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Newsletter 118 / March 9th 2014

Welcome

Hello

Welcome to the 118th 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 research studies include a randomized controlled trial on cognitive therapy early in critically illness; meta analyses address proning in ARDS, videolaryngoscopy in ICU, β lactam infusions and right ventricular dilatation on CT in pulmonary embolism; observational studies focus on the effect of hospital case volume in sepsis, outcomes in terminal cancer patients receiving palliative chemotherapy, sedation and analgesia protocols and long term outcomes after mild acute kidney injury, while additional studies investigate pneumonia diagnosis and fluid costs in resuscitation.

This month's Cochrane reviews includes one new analysis on automated weaning and several updated analyses on fluid resuscitation in haemorrhage, hepatic encephalopathy, mechanical chest compression devices for CPR and antifungals for the neutropaenic cancer patient.

There is one guideline this week, from the AHA/ACC on the management of valvular heart disease. Editorials address mechanical ventilation provision, ICU bed provision, ARDS outcomes and rehabilitation; commentaries focus on news drugs for myocardial infarction, prediction models, and regret, in addition to an entire issue of ICU Management. There is one case report on acute kidney injury. Amongst the clinical review articles are papers on traumatic brain injury, early mobilization in ICU, goal directed fluid resuscitation, a series of airway articles from the International Journal of Critical Illness and Injury Science, tracheal tube cuffs, idiopathic pulmonary fibrosis, obesity, protein calorie targets, variceal bleeding, red cell transfusion, massive obstetric haemorrhage, and care bundles.

There is one basic science review article on mitochondria, as well as two non-clinical reviews on staffing models and leadership. The topic for This Week's Papers is drainage of abscesses and collections, starting with a general paper on abscess drainage in tomorrow's Paper of the Day.

Next week's newsletter will be out early (hopefully) as I will be travelling to SMACCgold over the weekend.

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Research

Randomized Controlled Trials

Brummel and colleagues examined the feasibility and safety of administering combined cognitive and physical therapy early during critical illness in 87 ICU patients with respiratory failure and/or shock to three groups: usual care (n=22), early once-daily physical therapy (n=22), or early once-daily physical therapy plus twice-daily cognitive therapy (n=43), and found:

early cognitive therapy was a delivered to 95 % of cognitive plus physical therapy patients on 100 % (92–100 %) of study days beginning 1.0 (1.0–1.0) day following enrollment
physical therapy was received by
- 77 % of usual care patients on 17 % (10–26 %) of study days
- 95 % of physical therapy only patients on 67 % (46–87 %) of study days
- 98 % of cognitive plus physical therapy patients on 75 % (59–88 %) of study days
at three months there was no inter-group differences in various outcomes:
- cognitive
- functional
- health-related quality of life

Abstract: Brummel. Feasibility and safety of early combined cognitive and physical therapy for critically ill medical and surgical patients: the Activity and Cognitive Therapy in ICU (ACT-ICU) trial. Intensive Care Med 2014;40(3):370-379

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Meta Analyses

Beitler et al pooled data from seven randomized controlled trials (n=2,119) investigating prone positioning for patients with ARDS and found:

overall, prone positioning was not associated with a reduced risk ratio of death
- RR 0.83; 95 % CI 0.68 to 1.02; p = 0.073; I ² = 64 %
stratified by high or low tidal volume, prone positioning was associated with
- a significant decrease in risk ratio of death only among studies with low baseline tidal volume
- RR 0.66; 95 % CI 0.50 to 0.86; p = 0.002; I² = 25 %
stratification by tidal volume explained over half the between-study heterogeneity observed in the unstratified analysis

Abstract: Beitler. Prone positioning reduces mortality from acute respiratory distress syndrome in the low tidal volume era: a meta-analysis. Intensive Care Med 2014;40(3):332-341

De Jong reviewed data from 9 studies (n = 2,133; DL: 1,067 & VL: 1,066), comparing videolaryngoscopy with direct laryngoscopy in the ICU, and found:

videolaryngoscopy was associated with
- reduced risk of
  - difficult orotracheal intubation
    - OR 0.29, 95 % CI 0.20 to 0.44, p < 0.001
  - Cormack 3/4 grades
    - OR 0.26, 95 % CI 0.17 to 0.41, p < 0.001
  - esophageal intubation
    - OR 0.14, 95 % CI 0.02 to 0.81, p = 0.03
- increased
  - first-attempt success
    - OR 2.07, 95 % CI 1.35 to 3.16, p < 0.001
There was no difference in
- severe hypoxemia
- severe cardiovascular collapse
- airway injury

Abstract: De Jong. Video laryngoscopy versus direct laryngoscopy for orotracheal intubation in the intensive care unit: a systematic review and meta-analysis. Intensive Care Medicine 2014;epublished February

Teo et al performed a meta analysis of 29 studies (18 RCTs and 11 observational studies; n=2,206) comparing prolonged infusion with intermittent bolus administration of ß-lactam antibiotics in hospitalised adult patients, and found:

use of prolonged infusion was associated with a
- significant reduction in mortality
  - relative risk 0.66, 95% CI 0.53 to 0.83
- improvement in clinical success
  - RR 1.12, 95% CI 1.03 to 1.21
statistically significant benefit was supported by
- non-randomised studies
  - mortality
    - RR 0.57, 95% CI 0.43 to 0.76
  - clinical success
    - RR 1.34, 95% CI 1.02 to 1.76
- but not by RCTs
  - mortality
    - RR 0.83, 95% CI 0.57 to 1.21
  - clinical success
    - RR 1.05, 95% CI 0.99 to 1.12

Abstract: Teo. Prolonged infusion versus intermittent boluses of ß-lactam antibiotics for treatment of acute infections: a meta-analysis. International Journal of Antimicrobial Agents 2014;epublished March 1st

