Dashiell Gantner - Academia.edu (original) (raw)
Papers by Dashiell Gantner
Anaesthesia & Intensive Care Medicine, 2015
Annals of Surgery, 2016
To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of e... more To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of erythropoiesis-stimulating agents (ESAs) in critically ill trauma patients. ESAs have effects beyond erythropoiesis. The administration of the ESA epoetin alfa to critically ill trauma patients has been associated with a reduction in mortality. We performed a systematic review and meta-analysis with trial sequential analysis. We searched Medline, Medline in Process, and other nonindexed citations, EMBASE, and the Cochrane Database from inception until September 9, 2015, for randomized controlled trials comparing ESAs to placebo (or no ESA). We identified 9 eligible studies that randomly assigned 2607 critically ill patients after trauma to an ESA or placebo (or no ESA). Compared with placebo (or no ESA), ESA therapy was associated with a substantial reduction in mortality [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.49-0.79, P = 0.0001, I = 0%). In patients with traumatic brain injury, ESA therapy did not increase the number of patients surviving with moderate disability or good recovery (RR 1.00, 95% CI 0.88-1.15, P = 0.95, I = 0%). With the dosing regimens employed in the included studies, ESA therapy did not increase the risk of lower limb proximal deep venous thrombosis (RR 0.97, 95% CI 0.72-1.29, P = 0.78, I = 0%). The administration of ESAs to critically ill trauma patients is associated with a significant improvement in mortality without an increase in the rate of lower limb proximal deep venous thrombosis. Given the worldwide public health significance of these findings research to validate or refute them is required.
Annals of surgery, Jan 8, 2016
To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of e... more To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of erythropoiesis-stimulating agents (ESAs) in critically ill trauma patients. ESAs have effects beyond erythropoiesis. The administration of the ESA epoetin alfa to critically ill trauma patients has been associated with a reduction in mortality. We performed a systematic review and meta-analysis with trial sequential analysis. We searched Medline, Medline in Process, and other nonindexed citations, EMBASE, and the Cochrane Database from inception until September 9, 2015, for randomized controlled trials comparing ESAs to placebo (or no ESA). We identified 9 eligible studies that randomly assigned 2607 critically ill patients after trauma to an ESA or placebo (or no ESA). Compared with placebo (or no ESA), ESA therapy was associated with a substantial reduction in mortality [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.49-0.79, P = 0.0001, I = 0%). In patients with traumatic brain i...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2016
Trials in critical care have previously used unvalidated systems to classify cause of death. We a... more Trials in critical care have previously used unvalidated systems to classify cause of death. We aimed to provide initial validation of a method to classify cause of death in intensive care unit patients. One hundred case scenarios of patients who died in an ICU were presented online to raters, who were asked to select a proximate and an underlying cause of death for each, using the ICU Deaths Classification and Reason (ICU-DECLARE) system. We evaluated two methods of categorising proximate cause of death (designated Lists A and B) and one method of categorising underlying cause of death. Raters were ICU specialists and research coordinators from Australia, New Zealand and the United Kingdom. Inter-rater reliability, as measured by the Fleiss multirater kappa, and the median proportion of raters choosing the most likely diagnosis (defined as the most popular classification choice in each case). Across all raters and cases, for proximate cause of death List A, kappa was 0.54 (95% CI, ...
Journal of neurotrauma
Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent ... more Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, Pubmed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult TBI patients. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18%-100%) and was higher in guideline recommendations based on strong evidence compared to those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.
Journal of Neurotrauma, 2015
Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent ... more Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, Pubmed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult TBI patients. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18%-100%) and was higher in guideline recommendations based on strong evidence compared to those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.
Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
To determine if using freshest available rather than standard-issue red blood cells (RBCs) can re... more To determine if using freshest available rather than standard-issue red blood cells (RBCs) can reduce mortality in critically ill intensive care unit patients. Our study is the largest ongoing randomised controlled trial (RCT) of RBC age in critically ill patients and will help determine if the use of the freshest available RBCs should become standard policy for the critically ill. A double-blind, multicentre, Phase III RCT of 5000 adult ICU patients in Australia, New Zealand, Europe and the Middle East. Transfusion of the freshest available RBCs in place of standard-care RBCs until hospital discharge. The primary outcome measure is 90-day all-cause mortality. Secondary outcome measures are time to death, 28-day and 180-day mortality, persistent organ dysfunction combined with death, days alive and free of mechanical ventilation and renal replacement therapy, bloodstream infection in the ICU, length of stay in the ICU and in hospital, proportion of patients with febrile non-haemolyt...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2013
Clinical Nutrition, 2015
The provision of nutrition to critically ill patients is internationally accepted as standard of ... more The provision of nutrition to critically ill patients is internationally accepted as standard of care in intensive care units (ICU). Nutrition has the potential to positively impact patient outcomes, is relatively inexpensive compared to other commonly used treatments, and is increasingly identified as a marker of quality ICU care. Furthermore, we are beginning to understand its true potential, with positive and deleterious consequences when it is delivered inappropriately. As with many areas of medicine the evidence is rapidly changing and often conflicting, making interpretation and application difficult for the individual clinician. This narrative review aims to provide an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions.
