Bedford Park, Australia
Bedford Park, Australia

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Sampson B.G.,Intensive and Critical Care Unit | Datson L.D.,Intensive and Critical Care Unit | Bihari S.,Intensive and Critical Care Unit
Critical Care and Resuscitation | Year: 2017

Objectives: To describe the use of imaging studies (four-vessel angiography or radionuclide scan) for brain death determination in South Australian intensive care units, and to determine the rates of adherence with The ANZICS statement on death and organ donation of the Australian and New Zealand Intensive Care Society (ANZICS). Design, patients and setting: Retrospective case-note review of 190 South Australian adult patients (≥ 18 years) who were brain dead and were organ donors (actual and intended), from 1 January 2008 to 31 December 2014. Main outcome measures: We compared brain death determination by clinical examination and by imaging, and identified, using logistic regression, the independent predictors of brain death determination by imaging (and for imaging without a documented indication). Results: Brain death determination by imaging occurred for 79 patients who were brain-dead donors (41.6%), with a documented indication in only 38 patients (48.1%), of whom 35 had an indication which adhered to ANZICS recommendations. The group who had brain death determined by imaging were younger (P < 0.001), with a higher proportion of hypoxic brain injury (P = 0.01) and therapeutic hypothermia (P = 0.02). Independent predictors of brain death determination by imaging were female sex (β = 3.101, P = 0.03), age (β = 0.964, P = 0.01), brain death determination between 5 pm and 8 am (β = 0.332, P = 0.04), cause of death (β = 1.833, P = 0.04), therapeutic hypothermia (β = 0.162, P = 0.04) and terminal serum sodium level = 150 mmol/L (β = 0.131, P = 0.005); Nagelkerke R2 = 0.669. Hypoxia was the only independent predictor of imaging without a documented ANZICS indication (β = 0.071, P = 0.032; Nagelkerke R2 = 0.581). Conclusions: Therapeutic hypothermia, terminal serum sodium level ≥ 150 mmol/L and cause of death were independent predictors of brain death determination by imaging study. Documentation of imaging indication was poor, particularly after hypoxic brain injury. This may reflect emerging indications for imaging, poor adherence to ANZICS recommendations, or simple omissions. © 2017 Australasian Medical Publishing co. All rights reserved.


Sampson B.G.,Intensive and Critical Care Unit | Sampson B.G.,Flinders University | O'Callaghan G.P.,Intensive and Critical Care Unit | O'Callaghan G.P.,Flinders University | And 2 more authors.
Critical Care and Resuscitation | Year: 2013

Background: Donation after cardiac death (DCD) has increased faster than donation after brain death (DBD) in Australia. However, DBD is the preferred pathway because it provides more organs per donor, the donation process is simpler and transplant outcomes are optimised. Objective: To determine if the increase in DCD has reduced the brain-dead donor pool in Australia. Design, setting and participants: Retrospective analysis of records of organ donors (intended and actual) with brain injury as the cause of death from 2001 to 2011 in Australian intensive care units. Main outcome measures: Change in median ventilation period, over time, before brain-death determination in DBD donors (as DCD increased); a decreased median ventilation period in DBD donors being consistent with the conversion of DBD to DCD. Results: As DCD (n = 311) increased, the median ventilation period in DBD donors (n = 2218) did not fall overall (P = 0.83), in all jurisdictions (P > 0.25) and for all causes of death (P > 0.3). The proportion of patients ventilated for less than 2 days was unchanged over time in both DBD (P =1) and DCD (P=0.99). The overall ventilation period in DCD donors (3.8 days; interquartile range [IQR], 2.1-6.3 days), exceeded the ventilation period in DBD donors (1.3 days; IQR, 1.0-2.4 days; P < 0.0001). DCD ventilation period was significantly longer in all jurisdictions, for all causes of death and annually (P < 0.05). Conclusions: In Australia, brain-injured donors appear to be ventilated long enough to allow progression to brain death before proceeding to DCD. Therefore, DCD is unlikely to have reduced the brain-dead donor pool.


