Critical Care Reviews Newsletter 364 3rd December 2018

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 a randomised controlled trial on APRV in paediatric ARDS; a systematic review and meta analysis on non-pharmacological interventions in reducing the incidence and duration of delirium; and an observational study looking at the mortality changes associated with mandated public reporting for sepsis in New York. There are also multiple guidelines, including a series from the American Society of Hematology on venothromboembolism; as well as narrative reviews on decompressive craniectomy in traumatic brain injury & what’s new in heart failure therapy 2018; editorials on guiding ventilation with transpulmonary pressure &chloride; and commentaries on hemoadsorption with CytoSorb & management of victims contaminated with radionuclides after a “dirty bomb” attack.”
The full text of the newsletter is available via this link.

Characteristics, management, and in-hospital mortality among patients with severe sepsis in intensive care units in Japan: the FORECAST study.

This article by Abe and colleagues appeared in the November 2018 issue of Critical Care.
Background:  Sepsis is a leading cause of death and long-term disability in developed countries. A comprehensive report on the incidence, clinical characteristics, and evolving management of sepsis is important. Thus, this study aimed to evaluate the characteristics, management,and outcomes of patients with severe sepsis in Japan.
Methods:  This is a cohort study of the Focused Outcomes Research in Emergency Care in Acute Respiratory Distress Syndrome,Sepsis, and Trauma (FORECAST) study, which was a multicentre, prospective cohort study conducted at 59 intensive care units (ICUs) from January 2016 to March 2017. We included adult patients with severe sepsis based on the sepsis-2 criteria.
Results:  In total, 1184 patients (median age 73 years,inter quartile range (IQR) 64-81) with severe sepsis were admitted to the ICU during the study period. The most common comorbidity was diabetes mellitus(23%). Moreover, approximately 63% of patients had septic shock. The median Sepsis-related Organ Failure Assessment (SOFA) score was 9 (IQR 6-11). The most common site of infection was the lung (31%). Approximately 54% of the participants had positive blood cultures. The compliance rates for the entire 3-h bundle, measurement of central venous pressure, and assessment of central venous oxygen saturation were 64%, 26%, and 7%, respectively. A multi level logistic regression model showed that closed ICUs and non-university hospitals were more compliant with the entire 3-h bundle. The in-hospital mortality rate of patients with severe sepsis was 23% (21-26%). Older age, multiple co-morbidities, suspected site of infection, and increasing SOFA scores correlated with in-hospital mortality, based on the generalized estimating equation model. The length of hospital stay was 24 (12-46) days. Approximately 37% of the patients were discharged home after recovery.
Conclusion:  Our prospective study showed that sepsis management in Japan was characterized by a high compliance rate for the 3-h bundle and low compliance rate for central venous catheter measurements. The in-hospital mortality rate in Japan was comparable to that of other developed countries. Only one third of the patients were discharged home, considering the aging population with multiple co-morbidities in the ICUs in Japan.
The full text of the article is freely available via this link.

TroponinI at admission in the intensive care unit predicts the need of dialysis in septic patients

This article by de Almeida Thiengo and colleagues was published in BMC Nephrology in November 2018.
Background:  In a previous study we showed that troponin I (TnI) > 0.42 ng/mL predicted the need of dialysis in a group of 29 septic patients admitted to the intensive care unit (ICU). We aimed to confirm such finding in a larger independent sample.
Methods:  All septic patients admitted to an ICU from March 2016 to February 2017 were included if age between 18 and 90 years, onset of sepsis  0.42 ng/mL. These patients had serum creatinine slightly higher (1.66 ± 0.34 vs. 1.32 ± 0.39 mg/dL; P <  0.0001)than those with lower TnI and similar urine output (1490 ± 682 vs. 1406 ± 631 mL;P = 0.44). At the end of the follow-up period, 70.0% of the patients with lower TnI were alive in comparison with 38.6% of those with higher TnI (p = 0.0014).After 30 days, 69.3 and 2.9% of the patients with lower and higher TnI levels remained free of dialysis, respectively (p  0.42 ng/mL persisted as a strong predictor of dialysis need (hazard ratio 3.48 [95%CI 1.69-7.18]).
Conclusions:  TnI levels at ICU admission are a strong independent predictor of dialysis need in sepsis.
The full text of the article is freely available via this link.

