Objective Out-of-hospital cardiac arrest (OHCA) is a devastating event that can have ongoing neurological and functional sequelae for survivors, which impact their whānau/family and society. Information on long-term survival remains incomplete. We aimed to understand the long-term neurological, functional, and health-related quality of life outcomes and survival of patients with OHCA at 24 months in New Zealand. Design We performed a preplanned prospective, longitudinal cohort study. Setting New Zealand Participants Participants enrolled in the Targeted Therapeutic Mild Hypercapnia after resuscitated Cardiac Arrest (TAME trial) in New Zealand. Main outcome measures Participants had a comprehensive follow-up at 6 and 24 months using the Glasgow Outcome Scale-Extended to determine neurological outcome as well as multiple other patient-centred functional outcome assessment tools. Results We included all 200 TAME participants enrolled in New Zealand, of whom 194 (97%) had 24-month data. There was no difference in the primary and secondary TAME study outcomes between groups, with overall 56.3% of participants having a favourable neurological outcome at 6 months. In the New Zealand subpopulation, functional and health-related quality of life status at 24 months was not worse than at 6 months for most survivors, with very few participants reporting more than slight disability. Conclusions Among New Zealand TAME trial participants, neurological and functional outcomes measured across multiple domains generally remained stable or improved between 6 and 24 months. These findings provide important information for survivors of OHCA, their whānau/family, clinicians, and researchers on the timing and trajectory of neurological and functional recovery.

Objectives: To determine whether perioperative IV magnesium sulfate infusion, targeting serum magnesium concentrations of 1.5-2.0 mmol/L, reduces the incidence of postoperative atrial fibrillation (POAF) in patients undergoing cardiac surgery. Design: Double-blind, randomized, placebo-controlled, single-center clinical trial with interim analysis for futility. Setting: HagaZiekenhuis, The Hague, The Netherlands (February 2022-November 2023). Patients: Adult patients undergoing coronary artery bypass grafting and/or valvular surgery without prior atrial arrhythmias or severe renal dysfunction. Interventions: Continuous IV infusion of magnesium sulfate (3 mmol/hr, with bolus if [baseline] magnesium < 1.0 mmol/L) or placebo (Ringer's lactate), initiated after induction of anesthesia and continued until ICU discharge. Measurements and Main Results: A total of 265 patients underwent randomization before the trial was stopped at interim analysis for futility. Magnesium supplementation achieved clear separation in serum magnesium concentrations between groups. POAF occurred in 50 of 132 patients (37.9%) in the magnesium group and 38 of 133 patients (28.6%) in the placebo group (relative risk, 1.29; 95% CI, 0.92-1.80). No subgroup demonstrated benefit. Time-to-event and day-by-day analyses showed no early reduction in POAF with magnesium. Vasopressor use was more frequent in the magnesium group, although differences were not statistically significant. No safety signal was identified. Conclusions: In this randomized trial, perioperative magnesium infusion targeting serum concentrations of 1.5-2.0 mmol/L did not reduce POAF after cardiac surgery. These findings do not support routine prophylactic magnesium supplementation for prevention of POAF.

BACKGROUND:Patients receiving extracorporeal membrane oxygenation (ECMO) are considered nutritionally vulnerable, with previous studies focussed on Intensive Care Unit (ICU) admission alone. We aimed to address this gap by describing nutrition provision and practices during the ICU and post-ICU ward admission in adults who received ECMO. METHODS:A prospective observational study was conducted across ten tertiary hospitals within the ECMO registry (EXCEL) in Australia. Data were collected on day 1 (ECMO initiation), 3, 7 and then 7-daily to day 60. The primary outcome was energy provision (% of clinician-prescribed target). Secondary outcomes were energy delivery (kcal/day), protein delivery (g/day) and protein provision (% of clinician-prescribed target). Mixed-effects linear modelling was used to compare data in the ICU and post-ICU ward setting. RESULTS:147 patients were included between June 2022 and July 2023; 91 (62%) males, mean ± standard deviation age 48 ± 16 y. The median [interquartile range] duration of ECMO was 6 d [4-12], with an ICU and hospital stay of 18 d [10-28] and 27 d [12-48] respectively. Energy delivery was 1223 ± 568 kcal/d in ICU (n = 140) and 1519 ± 765 kcal/d on the post-ICU ward in a subgroup with available data (n = 37), providing 64 ± 26% and 70 ± 34% of energy targets, respectively. Protein delivery was 60 ± 31 g/d in ICU and 72 ± 40 g/d on the post-ICU ward meeting 61 ± 29% and 77 ± 40% of protein targets, respectively. No significant differences were observed between the ICU and post-ICU ward. CONCLUSIONS:Energy and protein delivery were comparable between the ICU and post-ICU ward, consistently remaining below prescribed targets. This may reflect an evidence-based shift early in ICU, but persistent deficits post-ICU may impair recovery and warrant further investigation. STUDY REGISTRATION:https://www.anzctr.org.au/. TRIAL ID:ACTRN12623000304639.

