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Current Issue of “Journal of Intensive Care Medicine” Volume 32 Number 1 January 2017

jicm

The January 2017 issue can now have its contents page accessed via this link.

The articles contained in this issue include “Approach to the Complicated Alcohol Withdrawal Patient”, “Insulin and the Brain: A Sweet Relationship With Intensive Care” and “Improving Caregivers’ Perceptions Regarding Patient Goals of Care/End-of-Life Issues for the Multidisciplinary Critical Care Team”.

To access the full text of this issue direct from the journal’s own 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 request individual articles online via this link.

Care of the eye during anaesthesia and intensive care

 O’Driscoll, A. & White, E. Anaesthesia and Intensive Care Medicine. Published online: November 26 2016

B0004383 Distorted reflection of an eye

Image source: Dianne Harris – Wellcome Images // CC BY-NC-ND 4.0

Perioperative eye injuries and blindness are rare but important complications of anaesthesia. The three causes of postoperative blindness are ischaemic optic neuropathy, central retinal artery thrombosis (these can exist in tandem and have been described as ischaemic oculopathies) and cortical blindness.

This review aims to improve anaesthetists’ knowledge of orbital anatomy, ocular physiology and the mechanisms of perioperative eye injuries to help reduce their occurrence.

Read the abstract here

Chlorhexidine bathing and health care-associated infections among adult intensive care patients

Frost, S.A. et al. Critical Care. Published online: 23 November 2016

L0075034 An intensive care unit in a hospital.

Image source: Robert Priseman – Wellcome Images // CC BY-NC-ND 4.0

Background: Health care-associated infections (HAI) have been shown to increase length of stay, the cost of care, and rates of hospital deaths . Importantly, infections acquired during a hospital stay have been shown to be preventable. In particular, due to more invasive procedures, mechanical ventilation, and critical illness, patients cared for in the intensive care unit (ICU) are at greater risk of HAI and associated poor outcomes.

Conclusion: This meta-analysis of the effectiveness of CHG bathing to reduce infections among adults in the ICU has found evidence for the benefit of daily bathing with CHG to reduce CLABSI and MRSA infections. However, the effectiveness may be dependent on the underlying baseline risk of these events among the given ICU population. Therefore, CHG bathing appears to be of the most clinical benefit when infection rates are high for a given ICU population.

Read the full abstract and article here

Recruitment manoeuvres as a ventilation strategy for adults with acute respiratory failure due to lung injury

This wcochrane-57-1as published in the Cochrane Database of Systematic Reviews in November 2016.  The plain language summary is shown below with links to the full text of the review available via this link.

Background:  Acute respiratory failure is a common condition amongst adults admitted to intensive care units (ICUs) worldwide. Although respiratory failure has many causes, it may be due to a condition known as acute respiratory distress syndrome (ARDS). This term describes a condition in which both of the lungs have become injured and inflamed from one of various causes, and they do not work as they normally would to provide oxygen to and remove carbon dioxide from the body. This leads to a reduced amount of oxygen in the blood. Patients may require connection to a ventilator (breathing machine) to support their breathing. This therapy is known as mechanical ventilation. Supportive care with mechanical ventilation is an important pillar of standard treatment for patients with ARDS.

Although it may be life-saving, mechanical ventilation may further contribute to lung injury by expanding and collapsing the lungs or overstretching lung tissue. To minimize damage to injured lungs, smaller volumes of air at lower pressures have been used in conjunction with a positive opening pressure at the end of expiration (PEEP). This ventilation strategy has been shown to shorten the time that patients require mechanical ventilation while improving survival; it has been adopted as standard care for patients with ARDS who are in intensive care.

Along with this strategy, additional ventilation techniques have been developed. One such technique is known as a recruitment manoeuvre; when combined with higher PEEP, it is called the open lung ventilation strategy. A recruitment manoeuvre uses sustained deep breaths to assist in the recruitment – or re-opening – of collapsed lung units. This may increase the number of lung units available for breathing and may improve patient outcomes. Effects of recruitment manoeuvres have not been well established.

