Activin A level is associated with physical function in critically ill patients.

BACKGROUND: Activin A is a potent negative regulator of muscle mass elevated in critical illness. It is unclear whether muscle strength and physical function in critically ill humans are associated with elevated activin A levels. OBJECTIVES: The objective of this study was to investigate the relationship between serum activin A levels, muscle strength, and physical function at discharge from the intensive care unit (ICU) and hospital. METHODS: Thirty-six participants were recruited from two tertiary ICUs in Melbourne, Australia. Participants were included if they were mechanically ventilated for >48 h and expected to have a total ICU stay of >5 days. The primary outcome measure was the Six-Minute Walk Test distance at hospital discharge. Secondary outcome measures included handgrip strength, Medical Research Council Sum Score, Physical Function ICU Test Scored, Six-Minute Walk Test, and Timed Up and Go Test assessed throughout the hospital admission. Total serum activin A levels were measured daily in the ICU. RESULTS: High peak activin A was associated with worse Six-Minute Walk Test distance at hospital discharge (linear regression coefficient, 95% confidence interval, p-value: -91.3, -154.2 to -28.4, p = 0.007, respectively). Peak activin A concentration was not associated with the secondary outcome measures. CONCLUSIONS: Higher peak activin A may be associated with the functional decline of critically ill patients. Further research is indicated to examine its potential as a therapeutic target and a prospective predictor for muscle wasting in critical illness. STUDY REGISTRATION: ACTRN12615000047594.

Severe acute maternal morbidity trends in Victoria, 2001-2017.

BACKGROUND: The incidence of severe acute maternal morbidity (SAMM) is one method of measuring the complexity of maternal health and monitoring maternal outcomes. Monitoring trends may provide a quantitative method for assessing health care at local, regional, or jurisdictional levels and identify issues for further investigation. AIMS: Identify temporal trends for SAMM event rates and maternal outcomes over 17 years in the state of Victoria, Australia. MATERIALS AND METHODS: All maternal public health service admissions were extracted from an administrative dataset from July 2000 to June 2017. SAMM-related diagnoses were defined by matching as closely as possible with published definitions. Outcomes included annual SAMM event rates, hospital survival, and hospital length of stay (LOS). Temporal trends were analysed using mixed-effects generalised linear models. RESULTS: There were 854 777 live births and 1.21 million pregnancy-related hospital admissions which included 34 008 SAMM events in 29 273 records and in 3.42% (95%CI = 3.39-3.46) of births. Most common were severe pre-eclampsia (0.87% of births), severe postpartum haemorrhage (0.59%), and sepsis (0.62%). SAMM-related admissions were associated with longer LOS and higher mortality risk (P < 0.001). Maternal mortality ratio remained unchanged at 8.6 fatalities per 100 000 births (P = 0.65). CONCLUSION: Over 17 years, there was a significant increase in birth rate and SAMM-related events in Victoria. Administrative data may provide a pragmatic approach for monitoring SAMM-related events in maternal health services.

Predictors of acute hospital mortality and length of stay in patients with new-onset atrial fibrillation: a first-hand experience from a medical emergency team response provider.

BACKGROUND: Atrial fibrillation (AF) occurs frequently following cardiothoracic surgery and treatment decisions are informed by evidence-based clinical guidelines. Outside this setting there are few data to guide clinical management. AIM: To describe the characteristics, management and outcomes of hospitalised adult patients with new-onset AF. METHODS: The medical emergency team (MET) database was utilised to identify patients who had a 'MET call' activated for tachycardia between 2015 and 2016. Patients with sinus tachycardia, pre-existing AF/atrial flutter or other known tachyarrhythmia were excluded. Primary outcomes were length of hospital stay and in-hospital mortality. RESULTS: New-onset AF was identified in 137 patients: 68 medically managed; 38 non-cardiothoracic post-operative; and 31 cardiothoracic post-operative. Mean age was 74 ± 11.6 years and 72 (53%) were male. Of 79 patients who underwent echocardiography, 80% had left atrial dilatation and 14% had reduced left ventricular ejection fraction (LVEF). Mean length of stay (LOS) was 12 days and in-hospital mortality rate was 11%. On multivariable analysis, the odds of death during acute hospitalisation was 7.4 times higher in patients with heart failure with reduced LVEF (odds ratio 7.4, 95% confidence interval (CI) 1.23-44.8, P = 0.028). Length of acute hospital stay increased by 36% if the duration of AF was longer than 48 h (beta coefficient 0.36, 95% CI -0.015 to 0.74, P = 0.059). CONCLUSION: Left ventricular systolic dysfunction in hospitalised patients with new-onset AF is associated with increased all-cause mortality whereas lower serum potassium levels are associated with an increased LOS. A prospective study is planned to compare outcomes based on in-hospital treatment strategies.

Risk factors for mortality in patients admitted to intensive care units with pneumonia.

