Nutrition practices in Australia and New Zealand in response to evolving evidence: Results of three point-prevalence audits.

BACKGROUND: The Augmented versus Routine Approach to Giving Energy Trial (TARGET) was a 4000-patient trial in which augmented enteral calorie dose did not influence outcomes. AIM: We aimed to quantify practice change following TARGET. METHODS: Three single-day, prospective, multicentre, point-prevalence audits of adult patients receiving enteral nutrition (EN) in participating Australian and New Zealand intensive care units at 10:00 AM were conducted: (i) 2010 (before conducting TARGET); (ii) 2018 (immediately before publishing TARGET results); and (iii) 2020 (2 years after TARGET publication). Data included baseline characteristics, clinical outcomes, and nutrition data. Data are n (%), mean ± standard deviation, or median [interquartile range]. Differences in enteral calorie prescription between 2018 and 2020 were compared using the Mann-Whitney test. RESULTS: The percentage of patients receiving EN (2010 42%, 2018 38%, 2020 33%; P = 0.012) and the prescription of calorie-dense EN formula (≥1.5 kcal/ml) (2010 33%, 2018 24%, 2020 23%; P = 0.038) decreased over time. However, when comparing prepublication and postpublication (2018-2020), calorie dose and calorie density were similar: 22.9 ± 8.6 versus 23.4 ± 12.8 kcal/kg/day (P = 0.816) and <1.5 kcal/ml: 76 versus 77% (P = 0.650), respectively. CONCLUSION: In Australian and New Zealand intensive care units, enteral calorie dose and calorie density of prescribed EN were similar before TARGET publication and 2 years later.

Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013.

INTRODUCTION: Recent evidence indicates that the choice of intravenous fluids may affect outcomes in critically ill patients. METHODS: We recorded the administration of resuscitation fluids in patients admitted to Australian and New Zealand adult intensive care units (ICUs) for a 24-h period at 6 time points between 2007 and 2013. Changes in patterns of fluid use over this period were determined using regression analyses. RESULTS: Of the 2825 patients admitted to the 61 ICUs on the 6 study days, 754 (26.7%) patients received fluid resuscitation. Of those receiving fluid resuscitation, the proportion of patients receiving crystalloid significantly increased from 28.9% (41/142) in 2007 to 50.5% (48/95) in 2013 (adjusted odds ratio (OR) 2.93; 95% confidence intervals (CI) 1.35-6.33; p = 0.006); of these, the proportion of patients receiving buffered salt solutions significantly increased from 4.9% (7/142) in 2007 to 31.6% (30/95) in 2013 (OR 7.00; 95% CI 2.14-22.92; p = 0.001). The use of colloids significantly decreased from 59.9% (85/142) in 2007 to 42.1% (40/95) in 2013 (adjusted OR 0.34; 95% CI 0.16-0.74; p = 0.007) due to a significant decrease in the proportion of patients receiving gelatin; 28.9% (41/142) to 2.1% (2/95) (OR 0.10; 95% CI 0.03-0.29; p ≤ 0.001). CONCLUSION: Fluid resuscitation practice in Australia and New Zealand adult ICUs has changed over the 6-year study period. Crystalloid use increased primarily due to an increase in the use of buffered salt solutions while overall the use of colloid has decreased.

A review of current statistical methodologies for in-storage sampling and surveillance in the grains industry.

Effective, statistically robust sampling and surveillance strategies form an integral component of large agricultural industries such as the grains industry. Intensive in-storage sampling is essential for pest detection, integrated pest management (IPM), to determine grain quality and to satisfy importing nation's biosecurity concerns, while surveillance over broad geographic regions ensures that biosecurity risks can be excluded, monitored, eradicated or contained within an area. In the grains industry, a number of qualitative and quantitative methodologies for surveillance and in-storage sampling have been considered. Primarily, research has focussed on developing statistical methodologies for in-storage sampling strategies concentrating on detection of pest insects within a grain bulk; however, the need for effective and statistically defensible surveillance strategies has also been recognised. Interestingly, although surveillance and in-storage sampling have typically been considered independently, many techniques and concepts are common between the two fields of research. This review aims to consider the development of statistically based in-storage sampling and surveillance strategies and to identify methods that may be useful for both surveillance and in-storage sampling. We discuss the utility of new quantitative and qualitative approaches, such as Bayesian statistics, fault trees and more traditional probabilistic methods and show how these methods may be used in both surveillance and in-storage sampling systems.

