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Research paper thumbnail of Functional electrical stimulation with cycling in the critically ill: A pilot case-matched control study

Journal of Critical Care, 2014

To determine (a) safety and feasibility of functional electrical stimulation (FES)cycling and (b)... more To determine (a) safety and feasibility of functional electrical stimulation (FES)cycling and (b) compare FES-cycling to case-matched controls in functional recovery and delirium outcomes.

Research paper thumbnail of The pursuit of a high central venous oxygen saturation in sepsis: growing concerns

Critical Care, 2008

In this issue of Critical Care, Dutch investigators report that, in a cohort of patients with sep... more In this issue of Critical Care, Dutch investigators report that, in a cohort of patients with sepsis/septic shock admitted to three different intensive care units (ICUs), low central venous oxygen saturation (ScvO 2 ) was uncommon at the time of ICU admission, and hospital mortality was <30%. Their findings, taken together with those of recent reports from Australia and New Zealand (ANZ), raise serious concerns about the utility of early goal directed therapy (EGDT) outside the context of the original trial. Despite inclusion of EGDT into the Surviving Sepsis Guidelines, in response to growing uncertainty, ANZ and US investigators will soon begin randomization of patients into two large multicentre trials comparing EGDT to standard therapy. Until such studies are completed, basing international treatment guidelines on a single centre study performed in what may turn out to be a highly atypical environment would seem premature. Commentary See related research by van Beest et al., http://ccforum.com/content/12/2/R33 ANZ = Australia and New Zealand; ANZICS = ANZ Intensive Care Society; DO 2 = oxygen delivery; EGDT = early goal directed therapy; ICU = intensive care unit; ScvO 2 = central venous oxygen saturation.

Research paper thumbnail of Effect of an education programme on the utilization of a medical emergency team in a teaching hospital

Internal Medicine Journal, 2006

Medical Emergency Teams (MET) have been developed to identify, review and manage acutely unwell w... more Medical Emergency Teams (MET) have been developed to identify, review and manage acutely unwell ward patients. Previous studies have suggested that there may be obstacles to the utilization and activation of the MET. To determine the effect of a detailed education programme on the rate of utilization of the MET system 3.5 years after its introduction in a University teaching hospital. Prospective interventional study involving a detailed programme of education, feedback and decision support for nursing and medical staff given before, during and after implementation of a MET system. We measured the number of MET calls per month for both medical and surgical patients for 109 250 consecutive admissions to the acute care campus of Austin Health from August 2000 to June 2004. Overall activation of the MET increased from 25 calls per month to a peak of 79 calls per month over the study period (average increase of one MET call/month). After standardization for monthly admissions, the increase in MET utilization for surgical patients (increase by 1.13 MET/1000 admissions/month) was 4.9-fold greater than for medical patients (increase by 0.23 MET/1000 admissions/month; P &lt; 0.0001). At the peak level of activity (April 2004), the MET was called to review 8.4% of surgical and 2.7% of medical admissions (P &lt; 0.0001). There was a progressive increase in the utilization of the MET service in the 3.5 years after implementation, with the rate of uptake 4.9 times greater for surgical than for medical patients. Sustained uptake of the MET system is possible, but increased utilization may take several years to develop. Short-term studies testing the efficacy of the MET system are likely to significantly underestimate its effect on reducing adverse events. Intensive care unit resource adjustments will become necessary to meet increased demand.

Research paper thumbnail of Pilot randomised double-blind controlled trial of high-dose spironolactone in critically ill patients receiving a frusemide infusion

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2008

Hypernatraemia may develop during intravenous infusion of frusemide. Spironolactone is an aldoste... more Hypernatraemia may develop during intravenous infusion of frusemide. Spironolactone is an aldosterone antagonist that promotes natriuresis and may attenuate such hypernatraemia, but its effect in this setting has not been previously studied. To assess whether the administration of spironolactone to ventilated patients receiving a frusemide infusion attenuates the increase in serum sodium concentration. Randomised, double-blind, placebo-controlled trial (January 2005 to December 2006). 20 patients with a serum creatinine concentration < 300 micromol/L who were undergoing mechanical ventilation in the intensive care unit and had begun a frusemide infusion as treatment for fluid overload within the previous 24 hours. Patients were randomly allocated to receive either spironolactone (100 mg three times daily) or placebo by nasogastric tube for the duration of the frusemide infusion. Daily serum levels of urea and creatinine, 24-hour urine sodium and potassium levels, fluid balance an...

Research paper thumbnail of Normothermic extracorporeal human liver perfusion following donation after cardiac death

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2013

Liver transplantation is a major life-saving procedure and donation after cardiac death (DCD) has... more Liver transplantation is a major life-saving procedure and donation after cardiac death (DCD) has increased the pool of potential liver donors. However, livers procured after DCD are at increased risk of primary graft dysfunction and biliary tract ischaemia. Normothermic extracorporeal liver perfusion (NELP) may increase the ability to protect, evaluate and, in future, transplant DCD livers. We conducted a proof-of-concept experiment using a human liver procured by DCD (deemed not suitable for liver donation) to assess the short-term (3 hours) feasibility, histological effects and functional efficacy of NELP. We used an extracorporeal membrane oxygenation circuit with separate hepatic artery and portal vein perfusion to achieve physiological perfusion pressures, and coupled this with parenteral nutrition and an insulin infusion. We achieved NELP with evidence of liver function (bile production, paracetamol removal and control of ammonia, bilirubin and lactate levels) for 3 hours. Th...

