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Barry Dixon,1– 3 Jessica M Sharkey,1 Elliot J Teo,1,2 Sally A Grace,1 Jacqui S Savage,1 Andrew Udy,4 Paul Smith,5,6 Jack Hellerstedt,1 John D Santamaria2 1Cyban Pty Ltd, Melbourne, VIC, Australia; 2Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia; 3Department of Medicine, University of Melbourne, Melbourne, Vic, Australia; 4Department of Critical Care Medicine, The Alfred Hospital, Melbourne, Australia; 5Department of Neurosurgery, St Vincent’s Hospital, Melbourne, Australia; 6University of Melbourne Medical School, Melbourne, Vic, AustraliaCorrespondence: Barry Dixon, Department of Critical Care Medicine, St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia, Tel +61 3 9231 4425, Email barry.dixon@svha.org.auBackground: Intracranial pressure (ICP) monitoring requires placing a hole in the skull through which an invasive pressure monitor is inserted into the brain. This approach has risks for the patient and is expensive. We have developed a non-invasive brain pulse monitor that uses red light to detect a photoplethysmographic (PPG) signal arising from the blood vessels on the brain’s cortical surface. The brain PPG and the invasive ICP waveform share morphological features which may allow measurement of the intracranial pressure.Methods: We enrolled critically ill patients with an acute brain injury with invasive ICP monitoring to assess the new monitor. A total of 24 simultaneous invasive ICP and brain pulse monitor PPG measurements were undertaken in 12 patients over a range of ICP levels.Results: The waveform morphologies were similar for the invasive ICP and brain pulse monitor PPG approach. Both methods demonstrated a progressive increase in the amplitude of P2 relative to P1 with increasing ICP levels. An automated algorithm was developed to assess the PPG morphological features in relation to the ICP level. A correlation was demonstrated between the brain pulse waveform morphology and ICP levels, R2=0.66, P < 0.001.Conclusion: The brain pulse monitor’s PPG waveform demonstrated morphological features were similar to the invasive ICP waveform over a range of ICP levels, these features may provide a method to measure ICP levels.Trial Registration: ACTRN12620000828921.Keywords: intracranial pressure, acute brain injury, monitoring, non-invasive, photoplethysmography

BACKGROUND: The national hospital-acquired complications (HAC) system has been promoted as a method to identify health care errors that may be mitigated by clinical interventions. OBJECTIVES: To quantify the rate of HAC in multiday stay adults admitted to major hospitals. DESIGN: Retrospective observational analysis of 5-year (July 2014 – June 2019) administrative dataset abstracted from medical records. SETTING: All 47 hospitals with on-site intensive care units (ICUs) in the State of Victoria. PARTICIPANTS: All adults (aged ≥ 18 years) stratified into planned or unplanned, surgical or medical, ICU or other ward, and by hospital peer group (tertiary referral, metropolitan, regional). MAIN OUTCOME MEASURES: HAC rates in ICU compared with ward, and mixed-effects regression estimates of the association between HAC and i) risk of clinical deterioration, and ii) admission hospital site (intraclass correlation coefficient [ICC] > 0.3). RESULTS: 211 120 adult ICU separations with mean hospital mortality of 7.3% (95% CI, 7.2–7.4%) reported 110 132 (42.6%) HAC events (commonly, delirium, infection, arrhythmia and respiratory failure) in 62 945 records (29.8%). Higher HAC rates were reported in elective (cardiac [50.3%] and non-cardiac [40.6%]) surgical subgroups compared with emergency medical subgroup (23.9%), and in tertiary (35.4%) compared with non-tertiary (22.7%) hospitals. HAC was strongly associated with on-admission patient characteristics (P < 0.001), but was weakly associated with hospital site (ICC, 0.08; 95% CI, 0.05–0.11). CONCLUSIONS: Critically ill patients have a high burden of HAC events, which appear to be associated with patient admission characteristics. HAC may an indicator of hospital admission complexity rather than hospital-acquired complications.

Background Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. Method This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH Results We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. Conclusions Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Introduction Intravenous drug use (IVDU) associated infective endocarditis (IE) is a clinically challenging case. Not only can the natural history of IE in the IVDU population be significantly different, making detection a diagnostic dilemma, additional social factors associated with this population can drastically change management, including suitability for surgery or long-term intravenous access for antibiotics Furthermore, the rates of IVDU are increasing globally, leading to increasing incidence of IVDU associated IE. Purpose With a lack of clear mangement guidelines for IVDU associated IE, our study assesses the differences in presentation, management and long-term prognosis of IE between the IVDU population and the non-IVDU population to help guide future care. Methods This is an observational cohort study on a prospectively collected database of 350 patients treated for IE at our centre between 1999 and 2015. Patients were followed-up until death or January 2021. The primary outcome was all-cause mortality. Continuous variables were compared using unpaired t-test. Categorical variables were compared using Chi-square test when sample size was >5 or Fisher's exact test when sample size was ≤5. Long-term survival data was analysed using Kaplan-Meier survival curves. Results The IVDU population was younger, more likely to have concurrent infections and other substance use, while the non-IVDU population was older with a higher level of overall comorbidity. IVDU patients were more likely to become reinfected (p-value=0.034) but had better long-term survival compared to the non-IVDU population (p Conclusion Despite having higher levels of reinfection, IVDU patients have better long-term outcomes of IE compared to non-IVDU patients. Therefore, IVDU patients should not have blanket restrictions on the management they are offered unless the individual has clear contraindications to a particular therapy. Funding Acknowledgement Type of funding sources: None.

To quantify the prevalence of hospital-acquired complications; to determine the relative influence of patient- and hospital-related factors on complication rates.Retrospective analysis of administrative data (Integrated South Australian Activity Collection; Victorian Admitted Episodes Dataset) for multiple-day acute care episodes for adults in public hospitals.Thirty-eight major public hospitals in South Australia and Victoria, 2015-2018.Hospital-acquired complication rates, overall and by complication class, by hospital and hospital type (tertiary referral, major metropolitan service, major regional service); variance in rates (intra-class correlation coefficient, ICC) at the patient, hospital, and hospital type levels as surrogate measures of their influence on rates.Of 1 558 978 public hospital episodes (10 029 918 bed-days), 151 486 included a total of 214 286 hospital-acquired complications (9.72 [95% CI, 9.67-9.77] events per 100 episodes; 2.14 [95% CI, 2.13-2.15] events per 100 bed-days). Complication rates were highest in tertiary referral hospitals (12.7 [95% CI, 12.6-12.8] events per 100 episodes) and for episodes including intensive care components (37.1 [95% CI, 36.7-37.4] events per 100 episodes). For all complication classes, inter-hospital variation was determined more by patient factors (overall ICC, 0.55; 95% CI, 0.53-0.57) than by hospital factors (ICC, 0.04; 95% CI, 0.02-0.07) or hospital type (ICC, 0.01; 95% CI, 0.001-0.03).Hospital-acquired complications were recorded for 9.7% of hospital episodes, but patient-related factors played a greater role in determining their prevalence than the treating hospital.

