Critical Care and Resuscitation最新文献

{"title":"Regional access to a centralized extracorporeal membrane oxygenation (ECMO) service in Victoria, Australia","authors":"Joanna WY. Chow MBBS ,&nbsp;John F. Dyett MBBS ,&nbsp;Steve Hirth MIT ,&nbsp;Julia Hart MD ,&nbsp;Graeme J. Duke MBBS, MD","doi":"10.1016/j.ccrj.2023.11.007","DOIUrl":"10.1016/j.ccrj.2023.11.007","url":null,"abstract":"<div><h3>Introduction</h3><p>Victoria, Australia provides a centralised state ECMO service, supported by ambulance retrieval. Equity of access to this service has not been previously described.</p></div><div><h3>Objective</h3><p>Describe the characteristics of ECMO recipients and quantify geographical and socioeconomic influence on access.</p></div><div><h3>Design</h3><p>Retrospective observational study with spatial mapping.</p></div><div><h3>Participants and setting</h3><p>Adult (≥18 years) ECMO recipients from July 2016–June 2022. Data from administrative Victorian Admissions Episodes Database analysed in conjunction with Australian Urban Research Infrastructure Network population data and choropleth mapping. Presumed ECMO modes were inferred from cardiopulmonary bypass and pre-hospital cardiac arrest codes. Spatial autoregressive models including Moran's test used for spatial lag testing.</p></div><div><h3>Outcomes</h3><p>Demographics and outcomes of ECMO recipients; ECMO incidence by patient residence (Statistical-Area Level 2, SA-2) and Index of Relative Socioeconomic Advantage and Disadvantage (IRSAD); and ECMO utilisation adjusted for patient factors and linear distance from the central ECMO referral site.</p></div><div><h3>Results</h3><p>631 adults received ECMO over 6 years, after exclusion of paediatric (n = 242), duplicate (n = 135), and interstate or incomplete (n = 72) records. Mean age was 51.8 years, and 68.8 % were male. Overall ECMO incidence was 3.00 ± 3.95 per 10⁵ population. 135 (21.4 %) were presumed VA-ECMO, 59 (9.3 %) presumed ECPR, and 437 (69.3 %) presumed VV-ECMO. Spatial lag was non-significant after adjusting for patient characteristics. Distance from the central referral site (dy/dx = 0.19, 95% CI −0.41–0.04, p = 0.105) and IRSAD score (dy/dx = 0.17, 95% CI −0.19–0.53, p = 0.359) did not predict ECMO utilisation.</p></div><div><h3>Conclusion</h3><p>Victorian ECMO incidence rates were low. We did not find evidence of inequity of access to ECMO irrespective of regional area or socioeconomic status.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 1","pages":"Pages 47-53"},"PeriodicalIF":2.9,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022305/pdfft?md5=874c0a47498fe407518adfd01eb39f56&pid=1-s2.0-S1441277223022305-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139017810","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"An intensivist-led ECMO accreditation pathway and safety data over the first 4 years","authors":"Stuart C. Duffin BMedSci, MBBS, FCICM, DESA, EDIC ,&nbsp;Judith H. Askew BAppSci, MBBS, FCICM ,&nbsp;Timothy J. Southwood MBBS, MSc, FCICM ,&nbsp;Paul Forrest MBCHB, FANZCA ,&nbsp;Brian Plunkett MBChB, FRACS ,&nbsp;Richard J. Totaro MBBS, FRACP, FCICM","doi":"10.1016/j.ccrj.2023.11.006","DOIUrl":"10.1016/j.ccrj.2023.11.006","url":null,"abstract":"<div><h3>Objective</h3><p>To describe the training and accreditation process behind an intensivist-led extracorporeal membrane oxygenation (ECMO) cannulation program, and identify the rate of complications associated with the ECMO cannulation procedure.</p></div><div><h3>Design</h3><p>A narrative review of the accreditation process, and a retrospective review of complications related to cannulation during the first four years of the intensivist program.</p></div><div><h3>Setting</h3><p>Royal Prince Alfred Hospital, a quaternary referral hospital in Sydney.</p></div><div><h3>Participants</h3><p>All patients initiated onto ECMO during the first four years of the intensivist cannulation program (August 2018 to August 2022).