EDITORIAL by wuzhenguang


235 Should we question if something works just
because we don’t know how it works?
Michael C Reade

238 Oxygen delivery to patients after cardiac surgery:
a medical record audit
Glenn M Eastwood, Bev O’Connell and Julie Considine

Objective: To describe how intensive care nurses manage
the administration of supplemental oxygen to patients
during the first 24 hours after cardiac surgery.
Methods: A retrospective audit was conducted of the
medical records of 245 adult patients who underwent
cardiac surgery between 1 January 2005 and 31 May 2008
in an Australian metropolitan hospital. Physiological data
(oxygen saturation measured by pulse oximetry and
respiratory rate) and intensive care unit management data
(oxygen delivery device, oxygen flow rate and duration of
mechanical ventilation) were collected at hourly intervals
over the first 24 hours of ICU care.
Results: Of the 245 patients whose records were audited,
185 were male; mean age was 70 years (SD, 10), and mean
APACHE II score was 17.5 (SD, 5.14). Almost half the
patients (122, 49.8%) were extubated within 8 hours of
ICU admission. The most common oxygen delivery device
used immediately after extubation was the simple face
mask (214 patients, 87%). Following extubation, patients
received supplemental oxygen via, on average, two
different delivery devices (range, 1–3), and had the delivery
device changed an average of 1.38 times (range, 0–6)
during the 24 hours studied. Twenty-two patients (9%)
received non-invasive ventilation or high-flow oxygen
therapy, and 16 (7%) experienced one or more episode of
hypoxaemia during mechanical ventilation. A total of 148
patients (60%) experienced one or more episodes of low
oxygenation or abnormal respiratory rate during the first 24
hours of ICU care despite receiving supplemental oxygen.
Conclusion: These findings suggest that the ICU
environment does not protect cardiac surgical patients from
suboptimal oxygen delivery, and highlights the need for
strategies to prompt the early initiation of interventions
aimed at optimising blood oxygen levels in cardiac surgical
patients in the ICU.
Crit Care Resusc 2009; 11: 238 243
244 Prospective observational study of postoperative
complications after percutaneous dilatational or
surgical tracheostomy in critically ill patients
Julie K Barbetti, Alistair D Nichol, Kim R Choate,
Michael J Bailey, Geraldine A Lee and D James Cooper

Objective: To assess and describe postoperative
complications of single dilator percutaneous dilatational
tracheostomy (PDT) and surgical tracheostomy (ST) in a
large series of critically ill patients.
Methods: A prospective observational study was
conducted in 1163 critically ill patients in a universityaffiliated
tertiary referral hospital between 2002 and 2007.
PDT was the procedure of choice for all critically ill patients
requiring tracheostomy except for those with an anatomic
abnormality or refractory coagulopathy, who underwent ST.
Demographic and postoperative complication data were
collected in a web-based database.
Results: 913 patients (79%) underwent PDT at the
bedside in the ICU, and 250 (21%) underwent ST in the
operating theatre. The tracheostomy tube was larger, and
the duration of tracheostomy cannulation was shorter after
PDT than after ST. The postoperative complication rate for
PDT was 9.6% compared with 19.6% for ST (P<0.001).
Tracheal tube obstruction and displacement were
significantly less frequent after PDT (obstruction 1.0% for
PDT v 3.6% for ST, P = 0.007; displacement, 1.3% for PDT v
4.8% for ST, P = 0.002).
Conclusions: In a large heterogeneous group of critically ill
patients, single dilator PDT was safe and had few
postoperative complications. Although ST was used in
higher-risk patients, those who underwent PDT were more
likely to receive a larger-sized tracheostomy tube; they were
also less likely to experience obstruction or displacement of
the postoperative tracheostomy tube. These differences are
probably related to a combination of patient selection,
smaller, shorter tracheostomy tubes, and larger tissue
incision size with ST.
Crit Care Resusc 2009; 11: 244 249
250 Effects of saline or albumin resuscitation on
standard coagulation tests
Rinaldo Bellomo, Hiroshi Morimatsu, Jeff Presneill,
Craig French, Louise Cole, David Story, Shigehiko Uchino,
Toshio Naka, Simon Finfer, D James Cooper and
John Myburgh, on behalf of the SAFE Study Investigators
and the Australian and New Zealand Intensive Care Society
Clinical Trials Group

