Journal of Critical Care Volume 35 December 2016

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The content page of the latest issue can be accessed via this link

This issue includes articles such as “Triage decisions for ICU admission: Report from the Task Force of the World Federation of Societies of Intensive and Critical Care Medicine”, “Early goal-directed therapy for severe sepsis and septic shock: A living systematic review” and “Predictive value of the National Early Warning Score–Lactate for mortality and the need for critical care among general emergency department patients”.

To access the full text of these articles from the journal’s website you require your own subscription.  However, the full text of any articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  You can do this in person or if you are a registered member of the library you can use this link to an internet form.

Antibiotics for ventilator-associated pneumonia: Cochrane Review

This review by Arthur et al was published on 20th October 2016.  The plain language summary is shown below.  Full details of the review can be found via this link.

Background.  Ventilators are machines that breathe for patients. The ventilator tube goes into the mouth and through the windpipe. Sometimes there are bacteria on the ventilator tube that infect the patient’s lungs, leading to a disease called ventilator-associated pneumonia. Ventilator-associated pneumonia can cause significant harmful effects, and can sometimes lead to death. When treating people with ventilator-associated pneumonia, doctors must decide which antibiotic therapy to prescribe, usually without knowing the particular type of bacterial infection. This decision is important because inappropriate initial treatment may increase risk of harmful effects and longer hospital stays.

Search date  We searched for studies to December 2015.

Study characteristics  We looked at studies involving adults aged over 18 years who were treated in intensive care units for ventilator-associated pneumonia and needed antibiotic treatment. We analysed 12 studies with 3571 participants.

Key results  All included studies looked at the use of one antibiotic treatment plan versus another, but these varied among studies. There was potential for bias because some studies did not report outcomes for all participants, and funding for many was provided by pharmaceutical companies and study authors were affiliated with these companies.

We used statistical techniques to evaluate our results. For single versus multiple antibiotics, we found no difference in rates of death or cure, or adverse events. For our comparison of combination therapies with optional adjunctives we were only able to analyse clinical cure for one the antibiotics Tigecycline and imipenem-cilastatin for which imipenem-cilastatin was found to have higher clinica cure. We also looked at carbapenem (antibiotics used to treat infections caused by multidrug-resistant bacteria) versus non-carbapenem treatment; we found no difference in death rate or adverse effects, but we found that carbapenems are associated with an increase in clinical cure.

Quality of evidence  We assessed evidence quality as moderate for most outcomes, and very low for clinical cure when single-antibiotic treatment was compared with multiple antibiotic therapy. We also found that evidence quality was low for adverse events when carbapenem was compared with non-carbapenem treatment.

Conclusions  We did not find differences between single and combination therapy, lending support to use of a single-antibiotic treatment plan for people with ventilator-associated pneumonia. This may not be applicable to all patients because studies did not identify patients who are at risk of exposure to harmful types of bacteria.

We could not evaluate the best single-antibiotic choice to treat people with ventilator-associated pneumonia because there were too few studies, but carbapenems may achieve better cure rates than other tested antibiotics.

Latest Issue of Intensive Care Medicine Volume 42 Number 11

The contents page of this current issue can be accessed via this link.

Research published in this includes “The rate of brain death and organ donation in patients resuscitated from cardiac arrest: a systematic review and meta-analysis”, “Protein C zymogen in severe sepsis: a double-blinded, placebo-controlled, randomized study” and “Intravenous iron or placebo for anaemia in intensive care: the IRONMAN multicentre randomized blinded trial”.

To access the full text of these articles from the journal’s homepage requires a personal subscription.  The full text of articles from Intensive Care Medicine from issue older than one year ago can be accessed via this link.  A Rotherham NHS Athens password is required.  Eligible staff can register for one via this link.

Individual articles from the last year can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

New issue of “Intensive and Critical Care Nursing” Volume 36 Issue December 2016

The contents page of this current issue can be accessed via this link.

Amongst the articles published in this issue are “Consultation or confrontation when interacting through an ICU diary: a phenomenological-hermeneutical study”, “Clinical nurses’ knowledge level on pulse oximetry: a descriptive multi-centre study” and “Implementing a pressure ulcer prevention bundle in an adult intensive care”.

To access the full text of these articles direct from the journal’s homepage requires a personal subscription.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

The full text of articles from Intensive and Critical Care Nursing from issue older than one year ago is available via this link.  A Rotherham NHS Athens password is required.  Eligible staff can register for one via this link.

