Publications by authors named "Kiran Shekar"

110 Publications

Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia.

PLoS One 2021 8;16(4):e0249840. Epub 2021 Apr 8.

Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.

Background: Although critical illness is usually of high acuity and short duration, some patients require prolonged management in intensive care units (ICU) and suffer long-term morbidity and mortality.

Objective: To describe the long-term survival and examine determinants of death among patients with prolonged ICU admission.

Methods: A retrospective cohort of adult Queensland residents admitted to ICUs for 14 days or longer in North Brisbane, Australia was assembled. Comorbid illnesses were classified using the Charlson definitions and all cause case fatality established using statewide vital statistics.

Results: During the study a total of 28,742 adult Queensland residents had first admissions to participating ICUs of which 1,157 (4.0%) had prolonged admissions for two weeks or longer. Patients with prolonged admissions included 645 (55.8%), 243 (21.0%), and 269 (23.3%) with ICU lengths of stay lasting 14-20, 21-27, and ≥28 days, respectively. Although the severity of illness at admission did not vary, pre-existing comorbid illnesses including myocardial infarction, congestive heart failure, kidney disease, and peptic ulcer disease were more frequent whereas cancer, cerebrovascular accidents, and plegia were less frequently observed among patients with increasing ICU lengths of stay lasting 14-20, 21-27, and ≥28 days. The ICU, hospital, 90-day, and one-year all cause case-fatality rates were 12.7%, 18.5%, 20.2%, and 24.9%, respectively, and were not different according to duration of ICU stay. The median duration of observation was 1,037 (interquartile range, 214-1888) days. Although comorbidity, age, and admitting diagnosis were significant, neither ICU duration of stay nor severity of illness at admission were associated with overall survival outcome in a multivariable Cox regression model.

Conclusions: Most patients with prolonged stays in our ICUs are alive at one year post-admission. Older age and previous comorbidities, but not severity of illness or duration of ICU stay, are associated with adverse long-term mortality outcome.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0249840PLOS
April 2021

Ceftriaxone exposure in patients undergoing extracorporeal membrane oxygenation.

Int J Antimicrob Agents 2021 Mar 26:106326. Epub 2021 Mar 26.

KU Leuven Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Herestraat 49, B‑3000 Leuven, Belgium; Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.

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http://dx.doi.org/10.1016/j.ijantimicag.2021.106326DOI Listing
March 2021

Venoarterial Extracorporeal Membrane Oxygenation for Postcardiotomy Shock-Analysis of the Extracorporeal Life Support Organization Registry.

Crit Care Med 2021 Feb 23. Epub 2021 Feb 23.

1 Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands. 2 Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior and Administration, Centre of Postgraduate Medical Education, Warsaw, Poland. 3 Thoracic Research Centre, Collegium Medicum, Nicolaus Copernicus University, Innovative Medical Forum, Bydgoszcz, Poland. 4 Warsaw Medical University, Warsaw, Poland. 5 Center for Acute Respiratory Failure and Department of Medicine, Columbia University College of Physicians & Surgeons/New York-Presbyterian Hospital, New York, NY. 6 Cardiothoracic Intensive Care Unit, National University Hospital, Singapore;. 7 Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD. 8 Cardiac Surgery Unit, ISMETT, Palermo, Italy. 9 Department of Cardiac Surgery, University of Dusseldorf, Dusseldorf, Germany. 10 Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, VIC, Australia. 11 Cardiovascular Surgery and Pediatric Cardiovascular Surgery, National Taiwan University Hospital, Taipei, Taiwan. 12 Department of Cardiothoracic Surgery, Jefferson University, Philadelphia, PA. 13 Department of Cardio-Thoracic Surgery, Massachusetts Medical Centre, Boston, MA. 14 Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, P.R. of China. 15 Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI. 16 2nd Department of Medicine-Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University, Prague, and General University Hospital, Prague, Czech Republic. 17 Department of Pathophysiology, Faculty of Pharmacy, Collegium Medicum, Nicolaus Copernicus University, Toruń, Poland. 18 Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA. 19 Department of Pediatrics, C.S. Mott Children's Hospital, University of Michigan Ann Arbor, MI. 20 Department of Cardio-Thoracic Surgery, Well Cornell Medicine, New York, NY. 21 Cardiac Surgery Unit, University Hospital, University of Chieti, Chieti, Italy. 22 Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands.

Objectives: Refractory postcardiotomy cardiogenic shock complicating cardiac surgery yields nearly 100% mortality when untreated. Use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock has increased worldwide recently. The aim of the current analysis was to outline the trends in use, changing patient profiles, and in-hospital outcomes including complications in patients undergoing venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Design: Analysis of extracorporeal life support organization registry from January 2010 to December 2018.

Setting: Multicenter worldwide registry.

Patients: Seven-thousand one-hundred eighty-five patients supported with venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock.

Interventions: Venoarterial extracorporeal membrane oxygenation.

Measurements And Main Results: Hospital death, weaning from extracorporeal membrane oxygenation, hospital complications. Mortality predictors were assessed by multivariable logistic regression. Propensity score matching was performed for comparison of peripheral and central cannulation for extracorporeal membrane oxygenation. A significant trend toward more extracorporeal membrane oxygenation use in recent years (coefficient, 0.009; p < 0.001) was found. Mean age was 56.3 ± 14.9 years and significantly increased over time (coefficient, 0.513; p < 0.001). Most commonly, venoarterial extracorporeal membrane oxygenation was instituted after coronary artery bypass surgery (26.8%) and valvular surgery (25.6%), followed by heart transplantation (20.7%). Overall, successful extracorporeal membrane oxygenation weaning was possible in 4,520 cases (56.4%), and survival to hospital discharge was achieved in 41.7% of cases. In-hospital mortality rates remained constant over time (coefficient, -8.775; p = 0.682), whereas complication rates were significantly reduced (coefficient, -0.009; p = 0.003). Higher mortality was observed after coronary artery bypass surgery (65.4%), combined coronary artery bypass surgery with valve (68.4%), and aortic (69.6%) procedures than other indications. Lower mortality rates were observed in heart transplantation recipients (46.0%). Age (p < 0.001), central cannulation (p < 0.001), and occurrence of complications while on extracorporeal membrane oxygenation were independently associated with poorer prognosis.

