Randomised, controlled, feasibility trial comparing vasopressor infusion administered via peripheral cannula versus central venous catheter for critically ill adults: A study protocol.

BACKGROUND: When clinicians need to administer a vasopressor infusion, they are faced with the choice of administration via either peripheral intravenous catheter (PIVC) or central venous catheter (CVC). Vasopressor infusions have traditionally been administered via central venous catheters (CVC) rather than Peripheral Intra Venous Catheters (PIVC), primarily due to concerns of extravasation and resultant tissue injury. This practice is not guided by contemporary randomised controlled trial (RCT) evidence. Observational data suggests safety of vasopressor infusion via PIVC. To address this evidence gap, we have designed the "Vasopressors Infused via Peripheral or Central Access" (VIPCA) RCT. METHODS: The VIPCA trial is a single-centre, feasibility, parallel-group RCT. Eligible critically ill patients requiring a vasopressor infusion will be identified by emergency department (ED) or intensive care unit (ICU) staff and randomised to receive vasopressor infusion via either PIVC or CVC. Primary outcome is feasibility, a composite of recruitment rate, proportion of eligible patients randomised, protocol fidelity, retention and missing data. Primary clinical outcome is days alive and out of hospital up to day-30. Secondary outcomes will include safety and other clinical outcomes, and process and cost measures. Specific aspects of safety related to vasopressor infusions such as extravasation, leakage, device failure, tissue injury and infection will be assessed. DISCUSSION: VIPCA is a feasibility RCT whose outcomes will inform the feasibility and design of a multicentre Phase-3 trial comparing routes of vasopressor delivery. The exploratory economic analysis will provide input data for the full health economic analysis which will accompany any future Phase-3 RCT.

Interventions to improve patient admission and discharge practices in adult intensive care units: A systematic review.

OBJECTIVES: To identify and synthesise interventions and implementation strategies to optimise patient flow, addressing admission delays, discharge delays, and after-hours discharges in adult intensive care units. METHODS: This systematic review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting guidelines. Five electronic databases, including CINAHL, PubMed, Emcare, Scopus, and the Cochrane Library, were searched from 2007 to 2023 to identify articles describing interventions to enhance patient flow practices in adult intensive care units. The Critical Appraisal Skills Program (CASP) tool assessed the methodological quality of the included studies. All data was synthesised using a narrative approach. SETTING: Adult intensive care units. RESULTS: Eight studies met the inclusion criteria, mainly comprising quality improvement projects (n = 3) or before-and-after studies (n = 4). Intervention types included changing workflow processes, introducing decision support tools, publishing quality indicator data, utilising outreach nursing services, and promoting multidisciplinary communication. Various implementation strategies were used, including one-on-one training, in-person knowledge transfer, digital communication, and digital data synthesis and display. Most studies (n = 6) reported a significant improvement in at least one intensive care process-related outcome, although fewer studies specifically reported improvements in admission delays (0/0), discharge delays (1/2), and after-hours discharge (2/4). Two out of six studies reported significant improvements in patient-related outcomes after implementing the intervention. CONCLUSION: Organisational-level strategies, such as protocols and alert systems, were frequently employed to improve patient flow within ICUs, while healthcare professional-level strategies to enhance communication were less commonly used. While most studies improved ICU processes, only half succeeded in significantly reducing discharge delays and/or after-hours discharges, and only a third reported improved patient outcomes, highlighting the need for more effective interventions. IMPLICATIONS FOR CLINICAL PRACTICE: The findings of this review can guide the development of evidence-based, targeted, and tailored interventions aimed at improving patient and organisational outcomes.

Time in ICU and post-intensive care syndrome: how long is long enough?