OBJECTIVES:The mortality among patients admitted with sepsis remains high and varies depending on the site of infection. The impact of hypercapnia and acidemia on clinical outcomes in mechanically ventilated patients with sepsis is not well understood. DESIGN:Multicenter, binational, retrospective study assessed the association of compensated hypercapnia, hypercapnic acidemia, and nonrespiratory acidemia, in mechanically ventilated patients with mortality in sepsis. SETTING:Data were extracted from the "Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation adult patient" database over a 17-year period (from January 2006 to December 2022) from 201 ICUs. PATIENTS:Patients were classified into four mutually exclusive groups based on a combination of arterial pH and arterial C o2 recorded during the first 24 hours of ICU stay: normocapnia with normal pH, fully compensated hypercapnia, hypercapnic acidemia, and nonrespiratory acidemia. Logistic regression and Cox proportional hazards regression were used to examine the association of compensated hypercapnia, hypercapnic, and nonrespiratory academia to hospital mortality. INTERVENTIONS:None. MEASUREMENTS AND MAIN RESULTS:Fifty-two thousand four hundred five patients were included. Overall compensated hypercapnia (odds ratio [OR], 1.39; 95% CI, 1.24-1.55; p < 0.001), hypercapnic acidemia (OR, 1.68; 95% CI, 1.57-1.80; p < 0.001), and nonrespiratory acidemia (OR, 1.75; 95% CI, 1.61-1.90; p < 0.001) was associated with increased risk of hospital mortality as compared with patients with normocapnia and normal pH. The risk of increased hospital mortality associated with hypercapnic and nonrespiratory acidemia persisted in all prespecified diagnostic subgroups when compared with patients who had normal pH and normocapnia. Compensated hypercapnia was associated with increased mortality risk in neurologic and unspecified subgroups of sepsis. CONCLUSIONS:Hypercapnic acidemia and nonrespiratory acidemia within the first 24 hours of ICU admission are associated with increased risk of hospital mortality in mechanically ventilated patients with sepsis. This association remains consistent in all diagnostic subgroups of sepsis.

Background:The cost-effectiveness of conservative versus liberal oxygen therapy in critically ill adults with post-cardiac arrest hypoxic ischemic encephalopathy is unknown. Methods:A cost-effectiveness analysis alongside the LOGICAL trial was conducted from a health system perspective. Conservative oxygen targeted arterial oxygen saturation (SpO2) of 90-95% using the lowest fraction of inspired oxygen (FiO2), while liberal oxygen had no upper SpO2 limit and a minimum FiO2 of 0.3 during invasive ventilation. Patient-level data were analyzed from 53 intensive care units (ICU) in Australia, New Zealand, and Ireland. Costs (2024, US$) included ICU, ward, and inpatient rehabilitation stays. Health outcomes included favorable functional outcome (Glasgow Outcome Scale-Extended score 5-8) and quality-adjusted life years (QALYs) at 180 days derived from EQ-5D-5L. Uncertainty was explored using bootstrapping. Discounting was not applied. Results:Among 1821 participants (median age 62 years; 28.6% female), 873 were randomized to conservative and 948 to liberal oxygen. Mean per-patient cost was $33,629 ($33,517) in the conservative group, with an incremental cost of -$1392 (95% CI, -$4696 to $1911). Favorable functional outcome occurred in 38.2% with conservative oxygen (risk difference, -1.5 percentage points; 95% CI, -6.1 to 3.2). Incremental QALYs were -0.002 (95% CI, -0.013 to 0.008). Conservative oxygen was associated with cost-savings of $635,151 per QALY forgone with considerable uncertainty (>55% bootstrapped replications). Incremental net monetary benefit was $1173 (95% CI, -$2096 to $4442) at $100,000 per QALY. Conclusions:Conservative oxygen was associated with modest cost savings and small differences in health outcomes, with no clear economic advantage over liberal oxygen.

