Practice patterns and predictors of outpatient care following acute kidney injury in an Australian healthcare setting.

BACKGROUND: Survivors of acute kidney injury (AKI) are at increased risk of major adverse kidney events and international guidelines recommend individuals be evaluated 3 months following AKI. AIM: We describe practice patterns and predictors of post-AKI care in an Australian tertiary hospital. METHODS: A retrospective analysis was undertaken of adults with AKI (defined by KDIGO criteria) admitted to a single centre between 2012 and 2016. The primary outcome was outpatient nephrology review at 3 months. Secondary outcomes included inpatient nephrology review, and outpatient serum creatinine and urinary protein measurements. Data were analysed using multivariable logistic and competing risk regression. RESULTS: Only 117 of 2111 (6%) patients with AKI were reviewed by a nephrologist at 3 months. Reviewed patients were more likely to have a higher discharge serum creatinine (odds ratio (OR) 1.20 per 10 µmol/L increase; 95% confidence interval (CI) 1.16-1.25) or a history of peripheral vascular disease (OR 1.77; 95% CI 1.00-3.14). They were less likely to be older (OR 0.66 per decade; 95% CI 0.57-0.76) or to have a history of liver (OR 0.47; 95% CI 0.26-0.87) or ischaemic heart (OR 0.50; 95% CI 0.27-0.94) disease. AKI stage did not predict follow up. The median time from discharge to outpatient serum creatinine testing was 12 days (interquartile range 4-47) and proteinuria was measured in 538 (25%) patients. CONCLUSIONS: A minority of admitted AKI patients receive recommended post-AKI care. Studies in other Australian institutions are required to confirm or refute these concerning findings.

Inpatient and outpatient nephrology management of critically ill patients with acute kidney injury.

INTRODUCTION: Acute kidney injury (AKI) during critical illness increases the risk of subsequent chronic kidney disease. Guidelines recommend inpatient nephrology assessment and review at 3 months. OBJECTIVES: To quantify the prevalence and predictors of inpatient and outpatient nephrology follow-up of AKI patients admitted to critical care areas within a tertiary hospital. METHODS: Retrospective study of all critically ill adults with AKI between January 1, 2012 and December 31, 2016 with a baseline estimated glomerular filtration rate (eGFR) >30 mL/min/1.73 m2 and alive and independent of renal replacement therapy for 30 days after hospital discharge. We used logistic regression models to examine the primary outcome of nephrology review at 3 months. Secondary outcomes included inpatient nephrology review, renal recovery at discharge and the development of a major adverse kidney event (MAKE) at 1 year. RESULTS: Of 702 critically ill patients with AKI (mean age 66 years, 64% male, baseline eGFR 78 mL/min/1.73 m2 ), 43 patients (6%) received nephrology follow-up at 3 months and 63 patients (9%) at 1 year. Nephrology follow-up occurred more frequently in patients with a higher baseline creatinine, a higher discharge creatinine and greater severity of AKI. Seventy patients (10%) underwent inpatient nephrology review. Overall, 414 (59%) had recovery of renal function by the time of discharge and 239 (34%) developed a MAKE at 12 months. CONCLUSION: Inpatient and outpatient nephrology follow-up of AKI patients after admission to a critical care area was uncommon although one-third developed a MAKE. These findings provide the rationale for controlled studies of nephrology follow-up.

Characteristics and outcomes of rapid response team activations for hypotension in orthopaedic patients.

BACKGROUND: Hypotension following orthopaedic surgery has been associated with increased morbidity and mortality. Rapid response teams (RRT) review patients on hospital wards with hypotension. AIM: To evaluate the epidemiology of hypotensive RRT activations in adult orthopaedic patients to identify contributing factors and areas for future quality improvement. METHODS: Timing of RRT activations, presumed causes of hypotension and associated treatments were assessed. RESULTS: Among 963 RRT activations in 605 patients over 3 years, the first calls of 226 of 605 patients were due to hypotension, and 213 (94.2%) of 226 had sufficient data for analysis. The median age was 79 (interquartile range 66-87) years; 58 (27.2%) were male, and comorbidities were common. Most (68%) surgery was emergent, and 75.1% received intraoperative vasopressors for hypotension. Most activations occurred within 24 h of surgery, and hypovolaemia, infection and arrhythmias were common presumed causes. Fluid boluses occurred in 173 (81.2%), and the time between surgery and RRT activation was 10 (4.0-26.5) h. in cases where fluid boluses were given, compared with 33 (15.5-61.5) h. where they were not (P < 0.001). Blood transfusion (30, 14.1%) and withholding of medications were also common. Hospital mortality was 8.5% (18), and 13.6% (29) were admitted to critical care at some stage. In-hospital death was associated with older age, functional dependence, arrhythmia and presumed infection. CONCLUSIONS: Hypotension-related RRT calls in orthopaedic patients are common. Future interventional studies might focus on perioperative fluid therapy and vaso-active medications, as well as withholding of anti-hypertensive medications preoperatively.

