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Patient-centered outcomes beyond mortality such as institution-free days (IFD) are becoming increasingly relevant in critical care trials. We calculated IFD using three definitions which differed in the way death and censoring of after-hospital deaths were handled analysing data from adult patient databases admitted to four ICUs of North Brisbane, Australia. Differences in distribution of IFD using different definitions were explored with descriptive statistics and histograms. Six pre-specified variables (age, illness severity, comorbidities index, elective status, surgical/medical admission and treatment limitations) were assessed and reported as determinants of IFDs for the proposed definitions. Data from 25,371 ICU admissions was analysed. The density distribution of IFD was bimodal with a peak at 0 days and a variable right-sided peak depending on the definition used. The mean IFD varied from 253 (standard deviation(SD) 151.3) to 295 (SD 116.2) depending on definition used. Multivariable zero-inflated negative binomial regression modelling showed that the six pre-specified variables had significant associations with IFD and their magnitude of effect varied with the definition used. IFD is a simple, easily measurable patient-centered outcome that varies depending on the definition used. Patient input should be sought to define the optimum definition and clinical use of IFD. •“Institution-free days” is a composite outcome incorporating hospitalisation, readmission, outpatient visits and mortality.•It may be more patient-centred than outcomes commonly used in critical care, as it includes time spent away from home.•It is dependent on definitions used to calculate it, and patient/family input is needed to delineate the best definition.

Clinical trials focusing on critically ill patients with metabolic acidosis, a common exclusion criterion is the presence of a PaCO2 > 45 mmHg. The aim of this study was to assess the impact of mild hypercapnia on patient characteristics, severity, and clinical outcomes in critically ill patients with metabolic acidosis. Multicentre, retrospective, observational study conducted in 12 intensive care units (ICUs) in Queensland, Australia. Patients with metabolic acidosis and concurrent vasopressor requirement were included and the exposure of interest was the PaCO2 level at the time of meeting the eligibility criteria divided in two groups: PaCO2 ≤ 45 mmHg and PaCO2 46–50 mmHg. Primary clinical outcome was major adverse kidney events within 30 days (MAKE30). We studied 5601 patients, with 3605 (64.4 %) in the PaCO2 ≤ 45 mmHg group and 1996 (35.6 %) in the PaCO2 46–50 mmHg group. The incidence of MAKE30 was lower in the PaCO2 46–50 mmHg group (29 % vs. 34 %; OR, 0.79 [95 %CI, 0.69 to 0.90]; p < 0.001) as was the use of renal replacement therapy, and the incidence of acute kidney injury. After adjustment for confounders, no outcome was different between the groups. The maximum fall of pH associated with an increase of 1 mmHg of PaCO2 in the PaCO2 46–50 mmHg group was 0.006. In patients with metabolic acidosis, after adjustment for potential confounders, mild hypercapnia does not increase the MAKE-30 rate and does not have a major impact on pH. •Patients with mild hypercapnia and metabolic acidosis have different characteristics.•Patients with mild hypercapnia and metabolic acidosis have different outcomes.•The decrease in pH with mild hypercapnia is small and appeared of limited clinical relevance.

In critically ill patients with acute kidney injury (AKI), a fluid balance (FB) > 2 L at 72 h after AKI diagnosis is associated with adverse outcomes. Identification of patients at high-risk for such fluid accumulation may help prevent it. We used Australian electronic medical record (EMR)-based clinical data to develop the “AKI-FB risk score”, validated it in a British cohort and used it to predict a positive FB >2 L at 72 h after AKI diagnosis. We developed the AKI-FB score in 32,030 patients with a median age of 63 years and a median APACHE 2 score of 16. We validated it in 4465 patients, with significant differences in admission diagnoses and interventions. The key score variables were admission after trauma, sepsis or septic shock, and, on the day of AKI diagnosis, highest creatinine, daily cumulative FB, mechanical ventilation, noradrenaline use, noradrenaline equivalent dose >0.07 μg/kg/min, lactate ≥2 mmol/L, transfusion, and nutritional support. A score threshold of 32 had a sensitivity of 75 % and a specificity of 72 % for predicting a > 2 L positive FB with an AUC-ROC of 0.805; 95 % CI 0.799 to 0.810. External validation demonstrated an AUC of 0.761 (95 % CI 0.746 to 0.775). We developed and validated the “AKI-FB risk score” to predict patients who developed a positive FB >2 L within 72 h of AKI diagnosis. This prediction score was robust and facilitated the identification of high-risk AKI patients who could be the tarted for preventive measures and be included in future clinical trials of FB management. •Developed AKI-FB risk score for the prediction of a strongly positive fluid balance 72 hours after diagnosis of AKI.•The AKI-FB risk score had excellent predictive ability and was validated in a large cohort from another country.•A score of 32 or higher had high sensitivity and specificity for a positive fluid balance greater than 2L at 72 hours.

