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Stress ulcer prophylaxis is commonly prescribed in the intensive care unit but can be inappropriately commenced or continued on discharge, exposing patients to potential harm. We aimed to evaluate whether a prescribing guideline, education program and pharmacist oversight would reduce inappropriate continuation of stress ulcer prophylaxis. This was a multicentre pre- (2014) and post- (2016) quality improvement study across five Australian intensive care units. Cost data were estimated using local information about prescribing patterns, and the relationship between long-term use and adverse events. A total of 531 patients were included in the pre- and 393 in the post-implementation periods. The proportion of hospital survivors inappropriately continued on stress ulcer prophylaxis reduced from 78/184 (42.4%) to 11/143 (7.7%) in the post-implementation period (odds ratio = 8.83; 95% confidence interval 4.47–17.45; P

Background Both anaemia and red blood cell (RBC) transfusion are common and associated with adverse outcomes in patients admitted to the intensive care unit (ICU). The aim of this study was to determine whether serum hepcidin concentration, measured early after ICU admission in patients with anaemia, could identify a group in whom intravenous (IV) iron therapy decreased the subsequent RBC transfusion requirement. Methods We conducted a prospective observational study nested within a multicenter randomized controlled trial (RCT) of IV iron versus placebo. The study was conducted in the ICUs of four tertiary hospitals in Perth, Western Australia. Critically ill patients with haemoglobin (Hb) of

Patients admitted to intensive care units (ICUs) undergo multiple blood tests. Small volume vacuum phlebotomy tubes (SVTs) provide an important blood conservation measure. SVTs reduce summative blood loss and may reduce odds of transfusion. We aimed to determine whether low volume blood sampling using SVTs for routine diagnostic purposes translates to decreased fall in haemoglobin concentration, and examine downstream effects on anaemia and need for transfusion during ICU admission.A single-centre, controlled before-and-after study, evaluating a unit-wide changeover from conventional volume vacuum phlebotomy tubes (CVTs) to SVTs on April 2015. All ICU patients admitted for48 hours during the 12 months before and after the intervention were included in multivariate and univariate analysis. Groups were stratified into short admissions (2-7 days) and long admissions (7 days).A total of 318 patients were analysed. For short admissions, SVTs decreased fall in haemoglobin concentration (unstandardized coefficient, -6.7;SVTs reduce sampling volume without increasing laboratory error. Follow-on effects include reduced fall in haemoglobin concentration and severe anaemia. These correlations are absent in long admissions.

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

To describe current patterns in initiation and cessation of proton pump inhibitors (PPIs) for stress ulcer prophylaxis (SUP) in intensive care units, and to assess the costs associated with inappropriate (non-evidence-based) SUP.Retrospective observational study in five ICUs in Western Australia. We assessed the medical records of consecutive patients admitted to the ICUs between September 2013 and January 2015. Patients aged18 years were excluded.We included 531 patients in the study. Of the 184 patients in whom PPIs were initiated for SUP in the ICU, 90 (48.9%) were still taking the therapy at the time of discharge from hospital. A documented indication for ongoing therapy was present in only nine patients (10%). We assumed a 10-year life expectancy after ICU discharge and that most patients continued taking a PPI, and calculated an additional cost of $180.20 per patient admitted to the ICU. This was based only on unnecessary PPI costs (ignoring costs of managing additional adverse events). The direct cumulative annual cost to the WA health system of PPIs continued unnecessarily for patients at discharge from hospital is estimated to be $250 800 for each year they continue to receive them.A substantial proportion of patients prescribed SUP in the ICU continue receiving this therapy at hospital discharge despite no clear indication. In addition to potential adverse clinical effects, this is associated with major direct and indirect cost implications.

