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Critical Care Reviews Newsletter

June 24th 2013



Welcome to the 81st 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 multiple research studies include investigations into stroke thrombolysis, acute kidney injury, route of feeding, central venous pressure as a guide for fluid therapy, ventilator-associated pneumonia, ICU provision for elderly patients and beta 2 agonists for acute lung injury.

This week's guidelines are on red cell transfusion in the critically ill, and the management of cytomegalovirus infection in haematology patients. There are editorials on non-ST elevation myocardial infarction and medical journalism. Commentaries address the UK NHS, MERS-CoV, MRSA, aquaretics, guidelines, pandemic influenza and informed scepticism.

Amongst the clinical review articles are papers on intracerebral haemorrhage, traumatic brain injury, volaemic status and fluid responsiveness, mechanical suport devices, cirrhosis and its associated complications, acute kidney injury, traumatic coagulopathy, fungal infections, polytrauma management and hypertonc saline for trauma resuscitation

The topic for This Week's Papers is hyperthermic conditions, starting with a paper on neuroleptic malignant syndrome in today's Paper of the Day.



Journal of the American Medical Association:     Stroke Thrombolysis

Saver and colleagues performed a registary database analysis, investigating 58 353 patients with acute ischemic stroke treated with tPA within 4.5 hours of symptom onset. Shorter onset to treatment time was associated with reduced in-hospital mortality (odds ratio 0.96; 95% CI 0.95-0.98; P < 0.001), reduced symptomatic intracranial hemorrhage (OR 0.96; 95% CI 0.95-0.98; P < 0.001), increased achievement of independent ambulation at discharge (OR 1.04; 95% CI 1.03-1.05; P < 0.001), and increased discharge to home (OR 1.03; 95% CI 1.02-1.04; P < 0.001). The main patient factors associated with a shorter onset to treatment time were increased stroke severity (OR 2.8; 95% CI 2.5-3.1 per 5-point increase), arrival by ambulance (OR 5.9; 95% CI 4.5-7.3), and presentation in regular hours (OR 4.6; 95% CI 3.8-5.4). Inhospital mortality was 8.8%, with just 38.6% being discharged home.

Abstract:  Saver. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA 2013;309(23):2480-2488


Critical Care Medicine:     Acute Kidney Injury

McGuinness et al completed a phase IIb multicenter double-blind randomized controlled trial, comparing sodium bicarbonate infusion (n=215) with 0.9% saline infusion (n=212) for the prevention of cardiac surgery–associated acute kidney injury in 427 at risk patients. There was no difference in the incidence in AKI, (bicarbonate 47% versus saline 44%; p=0.58), duration of either ventilation, ICU stay, or hospital stay, or mortality.

Abstract:  McGuinness. Sodium Bicarbonate Infusion to Reduce Cardiac Surgery-Associated Acute Kidney Injury: A Phase II Multicenter Double-Blind Randomized Controlled Trial. Critical Care Medicine 2013;41(7):1599-1607


Critical Care Medicine:     Extracorporeal Membrane Oxygenation

Bréchot undertook a retrospective, single-center, observational study and cross-sectional survey to assess health-related quality of life in 14 patients who received venoarterial extracorporeal membrane oxygenation for septic shock refractory to conventional treatment. Twelve patients (86%) were weaned off venoarterial extracorporeal membrane oxygenation after 5.5 days (2–12) days of support and 10 patients (71%) were discharged home and were alive after a median follow-up of 13 months (3–43). All 10 survivors had normal left ventricular ejection fraction and reported good health-related quality of life at long-term follow-up.

