June 30th 2013
Welcome to the 82nd 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.
The ongoing saga of starches begins to draw to a close, with British and American regulators joining European authorities in effectively banning the use of these formulations due to an unfavourable safety profile. It only took them a year. With an estimated 21% of global fluid resuscitation being with starches in 2007, how much unnecessary iatrogenic harm has been caused by this delay?
This week's research studies include a randomized controlled trial reporting superior outcomes with the combination of clopidogrel plus aspirin over aspirin alone in ischaemic stroke and TIA, a one year follow up of the EDEN trial participants, meta analyses on magnesium sulphate in subarachnoid haemorrhage, ultrafiltration versus diuretics in acute heart failure, and selenium for sepsis, as well as observational studies demonstrating the actual clearance rate of ammonia with continuous renal replacement therapy, an association between hyperoxia and mortality in traumatic brain injury and a report suggesting traumatic brain injury is a risk factor for later ischaemic stroke.
This week's guidelines address the surgical management of burns, pacing, bariatric perioperative nutrition and CPR.
Amongst the clinical review articles are papers on hypertension, stroke, therapeutic hypothermia, right ventricular failure, COPD, pulmonary hypertension, end-stage liver disease, venothromboembolism, clostridium difficile, fungal infections, burns, contrast reactions and wind disasters (tornados ad hurricanes).
- In a press release yesterday, the UK regulatory authority the Medicines and Healthcare Products Regulatory Agency (MHRA) has joined the increasing list of regulators suspending approval for starches in the critically ill.
- Consistent with the recent European Medicines Agency’s Pharmacovigilance Risk Assessment Committee recommendation on the suspension of marketing authorisation for hydroxyethyl starches, the US Food and Drug Administration announces hydroxyethyl starches should not be used in critically ill adult patients
Randomized Controlled Trials:
New England Journal of Medicine: Stroke
In a Chinese randomized, double-blind, placebo-controlled trial in 5170 patients within 24 hours of a minor ischemic stroke or high-risk transient ischemic attack, the combination of clopidogrel (initially 300 mg, followed by 75 mg per day for 90 days) and aspirin (75 mg per day for the first 21 days), in comparison with placebo plus aspirin (75 mg per day for 90 days), was associated with a reduction in the occurance of stroke at 90 days (8.2% versus 11.7%; hazard ratio 0.68; 95% CI 0.57 to 0.81; P<0.001). There was no difference in the incidence of moderate or severe hemorrhage (0.3% both groups), or haemorhagic stroke (also 0.3% both groups).
American Journal of Respiratory and Critical Care Medicine: Acute Lung Injury
In a cohort of 115 consecutive patients (1000 patients in main EDEN trial) within 48 hours of developing acute lung injury requiring mechanical ventilation, randomized to receive full or trophic (20% target) enteral feeding for 6 days, there was no difference in 6 month and 1 year outcomes in physical and cognitive performance. However, EDEN survivors demonstrated impairments in 6-minute walk distance (64% predicted at 6 months and 66% predicted at 12 months) and cognition (impairment in 36% at 6 months and 25% 12 months), with improvements in both measures over the 6 month period (p=0.011 and p=0.001, respectively, for difference between assessments).
Abstract: Needham. Physical and Cognitive Performance of Acute Lung Injury Patients One Year after Initial Trophic vs Full Enteral Feeding: EDEN Trial Follow-Up. Am J Respir Crit Care Med 2013;epublished June 2nd
Original Study: The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. Initial Trophic vs Full Enteral Feeding in Patients With Acute Lung Injury: The EDEN Randomized Trial. JAMA 2012;307(8):795-803
Systematic Review and Meta Analysis
Australian Critical Care: Subarachnoid Haemorrhage
In a systematic review and meta analysis, including 9 trials, Yarad and colleagues demonstrated a reduction in the incidence of cerebral vasospasm post subarachnoid haemorrhage with intravenous magnesium sulphate (relative risk 0.83; 95% CI 0.71 to 0.98; P=0.03). However, magnesium therapy was not assciated with an improvement in favourable functional outcome (RR 1.00; 95% CI 0.96 to 1.05; P=0.84) or mortality (RR 0.95; 95% CI 0.77 to 1.18; P=0.67).
American Journal of Cardiovascular Drugs: Acute Heart Failure
In a systematic review and meta analysis, including 5 trials (n=477), Wen et al showed that in this dataset, ultrafiltration, in comparison with diuretic therapy, was associated with greater 48 hour weight loss (Z = 3.72; weighted mean difference 1.25 kg, 95 % CI 0.59–1.91, P < 0.001) and greater 48 hour fluid removal (Z = 4.23; WMD = 1.06 L, 95 % CI 0.57–1.56, P < 0.001), without an increase in adverse events.
American Journal of Emergency Medicine: Selenium
In a systematic review and meta analysis, including 5 studies and 530 patients, Kong et al report a lack of efficacy of selenum in sepsis, with no effect on mortality (relative risk 0.89, 95% CI 0.73-1.07, P = 0.21), incidence of hospital-acquired pneumonia (RR 1.15, 95% CI 0.73-1.82, P = 0.55), length of intensive care unit stay (weighted mean differences = 2.32 days, 95% CI −0.05 to 4.69; P = 0.05), or adverse events (RR = 0.97, 95% CI 0.72-1.33, P = 0.87).
Liver International: Ammonia Clearance
Although continuous renal replacement therapy is used to decrease ammonia levels, clearance kinetics have been poor characterized to date. In a prospective observational study of 24 hyperammonaeic patients (arterial ammonia >100 μmol/L), ammonia clearance was highly correlated with ultrafiltration dose (r = 0.86, P < 0.001), with low dose CRRT (35 ml/kg/h) having an ammonia clearance at 1 hour of 39 (34–54) ml/min and high dose CRRT (90 ml/kg/h) a clearance of 85 (62–105) ml/min (P < 0.001). Similarly, this difference was maintained at 24 hours; 44 (34–63) vs 105 (82–109) ml/min (P = 0.01). At 24 hours median arterial ammonia had decreased by 22%. Interestingly, urea and ammonia clearances were also highly correlated (r = 0.819, P = 0.007).
Neurology: Traumatic Brain Injury
Using a large Californian database of 1,173,353 trauma subjects, 436,630 (37%) of whom had suffered a traumatic brain injury, Burke and colleagues showed that, independent of other major predictors, subsequent ischaemic stroke was more common in those with a TBI than trauma controls 28 months post injury (hazard ratio 1.31, 95% CI 1.25–1.36).
Journal of Neurology, Neurosurgery and Psychiatry: Traumatic Brain Injury
In keeping with numerous recent studies demonstrating worse outcomes with hyperoxia, Rincon and colleagues report retrospective results from a multi-centre cohort study including 1212 ventilated traumatic brain injury patients. While mortality (224/553, 41%; crude odds ratio 2.3, 95% CI 1.7-3.0, p<.0001) was hightest in those with early hypoxia (PaO2 <60 mm Hg / 7.99 kPa or PaO2/FiO2 ratio ≤ 300), early hyperoxia (PaO2 ≥300 mm Hg / 39.99 kPa) was also associated with increased mortality (80/256, 32%; adjusted OR 1.5, 95% CI 1.02-2.4, p=0.04) in comparison with normoxic patients (87/403, 23%).
Journal of Burn Care & Research: Surgical Management of Burns
- Kagan. Surgical Management of the Burn Wound and Use of Skin Substitutes: An Expert Panel White Paper. Journal of Burn Care & Research 201334(2):e60-e79
European Heart Journal: Pacing
- Brignole. 2013 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy: The Task Force on cardiac pacing and resynchronization therapy of the European Society of Cardiology (ESC). Developed in collaboration with the European Heart Rhythm Association (EHRA). Eur Heart J 2013;epublished June 24th
Obesity: Perioperative Bariatric Nutrition
- Mechanick. Clinical practice guidelines for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient—2013 update: Cosponsored by american association of clinical endocrinologists, The obesity society, and american society for metabolic & bariatric surgery. Obesity 2013;21:S1–S27
Anaesthesia Essays and Researches: Insulin Administration
- Bajwa. An acute need for awareness of insulin injection guidelines in operative and intensive care units. Anesth Essays Res 2013;7:1-3
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine: Emergency Airway
- Crewdson. Needle, knife, or device -- which choice in an airway crisis? Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2013;21:49
Review - Clinical
Annals of Intensive Care: Hypertension
- Ribeiro Salgad. Control of hypertension in the critically ill: a pathophysiological approach. Annals of Intensive Care 2013;3:17
Quarterly Journal of Medicine: Stroke
Brain Science: Stroke
- Stone. Neural Repair and Neuroprotection with Stem Cells in Ischemic Stroke. Brain Sci 2013;3(2):599-614
- Watts. Stroke Neuroprotection: Targeting Mitochondria. Brain Sci 2013;3(2):540-560
Anaesthesia Essays and Researches: Therapeutic Hypothermia
- Malhotra. Improving neurological outcome after cardiac arrest: Therapeutic hypothermia the best treatment. Anesth Essays Res 2013;7:18-24
Vascular Health and Risk Management: Aldosterone Receptor Antagonists
- Guichard. Aldosterone receptor antagonists: current perspectives and therapies. Vascular Health and Risk Management 2013;2013(9):321-331
Cardiorenal Medicine: Right Heart Failure
