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Critical Care Reviews Newsletter

January 28th 2013



Welcome to the 60th 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. Critical Care Reviews continues to grow and last week hosted it's first meeting, with some of the best Intensivists from across Northern Ireland discussing the biggest studies from 2012. Many thanks to all involved.

This week's research studies include the long awaited high frequency oscillation studies from Canada and the UK. The results were disappointing, with OSCILLATE being prematurely stopped for excess mortality and OSCAR showing no benefit from HFOV. Disappointingly, a randomized controlled trial from ANZICS failed to demonstrate any benefit from statins in sepsis. In a randomized controlled trial in prolonged ventilation patients transferred to a long-term acute care hospital, unsuppported ventilation through a tracheostomy was associated with a quicker time to liberation from mechanical ventilation than pressure support ventilation.

There were several guidelines published in the past week, including the long awaited update to the Surviving Sepsis Campaign Guidelines. The American Society of Anesthesiology has published guidelines on difficult airways, postanaesthetic management and theatre fires. The Canadian Cardiovascular Society have published guidelines on the management of acute and chronic heart failure, and the American Association for Respiratory Care has published guidance on the use of transcutaneous gas monitoring.

Amongst the clinical review articles are papers on awareness, haemodynamic monitoring, circulatory assist devices, pleural effusions, two sets of review articles on oxygen therapy and liberation from mechanical ventilation, hyponatraemia, sepsis biomarkers and end-of-life care. The field of metabolomics is discussed in a basic science paper.

The topic for This Week's Papers is embolic conditions, starting with a paper on venous gas embolism in today's Paper of the Day.



New England Journal of Medicine:     High Frequency Oscillation

Ferguson and colleagues completed an international multicenter, randomized, controlled trial in adults with new-onset, moderate-to-severe ARDS comparing high flow oscillatory ventilation (HFOV, n=275) with conventional mechanical ventilation (n=273) using low tidal volumes and high positive end-expiratory pressure. The trial was terminated on the advice of the data monitoring committee after 548 of a planned 1200 patients had undergone randomization, due to excess mortality with HFOV (HFOV 47%, n=129 versus control: 35%, n=96; relative risk of death with HFOV, 1.33; 95% CI 1.09 to 1.64; P=0.005). Compared with the control group, patients in the HFOV group received higher doses of midazolam (199 mg per day [IQR 100 to 382] vs. 141 mg per day [IQR 68 to 240], P<0.001), as well as more patients receiving neuromuscular blockers (83% vs. 68%, P<0.001), and vasoactive drugs (91% vs. 84%, P=0.01) and received them for a longer period (5 days vs. 3 days, P=0.01) than did patients in the control group. Conclusion:  High frequency oscilatory ventilation was associated with increased mortality in comparison with conventional mechanical ventilation in adult patients with new-onset moderate-to-severe ARDS.

Full Text:  Ferguson. High-Frequency Oscillation in Early Acute Respiratory Distress Syndrome (OSCILLATE). New Engl J Med 2013;epublished January 22rd


Young et al performed a multicenter study, comparing HFOV (n=398) with conventional mechanical ventilation (n=397) in adults with moderate-to-severe ARDS. There was no  difference in mortality between modes of ventilation (HFOV 41.7%, n=166 versus CMV 41.1%, n=163; P=0.85). Similarly, there were no differences in the duration of antimicrobial agents (HFOV 12.8±12.0 days  vs CMV 12.4±10.3 days, P=0.56); duration of inotropic agents or pressor infusions (HFOV 2.9±4.5 days vs CMV 2.8±5.6 days; P=0.74); duration of ICU stay (HFOV 17.6±16.6 days vs CMV 16.1±15.2 days; P=0.18) or in durations of hospital stay ( HFOV 33.9±41.6 days vs 33.1±44.3 days; P=0.79). Conclusion: High frequency oscillatory ventilation was not superior to conventional mechanical ventilation for the management of moderate-to-severe ARDS.

Full Text:  Young. High-Frequency Oscillation for Acute Respiratory Distress Syndrome (OSCAR). New Engl J Med 2013;epublished January 22nd

Editorial: Malhotra. High-Frequency Oscillatory Ventilation on Shaky Ground. New Eng J Med 2013;epublished ahead of print


Journal of the American Medical Association:     Weaning in Prolonged Ventilation

Jurban et al performed a randomized study comparing weaning duration with pressure support (n = 155) vs unassisted breathing through a tracheostomy (n = 161) in patients transferred to a single long-term acute care hospital for weaning from prolonged ventilation. Of 152 patients in the pressure-support group, 68 (44.7%) were weaned and 22 (14.5%) died. Of 160 patients in the unassisted breathing group, 85 (53.1%) were weaned and 16 (10.0%) died. Median weaning time was shorter with tracheostomy collar use (15 days; IQR 8-25) than with pressure support (19 days; IQR 12-31), P = .004. The hazard ratio for successful weaning rate was higher with unassisted breathing than with pressure support (HR, 1.43; 95% CI, 1.03-1.98; P = 0.033) after adjusting for baseline clinical covariates. Mortality was equivalent in the pressure-support and unassisted breathing groups at 6 months (55.92% vs 51.25%; 4.67% difference, 95% CI −6.4% to 15.7%) and at 12 months (66.45% vs 60.00%; 6.45% difference, 95% CI −4.2% to 17.1%). Conclusion: In a long-term acute care hospital, weaning from prolonged mechanical ventilation was quicker with unassisted breathing through a tracheostomy than with pressure support; although there was no difference on medium term mortality.

