Rationale Blood glucose concentrations affect outcomes in critically ill patients but the optimal target blood glucose range in those with type 2 diabetes is unknown. Objective To evaluate the effects of a 'liberal' approach to targeted blood glucose range during intensive care unit (ICU) admission. Methods This mutlicenter, parallel-group, open-label, randomized clinical trial included 419 adult patients with type 2 diabetes expected to be in the ICU on at least three consecutive days. In the intervention group intravenous insulin was commenced at a blood glucose >252 mg/dL and titrated to a target range of 180 to 252 mg/dL. In the comparator group insulin was commenced at a blood glucose >180 mg/dL and titrated to a target range of 108 to 180 mg/dL. The primary outcome was incident hypoglycemia (<72 mg/dL). Secondary outcomes included glucose metrics and clinical outcomes. Main Results At least one episode of hypoglycemia occurred in 10 of 210 (5%) patients assigned the intervention and 38 of 209 (18%) patients assigned the comparator (incident rate ratio: 0.21 (95% CI, 0.09 to 0.49); P<0.001). Those assigned the intervention had greater blood glucose concentrations (daily mean, minimum, maximum), less glucose variability and less relative hypoglycaemia (P<0.001 for all comparisons). By day 90, 62 of 210 (29.5%) in the intervention and 52 of 209 (24.9%) in the comparator group had died (absolute difference 4.6 percentage points (95%CI, -3.9 to 13.2%); P=0.29). Conclusions A liberal approach to blood glucose targets reduced incident hypoglycemia but did not improve patient-centered outcomes. Clinical trial registration available at www.anzctr.org.au, ID: ACTRN12616001135404.

BACKGROUND:Contemporary glucose management of intensive care unit (ICU) patients with type 2 diabetes is based on trial data derived predominantly from patients without type 2 diabetes. This is despite the recognition that patients with type 2 diabetes may be relatively more tolerant of hyperglycaemia and more susceptible to hypoglycaemia. It is uncertain whether glucose targets should be more liberal in patients with type 2 diabetes. OBJECTIVE:To detail the protocol, analysis and reporting plans for a randomised clinical trial - the Liberal Glucose Control in Critically Ill Patients with Pre-existing Type 2 Diabetes (LUCID) trial - which will evaluate the risks and benefits of targeting a higher blood glucose range in patients with type 2 diabetes. DESIGN, SETTING, PARTICIPANTS AND INTERVENTION:A multicentre, parallel group, open label phase 2B randomised controlled clinical trial of 450 critically ill patients with type 2 diabetes. Patients will be randomised 1:1 to liberal blood glucose (target 10.0-14.0 mmol/L) or usual care (target 6.0-10.0 mmol/L). MAIN OUTCOME MEASURES:The primary endpoint is incident hypoglycaemia (< 4.0 mmol/L) during the study intervention. Secondary endpoints include biochemical and feasibility outcomes. RESULTS AND CONCLUSION:The study protocol and statistical analysis plan described will delineate conduct and analysis of the trial, such that analytical and reporting bias are minimised. TRIAL REGISTRATION:This trial has been registered on the Australian New Zealand Clinical Trials Registry (ACTRN No. 12616001135404) and has been endorsed by the Australian and New Zealand Intensive Care Society Clinical Trials Group.

