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Clostridioides difficile infection (CDI) remains a significant clinical challenge both in the management of severe and severe-complicated disease and the prevention of recurrence. Guidelines released by the Infectious Diseases Society of America and Society for Healthcare Epidemiology of America (IDSA/SHEA) and ESCMID had some consensus as well as some discrepancies in disease severity classification and treatment recommendations. We review and compare the key clinical strategies from updated IDSA/SHEA, ESCMID and current Australasian guidelines for CDI management in adults and discuss relevant issues for clinicians, particularly in the management of severe-complicated infection. Updated IDSA/SHEA and ESCMID guidelines now reflect the increased efficacy of fidaxomicin in preventing recurrence and have both promoted fidaxomicin to first-line therapy with an initial CDI episode in both non-severe and severe disease and endorsed the role of bezlotoxumab in the prevention of recurrent infection. Vancomycin remains acceptable therapy and metronidazole is not preferred. For severe-complicated infection the IDSA/SHEA recommends high-dose oral ± rectal vancomycin and IV metronidazole, whilst in an important development, ESCMID has endorsed fidaxomicin and tigecycline as part of combination anti-CDI therapy, for the first time. The role of faecal microbiota transplantation (FMT) in second CDI recurrence is now clearer, but timing and mode of FMT in severe-complicated refractory disease still requires further study.

The presence of treatment limitations in patients with frailty at intensive care unit (ICU) admission is unknown. We aimed to evaluate the presence and predictors of treatment limitations in patients with and without COVID-19 pneumonitis in those admitted to Australian and New Zealand ICUs.This registry-based multicenter, retrospective cohort study included all frail adults (≥16 years) with documented clinical frailty scale (CFS) scores, admitted to ICUs with admission diagnostic codes for viral pneumonia or acute respiratory distress syndrome (ARDS) over 2 years between January 01, 2020 and December 31, 2021. Frail patients (CFS ≥5) coded as having viral pneumonitis or ARDS due to COVID-19 were compared to those with other causes of viral pneumonitis or ARDS for documented treatment limitations.884 frail patients were included in the final analysis from 129 public and private ICUs. 369 patients (41.7%) had confirmed COVID-19. There were more male patients in COVID-19 (55.3% vs 47.0%; p = 0.015). There were no differences in age or APACHE-III scores between the two groups. Overall, 36.0% (318/884) had treatment limitations, but similar between the two groups (35.8% [132/369] vs 36.1% [186/515]; p = 0.92). After adjusting for confounders, increasing frailty (OR = 1.72; 95%-CI 1.39-2.14), age (OR = 1.05; 95%-CI 1.04-1.06), and presence of chronic respiratory condition (OR = 1.58; 95%-CI 1.10-2.27) increased the likelihood of instituting treatment limitations. However, the presence of COVID-19 by itself did not influence treatment limitations (odds ratio [OR] = 1.39; 95%-CI 0.98-1.96).The proportion of treatment limitations was similar in patients with frailty with or without COVID-19 pneumonitis at ICU admission.

BACKGROUND Code Blues allow a rapid, hospital wide response to acutely deteriorating patients. The concept of frailty is being increasingly recognised as an important element in determining outcomes of critically ill patients. We hypothesised that increasing frailty would be associated with worse outcomes following a Code Blue. AIMS We investigated the association between increasing frailty and outcomes of Code Blues. METHODS Single-centre retrospective design of patients admitted to Frankston Hospital in Australia between 1/1/13 and 31/12/17 who triggered a Code Blue. Frailty evaluation was made based on electronic medical records as were the details and the outcomes of the Code Blue. The primary outcome measure was a composite of hospital mortality or Cerebral Performance Categories (CPC) scale ≥3. Secondary outcomes included the immediate outcome of the Code Blue and hospital mortality. RESULTS 148 of 911 screened patients were included in the final analysis. 73 were deemed 'frail' and the remainder deemed 'fit'. 78% of frail patients reached the primary outcome, compared to 41% of fit patients (p

