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OBJECTIVE:A definition of refractory septic shock is necessary to guide diagnosis, management, prognostication, research, and future guidelines for this most severe form of the disease. We sought to achieve consensus on clinical criteria that would be used to define refractory septic shock. DESIGN:Review of literature, expert panel position statements, and Delphi rounds with an international expert group. SETTING:Consensus was defined as having at least 75% of panellists in agreement or disagreement on the three highest or lowest levels of a 7-point Likert scale or based on responses to single- or multiple-choice questions, respectively. SUBJECTS:A panel of multinational, multiprofessional and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine (57 invitations and 56 participants). MEASUREMENTS AND MAIN RESULTS:A five-round Delphi process was conducted for consensus and stability. The steering committee proposed 34 statements, and five of them were rejected by panel experts after round 2. Among 29 statements selected from eight domains, consensus was reached for 13. The panel agreed on the need for a comprehensive consensus set of clinical criteria for refractory septic shock. Markers of organ dysfunction (75%, 2 rounds), tissue perfusion (91.1%, 2 rounds) including lactate (94.6%, 2 rounds) and capillary refill time (76.8%, 2 rounds), assessment of fluid-responsiveness after initial resuscitation (92.9%, 5 rounds), and use of vasoactive drugs at norepinephrine equivalents greater than 0.5 µg/kg/min (75.0%, 3 rounds), were selected as clinical criteria of refractory septic shock. The use of critical care ultrasound (CCUS) (92.9%, 3 rounds) was the single diagnostic modality that reached a consensus-based agreement. CONCLUSIONS:A consensus for 13 criteria to frame the definition of refractory septic shock was reached. Refractory septic shock is characterised by persistently elevated lactate concentrations and or prolonged capillary refill time in patients with septic shock who are fluid unresponsive, require a norepinephrine base equivalent dose greater than 0.5 micrograms per kilogram per minute, and undergo CCUS assessment when mixed shock is suspected.
Aims:Total talus replacement (TTR) is an innovative technology with increasing availability. The aim of this study was to present the largest series to date of TTRs performed in the UK describing the outcomes, expected function, and complications. Methods:A total of 27 consecutive TTRs, which were undertaken between June 2019 and Decemeber 2024 in four tertiary centres, were included in the study. Prospectively collected patient-reported outcome measures (PROMs) including the Manchester-Oxford Foot Questionnaire (MOXFQ), visual analogue scale (VAS), EuroQol five-dimension questionnaire (EQ-5D) scores, and the Tegner Activity Scale (TAS), at various timepoints were recorded and compared. Results:Of the 27 TTRs, eight were combined with a total ankle replacement (TATTR). Of the remaining 19 TTRs, 15 were fully articulating and four were constrained by intended bone-metal incorporation at one or more joint surface. The most common indication was idiopathic or post-traumatic avascular necrosis (AVN) of the talus (18/27). At a mean follow-up of 22 months (7 to 68), the mean MOXFQ improved significantly from 80.8% (95% CI 75.1 to 86.4) preoperatively to 43.2% (95% CI 32.1 to 54.3) (p < 0.001). The mean VAS score increased significantly from 44.5 (95% CI 33.8 to 55.2) preoperatively to 76.2 (95% CI 69.7 to 82.7) (p < 0.001). The mean EQ-5D improved significantly from 10.7 (SD 2.141 preoperatively to 7.4 (SD 2.8; p < 0.001). The mean TAS increased by 1.8 (0 to 6). Three patients (11%) underwent revision, two requiring increased constraint and another for deep infection. Conclusion:TTR can be used for patients with destruction of the talus to relieve pain and to improve both function and activity. Patients having surgery for an elective indication appear to improve more than those whose replacement follows trauma. Constrained implants produced similar results to fully articulating implants. It is a technically difficult procedure and as the numbers which are undertaken increases, standardized terminology must be used in further prospective follow-up.