Dixon D.-L.,Intensive and Critical Care Unit | De Pasquale C.G.,Flinders Medical Center | De Pasquale C.G.,Flinders University | Bersten A.D.,Intensive and Critical Care Unit
Heart Lung and Circulation | Year: 2015

Background: Chronic heart failure (CHF) following coronary artery ligation and myocardial infarction in the rat leads to a homeostatic reduction in surface tension with associated alveolar type II cell hyperplasia and increased surfactant content, which functionally compensates for pulmonary collagen deposition and increased tissue stiffness. To differentiate the effects on lung remodelling of the sudden rise in pulmonary microvascular pressure (Pmv) with myocardial infarction from its consequent chronic elevation, we examined a hypertensive model of CHF. Methods: Cardiopulmonary outcomes due to chronic pulmonary capillary hypertension were assessed at six and 15 weeks following abdominal aortic banding (AAB) in the rat. Results: At six weeks post-surgery, despite significantly elevated left ventricular end-diastolic pressure, myocardial hypertrophy and increased left ventricular internal circumference in AAB rats compared with sham operated controls (p. ≤. 0.003), lung weights and tissue composition remained unchanged, and lung compliance was normal. At 15 weeks post-surgery increased lung oedema was evident in AAB rats (p. =. 0.002) without decreased lung compliance or evidence of tissue remodelling. Conclusion: Despite chronically elevated Pmv, comparable to that resulting from past myocardial infarction (LVEDP. >. 19. mmHg), there is no evidence of pulmonary remodelling in the AAB model of CHF. © 2014 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ).


Baldwin C.E.,University of South Australia | Baldwin C.E.,Flinders Medical Center | Bersten A.D.,Flinders University | Bersten A.D.,Intensive and Critical Care Unit
Current Opinion in Clinical Nutrition and Metabolic Care | Year: 2015

Purpose of review Survivors of a critical illness may experience poor physical function and quality of life as a result of reduced skeletal muscle mass and strength during their acute illness. Patients diagnosed with sepsis are particularly at risk, and mechanical ventilation may result in diaphragm dysfunction. Interest in the interaction of these conditions is both growing and important to understand for individualized patient care. Recent findings This review describes developments in the presentation of both diaphragm and limb myopathy in critical illness, as measured from muscle biopsy and at the bedside with various imaging and strength-testing modalities. The influence of unloading of the diaphragm with mechanical ventilation and peripheral muscles with immobilization in septic patients has been recently questioned. Systemic inflammation appears to primarily accelerate and accentuate dysfunction, which may be remedied by early mobilization and augmented with developing muscle and/or nerve stimulation techniques. Summary Many acute muscle changes in septic patients are likely to stem from pre-existing impairments, which should provide context for clinical evaluations of strength. During illness, sarcolemmal injury promotes a cascade of intra-cellular abnormalities. As unique characteristics of ICU-acquired weakness and differential effects on muscle groups are understood, early diagnosis and management should be facilitated. © 2015 Wolters Kluwer Health, Inc. All rights reserved.


Dixon D.-L.,Intensive and Critical Care Unit | Dixon D.-L.,Flinders University | Griggs K.M.,Flinders University | Forsyth K.D.,Flinders University | And 2 more authors.
Pediatric Allergy and Immunology | Year: 2010

