October 7th 2012
Welcome to the 44th 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 comparison of prasugrel and clopidogrel in non-revascularized acute coronary syndrome, reduced catheter related infections with the use of chlorhexidine impregnated dressings, an intriguing suggestion that non-clinical transfer of critically ill patients is associated with prolonged ICU and hospital stay and a RCT demonstrating efficacy of eicosapentaenoic acid in reducing cerebral vasospasm and related infarction in subarachnoid haemorrhage. There are 2 new guidelines and about 20 free review articles on a wide range of topics.
The topic for This Week's Papers is the first of a multi-part series on critical care controversies, starting with a paper from a group of paediatricians calling for a moratorium on cardiocirculatory death in tomorrow's Paper of the Day. These papers are stimulating and should challenge mainstream beliefs.
The new CPD / CME facility has finally gone live. The UK Royal College of Anaesthetist don't actually approve external non-RCoA CPD/CME work but are happy to accept external certficates as prove of CPD/CME activity for revalidation purposes. These quizzes are mapped to the RCoA CPD matrix. There are two quizzes currently available and I'll try to add a new one each week. Check them out here.
New England Journal of Medicine: Acute Coronary Syndrome
In 7243 patients with acute coronary syndrome not treated with revascularization, Roe et al compared prasugrel (10 mg daily) with clopidogrel (75 mg daily) in a double-blind, randomized trial. At 17 months there was no difference in the primary end point of death from cardiovascular causes, myocardial infarction, or stroke (prasugrel: 13.9% vs clopidogrel: 16.0%; prasugrel hazard ratio 0.91; 95% CI: 0.79 to 1.05; P=0.21). A prespecified analysis of multiple recurrent ischemic events (all components of the primary end point) suggested a lower risk for prasugrel among patients under the age of 75 years (hazard ratio, 0.85; 95% CI, 0.72 to 1.00; P=0.04). Rates of intracranial bleeding and nonhemorrhagic serious adverse events were similar in the two groups, although there was a higher frequency of heart failure in the clopidogrel group.
American Journal of Respiratory and Critical Care Medicine: Catheter-Related Infections
Timsit et al performed an assessor-blinded randomized trial in 1879 patients with vascular catheters (4163 catheters, 34,339 catheter-days) comparing chlorhexidine dressings, highly adhesive dressings, and standard dressings on rates of catheter-related infections and catheter detachment. The chlorhexidine dressings were associated with a 67% lower rate of major catheter-related infections (0.7/1000 vs. 2.1/1000 catheter-days; hazard ratio [HR], 0.328; 95% CI: 0.174-0.619 P=0.0006) and a 60% lower rate of catheter-related blood stream infections (0.5/1000 vs. 1.3/1000 catheter-days; HR, 0.402; 95% CI, 0.186-0.868, P=0.02) than with non-chlorhexidine dressings. Decreases were noted in catheter colonization and skin colonization rates at catheter removal. The contact dermatitis rate was 1.1% with and 0.29% without chlorhexidine. Highly adhesive dressings decreased the detachment rate to 64.3% vs. 71.9% (P<0.0001) and the number of dressings per catheter to 2 (1-4) vs. 3 (1-5) (P<0.0001) but increased skin colonization (P<0.0001) and catheter colonization (HR=1.650; 95%CI, 1.21-2.26; P=0.0016) without influencing CRI or CR-BSI rates.
Abstract: Timsit. Randomized Controlled Trial of Chlorhexidine Dressing and Highly Adhesive Dressing for Preventing Catheter-Related Infections in Critically Ill Adults. Am J Respir Crit Care Med epublished 4 October 2012
Critical Care: Non-Clinical Patient Transfer
Barratt et al performed a propensity-matched cohort analysis comparing critical care patients who underwent a non-clinical, critical care unit to unit transfer to another hospital with those who were not transferred. Of 308,323 patients admitted to one of 198 adult general critical care units in England and Wales 759 patients underwent a non-clinical transfer within 48 hours of admission to the unit and were compared with 1518 propensity matched patients who were not transferred. There was no difference in the risk of ICU mortality or relative risk of ultimate acute hospital mortality was 1.01 (95% CI 0.87 to 1.16) for the non-clinical transfer group. Transferred patients received on average three additional days of critical care (p <0.001) with the difference in length of acute hospital stay being of borderline significance (p=0.05).
Journal of Anesthesia: Atrial Fibrillation
Khalil et al prospectively compared amiodarone (n=219; IV loading dose of 5 mg/kg followed by an infusion of 15 mg/kg for 48 h postoperatively) with magnesium sulfate (n=219, IV loading dose 80 mg/kg over 30 min preoperatively followed by an IV infusion of 8 mg/kg/h for 48 h) in patients undergoing lobectomy. These two groups were compared with a control group of 219 patients who were analyzed retrospectively. Both amiodarone (n=21, 10 %) and magnesium sulphate (n=27, 12.5%) therapy were associated with reduced incidence of AF in comparison with the control group (n=44, 20.5 %) (p<0.05), although there was no difference in AF rates between the two active prophylactic agent. Also, there were significant differences between the three groups concerning ICU and total hospital stays (P < 0.05).
