Newsletter 117 / March 2nd 2014
Welcome to the 117th 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, guidelines, commentaries and editorials from hundreds of clinical and scientific journals.
This week's research studies include randomized controlled trials on dexmedetomidine during non-invasive ventilation, vasopressin and corticosteroids in septic shock, contrast-induced nephropathy and caspofungin prophylaxis; meta analyses address hydrocortisone for septic shock, delirium interventions in the critically ill, anti-TNFα therapy in sepsis and ICP monitoring in traumatic brain injury; while observational studies focus on stress ulcer prophylaxis plus lung recruitment in ARDS. There are also several other additional studies of interest.
There are two guidelines this week, including a multi-societal, and endorsed by ESICM, paper on hyponatraemia, as well as a Korean paper on influenza. One study critique looks at the TTM study, while editorials also address temperature management, consent to publish and medical reversal. Commentaries focus on influenza, tolvaptan, subcutaneous emphysema and testosterone. Amongst the clinical review articles are papers on sugammadex, stroke thrombolysis, intracranial hypertension, serelaxin, both cardiology and respiratory updates from 2013, contrast-induced nephropathy, micafungin, and metamphetamine abuse. One non-clinical review article discusses the role of revalidation in Australia.
The beginning of each month marks the addition of recently made open access articles from the major critical care journals, with the latest papers from the American Journal of Respiratory and Critical Care Medicine, Chest, Critical Care, Anesthesiology, Anesthesia & Analgesia, British Journal of Anaesthesia, Anaesthesia, and Anaesthesia and Intensive Care all added.
The topic for This Week's Papers is recreational drug toxicity, starting with a paper on opioid toxicity in tomorrow's Paper of the Day.
It's just two weeks to SMACCgold, the biggest critical care conference in the Southern Hemisphere. If you're coming along, there are a number of workshops the day before the main meeting starts, including one on Evidence-Based Medicine, being run by Simon Carley and Rick Body from Manchester, England, with me helping out. Simon and Rick have been busy, and have posted pre-course material on their excellent St. Emlyns blog. Check out Simon and Rick's other website, BestBETs, to learn how to perform a pragmatic appraisal of the evidence to answer a specific clinical question. If you want to improve your ability to appraise the literature, understand statisitcs and improve your journal club, then this is the workshop to attend. We're hoping each attendee will be able to produce an evidence-based appraisal that might just get published! Of course, the day before the workshop is St Patricks Day, where SMACCgold becomes SMACCgreen - it promises to be fun. Follow on twitter (@critcarereviews) for the latest news and I'll tweet whatever is planned. I hope to see you on the Gold Coast, Queensland, Australia. Be sure to say hi.
FFICM Exam
Earlier this week I gave a Hot Topics talk at the National FFICM Preparation Course in London. Both references and slides of a collection of most know research papers and guidelines from 2013 and 2012 are available here.
Devlin and colleagues completed a double blind, randomized, placebo-controlled trial, investigating the efficacy and safety of dexmedetomidine (n=16), in the presence of protocolized midazolam and fentanyl sedation, for non-invasive ventilation in 33 patients with early acute respiratory failure, and found:
dexmedetomidine was associated with
no improvement in
NIV tolerance (OR=1.44; 95% CI 0.44 to 4.70, p=0.54)
percentage time tolerating NIV (dex: 99 hr (61-100) vs. placebo: 67 (40-100); p=0.56)
time at desired sedation level (SAS=3 or 4) (dex: 100 hr (86-100) vs. placebo: 100 (100-100); p=0.28)
avoidance of intubation
total duration of ventilation
severe bradycardia
duration of non-invasive ventilation
Abstract: Devlin. Efficacy and Safety of Early Dexmedetomidine during Non-Invasive Ventilation for Patients with Acute Respiratory Failure: A Randomized, Double-Blind, Placebo-Controlled, Pilot Study. Chest 2014;epublished February 27th
