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Purpose The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to described the epidemiology of SA-AKI. Methods Retrospective cohort study in 12 intensive care units (ICU) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of the ADQI SA-AKI definition. Results Of 84,831 admissions, 15,549 met the SA-AKI criteria with its incidence peaking at > 20% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with median time to SA-AKI diagnosis of one day (IQR 1–1) from ICU admission. At diagnosis, most SA-AKI patients had a stage 1 (55%) AKI, mostly due to the low urinary output (UO) criterion only (67%). Compared to diagnosis by creatinine alone, or both UO and creatinine criteria, patients diagnosed by UO alone had lower RRT requirement (3.3% vs 19% vs 51%; p

Internationally, diabetes mellitus is recognised as a risk factor for severe COVID-19. The relationship between diabetes mellitus and severe COVID-19 has not been reported in the Australian population.The objective of this study was to determine the prevalence of and outcomes for patients with diabetes admitted to Australian intensive care units (ICUs) with COVID-19.This is a nested cohort study of four ICUs in Melbourne participating in the Short Period Incidence Study of Severe Acute Respiratory Infection (SPRINT-SARI) Australia project. All adult patients admitted to the ICU with COVID-19 from 20 February 2020 to 27 February 2021 were included. Blood glucose and glycated haemoglobin (HbA1c) data were retrospectively collected. Diabetes was diagnosed from medical history or an HbA1c ≥6.5% (48 mmol/mol). Hospital mortality was assessed using logistic regression.There were 136 patients with median age 58 years [48-68] and median Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 14 [11-19]. Fifty-eight patients had diabetes (43%), 46 patients had stress-induced hyperglycaemia (34%), and 32 patients had normoglycaemia (23%). Patients with diabetes were older, were with higher APACHE II scores, had greater glycaemic variability than patients with normoglycaemia, and had longer hospital length of stay. Overall hospital mortality was 16% (22/136), including nine patients with diabetes, nine patients with stress-induced hyperglycaemia, and two patients with normoglycaemia.Diabetes is prevalent in patients admitted to Australian ICUs with severe COVID-19, highlighting the need for prevention strategies in this vulnerable population.

Background Admissions to intensive care units (ICUs) are increasing due to an ageing population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care. Methods This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60-min sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed. Discussion This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units. Trial registration Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268; prospectively registered on 13 March 2018/https://www.anzctr.org.au Trial funding: Metro South Health Research Support Scheme Postgraduate Scholarship

Objective: Assess change in ultrasound measures of diaphragm mechanics over the course of a 30-minute spontaneous breathing trial (SBT). Design: Prospective observational study. Setting: Single intensive care unit (Logan Hospital, Queensland, Australia), patients recruited from August 2016 to April 2018. Participants: Eligible patients were over the age of 18 years, ventilated for >24 hours, and planned to undergo an SBT. In total, 129 patients were screened. Main outcome measures: Ultrasound measures taken at 5 and 30 minutes during SBT: diaphragmatic excursion (DE), diaphragmatic thickening fraction (DTF), and diaphragmatic contraction speed (DCS). Diaphragmatic rapid shallow breathing index (DRSBI) was calculated using DE/respiratory rate. The presence of diaphragmatic dysfunction (DD) was also determined using DTF < 30%, DE < 11 mm, or DRSBI > 1.6. Results: Eighteen patients had ultrasound measures during an SBT. Four were unable to have DTF visualized. There was no significant change in DTF (n = 14, 32.41 ± 32.21 vs 23.19 ± 17.42, P = .33) or DE (n = 18, 1.72 ± 0.63 vs 1.66 ± 0.59, P = .63) over time. Diaphragmatic contraction speed increased over time (n = 18, 2.21 ± 1.25 vs 2.67 ± 1.61, P = .007). Diaphragmatic rapid shallow breathing index worsened over time (n = 18, 1.65 ± 1.02 vs 2.08 ± 1.51, P = .03). There was no significant change in the presence of DD. Diaphragmatic dysfunction by DTF 8/14 versus 10/14, by DE 4/18 versus 3/18, and by DRSBI 7/18 versus 9/18. No patients failed SBT and one patient failed extubation. Conclusions: Diaphragmatic mechanics may change over the course of an SBT. Further research is required to determine the clinical implications of these changes and the optimal timing of diaphragmatic ultrasound to predict weaning outcome. Diaphragmatic ultrasound may be less feasible than the published data suggest.

