ccr logo 246x225 13121Critical Care Reviews Newsletter

August 19th 2012





Welcome to the 37th Critical Care Reviews Newsletter. Every week over three hundred clinical and scientific journals are monitored and the most important and interesting research publications in critical care are highlighted. These studies are added to the Current Articles section of the website on a daily basis, as publication occurs. A link to either the full text or abstract, depending on the publishers degree of open access, is attached. Also, links to other important papers, such as guidelines or consensus statements are included. Free review articles from across the medical literature are also highlighted.

This week's research papers include an intriguing paper suggesting benefit from a combined approach of ECMO with PCI in acute coronary syndrome associated cardiac arrest, plus a systematic review suggesting improved outcomes with vasopressin,  compared with catecholamines, for management of vasodilatory shock. Three review articles look at various aspects of anti-bacterial therapy, including one on the increasing problem of ESBL infections. The Cochrane Collaboration have issued reviews on therapy for refractory status epilepticus and acute kidney injury.

The focus for This Week's Papers is muscular disorders, starting with a review of rhabdomyolysis in tomorrow's Paper of the Day

I've had 2 requests for additional features for the website in the past week. Firstly, for the facility for continuing professional development (CPD) / continuing medical education (CME) certificates, stating a specific paper has been read and a multiple choice question examination has been passed. Secondly, for further information on critical care exams. I'm working on adding a CPD facility, which I hope to have active in the next few weeks. If you have recently sat a critical care examination and would like to share your experience to assist others in their preparation, please email me, and I'll add this to the relevant webpage. Information on any exam would be useful.



Circulation:     Cardiac Arrest

Using the 2004-2011 database of ECMO in Hiroshima City, Japan, Kagawa at al performed a multicentre cohort study in 86 patients to assess the efficacy of rapid-response ECMO and intra-arrest percutaneous coronary intervention in acute coronary syndrome cardiac arrest patients unresponsive to conventional CPR. Most received both emergency coronary angiography (n=81, 94%) and intra-arrest PCI (n=61, 71%). The rates of return of spontaneous heart-beat, 30-day survival, and favourable neurological outcomes were 88%, 29%, and 24%, respectively. All of the patients who received intra-arrest PCI achieved return of spontaneous heart-beat. In patients who survived up to day 30, the rate of out-of-hospital cardiac arrest was lower (58% vs. 28%, P = 0.01), the intra-arrest PCI was higher (88% vs. 70%, P = 0.04), and the time interval from collapse to the initiation of ECMO was shorter (40 min [25-51 min] vs. 54 min [34-74 min], P = 0.002).

Abstract: Kagawa. Should We Emergently Revascularize Occluded Coronaries for Cardiac Arrest?: Rapid-Response Extracorporeal Membrane Oxygenation and Intra-Arrest Percutaneous Coronary Intervention. Circulation epublished 16 August 2012


Critical Care:     Vasodilatory Shock

Neto et al performed a systematic review and meta-analysis, totalling 9 trials and 998 subjects, to compare vasopressin, and its analogue terlipressin, with cathecolamine infusion alone in vasodilatory shock. Using a fixed-effect model, subjects receiving terlipressin or vasopressin infusion had a reduced noradrenaline requirement (standardized mean difference, -1.58 [95% CI, -1.73 - -1.44]; p < 0.0001). Vasopressin and terlipressin, as compared with norepinephrine alone, reduced mortality (relative risk, RR: 0.87 [0.77 - 0.99]; p = 0.04); vasopressin decreased mortality in adult patients (RR: 0.87 [0.76 - 1.00]; p = 0.05) and in patients with septic shock (42.5 vs. 49.2%, respectively; RR: 0.87 [95% CI, 0.75 - 1.00]; p = 0.05). There was no difference between in adverse events between the vasopressin and control groups (RR: 0.98 [0.65 - 1.47]; p = 0.92).