Becattini and colleagues examined 36 studies (9 prospective, 27 retrospective) evaluating whether right ventricular dilatation at CT angiography predicts the risk of death in patients with acute pulmonary embolism, and found:

CT-detected right ventricular dilatation was associated with
- increased 30 day-mortality in
  - all-comers with pulmonary embolism
    - OR 2.08, 95% CI 1.63 to 2.66; p<0.00001
  - haemodynamically stable patients
    - OR 1.64, 95% CI 1.06 to 2.52; p = 0.03
- death due to pulmonary embolism
  - OR 7.35, 95% CI 3.59 to 15.09; p<0.00001
- 3-month mortality
  - OR 4.65, 95% CI 1.79 to 12.07; p = 0.002

Abstract: Becattini. Computed tomography to assess risk of death in acute pulmonary embolism: a meta-analysis. Eur Respir J 2014;erj01478

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Observational Studies

Walkey and colleagues assessed the associations between hospital severe sepsis caseload and outcomes in 56,997 patients with severe sepsis admitted to 124 U.S. academic hospitals during 2011, using the University HealthSystem Consortium’s sepsis mortality model (c-statistic, 0.826) for risk adjustment, and found:

basic data
- hospitals admitted 460 ± 216 patients with severe sepsis
- median length of stay 12.5 days (IQR 11.1 to 14.2)
- median direct costs $26,304 (IQR $21,900 to $32,090)
- hospital mortality 25.6 ± 5.3%
higher severe sepsis case volume was associated with lower
- unadjusted severe sepsis mortality (R² = 0.10, P = 0.01)
- risk-adjusted severe sepsis mortality (R² = 0.21, P < 0.001)
- adjusted absolute 7% (95% CI 2.4 to 11.6%) lower hospital mortality (highest versus lowest quartile)
there was no association between case volume and resource use

Abstract: Walkey. Hospital Case Volume and Outcomes among Patients Hospitalized with Severe Sepsis. Am J Respir Crit Care Med 2014;189(5):548-555

Wright et al completed a secondary analysis of a prospective, multi-centre study of 386 terminally ill cancer patients, analysing whether receipt of chemotherapy at enrollment was associated with patients’ subsequent intensive medical care and place of death, and found:

palliative chemotherapy
- was received by 56%
- a median of 4.0 months before death
- was associated with (propensity analysis)
  - higher rates of
    - cardiopulmonary resuscitation
    - mechanical ventilation
    - both in the last week of life
      - 14% v 2%; adjusted risk difference 10.5%, 95% CI 5.0% to 15.5%
    - late hospice referrals
      - 54% v 37%; adjusted risk difference 13.6%, 95% CI 3.6% to 23.6%
  - no difference in survival
    - hazard ratio 1.11, 95% CI 0.90 to 1.38
patients receiving palliative chemotherapy were
- more likely to die in an intensive care unit
  - 11% v 2%; adjusted risk difference 6.1%, 95% CI 1.1% to 11.1%
- less likely to die
  - at home
    - 47% v 66%; adjusted risk difference −10.8%, 95% CI −1.0% to −20.6%
  - in their preferred place
    - 65% v 80%; adjusted risk difference −9.4%, 95% CI −0.8% to −18.1%

Full Text: Wright. Associations between palliative chemotherapy and adult cancer patients’ end of life care and place of death: prospective cohort study. BMJ 2014;348:g1219

Dale and colleagues performed a single centre, before (n=703) and after (n=708) study, evaluating the implementation of three protocol updates:

documentation of Richmond Agitation Sedation Scale scores every 4 hours
documentation of Confusion Assessment Method-ICU twice daily
systematic, protocolized de-escalation of excess sedation

and found:

protocol updates were associated with more assessments per day
- RASS
  - 5.38 vs. 4.16; difference 1.22, 95% CI 1.05 to 1.39; P <0.01
- CAM-ICU
  - 1.49 vs. 0.35; difference 1.15, 95% CI 1.08 to 1.21, P <0.01
decreased
- hourly benzodiazepine dose
  - - 34.8%, 0.08 mg lorazepam equivalents/hour; 0.15 vs. 0.23; P <0.01
- duration of mechanical ventilation
  - - 17.6%, 95% CI, 0.6-31.7%; P = 0.04
- delirium
  - OR 0.67, 95% CI 0.49 to 0.91; P = 0.01
- duration of
  - ICU stay
    - -12.4%, 95% CI 0.5 to 22.8%; P = 0.04
  - hospitalization
    - - 14%, 95% CI 2.0 to 24.5%; P = 0.02
there was no association with mortality
- OR 1.18; 95% CI 0.80 to 1.76, P = 0.40

Abstract: Dale. Improved Analgesia, Sedation and Delirium Protocol Associated with Decreased Duration of Delirium and Mechanical Ventilation. Annals of the American Thoracic Society 2014;epublished March 5th

Linder et al assessed whether a single episode of minimal (stage I KDIGO) acute kidney injury is associated with reduced long-term survival compared to no acute kidney injury in 2,010 patients (1,844 analysed) after recovery from critical illness, and found:

AKI development rates
1. AKI stage 1: 18.4%
2. AKI stage 2: 12.1%
3. AKI stage 3: 26.5%
4. No AKI: 43.0%
survival rates for patients with stage 1 AKI versus no AKI were (p<0.01)
- 28-day: 67.1%
- 1-year: 51.8%
- 5-year: 44.1%
- 10-year: 36.3%
increased 10-year mortality hazard ratio for 28-day survivors with stage 1 AKI compared with no AKI
- unadjusted 1.53 (95% CI 1.2 to 2.0)
- adjusted 1.26 (1.0 to 1.6).
- propensity matching (p=0.036)