Trial number: ACTRN12621000518864.

Leukocyte count is widely available and included in Intensive Care Unit prognostic systems. We hypothesised that the relationship between leukocytosis and mortality risk might differ in critically ill patients admitted with infection, where leukocytosis may be an adaptive response. We performed a registry-based study using the Australian and New Zealand Intensive Care Society Adult Patient Database between 2010 and 2023, across 212 Intensive Care Units. Using descriptive statistics and mixed-effects multivariable logistic regression, we evaluated the association between early peak leukocyte count and mortality, according to whether infection was the primary diagnosis. We examined 2,016,578 patients, of whom 1,742,195 had non-infective illnesses (86.4

AIM:This study aimed to assess the incidence, predictors, and clinical outcomes of patient-prosthesis mismatch after surgical aortic valve replacement using the binational Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database. METHOD:Data from all adult patients undergoing surgical aortic valve replacement between 2001 and 2021 across 58 participating hospitals in the Database were included. Effective orifice areas of the prosthetic valves were collected from the manufacturer's specifications and existing literature. Patient-prosthesis mismatch was classified by indexed effective orifice areas: no mismatch (>0.85 cm2/m2), moderate mismatch (0.66-0.85 cm2/m2), and severe mismatch (≤0.65 cm2/m2). RESULTS:We included 36,150 patients in the study, of whom 19,330 (53.5%) had no mismatch, 15,405 (42.6%) had moderate mismatch, and 1,415 (3.9%) had severe mismatch. Predictors of mismatch included older age, larger body surface area, diabetes, hypertension, poorer New York Heart Association class, earlier year of operation, urgent operation, and use of bioprostheses. Patients with severe mismatch had the highest 30-day mortality (4.5%; moderate mismatch, 3%; no mismatch, 2.4%; p<0.0001). Both moderate and severe mismatch were associated with significantly increased long-term mortality (p=0.0003) and reduced long-term survival (log-rank p<0.0001). CONCLUSIONS:Moderate patient-prosthesis mismatch is common following surgical aortic valve replacement. Older age, larger body surface area, diabetes, hypertension, poorer New York Heart Association class, earlier year of surgery, urgent operation status, and the use of bioprosthetic valves were associated with mismatch. Patient-prosthesis mismatch of any severity was associated with increased risk of short- and long-term mortality, and worse survival.

BACKGROUND:Targeting mild hypercapnia reduced myocardial injury in a single-centre cohort of STelevation myocardial infarction (STEMI) patients from the multinational Targeted Therapeutic Mild Hypercapnia after Resuscitated Cardiac Arrest (TAME) trial. We examined the effect of mild hypercapnia on myocardial injury and outcomes in all acute myocardial infarction (AMI) patients of the TAME trial. METHODS:Post-hoc exploratory study of the TAME trial that compared the effect of targeted mild hypercapnia or normocapnia in comatose adults after out-of-hospital cardiac arrest (OHCA). The primary outcome was myocardial injury assessed by peak high-sensitivity cardiac troponin T (hs-cTnT) or troponin I (cTnI) levels during hospitalisation in STEMI and successfully percutaneous coronary intervention (PCI) treated STEMI patients. Secondary outcomes included lactate clearance, in-hospital mortality, and neurological outcome at six months. RESULTS:We studied 810 of 1700 TAME patients (49%) that were diagnosed with AMI. Of these, 593 had STEMI (73%), with 287 patients (48%) in the mild hypercapnia group and 306 (52%) in the normocapnia group. Troponin levels were available for 562 STEMI patients (95%). There was no difference in troponin level (ratio of geometric means (95% (CI) (mild hypercapnia/normocapnia) cTnI 1.18 (0.79-1.77), hs-cTnT 1.20 (0.88-1.63)) or lactate clearance over the first 24 h according to treatment allocation. In-hospital mortality in STEMI patients was 112 of 287 (39%) vs. 124 of 306 (40.5%) patients in the mild hypercapnia group vs. normocapnia group, respectively (Relative Risk 0.97, 95% CI, 0.82-1.14). At six months, 129 of 267 (44.3%) vs. 125 of 282 (48.5%) patients in the mild hypercapnia group vs normocapnia group had a favourable neurological outcome (Relative Risk 1.09, 95% CI, 0.92-1.29). For successful PCI STEMI patients there were no significant differences in any outcomes according to treatment allocation. CONCLUSION:Among STEMI patients of the TAME trial, myocardial injury, in-hospital mortality, and neurological outcome at six months were not modified by allocation to targeted mild hypercapnia.