Rationale: Hypercapnia may affect the outcome of sepsis. Very few clinical studies conducted in noncritically ill patients have investigated the effects of hypercapnia and hypercapnic acidemia in the context of sepsis. The effect of hypercapnia in critically ill patients with sepsis remains inadequately studied. Objectives: To investigate the association of hypercapnia with hospital mortality in critically ill patients with sepsis. Methods: This is a retrospective study conducted in three tertiary public hospitals. Critically ill patients with sepsis from three intensive care units between January 2011 and May 2019 were included. Five cohorts (exposure of at least 24, 48, 72, 120, and 168 hours) were created to account for immortal time bias and informative censoring. The association between hypercapnia exposure and hospital mortality was assessed with multivariable models. Subgroup analyses compared ventilated versus nonventilated and pulmonary versus nonpulmonary sepsis patients. Results: We analyzed 84,819 arterial carbon dioxide pressure measurements in 3,153 patients (57.6% male; median age was 62.5 years). After adjustment for key confounders, both in mechanically ventilated and nonventilated patients and in patients with pulmonary or nonpulmonary sepsis, there was no independent association of hypercapnia with hospital mortality. In contrast, in ventilated patients, the presence of prolonged exposure to both hypercapnia and acidemia was associated with increased mortality (highest odds ratio of 16.5 for ⩾120 hours of potential exposure; P = 0.007). Conclusions: After adjustment, isolated hypercapnia was not associated with increased mortality in patients with sepsis, whereas prolonged hypercapnic acidemia was associated with increased risk of mortality. These hypothesis-generating observations suggest that as hypercapnia is not an independent risk factor for mortality, trials of permissive hypercapnia avoiding or minimizing acidemia in sepsis may be safe.

OBJECTIVE Hospitalised frail older patients are at risk of clinical deterioration. Early goals of care documentation (GOC) is vital to avoid futile/unwarranted interventions in the event of deterioration. We aimed to investigate the impact of frailty on timely GOC and its association with clinical outcomes in hospitalised older patients. DESIGN, SETTING, PARTICIPANTS Single-centre retrospective study of all medical patients aged ≥80 years admitted to acute medical unit between 1/3/2015 and 31/8/2015, with GOC derived from electronic records. Frailty was measured using Hospital Frailty Risk Score (HFRS) derived from hospital coding data. MAIN OUTCOME MEASURES Primary outcome compared proportions timely GOC within 72-h between frail (HFRS≥5) and non-frail (HFRS

BackgroundMelbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020).MethodsWe used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020.ResultsED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and ConclusionsOur analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne’s lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.

Supplemental Digital Content is available in the text., OBJECTIVES: Several studies have reported prone positioning of nonintubated patients with coronavirus diseases 2019–related hypoxemic respiratory failure. This systematic review and meta-analysis evaluated the impact of prone positioning on oxygenation and clinical outcomes. DESIGN AND SETTING: We searched PubMed, Embase, and the coronavirus diseases 2019 living systematic review from December 1, 2019, to November 9, 2020. SUBJECTS AND INTERVENTION: Studies reporting prone positioning in hypoxemic, nonintubated adult patients with coronavirus diseases 2019 were included. MEASUREMENTS AND MAIN RESULTS: Data on prone positioning location (ICU vs non-ICU), prone positioning dose (total minutes/d), frequency (sessions/d), respiratory supports during prone positioning, relative changes in oxygenation variables (peripheral oxygen saturation, Pao2, and ratio of Pao2 to the Fio2), respiratory rate pre and post prone positioning, intubation rate, and mortality were extracted. Twenty-five observational studies reporting prone positioning in 758 patients were included. There was substantial heterogeneity in prone positioning location, dose and frequency, and respiratory supports provided. Significant improvements were seen in ratio of Pao2 to the Fio2 (mean difference, 39; 95% CI, 25–54), Pao2 (mean difference, 20 mm Hg; 95% CI, 14–25), and peripheral oxygen saturation (mean difference, 4.74%; 95% CI, 3–6%). Respiratory rate decreased post prone positioning (mean difference, –3.2 breaths/min; 95% CI, –4.6 to –1.9). Intubation and mortality rates were 24% (95% CI, 17–32%) and 13% (95% CI, 6–19%), respectively. There was no difference in intubation rate in those receiving prone positioning within and outside ICU (32% [69/214] vs 33% [107/320]; p = 0.84). No major adverse events were recorded in small subset of studies that reported them. CONCLUSIONS: Despite the significant variability in frequency and duration of prone positioning and respiratory supports applied, prone positioning was associated with improvement in oxygenation variables without any reported serious adverse events. The results are limited by a lack of controls and adjustments for confounders. Whether this improvement in oxygenation results in meaningful patient-centered outcomes such as reduced intubation or mortality rates requires testing in well-designed randomized clinical trials.

