Newsletter 127 / May 11th 2014
Welcome
Hello
Welcome to the 127th 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 hundreds of clinical and scientific journals.
This week's research studies include randomized controlled trials on IV iron supplementation, intermittent sedation, Clostridium difficile therapy and eplerenone in acute STEMI; one meta analysis addresses the significance of echocardiographic right ventricular dysfunction in PE; observational studies focus on use of analgesics, sedatives and neuromuscular blockade in Canada, and glutamine (in a post hoc analysis of REDOXS). Additional studies include a study related to FEAST, this time investigating red cell transfusion in anaemic Ugandan children, as well as studies on fluconazole prophylaxis in premature infants, lung ultrasound for fluid loading, causes of death in the USA, perioperative mortality in the UK, perioperative TRALI, cardivascular events post acute kidney injury, lactate measurement post cardiac arrest and the development of a new perioperative geriatric fraility score
This month's Cochrane reviews include new reviews on hypoxaemia in mechanical ventilation and subsegmental PE therapy, as well as updated reviews on digoxin therpy for heart failure and fluid therapy in bacterial meningitis.
There are a number of guidelines this week, on the correct measurement of cerebral perfusion pressure (ht @elfyn_thomas), surgical site infection, C. diff infection and hypertension. Commentaries focus on ebola, ultrasound for pneumothorax and transcatheter aortic valve replacement plus pragmatic clinical trials, and there are four interesting case reports.
Amongst the clinical review articles are papers on status epilepticus, mechanical circulatory support, several on myocarditis, ECMO, negative pressure pulmonary oedema, cardiac dysfunction post liver transplantation, uncontrolled sepsis, traumatic haemorrhagic shock, and bioterrorism. Non-clinical reviews discuss social media in education, perioperative physician performance feedback, clinical trials and clinical inertia.
The topic for This Week's Papers is septic shock, starting with a paper on the general management of this condition in tomorrow's Paper of the Day.
Research
Randomized Controlled Trial
Pieracci and colleagues compared iron sucrose 100 mg IV with placebo thrice weekly for up to 2 weeks in 150 critically ill trauma patients with anaemia (Hb < 12 g/dL), and found:
- at baseline, patient profiles were consistent with functional iron deficiency
- 89.3% were hypoferremic
- 34.0% were hyperferritinemic
- 42.7% had iron-deficient erythropoiesis
- transferrin saturation was 8% (range, 2-58%)
- in the subgroup (n=57) of patients who received all six doses of study drug
- iron supplementation was associated with increased serum ferritin concentrations
- day 7 (808.0 ng/mL vs 457.0 ng/mL, p < 0.01)
- day 14 (1,046.0 ng/mL vs 551.5 ng/mL, p < 0.01)
- iron supplementation was associated with increased serum ferritin concentrations
- there was no significant difference between groups in
- transferrin saturation
- erythrocyte zinc protoporphyrin concentration
- hemoglobin concentration
- packed RBC transfusion requirement
- risk of infection
- length of stay
- mortality
Junior and colleagues compared interruption of continuous daily sedation with intermittent sedation in 60 patients critically ill patients expected to need mechanical ventilation for more than 24 hours, in a low nurse staffing ICU, and found:
- no differences in
- ventilator-free days at day 28 (interruption group 24 days vs intermittent group 25 days, P = 0.160)
- ICU mortality (40 versus 23.3%, P = 0.165)
- hospital mortality (43.3 versus 30%, P = 0.284)
- incidence of delirium (30 versus 40%, P = 0.472)
- self-extubation (3.3 versus 6.7%, P = 0.514)
- psychological stress six months after ICU discharge
- nurse workload
