Intravenous Access Research Articles

A randomized feasibility pilot-study of intravenous and subcutaneous administration of ketamine to prevent postpartum depression after planned cesarean delivery under neuraxial anesthesia

BackgroundEvidence suggests ketamine may prevent postpartum depression (PPD) after cesarean delivery (CD) although intolerability and inconvenience of administration are problematic. We assessed the feasibility of studying ketamine (0.5 mg/kg, via subcutaneous injection or 40-min intravenous infusion) to prevent PPD after CD.MethodsTwenty-three women scheduled for cesarean delivery under neuraxial anesthesia were randomized to one of three groups: subcutaneous ketamine (SC Group, n = 8), intravenous ketamine (IV Group, n = 8) or placebo (n = 7). We measured depression (Edinburgh Postpartum Depression Scale [EPDS]) scores pre-operatively and at 1, 2, 21 and 42 days postoperatively. Anxiety, adverse effects, surgical site pain and analgesic consumption were also assessed. Feasibility was assessed based on acceptability, burden of disease, ability to collect study data and, tolerability of interventions.ResultsBaseline characteristics of groups were similar, however, more women in the placebo group had pre-existing anxiety disorder (p = 0.03). 20.7% (25/121) of those approached consented to participate and 34.8% (8/23), of those assessed, screened positive for depression in the postpartum (EPDS > 12). PPD screening data was complete in 78.3% (18/23). No differences were observed for any adverse effect outcomes except for fewer incidences of intraoperative shivering with ketamine (SC: 25%, IV: 0% and Placebo: 85.7%, p = 0.01). No statistically significant difference in positive screening for PPD was observed (SC: 14.3%, IV: 50% and Placebo: 42.9%, p = 0.58).ConclusionAn RCT was judged to be feasible and there was no evidence of intolerability of either route of ketamine administration. Dispensing with the need for intravenous access makes the subcutaneous route a particularly attractive option for use in the postpartum population. Further examination of these interventions to prevent, and possibly treat, postpartum depression is warranted.Trial registrationNCT04227704, January 14th, 2020.

Modified DIVA Score: An Improved Clinical Predictive Tool for Detecting Difficult Access in Children.

This study aims to validate the DIVA (Difficult Intravenous Access) score in our population and to identify any additional patient characteristics that may be associated with difficult access in children. This was a cross-sectional study in an urban quaternary pediatric emergency department with patients younger than 21 years and Emergency Severity Index ≥2 who require intravenous (IV) access for their management. In addition to patient characteristics comprising the DIVA score, data were collected on patient "history of difficult access," hydration status, skin shade, history of sickle cell disease or diabetes, technology dependence, and body mass index. The number of IV cannulation attempts and total time taken were recorded for each patient. "Difficult access" was defined as ≥2 or more attempts or time >30 minutes to achieve successful IV cannulation. A convenience sample of 300 pediatric patients was enrolled. The DIVA score had a sensitivity of 51% (95% confidence interval [CI], 40.8%-61.14%) and a specificity of 82.99% (95% CI, 76.95%-87.99%) for predicting "difficult access" in our population. Among all patient characteristics examined in this study, only "history of difficult access" improved the identification of "difficult access" patients. The "history of difficult access" variable had a sensitivity of 61% (95% CI, 50.7%-70.6%) and a specificity of 75.7% (95% 95% CI, 69.12%-81.62%) in predicting "difficult access." With the addition of "history of difficult access" to the original DIVA score, we developed a "modified DIVA score (m-DIVA)." The m-DIVA score had a sensitivity of 78% (95% CI, 68.6%-85.6%) and specificity of 67% (95% CI, 59.9%-73.58%), representing a 52.9% improvement in correctly identifying "difficult access" patients over the original DIVA score. The m-DIVA score, which incorporates prior history, increases the screening test's sensitivity in identifying "difficult access" patients and should be further investigated as clinical tool.

