Critical Care & Anaesthesia – Evidence Update
Welcome to the second bulletin highlighting new evidence published on selected topics
relating to Critical Care, Anaesthesia, Pain and Resuscitation. Journals such as – Lancet,
NEJM, JAMA, BMJ and American Journal of Critical Care Medicine have been scanned to
identify relevant articles. Articles from other journals as retrieved via searches on MEDLINE
and EMBASE are also listed. This bulletin features evidence published in the previous four
weeks. Full text articles can be accessed via your HEFT Athens ID.
The following sub-topics are covered:
· Cell salvage in surgery (including obstetric surgery)
· Anaesthesia and surgical outcomes (including epidurals, regional anaesthesia)
· Anaesthesia and Immunomodulation
· Anaesthesia and post operative confusion
Title: The use of cell salvage in routine cardiac surgery is ineffective and not cost-effective and
should be reserved for selected cases
Citation: Interactive Cardiovascular and Thoracic Surgery, May 2011, vol./is. 12/5(824-826), 1569-
9293;1569-9285 (May 2011) Author(s): Attaran S., McIlroy D., Fabri B.M., Pullan M.D.
Abstract: The reported benefits of intraoperative cell salvage are decreased requirement for blood
transfusion and cost-effectiveness. This study was designed to challenge this hypothesis. We
assessed intraoperative blood loss and the use of cell saver in our institution. In -7% of cases the
volume of blood loss was sufficient enough to be washed and returned. We conclude that the
routine use of cell savers in all cardiac operations affords no benefit and consumes additional
revenue. We recommend that the system only be considered in selected high-risk cases or
complex procedures. 2011 Published by European Association for Cardio-Thoracic Surgery. Full
Text: Available in fulltext at Highwire Press
Kindly note the journal literature has not highlighted any evidence on – anaesthesia and surgical
outcomes; anaesthesia and Immunomodulation and anaesthesia and post operative confusion.
Cardiac arrests/cardiopulmonary resuscitation (CPR)
The following sub-topics are covered:
· Quality of CPR
· Use of feedback devices
· Leadership and team factors
Title: Effects and limitations of an AED with audiovisual feedback for cardiopulmonary
resuscitation: A randomized manikin study
Citation: Resuscitation, July 2011, vol./is. 82/7(902-907), 0300-9572;1873-1570 (July 2011)
Author(s): Fischer H., Gruber J., Neuhold S., Frantal S., Hochbrugger E., Herkner H., Schochl H.,
Steinlechner B., Greif R.
Abstract: Purpose: Correctly performed basic life support (BLS) and early defibrillation are the
most effective measures to treat sudden cardiac arrest. Audiovisual feedback improves BLS.
Automated external defibrillators (AED) with feedback technology may play an important role in
improving CPR quality. The aim of this simulation study was to investigate if an AED with
audiovisual feedback improves CPR parameters during standard BLS performed by trained
laypersons. Conclusion: Use of an AED's audiovisual feedback system improved some CPR-
quality parameters, thus confirming findings of earlier studies with the notable exception of
decreased compression depth, which is a key parameter that might be linked to reduced cardiac
output. Full Text: Available in fulltext at Elsevier; Note: You will need to register (free of charge)
with Science Direct the first time you use it.
Title: Combining video instruction followed by voice feedback in a self-learning station for
acquisition of Basic Life Support skills: A randomised non-inferiority trial
Citation: Resuscitation, July 2011, vol./is. 82/7(896-901), 0300-9572;1873-1570 (July 2011)
Author(s): Mpotos N., Lemoyne S., Calle P.A., Deschepper E., Valcke M., Monsieurs K.G.
Abstract: Introduction: Current computerised self-learning (SL) stations for Basic Life Support
(BLS) are an alternative to instructor-led (IL) refresher training but are not intended for initial skill
acquisition. We developed a SL station for initial skill acquisition and evaluated its efficacy.
Methods: In a non-inferiority trial, 120 pharmacy students were randomised to IL small group
training or individual training in a SL station. In the IL group, instructors demonstrated the skills and
provided feedback. In the SL group a shortened Mini Anne video, to acquire the skills, was
followed by Resusci Anne Skills Station software (both Laerdal, Norway) with voice feedback for
further refinement. Testing was performed individually, respecting a seven week interval after
training for every student. Conclusions: Compression skills acquired in a SL station combining
video-instruction with training using voice feedback were not inferior to IL training.
Full Text: Available in fulltext at Elsevier; Note: You will need to register (free of charge) with
Science Direct the first time you use it.
Title: What is new in the Australasian Adult Resuscitation Guidelines for 2010?
