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Critical Care Reviews Newsletter 310 19th November 2017

The 310th Critical Care Reviews Newsletter brings you the best critical care research and open acritcal care reviewsccess articles from across the medical literature over the past seven days.  The highlights of this week’s issue are narrative reviews on airway management in trauma, ischaemic stroke care and critical care echocardiography; commentaries on ICU sedation and fluid administration in the critically ill patient; a guideline on sonography in hypotension and cardiac arrest, and an editorial debate on whether “social media has created emergency medicine celebrities who now influence practice more than published evidence”.

The full copy of newsletter 3095 19th November 2017 can be accessed via this link.

Intensive Care Unit Outcomes Among Patients With Cancer After Palliative Radiation Therapy

This paper by Kruser and colleagues was published in the November issue of the International Journal of Radiation Oncology, Biology and Physics.
Purpose:  To inform goals of care discussions at the time of palliative radiation therapy (RT) consultation, we sought to characterize intensive care unit (ICU) outcomes for patients treated with palliative RT compared to all other patients with metastatic cancer admitted to the ICU.
Methods and materials:  We conducted a retrospective cohort study of patients with metastatic cancer admitted to an ICU in a tertiary medical centre from January 2010 to September 2015. We compared in-hospital mortality between patients who received palliative RT in the 12 months before admission and all other patients with metastatic cancer. We used multivariable logistic regression to evaluate the association between receipt of palliative RT and in-hospital mortality, adjusting for patient characteristics and acute illness severity.
Results:  Among 1424 patients with metastatic cancer, 11.3% (n=161) received palliative RT before ICU admission. In-hospital mortality was 36.7% for palliative RT patients, compared with 16.6% for other patients with metastatic cancer (P<.001). Receipt of palliative RT was associated with increased in-hospital mortality (odds ratio 2.08, 95% confidence interval 1.34-3.21, P=.001), after adjusting for patient characteristics and severity of critical illness. Only 34 patients (21.1%) treated with palliative RT received additional cancer-directed treatment after ICU admission.
Conclusions:  For patients with metastatic cancer, prior treatment with palliative RT is associated with increased in-hospital mortality after ICU admission. Nearly half of patients previously treated with palliative RT either died during hospitalization or were discharged with hospice care, and few received further cancer-directed therapy. Palliative RT referral may represent an opportunity to discuss end-of-life treatment preferences with patients and families.
The article is available on the internet to those who have a personal subscription via this link to the full text.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

The Effect of ICU Out-of-Hours Admission on Mortality: A Systematic Review and Meta-Analysis

This article by Galloway and others was published in the November 2017 issue of “Critical Care Medicine”

Objectives:  Organizational factors are associated with outcome of critically ill patients and may vary by time of day and day of week. We aimed to identify the association between out-of-hours admission to critical care and mortality.
Data Sources:  MEDLINE (via Ovid) and EMBASE (via Ovid).
Study Selection:  We performed a systematic search of the literature for studies on out-of-hours adult general ICU admission on patient mortality.
Data Extraction:  Meta-analyses were performed and Forest plots drawn using RevMan software. Data are presented as odds ratios ([95% CIs], p values).
Data Synthesis:  A total of 16 studies with 902,551 patients were included in the analysis with a crude mortality of 18.2%. Fourteen studies with 717,331 patients reported mortality rates by time of admission and 11 studies with 835,032 patients by day of admission. Admission to ICU at night was not associated with an increased odds of mortality compared with admissions during the day (odds ratio, 1.04 [0.98-1.11]; p = 0.18). However, admissions during the weekend were associated with an increased odds of death compared with ICU admissions during weekdays (1.05 [1.01-1.09]; p = 0.006). Increased mortality associated with weekend ICU admissions compared with weekday ICU admissions was limited to North American countries (1.08 [1.03-1.12]; p = 0.0004). The absence of a routine overnight on-site intensivist was associated with increased mortality among weekend ICU admissions compared with weekday ICU admissions (1.11 [1.00-1.22]; p = 0.04) and night time admissions compared with daytime ICU admissions (1.11 [1.00-1.23]; p = 0.05).
Conclusions: Adjusted risk of death for ICU admission was greater over the weekends compared with weekdays. The absence of a dedicated intensivist on-site overnight may be associated with increased mortality for acute admissions. These results need to be interpreted in context of the organization of local healthcare resources before changes to healthcare policy are implemented.
The article is available on the internet to those who have a personal subscription via this link to the full text.  Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Critical Care Reviews Newsletter 309 12th November 2017

The Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the medical literature from the past week.  “It has been another great week of critical care publications, including the French NUTRIREA-2 trial, comparing early enteral with early parenteral nutrition in ventilated adults with shock (following on from CALORIES and PePANIC), the Canadian/Australian/New Zealand TRICS3 trial, comparing restrictive with liberal transfusion thresholds in the cardiac surgery patients (following on from TITRe2), as well as RCTs looking at contrast-induced nephropathy (PRESERVE) and late thromboectomy after stroke (DAWN). There are also new guidelines on cardiopulmonary resuscitation and emergency cardiovascular care, and European guidelines on perioperative venous thromboembolism prophylaxis in various settings, as well as narrative reviews on the neurological wake-up test, improving CPR performance and chloride in intensive care units.”

The full copy of newsletter 3094 12th November 2017 can be accessed via this link.

