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2.
J Neurotrauma ; 2019 Sep 10.
Artigo em Inglês | MEDLINE | ID: mdl-31286839

RESUMO

The optimal osmotic agent to treat intracranial hypertension in patients with severe traumatic brain injury (TBI) remains uncertain. We aimed to test whether the choice of mannitol or hypertonic saline (HTS) as early (first 96 h) osmotherapy in these patients might be associated with a difference in mortality. We retrospectively analyzed data from 2015 from 14 tertiary intensive care units (ICUs) in Australia, UK, and Europe treating severe TBI patients with intracranial pressure (ICP) monitoring and compared mortality in those who received mannitol only versus HTS only. We performed multi-variable analysis adjusting for site and illness severity (Injury Severity Score, extended IMPACT score, and mean ICP over the first 96 h) using Cox proportional hazards regression. We collected data on 262 patients and compared patients who received early osmotherapy with mannitol alone (n = 46) with those who received HTS alone (n = 46). Mannitol patients were older (median age, 49.2 (19.2) vs. 40.5 (16.8) years; p = 0.02), with higher Injury Severity Scores (42 (15.9) vs. 32.1 [11.3]; p = 0.001), and IMPACT-TBI predicted 6-month mortality (34.5% [23-46] vs. 25% [13-38]; p = 0.02), but had similar APACHE-II scores, and mean and maximum ICPs over the first 96 h. The unadjusted hazard ratio for in-hospital mortality in patients receiving only mannitol was 3.35 (95% confidence interval [CI], 1.60-7.03; p = 0.001). After adjustment for key mortality predictors, the hazard ratio for in-hospital mortality in patients receiving only mannitol was 2.64 (95% CI, 0.96-7.30; p = 0.06). The choice of early osmotherapy in severe TBI patients may affect survival, or simply reflect clinician beliefs about their different roles, and warrants controlled investigation.

3.
Crit Care Resusc ; 21(2): 96-101, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31142239

RESUMO

OBJECTIVE: To describe the prevalence of low-normal body temperatures in emergency department (ED) patients presenting with severe infection, and to determine whether active warming is used in this setting. DESIGN, SETTING AND PARTICIPANTS: We performed a singlecentre retrospective cohort study in ED patients with community-acquired infection who required admission to the intensive care unit (ICU). Temperatures recorded from presentation up until 24 hours in the ICU were extracted from the patients' clinical records. Body temperatures were then classified as low (≤ 36.4°C), normothermic (36.5-37.9°C) or fever ≥ 38°C. RESULTS: Over the study period, 574 patients were admitted to the ICU with infection. Of them, 151 fulfilled the inclusion criteria, and the in-hospital mortality rate for these patients was 8.6%. On presentation, 22.5% (34 patients) had a low body temperature (35-35.9°C for six patients, and < 35.0°C for three patients). In contrast, 26.5% (40 patients) had a temperature ≥ 38.0°C. Among those who presented with low temperature, the median time to reach normothermia was 7.9 hours (range, 3.3-14.0 hours). Active warming was only applied to one patient, (whose body temperature was < 35°C). CONCLUSION: Among patients with community-acquired infection requiring ICU admission, about a quarter have a low temperature and active warming was essentially not applied. These findings suggest that active warming of such patients would likely achieve separation from usual care.


Assuntos
Temperatura Corporal , Serviço Hospitalar de Emergência/estatística & dados numéricos , Hipotermia/epidemiologia , Unidades de Terapia Intensiva/estatística & dados numéricos , Sepse/mortalidade , China/epidemiologia , Mortalidade Hospitalar , Humanos , Prevalência , Estudos Retrospectivos , Índice de Gravidade de Doença
4.
Crit Care Resusc ; 21(2): 119-125, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31142242

