Newsletter 102 / November 17th 2013




Welcome to the 102th 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. In news, the UK Intensive Care Society have released core standards for the staffing and management of the intensive care unit.

This week's research studies include randomized controlled trials investigating ultrasound-assisted catheter-directed thrombolysis in pulmonary embolism, recombinant Factor XIII administration in cardiac surgery, post-operative non-invasive ventilation, oesophageal Doppler-guided fluid administration in gynaecological surgery and laryngoscope choice for placement of double-lumen endotracheal tubes. Meta analyses examine respiratory support in cardiogenic pulmonary oedema, oesophageal Doppler-guided fluid administration in colorectal surgery and ECMO complications. Observational studies look at non-invasive ventilation in the managment of acute hypoxaemic respiratory failure, the bioreactance (NICOM) cardiac output monitor, ultrasound confirmation of endotracheal tube placement, post cardiac arrest fever, and fluid responsiveness, as well as several other non-featured studies.

This week's guidelines address exercise tolerance, cardiovascular risk, myocardial infarction plus the Durban Declaration on the basic principles of the delivery of care to the critically ill. There is a critique on the 2013 Surviving Sepsis Campaign Guidelines as well as multiple commentaries and a couple of editiorials.

Amongst the clinical review articles are papers on delayed cerebral ischaemia, acute coronary syndrome, hypercapnoea, artificial nutrition, end-stage liver disease, acute kidney injury biomarkers, antithrombotic therapy, necrotizing fasciitis and gentamicin. Non-clinical review articles include papers on adverse outcomes in anaesthesia and qualitative research.

The topic for This Week's Papers is infective endocarditis, starting with a general paper on this topic in tomorrow's Paper of the Day.

If you only have time to read one paper, try this excellent paper from Sjöberg on oxygen use.

If you need a break from all the critical care reading, you could try a general interest article from Nature on the risk of massive asteroid strike.




Critical Care Reviews Meeting January 24th, 2014 - Belfast, Northern Ireland

  • If you are in Ireland or Great Britain (or a short flight away), Critical Care Reviews will be hosting it's second meeting outside Belfast, Northern Ireland. It's an all-day event with a fantastic programme consisting of local intensivists, local non-critical care specialists, and outstanding international guest speakers. Registration is now open.


SMACC GOLD March 19-21st, 2014 Gold Coast, Queensland, Australia

  • This major international conference, also in it's second year, is a must for those active in the online critical care community. Webmasters of the most prominent critical care websites and blogs will descend on the beautiful Gold Coast for an amazing get together of like-minded people in a totally different style of conference. The deadline for abstracts is this Friday.



The UK Intensive Care Society has released Core Standards for the  staffing and management of the Intensive Care Unit.



Randomized Controlled Trials

Circulation:     Pulmonary Embolism

Kucher and colleagues completed a multicenter, randomized controlled trial in 59 patients with acute main or lower lobe pulmonary embolism and echocardiographic right-to-left ventricular dimension ratio ≥1.0, comparing unfractionated heparin plus an ultrasound-assisted catheter-directed thrombolysis regimen of 10-20 mg rt-PA over 15 hours (USAT group, N = 30) with unfractionated heparin alone (n=29), and found:

  1. for the mean right ventricle/left ventricle ratio
    • USAT group: a decrease from 1.28±0.19 to 0.99±0.17 at 24 hours (p<0.001)
    • heparin group: no change 1.20±0.14 to 1.17±0.20 (p=0.31)
    • a larger decrease with USAT (0.30±0.20 versus 0.03±0.16; p<0.001)
  2. at 90 days
    • one death in the heparin group
    • no major bleeding,
    • 4 minor bleeds (3 in the USAT group versus 1 in the heparin group; p=0.61)
    • no recurrent VTE

Abstract:  Kucher. Randomized Controlled Trial of Ultrasound-Assisted Catheter-Directed Thrombolysis for Acute Intermediate-Risk Pulmonary Embolism. Circulation 2013;epublished November 13th


Journal of Thoracic & Cardiovascuar Surgery:     Recombinant Factor XIII

Karouti et al undertook a double-blinded, placebo-controlled, multicenter trial in 409 cardiac surgical patients at moderate risk for transfusion, evaulating replenishment of FXIII levels 17.5 IU/kg (n = 143), 35 IU/kg (n = 138), or placebo (n = 128) after cardiopulmonary bypass, and found:

