Death and dying are significant and impactful, for individuals, families and broader society. For clinical teams working in the intensive care unit (ICU), caring for a dying patient and supporting their family are an important part of their professional role. Australian ICU practice has evolved over several decades to optimise end of life care, so that it is patient centred and adheres to accepted ethical standards as well the established legal framework. In addition to acquiring necessary technical skills, intensivists working in Australia must complete training in advanced communication as well as clinical ethics and are required to maintain competence in these domains for the duration of their professional lives. Important considerations for Australian intensivists managing end of life care include cultural humility, avoidance of assumptions, respectful curiosity, prioritising individual patient values and preferences, and the avoidance of non-beneficial treatments that may simply prolong dying or contribute to suffering. As well as having a legislated legal framework, Australia has endorsed national guidelines developed by relevant the specialist training colleges and intensive care professional societies.

In Australian intensive care units (ICUs), Artificial Intelligence (AI) promises to enhance efficiency and improve patient outcomes. However, ethical concerns surrounding AI must be addressed before widespread adoption. We examine the ethical challenges of of AI using the framework of the four pillars of biomedical ethics—beneficence, nonmaleficence, autonomy, and justice, and discuss the need for a fifth pillar of explicability. We consider the risks of perpetuating inequities, privacy breaches, and unintended harms, particularly in disadvantaged populations such as First Nations people. We advocate for a national strategy for ICUs to guide the ethical implementation of AI, that aligns with existing National AI Frameworks. Our recommendations for implementation of safe and ethical AI in ICU include education, developing guidelines, and ensuring transparency in AI decision-making. A coordinated strategy is essential to balance AI’s benefits with the ethical responsibility to protect patients and healthcare providers in critical care settings.

BACKGROUND:An increased body mass index (BMI) is associated with improved outcomes in intensive care unit patients, known as the "obesity paradox". OBJECTIVE:The objective of this study was to investigate whether sex and age modify the obesity paradox. METHODS:We performed a retrospective, multicentre, observational study of a binational registry. All patients with a recorded BMI admitted to the intensive care unit in Australia and New Zealand between 2010 and 2022 were included in the study cohort. The primary outcome was in-hospital mortality. Using multivariable models, we analysed the impact of sex and age on the relationship between BMI and outcome. RESULTS:We studied 957 873 patients (565 759 men and 392 114 women; median BMI: 27.8 kg/m2 for both groups). For both groups, an increased BMI was associated improved survival, for a BMI up to >35 kg/m2. However, this protective association was modified by sex. At a BMI of 30 kg/m2, compared to a baseline BMI of 22.5 kg/m2, an odds ratio (OR) (95% confidence interval [CI]) of 0.83 (0.81-0.87) was estimated for men and 0.93 (0.89-0.98) for women, implying a stronger association for men. Furthermore, the paradox was also modified by age with a more pronounced effect for older patients. For men, the OR of 0.89 (0.82-0.98) at a BMI of 30 kg/m2 and age of 40 years reduces to 0.80 (0.76-0.84) at the same BMI and an age of 75 years. For women, the OR of 0.99 (0.92-1.13) at a BMI of 30 kg/m2 and age of 40 years reduces to 0.89 (0.84-0.93) at the same BMI and an age of 75 years. CONCLUSION:The obesity paradox is modified by both sex and age. The paradox is more pronounced for men and within the group of older patients.

