Intensive Care Medicine Volume 44 Number 4 April 2018

intensive-care-medicine

To view Intensive Care Medicine’s April issue’s contents page follow this link.

Articles published in this issue include: “Organ support therapy in the intensive care unit and return to work: a nationwide, register-based cohort study”, “Procalcitonin algorithm to guide initial antibiotic therapy in acute exacerbations of COPD admitted to the ICU: a randomized multicenter study” and “Fluid therapy in neurointensive care patients: ESICM consensus and clinical practice recommendations”.

To read the full text of any of these articles via the journal’s homepage requires a personal subscription to “Intensive Care Medicine” though some are available open access.  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 333 29th April 2018

The Critical Care Reviews Newsletter brings you the best critical care research and open access articles from across the last week’s medical literature. The edition’s “highlights are randomicritcal care reviewssed controlled trials on oxygen titration after resuscitation from out-of-hospital cardiac arrest, rapid response systems in acute hospitals, & tenecteplase versus alteplase before thrombectomy for ischemic stroke; meta-analysis on early goal-directed therapy in sepsis & viscoelastic haemostatic assays in non-cardiac surgical settings, an observation study on nutritional therapy in Australian and New Zealand ICUs; plus guidelines & statements on hypovolemia in sepsis & scientific knowledge gaps and clinical research priorities for CPR and emergency cardiovascular care. There are also narrative reviews on rethinking current resuscitation strategies, mechanically ventilating the severe asthmatic & tissue oedema in sepsis; as well as commentaries on direct oral anticoagulants & time for a new definition of death?”

The full text of newsletter 333 can be found via this link

Forced fluid removal in intensive care patients with acute kidney injury: The randomised FFAKI feasibility trial

This article by Berthelsen et al was published in the April 2018 issue of Acta Anaesthesiologica Scandinavica.
Background:  Accumulation of fluids is frequent in intensive care unit (ICU) patients with acute kidney injury and may be associated with increased mortality and decreased renal recovery. We present the results of a pilot trial assessing the feasibility of forced fluid removal in ICU patients with acute kidney injury and fluid accumulation of more than 10% ideal bodyweight.
Methods:  The FFAKI-trial was a pilot trial of forced fluid removal vs standard care in adult ICU patients with moderate to high risk acute kidney injury and 10% fluid accumulation. Fluid removal was done with furosemide and/or continuous renal replacement therapy aiming at net negative fluid balance > 1 mL/kg ideal body weight/hour until cumulative fluid balance calculated from ICU admission reached less than 1000 mL.
Results:  After 20 months, we stopped the trial prematurely due to a low inclusion rate with 23 (2%) included patients out of the 1144 screened. Despite the reduced sample size, we observed a marked reduction in cumulative fluid balance 5 days after randomisation (mean difference -5814 mL, 95% CI -2063 to -9565, P = .003) with forced fluid removal compared to standard care. While the trial was underpowered for clinical endpoints, no point estimates suggested harm from forced fluid removal.
Conclusions:  Forced fluid removal aiming at 1 mL/kg ideal body weight/hour may be an effective treatment of fluid accumulation in ICU patients with acute kidney injury. A definitive trial using our inclusion criteria seems less feasible based on our inclusion rate of only 2%.
To access the full text of these articles 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.

Accuracy of Acid-Base Diagnoses Using the Central Venous Blood Gas in the Medical Intensive Care Unit

This research by Schrauben and colleagues was published in Nephron in April 2018.
Background:  Acid-base disturbances are frequent in critically ill patients. Arterial blood gas (ABG) is the gold standard in the diagnosis of these disturbances, but it is invasive with potential hazards. For patients with a central venous catheter, venous blood gas (VBG) sampling may be an alternative, less-invasive diagnostic tool. However, the accuracy of a central VBG-based acid-base disorder diagnosis compared to an ABG is unknown. The primary objective of this study was to assess the accuracy of a central VBG-based acid-base disorder diagnosis compared to the “gold standard” ABG in critically ill patients.
Methods:  This was a study of adult patients in a medical intensive care unit that had simultaneously drawn ABG and central VBG samples. Expert acid-base diagnosticians, all nephrologists, diagnosed the acid-base disorder(s) in each blood gas sample. The central VBG diagnostic accuracy was assessed with percent agreement, sensitivity, and specificity compared to the ABG-based diagnosis.
Results:  The study involved 23 participants. Overall, the central VBG had 100% sensitivity for metabolic acidosis, metabolic alkalosis, and respiratory acidosis, and lower sensitivity (71%) for respiratory alkalosis, and high percent agreement, ranging from 75 to 94%. VBG-based diagnoses in vasopressor-dependent patients (n = 13, 56.5%) performed similarly to the entire sample.
Conclusions:  In critically ill adult patients, central VBG may be used to detect and diagnose acid-base disturbances with reasonable diagnostic accuracy, even in shock states, compared to the ABG. This study supports the use of central VBG for diagnosis of acid-base disturbances in critically ill patients.
To access the full text of these articles 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.

