Newsletter 125 / April 27th 2014
Welcome
Hello
Welcome to the 125th 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. It's a relatively quiet week on the research front, but an abundance of commentaries and review articles provide plenty of reading for the next week.
This week's research studies include randomized controlled trials on ulinastatin for severe sepsis, prehospital stroke management, paediatric status epilepticus and tuberculous meningitis; meta analyses address carbapenam-associated seizures, lung ultrasound for pneumonia and noninvasive ventilation for post-extubation respiratory failure; observational studies focus on glycopeptide use for Enterococcus faecalis bacteraemia, ventilator-associated pneumonia and ventilator-associated condition. Additional studies investigate nasotracheal intubation, surgical scrub wearing outside the theatre complex, ischaemic stroke and clinical trial registration.
This week's guidelines and position statements include a new definition of epilepsy, plus guidance on pressure ulcer management and antiplatelet therapy in CABG. There are four study critiques looking at the RAIN, HOPE ICU, CHEST, and TTM studies. Amongst the commentaries are papers on patient-ventilator asynchrony and the ICU of the future, as well as one case report on thoraco-abdominal impalement injury. Amongst the clinical review articles are papers on sedation interruption, perioperative myocardial ischaemia, short bowel syndrome, micronutrients, heparin-induced thrombocytopaenia, coronaviruses, patient safety and wilderness medicine.
If you prefer a break from all the serious reading, take a look at the general interest articles, containing the latest episode of Lemmingaid.
The topic for This Week's Papers is critical care iatrogenesis, starting with a paper on ventilator-induced lung injury in tomorrow's Paper of the Day.
Research
Randomized Controlled Trials
Karnad and colleagues compared ulinastatin (200,000 IU 12 hourly for 5 days, n=55), a serine protease inhibitor, with placebo (n=59), in patients within 48 hours of onset of severe sepsis, and found:
- baseline data
- mean APACHE II score: 13.4 (SD 4.4)
- 42% receiving mechanical ventilation
- 51% receiving vasopressors
- 35% had multiple organ failure
- ulinastatin was associated with
- intention-to-treat analysis
- no significant reduction in 28 day mortality
- ulinastatin: 10.2 % (n=6) vs. placebo: 20.6 % (n=13) (p = 0.11)
- no significant reduction in 28 day mortality
- modified intention-to-treat analysis (patients receiving six or more doses of study drugs)
- reduced 28 day mortality
- ulinastatin: 7.3 % (n=4) vs. placebo: 20.3% (n=12) (p = 0.045)
- odds ratio 0.26, 95 % CI 0.07 to 0.95; p = 0.042
- reduced 28 day mortality
- reduced
- incidence of new-onset organ failure
- 10 vs. 26 patients, p = 0.003)
- hospital stay
- 11.8 ± 7.1 days vs. 24.2 ± 7.2 days, p < 0.001
- incidence of new-onset organ failure
- increased
- ventilator-free days
- 19.4 ± 10.6 days vs. 10.2 ± 12.5 days, p = 0.019
- ventilator-free days
- intention-to-treat analysis
Ebinger and colleagues compared weeks (3,213 patients) with the utility of a prehospital stroke unit, consisting of a Stroke Emergency Mobile (STEMO) ambulance containing a CT scanner, point-of-care laboratory, and telemedicine connection; a stroke identification algorithm at dispatcher level; and a prehospital stroke team, with weeks (2,969 patients) of conventional ambulance care in 6,182 patients with suspected stroke, and found:
- groups were similar at baseline
- age 74
- 45% male
- STEMO availability (n=3,213) was associated with
