Healthcare Library Current Awareness Bulletin – Acute and Critical Care

May and June 2015

This Current Awareness Bulletin is produced by the Healthcare Library to provide Salisbury NHS Foundation Trust staff with a range of resources to support practice. It will include recently published guidelines and research articles, news and policy items, and details of forthcoming events and conferences. OpenAthens To access journal articles that are available in full text you will need to have a username and password for OpenAthens. To register for an OpenAthens account click here. For further information or support please contact the Healthcare Library, SDH Central, Salisbury District Hospital, Salisbury, Wiltshire SP2 8BJ. 01722 429054 or 01722 336262 ext 4430, Library.office@salisbury.nhs.uk, or visit the library website at www.library.salisbury.nhs.uk

Guidelines

National Institute for Health and Care Excellence (NICE)

Falls in older people: assessment after a fall and preventing further falls NICE quality standard [QS86] Published date: March 2015

The Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters NICE medical technology guidance [MTG24] Published date: March 2015

NICE medical technology adoption support for the Sherlock 3CG Tip Confirmation System for placement of peripherally inserted central catheters – insights from the NHS NICE medical technology support [HTMTG24] Published date: March 2015

Rivaroxaban for preventing adverse outcomes after acute management of acute coronary syndrome NICE technology appraisal guidance [TA335] Published date: March 2015

Violence and aggression: short-term management in mental health, health and community settings NICE guidelines [NG10] Published date: May 2015

Apixaban for the treatment and secondary prevention of deep vein thrombosis and/or pulmonary embolism NICE technology appraisal guidance [TA341] Published date: June 2015

Ultrasound-enhanced, catheter-directed thrombolysis for deep vein thrombosis NICE interventional procedure guidance [IPG523] Published date: June 2015

Ultrasound-enhanced, catheter-directed thrombolysis for pulmonary embolism NICE interventional procedure guidance [IPG524] Published date: June 2015

Pressure ulcers NICE quality standard [QS89] Published date: June 2015

New and Updated Cochrane Systematic Reviews

New Reviews – March 2015

Enteral nutrition formulations for acute pancreatitis

HMG CoA reductase inhibitors (statins) for preventing acute kidney injury after surgical procedures requiring cardiac bypass

Physical rehabilitation for critical illness myopathy and neuropathy

Updated reviews – March 2015

Antiarrhythmics for maintaining sinus rhythm after cardioversion of atrial fibrillation

Anticoagulants for acute ischaemic stroke

Azithromycin for acute lower respiratory tract infections

Fluid replacement therapy for acute episodes of pain in people with sickle cell disease

Interventions for reducing wrong-site surgery and invasive clinical procedures

Intra-aortic balloon pump counterpulsation (IABP) for myocardial infarction complicated by cardiogenic shock

New Reviews – May 2015

Alginate dressings for treating pressure ulcers

Negative pressure wound therapy for treating pressure ulcers

Updated reviews – May 2015

Anti-inflammatory treatment for carditis in acute rheumatic fever

Antifibrinolytic drugs for acute traumatic injury

Percutaneous endoscopic gastrostomy versus nasogastric tube feeding for adults with swallowing disturbances

New from UpToDate

What's new in adult and pediatric emergency medicine

What's new in pulmonary and critical care medicine New additions to UpToDate considered by the editors and authors to be of particular interest. You may need an OpenAthens username and password. To register for an OpenAthens account click here.

Journal Articles Please click on the blue links (where available) to access full text. You may need an OpenAthens username and password. To register for an OpenAthens account click here. If you have any difficulty accessing the full text articles, or if you would like us to obtain any of the articles for you, please contact the Healthcare Library.

Table of Contents

1. A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium

and their effect on clinical outcomes

2. Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac

arrest: a systematic review and metaanalysis of randomized controlled trials

3. Acute stroke intervention: a systematic review.

4. Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill

adults and children: A cochrane systematic review and meta-analysis

5. Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical

ventilation? An update meta-analysis from 17 randomized controlled trials

6. Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill

patients: A systematic review

7. Early goal-directed therapy in the management of severe sepsis or septic shock in adults: A meta-analysis of

randomized controlled trials

8. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of

randomized controlled trials .

