ccr logo 246x225 13121Critical Care Reviews Newsletter

August 26th 2012





Welcome to the 38th Critical Care Reviews Newsletter. Every week over three hundred clinical and scientific journals are monitored and the most important and interesting research publications in critical care are highlighted. These studies are added to the Current Articles section of the website on a daily basis, as publication occurs. A link to either the full text or abstract, depending on the publishers degree of open access, is attached. Also, links to other important papers, such as guidelines or consensus statements are included. Free review articles from across the medical literature are also highlighted.

This week's newsletter is enormous, containing 7 research articles, 1 consensus statement and 38 free review articles. The standout paper is a meta analysis from Transfusion, suggesting increased mortality from older red cells.  The latest universal definition of myocardial infarction is published and a wide range of review articles from numerous journals are included.

The focus for This Week's Papers is biomarkers, starting with a review of biomarkers post cardiac arrest in Paper of the Day.



Transfusion:  Age of Transfused Red Cells

Wang et al performed a meta analysis to determine the effect of age of transfused red cells.  21 studies were identified (n=409,966). Older blood was associated with a significantly increased risk of death (odds ratio, 1.16; 95% CI: 1.07-1.24). It was estimated that 97 patients (95% CI: 63-199) would need to be treated with only new blood to save one life. The increased risk was not restricted to a particular type of patient, size of trial, or amount of blood transfused.

Abstract:  Wang. Transfusion of older stored blood and risk of death: a meta-analysis.Transfusion 2012;52(6):1184-95


PLoS One:     ARDS Ventilation

McMullan and the Canadian Critical Care Trials Group perfomed a meta analysis to assess the effects of partial ventilatory support on mortality, duration of mechanical ventilation, and both hospital and intensive care unit lengths of stay (LOS) for patients with ALI and ARDS. Two randomized controlled trials, six prospective cohort studies, one retrospective cohort study, one case control study, 41 clinical physiologic studies and 28 pre-clinical studies were identified. Although no study was powered to assess mortality, one RCT showed shorter ICU length of stay, and the other demonstrated more ventilator free days. Beneficial effects of preserved spontaneous breathing were mainly physiological effects demonstrated as improvement of gas exchange, hemodynamics and non-pulmonary organ perfusion and function.

Full Text:  McMullen. Partial Ventilatory Support Modalities in Acute Lung Injury and Acute Respiratory Distress Syndrome-A Systematic Review. PLoS One 2012;7(8):e40190


Intensive Care Medicine:     Fluid Responsiveness

Sandroni et al performed a sysematic review and meta-analysis to assess the accuracy of the variation in pulse oxymetry plethysmographic waveform amplitude (∆POP) and the Pleth Variability Index (PVI) as predictors of fluid responsiveness in mechanically ventilated adults. Ten studies totalling 233 patients were identified. The pooled area under receiver operating characteristic curve (AUC) for identification of fluid responders was 0.85 (95% CI: 0.79–0.92), with the pooled sensitivity and specificity being 0.80 (95% CI: 0.74–0.85) and 0.76 (95% CI 0.68–0.82), respectively. Studies using a large bolus, in contrast to those using a small bolus, had a greater AUC [0.92 (95% CI: 0.87–0.96) vs. 0.70 (95% CI: 0.62–0.79); p < 0.0001], with specificity [AUC 0.86 (95% CI: 0.75–0.93) vs. 0.68 (95% CI: 0.56–0.77), p = 0.02], but not sensitivity [AUC 0.84 (95% CI: 0.77–0.90) vs. 0.72 (95% CI: 0.60–0.82), p = 0.08], being higher in large bolus versus small bolus studies, respectively.

Abstract:  Sandroni. Accuracy of plethysmographic indices as predictors of fluid responsiveness in mechanically ventilated adults: a systematic review and meta-analysis. Intensive Care Med 2012;38(9):1429-1437


Critical Care Medicine:    Rapid Response Team

Howell et al performed a time interuppted series analysis on 171,341 consecutive patients to determine whether rapid-response system that relied on a patient’s usual care providers, rather than critical-care–trained rapid-response team, would improve patient outcomes. The unadjusted risk of unexpected mortality was 72% lower (95% CI 55%–83%) in the intervention period (absolute risk: 0.02% vs. 0.09%, p < 0.0001). The unadjusted in-hospital mortality rate was not significantly lower (1.9% vs. 2.1%, p = .07). After adjustment for age, gender, race, season of admission, case mix, Charlson Comorbidity Index, and intensive care unit bed capacity, the intervention period was associated with an 80% reduction (95% CI 63%–89%, p < 0.0001) in the odds of unexpected death, but no significant change in overall mortality [odds ratio 0.91 (95% CI 0.82–1.02), p = 0.09]. Analyses that also adjusted for secular time trends confirmed these findings (relative risk reduction for unexpected mortality at end of intervention period: 65%, p = 0.0001; for in-hospital mortality, relative risk reduction = 5%, p = 0.2).