- Di Lullo. Pulmonary Hypertension and Right Heart Failure in Chronic Kidney Disease: New Challenge for 21st-Century Cardionephrologists. Cardiorenal Med 2013;3:96-103
Current Opinion in Critical Care: Resuscitation
International Journal of Chronic Obstructive Pulmonary Disease: COPD
- de Miguel Díez. The association between COPD and heart failure risk: a review. International Journal of Chronic Obstructive Pulmonary Disease 2013;2013(8):305-312
Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine: COPD
High Altitude Medicine & Biology: Hypoxic Pulmonary Vasoconstriction
High Altitude Medicine & Biology: Pulmonary Arterial Hypertension
- Fraidenburg. Current and Future Therapeutic Targets for Pulmonary Arterial Hypertension. High Altitude Medicine & Biology 2013;14(2):134-143
Respiratory Care: Pulmonary Arterial Hypertension
- Demerouti. Complications Leading to Sudden Cardiac Death in Pulmonary Arterial Hypertension. Respir Care 2013;58:1246-1254
Gut Pathogens: Holobionts
International Journal of Hepatology: Bleeding in Extrahepatic Portal Venous Obstruction
- Chaudhary. Management of Bleeding in Extrahepatic Portal Venous Obstruction. International Journal of Hepatology 2013;2013:784842
Clinical and Molecular Hepatology: End-Stage Liver Disease
- Joon Kim. Important predictor of mortality in patients with end-stage liver disease. CMH 2013;19:105-115
Journal of Clinical & Experimental Hepatology: MELD
- Singal. Model for End-stage Liver Disease. Journal of Clinical & Experimental Hepatology 2013;3(1):50-60
Biomedical Papers: Acute Kidney Injury
- Petejova. Acute kidney injury following acute pancreatitis: A review. Biomedical Papers 2013;157(2):105-113
Clinical and Experimental Pharmacology and Physiology: Ticagrelor
- Steiner. Ticagrelor: Positive, negative and misunderstood properties as a new antiplatelet agent. Clinical and Experimental Pharmacology and Physiology 2013;40:398–403
International Journal of Critical Illness and Injury Science: Venous Thromboembolism
- Adriance. Prophylaxis and treatment of venous thromboembolism in the critically ill. Int J Crit Illn Inj Sci 2013;3:143-51
North American Journal of Medical Science: Clostridium Difficile
- Karadsheh. Fecal transplantation for the treatment of recurrent Clostridium difficile infection. North Am J Med Sci 2013;5:339-43
Infection and Drug Resistance: Clostridium Difficile
- Chaparro-Rojas. Emerging therapies for Clostridium difficile infection – focus on fidaxomicin. Infection and Drug Resistance 2013;2013(6):41-53
New England Journal of Medicine: Contaminated Methylprednisolone Injections
- Kauffman. Current Concepts: Fungal Infections Associated with Contaminated Methylprednisolone Injections. N Engl J Med 2013;368:2495-2500
Pathogens: Antimicrobial Resistance
- Soothill. Can We Prevent Antimicrobial Resistance by Using Antimicrobials Better? Pathogens 2013;2(2):422-435
Clinical Therapeutics: Antimicrobial Stewardship
- Rhode. Role of the Hospitalist in Antimicrobial Stewardship: A Review of Work Completed and Description of a Multisite Collaborative. Clinical Therapeutics 2013;35(6):751-757
- Wainwright. Photobactericides—A Local Option against Multi-Drug Resistant Bacteria. Antibiotics 2013;2(2):182-190
Therapeutic Advances in Infectious Diseases: Fungal Infections
- Vazquez. Invasive fungal infections in transplant recipients. Therapeutic Advances in Infectious Disease 2013;1:85
Journal of Burn Care & Research: Burns
- Mosier. Use of Therapeutic Plasma Exchange in the Burn Unit: A Review of the Literature. Journal of Burn Care & Research 2013;34(3):289-298
International Journal of Artificial Organs: Neonatal Lung Assist
- Rochow. Artificial placenta - Lung assist devices for term and preterm newborns with respiratory failure. Int J Artif Organs 2013;36(6):377-391
Respiratory Care: Neonatal Hypertension
- da Silva. Unplanned Extubation in the Neonatal ICU: A Systematic Review, Critical Appraisal, and Evidence-Based Recommendations. Respir Care 2013;58:1237-1245
Indian Journal of Dermatology: Drug Interactions
- Coondoo. Drug interactions in dermatology: What the dermatologist should know. Indian J Dermatol 2013;58:249-54
International Journal of Critical Illness and Injury Science: Wind Disasters
- Marchigiani. Wind disasters: A comprehensive review of current management strategies. Int J Crit Illn Inj Sci 2013;3:130-42
Reports in Medical Imaging: Contrast Reactions
- Nielsen. Optimal management of acute nonrenal adverse reactions to iodine-based contrast media. Reports in Medical Imaging 2013;2013(6):49-55
I hope you find these brief summaries and links useful.
Until next week