129 results on '"Subramaniam, Ashwin"'
Search Results
102. Management of sodium–glucose cotransporter 2 inhibitors during the perioperative period: A retrospective comparative study
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Ge, Victor, Subramaniam, Ashwin, Banakh, Iouri, Wang, Wei Chun, and Tiruvoipati, Ravindranath
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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.
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- 2021
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103. Evaluating the influence of data collector training for predictive risk of death models: an observational study.
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Rajamani, Arvind, Huang, Stephen, Subramaniam, Ashwin, Thomson, Michele, Jinghang Luo, Simpson, Andrew, McLean, Anthony, Aneman, Anders, Madapusi, Thodur Vinodh, Lakshmanan, Ramanathan, Flynn, Gordon, Poojara, Latesh, Gatward, Jonathan, Pusapati, Raju, Howard, Adam, and Odlum, Debbie
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APACHE (Disease classification system) ,AUDITING ,CRITICALLY ill ,INTENSIVE care units ,MULTIVARIATE analysis ,SCIENTIFIC observation ,PATIENTS ,QUALITY assurance ,RISK assessment ,ACQUISITION of data ,SEVERITY of illness index ,DESCRIPTIVE statistics ,HOSPITAL mortality ,INTRACLASS correlation - Abstract
Background Severity-of-illness scoring systems are widely used for quality assurance and research. Although validated by trained data collectors, there is little data on the accuracy of real-world data collection practices. Objective To evaluate the influence of formal data collection training on the accuracy of scoring system data in intensive care units (ICUs). Study design and methods Quality assurance audit conducted using survey methodology principles. Between June and December 2018, an electronic document with details of three fictitious ICU patients was emailed to staff from 19 Australian ICUs who voluntarily submitted data on a web-based data entry form. Their entries were used to generate severity-of-illness scores and risks of death (RoDs) for four scoring systems. The primary outcome was the variation of severity-of-illness scores and RoDs from a reference standard. Results 50/83 staff (60.3%) submitted data. Using Bayesian multilevel analysis, severity-of-illness scores and RoDs were found to be significantly higher for untrained staff. The mean (95% high-density interval) overestimation in RoD due to training effect for patients 1, 2 and 3, respectively, were 0.24 (0.16, 0.31), 0.19 (0.09, 0.29) and 0.24 (0.1, 0.38) respectively (Bayesian factor ≥300, decisive evidence). Both groups (trained and untrained) had wide coefficients of variation up to 38.1%, indicating wide variability. Untrained staff made more errors in interpreting scoring system definitions. Interpretation In a fictitious patient dataset, data collection staff without formal training significantly overestimated the severity-of-illness scores and RoDs compared with trained staff. Both groups exhibited wide variability. Strategies to improve practice may include providing adequate training for all data collection staff, refresher training for previously trained staff and auditing the raw data submitted by individual ICUs. The results of this simulated study need revalidation on real patients. [ABSTRACT FROM AUTHOR]
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- 2021
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104. Case Fatality Rates for Patients with COVID-19 Requiring Invasive Mechanical Ventilation. A Meta-analysis.
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Zheng Jie Lim, Subramaniam, Ashwin, Reddy, Mallikarjuna Ponnapa, Blecher, Gabriel, Kadam, Umesh, Afroz, Afsana, Billah, Baki, Ashwin, Sushma, Kubicki, Mark, Bilotta, Federico, Curtis, J. Randall, and Rubulotta, Francesca
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ARTIFICIAL respiration ,COVID-19 ,MORTALITY ,HETEROGENEITY ,META-analysis - Abstract
Rationale: Initial reports of case fatality rates (CFRs) among adults with coronavirus disease (COVID-19) receiving invasive mechanical ventilation (IMV) are highly variable.Objectives: To examine the CFR of patients with COVID-19 receiving IMV.Methods: Two authors independently searched PubMed, Embase, medRxiv, bioRxiv, the COVID-19 living systematic review, and national registry databases. The primary outcome was the "reported CFR" for patients with confirmed COVID-19 requiring IMV. "Definitive hospital CFR" for patients with outcomes at hospital discharge was also investigated. Finally, CFR was analyzed by patient age, geographic region, and study quality on the basis of the Newcastle-Ottawa Scale.Measurements and Results: Sixty-nine studies were included, describing 57,420 adult patients with COVID-19 who received IMV. Overall reported CFR was estimated as 45% (95% confidence interval [CI], 39-52%). Fifty-four of 69 studies stated whether hospital outcomes were available but provided a definitive hospital outcome on only 13,120 (22.8%) of the total IMV patient population. Among studies in which age-stratified CFR was available, pooled CFR estimates ranged from 47.9% (95% CI, 46.4-49.4%) in younger patients (age ≤40 yr) to 84.4% (95% CI, 83.3-85.4%) in older patients (age >80 yr). CFR was also higher in early COVID-19 epicenters. Overall heterogeneity is high (I2 >90%), with nonsignificant Egger's regression test suggesting no publication bias.Conclusions: Almost half of patients with COVID-19 receiving IMV died based on the reported CFR, but variable CFR reporting methods resulted in a wide range of CFRs between studies. The reported CFR was higher in older patients and in early pandemic epicenters, which may be influenced by limited ICU resources. Reporting of definitive outcomes on all patients would facilitate comparisons between studies.Systematic review registered with PROSPERO (CRD42020186997). [ABSTRACT FROM AUTHOR]
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- 2021
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105. Non-invasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey.
