Breaches of pre-medical emergency team call criteria in an Australian hospital.

Objectives and outcomes: To evaluate the 24hrs before medical emergency team (MET) calls to examine: 1) the frequency, nature, and timing of pre-MET criteria breaches; 2) differences in characteristics and outcomes between patients who did and didn't experience pre-MET breaches. Design: Retrospective observational study November 2020-June 2021. Setting: Tertiary referral Australian hospital. Participants: Adults (≥18 years) experiencing MET calls. Results: Breaches in pre-MET criteria occurred prior to 1886/2255 (83.6%) MET calls, and 1038/1281 (81.0%) of the first MET calls. Patients with pre-MET breaches were older (median [IQR] 72 [57-81] vs 66 [56-77] yrs), more likely to be admitted from home (87.8% vs 81.9%) and via the emergency department (73.0% vs 50.2%), but less likely to be for full resuscitation after (67.3% vs 76.5%) the MET. The three most common pre-MET breaches were low SpO2 (48.0%), high pulse rate (39.8%), and low systolic blood pressure (29.0%) which were present for a median (IQR) of 15.4 (7.5-20.8), 13.2 (4.3-21.0), and 12.6 (3.5-20.1) hrs before the MET call, respectively. Patients with pre-MET breaches were more likely to need intensive care admission within 24 h (15.6 vs 11.9%), have repeat MET calls (33.3 vs 24.7%), and die in hospital (15.8 vs 9.9%). Conclusions: Four-fifths of MET calls were preceded by pre-MET criteria breaches, which were present for many hours. Such patients were older, had more limits of treatment, and experienced worse outcomes. There is a need to improve goals of care documentation and pre-MET management of clinical deterioration.

The hemodynamic effects of warm versus room-temperature crystalloid fluid bolus therapy in post-cardiac surgery patients.

INTRODUCTION: The contribution of fluid temperature to the effect of crystalloid fluid bolus therapy (FBT) in post-cardiac surgery patients is unknown. We evaluated the hemodynamic effects of FBT with fluid warmed to 40°C (warm FBT) versus room-temperature fluid. METHODS: In this single centre prospective before-and-after study, we evaluated the effects of 500 ml of warm versus room-temperature compound sodium lactate administered over <30 minutes, in 50 cardiac surgery patients admitted to ICU. We recorded hemodynamics continuous before and for 30 minutes after the first FBT. We defined CI responsiveness (CI-R) as an CI increase >15% of baseline immediately after FBT and effect dissipation if the CI returned to <5% of baseline and MAP responsiveness as >10% increase and dissipation as return to <3 mmHg of baseline. RESULTS: Hypotension (56%) and low CI (40%) typically triggered FBT. Temperature decreased >0.3°C in 13 (52%) patients after room-temperature FBT versus 0 (0%) after warm FBT (p < 0.01). CI and MAP responsiveness was similar (16 [64%] versus 11 [44%], p = 0.15 and 15 [60%] versus 17 [68%], p = 0.77, respectively). Among CI responders, CI increased more with room-temperature FBT (+0.6 [IQR, 0.5-1.1] versus +0.5 [IQR, 0.4-0.6] L/min/m2, p = 0.01). However, dissipation was more common after room-temperature versus warm FBT (9/16 [56%] versus 1/11 [9%], p = 0.02). CONCLUSION: In postoperative cardiac surgery patients, warm FBT preserved core temperature and induced smaller but more sustained CI increases among responders. Fluid temperature appears to impact both core temperature and the duration of CI response.

Glycemic lability index and mortality in critically ill patients-A multicenter cohort study.

