June 24th 2013
Welcome to the 81st 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 multiple research studies include investigations into stroke thrombolysis, acute kidney injury, route of feeding, central venous pressure as a guide for fluid therapy, ventilator-associated pneumonia, ICU provision for elderly patients and beta 2 agonists for acute lung injury.
This week's guidelines are on red cell transfusion in the critically ill, and the management of cytomegalovirus infection in haematology patients. There are editorials on non-ST elevation myocardial infarction and medical journalism. Commentaries address the UK NHS, MERS-CoV, MRSA, aquaretics, guidelines, pandemic influenza and informed scepticism.
Amongst the clinical review articles are papers on intracerebral haemorrhage, traumatic brain injury, volaemic status and fluid responsiveness, mechanical suport devices, cirrhosis and its associated complications, acute kidney injury, traumatic coagulopathy, fungal infections, polytrauma management and hypertonc saline for trauma resuscitation
Journal of the American Medical Association: Stroke Thrombolysis
Saver and colleagues performed a registary database analysis, investigating 58 353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset. Shorter onset to treatment time was associated with reduced in-hospital mortality (odds ratio 0.96; 95% CI 0.95-0.98; P < 0.001), reduced symptomatic intracranial hemorrhage (OR 0.96; 95% CI 0.95-0.98; P < 0.001), increased achievement of independent ambulation at discharge (OR 1.04; 95% CI 1.03-1.05; P < 0.001), and increased discharge to home (OR 1.03; 95% CI 1.02-1.04; P < 0.001). The main patient factors associated with a shorter onset to treatment time were increased stroke severity (OR 2.8; 95% CI 2.5-3.1 per 5-point increase), arrival by ambulance (OR 5.9; 95% CI 4.5-7.3), and presentation in regular hours (OR 4.6; 95% CI 3.8-5.4). Inhospital mortality was 8.8%, with just 38.6% being discharged home.
Critical Care Medicine: Acute Kidney Injury
McGuinness et al completed a phase IIb multicenter double-blind randomized controlled trial, comparing sodium bicarbonate infusion (n=215) with 0.9% saline infusion (n=212) for the prevention of cardiac surgery–associated acute kidney injury in 427 at risk patients. There was no difference in the incidence in AKI, (bicarbonate 47% versus saline 44%; p=0.58), duration of either ventilation, ICU stay, or hospital stay, or mortality.
Abstract: McGuinness. Sodium Bicarbonate Infusion to Reduce Cardiac Surgery-Associated Acute Kidney Injury: A Phase II Multicenter Double-Blind Randomized Controlled Trial. Critical Care Medicine 2013;41(7):1599-1607
Critical Care Medicine: Extracorporeal Membrane Oxygenation
Bréchot undertook a retrospective, single-center, observational study and cross-sectional survey to assess health-related quality of life in 14 patients who received venoarterial extracorporeal membrane oxygenation for septic shock refractory to conventional treatment. Twelve patients (86%) were weaned off venoarterial extracorporeal membrane oxygenation after 5.5 days (2–12) days of support and 10 patients (71%) were discharged home and were alive after a median follow-up of 13 months (3–43). All 10 survivors had normal left ventricular ejection fraction and reported good health-related quality of life at long-term follow-up.
Critical Care Medicine: Fluid Responsiveness
Using data from healthy controls studies (n = 1), ICU studies (n = 22) and operating room studies (n = 20), Marik updated his previous systematic review and meta analysis examining the utility of central venous pressure to predict fluid responsiveness. Just over half of patients were fluid responsive (57%± 13%). Overall, CVP had no ability to predict fluid responsiveness (AUC 0.56, 95% CI 0.54–0.58) with no improvement in subgroups; ICU patients 0.56 (95% CI, 0.52–0.60 and OR patients 0.56 (95% CI, 0.54–0.58). Similarly, correlation between baseline CVP and change in stroke volume index/cardiac index was also poor, being 0.18 (95% CI, 0.1–0.25) overall, 0.28 (95% CI, 0.16–0.40) in ICU patients, and 0.11 (95% CI, 0.02–0.21) in OR patients.
Critical Care Medicine: Chest Compressions
Westfall and colleagues undertook a systematic review and meta analysis questioning whether mechanical or manual chest compression was superior for achieving a return of spontaneous circulation in cardiac arrest. 12 studies (n=6,538, 1,824 return of spontaneous circulation events), were included. Load-distributing band CPR was superior to manual CPR (odds ratio 1.62, 95% CI 1.36 - 1.92, p <0.001), although piston-driven CPR was as effective as manual CPR (OR 1.25, 95% CI 0.92 - 1.68; p = 0.151). Compared with manual CPR, combining both mechanical devices was associated with a higher odds of return of spontaneous circulation (OR 1.53; 95% CI 1.32 - 1.78], p < 0.001).
