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Critical Care Reviews Newsletter

April 28th 2013



Welcome to the 73rd 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.

No major critical care studies have been published this week, with the best research publications including large propensity matched cohort studies investigating perioperative beta blockade and coronary revascularization methods, respectively. There are also studies evaluating levosimendan in cardiogenic shock post MI, fish oils and probiotics, pharmacological thromboprophylaxis for traumatic brain injury and a review of current management for traumatic brain injury.

This week's guidelines address the management of hypertension, dialysis at end-of-life and imaging in heart failure. There is an editorial on healthcare-associated infections in the USA and commentaries on etomidate, the medical management of the Boston marathon bombing casualties, and the current coronavirus outbreak.

The clinical review articles include papers on cerebral monitoring, stroke, haemorrhagic shock models, heart transplantation, alcoholic liver disease, NGAL, TB and anti-bacterial drug development. Non-clinical review articles focus on both radiology and EM specialities, ethics, social media, presenting, and having a manuscript rejected for publication.

The topic for This Week's Papers is rapid sequence intubation, starting with a paper on controversies in this area in tomorrow's Paper of the Day.

After a long break, the latest CPD / CME  article and quiz, covering delirium, is now availabe. A personalised certificate of CPD activity can be saved and printed after successful completion of the activity.



Journal of American Medical Association:     Perioperative Beta Blockade

London et al performed a retrospective cohort analysis evaluating perioperative exposure to β-blockers in major noncardiac surgery among a population-based sample of 136 745 patients who were 1:1 matched on propensity scores (37 805 matched pairs). 55 138 patients (40.3%) were exposed to β-blockers. Exposure was higher in patients undergoing vascular surgery (n=13,863, 66.7%; 95% CI 65.9%-67.5%) than nonvascular surgery (n=122 882, 37.4%; 95% CI 37.1%-37.6%, P < 0.001). Exposure increased as Revised Cardiac Risk Index factors increased, with 25.3% (95% CI 24.9%-25.6%) of those with no risk vs 71.3% (95% CI 69.5%-73.2%) of those with 4 risk factors or more exposed to β-blockers (P < 0.001). Death occurred in 1.1% (95% CI 1.1%-1.2%) and cardiac morbidity in 0.9% (95% CI 0.8%-0.9%). In the propensity matched cohort, β-blockers was associated with lower mortality (RR 0.73; 95% CI 0.65-0.83; P < 0.001; NNT 241, 95% CI 173-397). When stratified by cumulative numbers of Revised Cardiac Risk Index factors, β-blocker exposure was associated with significantly lower mortality among patients with 2 factors (RR 0.63, 95% CI, 0.50-0.80, P < 0.001; NNT 105, 95% CI 69-212), 3 factors (RR 0.54, 95% CI 0.39-0.73, P < 0.001; NNT 41, 95% CI, 28-80), or 4 factors or more (RR 0.40, 95% CI 0.25-0.73, P < 0.001; NNT 18, 95% CI 12-34). This association was limited to patients undergoing nonvascular surgery. β-Blocker exposure was also associated with a lower rate of nonfatal Q-wave infarction or cardiac arrest (RR 0.67, 95% CI 0.57-0.79, P < .001; NNT 339, 95% CI 240-582), again limited to patients undergoing nonvascular surgery. Conclusion: Among propensity-matched patients undergoing noncardiac, nonvascular surgery, perioperative β-blocker exposure was associated with lower rates of 30-day all-cause mortality in patients with 2 or more Revised Cardiac Risk Index factors

Abstract: London. Association of Perioperative β-Blockade With Mortality and Cardiovascular Morbidity Following Major Noncardiac Surgery. JAMA 2013;309(16):1704 


Annals of Internal Medicine:     Coronary Revascularization

In an observational cohort study comparing CABG versus PCI in an unselected, general patient population, in 105,156 propensity score–matched patients,  CABG was associated with lower mortality than PCI (HR 0.92; 95% CI 0.90 to 0.95; P < 0.001). CABG was also associated with lower mortality in diabetics (HR 0.88), smokers or ex-smokers (HR 0.82), and both patients with heart failure (HR 0.84), and peripheral arterial disease (HR 0.85) (p <  0.002 for all). The overall predicted difference in survival between CABG and PCI treatment over 5 years was 0.053 life-year (range, −0.017 to 0.579 life-years).

Abstract:  Hlatky. Comparative Effectiveness of Multivessel Coronary Bypass Surgery and Multivessel Percutaneous Coronary Intervention: A Cohort Study. Annals of Internal Med 2013;epublished April 23rd


Journal of Enteral and Parenteral Nutrition:     Fish Oils

In a systematic review and meta analysis (6 RCTs, n = 390) the administration of either enteral or parenteral fish oils, containing ω-3 polyunsaturated fatty acids, was associated with a trend toward a reduction in mortality (risk ratio 0.71; 95% CI 0.49 to 1.04; p = 0.08; heterogeneity I2 = 0%), and a reduction in the duration of mechanical ventilation (weighted mean difference in days −1.41; 95% CI −3.43 to 0.61; p = 0.17), but had no effect on infections (RR 0.76; 95% CI 0.42–1.36; p = 0.35) or ICU length of stay (weighted mean difference in days −0.46; 95% CI −4.87 to 3.95; p = 0.84, heterogeneity I2 = 75%).

