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.

Achieving High Dialysis Dose via Continuous Renal Replacement Therapy in the Setting of Metformin Associated Lactic Acidosis. A Case Series.

Severe and life-threatening cases of metformin-associated lactic acidosis (MALA) are treated with renal replacement therapy. Intermittent hemodialysis is recommended, as it achieves rapid more elimination of metformin compared to continuous renal replacement therapy (CRRT). This case series describes 4 patients, 2 with acute metformin intoxications and 2 with insidious metformin toxicity. All were treated using a novel approach with dual CRRT to achieve rapid elimination of metformin. Three of the 4 patients survived to hospital discharge. Dual CRRT may be an effective alternative when dialysis is not readily available.

Safety and efficacy of peripheral versus centrally administered vasopressor infusion: A single-centre retrospective observational study.

BACKGROUND: Shock affects one-third of patients admitted to intensive care and is associated with increased mortality. Vasopressor medications are used to maintain blood pressure in shock. Central venous catheters are associated with serious complications and pose logistical difficulties for insertion. Delivery of vasopressors via peripheral intravenous cannula may be a safe alternative. METHODS: This is a retrospective cohort study comparing safety profile and outcomes of vasopressor delivery via peripheral and central routes in critically ill patients over a 12-month period in a mixed medical-surgical intensive care unit. Demographics, clinical characteristics, treatments, and safety outcome data were extracted from medical records. Patients were classified into three groups: vasopressor infusions via peripheral intravenous cannula, combined peripheral intravenous cannula followed by central venous catheter, and central venous catheter only. Groups were compared using the Kruskal-Wallis test for continuous variables and Fisher's exact test for categorical variables. The impact of duration of vasopressor infusion on complication rates was assessed using logistic regression. RESULTS: We identified 212 patients who received vasopressor infusion, 39 received via peripheral only (Group 1), 155 via peripheral followed by central (Group 2), and 18 via central only (Group 3). There were some baseline differences between groups. Group 1 had the lowest median Acute Physiology and Chronic Health Evaluation III score (64, interquartile range = 44-77), and Group 3, the highest (86, interquartile range = 57-101). Duration of vasopressor infusion was shortest in Group 1 and longer in Groups 2 and 3. There were no major complications; however, minor complications such as leakage, extravasation, and erythema occurred in 41% of Group 1 and 28% of Group 2 patients. Duration of peripheral vasopressor infusion was not associated with an increased risk of complications. CONCLUSIONS: Administration of vasopressor infusions for short duration in critically ill patients via a peripheral venous cannula may be feasible, with low rates of complications, and offers a safe alternative to central venous access.

Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a relatively common condition of varied aetiology associated with high morbidity and mortality. A range of therapies have been proven to be useful for patients with ARDS, including ventilatory and nonventilatory strategies. Prone positioning is one of the nonventilatory strategies and has been proven to be safe and is associated with significant mortality benefit in patients with moderate to severe ARDS. It is now included in several international guidelines as the standard of care for these cases. OBJECTIVES: The aim of the study was to develop, implement, and evaluate a prone positioning program in two nonmetropolitan, nontertiary intensive care units in South East Queensland. METHODS: A Plan-Do-Study-Act quality improvement model was used to implement changes in clinical practice in relation to prone positioning of patients. RESULTS: A description of the methods used to promote a complex change strategy is provided in this article. CONCLUSIONS: In this article, we demonstrate the feasibility of introducing a nonventilatory intervention of prone positioning in the management of patients with moderate to severe ARDS in regional intensive care in South East Queensland. This implementation strategy could be replicated and adopted in other similar intensive care units that do not have the ability to provide tertiary services such as extracorporeal life support.

Clinical management practices of life-threatening asthma: an audit of practices in intensive care.