Gordon and colleagues undertook a multi-centre, open-label, randomized controlled pilot trial, in 61 patients with septic shock, evaluating the addition of IV hydrocortisone (50 mg 6 hourly, n=31) or placebo (n=30) to a vasopressin infusion (titrated up to 0.06 U/min), examining for an interaction between vasopressin and corticosteroids in septic shock, and found:
hydrocortisone therapy was associated with a
shorter duration of vasopressin therapy (difference 3.1 d; 95% CI 1.1 to 5.1)
lower total dose of vasopressin (ratio 0.47; 95% CI 0.32 to 0.71)
there was no difference in
plasma vasopressin levels (hydrocortisone group +64 pmol/L difference at 6- to 12-hour time point; 95% CI -32 to 160 pmol/L)
28 day mortality rate (23% both groups)
vasopressin use was well tolerated
Abstract: Gordon. The Interaction of Vasopressin and Corticosteroids in Septic Shock: A Pilot Randomized Controlled Trial. Crit Care Med 2014;2014 February 19th
Kooiman and colleagues performed an noninferiority, open-label, multicentre randomized trial in 570 adults (intention-to-treat n=548) with chronic kidney disease, comparing 250 mL of 1.4% sodium bicarbonate hydration with 1000 mL of 0.9% saline hydration prior to intravenous contrast CT, and found:
sodium bicarbonate therapy was associated with
a smaller relative increase in serum creatinine
1.2% vs 1.5%; mean difference −0.3%; 95% CI −2.7 to 2.1, P-value for non-inferiority <0.0001
reduced hydration costs per patient
€224 versus €683; P < 0.001
contrast-induced acute kidney injury
sodium bicarbonate: n=8 (3.0%) versus saline: 14 (5.1%); P = 0.23
need for dialysis
n=0 both groups
renal recovery
sodium bicarbonate: 75% versus saline: 69%; P = 0.81
other healthcare costs
Abstract: Kooiman. A randomized comparison of 1-h sodium bicarbonate hydration versus standard peri-procedural saline hydration in patients with chronic kidney disease undergoing intravenous contrast-enhanced computerized tomography. Nephrol Dial Transplant 2014;epublished February 27th
Ostrosky-Zeichner and colleagues undertook a multicenter, randomized, double-blind, placebo-controlled trial of caspofungin as either pre-emptive or prophylactic antifungal therapy in 222 patients at risk for invasive candidiasis, and found:
including patients with baseline disease
prophylactic caspofungin was associated with
no reduction in the incidence of proven/probable invasive candidiasis
placebo: 16.7% (14/84) versus caspofungin 9.8% (10/102); (P = 0.14)
pre-emptive caspofungin was associated with
reduced incidence of proven/probable invasive candidiasis
placebo: 30.4% (31/102) versus caspofungin 18.8% (22/117); (P = 0.04)
there were no significant differences in secondary endpoints:
antifungal use
Abstract: Ostrosky-Zeichner. A Randomized, Double-Blind, Placebo-Controlled Trial of Caspofungin Prophylaxis Followed by Preemptive Therapy for Invasive Candidiasis in High-Risk Adults in the Critical Care Setting. Clin Infect Dis 2014;epublished February 18th
Meta Analysis
Wang et al pooled data from 8 randomized controlled trials, investigating the efficacy of low-dose hydrocortisone therapy in septic shock, and found:
low-dose hydrocortisone therapy did not reduce 28-day mortality
n=1063; odds ratio 0.891, 95% CI 0.69 to 1.15
low-dose hydrocortisone therapy ameliorated shock at
6 RCTs, n=964, OR 2.078, 95% CI 1.58 to 2.73, P < 0.0001, I2 = 26.9%
6 RCTs, n=947, OR 1.495, 95% CI 1.12 to 1.99, P = 0.006, I2 = 0.0%
Abstract: Wang. Low-Dose Hydrocortisone Therapy Attenuates Septic Shock in Adult Patients but Does Not Reduce 28-Day Mortality: A Meta-Analysis of Randomized Controlled Trials. Anesth Analg 2014;118(2):346–357
Al-Qadheeb reviewed data from 17 trials (n=2,849) examining whether interventions that are effective at reducing the duration of delirium are associated with a reduction in short-term mortality, and found:
delirium duration was
lower in the intervention groups
difference 0.64 day; 95% CI -1.15 to -0.13; p = 0.01
reduced by ≥ 3 days in three studies
0.1 to < 3 days in six studies
0 day in seven studies
< 0 day in one study
short-term mortality was not reduced in 13 studies reporting this outcome
risk ratio 0.90; 95% CI 0.76 to 1.06; p = 0.19
delirium duration was not associated with reduced short-term mortality (p = 0.11)