Background: Low tidal volume ventilation (LTVV) of 4-8 mL/kg of ideal body weight (IBW) reduces mortality in patients with acute respiratory distress syndrome, and, more recently, it has been recommended as the default therapy for all controlled ventilation. However, adherence to LTVV is poor. Barriers to adherence include not having height measurements taken or IBW calculated during admission. The aim of our project was to develop and validate a simple one step biometric measuring tool to directly estimate tidal volume (V-T) in ventilated patients based on their demispan. Objectives: To validate our novel biometric approach for the estimation of V-T in mechanically ventilated patients by demonstrating its accuracy as a simple reliable alternative to IBW derived from measured height. Design and setting: A simple computer program was written based on regression equations for demispan, height and IBW which used simple substitution to produce a vector graphic scale with markings in millilitres of 6 mL/kg IBW V-T printed onto a paper tape. We performed an observational validation study on ventilated patients after cardiac surgery comparing the V-T derived from demispan measurements using our tape with the V-T based on IBW calculated from pre-operative vertical height. Main outcome measure: We compared compliance with a target V-T <= 6.5 mL/kg for V-T derived using our demispan method and with V-T based on IBW calculated from vertical height. Results: Eighty-two patients were studied. The mean age was 65.7 years (SD, 11.4) and 61 patients (74%) were male. Mean height was 170.4 cm (SD, 9.5) and mean body mass index for the group was 28.6 kg/m(2) (SD, 5.5). The V-T based on 6 mL/kg IBW estimated by traditional height method and using our biometric tape method correlated well (r = 0.8) and was not statistically different, with a mean difference of -7.5 mL (SEM, 8.8). Bland-Altman plot showed 95% limits of agreement from -64 mL to 79 mL around the mean difference of 7.5 mL, with 4 points (4.9%) outside the limits of agreement. Fifty-one of the initial V-T (62%) were compliant, with a target of <= 6.5 mL/kg IBW using volumes determined from measured height, while 66 of the tape volumes (80%) would have been compliant at a target of <= 6.5 mL/kg IBW. Conclusion: Estimating V-T using of our biometric one step approach based on demispan correlates well with V-T derived from vertical height. The simplicity of its use and accuracy could lead to improved adherence in a large cohort of patients who currently do not receive the recommended V-T restriction.

Intense exercise induces pronounced hyperkalemia, followed by transient hypokalemia in recovery. We investigated whether the β2 agonist salbutamol attenuated the exercise hyperkalemia and exacerbated the postexercise hypokalemia, and whether hypokalemia was associated with impaired cardiac repolarization (QT hysteresis). Eleven healthy adults participated in a randomized, counterbalanced, double-blind trial receiving either 1,000 µg salbutamol (SAL) or placebo (PLAC) by inhalation. Arterial plasma potassium concentration ([K+]a) was measured at rest, during 3 min of intense rowing exercise, and during 60 min of recovery. QT hysteresis was calculated from ECG ( n = 8). [K+]a increased above baseline during exercise (rest, 3.72 ± 0.7 vs. end-exercise, 6.81 ± 1.4 mM, P < 0.001, mean ± SD) and decreased rapidly during early recovery to below baseline; restoration was incomplete at 60 min postexercise ( P < 0.05). [K+]a was less during SAL than PLAC (4.39 ± 0.13 vs. 4.73 ± 0.19 mM, pooled across all times, P = 0.001, treatment main effect). [K+]a was lower after SAL than PLAC, from 2 min preexercise until 2.5 min during exercise, and at 50 and 60 min postexercise ( P < 0.05). The postexercise decline in [K+]a was correlated with QT hysteresis ( r = 0.343, n = 112, pooled data, P = 0.001). Therefore, the decrease in [K+]a from end-exercise by ~4 mM was associated with reduced QT hysteresis by ~75 ms. Although salbutamol lowered [K+]a during exercise, no additive hypokalemic effects occurred in early recovery, suggesting there may be a protective mechanism against severe or prolonged hypokalemia after exercise when treated by salbutamol. This is important because postexercise hypokalemia impaired cardiac repolarization, which could potentially trigger arrhythmias and sudden cardiac death in susceptible individuals with preexisting hypokalemia and/or heart disease. NEW & NOTEWORTHY Intense rowing exercise induced a marked increase in arterial potassium, followed by a pronounced decline to hypokalemic levels. The β2 agonist salbutamol lowered potassium during exercise and late recovery but not during early postexercise, suggesting a protective effect against severe hypokalemia. The decreased potassium in recovery was associated with impaired cardiac QT hysteresis, suggesting a link between postexercise potassium and the heart, with implications for increased risk of cardiac arrhythmias and, potentially, sudden cardiac death.

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 Julye 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. (c) 2018 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.

