Critical Care Reviews Newsletter
March 4th 2012
Welcome to the 13th 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. A link to either the full text or abstract, depending on the publishers degree of open access, is attached.
Egi and colleagues performed a prospective observational study to investigate the association of fever and the use of antipyretic treatments with mortality in 1,425 critically ill patients without neurological injury. 1,425 consecutive adult critically ill patients (without neurological injury) requiring >48 hours intensive care admitted in twenty-five ICUs were studied. Body temperature was recorded 63,441 times, and antipyretic treatment was given 4,863 times to 737 patients (51.7%). Treatment with NSAIDs or acetaminophen independently increased 28-day mortality for septic patients (adjusted odds ratio: NSAIDs: 2.61, p=0.028, acetaminophen: 2.05, p=0.01), but not for non-septic patients (adjusted odds ratio: NSAIDs: 0.22, p=0.15, acetaminophen: 0.58, p=0.63). Physical cooling was not associated with mortality in either group. Relative to the temperature reference range (36.5 -37.4 C), maximum temperature (> 39.4 C) increased risk of 28-day mortality in septic patients (adjusted odds ratio 8.14, p=0.01), but not in non-septic patients (adjusted odds ratio 0.47, p=0.11).
Abstract: Egi. Association of body temperature and antipyretic treatments with mortality of critically ill patients with and without sepsis: multi-centered prospective observational study. Critical Care 2012, 16:R33
Nephrology Dialysis Transplantation
Renal Replacement Therapy
Zhang and colleagues performed a single-centre, randomized control trial, comparing high-volume hemofiltration (50 mL/kg/h, HVHF) or extra high-volume hemofiltration (85 mL/kg/h, EHVHF) in 280 patients with sepsis and acute kidney injury. The two groups had similar baseline characteristics and received treatment for an average of 9.38 days (EHVHF group) and 8.88 days (HVHF group). There were no significant differences between the groups in number of deaths at 28, 60 or 90 days. There were also no differences between the groups in renal outcome of survivors at 90 days.
Abstract: Zhang. Effect of the intensity of continuous renal replacement therapy in patients with sepsis and acute kidney injury: a single-centre randomized clinical trial. Nephrol. Dial. Transplant. (2012)27 (3): 967-973.
Schneider and colleagues compared the characteristics and outcome of 90 patients with severe (RIFLE-F) acute kidney injury who did not receive renal replacement therapy (RRT) with 105 patients who did receive RRT. Both groups were similar in terms of age, gender and ward of origin. However, patients not receiving RRT had a shorter median ICU stay (2.7 v 7.9 days; P < 0.001), required less mechanical ventilation (56.2 v 70%; P < 0.05) and had a lower mean Acute Physiology and Chronic Health Evaluation III score (82.7 v 86.7; P < 0.05). The two main reasons these patients did not receive RRT were limitations of medical therapy (LOMT) orders in 41 (39%) cases and expected renal functional improvement in 59 (56.2%). Mortality in no-RRT patients was 58.1% compared with 55.5% in the RRT group (P = 0.72). After exclusion of LOMT patients, the mortality of the no-RRT group, although lower than that of the RRT group, remained high (30.5 v 55%; P < 0.001). Most of these deaths occurred after ICU discharge and appeared secondary to underlying chronic diseases or recurrence of the initial insult.
Journal of Antimicrobial Chemotherapy
Peman and colleagues, over a 13 month period at 44 Spanish hospitals, prospectively evaluated the incidence of fungaemia and susceptibility to commonly used antifungal agents. There were 1357 fungaemia episodes, with a incidence of 0.92 per 1000 admissions. The incidence in numerical order was Candida albicans (0.41 episodes/1000 admissions), Candida parapsilosis (0.22), Candida glabrata, Candida tropicalis and Candida orthopsilosis (0.02). The incidence of Candida orthopsilosis and Candida metapsilosis fungaemias were rare. Neither Candida nivariensis nor Candida bracarensis was isolated. Fungaemia was more common in non-intensive care unit settings (65.2%) and among elderly patients (46.4%), with mixed fungaemia being infrequent (1.5%). Overall susceptibility rates were 77.6% for itraconazole, 91.9% for fluconazole and 96.5%–99.8% for the other agents. Important resistance rates were only observed in C. glabrata for itraconazole (24.1%) and posaconazole (14.5%), and in Candida krusei for itraconazole (81.5%).
