http://ccforum.com/ The latest research articles published by Critical Care 2012-02-11T00:00:00Z IntroductionPre-hospital airway management is a controversial subject, but there is general agreement that a small number of seriously ill or injured patients require urgent emergency tracheal intubation (ETI) and ventilation. Many European emergency medical services (EMS) systems provide physicians to care for these patients, while other systems rely on paramedics (or, rarely, nurses). The ETI success rate is an important measure of provider and EMS system success and a marker of patient safety. Methods: We conducted a systematic search of Medline and EMBASE to identify all of the published original English-language articles reporting pre-hospital ETI in adult patients. We selected all of the studies that reported ETI success rates, and extracted information on the number of attempted and successful ETIs, type of provider, level of ETI training and the availability of drugs on scene. We calculated the overall success rate using meta-analysis, and assessed the relationships between the ETI success rate and type of provider and between the ETI success rate and the types of drugs available on the scene. Results: From 1070 studies initially retrieved, we identified 58 original studies meeting the selection criteria. Sixty-four per cent of the non-physician-manned services and 54% of the physician-manned services reported ETI success rates, but the success rate reporting was incomplete in three studies from non-physician-manned services. Median success rate was 0.905 (0.491, 1.000). In a weighted linear regression analysis, physicians as providers were significantly associated with increased success rates, 0.092 (p=0.0345). In the non-physician group, the use of drug-assisted intubation significantly increased the success rates. All physicians had access to traditional rapid sequence induction (RSI), and comparing these to non-physicians using muscle paralytics or a traditional RSI, there still was a significant difference in success rate in favour of physicians, 0.991 and 0.955 respectively (p=0.047). Conclusion: This comprehensive meta-analysis suggests that physicians have significantly fewer pre-hospital ETI failures overall than non-physicians. This finding, which remains true when the non-physicians administer muscle paralytics or RSI, raises significant patient safety issues. In the absence of pre-hospital physicians, conducting basic or advanced airway techniques other than ETI should be strongly considered. http://ccforum.com/content/16/1/R24 Hans Morten Lossius Jo Roislien David Lockey Critical Care 2012, null:R24 2012-02-11T00:00:00Z doi:10.1186/cc11189 /content/figures/cc11189-toc.gif Critical Care 1364-8535 ${item.volume} R24 2012-02-11T00:00:00Z PDF Recruitment maneuvers and the application of high levels of positive end-expiratory pressure combined with lung protective mechanical ventilation strategies have been proposed to improve pulmonary function in patients with severe acute respiratory distress syndrome. However, the optimal way to achieve and maintain alveolar recruitment is still under debate. http://ccforum.com/content/16/1/108 Peter Spieth Marcelo Gama de Abreu Critical Care 2012, null:108 2012-02-09T00:00:00Z doi:10.1186/cc11177 /content/figures/cc11177-toc.gif Critical Care 1364-8535 ${item.volume} 108 2012-02-09T00:00:00Z XML IntroductionRenal dysfunction is a common complication in patients with end-stage cirrhosis. Since the original publication of the definition and diagnostic criteria for the hepatorenal syndrome (HRS), there have been major advances in our understanding of its pathogenesis. The prognosis of patients with cirrhosis who develop HRS remains poor, with a median survival without liver transplantation of less than 6 months. However, a number of pharmacological and other therapeutic strategies have now become available which offer the ability to more effectively prevent or treat renal dysfunction in this setting. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies. Methods: We undertook a systematic review of the literature using Medline, PubMed and Web of Science, data provided by the Scientific Registry of Transplant Recipients and bibliographies of key reviews. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research. Results: Of the 30 questions considered, we found inadequate evidence for the majority of questions and our recommendations were mainly based on expert opinion. There was insufficient evidence to grade 3 questions, but we were able to develop a consensus definition for AKI in patients with cirrhosis and provide consensus recommendations for future investigations to address key areas of uncertainty. Conclusions: Despite a paucity of sufficiently powered prospectively randomized trials, we were able to establish an evidence-based appraisal of this field and develop a set of consensus recommendations to standardize care and direct further research for patients with cirrhosis and renal dysfunction. http://ccforum.com/content/16/1/R23 Mitra Nadim John Kellum Andrew Davenport Florence Wong Connie Davis Neesh Pannu Ashita Tolwani Rinaldo Bellomo Yuri Genyk Critical Care 2012, null:R23 2012-02-09T00:00:00Z doi:10.1186/cc11188 /content/figures/cc11188-toc.gif Critical Care 1364-8535 ${item.volume} R23 2012-02-09T00:00:00Z PDF no abstract available. http://ccforum.com/content/16/1/410 Zhao-Jun Liu Jia-Lin Liu Hong-Ping Qu Critical Care 2012, null:410 2012-02-08T00:00:00Z doi:10.1186/cc11156 /content/figures/cc11156-toc.gif Critical Care 1364-8535 ${item.volume} 410 2012-02-08T00:00:00Z XML Inadequate gas conditioning during non-invasive ventilation (NIV) can impair the anatomy and function of nasal mucosa. The resulting symptoms may have a negative effect on patients' adherence to ventilatory treatment, especially for chronic use. Several parameters, mostly technical aspects of NIV, contribute to inefficient gas conditioning. Factors affecting airway humidity during NIV include inspiratory flow, inspiratory oxygen fraction, leaks, type of ventilator, interface used to deliver NIV, temperature and pressure of inhaled gas, and type of humidifier. The correct application of a humidification system may avoid the effects of NIV-induced drying of the airway. This brief review analyses the consequences of airway dryness in patients receiving NIV and the technical tools necessary to guarantee adequate gas conditioning during ventilatory treatment. Open questions remain about the timing of gas conditioning for acute or chronic settings, the choice and type of humidification device, the interaction between the humidifier and the underlying disease, and the effects of individual humidification systems on delivered humidity. http://ccforum.com/content/16/1/203 Antonio Esquinas Raffaele Scala Alan de Klerk Arschang Valipour Davide Chiumello Claude Martin Anne Holland Arie Soroksky Ahmed BaHammam Critical Care 2011, null:203 2012-02-08T00:00:00Z doi:10.1186/cc10534 /content/figures/cc10534-toc.gif Critical Care 1364-8535 ${item.volume} 203 2012-02-08T00:00:00Z XML Over the past decade several investigators have applied microarray technology and related bioinformatic approaches to clinical sepsis and septic shock, thus allowing for an assessment of how, or if, this branch of genomic medicine has meaningfully impacted the field of sepsis research. The ability to simultaneously and efficiently measure the steady-state mRNA abundance of thousands of transcripts from a given tissue source (that is, 'transcriptomics') has provided an unprecedented opportunity to gain a broader, genome-level 'picture' of complex and heterogeneous clinical syndromes such as sepsis. A trancriptomic approach to sepsis and septic shock is technically challenging on multiple levels, but nonetheless modest, tangible advances are being realized. These include a genome-level understanding of the complexity of sepsis and septic shock, identification of novel candidate pathways and targets for potential intervention, discovery of novel, candidate diagnostic and stratification biomarkers, and the ability to stratify patients into clinically relevant, expression-based subclasses. The challenges moving forward include robust validation studies, standardization of technical approaches, standardization and further development of analytical algorithms, and large-scale collaborations. http://ccforum.com/content/16/1/204 Hector Wong Critical Care 2012, null:204 2012-02-08T00:00:00Z doi:10.1186/cc10537 /content/figures/cc10537-toc.gif Critical Care 1364-8535 ${item.volume} 204 2012-02-08T00:00:00Z XML Hospital handoffs are believed to be a key locus of communication breakdown that can endanger patient safety and undermine quality of care. Substantial new efforts to better understand handoffs and to improve handoff practices are under way. Many such efforts appear to be seriously hampered, however, by an underlying presumption that the essential function of a handoff is one-way information transmission. Here, we examine social science literature that supports a richer framing of handoff conversations, one that