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Subramaniam, Ashwin, Haji, Jumana Y., Kumar, Prashant, Ramanathan, Kollengode, and Rajamani, Arvind
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INTENSIVE care units , *VIRAL pneumonia , *COVID-19 , *ACADEMIC medical centers , *POSITIVE pressure ventilation , *NASAL cannula , *PHYSICIANS' attitudes , *FISHER exact test , *ARTIFICIAL respiration , *NURSE anesthetists , *OXYGEN therapy , *CRITICAL care medicine , *QUESTIONNAIRES , *CASE studies , *PUBLIC hospitals , *DESCRIPTIVE statistics , *PROPRIETARY hospitals , *DATA analysis software , *HYPOXEMIA - Abstract
Background: About 5% of hospitalized coronavirus disease 2019 (COVID-19) patients will need intensive care unit (ICU) admission for hypoxemic respiratory failure requiring oxygen support. The choice between early mechanical ventilation and noninvasive oxygen therapies, such as, high- flow nasal oxygen (HFNO) and/or noninvasive positive-pressure ventilation (NPPV) has to balance the contradictory priorities of protecting healthcare workers by minimizing aerosol-generation and optimizing resource management. This survey over two timeframes aimed to explore the controversial issue of location and noninvasive oxygen therapy in non-intubated ICU patients using a clinical vignette. Materials and methods: An online survey was designed, piloted, and distributed electronically to Indian intensivists/anesthetists, from Private Hospitals, Government Hospitals, and Medical College Hospitals (the latter two referred to as first-responder hospitals), who are directly responsible for admitting/managing patients in ICU. Results: Of the 204 responses (125/481 in phase 1 and 79/320 in phase 2), 183 responses were included. Respondents from first-responder hospitals were more willing to manage non-intubated hypoxemic patients in neutral pressure rooms, while respondents from private hospitals preferred negative-pressure rooms (p < 0.001). In both the phases, private hospital doctors were less comfortable to use any form of noninvasive oxygen therapies in neutral-pressure rooms compared to first-responder hospitals (low-flow oxygen therapy: 72 vs 50%, p < 0.01; HFNO: 47 vs 24%, p < 0.01 and NPPV: 38 vs 28%, p = 0.20). Interpretation: Variations existed in practices among first-responder and private intensivists/anesthetists. The resource optimal private hospital intensivists/anesthetists were less comfortable using noninvasive oxygen therapies in managing COVID-19 patients. This may reflect differential resource availability necessitating resolution at national, state, and local levels. [ABSTRACT FROM AUTHOR]
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- 2020
106. State of Personal Protective Equipment Practice in Indian Intensive Care Units amidst COVID-19 Pandemic: A Nationwide Survey.
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Haji, Jumana Yusuf, Subramaniam, Ashwin, Kumar, Prashant, Ramanathan, Kollengode, and Rajamani, Arvind
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INTENSIVE care units , *COVID-19 , *MEDICAL protocols , *DESCRIPTIVE statistics , *PERSONAL protective equipment , *MEDICAL waste disposal , *COVID-19 pandemic , *N95 respirators - Abstract
Background: Optimal personal protective equipment (PPE) preparedness is key to minimize healthcare workers (HCW) infection with COVID- 19. This two-phase survey evaluated PPE preparedness (adherence to Ministry of Health India (MoH) PPE-recommendations; HCW-training; PPE-inventory; PPE-breach management) in Indian intensive care units (ICU). Materials and methods: The phase 1 survey was distributed electronically to intensivists from 481 Indian hospitals between March 25, 2020, and April 06, 2020, as part of a multinational survey. Phase 2 was repeated in 320 Indian hospitals between April 20, 2020, and April 30, 2020. Results: Response rate was 25% from 22 states. PPE practice varied between states and between private, government, and medical colleges. Between phase 1 and phase 2, all aspects of PPE training improved: donning/doffing 43% vs 66%, respectively; p value <0.01); safe waste disposal practices (38% vs 52%; p value = 0.09); intubation training (18% vs 31%; p value = 0.05); and transport (18% vs 31%; p value = 0.05). Perception of confidence for adequate PPE-training improved from 39 to 53% (p value = 0.26). In all, 47 to 60% ICUs adhered to MoH recommendations. Wearing N95-masks at all times increased from 47 to 60% (p value = 0.89). Very few ICUs provided quantitative/qualitative N95 masks fit testing (12% vs 29%; p value <0.01). Low-cost practices like "buddy-system" for donning-doffing (27% vs 44%; p value = 0.02) and showering after PPE breach (10% vs 8%; p value = 0.63) were underutilized. There was reluctance to PPE reuse. In all, 71% were unaware/diffident about PPE inventory. Conclusion: Despite interstate variability, most ICUs conformed to MoH recommendations. This survey conducted during initial pandemic phase demonstrated improved PPE preparedness uniformly across India with scope for further improvement. We suggest implementation of quality improvement measures to improve pandemic preparedness and minimize HCW infection rates, focused on regular PPE training, buddy system, and PPE-breach management. [ABSTRACT FROM AUTHOR]
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- 2020
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107. Post-operative outcomes in older patients: a single-centre observational study
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Tang, Benjamin, primary, Green, Cameron, additional, Yeoh, Aun Chian, additional, Husain, Faisal, additional, and Subramaniam, Ashwin, additional
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- 2018
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108. Predictors of respiratory failure in patients with Guillain–Barré syndrome: a systematic review and meta‐analysis
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Green, Cameron, primary, Baker, Tess, additional, and Subramaniam, Ashwin, additional
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- 2018
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109. Anterior spinal artery syndrome after double valve replacement and coronary artery bypass surgery
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Subramaniam, Ashwin, primary, Pick, Adrian, additional, and Tiruvoipati, Ravi, additional
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- 2017
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110. The impact of delay in rapid response activation on patient outcomes at a metropolitan hospital
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Gupta, Sachin, primary, Green, Cameron, additional, Subramaniam, Ashwin, additional, Lim, Dee Zhen, additional, Low, Elizabeth, additional, and Tiruvoipati, Ravi, additional
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- 2017
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111. Anesthetic management of a myotonic dystrophy patient with paraganglionoma
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Subramaniam, Ashwin, primary, Grauer, Robert, additional, Beilby, David, additional, and Tiruvoipati, Ravindranath, additional
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- 2016
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112. Mushroom Recognition Using PCA Algorithm
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Subramaniam, Ashwin, primary and Oh, Byung-Joo, additional
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- 2016
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113. Circulating tumour DNA (ctDNA) as a predictor of clinical outcome in non-small cell lung cancer undergoing targeted therapies: A systematic review and meta-analysis.
