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Critical Care Reviews Newsletter

December 16th 2012



Welcome to the 54th 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.

This week's research studies include an article from the New England Journal of Medicine, suggesting a lack of advantage to ICP guided management of traumatic brain injury, a study from The Lancet demonstrating reduced infection rates when supplemental parenteral nutrition was added to standard enteral nutrition to achieve 100% target energy provision, and a small pilot study from Critical Care showing reduced progression of sepsis to severe sepsis with the use of statins in statin-naïve subjects. Additionally there are studies on room disinfection with hydrogen peroxide vapour, two studies on renal replacement therapy and three Cochrane Reviews.

This week's guideline is from the Canadian Cardiovascular Society on the management of heart failure.

Topics covered in the clinical review articles are inhalational sedation, percardial effusion, lung injury, septic therapies, klebsiella pneumonia, MRSA and military trauma.

The topic for This Week's Papers is ICU viruses, starting with a paper on cytomegalovirus in tomorrow's Paper of the Day.



New England Journal of Medicine:     Traumatic Brain Injury

Chesnut and colleagues performed a randomized controlled trial in 324 patients in Bolivia and Equador with severe traumatic brain injury comparing intracranial pressure guided management with management based on a combination of imaging and clinical findings. There was no difference between groups in the primary outcome, a composite value of 21 functional and cognitive measures (p=0.49). Similarly, there was no difference in 6 month mortality (pressure guided 39% versus imaging-clinical guided 41%, p=0.60), median ICU length of stay (pressure guided 12 days versus imaging-clinical guided 9 days, p=0.25). There were more days of administration of specific brain therapies in the imaging-clinical group (4.8 versus 3.4, p=0.002). 

Full Text: Chesnut. A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury. New Engl J Med 2012; epublished December 12th

EditorialRopper. Brain in a Box. New Engl J Med 2012; epublished December 12th


Lancet:     Parenteral Nutrition

Heidegger et al performed a two-centre randomized controlled trial comparing enteral nutrition with additional supplemental parenteral nutrition (n=153), to achieve 100% energy target, with just enteral nutrition alone (n=152), in patients on day 3 of their ICU admission who had received less than 60% of their energy target from enteral nutrition. 30 patients did not complete the study. Mean energy delivery between day 4 and 8, the supplemented group received a mean daily energy intake of 28 kcal/kg (SD 5) (103% [SD 18%] of energy target), compared with 20 kcal/kg per day (7) for the non-supplemented group group (77% [27%]). The rate of nosocomial infection between days 9 and 28 was 27% for the supplememntal group and 38% for the non-supplemented group (hazard ratio 0·65, 95% CI 0·43—0·97; p=0·0338). The supplemental group had a lower mean number of nosocomial infections per patient (−0·42 [−0·79 to −0·05]; p=0·0248).

Abstract:Heidegger. Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 2012; epublished ahead of print


Clinical Infectious Disease:     Hydrogen Peroxide Vapour Cleansing

In a single centre 30-month prospective cohort intervention study, comparing hydrogen peroxide vaporization with standard disinfection, on acquisition rates of multi-drug resistant infection after admission to a room previously inhabited by a patient with an MDR microbe. There were 1397 episodes of admission into a room previously inhabited by a patient with a MDR microbe. Patients admitted to a HPV treated room were 64% less likely to acquire a MDR microbe (incidence rate ratio 0.36; 95% CI 0.19–0.70; P < 0.001) and 80% less likely to acquire vancomycin resistant enterococci (IRR, 0.20; 95% CI, 0.08–0.52; P < 0.001) after adjusting for other factors. The risk of reducing individual infection was not reduced for MRSA, C.diff, and gram negative rods. The proportion of rooms environmentally contaminated with MDR organisms was reduced significantly after HPV cleansing (relative risk, 0.65, P = .03), but not with standard cleansing.

Abstract:Passaretti. An Evaluation of Environmental Decontamination With Hydrogen Peroxide Vapor for Reducing the Risk of Patient Acquisition of Multidrug-Resistant Organisms. Clin Infect Disease 2013;56(1):27-35


Clinical Kidney Journal:     High-Volume Haemofiltration in Septic Shock

Bourquin et al performed a single-centre cohort study in 55 patients with refractory septic shock (norepinephrine dose >0.2 µg/kg/min) and acute kidney injury, using high-volume continuous venovenous haemodiafiltration (dialysis dose of 70 mL/kg/h)  within the first 24 h of refractory septic shock and until reversal of shock or death. The mortality of 63% was similar to that  predicted by the APACHE II and SAPS II scores, suggesting a lack of additional benefit over standard care.

Abstract:Bourquin. Use of high-volume haemodiafiltration in patients with refractory septic shock and acute kidney injury. Clin Kidney J 2012; epublished December 9th


Nephrology Dialysis Transplantation:     Renal Replacement Therapy

In a single-centre randomized, controlled trial, Škofic et al compared intermittent high-volume predilution on-line haemofiltration (HF) with standard intermittent haemodialysis (HD) in 373 critically ill patients. There was no-difference in 60 day all-cause mortality (HF: 65.0% versus HD: 65.5%; hazard ratio, 0.98; 95% CI, 0.71–1.33; P = 0.87),  30-day mortality, in-hospital all-cause mortality Similarly there were no differences in recovery of kidney function, time to kidney function recovery or the number of required dialysis procedures.

