Prospective Randomized Controlled Trial of Video- Versus Recall-Assisted Reflection in Simulation-Based Teaching on Acquisition and Retention of Airway Skills Among Trainees Intubating Critically Ill Patients.

OBJECTIVES: Conventionally, simulation-based teaching involves reflection on recalled events (recall-assisted reflection). Instead of recall, video-assisted reflection may reduce recall bias and improve skills retention by contributing to visual memory. Here, we test the hypothesis that when compared with recall, video-assisted reflection results in higher acquisition and retention of skills involved in airway management among junior critical care doctors. DESIGN: Randomized control trial. Participants were randomized 1:1 to video-assisted reflection or recall-assisted reflection group. SETTING: University-affiliated tertiary care center. SUBJECTS: Junior critical care doctors. INTERVENTION: Video-assisted reflection. MEASUREMENTS AND MAIN RESULTS: All participants underwent simulation-based teaching of technical and nontechnical airway skills involved in managing a critically ill patient. These skills were assessed before, post-workshop, and in the following fourth week, by two independent blinded assessors using a validated scoring tool. Quality of debrief was assessed using a validated questionnaire. Repeated-measures analysis of variance was used to assess time and group interaction. Forty doctors were randomized. At baseline, the groups had similar airway experience (p = 0.34) and skill scores (p = 0.97). There was a significant interaction between study groups and changes over time for total skill scores (F[2, 37] = 4.06; p = 0.02). Although both the study groups had similar and significant improvement in total skills scores at the postworkshop assessment, the decline in total skills scores at delayed assessment (F[1, 38] = 5.64; p = 0.02) was significantly more in the recall-assisted reflection group when compared with the video-assisted reflection group. This resulted in lower mean skill scores in the recall-assisted reflection group when compared with the video-assisted reflection group in the delayed assessment (89.45 [19.32] vs 110.10 [19.54]; p < 0.01). Better retention was predominantly in the nontechnical skills. The perceived quality of debrief was similar between the two groups. CONCLUSION: When compared with recall, video-assisted reflection resulted in similar improvement in airway skills, but better retention over time.

Interventions to improve diagnostic decision making: A systematic review and meta-analysis on reflective strategies.

Aims: To identify, appraise and describe studies of cognitive interventions to improve diagnostic decision making (DDM) amongst medical professionals, assess their effectiveness and identify methodological limitations in existing studies. Methods: We systematically searched for studies (publication date 2000-2016) in multiple databases including Cochrane Controlled Trials, EMBASE, ERIC, Medline, PubMed and PsycINFO, and used additional strategies such as hand searching and snowballing. Included studies evaluated cognitive interventions to enhance DDM amongst medical professionals, using defined outcomes such as diagnostic accuracy. A meta-analysis assessed the impact of "reflection". Results: Forty-four studies out of 10,114 screened citations, involving 4380 medical professionals, were included. Studies evaluated reasoning workshops/curricula, de-biasing workshops, checklists, reflection, feedback, and instructions to induce analytical thinking. Guided reflection was demonstrated to improve DDM [effect size 0.38(95%CI 0.23-0.52), p < 0.001]. Immediate feedback and modeling reflection using contrasting examples also appeared to improve diagnostic accuracy, however underlying methodological issues prevented a quantitative assessment of any strategies other than reflection. Conclusions: Educational interventions incorporating practising deliberate reflection on a formulated diagnosis, modeled reflection on contrasting examples and immediate feedback are promising strategies for improving DDM. The effectiveness of other strategies is unknown, with more methodological refinements required in future research.

Concordance between point-of-care blood gas analysis and laboratory autoanalyzer in measurement of hemoglobin and electrolytes in critically ill patients.