RESUMO

BACKGROUND: Septic shock is associated with poor outcomes. Vitamin C (ascorbic acid) is a cellular antioxidant and has anti-inflammatory properties. Whether the combination therapy of vitamin C, thiamine and hydrocortisone reduces vasopressor dependency in septic shock is unclear. OBJECTIVES: To describe the protocol and statistical analysis plan of a multicentre, open-label, prospective, phase 2 randomised clinical trial evaluating the effects of vitamin C, thiamine and hydrocortisone when compared with hydrocortisone monotherapy on the duration of vasopressor administration in critically ill patients with septic shock. METHODS: VITAMINS is a multicentre cardiovascular efficacy trial in adult patients with septic shock. Randomisation occurs via a secure website with stratification by site, and allocation concealment is maintained throughout the trial. The primary outcome is the duration of time alive and free of vasopressor administration at Day 7. Secondary outcomes include feasibility endpoints and some patientcentred outcomes. All analyses will be conducted on an intention-to-treat basis. CONCLUSION: The VITAMINS trial will determine whether combination therapy of vitamin C, thiamine and hydrocortisone when compared with hydrocortisone increases vasopressor-free hours in critically ill patients with septic shock. The conduct of this study will provide important information on the feasibility of studying this intervention in a phase 3 trial. TRIAL REGISTRATION: ClinicalTrials.gov, identification No. NCT03333278.


Assuntos
Ácido Ascórbico/administração & dosagem , Mortalidade Hospitalar , Hidrocortisona/administração & dosagem , Choque Séptico/tratamento farmacológico , Tiamina/administração & dosagem , Vitaminas/administração & dosagem , Adulto , Ácido Ascórbico/uso terapêutico , Quimioterapia Combinada , Feminino , Humanos , Hidrocortisona/uso terapêutico , Unidades de Terapia Intensiva , Masculino , Estudos Prospectivos , Choque Séptico/mortalidade , Tiamina/uso terapêutico , Resultado do Tratamento , Vasoconstritores/uso terapêutico , Vitaminas/uso terapêutico
6.
Emerg Med Australas ; 31(1): 90-96, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30669181

RESUMO

OBJECTIVE: There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). METHODS: ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in-hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. DISCUSSION: This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension.


Assuntos
Hidratação/normas , Sepse/tratamento farmacológico , Vasoconstritores/normas , APACHE , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Austrália , Serviço Hospitalar de Emergência/organização & administração , Hidratação/métodos , Hemodinâmica/efeitos dos fármacos , Humanos , Nova Zelândia , Ressuscitação/métodos , Ressuscitação/normas , Fatores de Tempo , Vasoconstritores/uso terapêutico
7.
Shock ; 2018 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-30379749

RESUMO

INTRODUCTION: To describe the utilization of vasopressors (VP) in patients enrolled in the Australasian Resuscitation In Sepsis Evaluation (ARISE) trial, and to explore the association between time to VP and 90-day mortality. METHODS: The primary exposure variable was VP use after arrival in the emergency department (ED). Vasoactive agents considered as VP included: norepinephrine, epinephrine, metaraminol, or vasopressin. Time-to-event analysis, multivariable logistic regression, and propensity-matched treatment effects modeling were used to assess the association between time to VP and 90-day mortality. RESULTS: In total 1,102 of 1,588 patients (69%) in ARISE received VP at any point. The median [interquartile range (IQR)] time from ED presentation to commencing VP was 4.4 [2.7, 7.1] h, and 38% did so prior to central venous access. The median [IQR] volume of intravenous (i.v.) fluid administered prior to commencing VP was 3.1 [2.3, 4.3] L. Increasing age and volume of i.v. fluid therapy were associated with a lower likelihood of commencing VP early (within 4 h of ED presentation), while greater illness severity was associated with a higher likelihood, P < 0.001, respectively. In those who subsequently died within 90 days, the sub-hazard ratio (95% confidence interval) for commencing VP was 1.4 (1.20, 1.68), P < 0.001, adjusted for age, acute physiology and chronic health evaluation II score, study group, inclusion criteria, plasma lactate, i.v. fluid prior to VP, study institution, and site of infection. DISCUSSION: 50% of the ARISE cohort commenced VP within 4.4 h of ED presentation, and many did so prior to central venous access. Earlier initiation of VP was associated with greater crude and adjusted 90-day mortality.

