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Extracorporeal membrane oxygenation (ECMO) is an invasive procedure used to support critically ill patients with the most severe forms of cardiac or respiratory failure in the short term, but long-term effects on incidence of death and disability are unknown. We aimed to assess incidence of death or disability associated with ECMO up to 6 months (180 days) after treatment. This prospective, multicentre, registry-embedded cohort study was done at 23 hospitals in Australia from Feb 15, 2019, to Dec 31, 2020. The EXCEL registry included all adults (≥18 years) in Australia who were admitted to an intensive care unit (ICU) in a participating centre at the time of the study and who underwent ECMO. All patients who received ECMO support for respiratory failure, cardiac failure, or cardiac arrest during their ICU stay were eligible for this study. The primary outcome was death or moderate-to-severe disability (defined using the WHO Disability Assessment Schedule 2.0, 12-item survey) at 6 months after ECMO initiation. We used Fisher's exact test to compare categorical variables. This study is registered with ClinicalTrials.gov , NCT03793257. Outcome data were available for 391 (88%) of 442 enrolled patients. The primary outcome of death or moderate-to-severe disability at 6 months was reported in 260 (66%) of 391 patients: 136 (67%) of 202 who received veno-arterial (VA)-ECMO, 60 (54%) of 111 who received veno-venous (VV)-ECMO, and 64 (82%) of 78 who received extracorporeal cardiopulmonary resuscitation (eCPR). After adjustment for age, comorbidities, Acute Physiology and Chronic Health Evaluation (APACHE) IV score, days between ICU admission and ECMO start, and use of vasopressors before ECMO, death or moderate-to-severe disability was higher in patients who received eCPR than in those who received VV-ECMO (VV-ECMO vs eCPR: risk difference [RD] –32% [95% CI –49 to –15]; p<0·001) but not VA-ECMO (VA-ECMO vs eCPR –8% [–22 to 6]; p=0·27). In our study, only a third of patients were alive without moderate-to-severe disability at 6 months after initiation of ECMO. The finding that disability was common across all areas of functioning points to the need for long-term, multidisciplinary care and support for surviving patients who have had ECMO. Further studies are needed to understand the 180-day and longer-term prognosis of patients with different diagnoses receiving different modes of ECMO, which could have important implications for the selection of patients for ECMO and management strategies in the ICU. The National Health and Medical Research Council of Australia. [ABSTRACT FROM AUTHOR]

Aims: To identify clinical and biochemical markers associated with nutrition adequacy and gastrointestinal and liver dysfunction in adults on extracorporeal membrane oxygenation (ECMO). Methods: A retrospective, observational, study was conducted at 2 centres in Australia. Adult patients who received ECMO from July 2011 to June 2015 were included. Mode of ECMO used, fluid balance, number of systemic inflammatory response syndrome (SIRS) criteria present, vasoactive‐inotropic scores (VIS) and liver function tests (LFTs) were collected for the duration of ECMO until 7 days after ECMO cessation. Multiple regression models were used to determine if the collected variables were associated with nutrition adequacy. The mean LFTs during ECMO were also compared to mean LFTs post ECMO cessation. Results: During the first 5 days of ECMO commencement, mean nutrition adequacy was 10% higher in the veno‐venous (VV) ECMO group than in the veno‐arterial (VA) group (95% confidence interval [CI], 2% to 17%). For every 5000 ml increase of fluid balance, an associated decrease in nutrition adequacy was observed (−8%, 95% CI: −15% to −2%). A doubling of bilirubin and VIS were associated with a mean reduction in nutrition adequacy of −5% (95% CI –8% to −2%) and − 2% (95% CI: −3% to −1%), respectively. Conclusions: In the first 5 days of ECMO commencement, higher nutrition adequacy was associated with the VV mode of ECMO and reduced nutrition adequacy with increased fluid balance, more vasopressor and inotropic support and raised bilirubin. Prospective investigation is required to confirm whether these associations have a causal relationship. [ABSTRACT FROM AUTHOR]

Background: Bronchiolitis is the most common reason for hospital admission in infants. High-flow oxygen therapy has emerged as a new treatment; however, the cost-effectiveness of using it as first-line therapy is unknown.Objective: To compare the cost of providing high-flow therapy as a first-line therapy compared with rescue therapy after failure of standard oxygen in the management of bronchiolitis.Methods: A within-trial economic evaluation from the health service perspective using data from a multicentre randomised controlled trial for hypoxic infants (≤12 months) admitted to hospital with bronchiolitis in Australia and New Zealand. Intervention costs, length of hospital and intensive care stay and associated costs were compared for infants who received first-line treatment with high-flow therapy (early high-flow, n=739) or for infants who received standard oxygen and optional rescue high-flow (rescue high-flow, n=733). Costs were applied using Australian costing sources and are reported in 2016-2017 AU$.Results: The incremental cost to avoid one treatment failure was AU$1778 (95% credible interval (CrI) 207 to 7096). Mean cost of bronchiolitis treatment including intervention costs and costs associated with length of stay was AU$420 (95% CrI -176 to 1002) higher per infant in the early high-flow group compared with the rescue high-flow group. There was an 8% (95% CrI 7.5 to 8.6) likelihood of the early high-flow oxygen therapy being cost saving.Conclusions: The use of high-flow oxygen as initial therapy for respiratory failure in infants with bronchiolitis is unlikely to be cost saving to the health system, compared with standard oxygen therapy with rescue high-flow. [ABSTRACT FROM AUTHOR]