Search date: Evidence is current to August 2016.

Study characteristics: We included 10 trials in this review, which included a total of 1658 participants with acute respiratory distress syndrome.

Key results: Low-quality evidence suggests that recruitment manoeuvres improve ICU survival but not 28-day or hospital survival. Recruitment manoeuvres have no effect on the risk of air leakage from the lungs.

Quality of the evidence: We found the evidence for most outcomes to be of low to moderate quality, primarily because of the design of included trials. Many trials used the recruitment manoeuvre in conjunction with other ventilation techniques or strategies, and this might have influenced outcomes. Caution should be applied when conclusions are drawn about the effectiveness of the recruitment manoeuvre alone.

High-flow nasal cannula oxygen therapy vs conventional oxygen therapy in cardiac surgical patients: A meta-analysis

This article is to be published in the Journal of Critical Care.  The full text of the article can be accessed via this link.

Introduction:  The use of high-flow nasal cannula (HFNC) for the treatment of many diseases has gained increasing popularity. In the present meta-analysis, we aimed to assess the efficacy and safety of HFNCs compared with conventional oxygen therapy (COT) in adult postextubation cardiac surgical patients.

Method:  We reviewed the Embase, PubMed, Cochrane Central Register of Controlled Trials, Wanfang databases, and the China National Knowledge Infrastructure. Two investigators independently collected the data and assessed the quality of each study. RevMan 5.3 was used for the present meta-analysis.

Results:  We included 495 adult postextubation cardiac surgical patients. There was no significant heterogeneity among the studies. Compared with COT, HFNCs were associated with a significant reduction in the escalation of respiratory support (risk ratio, 0.61; 95% confidence interval [CI], 0.46-0.82; z = 3.32, P < .001). There were no significant differences in the reintubation rate (risk ratio, 0.96; 95% CI, 0.04-24.84; z = 0.02, P = .98) or length of intensive care unit stay (weighted mean difference, 0.13; 95% CI, −0.88 to 7.92; z = 1.57, P = .12) between the 2 groups. No severe complications were reported in either group.

Conclusions:  The HFNC could reduce the need for escalation of respiratory support compared with COT, and it could be safely administered in adult postextubation cardiac surgical patients.

COOLIST (Cooling for Ischemic Stroke Trial): A Multicenter, Open, Randomized, Phase II, Clinical Trial

This article was published on the journal Stroke’s website in November 2017.  Subscribers to the journal may access the full text of the article via this link.

Background and Purpose—Animal studies suggest that cooling improves outcome after ischemic stroke. We assessed the feasibility and safety of surface cooling to different target temperatures in awake patients with acute ischemic stroke.

Methods—A multi centre, randomized, open, phase II, clinical trial, comparing standard treatment with surface cooling to 34.0°C, 34.5°C, or 35.0°C in awake patients with acute ischemic stroke and an National Institutes of Health Stroke Scale score of ≥6, initiated within 4.5 hours after symptom onset and maintained for 24 hours. The primary outcome was feasibility, defined as the proportion of patients who had successfully completed the assigned treatment. Safety was a secondary outcome.

Results—Inclusion was terminated after 22 patients because of slow recruitment. Five patients were randomized to 34.0°C, 6 to 34.5°C, 5 to 35.0°C (cooling was initiated in 4), and 6 to standard care. No (0%), 1 (17%), and 3 (75%) patients, respectively, completed the assigned treatment (P=0.03). No (0%), 2 (33%), and 4 (100%) patients reached the target temperature (P=0.01). Pneumonia occurred in 8 cooled patients but not in controls (absolute risk increase, 53%; 95% confidence interval, 28–79%; P=0.002).

Conclusions—In awake patients with acute ischemic stroke, surface cooling is feasible to 35.0°C, but not to 34.5°C and 34.0°C. Cooling is associated with an increased risk of pneumonia.