January 6th 2012
Welcome to the 57th 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.
This week's research studies include yet another paper demonstrating worse outcomes with a higher red cell transfusion threshold, this time in the setting of upper GI bleeding. The latest negative study on MARS has been published, as well as the latest negative compound tested for acute heart failure. On a more positive note, a prospective study on ECMO provides further support for the use of this therapy and sonothrombolysis appears to have a possible beneficial effect in acute cerebral infarction, although study numbers were low.
This week's guideline is from the American College of Cardiology Foundation, on the generation of guidelines.
Amongst the clinical review articles are papers on ICU acquired weakness, ventricular assist devices, capnography, haemorrhagic liver injury, peri-operative diabetic management, anti-coagulants, candida, mitochondrial therapy and do-not-resuscitate orders. A non-clinical review article looks at the future of the anaesthesia profession.
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New England Journal of Medicine: Upper Gastrointestinal Haemorrhage
Villanueva et al performed a randomized study comparing the efficacy and safety of a restrictive transfusion strategy (Hb <7g/dL) with those of a liberal transfusion strategy (Hb<9g/dL) in 921 patients with severe acute upper gastrointestinal bleeding. More patients in the restrictive group did not receive a transfusion (n=225/51% versus n=65/15%, p<0.001). The restrictive practice was associated with numerous benefits, including increased probability of survival (95% versus 91%; hazard ratio for death 0.55; 95% CI: 0.33-0.92; p=0.02); decreased rebleeding (10% versus 16%, p=0.01) and adverse events (40% versus 48%, p=0.02). In subgroup analysis, restrictive transfusion was associated with improved probability of survival in patients with cirrhosis and Child–Pugh class A or B disease (HR 0.30; 95% CI 0.11 to 0.85), but not in those with cirrhosis and Child–Pugh class C disease (HR 1.04; 95% CI 0.45 to 2.37) or bleeding associated with a peptic ulcer (HR 0.70; 95% CI 0.26 to 1.25). Liberal transfusion was associated with an increase in portal-pressure gradient at 5 days (p=0.03). Conclusion: In a large multi-centre randomized study in upper GI bleeding, red cell transfusion based on a haemoglobin threshold of 7g/dL, was associated with improved mortality, reduced rebleeding rates and reduced adverse events than a transfusion policy based on a 9g/dL threshold.
Hepatology: Extracorporeal Albumin Dialysis
Bañares and colleagues performed a prospective, randomized controlled trial in 189 patients with acute-on-chronic liver failure, comparing extracorporeal albumin dialysis (molecular adsorbent recirculating system (MARS), up to ten 6-8 hours sessions, n=95) or to standard therapy (n=94). A number of patients were excluded for protocol violations. Both groups were similar at baseline. There was no difference in 28-day survival, 60% vs 59%. After adjusting for confounders, MARS had no effect on survival (odds ratio: 0.87; CI 95 % 0.44-1.72). Severe adverse events were similar. Conclusion: In this study, MARS did not improve survival in acute-on-chronic liver failure, but did demonstrate a significant dialysis effect (lower creatinine, p=0.02 and lower bilirubin p=0.001).
European Heart Journal: Acute Heart Failure
Erdmann and colleagues completed a placebo-controlled, phase IIb study evaluating the haemodynamic effect and safety of cinaciguat, a novel soluble guanylate cyclase activator, added to standard therapy in 139 patients with acute decompensated heart failure. Cinaciguat was titrated for 8 h and maintained for 16–40 h (starting dose: 100 μg/h). At 8 h, cinaciguat was associated with greater decreases in mean PCWP (decrease of 7.7 mmHg from a baseline of 25.7 ± 5.0 mmHg versus a decrease of 3.7 mmHg from a baseline of 25.0 ± 5.3 mmHg; p < 0.0001), mean right atrial pressure (decrease of 2.7 mmHg from a baseline of 12.4 ± 5.3 mmHg versus a decrease of 0.6 mmHg from a baseline of 11.8 ± 4.9 mmHg; p= 0.0019) and pulmonary and systemic vascular resistance and mean arterial pressure (all p < 0.0001 vs. placebo) in addition to an increase in cardiac index (p < 0.0001). Cinaciguat was associated with a larger decrease in systolic blood pressure, falling by 21.6 ± 17.0 mmHg in comparison with a decrease of 5.0 ± 14.5 mmHg with placebo. There was a greater incidence of adverse effects with cinaciguat; 71% versus 45%. No adverse effects on the 30-day mortality were seen; however, the trial was stopped prematurely due to an increased occurrence of hypotension at cinaciguat doses ≥200 µg/h. Conclusion: Cinaciguat therapy was associated with greater decreases in pulmonary and systemic venous and arterial pressures than placebo. Significant systemic arterial hypotension necessitated termination of this study.
