Critical Care Reviews Newsletter

April 22nd 2012



Welcome to the 20th 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.



New England Journal of Medicine:     Coronary Revascularization

Using 2 data bases of revascularization records, Weintraub et al performed an observational study comparing outcomes in patients aged 65 years or older who had two-vessel or three-vessel coronary artery disease without acute myocardial infarction, and who  underwent CABG (n=86,244) or underwent PCI (n=103,549). At 1 year, there was no significant difference in adjusted mortality between the groups (CABG group 6.24% vs  PCI group 6.55%; risk ratio, 0.95; 95% CI, 0.90 to 1.00). At 4 years, there was lower mortality with CABG than with PCI (16.4% vs. 20.8%; risk ratio, 0.79; 95% CI, 0.76 to 0.82). Similar results were noted in multiple subgroups and with the use of several different analytic methods.

Abstract: Weintraub. Comparative Effectiveness of Revascularization Strategies. N Engl J Med 2012;366:1467-1476


New England Journal of Medicine:      CABG

In an international, phase III randomized controlled trial, Lamy and colleagues assigned 4752 patients in whom CABG was planned to undergo the procedure off-pump or on-pump. There was no significant difference in the rate of the primary composite outcome of death, nonfatal stroke, nonfatal myocardial infarction, or new renal failure requiring dialysis at 30 days after randomization, (off-pump 9.8% vs on-pump CABG 10.3%; hazard ratio for the off-pump group, 0.95; 95% CI, 0.79 to 1.14; P=0.59) or in any of its individual components. The use of off-pump CABG, as compared with on-pump CABG, significantly reduced the rates of blood-product transfusion (50.7% vs. 63.3%; relative risk, 0.80; 95% CI, 0.75 to 0.85; P<0.001), reoperation for perioperative bleeding (1.4% vs. 2.4%; relative risk, 0.61; 95% CI, 0.40 to 0.93; P=0.02), acute kidney injury (28.0% vs. 32.1%; relative risk, 0.87; 95% CI, 0.80 to 0.96; P=0.01), and respiratory complications (5.9% vs. 7.5%; relative risk, 0.79; 95% CI, 0.63 to 0.98; P=0.03) but increased the rate of early repeat revascularizations (0.7% vs. 0.2%; hazard ratio, 4.01; 95% CI, 1.34 to 12.0; P=0.01).

Abstract: Lamy. Off-Pump or On-Pump Coronary-Artery Bypass Grafting at 30 Days (CORONARY Study). N Engl J Med 2012;366:1467-1476


JAMA:    Pre-Hospital Trauma Transfer

To assess the association between the use of helicopter vs ground services and survival among adults with serious traumatic injuries, Galvagno et al performed a retrospective cohort study utilizing the 2007-2009 versions of the American College of Surgeons National Trauma Data Bank. A total of 61,909 patients were transported by helicopter and 161,566 patients were transported by ground. Overall, 7,813 patients (12.6%) transported by helicopter died compared with 17,775 patients (11%) transported by ground services. In the propensity score–matched multivariable regression model, for patients transported to level I trauma centers, helicopter transport was associated with an improved odds of survival compared with ground transport (OR, 1.16; 95% CI, 1.14-1.17; P < .001; absolute risk reduction [ARR], 1.5%). For patients transported to level II trauma centers, helicopter transport was associated with an improved odds of survival (OR, 1.15; 95% CI, 1.13-1.17; P < .001; ARR, 1.4%). A greater proportion (18.2%) of those transported to level I trauma centers by helicopter were discharged to rehabilitation compared with 12.7% transported by ground services (P < .001), and 9.3% transported by helicopter were discharged to intermediate facilities compared with 6.5% by ground services (P < .001).

Abstract: Galvagno. Association Between Helicopter vs Ground Emergency Medical Services and Survival for Adults With Major Trauma. JAMA 2012; 307:1602-1610


American Journal of Respiratory and Critical Care Medicine:     Aspergillus Diagnosis

To externally validate a clinical algorithm to discriminate Aspergillus colonization from putative invasive pulmonary aspergillosis, Blot and colleagues undertook a multicentre (n=30) observational study including critically ill patients with ≥1 Aspergillus-positive endotracheal aspirate culture (n=524). The algorithm had a specificity of 61% and a sensitivity of 92%. The positive and negative predictive values were 61% and 92% respectively.

Abstract: Blot. A Clinical Algorithm to Diagnose Invasive Pulmonary Aspergillosis in Critically Ill Patients. Am J Respir Crit Care Med 2012; epublished ahead of print


Nephrology Dialysis & Transplantation:     Renal Replacement Therapy

In a prospective, randomized, controlled single-centre study, Skofic and colleagues compared mortality and recovery of renal function between intermittent high-volume predilution on-line haemofiltration (HF) and standard intermittent haemodialysis (HD) in 273 critically ill adult patients with acute kidney injury. All-cause mortality by day 60 was 65.0% in the HF group and 65.5% in the HD group (hazard ratio, 0.98; 95% CI, 0.71–1.33; P = 0.87). There were also no significant differences between the two groups in 30-day and in-hospital all-cause mortality or recovery of kidney function. Time to kidney function recovery and the number of required dialysis procedures were similar between the HF and the HD subgroup of patients with in-hospital recovery of kidney function.

Full Text: Skofic. Intermittent high-volume predilution on-line haemofiltration versus standard intermittent haemodialysis in critically ill patients with acute kidney injury: a prospective randomized study.Nephrol Dial Transplant 2012 epublished ahead of print


Cochrane Reviews

Authors' conclusions: There is inadequate evidence to draw strong conclusions on the efficacy or safety of the drug interventions included in this review. There is some low quality evidence from a meta-analysis of two studies investigating urokinase (various strengths) and some very low evidence from two single studies investigating alteplase 2 mg/2 mL that suggest that these two drug interventions may be effective in treating withdrawal or total occlusion of CVC lumens caused by thrombosis. Further high quality, sufficiently powered research is still required to look at the efficacy and safety of urokinase, alteplase and other chemical, surgical and drug interventions for treating CVC lumen occlusion. Research studies which exclusively include child participants are especially warranted.


Author's Conclusion: We are, based on this review, unable to make any recommendations for the use of glucocorticoids in the treatment of anaphylaxis.


Author's Conclusion: The existing evidence supports the use of restrictive transfusion triggers in most patients including those with pre-existing cardiovascular disease. As there are no trials, the effects of restrictive transfusion triggers in high risk groups such as acute coronary syndrome need to be tested in further large clinical trials. In countries with inadequate screening of donor blood, the data may constitute a stronger basis for avoiding transfusion with allogeneic red cells.


Authors' conclusions: Subclavian and internal jugular CVA routes have similar risks for catheter-related complications in long-term catheterization in cancer patients. Subclavian CVA is preferable to femoral CVA in short-term catheterization because of lower risks of catheter colonization and thrombotic complications. In short-term haemodialysis catheterization, femoral and internal jugular CVA routes have similar risks for catheter-related complications except internal jugular CVA routes are associated with higher risks of mechanical complications.



Current Opinion in Critical Care:     Consciousness Assessment


Antioxidants & Redox Signalling:     H2S


Postgraduate Medical Journal:     Pulmonary Hypertension


Journal of the Saudi Heart Association:     Diastolic Dysfunction


Cardiology:     Troponin


European Heart Journal Cardiovascular Imaging:     Optical coherence imaging


Critical Care Research and Practice:    Traumatic Brain Injury



I hope you find this newsletter useful.

Until next week