Conclusions: The analysis confirmed increased use of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock. Mortality rates remained relatively constant over time despite a decrease in complications, in the setting of supporting older patients.
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http://dx.doi.org/10.1097/CCM.0000000000004922DOI Listing
February 2021

A Systematic Review of the Incidence and Outcomes of In-Hospital Cardiac Arrests in Patients With Coronavirus Disease 2019.

Crit Care Med 2021 Mar 12. Epub 2021 Mar 12.

Department of Anaesthesia, Austin Hospital, Heidelberg, VIC, Australia. Department of Intensive Care Medicine, Calvary Hospital, Canberra, ACT, Australia. Cambia Palliative Care Centre of Excellence, University of Washington, Seattle, WA. Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of Washington, Seattle, WA. Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. Centre for Integrated Critical Care, Department of Medicine and Radiology, Melbourne Medical School, Melbourne, VIC, Australia. Division of Pulmonary and Critical Care Medicine, Mount Sinai Morningside, New York City, NY. Division of Cardiology, Department of Medicine, University of Michigan, Frankel Cardiovascular Centre, Ann Arbor, MI. Division of Renal Medicine, Brigham and Women's Hospital, Boston, MA. Division of Cardiology, Montefiore Medical Centre, Albert Einstein College of Medicine, Bronx, NY. Department of Cardiology, Phoebe Putney Memorial Hospital, Albany, GA. Division of Cardiology, Department of Medicine, NYU Langone Medical Center, New York City, NY. Department of Intensive Care Medicine, Austin Hospital, Heidelberg, VIC, Australia. Department of Intensive Care Medicine, The Prince Charles Hospital, Brisbane, QLD, Australia. School of Medicine, University of Queensland, Brisbane, QLD, Australia. Institute of Health and Biomedical Innovation, Queensland University of Technology, Brisbane, QLD, Australia. Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia. Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia.

Objectives: To investigate the incidence, characteristics, and outcomes of in-hospital cardiac arrest in patients with coronavirus disease 2019 and to describe the characteristics and outcomes for patients with in-hospital cardiac arrest within the ICU, compared with non-ICU patients with in-hospital cardiac arrest. Finally, we evaluated outcomes stratified by age.

Data Sources: A systematic review of PubMed, EMBASE, and preprint websites was conducted between January 1, 2020, and December 10, 2020. Prospective Register of Systematic Reviews identification: CRD42020203369.

Study Selection: Studies reporting on consecutive in-hospital cardiac arrest with a resuscitation attempt among patients with coronavirus disease 2019.

Data Extraction: Two authors independently performed study selection and data extraction. Study quality was assessed with the Newcastle-Ottawa Scale. Data were synthesized according to the Preferred Reporting Items for Systematic Reviews guidelines. Discrepancies were resolved by consensus or through an independent third reviewer.

Data Synthesis: Eight studies reporting on 847 in-hospital cardiac arrest were included. In-hospital cardiac arrest incidence varied between 1.5% and 5.8% among hospitalized patients and 8.0-11.4% among patients in ICU. In-hospital cardiac arrest occurred more commonly in older male patients. Most initial rhythms were nonshockable (83.9%, [asystole = 36.4% and pulseless electrical activity = 47.6%]). Return of spontaneous circulation occurred in 33.3%, with a 91.7% in-hospital mortality. In-hospital cardiac arrest events in ICU had higher incidence of return of spontaneous circulation (36.6% vs 18.7%; p < 0.001) and relatively lower mortality (88.7% vs 98.1%; p < 0.001) compared with in-hospital cardiac arrest in non-ICU locations. Patients greater than or equal to 60 years old had significantly higher in-hospital mortality than those less than 60 years (93.1% vs 87.9%; p = 0.019).

Conclusions: Approximately, one in 20 patients hospitalized with coronavirus disease 2019 received resuscitation for an in-hospital cardiac arrest. Hospital survival after in-hospital cardiac arrest within the ICU was higher than non-ICU locations and seems comparable with prepandemic survival for nonshockable rhythms. Although the data provide guidance surrounding prognosis after in-hospital cardiac arrest, it should be interpreted cautiously given the paucity of information surrounding treatment limitations and resource constraints during the pandemic. Further research is into actual causative mechanisms is needed.
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http://dx.doi.org/10.1097/CCM.0000000000004950DOI Listing
March 2021

ECMO for COVID-19: Updated 2021 Guidelines from the Extracorporeal Life Support Organization (ELSO).

ASAIO J 2021 Feb 26. Epub 2021 Feb 26.