OBJECTIVE:The aim of this study was to investigate the association between socioeconomic status (SES) and sepsis survival in Australian intensive care unit (ICU) admissions. METHODS:We conducted a retrospective cohort study of adult sepsis ICU admissions between 2018 and 2023, using ICU registry and national death data. SES was derived using the Australian Bureau of Statistics Index of Relative Socioeconomic Advantage and Disadvantage deciles mapped from residential postcodes and categorised as low, middle, or high. Unadjusted survival to 180 days and in-hospital 30-day survival were described using Kaplan-Meier estimates. Cox proportional hazard models, adjusted for age, sex, organ failure, ICU admission source, elective surgical status, chronic conditions, admission year, study site, and the presence of septic shock, were used to determine associations between SES and survival. RESULTS:Of 794,756 admissions, 80,422 (10.1%) were sepsis admissions; 180-day mortality was 7570 of 31,528 (24·0%) in low SES admissions compared to 5109 of 22262 (22.9%) and 6009 of 26,088 (23·0%) in middle and high SES admissions, respectively. In-hospital 30-day mortality was 4662 of 31,613 (14·7%) in low SES admissions compared to 3079 of 22348 (13.7%) and 3695 of 26,221 (14·1%) in middle and high SES admissions, respectively. In adjusted Cox regression models, high SES was associated with greater 180-day and in-hospital 30-day survival (adjusted hazard ratio: 0·86, 95% confidence interval: 0·83-0·90; p < 0·001 and adjusted hazard ratio: 0·88, 95% confidence interval: 0·84-0·93; p < 0·001, respectively). CONCLUSION:People living in areas of socioeconomic disadvantage had lower survival to day 180 after an ICU admission for sepsis than people living in other areas.

BACKGROUND:Metabolic acidosis is common in critically ill patients and is associated with organ dysfunction and death. Sodium bicarbonate is used to correct acidemia, but its benefit in patients with metabolic acidosis who are receiving vasopressors remains uncertain. METHODS:In this pragmatic, adaptive, double-blind, randomized trial, we assigned adults with metabolic acidosis (pH, <7.30; base excess, no more than -4 mmol per liter; and partial pressure of arterial carbon dioxide, ≤45 mm Hg without intubation or ≤50 mm Hg with intubation) who were receiving vasopressors in the intensive care unit (ICU) to receive either sodium bicarbonate or placebo (5% dextrose). Sodium bicarbonate or placebo was infused for up to 5 hours, with the infusion rate adjusted for a target pH of at least 7.30 and base excess of at least 0 mmol per liter. The primary outcome was a major adverse kidney event, defined as death, use of renal-replacement therapy, or persistent renal dysfunction, within 30 days. RESULTS:A total of 500 patients were enrolled in 55 ICUs across seven countries; 245 patients were assigned to receive sodium bicarbonate and 255 to receive placebo. A major adverse kidney event within 30 days occurred in 98 of 244 patients (40.2%) in the sodium bicarbonate group and in 100 of 254 patients (39.4%) in the placebo group (adjusted difference, 1.2 percentage points; 95% confidence interval [CI], -7.1 to 9.4; P = 0.78). Renal-replacement therapy was used within 30 days in 16.8% of the patients in the sodium bicarbonate group and in 20.9% of those in the placebo group (adjusted difference, -3.9 percentage points; 95% CI, -10.6 to 2.7). In-hospital mortality by day 30 was 25.4% in the sodium bicarbonate group and 24.0% in the placebo group (adjusted difference, 1.8 percentage points; 95% CI, -5.6 to 9.2). Four patients (1.6%) in the sodium bicarbonate group had an adverse effect, as compared with none in the placebo group (P = 0.06). CONCLUSIONS:The use of sodium bicarbonate in critically ill patients with metabolic acidosis receiving vasopressors did not lead to a lower risk of major adverse kidney events within 30 days than placebo. (Funded by the National Health and Medical Research Council of Australia; SODa-BIC ClinicalTrials.gov number, NCT05697770.).