BACKGROUND: Our understanding of post-ICU recovery is influenced by which patients are selected to study and treat. Many studies currently list an ICU length of stay of at least 24, 48, or 72 h as an inclusion criterion. This may be driven by established evidence that prolonged time in an ICU bed and prolonged ventilation can complicate post-ICU rehabilitation. However, recovery after short ICU stays still needs to be explored. METHODS: This is a secondary analysis from the tracking outcomes post-intensive care (TOPIC) study. One hundred and thirty-two participants were assessed 6-months post-ICU discharge using standardised and validated self-report tools for physical function, cognitive function, anxiety, depression and post-traumatic stress disorder (with clinically significant impairment on any tool being considered a complicated recovery). Routinely collected data relating to the ICU stay were retrospectively accessed, including length of stay and duration of mechanical ventilation. Patients with short ICU stays were intentionally included, with 77 (58%) participants having an ICU length of stay < 72 h. RESULTS: Of 132 participants, 40 (30%) had at least one identified post-ICU impairment 6 months after leaving ICU, 22 (17%) of whom had an ICU length of stay < 72 h. CONCLUSION: Many patients with an ICU length of stay < 72 h are reporting post-ICU impairment 6 months after leaving ICU. This is a population often excluded from studies and interventions. Future research should further explore post-ICU impairment among shorter stays.

Determinants of 90-day case fatality among older patients admitted to intensive care units: A retrospective cohort study.

BACKGROUND: A recent systematic review identified highly variable case-fatality rates among studies of older patients admitted to intensive care units (ICUs). However, structural and process determinants including patient resident status, tertiary ICU status, and treatment limitations were unavailable. OBJECTIVE: The objective of this study was to evaluate the role of determinants such as resident status, tertiary ICU, and treatment limitations on 90-day case fatality among older ICU patients. METHODS: A retrospective cohort of all Queensland residents aged 75 years and older admitted to four ICUs within the Metro North Hospital and Health Service was included. The impact of Metro North Hospital and Health Service resident status, tertiary ICU, treatment limitations, and other known determinants on 90-day all-cause case fatality (case-fatality) was assessed. RESULTS: Of the 2144 eligible first admissions included, 1365 were residents, and 893 were nonelective admissions. The case-fatality rates were higher in residents (21% vs 12%, p < 0.001), nonelective admissions (32% vs 7%, p < 0.001), and non-tertiary ICU admissions (27% vs 16%, p < 0.001). The case fatality increased progressively with age, being highest (29.6%) in the >90 years age-group. Multivariable mixedeffects logistic regression modelling demonstrated that presence of treatment limitations was strongly associated with case fatality, but neither resident status nor the tertiary ICU was associated. CONCLUSION: The presence of treatment limitations should be considered when evaluating variations in case fatality among cohorts of older ICU patients, in addition to variables with well-established association with case fatality such as comorbidities and illness severity.

Balanced crystalloids versus saline for critically ill patients (BEST-Living): a systematic review and individual patient data meta-analysis.