Abstract: Manzanares. Parenteral Fish Oil Lipid Emulsions in the Critically Ill: A Systematic Review and Meta-Analysis. JPEN 2013;epublished April 22nd


Journal of Enteral and Parenteral Nutrition:     Probiotics for Trauma

In a systematic review and meta-analysis (5 RTCs, n=281) probiotics were associated with a reduced incidence of nosocomial infections (RR 0.65; 95% CI 0.45–0.94, p = 0.02), ventilator-associated pneumonia (3 trials; RR 0.59; 95% CI 0.42–0.81, P = 0.001), and length of ICU stay (2 trials; standardized mean difference −0.71; 95% CI −1.09 to −0.34, p < 0.001) but not a reduction in mortality (4 trials; RR 0.63; 95% CI 0.32–1.26, p = 0.19). There was significant heterogeneity amongst studies limiting these results.

Abstract:  Gu. The Effects of Probiotics in Early Enteral Nutrition on the Outcomes of Trauma. A Meta-Analysis of Randomized Controlled Trials. JPEN 2013;37(3):342-351


European Journal of Heart Failure:     Levosimendan

In a blinded, placebo-controlled, randomized trial in 61 patients with heart failure 48 hours after a primary PCI-treated STEMI (including cardiogenic shock), a 25 hour infusion of levosimendan was associated with (1) a significantly larger improvement in wall motion score index (from baseline to day 5; levosimendan: 1.94 ± 0.20 to 1.66 ± 0.31 vs. placebo: 1.99 ± 0.22 to 1.83 ± 0.26, respectively, P = 0.031) (2) significantly more episodes of hypotension  (67% vs. 36%, P = 0.029), but (3) no significant differences in blood pressure at the end of infusion, use of vasopressors, between-group differences in changes in NT-proBNP levels, clinical composite score, frequency of atrial fibrillation or ventricular arrhythmia, infarct size at 6 weeks, or new clinical events up to 6 months. One and four patients died in the levosimendan and placebo group, respectively.

Abstract:  Husebye. Levosimendan in acute heart failure following primary percutaneous coronary intervention-treated acute ST-elevation myocardial infarction. Results from the LEAF trial: a randomized, placebo-controlled study. Eur J Heart Fail 2013;15 (5):565-572


Journal of Neurotrauma:     Traumatic Brain Injury

Using 44 systematic reviews (21 Cochrane Reviews and 23 from peer-reviewed journals) with satisfactory methodological quality to assess therapeutic interventions for acute traumatic brain injury, 29  high-quality reviews provided no conclusive evidence for the investigated 22 interventions except for an adverse effect of corticosteroids. Less than one-third of the component trials were reported with adequate allocation concealment. Additionally other methodological flaws in design, such as ignoring heterogeneity among the TBI population, also contributed to the failure of past clinical research. Evidence from both systematic reviews and clinical trials does not fully support current management of acute TBI.


Journal of Neurotrauma:     Traumatic Brain Injury

In a systematic review and meta analysis, including five retrospective cohort studies (n=1624 patients), early pharmacological thromboprophylaxis (<72 hours, n=713), in comparison with late pharmacological thromboprophylaxis (>72 hours, n=911), was associated with less episodes of venothromboembolism (43 versus 106, risk ratio 0.52, 95% CI 0.37 - 0.73). The relative risk of intracerebral haemorrhage progression in the early compared with the late group was 0.64 ( 95% CI 0.35 - 1.14). Prospective randomized controlled trials are required to adequately address this issue.

Abstract:  Jamjoom. Safety and Efficacy of Early Pharmacological Thromboprophylaxis in Traumatic Brain Injury: Systematic Review and Meta-Analysis. Journal of Neurotrauma 2013;30(7):503-511



Canadian Journal of Cardiology:     Hypertension



Lancet Infectious Diseases:     Healthcare Associated Infection



Annals of Emergency Medicine:     Etomidate


New England Journal of Medicine:     Boston Marathon Bombing


Lancet Infectious Diseases:     Novel Coronavirus


Review - Clinical


ISRN Critical Care:     Circulatory Arrest


Neurology Research International:     Subarachnoid Haemorrhage Monitoring



Circulation Journal:     Heart Transplantation


European Surgical Research:     Haemorrhagic Shock Models


Stem Cells and Cloning: Advances and Applications:     Stem Cells for Heart Failure



Vascular Health and Risk Management:     Vernakalant for Atrial Fibrillation


Journal of the American College of Cardiology:     High-Sensitivity Troponin Assays



Annals of Intensive Care:     ARDS



Clinical Cardiology:     Proton Pump Inhibitors & Clopidogrel



Clinical Liver Disease:      Alcoholic Liver Disease



BioMed Research International:     NGAL in Acute Kidney Injury


Saudi Journal of Kidney Disease Transplantation:     ABO-Incompatible Kidney Transplantation



International Journal of Medical Science:     Melatonin



Blood:     Platelets



Clinical Infectious Diseases:     Anti-Bacterial Development


Indian Journal of Medical Research:     Tuberculosis


Review - Non-Clinical

PLoS Biology:     Social Media


Cerebrovascular Diseases:     Presenting


Cerebrovascular Diseases:     Article Rejection


Canadian Association of Radiologists Journal


Annals of Emergency Medicine:     Emergency Medicine in UK & Ireland


Nephrology:     Ethics



I hope you find these brief summaries and links useful.

Until next week