Therapeutic hypothermia and pressure ulcer risk in critically ill intensive care patients: A retrospective study

This article by Ahtiala et al was published in Intensive and Critical Care Nursing in April 2018.
Objective:  To examine the role of therapeutic hypothermia in pressure ulcer development in critically ill patients.
Research Methodology:  Retrospective study in a mixed intensive care unit over 2010-2013. The incidences of pressure ulcers among patients treated with therapeutic hypothermia (n = 148) and the non-hypothermia patient population (n = 6197) were compared.
Results:  Patients treated with hypothermia developed more pressure ulcers (25.0%) than the non-hypothermia group 6.3% (p < 0.001). More patients in the hypothermia group were rated as the high pressure ulcer risk group, as defined by the modified Jackson/Cubbin (mJ/C) risk score ≤29 than the rest of the patients. Among the therapeutic hypothermia patients more pressure ulcers tended to emerge in the lower risk group (mJ/C score ≥30) (p = 0.056). Intensive care mortality was higher in the hypothermia (24.3%) than the non-hypothermia group (9.3%, p < 0.0001).
Conclusion:  Patients treated with therapeutic hypothermia should be considered at high risk for pressure ulcer development and should be managed accordingly. The hypothermia may not as such increase the risk for pressure ulcers, but combined with the severity of the underlying illness, may be more likely. The pressure ulcer risk in this patient group cannot be reliably assessed by the Jackson/Cubbin risk scale.
To access the full text of these articles 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.

BIS monitoring versus clinical assessment for sedation in mechanically ventilated adults in the intensive care unit and its impact on clinical outcomes and resource utilization

cochrane-57-1This Cochrane Systematic Review by Shety and colleagues was published on 21 February 2018

BackgroundPatients admitted to intensive care and on mechanical ventilation, are administered sedative and analgesic drugs to improve both their comfort and interaction with the ventilator. Optimizing sedation practice may reduce mortality, improve patient comfort and reduce cost. Current practice is to use scales or scores to assess depth of sedation based on clinical criteria such as consciousness, understanding and response to commands. However these are perceived as subjective assessment tools. Bispectral index (BIS) monitors, which are based on the processing of electroencephalographic signals, may overcome the restraints of the sedation scales and provide a more reliable and consistent guidance for the titration of sedation depth.

The benefits of BIS monitoring of patients under general anaesthesia for surgical procedures have already been confirmed by another Cochrane review. By undertaking a well‐conducted systematic review our aim was to find out if BIS monitoring improves outcomes in mechanically ventilated adult intensive care unit (ICU) patients.

Objectives:  To assess the effects of BIS monitoring compared with clinical sedation assessment on ICU length of stay (LOS), duration of mechanical ventilation, any cause mortality, risk of ventilator‐associated pneumonia (VAP), risk of adverse events (e.g. self‐extubation, unplanned disconnection of indwelling catheters), hospital LOS, amount of sedative agents used, cost, longer‐term functional outcomes and quality of life as reported by authors for mechanically ventilated adults in the ICU.

Search methods:  We searched CENTRAL, MEDLINE, Embase, CINAHL, ProQuest, OpenGrey and SciSearch up to May 2017 and checked references citation searching and contacted study authors to identify additional studies. We searched trial registries, which included clinicaltrials.gov and controlled‐trials.com.

Selection criteria:  We included all randomized controlled trials comparing BIS versus clinical assessment (CA) for the management of sedation in mechanically ventilated critically ill adults.

Data collection and analysis:  We used Cochrane’s standard methodological procedures. We undertook analysis using Revman 5.3 software.