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Zaman, Farzana Yasmin, Subramaniam, Ashwin, Afroz, Afsana, Samoon, Zarka, Zwieky, Walid, Arulananda, Surein, and Alamgeer, Muhammad
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- 2023
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114. Impact of frailty on long-term survival in patients discharged alive from hospital after an ICU admission with COVID-19
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Subramaniam, Ashwin, Ling, Ryan Ruiyang, and Pilcher, David
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Though frailty is associated with mortality, its impact on long-term survival after an ICU admission with COVID-19 is unclear. To investigate the association between frailty and long-term survival in patients after an ICU admission with severe COVID-19 in Australia and New Zealand (ANZ).
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- 2023
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115. Is Cooling Still Cool?
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Subramaniam, Ashwin, Tiruvoipati, Ravindranath, and Botha, John
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Therapeutic hypothermia (TH), where patients are cooled to between 32°C and 36°C for a period of 12–24 hours and then gradually rewarmed, may reduce the risk of ischemic injury to cerebral tissue following a period of insufficient blood flow. This strategy of TH could improve mortality and neurological function in patients who have experienced out-of-hospital cardiac arrest (OOHCA). The necessity of TH in OOHCA was challenged in late 2013 by a fascinating and potentially practice changing publication, which found that targeting a temperature of 36°C had similar outcomes to cooling patients to 33°C. This article reviews the current literature and summarizes the uncertainties and questions raised when considering cooling of patients at risk of hypoxic brain injury. Irrespective of whether TH or targeted temperature management is deployed in patients at risk of hypoxic brain injury, it would seem that avoiding hyperpyrexia is important and that a more rigorous approach to neurological evaluation is mandated.
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- 2015
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116. Tackling Water Challenges to Drive Business in Asia.
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Subramaniam, Ashwin
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CONSUMER goods ,WATER purification - Published
- 2017
117. Epidemiology of acute hypoxaemic respiratory failure in Australian and New Zealand intensive care units during 2005–2022. A binational, registry-based study.
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Ling, Ryan Ruiyang, Ponnapa Reddy, Mallikarjuna, Subramaniam, Ashwin, Moran, Benjamin, Ramanathan, Kollengode, Ramanan, Mahesh, Burrell, Aidan, Pilcher, David, and Shekar, Kiran
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INTENSIVE care units , *PARTIAL pressure , *DEATH rate , *CLINICAL deterioration , *BLOOD gases - Abstract
Purpose: Acute hypoxaemic respiratory failure (AHRF) is a common reason for intensive care unit (ICU) admission. However, patient characteristics, outcomes, and trends over time are unclear. We describe the epidemiology and outcomes of patients with AHRF over time.In this binational, registry-based study from 2005 to 2022, we included all adults admitted to an Australian or New Zealand ICU with an arterial blood gas within the first 24 h of ICU stay. AHRF was defined as a partial pressure of oxygen/inspired oxygen ratio (PaO2/FiO2) ≤ 300. The primary outcome was adjusted in-hospital mortality, categorised based on PaO2/FiO2 (mild: 200–300, moderate: 100–200, and severe < 100, and non-linearly). We investigated how adjusted mortality evolved based on temporal trends (by year of admission), sex, age, admission diagnosis and the receipt of mechanical ventilation.Of 1,560,221 patients, 826,106 (52.9%) were admitted with or developed AHRF within the first 24 h of ICU stay. Of these 826,106 patients, 51.4% had mild, 39.3% had moderate, and 9.3% had severe AHRF. Compared to patients without AHRF (5.3%), patients with mild (8%), moderate (14.2%) and severe (29.9%) AHRF had higher in-hospital mortality rates. As PaO2/FiO2 ratio decreased, adjusted in-hospital mortality progressively increased, particularly below an inflection point at a PaO2/FiO2 ratio of 200. The adjusted in-hospital mortality for all patients decreased over time (13.3% in 2005 to 8.2% in 2022), and this trend was similar in patients with and without AHRF.The healthcare burden due to AHRF may be larger than expected, and mortality rates remain high in severe AHRF. Although mortality has decreased over time, this may reflect improvements in ICU care in general, rather than specifically in AHRF. More research is required to earlier identify AHRF and stratify these patients at risk of deterioration early, and to validate our findings.Methods: Acute hypoxaemic respiratory failure (AHRF) is a common reason for intensive care unit (ICU) admission. However, patient characteristics, outcomes, and trends over time are unclear. We describe the epidemiology and outcomes of patients with AHRF over time.In this binational, registry-based study from 2005 to 2022, we included all adults admitted to an Australian or New Zealand ICU with an arterial blood gas within the first 24 h of ICU stay. AHRF was defined as a partial pressure of oxygen/inspired oxygen ratio (PaO2/FiO2) ≤ 