Full Text:Škofic. Intermittent high-volume predilution on-line haemofiltration versus standard intermittent haemodialysis in critically ill patients with acute kidney injury: a prospective randomized study. Nephrol. Dial. Transplant 2012;27:4348-4356


Critical Care:     Statins in Sepsis

Patel and colleagues completed a single centre phase II randomized double-blind placebo-controlled trial, comparing atorvastatin 40mg daily (n=49) or placebo (n=51), on the rate of sepsis progressing to severe sepsis during hospitalization in 100 statin-naïve subjects. Statin therapy appeared to have a therapeutic effect, with less statin treated patients progressing to severe sepsis (4% versus 24%, p=0.007; NNT=7). However, the clinical effects of this were less apparent, with no difference noted in length of hospital stay, critical care unit admissions, 28-day and 12-month readmissions or mortality, although the numbers recruited may have been too low to adequately address this. Statin therapy was associated with reductions in both plasma cholesterol, as expected, and the urinary albumin creatinine ratio, a marker of endothelial dysfunction.  Adverse events were similar in the two groups.

Full Text:Patel. Randomized double-blind placebo-controlled trial of 40 mg/day of atorvastatin in reducing the severity of sepsis in ward patients (ASEPSIS Trial). Critical Care 2012;16:R231


Cochrane Review:     Perioperative Fluids    

Burdett et al performed a systematic review and meta analysis to compare the safety and efficacy of perioperative administration of buffered versus non-buffered fluids for plasma volume expansion or maintenance in adult patients undergoing surgery. 13 randomized trials totalling 706 subjects were identified. There was no difference in the primary outcome of mortality, which was 2.9% for the buffered fluids group and 1.5% for the non-buffered fluids. This was based on just 3 studies with a total of 267 patients. There was no difference in renal insufficiency leading to renal replacement therapy between the buffered and non-buffered groups (OR 0.61, 95% CI 0.23 to 1.63, P = 0.32, I2 = 0%). There was no difference in organ dysfunction, with a lower PaC02 levels in the non-buffered fluid group (95% CI 0.09 to 2.28, P = 0.03, I2 = 0%). There was no difference in intraoperative blood loss nor the volumes of intraoperative red cell or fresh frozen plasma transfused between groups. There was an increase in platelet transfusion in the non-buffered group which was statistically significant after analysing the transformed data . There was a difference in day of operation postoperative pH of 0.06 units, lower in the non-buffered fluid group (95% CI 0.04 to 0.08, P < 0.00001, I2 = 74%). The non-buffered fluid group also had significantly greater base deficit, serum sodium and chloride levels. There was no difference demonstrated in length of hospital stay and no data were reported on cost or quality of life.

Full Text:Burdett. Perioperative buffered versus non-buffered fluid administration for surgery in adults. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD004089.


Cochrane Review:    Beta 2 Agonists in Asthma

Travers performed a systematic review and identified just three trials, of differing methodology, investigating the addition of intravenous beta 2 agonists to inhaled beta 2 agonists in acute asthma. The authors concluded the evidence was insufficient to adequately evaluate the efficacy of this therapeutic approach.

Full Text:Travers. Addition of intravenous beta2-agonists to inhaled beta2-agonists for acute asthma. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.:CD010179


Cochrane Review:    Beta 2 Agonists or Aminophylline in Asthma

Travers et al compared the benefit of IV beta2-agonists versus IV aminophylline for acute asthma treated in the emergency department and in patients admitted to hospital with acute severe asthma. Eleven studies including 350 subjects were included. There was no difference in length of stay, pulmonary function or heart rate. Adverse effects, including giddiness, and nausea and vomiting were more frequent with aminophylline therapy.

Full Text:Travers. Intravenous beta2-agonists versus intravenous aminophylline for acute asthma. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD010256



Canadian Journal of Cardiology:     Heart Failure


Review - Clinical


Indian Journal of Anaesthesia:     Inhalational Sedation


European Heart Journal:     Mitochondrial DNA Disease



Korean Circulation Journal:     Pericardial Effusion


BMC Medicine:     Atrial Fibrillation



Journal of Pulmonary and Respiratory Medicine:     Lung Injury



Journal of Hematology & Oncology:     Tumor Lysis Syndrome



Core Evidence:     MRSA


International Journal of Inflammation:     Sepsis Therapies


Annals of Clinical Microbiology and Antimicrobials:     Klebsiella Pneumoniae Carbapenemase Infections



Journal of Trauma and Acute Care Surgery:     Military Medicine


Review - Non-Clinical

Indian Journal of Anaesthesia:     Anaesthesia


I hope you find these brief summaries and links useful.

Until next week