David A Reid

The association of blood transfusion with mortality after cardiac surgery: cause or confounding? (CME)

BACKGROUND: Bleeding into the chest is a life‐threatening complication of cardiac surgery. Blood transfusion has been implicated as an important cause of harm associated with bleeding, based largely on studies demonstrating an independent association between transfusion and mortality. These studies did not, however, consider the possibility that bleeding may in itself be harmful, inasmuch as drains are inefficient at clearing blood from the chest and retained blood may compromise cardiac and lung function.

The Operating Surgeon Is an Independent Predictor of Chest Tube Drainage Following Cardiac Surgery

OBJECTIVES Bleeding into the chest is a major cause of blood transfusion and adverse outcomes following cardiac surgery. The authors investigated predictors of bleeding following cardiac surgery to identify potentially correctable factors. DESIGN Data were retrieved from the medical records of patients undergoing cardiac surgery over the period of 2002 to 2008. Multivariate analysis was used to identify the independent predictors of chest tube drainage. SETTING Tertiary hospital. PARTICIPANTS Two thousand five hundred seventy-five patients. INTERVENTIONS Cardiac surgery. RESULTS The individual operating surgeon was independently associated with the extent of chest tube drainage. Other independent factors included internal mammary artery grafting, cardiopulmonary bypass time, urgency of surgery, tricuspid valve surgery, redo surgery, left ventricular impairment, male gender, lower body mass index and higher preoperative hemoglobin levels. Both a history of diabetes and administration of aprotinin were associated with reduced levels of chest tube drainage. CONCLUSIONS The individual operating surgeon was an independent predictor of the extent of chest tube drainage. Attention to surgeon-specific factors offers the possibility of reduced bleeding, fewer transfusions, and improved patient outcomes.

Do outlier inpatients experience more emergency calls in hospital? An observational cohort study

Objective: To determine the effect of spending time as an outlier (ie, an inpatient who spends time away from his or her “home” ward) on the frequency of emergency calls for patients admitted to a tertiary referral hospital.

The duration of hospitalization before review by the rapid response team: A retrospective cohort study☆

PURPOSE The purpose of this study is to compare cases of rapid response team (RRT) review for early deterioration (<48 hours after admission), intermediate deterioration (48 to <168 hours after admission), late deterioration (≥168 hours after admission), and cardiac arrest and to determine the association between duration of hospitalization before RRT review and mortality. METHODS This is a retrospective cohort study of RRT cases from a single hospital over 5 years (2009-2013) using administrative data and data for the first RRT attendance of each hospital episode. RESULTS Of 2843 RRT cases, 971 (34.2%) were early deterioration, 917 (32.3%) intermediate, 775 (27.3%) late, and 180 (6.3%) cardiac arrest. Compared with early deterioration patients, late deterioration patients were older (median, 71 vs 69 years; P = .005), had a higher Charlson comorbidity index (median, 2 vs 1; P < .001), more often had RRT review for respiratory distress (32.5% vs 23.5%; P < .001), more often received RRT-initiated not for resuscitation orders (8.4% vs 3.9%; P < .001), less often were discharged directly home (27.9% vs 58.4%; P < .001), and more often died in hospital (30.6% vs 12.8%; P < .001). Compared with early deterioration and adjusted for confounders, the odds ratio of death in hospital for late deterioration was 2.36 (1.81-3.08; P < .001). CONCLUSIONS Late deterioration is frequently encountered by the RRT and, compared with early deterioration, is associated with greater clinical complexity and a worse hospital outcome.

Heatwave hyponatraemia: a case series at a single Victorian tertiary centre during January 2014

Heatwaves are a major public health threat for Australians. Hyponatraemia is common, with an increased incidence previously described during heatwaves. We report a series of 10 patients admitted with moderate to profound hyponatraemia, the majority with a history of excess water consumption, during the January 2014 heatwave.

Trends and Outcomes of Chronic Kidney Disease in Intensive Care- a 5 year study

The prevalence of chronic kidney disease (CKD) is increasing in Australia and is independently associated with a higher risk of hospitalisation and death. Australian data may be useful in guiding improved hospital management of this growing cohort of patients.