300. The primary outcome was adjusted in-hospital mortality, categorised based on PaO2/FiO2 (mild: 200–300, moderate: 100–200, and severe < 100, and non-linearly). We investigated how adjusted mortality evolved based on temporal trends (by year of admission), sex, age, admission diagnosis and the receipt of mechanical ventilation.Of 1,560,221 patients, 826,106 (52.9%) were admitted with or developed AHRF within the first 24 h of ICU stay. Of these 826,106 patients, 51.4% had mild, 39.3% had moderate, and 9.3% had severe AHRF. Compared to patients without AHRF (5.3%), patients with mild (8%), moderate (14.2%) and severe (29.9%) AHRF had higher in-hospital mortality rates. As PaO2/FiO2 ratio decreased, adjusted in-hospital mortality progressively increased, particularly below an inflection point at a PaO2/FiO2 ratio of 200. The adjusted in-hospital mortality for all patients decreased over time (13.3% in 2005 to 8.2% in 2022), and this trend was similar in patients with and without AHRF.The healthcare burden due to AHRF may be larger than expected, and mortality rates remain high in severe AHRF. Although mortality has decreased over time, this may reflect improvements in ICU care in general, rather than specifically in AHRF. More research is required to earlier identify AHRF and stratify these patients at risk of deterioration early, and to validate our findings.Results: Acute hypoxaemic respiratory failure (AHRF) is a common reason for intensive care unit (ICU) admission. However, patient characteristics, outcomes, and trends over time are unclear. We describe the epidemiology and outcomes of patients with AHRF over time.In this binational, registry-based study from 2005 to 2022, we included all adults admitted to an Australian or New Zealand ICU with an arterial blood gas within the first 24 h of ICU stay. AHRF was defined as a partial pressure of oxygen/inspired oxygen ratio (PaO2/FiO2) ≤ 300. The primary outcome was adjusted in-hospital mortality, categorised based on PaO2/FiO2 (mild: 200–300, moderate: 100–200, and severe < 100, and non-linearly). We investigated how adjusted mortality evolved based on temporal trends (by year of admission), sex, age, admission diagnosis and the receipt of mechanical ventilation.Of 1,560,221 patients, 826,106 (52.9%) were admitted with or developed AHRF within the first 24 h of ICU stay. Of these 826,106 patients, 51.4% had mild, 39.3% had moderate, and 9.3% had severe AHRF. Compared to patients without AHRF (5.3%), patients with mild (8%), moderate (14.2%) and severe (29.9%) AHRF had higher in-hospital mortality rates. As PaO2/FiO2 ratio decreased, adjusted in-hospital mortality progressively increased, particularly below an inflection point at a PaO2/FiO2 ratio of 200. The adjusted in-hospital mortality for all patients decreased over time (13.3% in 2005 to 8.2% in 2022), and this trend was similar in patients with and without AHRF.The healthcare burden due to AHRF may be larger than expected, and mortality rates remain high in severe AHRF. Although mortality has decreased over time, this may reflect improvements in ICU care in general, rather than specifically in AHRF. More research is required to earlier identify AHRF and stratify these patients at risk of deterioration early, and to validate our findings.Conclusion: Acute hypoxaemic respiratory failure (AHRF) is a common reason for intensive care unit (ICU) admission. However, patient characteristics, outcomes, and trends over time are unclear. We describe the epidemiology and outcomes of patients with AHRF over time.In this binational, registry-based study from 2005 to 2022, we included all adults admitted to an Australian or New Zealand ICU with an arterial blood gas within the first 24 h of ICU stay. AHRF was defined as a partial pressure of oxygen/inspired oxygen ratio (PaO2/FiO2) ≤ 300. The primary outcome was adjusted in-hospital mortality, categorised based on PaO2/FiO2 (mild: 200–300, moderate: 100–200, and severe < 100, and non-linearly). We investigated how adjusted mortality evolved based on temporal trends (by year of admission), sex, age, admission diagnosis and the receipt of mechanical ventilation.Of 1,560,221 patients, 826,106 (52.9%) were admitted with or developed AHRF within the first 24 h of ICU stay. Of these 826,106 patients, 51.4% had mild, 39.3% had moderate, and 9.3% had severe AHRF. Compared to patients without AHRF (5.3%), patients with mild (8%), moderate (14.2%) and severe (29.9%) AHRF had higher in-hospital mortality rates. As PaO2/FiO2 ratio decreased, adjusted in-hospital mortality progressively increased, particularly below an inflection point at a PaO2/FiO2 ratio of 200. The adjusted in-hospital mortality for all patients decreased over time (13.3% in 2005 to 8.2% in 2022), and this trend was similar in patients with and without AHRF.The healthcare burden due to AHRF may be larger than expected, and mortality rates remain high in severe AHRF. Although mortality has decreased over time, this may reflect improvements in ICU care in general, rather than specifically in AHRF. More research is required to earlier identify AHRF and stratify these patients at risk of deterioration early, and to validate our findings. [ABSTRACT FROM AUTHOR]
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- 2024
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118. Long-term survival comparison of patients admitted to the intensive care unit following in-hospital cardiac arrest in perioperative and ward settings. A multicentre retrospective cohort study.
