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Critical Care Reviews Newsletter

September 16th 2012





Welcome to the 41st 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.

There is a paucity of major critical care research studies published this week, althought the significance of perioperative hyponatraemia is highlighted in a large database study by Leung. This months edition of the Cochrane Library has several reviews relevant to critical care. The review articles cover a wide spectrum, both clinical and pre-clinical, and include weaning, liver tranplantation, neuromonitoring, troponin, and even western blotting, if you ever wanted to know what it actually is.

The topic for This Week's Papers is pneumonia, starting with viral pneumonia in the immunocompromised in tomorrow's Paper of the Day. It's a free and easy way to stay up-to-date with your reading.

The new CPD / CME facility is almost ready to go. The first quiz is complete and functional, with a certificate of completion to be saved or printed upon successfully passing the multiple choice examination. As soon as official approval is received I'll make this facility available.



Archives of Internal Medicine:     Hyponatraemia

Using the American College of Surgeons National Surgical Quality Improvement Program database, Leung et al sought to determine whether preoperative hyponatremia is a predictor of 30-day perioperative morbidity and mortality. 964 263 adults undergoing major surgery from more than 200 hospitals ( January 1st 2005, to December 31st 2010) were identified. 75 423 patients with preoperative hyponatremia (sodium level <135 mEq/L) were compared with 888 840 patients with normal baseline sodium levels (135-144 mEq/L). Preoperative hyponatremia was associated with a higher risk of 30-day mortality (5.2% vs 1.3%; adjusted odds ratio [aOR], 1.44; 95% CI, 1.38-1.50), with this finding being consistent across all subgroups. This association was particularly marked in patients undergoing nonemergency surgery (aOR, 1.59; 95% CI, 1.50-1.69; P < .001 for interaction) and American Society of Anesthesiologists class 1 and 2 patients (aOR, 1.93; 95% CI, 1.57-2.36; P < .001 for interaction). Furthermore, hyponatremia was associated with a greater risk of perioperative major coronary events (1.8% vs 0.7%; aOR, 1.21; 95% CI, 1.14-1.29), wound infections (7.4% vs 4.6%; 1.24; 1.20-1.28), and pneumonia (3.7% vs 1.5%; 1.17; 1.12-1.22) and prolonged median lengths of stay by approximately 1 day.

Abstract:  Leung. Preoperative Hyponatremia and Perioperative Complications. Arch Intern Med 2012; epublished ahead of print


Archives of Internal Medicine:     ICU Admission

To identify admission characteristics of medical patients to the ICU, Chen et al performed a retrospective cohort study of 289 310 patients, admitted from the emergency department or the outpatient clinic, in 118 Veterans Affairs hospitals.  Admission characteristics varied widely. Of those directed admitted to ICU (n=31,555), 53.2% were low risk, with a predicted 30 day mortality ≤ 2%, although this varied widely across institutions with low risk admisission rates of 1.2 - 38.9%. As a result, 66.1% of hospitals were in different quartiles of ICU use for low- vs high-risk patients (weighted κ = 0.50).

Abstract: Chen. Intensive Care Unit Admitting Patterns in the Veterans Affairs Health Care System. Arch Intern Med 2012;172(16):1


Cochrane Reviews

Cochrane Review:     Subarachnoid Haemorrhage

Full Text:  Guo and colleagues performed a systematic review and meta analysis, identifying 4 studies totalling 2024 subjects, to assess the efficacy and tolerability of endothelin receptor antagonists for subarachnoid haemorrhage. ETAs reduced the incidence of delayed neurological deficits (RR 0.80; 95% CI 0.67 to 0.95) and angiographic vasospasm (RR 0.62; 95% CI 0.52 to 0.72) but did not reduce the incidence of unfavorable outcomes (RR 0.87; 95% CI 0.74 to 1.02) or mortality (RR 1.05; 95% CI 0.77 to 1.45). ETAs increased the incidence of hypotension (RR 2.53; 95% CI 1.77 to 3.62) and pneumonia (RR 1.56; 95% CI 1.23 to 1.97).