Objective: This study aimed to determine the associations between lactate clearance in hyperlactataemic patients with diabetic ketoacidosis (DKA) and intensive care unit (ICU), hospital length of stay (LOS), and case-fatality. Methods: A retrospective, multicentre, cohort study of adult patients admitted to ICU with hyperlactataemia and a primary diagnosis of DKA from twelve sites in Queensland, Australia was conducted utilising pre-existing datasets that were linked for research purposes. The patients were divided into early and late lactate clearance groups; the early lactate clearance group included patients whose lactate returned to <2.0 mmol/L within 12 h, and the remainder were classified as late lactate clearance group. Results: The final dataset included 511 patients, 427 in the early lactate clearance group and 84 in the late lactate clearance group. Late lactate clearance was associated with increasing ICU LOS (β = +15.82, 95% CI +0.05 to +31.59, p < 0.049), increasing hospital LOS (β = +7.24, 95% CI +0.11 to 14.37, p = 0.048) and increasing Acute Physiology and Chronic Health Evaluation(APACHE) III score (ICU LOS outcome variable β = +1.05, 95% CI +0.88 to +1.22, p < 0.001; hospital LOS outcome variable β = +3.40, 95% CI +2.22 to 4.57, p < 0.001). Hospital case-fatality was not significantly different (2.2% in the early clearance group vs. 1.7% in the late clearance group, p = 0.496). Conclusions: In hyperlactataemic patients with DKA, late lactate clearance was associated with a statistically significant increase in both ICU and hospital LOS, though the clinical significance in both is minor.

Background In septic shock, the optimal timing of adjunctive vasopressin initiation shock is unknown. We aimed to assess the effect of its early initiation for patients with septic shock. Methods We conducted a multicenter target trial emulation to estimate the intensive care unit (ICU) mortality effect of early (≤ 6 h) adjunctive vasopressin compared with usual care. Eligible patients had septic shock diagnosed within 6 h of ICU admission. The primary outcome of this study was 30-day ICU mortality. Subgroup analyses were conducted to test the interaction of early vasopressin start with peak norepinephrine-equivalent dose (NED) at 6 h, APACHE score, peak lactate at 6 h and invasive mechanical ventilation. Secondary outcomes were the impact of delayed vasopressin introduction on 30-day ICU mortality and effect of NED at vasopressin start on 30-day ICU mortality. We used the parametric g-formula to emulate a target trial. Results Overall, 3,105 patients fulfilled the inclusion criteria. Mean age was 62 years and mean APACHE III score was 83. In the first six hours of vasopressor therapy, 1,864 (60%) patients were invasively ventilated. Estimated 30-day ICU mortality was 19.34% (95%CI, 17.0 to 21.68) in the no vasopressin group and 18.45% (95%CI, 16.26 to 20.63) in the early vasopressin group; relative risk 0.95 (95%CI, 0.93 to 0.98). The estimated 30-day ICU mortality effect of starting vasopressin was particularly strong at lower norepinephrine doses (< 0.25 µg.kg −1 .min −1 ) and significant at lower norepinephrine doses than recommended by the Surviving Sepsis Campaign Guidelines. Vasopressin administration progressively increased over the study period, from 35.2% (95%CI, 30.0 to 40.5) in 2015 to 45.1% (95%CI, 40.7 to 49.6) in 2021 (ß =  + 1.3% per year; 95%CI, + 0.46 to + 2.16, p  = 0.011). Patients had progressively lower norepinephrine equivalent dose (ß = − 0.05 µg.kg −1 .min −1 per year; 95%CI, − 0.09 to − 0.002, p  = 0.038) and lower total SOFA score (ß = − 0.1 point per year; 95%CI, − 0.18 to − 0.07, p  < 0.001) at vasopressin start. Conclusions In this emulation of a hypothetical target trial, patients with septic shock benefited from early vasopressin administration. These findings can help design prospective randomised-control trials of early adjunctive vasopressin use in septic shock.

Background Although comorbid medical diseases are important determinants of outcome among the critically ill, the role of psychiatric comorbidity is not well defined. The objective of this study was to determine the occurrence of psychiatric comorbidity and its effect on the outcome of patients admitted to adult intensive care units (ICU) in Queensland. Methods Admissions among adults to 12 ICUs in Queensland during 2015–2021 were included and clinical and outcome information was obtained through linkages between the ANZICS Adult Patient Database, the state-wide Queensland Hospital Admitted Patient Data Collection, and death registry. Results A total of 89,123 admissions were included among 74,513 individuals. Overall, 7,178 (8.1%) admissions had psychiatric co-morbidity with 6,270 (7.0%) having one major psychiatric diagnosis and 908 (1%) having two or more. Individual diagnoses of mood, psychotic, anxiety, or affective disorders were present in 1,801 (2.0%), 874 (1.0%), 3,241 (3.6%) and 354 (0.4%) admissions respectively. Significant differences were observed among the main groups (mood, affective, anxiety, psychotic, or multiple disorders) and those without psychiatric comorbidity with respect to main diagnosis, Acute Physiology and Chronic Health Evaluation (APACHE II) score, sex, age, and medical comorbidity. Crude 30-day case-fatality rates were significantly lower (5.1%) compared to the general ICU population (10.1%) ( p  < 0.001). After controlling for confounding variables in the logistic regression model, patients with psychiatric comorbidity were at lower odds of death. Conclusions Psychiatric comorbidity is common among ICU presentations and is associated with a lower risk of death. This association is likely to be more complex than being a simple protective factor, and future research needs to further delineate how psychiatric comorbidity informs outcomes of specific ICU presentations.

Prolonged ventilation leads to a higher incidence of ventilator associated pneumonia(VAP) resulting in ventilator dependency, increased costs and subsequent weaning failures. Prevention and aggressive treatment of VAP along with patient friendly newer modes of ventilation like adaptive support ventilation go a long way in successful management of these cases.