the interventions studied were:
pharmacological studies (n=13)
dexmedetomidine, 6 studies
antipsychotics, 4 studies
rivastigmine, 2 studies
clonidine, 1 study
multimodal intervention
spontaneous awakening, 2 studies
nonpharmacologic intervention
early mobilization, 1 study
increased perfusion, 1 study
Abstract: Al-Qadheeb. Randomized ICU Trials Do Not Demonstrate an Association Between Interventions That Reduce Delirium Duration and Short-Term Mortality: A Systematic Review and Meta-Analysis. Crit Care Med 2014;epublished February 19th
Lv pooled data from 17 studies (n=8,971) comparing anti-TNF-α therapies with placebo in patients with severe sepsis or septic shock, and found:
anti-TNF-α therapy was associated with
reductions in
28-day all-cause mortality (OR = 0.91, 95% CI 0.83 to 0.99; p = 0.04)
including subgroups of anti-TNF-α antibodies (monoclonal and polyclonal) (OR 0.90, 95% CI 0.81 to 0.99; p = 0.04)
improved survival with
monoclonal antibodies (OR 0.91, 95% CI 0.82 to 1.00; p = 0.05)
no improved survival with
polyclonal antibodies (OR 0.71, 95% CI 0.39 to 1.28, p = 0.25)
receptor blockers (OR 0.95, 95% CI 0.78 to 1.17, p = 0.65)
there was no publication bias or statistical heterogeneity; (I2 < 50%, p > 0.1)
sensitivity analysis suggested results were highly stable
Abstract: Lv. Anti-TNF-α therapy for patients with sepsis: a systematic meta-analysis. International Journal of Clinical Practice 2014;epublished February 18th
Su et al pooled data from two randomized controlled trials and seven cohort studies (n=11,038) investigating the efficacy and safety of intracranial pressure monitoring in patients with traumatic brain injury, and found:
ICP monitoring was not associated with
mortality reduction
OR 1.16; 95% CI 0.87 to 1.54, I2 80%, P<0.00001
unfavourable outcome
OR 1.40; 95% CI 0.99 to 1.98; I2 = 4%, P = 0.35
advese events
OR 1.04; 95% CI, 0.64 to 1.70; I2 = 78%, P = 0.03
Full Text: Su. The Effects of Intracranial Pressure Monitoring in Patients with Traumatic Brain Injury. PLoS ONE 2014;9(2):e87432
Observational Studies
Wang and colleagues completed a large pharmacoepidemiological cohort study (71 hospitals, n=35,312) comparing histamine-2 receptor antagonists (n=13 439, 38.1%) with proton pump inhibitors (21 873, 61.9%) in adult patients requiring mechanical ventilation for ≥ 24 hours , and found:
histamine-2 receptor antagonists were associated with less
gastrointestinal hemorrhage (2.1% vs 5.9%; P < 0.001)
pneumonia (27% vs 38.6%; P < 0.001)
Clostridium difficile infection (2.2% vs 3.8%; P < .001)
after adjusting for propensity score and covariates, histamine-2 receptor antagonists remained associated with less
GI hemorrhage (odds ratio 2.24; 95% CI, 1.81-2.76)
pneumonia (OR 1.2; 95% CI, 1.03-1.41)
Clostridium difficile infection (OR 1.29; 95% CI, 1.04-1.64)
similar results were obtained in the propensity-matched models of 8,799 patients in each cohort
Abstract: Wang. Histamine-2 Receptor Antagonists vs Proton Pump Inhibitors on Gastrointestinal Tract Hemorrhage and Maclaren. Infectious Complications in the Intensive Care Unit. JAMA Intern Med 2014;epublished February 17th
Liu and colleagues performed a prospective, single-center study investigating the efficacy of a lung recruitment maneuver (30 cmH2O for 60 seconds) with high-level positive end-expiratory pressure in 84 hypoxic (SpO2 < 88% for > 30 minutes) patients with 2009 influenza A (H1N1)-associated ARDS, and found:
after the recruitment maneuver,
40 patients (47.6%) had an increase (≥3%) in SpO2 (the responder group)
44 patients (52.4%) had no increase (<3%) in SpO2 (the nonresponder group)
SpO2 response was associated with
7/40 vs 18/ 44; P = 0.019
duration of mechanical ventilation (P = 0.011)
a lower initial PEEP level (P = 0.028)
higher initial dynamic lung-thorax compliance (P = 0.038)
Full Text: Liu. Efficacy of Lung Recruitment Maneuver with High-Level Positive End-Expiratory Pressure in Patients with Influenza-Associated Acute Respiratory Distress: A Single-Center Prospective Study. Curr Ther Res Clin Exp 2013;75:83–87
Additional Studies
Full Text: Aiken. Nurse staffing and education and hospital mortality in nine European countries: a retrospective observational study. Lancet 2014;epublished February 26th (free registration required)