Full TextGuo. Endothelin receptor antagonists for subarachnoid hemorrhage. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD008354


Cochrane Review:     Community-Acquired Pneumonia

Full Text:  For community-acquired pneumonia, Eliakim-Raz et al estimated the mortality and proportion with treatment failure using regimens containing atypical antibiotic coverage compared to those that had typical coverage only. 28 trials, toalling 5939 randomized patients were included in the analysis. There was no difference in mortality between the atypical arm and the non-atypical arm (RR 1.14; 95% CI 0.84 to 1.55). The atypical arm showed an insignificant trend toward clinical success and a significant advantage to bacteriological eradication, which disappeared when evaluating methodologically high quality studies alone. Clinical success for the atypical arm was significantly higher for Legionella pneumophilae and non-significantly lower for pneumococcal pneumonia. There was no significant difference between the groups in the frequency of adverse events, or those requiring discontinuation of treatment. However, gastrointestinal events were less common in the atypical arm (RR 0.70; 95% CI 0.53 to 0.92). Although the trials assessed different antibiotics, no significant heterogeneity was detected in the analyses. The authors conclude that no benefit of survival or clinical efficacy was shown with empirical atypical coverage in hospitalized patients with CAP. This conclusion relates mostly to the comparison of quinolone monotherapy to beta-lactams

Eliakim-Raz. Empiric antibiotic coverage of atypical pathogens for community-acquired pneumonia in hospitalized adults. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004418


Cochrane Review:     N-Acetylcysteine

Full Text:  Szakmany et al performed a systematic review and meta analysis, identifying 41 studies totalling 2768 patients, to determine the effect of the antioxidant N-acetylcysteine on outcome in sepsis and SIRS. Mortality was similar in the N-acetylcysteine group and the placebo group (RR 1.06, 95% CI 0.79 to 1.42; I2 = 0%). N-acetylcysteine did not show any significant effect on length of stay, duration of mechanical ventilation or incidence of new organ failure. Early application of N-acetylcysteine to prevent the development of an oxidato-inflammatory response did not affect the outcome, nor did late application after 24 hours of developing symptoms. Late application was associated with cardiovascular instability.

Full Text:  Szakmany. N-acetylcysteine for sepsis and systemic inflammatory response in adults. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD006616.


Cochrane Review:     Procalcitonin

Full Text: Schuetz at al performed a systematic review and meta analysis, identifying 14 trials with 4221 participants, to determine the efficacy of basing initiation and duration of antibacterial therapy on serum procalcitonin levels. There were 118 deaths in 2085 patients (5.7%) assigned to procalcitonin groups compared to 134 deaths in 2126 control patients (6.3%) (adjusted OR 0.94, 95% CI 0.71 to 1.23). Treatment failure occurred in 398 procalcitonin group patients (19.1%) and in 466 control patients (21.9%). Procalcitonin guidance was not associated with increased mortality or treatment failure in any clinical setting. These results proved robust in various sensitivity analyses. Total antibiotic exposure was significantly reduced overall (median (interquartile range) from 8 (5-12) to 4 (0-8) days; adjusted difference in days, -3.47, 95% CI -3.78 to -3.17, and across all the different clinical settings and diagnoses.

Full Text:  Schuetz. Procalcitonin to initiate or discontinue antibiotics in acute respiratory tract infections. Cochrane Database of Systematic Reviews 2012;(9):CD007498        Editorial


Cochrane Review:     Hypothermia post Cardiac Arrest

Full Text:  In an updated Cochrane Review Arrich et al assessed whether hypothermia was efficacous as a neuroprotectant post cardiac arrest. The updated search resulted in no new studies; Four trials and one abstract reporting on 481 patients were included.  With conventional cooling methods, patients in the hypothermia group were more likely to reach a best cerebral performance categories (CPC) score of one or two (five point scale: 1 = good cerebral performance, to 5 = brain death) during the hospital stay (individual patient data; RR 1.55; 95% CI 1.22 to 1.96) and were more likely to survive to hospital discharge (individual patient data; RR 1.35; 95% CI 1.10 to 1.65) compared to standard post-resuscitation care. Across all studies, there was no significant difference in reported adverse events between hypothermia and control.