Acta Anaesthesiologica Scandinavica: ECMO
Lindskov et al present data from a 14 year prospective observational study (1997-2011) on 124 Scandanavian patients treated with ECMO for severe respiratory failure. The treatment was based mainly on venous-venous ECMO and centrifugal pumps. The median patient age was 45 years (range 16–67) and the median Murray score was 3.7 (2.5–4.0). One hundred and six (85%) of the patients were retrieved from referring hospitals on ECMO. The median duration of the ECMO was 215 (1–578) h. Ninety-seven (78%) of the patients could be weaned from ECMO. A total of 88 (71%) were discharged alive to the referring hospitals. High SAPS-II, SOFA and Murray scores were associated with a high mortality. Conclusion: ECMO therapy was associated with a high survival rate in this prospective observational study of patients with severe respiratory failure.
Stroke: Sonothrombolysis for Acute Ischemic Stroke
Ricci and colleagues performed a systematic review and meta analysis of studies evaluating the effects of ultrasound to enhance the lysis of intra-arterial thrombi in acute ischemic stroke during systemic intravenous thrombolysis with tissue plasminogen activator (tPA). Five studies (n=233) were included, with 3 studies using transcranial color-coded duplex, and 2 using transcranial color doppler. Sonothrombolysis was associated with a statistically significant difference for the primary outcome of death or disability at 3 months; (n=206; OR: 0.50; 95% CI: 0.27–0.91), failure to recanalize (n=230; OR: 0.28; 95% CI, 0.16–0.50) . There was no effect on mortality (n=206; OR: 1.00; 95% CI, 0.46–2.16) or increasing cerebral hemorrhages (n=233; OR: 2.35; 95% CI: 0.95–5.80). Conclusion: Sonothrombolysis was associated with an improvement in the combined primary outcome of death or disability at 3 months, without an increase in intracranial haemorrhage.
Circulation: Guideline Methodology
- ACCF/AHA Clinical Practice Guideline Methodology Summit Report : A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation 2012;epublished 2012
Intensive Care Medicine: Tidal Volume
- Marini. Lower tidal volumes for everyone: principle or prescription? Intensive Care Med (2013) 39:3–5
Intensive Care Medicine: Physical Restraint
Surgical Neurology International
Review - Clinical
Anesthesiology: ICU Acquired Weakness
- Lipshutz. Acquired Neuromuscular Weakness and Early Mobilization in the Intensive Care Unit. Anesthesiology. 118(1):202-215
Journal of Neurosciences in Rural Practice
- Honeybul. Initial management of traumatic brain injury in the rural setting. J Neurosci Rural Pract 2013;4:33-8
Journal of American College of Cardiology: Myocardial Recovery
- Mann. Myocardial Recovery and the Failing Heart. Myth, Magic, or Molecular Target? J Am Coll Cardiol 2012;60(24):2465-2472
Journal of American College of Cardiology: Acute Coronary Syndrome
Journal of the American College of Cardiology: Ventricular Assist Devices
- Miller. Patient Selection for Ventricular Assist Devices: A Moving Target. J Am Coll Cardiol 2013; epublished January 2nd
Interactive Cardiovascular Thoracic Surgery: Anticoagulation with Intracranial Bleed
- Chandra. When should you restart anticoagulation in patients who suffer an intracranial bleed who also have a prosthetic valve? Interact CardioVasc Thorac Surg 2013; epublished January 3rd