Department of Emergency Medicine, University of Washington, USA Division of Pulmonary Critical Care and Sleep Medicine, University of Washington, USA General ICU, University Hospital of Parma, Italy Department of Biomedical, Metabolic and Neural Sciences, University of Modena & Reggio Emilia, Italy Extracorporeal Life Support Organization Texas Children's Hospital, Baylor College of Medicine Children's Medical Center of Dallas, University of Texas Southwestern Medical Center Extracorporeal Life Support Organization, President; Children's Healthcare of Atlanta, Emory University Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA University of Michigan Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust Centre for Human & Applied Physiological Sciences, Faculty of Life Sciences & Medicine, King's College London Sorbonne Université, INSERM, Institute of Cardiometabolism and Nutrition Service de médecine intensive-réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié-Salpêtrière, F-75013 PARIS, France Department of Cardio-Thoracic Surgery - Maastricht University Medical Centre - Cardiovascular Research Institute Maastricht Maastricht, The Netherlands Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany Nemours Children's Health System Congenital Heart Center, Departments of Surgery and Pediatrics, University of Florida, Gainesville, USA Intensive Care Unit, Alfred Health Melbourne, Victoria, Australia Critical Care ECMO service, King Saud Medical City - Ministry Of Health (MOH), Riyadh - Saudi Arabia. Fundación Cardiovascular de Colombia Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP, Sorbonne Université Hôpital Pitié-Salpêtrière, Paris, France. Sorbonne Université, GRC n°30, GRC RESPIRE, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France. Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia National University Hospital, Singapore Department of Medicine, Columbia University College of Physicians and Surgeons, New York, USA Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, USA.

This is an updated guideline from the Extracorporeal Life Support Organization (ELSO) for the role of extracorporeal membrane oxygenation (ECMO) for patients with severe cardiopulmonary failure due to coronavirus disease 2019 (COVID-19). The great majority of COVID-19 patients (>90%) requiring ECMO have been supported using venovenous (V-V) ECMO for acute respiratory distress syndrome (ARDS). While COVID-19 ECMO run duration may be longer than in non-COVID-19 ECMO patients, published mortality appears to be similar between the two groups. However, data collection is ongoing, and there is a signal that overall mortality may be increasing. Conventional selection criteria for COVID-19-related ECMO should be used; however, when resources become more constrained during a pandemic, more stringent contraindications should be implemented. Formation of regional ECMO referral networks may facilitate communication, resource sharing, expedited patient referral, and mobile ECMO retrieval. There are no data to suggest deviation from conventional ECMO device or patient management when applying ECMO for COVID-19 patients. Rarely, children may require ECMO support for COVID-19-related ARDS, myocarditis or multisystem inflammatory syndrome in children (MIS-C); conventional selection criteria and management practices should be the standard. We strongly encourage participation in data submission to investigate the optimal use of ECMO for COVID-19.
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http://dx.doi.org/10.1097/MAT.0000000000001422DOI Listing
February 2021

Prone Positioning of Patients during Venovenous Extracorporeal Membrane Oxygenation.

Ann Am Thorac Soc 2021 03;18(3):421-423

Columbia University College of Physicians and Surgeons/NewYork-Presbyterian Hospital, New York, New York; and.

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http://dx.doi.org/10.1513/AnnalsATS.202011-1444EDDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7919146PMC
March 2021

Elevated Venous to Arterial Carbon Dioxide Gap and Anion Gap Are Associated with Poor Outcome in Cardiogenic Shock Requiring Extracorporeal Membrane Oxygenation Support.

ASAIO J 2021 03;67(3):263-269

Critical Care Research Group, The Prince Charles Hospital and The University of Queensland, Queensland, Australia.

Optimal management of cardiogenic shock requiring extracorporeal membrane oxygenation (ECMO) is still an evolving area in which assessment and optimization of the microcirculation may be critically important. We hypothesized that the venous arterial carbon dioxide gap (P(v-a)CO2 gap); the ratio of this gap to arterio-venous oxygen content (P(v-a)CO2/C(a-v)O2 ratio) and the anion gap would be early indicators of microcirculatory status and useful parameters for outcome prediction during ECMO support. We retrospectively reviewed 31 cardiogenic shock patients requiring veno-arterial ECMO, calculating P(v-a)CO2 gap and P(v-a)CO2/C(a-v)O2 ratios in the first 36 hours and the final 24 hours of ECMO support. Sixteen patients (52%) survived and 15 (48%) died. After 24 hours of ECMO support, the P(v-a)CO2 gap (4.9 ± 1.5 vs. 6.8 ± 1.9 mm Hg; p = 0.004) and anion gap (5.2 ± 1.8 vs. 8.7 ± 2.7 mmol/L; p < 0.001) were significantly higher in non-survivors. In the final 24 hours of ECMO support, the P(v-a)CO2 gap (3.5 ± 1.6 vs. 10.5 ± 3.2 mm Hg; p < 0.001), P(v-a)CO2/C(a-v)O2 ratio (1.1 ± 0.5 vs. 2.7 ± 1.0; p < 0.001), anion gap (5.1 ± 3.0 vs. 9.3 ± 5.9 mmol/L; p = 0.02), and lactate (median 1.0 [interquartile range {IQR}: 0.7-1.5] vs. 2.8 [IQR: 1.7-7.7] mmol/L; p = <0.001) were all significantly lower in survivors. Increasing P(v-a)CO2 gap and increasing anion gap were significantly associated with increased risk of mortality. Optimum cut-points for prediction of mortality were 6 mm Hg for P(v-a)CO2 gap in combination with an anion gap above 6 mmol/L in the first 24 hours of ECMO in patients with cardiogenic shock requiring ECMO.
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http://dx.doi.org/10.1097/MAT.0000000000001215DOI Listing
March 2021

Intensive care digital health response to emerging infectious disease outbreaks such as COVID-19.

Anaesth Intensive Care 2021 Jan 27:310057X20975777. Epub 2021 Jan 27.

Faculty of Medicine, University of Queensland, Brisbane, Australia.