Objective: To explore associations between frailty (Clinical Frailty Scale score of 5 or more) in very old patients in intensive care units (ICUs) and their clinical outcomes (mortality, discharge destination). Design, setting and participants: Retrospective population cohort analysis of Australian and New Zealand Intensive Care Society (ANZICS) Adult Patient Database data for all patients aged 80 years or more admitted to participating ICUs between 1 January 2017 and 31 December 2018. Main outcome measures: Primary outcome: in-hospital mortality; secondary outcomes: length of stay (hospital, ICU), re-admission to ICU during the same hospital admission, discharge destination (including new chronic care or nursing home admission). Results: Frailty status data were available for 15 613 of 45 773 patients aged 80 years or more admitted to 178 ICUs (34%); 6203 of these patients (39.7%) were deemed frail. A smaller proportion of frail than non-frail patients were men (47% v 57%), the mean illness severity scores of frail patients were slightly higher than those of non-frail patients, and they were more frequently admitted from the emergency department (28% v 21%) or with sepsis (12% v 7%) or respiratory complications (16% v 12%). In-hospital mortality was higher for frail patients (17.6% v 8.2%; adjusted odds ratio [OR], 1.87 [95% CI, 1.65–2.11]). Median lengths of ICU and hospital stay were slightly longer for frail patients, and they were more frequently discharged to new nursing home or chronic care (4.9% v 2.8%; adjusted OR, 1.61 [95% CI, 1.34–1.95]). Conclusions: Many very old critically ill patients in Australia and New Zealand are frail, and frailty is associated with considerably poorer health outcomes. Routine screening of older ICU patients for frailty could improve outcome prediction and inform intensive care and community health care planning.

Background Frailty is common among acute hospital patients and might adversely affect recovery from inpatient cardiac arrest. Aim To assess the relationship between hospital admission characteristics, including frailty, and discharge outcome after in-hospital cardiac arrest. Methods Prospectively collected data were retrospectively analysed for all separations from a tertiary hospital during 2008-2017 that involved rapid response team attendance for cardiac arrest. Hospital Frailty Risk Score (HFRS) and Charlson index of comorbidity were calculated from 'primary' and 'associated' International Classification of Diseases, 10th revision, Australian Modification diagnoses. HFRS ≥5 was taken to signify frailty. Discharge home from hospital and death in hospital were modelled using logistic regression. Results There were 388 in-hospital arrest patients: 91% were aged ≥50 years, 34% were previously discharged in the past 6 months, 66% were unplanned admissions, 63% were non-cardiology-cardiothoracic admissions, 45% had a Charlson comorbidity index ≥2 and 19% were identified as frail. Discharge home occurred in 22%, discharge to another hospital 17% and death 62%. Of the frail patients, only 3 (4%) were discharged home, 12 (17%) were discharged to another hospital and 57 (79%) died in hospital. Fewer frail patients were discharged home compared with non-frail patients (4 vs 26%; odds ratio (OR) 0.13, P = 0.001). On multivariable analysis, patients were less likely to be discharged home if they had frailty (OR 0.24, P = 0.02), age ≥ 50 years (OR 0.36, P = 0.01), non-cardiology-cardiothoracic unit admission (OR 0.40, P = 0.001) and unplanned admission (OR 0.57, P = 0.04). Frail patients discharged to another hospital spent a median of 15 days (interquartile range 11-23) in the hospital post-arrest before leaving to continue inpatient care elsewhere. Frailty was associated with death in hospital on univariate analysis (79 vs 58%; OR 2.80, P = 0.001) but not after controlling for other factors. Conclusion Frail patients are unlikely to make a good recovery after in-hospital arrest. This should be taken into account when planning care with patients and their families.

Summary Background Mechanical ventilation in intensive care for 48 h or longer is associated with the acute respiratory distress syndrome (ARDS), which might be present at the time ventilatory support is instituted or develop afterwards, predominantly during the first 5 days. Survivors of prolonged mechanical ventilation and ARDS are at risk of considerably impaired physical function that can persist for years. An early pathogenic mechanism of lung injury in mechanically ventilated, critically ill patients is inflammation-induced pulmonary fibrin deposition, leading to thrombosis of the microvasculature and hyaline membrane formation in the air sacs. The main aim of this study was to determine if nebulised heparin, which targets fibrin deposition, would limit lung injury and thereby accelerate recovery of physical function in patients with or at risk of ARDS. Methods The Can Heparin Administration Reduce Lung Injury (CHARLI) study was an investigator-initiated, multicentre, double-blind, randomised phase 3 trial across nine hospitals in Australia. Adult intensive care patients on invasive ventilation, with impaired oxygenation defined by a PaO2/FiO2 ratio of less than 300, and with the expectation of invasive ventilation beyond the next calendar day were recruited. Key exclusion criteria were heparin allergy, pulmonary bleeding, and platelet count less than 50 X 109/L. Patients were randomly assigned 1:1, with stratification by site and using blocks of variable size and random seed, via a web-based system, to either unfractionated heparin sodium 25 000 IU in 5 mL or identical placebo (sodium chloride 0·9% 5 mL), administered using a vibrating mesh membrane nebuliser every 6 h to day 10 while invasively ventilated. Patients, clinicians, and investigators were masked to treatment allocation. The primary outcome was the Short Form 36 Health Survey Physical Function Score (out of 100) of survivors at day 60. Prespecified secondary outcomes, which are exploratory, included development of ARDS to day 5 among at-risk patients, deterioration of the Murray Lung Injury Score (MLIS) to day 5, mortality at day 60, residence of survivors at day 60, and serious adverse events. Analyses followed the intention-to-treat principle. There was no imputation of missing data. The trial is registered with the Australian and New Zealand Clinical Trials Register, number ACTRN12612000418875 . Findings Between Sept 4, 2012, and Aug 23, 2018, 256 patients were randomised. Final follow-up was on Feb 25, 2019. We excluded three patients who revoked consent and one ineligible participant who received no intervention. Of 252 patients included in data analysis, the mean age was 58 years (SD 15), 157 (62%) were men, and 118 (47%) had ARDS. 128 (51%) patients were assigned to the heparin group and 124 (49%) to the placebo group, all of whom received their assigned intervention. Survivors in the heparin group (n=97) had similar SF-36 Physical Function Scores at day 60 compared to the placebo group (n=94; mean 53·6 [SD 31·6] vs 48·7 [35·7]; difference 4·9 [95% CI −4·8 to 14·5]; p=0·32). Compared with the placebo group, the heparin group had fewer cases of ARDS develop to day 5 among the at-risk patients (nine [15%] of 62 patients vs 21 [30%] of 71 patients; hazard ratio 0·46 [95% CI 0·22 to 0·98]; p=0·0431), less deterioration of the MLIS to day 5 (difference −0·14 [–0·26 to −0·02]; p=0·0215), similar day 60 mortality (23 [18%] of 127 patients vs 18 [15%] of 123 patients; odds ratio [OR] 1·29 [95% CI 0·66 to 2·53]; p=0·46), and more day 60 survivors at home (86 [87%] of 99 patients vs 73 [73%] of 100 patients; OR 2·45 [1·18 to 5·08]; p=0·0165). A similar number of serious adverse events occurred in each group (seven [5%] of 128 patients in the heparin group vs three [2%] of 124 patients in the placebo group; OR 2·33 [0·59 to 9·24]; p=0·23), which were a transient increase in airway pressure during nebulisation (n=3 in the heparin group), major non-pulmonary bleeding (n=2 in each group), haemoptysis (n=1 in the heparin group), tracheotomy site bleeding (n=1 in the heparin group), and hypoxaemia during nebulisation (n=1 in the placebo group). Interpretation In patients with or at risk of ARDS, nebulised heparin did not improve self-reported performance of daily physical activities, but was well tolerated and exploratory outcomes suggest less progression of lung injury and earlier return home. Further research is justified to establish if nebulised heparin accelerates recovery in those who have or are at risk of ARDS. Funding Rowe Family Foundation, TR and RB Ditchfield Medical Research Endowment Fund, Patricia Madigan Charitable Trust, and The J and R McGauran Trust Fund.