BACKGROUND:The prevalence of chronic kidney disease (CKD) is increasing in Australia and is independently associated with a higher risk of hospitalisation and death. Australian data may be useful in guiding improved hospital management of this growing cohort of patients.AIM:To assess and compare the trends and outcomes of CKD patients requiring hospital and intensive care unit (ICU) admission at a tertiary referral hospital and state public hospitals.METHODS:We conducted a retrospective analysis of all acute care admissions to St Vincent's Hospital Melbourne and all Victorian public hospitals using the Victorian Admitted Episodes Data Set (VAED) for the years 2010-2014 to determine CKD prevalence, demographic and outcome associations. The Elixhauser ICD-10 comorbidity classification of renal failure was used to identify CKD (ElixRF). Chi-squared test, Kruskal-Wallis test and logistic regression were used for analysis.RESULTS:A total of 101 817 patients was included from our institution, with 6.4% classified as having ElixRF. ELixRF increased from 5.2% in 2010 to 8.6% in 2014 for all hospital admissions and from 8.3% to 13.3% for ICU admissions. ElixRF was associated with longer hospital and ICU length of stay, male gender, older age, higher comorbidity and independently with increased mortality. The VAED contained 2 044 507 episodes for the same period with similar trends and associations.CONCLUSIONS:CKD prevalence amongst patients admitted to hospital and ICU is increasing and is associated with worse outcomes. ElixRF may be a useful administrative flag for nephrologist involvement in care and for prompting consideration of advanced care planning.

Dexmedetomidine-associated hyperthermia has not been previously studied. Analysis is warranted to determine whether this potentially dangerous complication is more prevalent than previously realised. We aimed to examine the association between dexmedetomidine and temperature ≥39.5°C, including patient characteristics, temporality and potential risk factors. We conducted a retrospective cohort study of all intensive care unit (ICU) admissions between 1 July 2009 and 31 May 2016 in a tertiary ICU in Australia. Temperature data was available for 9,782 ICU admissions. Dexmedetomidine was given intravenously to 611 (6.3%) patients at a dose of 0 to 1.5 g/kg/hour. Temperatures ≥39.5°C were recorded in 341 (3.5%) patients. Overall hospital mortality was 10.8% for all admissions and 29.3% for patients with temperatures ≥39.5°C. Dexmedetomidine exposure was more frequent in patients with temperature recordings ≥39.5°C compared to those with temperatures <39.5°C, 11.94% versus 2.94% (odds ratio [OR] 4.49; 95% confidence intervals [CI] 3.37, 5.92; P <0.001). The association was stronger for patients post-open heart surgery (OHS) with temperatures ≥39.5°C (OR 12.9; 95% CI 5.01, 31.62; P <0.001). Multivariate analysis showed an independent association between dexmedetomidine and a temperature ≥39.5°C in two particular patient groups: OHS (OR 2.72; 95% CI 1.1, 6.9; P <0.001), and obesity (OR 3.44; 95% CI 1.5, 7.9; P <0.001). Dexmedetomidine exposure is associated with an increased risk of hyperthermia. Possible risk factors are open heart surgery and obesity.

Background: Low tidal volume ventilation reduces mortality in patients with acute lung injury (ALI) and may reduce the risk of ALI in ventilated patients. A previous audit of our ventilation practices showed poor adherence to low tidal volume ventilation, and we subsequently introduced written ventilation guidelines and an education program to change practice.Objectives: To determine if adherence to low tidal volume ventilation (defined as mandatory tidal volumes of <= 6.5 mL/kg predicted body weight [PBW]) in ventilated patients was improved with a written guideline and staff education. Design and setting: Retrospective analysis of recorded mandatory ventilator settings from the clinical information system of a tertiary referral intensive care unit from 1 January 2012 to 31 December 2015, involving analysis of mandatory ventilator settings in relation to PBW to determine adherence to guidelines, and interrupted time-series analysis to assess the impact of education.Main outcome measure: Adherence to low tidal volume ventilation. Results: The mean tidal volume for the cohort was 7.4 mL/kg (SD, 1.3 mL/kg) PBW, and 760 patients (26.9%) received an average tidal volume during mandatory ventilation of <= 6.5 mL/kg PBW. Interrupted time-series analysis showed improved adherence after education, with an increase in adherence of 29.4% (95% CI, 19.3%-39.5%) from baseline. Multivariate logistic analysis found height, weight and staff education, but not sex, were associated with adherence to low tidal volume ventilation.Conclusion: Written protocols and education can influence clinician behaviour, with substantial improvements in adherence to low tidal volume ventilation. Efforts to improve adherence through ward-based education appear warranted and necessary. Adherence was strongly associated with patient height, which suggested that adherence was partly the result of chance rather than design.

