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Objective: We tested the hypothesis that responses to physiologic deterioration in hospital ward patients delayed by more than 15 minutes are associated with increased mortality.Design, Setting, and Participants: We used data from a 23-hospital cluster randomized trial (January 2004 to December 2004) of implementation of rapid response teams (intervention) versus standard practice with conventional cardiac arrest team-based responses to emergencies (control). We examined emergency calls in all hospitals. In intervention hospitals, we also examined such calls in the period before, during the introduction, and after the full implementation of a rapid response system. We studied the statistical association between such delayed calls and mortality.Main Outcomes and Measures: Hospital outcomes (mortality, unplanned ICU admissions, and cardiac arrests).Results: There were 3,135 emergency team calls in all hospitals. Overall, almost one third of such calls were delayed. In intervention hospitals, the proportion of delayed calls was similar before and after implementation of rapid response teams. Compared with control hospitals, in intervention hospitals, there was a significant decrease in the proportion of delayed calls during both the introduction (27.3% vs 34.3% weekly rate; incidence rate ratio, 0.84; p = 0.001) and the full implementation period (29.0% vs 34.5% weekly rate; incidence rate ratio, 0.84; p = 0.023). Delayed calls more likely occurred at night, in high dependence or coronary care units, in patients older than 75 years, in those with a decrease in Glasgow Coma Scale, or in those with hypotension as the reason for the call. Finally, in all hospitals, delayed calls were associated with an increased risk of unplanned ICU admissions (adjusted odds ratio = 1.56; 95% CI, 1.23-2.04; p ≤ 0.001) and death (adjusted odds ratio = 1.79; 95% CI, 1.43-2.27; p < 0.001).Conclusions: Among ward patients, emergency team activation in response to acute deterioration triggered more than 15 minutes after detection and documentation of instability is independently associated with an increased risk of ICU admission and death. [ABSTRACT FROM AUTHOR]

Objectives: To explore the relationship between timing of continuous renal replacement therapy commencement and clinical outcomes in critically ill patients with acute kidney injury. The primary outcomes were all-cause mortality at 28 and 90 days. Design: Nested observational cohort study using data from the Randomized Evaluation of Normal Versus Augmented Level Replacement Therapy Study. Setting: Twenty-three ICUs in Australia and New Zealand. Patients: Four hundred thirty-nine critically ill patients with acute kidney injury Risk, Injury, Failure, Loss, End-stage kidney disease-injury (RIFLE-I) criteria. Interventions: None. Measurements and Main Results: The time between RIFLE-I acute kidney injury and randomization in the Randomized Evaluation of Normal Versus Augmented Level Replacement Therapy Study (proxy for continuous renal replacement therapy commencement) was the variable of interest. All baseline variables in the Randomized Evaluation of Normal Versus Augmented Level Replacement Therapy Study were assessed. Multivariable Cox, logistic, and linear regression models were used to assess the independent relationship of time of onset of RIFLE-I acute kidney injury and randomization and patient outcomes. The median time between RIFLE-I acute kidney injury and continuous renal replacement therapy commencement was 17.6 hours (interquartile range, 7.1-46 hr). Based on four groups of continuous renal replacement therapy commencement ([group 1; reference]: <7.1, [group 2]: ⩾ 7.1 to < 17.6, [group 3]: ⩾ 17.6 to < 46.0, [group 4]: ⩾ 46.0hr), earlier commencement of continuous renal replacement therapy was not associated with a significantly lower risk of death at 28 days (hazard ratio for group 2: 1.06, 95% Cl: 0.62-1.81; p = 0.83; hazard ratio for group 3: 1.23, 95% Cl: 0.71-2.12; p = 0.46; hazard ratio for group 4: 1.33, 95% Cl: 0.77- 2.31 ;p = 0.31). Similar findings were observed for death at 90 days. Conclusions: In a subgroup of participants of the Randomized Evaluation of Normal Versus Augmented Level Replacement Therapy Study, earlier commencement of continuous renal replacement therapy relative to RIFLE-I acute kidney injury was not significantly associated with improved survival. Additional studies with larger sample sizes and broader commencement times are warranted. [ABSTRACT FROM AUTHOR]

The article reports on a study of the value of novel and conventional serum biomarkers in predicting acute kidney injury (AKI) among adult cardiac surgical patients. It examined concentrations of plasma neutrophil gelatinase-associated lipocalin (NGAL) serum cystatin C, creatinine, and urea of 100 cardiac surgical patients. It showed that plasma NGAL and serum cystatin C were conventional biomarkers which are good in identifying patients who developed AKI after cardiac surgery.

The article offers information on extracorporeal therapy. It states that this kind of therapy has expanded over the past years from solely artificial renal replacement therapy. It also forwards that it is crucial to provide multiple organ support therapy to patients with multiple organ dysfunction syndrome. Nanotechnology has also changed the way therapy is delivered to patients with kidney ailments.

