Epidemiology, Management, and Outcomes of Sepsis in ICUs among Countries of Differing National Wealth across Asia.

Rationale: Directly comparative data on sepsis epidemiology and sepsis bundle implementation in countries of differing national wealth remain sparse. Objectives: To evaluate across countries/regions of differing income status in Asia 1) the prevalence, causes, and outcomes of sepsis as a reason for ICU admission and 2) sepsis bundle (antibiotic administration, blood culture, and lactate measurement) compliance and its association with hospital mortality. Methods: A prospective point prevalence study was conducted among 386 adult ICUs from 22 Asian countries/regions. Adult ICU participants admitted for sepsis on four separate days (representing the seasons of 2019) were recruited. Measurements and Main Results: The overall prevalence of sepsis in ICUs was 22.4% (20.9%, 24.5%, and 21.3% in low-income countries/regions [LICs]/lower middle-income countries/regions [LMICs], upper middle-income countries/regions, and high-income countries/regions [HICs], respectively; P < 0.001). Patients were younger and had lower severity of illness in LICs/LMICs. Hospital mortality was 32.6% and marginally significantly higher in LICs/LMICs than HICs on multivariable generalized mixed model analysis (adjusted odds ratio, 1.84; 95% confidence interval, 1.00-3.37; P = 0.049). Sepsis bundle compliance was 21.5% at 1 hour (26.0%, 22.1%, and 16.2% in LICs/LMICs, upper middle-income countries/regions, and HICs, respectively; P < 0.001) and 36.6% at 3 hours (39.3%, 32.8%, and 38.5%, respectively; P = 0.001). Delaying antibiotic administration beyond 3 hours was the only element independently associated with increased mortality (adjusted odds ratio, 2.53; 95% confidence interval, 2.07-3.08; P < 0.001). Conclusions: Sepsis is a common cause of admission to Asian ICUs. Mortality remains high and is higher in LICs/LMICs after controlling for confounders. Sepsis bundle compliance remains low. Delaying antibiotic administration beyond 3 hours from diagnosis is associated with increased mortality. Clinical trial registered with www.ctri.nic.in (CTRI/2019/01/016898).

A randomized controlled trial of adaptive support ventilation mode to wean patients after fast-track cardiac valvular surgery.

BACKGROUND: Adaptive support ventilation can speed weaning after coronary artery surgery compared with protocolized weaning using other modes. There are no data to support this mode of weaning after cardiac valvular surgery. Furthermore, control group weaning times have been long, suggesting that the results may reflect control group protocols that delay weaning rather than a real advantage of adaptive support ventilation. METHODS: Randomized (computer-generated sequence and sealed opaque envelopes), parallel-arm, unblinded trial of adaptive support ventilation versus physician-directed weaning after adult fast-track cardiac valvular surgery. The primary outcome was duration of mechanical ventilation. Patients aged 18 to 80 yr without significant renal, liver, or lung disease or severe impairment of left ventricular function undergoing uncomplicated elective valve surgery were eligible. Care was standardized, except postoperative ventilation. In the adaptive support ventilation group, target minute ventilation and inspired oxygen concentration were adjusted according to blood gases. A spontaneous breathing trial was carried out when the total inspiratory pressure of 15 cm H2O or less with positive end-expiratory pressure of 5 cm H2O. In the control group, the duty physician made all ventilatory decisions. RESULTS: Median duration of ventilation was statistically significantly shorter (P = 0.013) in the adaptive support ventilation group (205 [141 to 295] min, n = 30) than that in controls (342 [214 to 491] min, n = 31). Manual ventilator changes and alarms were less common in the adaptive support ventilation group, and arterial blood gas estimations were more common. CONCLUSION: Adaptive support ventilation reduces ventilation time by more than 2 h in patients who have undergone fast-track cardiac valvular surgery while reducing the number of manual ventilator changes and alarms.

Utilisation and outcome of renal replacement therapy in an Asian tertiary intensive care unit.

