ccr logo

Critical Care Reviews Newsletter

December 2nd 2012

Welcome

Hello

Welcome to the 52nd 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. The Newsletter has reached its first anniversary and in this time has monitored over 10,000 journal issues, provided links to over 1,000 free review articles and highlighted all major critical care research, including landmark papers such as Chest and 6S, usually well ahead of print.

This week's research studies include 2 papers from JAMA on the efficacy of aldosterone antagonists in heart failure, a retrospective study from Intensive Care Medicine, further supporting restrictive red cell transfusion, and a meta analysis from the International Journal of Cardiology confirming the utility of beta blockade in acute coronary syndromes.

This week's guideline is on the design of randomized cluster trials

Amongst the clinical review articles are papers on depth of anaesthesia monitoring, ultrasound for intravascular volume assessment, pulmonary hypertension, idiopathic pulmonary fibrosis, abdominal vein thrombosis, bioartificial liver support, cardiac surgery-associated AKI, malignant hyperthermia, tropical infections, and, as a nice foil to the above transfusion study, a review on transfusion in the anaemic critically ill patient.

The topic for This Week's Papers is alcohol, starting with a paper on alcoholic ketoacidosis in tomorrow's Paper of the Day.

Research

Intensive Care Medicine: Red Cell Transfusion

To investigate the efficacy of red blood cell transfusion at reversing the deleterious effects of moderate anemia (7-9 g/dL) in critically ill, non-bleeding patients, Leal-Noval undertook a retrospective, pair-matched (ratio 1:1) cohort study in 428 patients. Compared with transfused anaemic patients (TAPS), non-transfused anaemic patients (NTAPs) showed significantly lower rates of hospital mortality (21 vs.13 %, respectively; p < 0.05) and ICU re-admission (7.4 vs. 1.9 %, respectively; p < 0.05). Additionally, NTAPs had significantly lower rates of nosocomial infection (12.9 vs. 6.7 %, respectively; p < 0.05) and acute kidney injury (24.8 vs. 16.7 %, respectively; p < 0.05). Similar results were obtained in subgroup analysis where only more anemic patients (68 matched pairs) or patients with cardiovascular comorbidities (63 matched pairs) were considered.

Abstract: Leal-Noval. Red blood cell transfusion in non-bleeding critically ill patients with moderate anemia: is there a benefit? Intensive Care Med 2012; epublished Nov 27th

Journal of the American Medical Association: Aldosterone Antagonists in Heart Failure with Reduced Ejection Fraction

Hernandez et al used clinical registry data to examine the effectiveness of newly initiated aldosterone antagonist therapy among 5887 elderly patients hospitalized with heart failure and reduced ejection fraction. Mortality among treated and untreated patients was 49.9% vs 51.2% (P = .62); 63.8% vs 63.9% (P = .65) for cardiovascular readmission; and 38.7% vs 44.9% (P < .001) for heart failure readmission at 3 years; and 2.9% vs 1.2% (P < .001) for hyperkalemia readmission within 30 days and 8.9% vs 6.3% (P = .002) within 1 year. After inverse weighting for the probability of treatment, there were no significant differences in mortality (hazard ratio [HR], 1.04; 95% CI, 0.96-1.14; P = .32) and cardiovascular readmission (HR, 1.00; 95% CI, 0.91-1.09; P = .94). Heart failure readmission was lower among treated patients at 3 years (HR, 0.87; 95% CI, 0.77-0.98; P = .02). Readmission associated with hyperkalemia was higher with aldosterone antagonist therapy at 30 days (HR, 2.54; 95% CI, 1.51-4.29; P < .001) and 1 year (HR, 1.50; 95% CI, 1.23-1.84; P < .001).