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2014
To determine if using freshest available rather than standard-issue red blood cells (RBCs) can re... more To determine if using freshest available rather than standard-issue red blood cells (RBCs) can reduce mortality in critically ill intensive care unit patients. Our study is the largest ongoing randomised controlled trial (RCT) of RBC age in critically ill patients and will help determine if the use of the freshest available RBCs should become standard policy for the critically ill. A double-blind, multicentre, Phase III RCT of 5000 adult ICU patients in Australia, New Zealand, Europe and the Middle East. Transfusion of the freshest available RBCs in place of standard-care RBCs until hospital discharge. The primary outcome measure is 90-day all-cause mortality. Secondary outcome measures are time to death, 28-day and 180-day mortality, persistent organ dysfunction combined with death, days alive and free of mechanical ventilation and renal replacement therapy, bloodstream infection in the ICU, length of stay in the ICU and in hospital, proportion of patients with febrile non-haemolyt...
Current opinion in critical care, 2014
Intravenous fluid is a fundamental component of trauma care and fluid management influences patie... more Intravenous fluid is a fundamental component of trauma care and fluid management influences patient outcomes. This narrative review appraises recent clinical studies of fluid therapy in patients with traumatic brain injury (TBI), with respect to its use in volume resuscitation and prevention of secondary injury. Despite the development of level 1 evidence in fluid resuscitation, in patients with TBI key questions concerning optimal composition and volume remain unanswered. In the absence of randomized trials demonstrating patient outcome differences, clinical practice is often based on physiological principles and surrogate endpoints. There is a physiological rationale why excessive fluid administration and positive fluid balance may increase brain swelling and intracranial pressure (ICP); in some patients, a lower cumulative fluid balance may improve outcomes, but limited human data exist. Resuscitation with 4% albumin in TBI patients in ICU worsens mortality, which may be mediated...
Intensive Care Medicine, 2014
After-hours discharge from the intensive care unit (ICU) is associated with adverse patient outco... more After-hours discharge from the intensive care unit (ICU) is associated with adverse patient outcomes including increased ICU readmissions and mortality. Since Australian and New Zealand data were last published, overall ICU patient mortality has decreased; however it is unknown whether changes in discharge practices have contributed to these improved outcomes. Our aim was to examine trends over time in discharge timing and the contemporary associations with mortality and ICU readmission. Retrospective cohort study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) for patients admitted to Australian and New Zealand ICUs between January 2005 and December 2012. Data collected included patient characteristics, time of ICU discharge, hospital mortality and ICU readmissions. Between 1 January 2005 and 31 December 2012, there were 710,535 patients available for analysis, of whom 109,384 (15.4 %) were discharged after-hours (1800-0600 hours). There were no changes in timing of ICU discharge over the 8 years of the study. Patients discharged after-hours had a higher hospital mortality (6.4 versus 3.6 %; P < 0.001) and more ICU readmissions (5.1 versus 4.5 %; P < 0.001) than patients discharged in-hours. Although post-ICU mortality for all patients declined during the study period, the risk associated with after-hours discharge remained elevated throughout (odds ratio 1.34, 95 % confidence intervals 1.30-1.38). After-hours discharge remains an important independent predictor of hospital mortality and readmission to ICU. Despite widespread dissemination this evidence has not translated into fewer after-hours discharges or reduction in risk in Australian and New Zealand hospitals.
Respirology, 2010
OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnose... more OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnosed globally in part due to the limited availability and technical requirements of polysomnography (PSG). The aim of this study was to test the accuracy of two simple methods for diagnosing OSA. Consecutive subjects identified from a community register with high CV risk were invited to complete the Berlin Sleep Questionnaire and undergo simultaneous, home, overnight PSG and ApneaLink device oximetry and nasal pressure recordings. The relative accuracies of the Berlin Questionnaire, oximetry and nasal pressure results in diagnosing PSG-defined moderate-severe OSA were assessed. Of 257 eligible high CV risk subjects enrolled, 190 completed sleep studies and 143 subjects' studies were of sufficient quality to include in final analyses. Moderate-severe OSA was confirmed in 43% of subjects. The Berlin Questionnaire had low overall diagnostic accuracy in this population. However, ApneaLink recordings of oximetry and nasal pressure areas had high diagnostic utility with areas under the receiver operating characteristic curves of 0.933 and 0.933, respectively. At optimal diagnostic thresholds, oximetry and nasal pressure measurements had similar sensitivity (84% vs 86%) and specificity (84% vs 85%). Technical failure was lower for oximetry than nasal pressure (5.8% vs 18.9% of tests). In patients with high CV risk overnight single-channel oximetry and nasal pressure measurements may provide high diagnostic accuracy and offer an accessible alternative to full PSG.
