Newsletter 122 / April 6th 2014
Welcome
Hello
Welcome to the 122nd 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, guidelines, commentaries and editorials from hundreds of clinical and scientific journals.
This week's highlighted research studies include randomized controlled trials on the use of both aspirin and clonidine in non-cardiac surgery, plus bolus glucose for the treatment of hyperkalaemia; meta analyses address selective digestive decontamination, red cell transfusion-associated infections and adrenaline for out-of-hospital cardiac arrest; observational studies focus on non-invasive mechanical ventilation for acute respiratory failure, healthcare-associated infection prevalence, and CPR in ventilated patients; while additional studies investigate disorders of consciousness, subarachnoid haemorrhage monitoring, ARDS, acute pancreatitis, enteral feeding route, antimicrobial-resistant bacteria, haemorrhagic stroke, ECMO and traumatic brain injury. There is a new category commencing this week, following the correspondence of major studies and other items of interest, starting with the discussion around the TTM study.
There is a single position statement from the World Society of Emergency Surgery on the concept of abdominal sepsis, and also a single editorial addressing "Things to Stop Doing in the Intensive Care Unit to Limit Waste". There are two commentaries, a response from the Surviving Sepsis Campaign to the publication of the ProCESS trial, and a paper from JAMA on big data for future academia-industry collaboration; and several interesting case reports.
Amongst the clinical review articles are papers on non-invasive measurement of intra-cranial pressure, stroke thrombolysis, acute coronary syndromes, pleural ultrasound-guided interventions, kidney injury, haematological emergencies, procalcitonin, and penetrating torso injuries. The beginning of each month marks the addition of recently made open access articles from the major critical care journals, with 24 papers included.
If you prefer a break from all the journal reading, take a look at the general interest articles, where a newspaper report describes the hazards of conducting sensitive conversations at the bedside.
The topic for This Week's Papers is seizures, starting with a paper on refractory status epilepticus in tomorrow's Paper of the Day.
Research
Randomized Controlled Trials
Devereaux and colleagues performed an international, multicentre, blinded, randomized, controlled, 2-by-2 factorial trial permitting separate evaluation of low-dose clonidine versus placebo and low-dose aspirin versus placebo in 10,010 patients with, or at risk for, atherosclerotic disease who were undergoing noncardiac surgery.
In the aspirin arm, patients were statified by those already receiving aspirin (continuation stratum, n=4382) or not (initiation stratum, n=5628), to the perioperative administration of aspirin or placebo. Patients started taking aspirin (at a dose of 200 mg) or placebo just before surgery and continued it daily (at a dose of 100 mg) for 30 days in the initiation stratum and for 7 days in the continuation stratum, after which patients resumed their regular aspirin regimen. The authors found:
- no difference in the primary endpoint, a composite of death or nonfatal myocardial infarction at 30 days
- aspirin group: 7.0% (351/4998) versus placebo group: 7.1% (355/5012)
- hazard ratio in the aspirin group 0.99, 95% CI 0.86 to 1.15; P=0.92
- increased major bleeding with aspirin
- 4.6% vs 3.8%, hazard ratio 1.23; 95% CI 1.01 to 1.49; P=0.04
- no differences in 1° or 2° outcomes between aspirin strata
In the clonidine arm, Deveraux compared low-dose clonidine (200 μg per day, commenced just before surgery and until 72 hours post surgery) with placebo, and found:
- no difference in
- the primary endpoint, a composite of death or nonfatal myocardial infarction at 30 days
- clonidine: n=367 vs placebo: n=339
- hazard ratio with clonidine 1.08, 95% CI 0.93 to 1.26; p=0.29
- the primary endpoint, a composite of death or nonfatal myocardial infarction at 30 days
- clonidine was associated with increased incidence of
- myocardial infarction
- clonidine 6.6% vs placebo 5.9%
- hazard ratio with clonidine 1.11, 95% CI 0.95 to 1.30; P=0.18