Main results:  We identified 4245 possible studies from the initial search. Of those studies, four studies (256 participants) met the inclusion criteria. One more study is awaiting classification. Studies were, conducted in single‐centre surgical and mixed medical‐surgical ICUs. BIS monitor was used to assess the level of sedation in the intervention arm in all the studies. In the control arm, the sedation assessment tools for CA included the Sedation‐Agitation Scale (SAS), Ramsay Sedation Scale (RSS) or subjective CA utilizing traditional clinical signs (heart rate, blood pressure, conscious level and pupillary size). Only one study was classified as low risk of bias, the other three studies were classified as high risk.

There was no evidence of a difference in one study (N = 50) that measured ICU LOS (Median (Interquartile Range IQR) 8 (4 to 14) in the CA group; 12 (6 to 18) in the BIS group; low‐quality evidence).There was little or no effect on the duration of mechanical ventilation (MD ‐0.02 days (95% CI ‐0.13 to 0.09; 2 studies; N = 155; I2 = 0%; low‐quality evidence)). Adverse events were reported in one study (N = 105) and the effects on restlessness after suction, endotracheal tube resistance, pain tolerance during sedation or delirium after extubation were uncertain due to very low‐quality evidence. Clinically relevant adverse events such as self‐extubation were not reported in any study. Three studies reported the amount of sedative agents used. We could not measure combined difference in the amount of sedative agents used because of different sedation protocols and sedative agents used in the studies. GRADE quality of evidence was very low. No study reported other secondary outcomes of interest for the review.

Authors’ conclusions:  We found insufficient evidence about the effects of BIS monitoring for sedation in critically ill mechanically ventilated adults on clinical outcomes or resource utilization. The findings are uncertain due to the low‐ and very low‐quality evidence derived from a limited number of studies.

The full text of the review can be found via this link.

Critical Care Reviews Newsletter 331 15th April 2018

The Critical Care Reviews Newsletter provides you with the best critical care research and open access articles from across the medical literature over the last week. “The highlights of this week’s newsletter are randomised controlled trials on APRV in paediatric ARDS & a polyclonal antibody preparation in patients with severe community-acquired pneumonia; observational studies on Karoshi and cerebral autoregulation in the prediction of delayed cerebral ischemia; guidelines on acute non-invasive ventilation & right-sided heart failure; narrative reviews on chloride levels in critical illness, antibiotic therapy in ventilator-associated tracheobronchitis & reversal agents for non-vitamin K antagonist oral anticoagulants.”
The full text of newsletter 331 can be found via this link

