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Schuster M, Bein T. [Environmental sustainability in intensive care medicine]. DIE ANAESTHESIOLOGIE 2025; 74:189-203. [PMID: 39668229 DOI: 10.1007/s00101-024-01485-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/27/2024] [Indexed: 12/14/2024]
Abstract
Intensive care medicine is an area with a particularly high consumption of resources. This review presents important new findings relating to the environmental sustainability of intensive care medicine. For example, the drugs used in intensive care medicine can end up in the environment and cause relevant ecotoxicity. The consumption of material items is very high in intensive care medicine and the increasing replacement of reusable items by disposable items is a major problem. Simple measures can reduce the ecological footprint of materials and introduce the recycling of waste in intensive care units. The high energy consumption of air conditioning, lighting and medical technology varies between facilities but in most cases is substantial and can be significantly reduced through appropriate measures. Ideally, the consumption should be measured and analyzed in detail. In the future, support from artificial intelligence is conceivable in this aspect. Sustainability must be given a much higher priority in the training, continued and advanced education in intensive care medicine than it has been to date and in intensive care research sustainability aspects should be given equal consideration alongside economic aspects when it comes to assessing otherwise equivalent treatments. It is particularly important to avoid the misuse and overuse of intensive care. It brings no benefit to patients and hinders needs-based treatment that is oriented towards the patient's well-being. In addition, misuse and overuse increases costs and drives up the consumption of resources and thus the ecological footprint. Sustainability in the intensive care unit can only be achieved as a team. Various approaches are presented on how a networked Green Team can promote sustainability in the intensive care unit.
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Affiliation(s)
- Martin Schuster
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, RKH-Kliniken Landkreis Karlsruhe, Fürst-Stirum-Klinik Bruchsal und Rechbergklinik Bretten, Akademische Lehrkrankenhäuser der Universität Heidelberg, Gutleutstr. 1-14, 76646, Bruchsal, Deutschland.
| | - Thomas Bein
- Deutsche Allianz für Klimawandel und Gesundheit, Regensburg, Deutschland.
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Ayebare E, Tumwine JK, Nankunda J, Hjelmstedt A, Jonas W, Ndeezi G, Orsini N, Hanson C. Evaluating predictive values of umbilical cord arterial lactate for adverse newborn outcomes among term-births in northern Uganda: A cross sectional analytical study. Int J Gynaecol Obstet 2025; 169:408-420. [PMID: 39614695 PMCID: PMC11911978 DOI: 10.1002/ijgo.16037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 10/16/2024] [Accepted: 10/29/2024] [Indexed: 12/01/2024]
Abstract
OBJECTIVE Birth asphyxia is one of the leading causes of death for neonates worldwide. Lack of an objective cost effective test to predict poor newborn outcomes at birth affects the ability to respond appropriately. This study determined predictive values of umbilical cord arterial lactate in relation to adverse neonatal outcomes. METHODS This was a cross-sectional analytical study conducted between March 2018 and March 2019 at two hospitals in Northern Uganda. A total of 2655 women admitted for birth and their newborns were recruited. At birth, umbilical cord arterial blood was tested for lactate using the Nova Biomedical StatStrip Xpress meter. Apgar scores were assessed at 5 min by trained research midwives. Area under the receiver operator characteristics curve (AUROC) was calculated relating umbilical arterial lactate (UAL) levels and four outcomes. We modeled the best lactate cutoff level associated with the highest AUROC for the four outcomes. RESULTS The estimated AUROC for lactate was: 88.42% for Apgar score <7 at 5 min, 83.35% for resuscitation with bag and mask, 84.55% for oxygen therapy after resuscitation and 87.72% for admission to neonatal care unit. The UAL cutoff value of 5.5 mmol/L was associated with the best AUROC of between 75.81% to 81.75% for the four adverse outcomes with no significant differences when adjusted for infectious disease parameters. The sensitivity, specificity, PPV, and NPV were; 78.95%, 86.48%, 23.54%, and 98.73% for Apgar scores <7 at 5 min, 64.40%, 88.11%, 36.59%, and 95.87% for resuscitation with bag and mask, 67.17%, 87.20%, 30.23%, and 96.99% for oxygen therapy after resuscitation, and 77.17%, 86.15%, 22.27%, and 98.65% for admission to the special care unit, respectively. CONCLUSION Umbilical cord lactate point-of-care (POC) estimate of ≥5.5 mmol/L predicts adverse neonatal outcomes. This test may be used to trigger early interventions and intensified neonatal care complementing the clinical Apgar score assessment in settings like Uganda.