Research paper thumbnail of Antecedents to cardiac arrests in a teaching hospital intensive care unit

Resuscitation, 2014

Background: In hospital cardiac arrests (CA) treated with cardio-pulmonary resuscitation (CPR) ou... more Background: In hospital cardiac arrests (CA) treated with cardio-pulmonary resuscitation (CPR) outside of the intensive care unit (ICU) have poor outcomes. Most are preceded by deranged vital signs. There are, however, limited studies assessing antecedents to CAs inside the ICU. Objectives: To study the antecedents to, and characteristics of CAs in ICU. Study population: We prospectively identified CA cases that occurred inside our ICU between January 2010 and July 2012. Controls were obtained by sequentially matching ICU patients based on APACHE III diagnosis, APACHE III score, age, gender and length of stay in ICU. Results: Thirty-six patients had a CA during the study period (6.28/1000 admissions). In the 12 h prior to CA, index patients had higher maximum (22 breaths/min vs. 18 breaths/min, p = 0.001) and minimum respiratory rates (16 breaths/min vs. 12 breaths/min, p = 0.031), a lower median mean arterial pressure (65 mmHg vs. 70 mmHg, p = 0.029) and systolic blood pressure (97 mmHg vs. 106 mmHg, p = 0.033), a higher central venous pressure (14 cm H 2 O vs. 11 cm H 2 O, p = 0.008) and a lower bicarbonate level (20.5 mmol vs. 26 mmol, p = 0.018) compared to controls. CA patients also had a higher maximum dose of noradrenaline (norepinephrine) (17.5 mcg/min vs. 8.0 mcg/min, p = 0.052) but there was no difference in any other levels of intensive care support. Two-thirds of CA's occurred within the first 48 h of ICU admission. The initial monitored rhythm was non-shock responsive (pulseless electrical activity, bradycardia or asystole) in 26/36 (72%). Return of spontaneous circulation was achieved in 29/36 (80.6%) patients, with 16/36 (44.4%) surviving to hospital discharge. Conclusions: In the period leading up to the CA inside ICU, there were signs of physiological instability and the need for higher doses of noradrenaline. Return of spontaneous circulation was achieved in 80%. However, in-hospital mortality was greater than 50%.

Research paper thumbnail of Functional electrical stimulation with cycling in the critically ill: A pilot case-matched control study

Journal of Critical Care, 2014

To determine (a) safety and feasibility of functional electrical stimulation (FES)cycling and (b)... more To determine (a) safety and feasibility of functional electrical stimulation (FES)cycling and (b) compare FES-cycling to case-matched controls in functional recovery and delirium outcomes.

Research paper thumbnail of The pursuit of a high central venous oxygen saturation in sepsis: growing concerns

Critical Care, 2008

In this issue of Critical Care, Dutch investigators report that, in a cohort of patients with sep... more In this issue of Critical Care, Dutch investigators report that, in a cohort of patients with sepsis/septic shock admitted to three different intensive care units (ICUs), low central venous oxygen saturation (ScvO 2 ) was uncommon at the time of ICU admission, and hospital mortality was <30%. Their findings, taken together with those of recent reports from Australia and New Zealand (ANZ), raise serious concerns about the utility of early goal directed therapy (EGDT) outside the context of the original trial. Despite inclusion of EGDT into the Surviving Sepsis Guidelines, in response to growing uncertainty, ANZ and US investigators will soon begin randomization of patients into two large multicentre trials comparing EGDT to standard therapy. Until such studies are completed, basing international treatment guidelines on a single centre study performed in what may turn out to be a highly atypical environment would seem premature. Commentary See related research by van Beest et al., http://ccforum.com/content/12/2/R33 ANZ = Australia and New Zealand; ANZICS = ANZ Intensive Care Society; DO 2 = oxygen delivery; EGDT = early goal directed therapy; ICU = intensive care unit; ScvO 2 = central venous oxygen saturation.

Research paper thumbnail of Effect of an education programme on the utilization of a medical emergency team in a teaching hospital

