ORCID Profile
0000-0003-4707-7462
Current Organisations
Australian and New Zealand College of Anaesthetists
,
College of Intensive Care Medicine of Australia and New Zealand
,
Australian Institute of Company Directors
,
Monash University
,
Monash Health
,
University of Technology Sydney
,
University of New South Wales
,
University of Jordan
,
UNSW Prince of Wales Clinical School
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Publications
Prevalence of Delirium with Dexmedetomidine Compared with Morphine Based Therapy after Cardiac Surgery
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 11-2009
DOI: 10.1097/ALN.0B013E3181B6A783
Abstract: Commonly used sedatives/analgesics can increase the risk of postoperative complications, including delirium. This double-blinded study assessed the neurobehavioral, hemodynamic, and sedative characteristics of dexmedetomidine compared with morphine-based regimen after cardiac surgery at equivalent levels of sedation and analgesia. A total of 306 patients at least 60 yr old were randomized to receive dexmedetomidine (0.1-0.7 microg x kg(-1) x h(-1)) or morphine (10-70 microg x kg(-1) x h(-1)) with open-label propofol titrated to a target Motor Activity Assessment Scale of 2-4. Primary outcome was the prevalence of delirium measured daily via Confusion Assessment Method for intensive care. Secondary outcomes included ventilation time, additional sedation/analgesia, and hemodynamic and adverse effects. Of all sedation assessments, 75.2% of dexmedetomidine and 79.6% (P = 0.516) of morphine treatment were in the target range. Delirium incidence was comparable between dexmedetomidine 13 (8.6%) and morphine 22 (15.0%) (relative risk 0.571, 95% confidence interval [CI] 0.256-1.099, P = 0.088), however, dexmedetomidine-managed patients spent 3 fewer days (2 [1-7] versus 5 [2-12]) in delirium (95% CI 1.09-6.67, P = 0.0317). The incidence of delirium was significantly less in a small subgroup requiring intraaortic balloon pump and treated with dexmedetomidine (3 of 20 [15%] versus 9 of 25 [36%]) (relative risk 0.416, 95% CI 0.152-0.637, P = 0.001). Dexmedetomidine-treated patients were more likely to be extubated earlier (relative risk 1.27, 95% CI 1.01-1.60, P = 0.040, log-rank P = 0.036), experienced less systolic hypotension (23% versus 38.1%, P = 0.006), required less norepinephrine (P & 0.001), but had more bradycardia (16.45% versus 6.12%, P = 0.006) than morphine treatment. Dexmedetomidine reduced the duration but not the incidence of delirium after cardiac surgery with effective analgesia/sedation, less hypotension, less vasopressor requirement, and more bradycardia versus morphine regimen.
Angiotensin-converting enzyme inhibitor usage and acute kidney injury: A secondary analysis of RENAL study outcomes
Publisher: Wiley
Date: 27-09-2014
DOI: 10.1111/NEP.12284
Abstract: Acute kidney injury (AKI) is associated with increased mortality. While angiotensin-converting enzyme inhibitors (ACEI) are known to slow progression of chronic kidney disease, their role in AKI remains unclear. The Randomised Evaluation of Normal vs. Augmented Level Replacement Therapy (RENAL) study data were analysed according to ACEI use over time. The primary outcome was all-cause mortality at 90 days following randomisation. Analyses used a multivariate Cox model adjusted for either baseline or for time-dependent covariates, and a sensitivity analysis of patients surviving to at least the median time to ACEI initiation. Of the 1463 participants with available data on ACE inhibitors usage, 142 (9.7%) received ACEI at least once during study data collection. Participants treated with ACEI were older (P = 0.02) and had less sepsis at baseline (P < 0.001). ACEI use was significantly associated with lower mortality at 90 days (HR 0.46, 95% CI 0.30-0.71, P < 0.001), and an increase in renal replacement therapy-free days (P < 0.001), intensive care unit-free days (P < 0.001) and hospital free-days (P < 0.001) after adjusting for baseline covariates. Using the time-dependent analysis, however, the effect of ACEI administration was not significant (HR 0.78, 95% CI 0.51-1.21, P = 0.3). The sensitivity analysis in day 8 survivors produced similar results. In the RENAL study cohort, the use of ACEI during the study was not common and, after adjustment for time-dependent covariates, was not significantly associated with reductions in mortality. Further assessment of the effect of ACEI use in AKI patients is needed.
