Intensive Care Units In Australia Research Articles

Empiric antibiotic regimens for neonatal sepsis in Australian and New Zealand neonatal intensive care units.

Neonatal sepsis remains an important cause of morbidity and mortality, and requires prompt empiric treatment. However, only a minority of babies who receive antibiotics for suspected sepsis have an infection. Antimicrobial exposure in infancy has important short- and long-term consequences. There is no consensus regarding empirical antimicrobial regimens. The study included a survey of empiric antimicrobial regimens in all tertiary neonatal intensive care units in Australia and New Zealand in 2013-2014. All 27 units responded. For early-onset sepsis, all units used a combination of gentamicin with either penicillin or ampicillin. For late-onset sepsis, the frequency of units using empiric vancomycin (41%) versus empiric flucloxacillin (48%) was similar. Gestational age or the presence of a central venous catheter had little influence on using vancomycin instead of flucloxacillin. For late-onset sepsis with meningitis there was marked variation in antimicrobial combinations, with 15 different regimens described. A total of 93% used a cefotaxime-based regimen, either as monotherapy (22%) or combined with a second (22%) or third (48%) agent. For suspected necrotising enterocolitis, 89% used an aminoglycoside, metronidazole and a penicillin. Historical outbreaks of multi-resistant organisms exerted long-term influence over regimen choice. There was limited use of broad-spectrum agents such as carbapenems or third-generation cephalosporins. In this region with low methicillin-resistant Staphylococcus aureus prevalence, empiric vancomycin use was common, selected for activity against coagulase-negative staphylococci. Empiric vancomycin is rarely necessary because coagulase-negative staphylococci are often contaminants and sepsis is rarely fulminant, occurring almost exclusively in extremely low birthweight infants. Implementation of appropriate, local antimicrobial policies is crucial to minimise antimicrobial exposure in this vulnerable population and halt the development of antimicrobial resistance.

Delirium After Mechanical Ventilation in Intensive Care Units: The Cognitive and Psychosocial Assessment (CAPA) Study Protocol.

BackgroundIn the intensive care unit (ICU), critical illness delirium occurs in the context of multiple comorbidities, multi-organ failure, and invasive management techniques, such as mechanical ventilation, sedation, and lack of sleep. Delirium is characterized by an acute confusional state defined by fluctuating mental status, inattention, and either disorganized thinking or an altered level of consciousness. The long-term cognitive and psychosocial function of patients that experience delirium in the ICU is of crucial interest because preliminary data suggest a strong association between ICU-related delirium and long-term cognitive impairment.ObjectiveThe aim of this study is to explore the relationship between delirium in the ICU and adverse outcomes by following mechanically ventilated patients for one year following their discharge from the ICU and collecting data on their long-term cognition and psychosocial function.MethodsThis study will be conducted by enrolling patients in two tertiary ICUs in Australia. We aim to recruit 200 patients who have been mechanically ventilated for more than 24 hours. Data will be collected at the following three time points: (1) at discharge where they will be administered the Mini-Mental State Examination (MMSE); (2) at 6 months after discharge from the ICU discharge where the Impact of Events Scale Revised (IES-R) and the Telephone Inventory for Cognitive Status (TICS) tests will be administered; and (3) at 12 months after discharge from the ICU where the patients will be administered the TICS and IES-R tests, as well as the Informant Questionnaire for Cognitive Decline in the Elderly (IQCODE). The IQCODE will be administered to their “person responsible” or the significant other of the patient.ResultsLong-term cognition and psychosocial function will be the primary outcome of this study. Mortality will also be investigated as a secondary outcome. Active enrollment will take place until the end of September 2016 and data collection will conclude at the end of September 2017. The analysis and results are expected to be available by March 2018.ConclusionDelirium during mechanical ventilation has been linked to longer ICU and hospital stays, higher financial burdens, increased risks of long-term cognitive impairment (ie, dementia), poor functional outcomes and quality of life, and decreased survival. However, delirium during mechanical ventilation in the ICU is not well understood. This study will advance our knowledge of the comprehensive, long-term effects of delirium on cognitive and psychosocial function.Trial RegistrationAustralian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12616001116415; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=371216 (Archived by WebCite at http://www.webcitation.org/ 6nfDkGTcW)

