Critical Care Reviews Newsletter

January 29th 2012




Welcome to the eighth Critical Care Reviews Newsletter. Every weekend some of the more important studies in critical care, which were published that week, are highlighted. These studies are added to the News section of the website, usually on a daily basis as publication occurs.

Unfortunately, there are too many studies to include this week, so I'll add the remaining ones to the News section over the next few days and include them in next week's newsletter.


Journal of Enteral and Parenteral Nutrition

Parenteral Nutrition

Pontes-Arruda report the results of an international, multicenter, prospective, randomized, open-label, controlled trial which investigated the differences in bacteraemias associated with 2 different parenteral nutrition systems. In 406 patients receiving PN via either a multi-chamber delivery system (n=202), or compounded PN (2 groups, n=101 and n=103 ) the incidence of bacteraemias was significantly lower with the multi-chamber delivery system ( 34 vs 46; p = 0.03). Central line-associated bacteraemias were also significantly lower with the multi-chamber delivery system (10.3 vs 13.2; p < 0.0001).

Abstract: Pontes-Arruda. Influence of Parenteral Nutrition Delivery System on the Development of Bloodstream Infections in Critically Ill Patients: An International, Multicenter, Prospective, Open-Label, Controlled Study—EPICOS Study. JPEN J Parenter Enteral Nutr published 23 January 2012.

Critical Care

Septic Acute Kidney Injury

Pickkers report the results of a small randomized placebo controlled trial investigating the use of alkaline phosphate in septic acute kidney injury. Thirty six adults with severe sepsis or septic shock, and new AKI requiring renal replacement therapy received either alaline phosphatase (bolus injection of 67.5U/kg body weight followed by continuous infusion of 132.5U/kg/24h for 48 hours) or placebo. Endogenous creatinine clearance (baseline to day 28) was significantly higher in the AP group relative to placebo (from 50+/-27 to 108+/-73mL/min (mean+/-SEM) versus from 40+/-37 to 65+/-30mL/min; p=0.01). Reductions in RRT requirement and duration did not reach significance. Both the systemic markers C-reactive protein, Interleukin 6, and LPS-binding protein, and the urinary markers Kidney Injury Molecule-1 and Interleukin-18 were reduced in AP-treated patients relative to placebo.

Full Text: Pickkers. Alkaline phosphatase for treatment of sepsis-induced acute kidney injury: a prospective randomized double-blind placebo-controlled trial. Critical Care 2012, 16:R14


American Journal of Respiratory and Critical Care Medicine


Schädler performed a prospective randomized controlled trial investigating whether automated weaning decreases overall ventilation time compared to weaning based on a standardized written protocol in an unselected surgical patient population. In 300 subjects, there was no difference in duration of ventilation {(median/IQR),  31 [19-101] hours, n=150 vs 39 [20-118] hours, n=150, respectively; p=0.178}.

Abstract: Schädler. Automatic Control of Pressure Support for Ventilator Weaning in Surgical Intensive Care Patients. Am J Respir Crit Care Med 2012, epublished ahead of print


European Heart Journal

Contrast-Induced Nephropathy

Klima et al conducted a prospective, randomized trial in 258 consectutive patients with renal insufficiency undergoing contrast procedures. Patients received intravenous volume supplementation with either (A) sodium chloride 0.9% 1 mL/kg/h for at least 12h prior and after the procedure or (B) sodium bicarbonate (166 mEq/L) 3 mL/kg for 1h before and 1 mL/kg/h for 6h after the procedure or (C) sodium bicarbonate (166 mEq/L) 3 mL/kg over 20min before the procedure plus sodium bicarbonate orally (500 mg per 10 kg). GFR was least affected with sodium chloride therapy, with both sodium bicarbonate therapies being similar. The incidence of contrast-induced nephropathy was significantly smaller with sodium chloride, at 3%, but higher with the bicarbonate therapies at 9% and 10%, respectively.