BACKGROUND: To allow better allocation of staff and resources, rapid response teams attending to acutely deteriorating or aggressive patients with suspected or confirmed COVID-19 infection were pre-warned with the announcement of 'Code-95' with calls. AIM: To assess healthcare worker (HCW) perspectives on pre-warning rapid response calls (RRC) with 'Code-95' in announcements when attending to deteriorating or aggressive patients with suspected/confirmed COVID-19 infection. METHODS: Design: prospective cross-sectional single-centre survey of HCW over a 3-week period. SETTING: tertiary public hospital. PARTICIPANTS: HCW caring for deteriorating or aggressive patients. MAIN OUTCOME MEASURES: the primary outcome was to assess HCW perspectives in attending Code-95 calls. Secondary outcomes were to identify any differences related to craft group, age, experience or presence of comorbidities. RESULTS: A total of 297 responses was analysed; 86.7% of HCW (n = 257) attending Code-95 calls reported anxiety. Medical staff reported greater anxiety in comparison to nursing staff (93.8% vs 78.5%; P = 0.002). Efferent team reported higher anxiety in contrast to afferent team (92.6% vs 58.8%; P = 0.021). There was no significant difference in perceived anxiety based on age (≤40 vs >40 years of age), years of experience (≤5 vs >5 years), comorbidities or mental illness; 54% reported concerns about adequacy of infection-control policies and personal protective equipment; 45% were worried about inadequate training for responding to Code-95 calls. CONCLUSIONS: Most surveyed HCW supported Code-95 announcements pre-warning them of potential COVID-19 exposure when attending a RRC. However, the majority of HCW reported anxiety when attending these calls. Medical and efferent team HCW perceived greater anxiety compared to nursing and afferent team HCW. The Code-95 system to pre-warn rapid response teams may be a useful addition to protecting HCW from infectious diseases, although broader implementation will require greater resourcing, training and support.

Background There are currently no validated globally and freely available tools to estimate the modified frailty index (mFI). The widely available and non-proprietary International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) coding could be used as a surrogate for the mFI. We aimed to establish an appropriate set of the ICD-10 codes for comorbidities to be used to estimate the eleven-variable mFI. Methods A three-stage, web-based, Delphi consensus-building process among a panel of intensivists and geriatricians using iterative rounds of an online survey, was conducted between March and July 2021. The consensus was set a priori at 75% overall agreement. Additionally, we assessed if survey responses differed between intensivists and geriatricians. Finally, we ascertained the level of agreement. Results A total of 21 clinicians participated in all 3 Delphi surveys. Most (86%, 18/21) had more than 5-years’ experience as specialists. The agreement proportionately increased with every Delphi survey. After the third survey, the panel had reached 75% consensus in 87.5% (112/128) of ICD-10 codes. The initially included 128 ICD-10 variables were narrowed down to 54 at the end of the 3 surveys. The inter-rater agreements between intensivists and geriatricians were moderate for surveys 1 and 3 (κ = 0.728, κ = 0.780) respectively, and strong for survey 2 (κ = 0.811). Conclusions This quantitative Delphi survey of a panel of experienced intensivists and geriatricians achieved consensus for appropriate ICD-10 codes to estimate the mFI. Future studies should focus on validating the mFI estimated from these ICD-10 codes. Trial registration Not applicable.

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.

A combination of pregabalin and tapentadol may be associated with prolonged encephalopathy., A combination of rregabalin and tapentadol may be associated with prolonged encephalopathy.

Rationale: ICU discharge delay occurs when a patient is considered ready to be discharged but remains in the ICU. The effect of discharge delay on patient outcomes is uncertain.Objectives: To investigate the association between discharge delay and patient outcomes including hospital mortality, readmission to ICU, and length of hospital stay after ICU discharge.Methods: Data were accessed from the Australian and New Zealand Intensive Care Society Adult Patient Database between 2011 and 2019. Descriptive analyses and hierarchical logistic and Cox proportional hazards regression were used to examine association between discharge delay and adjusted outcomes. Patients were stratified and analyzed by categories of mortality risk at ICU admission.Measurements and Main Results: The study included 1,014,540 patients from 190 ICUs: 756,131 (75%) were discharged within 6 hours of being deemed ready, with 137,042 (13%) discharged in the next 6 hours; 17,656 (2%) were delayed 48-72 hours; 31,389 (3.1%) died in hospital; and 45,899 (4.5%) patients were readmitted to ICU. Risk-adjusted mortality declined with increasing discharge delay and was lowest at 48-72 hours (adjusted odds ratio, 0.87; 95% confidence interval, 0.79-0.94). The effect was seen in patients with predicted risk of death on admission to ICU of greater than 5% (adjusted odds ratio, 0.77; 95% confidence interval, 0.70-0.84). There was a progressive reduction in adjusted odds of readmission with increasing discharge delay.Conclusions: Increasing discharge delay in ICUs is associated with reduced likelihood of mortality and ICU readmission in high-risk patients. Consideration should be given to delay the discharge of patients with high risk of death on ICU admission.

