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Critical Care Reviews Newsletter

November 11th 2012





Welcome to the 49th 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 a report of superior outcomes with pharamacological therapy in comparison with ultrafiltration for acute decompensated heart failure with cardiorenal syndrome, a suggestion that post cardiac arrest therapeutic hypothermia of 32°C is superior to 34°C, equivalence of propofol and sevoflurane for perioperative cardioprotection, two studies on cardiac surgery and two studies on the use of stem cells for myocardial infarction.

The Spanish Scientific Committee of the Sociedad Espanola de Medicina Intensiva y Unidades Coronarias (SEMICYUC) published guidelines on early management of acute pancreatitis.

Amongst the clinical review articles are three papers on antimicrobial therapy, plus other papers on AKI biomarkers, fever,  spinal cord injury and blood purification. Nonclinical papers include articles on multiple testing in statistics and industry transparency in research.

The topic for This Week's Papers is antibacterial drugs, starting with a paper on carbapenams in tomorrow's Paper of the Day.

This week's CPD / CME  article and quiz are on drug-induced haematological syndromes. A personalised certificate of CPD activity can be saved and printed after successful completion of the activity.



New England Journal of Medicine:     Acute Decompensated Heart Failure

Bart and colleagues undertook a prospective randomized trial in 188 patients with acute decompensated heart failure, worsened renal function, and persistent congestion, comparing stepped pharmacologic therapy (n=94) with ultrafiltration (n=94). The pharmacological strategy aimed to produce a urinary output of 3 - 5 l of urine per day (described in full here), while the UF removed fluid at 200 ml/hr. At 96 hours ultrafiltration was inferior to pharmacologic therapy with respect to the primary end point of change in serum creatinine level and body weight (P=0.003). Creatinine increased in the UF group, but not in the pharmacological group (UF: creatinine +20.3±61.9 μmol/l v pharmaological therapy: −3.5±46.9 μmol/l; P=0.003). There was no significant difference in weight loss at 96 hours (UF: - 5.7±3.9 kg v pharmacological therapy: -5.5±5.1 kg; P=0.58). There were more serious adverse events in the UF group (72% vs. 57%, P=0.03).

Full Text:  Bart. Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome (CARRESS). N Engl J Med 2012; epublished November 6th

Associated Editorial:  Tang. Reconsidering Ultrafiltration in the Acute Cardiorenal Syndrome. N Engl J Med 2012; epublished November 6th


Circulation:     Perioperative Myocardial Protection

In a randomized trial Buse and colleagues compared sevoflurane anaesthesia with propofol anaesthesia for myocardial protection in 385 patients with cardiac risk factors indergoing non-cardiac surgery. There was no difference in either myocardial ischemia (sevoflurane 40.8% v propofol 40.3%; relative risk: 1.01; 95% CI: 0.78-1.30) or NT-proBNP levels 1 or 2 days postoperatively, or incidence of delirium (11.4% vs. 14.4%, P=0.760). At 1 year, there were no differences in major cardiac events 14 patients (sevoflurane 7.6% v propofol 8.5%; RR: 0.90; 95% CI, 0.43-1.87).

Abstract: Buse. Randomized Comparison of Sevoflurane vs. Propofol to Reduce Perioperative Myocardial Ischemia in Patients Undergoing Noncardiac Surgery. Circulation 2012; epublished November 7th


Circulation:     Post Cardiac Arrest Therapeutic Hypothermia

In a prospective randomized pilot trial Lopez-de-Sa and colleagues compared 32°C (n=18) with 34°C (n=18) for therapeutic hypothermia post witnessed out-of-hospital cardiac arrest. Twenty six subjects had a shockable rhythm and 10 were asystolic. The primary outcome of survival free from severe dependence (Barthel Index score ≥60 points) at 6 months occurred more often in the 32°C group (8/18,44.4%) than in the 34°C group (2/18;11.1%) (log-rank P=0.12). All patients whose initial rhythm was asystole died before 6 months in both groups. Eight of 13 patients (61.5%) with initial shockable rhythm assigned to 32°C were alive free from severe dependence at 6 months compared with 2 of 13 (15.4%) assigned to 34°C (log-rank P=0.029). The incidence of complications was similar in both groups except for the incidence of clinical seizures, which was lower (1 versus 11; P=0.0002) in patients assigned to 32°C compared with 34°C. There was a trend toward a higher incidence of bradycardia (7 versus 2; P=0.054) in patients assigned to 32°C. Although potassium levels decreased to a greater extent in patients assigned to 32°C, the incidence of hypokalemia was similar in both groups.

Full Text: Lopez-de-Sa. Hypothermia in Comatose Survivors From Out-of-Hospital Cardiac Arrest: Pilot Trial Comparing 2 Levels of Target Temperature. Circulation 2012; epublished November 6th


New England Journal of Medicine:     Coronary Revascularization in Diabetes

Farkouh and collegues completed a multi-centre, international randomized trial, comparing PCI with drug-eluting stents or CABG in 1900 diabetic patients with multivessel coronary artery disease. The patients' mean age was 63.1±9.1 years, 29% were women, and 83% had three-vessel disease. At 5 years, the primary outcome, a composite of death from any cause, nonfatal myocardial infarction, or nonfatal stroke, was decreased with CABG (18.7% v 26.6%, p=0.005). The benefit of CABG was driven by differences in rates of both myocardial infarction (P<0.001) and death from any cause (P=0.049). Stroke was more frequent in the CABG group, with 5-year rates of 5.2% vs 2.4%; P=0.03.