Aims: To explore whether fluid resuscitation with normal
saline or 4% albumin is associated with differential changes
in routine clinical coagulation tests.
Design: Substudy from a large double-blind randomised
controlled trial, the SAFE (Saline versus Albumin Fluid
Evaluation) study.
Setting: Three general intensive care units.
Patients: Cohort of 687 critically ill patients.
Intervention: We randomly allocated patients to receive
either 4% human albumin or normal saline for fluid
resuscitation, and collected demographic and
haematological data.
Methods and main results: Albumin was administered
to 338 patients and saline to 349. At baseline, the two
groups had similar mean activated partial thromboplastin
time (APTT) of 37.2 s (albumin) v 39.1 s (saline); mean
international normalised ratio (INR) of 1.38 v 1.34, and
mean platelet count of 244 x 109/L v 249 x 109/L. After
randomisation, during the first day of treatment, the APTT
in the albumin group was prolonged by a mean of 2.7 s, but
shortened slightly by a mean of -0.9 s in the saline group.
The INR did not change in either group, while the platelet
count decreased transiently in both groups. Using
multivariate analysis of covariance to account for baseline
coagulation status, albumin fluid resuscitation (P = 0.01)
and a greater overall volume of resuscitation (P = 0.03) were
independently associated with prolongation of APTT during
the first day.
Conclusions: Administration of albumin or of larger fluid
volumes is associated with a prolongation of APTT. In ICU
patients, the choice and amount of resuscitation fluid may
affect a routinely used coagulation test.
Crit Care Resusc 2009; 11: 250 256
257 Predicting future intensive care demand in
Charlie Corke, Evelyne de Leeuw, Sing K Lo and
Carol George

Background: Predicting future demand for intensive care
is vital to planning the allocation of resources.
Method: Mathematical modelling using the autoregressive
integrated moving average (ARIMA) was applied to
intensive care data from the Australian and New Zealand
Intensive Care Society (ANZICS) Core Database and
population projections from the Australian Bureau of
Statistics to forecast future demand in Australian intensive
Results: The model forecasts an increase in ICU demand of
over 50% by 2020, with current total ICU bed-days (in
2007) of 471 358, predicted to increase to 643 160 by
2020. An increased rate of ICU use by patients older than
80 years was also noted, with the average bed-days per
10 000 population for this group increasing from 396 in
2006 to 741 in 2007.
Conclusion: An increase in demand of the forecast
magnitude could not be accommodated within current ICU
capacity. Significant action will be required.
Crit Care Resusc 2009; 11: 257 260

261 Automated external defibrillators and survival after
in-hospital cardiac arrest: early experience at an
Australian teaching hospital
Roger J Smith, Bernadette B Hickey and John D Santamaria

Objective: To evaluate the effect of the introduction of
automated external defibrillators (AEDs) on survival after inhospital
cardiac arrest.
Design, setting and participants: Before-and-after study
that compared patients during the 2 years before
(8 November 2005 to 7 November 2007) and the year after
(8 November 2007 to 7 November 2008) the deployment of
AEDs to the non-critical care areas of a university teaching
Main outcome measures: Return of spontaneous
circulation (ROSC) and survival to hospital discharge.
Results: 55 in-hospital cardiac arrests occurred in the
2-year pre-AED period and 31 in the 1-year AED period.
Patients had similar baseline characteristics in the pre-AED
and AED periods including witnessed arrest (53% v 48%),
arrest in an acute inpatient ward (78% v 90%), and initial
arrest rhythm of pulseless ventricular tachycardia or
ventricular fibrillation (18% v 16%). The proportions of
patients with ROSC were similar in the pre-AED and AED
periods (42% v 55%), as were the proportions who
survived to hospital discharge (22% v 29%). In the AED
period, the relative risk of ROSC was 1.31 (95% CI, 0.84–
2.04) and the relative risk of survival to hospital discharge
was 1.33 (95% CI, 0.63–2.80).
Conclusions: ROSC and survival to hospital discharge did
not change significantly after deployment of AEDs. The
existence of a timely and robust resuscitation response with
relatively good baseline outcomes, and the low proportion
of initial shockable arrest rhythms may have limited the
capacity of AEDs to improve survival.
Crit Care Resusc 2009; 11: 261 265