BACKGROUND: The effect of balanced crystalloids compared with that of saline in critically ill patients overall and in specific subgroups is unclear. We aimed to assess whether use of balanced solutions, compared with 0·9% sodium chloride (saline), decreased in-hospital mortality in adult patients in intensive care units (ICUs). METHODS: For this systematic review and individual patient data meta-analysis, we searched PubMed, Embase, and CENTRAL databases from inception until March 1, 2022 (updated Sept 1, 2023) for individually randomised and cluster-randomised trials comparing balanced solutions with saline for adult patients in the ICU. Eligible trials were those that allocated patients to receive balanced solutions or saline for fluid resuscitation and maintenance fluids, or for maintenance fluids only; and administered the allocated fluid throughout ICU admission or, for trials using landmark mortality as their primary outcome, until the timepoint at which mortality was assessed (if ≥28 days). Authors of eligible trials were contacted to request individual patient data. Data obtained from eligible trials were merged, checked for accuracy, and centrally analysed by use of Bayesian regression models. The primary outcome was in-hospital mortality. Prespecified subgroups included patients with traumatic brain injury. This study was registered with PROSPERO (CRD42022299282). FINDINGS: Our search identified 5219 records, yielding six eligible randomised controlled trials. Data obtained for 34 685 participants from the six trials, 17 407 assigned to receive balanced crystalloids and 17 278 to receive saline, were included in the analysis. The mean age of participants was 58·8 years (SD 17·5). Of 34 653 participants with available data, 14 579 (42·1%) were female and 20 074 (57·9%) were male. Among patients who provided consent to report in-hospital mortality, 2907 (16·8%) of 17 313 assigned balanced solutions and 2975 (17·3%) of 17 166 assigned saline died in hospital (odds ratio [OR] 0·962 [95% CrI 0·909 to 1·019], absolute difference -0·4 percentage points [-1·5 to 0·2]). The posterior probability that balanced solutions reduced mortality was 0·895. In patients with traumatic brain injury, 191 (19·1%) of 999 assigned balanced and 141 (14·7%) of 962 assigned saline died (OR 1·424 [1·100 to 1·818], absolute difference 3·2 percentage points [0·7 to 8·7]). The probability that balanced solutions increased mortality in patients with traumatic brain injury was 0·975. In an independent risk of bias assessment, two trials were deemed to be at low risk of bias and four at high risk of bias. INTERPRETATION: The probability that using balanced solutions in the ICU reduces in-hospital mortality is high, although the certainty of the evidence was moderate and the absolute risk reduction was small. In patients with traumatic brain injury, using balanced solutions was associated with increased in-hospital mortality. FUNDING: HCor (Brazil) and The George Institute for Global Health (Australia).

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.

Cannabis use disorders and outcome of admission to intensive care: A retrospective multi-centre cohort study.

PURPOSE: To identify factors associated with cannabinoid use among patients admitted to ICU and its impact on survival. METHODS: A cohort of adult patients admitted to four public Australian ICUs was assembled. Individuals with mental and behavioural disorders related to cannabinoids were identified using ICD10-AM codes. RESULTS: Of a cohort of 34,680 admissions among 28,689 adults, 292 (0.8%) had an associated diagnosis related to cannabinoids, of which 66% were classified as harmful use, 26% as dependence syndrome/withdrawal state, 4% as psychosis/delirium, and 4% as acute intoxication. Patients with cannabinoid-use disorders were more likely to be male (73%), tended to be younger (36 vs 62 years), with fewer comorbidities and lesser severity of disease. ICU LOS was longer for those with cannabinoid-use disorders (2 vs 1 days; p < 0.0001). Patients with cannabinoid-use disorders had lower 90-day case-fatality (6% vs. 10%; p = 0.034), however no significant effect on mortality was present after adjustment for severity of illness, age, and chronic comorbidities (p = 1.0). CONCLUSION: Cannabinoid-use disorders were present in 0.8% of ICU admissions in our region and were associated with increased ICU length of stay. Further studies are needed to examine cannabinoids as contributors to and modifiers of critical illness.

Association between elevated lactate and clinical outcomes in adults with diabetic ketoacidosis.

PURPOSE: To assess the occurrence of hyperlactatemia among patients admitted to the intensive care unit (ICU) with diabetic ketoacidosis (DKA), and effect on in-hospital mortality. MATERIALS AND METHODS: A retrospective, multicentre, cohort study of adult patients admitted to ICU with a primary diagnosis of DKA in Australia and New Zealand, utilising a pre-existing dataset. The primary exposure variable was lactate, dichotomised into normolactatemia (lactate <2.0 mmol/L) and hyperlactatemia (lactate ≥ 2.0 mmol/L) groups. The primary outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay (LOS), requirement for ventilation, renal replacement therapy (RRT) and inotropes. RESULTS: The final dataset included 9061 patients. Hyperlactatemia was associated with in-hospital mortality (Odds Ratio [OR] 1.785 (95% CI 1.122-2.841, p = 0.014), hospital LOS (Geometric mean ratio [GMR] 1.063, 95% CI 1.025-1.103, p = 0.001), ICU LOS (GMR 1.057, 95% CI 1.026-1.09. p < 0.001), RRT (OR 2.198, 95% CI 1.449-3.334, p < 0.001) and inotropes (OR 1.578, 95% CI 1.311-1.899, p < 0.001). These associations persisted in Type 2 but not Type 1 diabetics. CONCLUSIONS: Hyperlactatemia in patients admitted to ICU with DKA is associated with higher mortality, longer hospital and ICU LOS, and higher rates of mechanical ventilation, RRT and inotropes.

