Raise the Flag II: sepsis mortality before and after the introduction of a whole-of-system quality improvement programme at a tertiary hospital in New Zealand.

AIMS: To study in-patient mortality before and after the introduction of a whole-of-system sepsis quality improvement programme at a tertiary hospital in New Zealand. METHODS: The "Raise the Flag" sepsis quality improvement programme was launched in 2018. Discharge coding data were used to identify sepsis cases between May 2015 and July 2021. RESULTS: Of 4,268 cases of sepsis identified, 81% were over 55 years old, 34% were of Maori or Pacific Island ethnicity, 61% had significant co-morbid illness and over two thirds (68%) lived in the two highest quintiles of socio-economic deprivation. The adjusted odds of in-patient mortality were lower in the post-launch period (adjusted odds ratio [aOR] 0.83, 95% confidence interval [CI] 0.7-0.98, p<0.05), and were higher in association with age (aOR 1.04 for every additional year of age, 95% CI 1.03-1.05, p<0.01), socio-economic status (aOR 1.47 comparing the highest quintile of socio-economic deprivation with the lowest, 95% CI 1.06-2.04, p=0.02) and comorbidity (aOR 2.42 comparing a comorbidity score of 1 with a score of 0, 95% CI 2.1-3.52, p<0.01). CONCLUSION: In patients with a sepsis diagnosis, the odds of in-patient death were lower following the launch of the Raise the Flag sepsis quality improvement programme.

Mortality outcomes for Maori requiring renal replacement therapy during critical illness: a single unit audit in Aotearoa New Zealand.

BACKGROUND: Maori in New Zealand (NZ) are disproportionately affected by chronic kidney disease (CKD) and experience lower life expectancy on community dialysis compared with non-Maori. We previously identified a higher renal replacement therapy (RRT) requirement for Maori in our intensive care unit (ICU), the tertiary referral centre for NZ's Te Manawa Taki region. AIM: To describe mortality outcomes by ethnicity in the population requiring RRT in our ICU. METHODS: Retrospective audit of the Australia and NZ Intensive Care Society database for adult admissions to our general ICU from Te Manawa Taki between 2014 and 2018. Patients were stratified by non-RRT requirement (non-RRT), RRT-requiring acute kidney injury (AKI-RRT) and RRT-requiring end-stage renal disease (ESRD). RESULTS: Relative to the population of Te Manawa Taki, Maori were over-represented across all strata, especially ESRD (61.8%), followed by AKI-RRT (35.0%) and non-RRT (32.4%) (P < 0.001). There was no excess mortality by ethnicity in any stratum. Crude in-ICU mortality was similar by ethnicity among AKI-RRT (30.8% among Maori, vs 31.5%; P = 1.000) and ESRD (16.4% among Maori, vs 20.6%; P = 0.826). This trend remained at 1 year. Adjusted for clinically selected variables, neither AKI-RRT nor ESRD mortality was predicted by Maori ethnicity, both in-ICU and at 1 year. Irrespective of ethnicity, AKI-RRT patients had highest in-ICU mortality (31.2%; P < 0.001), while ESRD had highest 1-year mortality (46.1%; P < 0.001). CONCLUSION: Increased RRT requirement among Maori in our ICU is due to higher representation among ESRD. We did not demonstrate excess mortality by ethnicity in any stratum. AKI-RRT had higher in-ICU mortality than ESRD, but this reversed at 1 year.

Non-invasive ventilation for acute hypoxaemic respiratory failure: a propensity-matched cohort study.

BACKGROUND: Non-invasive ventilation (NIV), although effective in treating hypercapnic respiratory failure, has not demonstrated the same efficacy in treating acute hypoxaemic respiratory failure. We aimed to examine the effect of NIV use on ventilator-free days in patients with acute hypoxaemic respiratory failure admitted to the intensive care unit (ICU). METHODS: We conducted a retrospective study of patients admitted to the ICU with acute hypoxaemic respiratory failure at Waikato Hospital, New Zealand, from 1 January 2009 to 31 December 2018. Patients treated with NIV as the initial oxygenation strategy were compared with controls treated with early intubation. The two groups were matched using a propensity score based on baseline characteristics. The primary outcome was the number of ventilator-free days at day 28. The secondary outcomes were ICU and hospital length of stay and in-hospital mortality. RESULTS: Out of 175 eligible patients, 79 each out of the NIV and early intubation groups were matched using a propensity score. Early NIV was associated with significantly higher median ventilator-free days than early intubation (17 days vs 23 days, p=0.013). There was no significant difference in median ICU length of stay (112.5 hours vs 117.7 hours), hospital length of stay (14 days vs 14 days) or in-hospital mortality (31.6% vs 37.9%) between the NIV and the early intubation group. CONCLUSION: Compared with early intubation, NIV use was associated with more ventilator-free days in patients with hypoxaemic respiratory failure. However, this did not translate into a shorter length of stay or reduced mortality based on our single-centre experience.

Maori Health Outcomes in Intensive Care Following Cardiac Surgery in Aotearoa New Zealand.