IntroductionCOVID-19 is associated with the development of ARDS displaying the typical features of diffuse alveolar damage with extensive pulmonary coagulation activation resulting in fibrin deposition in the microvasculature and formation of hyaline membranes in the air sacs. The anti-coagulant actions of nebulised heparin limit fibrin deposition and progression of lung injury. Serendipitously, unfractionated heparin also inactivates the SARS-CoV-2 virus and prevents its entry into mammalian cells. Nebulisation of heparin may therefore limit both fibrin-mediated lung injury and inhibit pulmonary infection by SARS-CoV-2. For these reasons we have initiated a multi-centre international trial of nebulised heparin in patients with COVID-19.Methods and interventionMechanically ventilated patients with confirmed or strongly suspected SARS-CoV-2 infection, hypoxaemia and an acute pulmonary opacity in at least one lung quadrant on chest X-ray, will be randomised to nebulised heparin 25,000 Units every 6 hours or standard care for up to 10 days while mechanically ventilated. The primary outcome is the time to separation from invasive ventilation to day 28, where non-survivors to day 28 are treated as though not separated from invasive ventilation.Ethics and disseminationThe study protocol has been submitted to the human research and ethics committee of St Vincent’s Hospital, Melbourne, Australia. Submission is pending in other jurisdictions. Results of this study will be published in scientific journals and presented at scientific meetings.Trial RegistrationACTRN: 12620000517976

Rationale The endotracheal tube (ETT) is the most common route for invasive mechanical ventilation (MV) yet controversy attends its long-term safety. Objective Assess the safety of ETT compared with tracheostomy tube (TT) for MV support in the intensive care unit (ICU). Methods Retrospective analysis of five year national dataset of 128,977 adults (age > 15-years) admitted for MV therapy with tracheostomy tube (TT; n = 4772) or without (ETT; n = 124,204), excluding those with neurological diagnoses or likely to require a surgical airway (n = 27,466), in 93 public health service ICUs across Australia, between July 2013–June 2018. Measurements Hospital survival (including liberation from MV) for ETT Group compared with TT Group using a probit regression model adjusted for confounding using fixed, endogenous and non-random treatment assignment covariates, and their interactions; analysed and plotted as marginal effects by duration of MV. Results Median duration of MV was 2 (IQR =1–4) days, predominantly via ETT (124,205; 96.3%), and 21,620 (16.7%) died. Temporal trend for ETT increased (OR = 1.06 per year, 95%CI =1.03–1.10) compared to TT, even for prolonged (>3 weeks) MV (38.1%). Higher risk-adjusted mortality was associated with longer duration of MV and after 9 days of MV with retention of ETT compared with TT - average (mortality) treatment effect 12.6% (95%CI =10.7–14.5). The latter was not significant after 30 days of MV. Conclusions The safety of ETT compared with TT beyond short-term MV (≤9-days) is uncertain and requires prospective evaluation with additional data.

Objectives Medical emergency teams were established to rescue patients experiencing clinical deterioration thus preventing cardiac arrest and unexpected hospital mortality. Although hospitals are encouraged to increase emergency calling rates to improve in-hospital mortality, there are increasing concerns about the impact these calls have on the workload of the teams and the skill levels on the general wards. We set out to examine the relationship between emergency calling rates and adjusted in-hospital mortality. Design Retrospective analysis of prospectively collected patient and emergency call data. Setting Tertiary, metropolitan, and regional hospitals in the State of Victoria, Australia. Patients Consecutive patients discharged from 1) St Vincent's Hospital Melbourne from January 2008 to June 2016 and 2) 15 Victorian hospitals from July 2010 to June 2015. Measurements and main results We studied 441,029 patients from St Vincent's Hospital Melbourne. Median age was 61.0 years (interquartile range, 45-74 yr), 57.2% were men, and 0.70% died; monthly emergency calling rates varied between 9.21 and 30.69 (median 18.4) per 1,000 discharges. In-hospital mortality adjusted for age, gender, emergency status, same day admission, year of discharge, and Charlson Comorbidity Index was not reduced by higher calling rates in the month of discharge (odds ratio, 1.019; 95% CI, 1.008-1.031). We then examined 3,339,789 discharges from 15 Victorian hospitals with median age 61 years (interquartile range, 43-74 yr), 51.4% men, and hospital mortality 0.83% where yearly emergency calling rates varied from 18.46 to 33.40 (median, 25.75) per 1,000 discharges. Again, adjusted mortality was not reduced by higher calling rates in the year of discharge (odds ratio, 1.003; 95% CI, 1.001-1.006). Conclusions With adjustment for patient factors, illness, and comorbidities, increased emergency calling rates were not associated with reduced in-hospital mortality. Efforts to increase calling rates do not seem warranted.

BACKGROUND: Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS). AIMS: To identify factors that predict a slower time to resolution of DKA in adults with diabetes. METHODS: Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored. RESULTS: Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P < 0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P < 0.001). CONCLUSIONS: Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.

