Newsletter 105 / December 8th 2013




Welcome to the 105th 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 been a quiet week for research publications, which has been compensated for by a large number of excellent review articles.

This week's research studies include randomized trials investigating communication skills and bivalirudin for STEMI PCI, meta analyses address ventilator-associated pneumonia and anaemia management in patients with heart failure, while observational studies focus on ICU telemedicine, heparin-induced thrombocytopenia, CT pulmonary angiography for pulmonary embolism, and substance use disorder among anesthesiology residents.

This week's guidelines look at perioperative care of the elderly and radiation protection, editorials highlight patient hand-over and patient privacy, while commentaries focus on guidelines, statins, bacteria and the one million deaths study. Amongst the clinical review articles are papers on stroke, acute coronary syndrome, perioperative cardiac protection, pulmonary embolism, clostridium difficile, constipation, liver transplantation, hepatectomy, portopulmonary hypertension, therapeutic hypothermia, contrast-induced nephropathy, and acute pain.

The beginning of each month marks the addition of recently made open access articles from the major critical care journals, with papers from the American Journal of Respiratory and Critical Care Medicine, Chest, Anesthesiology, Anesthesia & Analgesia, Critical Care, British Journal of Anaesthesia including Continuing Education in Anaesthesia, Critical Care and Pain, Anesthesia & Intensive Care and Shock.

The topic for This Week's Papers is neuromuscular blockade, starting with a general paper in tomorrow's Paper of the Day.


Annual Survey

Last week I started a survey to get your opinion on how to improve Critical Care Reviews. Thank you if you have already completed this very brief anonymous survey; if not, I would be very grateful if you could take a minute to do so. This survey was run last December, with most recommendations either trialled or fully implemented. There are a few that I just haven't got round to yet, as they require quite some work, but I plan on getting to them. Every comment will be gratefully received, read and considered. On the basis of one suggestion from last week's responses, I have introduced links within the newsletter, enabling easier navigation.

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Critical Care Reviews Meeting

It's just 7 weeks to the 2014 Critical Care Reviews Meeting. This year we discuss the major studies from the past 12 months, hear from our international guest speakers, Prof Alistair Nichol (Dublin/Melbourne), Prof Mervyn Singer (London) and Prof John Marshall (Toronto), and have updates on ICU infections, massive haemorrhage and acute liver failure. The evening session provides an opportunity to chat with our guest speakers in a novel, informal setting - beside a blazing log fire in a beautiful lounge - perfect for a cold winters night. This will be followed by dinner and the chance to meet new colleagues and friends.

If you're a drive or short flight away, it would be great to have you come along. Travel on Thursday, attend the meeting on Friday and see some of the local landmarks over the weekend, before returning home on Sunday evening after a great winter break. On Saturday visit the North Coast: the World Heritage site Giants Causeway, Carrick-a-Rede rope bridge, Dunluce Castle and Bushmills Distillary, the oldest distillary in the world; while on Sunday experience Belfast: the new acclaimed Titanic Centre followed by a famous black taxi tour describing the troubled past of one of Europe's now most vibrant cities. The Galgorm Resort and Spa is one of Northern Ireland's premier hotels and is a 30 minute drive from Belfast International Airport. Special room rates are available, by quoting the meeting. Please feel free to contact me if you're thinking about making the trip - it would be great to hear from you. Now is a good time to register before such thoughts are rightly forgotten during the approaching festivities.

This year, the meeting will be run in association with the Northern Ireland Intensive Care Society. Further details, the meeting programme, and registration can be accessed via these links.

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Randomized Controlled Trials

Curtis and colleagues performed a randomized trial to assess the effects of a communication skills intervention for internal medicine (n=391) and nurse practitioner trainees (n=81) on patient- and family-reported outcomes, comparing an 8-session, simulation-based, communication skills intervention (N = 232) with usual education (N = 240), and found:

  1. there were 1,866 patient ratings (44% response) and 936 family ratings (68% response)
  2. The intervention was not associated with significant changes in
    • patient-reported quality of communication (mean rating of 17 items rated from 0-10, with 0 = poor and 10 = perfect)
      • intervention: 6.5 (95% CI 6.2 to 6.8)
      • control: 6.3 (95% CI 6.2 to 6.5)
        • after adjustment, comparing intervention with control, there remained no significant difference
          • patients; difference 0.4 points; (95% CI −0.1 to 0.9); P = 0.15
          • families; difference 0.1; (95% CI −0.8 to 1.0); P =0 .81
    • patient-reported quality of end-of-life care (mean rating of 26 items rated from 0-10)
      • intervention: 8.3 (95% CI 8.1 to 8.5)
      • control:  8.3 (95% CI 8.1 to 8.4)
        • after adjustment, comparing intervention with control, there remained no significant difference
          • patients; difference 0.3 points (95% CI −0.3 to 0.8); P = 0.34 
          • families; difference 0.1 points (95% CI −0.7 to 0.8); P= 0.88
  3. The intervention was associated with
    • significantly increased mean depression scores among patients of postintervention trainees
      • intervention: 10.0 (95% CI 9.1 to 10.8)
      • control: 8.8 (95% CI 8.4 to 9.2)
      • adjusted intervention effect 2.2 (95% CI 0.6 to 3.8); P = 0.006