Use of resuscitation plans at a tertiary Australian hospital: room for improvement: Use of resuscitation plans

Objectives To evaluate the introduction of a document for recording the resuscitation plans of patients at a tertiary hospital. The ‘Acute Resuscitation Plan’ (ARP) was introduced in September 2014, superseding the ‘Not for Cardiopulmonary Resuscitation (CPR)’ form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. Design Retrospective audit of the records of all admissions to the hospital from January-June 2014 (Not for CPR period) and January-June 2015 (ARP period). Main outcomes Incidence of resuscitation plans; proportion of ARPs specifying consultation with the patient (or representative) and with senior medical staff and; proportion of ARPs among older patients and those with significant comorbidity. Results Resuscitation plans were present for 453/23,325 (1.9%) admissions in the Not for CPR period vs. 1,801/24,037 (7.5%) in the ARP period (OR 4.1, 95%CI 3.7-4.5, P<0.001). Forty-two percent (42%) of ARPs specified ‘care of the dying’ in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARPs and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥ 90 years, 59% from aged care, 90% with metastatic cancer, and 64% aged ≥ 80 years and with a Charlson comorbidity index ≥ 3. Conclusions More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.The ‘Acute Resuscitation Plan’ (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the ‘Not for Cardiopulmonary Resuscitation (CPR)’ form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits.

Changing clinical guidelines from delayed to early aperient administration for enterally fed intensive care patients was associated with increased diarrhoea: A before-and-after, intention-to-treat evaluation

BACKGROUND The 14-bed intensive care unit of a tertiary referral hospital adopted a guideline to start docusate sodium with sennosides when enteral nutrition was started. This replaced a guideline to start aperients after 24h of enteral nutrition if no bowel action had occurred. We sought to determine the effect of this change on the incidence of diarrhoea and constipation in intensive care. METHODS Retrospective audit of the medical records of consecutive adult patients admitted to intensive care and given enteral nutrition, excluding those with a primary gastrointestinal system diagnosis, between Jan-Aug 2011 (the delayed group, n=175) and Jan-Aug 2012 (the early group, n=175). The early aperient guideline was implemented during Sep-Dec 2011. RESULTS The early and delayed groups were similar in age (median 62 years vs. 64 years; P=0.17), sex (males 65% vs. 63%; P=0.91), and postoperative cases (31% vs. 33%; P=0.82) and had similar proportions who received mechanical ventilation (95% vs. 95%; P=1.00), an inotrope or vasopressor (63% vs. 70%; P=0.17), renal replacement therapy (8% vs. 10%; P=0.71), opiates (77% vs. 80%; P=0.60), antibiotics (89% vs. 91%; P=0.72) and metoclopramide (46% vs. 55%; P=0.11). A significantly larger proportion of the early group received an aperient (54% vs. 29%, P<0.001) and experienced diarrhoea (38% vs. 27%, P=0.04), but the groups had similar proportions affected by constipation (42% vs. 43%, P=0.91). CONCLUSIONS Changing guidelines from delayed to early aperient administration was associated with an increase in the incidence of diarrhoea but was not associated with the incidence of constipation. These findings do not support changing guidelines from delayed to early aperient administration.

The use of resuscitation plans at a tertiary Australian hospital: room for improvement

Objectives To evaluate the introduction of a document for recording the resuscitation plans of patients at a tertiary hospital. The ‘Acute Resuscitation Plan’ (ARP) was introduced in September 2014, superseding the ‘Not for Cardiopulmonary Resuscitation (CPR)’ form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits. Design Retrospective audit of the records of all admissions to the hospital from January-June 2014 (Not for CPR period) and January-June 2015 (ARP period). Main outcomes Incidence of resuscitation plans; proportion of ARPs specifying consultation with the patient (or representative) and with senior medical staff and; proportion of ARPs among older patients and those with significant comorbidity. Results Resuscitation plans were present for 453/23,325 (1.9%) admissions in the Not for CPR period vs. 1,801/24,037 (7.5%) in the ARP period (OR 4.1, 95%CI 3.7-4.5, P<0.001). Forty-two percent (42%) of ARPs specified ‘care of the dying’ in the event of arrest. Acknowledgement of the views of the patient (or representative) was indicated on 37% of ARPs and of a senior physician on 28%. An ARP was not present for 67% of patients aged ≥ 90 years, 59% from aged care, 90% with metastatic cancer, and 64% aged ≥ 80 years and with a Charlson comorbidity index ≥ 3. Conclusions More patients had resuscitation plans after introducing the ARP. However, patients and senior physicians were often remote from the consultation process and an ARP was not present for many patients likely to have a poor outcome from cardiopulmonary arrest.The ‘Acute Resuscitation Plan’ (ARP) is a document for recording the resuscitation plans of patients at a tertiary hospital for adult patients. The ARP was introduced at the hospital in September 2014, superseding the ‘Not for Cardiopulmonary Resuscitation (CPR)’ form. Unlike the Not for CPR form, the ARP was relevant to patients with and without resuscitation limits.