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Background: The relationship between body mass index (BMI) and outcomes in the acute care setting is controversial, with evidence suggesting that obesity is either protective - which is also called obesity paradox - or associated with worse outcomes. The purpose of this study was to assess whether BMI was related to frailty and biological age, and whether BMI remained predictive of mortality after adjusting for frailty and biological age., Subjects: Of the 2950 patients who had a biological age estimated on admission to the intensive care unit, 877 (30 %) also had BMI and frailty data available for further analysis in this retrospective cohort study., Methods: Biological age of each patient was estimated using the Levine PhenoAge model based on results of nine blood tests that were reflective of DNA methylation. Biological age in excess of chronological age was then indexed to the local study context by a linear regression to generate the residuals. The associations between BMI, clinical frailty scale, and the residuals were first analyzed using univariable analyses. Their associations with mortality were then assessed by multivariable analysis, including the use of a 3-knot restricted cubic spline function to allow non-linearity., Results: Both frailty (p = 0.003) and the residuals of the biological age (p = 0.001) were related to BMI in a U-shaped fashion. BMI was not related to hospital mortality, but both frailty (p = 0.015) and the residuals of biological age (OR per decade older than chronological age 1.50, 95 % confidence interval [CI] 1.04-2.18; p = 0.031) were predictive of mortality after adjusting for chronological age, diabetes mellitus and severity of acute illness., Conclusions: BMI was significantly associated with both frailty and biological age in a U-shaped fashion but only the latter two were related to mortality. These results may, in part, explain why obesity paradox could be observed in some studies., Competing Interests: Declaration of Competing Interest The author, A/Prof Kwok Ming Ho, has no financial and non-financial conflict of interest to declare in relation to the subject matter discussed in this manuscript – Associations between body mass index, frailty and biological age in the critically ill., (Crown Copyright © 2024. Published by Elsevier Ltd. All rights reserved.)

Biological age is increasingly recognized as being more accurate than chronological age in determining chronic health outcomes. This study assessed whether biological age, assessed on intensive care unit (ICU) admission, can predict hospital mortality. This retrospective cohort study, conducted in a tertiary multidisciplinary ICU in Western Australia, used the Levine PhenoAge model to estimate each patient's biological age (also called PhenoAge). Each patient's PhenoAge was calibrated to generate a regression residual which was equivalent to biological age unexplained by chronological age in the local context. PhenoAgeAccel was a dichotomized measure of the residuals, and its presence suggested that one was biologically older than the corresponding chronological age. Of the 2950 critically ill adult patients analyzed, 291 died (9.9%) before hospital discharge. Both PhenoAge and its residuals (after regressing on chronological age) had a significantly better ability to differentiate between hospital survivors and non-survivors than chronological age (area under the receiver-operating-characteristic curve 0.648 and 0.654 vs. 0.547 respectively). Being phenotypically older than one's chronological age was associated with an increased risk of mortality (PhenoAgeAccel hazard ratio [HR] 1.997, 95% confidence interval [CI] 1.568-2.542; p = 0.001) in a dose-related fashion and did not reach a plateau until at least a 20-year gap. This adverse association remained significant (adjusted HR 1.386, 95% CI 1.077-1.784; p = 0.011) after adjusted for severity of acute illness and comorbidities. PhenoAgeAccel was more prevalent among those with pre-existing chronic cardiovascular disease, end-stage renal failure, cirrhosis, immune disease, diabetes mellitus, or those treated with immunosuppressive therapy. Being phenotypically older than one's chronological age was more common among those with comorbidities, and this was associated with an increased risk of mortality in a dose-related fashion in the critically ill that was not fully explained by comorbidities and severity of acute illness., (© 2023. Crown.)

Background: Persistent critical illness is common in critically ill patients and is associated with vast medical resource use and poor clinical outcomes. This study aimed to define when patients with sepsis would be stabilized and transitioned to persistent critical illness, and whether such transition time varies between latent classes of patients., Methods: This was a retrospective cohort study involving sepsis patients in the eICU Collaborative Research Database. Persistent critical illness was defined at the time when acute physiological characteristics were no longer more predictive of in-hospital mortality (i.e., vital status at hospital discharge) than antecedent characteristics. Latent growth mixture modeling was used to identify distinct trajectory classes by using Sequential Organ Failure Assessment score measured during intensive care unit stay as the outcome, and persistent critical illness transition time was explored in each latent class., Results: The mortality was 16.7% (3828/22,868) in the study cohort. Acute physiological model was no longer more predictive of in-hospital mortality than antecedent characteristics at 15 days after intensive care unit admission in the overall population. Only a minority of the study subjects (n = 643, 2.8%) developed persistent critical illness, but they accounted for 19% (15,834/83,125) and 10% (19,975/198,833) of the total intensive care unit and hospital bed-days, respectively. Five latent classes were identified. Classes 1 and 2 showed increasing Sequential Organ Failure Assessment score over time and transition to persistent critical illness occurred at 16 and 27 days, respectively. The remaining classes showed a steady decline in Sequential Organ Failure Assessment scores and the transition to persistent critical illness occurred between 6 and 8 days. Elevated urea-to-creatinine ratio was a good biochemical signature of persistent critical illness., Conclusions: While persistent critical illness occurred in a minority of patients with sepsis, it consumed vast medical resources. The transition time differs substantially across latent classes, indicating that the allocation of medical resources should be tailored to different classes of patients.