  1. at baseline
    • comparable group characteristics
    • approximately 40% decrease in FXIII levels after cardiopulmonary bypass.
  2. 30 minutes postdose, FXIII levels were restored to higher than the lower 2.5th percentile of preoperative activity in
    • placebo group: 49%
    • 17.5 IU/kg recombinant FXIII groups:  85% (P<0.05 versus placebo)
    • 35-IU/kg recombinant FXIII groups:     95%   (P<0.05 versus placebo)
  3. transfusion avoidance rates
    • placebo group:  64.8%,
    • 17.5 IU/kg recombinant FXIII groups:  64.3%  (odds ratios against placebo 1.05, 95% CI 0.61-1.80)
    • 35-IU/kg recombinant FXIII groups: 65.9% (odds ratios against placebo 0.99, 95% CI 0.57-1.72)
  4. groups had comparable adverse event rates

Abstract:  Karkouti. Efficacy and safety of recombinant factor XIII on reducing blood transfusions in cardiac surgery: a randomized, placebo-controlled, multicenter clinical trial. J Thorac Cardiovasc Surg 2013;146(4):927-39


Journal of Thoracic & Cardiovascuar Surgery:     Post-Operative NIV

Al Jaaly and colleagues performed a parallel group, randomized controlled trial, comparing bilevel positive airway pressure (n=66) with usual care (n=63) in 129 patients post coronary artery bypass grafting, and found:

  1. median duration of BiPAP of 16 hours (IQR 11-19)
  2. median duration of hospital stay until fit for discharge
    • BiPAP: 5 days (IQR 4-6)
    • usual care: 6 days (IQR 5-7)
    • hazard ratio 1.68; 95% CI 1.08-2.31; P=0.019
  3. no significant difference in
    • duration of ICU stay
    • duration of actual postoperative stay
    • mean percentage of predicted FEV1 on day 3
  4. mean partial pressure of carbon dioxide was
    • reduced after 1 hour of BiPAP 
    • no inter-group difference at 24 hours
  5. basal atelectasis occurred in
    • BiPAP group: 2 patients (3%)
    • usual care group: 15 patients (24%)
  6. adverse events occurred in
    • BiPAP group: 30%
    • usual care group: 59%

Abstract:   Al Jaaly. Effect of adding postoperative noninvasive ventilation to usual care to prevent pulmonary complications in patients undergoing coronary artery bypass grafting: a randomized controlled trial. J Thorac Cardiovasc Surg. 2013;146(4):912-8


Anaesthesia:     Oesophageal Doppler-Guided Fluid Administration

McKenny et al completed a single centre, evaluator-blinded study comparing intra-operative oesophageal Doppler monitor-guided fluid management (n=51) with standard intra-operative fluid management based on conventional haemodynamic indices (n=50) in major elective open gynaecological surgery, and found:

  1. no difference in
    • length of postoperative hospital stay until ready for discharge {median (IQR [range])}
      • ODM: 6 (5–8 [4–25]) days
      • control: 7 (5–9 [4–42]) (P = 0.5) 
    • postoperative morbidity survey scores on postoperative days 1, 3 or 5
    • postoperative complications
      • ODM: 7 patients
      • control:  11 patients (P = 0.41)

Abstract:  McKenny. A randomised prospective trial of intra-operative oesophageal Doppler-guided fluid administration in major gynaecological surgery. Anaesthesia 2013;68:1224–1231


Anaesthesia:     Double-Lumen Tube Placement

Russell et al compared the Macintosh laryngoscope with the GlideScope® for double-lumen tube endobronchial intubation by 30 anaesthetists in 70 patients with no predictors for difficult laryngoscopy, and found:

  1. quicker intubation with the Macintosh laryngoscope {median (IQR [range])}
    • 33 (22–52 [11–438]) s vs 70 (39–129 [21–242]) s, respectively, p = 0.0013
  2. no difference in first attempt success rate
    • 91% vs 83%, respectively
  3. easier intubation with the Macintosh laryngoscope, as rated by the anaesthetists
    • 2 (1–3 [0–8]) vs 3 (2–6 [0–10], respectively, p = 0.003
  4. less postoperative voice changes with Macintosh laryngoscopy
    • 8 (22%) vs 17 (58%), p = 0.045