To the Editor: We thank Xue and colleagues for their considered comments.1Xue F-S, Li R-P, Liu G-P, Sun C. Fluid balance and kidney injury. J Cardiothorac Vasc Anesth, In press. The authors are correct that the AKIN classification system2Mehta R.L. Kellum J.A. Shah S.V. et al.Acute Kidney Injury Network: Report of an initiative to improve outcomes in acute kidney injury.Critical Care (London, England). 2007; 11: R31Crossref PubMed Scopus (5223) Google Scholar includes urine output criteria, as do the associated RIFLE3Bellomo R. Ronco C. Kellum J.A. et al.Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.Crit Care. 2004; 8: R204-212Crossref PubMed Google Scholar and KDIGO4KDIGO Clinical Practice Guideline for Acute Kidney Injury: Kidney International – Supplement 2:1-138, 2012 classification systems for AKI, but many AKI studies use serum creatinine alone to classify AKI because urine output may not be available or feasible to collect.5Ali T. Khan I. Simpson W. et al.Incidence and outcomes in acute kidney injury: A comprehensive population-based study.J Am Soc Nephrol. 2007; 18: 1292-1298Crossref PubMed Scopus (663) Google Scholar, 6Coca S.G. Bauling P. Schifftner T. et al.Contribution of acute kidney injury toward morbidity and mortality in burns: A contemporary analysis.Am J Kidney Dis. 2007; 49: 517-523Abstract Full Text Full Text PDF PubMed Scopus (115) Google Scholar, 7Ostermann M. Chang R.W.S. Acute kidney injury in the intensive care unit according to RIFLE.Crit Care Med. 2007; 35: 1837-1843Crossref PubMed Scopus (535) Google Scholar, 8Ricci Z. Cruz D. Ronco C. The RIFLE criteria and mortality in acute kidney injury: A systematic review.Kidney Int. 2008; 73: 538-546Abstract Full Text Full Text PDF PubMed Scopus (618) Google Scholar, 9Uchino S. Bellomo R. Goldsmith D. et al.An assessment of the RIFLE criteria for acute renal failure in hospitalized patients.Crit Care Med. 2006; 34: 1913-1917Crossref PubMed Scopus (730) Google Scholar By omitting the use of urine output in our classification, we made our results more accessible and generalizable. Furthermore, the use of urine output criteria in our study would have complicated the groupings and the analysis. By using serum creatinine criteria alone, we avoided unnecessary complexity and facilitate understanding of the results. Xue F-S, Li R-P, Liu G-P, Sun C. Fluid balance and kidney injury. J Cardiothorac Vasc Anesth, In press. KDIGO Clinical Practice Guideline for Acute Kidney Injury: Kidney International – Supplement 2:1-138, 2012 Xue et al are correct in that the inclusion of urine output in the definition of AKI provides a more “permissive” classification.10Wlodzimirow K.A. Abu-Hanna A. Slabbekoorn M. et al.A comparison of RIFLE with and without urine output criteria for acute kidney injury in critically ill patients.Crit Care. 2012; 16: R200Crossref PubMed Scopus (100) Google Scholar However, the urine output criteria are not “well-balanced” with the creatinine criteria and may be too sensitive and lack specificity, which can hinder the ability to achieve significant results. For example, patients with Stage I AKI/RIFLE Risk category detected by serum creatinine are more severely ill than Stage I AKI/RIFLE Risk category patients defined with urine output criteria alone.10Wlodzimirow K.A. Abu-Hanna A. Slabbekoorn M. et al.A comparison of RIFLE with and without urine output criteria for acute kidney injury in critically ill patients.Crit Care. 2012; 16: R200Crossref PubMed Scopus (100) Google Scholar This would explain the higher mortality in patients classified with serum creatinine versus the composite (creatinine/urine output) criteria that the authors mention. We have used the first 18 hours after surgery to calculate fluid balance given that (1) most patients (89%) were discharged from ICU after 18 hours and also because (2) we assumed that the most aggressive fluid therapy was given in the initial postoperative period. The 48-hour postoperative timeframe used for AKIN classification extends more than 24 hours beyond the first postoperative 18 hours, allowing considerable time for a delayed rise in serum creatinine to manifest and for rectification of the “dilutional” effect of a positive fluid balance on serum creatinine to which the authors refer. Having said that, we agree with the authors that a comparison of our results with an analysis for “late” AKI (detected later than 48 hours postoperatively) with adjustment/no adjustment for fluid balance could be of interest. In this study, we have used a pragmatic approach in our methods in order to make use of observational data to address our question. Xue F-S, Li R-P, Liu G-P, Sun C. Fluid balance and kidney injury. J Cardiothorac Vasc Anesth, In press. KDIGO Clinical Practice Guideline for Acute Kidney Injury: Kidney International – Supplement 2:1-138, 2012