Abstract: Howell. Sustained effectiveness of a primary-team–based rapid response system. Critical Care Medicine 2012;40(9):2562–2568


Intensive Care Medicine:     Traumatic Aortic Injury

Using a retrospectively derived cohort (aortic injury n=76, no aortic injury n=304) and a subsequent validation cohort (aortic injury n=52, no aortic injury n=208 ) Mosquera generated a prediction model for the identification of traumatic aortic injury. Using logistic regression, predictors of aortic injury included widened mediastinum, hypotension less than 90 mmHg, long bone fracture, pulmonary contusion, left scapula fracture, hemothorax, and pelvic fracture. The area under receiver operating characteristic curve (AUC) was 0.96. In the  derivation data set, sensitivity was 93.42%, specificity 85.85%, Youden’s index 0.79, positive likelihood ratio 6.60, and negative likelihood ratio 0.08. In the validation data set, sensitivity was 92.31% and specificity 85.1%.

Thibon et al performed a randomized controlled multicenter trial in 434 patients comparing the effects of 80% (n=226) with 30% (n=208) oxygen therapy on the frequency of surgical site infections in routine abdominal, gynecologic, and breast surgery. There was no difference between the two groups for baseline, intraoperative, and postoperative characteristics, except for oxygen saturation at closure, being higher in the 80% group (P = 0.01). There was no difference in 30-day surgical site infection rate  {30% group: 7.2% (15/208)  vs 80% group: 6.6% (15/226) (RR: 0.92; 95% CI: 0.46–1.84, P = 0.81} or adverse events including nausea and vomiting, sternal pain, cough, hypotension. Desaturation and bradycardia were more frequent in the 30% group. In an updated meta-analysis including the result of this trial and those of eight published randomized trials, the overall relative risk was 0.97; 95% CI 0.68–1.40.

Abstract:  Thibon. Effect of Perioperative Oxygen Supplementation on 30-day Surgical Site Infection Rate in Abdominal, Gynecologic, and Breast Surgery: The ISO2 Randomized Controlled Trial. Anesthesiology 2012;117(3):504–511


Critical Care Medicine:     Fluid Therapy

Bayer et al compared the the effects of different fluids therapies (hydroxyethyl starch n = 360, gelatin n = 352, only crystalloids n = 334) on time to shock reversal (serum lactate <2.2 mmol/L and discontinuation of vasopressor use). There were no differences in time to shock reversal, severity scores, hospital length of stay, intensive care unit or hospital mortality. More fluid was needed over the first 4 days in the crystalloid group (fluid ratios 1.4:1 [crystalloids to hydroxyethyl starch] and 1.1:1 [crystalloids to gelatin]). After day 5, fluid balance was more negative in the crystalloid group. Hydroxyethyl starch and gelatin were independent risk factors for acute kidney injury (odds ratio 95% CI 2.55, 1.76-3.69 and 1.85, 1.31-2.62, respectively). Patients receiving synthetic colloids received significantly more allogeneic blood products.

Bayer. Effects of fluid resuscitation with synthetic colloids or crystalloids alone on shock reversal, fluid balance, and patient outcomes in patients with severe sepsis: A prospective sequential analysis. Crit Care Med. 2012 Sep;40(9):2543-2551.


Consensus Statement

Circulation:     Myocardial Infarction

Full Text: Thygesen,on behalf of the Joint ESC/ACCF/AHA/WHF Task Force for the Universal Definition of Myocardial Infarction. Third Universal Definition of Myocardial Infarction.Circulation epublished 24 August 2012


Review - Clinical

Critical Care Research and Practice:     ARDS


Critical Care Research and Practice:     Sepsis


Current Biomarker Findings:     Hepatotoxicity


Lung India:     Haemoptysis


Nephrology Times:     Sepsis


Canadian Journal of Anaesthesia:     Acute Kidney Injury


Current Opinion in Critical Care:     Sepsis

Journal of Trauma and Acute Care Surgery:     Immunosuppression


Clinical Pharmacology and Therapeutics:     Hepatic Encephalopathy


New England Journal of Medicine:     HIV


Frontiers in Immunology:     Polymyxins

European Heart Journal: Acute Cardiovascular Care:     Myocardial Ischaemia


European Heart Journal: Acute Cardiovascular Care:     Prosthetic Heart Valve Obstruction


European Heart Journal: Acute Cardiovascular Care:     Lactate


Digestive Diseases and Sciences:     Probiotics / Synbiotics


Anaesthesiology:     Home NIV


JRSM:Cardiovascular Disease    Adrenomedullin


Clinical Cardiology:     Cardiac Arrest


Clinical Cardiology:     Computed Tomography


Journal of the Intensive Care Society:     Fluids


Journal of the Intensive Care Society:     Outreach


Swiss Medical Weekly:     Malignant Hyperthermia


Swiss Medical Weekly:     Reactive Oxygen Species


Swiss Medical Weekly:     Acute Renal Failure


Journal of the Intensive Care Society:     Lung Water


Journal of the Intensive Care Society:     ICU Acquired Weakness


Journal of the Intensive Care Society:     Decompressive Craniectomy


Journal of the Intensive Care Society:     Cervical Spine Clearance


Journal of the Intensive Care Society:     ECCO2R


Journal of the Intensive Care Society:     COPD


Circulation: Cardiovascular Genetics:     Circulatory Biomarkers


Review - Basic Science

 Journal of Antimicrobial Chemotherapy:     Anti-Microbial Therapy


Review - Non-Clinical

Annals of Intensive Care:     Crew Resource Management


Anaesthesiology:     Leaders


Trials:     Drug Safety in Clinical Trials


Trials:     Randomized Controlled Trials



I hope you find these links and brief summaries useful.

Until next week