Critical Care Reviews Newsletter 363 25th November 2018

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 are guidelines on paediatric parenteral nutrition, narrative reviews on minimal invasive monitoring and initial treatment of the septic patient & acute-on-chronic liver failure vs. traditional acute decompensation of cirrhosis; editorials on extra corporeal life support & ventilation management”.
The full text of the newsletter is available via this link.

The Impact of Social Support Networks on Family Resilience in an Australian Intensive Care Unit: A Constructivist Grounded Theory.

This article by Wong and colleagues was published in the Journal of Nursing Scholarship during November 2018.
Purpose:  This article discusses the findings of a grounded theory of family resilience in an Australian intensive care unit (ICU) with a specific focus on families’experiences of their interactions with other members within their own family,and the families of other patients in the ICU.
Design:  A constructivist grounded theory methodology was adopted. Data were collected using in-depth interviews with 25 family members of 21 critically ill patients admitted to a tertiary-level ICU in Australia.
Findings:  The core category regaining control represents the families’ journey toward resilience when in ICU. The major categories represent facilitators for, and barriers to,regaining control. One of the main facilitators is drawing strength, and it explains the manner with which families receive social support from their own and other family members to help them cope.
Conclusions:  This study offers a framework to improve patient- and family-centered care in the ICU by facilitating families’ ability to manage their situation more effectively.Social support offered by family members facilitates the families’ ability to regain control. An ICU family resilience theoretical framework, situated within the context of the Australian healthcare system, adds to what is currently known about the families’ experiences in the ICU.
Clinical Relevance: The relationships that develop between families in the ICU may provide a source of social support; however, not all families welcome interactions with other ICU families, and it may cause further emotional distress. Further research is warranted to determine whether families suffer a secondary stress reaction from incidental interactions with other patients’ families in the ICU.Furthermore, when family members pull together and offer social support to each other, they are better able to regain control. This process contributes to an ICU family resilience framework.
To access the full text of this article via the journal’s homepage you require a personal subscription to the journal.  Some articles may be available freely without a password. Library members can order individual articles via the Rotherham NHS Foundation Trust Library and Knowledge Service using the article requests online via this link.

Effects of a Multimodal Program Including Simulation on Job Strain Among Nurses Working in Intensive Care Units: A Randomized Clinical Trial

This article by El Khamali and others was published inJAMA during November 2018.
Importance:  Nurses working in an intensive care unit (ICU) are exposed to occupational stressors that can increase the risk of stress reactions, long-term absenteeism, and turnover.
Objective:  To evaluate the effects of a program including simulation in reducing work-related stress and work-related outcomes among ICU nurses.
Design, Setting, and Participants:  Multi-center randomized clinical trial performed at 8 adult ICUs in France from February 8, 2016, through April 29,2017. A total of 198 ICU nurses were included and followed up for 1 year until April 30, 2018.
Interventions:  The ICU nurses who had at least 6 months of ICU experience were randomized to the intervention group (n = 101) or to the control group (n = 97). The nurses randomized to the intervention group received a 5-day course involving a nursing theory recap and situational role-play using simulated scenarios (based on technical dexterity, clinical approach, decision making, aptitude to teamwork, and task prioritization),which were followed by debriefing sessions on attitude and discussion of practices.
Main Outcomes and Measures:  The primary outcome was the prevalence of job strain assessed by combining a psychological demand score greater than 21(score range, 9 [best] to 36 [worst]) with a decision latitude score less than 72 (score range, 24 [worst] to 96 [best]) using the Job Content Questionnaire and evaluated at 6 months. There were 7 secondary outcomes including absenteeism and turnover.
Results:  Among 198 ICU nurses who were randomized (95 aged ≤30 years [48%] and 115 women [58%]),182 (92%) completed the trial for the primary outcome. The trial was stopped for efficacy at the scheduled interim analysis after enrollment of 198 participants. The prevalence of job strain at 6 months was lower in the intervention group than in the control group (13% vs 67%, respectively;between-group difference, 54% [95% CI, 40%-64%]; P < .001). Absenteeism during the 6-month follow-up period was 1% in the intervention group compared with 8% in the control group (between-group difference, 7% [95% CI, 1%-15%];P = .03). Four nurses (4%) from the intervention group left the ICU during the 6-month follow-up period compared with 12 nurses (12%) from the control group(between-group difference, 8% [95% CI, 0%-17%]; P = .04).
Conclusions and Relevance:  Among ICU nurses, an intervention that included education, role-play, and debriefing resulted in a lower prevalence of job strain at 6 months compared with nurses who did not undergo this program.Further research is needed to understand which components of the program may have contributed to this result and to evaluate whether this program is cost-effective.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.

Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients without ARDS: A Randomized Clinical Trial.

This article by the Writing Group for the PReVENT Investigators was published in JAMA in November 2018.
Importance:  It remains uncertain whether invasive ventilation should use low tidal volumes in critically ill patients without acute respiratory distress syndrome (ARDS).
Objective:  To determine whether a low tidal volume ventilation strategy is more effective than an intermediate tidal volume strategy.
Design,Setting, and Participants:  A randomized clinical trial, conducted from September 1, 2014, through August 20, 2017,including patients without ARDS expected to not be extubated within 24 hours after start of ventilation from 6 intensive care units in the Netherlands.
Interventions:  Invasive ventilation using low tidal volumes(n = 477) or intermediate tidal volumes (n = 484).
Main Outcomes and Measures:  The primary outcome was the number of ventilator-free days and alive at day 28. Secondary outcomes included length of ICU and hospital stay; ICU, hospital, and 28- and 90-day mortality; and development of ARDS, pneumonia, severe atelectasis, orpneumothorax.
Results:  In total, 961 patients (65% male), with a median age of 68 years (interquartile range [IQR], 59-76), were enrolled. Atday 28, 475 patients in the low tidal volume group had a median of 21 ventilator-free days (IQR, 0-26), and 480 patients in the intermediate tidal volume group had a median of 21 ventilator-free days (IQR, 0-26) (mean difference, -0.27 [95% CI, -1.74 to 1.19]; P = .71). There was no significant difference in ICU (median, 6 vs 6 days; 0.39 [-1.09 to 1.89]; P = .58) and hospital (median, 14 vs 15 days; -0.60 [-3.52 to 2.31]; P = .68) length of stayor 28-day (34.9% vs 32.1%; hazard ratio [HR], 1.12 [0.90 to 1.40]; P = .30) and90-day (39.1% vs 37.8%; HR, 1.07 [0.87 to 1.31]; P = .54) mortality. There was no significant difference in the percentage of patients developing the following adverse events: ARDS (3.8% vs 5.0%; risk ratio [RR], 0.86 [0.59 to 1.24];P = .38), pneumonia (4.2% vs 3.7%; RR, 1.07 [0.78 to 1.47]; P = .67), severeatelectasis (11.4% vs 11.2%; RR, 1.00 [0.81 to 1.23]; P = .94), and pneumothorax (1.8% vs 1.3%; RR, 1.16 [0.73 to 1.84]; P = .55).  
Conclusions and Relevance:  In patients in the ICU without ARDS who were expected not to be extubated within 24 hours of randomization, a low tidal volume strategy did not result in a greater number of ventilator-free days than an intermediate tidal volume strategy.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.  The full text of the article should be available using a Rotherham NHS Athens password one month after publication via this link.

Effect of Protocolized Weaning With Early Extubation to Non-invasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial

This article by Perkins and colleagues was published in JAMA during November 2018.
Importance:  In adults in whom weaning from invasive mechanical ventilation is difficult, non-invasive ventilation may facilitate early liberation, but there is uncertainty about its effectiveness in a general intensive care patient population.
Objective:  To investigate among patients with difficulty weaning the effects of protocolized weaning with early extubation to non-invasive ventilation on time to liberation from ventilation compared with protocolized invasive weaning.
Design,Setting, and Participants:  Randomized,allocation-concealed, open-label, multicenter clinical trial enrolling patients between March 2013 and October 2016 from 41 intensive care units in the UK National Health Service. Follow-up continued until April 2017. Adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed were enrolled.
Interventions:  Patients were randomized to receive either protocolized weaning via early extubation to non-invasive ventilation (n = 182)or protocolized standard weaning (continued invasive ventilation until successful spontaneous breathing trial, followed by extubation) (n = 182).
Main Outcomes and Measures:  Primary outcome was time from randomization to successful liberation from all forms of mechanical ventilation among survivors, measured in days, with the minimal clinically important difference defined as 1 day. Secondary outcomes were duration of invasive and total ventilation (days), reintubation or tracheostomyrates, and survival.
Results:  Among 364 randomized patients (mean age, 63.1[SD, 14.8] years; 50.5% male), 319 were evaluable for the primary effectiveness outcome (41 died before liberation, 2 withdrew, and 2 were discharged with ongoing ventilation). The median time to liberation was 4.3 days in the non-invasive group vs 4.5 days in the invasive group (adjusted hazard ratio, 1.1; 95% CI, 0.89-1.40).Competing risk analysis accounting for deaths had a similar result (adjusted hazard ratio, 1.1; 95% CI, 0.86-1.34). The non-invasive group received less invasive ventilation (median, 1 day vs 4 days; incidence rate ratio, 0.6; 95%CI, 0.47-0.87) and fewer total ventilator days (median, 3 days vs 4 days;incidence rate ratio, 0.8; 95% CI, 0.62-1.0). There was no significant difference in reintubation, tracheostomy rates, or survival. Adverse events occurred in 45 patients (24.7%) in the non-invasive group compared with 47(25.8%) in the invasive group.
Conclusions and Relevance:  Among patients requiring mechanical ventilation in whom a spontaneous breathing trial had failed, early extubation to non-invasive ventilation did not shorten time to liberation from any ventilation.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital. 
The full text of the article should be available using a Rotherham NHS Athens password one month after publication via this link.