BACKGROUND: Despite the high mortality in patients with pneumonia admitted to an ICU, data on risk factors for death remain limited. METHODS: In this secondary analysis of PROTECT (Prophylaxis for Thromboembolism in Critical Care Trial), we focused on the patients admitted to ICU with a primary diagnosis of pneumonia. The primary outcome for this study was 90-day hospital mortality and the secondary outcome was 90-day ICU mortality. Cox regression model was conducted to examine the relationship between baseline and time-dependent variables and hospital and ICU mortality. RESULTS: Six hundred sixty seven patients admitted with pneumonia (43.8 % females) were included in our analysis, with a mean age of 60.7 years and mean APACHE II score of 21.3. During follow-up, 111 patients (16.6 %) died in ICU and in total, 149 (22.3 %) died in hospital. Multivariable analysis demonstrated significant independent risk factors for hospital mortality including male sex (hazard ratio (HR) = 1.5, 95 % confidence interval (CI): 1.1 - 2.2, p-value = 0.021), higher APACHE II score (HR = 1.2, 95 % CI: 1.1 - 1.4, p-value < 0.001 for per-5 point increase), chronic heart failure (HR = 2.9, 95 % CI: 1.6 - 5.4, p-value = 0.001), and dialysis (time-dependent effect: HR = 2.7, 95 % CI: 1.3 - 5.7, p-value = 0.008). Higher APACHE II score (HR = 1.2, 95 % CI: 1.1 - 1.4, p-value = 0.002 for per-5 point increase) and chronic heart failure (HR = 2.6, 95 % CI: 1.3 - 5.0, p-value = 0.004) were significantly related to risk of death in the ICU. CONCLUSION: In this study using data from a multicenter thromboprophylaxis trial, we found that male sex, higher APACHE II score on admission, chronic heart failure, and dialysis were independently associated with risk of hospital mortality in patients admitted to ICU with pneumonia. While high illness severity score, presence of a serious comorbidity (heart failure) and need for an advanced life support (dialysis) are not unexpected risk factors of mortality, male sex might necessitate further exploration. More studies are warranted to clarify the effect of these risk factors on survival in critically ill patients admitted to ICU with pneumonia. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT00182143 .

Inappropriate continuation of stress ulcer prophylaxis beyond the intensive care setting.

OBJECTIVE: To determine how frequently stress ulcer prophylaxis (SUP) medications prescribed in the intensive care unit are inappropriately continued on the ward and on hospital discharge. DESIGN: Retrospective cohort study; chart review. SETTING: Two Australian ICUs: one tertiary centre and one metropolitan centre. PARTICIPANTS: We included 387 adult, non-pregnant patients who were admitted to the ICU between 1 February 2011 and 31 March 2011 and who survived to hospital discharge. MAIN OUTCOME MEASURES: Rate of unnecessary continuation of ICU-prescribed SUP medications on the ward and on discharge from hospital. RESULTS: While in the ICU, 329 of the 387 patients (85%) were prescribed SUP medications. Of the 233 patients who had not been taking acid-suppressive medications before admission to the ICU, 190 were prescribed SUP medications in the ICU. Of these 190 patients, most (63%) had their SUP continued in the ward without any obvious indication, and many (39%) had their SUP medications inappropriately continued on discharge from hospital. CONCLUSIONS: SUP medications commenced in ICU are frequently continued unnecessarily, both in the wards and hospital discharge.

Treatment goals: health care improvement through setting and measuring patient-centred outcomes.

OBJECTIVE: To determine how frequently stress ulcer prophylaxis (SUP) medications prescribed in the intensive care unit are inappropriately continued on the ward and on hospital discharge. DESIGN: Retrospective cohort study; chart review. SETTING: Two Australian ICUs: one tertiary centre and one metropolitan centre. PARTICIPANTS: We included 387 adult, non-pregnant patients who were admitted to the ICU between 1 February 2011 and 31 March 2011 and who survived to hospital discharge. MAIN OUTCOME MEASURES: Rate of unnecessary continuation of ICU-prescribed SUP medications on the ward and on discharge from hospital. RESULTS: While in the ICU, 329 of the 387 patients (85%) were prescribed SUP medications. Of the 233 patients who had not been taking acid-suppressive medications before admission to the ICU, 190 were prescribed SUP medications in the ICU. Of these 190 patients, most (63%) had their SUP continued in the ward without any obvious indication, and many (39%) had their SUP medications inappropriately continued on discharge from hospital. CONCLUSIONS: SUP medications commenced in ICU are frequently continued unnecessarily, both in the wards and on hospital discharge.

Heparin-induced thrombocytopenia in medical surgical critical illness.

