Critical Care Reviews Newsletter 419 22nd December 2019

The Critical Care Reviews Newsletter includes 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 randomised controlled trials on comparing rocuronium with succinylcholine on endotracheal intubation in out-of-hospital rapid sequence intubation & inhaled amikacin adjunctive to intravenous standard-of-care antibiotics in mechanically ventilated patients with Gram-negative pneumonia; systematic reviews and meta analyses on adverse events during intrahospital transport of critically ill children & whether norepinephrine or vasopressin should be discontinued first in septic shock; and observational studies on vitamin E acetate in bronchoalveolar-lavage fluid associated with EVALI & the association of prehospital plasma transfusion with survival in trauma patients with hemorrhagic shock.
There are also narrative reviews on fluid administration strategies in traumatic brain injury & comparison between thromboelastography and thromboelastometry; editorials on controversies surrounding prevention of ventilator-associated pneumonia & anaesthetic management of the airway after blunt and penetrating neck injury; and commentaries on clinically meaningful benefit in clinical research & organising international research in critical care medicine.
The full text of the newsletters is available via this link.

Impact of obstructive sleep apnea on the obesity paradox in critically ill patients

This research by Bailly and others was published online in the Journal of Critical Care in December 2019
Objective:  Patients admitted to an intensive care unit (ICU) frequently suffer from multiple chronic diseases, including obstructive sleep apnea (OSA). Until recently OSA was not considered as a key determinant in an ICU patient’s prognosis. The objective of this study was to document the impact of OSA on the prognosis of ICU patients.
Methods:  Data were retrospectively collected concerning adult patients admitted to ICU at two university hospitals. In a nested study OSA status was checked using the hospital electronic medical records to identify exposed and unexposed cases. The following outcomes were considered: length of stay in the ICU, ICU mortality, in-hospital mortality, ventilator-associated pneumonia (VAP).
Results:  Out of 5146 patients included in the study, 289 had OSA at ICU admission (5.6%). After matching, the overall impact of OSA on length of ICU stay was not significant (p = .24). In a predefined subgroup analysis, there was a significant impact of OSA on the length of ICU stay for patients with BMI over 40 kg/m2 (IRR: 1.56 [1.05; 2.32], p = .03). OSA status had no impact on ICU or hospital mortality and VAP.
Conclusion:  In general, known OSA did not increase the ICU stay except for patients with both OSA and morbid obesity.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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.

Muscle degradation, vitamin D and systemic inflammation in hospitalized septic patients

This article by Borges and colleagues was first published online in the Journal of Critical Care during December 2019.
Purpose:  To date, the relationship between systemic inflammation and muscle changes observed by ultrasonography in septic patients in clinical studies is not known. Furthermore, the role of vitamin D on muscle changes in these patients needs to be investigated.
Materials and methods:  Forty-five patients admitted to the ICU due to severe sepsis or septic shock. Blood samples were collected to evaluate systemic inflammation (interleukin (IL)-10, IL-1β, IL-1α, IL-6, IL-8 and tumor necrosis factor–α(TNF-α)) and vitamin D. Muscle mass was evaluated by ultrasound during hospitalization. Clinical tests of muscle strength (Medical Research Council (MRC) scale and handgrip) were performed after the awakening of patients.
Results:  There was a reduction in day 2 values to hospital discharge on TNF-alpha, IL-8, IL-6 and IL-10 (p < .05). The muscle mass showed a significant decline from day 6 of the ICU. After awakening, the patients had a significant increase in muscle strength (p < .05). There was a positive association between muscle mass variation (day 2 – ICU) with absolute values of IL-8 (r = 0.38 p = .05). For muscle strength, there was a negative association between handgrip strength with IL-8 (r = −0.36 p < .05) on ICU discharge. The vitamin D showed a positive association with the handgrip strength of the day 1 of the awakening (r = 0.51 p < .05).
Conclusions:  In septic patients, there is an association between inflammation and changes in muscle mass and strength during ICU stay, which is similar to those observed in experimental studies. In addition, there was an association of vitamin D with recovery of muscle strength during hospitalization.
The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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 418 19th December 2019

The Critical Care Reviews Newsletter includes 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 randomised controlled trials on high-dose vitamin D3 for critically ill, vitamin D–deficient patients & fresh vs standard-issue red blood cell transfusions in critically ill pediatric patients; systematic reviews and meta analyses on return to work after critical illness & early versus delayed mobilization; and observational studies on frailty, cognition, activity of daily life and comorbidities on outcome in acutely admitted patients over 80 years in European ICUs, & assessment of variability in end-of-life care delivery in American ICUs.
There are also guidelines on lung–kidney interactions in critically ill patients & bleeding in patients hospitalized in the intensive cardiac care unit; narrative reviews on reversal of vasodilatory shock & drug-induced acute kidney injury; and commentaries on whether enteral nutrition can be given to patients on vasopressors  & whether critical care patients hibernate? There are also editorials on tranexamic acid and the CRASH III trial & the persistent potential of extracorporeal therapies in liver failure; as well as correspondence on how high PEEP may have reduced injurious transpulmonary pressure swings in the ROSE trial.”
The full text of the newsletters is available via this link.

Pulmonary mucormycosis in a patient with acute liver failure: A case report and systematic review of the literature

This article by Huang and colleagues was first published online in the “Journal of Critical Care” during December 2019.

Purpose:  Pulmonary mucormycosis is a highly lethal invasive fungal infection usually found in immunocompromised patients. We report herein the case of an adult woman who developed pulmonary mucormycosis with possible systemic dissemination after recovering from acute liver failure secondary to acetaminophen overdose.