Purpose: Using urinary indices as a quick bedside test to assist management of oliguria and acute kidney injury (AKI) has long been sought. This study assessed whether urinary potassium excretion is related to simultaneously calculated creatinine clearance (CrCl) and can predict AKI in the critically ill., Materials and Methods: In this prospective cohort study, the correlation between 2-h urinary potassium excretion and simultaneously calculated CrCl of 61 critically ill patients was assessed by Pearson's correlation coefficient, and their ability to predict AKI (≥stage 1 KDIGO) in the subsequent 7 days was assessed by area under the receiver-operating-characteristic (AUROC) curve., Results: Urinary potassium excretion (median 6.2 mmol, range 0.8-24.3) correlated linearly with CrCl (correlation coefficient: 0.58, 95% confidence interval [CI] 0.38-0.72; p = 0.001), and had a moderate ability to predict subsequent AKI (n = 19 [31%]; AUROC 0.747, 95%CI 0.620-0.850; p = 0.001), especially in patients without prior exposure to furosemide within 24-h (correlation coefficient 0.61, 95%CI 0.41-0.76; AUROC 0.789, 95%CI 0.654-0.890; p = 0.001, respectively)., Conclusions: Urinary potassium excretion correlates with CrCl and predicts AKI in the critically ill without recent furosemide exposure. Given 2-h urinary potassium excretion can be measured easily, its potential as a marker of renal function deserves further study., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: This study compared the performance of 3 admission prognostic scores in predicting hospital mortality., Materials and Methods: Patient admission characteristics and hospital outcome of 9549 patients were recorded prospectively. The discrimination and calibration of the predicted risks of death derived from the Simplified Acute Physiology Score (SAPS III), Admission Mortality Prediction Model (MPM0 III), and admission Acute Physiology and Chronic Health Evaluation (APACHE) II were assessed by the area under the receiver operating characteristic curve and a calibration plot, respectively., Measurements and Main Results: Of the 9549 patients included in the study, 1276 patients (13.3%) died after intensive care unit admission. Patient admission characteristics were significantly different between the survivors and nonsurvivors. All 3 prognostic scores had a reasonable ability to discriminate between the survivors and nonsurvivors (area under the receiver operating characteristic curve for SAPS III, 0.836; MPM0 III, 0.807; admission APACHE, 0.845), with best discrimination in emergency admissions. The SAPS III model had a slightly better calibration and overall performance (slope of calibration curve, 1.03; Brier score, 0.09; Nagelkerke R(2), 0.297) compared to the MPM0 III and admission APACHE II model., Conclusions: All 3 intensive care unit admission prognostic scores had a good ability to predict hospital mortality of critically ill patients, with best discrimination in emergency admissions., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: It is uncertain whether bariatric surgery can be safely performed in secondary hospitals without on-site intensive care unit (ICU) support. This study describes the outcomes of elective bariatric surgery patients who required inter-hospital transfers for unplanned ICU management, extrapolating this as a parameter for secondary hospital safety after bariatric surgery., Methods: This was a retrospective, statewide, population-based, linked data cohort study capturing all adult bariatric surgery patients for an entire Australian state between 2007 and 2011 (n = 12,062) with minimum 12-month follow-up., Results: In secondary hospitals, 2663 (22.1%) bariatric patients were operated on, with the majority (n = 2553) undergoing sleeve gastrectomies (SG) or adjustable gastric bands (LAGB). Forty-two patients (including 19 LAGB and 20 SG) required inter-hospital transfer to a tertiary hospital for unplanned ICU care (1.6%, 95% confidence interval 1.2-2.1), mainly due to surgical complications. Inter-hospital transfers incurred two deaths, both following sleeve gastrectomies. When compared to patients requiring unplanned ICU admissions after bariatric surgery in tertiary hospitals with an on-site ICU (n = 155), there was no difference in their demographic parameters, comorbid illnesses, or mortality (4.8 vs 3.9%, p = 0.68). The mortality following bariatric procedures both statewide (0.2%) and in secondary hospitals (0.2%) was both uncommon and comparable., Conclusions: Statewide inter-hospital transfers for unplanned ICU care from secondary hospitals were low. Inter-hospital transfer mortality was comparable to a similar bariatric cohort requiring unplanned ICU care after surgery in a tertiary hospital. This suggests that certain bariatric procedures can be safely done in most secondary hospitals where elective ICU admission is deemed unnecessary.

Background: A multidisciplinary bariatric surgical approach is currently the most effective treatment for obesity. However, little is known about how the physiologic impact of weight reduction surgery superimposed on premorbid obesity-related co-morbidities may adversely influence perioperative renal function., Methods: This observational, multicenter study investigated all bariatric surgery patients (n = 590) admitted to any intensive care unit (ICU) in Western Australia between 2007 and 2011. Using Acute Kidney Injury Network (AKIN) criteria, we ascertained the incidence and contributing risk factors for acute kidney injury (AKI)., Results: Acute kidney injury (AKI) occurred in 103 patients, accounting for 17.5% of all ICU admissions after bariatric surgery with 76.8% of the AKI episodes limited to AKIN stage 1. In a multivariate analysis, male gender, premorbid hypertension, higher admission APACHE II scores, and blood transfusions were all associated with AKI, while preexisting chronic kidney disease and body mass index (BMI) appeared not to influence renal decline. Both ICU (6.7 versus 2.5 d, P<.001) and hospital (18.6 versus 6.8 d, P<.001) length of stays were significantly increased after AKI. Six patients required hemodialysis while both ICU mortality (2.9 versus 0%, P = .005) and long-term mortality (18.2 versus 4.7 deaths per 1000 bariatric patient-yr, P = .01) were greater in patients experiencing AKI., Conclusions: AKI is common in bariatric patients requiring critical care support leading to increased healthcare utilization, prolonged hospitalization, and is associated with a higher mortality. BMI, a previously described risk factor, was not predictive of AKI in this cohort., (Copyright © 2015 American Society for Bariatric Surgery. Published by Elsevier Inc. All rights reserved.)