RATIONALE:Variability in the outcomes of mobilization interventions is expected due to their complexity, and one of the post hoc hypotheses for the findings of the TEAM trial is the impact of "dosage" of mobilization on clinical outcomes. OBJECTIVES:The aim of the present study is to understand the impact of the "dose" of mobilization on 28-day mortality of patients included in the TEAM trial. METHODS:A target trial emulation estimating the per-protocol effect, which is the effect had all patients in the trial adhered to strategies with different "doses" and timing, was used. All patients included in the TEAM trial (adults in the intensive care unit [ICU] who were undergoing invasive mechanical ventilation) were included and the primary outcome was 28-day mortality. Simulated interventions combining different thresholds of duration of mobilization and different thresholds of highest ICU Mobility Scale (IMS) achieved in each day were assessed using g-formulas considering baseline and time-varying confounders. MEASUREMENTS AND MAIN RESULTS:Overall, 741 patients were included, with a median age of 62 (IQR, 51-71) years; 37% were female. Prolonged mobilization time carried worse outcomes when lower levels of mobility were achieved (risk ratio [RR], 1.33 [95% CI, 1.10-1.63] for mobilization time ≤20 minutes and mobility scale of 2). When an IMS >4 was achieved on a given day, prolonged duration of mobilization did not increase mortality compared to natural course (RR, 1.13 [95% CI, 0.96-1.46] for mobilization time ≤20 minutes and IMS of 4). CONCLUSIONS:Prolonged mobilization when only lower IMS levels could be achieved was associated with increased 28-day mortality.

Objective:We aimed to investigate patients discharged alive from hospital following an ICU admission for drug overdose and whether exposure of prior overdose-related ICU admission was associated with a future ICU readmission. Design setting participants:This multicentre registry-based study included data from 167 ICUs across Australia that reported to the Australia New Zealand Intensive Care Society Adult Patient Database. We included all adult patients (≥16 years) discharged alive from the hospital after an ICU admission for an overdose between 1st July 2018 and 31st December 2023. The exposure of interest was an overdose-related ICU admission in the six months prior to the index ICU admission. Main outcome measures:The primary outcome was all-cause ICU readmission within the following six months. The secondary outcome was ICU readmission due to an overdose within six months. We used mixed-effects multivariable logistic regression to adjust for confounders and identify risk factors for ICU readmission. Results:Of 30,125 index episodes of ICU overdose admissions (25,604 individuals), 2555 (8.5%) had an overdose-related ICU admission in the prior six months. They had higher rates of all-cause ICU readmission compared to those without a prior overdose-related ICU admission (40.9% vs. 8.9%; p < 0.001). After accounting for other factors including younger age, female sex, Indigenous status, higher SOFA scores, chronic respiratory disease, cirrhosis, dialysis dependence and frailty, an overdose in the six months prior to the index ICU admission was associated with ICU readmission in the following six months (OR = 1.93; 95%CI: 1.59-2.34; p < 0.001). Conclusions:This large Australian registry-based study found that in patients discharged alive from hospital following an ICU admission for overdose, patients with a history of prior ICU admission for overdose had almost double the risk for ICU readmission. These findings have implications for risk stratification, clinical decision-making and resource planning.