Relative Hypoglycemia in Diabetic Patients With Critical Illness.

OBJECTIVES: Relative hypoglycemia is a decrease in glucose greater than or equal to 30% below prehospital admission levels (estimated by hemoglobin A1C) but not to absolute hypoglycemia levels. It is a recognized pathophysiologic phenomenon in ambulant poorly controlled diabetic patients but remains unexamined during critical illness. We examined the frequency, characteristics, and outcome associations of relative hypoglycemia in diabetic patients with critical illness. DESIGN: Retrospective cohort study. SETTING: ICU of a tertiary hospital. PATIENTS: One-thousand five-hundred ninety-two critically ill diabetic patients between January 2013 and December 2017. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The median age of patients was 67 years (interquartile range, 60-75 yr). The median Acute Physiology and Chronic Health Evaluation III score was 53 (interquartile range, 40-68). Thirty-four percent of patients with diabetes experienced relative hypoglycemia (exposure) during their ICU admission. Such patients had higher glycemic lability, hemoglobin A1C levels, and Acute Physiology and Chronic Health Evaluation III scores. The hazard ratio for 28-day mortality of diabetic patients, censored at hospital discharge, for patients with relative hypoglycemia was 1.9 (95% CI, 1.3-2.8) and was essentially unchanged after adjustment for episodes of absolute hypoglycemia. After an episode of relative hypoglycemia, the hazard ratio for subsequent absolute hypoglycemia in the ICU was 3.5 (95% CI, 2.3-5.3). CONCLUSIONS: In ICU patients with diabetes, relative hypoglycemia is common, increases with higher hemoglobin A1C levels, and is a modifiable risk factor for both mortality and subsequent absolute hypoglycemia. These findings provide the rationale for future interventional studies to explore new blood glucose management strategies and to substantiate the clinical relevance of relative hypoglycemia.

Initial Experience of the Use of 3-Factor Prothrombin Complex Concentrate and Thromboembolic Complications After Cardiac Surgery.

BACKGROUND: 3-factor prothrombin complex concentrate (3F-PCC) may provide a valuable treatment option for coagulopathy in cardiac surgery patients. However, it may expose patients to increased risk of thromboembolic events. Accordingly, we compared the incidence of thromboembolic events between patients exposed to 3F-PCC and those receiving conventional therapy. METHODS: Demographic, operative and postoperative data was obtained in a cohort of consecutive patients exposed to 3F-PCC and a contemporaneous control population. Propensity-score matching was performed for risk adjustment. Unadjusted and adjusted patient demographics and incidence of thromboembolism were compared. RESULTS: Patients receiving 3F-PCC (PCC) were younger (mean age PCC: 64±14.2 vs. No PCC: 67.6±11.6, p=0.022), and less likely to have diabetes or previous myocardial infarction. PCC patients experienced more prolonged aortic cross clamp times (mean time in minutes PCC: 119.9±58.8 vs. No PCC: 92.3±54), more complex cardiac surgeries and were more likely to have received more fresh frozen plasma (FFP), cryoprecipitate and red blood cells. Despite this, both unadjusted and adjusted 30-day mortality and readmission rates were similar between groups. There were 9 (9.2%) and 34 (6.8%) (p=0.40) thromboembolic events in the unadjusted PCC and control groups respectively. Adjusted risk for thromboembolic event rates was also comparable (Odds ratio: 1.512, 95% Confidence Interval 0.401-5.7, p=0.541). CONCLUSIONS: 3-factor prothrombin complex concentrate was administered to patients at greater risk of complications including bleeding. Our initial experience suggests that the use of PCC does not appear to increase thromboembolic risks compared to conventional treatment.