Both anaemia and allogenic red blood cell transfusion are common and potentially harmful in patients admitted to the intensive care unit. Whilst intravenous iron may decrease anaemia and RBC transfusion requirement, the safety and efficacy of administering iron intravenously to critically ill patients is uncertain. The multicentre, randomized, placebo-controlled, blinded Intravenous Iron or Placebo for Anaemia in Intensive Care (IRONMAN) study was designed to test the hypothesis that, in anaemic critically ill patients admitted to the intensive care unit, early administration of intravenous iron, compared with placebo, reduces allogeneic red blood cell transfusion during hospital stay and increases the haemoglobin level at the time of hospital discharge. Of 140 patients enrolled, 70 were assigned to intravenous iron and 70 to placebo. The iron group received 97 red blood cell units versus 136 red blood cell units in the placebo group, yielding an incidence rate ratio of 0.71 [95 % confidence interval (0.43–1.18), P = 0.19]. Overall, median haemoglobin at hospital discharge was significantly higher in the intravenous iron group than in the placebo group [107 (interquartile ratio IQR 97–115) vs. 100 g/L (IQR 89–111), P = 0.02]. There was no significant difference between the groups in any safety outcome. In patients admitted to the intensive care unit who were anaemic, intravenous iron, compared with placebo, did not result in a significant lowering of red blood cell transfusion requirement during hospital stay. Patients who received intravenous iron had a significantly higher haemoglobin concentration at hospital discharge. The trial was registered at http://www.anzctr.org.au as # ACTRN12612001249842.

We report the difficult airway management of a child impaled through the neck by a wooden plant support. The various options are discussed and the involvement of experienced personnel together with a clear preformulated plan of action is stressed.

Atypical antipsychotics (quetiapine, olanzapine, risperidone and clozapine) are increasingly prescribed in Australia, and emergency departments report growing rates of overdose of these agents. As these drugs are comparatively new, the spectrum of toxicity may be unfamiliar to critical care physicians. Severe hypotension is a recognised consequence of quetiapine poisoning. We describe three patients with massive quetiapine overdose who developed significant hypotension resistant to fluid resuscitation. In each case, blood pressure fell dramatically after commencement of adrenaline infusions. Haemodynamic stability was restored when noradrenaline was substituted for adrenaline. The pharmacodynamics of quetiapine and the literature on overdose are reviewed. We present these cases to broaden the knowledge of physicians treating quetiapine overdose and to publicise the potential deleterious interaction with adrenaline. We recommend use of noradrenaline in preference to adrenaline in pharmacological management of shock in these patients.

The decomposition of a system into simpler subsystems, followed by the optimization of the individual subsystems, and then co-ordinating the subsystem optimal solutions to yield the optimal control policy for the original system, is considered. Lasdon's co-ordination algorithm, in which the subsystems are regarded as being completely independent, is improved by including the interdependence of the adjacent subsystems. For linear systems with a quadratic performance index, this procedure yields the optimal control policy in a single iteration from an arbitrary initial guess of the decomposition parameters. For nonlinear systems, the method includes linearizing the state equations, the calculation of the optimal control for the linearized system, and the adjustment of the corresponding decomposition parameters of the original problem until convergence is achieved. For the optimization of a nonlinear continuous stirred tank reactor such a procedure requires considerably more computation time than the standard techniques, and the optimum policies are less accurate. On considere la resolution d'un systeme en systemes secondaires plus simples, laquelle est suivie de l'optimisation de chacun d'eux et de la coordination de leurs solutions optimales, pour realiser la meilleure methode de controle du systeme original. On ameliore l'algorithme de coordination de Lasdan, dans lequel on considere les systemes secondaires completement independents, en incluant l'interdependance des systemes secondaires adjacents. Dans le cas de systemes lineaires dont l'indice de rendement est quadratique, cela permet de realiser la methode optimale de controle dans une simple iteration a partir d'une estimation initiale arbitraire des parametres de decomposition. Dans le cas de systemes non-lineaires, la methode comprend la transformation des equations d'etat en equations lineaires, le calcul du controle optimal pour le systemelinearise et l'ajustement des parametres correspondents de resolution du systeme original jusqu'a ce qu'on obtienne une convergence. Dans le cas de l'optimisation d'un reacteur dont le reservoir est constamment agite, la dite methode requiert un temps de calcul bien plus considerable que lorsqu'on emploie les methodes normales; en outre, les plans optimaux de conduite sont moins exacts.

This report supplements EHL(W) TR 83-08, An Industrial Hygiene Evaluation of F-16 Aircraft Refueling Inside Closed Aircraft Shelters. This study considers F-16 refueling inside third generation shelters using JP-8 was well as JP-4 fuel. The position of the fuel truck differed from previous work. Workplace concentrations of fuel vapors, carbon monoxide, and benzene were measured. The conclusions is that F-16 refueling in third generation shelters need not be limited because of industrial hygiene considerations.

An extension of the pseudodiagonalisation technique leads to a minimisation of the off-diagonal terms of the inverse Nyquist array in a way which reflects dominance over an entire frequency range. This new formulation also permits the design of certain types of dynamic compensation for multivariable control systems.