who died, patients who survived had a lower risk of ARDS according to the 'Lung Injury Prediction Score' and received lower maximum airway pressure (Pmax), driving pressure (ΔP), positive end-expiratory pressure, and FiO2 levels. Tidal volume size was similar between the groups. Higher Pmax was a potentially modifiable ventilatory variable associated with in-hospital mortality in multivariable analyses. ΔP was not independently associated with in-hospital mortality, but reliable values for ΔP were available for 343 patients only. Non-modifiable factors associated with in-hospital mortality were older age, presence of immunosuppression, higher non-pulmonary sequential organ failure assessment scores, lower pulse oximetry readings, higher heart rates, and functional dependence. CONCLUSIONS Higher Pmax was independently associated with higher in-hospital mortality in mechanically ventilated critically ill patients under mechanical ventilatory support for reasons other than ARDS. Trial Registration ClinicalTrials.gov (NCT01868321).
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Affiliation(s)
- Fabienne D Simonis
- Department of Intensive Care and Lab. of Experimental Intensive Care and Anesthesiology (L E I C A), Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Carmen S V Barbas
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.,Department of Pulmonology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Antonio Artigas-Raventós
- Department of Intensive Care Medicine and CIBER de Enfermedades Respiratorias, Hospital de Sabadell, Corporació Sanitaria I Universitària Parc Taulí, Sabadell, Spain
| | - Jaume Canet
- Department of Anesthesiology, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
| | | | - James Anstey
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Australia
| | | | - Sabrine N T Hemmes
- Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Greet Hermans
- Medical Intensive Care Unit, Division of General Internal Medicine, University Hospital Leuven, Louvain, Belgium.,Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, and Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Markus W Hollmann
- Department of Anesthesiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Samir Jaber
- Department of Critical Care Medicine and Anesthesiology (SAR B), Saint Eloi University Hospital, Montpellier, France
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, Trinity Centre for Health Sciences, Multidisciplinary Intensive Care Research Organization (MICRO), Welcome Trust, HRB Clinical Research, St James's University Hospital Dublin, Dublin, Ireland.,Irish Centre for Vascular Biology, Irish Centre for Vascular Biology (ICVB), Dublin, Ireland
| | - Gary H Mills
- Department of Anaesthesia and Critical Care Medicine, Sheffield Teaching Hospital, Sheffield, UK
| | - Rupert M Pearse
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division of Cardiac, Thoracic, and Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnologies and Sciences of Life, Insubria University, Varese, Italy
| | - Roger Smith
- Department of Intensive Care, St Vincent's Hospital, Melbourne, Australia
| | - Tanja A Treschan
- Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Edda M Tschernko
- Division of Cardiac, Thoracic, and Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Marcos F Vidal Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, Dresden, Germany.,Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, Ospedale Policlinico per la Oncologia, IRCCS per l'Oncologia, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care and Lab. of Experimental Intensive Care and Anesthesiology (L E I C A), Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Mahidol Oxford Research Unit (MORU), Mahidol University, Bangkok, Thailand
| | - Ary Serpa Neto
- Department of Intensive Care and Lab. of Experimental Intensive Care and Anesthesiology (L E I C A), Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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34
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Neto AS, Barbas CSV, Simonis FD, Artigas-Raventós A, Canet J, Determann RM, Anstey J, Hedenstierna G, Hemmes SNT, Hermans G, Hiesmayr M, Hollmann MW, Jaber S, Martin-Loeches I, Mills GH, Pearse RM, Putensen C, Schmid W, Severgnini P, Smith R, Treschan TA, Tschernko EM, Melo MFV, Wrigge H, de Abreu MG, Pelosi P, Schultz MJ. Epidemiological characteristics, practice of ventilation, and clinical outcome in patients at risk of acute respiratory distress syndrome in intensive care units from 16 countries (PRoVENT): an international, multicentre, prospective study. Lancet Respir Med 2016; 4:882-893. [PMID: 27717861 DOI: 10.1016/s2213-2600(16)30305-8] [Citation(s) in RCA: 110] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/02/2016] [Accepted: 08/04/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Scant information exists about the epidemiological characteristics and outcome of patients in the intensive care unit (ICU) at risk of acute respiratory distress syndrome (ARDS) and how ventilation is managed in these individuals. We