9. Effect of initial calorie intake via enteral nutrition in critical illness: A meta-analysis of randomised controlled trials

10. Effect of performance improvement programs on compliance with sepsis bundles and mortality: A systematic

review and meta-analysis of observational studies

11. Effect of protocolized sedation on clinical outcomes in mechanically ventilated intensive care unit patients: A

systematic review and meta-analysis of randomized controlled trials

12. Effects of in-hospital low targeted temperature after out of hospital cardiac arrest: A systematic review with

meta-analysis of randomized clinical trials

13. Efficacy of noninvasive ventilation after planned extubation: A systematic review and meta-analysis of

randomized controlled trials

14. EuReCa and international resuscitation registries

15. Factors affecting registered nurses' use of medication administration technology in acute care settings: A

systematic review

16. Hydroxyethyl starch versus other fluids for non-septic patients in the intensive care unit: A meta-analysis of

randomized controlled trials

17. Impact of daily bathing with chlorhexidine gluconate on ventilator associated pneumonia in intensive care units: A

meta-analysis

18. Impact of follow-up consultations for ICU survivors on post-ICU syndrome: a systematic review and meta-analysis.

19. Impact of obesity on sepsis mortality: A systematic review

20. Intravenous lipid emulsion in the emergency department: A systematic review of recent literature

21. Management of critically ill patients with type 2 diabetes: The need for personalised therapy.

22. Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster

randomised controlled trial

23. Nebulized antibiotics for ventilator-associated pneumonia: A systematic review and meta-analysis

24. Noninvasive continuous cardiac output monitoring in perioperative and intensive care medicine.

25. Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence,

etiology, and mortality: A systematic review

26. Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review.

27. Rapid detection of health-care-associated bloodstream infection in critical care using Multipathogen real-time

polymerase chain reaction technology: A diagnostic accuracy study and systematic review

28. Recent advances in the diagnosis and treatment of acute myocardial infarction.

29. Reducing Pressure Injuries in Critically Ill Patients by Using a Patient Skin Integrity Care Bundle (Inspire)

30. Sedation options for intubated intensive care unit patients.

31. Should suspected cervical spinal cord injury be immobilised?: A systematic review

32. The etiology and outcome of non-traumatic coma in critical care: A systematic review

33. The role of colonoscopy within 24 hours of presentation for acute lower gastrointestinal bleeding (Algib) - A

systematic review

34. The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following

critical illness in intensive care: a literature review

35. Trial of early, goal-directed resuscitation for septic shock

36. Ventilator-associated events prevention, learning lessons from the past: A systematic review

37. Why Are We Prolonging QT Interval Monitoring?

1.Title: A systematic review of implementation strategies for assessment, prevention, and management of ICU delirium and their effect on clinical outcomes Citation: Critical Care, April 2015, vol./is. 19/1, 1364-8535;1466-609X (April 09, 2015) Author(s): Trogrlic Z., van der Jagt M., Bakker J., Balas M.C., Ely E.W., van der Voort P.H.J., Ista E. Language: English Abstract: Introduction: Despite recommendations from professional societies and patient safety organizations, the majority of ICU patients worldwide are not routinely monitored for delirium, thus preventing timely prevention and management. The purpose of this systematic review is to summarize what types of implementation strategies have been tested to improve ICU clinicians' ability to effectively assess, prevent and treat delirium and to evaluate the effect of these strategies on clinical outcomes. Method: We searched PubMed, Embase, PsychINFO, Cochrane and CINAHL (January 2000 and April 2014) for studies on implementation strategies that included delirium-oriented interventions in adult ICU patients. Studies were suitable for inclusion if implementation strategies' efficacy, in terms of a clinical outcome, or process outcome was described. Results: We included 21 studies, all including process measures, while 9 reported both process measures and clinical outcomes. Some individual strategies such as "audit and feedback" and "tailored interventions" may be important to establish clinical outcome improvements, but otherwise robust data on effectiveness of specific implementation strategies were scarce. Successful implementation interventions were frequently reported to change process measures, such as improvements in adherence to delirium screening with up to 92%, but relating process measures to outcome changes was generally not possible. In meta-analyses, reduced mortality and ICU length of stay reduction were statistically more likely with implementation programs that employed more (six or more) rather than less implementation strategies and when a framework was used that either integrated current evidence on pain, agitation and delirium management (PAD) or when a strategy of early awakening, breathing, delirium screening and early exercise (ABCDE bundle) was employed. Using implementation strategies aimed at organizational change, next to behavioral change, was also associated with reduced mortality. Conclusion: Our findings may indicate that multi-component implementation programs with a higher number of strategies targeting ICU delirium assessment, prevention and treatment and integrated within PAD or ABCDE bundle have the potential to improve clinical outcomes. However, prospective confirmation of these findings is needed to inform the most effective implementation practice with regard to integrated delirium management and such research should clearly delineate effective practice change from improvements in clinical outcomes. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at Critical Care 2.Title: Active compression-decompression resuscitation and impedance threshold device for out-of-hospital cardiac arrest: a systematic review and metaanalysis of randomized controlled trials Citation: Critical care medicine, April 2015, vol./is. 43/4(889-896), 1530-0293 (01 Apr 2015) Author(s): Wang C.-H., Tsai M.-S., Chang W.-T., Huang C.-H., Ma M.H.-M., Chen W.-J., Fang C.-C., Chen S.-C., Lee C.-C. Language: English Abstract: OBJECTIVE: Active compression-decompression resuscitation and impedance threshold device are proposed to improve survival of patients of cardiac arrest by lowering intrathoracic pressure and increasing cardiac output. The