Patient characteristics, incidence, technique, outcomes and early prediction of tracheostomy in the state of Victoria, Australia.

BACKGROUND: Tracheostomy is a relatively common procedure in Intensive Care Unit (ICU) patients. AIMS: To study the patient characteristics, incidence, technique, outcomes and prediction of tracheostomy in the State of Victoria, Australia. METHODS: We used data from the Australian and New Zealand Intensive Care Society Adult Patient Database (ANZICS APD) and the Victorian Admitted Episode Dataset (VAED) to identify and match patients who had received a tracheostomy from 2004 to 2014. RESULTS: Between 1st January 2004 and 30th June 2014, 9750 patients received a tracheostomy with 7670 available for matching and 6010 (78.4%) successfully matched. Of the matched tracheostomy patients, median age was 61years, median APACHE IIIJ score was 66 and overall hospital mortality was 21%. The incidence of tracheostomy almost halved over the decade with more than half of tracheostomies (53.5%) being percutaneous. Hospital mortality of patients receiving a tracheostomy decreased from 26.5% in 2004 to 16.5% in 2014 by an average decrease of 6%/year. No robust model could be developed to predict tracheostomy. CONCLUSION: The incidence of tracheostomy and the adjusted mortality rate of patients who received a tracheostomy have significantly decreased over a decade. Day of admission information could not be used to predict subsequent tracheostomy.

Health economic implications of complications associated with pancreaticoduodenectomy at a University Hospital: a retrospective cohort cost study.

BACKGROUND: A cost analyses of complications following pancreaticoduodenectomy (PD) was performed in a high volume hepato-biliary-pancreatic service. We hypothesised that costs are increased with both severity and number of complications; we investigated the relationship between complications and specific cost centres. METHODS: 100 patients from 2011 to 2016 were included. Data relating to their perioperative course were collected. Complications were documented by the Clavien-Dindo classification and costs were inflated and converted to 2017 USD. RESULTS: Mean hospital costs in complicated patients more than doubled those of uncomplicated patients ($28 330 vs. $57 150, p < 0.0001). Total hospital costs significantly increased with both severity and number of complications. This cost increase was influenced by medical consult, pathology, pharmacy, radiology, ward, intensive care, and allied health costs, but not operating theatre or anaesthesia costs. Postoperative pancreatic fistula, postoperative haemorrhage, delayed gastric emptying and infection were associated with cost differentials of $65 438, $74 079, $35 620 and $46 316 respectively over uncomplicated patients. CONCLUSION: The development of complications following PD is common, costly and associated with increased length of stay. Costs increased with greater complication severity, and specific complications. The in-depth breakdown of hospital costs suggests specific targets for cost containment.

Long-term outcomes after severe drug overdose.

OBJECTIVE: The long-term outcomes of patients with drug overdose admitted to the intensive care unit compared with those admitted to general wards have not been assessed. We aimed to compare the recurrence of overdose, mortality after hospital discharge, cause of death and quality-of-life scores (using the EQ-5D questionnaire) between the ICU patients and general ward patients. METHODS: We performed a retrospective cohort study of 102 ICU patients with drug overdose and 102 matched general ward patients with drug overdose in a university-affiliated teaching hospital between 2009 and 2013. We undertook standardised follow-up of patients for recurrence of overdose, long-term mortality and quality-oflife assessment. RESULTS: At 4-year follow-up, 33.3% of ICU patients had experienced further self-harm attempts, compared with 36.3% of general ward patients (P = 0.66). Ten ICU patients (10%) and five general ward patients (5%) had died. Causes of death included hanging in three patients and drug overdose in another three. On multivariate regression analysis, previous overdose attempts significantly predicted future overdoses and self-harm (odds ratio, 2.34; 95% CI, 1.27-4.30; P = 0.006). Overall, 101 patients (49.5%) were lost to follow-up and eight (3.9%) refused participation. For those remaining, EQ-5D scores were low, especially in the dimensions of anxiety/depression, usual activities and pain/discomfort. CONCLUSIONS: ICU and general ward patients with overdose have similar, overwhelming prevalences of psychiatric disease, and similar outcome profiles. Such patients experience frequent overdoses and, despite being young, if admitted to the ICU, have a 10% 4-year mortality, with self-harm the dominant cause of death. Finally, among survivors who responded to the follow-up questionnaire, quality of life is poor.