Background Metabolic acidosis is a major complication of critical illness. However, its current epidemiology and its treatment with sodium bicarbonate given to correct metabolic acidosis in the ICU are poorly understood. Method This was an international retrospective observational study in 18 ICUs in Australia, Japan, and Taiwan. Adult patients were consecutively screened, and those with early metabolic acidosis (pH Results We screened 9437 patients. Of these, 1292 had early metabolic acidosis (14.0%). Early sodium bicarbonate was given to 18.0% (233/1292) of these patients. Dosing, physiological, and clinical outcome data were assessed in 360 patients. The median dose of sodium bicarbonate in the first 24 h was 110 mmol, which was not correlated with bodyweight or the severity of metabolic acidosis. Patients who received early sodium bicarbonate had higher APACHE III scores, lower pH, lower base excess, lower PaCO2, and a higher lactate and received higher doses of vasopressors. After adjusting for confounders, the early administration of sodium bicarbonate was associated with an adjusted odds ratio (aOR) of 0.85 (95% CI, 0.44 to 1.62) for ICU mortality. In patients with vasopressor dependency, early sodium bicarbonate was associated with higher mean arterial pressure at 6 h and an aOR of 0.52 (95% CI, 0.22 to 1.19) for ICU mortality. Conclusions Early metabolic acidosis is common in critically ill patients. Early sodium bicarbonate is administered by clinicians to more severely ill patients but without correction for weight or acidosis severity. Bicarbonate therapy in acidotic vasopressor-dependent patients may be beneficial and warrants further investigation.

Background: Type II myocardial injury following surgical procedures is associated with adverse outcomes. The prognostic value of prognostic value of high-sensitivity cardiac troponin (hs-cTn) due to type II myocardial injury in surgical patients admitted to intensive care unit (ICU) remains unclear. The aim of this study was to assess prognostic value of hs-cTn in type II acute myocardial injury in noncardiac surgical patients requiring post-operative ICU admission.Methods: Retrospective analysis of patients admitted to two level III ICUs following surgery and had hs-cTn measured on the day of ICU admission. Patients who had type I acute myocardial infarction (AMI) during their admission were excluded from the study. The primary outcome was hospital mortality. Secondary outcomes included ICU mortality, ICU length of stay (LOS) and hospital LOS.Results: A total of 420 patients were included. On univariable analysis, higher hs-cTn was associated with increased hospital mortality (14.6% vs 6.3%, p = 0.008), ICU LOS (41.1, vs 25 hours, p = 0.004) and hospital LOS (253 hours vs 193 hours, p = 0.02). On multivariable analysis, hs-cTn was not independently associated with increased risk of hospital mortality. However, in patients who had elective surgery, hs-cTn was associated with increased risk (OR 1.048; 95% CI 1.004-1.094; p = 0.031) of hospital morality with area under the receiver operating characteristic curves of 0.753 (95% CI 0.598- 0.908).Conclusions: In elective surgical patients, hs-cTn was associated with increased risk of mortality. Larger multicentre studies are required to confirm this association that may assist in risk stratification of elective surgical patients requiring ICU admission.

Objectives: To compare the characteristics and outcomes of patients presenting to hospital with alcohol-induced and gallstone-induced acute pancreatitis. Methods: Retrospective study of all patients with alcohol-induced or gallstone-induced pancreatitis during the period 1 June 2012 to 31 May 2016. The primary outcome measure was hospital mortality. Secondary outcome measures included hospital length of stay, requirements for intensive care unit admission, intensive care unit mortality, mechanical ventilation, renal replacement therapy, requirement of inotropes and total parenteral nutrition. Results: A total of 642 consecutive patients (49% alcohol; 51% gallstone) were included. No statistically significant differences were found between alcohol-induced and gallstone-induced acute pancreatitis with respect to hospital mortality, requirement for intensive care unit admission, intensive care unit mortality and requirement for mechanical ventilation, renal replacement therapy, inotropes or total parenteral nutrition. There was significant difference in hospital length of stay (3.07 versus 4.84; p Conclusion: Hospital mortality did not differ between patients with alcohol-induced and gallstone-induced acute pancreatitis. The duration of hospital stay was longer with gallstone-induced pancreatitis. Bedside Index of Severity in Acute Pancreatitis score and admission haematocrit were independently associated with hospital length of stay.

Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels.The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital.Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for48 h and expected to have a total ICU stay of5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU.High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures.Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness.ACTRN12615000047594.