Internal Medicine Journal, 2006

Medical Emergency Teams (MET) have been developed to identify, review and manage acutely unwell w... more Medical Emergency Teams (MET) have been developed to identify, review and manage acutely unwell ward patients. Previous studies have suggested that there may be obstacles to the utilization and activation of the MET. To determine the effect of a detailed education programme on the rate of utilization of the MET system 3.5 years after its introduction in a University teaching hospital. Prospective interventional study involving a detailed programme of education, feedback and decision support for nursing and medical staff given before, during and after implementation of a MET system. We measured the number of MET calls per month for both medical and surgical patients for 109 250 consecutive admissions to the acute care campus of Austin Health from August 2000 to June 2004. Overall activation of the MET increased from 25 calls per month to a peak of 79 calls per month over the study period (average increase of one MET call/month). After standardization for monthly admissions, the increase in MET utilization for surgical patients (increase by 1.13 MET/1000 admissions/month) was 4.9-fold greater than for medical patients (increase by 0.23 MET/1000 admissions/month; P &lt; 0.0001). At the peak level of activity (April 2004), the MET was called to review 8.4% of surgical and 2.7% of medical admissions (P &lt; 0.0001). There was a progressive increase in the utilization of the MET service in the 3.5 years after implementation, with the rate of uptake 4.9 times greater for surgical than for medical patients. Sustained uptake of the MET system is possible, but increased utilization may take several years to develop. Short-term studies testing the efficacy of the MET system are likely to significantly underestimate its effect on reducing adverse events. Intensive care unit resource adjustments will become necessary to meet increased demand.

Research paper thumbnail of Pilot randomised double-blind controlled trial of high-dose spironolactone in critically ill patients receiving a frusemide infusion

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2008

Hypernatraemia may develop during intravenous infusion of frusemide. Spironolactone is an aldoste... more Hypernatraemia may develop during intravenous infusion of frusemide. Spironolactone is an aldosterone antagonist that promotes natriuresis and may attenuate such hypernatraemia, but its effect in this setting has not been previously studied. To assess whether the administration of spironolactone to ventilated patients receiving a frusemide infusion attenuates the increase in serum sodium concentration. Randomised, double-blind, placebo-controlled trial (January 2005 to December 2006). 20 patients with a serum creatinine concentration < 300 micromol/L who were undergoing mechanical ventilation in the intensive care unit and had begun a frusemide infusion as treatment for fluid overload within the previous 24 hours. Patients were randomly allocated to receive either spironolactone (100 mg three times daily) or placebo by nasogastric tube for the duration of the frusemide infusion. Daily serum levels of urea and creatinine, 24-hour urine sodium and potassium levels, fluid balance an...

Research paper thumbnail of Normothermic extracorporeal human liver perfusion following donation after cardiac death

Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine, 2013

Liver transplantation is a major life-saving procedure and donation after cardiac death (DCD) has... more Liver transplantation is a major life-saving procedure and donation after cardiac death (DCD) has increased the pool of potential liver donors. However, livers procured after DCD are at increased risk of primary graft dysfunction and biliary tract ischaemia. Normothermic extracorporeal liver perfusion (NELP) may increase the ability to protect, evaluate and, in future, transplant DCD livers. We conducted a proof-of-concept experiment using a human liver procured by DCD (deemed not suitable for liver donation) to assess the short-term (3 hours) feasibility, histological effects and functional efficacy of NELP. We used an extracorporeal membrane oxygenation circuit with separate hepatic artery and portal vein perfusion to achieve physiological perfusion pressures, and coupled this with parenteral nutrition and an insulin infusion. We achieved NELP with evidence of liver function (bile production, paracetamol removal and control of ammonia, bilirubin and lactate levels) for 3 hours. Th...

Research paper thumbnail of Antecedents to cardiac arrests in a teaching hospital intensive care unit

Resuscitation, 2014

Background: In hospital cardiac arrests (CA) treated with cardio-pulmonary resuscitation (CPR) ou... more Background: In hospital cardiac arrests (CA) treated with cardio-pulmonary resuscitation (CPR) outside of the intensive care unit (ICU) have poor outcomes. Most are preceded by deranged vital signs. There are, however, limited studies assessing antecedents to CAs inside the ICU. Objectives: To study the antecedents to, and characteristics of CAs in ICU. Study population: We prospectively identified CA cases that occurred inside our ICU between January 2010 and July 2012. Controls were obtained by sequentially matching ICU patients based on APACHE III diagnosis, APACHE III score, age, gender and length of stay in ICU. Results: Thirty-six patients had a CA during the study period (6.28/1000 admissions). In the 12 h prior to CA, index patients had higher maximum (22 breaths/min vs. 18 breaths/min, p = 0.001) and minimum respiratory rates (16 breaths/min vs. 12 breaths/min, p = 0.031), a lower median mean arterial pressure (65 mmHg vs. 70 mmHg, p = 0.029) and systolic blood pressure (97 mmHg vs. 106 mmHg, p = 0.033), a higher central venous pressure (14 cm H 2 O vs. 11 cm H 2 O, p = 0.008) and a lower bicarbonate level (20.5 mmol vs. 26 mmol, p = 0.018) compared to controls. CA patients also had a higher maximum dose of noradrenaline (norepinephrine) (17.5 mcg/min vs. 8.0 mcg/min, p = 0.052) but there was no difference in any other levels of intensive care support. Two-thirds of CA's occurred within the first 48 h of ICU admission. The initial monitored rhythm was non-shock responsive (pulseless electrical activity, bradycardia or asystole) in 26/36 (72%). Return of spontaneous circulation was achieved in 29/36 (80.6%) patients, with 16/36 (44.4%) surviving to hospital discharge. Conclusions: In the period leading up to the CA inside ICU, there were signs of physiological instability and the need for higher doses of noradrenaline. Return of spontaneous circulation was achieved in 80%. However, in-hospital mortality was greater than 50%.