Objectives: To describe haemodynamic resuscitation practices in ED patients with suspected sepsis and hypotension. Methods: This was a prospective, multicentre, observational study conducted in 70 hospitals in Australia and New Zealand between September 2018 and January 2019. Consecutive adults presenting to the ED during a 30‐day period at each site, with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation, were eligible. Data included baseline demographics, clinical and laboratory variables and intravenous fluid volume administered, vasopressor administration at baseline and 6‐ and 24‐h post‐enrolment, time to antimicrobial administration, intensive care admission, organ support and in‐hospital mortality. Results: A total of 4477 patients were screened and 591 were included with a mean (standard deviation) age of 62 (19) years, Acute Physiology and Chronic Health Evaluation II score 15.2 (6.6) and a median (interquartile range) systolic blood pressure of 94 mmHg (87–100). Median time to first intravenous antimicrobials was 77 min (42–148). A vasopressor infusion was commenced within 24 h in 177 (30.2%) patients, with noradrenaline the most frequently used (n = 138, 78%). A median of 2000 mL (1500–3000) of intravenous fluids was administered prior to commencing vasopressors. The total volume of fluid administered from pre‐enrolment to 24 h was 4200 mL (3000–5661), with a range from 1000 to 12 200 mL. Two hundred and eighteen patients (37.1%) were admitted to an intensive care unit. Overall in‐hospital mortality was 6.2% (95% confidence interval 4.4–8.5%). Conclusion: Current resuscitation practice in patients with sepsis and hypotension varies widely and occupies the spectrum between a restricted volume/earlier vasopressor and liberal fluid/later vasopressor strategy. [ABSTRACT FROM AUTHOR]

Objective: There is uncertainty about the optimal i.v. fluid volume and timing of vasopressor commencement in the resuscitation of patients with sepsis and hypotension. We aim to study current resuscitation practices in EDs in Australia and New Zealand (the Australasian Resuscitation In Sepsis Evaluation: FLUid or vasopressors In Emergency Department Sepsis [ARISE FLUIDS] observational study). Methods: ARISE FLUIDS is a prospective, multicentre observational study in 71 hospitals in Australia and New Zealand. It will include adult patients presenting to the ED during a 30 day period with suspected sepsis and hypotension (systolic blood pressure <100 mmHg) despite at least 1000 mL fluid resuscitation. We will obtain data on baseline demographics, clinical and laboratory variables, all i.v. fluid given in the first 24 h, vasopressor use, time to antimicrobial administration, admission to intensive care, organ failure and in‐hospital mortality. We will specifically describe (i) the volume of fluid administered at the following time points: when meeting eligibility criteria, in the first 6 h, at 24 h and prior to vasopressor commencement and (ii) the frequency and timing of vasopressor use in the first 6 h and at 24 h. Screening logs will provide reliable estimates of the proportion of ED patients meeting eligibility criteria for a subsequent randomised controlled trial. Discussion: This multicentre, observational study will provide insight into current haemodynamic resuscitation practices in patients with sepsis and hypotension as well as estimates of practice variation and patient outcomes. The results will inform the design and feasibility of a multicentre phase III trial of early haemodynamic resuscitation in patients presenting to ED with sepsis and hypotension. [ABSTRACT FROM AUTHOR]

Background: Guidelines recommend an initial intravenous (IV) fluid bolus of 30 ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this. Accumulating observational data suggest harm associated with the injudicious use of fluids in sepsis. There is currently equipoise regarding liberal or restricted fluid-volume resuscitation as first-line treatment for sepsis-related hypotension. A randomised trial comparing these two approaches is, therefore, justified.Methods/design: The REstricted Fluid REsuscitation in Sepsis-associated Hypotension trial (REFRESH) is a multicentre, open-label, randomised, phase II clinical feasibility trial. Participants will be patients presenting to the emergency departments of Australian metropolitan hospitals with suspected sepsis and a systolic blood pressure of < 100 mmHg, persisting after a 1000-ml fluid bolus with isotonic crystalloid. Participants will be randomised to either a second 1000-ml fluid bolus (standard care) or maintenance rate fluid only, with the early commencement of a vasopressor infusion to maintain a mean arterial pressure of > 65 mmHg, if required (restricted fluid). All will receive further protocolised fluid boluses (500 ml or 250 ml, respectively), if required during the 6-h study period. The primary outcome measure is total volume administered in the first 6 h. Secondary outcomes include fluid volume at 24 h, organ support 'free days' to day 28, 90-day mortality, and a range of feasibility and process-of-care measures. Participants will also undergo serial measurement, over the first 24 h, of biomarkers of inflammation, endothelial cell activation and glycocalyx degradation for comparison between the groups.Discussion: This is the first randomised trial examining fluid volume for initial resuscitation in septic shock in an industrialised country. A pragmatic, open-label design will establish the feasibility of undertaking a large, international, multicentre trial with sufficient power to assess clinical outcomes. The embedded biomarker study aims to provide mechanistic plausibility for a larger trial by defining the effects of fluid volume on markers of systemic inflammation and the vascular endothelium.Trial Registration: Australia and New Zealand Clinical Trials Registry, ID: ACTRN12616000006448. Registered on 12 January 2016. [ABSTRACT FROM AUTHOR]

Background Acid suppression medications are routinely used in general intensive care unit patients for prevention of stress-related gastric mucosal bleeding. Their use has been extrapolated to include elective postoperative cardiac surgical patients. The evidence for their use in this group of patients remains inconclusive (Shin and Abah, Interact Cardiovasc Thorac Surg, 2012; 14: 622-8). Aim To audit the use of acid suppression therapy in postoperative cardiac surgical patients as inpatients and after discharge, and ascertain whether these patients experienced postoperative gastrointestinal bleeding. Method A retrospective chart review was undertaken, focusing on cases of cardiac surgical intensive care patients to investigate the use of stress ulcer prophylaxis and the occurrence of post-surgical gastrointestinal bleeding. The continuation of therapy after discharge was also audited. Results The cases of 78 patients were included in the audit: all received stress ulcer prophylaxis, and no patients experienced gastrointestinal bleeding postoperatively. In all, 27% of these patients were dispensed acid suppression therapy without a valid indication at the time of discharge. Conclusions It cannot be conclusively determined if the absence of postoperative gastrointestinal bleeding was due to the administration of prophylaxis. An alternative explanation is that stress ulcers were not likely to occur in this cohort of patients. Despite not having any indication for continuation of acid suppression, 20 patients were discharged with these medications. [ABSTRACT FROM AUTHOR]

Abstract: The purpose of this study was to assess plasma selenium levels in an Australian blood donor population and measure extra-cellular selenium levels in fresh manufactured blood components. Selenium levels were measured using graphite furnace atomic absorption spectrometry with Zeeman background correction. The mean plasma selenium level in healthy plasmapharesis donors was 85.6±0.5μg/L and a regional difference was observed between donors in South East Queensland and Far North Queensland. Although participants had selenium levels within the normal range (55.3–110.5μg/L), 88.5% had levels below 100μg/L, a level that has been associated with sub-optimal activity of the antioxidant enzyme glutathione peroxidase (GPx). Extra-cellular selenium levels in clinical fresh frozen plasma (cFFP) and apheresis-derived platelets (APH Plt) were within the normal range. Packed red blood cells (PRBC) and pooled buffy coat-derived platelets (BC Plt) had levels at the lower limit of detection, which may have clinical implications to the massively transfused patient. [Copyright &y& Elsevier]

Objective: To investigate associations between transfusion of blood products close to the end of shelf‐life and clinical outcomes in obstetric inpatients. Methods: Mortality and morbidity were compared in patients transfused exclusively with red blood cells (RBC) stored for less than 21 days (fresh) versus RBC stored for 35 days or longer (old), and platelets (PLT) stored for 3 days or fewer (fresh) versus 4 days or longer (old) in Queensland, Australia from 2007 to 2013. Multivariable models were used to examine associations between these groups of blood products and clinical end points. Results: There were 3371 patients who received RBC and 280 patients who received PLT of the eligible storage durations. Patients transfused with old RBC received fewer transfusions (2.7 ± 1.8 vs. 2.3 ± 1.0 units; P < 0.001). However, a higher rate of single‐unit transfusions was also seen in those patients who exclusively received old RBC (252 [9.3%] vs. 92 [13.7%]; P = 0.003). Comparison of fresh vs. old blood products revealed no differences in the quantities of transfused RBC (9.5 ± 5.9 vs. 9.1 ± 5.2 units; P = 0.680) or PLT (1.5 ± 0.8 vs. 1.4 ± 1.1 units; P = 0.301) as well as the length of hospital stay for RBC (3 [2–5] vs. 3 [2–5] days; P = 0.124) or PLT (5 [4–8] vs. 6 [4–9] days; P = 0.120). Conclusion: Transfusing exclusively older RBC or PLT was not associated with increased morbidity or mortality. Synopsis: Transfusing older red blood cells (≥35 days) or platelets (≥4 days) was not associated with worse outcomes in obstetric patients in Queensland. [ABSTRACT FROM AUTHOR]

A letter to the editor is presented concerning an appraisal of endotracheal tube use as an alternative treatment method to intercostal catheters.

Background: The H1N1 Influenza A pandemic arrived in Australia in early May 2009. In Queensland, the highest number of H1N1 cases were admitted to the intensive care unit when compared with the other Australian states. While many recent studies examining the H1N1 pandemic have focussed on service delivery and disease epidemiology, few have explored the lived experiences of frontline health care workers caring for the patients in the intensive care unit. Objectives: The purposes of this study were to: document and describe the lived experiences of the nursing and medical staff caring for patients in the intensive care unit during the H1N1 pandemic; to validate the staffs’ experiences; and to assist in informing future pandemic planning by highlighting the collective experiences of these frontline health care workers. Design: A phenomenological study method was used. Setting and participants: 34 staff from a tertiary referral hospital in Brisbane, Australia participated in the study. Methods: Data was collected using an open ended questionnaire and focus groups. The resulting responses were analysed using Colaizzi''s framework to discover regular patterns of meaning that emerged. Results: Eight common themes emerged: the wearing of personal protective equipment; infection control procedures; the fear of contracting and transmitting the disease; adequate staffing levels within the intensive care unit; new roles for staff; morale levels; education regarding extracorporeal membrane oxygenation; and the challenges of patient care. These eight themes articulate the lived experience of the staff during the height of the H1N1 Influenza pandemic period. Conclusions: Planning for a pandemic situation is invariably difficult due to the unpredictable nature of the event itself. Recommendations for future pandemic planning which can be drawn from this study include the appointment of a dedicated infection control representative to provide information and support regarding infection control matters; the maintenance of effective communication channels is crucial; and the increased staffing requirements across nursing, medical, allied health and ancillary staff to cope with the higher patient numbers and acuity must be anticipated and planned for. [Copyright &y& Elsevier]

Background: There is a paucity of data in regards to longer term morbidity outcomes in Indigenous Australian patients undergoing coronary artery bypass grafting (CABG). No comparative data on re-infarction, stroke or reintervention rates exist. Outcome data following percutaneous coronary intervention (PCI) is also extremely limited. Addressing this gap in knowledge forms the major aim of our study.Methods: This was a single centre cohort study conducted at the Townsville Hospital, Australia which provides tertiary adult cardiac surgical services to the northern parts of the state of Queensland. It incorporated consecutive patients (n=350) undergoing isolated CABG procedures, 2008-2010, 20.9% (73/350) of whom were Indigenous Australians. The main outcome measures were major adverse cardiac or cerebrovascular events (MACCE) at mid-term follow-up (mean 38.9 months).Results: The incidence of MACCE among Indigenous Australian patients was approximately twice that of non-Indigenous patients at mid-term follow-up (36.7% vs. 18.6%; p=0.005; OR 2.525 (1.291-4.880)). Following adjustment for preoperative and operative variables, Indigenous Australian status itself was not significantly associated with MACCE (AOR 1.578 (0.637-3.910)). Significant associations with MACCE included renal impairment (AOR 2.198 (1.010-4.783)) and moderate-severe left ventricular impairment (AOR 3.697 (1.820-7.508)). An association between diabetes and MACCE failed to reach statistical significance (AOR 1.812 (0.941-3.490)).Conclusions: Indigenous Australians undergoing CABG suffer an excess of MACCE when followed-up in the longer term. High rates of comorbidities in the Indigenous Australian population likely play an aetiological role. [ABSTRACT FROM AUTHOR]

Background: Indigenous Australians experience poorer health outcomes than non-Indigenous Australians and a significant life expectancy gap exists. Ischaemic heart disease (IHD) represents the leading specific cause of death in Indigenous Australians and is a significant, if not the most significant, contributor to the mortality gap. With this narrative review we aim to describe the burden of IHD within the Indigenous Australian community and explore the factors driving this disparity.Methods: A broad search of the literature was undertaken utilising an electronic search of the PubMed database along with national agency databases-the Australian Institute of Health and Welfare (AIHW) and the Australian Bureau of Statistics (ABS).Results: A complex interplay between multiple factors contributes to the excess burden of IHD in the Indigenous Australian population: CONCLUSIONS: In terms of IHD, Indigenous Australians experience disadvantage at multiple stages of the disease process. Ongoing efforts are needed to continue to inform clinicians of both this disadvantage and strategies to assist negating it. Further research is needed to develop evidence based practices which may help reduce this disparity in outcomes. [ABSTRACT FROM AUTHOR]

Haemorrhage in the setting of severe trauma is associated with significant morbidity and mortality. There is increasing awareness of the important role fibrinogen plays in traumatic haemorrhage. Fibrinogen levels fall precipitously in severe trauma and the resultant hypofibrinogenaemia is associated with poor outcomes. Hence, it has been postulated that early fibrinogen replacement in severe traumatic haemorrhage may improve outcomes, although, to date there is a paucity of high quality evidence to support this hypothesis. In addition there is controversy regarding the optimal method for fibrinogen supplementation. We review the current evidence regarding the role of fibrinogen in trauma, the rationale behind fibrinogen supplementation and discuss current research. [ABSTRACT FROM AUTHOR]

Background: Cold static storage preservation of donor hearts for periods longer than 4 hours increases the risk of primary graft dysfunction (PGD). The aim of the study was to determine if hypothermic oxygenated perfusion (HOPE) could safely prolong the preservation time of donor hearts., Methods: We conducted a nonrandomized, single arm, multicenter investigation of the effect of HOPE using the XVIVO Heart Preservation System on donor hearts with a projected preservation time of 6 to 8 hours on 30-day recipient survival and allograft function post-transplant. Each center completed 1 or 2 short preservation time followed by long preservation time cases. PGD was classified as occurring in the first 24 hours after transplantation or secondary graft dysfunction (SGD) occurring at any time with a clearly defined cause. Trial survival was compared with a comparator group based on data from the International Society of Heart and Lung Transplantation (ISHLT) Registry., Results: We performed heart transplants using 7 short and 29 long preservation time donor hearts placed on the HOPE system. The mean preservation time for the long preservation time cases was 414 minutes, the longest being 8 hours and 47 minutes. There was 100% survival at 30 days. One long preservation time recipient developed PGD, and 1 developed SGD. One short preservation time patient developed SGD. Thirty day survival was superior to the ISHLT comparator group despite substantially longer preservation times in the trial patients., Conclusions: HOPE provides effective preservation out to preservation times of nearly 9 hours allowing retrieval from remote geographic locations., (Copyright © 2024 International Society for the Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.)

