Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation: A Randomized Clinical Trial

This research by van Meenen and colleagues was published in JAMA March 2018 volume 319 issue 10.
Importance:  It remains uncertain whether nebulization of mucolytics with bronchodilators should be applied for clinical indication or preventively in intensive care unit (ICU) patients receiving invasive ventilation.
Objective:  To determine if a strategy that uses nebulization for clinical indication (on-demand) is non-inferior to one that uses preventive (routine) nebulization.
Design, Setting, and Participants:  Randomized clinical trial enrolling adult patients expected to need invasive ventilation for more than 24 hours at 7 ICUs in the Netherlands.
Interventions:  On-demand nebulization of acetylcysteine or salbutamol (based on strict clinical indications, n = 471) or routine nebulization of acetylcysteine with salbutamol (every 6 hours until end of invasive ventilation, n = 473).
Main Outcomes and Measures:  The primary outcome was the number of ventilator-free days at day 28, with a non-inferiority margin for a difference between groups of -0.5 days. Secondary outcomes included length of stay, mortality rates, occurrence of pulmonary complications, and adverse events.
Results:  Nine hundred twenty-two patients (34% women; median age, 66 (interquartile range [IQR], 54-75 years) were enrolled and completed follow-up. At 28 days, patients in the on-demand group had a median 21 (IQR, 0-26) ventilator-free days, and patients in the routine group had a median 20 (IQR, 0-26) ventilator-free days (1-sided 95% CI, -0.00003 to ∞). There was no significant difference in length of stay or mortality, or in the proportion of patients developing pulmonary complications, between the 2 groups. Adverse events (13.8% vs 29.3%; difference, -15.5% [95% CI, -20.7% to -10.3%]; P #
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.
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February 2018 Issue of “Intensive Care Medicine” Volume 44 Number 2

To view Intensive Care Medicine’s latest issue’s contents page follow this link.
Articles in the issue include a systematic review on “Polymyxin B-immobilized hemoperfusion and mortality in critically ill adult patients with sepsis/septic shock” and original research on “Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit”.intensive-care-medicine

To read the full text of these articles from the journal’s homepage requires a personal subscription to “Intensive Care Medicine”.  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 327 18th March 2018

The 327th Crcritcal care reviewsitical Care Reviews Newsletter includes the best critical care research and open access articles from the literature in the past seven days. The highlights “are randomised controlled trials on light exposure in critically ill patients, prevention of acute kidney injury after cardiac surgery, & induced hypertension for delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage; guidelines on tracheostomy in the ICU & cardiac ultrasound; reviews on emergency thrombectomy for acute ischaemic stroke, transfusion practices in traumatic brain injury & smoke inhalation injury; plus commentaries on ten false beliefs in neurocritical care, have we averted deaths using venoarterial ECMO? & why research on research matters.”

The full text of newsletter 327 can be found via this link

Critical Care Reviews Newsletter 326 11th March 2018

The Critical Care Reviews Newsletter provides the best critical care research and open access articles from across the medical literature over the past seven days. The highlights of the 326th edition are “narrative clinical reviews on seizure prophylaxis in the neuroscience ICU, prolonged mechanical ventilation, cholestatic alterations in the critically ill, critcal care reviewsand acute decompensated pulmonary hypertension, plus a non-clinical review on adaptive clinical trials; editorials on CULPRIT-SHOCK & emergency room hyperoxia; commentaries on vitamin therapy & respiratory drive; plus a guideline on multidrug-resistant Gram-negative bacteria.”

The full copy of newsletter 326 11th March 2018 can be accessed via this link.