- interruption of daily sedation was associated with
- increased total doses of fentanyl and midazolam
- intermittent sedation was associated with
- higher tidal volumes
Johnson and colleagues completed two multinational trials, comparing oral tolevamer (n=563; 9g loading dose, followed by 3 g 8 hourly for 14 days), vancomycin (n=266; 125 mg 6 hourly for 10 days), or metronidazole (n=289; 375 mg 6 hourly for 10 days) in a 2:1:1 ratio, and found:
- in a pooled analysis,
- clinical success of each drug was
- tolevamer (44.2%)
- metronidazole (72.7%)
- vancomycin (81.1%)
- tolevamer was inferior to both metronidazole and vancomycin (P<0.001)
- metronidazole was inferior to vancomycin (P=0.02)
- clinical success of each drug was
- for patients with severe Clostridium difficile infection
- metronidazole trended towards being inferior to vancomycin (66.3% vs 78.5%; p=0.059)
- no difference in adverse events
Montalescot and colleagues compared eplerenone (25–50 mg once daily) with placebo in 1,012 patients with acute STEMI without heart failure, and found:
- eplerenone was associated with
- reduction in the composite primary outcome
- 18.2% vs 29.4%; adjusted hazard ratio 0.58; 95% CI 0.45 to 0.76; P < 0.0001
- the primary endpoint was driven by a high BNP/NT-proBNP level
- adjusted HR 0.60; 95% CI 0.45 to 0.79; P < 0.0003
- reduced incidence of hypokalaemia (< 3.5 mmol/L)
- 1.4 vs. 5.6% (P = 0.0002)
- a trend towards increased incidence of hyperkalaemia (> 5.5 mmol/L)
- 5.6 vs. 3.2% (P = 0.09)
- reduction in the composite primary outcome
- no difference in adverse events
Meta Analysis
Cho et al pooled data from 12 studies investigating right ventricular dysfunction (RVD) on echocardiography in 3,283 hemodynamically stable patients with acute PE, and found:
- 37.3% (n=1,223) had RVD
- 62.7% (n=2,060) had normal right ventricular function
- short-term mortality was reported in
- 13.7% (167/1223) of patients with RVD
- 6.5% (134/2060) of patients without RVD
- RVD on echocardiogram was associated with a
- increased in short-term mortality
- odds ratio 2.29, 95% CI 1.61 to 3.26
- increased in short-term mortality
Burry and colleagues performed a two week observational study (n=712, 3,620 patient days) in 51 Canadian ICUs aiming to describe analgo-sedation, antipsychotic and neuromuscular blocking drug use, and found:
- regarding mechanical ventilation
- median duration 3.0 days (IQR 2 to 6)
- during mechanical ventilation
- 92% received analgo-sedation,
- 32% received adjunct agent (e.g., acetaminophen),
- 18% received neuromuscular blockers
- 10% received antipsychotics
- opioids were used more frequently than (P < 0.0001)
- benzodiazepines (84.8% vs 62.2)
- propofol (84.8%vs 10.1%)
- independent predictors of opioid and benzodiazepine use were
- longer MV duration
- assessment scales
- physical restraints
- university-affiliated hospital
- the use of scales, protocols etc were
- sedation scale 53.0%,
- pain scale 19.1%,
- delirium scale 5.2%,
- protocol 25.0%,
- daily sedation interruption 42.1%
Heyland and colleagues performed a post hoc analysis of the REDOXS study (1,223 critically ill mechanically ventilated patients with multiorgan failure randomized to receive glutamine, antioxidants, both glutamine and antioxidants, or placebo) aiming to reevaluate the effect of supplementation after controlling for baseline covariates and to identify potentially important subgroup effects, and found:
- the 28-day mortality rates were
- placebo 25%
- glutamine 32%
- antioxidant 29%
- combination 33%
- adjusted odds ratio of 28-day mortality vs placebo
- glutamine 1.5 (95% CI 1.0 to 2.1, P = 0.05)
- antioxidants 1.2 (95% CI 0.8 to 1.8, P = 0.40)
- glutamine & antioxidants 1.4 (0.9 to 2.0, P = 0.09)
- in subgroup analysis
- both glutamine and antioxidants appeared most harmful in patients with baseline renal dysfunction.