The COVID-19 pandemic has required intensive care units to rapidly adjust and adapt their existing practices. Although there has a focus on expanding critical care infrastructure, equipment and workforce, plans have not emphasised the need to increase digital capabilities. The objective of this report was to recognise key areas of digital health related to the COVID-19 response. We identified and explored six focus areas relevant to intensive care, including using digital solutions to increase critical care capacity, developing surge capacity within an electronic health record, maintenance and downtime planning, training considerations and the role of data analytics. This article forms the basis of a framework for the intensive care digital health response to COVID-19 and other emerging infectious disease outbreaks.
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http://dx.doi.org/10.1177/0310057X20975777DOI Listing
January 2021

Extracorporeal Membrane Oxygenation and Coronavirus Disease 2019.

JAMA Surg 2021 Apr;156(4):400-401

Department of Medicine, Columbia University College of Physicians and Surgeons, New York, New York.

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http://dx.doi.org/10.1001/jamasurg.2020.6631DOI Listing
April 2021

Current Understanding of Leukocyte Phenotypic and Functional Modulation During Extracorporeal Membrane Oxygenation: A Narrative Review.

Front Immunol 2020 8;11:600684. Epub 2021 Jan 8.

Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia.

A plethora of leukocyte modulations have been reported in critically ill patients. Critical illnesses such as acute respiratory distress syndrome and cardiogenic shock, which potentially require extracorporeal membrane oxygenation (ECMO) support, are associated with changes in leukocyte numbers, phenotype, and functions. The changes observed in these illnesses could be compounded by exposure of blood to the non-endothelialized surfaces and non-physiological conditions of ECMO. This can result in further leukocyte activation, increased platelet-leukocyte interplay, pro-inflammatory and pro-coagulant state, alongside features of immunosuppression. However, the effects of ECMO on leukocytes, in particular their phenotypic and functional signatures, remain largely overlooked, including whether these changes have attributable mortality and morbidity. The aim of our narrative review is to highlight the importance of studying leukocyte signatures to better understand the development of complications associated with ECMO. Increased knowledge and appreciation of their probable role in ECMO-related adverse events may assist in guiding the design and establishment of targeted preventative actions.
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http://dx.doi.org/10.3389/fimmu.2020.600684DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7821656PMC
January 2021

Concurrent Use of Renal Replacement Therapy during Extracorporeal Membrane Oxygenation Support: A Systematic Review and Meta-Analysis.

J Clin Med 2021 Jan 11;10(2). Epub 2021 Jan 11.

Cardiothoracic Intensive Care Unit, National University Heart Centre, National University Hospital, Singapore 119228, Singapore.

Patients supported with extracorporeal membrane oxygenation (ECMO) often receive renal replacement therapy (RRT). We conducted this systematic review and meta-analysis (between January 2000 and September 2020) to assess outcomes in patients who received RRT on ECMO. Random-effects meta-analyses were performed using R 3.6.1 and certainty of evidence was rated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The primary outcome was pooled mortality. The duration of ECMO support and ICU/hospital lengths of stay were also investigated. Meta-regression analyses identified factors associated with mortality. A total of 5896 adult patients (from 24 observational studies and 1 randomised controlled trial) were included in this review. Overall pooled mortality due to concurrent use of RRT while on ECMO from observational studies was 63.0% (95% CI: 56.0-69.6%). In patients receiving RRT, mortality decreased by 20% in the last five years; the mean duration of ECMO support and ICU and hospital lengths of stay were 9.33 days (95% CI: 7.74-10.92), 15.76 days (95% CI: 12.83-18.69) and 28.47 days (95% CI: 22.13-34.81), respectively, with an 81% increased risk of death (RR: 1.81, 95% CI: 1.56-2.08, < 0.001). RRT on ECMO was associated with higher mortality rates and a longer ICU/hospital stay compared to those without RRT. Future research should focus on minimizing renal dysfunction in ECMO patients and define the optimal timing of RRT initiation.
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http://dx.doi.org/10.3390/jcm10020241DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7827381PMC
January 2021

Impact of an aerosol box on time to tracheal intubation: systematic review and meta-analysis.

Br J Anaesth 2021 03 4;126(3):e122-e125. Epub 2020 Dec 4.

Department of Intensive Care Medicine, Peninsula Health, Frankston, VIC, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia.

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http://dx.doi.org/10.1016/j.bja.2020.11.036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7833650PMC
March 2021

Assessing need for extracorporeal cardiopulmonary resuscitation for out-of-hospital cardiac arrest using Power BI for data visualisation.

Emerg Med Australas 2020 Dec 20. Epub 2020 Dec 20.

Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.

Objective: To estimate the number of patients in refractory out-of-hospital cardiac arrest (OHCA) potentially suitable for transport to an extracorporeal cardiopulmonary resuscitation (ECPR)-capable hospital in Brisbane, Queensland, Australia, based on outcome predictors for ECPR, ambulance geolocation and patient data.

Methods: A retrospective cohort study was performed using data from all patients in OHCA attended by Queensland Ambulance Service between 1 January 2014 and 31 December 2018. The number of refractory arrest patients who could potentially be transferred to an ECPR-capable centre within 45 min of the time of arrest was modelled using theoretical on-scene treatment times.

Results: Of 25 518 ambulance-attended OHCA in Queensland during the study period, 540 (2%) patients met criteria of refractory arrest for study inclusion. Further age and arrest rhythm criteria for transport to an ECPR-capable hospital were met in 253 (47%) study patients, an average of 51 patients per year. In 2018, 72 patients met study criteria for transport to an ECPR-capable centre. Based on theoretical on-scene treatment times of 12 and 20 min, in 2018 only 14 (19%) and 11 (15%) patients respectively would potentially arrive at an ECPR-capable hospital within accepted timeframes for ECPR.

