ccr logo 246x225 13121Critical Care Reviews Newsletter

August 12th 2012





Welcome to the 36th 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 a systematic review suggesting superiority of haemodialysis over haemofiltration in acute kidney injury, the safety and efficacy of procalcitonin guided therapy and data on exhaled acetone, a new biomarker of heart failure. Free review articles include excellent papers on acquired liver injury in the ICU, a debate on using benzodiazepines in ICU, necrotizing pancreatitis and ARDS. This month's articles in Chest are free to access at present, but may be locked down shortly, so access them now if you are interested.

The second part of a 2 week focus on statistics forms the topic for This Week's Papers, starting with the tests of association in tomorrow's Paper of the Day. This 2 part series is based on an excellent set of papers published in Critical Care in 2004-5.

If you think a colleague may find this service useful, please forward the email. It's a free and easy way to stay up to date with the literature.



Critical Care:     Renal Replacement Therapy

Friedrich et al performed a systematic review and meta-analysis to evaluate the comparartive effects of haemofiltration and haemodialysis on outcome in acute kidney injury. 19 RCTs (10 parallel-group and 9 crossover) met inclusion criteria, with 16 trials using continuous RRT. Hemofiltration had no effect on mortality (RR 0.96, 95% CI 0.73-1.25, p=0.76; 3 trials, n=121 [primary analysis]; RR 1.10, 95%CI 0.88-1.38, p=0.38; 8 trials, n=540 [sensitivity analysis]) or other clinical outcomes (RRT dependence in survivors, vasopressor use, organ dysfunction) compared to hemodialysis. Hemofiltration appeared to shorten time to filter failure (mean difference [MD] -7 hours, 95% CI -19 to +5, p=0.24; 2 trials, n=50 [primary analysis]; MD -5 hours, 95% CI -10 to -1, p=0.01; 3 trials, n=113 [including combined hemofiltration-hemodialysis trials comparing similar doses]; MD -6 hours, 95% CI -10 to -1, p=0.02; 5 trials, n=383 [sensitivity analysis]).  Meta-analyses were based on very limited data.

Full TextFriedrich. Hemofiltration compared to hemodialysis for acute kidney injury: systematic review and meta-analysis. Critical Care 2012, 16:R146


Chest:     Heart Failure

Marcondes-Braga and colleagues compared exhaled acetone levels between 89 patients with systolic heart failure and 20 controls to evaluate its possible role as a biomarker of heart failure diagnosis and severity. Exhaled acetone was higher in the heart failure group (median: 3.7 μg/L; IQR: 1.69-10.45 μg/L) than in the control group (median: 0.39 μg/L; IQR: 0.30-0.79 μg/L; P < .001). Additionally, acetone was higher in those with acute decompensated heart failure  (n=59; median: 7.8 μg/L; IQR: 3.6-15.2 μg/L) than in those with chronic heart failure (n=30; median: 1.22 μg/L; IQR: 0.68-2.19 μg/L; P < .001). Based on these data, acetone was as accurate and sensitive in the diagnosis of heart failure and decompensated heart failure (about 85%) as B-type natriuretic peptide, with a significant correlation between the two biomarkers (r=0.772, p<0.001). Acetone levels differed significantly as a function of severity of heart failure, as determined by New York Heart Association classification (P < .001). 

Full Text:  Marcondes-Braga. Exhaled Acetone as a New Biomarker of Heart Failure Severity. Chest 2012;142(2):457-466


Clinical Infectious Disease:     Procalcitonin

Schuetz et al performed an individual patient data meta-analysis to assess the safety of a procalcitonin guided approach to manage acute respiratory infections. In 14 trials involving 4221 adults, mortality was 5.7% (118/2085) in the procalcitonin group and 6.3% (134/2126) in the control group (adjusted odds ratio 0.94; 95% CI: 0.71–1.23). Treatment failure occurred in 19.1% (n=398) of the procalcitonin group and 21.9 (n=466) of the control group (adjusted odds ratio 0.82; 95% CI: 0.71–0.97). Procalcitonin guidance was not associated with increased mortality or treatment failure and was associated with reduced antibiotic exposure  (median [interquartile range], from 8 [5–12] to 4 [0–8] days; adjusted difference in days, −3.47 [95% CI: −3.78 to −3.17]).

Full Text:  Schuetz. Procalcitonin to Guide Initiation and Duration of Antibiotic Treatment in Acute Respiratory Infections: An Individual Patient Data Meta-Analysis. Clin Infect Dis 2012 55: 651-662


British Journal of Anaesthesia:     Non-Invasive Ventilation

Glossop et al performed a meta-analysis of 16 randomized controlled trials to evaluate the effects of non-invasive ventilation on weaning, reduction in reintubation rates post-extubation in ICU, and reduction in respiratory failure post major surgery. When used for weaning, NIV reduced ICU length of stay by 5 days and hospital stay by 6.5 days. NIV did not reduced lengths of stay for either measure when used post extubation in ICU. There was a clinically insignificant decrease in ICU LOS, and a 1 day decrease in hospital stay when used post surgery. NIV reduced the risk of reintubation post surgery (OR 0.24), but not when used for weaning or post-extubation in the ICU. NIV reduced the risk of pneumonia when used for weaning (OR 0.12) and post surgery (OR 0.27) but not post ICU extubation. NIV did not increase ICU survival when used for weaning or post-extubation in ICU. 

Abstract:  Glossop. Non-invasive ventilation for weaning, avoiding reintubation after extubation and in the postoperative period: a meta-analysis. Br J Anaesth 2012;109:305-314



Nephron Clinical Practice:     Acute Kidney Injury


Review - Clinical

Clinical Medicine and Diagnostics:     Pancreatitis

Chest:     Debate on utility of benzodiazepines in ICU


Chest:     Malaria


Chest:     Pneumococcus


Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine:     ARDS


World Journal of Critical Care Medicine:     Burns


World Journal of Critical Care Medicine:    Ultrasound


World Journal of Critical Care Medicine:     Therapeutic Hypothermia


European Journal of Cardiothoracic Surgery:     Infective Endocarditis


Circulation:     DVT


Anesthesiology:     Liver Injury


Indian Journal of Medical Microbiology:     Candida


Review - Basic Science

Chest:     Lung Volumes


Review - Non-Clinical

Medicolegal and Bioethics



I hope you find these papers useful.

Until next week