BACKGROUND:Healthcare professionals may have difficulty in recognising the dying patient in acute care settings, and yet, this is essential if timely end-of-life care is to be provided. While approximately one-third of patients who pass away in-hospital are reviewed by the rapid response team (RRT), there is limited available research on other factors associated with mortality within the hospital setting.AIMS:To describe the epidemiology of in-hospital mortality within a tertiary-level hospital, particularly in the context of RRT activation.METHODS:We utilised the database extraction of demographic, admission and RRT activation data on acute patients discharged from an Australian acute tertiary hospital between 1 January 2009 and 31 December 2013. Analyses included simple descriptors, Chi-squared and non-parametric Kruskal-Wallis tests as appropriate.RESULTS:Of the 44,297 patients discharged from our hospital, 1603 died during admission. The general medical, haematology/oncology and intensive care teams provided care for the majority of the patients who died. A small number of diagnoses had in-patient mortality rates of greater than 25%. These included respiratory failure, alcoholic liver disease, vascular disorders of the intestine, sepsis and aspiration pneumonia. Over 75% of patients who received a RRT call survived to hospital discharge; however, patients who received four or more RRT calls during admission had an in-hospital mortality rate of over 40%.CONCLUSION:Acute in-patient mortality is unequally distributed throughout the hospital, and a small number of diagnoses has large associated in-patient mortality rates. Repeated involvement of the RRT is associated with in-patient mortality.

Salbutamol inhalation is permissible by WADA in athletic competition for asthma management and affects potassium regulation, which is vital for muscle function. Salbutamol effects on arterial potassium concentration ([K+]a) during and after high-intensity continuous exercise (HIcont) and intermittent exercise comprising repeated, brief sprints (HIint), and on performance during HIint are unknown and were investigated.