- reduced alarm-to-thrombolysis times
- minus 15 minutes (95% CI 11 to 19)
- 76.3 min (95% CI 73.2 to 79.3) vs 61.4 min (95% CI 58.7 to 64.0) p < 0.001
- increased thrombolysis rates in ischemic stroke
- 29% versus 21%; difference 8%, 95% CI 4% to 12%; p < 0.001
- reduced alarm-to-thrombolysis times
- STEMO deployment (n=1,804) was associated with
- reduced alarm-to-thrombolysis times
- minus 25 minutes (95% CI 20 to 29; p < 0.001)
- 76.3 min (95% CI 73.2 to 79.3) versus 51.8 min (95% CI 49.0 to 54.6)
- increased thrombolysis rates in ischemic stroke
- 33% versus 21%; difference 12%, 95% CI 7% to 16%; p < 0.001
- no increase in
- intracerebral hemorrhage
- adjusted odds ratio with STEMO 0.42, 95% CI 0.18 to 1.03; p = 0.06
- 7-day mortality
- adjusted odds ratio with STEMO 0.76; 95% CI 0.31 to 1.82; p = 0.53
- intracerebral hemorrhage
- reduced alarm-to-thrombolysis times
Chamberlain and colleagues compared diazepam (0.2 mg/kg, n=140) with lorazepam (0.1 mg/kg, n=133) in 273 children (aged 3 months to 18 years) with status epilepticus, repeating half the dose after 5 minutes if unsuccessful, followed by fosphenytoin at 12 minutes if ongoing status, and found:
- no difference in
- cessation of status epilepticus for 10 minutes without recurrence within 30 minutes
- diazepam group 72.1% versus lorazepam group 72.9%
- absolute efficacy difference of 0.8% (95% CI −11.4% to 9.8%)
- requirement for assisted ventilation
- diazepam group 16.0% vs lorazepam group 17.6%
- absolute risk difference 1.6% (95% CI −9.9% to 6.8%)
- secondary outcomes
- cessation of status epilepticus for 10 minutes without recurrence within 30 minutes
- lorazepam patients were more likely to be sedated
- 66.9% vs 50%
- absolute risk difference 16.9% (95% CI 6.1% to 27.7%)
Kalita and colleagues performed an open-label comparison of levofloxacin (10 mg/kg, maximum 500 mg) with rifampicin (10 mg/kg, maximum 450 mg) in 60 patients with tuberculous meningitis also treated with isoniazid, pyrazinamide, ethambutol, prednisolone and aspirin, and found:
- at baseline
- median age 34.5 (16-75) years
- groups were similar with respect to
- clinical findings
- MRI imaging
- levofloxacin therapy was associated with
- a trend for reduced 6 month mortality
- 21.7% vs 38.3%; p = 0.07
- reduced 6 month mortality on Cox regression analysis
- hazard ratio 2.13, 95% CI 1.04 to 4.34, p = 0.04
- no difference
- in functional outcome (p = 0.47)
- but in intention-to-treat analysis,
- levofloxacin 21.3% (10/47) vs rifampicin 13.5% (5/37)
- but in intention-to-treat analysis,
- repeat MRI findings
- in functional outcome (p = 0.47)
- increased discontinuation due to serious adverse events
- 16 vs 4; p=0.01
- a trend for reduced 6 month mortality
Meta Analyses
Cannon et al pooled data from all randomized controlled trials comparing carbapenems (imipenem, meropenem, ertapenem and doripenem) with each other and with non-carbapenem antibiotics to assess the risk of seizures, and found:
- carbapenams were associated with
- increased seizure risk
- 2 per 1000 persons (95% CI 0.001 to 0.004)
- OR 1.87 (95% CI 1.35 to 2.59)
- largely attributed to imipenem
- 4 patients per 1000 (95% CI 0.002 to 0.007)
- OR 3.50 (95% CI 2.23 to 5.49)
- increased seizure risk
- none of the other carbapenems were associated with increased seizure
- odds ratios
- meropenem: 1.04 (95% CI 0.61 to 1.77)
- ertapenem: 1.32 (95% CI 0.22 to 7.74)
- doripenem: 0.44 (95% CI 0.13 to 1.53)
- odds ratios
Santosham et al reviewed data from 10 studies (n=1,172, 4 studies in the critically ill) comparing the diagnostic accuracy of lung ultrasound with chest radiography or CT scanning and/or clinical criteria for pneumonia, and found:
- lung ultrasound was performed by
- highly-skilled sonographers (7 studies)
- trained physicians (2 studies)
- unmentioned (1 study)
- lung untrasound duration
- maximum 13 minutes
- probes used were
- 3.5-5 MHz micro-convex transducer (9 studies)
- 5-9 MHz convex probe (1 study)
- lung ultrasound test characteristics
- sensitivity 94% (95% CI 92% to 96%)
- specificity 96% (95% CI 94% to 97%)
- positive liklihood ratio 16.8 (95% CI 7.7 to 37.0)
- negative liklihood ratio 0.07 (95% CI 0.05 to 0.10)
- area-under-the-ROC curve 0.99 (95% CI 0.98 to 0.99)
Lin et al reviewed ten studies (n=1,382) comparing noninvasive ventilation with standard medical therapy in the management of postextubation respiratory failure, and found:
- in patients with established postextubation respiratory failure (2 studies, n=302)
- NIV was not associated with reductions in
- reintubation rate (RR 1.02, 95% CI 0.83 to 1.25)
- ICU mortality (RR 1.14, 95% CI 0.43 to 3.00)
- NIV was not associated with reductions in
- in patients with early NIV after extubation (n=1,080)
- NIV was not associated with reductions in
- reintubation rate (RR 0.75, 95% CI 0.45 to 1.15)
- NIV was not associated with reductions in
- in patients with planned NIV use (n=849)
- NIV use was associated with reductions in
- reintubation rate (RR 0.65, 95% CI 0.46 to 0.93)
- ICU mortality rate (RR 0.41, 95% CI 0.21 to 0.82)
- hospital mortality rate (RR 0.59, 95% CI 0.38 to 0.93)
- NIV use was associated with reductions in
Observational Studies
Foo and colleagues completed a retrospective cohort study comparing an appropriate β-lactam (n = 126) with a glycopeptide (n = 46) for the management of 172 episodes of Enterococcus faecalis bacteraemia, and found:
- glycopeptide therapy was associated with
- increased 30 day mortality
- 26.1% vs 11.1%, p = 0.015
- increased 30 day mortality
- independent predictors of 30 day mortality were
- glycopeptide use
- OR 2.46, 95% CI 1.01 to 6.02; p = 0.048
- APACHE II score
- OR 1.10, 95% CI 1.02 to 1.18; p = 0.011
- malignancy
- OR 2.58, 95% CI 1.03 to 6.49; p = 0.044
- glycopeptide use
Lorente and colleagues completed a prospective observational study, comparing the incidence of ventilator-associated pneumonia in 284 critically ill patients being mechanically ventilated > 48 hours, receiving either continuous (n=150) or intermittent (n=134) control of endotracheal tube cuff pressure, and found:
- a lower incidence of VAP was associated with
- continuous cuff pressure control
- 22.0% vs 11.2%; p=0.02
- OR 0.45; 95% CI 0.22 to 0.89; p=0.02
- HR=0.45; 95% CI=0.24 to 0.84; p=0.01
- subglottic drainage endotracheal tube
- OR 0.39; 95% CI 0.19 to 0.84; p=0.02
- HR=0.29; 95% CI=0.15 to 0.56; p<0.001
- continuous cuff pressure control
- no interaction between type of endotracheal cuff pressure control system (continuous or intermittent) and endotracheal tube (with or without subglottic drainage)
- OR 0.41; 95% CI 0.07 to 2.37; p=0.32
- HR 0.35; 95% CI 0.06 to 1.84; p=0.21
Lewis and colleagues completed a retrospective case-control study, comparing 110 patients with ventilator-associated conditions with 110 matched controls without ventilator-associated conditions, and found:
- groups were similar at baseline
- risk factors for ventilator-associated conditions
- mandatory modes of ventilation
- odds ratio 3.4; 95% CI 1.6 to 8.0
- positive fluid balance
- odds ratio 1.2 per L positive; 95% CI 1.0 to 1.4
- mandatory modes of ventilation
- possible risk factors for infection-related ventilator-associated complications