- clinically important hypotension
- 47.6% vs 37.1%
- hazard ratio with clonidine 1.32; 95% CI 1.24 to 1.40; P<0.001
- nonfatal cardiac arrest
- 0.3% (n=16) 0.1% (n=5)
- hazard ratio 3.20; 95% CI 1.17 to 8.73; P=0.02
- myocardial infarction
Chothia and colleagues compared the administration of 10 units of insulin with 100 ml of 50% glucose (50 g) with the administration of 100 ml of 50% glucose only in 10 chronic hemodialysis patients prone to hyperkalemia, and found:
- both groups were hyperkalaemic at baseline:
- insulin group: serum [K+] 6.01 ± 0.87
- glucose-only group: serum [K+] 6.23 ± 1.20 mmol/l (p = 0.45)
- at 60 minutes
- both groups had reductions in serum [K+]
- insulin group: -0.83 ± 0.53 mmol/l (p < 0.001)
- glucose-only group: -0.50 ± 0.31 mmol/l (p < 0.001)
- the insulin group had a lower serum [K+]
- 5.18 ± 0.76 vs. 5.73 ± 1.12 mmol/l; p = 0.01
- two patients in the insulin group developed hypoglycemia
- both groups had reductions in serum [K+]
Meta Analysis
Price pooled data from 29 randomized, controlled trials evaluating selective digestive decontamination, selective oropharyngeal decontamination, or topical oropharyngeal chlorhexidine compared with standard care or placebo in general ICUs, and found:
- decreased mortality was observed with
- selective digestive decontamination
- odds ratio of 0.73 (95% CI 0.64 to 0.84)
- selective oropharyngeal decontamination
- odds ratio 0.85 (0.74 to 0.97)
- selective digestive decontamination
- increased mortality was observed with
- chlorhexidine
- odds ratio 1.25, 95% CI 1.05 to 1.50
- chlorhexidine
- comparing interventions
- both selective digestive decontamination and selective oropharyngeal decontamination were superior to chlorhexidine
- the difference between selective digestive decontamination and selective oropharyngeal decontamination was uncertain
Rohde and colleagues reviewed data from 18 randomized controlled trials (n=7,593) evaluating whether red blood cell transfusion thresholds (restrictive vs liberal) are associated with the risk of infection, and whether this risk is independent of leukocyte reduction, and found:
- a decreased risk of all serious infections with restrictive transfusion
- 11.8% (95% CI 7.0% to 16.7%) versus 16.9% (95% CI 8.9% to 25.4%)
- risk ratio 0.82 (95% CI 0.72 to 0.95; I2 = 0%; τ2 <.0001)
- NNT 38 (95% CI 24 to 122)
- the risk reduction with restrictive transfusion remained with leukocyte reduction
- RR 0.80 (95% CI 0.67 to 0.95)
- 11.8% (95% CI 7.0% to 16.7%) versus 16.9% (95% CI 8.9% to 25.4%)
- for trials with a restrictive hemoglobin threshold of <7.0 g/dL
- RR 0.82 (95% CI 0.70 to 0.97)
- NNT 20 (95% CI 12 to 133)
- stratifying by patient type
- the risk reduction remained with
- orthopaedic surgery: RR 0.70 (95% CI 0.54 to 0.91)
- sepsis: RR 0.51 (95% CI 0.28 to 0.95)
- but not in
- cardiac disease
- the critically ill
- acute upper gastrointestinal bleeding
- infants with low birth weight
- the risk reduction remained with
Lin et al pooled data from 14 randomized controlled trials (n=12,246) examining the efficacy of adrenaline in out-of-hospital cardiac arrest, and found:
- standard dose adrenaline was associated with
- versus placebo (n=534)
- improved
- return of spontaneous circulation
- RR 2.80, 95% CI 1.78 to 4.41, p < 0.001
- survival to admission
- RR 1.95, 95% CI 1.34 to 2.84, p < 0.001
- return of spontaneous circulation
- improved
- versus high dose adrenaline (n=6,174)
- decreased
- return of spontaneous circulation
- RR 0.85, 95% CI 0.75 to 0.97, p = 0.02; I2 = 48%
- survival to admission
- RR 0.87, 95% CI 0.76 to 1.00, p = 0.049; I2 = 34%
- return of spontaneous circulation
- decreased
- versus vasopressin alone (n=336)
- no difference in outcomes
- versus vasopressin in combination with adrenaline (n=5,202)
- no difference in outcomes
- versus placebo (n=534)
- there was no survival to discharge or neurological outcome differences in any comparison group, including subgroup analyses
Observational Studies
Schnell et al undertook a multicentre database study of 3,163 critically ill patients who required ventilatory support for acute respiratory failure between 1997 and 2011, examining the use and outcomes of non-invasive ventilation (n=1,232; 39%) versus first-line intubation, and found:
- over the study period,
- first-line NIV increased from 29% to 42%
- NIV success rates increased from 69% to 84%
- NIV decreased
- 60-day mortality
- adjusted hazard ratio (aHR) 0.75; 95% CI 0.68 to 0.83; P < 0.0001
- this protective effect was observed in patients with
- acute-on-chronic respiratory failure (aHR 0.71; 95% CI 0.57 to 0.90; P = 0.004)
- but not in patients with
- cardiogenic pulmonary edema (aHR 0.85; 95% CI 0.70 to 1.03; P = 0.10)
- hypoxemic acute respiratory failure
- immunocompetent (aHR 1.18; 95% CI 0.87 to 1.59; P = 0.30)
- immunocompromised (aHR 0.89; 95% CI 0.70 to 1.13; P = 0.35)
- this protective effect was observed in patients with
- adjusted hazard ratio (aHR) 0.75; 95% CI 0.68 to 0.83; P < 0.0001
- fewer ICU-acquired infections
- 60-day mortality
- NIV failure was an independent time-dependent risk factor for mortality (aHR 4.2; 95% CI 2.8 to 6.2; P < 0.0001)
Magill et al completed a prevalence survey in 10 geographically diverse states (183 hospitals) to determine the prevalence of healthcare–associated infections in acute care hospitals and generate updated estimates of the national burden of such infections, and found:
- of 11,282 patients, 452 had 1 or more health care–associated infections (4.0%; 95% CI 3.7 to 4.4)
- of 504 such infections, the most common types were
- pneumonia (21.8%)
- surgical-site infections (21.8%)
- gastrointestinal infections (17.1%)
- device-associated infections (25.6%)
- central-catheter–associated bloodstream infection
- catheter-associated urinary tract infection
- ventilator-associated pneumonia
- Clostridium difficile was the most commonly reported pathogen
- 12.1% of health care–associated infections
- extrapolating, it was estimated
- there were 648,000 patients with 721,800 health care–associated infections in U.S. acute care hospitals in 2011
Al-Alwan analyzed Medicare data from 1994 to 2005 to evaluate the outcomes, including long-term survival, after cardiopulmonary resuscitation in mechanically ventilated patients, and found:
- 471,962 patients received in-hospital CPR
- overall survival to hospital discharge of 18.4 % (95% CI 18.3 to 18.5% )
- 42,163 received CPR one or more days after mechanical ventilation initiation
- survival to hospital discharge after CPR in
- ventilated patients: 10.1% (95% CI 9.8 to 10.4%)
- non-ventilated patients: 19.2% (95% CI 19.1 to 19.3%) (p < 0.001)
- variables associated with decreased survival were
- older age
- race other than white
- higher burden of chronic illness
- admission from a nursing facility
- among all CPR recipients, those who were ventilated had 52% lower odds of survival
- odds ratio 0.48, 95 % CI 0.46 to 0.49, p < 0.001
- median long-term survival
- ventilated patients receiving CPR who survived to hospital discharge
- 6.0 months (95% CI 5.3 to 6.8 months)
- non-ventilated patients receiving CPR
- 19.0 months (95% CI 18.6 to 19.5 months) (p < 0.001 by logrank test)
- ventilated patients receiving CPR who survived to hospital discharge
- of all patients receiving CPR while ventilated, only 4.1% were alive at 1 year
- survival to hospital discharge after CPR in
Additional
Randomized Controlled Trials
- Abstract: Hibaut. tDCS in patients with disorders of consciousness. Sham-controlled randomized double-blind study. Neurology 2014;82(13):1112-1118
- Abstract: Mutoh. Early Intensive Versus Minimally Invasive Approach to Postoperative Hemodynamic Management After Subarachnoid Hemorrhage. Stroke 2014; April 1st
Systematic Review
- Abstract: Zhu. Enteral omega-3 fatty acid supplementation in adult patients with acute respiratory distress syndrome: a systematic review of randomized controlled trials with meta-analysis and trial sequential analysis. Intensive Care Med 2014;40(4):504-512
- Full Text: Gou. Use of probiotics in the treatment of severe acute pancreatitis: a systematic review and meta-analysis of randomized controlled trials. Critical Care 2014;18:R57
- Abstract: Sajid. An integrated systematic review and meta-analysis of published randomized controlled trials evaluating nasogastric against postpyloris (nasoduodenal and nasojejunal) feeding in critically ill patients admitted in intensive care unit. Eur J Clin Nutr 2014;68:424-432