BACKGROUND:The optimal approach to early resuscitation in septic shock is unknown. Equipoise exists between the use of larger volumes of intravenous fluids to restore perfusion and the use of early vasopressor therapy along with smaller volumes of fluids to minimize potential harm from excess fluid. METHODS:We randomly assigned adult patients who presented to the emergency department with septic shock to receive either fluids at restricted volumes and early vasopressor therapy (vasopressor group) or higher volumes of fluids and later vasopressor therapy (fluids group) for at least 6 hours and up to 24 hours. The primary outcome was days alive and out of the hospital from randomization to day 90. RESULTS:A total of 1000 patients underwent randomization, with 499 assigned to the vasopressor group and 501 to the fluids group. Informed consent was not obtained for 37 patients, which left 963 patients in the intention-to-treat population (481 in the vasopressor group and 482 in the fluids group). Three patients in the fluids group were lost to follow-up for the primary outcome. In the first 24 hours after randomization, patients in the vasopressor group received less intravenous fluid than those in the fluids group (median difference, -1108 ml; 95% confidence interval [CI], -1395 to -850). The percentage of patients who received vasopressors was higher by 18.9 percentage points (95% CI, 13.3 to 24.5) in the vasopressor group. The median number of days alive and out of the hospital at day 90 was 76 (interquartile range, 55 to 83) in the vasopressor group and 76 (interquartile range, 55 to 82) in the fluids group (difference, 0.0 days; 95% CI, -2.7 to 2.7; P = 1.00). Adverse events occurred in similar percentages of patients in the two groups, except for pulmonary edema (0.6% in the vasopressor group vs. 5.0% in the fluids group; P<0.001). CONCLUSIONS:Among adult patients who presented to the emergency department with septic shock, an approach that involved restricted fluid volume and early vasopressors did not result in a greater number of days alive and out of the hospital at day 90 than an approach involving greater fluid volume and later administration of vasopressors. (Funded by the Australian National Health and Medical Council Medical Research Future Fund and the New Zealand Health Research Council; ARISE FLUIDS ClinicalTrials.gov number, NCT04569942.).

BACKGROUND:In patients who are unresponsive after resuscitation from cardiac arrest, limiting oxygen exposure to that necessary to achieve acceptable oxygenation may increase the likelihood of survival with a favorable functional outcome. METHODS:We randomly assigned unresponsive adults receiving mechanical ventilation in the intensive care unit (ICU) after cardiac arrest to conservative or liberal oxygen therapy. In the two groups, the default lower limit of arterial oxygen saturation as measured by pulse oximetry (Spo2) was 90%. In the conservative-oxygen group, the alarm for the upper limit of the Spo2 was set at 95%, and the fraction of inspired oxygen (Fio2) was decreased to 0.21 provided that the Spo2 was above the lower limit. In the liberal-oxygen group, there were no measures limiting the upper Spo2, but the minimum Fio2 permitted during mechanical ventilation was 0.3. The primary outcome was survival with a favorable functional outcome at 180 days, assessed with the Extended Glasgow Outcome Scale (GOS-E). Levels on the GOS-E range from 1 (death) to 8 ("upper good recovery"). We defined survival with a favorable functional outcome as a GOS-E level of 5 ("lower moderate disability") or higher. RESULTS:A total of 1840 patients were recruited from 53 ICUs in Australia, New Zealand, and Ireland, with 882 assigned to conservative oxygen therapy and 958 assigned to liberal oxygen therapy. A favorable functional outcome at 180 days was observed for 313 of 819 patients (38.2%) in the conservative-oxygen group and 353 of 890 patients (39.7%) in the liberal-oxygen group (relative risk, 0.97; 95% confidence interval, 0.87 to 1.09; P = 0.65). No adverse events were reported. CONCLUSIONS:Among unresponsive adults undergoing mechanical ventilation in the ICU after a cardiac arrest, the percentage who survived with a favorable functional outcome was not higher with conservative oxygen therapy than with liberal oxygen therapy. (Funded by the Health Research Council of New Zealand and others; LOGICAL Australian New Zealand Clinical Trials Registry number, ACTRN12621000518864.).

Background and Aims: Energy and protein provision for critically ill patients who receive oral nutrition often falls below recommended targets. We compared characteristics and nutrition processes during hospital stay (within and post-intensive care unit [ICU] stay) of those who received oral nutrition as the sole nutrition source to those who first commenced enteral (EN) or parenteral nutrition (PN) within an Australian or New Zealand (ANZ) ICU. Methods: Multicentre, observational study of routine nutrition care in 44 hospitals across ANZ, including adult patients within ICU admitted for at least 48 h. Those receiving oral nutrition as the sole source of nutrition (with or without oral nutrition supplements) were included in the 'oral nutrition' group and those who first received EN and/or PN in the ICU as the 'EN/PN group'. The primary outcome was median daily energy delivery in ICU. Data are presented as number (%) or median [interquartile range]. Results: Of the 409 patients enroled, median [IQR] age was 64 [51-74] years and 257 patients (62%) were male. APACHE II score, use of invasive ventilation and hospital length of stay (LOS) were all lower in those receiving oral nutrition (n = 200) compared to those receiving EN/PN (n = 209). In ICU, 63 (31.5%) and 169 (81%) (p < 0.001), patients who were receiving oral nutrition and in the EN/PN group received a nutrition assessment, respectively. Oral nutrition supplements were provided for 40 (20%) patients in the oral nutrition group and 31 of 94 (33%) of those receiving oral nutrition in the EN/PN group (p = 0.019). Energy and protein intake in ICU for the oral nutrition group was 716 [597-1069] kcal/day and 37 [19-46] g/day versus 1158 [664-1583] kcal/day and 57 [31-77] g/day for those receiving EN/PN (p = 0.020 energy, p = 0.016 protein). Quantification of oral nutrition was attempted in 78/294 (27%) patients in ICU and completed on 27/78 (36%) occasions. On the ward, attempts were made for 120/273 (44%) patients, with 60/120 (50%) complete. Conclusion: Patients who received oral nutrition as the sole nutrition source in ICU had lower illness severity, rates of nutrition assessment and provision of oral supplements compared to those who first received EN/PN. Quantification of oral nutrition was often incomplete for all patients in ICU and on the ward.