- benzodiazepines prior to intubation
- odds ratio 5.0; 95% CI 1.3 to 29
- total opioid exposures
- odds ratio 3.3 per 100 μg fentanyl equivalent/kg; 95% CI 0.90 to 16
- paralytic medications
- odds ratio 2.3; 95% CI 0.79 to 80
- benzodiazepines prior to intubation
- traditional ventilator bundle elements were not associated with ventilator-associated conditions or infection-related ventilator-associated complications
- semirecumbent positioning
- oral care with chlorhexidine
- venous thromboembolism prophylaxis
- stress ulcer prophylaxis
- daily spontaneous breathing trials
- sedative interruptions
Additional Studies
Randomized Controlled Trials
- Abstract: Lim. The use of a nasogastric tube to facilitate nasotracheal intubation: a randomised controlled trial. Anaesthesia 2014;epublished April 18th
- Abstract: Hee. Bacterial contamination of surgical scrub suits worn outside the operating theatre: a randomised crossover study. Anaesthesia 2014;epublished April 18th
Before and After Study
Observational Studies
Guidelines and Position Statements
- Fisher. ILAE Official Report: A practical clinical definition of epilepsy. Epilepsia 2014;55(4):475–482
- NICE. Pressure Ulcers. Preventiona and Management of Pressure Ulcers. NICE 2014;epublished April 23rd
- Sousa-Uva. Expert position paper on the management of antiplatelet therapy in patients undergoing coronary artery bypass graft surgery. Eur Heart J;epublished April 18th
Study Critiques
- Fuller. The optimum location of care for traumatic brain injury patients admitted to non-specialist hospitals. JICS 2014;15(2):164-166
- Drinkwater. Effect of intravenous haloperidol on the duration of delirium and coma in critically ill patients (Hope-ICU). JICS 2014;15(2):167-168
- Banks. Crystalloid or hydroxyethyl starch for resuscitation in intensive care? JICS 2014;15(2):169-170
- Claxton. Targeted temperature management at 33°C versus 36°C after cardiac arrest. JICS 2014;15(2):171-172
Commentaries
- Ravitz. A Model for the Intensive Care Unit as a High Reliability Organisation. ICU Management 2014;14(1)
- Pronovost. Creating the ICU of the Future: A Day of Innovation. ICU Management 2014;14(1)
- Longhini. Patient-Ventilator Asynchrony. ICU Management 2014;14(1)
- Krinsley. Glycaemic Control in the Critically Ill: What Have We Learned Since NICE-SUGAR? ICU Management 2014;14(1)
- Combes. The ECMO Retrieval Team. ICU Management 2014;14(1)
- McClean. Implementing an Echocardiography Service in the Intensive Care Unit. ICU Management 2014;14(1)
- Clarke. How a Critical Care Network Implemented Lean Methodology. ICU Management 2014;14(1)
- Nolan. The Importance of Resuscitation. ICU Management 2014;14(1)
- Freebairn. College of Intensive Care Medicine Training in the Antipodes. ICU Management 2014;14(1)
- Pilcher. Intensive Care Registries in Australia & New Zealand. ICU Management 2014;14(1)
- Rajkumar. CMS—Engaging Multiple Payers in Payment Reform. JAMA 2014epublished April 21st
- Kaiser Family Foundation. A Snapshot of US Global Health Funding. JAMA 2014;311(16):1601
- Kupferschmidt. Soaring MERS Cases Cause Pandemic Jitters, but Causes Are Unclear. ScienceMag 2014;epublished April 24th
- Bridget. Nationwide IV Fluid Shortage Threatens Care. JAMA 2014;epublished April 23rd
Case Reports
Clinical Review Articles
Neurological
- Edwards. Electrical muscle stimulation in the intensive care unit: an integrative review. JICS 2014;15(2):142-149
- Keough. Daily interruption of sedation in mechanically ventilated adults without tracheostomy. JICS 2014;15(2):150-153
- Diekelmann. Sleep for cognitive enhancement. Front Syst Neurosci 2014;epublished April 2nd
