Newsletter 115 / February 16th 2014




Welcome to the 115th 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 over 300 clinical and scientific journals.

This week's highlighted research studies include randomized controlled trials on haemofiltration for severe acute pancreatitis, low dose heparin for DIC and a 4 year followup of the RENAL study; meta analyses on steroids for cardiac surgery and ultrafiltration in decompensated heart failure; while one observational study focuses on emergency GI surgery outcomes.

This month's Cochrane reviews include new articles on fibreoptic intubation, inotropes, chest radiography in lower respiratory tract infections andplasma transfusion, while updated articles look at post stroke seizure prophylaxis, beta lactam therapy, ICU acquired weakness and non-invasive ventilation for weaning. This week's guidelines address acute pancreatitis and parenteral nutrition, while a single study critique focuses on the recent Mourville trial investigating induced hypothermia in severe bacterial meningitis. Editorials address on systolic anterior motion of the mitral valve, weekend staffing and blood purification membranes; commentaries discuss heart failure in 2013, HIV cure, meta analysis and organ donation.

Amongst the clinical review articles are papers on spinal cord repair, levosimendan, emergency chest ultrasound, autoimmune hepatitis, contrast-induced nephropathy, reversal agents for the novel oral anticoagulants, fungal infections in the ICU, snake bite, anaphylaxis plus an entire supplement on tedizolid. Two non-clinical reviews consider social media in medicine and medical philanthropy.

If you only have time to read one article this week, check out the basic science review article published in Nature on the use, and missue, of p values.

As SMACCgold is now just a month away, in preparation for the Evidence-Based Medicine Workshop I'll be helping run with Prof Simon Carley and Dr Rick Body, two emergency physicians from Manchester, UK, this is the topic forThis Week's Papers, starting with a general paper in tomorrow's Paper of the Day. Simon and Rick have been busy, and have posted pre-course material on their excellent St. Emlyns blog. Check out Simon and Rick's other website, BestBETs, to learn how to perform a pragmatic appraisal of the evidence to answer a specific clinical question. The workshop will be a superb educational opportunity, and with the two Manchester clinicians bringing a huge amount of EBM experience, I'll be learning as much as I'm teaching. If you're lucky enough to be coming to SMACCgold, sign up for the workshop - you might just leave the day with a publication.....

If reading is just too much trouble this week, sit back and watch the first 7 presentations from last months Critical Care Reviews Meeting, available now online. The next 7 will hopefully be posted on Tuesday.

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Randomized Controlled Trials

Guo and colleagues completed a single-center prospective trial comparing short-term continuous high-volume hemofiltration (n=32) with standard therapy (n=29) in 61 patients with predicted severe acute pancreatitis (APACHE II >15), and found:

  1. high-volume hemofiltration treatment was associated with reductions in the
    • incidence of
      • renal failure (p = 0.013)
      • infected pancreatic necrosis (p = 0.048)
    • length of hospitalization (p = 0.005)
    • mortality (p = 0.033)
    • duration of
      • renal (p < 0.001)
      • respiratory (p = 0.002)
      • hepatic failure (P = 0.001)
    • APACHE II score on days 1, 3, and 7 (p < 0.05)
    • C-reactive protein on days 1, 3, and 7 (p < 0.05)
    • interleukin 6 levels on days 1, 3, and 7(p < 0.05)

Liu and colleagues undertook a randomized, double‑blind, placebo controlled single‑center trial, evaluating low‑dose heparin infusion (70 U/kg/24h) in 37 patients with sepsis-related early disseminated intravascular coagulation, and found:

  1. heparin therapy was associated with
    • greater reduction in APACHE II scores
    • reductions in
      • prothrombin fragment levels
      • thrombin‑antithrombin complex levels
    • decreased duration of
      • ventilation  
        • 7.00 ± 5.74  vs 11.73 ± 8.34 days;  (p=0.048)
      • ICU stay   
          9.00 ± 5.35 vs 14.20 ± 7.31 days; (p=0.017)
    • fewer complications
      • multiple organ dysfunction incidence 
        • 8 (36.4%) vs 11 (73.3%);  (p=0.030)
      • DIC incidence 
        • 2 (9.1%) vs 6 (40.0%);  (p=0.034)
    • no difference in the 28‑day mortality rate   
      • 7 (31.8%)  vs  6 (40%);  (p=0.434)

Gallagher and colleagues undertook a 4 year followup of the RENAL study, a randomised controlled trial comparing continuous venovenous hemodiafiltration with an effluent flow of 40 ml per kilogram of body weight per hour (higher intensity, n=721 with data available) with 25 ml per kilogram per hour (lower intensity, n=743 with data available) in 1,508 patients with acute kidney injury, and found:

  1. baseline data
    • further analysis was available for 1,464 (97%) patients
    • median follow up 43.9 months (IQR 30.0 – 48.6 months)
  2. there was no difference in
    • mortality
      • lower intensity: 468/743 (63%)
      • higher intensity: 444/721 (62%)
      • risk ratio 1.04, 95% CI 0.96 to 1.12; p = 0.49
    • requirement for ongoing dialysis amongst survivors to day 90
      • lower intensity: 21/411 (5.1%)
      • higher intensity: 23/399 (5.8%)
      • risk ratio 1.12, 95% CI 0.63 to 2.00; p = 0.69
    • prevalence of albuminuria among survivors
      • lower intensity: 40% 
      • higher intensity: 44%
      • p = 0.48
    • quality of life

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Meta Analysis

Liu et al pooled data from 42 randomized controlled trials (n=7,621) evaluating the use of glucocorticoid therapy in cardiac surgery, and found:

  1. glucocorticoid prophylaxis was
    • associated with reduced
      • risk of perioperative atrial fibrillation
        • RR 0.77; 95% CI 0.66 to 0.90; P<0.01
      • length of ICU stay
        • RR 0.25; 95% CI -0.40 to -0.10; P<0.01
    • not associated with increased
      • infection
        • RR 0.68, 95% CI 0.58 to 0.78; P<0.01
      • mortality
        • RR 0.75, 95% CI 0.52 to 1.08; P=0.12

Kwong et al reviewed 12 studies (n=659) examining ultrafiltration in acute decompensated heart failure, and found, compared with control:
  1. ultrafiltration was associated with:
    • increased
      • fluid removal
        • mean difference 1.28 L, 95% CI 0.43 to 2.12, P=0.003
      • weight loss
        • mean difference 1.23 L, 95% CI 0.03 to 2.44, P=0.04
    • no difference
      • all-cause mortality
        • OR 1.08, 95% CI 0.63 to 1.86, P=0.77
      • all-cause rehospitalization
        • OR 0.89, 95% CI 0.39 to 2.00, P=0.77
      • serum creatinine 
      • unscheduled medical care
  2. there was insufficient data on adverse effects

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Observational Studies

Vester-Andersen and colleagues performed a population-based cohort study in 2,904 Danish patients undergoing emergency major GI laparotomy or laparoscopy surgery, and found:

  1. 30 day mortality was 18.5% (95% CI 17.1 to 19.9)
  2. 84.2% of patients were treated postoperatively in the standard ward
    • 30 day mortality 14.3%,
    • 4.8% were subsequently admitted to ICU
    • after a median stay of 2 days (IQR 1–6)
  3. compared with admission to standard ward
    • 30 day mortality:
      • admission to standard ward before ICU admission:
        • odds ratio 5.45 (95% CI: 3.48 to 8.56)
      • ICU admission after surgery
        • odds ratio 3.27 (95% CI: 2.45 to 4.36)

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Other Studies of Interest

Randomized Controlled Trial

Meta Analysis

Observational Studies

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Cochrane Reviews



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Guidelines & Position Papers

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Study Critique

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Case Report

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Clinical Reviews








Clinical Infectious Disease Supplement