Sepsis-associated acute kidney injury in the intensive care unit: incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes. A multicenter, observational study.

PURPOSE: The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to describe the epidemiology of SA-AKI. METHODS: This is a retrospective cohort study carried out in 12 intensive care units (ICUs) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of SA-AKI based on the ADQI definition. RESULTS: Out of 84,528 admissions, 13,451 met the SA-AKI criteria with its incidence peaking at 18% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with a median time to SA-AKI diagnosis of 1 day (interquartile range (IQR) 1-1) from ICU admission. At diagnosis, most SA-AKI patients (54%) had a stage 1 AKI, mostly due to the low urinary output (UO) criterion only (65%). Compared to diagnosis by creatinine alone, or by both UO and creatinine criteria, patients diagnosed by UO alone had lower renal replacement therapy (RRT) requirements (2.8% vs 18% vs 50%; p < 0.001), which was consistent across all stages of AKI. SA-AKI hospital mortality was 18% and SA-AKI was independently associated with increased mortality. In SA-AKI, diagnosis by low UO only, compared to creatinine alone or to both UO and creatinine criteria, carried an odds ratio of 0.34 (95% confidence interval (CI) 0.32-0.36) for mortality. CONCLUSION: SA-AKI occurs in 1 in 6 ICU patients, is diagnosed on day 1 and carries significant morbidity and mortality risk with patients mostly admitted from home via the ED. However, most SA-AKI is stage 1 and mostly due to low UO, which carries much lower risk than diagnosis by other criteria.

A protocol for a pilot randomised controlled trial of an Early Psychiatric Assessment, Referral, and Intervention Study (EPARIS) for intensive care patients.

BACKGROUND: Up to 80% of Intensive Care Unit patients experience physical, cognitive, and/or psychological complications post-discharge, known as 'Post Intensive Care Syndrome' (PICS). Early diagnosis and intervention are a priority, but while current post-intensive care follow-up processes endorse a multidisciplinary model, incorporating a psychiatric consultation has not been studied. METHODS: A pilot, open-label randomised controlled trial was developed by a multidisciplinary team to evaluate the feasibility and acceptability of incorporating a psychiatric review into an existing post-ICU clinic. The study will run for 12 months and aim to recruit 30 participants. Inclusion criteria for participants: a) ICU admission greater than 48 hours, b) no cognitive impairment that prevents participation, c) ≥ 18 years old, d) residing in Australia, e) fluent in English, f) able to provide GP information, and g) likely to be contactable in 6 months. Patient recruitment will be at Redcliffe Hospital, Queensland, Australia, and will involve patients attending the Redcliffe post intensive care clinic. Participants will be allocated to intervention or control using block randomisation and allocation concealment. Participants allocated to the control arm will receive the standard cares provided by the clinic, which involves an unstructured interview about their ICU experience and a battery of surveys about their psychological, cognitive, and physical function. Those allocated to the intervention arm will receive these same cares as well as an appointment with a psychiatrist for a single session intervention. The psychiatric intervention will involve a comprehensive review, including comorbid disorders, substance use, suicidal ideation, psychosocial stressors, social/emotional supports. Psychoeducation and initial treatment will be provided as indicated and recommendations given to the patient and their GP about how to access ongoing care. In addition to surveys conducted as part of standard clinic cares, all participants will complete additional questionnaires about their history, hospital experience, mental and physical health as well as employment circumstances. All participants will be followed up 6 months after their appointment and will be invited to complete follow-up questionnaires about their mental and physical health, as well as health service use and employment circumstances. The trial has been registered with ANZCTR (ACTRN12622000894796). RESULTS: To evaluate the feasibility and acceptability of the intervention to the patient population. Differences between groups will be assessed using an independent samples t-test. Resource requirements to administer the intervention will be evaluated by reporting the mean duration of the EPARIS assessment and approximate cost per patient to provide this service. To estimate the effect size of any treatment effects, changes in secondary outcome measures between baseline and 6 months will be compared between intervention and control groups using Analysis of Covariance regression. As this is a pilot, we will not use p-values or test a null hypothesis, but will give confidence intervals. CONCLUSIONS: This protocol provides a pragmatic evaluation of the acceptability of introducing early psychiatric assessment into an existing post-ICU follow-up process, and if considered acceptable will inform future research into the efficacy and generalisability of the intervention. The strengths of EPARIS are the prospective, longitudinal design with a control population, and its use of validated post-ICU outcome measures.