</p><p>Main outcome measures: All cases were reviewed for identification of 14 pre-defined adverse events which were classified as low, medium or high clinical significance complications.</p></div><div><h3>Results</h3><p>A total of 402 cannulations were attempted by the intensivist group in 194 separate cannulation episodes involving 179 patients. This included 93 V–V initiations, 69 V-A initiations (36 of these ECMO-CPR), 3 V-AV (veno-arteriovenous) initiations, 25 ECMO reconfigurations and four patients cannulated for peripheral cardiopulmonary bypass in cardiothoracic theatre. One of the 402 cannulations was halted as resuscitation was ceased, and one was halted and the patient transferred to theatre for central arterial cannulation. 394 out of the remaining 400 cannulations were successful (98.5%). Of 402 total cannulations, 32 complication events occurred (7.96% event rate), of which 15 (3.7% event rate) were low significance complications, 10 medium significance (2.5% event rate), and seven high clinical significance (1.7% event rate).</p></div><div><h3>Conclusions</h3><p>Our experience of the first four years of an intensivist-led ECMO service demonstrates that our training process and cannulation technique result in the provision of a complex therapy with low levels of complications, on par with those in the published literature.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"26 1","pages":"Pages 41-46"},"PeriodicalIF":2.9,"publicationDate":"2024-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022299/pdfft?md5=9c4c5445c9260ca547003e4f7a54ce7b&pid=1-s2.0-S1441277223022299-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139019948","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"The pressure reactivity index as a measure of cerebral autoregulation and its application in traumatic brain injury management","authors":"Zac A. Tsigaras MD ,&nbsp;Mark Weeden MBBS ,&nbsp;Robert McNamara BMBS ,&nbsp;Toby Jeffcote PhD ,&nbsp;Andrew A. Udy PhD","doi":"10.1016/j.ccrj.2023.10.009","DOIUrl":"10.1016/j.ccrj.2023.10.009","url":null,"abstract":"<div><p>Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality globally. The Brain Trauma Foundation guidelines advocate for the maintenance of a cerebral perfusion pressure (CPP) between 60 and 70 mmHg following severe TBI. However, such a uniform goal does not account for changes in cerebral autoregulation (CA). CA refers to the complex homeostatic mechanisms by which cerebral blood flow is maintained, despite variations in mean arterial pressure and intracranial pressure. Disruption to CA has become increasingly recognised as a key mediator of secondary brain injury following severe TBI. The pressure reactivity index is calculated as the degree of statistical correlation between the slow wave components of mean arterial pressure and intracranial pressure signals and is a validated dynamic marker of CA status following brain injury. The widespread acceptance of pressure reactivity index has precipitated the consideration of individualised CPP targets or an optimal cerebral perfusion pressure (CPPopt). CPPopt represents an alternative target for cerebral haemodynamic optimisation following severe TBI, and early observational data suggest improved neurological outcomes in patients whose CPP is more proximate to CPPopt. The recent publication of a prospective randomised feasibility study of CPPopt guided therapy in TBI, suggests clinicians caring for such patients should be increasingly familiar with these concepts. In this paper, we present a narrative review of the key landmarks in the development of CPPopt and offer a summary of the evidence for CPPopt-based therapy in comparison to current standards of care.