Critical Care Reviews Newsletter

March 19th 2012

 

Welcome

Hello

Welcome to the 15th Critical Care Reviews Newsletter. Every week over two 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 Journal Watch section of the website on a daily basis, as publication occurs. Full access reviews, editorials and guidelines are included, while important prospective studies are summarized regardless of access.

 

Review

European Journal of Cardiothoracic Surgery

 

Indian Journal of Endocrinology & Metabolism

 

Editorial

Anaesthesia

 

Journal of Antimicrobial Chemotherapy

Guideline

Anaesthesia

Research 

JAMA:     Acute Pancreatitis

In a prospective, randomized controlled trial, Bakker et al compared outcomes betweenendoscopic or surgical necrosectomy in 22 patients (20 evaluated) with acute pancreatitis. Endoscopic transgastric necrosectomy reduced the postprocedural IL-6 levels compared with surgical necrosectomy (P = .004). The composite clinical end point occurred less often after endoscopic necrosectomy (20% vs 80%; risk difference [RD], 0.60; 95% CI, 0.16-0.80; P = .03). Endoscopic necrosectomy did not cause new-onset multiple organ failure (0% vs 50%, RD, 0.50; 95% CI, 0.12-0.76; P = .03) and reduced the number of pancreatic fistulas (10% vs 70%; RD, 0.60; 95% CI, 0.17-0.81; P = .02).

Abstract: Bakker. Endoscopic Transgastric vs Surgical Necrosectomy for Infected Necrotizing Pancreatitis: A Randomized Trial. JAMA 2012;307(10):1053-106 

 

Archives of Internal Medicine:     ICU Bed Availability & Outcomes

Stelfox et al evaluated the effect of ICU bed availability on processes and outcomes of care in 3494 hospitalized patients with sudden clinical deterioration over a 2 year period. Reduced ICU bed availability was associated with a decreased likelihood of patient admission within 2 hours of medical emergency team activation (P = .03) and with an increased likelihood of change in patient goals of care (P < .01). Patients with sudden clinical deterioration when no ICU beds were available were 33.0% (95% CI, –5.1% to 57.3%) less likely to be admitted to the ICU and 89.6% (95% CI, 24.9% to 188.0%) more likely to have their goals of care changed compared with when more than 2 ICU beds were available. Hospital mortality did not vary significantly by ICU bed availability (P = .82).

Abstract: Stelfox. Intensive Care Unit Bed Availability and Outcomes for Hospitalized Patients With Sudden Clinical Deterioration. Arch Intern Med 2012;epublished ahead of print

 

Clinical Infectious Diseases:     Hypothermia and Subsequent Infection

To assess the risk of acquiring infection after hypothermia in medical ICU patients, Laupland and colleagues followed up 6237 patients who suffered hypothermia during their ICU admission. Of this cohort, 320 patients (5%) developed ICU-acquired bloodstream infection and 724  patients (12%) developed ICU-acquired pneumonia. After controlling for confounding variables in multivariable analyses, severe hypothermia was found to increase the risk for subsequent ICU-acquired infection, particularly in patients who did not present with severe sepsis or septic shock.

Abstract: Laupland. Severe Hypothermia Increases the Risk for Intensive Care Unit–Acquired Infection. Clin Infect Dis 2012;

 

Anaesthesia:     Scientific Integrity

To determine the scientific integrity of research undertaken by a Japanese investigator (Yoshitaka Fujii), Carlisle performed a systematic review of 169 randomized controlled trials undertaken over a 20 year period. The distributions of continuous and categorical variables reported in Fujii’s papers, both human and animal, were extremely unlikely to have arisen by chance and if so, in many cases with likelihoods that were infinitesimally small. The author concludes that until such a time that these results can be explained, it is essential that all Fujii et al.’s data are excluded from meta-analyses or reviews of the relevant fields.

Full Text: Carlisle. The analysis of 169 randomised controlled trials to test data integrity. Anaesthesia 2012;epublished ahead of print

Associated Editorials (full text):

 

American Journal of Respiratory & Critical Care Medicine:     Weaning Methods

In a single-centre, prospective, randomized controlled trial, Schädler et al compared weaning with automatic control of pressure support ventilation (n=150) or weaning based on a standardized written protocol for pressure support mode (n=150) in unselected surgical patients. Overall duration of ventilation did not differ between the two methods {median/IQR: 31 [19–101] h (automated) versus (39 [20–118] h (written); p=0.178}, although in the subgroup of cardiac surgical patients those receiving automated weaning were liberated more quickly {24 [18–57] h versus 35 [20–93] h; P = 0.035.