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Affiliation(s)
| | - James K Tumwine
- Department of Pediatrics and Child Health, Kabale University, Kabale, Uganda
- Department of Pediatrics and Child Health, Makerere University, Kampala, Uganda
| | - Jolly Nankunda
- Department of Pediatrics and Child Health, Kabale University, Kabale, Uganda
- Newborn department, Mulago Specialized Women's and Neonatal Hospital, Kampala, Uganda
| | - Anna Hjelmstedt
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Wibke Jonas
- Department of Women's and Children's Health, Karolinska Institutet, Stockholm, Sweden
| | - Grace Ndeezi
- Department of Pediatrics and Child Health, Kabale University, Kabale, Uganda
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Claudia Hanson
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
- Department of Disease Control, London School of Hygiene and Tropical Medicine, London, UK
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Hansell L, Delaney A, Milross M, Henderson E. Reducing unnecessary use of intermittent pneumatic compression in intensive care: A before-and-after pilot study with environmental perspective. Aust Crit Care 2025; 38:101125. [PMID: 39505589 DOI: 10.1016/j.aucc.2024.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2024] [Revised: 09/02/2024] [Accepted: 09/26/2024] [Indexed: 11/08/2024] Open
Abstract
BACKGROUND The healthcare sector in Australia has committed to reducing carbon emissions associated with care delivery. Thirty percent of care delivered in the Australian hospital sector is considered low-value care. Intensive care uses chemical prophylaxis to reduce risk of venous thromboembolism (VTE). Mechanical prophylaxis methods, which include intermittent pneumatic compression (IPC), are often used as an adjunct to chemical prophylaxis but can also be used in patients where chemical prophylaxis is contraindicated. Recent literature demonstrates, however, that there is no additional benefit to the routine use of IPC, in reducing VTE risk when used as an adjunct to chemical VTE prophylaxis. OBJECTIVE The aims of this study were to assess the effect of the implementation of an education package on the use of single-use IPC devices in the intensive care unit to determine the carbon footprint of a pair of IPC devices, and to determine change in waste production, greenhouse gas emissions, and the financial cost associated with change in IPC use. METHODS A before-and-after pilot study was undertaken in a single, level III intensive care unit. An audit was conducted to determine the appropriate use of IPC over a 3-month period before and after the delivery of an education package to guide prescription and use of IPC. RESULTS Unnecessary use of IPC reduced from 33/58 (56.9%) to 3/31 (9.7%) after delivery of an education package. According to a bottom-up carbon footprinting analysis, embodied carbon of a single pair of IPC devices was 432.2 g carbon dioxide equivalent (CO2e). This study represents a minimum annual saving of $7682.40, 14.9 Kg waste and 51.8 KgCO2e associated with reduced unnecessary use of IPC. CONCLUSION Staff education and behaviour change reduced the number of IPC devices used. The number of IPC devices applied inappropriately also reduced, as did associated greenhouse gas emissions and financial cost.
