Intensive Care Medicine Volume 45 Number 12 December 2019

To view Intensive Care Medicine’s December issue’s contents page follow this link.
Articles published in this issue include: “Effect of lung recruitment maneuver on oxygenation, physiological parameters and mortality in acute respiratory distress syndrome patients: a systematic review and meta-analysis, “Invasive pulmonary aspergillosis in critically ill patients with hematological malignancies” and The association of cardiovascular failure with treatment for ventilator-associated lower respiratory tract infection.”
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.

Non-invasive ventilation support during fiberoptic bronchoscopy-guided nasotracheal intubation effectively prevents severe hypoxemia

This article by Nong and others was first published online in the Journal of Critical Care during November 2019.
Purpose:  This study investigated the feasibility and efficacy of continuous noninvasive ventilation (NIV) support with 100% oxygen using a specially designed face mask, for reducing desaturation during fiberoptic bronchoscopy (FOB)-guided intubation in critically ill patients with respiratory failure.
Materials and methods: This was a single-center prospective randomized study. All patients undergoing FOB-guided nasal tracheal intubation were randomized to bag-valve-mask ventilation or NIV for preoxygenation followed by intubation. The NIV group were intubated through a sealed hole in a specially designed face mask during continuous NIV support with 100% oxygen. Control patients were intubated with removal of the mask and no ventilatory support.
Results:  We enrolled 106 patients, including 53 in each group. Pulse oxygen saturation (SpO2) after preoxygenation (99% (96%–100%) vs. 96% (90%–99%), p = .001) and minimum SpO2 during intubation (95% (87%–100%) vs. 83% (74%–91%), p < .01) were both significantly higher in the NIV compared with the control group. Severe hypoxemic events (SpO2 < 80%) occurred less frequently in the NIV group than in controls (7.4% vs. 37.7%, respectively; p < .01).
Conclusions:  Continuous NIV support during FOB-guided nasal intubation can prevent severe desaturation during intubation in critically ill patients with respiratory failure.
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 414 18th November 2019

The Critical Care Reviews Newsletter delivers 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 simvastatin for pneumonia & colchicine after myocardial infarction; systematic reviews and meta analyses on lung recruitment in ARDS & methods of temperature management in comatose patients post cardiac arrest; and observational studies on how impaired right ventricular performance is associated with adverse outcome after hypoxic ischemic encephalopathy & how host-response subphenotypes offer prognostic enrichment in ARDS.
There are also guidelines on awake tracheal intubation, type 2 myocardial infarction and acute nonischemic myocardial injury & the latest 2019 ILCOR guidance on cardiopulmonary resuscitation and emergency cardiovascular care. In addition, there are narrative reviews on AKI and hepatorenal syndrome & early brain injury after poor-grade subarachnoid hemorrhage; editorials on whether critical care patients hibernate & if a microbiologist consultant should attend daily ICU rounds; and commentaries on ‘less is more’ in modern icu & a trilogy of papers on the ADRENAL & APROCCHSS.
The full text of the newsletters is available via this link.

Low serum albumin levels and new-onset atrial fibrillation in the ICU a prospective cohort study

This research by van Beek et others was published on line in the Journal of Critical Care during November 2019.
Purpose:  The aim was to determine if a low serum albumin (SA) level was associated with the occurrence of new onset atrial fibrillation (NOAF) during the first 48 h of intensive care unit (ICU) admission.
Methods:  Overall, 97 patients admitted to the ICU were included in this prospective study. NOAF during the first 48 h was defined as irregularity and absence of p-waves on the continuous electrocardiogram, lasting longer than 2 min. Association were analysed using logistic regression with correction for confounding variables in multivariable analysis.
Results:  The incidence of NOAF during the first 48 h of ICU admission was 18%. SA levels at ICU admission were significantly associated with NOAF after correction for confounders (odds ratio [OR] 0.86, 95%CI 0.77–0.97, p = .010). SA levels were also significantly associated with the number of episodes of NOAF in multivariate analysis (−0.09 episodes, 95%CI [−0.15/−0.04], p = .001), but not with the presence of sinus rhythm at 48 h (OR 1.05, 95%CI [0.93–1.12], p = .46).
Conclusion:  In this small hypothesis generating study low levels of SA were associated with the occurrence of NOAF. It remains to be shown if increasing SA levels lowers the incidence of NOAF.
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 between organizational characteristics and adequate pain management at the intensive care unit