results of clinical studies of active compression-decompression resuscitation or impedance threshold device were controversial. This metaanalysis pooled results of randomized controlled trials to examine whether active compression-decompression resuscitation or impedance threshold device would improve outcomes of out-of-hospital cardiac arrest in comparison with standard cardiopulmonary resuscitation and to explore factors modifying these effects.DATA SOURCES: Medline and Embase were searched from inception to September 2013.STUDY SELECTION: Randomized controlled trials comparing active compression-decompression resuscitation or impedance threshold device with standard cardiopulmonary resuscitation in out-of-hospital cardiac arrest patients were selected. There were no restrictions for language, population, or publication year.DATA EXTRACTION: Data on study characteristics, including patients, intervention details, and outcome measures, were independently extracted.DATA SYNTHESIS: Fifteen trials, including 16,088 patients, were identified from 331 potentially relevant references. Return of spontaneous circulation was designated as the primary outcome. The pooled result showed no significant improvement in return of spontaneous circulation by active compression-decompression resuscitation or impedance threshold device in comparison with standard cardiopulmonary resuscitation (risk ratio, 1.04; 95% CI, 0.93-1.16; I, 46%). There was also no significant difference in survival or neurologic outcome at hospital discharge between active compression-decompression resuscitation or impedance threshold device and standard cardiopulmonary resuscitation. The meta-regression indicated that this minimal effect might be modified by two important prognostic factors, that is, witnessed status and response time. After adjustment of these two factors, impedance threshold device appeared to improve return of spontaneous circulation, which could be further augmented by advanced airway use.CONCLUSIONS: Active compression-decompression resuscitation or impedance threshold device seemed not to improve return of spontaneous circulation in out-of-hospital cardiac arrest patients. The meta-regression indicated two probable prognostic factors causing this minimal effect. Nonetheless, these findings referred to differences between trials and could not necessarily be extrapolated to individual patients. The individual patient-level extrapolation may need to be solved by a future randomized controlled trial. Publication type: Journal: Article Source: EMBASE Full text: Available Critical care medicine at Critical Care Medicine 3.Title: Acute stroke intervention: a systematic review. Citation: JAMA, Apr 2015, vol. 313, no. 14, p. 1451-1462 (April 14, 2015) Author(s): Prabhakaran, Shyam, Ruff, Ilana, Bernstein, Richard A Abstract: Acute ischemic stroke is a major cause of mortality and morbidity in the United States. We review the latest data and evidence supporting catheter-directed treatment for proximal artery occlusion as an adjunct to intravenous thrombolysis in patients with acute stroke. To review the pathophysiology of acute brain ischemia and infarction and the evidence supporting various stroke reperfusion treatments. Systematic literature search of MEDLINE databases published between January 1, 1990, and February 11, 2015, was performed to identify studies addressing the role of thrombolysis and mechanical thrombectomy in acute stroke management. Studies included randomized clinical trials, observational studies, guideline statements, and review articles. Sixty-eight articles (N = 108,082 patients) were selected for review. Intravenous thrombolysis is the mainstay of acute ischemic stroke management for any patient with disabling deficits presenting within 4.5 hours from symptom onset. Randomized trials have demonstrated that more patients return to having good function (defined by being independent and having slight disability or less) when treated within 4.5 hours after symptom onset with intravenous recombinant tissue plasminogen activator (IV rtPA) therapy. Mechanical thrombectomy in select patients with acute ischemic stroke and proximal artery occlusions has demonstrated substantial rates of partial or complete arterial recanalization and improved outcomes compared with IV rtPA or best medical treatment alone in multiple randomized clinical trials. Regardless of mode of reperfusion, earlier reperfusion is associated with better clinical outcomes. Intravenous rtPA remains the standard of care for patients with moderate to severe neurological deficits who present within 4.5 hours of symptom onset. Outcomes for some patients with acute ischemic stroke and moderate to severe neurological deficits due to proximal artery occlusion are improved with endovascular reperfusion therapy. Efforts to hasten reperfusion therapy, regardless of the mode, should be undertaken within organized stroke systems of care. Source: Medline Full text: Available American Medical Association at JAMA 4.Title: Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill

adults and children: A cochrane systematic review and meta-analysis Citation: Critical Care, February 2015, vol./is. 19/1, 1364-8535;1466-609X (February 24, 2015) Author(s): Rose L., Schultz M.J., Cardwell C.R., Jouvet P., McAuley D.F., Blackwood B. Language: English Abstract: Introduction: Automated weaning systems may improve adaptation of mechanical support for a patient's ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. Our objective was to compare mechanical ventilator weaning duration for critically ill adults and children when managed with automated systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events. Methods: Electronic databases were searched to 30 September 2013 without language restrictions. We also searched conference proceedings; trial registration websites; and article reference lists. Two authors independently extracted data and assessed risk of bias. We combined data using random-effects modelling. Results: We identified 21 eligible trials totalling 1,676 participants. Pooled data from 16 trials indicated that automated systems reduced the geometric mean weaning duration by 30% (95% confidence interval (CI) 13% to 45%), with substantial heterogeneity (I² = 87%, P <0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PSTM (28%, 95% CI 7% to 49%) but not with surgical populations or using other systems. Automated systems reduced ventilation duration with no heterogeneity (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of effect on mortality, hospital LOS, reintubation, self-extubation and non-invasive ventilation following extubation. Automated systems reduced prolonged mechanical ventilation and tracheostomy. Overall quality of evidence was high. Conclusions: Automated systems may reduce weaning and ventilation duration and ICU stay. Due to substantial trial heterogeneity an adequately powered, high quality, multi-centre randomized controlled trial is needed. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at Critical Care 5.Title: Can routine oral care with antiseptics prevent ventilator-associated pneumonia in patients receiving mechanical ventilation? An update meta-analysis from 17 randomized controlled trials Citation: International Journal of Clinical and Experimental Medicine, February 2015, vol./is. 8/2(1645-1657), 1940-5901 (28 Feb 2015) Author(s): Ai Z., Li L., Zheng X., Jie L. Language: English Abstract: Background: Whether oral antiseptics could reduce the risk of ventilator associated pneumonia (VAP) in patients receiving mechanical ventilation remains controversial. We performed a meta-analysis to assess the effect of oral care with antiseptics on the prevalence of ventilator associated pneumonia in adult critically ill patients. Methods: A comprehensive search of PubMed, Embase and Web of Science were performed to identity relevant studies. Eligible studies were randomized controlled trials of mechanically ventilated adult patients receiving oral care with antiseptics. The quality of included studies was assessed by the Jadad score. Relative risks (RRs), weighted mean differences (WMDs), and 95% confidence intervals (CIs) were calculated and pooled using a fixed-effects model or random-effects model. Heterogeneity among the studies was assessed with I2 test. Results: 17 studies with a total number of 4249 met the inclusion criteria. Of the 17 studies, 14 assessed the effect of chlorhexidine, and 3 investigated the effect of povidone-iodine. Overall, oral care with antiseptics significantly reduced the prevalence of VAP (RR=0.72, 95% CI: 0.57, 0.92; P=0.008). The use of chlorhexidine was shown to be effective (RR=0.73, 95% CI: 0.57, 0.93; P=0.012), whereas this effect was not observed in povidone-iodine (RR=0.51, 95% CI: 0.09, 2.82; P=0.438). Subgroup analyses showed that oral antiseptics were most marked in cardiac surgery patients (RR=0.54, 95% CI: 0.39, 0.74; P=0.00). Patients with oral antiseptics did not have a reduction in intensive care unit (ICU) mortality (RR=1.11, 95% CI: 0.95, 1.29; P=0.201), length of ICU stay (WMD=-0.10 days, 95% CI: -0.25, 0.05; P=0.188), or duration of mechanical ventilation (WMD=-0.05 days, 95% CI: -0.14, 0.04; P=0.260). Conclusion: Oral care with antiseptics significantly reduced the prevalence of VAP. Chlorhexidine application prevented the occurrence of VAP in mechanically ventilated patients but povidone-iodine did not. Further large-scale, well-designed randomized controlled trials are needed to identify the findings and determine the effect of povidone-iodine application. Publication type: Journal: Article Source: EMBASE