Objectives To evaluate the introduction of a document for recording the resuscitation plans of patients at a tertiary hospital. The ‘Acute Resuscitation Plan’ (ARP) was introduced in September 2014, superseding the ‘Not for Cardiopulmonary Resuscitation (CPR)’ form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. Design Retrospective audit of the records of all admissions to the hospital from January-June 2014 (Not for CPR period) and January-June 2015 (ARP period). Main outcomes Incidence of resuscitation plans; proportion of ARPs specifying consultation with the patient (or representative) and with senior medical staff and; proportion of ARPs among older patients and those with significant comorbidity. Results Resuscitation plans were present for 453/23,325 (1.9%) admissions in the Not for CPR period vs. 1,801/24,037 (7.5%) in the ARP period (OR 4.1, 95%CI 3.7-4.5, P

Opioid prescriptions have significantly increased in recent years and are used for a wide variety of indications. Electronic medical records of 45 patients who received naloxone by a rapid response team over an 18-month period were retrospectively reviewed. This study found inconsistencies in the management of possible opioid toxicity with variation in the total naloxone dose and number of doses administered. This highlights the importance of a standardised protocol for recognition and management of opioid overdose.

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 to168 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.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.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).Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.

Background and Aim We have previously found high incidence of inflammatory bowel disease (IBD) in Australia. A population-based registry was established to assess disease severity, frequency of complications, and prognostic factors. Methods Incident cases were prospectively identified over 4 years. Early disease severity was assessed according to need for hospitalization and resective surgery and medication use. Results We report on the early outcomes (median 18 months, range 12–60 months) for 252 patients comprising 146 with Crohn's disease (CD), 96 with ulcerative colitis (UC), and 10 IBD undifferentiated. Eighty-seven percent of CD patients had inflammatory disease at diagnosis, and this reduced to 73% at 5 years (n = 38). Immunomodulators were prescribed in 57% of CD patients and 19% with UC. A third of all CD patients were hospitalized, the majority (77%) in the first 12 months. Risk factors for hospitalization included penetrating, perianal, and ileocolonic disease (P

Diabetic ketoacidosis (DKA) is an acute life-threatening metabolic complication of diabetes that imposes substantial burden on our healthcare system. There is a paucity of published data in Australia assessing factors influencing time to resolution of DKA and length of stay (LOS).To identify factors that predict a slower time to resolution of DKA in adults with diabetes.Retrospective audit of patients admitted to St Vincent's Hospital Melbourne between 2010 to 2014 coded with a diagnosis of 'Diabetic Ketoacidosis'. The primary outcome was time to resolution of DKA based on normalisation of biochemical markers. Episodes of DKA within the wider Victorian hospital network were also explored.Seventy-one patients met biochemical criteria for DKA; median age 31 years (26-45 years), 59% were male and 23% had newly diagnosed diabetes. Insulin omission was the most common precipitant (42%). Median time to resolution of DKA was 11 h (6.5-16.5 h). Individual factors associated with slower resolution of DKA were lower admission pH (P0.001) and higher admission serum potassium level (P = 0.03). Median LOS was 3 days (2-5 days), compared to a Victorian state-wide LOS of 2 days. Higher comorbidity scores were associated with longer LOS (P0.001).Lower admission pH levels and higher admission serum potassium levels are independent predictors of slower time to resolution of DKA. This may assist to stratify patients with DKA using markers of severity to determine who may benefit from closer monitoring and to predict LOS.

To describe the frequency and hospital mortality of problems (diagnoses) encountered by a rapid response team (RRT), and to identify the most common diagnoses for RRT triggers and for treating units.For each RRT event in 2015 at a tertiary hospital for adults, we chose the diagnosis that best explained the RRT event from a pre-defined list after reviewing relevant test results and clinical notes.There were 937 RRT events during 700 admissions and there were 58 different RRT diagnoses in 11 diagnosis groups. The largest groups were neurological and consciousness problems (22.9%), circulatory problems (19.0%) and breathing problems (16.0%). The most common diagnoses were rapid atrial fibrillation (7.6%) and oversedation or narcosis (4.8%). When SpOThe RRT activation trigger provides only a general indication of the diagnosis. Some problems appear preventable and could provide a focus for unit-based quality initiatives. The mortality of some diagnoses is substantial, and this may help in setting treatment goals, but more work is needed to understand the association of RRT diagnosis and outcome.

Heat and Moisture Exchanger (HME) is a simple solution to the problems of warming and humidification of inspired gases during ventilator treatment. The device acts as an “artificial” nose or passive humidifier, added to the breathing circuit to retain and exchange heat and moisture between inspiration and expiration. The HME traps expiratory heat and moisture from patient’s exhaled breath in a porous medium and returns a portion of them through the subsequent inspiratory cycle. The aim of our paper is to develop a computational fluid dynamics (CFD) model of an HME device commonly used in anaesthesia and intensive care. The CFD results allow a better understanding of flow behaviour leading to the design of more efficient devices. The CFD model solves the gas flow, heat and mass transfer equations in a DAR Hygrobac S (Mallinckrodt DAR, Mirandola, Italy). The temperature, absolute humidity and pressure fields are obtained during expiratory phase to evaluate heat and moisture conserving efficiencies and air flow resistance. The effect of flow rate as one of the major parameters in ventilator setting on temperature, humidity and pressure drop is determined. Inside the HME device, areas of recirculation are observed. As the flow rate increases the output temperature and absolute humidity go up causing a reduction in heat and moisture conserving capacities. Comparison of the CFD results with previously obtained experimental data shows a satisfactory agreement.

Background: To compare and contrast the coronary heart disease (CHD) risk factors of lower socio-economic status public hospital patients with those of privately insured CHD patients before and after six months of telephone delivered coaching using The COACH Program. Methods: A retrospective observational study which contrasts the lifestyle and biomedical coronary risk factor status of 2256 public hospital patients with the same risk factors of 3278 patients who had private health insurance. All patients received an average of 5 coach sessions over 6 months. Results: The public hospital patients were four years younger and had multiple measures confirming their lower socio-economic status than their private hospital counterparts. At entry to the program, the public hospital patients had worse risk factor levels than the privately insured patients for total and LDL-cholesterol, triglycerides, fasting glucose, smoking and physical activity levels (P < 0.0001) but better status for systolic and diastolic blood pressures and alcohol intake. At exit from the program, many of these differences had diminished or disappeared. The public hospital patients had greater improvements in their risk factor status for total and LDL-cholesterol, fasting glucose, body weight, smoking status and physical activity level than did the privately insured patients (P < 0.05). Conclusions: This paper demonstrates that a program of initiating contact with patients with CHD, identifying treatment gaps in their management and coaching to achieve guideline recommended risk factor targets can help reduce health inequalities in such patients and thus benefit all patients in the context of ongoing secondary prevention.

a b s t r a c t Background: Arterial carbon dioxide tension (PaCO2) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated. Methods and results: Observational cohort study using data from the Australian New Zealand (ANZ) Inten- sive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO2 and propensity score. We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO2 (obtained within 24 h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO2 45 mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 (95% CI 1.00-1.24, p = 0.04)), lower rate of discharge home (OR 0.81 (0.70-0.94, p < 0.01)) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 (1.10-1.37, p < 0.001)). In contrast, the hypercapnia group had similar in- hospital mortality (OR 1.06 (0.97-1.15, p = 0.19)) but higher rate of discharge home among survivors (OR 1.16 (1.03-1.32, p = 0.01)) and similar likelihood of fulfilling the composite outcome (OR 0.97 (0.89-1.06, p = 0.52)). Cox-proportional hazards modelling supported these findings. Conclusions: Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocap- nia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors.