Background and aims: Prone positioning is commonly applied to improve gas exchange in mechanically ventilated patients with coronavirus disease 2019 (COVID-19)erelated acute respiratory distress syndrome (ARDS). Whilst prone positioning is effective, specific complications may arise. We aimed to assess the prevalence of specific complications related to prone positioning in patients mechanically ventilated for COVID-19-related ARDS. Design: Multicentre, retrospective observational study. Methods: Multi-centre observational study of mechanically ventilated patients with COVID-19-related ARDS admitted to intensive care units in Melbourne, Australia, from August to November 2021. Data on baseline characteristics, prone positioning, complications, and patient outcomes were collected. Results: We assessed 553 prone episodes in 220 patients across seven sites (mean +/- standard deviation age: 54 +/- 13 years, 61% male). Overall, 58% (127/220) of patients experienced at least one prone-positioning-related complication. Pressure injury was the most prevalent (n 1/4 92/220, 42%) complication reported. Factors associated with increased risk of pressure injury were male sex (adjusted odds ratio = 1.15, 95% confidence interval: [1.02-1.31]) and the total number of prone episodes (adjusted odds ratio = 1.11, 95% confidence interval: [1.07-1.15]). Device dislodgement was the next most common complication, occurring in 28 of 220 (13%) patients. There were no nerve or retinal injuries reported. Conclusions: Pressure injuries and line dislodgement were the most prevalent complications associated with prone positioning of patients mechanically ventilated for COVID-19. The risk of pressure injuries was associated with male sex and the number of prone positioning episodes. (c) 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights are reserved, including those for text and data mining, AI training, and similar technologies.

Intensive care physicians use key interventions like mechanical ventilation or vasopressor support in response to physiological deterioration, aiming to give each patient their best chance to not only survive critical illness, but to return back to their pre-admission lives.However, it is recognised that the provision of intensive care interventions cannot be explained entirely by physiological or other clinical factors like patient comorbidities [1,2].Instead, many large-scale retrospective studies found that the treatment provided to critically ill patients is independently associated with sociodemographic factors including patient race, gender and socioeconomic status [2][3][4][5][6].This suggests possible inequity in intensive care unit (ICU) interventions across sociodemographic groups.Understanding these sociodemographic differences in critical illness and intensive care interventions could better ensure we provide equitable care to our patients.

OBJECTIVES:To compare the incidence and distribution of pressure injuries (PIs) with two approaches to prone positioning for mechanically ventilated COVID-19 patients, and to determine the prevalence of these PIs on intensive care unit (ICU) and hospital discharge. DESIGN:A prospective observational study. SETTING:Adult patients admitted to a quaternary ICU with COVID-19-associated acute lung injury, between September 2021 and February 2022. MAIN OUTCOME MEASURES:Incidence and anatomical distribution of PIs during ICU stay for "Face Down" and "Swimmers Position" as well as on ICU and hospital discharge. RESULTS:We investigated 206 prone episodes in 63 patients. In the Face Down group, 26 of 34 patients (76 %) developed at least one PI, compared to 10 of 22 patients (45 %) in the Swimmers Position group (p = 0.02). Compared to the Swimmers Position group, the Face Down group developed more pressure injuries per patient (median 1 [1, 3] vs 0 [0, 2], p = 0.04) and had more facial PIs (p = 0.002). In a multivariate logistic regression model, patients were more likely to have at least one PI with Face Down position (OR 4.67, 95 % CI 1.28, 17.04, p = 0.02) and greater number of prone episodes (OR 1.75, 95 % CI 1.12, 2.74, p = 0.01). Over 80 % of all PIs were either stage 1 or stage 2. By ICU discharge, 29 % had healed and by hospital discharge, 73 % of all PIs had healed. CONCLUSION:Swimmers Position had a significantly lower incidence of PIs compared to the Face Down approach. One-quarter of PIs had healed by time of ICU discharge and three-quarters by time of hospital discharge. IMPLICATIONS FOR CLINICAL PRACTICE:There are differences in incidence of PIs related to prone positioning approaches. This study validates and helps better inform current prone position guidelines recommending the use of Swimmers Position. The low prevalence of PIs at hospital discharge is reassuring.