The utility of procalcitonin in diagnosis of H1N1 influenza in intensive care patients.

Procalcitonin (PCT) has been reported to differentiate between bacterial and viral causes of respiratory tract infections. We aimed to assess its ability to discriminate between viral and bacterial infection during the H1N1 pandemic of 2009. The design of this study was a retrospective single centre case series review. Subjects were 17 adult patients admitted to the intensive care unit with suspected or confirmed isolated H1N1 influenza infection, from whom a PCT level was assessed within 24 hours of admission. All patients were admitted during the H1N1 pandemic in Queensland from 6 July 2009 to 2 August 2009. The relationship between PCT levels and H1N1 status was measured by a Wilcoxon rank sum test. Patients were proven to have isolated H1N1 infection as judged by Polymerase Chain Reaction, with no bacterial super-infection. Of this number, 37% had a PCT <1 microg/l, and 63% of patients had an indeterminate PCT between 1 and 10 microg/l. The demographics of all 17 patients were mean age 48.2 years (SD 13.6 years); 59% female; mean Acute Physiological and Chronic Health Evaluation II score 20.3 (SD 5.8); mean intensive care unit 477.5 hours (SD 330.0 hours); 82% of cases required mechanical ventilation; 24% of cases required extracorporeal membrane oxygenation and 94% of cases were alive at intensive care unit discharge. PCT was neither sensitive nor specific in determining isolated H1N1 infection in this series of patients. The use of PCT to assist in isolation triage of patients suspected of infection with H1N1 influenza in the intensive care unit should be made with caution. A larger study may be required.

Pharmacological versus non-pharmacological antipyretic treatments in febrile critically ill adult patients: a systematic review and meta-analysis.

OBJECTIVES: Fever is common in critically ill patients and there are myriad of antipyretic and cooling treatments used. A systematic review was undertaken of the safety and efficacy of methods used to reduce fever. METHODS: Medline, EMBASE, CINAHL and Cochrane Database of Systematic Reviews were searched for randomised control trials (RCTs) of head-to-head and versus placebo/no treatment comparisons of pharmacological and/or non-pharmacological treatments for reducing fever in critically ill adult patients. Primary outcomes were reduction of fever and haemodynamic effects of treatments. RESULTS: 11 of 48 trials reviewed were included. The studies analysed were separated into common antipyretic treatment groups for comparison. Our main findings include, newer versus conventional external cooling therapies where newer external cooling methods (intravascular cooling and hydrogel cooling system) were better at reducing the fever burden than conventional methods (surface cooling) (MD, -8.00, 95% CI=-12.54, -3.47, P<0.001), with a trend for higher mortality for newer methods (RR, 1.42; 95% CI, 0.99-2.03; P=0.06). In the group comparison of the effectiveness of pharmacological antipyretic treatments, reduction on core body temperature favoured continuous antipyretic infusions rather than bolus doses (MD, 0.30, 95% CI 0.09, 0.51, P=0.005). For aggressive versus permissive antipyretic treatments, a reduction in mean daily temperatures favoured the aggressive group (MD, -1.09, 95% CI -1.37, -0.81, P<0.001) with a trend towards higher mortality for aggressive treatment (RR, 6.05, 95% CI 0.78, 46.95, P=0.09). CONCLUSION: Additional studies are needed to explore and clarify the role of antipyretic treatments in febrile critically ill adult patients.