Citation: EMA - Emergency Medicine Australasia, June 2011, vol./is. 23/3(237-239), 1742-
6731;1742-6723 (June 2011)
Author(s): Leman P., Jacobs I.
Title: Updated teaching techniques improve CPR performance measures: A cluster randomized,
Citation: Resuscitation, June 2011, vol./is. 82/6(730-735), 0300-9572;1873-1570 (June 2011)
Author(s): Ettl F., Testori C., Weiser C., Fleischhackl S., Mayer-Stickler M., Herkner H., Schreiber
W., Fleischhackl R. Abstract: Introduction: The first-aid training necessary for obtaining a drivers
license in Austria has a regulated and predefined curriculum but has been targeted for the
implementation of a new course structure with less theoretical input, repetitive training in
cardiopulmonary resuscitation (CPR) and structured presentations using innovative media.
Methods: The standard and a new course design were compared with a prospective, participant-
and observer-blinded, cluster-randomized controlled study. Six months after the initial training, we
evaluated the confidence of the 66 participants in their skills, CPR effectiveness parameters and
correctness of their actions. Conclusions: Motivation and self-confidence as well as skill retention
after six months were shown to be dependent on the teaching methods and the time for practical
training. Courses may be reorganized and content rescheduled, even within predefined curricula,
to improve course outcomes. Full Text: Available in fulltext at Elsevier; Note: You will need to
register (free of charge) with Science Direct the first time you use it.
Title: Teamwork and leadership in cardiopulmonary resuscitation
Citation: Journal of the American College of Cardiology, June 2011, vol./is. 57/24(2381-2388),
0735-1097;1558-3597 (14 Jun 2011) Author(s): Hunziker S., Johansson A.C., Tschan F., Semmer
N.K., Rock L., Howell M.D., Marsch S. Abstract: Despite substantial efforts to make
cardiopulmonary resuscitation (CPR) algorithms known to healthcare workers, the outcome of CPR
has remained poor during the past decades. Resuscitation teams often deviate from algorithms of
CPR. Emerging evidence suggests that in addition to technical skills of individual rescuers, human
factors such as teamwork and leadership affect adherence to algorithms and hence the outcome of
CPR. This review describes the state of the science linking team interactions to the performance of
CPR. Teamwork and leadership training have been shown to improve subsequent team
performance during resuscitation and have recently been included in guidelines for advanced life
support courses. Future efforts to better understand the influence of team factors (e.g., team
member status, team hierarchy, handling of human errors), individual factors (e.g., sex differences,
perceived stress), and external factors (e.g., equipment, algorithms, institutional characteristics) on
team performance in resuscitation situations are critical to improve CPR performance and medical
outcomes of patients.
Title: "Booster" training: Evaluation of instructor-led bedside cardiopulmonary resuscitation skill
training and automated corrective feedback to improve cardiopulmonary resuscitation compliance
of Pediatric Basic Life Support providers during simulated cardiac arrest
Citation: Pediatric Critical Care Medicine, May 2011, vol./is. 12/3(e116-e121), 1529-7535 (May
2011) Author(s): Sutton R.M., Niles D., Meaney P.A., Aplenc R., French B., Abella B.S., Lengetti
E.L., Berg R.A., Helfaer M.A., Nadkarni V. Abstract: OBJECTIVE:: To investigate the
effectiveness of brief bedside "booster" cardiopulmonary resuscitation (CPR) training to improve
CPR guideline compliance of hospital-based pediatric providers. CONCLUSIONS:: Before booster
CPR instruction, most certified Pediatric Basic Life Support providers did not perform guideline-
compliant CPR. After a brief bedside training, CPR quality improved irrespective of training content
(instructor vs. automated feedback). Future studies should investigate bedside training to improve
CPR quality during actual pediatric cardiac arrests. Full Text: Available in fulltext at MD Consult;
Note: You will need to register (free of charge) with MD Consult the first time you use it.
The following sub-topics are covered:
· Sepsis – the use of statins, biomarker MMP9
· Acute lung injury (ALI)/adult respiratory distress syndrome (ARDS)
· Use of non invasive ventilation (NIV) in weaning
Title: Leptin in fibroproliferative acute respiratory distress syndrome: not just a satiety factor.
Citation: American Journal of Respiratory & Critical Care Medicine, June 2011, vol./is.