OBJECTIVES: To determine the period prevalence, demographic characteristics, cost of treatment, and outcomes of patients admitted to the intensive care unit for continuous renal replacement therapy. DESIGN: Descriptive case series. SETTING: Intensive Care Unit in a Hong Kong tertiary referral, teaching hospital. PATIENTS: All patients admitted to the Intensive Care Unit from January to December 2007 who underwent continuous renal replacement therapy. MAIN OUTCOME MEASURES: Period prevalence of continuous renal replacement therapy, patient demographic data, referral sources by specialty and hospital location, diagnosis, daily cost of disposable items, duration of renal replacement therapy, intensive care unit length of stay, and hospital mortality. RESULTS: Of 1652 patients admitted to the intensive care unit over a 12-month period, 131 (8%) underwent continuous renal replacement therapy, of whom 56% were admitted from general wards (the department of medicine being the source of 59% of referrals). The median age of these continuous renal replacement therapy patients was 67 (interquartile range, 55-76) years, with a slight male predominance (66%). The mean APACHE II score of the patients was 29 (standard deviation, 7). Chronic renal failure requiring either haemodialysis or peritoneal dialysis was present in 20/131 (15%) patients. Sepsis was the diagnosis most commonly associated with renal failure deemed to warrant continuous renal replacement therapy (43%). The median duration of such continuous therapy was 55 (interquartile range, 25-93) hours and the median intensive care unit length of stay was 120 (interquartile range, 51-289) hours. The mean daily cost of disposables for the provision of continuous renal replacement therapy was HK$3510. The overall intensive care unit mortality of patients having continuous renal replacement therapy was 38% and the hospital mortality was 53%. The corresponding rates for patients with acute renal failure were 45% and 56%, respectively. Patients undergoing continuous renal replacement therapy had prolonged intensive care unit stays (120 vs 24 hours; P<0.05) and higher corresponding hospital mortality rates (53% vs 20%; P<0.001) compared to those not having such therapy. CONCLUSION: The 8% period prevalence of patients admitted to the intensive care unit undergoing continuous renal replacement therapy was somewhat higher than in recently published reports in the international literature. However intensive care unit and hospital mortality rates for such patients were lower than previously reported. The corresponding total daily cost of relevant disposables was similar to costs reported internationally, whilst the length of intensive care unit stays for our cohort were relatively short.

How the COVID-19 pandemic will change the future of critical care.

Coronavirus disease 19 (COVID-19) has posed unprecedented healthcare system challenges, some of which will lead to transformative change. It is obvious to healthcare workers and policymakers alike that an effective critical care surge response must be nested within the overall care delivery model. The COVID-19 pandemic has highlighted key elements of emergency preparedness. These include having national or regional strategic reserves of personal protective equipment, intensive care unit (ICU) devices, consumables and pharmaceuticals, as well as effective supply chains and efficient utilization protocols. ICUs must also be prepared to accommodate surges of patients and ICU staffing models should allow for fluctuations in demand. Pre-existing ICU triage and end-of-life care principles should be established, implemented and updated. Daily workflow processes should be restructured to include remote connection with multidisciplinary healthcare workers and frequent communication with relatives. The pandemic has also demonstrated the benefits of digital transformation and the value of remote monitoring technologies, such as wireless monitoring. Finally, the pandemic has highlighted the value of pre-existing epidemiological registries and agile randomized controlled platform trials in generating fast, reliable data. The COVID-19 pandemic is a reminder that besides our duty to care, we are committed to improve. By meeting these challenges today, we will be able to provide better care to future patients.

Risk of dispersion or aerosol generation and infection transmission with nasopharyngeal and oropharyngeal swabs for detection of COVID-19: a systematic review.