aimed to establish the epidemiological characteristics of patients at risk of ARDS, describe ventilation management in this population, and assess outcomes compared with people at no risk of ARDS. METHODS PRoVENT (PRactice of VENTilation in critically ill patients without ARDS at onset of ventilation) is an international, multicentre, prospective study undertaken at 119 ICUs in 16 countries worldwide. All patients aged 18 years or older who were receiving mechanical ventilation in participating ICUs during a 1-week period between January, 2014, and January, 2015, were enrolled into the study. The Lung Injury Prediction Score (LIPS) was used to stratify risk of ARDS, with a score of 4 or higher defining those at risk of ARDS. The primary outcome was the proportion of patients at risk of ARDS. Secondary outcomes included ventilatory management (including tidal volume [VT] expressed as mL/kg predicted bodyweight [PBW], and positive end-expiratory pressure [PEEP] expressed as cm H2O), development of pulmonary complications, and clinical outcomes. The PRoVENT study is registered at ClinicalTrials.gov, NCT01868321. The study has been completed. FINDINGS Of 3023 patients screened for the study, 935 individuals fulfilled the inclusion criteria. Of these critically ill patients, 282 were at risk of ARDS (30%, 95% CI 27-33), representing 0·14 cases per ICU bed over a 1-week period. VT was similar for patients at risk and not at risk of ARDS (median 7·6 mL/kg PBW [IQR 6·7-9·1] vs 7·9 mL/kg PBW [6·8-9·1]; p=0·346). PEEP was higher in patients at risk of ARDS compared with those not at risk (median 6·0 cm H2O [IQR 5·0-8·0] vs 5·0 cm H2O [5·0-7·0]; p<0·0001). The prevalence of ARDS in patients at risk of ARDS was higher than in individuals not at risk of ARDS (19/260 [7%] vs 17/556 [3%]; p=0·004). Compared with individuals not at risk of ARDS, patients at risk of ARDS had higher in-hospital mortality (86/543 [16%] vs 74/232 [32%]; p<0·0001), ICU mortality (62/533 [12%] vs 66/227 [29%]; p<0·0001), and 90-day mortality (109/653 [17%] vs 88/282 [31%]; p<0·0001). VT did not differ between patients who did and did not develop ARDS (p=0·471 for those at risk of ARDS; p=0·323 for those not at risk). INTERPRETATION Around a third of patients receiving mechanical ventilation in the ICU were at risk of ARDS. Pulmonary complications occur frequently in patients at risk of ARDS and their clinical outcome is worse compared with those not at risk of ARDS. There is potential for improvement in the management of patients without ARDS. Further refinements are needed for prediction of ARDS. FUNDING None.
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Affiliation(s)
- Ary Serpa Neto
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, Netherlands; Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil.
| | - Carmen S V Barbas
- Department of Intensive Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil; Department of Pulmonology, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fabienne D Simonis
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, Netherlands
| | - Antonio Artigas-Raventós
- Department of Intensive Care Medicine, Hospital de Sabadell, CIBER de Enfermedades Respiratorias, Corporació Sanitaria I Universitària Parc Taulí, Sabadell, Spain
| | - Jaume Canet
- Department of Anesthesiology, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
| | | | - James Anstey
- Department of Intensive Care, St Vincent's Hospital, Melbourne, VIC, Australia
| | | | - Sabrine N T Hemmes
- Department of Anesthesiology, Academic Medical Center, Amsterdam, Netherlands
| | - Greet Hermans
- Medical Intensive Care Unit, Division of General Internal Medicine, University Hospital Leuven, Leuven, Belgium; Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Leuven, Belgium
| | - Michael Hiesmayr
- Division of Cardiac, Thoracic, and Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Markus W Hollmann
- Department of Anesthesiology, Academic Medical Center, Amsterdam, Netherlands
| | - Samir Jaber
- Department of Critical Care Medicine and Anesthesiology (SAR B), Saint Eloi University Hospital, Montpellier, France
| | - Ignacio Martin-Loeches
- Department of Clinical Medicine, St James's Hospital, Multidisciplinary Intensive Care Research Organization (MICRO), Trinity Centre for Health Sciences, Dublin, Ireland
| | - Gary H Mills
- Department of Anaesthesia and Critical Care Medicine, Sheffield Teaching Hospital, Sheffield, UK
| | - Rupert M Pearse
- Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Werner Schmid
- Division of Cardiac, Thoracic, and Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Paolo Severgnini
- Department of Biotechnologies and Sciences of Life, Insubria University, Varese, Italy
| | - Roger Smith
- Department of Intensive Care, St Vincent's Hospital, Melbourne, VIC, Australia
| | - Tanja A Treschan
- Department of Anaesthesiology, Düsseldorf University Hospital, Düsseldorf, Germany
| | - Edda M Tschernko
- Division of Cardiac, Thoracic, and Vascular Anesthesia and Intensive Care, Medical University Vienna, Vienna, Austria
| | - Marcos F V Melo