Interactive Cardiovascular Thoracic Surgery: Mechanical Support post Cardiac Surgery
- Urban. What is the optimal mode of mechanical support in transplanted patients with acute graft failure? Interactive CardioVascular and Thoracic Surgery 2012:1–3
The Journal of Herat and Lung Transplantation: Axial and Centrifugal Continuous-Flow Rotary Pumps
- Moazami. Axial and centrifugal continuous-flow rotary pumps: A translation from pump mechanics to clinical practice. J Heart Lung Transplant 2013;32:1–11
JACC Cardiovascular Interventions: Uncontrolled Hypertension
- Bunte. Endovascular Treatment of Resistant and Uncontrolled Hypertension: Therapies on the Horizon. J Am Coll Cardiol Intv 2012;ePublished December 19th
Cleveland Clinic Journal of Medicine: Advanced Heart Failure Therapy
- Starling. Advanced heart failure: Transplantation, LVADs, and beyond. Cleve Clin J Med 2013;80:33-40
Cleveland Clinic Journal of Medicine: Short QT Interval
European Radiology: Cardiac MR
- Wong. The role of cardiac magnetic resonance imaging following acute myocardial infarction. Eur Radiol 2012;22:1757–1768
Annals of Cardiac Anaesthesia: Anaesthesia for Off-Pump CABG
Pulmonary Medicine: Pulmonary Effects of Heart Failure
Journal of Medical Nutrients and Pharmaceuticals: Peri-Operative Diabetic Management
- Baruah. Peri-operative management of hyperglycemia in obese diabetic patients. J Med Nutr Nutraceut 2013;2:19-25
European Journal of Clinical Nutrition: Water Requirements
- Vivanti. Origins for the estimations of water requirements in adults. Eur J Clin Nutr 2012 66: 1282-1289
Annals of Hepatology: N-Acetylcysteine in Non-Paracetamol induced-Acute Liver Failure
- Sales. Use of acetylcysteine for non-acetaminophen-induced acute liver failure. Annals of Hepatology 2013;12(1):6-10
Journal of Anesthesia: Liver in Haemorrhagic Shock
Journal of Postgraduate Medicine: Anticoagulants
Laboratory Medicine: Haemostasis
Laboratory Medicine: Complications of Blood Transfusion
- Torres. Diagnosis, Treatment, and Reporting of Adverse Effects of Transfusion. Lab Medicine 2012;43:217-231
Thrombosis Journal: Venous Thromboembolism
- Hass. Treatment of venous thromboembolism - effects of different therapeutic strategies on bleeding and recurrence rates and considerations for future anticoagulant management . Thrombosis Journal 2012;10:24
PLoS Pathogens: Candida
- Lionakis. Candida and Host Determinants of Susceptibility to Invasive Candidiasis. PLoS Pathog 2013;9(1):e1003079
EMBO Molecular Medicine: Studying Sepsis
Frontiers in Immunology: C5a and C5a receptors in sepsis
Journal of Critical Care: DNR
British Journal of Haematology: Allergic Response
- Hirayama. Current understanding of allergic transfusion reactions: incidence, pathogenesis, laboratory tests, prevention and treatment. British Journal of Haematology 2012;epublished Decembr 6th
Journal of Cerebral Blood Flow & Metabolism: Mitochondrial Therapuetics
- Stetler. The dynamics of the mitochondrial organelle as a potential therapeutic target. J Cereb Blood Flow Metab 2013;33:22-32
Review - Non-Clinical
Canadian Journal of Anesthesia: Anaesthesia
- Orser. Canadian Anesthesiologists’ Society 2011 Royal College Lecture: Anesthesiology: A Profession at a Crossroads. Can J Anesth
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Until next week