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Critical Care Reviews Newsletter

October 15th 2012





Welcome to the 45th 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.

This week's research studies follow on nicely from last week's Lancet report of European surgical moratlity, with a large American database study reporting an intra-operative cardiac arrest rate of 7/10,000 surgeries. Also, a neonatal study failed to show any benefit from transfusion of fresh versus older blood in premature, very low-birth-weight babies. A series of commentaries from CMAJ discuss the ethics of pre-mortem ventilation to secure organs for donation, while a saddening report from the Syrian American Medical Society describes the decimation of the Syrian Healthcare System during the country's civil war.  The usual wide range of free review articles cover mechanical ventilation, a review of the Berlin ARDS definition, ICU acquired-weakness, muscle relaxation, PE, hepatorenal syndrome plus much more. There are two updates from the US Centre for Disease Control on the latest coronavirus and steroid-related meningitis outbreaks.

The topic for This Week's Papers is the second of a multi-part series on critical care controversies, starting with a paper questioning the traditional practice of controlling fever in tomorrow's Paper of the Day. These stimulating papers should challenge mainstream beliefs.

After last week's launch of the requested CPD / CME facility, a new quiz is now ready and will be added later today.  Check these quizzes out here.



Anesthesiology:     Intra-Operative Cardiac Arrest  

Using the 2005 to 2007 American College of Surgeons National Surgical Quality Improvement Program database (n = 362,767), Goswami and colleagues assessed the incidence, risk factors, and survival outcome of intraoperative cardiac arrests in adults undergoing noncardiac surgery.  The incidence of ICA was 7.22 per 10,000 surgeries. After adjustment for American Society of Anesthesiologists physical status and other covariates, the odds of ICA increased progressively with the amount of transfusion (adjusted odds ratios = 2.51, 7.59, 11.40, and 29.68 for those receiving 1-3, 4-6, 7-9, and ≥ 10 units of erythrocytes, respectively). Other significant risk factors for ICA were emergency surgery (adjusted odds ratio = 2.04, 95% CI = 1.45-2.86) and being functionally dependent presurgery (adjusted odds ratio = 2.33, 95% CI = 1.69-3.22). Of the 262 patients with ICA, 116 (44.3%) died within 24 h, and 164 (62.6%) died within 30 days.

 Abstract: Goswami. Intraoperative Cardiac Arrests in Adults Undergoing Noncardiac Surgery: Incidence, Risk Factors, and Survival Outcome. Anesthesiology 2012; epublished ahead of print


Journal of the American Medical Association:     Red Cell Transfusion   (neonatal study)

Fergusson et al performed a double-blind, randomized controlled trial to determine if red blood cells stored for 7 days or less (n=188), compared with red cells issued in a standard manner (n=189), decreased rates of major nosocomial infection and organ dysfunction in neonatal intensive care unit patients requiring at least 1 RBC transfusion. The mean age of transfused blood was 5.1 (SD, 2.0) days in the fresh RBC group and 14.6 (SD, 8.3) days in the standard group. Of those in the fresh RBC group, 99 (52.7%) had the primary outcome (a composite measure of major neonatal morbidities, including necrotizing enterocolitis, retinopathy of prematurity, bronchopulmonary dysplasia, and intraventricular hemorrhage, and death) compared with 100 (52.9%) in the standard RBC group (relative risk, 1.00; 95% CI, 0.82-1.21). The rate of clinically suspected infection in the fresh RBC group was 77.7% (n = 146) compared with 77.2% (n = 146) in the standard RBC group (relative risk, 1.01; 95% CI, 0.90-1.12), and the rate of positive cultures was 67.5% (n = 127) in the fresh RBC group compared with 64.0% (n = 121) in the standard RBC group (relative risk, 1.06; 95% CI, 0.91-1.22).

Full Text:  Fergusson. Effect of Fresh Red Blood Cell Transfusions on Clinical Outcomes in Premature, Very Low-Birth-Weight Infants: The ARIPI Randomized Trial. JAMA 2012;308(14):1


Biomedical Research-India:     Heart Failure

Lu et al undertook a multicenter, randomized, controlled, parallel-group study study comparing the effectiveness and safety of intravenous Cinepazide (n=120; continuous infusion of 4 μg/kg/min for 23 hours) with dobutamine control ( n=106; 2 μg/kg/min for 1 hour followed by 4 μg/kg/min for 23 hours) in the treatment of severe decompensated heart failure in patients who were unresponsive to diuretics, angiotensin-converting enzyme inhibitors (ACEIs) and digitalis drugs. The effective rate was 31.9% (38/120) in the Cinepazide group and 17.9% (19/105) in the control group (P<0.01). After treatment for 24 h, the left ventricular ejection fraction (LVEF) was increased by 6.35% in the Cinepazide group and 4.6% in the control group (P>0.05). The mean stroke volume (SV) was increased by 11.1 ml in the Cinepazide group and 2.8 ml in the control group (P<0.05).  Dyspnoea and other clinical manifestations were significantly improved in the Cinepazide group as compared to the control group. The plasma brain natriuretic peptide (BNP) level was significantly reduced after treatment with cinepazide (1997±865 pg/ml vs 384±114 pg/ml, P<0.005), and with dobutamine (1879±202 pg/ml vs 1025±48 pg/ml, P<0.005), with the post treatment BNP level being lower in the cinepazide group than control group (P<0.005). No severe adverse effects (hypokalemia, hypotension and premature ventricular contraction) were observed in either two groups. The incidence of adverse effects in the Cinepazide group was dramatically lower than in the control group (P <0.05).

Full TextLu. Clinical efficacy of intravenous Cinepazide in the treatment of severe decompensated heart failure. Biomed Res-India 2012;23(4):561-565


Journal of Cardiothoracic and Vascular Anesthesia

Majure et al performed an updated meta-analysis of 20 randomized trials (n=1037) in patients undergoing cardiac surgery to determine the effect of milrinone on survival. There was no difference in overall mortality (milrinone group: 12/554 [2.2%] versus control group: 10/483 [2.1%]; relative risk = 1.15; 95% CI: 0.55-2.43; p = 0.7) or in analysis restricted to adults (milrilone group: 11/364 [3%] v control group: 9/371 [2.4%]; RR = 1.17; 95% CI, 0.54-2.53; p = 0.7). Sensitivity analyses in trials with a low risk of bias showed a trend toward an increase in mortality with milrinone (8/153 [5.2%] v control: 2/152 [1.3%]; RR = 2.71; 95% CI, 0.82-9; p for effect = 0.10).

Abstract:  Majure. Meta-analysis of Randomized Trials of Effect of Milrinone on Mortality in Cardiac Surgery: An Update. J Cardiothoracic Vascular Anesthesia 2012; epublished ahead of print



Annals of Thoracic Surgery:     Asthma



Avicenna Journal of Medicine:     Syrian Crisis


Emergency Medicine Australasia:     Stroke


Canadian Medical Association Journal:     Organ Donation



Centers for Disease Control and Prevention:     Novel Coronavirus


Centers for Disease Control and Prevention:     Contaminated Steroid Products


Review - Clinical

 BMC Medicine:     ICU-Acquired Weakness


Annals of Intensive Care:     Muscle Relaxants


Minerva Anestesiologica:     Mechanical Ventilation


Minerva Anestesiologica:     ARDS


Congestive Heart Failure:     Natriuretic Peptides


Circulation:     Pulmonary Embolism


Avicenna Journal of Medicine:     Atrial Fibrillation


Indian Journal of Neurosurgery:     Pulmonary Complications


Journal of Pulmonary Respiratory Medicine:     Inotropes & Vasopressors


World Journal of Gastroenterology:     Hepatorenal Syndrome

Journal of Cardiovascular Translational Research:     Cardiac Resynchronization Therapy

Review - Basic Science

Circulation Research:     Mitochondria


Clinical and Developmental Immunology:     Septic Shock


Frontiers in Immunology:     Antimicrobial Peptides


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Until next week