Abstract: Peman. Epidemiology, species distribution and in vitroantifungal susceptibility of fungaemia in a Spanish multicentre prospective survey. J. Antimicrob. Chemother 2012;epublished ahead of print
Annals of Internal Medicine
In a systematic review and meta-analysis, Chartrand investigated the accuracy of rapid influenza diagnostic tests (RIDTs) in 159 studies that evaluated 26 different RIDTs. 35% were conducted during the H1N1 pandemic. The pooled sensitivity and specificity were 62.3% (95% CI, 57.9% - 66.6%) and 98.2% (CI, 97.5% - 98.7%), respectively. The positive and negative likelihood ratios were 34.5 (CI, 23.8 - 45.2) and 0.38 (CI, 0.34 - 0.43), respectively. Sensitivity estimates were highly heterogeneous, which was partially explained by lower sensitivity in adults (53.9% [CI, 47.9% to 59.8%]) than in children (66.6% [CI, 61.6% to 71.7%]) and a higher sensitivity for influenza A (64.6% [CI, 59.0% to 70.1%) than for influenza B (52.2% [CI, 45.0% to 59.3%). The stdies were limited by an inability to determine specimen type and duration of influenza symptoms, on diagnostic accuracy. The authors conclude influenza can be ruled in but not ruled out through the use of RIDTs.
In a systematic review and meta-analysis of 74 studies investigating the efficacy of antivirals for the treatment of influenza, Hsu and colleagues found that, with adjustment for confounders, in high-risk populations, oral oseltamivir may reduce mortality (OR 0.23 [95% CI, 0.13 to 0.43]; hospitalization (OR 0.75 [CI, 0.66 to 0.89]; and duration of symptoms (33 hours [CI, 21 to 45 hours]; compared with no treatment, all of which was based on low quality evidence. Earlier treatment with oseltamivir was generally associated with better outcomes. Inhaled zanamivir may lead to shorter symptom duration (23 hours [CI, 17 to 28 hours]; moderate-quality evidence) and fewer hospitalizations (OR 0.66 [CI, 0.37 to 1.18]) but more complications than no treatment. Direct comparison of oral oseltamivir and inhaled zanamivir suggests no important differences in key outcomes. Data from 1 study suggests that oral amantadine may reduce mortality and pneumonia associated with influenza A.
Journal of Neurotrauma
Traumatic Brain Injury
In a prospective observational study, Stein and colleagues measured the association between serum S100ß, neuron-specific enolase (NSE), and glial fibrillary acidic protein (GFAP) and cerebral hypoxia in the serum of 76 patients with severe traumatic brain injury. 24 of the 76 had cerebral oxygen partial pressure measured, and had a total of 130 serum samples drawn and matched to 12 hour periods of cerebral oxygenation. Significant associations were found in adjusted analysis between increasing serum levels of S100ß (coefficient=0.57, 0.56; p<0.001), NSE (coeff=0.48, 0.52; p<0.001), and GFAP (coeff=0.29, 0.30; p=0.003 and 0.002) and increasing depth and duration of hypoxia, both moderate (PbO2 <20) and severe (PbO2 <15). Area under the curves for prediction of moderate and severe cerebral hypoxia were 0.62 and 0.66 for S100ß, 0.55 and 0.71 for NSE, and 0.50 and 0.62 for GFAP, respectively. Specificities were between 76% and 90% for S100ß and NSE. The authors conclude that S100ß, NSE, and GFAP demonstrate promise as candidate serum markers of impending cerebral hypoxia, although these AUCs seem very low.
New England Journal of Medicine
Traumatic Brain Injury
In a placebo controlled trial in 184 patients in a vegetative or minimally conscious state 4 to 16 weeks after traumatic brain injury, Giacino and colleagues investigated the effects of amantadine on the rate of functional recovery using the Disability Rating Scale. During a 4 week treatment period, the rate of recovery was significantly faster with amantidine, although this improved recovery was lost by 6 weeks, 2 weeks after stopping this therapy.
I hope you find these brief summaries useful.
Until next week