High flow nasal cannula compared with conventional oxygen therapy for acute hypoxemic respiratory failure: a systematic review and meta-analysis

This article was published on-line in Intensive Care Medicine during April 2019 by Rochwerg and colleagues.
Background:  This systematic review and meta-analysis summarizes the safety and efficacy of high flow nasal cannula (HFNC) in patients with acute hypoxemic respiratory failure.
Methods:  We performed a comprehensive search of MEDLINE, EMBASE, and Web of Science. We identified randomized controlled trials that compared HFNC to conventional oxygen therapy. We pooled data and report summary estimates of effect using relative risk for dichotomous outcomes and mean difference or standardized mean difference for continuous outcomes, with 95% confidence intervals. We assessed risk of bias of included studies using the Cochrane tool and certainty in pooled effect estimates using GRADE methods.
Results:  We included 9 RCTs (n = 2093 patients). We found no difference in mortality in patients treated with HFNC (relative risk [RR] 0.94, 95% confidence interval [CI] 0.67–1.31, moderate certainty) compared to conventional oxygen therapy. We found a decreased risk of requiring intubation (RR 0.85, 95% CI 0.74–0.99) or escalation of oxygen therapy (defined as crossover to HFNC in the control group, or initiation of non-invasive ventilation or invasive mechanical ventilation in either group) favouring HFNC-treated patients (RR 0.71, 95% CI 0.51–0.98), although certainty in both outcomes was low due to imprecision and issues related to risk of bias. HFNC had no effect on intensive care unit length of stay (mean difference [MD] 1.38 days more, 95% CI 0.90 days fewer to 3.66 days more, low certainty), hospital length of stay (MD 0.85 days fewer, 95% CI 2.07 days fewer to 0.37 days more, moderate certainty), patient reported comfort (SMD 0.12 lower, 95% CI 0.61 lower to 0.37 higher, very low certainty) or patient reported dyspnea (standardized mean difference [SMD] 0.16 lower, 95% CI 1.10 lower to 1.42 higher, low certainty). Complications of treatment were variably reported amongst included studies, but little harm was associated with HFNC use.
Conclusion:  In patients with acute hypoxemic respiratory failure, HFNC may decrease the need for tracheal intubation without impacting mortality.
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Critical Care Reviews Newsletter 385 29th April 2019

The 385th Critical Care Reviews Newsletter, highlights “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 two randomised controlled trials comparing levetiracetam with phenytoin in paediatric status epilepticus; a systematic review and meta analysis on renal replacement therapy strategies for septic-acute kidney injury; and observational studies on fragility of statistically significant findings in pediatric critical care & neuron specific enolase after cardiac arrest.
“There are also guidelines on perioperative red blood cell transfusion & medical applications of blockchain technology; narrative reviews on brainstem haemorrhages & sepsis-associated acute kidney injury; a commentary on the four horsemen of irreproducibility; and editorials on intelligently learning from data & endotypes to guide antibiotic discontinuation in sepsis.
The full text of the newsletter is available via this link.

Cohort study to determine the risk of pressure ulcers and developing a care bundle within a paediatric intensive care unit setting

This research by Smith and colleagues was published online in “Intensive and Critical Care Nursing” in April 2019.
Objective:  Determine the incidence and risk factors for pressure ulcers in a paediatric intensive care unit. Use the information gathered to develop preventive pressure ulcer care bundles.
Research methodology:  Prospective cohort study using Braden Q Scale for Predicting Pressure Sore Risk and European Pressure Ulcer Advisory Panel Pressure Ulcer Staging tool.
Setting:  General paediatric intensive care unit in a tertiary level hospital between May and October 2017.
Results:  Seventy-seven children were recruited. Most children were male (n = 42, 54.5%) and all nine children (11.7%) that developed a pressure ulcer were male. The main risk factor for developing a pressure ulcer was lack of physical activity. None of the children assessed as high or severe risk developed a pressure ulcer. Eight (89%) pressure ulcers were assessed as grade one. Seven pressure ulcers (77.8%) were on the facial and scalp area and all seven children were receiving airway support at the time the pressure ulcers developed.
Conclusion:  Incidence of pressure ulcers was 11.7%, with the facial and scalp area the most common anatomical areas affected. Medical devices appeared to be the prime causative factor. Based on our data we have modified and launched the SSKIN care bundle for the paediatric intensive care unit setting.
Subscribers to Intensive and Critical Care Nursing can access the full text of the article via this link.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Intensive and Critical Care Nursing.  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 384 22nd April 2019

