Critical Care Reviews Newsletter
February 12th 2012
Welcome to the tenth 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 Journal Watch section of the website on a daily basis, as publication occurs.
British Journal of Anaesthesia
Rapid Sequence Intubation
Sørensen et al report the results of a double blind, randomized trial comparing the time period from tracheal intubation to spontaneous ventilation between rocuronium (1mg/kg)/suggamadex (16mg/kg) and suxamethonium (1mg/kg). In 61 subjects undergoing general anaesthesia for abdominal surgery, the median time from tracheal intubation to spontaneous ventilation was 216 s with rocuronium–sugammadex and 406 s with suxamethonium (P = 0.002). Intubation conditions and time to tracheal intubation were not significantly different.
In a single-centre cohort study over a 5 year period, Bird investigated the epidemiology of patients with haematological malignancy admitted to the ICU. 199 patients were studied. Their median age was 58 yr. 51.7% were emergency admissions, 42.2% post-haematopoietic stem cell transplant, 51.9% required mechanical ventilation, median APACHE II was 21, and median organ failure was 2. ICU, in-hospital, and 6 month mortalities were 33.7%, 45.7%, and 59.3%, respectively. Univariate analysis revealed bilirubin >32 µmol litre−1, mechanical ventilation, ≥2 organ failures, renal replacement therapy, vasopressor support (all P<0.001), graft-vs-host disease (P=0.007), APACHE II score (P=0.02), platelets ≤20×109 litre−1 (P=0.03), and proven invasive fungal infection (P=0.04) were associated with in-hospital mortality. Multivariate analysis revealed that ≥2 organ failures [odds ratio (OR) 5.62; 95% confidence interval (95% CI), 2.30–13.70] and mechanical ventilation (OR 3.03; 95% CI, 1.33–6.90) were independently associated with in-hospital mortality.
After completing a systematic literature review, the Acute Dialysis Quality Initiative group convened a 2-day consensus conference to determine a list of key questions and develop summary statements to address these issues. They found inadequate evidence for the majority of questions and their recommendations were mainly based on expert opinion. The ADQI group developed a consensus definition for AKI in patients with cirrhosis and provide consensus recommendations for future investigations to address key areas of uncertainty
In a multi-centre hospital-wide study in 12 Dutch hospitals, Wassenberg et al quantified cost per isolation day avoided using rapid detection tests for MRSA, added to conventional cultures, in ICUs. 163 patients at risk for MRSA carriage were screened and MRSA prevalence was 3.1%. The duration of isolation was 27.6 (BD GeneOhmTM MRSA PCR (IDI)) and and 21.4 (Xpert MRSA (GeneXpert)) hours with rapid diagnostic tests, and would have been 96.0 hours when based on conventional cultures. The negative predictive value was 100% for both tests. Numbers of isolation days were reduced by 44.3% with PCR-based screening at the additional costs of E327.84 (IDI) and E252.14 (GeneXpert) per patient screened. Savings per isolation day avoided were 136.04 euro (IDI) and 121.76 euro (GeneXpert).
Full Text: Wassenberg. Costs and benefits of rapid screening of methicillin-resistant Staphylococcus aureus carriage in intensive care units: a prospective multicenter study. Critical Care 2012, 16:R22
Haneya reports early experience with a new, compact, portable venovenous ECMO machine (Cardiohelp) in 22 adults with severe ARDS. 15 patients were too unstable for transfer on conventional mechanical ventilation and were commenced on ECMO prior to transfer. The median duration of support was 13 days (8 to 19). An exchange of the device was necessary in 9 patients. Sixteen patients (72.7%) were successfully weaned from ECMO and fifteen patients (68.2%) survived. Device-related complications were not observed.
Critical Care Medicine
NIV in ALI
In a multicentre study of ICU patients with early acute lung injury, Zhan et al compared noninvasive pressure support (n=21) with high concentration oxygen therapy via a Venturi mask (n=19). Noninvasive pressure support appeared superior, improving PaO2/FIO2 and reducing respiratory rate plus both the need for, and the actual number of, intubations (1/21 vs. 7/19; p = .02, and 1/21 vs. 4/19; p = .04, respectively). Although the total number of organ failures in the noninvasive positive pressure ventilation group was significantly lower (3 vs. 14; p < .001), there was no difference in inhospital mortality (1/21 vs. 5/19; p = .09).
