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Newsletter 109 / January 8th 2014

Welcome

Hello

Welcome to the 109th 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. Apologies for the very late delivery of this week's newsletter - I've been busy preparing for a series of three podcasts, reviewing the best critical care literature of 2013, with Chris Nickson from Life in the Fastlane and the SMACCgold conference. These should be available in the near future.

In news this week is the tragic story of American schoolgirl Jahi McMath, pronounced brain dead by her clinical team in California after suffering postoperative complications, yet transferred out of the ICU in which she was being treated after her parents won a court order preventing the withdrawal of mechanical ventilation.

This week's research studies include randomized controlled trials evaluating the utility of limited echocardiography in trauma, salbutamol for the prevention of post oesophagectomy lung injury, and bivalirudin for myocardial infarction PCI; meta analyses address the use of parenteral fish oil lipid emulsions, dexmedetomidine sedation, and urinary kidney injury molecule 1 for the detection of acute kidney injury; while observational studies include investigations into pulse pressure variation monitors, tracheostomy timing in traumatic brain injury and pulmonary dead-space fraction in ARDS.

This week's guidelines focus on renal replacement therapy for AKI, apixaban, and the management of perforated sigmoid diverticulitis. Editorials discuss conflicts of interest, checklists, and scientific writing, while commentaries focus on antibiotics, the total artificial heart and perioperative mortality.

Amongst the clinical review articles are papers on ischaemic stroke, heart failure, CABG, mechanical ventilation, bariatric emergencies, drug-induced liver injury, haemodialysis, the KDIGO guidelines, mitochondrial homeostasis, novel oral anticoagulants, thrombotic thrombocytopenic purpura and atypical haemolytic uraemic syndrome, septic shock, anaphylaxis, major limb injuries, local anaesthetic toxicity and NSAID toxicity. If you work in a rural area, then you'll be interested in a review of swine zoonoses documenting all manner of transmissible infections, including ebola. Non-clinical reviews discuss retractions and plagarism, while general interest articles consider the major scientific advances and setbacks of 2013. The topic for This Week's Papers is interesting review articles of 2013, with today's Paper of the Day examining fluid balance in acute kidney injury.

Critical Care Reviews Meeting

It's just 2 weeks to the 2014 Critical Care Reviews Meeting. This year we discuss the major studies from the past 12 months, hear from our international guest speakers, Prof Alistair Nichol (Dublin/Melbourne), Prof Mervyn Singer (London) and Prof John Marshall (Toronto), and have updates on ICU infections, massive haemorrhage and acute liver failure. The evening session provides an opportunity to chat with our guest speakers in a novel, informal setting - beside a blazing log fire in a beautiful lounge - perfect for a cold winters night. This will be followed by dinner and the chance to meet new colleagues and friends.

If you're a drive or short flight away, it would be great to have you come along. Travel on Thursday, attend the meeting on Friday and see some of the local landmarks over the weekend, before returning home on Sunday evening after a great winter break. On Saturday visit the North Coast: the World Heritage site Giants Causeway, Carrick-a-Rede rope bridge, Dunluce Castle and Bushmills Distillary, the oldest distillary in the world; while on Sunday experience Belfast: the new acclaimed Titanic Centre followed by a famous black taxi tour describing the troubled past of one of Europe's now most vibrant cities. The Galgorm Resort and Spa is one of Northern Ireland's premier hotels and is a 30 minute drive from Belfast International Airport. Special room rates are available, by quoting the meeting. Please feel free to contact me if you're thinking about making the trip - it would be great to hear from you.

This year, the meeting will be run in association with the Northern Ireland Intensive Care Society. Further details, the meeting programme, and registration can be accessed via these links.

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News

Payne. Brain-dead girl Jahi McMath released from California hospital. CNN;epublished January 7th

Research

Randomized Controlled Trials

Ferrada and colleagues randomized 240 trauma patients with an episode of hypotension or tachycardia to either limited transthoracic echocardiography (n=123), consisting of simple evaluations of (1) ventricular contractility, (2) fluid status, and (3) pericardial effusion, or no echo (n=92) and found:

25 patients died on arrival and were excluded
there were no baseline differences between groups
limited echo was associated with
- less intravenous fluid therapy
  - 1.5 L vs. 2.5 L, p < 0.0001
- shorter duration between trauma bay and operating theatre
  - 35.6 minutes vs. 79.1 min, p = 0.0006
- higher rate of ICU admission
  - 80.4% vs. 67.2%, p = 0.04
- a nonsignificant lower mortality rate
  - 11% vs. 19.5%, p = 0.09
    - most marked in those with traumatic brain injury patients
      - 14.7% vs. 39.5%, p = 0.03

Abstract: Ferrada. Findings of a randomized controlled trial using limited transthoracic echocardiogram (LTTE) as a hemodynamic monitoring tool in the trauma bay. Journal of Trauma and Acute Care Surgery 2013;76(1):31-38

Perkins and colleagues compared inhaled salmeterol (100 mcg twice daily, n=179) or a matching placebo (n=183) on the development of acute lung injury in 362 patients undergoing elective oesophagectomy, and found:

groups were similar at baseline
there was no difference in
- early lung injury
  - salmeterol 19·2% vs. placebo 16·0%; odds ratio 1·25 (95% CI 0·71 – 2·22)
- organ failure
- survival
- health related quality of life
salmeterol was associated with
- less adverse events
  - 55 versus 70; odds ratio 0·63 (95% CI 0·39 to 0.99)
- mainly due to less pneumonia
  - 7 versus 17; odds ratio 0·39 (95% CI 0·16 to 0·96)