Developing a minimum dataset for nursing team leader handover in the intensive care unit: A focus group study

BackgroundDespite increasing demand for structured processes to guide clinical handover, nursing handover tools are limited in the intensive care unit. ObjectivesThe study aim was to identify key items to include in a minimum dataset for intensive care nursing team leader shift-to-shift handover. MethodsThis focus group study was conducted in a 21-bed medical/surgical intensive care unit in Australia. Senior registered nurses involved in team leader handovers were recruited. Focus groups were conducted using a nominal group technique to generate and prioritise minimum dataset items. Nurses were presented with content from previous team leader handovers and asked to select which content items to include in a minimum dataset. Participant responses were summarised as frequencies and percentages. ResultsSeventeen senior nurses participated in three focus groups. Participants agreed that ISBAR (Identify-Situation-Background-Assessment-Recommendations) was a useful tool to guide clinical handover. Items recommended to be included in the minimum dataset (≥65% agreement) included Identify (name, age, days in intensive care), Situation (diagnosis, surgical procedure), Background (significant event(s), management of significant event(s)) and Recommendations (patient plan for next shift, tasks to follow up for next shift). Overall, 30 of the 67 (45%) items in the Assessment category were considered important to include in the minimum dataset and focused on relevant observations and treatment within each body system. Other non-ISBAR items considered important to include related to the ICU (admissions to ICU, staffing/skill mix, theatre cases) and patients (infectious status, site of infection, end of life plan). Items were further categorised into those to include in all handovers and those to discuss only when relevant to the patient. ConclusionsThe findings suggest a minimum dataset for intensive care nursing team leader shift-to-shift handover should contain items within ISBAR along with unit and patient specific information to maintain continuity of care and patient safety across shift changes.

Content validity testing of the ESAT©: A decision aid tool for performing endotracheal suction in children

Background and purposeEndotracheal tube suction performed in children can affect clinical stability. Previous research has identified clinical indicators used to perform endotracheal suction. These were used to develop the Endotracheal Suction Assessment Tool© (ESAT©). This study sought to evaluate the degree to which the ESAT© items as a whole constitute an operational definition of the construct used to determine whether a paediatric intensive care nurse should perform the endotracheal tube suction procedure. MethodsLynn's process for calculation of content validity and scale content validity index using a team of expert reviewers was adopted. Experts were drawn from paediatric intensive care units in Australia (n=6), United Kingdom (n=1), Switzerland (n=1) and Canada (n=1). These experts established the content validity index of the Endotracheal Suction Assessment Tool© using a minimum preset a-priori criterion agreement of 0.78 and a scale content validity index of 0.8. Scale content validity index was used to enhance the interpretability of the content validity data. ResultsAll 15 items achieved the preset a-priori agreement for apparent internal consistency. Minor adjustments were required to improve the clarity of four items. The content validity index ranged from 0.8 to 1.0 and scale content validity index ranged from 0.9 to 1.0 for all items. ConclusionItem and scale content validity indexes of the tool were established. Further psychometric testing for construct validity and stability over time is required to establish clinical utility of the tool and practice of novice paediatric intensive care nurses and other PIC health professionals.

Approaches and adjuncts used by physiotherapists when suctioning adult patients who are intubated and ventilated in intensive care units in Australia and New Zealand: A cross-sectional survey