Abstract:  Russell. A randomised controlled trial comparing the GlideScope® and the Macintosh laryngoscope for double-lumen endobronchial intubation. Anaesthesia 2013;68:1253–1258 


Meta Analysis

American Journal of Emergency Medicine:     Cardiogenic Pulmonary Oedema

Li and colleagues pooled data from 12 randomized controlled trials (n=1,433), comparing continuous positive airway pressure with bilevel positive airway pressure for the treatment of acute cardiogenic pulmonary edema, and found:

  1. no difference in
    • hospital mortality (RR 0.86; 95% CI 0.65 to 1.14; P = 0.46; I2 = 0%)
    • requirement for invasive ventilation (RR 0.89; 95% CI 0.57 to 1.38; P = 0.64; I2 = 0%)
    • myocardial infarction (RR 0.95; 95% CI 0.77 to 1.17; P = 0.53, I2 = 0%)
    • length of hospital stay (RR 1.01; 95% CI −0.40 to 2.41; P = 0.98; I2 = 0%)

Abstract:  Li. A comparison of bilevel and continuous positive airway pressure noninvasive ventilation in acute cardiogenic pulmonary edema. Am J Emerg Med 2013;31(9):1322-7 


British Journal of Surgery:     Oesophageal Doppler-Guided Fluid Administration

Srinivasa and colleagues completed a systematic review and meta-analysis of six high-quality randomized trials (n=691) examining oesophageal Doppler monitor guided fluid management in major colorectal surgery, and found:

  1. ODM-guided fluid therapy, in comparison with standard therapy, had no effect on:
    • incidence of complications (odds ratio 0·74, 95% CI 0·50 to 1·11; P = 0·15; I2 = 33%; P = 0·19)
    • mean length of stay (mean difference −0·88 days, 95% CI –2·89 to 1·13 days; P = 0·39)
    • regardless of whether ODM-guided fluid therapy was compared with fluid restriction or used within an otherwise optimized perioperative environment

Abstract:  Srinivasa. Systematic review and meta-analysis of oesophageal Doppler-guided fluid management in colorectal surgery. Br J Surg 2013;100:1701–1708


The Annals of Thoracic Surgery:     ECMO

Cheng et al pooled 20 studies (n=1,866) evaluating the use of extracorporeal membrane oxygenation in the management of cardiogenic shock or cardiac arrest in adult patients, and found:

  1. survival to hospital discharge (17 studies)
    • cumulative survival rate of 35% (534 of 1,529)
    • range of 20.8% to 65.4%
  2. ECMO was associated with multiple comorbidities
    • lower extremity ischemia (16.9%, 95% CI 12.5% to 22.6%)
    • fasciotomy or compartment syndrome (10.3%, 95% CI 7.3% to 14.5%)
    • lower extremity amputation (4.7%, 95% CI 2.3% to 9.3%)
    • stroke (5.9%, 95% CI 4.2% to 8.3%)
    • neurologic complications (13.3%, 95% CI 9.9% to 17.7%)
    • acute kidney injury (55.6%, 95% CI 35.5% to 74.0%)
    • renal replacement therapy (46.0%, 95% CI 36.7% to 55.5%)
    • major or significant bleeding (40.8%, 95% CI 26.8% to 56.6%)
    • rethoracotomy for bleeding or tamponade in postcardiotomy patients (41.9%, 95% CI 24.3% to 61.8%) 
    • significant infection (30.4%, 95% CI 19.5% to 44.0%)

Abstract:  Cheng. Complications of Extracorporeal Membrane Oxygenation for Treatment of Cardiogenic Shock and Cardiac Arrest: A Meta-Analysis of 1,866 Adult Patients. Annals Thor Surg 2013;epublished November 11th


Observational Studies

Critical Care:    Non-Invasive Respiratory Failure

Thille et al completed a single centre cohort study in 113 patients examining non-invasive ventilation in the managment of acute hypoxaemic respiratory failure, and found:

  1. Incidence of ARDS
    • ARDS:  82 patients 
    • non-ARDS:  31 patients
  2. Intubation rates differed 
    • presence of ARDS (P = 0.015)
      • ARDS:  61%
      • non-ARDS: 35% 
    • severity of ARDS (P = 0.0016)
      • mild: 31% 
      • moderate: 62%
      • severe: 84% 
  3. ICU mortality (P=0.22)
    • non-ARDS: 13% 
    • mild ARDS: 19%,
    • moderate ARDS: 32% 
    • severe ARDS: 32% 
  4. among patients with moderate ARDS, NIV failure was lower among those having a PaO2/FiO2 >150 mmHg (45% vs. 74%, p=0.04)
  5. NIV failure was associated with active cancer, shock, moderate/severe ARDS, lower Glasgow coma score and lower positive end-expiratory pressure level at NIV initiation
  6. among intubated patients, ICU mortality rate was 46% overall and did not differ according to the time to intubation

Abstract:  Thille. Non-invasive ventilation for acute hypoxemic respiratory failure: intubation rate and risk factors. Critical Care 2013;17:R269 


British Journal of Anaesthesia:     Bioreactance Cardiac Output Monitoring

Kupersztych-Hagege evaluated the non-invasive bioreactance cardiac output monitor (NICOM) against a PiCCO device (transpulmonary thermodilution), in 48 critically ill patients, and found:

  1. following a passive leg raise manouvere, followed by a 500ml saline challenge (n=144)
    • poor agreement in cardiac index measurement
    • bias (lower and upper limits of agreement) between CItd and CINicom was 0.9 (−2.2 to 4.1) litre min−1 m−2
    • percentage error 82%
    • no significant correlation between the changes in CItd and CINicom induced by volume expansion (P=0.24)
  2. an increase in cardiac index estimated by pulse contour analysis >9% during a passive leg raise manouvere predicted fluid responsiveness
    • sensitivity of 84% (95% CI 60–97%) 
    • specificity of 97% (95% CI 82–100%)
  3. the AUC of the ROC curve constructed to test the ability of the PLR-induced changes in CINicom in predicting fluid responsiveness did not differ significantly from 0.5 (P=0.77)

Abstract:  Kupersztych-Hagege. Bioreactance is not reliable for estimating cardiac output and the effects of passive leg raising in critically ill patients Br J Anaesth 2013;111(6):961-966 


Resuscitation:     Endotracheal Tube Placement Confirmation

Cho et al completed a prospective observational study of 89 patients undergoing emergency intubation during CPR, using real-time tracheal ultrasonography during intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation, and found:

  1. oesophageal intubation occurred in 7 patients (7.8%)
  2. the test characterisitics for tracheal ultrasonograph were
    • sensitivity 100% (95% CI 94.4 100%)
    • specificity  85.7% (95% CI 42.0 to 99.2%)
    • positive predictive value 98.8% (95% CI 92.5 to 99.0%)
    • negative predictive value 100% (95% CI 54.7 to 100%), respectively
    • positive likelihood ratios 7.0 (95% CI 1.1 to 43.0) and 0.0, respectively
    • negative likelihood ratios  0.0

Abstract:  Cho. Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation. Resuscitation 2013;84(12):1708-1712    


Resuscitation:     Post-Cardiac Arrest Fever

Bro-Jeppese and colleagues evauated a large consecutive cohort of comatose survivors (n=270) after out-of-hospital cardiac arrest (OHCA) treated with therapeutic hypothermia (32–34°C), stratified into two groups by median peak temperature (≥38.5°C) within 36h after rewarming, and found:

  1. post-hypothermia fever (≥38.5°C) compared with no fever, was associated with
    • increased 30-days mortality
      • 36% versus 22%, plog-rank=0.02
      • adjusted hazard rate 1.8, 95% CI 1.1 to 2.7; P=0.02
    • independent predictors of 30-day mortality in multivariable models
      • maximum temperature (aHR2.0 per °C above 36.5°C, 95% CI 1.4 to 3.0, P=0.0005)
      • duration of post-hypothermia fever (aHR1.6 per 8h, 95% CI 1.3 to 2.0, P<0.0001)
    • worse ratio of good neurological outcome (Cerebral Performance Category 1-2) to unfavourable outcome (Cerebral Performance Category 3-5) at hospital discharge
      • post-hypothermia fever group 61% vs. 39%
      • non post-hypothermia fever 75% vs. 25% (P=0.02)

