November 18th 2012
Welcome to the 50th 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.
Celebrating a half century of newsletters, and almost 1 year of bringing you the best critical care research from the literature, Critical Care Reviews has organised a free review meeting, with 8 eminent intensivists from Northern Ireland talking about the most important clinical trials published in 2012. Put the date of January 22nd in your diary. Further details to follow shortly.
This week's research studies include a report of improving outcomes following inhospital cardiac arrest, superior outcomes with the use of recombinant human relaxin-2 in acute heart failure, a suggestion following meta analysis that probiotics may decrease the incidence of clostridium difficile associated-diarrhoea and a paper describing the international epidemiology of bloodstream infections.
Recently published guidelines come from the American College of Cardiology Foundation, on the interpretation of troponin measurements, and from Croatia, on the application of therapeutic plasma exchange. There are editiorials on the perioperative use of oxygen and on a recently highlighted paper describing increased mortality with steroid use in sepsis, as recommended by the surviving sepsis campaign.
There are 26 free full text review articles from across the medical literature. Amongst these are papers on disorders of consciousness, mini-cardiopulmonary bypass, asthma, a number of papers on variceal haemorrhage, haemodialysis, porphyria and regional anaesthesia in ICU.
New England Journal of Medicine: Cardiac Arrest
To determine whether survival and neurologic function after in-hospital cardiac arrest have improved over time, Girota et al interogated the Get with Guidelines–Resuscitation Registry from 2000 and 2009. In 374 hospitals, 84,625 hospitalized patients had a cardiac arrest, with 79.3% had an initial rhythm of asystole or pulseless electrical activity, and 20.7% had ventricular fibrillation or pulseless ventricular tachycardia. The proportion of cardiac arrests due to asystole or pulseless electrical activity increased over time (P<0.001 for trend). Risk-adjusted rates of survival to discharge increased from 13.7% in 2000 to 22.3% in 2009 (adjusted rate ratio per year, 1.04; 95% CI, 1.03 to 1.06; P<0.001 for trend). Survival improvement was similar in the two rhythm groups and was due to improvement in both acute resuscitation survival and postresuscitation survival. Rates of clinically significant neurologic disability among survivors decreased over time, with a risk-adjusted rate of 32.9% in 2000 and 28.1% in 2009 (adjusted rate ratio per year, 0.98; 95% CI, 0.97 to 1.00; P=0.02 for trend).
Lancet: Acute Heart Failure
Teerlink et al performed an international, double-blind, placebo-controlled trial, investigating Serelaxin (recombinant human relaxin-2) in 1161 patients admitted to hospital for acute heart failure. Serelaxin (n=581) improved one primary outcome of change from baseline dyspnoea score, as measured with a visual analog scale (448 mm × h, 95% CI 120—775; p=0·007), but not the other primary outcome of effect on the proportion of patients with moderate or marked dyspnoea improvement measured by Likert scale during the first 24 hours (Likert scale; placebo: 150 patients [26%]; serelaxin: 156 [27%]; p=0·70). No significant effects were recorded for the secondary endpoints of cardiovascular death or readmission to hospital for heart failure or renal failure (placebo: 75 events [60-day Kaplan-Meier estimate, 13·0%]; serelaxin: 76 events [13·2%]; hazard ratio [HR] 1·02 [0·74—1·41], p=0·89] or days alive out of the hospital up to day 60 (placebo: 47·7 [SD 12·1] days; serelaxin: 48·3 [11·6]; p=0·37). Serelaxin treatment was associated with significant reductions of other prespecified additional endpoints, including fewer deaths at day 180 (placebo: 65 deaths; serelaxin: 42; HR 0·63, 95% CI 0·42—0·93; p=0·019).