Clinical Infectious Disease
Linezolid in MRSA Nosocomial Pneumonia
In a prospective, double-blind, controlled, multicenter trial, Wunderink compared intravenous linezolid (600 mg every 12 hours) with vancomycin (15 mg/kg every 12 hours) in 1184 patients with hospital-acquired or healthcare–associated MRSA pneumonia. Both all-cause 60-day mortality (linezolid, 15.7%; vancomycin, 17.0%) and the incidence of adverse events, were similar between groups. Nephrotoxicity occurred more frequently with vancomycin (18.2% vs 8.4%). At the end of the study period, in a subgroup evaluation, in patients evaluated by protocol, 95 of 165 (57.6%) linezolid-treated patients and 81 of 174 (46.6%) vancomycin-treated patients achieved clinical success (95% CI: 0.5%–21.6%; P = .042).
European Journal of Heart Failure
Vitamin D Supplementation in Heart Failure
Gotsman et al evaluated the effects of vitamin D deficiency and supplementation in heart failure. In a health maintenance organization, 3009 patients with heart failure were compared with the remaining 46,825 subjects in the organization. Patients with heart failure had a lower median vitamin D level: 36.9 nmol/L (interquartile range 23.2–55.9) vs. 40.7 nmol/L (26.7–56.9), P < 0.00001. The percentage of patients with vitamin D deficiency [vitamin )D <25 nmol/L] was higher in patients with HF compared with the control group (28% vs. 22%, P < 0.00001). Only 8.8% of the heart failure patients had optimal vitamin D levels (≥75 nmol/L). Vitamin D deficiency was an independent predictor of mortality in both patients with HF [hazard ratio 1.52, 95% CI 1.21–1.92, P < 0.001] and the control group (HR 1.91, 95% CI 1.48–2.46, P < 0.00001). Vitamin D supplementation was independently associated with reduced mortality in HF patients (HR 0.68, 95% CI 0.54–0.85, P < 0.0001).
Anesthesia & Analgesia
Red Cell Transfusion
Weiskopf et al conducted a study in 35 healthy volunteers to determine if the age of red cells being transfused had an effect on pulmonary oxygenation. Subjects donated 2 units of blood, the first 4 weeks and the second 3 weeks before 2 study days. On the study days a further 2 units were donated, with isovolaemia being maintained. Either the old or freshly drawn blood was retransfused, in random order, and the change in alveolar to arterial difference in oxygen partial pressure (AaDo2) from before to 60 minutes post transfusion was recorded. The second pair of units of red cells were then transfused on the second study day. The investigators found fresh RBCs and older RBCs (24.5 days) equally (P = 0.85) caused an increase of AaDo2 (fresh: 2.8 mm Hg [95% confidence interval: 0.8–4.8; P = 0.007]; stored: 3.0 mm Hg [1.4–4.7; P = 0.0006]).
Intensive Care Medicine
Renal Replacement Therapy
In a randomized, controlled, open-label trial Hermite compared sodium citrate with saline catheter locks for non-tunneled hemodialysis central venous catheters in 78 critically ill adult patients with acute renal failure. Median catheter life span without complication was 6 days (saline group) versus 12 days (citrate group) [hazard ratio (HR) 2.12 (95% CI 1.32–3.4), p = 0.0019], with higher rate of catheter malfunction in the saline group compared with in the citrate group (127 catheter events/1,000 catheter-days, saline group vs. 26 events/1,000 catheter-days, citrate group, p < 0.00001). Additionally, there was a longer infection-free period in the citrate group (20 days vs. 14 days, HR 2.8, 95% CI 1.04–7.6, p = 0.04), however there was no significant difference in incidence of infections between groups.
Abstract: Hermite. Sodium citrate versus saline catheter locks for non-tunneled hemodialysis central venous catheters in critically ill adults: a randomized controlled trial. Intensive Care Med 2012;38(2):279-285
American Journal of Respiratory and Critical Care Medicine
Red Cell Transfusion
In the , Kor report a double-blind, randomized, clinical trial comparing fresh (≤ 5 days storage) versus standard issue single-unit RBC transfusion in 100 adult patients receiving invasive mechanically ventilation. Median storage age was 4.0 days (IQR 3.0 - 5.0) versus 26.5 days (IQR 21.0 - 40.0). No differences were noted in the primary outcome of ∆ PaO2/FiO2 (difference between the mean ∆ PaO2/FiO2 in the standard issue RBC group vs. the fresh RBC group = -11.5; 95% CI = -35.3 to 12.3; p = 0.22) or secondary outcomes of markers of immunologic or coagulation status.
- In a retrospective cohort study utilizing 196,202 patients in 156 medical and surgical ICUs in 106 community and academic hospitals, Brown examined the pattern of readmissions to American ICU. 3,905 patients (2.0%) were readmitted to the ICU within 48 hours; 7,171 (3.7%) within 120 hours. Medical patients in academic hospitals are more likely to be readmitted than patients in community hospitals without residents.
- Abstract: Brown. The Epidemiology of Intensive Care Unit Readmissions in the United States. Am J. Respir Crit Care Med 2012; published 26 January
I hope you find these brief summaries useful.
Until next week