Objective: Although extensively studied in children, the safety and tolerability of ketone supplementation in adults is unclear, particularly in the acute brain injury population. The purpose of this study was to examine the feasibility and safety of inducing ketosis using an enteric ketogenic formulation and determine its impact on intracranial and cerebral perfusion pressures and metabolic parameters.Methods: Prospective interventional Phase II trial of ventilated critically ill patients with acute brain injury administered a ketogenic feed over a 6 day period.Results: 20 patients were recruited, 5 females and 15 males, 3 with stroke, 2 with subarachnoid haemorrhage and 15 with traumatic brain injury. Feeds were well tolerated with 19 patients completing study. There was a significant increase in both plasma beta-hydroxybutyrate and acetoacetate from 0.24± 0.31 mmol/l and 0.19 ± 0.16 mmol/l to 0.61 ± 0.53 mmol/l (p =0.0005) and 0.52 ± 0.40 mmol/l (p

Background: Admissions to intensive care units (ICUs) are increasing due to an aging population, and rising incidence of cardiac and respiratory disease. With advances in medical care, more patients are surviving an initial stay in critical care; however, they can experience ongoing health and cognitive limitations, that may influence return to baseline function up to a year post-admission. Recent research has focused on the introduction of early rehabilitation within the ICU to reduce long-term physical and cognitive complications. The aim of this study is to explore the feasibility and impact of providing early enhanced occupation-based therapy, including cognitive stimulation and activities of daily living, to patients in intensive care. Methods: This study involves a single site randomised-controlled feasibility trial comparing standard occupational therapy care to an early enhanced occupation-based therapy. Thirty mechanically ventilated ICU patients will be recruited and randomly allocated to the intervention or control group. The primary outcome measure is the Functional Independence Measure (FIM), and secondary measures include the Modified Barthel Index (MBI), Montreal Cognitive Assessment (MoCA), grip strength, Hospital Anxiety and Depression Scale (HADS) and Short-Form 36 Health survey (SF-36). Measures will be collected by a blind assessor at discharge from intensive care, hospital discharge and a 90-day follow-up. Daily outcome measures including the Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Confusion Assessment Measure for intensive care units (CAM-ICU) will be taken prior to treatment. Participants in the intervention group will receive daily a maximum of up to 60 minute sessions with an occupational therapist involving cognitive and functional activities such as self-care and grooming. At the follow-up, intervention group participants will be interviewed to gain user perspectives of the intervention. Feasibility data including recruitment and retention rates will be summarised descriptively. Parametric tests will compare outcomes between groups. Interview data will be thematically analysed.Discussion: This trial will provide information about the feasibility of investigating how occupational therapy interventions in ICU influence longer term outcomes. It seeks to inform the design of a phase III multicentre trial of occupational therapy in critical care general medical intensive care units.Trial registration: Australia New Zealand Clinical Trials Registry (ANZCTR): ACTRN12618000374268; prospectively registered on 13th March 2018 / https://www.anzctr.org.auTrial funding: Metro South Health Research Support Scheme Postgraduate Scholarship

To the Editor: The global coronavirus disease (COVID-19) pandemic has seen a significant increase in the use of preprint services to enable the widespread dissemination of research findings (1). However, whether such facilities influence practice change is currently unknown. Here, we describe the impact of the preprint release and eventual publication of the RECOVERY (Randomised Evaluation of COVID-19 Therapy) trial (2) on corticosteroid use in clinical practice in Australian ICUs. The RECOVERY trial tested the efficacy of dexamethasone (6 mg by mouth or intravenously for up to 10 d) in hospitalized patients with clinically suspected or confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and demonstrated a reduction in 28-day mortality, particularly in those receiving either mechanical ventilation or oxygen. Before these results, the Australian and New Zealand Intensive Care Society COVID-19 guidelines recommended against the routine use of corticosteroids (3).

