Critical Care Reviews Newsletter
February 6th 2012
Welcome to the ninth Critical Care Reviews Newsletter. Every weekend some of the more important studies in critical care, which were published that week, are highlighted. These studies are added to the renamed Journal Watch section of the website on a daily basis, as publication occurs.
British Journal of Anaesthesia
In a single-centre cohort study over a 5 year period, Bird investigated the epidemiology of patients with haematological malignancy admitted to the ICU. 199 patients were studied. Their median age was 58 yr. 51.7% were emergency admissions, 42.2% post-haematopoietic stem cell transplant, 51.9% required mechanical ventilation, median APACHE II was 21, and median organ failure was 2. ICU, in-hospital, and 6 month mortalities were 33.7%, 45.7%, and 59.3%, respectively. Univariate analysis revealed bilirubin >32 µmol litre−1, mechanical ventilation, ≥2 organ failures, renal replacement therapy, vasopressor support (all P<0.001), graft-vs-host disease (P=0.007), APACHE II score (P=0.02), platelets ≤20×109 litre−1 (P=0.03), and proven invasive fungal infection (P=0.04) were associated with in-hospital mortality. Multivariate analysis revealed that ≥2 organ failures [odds ratio (OR) 5.62; 95% confidence interval (95% CI), 2.30–13.70] and mechanical ventilation (OR 3.03; 95% CI, 1.33–6.90) were independently associated with in-hospital mortality.
Intensive Care Medicine
Renal Replacement Therapy
In a randomized, controlled, open-label trial Hermite compared sodium citrate with saline catheter locks for non-tunneled hemodialysis central venous catheters in 78 critically ill adult patients with acute renal failure. Median catheter life span without complication was 6 days (saline group) versus 12 days (citrate group) [hazard ratio (HR) 2.12 (95% CI 1.32–3.4), p = 0.0019], with higher rate of catheter malfunction in the saline group compared with in the citrate group (127 catheter events/1,000 catheter-days, saline group vs. 26 events/1,000 catheter-days, citrate group, p < 0.00001). Additionally, there was a longer infection-free period in the citrate group (20 days vs. 14 days, HR 2.8, 95% CI 1.04–7.6, p = 0.04), however there was no significant difference in incidence of infections between groups.
Hermite. Sodium citrate versus saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adults: a randomized controlled trial. Intensive Care Med 2012;38(2):279-285
American Journal of Respiratory and Critical Care Medicine
Red Cell Transfusion
In the , Kor report a double-blind, randomized, clinical trial comparing fresh (≤ 5 days storage) versus standard issue single-unit RBC transfusion in 100 adult patients receiving invasive mechanically ventilation. Median storage age was 4.0 days (IQR 3.0 - 5.0) versus 26.5 days (IQR 21.0 - 40.0). No differences were noted in the primary outcome of ∆ PaO2/FiO2 (difference between the mean ∆ PaO2/FiO2 in the standard issue RBC group vs. the fresh RBC group = -11.5; 95% CI = -35.3 to 12.3; p = 0.22) or secondary outcomes of markers of immunologic or coagulation status.
- Kor. Fresh Red Blood Cell Transfusion and Short-term Pulmonary, Immunologic, and Coagulation Status: a Randomized Clinical Trial. Am J Respir Crit Care Med 2012; published January 26
In a retrospective cohort study utilizing 196,202 patients in 156 medical and surgical ICUs in 106 community and academic hospitals, Brown examined the pattern of readmissions to American ICU. 3,905 patients (2.0%) were readmitted to the ICU within 48 hours; 7,171 (3.7%) within 120 hours. Medical patients in academic hospitals are more likely to be readmitted than patients in community hospitals without residents.
Nutrition in Acute Lung Injury
Rice et al publish the EDEN study, a randomized, open-label, multicenter trial, comparing full versus trophic (20% target) enteral feeding for 6 days, in 1000 adults within 48 hours of developing acute lung injury requiring mechanical ventilation. The aim of achieving a difference calorific intake was achieved, with about 1300 kcal/d compared with 400 kcal/d (P < .001) being delivered. Initial trophic feeding did not increase the number of ventilator-free days (14.9 [95% CI, 13.9 to 15.8] vs 15.0 [95% CI, 14.1 to 15.9]; difference, −0.1 [95% CI, −1.4 to 1.2]; P = .89) or reduce 60-day mortality (23.2% [95% CI, 19.6% to 26.9%] vs 22.2% [95% CI, 18.5% to 25.8%]; difference, 1.0% [95% CI, −4.1% to 6.3%]; P = .77) compared with full feeding. There were no differences in infectious complications between the groups. Despite receiving more prokinetic agents, the full-feeding group experienced more vomiting, elevated gastric residual volumes, and constipation, and had higher plasma glucose values and average hourly insulin administration.
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Initial Trophic vs Full Enteral Feeding in Patients With Acute Lung Injury: The EDEN Randomized Trial. JAMA Published online February 5, 2012.
In a prospective randomized open-label crossover study Meijers and colleagues compared regional citrate anticoagulation against no anticoagulation for molecular adsorbent recycling system (MARS) in ten patients with liver failure. Over 27 sessions, four coagulation related events (circuit thrombosis (3) and cannula-site haemorhage (1)) occurred in the non-anticoagulated group, versus no events in the citrate group. Patients receving citrate anticoagulation were significantly more likely to complete their MARS session (P=0.04), resulting in greater bilirubin clearance. Ionised calcium levels fell more during citrate anticoagulation, but remained at a safe level (P<0.001).
Meijers. A prospective randomized open-label crossover trial of regional citrate anticoagulation vs. anticoagulation free liver dialysis by the Molecular Adsorbents Recirculating System. Critical Care 2012, 16:R20
American Heart Journal
Ranchord and colleagues performed a pilot, randomized controlled trial evaluation titrated oxygen therapy (SpO2 93-96%) versus 6 L/min O2 in 136 patient with uncomplicated NSTEMI. There was no difference in mortality or infarct size between the 2 groups, although confidence intervals were wide.
I hope you find these brief summaries useful.
Until next week