There is a new migration of anaesthetists outside the confines of operating theatres that parallels the migration of their cousins, the intensivists, outside intensive care to deliver ‘critical care without walls’ 1, 2. Intensivists aim to avoid critical organ dysfunction that mandates intensive care admission by intervening earlier. Intensivists also want to talk with competent patients who would decline the default treatment given to the deliriously sick. Similarly, anaesthetists are treading upstream towards the source of the scheduled surgical pathway, intervening earlier to limit the impact of peri-operative physiological deterioration on postoperative survival and recovery. Should they reach the fabled ‘land of the open mind’, anaesthetists (or others) might hope to prevent the one-fifth of scheduled operations that are rejected by informed patients who have participated in early discussions of harm, benefit and expectations 3. The migration of Homo sapiens out of Africa 200 000 years ago was preceded by at least four transcontinental migrations of the Homo genus that started, with Homo erectus, about two million years ago. The fossils of previous migrations of anaesthetists have also left their mark, in the pages of Anaesthesia and elsewhere, as remarked in the first article in this Special Issue 4. Modern pre-operative clinics have refined the objective to clarify the scheduled flow of patients, particularly for those more likely to be harmed by surgery. The aim is to deliver to the anaesthetic room an informed patient with realistic expectations of both harm and benefit, who is ‘fed’, euvolaemic and who has had the opportunity to stop smoking and have their anaemia treated 5, 6. The continuation of chronic medications in most circumstances, other than antiplatelet drugs, remains the standard approach, whilst coronary arteries should be left alone in patients who are content with the control of their angina 7. Another aim is to prepare the operating theatre, staff and postoperative environment to limit the burden of ‘peri-operative disease’. Anaesthetists can ameliorate this disease by trying to prevent derangements in the lungs and blood vessels 8, 9. The mastery of fluid – its volume, pressure, flow and composition – is a defining characteristic of an unexciting anaesthetic. Pulmonary artery flow catheters, oesophageal Doppler probes, thermodilution with pulse contour analyses and subsequently pulse pressure variation have become familiar tools with which to tailor the liquid to the patient. We know that goal-directed fluid management has reduced postoperative morbidity in a wide selection of studies 10. However, stable euvolaemic patients might avoid postoperative disease with less liquid than we're accustomed to giving. Flow-directed infusions may be redundant, particularly when laparoscopic surgery turns the familiar on its head. Urine flow is a simple measure of renal perfusion and the balance of water and salt: it is integral to the definition of kidney injury under most circumstances. Unfortunately, peri-operative urine output is a misleading warning siren, to the extent that intravenous infusions in response to postoperative oliguria may be doing more harm than good 11. I think, therefore I am; my brain. Take out my cancer. Relieve the pain in my hip. I will thank you. Give me ‘cognitive dysfunction’, delirium or dementia and I will damn you, if I could 12. Our migration upstream may be mirrored by a similar downstream migration, in search of honest measures of postoperative survival and living, in preference to the paltry meaning provided by mortality at one postoperative month, which should include the burden of chronic postoperative pain 13, 14. Intensivists are learning through follow-up clinics of the afflictions that burden the survivors of critical illness, months and years later. Low standardised mortality ratios provided through ICNARC might be unable to differentiate between a system that delivers life from a system that briefly delays death. Nevertheless, a system as good as ICNARC is something that the peri-operative anaesthetist might aspire to: measure before, during and after surgery, feed the measurements back, amend prognostications and interventions, repeat. The scale of scheduled surgery provides a prime opportunity to benefit from ‘big data’ techniques 15. Postoperative recovery is largely determined by what happens before surgery, through preparation of the patients and the planning of their peri-operative pathway, as well as the skilful limitation of harm during surgery. Nevertheless, the opportunities to limit harm by changing the postoperative plan in response to a recovery that goes ‘off trajectory’ remain extensive 16. Responsive postoperative care is one of the putative explanations for why survival is better in some hospitals than others, despite similar rates of postoperative morbidities 17. Pre-operative preparation, intra-operative management and postoperative care have to work together in a continuous loop to improve outcomes for patients. The avoidance of ‘wrong patient surgery’ will be as important as implementing ‘right peri-operative care’. The penultimate mass migration out of Africa by our genus was by a species named Homo heidelbergensis, the forbear of both Neanderthal and modern human. Neanderthals are now extinct. The migration of anaesthetists from operating theatres, both upstream and downstream, must be accompanied by an evolution in how we think.

Internal Medicine JournalVolume 46, Issue 11 p. 1349-1349 Letter to the Editor Family escalation of care: well meaning, but where's the evidence A. Tobin, A. Tobin Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, AustraliaSearch for more papers by this author A. Tobin, A. Tobin Department of Intensive Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, AustraliaSearch for more papers by this author First published: 03 November 2016 https://doi.org/10.1111/imj.13238Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume46, Issue11November 2016Pages 1349-1349 RelatedInformation

Rapid Response Systems (RRSs) have been widely introduced throughout hospital health systems, yet there is limited research on the characteristics and outcomes of patients admitted to an intensive care unit (ICU) following RRS activation. Using database extraction, this study examined the factors associated with ICU admission and patient outcome in patients receiving RRS activation in a tertiary level hospital between 2009 and 2013. Of 3004 RRS activations, 392 resulted in ICU admissions. Call factors associated with ICU admission and increased hospital mortality included tachypnoea (P <0.001 and P <0.001, respectively), hypoxia (P <0.001 and P <0.001, respectively) and having multiple Medical Emergency Team call triggers breached simultaneously (P <0.001 and P <0.001, respectively). Patients with seizures (P <0.001) and tachycardia (P=0.004) were more likely to survive to hospital discharge. Patient factors associated with ICU admission included young age (P <0.001) and having severe liver disease (P <0.001). Factors associated with increased hospital mortality included delayed RRS activation (P <0.001), increased age (P <0.001) and comorbidities including ischaemic heart disease (P=0.006), congestive heart failure (P <0.001), chronic kidney disease (P <0.001) and severe liver disease (P <0.001). Multiple factors relating to both the nature of the RRS activation call and patient characteristics are associated with ICU admission and hospital mortality post RRS activation. This information may be useful for risk stratification of deteriorating patients and determination of appropriate escalation.