A cost-minimization analysis of dexmedetomidine compared with midazolam for long-term sedation in the intensive care unit*
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 02-2010
Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition A Randomized Controlled Trial
Publisher: American Medical Association (AMA)
Date: 22-05-2013
Abstract: Systematic reviews suggest adult patients in intensive care units (ICUs) with relative contraindications to early enteral nutrition (EN) may benefit from parenteral nutrition (PN) provided within 24 hours of ICU admission. To determine whether providing early PN to critically ill adults with relative contraindications to early EN alters outcomes. Multicenter, randomized, single-blind clinical trial conducted between October 2006 and June 2011 in ICUs of 31 community and tertiary hospitals in Australia and New Zealand. Participants were critically ill adults with relative contraindications to early EN who were expected to remain in the ICU longer than 2 days. Random allocation to pragmatic standard care or early PN. Day-60 mortality quality of life, infections, and body composition. A total of 1372 patients were randomized (686 to standard care, 686 to early PN). Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI, 36 to 55). Day-60 mortality did not differ significantly (22.8% for standard care vs 21.5% for early PN risk difference, -1.26% 95% CI, -6.6 to 4.1 P = .60). Early PN patients rated day-60 quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care vs 49.8 for early PN mean difference, 4.3 95% CI, 0.95 to 7.58 P = .01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference, -0.47 95% CI, -0.82 to -0.11 P = .01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week mean difference, -0.16 95% CI, -0.28 to -0.038 P = .01) and fat loss (0.44 vs 0.31 score increase per week mean difference, -0.13 95% CI, -0.25 to -0.01 P = .04). The provision of early PN to critically ill adults with relative contraindications to early EN, compared with standard care, did not result in a difference in day-60 mortality. The early PN strategy resulted in significantly fewer days of invasive ventilation but not significantly shorter ICU or hospital stays. anzctr.org.au Identifier: ACTRN012605000704695.
Critical care services and the H1N1 (2009) influenza epidemic in Australia and New Zealand in 2010: the impact of the second winter epidemic
Publisher: Springer Science and Business Media LLC
Date: 2011
DOI: 10.1186/CC10266
Timing and interventions of emergency teams during the MERIT study
Publisher: Elsevier BV
Date: 2010
DOI: 10.1016/J.RESUSCITATION.2009.09.025
Abstract: To examine interventions and timing of emergency team calls in hospitals with or without a medical emergency team (MET). Interventions were recorded, categorized and classified as critical care interventions (e.g. airway intervention, ventilation and use of inotropic drugs) ward level interventions (e.g. fluids, oxygen by mask) assessment, physical examination and investigations. Only 5 of the 2376 calls were free of critical care interventions. For non-cardiac arrest-related calls, MET hospitals had a lower proportion of airway, circulation and drug-related interventions and a higher proportion of ward level interventions. The majority of calls were between 0601 and 1200 h and cardiac arrest survival was greatest in the 1200-2400 h period. Overall median time at the scene was 25 min. Nearly all emergency team calls required critical care type interventions. Emergency team calls show a unique temporal pattern for both MET and control hospitals. These findings have important organizational and resource-related implications for hospitals evaluating and establishing rapid response systems.
Assessment of the accuracy of continuous cardiac output and pulse contour cardiac output in tracking cardiac index changes induced by volume load
Publisher: Elsevier BV
Date: 08-2007
DOI: 10.1016/J.AUCC.2007.05.003
Abstract: To assess the ability to track changes in cardiac index (Delta CI) induced by volume loading using continuous pulsed heat thermodilution (CCO), and pulse contour (PCCO) cardiac output (CO) with transpulmonary thermodilution (TD(tp)) CO as reference. Prospective observational clinical trial. Intensive care unit. Twelve ventilated and sedated post-operative cardiac surgery patients. Each patient had a 7.5F CCO pulmonary artery catheter (Edwards Lifesciences) and a 5F, 20 cm PCCO femoral artery catheter (Pulsion Medical Systems). Forty-five data sets were taken before and after 25 volume loadings of 5 mL/kg of 4% albumin. Volume loading resulted in an increase in CI (2.84 L/(min m(2)) versus 3.12L/(min m(2)), p or =14%. The change in CI using PCCO (Delta PCCI) was correlated with Delta CI (TD(tp)) (R(2)=.50, p or =14%. In this small group of patients the continuous cardiac output methods tracked changes in CI, although, in in idual cases they did not change in the same direction as the thermodilution method. Critical care nurses need to critically appraise the accuracy and clinical relevance of continuous CO data within the clinical context.
Dexmedetomidine infusion for more than 24 hours in critically ill patients: sedative and cardiovascular effects.