Full text: Available International Journal of Clinical and Experimental Medicine at International Journal of Clinical and Experimental Medicine 6.Title: Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: A systematic review Citation: Critical Care, April 2015, vol./is. 18/6, 1364-8535;1466-609X (April 06, 2015) Author(s): Chen H., Yu R.-G., Yin N.-N., Zhou J.-X. Language: English Abstract: Introduction: Extracorporeal membrane oxygenation (ECMO) is used in critically ill patients presenting acute cardiac and/or pulmonary dysfunctions, who are at high risk of developing acute kidney injury and fluid overload. Continuous renal replacement therapy (CRRT) is commonly used in intensive care units (ICU) to provide renal replacement and fluid management. We conducted a review to assess the feasibility, efficacy and safety of the combination of ECMO and CRRT and to illustrate the indications and methodology of providing renal replacement therapy during the ECMO procedure. Method: We searched for all published reports of a randomized controlled trial (RCT), quasi-RCT, or other comparative study design, conducted in patients undergoing ECMO plus CRRT. Two reviewers independently selected potential studies and extracted data. We used the modified Jadad scale and the Newcastle-Ottawa for quality assessment of RCTs and non-RCTs, respectively. Statistical analyses were performed using RevMan 5.2. Results: We identified 19 studies meeting the eligibility criteria (seven cohort, six case control, one historically controlled trial and five studies of technical aspects). There are three major methods for performing CRRT during ECMO: 'independent CRRT access', 'introduction of a hemofiltration filter into the ECMO circuit (in-line hemofilter)' and 'introduction of a CRRT device into the ECMO circuit'. We conducted a review with limited data synthesis rather than a formal meta-analysis because there could be greater heterogeneity in a systematic review of non-randomized studies than that of randomized trials. For ECMO survivors receiving CRRT, overall fluid balance was less than that in non-CRRT survivors. There was a higher mortality and a longer ECMO duration when CRRT was added, which may reflect a relatively higher severity of illness in patients who received ECMO plus CRRT. Conclusions: The combination of ECMO and CRRT in a variety of methods appears to be a safe and effective technique that improves fluid balance and electrolyte disturbances. Prospective studies would be beneficial in determining the potential of this technique to improve the outcome in critically ill patients. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at Critical Care 7.Title: Early goal-directed therapy in the management of severe sepsis or septic shock in adults: A meta-analysis of randomized controlled trials Citation: BMC Medicine, April 2015, vol./is. 13/1, 1741-7015 (April 03, 2015) Author(s): Zhang L., Zhu G., Han L., Fu P. Language: English Abstract: Background: The Surviving Sepsis Campaign guidelines have proposed early goal-directed therapy (EGDT) as a key strategy to decrease mortality among patients with severe sepsis or septic shock. However, its effectiveness is uncertain. Methods: We searched for relevant studies in Medline, Embase, the Cochrane Library, Google Scholar, and a Chinese database (SinoMed), as well as relevant references from January 1966 to October 2014. We performed a systematic review and meta-analysis of all eligible randomized controlled trials (RCTs) of EGDT for patients with severe sepsis or septic shock. The primary outcome was mortality; secondary outcomes were length of ICU and in-hospital stay, mechanical ventilation support, vasopressor and inotropic agents support, fluid administration, and red cell transfusion. We pooled relative risks (RRs) or weighted mean differences (MDs) with 95% confidence intervals (95% CI) using Review Manager 5.2. Results: We included 10 RCTs from 2001 to 2014 involving 4,157 patients. Pooled analyses of all studies showed no significant difference in mortality between the EGDT and the control group (RR 0.91, 95% CI: 0.79 to 1.04, P = 0.17), with substantial heterogeneity (chi²=23.65, I² = 58%). In the subgroup analysis, standard EGDT, but not modified EGDT, was associated with lower mortality rate in comparison with the usual care group (RR 0.84, 95%CI: 0.72 to 0.98, P = 0.03). However, EGDT was associated with a higher mortality rate in comparison with the early lactate clearance group (RR 1.52, 95% CI: 1.06 to 2.18, P = 0.02). In the first 6 h, compared with usual care, patients in EGDT received more inotropic agents (P = 0.04), fluid administration (P = 0.05), and red cell transfusion (P < 0.01). There were no significant differences in length of ICU stay (P = 0.73) or in-hospital stay (P = 0.57), ventilation