BACKGROUND: In a recent multicenter randomized trial comparing unfractionated heparin (UFH) with low-molecular-weight heparin (dalteparin) for thromboprophylaxis in 3,746 critically ill patients, 17 patients (0.5%) developed heparin-induced thrombocytopenia (HIT) based on serotonin-release assay-positive (SRA+) status. A trend to a lower frequency of HIT with dalteparin vs UFH was observed in the intention-to-treat analysis (five vs 12 patients, P = .14), which was statistically significant (three vs 12 patients, P = .046) in a prespecified per-protocol analysis that excluded patients with DVT at study entry. We sought to characterize HIT outcomes and to determine how dalteparin thromboprophylaxis may reduce HIT frequency in patients in the ICU. METHODS: In 17 patients with HIT, we analyzed platelet counts and thrombotic events in relation to the study drug and other open-label heparin, to determine whether the study drug plausibly explained seroconversion to SRA+ status and/or breakthrough of thrombocytopenia/thrombosis. We also compared antibody frequencies (dalteparin vs UFH) in 409 patients serologically investigated for HIT. RESULTS: HIT-associated thrombosis occurred in 10 of 17 patients (58.8%) (8:1:1 venous:arterial:both). Dalteparin was associated with fewer study drug-attributable HIT-related events (P = .020), including less seroconversion (P = .058) and less breakthrough of thrombocytopenia/thrombosis (P = .032). Antiplatelet factor 4/heparin IgG antibodies by enzyme-linked immunosorbent assay were less frequent among patients receiving dalteparin vs UFH (13.5% vs 27.3%, P < .001). One patient with HIT-associated DVT died after UFH bolus (anaphylactoid reaction), whereas platelet counts recovered in two others with HIT-associated VTE despite continuation of therapeutic-dose UFH. CONCLUSIONS: The lower risk of HIT in patients in the ICU receiving dalteparin appears related to both decreased antibody formation and decreased clinical breakthrough of HIT among patients forming antibodies.

Obstetric admissions to an integrated general intensive care unit in a quaternary maternity facility.

BACKGROUND: Monash Medical Centre (MMC) is a university-affiliated tertiary referral hospital in Melbourne, Victoria, Australia. The hospital has a large obstetric service and is the only quarternary obstetric unit in Victoria. The intensive care unit (ICU) is a busy 21-bed general unit with a broad casemix. While there is no designated state service obstetric ICU in Victoria, MMC ICU has increasingly tried to accept all obstetric patients referred, from both MMC and externally. AIM: To provide a local perspective on obstetric intensive care in Australia. METHODS: A retrospective audit of obstetric ICU admissions over 2 years. RESULTS: Sixty women were admitted, of whom 46 were postpartum. Twenty-nine women were transferred from external sites. Mean maternal age was 30.7 years, mean gestational age 34.5 weeks and mean Acute Physiology and Chronic Health Evaluation (APACHE) version IIIj score 33. Obstetric haemorrhage was the most common admission diagnosis, followed by hypertensive spectrum disorders. Three women were admitted for induction of labour. Median length of stay was 35 h. Twenty-seven women (45%) required mechanical ventilation. No woman died in the ICU, although one died in hospital post-ICU discharge. No data were collected on neonatal outcomes. CONCLUSIONS: Critically ill obstetric patients can be managed successfully in a general ICU with obstetric input. It may be sensible to cluster these patients into units that are best equipped to deal with them, especially in the ante- and peripartum period.

Long-stay patients in Australian and New Zealand intensive care units: demographics and outcomes.

AIM AND METHODS: There is no consensus definition on what constitutes a long stay in the intensive care unit, and little published information on the demographic characteristics, resource usage or outcomes of long-stay patients. We used data from the Australian and New Zealand Intensive Care Society Adult Patient Database to identify patients who had spent > 21 days in the ICU. We examined their resource usage, hospital type, diagnoses and outcomes, and trends in these characteristics over 5 years (2000-2004). RESULTS: 6,565 patients (2.3% of all ICU patients) had one or more admissions > 21 days and accounted for 23% of total ICU bed-hour usage. Long-stay patients had a mean (SD) age of 60.3 (15.3) years and an APACHE III-J risk of death of 32.7% (21.3%). Metropolitan and tertiary hospitals had the highest proportions of long-stay patients. The three diagnoses most strongly associated with long ICU stay were neuromuscular disease (odds ratio [OR], 13.3; 95% CI, 10.2-17.4; P < 0.001), burns (OR, 6.0; 95% CI, 4.9-7.3; P < 0.001) and cervical spine injury (OR, 5.1; 95% CI, 3.4-7.5; P < 0.001), while the most common diagnosis was pneumonia (12.7% of total). During the period 2000- 2004, there was no significant change in the proportion, age, resource usage or outcomes of these patients. Overall observed mortality was 28% (predicted, 32.7%; 95% CI, 31.4%-34.5%). Of those aged >or= 80 years, 37% were discharged home, and 39% died. CONCLUSIONS: Patients who spend > 21 days in the ICU use significant resources but appear to have worthwhile outcomes in all age brackets.