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Critical Care Reviews Newsletter

June 30th 2013



Welcome to the 82nd 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.

The ongoing saga of starches begins to draw to a close, with British and American regulators joining European authorities in effectively banning the use of these formulations due to an unfavourable safety profile. It only took them a year. With an estimated 21% of global fluid resuscitation being with starches in 2007, how much unnecessary iatrogenic harm has been caused by this delay?

This week's research studies include a randomized controlled trial reporting superior outcomes with the combination of clopidogrel plus aspirin over aspirin alone in ischaemic stroke and TIA, a one year follow up of the EDEN trial participants, meta analyses on magnesium sulphate in subarachnoid haemorrhage, ultrafiltration versus diuretics in acute heart failure, and selenium for sepsis, as well as observational studies demonstrating the actual clearance rate of ammonia with continuous renal replacement therapy, an association between hyperoxia and mortality in traumatic brain injury and a report suggesting traumatic brain injury is a risk factor for later ischaemic stroke.

This week's guidelines address the surgical management of burns, pacing, bariatric perioperative nutrition and CPR.

Amongst the clinical review articles are papers on hypertension, stroke, therapeutic hypothermia, right ventricular failure, COPD, pulmonary hypertension, end-stage liver disease, venothromboembolism, clostridium difficile, fungal infections, burns, contrast reactions and wind disasters (tornados ad hurricanes).

The topic for This Week's Papers is resistant bacteria, starting with a paper on glycopeptide resistant enterococci in tomorrow's Paper of the Day.





Randomized Controlled Trials:

New England Journal of Medicine:     Stroke

In a Chinese randomized, double-blind, placebo-controlled trial in 5170 patients within 24 hours of a minor ischemic stroke or high-risk transient ischemic attack, the combination of clopidogrel (initially 300 mg, followed by 75 mg per day for 90 days) and aspirin (75 mg per day for the first 21 days), in comparison with placebo plus aspirin (75 mg per day for 90 days), was associated with a reduction in the occurance of stroke at 90 days (8.2% versus 11.7%; hazard ratio 0.68; 95% CI 0.57 to 0.81; P<0.001). There was no difference in the incidence of moderate or severe hemorrhage (0.3% both groups), or haemorhagic stroke (also 0.3% both groups).

Abstract:  Wang. Clopidogrel with Aspirin in Acute Minor Stroke or Transient Ischemic Attack. New Eng J Med 2013;epublished June 26th

Editorial:  Hankey. Dual Antiplatelet Therapy in Acute Transient Ischemic Attack and Minor Stroke. New Eng J Med 2013;epublished June 26th


American Journal of Respiratory and Critical Care Medicine:     Acute Lung Injury

In a cohort of 115 consecutive patients (1000 patients in main EDEN trial) within 48 hours of developing acute lung injury requiring mechanical ventilation, randomized to receive full or trophic (20% target) enteral feeding for 6 days, there was no difference in 6 month and 1 year outcomes in physical and cognitive performance. However, EDEN survivors demonstrated impairments in 6-minute walk distance (64% predicted at 6 months and 66% predicted at 12 months) and cognition (impairment in 36% at 6 months and 25% 12 months), with improvements in both measures over the 6 month period (p=0.011 and p=0.001, respectively, for difference between assessments).

Abstract:  Needham. Physical and Cognitive Performance of Acute Lung Injury Patients One Year after Initial Trophic vs Full Enteral Feeding: EDEN Trial Follow-Up. Am J Respir Crit Care Med 2013;epublished June 2nd


Systematic Review and Meta Analysis

Australian Critical Care:     Subarachnoid Haemorrhage

In a systematic review and meta analysis, including 9 trials, Yarad and colleagues demonstrated a reduction in the incidence of cerebral vasospasm post subarachnoid haemorrhage with intravenous magnesium sulphate (relative risk 0.83; 95% CI 0.71 to 0.98; P=0.03). However, magnesium therapy was not assciated with an improvement in favourable functional outcome (RR 1.00; 95% CI 0.96 to 1.05; P=0.84) or mortality (RR 0.95; 95% CI 0.77 to 1.18; P=0.67).

Abstract:  Yarad. Intravenous magnesium therapy in adult patients with an aneurysmal subarachnoid haemorrhage: A systematic review and meta-analysis. Aust Crit Care 2013;epublished Jun 24th


American Journal of Cardiovascular Drugs:     Acute Heart Failure

In a systematic review and meta analysis, including 5 trials (n=477), Wen et al showed that in this dataset, ultrafiltration, in comparison with diuretic therapy, was associated with greater 48 hour weight loss (Z = 3.72;  weighted mean difference 1.25 kg, 95 % CI 0.59–1.91, P < 0.001) and greater 48 hour fluid removal (Z = 4.23; WMD = 1.06 L, 95 % CI 0.57–1.56, P < 0.001), without an increase in adverse events.