8.
Aust Crit Care ; 2018 Oct 19.
Artigo em Inglês | MEDLINE | ID: mdl-30348487

RESUMO

BACKGROUND: Approximately 9000 patients with type-2 diabetes mellitus (T2DM) are admitted to an intensive care unit (ICU) in Australia and New Zealand annually. For these patients, recent exploratory data suggest that targeting a more liberal blood glucose range during ICU admission may be safe and potentially beneficial. However, the current approach to blood glucose management of patients with T2DM in Australia and New Zealand ICUs is not well described, and there is uncertainty about clinician equipoise for trials of liberal glycaemic control in these patients. AIM: The aim is to describe self-reported blood glucose management in patients with T2DM by intensivists working in Australian and New Zealand ICUs and to establish whether equipoise exists for a trial of liberal versus standard glycaemic control in such patients. METHOD: An online questionnaire of Australia and New Zealand intensivists conducted in July-September 2016. RESULTS: Seventy-one intensivists responded. Forty-five (63%) used a basic nomogram to titrate insulin. Sixty-six (93%) reported that insulin was commenced at blood glucose concentrations >10 mmol/L and titrated to achieve a blood glucose concentration between 6.0 and 10.0 mmol/L. A majority of respondents (75%) indicated that there was insufficient evidence to define optimal blood glucose targets in patients with T2DM, and 59 (83%) were prepared to enrol such patients in a clinical trial to evaluate a more liberal approach. CONCLUSION: A majority of respondents were uncertain about the optimal blood glucose target range for patients with T2DM and would enrol such patients in a comparative trial of conventional versus liberal blood glucose control.

9.
J Crit Care ; 48: 21-25, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30138904

RESUMO

PURPOSE: To determine predictors of inability to return to work due to health six-months after intensive care admission; and compare functional recovery between patients who had not returned to work and employed patients. METHODS: Participants were working adults admitted to ICU who received >24 h of mechanical ventilation. Outcomes included inability to return to work due to health at six-months post-ICU admission, disability, health status, anxiety, depression and post-traumatic stress. RESULTS: Of 107 patients, 31 (29%) were unable to return to work due to health at six-months after ICU admission. Predictors of inability to return to work included longer hospital stay (odds ratio [OR], 1.05; 95% confidence interval [CI], 1.02-1.08; P = .004); lower Glasgow Coma Scale (GCS) at admission (OR, 0.86; CI, 0.75-0.99; P = .03); and admission due to major trauma (OR, 8.83; CI, 2.57-30.38; P < .001). Compared to employed patients, those who had not returned to work reported higher levels of disability and psychological distress, and poorer health-related quality of life. CONCLUSION: Major trauma, lower GCS and increased hospital length of stay predicted inability to return to work due to health at six-months post-ICU admission. Compared to employed patients, those who had not returned to work reported poorer functional recovery.

11.
Neurocrit Care ; 29(3): 443-451, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-29949002

RESUMO

BACKGROUND: Early hyperoxia may be an independent risk factor for mortality in critically ill traumatic brain injury (TBI) patients, although current data are inconclusive. Accordingly, we conducted a retrospective cohort study to determine the association between systemic oxygenation and in-hospital mortality, in critically ill mechanically ventilated TBI patients. METHODS: Data were extracted from the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database. All adult TBI patients receiving mechanical ventilation in 129 intensive care units between 2000 and 2016 were included in analysis. The following data were extracted: demographics, illness severity scores, physiological and laboratory measurements, institutional characteristics, and vital status at discharge. In-hospital mortality was used as the primary study outcome. The primary exposure variable was the 'worst' partial arterial pressure of oxygen (PaO2) recorded during the first 24 h in ICU; hyperoxia was defined as > 299 mmHg. Adjustment for illness severity utilized multivariable logistic regression, the results of which are reported as the odds ratio (OR) 95% CI. RESULTS: Data concerning 24,148 ventilated TBI patients were extracted. By category of worst PaO2, crude in-hospital mortality ranged from 27.1% (PaO2 40-49 mmHg) to 13.3% (PaO2 140-159 mmHg). When adjusted for patient and institutional characteristics, the only PaO2 category associated with a significantly greater risk of death was < 40 mmHg [OR 1.52, 1.03-2.25]. A total of 3117 (12.9%) patients were hyperoxic during the first 24 h in ICU, with a crude in-hospital mortality rate of 17.8%. No association was evident in between hyperoxia and mortality in adjusted analysis [OR 0.97 (0.86-1.11)]. CONCLUSIONS: In this large multicenter cohort of TBI patients, hyperoxia in the first 24 h after ICU admission was not independently associated with greater in-hospital mortality. Hypoxia remains associated with greater in-hospital mortality risk and should be avoided where possible.