Publisher: Springer Science and Business Media LLC
Date: 26-08-2004
DOI: 10.1007/S00134-004-2417-Z
Abstract: To assess the potential of dexmedetomidine for targeted sedation in complex Intensive Care (ICU) patients for >24 h. Prospective, open label, clinical trial. Tertiary general ICU. Twenty critically ill patients, mean APACHE II 23(+/-9). A continuous infusion of dexmedetomidine, median infusion time 71.5 (35-168) h, starting at 0.4 microg.kg.h without a loading dose and adjusted (0.2-0.7 microg.kg.h) to a target Ramsay Sedation Score (RSS) of 2-4. Rescue midazolam and/or morphine/fentanyl were given as clinically indicated. Haemodynamic parameters and RSSs were collected until 24 h after cessation. An RSS 2-5 was achieved in 1,147 (83%) of observations with a reduction in RSS of 6 from 13% in the first 6 h to 3% between 18 h and 24 h. Sixteen patients needed minimal or no additional midazolam, median 4 mg/day (0.5-10) and ten required minimal or no additional analgesia, median 2 mg/day (0.5-4.5), 55 microg/day (14-63) of morphine/fentanyl. A 16% reduction in mean systolic blood pressure (SBP) and 21% reduction in heart rate (HR) occurred over the first 4 h followed by minimal (+/- 10%) changes throughout the infusion. A rise in SBP was observed in two patients. After abrupt cessation, SBP and HR monitored for 24 h rose by 7% and 11%, respectively. Dexmedetomidine was an effective sedative and analgesic sparing drug in critically ill patients when used without a loading dose for longer than 24 h with predictable falls in blood pressure and HR. There was no evidence of cardiovascular rebound 24 h after abrupt cessation of infusion.
Timing of renal replacement therapy and patient outcomes in the randomized evaluation of normal versus augmented level of replacement therapy study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2014
Age of red blood cells and mortality in the critically ill
Publisher: Springer Science and Business Media LLC
Date: 2011
DOI: 10.1186/CC10142
Dexmedetomidine vs Midazolam for Sedation of Critically Ill Patients<subtitle>A Randomized Trial</subtitle>
Publisher: American Medical Association (AMA)
Date: 04-02-2009
DOI: 10.1001/JAMA.2009.56
Abstract: Gamma-aminobutyric acid receptor agonist medications are the most commonly used sedatives for intensive care unit (ICU) patients, yet preliminary evidence indicates that the alpha(2) agonist dexmedetomidine may have distinct advantages. To compare the efficacy and safety of prolonged sedation with dexmedetomidine vs midazolam for mechanically ventilated patients. Prospective, double-blind, randomized trial conducted in 68 centers in 5 countries between March 2005 and August 2007 among 375 medical/surgical ICU patients with expected mechanical ventilation for more than 24 hours. Sedation level and delirium were assessed using the Richmond Agitation-Sedation Scale (RASS) and the Confusion Assessment Method for the ICU. Dexmedetomidine (0.2-1.4 microg/kg per hour [n = 244]) or midazolam (0.02-0.1 mg/kg per hour [n = 122]) titrated to achieve light sedation (RASS scores between -2 and +1) from enrollment until extubation or 30 days. Percentage of time within target RASS range. Secondary end points included prevalence and duration of delirium, use of fentanyl and open-label midazolam, and nursing assessments. Additional outcomes included duration of mechanical ventilation, ICU length of stay, and adverse events. There was no difference in percentage of time within the target RASS range (77.3% for dexmedetomidine group vs 75.1% for midazolam group difference, 2.2% [95% confidence interval {CI}, -3.2% to 7.5%] P = .18). The prevalence of delirium during treatment was 54% (n = 132/244) in dexmedetomidine-treated patients vs 76.6% (n = 93/122) in midazolam-treated patients (difference, 22.6% [95% CI, 14% to 33%] P < .001). Median time to extubation was 1.9 days shorter in dexmedetomidine-treated patients (3.7 days [95% CI, 3.1 to 4.0] vs 5.6 days [95% CI, 4.6 to 5.9] P = .01), and ICU length of stay was similar (5.9 days [95% CI, 5.7 to 7.0] vs 7.6 days [95% CI, 6.7 to 8.6] P = .24). Dexmedetomidine-treated patients were more likely to develop bradycardia (42.2% [103/244] vs 18.9% [23/122] P < .001), with a nonsignificant increase in the proportion requiring treatment (4.9% [12/244] vs 0.8% [1/122] P = .07), but had a lower likelihood of tachycardia (25.4% [62/244] vs 44.3% [54/122] P < .001) or hypertension requiring treatment (18.9% [46/244] vs 29.5% [36/122] P = .02). There was no difference between dexmedetomidine and midazolam in time at targeted sedation level in mechanically ventilated ICU patients. At comparable sedation levels, dexmedetomidine-treated patients spent less time on the ventilator, experienced less delirium, and developed less tachycardia and hypertension. The most notable adverse effect of dexmedetomidine was bradycardia. clinicaltrials.gov Identifier: NCT00216190 Published online February 2, 2009 (doi:10.1001/jama.2009.56).