Rationale: Intensive care unit (ICU) patients undergo several diagnostic and therapeutic procedures every day. The prevalence, intensity, and risk factors of pain related to these procedures are not well known., Objectives: To assess self-reported procedural pain intensity versus baseline pain, examine pain intensity differences across procedures, and identify risk factors for procedural pain intensity., Methods: Prospective, cross-sectional, multicenter, multinational study of pain intensity associated with 12 procedures. Data were obtained from 3,851 patients who underwent 4,812 procedures in 192 ICUs in 28 countries., Measurements and Main Results: Pain intensity on a 0-10 numeric rating scale increased significantly from baseline pain during all procedures (P < 0.001). Chest tube removal, wound drain removal, and arterial line insertion were the three most painful procedures, with median pain scores of 5 (3-7), 4.5 (2-7), and 4 (2-6), respectively. By multivariate analysis, risk factors independently associated with greater procedural pain intensity were the specific procedure; opioid administration specifically for the procedure; preprocedural pain intensity; preprocedural pain distress; intensity of the worst pain on the same day, before the procedure; and procedure not performed by a nurse. A significant ICU effect was observed, with no visible effect of country because of its absorption by the ICU effect. Some of the risk factors became nonsignificant when each procedure was examined separately., Conclusions: Knowledge of risk factors for greater procedural pain intensity identified in this study may help clinicians select interventions that are needed to minimize procedural pain. Clinical trial registered with www.clinicaltrials.gov (NCT 01070082).

Purpose: Patients who survive an episode of critical illness continue to experience significant mortality after hospital discharge. This study assessed the accuracy of physician prediction of 2-year mortality and compared it with 2 objective prognostic models., Methods: Sensitivity (probability of a prediction of death in patients who died within 2 years) and specificity (probability of a prediction of survival in patients who survived at least 2 years) of physicians' 2-year prediction were compared with those from 2 objective prognostic models, Acute Physiology and Chronic Health Evaluation (APACHE) II and Predicted Risk Existing Disease Intensive Care Therapy (PREDICT)., Results: Physician prediction of 2-year mortality was available for 2497 (94.8%) intensive care unit admissions. Specificity was high (85.2%; 95% confidence interval [CI], 83.7-86.4), but sensitivity (65.0%; 95% CI, 61.1-68.8) and positive predictive value (57.4%; 95% CI, 53.6-61.2) were relatively low, suggesting overpessimistic prediction of 2-year mortality. Age, Charlson comorbidity index, and APACHE score were independent risk factors for an inaccurate physician prediction. The diagnostic odds ratio for the physician predictions was at least comparable with the APACHE and PREDICT models, which both had very good discrimination of mortality at 2-year follow-up., Conclusions: Physicians tended to overpredict the risk of 2-year mortality of critically ill patients, but accuracy was comparable with 2 objective prognostic models., (Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.)

Purpose: The aim of this study is to assess the effect of comorbidities on risk of readmission to an intensive care unit (ICU) and the excess hospital mortality associated with ICU readmissions., Materials and Methods: A cohort study used clinical data from a 22-bed multidisciplinary ICU in a university hospital and comorbidity data from the Western Australian hospital morbidity database., Results: From 16,926 consecutive ICU admissions between 1987 and 2002, and 654 (3.9%) of these patients were readmitted to ICU readmissions within the same hospitalization. Patients with readmission were older, more likely to be originally admitted from the operating theatre or hospital ward, had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-predicted mortality, and had more comorbidities when compared with patients without readmission. The number of Charlson comorbidities was significantly associated with late readmission (>72 hours) but not early readmission (

Purpose: To assess the ability of potential clinical predictors and inflammatory markers to predict in-hospital mortality after patient discharge from the intensive care unit., Setting and Participants: 1272 patients who survived their index admission to a 22-bed multidisciplinary ICU of a university hospital in 2004., Design: Nested case-control study with two concurrent control patients for each case of post-ICU discharge in hospital mortality., Results: There were 29 unexpected in-hospital deaths after ICU discharge (2.3%). C-reactive protein (CRP) concentrations within 24 hours of ICU discharge were available for 14 of these 29 patients and 22 concurrent control patients. CRP concentration at ICU discharge was associated with subsequent mortality (mean CRP concentrations: cases, 204 mg/L v controls, 63 mg/L; P = 0.001). CRP concentration remained significantly associated with post-ICU mortality after adjustment with other potential predictors of mortality (odds ratio [OR] of death for a 10mg/L increase in CRP concentration, 1.27; 95% CI, 1.09-1.49; P = 0.005) and with propensity score (OR, 1.19; 95% CI, 1.05-1.33; P=0.004). The area under the receiver operating characteristic curve for CRP concentrations to predict in-hospital mortality was 0.87 (95% CI, 0.73-0.99; P=0.001). The destination and timing of ICU discharge, SOFA (Sequential Organ Failure Assessment) score, white cell count and fibrinogen concentration at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge., Conclusions: A high CRP concentration at ICU discharge is an independent predictor of subsequent in-hospital mortality. Prospective cohort studies in ICUs with different casemix, discharge criteria and post-ICU mortality rates are needed to validate and generalise our findings.

