The question of fluid volume in resuscitation has been identified as the top priority in sepsis research by emergency physicians in the United Kingdom, Australia and New Zealand. Guidelines and sepsis pathways recommend an initial intravenous (IV) fluid bolus of 30ml/kg isotonic crystalloid for patients with sepsis and hypotension. However, there is a lack of evidence from clinical trials to support this strategy. Both observational data as well as randomised studies suggest there may be harm associated with injudicious use of fluids in sepsis. Since there is equipoise regarding a more liberal or restricted fluid volume resuscitation as first line treatment for sepsis-related hypotension, we conducted the pilot multicentre REstricted Fluid REsuscitation in Sepsis-associated Hypotension (REFRESH) trial comparing a restricted fluid protocol with early initiation of vasopressor support against standard guideline care.
The data from REFRESH will inform feasibility of a large, multicentre phase III study. However, further ground work is essential for the optimal design of a Phase III trial that will provide valuable information on feasibility (road test recruitment rate and screening processes) as well as refinement of the protocol (sample size estimation, processes of care, prevalence of the population of interest, real world clinical practice regarding fluid use).
In this ARISE Fluids study, we aim to provide more insight into current practice by conducting a bi-national multi-site prospective observational study of fluid administration in (suspected) sepsis and hypotension in the Emergency Departments of Australia and New Zealand hospitals. Sites have been selected on the basis of having expressed interest in participating in a phase III trial.READ MORE
This study aims to improve our understanding of sepsis in Australian Emergency Departments. We will do this by analysing in great detail the spectrum of infection syndromes presenting to the Emergency Department of a typical large Australian hospital over a period of several years. This will allow us to:
1) Identify the number of patients presenting to hospitals each year with severe infections and the outcome of these presentations.
2) Analyse the factors and information available to doctors in the Emergency Department that are associated with overall prognosis in patients with infection.
3) Build a comprehensive picture of the spectrum of infective agents that cause patients to be admitted to Australian hospitals.
4) Identify the most appropriate combination of antibiotics which should be used in the early treatment of the most severely ill patients with infection.
The cornerstone of this project is a large database which will capture detailed information on all patients presenting to the Emergency Department of a typical large Australian hospital who are subsequently admitted with infection.READ MORE
Children present to emergency departments (EDs) with injuries that require painful procedures such as straightening broken bones and suturing cuts. Medicines used for these procedures include midazolam (a sleeping medicine), nitrous oxide (laughing gas), and morphine (pain killer) as well as many others. Ketamine is one medicine that combines pain relief and sedation. Ketamine is very safe and has been used in millions of procedures around the world. Children when they wake up after ketamine may be agitated or feel like vomiting. Ketamine can raise blood pressure and some situations it should not be used. Ketamine is Australia’s preferred sedative for children in EDs. Perhaps we can improve on ketamine by using different dosing methods or mixing with other medicines.
Propofol is another medicine used to deeply sedate children. In large amounts it will interfere with breathing and lower blood pressure, so it needs to be given in the right place and at the right time. Propofol’s main advantage is that it is much faster to work than ketamine and its effects wear off very fast. Interestingly when propofol is given with ketamine they may balance each other’s side effects; keeping blood pressure even, providing relaxation, reducing vomiting. Since propofol recovery is faster than ketamine, children may wake up sooner.
Emergency doctors have been mixing ketamine and propofol together and calling this combination “ketofol” and find it very effective in adults. Some give ketamine and then propofol, although how much is required is not clear. A number of emergency doctors prefer to give ketamine alone and treat side effects if they occur.
Infections, particularly serious infections leading to sepsis, cost the Australian healthcare system millions of dollars every year and impose a significant burden of illness on the Australian community. Serious infections also have the capacity to cause tragedy at a much more personal level, with lethal outcomes possible even in young healthy individuals. Despite the significant consequences of these illnesses, we have very limited information about the best way to identify and treat infection in Emergency Departments. Therefore, research that provides more information is vital.
We are conducting a ground breaking body of research to improve our understanding of infection in Australian Emergency Departments. We will conduct a group of studies focusing on early identification and treatment of infection. Specifically, four studies will be conducted across two hospitals. The first will identify the types of historical and clinical information available to doctors during the early stages of assessment that predicts whether an individual is likely to become very ill with infection. Identifying these patients at risk of progression to severe illness can be difficult, and is important because certain potentially life-saving treatments are most effective when given early. The second study will identify the types of bacteria that cause infection in our community. The third study will examine the potential beneficial effect of a commonly prescribed class of cholesterol-lowering drugs (“statins”) on patients admitted with infection. Finally, in the fourth study we will develop an antibiotic order set that covers the major bacteria causing severe infections. This will enable earlier effective treatment of seriously ill patients. These studies are the first of their kind conducted in Australia and will ultimately enable doctors to identify and treat severe infection earlier.READ MORE
Shortness of breath (dyspnoea) is a terrifying symptom experienced by patients and is a common reason for presentation to Emergency Departments. There are a wide range of causes including flair up due to chronic conditions such as asthma, heart failure, chronic lung disease or liver or kidney failure. Acute conditions such as a collapsed lung, chest infection (including pneumonia), trauma (including fractured ribs), airway blockage or an allergic reaction can also be the cause.
