Category Archives: Concise Critical Appraisal

Sepsis and Therapeutic Interventions

The global burden of sepsis is substantial. Therefore, in a retrospective before-after clinical study, Marik et al compared the outcome and clinical course of consecutive septic patients treated with intravenous vitamin C, hydrocortisone and thiamine during a seven-month period (treatment group) at an intensive care unit (ICU) at Sentara Norfolk General Hospital compared to a control group treated (without intravenous vitamin C or thiamine) during the preceding seven months at the same ICU. The primary outcome was hospital survival.

The study’s results suggest that the early use of intravenous vitamin C, together with corticosteroids and thiamine, may prove to be effective in preventing progressive organ dysfunction and in reducing the mortality of patients with severe sepsis and septic shock.

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Sevoflurane for Sedation

Sevoflurane improves gas exchange, and reduces alveolar edema and inflammation in preclinical studies of lung injury, but its therapeutic effects have never been investigated in acute respiratory distress syndrome (ARDS). Jabaudon et al set out to assess whether sevoflurane would improve gas exchange and inflammation in ARDS.

They found that in patients with ARDS, use of inhaled sevoflurane improved oxygenation and decreased levels of a marker of epithelial injury and of some inflammatory markers, compared with midazolam.

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Molecular Detection of Pathogens

Microbiological diagnosis of infections remains insufficient. The resulting empirical antimicrobial therapy leads to multidrug resistance and inappropriate treatments. Cambau et al therefore evaluated the cost-effectiveness of direct molecular detection of pathogens in blood for patients with severe sepsis, febrile neutropenia, and suspected infective endocarditis.

They found that the addition of molecular detection to standard care improves microbiological diagnosis and thus efficiency of healthcare resource usage in patients with severe sepsis.

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Examining Tracheal Intubation

Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting. Andersen et al set out to determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

They found that among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge.

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Prognostic Accuracy of Sepsis-3

Does the quick Sequential Organ Failure Assessment (qSOFA) score more accurately predict in-hospital mortality than the systemic inflammatory response syndrome (SIRS) or severe sepsis criteria among emergency department patients with suspected infection? Freund et al set out to answer this question.

They found that among patients presenting to the emergency department setting with suspected infection, the use of qSOFA resulted in greater prognostic accuracy for in-hospital mortality than either SIRS or severe sepsis.

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Relative Bradycardia and Septic Shock

Tachycardia is common in septic shock, but many patients with septic shock are relatively bradycardic. The prevalence, determinants, and implications of relative bradycardia in septic shock are unknown. Therefore, Beesley et al set out to determine mortality associated with patients who are relatively bradycardic while in septic shock.

They found that relative bradycardia in patients with septic shock is associated with lower mortality, even after adjustment for confounding.

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Examining Very Short Antibiotic Courses

Many patients started on antibiotics for possible ventilator-associated pneumonia (VAP) do not have pneumonia. Patients with minimal and stable ventilator settings may be suitable candidates for early antibiotic discontinuation. Therefore, Klompas et al set out to compare outcomes amongst patients with suspected VAP but minimal and stable ventilator settings treated with one to three versus more than three days of antibiotics.

Very short antibiotic courses (one to three days) were associated with outcomes similar to longer courses (more than three days) in patients with suspected VAP but minimal and stable ventilator settings.

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High-Flow Nasal Cannula vs. Noninvasive Ventilation

High-flow conditioned oxygen therapy delivered through nasal cannulae and noninvasive mechanical ventilation (NIV) may reduce the need for reintubation. Therefore, Hernández et al set out to test if high-flow conditioned oxygen therapy is noninferior to NIV for preventing postextubation respiratory failure and reintubation in patients at high risk of reintubation.

They found that among high-risk adults who have undergone extubation, high-flow conditioned oxygen therapy was not inferior to NIV for preventing reintubation and postextubation respiratory failure.

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Efficacy of Combined Intravenous Thrombolysis and Thrombectomy

Mechanical thrombectomy (MT) improves clinical outcomes in patients with acute ischemic stroke (AIS) caused by a large vessel occlusion. However, it is not known whether intravenous thrombolysis (IVT) is of added benefit in patients undergoing MT. Coutinho et al set out to address this unknown.

The results indicate that treatment of patients experiencing AIS due to a large vessel occlusion with IVT before MT does not appear to provide a clinical benefit over MT alone.

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Culture Negative Severe Sepsis: Nationwide Trends and Outcomes

Although 28% to 49% of severe sepsis hospitalizations have been described as being “culture negative,” there are very limited data on the epidemiology and outcomes of those with culture negative severe sepsis (CNSS). The objectives of a study by Gupta et al were to investigate the proportion and trends of CNSS and its association with mortality.

They found that CNSS among hospitalized patients is common, and its proportion is on the rise. They also found that CNSS is associated with greater acute organ dysfunction and mortality.

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Effects of Epinephrine on Cerebral Oxygenation during CPR

Epinephrine has been presumed to improve cerebral oxygen delivery during cardiopulmonary resuscitation (CPR), but animal and registry studies suggest that epinephrine-induced capillary vasoconstriction may decrease cerebral capillary blood flow and worsen neurological outcome. The effect of epinephrine on cerebral oxygenation during CPR has not been documented in the clinical setting. Therefore, Deakin et al examined the effect of epinephrine on cerebral brain oxygenation during in-hospital cardiac arrest.

They found that 1 mg intravenous epinephrine, administered during advanced life support resuscitation, was not associated with a clinically significant change in cerebral tissue oxygenation.

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Airway Driving Pressure and Lung Stress in ARDS Patients

Since the first description of acute respiratory distress syndrome (ARDS) in the 1960s, numerous studies have sought the optimal tidal volume, positive end-expiratory pressure, plateau pressure, and inspired fraction of oxygen to reduce ventilator-induced lung injury. Chiumello et al set out to evaluate if airway driving pressure could accurately predict lung stress in ARDS patients.

They found that airway driving pressure can detect lung overstress with an acceptable accuracy.

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EIP Prolongation in ARDS Patients

End-inspiratory pause (EIP) prolongation decreases dead space-to-tidal volume ratio and partial pressure of carbon dioxide in arterial blood (PaCO2). We do not know the physiological benefits of this approach to improve respiratory system mechanics in acute respiratory distress syndrome (ARDS) patients when mild hypercapnia is of no concern. Aguirre-Bermeo et al, therefore, set out to address this unknown.

They found that prolonging EIP allowed a significant decrease in tidal volume without changes in PaCO2 in passively ventilated ARDS patients. This produced a significant decrease in plateau pressure and driving pressure and significantly increased respiratory system compliance, which suggests less overdistension and less dynamic strain.

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Examining Pantoprazole or Placebo for Stress Ulcer Prophylaxis

Pantoprazole is frequently administered to critically ill patients for prophylaxis against gastrointestinal bleeding. However, comparison to placebo has been inadequately evaluated, and pantoprazole has the potential to cause harm. Therefore, Selvanderan and colleagues set out to evaluate benefit or harm associated with pantoprazole administration.

They found no evidence of benefit or harm with the prophylactic administration of pantoprazole to mechanically ventilated critically ill patients anticipated to receive enteral nutrition.

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