Systematic review of incretin therapy during peri-operative and intensive care

This research by Hulst and colleagues was published in Critical Care in November 2018.  
Background:  Glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic peptide (GIP) are incretin hormones. By lowering blood glucose in a glucose-dependent manner, incretin-based therapies represent a novel and promising intervention to treat hyperglycaemia in hospital settings. We performed a systematic review of the literature for allcurrent applications of incretin-based therapies in the peri-operative and critical care settings.
Methods:  We searched MEDLINE, the Cochrane Library,and Embase databases for all randomised controlled trials using exogenous GLP-1, GLP-1 receptor agonists, exogenous GIP and dipeptidyl peptidase IVinhibitors in the setting of adult peri-operative care or intensive care. We defined no comparator treatment. Outcomes of interest included blood glucose,frequency of hypoglycaemia and insulin administration.
Results:  Of the 1190 articles identified during the initial literature search, 38 fulfilled criteria for full-text review, and 19 single-centre studies were subsequently included in the qualitative review. Of the 18 studies reporting glycaemic control, improvement was reported in 15,defined as lower glucose concentrations in 12 and as reduced insulin administration (with similar glucose concentrations) in 3. Owing to heterogeneity, meta-analysis was possible only for the outcome of hypoglycaemia. This revealed an incidence of 7.4% in those receiving incretin-based therapies and 6.8% in comparator groups (P = 0.94).
Conclusions:  In small, single-centre studies, incretin-based therapies lowered blood glucose and reduced insulin administration without increasing the incidence of hypoglycaemia.
The full text of the article is freely available via this link.

ICU physicians’ and internists’ survival predictions for patients evaluated for admission to the intensive care unit

This article by Escher et al was published in the November issue of Annals of Intensive Care.
Background:  A higher chance of survival is a key justification for admission to the intensive care unit (ICU). This implies that physicians should be able to accurately estimate a patient’s prognosis, whether cared for on the ward or in the ICU. We aimed to determine whether physicians’survival predictions correlate with the admission decisions and with patients’observed survival. Consecutive ICU consultations for internal medicine patients were included. The ICU physician and the internist were asked to predict patient survival with intensive care and with care on the ward using 5 categories of probabilities ( 90%). Patient mortality at 28 days was recorded.
Results:  Thirty ICU physicians and 97 internists assessed 201 patients for intensive care. Among the patients, 140 (69.7%) were admitted to the ICU. Fifty-eight (28.9%) died within 28 days. Admission to intensive care was associated with predicted survival gain in the ICU, particularly for survival estimates made by ICU physicians. Observed survival was associated with predicted survival, for both groups of physicians. The discrimination of the predictions for survival with intensive care, measured by the area under the ROC curve, was 0.63 for ICU physicians and 0.76 for internists; for survival on the ward the areas under the ROC curves were 0.69 and 0.74, respectively.
Conclusions:  Physicians are able to predict survival probabilities when they assess patients for intensive care, albeit imperfectly.Internists are more accurate than ICU physicians. However, ICU physicians’estimates more strongly influence the admission decision. Closer collaboration between ICU physicians and internists is needed.
The full text of the article is freely available via this link.