Critical Care and Anaesthesia- July 2011


Critical Care & Anaesthesia Evidence Update

July 2011


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,

controlled trial

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.




Critical Care

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

ventilator-associated pneumonia

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-

associated pneumonia

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

and survival

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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