Abstract: Suzuki. Conservative Oxygen Therapy in Mechanically Ventilated Patients: A Pilot Before-and-After Trial. Crit Care Med 2014;epublished February 20th
Abstract: Quraishi. Prospective Study of Vitamin D Status at Initiation of Care in Critically Ill Surgical Patients and Risk of 90-Day Mortality. Crit Care Med 2014;epublished February 19th
Abstract: Sutter. Anesthetic drugs in status epilepticus: Risk or rescue? A 6-year cohort study. Neurology 2014;82(8):656-664
Abstract: Sherwood. Patterns and Outcomes of Red Blood Cell Transfusion in Patients Undergoing Percutaneous Coronary Intervention. JAMA 2014;311(8):836-843
Abstract: Al-Alwan. Cardiopulmonary resuscitation among mechanically ventilated patients. Intensive Care Med 2014;epublished February 26th
Abstract: Louis. Correlation of Missed Doses of Enoxaparin With Increased Incidence of Deep Vein Thrombosis in Trauma and General Surgery Patients. JAMA Surg 2014;epublished February 26th
Spasovski. Clinical practice guideline on diagnosis and treatment of hyponatraemia. Nephrol Dial Transplant 2014;0:1–39
Choi. Severe influenza treatment guideline. Korean J Intern Med Jan;29(1):132–147
Study Critique
Rolston. Is It Still Cool to Cool? Interpreting the Latest Hypothermia for Cardiac Arrest Trial. Annals of Emergency Medicine 2014;63(3):368-369
Original Study: Nielsen. Targeted Temperature Management at 33°C versus 36°C after Cardiac Arrest. N Engl J Med 2013;369:2197-2206
Dickerson. Yesterday, today and tomorrow in Targeted Temperature Management. African Journal of Emergency Medicine 2014;4(10):3–5
Bryson. Back to the future: medical reversals and perioperative medicine. Can J Anesth 2014;61:215–219
Fletcher. Consent to publish is a matter of trust. CMAJ 2014;epublished February 24th
Napolitano. Critically Ill Patients With Influenza A(H1N1)pdm09 Virus Infection in 2014. JAMA 2014;epublished February 24th
Chirinos. Systemic Arterial Hemodynamics and the "Renal Resistive Index:" What is in a Name?. The Journal of Clinical Hypertension 2014;epublished February 19th
Johnson. In patients with extensive subcutaneous emphysema, which technique achieves maximal clinical resolution: infraclavicular incisions, subcutaneous drain insertion or suction on in situ chest drain? Interact CardioVasc Thorac Surg 2014;epublished February 26th
Dohi. Immediate and Short-Term Use of Tolvaptan for Acute Decompensated Heart Failure. Circ J 2014;epublished February 27th
Wolfe. Increased heart attacks in men using testosterone: the UK importantly lags far behind the US in prescribing testosterone. BMJ 2014;348:g1789
Friedman. Becoming a Clinician-Educator: Lessons Learned. Gastroenterology 2014;146(3):599-601
Ladizinski. Vanishing Lung Syndrome. N Engl J Med 2014;370:e14
Clinical Review Articles
Lobaz. Safety and Efficacy of Sugammadex for Neuromuscular Blockade Reversal. Clinical Medicine Insights: Therapeutics 2014;6:1–14
Chapman. Current perspectives on the use of intravenous recombinant tissue plasminogen activator (tPA) for treatment of acute ischemic stroke. Vascular Health and Risk Management. 2014;2014(10):75-87
Kalladka. Brain repair: cell therapy in stroke. Stem Cells and Cloning: Advances and Applications 2014;;7:31-44
Bithal. Anaesthetic considerations for evoked potentials monitoring. J Neuroanaesthesiol Crit Care 2014;1:2-12
Umamaheswara Rao. Translational research in neuroanaesthesia. J Neuroanaesthesiol Crit Care 2014;1:13-9
Abraham. Protecting the anaesthetised brain. J Neuroanaesthesiol Crit Care 2014;1:20-39
Alvis-Miranda. Traumatic cerebral contusion: pathobiology and critical aspects. Romanian Neurosurgery 2014;20(2):125–137
Iencean. Classification of the intracranial hypertension and characteristics of intracranial pressure increase. Romanian Neurosurgery 2014;20(4):319–326
Iencean. Rational management of intracranial hypertension. Romanian Neurosurgery 2013;20(1):22–28
Iencean. Emergency treatment principles in intracranial hypertension. Romanian Neurosurgery 2014;20(1):29–33
Du. Therapeutic Effects of Serelaxin in Acute Heart Failure – Necessity for Bilateral Research Translation. Circ J 2014;78:542–552
Liu. Heart failure highlights in 2012–2013. European Journal of Heart Failure 2014;16:122–132