- no subgroups suggested reduced mortality with supplements
Additional Studies
Randomized Controlled Trials
- Abstract: Benjamin. Effect of Fluconazole Prophylaxis on Candidiasis and Mortality in Premature Infants. A Randomized Clinical Trial. JAMA 2014;311(17):1742-1749
- Full Text: Olupot-Olupot. Phase II trial of standard versus increased transfusion volume in Ugandan children with acute severe anemia. BMC Medicine 2014;12:67
- Full Text: Möckel. Early discharge using single cardiac troponin and copeptin testing in patients with suspected acute coronary syndrome (ACS): a randomized, controlled clinical process study. Eur Heart J 2014;epublished April 30th
Observational Studies
- Full Text: Caltabeloti. Early fluid loading in acute respiratory distress syndrome with septic shock deteriorates lung aeration without impairing arterial oxygenation: a lung ultrasound observational study. Critical Care 2014;18:R91
- Abstract: Donnino. Initial Lactate and Lactate Change in Post-Cardiac Arrest: A Multicenter Validation Study. Critical Care Med 2014;epublished April 25th
- Abstract: Yoon. Potentially Preventable Deaths from the Five Leading Causes of Death - United States, 2008-2010. MMWR Morb Mortal Wkly Rep 2014;63(17):369-374
- Abstract: Schiff. Major incidents and complications in otherwise healthy patients undergoing elective procedures: results based on 1.36 million anaesthetic procedures. Br J Anaesth 2014;epublished May 5th
- Abstract: Alam. Perioperative transfusion-related acute lung injury: The Canadian Blood Services experience. Transfus Apher Sci 2014;epublished April 19th
- Abstract: Wu. Long-term risk of coronary events after AKI. J Am Soc Nephrol 2014;25(3):595-605
- Full Text: Kim. Multidimensional Frailty Score for the Prediction of Postoperative Mortality Risk. JAMA Surg 2014;epublished May 7th
Cochrane Reviews
New
- Gilbert-Kawai. Permissive hypoxaemia versus normoxaemia for mechanically ventilated critically ill patients. Cochrane Database of Systematic Reviews 2014;Issue 5. Art. No.: CD009931
- Yoo. Anticoagulant treatment for subsegmental pulmonary embolism. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD010222
Updated
- Hood. Digitalis for treatment of heart failure in patients in sinus rhythm. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD002901
- Maconochie. Fluid therapy for acute bacterial meningitis. Cochrane Database of Systematic Reviews 2014, Issue 5. Art. No.: CD004786
Guidlines and Position Statements
- Joint Position Statement by the Councils of the Neuroanaesthesia Society of Great Britain and Ireland (NASGBI) and the Society of British Neurological Surgeons (SBNS) with regards to the calculation of cerebral perfusion pressure in the management of traumatic brain injury, May 2014
- Anderson. Strategies to Prevent Surgical Site Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology 2014;35(6):605-627
- Dubberke. Strategies to Prevent Clostridium difficile Infections in Acute Care Hospitals: 2014 Update. Infection Control and Hospital Epidemiology 2014;35(6):628-645
- Dasgupta. The 2014 Canadian Hypertension Education Program Recommendations for Blood Pressure Measurement, Diagnosis, Assessment of Risk, Prevention, and Treatment of Hypertension. Canadian Journal of Cardiology 2014;30(5):485-501
- Feldmann. Ebola — A Growing Threat? New Eng J Med 2014;epublished May 7th
- Volpicelli. Unusual new signs of pneumothorax at lung ultrasound. Critical Ultrasound Journal 2013;5:10
- Feldman. Transcatheter Aortic Valve Replacement. Flattening the Cost Curve. JAMA 2014;epublished May 5th
- Sugarman. Ethics and Regulatory Complexities for Pragmatic Clinical Trials. JAMA 2014;epublished May 8th
- Colli. Traumatic Tension Pneumothorax Causing Heart Rotation N Engl J Med 2014;370:e30
- Qi. Abdominal-Wall Varices in the Budd–Chiari Syndrome. N Engl J Med 2014;370:1829
- McDonald. Misdiagnosed pneumothorax interpreted as necrotizing fasciitis of the chest wall: case report of a potentially preventable death. Patient Safety in Surgery 2014;8:20
- Agrusa. Right diaphragmatic injury and lacerated liver during a penetrating abdominal trauma: case report and brief literature review. World Journal of Emergency Surgery 2014;9:33
Clinical Review Articles
Neurological
- Arora. Status epilepticus: Having treatment paradigms in place in Neurosurgical settings. Indian J Neurosurg 2014;3:14-8
