Critical Care Reviews Newsletter
March 3rd 2013
Welcome
Hello
Welcome to the 65th 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.
It's probably the biggest Newsletter to date, bringing you 8 research studies, 6 Cochrane Reviews, 2 guidelines, 3 editorials, 3 commentaries, 4 study critiques and a massive 82 review articles, including 41 excellent update papers from the World Federation of Societies of Anaesthesiologists.
This week's research studies include studies on prone positioning in obese patients, pathological analysis of cell injury in sepsis-induced organ failure, and further bad news for proponents of colloids, with a negative meta analysis of albumin use in sepsis and yet another report of harm with starches, this time with tetrastarch. The Cochrane Reviews continue the colloid theme and following a comprehensive review of all types of colloid, state it is difficult to justify their use clinically. The Cochrane Group also review pulmonary artery catheters and protective ventilation in ARDS. This week's guidelines are on peripheral arterial disease and implantable cardioverter - defibrillators and cardiac resynchronization therapy.
Amongst the clinical review articles are interesting papers on brian death, sepsis, and nutrition. If it's all a bit too much, try Lemmingaid, a much needed dose of humour from the Journal of The Intensive Care Society. If it's popular I'll add the rest in the series. The New England Journal of Medicine have published a set of 4 articles on the ever expanding open access publication movement, of which Critical Care Reviews is a clear supporter.
Based on a supplement in Critical Care, the topic for This Week's Papers is the pulmonary artery catheter, starting with a reappraisal of its use in tomorrow's Paper of the Day.
Research
Intensive Care Medicine: Tetrastarch
Patel and colleagues performed a systematic review and meta-analysis to assess the effect of fluid resuscitation with 6% tetrastarch in comparison with other non-HES fluids in adults with severe sepsis. Six randomized controlled trials (n=3,033) were included, with a median tetrastarch dose of 37 ml/kg. In comparison with crystalloids, there was a 13% relative increase in 90 day mortality (RR 1.13; 95% CI 1.02-1.25; p=0.02), with a number needed to harm of 28.8 (95% CI 14.6–942.5).Tetrastarch exposure was also associated with renal replacement therapy (p = 0.01; NNH 15.7) and allogeneic transfusion support (p = 0.001; NNH 9.9). Conclusion: Fluid resuscitation with 6% tetrastarch is associated with increased mortality, need for renal replacement therapy and red cell transfusion in adults with severe sepsis.
American Journal of Respiratory and Critical Care Medicine: Sepsis-Induced Organ Failure
To evaluate the degree of sepsis-induced cardiomyocyte and renal tubular cell injury and death, using light and electron microscopy and immunohistochemical staining for markers of cellular injury and stress, Takasu and colleagues compared rapid postmortem cardiac and renal analysis in 44 septic patients with control hearts from 12 transplant and 13 brain-dead patients and control kidneys from 20 trauma patients and 8 patients with cancer. They determined cell death is rare in sepsis-induced cardiac dysfunction, but cardiomyocyte injury occurs. Renal tubular injury is common in sepsis but presents focally; most renal tubular cells appear normal. Conclusion: In sepsis, the degree of cell injury and death does not account for severity of organ dysfunction.
Journal of Hepatology: Liver Transplantation in Europe
Using data from 145 centres in 26 European countries, Karam et al detailed the profile of liver transplantation in Europe. Approximately 5,800 liver transplantations are performed annually across the continent, with France perfoming the most transplantations over the past 40 years (16,366). Over the last 10 years (1999-2009), the main indications, and 5 year graft/patient survial rates, were: viral cirrhosis 23% (56% / 74%); alcoholic cirrhosis 20% (83% / 86%); cryptogenic cirrhosis 4% (79% / 83%); autoimmune cirrhosis 2% (84% / 88%); cholestatic disease 10% (83% / 89%); acute hepatic failure 7% (70% / 76%) and congenital biliary disease 4% (84% / 90%); plus others.
Critical Care: Diabetic Glycaemic Control
Krinsley et al completed a retrospective study of 44,964 patients admitted to 23 intensive care units (ICU's) from 9 countries, between February, 2001 and May, 2012 to analyze the independent association of blood glucose with mortality. In non-diabetic patients, mean blood glucose between 80-140 mg/dL was independently associated with reduced mortality and mean blood glucose greater than 140 mg/dL with increased mortality. In diabetics, mean blood glucose of 80-110 mg/dL was associated with increased mortality and mean blood glucose of 10-180 mg/dL with decreased risk of mortality. Hypoglycemia (blood glucose < 70 mg/dL) was independently associated with increased risk of mortality among both diabetics and non-diabetics. Increased glycemic variability, defined as a coefficient of variability greater than 20%, was independently associated with increased mortality in non-diabetics. Derangements of more than 1 domain of glycemic control had a cumulative association with mortality, especially for patients without diabetes. Conclusion: In a large retrospective study, dysglycaemia is associated with increased mortality in the critically ill; diabetics may benefit from a higher blood glucose level.