Objectives: The optimal time to initiate renal replacement therapy in critically ill patients with acute kidney injury is controversial. We investigated the effect of such earlier versus later initiation of renal replacement therapy on the primary outcome of 28-day mortality and other patient-centered secondary outcomes.Design: We searched MEDLINE (via PubMed), EMBASE, and Cochrane databases to July 17, 2020, and included randomized controlled trials comparing earlier versus later renal replacement therapy.Setting: Multiple centers involved in eight trials.Patients: Total of 4,588 trial participants.Intervention: Two independents investigators screened and extracted data using a predefined form. We selected randomized controlled trials in critically ill adult patients with acute kidney injury and compared of earlier versus later initiation of renal replacement therapy regardless of modality.Measurements and Main Results: Overall, 28-day mortality was similar between earlier and later renal replacement therapy initiation (38.43% vs 38.06%, respectively; risk ratio, 1.01; [95% CI, 0.94-1.09]; I2 = 0%). Earlier renal replacement therapy, however, shortened hospital length of stay (mean difference, -2.14 d; [95% CI, -4.13 to -0.14]) and ICU length of stay (mean difference, -1.18 d; [95% CI, -1.95 to -0.42]). In contrast, later renal replacement therapy decreased the use of renal replacement therapy (relative risk, 0.69; [95% CI, 0.58-0.82]) and lowered the risk of catheter-related blood stream infection (risk ratio, 0.50, [95% CI, 0.29-0.86). Among survivors, renal replacement therapy dependence at day 28 was similar between earlier and later renal replacement therapy initiation (risk ratio, 0.98; [95% CI, 0.66-1.40]).Conclusions: Earlier or later initiation of renal replacement therapy did not affect mortality. However, earlier renal replacement therapy was associated with significantly shorter ICU and hospital length of stay, whereas later renal replacement therapy was associated with decreased use of renal replacement therapy and decreased risk of catheter-related blood stream infection. These findings can be used to guide the management of critically ill patients with acute kidney injury. [ABSTRACT FROM AUTHOR]

Objectives: To evaluate what proportion of unplanned ICU admissions from hospital wards occurred after rapid response team review and compare baseline characteristics and outcomes of patients admitted after rapid response team review with non-rapid response team-related admissions.Design: Multicenter binational retrospective cohort study.Setting: One-hundred seventy-eight ICUs across Australia and New Zealand.Patients: All adults (≥ 17 yr) in the Australian and New Zealand Intensive Care Society Adult Patient Database between 2012 and 2017.Interventions: None.Measurements and Main Results: Among 97,181 unplanned ICU admissions from the ward, prior rapid response team review occurred in 55,084 cases (56.7%). Rapid response team patients were slightly older (65.4 [16.9] vs 63.3 [18]), had a higher Acute Physiology and Chronic Health Evaluation III score (64.6 [27.1] vs 54.7 [25.3]) and more frequently had limitations of medical treatment (13.1% vs 8.5%) compared with patients with no rapid response team review. The strongest independent associations with ICU admission following rapid response team review included age, ICU admission diagnosis (especially sepsis-, neurologic-, respiratory-, and cardiovascular-related), tertiary ICU status, and presence of limitations of medical treatment (p < 0.0001 all comparisons). Rapid response team-related ICU admissions had a longer median ICU (2.4 d [1.2-4.6 d] vs 2.1 d [1.0-4.2 d]) and hospital (12.8 d [7.0-23.6 d] vs 10.8 d [5.9-20.3 d]) length of stay, and were more likely to die in the ICU (12.3% vs 7.5%) and in-hospital (20.8% vs 13.5%) (p < 0.0001). After adjusting for illness severity and institution, patients admitted following rapid response team review stayed longer in hospital but were not at increased risk of dying in-hospital (adjusted odds ratio, 1.03; 0.98-1.07).Conclusions: In Australia and New Zealand, hospital ward patients admitted to ICU following rapid response team review represent the majority of ward-based ICU admissions, are more chronically and acutely ill, and more frequently have sepsis than those admitted from the ward without rapid response team review. Their unadjusted outcomes are worse, but after adjustment their mortality is similar. [ABSTRACT FROM AUTHOR]