Abstract: Perkins. The Beta Agonist Lung Injury Trial (BALTI) Prevention: A Randomized Controlled Trial. Am J Respir Crit Care Med 2014;epublished January 7th

Meta Analysis

Pasin and colleagues reviewed 28 randomized studies comparing dexmedetomidine (n=1,870) with a comparitor (n=1,778) as a sedative in critically ill, mechanically ventilated patients, and found:

dexmedetomidine was associated with significant reductions in
- length of ICU stay
  - weighted mean difference −0.79 (95% CI −1.17 to −0.40) days, p for effect <0.001
- time to extubation
  - weighted mean difference −2.74 (95% CI −3.80 to −1.65) hours, p for effect <0.001
no mortality difference
- risk ratio 1.00 (0.84 to 1.21), p for effect = 0.9
high heterogeneity between studies

Full Text: Pasin. Dexmedetomidine as a Sedative Agent in Critically Ill Patients: A Meta-Analysis of Randomized Controlled Trials. PLoS One 2013;8(12):e82913

Manzanares et al pooled data from 6 randomized controlled trials evaluating fish oil-containing emulsions, either parenteral or enteral, in 390 critically ill patients, and found:

administration of fish oil-containing emulsions were not associated with improvements in
- mortality
  - risk ratio 0.71; 95% CI 0.49 to 1.04; P = 0.08; heterogeneity I² = 0%
- duration of mechanical ventilation
  - weighted mean difference −1.41 days; 95% CI −3.43 to 0.61; P = 0.17
- infections
  - RR 0.76; 95% CI 0.42 to 1.36; P = 0.35
- intensive care unit length of stay
  - weighted mean difference −0.46; 95% CI −4.87 to 3.95; P = 0.84, heterogeneity I² = 75%

Full Text: Manzanares. Parenteral Fish Oil Lipid Emulsions in the Critically Ill. A Systematic Review and Meta-Analysis. JPEN J Parenter Enteral Nutr 2014;38(1):20-28

Observational Studies

Mahjoub et al investigated the proportion of patients satisfying criteria for valid application of respiratory variation in pulse pressure (ΔPP) as a measure of fluid responsiveness at a given time-point in all patients in 26 French ICUs (n=311) and found:

only six patients (2%) patients satisfied all validity criteria
of 170 patients with an arterial line, only five (3%) satisfied the validity criteria
during the 24 hours preceding the study time-point, fluid responsiveness was assessed for in 79 patients
ΔPP had been used to assess fluid responsiveness in 15 of these cases (19%)

Abstract: Mahjoub. Evaluation of pulse pressure variation validity criteria in critically ill patients: a prospective observational multicentre point-prevalence study. Br J Anaesth 2013;epublished December 29th

Using data from the American College of Surgeons’ Trauma Quality Improvement Program, Alali and colleagues compared early tracheostomy (≤8 days) versus late tracheostomy (>8 days) in a propensity-matched cohort of 1,154 patients with isolated traumatic brain injury and found:

early tracheostomy was associated with
- reduced durations of
  - mechanical ventilation
    - 10 days vs. 16 days; rate ratio 0.70; 95% CI 0.66 to 0.75
  - ICU stay
    - 13 days vs. 19 days; RR 0.70; 95% CI 0.66 to 0.75
  - hospital stay
    - 20 days vs. 27 days; RR 0.80; 95% CI 0.74 to 0.86
- lower odds of
  - pneumonia
    - 41.7% vs. 52.7%; odds ratio 0.64; 95% CI 0.51 to 0.80
  - deep venous thrombosis
    - 8.2% vs. 14.4%; OR 0.53; 95% CI 0.37 to 0.78
  - decubitus ulcer
    - 4.0% vs. 8.9%; OR 0.43; 95% CI 0.26 to 0.71
- no significant difference in
  - pulmonary embolism
    - 1.8% vs. 3.3%; OR 0.52; 95% CI 0.24 to 1.10
  - hospital mortality
    - 8.4% vs. 6.8%; OR 1.25; 95% CI 0.80 to 1.96

Abstract: Alali. Tracheostomy timing in traumatic brain injury: A propensity-matched cohort study. Journal of Trauma and Acute Care Surgery 2013;76(1):70–78

Kallet and colleagues performed a secondary examination of the multi-centre, randomized controlled, β agonist ALTA study, evaluating the association between pulmonary dead-space fraction (VD/VT) and mortality in 126 patients with ARDS, and found:

differences in VD/VT between non-survivors and survivors:
- at baseline
  - 0.62 ± 0.11 vs. 0.56 ± 0.11, p = 0.08
- at day 1
  - 0.64 ± 0.12 vs. 0.55 ± 0.11, p = 0.01
- at day 2
  - 0.67 ± 0.12 vs. 0.56 ± 0.11, p=0.004
adjusted associations between VD/VT and mortality:
- day 1
  - odds ratio per 0.10 change in VD/VT: 6.84 (95% CI 1.62 to 28.84); p = 0.01
- day 2:
  - odds ratio per 0.10 change in VD/VT: 4.90 (95% CI 1.28 to 18.73); p = 0.02
VD/VT was associated with a trend towards higher mortality
- HR 4.37 (95% CI 0.99 to 19.32); p = 0.052
  - adjusted for daily oxygenation index
  - HR 1.74 (95% CI 1.12 to 3.35); p = 0.04