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NEWS - Critical Care & Emergencies

Focus on randomised clinical trials – Intensive Care Medicine (free PDF) (via @CritCareReviews)

Related: What should we stop doing in the ICU? – ICU Management & Practice (free)

“Their results add to what appears to be a constant theme in critical care, ‘less is more’ based on RCT results”

 


Graduated compression stockings for prevention of deep vein thrombosis – Cochrane Library (free)

Summary: Graduated compression stockings for prevention of deep vein thrombosis during a hospital stay – Cochrane Library (free)

“There is high-quality evidence that GCS are effective in reducing the risk of DVT in hospitalised patients who have undergone general and orthopaedic surgery”

 


Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU – New England Journal of Medicine (free for a limited period)

Editorial: Proton-Pump Inhibitor Prophylaxis in the ICU — Benefits Worth the Risks? (free for a limited period)

“Proton pump inhibitors are minimally effective to reduce GI bleeding among the critically ill folks at high risk for stress ulcers. Takeaways: no role for routine PPI for any patients on the WARDS, and shouldn’t be considered ‘routine’ in the ICU” (via @AnilMakam see Tweet)

 


Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial – JAMA (free for a limited period)

Editorial: Lessons From ARDS for Non-ARDS Research: Remembrance of Trials Past (free)

“Among patients in the ICU receiving invasive ventilation, a strategy with low tidal volume was not more effective than a strategy using intermediate tidal volume.”

 


Energy-Dense versus Routine Enteral Nutrition in the Critically Ill – New England Journal of Medicine (free for a limited period)

Energy-dense formulation for enteral delivery of nutrition was not associated with better outcomes.

 


Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial – JAMA (free for a limited period)

Editorial: Decontamination of Oral or Digestive Tract for Patients in the Intensive Care Unit (free for a limited period)

“Among patients receiving mechanical ventilation in ICUs with moderate to high ABX resistance prevalence, use of chlorhexidine mouthwash, selective oropharyngeal decontamination, or selective digestive tract decontamination was not associated with reductions in ICU-acquired bloodstream infections caused by MDRGNB vs standard care” (via @JAMA_current see Tweet with visual abstract)

 


Effect of Protocolized Weaning with Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial – JAMA (free for a limited period)

Editorial: Weaning From Mechanical Ventilation: What Should Be Done When a Patient’s Spontaneous Breathing Trial Fails? (free for a limited period)

“Among patients requiring mechanical ventilation in whom a spontaneous breathing trial had failed, early extubation to noninvasive ventilation did not shorten time to liberation from any ventilation.”

 


Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis – New England Journal of Medicine (link to abstract – $ for full-text)

Video Summary: Renal-Replacement Therapy for AKI (free)

Commentary: Is Kidney Dialysis Always Needed When Septic Shock Strikes? – HealthDay (free)

“Trial comparing early vs. delayed strategies of renal-replacement therapy in patients with early-stage septic shock who had severe acute kidney injury finds no significant between-group difference in overall mortality at 90 days.” (via @NEJM see Tweet)

 


Laparoscopic cholecystectomy versus percutaneous catheter drainage for acute cholecystitis in high risk patients (CHOCOLATE): multicentre randomised clinical trial – The BMJ (free)

“Laparoscopic cholecystectomy compared with percutaneous catheter drainage reduced the rate of major complications in high risk patients with acute cholecystitis.”

 


Antibiotics for acute rhinosinusitis in adults – Cochrane Library (free for a limited period)

Summary: Antibiotics for sinus infection of short duration in adults – Cochrane Library (free)

“Considering antibiotic resistance, and the very low incidence of serious complications, we conclude there is no place for antibiotics for people with uncomplicated acute rhinosinusitis.”

