Newsletter 126 / May 4th 2014




Welcome to the 126th 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. Although it's another quiet week for critical care research, a vast amount of other literature makes up the reading shortfall.

This week's research studies include a randomized controlled trial on contrast-induced nephropathy, a meta analysis on septic shock, plus observational studies on critical care trial methodology, steroid dosing during acute exacerbations of COPD, preventable ICU infections and ventilator-associated events. Additional studies investigate expiratory rib cage compression during chest physiotherapy, colonic perforation, cardiac tamponade, night-time ICU coverage, paediatric ICP monitoring and transfusion-related acute lung injury.

This week's guidelines focus on neutropaenic sepsis, urinary catheter-associated infections and healthcare-associated infections. Two editorials from Anaesthesia address quality and safety in healthcare; commentaries look at sepsis care, hospitalization, p values and global health; while two case reports discuss deep hypothermia and ECMO following thrombolysis for massive PE.

Amongst the clinical review articles are papers on neuroprotection post cardiac arrest, subarachnoid haemorrhage, ischaemic stroke, hydroxyethyl starch fluids, ventricular assist devices, ivabradine, atrial fibrillation, ultrasound for airway assessment, idiopathic pulmonary fibrosis, oesophageal perforation, haemobilia, illnes-related anorexia, acute-on-chronic liver failure, acute kidney injury in the alcoholic, contrast-induced nephropathy, cotrimoxazole and neonatal perioperative pain.

The beginning of each month marks the addition of recently made open access articles from the major critical care journals, and this week there are 22 papers to choose from.

The topic for This Week's Papers is pulmonary hypertension, starting with a paper on ARDS-related pulmonary hypertension in tomorrow's Paper of the Day.

In news this week are stories of the WHO warning of the global threat to antibiotic efficacy and the CDC reporting the first case of MERS-CoV in the USA.

Critical Care Reviews Meting 2015 - date announcement

Behind the scenes, preparations are in full swing for the 2015 Critical Care Reviews Meeting, held in association with the Northern Ireland Intensive Care Society. Next year's meeting will be held on Friday January 23rd, again at the Galgorm Resort and Spa, outside Belfast, Northern Ireland. The theme of the meeting is to discuss the major research of the previous 12 months, where we try to answer a single question - should we be implementing the results of this study? In addition to a host of local intensivists critiquing major randomized controlled trials from 2014, we are fortunate to have the primary investigators from some of the biggest RCTS of the year join us. Some of these studies will publish later this year, so it will be one of the most topical meetings you could attend. Further details will follow over the next couple of months. If you enjoy this weekly newsletter, then you'll love the opportunity to discuss the major studies of 2014 in person; however, if you can't make it, then you'll still be able to benefit, as all talks will once again be made freely available on the internet afterwards.  Please join us for another fantastic not-for-profit event, where the focus is on improving critical care, not making money.

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Randomized Controlled Trials

Kooiman and colleagues completed an open-label, multicentre, non-inferiority, randomized trial comparing 250 mL of 1.4% sodium bicarbonate hydration with 1000 mL of 0.9% saline hydration prior to, and after, contrast media-enhanced CT in 570 adults with chronic kidney disease, and found:

  1. sodium bicarbonate infusion was associated with
    • a reduced
      • increase in mean relative serum creatinine
        • 1.2% vs. 1.5%
        • mean difference −0.3%; 95% CI −2.7 to 2.1, p-value for non-inferiority <0.0001
      • mean hydration cost per patient
        • €224 vs. €683 (p < 0.001)
    • no difference in
      • incidence of contrast-induced acute kidney injury (serum creatinine increase >25% / >44 µmol/L / 0.5 mg/dL)
        • sodium bicarbonate group 4.1% (n=22) vs. saline group 3.0% (n=8) (P = 0.23)
      • recovery of renal function
        • sodium bicarbonate group 75% vs saline group 69% (P = 0.81)
      • no patients required dialysis.

Abstract: Kooiman. A randomized comparison of 1-h sodium bicarbonate hydration versus standard peri-procedural saline hydration in patients with chronic kidney disease undergoing intravenous contrast-enhanced computerized tomography. Nephrol Dial Transplant 2014;29:1029-1036

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Meta Analyses

Using a Bayesian meta-analysis, Oba et al pooled data from 14 randomized controlled trials (n=2,811) investigating vasopressor and inotropic agents in septic shock, and found:

  1. compared with dopamine
    • mortality was reduced with
      • noradrenaline (OR 0.80, 95% CI 0.65 to 0.99)
      • noradrenaline pluslow-dose vasopressin (OR 0.69, 95% CI 0.48 to 0.98)
    • but not with
      • adrenaline (OR 0.56, 95% CI 0.26 to 1.18)
  2. compared with noradrenaline or adrenaline
    • mortality was not reduced with
      • the addition of an inotropic agent such as dobutamine or dopexamine

Abstract:  Oba. Mortality benefit of vasopressor and inotropic agents in septic shock: A Bayesian network meta-analysis of randomized controlled trials. J Crit Care 2014;epublished April 28th