Abstract:  Curtis. Effect of Communication Skills Training for Residents and Nurse Practitioners on Quality of Communication With Patients With Serious Illness. A Randomized Trial. JAMA 2013;310(21):2271-2281 


Steg and colleagues completed a randomized controlled trial in 2,218 patients with ST-segment elevation myocardial infarction being transported for primary PCI, comparing bivalirudin (intervention) with either unfractionated or low-molecular-weight heparin with optional glycoprotein IIb/IIIa inhibitors (control group), and found:

  1. bivalirudin was associated with a reduced risk of
    • the primary outcome (a composite of death or major bleeding not associated with coronary-artery bypass grafting at 30 days)
      • 5.1% vs. 8.5%;
      • relative risk 0.60; 95% CI 0.43 to 0.82; P=0.001
    • the principal secondary outcome (a composite of death, reinfarction, or non-CABG major bleeding)
      • 6.6% vs. 9.2%;
      • relative risk 0.72; 95% CI 0.54 to 0.96; P=0.02
    • risk of major bleeding
      • 2.6% vs. 6.0%;
      • relative risk 0.43; 95% CI 0.28 to 0.66; P<0.001
  2. bivalirudin was associated with
    • an increased risk of acute stent thrombosis
      • 1.1% vs. 0.2%
      • relative risk 6.11; 95% CI 1.37 to 27.24; P=0.007
  3. There was no significant difference in rates of
    • death (2.9% vs. 3.1%)
    • reinfarction (1.7% vs. 0.9%)
  4. results were consistent across subgroups 

Abstract:  Steg. Bivalirudin Started during Emergency Transport for Primary PCI (EUROMAX study). N Engl J Med 2013;369:2207-2217

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Meta Analysis

Dimopoulos et al pooled data from four randomized controlled trials comparing short- (7 to 8 days) with long- (10 to 15 days) duration antibiotic regimens for ventilator-associated pneumonia, and found: 

  1. no difference in
    • mortality
      • (OR 1.20; 95% CI 0.84 to 1.72; P = 0.32)
    • relapses
      • with a trend to lower relapses in the long-course treatment
        • (OR = 1.67; 95% CI, 0.99-2.83; P = 0.06)
    • remaining outcomes
  2. short-course treatment was associated with
    • an increase in antibiotic-free days
    • pooled weighted mean difference of 3.40 days (95% CI 1.43 to 5.37; P <0.001)
  3. sensitivity analyses yielded similar results

Abstract:  Dimopoulos. Short- vs Long-Duration Antibiotic Regimens for Ventilator-Associated Pneumonia: A Systematic Review and Meta-analysis. Chest 2013;144(6):1759-1767


Kansagara et al completed an English language systematic review and meta analysis evaluating treatments for anemia in adults with heart disease, and found:

  1. liberal transfusion protocols, compared with less aggressive protocols,
    • did not improve short-term mortality rates  (low-strength evidence from 6 trials and 26 observational studies)
      • combined relative risk 0.94 (95% CI 0.61 to 1.42); I2 = 16.8%
    • were associated with a decreased mortality rate in a small trial of patients with the acute coronary syndrome
      • 1.8% vs. 13.0%; P = 0.032
  2. intravenous iron was associated with (moderate-strength evidence from 3 trials)
    • improved short-term exercise tolerance 
    • quality of life in patients with heart failure 
  3. erythropoiesis-stimulation was associated with (moderate- to high-strength evidence from 17 trials)
    • no consistent benefits
    • possible harm, such as venous thromboembolism

Abstract:  Kansagara. Treatment of anemia in patients with heart disease: a systematic review. Ann Intern Med 2013;159(11):746-57

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Observational Studies

In a multi-centre American observational study of 118,990 adult patients, Lilly and colleagues evaluated the effects of ICU telemedicine programs (11,558 control; 107,432 intervention) on clinical outcomes, and found:

  1. telemedicine programs were associated with adjusted reduced rates of 
    • ICU mortality
      • HR 0.74, 95% CI 0.68 to 0.79, p<.001
    • hospital mortality 
      • HR 0.84, 95% CI: 0.78 to 0.89, p<.001
    • length of stay, for patients who stayed in the ICU for
      • ≥7 days:
        • ICU LOS was reduced by 1.1 days (95% CI: 0.8-1.4)
        • hospital LOS was reduced 0.5 days (95% CI: 0.4-0.5)
      • ≥14 days:
        • ICU LOS was reduced by 2.5 days (95% CI: 1.6-3.4)
        • hospital LOS was reduced by 1.0 (95% CI: 0.7-1.3)
      • ≥30 days:
        • ICU LOS was reduced by 4.5 (95% CI: 1.5-7.2) days among those , respectively.
        • hospital LOS was reduced by 3.6 (95% CI: 2.3-4.8)
  2. individual components of the interventions that were associated with lower mortality and/or reduced LOS were
    • intensivist case review within 1 hour of admission
    • timely use of performance data
    • adherence to ICU best practices
    • quicker alert response times