Abstract:   Wen. Ultrafiltration versus Intravenous Diuretic Therapy to Treat Acute Heart Failure: A Systematic Review. Am J Cardiovasc Drugs 2013;epublished June 26th


American Journal of Emergency Medicine:     Selenium

In a systematic review and meta analysis, including 5 studies and 530 patients, Kong et al report a lack of efficacy of selenum in sepsis, with no effect on mortality (relative risk 0.89, 95% CI 0.73-1.07, P = 0.21), incidence of hospital-acquired pneumonia (RR 1.15, 95% CI 0.73-1.82, P = 0.55), length of intensive care unit stay (weighted mean differences = 2.32 days, 95% CI −0.05 to 4.69; P = 0.05), or adverse events (RR = 0.97, 95% CI 0.72-1.33, P = 0.87).

Abstract:  Kong. Selenium supplementation for sepsis: a meta-analysis of randomized controlled trials. American Journal of Emergency Medicine 2013;epublished June 24th


Prospective Observational

Liver International:     Ammonia Clearance

Although continuous renal replacement therapy is used to decrease ammonia levels, clearance kinetics have been poor characterized to date. In a prospective observational study of 24 hyperammonaeic patients (arterial ammonia >100 μmol/L), ammonia clearance was highly correlated with ultrafiltration dose (r = 0.86, P < 0.001), with low dose CRRT (35 ml/kg/h) having an ammonia clearance at 1 hour of 39 (34–54) ml/min and high dose CRRT (90 ml/kg/h) a clearance of 85 (62–105) ml/min (P < 0.001). Similarly, this difference was maintained at 24 hours; 44 (34–63) vs 105 (82–109) ml/min (P = 0.01). At 24 hours median arterial ammonia had decreased by 22%. Interestingly, urea and ammonia clearances were also highly correlated (r = 0.819, P = 0.007).

Abstract:  Slack. Ammonia clearance with haemofiltration in adults with liver disease. Liver Int 2013;epublished May 17th


Retrospective Observational

Neurology:     Traumatic Brain Injury

Using a large Californian database of 1,173,353 trauma subjects, 436,630 (37%) of whom had suffered a traumatic brain injury,  Burke and colleagues showed that, independent of other major predictors, subsequent ischaemic stroke was more common in those with a TBI than trauma controls 28 months post injury (hazard ratio 1.31, 95% CI 1.25–1.36).

Abstract:  Burke. Traumatic brain injury may be an independent risk factor for stroke. Neurology 2013;epublished June 26th


Journal of Neurology, Neurosurgery and Psychiatry:     Traumatic Brain Injury

In keeping with numerous recent studies demonstrating worse outcomes with hyperoxia, Rincon and colleagues report retrospective results from a multi-centre cohort study including 1212 ventilated traumatic brain injury patients. While mortality (224/553, 41%; crude odds ratio 2.3, 95% CI 1.7-3.0, p<.0001) was hightest in those with early hypoxia (PaO2 <60 mm Hg / 7.99 kPa or PaO2/FiO2 ratio ≤ 300), early hyperoxia (PaO2 ≥300 mm Hg / 39.99 kPa) was also associated with increased mortality (80/256, 32%; adjusted OR 1.5, 95% CI 1.02-2.4, p=0.04) in comparison with normoxic patients  (87/403, 23%).

Abstract:  Rincon. Significance of arterial hyperoxia and relationship with case fatality in traumatic brain injury: a multicentre cohort study. J Neurol Neurosurg Psychiatry



Journal of Burn Care & Research:     Surgical Management of Burns


European Heart Journal:     Pacing


Obesity:     Perioperative Bariatric Nutrition




Anaesthesia Essays and Researches:     Insulin Administration



Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine:     Emergency Airway


Review - Clinical


Annals of Intensive Care:     Hypertension

Quarterly Journal of Medicine:     Stroke


Brain Science:     Stroke



Anaesthesia Essays and Researches:     Therapeutic Hypothermia


Vascular Health and Risk Management:     Aldosterone Receptor Antagonists


Cardiorenal Medicine:     Right Heart Failure


Current Opinion in Critical Care:     Resuscitation



International Journal of Chronic Obstructive Pulmonary Disease:     COPD


Clinical Medicine Insights: Circulatory, Respiratory and Pulmonary Medicine:     COPD


High Altitude Medicine & Biology:     Hypoxic Pulmonary Vasoconstriction


High Altitude Medicine & Biology:     Pulmonary Arterial Hypertension


Respiratory Care:     Pulmonary Arterial Hypertension



Gut Pathogens:   Holobionts


International Journal of Hepatology:    Bleeding in Extrahepatic Portal Venous Obstruction


Clinical and Molecular Hepatology:     End-Stage Liver Disease


Journal of Clinical & Experimental Hepatology:     MELD



Biomedical Papers:     Acute Kidney Injury


Clinical and Experimental Pharmacology and Physiology:     Ticagrelor


New England Journal of Medicine:    Contaminated Methylprednisolone Injections


Pathogens:     Antimicrobial Resistance


Journal of Burn Care & Research:     Burns



International Journal of Artificial Organs:     Neonatal Lung Assist


Respiratory Care:     Neonatal Hypertension



Indian Journal of Dermatology:     Drug Interactions


International Journal of Critical Illness and Injury Science:     Wind Disasters


Reports in Medical Imaging:     Contrast Reactions



I hope you find these brief summaries and links useful.

Until next week