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Ueno, Ryo, Chan, Rachel, Reddy, Mallikarjuna Ponnapa, Jones, Daryl, Pilcher, David, and Subramaniam, Ashwin
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PROPORTIONAL hazards models , *OLDER patients , *INTENSIVE care patients , *INTENSIVE care units , *CARDIAC intensive care - Abstract
Purpose: Perioperative in-hospital cardiac arrests (Perioperative IHCAs) may have better outcomes than IHCAs in the ward (Ward IHCAs), due to enhanced monitoring and faster response. However, quantitative comparisons of their long-term outcomes are lacking, posing challenges for prognostication. Methods: This retrospective multicentre study included adult intensive care unit (ICU) admissions from theatre/recovery or wards with a diagnosis of cardiac arrest between January 2018 and March 2022. We used data from 175 ICUs in the ANZICS adult patient database. The primary outcome was a survival time of up to 4 years. We used the Cox proportional hazards model adjusted for Sequential Organ Failure Assessment (SOFA) score, age, sex, comorbidities, hospital type, treatment limitation on admission to the ICU, and ICU treatments. Subgroup analyses examined age (≥ 65 years), intubation within the first 24 h, elective vs. emergency admission, and survival on discharge. Results: Of 702,675 ICU admissions, 5,659 IHCAs were included (Perioperative IHCA 38%; Ward IHCA 62%). Perioperative IHCA group were younger, less frail, and less comorbid. Perioperative IHCA were most frequent in patients admitted to ICU after cardiovascular, gastrointestinal, or trauma surgeries. Perioperative IHCA group had longer 4-year survival (59.9% vs. 33.0%, p < 0.001) than the Ward IHCA group, even after adjustments (adjusted hazard ratio [HR]: 0.63, 95% confidence interval [CI] 0.57–0.69). This was concordant across all subgroups. Of note, older patients with Perioperative IHCA survived longer than both younger and older patients with Ward IHCA. Conclusion: Patients admitted to the ICU following Perioperative IHCA had longer survival than Ward IHCA. Future studies on IHCA should distinguish these patients. [ABSTRACT FROM AUTHOR]
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- 2024
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119. FRailty in Australian patients admitted to Intensive care unit after eLective CANCER-related SURGery: a retrospective multicentre cohort study (FRAIL-CANCER-SURG study).
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Ling, Ryan R., Ueno, Ryo, Alamgeer, Muhammad, Sundararajan, Krishnaswamy, Sundar, Raghav, Bailey, Michael, Pilcher, David, and Subramaniam, Ashwin
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INTENSIVE care patients , *ELECTIVE surgery , *FRAILTY , *COHORT analysis - Abstract
The association between frailty and short-term and long-term outcomes in patients receiving elective surgery for cancer remains unclear, particularly in those admitted to the ICU. In this multicentre retrospective cohort study, we included adults ≥16 yr old admitted to 158 ICUs in Australia from January 1, 2018 to March 31, 2022 after elective surgery for cancer. We investigated the association between frailty and survival time up to 4 yr (primary outcome), adjusting for a prespecified set of covariates. We analysed how this association changed in specific subgroups (age categories [<65, 65–80, ≥80 yr], and those who survived hospitalisation), and over time by splitting the survival information at monthly intervals. We included 35,848 patients (median follow-up: 18.1 months [inter-quartile range: 8.3–31.1 months], 19,979 [56.1%] male, median age 69.0 yr [inter-quartile range: 58.8–76.0 yr]). Some 3502 (9.8%) patients were frail (defined as clinical frailty scale ≥5). Frailty was associated with lower survival (hazard ratio: 1.72, 95% confidence interval [CI]: 1.59–1.86 compared with clinical frailty scale ≤4); this was concordant across several sensitivity analyses. Frailty was most strongly associated with mortality early on in follow-up, up to 10 months (hazard ratio: 1.39, 95% CI: 1.03–1.86), but this association plateaued, and its predictive capacity subsequently diminished with time up until 4 yr (1.96, 95% CI: 0.73–5.28). Frailty was associated with similar effects when stratified based on age, and in those who survived hospitalisation. Frailty was associated with poorer outcomes after an ICU admission after elective surgery for cancer, particularly in the short term. However, its predictive capacity with time diminished, suggesting a potential need for longitudinal reassessment to ensure appropriate prognostication in this population. [ABSTRACT FROM AUTHOR]
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- 2024
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120. Depok: The Front Line in Indonesia's Fight Against Waste.
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Subramaniam, Ashwin
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HAZARDOUS waste sites ,WASTE management laws - Published
- 2017
121. Psychiatric Manifestations of Neurological Diseases: A Narrative Review.
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Maristany AJ, Sa BC, Murray C, Subramaniam AB, and Oldak SE
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Neurological diseases often manifest with psychiatric symptoms, profoundly impacting patients' well-being and treatment outcomes. This comprehensive review examines the psychiatric manifestations associated with Alzheimer's disease, frontotemporal dementia (FTD), Parkinson's disease, multiple sclerosis (MS), stroke, epilepsy, Huntington's disease, amyotrophic lateral sclerosis (ALS), traumatic brain injury (TBI), and multiple system atrophy (MSA). Key psychiatric symptoms include agitation, depression, anxiety, apathy, hallucinations, impulsivity, and aggression across these diseases. In addition, ethical considerations in treating these symptoms are paramount, particularly regarding genetic testing implications, end-of-life discussions, informed consent, and equitable access to innovative treatments. Effective management necessitates interdisciplinary collaboration, personalized interventions, and a focus on patient autonomy. Understanding the psychiatric burden of neurological diseases is crucial for enhancing patients' quality of life. Further research is needed to elucidate underlying mechanisms and develop targeted interventions. This review underscores the importance of comprehensive assessment and ethical treatment practices to address psychiatric manifestations effectively., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Maristany et al.)
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- 2024
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122. Oncology and intensive care doctors' perception of intensive care admission of cancer patients: A cross-sectional national survey.
