ccr logo 246x225 13121Critical Care Reviews Newsletter

September 23rd 2012





Welcome to the 42nd 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.

In comparison with last week, there have been a number of interesting studies published this week, with the stand out paper being a retrospective review by the NICE-SUGAR investigators of their trial data, demonstrating a strong association between hyponatraemia and mortality. For clinicians using etomidate, a systematic review of the safety of this induction agent may make uncomfortable reading. Three study protocols have been published - one in sepsis and two in ARDS, including the Belfast based HARP-2 study. The review articles cover the usual wide range of topics, including a paper on the top 50 cited respiratory articles.

The topic for This Week's Papers is colloids, starting with a paper overviewing the contrasting properties of the different solutions  in tomorrow's Paper of the Day. It's a free and easy way to stay up-to-date with your reading.

The new CPD / CME facility is ready to go, but I'm still awaiting official approval. Hopefully I'll be able to release it this week.



New England Journal of Medicine:     Glycaemic Control

The NICE-SUGAR investigators performed a retrospective analysis of 6026 patients enrolled in the randomized NICE-SUGAR study, to assess the associations between moderate hypoglycaemia (41 to 70 mg/dL; 2.3 to 3.9 mmol/L), severe hypoglycemia (≤40 mg/dL; ≤ 2.2 mmol/L] and death. Data was available for 3010 patients assigned to undergo intensive glycaemic control and 3012 undergoing conventional control. 829 patients (27.5%) in the intensive-control group and 751 (24.9%) in the conventional-control group died (odds ratio for intensive control, 1.14; 95% CI 1.02 to 1.28; P=0.02). The treatment effect did not differ significantly between surgical patients and medical patients (odds ratio for death in the intensive-control group, 1.31 and 1.07, respectively; P=0.10). Severe hypoglycemia was reported in 206 of 3016 patients (6.8%) in the intensive-control group and 15 of 3014 (0.5%) in the conventional-control group (P<0.001). There was no significant difference between the two treatment groups in the median number of days in the ICU (P=0.84) or hospital (P=0.86) or the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39).

Abstract:  The NICE-SUGAR Study Investigators. Hypoglycemia and Risk of Death in Critically Ill Patients. N Engl J Med 2012;367:1108-1118


New England Journal of Medicine:     Funding & Study Interpretation

To understand the effects of funding on the interpretation of study data, Kesselheim et al performed a randomized trial, presenting 503 board-certified internists with 3 hypothetical drug study abstracts of differing methodological quality (low, medium, high). One of three different funding bodies (NIH, industry or not specified) was randomly allocated to each abstract. Therefore, for both factors studied (rigor and funding), one of the three possible variations was randomly selected for inclusion in the abstracts. The response rate was 53%. Physicians were half as willing to prescribe drugs studied in industry-funded trials as they were to prescribe drugs studied in NIH-funded trials (odds ratio, 0.52; 95% CI, 0.37 to 0.71; P<0.001). These effects were consistent across all levels of methodologic rigor.

Full Text:  Kesselheim. A Randomized Study of How Physicians Interpret Research Funding Disclosures. N Engl J Med 2012;367:1119-1127  (associated editorial)


American Journal of Respiratory and Critical Care Medicine:     Weaning

Dessap et al performed a randomized controlled multicentre study in 304 patients to determine whether fluid management guided by daily B-type natriuretic peptide improved weaning from mechanical ventilation compared with empirical therapy dictated by clinical acumen. In the BNP-driven group, furosemide and acetazolamide were given more often and in higher doses than in the control group, resulting in a more negative median (interquartile range) fluid balance during weaning (-2320 (-4735, 738) mL vs. -180 (-2556, 2832) mL, p<0.0001). Time to successful extubation was significantly shorter with the BNP-driven strategy (58.6 (23.3, 139.8) hours vs. 42.4 (20.8, 107.5) hours, p=0.034). The BNP-driven strategy increased the number of ventilator-free days but did not change length of stay or mortality. The effect on weaning time was strongest in patients with left ventricular systolic dysfunction. The two strategies did not differ significantly regarding electrolyte imbalance, renal failure, or shock.