New England Journal of Medicine: MERS-CoV
Assiri et al describe a cluster of 23 cases of healthcare associated MERS-CoV occuring between April 1st and May 23rd 2013 in Saudi Arabia. By June 15th, the mortality rate was 65% (n=15), with the remained either having recovered (n=6, 26%) or remaining hospitalized (n=2, 9%). Symptoms included fever (87%), cough (87%), dyspnoea (48%) and GI symptoms (35%), with 87% presenting with an abnormal chest radiograph. The majority of infections (21/23) were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units, with a median incubation period of 5.2 days.
British Journal of Anaesthesia: Sedation
Adams and colleagues performed an objective appraisal of 6 randomized control trials comparing the sedative and clinical effectiveness of dexmedetomidine with midazolam in adult ICU patients. Superior sedative effects of dexmedetomidine, as measured by duration at target sedation zone, were not demonstrated. Some secondary endpoints demonstrated clinical effectiveness, but more studies are required to verify these findings.
Intensive Care Medicine: Decision Making for Elderly Patients
To determine the preferences of elderly people (≥ 80 years) for life-sustaining therapy during a future hypothetical critical illness, Philippart et al undertook an observational cohort study of consecutive previously hospitalised community-dwelling elderly people and of volunteers residing in nursing homes or assisted-living facilities. Of the 115 participants (response rate 87%), there was a high rate of refusal of life saving therapy - noninvasive ventilation 27% , invasive mechanical ventilation 43%, renal replacement therapy after invasive ventilation 63%. Perceived quality of life post therapy was a major reason for therapy refusal.
Garrouste-Orgeas performed an observational simulation study to evaluate physician decisions on ICU admission for life-sustaining treatments for patients aged ≥ 80 years. One hundred physicians participated (46% participation rate). Using logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for noninvasive ventilation and invasive mechanical ventilation. Intensivists were less likely to institute invasive mechanical ventilation if patients had a previous ICU admission (odds ratio 0.29, 95 % CI 0.13–0.65, p = 0.01), or cancer (OR 0.23, 95 % CI 0.10–0.52, p = 0.003). Renal replacement therapy was more likely to be commenced if there was a living spouse (OR 2.03, 95 % CI 1.04–3.97, p = 0.038), but less likely if there was co-existing respiratory disease (OR 0.42, 95 % CI 0.23–0.76, p = 0.004). There was little agreement among physicians as to when to begin life-supporting treatment.
Abstract: Garrouste-Orgeas. The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over. Intensive Care Med 2013;epublished June 14th
Critical Care: Feeding Route
Deane and colleagues completed a systematic review and meta analysis (15 studies) comparing intragastric feeding with small bowel feeding in critically ill adult patients. Small bowel feeding was associated with a reduced risk of pneumonia (relative risk 0.75, 95% CI 0.60-0.93; P = 0.01; I2=11%). There was no difference in duration of ventilation (weighted mean difference: -0.36 days, 95% CI -2.02 to 1.30; P = 0.65; I2=42%), length of ICU stay (WMD: 0.49 days, 95% CI -1.36 to 2.33; P = 0.60; I2=81%) or mortality (RR 1.01, 95% CI 0.83 to 1.24; p = 0.92; I2=0%). Small bowel feeding was associated with significantly improved nutrient delivery (% goal rate received: 11%, 95% CI 5-16; P = 0.0004; I2=88%).
Chest: Prehospital Management of Critical Illness
Ellis et al completed a multi-center cross sectional descriptive study, totalling 390 critical care encounters, evaluating primary care providers (PCPs) pre-hospital management of evolving acute severe illness. In 300 encounters primary care providers implemented pre-hospital management for 8 episodes of acute illness, attributed a lack of awareness of the patient’s evolving acute illness. Just 21% of primary care providers were aware of the acute severe illness before their patient was admitted to an ICU and 33% were not aware that their patient was in an ICU.
Chest: Ventilator-Associated Pneumonia
Dimopoulos performed a systematic review and meta-analysis, totalling 4 randomized controlled trials, comparing short (7-8 days)- with long (10-15 days)-duration antibiotic regimens for ventilator-associated pneumonia.There was no difference in mortality (odds ratio 1.20, 95% CI 0.84-1.72, p=0.32), or in relapses, although long-course treatment was associated with a strong trend to lower relapses (OR 1.67, 95% CI 0.99-2.83, p=0.06). Short-course treatment was associated with an increase in antibiotic-free days, with a pooled weighted mean difference of 3.40 days ( 95% CI 1.43 to 5.37, p<0.001).