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Padhi S, Shrestha P, Alamgeer M, Stevanovic A, Karikios D, Rajamani A, and Subramaniam A
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- Humans, Cross-Sectional Studies, Australia, Female, Male, Surveys and Questionnaires, Intensive Care Units, Middle Aged, Adult, Medical Oncology, Attitude of Health Personnel, Critical Care, Patient Admission, Neoplasms therapy
- Abstract
Introduction: Prognosis in oncology has improved with early diagnosis and novel therapies. However, critical illness continues to trigger clinical and ethical dilemmas for the treating oncology and intensive care unit (ICU) doctors., Objectives: The objective of this study was to investigate the perceptions of oncology and ICU doctors in managing critically ill cancer patients., Methods: A cross-sectional web-based survey exploring the management of a fictitious acutely deteriorating case vignette with solid-organ malignancy. The survey weblink was distributed between May and July 2022 to all Australian oncology and ICU doctors via newsletters to the members of the Medical Oncology Group of Australia, the Australian and New Zealand Intensive Care Society, and the College of Intensive Care Medicine inviting them to participate. The weblink was active till August 2022. The six domains included patient prognostication, advanced care plan, collaborative management, legal/ethical/moral challenges, ICU referral, and protocol-based ICU admission. The outcomes were reported as the level of agreement between oncology and ICU doctors for each domain/question., Results: 184 responses (64 oncology and 120 ICU doctors) were analysed. Most respondents were specialists (78.1% [n = 50] oncology, 78.3% [n = 94] ICU doctors). Oncology doctors more commonly reported managing cancer patients with poor prognosis than ICU doctors (p < 0.001). Oncology doctors less commonly referred such patients for ICU admission (29.7% [n = 19] vs. 80.8% [n = 97], p < 0.001; odds ratio [OR] = 0.07; 95% confidence interval [CI]: 0.03-0.16) and infrequently encountered patients with prior goals of care (GOC) in medical emergency team escalations (40.6% [n = 26] vs. 86.7% [n = 104]; p < 0.001; OR = 0.06; 95% CI: 0.02-0.15; p < 0.001). Oncology doctors were less likely to discuss GOC during medical emergency team calls or within 24 h of ICU admission. More oncology doctors than ICU doctors thought that training rotation in the corresponding speciality group was beneficial (56.3% [n = 36] vs. 31.7% [n = 38]; p = 0.012; OR = 2.07; 95% CI: 1.02-4.23; p = 0.045)., Conclusion: Oncology doctors were less likely to encounter acute patient deterioration or establish timely GOC for such patients. Oncology doctors believed that an ICU rotation during their training may have helped manage challenging situations., (Copyright © 2024 Australian College of Critical Care Nurses Ltd. Published by Elsevier Ltd. All rights reserved.)
- Published
- 2024
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123. The impact of frailty on survival times up to one year among patients admitted to ICU with in-hospital cardiac arrest.
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Ueno R, Reddy MP, Jones D, Pilcher D, and Subramaniam A
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- Humans, Male, Female, Retrospective Studies, Aged, Middle Aged, Australia epidemiology, Organ Dysfunction Scores, Aged, 80 and over, Proportional Hazards Models, Critical Illness mortality, Survival Analysis, Hospital Mortality, Intensive Care Units statistics & numerical data, Frailty mortality, Heart Arrest mortality, Heart Arrest therapy
- Abstract
Background: In-hospital cardiac arrest (IHCA) is a serious medical emergency. When IHCA occurs in patients with frailty, short-term survival is poor. However, the impact of frailty on long-term survival is unknown., Methods: We performed a retrospective multicentre study of all critically ill adult (age ≥ 16 years) patients admitted to Australian intensive care units (ICU) between 1st January 2018 to 31st March 2022. We included all patients who had an IHCA within the 24 h before ICU admission with a documented Clinical Frail Scale (CFS). The primary outcome was median survival up to one year following ICU admission. The effect of frailty on one-year survival was assessed using a Cox proportional hazards model, adjusting for age, sex, comorbidities, sequential organ failure assessment (SOFA) score, and hospital type., Results: We examined 3769 patients, of whom 30.8% (n = 1160) were frail (CFS ≥ 5). The median survival was significantly shorter for patients with frailty (median [IQR] days 19 [1-365] vs 302 [9-365]; p < 0.001). The overall one-year mortality was worse for the patients with frailty when compared to the non-frail group (64.8% [95%CI 61.9-67.5] vs 36.4% [95%CI 34.5-38.3], p < 0.001). Each unit increment in the CFS was associated with 22% worse survival outcome (adjusted Hazard ratio = 1.22, 95%-CI 1.19-1.26), after adjustment for confounders. The survival trend was similar among patients who survived the hospitalization., Conclusion: In this retrospective multicentre study, frailty was associated with poorer one-year survival in patients admitted to Australian ICUs following an IHCA., (Copyright © 2024. Published by Elsevier Inc.)
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- 2024
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124. Persistent Critical Illness and Long-Term Outcomes in Patients With COVID-19: A Multicenter Retrospective Cohort Study.
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Ling RR, Bonavia W, Ponnapa Reddy M, Pilcher D, and Subramaniam A
- Abstract
Objectives: A nontrivial number of patients in ICUs experience persistent critical illness (PerCI), a phenomenon in which features of the ICU course more consistently predict mortality than the initial indication for admission. We aimed to describe PerCI among patients with critical illness caused by COVID-19, and these patients' short- and long-term outcomes., Design: Multicenter retrospective cohort study., Setting: Australian and New Zealand Intensive Care Society Adult Patient Database of 114 Australian ICUs between January 1, 2020, and March 31, 2022., Patients: Patients 16 years old or older with COVID-19, and a documented ICU length of stay., Exposure: The presence of PerCI, defined as an ICU length of stay greater than or equal to 10 days., Measurements: We compared the survival time up to 2 years from ICU admission using time-varying robust-variance estimated Cox proportional hazards models. We further investigated the impact of PerCI in subgroups of patients, stratifying based on whether they survived their initial hospitalization., Main Results: We included 4961 patients in the final analysis, and 882 patients (17.8%) had PerCI. ICU mortality was 23.4% in patients with PerCI and 6.5% in those without PerCI. Patients with PerCI had lower 2-year (70.9% [95% CI, 67.9-73.9%] vs. 86.1% [95% CI, 85.0-87.1%]; p < 0.001) survival rates compared with patients without PerCI. Patients with PerCI had higher mortality (adjusted hazards ratio: 1.734; 95% CI, 1.388-2.168); this was consistent across several sensitivity analyses. When analyzed as a nonlinear predictor, the hazards of mortality were inconsistent up until 10 days, before plateauing., Conclusions: In this multicenter retrospective observational study patients with PerCI tended to have poorer short-term and long-term outcomes. However, the hazards of mortality plateaued beyond the first 10 days of ICU stay. Further studies should investigate predictors of developing PerCI, to better prognosticate long-term outcomes., Competing Interests: The authors have disclosed that they do not have any potential conflicts of interest., (Copyright © 2024 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine.)