Preoperative frailty may be a strong predictor of adverse postoperative outcomes. We investigated the association between frailty and clinical outcomes in surgical patients admitted to the ICU.PubMed, Embase, and Ovid MEDLINE were searched for relevant articles. We included full-text original English articles that used any frailty measure, reporting results of surgical adult patients (≥18 yr old) admitted to ICUs with mortality as the main outcome. Data on mortality, duration of mechanical ventilation, ICU and hospital length of stay, and discharge destination were extracted. The quality of included studies and risk of bias were assessed using the Newcastle Ottawa Scale. Data were synthesised according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines.Thirteen observational studies met inclusion criteria. In total, 58 757 patients were included; 22 793 (39.4%) were frail. Frailty was associated with an increased risk of short-term (risk ratio [RR]=2.66; 95% confidence interval [CI]: 1.99-3.56) and long-term mortality (RR=2.66; 95% CI: 1.32-5.37). Frail patients had longer ICU length of stay (mean difference [MD]=1.5 days; 95% CI: 0.8-2.2) and hospital length of stay (MD=3.9 days; 95% CI: 1.4-6.5). Duration of mechanical ventilation was longer in frail patients (MD=22 h; 95% CI: 1.7-42.3) and they were more likely to be discharged to a healthcare facility (RR=2.34; 95% CI: 1.36-4.01).Patients with frailty requiring postoperative ICU admission for elective and non-elective surgeries had increased risk of mortality, lengthier admissions, and increased likelihood of non-home discharge. Preoperative frailty assessments and risk stratification are essential in patient and clinician planning, and critical care resource utilisation.PROSPERO CRD42020210121.

Background Coronavirus disease-2019 (COVID-19) has effected major changes to healthcare delivery within acute care settings. Rapid response calls (RRCs) in healthcare organisations have been effective at identifying and urgently managing acute clinical deterioration. Code-95 RRC were introduced to prewarn healthcare workers (HCWs) attending to patients suspected or confirmed with COVID-19 infection. Aims The primary aim of the study was to identify the personal impact of the COVID-19 pandemic on HCWs involved in attending Code-95 RRC. We sought to evaluate their perception of risks and effects on wellbeing and identify potential opportunities for improvement at organisational levels. Methods We undertook a detailed survey on HCWs attending Code-95 RRCs, including questions that sought to understand the impact of the pandemic as well as their perception of infection risk and emotional wellbeing. This was a substudy of the prospective cross-sectional single-centre survey of HCWs that was conducted over a 3-week period at Frankston Hospital, Victoria, Australia. We adopted a quantitative content analysis approach for free-text responses in this secondary analysis. Results Four hundred two free-text comments were received from 297 respondents and were analysed. More than two-thirds (68%, 223/297) were female. Of all comments, 39% (155/402) were related to organisational issues including communication, confusion due to constantly changing infection control policies, and insufficient training. Thirty-three percent of comments (133/402) raised issues regarding the adequacy of personal protective equipment. Anxiety was reported in 25% of comments (101/402) with concerns predominantly relating to emotional stress and fatigue, risks of virus exposure and transmitting the infection to others, and COVID-19 precautions impairing care delivery. Conclusion(s) Our study raises important issues that have relevance for all healthcare organisations in the management of patients with COVID-19. These include the importance of improving communication, especially when infection control policies are revised, optimising training, maintaining adequate personal protective equipment, and HCW support. Early recognition and management of these issues are crucial to maintain optimal healthcare delivery.

Key Clinical Message Sodium–glucose cotransporter 2 inhibitors (SGLT2Is) can be associated with euglycemic diabetic ketoacidosis (eDKA). Severe metabolic acidosis with extreme electrolyte abnormalities can occur with nonsignificant blood glucose elevations in SGLT2I‐treated patients. Additional risk factors for eDKA include prolonged fasting, major illness, large weight loss, and reductions in insulin doses.

Objective Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine whether NP-led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR)-led MET calls. Methods The composite primary outcome included recurrence of MET call, occurrence of code blue or ICU admission within 24 h. Secondary outcomes were mortality within 24 h of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group. Results A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR-led MET calls (26.7% vs. 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 h (3.4% vs. 7.7%, p = 0.002) and hospital mortality (12.7% vs. 20.5%, p = 0.001) were higher in ICUR-led MET calls. Propensity score-matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups, but NP-led group was associated with reduced risk of hospital mortality (OR 0.57, 95% CI 0.35–0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09–2.2, p = 0.015). Conclusion Acute patient deterioration was comparable between ICUR- and NP-led MET calls. NP-led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