Full Text: Jubran. Effect of Pressure Support vs Unassisted Breathing Through a Tracheostomy Collar on Weaning Duration in Patients Requiring Prolonged Mechanical Ventilation: A Randomized Trial. JAMA 2013;epublished January 22nd


American Journal of Respiratory and Critical Care Medicine:      Difficult Intubation

De Jong et al performed a prospective multicenter-study in 1000 consecutive intubation from 42 ICUs to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubations from 18 other ICUs and internally by bootstrap on 1000 iterations. In the inception cohort, the main predictors of difficult intubation were Mallampati score III or IV, obstructive apnea syndrome, reduced cervical spine mobility, limited mouth opening, severe hypoxia, coma  and a non-anesthesiologist intubator; this 7-item simplified score (MACOCHA-score) predicted difficult intubation (prevalence 11.3%) with an area under the curve (AUC) of 0.89 (95% CI: 0.85-0.94). In the validation cohort (prevalence of difficult intubation 8%), the AUC was 0.86 (95% CI: 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98% and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was of 0.89 (95% CI 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest or death) occurred in 38% of the 1000 cases. Patients with difficult intubation (n=113) had significantly more severe life-threatening complications than those without difficult intubation (51% vs 36%, p<0.0001). Conclusion: a 7 point score had a high negative predictive value for difficult intubation in critically ill patients; difficult intubation was associated with increased rates of severe life threatening complications

Abstract: De Jong. Early Identification of Patients at Risk for Difficult Intubation in ICU: Development and validation of the MACOCHA Score in a Multicenter Cohort Study. Am J Respir Crit Care Med 2013;epublished January 24th


American Journal of Respiratory and Critical Care Medicine:      Statins in Sepsis

To investigate the effects of statin therapy in severe sepsis, Kruger and colleagues completed a phase II, multicenter,  randomized, double-blind, placebo controlled trial, comparing atorvastatin 20mg daily (n=123) versus placebo (n=127). There was no difference in the primary end-point of IL-6 concentrations (p=0.76) or in secondary endpoints including length of stay, change in SOFA scores or mortality at ICU discharge, hospital discharge, 28 days or 90 days (15 vs. 19%) or adverse effects between the two groups. Cholesterol was lower in atorvastatin treated patients [2.4(0.07) vs. 2.6(0.06) mmol/L, p=0.006]. In the pre -defined group of 77 prior statin users, those randomised to placebo had a greater 28 day mortality (28% vs.5%, P=0.01). The difference was not statistically significant at 90 days (28 vs. 11%, p=0.06). Conclusion: Atorvastatin therapy was not associated with improvements in biological or clinical endpoints in severe sepsis.

Abstract:  Kruger. A Multicentre Randomised Trial of Atorvastatin Therapy in Intensive Care Patients with Severe Sepsis. Am J Respir Crit Care Med 2013;epublished ahead of print



Critical Care Medicine:     Surviving Sepsis Campaign Guidelines 2013


Anesthesiology:    Difficult Airway Management


Anesthesiology:    Postanaesthetic Care


Anesthesiology:     Theatre Fires


Canadian Journal of Cardiology:     Heart Failure


Respiratory Care:     Transcutaneous Carbon Dioxide and Oxygen Monitoring



Hepatology:     Liver Transplantation for Alcoholic Hepatitis


Artificial Organs:     Haemodialysis Buffers


Review - Clinical


Anesthesiology:    Operative Awareness



Medicina Intensiva:     Haemodynamic Monitoring


Journal of Geriatric Cardiology:     Circulatory Assist Devices


Swiss Medical Weekly:     Vascular Graft Infections



Archivos de Bronconeumologia:     Pulmonary complications of Vasculitides


Medicina Intensiva:     Fibreoptic Bronchoscopy


Anaesthesiology Intensive Therapy:     Lung Aeration in Mechanical Ventilation


Respirology:     Pleural Effusions


Respirology:     Opioids & Pulmonary Function


Respirology:     Tuberculosis


Respiratory Care:     Oxygen Therapy


Respiratory Care:     Liberation from Mechanical Ventilation



Journal of the American Heart Association:     Hyponatraemia


International Journal of Applied & Basic Medical Research:     Vaptans



 New England Journal of Medicine:     Antibiotic Resistance


Anaesthesiology Intensive Therapy:     Sepsis Pathophysiology


Bangladesh Journal of Medical Science:     Sepsis Biomarkers



Medical Journal Armed Forces India:     End of Life

Blood:     Graft-versus-Host Disease


Review - Basic Science

Swiss Medical Weekly:     Metabolomics


I hope you find these brief summaries and links useful.

Until next week