BackgroundSuctioning is an integral component of care for patients who are intubated and ventilated in an intensive care unit (ICU). There appears to be no published data of physiotherapy suctioning practices in Australia or New Zealand. ObjectiveTo describe suctioning practices and the factors which have shaped these practices, of experienced physiotherapists working with adults who are intubated and ventilated in an ICU across Australia and New Zealand. Areas of investigation focused on: (i) suctioning approach (i.e. open vs. closed system); (ii) use of adjuncts to suctioning such as hyperoxygenation, hyperinflation and saline lavage; (iii) use of subglottic suctioning and; (iv) factors influencing suctioning practices. MethodsElectronic surveys were emailed to experienced physiotherapists working in ICUs across Australia and New Zealand which had the capacity to intubate and ventilate adult patients for ≥24h. ResultsThe participation rate was 84.8% (112/132). Closed suction system was used in most ICUs (97/112, 86.6%). Hyperoxygenation was commonly performed on ‘all’ or ‘most’ patients before suctioning (71/112, 63.4%), but less frequently after suctioning (38/112, 33.9%). Hyperinflation was infrequently performed on ‘all’ or ‘most’ patients before (22/112, 19.6%) or after suctioning (22/112, 19.6%). Saline lavage and subglottic suctioning were infrequently performed on ‘all’ or ‘most’ patients (3/112, 2.7%; 17/112, 15.2%, respectively). ‘Personal experience’ and ‘established practice in the ICU’ had the greatest influence on suctioning practices. ConclusionsMost ICUs in Australia and New Zealand are equipped for closed system suctioning. As hyperoxygenation minimises desaturation during suctioning, there may be scope for a larger proportion of physiotherapists to use this adjunct. The practice of hyperinflation before and after suctioning was uncommon despite the emerging evidence for improved lung compliance with this procedure. Subglottic suctioning was infrequently available as a choice for physiotherapists despite the strong evidence, which suggests an evidence-practice gap.

The burden of invasive infections in critically ill Indigenous children in Australia.

To describe the incidence and mortality of invasive infections in Indigenous children admitted to paediatric and general intensive care units (ICUs) in Australia. Retrospective multi-centre cohort study of Australian and New Zealand Paediatric Intensive Care Registry data. All children under 16 years of age admitted to an ICU in Australia, 1 January 2002 - 31 December 2013. Indigenous children were defined as those identified as Aboriginal and/or Torres Strait Islander in a mandatory admissions dataset. Population-based ICU mortality and admission rates. Invasive infections accounted for 23.0% of non-elective ICU admissions of Indigenous children (726 of 3150), resulting in an admission rate of 47.6 per 100 000 children per year. Staphylococcus aureus was the leading pathogen identified in children with sepsis/septic shock (incidence, 4.42 per 100 000 Indigenous children per year; 0.57 per 100 000 non-Indigenous children per year; incidence rate ratio 7.7; 95% CI, 5.8-10.1; P <0.001). While crude and risk-adjusted ICU mortality related to invasive infections was not significantly different for Indigenous and non-Indigenous children (odds ratio, 0.75; 95% CI, 0.53-1.07; P = 0.12), the estimated population-based age-standardised mortality rate for invasive infections was significantly higher for Indigenous children (2.67 per 100 000 per year v 1.04 per 100 000 per year; crude incidence rate ratio, 2.65; 95% CI, 1.88-3.64; P <0.001). The ICU admission rate for severe infections was several times higher for Indigenous than for non-Indigenous children, particularly for S. aureus infections. While ICU case fatality rates were similar, the population-based mortality was more than twice as high for Indigenous children. Our study highlights an important area of inequality in health care for Indigenous children in a high income country that needs urgent attention.

Minimum standards for ultrasound equipment in intensive care. Recommendations from CICM Ultrasound Special Interest Group.

Critical care ultrasonography allows rapid bedside assessment and monitoring of severely ill patients. It provides important information on a real-time basis for patients' management and clinical decision-making, leading to improvements in delivered quality of care. Provision of this service is not possible without appropriate equipment. This document recommends minimum standards for ultrasound equipment required for use in intensive care units in Australia and New Zealand.