Propofol for the promotion of sleep in adults in the intensive care unit

This Cochrane Systematic Review by Lewis and colleagues was published on 8th January 2018.
Background:  People in the intensive care unit (ICU) experience sleep deprivation caused by environmental disruption, such as high noise levels and 24‐hour lightcochrane-57-1ing, as well as increased patient care activities and invasive monitoring as part of their care. Sleep deprivation affects physical and psychological health, and people perceive the quality of their sleep to be poor whilst in the ICU. Propofol is an anaesthetic agent which can be used in the ICU to maintain patient sedation and some studies suggest it may be a suitable agent to replicate normal sleep.
Objectives:  To assess whether the quantity and quality of sleep may be improved by administration of propofol to adults in the ICU and to assess whether propofol given for sleep promotion improves both physical and psychological patient outcomes.
Search methods:  We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2017, Issue 10), MEDLINE (1946 to October 2017), Embase (1974 to October 2017), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1937 to October 2017) and PsycINFO (1806 to October 2017). We searched clinical trials registers for ongoing studies, and conducted backward and forward citation searching of relevant articles.
Selection criteria:  We included randomized and quasi‐randomized controlled trials with adults, over the age of 16 years, admitted to the ICU with any diagnoses, given propofol versus a comparator to promote overnight sleep. We included participants who were and were not mechanically ventilated. We included studies that compared the use of propofol, given at an appropriate clinical dose with the intention of promoting night‐time sleep, against: no agent; propofol at a different rate or dose; or another agent, administered specifically to promote sleep. We included only studies in which propofol was given during ‘normal’ sleeping hours (i.e. between 10 pm and 7 am) to promote a sleep‐like state with a diurnal rhythm.
Data collection and analysis:  Two review authors independently assessed studies for inclusion, extracted data, assessed risk of bias and synthesized findings.
Main results:  We included four studies with 149 randomized participants. We identified two studies awaiting classification for which we were unable to assess eligibility and one ongoing study.
Participants differed in severity of illness as assessed by APACHE II scores in three studies and further differences existed between comparisons and methods. One study compared propofol versus no agent, one study compared different doses of propofol and two studies compared propofol versus a benzodiazepine (flunitrazepam, one study; midazolam, one study). All studies reported randomization and allocation concealment inadequately. We judged all studies to have high risk of performance bias from personnel who were unblinded. We noted that some study authors had blinded study outcome assessors and participants for relevant outcomes.  It was not appropriate to combine data owing to high levels of methodological heterogeneity.
One study comparing propofol with no agent (13 participants) measured quantity and quality of sleep using polysomnography; study authors reported no evidence of a difference in duration of sleep or sleep efficiency, and reported disruption to usual REM (rapid eye movement sleep) with propofol.
One study comparing different doses of propofol (30 participants) measured quantity and quality of sleep by personnel using the Ramsay Sedation Scale; study authors reported that more participants who were given a higher dose of propofol had a successful diurnal rhythm, and achieved a greater sedation rhythmicity.
Two studies comparing propofol with a different agent (106 participants) measured quantity and quality of sleep using the Pittsburgh Sleep Diary and the Hospital Anxiety and Depression Scale; one study reported fewer awakenings of reduced duration with propofol, and similar total sleep time between groups, and one study reported no evidence of a difference in sleep quality. One study comparing propofol with another agent (66 participants) measured quantity and quality of sleep with the Bispectral Index and reported longer time in deep sleep, with fewer arousals. One study comparing propofol with another agent (40 participants) reported higher levels of anxiety and depression in both groups, and no evidence of a difference when participants were given propofol.
No studies reported adverse events.
We used the GRADE approach to downgrade the certainty of the evidence for each outcome to very low. We identified sparse data with few participants, and methodological differences in study designs and comparative agents introduced inconsistency, and we noted that measurement tools were imprecise or not valid for purpose.
Authors’ conclusions:  We found insufficient evidence to determine whether administration of propofol would improve the quality and quantity of sleep in adults in the ICU. We noted differences in study designs, methodology, comparative agents and illness severity amongst study participants. We did not pool data and we used the GRADE approach to downgrade the certainty of our evidence to very low.

The full text of the review can be found via this link.

Critical Care Reviews Newsletter 330 8th April 2018

The 330th Critical Care Reviews Newsletter brings “you the best critical care research and open access articles from across the medical literature over the past seven days. The highcritcal care reviewslights of this week’s newsletter are clinical reviews on reperfusion in patients with acute coronary syndrome, hypomagnesemia in critically ill patients & lung ultrasonography and echocardiography in ICU; plus non-clinical reviews on preprints & how pragmatic are randomized controlled trials labelled as pragmatic.”

The full text of newsletter 330 can be found via this link

Organ support therapy in the intensive care unit and return to work: a nationwide, register-based cohort study

This study by Riddersholm and colleagues was published in Intensive Care Medicine in April 2018.
Purpose:  The association between severity of illness and ability to return to work is unclear. Therefore, we investigated return to work and associations with measures of illness severity in ICU survivors.
Methods:  We conducted this cohort study using Danish registry data for the period 2005-2014 on ICU patients who were discharged alive from hospital, had an ICU length of stay (LOS) of at least 72h, were not treated with dialysis before hospital admission and were working prior to admission. We assessed (1) the cumulative incidence (chance) of return to work (2005-2017) and receipt of social benefits after discharge from a hospital stay with ICU admission and (2) the association between organ support therapies (renal replacement therapy, cardiovascular support and mechanical ventilation), and during 2011-2014 SAPS II and ICU LOS, and return to work, using multi-variable Cox regression.
Results:  Among 5762 ICU survivors, 68% returned to work within 2 years after hospital discharge. Disability and sickness benefits constituted 89% of social benefits among patients not returning to work and 59% among patients withdrawing from work following an initial return to work. Mechanical ventilation (HR 0.70, 95% CI [0.65-0.77]), but not RRT (HR 0.85, 95% CI [0.71-1.02]), cardiovascular support (HR 0.93, 95% CI [0.82-1.07]) and increasing SAPS II, was associated with decreased chance of return to work. Increasing ICU LOS was also associated with a decreased chance of return to work.
Conclusions:  The majority of a nationwide cohort of ICU survivors returned to work. Sick leave and receipt of disability pension were common following ICU admission. Mechanical ventilation and longer ICU LOS were associated with reduced chances of return to work.
To access the full text of these articles 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.