Critical Care Reviews Newsletter 461 12th October 2020

The Critical Care Reviews Newsletter, brings you the best critical care research and open access articles from across the medical literature over the past seven days.
“The highlights of this week’s edition are randomised controlled trials on tranexamic acid for prehospital trauma; the final report of the ACTT-1 Study, investigating remdesivir for the treatment of Covid-19, and the latest two results from the RECOVERY platform trial investigating therapies for COVID-19 hydroxychloroquine and lopinavir–ritonavir; systematic reviews and meta analyses on ECMO for severe ARDS and intravenous thiamine for septic shock; and observational studies on left ventricular unloading in cardiogenic shock treated with veno-arterial ECMO and pressure injuries in adult intensive care unit patients.
There are also guidelines on post-cardiotomy extracorporeal life support & acute kidney injury biomarkers; narrative reviews on human albumin solutions & acute kidney injury in COVID-19; and commentaries on why corticosteroid therapy reduces mortality in severe COVID-19 and why critically ill status is not a carte blanche for unlimited antibiotic use.”
The full text of this newsletter is freely available via this link

High-Flow Oxygen with Capping or Suctioning for Tracheostomy Decannulation

This article by Hernandez Martinez and others was first published in the New England Journal of Medicine in October 2020.
Background:  When patients with a tracheostomy tube reach a stage in their care at which decannulation appears to be possible, it is common practice to cap the tracheostomy tube for 24 hours to see whether they can breathe on their own. Whether this approach to establishing patient readiness for decannulation leads to better outcomes than one based on the frequency of airway suctioning is unclear.
Methods:  In five intensive care units (ICUs), we enrolled conscious, critically ill adults who had a tracheostomy tube; patients were eligible after weaning from mechanical ventilation. In this unblinded trial, patients were randomly assigned either to undergo a 24-hour capping trial plus intermittent high-flow oxygen therapy (control group) or to receive continuous high-flow oxygen therapy with frequency of suctioning being the indicator of readiness for decannulation (intervention group). The primary outcome was the time to decannulation, compared by means of the log-rank test. Secondary outcomes included decannulation failure, weaning failure, respiratory infections, sepsis, multiorgan failure, durations of stay in the ICU and hospital, and deaths in the ICU and hospital.
Results:  The trial included 330 patients; the mean (±SD) age of the patients was 58.3±15.1 years, and 68.2% of the patients were men. A total of 161 patients were assigned to the control group and 169 to the intervention group. The time to decannulation was shorter in the intervention group than in the control group (median, 6 days [interquartile range, 5 to 7] vs. 13 days [interquartile range, 11 to 14]; absolute difference, 7 days [95% confidence interval, 5 to 9]). The incidence of pneumonia and tracheobronchitis was lower, and the duration of stay in the hospital shorter, in the intervention group than in the control group. Other secondary outcomes were similar in the two groups.
Conclusions:  Basing the decision to decannulate on suctioning frequency plus continuous high-flow oxygen therapy rather than on 24-hour capping trials plus intermittent high-flow oxygen therapy reduced the time to decannulation, with no evidence of a between-group difference in the incidence of decannulation failure.
The paper copy of the New England Journal of Medicine is available in the Healthcare Library on D Level of Rotherham Hospital.

In-hospital cardiac arrest in critically ill patients with covid-19: multicenter cohort study

This research by the STOP-COVID Investigators was published in the BMJ during September 2020.
Objectives:  To estimate the incidence, risk factors, and outcomes associated with in-hospital cardiac arrest and cardiopulmonary resuscitation in critically ill adults with coronavirus disease 2019 (covid-19).
Design:  Multicenter cohort study.
Setting:  Intensive care units at 68 geographically diverse hospitals across the USA.
Participants:  Critically ill adults (age ≥18 years) with laboratory confirmed covid-19.
Main Outcome Measures:  In-hospital cardiac arrest within 14 days of admission to an intensive care unit and in-hospital mortality.
Results:  Among 5019 critically ill patients with covid-19, 14.0% (701/5019) had in-hospital cardiac arrest, 57.1% (400/701) of whom received cardiopulmonary resuscitation. Patients who had in-hospital cardiac arrest were older (mean age 63 (standard deviation 14) v 60 (15) years), had more comorbidities, and were more likely to be admitted to a hospital with a smaller number of intensive care unit beds compared with those who did not have in-hospital cardiac arrest. Patients who received cardiopulmonary resuscitation were younger than those who did not (mean age 61 (standard deviation 14) v 67 (14) years). The most common rhythms at the time of cardiopulmonary resuscitation were pulseless electrical activity (49.8%, 199/400) and asystole (23.8%, 95/400). 48 of the 400 patients (12.0%) who received cardiopulmonary resuscitation survived to hospital discharge, and only 7.0% (28/400) survived to hospital discharge with normal or mildly impaired neurological status. Survival to hospital discharge differed by age, with 21.2% (11/52) of patients younger than 45 years surviving compared with 2.9% (1/34) of those aged 80 or older.
Conclusions:  Cardiac arrest is common in critically ill patients with covid-19 and is associated with poor survival, particularly among older patients.
The full text of this article is available via this link.  The paper copy of the BMJ is also available on D Level of the hospital.