External Validation of the Difficult Intravenous Access (DIVA3) Score as a Clinical Predictive Rule for Identifying Difficult Intravenous Access in Children

External Validation of the Difficult Intravenous Access (DIVA3) Score as a Clinical Predictive Rule for Identifying Difficult Intravenous Access in Children

Anesthesia considerations and management in a case of abdominal pregnancy undergoing emergency laparotomy: A case report

Abdominal pregnancy is a very rare form of ectopic pregnancy associated with high mortality and morbidity of the mother as well as the fetus. It is often observed in developing nations with poor outcomes as in most cases there is fetal demise. We report a 28-year-old parturient diagnosed with abdominal pregnancy and shifted for an emergency laparotomy. General anesthesia was provided with multiple wide bore intravenous access in anticipation of hemorrhage. Our primary concern was maternal safety and the patient did extremely well with blood loss successfully managed with tranexamic acid, crystalloids, colloids and blood products. She was extubated postoperatively, was shifted to Critical care unit for 2 days for post operative monitoring and was discharged on post operative day 10.

PEDIATRIC AND MEDICINE RESIDENTS’ PERCEPTIONS OF ULTRASOUND VASCULAR ACCESS AND RESULTS OF AN INTERSPECIALTY, SIMULATION-BASED ULTRASOUND VASCULAR ACCESS WORKSHOP

PEDIATRIC AND MEDICINE RESIDENTS’ PERCEPTIONS OF ULTRASOUND VASCULAR ACCESS AND RESULTS OF AN INTERSPECIALTY, SIMULATION-BASED ULTRASOUND VASCULAR ACCESS WORKSHOP

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

MALPOSITION OF RIGHT INTERNAL JUGULAR VEIN CATHETER IN RIGHT AXILLARY VEIN: A RARE CASE DIAGNOSED BY BEDSIDE ULTRASOUND

Comparison between oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in autism spectrum disorder: double-blind randomized clinical trial

BackgroundConventional dental care is often impossible in patients with Autism Spectrum Disorder (ASD). Non-collaborative behaviors, sometimes associated with aggressiveness, are usual justifications for premedication in this population. Thereby, this research focuses on the effects of oral midazolam versus oral ketamine plus midazolam as preanesthetic medication in ASD. MethodsThe sample included 64 persons with ASD, aged 2˗59 years, scheduled for dental care under general anesthesia. The primary objective of this study was to compare degrees of sedation between two parallel, double-blinded, equally proportional groups randomized to receive oral midazolam (0.5 mg.kg−1, maximum 15 mg) or oral midazolam (0.5 mg.kg−1) associated with oral S(+)-ketamine (3 mg.kg−1, maximum 300 mg). The secondary outcomes were the need of physical stabilization to obtain intravenous line, awakening time, and occurrence of adverse events. ResultsAccording to the dichotomous analysis of sedation level (Ramsay score 1 and 2 versus Ramsay ≥ 3), oral association of S(+)-ketamine and midazolam improved sedation, with increased probability of Ramsay ≥ 3, Relative Risk (RR) = 3.2 (95% Confidence Interval [95% CI] = 1.32 to 7.76) compared to midazolam alone. Combined treatment also made it easier to obtain venous access without physical stabilization, RR = 2.05 (95% CI = 1.14 to 3.68). There were no differences between groups regarding awakening time and the occurrence of adverse events. ConclusionThe association of oral S(+)-ketamine with midazolam provides better preanesthetic sedation rates than midazolam alone and facilitates intravenous line access in patients with autism.

Elderly Male With Out-of-Hospital Cardiac Arrest

A 92-year-old man with an out-of-hospital cardiac arrest arrived at the emergency department, and, because of challenging intravenous catheter access, we inserted a proximal humeral intraosseous catheter. We used transesophageal echocardiography and observed visible echogenic bubbles reaching the right atrium after the infusion of a saline solution bolus (Figure, Video 1 [available at http://www.annemergmed.com]).

