Effect of level of sedation on outcomes in critically ill adult patients: a systematic review of clinical trials with meta-analysis and trial sequential analysis

Background

Sedation is routinely administered to critically ill patients to alleviate anxiety, discomfort, and patient-ventilator asynchrony. However, it must be balanced against risks such as delirium and prolonged intensive care stays. This study aimed to investigate the effects of different levels of sedation in critically ill adults.

Methods

Systematic review with meta-analysis and trial sequential analysis (TSA) of randomised clinical trials including critically ill adults admitted to the intensive care unit. CENTRAL, MEDLINE, Embase, LILACS, and Web of Science were searched from their inception to 13 June 2023. Risks of bias were assessed using the Cochrane risk of bias tool. Primary outcome was all-cause mortality. Aggregate data were synthesised with meta-analyses and TSA, and the certainty of the evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. This study is registered with PROSPERO: CRD42023386960.

Findings

Fifteen trials randomising 4352 patients were included, of which 13 were assessed high risk of bias. Meta-analyses comparing lighter to deeper sedation showed no evidence of a difference in all-cause mortality (risk ratio (RR) 0.94, 95% confidence interval (CI) 0.83-1.06; p = 0.28; 15 trials; moderate certainty evidence), serious adverse events (RR 0.99, CI 0.92-1.06; p = 0.80; 15 trials; moderate certainty evidence), or delirium (RR 1.01, 95% CI 0.94-1.09; p = 0.78; 11 trials; moderate certainty evidence). TSA showed that when assessing mortality, a relative risk reduction of 16% or more between the compared interventions could be rejected.

Interpretation

The level of sedation has not been shown to affect the risks of death, delirium, and other serious adverse events in critically ill adult patients. While TSA suggests that additional trials are unlikely to significantly change the conclusion of the meta-analyses, the certainty of evidence was moderate. This suggests a need for future high-quality studies with higher methodological rigor.

Funding

None.

Serratus Anterior Plane Blocks for Early Rib Fracture Pain Management: The SABRE Randomized Clinical Trial

Importance

Rib fractures secondary to blunt thoracic trauma typically result in severe pain that is notoriously difficult to manage. The serratus anterior plane block (SAPB) is a regional anesthesia technique that provides analgesia to most of the hemithorax; however, SAPB has limited evidence for analgesic benefits in rib fractures.

Objective

To determine whether the addition of an SAPB to protocolized care bundles increases the likelihood of early favorable analgesic outcomes and reduces opioid requirements in patients with rib fractures.

Design, Setting, and Participants

This multicenter, open-label, pragmatic randomized clinical trial was conducted at 8 emergency departments across metropolitan and regional New South Wales, Australia, between April 12, 2021, and January 22, 2022. Patients aged 16 years or older with clinically suspected or radiologically proven rib fractures were included in the study. Participants were excluded if they were intubated, transferred for urgent surgical intervention, or had a major concomitant nonthoracic injury. Data were analyzed from September 2022 to July 2023.

Interventions

Patients were randomly assigned (1:1) to receive an SAPB in addition to usual rib fracture management or standard care alone.

Main Outcomes and Measures

The primary outcome was a composite pain score measured 4 hours after enrollment. Patients met the primary outcome if they had a pain score reduction of 2 or more points and an absolute pain score of less than 4 out of 10 points.

Results

A total of 588 patients were screened, of whom 210 patients (median [IQR] age, 71 [55-84] years; 131 [62%] male) were enrolled, with 105 patients randomized to receive an SAPB plus standard care and 105 patients randomized to standard care alone. In the complete-case intention-to-treat primary outcome analysis, the composite pain score outcome was reached in 38 of 92 patients (41%) in the SAPB group and 18 of 92 patients (19.6%) in the control group (relative risk [RR], 0.73; 95% CI, 0.60-0.89; P = .001). There was a clinically significant reduction in overall opioid consumption in the SAPB group compared with the control group (eg, median [IQR] total opioid requirement at 24 hours: 45 [19-118] vs 91 [34-155] milligram morphine equivalents). Rates of pneumonia (6 patients [10%] vs 7 patients [11%]), length of stay (eg, median [IQR] hospital stay, 4.2 [2.2-7.7] vs 5 [3-7.3] days), and 30-day mortality (1 patient [1%] vs 3 patients [4%]) were similar between the SAPB and control groups.

Conclusions and Relevance

This randomized clinical trial found that the addition of an SAPB to standard rib fracture care significantly increased the proportion of patients who experienced a meaningful reduction in their pain score while also reducing in-hospital opioid requirements.

Trial Registration

http://anzctr.org.au Identifier: ACTRN12621000040864.

Quantifying the Impact of Alternative Definitions of Sepsis-Associated Acute Kidney Injury on its Incidence and Outcomes: A Systematic Review and Meta-Analysis

OBJECTIVES

To derive a pooled estimate of the incidence and outcomes of sepsis-associated acute kidney injury (SA-AKI) in ICU patients and to explore the impact of differing definitions of SA-AKI on these estimates.

DATA SOURCES

Medline, Medline Epub, EMBASE, and Cochrane CENTRAL between 1990 and 2023.

STUDY SELECTION

Randomized clinical trials and prospective cohort studies of adults admitted to the ICU with either sepsis and/or SA-AKI.

DATA EXTRACTION

Data were extracted in duplicate. Risk of bias was assessed using adapted standard tools. Data were pooled using a random-effects model. Heterogeneity was assessed by using a single covariate logistic regression model. The primary outcome was the proportion of participants in ICU with sepsis who developed AKI.

DATA SYNTHESIS

A total of 189 studies met inclusion criteria. One hundred fifty-four reported an incidence of SA-AKI, including 150,978 participants. The pooled proportion of patients who developed SA-AKI across all definitions was 0.40 (95% CI, 0.37-0.42) and 0.52 (95% CI, 0.48-0.56) when only the Risk Injury Failure Loss End-Stage, Acute Kidney Injury Network, and Improving Global Outcomes definitions were used to define SA-AKI. There was significant variation in the incidence of SA-AKI depending on the definition of AKI used and whether AKI defined by urine output criteria was included; the incidence was lowest when receipt of renal replacement therapy was used to define AKI (0.26; 95% CI, 0.24-0.28), and highest when the Acute Kidney Injury Network score was used (0.57; 95% CI, 0.45-0.69; p < 0.01). Sixty-seven studies including 29,455 participants reported at least one SA-AKI outcome. At final follow-up, the proportion of patients with SA-AKI who had died was 0.48 (95% CI, 0.43-0.53), and the proportion of surviving patients who remained on dialysis was 0.10 (95% CI, 0.04-0.17).

CONCLUSIONS

SA-AKI is common in ICU patients with sepsis and carries a high risk of death and persisting kidney impairment. The incidence and outcomes of SA-AKI vary significantly depending on the definition of AKI used.

Fluid therapy in diabetic ketoacidosis

PURPOSE OF REVIEW

To evaluate recent evidence (2021-2023) on fluid therapy in diabetic ketoacidosis. Key evidence gaps which require generation of new evidence are discussed.

RECENT FINDINGS

Balanced crystalloid solutions, compared to the commonly recommended and used 0.9% sodium chloride solution (saline), may result in better outcomes for patients with diabetic ketoacidosis, including faster resolution of acidosis, less hyperchloremia and shorter hospital length of stay. Upcoming results from randomized trials may provide definitive evidence on the use of balanced crystalloid solutions in diabetic ketoacidosis. Evidence remains scarce or conflicting for the use of "two-bag" compared to conventional "one-bag" fluid, and rates of fluid administration, especially for adult patients. In children, concerns about cerebral oedema from faster fluid administration rates have not been demonstrated in cohort studies nor randomized trials.

SUMMARY

Fluid therapy is a key aspect of diabetic ketoacidosis management, with important evidence gaps persisting for several aspects of management despite recent evidence.

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

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.

The feasibility and acceptability of a physician-led ICU follow-up service: A prospective cohort study

BACKGROUND

Increased recognition of post-intensive care syndrome has led to widespread development of intensive care follow-up services internationally.

OBJECTIVE

The objective of this study was to determine the feasibility and acceptability of an intensive care unit (ICU) follow-up clinic in Australia for patients and their caregivers and to describe satisfaction with this service.

METHODS

This was a prospective cohort study in a mixed tertiary ICU in Australia. Eligible patients were adults admitted to the ICU for 7 days or more and/or ventilated for 48 h or more, as well as their primary caregiver. Patients and their primary caregivers were invited to attend a follow-up clinic 4-8 weeks after hospital discharge. The clinic appointment was attended by an ICU physician and nurse, with multidisciplinary support. Feasibility and acceptability were defined as the proportion of clinic attendance and frequency of interventions initiated at the clinic. Satisfaction was measured by a 5-point satisfaction survey (very dissatisfied to very satisfied). The burden of ongoing disease was reported via multiple validated instruments.