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- 2024
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125. Intensive care admissions following rapid response team reviews in patients with COVID-19 in Australia.
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Johnston C, Subramaniam A, Orosz J, Burrell A, Neto AS, Young M, Bailey M, Pilcher D, Udy A, and Jones D
- Abstract
Objectives : To evaluate the epidemiology of rapid response team (RRT) reviews that led to intensive care unit (ICU) admissions, and to evaluate the frequency of in-hospital cardiac arrests (IHCAs) among ICU patients with confirmed coronavirus disease 2019 (COVID-19) in Australia . Design : Multicentre, retrospective cohort study. Setting: 48 public and private ICUs in Australia. Participants: All adults (aged ≥ 16 years) with confirmed COVID-19 admitted to participating ICUs between 25 January and 31 October 2020, as part of SPRINT-SARI (Short PeRiod IncideNce sTudy of Severe Acute Respiratory Infection) Australia, which were linked with ICUs contributing to the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD). Main outcome measures and results: Of the 413 critically ill patients with COVID-19 who were analysed, 48.2% (199/413) were admitted from the ward and 30.5% (126/413) were admitted to the ICU following an RRT review. Patients admitted following an RRT review had higher Acute Physiology and Chronic Health Evaluation (APACHE) scores, fewer days from symptom onset to hospitalisation (median, 5.4 [interquartile range (IQR), 3.2-7.6] v 7.1 days [IQR, 4.1-9.8]; P < 0.001) and longer hospitalisations (median, 18 [IQR, 11-33] v 13 days [IQR, 7-24]; P < 0.001) compared with those not admitted via an RRT review. Admissions following RRT review comprised 60.3% (120/199) of all ward-based admissions. Overall, IHCA occurred in 1.9% (8/413) of ICU patients with COVID-19, and most IHCAs (6/8, 75%) occurred during ICU admission. There were no differences in IHCA rates or in ICU or hospital mortality rates based on whether a patient had a prior RRT review or not. Conclusions : This study found that RRT reviews were a common way for deteriorating ward patients with COVID-19 to be admitted to the ICU, and that IHCA was rare among ICU patients with COVID-19., Competing Interests: All authors declare that they do not have any potential conflict of interest in relation to this manuscript., (© 2022 College of Intensive Care Medicine of Australia and New Zealand.)
- Published
- 2023
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126. Pressure support ventilation in intensive care patients receiving prolonged invasive ventilation.
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Al-Bassam W, Parikh T, Neto AS, Idrees Y, Kubicki MA, Hodgson CL, Subramaniam A, Reddy MP, Gullapalli N, Michel C, Matthewman MC, Naughton J, Pereira J, Shehabi Y, and Bellomo R
- Abstract
Background: To our knowledge, the use and management of pressure support ventilation (PSV) in patients receiving prolonged (≥ 7 days) invasive mechanical ventilation has not previously been described. Objective: To collect and analyse data on the use and management of PSV in critically ill patients receiving prolonged ventilation. Design, setting and participants: We performed a multicentre retrospective observational study in Australia, with a focus on PSV in patients ventilated for ≥ 7 days. Main outcome measures: We obtained detailed data on ventilator management twice daily (8am and 8pm moments) for the first 7 days of ventilation. Results: Among 143 consecutive patients, 90/142 (63.4%) had received PSV by Day 7, and PSV accounted for 40.5% (784/1935) of ventilation moments. The most common pressure support level was 10 cmH
2 O (352/780) observations [45.1%]) with little variation over time, and 37 of 114 patients (32.4%) had no change in pressure support. Mean tidal volume during PSV was 8.3 (7.0-9.5) mL/kg predicted bodyweight (PBW) compared with 7.5 (7.0-8.3) mL/kg PBW during mandatory ventilation (P < 0.001). For 74.6% (247/331) of moments, despite a tidal volume of more than 8 mL/kg PBW, the pressure support level was not changed. Among 122 patients exposed to PSV, 97 (79.5%) received likely over-assistance according to rapid shallow breathing index criteria. Of 784 PSV moments, 411 (52.4%) were also likely over-assisted according to rapid shallow breathing index criteria, and 269/346 (77.7%) having no subsequent adjustment of pressure support. Conclusions: In patients receiving prolonged ventilation, almost two-thirds received PSV, which accounted for 40.5% of mechanical ventilation time. Half of the PSV-treated patients were exposed to high tidal volume and two-thirds to likely over-assistance. These observations provide evidence that can be used to inform interventional studies of PSV management., Competing Interests: No relevant disclosures., (© 2021 College of Intensive Care Medicine of Australia and New Zealand.)- Published
- 2023
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127. Evaluation of the safety and efficacy of extracorporeal carbon dioxide removal in the critically ill using the PrismaLung+ device.