BACKGROUND: Emerging evidence indicates a relationship between glycemic variability during intensive care unit (ICU) admission and death. We assessed whether mean glucose, hypoglycemia occurrence, or premorbid glycemic control modified this relationship. METHODS: In this retrospective, multicenter cohort study, we included adult patients admitted to five ICUs in Australia and Sweden with available preadmission glycated hemoglobin A1c (HbA1c) and three or more glucose readings. We calculated the glycemic lability index (GLI), a measure of glycemic variability, and the time-weighted average blood glucose (TWA-BG) from all glucose readings. We used logistic regression analysis with adjustment for hypoglycemia and admission characteristics to assess the independent association of GLI (above vs. below cohort median) and TWA-BG (above vs. below cohort median) with hospital mortality. RESULTS: Among 2305 patients, 859 (37%) had diabetes, median GLI was 40 [mmol/L]2 /h/week, median TWA-BG was 8.2 mmol/L, 171 (7%) developed hypoglycemia, and 371 (16%) died. The adjusted odds ratio for death was 1.61 (95% CI, 1.19-2.15; P = .002) for GLI above versus below median and 1.06 (95% CI, 0.80-1.41; P = .67) for TWA-BG above versus below median. The relationship between GLI and mortality was not modified by TWA-BG (P [interaction] = 0.66), a history of diabetes (P [interaction] = 0.89) or by HbA1c ≥52 mmol/mol (vs. <52 mmol/mol) (P [interaction] = 0.29). CONCLUSION: In adult patients admitted to an ICU in Sweden and Australia, a high GLI was associated with increased hospital mortality irrespective of the level of mean glycemia, hypoglycemia occurrence, or premorbid glycemic control. These findings support the assessment of interventions to reduce glycemic variability during critical illness.

Accuracy of non-invasive body temperature measurement methods in critically ill patients: a prospective, bicentric, observational study.

Objective: The accuracy of different non-invasive body temperature measurement methods in intensive care unit (ICU) patients is uncertain. We aimed to study the accuracy of three commonly used methods. Design: Prospective observational study. Setting: ICUs of two tertiary Australian hospitals. Participants: Critically ill patients admitted to the ICU. Interventions: Invasive (intravascular and intra-urinary bladder catheter) and non-invasive (axillary chemical dot, tympanic infrared, and temporal scanner) body temperature measurements were taken at study inclusion and every 4 hours for the following 72 hours. Main outcome measures: Accuracy of non-invasive body temperature measurement methods was assessed by the Bland-Altman approach, accounting for repeated measurements and significant explanatory variables that were identified by regression analysis. Clinical adequacy was set at limits of agreement (LoA) of 1°C compared with core temperature. Results: We studied 50 consecutive critically ill patients who were mainly admitted to the ICU after cardiac surgery. From over 375 observations, invasive core temperature (mostly pulmonary artery catheter) ranged from 33.9°C to 39°C. On average, the LoA between invasive and non-invasive measurements methods were about 3°C. The temporal scanner showed the worst performance in estimating core temperature (bias, 0.66°C; LoA, -1.23°C, +2.55°C), followed by tympanic infrared (bias, 0.44°C; LoA, -1.73°C, +2.61°C) and axillary chemical dot methods (bias, 0.32°C; LoA, -1.64°C, +2.28°C). No methods achieved clinical adequacy even accounting for significant explanatory variables. Conclusions: The axillary chemical dot, tympanic infrared and temporal scanner methods are inaccurate measures of core temperature in ICU patients. These non-invasive methods appeared unreliable for use in ICU patients.

Accuracy of non-invasive body temperature measurement methods in adult patients admitted to the intensive care unit: a systematic review and meta-analysis.

Objective: Non-invasive thermometers are widely used in both clinical practice and trials to estimate core temperature. We aimed to investigate their accuracy and precision in patients admitted to the intensive care unit (ICU). Study design: Systematic review and meta-analysis. Data sources: We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials to identify all relevant studies from 1966 to 2017. We selected published trials that reported the accuracy and precision of non-invasive peripheral thermometers (index test) in ICU patients compared with intravascular temperature measurement (reference test). The extracted data included the study design and setting, authors, study population, devices, and body temperature measurements. Methods: Two reviewers performed the initial search, selected studies, and extracted data. Study quality was assessed using the QUADAS-2 tool. Pooled estimates of the mean bias between index and reference tests and the standard deviation of mean bias were synthesised using DerSimonian and Laird random effects meta-analyses. Results: We included 13 cohort studies (632 patients, 105 375 measurements). Axillary, tympanic infrared and zero heat flux thermometers all underestimated intravascular temperature. Only oesophageal measurements showed clinically acceptable accuracy. We found an insufficient number of studies to assess precision for any technique. Study heterogeneity was high (99-100%). Risk of bias for the index test was unclear, mostly because of no device calibration or control for confounders. Conclusions: Compared with the gold standard of intravascular temperature measurement, non-invasive peripheral thermometers have low accuracy. This makes their clinical and trial-related use in ICU patients unreliable and potentially misleading.