Critical Care Reviews Newsletter 460 4th October 2020

The Critical Care Reviews Newsletter, which provides the best critical care research and open access articles from across the medical literature during the last week.
The highlights of this week’s edition are randomised controlled trials on early mechanical ventilation in patients with Guillain-Barré syndrome at high risk of respiratory failure and hydroxychloroquine for pre-exposure SARS-CoV-2 prophylaxis among health care workers; systematic reviews and meta analyses on the efficacy and safety of in–ICU leg-cycle ergometry and the association of weaning failure from mechanical ventilation with transthoracic echocardiography parameters; and observational studies on epinephrine’s effects on cerebrovascular and systemic hemodynamics during CPR & surgical mask on top of high-flow nasal cannula in critically ill COVID-19 patients with hypoxemic respiratory failure.
There are also guidelines on critically ill children with COVID-19 and anaesthesia during the COVID-19 pandemic; narrative reviews on hospital-acquired and ventilator-associated pneumonia and Ileus in the critically ill; editorials on whether mortality is a useful endpoint in stress ulcer prophylaxis and COVID-19-related and non-COVID-related ARDS; and commentaries on mechanical ventilation in the obese patient, de-adopting low-value care and survival time as an endpoint in COVID-19 trials.
The full text of the newsletter is available to all via this link.

Intensive Care Medicine Volume 46 Issue 10 October 2020

To view Intensive Care Medicine’s October issue’s contents page follow this link.
Articles published in this issue include: Prediction of poor neurological outcome in comatose survivors of cardiac arrest: a systematic review and Clinical characteristics and outcomes of critically ill patients with novel coronavirus infectious disease (COVID-19) in China: a retrospective multicenter study
Articles on COVID 19 these are freely available in full text to everyone.
To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine” though some are available open access.  Individual articles can be ordered from the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.
The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.  A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Critical Care Reviews Newsletter 459 27th September 2020

The Critical Care Reviews Newsletter, which provides the best critical care research and open access articles from across the medical literature during the last week.
The highlights of this week’s edition are randomised controlled trials on N-acetylcysteine for the treatment of severe acute respiratory syndrome caused by COVID-19, and rezafungin versus caspofungin for the treatment of candidemia and invasive candidiasis; systematic reviews and meta analyses on the attributable mortality of acute kidney injury, & clinical features and outcomes of adults with COVID-19; and observational studies on ECMO in COVID-19 & the association of RNAaemia and severe SARS-CoV-2 disease.
There is also a guideline on the treatment of SARS-CoV-2 in ICU; narrative reviews on neurological dysfunction of critically ill COVID-19 patients and monitoring in patients receiving oxygen therapy; editorials on how systems engineering can improve care in the ICU & why it’s always about numerators and denominators; and commentaries on first-generation COVID-19 vaccines & rapid review methods and knowledge synthesis.
The full text of the newsletter is available to all via this link.

Journal of Critical Care Volume 59 October 2020

The latest issue of this journal was published online in September 2020.  The contents include the following articles:  “High-flow tracheal oxygen in tracheostomised COVID-19 patients, “Clinically significant anticardiolipin antibodies associated with COVID-19” and “Adjunctive therapy with vitamin c and thiamine in patients treated with steroids for refractory septic shock: A propensity matched before-after, case-control study”.
The full text of all these articles is freely available from the journals contents page.