RESULTS

From April 2020-July 2021, 386 patients met the inclusion criteria. Only 146 patients were approached for consent due to site staffing limitations. Eighty-three patients and 32 caregivers consented to attend the clinic. Seventy percent (54/77) of patients attended scheduled appointments and 50% (16/32) of caregivers. For patients, 23 medical referrals were made, 8 patients had medication changes, and 10 patients were offered social work support. Satisfaction surveys were completed by 65% (35/54) of attending patients; 97% (34) patients reported either being 'very satisfied' or 'satisfied' with the service. All responding caregivers (10) were either 'very satisfied' or 'satisfied' with the clinic.

CONCLUSION

There were a large number of patients meeting the inclusion criteria to the ICU follow-up clinic, and clinic attendance was moderate for patients but lower for caregivers. Reported satisfaction with the service was high for both patients and their caregiver.

Accuracy of International Classification of Disease Coding Methods to Estimate Sepsis Epidemiology: A Scoping Review

PURPOSE

To provide an overview of various sepsis International Classification of Diseases (ICD) coding methods and their diagnostic accuracy.

METHODS

We undertook a systematic scoping review between 1991 and 2020 (search terms: sepsis, coding, and epidemiology) to include studies reporting the accuracy of a sepsis ICD coding method. Studies were grouped by ICD coding method, number of diagnostic accuracy parameters, ICD version, reference standard, design, country, setting, type of dataset and sepsis definition. ICD coding methods were categorised as explicit or implicit, with the explicit methods further divided into wide and narrow groups. Descriptive statistics were used to present data.

RESULTS

We analysed 17 studies, of which 16 (94.1%) used retrospective medical chart review as the reference standard for clinical sepsis, and eight (47.1%) used hospital administrative data to identify sepsis. There were 53 assessments of various ICD coding methods, with 32 (60.4%) of them being explicit and 21 (39.6%) implicit methods. The coding methods had a median sensitivity of <75% but a median specificity of >85%. However, a wide variation was noted in the diagnostic accuracy parameters of all ICD coding methods. Most of the studies showed high methodological quality.

CONCLUSION

None of the current ICD coding methods is optimal for identifying sepsis.

The effect of sugammadex on patient morbidity and quality of recovery after general anaesthesia: a systematic review and meta-analysis

BACKGROUND

Residual neuromuscular block is associated with increased patient morbidity. Therefore prevention of residual neuromuscular block is an important component of general anaesthesia where neuromuscular blocking agents are used. Whereas sugammadex improves reversal based on neuromuscular twitch monitoring parameters, there have been no prospective, adequately powered definitive studies demonstrating that sugammadex is also associated with less patient morbidity.

METHODS

We performed a systematic review of randomised trials comparing sugammadex with anticholinesterase-based reversal or placebo reversal that reported important patient outcomes beyond the postanaesthesia care unit.

RESULTS

We identified 43 articles, including 5839 trial participants. Only one trial reported days alive and out of hospital to 30 days (DAOH-30), which showed that the number of DAOH-30 was similar in those allocated to sugammadex compared with neostigmine-based reversal (25 days [19-27] vs 24 days [21-27], median difference 0.00 [-2.15 to 2.15]). Pooled analyses of data from 16 trials showed an estimated odds ratio (OR) for postoperative pulmonary complications of 0.67 (95% confidence interval 0.47-0.95) with sugammadex use. Pooled analysis showed that pneumonia (eight trials OR 0.51 [0.24-1.01] with sugammadex use), hospital length of stay (23 trials, mean difference -0.31 [-0.84 to 0.22] with sugammadex use), and patient-reported quality of recovery (11 trials, varied depending on metric used) are similar in those allocated to sugammadex vs control. The difference seen in mortality (11 trials, OR 0.39 [0.15-1.01] with sugammadex use) would be considered to be clinically significant and warrants further investigation, however, the rarity of these events precludes drawing definitive conclusions.

CONCLUSION

Although few trials reported on DAOH-30 or important patient outcomes, sugammadex is associated with a reduction in postoperative pulmonary complications, however, this might not translate to a difference in hospital length of stay, patient-reported quality of recovery, or mortality.

CLINICAL TRIAL REGISTRATION

PROSPERO database (CRD42022325858).

Selective digestive tract decontamination in critically ill adults with acute brain injuries: a post hoc analysis of a randomized clinical trial

PURPOSE

The aim of this study was to determine whether selective decontamination of the digestive tract (SDD) reduces in-hospital mortality in mechanically ventilated critically ill adults admitted to the intensive care unit (ICU) with acute brain injuries or conditions.

METHODS

We carried out a post hoc analysis from a crossover, cluster randomized clinical trial. ICUs were randomly assigned to adopt or not to adopt a SDD strategy for two alternating 12-month periods, separated by a 3-month inter-period gap. Patients in the SDD group (n = 2791; 968 admitted to the ICU with an acute brain injury) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191; 1093 admitted to the ICU with an acute brain injury) received standard care. The primary outcome was in-hospital mortality within 90 days. There were four secondary clinical outcomes: death in ICU, ventilator-, ICU- and hospital-free days to day 90.

RESULTS

Of 2061 patients with acute brain injuries (mean age, 55.8 years; 36.4% women), all completed the trial. In patients with acute brain injuries, there were 313/968 (32.3%) and 415/1093 (38%) in-hospital deaths in the SDD and standard care groups (unadjusted odds ratio [OR], 0.76, 95% confidence interval [CI] 0.63-0.92; p = 0.004). The use of SDD was associated with statistically significant improvements in the four clinical secondary outcomes compared to standard care. There was no significant heterogeneity of treatment effect between patients with and without acute brain injuries (interaction p = 0.22).

CONCLUSIONS

In this post hoc analysis of a randomized clinical trial in critically ill patients with acute brain injuries receiving mechanical ventilation, the use of SDD significantly reduced in-hospital mortality in patients compared to standard care without SDD. These findings require confirmation.

Early sepsis in Australia and New Zealand: A point-prevalence study of haemodynamic resuscitation practices

OBJECTIVE

Optimal resuscitation of sepsis-induced hypotension is uncertain, particularly the role of restrictive fluid strategies, leading to variability in usual practice. The objective of this study is to understand resuscitation practices in patients presenting to ED with early sepsis.

METHODS

Design, participants and setting: Prospective, observational, multicentre, single-day, point-prevalence study enrolling adult patients present in 51 Australian and New Zealand ICUs at 10.00 hours, 8 June 2021.

MAIN OUTCOME MEASURES

Site-level data on sepsis policies and patient-level demographic data, presence of sepsis and fluid and vasopressor administration in the first 24 h post-ED presentation.

RESULTS

A total of 722 patients were enrolled. ED was the ICU admission source for 222 of 722 patients (31.2%) and 78 of 222 patients (35%) met the criteria for sepsis within 24 h of ED presentation. Median age of the sepsis cohort was 61 (48-72) years, 58% were male and respiratory infection was the commonest cause (53.8%). The sepsis cohort had a higher severity of illness than the non-sepsis cohort (144/222 patients) and chronic immunocompromise was more common. Of 78 sepsis patients, 55 (71%) received ≥1 fluid boluses with 500 and 1000 mL boluses equally common (both 49%). In the first 24 h, 2335 (1409-3125) mL (25.3 [13.2-42.9] mL/kg) was administered. Vasopressors were administered in 53 of 78 patients (68%) and for 25 patients (47%) administration was peripheral.

CONCLUSIONS

ICU patients presenting to the ED with sepsis receive less fluids than current international recommendations and peripheral vasopressor administration is common. This finding supports the conduct of clinical trials evaluating optimal fluid dose and vasopressor timing for early sepsis-induced hypotension.

Sepsis-coded hospitalisations and associated costs in Australia: a retrospective analysis

OBJECTIVE

To report trends in Australian hospitalisations coded for sepsis and their associated costs.

DESIGN

Retrospective analysis of Australian national hospitalisation data from 2002 to 2021.

METHODS

Sepsis-coded hospitalisations were identified using the Global Burden of Disease study sepsis-specific ICD-10 codes modified for Australia. Costs were calculated using Australian-Refined Diagnosis Related Group codes and National Hospital Cost Data Collection.

RESULTS

Sepsis-coded hospitalisations increased from 36,628 in 2002-03 to 131,826 in 2020-21, an annual rate of 7.8%. Principal admission diagnosis codes contributed 13,843 (37.8%) in 2002-03 and 44,186 (33.5%) in 2020-21; secondary diagnosis codes contributed 22,785 (62.2%) in 2002-03 and 87,640 (66.5%) in 2020-21. Unspecified sepsis was the most common sepsis code, increasing from 15,178 hospitalisations in 2002-03 to 68,910 in 2020-21. The population-based incidence of sepsis-coded hospitalisations increased from 18.6 to 10,000 population (2002-03) to 51.3 per 10,000 (2021-21); representing an increase from 55.1 to 10,000 hospitalisations in 2002-03 to 111.4 in 2020-21. Sepsis-coded hospitalisations occurred more commonly in the elderly; those aged 65 years or above accounting for 20,573 (55.6%) sepsis-coded hospitalisations in 2002-03 and 86,135 (65.3%) in 2020-21. The cost of sepsis-coded hospitalisations increased at an annual rate of 20.6%, from AUD199M (€127 M) in financial year 2012 to AUD711M (€455 M) in 2019.

CONCLUSION

Hospitalisations coded for sepsis and associated costs increased significantly from 2002 to 2021 and from 2012 to 2019, respectively.