Conclusions: Retrospective data collected from existing ambulance databases can be used to model patient suitability for ECPR. Relatively few patients with refractory OHCA in Queensland, Australia, could be attended and transported to an ECPR-capable centre within clinically acceptable timeframes. Further studies of the transport logistics and economic implications of providing ECPR services for OHCA are required to better inform decisions around this intervention.
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http://dx.doi.org/10.1111/1742-6723.13704DOI Listing
December 2020

Protocol-driven daily optimisation of venovenous extracorporeal membrane oxygenation blood flows: an alternate paradigm?

J Thorac Dis 2020 Nov;12(11):6854-6860

Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA.

Venovenous extracorporeal membrane oxygenation (VV ECMO) is now an established modality of support for patients with the who are failing evidence-based conventional therapies. Minimising ventilator-induced lung injury is the guiding principle behind patient management with VV ECMO. Patients with acute respiratory distress syndrome (ARDS) supported with VV ECMO are liberated from ECMO at a stage when native lungs have recovered sufficiently to support physiologic demands and the risks of iatrogenic lung injuries after discontinuation of ECMO are perceived to be small. However, native lung recovery is a dynamic process and patients rely on varying degrees of contributions from both native lungs and ECMO for gas exchange support. Patients often demonstrate near total ECMO dependence for oxygenation and decarboxylation early in the course of the illness and this may necessitate higher ECMO blood flow rates (EBFRs). Although, reliance on high EBFR for oxygenation support may remain variable over the course of ECMO, blood flow requirements typically diminish over time as native lungs start to recover. Currently, protocol-driven modulation of the EBFR based on changing physiologic needs is not common practice and consequently patients may remain on higher than physiologically necessary EBFR. This exposes the patient to potential risks because maintaining higher blood flows often requires a less restrictive fluid balance and deeper sedation. Both may be harmful in the setting of recovery from ARDS. In this article, we propose a strategy that involves daily assessments of native lung function and a protocol-driven daily optimisation of EBFR. This is followed by optimisation of sweep gas flow rate (SGFR) and the fraction of delivered oxygen in the sweep gas (FdO). This staged approach to weaning VV ECMO allows us to fully utilise the "decoupling" of oxygenation and decarboxylation that is possible only during extracorporeal support. This approach may benefit patients by allowing for greater fluid restriction, more aggressive fluid removal, expedited weaning of sedation and neuromuscular blocking agents (NMBAs), and early physical rehabilitation. Ultimately, prospective studies are needed to evaluate optimal VV ECMO weaning practices.
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http://dx.doi.org/10.21037/jtd-20-1515DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7711363PMC
November 2020

Will Not Breathing on Extracorporeal Membrane Oxygenation Help One Survive Acute Respiratory Distress Syndrome?

Crit Care Med 2020 Dec;48(12):1901-1904

Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital; Queensland University of Technology; and University of Queensland, Brisbane, QLD, Australia, Brisbane and Bond University, Gold Coast, QLD, Australia Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast; and Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom Department of Medicine, Columbia University College of Physicians and Surgeons; and, Centre for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY.

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http://dx.doi.org/10.1097/CCM.0000000000004647DOI Listing
December 2020

Personal protective equipment preparedness in Asia-Pacific intensive care units during the coronavirus disease 2019 pandemic: A multinational survey.

Aust Crit Care 2021 Mar 29;34(2):135-141. Epub 2020 Sep 29.

National University Hospital, Singapore. Electronic address:

Background: There has been a surge in coronavirus disease 2019 admissions to intensive care units (ICUs) in Asia-Pacific countries. Because ICU healthcare workers are exposed to aerosol-generating procedures, ensuring optimal personal protective equipment (PPE) preparedness is important.

Objective: The aim of the study was to evaluate PPE preparedness across ICUs in six Asia-Pacific countries during the initial phase of the coronavirus disease 2019 pandemic, which is defined by the World Health Organization as guideline adherence, training healthcare workers, procuring stocks, and responding appropriately to suspected cases.

Methods: A cross-sectional Web-based survey was circulated to 633 level II/III ICUs of Australia, New Zealand (NZ), Singapore, Hong Kong (HK), India, and the Philippines.

Findings: Two hundred sixty-three intensivists responded, representing 231 individual ICUs eligible for analysis. Response rates were 68-100% in all countries except India, where it was 24%. Ninety-seven percent of ICUs either conformed to or exceeded World Health Organization recommendations for PPE practice. Fifty-nine percent ICUs used airborne precautions irrespective of aerosol generation procedures. There were variations in negative-pressure room use (highest in HK/Singapore), training (best in NZ), and PPE stock awareness (best in HK/Singapore/NZ). High-flow nasal oxygenation and noninvasive ventilation were not options in most HK (66.7% and 83.3%, respectively) and Singapore ICUs (50% and 80%, respectively), but were considered in other countries to a greater extent. Thirty-eight percent ICUs reported not having specialised airway teams. Showering and "buddy systems" were underused. Clinical waste disposal training was suboptimal (38%).

Conclusions: Many ICUs in the Asia-Pacific reported suboptimal PPE preparedness in several domains, particularly related to PPE training, practice, and stock awareness, which requires remediation. Adoption of low-cost approaches such as buddy systems should be encouraged. The complete avoidance of high-flow nasal oxygenation reported by several intensivists needs reconsideration. Consideration must be given to standardise PPE guidelines to minimise practice variations. Urgent research to evaluate PPE preparedness and severe acute respiratory syndrome coronavirus 2 transmission is required.
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http://dx.doi.org/10.1016/j.aucc.2020.09.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522707PMC
March 2021

Extracorporeal life support for adults with acute respiratory distress syndrome.