Results:  Our case developed an invasive pulmonary mucormycosis with probable potential systemic dissemination. She did not suffer from any immunocompromising disease other than severe acute liver failure. She did not survive the disease, although she received appropriate antifungal treatment. We also performed a systematic review of the literature on pulmonary mucormycosis, with or without dissemination, in immunocompetent patients. We found 16 cases of pulmonary or disseminated mucormycosis in immunocompetent patients. Fifty-seven percent of them died and none occurred after an acute liver failure episode.

Conclusion:  This case report is the first one to present an invasive pulmonary mucormycosis infection after acute liver failure in an adult patient. The clinical course of this disease is highly lethal, even in immunocompetent adults.

The full text of this article is available to subscribers via this link to the journal’s homepage.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Journal of Critical Care.  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.

Corticosteroids for treating sepsis in children and adults

This systematic review by Annane and colleagues was first published online during December 2019
Review question:  We reviewed the evidence on the effect on death of using corticosteroids in children and adults with sepsis.
Background:  Sepsis is present when an infection is complicated by organ failure. People develop rapid breathing, hypotension (low blood pressure), and mental confusion. Sepsis can interfere with the effectiveness of the body’s corticosteroids, which serve as a key defence against infection. Corticosteroids have been given for decades to people with infection resulting from various causes.
Search date:  The evidence provided in this review is current to July 2019.
Study characteristics:  This review included 61 trials (12,192 participants). Fifty‐eight trials compared corticosteroids to no corticosteroids (placebo or usual care in 48 and nine trials, respectively); three trials also compared continuous versus bolus administration of corticosteroids.
Study funding sources:  Three trials were funded by a drug company, 27 by public organizations or through charitable funding, and six by both a drug company and public organizations or charitable funding; 25 did not declare the source of funding.
Key results:  We have analysed the following two comparisons.
• Corticosteroids versus placebo/usual care.
Corticosteroids probably reduce the risk of death at 28 days by 9% (50 trials; 11,233 participants), with consistent treatment effects between children and adults. They also probably slightly reduce the risk of dying in hospital. There may be little or no effect of corticosteroids on risk of dying over the long term (longer than three months), but these results are less certain. Corticosteroids result in a large reduction in length of stay in the intensive care unit (ICU) and in hospital. Corticosteroids increase the risk of muscle weakness and hypernatraemia. They probably increase the risk of hyperglycaemia. They probably do not increase the risk of superinfection. There may be little or no effect of corticosteroids on risk of gastroduodenal bleeding, neuropsychiatric events, stroke, or cardiac events.
• Continuous infusion versus intermittent boluses of corticosteroids.
We are uncertain about the effects of continuous infusion of corticosteroids compared with intermittent bolus administration. Three studies reported data for this comparison, and the certainty of evidence for all outcomes was very low.
Certainty of evidence
• Corticosteroids versus placebo/usual care
We judged the certainty of evidence for 28‐day mortality as moderate due to some inconsistency related to differences among study populations, types of corticosteroids and how they were given, and use of additional interventions.
• Continuous infusion versus intermittent boluses of corticosteroids
We judged the certainty of evidence for 28‐day mortality as very low due to inconsistency and imprecision.
Implications for practice:  Moderate‐certainty evidence indicates that corticosteroids probably reduce 28‐day, 90‐day, and hospital mortality among patients with sepsis. Corticosteroids result in a large reduction in ICU and hospital length of stay (high‐certainty evidence). There may be little or no difference in the risk of major complications; however, corticosteroids increase the risk of muscle weakness and hypernatraemia (high‐certainty evidence), and probably increase the risk of hyperglycaemia (moderate‐certainty evidence). The effects of continuous versus intermittent bolus administration of corticosteroids are uncertain.
Implications for research:  The criteria for critical illness‐related corticosteroid insufficiency in septic shock remain to be defined.
Subgroup analyses suggest that additional studies are needed to address these topics related to the use of corticosteroids in patients with sepsis.

  • The role of a long course of low‐dose corticosteroids for treatment of septic shock in children.
  • The role of a long course of low‐dose corticosteroids for treatment of patients with sepsis without shock, or with a mild form of septic shock; patients with ARDS; and patients with sepsis related to community‐acquired pneumonia.
  • The role of mineralocorticoid replacement.
  • Optimal timing of initiation of treatment.
  • Optimal dose and duration of hydrocortisone (or equivalent).
  • Optimal modality to administer treatment that is continuous versus intermittent bolus.
  • Optimal modality to stop treatment with or without taper off.
  • The role of a long course of low‐dose corticosteroids for treatment of sepsis caused by different types of infections.
  • Long‐term neuromuscular effects of steroids.
    The full details of this Cochrane Systematic Review are available via this link.

Critical Care Reviews Newsletter 417 9th December 2019

The Critical Care Reviews Newsletter includes 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 the VAPrapid2 randomised controlled trial investigating biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia; a systematic review and meta analysis investigating the effects of continuous epinephrine infusion on survival; and an observational studies assessing the association between supraphysiologic arterial oxygen levels and mortality. There is also a guideline on the transfer of the brain‐injured patient; narrative reviews on processed EEG monitoring for anesthesia and intensive care, ventricular assist device implantation in patients with a failing systemic right ventricle & monitoring of regional lung ventilation using electrical impedance tomography; and a commentary on producing and using trustworthy evidence.
The full text of the newsletters is available via this link.