BACKGROUND: Patient sex affects treatment and outcomes in critical illness. Previous studies of sex differences in critical illness compared female and male patients. In this study, we describe the group of patients classi fi ed as a third sex admitted to ICUs in Australia and New Zealand. RESEARCH QUESTION: What are the admission characteristics and outcomes of ICU patients classi fi ed as belonging to a third sex group compared with patients classi fi ed as female or male? STUDY DESIGN AND METHODS: Retrospective observational study of admissions to 200 ICUs, recorded in the Australian and New Zealand Intensive Care Society ' s Adult Patient Database from 2018 to 2022. We undertook mixed effect logistic regression to compare hospital mortality across the sex groups, adjusted for illness severity, diagnosis, treatment limitation, year, and hospital. RESULTS: We examined 892,161 admissions, of whom 525 (0.06%) were classi fi ed as third sex. Patients classi fi ed as third sex were represented across all diagnostic categories, jurisdictions, and hospital types. On average, they were younger than the groups classi fi ed as female (59.2 +/- 20.0 vs 61.3 +/- 18.4 years; P = .02) or male (63.2 +/- 16.7 years; P < .001), respectively. Patients classi fi ed as third sex were more likely to be admitted after orthopedic surgery (10.1% third sex admissions [95% CI, 7.7%-13.0%]; 6.2% female [95% CI, 6.1%6.3%]; 4.8% male [95% CI, 4.7%-4.9%]) and drug overdose (8.8% third sex admissions [95% CI, 6.5%-11.5%]; 4.2% female [95% CI, 4.1%-4.2%]; 3.1% male [95% CI, 3.0%-3.1%]). There was no difference in the adjusted hospital mortality of patients classi fi ed as third sex compared with the other groups. INTERPRETATION: Patients classi fi ed as third sex composed a small minority group of adult ICU patients. This group had a different diagnostic case mix but similar outcomes to the groups classi fi ed as female or male. Further characterizing a third sex group will require improved processes for recording sex and gender in health records.

Objective: The objective of this study was to determine the association between gender and perceived gender equity in the critical care workforce and other health specialties. Design and setting: We conducted an online cross-sectional survey between September and November 2020. Data on demographics and perceptions of equity including the representation of women across departments and in leadership roles, knowledge of and access to flexible work practices and carers leave, and opportunities for promotion were collected. Participants: The study population included health professionals from critical care (defined as intensive care and emergency) and other specialties. We conducted a descriptive gender-disaggregated analysis. Results: A total of 478 respondents (70% women) completed the survey. The mean age of respondents was 43.9 +/- 11.2 years. Approximately half of respondents were medical practitioners (n = 235, 54%), followed by nurses (n = 135, 36%)-the remainder were from other professions. The critical care workforce accounted for 280 (64%) of responder practice settings. Statistically significant differences were reported between genders on issues such as having confidence that their department would resolve equity issues (87 [70.7%] men vs. 146 [48.2%] women; p = 0.007), access to flexible work practices (5/124 [4.0%] men vs. 20/305 [6.6%] women p = 0.001), and taking unpaid leave for carer responsibilities (91 [30.3%] women vs 9 [7.4%] men, p < 0.001). Conclusions: This work highlights differences in how men and women perceive gender equity, particularly in the critical care workforce. These findings are important to understand health care practitioners' perceptions of gender equity, as these perceptions inform behaviour.

Purpose: Neuromuscular blockers (NMBs) are often used during prone positioning to facilitate mechanical ventilation in COVID-19 related ARDS. However, their impact on oxygenation is uncertain.Methods: Multi-centre observational study of invasively ventilated COVID-19 ARDS adults treated with prone positioning. We collected data on baseline characteristics, prone positioning, NMB use and patient outcome. We assessed arterial blood gas data during supine and prone positioning and after return to the supine position.Results: We studied 548 prone episodes in 220 patients (mean age 54 years, 61% male) of whom 164 (75%) received NMBs. Mean PaO2:FiO(2) (P/F ratio) during the first prone episode with NMBs reached 208 +/- 63 mmHg compared with 161 +/- 66 mmHg without NMBs (Delta(mean) = 47 +/- 5 mmHg) for an absolute increase from baseline of 76 +/- 56 mmHg versus 55 +/- 56 mmHg (p(adj) < 0.001). The mean P/F ratio on return to the supine position was 190 +/- 63 mmHg in the NMB group versus 141 +/- 64 mmHg in the non-NMB group for an absolute increase from baseline of 59 +/- 58 mmHg versus 34 +/- 56 mmHg (p(adj) < 0.001).Conclusion: During prone positioning, NMB is associated with increased oxygenation compared to non-NMB therapy, with a sustained effect on return to the supine position. These findings may help guide the use of NMB during prone positioning in COVID-19 ARDS.

