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Newsletter 114 / February 9th 2014

Welcome

 

Hello

Welcome to the 114th 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, guidelines, commentaries and editorials from over 300 clinical and scientific journals.

This week's research studies include a single randomized controlled trial investigating blood pressure control in ischaemic stroke; meta analyses address β2 agonist therapy in acute lung injury and delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage; while featuerd observational studies focus on fraility and cardiac output measurement. One guideline outlines the management of hypertension, while a study critique, looks at the BEST TRIP study, assessing intracranial pressure monitoring in traumatic brain injury. Case reports, address avian influenza H10N8, metabolic alkalosis and air embolism, while commentaries focus on brain death, palliative care, highlights from the recent SCCM meeting and cardiology updates.

Amongst the clinical review articles are papers on cerebral vasculitis, acute coronary syndromes, extracorporeal life support, intra-abdominal hypertension, hepatic encephalopathy, adrenocortical insufficiency, blood transfusion, VRE, direct laryngoscopy, and leadership during resuscitation. Non-clinical reviews include an entire issue of Emergency Medicine Australasia on research, publishing, progress and medical education in emergency medicine. The beginning of each month marks the addition of recently made open access articles from the major critical care journals, with 27 papers now available.

The topic for This Week's Papers is myocardial conditions, starting with a paper on stress related cardiomyopathies in tomorrow's Paper of the Day.

Following on from the recent Critical Care Reviews Meeeting, another speaker has an upcoming event - Prof Mervyn Singers' 42nd Medical Emergencies Course for Trainees, on March 29th and 30th. Registration and the programme can be accessed via these links.

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News

 

Research

Randomized Controlled Trials

He and colleagues completed a blinded, randomized clinical trial (China Antihypertensive Trial in Acute Ischemic Stroke) in 4,071 patients with nonthrombolysed ischemic stroke within 48 hours of onset and elevated systolic blood pressure, comparing antihypertensive therapy (aimed at lowering systolic blood pressure by 10% to 25% within the first 24 hours after randomization, achieving blood pressure less than 140/90 mm Hg within 7 days, and maintaining this level during hospitalization) with no antihypertensive therapy during hospitalization, and found:
  1. antihypertensive therapy was associated with
    • a greater reduction in mean systolic blood pressure
      • within the first 24 hours
        • 166.7 mm Hg to 144.7 mm Hg (−12.7%) versus 165.6 mm Hg to 152.9 mm Hg (−7.2%) 
        • difference −5.5% (95% CI −4.9 to −6.1%)
        • absolute difference −9.1 mm Hg (95% CI −10.2 to −8.1) p <  0.001
      • at day 7
        • 137.3 mm Hg versus 146.5 mm Hg
        • difference −9.3 mm Hg (95% CI −10.1 to −8.4); p < 0.001
  2. there was no difference in
    • 1° outcome
      • combination of death and major disability (modified Rankin Scale score ≥3) at 14 days or hospital discharge
        • antihypertensive group: 683 events versus control group: 681 events
        • odds ratio 1.00 (95% CI 0.88 to 1.14); p = 0.98
    • 2° outcome
      • composite outcome of death and major disability at 3-month posttreatment
        • antihypertensive group: 500 events versus control group: 502 events
        • odds ratio 0.99 (95% CI 0.86 to 1.15); p = 0.93
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Meta Analysis

Singh et al pooled data from 3 randomized, placebo-controlled trials investigating β2 agonist therapy in 646 patients with acute lung injury (ALI), and found:

  1. β2 agonist therapy was associated with
    • no significant decrease in
      • 28-day mortality 
        • relative risk 1.04, 95% CI 0.50 to 2.16
      • hospital mortality
        • relative risk 1.22, 95% CI 0.95 to 1.56
    • decreases in
      • ventilator-free days
        • mean difference −2.19 days (95% CI −3.68 to −1.99 d)
      • organ-failure-free days
        • mean difference −2.04 days (95% CI −3.74 to −0.35 d)