Epidemiology of RBC transfusions in patients with severe acute kidney injury: Analysis from the randomized evaluation of normal versus augmented level study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 05-2016
Comparison of dynamic measurements of pulse contour with pulsed heat continuous cardiac output in postoperative cardiac surgical patients
Publisher: Elsevier BV
Date: 02-2007
DOI: 10.1016/J.AUCC.2006.11.003
Abstract: Cardiac output (CO) can be measured using bolus thermodilution via a pulmonary artery catheter (PAC) and as continuous cardiac output (CCO), using pulsed heat thermoditution. Pulse contour cardiac output (PCCO) measures continuous CO by analysis of the arterial waveform after calibration with thermodilution CO. The Pulsion Medical Systems (PiCCO system) achieves this by transpulmonary aortic thermodilution (TDtpa). There is uncertainty regarding the agreement between TDtpa, CCO, and PCCO CO measurements in situations of rapid haemodynamic changes. We studied the agreement of the measures by comparing digital recordings of cardiac index (CI) determined by PCCO and CCO (PCCI and CCI, respectively) made during periods of haemodynamic instability. After ethics committee approval we studied four post-coronary artery bypass graft patients, in the immediate postoperative period. Each patient had a 7.5F CCO catheter (Edwards Lifesciences) and a 5F, 20cm PCCO femoral artery catheter. Digital recordings were obtained for the first 12-18 postoperative hours. Six epochs of instability were identified in the first two to three postoperative hours, and at the commencement of inotropic or vasoactive drugs. Notable features, despite frequent PCCO calibrations, were the marked difference of PCCI compared to CCI. In contradistinction, they tracked very closely during a period of stability. Limitations of both methods were noted. Whilst PCCO responded to rapid change, it developed significant error during haemodynmamic instability and requires frequent recalibration. CCO on the other hand has a considerable time lag in responding to changes in CO. The way a monitor measures CO must be taken into account when using the data in clinical management.
Australasian resuscitation of sepsis evaluation (ARISE)
Publisher: Elsevier BV
Date: 07-2009
Perioperative change in creatinine following cardiac surgery with cardiopulmonary bypass is useful in predicting acute kidney injury: a single-centre retrospective cohort study
Publisher: Oxford University Press (OUP)
Date: 09-07-2015
DOI: 10.1093/ICVTS/IVV184
Abstract: Acute kidney injury is common following cardiac surgery. Experimental models of acute kidney injury suggest that successful therapy should be implemented within 24-48 h of renal injury. However, it is difficult to detect acute kidney injury shortly after cardiac surgery, because creatinine concentration is diluted by cardiopulmonary bypass. We hypothesized that, following cardiopulmonary bypass, creatinine reduction ratios would correlate with haematocrit reduction ratios and would be associated with the incidence of acute kidney injury. We collected demographic and blood test data from consecutive patients (n = 1137) who had undergone cardiac surgery with cardiopulmonary bypass. The creatinine reduction ratio was calculated as follows: (preoperative creatinine-postoperative creatinine) reoperative creatinine. Patients were assigned to either of two groups. The first group (Group 1) was used to determine the threshold for acute kidney injury, and the second group (Group 2) was used to assess diagnostic performance. Acute kidney injury was defined as an increase in serum creatinine level >0.3 mg/dl or >150% from baseline. The incidence of acute kidney injury was 14.5% (79/545) in Group 1 and 15.5% (92/592) in Group 2. Postoperatively, creatinine concentration correlated strongly with haematocrit concentration (Pearson's r(2): 0.91). In Group 1, the area under the receiver operating characteristic curve, sensitivity and specificity were 0.71, 64.1 and 66.4%, respectively, for creatinine reduction ratios of <20%. In Group 2, the odds ratio, positive predictive value, negative predictive value and relative risk for creatinine reduction ratio performance were 4.3 (95% confidence interval 2.6-7.0), 0.27 (0.21-0.32), 0.92 (0.89-0.95) and 3.42 (2.22-5.27), respectively. The creatinine reduction ratio may be associated with perioperative renal injury. Therefore, it is a good diagnostic indicator with high performance, and may be useful in detecting acute kidney injury at an earlier stage relative to conventional means. In addition, using creatinine reduction ratios in this manner is financially feasible.
An observational study fluid balance and patient outcomes in the randomized evaluation of normal vs. augmented level of replacement therapy trial
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 06-2012
Early Sedation with Dexmedetomidine in Critically Ill Patients
Publisher: Massachusetts Medical Society
Date: 27-06-2019
Pro/con debate: Is etomidate safe in hemodynamically unstable critically ill patients?