Chest: Prone Positioning
To determine the potential role prone positioning may have in obese patients with ARDS, De Jong and colleagues undertook a case control study comparing outcomes between 33 morbidly obese patients with ARDS (BMI ≥ 35 kg/m2) and 33 matched non-obese (BMI < 30 kg/m2) ARDS patients. Median (range) durations of prone positioning were similar {obese 9 (6-11) hours versus non-obese 8(7-12) hours; P=0.28}. PaO2/FiO2 ratio increased significantly more in obese patients (from 118±43 to 222±84 mmHg) than in non-obese patients (from 113±43 mmHg to 174±80mmHg; P=0.03). Complications, length of mechanical ventilation, ICU stay and nosocomial infections did not differ, but mortality at 90 days was significantly lower in obese patients (27 vs 48%, P<0.05). Conclusion: Prone positioning appears to be safe in obese patients with ARDS, and may benefit this group more than non-obese patients.
Intensive Care Medicine: Renal Replacement Therapy
Schneider and colleagues undertook a systematic review and meta analysis to compare the rate of dialysis dependence among severe acute kidney injury survivors according whether continuous renal replacement therapy (CRRT) or intermittent haemodialysis (IHD) was the initial mode of renal replacement therapy. 23 studies were identified: seven randomized controlled trials (RCTs) and 16 observational studies involving 472 and 3,499 survivors, respectively. Pooled analyses of RCTs showed no difference in the rate of dialysis dependence among survivors (relative risk, RR 1.15 [95 % CI 0.78–1.68], I2 = 0 %). However, pooled analyses of observational studies suggested a higher rate of dialysis dependence among survivors who initially received IHD as compared with CRRT (RR 1.99 [95 % CI 1.53–2.59], I2 = 42 %). Conclusion: Observational, but not interventional, data suggests initial IHD therapy may be associated with prolonged dependence on renal replacement therapy.
PLoS Medicine: Out-of-Hospital Cardiac Arrest
Hagihara conducted a prospective, non-randomized, observational study using national data of all 531,854 patients with out-of-hospital cardiac arrest (OHCA) from 2005 through 2009 in Japan to assess the effect of prehospital use of Ringers Lactate on outcome. Among propensity-matched patients, compared with those who did not receive pre-hospital intravenous fluids, pre-hospital use of LR solution was associated with an increased likelihood of ROSC before hospital arrival (OR adjusted for all covariates 1.239; 95% CI 1.146–1.339; p<0.001), but with a reduced likelihood of 1-month survival with minimal neurological or physical impairment (cerebral performance category 1 or 2, OR adjusted for all covariates 0.764, 95% CI 0.589–0.992; p = 0.04); and overall performance category 1 or 2, OR adjusted for all covariates 0.746, 95% CI 0.573–0.971; p = 0.03). There was no association between prehospital use of LR solution and 1-month survival (OR adjusted for all covariates 0.96, 95% CI 0.854–1.078). Conclusion: In patients with out-of-hospital cardiac arrest, pre-hospital use of Ringers Lactate was not associated with improved outcomes.
Journal of the Intensive Care Society: Human Albumin Solution
Leitch and colleagues performed a meta-analysis of randomised controlled trials comparing the effect of human albumin solution with other fluid resuscitation on mortality in patients with severe sepsis. Nine trials (n=1,435) were included. Albumin was not associated with a decrease in mortality (relative risk 0.90, 95% CI 0.79-1.02), although most trials reported to date are small and of variable methodological quality. Soon to be published studies from Italy (Albumin Italian Outcome Sepsis, ALBIOS study) and France (Early Albumin Resuscitation in Septic Shock trial, EARSS) were not included but have also reported negative results to date.
Cochrane Review
Cochrane Review: Colloids versus Crystalloids for Fluid Resuscitation
In an updated systematic review and meta analysis, Perel and colleagues compared crystalloids with colloids for fluid resuscitation in the critically ill.
Colloids compared to crystalloids:Albumin or plasma protein fraction - 24 trials reported data on mortality, including a total of 9920 patients. The pooled risk ratio (RR) from these trials was 1.01 (95% confidence interval (CI) 0.93 to 1.10). When we excluded the trial with poor-quality allocation concealment, pooled RR was 1.00 (95% CI 0.92 to 1.09).