Sepsis triggers and tools to support early identification in healthcare settings: An integrative review

BACKGROUND

There is no universal trigger or tool to aid sepsis diagnosis.

OBJECTIVES

The objective of this study was to identify triggers and tools to assist the early detection of sepsis that can be readily implemented across various health care settings.

METHODS

A systematic integrative review was conducted using MEDLINE, CINAHL, EMBASE, Scopus, and the Cochrane Database of Systematic Reviews. Relevant grey literature and subject-matter expert consultation also informed the review. Study types included systematic reviews, randomised controlled trials, and cohort studies. All patient populations across prehospital, emergency department, and acute hospital inpatient settings, excluding the intensive care unit, were included. Sepsis triggers and tools were evaluated for efficacy in detecting sepsis and association with process measures and patient outcomes. Methodological quality was appraised using Joanna Briggs Institute tools.

RESULTS

Of the 124 included studies, most were retrospective cohort (49.2%) in adults (83.9%) within the emergency department (44.4%). The most commonly evaluated sepsis tools were qSOFA (12 studies) and SIRS (11 studies) with a median sensitivity of 28.0% versus 51.0% and a specificity of 98.0% versus 82.0%, respectively, for sepsis diagnosis. Lactate plus qSOFA (two studies) had a sensitivity between 57.0 and 65.5%, whereas the National Early Warning Score (four studies) demonstrated median sensitivity and specificity >80%, but the latter was considered difficult to implement. Amongst triggers, lactate (18 studies) at the threshold of ≥2.0 mmol/L showed higher sensitivity for predicting sepsis-related clinical deterioration than <2.0 mmol/L. Automated sepsis alerts and algorithms (35 studies) showed median sensitivity between 58.0 and 80.0% and specificity between 60.0 and 93.1%. There were limited data for other sepsis tools and maternal, paediatric, and neonatal populations. Overall methodological quality was high.

CONCLUSION

No single sepsis tool or trigger is applicable across various settings and populations, but considering efficacy and ease of implementation, there is evidence to use lactate plus qSOFA for adult patients. More research is needed in maternal, paediatric, and neonatal populations.

Intensive glucose control in critically ill adults: a protocol for a systematic review and individual patient data meta-analysis

OBJECTIVE

The optimal target for blood glucose concentration in critically ill patients is unclear. We will perform a systematic review and meta-analysis with aggregated and individual patient data from randomized controlled trials, comparing intensive glucose control with liberal glucose control in critically ill adults.

DATA SOURCES

MEDLINE®, Embase, the Cochrane Central Register of Clinical Trials, and clinical trials registries (World Health Organization, clinical trials.gov). The authors of eligible trials will be invited to provide individual patient data. Published trial-level data from eligible trials that are not at high risk of bias will be included in an aggregated data meta-analysis if individual patient data are not available.

METHODS

Inclusion criteria: randomized controlled trials that recruited adult patients, targeting a blood glucose of ≤ 120mg/dL (≤ 6.6mmol/L) compared to a higher blood glucose concentration target using intravenous insulin in both groups. Excluded studies: those with an upper limit blood glucose target in the intervention group of > 120mg/dL (> 6.6mmol/L), or where intensive glucose control was only performed in the intraoperative period, and those where loss to follow-up exceeded 10% by hospital discharge.

PRIMARY ENDPOINT

In-hospital mortality during index hospital admission. Secondary endpoints: mortality and survival at other timepoints, duration of invasive mechanical ventilation, vasoactive agents, and renal replacement therapy. A random effect Bayesian meta-analysis and hierarchical Bayesian models for individual patient data will be used.

DISCUSSION

This systematic review with aggregate and individual patient data will address the clinical question, 'what is the best blood glucose target for critically ill patients overall?'Protocol version 0.4 - 06/26/2023PROSPERO registration:CRD42021278869.

Acetazolamide for metabolic alkalosis complicating respiratory failure with chronic obstructive pulmonary disease or obesity hypoventilation syndrome: a systematic review

BACKGROUND

Metabolic alkalosis may lead to respiratory inhibition and increased need for ventilatory support or prolongation of weaning from ventilation for patients with chronic respiratory disease. Acetazolamide can reduce alkalaemia and may reduce respiratory depression.

METHODS

We searched Medline, EMBASE and CENTRAL from inception to March 2022 for randomised controlled trials comparing acetazolamide to placebo in patients with chronic obstructive pulmonary disease, obesity hypoventilation syndrome or obstructive sleep apnoea, hospitalised with acute respiratory deterioration complicated by metabolic alkalosis. The primary outcome was mortality and we pooled data using random-effects meta-analysis. Risk of bias was assessed using the Cochrane RoB 2 (Risk of Bias 2) tool, heterogeneity was assessed using the I2 value and χ2 test for heterogeneity. Certainty of evidence was assessed using GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) methodology.

RESULTS

Four studies with 504 patients were included. 99% of included patients had chronic obstructive pulmonary disease. No trials recruited patients with obstructive sleep apnoea. 50% of trials recruited patients requiring mechanical ventilation. Risk of bias was overall low to some risk. There was no statistically significant difference with acetazolamide in mortality (relative risk 0.98 (95% CI 0.28 to 3.46); p=0.95; 490 participants; three studies; GRADE low certainty) or duration of ventilatory support (mean difference -0.8 days (95% CI -7.2 to 5.6); p=0.36; 427 participants; two studies; GRADE: low certainty).

CONCLUSION

Acetazolamide may have little impact on respiratory failure with metabolic alkalosis in patients with chronic respiratory diseases. However, clinically significant benefits or harms are unable to be excluded, and larger trials are required.

PROSPERO REGISTRATION NUMBER

CRD42021278757.

Acute assessment of spinal cord injury in New South Wales: A retrospective study of current practice in two spinal cord injury referral centers

INTRODUCTION

Interventions provided in the early phases after spinal cord injury (SCI) may improve neurological recovery and provide for best possible functional outcomes. Knowing this relies on early and clear documentation of the level and grade of the spinal cord injury. Guidelines advocate for early documentation of neurological status within 72 h of injury to allow early prognostication and to help guide initial management. It is unclear whether this is current practice in New South Wales (NSW).

METHODS

Patients with acute SCI who were admitted to two SCI referral centers during 2018-2019 in NSW were included. Data relating to documentation of neurological status, timing of imaging, surgery and transfer to spinal cord injury center were collected and summarized using descriptive statistics.

RESULTS

Only 18 percent of patients had an acceptable neurological examination according to the International Standards for Classification of Spinal Cord Injury (ISNCSCI) within 72 h of injury (either not done, or unable to determine the neurological level of injury). At the first neurological examination, the neurological level of injury and grade was unable to be determined in 26.8% of patients and 29.9% of patients respectively. At discharge from acute care and transfer to rehabilitation, the neurological level was undetermined in 28.9% of patients and grade undetermined in 26.8%. ISNCSCI examination was most commonly performed by spinal rehabilitation doctors after patients were discharged from the intensive care unit (ICU).

CONCLUSIONS

Documentation of neurological level and grade of SCI within 72 h of injury is not being performed in the large majority of this cohort, which may impede evaluation of neurological improvement in response to acute treatment, and hinder prognostication.

Interrater reliability in assigning a lung ultrasound score

BACKGROUND AND PURPOSE

Lung ultrasound (LUS) for physiotherapists is an emerging bedside tool. The LUS score of aeration presents as a possible means of assessing and monitoring lung aeration associated with respiratory physiotherapy treatments. There are no studies to date that have assessed the interrater reliability (IRR) of physiotherapists assigning the LUS score of aeration. This study assessed the IRR of assigning the LUS score among adult, mechanically ventilated patients in an intensive care unit with a clinical suspicion of acute lobar atelectasis.

METHODS

A convenience sample of patients had an LUS performed by a physiotherapist, and images were independently reviewed by two physiotherapists. Each lung zone was assigned an LUS score between 0 and 3 (with 0 being normal aeration and 3 being complete consolidation, presence of effusion, or pneumothorax). IRR was assessed using the kappa statistic.

RESULTS

A total of 1032 LUS images were obtained. Assigning of the LUS across all lung zones demonstrated substantial agreement with kappa 0.685 (95% confidence interval: 0.650, 0.720). Right (0.702 [0.653, 0.751]) and left (0.670 [0.619, 0.721]) lung zones also demonstrated substantial agreement.

CONCLUSION

We found substantial IRR between physiotherapists in assigning the LUS score in a mechanically ventilated adult population in the intensive care unit.

AUSTRALIAN NEW ZEALAND CLINICAL TRIALS REGISTRATION NUMBER

ACTRN12619000783123.

Blood Pressure Management Goals in Critically Ill Aneurysmal Subarachnoid Hemorrhage Patients in Australia and New Zealand

INTRODUCTION

Blood pressure (BP) management is common in patients with aneurysmal subarachnoid hemorrhage (SAH) admitted to an intensive care unit. However, the practice patterns of BP management (timing, dose, and duration) have not been studied locally.

