Critical Care Reviews Newsletter 411 28th October 2019

Critical Care Reviews Newsletter includes the best critical care research and open access articles from across the medical literature during the last week.
The highlights of this week’s edition are randomised controlled trials comparing fibrinogen concentrate with cryoprecipitate after cardiac surgery & depths of anaesthesia in major surgery; systematic reviews and meta analyses on timing of initiation of renal replacement therapy for acute kidney injury & procalcitonin-guided antibiotic therapy; and observational studies on laryngeal injury after prolonged mechanical ventilation & IMPELLA mechanical support in patients with acute myocardial infarction complicated by cardiogenic shock. There are also narrative reviews on the perioperative stress response & technology-enabled clinical trials; and editorials on optimising power to avoid VILI & the role of sugammadex; as well as correspondence which has caused some controversy on social media, on sepsis hysteria
The full text of the newsletter is available via this link.

Fluid resuscitation in patients with end-stage renal disease on hemodialysis presenting with severe sepsis or septic shock: A case control study

This research by Rajdev and colleagues was first published in October 2019 in the online edition of Journal of Critical Care.
Due to the potential risk of volume overload, physicians are hesitant to aggressively fluid-resuscitate septic patients with end-stage renal disease (ESRD) on hemodialysis (HD). Primary objective: To calculate the percentage of ESRD patients on HD (Case) who received ≥30 mL/Kg fluid resuscitation within the first 6 h compared to non-ESRD patients (Control) that presented with severe sepsis (SeS) or septic shock (SS). Secondary objectives: Effect of fluid resuscitation on intubation rate, need for urgent dialysis, hospital length of stay (LOS), intensive care unit (ICU) admission and LOS, need for vasopressors, and hospital mortality. Medical records of 715 patients with sepsis, SeS, SS, and ESRD were reviewed. We identified 104 Case and 111 Control patients. In the Case group, 23% of patients received ≥30 mL/Kg fluids compared to 60% in the Control group (p < 0.001). There was no significant difference in mortality, need for urgent dialysis, intubation rates, ICU LOS, or hospital LOS between the two groups. Subgroup analysis between ESRD patients who received ≥30 mL/Kg (N = 80) vs those who received <30 mL/Kg (N = 24) showed no significant difference in any of the secondary outcomes. Compliance with 30 mL/Kg fluids was low for all patients but significantly lower for ESRD patients. Aggressive fluid resuscitation appears to be safe in ESRD patients.
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.

Cost-effectiveness of second-line vasopressors for the treatment of septic shock

This article by Lam and associates was first published online in the Journal of Critical Care during October 2019.
Purpose:  To determine the cost-effectiveness of escalating doses of norepinephrine or norepinephrine plus the adjunctive use of vasopressin or angiotensin II as a second-line vasopressor for septic shock.
Materials and methods:  Decision tree analysis was performed to compare costs and outcomes associated with norepinephrine monotherapy or the two adjunctive second-line vasopressors. Short- and long-term outcomes modeled included ICU survival and lifetime quality-adjusted-life-years (QALY) gained. Costs were modeled from a payer’s perspective, with a willingness-to-pay threshold set at $100,000/unit gained. One-way (tornado diagrams) and probabilistic sensitivity analyses were performed.
Results:  Adjunctive vasopressin was the most cost-effective therapy, and dominated both norepinephrine monotherapy and adjunctive angiotensin II by producing higher ICU survival at less cost. For the lifetime horizon, while norepinephrine monotherapy was least expensive, adjunctive vasopressin was the most cost-effective with an incremental cost-effectiveness ratio of $19,762 / QALY gained. Although adjunctive angiotensin II produced more QALYs compared to norepinephrine monotherapy, it was dominated in the long-term evaluation by second-line vasopressin. Sensitivity analyses demonstrated model robustness and medication costs were not significant drivers of model results.
Conclusions:  Vasopressin is the most cost-effective second-line vasopressor in both the short- and long-term evaluations. Vasopressor price is a minor contributor to overall cost.
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.