Implementation of an Evidence-Based Practice Nursing Handover Tool in Intensive Care Using the Knowledge-to-Action Framework

This article in the March 2018 issue of “Worldviews on Evidence Based Nursing” is by Spooner and colleagues.
Background:  Miscommunication during handover has been linked to adverse patient events and is an international patient safety priority. Despite the development of handover resources, standardized handover tools for nursing team leaders (TLs) in intensive care are limited.
Aims:  The study aim was to implement and evaluate an evidence-based electronic minimum data set for nursing TL shift-to-shift handover in the intensive care unit using the knowledge-to-action (KTA) framework.
Methods:  This study was conducted in a 21-bed medical-surgical intensive care unit in Queensland, Australia. Senior registered nurses involved in TL handover were recruited. Three phases of the KTA framework (select, tailor, and implement interventions; monitor knowledge use; and evaluate outcomes) guided the implementation and evaluation process. A post-implementation practice audit and survey were carried out to determine nursing TL use and perceptions of the electronic minimum data set 3 months after implementation. Results are presented using descriptive statistics (median, IQR, frequency, and percentage).
Results:  Overall (86%, n = 49), TLs’ use of the electronic minimum data set for handover and communication regarding patient plan increased. Key content items, however, were absent from handovers and additional documentation was required alongside the minimum data set to conduct handover. Of the TLs surveyed (n = 35), those receiving handover perceived the electronic minimum data set more positively than TLs giving handover (n = 35). Benefits to using the electronic minimum data set included the patient content (48%), suitability for short-stay patients (16%), decreased time updating (12%), and printing the tool (12%). Almost half of the participants, however, found the minimum data set contained irrelevant information, reported difficulties navigating and locating relevant information, and pertinent information was missing. Suggestions for improvement focused on modifications to the electronic handover interface.
Linking Evidence to Action:  Prior to developing and implementing electronic handover tools, adequate infrastructure is required to support knowledge translation and to ensure clinician and organizational needs are met.
The full text of this article as a PDF is available via link from this website

Electrodermal Activity during Blood Pooling for Arterial Blood Gases Analysis in Sedated Adult Intensive Care Unit Patients

This article by Aslanidis et al was published in Medical Sciences March 2018 Volume 6 Number 1.
Electrodermal activity (EDA) is considered a measure of autonomous nervous system activity. This study performed an exploratory analysis of the EDA changes during blood pooling for arterial blood gas analysis in sedated adult critical care patients and correlated the variations to other monitored parameters. EDA, along with other parameters, were monitored during 4 h routine daytime intensive care nursing and treatment in an adult ICU. 4 h measurements were divided into two groups based upon the sedation level. Selected recordings before and after blood pooling for arterial blood gases analysis (stress event) was performed. Nine stress events from Group A and 17 from Group B were included for further analysis. Patients’ demographics, laboratory exams, and severity scores were recorded. For both sedation levels, EDA changes are much greater than any other monitoring parameters used. The changes are noticed in both measurement (15 s and 60 s), even though in the 60 s measurement only selected EDA parameters are significantly changed after the start of the procedure. EDA measurements are more sensitive to a given stress event than cardiovascular or respiratory parameters. However, the present results could only be considered as a pilot study. More studies are needed in order to identify the real stress-load and clinical significance of such stimuli, which are considered otherwise painless in those patients.
The full text of this article as a PDF is available via link from this website

Fluid accumulation during acute kidney injury in the intensive care unit

This research was published in Acta Anaesthesiologica Scandinavica in March 2018 by Berthelsen et al.
Introduction:  Fluid therapy is a ubiquitous intervention in patients admitted to the intensive care unit, but positive fluid balance may be associated with poor outcomes and particular in patients with acute kidney injury. Studies describing this have defined fluid overload either at specific time points or considered patients with a positive mean daily fluid balance as fluid overloaded. We wished to detail this further and performed joint model analyses of the association between daily fluid balance and outcome represented by mortality and renal recovery in patients admitted with acute kidney injury.
Method:  We did a retrospective cohort study of patients admitted to the intensive care unit with acute kidney injury during a 2-year observation period. We used serum creatinine measurements to identify patients with acute kidney injury and collected sequential daily fluid balance during the first 5 days of admission to the intensive care unit. We used joint modelling techniques to correlate the development of fluid overload with survival and renal recovery adjusted for age, gender and disease severity.
Results:  The cohort contained 863 patients with acute kidney injury of whom 460 (53%) and 254 (29%) developed 5% and 10% fluid overload, respectively. We found that both 5% and 10% fluid overload was correlated with reduced survival and renal recovery.
Conclusion:  Joint model analyses of fluid accumulation in patients admitted to the intensive care unit with acute kidney injury confirm that even a modest degree of fluid overload (5%) may be negatively associated with both survival and renal recovery.
Library members can order the full text of individual articles such as this one via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Effect of Sedation Regimen on Weaning from Mechanical Ventilation in the Intensive Care Unit