Prophylactic Melatonin for Delirium in Intensive Care (Pro-MEDIC): study protocol for a randomised controlled trial

BackgroundDelirium is an acute state of brain dysfunction characterised by fluctuating inattention and cognitive disturbances, usually due to illness. It occurs commonly in the intensive care unit (ICU), and it is associated with greater morbidity and mortality. It is likely that disturbances of sleep and of the day-night cycle play a significant role. Melatonin is a naturally occurring, safe and cheap hormone that can be administered to improve sleep. The main aim of this trial will be to determine whether prophylactic melatonin administered to critically ill adults, when compared with placebo, decreases the rate of delirium.MethodsThis trial will be a multi-centre, randomised, placebo-controlled study conducted in closed ICUs in Australia. Our aim is to enrol 850 adult patients with an expected ICU length of stay (LOS) of 72 h or more. Eligible patients for whom there is consent will be randomised to receive melatonin 4 mg enterally or placebo in a 1:1 ratio according to a computer-generated randomisation list, stratified by site. The study drug will be indistinguishable from placebo. Patients, doctors, nurses, investigators and statisticians will be blinded. Melatonin or placebo will be administered once per day at 21:00 until ICU discharge or 14 days after enrolment, whichever occurs first. Trained staff will assess patients twice daily to determine the presence or absence of delirium using the Confusion Assessment Method for the ICU score. Data will also be collected on demographics, the overall prevalence of delirium, duration and severity of delirium, sleep quality, participation in physiotherapy sessions, ICU and hospital LOS, morbidity and mortality, and healthcare costs. A subgroup of 100 patients will undergo polysomnographic testing to further evaluate the quality of sleep.DiscussionDelirium is a significant issue in ICU because of its frequency and associated poorer outcomes. This trial will be the largest evaluation of melatonin as a prophylactic agent to prevent delirium in the critically ill population. This study will also provide one of the largest series of polysomnographic testing done in ICU.Trial registrationAustralian New Zealand Clinical Trial Registry (ANZCTR) number: ACTRN12616000436471. Registered on 20 December 2015.

Prevalence of ketosis, ketonuria, and ketoacidosis during liberal glycemic control in critically ill patients with diabetes: an observational study.

BackgroundIt is uncertain whether liberal glucose control in critically ill diabetic patients leads to increased ketone production and ketoacidosis. Therefore, we aimed to assess the prevalence of ketosis, ketonuria and ketoacidosis in critically ill diabetic patients treated in accordance with a liberal glycemic control protocol.MethodsWe performed a prospective observational cohort study of 60 critically ill diabetic patients with blood and/or urine ketone bodies tested in ICU. All patients were treated according to a liberal glucose protocol targeting a blood glucose level (BGL) between 10 and 14 mmol/l in a single tertiary intensive care unit in Australia. We measured quantitative bedside blood 3-beta-hydroxybutyrate (β-OHB) and semi-quantitative urine ketones on ICU admission and daily during ICU stay, for a maximum of 10 consecutive days.ResultsMedian blood β-OHB level on admission was 0.3 (0.1, 0.8) mmol/l. Ketoacidosis was rare (3 %), but some level of ketosis (β-OHB ≥0.6 mmol/l) was found in 38 patients (63 %) early during their ICU stay. However, there was no significant difference in prevalence or severity of ketonemia and ketonuria among patients with BGL above (permissive hyperglycemia) or below 10 mmol/l. On multivariable linear regression analysis there was no association between blood ketone levels and BGL, HbA1c, lactate levels, hematocrit, catecholamine infusion or APACHE III score. In contrast, blood ketone levels tended to be higher after cardiopulmonary bypass surgery (P = 0.06).ConclusionsLiberal glycemic control in critically ill diabetic patients does not appear to be associated with a high prevalence of ketoacidosis or ketonemia. Moreover, ketosis is typically present on admission and resolves rapidly. Finally, cardiopulmonary bypass surgery may be an important trigger of ketone body production.Trial registrationAustralian New Zealand Clinical Trials Registry (ACTRN12615000216516; trial registration date 5 March 2015).Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1462-7) contains supplementary material, which is available to authorized users.

Variability of intravenous medication preparation in Australian and New Zealand intensive care units.