P011 Antifungal lock therapy

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM Objective Candida spp is the fourth leading cause of catheter-related blood stream infection (CRBSI). The standard treatment is prompt removal of the device (central venous catheter, CVC, or port or hemodialysis catheter) along with administration of systemic antifungal therapy. However, in patients with a lack of alternative intravenous access and in some critically ill patients, this standard of care is challenging. Our success with antibiotic lock solution in MDR GNB CRBSI, prompted us to consider similar therapy in Candida spp CRBSI.MethodsCatheter salvage using antifungal lock therapy was tried in a total of 15 cases in two centers. In 10 cases echinocandin (9 anidulafungin, 1 micafungin) and in 5 cases amphotericin b deoxycholate (AmB-d) were used to obtain an antifungal concentration of ∼ 1000 mcg/ml in the lock solutions. All these formulations had additional NAC, heparin, and normal saline. Systemic antifungal therapy was also administered concurrently.Success was defined as clearance of candidemia at 48 h and 14 days and/or till the use of the device was needed. Some of these patients had prior/co-infections with bacterial pathogens and they were managed with appropriate systemic antibiotics with antibiotic lock therapy.ResultsIn 11/15 episodes of CRBSI due to Candida species, catheter salvage was achieved. One case could not be assessed at 14 days as a port was removed in view of megaprosthesis in situ. In two cases this therapy failed and one patient lost to follow-up.See Figures 1 and 2 for details of all cases.ConclusionsAntifungal lock therapy using echinocandins and AmB-d appears to be a promising therapy in patients where catheter removal is difficult. However, this success neither means that this can become standard practice, nor should it make clinicians and hospital staff complacent about infection control practices.

An Observational Study on the Use of Peripheral Intravenous Lines vs. Central Lines in a Neonatal Intensive Care Unit.

Background and Objectives: There is a debate regarding the preferred intravenous (IV) access for newborns. Our aim was to study practices regarding the choice of vascular access and outcomes. Methods: A seven-month prospective observational study on IV lines used in all newborns admitted to Bnai Zion Medical Center’s neonatal intensive care unit (NICU). Results: Of 120 infants followed, 94 required IV lines. Infants born at ≤32 weeks gestation, or with a head circumference ≤29 cm were more likely to require two or more IV lines or a central line for the administration of parenteral nutrition or medications for longer periods. However, central lines (umbilical or peripherally inserted central catheters (PICC)) were not associated with better nutritional status at discharge based on weight z-scores. Only one complication was noted—a central line-associated bloodstream infection in a PICC. Conclusions: Our data suggest preferring central IV access for preterm infants born at ≤32 weeks or with a head circumference ≤29 cm. We encourage other NICUs to study their own data and draw their practice guidelines for preferred IV access (central vs. peripheral) upon admission to the NICU.

Remotely supervised ultrasound-guided peripheral intravenous cannulation training: A prospective cohort study examining success rates and patient experience.

Ultrasound-guided peripheral intravenous cannulation (USGPIVC) benefits patients with difficult intravenous access (DIVA) through visualising otherwise non-visible and non-palpable veins. Supervised live-case training is an important component of learning this skill, but supervisor availability can present a barrier limiting or delaying staff completing their training. The aim of this study was to determine the first-attempt success rate of newly trained USGPIVC inserters using remote supervision and timely written feedback based on app-based screen recordings taken during insertion. Secondary aims were overall procedural success, and inserter and patient experiences. This study is an observational cohort study carried out between October and December 2021. Fourteen newly trained junior medical officers (JMOs) were eligible to utilise USGPIVC on a minimum of five consenting patients while simultaneously recording the ultrasound screen during insertion to capture their technique. Feedback was generated following expert review of these recordings against a standardised feedback tool. Average first-attempt success was 71% (n = 72) in the 102 patients recruited. The average time for JMOs to receive feedback was 30 h, and 13 JMOs (93%) felt well supported and completed the remote training pathway. The majority of patients were female (n = 59; 58%), were aged 41-80 years (n = 75; 74%) and had ≥2 risk factors for DIVA (n = 57; 56%). First-attempt success rates were similar when comparing remote supervision used in this study to direct supervision used by other studies.This finding supports incorporating remote supervision into training guidelines for USGPIVC as an alternative method of supervision, particularly when supervisor availability is limited.