BACKGROUND: We tested the hypothesis that the results of the same test performed on point-of-care blood gas analysis (BGA) machine and automatic analyzer (AA) machine in central laboratory have high degree of concordance in critical care patients and that the two test methods could be used interchangeably. METHODS: We analyzed 9398 matched pairs of BGA and AA results, obtained from 1765 patients. Concentration pairs of the following analytes were assessed: hemoglobin, glucose, sodium, potassium, chloride, and bicarbonate. We determined the agreement using concordance correlation coefficient (CCC) and Bland-Altman analysis. The difference in results was also assessed against the United States Clinical Laboratory Improvement Amendments (US-CLIA) 88 rules. The test results were considered to be interchangeable if they were within the US-CLIA variability criteria and would not alter the clinical management when compared to each other. RESULTS: The median time interval between sampling for BGA and AA in each result pair was 5 minutes. The CCC values ranged from 0.89(95% CI 0.89-0.90) for chloride to 0.98(95% CI 0.98-0.99) for hemoglobin. The largest bias was for hemoglobin. The limits of agreement relative to bias were largest for sodium, with 3.4% of readings outside the US-CLIA variation rule. The number of readings outside the US-CLIA acceptable variation was highest for glucose (7.1%) followed by hemoglobin (5.9%) and chloride (5.2%). CONCLUSION: We conclude that there is moderate to substantial concordance between AA and BGA machines on tests performed in critically ill patients. However, the two tests methods cannot be used interchangeably, except for potassium.

ICU mortality is increased with high admission serum osmolarity in all patients other than those admitted with pulmonary diseases and hypoxia.

BACKGROUND AND OBJECTIVE: High serum osmolarity has been shown to be lung protective. There is lack of clinical studies evaluating the impact on outcomes such as mortality. We aimed to examine the effect of serum osmolarity on intensive care unit (ICU) mortality in critically ill patients METHODS: Data from January 2000 to December 2012 was accessed using the Australian and New Zealand Intensive Care Society (ANZICS) Clinical Outcomes and Resource Evaluation (CORE) database. A total of 509 180 patients were included. Serum osmolarity was calculated from data during the first 24 h of ICU admission. Predefined subgroups (Acute Physiology and Chronic Health Evaluation (APACHE) III diagnostic codes), including patients with acute pulmonary diagnoses, were examined. The effect of serum osmolarity on ICU mortality was assessed with analysis adjusted for illness severity (serum sodium, glucose and urea component removed) and year of admission. Results are presented as OR (95% CI) referenced against a serum osmolarity of 290-295 mmol/L. RESULTS: The ICU mortality was elevated at each extremes of serum osmolarity (U-shaped relationship). A similar relationship was found in various subgroups, with the exception of patients with pulmonary diagnoses in whom ICU mortality was not influenced by high serum osmolarity and was different from other non-pulmonary subgroups (P < 0.01). Any adverse associations with high serum osmolarity in pulmonary patients were confined to patients with a PaO2 /FiO2 ratio > 200. CONCLUSION: High admission serum osmolarity was not associated with increased odds for ICU death in pulmonary patients, unlike other subgroup of patients, and could be a potential area for future interventional therapy.

Immersive high fidelity simulation of critically ill patients to study cognitive errors: a pilot study.

BACKGROUND: The majority of human errors in healthcare originate from cognitive errors or biases. There is dearth of evidence around relative prevalence and significance of various cognitive errors amongst doctors in their first post-graduate year. This study was conducted with the objective of using high fidelity clinical simulation as a tool to study the relative occurrence of selected cognitive errors amongst doctors in their first post-graduate year. METHODS: Intern simulation sessions on acute clinical problems, conducted in year 2014, were reviewed by two independent assessors with expertise in critical care. The occurrence of cognitive errors was identified using Likert scale based questionnaire and think-aloud technique. Teamwork and leadership skills were assessed using Ottawa Global Rating Scale. RESULTS: The most prevalent cognitive errors included search satisfying (90%), followed by premature closure (PC) (78.6%), and anchoring (75.7%). The odds of occurrence of various cognitive errors did not change with time during internship, in contrast to teamwork and leadership skills (x2 = 11.9, P = 0.01). Anchoring appeared to be significantly associated with delay in diagnoses (P = 0.007) and occurrence of PC (P = 0.005). There was a negative association between occurrence of confirmation bias and the ability to make correct diagnosis (P = 0.05). CONCLUSIONS: Our study demonstrated a high prevalence of anchoring, premature closure, and search satisfying amongst doctors in their first post-graduate year, using high fidelity simulation as a tool. The occurrence of selected cognitive errors impaired clinical performance and their prevalence did not change with time.