Publisher: Springer Science and Business Media LLC
Date: 2012
DOI: 10.1186/CC11242
Femoral Access and Delivery of Continuous Renal Replacement Therapy Dose
Publisher: S. Karger AG
Date: 20-10-2016
DOI: 10.1159/000439581
Abstract: b i Aims: /i /b The study aims to describe the use of dialysis catheters in critically ill patients treated with continuous renal replacement therapy (CRRT) and to study the impact of femoral versus non-femoral access on CRRT dose. b i Methods: /i /b Statistical analysis and predictive modelling of data from the Randomized Evaluation of Normal vs. Augmented Level renal replacement therapy trial. b i Results: /i /b The femoral vein was the first access site in 937 (67%) of 1,399 patients. These patients had higher Acute Physiology and Chronic Health Evaluation and Sequential Organ Failure Assessment scores (p = 0.009) and lower pH (p 0.001) but similar mortality to patients with non-femoral access (44 vs. 45% p = 0.63). Lower body weight was independently associated with femoral access placement (OR 0.97, 95% CI 0.96-0.98). Femoral access was associated with a 1.03% lower CRRT dose (p = 0.05), but a 4.20% higher dose was achieved with 13.5 Fr catheters (p = 0.03). b i Conclusions: /i /b Femoral access was preferred in lighter and sicker patients. Catheter gauge had greater impact than catheter site in CRRT dose delivery. Video Journal Club “Cappuccino with Claudio Ronco” at www.karger.com/?doi=439581.
Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Followup of a Randomized Controlled Trial
Publisher: Public Library of Science (PLoS)
Date: 11-02-2014
Correlation of patient-reported outcome measures to performance-based function in critical care survivors: PREDICTABLE
Publisher: Elsevier BV
Date: 07-2023
Baseline hospital performance and the impact of medical emergency teams
Publisher: Springer Science and Business Media LLC
Date: 12-2009
Transfusion practice and guidelines in Australian and New Zealand intensive care units.
Publisher: Springer Science and Business Media LLC
Date: 04-05-2010
Pro/Con debate: is procalcitonin useful for guiding antibiotic decision making in critically ill patients?
Publisher: Springer Science and Business Media LLC
Date: 2008
DOI: 10.1186/CC6860
Critical Care Services and 2009 H1N1 Influenza in Australia and New Zealand
Publisher: Massachusetts Medical Society
Date: 12-11-2009
Goals of goal-directed sedation.
Publisher: GN1 Genesis Network
Date: 2015
Intensive versus Conventional Glucose Control in Critically Ill Patients
Publisher: Massachusetts Medical Society
Date: 26-03-2009
A ustralasian R esuscitation I n S epsis E valuation trial statistical analysis plan
Publisher: Wiley
Date: 09-09-2013
Abstract: The Australasian Resuscitation In Sepsis Evaluation (ARISE) study is an international, multicentre, randomised, controlled trial designed to evaluate the effectiveness of early goal-directed therapy compared with standard care for patients presenting to the ED with severe sepsis. In keeping with current practice, and taking into considerations aspects of trial design and reporting specific to non-pharmacologic interventions, this document outlines the principles and methods for analysing and reporting the trial results. The document is prepared prior to completion of recruitment into the ARISE study, without knowledge of the results of the interim analysis conducted by the data safety and monitoring committee and prior to completion of the two related international studies. The statistical analysis plan was designed by the ARISE chief investigators, and reviewed and approved by the ARISE steering committee. The data collected by the research team as specified in the study protocol, and detailed in the study case report form were reviewed. Information related to baseline characteristics, characteristics of delivery of the trial interventions, details of resuscitation and other related therapies, and other relevant data are described with appropriate comparisons between groups. The primary, secondary and tertiary outcomes for the study are defined, with description of the planned statistical analyses. A statistical analysis plan was developed, along with a trial profile, mock-up tables and figures. A plan for presenting baseline characteristics, microbiological and antibiotic therapy, details of the interventions, processes of care and concomitant therapies, along with adverse events are described. The primary, secondary and tertiary outcomes are described along with identification of subgroups to be analysed. A statistical analysis plan for the ARISE study has been developed, and is available in the public domain, prior to the completion of recruitment into the study. This will minimise analytic bias and conforms to current best practice in conducting clinical trials.
Intensive versus conventional glucose control in critically ill patients with traumatic brain injury: long-term follow-up of a subgroup of patients from the NICE-SUGAR study
Publisher: Springer Science and Business Media LLC
Date: 06-2015
DOI: 10.1007/S00134-015-3757-6
Abstract: To compare the effect of intensive versus conventional blood glucose control in patients with traumatic brain injury. In a large international randomized trial patients were randomly assigned to a target blood glucose (BG) range of either 4.5-6.0 mmol/L (intensive control) or <10 mmol/L (conventional control). Patients with traumatic brain injury (TBI) were identified at randomization and data were collected to examine the extended Glasgow outcome score (includes mortality) at 24 months. Of the 6104 randomized patients, 391 satisfied diagnostic criteria for TBI 203 (51.9%) were assigned to intensive and 188 (48.1%) to conventional control the primary outcome was available for 166 (81.8%) and 149 (79.3%) patients, respectively. The two groups had similar baseline characteristics. At 2 years 98 (58.7%) patients in the intensive group and 79 (53.0%) in the conventional group had a favorable neurological outcome (odds ratio [OR] 1.26, 95% CI 0.81-1.97 P = 0.3) 35 patients (20.9%) in the intensive group and 34 (22.8%) in the conventional group had died (OR 0.90, 95% CI 0.53-1.53 P = 0.7) moderate hypoglycemia (BG 2.3-3.9 mmol/L 41-70 mg/dL) occurred in 160/202 (79.2%) and 17/188 (9.0%), respectively (OR 38.3, 95% CI 21.0-70.1 P < 0.0001) severe hypoglycemia (BG ≤ 2.2 mmol/L ≤40 mg/dL) in 10 (4.9%) and 0 (0.0%), respectively (OR 20.5 95% CI 1.2-351.6, P = 0.003). Although patients with traumatic brain injury randomly assigned to intensive compared to conventional glucose control experienced moderate and severe hypoglycemia more frequently, we found no significant difference in clinically important outcomes.