Use of Albumin as a Resuscitative Fluid in the Intensive Care Unit.

Use of Albumin as a Resuscitative Fluid in the Intensive Care Unit.

Predictors of ultrasound-guided peripheral intravenous catheter failure: A secondary analysis of existing trial data.

Ultrasound-guided (US) peripheral intravenous catheters (PIVC) have a high failure rate with many failing prior to completion of therapy. Risk factors associated with catheter failure are poorly delineated. This study aimed to assess risk factors related to catheter failure including patient, procedure, catheter, and vein characteristics to further elucidate which variables may impact catheter longevity. This was a secondary analysis using an existing trial dataset that primarily compared survival of two catheters: a standard long (SL) and an ultra-long (UL) US PIVC. Adult emergency room patients with difficult intravenous access at a tertiary care suburban academic center were study participants. Kaplan-Meier was employed to estimate the median catheter survival time. Cox regression univariable and multivariable analyses were used to evaluate the primary outcome of catheter survival. Among 257 subjects, 63% of PIVCs survived until completion of therapy. In a multivariable Cox regression model, length of catheter in vein >2.75 cm (adjusted hazard ratio [aHR] 0.58, 95% confidence interval [CI] 0.37-0.90, p = 0.01) was associated with improved survival. First stick success decreased the risk of catheter failure (aHR 0.68, 95% CI 0.44-1.06, p = 0.09) but was not statistically significant. Factors associated with the increased risk of catheter failure included: depth of vein >1.2 cm (aHR 1.68, 95% CI 1.06-2.66, p = 0.03) and PIVC placement in right extremity (aHR 1.64, 95% CI 1.07-2.51, p = 0.02). This study demonstrated that catheter length in vein (>2.75 cm) was associated with improved US PIVC survival highlighting the value of longer catheters in US PIVC survival. Choosing targets in the non-dominant extremity with shallower depths (⩽1.2 cm) may also increase catheter survival.

Impact of Obesity on Perioperative Complications on Treatment of Spinal Metastases: A Multicenter Surveillance Study from the German Spine Registry (DWG-Register).

Background The spine is a common location for the development of primary and metastatic tumors, spinal metastases being the most common tumor in the spine. Spinal surgery in obesity is challenging due to difficulties with anesthesia, intravenous access, positioning, and physical access during surgery. The objective was to investigate the effect of obesity on perioperative complications by discharge in patients undergoing surgery for spinal metastases. Methods Retrospective analysis of data from the DWG-register on patients undergoing surgery for metastatic disease in the spine from January 2012 to December 2016. Preoperative variables included obesity (≥ 30 kg/m 2 ), age, gender, and smoking status. In addition, the influence of pre-existing medical comorbidity was determined, using the American Society of Anesthesiologists (ASA) score. Results In total, 528 decompressions with and without instrumentation undergoing tumor debulking, release of the neural structures, or tumor extirpation in metastatic disease of the spine were identified; 143 patients were obese (body mass index [BMI] ≥ 30 kg/m 2 ), and 385 patients had a BMI less than 30 kg/m 2 . The mean age in the group with BMI 30 kg/m 2 or higher (group 1) was 67 years (56.6%). In the group with BMI less than 30 kg/m 2 (group 2), the mean age was 64 years. Most of the patients had preoperatively an ASA score of 3 and 4 (patients with severe general disease). The likelihood of being obese in the logistic regression model seems to be protective by 47.5-fold for blood loss 500 mL or higher. Transfusions occurred in 321/528 (60.7%) patients (group 1, n = 122 and group 2, n = 299; p = 0.04). A total of 19 vertebroplasties with percutaneous stabilization (minimally invasive spine [MIS]), 6 vertebroplasties, and 31 MIS alone were identified. The variables between these groups, with exception of preoperative status (ASA-score; p = 0.02), remained nonsignificant. Conclusion Obese patients were predisposed to have blood loss more than 500 mL more often than nonobese patients undergoing surgery for spinal metastases but with perioperative blood transfusions, invasiveness, nor prolonged hospitalization. Early postoperative mobilization and a low threshold for perioperative venous thromboembolism (VTE) are important in obese patients to appropriately diagnose, treat complications, and minimize morbidity.