OBJECTIVE: Lack of management guidelines for lifethreatening asthma (LTA) risks practice variation. This study aims to elucidate management practices of LTA in the intensive care unit (ICU). DESIGN: A retrospective cohort study. SETTING: Thirteen participating ICUs in Australia between July 2010 and June 2013. PARTICIPANTS: Patients with the principal diagnosis of LTA. MAIN OUTCOME MEASURES: Clinical history, ICU management, patient outcomes, ward education and discharge plans. RESULTS: Of the 270 (267 patients) ICU admissions, 69% were female, with a median age of 39 years (interquartile range [IQR], 26-53 years); 119 (44%) were current smokers; 89 patients (33%) previously required ICU admission, of whom 23 (25%) were intubated. The median ICU stay was 2 days (IQR, 2-4 days). Three patients (1%) died. Seventy-nine patients (29%) received non-invasive ventilation, with 11 (14%) needing subsequent invasive ventilation. Sixty-eight patients (25%) were intubated, with the majority of patients receiving volume cycled synchronised intermittent mechanical ventilation (n = 63; 93%). Drugs used included ß2-agonist by intravenous infusion (n = 69; 26%), inhaled adrenaline (n = 15; 6%) or an adrenaline intravenous infusion (n = 23; 9%), inhaled anticholinergics (n = 238; 90%), systemic corticosteroids (n = 232; 88%), antibiotics (n = 126; 48%) and antivirals (n = 22; 8%). When suitable, 105 patients (n = 200; 53%) had an asthma management plan and 122 (n = 202; 60%) had asthma education upon hospital discharge. Myopathy was associated with hyperglycaemia requiring treatment (odds ratio [OR], 31.6; 95% CI, 2.1-474). Asthma education was more common under specialist thoracic medicine care (OR, 3.0; 95% CI, 1.61-5.54). CONCLUSION: In LTA, practice variation is common, with opportunities to improve discharge management plans and asthma education.

An unusual manifestation of Cardiac Sarcoidosis.

Non tropical, non hypereosinophilic endo myocardial fibrosis has been reported in literature and is a rare entity.  Cardiac Sarcoidosis manifesting as non-tropical, non hypereosinophilic endomyocardial fibrosis is unknown, though it classically affects the left ventricle and is not associated with specific risk factors. We describe an atypical presentation of sarcoidosis as non-tropical non hypereosinophilic endomyocardial fibrosis in a middle aged female who presented to us with refractory heart failure.

Pilot randomised double-blind controlled trial of high-dose spironolactone in critically ill patients receiving a frusemide infusion.

BACKGROUND: Hypernatraemia may develop during intravenous infusion of frusemide. Spironolactone is an aldosterone antagonist that promotes natriuresis and may attenuate such hypernatraemia, but its effect in this setting has not been previously studied. OBJECTIVE: To assess whether the administration of spironolactone to ventilated patients receiving a frusemide infusion attenuates the increase in serum sodium concentration. DESIGN AND SETTING: Randomised, double-blind, placebo-controlled trial (January 2005 to December 2006). PATIENTS: 20 patients with a serum creatinine concentration < 300 micromol/L who were undergoing mechanical ventilation in the intensive care unit and had begun a frusemide infusion as treatment for fluid overload within the previous 24 hours. METHODS: Patients were randomly allocated to receive either spironolactone (100 mg three times daily) or placebo by nasogastric tube for the duration of the frusemide infusion. Daily serum levels of urea and creatinine, 24-hour urine sodium and potassium levels, fluid balance and 24- hour blood levels of aldosterone, human atrial natriuretic peptide and plasma renin activity were measured throughout the period of frusemide infusion. RESULTS: Change in serum sodium concentration over 48 hours from baseline was 3.0 mmol/L for placebo versus 1.0 mmol/L for the spironolactone group (P = 0.08). Change in serum potassium concentration did not differ between the groups (0.125 mmol/L over 48 hours). There were no significant differences in total urinary sodium or potassium excretion. Serum creatinine, urea, urine volume, fluid balance, potassium requirements and hormone levels were similar in both groups. CONCLUSIONS: In this pilot study, the administration of high-dose spironolactone to ventilated critically ill patients receiving frusemide by infusion had no significant effects on serum sodium level, natriuresis or potassium balance when compared with placebo.