Background Coronavirus disease 2019 (COVID-19) pandemic has caused unprecedented pressure on healthcare system globally. Lack of high-quality evidence on the respiratory management of COVID-19-related acute respiratory failure (C-ARF) has resulted in wide variation in clinical practice. Methods Using a Delphi process, an international panel of 39 experts developed clinical practice statements on the respiratory management of C-ARF in areas where evidence is absent or limited. Agreement was defined as achieved when > 70% experts voted for a given option on the Likert scale statement or > 80% voted for a particular option in multiple-choice questions. Stability was assessed between the two concluding rounds for each statement, using the non-parametric Chi-square (χ2) test (p Results Agreement was achieved for 27 (73%) management strategies which were then used to develop expert clinical practice statements. Experts agreed that COVID-19-related acute respiratory distress syndrome (ARDS) is clinically similar to other forms of ARDS. The Delphi process yielded strong suggestions for use of systemic corticosteroids for critical COVID-19; awake self-proning to improve oxygenation and high flow nasal oxygen to potentially reduce tracheal intubation; non-invasive ventilation for patients with mixed hypoxemic-hypercapnic respiratory failure; tracheal intubation for poor mentation, hemodynamic instability or severe hypoxemia; closed suction systems; lung protective ventilation; prone ventilation (for 16–24 h per day) to improve oxygenation; neuromuscular blocking agents for patient-ventilator dyssynchrony; avoiding delay in extubation for the risk of reintubation; and similar timing of tracheostomy as in non-COVID-19 patients. There was no agreement on positive end expiratory pressure titration or the choice of personal protective equipment. Conclusion Using a Delphi method, an agreement among experts was reached for 27 statements from which 20 expert clinical practice statements were derived on the respiratory management of C-ARF, addressing important decisions for patient management in areas where evidence is either absent or limited. Trial registration: The study was registered with Clinical trials.gov Identifier: NCT04534569.

Additional file 1. Supplementary materials include detailed methods and supplementary results as referenced inthe article.

Objective: Medical emergency teams (MET) are mostly led by physicians. Some hospitals are currently using nurse practitioners (NP) to lead MET calls. These are no studies comparing clinical outcomes between these two care models. To determine if NP led MET calls are associated with lower risk of acute patient deterioration, when compared to intensive care (ICU) registrar (ICUR) led MET calls.Methods: The composite primary outcome included recurrence of MET call, occurrence of Code blue or ICU admission within 24 hours. Secondary outcomes were mortality within 24 hours of MET call, length of hospital stay, hospital mortality and proportion of patients discharged home. Propensity score matching was used to reduce selection bias from confounding factors between the ICUR and NP group.Results: A total of 1343 MET calls were included (1070 NP, 273 ICUR led). On Univariable analysis, the incidence of the primary outcome was higher in ICUR led MET calls (26.7% vs 20.6%, p = 0.03). Of the secondary outcome measures, mortality within 24 hours (3.4% vs 7.7%, p = 0.002) and hospital mortality (12.7% vs 20.5%, p = 0.001) was higher in ICUR led MET calls. Propensity score matched analysis of 263 pairs revealed the composite primary outcome was comparable between both groups but NP led group was associated with reduced risk of hospital mortality (OR 0.57, 95%CI 0.35-0.91, p = 0.02) and higher likelihood of discharge home (OR 1.55, 95% CI 1.09-2.2, p=0.015). Conclusion: Acute patient deterioration was comparable between ICUR and NP led MET Calls. NP led MET calls were associated with lower hospital mortality and higher likelihood of discharge home.

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).

PurposeSeveral studies have reported adopting prone positioning (PP) in non-intubated patients with COVID-19-related hypoxaemic respiratory failure. This systematic review and meta-analysis evaluated the impact of PP on oxygenation and clinical outcomes.MethodsWe searched PubMed, Embase and COVID-19 living systematic review from December1st 2019 to July23rd 2020. We included studies that reported using PP in hypoxaemic, non-intubated adult COVID-19 patients. Primary outcome measure was the weighted mean difference (MD) in oxygenation parameters (PaO2/FiO2, PaO2 or SpO2) pre and post-PP.ResultsFifteen single arm observational studies reporting PP in 449 patients were included. Substantial heterogeneity was noted in terms of, location within hospital where PP was instituted, respiratory supports, frequency and duration of PP. Significant improvement in oxygenation was reported post-PP: PaO2/FiO2, (MD 37.6, 95%CI 18.8, 56.5); PaO2, (MD 30.4 mmHg, 95%CI 10.9, 49.9); and SpO2, (MD 5.8%, 95%CI 3.7, 7.9). Patients with a pre-PP PaO2/FiO2 ≤150 experienced greater oxygenation improvements compared with those with a pre-PP PaO2/FiO2 >150 (MD 40.5, 95%CI −3.5, 84.6) vs. 37, 95%CI 17.1, 56.9). Respiratory rate decreased post-PP (MD −2.9, 95%CI −5.4, −0.4). Overall intubation and mortality rates were 21% (90/426) and 26% (101/390) respectively. No major adverse events were reported.ConclusionsDespite significant variability in frequency and duration of PP and respiratory supports, PP was associated with improvements in oxygenation parameters without any reported serious adverse events. Major limitation being lack of control arm and adjustment for confounders. Clinical trials are required to determine the effect of awake PP on patient-centred outcomes.Systematic review registrationRegistration/protocol in PROSPERO (CRD42020194080).What is the key question?Is the novel approach of prone positioning in non-intubated patients associated with improvement in oxygenation?What is the bottom line?Prone position in non-intubated severe COIVD 19 suffers is associated with improvement of oxygenation while the short- and long-term patient centred out comes in this awake prone patient need more investigation.Why read on?Our study is first of its kind (Systematic review and Meta-analysis) summarising the evidence surrounding the less invasive innovate technique of prone position in non-intubated COVID-19 patients.

