Premorbid beta blockade in sepsis is associated with a lower risk of a lactate concentration above the lactate threshold, a retrospective cohort study.

Sepsis and septic shock represent a significant worldwide mortality burden. A lactate greater than 4 mmol/L is associated with increased mortality in septic patients. This is the concentration at the "lactate threshold" where serum lactate concentrations rise markedly with increased workload in exercise. Hyperlactatemia in both sepsis and exercise is contributed to by adrenergic agonism which stimulates aerobic glycolysis, increasing lactate production and decreasing lactate clearance. Our hypothesis is that in patients with sepsis, treatment with beta blockers in the community will be associated with a lower probability of initial lactate ≥ 4 mmol/L. This was single centre retrospective cohort study. We used an in-house SQL Database for all admissions to ICU/HDU for the 2017-2020 calendar years. The dataset was filtered for an APACHE III Diagnosis of sepsis. T-tests were used for continuous data, Chi squared and Fisher's exact test were used as appropriate to compare proportions. Logistic regression was used to investigate covariate effects. Of the 160 patient records analysed, 49 were prescribed beta blockers. A greater proportion of patients not prescribed beta blockers in the community had a first lactate ≥ 4 mmol/L (p = 0.049). This was robust to regression analysis. There was no difference in the proportion of patients with lactate ≥ 2 mmol/L (p = 0.52). In our cohort patients previously prescribed beta blockers were less likely to have a lactate of ≥ 4 mmol/mL. This supports the proposed mechanism that treatment with beta blockers increases the lactate threshold in sepsis. Further study is warranted.

What are the solutions for well-being and burn-out for healthcare professionals? An umbrella realist review of learnings of individual-focused interventions for critical care.

OBJECTIVE: To determine what, how, for whom and under what conditions individual-focused interventions are effective to improve well-being and decrease burn-out among critical care healthcare professionals. DESIGN: This study is an umbrella review that used the realist approach, using Realist and Meta-narrative Evidence Synthesis: Evolving Standards guidelines. PsycINFO, Web of Science, CINAHL, MEDLINE, Scopus, ClinicalTrials.gov and ISRCTN databases were searched for published and unpublished systematic reviews and meta-analyses literature between 2016 and 2020. The team appraised and extracted data and identified relationships between content, mechanism and outcomes (CMOs). Theory prepositions were developed using CMOs and were used to refine the existing programme. RESULTS: A total of 81 interventions from 17 reviews were mapped, including mindfulness interventions, cognitive-behavioural therapy, self-care and coping strategies. The revised programme theory determined that contextual factors such as ethnicity, workload, and work schedules play a crucial role in determining the effectiveness of interventions. Mechanisms including the interventions' interests, acceptance, and receptivity are also influential in determining engagement and adherence to the intervention. Findings suggest that the solution for burn-out is complex. However, it offers an optimistic view of tailoring and customising one or a combination of interventions, integrating structured education and components of emotional intelligence. Self-care, social support, awareness or mindfulness and self-efficacy are prime components to improve emotional intelligence and resilience for critical care healthcare professionals to improve well-being and decrease burn-out experience. CONCLUSIONS: These findings provide realistic and reliable reporting of outcomes to better support implementation within the 'real world'. Future research such as seeking validation using expert opinions can provide further in depth understanding of hidden contextual factors, mechanisms and their interactions to provide a greater depth of knowledge ready for application with the critical care population.

A cross-sectional survey of Australian and New Zealand public opinion on methods totriage intensive care patients in an influenza pandemic.

BACKGROUND AND OBJECTIVE: An influenza pandemic has the potential to overwhelm intensive care resources, but the views of the general public on how resources should be allocated in such a scenario were unknown. We aimed to determine Australian and New Zealand public opinion on how intensive care unit beds should be allocated during an influenza pandemic. DESIGN, SETTING, AND PARTICIPANTS: A postal questionnaire was sent to 4000 randomly selected registered voters; 2000 people each from the Australian Electoral Commission and New Zealand Electoral Commission rolls. MAIN OUTCOME MEASURE: The respondents' preferred method to triage ICU patients in an influenza pandemic. Respondents chose from six methods: use a "first in, first served" approach; allow a senior doctor to decide; use pre-determined health department criteria; use random selection; use the patient's ability to pay; use the importance of the patient to decide. Respondents also rated each of the triage methods for fairness. RESULTS: Australian respondents preferred that patients be triaged to the ICU either by a senior doctor (43.2%) or by pre-determined health department criteria (38.7%). New Zealand respondents preferred that triage be performed by a senior doctor (45.9%). Respondents from both countries perceived triage by a senior doctor and by pre-determined health department criteria to be fair, and the other four methods of triage to be unfair. CONCLUSION: In an influenza pandemic, when ICU resources would be overwhelmed, survey respondents preferred that ICU triage be performed by a senior doctor, but also perceived the use of pre-determined triage criteria to be fair.