Objective To estimate key statistical parameters and provide practical guidance for planning stepped wedge cluster randomised trials in Australian and New Zealand intensive care units (ICUs). Design Cross-sectional retrospective observational study using routinely collected ICU data. Setting Adult public hospital ICUs contributing to the Australian and New Zealand Intensive Care Society Adult Patient Database between 2010 and 2023. Participants All adult ICU admissions to 132 ICUs. Subgroups included unplanned admissions and admissions involving invasive mechanical ventilation or vasopressor use. Main outcome measures In-hospital mortality during the index hospitalisation within 90 days of ICU admission. Intra-cluster correlation coefficients (ICCs) and cluster auto-correlations (CACs) were estimated using exchangeable, block-exchangeable, and discrete time decay models using a cross-sectional design. Results Among 1,291,849 eligible ICU admissions, observed mortality ranged from 10.3% (all ICU admissions) to 23.0% (non-elective invasively ventilated patients in Mega-ROX ICUs). ICCs ranged from 0.008 to 0.022 and CACs from 0.83 to 1.00, with block-exchangeable or discrete time decay models most often providing the best fit. In a worked example, a 50-ICU stepped wedge trial with 10 steps (11 two-month periods) enrolling 45 unplanned ventilated patients per ICU per period (total ≈24,750 patients) would have 81.6% power to detect an absolute mortality reduction of 2.7%. Conclusions Stepped wedge cluster randomised trials are feasible for evaluating ICU-wide interventions when routine data are available. The ICC and CAC estimates presented here provide Australian and New Zealand-specific parameters for future trial planning and demonstrate the potential of this design for pragmatic large-scale ICU research.
BACKGROUND:Major trauma centres generally deliver better outcomes than non-specialist centres, but whether this association holds true in New Zealand, a country with challenging geography and a dispersed population, is uncertain. AIMS:The aim of this study was to determine whether definitive care at a tertiary trauma hospital compared with a regional (non-tertiary) hospital was associated with improved survival in patients with major trauma in New Zealand. We also aimed to identify factors that predict transfer from a regional hospital to a tertiary centre. METHODS:A registry-based cohort study of adults with major trauma was conducted using data from the New Zealand Trauma Registry. All patients who were in a tertiary hospital at any time during their hospitalisation were considered to have received definitive care in a tertiary centre. The primary outcome was in-hospital mortality during the index hospitalisation episode (including where a hospitalisation episode included care in multiple hospitals). Secondary outcomes were 30 and 90-day mortality, requirement for secondary transfer, and discharge destination. Multivariable logistic regression analysis was used to assess the association between definitive care hospital level and in-hospital mortality, and to identify factors associated with secondary transfer. RESULTS:10,001 major trauma patients were identified, with inpatient case fatality rate of 11.1% (regional hospitals 12.7%, tertiary hospitals 10.5%; P = 0.001). After risk adjustment, definitive care at a tertiary trauma hospital was associated with substantially lower odds of in-hospital death compared with regional hospitals (adjusted odds ratio 0.68 [95% CI, 0.57-0.82]; P < 0.001). Factors associated with secondary inter-hospital transfer included intubation, injury due to falls, Māori ethnicity, higher injury severity, and younger age. CONCLUSION:Definitive care provided at a tertiary trauma hospital was associated with decreased odds of mortality in major trauma patients in New Zealand, indicating the importance of improving equity of access to specialised trauma care for patients suffering from serious injuries.
Optical coherence tomography (OCT) is a high-resolution intravascular imaging modality that provides detailed assessment of plaque morphology, stent optimization and procedural complications during percutaneous coronary intervention (PCI). Conventional OCT requires injection of contrast for blood clearance during image acquisition, which can increase the risk of contrast-induced nephropathy particularly in patients with renal dysfunction. Saline-based OCT has emerged as an alternative strategy to reduce contrast exposure, with available data supporting its safety and diagnostic quality in a substantial proportion of cases. However, its adoption remains limited, largely due to technical challenges in achieving adequate blood clearance with saline. This review article aims to outline the differences in physical properties between saline and contrast, highlights practical technical considerations for saline-based OCT acquisition, and proposes strategies for workflow integration in contemporary PCI practice.
