ccr logo 246x225 13121Critical Care Reviews Newsletter

July 23rd 2012





Welcome to the 33rd 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 newsletter is busy and wide-ranging, with review articles on conditions as diverese as haemolytic uraemic syndrome and post transplantation plasma exchange. The new ACCF/AHA guidelines on the management of unstable angina/NSTEMI are included, as are several important research studies.

The topic for This Week's Papers is inotropes & vasopressors, starting with a general paper on the approach to shock and vasopressors in today's Paper of the Day

For those who use social media, links the most popular sites are now included, including facebook and twitter. This will enable bookmarking as well as making friends and colleagues aware of this free resource.



Critical Care Medicine:     Feeding

The ANZICS trial group performed a randomized, controlled trial in 17 ICUs across Australia comparing early nasojejunal (n=92) with nasogastric (n=89) in critically ill patients mechanically ventilated patients with mildly elevated gastric residual volumes and already receiving nasogastric nutrition. There was no difference in the proportion of targeted energy delivered from enteral nutrition between the early nasojejunal nutrition group and the continued nasogastric nutrition group (72% vs 71% respectively, mean difference 1%, 95% CI −3% to 5%, p = .66). Complications such as ventilator-associated pneumonia (20% vs. 21%, p = .94), vomiting, witnessed aspiration, diarrhea, and mortality were similar, although minor gastrointestinal hemorrhage was more common in the early nasojejunal nutrition group (12 [13%] vs. 3 [3%], p = .02).

Abstract:  Davies. A multicenter, randomized controlled trial comparing early nasojejunal with nasogastric nutrition in critical illness (ENTERIC Study). Crit Care Med 2012;40(8):2342-2348


Critical Care Medicine:     Procalcitonin

In a single centre, randomized, controlled study Layios et al compared outcomes from procalcitonin guided antibiotic therapy with standard care in 509 critically ill patients with suspected infection. Although patients in the procalcitonin guided cohort had more withheld anbibiotic therapy, it did not result in reduced antibiotic consumption. The ability of procalcitonin to differentiate between certain or probable infection and possible or no infection, upon initiation of antibiotic treatment was low, as confirmed by the receiving operating curve analysis (area under the curve = 0.69).

Abstract:  Layios. Procalcitonin usefulness for the initiation of antibiotic treatment in intensive care unit patients. Crit Care Med 2012;40(8):2304-2309


Critical Care Medicine:     Sepsis

In a randomized, double-blind, placebo controlled study, Bruno et al investigated the safety, pharmacokinetics and ability to prevent ventilator-associated pneumonia in 39 critically ill mechanically ventilated patients colonized with Pseudomonas aeruginosa. Participants received either 2 different doses of KB100, a recombinant monoclonal antibody directed against the PcrV epitope of Pseudomonas aeruginosa, or placebo. The intervention was safe, had a half-life of approximately 8 to 9 days, was measurable in tracheal aspirates as early as day 1 after administration, and was associated with lower rates of VAP (33%, 31% versus 60%).

Abstract: Bruno. Safety and pharmacokinetics of an anti-PcrV PEGylated monoclonal antibody fragment in mechanically ventilated patients colonized with Pseudomonas aeruginosa: A randomized,double-blind, placebo-controlled trial. Criti Care Med 2012;40(8):2320-2326


Clinical Infectious Diseases:     Ventilator Associated Pneumonia

In a systematic review and meta analysis of 21 studies, O'Horo et al determined that a negative gram stain has a high negative predictive value for the presence of VAP, but the positive predictive value of a positive stain was only 40%. The authors recommend that culture results, but not a positive gram stain, be used to narrow antimicrobial therapy.

