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Critical Care Reviews Newsletter

January 14^th 2012

Welcome

Hello

Welcome to the 58th 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. Apologies for being a day late.

There's hasn't been much major research published in the past week. In a systematic review and meta analysis ω-3 fatty acid supplemented parenteral nutrition proved to be of little benefit, as did nebulised magnesium in acute exacerbations of COPD. Ultra-low tidal volume ventilation combined with extra-corporeal CO2 removal also failed to demonstrate any additional benefit over standard ARDS ventilation, although in a post hoc analysis there was a small reduction in the duration of ventilation in the most hypoxaemic group. Also, the US Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients present their 21st annual report based largely on data pertaining to the period 1998-2011.

This week's guidelines include an update on the previously influential SCCM paper on the management of pain, agitation and delirium in the critically ill. There are also guidelines on the management of intra-abdominal sepsis and the development of protocols for clinical trials.

There is a commentary from JAMA, comparing the US healthcare system with other international systems.

Amongst the clinical review articles are papers on protection for ischaemic stroke, haemorrhagic and circulatory shock, postoperative pulmonary oedema, TEG in liver disease, disaster medicine, and studying sepsis.

The topic for This Week's Papers is Guidelines from 2012, starting with a paper on the KDIGO guideline on acute kidney injury in today's Paper of the Day.

Survey

Many thanks to those of you who were able to complete the survey on Critical Care Reviews. The comments were overwhelmingly positive and very helpful for the development of the site. Some useful feedback included a request for more rheumatological/neurological/immunological papers, more pharmacology topics, a conclusion to the research abstracts, podcasts, a mobile app, plus the option to store CPD certificates on the site. Most were happy with the look of the site, but it was a bit dated for some. Several asked for the newsletters to be archived on the site. The newsletter seems to largely ok, although some thought my including articles from some of the more obscure journals didn't add much. A large majority requested that review articles from the major journals (Chest, AJRCCM, Anesthesiology, Critical Care, BJA etc) that are 6 months old or older, and recently made open access, be added to the newsletter.

I'll get to work on these features over the next few weeks, but unfortunately don't have the resources to produce a mobile application at present.

Research

Critical Care Medicine: ω-3 Fatty Acid Supplemented Parenteral Nutrition

Palmer and colleagues performed a systematic review and meta analysis of randomized controlled trials (n=8), comparing parenteral nutrition with ω-3 fatty acid supplementation to parenteral nutrition without this supplement in 391 critically ill patients. There was no difference in mortality between the two groups (relative risk for death: 0.83; 95% CI 0.57, 1.20; p = 0.320), infectious complications (5 studies, 337 subjects; relative risk for infection: 0.78; 95% CI 0.43, 1.41; p = 0.41), or ICU length of stay (6 studies, 305 subjects; 0.57 days in favor of the ω-3 fatty acid group; 95% CI –5.05, 3.90; p = 0.80). ω-3 fatty acid supplementation reduced hospital length of stay (3 studies, 117 subjects; by 9.49 days; 95% CIl –16.51, –2.47; p = 0.008), although these results were strongly influenced by one small study. Conclusion: Based on this systematic review and meta-analysis, ω-3 fatty acid supplementation of parenteral nutrition appears to have little effect on outcomes in the critically ill.

Abstract: Palmer. The Role of ω-3 Fatty Acid Supplemented Parenteral Nutrition in Critical Illness in Adults: A Systematic Review and Meta-Analysis. Crit Care Med 2013;41(1):307-316

Intensive Care Medicine: ARDS

Bein performed a randomized trial in 79 patients with ARDS comparing a low tiidal volume ventilation (≈3 ml/kg) combined with extracorporeal CO₂ elimination, or to a standard ≈6 ml/kg ARDSNet strategy. There were no differences in any of the major endpoints, including the primary endpoint of ventilator free days at 28 days (10 ± 8 vs 9.9 ± 9; p=0.779); non-pulmonary organ free days at day 60 (21.0 ± 14 vs 23.9 ± 15; p=0.447); length of ICU stay (31.3 ± 23 vs 22.9 ± 11; p=0.144) or length of hospital stay (46.7 ± 33 vs 35.1 ± 17, p=0.113) or in-hospital mortality (7/40 (17.5 %) vs 6/39 (15.4 %); p≈1.0). In a post-hoc analysis the most hypoxaemic group treated with combined ultra-low tidal volume/extracorporeal CO₂ elimination had improved duration of ventilation at both day 28 and day 60.

Full Text: Bein. Lower tidal volume strategy (≈3 ml/kg) combined with extracorporeal CO(2) removal versus 'conventional' protective ventilation (6 ml/kg) in severe ARDS : The prospective randomized Xtravent-study. Intensive Care Med 2013; epublished January 10th

Editorial: Schultz. From protective ventilation to super-protective ventilation for acute respiratory distress syndrome. Intensive Cre Med 2013; eublished ahead of print

Thorax: Asthma

Edwards et al performed a randomised double-blind placebo-controlled trial in 116 patients with an acute exacerbation of COPD in the emergency department, comparing 2.5 mg salbutamol mixed with either 2.5 ml isotonic magnesium sulphate (151 mg per dose) or 2.5 ml isotonic saline (placebo) on three occasions at 30 min intervals via nebuliser. At 90 min the mean (SD) FEV₁ in the magnesium group (N=47) was 0.78 (0.33) l compared with 0.81 (0.30) l in the saline group (N=61) (difference −0.026 l (95% CI −0.15 to 0.095, p=0.67). No patients required non-invasive ventilation. There were 43/48 admissions to hospital in the magnesium group and 56/61 in the saline group (RR 0.98, 95% CI 0.86 to 1.10, p=0.69). Conclusion: Nebulised magnesium sulphate had no additonal effect on FEV1 over that of standard bronchodilator therapy in ED patients with an acute exacerbation of COPD.

Abstract: Edwards. Use of nebulised magnesium sulphate as an adjuvant in the treatment of acute exacerbations of COPD in adults: a randomised double-blind placebo-controlled trial. Thorax 2013;