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Newsletter 116 / February 23rd 2014

Welcome

 

Hello

Welcome to the 116th 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, guidelines, commentaries and editorials from over 300 clinical and scientific journals.

This week's featured research studies include randomized controlled trials on ramelteon for delirium prophylaxis, glutamine in trauma and ultrafiltration for congestive heart failure; meta analyses address ARDS biomarkers and CRP for the prediction of colorectal anastamotic leak; while observational studies focus on the efficacy of cricoid pressure and extracorporeal CPR for out-of-hospital cardiac arrest. Case reports demonstrate the increasing spread of influenza viruses, including a report from Eurosurveillance, on the latest avian influenza pandemic threat.

This week's single guideline addresses arterial catheter blood sampling, while editorials look at surgical patient safety, health during austerity and statins, and commentaries focus on fluid resuscitation, post-acute care and the hospital-dependent patient. Amongst the clinical review articles are papers on subarachnoid haemorrhage, rhabdomyolysis, fluid therapy, ARDS, ventilation-induced barotrauma, pulmonary embolism, cirrhosis, hepatic encephalopathy, acute kidney injury, temperature disorders, major haemorrhage, end-of-life care, critical care transport, plus an entire issue of a new journal, Diagnosis.

Basic science review articles discuss living systematic reviews and meta analysis. The topic for This Week's Papers is clinical reasoning, starting with a paper on misdiagnosis in tomorrow's Paper of the Day.

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Research

Randomized  Controlled Trials

Hatta and colleagues completed a multicenter, rater-blinded, randomized placebo-controlled trial, evaluating ramelteon, a melatonin agonist, for the prevention of delirium, in 67 patients aged 65 to 89 years old, and found:

  1. ramelteon was associated with
    • a lower incidence of delirium (3% vs 32%; RR 0.09, 95% CI 0.01 to 0.069; p=0.003)
      • including controlling for risk factors (OR 0.07, 95% CI 0.008 to 0.54; p=0.01)
    • a longer time to the development of delirium (6.94 days vs 5.74)
    • a lower frequency of delirium (log rank test: χ2 = 9.83; p = 0.002)

Abstract:  Hatta. Preventive Effects of Ramelteon on Delirium. A Randomized Placebo-Controlled Trial. JAMA Psychiatry 2014;epublished February 19th  


Pérez-Bárcena et al performed a multicentre, randomized, double-blind, placebo-controlled trial, evaluating intravenous l-alanyl-l-glutamine  dipeptide (0.5g/kg/day) supplementation, administered independently from nutrition, in 142 critically ill trauma patients, and found:

  1. both groups were similar at baseline
  2. there was no difference in
    • infections (placebo 62% vs glutamine 63%)
    • length of stay
      • ICU (both groups 14 days)
      • hospital (placebo 27 days vs glutamine 29 days)
    • ICU mortality (both groups 4.2%)
  3. regarding the efficacy of glutamine supplementation on glutamine levels
    • 60% of patients had low glutamine levels at baseline
    • 48% had low glutamine levels after the full 5 study days (placebo group 57% vs glutamine group 39%)
    • low glutamine levels at day 6 were associated with
      • more infections (58.8 vs. 80.9 %; p = 0.032)
      • increased length of stay
        • ICU (9 vs 20 days; p < 0.01)
        • hospital (24 vs 41 days; p = 0.01)

Abstract:  Pérez-Bárcena. A randomized trial of intravenous glutamine supplementation in trauma ICU patients. Intensive Care Med 2014;epublished February


Marenzi and colleagues compared ultrafiltration with conventional therapy in 56 patients hospitalized for congestive heart failure with overt fluid overload, and found

  1. both groups achieved a similar degree of weight reduction at hospital discharge
    • UF 7.5 ± 5.5 vs control 7.9 ± 9.0 kg,  p = 0.75
  2. UF was associated with
    • a lower incidence of rehospitalisations over the following year
      • hazard ratio 0.14, 95% CI 0.04 to 0.48; p = 0.002
    • more stable renal function
    • unchanged furosemide dose
    • lower B-type natriuretic peptide levels
  3. there was no difference in 1 year mortality
    • 7/27 (30%) vs 11/29 (44%), p=0.33

Full Text:  Marenzi. Continuous Ultrafiltration for Congestive Heart Failure: The CUORE Trial. Journal of Cardiac Failure 2014;20(1):9-17

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Meta Analysis

Terpstra et al pooled data from 54 studies (n=3,753), examining plasma biomarkers for the prediction of, or mortality in, ARDS, and found:

  1. 20 biomarkers were identified for the prediction of the development of ARDS
    • the most strongly associated biomarkers were
      • Krebs von den Lungen-6 (odds ratio 6.1, 95% CI 3.0 to 12.1)
      • lactate dehydrogenase (odds ratio 5.7, 95% CI 1.7 to 19.1)
      • soluble receptor for advanced glycation end products (OR 3.5, 95% CI 1.7 to 7.2)
      • von Willebrand Factor (OR 3.1, 95% CI 2.0 to 5.2)
  2. 19 biomarker were identified for the prediction of death in ARDS
    • the most strongly associated biomarkers were
      • interleukin-4 (OR 18.0, 95% CI 6.0 to 54.2)
      • interleukin-2 (OR 11.8, 95% CI 4.3 to 32.2)
      • angiopoietin-2 (OR 6.4, 95% CI 1.3 to 30.4)
      • Krebs von den Lungen-6 (OR 5.1, 95% CI 3.0 to 12.2)

Abstract:  Terpstra. Plasma Biomarkers for Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Critical Care Med 2014;42(3):691-700


Singh et al reviewed 7 studies (n=2,483)  examining the predictive value of C-reactive protein as an early marker of anastomotic leakage following colorectal surgery, and found:

  1. basic data
    • leakage prevalence was 9·6 %
    • median leakage diagnosis was made between 6 to 9 days post-operatively
  2. the predictive capacity of CRP 
    • postop day 3:
      • AUC 0·81 (95% CI 0·75 to 0·86)
      • cut-off value: 172 mg/l
    • postop day 4:
      • AUC 0·80 (95% CI 0·74 to 0·86)
      • cut-off value: 124 mg/l
    • postop day 5:
      • AUC 0·80 (95% CI 0·73 to 0·87)
      • cut-off value: 144 mg/l
  3. all three time points had
    • negative likelihood ratio of 0·26 to 0·33
    • positive predictive value of 21 to 23%

Abstract: Singh. Systematic review and meta‐analysis of use of serum C‐reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg 2014;101(4):339-346

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Observational Studies

Zeidan and colleagues investigated the efficacy of cricoid pressure (30 N) in 79 nonobese ASA I - II patients undergoing general anaesthesia with paralysis, using a glidoscope to visualise whether blinded nasogastric tube (both sizes 12 and 20 F) insetion into the oesophagus was successful both in the presence and absence of cricoid pressure, and found:

  1. the study was stopped after the recruitment of 79 patients
  2. success at NGT placement
    • in the presence of cricoid pressure - 0%
    • in the absence of cricoid pressure - 100%
  3. oesophageal patency was observed
    • in the presence of cricoid pressure - 0%
    • in the absence of cricoid pressure - 100%
  4. cricoid pressure did not change the position of the oesophageal entrance, relative to the glottis, which was
    • left lateral position: 57% (95% CI 45%–68%)
    • midline: 32% (95% CI 22%–43%), and in a
    • right lateral position: 11% (95% CI 5%–21%)

Abstract:  Zeidan. The Effectiveness of Cricoid Pressure for Occluding the Esophageal Entrance in Anesthetized and Paralyzed Patients: An Experimental and Observational Glidescope Study. Anesth Analg 2014;118(3):580–586


Sakamoto and colleagues compared the effect of extracorporeal CPR (20 hospitals, n=260) with standard CPR (20 hospitals, n=194) in out-of-hospital VF/VT cardiac arrest, and found:

  1. for the primary outcome of Glasgow-Pittsburgh Cerebral Performance and Overall Performance Categories (CPC) 1 or 2 (favourable outcome)
    • on intention-to-treat analysis, 
      • at 1 month
        • ECPR group: 12.3% (32/260) vs non-ECPR group 1.5% (3/194) (P < 0.0001)
      • at 6 months
        • ECPR group: 11.2% (29/260) vs non-ECPR group 2.6% (5/194)  (P = 0.001)
    • by per protocol analysis
      • at 1 month
        • ECPR group: 13.7% (32/234) vs non-ECPR group: 1.9% (3/159) (P < 0.0001)
      • at 6 months
        • ECPR group: 12.4% (29/234) vs non-ECPR group 3.1% (5/159) (P = 0.002)

Abstract:  Sakamoto. Extracorporeal Cardiopulmonary Resuscitation versus Conventional Cardiopulmonary Resuscitation in Adults with Out-of-Hospital Cardiac Arrest: A Prospective Observational Study (SAVE-J study). Resuscitation 2014;epublished February 14th

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Case Report


Other Studies of Interest

Meta Analysis

Observational Studies

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Guideline

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Clinical Review Articles

Neurological

Circulatory

Renal

Metabolic

Haematological

Sepsis

Trauma

Clinical Reasoning

Miscellaneous

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Non-Clinical Review Articles

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I hope you find these brief summaries and links useful.


Until next week

Rob

 

 

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