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Tiruvoipati R, Ludski J, Gupta S, Subramaniam A, Ponnapa Reddy M, Paul E, and Haji K
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- Adult, Humans, Male, Middle Aged, Female, Critical Illness therapy, Carbon Dioxide, Renal Dialysis, Continuous Renal Replacement Therapy, Body Fluids, Respiratory Insufficiency
- Abstract
Background: Several extracorporeal carbon dioxide removal (ECCO
2 R) devices are currently in use with variable efficacy and safety profiles. PrismaLung+ is an ECCO2 R device that was recently introduced into clinical practice. It is a minimally invasive, low flow device that provides partial respiratory support with or without renal replacement therapy. Our aim was to describe the clinical characteristics, efficacy, and safety of PrismaLung+ in patients with acute hypercapnic respiratory failure., Methods: All adult patients who required ECCO2 R with PrismaLung+ for hypercapnic respiratory failure in our intensive care unit (ICU) during a 6-month period between March and September 2022 were included., Results: Ten patients were included. The median age was 55.5 (IQR 41-68) years, with 8 (80%) male patients. Six patients had acute respiratory distress syndrome (ARDS), and two patients each had exacerbations of asthma and chronic obstructive pulmonary disease (COPD). All patients were receiving invasive mechanical ventilation at the time of initiation of ECCO2 R. The median duration of ECCO2 R was 71 h (IQR 57-219). A significant improvement in pH and PaCO2 was noted within 30 min of initiation of ECCO2 R. Nine patients (90%) survived to weaning of ECCO2 R, eight (80%) survived to ICU discharge and seven (70%) survived to hospital discharge. The median duration of ICU and hospital stays were 14.5 (IQR 8-30) and 17 (IQR 11-38) days, respectively. There were no patient-related complications with the use of ECCO2 R. A total of 18 circuits were used in ten patients (median 2 per patient; IQR 1-2). Circuit thrombosis was noted in five circuits (28%) prior to reaching the expected circuit life with no adverse clinical consequences., Conclusion(s): PrismaLung+ rapidly improved PaCO2 and pH with a good clinical safety profile. Circuit thrombosis was the only complication. This data provides insight into the safety and efficacy of PrismaLung+ that could be useful for centres aspiring to introduce ECCO2 R into their clinical practice., (© 2023. BioMed Central Ltd., part of Springer Nature.)- Published
- 2023
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128. Noninvasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey.
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Subramaniam A, Haji JY, Kumar P, Ramanathan K, and Rajamani A
- Abstract
Background: About 5% of hospitalized coronavirus disease 2019 (COVID-19) patients will need intensive care unit (ICU) admission for hypoxemic respiratory failure requiring oxygen support. The choice between early mechanical ventilation and noninvasive oxygen therapies, such as, high-flow nasal oxygen (HFNO) and/or noninvasive positive-pressure ventilation (NPPV) has to balance the contradictory priorities of protecting healthcare workers by minimizing aerosol-generation and optimizing resource management. This survey over two timeframes aimed to explore the controversial issue of location and noninvasive oxygen therapy in non-intubated ICU patients using a clinical vignette., Materials and Methods: An online survey was designed, piloted, and distributed electronically to Indian intensivists/anesthetists, from private hospitals, government hospitals, and medical college hospitals (the latter two referred to as first-responder hospitals), who are directly responsible for admitting/managing patients in ICU., Results: Of the 204 responses (125/481 in phase 1 and 79/320 in phase 2), 183 responses were included. Respondents from first-responder hospitals were more willing to manage non-intubated hypoxemic patients in neutral pressure rooms, while respondents from private hospitals preferred negative-pressure rooms ( p < 0.001). In both the phases, private hospital doctors were less comfortable to use any form of noninvasive oxygen therapies in neutral-pressure rooms compared to first-responder hospitals (low-flow oxygen therapy: 72 vs 50%, p < 0.01; HFNO: 47 vs 24%, p < 0.01 and NPPV: 38 vs 28%, p = 0.20)., Interpretation: Variations existed in practices among first-responder and private intensivists/anesthetists. The resource optimal private hospital intensivists/anesthetists were less comfortable using noninvasive oxygen therapies in managing COVID-19 patients. This may reflect differential resource availability necessitating resolution at national, state, and local levels., How to Cite This Article: Subramaniam A, Haji JY, Kumar P, Ramanathan K, Rajamani A. Noninvasive Oxygen Strategies to Manage Confirmed COVID-19 Patients in Indian Intensive Care Units: A Survey. Indian J Crit Care Med 2020;24(10):926-931., Competing Interests: Source of support: Nil Conflict of interest: None, (Copyright © 2020; Jaypee Brothers Medical Publishers (P) Ltd.)
- Published
- 2020
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129. Cost implications of avoidable rapid response call activations in older patients.
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Subramaniam A, Green C, Omair M, Soh L, Yeoh AC, and Tiruvoipati R
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- Aged, 80 and over, Costs and Cost Analysis, Emergency Treatment statistics & numerical data, Female, Hospital Rapid Response Team organization & administration, Humans, Intensive Care Units organization & administration, Male, Patient Admission economics, Retrospective Studies, Emergency Treatment economics, Hospital Rapid Response Team economics, Intensive Care Units economics
- Abstract
Background: Rapid response calls (RRCs) are designed to appropriately manage clinical deterioration. However, not all RRCs are appropriate due to medical futility or the patient's wishes. Incidence and costs associated with avoidable-RRC (ARRC) remain underexplored., Aims: The aim of this study was to describe the incidence and costs of ARRC activations in older patients., Methods: We retrospectively reviewed RRCs in patients aged ≥80 years over six months. We defined ARRC as RRC activations despite clear documentation confirming not for further RRCs. Data on investigations, equipment and management of each ARRC were analysed. We then micro-costed each ARRC using standard references., Results: Ten percent (25/255) of RRCs were ARRC (mean age 85.6 years) with most patients (88%) admitted under medical teams. Median duration of ARRC was 22 minutes (IQR 7-38 minutes). Palliative care services were underutilised (40%). Most patients (94.4%) died soon after ARRC. The costs for investigations, equipment and management was AUD $2,267.01, opportunity costs were AUD $3,861.55, with a grand total cost of AUD $6,128.56., Conclusion: ARRC, noted in 10% of RRCs, are associated with increased time and financial costs. Further research is required to better understand ARRC triggers to reduce the burden of ARRC on patients, carers and hospital staff., Competing Interests: Nil.
- Published
- 2018
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