Andrew D Bersten

Flinders University, Tarndarnya, South Australia, Australia

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Publications (145)754.59 Total impact

  • Shailesh Bihari · Andrew W. Holt · Shivesh Prakash · Andrew D. Bersten
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    ABSTRACT: Fluid and sodium overload are a common problem in critically ill patients. Frusemide may result in diuresis in excess of natriuresis. The addition of indapamide may achieve a greater natriuresis, and also circumvent some of the problems associated with frusemide. The objective of this study was to examine the effect of adding indapamide to frusemide on diuresis, natriuresis, creatinine clearance and serum electrolytes.
    No preview · Article · Jan 2016
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    Full-text · Article · Dec 2015 · Heart, Lung and Circulation
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    Full-text · Article · Dec 2015 · Critical care medicine
  • Shailesh Bihari · Michael Bailey · Andrew D Bersten

    No preview · Article · Nov 2015 · Intensive Care Medicine

  • No preview · Article · Sep 2015 · Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
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    ABSTRACT: Rapid intravenous infusion of 0.9% saline alters respiratory mechanics in healthy subjects. However, the relative cardiovascular and respiratory effects of bolus intravenous crystalloid versus colloid are unknown. Six healthy male volunteers were given 30 ml/kg intravenous 0.9% saline, 4% albumin and 5% glucose at a rate of 100 ml/minute on three separate days in a double-blind randomized crossover study. Impulse oscillometry, spirometry, lung volumes, diffusing capacity and blood samples were measured before and after fluid administration. Lung ultrasound B-line score (indicating interstitial pulmonary edema) and Doppler echocardiography indices of cardiac preload were measured before, midway, immediately after and one hour after fluid administration. Infusion of 0.9% saline increased small airway resistance at 5 Hz (P = 0.04) and lung ultrasound B-line score (P = 0.01), without changes in Doppler echocardiography measures of preload. In contrast, 4% albumin increased diffusing capacity, decreased lung volumes, and increased Doppler echocardiopraphy mitral E velocity (P = 0.001) and E to lateral/septal e' ratio, estimated blood volume and NT-proBNP (P = 0.01), but not lung ultrasound B-line score; consistent with increased pulmonary blood volume without interstitial pulmonary edema. There were no significant changes with 5% glucose. Plasma angiopoietin-2 concentration increased only after 0.9% saline (P = 0.001), suggesting an inflammatory mechanism associated with edema formation. In healthy subjects 0.9% saline and 4% albumin have differential pulmonary effects not attributable to passive fluid filtration. This may reflect either different effects of these fluids on active signaling in the pulmonary circulation, or a protective effect of albumin. Copyright © 2015, Journal of Applied Physiology.
    Full-text · Article · Jul 2015 · Journal of Applied Physiology
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    ABSTRACT: To derive and validate a mortality prediction model from information available at ED triage. Multivariable logistic regression of variables from administrative datasets to predict inpatient mortality of patients admitted through an ED. Accuracy of the model was assessed using the receiver operating characteristic area under the curve (ROC-AUC) and calibration using the Hosmer-Lemeshow goodness of fit test. The model was derived, internally validated and externally validated. Derivation and internal validation were in a tertiary referral hospital and external validation was in an urban community hospital. The ROC-AUC for the derivation set was 0.859 (95% CI 0.856-0.865), for the internal validation set was 0.848 (95% CI 0.840-0.856) and for the external validation set was 0.837 (95% CI 0.823-0.851). Calibration assessed by the Hosmer-Lemeshow goodness of fit test was good. The model successfully predicts inpatient mortality from information available at the point of triage in the ED. © 2015 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine.
    No preview · Article · Jul 2015 · Emergency medicine Australasia: EMA
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    Full-text · Dataset · Apr 2015
  • Claire E Baldwin · Andrew D Bersten
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    ABSTRACT: Purpose of review: Survivors of a critical illness may experience poor physical function and quality of life as a result of reduced skeletal muscle mass and strength during their acute illness. Patients diagnosed with sepsis are particularly at risk, and mechanical ventilation may result in diaphragm dysfunction. Interest in the interaction of these conditions is both growing and important to understand for individualised patient care. Recent findings: This review describes developments in the presentation of both diaphragm and limb myopathy in critical illness, as measured from muscle biopsy and at the bedside with various imaging and strength testing modalities. The influence of unloading of the diaphragm with mechanical ventilation and peripheral muscles with immobilisation in septic patients has been recently questioned. Systemic inflammation appears to primarily accelerate and accentuate dysfunction, which may be remedied by early mobilisation and augmented with developing muscle and/or nerve stimulation techniques. Summary: Many acute muscle changes in septic patients are likely to stem from pre-existing impairments, which should provide context for clinical evaluations of strength. During illness, sarcolemmal injury promotes a cascade of intra-cellular abnormalities. As unique characteristics of ICU acquired weakness and differential effects on muscle groups are understood, early diagnosis and management should be facilitated.
    No preview · Article · Mar 2015 · Current Opinion in Clinical Nutrition and Metabolic Care
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    ABSTRACT: Large positive sodium balances, independent of fluid balance, may lead to expanded extracellular fluid volumes and adverse clinical outcomes in the critically ill, including impaired oxygenation. To estimate sodium and fluid balances in critically ill patients needing invasive mechanical ventilation (MV) for more than 48 hours and to evaluate the relationship between fluid balance, sodium balance and respiratory function (PaO2/FiO2 ratio and length of MV). A prospective, observational study of 50 patients on MV in four tertiary intensive care units. Daily sodium and fluid input and output, biochemistry, haemodynamic variables, oxygenation (PaO2/FiO2) and steroid and vasopressor administration were recorded for 3 days after study enrolment. Outcome data included the duration of invasive MV, ICU and hospital mortality and ICU and hospital lengths of stay. Fifty patients (33 men [66%]) with a mean age of 62.8 years (standard deviation, 14.6 years) and a median admission Acute Physiology and Chronic Health Evaluation III score of 82 (interquartile range [IQR], 61-99) were studied. By Day 3 after enrolment, the median cumulative fluid balance was 2668mL (IQR, 875-3507mL) and the cumulative sodium balance was +717mmol (IQR, +422 to +958mmol). Intravenous steroids and the presence of shock led to a lower daily sodium excretion (P=0.004 and P = 0.01, respectively). A positive sodium balance was associated with a reduction in the next day's PaO2/FiO2 ratio (?=-0.36, P = 0.001) and an increased length of MV (linear regression analysis, P< 0.01). The cumulative fluid balance was not associated with either parameter. The cumulative positive sodium balance, not the cumulative positive fluid balance, is associated with respiratory dysfunction and an increased length of MV.
    No preview · Article · Mar 2015 · Critical care and resuscitation: journal of the Australasian Academy of Critical Care Medicine
  • Shailesh Bihari · Andrew D Bersten