OBJECTIVES: SARS-CoV-2-related disease, referred to as COVID-19, has emerged as a global pandemic since December 2019. While there is growing recognition regarding possible airborne transmission, particularly in the setting of aerosol-generating procedures and treatments, whether nasopharyngeal and oropharyngeal swabs for SARS-CoV-2 generate aerosols remains unclear. DESIGN: Systematic review. DATA SOURCES: We searched Ovid MEDLINE and EMBASE up to 3 November 2020. We also searched the China National Knowledge Infrastructure, Chinese Medical Journal Network, medRxiv and ClinicalTrials.gov up to 29 March 2020. ELIGIBILITY CRITERIA: All comparative and non-comparative studies that evaluated dispersion or aerosolisation of viable airborne organisms, or transmission of infection associated with nasopharyngeal or oropharyngeal swab testing. RESULTS: Of 7702 citations, only one study was deemed eligible. Using a dedicated sampling room with negative pressure isolation room, personal protective equipment including N95 or higher masks, strict sterilisation protocols, structured training with standardised collection methods and a structured collection and delivery system, a tertiary care hospital proved a 0% healthcare worker infection rate among eight nurses conducting over 11 000 nasopharyngeal swabs. No studies examining transmissibility with other safety protocols, nor any studies quantifying the risk of aerosol generation with nasopharyngeal or oropharyngeal swabs for detection of SARS-CoV-2, were identified. CONCLUSIONS: There is limited to no published data regarding aerosol generation and risk of transmission with nasopharyngeal and oropharyngeal swabs for the detection of SARS-CoV-2. Field experiments to quantify this risk are warranted. Vigilance in adhering to current standards for infection control is suggested.

The story of critical care in Asia: a narrative review.

BACKGROUND: Asia has more critically ill people than any other part of our planet. The aim of this article is to review the development of critical care as a specialty, critical care societies and education and research, the epidemiology of critical illness as well as epidemics and pandemics, accessibility and cost and quality of critical care, culture and end-of-life care, and future directions for critical care in Asia. MAIN BODY: Although the first Asian intensive care units (ICUs) surfaced in the 1960s and the 1970s and specialisation started in the 1990s, multiple challenges still exist, including the lack of intensivists, critical care nurses, and respiratory therapists in many countries. This is aggravated by the brain drain of skilled ICU staff to high-income countries. Critical care societies have been integral to the development of the discipline and have increasingly contributed to critical care education, although critical care research is only just starting to take off through collaboration across groups. Sepsis, increasingly aggravated by multidrug resistance, contributes to a significant burden of critical illness, while epidemics and pandemics continue to haunt the continent intermittently. In particular, the coronavirus disease 2019 (COVID-19) has highlighted the central role of critical care in pandemic response. Accessibility to critical care is affected by lack of ICU beds and high costs, and quality of critical care is affected by limited capability for investigations and treatment in low- and middle-income countries. Meanwhile, there are clear cultural differences across countries, with considerable variations in end-of-life care. Demand for critical care will rise across the continent due to ageing populations and rising comorbidity burdens. Even as countries respond by increasing critical care capacity, the critical care community must continue to focus on training for ICU healthcare workers, processes anchored on evidence-based medicine, technology guided by feasibility and impact, research applicable to Asian and local settings, and rallying of governments for support for the specialty. CONCLUSIONS: Critical care in Asia has progressed through the years, but multiple challenges remain. These challenges should be addressed through a collaborative approach across disciplines, ICUs, hospitals, societies, governments, and countries.

Mechanical Ventilation Discontinuation Practices in Asia: A Multinational Survey.

Rationale: There are limited data on mechanical discontinuation practices in Asia. Objectives: To document self-reported mechanical discontinuation practices and determine whether there is clinical equipoise regarding protocolized weaning among Asian Intensive Care specialists. Methods: A survey using a validated questionnaire, distributed using a snowball method to Asian Intensive Care specialists. Results: Of the 2,967 invited specialists from 20 territories, 2,074 (69.9%) took part. The majority of respondents (60.5%) were from China. Of the respondents, 42% worked in intensive care units (ICUs) where respiratory therapists were present; 78.9% used a spontaneous breathing trial as the initial weaning step; 44.3% frequently/always used pressure support (PS) alone, 53.4% intermittent spontaneous breathing trials with PS in between, and 19.8% synchronized intermittent mandatory ventilation with PS as a weaning mode. Of the respondents, 56.3% routinely stopped feeds before extubation, 71.5% generally followed a sedation protocol or guideline, and 61.8% worked in an ICU with a weaning protocol. Of these, 78.2% frequently always followed the protocol. A multivariate analysis involving a modified Poisson regression analysis showed that working in an ICU with a weaning protocol and frequently/always following it was positively associated with an upper-middle-income territory, a university-affiliated hospital, or in an ICU that employed respiratory therapists; and negatively with a low-income or lower-middle-income territory or a public hospital. There was no significant association with "in-house" intensivist at night, multidisciplinary ICU, closed ICU, or nurse-patient ratio. There was heterogeneity in agreement/disagreement with the statement, "evidence clearly supports protocolized weaning over nonprotocolized weaning." Conclusions: A substantial minority of Asian Intensive Care specialists do not wean patients in accordance with the best available evidence or current guidelines. There is clinical equipoise regarding the benefit of protocolized weaning.

