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Critical Care Reviews Newsletter

April 14th 2013



Welcome to the 71st 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 include a description of pathobiology of the evolving H7N9 avian influenza outbreak in China, a report demonstrating the limitations of chest radiography for the diagnosis of ARDS, a lack of association between the age of transfused red cells and outcomes, plus a fascinating study describing incredible outcomes with liver transplantation for metastatic liver disease.

This week's guidelines are in the form of two position papers from the European Society of Cardiology Working Group on Thrombosis. There is an editorial on blood pressure management in trauma and a critique of the recent Chestnut ICP study published in the New England Journal of Medicine. There are two commentaries on evidence-based medicine and physician-assisted suicide.

Amongst the clinical review articles are papers on traumatic encephalopathy, cardiogenic shock, lung transplantation, acute liver failure, anticoagulation in the acutely ill medical patient, neutropenic sepsis, sepsis biomarkers, and a couple of papers on opioids.

For a speciality closely associated with death, this week's general interest paper will be of intriguing to many - biogenesis and the origin of life.

The topic for This Week's Papers is toxicology, starting tomorrow with a paper on the general overview and approach to treatment in Paper of the Day.



New England Journal of Medicine:     H7N9

Full Text:  Gao. Human Infection with a Novel Avian-Origin Influenza A (H7N9) Virus. N Eng J Med 2013; epublished April 11th

Commentary: Uyeki. Global Concerns Regarding Novel Influenza A (H7N9) Virus Infections. N Eng J Med 2013; epublished April 11th


Journal of Critical Care:     Radiological Diagnosis in ARDS

Using chest CT as reference standard, 90 patients who met criteria for ARDS, regardless of the radiographic criterion, had their radiologic studies blindly reviewed in an independent fashion by 2 radiologists for the presence or absence of bilateral pulmonary abnormalities consistent with ARDS. Sensitivity was 0.73; specificity, 0.70; positive and negative predictive values were 0.88 and 0.47, respectively, demonstrating the limitations of the portable chest radiograph to identify radiological features of ARDS.

Abstract:  Figueroa-Casas. Accuracy of the chest radiograph to identify bilateral pulmonary infiltrates consistent with the diagnosis of acute respiratory distress syndrome using computed tomography as reference standard. J Crit Care 2013; epublished April 5th


Journal of Anesthesia:     Awake Fibreoptic Intubation

In a double blind, randomized controlled trial in 40 patients undergoing elective awake fiberoptic nasotracheal intubation, dexmedetomidine sedation, in contrast to remifentanil sedation, was associated with a superior endoscopy score {median/IQR: (2 [1–2]) versus (3 [2–3]; p < 0.01}, lower recall of intubation (p = 0.027), better patient satisfaction (2 [1–2] and 2 [2–3], respectively; p = 0.022) as well as fewer heart rate responses during endoscopy and intubation (p < 0.001 and p = 0.004, respectively) and superior oxygen saturation (p = 0.003). There were no significant differences in intubation and post-intubation conditions.

Abstract: Ho. Dexmedetomidine versus remifentanil sedation during awake fiberoptic nasotracheal intubation: a double-blinded randomized controlled trial.Journal of Anesthesia 2013;27(2):211-217


The Lancet:     Pneumothorax

In an open-label, parallel-group, prospective, randomised, controlled trial, Chen et al demonstrated in 214 males aged 15—40 years having a first episode of primary spontaneous pneumothorax, that simple aspiration and drainage coupled with intrapleural minocycline  pleurodesis (n=106) was superior to simple aspiration alone (n=108), and resulted in reduced pneumothorax recurrence rate at one year {31/106 (29·2%) versus 53/108 (49·1%); p=0·003}.

Abstract:  Chen. Simple aspiration and drainage and intrapleural minocycline pleurodesis versus simple aspiration and drainage for the initial treatment of primary spontaneous pneumothorax: an open-label, parallel-group, prospective, randomised, controlled trial. Lancet 2013;381(9874):1277-1282


Annals of Surgery:     Liver Transplantation for Nonresectable Liver Metastases

In a prospective pilot study in 21 individuals with liver-only colorectal liver metastases, excised primary tumors, and at least 6 weeks of chemotherapy, liver transplantation was associated with overall survival  at 1, 3, and 5 years of 95%, 68%, and 60%, respectively, which was far superior to chemotherapy, the only available treatment for this group of patients.