Objectives: Critically ill women may receive less vital organ support than men but the mortality impact of this differential treatment remains unclear. We aimed to quantify sex differences in vital organ support provided to adult ICU patients and describe the relationship between sex, vital organ support, and mortality. Design: In this retrospective observational study, we examined the provision of invasive ventilation (primary outcome), noninvasive ventilation, vasoactive medication, renal replacement therapy, extracorporeal membrane oxygenation (ECMO), or any one of these five vital organ supports in women compared with men. We performed logistic regression investigating the association of sex with each vital organ support, adjusted for illness severity, diagnosis, preexisting treatment limitation, year, and hospital. We performed logistic regression for hospital mortality adjusted for the same variables, stratified by vital organ support (secondary outcome). Setting and Patients: ICU admissions in the Australia and New Zealand Intensive Care Society Adult Patient Database 2018–2021. This registry records admissions from 90% of ICUs in the two nations. Interventions: None. Measurements and Main Results: We examined 699,535 ICU admissions (43.7% women) to 199 ICUs. After adjustment, women were less likely than men to receive invasive ventilation (odds ratio [OR], 0.64; 99% CI, 0.63–0.65) and each other organ support except ECMO. Women had lower adjusted hospital mortality overall (OR, 0.94; 99% CI, 0.91–0.97). Among patients who did not receive any organ support, women had significantly lower adjusted hospital mortality (OR, 0.82; 99% CI, 0.76–0.88); among patients who received any organ support women and men were equally likely to die (OR, 1.01; 99% CI, 0.97–1.04). Conclusions: Women received significantly less vital organ support than men in ICUs in Australia and New Zealand. However, our findings suggest that women may not be harmed by this conservative approach to treatment.

Objective To determine the effect of sex on sepsis-related ICU admission and survival for up to 3-years. Methods Retrospective cohort study of adults admitted to Australian ICUs between 2018 and 2020. Men and women with a primary diagnosis of sepsis were included. The primary outcome of time to death for up to 3-years was examined using Kaplan Meier plots. Secondary outcomes included the duration of ICU and hospital stay. Results Of 523,576 admissions, there were 63,039 (12·0%) sepsis-related ICU admissions. Of these, there were 50,956 patients (43·4% women) with 3-year survival data. Men were older (mean age 66·5 vs 63·6 years), more commonly received mechanical ventilation (27·4% vs 24·7%) and renal replacement therapy (8·2% vs 6·8%) and had worse survival (Hazard Ratio [HR] 1·11; 95% Confidence Interval [CI] 1·07 to 1·14, P<0·001) compared to women. The duration of hospital and ICU stay was longer for men, compared to women (median hospital stay, 9.8 vs 9.4 days; p<0.001 and ICU stay, 2.7 vs 2.6 days; p<0.001). Conclusion Men are more likely to be admitted to ICU with sepsis and have worse survival for up to 3-years. Understanding causal mechanisms of sex differences may facilitate the development of targeted sepsis strategies.

BACKGROUND:Prone positioning improves oxygenation in patients with acute respiratory distress syndrome (ARDS) secondary to COVID-19. However, its haemodynamic effects are poorly understood. OBJECTIVES:The objective of this study was to investigate the acute haemodynamic changes associated with prone position in mechanically ventilated patients with COVID-19 ARDS. The primary objective was to describe changes in cardiac index with prone position. The secondary objectives were to describe changes in mean arterial pressure, FiO2, PaO2/FiO2 ratio, and oxygen delivery (DO2) with prone position. METHODS:We performed this cohort-embedded study in an Australian intensive care unit, between September and November 2021. We included adult patients with severe COVID-19 ARDS, requiring mechanical ventilation and prone positioning for respiratory failure. We placed patients in the prone position for 16 h per session. Using pulse contour technology, we collected haemodynamic data every 5 min for 2 h in the supine position and for 2 h in the prone position consecutively. RESULTS:We studied 18 patients. Cardiac index, stroke volume index, and mean arterial pressure increased significantly in the prone position compared to supine position. The mean cardiac index was higher in the prone group than in the supine group by 0.44 L/min/m2 (95% confidence interval, 0.24 to 0.63) (P < 0.001). FiO2 requirement decreased significantly in the prone position (P < 0.001), with a significant increase in PaO2/FiO2 ratio (P < 0.001). DO2 also increased significantly in the prone position, from a median DO2 of 597 mls O2/min (interquartile range, 504 to 931) in the supine position to 743 mls O2/min (interquartile range, 604 to 1075) in the prone position (P < 0.001). CONCLUSION:Prone position increased the cardiac index, mean arterial pressure, and DO2 in invasively ventilated patients with COVID-19 ARDS. These changes may contribute to improved tissue oxygenation and improved outcomes observed in trials of prone positioning.

BACKGROUND:The coronavirus disease 2019 (COVID-19) pandemic resulted in a surge of patients with refractory hypoxaemic respiratory failure being admitted to the intensive care unit (ICU). Prone positioning can improve oxygenation but requires a team of skilled personnel to complete safely. Critical care physiotherapists (PTs) are ideally suited to lead proning teams, due to their expertise in moving critically unwell, invasively ventilated patients. OBJECTIVES:The aim of this study was to describe the feasibility of implementing a physiotherapy-led intensive proning (PhLIP) team to support the critical care team during surges. METHODS:This study involves descriptive evaluation of feasibility and implementation of the PhLIP team, a novel model of care, during the Delta wave of the COVID-19 pandemic, through a retrospective, observational audit of PhLIP team activity, ICU clinical activity, and a description of clinical outcomes. RESULTS:Between 17 September and 19 November 2021, 93 patients with COVID-19 were admitted to the ICU. Fifty-one patients (55%) were positioned prone, a median [interquartile range] 2 [2, 5] times, for a mean (±standard deviation) duration of 16 (±2) h, across 161 episodes. Twenty-three PTs were upskilled and deployed to the PhLIP team, adding 2.0 equivalent full time to the daily service. Ninety-four percent of prone episodes (154) were led by the PhLIP PTs with a median 4 [interquartile range: 2, 8] turns per day. Potential airway adverse events occurred on three occasions (1.8%) and included an endotracheal tube leak, displacement, and obstruction. Each incident was promptly managed without prolonged impact on the patient. No manual handling injuries were reported. CONCLUSION:The implementation of a physiotherapy-led proning team was safe and feasible and can release critical care-trained medical and nursing staff to other duties in the ICU.

BACKGROUND:Prone positioning may improve oxygenation in acute hypoxemic respiratory failure and was widely adopted in COVID-19 patients. However, the magnitude and timing of its peak oxygenation effect remain uncertain with the optimum dosage unknown. Therefore, we aimed to investigate the magnitude of the peak effect of prone positioning on the PaO2 :FiO2 ratio during prone and secondly, the time to peak oxygenation. METHODS:Multi-centre, observational study of invasively ventilated adults with acute hypoxemic respiratory failure secondary to COVID-19 treated with prone positioning. Baseline characteristics, prone positioning and patient outcome data were collected. All arterial blood gas (ABG) data during supine, prone and after return to supine position were analysed. The magnitude of peak PaO2 :FiO2 ratio effect and time to peak PaO2 :FIO2 ratio effect was measured. RESULTS:We studied 220 patients (mean age 54 years) and 548 prone episodes. Prone positioning was applied for a mean (±SD) 3 (±2) times and 16 (±3) hours per episode. Pre-proning PaO2 :FIO2 ratio was 137 (±49) for all prone episodes. During the first episode. the mean PaO2 :FIO2 ratio increased from 125 to a peak of 196 (p < .001). Peak effect was achieved during the first episode, after 9 (±5) hours in prone position and maintained until return to supine position. CONCLUSIONS:In ventilated adults with COVID-19 acute hypoxemic respiratory failure, peak PaO2 :FIO2 ratio effect occurred during the first prone positioning episode and after 9 h. Subsequent episodes also improved oxygenation but with diminished effect on PaO2 :FIO2 ratio. This information can help guide the number and duration of prone positioning episodes.