 Abstract: Schädler. Automatic Control of Pressure Support for Ventilator Weaning in Surgical Intensive Care Patients.  Am J Respir Crit Care Med 2012;185:637-644

 

Shock:     Intra-Aortic Ballon Counterpulsation

In a single-centre, prospective, randomized controlled trial, Prodzinsky et al evaluated the haemodynamic effects of intra-aortic ballon counterpulsation in 40 subjects with cardiogenic shock after myocardial infarction. Although there were  improvements in cardiac output (4.8 ± 0.5 to 6.0 ± 0.5 L/min), systemic vascular resistance (926 ± 73 to 769 ± 101 dyn · s−1 · cm−5), and the prognosis-validated cardiac power output (0.78 ± 0.06 to 1.01 ± 0.2 W) within the IABP group, this treatment did not result in a significant hemodynamic improvement compared with medical therapy alone.

Abstract: Prondzinsky. Hemodynamic Effects of Intra-aortic Balloon Counterpulsation in Patients With Acute Myocardial Infarction Complicated by Cardiogenic Shock: The Prospective, Randomized IABP Shock Trial. Shock 2012;37(4):378–384

 

Critical Care Medicine:     Guided Haemodynamic Resuscitation 

In a single-centre prospective randomized controlled trial, Trof et al compared the effect of hemodynamic management guided by upper limits of cardiac filling volumes (transpulmonary thermodilution) or pressures (pulmonary artery catheter) on durations of mechanical ventilation and lengths of stay in critically ill patients with shock. In 120 patients (72 with sepsis and 48 without sepsis). There were no differences in ventilator-free days, lengths of stay, organ failures, and mortality of critically ill patients between the two groups, although pulmonary artery catheter guided management improved some outcomes in the nonseptic cohort.

Abstract: Trof. Volume-limited versus pressure-limited hemodynamic management in septic and nonseptic shock. Crit Care Med 2012;40(4):1177-1185

 

British Journal of Anaesthesia:     Rocuronium vs Suxamethonium

In a randomized controlled trial in 61 subjects (55 evaluated), Sørensen et al compared the speed to return of spontaneous ventilation after induction of general anaesthesia and tracheal intubation, between rocuronium 1mg/kg followed by suggamadex 16 mg/kg after intubation, or suxamethonium 1mg/kg. The use of Rocuronium/Suggamadex allowed a significantly faster return to both spontaneous ventilation (median time 216 s v 406 s; P = 0.002), and first twitch in train-of-four (T1 90%) (168 s v 518 s; P < 0.0001). Intubation conditions and time to tracheal intubation were not significantly different.

Abstract: Sørensen. Rapid sequence induction and intubation with rocuronium–sugammadex compared with succinylcholine: a randomized trial. Br J Anaesth 2012;108(4):682-689

 

British Journal of Anaesthesia:     Cardiac Output Monitoring

In a small physiological study in 60 critically ill patietns with circulatory failure, Monnet and colleagues found the third-generation FloTrac/Vigileo device was moderately reliable for tracking changes in cardiac induced by volume expansion and poorly reliable for tracking changes in cardiac index induced by norepinephrine, when compared with transpulmonary thermodilution derived measurements.

Abstract: Monnet. Third-generation FloTrac/Vigileo does not reliably track changes in cardiac output induced by norepinephrine in critically ill patients. Br J Anaesth 2012;108(4):615-622

 

British Medical Journal:     Quality of Subgroup Analyses

Sun et al examined 207 randomized controlled trials published in 2007 to asess the strength of subgroup analyses and found that 64 (31%) made claims for the primary outcome. A number of methodological weakness were found, including, of the 64 claims, 54 (84%) met four or fewer of the 10 necessary critieria to support subgroup analyses, and for strong claims, more than 50% failed each of the individual criteria. Only three (15%) met more than five criteria. They conculded the credibility of subgroup effects, even when claims are strong, was usually low, and that users of the information should treat claims that fail to meet most criteria required for subgroup analysis, with scepticism.

Full Text: Sun. Credibility of claims of subgroup effects in randomised controlled trials: systematic review. BMJ 2012;344

 

 

I hope you find these brief summaries useful.


Until next week

Rob

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