A rare case of rapidly enlarging tracheal lobular capillary hemangioma presenting as difficult to ventilate acute asthma during pregnancy.

BACKGROUND: Lobular Capillary Hemangioma (LCH) is a benign tumour that is known to be hormone responsive and have a relatively high incidence during pregnancy, the most common site being the gingival surfaces. A tracheal origin for this tumour is extremely rare, with no case reported so far in this patient population, and the only reported clinical presentation of tracheal LCH in the literature is with haemoptysis. CASE PRESENTATION: We describe a case of a 23-year-old known asthmatic who presented at 32 weeks gestation with life-threatening respiratory failure resembling acute severe asthma, requiring invasive ventilation which was extremely difficult. This was subsequently found to be due to a large tracheal LCH producing a ball-valve phenomenon and predominantly expiratory airflow limitation similar to acute asthma. The endotracheal tube was advanced past the lesion under bronchoscopic guidance, and urgent Caesarean section performed due to foetal distress. The tumour was subsequently debulked and the trachea stented, facilitated by bi-femoral veno-venous extra-corporeal membrane oxygenation with relatively low dose of heparin. CONCLUSION: To our knowledge, this is the first report of a unique presentation and management of largest tracheal LCH so far occurring during pregnancy. Pulmonary and critical care physicians should be aware of this unique differential of refractory asthma, the aggressive nature of this benign tumour due to hormonal influences during pregnancy, and feasibility of using bi-femoral veno-venous extra-corporeal membrane oxygenation with low dose heparin as a rescue, given the high risk of bleeding.

A Pilot Study to Examine the Effect of Passive Straight Leg Raise Performed During Cardiopulmonary Resuscitation on Cerebral Perfusion Measured by Noninvasive Cerebral Oximetry.

Passive leg raise (PLR) during cardiopulmonary resuscitation (CPR) is simple and noninvasive maneuver, which can potentially improve patient-related outcomes. Initial CPR guidelines have previously advocated "elevation of the lower extremities to augment artificial circulation during CPR." There is lack of supporting evidence for this recommendation. DESIGN: This was a double cross-over physiologic efficacy randomized study. SETTING AND PATIENTS: Study in 10 subjects with in-hospital cardiac arrest for whom CPR was undertaken. INTERVENTION: Subjects were randomized to receive two cycles of CPR with PLR followed by two cycles of CPR without PLR (Group I) or vice-versa (Group II). Subjects had their foreheads (right and left) fitted with near infrared spectroscopy (NIRS) electrodes (O3 System-Masimo, Masimo corporation Forty Parker, Irvine CA) while undergoing CPR during the study. NIRS readings, a measure of mixed venous, arterial, and capillary blood oxygen saturation, act as a surrogate measure of cerebral blood perfusion during CPR. MEASUREMENT AND MAIN RESULTS: PLR was randomly used "first" in five of them, whereas it was used "second" in the remaining five subjects. In subjects in whom PLR was performed during first two cycles (Group I), NIRS values were initially significantly greater. The performance of PLR during CPR in Group II attenuated the decline in NIRS readings during CPR. CONCLUSIONS: PLR during CPR is feasible and leads to augmentation of cerebral blood flow. Furthermore, the expected decline in cerebral blood flow over time during CPR may be attenuated by this maneuver. The clinical significance of these findings will require further investigations.

Induced hypernatremia in patients with moderate-to-severe ARDS: a randomized controlled study.