In vitro adsorption of gentamicin and netilmicin by polyacrylonitrile and polyamide hemofiltration filters.

Adsorption of gentamicin and netilmicin by new polyacrylonitrile and polyamide hemofiltration filters was studied over 4 h, using a single-compartment in vitro continuous venovenous hemofiltration model. After the first dose (16.6 mg of gentamicin, 19.3 mg of netilmicin), 14.9 mg of gentamicin and 19.2 mg of netilmicin were adsorbed to polyacrylonitrile filters in vitro. Adsorption by polyacrylonitrile filters was rapid and irreversible and could be increased by repeated dosing. Adsorption by polyamide filters was substantially less.

Critical care in the developing world - a challenge for us all.

The rapid economic growth in parts of the developing world is being accompanied by an expansion of critical care. Hurdles to expansion include lack of critical care training for healthcare workers. This is coupled with a need for a huge number of healthcare workers due to the high populations of countries such as China and India. Intensivists in the developed world can and should help.

Principles of antibacterial dosing in continuous renal replacement therapy.

BACKGROUND: Appropriate antibacterial therapy is important to maximize patient survival in sepsis. Acute renal failure complicates optimal antibiotic administration. METHODS: MEDLINE search from 1986 to 2010 using the terms 'acute renal failure', 'pharmacokinetics', 'clearance', 'dosage', 'h(a)emofiltration', 'h(a)emodialysis', 'h(a)emodiafiltration', 'continuous renal replacement therapy', 'antibiotics', 'intensive care' and 'critically ill'. RESULTS: Maximal bacterial killing and minimization of side effects depend on achieving pharmacokinetic targets appropriate to the selected antibacterial agent. Volume of distribution and clearance may be altered by critical illness and/or acute kidney injury. Clearance is determined by nonrenal clearance, residual renal clearance and continuous renal replacement therapy dose. Sieving and saturation coefficients are membrane specific, but may be altered by changes in protein binding induced by critical illness. A significant proportion of studies failed to report the essential dataset required for adequate antibacterial dosage calculation. CONCLUSIONS: Individualized dosing based on first principles may be the most appropriate method of dosing, particularly when enhanced by therapeutic drug monitoring.

Intensive care management of coronavirus disease 2019 (COVID-19): challenges and recommendations.

As coronavirus disease 2019 (COVID-19) spreads across the world, the intensive care unit (ICU) community must prepare for the challenges associated with this pandemic. Streamlining of workflows for rapid diagnosis and isolation, clinical management, and infection prevention will matter not only to patients with COVID-19, but also to health-care workers and other patients who are at risk from nosocomial transmission. Management of acute respiratory failure and haemodynamics is key. ICU practitioners, hospital administrators, governments, and policy makers must prepare for a substantial increase in critical care bed capacity, with a focus not just on infrastructure and supplies, but also on staff management. Critical care triage to allow the rationing of scarce ICU resources might be needed. Researchers must address unanswered questions, including the role of repurposed and experimental therapies. Collaboration at the local, regional, national, and international level offers the best chance of survival for the critically ill.