In the early nineteenth century, however, it became conventional, at least among historians, to identify truth with fact and to regard fiction as the opposite of truth, hence as a hindrance to the understanding of reality rather than as a way of apprehending it. Typically, the nineteenth-century historian’s aim was to expunge every hint of the fictive, or merely imaginable, from his discourse, to eschew the techniques of the poet and orator, and to forego what were regarded as the intuitive procedures of the maker of fictions in his apprehension of reality. Truth was not equated with fact, but with a combination of fact and the conceptual matrix within which it was appropriately located in the discourse. There are many kinds of facts invoked in The Origin of Species: Darwin speaks of ‘astonishing’ facts, ‘remarkable’ facts, ‘leading’ facts, ‘unimportant’ facts, ‘well-established’ facts, even ‘strange’ facts; but there are no ‘surprising’ facts.

Tekst dotyczy różnicy między dwoma typami dyskursu historiograficznego odnoszącego się do Zagłady, reprezentowanego przez dwa wybitne opracowania tematu. Autor argumentuje, że w przypadku dyskursu bliskiego doświadczeniu świadka rolę odgrywa nie tylko referencja, lecz także specyficzny punkt widzenia i emocje osoby ocalonej, które bierze pod uwagę Saul Friedländer. White analyses the difference between two types of historiographic discourse related to the Holocaust as represented in two outstanding studies on the subject. He argues that in the case of discourses connected to the witness’s experience, it is not only the reference that plays a role but also the specific point of view and emotions of the rescued person. These are taken into account by Saul Friedländer.

Acute brain injury (ABI), including cerebral vascular accidents (CVA) and traumatic brain injury (TBI), are relatively common diseases which may lead to death, significant morbidity and place a heaving burden on health care systems globally, both in suffering and cost. Evidence has emerged from basic science research that ketones (beta-hydroxybutyrate and acetoacetate) which are water-soluble molecules produced by the liver during times of starvation, may have neuroprotective effects. It is therefore theoretically possible that increasing plasma ketone concentrations via intravenous or oral supplementation, may lead to improved outcomes following ABI.This thesis documents a systematic investigation into the possibility that ketone supplementation may lead to benefits in patients with a variety of chronic and acute neurological conditions. While the main emphasis is on ABI, other conditions where ketones may be useful are also reviewed. Beginning with a review of ketones, their potential mechanisms of action and likely neuroprotective roles in disease, this thesis examines the effects of a novel hypertonic intravenous ketone solution on plasma, cerebrospinal fluid (CSF) and brain ketone concentrations in animals, then looks at the hurdles in producing such an intravenous solution as opposed to enteral formulations for humans, before investigating baseline ketone concentrations in patients with ABI and finally culminating in an interventional study where a modified enteral ketone supplement is administered to patients with ABI to determine whether adequate plasma ketone concentrations are attainable.The animal study performed in rats involved the administration of hypertonic saline/ketone solutions of varying concentrations to anaesthetised rats. The results demonstrated that both CSF and beta-hydroxybutyrate (BHB) concentrations increased over time (p

Purpose To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit. Methods A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥18years and requiring invasive MV for more than 48hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2mL) or placebo nebulization with 0.9% sodium chloride (2mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12612000038897. Results Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6–7%, P=1.00) or clinical diagnosis (24–26%, P=0.85). There was no difference in the clinical consistency (P=0.70), number (P=0.28) or the total volume of secretions per day (P=.54). The presence of blood in secretions was significantly less in the usual care group (P=0.005). Conclusion Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

Purpose To determine whether prophylactic inhaled heparin is effective for the prevention and treatment of pneumonia patients receiving mechanical ventilation (MV) in the intensive care unit. Methods A phase 2, double blind randomized controlled trial stratified for study center and patient type (non-operative, post-operative) was conducted in three university-affiliated intensive care units. Patients aged ≥ 18 years and requiring invasive MV for more than 48 hours were randomized to usual care, nebulization of unfractionated sodium heparin (5000 units in 2 mL) or placebo nebulization with 0.9% sodium chloride (2 mL) four times daily with the main outcome measures of the development of ventilator associated pneumonia (VAP), ventilator associated complication (VAC) and sequential organ failure assessment scores in patients with pneumonia on admission or who developed VAP. Trial Registration: Australian and New Zealand Clinical Trials Registry ACTRN12612000038897. Results Two hundred and fourteen patients were enrolled (72 usual care, 71 inhaled sodium heparin, 71 inhaled sodium chloride). There were no differences between treatment groups in terms of the development of VAP, using either Klompas criteria (6–7%, P = 1.00) or clinical diagnosis (24–26%, P = 0.85). There was no difference in the clinical consistency (P = 0.70), number (P = 0.28) or the total volume of secretions per day (P = .54). The presence of blood in secretions was significantly less in the usual care group (P = 0.005). Conclusion Nebulized heparin cannot be recommended for prophylaxis against VAP or to hasten recovery from pneumonia in patients receiving MV.