    No preview · Article · Feb 2015 · Critical Care Medicine
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    Arnaud W. Thille · Alain Vuylsteke · Andrew Bersten
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    ABSTRACT: Guérin et al. retrospectively examined all open lung biopsies (OLB) performed in patients with non-resolving acute respiratory distress syndrome (ARDS), without an identified cause [1]. Eighty-three of the 113 patients who underwent OLB over a 16-year period (1998–2013) met the clinical criteria for ARDS according to the Berlin definition [2, 3], which represents 14 % of all patients they diagnosed with ARDS over that period (83/597). Does this report help address the relevance of OLB for management of ARDS today?The authors’ main objective was to assess the proportion of patients with diffuse alveolar damage (DAD); they observed that 58 % of patients with ARDS (48/83) had hallmark signs of DAD. These findings are similar to those reported by Thille et al. from postmortem reports [4], where DAD was present in 56 % (118/229) of patients who met ARDS clinical criteria for longer than 72 h. In both studies, the authors also reported the distribution of DAD according to the ARDS severity. ...
    Full-text · Article · Jan 2015 · Intensive Care Medicine
  • Shailesh Bihari · Andrew D. Bersten
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    ABSTRACT: Critically ill patients are at risk of sodium retention. Current practices of patient management lead to high amount of sodium being administered often inadvertently and lead to high daily and cumulative sodium balance. Positive sodium balance may have adverse outcomes in addition to those observed with positive fluid balance as sodium being an extracellular ion leads to expansion of extracellular spaces with concomitant intracellular dehydration.
    No preview · Article · Jan 2015
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    ABSTRACT: We hypothesized that the thromboelastometry (ROTEM; Pentapharm GmbH, Munich, Germany) fibrinolysis parameter "maximum lysis" (ML) would have an independent inverse association with the severity of organ failure in sepsis. Selected adult patients with sepsis (n = 77) were recruited within 24 hours of antibiotic commencement. Patients with Sequential Organ Failure Assessment score higher than 1 (n = 57) were followed for 72 hours. Prothrombin fragments 1 + 2, plasminogen activator inhibitor-1 (aPAI-1), ROTEM, and routine coagulation tests were measured daily along with Sequential Organ Failure Assessment scores. The activity of functional aPAI-1 increased with increasing severity of organ failure (P = .01) and was higher as compared with healthy controls (95% confidence interval, -65.4 to -29.9; P < .001). There was a decreasing trend in ML with increased organ failure (P = .001); however, there was no trend in d-dimer. Among all tests, only the lower ML (ß = -0.38, P < .001) and higher international normalized ratio (INR; ß = 0.32, P = .002) values significantly contributed to greater severity of organ failure (R(2) = 0.35, F2,73 = 19.29, P < .001). Despite an increase in INR, the prothrombin fragment remained unchanged (P = .89). Strong correlations were observed between early (24 hours) increase in fibrinolysis and recovery of organ failures for 48 hours (ML: r = 0.679, P = .001; aPAI-1: r = 0.694, P < .001). Lower ML and higher INR values predicted greater severity of organ failure at presentation. Further studies are required, as ROTEM could aid selection of patients and guide interventions aimed at fibrinolysis in severe sepsis. Copyright © 2014 Elsevier Inc. All rights reserved.
    No preview · Article · Oct 2014 · Journal of Critical Care
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    ABSTRACT: Background Chronic heart failure (CHF) following coronary artery ligation and myocardial infarction in the rat leads to a homeostatic reduction in surface tension with associated alveolar type II cell hyperplasia and increased surfactant content, which functionally compensates for pulmonary collagen deposition and increased tissue stiffness. To differentiate the effects on lung remodelling of the sudden rise in pulmonary microvascular pressure (Pmv) with myocardial infarction from its consequent chronic elevation, we examined a hypertensive model of CHF. Methods Cardiopulmonary outcomes due to chronic pulmonary capillary hypertension were assessed at six and 15 weeks following abdominal aortic banding (AAB) in the rat. Results At six weeks post-surgery, despite significantly elevated left ventricular end-diastolic pressure, myocardial hypertrophy and increased left ventricular internal circumference in AAB rats compared with sham operated controls (p≤0.003), lung weights and tissue composition remained unchanged, and lung compliance was normal. At 15 weeks post-surgery increased lung oedema was evident in AAB rats (p = 0.002) without decreased lung compliance or evidence of tissue remodelling. Conclusion Despite chronically elevated Pmv, comparable to that resulting from past myocardial infarction (LVEDP >19 mmHg), there is no evidence of pulmonary remodelling in the AAB model of CHF.
    No preview · Article · Sep 2014 · Heart, Lung and Circulation
  • D Bihari · S Prakash · A Bersten