266 Withholding and withdrawal of life-sustaining
therapies in intensive care: an Australian experience
Jorge L Brieva, Prashanth Cooray and Martin Rowley

Objectives: Withholding and withdrawal of treatment in
intensive care is currently widely accepted, but little has
been published about Australian practice.
Design and setting: Retrospective audit of all deaths in
two major tertiary intensive care units in the Hunter New
England Area Health Service during 2008. Patients who
died were classified as “no limitations” (died while receiving
full treatment), “treatments withheld” (specific treatment
limitations) or “withdrawal of life-sustaining treatment”
Results: Of 1950 patients admitted to an ICU, 283 died
(14.5%). Of these 283, 54 (19%) died despite all
therapeutic efforts; 97 (34%) had treatments withheld, and
132 (47%) had WLST. There were no statistically significant
differences in length of stay between the three groups.
Patients who died despite all therapeutic efforts were
younger than those who died after treatments were
withheld or WLST (mean age [SD], 58.7 [21.1] v 73.1 [12.5]
v 69.3 [13.5]; P = 0.001). APACHE II score was higher in the
group who died than in the total ICU group (mean [SD],
25.5 [8.3] v 17.7 [8.7], P = 0.001).
Conclusions: In this population of critically ill patients,
most deaths occurred after discussion of end-of-life
decisions and withholding or withdrawal of treatment.
Crit Care Resusc 2009; 11: 266 268

269 Emphysematous pyelonephritis: an unusual
complication of blunt abdominal trauma
Gregor B S McNeill, Anthony Holley and Jeffrey Lipman

We report an unusual case of emphysematous
pyelonephritis after blunt abdominal trauma in a 28-yearold
woman. She was previously healthy and did not have
diabetes. Treatment with antibiotics and percutaneous
drainage was successful. We review the diagnostic and
management strategies for this condition.
Crit Care Resusc 2009; 11: 269 271

272 Prolonged serotonin toxicity with proserotonergic
drugs in the intensive care unit
Luke E Torre, Rajiv Menon and Bradley M Power

Serotonin toxicity secondary to drug therapy, interaction or
overdose is an increasing phenomenon worldwide. A
proportion of patients require admission to an intensive care
unit, but the treatment needed is usually supportive and of
short duration. Prolonged ICU admission to control ongoing
or long-lasting serotonin toxicity has not been reported
We describe three patients with prolonged serotonin
toxicity, lasting 12–18 days. Symptoms of toxicity were
easily demonstrable in each and were refractory to currently
recommended therapies.
We review the pharmacological mechanisms that led to
prolonged serotonin toxicity in these patients. Predictors for
prolonged serotonin toxicity include involvement of
irreversible monoamine oxidase inhibitors (MAOIs) or slow release
preparations resistant to the effects of activated
charcoal (eg, lithium). We also discuss the implications of
prolonged toxicity for critical care management, to maintain
optimal patient outcomes.
Crit Care Resusc 2009; 11: 272 275
276 A new paradigm for treating infections:
“go hard and go home”
Jeffrey Lipman and Rob Boots