Purpose: The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (>= 168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality.Methods: This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode.Results: Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P =. 005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001).Conclusions: Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome. (C) 2015 Elsevier Inc. All rights reserved.

The objective of this study is to describe the population of patients receiving emergency airway management outside operating theatres at our institution, a tertiary referral centre in Melbourne. A registry of all patients receiving emergency airway management in the emergency department, ICU and on the wards as part of Medical Emergency Response teams' care, was prospectively collected. There were 128 adults and one paediatric patient requiring emergency airway management recruited to the study. Data for analysis included patient demographics, pre-oxygenation and apnoeic oxygenation, staff, drugs, details of laryngoscopic attempts, adjuncts, airway manoeuvres, complications sustained and method of confirmation of endotracheal tube placement. Over a 12-month period, there were 139 intubations of 129 patients, requiring a total of 169 attempts. Respiratory failure was the most common indication for intubation. Intubation was successful on the first episode of laryngoscopy in 116 (83.5%) patients. Complications occurred in 48 patients. In the cohort of patients without respiratory failure, nasal cannulae apnoeic oxygenation significantly reduced the incidence of hypoxaemia (0 out of 31 [0.0%] versus 10 out of 60 [16.7%], P=0.016; absolute risk reduction 16.7%; number needed to treat: 6). Waveform capnography was used to confirm endotracheal tube placement in 133 patients and there were four episodes of oesophageal intubation, all of which were recognised immediately. In the critical care environment of our institution, emergency airway management is achieved with a first-attempt success rate that is comparable to overseas data. Nasal cannulae apnoeic oxygenation appears to significantly reduce the risk of hypoxaemia in patients without respiratory failure and the use of waveform capnography eliminates episodes of unrecognised oesophageal intubation.

Heatwaves are a major public health threat for A ustralians. Hyponatraemia is common, with an increased incidence previously described during heatwaves. We report a series of 10 patients admitted with moderate to profound hyponatraemia, the majority with a history of excess water consumption, during the J anuary 2014 heatwave.

Background: Low tidal volume ventilation (LTVV) has been shown to reduce mortality of patients with acute lung injury (ALI) but uptake by clinicians has been low. Recent studies have shown that LTVV results in survival benefit at 24 months after discharge and, importantly, benefits patients without ALI.Objective: To determine adherence to LTVV in patients on mechanical ventilation (MV).Design, setting and participants: Retrospective analysis of ventilator settings recorded within the clinical information system of a 15-bed general ICU in a tertiary referral hospital, between 1 January 2000 and 31 May 2013.Methods: Analysis of mandatory MV with volume or pressure control.Main outcome measures: Adherence to LTVV (<= 6.5 mL/kg predicted body weight [PBW]).Results: We studied 4923 patients with a median age of 66 years (interquartile range [IQR], 57-74 years), and a median Acute Physiology and Chronic Health Evaluation II score of 16 (IQR, 13-19). Included were 3486 men (70.8%), and 3386 (66.8%) had undergone cardiac surgery. There were 249 450 ventilator measurements, with a median per patient of 75 measurements (IQR, 17-255 measurements). The median tidal volume was 8.15 mL/kg PBW (IQR, 7.15 9.34 mL/kg PBW) for an adherence of 13.4%. Independent factors associated with adherence were sex, high inspiratory pressures, high positive end expiratory pressure and low Pao(2)/Fio(2) ratio.Conclusion: Adherence to LTVV in a general cohort of ICU patients was low, but it was better in patients with more severe lung disease. Overestimation of PBW may have contributed to our findings. Regular auditing of LTVV adherence might be considered a clinical indicator of good MV practice.