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Affiliation(s)
- Louise Hansell
- Royal North Shore Hospital, St Leonards, NSW Australia; Planetary Health, Northern Sydney Local Health District, St Leonards, NSW Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
| | - Anthony Delaney
- Royal North Shore Hospital, St Leonards, NSW Australia; Division of Critical Care, The George Institute for Global Health, UNSW, Sydney, Australia; Northern Clinical School, The University of Sydney, Sydney, Australia; ANZIC Research Centre, Department of Epidemiology and Preventative Medicine, Monash University, Melbourne, Australia
| | - Maree Milross
- Faculty of Medicine and Health, The University of Sydney, Sydney, Australia
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Sheng S, Li A, Zhang C, Liu X, Zhou W, Shen T, Ma Q, Ma S, Zhu F. Association between hemoglobin and in-hospital mortality in critically ill patients with sepsis: evidence from two large databases. BMC Infect Dis 2024; 24:1450. [PMID: 39702030 PMCID: PMC11660889 DOI: 10.1186/s12879-024-10335-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2024] [Accepted: 12/10/2024] [Indexed: 12/21/2024] Open
Abstract
BACKGROUND The relationship between baseline hemoglobin levels and in-hospital mortality in septic patients remains unclear. This study aimed to clarify this association in critically ill patients with sepsis. METHODS Patients with sepsis were retrospectively identified from the Medical Information Mart for Intensive Care-IV (MIMIC-IV 2.2) and eICU Collaborative Research Database (eICU-CRD). Multivariate logistic regression analysis and restricted cubic spline regression were used to investigate the association between hemoglobin and the risk of in-hospital mortality. Additionally, a two-part linear regression model was used to determine threshold effects. Stratified analyses were also performed. RESULTS A total of 21,946 patients from MIMIC-IV and 15,495 patients from eICU-CRD were included in the study. In-hospital mortality was 14.95% in MIMIC-IV and 17.40% in eICU-CRD. Multivariate logistic regression showed that hemoglobin was significantly and nonlinearly associated with the risk of in-hospital mortality after adjusting for other covariates. Furthermore, we found a nonlinear association between hemoglobin and in-hospital mortality, with mortality plateauing at 10.2 g/dL. The risk of mortality decreased with increasing hemoglobin levels below 10.2 g/dL but increased when hemoglobin levels exceeded 10.2 g/dL. These findings were validated in the eICU-CRD dataset. CONCLUSIONS A nonlinear correlation between hemoglobin levels and in-hospital mortality was observed in patients with sepsis, with a threshold of 10.2 g/DL. These findings suggested that hemoglobin levels below or above the threshold may be associated with worse outcomes, warranting further investigation in prospective studies.
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Affiliation(s)
- Shuyue Sheng
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Andong Li
- School of Artificial Intelligence and Computer Science, Jiangnan University, Wuxi, 214122, China
| | - Changjing Zhang
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Xiaobin Liu
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Wei Zhou
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Tuo Shen
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Qimin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China
| | - Shaolin Ma
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China.
| | - Feng Zhu
- Department of Critical Care Medicine, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, 200120, China.
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Pilowsky JK, Lane K, Learmonth G, Walsh O, Scowen C, Williams L, Nguyen N. Environmental impact of a blood test reduction intervention in adult intensive care units: A before and after quality improvement project. Aust Crit Care 2024; 37:761-766. [PMID: 38755050 DOI: 10.1016/j.aucc.2024.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2024] [Revised: 03/28/2024] [Accepted: 03/28/2024] [Indexed: 05/18/2024] Open
Abstract
BACKGROUND Pathology testing is a very common investigation in the intensive care unit (ICU). Many tests are ordered on a routine basis rather than for a specific clinical indication, resulting in potential patient harm and unnecessary financial and environmental costs. OBJECTIVE The objective of this study was to determine whether a multifaceted intervention based on the principles of education, audit, and feedback can result in a decrease in unnecessary pathology tests without a commensurate increase in adverse patient outcomes and to measure this decrease in terms of the associated reduction in environmental and financial costs. METHODS A before and after quality improvement project was conducted between 2017 and 2019 across four ICUs in three 12-month phases, divided according to baseline, intervention implementation, and follow-up. Local clinician champions from each site partnered with the project coordinating centre to develop and implement a range of interventions based on the principles of education, audit, and feedback. Data were collected for the number of pathology tests performed and the clinical characteristics of patients admitted to a participating ICU across the three phases. RESULTS A total of 196 323 arterial blood gases and 460 258 other tests across eight categories were performed on the 22 210 patients admitted to participating ICUs during the project. A decrease in testing was observed across all but one category, with the greatest reduction seen in arterial blood gases (31.2% reduction in tests per bed-day). Across all categories, this equated to a mean reduction of 1.8 tCO2e (tonnes of carbon dioxide equivalent), a potential estimated total saving of Australian dollar $918 497.50. No increase in adverse clinical outcomes was observed. CONCLUSION A multifaceted intervention based on the principles of education, audit, and feedback can produce a significant decrease in the number of unnecessary pathology tests performed. This reduction translates to substantial environmental and financial savings without any associated increase in adverse patient outcomes.