Comparison of Thromboelastography and Conventional Coagulation Tests in Patients With Severe Liver Disease.

OBJECTIVE: Thromboelastography (TEG) may provide rapid and clinically important coagulation information in acutely ill patients with chronic liver disease (CLD). Our objective was to describe the relationship between TEG and conventional coagulation tests (CCTs), which has not been previously explored in this population. METHODS: In acutely ill patients with severe CLD (Child-Pugh score > 9, category C), we conducted a prospective observational study investigating coagulation assessment as measured by both CCTs and TEG. We used quantile regression to explore 30 associations between TEG parameters and corresponding CCTs. We compared TEG and CCT measures of coagulation initiation, clot formation, clot strength, and fibrinolysis. RESULTS: We studied 34 patients on a total of 109 occasions. We observed inconsistent associations between TEG and CCT measures of coagulation initiation: TEG (citrated kaolin [CK] assay) standard reaction time and international normalized ratio: R 2 = 0.117 (P = .044). Conversely, there were strong and consistent associations between tests of clot formation: TEG (CK) kinetics time and fibrinogen: R 2 = 0.202 (P < .0001) and TEG (CK) α angle and fibrinogen 0.263 (P < .0001). We also observed strong associations between tests of clot strength, specifically TEG MA and conventional fibrinogen levels, across all TEG assays: MA (CK) and fibrinogen: R 2 = 0.485 (P < .0001). There were no associations between TEG and D-dimer levels. CONCLUSIONS: In acutely ill patients with CLD, there are strong and consistent associations between TEG measures of clot formation and clot strength and conventional fibrinogen levels. There are weak and/or inconsistent associations between TEG and all other conventional measures of coagulation.

Assessing TEG6S reliability between devices and across multiple time points: A prospective thromboelastography validation study.

The TEG6S is a novel haemostasis analyser utilising resonance technology. It offers potentially greater coagulation information and ease of use, however has not been independently validated in a clinical setting. We aimed to determine if the TEG6S is reliable between devices and across time points. We performed a prospective observational study with ethical approval. For interdevice reliability, we performed simultaneous analysis on two TEG6S devices on 25 adult ICU patients. For time point reliability, we performed repeated sampling across five different time points on 15 adult participants. Blood was collected with informed consent, or as standard care, before four-channel citrated kaolin analysis. We observed almost perfect interdevice reliability across all TEG parameters. The Lin's concordance correlation coefficients (95% CI, major axis regression slope, intercept) were R-time: 0.96 (0.92-0.99, 0.88, 0.57); K-time: 0.93 (0.87-0.98, 1.07, 0.00); Alpha Angle: 0.87 (0.78-0.96, 1.20, -14.10); Maximum Amplitude: 0.99 (0.98-0.99, 1.02, -1.38); Clot Lysis: 0.89 (0.82-0.97, 1.20, 0.07). Additionally, we observed moderate-to-high reliability across time points. Demonstrating almost perfect agreement across different devices and moderate-to-high reliability across multiple time points, suggests the TEG6S platform can be used with haemostatic accuracy and generalisability. This has potentially significant implications for clinical practice and multi-site research programs.

Point-of-care creatinine measurements to predict acute kidney injury.

BACKGROUND: Plasma creatinine (Cr) is a marker of kidney function and typically measured once daily. We hypothesized that Cr measured by point-of-care technology early after ICU admission would be a good predictor of acute kidney injury (AKI) the next day in critically ill patients. METHODS: We conducted a retrospective database audit in a single tertiary ICU database. We included patients with normal first admission Cr (CrF ) and identified a Cr value (CrP ) obtained within 6-12 hours from ICU admission. We used their difference converted into percentage (delta-Cr-%) to predict subsequent AKI (based on Cr and/or need for renal replacement therapy) the next day. We assessed predictive value by calculating area under the receiver characteristic curve (AUC), logistic regression models for AKI with and without delta-Cr-%, and the category-free net reclassifying index (cfNRI). RESULTS: We studied 780 patients. Overall, 70 (9.0%) fulfilled the Cr AKI definition by CrP measurement. On day 2, 148 patients (19.0%) were diagnosed with AKI. AUC (95% CI) for delta-Cr-% to predict AKI on day 2 was 0.82 (95% CI 0.78-0.86), and 0.74 (95% CI 0.69-0.80) when patients with AKI based on the CrP were excluded. Using a cut-off of 17% increment, the positive likelihood ratio (95% CI) for delta-Cr-% to predict AKI was 3.5 (2.9-4.2). The cfNRI was 90.0 (74.9-106.1). CONCLUSIONS: Among patients admitted with normal Cr, early changes in Cr help predict AKI the following day.