Full Text:  Arrich. Hypothermia for neuroprotection in adults after cardiopulmonary resuscitation. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD004128.


Cochrane Review:     Hepatorenal Syndrome

Full Text:  In an updated Cochrane Review, Gluud et al assessed the effects of terlipressin alone or with albumin versus placebo, no intervention or albumin for hepatorenal syndrome. Six randomised clinical trials, all with a high risk of bias, were identified. Five trials assessed terlipressin (with albumin in three trials) versus no intervention (with albumin in three trials) and one trial assessed terlipressin versus albumin. 74 of 155 (47.7%) patients randomised to terlipressin alone or terlipressin with albumin versus 98 of 154 (63.6%) patients randomised to no intervention, placebo or albumin died. Random-effects model meta-analysis found that terlipressin reduced mortality (RR 0.76, 95% CI 0.61 to 0.95). The authors concluded that terlipressin may reduce mortality and improve renal function in patients with type 1 hepatorenal syndrome, although the strength of the evidence is debatable.

Full Text:  Gluud. Terlipressin for hepatorenal syndrome. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD005162


Stroke:     Cochrane Review on Antibiotic Therapy

Full Text:  Westendorp et al performed a meta analysis investigating whether preventive antibiotic therapy in patients with acute stroke reduces infection rate, risk of dependency, and risk of death at follow-up. Five studies involving 506 patients were included. Preventive antibiotic therapy reduced infection rate from 36% to 22% (RR 0.58; 95% CI: 0.43– 0.79), whereas effects on mortality and functional outcome were not significant: 13% died in the preventive antibiotic group vs 15% in the control group (RR 0.85; 95% CI: 0.47–1.51) and 47% of patients in the preventive antibiotic group were dependent vs 61% in the control group (RR 0.67; 95% CI: 0.32–1.43). No major side effects of preventive antibiotic therapy were reported.

Full Text:  Westendorp. Preventive Antibiotics in Acute Stroke: Summary of a Cochrane Systematic Review and Meta-Analysis. Stroke 2012; epublished 13 September



 Circulation:     Device-Based Therapy for Dysrhythmias


Review - Clinical

Indian Journal of Anaesthesia:     Liver Transplantation


Minerva Anestesiologica:     Troponin


Minerva Anestesiologica:     Weaning


Minerva Anestesiologica:     VILI


Minerva Anestesiologica:     Neuromonitoring


Open Medicine:     Notable General Medical Articles


Swiss Medical Weekly:     Elderly ICU Patients


European Heart Journal:     Troponin

Clinical Endoscopy:     Upper GI Bleeding


(free from Seminars in Cardiothoracic & Vascular Anaesthesia until October 15th)

Seminars in Cardiothoracic & Vascular Anesthesia:     Myocardial Infarction


Seminars in Cardiothoracic & Vascular Anesthesia:     Echocardiography


Seminars in Cardiothoracic & Vascular Anesthesia:     Aortic Dissection


Scandanavian Journal of Trauma, Resuscitation and Emergency Medicine:     Trauma

Scandanavian Journal of Trauma, Resuscitation and Emergency Medicine:     Cardiac Arrest


BMC Medicine:     Influenza


Archives of Internal Medicine:     West Nile Virus


Journal of the American Heart Association:     Obstructive Sleep Apnoea


Review - Basic Science

Journal of Advanced Pharmaceutical Technology & Research:     Antiviral Therapy


Drug Design, Development and Therapy:     Tuberculosis


North American Journal of Medical Science:     Western Blot


World Journal Of Emergency Medicine:     High Mobility Group Box 1 Protein



I hope you find these brief summaries useful.

Until next week