METHODS

This post hoc analysis explored BP management goals (defined as the setting of a minimum systolic BP target or application of induced hypertension) in patients enrolled into the PROMOTE-SAH study in eleven neurosurgical centers in Australia and New Zealand. The primary outcome was 'dead or disabled' (modified Rankin Score ≥4) at 6 months, with the hypothesis being that setting BP management goals would be associated with improved outcomes.

RESULTS

BP management goals were recorded in 266 of 357 (75%) patients, of which 149 were recorded as receiving induced hypertension for delayed cerebral ischemia (DCI) or vasospasm on 738 (19%) study days. In patients with a minimum systolic BP goal recorded (on 2067 d), the indication for the BP management goal was vasospasm or DCI on 651 (32%) days; no indication for BP management goals was documented on 1416 (69%) days. Crude analysis demonstrated an association between setting BP management goals and reduced death or disability (P=0.03), but this association was not significant after adjustment for the presence of DCI or vasospasm and clustered by the site.

CONCLUSIONS

BP management goals are commonly 'prescribed' to aSAH patients admitted to an intensive care unit in Australia and New Zealand, but BP management goal setting was not associated with improved outcomes in the adjusted analysis.

Patient-Level Meta-Analysis of Low-Dose Hydrocortisone in Adults with Septic Shock

Low-Dose Hydrocortisone and Septic ShockCorticosteroids have been evaluated as a therapy for septic shock for more than 50 years. However, uncertainty persists about their effects on mortality. Pirracchio and colleagues undertake a patient-level meta-analysis to answer this important question.

Mortality and costs related to severe acute pancreatitis in the intensive care units of Australia and New Zealand (ANZ), 2003-2020

BACKGROUND AND OBJECTIVE

Comprehensive data on the burden of severe acute pancreatitis (SAP) in global intensive care units (ICUs) and trends over time are lacking. Our objective was to compare trends in hospital and ICU mortality, in-hospital and ICU length of stay, and costs related to ICU admission in Australia and New Zealand (ANZ) for SAP.

METHODS

We performed a retrospective, observational, cohort study of ICU admissions reported to the ANZ Intensive Care Society Adult Patient Database over three consecutive six-year time periods from 2003 to 2020.

RESULTS

12,635 patients with SAP from 189 ICUs in ANZ were analysed. No difference in adjusted hospital mortality (11.4% vs 11.5% vs 11.0%, p = 0.85) and ICU mortality rates (7.5% vs 8.0% vs 8.1%, p = 0.73) were noted over the study period. Median length of hospital admission reduced over time (13.9 days in 2003-08, 13.1 days in 2009-14 and 12.5 days in 2015-20; p < 0.01). No difference in length of ICU stay was noted over the study period (p = 0.13). The cost of managing SAP in ANZ ICUs remained constant over the three time periods.

CONCLUSIONS

In critically-ill SAP patients in ANZ, no change in mortality has been noted over nearly two decades. There was a slight reduction in hospital stay (1 day), while the length of ICU stay remained unchanged. Given the significant costs related to care of patients with SAP in ICU, these findings highlight the need to prioritise resource allocation for healthcare delivery and targeted clinical research to identify treatments aimed at reducing mortality.

The association between ventriculostomy - Related infection and clinical outcomes: A systematic review and meta-analysis

BACKGROUND

Ventriculostomy - related infection (VRI) is a common complication of patients who require placement of an external ventricular drain (EVD). The clinical outcomes of people who are diagnosed with VRI is poorly characterised. We performed a systematic review and meta-analysis to assess the association between VRI, and clinical outcomes and resource use, in patients treated with an EVD.

METHODS

We searched MEDLINE, EMBASE, CINAHL and the Cochrane Central Register of clinical trials to identify clinical trial and cohort studies that reported outcomes including mortality, functional outcome, duration of EVD insertion, and intensive care and hospital length of stay. Inclusion criteria and data extraction were conducted in duplicate. Where sufficient data were available, data synthesis was conducted using a random effects model to provide a pooled estimate of the association between VRI and clinical outcomes and resource use. We also pooled data to provide an estimate of the incidence of VRI in this population.

RESULTS

Nineteen studies including 38,247 patients were included in the meta-analysis. There were twelve different definitions of VRI in the included studies. The pooled estimate of the incidence of VRI was 11 % (95 % confidence interval (CI), 9 % to 14 %). A diagnosis of VRI was not associated with an increase in the estimated odds ratio (OR) for mortality (OR 1.07, 95 % CI 0.59 to 1.92, p = 0.83 I² = 83.5 %), nor was a diagnosis of VRI associated with changes in neurological outcome (OR 1.42, 95 % CI 0.36 to 5.56, p = 0.89, I² = 0.3 %). Those diagnosed with VRI had longer intensive care unit length of stay (estimated pooled mean difference 8.4 days 95 % CI 3.4 to 13.4 days, p = 0.0009, I² = 78.7 %) an increase in hospital length of stay (estimated mean difference 16.4 days. 95 % CI 11.6 to 21.2 days, p < 0.0005, I² = 76.6 %), a prolonged duration of EVD placement (mean difference 5.24 days, 95 % CI 3.05 to 7.43, I² = 78.2 %, p < 0.01), and an increased requirement for an internal ventricular shunt (OR 1.80, 95 % CI 1.32 to 2.46, I² = 8.92 %, p < 0.01).

CONCLUSIONS

Ventriculostomy related infection is not associated with increased mortality or an increased risk of poor neurological outcome, but is associated with prolonged duration of EVD placement, prolonged duration of ICU and hospital admission, and an increased rate of internal ventricular shunt placement.

The Uncertainty Associated with Moving Early

Some of the most common questions asked of clinicians caring for patients with critical illness are about prognosis: Will my loved one survive? If they do survive, at what cost to their quality of life? While some consolation can be provided that mortality rates for common conditions have fallen,1 patients who survive the initial intensive care unit admission face an uncertain future, with the potential for significant morbidity, poor mental health, cognitive dysfunction, frequent hospital readmissions, and poor functional recovery.2,3.

Impact of time of intensive care unit transfer and outcomes in patients with septic shock: An observational study

OBJECTIVE

To evaluate the association between time from ED presentation to intensive care unit (ICU) transfer on mortality in patients presenting with septic shock.

METHODS

Adult patients with suspected septic shock enrolled in the Australasian Resuscitation in Sepsis Evaluation trial were included. The primary outcome of this post-hoc analysis was 90-day mortality. ED-to-ICU time was analysed as both a continuous variable and a binary variable (≤ vs >4 h). Analysis incorporated mixed effects regression, with ICU site as a random effect, time-to-event analysis and competing risks regression; all with and without inverse probability of treatment weighting to account for confounding baseline covariates.

RESULTS

Data from 1301 patients were included. Median (interquartile range [IQR]) ED-to-ICU time was 4.3 (3.1, 6.3) hours, with 588 patients (45%) transferred within 4 h. The ≤4-h group were younger, 64 (51, 74) versus 67 (52, 76) years (P = 0.04), with higher APACHE III scores, 50 (37, 65) versus 47 (35, 62) (P = 0.002), and higher unadjusted 90-day mortality, odds ratio (OR) 1.53 (95% confidence interval 1.15, 2.03), P = 0.01. After adjustment for pre-specified confounders, the 90-day mortality OR was 1.09 (0.83, 1.44), P = 0.52. Adjusted for death as a competing event and illness severity, hospital length of stay was similar between groups, whereas ICU duration remained longer for the ≤4-h group.

CONCLUSION

In patients presenting to the ED with septic shock, ED-to-ICU time less than 4 h was not associated with altered 90-day mortality, although this should be interpreted with caution due to study limitations.

Healthcare provider perceptions of safety culture: A multi-site study using the safety attitudes questionnaire

Introduction

Patient safety culture, the way in which members of a healthcare organisation think about and prioritise safety, has been linked to positive patient outcomes. The aim of this study was to use the Safety Attitudes Questionnaire (SAQ) to measure the safety culture in a variety of healthcare settings located in the province of Munster of Ireland.

Methods

The SAQ was applied in six healthcare settings in the Munster province of Ireland between December 2017 and November 2019. The attitudes of healthcare staff towards six domains of safety culture were assessed over 32 Likert-scaled items. The mean, median, interquartile range and percent positive scores for each domain were calculated for the study population, and subgroup analyses were carried out between study sites and professions. Results for each setting were compared to international benchmarking data. Chi-Squared tests were used to determine whether study site or profession were related to domain scores. Reliability analysis was carried out using Cronbach's alpha.

Results

Study participants (n = 1749) comprising doctors, pharmacists, nurses, and healthcare assistants, were found to have positive attitudes towards patient safety culture but scored poorly in the domains Working Conditions and Perceptions of Management. Perceptions of safety culture were more positive in smaller healthcare settings, and amongst nurses and HCAs. The survey had acceptable internal consistency.

Conclusions

In this study investigating the safety culture of healthcare organisations in Ireland, study participants had generally positive attitudes towards the safety culture in their organisation, however working conditions, perceptions of management, and medication incident reporting were identified as key areas for improvement.

Fire in the belly: A scoping review of the immunopathological mechanisms of acute pancreatitis

Introduction

Acute pancreatitis (AP) is characterised by an inflammatory response that in its most severe form can cause a systemic dysregulated immune response and progression to acute multi-organ dysfunction. The pathobiology of the disease is unclear and as a result no targeted, disease-modifying therapies exist. We performed a scoping review of data pertaining to the human immunology of AP to summarise the current field and to identify future research opportunities.