Haemodynamic effect of a 20% albumin fluid bolus in post-cardiac surgery patients.

OBJECTIVE: To study the cardiovascular effect over 30 minutes following the end of fluid bolus therapy (FBT) with 20% albumin in patients after cardiac surgery. DESIGN: Prospective observational study. SETTING: Intensive care unit of a tertiary university-affiliated hospital. PARTICIPANTS: Twenty post-cardiac surgery mechanically ventilated patients with a clinical decision to administer FBT. INTERVENTION: FBT with a 100 mL bolus of 20% albumin. MAIN OUTCOME MEASURES: Cardiac index (CI) response was defined by a ≥ 15% increase, while mean arterial pressure (MAP) response was defined by a ≥ 10% increase. RESULTS: The most common indication for FBT was hypotension (40%). Median duration of infusion was 7 minutes (interquartile range [IQR], 3-9 min). At the end of FBT, five patients (25%) showed a CI response, which increased to almost half in the following 30 minutes and dissipated in one patient. MAP response occurred in 11 patients (55%) and dissipated in five patients (45%) by a median of 6 minutes (IQR, 6-10 min). CI and MAP responses coexisted in four patients (20%). An intrabolus MAP response occurred in 17 patients (85%) but dissipated in 11 patients (65%) within a median of 7 minutes (IQR, 2-11 min). On regression analysis, faster fluid bolus administration predicted MAP increase at the end of the bolus. CONCLUSION: In post-cardiac surgery patients, CI response to 20% albumin FBT was not congruous with MAP response over 30 minutes. Although hypotension was the main indication for FBT and a MAP response occurred in most of patients, such response was maximal during the bolus, dissipated in a few minutes, and was dissociated from the CI response.

Patient characteristics, ICU-specific supports, complications, and outcomes of persistent critical illness.

OBJECTIVES: The primary objective was to identify the proportion of patients on mechanical ventilation (MV) beyond day 10, the recently defined time of onset of Persistent Critical Illness (PerCI). The secondary objective was to identify underlying diagnoses, intensive care unit (ICU) based therapies, relevant complications, and outcomes of patients with PerCI. SUBJECTS: 100 PerCI patients and 100 age, sex, mechanical ventilation for >24 h, acute physiology and chronic health score (APACHE III) and co-morbidity score-matched controls. MAIN RESULTS: The maximum proportion of PerCI patients requiring invasive MV beyond day 10 was 66%. PerCI patients were more likely to have respiratory, septic, or neurosurgical admission diagnoses (p = .01). In the first 10 ICU days, they received multiple types of ICU-based treatments for longer duration and had a higher incidence rate of ventilator-associated pneumonia (VAP) (p = .008). Hospital discharge destination differed significantly (p≤.001), with greater mortality (34% vs. 22%) and discharge to chronic care facility (11% vs. 0%). CONCLUSIONS: Mechanical ventilation beyond day 10 affected only two thirds of PerCI patients. However, VAP was a key complication in such patients. Discharge to chronic care facilities and hospital mortality were more common in PerCI patients.

Conservative versus conventional oxygen therapy for cardiac surgical patients: A before-and-after study.