Abstract: Klima. Sodium chloride vs. sodium bicarbonate for the prevention of contrast medium-induced nephropathy: a randomized controlled trial. Eur Heart J 2012 epublished ahead of print 


European Journal of Heart Failure

NT-Pro B Natriuretic Peptide

Epublished ahead of print, the PROMPT study investigated the value of NT-proBNP testing in the medical emergency department  in patients over 65 years old. The median NT-proBNP was 582 pg/mL, with subjects divided into low NT-proBNP <150 pg/mL, intermediate NT-proBNP 150 and 1800 pg/mL (55%), and high NT-proBNP >1800 pg/ml(29%). NT-proBNP was positively correlated with hospital admission, length of stay, in-hospital death, 6 months re-hospitalization, and 6 months death or re-hospitalization (all p<0.01 or more extreme). Interestingy, in the total cohort,  knowledge of NT-proBNP had no significant effect on the primary endpoint hospital admission and the secondary endpoints intermediate/intensive care unit admission, length of stay, re-hospitalization and death, or re-hospitalization.  Comparing the open NT-proBNP cohort with the blind cohort, patients with high NT-proBNP were more likely to be admitted to hospital and/or ICU, and those with low values less likely.

Abstract: Luchner. N-terminal pro brain natriuretic peptide in the management of patients in the medical emergency department (PROMPT): correlation with disease severity, utilization of hospital resources, and prognosis in a large, prospective, randomized multicentre trial. Eur J Heart Fail 2012 published 20 January 2012.



Hyperoxia to prevent Surgical-Site Infections

Seven trials, totalling 2728 patients, were identified, with 1358 patients randomly assigned to hyperoxia and 1370 to control. The pooled infection rate in the hyperoxia group was 15.5% versus 17.5% in the control group, p=0.58 ( Odds Ratio 0.85 for preventing surgical site infection (0.52, 1.38) (P = 0.51). Subgroup analysis suggested a possibe role for hyperoxia in those receiving general anaesthesia and colorectal patients.

Abstract: Togioka. The Role of Perioperative High Inspired Oxygen Therapy in Reducing Surgical Site Infection: A Meta-Analysis. Anesth Analg 2012;114 334-342


The Journal of Trauma and Acute Care Surgery

Residual Haemothorax

DuBose reports the results of a prospective, observational, multicentre study investigating current management of residual haemothorax in the USA and predictors for thoracotomy. In 328 patients from 20 centres, video-assisted thoracostomy (33%) was the most commonly initial approach with 20% requiring thoracotomy. The best predictor of successful conservative management was a small haemothorax volume (<300 ml), OR 3.7 [2.0–7.0]; p < 0.001. The best predictors of thoracotomy were diaphragm injury (OR, 4.9 [2.4–9.9]; p < 0.001), residual haeothorax >900 ml (OR, 3.2 [1.4–7.5]; p = 0.007), and failure to give periprocedural antibiotics for initial chest tube placement (OR 2.3 [1.2–4.6]; p = 0.015). The overall empyema and pneumonia rates for 27% and 19.5%, respectively.

Abstract: DuBose. Management of post-traumatic retained hemothorax: A prospective, observational, multicenter AAST study. J Trauma 2012;72(1):11–24


Haematocrit in early Trauma

In a retrospective study on 198 tauma patients, Ryan and colleagues show a clear correlation between signs of shock and the initial haematocrit, questioning the suggestion that fluid shifts occur too slowly for Hct to be useful in early haemorrhagic trauma. In a redominantly young, male population with penetrating injuries initial Hct correlated with hypotension, acidosis, altered mental status, Injury Severity Score, Revised Trauma Score, estimated blood loss, usage of packed red blood cells and vasopressors (all p < 0.001), as well as fresh frozen plasma (p = 0.003), and crystalloid (p = 0.021).

Abstract: Ryan. Initial hematocrit in trauma: A paradigm shift? J Trauma 2012;72(1):54-60



I hope you find these brief summaries useful.

Until next week