November 11th 2012
Welcome to the 49th 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 include a report of superior outcomes with pharamacological therapy in comparison with ultrafiltration for acute decompensated heart failure with cardiorenal syndrome, a suggestion that post cardiac arrest therapeutic hypothermia of 32°C is superior to 34°C, equivalence of propofol and sevoflurane for perioperative cardioprotection, two studies on cardiac surgery and two studies on the use of stem cells for myocardial infarction.
The Spanish Scientific Committee of the Sociedad Espanola de Medicina Intensiva y Unidades Coronarias (SEMICYUC) published guidelines on early management of acute pancreatitis.
Amongst the clinical review articles are three papers on antimicrobial therapy, plus other papers on AKI biomarkers, fever, spinal cord injury and blood purification. Nonclinical papers include articles on multiple testing in statistics and industry transparency in research.
This week's CPD / CME article and quiz are on drug-induced haematological syndromes. A personalised certificate of CPD activity can be saved and printed after successful completion of the activity.
New England Journal of Medicine: Acute Decompensated Heart Failure
Bart and colleagues undertook a prospective randomized trial in 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion, comparing stepped pharmacologic therapy (n=94) with ultrafiltration (n=94). The pharmacological strategy aimed to produce a urinary output of 3 - 5 l of urine per day (described in full here), while the UF removed fluid at 200 ml/hr. At 96 hours ultrafiltration was inferior to pharmacologic therapy with respect to the primary end point of change in serum creatinine level and body weight (P=0.003). Creatinine increased in the UF group, but not in the pharmacological group (UF: creatinine +20.3±61.9 μmol/l v pharmaological therapy: −3.5±46.9 μmol/l; P=0.003). There was no significant difference in weight loss at 96 hours (UF: - 5.7±3.9 kg v pharmacological therapy: -5.5±5.1 kg; P=0.58). There were more serious adverse events in the UF group (72% vs. 57%, P=0.03).
Circulation: Perioperative Myocardial Protection
In a randomized trial Buse and colleagues compared sevoflurane anaesthesia with propofol anaesthesia for myocardial protection in 385 patients with cardiac risk factors indergoing non-cardiac surgery. There was no difference in either myocardial ischemia (sevoflurane 40.8% v propofol 40.3%; relative risk: 1.01; 95% CI: 0.78-1.30) or NT-proBNP levels 1 or 2 days postoperatively, or incidence of delirium (11.4% vs. 14.4%, P=0.760). At 1 year, there were no differences in major cardiac events 14 patients (sevoflurane 7.6% v propofol 8.5%; RR: 0.90; 95% CI, 0.43-1.87).
Circulation: Post Cardiac Arrest Therapeutic Hypothermia
In a prospective randomized pilot trial Lopez-de-Sa and colleagues compared 32°C (n=18) with 34°C (n=18) for therapeutic hypothermia post witnessed out-of-hospital cardiac arrest. Twenty six subjects had a shockable rhythm and 10 were asystolic. The primary outcome of survival free from severe dependence (Barthel Index score ≥60 points) at 6 months occurred more often in the 32°C group (8/18,44.4%) than in the 34°C group (2/18;11.1%) (log-rank P=0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients (61.5%) with initial shockable rhythm assigned to 32°C were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P=0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P=0.0002) in patients assigned to 32°C compared with 34°C. There was a trend toward a higher incidence of bradycardia (7 versus 2; P=0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups.
New England Journal of Medicine: Coronary Revascularization in Diabetes
Farkouh and collegues completed a multi-centre, international randomized trial, comparing PCI with drug-eluting stents or CABG in 1900 diabetic patients with multivessel coronary artery disease. The patients' mean age was 63.1±9.1 years, 29% were women, and 83% had three-vessel disease. At 5 years, the primary outcome, a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke, was decreased with CABG (18.7% v 26.6%, p=0.005). The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 5.2% vs 2.4%; P=0.03.
Journal of the American Medical Association: Dexamethasone in Cardiac Surgery
Dieleman et al performed a multicenter, randomized, double-blind, controlled trial compared 1mg/kg of intraoperative dexamethasone (n=2239) with placebo (n=2255) on the incidence of major adverse events in patients undergoing cardiac surgery. There was no difference in the primary composite outcome of death, myocardial infarction, stroke, renal failure, or respiratory failure, within 30 days of randomization (dex: 157/2239;7.0% versus 191/2255;8.5%); relative risk: 0.83; 95% CI, 0.67-1.01; absolute risk reduction: −1.5%; 95% CI: −3.0% to 0.1%; P=0.07). Dexamethasone was associated with reductions in postoperative infection, duration of postoperative mechanical ventilation, and lengths of intensive care unit and hospital stays. In contrast, dexamethasone was associated with higher postoperative glucose levels.
