Turgeon, Alexis F. MD, MSc, FRCPC; Lauzier, François MD, MSc, FRCPC et al; for the Canadian Critical Care Trials Group Critical Care Medicine: April 2013 - Volume 41 - Issue 4 - p 1017–1026 Accurate prognostic information in patients with severe traumatic brain injury remains limited, but mortality following the withdrawal of life-sustaining therapies is high and variable across centers.We designed a survey to understand attitudes of physicians caring for patients with severe traumatic brain injury toward the determination of prognosis and clinical decision making on the level of care. This group conducted a cross-sectional study of intensivists, neurosurgeons, and neurologists that participate in the care of patients with severe traumatic brain injury at all Canadian level 1 and level 2 trauma centers. No interventions were done. The main outcome measure was physicians’ perceptions of prognosis and recommendations on the level of care. Main Results: The response rate was 64% (455/712). Most respondents (65%) reported that an accurate prediction of prognosis would be most helpful during the first 7 days. Most respondents (>80%) identified bedside monitoring, clinical exam, and imaging to be useful for evaluating prognosis, whereas fewer considered electrophysiology tests (<60%) and biomarkers (<15%). In a case-based scenario, approximately one-third of respondents agreed, one-third were neutral, and onethird disagreed that the patient prognosis would be unfavorable at one year. About 10% were comfortable recommending withdrawal of life-sustaining therapies. Conclusions: A significant variation in perceptions of neurologic prognosis and in clinical decision making on the level of care was found among Canadian intensivists, neurosurgeons, and neurologists. Improved understanding of the factors that can accurately predict prognosis for patients with traumatic brain injury is urgently needed.
Acute Kidney Injury in the Critically Ill: Is Iodinated Contrast Medium Really Harmful?* Ehrmann, Stephan MD; Badin, Julie MD et al. Critical Care Medicine: April 2013 - Volume 41 - Issue 4 - p 1017–1026 Objectives: To assess whether the use of iodinated contrast medium increases the incidence of acute kidney injury in ICU patients, compared with patients not receiving iodinated contrast medium. Prospective observational matched cohort study. This study was conducted in two ICUs in two tertiary teaching hospitals. A total of 380 adults were included (20% more than once), before an iodinated contrast medium infusion (contrast inclusions, n = 307) or before an intrahospital transfer without iodinated contrast medium infusion (control inclusions, n = 170). No interventions were done. Measurements and Main Results: Among contrast inclusions, iodinated contrast medium–associated acute kidney injury occurred after 23 administrations (7.5%)
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Determination of Neurologic Prognosis and Clinical Decision Making in Adult Patients With Severe Traumatic Brain Injury: A Survey of Canadian Intensivists, Neurosurgeons, and Neurologists
A Bi-Monthly Newsletter of Indian Society of Critical Care Medicine
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The Critical Care Communications
according to the Acute Kidney Injury Network definition (stage ≥ 1, over 48 hr). As expected, a broader definition (≥ 25% increase in serum creatinine over 72 hr) yielded a greater incidence (16%). In 146 pairs of contrast and control inclusions, matched on propensity for iodinated contrast medium infusion, the incidence of acute kidney injury was similar (absolute difference in incidence, 0%; 95% confidence interval, –5.2; 5.2%), Acute Kidney Injury Network definition). Hospital mortality was also similar in 71 contrast and 71 control patients included only once and matched the same way. Contrary to iodinated contrast medium infusion (odds ratio, 1.57; 95% confidence interval, 0.69–3.53), the Sequential Organ Failure Assessment score at inclusion (odds ratio, 1.18; 95% confidence interval, 1.07–1.31) and the number of other nephrotoxic agents (odds ratio, 1.38; 95% confidence interval, 1.03–1.85) were independent risk factors for acute kidney injury. Conclusions: The specific toxic effect of monomeric nonionic low-osmolar iodinated contrast medium in ICU patients with multiple renal aggressions seemed minimal. Severity of disease and the global nephrotoxic burden were risk factors for acute kidney injury, regardless of iodinated contrast medium infusion.