Critical Care Reviews Newsletter 458 20th September 2020

The Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature over the previous week.
The highlights of this week’s edition are randomised controlled trials on antithrombin supplementation during extracorporeal membrane oxygenation and the effect of aspirin on deaths associated with sepsis in healthy older people; systematic reviews and meta analyses on high-flow nasal oxygen during the intraoperative period & polymyxin B-immobilized hemoperfusion for sepsis and septic shock; and observational studies on intra-arrest transport vs continued on-scene resuscitation in patients with out-of-hospital cardiac arrest and a prognostic score for 1-year unplanned rehospitalization or death of adult sepsis survivors. There are also guidelines on nutrition management for critically and acutely unwell hospitalised patients with COVID-19 and  the conduct of observational critical care research for the COVID-19 pandemic and beyond; narrative reviews on acute ischemic stroke and anticoagulation strategies in extracorporeal circulatory devices; editorials on vitamin C and thiamine for sepsis and severe COVID-19 infections; and commentaries on how i select which patients with ARDS should be treated with venovenous ECMO and delivering options for preventing and treating COVID-19.
The full text of the issue is available via this link

Assessment of fluid resuscitation on time to hemodynamic stability in obese patients with septic shock

This research by Kiracofe and colleagues was published on line in the Journal of Critical Care during September 2020.
Purpose:  Assess time to hemodynamic stability (HDS) in obese patients with septic shock who received <30 vs. ≥30 ml/kg of initial fluid resuscitation based on actual body weight (ABW).
Materials and methods:  Multicenter, retrospective, cohort analysis of 322 patients.
Results:  Overall 216 (67%) patients received <30 ml/kg of initial fluid resuscitation. Initial fluid received was lower in the <30 ml/kg vs. ≥30 ml/kg group (16 vs. 37 ml/kg). The ≥30 ml/kg group had shorter time to HDS (multivariable p = 0.038) and lower riskof in-hospital death (multivariable p = 0.038). An exploratory subgroup analysis (n = 227) was performed, classifying patients by dosing strategy [ABW, adjusted body weight (AdjBW), ideal body weight (IBW)] based on fluid received at 3 h divided by 30 mL/kg. ABW dosed patients had a shorter time to HDS (multivariable p = 0.013) and lower risk of in-hospital death (multivariable p = 0.008) vs. IBW. Similar outcomes were observed between ABW vs. AdjBW.
Conclusions:  Obese patients given ≥30 ml/kg based on ABW had a shorter time to HDS and a lower risk of in-hospital death. Exploratory results suggest improved outcomes resuscitating by ABW vs. IBW; ABW showed no strong benefit over AdjBW. Further prospective studies are needed to confirm the optimal fluid dosing in obese patients.
The full text of this article is freely available to all via this link.

Effectiveness of polymyxin B-immobilized hemoperfusion against sepsis and septic shock: A systematic review and meta-analysis

This article by Xiaoming Li and other researchers was published online in the Journal of Critical Care during September 2020.
Purpose:  To evaluate the efficacy and safety of Polymyxin B-immobilized hemoperfusion (PMX-HP) against sepsis or septic shock.
Methods:  We searched databases (PubMed, EMBASE and Cochrane Library) to identify eligible randomized controlled trials (RCTs). The primary outcomes we included in this review were mortality at the longest follow-up available and serious adverse events associated with treatments. We used the Cochrane risk of bias assessment tool to evaluate risk of bias. Trial Sequential Analysis (TSA) was performed to assess the conclusion reached in our research.
Results:  Thirteen studies including 1163 patients were identified. Use of PMX-HP could reduce overall mortality [relative risk (RR) 0.68, 95% confidence interval (CI) 0.51–0.91, P = 0.01]. An interesting finding was that the mortality of patients in Acute Physiology and Chronic Health Evaluation (APACHE II) scores <25 group (RR 0.64, 95% CI 0.52–0.78, P < 0.0001) and sepsis group (RR 0.48, 95% CI 0.32–0.72, P = 0.0003) significantly decreased after PMX-HP treatment. The result also showed that PMX-HP could reduce endotoxin levels [Standardized mean difference (SMD) -1.53, 95% CI -2.92– -0.13, P = 0.03] and improve mean arterial pressure (SMD 1.07, 95% CI 0.14–2.01, P = 0.02). Serious adverse events between the PMX-HP group and standard therapy group were not significantly different (RR 2.16, 95% CI 0.97–4.80, I2 = 0%, P = 0.06). However, TSA did not provide conclusive evidence and more high quality RCTs were required.
Conclusion:  Using PMX-HP to treat patients with less severe sepsis can reduce overall mortality and is safe. Treatment efficacy may benefit from the reduction of endotoxin level and the improvement of hemodynamics. More high quality RCTs are required to further evaluate the clinical role of PMX-HP against severe sepsis or septic shock.
The full text of this article is freely available to all via this link.