Establishing critical care nursing research priorities for three Australian regional public hospitals: A mixed method priority setting study.

OBJECTIVE: To determine key priorities for critical care nursing research in three Australian regional public hospitals, representing the shared priorities of healthcare professionals and patient representatives. METHODS: A three phase priority setting study, including consensus methods (nominal group), survey, qualitative interviews and focus groups were conducted between May 2021 and March 2022. Healthcare professionals and patient representatives from critical care units in regional public hospitals in Australia participated. A patient representative contributed to research design and co-authored this paper. RESULTS: In phase one, 29 research topics were generated. In phase two, during a nominal group ranking process, the top 5 priority areas for each site were identified. In the final phase, three themes from focus groups and interviews included patient flow through intensive care, patient care through intensive care journey and intensive care patient recovery. CONCLUSION: Identifying context specific research priorities through a priority setting exercise provides insight into the topics that are important to healthcare professionals and to patients in critical care. The top research priorities for nursing research in critical care in regional Australian hospitals include patient flow, patient recovery, and evidence based patient care through the intensive care journey, such as delirium management, pain and sedation, and mobilisation. These shared priorities will be used to guide future nursing research in critical care over the next 3-5 years. IMPLICATIONS FOR CLINICAL PRACTICE: The method we used in identifying the research priorities can be used by other researchers and clinicians; close collaboration among researchers and clinicians will be beneficial for practice improvement; and how we can be reassured that our practice is evidence based is worthy of attention.

Sodium chloride or plasmalyte-148 for patients presenting to emergency departments with diabetic ketoacidosis: A nested cohort study within a multicentre, cluster, crossover, randomised, controlled trial.

OBJECTIVE: To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission. METHODS: We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU. RESULTS: Eighty-four patients were enrolled (SC n = 38, PL n = 46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01-7.21], PL: 7.17 [IQR 6.99-7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000-3200 mL; SC) and 2200 mL (IQR 2000-3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13-3.97, P = 0.71). CONCLUSION: Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.

Institution-free days after critical illness: A multicenter retrospective study.

BACKGROUND: Patient-centered outcomes beyond mortality such as institution-free days (IFD) are becoming increasingly relevant in critical care trials. METHODS: We calculated IFD using three definitions which differed in the way death and censoring of after-hospital deaths were handled analysing data from adult patient databases admitted to four ICUs of North Brisbane, Australia. Differences in distribution of IFD using different definitions were explored with descriptive statistics and histograms. Six pre-specified variables (age, illness severity, comorbidities index, elective status, surgical/medical admission and treatment limitations) were assessed and reported as determinants of IFDs for the proposed definitions. RESULTS: Data from 25,371 ICU admissions was analysed. The density distribution of IFD was bimodal with a peak at 0 days and a variable right-sided peak depending on the definition used. The mean IFD varied from 253 (standard deviation(SD) 151.3) to 295 (SD 116.2) depending on definition used. Multivariable zero-inflated negative binomial regression modelling showed that the six pre-specified variables had significant associations with IFD and their magnitude of effect varied with the definition used. CONCLUSIONS: IFD is a simple, easily measurable patient-centered outcome that varies depending on the definition used. Patient input should be sought to define the optimum definition and clinical use of IFD.

