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Critical Care Reviews Newsletter

June 17th 2013



Welcome to the 80th 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. It's a smaller newsletter than usual this week, as I spent most of the past 3 days trying to get the site back online, after spectacularly crashing it on Friday night.

It's been a relatively quiet week for critical care research, with some minor studies catching my attention, including observational studies describing outcomes after haematological malignancy requiring ICU admission, invasive candidiasis, fluid boluses in resuscitated septic shock, as well as therapeutic studies of n-acetylcysteine for the prevention of contrast-induced nephropathy and albumin in stroke. I usually avoid retrospective studies, but have included a small interesting study evaluating the anion gap as measured using modern ion-specific electrodes, rather than the still oft quoted values as measued with older flame-photometry.

This week's guidelines are from ESPEN, on nutrition in burns, and the European Society of Cardiology, on arterial hypertension. There are several editiorials, focusing on topics such as cardiac arrest, noninvasive ventilation, and oesophageal doppler monitoring. In additon to an editorial on starches is news of a likely European ban on the sale of starches.

Amongst the clinical review articles are papers on cerebral vasospasm, neurological prognostication post cardiac arrest, pacing for biventricular failure, COPD, acute pancreatitis, acute-on-chronic liver failure, hypothermia, and vasopressin in septic shock.

The topic for This Week's Papers is burns, starting with a paper on pharmacotherapy for this condition in today's Paper of the Day.



The European Medicines Agency’s Pharmacovigilance Risk Assessment Committee has recommended suspending marketing authorisations for infusion solutions containing hydroxyethyl-starch.



Journal of Clinical Oncology:     Haematological Malignancies

Azoulay and colleagues performed a prospective, multicenter cohort study of 1,011 critically ill patients with hematologic malignancies to determine outcomes and prognostic factors. 38.2% had newly diagnosed malignancies, 23.1% were in remission, and 24.9% had received hematopoietic stem-cell transplantations (HSCT, including 145 allogeneic). ICU admission was mostly required for acute respiratory failure (62.5%) and/or shock (42.3%). On day1, 733 patients (72.5%) received life-supporting interventions. Hospital, day-90, and 1-year survival rates were 60.7%, 52.5%, and 43.3%, respectively. By multivariate analysis, cancer remission and time to ICU admission less than 24 hours were associated with better hospital survival. Poor performance status, Charlson comorbidity index, allogeneic HSCT, organ dysfunction score, cardiac arrest, acute respiratory failure, malignant organ infiltration, and invasive aspergillosis were associated with higher hospital mortality. Mechanical ventilation (47.9% of patients), vasoactive drugs (51.2%), and dialysis (25.9%) were associated with mortality rates of 60.5%, 57.5%, and 59.2%, respectively. On day 90, 80% of survivors had no health-related quality of life alterations (physical and mental health similar to that of the overall cancer population). After 6 months, 80% of survivors had no change in treatment intensity compared with similar patients not admitted to the ICU, and 80% were in remission.

Abstract:  Azoulay. Outcomes of Critically Ill Patients With Hematologic Malignancies: Prospective Multicenter Data From France and Belgium—A Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique Study. JCO 2013;epublished June 10th


Journal of Antimicrobial Chemotherapy:     Invasive Candidiasis

Guo and colleagues undertook a multicentre, prospective, observational study to describe the epidemiology, microbiology and management of invasive Candida infection in Chinese ICUs. The incidence of invasive Candida infection was 0.32% (306 patients/96 060 ICU admissions) with a median time from ICU admission to diagnosis of 10.0 days. Candida albicans was the most prevalent single isolate (41.8% of patients), although non-albicans species accounted for the majority of infections. Diagnostic confirmation was based solely on at least one positive blood culture in 290 (94.8%) cases. Treatment was initiated after diagnostic confirmation in 166/268 (61.9%) patients. Triazoles (62.7%) and echinocandins (34.2%) were the most commonly used antifungal agents; first-line therapy was typically fluconazole (37.7%). The median duration of antifungal therapy was 14 days. The mortality rate was 36.6% (112/306); the median time between diagnosis and death was 14.5 days.  Susceptibility to first-line antifungals was associated with lower mortality than dose-dependent susceptibility or complete resistance (P = 0.008).

Abstract: Guo. Invasive candidiasis in intensive care units in China: a multicentre prospective observational study. J Antimicrob Chemother 2013;68:1660-1668


Medscape:     Albumin in Stroke

Ginsberg presented the results of the phase 3 ALIAS (ALbumin In Acute Stroke) trial, comparing albumin with saline, at the XXII European Stroke Conference. The Data and Safety Monitoring Board recommended termination of the first part of the trial after 434 patients were recruited, due to an increased early death rate in the albumin group (13% vs 5.5%). The second part of the trial, using stricter exclusion criteria, evaluated a 2 g/kg human albumn IV infusion over 2 hours. Again, the trial was stopped by the Data and Safety Monitoring Board after 841 patients because of futility. There was no difference in the primary outcome (albumin group 44.1% versus control group 44.2%), a score of 0 to 1 on the National Institutes of Health Stroke Scale and/or modified Rankin scale at 90 days.