Early sedation with dexmedetomidine in ventilated critically ill patients and heterogeneity of treatment effect in the SPICE III randomised controlled trial
Publisher: Springer Science and Business Media LLC
Date: 08-03-2021
Assessment of the agreement between cardiac output measured by bolus thermodilution and continuous methods, with particular reference to the effect of heart rhythm.
Publisher: Elsevier BV
Date: 03-1997
DOI: 10.1016/S1036-7314(97)70380-1
Abstract: Cardiac output (CO) is a fundamentally important haemodynamic parameter and its continuous measurement has the potential to enable early recognition of haemodynamic trends and earlier therapeutic response. A method of continuous cardiac output (CCO) monitoring is now available for clinical use. The accuracy and reliability of this method has been confirmed in clinical trials but not, to our knowledge, in the presence of abnormal heart rhythms. A comparison was made between CCO and bolus thermodilution methods, to determine if there is a greater difference between their respective determinations of CO when heart rhythm is abnormal. A convenience s le of 38 intensive care patients was used to obtain 410 comparisons of CCO and bolus CO determinations. Heart rhythm associated with each comparison was determined. The comparison produced a measurement bias of -0.07 l/min and limits of agreement of -1.77 to 1.63 l/min. The bias of the two measurements was -0.35 l/min for sinus rhythm, -0.19 l/min for sinus tachycardia and -0.12 l/min for atrial flutter/fibrillation. Increased temperature and heart rate did not affect measurement agreement. In conclusion, the agreement between the bolus and continuous methods is clinically acceptable and is unaffected by the heart rhythms of sinus rhythm, sinus tachycardia and atrial flutter/fibrillation.
Intensity of continuous renal-replacement therapy in critically ill patients
Publisher: Massachusetts Medical Society
Date: 22-10-2009
Reply: early deep sedation is often not justified.
Publisher: American Thoracic Society
Date: 15-04-2013
The risk associated with hyperoncotic colloids in patients with shock
Publisher: Springer Science and Business Media LLC
Date: 07-08-2008
DOI: 10.1007/S00134-008-1225-2
Abstract: Crystalloids, artificial and natural colloids have been opposed as representing different strategies for shock resuscitation, but it may be relevant to distinguish fluids based on their oncotic characteristics. This study assessed the risk of renal adverse events in patients with shock resuscitated using hypo-oncotic colloids, artificial hyperoncotic colloids, hyperoncotic albumin or crystalloids, according to physician's choice. International prospective cohort study including 1,013 ICU patients needing fluid resuscitation for shock. Patients suffering from cirrhosis or receiving plasma were excluded. Influence of different types of colloids and crystalloids on the occurrence of renal events (twofold increase in creatinine or need for dialysis) and mortality was assessed using multivariate analyses and propensity score. Statistical adjustment was based on severity at the time of resuscitation, risks factor for renal failure, and on variables influencing physicians' preferences regarding fluids. A renal event occurred in 17% of patients. After adjustment on potential confounding factors and on propensity score for the use of hyperoncotic colloids, the use of artificial hyperoncotic colloids [OR: 2.48 (1.24-4.97)] and hyperoncotic albumin [OR: 5.99 (2.75-13.08)] was significantly associated with occurrence of renal event. Overall ICU mortality was 27.1%. The use of hyperoncotic albumin was associated with an increased risk of ICU death [OR: 2.79 (1.42-5.47)]. This study suggests that harmful effects on renal function and outcome of hyperoncotic colloids may exist. Although an improper usage of these compounds and confounding factors cannot be ruled out, their use should be regarded with caution, especially because suitable alternatives exist.
Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study
Publisher: Springer Science and Business Media LLC
Date: 24-01-2013
Early goal-directed sedation in mechanically ventilated patients
Publisher: Springer International Publishing
Date: 2014
Accuracy of the Securetec DrugWipe 6s Ketamine device in detecting acute and residual salivary ketamine following a stepwise intravenous treatment protocol
Publisher: Informa UK Limited
Date: 02-01-2020
The impact of bacterial and viral co-infection in severe influenza
Publisher: Wiley
Date: 06-04-2013
Reply
Publisher: American Thoracic Society
Date: 04-2015
Renal protection by N-acetylcysteine.