Association of negative fluid balance during the de-escalation phase of sepsis management on mortality: A cohort study

This article by Dhondup and others was published online in the Journal of Critical Care during October 2019.
Purpose:  We aimed to evaluate the impact of negative fluid balance during the fluid de-escalation phase of sepsis management.
Material and methods:  This is a historical cohort study of adult intensive care units (ICU) patients with septic shock and severe sepsis in a quaternary medical center, from January 2007 through December 2009. We used regression modeling to assess the impact of negative volume balance on mortality after adjustments for age, comorbidities, and illness severity.
Results:  Among 633 enrolled patients, 387 patients reached negative fluid balance who in comparison with others had a lower 90-day mortality rate (36% vs. 44%; P = .048), despite higher severity of illness. Each 1-L negative daily fluid balance was associated with reduced ICU, hospital, 90-day and 1-year mortality (hazard ratio [HR] 0.39[95%CI, 0.28–0.57], 0.76[95%CI, 0.63–0.94], 0.69[95%CI, 0.59–0.81], 0.67 [0.58–0.78], respectively; P < .05). This protective effect of negative volume balance was maintained when cumulative ICU fluid balance was utilized.
Conclusions:  There is not only a significant association between outcomes of patients who were resuscitated for sepsis and achieving negative fluid balance, but also the amount of daily or cumulative negative fluid balance is associated with lower mortality of these patients. Prospective clinical trials are needed to validate this finding.
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 410 21st October 2019

Critical Care Reviews Newsletter includes the best critical care research and open access articles from across the medical literature during the last week.

The highlights of this week’s edition are two randomised controlled trials presented at the World Congress of Intensive Care in Melbourne this week; CRASH-3, investigating tranexamic acid in traumatic brain injury, and ICU-ROX, one of the trials being discussed at #CCR20, comparing conservative with standard oxygenation in mechanically ventilated ICU patients. There are also systematic reviews and meta analyses on imaging for neuroprognostication after cardiac arrest & decompressive craniectomy for severe traumatic brain injury; observational studies comparing short-term dialysis catheter with central venous catheter infections in ICU patients & natural light exposure on delirium burden; and the protocol for the VITAMINS trial, another of our #CCR20 trials. There are also guidelines on inotropes for the management of acute and advanced heart failure & antimotility agents for acute noninfectious diarrhea; two ultrasound-based narrative reviews on whole body ultrasound in the operating room and ICU & ultrasound-guided peripheral venous cannulation; editorials on ventilation and ARDS, intracranial pressure monitoring & pneumonia research; and commentariess on extracorporeal devices in critical care & vasopressors, antiarrhythmics, oxygen, and intubation in out-of-hospital cardiac arrest.

The full text of the newsletter is available via this link..

Machine learning for prediction of septic shock at initial triage in emergency department

This research by Joonghee and colleagues was first published online in the Journal of Critical Care during October 2019.
Background:  We hypothesized utilizing machine learning (ML) algorithms for screening septic shock in ED would provide better accuracy than qSOFA or MEWS.
Methods:  The study population was adult (≥20 years) patients visiting ED for suspected infection. Target event was septic shock within 24 h after arrival. Demographics, vital signs, level of consciousness, chief complaints (CC) and initial blood test results were used as predictors. CC were embedded into 16-dimensional vector space using singular value decomposition. Six base learners including support vector machine, gradient-boosting machine, random forest, multivariate adaptive regression splines and least absolute shrinkage and selection operator and ridge regression and their ensembles were tested. We also trained and tested MLP networks with various setting.
Results:  A total of 49,560 patients were included and 4817 (9.7%) had septic shock within 24 h. All ML classifiers significantly outperformed qSOFA score, MEWS and their age-sex adjusted versions with their AUROC ranging from 0.883 to 0.929. The ensembles of the base classifiers showed the best performance and addition of CC embedding was associated with statistically significant increases in performance.
Conclusions:  ML classifiers significantly outperforms clinical scores in screening septic shock at ED triage.
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 409 14th October 2019

Critical Care Reviews Newsletter contains the best critical care research and open access articles from across the medical literature during the last week.