Critically ill patients with COVID-19 in Hong Kong: a multicentre retrospective observational cohort study

Objective: To report the first eight cases of critically ill patients with coronavirus disease 2019 (COVID-19) in Hong Kong, describing the treatments and supportive care they received and their 28-day outcomes. Design: Multicentre retrospective observational cohort study. Setting: Three multidisciplinary intensive care units (ICUs) in Hong Kong. Participants: All adult critically ill patients with confirmed COVID-19 admitted to ICUs in Hong Kong between 22 January and 11 February 2020. Main outcome measure: 28-day mortality. Results: Eight out of 49 patients with COVID-19 (16%) were admitted to Hong Kong ICUs during the study period. The median age was 64.5 years (range, 42­70) with a median admission Sequential Organ Failure Assessment (SOFA) score of 6 (IQR, 4­7). Six patients (75%) required mechanical ventilation, six patients (75%) required vasopressors and two (25%) required renal replacement therapy. None of the patients required prone ventilation, nitric oxide or extracorporeal membrane oxygenation. The median times to shock reversal and extubation were 9 and 11 days respectively. At 28 days, one patient (12%) had died and the remaining seven (88%) all survived to ICU discharge. Only one of the survivors (14%) still required oxygen at 28 days. Conclusion: Critically ill patients with COVID-19 often require a moderate duration of mechanical ventilation and vasopressor support. Most of these patients recover and survive to ICU discharge with supportive care using lung protective ventilation strategies, avoiding excess fluids, screening and treating bacterial co-infection, and timely intubation. Lower rather than upper respiratory tract viral burden correlates with clinical severity of illness.

Principles of antibacterial dosing in continuous renal replacement therapy.

OBJECTIVES: To outline the concepts involved in optimizing antibacterial dosing in critically ill patients with acute renal failure undergoing continuous renal replacement therapy (CRRT), provide a strategy for optimizing dosing, and summarize the data required to implement the strategy. DATA SOURCES: MEDLINE search from February 1986 to 2008. DATA EXTRACTION AND SYNTHESIS: Optimal dosing of antibacterials is dependent on achieving pharmacokinetic targets associated with maximal killing of bacteria and improved outcomes. The initial dose is dependent on the volume of distribution. Maintenance doses are dependent on clearance. Both should be adjusted according to the pharmacokinetic target associated with optimal bacterial killing, when known. The volume of distribution of some antibacterials is altered by critical illness or acute renal failure or both. Clearance by CRRT is dependent on the dose and mode of CRRT and the sieving or saturation coefficient of the drug. Both sieving and saturation coefficient are related to the plasma protein binding and thus may be altered in renal failure. CONCLUSIONS: Appropriate dose calculation requires knowledge of the pharmacokinetic target and the usual minimum inhibitory concentration of the suspected organism in the patient's locality (or if unavailable, the break point for the organism), published pharmacokinetic data (volume of distribution, non-CRRT clearance) on critically ill patients receiving CRRT (which may differ substantially from noncritically ill patients or those without renal failure), the sieving or saturation coefficient of the relevant drug in critically ill patients, the dose and mode of CRRT being used, and the actual dose of CRRT that is delivered. This large number of variables results in considerable inter- and intrapatient heterogeneity in dose requirements. This article provides basic principles and relevant data to guide the clinician in prescribing individualized dosing regimes.

Overdose of methyldopa, indapamide and theophylline resulting in prolonged hypotension, marked diuresis and hypokalaemia in an elderly patient.

