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Background: Optimal cerebral oxygenation is considered fundamental to cerebral protection in cardiac arrest (CA) patients. Hypercapnia increases cerebral blood flow and may also improve cerebral oxygenation. It is uncertain, however, whether this effect occurs in mechanically ventilated early survivors of CA.Methods: We enrolled mechanically ventilated resuscitated patients within 36h of their cardiac arrest. We performed a prospective double cross-over physiological study comparing the impact of normocapnia (PaCO2 35-45mmHg) vs. mild hypercapnia (PaCO2 45-55mmHg) on regional cerebral tissue oxygen saturation (SctO2) assessed by near infrared spectroscopy (NIRS).Results: We studied seven adult CA patients with a median time to return of spontaneous circulation of 28min at a median of 26h and 30min after CA. During normocapnia (median EtCO2 of 32mmHg [30-41mmHg] and PaCO2 of 37mmHg [32-45mmHg]) the median NIRS-derived left frontal SctO2 was 61% [52-65%] and the right frontal SctO2 was 61% [54-68%]. However, during mild hypercapnia (median EtCO2 of 49mmHg [40-57mmHg] and PaCO2 of 52mmHg [43-55mmHg) the median left frontal SctO2 increased to 69% [59-78%] and the right frontal SctO2 increased to 73% [61-76%])(p=0.001, for all comparisons).Conclusion: During the early post-resuscitation period, in mechanically ventilated CA patients, mild hypercapnia increases cerebral oxygenation as assessed by NIRS. Further investigations of the effect of prolonged mild hypercapnia on cerebral oxygenation and patient outcomes appear justified. [ABSTRACT FROM AUTHOR]

Abstract: Background: Arterial carbon dioxide tension (PaCO2) affects neuronal function and cerebral blood flow. However, its association with outcome in patients admitted to intensive care unit (ICU) after cardiac arrest (CA) has not been evaluated. Methods and results: Observational cohort study using data from the Australian New Zealand (ANZ) Intensive Care Society Adult-Patient-Database (ANZICS-APD). Outcomes analyses were adjusted for illness severity, co-morbidities, hypothermia, treatment limitations, age, year of admission, glucose, source of admission, PaO2 and propensity score. We studied 16,542 consecutive patients admitted to 125 ANZ ICUs after CA between 2000 and 2011. Using the APD-PaCO2 (obtained within 24h of ICU admission), 3010 (18.2%) were classified into the hypo- (PaCO2 <35mmHg), 6705 (40.5%) into the normo- (35–45mmHg) and 6827 (41.3%) into the hypercapnia (>45mmHg) group. The hypocapnia group, compared with the normocapnia group, had a trend toward higher in-hospital mortality (OR 1.12 [95% CI 1.00–1.24, p =0.04]), lower rate of discharge home (OR 0.81 [0.70–0.94, p <0.01]) and higher likelihood of fulfilling composite adverse outcome of death and no discharge home (OR 1.23 [1.10–1.37, p <0.001]). In contrast, the hypercapnia group had similar in-hospital mortality (OR 1.06 [0.97–1.15, p =0.19]) but higher rate of discharge home among survivors (OR 1.16 [1.03–1.32, p =0.01]) and similar likelihood of fulfilling the composite outcome (OR 0.97 [0.89–1.06, p =0.52]). Cox-proportional hazards modelling supported these findings. Conclusions: Hypo- and hypercapnia are common after ICU admission post-CA. Compared with normocapnia, hypocapnia was independently associated with worse clinical outcomes and hypercapnia a greater likelihood of discharge home among survivors. [Copyright &y& Elsevier]

Abstract: Aim: Determine current resuscitation practices and outcomes in patients presenting to the emergency department (ED) with sepsis and hypoperfusion or septic shock in Australia and New Zealand (ANZ). Methods: Three-month prospective, multi-centre, observational study of all adult patients with sepsis and hypoperfusion or septic shock in the ED of 32 ANZ tertiary-referral, metropolitan and rural hospitals. Results: 324 patients were enrolled (mean [SD] age 63.4 [19.2] years, APACHE II score 19.0 [8.2], 52.5% male). Pneumonia (n =138/324, 42.6%) and urinary tract infection (n =98/324, 30.2%) were the commonest sources of sepsis. Between ED presentation and 6hours post-enrolment (T6hrs), 44.4% (n =144/324) of patients received an intra-arterial catheter, 37% (n =120/324) a central venous catheter and 0% (n =0/324) a continuous central venous oxygen saturation (ScvO2) catheter. Between enrolment and T6hrs, 32.1% (n =104/324) received a vasopressor infusion, 7.4% (n =24/324) a red blood cell transfusion, 2.5% (n =8/324) a dobutamine infusion and 18.5% (n =60/324) invasive mechanical ventilation. Twenty patients (6.2%) were transferred from ED directly to the operating theatre, 36.4% (n =118/324) were admitted directly to ICU, 1.2% (n =4/324) died in the ED and 56.2% (n =182/324) were transferred to the hospital floor. Overall ICU admission rate was 52.4% (n =170/324). ICU and overall in-hospital mortality were 18.8% (n =32/170) and 23.1% (n =75/324) respectively. In-hospital mortality was not different between patients admitted to ICU (24.7%, n =42/170) and the hospital floor (21.4%, n =33/154). Conclusions: Management of ANZ patients presenting to ED with sepsis does not routinely include protocolised, ScvO2-directed resuscitation. In-hospital mortality compares favourably with reported mortality in international sepsis trials and nationwide surveys of resuscitation practices. [Copyright &y& Elsevier]