Current Issue of “Journal of Intensive Care Medicine” Volume 31 Number 10 December 2016

The contents page of the December 2016 issue can be accessed via this link.

The articles contained in this issue include “Acute Liver Failure: Diagnosis and Management”, “Management of Acute Respiratory Failure in Patients With Hematological Malignancy” and “Postintubation Hypotension in General Anesthesia: A Retrospective Analysis”.

To access the full text of these articles direct from the journal’s homepage you require a personal subscription to the journal (although certain articles may have been made freely available).  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make requests online via this link.

Perceived Nonbeneficial Treatment of Patients, Burnout, and Intention to Leave the Job Among ICU Nurses and Junior and Senior Physicians.

Schwarzkopf, D. et al. Critical Care Medicine. Published online: October 21 2016

businessman-150451_960_720Objectives: Perceiving nonbeneficial treatment is stressful for ICU staff and may be associated with burnout. We aimed to investigate predictors and consequences of perceived nonbeneficial treatment and to compare nurses and junior and senior physicians.

Design: Cross-sectional, multicenter paper-pencil survey on personal and work-related characteristics, perceived nonbeneficial treatment, burnout, and intention to leave the job.

Setting: Convenience sample of 23 German ICUs.

Subjects: ICU nurses and physicians.

Interventions: None.

Measurements and Main Results: A total of 847 questionnaires were returned (51% response); 778 had complete data for final multivariate analyses. Nonbeneficial treatment was in median perceived “sometimes.” Adjusted for covariates, it was perceived more often by nurses and junior physicians (both p <= 0.001 in comparison to senior physicians), while emotional exhaustion was highest in junior physicians (p <= 0.015 in comparison to senior physicians and nurses), who also had a higher intention to leave than nurses (p = 0.024). Nonbeneficial treatment was predicted by high workload and low quality collaboration with other departments (both p <= 0.001). Poor nurse-physician collaboration predicted perception of nonbeneficial treatment among junior physicians and nurses (both p <= 0.001) but not among senior physicians (p = 0.753). Nonbeneficial treatment was independently associated with the core burnout dimension emotional exhaustion (p <= 0.001), which significantly mediated the effect between nonbeneficial treatment and intention to leave (indirect effect: 0.11 [95% CI, 0.06-0.18]).

Conclusions: Perceiving nonbeneficial treatment is related to burnout and may increase intention to leave. Efforts to reduce perception of nonbeneficial treatment should improve the work environment and should be tailored to the different experiences of nurses and junior and senior physicians.

Read the abstract here


Does ventilator-associated event surveillance detect ventilator-associated pneumonia in intensive care units? A systematic review and meta-analysis

Fan, Y. et al. Critical Care. Published online: 24 October 2016

Background: Ventilator-associated event (VAE) is a new surveillance paradigm for monitoring complications in mechanically ventilated patients in intensive care units (ICUs). The National Healthcare Safety Network replaced traditional ventilator-associated pneumonia (VAP) surveillance with VAE surveillance in 2013. The objective of this study was to assess the consistency between VAE surveillance and traditional VAP surveillance.

Methods: We systematically searched electronic reference databases for articles describing VAE and VAP in ICUs. Pooled VAE prevalence, pooled estimates (sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV)) of VAE for the detection of VAP, and pooled estimates (weighted mean difference (WMD) and odds ratio ([OR)) of risk factors for VAE compared to VAP were calculated.

Results: From 2191 screened titles, 18 articles met our inclusion criteria, representing 61,489 patients receiving mechanical ventilation at ICUs in eight countries. The pooled prevalence rates of ventilator-associated conditions (VAC), infection-related VAC (IVAC), possible VAP, probable VAP, and traditional VAP were 13.8 %, 6.4 %, 1.1 %, 0.9 %, and 11.9 %, respectively. Pooled sensitivity and PPV of each VAE type for VAP detection did not exceed 50 %, while pooled specificity and NPV exceeded 80 %. Compared with VAP, pooled ORs of in-hospital death were 1.49 for VAC and 1.76 for IVAC; pooled WMDs of hospital length of stay were −4.27 days for VAC and −5.86 days for IVAC; and pooled WMDs of ventilation duration were −2.79 days for VAC and −2.89 days for IVAC.

Conclusions: VAE surveillance missed many cases of VAP, and the population characteristics identified by the two surveillance paradigms differed. VAE surveillance does not accurately detect cases of traditional VAP in ICUs.