Background: Evidence prior to the coronavirus disease 2019 (COVID-19) pandemic suggested that, compared with conventional ventilation strategies, airway pressure release ventilation (APRV) can improve oxygenation and reduce mortality in patients with acute respiratory distress syndrome. We aimed to assess the association between APRV use and clinical outcomes among adult patients receiving mechanical ventilation for COVID-19 and hypothesized that APRV use would be associated with improved survival compared with conventional ventilation. Methods: A total of 25 patients with COVID-19 pneumonitis was admitted to intensive care units (ICUs) for invasive ventilation in Perth, Western Australia, between February and May 2020. Eleven of these patients received APRV. The primary outcome was survival to day 90. Secondary outcomes were ventilation-free survival days to day 90, mechanical complications from ventilation, and number of days ventilated. Results: Patients who received APRV had a lower probability of survival than did those on other forms of ventilation (hazard ratio, 0.17; 95% confidence interval, 0.03-0.89; P=0.036). This finding was independent of indices of severity of illness to predict the use of APRV. Patients who received APRV also had fewer ventilator-free survival days up to 90 days after initiation of ventilation compared to patients who did not receive APRV, and survivors who received APRV had fewer ventilator-free days than survivors who received other forms of ventilation. There were no differences in mechanical complications according to mode of ventilation. Conclusions: Based on the findings of this study, we urge caution with the use of APRV in COVID-19. [ABSTRACT FROM AUTHOR]

Background: Using three patient characteristics, including age, Injury Severity Score (ISS) and transfusion within 24 h of admission (yes vs. no), the Geriatric Trauma Outcome Score (GTOS) and Geriatric Trauma Outcome Score II (GTOS II) have been developed to predict mortality and unfavourable discharge (to a nursing home or hospice facility), of those who were ≥65 years old, respectively.Objectives: This study aimed to validate the GTOS and GTOS II models. For the nested-cohort requiring intensive care, we compared the GTOS scores with two ICU prognostic scores - the Acute Physiology and Chronic Health Evaluation (APACHE) III and Australian and New Zealand Risk of Death (ANZROD).Methods: All elderly trauma patients admitted to the State Trauma Unit between 2009 and 2019 were included. The discrimination ability and calibration of the GTOS and GTOS II scores were assessed by the area under the receiver-operating-characteristic (AUROC) curve and a calibration plot, respectively.Results: Of the 57,473 trauma admissions during the study period, 15,034 (26.2%) were ≥65 years-old. The median age and ISS of the cohort were 80 (interquartile range [IQR] 72-87) and 6 (IQR 2-9), respectively; and the average observed mortality was 4.3%. The ability of the GTOS to predict mortality was good (AUROC 0.838, 95% confidence interval [CI] 0.821-0.855), and better than either age (AUROC 0.603, 95%CI 0.581-0.624) or ISS (AUROC 0.799, 95%CI 0.779-0.819) alone. The GTOS II's ability to predict unfavourable discharge was satisfactory (AUROC 0.707, 95%CI 0.696-0.719) but no better than age alone. Both GTOS and GTOS II scores over-estimated risks of the adverse outcome when the predicted risks were high. The GTOS score (AUROC 0.683, 95%CI 0.591-0.775) was also inferior to the APACHE III (AUROC 0.783, 95%CI 0.699-0.867) or ANZROD (AUROC 0.788, 95%CI 0.705-0.870) in predicting mortality for those requiring intensive care.Conclusions: The GTOS scores had a good ability to discriminate between survivors and non-survivors in the elderly trauma patients, but GTOS II scores were no better than age alone in predicting unfavourable discharge. Both GTOS and GTOS II scores were not well-calibrated when the predicted risks of adverse outcome were high. [ABSTRACT FROM AUTHOR]

Purpose: ICU discharge is often delayed by a requirement for intravenous vasopressor medications to maintain normotension. We hypothesised that the administration of midodrine, an oral α1-adrenergic agonist, as adjunct to standard treatment shortens the duration of intravenous vasopressor requirement. Methods: In this multicentre, randomised, controlled trial including three tertiary referral hospitals in the US and Australia, we enrolled adult patients with hypotension requiring a single-agent intravenous vasopressor for ≥ 24 h. Subjects received oral midodrine (20 mg) or placebo every 8 h in addition to standard care until cessation of intravenous vasopressors, ICU discharge, or occurrence of adverse events. The primary outcome was time to vasopressor discontinuation. Secondary outcomes included time to ICU discharge readiness, ICU and hospital lengths of stay, and ICU readmission rates. Results: Between October 2012 and June 2019, 136 participants were randomised, of whom 132 received the allocated intervention and were included in the analysis (modified intention-to-treat approach). Time to vasopressor discontinuation was not different between midodrine and placebo groups (median [IQR], 23.5 [10–54] vs 22.5 [10.4–40] h; difference, 1 h; 95% CI − 10.4 to 12.3 h; p = 0.62). No differences in secondary endpoints were observed. Bradycardia occurred more often after midodrine administration (5 [7.6%] vs 0 [0%], p = 0.02). Conclusion: Midodrine did not accelerate liberation from intravenous vasopressors and was not effective for the treatment of hypotension in critically ill patients. [ABSTRACT FROM AUTHOR]