Prevalence of peripheral venous cannula-related colonization and infections in pediatric intensive care unit

Background: Intravenous (IV) access exposes patients to risk of catheter-related infections. The source of infection is either microbial colonization of the cannula or contamination of the hub or drugs. The study objectives were to estimate the prevalence of the peripheral venous cannula (PVC)-related infection and the factors associated with colonization and the antibiotic sensitivity pattern of the organisms causing infection. Subjects and Methods: It was a cross-sectional study which included infants and children who required an indwelling PVC. Visual infusion phlebitis (VIP) score was recorded for insertion site changes. Cannula tip and blood were sent for culture and antibiotic sensitivity. Catheter-related bloodstream infection was diagnosed based on bacterial growth in both the cannula tip and blood culture. Results: Out of the 256 children recruited in the study, 57% were males and 13% were undernourished. The most common primary illness was respiratory disease. Cannula tip growth was noted in 8.5%. The PVC colonization rate was 37.9/1000 catheter days. Multivariate analysis showed significant association between the primary illness, multiple attempts for insertion, longer duration of IV fluid use, retention of cannula beyond 96 h, and higher VIP scores >2 and cannula colonization. Conclusions: Apart from strict adherence to infection prevention techniques, disposal of cannula after one failed attempt, changing IV cannula after 96 h, inspection of cannula site to identify phlebitis early, and removal of the cannula when the VIP score is >2 may help to minimize cannula-related colonization and infection.

Simulation-Based Outreach Program Improves Rural Hospitals' Team Confidence in Neonatal Resuscitation.

Introduction: Neonatal resuscitation is a high acuity, low occurrence event (HALO), and in rural community hospitals, low birth rates prevent providers from regular opportunities to maintain essential resuscitation skills. Simulation is an effective training modality for medical education, although resources for simulation are often limited in rural hospitals. Our primary objective was to test the hypothesis that in situ neonatal resuscitation simulation training improves rural hospitals' delivery room team confidence in performing key Neonatal Resuscitation Program® (NRP®) skills. Our secondary objective was to compare confidence to performance as measured by adherence to NRP® guidelines.Methods: We conducted a quasi-experimental pre-training survey and post-training survey of delivery room team confidence in NRP® skills at five level one delivery hospitals before and after an in situ simulation training program. Participants included rural hospitals’ usual delivery room team members. Participants rated their confidence on a five-point Likert scale. Simulations were analyzed using an adapted version of a validated scoring tool for NRP® adherence and presented as overall percentage scores.Results: Our data demonstrate a significant improvement in self-assessed confidence levels pre- and post-simulation training in key areas of neonatal resuscitation. Participants reported higher confidence in airway management (4 vs. 3, p=0.003), emergency intravenous access (3 vs. 2, p=0.007), and the ability to manage a code in the delivery room (4 vs. 3, p=0.013) and the operating room (4 vs. 3, p=0.028). Improvements were also noted in their team member’s knowledge and skills to perform neonatal resuscitation. While improvements were appreciated in confidence, the performance of skills (NRP® adherence scores) was often in the sub-optimal performance range.Conclusions: An in situ-based neonatal resuscitation outreach simulation program improves self-confidence among rural delivery room teams. Additional research is needed to understand how to translate improved confidence into actual improved performance.