Critical Care: Acute Kidney Injury
Ralib completed an observational study in 725 critically ill patients, aiming to prospectively validate the acute kidney injury urine output criterion of 0.5 ml/kg/h for 6-hours ("AKIUO"). 72% had either an increase in creatinine (increase in plasma creatinine of ≥26.5 mol/l within 48 hours or ≥50% from baseline, "AKICr") or both. AKIUO alone was more frequent than AKICr (33.7% versus 11.0%; P<0.0001). A 6-hour urine output threshold of 0.3 ml/kg/h best associated with mortality and dialysis and was independently predictive of both hospital and 1-year mortality.
Critical Care: Acute Pancreatitis
In a systematic review and meta analysis, totalling 3 randomized controlled trials (n=157), Chang and colleagues examined the differences in safety and tolerance between nasogastric and nasojejunal feeding in patients with severe acute pancreatitis. There was no differences in mortality (risk ratio 0.69, 95% CI 0.37-1.29, P = 0.25); tracheal aspiration (RR 0.46, 95% CI 0.14-1.53, P = 0.20); diarrhoea (RR 1.43, 95% CI 0.59-3.45, P = 0.43); exacerbation of pain (RR 0.94, 95% CI 0.32-2.70, P = 0.90), or meeting energy balance (RR 1.00, 95% CI 0.92-1.09, P = 0.97).
Anesthesia & Analgesia: Emergent Intubation
Kory and colleagues performed a before and after study to examine the effectiveness of using a video laryngoscope (n=78), rather than a direct laryngoscope (n=50) as the primary intubating device during urgent 138 endotracheal intubations in critically ill patients when performed by less experienced operators (Pulmonary and Critical Care Medicine fellows). The use of the video laryngoscope was associated with a superior first-attempt success rate (91% vs 68%, P < 0.01). Additionally, the video laryngoscope decreased the numer of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01).
Respiratory Care: Acute Lung Injury
In a systematic review and meta analysis, Singh and colleagues identified 3 randomized placebo controlled trials (n=646) comparing beta-2 agonists (51.7%) with placebo (48.3%) for the treatment of acute lung injury. There was no difference in 28-day (relative risk 1.04; 95% CI 0.50-2.16) or hospital mortality (RR 1.22; 95% CI 0.95-1.56) with β2-agonist therapy. β2-agonists therapy was associated with reduced ventilator-free days (mean difference -2.19 days; 95% CI=-3.68 to -1.99) and organ failure-free days (mean difference -2.04; 95% CI= -3.74 to -0.35).
British Journal of Haematology: Red Cell Transfusion
- Retter. Guidelines on the management of anaemia and red cell transfusion in adult critically ill patients. British Committee for Standards in Haematology. Br J Haematol 2013;160(4):445-64
British Journal of Haematology: Cytomegalovirus Infection
- Emery. Management of cytomegalovirus infection in haemopoietic stem cell transplantation. British Committee for Standards in Haematology. British Journal of Haematology 2013;162:25–39
Heart: STEMI Guidelines
- Terkelsen. The divergence between European STEMI guidelines and evidence: a potential threat to optimising reperfusion therapy for patients with ST-elevation myocardial infarction
Journal of the American Medical Association: Medical Journalism
- Bauchner. Editorial Policies for Clinical Trials and the Continued Changes in Medical Journalism. JAMA 2013;epublished June 20th
British Medical Journal: Guidelines
Kidney International: Aquaretics
New England Journal of Medicine: NHS
New England Journal of Medicine: Pandemic Influenza
International Journal of Emergency Medicine: Dutch Emergency Medicine Training
- Gaakeer. Emergency medicine training in the Netherlands, essential changes needed. International Journal of Emergency Medicine 2013;6:19
Journal of Microbiology, Immunology and Infection: MRSA
- The Infectious Diseases Society of Taiwan. Guidelines for the treatment of methicillin-resistant Staphylococcus aureus infections in Taiwan. Journal of Microbiology, Immunology and Infection 2013;46(3):17-150
British Medical Journal: Informed Scepticism
The Lancet: MERS-CoV
Review - Clinical
Anesthesiology: Intracerebral Haemorrhage
- Vincent. Perioperative Management of Coagulation in Nontraumatic Intracerebral Hemorrhage. Anesthesiology 2013;119(1):218-227
Frontiers Neurology: Traumatic Brain Injury
- Shear. A military-centered approach to neuroprotection for traumatic brain injury. Front Neurol 2013;epublished June 12th
Kidney International: Fluid Management