rate (P = 0.53), and vasopressor support (P = 0.63). Conclusions: EGDT was not associated with a survival benefit among patients with severe sepsis or septic shock. Instead, EGDT was associated with a higher mortality rate in comparison to the early lactate clearance group. Further high-quality RCTs comparing EGDT with early lactate clearance are desirable. Publication type: Journal: Article Source: EMBASE Full text: Available BioMed Central at BMC Medicine Full text: Available BioMed Central at BMC Medicine 8.Title: Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials Citation: British journal of anaesthesia, March 2015, vol./is. 114/3(396-405), 1471-6771 (01 Mar 2015) Author(s): Szakmany T., Russell P., Wilkes A.R., Hall J.E. Language: English Abstract: BACKGROUND: Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but the evidence is conflicting.METHODS: Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation, and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95% confidence intervals.RESULTS: Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83-1.05)]. There were no differences in duration of mechanical ventilation [-0.19 days (-1.13-0.75)], intensive care stay [-0.83 days (-2.05-0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [-2.78 days (-3.68 to -1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18-5.40)].CONCLUSION: We found no evidence that early (within 10 days) tracheostomy reduced mortality, duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation. Publication type: Journal: Article Source: EMBASE 9.Title: Effect of initial calorie intake via enteral nutrition in critical illness: A meta-analysis of randomised controlled trials Citation: Critical Care, April 2015, vol./is. 19/1, 1364-8535;1466-609X (April 20, 2015) Author(s): Tian F., Wang X., Gao X., Wan X., Wu C., Zhang L., Li N., Li J. Language: English Abstract: Introduction: Guidelines support the use of enteral nutrition to improve clinical outcomes in critical illness; however, the optimal calorie and protein intake remains unclear. The purpose of this meta-analysis was to quantitatively analyze randomised controlled trials with regard to clinical outcomes related to varying calorie and protein administration in critically ill adult patients. Method: We searched Medline, EMBASE, and Cochrane databases to identify randomised controlled trials that compared the effects of initially different calorie and protein intake in critical illness. The risk ratio (RR) and weighted mean difference with 95% confidence intervals (CI) were calculated using random-effects models. The primary endpoint was mortality; secondary endpoints included infection, pneumonia, gastrointestinal intolerance, hospital and intensive care unit lengths of stay, and mechanical ventilation days. Results: In the eight randomised controlled trials that enrolled 1,895 patients there was no statistical difference between the low-energy and high-energy groups in mortality (RR, 0.90; 95% CI, 0.71 to 1.15; P = 0.40), infection (RR, 1.09; 95% CI, 0.92 to 1.29; P = 0.32), or the risk of gastrointestinal intolerance (RR, 0.84; 95% CI, 0.59 to 1.19; P = 0.33). In subgroup analysis, the low-energy subgroup, fed 33.3 to 66.6% of goal energy, showed a lower mortality than the high-energy group (RR, 0.68; 95% CI, 0.51 to 0.92; P = 0.01). The improvements in mortality and gastrointestinal intolerance were absent when calorie intake was >66.6% of goal energy in the low-energy group. High-energy intake combined with high-protein intake reduced the infections (RR, 1.25; 95% CI, 1.04 to 1.52; P = 0.02); however, when the daily protein intake was similar in both groups, a high-energy intake did not decrease the infections. No statistical differences were observed in

