Impact of timing to source control in patients with septic shock: A prospective multi-center observational study

This work by Kim and others was first published on line during June 2019 in the Journal of Critical Care.
Purpose:  Current guidelines recommend that rapid source control should be adopted in patients not >6–12 h after sepsis is diagnosed. However, evidence level of this guideline is not specified, and there is no previous study on patients with septic shock visiting the emergency department (ED). Therefore, we aimed to assess the impact of rapid source control in patients with septic shock visiting the ED.
Materials and methods:  In a prospective, observational, multicenter, registry-based study in 11 EDs, Cox proportional hazards model was used to assess the independent effect of source control and time to source control on 28-day mortality.
Results:  Cox proportional hazard models revealed that 28-day mortality was significantly lower in patients who underwent source control (HR 0.538 (0.389–0.744), p < .001). However, no significant association between the performance of source control after 6 h or 12 h from enrollment and 28-day mortality was noted.
Conclusions:  Patients with septic shock visiting the ED who underwent source control showed better outcomes than those who did not. We failed to demonstrate the performance of rapid source control reduced the 28-day mortality in septic shock patients. Further studies are required to determine the impact of rapid source control in sepsis and septic shock.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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.

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Analgesia-first sedation in critically ill adults: A U.S. pilot, randomized controlled trial

This research by Tanios and colleagues was first published online in June 2019 in the Journal of Critical Care.
Purpose:  To determine the feasibility of conducting a multicenter ICU RCT of AFS compared to either protocol-directed sedation (PDS) or both PDS and daily sedation interruption (DSI) in North America.
Materials and methods:  This single-center RCT compared AFS with either PDS or both PDS and DSI daily in adults mechanically ventilated (MV) ≥48 h. Relevant feasibility, safety, and clinical outcomes were defined and evaluated.
Results:  90 of 160 eligible patients were enrolled [AFS = 27; PDS = 28; PDS + DSI = 31]; rate = 3/month. Time from intubation to randomization was 17.5 ± 11.6 h. Study days fully adherent to the study intervention [AFS = 95%; PDS = 99%; PDS + DSI = 96%] and time spent in the first 48 h after randomization without pain (CPOT ≤2)[AFS = 82%; PDS = 78%; PDS + DSI = 77%] and at goal RASS[AFS = 88%; PDS = 83%; PDS + DSI = 95%] were high and similar. Nurse-perceived [median (IQR)] study workload (10-point VAS) was higher with AFS [4(2–6)] than PDS [1(1–3)] or PDS + DSI [2(1–5)]; p = .002). Unplanned extubation was rare (AFS = 1; PDS = 0; PDS + DSI = 1). Days [median (IQR)] free of MV in the 28d after intubation [AFS 24(23,26); PDS 24(20,26); PDS + DSI 24(21,26)] was not different (p = .62).
Conclusion:  A multicenter RCT evaluating AFS is feasible to conduct in North America.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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.

Risk factors for new-onset atrial fibrillation on the general adult ICU: A systematic review

This article by Bedford and others was first published online in the Journal of Critical Care during June 2019.
Purpose:  This study was performed to systematically review the available evidence for the risk factors for NOAF on the general adult intensive care unit (ICU) and provide a semi-quantitative evidence synthesis.
Methods:  We searched the MEDLINE, EMBASE, Cochrane Database of Systematic Reviews and the CENTRAL databases from 1970 to 2018.
We included studies of adults based in general ICUs that evaluated potential risk factors for new-onset atrial fibrillation. We excluded studies involving patients with a history of AF.
We semi-qualitatively evaluated the strength of evidence for each identified variable.
Results:  We screened 1447 studies. Seventeen studies were included in the final analysis. We identified strong evidence for age, male sex, preceding cardiovascular disease, acute renal failure, acute respiratory failure, APACHE score and the use of vasopressors as risk factors for the development of NOAF on the ICU. Modifiable risk factors had not been studied in detail.
Conclusions:  We provide the first systematic review with evidence synthesis of risk factors for NOAF on the general adult ICU. Evidence for modifiable risk factors was limited. Further research is therefore required and may contribute towards the evidence-based prevention and management of this important condition.
The full text of this article is fully available to all.

Critical Care Reviews Newsletter 392 17th June 2019

The 392nd Critical Care Reviews Newsletter contains the best critical care research and open access articles from across the medical literature over the last week.
“The highlights of this week’s edition are randomised controlled trials comparing pressure support vs T-piece ventilation strategies during spontaneous breathing trials & analgesia-first sedation; systematic reviews and meta analyses on medical reversals & enhanced physical rehabilitation following ICU discharge; and observational studies, including a re-analysis of the FEAST trial, examining the effects of saline or albumin fluid bolus in resuscitation, & long-term outcome after prolonged mechanical ventilation.
There are also guidelines on ARDS & suspected immediate perioperative allergic reactions; narrative reviews on pulmonary embolism & frailty assessment; editorials on post-intensive care syndrome & achieving nutrition goals; and commentaries on post-traumatic stress in the ICU & medical misinformation. There is also a fantastic series from Critical Care on The Future of Critical Care Medicine.
The full text of the newsletter can be found via this link.