Objectives: To compare the characteristics of adults admitted to the ICU in Australia and New Zealand after trauma with nonelective, nontrauma admissions. To describe trends in hospital mortality and rates of discharge home among these two groups.Design: Retrospective review (2005-2017) of the Australia and New Zealand Intensive Care Society's Center for Outcome and Resource Evaluation Adult Patient Database.Setting: Adult ICUs in Australia and New Zealand.Patients: Adult (≥17 yr), nonelective, ICU admissions.Intervention: Observational study.Measurements and Main Results: We compared 77,002 trauma with 741,829 nonelective, nontrauma patients. Trauma patients were younger (49.0 ± 21.6 vs 60.6 ± 18.7 yr; p < 0.0001), predominantly male (73.1% vs 53.9%; p < 0.0001), and more frequently treated in tertiary hospitals (74.7% vs 45.8%; p < 0.0001). The mean age of trauma patients increased over time but was virtually static for nonelective, nontrauma patients (0.72 ± 0.02 yr/yr vs 0.03 ± 0.01 yr/yr; p < 0.0001). Illness severity increased for trauma but fell for nonelective, nontrauma patients (mean Australia and New Zealand risk of death: 0.10% ± 0.02%/yr vs -0.21% ± 0.01%/yr; p < 0.0001). Trauma patients had a lower hospital mortality than nonelective, nontrauma patients (10.0% vs 15.8%; p < 0.0001). Both groups showed an annual decline in the illness severity adjusted odds ratio (odds ratio) of hospital mortality, but this was slower among trauma patients (trauma: odds ratio 0.976/yr [0.968-0.984/yr; p < 0.0001]; nonelective, nontrauma: odds ratio 0.957/yr [0.955-0.959/yr; p < 0.0001]; interaction p < 0.0001). Trauma patients had lower rates of discharge home than nonelective, nontrauma patients (56.7% vs 64.6%; p < 0.0001). There was an annual decline in illness severity adjusted odds ratio of discharge home among trauma patients, whereas nonelective, nontrauma patients displayed an annual increase (trauma: odds ratio 0.986/yr [0.981-0.990/yr; p < 0.0001]; nonelective, nontrauma: odds ratio 1.014/yr [1.012-1.016/yr; p < 0.0001]; interaction: p < 0.0001).Conclusions: The age and illness severity of adult ICU trauma patients in Australia and New Zealand has increased over time. Hospital mortality is lower for trauma than other nonelective ICU patients but has fallen more slowly. Trauma patients have become less likely to be discharged home than other nonelective ICU patients. [ABSTRACT FROM AUTHOR]

Objectives: Angiotensin II is an emerging therapy for septic acute kidney injury, but it is unknown if its vasoconstrictor action induces renal hypoxia. We therefore examined the effects of angiotensin II on intrarenal PO2 in ovine sepsis. We also assessed the validity of urinary PO2 as a surrogate measure of medullary PO2.Design: Interventional study.Setting: Research Institute.Subjects: Sixteen adult Merino ewes (n = 8/group).Interventions: Sheep were instrumented with fiber-optic probes in the renal cortex, medulla, and within a bladder catheter to measure PO2. Conscious sheep were infused with Escherichia coli for 32 hours. At 24-30 hours, angiotensin II (0.5-33.0 ng/kg/min) or saline vehicle was infused.Measurements and Main Results: Septic acute kidney injury was characterized by hypotension and a 60% ± 6% decrease in creatinine clearance. During sepsis, medullary PO2 decreased from 36 ± 1 to 30 ± 3 mm Hg after 1 hour and to 20 ± 2 mm Hg after 24 hours; at these times, urinary PO2 was 42 ± 2, 34 ± 2, and 23 ± 2 mm Hg. Increases in urinary neutrophil gelatinase-associated lipocalin (12% ± 3%) and serum creatinine (60% ± 23%) were only detected at 8 and 24 hours, respectively. IV infusion of angiotensin II, at 24 hours of sepsis, restored arterial pressure and improved creatinine clearance, while not exacerbating medullary or urinary hypoxia.Conclusions: In septic acute kidney injury, renal medullary and urinary hypoxia developed several hours before increases in currently used biomarkers. Angiotensin II transiently improved renal function without worsening medullary hypoxia. In septic acute kidney injury, angiotensin II appears to be a safe, effective therapy, and urinary PO2 may be used to detect medullary hypoxia. [ABSTRACT FROM AUTHOR]

The article discusses a study which measured renal blood flow in septic patients with acute kidney injury using cine phase-contrast magnetic resonance imaging. Results show that there was no rank correlation between renal blood flow index and creatinine clearance in patients with septic acute kidney injury. It concluded that cine phase-contrast magnetic resonance imaging can be used to noninvasively and safely assess renal perfusion in critically ill patients.

The article provides a systematic review of randomized trials comparing intermittent renal replacement therapy (IRRT) and continuous RRT (CRRT) modality for critically-ill patients with acute kidney injury (AKI). The review's objectives were to evaluate whether modality influences mortality, renal recovery, treatment-related complications and physiologic outcomes. The study found no difference in mortality or renal recovery to RRT independence.

The article presents a study that investigated the characteristics and outcomes of patients receiving medical emergency treatment for acute change in conscious state or arrhythmia at a university teaching hospital. It evaluated the effect of delayed MET activation on their outcomes. Moreover, it found that an acute change in conscious state resulting to a MET call imparted a greater risk of death than activation due to arrhythmias.