Abstract: Khalil. A comparative study between amiodarone and magnesium sulfate as antiarrhythmic agents for prophylaxis against atrial fibrillation following lobectomy. J Anesth 2012; epublished ahead of print
World Journal of Neurosurgery: Subarachnoid Haemorrhage
As eicosapentaenoic acid inhibits vascular smooth muscle contraction in subarachnoid hemorrhage, and has been shown to reduce the occurrence of cerebral vasospasm after SAH onset in a prospective, non-randomized study, Yonda et al undertook a prospective, multicenter, randomized study to confirm the preventive effects of EPA on cerebral vasospasm in SAH. In 162 patients who underwent surgical clipping within 72 h of SAH onset, therapy of 2700 mg/day EPA from the day after surgery until day 30 (n=81) reduced the rate of symptomatic vasospasm (15% vs. 30%, P = 0.022) and cerebral infarction due to vasopasm (7% vs. 21%; P = 0.012) in comparison to the control group (n=81). Multivariate analysis revealed an adjusted odds ratio of 0.39 (95% CI, 0.17-0.89; P = 0.028) for symptomatic vasospasm inhibition by EPA and 0.27 (95% CI, 0.09-0.72; P = 0.012) for inhibition of vasospasm induced cerebral infarction.
Trials: STUDY PROTOCOL - Traumatic Brain Injury
Severe traumatic brain injury is associated with activation of the sympathetic nervous system, leading to catecholamine excess, hypertension, abnormal heart rate variability, and agitation, and potentially poor neuropsychological outcome. Propranolol and clonidine are centrally acting drugs that may decrease sympathetic outflow, brain edema, and agitation. The DASH after TBI study is an actively accruing, single-center, randomized, double-blinded, placebo-controlled, two-arm trial, comparing combined centrally acting sympatholytic drugs, propranolol (1 mg intravenously every 6 h for 7 days) plus clonidine (0.1 mg per tube every 12 h for 7 days), with, double placebo, within 48 h of severe TBI. The primary endpoint is reduction in plasma norepinephrine level as measured on day 8. Secondary endpoints include comprehensive plasma and urine catecholamine levels, heart rate variability, arrhythmia occurrence, infections, agitation measures using the Richmond Agitation-Sedation Scale and Agitated Behavior scale, medication use (anti-hypertensive, sedative, analgesic, and antipsychotic), coma-free days, ventilator-free days, length of stay, and mortality. Neuropsychological outcomes will be measured at hospital discharge and at 3 and 12 months.
Full Text: Patel. Decreasing adrenergic or sympathetic hyperactivity after severe traumatic brain injury using propranolol and clonidine (DASH After TBI Study): study protocol for a randomized controlled trial. Trials 2012,13:177
Lung India: Pneumonia
- Gupta. Guidelines for diagnosis and management of community- and hospital-acquired pneumonia in adults: Joint ICS/NCCP(I) recommendations. Lung India. 2012 Jul-Sep; 29(Suppl 2): S27–S62
Respiratory Care: Humidification
- Restrepo. Humidification During Invasive and Noninvasive Mechanical Ventilation: 2012. Respir Care 2012;57(5):782–788
Review - Clinical
Expert Reviews of Anti-Infective Therapy: Sepsis Therapy
- Artigas. What is next in sepsis: current trials in sepsis. Expert Review of Anti-infective Therapy 2012;10(8):859-862
Swiss Medical Weekly: Anticoagulant Therapy
Scientifica: ST Elevation Myocardial Infarction
- Hong. Recent Advances in the Treatment of ST-Segment Elevation Myocardial Infarction. Scientifica 2012;2012:Article ID 683683
Scientifica: Pulmonary Oedema
- Rassler. Contribution of α- and β-Adrenergic Mechanisms to the Development of Pulmonary Edema. Scientifica 2012;2012:Article ID 829504
- Lukasz. Role of Angiopoietin/Tie2 in Critical Illness: Promising Biomarker, Disease Mediator, and Therapeutic Target? Scientifica 2012;2012:Article ID 160174
PLoS Pathogen: Escherichia Coli
- Jorgensen. How to Make It in the Urinary Tract: A Tutorial by Escherichia coli. PLoS Pathog 2012;8(10):e1002907
Journal of Trauma & Treatment: Corticosteroid Insufficiency
- Walker. Critical Illness Related Corticosteroid Insufficiency in Trauma – A Review. J Trauma Treat 2012;1:139
Annals of Nutritional Metabolism: Probiotics
Current Biomarker Findings: Acute Kidney Injury
- Han. Biomarkers for early detection of acute kidney injury. Current Biomarker Findings 2012;2012:77-85
Journal of the American College of Cardiology: Percutaneous Coronary Intervention
- Teirstein. Left Main Percutaneous Coronary Intervention. J Am Coll Cardiol 2012; epublished ahead of print
Annals of Cardiac Anesthesia: Acute Kidney Injury
Annals of Cardiac Anesthesia: Cardiac Trauma
Cleveland Clinic Journal of Medicine: Cognitive Impairment
- Wergin. Cognitive impairment in ICU survivors: Assessment and therapy. Cleve Clin J Med 2012;79: 705-712
Journal of Cerebral Blood Flow & Metabolism: Antithrombotics
- Kraft. Next-generation antithrombotics in ischemic stroke: preclinical perspective on ‘bleeding-free antithrombosis’. J Cereb Blood Flow Metab 2012 32: 1831-1840
Archives of Internal Medicine: Lyme Disease
- Edlow. Diagnosing Lyme Disease - Getting the Details Right. Arch Intern Med 2012:epublished ahead of print
Annals of Cardiothoracic Surgery: Aortic Aneurysm
Indian Journal of Medical Research: Dengue
Review - Basic Science
Nature Reviews Gastroenterology and Hepatology
- Shanahan. Opinion: The gut microbiota—a clinical perspective on lessons learned. Nature Reviews Gastroenterology and Hepatology 2012;9:609-614
Review - Non-Clinical
Journal of The Scientific Society: Open Access
Journal of General Medicine: Resuscitation
Neurology Now: Medical Identity Theft
- Wise. Stop, Thief: How to protect yourself against medical identity theft. Neurology Now 2012;8(5):32-33
I hope you find these brief summaries and links useful.
Until next week