other secondary outcomes. Conclusion: This meta-analysis indicates that high-energy intake does not improve outcomes and may increase complications in critically ill patients who are not malnourished. Initial moderate nutrient intake (33.3 to 66.6% of goal energy), compared to high energy, may reduce mortality, and a higher protein intake combined with high energy (>0.85 g/kg per day) may decrease the infection rate. However, the contribution of energy versus protein intake to outcomes remains unknown. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at Critical Care 10.Title: Effect of performance improvement programs on compliance with sepsis bundles and mortality: A systematic review and meta-analysis of observational studies Citation: PLoS ONE, May 2015, vol./is. 10/5, 1932-6203 (06 May 2015) Author(s): Damiani E., Donati A., Serafini G., Rinaldi L., Adrario E., Pelaia P., Busani S., Girardis M. Language: English Abstract: Background: Several reports suggest that implementation of the Surviving Sepsis Campaign (SSC) guidelines is associated with mortality reduction in sepsis. However, adherence to the guideline-based resuscitation and management sepsis bundles is still poor. Objective: To perform a systematic review of studies evaluating the impact of performance improvement programs on compliance with Surviving Sepsis Campaign (SSC) guideline-based bundles and/or mortality. Data Sources: Medline (PubMed), Scopus and Intercollegiate Studies Institute Web of Knowledge databases from 2004 (first publication of the SSC guidelines) to October 2014. Study Selection: Studies on adult patients with sepsis, severe sepsis or septic shock that evaluated changes in compliance to individual/combined bundle targets and/or mortality following the implementation of performance improvement programs. Interventions may consist of educational programs, process changes or both. Data Extraction: Data from the included studies were extracted independently by two authors. Unadjusted binary data were collected in order to calculate odds ratios (OR) for compliance to individual/combined bundle targets. Adjusted (if available) or unadjusted data of mortality were collected. Random-effects models were used for the data synthesis. Results: Fifty observational studies were selected. Despite high inconsistency across studies, performance improvement programs were associated with increased compliance with the complete 6-hour bundle (OR = 4.12 [95% confidence interval 2.95-5.76], I² = 87.72%, k = 25, N = 50,081) and the complete 24-hour bundle (OR = 2.57 [1.74-3.77], I² = 85.22%, k = 11, N = 45,846) and with a reduction in mortality (OR = 0.66 [0.61-0.72], I² = 87.93%, k = 48, N = 434,447). Funnel plots showed asymmetry. Conclusions: Performance improvement programs are associated with increased adherence to resuscitation and management sepsis bundles and with reduced mortality in patients with sepsis, severe sepsis or septic shock. Publication type: Journal: Review Source: EMBASE Full text: Available National Library of Medicine at PLoS ONE 11.Title: Effect of protocolized sedation on clinical outcomes in mechanically ventilated intensive care unit patients: A systematic review and meta-analysis of randomized controlled trials Citation: Mayo Clinic Proceedings, May 2015, vol./is. 90/5(613-623), 0025-6196;1942-5546 (01 May 2015) Author(s): Minhas M.A., Velasquez A.G., Kaul A., Salinas P.D., Celi L.A. Language: English Abstract: Objective To assess the effects of protocolized sedation (algorithm or daily interruption) compared with usual care without protocolized sedation on clinical outcomes in mechanically ventilated adult intensive care unit (ICU) patients via a systematic review and meta-analysis of randomized controlled trials (RCTs). Methods We searched Ovid MEDLINE, EMBASE, Cochrane CENTRAL, Web of Science, and ClinicalTrials.gov from their inception to February 28, 2013. A random-effects model was used to synthesize risk ratios (RRs) and weighted mean differences (WMDs). Results Of 4782 records screened, 6 RCTs including 1243 patients met the inclusion criteria. Protocolized sedation was associated with significant reductions in overall mortality (RR, 0.85; 95% CI, 0.74 to 0.97; P=.02; number needed to treat, 20; P=.11), ICU length of stay (WMD, -1.73 days; 95% CI, -3.32 to -0.14 days; P=.03), hospital length of stay (WMD, -3.55 days; 95% CI, -5.98 to -1.12 days; P=.004), and tracheostomy (RR, 0.69; 95% CI, 0.50 to 0.96; P=.03; number needed to treat, 16.6; P=.04; 5 RCTs) compared with usual care. Protocolized sedation produced no significant differences in duration of mechanical ventilation (WMD, -1.04 days; 95% CI, -2.54 to 0.47 days; P=.18), reintubation (RR, 0.78; 95% CI,

0.52 to 1.15; P=.21; 3 RCTs), and self-extubation (RR, 1.49; 95% CI, 0.46 to 4.82; P=.51; 4 RCTs) compared with usual care. Included studies did not report delirium incidence. Conclusion In mechanically ventilated adults in closed, nonspecialty ICUs, protocolized sedation seems to decrease overall mortality (15%), ICU and hospital lengths of stay (1.73 and 3.55 days, respectively), and tracheostomy (31%) compared with usual care without protocolized sedation. Publication type: Journal: Article Source: EMBASE 12.Title: Effects of in-hospital low targeted temperature after out of hospital cardiac arrest: A systematic review with meta-analysis of randomized clinical trials Citation: Resuscitation, June 2015, vol./is. 91/(8-18), 0300-9572;1873-1570 (01 Jun 2015) Author(s): Vargas M., Servillo G., Sutherasan Y., Rodriguez-Gonzalez R., Brunetti I., Pelosi P. Language: English Abstract: Objective: We performed this systematic review to evaluate the effectiveness of in-hospital low targeted temperature in adult patients after out of hospital cardiac arrest on survival and neurologic performance. Data source: We systematically searched MEDLINE and PUBMED from inception to April 2014. Study selection: Citations were screened for studies evaluating the effect of in-hospital low targeted temperature in patients following out of hospital cardiac arrest. Data extraction: We analyzed randomized control trials (RCTs) that included adult patients resuscitated from out of hospital cardiac arrest, reporting mortality at hospital discharge and comparing in-hospital low targeted temperature with a control group. Data synthesis: This meta-analysis included 6 RCTs and 1418 adult patients. In-hospital low targeted (low T) temperature was associated to a reduction in mortality at hospital discharge and at 6 months when compared with in-hospital targeted and not targeted temperature while there was no reduction in mortality comparing low and high targeted temperature. In patients with initial ventricular fibrillation/ventricular tachycardia rhythm of out of hospital cardiac arrest, low T was associated with a reduction in short and long-term mortality when compared with no targeted temperature while not when compared to high targeted temperature. Low T was associated with good neurologic performance at hospital discharge compared with in-hospital high or not targeted temperature. Conclusion: In-hospital low targeted temperature (<4. degreeC) improved short and long-term mortality when compared to no targeted temperature. In contrast, low T did not improve outcome compared with a slightly higher targeted temperature (=36. degreeC). Publication type: Journal: Review Source: EMBASE 13.Title: Efficacy of noninvasive ventilation after planned extubation: A systematic review and meta-analysis of randomized controlled trials Citation: Heart and Lung: Journal of Acute and Critical Care, March 2015, vol./is. 44/2(150-157), 0147-9563;1527-3288 (01 Mar 2015) Author(s): Bajaj A., Rathor P., Sehgal V., Shetty A. Language: English Abstract: The objective our meta-analysis is to update the evidence on the efficacy of noninvasive ventilation (NIV) compared with conventional oxygen therapy after planned extubation. We did a systematic literature review of database, including Pubmed, EMBASE, and Cochrane. We included randomized controlled trials comparing NIV with conventional oxygen therapy after planned extubation in medical intensive care unit (ICU) in our analysis. The results of our meta-analysis is consistent with the results of previous reviews and show that NIV decreased reintubation rate significantly as compared to conventional oxygen therapy in chronic obstructive pulmonary disease (COPD) and patients at high risk for extubation failure; COPD (RR, 0.33; 95% CI, 0.16-0.69; I2 = 0), high risk (RR, 0.47; 95% CI, 0.32-0.70; I2 = 0). However, in a mixed medical ICU population, there was no statistical difference of reintubation rate between the two groups (RR, 0.66; 95% CI, 0.25-1.73; I2 = 68%). Our study suggests that use of NIV after planned extubation significantly decreases the reintubation rate in COPD patients and patients at high risk for extubation failure, confirming the findings of previous reviews. There is no difference in the reintubation rate between the two groups in the mixed medical ICU population. Publication type: Journal: Review Source: EMBASE 14.Title: EuReCa and international resuscitation registries