Blood gas analysers are point-of-care testing devices used in the management of critically ill patients. Controversy remains over the agreement between the results obtained from blood gas analysers and laboratory auto-analysers for haematological and biochemistry parameters. We conducted a prospective analytical observational study in five intensive care units in Western Australia, in patients who had a full blood count (FBC), urea, electrolytes and creatinine (UEC), and a blood gas performed within 1 h of each other during the first 24 h of their intensive care unit admission. The main outcome measure was to determine the agreement in haemoglobin, sodium, and potassium results between laboratory haematology and biochemistry auto-analysers and blood gas analysers. A total of 219 paired tests were available for haemoglobin and sodium, and 215 for potassium. There was no statistically significant difference between the results of the blood gas and laboratory auto-analysers for haemoglobin (mean difference -0.35 g/L, 95% confidence interval (CI) -1.20 to 0.51, P = 0.425). Although the mean differences between the two methods were statistically significant for sodium (mean difference 1.49 mmol/L, 95% CI 1.23-1.76, P < 0.0001) and potassium (mean difference 0.19 mmol/L, 95% CI 0.15-0.24, P < 0.0001), the mean biases on the Bland-Altman plots were small and independent of the magnitude of the measurements. The two methods of measurement for haemoglobin, sodium and potassium agreed with each other under most clinical situations when their values were within or close to normal range suggesting that routine concurrent blood gas and formal laboratory testing for haemoglobin, sodium and potassium concentrations in the intensive care unit is unwarranted. [ABSTRACT FROM AUTHOR]

Background: Road trauma is a leading cause of death and injury in young people. Traffic offences are common, but their importance as a risk indicator for subsequent road trauma is unknown. This cohort study assessed whether severe road trauma could be predicted by a history of prior traffic offences. Methodology and Principal Findings: Clinical data of all adult road trauma patients admitted to the Western Australia (WA) State Trauma Centre between 1998 and 2013 were linked to traffic offences records at the WA Department of Transport. The primary outcomes were alcohol exposure prior to road trauma, severe trauma (defined by Injury Severity Score >15), and intensive care admission (ICU) or death, analyzed by logistic regression. Traffic offences directly leading to the road trauma admissions were excluded. Of the 10,330 patients included (median age 34 years-old, 78% male), 1955 (18.9%) had alcohol-exposure before road trauma, 2415 (23.4%) had severe trauma, 1360 (13.2%) required ICU admission, and 267 (2.6%) died. Prior traffic offences were recorded in 6269 (60.7%) patients. The number of prior traffic offences was significantly associated with alcohol-related road trauma (odds ratio [OR] per offence 1.03, 95% confidence interval [CI] 1.02–1.05), severe trauma (OR 1.13, 95%CI 1.14–1.15), and ICU admission or death (OR 1.10, 95%CI 1.08–1.11). Drink-drinking, seat-belt, and use of handheld electronic device offences were specific offences strongly associated with road trauma leading to ICU admission or death—all in a ‘dose-related’ fashion. For those who recovered from road trauma after an ICU admission, there was a significant reduction in subsequent traffic offences (mean difference 1.8, 95%CI 1.5 to 2.0) and demerit points (mean difference 7.0, 95%CI 6.5 to 7.6) compared to before the trauma event. Significance: Previous traffic offences were a significant risk factor for alcohol-related road trauma and severe road trauma leading to ICU admission or death. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recombinant activated factor VII (rFVIIa) is widely used as an off-label rescue treatment for patients with nonhemophilic critical bleeding. STUDY DESIGN AND METHODS: Using data from the intensive care unit, transfusion service, and death registry, the long-term survival after using rFVIIa and the associated cost per life-year gained in a consecutive cohort of patients with critical bleeding requiring massive transfusion (≥10 red blood cell [RBC] units in 24 hr) were assessed. rFVIIa was only used as a lifesaving treatment when conventional measures had failed. RESULTS: Of the 353 patients with critical bleeding requiring massive transfusion, 81 (23%) required rFVIIa as a lifesaving rescue treatment. The patients requiring rFVIIa received a greater number of transfusions (number of units: RBCs, 18 vs. 12; fresh-frozen plasma, 16 vs. 10; platelets, 4 vs. 2; p < 0.001) and had a shorter survival time (24 months vs. 33 months; p = 0.002) than those who did not require rFVIIa. The total cost per life-year gained of massive transfusion and incremental cost of rFVIIa as a lifesaving treatment were US$1,148,000 (£711,760; 95% confidence interval [CI], US$825,000-US$1,471,000) and US$736,000 (£456,320; 95% CI, US$527,000-US$945,000), respectively. The incremental costs of rFVIIa increased with severity of illness and transfusion requirement and were greater than the usual acceptable cost-effective limit (

The article presents a study which aims to assess the association between omission of early thromboprophylaxis in less than 24 hours (h) after intensive care unit (ICU) admission and mortality in critically ill patients in Australia and New Zealand between 2006 and 2010. It notes that such association of concern issues remained significant after adjusting for other covariates particularly for patients with illnesses including multiple trauma, sepsis and cardiac arrest.