Summary: Objective: To examine NFR orders in relation to adverse events and emergency team calls in hospitals with or without a Medical Emergency Team (MET) system during the MERIT study. Method: Within a cluster randomized controlled trial (the MERIT study), examining the effect of introducing a MET system, we recorded NFR orders in relation to adverse events and emergency team calls. We compared the proportion and rate of NFR orders issued in relation to “adverse events” and “adverse event-free emergency team calls” in hospitals with or without a MET system. Results: Information on NFR orders was available for 3650 patients who died, 1466 patients who had an unplanned ICU admission, 574 patients who suffered a cardiac arrest and 1529 patients who had a adverse event-free emergency team call. Close to 90% of deaths occurred in patients with a previously documented NFR order. Only approximately 4% of cardiac arrests had a previously documented NFR order. In patients with unplanned ICU admission, NFR orders were present in approximately 3% of cases. An NFR order was issued at the time of an “event” in 3.85% of cases in MET hospitals compared with 1.72% in control hospitals (OR=2.29; 95% CI: 1.31–4.01; p =0.005). This difference was mostly due to a greater proportion of patients being made NFR in MET hospitals at the time of a “adverse event-free” emergency team call (7.96% vs. 3.05%; OR=2.75; 95% CI: 0.97–7.80; p =0.048). The number of NFR orders issued at the time of a serious adverse event-free emergency team call was 10 times higher in MET hospitals (0.398 vs. 0.041 per 1000 admissions; weighted absolute risk difference: 0.49 (95% CI: 0.20–0.78; p =0.002). Multivariate models could only account for less than 50% of the variance in the issuing of NFR orders. Conclusions: In a cohort of Australian hospitals, most deaths occurred in patients with a previously documented NFR order but NFR orders were uncommon before cardiac arrest calls or unplanned ICU admissions. During the conduct of a cluster randomised controlled trial, more NFR orders were issued by emergency teams in those hospitals that implemented a MET system than in control hospitals. MET allocation, teaching hospital status, number of hospital beds and metropolitan location could only explain less than 50% of variance in NFR orders. [Copyright &y& Elsevier]

Aim: A new definition of sepsis released by an international task-force has introduced the concept of quick Sequential (Sepsis-Related) Organ Failure Assessment (qSOFA). This study aimed to measure the proportion of patients who fulfilled qSOFA criteria during a Rapid Response Team (RRT) review and to assess their associated outcomes.Methods: We conducted a prospective study of adult RRT reviews over a one month period between 6th June and 10th July 2016 in a large tertiary hospital in Melbourne Australia RESULTS: Over a one-month period, there were 282 RRT reviews, 258 of which were included. One hundred out of 258 (38.8%) RRT review patients fulfilled qSOFA criteria. qSOFA positive patients were more likely to be admitted to the intensive care unit (29% vs 18%, P=0.04), to have repeat RRT reviews (27% vs 13%; p=0.007) and die in hospital (31% vs 10%, P<0.001). qSOFA positive patients with suspected infection were more likely to be admitted to the intensive care unit compared to patients with infection alone (37% vs 15%, P=0.002). Eleven of 42 patients (26%) who had infection and qSOFA died whilst in hospital, compared to 8/55 (15%) of patients with infection alone (P=0.2).Conclusion: Adult patients who are qSOFA positive at the time of their RRT review are at increased risk of in-hospital mortality. The assessment of qSOFA may be a useful triage tool during a RRT review. [ABSTRACT FROM AUTHOR]

Background: In mechanically ventilated (MV) cardiac arrest (CA) survivors admitted to the intensive care unit (ICU) avoidance of hypoxia is considered crucial. However, avoidance of hyperoxia may also be important. A conservative approach to oxygen therapy may reduce exposure to both.Methods: We evaluated the introduction of conservative oxygen therapy (target SpO2 88-92% using the lowest FiO2) during MV for resuscitated CA patients admitted to the ICU.Results: We studied 912 arterial blood gas (ABG) datasets: 448 ABGs from 50 'conventional' and 464 ABGs from 50 'conservative' oxygen therapy patients. Compared to the conventional group, conservative group patients had significantly lower PaO2 values and FiO2 exposure (p<0.001, respectively); more received MV in a spontaneous ventilation mode (18% vs 2%; p=0.001) and more were exposed to a FiO2 of 0.21 (19 vs 0 patients, p=0.001). Additionally, according to mean PaO2, more conservative group patients were classified as normoxaemic (36 vs 16 patients, p<0.01) and fewer as hyperoxaemic (14 vs 33 patients, p<0.01). Finally, ICU length of stay was significantly shorter for conservative group patients (p=0.04). There was no difference in the proportion of survivors discharged from hospital with good neurological outcome (14/23 vs 12/22 patients, p=0.67).Conclusions: Our findings provide preliminary support for the feasibility and physiological safety of conservative oxygen therapy in patients admitted to ICU for MV support after cardiac arrest (Trial registration, NCT01684124). [ABSTRACT FROM AUTHOR]