Abstract:  Bro-Jeppese. Post-hypothermia fever is associated with increased mortality after out-of-hospital cardiac arrest. Resuscitation 2013;84(12):1734-1740


Acta Anaesthesiologica Scandinavica:     Fluid Responsiveness

In 20 mechanically ventilated patients with septic shock, a decrease in mean arterial pressure in response to an elevation in positive end-expiratory pressure, from 10 cm H2O to 20 cm H2O during an end-expiratory pause, was predictive of fluid responsiveness. The best cut-off value of ΔMAP for clinical use was –8%, with a negative predictive value for fluid responsiveness of 100%.

Abstract:  Wilkman. Fluid responsiveness predicted by elevation of PEEP in patients with septic shock. Acta Anaesthesiologica Scandinavica 2013;epublished November 11th


Other Studies of Interest

British Journal of Anaesthesia:     High-Flow Nasal Oxygen

Abstract:  Parke. Open-label, phase II study of routine high-flow nasal oxygen therapy in cardiac surgical patients.  Br J Anaesth 2013;111(6):925-931


Journal of Critical Care:     Renal Replacement Therapy

Abstract:  Bagshaw. Association between renal replacement therapy in critically ill patients with severe acute kidney injury and mortality. Journal of Critical Care 2013;28(6):1011-1018 


Critical Care:     Antimicrobial Therapy

Abstract:  Adrie. Initial use of one or two antibiotics for critically ill patients with community-acquired pneumonia: impact on survival and bacterial resistance. Critical Care 2013;17:R265


PLoS One:     Thirst

Full Text:  Siami. Thirst Perception and Osmoregulation of Vasopressin Secretion Are Altered During Recovery From Septic Shock. PLoS ONE 2013;8(11):e80190


Journal of Critical Care:     Post-Pyloric Feeding

Abstract:  Kohata. A novel method of post-pyloric feeding tube placement at bedside. Journal of Critical Care 2013;28(6):1039-1041  


Journal of Critical Care:     Stewartonian Acid-Base Analysis

Abstract:  Moviat. Stewart analysis of apparently normal acid-base state in the critically ill. Journal of Critical Care 2013;28(6):1048-1054


Intensive Care Medicine:     Delirium Screening

Abstract:  Haenggi. Effect of sedation level on the prevalence of delirium when assessed with CAM-ICU and ICDSC. Intensive Care Medicine 2013;39(12):2171-2179


Resuscitation:     Post-Cardiac Arrest Curarization

Abstract:  Salciccioli. Continuous neuromuscular blockade is associated with decreased mortality in post-cardiac arrest patients. Resuscitation 2013;84(12):1728-1733


Guideline & Position Statement

Journal of the American College of Cardiology:     Cardiovascular Risk


Circulation:     Exercise Tolerance


Journal of Critical Care:     Durban Declaration


Guideline Critique

Critical Care:     Surviving Sepsis Campaign


Intensive Care Medicine:     Intra-Abdominal Candidiasis


Lancet Neurology:     Traumatic Brain Injury



Journal of the American Medical Association:     Hypertension


Lancet Neurology:     Traumatic Brain Injury


Antimicrobial Agents & Chemotherapy:     MRSA


Canadian Medical Association Journal:     Clinical Notes


Journal of Medical Physics:     Impact Factor


Journal of the American Medical Association:     Discharges Against Medical Advice 


Interactive CardioVascular Thoracic Surgery:     Haemoptysis


Interactive CardioVascular Thoracic Surgery:     Chest Radiographs


Interactive CardioVascular Thoracic Surgery:     Contrast-Induced Nephropathy


Nature:     Statistical Significance


Review - Clinical





Circulation:     Renal Denervation









Southern African Journal of Anaesthesia and Analgesia:     Anaesthesia Adverse Outcomes


Indian Journal of Medical Sciences:     Qualitative Research


General Interest

Nature:     Asteroid Strike



I hope you find these brief summaries and links useful.

Until next week