In Australia and New Zealand, there are no established standards for the final presentations of prepared intravenous medications in Intensive Care Units (ICUs). Variability has the potential to contribute to deficiencies in safety, efficiency and cost effectiveness. This study aimed to examine the variability in the preparation of intravenous medications in ICUs. An electronic survey was distributed to critical care pharmacists in Australia and New Zealand via an established email group. The preparation of vasopressors, inotropes, sedation, analgesia, heparin, insulin and neuromuscular blockers were examined. Respondents were asked about initial presentation, final concentration prepared, who prepared and current safety practices used. Questions also addressed opinions and attitudes to safety practices and responsibility for leading change. Forty responses to the survey were received, representing 17% of ICUs in Australia and New Zealand. Significant variation in final concentration was observed for all infusions except insulin and esmolol. The final volumes varied significantly for all drugs. The majority of infusions were prepared by nursing staff with only a small number of pre-prepared presentations currently in use. Labelling was usually hand-written with some colour-coding. Most respondents identified safety and efficiency but not cost effectiveness as likely to be improved by the use of pre-prepared infusions. Most respondents felt 'government' or peak clinical bodies should lead practice standardization. Significant variation exists in the preparation of intravenous medications across ICUs in Australia and New Zealand. Nationally or regionally coordinated rationalization and standardization could improve safety and efficiency and potentially reduce the barrier of cost.

Maintenance fluid practices in intensive care units in Australia and New Zealand

Maintenance fluid practices in intensive care units in Australia and New Zealand

Effect of Dexmedetomidine Added to Standard Care on Ventilator-Free Time in Patients With Agitated Delirium: A Randomized Clinical Trial.

Effective therapy has not been established for patients with agitated delirium receiving mechanical ventilation. To determine the effectiveness of dexmedetomidine when added to standard care in patients with agitated delirium receiving mechanical ventilation. The Dexmedetomidine to Lessen ICU Agitation (DahLIA) study was a double-blind, placebo-controlled, parallel-group randomized clinical trial involving 74 adult patients in whom extubation was considered inappropriate because of the severity of agitation and delirium. The study was conducted at 15 intensive care units in Australia and New Zealand from May 2011 until December 2013. Patients with advanced dementia or traumatic brain injury were excluded. Bedside nursing staff administered dexmedetomidine (or placebo) initially at a rate of 0.5 µg/kg/h and then titrated to rates between 0 and 1.5 µg/kg/h to achieve physician-prescribed sedation goals. The study drug or placebo was continued until no longer required or up to 7 days. All other care was at the discretion of the treating physician. Ventilator-free hours in the 7 days following randomization. There were 21 reported secondary outcomes that were defined a priori. Of the 74 randomized patients (median age, 57 years; 18 [24%] women), 2 withdrew consent later and 1 was found to have been randomized incorrectly, leaving 39 patients in the dexmedetomidine group and 32 patients in the placebo group for analysis. Dexmedetomidine increased ventilator-free hours at 7 days compared with placebo (median, 144.8 hours vs 127.5 hours, respectively; median difference between groups, 17.0 hours [95% CI, 4.0 to 33.2 hours]; P = .01). Among the 21 a priori secondary outcomes, none were significantly worse with dexmedetomidine, and several showed statistically significant benefit, including reduced time to extubation (median, 21.9 hours vs 44.3 hours with placebo; median difference between groups, 19.5 hours [95% CI, 5.3 to 31.1 hours]; P < .001) and accelerated resolution of delirium (median, 23.3 hours vs 40.0 hours; median difference between groups, 16.0 hours [95% CI, 3.0 to 28.0 hours]; P = .01). Using hierarchical Cox modeling to adjust for imbalanced baseline characteristics, allocation to dexmedetomidine was significantly associated with earlier extubation (hazard ratio, 0.47 [95% CI, 0.27-0.82]; P = .007). Among patients with agitated delirium receiving mechanical ventilation in the intensive care unit, the addition of dexmedetomidine to standard care compared with standard care alone (placebo) resulted in more ventilator-free hours at 7 days. The findings support the use of dexmedetomidine in patients such as these. clinicaltrials.gov Identifier: NCT01151865.

