Critical Care Reviews Newsletter

May 9th 2012



Welcome to the 22nd Critical Care Reviews Newsletter. Every week over two 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 Journal Watch 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.

Apologies for the late delivery of this week's Newsletter.



New England Journal of Medicine


Annals of Intensive Care


International Journal of Critical Illness and Injury Science


Israeli Medical Association Journal


Cardiology Research & Practice


Clinical Kidney Journal


Thrombosis and Haemostasis



Intensive Care Medicine:     Sepsis Biomarkers

Rosjo et al used the FINNSEPSIS dataset to assess the prognostic information of chromogranin A (CgA), a marker associated with adrenergic tone and myocardial function, in 232 patients with severe sepsis. CgA levels at inclusion and after 72 h correlated with several established indices of risk in sepsis. Patients who died during the hospitalization had higher baseline CgA levels than hospital survivors: 14.0 (Q1–3, 7.4–27.4) versus 9.1 (5.9–15.8) nmol/l, P = 0.002, and after 72 h: 16.2 (9.0–31.1) versus 9.8 (6.0–18.0) nmol/l, P = 0.001. CgA levels on study inclusion and after 72 h were independently associated with hospital mortality by logistic regression: OR (logarithmically transformed CgA levels) 1.95 (95 % CI 1.01–3.77), P = 0.046 and OR 2.03 (95 % CI 1.18–3.49), P = 0.01, respectively.

Abstract: Rosjo. Prognostic value of chromogranin A in severe sepsis: data from the FINNSEPSIS study. Intensive Care Med 2012;38(5):820-829.


Intensive Care Medicine:     Patient Volume

In asystematic review, Kanhere investigated the influence of patient volume affect clinical outcomes in adult intensive care units. Thirteen studies including 596,259 patients across 1,068 ICU were identified. The authors concluded that outcomes of certain subsets of ICU patients—especially those on mechanical ventilation, high-risk patients, and patients with severe sepsis—are better in high volume centres within the constraints of risk adjustments.

Abstract: Kanhere. Does patient volume affect clinical outcomes in adult intensive care units? Intensive Care Med 2012;38(5):741-751


Journal of Intensive Care Medicine:     Vasopressors for Septic Shock

In a systematic review and meta-analysis Vasu et al compared the effects of noradrenaline with dopamine for the treatment of septic shock. They identifed 6 studies totaling 2043 participants, with 995 in the norepinephrine and 1048 in the dopamine groups. There were 479 (48%) deaths in the norepinephrine group and 555 (53%) deaths in the dopamine group. Noradrenaline was associated with a lower in-hospital or 28-day mortality: pooled relative risk: 0.91 (95% CI 0.83 to 0.99; P = .028); and also a lower rate of cardiac arrhythmias: pooled RR: 0.43 (95% CI 0.26 to 0.69; P ≤ .001).

Abstract: Vasu. Norepinephrine or Dopamine for Septic Shock. Systematic Review of Randomized Clinical Trials. J Intensive Care Med 2012;27(3):172-178


JAMA:     GKI Infusions in Out-of-Hospital Acute Coronary Syndromes

In a randomized, placebo-controlled, double-blind effectiveness study in 13 US cities, Selker et al compared the effectivness of glucose-insulin-potassium infusion (GIK) (n=411) versus placebo (n=460) in out-of-hospital acute coronary syndromes. There was no difference in the rate of progression to MI among patients who received GIK (odds ratio [OR], 0.88; 95% CI, 0.66-1.13; P = .28); or 30 day mortality (hazard ratio [HR], 0.72; 95% CI, 0.40-1.29; P = .27). The composite of cardiac arrest or in-hospital mortality occurred in 4.4% with GIK vs 8.7% with placebo (OR, 0.48; 95% CI, 0.27-0.85; P = .01). Among patients with ST-segment elevation, there was no difference in progression to MI (OR, 0.74; 95% CI, 0.40-1.38; P = .34); or 30-day mortality (HR, 0.63; 95% CI, 0.27-1.49; P = .29). The composite outcome of cardiac arrest or in-hospital mortality was 6.1% with GIK vs 14.4% with placebo (OR, 0.39; 95% CI, 0.18-0.82; P = .01). Serious adverse events did not differ between the 2 groups (P = .26).