There is now significant evidence that initial use of the correct
antibiotic saves more lives than virtually all other intensive
care therapy. This means covering all possible causative
organisms with the initial empirical choice. For nosocomial
sepsis, broad-spectrum antibiotics must be started as soon as
the relevant samples have been taken for culture, with deescalation
of therapy targeted to the causative organisms
when results and susceptibilities are available.
There is an international trend to use shorter antibiotic courses.
Pseudomonas pneumonia probably needs a 7–10 day course.
In our ICU, provided the infection source is controlled, we
seldom use antibiotic courses longer than 7 days.
Evaluation of the kill characteristics of antibiotics in
experimental models suggests that different classes of
antibiotics should have different dosing regimens. For beta-
lactam antibiotics, the kill characteristic is almost entirely
related to the time that tissue and plasma levels exceed a
certain threshold, with no significant post-antibiotic effect,
particularly against gram-negative organisms. Kill
characteristics of other antibiotics, such as aminoglycosides,
relate to adequate peak concentrations and a significant
post-antibiotic effect.
Clinically, these kill characteristics translate into the need for
appropriate doses of the various antibiotics in patients with
sepsis. We have shown that some patients with normal
serum creatinine levels have very high creatinine clearance
rates; in ICU patients with sepsis, blood pressure and tissue
perfusion are maintained with large fluid loads and inotropic
agents, thereby raising creatinine clearance. High clearances
produce low trough concentrations of antibiotic, with
important implications for underdosing and the development
of antibiotic resistance.
The new paradigm for treating sepsis, particularly nosocomial
sepsis, is: get it right the first time, hit hard up front, and use
large doses of broad-spectrum antibiotics for a short period.
Crit Care Resusc 2009; 11: 276 281
282 New antimicrobial agents for methicillin-resistant
Staphylococcus aureus
Marin H Kollef

In bacterial and fungal infections, optimal outcomes are
obtained through the timely provision of adequate
antimicrobial coverage in an initial anti-infective treatment
regimen. However, selecting appropriate antimicrobial
regimens to treat infections in the intensive care unit is
challenging because of the expansion of antibiotic
resistance. Multidrug anti-infective regimens are typically
needed to adequately cover common important pathogens
in ICUs.
Here, we describe novel antibacterial agents in the late
stages of clinical development that show potential for
treating methicillin-resistant Staphylococcus aureus (MRSA)
These include the fifth-generation cephalosporins,
ceftaroline and ceftobiprole; the glycopeptides,
dalbavancin, oritavancin, and telavancin; and iclaprim.
Crit Care Resusc 2009; 11: 282 286
287 Assessment of tissue cortisol activity
Jeremy Cohen and Bala Venkatesh

The concept of relative adrenal insufficiency in patients with
severe sepsis continues to be controversial. This arises in part
from the lack of an accepted “gold standard” for the diagnosis
of adrenal insufficiency in the critically ill. Historically,
assessment of adrenal function in this population has relied on
measurement of plasma total cortisol level, in a blood sample
taken either at random or as part of a corticotropin stimulation
test. However, an alternative is to focus on the site of
glucocorticoid activity within the tissues as a potentially more
useful index of functional adrenal status.
We review the mechanisms known to affect tissue
glucocorticoid activity and examine how they may be modified
by critical illness. These include both free and interstitial cortisol
concentrations, intracellular cortisol generation, and
glucocorticoid-receptor activity and density. Changes in these
factors are not reflected in plasma total cortisol concentrations,
and more sophisticated techniques, including genetic
transcriptional surveys, may be required to reveal the role of
glucocorticoid insufficiency in critical illness.
Crit Care Resusc 2009; 11: 287 289
290 Should we mobilise critically ill patients?
A review
Enda D O’Connor and James Walsham
Background: Neuromuscular weakness, a frequent
complication of prolonged bed rest and critical illness, is
associated with morbidity and mortality. Mobilisation
physiotherapy has widespread application in patients
hospitalised with non-critical illness.
Objectives: We reviewed the literature to evaluate the
worldwide availability of mobilisation therapy in intensive
care units and the role of mobilisation therapy in patients
requiring medical or surgical high dependency or intensive
Methods: We searched PubMed (1980 to August 2009)
using the MeSH terms “physiotherapy” and “intensive
care”. Additional keyword search terms, “mobilisation”,
“mobilization”, and “fast-track”, were used. In addition,
we examined reference lists in recent studies and reviews.
Results: Routine mobilisation physiotherapy is least likely to
be available in ICUs in the United States. Early mobilisation
is appropriate for patients with pulmonary thromboembolic
disease, community-acquired pneumonia and in elderly
hospitalised patients. Although fast-track cardiac and noncardiac
surgery with early ambulation is safe and reduces
hospital length of stay, it does not alter postoperative
mortality. Up to 25% of patients can be safely mobilised
within 72 hours of ICU admission. This therapy may reduce
hospital and ICU length of stay, shorten duration of
mechanical ventilation, and improve muscle strength and
functional independence scores. Pooled data show a nonsignificant
mortality benefit in favour of early mobilisation
(odds ratio, 0.77; 95% CI, 0.49–1.21).
Conclusions: The data in support of mobilisation therapy
for perioperative and critically ill patients, while of a low
level of evidence, are substantial. This justifies a paradigm
shift in attitudes towards physiotherapy and the prevention
of critical illness weakness.
Crit Care Resusc 2009; 11: 290 300
301 Sick adrenal or sick euadrenal?
Bala Venkatesh and Jeremy Cohen

