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Newsletter 96 / October 6th 2013




Welcome to the 96th 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 a big week for Critical Care Reviews, with the opening of registration for the 2014 Meeting. In keeping with this, the newsletter contains a massive 86 free, full text articles, some new studies of importance, and a warning from the FDA regarding tigecycline.

After a couple of quiet weeks, there has been some major research publications in the past seven days, including a large interventional infection control study, an investigation into medium term cognitive outcomes post critical illness and temporal improvements in out-of-hospital cardiac arrest outcomes in a large Danish database study. Other studies include meta analyses addressing ruptured abdominal aortic aneurysm repair and mono- or dual-antiplatelet therapy for both CABG and stroke, as well as observational studies examining fresh frozen plasma post for bleeding post cardiac surgery, enteral feeding during haemodynamic failure, and ICU discharge outcomes. If you drink coffee, especially lots of it, you might be disappointed to read the latest paper on coffee consumption.

This week's guidelines focus on perioperative transoesophageal echo and platelet function testing for percutaneous coronary intervention. There are interesting commentaries on organ donation, influenza, teaching ethics and stellate ganglion block for cardiac surgery. Case reports are rarely highlighted, and the topic isn't new, but this report of a brain-dead preganant woman being supported until fetal maturation raises many ethical points.

Amongst the clinical review articles are papers on levobupivicaine, vasopressor dependent shock, ventilator-associated pneumonia, ventilator-associated lung injury, gastric variceal haemorrhage, cirrhosis, renal replacement therapy, contrast-induced nephropathy, fluid resuscitation in septic shock, aerosolised antibacterials, anaesthetic management of peritonitis, swine trauma models and ultrasound in critical care.

The latest articles recenty made open access from the major critical care journals are included and include papers from Anaesthesiology, Anesthesia & Analgesia, Critical Care, Chest, British Journal of Anaesthesia, Anaesthesia and Continuing Education in Anaesthesia, Critical Care and Pain.

The topic for This Week's Papers is minimally invasive cardiac output monitors, starting with a paper on the technology behind the Nexfin device in tomorrow's Paper of the Day.


There are three meetings coming up that might be of interest to you:

Critical Care Reviews Meeting January 24th, 2014 - Belfast, Northern Ireland

  • If you are in Ireland or Great Britain (or a short flight away), Critical Care Reviews will be hosting it's second meeting outside Belfast, Northern Ireland. It's an all-day event with a fantastic programme consisting of local intensivists, local non-critical care specialists, and outstanding international guest speakers. The programme has been finalised and registration is now open.

Intensive Care Society State-of-the-Art Meeting, December  16th - 18th, London

  • The ICS will be holding their annual State-of-the-Art meeting in London this December. It's the largest meeting of its kind in the UK and attracts a host of big names from the world of critical care.

SMACC GOLD March 19-21st, 2014 Gold Coast, Queensland, Australia

  • This major international conference, also in it's second year, is a must for those active in the online critical care community. Webmasters of the most prominent critical care websites and blogs will descend on the beautiful Gold Coast for an amazing get together of like-minded people in a totally different style of conference. Registration is currently open.



Food and Drug Administration:     Tigecycline

The American FDA have issued a recommendation that tigecycline should be reserved for use only when alternative therapies are not available. A new Boxed Warning describes an increased risk of death with tigecycline use following new data showing a higher risk of death among patients receiving tigecycline compared to other antibacterial drugs: 2.5% (66/2640) vs. 1.8% (48/2628), respectively. The adjusted risk difference for death was 0.6% (95% CI 0.0% - 1.2%). In general, the deaths resulted from worsening infections, complications of infection, or other underlying medical conditions. Presently, tigecycline is licensed to treat complicated skin and skin structure infections, complicated intra-abdominal infections, and community-acquired bacterial pneumonia.