The 'Acute Resuscitation Plan' (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the 'Not for Cardiopulmonary Resuscitation (CPR)' form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits.To evaluate the introduction of the ARP.This study is a retrospective audit of the records of all admissions to the hospital from January to June 2014 (Not for CPR period) and January to June 2015 (ARP period). The main outcomes are the incidence of resuscitation plans, the proportion of ARP specifying consultation with the patient (or representative) and with senior medical staff, and the proportion of ARP among older patients and those with significant comorbidity.Resuscitation plans were present for 453 of 23 325 (1.9%) admissions in the Not for CPR period versus 1801 of 24 037 (7.5%) in the ARP period (odds ratio (OR) 4.1, 95% confidence interval (CI) 3.7-4.5, P0.001). A total of 42% of ARP specified 'care of the dying' in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARP and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥90 years, 59% from aged care, 90% with metastatic cancer and 64% aged ≥80 years and with a Charlson comorbidity index ≥3.More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process, and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.

a b s t r a c t We aimed to describe the characteristics of medical emergencies that occurred in the medical imaging department (MID) of a university hospital in Melbourne, Australia. A database of 'Respond Medical Emergency Team (MET)' and 'Respond Blue' calls was retrospectively examined for the period June 2003 to November 2010 in relation to events that occurred in the MID. The hospital medical imaging database was also examined in relation to these events and, where necessary, patients' notes were reviewed. Ethics approval was granted by the hospital ethics review board. There were 124 medical emergency calls in the MID during the study period, 28% Respond Blue and 72% Respond MET. Of these 124 calls, 26% occurred outside of usual work hours and 12% involved cardiac arrest. The most common reasons for the emergency calls were seizures (14%) and altered conscious state (13%). Contrast anaphylaxis precipitated the emergency in 4% of cases. In 83% of cases the emergency calls were for patients attending the MID for diagnostic imaging, the remainder being for a procedure. Of the scheduled imaging techniques, 45% were for computed tomog- raphy. The scheduled imaging was abandoned due to the emergency in 12% of cases. When performed, imaging informed patient management in 34% of cases in diagnostic imaging and in all cases in the context of image-guided procedures. Medical emergency calls in the MID often occurred outside usual work hours and were attributed to a range of medical problems. The emergencies occurred in relation to all imaging techniques and imaging informed patient management in many cases.

V. Pettilä on työryhmän ARISE Investigators jäsen. Study objective: The influence of the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) on the conduct of future sepsis research is unknown. We seek to examine the potential effect of the new definitions on the identification and outcomes of patients enrolled in a sepsis trial. Methods: This was a post hoc analysis of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial of early goal-directed therapy that recruited 1,591 adult patients presenting to the emergency department (ED) with early septic shock diagnosed by greater than or equal to 2 systemic inflammatory response syndrome criteria and either refractory hypotension or hyperlactatemia. The proportion of participants who would have met the Sepsis-3 criteria for quick Sequential Organ Failure Assessment (qS0FA) score, sepsis (an increased Sequential Organ Failure Assessment score >= 2 because of infection) and septic shock before randomization, their baseline characteristics, interventions delivered, and mortality were determined. Results: There were 1,139 participants who had a qSOFA score of greater than or equal to 2 at baseline (71.6% [95% confidence interval [Cl) 69.4% to 73.8%]). In contrast, 1,347 participants (84.7% [95% CI 82.9% to 86.4%]) met the Sepsis-3 criteria for sepsis. Only 1,010 participants were both qSOFA positive and met the Sepsis-3 criteria for sepsis (63.5% [95% CI 61.1% to 65.8%]). The Sepsis-3 definition for septic shock was met at baseline by 203 participants (12.8% [95% CI 11.2% to 14.5%]), of whom 175 (86.2% [95% CI 81.5% to 91.0%]) were also qSOFA positive. Ninety-day mortality for participants fulfilling the Sepsis-3 criteria for sepsis and septic shock was 20.4% (95% CI 18.2% to 22.5%) (274/1,344) and 29.6% (95% CI 23.3% to 35.8% [60/203]) versus 9.4% (95% CI 5.8% to 13.1%) (23/244) and 17.1% (95% CI 15.1% to 19.1% [237/1,388]), respectively, for participants not meeting the criteria (risk differences 11.0% [95% CI 6.2% to 14.8%] and 12.5% [95% CI 6.3% to 19.4%], respectively). Conclusion: Most ARISE participants did not meet the Sepsis-3 definition for septic shock at baseline. However, the majority fulfilled the new sepsis definition and mortality was higher than for participants not fulfilling the criteria. A quarter of participants meeting the new sepsis definition did not fulfill the qSOFA screening criteria, potentially limiting its utility as a screening tool for sepsis trials with patients with suspected infection in the ED. The implications of the new definitions for patients not eligible for recruitment into the ARISE trial are unknown.

To determine factors independently associated with readmission to ICU and the independent association of readmission with subsequent mortality.Prospective multicenter observational study.Forty ICUs in Australia and New Zealand.Consecutive adult patients discharged alive from ICU to hospital wards between September 2009 and February 2010.Measurement of hospital mortality.We studied 10,210 patients and 674 readmissions. The median age was 63 years (interquartile range, 49-74), and 6,224 (61%) were male. The majority of readmissions were unplanned (84.1%) but only deemed preventable in a minority (8.9%) of cases. Time to first readmission was shorter for unplanned than planned readmission (3.2 vs 6.9 d; p0.001). Primary diagnosis changed between admission and readmission in the majority of patients (60.2%) irrespective of planned (58.2%) or unplanned (60.6%) status. Using recurrent event analysis incorporating patient frailty, we found no association between readmissions and hospital survival (hazard ratios: first readmission 0.88, second readmission 0.90, third readmission 0.44; p0.05). In contrast, age (hazard ratio, 1.03), a medical diagnosis (hazard ratio, 1.43), inotrope use (hazard ratio, 3.47), and treatment limitation order (hazard ratio, 17.8) were all independently associated with outcome.In this large prospective study, readmission to ICU was not an independent risk factor for mortality.

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.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.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.Adherence to low tidal volume ventilation.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.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.