Abstract:  Bréchot. Venoarterial Extracorporeal Membrane Oxygenation Support for Refractory Cardiovascular Dysfunction During Severe Bacterial Septic Shock. Critical Care Medicine 2013;41(7):1616-1626


Critical Care Medicine:     Fluid Responsiveness

Using data from healthy controls studies (n = 1), ICU studies (n = 22) and operating room studies (n = 20), Marik updated his previous systematic review and meta analysis examining the utility of central venous pressure to predict fluid responsiveness. Just over half of patients were fluid responsive (57%± 13%). Overall, CVP had no ability to predict fluid responsiveness (AUC 0.56, 95% CI 0.54–0.58) with no improvement in subgroups; ICU patients 0.56 (95% CI, 0.52–0.60 and OR patients 0.56 (95% CI, 0.54–0.58). Similarly, correlation between baseline CVP and change in stroke volume index/cardiac index was also poor, being 0.18 (95% CI, 0.1–0.25) overall, 0.28 (95% CI, 0.16–0.40) in ICU patients, and 0.11 (95% CI, 0.02–0.21) in OR patients.

Abstract:  Marik. Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Critical Care Medicine 2013;41(7):1774-1781


Critical Care Medicine:     Chest Compressions

Westfall and colleagues undertook a systematic review and meta analysis questioning whether mechanical or manual chest compression was superior for achieving a return of spontaneous circulation in cardiac arrest. 12 studies (n=6,538, 1,824 return of spontaneous circulation events), were included. Load-distributing band CPR was superior to manual CPR (odds ratio 1.62, 95% CI 1.36 - 1.92, p <0.001), although piston-driven CPR was as effective as manual CPR (OR 1.25, 95% CI 0.92 - 1.68; p = 0.151). Compared with manual CPR, combining both mechanical devices was associated with a higher odds of return of spontaneous circulation (OR 1.53; 95% CI 1.32 - 1.78], p < 0.001).

Abstract:  Westfall. Mechanical Versus Manual Chest Compressions in Out-of-Hospital Cardiac Arrest: A Meta-Analysis. Critical Care Medicine 2013;41(7):1782-1789


New England Journal of Medicine:     MERS-CoV

Assiri et al describe a cluster of 23 cases of healthcare associated MERS-CoV occuring between April 1st and May 23rd 2013 in Saudi Arabia. By June 15th, the mortality rate was 65% (n=15), with the remained either having recovered (n=6, 26%) or remaining hospitalized (n=2, 9%). Symptoms included fever (87%), cough (87%), dyspnoea (48%) and GI symptoms (35%), with 87% presenting with an abnormal chest radiograph. The majority of infections (21/23) were acquired by person-to-person transmission in hemodialysis units, intensive care units, or in-patient units, with a median incubation period of 5.2 days.

Full Text:  Assiri. Hospital Outbreak of Middle East Respiratory Syndrome Coronavirus. New Eng J Med 2013;epublished June 19th


British Journal of Anaesthesia:     Sedation

Adams and colleagues performed an objective appraisal of 6 randomized control trials comparing the sedative and clinical effectiveness of dexmedetomidine with midazolam in adult ICU patients.  Superior sedative effects of dexmedetomidine, as measured by duration at target sedation zone, were not demonstrated. Some secondary endpoints demonstrated clinical effectiveness, but more studies are required to verify these findings.

Abstarct:  Adams. Efficacy of dexmedetomidine compared with midazolam for sedation in adult intensive care patients: a systematic review. Br J Anaesth 2013;epublished June 7th


Intensive Care Medicine:     Decision Making for Elderly Patients

To determine the preferences of elderly people (≥ 80 years) for life-sustaining therapy during a future hypothetical critical illness, Philippart et al undertook an observational cohort study of consecutive previously hospitalised community-dwelling elderly people and of volunteers residing in nursing homes or assisted-living facilities. Of the 115 participants (response rate 87%), there was a high rate of refusal of life saving therapy - noninvasive ventilation 27% , invasive mechanical ventilation 43%, renal replacement therapy after invasive ventilation 63%. Perceived quality of life post therapy was a major reason for therapy refusal.