 


Six-Month Outcomes after Restrictive or Liberal Transfusion for Cardiac Surgery – New England Journal of Medicine (free for a limited period)

“In moderate-to-high-risk patients undergoing cardiac surgery, six-month outcomes show that a restrictive red-cell transfusion strategy is noninferior to a liberal strategy” (via @NEJM see Tweet with Visual Abstract)

 


High-sensitivity troponin in the evaluation of patients with suspected acute coronary syndrome: a stepped-wedge, cluster-randomised controlled trial – The Lancet (free)

Commentaries: Diagnosing myocardial infarction: a highly sensitive issue – The Lancet (free) AND Hs-TnI in Suspected ACS: High-STEACS Trial – American College of Cardiology (free) AND Is High Sensitivity Troponin Too Sensitive? – NEJM Journal Watch (free)

“Introduction of a high-sensitivity cardiac troponin I assay reclassified 1 in 6 patients with previously undetected myocardial necrosis, but did not lead to improved clinical outcomes in this large randomised trial” (via @chapdoc1 see Tweet)

“Very important study. What’s weird is that the “better” (more sensitive) troponin assays get, the less helpful the test becomes at the bedside. Look for a coming tsunami of iatrogenesis from overzealous evaluation of troponin bumps.” (via @drjohnm see Tweet)

 


ESC Council on hypertension position document on the management of hypertensive emergencies – European Heart Journal – Cardiovascular Pharmacotherapy (free) (@Abraham_RMI)

“Patients that lack acute hypertension-mediated end organ damage to the heart, retina, brain, kidneys, or large arteries do not have a hypertensive emergency and can be treated with oral BP-lowering agents and usually discharged after a brief period of observation.”

 


Extended antibiotic infusions could save lives: Here’s how to do it – PulmCCM (free)

Related Research: Mortality lower with prolonged vs. short-term IV infusion of antipseudomonal beta-lactams (free)

“The simplest (and cheapest) technique is simply to reduce the time between doses.”

 


Seven days of antibiotics were as good as 14 for gram-negative bacteremia – PulmCCM (free)

Related Commentary: Seven-day antibiotic course delivers similar outcomes to 14-days for Gram-negative bacteraemia – European Society of Clinical Microbiology and Infectious Diseases, via EurekAlert (free)

“It’s important to note that source control was believed to be achieved in all enrolled patients. If source control cannot be achieved (e.g., an abscess, or an infected heart valve or indwelling catheter that cannot safely be removed), prolonged antibiotic courses are often advisable.”

 


The Illness Is Bad Enough. The Hospital May Be Even Worse – The New York Times (10 articles per month are free)

Related: Post-Hospital Syndrome — An Acquired, Transient Condition of Generalized Risk – New England Journal of Medicine (free) AND Is Posthospital Syndrome a Result of Hospitalization-Induced Allostatic Overload? – Journal of Hospital Medicine (free) (via @hmkyale)

“The elderly are particularly vulnerable to “post-hospital syndrome,” some experts believe, and that may be why so many patients return.”

 


Colloids versus crystalloids for fluid resuscitation in critically ill people – Cochrane Library (link to abstract – $ for full-text)

Summary: Colloids or crystalloids for fluid replacement in critically people – Cochrane Library (free)

“Using starches, dextrans, albumin or FFP (moderate-certainty evidence), or gelatins (low-certainty evidence), versus crystalloids probably makes little or no difference to mortality. Starches probably slightly increase the need for blood transfusion and RRT (moderate-certainty evidence), and albumin or FFP may make little or no difference to the need for renal replacement therapy (low-certainty evidence)”.

 


Reports from the task force on tropical diseases by the World Federation of Societies of Intensive and Critical Care Medicine:

Sepsis in tropical regions

Intensive care in severe malaria

Dengue fever

Ebola virus disease

Leptospirosis

Zika virus

Chikungunya

Source: Critical Care Reviews Newsletter

 


Paramedic 2: Epinephrine harms/helps in out of hospital cardiac arrest – First10EM (free)

See Also: Original Article (free study and editorial) AND Expert Reaction (free commentaries)

“Paramedic 2 quick summary:

If 1000 people treated with epinephrine:

– 246 extra ROSC (return of spontaneous circulation)