Circulatory
- Bessissow. Addressing Perioperative Myocardial Ischemia. Curr Anesthesiol Rep 2014;4(2):107-112
- Hahn. Cancer Therapy–Induced Cardiotoxicity: Basic Mechanisms and Potential Cardioprotective Therapies. J Am Heart Assoc 2014;3:e000665
Respiratory
- Helmi. Less Invasive Mechanical Ventilation Strategies in ARDS: the Future? Acta Medica Indonesiana 2013;45(4)329-336
- Pedoto. Perioperative Arrhythmias and Acute Right Heart Failure in Noncardiac Thoracic Surgery. Curr Anesthesiol Rep 2014;4(2):142-149
- Kozian. Protective Ventilatory Approaches to One-Lung Ventilation: More than Reduction of Tidal Volume. Curr Anesthesiol Rep 2014;4(2):150-159
- Tusman. Alveolar Recruitment Maneuvers for One-Lung Ventilation During Thoracic Anesthesia. Curr Anesthesiol Rep 2014;4(2):160-169
- Walsh. Arterial Oxygenation and Management of Hypoxemia During VATS. Curr Anesthesiol Rep 2014;4(2):170-176
- Loop. Recent Advances in Postoperative Pain Therapy for Thoracic Surgery. Curr Anesthesiol Rep 2014;4(2):177-187
- Licker. Preoperative Evaluation of Lung Cancer Patients. Curr Anesthesiol Rep 2014;4(2):124-134
- Nonaka. Pulmonary Hypertension and Thoracic Surgery: Diagnostics and Advances in Therapy and Intraoperative Management. Curr Anesthesiol Rep 2014;4(2):135-141
Gastrointestinal
- Jeppesen. Spectrum of Short Bowel Syndrome in Adults. Intestinal Insufficiency to Intestinal Failure. JPEN J Parenter Enteral Nutr 2014;38(1):suppl 8S-13S
- Tappenden. Pathophysiology of Short Bowel Syndrome. Considerations of Resected and Residual Anatomy. JPEN J Parenter Enteral Nutr 2014;38(1):14S-22S
- Tappenden. Intestinal Adaptation Following Resection. JPEN J Parenter Enteral Nutr 2014;38(1):23S-31S
- Kumpf. Pharmacologic Management of Diarrhea in Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2014;38(1):38S-44S
- Jeppesen. Pharmacologic Options for Intestinal Rehabilitation in Patients With Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2014;38(1):45S-52S
- Iyer. Surgical Management of Short Bowel Syndrome. JPEN J Parenter Enteral Nutr 2014;38(1):53S-59S
- Matarese. Short Bowel Syndrome in Adults. The Need for an Interdisciplinary Approach and Coordinated Care. JPEN J Parenter Enteral Nutr 2014;38(1):60S-64S
Nutrition
Hepatobiliary
- Zamora Nava. Acute-on-chronic liver failure: a review. Therapeutics and Clinical Risk Management 2014;10:295-303
- Dhillon. Hepatitis B and C. JICS 2014;15(2):135-141
- Arroyo. Human Serum Albumin, Systemic Inflammation And Cirrhosis. J Hepatol 2014;epublished April 18th
Haematological
- Scott. Heparin-induced thrombocytopenia: is there a role for direct thrombin inhibitors in therapy? JICS 2014;15(2):131-134
- Babilonia. The role of prothrombin complex concentrates in reversal of target specific anticoagulants. Thrombosis Journal 2014;12:8
Sepsis
- Zou. Presepsin as a novel sepsis biomarker. World J Emerg Med 2014;5(1):16–19
- Coleman. Coronaviruses: Important Emerging Human Pathogens. J Virol 2014;88:5209-5212
Safety
- Weller. Making a Difference Through Improving Teamwork in the Operating Room: A Systematic Review of the Evidence on What Works. Curr Anesthesiol Rep 2014;4(2):77-83
- Dutton. Improving Safety Through Incident Reporting. Curr Anesthesiol Rep 2014;4(2):84-89
- Walker. Improving Anesthesia Safety in Low-Income Regions of the World. Curr Anesthesiol Rep 2014;4(2):90-99
- Latif. Evaluating Safety Initiatives in Healthcare. Curr Anesthesiol Rep 2014;4(2):100-106
- Wahr. Improving Patient Safety in the Cardiac Operating Room: Doing the Right Thing the Right Way, Every Time. Curr Anesthesiol Rep 2014;4(2):113-123