Citation: Current Opinion in Critical Care, June 2015, vol./is. 21/3(215-219), 1070-5295;1531-7072 (06 Jun 2015) Author(s): Grasner J.-T., Masterson S. Language: English Abstract: Purpose of review This review outlines knowledge on the epidemiology of out-of-hospital cardiac arrest (OHCA) internationally and the contribution that resuscitation registries make to OHCA research. The review focuses on recent advances in the European Cardiac Arrest Registry project, EuReCa. Recent findings Although literature describing the epidemiology of OHCA has proliferated in recent years, a 2010 systematic review by Berdowski et al. remains a most important publication, allowing international comparison of OHCA incidence and outcome. Recent literature supports the view that resuscitation registers are excellent sources of data on OHCA. Notable publications describe geographic variation in incidence, improvements in survival and the utility of registers in the development of survival prediction models. Summary Data from resuscitation registries are an invaluable source of information on the incidence, management and outcome of OHCA. Registries can be used to generate hypotheses for clinical research and registry data may even be used to facilitate clinical trials. To develop international research collaboration, registries must be based on the same dataset and definitions, and include descriptions of data collection methodologies and emergency medical service (EMS) configurations. If such standardization can be achieved, the possibility of an international resuscitation registry might be realized, leading to important OHCA research opportunities worldwide. Publication type: Journal: Review Source: EMBASE 15.Title: Factors affecting registered nurses' use of medication administration technology in acute care settings: A systematic review Citation: JBI Library of Systematic Reviews, 2015, vol./is. 10/8(471-512), 1838-2142 (2015) Author(s): San T.H., Siew Lin S.K., Fai C.M. Language: English Abstract: Background Information technology to aid reduction in medication errors has been encouraged over the years and one of them is the medication administration technology. It consists of the electronic Medication Administration Record, Bar-Code Medication Administration system and Automated Medication Dispensing system. Studies had examined the effectiveness and impact of this technology to reduce medication error. However, user?s acceptance towards this technology has often been neglected. To date, no systematic review has been undertaken to examine the possible factors that affect nurses' use of this technology in the acute care settings. Objectives The objective of this systematic review was to explore and determine the factors that affect nurses' use of medication administration technology in the acute care settings. Inclusion Criteria Type of studies All quantitative studies published in English which examined factors affecting nurses' use of the medication administration technology were considered. Types of participants Primary focus was on registered nurses with experience of operating medication administration technology in the acute care settings. Other healthcare personnel were excluded. Phenomenon of interest This review considered studies that evaluated factors affecting nurses' use of the medication administration technology. Types of outcome measures The outcome measures of interest were the factors that affect nurses' use of the medication administration technology in the acute care settings. