Search

Sengstaken–Blakemore tubes (SBTs) are rarely used in Australia, because of improved access to endoscopy and interventional radiology, as well as overall lower rate of variceal haemorrhage from improvements in primary prophylaxis. SBT's use is associated with significant rate of serious complications, such as oesophageal perforation, mucosal necrosis, aspiration pneumonia and respiratory compromise secondary to external compression of the trachea. As such, SBT is currently only recommended for use in life‐threatening variceal haemorrhage, where endoscopic, embolization and pharmacologic therapy have been unsuccessful or are unavailable. No data exist for its use in Australasia but one area that it could be indicated is for hemodynamically unstable patients in remote setting, where long transfer times often means delayed access to endoscopy. We present a case of SBT insertion in retrieval medicine and discuss placement in the management of an unstable upper gastrointestinal bleed, complicating factors such as lack of radiology to confirm balloon position, the impact of flight altitude on balloon pressures, the maintenance of traction in flight and logistics of long flight times across the state of Queensland. This is the first case report of SBT use in the Australian aeromedical environment. It is also the first one where SBT has been used for duodenal bleeding, although the source of bleeding was unknown prior to insertion. [ABSTRACT FROM AUTHOR]

A life-threatening disease such as breast cancer with its pervasive nature of uncertainty can lead to feelings of disempowerment. Nonetheless, survivors may reconstruct their identity within optimism and a celebration of a new self. In this qualitative constructionist study, we explored survivors' experiences, meaning-making, and identity transformation. Semi-structured interviews were undertaken with 11 women who identified as breast cancer survivors. Participants were aged 35 years old or above and were in post-diagnosis for at least 3 years. Interview data were collected and analyzed using thematic techniques. We identified three master themes: Diseased Self, focused on emotional distress and the presentation of a façade; Coping Self, explored resilience and post-traumatic growth; and Transformed Self, engaged in presentations of self-image, meaning-making, and psychological ownership addressing survivorship and empowerment. The findings may be used to inform guidelines and support for cancer survivors considering the impact of diagnosis, treatment, and post-treatment experiences on self-identity. [ABSTRACT FROM AUTHOR]

Rationale: There are no prospective observational studies exploring the relationship between relative hypotension and adverse kidney-related outcomes among critically ill patients with shock.Objectives: To investigate the magnitude of relative hypotension during vasopressor support among critically ill patients with shock and to determine whether such relative hypotension is associated with new significant acute kidney injury (AKI) or major adverse kidney events (MAKE) within 14 days of vasopressor initiation.Methods: At seven multidisciplinary ICUs, 302 patients, aged ≥40 years and requiring ≥4 hours of vasopressor support for nonhemorrhagic shock, were prospectively enrolled. We assessed the time-weighted average of the mean perfusion pressure (MPP) deficit (i.e., the percentage difference between patients' preillness basal MPP and achieved MPP) during vasopressor support and the percentage of time points with an MPP deficit > 20% as key exposure variables. New significant AKI was defined as an AKI-stage increase of two or more (Kidney Disease: Improving Global Outcome creatinine-based criteria).Measurements and Main Results: The median MPP deficit was 19% (interquartile range, 13-25), and 54% (interquartile range, 19-82) of time points were spent with an MPP deficit > 20%. Seventy-three (24%) patients developed new significant AKI; 86 (29%) patients developed MAKE. For every percentage increase in the time-weighted average MPP deficit, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 5.6% (95% confidence interval, 2.2-9.1; P = 0.001) and 5.9% (95% confidence interval, 2.2-9.8; P = 0.002), respectively. Likewise, for every one-unit increase in the percentage of time points with an MPP deficit > 20%, multivariable-adjusted odds of developing new significant AKI and MAKE increased by 1.2% (0.3-2.2; P = 0.008) and 1.4% (0.4-2.4; P = 0.004), respectively.Conclusions: Vasopressor-treated patients with shock are often exposed to a significant degree and duration of relative hypotension, which is associated with new-onset, adverse kidney-related outcomes.Study registered with Australian New Zealand Clinical Trial Registry (ACTRN 12613001368729). [ABSTRACT FROM AUTHOR]

Objective: To describe the effect of fluid bolus therapy (FBT) on blood pressure in children with sepsis. Secondary outcomes included the effect of FBT on systemic vascular resistance, shock index and shock phenotype (warm or cold). Methods: This was a prospective observational study in the ED of The Royal Children's Hospital, Melbourne, Australia. Participants were children meeting international consensus criteria for sepsis who received FBT for tachycardia or hypotension. FBT was defined as 10–20 mL/kg of 0.9% saline. Mean blood pressure (MBP) was recorded at baseline, 5 and 60 min after FBT. Total systemic vascular resistance index (TSVRi), shock index, and shock phenotype were derived for each time point. Hypotension was defined as MBP <55 + 1.5 × age (years). Warm shock was defined as TSVRi <800 dyne s/cm5/m2. Results: Fifty fluid boluses were recorded in 41 children. Median MBP was 78 mmHg (interquartile range [IQR] 63–86) at baseline, 72 mmHg (IQR 60–82) at 5 min, and 75 mmHg (IQR 66–84) at 60 min. Hypotension was observed in 16% at baseline, 26% at 5 min and 17% at 60 min. Median TSVRi was 1580 dyne s/cm5/m2 (IQR 1242–2206) at baseline, 1254 dyne s/cm5/m2 (IQR 1027–1787) at 5 min, and 1850 dyne s/cm5/m2 (IQR 1265–2140) at 60 min. Median shock index was 1.60 (IQR 1.34–1.90) at baseline, 1.49 (IQR 1.25–1.76) at 5 min and 1.37 (IQR 1.22–1.61) at 60 min. Two percent of cases had warm shock at baseline, 12% at 5 min and 2% at 60 min. Conclusions: MBP initially decreased following FBT for paediatric sepsis, returning towards baseline over the subsequent 60 min. The utility of FBT for increasing MBP and its effect on patient‐centred outcomes in children with sepsis warrants further exploration. [ABSTRACT FROM AUTHOR]

Childhood injury is the largest cause of paediatric hospitalisation in Australia. Parents' psychological wellbeing is important in enabling them to support their children's recovery, however little is known about parents' psychosocial support needs during their child's admission to the emergency department. This study explores the experiences and support needs of parents of critically injured children in the emergency department. An exploratory qualitative approach was used. Semi-structured face to face interviews were conducted with 40 parents of 30 critically injured children aged 0–12 years across 4 Australian hospitals. Transcribed data were managed using NVivo 10 and qualitative content analysis was performed. Four themes of parent experience emerged from analysis: being in shock and distress; feeling challenged by the ed environment; dealing with urgent priorities; and having immediate needs met. There is a need for easy-to-understand information for parents in the ED following their child's injury. Recommendations include use of a checklist for emergency clinicians on what information to provide parents and provision of anticipatory guidance to parents on what to expect psychologically following injury. A dedicated family support coordinator is needed to support parents and children throughout the injury trajectory. [ABSTRACT FROM AUTHOR]

Purpose: It is unclear if blood pressure targets for patients with shock should be adjusted to pre-morbid levels. We aimed to investigate mean deficit between the achieved mean perfusion pressure (MPP) in vasopressor-treated patients and their estimated basal (resting) MPP, and assess whether MPP deficit has any association with subsequent acute kidney injury (AKI). Materials and Methods: Fifty-one consecutive, non-trauma patients, aged ⩾40 years, with ⩾2 organ dysfunction and requiring vasopressor ⩾4 hours were observed at an academic intensive care unit. Mean MPP deficit [=%(basal MPP - achieved MPP)/basal MPP] and % time spent with >20% MPP deficit were assessed during initial 72 vasopressor hours (T0-T72) for each patient. Results: Achieved MPP was unrelated to basal MPP (P = .99). Mean MPP deficit was 18%(95%CI 15-21). Patients spent 48% (95% CI 39-57) time with >20% MPP deficit. Despite similar risk scores at T0, subsequent AKI (⩾2 RIFLE class increase from T0) occurred more frequently in patients with higher (Nmedian) MPP deficit compared to patients with lower MPP deficit (56% vs 28%; P = .045). Incidence of subsequent AKI was also higher among patients who spent greater % time with >20% MPP deficit (P = .04). Conclusions: Achieved blood pressure during vasopressor therapy had no relationship to the pre-morbid basal level. This resulted in significant and varying degree of relative hypotension (MPP deficit), which could be a modifiable risk factor for AKI in patients with shock. [ABSTRACT FROM AUTHOR]

Australia has a shortfall in donated hearts for transplantation. Hearts are usually procured from brain dead donors, but procurement from circulatory dead donors is a potential additional source. However, heart transplantation after circulatory death of the donor may not conform to the dead donor rule. An amendment in law is required to permit heart procurement for transplantation after circulatory death. [ABSTRACT FROM AUTHOR]