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 229-236"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022202/pdfft?md5=3aaa9706cf83c230ad90f982dca035d4&pid=1-s2.0-S1441277223022202-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139026239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Masking of an intravenous preparation of ceftriaxone for use in clinical trials: A technical report","authors":"David M. Golding MBBCh, BSc, PGDip ,&nbsp;Tak Wai Chan BMedSci, BMBS ,&nbsp;Nikola G. Orozov MPharm, PGDipClinPharm ,&nbsp;Paul J. Young MBChB, PhD","doi":"10.1016/j.ccrj.2023.10.002","DOIUrl":"https://doi.org/10.1016/j.ccrj.2023.10.002","url":null,"abstract":"<div><h3>Background</h3><p>Intravenous antibiotics are often evaluated in clinical trials in hospitalised patients but for blinded trials masking of antibiotics is required.</p></div><div><h3>Objective</h3><p>To evaluate the effectiveness of masking of ceftriaxone and amoxicillin / clavulanic acid for use in blinded clinical trials.</p></div><div><h3>Design, setting, and participants</h3><p>Amoxicillin / clavulanic acid (1.2g) and ceftriaxone (1g and 2g) were diluted in 100mL of sodium chloride. Clinicians from a single centre were asked to attempt to distinguish solutions containing antibiotics from solutions without added antibiotics at time points up to 12 hours following dilution.</p></div><div><h3>Results</h3><p>1g of ceftriaxone diluted in 100 mL of 0.9 sodium chloride stored in a light-protected bag and refrigerated at 3–4 °C for up to 10 h could not readily be distinguished from 100 mL of 0.9 % sodium chloride. However, solutions containing either amoxicillin / clavulanic acid (1.2g) or ceftriaxone (2g) were readily identifiable.</p></div><div><h3>Conclusions</h3><p>1 g of ceftriaxone can be effectively masked by dilution in 100mL of sodium chloride.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 172-174"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223005197/pdfft?md5=e7dacd1406f9e34280d35ca19a0c7474&pid=1-s2.0-S1441277223005197-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139038538","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Perceptions of intensive care triage in Australia and New Zealand in 2009 and 2023","authors":"William B. Blackburne MBChB, BMedSc(Hons),&nbsp;Paul J. Young MBChB, PhD, FCICM","doi":"10.1016/j.ccrj.2023.10.001","DOIUrl":"https://doi.org/10.1016/j.ccrj.2023.10.001","url":null,"abstract":"<div><h3>Objective</h3><p>Intensive care (ICU) beds are scarce and decision-making regarding admission is complex and multi-factorial. This study aimed to characterise differences in admission decision making between Australia and New Zealand and compare to previous data to establish changes over time.</p></div><div><h3>Design</h3><p>Online Survey.</p></div><div><h3>Setting and Participants</h3><p>An online survey was distributed to Australian and New Zealand intensive care doctors measuring triage behaviours in the last week and responses to ICU triage scenarios.</p></div><div><h3>Main Outcome Measures</h3><p>Perceived ICU admission behaviours.</p></div><div><h3>Results</h3><p>103 responses were obtained, 83(80.6%) from Australia and 97 (94.2%) from specialist intensivists. The median number of triage decisions and patients declined were 6-10 and 1-5 respectively. No difference was noted in the role of ICU bed capacity in decision making between Australia and New Zealand. Compared to Australian intensivists, New Zealand intensivists were less likely to admit a patient: with relapsed acute myeloid leukaemia (AML) and acute respiratory distress syndrome (ARDS)(p=0.03), with persistent vegetative state and community acquired (p=0.02) or iatrogenic (p=0.03) pneumonia. Compared to respondents in 2009 (n=238), 2023 respondents were more likely to admit a patient: with a severe intracranial bleed who may become braindead (p=0.005), with relapsed AML and ARDS (p=0.02), with stroke for palliative care (p&lt;0.001); and less likely to admit a patient with persistent vegetative state and iatrogenic pneumonia (p=0.03). In a multivariable analysis, respondents from Australian compared to New Zealand and from 2023 compared to 2009 were more likely to indicate they would admit patients to the ICU in the scenarios described (p&lt;0.001 for both comparisons).</p></div><div><h3>Conclusions</h3><p>Our study suggests that New Zealand intensivists may apply more restrictive ICU admission criteria than Australian intensivists. Changes in attitudes to admission since 2009 may reflect increased awareness of the importance of facilitating organ donation and the role of ICU as providers of palliative care.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 161-171"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223005173/pdfft?md5=fdcf748f336da0e420536690d82dd950&pid=1-s2.0-S1441277223005173-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139038539","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Protocol and statistical analysis plan for the identification and treatment of hypoxemic respiratory failure and acute respiratory distress syndrome with protection, paralysis, and proning: A type-1 hybrid stepped-wedge cluster randomised effectiveness-implementation study","authors":"Ken Kuljit S. Parhar MD, MSc ,&nbsp;Andrea Soo PhD ,&nbsp;Gwen Knight BA ,&nbsp;Kirsten Fiest PhD ,&nbsp;Daniel J. Niven MD MSc PhD ,&nbsp;Gordon Rubenfeld MD, MSc ,&nbsp;Damon Scales MD, PhD ,&nbsp;Henry T. Stelfox MD, PhD ,&nbsp;Danny J. Zuege MD MSc ,&nbsp;Sean Bagshaw MD, MSc","doi":"10.1016/j.ccrj.2023.10.008","DOIUrl":"10.1016/j.ccrj.2023.10.008","url":null,"abstract":"<div><h3>Objective</h3><p>To describe a study protocol and statistical analysis plan (SAP) for the identification and treatment of hypoxemic respiratory failure (HRF) and acute respiratory distress syndrome (ARDS) with protection, paralysis, and proning (TheraPPP) study prior to completion of recruitment, electronic data retrieval, and analysis of any data.</p></div><div><h3>Design</h3><p>TheraPPP is a stepped-wedge cluster randomised study evaluating a care pathway for HRF and ARDS patients. This is a type-1 hybrid effectiveness-implementation study design evaluating both intervention effectiveness and implementation; however primarily powered for the effectiveness outcome.</p></div><div><h3>Setting</h3><p>Seventeen adult intensive care units (ICUs) across Alberta, Canada.</p></div><div><h3>Participants</h3><p>We estimate a sample size of 18816 mechanically ventilated patients, with 11424 patients preimplementation and 7392 patients postimplementation. We estimate 2688 sustained ARDS patients within our study cohort.</p></div><div><h3>Intervention</h3><p>An evidence-based, stakeholder-informed, multidisciplinary care pathway called Venting Wisely that standardises diagnosis and treatment of HRF and ARDS patients.</p></div><div><h3>Main outcome measures</h3><p>The primary outcome is 28-day ventilator-free days (VFDs). The primary analysis will compare the mean 28-day VFDs preimplementation and postimplementation using a mixed-effects linear regression model. Prespecified subgroups include sex, age, HRF, ARDS, COVID-19, cardiac surgery, body mass index, height, illness acuity, and ICU volume.</p></div><div><h3>Results</h3><p>This protocol and SAP are reported using the Standard Protocol Items: Recommendations for Interventional Trials guidance and the Guidelines for the Content of Statistical Analysis Plans in Clinical Trials. The study received ethics approval and was registered (ClinicalTrials.gov-NCT04744298) prior to patient enrolment.</p></div><div><h3>Conclusions</h3><p>TheraPPP will evaluate the effectiveness and implementation of an HRF and ARDS care pathway.