Category Archives: Concise Critical Appraisal

Antibiotic Timing and Mortality in Sepsis

The current standard of care for sepsis is the early administration of antibiotics. However, efforts to shorten time to antibiotic administration may also cause harm because more patients may receive unnecessary antibiotics. Liu et al  evaluated the association between antibiotic timing and mortality among patients with sepsis receiving antibiotics within 6 hours of emergency department registration.

They found that hourly delays in antibiotic administration for patients with sepsis were associated with increased odds of hospital mortality, even among patients who received antibiotics within 6 hours.

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Age of Red Cells for Transfusion and Outcomes

Blood banks usually function by issuing the oldest available, patient-compatible products first. The goal is to preserve viability and functionality of cells and minimize waste of blood products.  Previous studies have shown conflicting evidence as to whether transfusion of older blood products is related to increased mortality. Therefore, Cooper et al set out to determine whether transfusion of older red blood cells (RBC) increased mortality for critically ill patients.

Their study findings support the current practice of using the oldest available RBCs for transfusion of critically ill adults, since there does not seem to be a benefit of using the freshest available RBCs.

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Outcomes of Mandated Sepsis Bundles

It is a requirement in some hospitals to follow protocols for the early identification and treatment of sepsis. However, there is controversy about whether more rapid treatment of sepsis improves outcomes in patients. Therefore, Seymour et al set out to determine the association between the time until completion of the 3-hour bundle and risk-adjusted mortality.

They found that more rapid completion of the 3-hour bundle of sepsis care and rapid antibiotics, but not rapid completion of an initial bolus of intravenous fluids, were associated with lower risk-adjusted in-hospital mortality.

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Examining Out-of-Hospital Cardiac Arrest

Out-of-hospital cardiac arrest is a major public health problem affecting over 300,000 persons in the United States each year. Therefore, Wang et al set out to determine if arterial oxygen and carbon dioxide abnormalities in the first 24 hours after return of spontaneous circulation are associated with increased mortality in adult out-of-hospital cardiac arrest.

They found that in the first 24 hours after return of spontaneous circulation, post-arrest
oxygen and carbon dioxide tension abnormalities are associated with increased out-of-hospital cardiac arrest mortality.

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Optimal Position for Intubation

Hypoxemia is the most common complication during endotracheal intubation of critically ill adults. Intubation in the ramped position has been hypothesized to prevent hypoxemia by increasing functional residual capacity and decreasing the duration of intubation, but has never been studied outside of the operating room. Therefore, Semler et al conducted a multicenter, randomized trial comparing the ramped position with the sniffing position among 260 adults undergoing endotracheal intubation by pulmonary and critical care medicine fellows in four intensive care units between July 22, 2015, and July 19, 2016.

They found that the ramped position did not improve oxygenation during endotracheal intubation of critically ill adults compared with the sniffing position.

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mRNA Expression of CD74 and IL10

Intensive care unit-acquired infections (IAIs) result in increased hospital and intensive care unit stay, costs and mortality. To date, no biomarker has shown sufficient evidence and ease of application in clinical routine for the identification of patients at risk of IAI. Therefore, Peronnet et al evaluated the association of the systemic mRNA expression of two host response biomarkers, CD74 and IL10, with IAI occurrence in a large cohort of intensive care unit patients.

Their results suggest that two immune biomarkers, CD74 and IL10, could be relevant tools for the identification of IAI risk in intensive care unit patients.

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Examining Stress Ulcer Prophylaxis

A decreased frequency of upper gastrointestinal bleeding and a possible association of proton pump inhibitor use with Clostridium difficile and ventilator-associated pneumonia have raised concerns recently. The Reevaluating the Inhibition of Stress Erosions (REVISE) Pilot Trial determined the feasibility of undertaking a larger trial investigating the efficacy and safety of withholding proton pump inhibitors in critically ill patients.

The results support the feasibility of a larger trial to evaluate the safety of withholding stress ulcer prophylaxis.

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Examining Chest Compressions

Mechanical chest compression (CC) during cardiopulmonary resuscitation (CPR) with AutoPulse or LUCAS devices has not improved survival from cardiac arrest. Cohort studies suggest risk of excess damage. Therefore, Koster et al studied the safety of mechanical CC compared with manual CC, as pertains to excess damage in patients with in-hospital cardiac arrest or with out-of-hospital cardiac arrest arriving with manual CPR at the emergency department.

They found that LUCAS does not cause significantly more serious or life-threatening visceral damage than manual CC. For AutoPulse, significantly more serious or life-threatening visceral damage than manual CC cannot be excluded.

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Examining Angiotensin II

Vasodilatory shock that does not respond to high-dose vasopressors is associated with high mortality. Khanna et al therefore investigated the effectiveness of angiotensin II for the treatment of patients with this condition.

They found that angiotensin II effectively increased blood pressure in patients with vasodilatory shock that did not respond to high doses of conventional vasopressors.

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Evaluating Transfusion Strategies

Cancer patients are at increased risk of septic shock. Therefore, Bergamin et al set out to assess whether a restrictive strategy of red blood cell (RBC) transfusion reduces 28-day mortality when compared with a liberal strategy in cancer patients with septic shock.

They observed a survival trend favoring a liberal transfusion strategy in cancer patients with septic shock when compared with the restrictive strategy.

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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.

Read the full Concise Critical Appraisal by logging into the SCCM eCommunity. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.