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Critical Care Reviews Newsletter

May 19th 2013



Welcome to the 76th 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 two studies on therapeutic hypothermia, one in paediatic brain trauma and the other in adult post in-hospital cardiac arrest. Other investigation include a randomized controlled trials examing weaning with tracheostomies and beta blockade in STEMI, as well as meta analyses examining the effect of renal replacement therapy modality on long term RRT dependence, and anti-coagulation post stroke.

This week's guideline is on the management of haemophilia. There are several editorials, concerning family satisfaction in ICU, the surviving sepsis campaign, critical care in China, and infection risks for anaesthetists. Commentaries are from Intensive Care Medicine and discuss red cell transfusion and tracheostomy.

Amongst the 33 clinical review articles are superb articles on fluids, subclavian vein catheterization, atrial fibrillation, ARDS, diffuse alveolar haemorrhage, adaptive support ventilation, lactate, copper, zinc, scrub typhus and logical empiricism. The non-clinical review articles include isomerism and critical care reimbursement in India. This week's general interest paper is a look at the dark side of open access publishing.

The topic for This Week's Papers is rashes in ICU, starting with a paper on cryoglobulinaemic vasculitis in tomorrow's Paper of the Day.



Lancet Neurology:     Paediatric Traumatic Brain Injury

Adelson and colleagues performed a phase 3, multicenter, multinational, randomised controlled trial to investigate whether therapeutic hypothermia for 48—72 h with slow rewarming improved mortality in children after traumatc brain injury. The study was terminated early for futility after an interim analysis on 77 patients (hypothermia n = 39,  normothermia n = 38). There was no difference in 3 month mortality (hypothermia group 6/39, 15% versus normothermia group 2/38, 5%; p=0·15). Similarly, there was no difference in poor outcomes using either the Glasgow Outcome Scale (hypothermia group 16/39, 42% versus normothermia group 16/38, 42%] or GOS-extended paediatrics (hypothermia group 18/39, 47% versus normothermia group 19/38, 51%]. There were no differences in the occurrence of adverse events or serious adverse events.

Abstract:  Adelson. Comparison of hypothermia and normothermia after severe traumatic brain injury in children (Cool Kids): a phase 3, randomised controlled trial. Lancet Neurol 2013;12(6):546-553


Intensive Care Medicine:     Tracheostomy

Hernandez and colleagues performed a single-center, randomized trial comparing inflated (n=87) verusus deflated (n=94) tracheostomy cuffs in critically ill patients undergoing protocolized, spontaneous breathing trials on a T-tube.  Cuff deflation was associated with reduced weaning time (hazard ratio 2.2, 95 % CI 1.5–3; p < 0.01), reduced respiratory infection (20 vs. 36 %; p = 0.02) and improved swallowing function (31 vs. 22 %; p = 0.02).  

Abstract:  Hernandez. The effects of increasing effective airway diameter on weaning from mechanical ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2013;39(6):1063-1070


Intensive Care Medicine:     Renal Replacement Therapy

Schneider et al completed a systematic review and meta analysis to compare the rate of dialysis dependence among severe acute kidney injury survivors according to the initial mode of renal replacement therapy, either continuous (CRRT) or intermittent (IRRT). Twenty three studies, consisting of 7 randomized controlled trials and 16 observational studies, and totalling 472 and 3,499 survivors, respectively, were inlcuded. In the RCTs, there was no difference in the rate of dialysis dependence among survivors (relative risk 1.15, 95% CI 0.78–1.68, I 2 = 0 %). The observational studies suggested a higher rate of dialysis dependence among survivors who initially received IRRT as compared with CRRT (RR 1.99, 95 % CI 1.53–2.59, I 2 = 42 %). 

Abstract:  Schneider. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med 2013;39(6):987-997


Critical Care Medicine:     Therapeutic Hypothermia post Cardiac-Arrest

Mikkelsen and colleagues undertook a multicentre, prospective cohort study in 538 hospitals 538 hospitals participating in the Get With the Guidelines-Resuscitation database (2003–2009) aiming to describe the use of therapeutic hypothermia after in-hospital cardiac arrest.In 67,498 patients who had return of spontaneous circulation after in-hospital cardiac arrest, therapeutic hypothermia was initiated in just 2.0%. In those who were cooled, the target temperature of 32–34°C was achieved in 55.7% within 24 hours and 17.6% were overcooled. The use of therapeutic hypothermia increased from 0.7% in 2003 to 3.3% in 2009 (p < 0.001). Four factors were associated with an increased liklihood of the initiation of therapeutic hypothermia: younger age (p < 0.001), occurrence in a non-ICU location (p < 0.001), and the event occuring a weekday (p = 0.005), and in a teaching hospital (p = 0.001). 