- Kalantari. Assessment of intravascular volume status and volume responsiveness in critically ill patients. Kidney Int 2013;83:1017-1028
Progress in Transplantation: Mechanical Circulatory Support
- Aggarwal. Evaluation and management of emergencies in patients with mechanical circulatory support devices. Progress in Transplantation 2013;23:119-127
European Journal of Clinical Investigation: Myocardial Infarction
- Christia. Targeting inflammatory pathways in myocardial infarction. Eur J Clin Invest 2013;epublished June 17th
European Heart Journal Cardiovascular Imaging: 3D Intracardiac Echocardiography
- Fontes-Carvalho. Three-dimensional intracardiac echocardiography: a new promising imaging modality to potentially guide cardiovascular interventions. Eur Heart J Cardiovasc Imaging 2013;epublished June 20th
Indian Journal of Endocrinology & Metabolism: Statins
Vascular Health and Risk Management: Heart Failure
- Bonsu. Statins in heart failure: do we need another trial? Vascular Health and Risk Management 2013;2013(9):303-319
Clinical Liver Disease: Cirrhosis
- Bernardi. Cirrhotic cardiomyopathy. Clinical Liver Disease 2013;2:99–101
- Fernandez. Bacterial infections in cirrhosis: A growing problem with significant implications. Clinical Liver Disease 2013;2:102–105
- Boyer. Renal failure and liver transplantation. Clinical Liver Disease 2013;2:106–108
- Fortune. Hypervolemic hyponatremia: Clinical significance and management. Clinical Liver Disease 2013;2:109–112
- Moreau. Acute-on-chronic liver failure: Is the definition ready for prime time? Clinical Liver Disease 2013;2:113–115
- Morabito. When to use renal replacement therapy and bioartificial support for renal failure in patients with cirrhosis. Clinical Liver Disease 2013;2:116–119
- Arroyo. Relationship between systemic hemodynamics, renal dysfunction, and fluid retention in cirrhosis. Clinical Liver Disease 2013;2:120–122
- Kanwal. Improving quality of care in patients with cirrhosis. Clinical Liver Disease 2013;2:123–124
- Angeli. Current management of uncomplicated ascites. Clinical Liver Disease 2013;2:125–127
- Graupera. Diagnostic approach to renal failure in cirrhosis. Clinical Liver Disease 2013;2:128–131
- Asrani. Predictors of outcomes in patients with ascites, hyponatremia, and renal failure. Clinical Liver Disease 2013;2:132–135
- Solà. Current treatment strategies for hepatorenal syndrome. Clinical Liver Disease 2013;2:136–139
- Bhogal. Treatment of refractory ascites. Clinical Liver Disease 2013;2:140–142
Journal of Clinical Gerontology and Geriatrics: Acute Kidney Injury
- Chao. Acute kidney injury in the elderly: Only the tip of the iceberg. Journal of Clinical Gerontology and Geriatrics 2013;epublished June 13th
Nephrology Dialysis Transplantation: Elegance in Nephrology
- Nathan. The importance of being elegant: a discussion of elegance in nephrology and biomedical science / The Importance of Being Elegant. Nephrol Dial Transplant 2013;28:1385-1389
Anesthesiology: Traumatic Coagulopathy
- David. Case Scenario: Management of Trauma-induced Coagulopathy in a Severe Blunt Trauma Patient. Anesthesiology 2013;119(1):191-200
Annals of Medical and Health Sciences Research: Fungal Infections
- Bajwa. Fungal infections in intensive care unit: Challenges in diagnosis and management. Ann Med Health Sci Res 2013;3:238-44
Marine Drugs: Gram Negative Sepsis
- Solov'eva. Marine Compounds with Therapeutic Potential in Gram-Negative Sepsis. Mar. Drugs 2013;11:2216-2229
Mediators of Inflammation: Sepsis
- Schulte. Cytokines in Sepsis: Potent Immunoregulators and Potential Therapeutic Targets—An Updated View. Mediators of Inflammation 2013;2013:165974
Malaysian Journal of Medical Science: Polytrauma
- Chak Wah. Evolving frontiers in severe polytrauma management - refining the essential principles. Malays J Med Sci 2013;20(1):1-12
Clinics (Sao Paulo): Hypertonic Saline for Resuscitation
- Dubick. ROC trials update on prehospital hypertonic saline resuscitation in the aftermath of the US-Canadian trials. Clinics (Sao Paulo) 2013 Jun;68(6):883–886
ISRN Emergency Medicine: Pain
Anesthesiology News: Opioid Abuse
- Vaghari. Perioperative Approach to Patients With Opioid Abuse and Tolerance. Anesthesiology News 2013;38(6):1-4
Oxidative Medicine and Cellular Longevity: Bruise
- Eaton. Natural history of the bruise: formation, elimination, and biological effects of oxidized hemoglobin. Oxid Med Cell Longev 2013;2013:703571
I hope you find these brief summaries and links useful.
Until next week