12.
Innovations (Phila) ; 13(2): 97-103, 2018 Mar/Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29697598

RESUMO

OBJECTIVE: Leg ischemia is a serious complication of femoral artery cannulation. The primary aim of this study was to assess the safety and efficacy of a novel bidirectional femoral arterial cannula (Sorin Group USA, a wholly owned subsidiary of LivaNova PLC, Arvada, CO USA) that provides both antegrade and retrograde flow, in patients undergoing peripheral cannulation for cardiopulmonary bypass during cardiac surgery. METHODS: Patients undergoing routine cardiac surgery requiring femoral artery cannulation for cardiopulmonary bypass were identified preoperatively. Informed written consent was obtained in all cases. Bidirectional cannula insertion used either a surgical cut-down and wire through needle approach or a percutaneous technique. Flow in the superficial femoral artery was assessed using Doppler ultrasound after commencement of cardiopulmonary bypass. Lower limb perfusion was assessed using reflectance near-infrared spectroscopy to measure regional oxygen saturations in the cannulated limb during cardiopulmonary bypass. RESULTS: Fifteen patients (median age = 61.3 years, range = 26-79 years, 10 males, 5 females) underwent femoral arterial cannulation using the novel bidirectional femoral cannula between August 2016 and May 2017. Fourteen cannulae were inserted directly into the femoral artery via a surgical cut-down and wire through needle technique. One bidirectional cannula was inserted using a percutaneous insertion technique. Indications included minimally invasive mitral and aortic valve surgery, thoracic aortic aneurysm repair, and redo cardiac surgery. The median duration of cardiopulmonary bypass was 129 minutes (range = 53-228 minutes). The cannula was inserted and positioned without difficulty in 14 of 15 patients. Incorrect sizing and arterial spasm prevented correct cannula positioning in one patient. Antegrade flow in the superficial femoral artery was observed on Doppler ultrasound in 12 of 12 patients in which this was performed. Continuous stable distal perfusion was demonstrated in the cannulated limb in 14 of 15 patients. No procedural complications occurred in the immediate or convalescent postoperative period. CONCLUSIONS: This study demonstrates that in patients undergoing femoral arterial cannulation for cardiopulmonary bypass during cardiac surgery, the use of a novel bidirectional cannula is safe and easy to insert and provides stable distal perfusion of the cannulated limb. Use of the device should largely obviate the need to insert a separate downstream perfusion cannula or use other techniques to protect against lower limb ischemia. Further research on a larger scale and in different patient populations is now warranted.


Assuntos
Cânula/normas , Procedimentos Cirúrgicos Cardíacos/métodos , Cateterismo Periférico/métodos , Artéria Femoral/cirurgia , Perfusão/instrumentação , Doenças Vasculares Periféricas/complicações , Adulto , Idoso , Aneurisma da Aorta Torácica/cirurgia , Valva Aórtica/cirurgia , Ponte Cardiopulmonar/métodos , Ponte Cardiopulmonar/estatística & dados numéricos , Cateterismo Periférico/efeitos adversos , Desenho de Equipamento , Feminino , Artéria Femoral/diagnóstico por imagem , Humanos , Isquemia/patologia , Masculino , Pessoa de Meia-Idade , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Valva Mitral/cirurgia , Doenças Vasculares Periféricas/diagnóstico por imagem , Doenças Vasculares Periféricas/patologia , Espectroscopia de Luz Próxima ao Infravermelho/métodos , Ultrassonografia Doppler
13.
Emerg Med Australas ; 30(2): 270-272, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-29145711

RESUMO

Significant tension surrounds the application of antibiotics in suspected infection. Guidelines stress the importance of early empirical broad-spectrum therapy, with select observational data suggesting inferior outcomes when this is delayed. In contrast, microbiological resistance is an ever increasing global problem, with many advocating for a more restricted, culture-driven approach to antibiotic prescription. Controlled trial data are urgently needed, although many clinicians would find withholding of antibiotic therapy unethical. A trial of prehospital antibiotic administration (by paramedics) in patients with suspected sepsis would therefore provide crucial data, and go a long way to determining whether earlier empirical therapy does actually improve outcomes.