The role of glucocorticoid supplementation in septic shock
remains contentious. In septic shock, the driver for steroid
therapy is the premise that there is relative adrenal
insufficiency (based on reduced plasma cortisol and blunted
cortisol response to corticotropin). The uncertainty arises
from the inability of current tests to clearly identify patients
who are truly corticosteroid “deficient” at a cellular level, and
hence require supplemental glucocorticoid administration.
We hypothesise that plasma measurements (total plasma
cortisol level and the response to corticotropin) do not
consistently reflect the functional adrenal response to stress.
Published evidence indicates that there are cellular
adaptations in stress, such as pre-receptor upregulation of
cortisol, altered receptor density and gene transcription
changes, none of which are reflected by plasma cortisol level.
This leads us to postulate that the lack of a clearly defined
plasma response in severe stress and the presence of an
adequate response at the cellular level suggest it is a “sick
euadrenal state”, analogous to the sick euthyroid state, and
not a sick adrenal indicating adrenal insufficiency.
Crit Care Resusc 2009; 11: 301 304

305 Forget glucose: what about lipids in critical illness?
Peter S Kruger

A high serum cholesterol level is a risk factor for
cardiovascular disease and has commonly been linked with
worse outcomes. It is now well recognised that, in many
critically ill patients, the opposite is true, with
hypocholesterolaemia being associated with poor outcomes.
In critical illness, particularly sepsis, total and high-density
lipoprotein (HDL) cholesterol levels are commonly decreased,
with varying changes in triglyceride levels. The magnitude of
the changes seems to reflect the severity of inflammation.
Plausible biological explanations exist to explain these
associations, including an interaction of lipoproteins with
endotoxin and the regulation of cytokine production. It
remains unclear whether these observed alterations in lipid
profile are a consequence of the physiological disturbance or
whether they have a more causative role, worsening organ
dysfunction or predisposing to infection.
Lipid emulsions provide a vehicle for drug delivery, have
become an important part of nutrition, and are emerging as
a therapy for specific intoxications. The nature, dietary source
and amount of lipid provided to critically ill patients may be
enormously important and warrant more rigorous
investigation. Further understanding of the alterations in lipid
metabolism may have therapeutic implications in treatment
of sepsis with specific compounds that manipulate lipid
profiles, such as fibrates, statins, niacin and even
reconstituted HDL.
Crit Care Resusc 2009; 11: 305 309
The association between preoperative eGFR and
outcomes in cardiac surgical patients
310 Elizabeth M Moore and Antony E Tobin
310 Daniel V Mullany, Carole L Foot and John F Fraser

260 Copyright transfer form

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