Background: Delirium is a common, yet underdiagnosed neuropsychiatric complication of intensive care unit (ICU) admission, associated with significant mortality and morbidity. Delirium can be difficult to diagnose, with gold standard assessments by a trained specialist being impractical and rarely performed. To address this, various tools have been developed, enabling bedside clinicians to assess for delirium efficiently and accurately. However, the performance of these tools varies depending on factors including the assessor's training. To address the shortcomings of current tools, electronic tools have been developed., Aims and Objectives: The aims of this validation study are to assess the feasibility, acceptability, and generalisability of a recently developed and pilot-tested electronic delirium screening tool (eDIS-ICU) and compare diagnostic concordance, sensitivity, and specificity between eDIS-ICU, Confusion Assessment Method for the ICU (CAM-ICU), and the Diagnostic and Statistical Manual of Mental Disorders - 5th edition (DSM-V) gold standard in diverse ICU settings., Methods: Seven hundred participants will be recruited across five sites in three countries. Participants will complete three assessments (eDIS-ICU, CAM-ICU, and DSM-V) twice within one 24-h period. At each time point, assessments will be completed within one hour. Assessments will be administered by three different people at any given time point, with the assessment order and assessor for eDIS-ICU and CAM-ICU randomly allocated. Assessors will be blinded to previous and concurrent assessment results., Results: The primary outcome is comparing diagnostic sensitivity of eDIS-ICU and CAM-ICU against the DSM-V., Relevance to Clinical Practice: This protocol describes a definitive validation study of an electronic diagnostic tool to assess for delirium in the ICU. Delirium remains a common and difficult challenge in the ICU and is linked with multiple neurocognitive sequelae. Various challenges to routine assessment mean many cases are still unrecognised or misdiagnosed. An improved ability for bedside clinicians to screen for delirium accurately and efficiently will support earlier diagnosis, identification of underlying cause(s) and timely treatments, and ultimately improved patient outcomes., Clinical Trial Registration Number: This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (ANZCTR) on 8th February 2022 (ACTRN12622000220763)., (Copyright © 2023 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Rationale: Data suggest that altered antimicrobial concentrations are likely during extracorporeal membrane oxygenation (ECMO). Objectives: The primary aim of this analysis was to describe the pharmacokinetics (PKs) of antimicrobials in critically ill adult patients receiving ECMO. Our secondary aim was to determine whether current antimicrobial dosing regimens achieve effective and safe exposure. Methods: This study was a prospective, open-labeled, PK study in six ICUs in Australia, New Zealand, South Korea, and Switzerland. Serial blood samples were collected over a single dosing interval during ECMO for 11 antimicrobials. PK parameters were estimated using noncompartmental methods. Adequacy of antimicrobial dosing regimens were evaluated using predefined concentration exposures associated with maximal clinical outcomes and minimal toxicity risks. Measurements and Main Results: We included 993 blood samples from 85 patients. The mean age was 44.7 ± 14.4 years, and 61.2% were male. Thirty-eight patients (44.7%) were receiving renal replacement therapy during the first PK sampling. Large variations (coefficient of variation of ⩾30%) in antimicrobial concentrations were seen leading to more than fivefold variations in all PK parameters across all study antimicrobials. Overall, 70 (56.5%) concentration profiles achieved the predefined target concentration and exposure range. Target attainment rates were not significantly different between modes of ECMO and renal replacement therapy. Poor target attainment was observed across the most frequently used antimicrobials for ECMO recipients, including for oseltamivir (33.3%), piperacillin (44.4%), and vancomycin (27.3%). Conclusions: Antimicrobial PKs were highly variable in critically ill patients receiving ECMO, leading to poor target attainment rates. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12612000559819).

Our study aimed to describe the population pharmacokinetics (PK) of vancomycin in critically ill patients receiving extracorporeal membrane oxygenation (ECMO), including those receiving concomitant renal replacement therapy (RRT). Dosing simulations were used to recommend maximally effective and safe dosing regimens. Serial vancomycin plasma concentrations were measured and analyzed using a population PK approach on Pmetrics . The final model was used to identify dosing regimens that achieved target exposures of area under the curve (AUC 0-24 ) of 400-700 mg · h/liter at steady state. Twenty-two patients were enrolled, of which 11 patients received concomitant RRT. In the non-RRT patients, the median creatinine clearance (CrCL) was 75 ml/min and the mean daily dose of vancomycin was 25.5 mg/kg. Vancomycin was well described in a two-compartment model with CrCL, the presence of RRT, and total body weight found as significant predictors of clearance and central volume of distribution ( V c ). The mean vancomycin renal clearance and V c were 3.20 liters/h and 29.7 liters respectively, while the clearance for patients on RRT was 0.15 liters/h. ECMO variables did not improve the final covariate model. We found that recommended dosing regimens for critically ill adult patients not on ECMO can be safely and effectively used in those on ECMO. Loading doses of at least 25 mg/kg followed by maintenance doses of 12.5-20 mg/kg every 12 h are associated with a 97-98% probability of efficacy and 11-12% probability of toxicity, in patients with normal renal function. Therapeutic drug monitoring along with reductions in dosing are warranted for patients with renal impairment and those with concomitant RRT. (This study is registered with the Australian New Zealand Clinical Trials Registry [ANZCTR] under number ACTRN12612000559819.).

