Crit Care Resusc
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The long-term outcomes of patients with drug overdose admitted to the intensive care unit compared with those admitted to general wards have not been assessed. We aimed to compare the recurrence of overdose, mortality after hospital discharge, cause of death and quality-of-life scores (using the EQ-5D questionnaire) between the ICU patients and general ward patients. ⋯ ICU and general ward patients with overdose have similar, overwhelming prevalences of psychiatric disease, and similar outcome profiles. Such patients experience frequent overdoses and, despite being young, if admitted to the ICU, have a 10% 4-year mortality, with self-harm the dominant cause of death. Finally, among survivors who responded to the follow-up questionnaire, quality of life is poor.
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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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The cardiac output (CO) response to sepsis is typically measured in the intensive care unit after modification by fluid and/or vasoactive drug resuscitation and found to be hyperdynamic. In contrast, the native (preresuscitation) CO in human sepsis is poorly defined. ⋯ Data about the native CO in human sepsis are scant because therapeutic intervention usually precedes measurement. From the limited data available, it appears that most patients are in a normodynamic haemodynamic state at presentation, and cardiac performance also seems to be impaired at the earliest stage of sepsis. As initial resuscitation is partly predicated on assumptions about the underlying cardiovascular physiology, our findings suggest the need to address this knowledge deficit in the management of patients with severe sepsis.
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Observational Study
Epidemiology of secondary fluid bolus therapy for infection-associated hypotension.
Fluid bolus therapy (FBT) is a common therapy for hypotensive sepsis, but no studies have compared primary FBT (in the first 6 hours after presentation to the emergency department [ED]) with secondary FBT (6-24 hours after presentation to the ED). We aimed to describe the patterns of use, physiological sequelae and outcomes of patients with hypotensive sepsis who were treated with primary FBT or combined primary and secondary FBT (secondary FBT). ⋯ Secondary FBT is given to about half of patients presenting with hypotensive sepsis, takes place in wards more often than in the ICU and delivers a significant proportion of overall fluids, but is associated with limited changes in measured physiological variables.