Read the full article here

Which Models Can I Use to Predict Adult ICU Length of Stay? A Systematic Review.

Verburg, I. et al. Critical Care Medicine. Published online: October 20 2016


Objective: We systematically reviewed models to predict adult ICU length of stay.

Data Sources: We searched the Ovid EMBASE and MEDLINE databases for studies on the development or validation of ICU length of stay prediction models.

Study Selection: We identified 11 studies describing the development of 31 prediction models and three describing external validation of one of these models.

Data Extraction: Clinicians use ICU length of stay predictions for planning ICU capacity, identifying unexpectedly long ICU length of stay, and benchmarking ICUs. We required the model variables to have been published and for the models to be free of organizational characteristics and to produce accurate predictions, as assessed by R2 across patients for planning and identifying unexpectedly long ICU length of stay and across ICUs for benchmarking, with low calibration bias. We assessed the reporting quality using the Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modelling Studies.

Data Synthesis: The number of admissions ranged from 253 to 178,503. Median ICU length of stay was between 2 and 6.9 days. Two studies had not published model variables and three included organizational characteristics. None of the models produced predictions with low bias. The R2 was 0.05-0.28 across patients and 0.01-0.64 across ICUs. The reporting scores ranged from 49 of 78 to 60 of 78 and the methodologic scores from 12 of 22 to 16 of 22.

Conclusion: No models completely satisfy our requirements for planning, identifying unexpectedly long ICU length of stay, or for benchmarking purposes. Physicians using these models to predict ICU length of stay should interpret them with reservation.

Read the abstract here

A Randomized Trial of Palliative Care Discussions Linked to an Automated Early Warning System Alert.

Picker, D. et al. Critical Care Medicine. Published online: October 20 2016


Objective: To determine whether an Early Warning System could identify patients wishing to focus on palliative care measures.

Design: Prospective, randomized, pilot study.

Setting: Barnes-Jewish Hospital, Saint Louis, MO (January 15, 2015, to December 12, 2015).

Patients: A total of 206 patients; 89 intervention (43.2%) and 117 controls (56.8%).

Interventions: Palliative care in high-risk patients targeted by an Early Warning System.

Measurements and Main Results: Advanced directive documentation was significantly greater prior to discharge in the intervention group (37.1% vs 15.4%; p < 0.001) as were first-time requests for advanced directive documentation (14.6% vs 0.0%; p < 0.001). Documentation of resuscitation status was also greater prior to discharge in the intervention group (36.0% vs 23.1%; p = 0.043). There was no difference in the number of patients requesting a change in resuscitation status between groups (11.2% vs 9.4%; p = 0.666). However, changes in resuscitation status occurred earlier and on the general medicine units for the intervention group compared to the control group. The number of patients transferred to an ICU was significantly lower for intervention patients (12.4% vs 27.4%; p = 0.009). The median (interquartile range) ICU length of stay was significantly less for the intervention group (0 [0-0] vs 0 [0-1] d; p = 0.014). Hospital mortality was similar (12.4% vs 10.3%; p = 0.635).

Conclusions: This study suggests that automated Early Warning System alerts can identify patients potentially benefitting from directed palliative care discussions and reduce the number of ICU transfers.

Read the abstract here

Why are patients still getting and dying from acute kidney injury?.

Kellum, J. Current Opinion in Critical Care. Published online: October 18 2016

Purpose of review: Acute kidney injury is common and is associated with increased morbidity and mortality. Rates of acute kidney injury in most settings remain high and in some settings are increasing. Moreover, outcomes associated with acute kidney injury remain relatively poor. This review focuses on recent advances in understanding of acute kidney injury and discusses possible interventions based on these advances.

Recent findings: Acute kidney injury is not a disease with a single etiology and clinical course but rather a loose collection of syndromes whose unifying phenotype is an acute loss of glomerular filtration. Traditional taxonomy based on anatomic locations (pre, intra, and post) in reference to the kidney is overly simplistic and has given way to specific ‘endotypes’ including hepatorenal, cardiorenal, nephrotoxic, and sepsis-associated and these syndromes all have unique pathophysiologies and treatments. Our tendency to lump all of these clinical syndromes into a single disease and seek a single treatment has led to the profound lack of progress observed in terms of improving outcomes. The hope is that this is about to change.

Summary: Understanding the epidemiology, pathogenesis, and pathophysiology of acute kidney injury is critical to achieving improved outcomes for the millions of patients who develop this loose constellation of syndromes.

Read the abstract here