Background: The intensive care environment and experiences during admission can negatively impact patient and family outcomes and can complicate recovery both in hospital and after discharge. While their perspectives based on intimate experiences of the environment could help inform design improvements, patients and their families are typically not involved in design processes. Rather than designing the environment around the needs of the patients, emphasis has traditionally been placed on clinical and economic efficiencies., Objective: The main objective was to inform design of an optimised intensive care bedspace by developing an understanding of how patients and their families experience the intensive care environment and its impact on recovery., Methods: A qualitative descriptive study was conducted with data collected in interviews with 17 intensive care patients and seven family members at a large cardiothoracic specialist hospital, analysed using a framework approach., Results: Participants described the intensive care as a noisy, bright, confronting and scary environment that prevented sleep and was suboptimal for recovery. Bedspaces were described as small and cluttered, with limited access to natural light or cognitive stimulation. The limited ability to personalise the environment and maintain connections with family and the outside world was considered especially problematic., Conclusions: Intensive care patients described features of the current environment they considered problematic and potentially hindering their recovery. The perspective of patients and their families can be utilised by researchers and developers to improve the design and function of the intensive care environment. This can potentially improve patient outcomes and help deliver more personalised and effective care to this vulnerable patient population and their families., (Copyright © 2020 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)

Background: The optimal duration of infusion set use to prevent life-threatening catheter-related bloodstream infection (CRBSI) is unclear. We aimed to compare the effectiveness and costs of 7-day (intervention) versus 4-day (control) infusion set replacement to prevent CRBSI in patients with central venous access devices (tunnelled cuffed, non-tunnelled, peripherally inserted, and totally implanted) and peripheral arterial catheters., Methods: We did a randomised, controlled, assessor-masked trial at ten Australian hospitals. Our hypothesis was CRBSI equivalence for central venous access devices and non-inferiority for peripheral arterial catheters (both 2% margin). Adults and children with expected greater than 24 h central venous access device-peripheral arterial catheter use were randomly assigned (1:1; stratified by hospital, catheter type, and intensive care unit or ward) by a centralised, web-based service (concealed before allocation) to infusion set replacement every 7 days, or 4 days. This included crystalloids, non-lipid parenteral nutrition, and medication infusions. Patients and clinicians were not masked, but the primary outcome (CRBSI) was adjudicated by masked infectious diseases physicians. The analysis was modified intention to treat (mITT). This study is registered with the Australian New Zealand Clinical Trials Registry ACTRN12610000505000 and is complete., Findings: Between May 30, 2011, and Dec, 9, 2016, from 6007 patients assessed, we assigned 2944 patients to 7-day (n=1463) or 4-day (n=1481) infusion set replacement, with 2941 in the mITT analysis. For central venous access devices, 20 (1·78%) of 1124 patients (7-day group) and 16 (1·46%) of 1097 patients (4-day group) had CRBSI (absolute risk difference [ARD] 0·32%, 95% CI -0·73 to 1·37). For peripheral arterial catheters, one (0·28%) of 357 patients in the 7-day group and none of 363 patients in the 4-day group had CRBSI (ARD 0·28%, -0·27% to 0·83%). There were no treatment-related adverse events., Interpretation: Infusion set use can be safely extended to 7 days with resultant cost and workload reductions., Funding: Australian National Health and Medical Research Council., Competing Interests: Declaration of interests CMR's employer has received on her behalf from manufacturers of vascular access products: investigator-initiated research grants and unrestricted educational grants from BD-Bard and Cardinal Health; and consultancy payments for educational lectures and expert advice from 3M, and BD-Bard. NMM's employer has received on her behalf from manufacturers of vascular access products investigator-initiated research grants and unrestricted educational grants from BD-Bard and Cardinal Health; and consultancy payments for educational lectures from 3M. ENL's employer has received on her behalf from manufacturers of vascular access products an investigator-initiated research grant from Cardinal Health; and a conference scholarship from Angiodynamics. AC's employer has received on her behalf from manufacturers of vascular access products investigator-initiated research grants from Cardinal Health. EA's employer has received on his behalf from manufacturers of vascular access products: investigator-initiated research grants from BD-Bard. All other authors declare no competing interests., (Copyright © 2021 Elsevier Ltd. All rights reserved.)