Thrombosis is a complication of many chronic illnesses. Chronic obstructive pulmonary disease (COPD) and diabetes mellitus are common medical conditions frequently associated with a hypercoagulable state. Acidaemia has been shown to reduce coagulation. COPD and diabetes mellitus during acute deterioration can present with a severe acidaemia. The impact of this acidaemia on coagulation is poorly studied. Patients presenting with a diagnosis of diabetic ketoacidosis or type II respiratory failure from COPD and a pH of less than 7.2 were included in our study. A coagulation screen and a thromboelastograph (TEG) were performed on admission and 24 hours later. The mean pH on admission was 7.07 and mean base excess was -16.3. The activated partial thromboplastin time was associated with pH change but remained within the normal range (26-41 s). All other coagulation and TEG parameters failed to show evidence of association (p>0.05). In the two models of non-haemorrhagic acidosis investigated, coagulation was not altered by the changes in pH. More work is needed to understand the complex relationship between factors affecting coagulation in individual disease processes.

It is often forgotten that the humanities—which are made up of history, philosophy, literary studies, philology, rhetoric, art history, musicology, and linguistics—are characterized not so much by their objects of study, which can change over time, as by their focus on reading, the reading of verbal texts, primarily, but also reading in the sense of decoding and recoding images, sounds, and movements. The disciplines that compose the humanities teach different kinds of reading practices. The products of these disciplines for the most part belong to the class of prose and poetic discourses. This is why they may often look similar or even the same, especially when they are cast in the same mode: narrative, argumentative, descriptive, or expressive as the case may be.

Background Early rehabilitation has been found to prevent delirium and weakness that can hamper the recovery of intensive care unit (ICU) survivors. Integrated clinical practice guidelines for managing patient pain, agitation and delirium (PAD) have been developed. The Awakening and Breathing Coordination, Delirium monitoring/management, and Early exercise/mobility (ABCDE) bundle provides a strategy to implement PAD guidelines into everyday clinical practice. However, there is limited evidence on the effectiveness of the ABCDE bundle in the literature. The purpose of this study was to evaluate the feasibility of conducting a full-scale randomised controlled trial comparing the ABCDE bundle to standard care in an ICU. Trial feasibility was defined as the successful recruitment and retention of trial participants, adherence to the intervention, identification of barriers to the intervention, and the rigorous collection of outcome data. Methods A prospective, single-centre, randomised controlled feasibility study was conducted. Thirty adult mechanically ventilated participants were recruited from an eight-bed ICU in south east Queensland, Australia, between April 2015 and December 2015. Participants were randomised to receive either the ABCDE bundle or standard routine management. The ABCDE bundle integrated prescribed awakening and breathing trials, delirium monitoring and management, and prescribed exercise and mobility regimes. Feasibility outcomes measured included recruitment and retention rates, intervention fidelity, and the feasibility of participant outcome data collection. Outcome measurement assessors were blinded to participant assignment. It was not possible to blind the research team or the participant to group assignment. Results In total, 30 (81.1%) of 37 eligible participants consented and were randomised to the intervention group (n = 15) or the control group (n = 15). Of these, 23 (76.6%) participants successfully completed the 90-day post discharge assessment. A lengthy recruitment period of 8 months was related to overly stringent inclusion and exclusion criteria. Intervention adherence exceeded defined success rates with participation in awakening and breathing trials, delirium monitoring and exercise interventions performed on 80.2, 97.4 and 90.2% of ventilated days respectively. Outcome assessments were successfully and accurately performed at ICU and hospital discharge and 90-day post hospital discharge. Intervention participants were deemed to be delirious on 39.6% of mechanically ventilated days indicating a requirement for a scripted regime to prevent delirium. Conclusions With minor adjustment of inclusion and exclusion criteria, the inclusion of delirium management protocols, and encouragement of family engagement and involvement, a large-scale definitive randomised controlled trial to test the impact of the ABCDEF bundle will be feasible. Trial registration Australian New Zealand Clinical Trials Registry 12614000763640 Date registered 17/08/2014 Electronic supplementary material The online version of this article (10.1186/s40814-017-0224-x) contains supplementary material, which is available to authorized users.