Good quality sleep is considered to be essential for healthy living and recovering from illness. It would be logical to think that good quality sleep is most required when a patient is critically ill in an intensive care unit (ICU). Several studies have demonstrated poor quality of sleep while the patients are in ICU. Subjective tools such as questionnaires while simple are unreliable to accurately assess sleep quality. Relatively few studies have used standardized polysomnography. The use of novel biological markers of sleep such as serum brain-derived neurotrophic factor concentrations may help in conjunction with polysomnography to assess sleep quality in critically ill patients. Attempts to improve sleep included nonpharmacological interventions including the use of earplugs, eye sleep masks, and pharmacological agents including ketamine, propofol, dexmedetomidine, and benzodiazepines. The evidence for these interventions remains unclear. Further research is needed to assess quality of sleep and improve the sleep quality in intensive care settings.

Purpose Current guidelines recommend withholding sodium–glucose cotransporter 2 inhibitors perioperatively due to concerns of euglycaemic diabetic ketoacidosis. However, such guidelines are largely based on case reports and small case series, many extrapolated from non-surgical patients. The aim was to investigate whether withholding sodium–glucose cotransporter 2 inhibitors as per current perioperative guidelines was associated with a reduction in serious adverse events, including euglycaemic diabetic ketoacidosis. Methods Instances of perioperative management of sodium–glucose cotransporter 2 inhibitors, over a four-year period were classified into two categories: those where sodium–glucose cotransporter 2 inhibitors were withheld as per guidelines and those where sodium–glucose cotransporter 2 inhibitors were administered in the perioperative period. The primary outcome was ‘total major perioperative complications’: a composite of serious adverse events including euglycaemic diabetic ketoacidosis, diabetic ketoacidosis, acute kidney injury, urosepsis and death. Results Eighty-two instances in 64 patients were included. Withholding sodium–glucose cotransporter 2 inhibitors was associated with an increased incidence of total major perioperative complications and poorer glycaemic control postoperatively. Multivariable logistic regression analysis revealed that withholding sodium–glucose cotransporter 2 inhibitors perioperatively (OR = 13.15; 95% CI = 1.8–138.9) and preoperative urea (OR 1.85 (95% CI = 1.17–3.43) were independently associated with an increase in total major postoperative complications. Conclusion Withholding sodium–glucose cotransporter 2 inhibitors as per current guidelines was associated with an increase in postoperative complications and reduced glycaemic control.

The use of lower tidal volume ventilation was shown to improve survival in mechanically ventilated patients with acute lung injury. In some patients this strategy may cause hypercapnic acidosis. A significant body of recent clinical data suggest that hypercapnic acidosis is associated with adverse clinical outcomes including increased hospital mortality. We aimed to review the available treatment options that may be used to manage acute hypercapnic acidosis that may be seen with low tidal volume ventilation. The databases of MEDLINE and EMBASE were searched. Studies including animals or tissues were excluded. We also searched bibliographic references of relevant studies, irrespective of study design with the intention of finding relevant studies to be included in this review. The possible options to treat hypercapnia included optimising the use of low tidal volume mechanical ventilation to enhance carbon dioxide elimination. These include techniques to reduce dead space ventilation, and physiological dead space, use of buffers, airway pressure release ventilation and prone positon ventilation. In patients where hypercapnic acidosis could not be managed with lung protective mechanical ventilation, extracorporeal techniques may be used. Newer, minimally invasive low volume venovenous extracorporeal devices are currently being investigated for managing hypercapnia associated with low and ultra-low volume mechanical ventilation.