OBJECTIVES Measurement of central venous oxygen (SvO2) levels remains an important method for the detection of circulatory shock. Plastic blood gas syringes have supplanted glass. These syringes are, however, permeable to atmospheric oxygen. Common sampling practices, including a delay between blood aspiration and analysis and continuous mixing of the sample, may promote equilibration of the blood sample with atmospheric oxygen and could result in over estimation of SvO2 levels. METHODS Pulmonary artery or central venous catheter blood samples were taken from 21 critically ill patients. Two venous blood gas samples were collected simultaneously in plastic syringes. One sample was continuously mixed through a gentle rotation. The other sample was not mixed. Blood gas analyses were undertaken on both samples at baseline and at 5, 10, 15, and 20 min. RESULTS Compared with baseline levels, the SvO2 increased significantly over time for both continuously mixed and nonmixed samples (P

Background The background of the study is a comparison of risk-adjusted mortality across hospitals from different jurisdictions is now common worldwide. Aim To examine temporal trends in risk-adjusted mortality in Victoria over the last decade. Methods Retrospective cohort study of 6.89 million adult (>14 years) patient episodes from 23 major Victorian public hospitals between 1999 and 2009. The primary outcome was in-hospital death. Three measures were calculated: the crude mortality rate, risk-adjusted mortality rate and standardised mortality ratio (SMR). The Hospital Outcome Prediction Equation (HOPE) was applied to generate estimates of predicted mortality that were used to compute the SMR and risk-adjusted mortality rates. The HOPE model includes 26 exogenous risk factors for which providers have no influence. The model was calibrated using the 2004–2005 data. Temporal mortality trends from 1999–2009 were evaluated using negative binomial regression for crude mortality and SMR estimates and random-intercept hierarchical logistic regression for risk-adjusted mortality. Results The study population included 84 423 in-hospital deaths (1.2%). Crude mortality risk declined from 1.5% in 2000 to 1.1% in 2005–2009 (incidence rate ratio (IRR): 0.96; 95% confidence interval (CI): 0.95–0.97; P < 0.001). There were 1.39 million episodes in the HOPE calibration cohort. Between 1999 and 2009, the SMR decreased from 1.4 to 0.9 (IRR = 0.91; 95% CI: 0.90–0.97; P < 0.001) and adjusted mortality risk declined from 2.1% to 0.9% (odds ratio = 0.94, 95% CI: 0.94–0.94, P < 0.001). Declining mortality trends were evident in the tertiary, metropolitan and regional peer groups (P < 0.001). Conclusion Analysis of in-hospital risk-adjusted mortality trends using the HOPE model indicates significant improvement in patient outcomes in the State of Victoria over the past decade.

BACKGROUND: Bleeding into the chest is a life-threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function. STUDY DESIGN AND METHODS: We undertook a multivariate logistic regression analysis of the risk factors associated with mortality in 2599 consecutive patients undergoing cardiac surgery. Unlike previous studies the risk factors examined included the volume of chest tube drainage at 24 hours. A stratified analysis was also undertaken that compared the adjusted risk of death for patients exposed or not exposed to a postoperative blood transfusion. RESULTS: Blood transfusion was not an independent predictor of mortality (p = 0.4). Chest tube drainage was the strongest independent predictor of mortality (p

To determine the epidemiology, in-hospital mortality, trends, patient characteristics and predictors of intensive care unit (ICU) readmission in Australia.A retrospective longitudinal study of data for 38 Australian ICUs extracted from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS-ADP) for the years 2000-2007. Demographic, diagnostic, physiological and outcome data were analysed. A multivariate model was constructed to identify risk factors for ICU readmission. Outcomes examined included observed and risk-adjusted in-hospital mortality.A total of 247,103 patients were discharged alive from their first ICU admission; 13,598 (5.5%) were readmitted at least once. Variables associated with an odds ratio greater than 1.05 for readmission (p0.001) were an initial ICU admission source other than elective surgery, any chronic health variable on severity scoring, tertiary hospital ICU and discharge between 6 p.m. and 6 a.m. Five initial diagnoses were associated with an odds ratio (OR) greater than 2 for readmission (p0.001). In-hospital mortality in readmitted patients was 20.7% compared with 4.4% in those not readmitted. Readmission rates have not changed over the study period. After adjustment for illness severity and readmission propensity, ICU readmission remained significantly associated with in-hospital mortality (OR 5.4, 95%, confidence interval (CI) 5.1-5.7).Many risk factors for increased ICU readmission were identified in this study including ICU discharge between 6 p.m. and 6 a.m. This was the only modifiable variable studied. Prospective studies are required to identify other factors and to determine whether interventions may reduce ICU readmission and its high associated in-hospital mortality.

OBJECTIVE To describe the relationship between clinical practice and national guidelines for the transfusion of red blood cells (RBCs), fresh frozen plasma (FFP), platelets, and cryoprecipitate in Australian and New Zealand intensive care units (ICUs). SETTING Forty-seven ICUs over a 5-week period from August to September 2008. DESIGN Prospective, observational, multicentre, cohort study. PATIENTS A total of 874 patients receiving any type of blood transfusion. METHODS All patients who were transfused at least one unit of any blood component were included. Patient-specific and blood-component specific data were gathered. Pre-transfusion haemoglobin, platelet count, international normalised ratio (INR), and fibrinogen levels were compared to national guidelines. RESULTS Of all 874 patients, 757 received RBCs (86.6%), 231 (26.4%) received platelets, 340 (38.9%) received FFP, and 78 (8.9%) received cryoprecipitate. Bleeding was the reason for administration of RBCs in 46%, FFP in 55%, and platelets in 47% of transfusions. The mean (SD) pre-transfusion haemoglobin was 77.6 (9.5) g/l, while the geometric means (95% CI) for platelet count, INR, and fibrinogen were 67.0 (59.7-75.3) x 10(9)/l, 1.84 (1.76-1.93), and 1.4 (1.1-1.8) g/l, respectively. The proportions of transfusions not adherent to guidelines were 2% for RBC, but 53% for platelets, 29% for FFP, and 88% for cryoprecipitate (RBC vs. other transfusion p < 0.001 for all). CONCLUSIONS Transfusion practice of RBCs in Australian and New Zealand ICUs is restrictive and is concordant with guidelines. However, the transfusion of other blood components is not.

To determine the long-term impact of a medical emergency team on survival and to assess the utility of administrative data to monitor outcomes.Prospective study of cardiac arrests and survival. Retrospective study of administrative data.University affiliated tertiary referral hospital in Melbourne, Australia.All patients admitted to hospital in three 6-month periods between 2002-2007 (prospective) and 1993-2007 (retrospective).Implementation of a medical emergency team in November 2002.In the prospective analysis, rates of unexpected cardiac arrest and hospital mortality (referenced to 1000 patient-care days) were measured before (July-August 2002) and after (December 2002-May 2003, December 2004-May 2005, December 2006-May 2007) the introduction of the medical emergency team. Cardiac arrest rates decreased progressively from 0.78 per 1000 (95% confidence interval, 0.50-1.16) to 0.25 per 1000 (95% confidence interval, 0.15-0.39, p.001), and hospital mortality from 0.58 per 1000 (95% confidence interval, 0.35-0.92) to 0.30 per 1000 (95% confidence interval, 0.20-0.46, p.05); cardiac arrest rates achieved statistical significance at 2 yrs and hospital mortality at 4 yrs. Using administrative data adjusted for age, sex, case-mix, and comorbidity, hazard ratios for mortality for the three post implementation periods were statistically lower than for the 10 yrs pre implementation (0.85, 0.74, 0.65). The intensity of calling (calls/1000 patient-days) inversely correlated with cardiac arrest rate, unexpected mortality rate, and total hospital mortality rate.The introduction of a medical emergency team was associated with a progressive decline of unexpected cardiac arrests within 2 yrs, and of unexpected mortality within 4 yrs. This suggests that changes to organizational practice take time and benefits may not be immediately obvious. Such changes are reflected in total hospital mortality measured from administrative data and make monitoring simpler in the longer term. Finally, efforts to increase calling of emergency teams should reduce cardiac arrests and mortality.

Background: The aim of this study was to validate a risk-adjusted hospital outcome prediction equation (HOPE) using a statewide administrative dataset. Methods: Retrospective observational study using multivariate logistic regression modelling. Calibration and discrimination were assessed by standardized mortality ratio (SMR), area under the receiver operating characteristic plot (ROC AUC), Hosmer–Lemeshow contingency tables and goodness-of-fit statistic in an independent dataset, and in all 23 important tertiary, metropolitan and regional hospitals. The dependent variable was in-hospital death. All consecutive adult hospital separations between 1 July 2004 and 30 June 2006, excluding obstetric and day-case only admissions, from all acute health services within the State of Victoria, Australia were included. Results: A total of 379 676 consecutive records (1 July 2004 to 30 June 2005) was used to derive the HOPE model. Six variables (age, male sex, admission diagnosis, emergency admission, aged-care resident and inter-hospital transfer) were selected for inclusion in the final model. It was validated in the 384 489 consecutive records from the following year (1 July 2005 to 30 June 2006). The 95% confidence interval for the SMR was 0.98–1.02, and for the ROC AUC, 0.87–0.88. Discrimination and (one or more) calibration criteria were achieved in 22 (96%) of the 23 hospitals. Conclusion: The HOPE model is a simple risk-adjusted outcome prediction tool, based on six variables from data that are routinely collected for administrative purposes and appears to be a reliable predictor of hospital outcome.

Introduction In this study, we aimed to examine the association between paracetamol administration in the intensive care unit (ICU) and mortality in critically ill patients. Methods We conducted a multicenter retrospective observational study in four ICUs. We obtained information on paracetamol use, body temperature, demographic, clinical and outcome data from each hospital’s clinical information system and admissions and discharges database. We performed statistical analysis to assess the association between paracetamol administration and hospital mortality. Results We studied 15,818 patients with 691,348 temperature measurements at 4 ICUs. Of these patients, 10,046 (64%) received at least 1 g of paracetamol. Patients who received paracetamol had lower in-hospital mortality (10% vs. 20%, P P P P P P Conclusions Paracetamol administration is common in the ICU and appears to be independently associated with reduced in-hospital mortality and time to death after adjustment for multiple potential confounders and propensity score. This association, however, was modified by the presence of fever, suspected infection and lesser illness severity and may represent the effect of indication bias.

We hypothesise that there exists a substantial and growing group of "persistently critically ill" patients who appear to be intensive care unit-dependent because of a cascade of critical illnesses rather than their original ICU admitting diagnosis. These persistently critically ill patients are those who remain in the ICU because of ongoing complications of care that continue after their reason for admission has been treated and is no longer active. We believe such patients can be distinguished from patients currently labelled as "chronic critical illness" or "prolonged mechanical ventilation". We further believe that their primary problem is not simply failure to wean from mechanical ventilation due to muscle weakness and impaired gas exchange. We outline a program of clinician consultation, epidemiological research, consensus conference and validation to develop a useful definition of persistent critical illness, with the aim of supporting investigations in preventing persistence, and improving the care of patients so affected.

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.To determine adherence to LTVV in patients on mechanical ventilation (MV).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.Analysis of mandatory MV with volume or pressure control.Adherence to LTVV (_6.5 mL/ kg predicted body weight [PBW]).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 PaO2/FiO2 ratio.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.

Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic.To determine factors independently associated with mortality after ICU discharge.This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010.We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49-74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3-25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00-18:00) and 1,672 (16.4%) after-hours (18:00-06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5-45.6).In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.

As a clinical indicator, unplanned admission to the Intensive Care Unit from the operating room has been thought to reflect the quality of anaesthesia care intraoperatively. To explore this concept, we examined all such admissions at three hospitals over a three-month period. Cases were classified according to the Victorian Consultative Council on Anaesthetic Mortality and Morbidity (VCCAMM) classification system and an assessment was made as to whether the admission was inevitable or not. Demographic data were collected as well as co-morbidities, severity of illness, length of stay, discharge functional status and destination. There were 165 admissions identified: 55.8% were male, the median age was 63.5 years (range 15–90). There were 24 in-hospital deaths: 151 patients suffered serious morbidity or mortality. In 32 patients (19.4%), the morbidity or mortality was considered at least partially anaesthetic-related, and in 20 (12.1 %), under the control of the anaesthetist. There were 28 admissions (17.0%) with a further 9 anaesthetic-related admissions (5.5%) which were considered potentially avoidable. Avoidable anaesthetic-related admissions were due to drug overdosage (5 cases), drug error (1 case), problems relating to preoperative assessment (1 case), aspiration (1 case) and pulmonary oedema (1 case). These findings suggest that unplanned admission to the Intensive Care Unit from the operating room is not a satisfactory indicator of quality of care by the anaesthesia team. This indicator appears to represent mainly the surgical and medical conditions of the patients, and their complications. Only one in twenty unplanned admissions in this series were potentially avoidable due to complications of the anaesthetic or the postoperative analgesia.