Excess burden of critical illness related to inflammatory bowel disease.

BACKGROUND: Although inflammatory bowel disease (IBD) is associated with major morbidity and mortality, few studies have evaluated its associated burden of critical illness. AIMS: To examine the epidemiology and outcome of intensive care unit (ICU) admission among patients with IBD in North Brisbane, Australia. METHODS: A population-based cohort design was used. All admissions to ICU serving the Metro North Hospital and Health Service among adult residents during 2017-2019 were included. Data were obtained from ICU clinical information systems with linkages to statewide admissions and death registries. RESULTS: Among 9011 ICU admissions, 101 (1.1%) were among patients with IBD, of which 57 (0.6%) and 44 (0.5%) had ulcerative colitis (UC) and Crohn disease (CD) respectively. The incidence of ICU admission was 379, 1336, 1514 and 1429 per 100 000 annually among those without IBD, CD, UC and IBD respectively. Patients with IBD were at excess risk for admission across all age groups, with women aged <50 years at highest risk and men thereafter. The all-cause 90-day case-fatality rates following ICU admission were not significantly different among patient groups and were 18%, 12%, 15% and 12% for CD, UC, IBD and non-IBD respectively. However, as compared with non-IBD patients, those with CD (151.8 vs 39.4 per 100 000; relative risk (RR) 3.85; 95% confidence interval (CI) 1.25-9.02; P = 0.013), UC (159.4 vs 39.4 per 100 000; RR 4.05; 95% CI 1.48-8.84; P = 0.005) and IBD (155.6 vs 39.4 per 100 000; RR 3.95; 95% CI 1.96-7.10; P = 0.002) were at significantly higher risk for mortality. CONCLUSIONS: Patients with IBD suffer a major burden of critical illness.

90-day Case-Fatality in Critically ill Patients with Chronic Liver Disease Influenced by Presence of Portal Hypertension, Results from a Multicentre Retrospective Cohort Study.

BACKGROUND: Critical illness in patients with chronic liver disease (CLD) is increasing in occurrence, and by virtue of its adverse effect on prognosis, its presence may influence the decision to offer admission to intensive care units (ICU). Our objective was to examine the determinants and outcome of patients with CLD admitted to ICU. METHODS: A retrospective cohort of patients admitted to four adult ICUs in Queensland, Australia from 2017 to 2019. Patients with mild or moderate-severe CLD were defined by the absence and presence of portal hypertension, respectively, and were was determined using granular ICU and state-wide administrative databases. The primary outcome was 90-day all cause case-fatality. RESULTS: We included 3836 patients in the analysis, of which, 60 (2%) had mild liver disease and 132 (3%) had moderate-severe liver disease . Patients with CLD had higher incidence of other co-morbidities with the median adjusted-Charlson co-morbidity index (CCI) was 1 (interquartile range; IQR 0-3) for no CLD, 2 (IQR 1.5-4) for mild CLD, and 3 (IQR 2-5) for moderate-severe CLD. Case-fatality rates at 90 days was 17% for no CLD, 25% for mild CLD, and 41% for moderate-severe CLD. Among those with mild and moderate-severe CLD, an increased co-morbidity burden as measured by an adjusted CCI score of low (0-3), medium (4-5), high (6-7) and very high (>7) resulted in increasing case-fatality rates of 24-40%, 11-28.5%, 33-62%, and 50% respectively. Moderate-severe CLD, but not mild CLD, was independently associated with increased case-fatality at 90 days (Odds Ratio 1.58; 95% confidence interval 1.01-2.48; p = 0.004) after adjusting for medical co-morbidities and severity of illness using logistic regression analysis. CONCLUSIONS: Although patients with moderate-severe CLD have an increased risk for 90-day case-fatality, patients with mild CLD are not at higher risk for death following ICU admission.