Abstract: Selker. Out-of-Hospital Administration of Intravenous Glucose-Insulin-Potassium in Patients With Suspected Acute Coronary Syndromes. The IMMEDIATE Randomized Controlled Trial. JAMA 2012;307(1):1925-1933


Cochrane Review:     Coronary Artery Bypass Grafting

Møller and colleagues performed a systematic review and meta analysis comparing the effects of on-pump versus off-pump coronary artery bypass grafting (CABG). The study included 86 trials, totaling 10,716 participants.  Pooled analysis of all trials showed that off-pump CABG increased all-cause mortality compared with on-pump CABG (189/5,180 (3.7%) versus 160/5144 (3.1%); RR 1.24, 95% CI 1.01 to 1.53; P =.04). In the trials at low risk of bias the effect was corroborated (154/2,485 (6.2%) versus 113/2,465 (4.5%), RR 1.35,95% CI 1.07 to 1.70; P =.01). Off-pump CABG resulted in fewer distal anastomoses (mean difference -0.28; 95% CI -0.40 to -0.16, P <.00001). No significant differences in myocardial infarction, stroke, renal insufficiency, or coronary re-intervention were observed. Off-pump CABG reduced post-operative atrial fibrillation compared with on-pump CABG, however, in trials at low risk of bias, the estimated effect was not significantly different.

Full Text: Møller. Off-pump versus on-pump coronary artery bypass grafting for ischaemic heart disease. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD007224.


Cochrane Review:     Intra-Aortic Balloon Pump for MI complicated by Cardiogenic Shock

In a systematic review Unverzagt identified 3 studies comparing IABP to standard treatment and 3 to percutaneous left assist devices (LVAD). Data from a total of 190 patients with acute myocardial infarction and cardiogenic shock were included in the meta-analysis: 105 patients were treated with IABP and 85 patients served as controls, 40 of whom had assist devices and 45 with LVADs. The hazard ratio for all-cause 30-day mortality was 1.04 (95% CI 0.62 to 1.73) and provides no evidence for a survival benefit. The authors concluded that the available evidence suggests that IABP may have a beneficial effect on haemodynamics, however there is no convincing randomised data to support the use of IABP in infarct related cardiogenic shock.

Full Text: Unverzagt. Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock. Cochrane Database of Systematic Reviews 2011, Issue 7. Art. No.: CD007398.


Critical Care:     Delirium

In a randomized controlled trial Van Rompaey compared the use of night-time ear plugs (n=69) with no ear plugs (n=67) on the (1) development of delirium or confusion and (2) the quality of sleep in the critically ill. The group sleeping with ear plugs had a lower delirium scores  with a median NEECHAM score of 26 (95% CI: 5 to 29) versus the control group 24 (95% CI: 8 to 29) (Mann-Whitney U, P = 0.04). Although the incidence of delirium was similar between the two groups (earplugs: 19% vs no earplugs 20%), when a composite score for delirium and confusion was used 60% of the control group showed cognitive disturbances against only 35% in the study group. Survival analysis showed a strong benefit for the prevention of cognitive disturbances in favor of the earplugs within the first 24 hours (Wilcoxon log rank, P = 0.006) and Cox regression showed the use of earplugs decreased the risk of delirium or confusion by 53% (HR .0.47, CI 0.27 to 0.82). Although patients with earplugs reported better sleep quality on the first study night, this benefit was lost on the second night and reversed on the third night. The generalizability of the study was limited by most subjects staying only 1 night in the ICU.

Full Text: Van Rompaey. The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients. Critical Care 2012, 16:R73


Critical Care:     Brain Natriuretic Peptide

In a systematic review and meta analysis of 12 studies, totaling 1,865 patients, investigating the prediction of BNP or NT-proBNP for mortality in sepsis, Wang et al found raised levels  of natriuretic peptides were  associated with increased mortality (odds ratio (OR) 8.65, 95% CI 4.94 to 15.13, P < 0.00001). The association was consistent for BNP (OR 10.44, 95% CI 4.99 to 21.58, P < 0.00001) and NT-proBNP (OR 6.62, 95% CI 2.68 to 16.34, P < 0.0001). The pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were 79% (95% CI 75 to 83), 60% (95% CI 57 to 62), 2.27 (95% CI 1.83 to 2.81) and 0.32 (95% CI 0.22 to 0.46),

Full Text: Wang. Brain natriuretic peptide for prediction of mortality in patients with sepsis: a systematic review and meta-analysis.Critical Care 2012;16:R74


Annals of Internal Medicine:     Clinical Decision-Support Systems

In a systematic review totalling 148 studies, the authors investigated the effect of clinical decision-support systems and concluded that both commercially and locally developed CDSSs are effective at improving health care process measures across diverse settings, but evidence for clinical, economic, workload, and efficiency outcomes remains sparse.

Full Text: Bright. Effect of Clinical Decision-Support Systems: A Systematic Review. Ann Intern Med 2012; epublished ahead of print 


Critical Care:     Acute Lung Injury

Full Text: Tuinman. Nebulized anticoagulants for acute lung injury - a systematic review of pre-clinical and clinical investigations.Critical Care 2012,16:R70



I hope you find these links and brief summaries useful.

Until next week