With dengue fever emerging as a global health problem and more Australians travelling to endemic areas, imported dengue infection is on the rise and clinicians need to remain vigilant. Primary cardiac and neurologic involvement in dengue infection has been rarely described in the medical literature and the pathophysiology is poorly understood. A rare and fatal case of primary dengue infection in a 34-yearold woman who returned from Papua New Guinea is reported; the unusual features of this case include severe primary dengue infection, myocarditis, and acute cerebral oedema resulting in death. This case demonstrates that severe atypical manifestations and fatality can occur with primary dengue infection.

Key Clinical Message Idiopathic Systemic Capillary Leak Syndrome is a potentially fatal disorder that is under diagnosed. It commonly presents as recurrent undifferentiated shock with hypotension, hypoalbuminemia and hemoconcentration. There are three distinct phases that define the syndrome; Prodromal, Extravasation and Recovery.

Summary Background & aim Nutritional intake of patients in acute respiratory failure receiving non-invasive ventilation has not previously been described, and no protocols have been developed to guide practice to optimise nutritional status. We aimed to measure energy and protein intakes of patients in acute respiratory failure requiring non-invasive ventilation receiving standard hospital nutritional care. Methods Food and fluid intake forms were completed by nursing staff for all meals and mid meals for patients admitted with respiratory failure commencing on non-invasive ventilation. Intake was converted from quartiles of food consumed into energy and protein to enable comparison with estimated daily requirements using descriptive statistics. Multinomial stepwise regression analysis was used to determine factors associated with inadequate protein and energy intake. Results Over 283 total days of intake, 36 participants (67% female, aged 65 ± 9 years) achieved on average 1434 ± 627 kcal and 63 ± 29 g protein daily. Overall, 28 patients (78%, 95% CI: 61–90%) met less than 80% of estimated energy requirements and 27 patients (75%, 95% CI: 58–88%) met less than 80% of estimated protein requirements. Being fed orally, longer time on non-invasive ventilation and higher BMI were associated with poorer intakes. Better nutritional status on admission and measuring intake closer to hospital discharge was associated with improved intakes. Conclusion Patients with acute respiratory failure requiring non-invasive ventilation often had inadequate oral intake, particularly with increasing time on non-invasive ventilation, and earlier during their hospital admission. Development of protocols to optimise nutritional intake for these patients may improve outcomes and reduce regular readmission rates.

Background: Ketosis is currently being utilized as treatment option in paediatric patients with resistant epilepsy. However, the evidence for efficacy in adult epilepsy and other neurological conditions is lacking. The purpose of this systematic review is to examine the evidence for inducing ketogenesis in adult humans with neurological and neurosurgical disorders, both acute and chronic. Method: We conducted a literature review through electronic databases, including Medline, the Cochrane Library and PubMed. Our search was focussed using the following MeSH terms: ketones, ketonaemia, Bhydroxybutyrate, ketogenic diet, adults, brain trauma, traumatic brain injury, status epilepticus, carbohydratefree diet, neurodegenerative disease, Parkinson’s disease, dementia, Alzheimer’s disease, mild cognitive impairment, intracranial bleed and subarachnoid haemorrhage. Results: From the literature search, we identified 14 publications that met the selection criteria for inclusion into this study. Of the 14 publications, 3 were randomised controlled trials, 10 were case series (6 prospective and 4 retrospective) and one was a non-randomised placebo control trial. Study subjects included Alzheimer’s disease, severe refractory status epilepticus, intracranial neoplasms, traumatic brain injury and idiopathic Parkinson’s disease. Although studies suggested ketosis may be beneficial, interpretation is limited by poor quality of evidence. Conclusion: This is the first systematic review of the role of ketones in the management of neurological and neurosurgical disorders. Ketone administration may prove beneficial in the management of a number of these conditions. Better quality studies are required before firm conclusions can be drawn.

