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Critical Care Reviews Newsletter

October 28th 2012





Welcome to the 47th 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.

After the biggest week of the year for critical care publications last week, this week is understandably quieter. A large meta analysis provides further evidence for the use of "low" tidal volume ventilation for all, including non-ARDS and operative patients. The questionable quality of guidelines surfaces again, with a further meta analysis in Archives of Internal Medicine showing many guidelines don't meet required quality standards. Continuing on the theme of guidelines, the Surviving Sepsis Campaign group have analysed their own large database and found a worrying increase in mortality with low dose steroid administration,  prescribed in accordance with their guideline. Long term retrospective data on outcomes after ECMO for refractory hypoxaemia  shows poor functional levels in this group, although a second report provides evidence that ECMO may be suitable as an means of avoiding invasive mechanical ventilation.

There are two updated Cochrane Reviews on fast-track cardiac surgery and traumatic brain injury. The fungal meningitis outbreak in the USA continues, with a further commentary in JAMA this week.

The usual spread of review articles cover most organ systems and include massive transfusion, post-partum haemorrhage, hepatic encephalopathy, ARDS, transcranial doppler ultrasound, sedation, drug-induced liver injury and a fascinating paper on clinical reasoning.

The topic for This Week's Papers is obstetric critical care, starting with a general paper on the obstetric critical care population in today's Paper of the Day

This week's CPD / CME  article and quiz are on the RUSH ultrasound protocol for the assessment of shock. A personalised certificate of CPD activity can be saved and printed after successful completion of the activity. This quiz will be available later today.



Journal of the American Medical Association:     Mechanical Ventilation

Neto and colleagues performed a systematic review and meta analysis (20 studies, 2822 subjects) to determine whether lower tidal volume ventilation is associated with improved outcomes in non-ARDS patients. Using a fixed effects model, lower tidal volume ventilation was associated with both a lower risk of the development of lung injury (RR: 0.33; 95% CI: 0.23 to 0.47; I2, 0%; NNT=11), and mortality (RR: 0.64; 95% CI: 0.46 to 0.89; I2, 0%; NNT: 23). Using a random-effects model, lower tidal volume ventilation was associated with a decreased incidence of pulmonary infection (RR:, 0.45; 95% CI: 0.22 to 0.92; I2, 32%; NNT:, 26), lower mean hospital length of stay (6.91 vs 8.870), and ratios of PaO2 to fraction of inspired oxygen (304.40 vs 312.97). A mixture of ICU and theatre patients were included in the analysis.

Abstract: Neto. Association Between Use of Lung-Protective Ventilation With Lower Tidal Volumes and Clinical Outcomes Among Patients Without Acute Respiratory Distress Syndrome: A Meta-analysis. JAMA 2012;308(16):1651


Archives of Internal Medicine:     Guidelines

Kung et al completed a systematic review and meta analysis to assess whether new guidelines have been formulated in accordance with the Institute of Medicine standards for clinical practice guidelines. 130 guidelines were selected at random from the National Guideline Clearinghouse website for compliance with 18 of 25 IOM standards.  Compliance with the IOM standard was poor. The overall number of IOM standards met  was 8/18 (44.4%) {IQR: 6.5 (36.1%) to 9.5 (52.8%)}. Less then than half of guidelines  met more than 50% of the IOM standards, with barely a third of subspeciality produced guidelines meeting more than 50% of the IOM standards.  Information on conflicts of interest (COIs) was given in fewer than half of the guidelines surveyed, with COIs present in 71.4% of committee chairpersons and 90.5% of co-chairpersons in guidelines providing such information. Except for US government agency–produced guidelines, criteria used to select committee members and the selection process were rarely described. Committees developing guidelines rarely included an information scientist or a patient or patient representative. Non-English literature, unpublished data, and/or abstracts were rarely considered in developing guidelines; differences of opinion among committee members generally were not aired in guidelines; and benefits of recommendations were enumerated more often than potential harms. Guidelines published from 2006 through 2011 varied little with regard to average number of IOM standards satisfied.

Abstract:  Kung. Failure of Clinical Practice Guidelines to Meet Institute of Medicine Standards. Two More Decades of Little, If Any, Progress. Arch Intern Med 2012;():1-6


Intensive Care Medicine:     Surviving Sepsis Campaign

Analysing the Surviving Sepsis Campaign database, Casserly identified 17,847 patients (from a total of 27,836) who required vasopressor therapy despite fluid resuscitation and therefore met the eligibility criteria for receiving low-dose steroids. 50.4 % received low-dose steroids for their septic shock. Patients in Europe (59.4 %) and South America (51.9 %) were more likely to be prescribed low-dose steroids than those in North America (46.2 %, p < 0.001). The adjusted hospital mortality was significantly higher (OR 1.18; 95 % CI 1.09–1.23, p < 0.001) in those receiving low-dose steroids., including an association with increased adjusted hospital mortality even if they were prescribed within 8 h (OR 1.23, 95 % CI 1.13–1.34, p < 0.001).

Abstract:  Casserly. Low-dose steroids in adult septic shock: results of the Surviving Sepsis Campaign. Intensive Care Med 2012; epublished ahead of print


Critical Care:    Renal Replacement Therapy

Wald et al performed a multicentre open-label parallel-group pilot randomized trial of CVVH versus CVVHD, with a small solute clearance of 35 mL/kg/hour in both arms, in 78 critically ill adults with AKI and hemodynamic instability. SOFA tended to decline more over the first week in CVVH recipients (-0.8, 95% CI -2.1, +0.5) driven by a reduction in vasopressor requirements. Mortality (54% CVVH; 55% CVVHD) and dialysis dependence in survivors (24% CVVH; 19% CVVHD) at 60 days were similar.

