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.

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.

Effect of Vitamin C, Hydrocortisone, and Thiamine vs Hydrocortisone Alone on Time Alive and Free of Vasopressor Support Among Patients With Septic Shock: The VITAMINS Randomized Clinical Trial.

Importance: It is unclear whether vitamin C, hydrocortisone, and thiamine are more effective than hydrocortisone alone in expediting resolution of septic shock. Objective: To determine whether the combination of vitamin C, hydrocortisone, and thiamine, compared with hydrocortisone alone, improves the duration of time alive and free of vasopressor administration in patients with septic shock. Design, Setting, and Participants: Multicenter, open-label, randomized clinical trial conducted in 10 intensive care units in Australia, New Zealand, and Brazil that recruited 216 patients fulfilling the Sepsis-3 definition of septic shock. The first patient was enrolled on May 8, 2018, and the last on July 9, 2019. The final date of follow-up was October 6, 2019. Interventions: Patients were randomized to the intervention group (n = 109), consisting of intravenous vitamin C (1.5 g every 6 hours), hydrocortisone (50 mg every 6 hours), and thiamine (200 mg every 12 hours), or to the control group (n = 107), consisting of intravenous hydrocortisone (50 mg every 6 hours) alone until shock resolution or up to 10 days. Main Outcomes and Measures: The primary trial outcome was duration of time alive and free of vasopressor administration up to day 7. Ten secondary outcomes were prespecified, including 90-day mortality. Results: Among 216 patients who were randomized, 211 provided consent and completed the primary outcome measurement (mean age, 61.7 years [SD, 15.0]; 133 men [63%]). Time alive and vasopressor free up to day 7 was 122.1 hours (interquartile range [IQR], 76.3-145.4 hours) in the intervention group and 124.6 hours (IQR, 82.1-147.0 hours) in the control group; the median of all paired differences was -0.6 hours (95% CI, -8.3 to 7.2 hours; P = .83). Of 10 prespecified secondary outcomes, 9 showed no statistically significant difference. Ninety-day mortality was 30/105 (28.6%) in the intervention group and 25/102 (24.5%) in the control group (hazard ratio, 1.18; 95% CI, 0.69-2.00). No serious adverse events were reported. Conclusions and Relevance: In patients with septic shock, treatment with intravenous vitamin C, hydrocortisone, and thiamine, compared with intravenous hydrocortisone alone, did not significantly improve the duration of time alive and free of vasopressor administration over 7 days. The finding suggests that treatment with intravenous vitamin C, hydrocortisone, and thiamine does not lead to a more rapid resolution of septic shock compared with intravenous hydrocortisone alone. Trial Registration: ClinicalTrials.gov Identifier: NCT03333278.

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 .

Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation.

Background: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described. Objective: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation. Design, setting and participants: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days. Main outcome measures: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation. Results: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH2O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0-9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0-8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support. Conclusions: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management.

"Likely overassistance" during invasive pressure support ventilation in patients in the intensive care unit: a multicentre prospective observational study.

OBJECTIVE: To evaluate the prevalence of "likely overassistance" (categorised by respiratory rate [RR] ≤ 17 breaths/min or rapid shallow breathing index [RSBI] ≤ 37 breaths/min/L) during invasive pressure support ventilation (PSV), and the additional prevalence of fixed ventilator settings. DESIGN: Multicentre prospective observational study of invasive PSV practice in six general Victorian intensive care units with blinding of staff members to data collection. PATIENTS: At each hospital, investigators collected data between 11 am and 2 pm on all invasive PSV-treated patients on 60 sequential days, excluding weekends and public holidays, between 22 February and 30 August 2017. Each patient was included for maximum of 3 days. MAIN RESULTS: We studied 231 patients, with a total of 379 observations episodes over the study period. There were 131 patients (56.7%) with at least one episode of RR ≤ 17 breaths/min; 146 patients (63.2%) with at least one episode of RSBI ≤ 37 breaths/min/L, and 85 patients (36.8%) with at least one episode of combined RR ≤ 17 breaths/min and RSBI ≤ 37 breaths/min/L. Moreover, the total number of observations with "likely overassistance" (RR ≤ 17 or RSBI ≤ 37 breaths/min/L) was 178 (47%) and 204 (53.8%), respectively; while for both combined criteria, it was 154 (40.6%). We also found that 10 cmH2O pressure support was delivered on 210 of the observations (55.4%) and adjusted in less than 25% of observations. Finally, less than half (179 observations) of all PSV-delivered tidal volumes (VT) were at the recommended value of 6-8 mL/kg predicted body weight (PBW) and more than 20% (79 observations) were at ≥ 10 mL/kg PBW. CONCLUSION: In a cohort of Victorian hospitals in Australia, during invasive PSV, "likely overassistance" was common, and the pressure support level was delivered in a standardised and unadjusted manner at 10 cmH2O, resulting in the frequent delivery of potentially injurious VT.

Characteristics, incidence, and outcome of patients admitted to the intensive care unit with myasthenia gravis.

BACKGROUND: There are limited data on the characteristics, incidence, and mortality of patients with myasthenia gravis (MG) admitted to the ICU. AIMS: To study the epidemiology, characteristics and outcome of patients with MG in Australian and New Zealand (ANZ) ICUs over a decade. METHODS: We performed a retrospective observational, cross sectional study of data from the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database (APD). We collected data on all adult patients admitted with a primary diagnosis of MG to 159 Australian and 19 New Zealand ICUs between January 1, 2005 and December 31, 2015.We extracted detailed relevant data and performed statistical assessment. RESULTS: We identified 245 patients admitted to ICU with the primary diagnosis of MG, with an incidence increasing from 1 to 2.5 per thousand ICU admissions (P<0.0001) and from 1 to 2.2 per million people (P=0.02). Mean age was 60years with more patients being female (53.7% vs 47.3%) and 91 (37.1%) patients received mechanical ventilation. Hospital mortality occurred in 13 (5.3%) patients with a mortality rate lower than in other ICU patients. CONCLUSIONS: In ANZ, the ICU and population incidence of MG has increased over the last decade. However, its mortality rate was low.