Category Archives: Concise Critical Appraisal

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.

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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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