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 207-215"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022196/pdfft?md5=2ae1ea805852b74cbfed73d30f40408e&pid=1-s2.0-S1441277223022196-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139025239","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Iron and erythropoietin to heal and recover after intensive care (ITHRIVE): A pilot randomised clinical trial","authors":"Edward Litton MBChB FCICM PhD ,&nbsp;Craig French FCICM ,&nbsp;Alan Herschtal PhD ,&nbsp;Simon Stanworth FRACP PhD ,&nbsp;Susan Pellicano RN ,&nbsp;Anne Marie Palermo RN ,&nbsp;Samantha Bates RN ,&nbsp;Sarah Van Der Laan MBChb ,&nbsp;Ege Eroglu BSc ,&nbsp;David Griffith MRCP PhD ,&nbsp;Akshay Shah MRCP PhD","doi":"10.1016/j.ccrj.2023.10.007","DOIUrl":"10.1016/j.ccrj.2023.10.007","url":null,"abstract":"<div><h3>Objective</h3><p>To determine the feasibility of a pivotal randomised clinical trial of intravenous (IV) iron and erythropoietin in adult survivors of critical illness with anaemia requiring treatment in the intensive care unit.</p></div><div><h3>Design</h3><p>An investigator-initiated, parallel group, placebo-controlled, randomised feasibility trial.</p></div><div><h3>Setting</h3><p>A tertiary intensive care unit (ICU) in Perth, Western Australia.</p></div><div><h3>Participants</h3><p>Adults with anaemia (haemoglobin &lt;100 g/L), requiring ICU-level care for more than 48 h, and likely to be ready for ICU discharge within 24 h.</p></div><div><h3>Interventions</h3><p>A single dose of IV ferric carboxymaltose and Epoetin alfa (active group) or an equal volume of 0.9% saline (placebo group).</p></div><div><h3>Main outcome measures</h3><p>Study feasibility was considered met if the pilot achieved a recruitment rate of ≥2 participants per site per month, ≥90% of participants received their allocated study treatment, and≥ 90% of participants were followed up for the proposed pivotal trial primary outcome - days alive and at home to day 90 (DAH₉₀).</p></div><div><h3>Results</h3><p>The 40-participant planned sample size included twenty in each group and was enrolled between 1/9/2021 and 2/3/2022. Participants spent a median of 3.4 days (interquartile range 2.8–5.1) in the ICU prior to enrolment and had a mean baseline haemoglobin of 83.7 g/L (standard deviation 6.7). The recruitment rate was 6.7 participants per month [95% confidence interval (CI) 4.8–9.0], DAH₉₀ follow-up was 100% (95% CI 91.2%–100%), and 39 (97.5%, 95% CI 86.8%–99.9%) participants received the allocated study intervention. No serious adverse events were reported.</p></div><div><h3>Conclusion</h3><p>The iron and erythropoietin to heal and recover after intensive care (ITHRIVE) pilot demonstrated feasibility based on predefined participant recruitment, study drug administration, and follow-up thresholds.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 201-206"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022184/pdfft?md5=c4a3fa18a31ed9b694b8d67d791717ab&pid=1-s2.0-S1441277223022184-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138989066","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Transfusion practices in intensive care units: An Australian and New Zealand point prevalence study","authors":"Andrew W.J. Flint MBBS (MD) ,&nbsp;Karina Brady PhD ,&nbsp;Erica M. Wood MBBS (MD) ,&nbsp;Le Thi Phuong Thao PhD ,&nbsp;Naomi Hammond PhD (RN) ,&nbsp;Serena Knowles PhD (RN) ,&nbsp;Conrad Nangla BMsc ,&nbsp;Michael C. Reade PhD (MD) ,&nbsp;Zoe K. McQuilten PhD (MD) ,&nbsp;The George Institute for Global Health, the Australian and New Zealand Intensive Care Society Clinical Trials Group and the Blood Synergy Program","doi":"10.1016/j.ccrj.2023.10.006","DOIUrl":"10.1016/j.ccrj.2023.10.006","url":null,"abstract":"<div><h3>Objective</h3><p>To describe current transfusion practices in intensive care units (ICUs) in Australia and New Zealand, compare them against national guidelines, and describe how viscoelastic haemostatic assays (VHAs) are used in guiding transfusion decisions.