Showing papers by "Steven A R Webb published in 2010"

Early observational research and registries during the 2009-2010 influenza A pandemic.

Abstract: As a critical care community, we have an obligation to provide not only clinical care but also the research that guides initial and subsequent clinical responses during a pandemic. There are many challenges to conducting such research. The first is speed of response. However, given the near inevitability of certain events, for example, viral respiratory illness such as the 2009 pandemic, geographically circumscribed natural disasters, or acts of terror, many study and trial designs should be preplanned and modified quickly when specific events occur. Template case report forms should be available for modification and web entry; centralized research ethics boards and funders should have the opportunity to preview and advise on such research beforehand; and national and international research groups should be prepared to work together on common studies and trials for common challenges. We describe the early international critical care research response to the influenza A 2009 (H1N1) pandemic, including specifics of observational study case report form, registry, and clinical trial design, cooperation of international critical care research organizations, and the early results of these collaborations.

Enhanced diagnosis of pandemic (H1N1) 2009 influenza infection using molecular and serological testing in intensive care unit patients with suspected influenza.

Abstract: During the 2009 outbreak of pandemic (H1N1) 2009 influenza (pH1N1) in Australia, acute and convalescent serum specimens were collected from 33 patients with severe respiratory disease admitted to intensive care units. Using hemagglutination inhibition of pH1N1, 29 paired serum samples showed significant increases in specific antibody titers. Of these 29 patients, 18 had pH1N1 RNA detected by routine nucleic acid testing. These results indicate that up to onethird of pH1N1 cases may not have laboratory confirmation of infection unless serological testing is included for suspected cases. © 2010 by the Infectious Diseases Society of America. All rights reserved.

A survey of antibiotic prescribing practices in Australian and New Zealand intensive care units

Abstract: Objective: To evaluate antibiotic prescribing practices in empirical and directed treatment of severe sepsis and septic shock in Australian and New Zealand intensive care units. Design, setting and participants: Case vignette survey of intended antibiotic prescribing for ICU patients with sepsis associated with community-acquired pneumonia (CAP), intra-abdominal infection (IAI), hospital-acquired pneumonia (HAP) or an unidentified infectious cause (UIC). Eighty-four specialists and advanced trainees working in an ICU setting in Australia and New Zealand responded to a questionnaire survey conducted between February and May 2009. Main outcome measures: Empirical and directed antibiotic therapy, including mode of administration, frequency of administration, dose and duration of therapy. Results: A total of 656 antibiotics were empirically 'prescribed', including 25 unique antibiotics. Combination therapy was prescribed in 82% of cases, with dual cover for CAP and triple therapy for IAI most common. Directed single-agent cover for Pseudomonas aeruginosa in HAP and flucloxacillin monotherapy for methicillin-sensitive Staphylococcus aureus bacteraemia were prescribed in 65% and 51% of cases, respectively. Supportive gentamicin therapy was commonly recommended (32% of all cases), predominantly in the form of once-daily dosing. Daily gentamicin dosage varied from 3 to 7mg/kg (excluding one outlier), and was largely compliant with recommendations (76% of doses being _5 mg/kg). Main areas of noncompliance with guidelines were provision of broader cover for resistant organisms and -lactam underdosing. Continuous and extended infusions were uncommon (5%). Conclusions: Antibiotic prescribing was largely appropriate, but consideration of site-specific resistance profiles and avoidance of low dosing is advocated to provide appropriate upfront cover, prevent underdosing and reduce the risk of developing resistant organisms.

Venous thromboembolism prophylaxis in the critically ill: a point prevalence survey of current practice in Australian and New Zealand intensive care units.

Abstract: Background: Critically ill patients are at high risk of morbidity and mortality caused by venous thromboembolism (VTE). In addition to premorbid predisposing conditions, critically ill patients may be exposed to prolonged immobility, invasive intravascular catheters and frequent operative procedures, and further may have contraindications to pharmaceutical prophylactic measures designed to attenuate VTE risk. There are limited data describing current VTE prophylaxis regimens in Australia and New Zealand.

Changes in case-mix and outcomes of critically ill patients in an Australian tertiary intensive care unit.

Abstract: Critical care service is expensive and the demand for such service is increasing in many developed countries This study aimed to assess the changes in characteristics of critically ill patients and their effect on long-term outcome This cohort study utilised linked data between the intensive care unit database and state-wide morbidity and mortality databases Logistic and Cox regression was used to examine hospital survival and five-year survival of 22,298 intensive care unit patients, respectively There was a significant increase in age, severity of illness and Charlson Comorbidity Index of the patients over a 16-year study period Although hospital mortality and median length of intensive care unit and hospital stay remained unchanged, one- and five-year survival had significantly improved with time, after adjusting for age, gender, severity of illness, organ failure, comorbidity, ‘new’ cancer and diagnostic group Stratified analyses showed that the improvement in five-year survival was particularly strong among patients admitted after cardiac surgery (P=0001) In conclusion, although critical care service is increasingly being provided to patients with a higher severity of acute and chronic illnesses, long-term survival outcome has improved with time suggesting that critical care service may still be cost-effectiveness despite the changes in case-mix

Acute kidney injury and 2009 H1N1 influenza-related critical illness.