characterizes them as co-constructions of an understanding of the patient. http://ccforum.com/content/16/1/303 Michael Cohen Brian Hilligoss André Amaral Critical Care 2011, null:303 2012-02-08T00:00:00Z doi:10.1186/cc10536 /content/figures/cc10536-toc.gif Critical Care 1364-8535 ${item.volume} 303 2012-02-08T00:00:00Z XML Following publication of our article [1], Dr Christine Geffers has been removed as co-author. http://ccforum.com/content/16/1/402 Anke Kohlenberg Frank Schwab Michael Behnke Petra Gastmeier Critical Care 2012, null:402 2012-02-08T00:00:00Z doi:10.1186/cc11179 /content/figures/cc11179-toc.gif Critical Care 1364-8535 ${item.volume} 402 2012-02-08T00:00:00Z XML IntroductionPre-emptive isolation of suspected methicillin-resistant Staphylococcus aureus (MRSA) carriers is a cornerstone of successful MRSA control policies. Implementation of such strategies is hampered when using conventional cultures with diagnostic delays of 3 to 5 days, as many non-carriers remain unnecessarily isolated. Rapid diagnostic testing (RDT) reduces the amount of unnecessary isolation days, but costs and benefits have not been accurately determined in intensive care units (ICUs). Methods: Embedded in a multi-centre hospital-wide study in 12 Dutch hospitals we quantified cost per isolation day avoided using RDT for MRSA, added to conventional cultures, in ICUs. BD GeneOhmTM MRSA PCR (IDI) and Xpert MRSA (GeneXpert) were subsequently used during 17 and 14 months, and their test characteristics were calculated with conventional culture results as reference. We calculated the number of pre-emptive isolation days avoided and incremental costs of adding RDT. Results: 163 patients at risk for MRSA carriage were screened and MRSA prevalence was 3.1% (n=5). Duration of isolation was 27.6 and 21.4 hours with IDI and GeneXpert, respectively, and would have been 96.0 hours when based on conventional cultures. The negative predictive value was 100% for both tests. Numbers of isolation days were reduced by 44.3% with PCR-based screening at the additional costs of E327.84 (IDI) and E252.14 (GeneXpert) per patient screened. Costs per isolation day avoided were E136.04 (IDI) and E121.76 (GeneXpert). Conclusions: In a low endemic setting for MRSA, RDT safely reduced the number of unnecessary isolation days on ICUs by 44%, at the costs of E121.76 to E136.04 per isolation day avoided. http://ccforum.com/content/16/1/R22 Marjan Wassenberg Jan Kluytmans Stephanie Erdkamp Ron Bosboom Anton Buiting Erika van Elzakker Willem Melchers Steven Thijsen Annet Troelstra Christina Vandenbroucke-Grauls Caroline Visser Andreas Voss Petra Wolffs Mireille Wulf Ton van Zwet Ardine de Wit Marc Bonten Critical Care 2012, null:R22 2012-02-07T00:00:00Z doi:10.1186/cc11184 /content/figures/cc11184-toc.gif Critical Care 1364-8535 ${item.volume} R22 2012-02-07T00:00:00Z PDF Following the failure of PROWESS-SHOCK to demonstrate efficacy, Eli Lilly and Company withdrew drotrecogin alfa (activated) from the worldwide market. Drotrecogin was initially approved after the original trial, PROWESS, was stopped early for overwhelming efficacy. These events prompt consideration of both the initial approval decision and the later decision to withdraw. It is regrettable that the initial decision was made largely on a single trial that was stopped early. However, the decision to approve was within the bounds of normal regulatory practice and was made by many approval bodies around the world. Furthermore, the overall withdrawal rate of approved drugs remains very low. The decision to withdraw was a voluntary decision by Eli Lilly and Company and likely reflected key business considerations. Drotrecogin does have important biologic effects, and it is probable that we do not know how best to select patients who would benefit. Overall, there may still be a small advantage to drotrecogin alfa, even used non-selectively, but the costs of determining such an effect with adequate certainty are likely prohibitive, and the point is now moot. In the future, we should consider ways to make clinical trials easier and quicker so that more information can be available in a timely manner when considering regulatory approval. At the same time, more sophisticated selection of patients seems key if we are to most wisely test agents designed to manipulate the septic host response. http://ccforum.com/content/16/1/107 Derek Angus Critical Care 2012, null:107 2012-02-06T00:00:00Z doi:10.1186/cc11152 /content/figures/cc11152-toc.gif Critical Care 1364-8535 ${item.volume} 107 2012-02-06T00:00:00Z XML