OBJECTIVES: To evaluate and synthesize the available literature on sex differences in the treatment of adult ICU patients. DATA SOURCES: MEDLINE and EMBASE. STUDY SELECTION: Two reviewers independently screened publications to identify observational studies of adult ICU patients that explicitly examined the association between sex and ICU treatment—specifically, mechanical ventilation, renal replacement therapy, and length of stay. DATA EXTRACTION: We extracted data independently and in duplicate: mean age, illness severity, use of mechanical ventilation and renal replacement therapy, and length of stay in ICU and hospital. We assessed risk of bias using the Newcastle-Ottawa Scale. We used a DerSimonian-Laird random-effects model to calculate pooled odds ratios (ORs) and mean differences between women and men. DATA SYNTHESIS: We screened 4,098 publications, identifying 21 eligible studies with 545,538 participants (42.7% women). The study populations ranged from 246 to 261,255 participants (median 4,420). Most studies (76.2%) were at high risk of bias in at least one domain, most commonly representativeness or comparability. Women were less likely than men to receive invasive mechanical ventilation (OR, 0.83; 95% CI, 0.77–0.89; I2 = 90.4%) or renal replacement therapy (OR, 0.79; 95% CI, 0.70–0.90; I2 = 76.2%). ICU length of stay was shorter in women than men (mean difference, –0.24 d; 95% CI, –0.37 to –0.12; I2 = 89.9%). These findings persisted in meta-analysis of data adjusted for illness severity and other confounders and also in sensitivity analysis excluding studies at high risk of bias. There was no significant sex difference in duration of mechanical ventilation or hospital length of stay. CONCLUSIONS: Women were less likely than men to receive mechanical ventilation or renal replacement therapy and had shorter ICU length of stay than men. There is substantial heterogeneity and risk of bias in the literature; however, these findings persisted in sensitivity analyses.

Introduction: Prone positioning (PP) may be utilised to improve oxygenation in mechanically ventilated patients with COVID-19 pneumonia. Pressure injuries (PIs) are a well-recognised complication of prolonged PP. It is unclear how best to position prone patients to minimise this risk. Objectives: To ascertain differences in the incidence and distribution of PIs with two prone positions. Methods: An iterative PP guideline for mechanically ventilated patients was developed in a tertiary intensive care unit during a pandemic surge between September and November 2021. PI data was collected prospectively on all prone patients. A default ‘Face Down’ approach utilised a neutral neck position with face resting on a foam pillow and arms resting by sides. After 3 weeks, this default approach was changed to ‘Swimmer’s Position’ which involved the patient’s head turned to the side, one hand resting next to patient’s face and other arm resting by side with 3-hourly turns. An endotracheal anchoring device was the preferred airway securement technique with both approaches. Results: Fifty-one mechanically ventilated patients had 161 prone episodes during this timeframe. Seven patients had both ‘Face Down’ and ‘Swimmer’s Position’ PP. Of the remaining 44 patients, 34 had ‘Face Down’ PP only. Twenty-six (76%) patients developed 55 PIs – cheek (22), chin (8) and nose (5) were the most common PI areas. Ten patients had ‘Swimmer’s Position’ PP only. Four (40%) patients developed 15 PIs – cheek (4), lip (3) and ear (2) were the most common PI areas. The majority (81%) of all PIs were Stage 1 or 2. No PIs required surgical intervention. Overall, fewer patients had PIs with Swimmer’s Position (OR 0.21, 95% CI 0.05, 0.91). Conclusion: ‘Swimmer’s Position’ yielded a lower overall incidence of PIs than ‘Face Down’ PP. The anatomical distribution of PIs differed for these two prone positions.