Full Text:  Farkouh. Strategies for Multivessel Revascularization in Patients with Diabetes (FREEDOM Trial). N Engl J Med 2012, epublished November 4th

Associated Editorial: Hlatky. Compelling Evidence for Coronary-Bypass Surgery in Patients with Diabetes. N Engl J Med 2012, epublished November 4th


Journal of the American Medical Association:     Dexamethasone in Cardiac Surgery

Dieleman et al performed a multicenter, randomized, double-blind, controlled trial compared 1mg/kg of intraoperative dexamethasone (n=2239) with placebo (n=2255) on the incidence of major adverse events in patients undergoing cardiac surgery. There was no difference in the primary composite outcome of death, myocardial infarction, stroke, renal failure, or respiratory failure, within 30 days of randomization (dex: 157/2239;7.0% versus 191/2255;8.5%); relative risk: 0.83; 95% CI, 0.67-1.01; absolute risk reduction: −1.5%; 95% CI: −3.0% to 0.1%; P=0.07). Dexamethasone was associated with reductions in postoperative infection, duration of postoperative mechanical ventilation, and lengths of intensive care unit and hospital stays. In contrast, dexamethasone was associated with higher postoperative glucose levels.

Abstract: Dieleman. Intraoperative High-Dose Dexamethasone for Cardiac Surgery - A Randomized Controlled Trial (Dexamethasone for Cardiac Surgery (DECS) Study). JAMA 2012;308(17):1761-1767


Journal of the American Medical Association:     Stem Cells for Myocardial Infarction

Traverse et al performed a randomized, 2 × 2 factorial, double-blind, placebo-controlled trial comparing intracoronary infusion of  bone marrow cells (BMCs) or placebo in 120 patients with left ventricular dysfunction  after successful primary percutaneous coronary intervention of anterior STEMI.  Therapy was administered  either 3 or 7 days (randomized 1:1) post PCI and within 12 hours of aspiration and cell processing. The mean (SD) patient age was 56.9 (10.9) years and 87.5% of participants were male. At 6 months, there was no significant increase in LV ejection fraction with BMCs (45.2% to 48.3%) vs the placebo  (44.5% to 47.8%; P = 0.96), or regional left ventricular function in either infarct or border zones. There was no change in global LV function for patients treated at day 3 (−0.9%; 95% CI: −6.6% to 4.9%; P = 0.76) or day 7 (1.1%; 95% CI: −4.7% to 6.9%; P = 0.70). Major adverse events were rare among all treatment groups.

Full Text:  Traverse. Effect of the Use and Timing of Bone Marrow Mononuclear Cell Delivery on Left Ventricular Function After Acute Myocardial Infarction: The TIME Randomized Trial. JAMA 2012; epublished November 2012


Journal of the American Medical Association:     Stem Cells for Myocardial Infarction

Hare et al performed a single centre randomized trial evaluating whether allogeneic mesenchymal stem cells (MSCs) are as safe and effective as autologous MSCs in 30 patients with left ventricular dysfunction due to ischaemic cardiomyopathy. Allogeneic and autologous MSCs reduced mean infarct size by −33.21% (95% CI, −43.61% to −22.81%; P < .001) and sphericity index but did not increase ejection fraction. Allogeneic MSCs reduced LV end-diastolic volumes. Low-dose concentration MSCs (20 million cells) produced greatest reductions in LV volumes and increased EF. Allogeneic MSCs did not stimulate significant donor-specific alloimmune reactions. Relative to baseline, autologous but not allogeneic MSC therapy was associated with an improvement in the 6-minute walk test and the MLHFQ score, but neither improved exercise VO2max. 

Full Text: Hare. Comparison of Allogeneic vs Autologous Bone Marrow–Derived Mesenchymal Stem Cells Delivered by Transendocardial Injection in Patients With Ischemic Cardiomyopathy: The POSEIDON Randomized Trial. JAMA 2012; epublished November 6th  



New England Journal of Medicine:     Fungal Meningitis Outbreak

Full Text:  Kainer. Fungal Infections Associated with Contaminated Methylprednisolone in Tennessee. N Engl J Med 2012; epublished November 6th



Medicina Intensiva:     Acute Pancreatitis


Review - Clinical

Annals of Intensive Care:     Gastrointestinal Bleeding


Journal of Antimicrobial Chemotherapy:     Antimicrobial Therapy for Resistant Microbes


ISRN Nephrology:     Acute Kidney Injury Biomarkers


Minerva Anesthesiologica:     Fever in Sepsis


Minerva Anesthesiologica:     Blood Purification in Sepsis


Minerva Anesthesiologica:     Ultrasound


Minerva Anesthesiologica:     Dead-Space in Acute Lung Injury


The Journal of Pharmacology and Experimental Therapeutics:     Acute Kidney Injury Therapy


North American Journal of Medical Science:     New Antibacterial Drugs


Neurocritical Care:     Traumatic Spinal Injury

International Journal of Emergency Medicine:     Angioedema


Clinics (Sao Paulo):     Community-Acquired Pneumonia

Journal of Antimicrobial Chemotherapy:     Discovery of Antibacterial Drugs


Interactive Cardiovascular Thoracic Surgery:     Pneumothorax Management


Anaesthesia:     Laryngeal Mask Airway


Pulmonary Circulation:     Platelet Biology


International Journal of General Medicine:     Clinical Reasoning


Review - Basic Science

Nature Medicine:     Multiple Testing in Statistics


Review - Non-Clinical

Nature Medicine:     Pharmaceutical Industry Research



I hope you find these brief summaries and links useful.

Until next week