BACKGROUND: Maori, the indigenous peoples of Aotearoa New Zealand (NZ) experience disproportionately worse outcomes in cardiovascular health compared to non-Maori. Waikato Hospital provides tertiary cardiothoracic services to the Midland region of NZ, and has instituted an official policy to eliminate ethnic inequity in health. We aimed to audit the outcomes of our cardiothoracic intensive care unit (ICU) against this standard. METHOD: We analysed data from the prospectively-entered Australia and NZ Intensive Care Society database for all planned cardiothoracic ICU admissions from 2014 to 2018 at Waikato Hospital for patients aged 15-years and older (n=2,736). Outcomes measured were in-ICU, in-hospital, and 1-year mortality. RESULTS: Maori were under-represented in this cohort (17.9%) compared to the general Midland population. Maori patients were younger (median 60 vs 68-years old, p<0.001), were more commonly female (34.8% vs 23.6%, p<0.001), domiciled in more deprived areas (2018 NZ Index of Deprivation of 9 vs 6, p<0.001), and more likely to have rheumatic heart disease (35.6% vs 16.6%, p<0.001). More non-Maori required coronary vessel only surgery (57.4% vs 45.2%), whilst more Maori required valvular only surgery (41.1% vs 31.2%) (p<0.001 overall). Baseline Acute Physiology and Chronic Health Evaluation (APACHE) III risk of death score was higher for Maori (1.53% vs 0.89%, p<0.001), as was the European System for Cardiac Operative Risk Evaluation (EuroSCORE) II (2.04% vs 1.55%, p<0.001). Unadjusted mortality was higher for Maori in-ICU (3.1% vs 1.3%, p=0.005) and at 1-year (7.1% vs 3.8%, p=0.002). Adjusted in-ICU mortality, however, was predicted by combined coronary-valvular surgery (adjusted odds ratio, AOR 25.5 [95% confidence interval (CI) 3.30-348.46], p=0.005), Australia and New Zealand Risk of Death (ANZROD) score (AOR 1.11 [CI 1.05-1.19] p<0.001), and renal replacement therapy requirement (AOR 154.56 [CI 30.86-1,107.17] p<0.001), but not by Maori ethnicity (AOR 0.27 [CI 0.03-1.43] p=0.156). CONCLUSION: Our audit has identified significant inequity for Maori at our cardiothoracic ICU. Maori are sicker on presentation for planned cardiac surgery, as evidenced by higher admission severity scores, and experience higher unadjusted mortality up to 1-year compared to non-Maori. Maori also appear under-represented despite a greater burden of cardiovascular disease in the community. Further study is required to identify if upstream risk factors, including failure of early detection and referral for disease, contribute to these findings.

Maori health outcomes in an intensive care unit in Aotearoa New Zealand.

Maori are the indigenous people of New Zealand, and suffer disparate health outcomes compared to non-Maori. Waikato District Health Board provides level III intensive care unit services to New Zealand's Midland region. In 2016, our institution formalised a corporate strategy to eliminate health inequities for Maori. Our study aimed to describe Maori health outcomes in our intensive care unit and identify inequities. We performed a retrospective audit of prospectively entered data in the Australian and New Zealand Intensive Care Society database for all general intensive care unit admissions over 15 years of age to Waikato Hospital from 2014 to 2018 (n = 3009). Primary outcomes were in-intensive care unit and in-hospital mortality. The secondary outcome was one-year mortality. In our study, Maori were over-represented relative to the general population. Compared to non-Maori, Maori patients were younger (51 versus 61 years, P < 0.001), and were more likely to reside outside of the Waikato region (37.2% versus 28.0%, P < 0.001) and in areas of higher deprivation (P < 0.001). Maori had higher admission rates for trauma and sepsis (P < 0.001 overall) and required more renal replacement therapy (P < 0.001). There was no difference in crude and adjusted mortality in-intensive care unit (16.8% versus 16.5%, P = 0.853; adjusted odds ratio 0.98 (95% confidence interval 0.68 to 1.40)) or in-hospital (23.7% versus 25.7%, P = 0.269; adjusted odds ratio 0.84 (95% confidence interval 0.60 to 1.18)). One-year mortality was similar (26.1% versus 27.1%, P=0.6823). Our study found significant ethnic inequity in the intensive care unit for Maori, who require more renal replacement therapy and are over-represented in admissions, especially for trauma and sepsis. These findings suggest upstream factors increasing Maori risk for critical illness. There was no difference in mortality outcomes.

Life-threatening bleeding due to persistent dabigatran effect in a patient with sepsis despite idarucizumab therapy and haemodialysis.

A 58-year-old man presented with necrotising fasciitis and septic shock requiring urgent surgical debridement. Idarucizumab was used preoperatively to reverse the effects of dabigatran, which he was taking for chronic atrial fibrillation. He developed multiorgan failure including an oliguric acute kidney injury and was given continuous venovenous haemodiafiltration. Adjunctive intravenous immunoglobulin therapy was used in addition to his antibiotic therapy for necrotising fasciitis. Significant clinical and laboratory coagulopathy continued for over 12 days with evidence of a persistent dabigatran effect. Here, we discuss the potential impact of the immunoglobulin therapy, the patient's weight on the degree of redistribution of dabigatran seen and the oliguria in the context of an acute kidney injury on the apparent lack of the effectiveness of idarucizumab.

Cytokine-dependent inflammatory cell recruitment patterns in the peritoneal cavity of mice exposed to the parasitic nematode Brugia malayi.

Mice exposed intraperitoneally to either adult or first larval stage (microfilaria) of the human nematode parasite Brugia malayi display polarized cytokine responses. We have used this model to investigate the impact of altered cytokine profiles on inflammatory cell recruitment patterns in vivo. Here we demonstrate that Th2-inducing adult parasites drive the recruitment of eosinophils and macrophages after implant into the murine peritoneal cavity whereas Th1-inducing microfilaria do not. The underlying mechanism of recruitment was further defined by use of mice deficient in the key Th2 cytokines IL-4 or IL5 and mice that lack T cells (nude mice). Recruitment dynamics differed in IL-4 and IL-5 deficient mice, showing reduced or absent eosinophilia. These data emphasize the pivotal role of these cytokines in shaping the cellular profile of inflammatory responses. Surprisingly, the absence of T cells failed to influence inflammatory cell recruitment indicating that recruitment signals are provided by other cell types.