Full Text:  Conference Presentation. ALbumin In Acute Stroke (ALIAS) trial. Medscape 2013;epublished June 7th


Shock:     Septic Shock

Shailesh and colleagues completed a prospective observational study in 50 septic shock patients who had been fluid resuscitated, to estimate the prevalence and efficacy of fluid blouses after initial resuscitation.  Low blood pressure (76.0%) and increased vasopressor requirement (60.3%) were the two most common indications for fluid boluses. Low filling pressure (70.9%) and clinical signs (79.4%) were perceived as the most successful indications. One hour after fluid boluses, there was a small increase in MAP (P < 0.01) and central venous pressure (P < 0.01); however, there was also concomitant increase in noradrenaline administered. There was a significant decrease in PaO2/FIO2 ratio, hemoglobin, and temperature, whereas urine output remained unchanged. 

Abstract:  Shailesh. Post Resusicitation Fluid Boluses in Severe Sepsis or Septic Shock: Prevalence and Efficacy (Price Study). Shock 2013;40(1):28–34


Shock:     Septic Shock

Sterling et al performed a secondary analysis of a large, multicenter randomized controlled trial to determine differences in outcomes of patients with tissue dysoxic (n=157, hypotension plus lactic acidosis) versus vasoplegic septic shock (n=157, hypotension with normal lactate). Patients with with vasoplegic shock had a lower initial Sequential Organ Failure Assessment score (5.5 vs. 7.0 points; P = 0.0002) and lower in-hospital mortality (9% versus 26%; proportion difference 17%; 95% CI 7%–26%; P < 0.0001; log-rank test P = 0.02). After adjusting for confounders, tissue dysoxic shock remained an independent predictor of in-hospital mortality.

Abstract:  Sterling. Characteristics and Outcomes of Patients With Vasoplegic Versus Tissue Dysoxic Septic Shock. Shock 2013;40(1):11-14


International Journal of Nephrology and Renovascular Diseases:     Anion Gap

Sadjadi retrospectively reviewed data from 708 patients to evaluate normal values for the anion gap, using modern ion-selective electrodes. In 409 patients with an estimated glomerular filtration rate ≥60 mL/min/1.73 m2 body surface area and serum albumin ≥4 g/dL, the mean AG was 7.2 ± 2 (range 3–11) meq/L. In 299 patients with lactic acidosis (lactate level ≥4 meq/L) and 68 patients with end-stage renal disease on dialysis, the mean AG was 12.5 meq/L and 12.4 meq/L, respectively.

Full Text:  Sadjadi. Ion-selective electrode and anion gap range: What should the anion gap be? International Journal of Nephrology and Renovascular Diseases 2013;2013(6):101-105



BMC Nephrology:     N-Acetylcysteine & Acute Kidney Injury

Poletti et al performed a randomized trial in 120 consecutive emergency department patients with renal impairment, comparing 6000 mg N-acetylcysteine iv or placebo one hour before contrast CT in addition to iv saline. There was no difference in the occurance of contrast nephrotoxicity (defined either as 25% or 44 μmol/l increase in serum creatinine or cystatin C), happening in 22% of patients who received placebo (13/58) and 27% of patients who received N-acetylcysteine (14/52, p = 0.66). 

Full Text:  Poletti. N-acetylcysteine does not prevent contrast nephropathy in patients with renal impairment undergoing emergency CT: a randomized study. BMC Nephrology 2013;14:119





Intensive Care Medicine:     Cardiac Arrest

Intensive Care Medicine:     Noninvasive Ventilation


Canadian Journal of Anesthesia:     Thrombocytopaenia


Canadian Journal of Anesthesia:     Starches


Canadian Journal of Anesthesia:     Neuromuscular Monitoring


Anaesthesia:     Oesophageal Doppler Monitoring


Review - Clinical


Neurology Research International:     Cerebral Vasospasm



Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine:     Cardiac Arrest


Circulation Journal:     Biventricular Pacing


Journal of the American College of Cardiology:     Cardiohepatic Interaction



Thorax:     COPD



European Medical Journal - Gastroenterology:    Acute Pancreatitis



EMJ Hepatology:     Acute-on-Chronic Liver Failure


EMJ Hepatology:     Hepatic Encephalopathy



Therapeutic Hypothermia and Temperature Management:     ECG in Hypothermia


Journal of Pharmaceutical Care:    Vasopressin


Allergy:     Eosinophils


Reports in Medical Imaging:     Ultrasound


I hope you find these brief summaries and links useful.

Until next week