Rinaldo Bellomo advanced critical care not only through randomised trials but also through rigorous use of observational data, particularly from the ANZICS Centre for Outcome and Resource Evaluation (ANZICS CORE) Registry. At a time when retrospective analyses were often confined to hypothesis generation, he showed that carefully curated, clinically grounded registry studies could inform policy and change practice. Recognising early the potential of ANZICS CORE to become a leading registry, he worked to strengthen its data architecture and published in journals such as The New England Journal of Medicine and JAMA, helping to spark global dialogue and shape guidelines. Using the Adult Patient Database, he described epidemiological trends, identified clinically relevant questions, designed, justified and evaluated randomised trials, and monitored the uptake of evidence-based practice. His work addressed key challenges in sepsis, acute kidney injury, glycaemic control, temperature management and health equity, and was marked by clear case definitions, extensive sensitivity analyses and transparent reporting. This article reviews selected contributions using ANZICS CORE data and outlines how his legacy endures through the value of these datasets and the many researchers he mentored.

Sepsis is a major cause of mortality in intensive care unit (ICU) patients. Significant temporal improvements in survival were observed in Australia and New Zealand (ANZ) from 2000 to 2012. Whether this has continued remains uncertain, and current sepsis-related mortality in ANZ ICUs is unknown. We studied adult ICU patients admitted with sepsis (based on the 3rd international consensus definition for sepsis and septic shock), between January 2000 and June 2023. Data were obtained from 219 ICUs that contributed to the ANZ Intensive Care Society Adult Patient Database. We used logistic regression models to study changes in in-hospital mortality over time. Among 2,975,149 ICU admissions, 303,389 patients had sepsis. In-hospital mortality was 28

Objective:Describe the association between the implementation of a shared decision-making (SDM) program and documentation of goals of care for critically ill patients with life-limiting illness (LLI). Methods:A prospective longitudinal cohort study was conducted from 1st January 2015 to 30th September 2020 in an Australian tertiary teaching hospital. Adult patients with LLI admitted to the intensive care unit (ICU) were included. A SDM program consisting of communication training, a new goals of care form, and clinical support was implemented. The primary outcome was the proportion of patients with a documented SDM discussion. Secondary outcomes included patient treatment preferences and hospital utilisation parameters. Results:A total of 1178 patients with LLI were admitted to the ICU during the study period and included in the study. Following the introduction of an SDM program, the proportion of patients with a documented SDM discussion increased from 22 % at baseline to a peak of 68 % at year five, then 60 % in year six of the study (adjusted odds ratio: 1.49, 95 % confidence interval: 1.38-1.60; p < 0.0001). Patients who had documented SDM were more likely to be older, female, frail, and have a prior advance care plan. SDM discussions resulted in higher rates of documented deterioration treatment preference plan (p < 0.0001), an increased ICU length of stay (3 vs. 2 days, p < 0.0001), referrals to palliative care services (p = 0.002), and a higher mortality rate. Time to death was significantly shorter in decedents with documented SDM compared to those without it (12 vs. 49 days, p < 0.0001). Conclusion:The implementation of a comprehensive clinical communication training program was associated with increased documentation of shared decision-making discussions for patients in ICU with LLI, which corresponded with changes in patient treatment preferences and healthcare utilisation by decedents. Further research is required to understand the impact of these conversations from the perspective of patients and their families.