Current practice, education and recommendations for training of central line insertion for trainees and fellows in adult intensive care units across Australia and New Zealand.

BACKGROUND: Central venous access device (CVAD) is a common procedure in ICU which, although generally safe, can lead to acute and delayed complications. Training and accreditation process for its insertion vary worldwide. AIMS: The objective of this study was to explore variability in existing training and accreditation processes for central venous access device (CVAD) insertion among different intensive care units (ICU), current practices of CVAD insertion among fellows of the College of Intensive Care Medicine (CICM) working in Australia and New Zealand (ANZ) and their recommendations for improvement. METHODS: A prospective cross-sectional web-based survey was sent through email and CICM e-newsletter to intensivists and directors of ICU across ANZ. All responses were tabulated, post-hoc exploratory analysis using multivariable ordinal logistic regression was used and free texts were analysed thematically and summarised. RESULTS: A total of 115 responses was received from various public and private ICU from all states of ANZ; 32% of the participants did not have any accreditation process for CVAD insertion skill in their ICU, whereas 91% of respondents revealed there were no processes to assess deskilling. Most intensivists recommended supervision, simulation, various education tools and ultrasound training to improve training and assessment. Thirty-five percent of the participants inserted 0-5 CVAD and more than half of the intensivists had inserted <10 CVAD in a 1-year period. Two-thirds of the respondents recommended inserting between 6 and 20 CVAD each year to maintain competence. CONCLUSION: The study identified wide variability in current practice, training methods and accreditation process for CVAD insertion among intensivists and ICU trainees in ANZ. Policy makers should consider revising the current clinical practice and training policies to new policies for accreditation and ongoing assessment for CVAD insertions across ANZ ICU.

Utility of Stewart's Approach to Diagnose Missed Complex Acid-Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study.

BACKGROUND: Traditional arterial blood gas (ABG) analysis may miss out on some metabolic acid-base disorders. We prospectively compared Stewart's approach in critically ill patients to traditional bicarbonate-anion gap-based methods (with and without correction for albumin) to diagnose acid-base disorders. PATIENTS AND METHODS: Five hundred ABG samples from medical or surgical patients in the ICU were analyzed with traditional bicarbonate-anion gap-based methodology with and without correction for albumin and Stewart's biochemical approach. The primary outcome identification of additional metabolic disorders diagnosed with Stewart's approach in comparison to bicarbonate system-based approaches. We also looked at the correlation between the strong ion gap (SIG) and the albumin-corrected anion gap (acAnion Gap). RESULTS: Stewart's approach detected missed metabolic disorders in 58 (11.6%) blood gas results reported as "within normal limits" with the bicarbonate-uncorrected anion gap approach. In 50 (10%) of these ABGs, the acAnion Gap approach was able to diagnose the missed metabolic disorders. Thus, the albumin-corrected anion gap method had a similar diagnostic performance to Stewart's approach, as it missed additional disorders in only eight (1.6%) blood gases. CONCLUSION: In this study, we found that the acAnion Gap approach was similar in diagnostic performance to Stewart's approach. We feel that the corrected anion gap approach can be safely used if a ready calculator for Stewart's approach is not available. HOW TO CITE THIS ARTICLE: Paliwal R, Pakavakis A, Divatia JV, Kulkarni AP. Utility of Stewart's Approach to Diagnose Missed Complex Acid-Base Disorders as Compared to Bicarbonate-anion Gap-based Methodology in Critically Ill Patients: An Observational Study. Indian J Crit Care Med 2022;26(1):23-32.

Postoperative 20% albumin vs standard care and acute kidney injury after high-risk cardiac surgery (ALBICS): study protocol for a randomised trial.

BACKGROUND: Acute kidney injury (AKI) is a common complication of cardiac surgery. Factors such as cardiopulmonary bypass, aortic cross-clamping and surgical stress may precipitate renal hypoperfusion and ischaemia, inflammation and oxidative stress are associated with development of AKI. Albumin's pharmacological properties and widespread availability have the potential to mitigate these factors. However, the effect of albumin on cardiac surgery-associated AKI is unknown. OBJECTIVE: To evaluate the impact of postoperative 20% albumin infusion on kidney function after high-risk cardiac surgery. METHODS: We designed an open-label, multicentre, randomised controlled trial-the ALBICS study (ALBumin Infusion and acute kidney injury following Cardiac Surgery). A total of 590 patients undergoing high-risk cardiac surgery (combined procedure or estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2) will be enrolled into the study and randomly allocated to receive a postoperative 20% albumin infusion or standard care in a 1:1 ratio, stratified by centre and baseline renal function. The study fluid will be administered upon arrival in intensive care for 15 h. Patients will be followed up until 28 days after surgery or until discharge from the hospital. The primary outcome is the proportion of patients who develop AKI in both groups. Secondary outcomes to be measured are proportions of AKI stage II and III, 28-day mortality, mechanical ventilation time and length of stay in intensive care and hospital. CONCLUSION: This trial aims to determine if a postoperative infusion of concentrated albumin reduces the risk of AKI following high-risk cardiac surgery. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619001355167. Registered on 03 October 2019-retrospectively registered. https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=378383 .

