Several different classes of sedative agents are used in the management of patients with traumatic brain injury (TBI). These agents are used at induction of anaesthesia, to maintain sedation, to reduce elevated intracranial pressure, to terminate seizure activity and facilitate ventilation. The intent of their use is to prevent secondary brain injury by facilitating and optimising ventilation, reducing cerebral metabolic rate and reducing intracranial pressure. There is limited evidence available as to the best choice of sedative agents in TBI, with each agent having specific advantages and disadvantages. This review discusses these agents and offers evidence-based guidance as to the appropriate context in which each agent may be used. Propofol, benzodiazepines, narcotics, barbiturates, etomidate, ketamine, and dexmedetomidine are reviewed and compared.

Aim Determine levels of depression, anxiety and stress symptoms and factors associated with psychological burden amongst critical care health care workers in the early stages of the coronavirus disease (2019) (COVID-19) pandemic. Methods Anonymous web-based survey distributed in April 2020. All health care workers employed in a critical care setting were eligible to participate. Invitations to the survey were distributed through Australian and New Zealand critical care societies and social media platforms. The primary outcome was the proportion of health care workers that reported moderate to extremely severe scores on the Depression Anxiety Stress Scale-21 (DASS-21) Results Of the 3770 complete responses, 3039 (80.6%) were from Australia. A total of 2871 respondents (76.2%) were female; median age was 41 years old. Nurses made up 2269 (60.2%) of respondents with most [2029 (53.8%)] working in Intensive Care Units.Overall, 813 (21.6%) respondents reported moderate to extremely severe depression, 1078 (28.6%) reported moderate to extremely severe anxiety and 1057 (28.0%) moderate to extremely severe stress scores. Mean ± standard deviation DASS-21 depression, anxiety and stress scores amongst woman vs men were: 8.0 ± 8.2 vs 7.1 ± 8.2 (p=0.003); 7.2 ± 7.5 vs 5.0 ± 6.7 (p<0.001); and 14.4 ± 9.6 vs 12.5 ± 9.4 (p<0.001) respectively.After adjusting for significant confounders, clinical concerns associated with higher DASS-21 scores included; not being clinically prepared (β 4.2, p<0.001), an inadequate workforce (β 2.4, p=0.001), having to triage patients due to lack of beds and or equipment (β 2.6, p=0.001), virus transmission to friends and family (β 2.1, p=0.009), contracting COVID-19 (β 2.8, p=0.011), being responsible for other staff (β 3.1, p<0.001), and being asked to work in an area that was not in the respondents expertise (β 5.7, p<0.001). Conclusion In this survey of critical care health care workers, between 22 and 29% of respondents reported moderate to extremely severe depression, anxiety and stress symptoms with females reporting higher scores compared to men. Although female gender appears to play a role, modifiable factors also contribute to psychological burden and should be studied further.

Paediatric bacterial meningitis is a neurological emergency which, despite advances in medical management, still has a significant morbidity and mortality. Over recent decades new vaccines have led to a change in epidemiology of the disease; however, it remains a condition that requires a high index of suspicion, prompt diagnosis, and early management in the emergency department. New laboratory techniques and clinical tools are aiding the diagnosis of bacterial meningitis, yet some controversies still exist in its management. This paper outlines the changing epidemiology of the disease, current diagnostic techniques as well as controversies and advances in the management of bacterial meningitis in the paediatric population.

ImportanceWhether selective decontamination of the digestive tract (SDD) reduces mortality in critically ill patients remains uncertain.ObjectiveTo determine whether SDD reduces in-hospital mortality in critically ill adults.Design, Setting, and ParticipantsA cluster, crossover, randomized clinical trial that recruited 5982 mechanically ventilated adults from 19 intensive care units (ICUs) in Australia between April 2018 and May 2021 (final follow-up, August 2021). A contemporaneous ecological assessment recruited 8599 patients from participating ICUs between May 2017 and August 2021.InterventionsICUs were randomly assigned to adopt or not adopt a SDD strategy for 2 alternating 12-month periods, separated by a 3-month interperiod gap. Patients in the SDD group (n = 2791) received a 6-hourly application of an oral paste and administration of a gastric suspension containing colistin, tobramycin, and nystatin for the duration of mechanical ventilation, plus a 4-day course of an intravenous antibiotic with a suitable antimicrobial spectrum. Patients in the control group (n = 3191) received standard care.Main Outcomes and MeasuresThe primary outcome was in-hospital mortality within 90 days. There were 8 secondary outcomes, including the proportion of patients with new positive blood cultures, antibiotic-resistant organisms (AROs), and Clostridioides difficile infections. For the ecological assessment, a noninferiority margin of 2% was prespecified for 3 outcomes including new cultures of AROs.ResultsOf 5982 patients (mean age, 58.3 years; 36.8% women) enrolled from 19 ICUs, all patients completed the trial. There were 753/2791 (27.0%) and 928/3191 (29.1%) in-hospital deaths in the SDD and standard care groups, respectively (mean difference, −1.7% [95% CI, −4.8% to 1.3%]; odds ratio, 0.91 [95% CI, 0.82-1.02]; P = .12). Of 8 prespecified secondary outcomes, 6 showed no significant differences. In the SDD vs standard care groups, 23.1% vs 34.6% had new ARO cultures (absolute difference, −11.0%; 95% CI, −14.7% to −7.3%), 5.6% vs 8.1% had new positive blood cultures (absolute difference, −1.95%; 95% CI, −3.5% to −0.4%), and 0.5% vs 0.9% had new C difficile infections (absolute difference, −0.24%; 95% CI, −0.6% to 0.1%). In 8599 patients enrolled in the ecological assessment, use of SDD was not shown to be noninferior with regard to the change in the proportion of patients who developed new AROs (−3.3% vs −1.59%; mean difference, −1.71% [1-sided 97.5% CI, −∞ to 4.31%] and 0.88% vs 0.55%; mean difference, −0.32% [1-sided 97.5% CI, −∞ to 5.47%]) in the first and second periods, respectively.Conclusions and RelevanceAmong critically ill patients receiving mechanical ventilation, SDD, compared with standard care without SDD, did not significantly reduce in-hospital mortality. However, the confidence interval around the effect estimate includes a clinically important benefit.Trial RegistrationClinicalTrials.gov Identifier: NCT02389036