Methods

A scoping review of all clinical studies of AP immunology was performed across multiple databases. Studies were included if they were human studies of AP with an immunological outcome or intervention.

Results

205 studies met the inclusion criteria for the review. Severe AP is characterised by significant immune dysregulation compared to the milder form of the disease. Broadly, this immune dysfunction was categorised into: innate immune responses (including profound release of damage-associated molecular patterns and heightened activity of pattern recognition receptors), cytokine profile dysregulation (particularly IL-1, 6, 10 and TNF-α), lymphocyte abnormalities, paradoxical immunosuppression (including HLA-DR suppression and increased co-inhibitory molecule expression), and failure of the intestinal barrier function. Studies including interventions were also included. Several limitations in the existing literature have been identified; consolidation and consistency across studies is required if progress is to be made in our understanding of this disease.

Conclusions

AP, particularly the more severe spectrum of the disease, is characterised by a multifaceted immune response that drives tissue injury and contributes to the associated morbidity and mortality. Significant work is required to develop our understanding of the immunopathology of this disease if disease-modifying therapies are to be established.

Intensive care nurse practitioners in Australia: A description of a service model in an adult tertiary intensive care unit

BACKGROUND

Although well-established internationally, nurse practitioners (NPs) in Australian adult intensive care units (ICUs) are rare. Australian literature clearly highlights the importance of creating ICU NP roles to meet emerging demands. An ICU NP model of care at a metropolitan hospital in Sydney provides care in four core practice areas: complex case management, vascular access, tracheostomy management, and intrahospital transport of critically ill patients. The ICU NPs also provide training and assessment for ICU nurses and medical officers in these same core practice areas and can efficiently meet service gaps in crisis such as the most recent COVID-19 pandemic.

RESULTS

The ICU NP program described is an innovative model of care that has demonstrated potential benefits to patients and their families. Potential benefits to the healthcare system including supporting advanced practice nursing development in regional and rural Australia and in addressing future ICU workforce issues are also identified. This model of care provides a clear role and structure for the integration of NPs in the adult ICU. Research to evaluate the impact of the role is required and is underway.

CONCLUSIONS

This model is being used to develop a national adult ICU NP fellowship training program for ICU transitional NPs preparing for endorsement or endorsed NPs who require additional ICU-specific training. This immersive clinical training program combined with didactic learning modules offers a framework to support the implementation of the adult ICU NP role as well as a framework for NP fellowship programs in other specialties.

Prioritizing outcome measures after aneurysmal subarachnoid hemorrhage: A q-sort survey of patients, health care providers and researchers

Objective

To understand which outcome measures patients and their families, health care providers, and researchers prioritize after aneurysmal subarachnoid hemorrhage (aSAH).

Methods

We conducted a cross-sectional q-sort survey with participants from three key stakeholder groups. Potential outcomes were identified from interviews and focus groups. Participants were purposively sampled to achieve diversity based on stakeholder group, geography, and profession. Respondents sorted 27 outcomes in a quasi-normally distributed grid (Q-Sort) from most to least important. Principal components analysis was used to determine similarities in the way participants sorted the outcome measures resulting in distinct groupings. Overall rankings were also reported.

Results

112 participants were invited. 70 responded and 64 participants from 25 different countries completed a Q-sort. Balanced stakeholder representation was achieved. Five distinct patterns were identified based on survival, pathophysiological, psychological, resource use, and functional outcome measures. Quality of life as reported by the patient was the highest ranked outcome measure followed by independence and functional measures. Survival and biomedical outcomes were ranked in the middle and cost measures last.

Conclusions

In this diverse sample of key stakeholders, we characterized several distinct perspectives with respect to outcome measure selection in aSAH. We did not identify a clear pattern of opinion based on stakeholder group or other participant characteristics. Patient-reported measure of quality of life was ranked the most important overall with function and independence also highly rated. These results will assist study design and inform efforts to improve outcome selection in aSAH research.

Fluids or vasopressors for the initial resuscitation of septic shock

Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.

Quantification of changes in lung aeration associated with physiotherapy using lung ultrasound in mechanically ventilated patients: a prospective cohort study

BACKGROUND

Lung ultrasound (LUS) is a novel and emerging tool for physiotherapists in ICU and may provide a way of monitoring lung aeration change in response to respiratory physiotherapy treatment during a patient's ICU stay.

OBJECTIVE

To measure change in the LUS score associated with a respiratory physiotherapy treatment; to determine whether change in LUS score correlates with other physiological measures.

DESIGN AND SETTING

A single-centre prospective cohort study was undertaken in a tertiary teaching hospital in Sydney, Australia.

PATIENTS

Adult mechanically ventilated patients in ICU with suspicion of atelectasis.

MEASUREMENTS

Primary outcome: pre-post difference in LUS score.

SECONDARY OUTCOMES

PaO₂/FiO₂ (PF) ratio, tidal volume (V_T), lung auscultation score, driving pressure (DP) and the modified radiological atelectasis score (mRAS) on CXR.

RESULTS

43 patients were included. There was a mean improvement in total LUS score after physiotherapy treatment of - 2.9 (95%CI -4.4, -1.4), and a mean improvement in LUS of the right and left lungs of - 1.6 (-2.5, -0.7) and - 1.3 (-2.5, -0.1) respectively. There was a mean improvement in PF ratio, V_T and auscultation score of 10.4 (-11.89, 32.7), 19 (-7.4, 44.5) and - 1.8 (-2.6, -1.0) respectively. There was no improvement in mRAS or DP. There was a weak correlation between change in LUS score compared with change in mRAS score.

LIMITATIONS

Limitations included the prospective cohort single site design and the small sample size.

CONCLUSIONS

The LUS score can be used to detect changes in lung aeration associated with respiratory physiotherapy treatment for acute lobar atelectasis in mechanically ventilated patients. Australian and New Zealand Clinical Trials Registry Number: ACTRN12619000783123. CONTRIBUTION OF THE PAPER.

Association Between Selective Decontamination of the Digestive Tract and In-Hospital Mortality in Intensive Care Unit Patients Receiving Mechanical Ventilation: A Systematic Review and Meta-analysis

Importance

The effectiveness of selective decontamination of the digestive tract (SDD) in critically ill adults receiving mechanical ventilation is uncertain.

Objective

To determine whether SDD is associated with reduced risk of death in adults receiving mechanical ventilation in intensive care units (ICUs) compared with standard care.

Data Sources

The primary search was conducted using MEDLINE, EMBASE, and CENTRAL databases until September 2022.

Study Selection

Randomized clinical trials including adults receiving mechanical ventilation in the ICU comparing SDD vs standard care or placebo.

Data Extraction and Synthesis

Data extraction and risk of bias assessments were performed in duplicate. The primary analysis was conducted using a bayesian framework.

Main Outcomes and Measures

The primary outcome was hospital mortality. Subgroups included SDD with an intravenous agent compared with SDD without an intravenous agent. There were 8 secondary outcomes including the incidence of ventilator-associated pneumonia, ICU-acquired bacteremia, and the incidence of positive cultures of antimicrobial-resistant organisms.

Results

There were 32 randomized clinical trials including 24 389 participants in the analysis. The median age of participants in the included studies was 54 years (IQR, 44-60), and the median proportion of female trial participants was 33% (IQR, 25%-38%). Data from 30 trials including 24 034 participants contributed to the primary outcome. The pooled estimated risk ratio (RR) for mortality for SDD compared with standard care was 0.91 (95% credible interval [CrI], 0.82-0.99; I2 = 33.9%; moderate certainty) with a 99.3% posterior probability that SDD reduced hospital mortality. The beneficial association of SDD was evident in trials with an intravenous agent (RR, 0.84 [95% CrI, 0.74-0.94]), but not in trials without an intravenous agent (RR, 1.01 [95% CrI, 0.91-1.11]) (P value for the interaction between subgroups = .02). SDD was associated with reduced risk of ventilator-associated pneumonia (RR, 0.44 [95% CrI, 0.36-0.54]) and ICU-acquired bacteremia (RR, 0.68 [95% CrI, 0.57-0.81]). Available data regarding the incidence of positive cultures of antimicrobial-resistant organisms were not amenable to pooling and were of very low certainty.

Conclusions and Relevance

Among adults in the ICU treated with mechanical ventilation, the use of SDD compared with standard care or placebo was associated with lower hospital mortality. Evidence regarding the effect of SDD on antimicrobial resistance was of very low certainty.

217 THE USE OF SIILO MESSAGING APP BETWEEN HOSPITAL-BASED FRAILTY INTERVENTION THERAPY TEAM AND COMMUNITY-BASED EMERGENCY DEPARTMENT IN THE HOME TEAM

Background

Effective communication is an important component of any healthcare system. There is frequent communication of patient care and information between the EDITH (Emergency Department In The Home) and the FIT (Frailty Intervention Therapy) teams, which are based across two sites. Traditionally handovers between therapists were completed via email/ fax. Siilo is a secure medical messaging app designed to facilitate instant communication of patient information between healthcare professionals in a confidential manner.