Full Text:  Wald. Optimal Mode of clearance in critically ill patients with Acute Kidney Injury (OMAKI) - a pilot randomized controlled trial of hemofiltration versus hemodialysis: a Canadian Critical Care Trials Group project. Critical Care 2012;16:R205


Interactive Cardiovascular Thoracic Surgery

Nosotti performed a retrospective review of 11 patients treated with extracorporeal membrane oxygenation as a bridge to transplantation, and compared outcomes in those receiving invasive mechanical ventilation (n=4) and those receiving ECMO with non-invasive ventilation (n=7). The mean age was 33.9 ± 13.2 years with 5 being male. 6 patients were affected by cystic fibrosis, 2 had chronic rejection after transplantation, 2 had pulmonary fibrosis and 1 had systemic sclerosis. Both groups were similar at baseline. The sequential organ failure assessment score significantly increased during bridging time and this increase was significantly higher in the intubated patients. All the patients had bilateral lung transplantation. Spontaneously breathing patients showed a tendency to require a shorter duration of invasive mechanical ventilation, intensive care unit stay and hospital stay after transplantation. One-year survival rate was 85.7% in patients with spontaneous breathing vs 50% in patients with invasive mechanical ventilation.

Full Text:  Nosotti. Extracorporeal membrane oxygenation with spontaneous breathing as a bridge to lung transplantation. Interact CardioVasc Thorac Surg 2012 epublished 24 October


Critical Care:     ECMO

To determine the long term outcome and quality of life of patients with ARDS receiving extracorporeal membrane oxygenation for refractory hypoxemia, Hodgson and colleagues performed a retrospective review with prospective health related quality of life (HRQoL) assessment. Of 21 ARDS patients, with a mean age of 36 years, there were 18 survivors. Eighteen (86%) patients were retrieved from external intensive care units (ICUs) by a dedicated ECMO retrieval team. Eleven (55%) had H1N1 influenza A-associated pneumonitis. Eighteen (86%) patients survived to hospital discharge. Of the 18 survivors, ten (56%) were discharged to other hospitals and 8 (44%) were discharged directly home. Sequelae and health related quality of life were evaluated for 15 of the 18 (71%) long-term survivors (assessment at median 8 months). Mean SF-36 scores were significantly lower across all domains compared to age and sex matched Australian norms. Mean SF-36 scores were lower (minimum important difference at least 5 points) than previously described ARDS survivors in the domains of general health, mental health, vitality and social function. One patient had long-term disability as a result of ICU acquired weakness. Only 26% of survivors had returned to previous work levels at the time of follow-up.

Full Text:  Hodgson. Long-term quality of life in patients with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation for refractory hypoxaemia. Critical Care 2012;16:R202


Cochrane Reviews

Cochrane Reviews:     Fast-Track Cardiac Surgery

Zhu et al completed an updated systematc review and meta analysis to asess the effectiveness of fast-track cardiac surgery. The fast-track interventions were the administration of low-dose opioid based general anaesthesia during surgery, and post-surgery, early extubation and the use of a time-directed extubation protocol. Twenty-five trials involving 4118 patients were identified. Although there were high levels of heterogeneity, both low-dose opioid anaesthesia and the use of time-directed extubation protocols were associated with reductions in the time to extubation (3.0 to 10.5 hours) and in the length of stay in the intensive care unit (0.4 to 8.7 hours). However, these fast-track care interventions were not associated with reductions in the total length of stay in hospital.


Cochrane Reviews:     Traumatic Brain Injury

Ma and colleagues performed a systematic review and meta analysis, identifying 3 randomised controlled trials (n=315) comparing progesterone versus no progesterone (or placebo) for the treatment of acute TBI. The pooled risk ratio for mortality at end of follow-up was 0.61 (95% CI: 0.40 to 0.93). The relative risk of death or severe disability in patients treated with progesterone to be 0.77 (95% CI 0.62 to 0.96). The authors concluded that further research, including multi-centre randomized controlled trials, are needed to confirm these findings.



Journal of the American Medical Association:    Fungal Meningitis Outbreak

Review - Clinical

Canadian Journal of Anaesthesia:     Massive transfusion

Tuberculosis and Respiratory Diseases:     Critical Care Papers


British Journal of Anaesthesia:     Postpartum Haemorrhage


Clinical Pharmacology: Advances and Applications:     Sedation


Critical Care Research and Practice:     Brain Injury


Clinical Molecular Hepatology:     Drug-Induced Liver Injury


International Journal of Hepatology:     Hepatic Encephalopathy


Swiss Medical Weekly:     Clinical Reasoning


Asian Journal of Pharmaceutics:     Drug Delivery Systems


Clinical Cardiology:     Aldosterone Receptor Antagonists


Medicina Intensiva:     Haemolytic Uraemic Syndrome


Medicina Intensiva:     ARDS


Circulation:     Optical Coherence Tomography

ISRN Rheumatology:     Cardiac Complications


Lung India:     Leptospirosis


Lung India:     Clubbing


Journal of Neurochemistry:     Transcranial Doppler Ultrasound


Journal of Neurochemistry:     Stroke


Journal of Neurochemistry:     Subarachnoid Haemorrhage



I hope you find links and these brief summaries useful.

Until next week