Annals of Internal Medicine: C. Diff Diarrhoea
Johnstone et al undertook a systematic review and meta analysis, including 20 trials (n=3818), to assess the efficacy and safety of probiotics for the prevention of Clostridium difficile–associated diarrhea (CDAD) in adults and children receiving antibiotics. Probiotics reduced the incidence of CDAD by 66% (pooled relative risk, 0.34 [95% CI, 0.24 to 0.49]; I2 = 0%). In a population with a 5% incidence of antibiotic-associated CDAD (median control group risk), probiotic prophylaxis would prevent 33 episodes (CI, 25 to 38 episodes) per 1000 persons. Of probiotic-treated patients, 9.3% experienced adverse events, compared with 12.6% of control patients (relative risk 0.82 [CI, 0.65 to 1.05]; I2 = 17%). In 13 trials, data on CDAD were missing for 5% to 45% of patients, although results were robust to worst-plausible assumptions regarding event rates in studies with missing outcome data.
Intensive Care Medicine: Hospital-Acquired Bloodstream Infections
Tabah et al undertook a prospective, multicentre non-representative cohort study in 162 ICUs in 24 countries to investigate the epidemiology of hospital-acquired bloodstream infections (HA-BSIs) and evaluated the impact of drug resistance on outcomes of critically ill patients. 1,156 patients with with HA-BSIs were enrolled, with 76 % of infections being ICU-acquired. The median time to diagnosis was 14 [IQR: 7–26] days after hospital admission. 12% of infections were polymicrobial. Of monomicrobial infections, 58.3 % were gram-negative, 32.8 % gram-positive, 7.8 % fungal and 1.2 % due to strict anaerobes. Overall, 629 (47.8 %) isolates were multidrug-resistant (MDR), including 270 (20.5 %) extensively resistant (XDR), and 5 (0.4 %) pan-drug-resistant (PDR). Micro-organism distribution and MDR occurrence varied significantly (p < 0.001) by country. The 28-day all-cause fatality rate was 36 %. In a multivariable model, independent predictors of 28-day mortality included MDR isolate [OR: 1.49; 95 % CI: 1.07–2.06], uncontrolled infection source (OR: 5.86; 95 % CI: 2.5–13.9) and timing to adequate treatment (before day 6 since blood culture collection versus never, OR 0.38; 95 % CI: 0.23–0.63; since day 6 versus never, OR 0.20; 95 % CI: 0.08–0.47).
Abstract: Tabah. Characteristics and determinants of outcome of hospital-acquired bloodstream infections in intensive care units: the EUROBACT International Cohort Study. Intensive Care Medicine 2012;38,12:1930-1945
Critical Care: Ventilator-Associated Pneumonia
Kollef et al undertook a prospective, double-blinded, randomized trial comparing a fixed 7-day course of doripenem (1 gram as a 4-hour infusion every 8 hours) with a fixed 10-day course of imipenem-cilastatin (1 gram as a 1-hour infusion every 8 hours) in 274 patients with ventilator-associated pneumonia (VAP) due to Gram-negative bacteria. The study was stopped prematurely at the recommendation of the Independent Data Monitoring Committee. There was no difference at the end of therapy in the microbiological intent-to-treat (MITT) analysis (doripenem: 45.6% vs imipenem-cilastatin: 56.8%; 95% CI, -26.3% to 3.8%). Similarly, there was no difference in clinical cure for patients with Pseudomonas aeruginosa VAP, the most common Gram-negative pathogen (doripenam: 41.2% versus imipenem-cilastatin: 60.0%; 95% CI, -57.2 to 19.5). There was no difference in all cause 28-day mortality in the MITT analysis (doripenam: 21.5% versus imipenem-cilastatin: 14.8%; 95% CI, -5.0 to 18.5). Doripenam was superior to imipenem-cilastatin as therapy for Pseudomonas aeruginosa VAP (doripenam: 35.3% versus imipenem-cilastatin: 0.0%; 95% CI, 12.6 to 58.0).