Abstract:  Hagness. Liver Transplantation for Nonresectable Liver Metastases From Colorectal Cancer. Annals of Surgery 2013;257(5):800–806


Thrombosis & Haemostasis:     Dabigatran

In an open-label, single-centre phase I study in seven patients with end-stage renal disease, using two fixed multiple dosing periods of dabigatran, 4 hour haemodialysis sessions with either 200 or 400 ml/min targeted blood flow removed 48.8% and 59.3% of total dabigatran from the central compartment, respectively. The anticoagulant activity of dabigatran was linearly related to its plasma levels. There was a minor redistribution of dabigatran (<16%) after the end of the haemodialysis session. Haemodialysis may be a suitable approach to eliminate dabigatran in emergency situations.

Full Text:  Khadzhynov. Effective elimination of dabigatran by haemodialysis. A phase I single-centre study in patients with end-stage renal disease. Thromb Haemost 2013;109(4):596-605


Critical Care:     Red Cell Transfusion

In a systematic review of 55 studies evaluating age of transfused red cells on outcomes, half the studies showed no deleterious effects from older red cells; 11 of 22 studies reported no increased mortality, and three of 9 showed no increased length of stay with older red cells. Ten of 18 studies showed increased infections and 8 of 12 studies showed no increased risks of organ failure with transfusion of older red cells. As many studies were either single-centre and/or retrospective in nature, the considerable study heterogeneity and numerous methodological flaws precluded a formal meta-analysis. 

Full Text:  Lelubre. Relationship between red cell storage duration and outcomes in adults receiving red cell transfusions: a systematic review. Critical Care 2013;17:R66


BMC Infectious Disease:     Clostridium Difficile

Using a large clostridium difficile infection datbase (derivation cohort), Miller and colleagues determined that a combination of five simple and commonly available clinical and laboratory variables (age, treatment with systemic antibiotics, leukocyte count, albumin and serum creatinine as a measure of renal function) measured at the time of clostridium difficile infection diagnosis, combined into a scoring system (ATLAS), was able to accurately predict treatment response to therapy (R2=0.95; P<0.001). The ATLAS scoring system showed excellent prediction of cure in the validation cohort (overall Kappa=95.2%; P<0.0001), as well as in the pooled cohort, regardless of treatment (fidaxomicin or vancomycin).

Full Text: Miller. Derivation and validation of a simple clinical bedside score (ATLAS) for Clostridium difficile infection which predicts response to therapy. BMC Infect Dis 2013;13:148


Guideline / Position Paper

Thrombosis Haemostasis:     Coagulation & Anticoagulants





Study Critique

Nature Reviews Neurology:   Traumatic Brain Injury 


Journal of the American Medical Association:     Evidence-Based Medicine


New England Journal of Medicine:     Physician-Assisted Suicide


Review - Clinical


Nature Reviews Neurology:     Traumatic Encephalopathies



British Journal of Medicine and Medical Research:     Cardiogenic Shock


Clinics (Sao Paulo):     Cardiorenal Syndrome


Journal of the American College of Cardiology:     Year in Review


Swiss Medical Weekly:     Lung Transplantation



Dimensions of Critical Care Nursing:     Gastroesophageal Reflux



Journal of Hepatology:     Acute Liver Failure


International Journal of Hepatology:     Variceal Haemorrhage


International Journal of Hepatology:     Hepatic Manifestations in Hematological Disorders



North American Journal of Medical Sciences:     Potassium Measurement Errors



Thrombosis Haemostasis:     Anticoagulation for Acutely Ill Medical Patients


Emergency Medicine and Health Care:     Effect of Fluids on Coagulation



Clinical Medicine:     Neutropenic Sepsis


Critical Reviews in Clinical Laboratory Sciences:     Sepsis Biomarkers



Anesthesiology & Clinical Science



BMC Medicine:     Autoimmunity


Review - Basic Science

British Journal of Pain:     Opioid Pharmacology


British Journal of Medicine and Medical Research:     Toll-Like Receptors


General Interest

Research and Reports in Biology:     Biogenesis



I hope you find these brief summaries and links useful.

Until next week