This article by Nunes and colleagues was published in the journal “Clinical Drug Investigation” March 2018.
Background:  Intensive care unit patients undergoing mechanical ventilation have traditionally been sedated to make them comfortable and to avoid pain and anxiety. However, this may lead to prolonged mechanical ventilation and a longer length of stay.
Objective:  The aim of this retrospective study was to explore whether different sedation regimens influence the course and duration of the weaning process.
Patients and Methods:  Intubated adult patients (n = 152) from 15 general intensive care units in Sweden were mechanically ventilated for ≥ 24h. Patients were divided into three groups according to the sedative(s) received during the weaning period (i.e. from being assessed as ‘fit for weaning’ until extubation): dexmedetomidine alone (DEX group, n = 32); standard of care with midazolam and/or propofol (SOC group, n = 67); or SOC plus dexmedetomidine (SOCDEX group, n = 53).
Results:  Patients receiving dexmedetomidine alone were weaned more rapidly than those in the other groups despite spending longer time on mechanical ventilation prior to weaning. Anxiety during weaning was present in 0, 9 and 24% patients in the DEX, SOC and SOCDEX groups, respectively. Anxiety after extubation was present in 41, 20 and 34% in the DEX, SOC and SOCDEX groups, respectively. Delirium during weaning was present in 1, 2 and 1 patient in the DEX, SOC and SOCDEX groups, respectively. Delirium at ICU discharge was present in 1, 0 and 3 patients in the DEX, SOC and SOCDEX groups, respectively. Few patients fulfilled criteria for post-traumatic stress disorder.
Conclusions:  Dexmedetomidine, used as a single sedative, may have contributed to a shorter weaning period than SOC or SOCDEX. Patients who received dexmedetomidine-only sedation tended to report better health-related quality of life than those receiving other forms of sedation.
The full text of this article as a PDF is available via link from this website

Critical Care Reviews Newsletter 325 25th February 2018

The Critical Care Reviews Newsletter provides the best published research from the last week.  “The highlights are the randomised controlled trials APROCCHSS, investigating stercritcal care reviewsoids in sepsis, (SMART) & (SALT-ED), two trials on saline vs balanced crystalloids in the ICU & ED, respectively, CAAM, comparing bag-mask ventilation with endotracheal intubation during CPR in out-of-hospital cardiac arrest, and NEBULAE, examining nebulization of acetylcysteine with salbutamol in mechanically ventilated patients; guidelines on inotropic agents for patients with acute circulatory failure and fluid therapy in neurointensive care patients; plus reviews on vasoplegia treatments and early mobilization”
The full copy of newsletter 325 4th March 2018 can be accessed via this link.

Balanced Crystalloids versus Saline in Critically Ill Adults

This research by Semler and colleagues, SMART Investigators and the Pragmatic Critical Care Research Group was published in the New England Journal of Medicine on 2nd March 2018.
Background:   Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomhospital-834152_960_720es.
Methods:   In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer’s solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days – a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) – all censored at hospital discharge or 30 days, whichever occurred first.
Results:   Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60).

Conclusions:   Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline.
The print copy of this issue of “The New England Journal of Medicine” is available in the Healthcare Library on D Level of Rotherham General Hospital.