Purpose: It is uncertain whether smoking has an independent dose-related adverse effect on mortality in critically ill patients. This study assessed whether the intensity of smoking history, measured in pack-years, has a dose-related effect on mortality in critically ill patients. Methods: In this multicentre cohort study data were collected from six tertiary intensive care units (ICU) in Australia and New Zealand. Results: Of the 8,962 patients considered in the study, data on patients' smoking status and smoking history were available from 5,063 and 2,865 patients, respectively. Male gender, and chronic respiratory, liver and cardiovascular diseases were over-represented among smokers compared to non-smokers. Smokers had a higher risk of requiring mechanical ventilation and dying in hospital than non-smokers (10.7% vs. 6.7%, p = 0.001), particularly after emergency admission. Smokers also had a longer ICU stay than non-smokers (mean 3.2 days, interquartile range 0.8-3.2 vs. 2.8 days, interquartile range 0.8-2.9; p = 0.024). After adjusting for age, gender, elective surgical admission, severity of acute illness, and severe chronic illnesses, the intensity of smoking history remained significantly associated with the risk of dying in hospital. This was in a relatively linear fashion (odds ratio 1.08 per 10 pack-years increment, 95% confidence interval 1.02-1.15; p = 0.02). Further grouping of smokers into active smokers and ex-smokers, or including patients with unknown smoking status in the sensitivity analyses did not change the association between the intensity of smoking history and mortality. Conclusions: Smoking has a dose-related adverse effect on mortality of critically ill patients after adjusting for other confounders. [ABSTRACT FROM AUTHOR]

To assess the effects of using dexmedetomidine as a sedative and analgesic agent on length of intensive care unit (ICU) stay, duration of mechanical ventilation, risk of bradycardia, and hypotension in critically ill adult patients. Two researchers searched MEDLINE, EMBASE, and the Cochrane controlled trial register independently for randomized controlled trials comparing dexmedetomidine with a placebo or an alternative sedative agent, without any language restrictions. A total of 2,419 critically ill patients from 24 trials were subject to meta-analysis. Dexmedetomidine was associated with a significant reduction in length of ICU stay [weighted mean difference −0.48 days, 95% confidence interval (CI) −0.18 to −0.78 days, P = 0.002], but not duration of mechanical ventilation, when compared with an alternative sedative agent. There was, however, significant heterogeneity in these two outcomes between the pooled studies. Dexmedetomidine was associated with increased risk of bradycardia requiring interventions in studies that used both a loading dose and maintenance doses >0.7 μg kg−1 h−1 [relative risk (RR) 7.30, 95% CI 1.73–30.81, P = 0.007]. Risks of hypotension requiring interventions (RR 1.43, 95% CI 0.78–2.6, P = 0.25), delirium (RR 0.79, 95% CI 0.56–1.11, P = 0.18), self-extubation, myocardial infarction, hyperglycemia, atrial fibrillation, and mortality were not significantly different between dexmedetomidine and traditional sedative and analgesic agents. Significant heterogeneity existed between the pooled studies. The limited evidence suggested that dexmedetomidine might reduce length of ICU stay in some critically ill patients, but the risk of bradycardia was significantly higher when both a loading dose and high maintenance doses (>0.7 μg kg−1 h−1) were used. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to evaluate whether central venous oxygen saturation can be used as an alternative to mixed venous oxygen saturation in patients with cardiogenic and septic shock. Design: Prospective clinical study. Setting: A tertiary intensive care unit in a university hospital. Participants: Twenty patients with cardiogenic or septic shock requiring a pulmonary artery catheter and inotropic support. Interventions: None. Measurements and Main Results: The central venous oxygen saturation overestimated the mixed venous oxygen saturation by a mean bias (or an absolute difference) of 6.9%, and the 95% limits of agreement were large (−5.0% to 18.8%). The difference between central and mixed venous oxygen saturation appeared to be more significant when mixed venous oxygen saturation was <70%. The changes in central and mixed venous oxygen saturation did not follow the line of perfect agreement closely in different clinical conditions. The central or mixed venous oxygen saturation had a significant ability to predict the status of cardiac output state, but this ability was reduced when the effect of hyperoxia was not considered. Conclusion: Central and mixed venous oxygen saturation measurements are not interchangeable numerically. [Copyright &y& Elsevier]

Abstract: Purpose: The aim of this study is to assess the effect of comorbidities on risk of readmission to an intensive care unit (ICU) and the excess hospital mortality associated with ICU readmissions. Materials and Methods: A cohort study used clinical data from a 22-bed multidisciplinary ICU in a university hospital and comorbidity data from the Western Australian hospital morbidity database. Results: From 16 926 consecutive ICU admissions between 1987 and 2002, and 654 (3.9%) of these patients were readmitted to ICU readmissions within the same hospitalization. Patients with readmission were older, more likely to be originally admitted from the operating theatre or hospital ward, had a higher Acute Physiology and Chronic Health Evaluation (APACHE)-predicted mortality, and had more comorbidities when compared with patients without readmission. The number of Charlson comorbidities was significantly associated with late readmission (>72 hours) but not early readmission (≤72 hours) in the multivariate analysis. Both early and late ICU readmissions were associated with an increased risk of hospital mortality (odds ratio, 1.68; 95% confidence interval, 1.18-2.39; P = .004; odds ratio, 1.45; 95% confidence interval, 1.05-1.99; P = .022, respectively) after adjusting for age, admission source, type of admission, the APACHE-predicted mortality, and the number of Charlson comorbidities and APACHE chronic health conditions. Conclusions: Comorbidity was a risk factor for late ICU readmission. Comorbidities could not account for the excess mortality associated with ICU readmissions. [Copyright &y& Elsevier]

