for the DahLIA Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group IMPORTANCE Effective therapy has not been established for patients with agitated delirium receiving mechanical ventilation. OBJECTIVE To determine the effectiveness of dexmedetomidine when added to standard care in patients with agitated delirium receiving mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS The Dexmedetomidine to Lessen ICU Agitation (DahLIA) study was a double-blind, placebo-controlled, parallel-group randomized clinical trial involving 74 adult patients in whom extubation was considered inappropriate because of the severity of agitation and delirium. The study was conducted at 15 intensive care units in Australia and New Zealand from May 2011 until December 2013. Patients with advanced dementia or traumatic brain injury were excluded. INTERVENTIONS Bedside nursing staff administered dexmedetomidine (or placebo) initially at a rate of 0.5 μg/kg/h and then titrated to rates between 0 and 1.5 μg/kg/h to achieve physician-prescribed sedation goals. The study drug or placebo was continued until no longer required or up to 7 days. All other care was at the discretion of the treating physician. MAIN OUTCOMES AND MEASURES Ventilator-free hours in the 7 days following randomization. There were 21 reported secondary outcomes that were defined a priori. RESULTS Of the 74 randomized patients (median age, 57 years; 18 [24%] women), 2 withdrew consent later and 1 was found to have been randomized incorrectly, leaving 39 patients in the dexmedetomidine group and 32 patients in the placebo group for analysis. Dexmedetomidine increased ventilator-free hours at 7 days compared with placebo (median, 144.8 hours vs 127.5 hours, respectively; median difference between groups, 17.0 hours [95% CI, 4.0 to 33.2 hours]; P = .01). Among the 21 a priori secondary outcomes, none were significantly worse with dexmedetomidine, and several showed statistically significant benefit, including reduced time to extubation (median, 21.9 hours vs 44.3 hours with placebo; median difference between groups, 19.5 hours [95% CI, 5.3 to 31.1 hours]; P < .001) and accelerated resolution of delirium (median, 23.3 hours vs 40.0 hours; median difference between groups, 16.0 hours [95% CI, 3.0 to 28.0 hours]; P = .01). Using hierarchical Cox modeling to adjust for imbalanced baseline characteristics, allocation to dexmedetomidine was significantly associated with earlier extubation (hazard ratio, 0.47 [95% CI, 0.27-0.82]; P = .007). CONCLUSIONS AND RELEVANCE Among patients with agitated delirium receiving mechanical ventilation in the intensive care unit, the addition of dexmedetomidine to standard care compared with standard care alone (placebo) resulted in more ventilator-free hours at 7 days. The findings support the use of dexmedetomidine in patients such as these.

Patients with cystic fibrosis are more likely to have glutathione deficiency, and greater susceptibility to liver injury. Delta miRNA may be a better detector of early liver injury than hepatic aminotransferases. Empiric treatment with acetylcysteine and serial biochemical reassessment in this setting should be considered.

Preeclampsia presenting as severe hyponatremia is an enigma of modern obstetric practice. The hyponatremia can cause severe maternal neurological morbidity, including cerebral edema and seizures. Neonates, with serum sodium reflecting maternal levels, are also at risk. Despite this, the literature remains ambiguous about its incidence, the pathophysiology is poorly understood, and guidelines on preeclampsia (including those of the American College of Obstetricians and Gynecologists) do not discuss the issue. This case of preeclampsia associated with severe hyponatremia in a laboring woman highlights these issues.

Background: Modifications to rapid response team (RRT) activation criteria occur commonly in Australian hospitals without evidence to define their use.Aims: To evaluate the effectiveness of RRT activation criteria modifications in preventing RRT activation and differences in adverse events associated with treatment delays caused by modifications.Methods: A prospective chart audit of hospital patients with RRT activation criteria modifications admitted during a 12-month period in a large regional hospital in Toowoomba, Australia. The incidence of RRT activation criteria modifications, RRT activations and rates of adverse events following criteria modifications were investigated. Adverse events were defined as a delayed treatment on the ward, unplanned intensive care unit admission, cardiac arrest and unexpected death. Differences in patient outcomes among medical and surgical patients were also investigated.Results: A total of 271 patients out of 4009 admitted patients had modifications to their RRT activation criteria. There was no difference in rates of RRT activation in patients with modified criteria compared with patients with unmodified criteria (P = 0.37). In patients with RRT activation criteria modifications, rates of adverse events were higher in patients who met their modified RRT criteria (93.3%) compared with those who did not meet modified RRT criteria (3.8%; P < 0.001). Additionally, in patients with modifications, rates of adverse events were higher in medical patients (27.6%; n = 50) compared with surgical patients (15.6%; n = 14; P = 0.03). Conclusions:The results strongly suggest that RRT criteria modification is associated with no difference in rates of RRT activation and with detrimental impacts on patient safety, particularly in medical patients.