BACKGROUND: Induced hypernatremia and hyperosmolarity is protective in animal models of lung injury. We hypothesized that increasing and maintaining plasma sodium between 145 and 150 mmol/l in patients with moderate-to-severe ARDS would be safe and will reduce lung injury. This was a prospective randomized feasibility study in moderate-to-severe ARDS, comparing standard care with intravenous hypertonic saline to achieve and maintain plasma sodium between 145 and 150 mmol/l for 7 days (HTS group). Both groups of patients were managed with lung protective ventilation and conservative fluid management. The primary outcome was 1-point reduction in lung injury score (LIS) or successful extubation by day 7. RESULTS: Forty patients were randomized with 20 in each group. Baseline characteristics of severity of illness were well balanced. Patients in the HTS group had higher plasma sodium levels during the first 7 days after randomization when compared with the control group (p = 0.04). Seventy five percent (15/20) of patients in the HTS group were extubated or had ≥ 1-point reduction in LIS compared with 35% (7/20) in the control group (p = 0.02). There was also a decrease in length of mechanical ventilation and hospital length of stay in the HTS group. CONCLUSION: We have shown clinical improvement in patients with moderate-to-severe ARDS following induced hypernatremia, suggesting that administration of hypertonic saline is a safe and feasible intervention in patients with moderate-to-severe ARDS. This suggests progress to a phase II study. Clinical Trial Registration Australian and New Zealand Clinical Trials Registry (ACTRN12615001282572).

Degree of hyperglycemia independently associates with hospital mortality and length of stay in critically ill, nondiabetic patients: Results from the ANZICS CORE binational registry.

PURPOSE: Hyperglycemia (HG) in critically ill patients influences clinical outcomes and hospitalization costs. We aimed to describe association of HG with hospital mortality and length of stay in large scale, real-world scenario. MATERIALS: From The Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD) we included 739,152 intensive care unit (ICU) patients admitted during 2007-2016. Hyperglycemia was quatified using midpoint blood glucose level (MBGL). Association with outcomes (hospital mortality and length of stay (LOS)) was tested using multivariable, mixed effects, 2-level hierarchical regression. RESULTS: Degree of HG (defined using MBGL as a continuous variable) was significantly associated with hospital mortality and longer hospital stay in a dose-dependent fashion. The fourth, third and second MBGL (compared to the first) quartiles were associated with hospital mortality (odds ratio 1.34, 1.05 and 0.97, respectively) and longer hospital stay (1.56, 1.38 and 0.93 days, respectively). These associations were stronger associations in trauma (especially head injury), neurological disease and coma patients. Significant variation across ICUs was observed for all associations. CONCLUSIONS: In this largest study of nondiabetic ICU patients, HG was associated with both study outcomes. This association was differential across ICUs and diagnostic categories.

Pharmacological profile, efficacy and safety of rupatadine in allergic rhinitis.

Allergic rhinitis (AR) is a disease with high prevalence. In AR, exposure to airborne allergens elicits an allergic response which involves epithelial accumulation of effector cells - e.g. mast cells and basophils - and subsequent inflammation. During the early response in AR, histamine has been found to be the most abundant mediator and it is associated with many symptoms of this disease mediated through the histamine H1 receptor. Therefore, anti-histamines have a role to play in the management of AR. However, the available antihistamines have certain well-known side effects like sedation and potential pro-arrythmic effects owing to their interactions with other drugs, as well as having poor or no effect on platelet activating factor (PAF) which also plays an important role in AR. This article is a qualitative systematic literature review on the pharmacological profile of rupatadine in order to evaluate its safety and efficacy in AR as compared to other anti-histamines. Rupatadine is a once-daily non-sedative, selective, long-acting H1 anti-histamine with antagonistic PAF effects through its interaction with specific receptors. Rupatadine significantly improves nasal symptoms in patients with AR. It has a good safety profile and is devoid of arrythmogenic effects. These properties make rupatadine a suitable first line anti-histamine for the treatment of AR.

Independent Association of Glucose Variability With Hospital Mortality in Adult Intensive Care Patients: Results From the Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Binational Registry.