Abstract:  Dessap. Natriuretic Peptide-Driven Fluid Management during Ventilator Weaning: A Randomized Controlled Trial. Am J Respir Crit Care Med 2012; epublished ahead of print


Critical Care Medicine:     Etomidate

Chan and colleagues performed a systematic review and meta-analysis to assess the effects of etomidate on adrenal insufficiency and all-cause mortality in sepsis. Mortality was assesed in 5 studies (n=865), with patients who received etomidate more likely to die (pooled relative risk 1.20; 95% CI 1.02-1.42; Q statistic, 4.20; I2 statistic, 4.9%). Adrenal suppression was assessed in 7 studies (n=1,303), with etomidate administration increasing the likelihood of developing adrenal insufficiency (pooled relative risk 1.33; 95% confidence interval 1.22-1.46; Q statistic, 10.7; I2 statistic, 43.9%).

Abstract:  Chan. Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis. Crit Care Med 2012; epublished ahead of print


PLoS One:     Ventilator-Associated Pneumonia

Capellier et al evaluated whether two different antibiotic treatment durations (8 versus 15 days) were equivalent in terms of clinical cure for early-onset ventilator-associated pneumonia. 225 patients were recruited in 13 centers. 191 (84.9%) patients were cured: 92 out of 109 (84.4%) in the 15 day cohort and 99 out of 116 (85.3%) in the 8 day cohort (difference = 0.9%, odds ratio = 0.929). 95% two-sided confidence intervals for difference and odds ratio were [−8.4% to 10.3%] and [0.448 to 1.928] respectively. Although the rate of secondary infection was greater in the 8 day than the 15 day cohort, the number of days of antibiotic treatment remained lower in the 8 day cohort. There was no difference in mortality rate between the 2 groups on days 21 and 90.

Full Text: Capellier. Early-Onset Ventilator-Associated Pneumonia in Adults Randomized Clinical Trial: Comparison of 8 versus 15 Days of Antibiotic Treatment. PLoS One 2012;7(8):e41290


Transfusion Medicine Reviews:     Study Protocol - Fluid Resuscitation in Sepsis

Investigators led by McIntyre plan a pragmatic early septic shock fluid resuscitation trial to compare the effectiveness of 5% albumin with normal saline on 90-day mortality (PRECISE).

Abstract:  McIntyre. The PRECISE RCT: Evolution of an Early Septic Shock Fluid Resuscitation Trial. Transfusion Medicine Reviews 2012;26(4):333-341


Trials:     Study Protocol - Acute Lung Injury

McAuley et al are undertaking a multicenter, prospective, randomized, allocation concealed, double-blind, placebo-controlled clinical trial to test whether simvastatin will improve clinical outcomes in ALI. Patients fulfilling the American-European Consensus Conference Definition of ALI will be randomized in a 1:1 ratio to receive enteral simvastatin 80 mg or placebo once daily for a maximum of 28 days. The primary outcome is number of ventilator-free days to day 28. A total of 540 patients will be recruited from approximately 35 ICUs in the UK and Ireland.

Full Text:  McAuley. Hydroxymethylglutaryl-CoA reductase inhibition with simvastatin in Acute lung injury to Reduce Pulmonary dysfunction (HARP-2) trial: study protocol for a randomized controlled trial. Trials 2012;17;13(1):170


BMJ Open:     Study Protocol - Aspirin in ARDS

LIPS-A is a multicentre, double-blind, randomised clinical trial testing the hypothesis that the early administration of ASA will result in a reduced incidence of ALI in adult patients at high risk. This investigation will enrol 400 study participants from 14 hospitals across the USA.

Full Text:  Jon Kor. Lung Injury Prevention with Aspirin (LIPS-A): a protocol for a multicentre randomised clinical trial in medical patients at high risk of acute lung injury. BMJ Open 2012; 2(5):e001606


Review - Clinical

Emergency Medicine International:     Traumatic Brain Injury


Swiss Medical Weekly:     Trauma


Saudi Journal of Anaesthesia:     Acute Epiglottitis


Scandanavian Journal of Trauma, Resuscitationa nd Emergency Medicine:     Trauma


Critical Care Research & Practice:     Weaning


Acta Medica Indonesiana


Pathobiology:     Sepsis

New England Journal of Medicine:     Liver Transplantation


New England Journal of Medicine:     History of Medicine - Therapy


Saudi Journal of Gastroenterology:     Hepatic Encephalopathy


Blood Transfusion:    Liver Disease


Respirology:     Top Cited Respiratory Articles


Review - Basic Science

Frontiers in Vascular Physiology:     Cerebral Blood Flow



I hope you find these brief summaries useful.

Until next week