Hospital overnight and evaluation of systems and timelines study: A point prevalence study of practice in Australia and New Zealand

BackgroundDiurnal variation in the performance of rapid response systems has not been fully elucidated. Afferent limb failure (ALF) is a significant problem and is an important measure of performance of rapid response systems. ObjectiveTo determine the diurnal variation in the detection and response to acute patient deterioration as measured by ALF, completeness of patient observations (Respiratory rate (RR); Pulse rate (PR) and Systolic blood pressure (SBP), and to explore the diurnal variation in the consequences of ALF in unanticipated admissions to the Intensive care unit (ICU) from the ward. Design, setting and participantsPoint Prevalence study conducted on two days in 2012 in 41 ICUs in Australia and New Zealand, examining emergency (unanticipated) admissions to the ICU from the ward. Results51 patients from the ward were admitted as an emergency to the ICU following a rapid response team call, of whom 48 patients had complete datasets and were enrolled; 32 (67%) were men. The prevalence of ALF was 37.5% (18/48). Median age was 62.5 (IQR 51.5–74.0), Median APACHE II score was 21.0 (IQR 17–26). There was no diurnal variation in the prevalence of ALF (day 28% versus night 28%; p=0.92), patient observations documented over time (p=0.78 for RR, p=0.95 for PR and p=0.74 for SBP) or 28-day mortality (p=0.24).There was a significant diurnal variation between the least recorded observation (SBP) and the most recorded observation (PR) (p<0.01). ALF was more likely (day and night) if a complete set of observations had been taken (p<0.01). ConclusionThe prevalence of ALF amongst patients admitted to the ICU from the ward is high. SBP is the least recorded patient observation. This study was unable to identify a diurnal variation in the prevalence of ALF, its consequences (i.e. mortality) and the completeness of patient observations. Observational studies with a larger sample are required to explore this important problem.

Incidence and outcome of adults with diabetic ketoacidosis admitted to ICUs in Australia and New Zealand.

BackgroundOver the last two decades, there have been several improvements in the management of diabetes. Whether this has impacted on the epidemiology and outcome of diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission is unknown.MethodThis was a retrospective study of 8533 patients with the diagnosis of DKA admitted to 171 ICUs in Australia and New Zealand between 2000–2013 with separate independent analysis of those on established insulin (Group I) or not on insulin (Group NI) at the time of hospitalisation.ResultsOf the 8553 patients, 2344 (27 %) were identified as NI. The incidence of ICU admission with DKA progressively increased fivefold from 0.97/100,000 (95 % CI 0.84–1.10) in 2000 to 5.3/100,000 (95 % CI 4.98–5.53) in 2013 (P < 0.0001), with the proportions between I and NI remaining stable. Rising incidences were observed mainly in rural and metropolitan hospitals (P < 0.01). In the first 24 hours in the ICU, mean worst pH increased over the study period from 7.20 ± 0.02 to 7.24 ± 0.01 (P < 0.0001), and mean lowest plasma bicarbonate from 12.1 ± 6.6 to 13.8 ± 6.6 mmol/L (P < 0.0001). In contrast, mean highest plasma glucose decreased from 26.3 ± 14 to 23.2 ± 13.1 mmol/L (P < 0.0001). Hospital mortality was significantly greater in NI as compared to I (2.4 % vs 1.1 %, P > 0.0001). Elevated plasma urea in the first 24 hours (≥25 mmol/L, adjusted odds ratio 20.6 (6.54–65.7), P < 0.0001) was the strongest individual predictor of mortality.ConclusionsThe incidence of ICU admission of patients with DKA in Australia and New Zealand has increased fivefold over the last decade, with a significant proportion of patients not on insulin at presentation. Overall physiological status in the first 24 hours of ICU admission has progressively improved and mortality rates have remained stable. However, DKA patients not on established insulin therapy at presentation had significantly worse outcomes. This notion has epidemiologic, diagnostic and management implications.