Wide variations in blood glucose excursions in critically ill patients may influence adverse outcomes such as hospital mortality. However, whether blood glucose variability is independently associated with mortality or merely captures the excess risk attributable to hyperglycemic and hypoglycemic episodes is not established. We investigated whether blood glucose variability independently predicted hospital mortality in nonhyperglycemic critical care patients. DESIGN: Retrospective, registry data analyses of outcomes. SETTING: Large, binational registry (Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database repository) of 176 ICUs across Australia and New Zealand. PATIENTS: We used 10-year data on nonhyperglycemic patients registered in the Australia and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database repository (n = 290,966). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Glucose variability was captured using glucose width defined as the difference between highest and lowest blood glucose concentration within first 24 hours of ICU admission. We used hierarchical, mixed effects logistic regression models that accounted for ICU variation and several fixed-effects covariates. Glucose width was specifically and independently associated with hospital mortality. The association of blood glucose variability with mortality remained significant (odds ratio for highest vs lowest quartile of glucose, 1.43; 95% CI, 1.32-1.55; p < 0.001) even after adjusting for the baseline risk of mortality, midpoint blood glucose level, occurrence of hypoglycemia and inter-ICU variation. Mixed effects modeling showed that there was a statistically significant variation in this association across ICUs. CONCLUSIONS: Our study demonstrates that glucose variability is independently associated with hospital mortality in critically ill adult patients. Inclusion of correction for glucose variability in glycemic control protocols needs to be investigated in future studies.

Addressing the inadvertent sodium and chloride burden in critically ill patients: a prospective before-and-after study in a tertiary mixed intensive care unit population.

BACKGROUND: Inadvertent fluid loading - and resultant sodium and chloride - is common in critically ill patients. Sources such as fluid used as vehicles for drug infusions and boluses (fluid creep) and maintenance fluid are a common cause. We hypothesised that total sodium and chloride loading can be safely reduced in critically ill patients both by the use of 5% glucose as a diluent for infusions and boluses, when possible, and by its use as a maintenance fluid. METHODS: This was a prospective before-and-after study design in a single centre tertiary mixed intensive care unit (ICU). Comprehensive data about patient demographics, sources of fluid, feeds, intravenous drugs, fluid balance and electrolyte levels were collected for 4 weeks before and after the intervention (2016 and 2017). The amount of administered sodium was estimated from these sources. RESULTS: There were 146 patients (643 study days) and 133 patients (684 study days) examined in 2016 and 2017 respectively. The change of practice lead to an increase in the use of 5% glucose as the maintenance fluid and as a diluent, which resulted in a decrease in the total daily administered sodium from a median of 197 mmol (interquartile range [IQR], 155-328 mmol) to a median of 109 mmol (IQR, 77-288 mmol) (P = 0.0001). It also resulted in decrease in daily fluid balance, plasma chloride and ICU-acquired hypernatraemia. CONCLUSIONS: It is safely possible to decrease the total sodium and chloride loading to ICU patients by intervening on fluid creep and on maintenance fluid types. This intervention was accompanied by favourable changes in serum electrolyte and fluid balance.

Dose-Dependent Effects of Statins for Patients with Aneurysmal Subarachnoid Hemorrhage: Meta-Regression Analysis.

OBJECTIVE: The study uses meta-regression analysis to quantify the dose-dependent effects of statin pharmacotherapy on vasospasm, delayed ischemic neurologic deficits (DIND), and mortality in aneurysmal subarachnoid hemorrhage. METHODS: Prospective, retrospective observational studies, and randomized controlled trials (RCTs) were retrieved by a systematic database search. Summary estimates were expressed as absolute risk (AR) for a given statin dose or control (placebo). Meta-regression using inverse variance weighting and robust variance estimation was performed to assess the effect of statin dose on transformed AR in a random effects model. Dose-dependence of predicted AR with 95% confidence interval (CI) was recovered by using Miller's Freeman-Tukey inverse. RESULTS: The database search and study selection criteria yielded 18 studies (2594 patients) for analysis. These included 12 RCTs, 4 retrospective observational studies, and 2 prospective observational studies. Twelve studies investigated simvastatin, whereas the remaining studies investigated atorvastatin, pravastatin, or pitavastatin, with simvastatin-equivalent doses ranging from 20 to 80 mg. Meta-regression revealed dose-dependent reductions in Freeman-Tukey-transformed AR of vasospasm (slope coefficient -0.00404, 95% CI -0.00720 to -0.00087; P = 0.0321), DIND (slope coefficient -0.00316, 95% CI -0.00586 to -0.00047; P = 0.0392), and mortality (slope coefficient -0.00345, 95% CI -0.00623 to -0.00067; P = 0.0352). CONCLUSIONS: The present meta-regression provides weak evidence for dose-dependent reductions in vasospasm, DIND and mortality associated with acute statin use after aneurysmal subarachnoid hemorrhage. However, the analysis was limited by substantial heterogeneity among individual studies. Greater dosing strategies are a potential consideration for future RCTs.

