Search

Purpose The Acute Disease Quality Initiative (ADQI) Workgroup recently released a consensus definition of sepsis-associated acute kidney injury (SA-AKI), combining Sepsis-3 and Kidney Disease Improving Global Outcomes (KDIGO) AKI criteria. This study aims to described the epidemiology of SA-AKI. Methods Retrospective cohort study in 12 intensive care units (ICU) from 2015 to 2021. We studied the incidence, patient characteristics, timing, trajectory, treatment, and associated outcomes of the ADQI SA-AKI definition. Results Of 84,831 admissions, 15,549 met the SA-AKI criteria with its incidence peaking at > 20% in 2021. SA-AKI patients were typically admitted from home via the emergency department (ED) with median time to SA-AKI diagnosis of one day (IQR 1–1) from ICU admission. At diagnosis, most SA-AKI patients had a stage 1 (55%) AKI, mostly due to the low urinary output (UO) criterion only (67%). Compared to diagnosis by creatinine alone, or both UO and creatinine criteria, patients diagnosed by UO alone had lower RRT requirement (3.3% vs 19% vs 51%; p

Background Handgrip strength (HGS), lung function and health-related quality of life (HRQoL) are relevant indicators of future cardiovascular risk and mortality. The impact of cardiac surgery on these predictive variables has been under-explored. The aim of this study was to determine the acute (within hospital) changes in HGS, lung function and HRQoL, and their relationships, in adults undergoing elective cardiac surgery. Further, the study examined the relationship between these variables and the predictors for lung function and HRQoL in these patients. Methods The study was a prospective cohort study that involved 101 patients who completed pre-operative (1–2 days before surgery) and physiotherapy discharge (5–7 days after surgery) assessments. Handgrip strength, lung function and HRQoL were assessed using JAMAR dynamometers, Vitalograph-Alpha or EasyOne spirometer, and Short-Form 36 questionnaire, respectively. Changes in these variables and their relationships were analysed using paired t-test and Pearson correlation coefficients, respectively. Prediction of lung function and HRQoL using HGS and other co-variates was conducted using regression analysis. Results At the time of physiotherapy discharge, lung function, HGS and the physical component of HRQoL were significantly ( Conclusions Undergoing cardiac surgery acutely and significantly reduced lung function, HGS and physical component of HRQoL in adults with cardiac disease. Assessment of HGS at physiotherapy discharge may be a poor indicator of operative changes in lung function and HRQoL. Clinicians may consider HGS as an inadequate tool in predicting lung function and HRQoL following cardiac surgery.

There is substantial interest by clinicians to improve the health outcomes of older and frail patients following major surgery, with prehabilitation a potential and important component of future standard patient care. We studied the feasibility of a randomised controlled trial of pre-operative prehabilitation in frail patients scheduled for colorectal surgery in regional Australia. We conducted a single blind, parallel arm, randomized controlled trial in a regional referral centre where colorectal surgical patients aged over 50 were invited to participate and screened for frailty. Frail patients were randomised to undertake either a four-week supervised exercise program with dietary advice, or usual care. The primary outcome was six-minute-walk-distance at baseline, pre-surgery (four weeks later) and at follow-up (four-six weeks post-operation). Secondary outcomes included physical activity level, health-related quality of life, and postsurgical complications. Feasibility outcomes were numbers of patients reaching each stage and barriers or reasons for withdrawal. Of 106 patients eligible for screening during the two-year study period, only five were able to be randomised, of which one alone completed the entire study to follow-up. Fewer patients than expected met the frailty criteria (23.6%), and many (22.6%) were offered surgery in a shorter timeframe than the required four weeks. Physical and psychological aspects of frailty and logistical issues were key for patients declining study participation and/or not complying with the intervention and/or all outcome assessments. Feasibility for a large randomised controlled trial of prehabilitation for frail colorectal patients was poor (~5%) for our regional location. Addressing barriers, examination of a large, dense population base and utilization of a frailty-screening tool validated in surgical patients are necessary for future studies to identify the impact of prehabilitation for frail patients.