    No preview · Article · Sep 2014 · Anaesthesia and intensive care
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    ABSTRACT: Background: Abdominal infections are frequent causes of sepsis and septic shock in the intensive care unit (ICU) and are associated with adverse outcomes. We analyzed the characteristics, treatments and outcome of ICU patients with abdominal infections using data extracted from a one-day point prevalence study, the Extended Prevalence of Infection in the ICU (EPIC) II. Methods: EPIC II included 13,796 adult patients from 1,265 ICUs in 75 countries. Infection was defined using the International Sepsis Forum criteria. Microbiological analyses were performed locally. Participating ICUs provided patient follow-up until hospital discharge or for 60 days. Results: Of the 7,087 infected patients, 1,392 (19.6%) had an abdominal infection on the study day (60% male, mean age 62 +/- 16 years, SAPS II score 39 +/- 16, SOFA score 7.6 +/- 4.6). Microbiological cultures were positive in 931 (67%) patients, most commonly Gram-negative bacteria (48.0%). Antibiotics were administered to 1366 (98.1%) patients. Patients who had been in the ICU for <= 2 days prior to the study day had more Escherichia coli, methicillin-sensitive Staphylococcus aureus and anaerobic isolates, and fewer enterococci than patients who had been in the ICU longer. ICU and hospital mortality rates were 29.4% and 36.3%, respectively. ICU mortality was higher in patients with abdominal infections than in those with other infections (29.4% vs. 24.4%, p < 0.001). In multivariable analysis, hematological malignancy, mechanical ventilation, cirrhosis, need for renal replacement therapy and SAPS II score were independently associated with increased mortality. Conclusions: The characteristics, microbiology and antibiotic treatment of abdominal infections in critically ill patients are diverse. Mortality in patients with isolated abdominal infections was higher than in those who had other infections.
    Full-text · Article · Jul 2014 · BMC Infectious Diseases
  • Shailesh Bihari · Shivesh Prakash · Andrew D Bersten

    No preview · Article · Jul 2014 · Intensive Care Medicine
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    Russell D Laver · Ubbo F Wiersema · Andrew D Bersten
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    ABSTRACT: Background Indirect assessment of mean pulmonary arterial pressure (MPAP) may assist management of critically ill patients with pulmonary hypertension and right heart dysfunction. MPAP can be estimated as the sum of echocardiographically derived mean right ventricular to right atrial systolic pressure gradient and right atrial pressure; however, this has not been validated in critically ill patients. Methods This prospective validation study was conducted in patients undergoing pulmonary artery catheterisation during intensive care admission. Pulmonary artery catheter (PAC) measurements of MPAP were contemporaneously compared to MPAP estimated utilising transthoracic echocardiography (TTE)-derived mean right ventricular to right atrial systolic pressure gradient added to invasively measured right atrial pressure. Results Of 53 patients assessed, 23 had estimable MPAP using TTE. The mean difference between TTE- and PAC-derived MPAP was 1.9 mmHg (SD 5.0), with upper and lower limits of agreement of 11.6 and −7.9 mmHg, respectively. The median absolute percentage difference between TTE- and PAC-derived MPAP was 7.5%. Inter-rater reliability assessment was performed for 15 patients, giving an intra-class correlation coefficient of 0.96 (95% confidence intervals, 0.89 to 0.99). Conclusions This echocardiographic method of estimating MPAP in critically ill patients was not equivalent to invasively measured MPAP, based on our predefined clinically acceptable range (±5 mmHg). The accuracy of this method in critically ill patients was similar to the results obtained in ambulatory patients and compared favourably with regard to the accuracy with echocardiographic estimation of systolic pulmonary arterial pressure. The utility of this technique is limited by frequent inability to obtain an adequate tricuspid regurgitant time-velocity integral in critically ill patients.
    Preview · Article · Jul 2014 · Critical ultrasound journal
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    ABSTRACT: Background: Because increased serum osmolarity may be lung protective, we hypothesized that increased mortality associated with increased serum sodium would be ameliorated in critically ill patients with an acute respiratory diagnosis. Methods: Data collected within the first 24 hours of intensive care unit (ICU) admission were accessed using ANZICS CORE database. From January 2000 to December 2010, 436,209 patients were assessed. Predefined subgroups including patients with acute respiratory diagnoses were examined. The effect of serum sodium on ICU mortality was assessed with analysis adjusted for illness severity and year of admission. Results are presented as odds ratio (95% confidence interval) referenced against a serum sodium range of 135 to 144.9 mmol/L. Results: Overall ICU mortality was increased at each extreme of dysnatremia (U-shaped relationship). A similar trend was found in various subgroups, with the exception of patients with respiratory diagnoses where ICU mortality was not influenced by high serum sodium (odds ratio, 1.3 [0.7-1.2]) and was different from other patient groups (P<.01). Any adverse associations with hypernatremia in respiratory patients were confined to those with arterial pressure of oxygen (PaO2)/fraction of inspired oxygen (Fio2) ratios of greater than 200. Conclusion: High admission serum sodium is associated with increased odds for ICU death, except in respiratory patients.
    No preview · Article · Jun 2014 · Journal of Critical Care

Publication Stats

3k Citations
754.59 Total Impact Points


  • 1991-2015
    • Flinders University
      • • Flinders Medical Centre
      • • Department of Critical Care Medicine
      • • School of Medicine
      • • Department of Human Physiology
      Tarndarnya, South Australia, Australia
  • 1986-2015
    • Flinders Medical Centre
      • Department of Cardiology
      Tarndarnya, South Australia, Australia
  • 2008
    • Catholic University of Louvain
      • School of Medicine
      Louvain-la-Neuve, WAL, Belgium
  • 2004
    • Royal Perth Hospital
      Perth City, Western Australia, Australia
  • 2002-2004
    • The Queen Elizabeth Hospital
      • Intensive Care Unit
      Tarndarnya, South Australia, Australia
  • 1999
    • Northern Inyo Hospital
      Bishop, California, United States