183/11(1443-4), 1073-449X;1535-4970 (2011 Jun 1) Author(s): Moss M, Standiford TJ
Full Text: Available in fulltext at ProQuest (Legacy Platform)
Title: Reducing ventilator-associated pneumonia in intensive care: Impact of
implementing a care bundle. Citation:Crit Care Med. 2011 Jun 9. [Epub ahead of print]
Author(s): Morris AC, Hay AW, Swann DG, Everingham K, McCulloch C, McNulty J, Brooks O,
Laurenson IF, Cook B, Walsh TS. Abstract: OBJECTIVES:: Ventilator-associated pneumonia is
the most common intensive care unit-acquired infection. Although there is widespread consensus
that evidenced-based interventions reduce the risk of ventilator-associated pneumonia,
controversy has surrounded the importance of implementing them as a "bundle" of care. This study
aimed to determine the effects of implementing such a bundle while controlling for potential
confounding variables seen in similar studies. SETTING:: An 18-bed, mixed medical-surgical
teaching hospital intensive care unit. CONCLUSIONS:: Implementation of a ventilator-associated
pneumonia prevention bundle was associated with a statistically significant reduction in ventilator-
associated pneumonia, which had not been achieved with earlier ad hoc ventilator-associated
pneumonia prevention guidelines in our unit. This occurred despite an inability to meet bundle
compliance targets of 95% for all elements. Our data support the systematic approach to achieving
high rates of process compliance and suggest systematic introduction can decrease both infection
incidence and antibiotic use, especially for patients requiring longer duration of ventilation.
Title: Determinants of prescription and choice of empirical therapy for hospital-acquired and
Citation: European Respiratory Journal, June 2011, vol./is. 37/6(1332-1339), 0903-1936;1399-
3003 (01 Jun 2011) Author(s): Rello J., Ulldemolins M., Lisboa T., Koulenti D., Manez R., Martin-
Loeches I., De Waele J.J., Putensen C., Guven M., Deja M., Diaz E., Annane D., Amaya-Villar R.,
Garnacho-Montero J., Armaganidis A., Blot S., Brun-Buisson C., Carneiro A., Dimopoulos G.,
Cardellino S., Komnos A., Krueger W., Macor A., Manno E., Marsh B., Martin C., Myrianthefs P.,
Nauwynck M., Papazian L., Wrigge H., Regnier B., Sole-Violan J., Spina G., Topeli A.
Abstract: The objectives of this study were to assess the determinants of empirical antibiotic
choice, prescription patterns and outcomes in patients with hospital-acquired pneumonia
(HAP)/ventilator-associated pneumonia (VAP) in Europe. We performed a prospective,
observational cohort study in 27 intensive care units (ICUs) from nine European countries.
Title: Effect of oral hygiene with 0.12% chlorhexidine gluconate on the incidence of nosocomial
pneumonia in children undergoing cardiac surgery
Citation: Infection Control and Hospital Epidemiology, June 2011, vol./is. 32/6(591-596), 0899-
823X (June 2011) Author(s): Jacomo A.D.N., Carmona F., Matsuno A.K., Manso P.H., Carlotti
A.P.C.P. Abstract: Objective. To evaluate the effect of oral hygiene with 0.12% chlorhexidine
gluconate on the incidence of nosocomial pneumonia and ventilator-associated pneumonia (VAP)
in children undergoing cardiac surgery. Design. Prospective, randomized, double-blind, placebo-
controlled trial. Setting. Pediatric intensive care unit (PICU) at a tertiary care hospital. patients. One
hundred sixty children undergoing surgery for congenital heart disease, randomized into 2 groups:
chlorhexidine (n = 87) and control (n = 73). Conclusions: Oral hygiene with 0.12% chlorhexidine
gluconate did not reduce the incidence of nosocomial pneumonia and VAP in children undergoing
cardiac surgery. 2011 by The Society for Healthcare Epidemiology of America. All rights reserved.
Title: Ventilator-associated pneumonia in critically ill stroke patients: Frequency, risk factors, and
Citation: Journal of Critical Care, June 2011, vol./is. 26/3(273-279), 0883-9441;1557-8615 (June
2011) Author(s): Kasuya Y., Hargett J.L., Lenhardt R., Heine M.F., Doufas A.G., Remmel K.S.,
Ramirez J.A., Akca O. Abstract: Purpose: Our main objective was to assess incidence, risk
factors, and outcomes of ventilator-associated pneumonia (VAP) in stroke patients. Conclusions:
Pneumonia appears as a frequent problem in mechanically ventilated stroke patients. Chronic lung
disease history, severity of stroke level at admission, and hemorrhagic transformation of stroke set
the stage for developing VAP. The duration of both mechanical ventilation and intensive care unit
stay gets significantly prolonged by VAP, but it does not affect mortality.