Healthcare costs and outcomes for patients undergoing tracheostomy in an Australian tertiary level referral hospital.

OBJECTIVE: Patients undergoing tracheostomy represent a unique cohort, as often they have prolonged hospital stay, require multi-disciplinary, resource-intensive care, and may have poor outcomes. Currently, there is a lack of data around overall healthcare cost for these patients and their outcomes in terms of morbidity and mortality. The objective of the study was to estimate healthcare costs and outcomes associated in tracheostomy patients at a tertiary level hospital in South Australia. DESIGN: Retrospective review of prospectively collected data in patients who underwent tracheostomy between July 2009 and May 2015. METHODS: Overall healthcare-associated costs, length of mechanical ventilation, length of intensive care unit stay, and mortality rates were assessed. RESULTS: A total of 454 patients with tracheostomies were examined. Majority of the tracheostomies (n = 386 (85%)) were performed in intensive care unit patients, predominantly using bedside percutaneous approach (85%). The median length of hospital stay was 44 (29-63) days and the in-hospital mortality rate was 20%. Overall total cost of managing a patient with tracheostomy was median $192,184 (inter-quartile range $122560-$295553); mean 225,200 (range $5942-$1046675) Australian dollars. There were no statistically significant differences in any of the measured outcomes, including costs, between patients who underwent percutaneous versus surgical tracheostomy and patients who underwent early versus late tracheostomy in their intensive care unit stay. Factors that predicted (adjusted R 2 = 0.53) the cost per patient were intensive care unit length of stay and hospital length of stay. CONCLUSION: Hospitalised patients undergoing tracheostomy experience high morbidity and mortality and typically experience highly resource-intensive and costly healthcare.

Small volume resuscitation with 20% albumin in intensive care: physiological effects : The SWIPE randomised clinical trial.

PURPOSE: We set out to assess the resuscitation fluid requirements and physiological and clinical responses of intensive care unit (ICU) patients resuscitated with 20% albumin versus 4-5% albumin. METHODS: We performed a randomised controlled trial in 321 adult patients requiring fluid resuscitation within 48 h of admission to three ICUs in Australia and the UK. RESULTS: The cumulative volume of resuscitation fluid at 48 h (primary outcome) was lower in the 20% albumin group than in the 4-5% albumin group [median difference - 600 ml, 95% confidence interval (CI) - 800 to - 400; P < 0.001]. The 20% albumin group had lower cumulative fluid balance at 48 h (mean difference - 576 ml, 95% CI - 1033 to - 119; P = 0.01). Peak albumin levels were higher but sodium and chloride levels lower in the 20% albumin group. Median (interquartile range) duration of mechanical ventilation was 12.0 h (7.6, 33.1) in the 20% albumin group and 15.3 h (7.7, 58.1) in the 4-5% albumin group (P = 0.13); the proportion of patients commenced on renal replacement therapy after randomization was 3.3% and 4.2% (P = 0.67), respectively, and the proportion discharged alive from ICU was 97.4% and 91.1% (P = 0.02). CONCLUSIONS: Resuscitation with 20% albumin decreased resuscitation fluid requirements, minimized positive early fluid balance and was not associated with any evidence of harm compared with 4-5% albumin. These findings support the safety of further exploration of resuscitation with 20% albumin in larger randomised trials. TRIAL REGISTRATION: http://www.anzctr.org.au . Identifier ACTRN12615000349549.

Athletes, yogis and individuals with sedentary lifestyles; do their lung functions differ?

Buffalo health study concluded that pulmonary function is a long-term predictor for overall survival rates. It is essential to be involved in physical activity or sports which help in achieving better lung function. Cross sectional observation study was conducted to determine if yoga and athletic activity (running) are associated with better lung functions as compared to subjects with sedentary lifestyles and how does athletes and yogis differ in lung function. Spirometric parameters were assessed in randomly selected 60 healthy male, non-smoking; non-obese subjects-athletes, yogis and sedentary workers. The groups differed significantly in FEV1 and PEFR. The highest mean FEV1 and PEFR were observed in yogis. Both yogis and athletes had significantly better FEV1 as compared to sedentary workers. Yogis also had significantly better PEFR as compared to sedentary workers and athletes. Yogis and athletes had similar lung functions except for better PEFR amongst yogis. Involvement in daily physical activity or sport preferably yoga can help in achieving better pulmonary function.

Maintenance fluid practices in paediatric intensive care units in Australia and New Zealand.

BACKGROUND: Maintenance fluid administration is a common practice in paediatric intensive care units (PICUs), contributing to daily fluid intake and fluid balance, but little is known about this practice. OBJECTIVES: To determine the volume and type of maintenance fluid delivered to PICU patients, and to assess changes in practice compared with a previous time point. METHODS: A prospective, observational, single-day, point prevalence study of paediatric patients from 11 Australian and New Zealand PICUs, conducted in 2014. RESULTS: Seventy-two patients were enrolled. The median age and weight of infants aged < 1 year (n = 34) were 2 months (interquartile range [IQR],1-4) and 5 kg (IQR, 4-6), respectively; while in children ≥ 1 year of age (n = 38), these were 4 years (IQR, 2-8) and 17 kg (IQR, 12-23), respectively. On the study day, 19 infants (56%) and 19 children aged ≥ 1 year (50%) received maintenance fluids. Infants received a median of 23 mL/kg (IQR, 12-45) of maintenance fluid in addition to 51 mL/kg (IQR, 40-72) of fluid and nutrition from other sources; maintenance fluids contributed 29% (IQR, 13%-60%) of the total daily fluid intake. Children ≥ 1 year of age received a median of 18 mL/kg (IQR, 9-37) of maintenance fluid in addition to 39 mL/kg (IQR, 25-53) of fluid and nutrition from other sources; maintenance fluids contributed 33% (IQR, 17%-69%) of the total daily fluid intake. When compared with similar data from 2011, there was no change in the amount of maintenance fluid given, which was administered mostly as isotonic fluids. CONCLUSION: Maintenance fluid contributes about a third of total fluid administration in children in Australian and New Zealand PICUs and is mostly administered as isotonic solutions.

Addition of indapamide to frusemide increases natriuresis and creatinine clearance, but not diuresis, in fluid overloaded ICU patients.

BACKGROUND: Fluid and sodium overload are a common problem in critically ill patients. Frusemide may result in diuresis in excess of natriuresis. The addition of indapamide may achieve a greater natriuresis, and also circumvent some of the problems associated with frusemide. The objective of this study was to examine the effect of adding indapamide to frusemide on diuresis, natriuresis, creatinine clearance and serum electrolytes. METHODS: Fluid overloaded ICU patients were randomised to either intravenous frusemide (Group F) or intravenous frusemide and enteral indapamide (Group F + I). Comprehensive exclusion criteria were applied to address confounders. 24 hour urine was analysed for electrolytes and creatinine. Serum electrolytes were measured before and 24 hours after administration of diuretics. RESULTS: Forty patients (20 in each group) were included in the study. The groups were similar in their baseline characteristics. Over the 24 h study period, patients in Group F + I, had a larger natriuresis (P = 0.01), chloride loss (P = 0.01) and kaliuresis (P = 0.047). Patients in Group F + I also had a greater 24 hour urinary creatinine clearance (P = 0.01). The 24 hour urine volume and fluid balance was similar between the groups. Patients in Group F had an increase in serum sodium (P = 0.04), while patients in Group F + I had a decrease in both serum chloride (P = 0.01) and peripheral oedema (P < 0.001) during the study duration. CONCLUSION: In fluid overloaded ICU patients, addition of indapamide to frusemide led to a greater natriuresis and creatinine clearance. Such a strategy might be utilised in optimising sodium balance in ICU patients.