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Observational Studies

O'Harhay and colleagues examined the rates of success, outcomes used, statistical power and design characteristics of 146 critical care randomized controlled trials published from January 2007 to May 2013 in 16 high-impact general or critical care journals, and found:

  1. 37% (n=54) were positive (the a priori hypothesis was found to be statistically significant)
  2. the most common primary outcomes, including percentage with positive results, were
    • mortality (n=40 trials), 10% positive
    • infection-related outcomes (n=33), 58% positive
    • ventilation-related outcomes (n=30), 43% positive
  3. regarding statistical power 
    • this was discussed in 92% (n=135)
    • 92 cited a rationale for their power parameters
    • 20 failed to achieve at least 95% of their reported target sample size
    • 11 were stopped early due to insufficient accrual/logistical issues
  4. Of 34 superiority RCTs comparing mortality between treatment arms
    • 38% (n=13) accrued a sample size large enough to find an absolute mortality reduction of ≤ 10% 
    • in 22 trials the observed control-arm mortality rate differed from the predicted rate by at least 7.5%

Abstract:  O'Harhay. Outcomes and Statistical Power in Adult Critical Care Randomized Trials. Am J Respir Crit Care Med 2014;epublished April 30th

In a propensity-matched analysis, Kiser et al investigated the effectiveness and safety of lower-dose (methylprednisolone ≤240 mg/d, n=6,156; 36%) versus higher-dose (methylprednisolone >240 mg/d, 11,083; 64%) corticosteroid dosing in 17,239 patients admitted to ICU with an acute exacerbation of chronic obstructive pulmonary disease, and found:
  1. lower-dose corticosteroid therapy was associated with 
    • a trend for reduction in
      • mortality
        • odds ratio 0.85; 95% CI 0.71 to 1.01; p = 0.06
  2. reduced
    • length of stay
      • hospital
        • −0.44 d; 95% CI −0.67 to −0.21; p < 0.01
      • ICU
        • −0.31 d; 95% CI −0.46 to −0.16; p < 0.01 
    • hospital costs
      • −$2,559; 95% CI −$4,508 to −$609; p = 0.01
    • length of invasive ventilation
      • −0.29 d; 95% CI −0.52 to −0.06; p = 0.01
    • need for insulin therapy
      • 22.7% vs. 25.1%; p < 0.01
    • fungal infections
      • 3.3% vs. 4.4%; p < 0.01

Abstract:  Kiser. Outcomes Associated with Corticosteroid Dosage in Critically Ill Patients with Acute Exacerbations of Chronic Obstructive Pulmonary Disease. Am J Respir Crit Care Med 2014;189(9):1052-1064

Lambert and colleagues analyzed prospectively collected, routine data on 78,222 patients admitted for more than 2 days to 525 ICUs in 6 European countries from 2005 to 2008 and, using model-based simulation, estimated the proportion of ICU-acquired ventilator-associated pneumonia and bloodstream infection cases that could be avoided, and found:

  1. the percentge of avoidable cases of ICU-acquired infections were:
    • VAP 52%
    • BSI 69%

Abstract:  Lambert. Preventable Proportion of Severe Infections Acquired in Intensive Care Units: Case-Mix Adjusted Estimations from Patient-Based Surveillance Data. Infect Control Hosp Epidemiol 2014;35(5):494-501

Klompas et al completed a retrospective, cohort study comprising 20,356 episodes of mechanical ventilation, and characterizing ventilator-associated condition events, found:

  1. there were
    • ventilator-associated condition events (5.6%, n=1,141)
      • infection-related ventilator-associated complications (2.1%, n=431)
      • possible pneumonias (0.7%, n=139)
      • probable pneumonias (0.6%, n=127)
  2. VAC hazard rates were
    • highest in
      • medical units
      • surgical units
      • thoracic units
    • lowest in
      • cardiac units
      • neuroscience units
  3. median number of days to VAC onset was 6 (IQR 4–11)
  4. most frequently identified organisms were
    • Staphylococcus aureus (29%)
    • Pseudomonas aeruginosa (14%)
    • Enterobacter species (7.9%)
  5. compared with matched controls
    • VAEs were associated with
      • more days to extubation (RR 3.12, 95% CI 2.96 to 3.29)
      • more days to hospital discharge (RR 1.46, 95% CI 1.37 to 1.55)
      • higher hospital mortality risk (OR 1.98, 95% CI 1.60 to 2.44)

Abstract:  Klompas. Descriptive Epidemiology and Attributable Morbidity of Ventilator-Associated Events. Infect Control Hosp Epidemiol 2014;35(5):502-510

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Additional Studies

Randomized Controlled Trials

Observational Studies

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Case Report

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Clinical Review Articles











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Recently Made Open Access Arti cles from the Major Journals

American Journal of Respiratory and Critical Care Medicine





Case Report

Critical Care





Case Report

Anesthesia & Analgesia


British Journal of Anaesthesia





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I hope you find these brief summaries and links useful.

Until next week