Intensive Care Med 2020 Dec 2;46(12):2464-2476. Epub 2020 Nov 2.

Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University College of Physicians and Surgeons, NewYork-Presbyterian Hospital, New York, USA.

Extracorporeal life support (ECLS) can support gas exchange in patients with the acute respiratory distress syndrome (ARDS). During ECLS, venous blood is drained from a central vein via a cannula, pumped through a semipermeable membrane that permits diffusion of oxygen and carbon dioxide, and returned via a cannula to a central vein. Two related forms of ECLS are used. Venovenous extracorporeal membrane oxygenation (ECMO), which uses high blood flow rates to both oxygenate the blood and remove carbon dioxide, may be considered in patients with severe ARDS whose oxygenation or ventilation cannot be maintained adequately with best practice conventional mechanical ventilation and adjunctive therapies, including prone positioning. Extracorporeal carbon dioxide removal (ECCOR) uses lower blood flow rates through smaller cannulae and provides substantial CO elimination (~ 20-70% of total CO production), albeit with marginal improvement in oxygenation. The rationale for using ECCOR in ARDS is to facilitate lung-protective ventilation by allowing a reduction of tidal volume, respiratory rate, plateau pressure, driving pressure and mechanical power delivered by the mechanical ventilator. This narrative review summarizes physiological concepts related to ECLS, as well as the rationale and evidence supporting ECMO and ECCOR for the treatment of ARDS. It also reviews complications, limitations, and the ethical dilemmas that can arise in treating patients with ECLS. Finally, it discusses future key research questions and challenges for this technology.
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http://dx.doi.org/10.1007/s00134-020-06290-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7605473PMC
December 2020

Incidence and outcome of out-of-hospital cardiac arrests in the COVID-19 era: A systematic review and meta-analysis.

Resuscitation 2020 12 1;157:248-258. Epub 2020 Nov 1.

Department of Intensive Care Medicine, Peninsula Health, Frankston, Victoria, Australia; Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.

Background: The impact of COVID-19 on pre-hospital and hospital services and hence on the prevalence and outcomes of out-of-hospital cardiac arrests (OHCA) remain unclear. The review aimed to evaluate the influence of the COVID-19 pandemic on the incidence, process, and outcomes of OHCA.

Methods: A systematic review of PubMed, EMBASE, and pre-print websites was performed. Studies reporting comparative data on OHCA within the same jurisdiction, before and during the COVID-19 pandemic were included. Study quality was assessed based on the Newcastle-Ottawa Scale.

Results: Ten studies reporting data from 35,379 OHCA events were included. There was a 120% increase in OHCA events since the pandemic. Time from OHCA to ambulance arrival was longer during the pandemic (p = 0.036). While mortality (OR = 0.67, 95%-CI 0.49-0.91) and supraglottic airway use (OR = 0.36, 95%-CI 0.27-0.46) was higher during the pandemic, automated external defibrillator use (OR = 1.78 95%-CI 1.06-2.98), return of spontaneous circulation (OR = 1.63, 95%CI 1.18-2.26) and intubation (OR = 1.87, 95%-CI 1.12--3.13) was more common before the pandemic. More patients survived to hospital admission (OR = 1.75, 95%-CI 1.42-2.17) and discharge (OR = 1.65, 95%-CI 1.28-2.12) before the pandemic. Bystander CPR (OR = 1.18, 95%-CI 0.95-1.46), unwitnessed OHCA (OR = 0.84, 95%-CI 0.66-1.07), paramedic-resuscitation attempts (OR = 1.19 95%-CI 1.00-1.42) and mechanical CPR device use (OR = 1.57 95%-CI 0.55-4.55) did not defer significantly.

Conclusions: The incidence and mortality following OHCA was higher during the COVID-19 pandemic. There were significant variations in resuscitation practices during the pandemic. Research to define optimal processes of pre-hospital care during a pandemic is urgently required.

Review Registration: PROSPERO (CRD42020203371).
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http://dx.doi.org/10.1016/j.resuscitation.2020.10.025DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7603976PMC
December 2020

Assessment of the Clinical Pulmonary Infection Scores for prediction of ventilator associated pneumonia in patients with out of hospital cardiac arrest.

Infect Dis Health 2021 Feb 19;26(1):48-54. Epub 2020 Sep 19.

Department of Infectious Diseases, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, Queensland, Australia; University of Queensland, Brisbane, Queensland, Australia.

Background: Patients suffering out-of-hospital cardiac arrest (OHCA) are at an increased risk of aspiration pneumonitis and development of subsequent aspiration pneumonia. The diagnostic uncertainty in this context can lead to a large proportion receiving broad spectrum antibiotics.

Methods: This was a three-year, retrospective cohort study of consecutive patients admitted with OHCA. Data were collected in an Australian tertiary centre intensive care unit (ICU) between December 2016-December 2019. We assessed the incidence of Ventilator associated pneumonia (VAP), admission Clinical Pulmonary Infection Scores (CPIS) in patients with OHCA and its' association with VAP at day 3 [1]. We also assessed antibiotics prescribing (timing of initiation and drug choice) and intensive care mortality relative to the day 1 CPIS.