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Affiliation(s)
- Julia K Pilowsky
- Agency for Clinical Innovation, NSW Health, Australia; University of Sydney, Australia
| | - Kathleen Lane
- Agency for Clinical Innovation, NSW Health, Australia
| | | | | | | | | | - Nhi Nguyen
- Agency for Clinical Innovation, NSW Health, Australia; University of Sydney, Australia; Nepean Hospital, Australia
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Mazzeffi M, Miller D, Wang A, Kothandaraman V, Money D, Clouse B, Zaaqoq AM, Teman N. Iatrogenic blood loss from phlebotomy during adult extracorporeal membrane oxygenation: A retrospective cohort study. Transfusion 2024; 64:475-482. [PMID: 38385665 DOI: 10.1111/trf.17729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/05/2024] [Accepted: 01/05/2024] [Indexed: 02/23/2024]
Abstract
BACKGROUND Adult extracorporeal membrane oxygenation (ECMO) patients are at high risk for allogeneic blood transfusion. Few studies have characterized iatrogenic blood loss from phlebotomy in adult ECMO patients. We hypothesized that iatrogenic phlebotomy would be a significant source of blood loss during ECMO. METHODS Adults who had their entire ECMO run at our medical center between 2020 and 2022 were included. Average daily phlebotomy volume and total phlebotomy volume during ECMO were estimated based on the total number of laboratory tests that were processed. In addition, the crude and adjusted association between total phlebotomy volume during ECMO and RBC transfusion during ECMO was evaluated using linear regression and Loess curve analysis. RESULTS A total of 161 patients who underwent 162 ECMO runs were included. Of the 162 ECMO runs, 88 (54.3%) were veno-arterial and 74 (45.7%) were veno-venous ECMO. Median duration of ECMO was 5 days [25th, 75th percentile = 2, 11]. Median daily phlebotomy volume was 130 mLs [25th, 75th percentile = 94, 170] and median total phlebotomy volume during ECMO was 579 mLs [25th, 75th percentile = 238, 1314]. There was a significant crude and adjusted association between total phlebotomy volume and RBC transfusion during ECMO (beta coefficient = 0.0023 and 0.0024 respectively, both p < .001) based on linear regression analysis. DISCUSSION Phlebotomy for laboratory testing is a significant source of blood loss during ECMO in adults. Comprehensive patient blood management for adult ECMO patients should include strategies to reduce laboratory testing and/or phlebotomy volume during ECMO.
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Affiliation(s)
- Michael Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - David Miller
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | - Angela Wang
- University of Virginia School of Medicine, Charlottesville, Virginia, USA
| | | | - Dustin Money
- University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Brian Clouse
- University of Virginia Medical Center, Charlottesville, Virginia, USA
| | - Akram M Zaaqoq
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia, USA
| | - Nicholas Teman
- Division of Cardiothoracic Surgery, Department of Surgery, University of Virginia, Charlottesville, Virginia, USA
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Ostermann M, De Waele JJ, Schefold JC. The environmental impact of laboratory measurements in high-resource ICUs. Intensive Care Med 2024; 50:449-452. [PMID: 38353712 DOI: 10.1007/s00134-023-07318-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/29/2023] [Indexed: 03/21/2024]
Affiliation(s)
- Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK.