There is significant knowledge about patients who are admitted to hospital with common causes, however there is little conclusive information about Dyspnoea as a symptom, the distribution of causes, the proportion of patients requiring admission and whether treatment complies with evidence-based guidelines.
A recent pilot study in Europe found that 53 per cent of patients had a respiratory cause for symptoms, 22 per cent had a cardiac cause, and 15 per cent had both cardiac and respiratory components. Almost two-thirds were admitted to hospital with over one-third discharged from ED. However, in many ways, the study raised more questions than it answered. The study was also too small to comment on adherence to evidence-based guidelines.
For that reason, a larger EuroDEM (digital elevation model) study is planned for 2014. The study will be complemented by the Australia, Asia and New Zealand Dyspnoea Departments of Emergency Medicine (AANZDEM) which will collect data from a different region with different systems of care. It will focus on the range of causes, variation over seasons and geographical areas, and compliance with recommended treatments.READ MORE
Sick and injured children in the Emergency Department (ED) often require procedures which can cause severe pain (like fracture reduction, stitching wounds, abscess drainage) or otherwise require the child to be still and cooperative (CT scans, lumbar punctures, removal of foreign bodies). Sedative drugs are given to these patients both to relieve pain/distress and to keep them still for the procedure.
ED sedation of children now has a well established body of evidence. Most of the literature relates to when the drug is given intravenously or intramuscularly. Drug delivery by these routes leads to reliable effects as the drug bypasses the liver without being broken down before it reaches the brain. However, both these routes require a needle which requires staff to hold down a young child against their will, frequently causing great distress along with the pain of the needle. Great efforts have gone into making EDs "Ouchless" where unnecessary pain for children is reduced or eliminated. Sedation is itself part of this effort. The intranasal route (injecting the medicine up the nose with a plastic syringe) could represent a needle-free alternative.
Ketamine is the most common drug used for paediatric sedation in Australian EDs and can be given intranasally. No studies have examined its use for ED sedation but many studies support its use in anaesthetics and dental clinics where it has been shown to be safe and effective.READ MORE
Gastrointestinal (GI) bleeding is a common emergency with a substantial mortality rate. Bleeding from the upper gastrointestinal system is caused by ulcers, stomach inflammation and oesophageal varices and carries a fatality rate of up to 10%. Lower GI bleeding has a variety of causes and a case fatality of about 15%. Between 10% and 25% of patients will have a repeat bleed after their first episode, and these people are four times more likely to die than people without repeated bleeding.
The clotting of blood helps to stem bleeding and blood clot break down may play an important role in GI bleeding and re-bleeding. Tranexamic acid (TXA) is a drug used to reduce clot breakdown. It has been shown to reduce the probability of requiring a blood transfusion by about a third in surgical patients, without causing serious side effects from promoting clotting. This high quality randomised controlled trial will investigate the effectiveness and safety of TXA in GI bleeding.READ MORE
The increasing demand on emergency health care in Australia has seen recent emphasis on clinical redesign initiatives that are focused on time-based performance measures and activity-based funding. While congestion in emergency departments continues, and emphasis is placed on reaching these time targets, the quality of care that patients receive when presenting with non-life threatening injuries is potentially compromised.
To date, there is a lack of high-level evidence surrounding the type of quality indicators (QIs) that should be used in EDs to measure quality of care. This project will develop QIs for care of patients who present to EDs with musculoskeletal injuries under appropriate expert review. The final QI set will allow application across EDs and will contribute to comparison and optimisation of emergency care for patients in ED with musculoskeletal injuries.READ MORE
Acute respiratory disease is the leading cause for infants and children needing hospital admission. The main focus of hospital treatment is oxygen therapy beside disease specific treatment like inhalers for asthma or antibiotics for pneumonia. 10 to 20% of these infants or children need higher level of care at some point of their illness and will be transferred to a children’s hospital intensive care unit. This is not only expensive and imposes a huge burden on health care costs but more importantly is very stressful for these children and families because they are taken out of their familiar environment. Recent research suggests that with early optimal respiratory support the need for transfer can be significantly reduced and many of these patients could be cared in their regional hospital allowing the family to be the main support group. This concept of “keeping the patients in their regional centre” is not only from a psychosocial aspect of advantage but will have as well a great impact on health care costs. Our research group has recently investigated the role of high flow therapy in infants with bronchiolitis and we were able to demonstrate a 40% reduction in intensive care admission. Early respiratory intervention is a fundamentally new approach, which has the potential to prevent progression and deterioration of respiratory illness. The aim of this study is to investigate the role of high flow therapy in infants with bronchiolitis, but future research and trials will also include other conditions such as asthma and pneumonia.READ MORE