Methods

A 3-month pilot of the Siilo app was commenced in August 2021 to improve the flow of information between teams, facilitate timely decision making and improve patient care. A questionnaire to rate speed, efficiency, accuracy, accessibility and confidentiality on a 4point scale was completed by all therapy staff members. Qualitative questions regarding positive and negative aspects, and future suggestions were included.

Results

Pre-pilot the median time from EDITH assessment to receipt of handover was 20 hours. During the pilot, median time to handover was 1 hour. Speed, efficiency and accessibility of communication between teams received a median rating of 2 (“average”) pre-pilot, increasing to 4 (“excellent”) during the pilot. Accuracy and confidentiality received a median rating of 3 (“good”) pre-pilot, improving to a median rating of 4 (“excellent”). 100% of respondents reported Siilo had a positive impact on decision making and on patient care.Qualitative themes included; earlier acute care discharge planning; ease of use and reduction in paperwork. Suggestions to further improve communication between the services were made and will be explored at a later date.

Conclusion

A significant reduction in time from assessment to handover improved the flow of communication between the teams, reduced duplication of assessments and improved patient care for older patients. Confidentiality and accuracy were maintained over this period. The use of the app will be continued and suggestions to further improve the integration between the services will be implemented.

215 WHAT VALUE DOES OCCUPATIONAL THERAPY ADD TO THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE?

Background

The EDITH team has provided an alternative care pathway for older adults with emergency care that takes place in the persons’ home. The EDITH service provides both medical and Occupational Therapy assessment and intervention in the home environment with onward referrals to appropriate agencies as indicated, thus negating the need for an emergency department presentation.

Methods

To assess consistency in OT practice and assessment, an audit was completed of OT logbooks and electronic patient data. Paper count method was used. Data gathered with regards to OT process and assessment.

Results

100% of patients had at least 1 type of OT assessment (e.g functional, home environment, falls prevention, cognitive etc), 80% had at least 2 and 43% had 3 or more types of OT assessments. 100% of patients had Clinical Frailty Scores completed, 100% had their living situation and level of care supports assessed and documented. 43% of patients received onwards referrals to community supports, day hospital, voluntary supports etc.

Conclusion

The OTs complete a thorough and multifactorial assessment of the older adult within the context of their home environment. This holistic assessment approach adds significant value to the overall EDITH assessment and service. It also ensures appropriate and relevant onwards referrals are completed. It is imperative to ensure value for money with regards to health care services. In line with the HSE “Value Improvement Programme” it is timely to review OT services and ensure they are delivering consistent, high quality and high value services for our stakeholders.

239 PATIENT PERCEPTIONS OF THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

The EDITH service provides an alternative to Emergency Department (ED) attendance for the older adult by providing emergency care in the person home. It is imperative to explore how this service is received by the key stakeholders in order to ensure it is meeting the needs of older adults and to improve and diversify same.

Methods

A patient feedback survey was circulated to patients and family members who received the EDITH service. A postal option and a QR code leading to an online option were utilised. 50 surveys were randomly selected for inclusion. Quantitative data was analysed via paper count method and thematic analysis was completed for the qualitative data.

Results

74% rated the service as “excellent”, 22% “very good” and 4% “good”. Alternative options to the service were identified as “going to ED” 22% , “going to GP” 22%, “waited until they would get better” 4%, “waited until they got worse” 2%, “would do nothing” 6%. 80% rated the combined expertise of a doctor and OT as “extremely important”, 94% rated the home visit aspect as “extremely important” and 90% rated ED avoidance as “extremely important”. Key themes that emerged regarding what the service does well included “personalised care”, “ED avoidance”, “compassion” and “timeliness of service”. Areas for improvement included “improving communication loop to both patients and/or community services! and “ability to directly access the service”. 95% of respondents advised they would or have already recommended the service to others. Of note, a key theme in the comments section was the need for a similar service in other hospitals.

Conclusion

The EDITH service appears to be meeting stake-holders expectations, areas for improvement have been identified and are currently being addressed. It is imperative to obtain the perception of the service user and to tailor interventions accordingly, this feedback is invaluable in order to meet future service needs.

228 LONG TERM OUTCOMES FOR FALLS PATIENTS WHO WERE TREATED BY THE EDITH (EMERGENCY DEPARTMENT IN THE HOME) SERVICE

Background

The EDITH service provides an alternative to an ED attendance for the older adult. Medical treatment and Occupational Therapy (OT) assessment take place within the patient’s home. Patients who experience an explained fall are routinely treated by the EDITH service, these patients receive OT falls prevention and home environment assessment as standard. It is imperative to assess the long-term outcomes for these patients in order to inform future service provision.

Methods

A total of 40 patients, who were referred following an explained fall to the EDITH service and remained at home following assessment, were selected for audit. These patients were seen over a 2-month period in 2021. Data were gathered with regards to ED presentations via healthcare records and mortality rates were captured via RIP.ie

Results

At 3 months, 4 patients had re-presented to ED with a fall and 3 required admission. At 6 months, 6 patients re-presented to ED with a fall with 5 requiring admission. At 9 months, 4 patients re-presented to ED with a fall and 3 required admission. 100% of patients had an OT home environment assessment and received advice regarding falls prevention. The average age of patient was 84 years. At 1 year, the mortality rate for this patient group was 10%.

Conclusion

Patients with explained falls that were treated by the EDITH service appear to have a reasonably low ED re-attendance rate at 3, 6 and 9 months for explained falls. This may be as a result of the tailored falls prevention education/home environment assessment that took place within the patient’s home by the OT. However further audit and a larger population group would be required to suggest a definite correlation between same.

Made to measure—Selecting outcomes in aneurysmal subarachnoid hemorrhage research

There has been limited new high-level evidence generated to guide aneurysmal subarachnoid hemorrhage (aSAH) management in the past decade. The choice of outcome measures used in aSAH clinical trials may be one of the factors hindering progress. In this narrative review we consider the current process for determining “what” to measure in aSAH and identify some of the shortcomings of these approaches. A consideration of the unique clinical course of aSAH is then discussed and how this impacts on selecting the best timepoints to assess change in the chosen constructs. We also review the how to critically appraise different measurement instruments and some of the issues with how these are applied in the context of aSAH. We conclude with current initiatives to improve outcome selection in aSAH and future directions in the research agenda.

Level of sedation in critically ill adult patients: a protocol for a systematic review with meta-analysis and trial sequential analysis

INTRODUCTION

It is standard of care to provide sedation to critically ill patients to reduce anxiety, discomfort and promote tolerance of mechanical ventilation. Given that sedatives can have differing effects based on a variety of patient and pharmacological characteristics, treatment approaches are largely based on targeting the level of sedation. The benefits of differing levels of sedation must be balanced against potential adverse effects including haemodynamic instability, causing delirium, delaying awakening and prolonging the time of mechanical ventilation and intensive care stay. This systematic review with meta-analysis aims to investigate the current evidence and compare the effects of differing sedation levels in adult critically ill patients.

METHODS AND ANALYSES

We will conduct a systematic review based on searches of preidentified major medical databases (eg, MEDLINE, EMBASE, CENTRAL) and clinical trial registries from their inception onwards to identify trials meeting inclusion criteria. We will include randomised clinical trials comparing any degree of sedation with no sedation and lighter sedation with deeper sedation for critically ill patients admitted to the intensive care unit. We will include aggregate data meta-analyses and trial sequential analyses. Risk of bias will be assessed with domains based on the Cochrane risk of bias tool. An eight-step procedure will be used to assess if the thresholds for clinical significance are crossed, and the certainty of the evidence will be assessed using Grades of Recommendations, Assessment, Development and Evaluation.

ETHICS AND DISSEMINATION

No formal approval or review of ethics is required as individual patient data will not be included. This systematic review has the potential to highlight (1) whether one should believe sedation to be beneficial, harmful or neither in critically ill adults; (2) the existing knowledge gaps and (3) whether the recommendations from guidelines and daily clinical practice are supported by current evidence. These results will be disseminated through publication in a peer-reviewed journal.

A multicentre observational study of the use of antiseizure medication in patients with aneurysmal subarachnoid haemorrhage in the PROMOTE-SAH study

Our objective was to describe antiseizure medication (ASM) prescription patterns, and associations between ASM use and death and disability outcomes in patients with aneurysmal subarachnoid haemorrhage (aSAH) admitted to ICU. This was a multi-centre prospective observational study. The study took place in eleven ICUs across Australia and New Zealand. Data was collected from 1 April 2017 to 1 October 2018. Three hundred and fifty-seven adult patients with aSAH were enrolled. The primary outcome was to describe patterns of ASM prescription. The secondary outcome of interest was death or disability (modified Rankin Scale (mRS) score ≥ 4) at six months, and its association with ASM therapy, and relevant clinical subgroups. Forty percent of patients received an ASM and the most commonly used agent was levetiracetam. The median length of ASM administration was eight days (IQR 4.5-12.5). A number of patients with prehospital seizures did not receive ASM therapy (14/55, 2725%). There was a tendency towards ASM prescription with both higher radiological and clinical grade aSAH. There was no significant association between death or disability at six month (mRS ≥ 4) and ASM vs No ASM prescription. Testing for an interaction effect between ASM administration and WFNS grade suggested inferior outcomes with ASM use in lower aSAH grades (p = 0.04). In conclusion, the prescription of ASM for aSAH in Australia is variable across and within sites, with the majority of patients not receiving ASM chemoprophylaxis. We demonstrated no significant association between death or disability at six months and the use of ASM. There may be an association with poorer outcomes in patients with lower grade aSAH. This finding requires further exploration.

