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Critical Care Reviews Newsletter

March 10th 2013



Welcome to the 66th 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.

Unfortunately, this week's research studies aren't the greatest, being either retrospective, post hoc, meta analytic or small in nature. This week's guidelines focus on warfarin reversal and haemostatic assessment pre-operatively. There are three study critiques and a number of editorials on sepsis and one on the declining rates of stroke mortality.

Amongst the clinical review articles are some excellent papers on nonconvulsive status epilepticus, colloids, goal-directed fluid resuscitation, lung-protective ventilation, acute pancreatitis, haemostasis, ultrafiltration, clostridium difficile, cyanide poisoning, burns, lung transplantation immunosuppression and ketamine. Also included are the latest batch of recently made open access review articles from the major critical care journals.

The topic for This Week's Papers is heart failure, starting with a paper on heart failure with preserved ejection fraction in tomorrow's Paper of the Day.



Critical Care:     Non-Invasive Ventilation Post-Extubation

Ornico completed a small single centre, randomized, prospective, controlled, unblinded clinical study to compare  non-invasive ventilation (NIV, n=20) applied immediately after planned extubation with oxygen mask (OM, n=20) in patients with acute respiratory failure. The rate of re-intubation was lower in the NIV group (5% versus 39%; p=0.016, relative risk for re-intubation 0.13; CI=0.017-0.946). There was an absolute risk reduction for re-intubation of 33.9% (NNT 3). Although there was no difference in the length of ICU stay (p=0.681), hospital mortality was 0% in NIV group and 22.2% in OM group (p= 0.041). Conclusion: In a small, single centre, unblinded study the use of immediate NIV post extubation was associated with reduced reintubation rates and improved mortality when compared with oxygen mask therapy

Full Text:  Ornico. Noninvasive ventilation immediately after extubation improves weaning outcome after acute respiratory failure: a randomized controlled trial. Critical Care 2013;17:R39


Intensive Care Medicine:     Weaning

Hernandez and colleagues undertook a single-center, randomized trial in 195 tracheostomized patients to determine the effects of deflating the tracheal cuff during spontaneous breathing trials. Patients at high risk of aspiration based on the drink test were excluded. 181 patients completed the study (94 patients with deflated cuff and 87 with inflated cuff). Deflating the tracheal cuff was associated with quicker weaning (HR 2.2, 95% CI 1.5–3; p < 0.01), reduced respiratory infections (20 versus 36 %; p = 0.02), and improved swallowing (31 versus. 22 %; p = 0.02). Conclusion: In this single centre study, early cuff deflation in tracheostomized patients was associated with quicker weaning, reduced respiratory infection and improved swallowing.

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;epublished March 8th


Chest:     Vasopressor Therapy

To characterize survival among patients with shock requiring high-dose vasopressor (HDV) therapy, Brown et al conducted a multi-centre retrospective study of patients with shock requiring HDV, with HDV defined as receipt at any point of ≥ 1 μg/kg/min of norepinephrine equivalent (calculated by summing norepinephrine-equivalent infusion rates of all vasopressors). Of 443 patients, 76 (17%) survived, with a similar survival amongst the 241 patients (20%) with septic shock. Among the 367 nonsurvivors, 254 (69%) experienced withholding/withdrawal of care, and 115 (31%) underwent CPR. Stress-dose corticosteroid therapy was associated with increased survival (P = 0.01). Conclusion:  One in six patients with shock survived to 90 days after HDV; stress-dose corticosteroid therapy was associated with improved survival.

Abstract:  Brown. Survival After Shock Requiring High-Dose Vasopressor Therapy. Chest 2013;143(3):664-671


Chest:     Probiotics

Barraud et al performed a systematic review and meta analysis (13 randomized controlled trials, n=1,439) to assess the effects of probiotics in the critically ill.  Probiotics did not significantly reduce ICU (OR 0.85; 95% CI 0.63-1.15) or hospital (OR 0.90; 95% CI 0.65-1.23) mortality. However, probiotics reduced the incidence of ICU-acquired pneumonia (OR 0.58; 95% CI 0.42-0.79) and was associated with a shorter stay in the ICU (weighted mean difference  −1.49 days; 95% CI, −2.12 to −0.87 days). Probiotics were not associated with a shorter duration of mechanical ventilation (weighted mean difference  − 0.18 days; 95% CI, −1.72 to 1.36 days) or a shorter hospital length of stay (weighted mean difference  −0.45 days; 95% CI, −1.41 to 0.52 days). Conclusion:  In a systematic review and meta analysis, probiotics were not associated with reductions in either ICU or hospital mortality, but did reduce the incidence of ICU-acquired pneumonia and ICU length of stay.

Abstract: Barraud. Impact of the Administration of Probiotics on Mortality in Critically Ill Adult Patients: A Meta-analysis of Randomized Controlled Trials. Chest 2013;143(3):646-655


Medizinische Klinik - Intensivmedizin und Notfallmedizin:     Enteral Nutrition

Elke and colleagues undertook a secondary analysis of the VISEP study to compare three nutritional strategies—enteral (EN), parenteral (PN), and combined nutrition (EN+PN)—on the outcome of patients with severe sepsis or septic shock. Only patients with an ICU length of stay of more than 7 days were included (n=353). 68.5 % received EN+PN, 24.4 % received EN, and only 7.1 % received PN. Median caloric intake was 918 kcal/day (EN), 1,210 kcal/day (PN), and 1,343 kcal/day (EN+PN; p < 0.001). In the latter group, calories were predominantly administered via the parenteral route within the first week. The rate of death at 90 days was lower with EN than with EN+PN (26.7 % vs. 41.3 %, p = 0.048), as was the rate of secondary infections, renal replacement therapy, and duration of mechanical ventilation. In the adjusted Cox regression analysis, the effect on mortality [hazard ratio = 1.86, 95 % CI: 1.16–2.98; p = 0.010] and the rate of secondary infections (HR = 1.89, 95 % CI: 1.27–2.81; p = 0.002) remained different between EN and EN+PN. Conclusion: In this secondary analysis of the VISEP study, in patients with severe sepsis or septic shock and prolonged ICU stay, the administration of EN alone was associated with improved clinical outcome compared to EN+PN.

Abstract:  Elke. Enteral nutrition is associated with improved outcome in patients with severe sepsis. Medizinische Klinik - Intensivmedizin und Notfallmedizin 2013;epublished March


Study Critique

Critical Care:     IABP II Study


Critical Care:     Fever Control in Sepsis



European Journal of Anaesthesiology:     Haemostasis


Medical Journal of Australia:     Warfarin Reversal


Immunotherapy:     Sepsis Therapy


Stroke:     Decline in Stroke Mortality


Expert Review of Anti-infective Therapy:     Pneumococcus


Expert Review of Anti-infective Therapy:     Anti-Infective News


Expert Review of Anti-infective Therapy:     Anti-Infective News


Review - Clinical


Frontiers in Cellular Neuroscience:     Epilepsy


Neurology India:     Nonconvulsive Status Epilepticus


Annals of the Indian Acadamy of Neurology:     Neuromuscular Junction Monitoing



South African Journal of Anaesthesia and Analgesia:     Colloids


Emergency Medicine Australasia:   Goal-Directed Resuscitation


Critical Care Research and Practice:     Circulation


Vojnosanitetski Pregled:     Left-Ventricular Assist Device


Review Espanola de Cardiologia:      Ischaemic Heart Disease

Review Espanola de Cardiologia:      Telecardiology


Review Espanola de Cardiologia:      Cardiac Imaging



South African Journal of Anaesthesia and Analgesia:     Lung-Protective Ventilation

Critical Care Research and Practice:     Paediatric Mechanical Ventilation Simulation



ISRN Surgery:     Necrosectomy




Thrombosis and Haemostasis:     Haemostasis


Thrombosis and Haemostasis:     Vascular Permeability


Chinese Medical Journal:     Clostridium Difficile


Chirurgia:     Innate Immunity


Annals of Africian Medicine:     NeuroAIDS


Frontiers in Cellular Infection and Microbiology:     Pneumococcus



Emergency Medicine Australasia:   Cyanide Poisoning



African Journal of Emergency Medicine:     Burn Management



Medicina Intensiva:     Lung Transplantation



InTech:     Gene Therapy


South African Journal of Anaesthesia and Analgesia:     Ketamine


Recently Made Open Access Review Articles from Major Journals


American Journal of respiratory and Critical Care Medicine:    


Critical Care:   




British Journal of Anaesthesia:


Anesthesia & Analgesia:




Canadian Journal of Anaesthesia:


I hope you find these brief summaries and links useful. If you have a suggestion for how to improve Critical Care Reviews, please let me know.

Until next week