BACKGROUND AND OBJECTIVE Salbutamol (SAL) has systemic effects that may adversely influence ventilation in asthmatic patients. The authors sought to determine the magnitude of this effect and mechanisms by which i.v. SAL affects ventilation. METHODS A prospective study of nine healthy subjects (eight men, one woman; age 23 +/- 1.4 years (SD)) was undertaken. Each subject received i.v. SAL at 5, 10 and 20 microg/min each for 30 min at each dose and was observed for 1 h post infusion. Minute ventilation ((VE)), oxygen consumption (VO(2)), CO(2) production (VCO(2)), occlusion pressure (P(0.1)), heart rate, blood pressure, respiratory rate, glucose, arterial blood gases, lactate and potassium (K(+)) were recorded at baseline and at 30-min intervals. The effect of 100% oxygen on (VE) and P(0.1) during SAL infusion at 20 microg/min was observed. Results are expressed as mean +/- SEM. RESULTS V(E) was significantly increased at 20 microg/min SAL (37.8 +/- 12.1%, P = 0.01), as were VO(2) (22.5 +/- 5.1%, P < 0.01) and VCO(2) (40.9 +/- 10.6%, P < 0.01). Ventilation was in excess of metabolic needs as demonstrated by a rise in the respiratory exchange ratio (0.87 +/- 0.03 to 0.99 +/- 0.04, P < 0.05). Serum lactate rose by 124 +/- 30.4% from baseline to 20 microg/min (1.1 +/- 0.1 to 2.3 +/- 0.25 mmol/L, P < 0.01) and base excess decreased (0.89 +/- 0.56 to vs. -1.75 +/- 0.52 mmol/L, P < 0.01) consistent with a lactic acidosis contributing to the excess ventilation. There was no significant differences in (VE) or P(0.1) with F(I)O(2) = 1.0, suggesting peripheral chemoreceptor stimulation was not responsible for the rise in (VE). At 20 microg/min SAL, K(+) fell significantly from baseline (3.8 +/- 0.06 to 2.8 +/- 0.09 mmol/L, P < 0.001). CONCLUSION Systemic SAL imposes ventilatory demands by increasing metabolic rate and serum lactate. This may adversely affect patients with severe asthma with limited ventilatory reserve.

To investigate the pathophysiology underlying raised lactate levels after cardiac surgery with cardiopulmonary bypass (CPB).Prospective observational study.Medical and surgical intensive care unit of a tertiary hospital.A total of 40 patients undergoing first-time coronary artery bypass grafting with CPB.The prothrombotic response to cardiac surgery with CPB was assessed by measuring plasma levels of prothrombin fragment 1 + 2 and plasminogen activator inhibitor (PAI) activity. The hemodynamic responses to cardiac surgery with CPB were also measured using standard techniques.After cardiac surgery, prothrombin fragment 1 + 2 levels increased 6-fold and PAI activity increase 2- to 3-fold (p.0001). Lactate levels were not associated with prothrombin fragment 1 + 2 and PAI activity levels after CPB. Lactate levels were associated with baseline PAI activity (p =.006), a history of hypertension (p =.02), raised baseline lactate levels (p =.02), an early increase in body temperature after CPB (p =.05), a late increase in oxygen consumption after CPB (p =.03), and a raised white cell count after CPB (p =.06). Lactate levels were inversely associated with the maximum activated clotting time level reached during CPB (p =.02). Multivariate linear regression demonstrated lactate levels were independently associated with baseline PAI activity.We found cardiac surgery with CPB was associated with a marked prothrombotic response. Lactate levels were associated with elevated baseline PAI activity and evidence of an amplified inflammatory response to cardiac surgery with CPB. Our findings implicate aspects of the inflammatory response, including microvascular thrombosis, in the development of raised lactate levels after cardiac surgery with CPB.

Community studies have demonstrated suboptimal achievement of lipid targets in the management of patients with coronary heart disease (CHD). An effective strategy is required for the application of evidence-based prevention therapy for CHD. The objective of this study was to test coaching as a technique to assist patients in achieving the target cholesterol level of

Aim: To retrospectively study 26 patients with squamous cell carcinoma (SCC) of the ocular surface to determine pathological and clinical characteristics of tumour associated with outcome. Methods: Patients with conjunctival SCC from St Vincent9s Hospital and the private ophthalmology practices of the authors were reviewed. Results: Patents were usually male (77%), elderly (69% > 60 years of age), with most lesions (81%) occurring at the limbus. Seven patients (27%) suffered recurrent ocular surface squamous neoplasia (OSSN) within 4–15 months and two of these patients (8%) died of metastatic disease. Intraocular invasion was noted in three patients (11%), while corneal and/or scleral invasion was found in eight (30%). Orbital invasion was noted in four patients (15%). Six required orbital exenteration. Preoperative impression cytology of five patients with minimally invasive disease showed OSSN in four (80%). In situ carcinoma could not be differentiated from minimally invasive disease using impression cytology. Preoperative diagnosis of SCC was made in 35% of cases. Clinical accuracy was higher for larger lesions (>10 mm) and those with hyperkeratosis. Conclusions: Conjunctival SCC occurs in sun damaged ocular surface, usually at the limbus in elderly men. Recurrence of OSSN is common with significantly increased risk for older patients, lesions of large diameter, high proliferation index (Ki-67 score), and positive surgical margins. Orbital exenteration may be required for control of local disease and death from metastatic disease occurs in a small percentage of patients.

Objectives There has been renewed interest in lactate as a risk biomarker in sepsis and septic shock. However, the ability of the odds ratio (OR) and change in the area under the receiver operator characteristic curve (AUC-ROC) to assess biomarker added-value has been questioned. Design, setting and participants A sepsis cohort was identified from the ICU database of an Australian tertiary referral hospital using APACHE III diagnostic codes. Demographic information, APACHE III scores, 24-hour post-admission patient lactate levels, and hospital mortality were accessed. Measurements and main results Hospital mortality was modelled using a base predictive logistic regression model and sequential addition of admission lactate, lactate clearance ([lactateadmission—lactatefinal]/lactateadmission), and area under the lactate-time curve (LTC). Added-value was assessed using lactate index OR; AUC-ROC difference (base-model versus lactate index addition); net (mortality) reclassification index (NRI; range -2 to +2); and net benefit (NB), the number of true positives per patient adjusted for the number of false positives. The data set comprised 717 patients with mean(SD) age and APACHE III score 61.1(16.5) years and 68.3(28.2) respectively; 59.2% were male. Admission lactate was 2.3(2.5) mmol/l; with lactate of ≥ 4 mmol/L (37% hospital mortality) in 17% and patients with lactate < 4 mmol/L having 18% hospital mortality. The admission base-model had an AUC-ROC = 0.81 with admission lactate OR = 1.127 (95%CI: 1.038, 1.224), AUC-ROC difference of 0.0032 (-0.0037, 0.01615; P = 0.61), and NRI 0.240(0.030, 0.464). The over-time model had an AUC-ROC = 0.86 with (i) clearance OR = 0.771, 95%CI: 0.578, 1.030; P = 0.08; AUC-ROC difference 0.001 (-0.003, 0.014; P = 0.78), and NRI 0.109(-0.193, 0.425) and (ii) LTC OR = 0.997, 95%CI: 0.989, 1.005, P = 0.49; AUC-ROC difference 0.004 (-0.002, 0.004; P = 0.34), and NRI 0.111(-0.222, 0.403). NB was not incremented by any lactate index. Conclusions Lactate added-value assessment is dependent upon the performance of the underlying predictive model and should incorporate risk reclassification and net benefit measures.