This article by Roos-Blom and others was first published online in the Journal of Critical Care during November 2019.
Purpose:  Half of the patients experience pain during their ICU stay which is known to influence their outcomes. Nurses and physicians encounter organizational barriers towards pain assessment and treatment. We aimed to evaluate the association between adequate pain management and nurse to patient ratio, bed occupancy rate, and fulltime presence of an intensivist.
Materials and methods:  We performed unadjusted and case-mix adjusted mixed-effect logistic regression modeling on data from thirteen Dutch ICUs to investigate the association between ICU organizational characteristics and adequate pain management, i.e. patient-shift observations in which patients’ pain was measured and acceptable, or unacceptable and normalized within 1 h.
All ICU patients admitted between December 2017 and June 2018 were included, excluding patients who were delirious, comatose or had a Glasgow coma score < 8 at the first day of ICU admission.
Results:  Case-mix adjusted nurse to patient ratios of 0.70 to 0.80 and over 0.80 were significantly associated with adequate pain management (OR [95% confidence interval] of respectively 1.14 [1.07–1.21] and 1.16 [1.08–1.24]). Bed occupancy rate and intensivist presence showed no association.
Conclusion:  Higher nurse to patient ratios increase the percentage of patients with adequate pain management especially in medical and mechanically ventilated 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.

Delayed vasopressor initiation is associated with increased mortality in patients with septic shock

This research by Hidalgo and others was first published online in the Journal of Critical Care during November 2019.
Purpose:  Mortality rate for septic shock, despite advancements in knowledge and treatment, remains high. Treatment includes administration of broad-spectrum antibiotics and stabilization of the mean arterial pressure (MAP) with intravenous fluid resuscitation. Fluid-refractory shock warrants vasopressor initiation. There is a paucity of evidence regarding the timing of vasopressor initiation and its effect on patient outcomes.
Materials and methods:  This retrospective, single-centered, cohort study included patients with septic shock from January 2017 to July 2017. Time from initial hypotension to vasopressor initiation was measured for each patient. The primary outcome was 30-day mortality.
Results:  Of 530 patients screened,119 patients were included. There were no differences in baseline patient characteristics. Thirty-day mortality was higher in patients who received vasopressors after 6 h (51.1% vs 25%, p < .01). Patients who received vasopressors within the first 6 h had more vasopressor-free hours at 72 h (34.5 h vs 13.1, p = .03) and shorter time to MAP of 65 mmHg (1.5 h vs 3.0, p < .01).
Conclusion:  Vasopressor initiation after 6 h from shock recognition is associated with a significant increase in 30-day mortality. Vasopressor administration within 6 h was associated with shorter time to achievement of MAP goals and higher vasopressor-free hours within the first 72 h.
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.

Gender differences in mortality and quality of life after septic shock: A post-hoc analysis of the ARISE study

This article by Luethi and others was published online in the Journal of Critical Care during November 2019.
Purpose:  To assess the impact of gender and pre-menopausal state on short- and long-term outcomes in patients with septic shock.
Material and methods:  Cohort study of the Australasian Resuscitation in Sepsis Evaluation (ARISE) trial, an international randomized controlled trial comparing early goal-directed therapy (EGDT) to usual care in patients with early septic shock, conducted between October 2008 and April 2014. The primary exposure in this analysis was legal gender and the secondary exposure was pre-menopausal state defined by chronological age (≤ 50 years).
Results:  641 (40.3%) of all 1591 ARISE trial participants in the intention-to-treat population were females and overall, 337 (21.2%) (146 females) patients were 50 years of age or younger. After risk-adjustment, we could not identify any survival benefit for female patients at day 90 in the younger (≤50 years) (adjusted Odds Ratio (aOR): 0.91 (0.46–1.89), p = .85) nor in the older (>50 years) age-group (aOR: 1.10 (0.81–1.49), p = .56). Similarly, there was no gender-difference in ICU, hospital, 1-year mortality nor quality of life measures.
Conclusions:  This post-hoc analysis of a large multi-center trial in early septic shock has shown no short- or long-term survival effect for women overall as well as in the pre-menopausal age-group.
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.

Acute kidney injury as a risk factor of hyperactive delirium: A case control study

This article by Wan and others was published online in the Journal of Critical Care during November 2019.
Purpose:  Delirium and acute kidney injury (AKI) are common organ dysfunctions during critical illness. Both conditions are associated with serious short- and long-term complications. We investigated whether AKI is a risk factor for hyperactive delirium.
Methods:  This was a single-centre case control study conducted in a 30 bedded mixed Intensive Care Unit in the UK. Hyperactive delirium cases were identified by antipsychotic initiation and confirmation of delirium diagnosis through validated chart review. Cases were compared with non-delirium controls matched by Acute Physiology and Chronic Health Evaluation II score and gender. AKI was defined by the KDIGO criteria.
Results:  142 cases and 142 matched controls were identified. AKI stage 3 was independently associated with hyperactive delirium [Odds ratio (OR) 5.40 (95% confidence interval (CI) 2.33–12.51]. Other independent risk factors were mechanical ventilation [OR 2.70 (95% CI 1.40–5.21)], alcohol use disorder [OR 5.80 (95% CI 1.90–17.72)], and dementia [OR 9.76 (95% CI 1.09–87.56)]. Hospital length of stay was significantly longer in delirium cases (29 versus 20 days; p = .004) but hospital mortality was not different.
Conclusions:  AKI stage 3 is independently associated with hyperactive delirium. Further research is required to explore the factors that contribute to this association.
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.