Full Text:  Neto. Vasopressin and terlipressin in adult vasodilatory shock: a systematic review and meta-analysis of nine randomized controlled trials. Critical Care 2012, 16:R154


Critical Care:     Pneumococcal Pneumonia

Mongaradon  et al performed a retrospective review of two prospectively-acquired multicentre ICU databases, totalling 222 patients (median SAPS 2 score 47 [36-64]), to evaluate epidemiological data and determine risk factors of mortality in severe pneumococcal pneumonia requiring ICU admission. The most frequent causes for ICU admssion were acute respiratory failure (n=154) and septic shock (n=54). Incidence of organ failure/support was septic shock 77% (n=170), mechanical ventilation 84% (n=186) and renal replacement therapy 32% (n=70). 101 patients were bacteraemic, with 39.7% of pneumococcal strains having reduced susceptibility to penicillin.  Despite adequate antibacterial therapy in 92.3% of cases, hospital mortality was 28.8%. In multivariate analysis, independent risk factors for mortality were age [OR 1.05 (95% CI: 1.02-1.08)], male sex [OR 2.83 (95% CI: 1.16-6.91)] and renal replacement therapy [OR 3.78 (95% CI: 1.71-8.36)], while co-morbidities, macrolide administration, concomitant bacteremia or penicillin susceptibility did not affect outcome.

Full TextMongardon. Epidemiology and outcome of severe pneumococcal pneumonia admitted to intensive care unit: a multicenter study. Critical Care 2012, 16:R155


British Medical Journal:     Haemorrhage Outcome Prediction

Based on the CRASH2 dataset, Perel et al performed a multivariable logistic regression on 20,127 trauma patients with, or at risk of, significant bleeding, within 8 hours of injury and then externally validated this model in 14,220 selected patients from the Trauma Audit and Research Network (TARN), which were mainly from the UK. Of the patients who died (CRASH2: n=3076 (15%); TARN n=1765 (12%)  Glasgow coma score, age, and systolic blood pressure were the strongest predictors of mortality, with other predictors included in the final model being geographical region (low, middle, or high income country), heart rate, time since injury, and type of injury. Discrimination and calibration were satisfactory, with a ROC area under the curve score above 0.80 in both CRASH-2 and TARN. A web based calculator is available to readily provide the probability of death within 28 days at the point of care.

Full Text:  Perel. To develop and validate a prognostic model for early death in patients with traumatic bleeding. BMJ 2012;345:e5166


Cochrane Review:     Status Epilepticus

Prabhaker et al performed a Cohrnae review to determine if propofol or sodium thiopentone provided superior seizure control in refractory status epilepticus. A single randomised, single-blind, multicentre trial involving just 24 patients was identifed. This study failed to identify a difference in seizure control, or of complications, although patients receiving thiopentone had an increased duration of mechanical ventilation. The authors concluded that given the lack of available data, further randomized controlled trials are required to adequately address this question.

Full Text:  Prabhakar. Propofol versus thiopental sodium for the treatment of refractory status epilepticus. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD009202


Cochrane Collaboration:     Acute Kidney Injury

Li et al evaluated the effectiveness and safety of nutritional support for patients with AKI. Eight randomized controlled trials were identified, totalling 257 subjects. Overall, the authors concluded there was insufficient evidence to support the effectiveness of nutritional support for AKI.

Full Text:  Li. Nutritional support for acute kidney injury. Cochrane Database Syst Rev. 2012 Aug 15;8:CD005426


Consensus Statement

Circulation:     Cardiovascular ICU

Full Text: Morrow. Evolution of Critical Care Cardiology: Transformation of the Cardiovascular Intensive Care Unit and the Emerging Need for New Medical Staffing and Training Models: A Scientific Statement From the American Heart Association. Circulation epublished 14 August 2012


European Heart Failure:     Natriuretic Peptides

Full Text:  Thygesen. Recommendations for the use of natriuretic peptides in acute cardiac care: A position statement from the Study Group on Biomarkers in Cardiology of the ESC Working Group on Acute Cardiac Care. Eur Heart J 2012;33:2001-2006


Review - Clinical

Critical Care Research and Practice:     ESBLs


Journal of Antimicrobial Chemotherapy:     Anti-Microbials


Annals of Nutrition and Metabolism:     Magnesium


American Journal of Cardiovascular Disease:     Ischaemia-Reperfusion


American Journal of Cardiovascular Disease:     Hypertension


Annals of Intensive Care Medicine:     Beta-Lactam Infusions


Annals of Intensive Care Medicine:     Pain


Journal of Pakistani Medical Association:     CRRT


Stroke:     Stroke (!)


Journal of Hematology & Oncology:     Liver Transplantation



I hope you find these links and brief summaries useful.

Until next week