Publisher: Elsevier BV
Date: 02-2007
DOI: 10.1093/BJA/AEL351
Hydroxyethyl Starch or Saline for Fluid Resuscitation in Intensive Care
Publisher: Massachusetts Medical Society
Date: 15-11-2012
Procalcitonin algorithm in critically ill adults with undifferentiated infection or suspected sepsis
Publisher: American Thoracic Society
Date: 15-11-2014
Sedation depth and mortality in mechanically ventilated critically ill adults.
Publisher: Springer Science and Business Media LLC
Date: 02-2012
DOI: 10.1186/CC10930
A novel method for insertion of post-pyloric feeding tubes at the bedside without endoscopic or fluoroscopic assistance: a prospective study
Publisher: Springer Science and Business Media LLC
Date: 2004
DOI: 10.1007/S00134-003-2071-X
Abstract: To assess a novel method, adapted from already published literature, for bedside placement of nasojejunal feeding tubes using erythromycin, air insufflation of the stomach and continuous ECG guidance. Prospective study in a tertiary teaching hospital. 40 consecutive patients who required enteral nutrition and mechanical ventilation for at least 48 h. Erythromycin (200 mg) was administered intravenously 30 min prior to the insertion of the feeding tube. The post-pyloric feeding tube was then inserted into the stomach and 500 ml air insufflated. Stomach ECG was performed, and during further insertion of the tube the QRS complex was continuously monitored for a change in polarity, suggesting passage across the midline through the pylorus. At the end of the procedure aspirate was obtained from the feeding tube and checked for alkaline pH. Exact tube position was determined by abdominal radiography. In 88% of cases the feeding tubes were post-pyloric, with a median time to insertion of 15 min (range 7-75). No major complications were seen in 52 attempts. Change in QRS polarity had 94% sensitivity in predicting post-pyloric tip placement. Of the 32 alkaline pH aspirates 31 were post-pyloric. This procedure is safe, effective and could be performed in a short time period within the confines of the intensive care unit without endoscopic assistance.
Calorie intake and patient outcomes in severe acute kidney injury: findings from The Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study trial
Publisher: Springer Science and Business Media LLC
Date: 2014
DOI: 10.1186/CC13767
Intensive care sedation
Publisher: Springer Science and Business Media LLC
Date: 2013
DOI: 10.1186/CC12679
Early intensive care sedation predicts long-term mortality in ventilated critically ill patients
Publisher: American Thoracic Society
Date: 15-10-2012
Triggers for emergency team activation: a multicenter assessment
Publisher: Elsevier BV
Date: 06-2010
DOI: 10.1016/J.JCRC.2009.12.011
Abstract: The purpose of the study was to examine triggers for emergency team activation in hospitals with or without a medical emergency team (MET) system. Within a cluster randomized controlled trial examining the effect of introducing a MET system, we recorded the triggers for emergency team activation. We compared the proportion and rate of such triggers in hospitals with or without a MET system and in relation to type of hospital, type of patient ward, and time of day. In control hospitals, the most common trigger for emergency team activation was a decrease in Glasgow Coma Score by 2 or more points (45.6%), whereas in MET hospitals, it was the fact that staff members were "worried" or the call occurred despite the lack of a "specified reason" (39.3%). In particular, MET hospitals were 35 times more likely to make a call because of staff being "worried" about the patient (14.1% vs 0.4%, P < .001). Control hospitals were also significantly more likely to call an emergency team because of a deteriorating respiratory (P = .003) or pulse (P < .001) rate, more calls had at least 3 triggers for activation (20.8% vs 10.2%, P = .036), and the average number of triggers per call was significantly higher (P = .013). Nonmetropolitan hospitals were more likely to call an emergency team because of respiratory rate abnormalities (33.6% vs 23.2%, P = .015). Coronary care unit calls were more likely to be triggered by abnormalities in pulse rate and systolic blood pressure, and more calls occurred during the period from 6:00 am to noon. In MET hospitals, more emergency team calls are triggered because staff members are worried about the patient and fewer calls have multiple triggers. Type of hospital, type of ward, and time of day also affect the nature and frequency of triggers for emergency team activation.