Improving access to extracorporeal membrane oxygenation for out of hospital cardiac arrest: pre-hospital ECPR and alternate delivery strategies.

BACKGROUND: The use of extracorporeal membrane oxygenation (ECPR) in refractory out-of-hospital cardiac arrest (OHCA) patients is usually implemented in-hospital. As survival in ECPR patients is critically time-dependent, alternative models in ECPR delivery could improve equity of access. OBJECTIVES: To identify the best strategy of ECPR delivery to provide optimal patient access, to examine the time-sensitivity of ECPR on predicted survival and to model potential survival benefits from different delivery strategies of ECPR. METHODS: We used transport accessibility frameworks supported by comprehensive travel time data, population density data and empirical cardiac arrest time points to quantify the patient catchment areas of the existing in-hospital ECPR service and two alternative ECPR strategies: rendezvous strategy and pre-hospital ECPR in Sydney, Australia. Published survival rates at different time points to ECMO flow were applied to predict the potential survival benefit. RESULTS: With an in-hospital ECPR strategy for refractory OHCA, five hospitals in Sydney (Australia) had an effective catchment of 811,091 potential patients. This increases to 2,175,096 under a rendezvous strategy and 3,851,727 under the optimal pre-hospital strategy. Assuming earlier provision of ECMO flow, expected survival for eligible arrests will increase by nearly 6% with the rendezvous strategy and approximately 26% with pre-hospital ECPR when compared to the existing in-hospital strategy. CONCLUSION: In-hospital ECPR provides the least equitable access to ECPR. Rendezvous and pre-hospital ECPR models substantially increased the catchment of eligible OHCA patients. Traffic and spatial modelling may provide a mechanism to design appropriate ECPR service delivery strategies and should be tested through clinical trials.

Different epidemiology of bloodstream infections in COVID-19 compared to non-COVID-19 critically ill patients: a descriptive analysis of the Eurobact II study.

BACKGROUND: The study aimed to describe the epidemiology and outcomes of hospital-acquired bloodstream infections (HABSIs) between COVID-19 and non-COVID-19 critically ill patients. METHODS: We used data from the Eurobact II study, a prospective observational multicontinental cohort study on HABSI treated in ICU. For the current analysis, we selected centers that included both COVID-19 and non-COVID-19 critically ill patients. We performed descriptive statistics between COVID-19 and non-COVID-19 in terms of patients' characteristics, source of infection and microorganism distribution. We studied the association between COVID-19 status and mortality using multivariable fragility Cox models. RESULTS: A total of 53 centers from 19 countries over the 5 continents were eligible. Overall, 829 patients (median age 65 years [IQR 55; 74]; male, n = 538 [64.9%]) were treated for a HABSI. Included patients comprised 252 (30.4%) COVID-19 and 577 (69.6%) non-COVID-19 patients. The time interval between hospital admission and HABSI was similar between both groups. Respiratory sources (40.1 vs. 26.0%, p < 0.0001) and primary HABSI (25.4% vs. 17.2%, p = 0.006) were more frequent in COVID-19 patients. COVID-19 patients had more often enterococcal (20.5% vs. 9%) and Acinetobacter spp. (18.8% vs. 13.6%) HABSIs. Bacteremic COVID-19 patients had an increased mortality hazard ratio (HR) versus non-COVID-19 patients (HR 1.91, 95% CI 1.49-2.45). CONCLUSIONS: We showed that the epidemiology of HABSI differed between COVID-19 and non-COVID-19 patients. Enterococcal HABSI predominated in COVID-19 patients. COVID-19 patients with HABSI had elevated risk of mortality. Trial registration ClinicalTrials.org number NCT03937245 . Registered 3 May 2019.