Assuntos
Antibacterianos/administração & dosagem , Sepse/tratamento farmacológico , Fatores de Tempo , Tempo para o Tratamento/normas , Antibacterianos/uso terapêutico , Estudos de Coortes , Infecções Comunitárias Adquiridas/tratamento farmacológico , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Serviços Médicos de Emergência/estatística & dados numéricos , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Humanos , New South Wales , Escores de Disfunção Orgânica , Avaliação de Resultados (Cuidados de Saúde)/normas , Estudos Prospectivos , Tempo para o Tratamento/estatística & dados numéricos
14.
Adv Drug Deliv Rev ; 123: 65-74, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-28964882

RESUMO

Patients suffering major burn injury represent a unique population of critically ill patients. Widespread skin and tissue damage causes release of systemic inflammatory mediators that promote endothelial leak, extravascular fluid shifts, and cardiovascular derangement. This phase is characterized by relative intra-vascular hypovolaemia and poor peripheral perfusion. Large volume intravenous fluid resuscitation is generally required. The patients' clinical course is then typically complicated by ongoing inflammation, protein catabolism, and marked haemodynamic perturbation. At all times, drug distribution, metabolism, and elimination are grossly distorted. For hydrophilic agents, changes in volume of distribution and clearance are marked, resulting in potentially sub-optimal drug exposure. In the case of antibiotics, this may then promote treatment failure, or the development of bacterial drug resistance. As such, empirical dose selection and pharmaceutical development must consider these features, with the application of strategies that attempt to counter the unique pharmacokinetic changes encountered in this setting.

16.
Crit Care Resusc ; 19(2): 103-109, 2017 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-28651504

RESUMO

Patients with an aneurysmal subarachnoid haemorrhage (SAH) frequently require admission to the intensive care unit. There, a variety of therapeutic strategies are initiated, in addition to definitive procedures aimed at securing the aneurysm. Despite a substantial investment in caring for these patients, outcomes for this group remain poor. Although the severity of the initial bleed is crucial in this context, many patients undergo further deterioration in the ICU. Delayed cerebral ischaemia is a significant cause of longterm morbidity and mortality after SAH. There are limited data supporting much of the critical care provided to patients with SAH in the ICU, leading to substantial institutional and practitioner variation in treatment. Whether this influences patient outcomes is unknown, although it represents a major knowledge gap in neurocritical practice in Australia and New Zealand.


Assuntos
Cuidados Críticos/métodos , Hipercapnia/sangue , Hipotermia Induzida , Hemorragia Subaracnóidea/terapia , Austrália , Pesquisa Comparativa da Efetividade , Humanos , Cooperação Internacional , Nova Zelândia , Hemorragia Subaracnóidea/mortalidade , Taxa de Sobrevida
17.
Intensive Care Med ; 43(7): 992-1001, 2017 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-28534110

RESUMO

PURPOSE: To use the World Health Organisation's International Classification of Functioning to measure disability following critical illness using patient-reported outcomes. METHODS: A prospective, multicentre cohort study conducted in five metropolitan intensive care units (ICU). Participants were adults who had been admitted to the ICU, received more than 24 h of mechanical ventilation and survived to hospital discharge. The primary outcome was measurement of disability using the World Health Organisation's Disability Assessment Schedule 2.0. The secondary outcomes included the limitation of activities and changes to health-related quality of life comparing survivors with and without disability at 6 months after ICU. RESULTS: We followed 262 patients to 6 months, with a mean age of 59 ± 16 years, and of whom 175 (67%) were men. Moderate or severe disability was reported in 65 of 262 (25%). Predictors of disability included a history of anxiety/depression [odds ratio (OR) 1.65 (95% confidence interval (CI) 1.22, 2.23), P = 0.001]; being separated or divorced [OR 2.87 (CI 1.35, 6.08), P = 0.006]; increased duration of mechanical ventilation [OR 1.04 (CI 1.01, 1.08), P = 0.03 per day]; and not being discharged to home from the acute hospital [OR 1.96 (CI 1.01, 3.70) P = 0.04]. Moderate or severe disability at 6 months was associated with limitation in activities, e.g. not returning to work or studies due to health (P < 0.002), and reduced health-related quality of life (P < 0.001). CONCLUSION: Disability measured using patient-reported outcomes was prevalent at 6 months after critical illness in survivors and was associated with reduced health-related quality of life. Predictors of moderate or severe disability included a prior history of anxiety or depression, separation or divorce and a longer duration of mechanical ventilation. TRIAL REGISTRATION: NCT02225938.