Abstract:  Philippart. The ETHICA study (part I): elderly's thoughts about intensive care unit admission for life-sustaining treatments. Intensive Care Med 2013;epublished June 14th


Garrouste-Orgeas performed an observational simulation study to evaluate physician decisions on ICU admission for life-sustaining treatments for patients aged ≥ 80 years. One hundred physicians participated (46% participation rate). Using logistic regression analysis, factors associated with admission were age <85 years, self-sufficiency, and bed availability for noninvasive ventilation and invasive mechanical ventilation. Intensivists were less likely to institute invasive mechanical ventilation if patients had a previous ICU admission (odds ratio 0.29, 95 % CI 0.13–0.65, p = 0.01), or cancer (OR 0.23, 95 % CI 0.10–0.52, p = 0.003). Renal replacement therapy was more likely to be commenced if there was a living spouse (OR 2.03, 95 % CI 1.04–3.97, p = 0.038), but less likely if there was co-existing respiratory disease (OR 0.42, 95 % CI 0.23–0.76, p = 0.004). There was little agreement among physicians as to when to begin life-supporting treatment.

Abstract:  Garrouste-Orgeas. The ETHICA study (part II): simulation study of determinants and variability of ICU physician decisions in patients aged 80 or over. Intensive Care Med 2013;epublished June 14th


Critical Care:     Feeding Route

Deane and colleagues completed a systematic review and meta analysis (15 studies) comparing intragastric feeding with small bowel feeding in critically ill adult patients. Small bowel feeding was associated with a reduced risk of pneumonia (relative risk  0.75, 95% CI 0.60-0.93; P = 0.01; I2=11%). There was no difference in duration of ventilation (weighted mean difference: -0.36 days, 95% CI -2.02 to 1.30; P = 0.65; I2=42%), length of ICU stay (WMD: 0.49 days, 95% CI -1.36 to 2.33; P = 0.60; I2=81%) or mortality (RR 1.01, 95% CI 0.83 to 1.24; p = 0.92; I2=0%). Small bowel feeding was associated with significantly improved nutrient delivery (% goal rate received: 11%,  95% CI 5-16; P = 0.0004; I2=88%).

Full Text:  Deane. Comparisons between intragastric and small intestinal delivery of enteral nutrition in the critically ill: a systematic review and meta-analysis. Critical Care 2013;17:R125


Chest:     Prehospital Management of Critical Illness

Ellis et al completed a multi-center cross sectional descriptive study, totalling 390 critical care encounters, evaluating primary care providers (PCPs) pre-hospital management of evolving acute severe illness. In 300 encounters primary care providers implemented pre-hospital management for 8 episodes of acute illness, attributed a lack of awareness of the patient’s evolving acute illness. Just 21% of primary care providers were aware of the acute severe illness before their patient was admitted to an ICU and 33% were not aware that their patient was in an ICU.

Abstract:  Ellis. Prehospital Management of Evolving Critical Illness by the Primary Care Provider. Chest 2013;epublished June 20th


Chest:     Ventilator-Associated Pneumonia

Dimopoulos performed a systematic review and meta-analysis, totalling 4 randomized controlled trials, comparing short (7-8 days)- with long (10-15 days)-duration antibiotic regimens for ventilator-associated pneumonia.There was no difference in mortality (odds ratio 1.20, 95% CI 0.84-1.72, p=0.32), or in relapses, although long-course treatment was associated with a strong trend to lower relapses (OR 1.67, 95% CI 0.99-2.83, p=0.06). Short-course treatment was associated with an increase in antibiotic-free days, with a pooled weighted mean difference of 3.40 days ( 95% CI 1.43 to 5.37, p<0.001).

Abstract:  Dimopoulos. Short- versus long-duration antibiotic regimens for ventilator-associated pneumonia: a systematic review and meta-analysis. Chest 2013;epublished June 20th


Critical Care:     Acute Kidney Injury

Ralib completed an observational study in 725 critically ill patients, aiming to prospectively validate the acute kidney injury urine output criterion of 0.5 ml/kg/h for 6-hours ("AKIUO"). 72% had either an increase in creatinine (increase in plasma creatinine of ≥26.5 mol/l within 48 hours or ≥50% from baseline, "AKICr") or both. AKIUO alone was more frequent than AKICr (33.7% versus 11.0%; P<0.0001). A 6-hour urine output threshold of 0.3 ml/kg/h best associated with mortality and dialysis and was independently predictive of both hospital and 1-year mortality.