</p></div><div><h3>Design, setting and participants</h3><p>Prospective, multicentre, binational point-prevalence study. All adult patients admitted to participating ICUs on a single day in 2021.</p></div><div><h3>Main outcome measures</h3><p>Transfusion types, amounts, clinical reasons, and triggers; use of anti-platelet medications, anti-coagulation, and VHA.</p></div><div><h3>Results</h3><p>Of 712 adult patients in 51 ICUs, 71 (10%) patients received a transfusion during the 24hr period of observation. Compared to patients not transfused, these patients had higher Acute Physiology and Chronic Health Evaluation II scores (19 versus 17, <em>p</em> = 0.02), a greater proportion were mechanically ventilated (49.3% versus 37.3%, <em>p</em> &lt; 0.05), and more had systemic inflammatory response syndrome (70.4% versus 51.3%, <em>p</em> &lt; 0.01). Overall, 63 (8.8%) patients received red blood cell (RBC) transfusions, 10 (1.4%) patients received platelet transfusions, 6 (0.8%) patients received fresh frozen plasma (FFP), and 5 (0.7%) patients received cryoprecipitate. VHA was available in 42 (82.4%) sites but only used in 6.6% of transfusion episodes when available. Alignment with guidelines was found for 98.6% of RBC transfusions, but only 61.6% for platelet, 28.6% for FFP, and 20% for cryoprecipitate transfusions.</p></div><div><h3>Conclusions</h3><p>Non-RBC transfusion decisions are often not aligned with guidelines and VHA is commonly available but rarely used to guide transfusions. Better evidence to guide transfusions in ICUs is needed.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 193-200"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022172/pdfft?md5=c6344f857a0f4b723f765b5b46f53869&pid=1-s2.0-S1441277223022172-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"138993732","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Breaches of pre-medical emergency team call criteria in an Australian hospital","authors":"Daryl Jones BSc Hons, MB BS, FRACP, FCICM, MD, PhD ,&nbsp;Kartik Kishore MSc Data Science ,&nbsp;Glenn Eastwood RN, BN, BNHons GDipNurs CritCare, PhD ,&nbsp;Stephanie K. Sprogis RN, BN, MuNrsPrac, PhD ,&nbsp;Neil J. Glassford BSc, MBChB, PhD, MRCP, FCICM","doi":"10.1016/j.ccrj.2023.11.002","DOIUrl":"10.1016/j.ccrj.2023.11.002","url":null,"abstract":"<div><h3>Objectives and outcomes</h3><p>To evaluate the 24hrs before medical emergency team (MET) calls to examine: 1) the frequency, nature, and timing of pre-MET criteria breaches; 2) differences in characteristics and outcomes between patients who did and didn't experience pre-MET breaches.</p></div><div><h3>Design</h3><p>Retrospective observational study November 2020–June 2021.</p></div><div><h3>Setting</h3><p>Tertiary referral Australian hospital.</p></div><div><h3>Participants</h3><p>Adults (≥18 years) experiencing MET calls.</p></div><div><h3>Results</h3><p>Breaches in pre-MET criteria occurred prior to 1886/2255 (83.6%) MET calls, and 1038/1281 (81.0%) of the first MET calls. Patients with pre-MET breaches were older (median [IQR] 72 [57–81] vs 66 [56–77] yrs), more likely to be admitted from home (87.8% vs 81.9%) and via the emergency department (73.0% vs 50.2%), but less likely to be for full resuscitation after (67.3% vs 76.5%) the MET. The three most common pre-MET breaches were low SpO₂ (48.0%), high pulse rate (39.8%), and low systolic blood pressure (29.0%) which were present for a median (IQR) of 15.4 (7.5–20.8), 13.2 (4.3–21.0), and 12.6 (3.5–20.1) hrs before the MET call, respectively. Patients with pre-MET breaches were more likely to need intensive care admission within 24 h (15.6 vs 11.9%), have repeat MET calls (33.3 vs 24.7%), and die in hospital (15.8 vs 9.9%).</p></div><div><h3>Conclusions</h3><p>Four-fifths of MET calls were preceded by pre-MET criteria breaches, which were present for many hours. Such patients were older, had more limits of treatment, and experienced worse outcomes. There is a need to improve goals of care documentation and pre-MET management of clinical deterioration.