Critical Care Reviews Newsletter 436 19th April 2020

The 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 highlights of this week’s edition are randomised controlled trials on empirical high-dose meropenem in critically ill patients with sepsis and septic shock & the effect of intermittent or continuous feeding on muscle wasting in critical illness; systematic reviews and meta analyses on ventilator-associated pneumonia & antibiotic discontinuation strategies; and observational studies on prognosis for COVID-19 patients receiving ECMO in China & SARS-CoV-2 viral load in clinical samples of critically ill patients. There are also guidelines on COVID-19 airway management & triage of scarce critical care resources in COVID-19.
The full text of the issue is available via this link

End-of-life practices in traumatic brain injury patients: Report of a questionnaire from the CENTER-TBI study

The research from the CENTRE TBI investigators and participants was first published online in the Journal of Critical Care.
Purpose:  We aimed to study variation regarding specific end-of-life (EoL) practices in the intensive care unit (ICU) in traumatic brain injury (TBI) patients.
Materials and methods:  Respondents from 67 hospitals participating in The Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study completed several questionnaires on management of TBI patients.
Results:  In 60% of the centers, ≤50% of all patients with severe neurological damage dying in the ICU, die after withdrawal of life-sustaining measures (LSM). The decision to withhold/withdraw LSM was made following multidisciplinary consensus in every center. Legal representatives/relatives played a role in the decision-making process in 81% of the centers. In 82% of the centers, age played a role in the decision to withhold/withdraw LSM. Furthermore, palliative therapy was initiated in 79% of the centers after the decision to withdraw LSM was made. Last, withholding/withdrawing LSM was, generally, more often considered after more time had passed, in a patient with TBI, who remained in a very poor prognostic condition.
Conclusion:  We found variation regarding EoL practices in TBI patients. These results provide insight into variability regarding important issues pertaining to EoL practices in TBI, which can be useful to stimulate discussions on EoL practices, comparative effectiveness research, and, ultimately, development of recommendations.
The full text of this article is freely available via this link.

Critical Care Reviews Newsletter 435 12th April 2020

The 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 highlights of this week’s edition are an observational study on the baseline characteristics and outcomes of 1591 critically ill COVID-19 patients in Lombardy and the protocol of the exciting REMAP-CAP trial.  There are also multiple COVID-19 guidelines, including one from the Infectious Diseases Society of America on treatment and management; narrative reviews on the intensive care management of COVID-19 & antibiotic treatment in patients with sepsis; editorials on neuro-critical care and ultrasound in intensive care; and commentaries on CAR‑T cells, the immunosuppressive effects of noradrenaline and sustaining a pandemic workforce.
The full text of the issue is available via this link

Conservative Oxygen Therapy during Mechanical Ventilation in the ICU.

This research by the ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group was published in The New England journal of medicine vol. 382 (no. 11) in March 2020.
Background:  Patients who are undergoing mechanical ventilation in the intensive care unit (ICU) often receive a high fraction of inspired oxygen (Fio2) and have a high arterial oxygen tension. The conservative use of oxygen may reduce oxygen exposure, diminish lung and systemic oxidative injury, and thereby increase the number of ventilator-free days (days alive and free from mechanical ventilation).  Methods:  We randomly assigned 1000 adult patients who were anticipated to require mechanical ventilation beyond the day after recruitment in the ICU to receive conservative or usual oxygen therapy. In the two groups, the default lower limit for oxygen saturation as measured by pulse oximetry (Spo2) was 90%. In the conservative-oxygen group, the upper limit of the Spo2 alarm was set to sound when the level reached 97%, and the Fio2 was decreased to 0.21 if the Spo2 was above the acceptable lower limit. In the usual-oxygen group, there were no specific measures limiting the Fio2 or the Spo2. The primary outcome was the number of ventilator-free days from randomization until day 28.
Results:  The number of ventilator-free days did not differ significantly between the conservative-oxygen group and the usual-oxygen group, with a median duration of 21.3 days (interquartile range, 0 to 26.3) and 22.1 days (interquartile range, 0 to 26.2), respectively, for an absolute difference of -0.3 days (95% confidence interval [CI], -2.1 to 1.6; P = 0.80). The conservative-oxygen group spent more time in the ICU with an Fio2 of 0.21 than the usual-oxygen group, with a median duration of 29 hours (interquartile range, 5 to 78) and 1 hour (interquartile range, 0 to 17), respectively (absolute difference, 28 hours; 95% CI, 22 to 34); the conservative-oxygen group spent less time with an Spo2 exceeding 96%, with a duration of 27 hours (interquartile range, 11 to 63.5) and 49 hours (interquartile range, 22 to 112), respectively (absolute difference, 22 hours; 95% CI, 14 to 30). At 180 days, mortality was 35.7% in the conservative-oxygen group and 34.5% in the usual-oxygen group, for an unadjusted odds ratio of 1.05 (95% CI, 0.81 to 1.37).
Conclusions:  In adults undergoing mechanical ventilation in the ICU, the use of conservative oxygen therapy, as compared with usual oxygen therapy, did not significantly affect the number of ventilator-free days.
The paper copy of the New England Journal of Medicine is available in the Healthcare Library on D Level of Rotherham Hospital.

Epidemiologic Features and Clinical Course of Patients Infected With SARS-CoV-2 in Singapore.

This article by Young and others in Singapore 2019 Novel Coronavirus Outbreak Research Team was published during March 2020.
Importance:  Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in Wuhan, China, in December 2019 and has spread globally with sustained human-to-human transmission outside China.
Objective:  To report the initial experience in Singapore with the epidemiologic investigation of this outbreak, clinical features, and management.
Design, Setting, and Participants:  Descriptive case series of the first 18 patients diagnosed with polymerase chain reaction (PCR)-confirmed SARS-CoV-2 infection at 4 hospitals in Singapore from January 23 to February 3, 2020; final follow-up date was February 25, 2020.Exposures Confirmed SARS-CoV-2 infection.
Main Outcomes and Measures:  Clinical, laboratory, and radiologic data were collected, including PCR cycle threshold values from nasopharyngeal swabs and viral shedding in blood, urine, and stool. Clinical course was summarized, including requirement for supplemental oxygen and intensive care and use of empirical treatment with lopinavir-ritonavir.
Results:  Among the 18 hospitalized patients with PCR-confirmed SARS-CoV-2 infection (median age, 47 years; 9 [50%] women), clinical presentation was an upper respiratory tract infection in 12 (67%), and viral shedding from the nasopharynx was prolonged for 7 days or longer among 15 (83%). Six individuals (33%) required supplemental oxygen; of these, 2 required intensive care. There were no deaths. Virus was detectable in the stool (4/8 [50%]) and blood (1/12 [8%]) by PCR but not in urine. Five individuals requiring supplemental oxygen were treated with lopinavir-ritonavir. For 3 of the 5 patients, fever resolved and supplemental oxygen requirement was reduced within 3 days, whereas 2 deteriorated with progressive respiratory failure. Four of the 5 patients treated with lopinavir-ritonavir developed nausea, vomiting, and/or diarrhea, and 3 developed abnormal liver function test results.
Conclusions and Relevance:  Among the first 18 patients diagnosed with SARS-CoV-2 infection in Singapore, clinical presentation was frequently a mild respiratory tract infection. Some patients required supplemental oxygen and had variable clinical outcomes following treatment with an antiretroviral agent.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.  The full text of this article is freely available vis this link.

Prevalence and Outcomes of Infection Among Patients in Intensive Care Units in 2017

This article by Vincent and other EPIC III Investigators was published in JAMA during March 2020.
Importance:  Infection is frequent among patients in the intensive care unit (ICU). Contemporary information about the types of infections, causative pathogens, and outcomes can aid the development of policies for prevention, diagnosis, treatment, and resource allocation and may assist in the design of interventional studies.
Objective:  To provide information about the prevalence and outcomes of infection and the available resources in ICUs worldwide.
Design, Setting, and Participants:  Observational 24-hour point prevalence study with longitudinal follow-up at 1150 centers in 88 countries. All adult patients (aged ≥18 years) treated at a participating ICU during a 24-hour period commencing at 08:00 on September 13, 2017, were included. The final follow-up date was November 13, 2017.
Exposures: Infection diagnosis and receipt of antibiotics.
Main Outcomes and Measures:  Prevalence of infection and antibiotic exposure (cross-sectional design) and all-cause in-hospital mortality (longitudinal design).
Results:  Among 15 202 included patients (mean age, 61.1 years [SD, 17.3 years]; 9181 were men [60.4%]), infection data were available for 15 165 (99.8%); 8135 (54%) had suspected or proven infection, including 1760 (22%) with ICU-acquired infection. A total of 10 640 patients (70%) received at least 1 antibiotic. The proportion of patients with suspected or proven infection ranged from 43% (141/328) in Australasia to 60% (1892/3150) in Asia and the Middle East. Among the 8135 patients with suspected or proven infection, 5259 (65%) had at least 1 positive microbiological culture; gram-negative microorganisms were identified in 67% of these patients (n = 3540), gram-positive microorganisms in 37% (n = 1946), and fungal microorganisms in 16% (n = 864). The in-hospital mortality rate was 30% (2404/7936) in patients with suspected or proven infection. In a multilevel analysis, ICU-acquired infection was independently associated with higher risk of mortality compared with community-acquired infection (odds ratio [OR], 1.32 [95% CI, 1.10-1.60]; P = .003). Among antibiotic-resistant microorganisms, infection with vancomycin-resistant Enterococcus (OR, 2.41 [95% CI, 1.43-4.06]; P = .001), Klebsiella resistant to β-lactam antibiotics, including third-generation cephalosporins and carbapenems (OR, 1.29 [95% CI, 1.02-1.63]; P = .03), or carbapenem-resistant Acinetobacter species (OR, 1.40 [95% CI, 1.08-1.81]; P = .01) was independently associated with a higher risk of death vs infection with another microorganism.
Conclusions and Relevance:  In a worldwide sample of patients admitted to ICUs in September 2017, the prevalence of suspected or proven infection was high, with a substantial risk of in-hospital mortality.
The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.

Intensive Care Medicine Volume 46 Number 4 April 2020

To view Intensive Care Medicine’s March issue’s contents page follow this link.
Articles published in this issue include: How to face the novel coronavirus infection during the 2019–2020 epidemic: the experience of Sichuan Provincial People’s Hospital”, “Angiotensin-converting enzyme 2 (ACE2) as a SARS-CoV-2 receptor: molecular mechanisms and potential therapeutic targetand Imaging changes in severe COVID-19 pneumonia
Together with other articles on COVID 19 these are freely available in full text to everyone.
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 Medicine April 2020 – Volume 48 – Issue 4

The latest issue of this journal published by the Society of Critical Care Medicine can be found via this link.  It includes articles such as Alterations in Skin Blood Flow at the Fingertip Are Related to Mortality in Patients With Circulatory Shockand “Association Between Cardiac Injury and Mortality in Hospitalized Patients Infected With Avian Influenza A (H7N9) Virus”.
To read the full text of any of these articles via the journal’s homepage requires a personal access to “Critical 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.