Full TextRalib. The urine output definition of acute kidney injury is too liberal. Critical Care 2013;17:R112


Critical Care:     Acute Pancreatitis

In a systematic review and meta analysis, totalling 3 randomized controlled trials (n=157), Chang and colleagues examined the differences in safety and tolerance between nasogastric and nasojejunal feeding in patients with severe acute pancreatitis. There was no differences in mortality (risk ratio 0.69, 95% CI 0.37-1.29, P = 0.25); tracheal aspiration (RR 0.46, 95% CI 0.14-1.53, P = 0.20); diarrhoea (RR 1.43, 95% CI 0.59-3.45, P = 0.43); exacerbation of pain (RR 0.94, 95% CI 0.32-2.70, P = 0.90), or meeting energy balance (RR 1.00, 95% CI 0.92-1.09, P = 0.97).


Anesthesia & Analgesia:     Emergent Intubation

Kory and colleagues performed a before and after study to examine the effectiveness of using a video laryngoscope (n=78), rather than a direct laryngoscope (n=50) as the primary intubating device during urgent 138 endotracheal intubations in critically ill patients when performed by less experienced operators (Pulmonary and Critical Care Medicine fellows). The use of the video laryngoscope was associated with a superior first-attempt success rate (91% vs 68%, P < 0.01). Additionally, the video laryngoscope decreased the numer of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01).

Abstract:  Kory. The Impact of Video Laryngoscopy Use During Urgent Endotracheal Intubation in the Critically Ill. Anesth Analg 2013;117(1):144-149


Respiratory Care:    Acute Lung Injury

In a systematic review and meta analysis, Singh and colleagues identified 3 randomized placebo controlled trials (n=646) comparing beta-2 agonists (51.7%) with placebo (48.3%) for the treatment of acute lung injury.  There was no difference in 28-day (relative risk 1.04; 95% CI 0.50-2.16) or hospital mortality (RR 1.22; 95% CI 0.95-1.56) with β2-agonist therapy.  β2-agonists therapy was associated with reduced ventilator-free days (mean difference -2.19 days; 95% CI=-3.68 to -1.99) and organ failure-free days (mean difference -2.04; 95% CI= -3.74 to -0.35).

Full Text:  Singh. Beta-2-agonist for the treatment of acute lung injury: a systematic review and meta-analysis. Respir Care 2013;epublished June 18th 



British Journal of Haematology:     Red Cell Transfusion


British Journal of Haematology:     Cytomegalovirus Infection



Heart:     STEMI Guidelines


Journal of the American Medical Association:     Medical Journalism   



British Medical Journal:     Guidelines


Kidney International:     Aquaretics


New England Journal of Medicine:     NHS


New England Journal of Medicine:     Pandemic Influenza


International Journal of Emergency Medicine:     Dutch Emergency Medicine Training


Journal of Microbiology, Immunology and Infection:     MRSA


British Medical Journal:     Informed Scepticism



Review - Clinical


Anesthesiology:     Intracerebral Haemorrhage


Frontiers Neurology:     Traumatic Brain Injury



Kidney International:     Fluid Management


Progress in Transplantation:     Mechanical Circulatory Support


European Journal of Clinical Investigation:     Myocardial Infarction


European Heart Journal Cardiovascular Imaging:     3D Intracardiac Echocardiography


Indian Journal of Endocrinology & Metabolism:     Statins


Vascular Health and Risk Management:     Heart Failure



Clinical Liver Disease:     Cirrhosis



Journal of Clinical Gerontology and Geriatrics:     Acute Kidney Injury


Nephrology Dialysis Transplantation:     Elegance in Nephrology



Anesthesiology:     Traumatic Coagulopathy



Annals of Medical and Health Sciences Research:     Fungal Infections


Marine Drugs:     Gram Negative Sepsis



Malaysian Journal of Medical Science:     Polytrauma


Clinics (Sao Paulo):     Hypertonic Saline for Resuscitation



ISRN Emergency Medicine:     Pain


Anesthesiology News:     Opioid Abuse



Oxidative Medicine and Cellular Longevity:     Bruise



I hope you find these brief summaries and links useful.

Until next week