Abstract:  Mikkelsen. Use of Therapeutic Hypothermia After In-Hospital Cardiac Arrest. Critical Care Med 2013;41(6):1385-1395


Critical Care Medicine:     Myocardial Infarction

Hirschl completed a multi-centre, nonrandomized, prospective observational cohort study examining the effect of immediate versus delayed β-blockade on all-cause mortality of patients with ST-segment elevation myocardial infarction.  In 664 patients with STEMI, 52% (n = 343) received immediate β-blockade and 48% (n=321) received delayed β-blockade. Both the probabilities of any death (19.2% versus 10.7%, p = 0.0022) and cardiovascular death (13.4% versus 5.2%, p = 0.0002) were higher in the delayed treatment group than in the immediate treatment group. Immediate β-blocker therapy was independently protective against death of any cause (odds ratio 0.55, p = 0.033) on multivariable Cox regression analysis. 

Abstract:  Hirschl. Benefit of Immediate Beta-Blocker Therapy on Mortality in Patients With ST-Segment Elevation Myocardial Infarction. Critical Care Med 2013;41(6):1396-1404


Lancet Neurology:     Venothromboembolism Prophylaxis in Stroke

Whitley et al completed an individual patient data meta analysis from the five largest randomised controlled trials in acute ischaemic stroke that compared heparins (unfractionated heparin, heparinoids, or low-molecular-weight heparin) with aspirin or placebo. Patients with ischaemic stroke who were of advanced age, had increased neurological impairment, or had atrial fibrillation had a high risk of both thrombotic and haemorrhagic events after stroke. Also, patients with CT-visible evidence of recent cerebral ischaemia were at increased risk of thrombotic events. In evaluation datasets, the area under a receiver operating curve for prediction models for thrombotic events was 0·63 (95% CI 0·59—0·67) and for haemorrhagic events was 0·60 (0·55—0·64). There was no evidence that the net benefit from heparins increased with either increasing risk of thrombotic events or decreasing risk of haemorrhagic events.

Full Text: Whitley. Targeted use of heparin, heparinoids, or low-molecular-weight heparin to improve outcome after acute ischaemic stroke: an individual patient data meta-analysis of randomised controlled trials. Lancet Neurology 2013;12(6):539-545   (free registration required)





Intensive Care Medicine:     Family Satisfaction in ICU

Chinese Medical Journal:     Surviving Sepsis Campaign


Chinese Medical Journal:     Critical Care in China


Indian Journal of Anaesthesiology:     Infections & the Anaesthetist



Intensive Care Medicine:     Tracheostomy


Intensive Care Medicine:     Red Cell transfusion


Review - Clinical



Indian Journal of Anaesthesiology:     Neuroanaesthesia



Indian Journal of Critical Care Medicine:     Supraclavicular Subclavian Catheterization


International Journal of Applied & Basic Medical Research:     Ticagrelor


Cardiology Research & Practice:     Anti-Platelet Agents


Global Journal of Health Science:     Heart Failure


Journal of the American Academy of Physician Assistants:     Shock


Acta Anaesthesiologica Taiwanica:     Atrial Fibrillation



Translational Respiratory Medicine:     ARDS


Tuberculosis & Respiratory Diseases:     Diffuse Alveolar Haemorrhage


Indian Journal of Critical Care Medicine:     Adaptive Support Ventilation


International Journal of Applied & Basic Medical Research:     Yawning



Journal of the American Academy of Physician Assistants:     Upper GI Haemorrhage


Gastroenterology Research & Practice:     Endoscopic Ultrasound Guided Procedures



Surgical Infections:     Surgical Malnutrition



HPB Surgery:     Liver Metastases



Nephrology Dialysis Transplantation:     Red Cell Transfusion in Chronic Renal Failure



Annals of Intensive Care:     Lactate


Medical Gas Research:     Molecular Hydrogen



Annals of Nutrition and Metabolism:     Zinc Biology

Indian Journal of Anaesthesiology:     Melatonin



Haemophilia:     Haemophilia



International Journal of Applied & Basic Medical Research:     Anti-Bacterial Agents


Virulence:     Bacterial Infections


Indian Journal of Anaesthesiology:     Scrub Typhus

Virulence:     Endothelial Activation


Medical Journal Armed Forces India:     Transplantation


Journal of Anaesthesiology & Clinical Pharmacology:     Critical Incident Reporting


Journal of Anaesthesiology & Clinical Pharmacology:     Logical Empiricism

Review - Basic Science

International Journal of Applied & Basic Medical Research:     Isomerism


Acta Anaesthesiologica Taiwanica:     HMGB1 in Inflammation


Review - Non-Clinical

Indian Journal of Critical Care Medicine:     Critical Care Reimbursement


General Interest

The Scientist:     The Dark Side of Open Access Publication



I hope you find these brief summaries and links useful.

Until next week