An 89-year-old man with a history of hypertension, chronic obstructive pulmonary disease, personality disorder and previous attempts of self-poisoning attempted suicide by swallowing two mouthfuls of tablets (methyldopa 250 mg, theophylline SR 200 mg, indapamide 2.5 mg and paracetamol 500 mg). He had prolonged, severe hypotension, necessitating the use of 3000 ml of Gelofusine and almost 2 days of intravenous norepinephrine infusion. He had marked diuresis for 4.5 days, requiring continuous and bolus infusions of intravenous fluids. He had marked renal potassium loss, requiring vigorous potassium replacement therapy. Multiple-dose activated charcoal was used to enhance theophylline elimination. The plasma paracetamol level was below the treatment line. Methyldopa via its metabolite stimulates postsynaptic alpha-adrenergic receptors in cardiovascular control centres in the brain, causing a reduction in peripheral sympathetic tone and a fall in arterial blood pressure and heart rate. In overdose, it causes hypotension, bradycardia and drowsiness. The natriuretic, kaliuretic and vasodilatory effects of indapamide are exaggerated in overdose, resulting in diuresis, hypokalaemia and hypotension. Theophylline markedly increases the level of circulating catecholamines, which stimulate the vascular beta(2)-adrenergic receptors with decreased peripheral vascular resistance. Peripheral vasodilation and hypotension occur in significant theophylline poisoning. Intracellular shift of potassium results in hypokalaemia. The prescribing physicians should recognise elderly patients at a high risk of self-poisoning and avoid using drugs with a high toxicity in overdose (e.g. theophylline and methyldopa). Restricting access to hazardous drugs (in overdose) would be of paramount importance to reduce the number of severe acute poisoning cases and case-fatalities.

The incidence of deep venous thrombosis in Chinese medical Intensive Care Unit patients.

OBJECTIVE: To evaluate the incidence of deep venous thrombosis in critically ill, Intensive Care Unit patients of Chinese ethnicity. DESIGN: Prospective, observational study. SETTING: Intensive Care Unit in a Hong Kong teaching hospital. PATIENTS: Consecutive adult Chinese medical patients not receiving pharmacological or mechanical prophylaxis for deep venous thrombosis. MAIN OUTCOME MEASURES: Compression and duplex Doppler ultrasound examinations of the lower limbs within 24 hours of admission and twice weekly thereafter during their Intensive Care Unit stay. After discharge, a 1-week follow-up investigation was also performed. Demographic data and risk factors for deep venous thrombosis were prospectively recorded. RESULTS: Over a 9-month study period, 80 patients were investigated. Deep venous thrombosis was detected by ultrasound examination in 15 (19%) of the patients (95% confidence interval, 14-23%). Nine of 15 had isolated below-knee deep venous thrombosis, and of these, five had bilateral involvement. Characteristics of patients with or without deep venous thrombosis were similar. Of the 15 patients who had a positive ultrasound examination, only four (27%) had clinical signs of deep venous thrombosis. Of the 65 patients without a positive ultrasound examination, only two (3%) had positive clinical signs (P=0.01). This yielded a moderate positive likelihood ratio of 9 (95% confidence interval, 2-43) and a small negative likelihood ratio of 0.76 (95% confidence interval, 0.56-1.03). There were no cases of pulmonary embolism. Hospital mortality in those with and without deep venous thrombosis was 33% and 28%, respectively. CONCLUSIONS: In the absence of prophylaxis, the incidence of deep venous thrombosis in Chinese medical Intensive Care Unit patients is lower than that reported in similar Caucasian patients, but higher than expected. As clinical features are not able to reliably exclude the presence of deep venous thrombosis, early routine prophylaxis for deep venous thrombosis in Chinese medical Intensive Care Unit patients should be considered.

Epidemiology and outcome of Candida bloodstream infection in an intensive care unit in Hong Kong.

OBJECTIVE: To study the epidemiology of Candida bloodstream infection in the Intensive Care Unit. DESIGN: Retrospective study. SETTING: A 22-bed, mixed medical and surgical Intensive Care Unit of a 1400-bed university teaching hospital in Hong Kong. PATIENTS: All adult patients (>18 years) who had at least one blood culture positive for Candida. RESULTS: During the 9 years of the study period, there were 128 patients with episodes of candidaemia (point prevalence, 9.6 per 1000 Intensive Care Unit admissions), 72 entailed albicans candidaemia and 56 non-albicans candidaemia. Albicans was still the predominant species, but the incidence of tropicalis was increasing. The median lengths of hospital and Intensive Care Unit stays prior to taking of the culture revealing candidaemia were 15 and 6 days, respectively. In all, 61% of patients did not have Candida colonisation within 2 weeks of their candidaemia. The main anti-fungal agents used were fluconazole and amphotericin B, but only 89 (70%) of the patients received appropriate anti-fungal treatment. Intensive Care Unit and hospital mortalities were 70% and 78%, respectively. Patients who did not receive appropriate treatment within 3 days had a worse outcome than those who did. CONCLUSIONS: Our data showed a high point prevalence of candidaemia in the Intensive Care Unit. Albicans was still the predominant species. Candidaemia occurred early during Intensive Care Unit stay, and a significant proportion of patients did not have prior fungal colonisation. Candidaemia in the Intensive Care Unit was associated with high morbidity and mortality. Many patients did not receive appropriately early anti-fungal therapy, and endured higher mortality than in the remainder.

