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Critical Care Reviews Newsletter

June 2^nd 2013

Welcome

Hello

Welcome to the 78th Critical Care Reviews Newsletter, bringing you the best critical care research published in the past week, plus a wide range of free full text review articles and guidelines from over 300 clinical and scientific journals.

This week's research studies show improved outcomes with universal decolonization at ICU admission, decreased morbidity with acute blood pressure reduction in intracerebral haemorrhage, quantification of the vascular and GI risks of NSAIDs, further reports on both the H7N9 and coronavirus outbreaks and an interesting phase II study investigating oxygen therapy in severe traumatic brain injury.

The only guideline I've come across this week is from the American College of Physicians and concerns glycaemic control. There are editiorials addressing critical care obstetrics, research, palliation, and patient safety. There also a critique of the Chest study. Two study protocols have been published in Trials, concerning clipping or coiling for subarachnoid haemorrhage (ISAT part 2) and red cell transfusion in sepsis (TRISS). Commentaries address physician payments from industry and personalised medicine.

Amongst the clinical review articles are papers on cerebral infarction, brain dysfunction in sepsis, atrial fibrillation, cricothyridotomy, several papers on pulmonary fibrosis, enhanced recovery for GI surgery, acute liver failure, blood conservation techniques, urosepsis and ethical differences between Islamic and Western societies.

The topic for This Week's Papers is sedation, starting with a general paper in tomorrow's Paper of the Day.

Research

New England Journal of Medicine: ICU Decolonization

Huang et al performed a pragmatic, cluster-randomized trial in 43 hospitals (74 ICUs, 74,256 patients) comparing three methods of infection control, with all adult ICUs in a given hospital assigned to the same strategy: (1) MRSA screening and isolation; (2) targeted decolonization (i.e., screening, isolation, and decolonization of MRSA carriers); (3) universal decolonization (i.e., no screening, and decolonization of all patients). Comparing the intervention period with the baseline period, universal decolonization resulted in a significantly greater reduction in the hazard of MRSA-positive clinical cultures than did screening and isolation (hazard ratio 0.63; 95% CI 0.52 to 0.75 versus hazard ratio 0.92; 95% CI 0.77 to 1.10; P=0.003 for test of all groups being equal). For ICU-attributable MRSA bloodstream infections, universal decolonization was more effective than the other strategies (HR 0.72, 95% CI 0.48 to 1.08 versus HR 1.23, 95% CI 0.82 to 1.85 for screening and isolation and HR 1.23, 95% CI 0.82 to 1.85 for targeted decolonization). For ICU-attributable bloodstream infection from any pathogen, universal decolonization resulted in a significantly greater reduction in the hazard of infection (HR 0.56, 95% CI 0.49 to 0.65) than either screening and isolation (HR 0.99; 95% CI 0.84 to 1.16; P<0.001) or targeted decolonization (HR 0.78; 95% CI 0.66 to 0.91; P=0.04). There was no difference in mortality between groups, although the trial was inadequately powered for this outcome.

Full Text: Huang. Targeted versus Universal Decolonization to Prevent ICU Infection. N Eng J Med 2013;epublished May 29th

Editorial: Edmond. Screening Inpatients for MRSA — Case Closed. N Eng J Med 2013;epublished May 29th

New England Journal of Medicine: Intracerebral Haemorrhage

Anderson and colleagues completed a randomized, controlled trial in 2,839 patients with a spontaneous intracerebral hemorrhage within the previous 6 hours and who had elevated systolic blood pressure, comparing a target systolic blood pressure <140 mm Hg within 1 hour with guideline-recommended treatment of a target systolic level of <180 mm Hg, with physician's using anti-hypertensives of their choice. In those for whom the primary outcome (death or major disability) could be determined, 52.0% (719/1382) receiving intensive treatment, as compared with 55.6% (785/1412) receiving guideline-recommended treatment, had a primary outcome event (odds ratio with intensive treatment 0.87; 95% CI 0.75 to 1.01; P=0.06). Ordinal analysis showed significantly lower modified Rankin scores with intensive treatment (odds ratio for greater disability 0.87; 95% CI, 0.77 to 1.00; P=0.04). There were no differences in mortality (intensive-treatment group 11.9% versus standard-treatment group 12.0%), the percentage of deaths attributed to the direct effect of the intracerebral hemorrhage (61.4% versus 65.3%, respectively) or nonfatal serious adverse events (23.3% versus 23.6% respectively).

Full Text: Anderson. Rapid Blood-Pressure Lowering in Patients with Acute Intracerebral Hemorrhage (INTERACT2). N Eng J Med 2013;epublished May 29th

Editorial: Frontera. Blood Pressure in Intracerebral Hemorrhage — How Low Should We Go? N Eng J Med 2013;epublished May 29th

