Category Archives: Concise Critical Appraisal

Informing Patient Decisions Through Video

Understanding the concepts associated with deciding a patient’s code status can be difficult for patients and family members. To help overcome some of the barriers to their ability to make informed code status choices, some institutions have used videos to explain these difficult concepts. Merino et al (J Hosp Med. 2017;12(9):700-704) examined the effect of a video versus usual care on code status choice.

Their study findings provide further evidence that videos can impact code status choice and that videos may be a helpful adjunct for patients who must make informed decisions.

Read the full Concise Critical Appraisal by logging in to 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

Prehospital Antibiotics for Sepsis

Due to the high prevalence, morbidity, and mortality of sepsis, its early recognition and treatment has become a target for research and quality improvement over the past decade. Timely administration of antibiotics presumably improves outcomes. Therefore, Alam et al (Lancet Respir Med. 2017. [Epub ahead of print]) set out to identify whether diagnosis of sepsis and administration of antibiotics in the prehospital setting has an impact on survival.

Their study findings determined that they cannot recommend the initiation of antibiotics in septic patients in the prehospital setting.

Read the full Concise Critical Appraisal by logging in to 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.

Classification of Patients with Sepsis

Despite years of research, sepsis remains a significant cause of mortality worldwide. The host response to sepsis is varied, and the patient response to directed therapies is heterogeneous, making it difficult to identify those at risk for poor outcomes using clinical features. Therefore, Scicluna et al (Lancet Respir Med. 2017;5:816-826) set out to identify biologically relevant molecular endotypes in patients with sepsis.

Their study methods and findings outline some early steps in the implementation of precision medicine in sepsis.

Read the full Concise Critical Appraisal by logging in to 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.

Predicting Mortality in Patients with Sepsis

Sepsis is an important cause of mortality in critical care, yet it is a heterogeneous syndrome in which patients with otherwise similar presenting clinical characteristics may rapidly progress to death or improve with minimal intervention. Therefore, Mikacenic et al (Am J Respir Crit Care Med. 2017;196:1004-1011) set out to assess the utility of a multibiomarker-based model to predict 28-day mortality among critically ill patients with at least two systemic inflammatory response syndrome criteria and/or sepsis.

Their findings offer insight into diagnostics to better prognosticate and ultimately direct specific therapies to achieve optimal clinical outcomes in heterogeneous groups of critically ill patients.

Read the full Concise Critical Appraisal by logging in to 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.

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.

Read the full Concise Critical Appraisal by logging in to 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.

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.

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.