Anaesthesia & Intensive Care Medicine, 2012
Severe sepsis is a heterogeneous condition affecting multiple organ systems, and is commonly enco... more Severe sepsis is a heterogeneous condition affecting multiple organ systems, and is commonly encountered in the hospital setting due to both community and nosocomial infections. The incidence of severe sepsis has increased over the past decades, and mortality remains alarmingly high. Management of the septic patient involves rapid evaluation and prompt initiation of both supportive and specific therapies. Such patients commonly require admission to the intensive care unit (ICU) for invasive monitoring and haemodynamic support. Resuscitation, early initiation of broad-spectrum antimicrobial therapy and source control remain the cornerstones of therapy. Controversy persists about the roles and benefits of early goal-directed therapy (EGDT), corticosteroids and the advantage of albumin over saline as resuscitation fluid. This review summarizes the contemporary evidence regarding diagnostic and treatment strategies of severe sepsis, with emphasis on patients in critical care settings.
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2015
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Prophylactic h... more Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Prophylactic hypothermia is effective in laboratory models, but clinical studies to date have been inconclusive, partly because of methodological limitations. Our Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomised controlled trial is currently underway comparing early, sustained hypothermia versus standard care in patients with severe TBI. We describe our study protocol and the challenges in conducting prophylactic hypothermia research in TBI. We aim to randomise 500 patients to either prophylactic 33°C hypothermia initiated within 3 hours of injury and continued for at least 72 hours, or standard normothermic management. Patients will be enrolled by paramedic services in the prehospital setting, or by emergency department staff at participating sites in Australia, New Zealand and Europe. The primary outcome will be the eight-level extended Glasgow outcome scale (GOSE),...
Anaesthesia & Intensive Care Medicine, 2015
Annals of Surgery, 2016
To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of e... more To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of erythropoiesis-stimulating agents (ESAs) in critically ill trauma patients. ESAs have effects beyond erythropoiesis. The administration of the ESA epoetin alfa to critically ill trauma patients has been associated with a reduction in mortality. We performed a systematic review and meta-analysis with trial sequential analysis. We searched Medline, Medline in Process, and other nonindexed citations, EMBASE, and the Cochrane Database from inception until September 9, 2015, for randomized controlled trials comparing ESAs to placebo (or no ESA). We identified 9 eligible studies that randomly assigned 2607 critically ill patients after trauma to an ESA or placebo (or no ESA). Compared with placebo (or no ESA), ESA therapy was associated with a substantial reduction in mortality [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.49-0.79, P = 0.0001, I = 0%). In patients with traumatic brain injury, ESA therapy did not increase the number of patients surviving with moderate disability or good recovery (RR 1.00, 95% CI 0.88-1.15, P = 0.95, I = 0%). With the dosing regimens employed in the included studies, ESA therapy did not increase the risk of lower limb proximal deep venous thrombosis (RR 0.97, 95% CI 0.72-1.29, P = 0.78, I = 0%). The administration of ESAs to critically ill trauma patients is associated with a significant improvement in mortality without an increase in the rate of lower limb proximal deep venous thrombosis. Given the worldwide public health significance of these findings research to validate or refute them is required.