BackgroundBurnout has been reported to be common amongst intensive care physicians and can be associated with staff absenteeism, drug and alcohol abuse, and suboptimal patient care. We aimed to investigate the prevalence and features of self-reported burnout amongst intensivists working in Australia and New Zealand (ANZ); and to evaluate workplace stressors associated with increased risk of self-reported burnout.MethodsElectronic survey amongst registered intensivists in Australia and New Zealand. Burnout and professional quality of life were measured using the Professional Quality of Life Scale 5 (ProQOL-5). Socio-organisational factors were defined a-priori and assessed using a five-point Likert scale. Thematic analysis was conducted on an open-ended question on workplace stressors. Associations between the ProQOL burnout subscale and demographic characteristics were investigated using analysis of variance or Kruskal-Wallis. Results261 of 921 estimated intensivists responded (response rate: 28.3%). Overall, few participants (0.8%) demonstrated high scores (>75th centile) for burnout, and 70.9% of participants scored in the average range for burnout. Of note, 98.1% of participants scored in the average to high range for compassion satisfaction. No association was found between gender, age, or years of practice with the level of burnout or compassion satisfaction. Seven themes emerged regarding intensivists’ most stressful aspects of work: (1) interpersonal interactions and workplace relationships (25.5%); (2) workload and its impact (24.9%); (3) resources and capacity (16.3%); (4) health systems leadership and bureaucracy (16.1%); (5) end-of-life issues and moral distress (8.4%); (6) clinical management (4.9%); and (7) job security and future uncertainty (1.3%). ConclusionFewer ANZ intensivists experienced burnout than has previously been reported. Many self-reported work stressors do not relate to clinical work, but instead potentially modifiable factors related to interpersonal interactions with other colleagues and, more importantly, hospital administrators.

Background High-risk patients presenting for surgery require complex decision-making and perioperative management. However, given there is no gold standard for identifying high-risk patients, doing so may be challenging for clinicians in practice. Before a gold standard can be established, the state of current practice must be determined. This study aimed to understand how working clinicians define and identify high-risk surgical patients. Methods Clinicians involved in the care of high-risk surgical patients at a public hospital in regional Australia were interviewed as part of an ongoing study evaluating a new shared decision-making process for high-risk patients. The new process, Patient-Centred Advanced Care Planning (PC-ACP) engages patients, families, and clinicians from all relevant specialties in shared decision-making in line with the patient’s goals and values. The semi-structured interviews were conducted before the implementation of the new process and were coded using a modified form of the ‘constant comparative method’ to reveal key themes. Themes concerning patient risk, clinician’s understanding of high risk, and methods for identifying high-risk surgical patients were extricated for close examination. Results Thirteen staff involved in high-risk surgery at the hospital at which PC-ACP was to be implemented were interviewed. Analysis revealed six sub-themes within the major theme of factors related to patient risk: (1) increase in high-risk patients, (2) recognising frailty, (3) risk-benefit balance, (4) suitability and readiness for surgery, (5) avoiding negative outcomes, and (6) methods in use for identifying high-risk patients. There was considerable variability in clinicians’ methods of identifying high-risk patients and regarding their definition of high risk. This variability occurred even among clinicians within the same disciplines and specialties. Conclusions Although clinicians were confident in their own ability to identify high-risk patients, they acknowledged limitations in recognising frail, high-risk patients and predicting and articulating possible outcomes when consenting these patients. Importantly, little consistency in clinicians’ reported methods for identifying high-risk patients was found. Consensus regarding the definition of high-risk surgical patients is necessary to ensure rigorous decision-making.

Introduction Patients who are frail, have multiple comorbidities or have a terminal illness often have poor outcomes from surgery. However, sole specialists may recommend surgery in these patients without consultation with other treating clinicians or allowing for patient goals. The Patient-Centred Advanced Care Planning (PC-ACP) model of care provides a framework in which a multidisciplinary advanced care plan is devised to incorporate high-risk patients9 values and goals. Decision-making is performed collaboratively by patients, their family, surgeons, anaesthetists, intensivists and surgical case managers. This study aims to evaluate the feasibility of this new model of care, and to determine potential benefits to patients and clinicians. Methods and analysis After being assessed for frailty, patients will complete a patient–clinician information engagement survey pretreatment and at 6 months follow-up. Patients (and/or family members) will be interviewed about their experience of care pretreatment and at 3 and 6 months follow-ups. Clinicians will complete a survey on workplace attitudes and engagement both preimplementation and postimplementation of PC-ACP and be interviewed, following each survey, on the implementation of PC-ACP. We will use process mapping to map the patient journey through the surgical care pathway to determine areas of improvement and to identify variations in patient experience. Ethics and dissemination This study has received ethical approval from Townsville Hospital and Health Service HREC (HREC/16/QTHS/100). Results will be communicated to the participating hospital, presented at conferences and submitted for publication in a peer-reviewed MEDLINE-indexed journal.

Augmented renal clearance (ARC) is being increasingly described in neurocritical care practice. The mechanisms driving this phenomenon are largely unknown. The aim of this project was therefore to explore changes in renal function, cardiac output (CO), and atrial natriuretic peptide (ANP) concentrations in patients with isolated traumatic brain injury (TBI). This prospective observational cohort study was conducted in a tertiary-level, university-affiliated intensive care unit (ICU). Patients with normal plasma creatinine concentrations ( 150 mL/min) were frequent and appeared to parallel changes in CO. Plasma ANP concentrations were also significantly elevated over the study period (minimum value = 243 pg/mL). These data suggest that ARC is likely to complicate the care of TBI patients with normal plasma creatinine concentrations, and may be driven by associated cardiovascular changes and/or elevated plasma ANP concentrations. However, significant additional research is required to further understand these findings.

ObjectiveTo evaluate the implementation of an intensive care unit (ICU) intervention designed to establish rules for making ICU decisions about postsurgery beds.DesignPreintervention/postintervention case study using a multimethod approach, involving two phases of staff interviews, process mapping and collection of administrative data.SettingICU in a 700-bed regional tertiary care hospital in Australia.Participants31 interview participants. Phases 1 and 2 participants drawn from three groups of staff: bedside nursing staff in the ICU, ICU specialist doctors and senior management staff involved in oversight of ICU operations. Phase 2 included an additional participant group: staff from surgery and emergency departments.InterventionImplementation of an ICU escalation plan and introduction of a multidisciplinary morning meeting to determine ICU bed status in accordance with the plan.Main outcome measuresInterview data consisted of preintervention staff perceptions of ICU workplace cohesiveness with bed pressure, and postintervention staff perceptions of the escalation plan and ICU performance. Administrative data consisted of bed status (red, amber or green), monthly number of planned elective surgeries requiring an ICU bed and monthly number of elective surgeries cancelled due to unavailability of ICU beds.ResultsImproved internal communication, decision making and cohesion within the ICU and better coordination between ICU and other hospital departments. Significant reduction in elective surgeries cancelled due to unavailability of ICU beds, χ21=24.9, pConclusionsBy establishing rules for decision making around ICU bed allocation, the intervention improved internal professional relationships within the ICU as well as between the ICU and external departments and reduced the number of elective surgeries cancelled.

Hypertonic saline and/or norepinephrine infusion are routinely used to achieve a desired cerebral perfusion pressure (CPP) in the management of traumatic brain injury (TBI). We hypothesized that creatinine clearances (CrCls) would be significantly augmented in this setting.This was an observational cohort study in TBI patients older than 16 years with normal serum creatinine concentrations, requiring maintenance of CPP. Eight-hour urinary CrCl collections were performed while on and off active management. Demographic data, use of vasoactive medications, fluid balance, feeding regimen, and hemodynamic variables were recorded throughout the study period. Augmented CrCl was defined as150 mL/min/1.73 m(2) in women and160 mL/min/1.73 m(2) in men.Twenty patients were enrolled, and augmented clearances were demonstrated in 17 (85%). The mean maximum CrCl was 179 mL/min/1.73 m(2) while receiving CPP therapy (95% confidence interval [CI], 159-198), returning to a mean of 111 mL/min/1.73 m(2) (95% CI, 91-131; P0.001) when measured after discharge from the intensive care unit. The mean CrCl in the intensive care unit while not receiving CPP therapy was 150 mL/min/1.73 m(2) (95% CI, 134-167; P = 0.03). The mean time to reach peak CrCl while receiving active treatment was 4.7 days (95% CI, 3.0-6.4). In a multivariate analysis, norepinephrine use, saline loading, mean arterial blood pressure, and central venous pressure were associated with augmented CrCl on the day of measurement.Augmented CrCls are common in TBI patients receiving active management of CPP and persist even after discontinuation of such therapy. Further work is needed to clarify the impact of such clearances on renally excreted drugs in this setting.

Use of hypertonic saline and/or vasopressor infusion to achieve a desired cerebral perfusion pressure (CPP) in traumatic brain injury (TBI) is common. We hypothesised that the use of such therapies would significantly augment creatinine clearances (CrCl) in this population.

The features of cardiac arrest will be familiar to any reader who has recently undertaken an Advanced Life Support course. Rather than reproducing algorithms which should be readily available in all UK hospitals, this article emphasises the importance of early recognitions and prevention, and looks at some of the more recent advances in resuscitation technique.