The incidence of cerebral arterial vasospasm following aneurysmal subarachnoid haemorrhage: a systematic review and meta-analysis

Purpose

To describe a pooled estimated incidence of cerebral arterial vasospasm (aVSP) following aneurysmal subarachnoid haemorrhage (aSAH) and to describe sources of variation in the reported incidence.

Methods

We performed a systematic review and meta-analysis of randomised clinical trials (RCTs) and cohort studies. The primary outcome was the proportion of study participants diagnosed with aVSP. We assessed for heterogeneity based on mode of imaging, indication for imaging, study design and clinical characteristics at a study level.

Results

We identified 120 studies, including 19,171 participants. More than 40 different criteria were used to diagnose aVSP. The pooled estimate of the proportion of patients diagnosed with aVSP was 0.42 (95% CI 0.39 to 0.46, I² = 96.5%). There was no evidence that the incidence aVSP was different, nor that heterogeneity was reduced, when the estimate was assessed by study type, imaging modalities, the proportion of participants with high grade CT scores or poor grade clinical scores. The pooled estimate of the proportion of study participants diagnosed with aVSP was higher in studies with routine imaging (0.47, 95% CI 0.43 to 0.52, I² = 96.5%) compared to those when imaging was performed when indicated (0.30, 95% CI 0.25 to 0.36, I² = 94.0%, p for between-group difference < 0.0005).

Conclusion

The incidence of cerebral arterial vasospasm following aSAH varies widely from 9 to 93% of study participants. Heterogeneity in the reported incidence may be due to variation in the criteria used to diagnose aVSP. A standard set of diagnostic criteria is necessary to resolve the role that aVSP plays in delayed neurological deterioration following aSAH.

PROSPERO registration

CRD42020191895

Supplementary Information

The online version contains supplementary material available at 10.1007/s00234-022-03004-w.

Temporal changes in the epidemiology of sepsis-related intensive care admissions from the emergency department in Australia and New Zealand

OBJECTIVES

The Australasian Resuscitation in Sepsis Evaluation (ARISE) study researched septic shock treatment within EDs. This study aims to evaluate whether: (i) conduct of the ARISE study was associated with changes in epidemiology and care for adults (≥18 years) admitted from EDs to ICUs with sepsis in Australia and New Zealand; and (ii) such changes differed among 45 ARISE trial hospitals compared with 120 non-trial hospitals.

METHODS

Retrospective study using interrupted time series analysis in three time periods; 'Pre-ARISE' (January 1997 to December 2007), 'During ARISE' (January 2008 to May 2014) and 'Post-ARISE' (June 2014 to December 2017) using data from the Australian and New Zealand Intensive Care Society Adult Patient Database.

RESULTS

Over 21 years there were 54 121 ICU admissions from the ED with sepsis; which increased from 8.1% to 16.4%; 54.6% male, median (interquartile range) age 66 (53-76) years. In the pre-ARISE period, pre-ICU ED length of stay (LOS) decreased in trial hospitals but increased in non-trial hospitals (P = 0.174). During the ARISE study, pre-ICU ED LOS declined more in trial hospitals (P = 0.039) as did the frequency of mechanical ventilation in the first 24 h (P = 0.003). However, ICU and hospital LOS, in-hospital mortality and risk of death declined similarly in both trial and non-trial hospitals.

CONCLUSIONS

Sepsis-related admissions increased from 8.1% to 16.4%. During the ARISE study, there was more rapid ICU admission and decreased early ventilation. However, these changes were not sustained nor associated with decreased risk of death or duration of hospitalisation.

Patient-centred outcomes are under-reported in the critical care burns literature: a systematic review

BACKGROUND

Developments in the care of critically ill patients with severe burns have led to improved hospital survival, but long-term recovery may be impaired. The extent to which patient-centred outcomes are assessed and reported in studies in this population is unclear.

METHODS

We conducted a systematic review to assess the outcomes reported in studies involving critically ill burns patients. Randomised controlled trials (RCTs) and cohort studies on the topics of fluid resuscitation, analgesia, haemodynamic monitoring, ventilation strategies, transfusion targets, enteral nutrition and timing of surgery were included. We assessed the outcomes reported and then classified these according to two suggested core outcome sets.

RESULTS

A comprehensive search returned 6154 studies; 98 papers met inclusion criteria. There were 66 RCTs, 19 clinical studies with concurrent controls and 13 interventional studies without concurrent controls. Outcome reporting was inconsistent across studies. Pain, reported using the visual analogue scale, fluid volume administered and mortality were the only outcomes measured in more than three studies. Sixty-six studies (67%) had surrogate primary outcomes. Follow-up was poor, with median longest follow-up across all studies 5 days (IQR 3-28). When compared to the suggested OMERACT core outcome set, 53% of papers reported on mortality, 28% reported on life impact, 30% reported resource/economic outcomes and 95% reported on pathophysiological manifestations. Burns-specific Falder outcome reporting was globally poor, with only 4.3% of outcomes being reported across the 98 papers.

CONCLUSION

There are deficiencies in the reporting of outcomes in the literature pertaining to the intensive care management of patients with severe burns, both with regard to the consistency of outcomes as well as a lack of focus on patient-centred outcomes. Long-term outcomes are infrequently reported. The development and validation of a core outcome dataset for severe burns would improve the quality of reporting.

Decompressive craniectomy practice following traumatic brain injury, in comparison with randomized trials

High quality evidence shows decompressive craniectomy (DC) following traumatic brain injury (TBI) may improve survival but increase the number of severely disabled survivors. Contemporary international practice is unknown. We sought to describe international use of DC, and the alignment with evidence and clinical practice guidelines, by analyzing the harmonized CENTER-TBI and OzENTER-TBI Core study datasets. These include patients admitted to ICUs in Europe, the United Kingdom and Australia between 2015 and 2017. Outcomes of interest were treatment with DC relative to clinical trial evidence and the Brain Trauma Foundation guidelines. Of 2336 people admitted to ICUs following TBI, DC was performed in 320 (13.7%): in 64/1422 (4.5%) patients with diffuse TBI, and 195/640 (30.5%) patients with traumatic mass lesions. Secondary DC (for treatment of intracranial hypertension) was used infrequently in patients who met enrolment criteria of the two randomised clinical trials informing the guidelines: in 11/124 (8.9%) of those matching DECRA enrolment, and in 30/224 (13.4%) of those matching RESCUEicp. Of patients who underwent DC 258/320 (80.6%) were ineligible for either trial: 149/320 (46.6%) underwent primary DC, 62/320 (19.4%) were outside the trials' age criteria, and 126/320 (39.4%) did not develop intracranial hypertension refractory to non-operative therapies prior to DC. Secondary DC was used infrequently in patients in whom it had been shown to be potentially harmful, indicating alignment between contemporaneous evidence and practice. However, most patients who underwent DC were ineligible for the key trials; whether they benefitted from DC remains unknown.

Balanced Multielectrolyte Solution versus Saline in Critically Ill Adults

BACKGROUND

Whether the use of balanced multielectrolyte solution (BMES) in preference to 0.9% sodium chloride solution (saline) in critically ill patients reduces the risk of acute kidney injury or death is uncertain.

METHODS

In a double-blind, randomized, controlled trial, we assigned critically ill patients to receive BMES (Plasma-Lyte 148) or saline as fluid therapy in the intensive care unit (ICU) for 90 days. The primary outcome was death from any cause within 90 days after randomization. Secondary outcomes were receipt of new renal-replacement therapy and the maximum increase in the creatinine level during ICU stay.

RESULTS

A total of 5037 patients were recruited from 53 ICUs in Australia and New Zealand - 2515 patients were assigned to the BMES group and 2522 to the saline group. Death within 90 days after randomization occurred in 530 of 2433 patients (21.8%) in the BMES group and in 530 of 2413 patients (22.0%) in the saline group, for a difference of -0.15 percentage points (95% confidence interval [CI], -3.60 to 3.30; P = 0.90). New renal-replacement therapy was initiated in 306 of 2403 patients (12.7%) in the BMES group and in 310 of 2394 patients (12.9%) in the saline group, for a difference of -0.20 percentage points (95% CI, -2.96 to 2.56). The mean (±SD) maximum increase in serum creatinine level was 0.41±1.06 mg per deciliter (36.6±94.0 μmol per liter) in the BMES group and 0.41±1.02 mg per deciliter (36.1±90.0 μmol per liter) in the saline group, for a difference of 0.01 mg per deciliter (95% CI, -0.05 to 0.06) (0.5 μmol per liter [95% CI, -4.7 to 5.7]). The number of adverse and serious adverse events did not differ meaningfully between the groups.