Short, and long-term mortality among cardiac intensive care unit patients started on continuous renal replacement therapy

This article by Keleshian and others was published online in the Journal of Critical Care during November 2019.
Purpose:  Patients requiring continuous renal replacement therapy (CRRT) are at high risk of death. Predictors of hospital mortality and post-discharge survival in cardiac intensive care unit (CICU) patients requiring CRRT have not been reported.
Materials and methods:  Retrospective review of 198 CICU patients undergoing CRRT from 2006 to 2015. Multivariable regression identified predictors of hospital mortality and Cox proportional-hazards identified predictors of post-discharge mortality among hospital survivors.
Results:  The indication for CRRT was volume overload in 129 (65%) and metabolic abnormalities in 76 (38%). 105 (53%) subjects died in hospital, with 22% dialysis-free hospital survival. Cardiogenic shock was present in 159 (80%) subjects; 150 (76%) subjects received vasopressors and 101 (51%) subjects required mechanical ventilation. Hospital mortality was similar in cardiogenic and non-cardiogenic causes of CICU admission. Predictors of hospital death included semi-quantitative RV function, Braden score, VIS, and PaO2/FIO2 ratio. Median post-discharge Kaplan-Meier survival was 1.9 years. Predictors of post-hospital death included age, VIS, diabetes, Braden score, semi-quantitative RV function, prior heart failure, and dialysis dependence. The indication for CRRT was not predictive of survival.
Conclusion:  Mortality is high among CICU patients requiring CRRT, and is predicted by the Braden score, RV dysfunction, respiratory failure and vasopressor load.
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.

Baclofen for Alcohol Withdrawl

This Cochrane Systematic Review by Liu and Wang was published in November 2019.
Review question:  This review attempted to evaluate the efficacy and safety of baclofen as a therapy for alcohol withdrawal syndrome (AWS) in people with alcoholism.
Background:  AWS is a distressing and life‐threatening condition that usually affects people who are alcohol dependent when they discontinue or decrease their alcohol consumption. The medicine baclofen has demonstrated potential to reduce symptoms of severe AWS in people with alcoholism. Treatment with baclofen is easy to manage, without producing any obvious side effects. This is an updated version of the original Cochrane Review published in 2011 and last updated in 2017.
Search date:  The evidence is current to June 2019.
Study characteristics:  We searched scientific databases for clinical trials comparing baclofen with placebo (a pretend treatment) or another potentially useful medicine in people with AWS. We included four randomised controlled trials (clinical studies where people are randomly put into one of two or more treatment groups) with 189 participants. One study from the USA compared baclofen to placebo given over at least 72 hours. The 31 participants were mainly men with the average age 47 years. Two studies with 85 participants compared baclofen to diazepam (a calming medicine) for 10 consecutive days, or for 10‐day inpatient stay with flexibility to allow negotiation of the discharge date between day 10 and day 15. One study compared baclofen to chlordiazepoxide given for nine days, in which the 60 participants were all men with an average age of 38 years. None of studies reported any conflict of interest. Addolorato 2006 was supported by Associazione Ricerca in Medicina, Italy. Girish 2016 was supported by KIMS Hospital and Research Centre (Bangalore, India). Jhanwar 2014 reported no funding source. Lyon 2011 was supported by Duluth Clinic Foundation (MN, USA).
Key results:  None of the included studies assess the main outcomes of the review, that is, alcohol withdrawal seizures (fits), alcohol withdrawal delirium (confused thinking and awareness), and craving. We are uncertain whether baclofen improves withdrawal symptoms and signs, and reduces side effects when compared with placebo or other medicines as the quality of the evidence was very low.
Quality of the evidence:  The quality of the evidence from the studies was very low and results should be interpreted with caution. In the future, well‐designed, double‐blind (where neither the participant nor the researcher knows which treatment has been given until after the results have been collected) RCTs with large numbers of participants are required to test how effective and well tolerated baclofen is in people with AWS.
The full text of this review can be found via this link.