Journal of the American Medical Association: Stem Cells for Myocardial Infarction
Traverse et al performed a randomized, 2 × 2 factorial, double-blind, placebo-controlled trial comparing intracoronary infusion of bone marrow cells (BMCs) or placebo in 120 patients with left ventricular dysfunction after successful primary percutaneous coronary intervention of anterior STEMI. Therapy was administered either 3 or 7 days (randomized 1:1) post PCI and within 12 hours of aspiration and cell processing. The mean (SD) patient age was 56.9 (10.9) years and 87.5% of participants were male. At 6 months, there was no significant increase in LV ejection fraction with BMCs (45.2% to 48.3%) vs the placebo (44.5% to 47.8%; P = 0.96), or regional left ventricular function in either infarct or border zones. There was no change in global LV function for patients treated at day 3 (−0.9%; 95% CI: −6.6% to 4.9%; P = 0.76) or day 7 (1.1%; 95% CI: −4.7% to 6.9%; P = 0.70). Major adverse events were rare among all treatment groups.
Full Text: Traverse. Effect of the Use and Timing of Bone Marrow Mononuclear Cell Delivery on Left Ventricular Function After Acute Myocardial Infarction: The TIME Randomized Trial. JAMA 2012; epublished November 2012
Journal of the American Medical Association: Stem Cells for Myocardial Infarction
Hare et al performed a single centre randomized trial evaluating whether allogeneic mesenchymal stem cells (MSCs) are as safe and effective as autologous MSCs in 30 patients with left ventricular dysfunction due to ischaemic cardiomyopathy. Allogeneic and autologous MSCs reduced mean infarct size by −33.21% (95% CI, −43.61% to −22.81%; P < .001) and sphericity index but did not increase ejection fraction. Allogeneic MSCs reduced LV end-diastolic volumes. Low-dose concentration MSCs (20 million cells) produced greatest reductions in LV volumes and increased EF. Allogeneic MSCs did not stimulate significant donor-specific alloimmune reactions. Relative to baseline, autologous but not allogeneic MSC therapy was associated with an improvement in the 6-minute walk test and the MLHFQ score, but neither improved exercise VO2max.
Full Text: Hare. Comparison of Allogeneic vs Autologous Bone Marrow–Derived Mesenchymal Stem Cells Delivered by Transendocardial Injection in Patients With Ischemic Cardiomyopathy: The POSEIDON Randomized Trial. JAMA 2012; epublished November 6th
New England Journal of Medicine: Fungal Meningitis Outbreak
Medicina Intensiva: Acute Pancreatitis
- Poma. Clinical pathways for acute pancreatitis: Recommendations for early multidisciplinary management. Med Intensiva. 2012;36:351-7
Review - Clinical
Annals of Intensive Care: Gastrointestinal Bleeding
- Osman. Management by the intensivist of gastrointestinal bleeding in adults and children. Annals of Intensive Care 2012;2:46
Journal of Antimicrobial Chemotherapy: Antimicrobial Therapy for Resistant Microbes
- Roux. Magic bullets for the 21st century: the reemergence of immunotherapy for multi- and pan-resistant microbes. J Antimicrob Chemother 2012 67:2785-2787
ISRN Nephrology: Acute Kidney Injury Biomarkers
- Simsek. New Biomarkers for the Quick Detection of Acute Kidney Injury. ISRN Nephrology 2013;2013:394582
Minerva Anesthesiologica: Fever in Sepsis
Minerva Anesthesiologica: Blood Purification in Sepsis
- Bello. New membranes for extracorporeal blood purification in septic conditions. Minerva Anestesiologica 2012;78(11):1265-81
Minerva Anesthesiologica: Ultrasound
- Via. Lung ultrasound in the ICU: from diagnostic instrument to respiratory monitoring tool. Minerva Anestesiologica 2012;78(11):1282-96
Minerva Anesthesiologica: Dead-Space in Acute Lung Injury
The Journal of Pharmacology and Experimental Therapeutics: Acute Kidney Injury Therapy
- Peters. Alkaline phosphatase as a treatment for sepsis-associated acute kidney injury. JPET 2012; epublished November 6th
North American Journal of Medical Science: New Antibacterial Drugs
Neurocritical Care: Traumatic Spinal Injury
- Stein. Emergency Neurological Life Support: Traumatic Spine Injury. Neurocrit Care (2012) 17:S102–S111
International Journal of Emergency Medicine: Angioedema
- Bernstein. Emerging concepts in the diagnosis and treatment of patients with undifferentiated angioedema. International Journal of Emergency Medicine 2012;5:39
Clinics (Sao Paulo): Community-Acquired Pneumonia
Journal of Antimicrobial Chemotherapy: Discovery of Antibacterial Drugs
- Chopra. The 2012 Garrod Lecture: Discovery of antibacterial drugs in the 21st century. J Antimicrob Chemother 2012; epublished November 6th
Interactive Cardiovascular Thoracic Surgery: Pneumothorax Management
- Kaneda. Three-step management of pneumothorax: time for a re-think on initial management. Interact CardioVasc Thorac Surg 2012; epublished November 1st
Anaesthesia: Laryngeal Mask Airway
- van Zundert. Archie Brain: celebrating 30 years of development in laryngeal mask airways. Anaesthesia 2012;67:1375–1385
Pulmonary Circulation: Platelet Biology
International Journal of General Medicine: Clinical Reasoning
- Shimizu. Pivot and cluster strategy: a preventive measure against diagnostic errors. International Journal of General Medicine 2012;2012(5):917-921
Review - Basic Science
Nature Medicine: Multiple Testing in Statistics
Review - Non-Clinical
Nature Medicine: Pharmaceutical Industry Research
I hope you find these brief summaries and links useful.
Until next week