Objective: To describe the characteristics of patients presenting to an Emergency Department (ED) following overdoses; to identify risk factors for intensive care unit (ICU) admission among these patients; and to identify the rate of mortality and repeat overdose presentations over four years. Methods: Adult patients presenting to ED following drug overdose during 2014 were included. Data were collected from medical notes and hospital databases. Results: During the study period, 654 patients presented to ED 800 times following overdose. Seventy-eight (9.8%) resulted in ICU admission, and 59 (7.4%) required intubation; 57.2% had no history of overdose presentations, and 72.9% involved patients with known psychiatric illness. Overdose of atypical antipsychotics (AAP), age and history of prior overdose independently predicted ICU admission. A third of patients ( n = 196, 30%) had subsequent presentations to ED following overdose, in the four years from their index presentation, with an all-cause four-year mortality of 3.4% ( n = 22). Conclusion: A history of overdose, use of AAP and older age were risk factors for ICU admission following ED presentations. Over a third of patients had repeat overdose presentation in the four-year follow-up with a mortality of 3.4%.

Key Clinical Message Given the current understanding of bleomycin‐induced pneumonitis (BIP), the use of tumor necrosis factor alpha (TNF‐α) inhibitors such as infliximab for late‐stage disease appears to be of limited benefit. Further research regarding prevention and management of advanced BIP is required.

A retrospective observational study of 21 patients admitted to the Intensive Care Unit (ICU) of Frankston Hospital with acute asthma between 2011 and 2014 was undertaken. We report the outcomes for three groups of patients; those that did (n = 7) or did not (n = 6) receive initial therapy with non-invasive ventilation (NIV) together with those that received invasive ventilation (n = 8). Patients successfully managed with NIV alone experienced a shorter ICU and hospital stay versus those who required invasive ventilation.

Background Patients who are intubated in the ICU are at risk of developing pressure injuries to the mouth and lips from endotracheal tubes. Clear documentation is important for pressure wound care; however, no validated instruments currently exist for the staging of pressure injuries to the oral mucosa. Instruments designed for the assessment of pressure injuries to other bodily regions are anatomically unsuited to the lips and mouth. Objectives This study aimed to develop and then assess the reliability of a novel scale for the assessment of pressure injuries to the mouth and oral mucosa. Methods The Reaper Oral Mucosa Pressure Injury Scale (ROMPIS) was developed in consultation with ICU nurses, clinical nurse educators, Intensivists, and experts in pressure wound management. ICU nurses and portfolio-holders in pressure wound care from Peninsula Health (Victoria, Australia) were invited to use the ROMPIS to stage 19 de-identified clinical photographs of oral pressure injuries via secure online survey. Inter-rater reliability (IRR) was calculated using Krippendorff's alpha ( α ). Results Among ICU nurses ( n = 52), IRR of the ROMPIS was α = 0.307; improving to α = 0.463 when considering only responses where injuries were deemed to be stageable using the ROMPIS (i.e. excluding responses where respondents considered an injury to be unstageable). Among a cohort of experts in pressure wound care ( n = 8), IRR was α = 0.306; or α = 0.443 excluding responses indicating that wounds were unstageable. Conclusions An instrument for the assessment and monitoring of pressure injuries to the mouth and lips has practical implications for patient care. This preliminary study indicates that the ROMPIS instrument has potential to be used clinically for this purpose; however, the performance of this scale may be somewhat reliant on the confidence or experience of the ICU nurse utilising it. Further validation is required.

To investigate the self-reported quality of sleep of non-mechanically ventilated patients admitted to an ICU, and to identify barriers to sleep in this setting.Patients admitted to the ICU of Frankston Hospital over a two month period who had spent at least one night in the ICU, and had not received mechanical ventilation were surveyed as they were discharged from the ICU. This survey required patients to rate the quality of their sleep in the ICU and at home immediately prior to hospitalisation on a 10cm visual analogue scale; and to identify perceived barriers to sleep in the ICU and at home prior to hospitalisation.56 respondents were surveyed during the study period. Median age was 74 years (range=18-92 years); median ICU length of stay was 1 day (range=1-7 days). Overall, respondents rated their quality of sleep in ICU (median=4.9/10) as significantly worse than at home immediately prior to ICU admission (median=7.15/10; Z=-3.02, p0.002); however 44% of respondents rated their quality of sleep in ICU as better, or no worse, than at home immediately prior to hospitalisation. Sub-group analysis revealed that among patients with reduced quality of sleep (5/10) prior to hospitalisation, 71.4% rated their quality of sleep in ICU as better, or no worse, than at home prior to hospitalisation, with no significant difference between sleep quality ratings in ICU and at home (p=0.341). Respondents identified the following as barriers to sleep in the ICU: noise levels overnight (53.6%); discomfort (33.9%); pain (32.1%); being awoken for procedures (32%); being attached to medical devices (28.6%); stress/anxiety (26.8%); and light levels (23.2%).Pre-hospitalisation sleep quality appears to be an important influence on sleep in ICU. Many barriers to sleep in the ICU identified by respondents are potentially modifiable.