Cremers and colleagues reviewed data on 570 patients from 11 studies evaluating CT perfusion for the prediction and diagnosis of delayed cerebral ischaemia in aneurysmal subarachnoid haemorrhage, and found:

  1. on admission, there was no difference in numerous variable between those who did and did not develop DCI
    • cerebral blood flow
    • cerebral blood volume
    • mean transit time
    • time-to-peak
  2. In the delayed cerebral ischemia time-window (4 to 14 days after subarachnoid hemorrhage),
    • DCI was associated with a
      • decreased cerebral blood flow
        • pooled mean difference −11.9 mL/100g per minute (95% CI −15.2 to −8.6)
      • increased mean transit time
        • pooled mean difference 1.5 seconds (0.9 to 2.2)
    • delayed cerebral ischaemia was not associated with
      • cerebral blood volume
    • time-to-peak was rarely reported

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Observational Studies

Bagshaw et al characterised fraility (loss of physiologic and cognitive reserves) in 421 critically ill Canadian adults aged ≥ 50, and found:

  1. prevalence of frailty was 32.8% (95% CI 28.3% to 37.5%)
  2. frail patients, in comparison with non-frail patients, were
    • older
    • more likely to be female
    • had more comorbidities 
    • greater functional dependence 
  3. fraility was associated with increased
    • hospital mortality
      • 32% v. 16%; adjusted odds ratio 1.81, 95% CI 1.09 to 3.01
        • remaining higher at 1 year
          • 48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28 to 2.60
    • major adverse events 
      • 39% v. 29%; OR 1.54, 95% CI 1.01 to 2.37 
    • functional dependence
      • 71% v. 52%; OR 2.25, 95% CI 1.03 to 4.89
    • hospital readmissions
      • 56% v. 39%; OR 1.98, 95% CI 1.22 to 3.23
    • reduction of quality of life

Metzelder and colleagues evaluated the validity and precision of pulse contour cardiac output (PCCO) using the PiCCOTM-device compared to transpulmonary thermodilution derived cardiac output (TPCO) in 20 neurosurgical patients requiring high-dose vasopressor-therapy, and found:

  1. measurements
    • PCCO- and TPCO-measurements were obtained at
      • baseline
      • 2 h, 6 h, 12 h, 24 h, 48 h and 72 h
      • 136 CO-data pairs were analyzed
  2. pharmacological and physiological data
    • vasoactive support (mean/SD)
      • 0.57 ± 0.49 μg/kg/min norepinephrine
    • mean arterial pressure of
      • 103 ± 13 mmHg 
    • mean systemic vascular resistance 
      • 943 ± 248 dyn.s/cm5
  3. cardiac output data
    • TPCO ranged from 5.2 to 14.3 l/min (8.5 ± 2.0 l/min)
    • PCCO ranged from 5.0 to 14.4 l/min (8.6 ± 2.0 l/min)
    • bias was  -0.03 ± 0.82 l/min
    • limits of agreement (1.96 SD of the bias) was 1.62 l/min
    • overall percentage error 18.8%.
    • PCCO-measurement precision 17.8%
    • trending ability was insufficient, as measured by
      • concordance rates of
        • 74% (exclusion zone of 15% (1.29 l/min))
        • 67% (without exclusion zone)
        • polar plot analysis 
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Other Studies of Interest

Systematic Review and Meta Analysis

Observational Studies

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Study Critique

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Case Reports

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Commentaries

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Clinical Review

Neurological

Circulatory

Respiratory

Gastrointestinal

Hepatobiliary

Renal

Endocrine

Haematological

Sepsis

Anaesthesia

Miscellaneous

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Recently Made Open Access from the Major Journals

American Journal of Respiratory and Critical Care Medicine

Review

Commentary

Chest

Debate

Review

Critical Care

Review

Commentary

Anesthesiology

Review

Anesthesia & Analgesia

Review

British Journal of Anasethesia

Review

Continuing Education in Anaesthesia, Critical Care & Pain

Review

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Review - Non-Clinical

Emergency Medicine Australasia Supplement

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I hope you find these brief summaries and links useful.


Until next week

Rob

 

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