Abstract:  Lilly. A Multi-center Study of ICU Telemedicine Reengineering of Adult Critical Care. Chest 2013;eublished December 5th


Seigerman and colleagues undertook a national database (n=186,771) retrospective analysis to quantify the impact of heparin-induced thrombocytopenia on outcomes after cardiac surgery, and found:

  1. heparin-induced thrombocytopenia was diagnosed in 506 (0.3%)
  2. secondary thrombocytopenia was diagnosed in 16,809 (8.7%).
  3. operative mortality was greater in patients with HIT, compared with:
    • HIT:  11.1% 
    • without thrombocytopenia:  4.5%  (p<0.001) 
    • secondary thrombocytopenia:  4.0% (p<0.001)
  4. the strongest adjusted independent predictors of HIT were
    • female gender (OR 1.4, 95% CI 1.28 to 1.48)
    • congestive heart failure (OR 1.8, 95% CI 1.71 to 1.98)
    • cardiac insufficiency (OR 2.2, 95% CI 1.97 to 2.39)
    • atrial fibrillation (OR 1.4, 95% CI 1.30 to 1.51)
    • liver disease (OR 2.2, 95% CI 1.96 to 2.50)
    • chronic renal failure (OR 1.4, 95% CI 1.30 to 1.51)
  5. HIT was associated with significantly increased risk of major adverse postoperative outcomes including
    • death (OR 1.5, 95% CI 1.3 to 1.7)
    • stroke (OR 2.4, 95% CI 1.9 to 3.1)
    • amputation (OR 7.46, 95% CI 4.0 to 14.0)
    • acute renal failure (OR 2.3, 95% CI 2.1 to 2.5)
    • respiratory failure (OR 1.9, 95% CI 1.8 to 2.1)
    • need for tracheostomy (OR 2.7, 95% CI 2.3 to 3.1)

Abstract:  Seigerman. Incidence and Outcomes of Heparin-induced Thrombocytopenia in Patients Undergoing Cardiac Surgery in North America: An Analysis of the Nationwide Inpatient Sample. J Cardiothorac Vasc Anesth 2013;epublished November 29th


Van Es and colleagues completed a prospective study (n=203) evaluating the clinical implication of abnormalities on CT pulmonary angiography, undertaken for a suspicion of pulmonary embolism, and found:

  1. 30% (61/203) had no abnormality on CTPA
  2. 19% (n=39) were diagnosed with PE
  3. before CTPA, alternative diagnoses were suspected in 48%
    • findings supporting an alternative diagnosis were detected in 43%
    • this was a new finding in 14% (n=28)
    • a conclusive and previously unknown alternative diagnosis was made on the basis of the CTPA results in 18 patients
  4. findings supporting alternative diagnoses had therapeutic consequences in 4.9% (n=10)
  5. incidental findings (nodules and enlarged lymph nodes) requiring diagnostic procedures were present in 8.4% (n=17), with 0.5% (n=1) having a therapeutic consequence

Abstract:  Van Es. Clinical Impact of Findings Supporting an Alternative Diagnosis on CT Pulmonary Angiography in Patients With Suspected Pulmonary Embolism. Chest 2013;144(6):1893-1899


Warner and colleagues performed a retrospective cohort study examining substance use disorder in 44,612 American anaesthesiology residents (177,848 resident-years), between 1975 to 2009, and found:

  1. 384 had evidence of substance use disorder during training
    • incidence of 2.16 (95% CI 1.95 to 2.39) per 1000 resident-years
      • 2.68 (95% CI 2.41 to 2.98) men 
      • 0.65 (95% CI, 0.44 to 0.93) women
  2. the highest incidence has occurred since 2003
    • 2.87 (95% CI 2.42 to 3.39) per 1000 resident-years
  3. the most commonly abused substances were
    1. intravenous opioids, followed by
    • alcohol
    • marijuana
    • cocaine
    • anesthetics/hypnotics
    • oral opioids
  4. 28 individuals died during the training period
    • 7.3%; 95% CI 4.9% to 10.4%
    • all deaths were related to SUD
  5. the cumulative proportion of survivors experiencing at least 1 relapse by 30 years after the initial episode was 43% (95% CI 34% to 51%)
  6. rates of relapse and death did not depend on the category of substance used
  7. relapse rates did not change over the study period

Abstract:  Warner. Substance Use Disorder Among Anesthesiology Residents, 1975-2009. JAMA 2013;310(21):2289-2296


Other Studies of Interest

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Recently Made Open Access Articles from Major Journals

American Journal of Respiratory and Critical Care Medicine







Critical Care


Study Critique






Anesthesia & Analgesia




British Journal of Anaesthesia




Continuing Education in Anaesthsia, Critical Care & Pain


Anaesthesia and Intensive Care






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I hope you find these brief summaries and links useful.

Until next week