Introduction: Extracorporeal membrane oxygenation (ECMO) provides cardiac and/or respiratory support when other therapies fail. Nosocomial infection is reported in up to 64% of patients receiving ECMO and increases morbidity and mortality. These patients are at high risk of infection due, in part, to the multiple invasive devices required in their management, the largest being the cannulae through which ECMO is delivered. Prevalence of nosocomial infection in ECMO patients, including ECMO cannula-related infection, is not well described across Australia and New Zealand., Methods and Analysis: This is a prospective, observational point prevalence study of 12 months duration conducted at 11 ECMO centres across Australia and New Zealand. Data will be collected for every patient receiving ECMO during 12 predetermined data collection weeks. The primary outcome is the prevalence of laboratory-confirmed bloodstream infection, and suspected or probable nosocomial infections; and the secondary outcomes include describing ECMO cannula dressing and securement practices, and adherence to local dressing and securement guidelines. Data collection will be finalised by March 2019., Ethics and Dissemination: Relevant ethical and governance approvals have been received. Study results will describe the prevalence of suspected and confirmed nosocomial infection in adult, paediatric and neonatal patients receiving ECMO across Australia and New Zealand. It is expected that the results will be hypothesis generating and lead to interventional trials aimed at reducing the high infection rates seen in this cohort. Results will be published in peer-reviewed journals and presented at relevant conferences., Trial Registration Number: ANZCTRN12618001109291; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Introduction: Indigenous Australians experience poorer health outcomes than non-Indigenous Australians. Ischaemic heart disease is a leading contributor to the mortality gap which exists between Indigenous and non-Indigenous Australians., Methods: We reviewed the literature in regards to Indigenous Australians undergoing coronary artery bypass grafting (CABG) for management of ischaemic heart disease., Results: Younger patients with higher rates of preventable risk factors constitute the Indigenous Australian CABG population. Indigenous Australian females are over-represented in series to date. High rates of left ventricular dysfunction are seen in the Indigenous CABG cohorts potentially reflecting barriers to medical care or the influence of high rates of diabetes observed in the Indigenous Australian population. The distribution of coronary artery disease appears to differ between Indigenous Australian and non-Indigenous CABG cohorts likely reflecting a difference in the referral patterns of the two population groups with diabetes again likely influencing management decisions. Reduced utilisation of arterial conduits in Indigenous Australian cohorts has been identified in a number of series. This is of particular concern given the younger age structure of the Indigenous Australian cohorts. Indigenous Australian patients suffer excess morbidity and mortality in the longer term after undergoing CABG. Ventricular dysfunction and excess comorbidities in the Indigenous Australian CABG population appear largely responsible for this., Conclusion: Excess morbidity and mortality endured by Indigenous Australians in the longer term following CABG appears largely contributed to by higher rates of ventricular dysfunction and comorbidities in the Indigenous Australian CABG population. Maximising internal mammary artery use and continued focus on strategies to reduce the impact of diabetes, renal impairment and heart failure in the Indigenous Australian population is essential to reduce the mortality gap experienced by Indigenous Australians secondary to ischaemic heart disease., (Copyright © 2018. Published by Elsevier B.V.)

Background: Mechanical circulatory and respiratory support (MCRS) systems provide short- to long-term life support for patients with severe cardiac or respiratory failure. Whereas the challenges of patients with these lifesaving systems are well understood, the challenges faced by nurses of patients receiving MCRS remain relatively unidentified., Objectives: In this study, we investigated the challenges and experiences of MCRS nurses, with the aim of informing the design of future interventions., Design: A qualitative approach was taken to develop an in-depth understanding of the emotional issues nurses experience in their daily interactions with patients., Participants and Setting: Nine MCRS nurses ranging in clinical experience were recruited from Australian hospitals., Methods: Participants were divided into 3 focus groups, with design prompts being used in the focus groups to facilitate discussion. Data from these focus groups were analyzed through a thematic analysis protocol., Results: The nurses' accounts were clustered around 2 themes, including (1) patient connection and (2) compassion vitality and fatigue. Each theme elicits a conflicting compromise that MCRS nurses face daily., Conclusion: The challenges of nurses who support patients with MCRS are complex, multifaceted, emotionally stimulating, and exhausting. We therefore contributes a set of design criteria to support such nurses, setting a direction for future research.

Background: Transcatheter aortic valve implantation (TAVI) is associated with a high incidence of cerebrovascular injury. As these injuries are thought to be primarily embolic, neuroprotection strategies have focused on embolic protection devices. However, the topographical distribution of cerebral emboli and how this impacts on the effectiveness of these devices have not been thoroughly assessed. Here, we evaluated the anatomical characteristics of magnetic resonance imaging (MRI)-defined cerebral ischemic lesions occurring secondary to TAVI to enhance our understanding of the distribution of cardioembolic phenomena., Methods: Forty patients undergoing transfemoral TAVI with an Edwards SAPIEN-XT valve under general anesthesia were enrolled prospectively in this observational study. Participants underwent brain MRI preprocedure, and 3 ± 1 days and 6 ± 1 months postprocedure., Results: Mean ± SD participant age was 82 ± 7 years. Patients had an intermediate to high surgical risk, with a mean Society of Thoracic Surgeons score of 6.3 ± 3.5 and EuroSCORE of 18.1 ± 10.6. Post-TAVI, there were no clinically apparent cerebrovascular events, but MRI assessments identified 83 new lesions across 19 of 31 (61%) participants, with a median ± interquartile range number and volume of 1 ± 2.8 lesions and 20 ± 190 μL per patient. By volume, 80% of the infarcts were cortical, 90% in the posterior circulation and 81% in the right hemisphere., Conclusions: The distribution of lesions that we detected suggests that cortical gray matter, the posterior circulation, and the right hemisphere are all particularly vulnerable to perioperative cerebrovascular injury. This finding has implications for the use of intraoperative cerebral embolic protection devices, particularly those that leave the left subclavian and, therefore, left vertebral artery unprotected., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Objectives: Ultrasound is a common and necessary part of acute care medicine, but may present an infection risk to patients secondary to transfer of infectious agents between patients. Our primary objective was to detect blood contamination on ultrasound equipment in emergency departments (EDs) and intensive care units. Secondary objectives included detection of microbial contamination and determination of factors associated with contamination., Design and Setting: We tested ultrasound equipment used in five EDs and five ICUs for blood and microbial contamination, and collated and analysed contamination data using tables and multiple logistic regression., Main Outcome Measures and Results: We performed 109 tests for blood and 131 tests for microbial contamination, with 61% of samples testing positive for blood contamination (95% CI, 52%-71%) and 48% testing positive for microbiological contamination (95% CI, 40%-57%). Transducer leads and transducers had high blood contamination (88% and 57%, respectively) and microbiological contamination (62% and 46%, respectively). Equipment from ICUs was less likely to test positive (odds ratio, 0.55; 95% CI, 0.37-0.79). Only 51% of blood-contaminated samples were visibly stained, and visible staining was not associated with microbiological contamination (57%; P=1)., Conclusion: Our results show significant contamination of ultrasound equipment, and that visual inspection of equipment is neither sufficient nor reliable in excluding contamination. Ultrasound equipment is a possible factor in the transmission of infectious diseases in EDs and ICUs. Guidelines must be formulated, disseminated and rapidly adopted to ensure the safety of the most acutely ill patients exposed to ultrasound procedures in acute care settings.