– 158 extra admissions

– 8 extra survivors (5 with bad neuro outcomes, 3 with good neuro outcomes)

– What those numbers mean is a value question, not a science question.” (via @First10EM see Tweet)

 


A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest – New England Journal of Medicine (free)

Editorial: Testing Epinephrine for Out-of-Hospital Cardiac Arrest (free)

Commentary: Using adrenaline in cardiac arrests results in less than 1 percent more people leaving hospital alive – University of Warwick, via EurekAlert (free)

See also: Infographic detailing result findings (free)

“A clinical trial of the use of adrenaline in cardiac arrests has found that its use results in less than 1% more people leaving hospital alive – but almost doubles the risk of severe brain damage for survivors of cardiac arrest” (from University of Warwick).

 


Association of Inferior Vena Cava Filter Placement for Venous Thromboembolic Disease and a Contraindication to Anticoagulation With 30-Day Mortality – JAMA Network Open (free)

Commentaries: Inferior Vena Cava Filters and Mortality: Is It the Underlying Process, the Patient, or the Device? (free)

“Could IVC filters be causing harm? They began being used before @US_FDA started approving devices. This article raises possibility of increased mortality. Maybe where we need trials to determine safety and effectiveness”. (via @hmkyale see Tweet)

 


Antibiotics should be restricted for COPD – National Institute for Health and Care Excellence (free)

Commentaries: Antibiotics should be restricted for COPD, says NICE – OnMedica (free) AND UK officials recommend limits on antibiotics for COPD – CIDRAP (free)

“The draft antimicrobial guidance recommends that antibiotics should be offered to people who have a severe flare up of symptoms, also known as a severe acute exacerbation”

 


A Multicenter Study of Patient-Reported Infectious and Noninfectious Complications Associated With Indwelling Urethral Catheters – JAMA Internal Medicine (free)

Commentary: Foleys Aren’t Fun: Patient Study Shows Catheter Risks – University of Michigan, via NewsWise (free)

“More than half of patients surveyed while they had a urinary catheter, and again weeks later, reported a complication – and infections were only part of the problem” (from NewsWise)

 


Out-of-hours discharge from intensive care, in-hospital mortality and intensive care readmission rates: a systematic review and meta-analysis – Intensive Care Medicine (free)

Source: Critical Care Reviews Newsletter

“Out-of-hours discharge from an ICU is strongly associated with both in-hospital death and ICU readmission. Whether these increases in mortality and readmission result from patient differences, differences in care, or a combination remains unclear”.

 


Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial – The Lancet (link to abstract – $ for full-text)

Commentary: BICAR-ICU – The Bottom Line (free)

“This study will reassure clinicians that already use sodium bicarbonate for correcting metabolic acidaemia, that this may delay and/or reduce the requirement for RRT. Equally, for those that opt to avoid sodium bicarbonate, there is no compelling evidence to change practice”

 


IOTA – Liberal vs Conservative Oxygen Therapy in the Critically Ill – The Bottom Line (free)

Original Meta-Analysis: Liberal vs Conservative Oxygen Therapy in Acutely ill Adults (link to abstract and commentary)

“Hyperoxia is BAD –> Aim for lowest safest inspired O2 in critically ill pts & titrate FiO2 down if SpO2 >95%” (via @srrezaie see Tweet)

 


Controversy: Is there still a place for the Swan-Ganz catheter? – Intensive Care Medicine

YES (free for a limited period) / NO (free for a limited period) WE ARE NOT SURE (free for a limited period)

 


Effect of Negative Pressure Wound Therapy vs Standard Wound Management on 12-Month Disability Among Adults With Severe Open Fracture of the Lower Limb: The WOLLF Randomized Clinical Trial – JAMA (free for a limited period)

Commentaries: High-tech treatment of open leg wounds no better than using regular dressings – University of Warwick (free) AND Negative-Pressure Therapy No Better for Open Fractures – Medscape (free registration required)

“Negative pressure wound therapy did not improve 12-month disability for patients with severe open fracture of the lower limb compared with standard wound dressing”

 


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