Results: Over the three years, 100 patients were admitted with OHCA. The incidence of VAP was 6%. The CPIS on admission was not associated with development of VAP at day 3 (p = 0.75) and no significant association was found between choice of antibiotic regimens and VAP incidence. Timing of initiation of antibiotics was associated with VAP (12hrs vs 48hrs, p = 0.035) but not the choice of antibiotic (penicillin and cephalosporins vs antipseudomonal antibiotics). CPIS score at day 1 was not associated with ICU mortality in a multivariate analysis.

Conclusion: We demonstrated a very low incidence of VAP in OHCA patients in comparison to published studies. In this context, there was no evidence for an association between CPIS score and VAP at day 3. The CPIS may have utility as a decision support tool for targeted antibiotic prescribing in this cohort.
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http://dx.doi.org/10.1016/j.idh.2020.09.001DOI Listing
February 2021

ECMO for severe ARDS associated with COVID-19: now we know we can, but should we?

Lancet Respir Med 2020 11 13;8(11):1066-1068. Epub 2020 Aug 13.

Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, NY, USA; Center for Acute Respiratory Failure, New York-Presbyterian Hospital, New York, NY, USA.

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http://dx.doi.org/10.1016/S2213-2600(20)30357-XDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7426085PMC
November 2020

Albumin Use After Cardiac Surgery.

Crit Care Explor 2020 Jul 15;2(7):e0164. Epub 2020 Jul 15.

Adult Intensive Care Services and Critical Care Research Group, The Prince Charles Hospital, Brisbane, Queensland, QLD, Australia.

Objectives: To investigate the effect of albumin exposure in ICU after cardiac surgery on hospital mortality, complications, and costs.

Design: A retrospective, single-center cohort study with economic evaluation.

Setting: Cardiothoracic ICU in Australia.

Patients: Adult patients admitted to the ICU after cardiac surgery.

Interventions: None.

Measurements And Main Results: Comparison of outcomes and costs in ICU after cardiac surgery based on 4% human albumin exposure. During the study period, 3,656 patients underwent cardiac surgery. After exclusions, 2,594 patients were suitable for analysis. One-thousand two-hundred sixty-four (48.7%) were exposed to albumin and 19 (1.4%) of those died. The adjusted hospital mortality of albumin exposure compared with no albumin was not significant (odds ratio, 1.24; 95% CI, 0.56-2.79; = 0.6). More patients exposed to albumin returned to the operating theater for bleeding and/or tamponade (6.1% vs 2.1%; odds ratio, 2.84; 95% CI, 1.81-4.45; < 0.01) and received packed red cell transfusions ( < 0.001). ICU and hospital lengths of stay were prolonged in those exposed to albumin (mean difference, 18 hr; 95% CI, 10.3-25.6; < 0.001 and 87.5 hr; 95% CI, 40.5-134.6; < 0.001). Costs (U.S. dollar) were higher in patients exposed to albumin, compared with those with no albumin exposure (mean difference in ICU costs, $2,728; 95% CI, $1,566-3,890 and mean difference in hospital costs, $5,427; 95% CI, $3,294-7,560).

Conclusions: There is no increased mortality in patients who are exposed to albumin after cardiac surgery. The patients exposed to albumin had higher illness severity, suffered more complications, and incurred higher healthcare costs. A randomized controlled trial is required to determine whether albumin use is effective and safe in this setting.
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http://dx.doi.org/10.1097/CCE.0000000000000164DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7365709PMC
July 2020

Provision of ECPR during COVID-19: evidence, equity, and ethical dilemmas.

Crit Care 2020 07 27;24(1):462. Epub 2020 Jul 27.

Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Queensland, Australia.

The use of extracorporeal cardiopulmonary resuscitation (ECPR) to restore circulation during cardiac arrest is a time-critical, resource-intensive intervention of unproven efficacy. The current COVID-19 pandemic has brought additional complexity and significant barriers to the ongoing provision and implementation of ECPR services. The logistics of patient selection, expedient cannulation, healthcare worker safety, and post-resuscitation care must be weighed against the ethical considerations of providing an intervention of contentious benefit at a time when critical care resources are being overwhelmed by pandemic demand.
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http://dx.doi.org/10.1186/s13054-020-03172-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7384274PMC
July 2020

The effect of hyperoxia on inflammation and platelet responses in an ex vivo extracorporeal membrane oxygenation circuit.

Artif Organs 2020 Dec 4;44(12):1276-1285. Epub 2020 Aug 4.

Critical Care Research Group, The Prince Charles Hospital, Brisbane, Australia.

Use of extracorporeal membrane oxygenation (ECMO) is expanding, however, it is still associated with significant morbidity and mortality. Activation of inflammatory and innate immune responses and hemostatic alterations contribute to complications. Hyperoxia may play a role in exacerbating these responses. Nine ex vivo ECMO circuits were tested using fresh healthy human whole blood, with two oxygen levels: 21% inspired fraction of oxygen (FiO ; mild hyperoxia; n = 5) and 100% FiO (severe hyperoxia; n = 4). Serial blood samples were taken for analysis of platelet aggregometry, leukocyte activation, inflammatory, and oxidative stress markers. ECMO resulted in reduced adenosine diphosphate- (P < .05) and thrombin receptor activating peptide-induced (P < .05) platelet aggregation, as well as increasing levels of the neutrophil activation marker, neutrophil elastase (P = .013). Additionally, levels of the inflammatory chemokine interleukin-8 were elevated (P < .05) and the activity of superoxide dismutase, a marker of oxidative stress, was increased (P = .002). Hyperoxia did not augment these responses, with no significant differences detected between mild and severe hyperoxia. Our ex vivo model of ECMO revealed that the circuit itself triggers a pro-inflammatory and oxidative stress response, however, exposure to supra-physiologic oxygen does not amplify that response. Extended-duration studies and inclusion of an endothelial component could be beneficial in characterizing longer term changes.
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http://dx.doi.org/10.1111/aor.13771DOI Listing
December 2020

Extracorporeal Life Support Organization Coronavirus Disease 2019 Interim Guidelines: A Consensus Document from an International Group of Interdisciplinary Extracorporeal Membrane Oxygenation Providers.