Aim: Feeding algorithms have been demonstrated to improve nutrition delivery and influence primary outcomes in critical care units. Most feeding algorithms assist decision-making related to initiation of enteral nutrition, use of prokinetics and the mode of delivery of feeding. The algorithm that is the subject of this evaluation enabled nursing staff to select type of feed and target feeding rate for enterally fed patients. The aims of this evaluation were to assess acceptance of the algorithm across disciplines, and to determine if energy and protein intakes achieved were comparable with data reported in an international multi-centre observational study.

Objective Acute brain injury (ABI) is a catastrophic event, leading to disruption of the normal cerebral metabolic pathways and a subsequent cerebral energy deficit. Ketones (beta-hydroxybutyrate (BHB) and acetoacetate) may represent an alternative metabolic substrate with the potential to improve cerebral energy supply and decrease injury. The purpose of this study was to evaluate baseline ketone concentrations in the ABI population. Methods Thirty-eight patients with ABI were enrolled into the study and followed for up to 7 days. We collected arterial blood samples immediately after admission and daily to measure the levels of BHB and acetoacetate. Where possible, matching cerebrospinal fluid (CSF) specimens were also collected. Results During the study period, plasma BHB levels were increased initially but normalized by day 3 while acetoacetate levels remained within the normal range. The change in BHB was significant. There were 30 observations in 10 patients where BHB could be measured in both blood and CSF. When the data were averaged over patients there was a weak correlation between blood and CSF BHB (Spearman's ρ = 0.62, p = 0.054). Conclusion Blood ketone concentrations remain low within the ABI population. An external source of ketones will be required to increase blood concentrations to clinically relevant levels.

Background: Tracheostomies are commonly performed on critically ill patients requiring prolonged mechanical ventilation. The purpose of this study was to review our experience with surgical and percutaneous tracheostomies and identify factors affecting outcome. Materials and Methods: Patients who underwent tracheostomy between January 1999 and June 2008 were identified on the basis of Diagnostic Related Group coding and the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification procedural code. The primary endpoint was in-hospital mortality. Contingency tables were generated for clinical variables and a chi-squared test was used to determine significance. Results: One hundred and sixty-eight patients underwent tracheostomy between January 1999 and 30 June 2008. In-hospital mortality was 22.6%. The probability of death was found to be independent of timing of tracheostomy, technique used (percutaneous vs. surgical), number of failed extubations and obesity. On univariate analysis, the null hypothesis of independence was rejected for age on admission ( P = 0.014), diagnosis of sepsis ( P = 0.0008) or cardiac arrest ( P = 0.0016), Acute Physiology and Chronic Health Evaluation II score ( P = 0.0319) and the Australasian Outcomes Research Tool for Intensive Care calculated risk of death ( P = 0.0432). Conclusion: Although a number of patient factors are associated with worse outcome, tracheostomy appears to be a relatively safe technique in the Intensive Care Unit population.

Thromboelastography (TEG®) is a potentially useful tool but analysis within 4-6 min of collection imposes limitations on its use and access. The use of citrate blood tubes potentially increases the time frame for processing specimens. There is, however, limited research on the stability of citrate specimens, timing of processing and the accuracy of TEG® results. The purpose of this study was to examine the effects of early and delayed processing on TEG® parameters using kaolin-activated citrated blood samples in the intensive care population. TEG® analysis was performed on 61 patients. Blood was collected into two 3.2% sodium citrate (0.105 m) tubes. Kaolin-activated samples were analysed at 15, 30 and 120 min postcollection. TEG® parameters analysed included reaction time (R), clot formation time (K), alpha angle (α), maximum amplitude, LY30, the coagulation index, time to maximum rate of thrombus generation, maximum rate of thrombus generation and total thrombus generation. Sixty-one critically ill patients were included. The results of the anova showed that time from collection was significantly associated with the TEG® results (P < 0.05). On comparison of individual outcome variables, this difference in most cases was due to changes over time from 30 to 120 min. Furthermore, progressive changes in TEG® parameters such as decreasing R were suggestive of a trend toward hypercoagulability of the specimens. Processing of kaolin-activated citrate TEG® specimens can begin as early as 15 min postvenipuncture. However, delaying processing by more than 30 min leads to a significant change in results.