In Vivo Microdialysis To Determine Subcutaneous Interstitial Fluid Penetration and Pharmacokinetics of Fluconazole in Intensive Care Unit Patients with Sepsis.

The objective of the study was to describe the subcutaneous interstitial fluid (ISF) pharmacokinetics of fluconazole in critically ill patients with sepsis. This prospective observational study was conducted at two tertiary intensive care units in Australia. Serial fluconazole concentrations were measured over 24 h in plasma and subcutaneous ISF using microdialysis. The concentrations in plasma and microdialysate were measured using a validated high-performance liquid chromatography system with electrospray mass spectrometer detector method. Noncompartmental pharmacokinetic analysis was performed. Twelve critically ill patients with sepsis were enrolled. The mean in vivo fluconazole recovery rates ± standard deviation (SD) for microdialysis were 51.4% ± 16.1% with a mean (±SD) fluconazole ISF penetration ratio of 0.52 ± 0.30 (coefficient of variation, 58%). The median free plasma area under the concentration-time curve from 0 to 24 h (AUC0-24) was significantly higher than the median ISF AUC0-24 (340.4 versus 141.1 mg · h/liter; P = 0.004). There was no statistical difference in median fluconazole ISF penetration between patients receiving and not receiving vasopressors (median, 0.28 versus 0.78; P = 0.106). Both minimum and the maximum concentrations of drug in serum (Cmax and Cmin) showed a significant correlation with the fluconazole plasma exposure (Cmax, R(2) = 0.86, P < 0.0001; Cmin, R(2) = 0.75, P < 0.001). Our data suggest that fluconazole was distributed variably, but incompletely, from plasma into subcutaneous interstitial fluid in this cohort of critically ill patients with sepsis. Given the variability of fluconazole interstitial fluid exposures and lack of clinically identifiable factors by which to recognize patients with reduced distribution/exposure, we suggest higher than standard doses to ensure that drug exposure is adequate at the site of infection.

Outborns or Inborns: Where Are the Differences? A Comparison Study of Very Preterm Neonatal Intensive Care Unit Infants Cared for in Australia and New Zealand and in Canada

Background: Very preterm infants born outside tertiary centers are at higher risks of adverse outcomes than inborn infants. Regionalization of perinatal care has been introduced worldwide to improve outcomes. Objective: To compare the risk-adjusted outcomes of both inborn and outborn infants cared for in tertiary neonatal intensive care units in Australia and New Zealand and in Canada. Methods: Deidentified data of infants <32 weeks' gestational age from the 29 Australian and New Zealand Neonatal Network units (ANZNN; n = 9,893) and 26 Canadian Neonatal Network units (CNN; n = 7,133) between 2005 and 2007 were analyzed for predischarge adverse outcomes. Results: ANZNN had lower rates of outborns compared to CNN (13 vs. 19%), particularly of late admissions (>2 days of age; 5.8 vs. 22.2% of outborns) who had high morbidity rates. After adjusting for confounding variables including gestation, ANZNN inborn infants had lower odds of chronic lung disease [CLD; 17.0 vs. 23.3%; adjusted odds ratio (AOR) = 0.70, 95% CI: 0.64-0.77], severe neurological injuries on ultrasound (SNI; 4.1 vs. 6.7%; AOR = 0.62, 95% CI: 0.53-0.73), severe retinopathy (5.6 vs. 7%; AOR = 0.71, 95% CI: 0.59-0.84) and necrotizing enterocolitis (3.5 vs. 5.4%; AOR = 0.67, 95% CI: 0.56-0.79), but no difference in mortality odds. After excluding the late outborn admissions, ANZNN outborns had lower odds of SNI (AOR = 0.43, 95% CI: 0.32-0.58) and CLD (AOR = 0.63, 95% CI: 0.49-0.81) than CNN. Conclusions: ANZNN inborn and early admitted outborn infants had lower odds of neonatal morbidities than their CNN counterparts. However, compared to ANZNN, the higher CNN rates of outborns and their late admissions are likely related to the differences in regionalization and referral practices, and may explain differences in outcomes.