The 384th Critical Care Reviews Newsletter, delivers the best critical care research and open access articles from the medical literature over the last seven days.
“The highlights of this week’s edition are randomised controlled trials on restrictive IV fluids in sepsis and septic shock & screening for weaning from mechanical ventilation; systematic reviews and meta analyses on airway management during cardiac arrest & vasopressors during cardiac arrest; and observational studies on lactatemia in sepsis & quality of life and 1-year survival in the ARISE trial. There are also guidelines on diversity & cardiorenal syndrome; narrative reviews on cardiogenic shockupper gastrointestinal bleeding & hepatorenal syndrome; and commentaries on broad spectrum vasopressors, early prophylactic hypothermia for patients with severe traumatic injury & liberal versus conservative oxygen therapy in critically ill patients.”
The full text of the newsletter is available via this link.

Critical Care Reviews Newsletter 383 15th April 2019

The 382th Critical Care Reviews Newsletter, delivers the best critical care research and open access articles from the medical literature over the last seven days.
“The highlights of this week’s edition are randomised controlled trials on laxative prophylaxis in ICU procalcitonin-guided treatment on duration of antibiotic therapy and cost in sepsis; systematic reviews and meta analyses on post-ICU follow-up lytic therapy for retained traumatic hemothorax; and observational studies on diagnostic accuracy of procalcitonin for early aspiration pneumonia in critically ill patients with coma & the furosemide stress test for prediction of worsening acute kidney injury.
The full text of the newsletter is available via this link.

High versus low mean arterial pressures in hepatorenal syndrome: A randomized controlled pilot trial

There is controversy regarding the mean arterial pressure (MAP) goals that should be targeted in the treatment of hepatorenal syndrome (HRS.) We conducted a study to assess different MAP targets in HRS in the intensive care unit (ICU).
Materials and methods:  This is a prospective randomized controlled pilot trial. ICU patients had target mean arterial pressure (MAP) ≥ 85 mmHg (control arm) or 65–70 mmHg (study arm). Urine output and serum creatinine were trended and recorded.
Results:  A total of 18 patients were enrolled. The day four urine output in the high and low MAP group was 1194 (SD = 1249) mL/24 h and 920 (SD = 812) mL/24 h, respectively. The difference in day four – day one urine output was −689 (SD = 1684) mL/24 h and 272 (SD = 582) mL/24 h for the high and low MAP groups. The difference in serum creatinine at day four – day one was −0.54 (SD = 0.63) mg/dL and − 0.77 (SD = 1.14) mg/dL in the high and low MAP groups, respectively.
Conclusion:  In this study, we failed to prove non-inferiority between a low and high target MAP in patients with HRS.
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.

Development and daily use of a numeric rating score to assess sleep quality in ICU patients

This publication by Rood and colleagues appeared online in Journal of Critical Care during April 2019.
Purpose:  Insufficient sleep burdens critically ill patients, optimizing sleep may enhance patient’s outcomes. Current assessment methods may unnecessary burden patients. Therefore, a single numeric rating score was validated for sleep assessment.
Materials and methods:  First, two cross-sectional measurements on two separate days, from cooperative patients from 19 centres assessed their sleep sufficiency, the numeric rating score (NRS) and the Richards Campbell Sleep Questionnaire (RCSQ). Assessments were compared using a Bland Altman plot. A NRS cut-off was determined using regression analysis. Second, daily sleep assessment was implemented and monitored single centre for a year.
Results:  Multicentre, 194 patients assessed sleep quality, of which 53% was rated as sufficient. Mean (±SD) difference between RCSQ and NRS-Sleep using Bland-Altman analysis was 0.25 (±1.21, 95% limits of agreement −2.12 to 2.62). The optimal cut-off was >5. Single centre, 1603 patients ranked 4532 ICU nights of sleep, of which 71% was sufficient; median NRS was 6 [IQR 5–7].
Conclusions:  A single numeric rating score for sleep is interchangeable for the RCSQ score for assessment of sleep quality. Optimal cut-off is >5. Use of a numeric rating score for sleep is a practical way to evaluate and monitor sleep as perceived by patients in daily ICU practice.
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.