Observational Studies
- Full Text: Haverkate. Duration of colonization with antimicrobial-resistant bacteria after ICU discharge. Intensive Care Med 2014;40(4):564-571
- Abstract: McCourt. Cerebral Perfusion and Blood Pressure Do Not Affect Perihematoma Edema Growth in Acute Intracerebral Hemorrhage. Stroke 2014;epublished April 1st
- Abstract: Schmidt. Predicting Survival after ECMO for Severe Acute Respiratory Failure: the Respiratory ECMO Survival Prediction (RESP)-Score. Am J Respir Crit Care Med 2014;epublished April 2nd
Guideline and Position Statement
- Surviving Sepsis Campaign Response to ProCESS Trial
- Jain. Is Big Data the New Frontier for Academic-Industry Collaboration? JAMA 2014;epublished April 3rd
Case Reports
- Simons. Forensic Imaging for Causal Investigation of Death. Korean J Radiol 2014;15(2):205-209
- Machicado. A Rare Cause of Gastrointestinal Bleeding in the Intensive Care Unit. Gastroenterology 2014;146(4):911-1137
- Mbuvah. An intravenous drug user with persistent dyspnea and lung infiltrates. Cleveland Clinic Journal of Medicine 2014;81(4):223-224
- Flament. Ultrasound-guided insertion of dialysis catheter in the prone position. Intensive Care Med 2014;40(4):620
- Zhao. Multiple embolisms resulted from a huge fishbone piercing the left atrium. Intensive Care Med 2014;40(4):621-622
Correspondence
Review -Clinical
Neurological
- Asiedu. A Review of Non-Invasive Methods of Monitoring Intracranial Pressure. J Neurol Res. 2014;4(1):1-6
- Pantoni. Thrombolysis in Acute Stroke Patients with Cerebral Small Vessel Disease. Cerebrovasc Dis 2014;37:5-13
Circulatory
- Lincoff. Managing acute coronary syndromes: Decades of progress. Cleveland Clinic Journal of Medicine 2014;81(4):233-242
- Shisehbor. Acute and critical limb ischemia: When time is limb. Cleveland Clinic Journal of Medicine 2014;81(4):209-216
- Varma. Hypertrophic cardiomyopathy: Part 1 - Introduction, pathology and pathophysiology. Ann Card Anaesth 2014;17:118-24
- Jha. Minimally invasive cardiac surgery and transesophageal echocardiograhttp://www.criticalcarereviews.com/administrator/index.phpphy. Ann Card Anaesth 2014;17:125-32
- van Ierssel. The Endothelium, A Protagonist in the Pathophysiology of Critical Illness: Focus on Cellular Markers. BioMed Research International 2014;(2014):985813
- O’Neill. Destination to Nowhere: A New Look at Aggressive Treatment for Heart Failure—A Case Study. Crit Care Nurse 2014;34:47-56
- De Cecco. Coronary Artery Computed Tomography Scanning. Circulation. 2014;129:1341-1345
Respiratory
- Calligaro. Pleural ultrasound-guided interventions: advances and future potentials. Curr Respir Care Rep 2014;epublished March 15th
- Finch. Parapneumonic effusions: epidemiology and predictors of pleural infection. Curr Respir Care Rep 2014;epublished March 28th
- Bintcliffe. Indwelling pleural catheters for benign pleural effusions. Curr Respir Care Rep 2014;epublished March 20th
Gastrointestinal
Renal
- Adewale. Kidney injury, fluid, electrolyte and acid-base abnormalities in alcoholics. Niger Med J 2014;55:93-8
- Aguirre. Physiology of fluid and solute transport across the peritoneal membrane. J Bras Nefrol 2014;36(1):74-79
Haematological
- Engelmann. Activators, therapeutics and immunity-related aspects of thrombosis. Thromb Haemost 2014;111(4):568-569
- Geddings. New players in haemostasis and thrombosis. Thromb Haemost 2014;111(4):570-574
- Schulman. New oral anticoagulant agents – general features and outcomes in subsets of patients. Thromb Haemost 2014;111(4):575-582
- Huntington. Natural inhibitors of thrombin. Thromb Haemost 2014;111(4):583-589
- Huck. The various states of von Willebrand factor and their function in physiology and pathophysiology. Thromb Haemost 2014;111(4):598-609
- Bock. Activated protein C based therapeutic strategies in chronic diseases. Thromb Haemost 2014;111(4):610-617
- Imberti. Evidence and Clinical Judgment: Vena cava filters. Thromb Haemost 2014;111(4):618-624
- Esmon. Targeting factor Xa and thrombin: impact on coagulation and beyond. Thromb Haemost 2014;111(4):625-633
- Tha. An Approach to the Patient with Non-surgical Bleeding and a Normal Coagulation Screen. Proceedings of Singapore Healthcare 2014;23(1):21-27