Incidence of ventilator-associated pneumonia in Australasian intensive care units: use of a consensus-developed clinical surveillance checklist in a multisite prospective audit

ObjectivesWith disagreements on diagnostic criteria for ventilator-associated pneumonia (VAP) hampering efforts to monitor incidence and implement preventative strategies, the study objectives were to develop a checklist for clinical surveillance of...

Health-Related Quality of Life in Australasian Survivors of H1N1 Influenza Undergoing Mechanical Ventilation. A Multicenter Cohort Study.

Patients surviving acute respiratory distress syndrome suffer decrements in physical function and health-related quality of life (HR-QoL); however, it is unclear whether HR-QoL is disproportionately affected in those with H1N1 influenza. The objective was to compare the HR-QoL of patients with a diagnosis of H1N1 influenza who were mechanically ventilated, 12 months after intensive care unit (ICU) discharge with healthy population data and ICU survivor data. A prospective, observational, binational, multicenter cohort study was conducted in 11 ICUs in Australia and New Zealand during June-September 2009. Eligible participants were mechanically ventilated in the ICU with a confirmed diagnosis of H1N1 influenza. People were excluded if they were less than 18 years of age or could not speak English. Two validated HR-QoL questionnaires (Short Form-36 version 2 [SF-36], and Assessment of Quality of Life [AQoL]) were administered 1 year after ICU discharge. Sixty-two patients (48% male) had a median (interquartile range) age of 42 (29-53) years and an APACHE II score of 18.0 (14-20); ventilation days, 10.0 (4-23); and ICU and hospital length of stay, 12.5 (7-27) and 20.0 (15-38) days, respectively. Hospital mortality was 7%, and 31% of the cohort received a tracheostomy. The mean (SD) health utility score at 1 year was 0.68 (0.30) compared with the healthy age-matched population (0.81 [0.23]). The mean (SD) SF-36 physical and mental component summary scores were within population normal ranges at 44.4 (12.3) and 45.5 (12.5), respectively. Health-related quality of life of Australasian survivors of severe H1N1 influenza was comparable to the healthy population 1 year after ICU discharge. Consensus should be sought on standardization of follow-up time points and outcome measurement. Clinical trial registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12609001037291).

The timing of discharge from the intensive care unit and subsequent mortality. A prospective, multicenter study.

Previous studies suggested an association between after-hours intensive care unit (ICU) discharge and increased hospital mortality. Their retrospective design and lack of correction for patient factors present at the time of discharge make this association problematic. To determine factors independently associated with mortality after ICU discharge. This was a prospective, multicenter, binational observational study involving 40 ICUs in Australia and New Zealand. Participants were consecutive adult patients discharged alive from the ICU between September 2009 and February 2010. We studied 10,211 patients discharged alive from the ICU. Median age was 63 years (interquartile range, 49-74), 6,224 (61%) were male, 5,707 (56%) required mechanical ventilation, and their median Acute Physiology and Chronic Health Evaluation III risk of death was 9% (interquartile range, 3-25%). A total of 8,539 (83.6%) patients were discharged in-hours (06:00-18:00) and 1,672 (16.4%) after-hours (18:00-06:00). Of these, 408 (4.8%) and 124 (7.4%), respectively, subsequently died in hospital (P < 0.001). After risk adjustment for markers of illness severity at time of ICU discharge including limitations of medical therapy (LOMT) orders, the time of discharge was no longer a significant predictor of mortality. The presence of a LOMT order was the strongest predictor of death (odds ratio, 35.4; 95% confidence interval, 27.5-45.6). In this large, prospective, multicenter, binational observational study, we found that patient status at ICU discharge, particularly the presence of LOMT orders, was the chief predictor of hospital survival. In contrast to previous studies, the timing of discharge did not have an independent association with mortality.

A survey of physiotherapy suctioning practices of adult patients in intensive care units in Australia and New Zealand

A survey of physiotherapy suctioning practices of adult patients in intensive care units in Australia and New Zealand