Abstract: Hernandez. Associations Between Aldosterone Antagonist Therapy and Risks of Mortality and Readmission Among Patients With Heart Failure and Reduced Ejection Fraction. JAMA 2012;308(20):2097-2107

Journal of the American Medical Association: Aldosterone Antagonists in Heart Failure with Preserved Ejection Fraction

To test the hypothesis that renin-angiotensin system (RAS) antagonists are associated with reduced all-cause mortality in patients with heart failure with a preserved ejection fraction (HFPEF), Lund et al performed a prospective study in 41 791 patients in the Swedish Heart Failure Registry. Of these, 16 216 patients with HFPEF (ejection fraction ≥40%; mean [SD] age, 75 [11] years; 46% women) were either treated (n = 12 543) or not treated (n = 3673) with RAS antagonists. In the matched HFPEF cohort, 1-year survival was 77% (95% CI, 75%-78%) for treated patients vs 72% (95% CI, 70%-73%) for untreated patients, with a hazard ratio (HR) of 0.91 (95% CI, 0.85-0.98; P = .008). In the overall HFPEF cohort, crude 1-year survival was 86% (95% CI, 86%-87%) for treated patients vs 69% (95% CI, 68%-71%) for untreated patients, with a propensity score–adjusted HR of 0.90 (95% CI, 0.85-0.96; P = .001). In the HFPEF dose analysis, the HR was 0.85 (95% CI, 0.78-0.83) for 50% or greater of target dose vs no treatment (P < .001) and 0.94 (95% CI, 0.87-1.02) for less than 50% of target dose vs no treatment (P = .14). In 20,111 age and propensity score–matched patients, heart failure with reduced ejection fraction patients, the HR was 0.80 (95% CI, 0.74-0.86; P < .001).

Abstract: Lund. Association Between Use of Renin-Angiotensin System Antagonists and Mortality in Patients With Heart Failure and Preserved Ejection Fraction. JAMA 2012;308(20):2108-2117

International Journal of Cardiology: Beta Blockade in Myocardial Infarction

Chatterjee and colleagues performed a meta analysis of studies comparing intravenous beta-blockers administered within 12hours of presentation of acute coronary syndromes with standard medical therapy and/or placebo. Sixteen studies enrolling 73,396 participants were included. In- hospital mortality was reduced 8% with intravenous beta-blockers, RR=0.92 (95% CI, 0.86–1.00; p=0.04) when compared with controls. Moreover, intravenous beta-blockade reduced the risk of ventricular tachyarrhythmias (RR=0.61; 95 % CI 0.47–0.79; p=0.0003) and myocardial reinfarction (RR=0.73, 95 % CI 0.59–0.91; p=0.004) without increase in the risk of cardiogenic shock, (RR=1.02; 95% CI 0.77–1.35; p=0.91) or stroke (RR=0.58; 95 % CI 0.17–1.98; p=0.38).

Abstract: Chatterjee. Early intravenous beta-blockers in patients with acute coronary syndrome—A meta-analysis of randomized trials. International Journal of Cardiology 2012; epublished November 19th

American Journal of Respiratory and Critical Care Medicine: Nutrition

Casaer et al performed a secondary analyses of data from the randomized controlled EPaNIC trial (n=4640), which, in the setting of insufficient enteral nutrition, evaluated the addition of early parenteral nutrition. In none of the subgroups defined by type or severity of illness was a beneficial effect of Early-PN observed. The lowest dose of macronutrients was associated with the fastest recovery and any higher dose, administered parenterally or enterally, was associated with progressively more delayed recovery. The amount of proteins/amino-acids rather than of glucose appeared to explain delayed recovery with early feeding

Abstract: Casaer. Role of Disease and Macronutrient Dose in the Randomized Controlled EPaNIC Trial, a Post-hoc Analysis. Am. J. Respir. Crit. Care Med 2012; epublished November 29th

Critical Care: sTREM

Wu et al performed a systematic review and meta-analysis of 11 studies to evaluate the accuracy of plasma sTREM-1 for sepsis diagnosis in 1,795 patients with systemic inflammation. The pooled sensitivity and specificity was 79% (95% CI, 65 - 89) and 80% (95% CI, 69 - 88), respectively. The positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 4.0 (95% CI, 2.4 – 6.9), 0.26 (95% CI, 0.14 - 0.48), and 16 (95% CI, 5 - 46), respectively. The area under the curve of the summary receiver operator characteristic was 0.87 (95% CI, 0.84 - 0.89). Meta-regression analysis suggested that patient sample size and assay method were the main sources of heterogeneity. Publication bias was suggested by an asymmetrical funnel plot (p = 0.02).

Full Text: Wu. Accuracy of plasma sTREM-1 for sepsis diagnosis in systemic inflammatory patients: a systematic review and meta-analysis. Critical Care 2012, 16:R229