The Lancet: Risks of NSAIDs

The Coxib and traditional NSAID Trialists' (CNT) Collaboration performed a meta-analyses of 280 trials of NSAIDs versus placebo (124 513 participants, 68 342 person-years) and 474 trials of one NSAID versus another NSAID (229 296 participants, 165 456 person-years) to assess the vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs. Major vascular events were increased by about a third by a coxib (rate ratio 1·37, 95% CI 1·14—1·66; p=0·0009) or diclofenac (1·41, 1·12—1·78; p=0·0036), chiefly due to an increase in major coronary events (coxibs 1·76, 1·31—2·37; p=0·0001; diclofenac 1·70, 1·19—2·41; p=0·0032). Ibuprofen also significantly increased major coronary events (2·22, 1·10—4·48; p=0·0253), but not major vascular events (1·44, 0·89—2·33). Compared with placebo, for 1000 patients allocated to a coxib or diclofenac for a year, three more had major vascular events, one of which was fatal. Naproxen did not significantly increase major vascular events (0·93, 0·69—1·27). Vascular death was increased significantly by coxibs (1·58, 99% CI 1·00—2·49; p=0·0103) and diclofenac (1·65, 0·95—2·85, p=0·0187), non-significantly by ibuprofen (1·90, 0·56—6·41; p=0·17), but not by naproxen (1·08, 0·48—2·47, p=0·80). The proportional effects on major vascular events were independent of baseline characteristics, including vascular risk. Heart failure risk was roughly doubled by all NSAIDs. All NSAID regimens increased upper gastrointestinal complications (coxibs 1·81, 1·17—2·81, p=0·0070; diclofenac 1·89, 1·16—3·09, p=0·0106; ibuprofen 3·97, 2·22—7·10, p<0·0001; and naproxen 4·22, 2·71—6·56, p<0·0001).

Full Text: Coxib and traditional NSAID Trialists' (CNT) Collaboration. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet 2013;epublished May 30th (free registration required)

The Lancet: H7N9 Influenza

Hu et al studied 14 patients in Eastern China with a novel influenza A subtype H7N9 virus (A/H7N9) A/H7N9, who were given antiviral treatment (oseltamivir or peramivir) for less than 2 days before admission. All patients developed pneumonia, seven of them required mechanical ventilation, and three of them further deteriorated to become dependent on extracorporeal membrane oxygenation (ECMO), two of whom died. Antiviral treatment was associated with a reduction of viral load in throat swab specimens in 11 surviving patients. Three patients with persistently high viral load in the throat in spite of antiviral therapy became ECMO dependent. An Arg292Lys mutation in the virus neuraminidase (NA) gene known to confer resistance to both zanamivir and oseltamivir was identified in two of these patients, both also received corticosteroid treatment.

Full Text: Hu. Association between adverse clinical outcome in human disease caused by novel influenza A H7N9 virus and sustained viral shedding and emergence of antiviral resistance. Lancet 2013;epublished May 29th (free registration required)

New England Journal of Medicine: Novel Coronavirus

Memish and colleagues report a family case cluster of the Middle East respiratory syndrome coronavirus (MERS-CoV), affecting three young men who became ill with MERS-CoV infection after the hospitalization of an elderly male relative, who died of the disease. Twenty-four other family members living in the same household and 124 attending staff members at the hospitals did not become ill. To date, 49 cases of MERS-CoV infection, with 26 deaths, have been reported.

Full Text: Memish. Brief Report: Family Cluster of Middle East Respiratory Syndrome Coronavirus Infections. N Eng J Med 2013;epublished May 29th

New England Journal of Medicine: Inflight Medical Emergencies

Peterson and colleagues reviewed 11,920 in-flight medical emergencies (1 medical emergency per 604 flights) from five domestic and international airlines referred to a physician-directed medical communications center. The most common problems were syncope or presyncope (37.4%), respiratory symptoms (12.1%), and nausea or vomiting (9.5%). Physician passengers provided medical assistance in 48.1% of in-flight medical emergencies, and aircraft diversion occurred in 7.3%. Of 10,914 patients for whom postflight follow-up data were available, 25.8% were transported to a hospital by emergency-medical-service personnel, 8.6% were admitted, and 0.3% died. The most common triggers for admission were suspected stroke (odds ratio 3.36; 95% CI 1.88 to 6.03), respiratory symptoms (odds ratio 2.13; 95% CI 1.48 to 3.06), and cardiac symptoms (odds ratio 1.95; 95% CI 1.37 to 2.77).

Full Text: Peterson. Outcomes of Medical Emergencies on Commercial Airline Flights. N Engl J Med 2013;368:2075-2083

Journal of Neurosurgery: Traumatic Brain Injury

Rockswold and colleagues undertook a prospective, randomized controlled phase II trial examing the effect of combined hyperbaric and normobarichyperoxia in 42 patients with severe traumatic brain injury (GCS 5-7). Within 24 hours of injury, patients were assigned to either combined hyperbaric and normobarichyperoxia (HBO₂/NBH) (60 minutes of HBO₂ at 1.5 atmospheres absolute [ATA] followed by NBH, 3 hours of FiO₂ 1.0 at 1.0 ATA) or control, standard care. Treatments occurred once every 24 hours for 3 consecutive days. HBO₂/NBH treatment was associated with higher levels of brain tissue partial pressure of O₂ (p < 0.0001), decreased microdialysate lactate/pyruvate ratios (p < 0.0078), reduced intracranial pressure (p < 0.0006), lower levels of microdialysate glycerol (p < 0.001) as well as a trend to decreased lower CSF injury biomarker F2-isoprostane (p = 0.0692). There was an absolute 26% reduction in mortality for the combined HBO₂/NBH group (p = 0.048) and an absolute 36% improvement in favorable outcome using the sliding dichotomized GOS (p = 0.024).

Full Text: Rockswold. A prospective, randomized Phase II clinical trial to evaluate the effect of combined hyperbaric and normobaric hyperoxia on cerebral metabolism, intracranial pressure, oxygen toxicity, and clinical outcome in severe traumatic brain injury. J Neurosurg 2013;118:1317–1328