Randomized Controlled Trials

Journal of the American Medical Association:     ICU Infections

Harris and colleagues performed a multi-centre cluster-randomized trial in 20 American ICUs (26,180 patients, 92,241 swabs) comparing the intervention of wearing of gloves and gown for all patient contact and when entering any patient room with the control of following current Centers for Disease Control and Prevention guidelines for infection control measures, and found:

  1. for the primary outcome
    • no difference in the rates of acquisition of MRSA or VRE (difference −1.71 acquisitions per 1000 person-days, 95% CI −6.15 to 2.73; P = 0.57)
    • intervention ICUs had a decrease in the primary outcome of MRSA or VRE from 21.35 acquisitions per 1000 patient-days (95% CI 17.57 to 25.94) in the baseline period to 16.91 acquisitions per 1000 patient-days (95% CI, 14.09 to 20.28) in the study period
    • control ICUs had a decrease in MRSA or VRE from 19.02 acquisitions per 1000 patient-days (95% CI 14.20 to 25.49) in the baseline period to 16.29 acquisitions per 1000 patient-days (95% CI 13.48 to 19.68) in the study period
  2. for secondary outcomes
    • no difference in VRE acquisition with the intervention (difference  0.89 acquisitions per 1000 person-days; 95% CI −4.27 to 6.04, P =0 .70)
    • for MRSA, there were fewer acquisitions with the intervention (difference −2.98 acquisitions per 1000 person-days; 95% CI −5.58 to −0.38; P = 0.046)
    • universal glove and gown use decreased health care worker room entry (4.28 vs 5.24 entries per hour, difference −0.96; 95% CI −1.71 to −0.21, P = 0.02)
    • increased room-exit hand hygiene compliance (78.3% vs 62.9%, difference 15.4%; 95% CI 8.99% to 21.8%; P  = 0.02) 
    • no difference in adverse events (58.7 events per 1000 patient days vs 74.4 events per 1000 patient days; difference −15.7; 95% CI −40.7 to 9.2, P = 0.24)

Full Text:  Harris. Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU: A Randomized Trial. JAMA 2013;epublished October 4th    


Meta Analysis

Journal of Vascular Surgery:     Emergency Abdominal Aortic Repair

Antoniou and colleagues pooled data from 41 studies (n=59,941; EVAR n=8,201, open repair n=51,740) comparing endovascular repair with open repair for ruptured abdominal aortic aneurysm, and found EVAR was associated with:

  1. decreased
    • in-hospital mortality (OR 0.56; 95% CI 0.50-0.64; P < 0.01) 
    • respiratory complications (OR 0.59; 95% CI 0.49-0.69; P < 0.01) 
    • acute renal failure (OR 0.65; 95% CI 0.55-0.78; P < 0.01)
    • intraoperative blood transfusion (standardized mean difference −0.88; 95% CI −1.06 to −0.70; P < 0.01)
  2. a trend toward a reduced
    • cardiac complications (OR −0.02; 95% CI −0.03 to 0.00; P = 0.05)
    • mesenteric ischemia (OR 0.66; 95% CI 0.44-1.00; P = 0.05)

Abstract:  Antoniou. Endovascular repair for ruptured abdominal aortic aneurysm confers an early survival benefit over open repair. J Vasc Surg. 2013 Oct;58(4):1091-105


American Journal of Cardiology:     Antiplatelet Therapy for CABG

Using a fixed-effects model, Nocerino and colleagues reviewed data from 5 randomized controlled trials, (n=958, 2,919 grafts with treatment up to 1 year) assessing single versus dual antiplatelet therapy after coronary artery bypass grafting, and found:

  1. early occlusion
    • occurred in 165 (6.5%) of 2,526 bypass grafts
    • was more common with single-agent therapy (7.7% versus 5.0%; p = 0.005; odds ratio 1.59, 95% CI 1.16 to 2.17)
  2.  single-agent therapy was associated with increased loss of venous grafts (10.8% versus 6.6%; odds ratio 1.70, 95% CI 1.20 to 2.40, p = 0.003)
  3. there was no effect on arterial grafts
  4. bleeding was noted in 3.3% and 4.9% of single and dual therapy treated patients (3 studies)

Abstract:  Nocerino. Meta-Analysis of Effect of Single Versus Dual Antiplatelet Therapy on Early Patency of Bypass Conduits After Coronary Artery Bypass Grafting


Annals of Internal Medicine:     Antiplatelet Therapy for Ischaemic Stroke

Using data from 7 randomized controlled trials (n=39,574), Lee and colleagues compared the risk for recurrent stroke and intracranial hemorrhage between long-term single- or dual-antiplatelet therapy in patients with ischemic stroke or transient ischemic attack, and found:

  1. no difference in
    • risk of recurrent stroke
      • dual-antiplatelet therapy versus aspirin monotherapy (RR 0.89, 95% CI 0.78 - 1.01)
      • dual-antiplatelet therapy versus clopidogrel monotherapy (RR 1.01, 95% CI 0.93 - 1.08
    • risk of intracranial haemorrhage
      • dual-antiplatelet therapy versus aspirin monotherapy (RR 0.99, CI 0.70 - 1.42)
  2. the risk of intracranial haemorrhage was greater with dual-antiplatelet therapy compared with clopidogrel monotherapy (RR 1.46, CI 1.17 - 1.82)

Abstract:  Lee. Risk–Benefit Profile of Long-Term Dual- Versus Single-Antiplatelet Therapy Among Patients With Ischemic Stroke: A Systematic Review and Meta-analysis. Ann Intern Med 2013;159(7):46


Observational Studies

New England Journal of Medicine:     Long-Term Cognitive Impairment after Critical Illness

Pandharipande and colleagues observed 821 critically ill adults with respiratory failure or shock to examine the effects of critical illness on cognitive function, and found:

  1. cognitive impairment was present in 6% at baseline
  2. delirium developed in 74% during the hospital stay
  3. at 3 months
    • 40% had global cognition scores 1.5 SD below population means (similar to patients with moderate traumatic brain injury)
    • 26% had scores 2 SD below population means (similar to patients with mild Alzheimer's disease)
  4. at 12 months
    • deficits persisted in both older and younger patients 
    • 34% of all assessed patients had scores similar to patients with moderate traumatic brain injury
    • 24% of all assessed patients had scores similar to patients with mild Alzheimer's disease
  5. a longer duration of delirium was independently associated with worse
    • global cognition at 3 (p=0.001) and 12 months (P=0.04)
    • executive function at 3 (P=0.004) and 12 months (P=0.007) 
  6. sedative or analgesic medications was not consistently associated with cognitive impairment at 3 and 12 months

Abstract:  Pandharipande. Long-Term Cognitive Impairment after Critical Illness. N Engl J Med 2013;369:1306-1316


Journal of the American Medical Association:     Out-of-Hospital Cardiac Arrest

Wissenberg and colleagues examined the Danish Cardiac Arrest Registry from 2001 to 2010, comprising 19,468 patients with out-of-hospital cardiac arrest of presumed cardiac origin and not witnessed by emergency medical services, and found:

  1. from 2001 to 2010, use of prehospital therapeutic interventions increased
    • bystander CPR: 21.1% (95% CI 18.8%-23.4%) to 44.9% (95% CI 42.6% - 47.1%) (P < 0.001) 
    • bystander defibrillation: 1.1% (95% CI 0.6%-1.9%) to 2.2% (95% CI 1.5% - 2.9%) (P = 0.003)
  2. from 2001 to 2010, clinical outcomes improved
    • survival on hospital arrival: 7.9% (95% CI 6.4%-9.5%) to 21.8% (95% CI 19.8% - 23.8%)  (P < 0.001)
    • 30-day survival: 3.5% (95% CI 2.5% - 4.5%) to 10.8% (95% CI 9.4% - 12.2%) (P <0 .001)
    • 1-year survival: 2.9% (95% CI 2.0% - 3.9%) to 10.2% (95% CI 8.9% - 11.6%) (P <0.001)
    • increased number of survivors per 100 000 persons (P <0 .001)
  3. There was a decreased incidence of out-of-hospital cardiac arrests during the study period (40.4 to 34.4 per 100 000 persons, P = 0.002)
  4. For the entire study period, bystander CPR was positively associated with 30-day survival, regardless of whether the arrest was witnessed or not

Abstract:  Wissenberg. Association of National Initiatives to Improve Cardiac Arrest Management With Rates of Bystander Intervention and Patient Survival After Out-of-Hospital Cardiac Arrest. JAMA 2013;310(13):1377 


Transfusion:     Fresh Frozen Plasma

In a multi-centre French study, Doussau and colleagues investigated the effects of fresh-frozen plasma therapy in 967 patients who underwent on-pump cardiac surgery and experienced excessive bleeding in the 48-hour perioperative period, and found:

  1. 58.1% received FFP
  2. median dose was 11.3 mL/kg (IQR 7.6 - 19.5)
  3. cumulative 30-day mortality rate was 11.3% (95% CI 9.5 - 13.5)
  4. in univariate analysis, FFP was associated with a higher 30-day mortality (HR 3.2; 95% CI 1.7 - 6.1)
  5. after adjusting for prognostic factors, FFP was not associated with 30-day mortality (HR 1.5; 95% CI 0.8 - 3.0, p = 0.20).
  6. a propensity score sensitivity analysis was consistent with the adjusted analysis

Abstract:  Doussau. Fresh-frozen plasma transfusion did not reduce 30-day mortality in patients undergoing cardiopulmonary bypass cardiac surgery with excessive bleeding: the PLASMACARD multicenter cohort study. Transfusion 2013;epublished September 30th 


Journal of Parenteral and Enteral Nutrition:     Enternal Nutrition during Haemodynamic Failure

Lasierra and colleagues examined the provision of enteral nutrition in patients with haemodynamic failure after cardiac surgery and found:

  1. 37/642 patients (5.8%) met the inclusion criteria
    • 11 (29.7%) required mechanical circulatory support
    • 25 (68.0%) met the criteria for early multiorgan dysfunction
    • mortality was 13.5%
  2. Regarding enteral nutrition
    • mean duration was 12.3 days (95% CI 9.6–15.0)
    • mean diet volume delivered per patient per day was 1199 mL (95% CI 1118.7–1278.8)
    • mean energy delivered per patient per day was 1228.4 kcal (95% CI 1145.8–1311)
    • set energy target was achieved in 15 patients (40.4%)
    • most common EN-related complication was constipation
    • no case of mesenteric ischemia was detected

Abstract:  Lasierra. Early Enteral Nutrition in Patients With Hemodynamic Failure Following Cardiac Surgery. J Parenter Enteral Nutr 2013;epublished October 4th


Other studies of interest

Circulation:     Dabigatran

Abstract:  Majeed. Management and Outcomes of Major Bleeding during Treatment with Dabigatran or Warfarin. Circulation 2013;epublished September 30th


Kidney International:     Acute Kidney Injury

Full Text:  Siew. Distinct injury markers for the early detection and prognosis of incident acute kidney injury in critically ill adults with preserved kidney function. Kidney Int 2013;84:786-794  


Annals of Internal Medicine:     ICU Discharge

Abstract:  Wagner. Outcomes Among Patients Discharged From Busy Intensive Care Units. Ann Intern Med 2013;159(7):447 


European Heart Journal:     Reperfusion Procedure Outcomes by Training Status

Full Text:  Jones. Clinical outcomes after myocardial revascularization according to operator training status: cohort study of 22 697 patients undergoing percutaneous coronary intervention or coronary artery bypass graft surgery. Eur Heart J 2013;4(37):2887-2895 


International Journal of Critical Illness & Injury Science:     Fluid Resuscitation and Acid-Base Status

Full Text:  Ahmed. Evaluation of the efficacy of simplified Fencl-Stewart equation in analyzing the changes in acid base status following resuscitation with two different fluids. Int J Crit Illn Inj Sci 2013;3:206-10


Mayo Clinic Proceedings:     Coffee Consumption

Abstract:  Liu. Association of Coffee Consumption With All-Cause and Cardiovascular Disease Mortality. Mayo Clinic Proceedings 2013;88(10):1066-1074


Guidelines & Position Statements


New England Journal of Medicine:     Dead-Donor Rule


Journal of the American Medical Association:     Influenza

Journal of Vascular Surgery:     Ethics of Teaching


Annals of Cardiac Anaesthesia:     Stellate Ganglion Block


Case Report

International Journal of Critical Illness & Injury Science:     Brain-Dead Pregnant Woman


Review - Clinical
















Recently Made Open Access Articles from Major Journals

American Journal of Respiratory and Critical Care Medicine






Critical Care





Anesthesia & Analgesia


British Journal of Anaesthesia






Continuing Education in Anaesthesia, Critical care and Pain



Review - Basic Science

Australian Prescriber:     Equivalence and Non-Inferiority Trials



I hope you find these brief summaries and links useful.

Until next week