Hydroxyethyl starch: 25 trials compared hydroxyethyl starch with crystalloids and included 9147 patients. The pooled RR was 1.10 (95% CI 1.02 to 1.19).
Modified gelatin: 11 trials compared modified gelatin with crystalloid and included 506 patients. The pooled RR was 0.91 (95% CI 0.49 to 1.72). (When the trials by Boldt et al were removed from the three preceding analyses, the results were unchanged.) Dextran - nine trials compared dextran with a crystalloid and included 834 patients. The pooled RR was 1.24 (95% CI 0.94 to 1.65).
Colloids in hypertonic crystalloid compared to isotonic crystalloid: Nine trials compared dextran in hypertonic crystalloid with isotonic crystalloid, including 1985 randomised participants. Pooled RR for mortality was 0.91 (95% CI 0.71 to 1.06).
Conclusion: The authors conclude that as colloids are more expensive than crystalloids, offer no benefit over crystalloids, and hydroxyethyl starches are associated with increased mortality, the ongoing clinical use of colloids is difficult to justify.
Cochrane Review: Pulmonary Artery Catheters
Rajaram et al performed a systematic review and meta analysis, including 13 studies (n=5686), comparing management with and without a pulmonary artery catheter in critically ill adults. The pooled risk ratio (RR) for mortality for 5 studies of general intensive care patients was 1.02 (95% CI 0.96 - 1.09) and for 8 studies of high-risk surgery patients the RR was 0.98 (95% CI 0.74 to 1.29). In 5 of the studies in high-risk surgery patients which evaluated the effectiveness of pre-operative optimization, there was no difference in mortality. PAC did not affect general ICU length of stay (reported by four studies) or hospital length of stay (reported by nine studies). Four studies, conducted in the United States (US), reported costs based on hospital charges billed, which on average were higher in the PAC groups. Two of these studies qualified for analysis and did not show a statistically significant hospital cost difference (mean difference USD 900, 95% CI -2620 to 4420, P = 0.62). Conclusion: The use of a pulmonary artery catheter was not associated with decreased mortality, general ICU or hospital length of stay, or cost for adult patients in intensive care; although whether this is due to the monitor or therapeutic strategy employed is unclear.
Cochrane Review: High-Frequency Oscillation
In an "updated" review (although already outdated as it was performed in 2011, before the recent OSCAR and OSCILLATE trials were reported, but only published now), Sud and colleagues determined in 8 randomized controlled trials (n=433) that high frequency oscillation was a promising treatment for ALI and ARDS prior to the uptake of current lung protective ventilation strategies. Conclusion: This meta analysis is outdated and the results obsolete.
Cochrane Review: Lung Protective Ventilation
In an updated review (no new data found) Petrucci and colleagues performed a systematic review and meta analysis (six trials, n = 1297) comparing protective ventilation with non-protectice ventilation in ALI/ARDS. Lung-protective ventilation was associated with a 26% relative decrease in mortality at 28 days (95% CI 0.61 - 0.88) and a 20% relative decrease in hospital mortality (95% CI 0.69 - 0.92). Overall mortality was not significantly different if a plateau pressure less than or equal to 31 cm H2O in the control group was used (RR 1.13, 95% CI 0.88 - 1.45). There was insufficient evidence for morbidity and long-term outcomes. Conclusion: Lung-protective ventilation is associated with significant improvements in mortality and length of hospital stay in ALI/ARDS patients.
Cochrane Review: Partial Liquid Ventilation in Paediatrics
In a systematic review and meta analysis evaluating the eficacy of partial liquid ventilation in paediatric lung injury, only one study enrolling 182 patients (reported as an abstract in conference proceedings) was identified and found eligible for inclusion; the authors reported only limited results. The trial was stopped prematurely and was, therefore, under-powered to detect any significant differences and at high risk of bias. The only available outcome of clinical significance was 28-day mortality. There was no statistically significant difference between groups, with a relative risk for 28-day mortality in the partial liquid ventilation group of 1.54 (95% confidence interval 0.82 to 2.9). Conclusion: There is no evidence from RCTs to support or refute the use of partial liquid ventilation in children with acute lung injury or acute respiratory distress syndrome
Cochrane Review: GABA Receptors for Acute Stroke
Liu and Wang performed a systematic review and meta analysis to determine the efficacy and safety of GABA receptor agonists in the treatment of acute stroke. Five trials (n= 3838) with a low risk of bias were identified. Four trials measured death and dependency at three months in chlormethiazole versus placebo without significant difference (risk ratio (RR) 1.03, 95% CI 0.95 - 1.11). One trial measured this outcome between diazepam and placebo (RR 0.94, 95% CI 0.82 - 1.07). In the subgroup analysis of total anterior circulation syndrome, a higher percentage of functional independence was found in the chlormethiazole group (RR 1.33, 95% CI 1.09 - 1.64). The frequent adverse events related to chlormethiazole were somnolence (RR 4.56, 95% CI 3.50 - 5.95) and rhinitis (RR 4.75, 95% CI 2.67 - 8.46). Conclusion: The evidence does not support the use of GABA receptor agonists (chlormethiazole or diazepam) for the treatment of patients with acute ischemic or hemorrhagic stroke
Guideline
Circulation: Peripheral Arterial Disease
Journal of the American College of Cardiology: Implantable Cardioverters-Defibrillation
Editorial
Journal of the Intensive Care Society: Brain Death
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine: Publishing Trial Protocols
Respiratory Care: Recruitment
Commentary
Antimicrobial Resistance and Infection: Chennai Declaration
Emergency Medicine News: Carbapenam Resistant Klebsiella Pneumonia
Study Critiques
Journal of the Intensive Care Society: Ultrasound-Guided Subclavian Vein Cannulation
Journal of the Intensive Care Society: 6S Study
Journal of the Intensive Care Society: Citrate Anticoagulation for CRRT
Journal of the Intensive Care Society:: Tranexamic Acid
Review - Clinical
Neurological
Critical Care: Mobilisation
Journal of the Intensive Care Society: Benzodiazepine Administration
Journal of the Intensive Care Society: Subarachnoid Haemorrhage
Journal of the Intensive Care Society: Delirium
Neuroscience Journal: Incidental Findings in Neuroimaging
Circulatory
Perioperative Medicine: Anaerobic Threshold
Indian Journal of Endocrinology and Metabolism: Natriuretic Hormones
Journal of Anesthesia and Clinical Research: Cirrhosis-Associated Cardiomyopathy
Journal of the American College of Cardiology: Heart Team
Respiratory
Journal of the Intensive Care Society: Pulmonary Embolism
Annals of Medical and Health Sciences Research: Postoperative Pulmonary Oedema
Revista da Associação Médica Brasileira: Viral Community-Acquired Pneumonia
Nutrition
Nutrition in Intensive Care Medicine: Beyond Physiology: Nutrition
- Alvárez- Falcóna. Oral Feeding. Book Chapter in Nutrition in Intensive Care Medicine: Beyond Physiology; Singer P (ed). World Rev Nutr Diet 2013;105:43–49
- Kim. Glutamine. Book Chapter in Nutrition in Intensive Care Medicine: Beyond Physiology; Singer P (ed). World Rev Nutr Diet 2013;105:90-96
- Kagan. Nutritional Imbalances during Extracorporeal Life Support. Book Chapter in Nutrition in Intensive Care Medicine: Beyond Physiology; Singer P (ed). World Rev Nutr Diet 2013;105:154-159
Hepatobiliary
Clinical Liver Disease: Hepatitis B
Liver International: Liver Transplantation
Renal
Nephrology: Melioidosis associated Acute Kidney Injury
Sepsis
Cleveland Clinic Journal of Medicine: Sepsis
Virology Journal: Novel Coronavirus
Therapeutic Advances in Infectious Diseases: Febrile Neutropaenia
Therapeutic Advances in Infectious Diseases: Clostridium Difficile
Therapeutic Advances in Infectious Diseases: Community-Acquired Pneumonia
Journal of Basic & Clinical Medicine: Procalcitonin
Indian Journal of Medical Science: New Delhi Metallo-Beta-Lactamase
Clinical Infectious Diseases: Fungal Infections
