Objective Postoperative delirium (POD) is a common neurological complication associated with adverse clinical outcomes. Intranasal insulin may improve cognitive function, but its effectiveness and optimal dose for preventing POD remain uncertain. We evaluated the effect of intranasal insulin on POD and explored its dose–response relationship. Review methods PubMed, Scopus, Web of Science, and the Cochrane Library were searched through November 2025. Randomised controlled trials comparing intranasal insulin with placebo in adult surgical patients were included. Random-effect pairwise and one-stage dose–response meta-analyses were performed. Risk of bias was assessed using the Cochrane Risk of Bias 2 tool, and certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation framework. Results Eight randomised controlled trials involving 892 patients were included (502 receiving intranasal insulin and 390 receiving placebo). Intranasal insulin probably reduces POD (moderate-certainty evidence) compared with placebo (risk ratio, 0.39; 95% confidence interval, 0.29–0.51). Subgroup analyses found no significant differences according to surgery type or anaesthetic technique. A dose–response analysis demonstrated a nonlinear association, with a rapid reduction in POD risk at lower doses and the greatest modelled benefit at 30 IU (risk ratio, 0.39; 95% confidence interval, 0.29–0.53). The dose–response curve plateaued above 30 IU, with no additional reduction in POD risk at higher doses. Seven trials had a low risk of bias, while one raised some concerns because of bias in measurement of the outcome. Conclusions Intranasal insulin probably reduces POD in adult surgical patients. The dose–response findings suggest that 30 IU may provide the greatest benefit, with no apparent additional reduction at higher doses. Larger multicentre trials are needed to confirm the optimal regimen and comprehensively evaluate safety.
Objective Data are limited regarding optimal low molecular weight heparin dosing for venous thromboembolism prophylaxis in heavier critically ill patients. This trial evaluated the feasibility of a weight-based dynamic dosing algorithm. Design, setting, participants Open-label, electronic medical record-embedded randomised feasibility trial. Patients, weighing ≥100 kg who required thromboprophylaxis were eligible. Enoxaparin was commenced with weight-based dosing and anti-Xa level-guided adjustment (target peak anti-Xa level 0.2–0.4 IU/mL) or usual care (40 mg twice daily). Main outcome measures The primary outcome was peak anti-Xa level at ‘steady state’ (after ≥3 enoxaparin doses). The feasibility threshold was set at 95% of steady state anti-Xa levels in the intervention group being less than the threshold for therapeutic anticoagulant effect (≤0.6 IU/mL). Results Fifty participants (intervention n = 17, control n = 33) received 331 doses of enoxaparin (median of 4 [interquartile range {IQR}: 3–7] doses per participant, and a dose of 50 [IQR: 50–60] mg (intervention) and 40 [IQR: 40-40] mg (control)). Thirty-two ‘steady state’ peak anti-Xa measurements were recorded from 24 patients (12 intervention and 12 control). The proportion of peak anti-Xa levels that were ≤0.6 IU/mL was: 15 of 17 (88%) vs. 15 of 15 (100%). There were fewer peak anti-Xa measurements below the prophylactic range (<0.2 IU/mL) in the intervention group compared with the control group (2 of 17 [12%] vs. 5 of 15 [33%]). Six patients developed venous thrombosis or pulmonary embolism (2 of 17 [12%] vs. 4 of 33 [12%]). Major bleeding occurred in one patient in the intervention group. Conclusions A weight-based dynamic thromboprophylaxis algorithm was implemented via the electronic medical record but did not meet the predefined feasibility threshold.
Objective To describe the components of institution-free days (IFD) after intensive care unit (ICU) admission and assess the distribution of IFD at 365 d across various admission categories. Design Multicentre, retrospective cohort study. Setting Adult patients (aged ≥18 y) admitted to 12 ICUs in Queensland from 2017 to 2020. Main outcome measures IFD is the primary composite outcome defined as the number of days alive and free of healthcare institution exposure. IFD is calculated by subtracting total number of days with healthcare institution exposure from 365. Distribution of IFD and its components were evaluated across four prespecified subgroups-diagnostic category, comorbidity groups, age quartiles, and remoteness of area of residence. Results 44 541 ICU admissions were analysed, of which 19 706 (44.2%), 17 488 (39.2%), and 7347 (16.5%) were medical, elective, and nonelective surgical admissions, respectively. The median IFD was higher for elective surgical patients as compared to nonelective surgical and medical admissions (348 d [interquartile range (IQR): 330–355] vs. 330 [IQR: 267–349] d vs. 325 [IQR: 185–349]). Hospital readmission days were the major contributor to IFD, with 60.4% of all survivors experiencing at least one hospital readmission day within 365 d. The mean hospital readmission days were highest for nonelective surgical admissions as compared to elective and medical admissions (18.5 [standard deviation (SD):18.4] vs. 13.9 [SD: 15.9] vs. 16.1 [SD: 19.2] days). Conclusion Hospital readmission days were the predominant contributor to institution-days and principal driver of lower IFD for ICU survivors. Medical ICU admissions had the least IFD, followed by nonelective surgical and elective surgical patients.