Abstract:  O'Horo. Is the Gram Stain Useful in the Microbiologic Diagnosis of VAP? A Meta-analysis. Clin Infect Dis 2012 55: 551-561


Critical Care:     Telemedicine

In a systematic review and meta analysis of 11 observational studies, Wilcox et al found that telemedicine, compared to standard care, was associated with lower ICU mortality (risk ratio 0.79; 95% CI 0.65-0.96; 9 studies, n=23526; I2=70%) and hospital mortality (RR 0.83; 95% CI 0.73-0.94; 9 studies, n=47943; I2=72%). Interventions with continuous patient data monitoring, with or without alerts, appeared to be superior and reduced ICU mortality (RR 0.78; 95% CI 0.64-0.95; 6 studies, n=21384; I2=74%) compared with remote intensivist consultation only (RR 0.64; 95% CI 0.20-2.07; 3 studies, n=2142; I2=71%), but effects were statistically similar (interaction p=0.74). Effects were also similar in higher (RR 0.83, 95% CI 0.68-1.02) vs. lower (RR 0.69; 95% CI 0.40-1.19; interaction p=0.53) quality studies. ICU and hospital length of stay were also reduced with telemedicine intervention.

Full Text: Wilcox. The effect of telemedicine in critically ill patients: systematic review and meta-analysis. Critical Care 2012;16:R127


BMC Infectious Diseases:     Sepsis Biomarkers

In a cohort study of 144 critically ill patients Su et al examined the diagnostic value of soluble triggering receptor expressed on myeloid cells 1 (sTREM-1), procalcitonin (PCT), and C-reactive protein (CRP) serum levels for differentiating sepsis from SIRS, identifying new fever caused by bacteremia, and assessing prognosis when new fever occurred. The sepsis group had higher serum sTREM-1, PCT, and CRP levels compared with the SIRS group (P <0.05), with the areas under the curve (AUC) for these indicators being 0.868 (95% CI, 0.798-0.938), 0.729 (95% CI, 0.637-0.821), and 0.679 (95% CI, 0.578- 0.771), respectively. In patients with new fever, there was no  difference in serum sTREM-1 or PCT levels between those with positive or negative blood cultures. Nonsurvivors with a bacteraemia had higher levels of serum sTREM-1 and PCT (P <0.05), with a prognostic AUC for serum sTREM-1 of 0.868 (95% CI, 0.740-0.997).

Full Text:  Su. Value of soluble TREM-1, procalcitonin, and Creactive protein serum levels as biomarkers for detecting bacteremia among sepsis patients with new fever in intensive care units: a prospective cohort study. BMC Infectious Diseases 2012;12:157


Chest:     Ventilator Induced Diaphragmatic Dysfunction

Grosu et al performed an observational study in 7 critically ill mechanical ventilated subjects, songraphically measuring diaphragmatic muscle thickess daily until extubation, tracheostomy or death. Diaphragm thickness decreased by 6% per day of mechanical ventilation. However, the relationship between diaphragm muscle thickness, diaphragm strength and pulmonary function remains to be determined.

Full Text:  Grosu. Diaphragm Muscle Thinning in Mechanically Ventilated Patients. CHEST 2012; epublished ahead of print



Circulation:     Acute Coronary Syndrome

2012 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction (Updating the 2007 Guideline and Replacing the 2011 Focused Update): A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation; epublished 16 July 2012

Review - Clinical

Indian Journal of Anaesthesiology:     Inflammation


Asian Journal of Neurosurgery:     Telemedicine


QJM:     Interstitial Cardiac Disease


QJM:     Anaphylaxis


Drug Design, Development & Therapy:     Haemolytic Uraemic Syndrome


Annals of Intensive Care Medicine:     Vasculitis


Annals of Intensive Care Medicine:    Biomarker Guided Antibiotic Therapy


Annals of Intensive Care Medicine:     Intra-abdominal Hypertension


Circulation Research:     Mitochondria & Heart Failure


Transfusion Medicine & Hemeotherapy:     Transplantation


Nephrology Dialysis Tranplantation:     Thrombotic Microangiopathy


Review - Non-Clinical

Indian Journal of Anaesthesiology:     Internet Resources

(they don't seem to have looked too hard.....)



I hope you find these links and brief summaries useful.

Until next week