Acute Physiologic Stress and Subsequent Anxiety Among Family Members of ICU Patients

This article by Beesley and colleagues was published in “Critical Care Medicine” in November 2017.  The full text of the article can be accessed via this link.
Objectives:  The ICU is a complex and stressful environment and is associated with significant psychologic morbidity for patients and their families. We sought to curtains-1854110_960_720

determine whether salivary cortisol, a physiologic measure of acute stress, was associated with subsequent psychologic distress among family members of ICU patients.
Design:  This is a prospective, observational study of family members of adult ICU patients.
Setting:  Adult medical and surgical ICU in a tertiary care centre.
Subjects:  Family members of ICU patients.
Interventions:  Participants provided five salivary cortisol samples over 24 hours at the time of the patient ICU admission. The primary measure of cortisol was the area under the curve from ground; the secondary measure was the cortisol awakening response. Outcomes were obtained during a 3-month follow-up telephone call. The primary outcome was anxiety, measured by the Hospital Anxiety and Depression Scale-Anxiety. Secondary outcomes included depression and post-traumatic stress disorder.
Measurement and main Results:  Among 100 participants, 92 completed follow-up. Twenty-nine participants (32%) reported symptoms of anxiety at 3 months, 15 participants (16%) reported depression symptoms, and 14 participants (15%) reported post-traumatic stress symptoms. In our primary analysis, cortisol level as measured by area under the curve from ground was not significantly associated with anxiety (odds ratio, 0.94; p = 0.70). In our secondary analysis, however, cortisol awakening response was significantly associated with anxiety (odds ratio, 1.08; p = 0.02).
Conclusions:  Roughly one third of family members experience anxiety after an ICU admission for their loved one, and many family members also experience depression and post-traumatic stress. Cortisol awakening response is associated with anxiety in family members of ICU patients 3 months following the ICU admission. Physiologic measurements of stress among ICU family members may help identify individuals at particular risk of adverse psychologic outcomes.

 

 

 

Admission of tetanus patients to the ICU: a retrospective multicentre study.

This research by Mahieu and colleagues was published in the journal Annals of Intensive Care in November 2017.  The full text of the article can be accessed via this link.
Background:  An extended course of tetanus (up to 6 weeks) requiring ICU admission and protracted mechanical ventilation (MV) may have a significant impact on short- and long-term survival. The subject is noteworthy and deserves to be discussed.
Methods:  Twenty-two ICUs in France performed tetanus screenings on patients admitted between January 2000 and December 2014. Retrospective data were collected from hospital databases and through the registers of the town hall of the patients.
Results:  Seventy patients were included in 15 different ICUs. Sixty-three patients suffered from severe or very severe tetanus according to the Ablett classification. The median age was 80 years [interquartile range 73-84], and 86% of patients were women. Ninety per cent of patients (n = 63) required MV for a median of 36 days [26-46], and 66% required administration of a neuromuscular-blocking agent for 23 days [14-29]. A nosocomial infection occurred in 43 patients (61%). ICU and 1-year mortality rates were 14% (n = 10) and 16% (n = 11), respectively. Forty-five per cent of deaths occurred during the first week. Advanced age, a higher SAPS II, any infection, and the use of vasopressors were significantly associated with a lower number of days alive without ventilator support by day 90. Age was the only factor that significantly differed between deceased and survivors at 1 year (83 [81-85] vs. 79 [73-84] years, respectively; p = 0.03). Sixty-one per cent of survivors suffered no impairment to their functional status.
Conclusion:  In a high-income country, tetanus mainly occurs in healthy elderly women. Despite prolonged MV and extended ICU length of stay, we observed a low 1-year mortality rate and good long-term functional status.

Universal or targeted approach to prevent the transmission of extended-spectrum beta-lactamase-producing Enterobacteriaceae in intensive care units: a cost-effectiveness analysis

This article by Kardas-Sloma and colleagues was published in the journal BMJ Open in November 2017.  The full text of the article can be accessed via this link.
Objective:  Several control strategies have been used to limit the transmission of multidrug-resiarrows-2023445_960_720stant organisms in hospitals. However, their implementation is expensive and effectiveness of interventions for the control of extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) spread is controversial. Here, we aim to assess the cost-effectiveness of hospital-based strategies to prevent ESBL-PE transmission and infections.
Design:  Cost-effectiveness analysis based on dynamic, stochastic transmission model over a 1-year time horizon.
Patients and setting:  Patients hospitalised in a hypothetical 10-bed intensive care unit (ICU) in a high-income country.
Interventions:  Base case scenario compared with (1) universal strategies (eg, improvement of hand hygiene (HH) among healthcare workers, antibiotic stewardship), (2) targeted strategies (eg, screening of patient for ESBL-PE at ICU admission and contact precautions or cohorting of carriers) and (3) mixed strategies (eg, targeted approaches combined with antibiotic stewardship).
Main outcomes and measures:  Cases of ESBL-PE transmission, infections, cost of intervention, cost of infections, incremental cost per infection avoided.
Results:  In the base case scenario, 15 transmissions and five infections due to ESBL-PE occurred per 100 ICU admissions, representing a mean cost of €94 792. All control strategies improved health outcomes and reduced costs associated with ESBL-PE infections. The overall costs (cost of intervention and infections) were the lowest for HH compliance improvement from 55%/60% before/after contact with a patient to 80%/80%.

Conclusions:  Improved compliance with HH was the most cost-saving strategy to prevent the transmission of ESBL-PE. Antibiotic stewardship was not cost-effective. However, adding antibiotic restriction strategy to HH or screening and cohorting strategies slightly improved their effectiveness and may be worthy of consideration by decision-makers.