- Tay. Haematological Emergencies. Proceedings of Singapore Healthcare 2014;23(1):28-32
- Cox. Practical Management of Stroke Prevention in Patients with Atrial Fibrillation and Renal Impairment Receiving Newer Oral Anticoagulants: Focus on Rivaroxaban. J Gen Pract 2014;2:2
Sepsis
- Fineberg. Global Health: Pandemic Preparedness and Response — Lessons from the H1N1 Influenza of 2009. N Engl J Med 2014;370:1335-1342
- Halebeedu. Revamping the role of biofilm regulating operons in device-associated Staphylococci and Pseudomonas aeruginosa. Indian J Med Microbiol 2014;32:112-23
- Cho. Biomarkers of Sepsis. Infect Chemother 2014;46(1):1–12
- Aw. The Use of Procalcitonin in Clinical Practice. Proceedings of Singapore Healthcare 2014;23(1):33-37
Trauma
Miscellaneous
- Makic. Examining the Evidence to Guide Practice: Challenging Practice Habits. Crit Care Nurse 2014;34:28-45
- Abelsson. Mapping the use of simulation in prehospital care - a literature review. Scand J Trauma Resusc Emerg Med 2014;22(1):22
- Welie. The ethics of forgoing life-sustaining treatment: theoretical considerations and clinical decision making. Multidisciplinary Respiratory Medicine 2014;9:14
Recently Made Open Access from the Major Journals
American Journal of Respiratory and Critical Care Medicine
Review
- Brouwer. Regenerative Medicine for the Respiratory System. Am J Respir Crit Care Med 2013;187(5):468-475
- Cazzola. β2-Agonist Therapy in Lung Disease. Am J Respir Crit Care Med 2013;187(7):690-696
Chest
Review
- King. Moving Toward a More Ideal Anticoagulant: The Oral Direct Thrombin and Factor Xa Inhibitors. Chest 2013;143(4):1106-1116
- Budinger. Balancing the Risks and Benefits of Oxygen Therapy in Critically III Adults. Chest 2013;143(4):1151-1162
- Curnow. Preparing for Accountable Care Organizations: A Physician Primer. Chest 2013;143(4):1140-1144
Case Report
- Sekiguchi. Making Paracentesis Safer: A Proposal for the Use of Bedside Abdominal and Vascular Ultrasonography to Prevent a Fatal Complication. Chest 2013;143(4):1136-1139
- Chung. A 59-Year-Old Woman Who Is Awake Yet Unresponsive and Stuporous After Liver Transplantation. Chest 2013;143(4):1163-1165
Critical Care
Review
- Ramsingh. Does it matter which hemodynamic monitoring system is used? Critical Care 2013;17:208
- Cecconi. Goal-directed therapy-what is the evidence in surgical patients? The effect on different risk groups. Critical Care 2013;17:209
- Sherren. Algorithm for the resuscitation of traumatic cardiac arrest patients in a physician-staffed helicopter emergency medical service. Critical Care 2013;17:308
Commentary
British Journal of Anaesthesia
Review
- Gibson. Misplaced central venous catheters: applied anatomy and practical management. Br J Anaesth 2013;110(3):333-346
- Moureau. Evidence-based consensus on the insertion of central venous access devices: definition of minimal requirements for training. Br J Anaesth 2013;110(3):347-356
- Georgiou. Role of therapeutic hypothermia in improving outcome after traumatic brain injury: a systematic review. Br J Anaesth 2013;110(3):357-367
Editorial
- Pandit. National Institute for Clinical Excellence guidance on measuring depth of anaesthesia: limitations of EEG-based technology. Br J Anaesth 2013;110(3):325-328
- Tanaka. On the reversal of new oral anti-coagulants: can we simply extrapolate data from the animal models to humans? Br J Anaesth 2013;110(3):329-332
Continuing Education in Anaesthesia, Critical Care & Pain
Review
- Reduque. Paediatric emergence delirium. Contin Educ Anaesth Crit Care Pain 2013;13(2):39-41
- Roberts. Illegal substances in anaesthetic and intensive care practices. Contin Educ Anaesth Crit Care Pain 2013;13(2):42-46
- Oshan. Anaesthesia for complex airway surgery in children. Contin Educ Anaesth Crit Care Pain 2013;13(2):47-51
- Luoma. Acute management of aneurysmal subarachnoid haemorrhage. Contin Educ Anaesth Crit Care Pain 2013;13(2):52-58
- Taylor. Radiation safety for anaesthetists. Contin Educ Anaesth Crit Care Pain 2013;13(2):59-62
- Boyce. Post-natal neurological problems. Contin Educ Anaesth Crit Care Pain 2013;13(2):63-66
Anaesthesia
Review
Commentary
General Interest
I hope you find these brief summaries and links useful.
Until next week
Rob