Title: A polyurethane cuffed endotracheal tube is associated with decreased rates of ventilator-
Citation: Journal of Critical Care, June 2011, vol./is. 26/3(280-286), 0883-9441;1557-8615 (June
2011) Author(s): Miller M.A., Arndt J.L., Konkle M.A., Chenoweth C.E., Iwashyna T.J., Flaherty
K.R., Hyzy R.C. Abstract: Purpose: The aim of this study was to determine whether the use of a
polyurethane-cuffed endotracheal tube would result in a decrease in ventilator-associated
pneumonia rate. Materials and Methods: We replaced conventional endotracheal tube with a
polyurethane-cuff endotracheal tube (Microcuff, Kimberly-Clark Corporation, Rosewell, Ga) in all
adult mechanically ventilated patients throughout our large academic hospital from July 2007 to
June 2008. We retrospectively compared the rates of ventilator-associated pneumonia before,
during, and after the intervention year by interrupted time-series analysis. Conclusions: Use of a
polyurethane-cuffed endotracheal tube was associated with a significant decrease in the rate of
ventilator-associated pneumonia in our study.
Title: The impact of COPD on ICU mortality in patients with ventilator-associated pneumonia
Citation: Respiratory Medicine, July 2011, vol./is. 105/7(1022-1029), 0954-6111;1532-3064 (July
2011) Author(s): Makris D., Desrousseaux B., Zakynthinos E., Durocher A., Nseir S.
Abstract: Objective: To determine the impact of COPD on intensive care unit (ICU) mortality in
patients with VAP. Methods: This prospective observational study was performed in a mixed ICU
during a 3-year period. Eligible patients received mechanical ventilation for >48 h and met criteria
for microbiologically confirmed VAP. Risk factors for ICU mortality were determined using
univariate and multivariable analyses. Conclusion: COPD, SAPS II, and shock at VAP diagnosis
are independently associated with ICU mortality in patients who present VAP. 2011 Elsevier Ltd.
All rights reserved.
Title: Lack of impact of selective digestive decontamination on Pseudomonas aeruginosa
ventilator-associated pneumonia: Benchmarking the evidence base
Citation: Journal of Antimicrobial Chemotherapy, June 2011, vol./is. 66/6(1365-1373), 0305-
7453;1460-2091 (June 2011) Author(s): Hurley J.C. Abstract: Background: The selective
digestive decontamination (SDD) component antibiotics have activity against Pseudomonas
aeruginosa, an important ventilator-associated pneumonia (VAP) isolate. Evaluating the
relationship between the anti-pseudomonal activity of SDD towards its VAP prevention effect is
complicated by postulated indirect effects of SDD mediated in the concurrent control groups. The
objective here is to address these effects through a benchmarking analysis of the evidence base.
Conclusions: There is no evidence for either direct or indirect effects of SDD on P. aeruginosa-IP
that could account for the profound effects of SDD on VAP incidence.
Title: Statin use and morbidity outcomes in septic shock patients: A retrospective cohort study
Citation: Critical Care and Shock, 2011, vol./is. 14/1(15-18), 1410-7767 (2011) Author(s): Chua
D., Choice K., Gellatly R., Brown G. Abstract: Objective: The purpose of this study is to determine
the association between statin use and septic shock morbidity. Design: A retrospective, single
center chart review. Location: Intensive care unit of an urban tertiary care hospital. Conclusion:
Prior statin use was not associated with decreased duration of vasopressor support or morbidity in
septic shock patients. Conversely, there were trends towards worse outcomes in patients on
statins prior to admission.
Title: Statins and sepsis: A magic bullet or just shooting blanks?
Citation: Critical Care Medicine, June 2011, vol./is. 39/6(1567-1569), 0090-3493;1530-0293 (June
2011) Author(s): Somma M.M., Weinstock P.J. Full Text: Available in fulltext at MD Consult;
Note: You will need to register (free of charge) with MD Consult the first time you use it.
Title: Weaning from prolonged invasive ventilation in motor neuron disease: Analysis of outcomes
Citation: Journal of Neurology, Neurosurgery and Psychiatry, June 2011, vol./is. 82/6(643-645),
0022-3050;1468-330X (June 2011) Author(s): Chadwick R., Nadig V., Oscroft N.S., Shneerson
J.M., Smith I.E. Abstract: Introduction: Non-invasive ventilation (NIV) improves prognosis in
patients with motor neuron disease (MND) in the absence of major bulbar involvement. However,
some experience a rapid and unexpected decline in respiratory function and may undergo
emergency tracheal intubation. Weaning from invasive ventilation can be difficult, and reported
independence from invasive ventilation is uncommon with poor prognosis. The outcomes of
patients with MND referred to a specialist weaning service following emergency tracheal intubation
were examined and compared with MND patients electively initiating NIV. Conclusion: The
prognosis in MND following acute respiratory failure and intubation is not always complete
ventilator dependence if patients are offered a comprehensive weaning programme. Full Text:
Available in fulltext at Highwire Press
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