Effect of On-Demand vs Routine Nebulization of Acetylcysteine With Salbutamol on Ventilator-Free Days in Intensive Care Unit Patients Receiving Invasive Ventilation: A Randomized Clinical Trial

This research by van Meenen et al was published in JAMA in February 2018.
Importance:  It remains uncertain whether nebulization of mucolytics with bronchodilators should be applied for clinical indication or preventively in intensive care unit (ICU) patients receiving invasive ventilation.
Objective:  To determine if a strategy that uses nebulization for clinical indication (on-demand) is noninferior to one that uses preventive (routine) nebulization.
Design, Setting, and Participants:  Randomized clinical trial enrolling adult patients expected to need invasive ventilation for more than 24 hours at 7 ICUs in the Netherlands.
Interventions:  On-demand nebulization of acetylcysteine or salbutamol (based on strict clinical indications, n = 471) or routine nebulization of acetylcysteine with salbutamol (every 6 hours until end of invasive ventilation, n = 473).
Main Outcomes and Measures:  The primary outcome was the number of ventilator-free days at day 28, with a noninferiority margin for a difference between groups of -0.5 days. Secondary outcomes included length of stay, mortality rates, occurrence of pulmonary complications, and adverse events.
Results:  Nine hundred twenty-two patients (34% women; median age, 66 (interquartile range [IQR], 54-75 years) were enrolled and completed follow-up. At 28 days, patients in the on-demand group had a median 21 (IQR, 0-26) ventilator-free days, and patients in the routine group had a median 20 (IQR, 0-26) ventilator-free days (1-sided 95% CI, -0.00003 to ∞). There was no significant difference in length of stay or mortality, or in the proportion of patients developing pulmonary complications, between the 2 groups. Adverse events (13.8% vs 29.3%; difference, -15.5% [95% CI, -20.7% to -10.3%]; P < .001) were more frequent with routine nebulization and mainly related to tachyarrhythmia (12.5% vs 25.9%; difference, -13.4% [95% CI, -18.4% to -8.4%]; P < .001) and agitation (0.2% vs 4.3%; difference, -4.1% [95% CI, -5.9% to -2.2%]; P < .001).
Conclusions and Relevance:  Among ICU patients receiving invasive ventilation who were expected to not be extubated within 24 hours, on-demand compared with routine nebulization of acetylcysteine with salbutamol did not result in an inferior number of ventilator-free days. On-demand nebulization may be a reasonable alternative to routine nebulization.
The full text of this article is available via this link.  The print copy of this issue JAMA is available in the Healthcare Library on D Level of Rotherham General Hospital.


Latest issue of “Journal of Critical Care” Volume 44 April 2018

“The Journal of Critical Care is a leading international, peer-reviewed journal providing original research, review articles, tutorials, and invited articles for physicians and allied health professionals involved in treating the critically ill.”
Articles published in this issue ijournal of critical care.pngnclude “The effect of sepsis and septic shock on the viscoelastic properties of clot quality and mass using rotational thromboelastometry: A prospective observational study”, “3-month prognostic impact of severe acute renal failure under veno-venous ECMO support: Importance of time of onset” and “Low tidal volume ventilation use remains low in patients with acute respiratory distress syndrome at a single centre”.  The full content page of this issue can be accessed via this link

A personal subscription to the journal is required to access the full text of these articles direct from this website.  However, articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  This can be done either in person or via this link if you are a registered member of the library.

Critical Care Reviews Newsletter 324 25th February 2018

The Critical Care Reviews Newsletter provides the best critical care research and open access articcritcal care reviewsles from across the medical literature over the past seven days. This week’s “highlights are the REDUCE randomised controlled trial, investigating haloperidol prophylaxis for delirium; narrative clinical reviews on cardiac arrest in theatre (parts 1 & 2), disseminated intravascular coagulation, and perioperative antifibrinolytic therapy; plus wonderful non-clinical reviews, including one on P values and confidence intervals. Articles accompanying plenary lectures from the Society of Critical Care Medicine Annual Congress are also included, as are excellent editorials on artificial oxygen carriers and critical care echocardiography.”

The full copy of newsletter 324 25th February 2018 can be accessed via this link.

Fluid therapy and outcome: a prospective observational study in 65 German intensive care units between 2010 and 2011