Differences in 90-day mortality of delirium subtypes in the intensive care unit: A retrospective cohort study

This article by Rood and colleagues was published online in the “Journal of Critical Care” during June 2019
Introduction:  Many intensive care unit (ICU) patients suffer from delirium which is associated with deleterious short-term and long-term effects, including mortality. We determined the association between different delirium subtypes and 90-day mortality.
Materials and methods:  Retrospective cohort study in ICU patients admitted in 2015–2017. Delirium, including its subtypes, was determined using the confusion assessment method-ICU (CAM-ICU) and Richmond agitation sedation scale (RASS). Exclusion criteria were insufficient assessments and persistent coma. Cox-regression analysis was used to determine associations of delirium subtypes with 90-day mortality, including relevant covariates (APACHE-IV, length of ICU stay and mechanical ventilation).
Results:  7362 ICU patients were eligible of whom 6323 (86%) were included. Delirium occurred in 1600 (25%) patients (stratified for delirium subtype: N = 571–36% mixed, N = 485–30% rapidly reversible, N = 433–27% hypoactive, N = 111–7% hyperactive). The crude hazard ratio (HR) for overall prevalent delirium with 90-day mortality was 2.84 (95%CI: 2.32–3.49), and the adjusted HR 1.29 (95%CI: 1.01–1.65). The adjusted HR for 90-day mortality was 1.57 (95%CI: 1.51–2.14) for the mixed subtype, 1.40 (95%CI: 0.71–2.73) for hyperactive, 1.31 (95%CI: 0.93–1.84) for hypoactive and 0.95 (95%CI: 0.64–1.42) for rapidly reversible delirium.
Conclusion:  After adjusting for covariates, including competing risk factors, only the mixed delirium subtype was significantly associated with 90-day mortality.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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 391 9th June 2019

The 391st Critical Care Reviews Newsletter, bringing 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 two randomised controlled trials on PEEP, one on intraoperative high PEEP with recruitment maneuvers & the other on PEEP and postoperative atelectasis; systematic reviews and meta analyses on physical therapy during ECMO & oxygenation and clinical outcomes to inform oxygen targets in critically ill trauma patients; and observational studies on the ongoing Ebola epidemic in Congo & survival in out-of-hospital cardiac arrest after standard CPR or chest compressions only.
There are also guidelines on acute-on-chronic liver failure & oesophageal emergencies; narrative reviews on rapid response systems & echocardiography in the management of VA ECMO; editorials on oxygen therapy & interventions to improve CPR; and a commentary on the role of the host response in influenza pneumonitis.
This week’s Topic of the Week is one I’ve wanted to cover for a while and is based on a fantastic series on the evaluation of scientific publications from the German journal Deutsches Ärzteblatt International, starting with a paper on critical appraisal of scientific articles in today’s Paper of the Day.
If you only have time to read one review article this week, try this one on atypical hemolytic uremic syndrome
The full newsletter can be accessed via this link.

Efficacy of music on sedation, analgesia and delirium in critically ill patients. A systematic review of randomized controlled trials

This article by Gonzalo and colleagues was published online in June 2019 in the Journal of Critical Care.
Purpose:  To systematically synthesize randomized controlled trial data on the efficacy of music to provide sedation and analgesia, and reduce incidence of delirium, in critically ill patients.
Material and methods:  Relevant databases (Medline, PubMed, Embase, CINAHL, Cochrane, Alt Healthwatch, LILACS, PsycINFO, CAIRSS, RILM) were searched from inception to April 26, 2018. We also searched the reference lists of included publications and for ongoing trials. The selection of relevant articles was conducted by two researchers at two levels of screening.
Data collection followed the recommendations from the Cochrane Systematic Reviews Handbook. We used the Cochrane Collaboration’s tool for assessing risk of bias. Quality of the evidence was rated according to GRADE.
Results:  The review identified six adult studies and no neonatal or pediatric studies. A descriptive analysis of study results was performed. Meta-analysis was not feasible due to heterogeneity. One study reported a reduction in sedation requirements with the use of music while the other five did not find any significant differences across groups.
Conclusions:  This systematic review revealed limited evidence to support or refute the use of music to reduce sedation/analgesia requirements, or to reduce delirium in critically ill adults, and no evidence in pediatric and neonatal critically ill patients.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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.