Background: Cardiovascular disease remains the leading cause of mortality in the Indigenous Australian population. Limited research exists in regards to cardiac surgery in the Aboriginal and Torres Strait Islander (ATSI) population. We aimed to investigate risk profiles, surgical pathologies, surgical management and short term outcomes in a contemporary group of patients., Methods: Variables were assessed for 557 consecutive patients who underwent surgery at our institution between August 2008 and March 2010., Results: 19.2% (107/557) of patients were of Indigenous origin. ATSI patients were significantly younger at time of surgery (mean age 54.1±13.23 vs. 63.1±12.46; p=<0.001) with higher rates of preventable risk factors. Rheumatic heart disease (RHD) was the dominant valvular pathology observed in the Indigenous population. Significantly higher rates of left ventricular impairment and more diffuse coronary artery disease were observed in ATSI patients. A non-significant trend towards higher 30-day mortality was observed in the Indigenous population (5.6% vs. 3.1%; p=0.244)., Conclusions: Cardiac surgery is generally required at a younger age in the Indigenous population with patients often presenting with more advanced disease. Despite often more advanced disease, surgical outcomes do not differ significantly from non-Indigenous patients. Continued focus on preventative strategies for coronary artery disease and RHD in the Indigenous population is required., (Copyright © 2013. Published by Elsevier B.V.)

Objectives: To examine the seasonal pattern in heart failure (HF) and cardiovascular disease (CVD) by climate and cause of death in Australia., Methods: A retrospective analysis of a national database of deaths in the eight Australian State and Territory capitals between January 1997 and November 2004. We examined the seasonal pattern in HF and CVD deaths, we identified variations in the pattern by: sex, age, time, climate and cause of death (for total CVD using seven groups determined by ICD-10 code)., Results: Deaths in all seven groups of CVD significantly increased in winter. The largest increase in mortality rates was 23.5% observed for HF. The magnitude of this increase varied greatly between cities, with the lowest winter mortality rates in the coldest (Hobart) and warmest (Darwin) cities. The pattern in CVD deaths showed a clearer correlation with climate than HF deaths., Conclusion and Implications: Winters in Australia are mild but winter increases in HF and CVD are a significant problem. Increased blood pressure and lack of vitamin D in winter are the most likely causes of the increase. Reducing exposure to cold, particularly in the elderly, should reduce the number of winter CVD deaths in Australia.

Objectives: To document and describe the effects of woodstove burns in children. To identify how these accidents occur so that a prevention strategy can be devised., Design, Patients and Setting: Retrospective departmental database and case note review of all children with woodstove burns seen at the Burns Unit of a Tertiary Referral Children's Hospital between January 1997 and September 2001., Main Outcome Measures: Number and ages of children burned; circumstances of the accidents; injuries sustained; treatment required and long-term sequelae., Results: Eleven children, median age 1.0 year, sustained burns, usually to the hands, of varying thickness. Two children required skin grafting and five required scar therapy. Seven children intentionally placed their hands onto the outside of the stove. In all children, burns occurred despite adult supervision., Conclusions: Woodstoves are a cause of burns in children. These injuries are associated with significant morbidity and financial costs. Through public education, woodstove burns can easily be prevented utilising simple safety measures.

Objectives: To document and describe the effects of campfire burns on children. To identify the sources of danger contributing to such injuries, so that a prevention strategy can be devised., Design, Patients and Setting: Departmental database and case note review of all children with campfire burns seen at the Burns Unit of a tertiary referral children's hospital between January 1999 and June 2001., Main Outcome Measures: Number and ages of children burned; risk factors contributing to the accidents; injuries sustained; treatment required and long-term sequelae., Results: Thirty-three children, median age 2.5 years, sustained burns, usually to the hands and feet, with eight requiring surgery and the majority requiring some form of scar therapy. Seventy-four percent of the children were burned by hot ashes and coals, usually from the previous night's fire, rather than by open flames., Conclusions: Campfires cause serious injuries to children. In particular, hot ashes and coals from inadequately extinguished campfires pose the greatest danger. Increasing the awareness of this easily preventable problem amongst campers is intended through a public education campaign.