Breastfeeding during the first 12months of life confers demonstrable immunologic benefit against infective pathogens, including those of the respiratory tract. However, the mechanism by which the ingestion of human milk modifies immunologic defense against such pathogens remains elusive. Bronchiolitis, caused predominantly by respiratory syncytial virus, is the most common clinical presentation of severe upper respiratory illness requiring hospitalization in infants and remains one of the developed world's leading causes of infant mortality and morbidity over both the short and long term. The mechanism by which an early, severe case of bronchiolitis can result in the development of recurrent childhood wheeze or asthma is unclear; however, mucosal inflammation and pulmonary neutrophilia are believed to play a significant role. The aim of this study was to examine the immune response of breastfed infants hospitalized with severe bronchiolitis, compared with formula-fed controls. Nasopharyngeal aspirates (NPA) were collected from 18 infants (aged ≤12months), seven breastfed and 11 formula fed and assayed by enzyme immunoassays for chemokines interleukin (IL)-8 and monocyte chemotactic protein (MCP)-1. NPA cellular component was quantified by light microscopy. Breastfed infants had lower levels of the chemokine IL-8 in their nasal airways with a concurrent decrease in cellular infiltrate (p≤0.04). NPA cell number correlated with lactoferrin concentration (p=0.02) but not with myeloperoxidase, suggesting the predominance of mature, secondary granule laden neutrophils. These findings indicate a potential mechanism of protective immune regulation during bronchiolitis in the breastfed infant. © 2010 John Wiley & Sons A/S.


Dixon D.-L.,Intensive and Critical Care Unit | Dixon D.-L.,Flinders University | Griggs K.M.,Flinders University | Bersten A.D.,Intensive and Critical Care Unit | And 3 more authors.
Cytokine | Year: 2011

Chronic heart failure (CHF) leads to complex effects distant from the heart. As these changes may be reflected in the balance of systemic inflammatory and fibrotic immunomodulators we measured these potential biomarkers in ambulatory CHF patients. Using the New York Heart Association (NYHA; levels II-IV) functional classification, 30 CHF patients were compared with 21 age and gender matched controls. Peripheral blood levels of regulatory cytokines (TNF-α, TGF-β, KGF, IL-8, IL-10 and IL-12) and markers of cellular activation (CD11b, CD16, CD18, CD34, HLADR, CXCR1 and CCR5) were analysed by ELISA and flow cytometry, respectively. NYHA classification, which reflected increasing pulmonary microvascular pressure (E:. E') but not ejection fraction, was positively associated with TGF-β and IL-10 (p≤ 0.03). Similarly, monocytes, as well as cell surface expression of the neutrophil adhesion molecule CD11b, and the macrophage complement receptor complex (CD11b/CD18), were increased in CHF patients (p≤ 0.03), while the chemokine receptor CXCR1 was decreased on cells of CHF patients. Twenty month follow-up of CHF subjects identified monocyte number as a powerful prognostic factor for cardio-pulmonary adverse events (p= 0.001); however, no concurrent relationship with cellular activation marker expression was found. In subjects with CHF, monocytes, TGF-β, IL-10, CD11b/CD18 and CXCR1 expression in peripheral blood may act as novel biomarkers of immune activation and remodelling. Given the importance of dyspnea and the relationship of pulmonary microvascular pressure to the NYHA classification, we suggest these findings may reflect a contribution by the lung. © 2011 Elsevier Ltd.


Prentice C.E.,Intensive and Critical Care Unit
Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine | Year: 2010

BACKGROUND: Critically ill patients are exposed to a combination of insults that affect both respiratory and peripheral skeletal muscle function. However, different muscle groups may not be affected to the same extent by a prolonged critical illness. OBJECTIVE: To review original observational studies that measured an aspect of respiratory and peripheral muscle function in adults in the intensive care setting. DESIGN: Systematic review strategy and qualitative data synthesis. DATA SOURCES AND REVIEW METHODS: Four major citation databases were searched. Search terms included intensive care, critical care, diaphragm, quadriceps, and skeletal, respiratory and limb muscle. Titles and abstracts were reviewed to identify studies that measured both respiratory and peripheral muscle function. Reference lists of suitable publications were screened. Studies sampling critically ill patients with a neurological condition were excluded. RESULTS: 1119 items were identified, and 19 full-text/ abstract publications were reviewed. Ten studies investigated patients with a critical illness-related neuromuscular disorder. Nine studies targeted septic patients with multiple organ failure or patients requiring prolonged mechanical ventilation. Clinical, electrophysiological and muscle biopsy specimen data were collected at different time-points and milestones relating to alertness, weaning criteria, respiratory support reduction and extubation. CONCLUSIONS: Currently available bedside methods of measuring respiratory and peripheral muscle function in critically ill patients are somewhat inadequate. Yet there is evidence suggesting that respiratory muscles may be relatively spared from the damage that can occur as a result of immobility, prolonged mechanical ventilation and systemic inflammation in critical illness.