Background: Long-term survival outcome of critically ill patients is important in assessing effectiveness of new treatments and making treatment decisions. We developed a prognostic model for estimation of long-term survival of critically ill patients. Methodology and Principal Findings: This was a retrospective linked data cohort study involving 11,930 critically ill patients who survived more than 5 days in a university teaching hospital in Western Australia. Older age, male gender, comorbidities, severe acute illness as measured by Acute Physiology and Chronic Health Evaluation II predicted mortality, and more days of vasopressor or inotropic support, mechanical ventilation, and hemofiltration within the first 5 days of intensive care unit admission were associated with a worse long-term survival up to 15 years after the onset of critical illness. Among these seven pre-selected predictors, age (explained 50% of the variability of the model, hazard ratio [HR] between 80 and 60 years old = 1.95) and co-morbidity (explained 27% of the variability, HR between Charlson co-morbidity index 5 and 0 = 2.15) were the most important determinants. A nomogram based on the pre-selected predictors is provided to allow estimation of the median survival time and also the 1-year, 3-year, 5-year, 10-year, and 15-year survival probabilities for a patient. The discrimination (adjusted c-index = 0.757, 95% confidence interval 0.745-0.769) and calibration of this prognostic model were acceptable. Significance: Age, gender, co-morbidities, severity of acute illness, and the intensity and duration of intensive care therapy can be used to estimate long-term survival of critically ill patients. Age and co-morbidity are the most important determinants of long-term prognosis of critically ill patients. [ABSTRACT FROM AUTHOR]

The objective was to assess the ability of potential clinical predictors and inflammatory markers within 24 h of intensive care unit (ICU) discharge to predict subsequent in-hospital mortality. A prospective cohort study of 603 consecutive patients who survived their first ICU admission, between 1 June and 31 December 2005, in a 22-bed multidisciplinary ICU of a university hospital. A total of 26 in-hospital deaths after ICU discharge (4.3%) were identified. C-reactive protein (CRP) concentrations at ICU discharge were associated with subsequent in-hospital mortality in the univariate analysis (mean CRP concentrations of non-survivors = 174 vs. survivors = 85.6 mg/l, p = 0.001). CRP concentrations remained significantly associated with post-ICU mortality (a 10-mg/l increment in CRP concentrations increased the odds ratio [OR] of death: 1.09, 95% confidence interval [CI]: 1.03–1.16); after adjusting for age, the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality, and the Delta Sequential Organ Failure Assessment (Delta SOFA) score. The area under the receiver operating characteristic curve of this multivariate model to discriminate between survivors and non-survivors after ICU discharge was 0.85 (95% CI: 0.73–0.96). The destination and timing of ICU discharge, and the Discharge SOFA score, white cell counts and fibrinogen concentrations at ICU discharge were not significantly associated with in-hospital mortality after ICU discharge. A high CRP concentration at ICU discharge was an independent predictor of in-hospital mortality after ICU discharge in our ICU. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: The purpose of this study is to assess the ability of potential clinical predictors and inflammatory markers to predict intensive care unit (ICU) readmission during the same hospitalization. Materials and Methods: A nested case-control study utilized prospectively collected de-identified data of a 22-bed multidisciplinary ICU in a university hospital. Results: There were 1405 consecutive ICU admissions in 2004, and of these, 18 were regarded as ICU readmissions (1.3%). The destination and timing of ICU discharge, the Sequential Organ Failure Assessment scores, white cell counts, and fibrinogen concentrations at discharge were not associated with ICU readmission. C-reactive protein (CRP) concentration within 24 hours before ICU discharge was associated with ICU readmission (mean CRP concentrations of cases vs controls, 177.8 vs 56.5 mg/L, respectively; P < .0001). The results remained unchanged after adjustment with the propensity scores. The area under the receiver operating characteristic curve for the CRP concentrations to predict ICU readmission was 0.884 (95% confidence interval, 0.765-0.999; P < .0001). Patients readmitted to the ICU had a higher predicted mortality in their second ICU admission (34.9% vs 26.1%; P < .01) and a longer total hospital stay (33.3 vs 20.3 days; P < .003) than patients without ICU readmission. Conclusions: A high CRP concentration within 24 hours before ICU discharge is associated with a higher risk of readmission to the ICU. [Copyright &y& Elsevier]