Meier. Almanac 2013: acute coronary syndromes. Seminars in Cardiovascular Medicine 2013;19:30–38
Liew. Almanac 2013: cardiac arrhythmias and pacing. Seminars in Cardiovascular Medicine 2013;19:39-52
Clark. Almanac 2013: heart failure. Seminars in Cardiovascular Medicine 2013;19:53-59
Meier. Almanac 2013: novel non-coronary cardiac interventions. Seminars in Cardiovascular Medicine 2013;19:60-71
Islam. Almanac 2013: stable coronary artery disease. Seminars in Cardiovascular Medicine 2013;19:72-80
Samet. The Surgeon Generals' Reports and Respiratory Diseases. From 1964 to 2014. Annals of the American Thoracic Society 2014;11(2):141-148
Piper. Year in review 2013: Acute lung injury, interstitial lung diseases, sleep and physiology. Respirology 2014;epublished February 21st
Ko. Year in review 2013: Chronic obstructive pulmonary disease, asthma and airway biology. Respirology 2014;epublished February 21st
Leung. Year in review 2013: Lung cancer, respiratory infections, tuberculosis, cystic fibrosis, pleural diseases, bronchoscopic intervention and imaging. Respirology 2014;epublished February 21st
Pattharanitima. Pharmacological Strategies to Prevent Contrast-Induced Acute Kidney Injury. BioMed Research International 2014;2014:236930
Gornik. Duplex Ultrasound in the Diagnosis of Lower-Extremity Deep Venous Thrombosis. Circulation 2014;129:917-921
Ahens. Clinical utility of rivaroxaban in stroke prevention associated with nonvalvular atrial fibrillation – patient considerations. Journal of Blood Medicine 2014;5:25-30
de la Torre. Micafungin: an evidence-based review of its place in therapy. Core Evidence 2014;9:27-39
Krolikowski. Methamphetamine and MDMA: 'Safe' drugs of abuse. African Journal of Emergency Medicine 2014;4:34-38
Ghooi. Institutional review boards: Challenges and opportunities. Perspect Clin Res 2014;5:60-5
Walanj. Research ethics committees: Need for harmonization at the national level, the global and Indian perspective. Perspect Clin Res 2014;5:66-70
Recently Made Open Access Articles from Major Journals
American Journal of Respiratory and Critical Care Medicine
Weibel. It Takes More than Cells to Make a Good Lung. Am J Respir Crit Care Med 2013;187(4):342-346
Brouwer. Regenerative Medicine for the Respiratory System. Am J Respir Crit Care Med 2013;187(5):468-475
Crouser. A Rare Glimpse behind the Mask of Sepsis-induced Organ Failures Provides Hope for an Eventual Cure. Am J Respir Crit Care Med 2013;187(5):460-462
Blum. United States Critical Illness and Injury Trials Group. Chest 2013;143(3):808-813
Vij. Diagnosis and Treatment of Connective Tissue Disease-Associated Interstitial Lung Disease. Chest 2013;143(3):814-824
Maclay. Cardiovascular Disease in COPD: Mechanisms. Chest 2013;143(3):798-807
Glen. Beyond Belief. Chest 2013;143(3):e1-e4
McCarthy. Integrating Advanced Practice Providers Into Medical Critical Care Teams. Chest 2013;143(3):847-850
Painter. Critical Care in the Surgical Global Period. Chest 2013;143(3):851-855
Manaker. Who Will Care for Our Critically Ill? Chest 2013;143(3):594-595
Overgaard-Steensen. Practical approach to hyponatraemia and hypernatraemia in critically ill patients. Critical Care 2012;17:206
Hodgson.Early patient mobilization in the ICU. Critical Care 2012;17:207
Moonesinghe. Risk Stratification Tools for Predicting Morbidity and Mortality in Adult Patients Undergoing Major Surgery: Qualitative Systematic Review. Anesthesiology 2013;119(4):959–981
Anesthesia & Analgesia
Zheng. Cerebral Near-Infrared Spectroscopy Monitoring and Neurologic Outcomes in Adult Cardiac Surgery Patients: A Systematic Review. Anesth Analg 2013;116(3):663-676
Anaesthesia & Intensive Care
Balushi. The clinical role of glutamine supplementation in patients with multiple trauma: a narrative review. Anaesth Intensive Care 2013;41:24-34 (free registration required)
Holley. Frozen blood products: clinically effective and potentially ideal for remote Australia. Anaesth Intensive Care 2013;41:10-19 (free registration required)
Isbister. Frozen blood: time for outcomes. Anaesth Intensive Care 2013;41:5-7 (free registration required)
Non-Clinical Review Articles
Breen. Revalidation — what is the problem and what are the possible solutions? Med J Aust 2014;200(3):153-156