Maintenance fluid practices in intensive care units in Australia and New Zealand.

BACKGROUND: Administration of maintenance fluid is common practice in the intensive care unit, contributing to daily fluid and sodium intake and balance. Despite this, there is little evidence to describe clinical practices relating to its administration to ICU patients. METHODS: We conducted a prospective, observational, point-prevalence study in 49 Australian and New Zealand ICUs in 2014. We aimed to document the type and volume of maintenance fluid administered to ICU patients, and to describe additional fluid received. We also assessed changes in maintenance fluid administration practices compared with our similar study conducted in 2011. RESULTS: Of 645 patients enrolled, 399 (62%) received maintenance fluid on the study day. A median volume of 630 mL (interquartile range [IQR], 272-1250 mL) was delivered, accounting for a median of 35% (IQR, 16%- 56%) of total daily administered fluids. This was in addition to other fluids administered as fluid resuscitation, drug infusions and boluses, flushes and enteral or parenteral feeds, as well as oral intake. 0.9% saline was the most commonly used maintenance fluid (36%), followed by balanced salt solutions (30%). Compared with data from 2011, there has been a decrease in the median volume of maintenance fluid administered (2011, 860 mL [IQR, 360- 1533 mL]; 2014, 630 mL [IQR, 287-1328 mL]; P = 0.01), although the proportion of patients receiving maintenance fluid remains unchanged. There has been no change in the types of fluids most commonly used for maintenance, but the use of balanced salt solutions has increased (2011, 24%; 2014, 30%; P = 0.01). CONCLUSION: Administration of maintenance fluids to patients in Australian and New Zealand ICUs is common. Although the volume being delivered has decreased, maintenance fluids contribute over one-third of daily total fluid administration.

Fluid bolus therapy in emergency department patients: Indications and physiological changes.

OBJECTIVE: The aim of the present paper is to study the indications for fluid bolus therapy (FBT) and its associated physiological changes in ED patients. METHODS: Prospective observational study of FBT in a tertiary ED, we recorded indications, number, types and volumes, resuscitation goals and perceived success rates of FBT. Moreover, we studied key physiological variables before, 10 min, 1 h and 2 h after FBT. RESULTS: We studied 500 FBT episodes (750 [500-1250] mL). Median age was 59 (36-76) years and 57% were male. Shock was deemed present in 135 (27%) patients, septic shock in 80 (16%), and cardiogenic shock in 30 (6%). Overall, 0.9% saline (84%) was the most common fluid and hypotension the most common indication (70%). 'Avoidance of hospital/ICU admission' was the goal perceived to have the greatest success rate (85%). However, although mean arterial pressure (MAP) increased (P < 0.01) and heart rate (HR) decreased (P = 0.04) at 10 min (P = 0.01), both returned to baseline at 1 and 2 h. In contrast, respiratory rate (RR) increased at 1 (P < 0.01) and 2 h (P = 0.03) and temperature decreased at 1 and 2 h (both P < 0.001). In patients with shock, 1 h after FBT, there was a median 3 mmHg increase in MAP (P = 0.01) but no change in HR (P = 0.44), while RR increased (P < 0.01) and temperature decreased (P = 0.01). CONCLUSIONS: In ED, FBT is used mostly in patients without shock. However, after an immediate haemodynamic effect, FBT is associated with absent or limited physiological changes at 1 or 2 h. Even in shocked patients, the changes in MAP at 1 or 2 h after FBT are small.