Annals of surgery, Jan 8, 2016
To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of e... more To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of erythropoiesis-stimulating agents (ESAs) in critically ill trauma patients. ESAs have effects beyond erythropoiesis. The administration of the ESA epoetin alfa to critically ill trauma patients has been associated with a reduction in mortality. We performed a systematic review and meta-analysis with trial sequential analysis. We searched Medline, Medline in Process, and other nonindexed citations, EMBASE, and the Cochrane Database from inception until September 9, 2015, for randomized controlled trials comparing ESAs to placebo (or no ESA). We identified 9 eligible studies that randomly assigned 2607 critically ill patients after trauma to an ESA or placebo (or no ESA). Compared with placebo (or no ESA), ESA therapy was associated with a substantial reduction in mortality [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.49-0.79, P = 0.0001, I = 0%). In patients with traumatic brain i...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2016
Trials in critical care have previously used unvalidated systems to classify cause of death. We a... more Trials in critical care have previously used unvalidated systems to classify cause of death. We aimed to provide initial validation of a method to classify cause of death in intensive care unit patients. One hundred case scenarios of patients who died in an ICU were presented online to raters, who were asked to select a proximate and an underlying cause of death for each, using the ICU Deaths Classification and Reason (ICU-DECLARE) system. We evaluated two methods of categorising proximate cause of death (designated Lists A and B) and one method of categorising underlying cause of death. Raters were ICU specialists and research coordinators from Australia, New Zealand and the United Kingdom. Inter-rater reliability, as measured by the Fleiss multirater kappa, and the median proportion of raters choosing the most likely diagnosis (defined as the most popular classification choice in each case). Across all raters and cases, for proximate cause of death List A, kappa was 0.54 (95% CI, ...
Journal of neurotrauma
Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent ... more Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, Pubmed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult TBI patients. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18%-100%) and was higher in guideline recommendations based on strong evidence compared to those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.
Journal of Neurotrauma, 2015
Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent ... more Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, Pubmed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult TBI patients. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18%-100%) and was higher in guideline recommendations based on strong evidence compared to those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.
Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
To determine if using freshest available rather than standard-issue red blood cells (RBCs) can re... more To determine if using freshest available rather than standard-issue red blood cells (RBCs) can reduce mortality in critically ill intensive care unit patients. Our study is the largest ongoing randomised controlled trial (RCT) of RBC age in critically ill patients and will help determine if the use of the freshest available RBCs should become standard policy for the critically ill. A double-blind, multicentre, Phase III RCT of 5000 adult ICU patients in Australia, New Zealand, Europe and the Middle East. Transfusion of the freshest available RBCs in place of standard-care RBCs until hospital discharge. The primary outcome measure is 90-day all-cause mortality. Secondary outcome measures are time to death, 28-day and 180-day mortality, persistent organ dysfunction combined with death, days alive and free of mechanical ventilation and renal replacement therapy, bloodstream infection in the ICU, length of stay in the ICU and in hospital, proportion of patients with febrile non-haemolyt...
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2013
Clinical Nutrition, 2015
The provision of nutrition to critically ill patients is internationally accepted as standard of ... more The provision of nutrition to critically ill patients is internationally accepted as standard of care in intensive care units (ICU). Nutrition has the potential to positively impact patient outcomes, is relatively inexpensive compared to other commonly used treatments, and is increasingly identified as a marker of quality ICU care. Furthermore, we are beginning to understand its true potential, with positive and deleterious consequences when it is delivered inappropriately. As with many areas of medicine the evidence is rapidly changing and often conflicting, making interpretation and application difficult for the individual clinician. This narrative review aims to provide an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions.
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2014
To determine if using freshest available rather than standard-issue red blood cells (RBCs) can re... more To determine if using freshest available rather than standard-issue red blood cells (RBCs) can reduce mortality in critically ill intensive care unit patients. Our study is the largest ongoing randomised controlled trial (RCT) of RBC age in critically ill patients and will help determine if the use of the freshest available RBCs should become standard policy for the critically ill. A double-blind, multicentre, Phase III RCT of 5000 adult ICU patients in Australia, New Zealand, Europe and the Middle East. Transfusion of the freshest available RBCs in place of standard-care RBCs until hospital discharge. The primary outcome measure is 90-day all-cause mortality. Secondary outcome measures are time to death, 28-day and 180-day mortality, persistent organ dysfunction combined with death, days alive and free of mechanical ventilation and renal replacement therapy, bloodstream infection in the ICU, length of stay in the ICU and in hospital, proportion of patients with febrile non-haemolyt...
Current opinion in critical care, 2014
Intravenous fluid is a fundamental component of trauma care and fluid management influences patie... more Intravenous fluid is a fundamental component of trauma care and fluid management influences patient outcomes. This narrative review appraises recent clinical studies of fluid therapy in patients with traumatic brain injury (TBI), with respect to its use in volume resuscitation and prevention of secondary injury. Despite the development of level 1 evidence in fluid resuscitation, in patients with TBI key questions concerning optimal composition and volume remain unanswered. In the absence of randomized trials demonstrating patient outcome differences, clinical practice is often based on physiological principles and surrogate endpoints. There is a physiological rationale why excessive fluid administration and positive fluid balance may increase brain swelling and intracranial pressure (ICP); in some patients, a lower cumulative fluid balance may improve outcomes, but limited human data exist. Resuscitation with 4% albumin in TBI patients in ICU worsens mortality, which may be mediated...