Avoiding hypoxaemia is considered crucial in cardiac surgery patients admitted to the intensive care unit (ICU). However, avoiding hyperoxaemia may also be important. A conservative approach to oxygen therapy may reduce exposure to hyperoxaemia without increasing the risk of hypoxaemia. Using a before-and-after design, we evaluated the introduction of conservative oxygen therapy (target SpO2 88%-92% using the lowest FiO2) for cardiac surgical patients admitted to the ICU. We studied 9041 arterial blood gas (ABG) datasets: 4298 ABGs from 245 'conventional' and 4743 ABGs from 298 'conservative' oxygen therapy patients. During mechanical ventilation (MV) and while in the ICU, compared to the conventional group, conservative group patients had significantly lower FiO2 exposure and PaO2 values ( P < 0.001 for each). Accordingly, using the mean PaO2 during MV, more conservative group patients were classified as normoxaemic (226 versus 62 patients, P < 0.01), fewer as hyperoxaemic (66 versus 178 patients, P < 0.01) and no patient in either group as hypoxaemic or severely hypoxaemic. Moreover, more ABG samples were hyperoxaemic or severely hyperoxaemic during conventional treatment ( P < 0.001). Finally, there was no difference in ICU or hospital length of stay, ICU or hospital mortality or 30-day mortality between the groups. Our findings support the feasibility and physiological safety of conservative oxygen therapy in patients admitted to ICU after cardiac surgery.

A Pilot Randomized Controlled Study of Mild Hypercapnia During Cardiac Surgery With Cardiopulmonary Bypass.

OBJECTIVES: To test whether targeted therapeutic mild hypercapnia (TTMH) would attenuate cerebral oxygen desaturation detected using near-infrared spectroscopy during cardiac surgery requiring cardiopulmonary bypass (CPB). DESIGN: Randomized controlled trials. SETTING: Operating rooms and intensive care unit of tertiary hospital. PARTICIPANTS: The study comprised 30 patients undergoing cardiac surgery with CPB. INTERVENTIONS: Patients were randomly assigned to receive either standard carbon dioxide management (normocapnia) or TTMH (target arterial carbon dioxide partial pressure between 50 and 55 mmHg) throughout the intraoperative period and postoperatively until the onset of spontaneous ventilation. MEASUREMENTS AND MAIN RESULTS: Relevant biochemical and hemodynamic variables were measured, and cerebral tissue oxygen saturation (SctO2) was monitored with near-infrared spectroscopy. Patients were followed-up with neuropsychological testing. Patient demographics between groups were compared using the Fisher exact and Mann-Whitney tests, and SctO2 between groups was compared using repeated measures analysis of variance. The median patient age was 67 years (interquartile range [IQR] 62-72 y), and the median EuroSCORE II was 1.1. The median CPB time was 106 minutes. The mean intraoperative arterial carbon dioxide partial pressure for each patient was significantly higher with TTMH (52.1 mmHg [IQR 49.9-53.9 mmHg] v 40.8 mmHg [IQR 38.7-41.7 mmHg]; p < 0.001) as was pulmonary artery pressure (23.9 mmHg [IQR 22.4-25.3 mmHg] v 18.5 mmHg [IQR 14.8-20.7 mmHg]; p = 0.004). There was no difference in mean percentage change in SctO2 during CPB in the control group for both hemispheres (left: -6.7% v -2.3%; p = 0.110; right: -7.9% v -1.0%; p = 0.120). Compliance with neuropsychological test protocols was poor. However, the proportion of patients with drops in test score >20% was similar between groups in all tests. CONCLUSIONS: TTMH did not increase SctO2 appreciably during CPB but increased pulmonary artery pressures before and after CPB. These findings do not support further investigation of TTMH as a means of improving SctO2 during and after cardiac surgery requiring CPB.

The normal cardiac index in older healthy individuals: a scoping review.

OBJECTIVE: Despite the growing number of older patients having major surgery, the normal resting values for the cardiac index of older patients remain unclear. We aim to derive a normative value for such patients. DESIGN: Scoping review. DATA SOURCES: We searched MEDLINE, EMBASE and CENTRAL for studies reporting measured values of cardiac output or cardiac index in healthy, older humans at rest. RESULTS: We retrieved 5340 citations and assessed 412 fulltext articles for eligibility. Twenty-nine studies, published between 1964 and 2017, met our inclusion criteria. Overall, the mean cardiac index in healthy volunteers over 60 years of age was reported between 2.1 and 3.2 L/min/m2 and the mean cardiac output was between 3.1 and 6.4 L/min. A yearly decline in cardiac index (between 3.5 and 8 mL/min/m2 per year) was reported in some but not all studies. Only one study measured the cardiac index in nine people over 80 years of age. CONCLUSIONS: The normal range of the cardiac index in older patients may be lower than previously reported. Its rate of decline with age is uncertain, but likely between 3.5 and 8 mL/min/m2 per year. Data on the normal cardiac index in people older than 80 years are scant.