Baldwin C.E.,Flinders University | Paratz J.D.,University of Queensland | Bersten A.D.,Flinders University | Bersten A.D.,Intensive and Critical Care Unit
Journal of Critical Care | Year: 2013

Purpose: Dynamometry is an objective tool for volitional strength evaluation that may overcome the limited sensitivity of the Medical Research Council scale for manual muscle tests, particularly at grades 4 and 5. The primary aims of this study were to investigate the reliability, minimal detectable change, and time to peak muscle force, measured with portable dynamometry, in critically ill patients. Materials and methods: Isometric hand grip, elbow flexion, and knee extension were measured with portable dynamometry. Results: Interrater consistency (intraclass correlation coefficient [95% confidence interval]) (0.782 [0.321-0.930] to 0.946 [0.840-0.982]) and test-retest agreement (0.819 [0.390-0.943] to 0.918 [0.779-0.970]) were acceptable for all dynamometry forces, with the exception of left elbow flexion. Despite generally good reliability, a mean change (upper 95% confidence interval) of 2.8 (7.8) kg, 1.9 (5.2) kg, and 2.6(7.1) kg may be required from a patient's baseline force measurement of right grip, elbow flexion, and knee extension to reflect real force changes. There was also a delay in the time for critically ill patients to generate peak muscle forces, compared with healthy controls (P ≤ .001). Conclusions: Dynamometry can provide reliable measurements in alert critically ill patients, but moderate changes in strength may be required to overcome measurement error, during the acute recovery period. Deficits in force timing may reflect impaired neuromuscular control. © 2013 Elsevier Inc.


PubMed | Intensive and Critical Care Unit
Type: Journal Article | Journal: Children (Basel, Switzerland) | Year: 2016

Infants who are breastfed are at an immunological advantage when compared with formula fed infants, evidenced by decreased incidence of infections and diminished propensity for long term conditions, including chronic wheeze and/or asthma. Exclusive breastfeeding reduces the duration of hospital admission, risk of respiratory failure and requirement for supplemental oxygen in infants hospitalised with bronchiolitis suggesting a potentially protective mechanism. This review examines the evidence and potential pathways for protection by immunomodulatory factors in human milk against the most common viral cause of bronchiolitis, respiratory syncytial virus (RSV), and subsequent recurrent wheeze in infants. Further investigations into the interplay between respiratory virus infections such as RSV and how they affect, and are affected by, human milk immunomodulators is necessary if we are to gain a true understanding of how breastfeeding protects many infants but not all against infections, and how this relates to long-term protection against conditions such as chronic wheezing illness or asthma.


PubMed | Bendigo Hospital, Lyell McEwin Hospital, Outreach, Canberra Hospital and 3 more.
Type: Journal Article | Journal: Critical care and resuscitation : journal of the Australasian Academy of Critical Care Medicine | Year: 2016

Rapid response team (RRT) responders would benefit from training, to ensure competent and efficient management of the deteriorating patient.We obtained delegate feedback on a pilot training course for RRTs, commissioned by the Australian and New Zealand Intensive Care Society (ANZICS), at the second ANZICS: The Deteriorating Patient Conference.We surveyed participants on their perceptions of the course overall, and their perceptions of sessions containing presentations and videotaped and live demonstrations of simulated scenarios of patients whose conditions were deteriorating.The survey response rate was 64% (96 of 150 potential attendees). Responses were positive, with 79.8% of responses (912/1143) agreeing that the participants had learnt something new, that the course would increase their confidence and competence during RRT calls, and that it had assisted them as an educator. The course was well received overall, with the interactive and live demonstration components of the course garnering positive feedback in the comments section of surveys.There was unanimous agreement by participants for further development of a formalised RRT training course for responding to the deteriorating patient. Participants who were RRT educators also supported the development of an RRT train-the-trainer course.

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