Intensive Care Medicine, 2014
After-hours discharge from the intensive care unit (ICU) is associated with adverse patient outco... more After-hours discharge from the intensive care unit (ICU) is associated with adverse patient outcomes including increased ICU readmissions and mortality. Since Australian and New Zealand data were last published, overall ICU patient mortality has decreased; however it is unknown whether changes in discharge practices have contributed to these improved outcomes. Our aim was to examine trends over time in discharge timing and the contemporary associations with mortality and ICU readmission. Retrospective cohort study using data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) for patients admitted to Australian and New Zealand ICUs between January 2005 and December 2012. Data collected included patient characteristics, time of ICU discharge, hospital mortality and ICU readmissions. Between 1 January 2005 and 31 December 2012, there were 710,535 patients available for analysis, of whom 109,384 (15.4 %) were discharged after-hours (1800-0600 hours). There were no changes in timing of ICU discharge over the 8 years of the study. Patients discharged after-hours had a higher hospital mortality (6.4 versus 3.6 %; P < 0.001) and more ICU readmissions (5.1 versus 4.5 %; P < 0.001) than patients discharged in-hours. Although post-ICU mortality for all patients declined during the study period, the risk associated with after-hours discharge remained elevated throughout (odds ratio 1.34, 95 % confidence intervals 1.30-1.38). After-hours discharge remains an important independent predictor of hospital mortality and readmission to ICU. Despite widespread dissemination this evidence has not translated into fewer after-hours discharges or reduction in risk in Australian and New Zealand hospitals.
Respirology, 2010
OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnose... more OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnosed globally in part due to the limited availability and technical requirements of polysomnography (PSG). The aim of this study was to test the accuracy of two simple methods for diagnosing OSA. Consecutive subjects identified from a community register with high CV risk were invited to complete the Berlin Sleep Questionnaire and undergo simultaneous, home, overnight PSG and ApneaLink device oximetry and nasal pressure recordings. The relative accuracies of the Berlin Questionnaire, oximetry and nasal pressure results in diagnosing PSG-defined moderate-severe OSA were assessed. Of 257 eligible high CV risk subjects enrolled, 190 completed sleep studies and 143 subjects' studies were of sufficient quality to include in final analyses. Moderate-severe OSA was confirmed in 43% of subjects. The Berlin Questionnaire had low overall diagnostic accuracy in this population. However, ApneaLink recordings of oximetry and nasal pressure areas had high diagnostic utility with areas under the receiver operating characteristic curves of 0.933 and 0.933, respectively. At optimal diagnostic thresholds, oximetry and nasal pressure measurements had similar sensitivity (84% vs 86%) and specificity (84% vs 85%). Technical failure was lower for oximetry than nasal pressure (5.8% vs 18.9% of tests). In patients with high CV risk overnight single-channel oximetry and nasal pressure measurements may provide high diagnostic accuracy and offer an accessible alternative to full PSG.
Anaesthesia & Intensive Care Medicine, 2012
Severe sepsis is a heterogeneous condition affecting multiple organ systems, and is commonly enco... more Severe sepsis is a heterogeneous condition affecting multiple organ systems, and is commonly encountered in the hospital setting due to both community and nosocomial infections. The incidence of severe sepsis has increased over the past decades, and mortality remains alarmingly high. Management of the septic patient involves rapid evaluation and prompt initiation of both supportive and specific therapies. Such patients commonly require admission to the intensive care unit (ICU) for invasive monitoring and haemodynamic support. Resuscitation, early initiation of broad-spectrum antimicrobial therapy and source control remain the cornerstones of therapy. Controversy persists about the roles and benefits of early goal-directed therapy (EGDT), corticosteroids and the advantage of albumin over saline as resuscitation fluid. This review summarizes the contemporary evidence regarding diagnostic and treatment strategies of severe sepsis, with emphasis on patients in critical care settings.
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2015
Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Prophylactic h... more Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Prophylactic hypothermia is effective in laboratory models, but clinical studies to date have been inconclusive, partly because of methodological limitations. Our Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury (POLAR) randomised controlled trial is currently underway comparing early, sustained hypothermia versus standard care in patients with severe TBI. We describe our study protocol and the challenges in conducting prophylactic hypothermia research in TBI. We aim to randomise 500 patients to either prophylactic 33°C hypothermia initiated within 3 hours of injury and continued for at least 72 hours, or standard normothermic management. Patients will be enrolled by paramedic services in the prehospital setting, or by emergency department staff at participating sites in Australia, New Zealand and Europe. The primary outcome will be the eight-level extended Glasgow outcome scale (GOSE),...