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hermann Wrigge
- Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Marcelo Gama de Abreu
- Pulmonary Engineering Group, Department of Anesthesiology and Intensive Care Medicine, University Hospital Carl Gustav Carus, and Technische Universität Dresden, Dresden, Germany
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, IRCCS San Martino IST, University of Genoa, Genoa, Italy
| | - Marcus J Schultz
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology (LEICA), Academic Medical Center, Amsterdam, Netherlands
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Anstey J, Yassaee A, Solomon A. Clinical outcomes of adult inpatients treated with continuous subcutaneous insulin infusion for diabetes mellitus: a systematic review. Diabet Med 2015; 32:1279-88. [PMID: 25763540 DOI: 10.1111/dme.12740] [Citation(s) in RCA: 9] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/10/2015] [Indexed: 01/22/2023]
Abstract
AIMS To provide a systematic review of the current evidence concerning the diabetes-related outcomes of patients provided with continuous subcutaneous insulin infusion for treating diabetes mellitus while a hospital inpatient. METHODS Relevant publications were obtained from MEDLINE and EMBASE databases concerning hospital inpatients with diabetes being treated with continuous subcutaneous insulin infusion. Studies were assessed independently by two reviewers, and data on the following outcomes were extracted: inpatient mortality; clinical complications, e.g. diabetic ketoacidosis; hyperglycaemia; hypoglycaemia; length of hospital stay; mean bedside glucose level; and glucose level on discharge. Obstetric cases were examined separately to look at maternal and neonatal glycaemic outcomes. RESULTS A total of 11 studies met the required criteria and were analysed in detail, 5 of which were predominantly obstetric. No significant complications were reported, with no incidences of death, ketoacidosis or severe hypoglycaemia. Length of hospital stay appeared to be shorter in those patients who remained on continuous subcutaneous insulin infusion, while data on mild hyperglycaemia and hypoglycaemia were inconclusive. CONCLUSIONS There are limited data available to form a significant conclusion about the safety of continuous subcutaneous insulin infusion continuation in hospital; however, its use can be justified with the presence of a specialized inpatient diabetes team for advice and support and an alternative treatment regime (e.g. subcutaneous basal bolus) should be accessible if the need were to arise.
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Affiliation(s)
- J Anstey
- UCL Medical School, University College London
- Royal Free London NHS Foundation Trust, London
| | - A Yassaee
- UCL Medical School, University College London
- Royal Free London NHS Foundation Trust, London
| | - A Solomon
- Royal Free London NHS Foundation Trust, London
- East and North Hertfordshire NHS Trust, Stevenage, UK
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Taccone FS, Crimi E, Anstey J, Infante T, Donadello K, Scolletta S, Al-Omran M, Napoli C. Endothelium and Regulatory Inflammatory Mechanisms During Organ Rejection. Angiology 2013; 65:379-87. [DOI: 10.1177/0003319713485282] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Endothelial integrity is mandatory for physiologic organ function; however, endothelium dysfunction can be caused by systemic inflammation, occurring during sepsis or organ rejection after transplantation. This article will address our current understanding of endothelial involvement in organ transplantation and rejection. Overall, more detailed studies focusing on the endothelial modulation after organ transplantation would be necessary to investigate the role of endothelium activation during organ rejection.
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Affiliation(s)
- Fabio Silvio Taccone
- Department of Intensive Care Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 1070 Bruxelles, Belgium
| | - Ettore Crimi
- Department of Anesthesia and Critical Care Medicine, Shands Hospital, University of Florida, Gainesville, FL, USA
| | - James Anstey
- Department of Intensive Care Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 1070 Bruxelles, Belgium
| | - Teresa Infante
- Fondazione-SDN (Institute of Diagnostic and Nuclear Development), IRCCS, Via E. Gianturco, Naples, Italy
| | - Katia Donadello
- Department of Intensive Care Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 1070 Bruxelles, Belgium
| | - Sabino Scolletta
- Department of Intensive Care Route de Lennik, Erasme Hospital, Université Libre de Bruxelles, 1070 Bruxelles, Belgium
| | | | - Claudio Napoli
- Fondazione-SDN (Institute of Diagnostic and Nuclear Development), IRCCS, Via E. Gianturco, Naples, Italy
- Division of Immunohematology and Transplantation Centre, Department of General Pathology and Excellence Research, Center on Cardiovascular Disease, Second University of Naples, School of Medicine, Naples, Italy
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