In-vitro adsorption and sieving coefficient of ticarcillin-clavulanate during continuous haemofiltration.

There are very limited data on ticarcillin-clavulanate elimination by haemofiltration. We measured in vitro ticarcillin-clavulanate adsorption to polyacrylonitrile (PAN) filters and the sieving coefficient using a well-described bench model of haemofiltration. The dose of ticarcillin-clavulanate was 60/2 mg or 180/3 mg, and 0 or 12 g albumin was added to the 1 L of circulating blood-crystalloid mixture to produce four different experimental conditions. The experiment was repeated four times under each condition. Median (interquartile range [IQR] ) ticarcillin adsorption varied from 28 (27-30) mg to 85 (78-90) mg. Adsorption was increased when the dose of ticarcillin was higher (P<0.001), but was not affected by the addition of albumin. Median (IQR) adsorption of clavulanate ranged from 0.67 (0.55-0.75) mg to 1.8 (0.33-3.5) mg and was neither dose dependent (P = 0.505) nor significantly affected by the addition of albumin. Median (IQR) ticarcillin sieving coefficient ranged from 0.73 (0.67-0.75) to 0.99 (0.97-1.03). It was significantly higher with a higher dose of ticarcillin (P = 0.021) and without addition of albumin (P = 0.015). Median (IQR) clavulanate sieving coefficient ranged from 1.03 (1.00-2.24) to 2.0 (1.98-2.47). Clavulanate sieving coefficient was not significantly affected by dose or the addition of albumin. These data indicate that significant adsorption of both ticarcillin and clavulanate occurs in vitro; however, this requires confirmation by clinical pharmacokinetic studies. The sieving coefficient data may help guide appropriate dosing of critically ill patients receiving haemofiltration until more extensive clinical pharmacokinetic data are available.

Changes in medical students' attitudes towards end-of-life decisions across different years of medical training.

BACKGROUND: Decisions to forgo life-sustaining medical treatments in terminally ill patients are challenging, but ones that all doctors must face. Few studies have evaluated the impact of medical training on medical students' attitudes towards end-of-life decisions and none have compared them with an age-matched group of non-medical students. OBJECTIVE: To assess the effect of medical education on medical students' attitudes towards end-of-life decisions in acutely ill patients. DESIGN: Cross-sectional study. PARTICIPANTS: Four hundred and two students at The Chinese University of Hong Kong. MEASUREMENTS: Completion of a questionnaire focused on end-of-life decisions. MAIN RESULTS: The number of students who felt that cardiopulmonary resuscitation must always be provided was higher in non-medical students (76/90 (84%)) and medical students with less training (67/84 (80%) in year 1 vs. 18/67 (27%) in year 5) (p < 0.001). Discontinuing life-support therapy was more accepted among senior medical students compared to junior medical and non-medical students (27/66 (41%) in year 5 vs. 18/83 (22%) in year 1 and 20/90 (22%) in non-medical students) (p = 0.003). An unexpectedly large proportion of non-medical students (57/89 (64%)) and year 1 medical students (42/84 (50%)) found it acceptable to administer fatal doses of drugs to patients with limited prognosis. Euthanasia was less accepted with more years of training (p < 0.001). When making decisions regarding limitation of life-support therapy, students chose to involve patients (98%), doctors (92%) and families (73%) but few chose to involve nurses (38%). CONCLUSIONS: Medical students' attitudes towards end-of-life decisions changed during medical training and differed significantly from those of non-medical students.