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Faculty of Medicine and Health Sciences, Ghent University Hospital, Ghent, Belgium
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, University of Bern, Bern, Switzerland
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See KC. Improving environmental sustainability of intensive care units: A mini-review. World J Crit Care Med 2023; 12:217-225. [PMID: 37745260 PMCID: PMC10515098 DOI: 10.5492/wjccm.v12.i4.217] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 07/08/2023] [Accepted: 07/17/2023] [Indexed: 09/05/2023] Open
Abstract
The carbon footprint of healthcare is significantly impacted by intensive care units, which has implications for climate change and planetary health. Considering this, it is crucial to implement widespread efforts to promote environmental sustainability in these units. A literature search for publications relevant to environmental sustainability of intensive care units was done using PubMed. This mini-review seeks to equip intensive care unit practitioners and managers with the knowledge necessary to measure and mitigate the carbon cost of healthcare for critically ill patients. It will also provide an overview of the current progress in this field and its future direction.
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Affiliation(s)
- Kay Choong See
- Department of Medicine, National University Hospital, Singapore 119228, Singapore
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Affiliation(s)
- Heather Baid
- School of Sport and Health Sciences, University of Brighton, Brighton, UK
| | - Eleanor Damm
- Intensive Care Medicine and Anaesthesia, Shrewsbury and Telford Hospital NHS Trust, Shrewsbury, UK
| | - Louise Trent
- Hawke's Bay Hospital, Te Matau a Māui, Te Whatu Ora, New Zealand
| | - Forbes McGain
- Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Carlton, Australia
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Walsh O, Harris R, Flower O, Anstey M, McGain F. Everyone's a winner if we test less: the CODA action plan. AUST HEALTH REV 2022; 46:460-462. [PMID: 35772927 DOI: 10.1071/ah22145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 06/15/2022] [Indexed: 11/23/2022]
Abstract
In this era of 'Choosing Wisely,' we present a four-step action plan to reduce unnecessary pathology testing and the associated patient harm (blood loss through repeated phlebotomy), economic cost and environmental impact. The authors are experts from the CODA group; a medical education and health-promotion charity that aims to build on the Choosing Wisely initiative to provide meaningful and sustainable actions to reduce the carbon footprint of healthcare, globally. Pathology testing is expensive and carbon-intensive, with as many as half of all tests being not clinically indicated. Reducing unnecessary testing is the only effective way to decrease the carbon footprint and other associated costs, as opportunities to reuse and recycle pathology specimens are limited. The four key steps for action are (i) auditing local practice; (ii) defining unnecessary testing including developing a clinical guideline for rational ordering; (iii) educating stakeholders; and (iv) measuring the impact of the intervention through re-audit. This proven method is designed to be used in any healthcare setting around the world; having a small group of passionate 'champions' is thought to be as important as strong clinical governance and more important than access to sophisticated equipment. Electronic medical record systems and other technological solutions offer new ways to help establish a sustainability mindset and reduce unnecessary testing. The Codachange.org/coda-earth/ website provides a dynamic crowdsourcing platform through which we can collectively learn to meet the diverse needs of our international medical community. Self-reported outcomes are gamified through collaborative feedback, amplification via social media and the ability to earn rewards, be uploaded to the CODA website, or added to the template as a success story. By combining our existing local networks with the emerging international CODA community, we can initiate meaningful change now and enter the era of environmental stewardship.
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Affiliation(s)
- Oliver Walsh
- Intensive Care Unit, The Canberra Hospital, ACT, Australia; and College of Health and Medicine, The Australian National University, Canberra, ACT, Australia
| | - Roger Harris
- Intensive Care Unit, Royal North Shore Hospital, Sydney, NSW, Australia; and Faculty of Health and Medicine, Sydney University, NSW, Australia
| | - Oliver Flower
- Intensive Care Unit, Royal North Shore Hospital, Sydney, NSW, Australia; and Faculty of Health and Medicine, Sydney University, NSW, Australia
| | - Matthew Anstey
- Intensive Care Unit, Sir Charles Gairdner Hospital, Perth, WA, Australia; and School of Public Health, Curtin University, Perth, WA, Australia
| | - Forbes McGain
- Departments of Anaesthesia and Intensive Care, Western Health, Vic., Australia; and Department of Critical Care, University of Melbourne, Vic., Australia
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