Effect of physostigmine on recovery from septic shock following intra-abdominal infection – Results from a randomized, double-blind, placebo-controlled, monocentric pilot trial (Anticholium® per Se)

This research by Pinder et al was published online during April 2019 in the Journal of Critical Care.
Purpose:  The cholinergic anti-inflammatory pathway has been shown to be accessible by physostigmine salicylate in animal models. However, the cholinesterase inhibitor is not approved for adjunctive therapy in sepsis, and tolerability and safety of high initial doses followed by continuous infusion have not been investigated.
Materials and methods:  In this trial, 20 patients with perioperative septic shock due to intra-abdominal infection were eligible. The physostigmine group received an initial dose of 0.04 mg/kg physostigmine salicylate, followed by continuous infusion of 1 mg/h for 120 h; the placebo group was treated with 0.9% sodium chloride. Primary outcome was the mean Sequential Organ Failure Assessment (SOFA) score during treatment and up to 14 days.
Results:  Administration of physostigmine salicylate was well tolerated. Mean SOFA scores were 8.9 ± 2.5 and 11.3 ± 3.6 (mean ± SD) for physostigmine and placebo group, respectively. Adjusted for age, difference between means was not statistically significant (−2.37, 95% CI: -5.43 to 0.70, p = 0.121). Norepinephrine doses required only appeared lower in the physostigmine group (p = 0.064), along with a more rapid reduction from an elevated heart rate possibly indicating less hemodynamic instability.
Conclusions:  Treatment with physostigmine salicylate was feasible and safe. Further studies are justified to assess the effect on recovery from septic shock.
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.

Meaningful experiences and end-of-life care in the intensive care unit: A qualitative study

This article by Stokes and colleagues was online during April 2019 in “Intensive and Critical Care Nursing”.
Objectives:  The purpose of this study was to provide a comprehensive exploration of nurses’ meaningful experiences of providing end-of-life care to patients and families in the intensive care unit (ICU). The objectives of this research were: (1) To explore what is meaningful practice for nurses regarding end-of-life care; (2) To describe how nurses create a good death in the intensive care unit and (3) To identify the challenges that nurses face that affect their meaningful experiences and ultimately the creation of a good death.
Research design:  This study utilised an interpretive phenomenological approach using Van Manen’s (1997) method.
Setting:  In-depth, face-to-face interviews were conducted with six intensive care nurses employed in a 32-bed medical/surgical intensive care unit of an academic tertiary care centre in Canada.
Findings:  The overarching theme from the analysis of this experience was “being able to make a difference” which was intricately woven around contributing to a good death. Three main themes were identified and included: creating a good death, navigating the challenges and making it work.
Conclusion:  The findings reveal how intensive care nurses provide good end-of-life care and create good deaths for patients and families.
Subscribers to Intensive and Critical Care Nursing can access the full text of the article via this link.  The full text of articles from issues older than sixty days is available via this link to an archive of issues of Intensive and Critical Care Nursing.  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.

Early target attainment of continuous infusion piperacillin/tazobactam and meropenem in critically ill patients: A prospective observational study

This article by Hay and others was published on line in the Journal of Critical Care during April 2019.
Purpose:  To evaluate target attainment of empirically dosed continuous infusion piperacillin/tazobactam (TZP) and meropenem (MER) in critically ill patients.
Patients and methods:  Patients were sampled on a daily basis. TZP or MER concentrations were evaluated during the first two days antibiotic therapy. The lower limit of the target range was defined as unbound concentrations equaling 4 times the epidemiological cutoff value of P. aeruginosa. The upper limit of the target range was based on the risk of toxicity, i.e. unbound concentrations >160 mg/L for TZP and > 45 mg/L for MER. Multivariable logistic regression was used to evaluate factors associated with target attainment.
ResultsData from 253 patients were analyzed. Overall, 76/205 (37.1%) and 36/48 (75%) of the patients receiving TZP or MER respectively, attained target concentrations. In multivariable analysis, estimated creatinine clearance was identified as a risk factor for target non-attainment (OR 0.988, 95%CI [0.982;0.994]). Patients receiving MER were more likely to attain target concentrations compared with patients receiving TZP (OR 6.02, 95%CI [2.12;18.4]).
ConclusionTarget attainment of empiric antibiotic therapy in critically ill patients was low (37%) for TZP and moderate (75%) for MER, despite the use of a loading dose and despite optimization of the mode of infusion.
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.