CONCLUSIONS

We found no evidence that the risk of death or acute kidney injury among critically ill adults in the ICU was lower with the use of BMES than with saline. (Funded by the National Health and Medical Research Council of Australia and the Health Research Council of New Zealand; PLUS ClinicalTrials.gov number, NCT02721654.).

Balanced Crystalloids versus Saline in Critically Ill Adults - A Systematic Review with Meta-Analysis

Balanced Crystalloids and Saline in Critical IllnessThis article presents a frequentist (showing no significant difference) and Bayesian (in which the posterior probability that balanced crystalloids reduced mortality was 89.5%) systematic review of randomized clinical trials comparing balanced crystalloids with saline in critically ill adults with the primary outcome of 90-day mortality.

Association of hypertension with mortality in patients hospitalised with COVID-19

Objective

To assess whether hypertension is an independent risk factor for mortality among patients hospitalised with COVID-19, and to evaluate the impact of ACE inhibitor and angiotensin receptor blocker (ARB) use on mortality in patients with a background of hypertension.

Method

This observational cohort study included all index hospitalisations with laboratory-proven COVID-19 aged ≥18 years across 21 Australian hospitals. Patients with suspected, but not laboratory-proven COVID-19, were excluded. Registry data were analysed for in-hospital mortality in patients with comorbidities including hypertension, and baseline treatment with ACE inhibitors or ARBs.

Results

546 consecutive patients (62.9±19.8 years old, 51.8% male) hospitalised with COVID-19 were enrolled. In the multivariable model, significant predictors of mortality were age (adjusted OR (aOR) 1.09, 95% CI 1.07 to 1.12, p<0.001), heart failure or cardiomyopathy (aOR 2.71, 95% CI 1.13 to 6.53, p=0.026), chronic kidney disease (aOR 2.33, 95% CI 1.02 to 5.32, p=0.044) and chronic obstructive pulmonary disease (aOR 2.27, 95% CI 1.06 to 4.85, p=0.035). Hypertension was the most prevalent comorbidity (49.5%) but was not independently associated with increased mortality (aOR 0.92, 95% CI 0.48 to 1.77, p=0.81). Among patients with hypertension, ACE inhibitor (aOR 1.37, 95% CI 0.61 to 3.08, p=0.61) and ARB (aOR 0.64, 95% CI 0.27 to 1.49, p=0.30) use was not associated with mortality.

Conclusions

In patients hospitalised with COVID-19, pre-existing hypertension was the most prevalent comorbidity but was not independently associated with mortality. Similarly, the baseline use of ACE inhibitors or ARBs had no independent association with in-hospital mortality.

215 WHAT IMPACT CAN ‘EMERGENCY DEPARTMENT IN THE HOME’ (EDITH) HAVE ON THE OLDER ADULT POPULATION PRESENTING WITH FALLS?

Background

EDITH is a frailty response service providing medical and occupational therapy input to older adults living within the catchment area of a level 4 acute hospital. EDITH aims to reduce avoidable Emergency Department (ED) attendances and utilise alternative care pathways. Falls are common among older people and are often associated with poorer outcomes. Traditionally, older patients who have had a fall and contact emergency services for assistance are transferred to the ED and this can be associated with elevated risks. Additionally, older patients who have had a fall and are discharged on scene by the emergency services are at greater risk of recurring falls in the absence of immediate onward referral to community falls prevention services (Nowak and Hubbard 2009).

Methods

Paper count method data collection was completed. Inclusion criteria included referrals from the National Ambulance Service within the last 6 months.

Results

75 patients met the inclusion criteria; 34 males, 41 females with an average age of 82. 11 patients were conveyed to hospital, giving a conveyance rate of 14.6%, the average conveyance rate for the EDITH service is 7.2%. 3 patients were conveyed to ED, while 8 patients were conveyed to the Medical Assessment Unit (MAU) in the local level 3 hospital. This resulted in 72% of patients that required hospital conveyance being streamed to the MAU; traditionally 100% of these patients would have presented to ED. Overall, 85.4% of patients seen remained at home.

Conclusion

EDITH are providing targeted medical and occupational therapy assessment(s) for older adults in their homes with successful outcomes. Implementation of alternative care pathways, reduction in avoidable ED attendances and prolonged independence in the home for this patient profile are some of the favourable findings.

Reference

1. Nowak A, Hubbard RE. (2009) Falls and frailty: lessons from complex systems. Journal of the Royal Society of Medicine. 102(3):98–102.

106 EDITH (EMERGENCY DEPARTMENT IN THE HOME): AN 18 MONTH AUDIT OF A NOVEL SERVICE

Background

The EDITH team has provided an alternative care pathway for older adults in need of emergency services. The traditional model, which involved the transport of an older adult to an emergency department has been replaced with emergency care that takes place in the persons’ home. The EDITH service provides both medical and Occupational Therapy assessment and intervention in the home environment with onward referrals to appropriate agencies as indicated, thus negating the need for an emergency department presentation.

Methods

Data from electronic patient records and OT logbooks were audited from the period 22/02/20 to 09/08/21. Data was gathered regarding attendances, outcomes and conveyance rates.

Results

Since its’ inception the EDITH service has treated 3,137 patients. Following treatment, 2,909 patients remained at home while 228 patients were transferred to hospital. This gives a conveyance rate of 7.2%. Three hundred and thirty six patients were referred to primary care or day hospital services. The average age of patients is 82 years and the average Manchester Triage category is priority 4. The EDITH service has saved the hospital 7.9 years of bed days (2,909 bed days) as these patients have not presented to the emergency department.

Conclusion

There is a growing body of evidence highlighting the detrimental impact a hospitalisation can have on an older adult (Mudge et al., 2019). There is a clear need for health care services to diversify in order to meet the needs of this ageing population. The EDITH service is leading this change in Irish healthcare by providing specialised emergency care and OT intervention for the older adult in their own homes.

Reference

1. Mudge et al. (2019). Hospital-Associated Complications of Older People: A Proposed Multicomponent Outcome for Acute Care. Journal of the American Geriatrics Society. 67(2).

107 EMERGENCY DEPARTMENT IN THE HOME, WHO IS THE EDITH PATIENT?

Background

The EDITH team has provided an alternative care pathway for older adults in need of emergency services. This vulnerable patient population receive emergency medical and occupational therapy treatment and intervention in their home environment. The typical patient profile is assumed to be ‘frail older adults’, but this needs to be more specifically defined within the clinical practice in EDITH.

Methods

A total of 230 electronic patient records were selected at random. Data was audited and analysed with regard to clinical descriptors for this patient population.

Results

Of the 230 patients treated, 26 were referred to hospital or rehabilitation facilities. This is a conveyance rate of 11% which is above the average rate of 7.2% for this service.

The Rockwood Clinical Frailty Scale (CFS): 22% had a CFS of 5 (mildly frail), 37% had a CFS of 6 (moderately frail), 22% had a CFS of 7 (severely frail), 3% had a CFS of 8 (very severely frail).

Living Status: 26% living alone, 48% living with family, 4% sheltered living accommodation and 22% in nursing homes.

Formal Supports: 37% have no formal supports, 18% have &lt;10 hours per week, 19% have between 11–21 hours, 4% have 24-hour care and 22% reside in nursing homes.

Presenting complaint: 41% medically unwell, 23% fall, 14% functional decline, 9% pain, 5% infection, 5% orthopaedic and 2% confusion.

Ages range from 61 years to 100 years with an average age of 82 years.

Conclusion

It is imperative to identify the type of patient that uses this service, in order to plan for future service needs and ensure their current clinical care needs are being met. Of note, a significant proportion of patients are living alone, have high CFS scores and have no formal supports in situ.

Association between intravenous fluid resuscitation and outcome among patients with suspected infection and sepsis: A retrospective cohort study

OBJECTIVE

To investigate the association between timing and volume of intravenous fluids administered to ED patients with suspected infection and all-cause in-hospital mortality.

METHODS

Retrospective cohort study of ED presentations at four metropolitan hospitals in Sydney, Australia, between October 2018 and May 2019. Patients over 16 years of age with suspected infection who received intravenous fluids within 24 h of presentation were included.

RESULTS

During the study period, 7533 patients with suspected infection received intravenous fluids. Of these, 1996 (26.5%) and 231 (3.1%) had suspected sepsis and septic shock, respectively. Each 1000 mL increase in intravenous fluids administered was associated with a reduction in risk of in-hospital mortality (adjusted odds ratio [AOR] 0.87, 95% confidence interval [CI] 0.76-0.99). This association was stronger in patients with septic shock (AOR 0.66, 95% CI 0.49-0.89), and those admitted to intensive care unit (ICU) (AOR 0.74, 95% CI 0.56-0.96). Patients with suspected sepsis and septic shock who received a total volume of >3600 mL had lower in-hospital mortality (AOR 0.44, 95% CI 0.22-0.91; AOR 0.16, 95% CI 0.05-0.57) compared to those administered <3600 mL within the first 24 h of presenting to the ED. There was no association between the time of initiation of fluids and in-hospital mortality among survivors and non-survivors (2.3 vs 2.5 h, P = 0.50).

CONCLUSION

We observed a reduction in risk of in-hospital mortality for each 1000 mL increase in intravenous fluids administered in patients with septic shock or admitted to ICU suggesting illness severity to be a likely effect modifier.