Crit Care Resusc
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To test a simple clinical guideline to reduce unnecessary routine testing of coagulation status. ⋯ A simple clinical guideline and educational package reduced unnecessary coagulation tests and costs in a tertiary referral ICU.
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Low tidal volume ventilation reduces mortality in patients with acute lung injury (ALI) and may reduce the risk of ALI in ventilated patients. A previous audit of our ventilation practices showed poor adherence to low tidal volume ventilation, and we subsequently introduced written ventilation guidelines and an education program to change practice. ⋯ Written protocols and education can influence clinician behaviour, with substantial improvements in adherence to low tidal volume ventilation. Efforts to improve adherence through ward-based education appear warranted and necessary. Adherence was strongly associated with patient height, which suggested that adherence was partly the result of chance rather than design.
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Outcomes for very old patients (≥ 80 years) referred but not admitted to an intensive care unit have not been described in Australia and New Zealand. ⋯ Very old patients considered too well for the ICU have a significantly lower hospital mortality rate than those admitted to the ICU after urgent referral. However, 12 months after referral, patients considered too well for ICU admission have a mortality rate approaching that of very old patients admitted to the ICU. Over half of very old patients urgently referred to the ICU die within 12 months.
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Recent viewpoints on critical care have expressed frustration at the slow development of new therapeutic agents and the failure of investigator-initiated trials. Several new directions have been proposed: personalised medicine and the embracing of "omic" technologies, resolving the heterogeneity of treatment effects, and adaptive trial designs. We examine these approaches in the context of analysis of randomised controlled trials (RCTs). ⋯ We find the uncritical appeal to personalised medicine to be misplaced because such treatments are not identified at the personal level, but at the group or stratified level. The analysis of RCTs has foundered over the problem of accounting for the centre effect and rejecting the random effects approach. Enthusiasm for adaptive trial designs has been articulated at the rhetorical, not the substantive, level.
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Observational Study
Prior exposure to hyperglycaemia attenuates the relationship between glycaemic variability during critical illness and mortality.
Our primary objective was to determine the impact of prior exposure to hyperglycaemia on the association between glycaemic variability during critical illness and mortality. Our secondary objectives included evaluating the relationships between prior hyperglycaemia and hyperglycaemia or hypoglycaemia during critical illness and mortality. ⋯ Prior exposure to hyperglycaemia attenuates the association between glycaemic variability and mortality in critically ill patients with diabetes.