Poisoning
Marine Drugs: Jellyfish Stings
Organ Transplantation
Clinical and Translational Medicine: Organ Transplantation
Ethics / End-of-Life
Journal of the Intensive Care Society: Assisted Suicide
Cleveland Clinic Journal of Medicine: End-of-Life
- Koller. Frailty in older adults: Implications for end-of-life care. Cleve Clin J Med 2013;80:168-174
Respiratory Care: Apnoea Testing
Miscellaneous
PLoS Biology: Animal Experiments
Review - Basic Science
Circulation Research: Therapeutic Transdifferentiation
International Journal of Vascular Medicine: MicroRNAs in Vascular Biology
Journal of Hematology & Oncology: Mitochondrial Reactive Species
Cardiovasc Research: Proteomics
Review - Non-Clinical
New England Journal of Medicine: Open Access Publication
- Wolpert. For the Sake of Inquiry and Knowledge — The Inevitability of Open Access. N Engl J Med 2013;368:785-787
- Frank. Open but Not Free — Publishing in the 21st Century. N Engl J Med 2013;368:787-789
- Carroll. Creative Commons and the Openness of Open Access. N Engl J Med 2013;368:789-791
- Haug. The Downside of Open-Access PublishingHaug. The Downside of Open-Access Publishing. N Engl J Med 2013;368:791-793
and a bit of humour:
Journal of the Intensive Care Society: Lemmingaid
World Federation of Societies of Anaesthesiologists: Update in Anaesthesia 2012
General Principles
- Dünser. Intensive care medicine in resource-limited settings: a general overview. Update in Anaesthesia 2012;7-10
- Brown. Systematic assessment of an ICU patient. Update in Anaesthesia 2012;11-17
- Towey. Intensive care medicine in rural sub-Saharan Africa - who to admit? Update in Anaesthesia 2012;18-21
- Baker. Identifying critically ill patients - Triage, Early Warning Scores and Rapid Response Teams. Update in Anaesthesia 2012;22-26
- Baker. Critical care where there is no ICU: Basic management of critically ill patients in a low income country. Update in Anaesthesia 2012;27-31
- Gupta. Monitoring in ICU - ECG, pulse oximetry and capnography. Update in Anaesthesia 2012;32-36
- Gupta. Invasive blood pressure monitoring. Update in Anaesthesia 2012;37-42
- Key. Central venous cannulation. Update in Anaesthesia 2012;43-50
- Lawson. Cardiac output monitoring. Update in Anaesthesia 2012;51-58
General Care
- Grice. Acid-base disorders in critical care. Update in Anaesthesia 2012;59-66
- Connor. Delirium in critical care. Update in Anaesthesia 2012;67-73
- Werrett. Sedation in intensive care patients. Update in Anaesthesia 2012;74-78
- Bratanow. Nutrition in the critically ill. Update in Anaesthesia 2012;79-87
- Davidson. Evidence-based medicine in critical care. Update in Anaesthesia 2012;88-94
Trauma
- Herbert. Management of major trauma. Update in Anaesthesia 2012;95-106
- Ali. Management of head injuries. Update in Anaesthesia 2012;107-111
- Ford. Acute cervical spine injures in adults: initial management. Update in Anaesthesia 2012;112-118
- Hormis. Thoracic trauma. Update in Anaesthesia 2012;119-124
- Rao. Guidelines for management of massive blood loss in trauma. Update in Anaesthesia 2012;125-129
- Barnard. Rhabdomyolysis. Update in Anaesthesia 2012;130-132
- Hollister. Management of burns. Update in Anaesthesia 2012;133-141
- Heikal. Management of drowning. Update in Anaesthesia 2012;141-144
Sepsis
- Stephens. Management of sepsis with limited resources. Update in Anaesthesia 2012;145-155
- English. Abdominal compartment syndrome. Update in Anaesthesia 2012;156-159
Microbiology
Cardiovascular
- Dodwell. Inotropes and vasopressors in critical care. Update in Anaesthesia 2012;169-176
- Margetts. Management of cardiac arrest - review of the 2012 European Resuscitation Guidelines. Update in Anaesthesia 2012;177-182
Respiratory
Renal
- Attwood. Acute kidney injury - diagnosis, management and prevention. Update in Anaesthesia 2012;207-214
- Baker. Renal replacement therapy in critical care. Update in Anaesthesia 2012;215-222
- Cullis. Peritoneal dialysis in acute kidney injury. Update in Anaesthesia 2012;223-227
Neuromuscular
- Guest. Neurological causes of muscle weakness in the Intensive Care Unit. Update in Anaesthesia 2012;228-232
- Towey. Tetanus. Update in Anaesthesia 2012;233-239
- Niranjan. Brainstem death. Update in Anaesthesia 2012;240-243
- Cook. Cultural issues in end-of-life care. Update in Anaesthesia 2012;243-246
Miscellaneous
- Preedy. Diabetic ketoacidosis. Update in Anaesthesia 2012;247-252
- Heikal. Emergency management of poisoning. Update in Anaesthesia 2012;253-260
- Kiran. Management of snake envenomation. Update in Anaesthesia 2012;261-266
I hope you find these brief summaries and links useful.
Until next week
Rob