This article written by Ertmer et al was published in Annals of Intensive Care in the February 2018 edition.
Background:  Outcome data on fluid therapy in critically ill patients from randomised controlled trials may be different from data obtained by observational studies under “real-life” conditions. We conducted this prospective, observational study to investigate current practice of fluid therapy (crystalloids and colloids) and associated outcomes in 65 German intensive care units (ICUs). In total, 4545 adult patients who underwent intravenous fluid therapy were included. The main outcome measures were 90-day mortality, ICU mortality and acute kidney injury (AKI). Data were analysed using logistic and Cox regression models, as appropriate.
Results:  In the predominantly post-operative overall cohort, unadjusted 90-day mortality was 20.1%. Patients who also received colloids (54.6%) had a higher median Simplified Acute Physiology Score II [25 (interquartile range 11; 41) vs. 17 (7; 31)] and incidence of severe sepsis (10.2 vs. 7.4%) on admission compared to patients who received exclusively crystalloids (45.4%). 6% hydroxyethyl starch (HES 130/0.4) was the most common colloid (57.0%). Crude rates of 90-day mortality were higher for patients who received colloids (OR 1.845 [1.560; 2.181]). After adjustment for baseline variables, the HR was 1.666 [1.405; 1.976] and further decreased to indicate no associated risk (HR 1.003 [0.980; 1.027]) when it was adjusted for vasopressor use, severity of disease and transfusions. Similarly, the crude risk of AKI was higher in the colloid group (crude OR 3.056 [2.528; 3.694]), after adjustment for baseline variables OR 1.941 [1.573; 2.397], and after full adjustment OR 0.696 [0.629; 0.770]), the risk of AKI turned out to be reduced. The same was true for the subgroup of patients treated with 6% HES 130/0.4 (crude OR 1.931 [1.541; 2.419], adjusted for baseline variables OR 2.260 [1.730; 2.953] and fully adjusted OR 0.800 [0.704; 0.910]) as compared to crystalloids only.
Conclusions:  The present analysis of mostly post-operative patients in routine clinical care did not reveal an independent negative effect of colloids (mostly 6% HES 130/0.4) on renal function or survival after multivariable adjustment. Signals towards a reduced risk in subgroup analyses deserve further study.
The full text of this article is available via the PDF that can be accessed via this link

Acute kidney injury epidemiology, risk factors, and outcomes in critically ill patients 16-25 years of age treated in an adult intensive care unit

This research by Fuhrum et al was published in Annals of Intensive Care in February 2018
Background:  Most studies of acute kidney injury (AKI) have focused on older adults, and little is known about AKI in young adults (16-25 years) that are cared for in an adult intensive care unit (ICU). We analysed data from a large single-center ICU database and defined AKI using the Kidney Disease Improving Global Outcomes criteria. We stratified patients 16-55 years of age into four age groups for comparison and used multivariable logistic regression to identify associations of potential susceptibilities and exposures with AKI and mortality.
Results:  AKI developed in 52.6% (n = 8270) of the entire cohort and in 39.8% of the young adult age group (16-25 years). The AUCs for the age categories were similar at 0.754, 0.769, 0.772, and 0.770 for the 16-25-, 26-35-, 36-45-, and 45-55-year age groups, respectively. For the youngest age group, diabetes (OR 1.89; 95% CI 1.09-3.29), surgical reason for admission (OR 1.79; 95% CI 1.44-2.23), severity of illness (OR 1.02; 95% CI 1.02-1.03), hypotension (OR 1.13; 95% CI 1.04-1.24), and certain medications (vancomycin and calcineurin inhibitors) were all independently associated with AKI. AKI was a significant predictor for longer length of stay, ICU mortality, and mortality after discharge.
Conclusions:  AKI is a common event for young adults admitted to an adult tertiary care center ICU with an associated increased length of stay and risk of mortality. Potentially modifiable risk factors for AKI including medications were identified for all stratified age groups.
The full text of this article is available via the PDF that can be accessed via this link

Association of admission serum levels of vitamin D, calcium, Phosphate, magnesium and parathormone with clinical outcomes in neurosurgical ICU patients

This article by Ardehali et al was published in Scientific Reports in February 2018.
To evaluate the association of admission serum levels of 25(OH)D, parathormone and the related electrolytes with severity of illness and clinical outcomes in neurosurgical critically ill patients, serum levels of 25(OH)D, parathormone, calcium, magnesium, and phosphate, along with APACHE II score were measured for 210 patients upon admission. Mean serum 25(OH)D was 21.1 ± 7.4 ng/mL. 25(OH)D deficiency (less than 20 ng/dL) and elevated serum parathormone level were found in 47.6% and 38% of patients respectively. Hypocalcaemia, hypophosphatemia, hypomagnesaemia and hypermagnesaemia were found in 29.5%, %63.8, 41.9% and 27.6% of patients respectively. The APACHE II score was significantly correlated with serum levels of 25(OH)D, parathormone, calcium, and phosphate. Multivariate regression analysis adjusted by other risk factors showed that among all clinical outcomes, admission hypovitaminosis D was associated with longer duration of ICU stay and a high admission of parathormone was associated with in ICU mortality. We concluded that disorders of admission serum levels of 25(OH)D, parathormone, calcium, magnesium, and phosphate are related to the presence of multiple causal factors such as severity of disease and are not independently associated with clinical outcomes. Most often they are normalize spontaneously with resolution of the disease process.
The full text of this article is available via the PDF that can be accessed via this link

Critical Care Reviews Newsletter 18th February 2018 Issue 323

The 323rd Critical Care Reviews Newsletter, brings you the best critical care research articles from across the medical literature in the last week.  “The highlights are randomiscritcal care reviewsed controlled trials on rehabilitation in the critically ill, contrast nephropathy, & carbapenem-resistant Gram-negative bacteria; guidelines on the organization of ECMO programs, haemodynamic assessment and support in sepsis and septic shock in resource-limited settings, & frailty in patients with acute cardiovascular disease; plus narrative reviews on perioperative stroke, delirium in the cardiac ICU, & traumatic brain injury.”

The full newsletter can be accessed via this link.