Assuntos
Resultados de Cuidados Críticos , Estado Terminal , Avaliação da Deficiência , Qualidade de Vida , Sobreviventes/psicologia , APACHE , Adulto , Idoso , Ansiedade/complicações , Depressão/complicações , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Medidas de Resultados Relatados pelo Paciente , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Índice de Gravidade de Doença , Fatores de Tempo
18.
PLoS One ; 12(5): e0176570, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28464035

RESUMO

PURPOSE: Comparisons between institutions of intensive care unit (ICU) length of stay (LOS) are significantly confounded by individual patient characteristics, and currently there is a paucity of methods available to calculate risk-adjusted metrics. METHODS: We extracted de-identified data from the Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database for admissions between January 1 2011 and December 31 2015. We used a mixed-effects log-normal regression model to predict LOS using patient and admission characteristics. We calculated a risk-adjusted LOS ratio (RALOSR) by dividing the geometric mean observed LOS by the exponent of the expected Ln-LOS for each site and year. The RALOSR is scaled such that values <1 indicate a LOS shorter than expected, while values >1 indicate a LOS longer than expected. Secondary mixed effects regression modelling was used to assess the stability of the estimate in units over time. RESULTS: During the study there were a total of 662,525 admissions to 168 units (median annual admissions = 767, IQR:426-1121). The mean observed LOS was 3.21 days (median = 1.79 IQR = 0.92-3.52) over the entire period, and declined on average 1.97 hours per year (95%CI:1.76-2.18) from 2011 to 2015. The RALOSR varied considerably between units, ranging from 0.35 to 2.34 indicating large differences after accounting for case-mix. CONCLUSIONS: There are large disparities in risk-adjusted LOS among Australian and New Zealand ICUs which may reflect differences in resource utilization.


Assuntos
Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Idoso , Austrália , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Modelos Estatísticos , Nova Zelândia , Medição de Risco
19.
Int J Antimicrob Agents ; 49(5): 624-630, 2017 May.
Artigo em Inglês | MEDLINE | ID: mdl-28286115

RESUMO

Augmented renal clearance (ARC) is known to influence ß-lactam antibiotic pharmacokinetics. This substudy of the BLING-II trial aimed to explore the association between ARC and patient outcomes in a large randomised clinical trial. BLING-II enrolled 432 participants with severe sepsis randomised to receive ß-lactam therapy by continuous or intermittent infusion. An 8-h creatinine clearance (CLCr) measured on Day 1 was used to identify ARC, defined as CLCr ≥ 130 mL/min. Patients receiving any form of renal replacement therapy were excluded. Primary outcome was alive ICU-free days at Day 28. Secondary outcomes included 90-day mortality and clinical cure at 14 days following antibiotic cessation. A total of 254 patients were included, among which 45 (17.7%) manifested ARC [median (IQR) CLCr 165 (144-198) mL/min]. ARC patients were younger (P <0.001), more commonly male (P = 0.04) and had less organ dysfunction (P <0.001). There was no difference in ICU-free days at Day 28 [ARC, 21 (12-24) days; no ARC, 21 (11-25) days; P = 0.89], although clinical cure was significantly greater in the unadjusted analysis in those manifesting ARC [33/45 (73.3%) vs. 115/209 (55.0%) P = 0.02]. This was attenuated in the multivariable analysis. No difference was noted in 90-day mortality. There were no statistically significant differences in clinical outcomes in ARC patients according to the dosing strategy employed. In this substudy of a large clinical trial of ß-lactam antibiotics in severe sepsis, ARC was not associated with any differences in outcomes, regardless of dosing strategy.


