Effect of 0.9% Saline or Plasma-Lyte 148 as Crystalloid Fluid Therapy in the Intensive Care Unit on Blood Product Use and Postoperative Bleeding After Cardiac Surgery.

OBJECTIVE: To evaluate the effect of Plasma-Lyte 148 (PL-148) compared with 0.9% saline (saline) on blood product use and postoperative bleeding in patients admitted to the intensive care unit (ICU) following cardiac surgery. DESIGN: A post hoc subgroup analysis conducted within a multicenter, double-blind, cluster-randomized, double-crossover study (study 1) and a prospective, single-center nested-cohort study (study 2). SETTING: Tertiary-care hospitals. PARTICIPANTS: Adults admitted to the ICU after cardiac surgery requiring crystalloid fluid therapy as part of the 0.9% saline vs. PL-148 for ICU fluid therapy (SPLIT) trial. INTERVENTIONS: Blinded saline or PL-148 for 4 alternating 7-week blocks. MEASUREMENTS AND MAIN RESULTS: 954 patients were included in study 1; 475 patients received PL-148, and 479 received saline. 128 of 475 patients (26.9%) in the PL-148 group received blood or a blood product compared with 94 of 479 patients (19.6%) in the saline group (OR [95% confidence interval], 1.51 [1.11-2.05]; p = 0.008). In study 2, 131 patients were allocated to PL-148 and 120 patients were allocated to saline. There were no differences between groups in chest drain output from the time of arrival in the ICU until 12 hours postoperatively (geometric mean, 566 mL for the PL-148 group v 547 mL in the saline group; p = 0.60). CONCLUSIONS: The findings did not support the hypothesis that using PL-148 for fluid therapy in ICU following cardiac surgery reduces transfusion requirements compared to saline. The significantly increased proportion of patients receiving blood or blood product with allocation to PL-148 compared to saline was unexpected and requires verification through further research.

A protocol for the 0.9% saline versus Plasma-Lyte 148 for intensive care fluid therapy (SPLIT) study.

BACKGROUND: 0.9% saline is the most commonly used intravenous (IV) fluid in the world. However, recent data raise the possibility that, compared with buffered crystalloid fluids such as Plasma-Lyte 148, the administration of 0.9% saline to intensive care unit patients might increase their risk of acute kidney injury (AKI). OBJECTIVE: To describe the protocol for the 0.9% Saline v Plasma-Lyte 148 for ICU Fluid Therapy (SPLIT) study. METHODS: This is a multicentre, cluster-randomised, double crossover feasibility study to be conducted in four New Zealand tertiary ICUs over a 28-week period and will enroll about 2300 participants. All ICU patients who need crystalloid IV fluid therapy (except those with established renal failure needing dialysis and those admitted to the ICU for palliative care) will be enrolled. Participating ICUs will be randomly assigned to 0.9% saline or Plasma-Lyte 148 as the routine crystalloid IV fluid, in a blinded fashion, in four alternating 7-week blocks. MAIN OUTCOME MEASURES: The primary outcome will be the proportion of patients who develop AKI in the ICU. Secondary outcomes will include the difference between the most recent serum creatinine level measured before study enrollment and the peak serum creatinine level in the ICU; use of renal replacement therapy; and ICU and in hospital mortality. All analyses will be conducted on an intention-to-treat basis. RESULTS AND CONCLUSION: The SPLIT study started on 1 April 2014 and will provide preliminary data on the comparative effectiveness of using 0.9% saline v Plasma- Lyte 148 as the routine IV fluid therapy in ICU patients.

A retrospective cohort study of the effect of medical emergency teams on documentation of advance care directives.

OBJECTIVE: To describe the longitudinal changes in documentation of advance care directives (ACDs), including limitation of medical therapy (LMT) and not-for-resuscitation (NFR) directives among patients reviewed by a medical emergency team (MET). DESIGN AND SETTING: Single-centre, retrospective cohort study at a tertiary teaching hospital in Wellington, New Zealand, from 1 October 2009 to 30 September 2010. PARTICIPANTS: Adult surgical and medical inpatients attended by the hospital's MET, which attends medical emergency calls and cardiac arrest calls. MAIN OUTCOME MEASURES: Chronology of LMT and NFR documentation rates in relation to hospital admission and MET attendance. Medical compliance with hospital NFR documentation policy. Differences in characteristics and outcomes of patients with and without documented ACDs. RESULTS: Documentation of LMT and NFR directives at admission was low (18%) in the 71 patient files included in the study. The LMT and NFR directive documentation rate before MET review (32%) doubled after MET involvement (62%). Universal NFR directive documentation was not achieved (66% NFR rate). Presence of pre-MET ACDs were associated with increased age, but this group had similar comorbidities and mortality rates to the group without directives. Presence of ACD documentation after MET review was associated with increased age, comorbidity burden and in hospital mortality. CONCLUSIONS: Compliance with hospital policy of universal documentation was low despite MET involvement. There was a strong association between ACDs and death, suggesting an opt-out culture. Further investigation is needed into the interaction between hospital systems, medical culture, human factors, and patient-centred clinical decision making.

Withdrawal of active treatment in intensive care: what is stopped - comparison between belief and practice.

OBJECTIVE: To assess the methods of withdrawal of active treatment in intensive care patients and to compare surveyed practice with the beliefs of medical and nursing staff. STUDY DESIGN: Staff beliefs were assessed prospectively using an anonymous questionnaire. Withdrawal methods were assessed retrospectively by a review of the medical records of 40 consecutive patients who had treatment withdrawn. SETTING: A 14-bed mixed tertiary-referral intensive care unit, February to June 2008. MAIN OUTCOME MEASURES: Results of the medical record review and questionnaire were compared. RESULTS: 11 medical and 45 nursing staff responded (78% and 53% response rate, respectively). Of the 56, 20% believed intravenous maintenance fluids should continue when it is decided to withdraw active treatment; 21% believed ventilation should continue, and approximately 40% believed electrocardiography and pulse oximetry monitoring should continue. Medical staff were more likely than nursing staff to recommend ceasing all treatment and monitoring. Audit of medical records showed that 38 of 40 patients (95%) had ongoing maintenance fluid administration at the time of death. All had respiratory support withdrawn, and one patient had all monitoring removed. Four patients (10%) had clear documentation of their not-for-resuscitation status, and 35 patients (88%) had documentation of a family meeting and the rationale for withdrawal. CONCLUSIONS: These results suggest a wide disparity between belief and practice, with variable documentation regarding end-of-life decision-making and treatment of patients for palliation in the ICU. Several guidelines have been published that might improve end-of-life care. We recommend a standardised approach to improve communication between medical and nursing staff.

Intensive care in an unusual setting: management of pneumonia in a chimpanzee.

We report a case in which intensive care doctors and nurses became involved in the care of a young chimpanzee who required ventilation for pneumonia at Wellington Zoo, New Zealand. This required staff to work outside the usual protected environment of a hospital intensive care unit. The chimpanzee, Bahati, was ventilated for 3 days, replicating intensive care practice, but died. Logistical challenges included equipment procurement, environment, electrical safety, gas supply and infection control. Other difficulties included differences in physiology, nursing care and therapeutics. End-of-life processes were similar, with zoo staff responding as if they were immediate family. Euthanasia was an unfamiliar process to ICU staff. Bahati's death received national media attention and some criticism of the involvement of intensive care staff. The zoo staff were overwhelmed and grateful that everything possible was done for Bahati.