Optimal Sedation and Pain Management: A Patient- and Symptom-Oriented Paradigm.

In the critically ill patient, optimal pain and sedation management remains the cornerstone of achieving comfort, safety, and to facilitate complex life support interventions. Pain relief, using multimodal analgesia, is an integral component of any orchestrated approach to achieve clinically appropriate goals in critically ill patients. Sedative management, however, remains a significant challenge. Subsequent studies including most recent randomized trials have failed to provide strong evidence in favor of a sedative agent, a mode of sedation or ancillary protocols such as sedative interruption and sedative minimization. In addition, clinical practice guidelines, despite a comprehensive evaluation of relevant literature, have limitations when applied to individual patients. These limitations have been most apparent during the coronavirus disease 2019 pandemic. As such, there is a need for a mindset shift to a practical and achievable sedation strategy, driven by patients' characteristics and individual patient needs, rather than one cocktail for all patients. In this review, we present key principles to achieve patient-and symptom-oriented optimal analgesia and sedation in the critically ill patients. Sedative intensity should be proportionate to care complexity with due consideration to an individual patient's modifiers. The use of multimodal analgesics, sedatives, and antipsychotics agents-that are easily titratable-reduces the overall quantum of sedatives and opioids, and reduces the risk of adverse events while maximizing clinical benefits. In addition, critical considerations regarding the choice of sedative agents should be given to factors such as age, medical versus operative diagnosis, and cardiovascular status. Specific populations such as trauma, neurological injury, and pregnancy should also be taken into account to maximize efficacy and reduce adverse events.

Does Obesity Influence the Outcome of the Patients Following a Cardiac Arrest?

BACKGROUND: Obesity is one of the major risk factors for cardiovascular and peripheral vascular diseases. However, the obesity paradox confers survival benefits in heart failure and cardiac surgery patients. Studies examining the outcomes of obese patients following cardiac arrest provided conflicting results. OBJECTIVE: To study the association between obesity and outcome in patients following cardiac arrest. MATERIALS AND METHODS: We conducted a retrospective cohort study at a tertiary intensive care unit (ICU). Data were collected from medical records between January 1, 2018 and December 31, 2018, for all adult ICU patients who were admitted to our ICU following a cardiac arrest. Data collected included demographics, anthropometrics, and details of the cardiac arrest. The primary outcome was survival to hospital discharge. Secondary outcomes were duration of mechanical ventilation, ICU, and hospital length of stay. RESULTS: A total of 126 patients were admitted to the ICU following a cardiac arrest during the study period, of whom 14 patients were excluded due to missing body mass index (BMI) data. Seventy-six patients were non-obese (BMI <30) and 36 patients were obese (BMI ≥30). There was no difference in survival to hospital discharge between obese and non-obese patients (52.8 vs 59.2%, p = 0.52, OR = 0.77, 95% CI 0.35-1.71). Moreover, there was no difference between obese and non-obese patients in ICU length of stay (81.50 vs 76.0 hours, p = 0.42), hospital length of stay (9 vs 10 days, p = 0.63), and duration of mechanical ventilation (55 vs 43 hours, p = 0.30). In the logistical regression analysis, BMI was not associated with improved survival (OR = 0.97, 95% CI 0.92-1.03, p = 0.23). CONCLUSION: For patients admitted to ICU following cardiac arrest, we could not show that obesity improves survival, length of stay, or duration of mechanical ventilation. HOW TO CITE THIS ARTICLE: Chavda MP, Pakavakis A, Ernest D. Does Obesity Influence the Outcome of the Patients Following a Cardiac Arrest? Indian J Crit Care Med 2020;24(11):1077-1080.

The use of veno-venous extracorporeal membrane oxygenation following thrombolysis for massive pulmonary embolism.

A 59-year-old man was diagnosed with a massive pulmonary embolism. Despite thrombolysis there were two episodes of cardiac arrest and following recovery of spontaneous circulation profound cardiorespiratory failure ensued. An extracorporeal membrane oxygenation retrieval team initiated veno-venous extracorporeal membrane oxygenation on site to facilitate transfer to the extracorporeal membrane oxygenation centre. An excellent outcome is reported in the short term. This represents one of the few published cases of veno-venous extracorporeal membrane oxygenation for a massive pulmonary embolism following thrombolysis.