Assuntos
Antibacterianos/farmacocinética , Infecções Bacterianas/tratamento farmacológico , Taxa de Depuração Metabólica/fisiologia , Sepse/tratamento farmacológico , beta-Lactamas/farmacocinética , Adulto , Idoso , Antibacterianos/administração & dosagem , Antibacterianos/uso terapêutico , Infecções Bacterianas/microbiologia , Estudos de Coortes , Creatinina/farmacocinética , Feminino , Humanos , Infusões Intravenosas , Masculino , Pessoa de Meia-Idade , Sepse/microbiologia , Resultado do Tratamento , beta-Lactamas/administração & dosagem , beta-Lactamas/uso terapêutico
20.
JAMA ; 317(3): 290-300, 2017 01 17.
Artigo em Inglês | MEDLINE | ID: mdl-28114553

RESUMO

Importance: The Sepsis-3 Criteria emphasized the value of a change of 2 or more points in the Sequential [Sepsis-related] Organ Failure Assessment (SOFA) score, introduced quick SOFA (qSOFA), and removed the systemic inflammatory response syndrome (SIRS) criteria from the sepsis definition. Objective: Externally validate and assess the discriminatory capacities of an increase in SOFA score by 2 or more points, 2 or more SIRS criteria, or a qSOFA score of 2 or more points for outcomes among patients who are critically ill with suspected infection. Design, Setting, and Participants: Retrospective cohort analysis of 184 875 patients with an infection-related primary admission diagnosis in 182 Australian and New Zealand intensive care units (ICUs) from 2000 through 2015. Exposures: SOFA, qSOFA, and SIRS criteria applied to data collected within 24 hours of ICU admission. Main Outcomes and Measures: The primary outcome was in-hospital mortality. In-hospital mortality or ICU length of stay (LOS) of 3 days or more was a composite secondary outcome. Discrimination was assessed using the area under the receiver operating characteristic curve (AUROC). Adjusted analyses were performed using a model of baseline risk determined using variables independent of the scoring systems. Results: Among 184 875 patients (mean age, 62.9 years [SD, 17.4]; women, 82 540 [44.6%]; most common diagnosis bacterial pneumonia, 32 634 [17.7%]), a total of 34 578 patients (18.7%) died in the hospital, and 102 976 patients (55.7%) died or experienced an ICU LOS of 3 days or more. SOFA score increased by 2 or more points in 90.1%; 86.7% manifested 2 or more SIRS criteria, and 54.4% had a qSOFA score of 2 or more points. SOFA demonstrated significantly greater discrimination for in-hospital mortality (crude AUROC, 0.753 [99% CI, 0.750-0.757]) than SIRS criteria (crude AUROC, 0.589 [99% CI, 0.585-0.593]) or qSOFA (crude AUROC, 0.607 [99% CI, 0.603-0.611]). Incremental improvements were 0.164 (99% CI, 0.159-0.169) for SOFA vs SIRS criteria and 0.146 (99% CI, 0.142-0.151) for SOFA vs qSOFA (P <.001). SOFA (AUROC, 0.736 [99% CI, 0.733-0.739]) outperformed the other scores for the secondary end point (SIRS criteria: AUROC, 0.609 [99% CI, 0.606-0.612]; qSOFA: AUROC, 0.606 [99% CI, 0.602-0.609]). Incremental improvements were 0.127 (99% CI, 0.123-0.131) for SOFA vs SIRS criteria and 0.131 (99% CI, 0.127-0.134) for SOFA vs qSOFA (P <.001). Findings were consistent for both outcomes in multiple sensitivity analyses. Conclusions and Relevance: Among adults with suspected infection admitted to an ICU, an increase in SOFA score of 2 or more had greater prognostic accuracy for in-hospital mortality than SIRS criteria or the qSOFA score. These findings suggest that SIRS criteria and qSOFA may have limited utility for predicting mortality in an ICU setting.


Assuntos
Mortalidade Hospitalar , Unidades de Terapia Intensiva/estatística & dados numéricos , Escores de Disfunção Orgânica , Sepse/mortalidade , Síndrome de Resposta Inflamatória Sistêmica , Adulto , Área Sob a Curva , Austrália/epidemiologia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Nova Zelândia/epidemiologia , Pneumonia Bacteriana/mortalidade , Prognóstico , Curva ROC , Estudos Retrospectivos
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