Objective The aim of this study was to evaluate the impact of decompressive craniectomy (DC) on functional outcomes, mortality, and quality of life in adults with moderate to severe traumatic brain injury (TBI). Design Systematic review and meta-analysis of randomised controlled trials (RCTs). Data sources We searched MEDLINE, Embase, Web of Science, Cochrane CENTRAL, and ClinicalTrials.gov from inception to August 1, 2026, for RCTs comparing DC with medical or surgical management in adults with moderate to severe TBI. Review methods Two reviewers independently extracted data and assessed risk of bias using the Cochrane Risk of Bias 2 tool. Certainty of evidence was evaluated with the Grading of Recommendations, Assessment, Development, and Evaluation framework. Risk ratios (RRs) with 95% confidence intervals (CIs) were pooled using random-effect models. A trial sequential analysis was performed to assess the robustness of the findings. Results Eight RCTs including 1326 patients met the eligibility criteria. Seven trials, including 1296 patients, reported neurological outcomes. DC did not reduce the risk of unfavourable neurological outcome, defined as Glasgow Outcome Scale scores of 1–3 or Glasgow Outcome Scale–Extended scores of 1–4, at the longest available follow-up (3–12 months) (RR: 1.00, 95% CI: 0.83–1.20; I2 = 68%; low certainty). Overall mortality did not differ significantly between groups (RR: 0.84, 95% CI: 0.59–1.19; I2 = 65%; low certainty). Subgroup analyses suggested a possible mortality benefit when DC was performed for refractory intracranial hypertension or when compared with medical management, however, with no improvement in functional neurological outcome. Conclusions In adults with moderate to severe TBI, DC does not reduce unfavourable neurological outcomes or overall mortality. A possible mortality benefit in selected subgroups cannot be excluded, but this may occur at the cost of survival with severe disability. Decisions should be individualised based on each patient’s balance between survival and quality of life considerations.
Objectives: Hospital-based bereavement care is an important source of support for families following the death of a child in a paediatric intensive care unit (PICU) but has been identified as lacking in many critical care units worldwide. Recent surveys exploring bereavement practices in intensive care units have not reported comprehensive paediatric data, meaning the extent of this problem within the PICU setting is currently unknown. The aim of this study was to describe current bereavement care practices in Australia PICUs. Design: A cross-sectional, self-reported, online survey, conducted between November 2024 and April 2025. A validated 34-point critical care bereavement survey was adapted for the paediatric setting and assessed for face validity with five PICU nurses before circulation. Participants: Representatives from Australian PICUs were surveyed via the Australian and New Zealand Intensive Care Society Paediatric Study Group mailing list. Results: Completed surveys were received from 11 dedicated PICUs in Australia (100% response rate). Most respondents reported more than half of the 10 elements of bereavement care provided within their PICUs, but only two PICUs (2/11 [18%]) provided a formal bereavement follow-up service. Six PICUs (6/11 [55%]) provided an informal service, while a further three PICUs (3/11 [27%]) provided no followup service. Only one unit (1/11 [9%]) reported paid, dedicated time allocated to bereavement. Conclusions: This national survey showed bereavement care provided within Australian PICUs was similar across units, but formal bereavement follow-up services were lacking. Bereavement follow-up in most Australian PICUs was delivered by clinicians within their other roles or in unpaid time. We suggest further research into family bereavement needs to strengthen the evidence-base for PICU bereavement care, along with increased training, resourcing, and funding for PICU clinicians to deliver bereavement follow-up services. (c) 2026 The Authors. Published by Elsevier B.V. on behalf of College of Intensive Care Medicine of Australia and New Zealand. This is an open access article under the CC BY license (http:// creativecommons.org/licenses/by/4.0/).