Goal-Directed Resuscitation for Patients with Early Septic Shock
Publisher: Massachusetts Medical Society
Date: 16-10-2014
Early acid-base and blood pressure effects of continuous renal replacement therapy intensity in patients with metabolic acidosis
Publisher: Springer Science and Business Media LLC
Date: 11-01-2013
DOI: 10.1007/S00134-012-2800-0
Abstract: In acute kidney injury patients, metabolic acidosis is common. Its severity, duration, and associated changes in mean arterial pressure (MAP) and vasopressor therapy may be affected by the intensity of continuous renal replacement therapy (CRRT). We aimed to compare key aspects of acidosis and MAP and vasopressor therapy in patients treated with two different CRRT intensities. We studied a nested cohort of 115 patients from two tertiary intensive care units (ICUs) within a large multicenter randomized controlled trial treated with lower intensity (LI) or higher intensity (HI) CRRT. Levels of metabolic acidosis at randomization were similar [base excess (BE) of -8 ± 8 vs. -8 ± 7 mEq/l p = 0.76]. Speed of BE correction did not differ between the two groups. However, the HI group had a greater increase in MAP from baseline to 24 h (7 ± 3 vs. 0 ± 3 mmHg p < 0.01) and a greater decrease in norepinephrine dose (from 12.5 to 3.5 vs. 5 to 2.5 μg/min p < 0.05). The correlation (r) coefficients between absolute change in MAP and norepinephrine (NE) dose versus change in BE were 0.05 and -0.37, respectively. Overall, LI and HI CRRT have similar acid-base effects in patients with acidosis. However, HI was associated with greater improvements in MAP and vasopressor requirements (clinical trial no. NCT00221013).
Delirium duration and mortality in lightly sedated, mechanically ventilated intensive care patients.
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 12-2010
Early goal-directed sedation versus standard sedation in mechanically ventilated critically III patients: a pilot study
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 08-2013
The relationship between early emergency team calls and serious adverse events
Publisher: Ovid Technologies (Wolters Kluwer Health)
Date: 2009
Primary and Secondary Care Consultations in Elderly Demented Individuals in France
Publisher: S. Karger AG
Date: 2008
DOI: 10.1159/000164692
Abstract: i Background/Aims: /i Our purpose was to analyze consultations with primary- and secondary-care physicians by demented people and identify factors that h er or facilitate consultation. i Methods: /i In total, 498 demented subjects were evaluated within the Three-City Study, a population-based cohort of in iduals aged ≧65 years.Primary- and secondary-care consultations (consultation with a specialist and/or treatment with anti-dementia drugs) were assessed by a neurologist or geriatrician. i Results: /i Thirty-five percent of the demented subjects did not seek advice for their cognitive problems and only 31% consulted a specialist. Consultation for primary care was principally dependent on the subjects’ own awareness of the cognitive disorder and on their age. Factors associated with consultation for secondary care were younger age, higher education level, higher instrumental activities of daily living disability and awareness of the cognitive disorder by the subject, all of which predicted more frequent consultation. The level of cognitive performance had only a slight influence on primary care and none on secondary care. i Conclusion: /i The failure to see a physician due to dementia, especially secondary-care practitioners, is frequent in the community, particularly in the oldest subjects.
Screening and study enrolment in the randomized evaluation of normal vs. augmented level (RENAL) replacement therapy trial
Publisher: S. Karger AG
Date: 2009
DOI: 10.1159/000195091
Abstract: i Background and Objectives: /i Aspects of trial design, screening and study efficiency can affect recruitment and the findings of the trial itself. A clear understanding of the screening and study inclusion process will assist clinicians in interpreting trial results. i Design: /i Prospective observational data collection on all patients screened for possible inclusion in a randomized controlled trial of normal vs. augmented renal replacement therapy in critically ill patients (the RENAL Trial). i Setting: /i 35 hospitals in Australia and New Zealand. i Participants: /i All patients screened for the RENAL Trial. i Results: /i We screened 4,551 patients. Of these patients, 767 were ineligible because of lack of inclusion criteria and 2,085 because of exclusion criteria. Of the remaining 1,699, 1,508 (88.7%) were enrolled. The three most common exclusion criteria which prevented recruitment of potentially eligible patients were that the patient had end-stage kidney failure and was already on chronic dialysis (484 23.2%), the patient’s body weight was either or kg (456 21.8%), and the fact that the patient had already received renal replacement therapy during the index admission. Important modifiable impediments to recruitment were inability to obtain consent in 191 cases, unavailability of research staff in 124 cases, physician objection in 89 cases, and inability to deliver the trial protocol in 78 cases. i Conclusion: /i The RENAL Trial’s enrolment efficiency was high and compared favourably with previous large intensive care units trials and with that of trials in patients with acute renal failure. The high rate of enrolment suggests that the results can be applied with confidence to most patients with de novo acute renal failure. The loss of close to 1.5% of patients due to consent issues highlights a common problem in critical care trials. The low rate of physician objection suggests clinical equipoise.
Related Organisations
Australian And New Zealand College Of Anaesthetists
Location: Australia
College Of Intensive Care Medicine Of Australia And New Zealand
Location: Australia
Related Funding Activities
No related grants have been discovered for Yahya SHEHABI.