Long-term risk of adverse outcomes after acute kidney injury: a systematic review and meta-analysis of cohort studies using consensus definitions of exposure.

Reliable estimates of the long-term outcomes of acute kidney injury (AKI) are needed to inform clinical practice and guide allocation of health care resources. This systematic review and meta-analysis aimed to quantify the association between AKI and chronic kidney disease (CKD), end-stage kidney disease (ESKD), and death. Systematic searches were performed through EMBASE, MEDLINE, and grey literature sources to identify cohort studies in hospitalized adults that used standardized definitions for AKI, included a non-exposed comparator, and followed patients for at least 1 year. Risk of bias was assessed by the Newcastle-Ottawa Scale. Random effects meta-analyses were performed to pool risk estimates; subgroup, sensitivity, and meta-regression analyses were used to investigate heterogeneity. Of 4973 citations, 82 studies (comprising 2,017,437 participants) were eligible for inclusion. Common sources of bias included incomplete reporting of outcome data, missing biochemical values, and inadequate adjustment for confounders. Individuals with AKI were at increased risk of new or progressive CKD (HR 2.67, 95% CI 1.99-3.58; 17.76 versus 7.59 cases per 100 person-years), ESKD (HR 4.81, 95% CI 3.04-7.62; 0.47 versus 0.08 cases per 100 person-years), and death (HR 1.80, 95% CI 1.61-2.02; 13.19 versus 7.26 deaths per 100 person-years). A gradient of risk across increasing AKI stages was demonstrated for all outcomes. For mortality, the magnitude of risk was also modified by clinical setting, baseline kidney function, diabetes, and coronary heart disease. These findings establish the poor long-term outcomes of AKI while highlighting the importance of injury severity and clinical setting in the estimation of risk.

Prediction of tracheostomy in critically ill trauma patients: a systematic review.

BACKGROUND: Tracheostomy is relatively common in mechanically ventilated patients in the intensive care unit (ICU). The prediction of which patients will receive a tracheostomy is crucial to both clinical decision making and the design of targeted interventional trials of its timing. OBJECTIVES: We aimed to systematically review the literature to ascertain whether useful predictors of eventual tracheostomy can be identified, with a particular focus on trauma patients. DATA SOURCES AND REVIEW METHODS: We searched three electronic databases to identify all studies of any design evaluating potential predictors of tracheostomy in mechanically ventilated ICU patients. Bias was assessed using the Quality in Prognosis Studies tool. RESULTS: Of 140 potentially eligible studies, we identified 12 relevant observational studies recruiting a total of 119 945 mechanically ventilated patients, of whom 14 080 (11.7%) received a tracheostomy. Seven studies were performed in trauma populations and included 24 858 patients, of whom 6140 (24.7%) received a tracheostomy. Factors predictive of receiving a tracheostomy in the trauma population included patient factors (age and comorbidities), diagnostic factors (injury type and injury severity score), and intervention factors (craniotomy or laparotomy). Profound clinical and methodological heterogeneity prevented meaningful metaanalysis. Significantly, more predictors were present on the day of admission in trauma populations than in non-trauma patients with brain injury and in other populations (89.7% v 73.3% v 25.0%). CONCLUSION: There are a number of clinical factors associated with subsequent tracheostomy in mechanically ventilated patients, in particular trauma patients. Given the need to prevent patients from receiving an unnecessary tracheostomy, these findings indicate that better predictive models are needed before the conduct of interventional trials. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO registry no. CRD42018084987.

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.

Body temperature measurement methods and targets in Australian and New Zealand intensive care units.