Journal of the American College of Cardiology: Troponin Interpretation
- Newby. ACCF 2012 Expert Consensus Document on Practical Clinical Considerations in the Interpretation of Troponin Elevations. J Am Coll Cardiol 2012; epublished ahead of print
Acta Clinica Croatica: Plasma Exchange
- Kes. Therapeutic plasma exchange in the neurologic intensive care setting: recommendation for clinical practice. Acta Clin Croat 2012; 51:137-153
Anaesthesia: Perioperative Oxygen
Intensive Care Medicine: Steroids in Sepsis
- Sprung. Randomized controlled trials and practice guidelines: the good, the bad, and the ugly. Intensive Care Med 2012;38:1911–1913
Review - Clinical
Critical Care Research and Practice: Disorders of Consciousness
- Guldenmund. Mindsight: Diagnostics in Disorders of Consciousness. Critical Care Research and Practice 2012;2012:624724
Stem Cells: Traumatic Brain Injury
- Ugoya. Bench to Bedside of Neural Stem Cell in Traumatic Brain Injury. Stem Cells International 2012;2012:141624
Stem Cells: Spinal Cord Injury
- Rosner. The Potential for Cellular Therapy Combined with Growth Factors in Spinal Cord Injury. Stem Cells International 2012;2012:826754
Applied Cardiopulmonary Pathophysiology: Brain Circulatory Imaging
- Zhou. Intraoperative imaging of the brain macro- and microcirculation. Applied Cardiopulmonary Pathophysiology 2012;16:270-275
Heart: Myocardial Infarction
- Delewi. Left ventricular thrombus formation after acute myocardial infarction. Heart 2012;98:1743-1749
Anaesthesia Essays and Researche: Cardiopulmonary Bypass
European Cardiology: Diastolic Heart Failure
- Smiseth. Heart Failure with Preserved Ejection Fraction – A Review. European Cardiology 2012;8(3):186-191
European Cardiology: Implantable Electrical Cardiac Devices
- Samii. Implantable Cardiac Devices in the Treatment of Arrhythmias and Congestive Heart Failure. US Cardiology 2012;9(2):99-104
Applied Cardiopulmonary Pathophysiology: Sublingual Microcirculatory Imaging
Archives of Medical Science: Asthma
- Mathew. State of the art paper. Therapeutic options for severe asthma. Arch Med Sci 2012;8(4):589-597
Clinical Liver Disease: Acute Variceal Haemorrhage
Clinical Liver Disease: Gastric Varices
Clinical Liver Disease: Ectopic Varices
Clinical Liver Disease: TIPSS
- Bhogal. Transjugular intrahepatic portosystemic shunt: An overview. Clinical Liver Disease 2012;1:173–176.
European Gastroenterology & Hepatology Review: Spontaneous Bacterial Peritonitis
- Pereira. Spontaneous Bacterial Peritonitis. European Gastroenterology & Hepatology Review 2012;8(1):22-26
Applied Cardiopulmonary Pathophysiology: Intestinal Microcirculatory Imaging
- Lehmann. Imaging of the intestinal microcirculation. Applied Cardiopulmonary Pathophysiology 2012;16:264-269
Saudi Journal of Kidney Diseases and Transplantation: Haemodialysis
- Karkar A. Modalities of hemodialysis: Quality improvement. Saudi J Kidney Dis Transpl 2012;23:1145-61
European Gastroenterology & Hepatology Review: Porphyria
- Weitz. Periprocedural Management and Approach to Bleeding in Patients Taking Dabigatran. Circulation 2012;126:2428-2432
Monaldi Archives for Chest Disease: Steroids for Pneumonia
- Confalonieri. To use or not to use corticosteroids for pneumonia? A clinician's perspective. Monaldi Arch Chest Dis 2012;77(2):94-101
Current Opinion in Infectious Diseases: Prosthetic Joint Infection
Nigerian Medical Journal: Healthcare-Associated Infections
Revista Brasileira de Anestesiologia: Regional Analgesia
Revista Brasileira de Anestesiologia: Opioids
Anaesthesia Essays and Researche: Anaesthetic Risk
- Bajwa. Risk and safety concerns in anesthesiology practice: The present perspective. Anesth Essays Res 2012;6:14-20
Review - Basic Science
European Journal of Anaesthesiology: Argon
- Coburn. Argon: the ‘lazy’ noble gas with organoprotective properties. European Journal of Anaesthesiology 2012;29(12):549–551
I hope you find these brief summaries and links useful.
Until next week