Harm reduction in the hospital: An overdose prevention site (OPS) at a Canadian hospital

BackgroundSubstance use management in hospitals can be challenging. In response, a Canadian hospital opened an overdose prevention site (OPS) where community members and hospital inpatients can inject pre-obtained illicit drugs under supervision. This study aims to: (1) describe program utilization patterns; (2) characterize OPS visits; and (3) evaluate overdose events and related outcomes. MethodsA retrospective chart review was completed at one hospital in Vancouver, Canada. All community members and hospital inpatients who visited the OPS between May 2018 and July 2019 were included. Client measures included: hospital inpatient status, use of intravenous access line for drug injection, and substances used. Program measures included: number of visits (daily/monthly), overdose (fatal/non-fatal) events and overdose-related outcomes. ResultsOverall, 11,673 OPS visits were recorded. Monthly visits increased from 306 to 1198 between May 2018 and July 2019 respectively. On average, 26 visits occurred daily. Among all visits, 20% reported being a hospital inpatient, and 5% reported using a hospital intravenous access line for drug injection. Opioids (56%) and stimulants (24%) were the most common substances used. Overall 39 overdose events occurred - 82% required naloxone reversal, 28% required transfer to the hospital’s emergency department and none were fatal. Overdose events were more common among hospital inpatients compared to community clients (6.6 vs 2.2 per 1000 visits respectively; p value = 0.046). ConclusionsThis unique OPS is an example of a hospital-based harm reduction initiative. Use of the site increased over time among both groups with no fatal overdose events occurring.

479 Closed Loop Quality Improvement Project Improving Time to Peripherally Inserted Central Catheters (PICCs) and Intravenous (IV) Antibiotic Administration in Patients with Complex Orthopaedic Infections

Abstract Aim Bone, joint and soft tissue infections often require long term antibiotic therapy. Reliable IV access is essential for IV antibiotic administration and monitoring. PICCs provide consistent, long-term IV access. Aim: improve time to PICC request, insertion, and reduce issues with poor IV access in patients requiring long term IV antibiotics. Method Standard audit protocol. Data tool was developed and tested. Data was collected retrospectively from departmental database and online records for all patients admitted with suspected bone, joint or soft tissues infection from 01/11/19–29/2/20. Department policy and induction programme were updated. Cycle 2 included all patients from 1/8/20–30/11/21. Results Cycle 1 included 91 patients. 30 PICCs were requested with 26 inserted. Mean time to PICC request from diagnosis was 8.7 days(1–33). Mean time to PICC from request was 6.7 days(1–15). Mean time to PICC from diagnosis was 15.9 days(4–39). 10 of 30(33.3%) patients missed antibiotics due to lack of IV access. Cycle 2 included 156 patients. 36 PICCs were requested with 18 inserted. Mean time from diagnosis to request was 4.4 days(1–15). Mean time from request to insertion was 4.2(1–8) days. Mean time from diagnosis to insertion was 8.6 days(1–21). Missed IV antibiotics were reduced from 33.3% to 15.4%. Conclusions Time to PICC insertion was improved through education and introduction of new policy at departmental induction. This low-cost change can significantly improve both treatment and patient experience when admitted for complex orthopaedic infection through reliable antibiotic administration and reducing the number of IV access attempts.

Efficacy and safety of perrectal 400 microgram misoprostol versus intravenous 200 microgram methylergometrine in the management of third stage of labor for prevention of postpartum haemorrhage

Background: Objective: Postpartum haemorrhage (PPH) is a major cause of mortality and morbidity during childbirth, especially in developing countries. Misoprostol is a cheap, safe, widely available, and stable at room temperature, does not required any intravenous accesses and having few mild side effects. In resource-poor countries with limited facilities, misoprostol may be one of the important interventions to prevent PPH. We aimed to assess the effectiveness of perrectal low dose misoprostol for the prevention of PPH. Method: We designed a prospective randomized control trial, single centre study. 138 indoor low risk pregnant women with gestational age at least 37 weeks who anticipated vaginal delivery were randomly assigned to perrectal 400 microgram misoprostol (n = 71) or intravenous 200 microgram (n = 67) methylergometrine after delivery of baby and placenta. The primary outcome was incidence of PPH (estimated blood loss >500 ml after delivery of baby and placenta). Results: In this study out of 138 low risk pregnancy, no women developed PPH, no patient required additional dose of oxytocin, no patient required any form of transfusion.

Characteristics of patients positive for methamphetamine in the emergency department, and the influence of the co-administration of GHB

The Emergency Department Admission Blood Psychoactive Testing (EDABPT) study surveyed blood taken from intoxicated ED patients at four metropolitan hospitals (Adelaide, South Australia). This report aims to describe the clinical, demographic and toxicological findings relating to MA and other drug detections in the blood of these patients. The study enrolled ED patients with symptoms of drug intoxication and for whom intravenous access was clinically required and 2 × 5 ml NaF/oxalate-preserved blood samples were collected (ethics approval CALHN HREC/17/RAH/439 R20171015). Limited demographic, symptomatic and clinical outcome data was recorded. The samples were analysed for alcohol (GC-FID), common pharmaceuticals, drugs of abuse and NPS (approx 600 compounds, supported liquid extraction followed by liquid chromatography-quadrupole time-of-flight mass spectrometry (LC-QTOF)), and gamma-hydroxybutyrate (GHB, acid cyclisation, liquid-liquid extraction) Quantification of 50 common drugs was conducted simultaneously. 1120 patients were enrolled in the program. Patient ages were 18-79yo with a median of 31yrs. 64% of patients were male. The most common symptoms observed across the cohort were central nervous system (CNS) depression (64%), CNS elevation (39%) and hypoventilation (20%). Overall, the main clinical outcomes recorded were: admitted to short stay ward 47%; discharged from ED 25%; and admitted to high dependency unit/intensive care unit 17%. The most common drugs detected were: MA 55%; alcohol 30%; GHB 28% and diazepam 19%. The average number of drugs detected MA positive samples was slightly higher than MA negative samples (3.2 cf. 2.6, excluding drug metabolites). Alcohol was less prevalent in MA positive patients (9%) compared to MA negative patients (54%). MA concentration median was 0.19 mg/L and the interquartile range was between 0.08 (Q1) and 0.38 mg/L (Q3). Analysis of the data by MA concentration quartile did not show significantly different observed symptom profiles. GHB was detected in 28% of patients overall. GHB was more prevalent in MA positive patients (42%) compared with MA negative patients (19%). 89% of GHB positive patients experienced CNS depression. 87% of GHB positive cases also contained MA. GHB prevalence increased from 26% in the first quartile of MA concentrations (up to 0.08 mg/L), to 44% in the interquartile range (0.081–0.38 mg/L), and to 54% in the highest quartile (0.39–3.2 mg/L). Compared to MA positive patients, patients with both MA and GHB had a higher prevalence of CNS depression (88% cf. 50%), hypoventilation (34% cf. 15%) and apnoea (18% cf. 7%). In the absence of GHB, MA positive patients had a greater prevalence of CNS elevation/agitation (47% cf. 27%), cardiovascular system (CVS) elevation (21% cf. 6%) and psychosis (26% cf. 3%). Although it was the most common drug detected in this cohort, it is apparent that the presence of MA does not necessarily result in expected stimulant-like symptoms, even in the high MA concentration quartile. This is likely due to the influence of poly-drug use in the cohort-particularly GHB, but also other depressant drugs unable to be discussed here. In general terms, GHB dominates the symptomatic profile regardless of MA concentration. Given the high incidence of GHB in the MA cohort and vice versa, a pattern of combined use is evident which is supported by interstate and local drugs in driver reports. It is not possible to say whether the patients in this study have miscalculated the deliberate combination of GHB and MA in the pursuit of a desired effect, or if one drug is administered in an attempt to reverse the undesirable effects of the other.