Newsletter 95 / September 29th 2013




Welcome to the 95th 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. It's been another quiet week for critical care research, with no major studies released in the past week that I've come across.

This week's interventional research studies include a surgical study comparing subcuticular sutures with staples for GI surgery wound closure and a pilot study on adaptive support ventilation; systematic reviews and meta analyses address ultrasound for pneumothorax diagnosis, high versus low intensity ICU staffing, and for the increasing number of prehospital personnel using the site, a paper on the evidence for critical care paramedics. Observational studies examine a new predictive tool for identifying subarachnoid haemorrhage and a study investigating the time to intubation in community-acquired pneumonia.

This week's single guideline focuses on the management of obstructive sleep apnoea. There is an editorial on journal publishing and ranking, study critiques on Villanueva's upper GI haemorrhage paper and INTERACT II, and commentaries on MERS-CoV and shared decision making.

Amongst the clinical review articles are papers on subarachnoid haemorrhage, sugammadex, natriuretic peptides, oxygen use, Boerhaave's Syndrome, acute kidney injury, septic shock, candidia, antimicrobial stewardship, noninvasive haemoglobin measurement, and a series of papers on trauma.    

Following on from last week review of metabolic acidosis, the topic for This Week's Papers is causes of metabolic acidosis, starting with a paper on alcoholic ketoacidosis  in tomorrow's Paper of the Day.

Registration should open this week for the 2nd Critical Care Reviews Meeting, being held outside Belfast on January 24th 2014. The SMACC GOLD Conference, being held at the Gold Coast, Queensland, Australia, next March is currently open for registration.




Interventional Trials

The Lancet:     Operative Abdominal Wound Closure

In a phase 3, multicentre, open-label, randomised controlled trial, Tsujinnaka and colleagues compared subcuticular sutures with staples for skin closure in 1080 patients with adequate organ function undergoing elective open upper or lower gastrointestinal surgery, and found:

  1. 558 patients received subcuticular sutures
    1. 382 underwent upper gastrointestinal surgery 
    2. 176 underwent lower gastrointestinal surgery
    3. wound complications occurred in 47 of 558 patients (8·4%, 95% CI 6·3—11·0)
  2. 514 received staples
    1. 413 underwent upper gastrointestinal surgery 
    2. 101 underwent lower gastrointestinal surgery
    3. wound complications occurred in 59 of 514 (11·5%, 95% CI 8·9—14·6)
  3. The rate of wound complications did not differ significantly between the subcuticular sutures and staples groups (odds ratio 0·709, 95% CI 0·474—1·062; p=0·12)

Abstract:  Tsujinaka. Subcuticular sutures versus staples for skin closure after open gastrointestinal surgery: a phase 3, multicentre, open-label, randomised controlled trial. Lancet 2013;382(9898):1105-1112


Respirology:     Adaptive Support Ventilation

Agarwal and colleagues undertook a pilot, randomized trial comparing adaptive supprt ventilation (ASV, n=23) with volume-cycled ventilation (VCV, n=25) in 48 patients with ARDS, and found:

  1. there was no difference in
    1. duration of mechanical ventilation
    2. delta sequential organ failure assessment scores
    3. duration of intensive care unit stay or hospital stay
    4. mortality (ASV-34.7% versus VCV-36%)

Abstract:  Agarwal. Adaptive support ventilation for complete ventilatory support in acute respiratory distress syndrome: A pilot, randomized controlled trial. Respirology 2013;18:1108–1115 


Meta Analysis

Critical Care:     Pneumothorax

Alrajab and colleagues pooled data from 13 studies, including 3028 hemithoraces from 1514 patients, comparing ultrasound with radiography for the diagnosis of pneumothorax, and found:

  1. ultrasonography had a
    1. sensitivity: 78.6% (95% CI 68.1-98.1)
    2. specificity: 98.4% (95% CI 97.3-99.5)
    3. diagnostic odds ratio: 279.31 (95% CI 106.29-733.94)
    4. area under the curve: 0.98 (SE 0.0065)
  2. chest radiography had a
    1. sensitivity: 39.8% (95% CI 29.4-50.3) and a
    2. specificity: 99.3% (95% CI 98.4-100)
    3. diagnostic odds ratio: 87.19 (95% CI 33.44-229.34)
    4. area under the curve 0.959 (SE 0.014)
  3. there was significant heterogenetity in sampling, operator and type of ultrasound probe used

Full Text:  Alrajab. Pleural ultrasonography versus chest radiography for the diagnosis of pneumothorax: review of the literature and meta-analysis. Critical Care 2013;17:R208


Critical Care Medicine:     ICU Staffing

Wilcox and colleagues examined 52 studies comparing high-intensity staffing (i.e. transfer of care to an intensivist-led team or mandatory consultation of an intensivist) with low-intensity staffing on clinical outcomes for critically ill patients and found:

  1. high-intensity staffing was associated with reduced
    • hospital mortality (risk ratio, 0.83; 95% CI, 0.70–0.99) 
    • ICU mortality (pooled risk ratio 0.81; 95% CI, 0.68–0.96)
    • hospital length of stay (–0.17 days, 95% CI –0.31 to –0.03 days)
    • ICU length of stay ( –0.38 days, 95% CI –0.55 to –0.20 days)
  2. within high-intensity staffing models, 24-hour in-hospital intensivist coverage, compared to daytime only coverage, did not improve
    • ICU mortality (risk ratio 0.88; 95% CI 0.70–1.1)
    • hospital mortality (risk ratio 0.97; 95% CI 0.89–1.1)
  3. the effect on hospital mortality varied throughout different decades; pooled risk ratios were
    • 1980 to 1989:  0.74 (95% CI, 0.63–0.87) 
    • 1990 to 1999:  0.96 (95% CI, 0.69–1.3) 
    • 2000 to 2009:  0.70 (95% CI, 0.54–0.90)  
    • 2010 to 2012:  1.2 (95% CI, 0.84–1.8)

Abstract:  Wilcox. Do Intensivist Staffing Patterns Influence Hospital Mortality Following ICU Admission? A Systematic Review and Meta-Analyses. Crit Care Med 2013;41(10):2253-2274

Emergency Medicine Journal:     Critical Care Paramedics

Von Vopelius-Feldt and colleagues performed a systematic review evaluating the evidence for prehospital critical care paramedics, and, from 11 retrospective and 1 prospective, randomised controlled trial, found:

  1. compared with critical care paramedics, physician-led care:
    • was associated with improved outcomes (3 studies), no difference in outcomes (2 studies)
  2. compared with non-physician-led care, critical care paramedic care:
    • was associated with improved outcomes (two studies), mixed effects (one study) and no difference (one study)
  3. for the addition of skills to critical care paramedic competencies:
    • rapid sequence intubation was associated with improved neurologic outcomes (prospective RCT)
    • tube thoracostomy had a similar complication rate whether performed prehospital or in the emergency department
    • a non-invasive ventilation protocol had no effect on long-term mortality

Observational Studies

Journal of the American Medical Association:     Subarachnoid Haemorrhage

Perry and colleagues performed a multicentre cohort study in 2,131 adults with a headache peaking within 1 hour and without neurologic deficits, aiming to produce a simple decision rule for the prediction of SAH, and found:

  1. 132 (6.2%) had subarachnoid hemorrhage
  2. factors most predictive of SAH were
    • age of 40 years or older
    • neck pain or stiffness
    • witnessed loss of consciousness
    • onset of headache during exertion
    • thunderclap headache
    • limited neck flexion
  3. using these variable, the Ottowa SAH rule predictied subarachnoid hemorrhage with a
    • sensitivity 100% (95% CI, 97.2%-100.0%)
    • specificity 15.3% (95% CI, 13.8%-16.9%)
  4. this rule requires further evaluation before introduction into routine practice

Abstract:  Perry. Clinical Decision Rules to Rule Out Subarachnoid Hemorrhage for Acute Headache. JAMA 2013;310(12):1248-1255


PLoS One:     Community-Acquired Pneumonia

Hraiech and colleagues performed a retrospective review of prospectively collected data on 100 patients with community-acquired pneumonia, comparing 47 patients with rapid respiratory failure treated with mechanical ventilation within 72 h of the onset of CAP with 53 patients with progressive respiratory failure requiring invasive mechanical ventilation 4 or more days after the onset of CAP, and found:

  1. progressive respiratory failure with later initiation of mechanical ventilation was associated with:
    • increased in-hospital mortality (51% versus 28%, P = 0.03)
    • increased ICU mortality (47% versus 23%, P = 0.02)
    • increased day 30 mortality (37.7% versus 21.3%, P = 0.03)
  2. after adjusting for propensity score and other confounding factors, progressive respiratory failure remained associated with hospital mortality only after 12 days of invasive mechanical ventilation

Full Text:  Hraiech. Time to intubation is associated with outcome in patients with community-acquired pneumonia. PLoS One 2013;8(9):e74937




Indian Journal of Medical Microbiology:     Biomedical Communication


Study Critique

Critical Care:     Upper GI Haemorrhage


Stroke:     INTERACT 2



PLoS Pathogens:     MERS-CoV


Journal of the American Medical Association:     Shared Decision Making


Review - Clinical


Interventional Neurology:     Subarachnoid Haemorrhage


Core Evidence:     Sugammadex     


Brain Sciences:     Neurological Repair 



PVRI Review:     Pulmonary Hypertension


Respiratory Care:     Evidence-Based Medicine



Scandanavian Journal of Surgery:     Boerhaave's Syndrome      


Therapeutic Advances in Chronic Disease:     Bacterial Overgrowth Syndrome


Gastroenterology Research and Practice:     NSAID-Induced Enteropathy  



Arab Journal of Nephrology and Transplantation:     Acute Kidney Injury



Thrombosis & Hemostasis:     Antithrombotic Therapy in Obesity



Boletín Médico del Hospital Infantil de México:     Septic Shock


Laboratory Investigations:     Septic Shock   


Virulence:     Septic Shock


Toxins:     Staphlococcal Superantigens


Indian Journal of Medical Microbiology:     Gut Translocation


Respirology:     Tuberculosis


PLoS Pathogens:     Candida


Antibiotics:     Antimicrobial Stewardship


Antibiotics:     Designing Antibiotics



Journal of Orthopaedics, Traumatology and Rehabilitation:     Trauma


Emergency Medicine International:     Noninvasive Haemoglobin Measurement


Emergency Medicine International:     Trauma Sonography   



Frontiers in Immunology:     Stem Cell Therapy


I hope you find these brief summaries and links useful.

Until next week