ASAIO J 2020 Jul;66(7):707-721

The Alfred, Melbourne, Victoria, Australia.

Disclaimer: The Extracorporeal Life Support Organization (ELSO) Coronavirus Disease 2019 (COVID-19) Guidelines have been developed to assist existing extracorporeal membrane oxygenation (ECMO) centers to prepare and plan provision of ECMO during the ongoing pandemic. The recommendations have been put together by a team of interdisciplinary ECMO providers from around the world. Recommendations are based on available evidence, existing best practice guidelines, ethical principles, and expert opinion. This is a living document and will be regularly updated when new information becomes available. ELSO is not liable for the accuracy or completeness of the information in this document. These guidelines are not meant to replace sound clinical judgment or specialist consultation but rather to strengthen provision and clinical management of ECMO specifically, in the context of the COVID-19 pandemic.
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http://dx.doi.org/10.1097/MAT.0000000000001193DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7228451PMC
July 2020

Effectiveness of Vancomycin Dosing Guided by Therapeutic Drug Monitoring in Adult Patients Receiving Extracorporeal Membrane Oxygenation.

Antimicrob Agents Chemother 2020 08 20;64(9). Epub 2020 Aug 20.

Adult Intensive Care Services and Critical Care Research Group, the Prince Charles Hospital, Brisbane, Queensland, Australia.

The clinical situation for patients receiving extracorporeal membrane oxygenation (ECMO) is complex, and drug dosing is complicated by significant pharmacokinetic alterations. We sought to describe the frequency of achievement of therapeutic vancomycin concentrations in critically ill patients receiving ECMO with therapeutic drug monitoring (TDM). In this retrospective observational study, we included all critically ill patients receiving TDM for vancomycin while on ECMO. The primary outcome was the proportion of plasma vancomycin concentrations in the therapeutic range (15 to 20 mg/liter). Factors associated with not achieving therapeutic concentrations were investigated, including ECMO duration and use of renal replacement therapies. Vancomycin TDM was performed for 77 of 116 (66%) patients on ECMO. Median (interquartile range) duration of ECMO support was 7 days (4 to 16 days). The proportion of measurements in the therapeutic range (15 to 20 mg/liter) was 24%, while 46% were subtherapeutic (<15 mg/liter) and 30% were supratherapeutic (>20 mg/liter). The proportion of measures in the therapeutic range was significantly higher on ECMO days for 6 to 13 (incidence rate ratio [IRR], 2.4; 95% confidence interval [CI], 1.2 to 4.6;  = 0.01). Supratherapeutic concentrations were more frequently observed in patients on renal replacement therapy (RRT) (IRR, 2.0; 95% CI, 1.3 to 3.1; = 0.002). The vancomycin concentrations in patients did not vary with age, gender, or type of ECMO support. Patients receiving vancomycin had suboptimal concentrations early in the course of ECMO. Patients not receiving RRT and those with mild to moderate acute kidney injury (AKI) were at a risk of underdosing, while those with established AKI on RRT were likelier to experience supratherapeutic concentrations.
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http://dx.doi.org/10.1128/AAC.01179-20DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7449221PMC
August 2020

ECMO use in COVID-19: lessons from past respiratory virus outbreaks-a narrative review.

Crit Care 2020 06 6;24(1):301. Epub 2020 Jun 6.

Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.

The spread of coronavirus disease 2019 (COVID-19) continues to grow exponentially in most countries, posing an unprecedented burden on the healthcare sector and the world economy. Previous respiratory virus outbreaks, such as severe acute respiratory syndrome (SARS), pandemic H1N1 and Middle East respiratory syndrome (MERS), have provided significant insights into preparation and provision of intensive care support including extracorporeal membrane oxygenation (ECMO). Many patients have already been supported with ECMO during the current COVID-19 pandemic, and it is likely that many more may receive ECMO support, although, at this point, the role of ECMO in COVID-19-related cardiopulmonary failure is unclear. Here, we review the experience with the use of ECMO in the past respiratory virus outbreaks and discuss potential role for ECMO in COVID-19.
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http://dx.doi.org/10.1186/s13054-020-02979-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275850PMC
June 2020

Treading Lightly in a Pandemic: #Zentensivist Reflections on COVID-19.

Chest 2020 08 21;158(2):471-473. Epub 2020 Apr 21.

Adult Intensive Care Services, the Prince Charles Hospital, Brisbane, Queensland, Australia; Critical Care Research Group and Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support (ACTIONS), Queensland, Australia; University of Queensland, Brisbane, Bond University, Gold Coast, Queensland, Australia.

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http://dx.doi.org/10.1016/j.chest.2020.04.013DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7172855PMC
August 2020

Blood transfusion strategies and ECMO during the COVID-19 pandemic - Authors' reply.

Lancet Respir Med 2020 05 16;8(5):e41. Epub 2020 Apr 16.

Bond University, Robina, QLD, Australia; University of Queensland, Brisbane, QLD, Australia; Adult Intensive Care Services, The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane, QLD 4032, Australia; Critical Care Research Group, Centre of Research Excellence for Advanced Cardio-respiratory Therapies Improving OrgaN Support, Brisbane, QLD, Australia. Electronic address:

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http://dx.doi.org/10.1016/S2213-2600(20)30174-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7162630PMC
May 2020