Abstract: The year 2009 was characterized by a pandemic with a new virus, the 2009 H1N1 influenza virus. This pandemic was responsible for thousands of deaths worldwide, many more hospital admissions, and thousands of admissions to intensive care units (ICUs). Among those admitted to ICUs, the pandemic was associated with a mortality of approximately 16%, a high incidence of acute lung injury and, in some cases, acute respiratory distress syndrome severe enough to require support with extracorporeal membrane oxygenation. As part of such a critical illness, a percentage of patients developed acute kidney injury (AKI) which complicated their clinical course and, in some patients, required support by renal replacement therapy. In a case series from Mexico, the incidence of severe AKI was reported in about 30% of the patients. Similarly, at the Austin Hospital, of 13 cases, 8 developed AKI with 3 being classified in the failure category of the RIFLE classification. Among the patients with AKI, hospital mortality was approximately 25%. Of the AKI patients, 3 (37.5%) received renal replacement therapy and, among these, 1 died. In a case of severe AKI and multi-organ failure from whom histological material was obtained, the renal histopathological findings were typical of acute tubular necrosis. One patient who suffered from hypoxic brain injury due to cardiac arrest at home secondary to H1N1 pneumonia became a kidney and liver donor. There was no evidence of viral infiltration on kidney biopsy and the recipient did not develop H1N1 infection.

The practical experience of managing the H1N1 2009 influenza pandemic in Australian and New Zealand intensive care units.

Abstract: Crit Care Resusc ISSN: 1441-2772 1 June 2010 12 2 121-130 © C r i t C a re Re sus c 20 10 www.jficm.anzca.edu.au/aaccm/journal/publications.htm Reviews hemisphere, including Australia and New Zeala The provision of intensive care in these countries other developed countries. The experience in help intensive care clinici ns elsewhere to tr illness associated with H1N1 2009. At the onset of the H1N1 2009 influenza p The influenza A virus undergoes periodic antigen shifts, resulting in new strains. The emergence of new strains provides the necessary conditions for a pandemic,1 and this occurred in 2009. It was the first pandemic since 1968, and the first to occur in an era of widespread intensive care.2 The H1N1 2009 virus emerged in the northern hemisphere, and winter outbreaks followed in countries in the southern nd (ANZ).3 is similar to ANZ may eat critical

CRITICAL CARE Effect of length of stay in intensive care unit on hospital and long-term mortality of critically ill adult patients

Abstract: Methods. Clinical and mortality data of 22 298 patients, aged 16 yr and older, admitted to ICU between 1987 and 2002 were included in this linked-data cohort study. Cox’s regression with restricted cubic spline function was used to model the effect of LOS on in-hospital and longterm mortality after adjusting for age, gender, acute physiology score (APS), maximum number of organ failures, era of admission, elective admission, Charlson’s co-morbidity index, and diagnosis. The variability each predictor explained was calculated by the percentage of the x statistic contribution to the total x statistic.

Extracorporeal life support. ECMO patients overestimated.

Abstract: We wish to point out a misinterpretation of our results in an otherwise useful review of extracorporeal life support.1 The authors suggested that a third of patients admitted to intensive care with severe respiratory failure during the recent H1N1 influenza A pandemic needed extracorporeal membrane oxygenation (ECMO). …

The second winter of influenza A (H1N1) 2009 in Australian and New Zealand intensive care units.

Abstract: Crit Care Resusc ISSN: 1441-2772 1 December 2010 12 4 219-220 ©Cr i t Ca re Resusc 2010 www.jficm.anzca.edu.au/aaccm/journal/publications.htm Editorials and morbidity relatively low. For a substantial people, however, pandemic influenza caused cri and ultimately 760 patients with confirmed influenza were cared for in 104 i tensive ca Australia and New Zealand (ANZ).2,3 There wer per million population, requiring 350 bed-days population, including up to 7.4 occupied bed The 2009 pandemic of H1N1 influenza A was a paradox. While large numbers of people were infected worldwide, in general the illness was mild and the attributable mortality number of tical illness, 2009/H1N1 re units in e 28 cases per million s daily per million at the peak of the epidemic; 14.3% of these patients died.2 This caseload put substantial stress on the critical care resources of ANZ, although systems were not overwhelmed. Importantly, the population affected in 2009 was very different from the population usually affected by seasonal influenza. Most patients admitted to intensive care were younger (92.7% were under 65 years of age, and many were young adults). Disproportionate numbers were obese or of Indigenous background,2 and 9.2% were pregnant or immediately postpartum when they contracted influenza. About half the patients had a very characteristic syndrome of influenza-associated acute respiratory distress syndrome (ARDS), with profound hypoxaemia and dependence on positive end-expiratory pressure (PEEP) but preserved compliance. This was associated with persisting fevers and, in many cases, acute kidney injury. Severity of illness was high, and 8.4% of patients admitted to the ICU received extracorporeal membrane oxygenation (ECMO).5 The ANZ experience provided valuable information for northern hemisphere countries preparing for their own responses to the pandemic during the winter of 2009/2010. Similar experiences have been seen in Canada and the United States6 and throughout Europe, from the United Kingdom7 to Turkey, France and Spain.8 In each of these countries, patients admitted to the ICU were younger and often obese or of indigenous background, and about 10% were pregnant or immediately postpartum. In this issue of Critical Care and Resuscitation, a group representing the Intensive Care Society of Ireland reports