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 223-228"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022251/pdfft?md5=49d96d5a66bdf44a262331a16cc3fe49&pid=1-s2.0-S1441277223022251-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139013131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Remi-fent 1—A pragmatic randomised controlled study to evaluate the feasibility of using remifentanil or fentanyl as sedation adjuncts in mechanically ventilated patients","authors":"Arvind Rajamani FCICM, DDU ,&nbsp;Ashwin Subramaniam FCICM, PHD ,&nbsp;Brian Lung MBBS ,&nbsp;Kristy Masters BN ,&nbsp;Rebecca Gresham BN ,&nbsp;Christina Whitehead BN, MBioethics ,&nbsp;Julie Lowrey BN ,&nbsp;Ian Seppelt FCICM ,&nbsp;Hemant Kumar BSc, BE, MEngg ,&nbsp;Jayashree Kumar BSc,BE, MCompSc ,&nbsp;Anwar Hassan MPhty ,&nbsp;Sam Orde PhD ,&nbsp;Pranav Arun Bharadwaj HSC ,&nbsp;Hemamalini Arvind PhD ,&nbsp;Stephen Huang MPhtySam Orde PhD ,&nbsp;the SPARTAN Collaborative","doi":"10.1016/j.ccrj.2023.10.012","DOIUrl":"10.1016/j.ccrj.2023.10.012","url":null,"abstract":"<div><h3>Objective</h3><p>To evaluate the feasibility of conducting a prospective randomised controlled trial (pRCT) comparing remifentanil and fentanyl as adjuncts to sedate mechanically ventilated patients.</p></div><div><h3>Design</h3><p>Single-center, open-labelled, pRCT with blinded analysis.</p></div><div><h3>Setting</h3><p>Australian tertiary intensive care unit (ICU).</p></div><div><h3>Participants</h3><p>Consecutive adults between June 2020 and August 2021 expected to receive invasive ventilation beyond the next day and requiring opioid infusion were included. Exclusion criteria were pregnant/lactating women, intubation &gt;12 h<strong>,</strong> or study-drug hypersensitivity.</p></div><div><h3>Interventions</h3><p>Open-label fentanyl and remifentanil infusions per existing ICU protocols.</p></div><div><h3>Outcomes</h3><p>Primary outcomes were feasibility of recruiting ≥1 patient/week and &gt;90 % compliance, namely no other opioid infusion used during the study period. Secondary outcomes included complications, ICU-, ventilator- and hospital-free days, and mortality (ICU, hospital). Blinded intention-to-treat analysis was performed concealing the allocation group.</p></div><div><h3>Results</h3><p>208 patients were enrolled (mean 3.7 patients/week). Compliance was 80.6 %. More patients developed complications with fentanyl than remifentanil: bradycardia (n = 44 versus n = 21; p &lt; 0.001); hypotension (n = 78 versus n = 53; p &lt; 0.01); delirium (n = 28 versus n = 15; p = 0.001). No differences were seen in ICU (24.3 % versus 27.6 %,p = 0.60) and hospital mortalities (26.2 % versus 30.5 %; p = 0.50). Ventilator-free days were higher with remifentanil (p = 0.01).</p></div><div><h3>Conclusions</h3><p>We demonstrated the feasibility of enrolling patients for a pRCT comparing remifentanil and fentanyl as sedation adjuncts in mechanically ventilated patients. We failed to attain the study-opioid compliance target, likely because of patients with complex sedative/analgesic requirements. Secondary outcomes suggest that remifentanil may reduce mechanical ventilation duration and decrease the incidence of complications. An adequately powered multicentric phase 2 study is required to evaluate these results.</p></div>","PeriodicalId":49215,"journal":{"name":"Critical Care and Resuscitation","volume":"25 4","pages":"Pages 216-222"},"PeriodicalIF":2.9,"publicationDate":"2023-12-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.sciencedirect.com/science/article/pii/S1441277223022238/pdfft?md5=c554bdeeac8427018f8fb72d8997cb06&pid=1-s2.0-S1441277223022238-main.pdf","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"139015795","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":4,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}