Proton Pump Inhibitors Versus Histamine 2 Receptor Antagonists for Stress Ulcer Prophylaxis in Critically Ill Patients: A Systematic Review and Meta-Analysis Alhazzani, Waleed MD; Alenezi, Farhan MD; et al. Critical Care Medicine: March 2013 - Volume 41 - Issue 3 - p 693–705 Critically ill patients may develop bleeding caused by stress ulceration. Acid suppression is commonly prescribed for patients at risk of stress ulcer bleeding. Whether proton pump inhibitors are more effective than histamine 2 receptor antagonists is unclear. Objectives: To determine the efficacy and safety of proton pump inhibitors vs. histamine 2 receptor antagonists for the prevention of upper gastrointestinal bleeding in the ICU. Search Methods: The Authors searched Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, ACPJC, CINHAL, online trials registries (clinicaltrials.gov, ISRCTN Register,WHO ICTRP), conference proceedings databases, and reference lists of relevant articles. Selection Criteria: Randomized controlled parallel group trials comparing proton pump inhibitors to histamine 2 receptor antagonists for the prevention of upper gastrointestinal bleeding in critically ill patients, published before March 2012. Data Collection and Analysis: Two reviewers independently applied eligibility criteria, assessed quality, and extracted data.The primary outcomes were clinically important upper gastrointestinal bleeding and overt upper gastrointestinal bleeding; secondary outcomes were nosocomial pneumonia, ICU mortality, ICU length of stay, and Clostridium difficile infection.Trial authors were contacted for additional or clarifying information. Results: Fourteen trials enrolling a total of 1,720 patients were included. Proton pump inhibitors were more effective than histamine 2 receptor antagonists at reducing clinically important upper gastrointestinal bleeding (relative risk 0.36; 95% confidence interval 0.19– 0.68; p = 0.002; I2 = 0%) and overt upper gastrointestinal
Dr. Jayant Shelgaonkar
Director, ICU, Aditya Birla Hospital, Pune
bleeding (relative risk 0.35; 95% confidence interval 0.21– 0.59; p < 0.0001; I2 = 15%). There were no differences between proton pump inhibitors and histamine 2 receptor antagonists in the risk of nosocomial pneumonia (relative risk 1.06; 95% confidence interval 0.73–1.52; p = 0.76; I2 = 0%), ICU mortality (relative risk 1.01; 95% confidence interval 0.83–1.24; p = 0.91; I2 = 0%), or ICU length of stay (mean difference -0.54 days; 95% confidence interval -2.20 to 1.13; p = 0.53;I2 = 39%). No trials reported on C. difficile infection. Conclusions: In critically ill patients, proton pump inhibitors seem to be more effective than histamine 2 receptor antagonists in preventing clinically important and overt upper gastrointestinal bleeding.The robustness of this conclusion is limited by the trial methodology, differences between lower and higher quality trials, sparse data, and possible publication bias. Authors observed no differences between drugs in the risk of pneumonia, death, or ICU length of stay.
Single-Dose Etomidate Is Not Associated With Increased Mortality in ICU Patients With Sepsis: Analysis of a Large Electronic ICU Database* McPhee, Laura C. DO; Badawi, Omar PharmD, MPH et al. Critical Care Medicine: March 2013 - Volume 41 - Issue 3 p 774–783 Retrospective analyses of several trials suggest etomidate may be unsafe for intubation in patients with sepsis. We evaluated the association of etomidate and mortality in a large cohort of septic patients to determine if singledose etomidate was associated with increased in-hospital mortality. Design and Setting: Retrospective cohort study at the Philips eICU Research Institute ICU clinical database. No interventions were done. Patients: Among 741,036 patients monitored from 2008 through 2010, the authors identified 2,014 adults intubated in the ICU 4–96 hrs after admission, having clinical criteria consistent with sepsis, severe sepsis, or septic shock. In all, 1,102 patients received etomidate and 912 received other induction agents for intubation. Measurements and Main Results: The primary endpoint was in-hospital mortality, but they also evaluated demographic and clinical factors, severity of illness, ICU mortality, ICU length of stay, hospital length of stay, ventilator days, and vasopressor days. Competing risk Cox proportional hazard regression models were used for primary outcomes. Demographics and illness severity were similar between the groups. Hospital mortality was similar between the groups (37.2% vs. 37.8%, p = 0.77), as were ICU mortality (30.1% vs. 30.2%, p = 0.99), ICU length of stay (8.7 days vs. 8.9 days, p = 0.66), and hospital length of stay (15.2 vs. 14.6 days, p = 0.31). More patients in the etomidate group received steroids before and after intubation (52.9% vs. 44.5%, p < 0.001), but vasopressor use and duration of mechanical ventilation were similar. No regression model showed an independent association of etomidate with mortality, shock, duration of mechanical ventilation, ICU or hospital length of stay, or vasopressor use. A hospital mortality model limited to only patients with septic shock (n = 650) also showed no association of etomidate and hospital mortality. Conclusion: In a mixed-diagnosis group of critically ill patients with sepsis, severe sepsis, and septic shock, single-dose etomidate administration for intubation in the ICU was not associated with higher mortality or other adverse clinical outcomes.