OBJECTIVE: In Australian and New Zealand (ANZ) intensive care units (ICUs), the preferred measurement methods and targets for temperature remain uncertain, but are crucial for future interventional studies. We aimed to investigate the reported use of temperature measurement methods and targets in ANZ ICUs. DESIGN, SETTINGS AND PARTICIPANTS: Structured online questionnaire delivered via the email list of the Australian and New Zealand Intensive Care Society Clinical Trials Group. MAIN OUTCOME MEASURES: Measurements methods and targets for temperature in ANZ ICUs. RESULTS: Of 209 respondents, 130 were nurses (62.2%) and 79 were doctors (37.8%). Only 21.5% of the respondents reported having a unit protocol for measuring body temperature. However, invasive temperature measurement methods were preferred by doctors (69.8% v 55.3%) and non-invasive methods by nurses (29.9% v 44.2%). Moreover, among non-invasive methods, tympanic measurement was preferred by doctors (66.0% v 26.9%) and axillary by nurses (11.7% v 51.9%). Both professions reported a wide range of temperature thresholds that they believed required cooling interventions, but 16.7% of doctors and 42.4% of nurses reported that, in patients with cardiac arrest, they would actively cool patients only if the temperature was ≥ 38°C. CONCLUSION: In ANZ ICUs, preferred temperature measurement methods and targets are typically not governed by protocol, vary greatly and differ between doctors and nurses. Targeted temperature management after cardiac arrest is not fully established. Future studies of the comparative accuracy of non-invasive temperature measurements methods and practice in patients with cardiac arrest appear important.

Ventilation management in Victorian intensive care unit patients without acute respiratory distress syndrome.

BACKGROUND: The setting of tidal volume (VT) during controlled mechanical ventilation (CMV) in critically ill patients without acute respiratory distress syndrome (ARDS) is likely important but currently unknown. We aimed to describe current CMV settings in intensive care units (ICUs) across Victoria. METHODS: We performed a multicentre, prospective, observational study. We collected clinical, ventilatory and arterial blood gas data twice daily for 7 days. We performed subgroup analysis by sex and assessment of arterial partial pressure of carbon dioxide (PaCO2) management where hypercapnia was potentially physiologically contraindicated. RESULTS: We recorded 453 observational sets in 123 patients across seven ICUs. The most commonly selected initial VT was 500 mL (33%), and this proportion did not differ according to sex (32% male, 34% female). Moreover, 38% of patients were exposed to initial VT per predicted body weight (VT-PBW) > 8.0 mL/kg. VT-PBW in this range were more likely to occur in females, those with a lower height, lower ideal body weight or in those for whom hypercapnia was potentially physiologically contraindicated. As a consequence, females were more frequently exposed to a lower PaCO2 and higher pH. CONCLUSIONS: In adults without ARDS undergoing CMV in Australian ICUs, the initial VT was a stereotypical 500 mL in one-third of participants, irrespective of sex. Moreover, around 40% of patients were exposed to an initial VT-PBW > 8.0 mL/kg. Finally, women were more likely to be exposed to a high VT and hyperventilation.

Impact of unit-wide chlorhexidine bathing in intensive care on bloodstream infection and drug-resistant organism acquisition.

BACKGROUND: Chlorhexidine gluconate (CHG) bathing has been reported to decrease bloodstream infections and colonisation of multidrug-resistant organisms (MROs) in intensive care units (ICUs). However, its effectiveness in an Australian setting has not been assessed. OBJECTIVE: To test whether the introduction of ICU-wide CHG bathing in place of triclosan would affect rates of the primary outcome of central line-associated bloodstream infections (CLABSI), or the secondary outcomes of ICU-acquired positive blood cultures or other clinical specimens, and MRO colonisation including methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE). METHODS: We conducted a single-centre, sequential, before-and-after observational study. Patient microbiological and clinical data were compared in the 12 months before and after the introduction of CHG bathing in the ICU. RESULTS: A total of 4262 ICU admissions were studied, 2117 before and 2145 during the CHG-bathing period. There were no significant changes in the rates of CLABSI (from 1.69/1000 central venous catheter-days [95% CI, 0.68-3.48] to 1.33 [95% CI, 0.49-2.90]; P = 0.68), or ICU-acquired positive blood cultures (from 5.14/1000 patientdays [95% CI, 3.45-7.39] to 4.45 [95% CI, 3.00-6.36]; P = 0.58). However, we observed a lower incidence of MRSA acquisition during the CHG-bathing period (mean difference, -2.13 [95% CI, -3.65 to -0.60] per 1000 patient-days; P = 0.007). There was no difference in the rate of isolates involving other pathogens including VRE. CONCLUSIONS: In a tertiary Australian ICU, routine CHG bathing compared with triclosan did not affect the rates of ICU-acquired CLABSI or positive blood cultures. However, it significantly decreased the incidence of MRSA acquisition.