- Shen. Addressing the needs of traumatic brain injury with clinical proteomics. Clinical Proteomics 2014;11:11
- Iannopollo. Efficacy versus safety: the dilemma of using novel platelet inhibitors for the treatment of patients with ischemic stroke and coronary artery disease. Therapeutics and Clinical Risk Management 2014;10:321-329
- Hylek. Gaps in translation from trials to practice: Non-vitamin K antagonist oral anticoagulants (NOACs) for stroke prevention in atrial fibrillation. Thromb Haemost 2014;111(5):783-788
- Chiang. Stroke prevention in atrial fibrillation: An Asian perspective. Thromb Haemost 2014;111(5):789-797
- Chan . New oral anticoagulants for stroke prevention in atrial fibrillation: impact of study design, double counting and unexpected findings on interpretation of study results and conclusions. Thromb Haemost 2014;111(5):798-807
- Hankey. Unanswered questions and research priorities to optimise stroke prevention in atrial fibrillation with the new oral anticoagulants. Thromb Haemost 2014;111(5):808-816
Circulatory
- Mallidi. State of the art of mechanical circulatory support. Tex Heart Inst J 2014;41(2):115-20
- Rose. Learning from myocarditis: mimicry, chaos and black holes. F1000Prime Reports 2014;6:(25)
- Kühl. Myocarditis: the causes. Heart Metab 2014;62:3–7
- Amm. Management of myocarditis. Heart Metab 2014;62:8-12
- Pozo. Differentiating infarction from myocarditis. Heart Metab 2014;62:13-17
- Frustaci. Immunosuppressive therapy in virus-negative inflammatory cardiomyopathy. Heart Metab 2014;62:18-21
- Parkhomenko. Metabolic remodeling as a target preventing myocardial dysfunction: focus on trimetazidine. Heart Metab 2014;62:22-26
- Caforio. Myocarditis: inflammatory and endocrine causes. Heart Metab 2014;62:31-35
- Zeb. Takotsubo cardiomyopathy: a possible metabolic disorder. Heart Metab 2014;62:36-40
- Weitz. Periprocedural Management of New Oral Anticoagulants in Patients Undergoing Atrial Fibrillation Ablation. Circulation 2014;129:1688-1694
- Ajit. Cardiac Magnetic Resonance Imaging for the Investigation of Cardiovascular Disorders. Part 2: Emerging Applications. Texas Heart Institute Journal 2014;41(2):135-143
- Ajit. Cardiac Magnetic Resonance Imaging for the Investigation of Cardiovascular Disorders. Part 1: Current Applications. Texas Heart Institute Journal 2014;41(1):7-20
- Friedrich. Review of direct renin inhibition by aliskiren. J Renin Angiotensin Aldosterone Syst 2013;14(3):193-6
Respiratory
- Abrams. Ethical Dilemmas Encountered With the Use of Extracorporeal Membrane Oxygenation in Adults. Chest 2014;145(4):876-882
- Woods. Corticosteroids in the treatment of acute exacerbations of chronic obstructive pulmonary disease. International Journal of Chronic Obstructive Pulmonary Disease 2014;9:421-430
- Lemyze. Understanding negative pressure pulmonary edema. Intensive Care Med 2014;epublished May 6th
- Ward. Acute lung injury and the role of histones. Translational Respiratory Medicine 2014;2:1
Hepatobiliary
- Zaky. Appraising Cardiac Dysfunction in Liver Transplantation:An Ongoing Challenge. Liver International 2014;epublished May 2nd
- Zhou. Stem Cells with Decellularized Liver Scaffolds in Liver Regeneration and Their Potential Clinical Applications. Liver International 2014;epublished May 2nd
- Das. Hepatic and biliary ascariasis. J Global Infect Dis 2014;6:65-72
- Wilder. The clinical utility of FibroScan® as a noninvasive diagnostic test for liver disease. Medical Devices: Evidence and Research 2014;2014(7):107-114
Renal
Haematological
Sepsis
- Cain. Uncontrolled sepsis: a systematic review of translational immunology studies in intensive care medicine. Intensive Care Medicine Experimental 2014;2:6
- Henriquez-Camacho. Biomarkers for Sepsis. Biomed Res Int 2014;2014:547818
Trauma
Toxicology
Miscellaneous
Non-Clinical Review Articles
- Kind. Twelve tips for using social media as a medical educator. Medical Teacher 2014;36(4):284-290
- Kaye. Clinical performance feedback and quality improvement opportunities for perioperative physicians. Advances in Medical Education and Practice 2014;5:115–123
- Okonta. Ethics of clinical trials in Nigeria. Niger Med J 2014;55:188-94
- Aujoulat. Factors associated with clinical inertia: an integrative review. Advances in Medical Education and Practice 2014;5:141-147
I hope you find these brief summaries and links useful.
Until next week
Rob