Objective: To investigate the prevalence and predictors of intensive care nurses' active involvement in end-of-life (EOL) decisions.Design and Setting: A survey of intensive care nurses from 36 intensive care units (ICUs) in New Zealand.Measurements and Results: A total of 611 ICU nurses from 35 ICUs responded to this survey. The response rate was estimated to be between 43% and 81%. Seventy-eight percent of respondents reported active involvement in EOL decisions, especially the senior nurses (level IV vs. I nurses, OR 7.9; nurse educators vs. level I nurses, OR 4.3). Asian (OR 0.2) and Pacific Islander nurses (OR 0.2) were less often involved than European nurses. Sixty-eight percent of respondents preferred more involvement in EOL decisions, and this preference was associated with the perception that EOL decisions are often made too late (OR 2.2). Sixty-five percent believed their active involvement in EOL decisions would improve nursing job satisfaction.Conclusions: Most ICU nurses in New Zealand reported that they are often involved in EOL decisions, especially senior and European nurses. [ABSTRACT FROM AUTHOR]

Cardiac arrest (CA) may occur due to a variety of causes with heterogeneity in their clinical presentation and outcomes. This study aimed to identify clinical patterns or subphenotypes of CA patients admitted to the intensive care unit (ICU). The clinical and laboratory data of CA patients in a large electronic healthcare database were analyzed by latent profile analysis (LPA) to identify whether subphenotypes existed. Multivariable Logistic regression was used to assess whether mortality outcome was different between subphenotypes. A total of 1,352 CA patients fulfilled the eligibility criteria were included. The LPA identified three distinct subphenotypes: Profile 1 (13%) was characterized by evidence of significant neurological injury (low GCS). Profile 2 (15%) was characterized by multiple organ dysfunction with evidence of coagulopathy (prolonged aPTT and INR, decreased platelet count), hepatic injury (high bilirubin), circulatory shock (low mean blood pressure and elevated serum lactate); Profile 3 was the largest proportion (72%) of all CA patients without substantial derangement in major organ function. Profile 2 was associated with a significantly higher risk of death (OR: 2.09; 95% CI: 1.30 to 3.38) whilst the mortality rates of Profiles 3 was not significantly different from Profile 1 in multivariable model. LPA using routinely collected clinical data could identify three distinct subphenotypes of CA; those with multiple organ failure were associated with a significantly higher risk of mortality than other subphenotypes. LPA profiling may help researchers to identify the most appropriate subphenotypes of CA patients for testing effectiveness of a new intervention in a clinical trial. [ABSTRACT FROM AUTHOR]

Purpose: International guidelines recommend targeting normocapnia in mechanically ventilated out-of-hospital cardiac arrest (OHCA) survivors, but the optimal arterial carbon dioxide (PaCO2) target remains controversial. We hypothesised that the relationship between PaCO2 and survival is non-linear, and targeting an intermediate level of PaCO2 compared to a low or high PaCO2 in the first 24-h of ICU admission is associated with an improved survival to hospital discharge (STHD) and at 12-months.Methods: We conducted a retrospective multi-centre cohort study of adults with non-traumatic OHCA requiring admission to one of four tertiary hospital intensive care units for mechanical ventilation. A four-knot restricted cubic spline function was used to allow non-linearity between the mean PaCO2 within the first 24 h of ICU admission after OHCA and survival, and optimal PaCO2 cut-points were identified from the spline curve to generate corresponding odds ratios.Results: We analysed 3769 PaCO2 results within the first 24-h of ICU admission, from 493 patients. PaCO2 and survival had an inverted U-shape association; normocapnia was associated with significantly improved STHD compared to either hypocapnia (<35 mmHg) (adjusted odds ratio [aOR] 0.45, 95% confidence interval [CI] 0.24-0.83) or hypercapnia (>45 mmHg) (aOR 0.45, 95% CI 0.24-0.84). Of the twelve predictors assessed, PaCO2 was the third most important predictor, and explained >11% of the variability in survival. The survival benefits of normocapnia extended to 12-months.Conclusions: Normocapnia within the first 24-h of intensive care admission after OHCA was associated with an improved survival compared to patients with hypocapnia or hypercapnia. [ABSTRACT FROM AUTHOR]

Background: Studies to identify safe oxygenation targets after out-of-hospital cardiac arrest (OHCA) have often assumed a linear relationship between arterial oxygen tension (PaO2) and survival, or have dichotomised PaO2 at a supra-physiological level. We hypothesised that abnormalities in mean PaO2 (both high and low) would be associated with decreased survival after OHCA.Methods: We conducted a retrospective multicentre cohort study of adult OHCA patients who received mechanical ventilation on admission to the intensive care unit (ICU). The potential non-linear relationship between the mean PaO2 within the first 24 -hs of ICU admission and survival to hospital discharge (STHD) was assessed by a four-knot restricted cubic spline function with adjustment for potential confounders.Results: 3764 arterial blood gas results were available for 491 patients in the first 24-hs of ICU admission. The relationship between mean PaO2 over the first 24-hs and STHD was an inverted U-shape, with highest survival for those with a mean PaO2 between 100 and 180 mmHg (reference category) compared to a mean PaO2 of <100 mmHg (adjusted odds ratio [aOR] 0.50 95% confidence interval [CI] 0.30, 0.84), or >180 mmHg (aOR 0.41, 95% CI 0.18, 0.92). Mean PaO2 within 24 -hs was the third most important predictor and explained 9.1% of the variability in STHD.Conclusion: The mean PaO2 within the first 24-hs after admission for OHCA has a non-linear association with the highest STHD seen between 100 and 180 mmHg. Randomised controlled trials are now needed to validate the optimal oxygenation targets in mechanically ventilated OHCA patients. [ABSTRACT FROM AUTHOR]