“The highlights of this week’s edition are randomised controlled trials on melatonin for prevention of post-operative delirium & an ultrasound-driven diagnostic protocol in ICU; systematic reviews and meta analyses on systemic corticosteroids and the incidence of gastrointestinal bleeding in critically ill adults & extracorporeal liver support in patients with liver failure; and observational studies on invasive pulmonary aspergillosis in critically ill patients with hematological malignancies & national trends in timing of death among patients with septic shock. There is also a French guideline on severe asthma exacerbation; narrative reviews on central pontine myelinosis and osmotic demyelination syndrome, intraoperative fraction of inspired oxygen & stepped wedge trials; commentaies on oxygen toxicity in major emergency surgery & alveolar recruitment in ARDS; as well as correspondence on venous and arterial base excess difference & ‘the pause’.

The full text of the newsletter is available via this link.

Integrating a safety smart list into the electronic health record decreases intensive care unit length of stay and cost

This paper by Lamkin and colleagues was first published online in the Journal of Critical Care during October 2019.
Purpose:  To measure how an integrated smartlist developed for critically ill patients would change intensive care units (ICUs) length of stay (LOS), mortality, and charges.
Materials and methods:  Propensity-score analysis of adult patients admitted to one of 14 surgical and medical ICUs between June 2017 and May 2018. The smart list aimed to certain preventative measures for all critical patients (e.g., removing unneeded catheters, starting thromboembolic prophylaxis, etc.) and was integrated into the electronic health record workflows at the hospitals under study.
Results:  During the study period, 11,979 patients were treated in the 14 participating ICUs by 518 unique providers. Patients who had the smart list used during ≥60% of their ICU stay (N = 432 patients, 3.6%) were significantly more likely to have a shorter ICU LOS (HR = 1.20, 95% CI:1.0 to 1.4, p = 0.015) with an average decrease of -$1218 (95% CI: -$1830 to -$607, P < 0.001) in the amount charged per day. The intervention cohort had fewer average ventilator days (3.05 vent days, SD = 2.55) compared to propensity score matched controls (3.99, SD = 4.68, p = 0.015), but no changes in mortality (16.7% vs 16.0%, p = 0.78).
Conclusions:  An integrated smart list shortened LOS and lowered charges in a diverse cohort of critically ill patients.
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.

Intensive care unit occupancy and premature discharge rates: A cohort study assessing the reporting of quality indicators

This paper by Blayney and colleagues was first published online in the Journal of Critical Care during October 2019.
Purpose:  ICU occupancy fluctuates. High levels may disadvantage patients. Currently, occupancy is benchmarked annually which may inaccurately reflect strained units. Outcomes potentially sensitive to occupancy include premature (early) ICU discharge and non-clinical transfer (NCT). This study assesses the association between daily occupancy and these outcomes, and evaluates benchmarking care across Scotland using daily occupancy.
Materials and methods:  Population: all Scottish ICU patients, 2006–2014. Exposure: bed occupancy per unit-day; Outcomes: proportion of early discharges and NCTs. Design: Retrospective cohort study. Outcome rates were calculated above various occupancy thresholds. Polynomial regression visualised associations, and inflection points between occupancy and outcomes. Spearman’s rho correlations between occupancy measures and outcomes were reported.
Results:  65,472 discharges occurred over 57,812 unit-days. 1954(3.0%) discharges were early; 429 (0.7%) were NCTs. Early discharge rates above 70%, 80% and 90% occupancy were 3.9%, 5.0% and 7.5% respectively. Occupancies at which outcome rates greatly increased were near 80% for early discharge, and 90% for NCT. Mean annual occupancy was not correlated with outcomes; annual proportion of days ≥90% occupancy correlated most strongly (early discharge rho = 0.46,p < .001; NCT rho = 0.31, p < .001).
Conclusions:  We demonstrate a clear association between daily ICU occupancy and early discharge/NCT. Daily occupancy may better benchmark care quality than mean annual occupancy.
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.

Intensive Care Medicine Volume 45 Number 10 October 2019

To view Intensive Care Medicine’s November issue’s contents page follow this link.
Articles published in this issue include:  “Predictors of gastrointestinal bleeding in adult ICU patients: a systematic review and meta-analysis”, “Randomised evaluation of active control of temperature versus ordinary temperature management (REACTOR) trial” and “Levosimendan in septic shock in patients with biochemical evidence of cardiac dysfunction: a subgroup analysis of the LeoPARDS randomised trial
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.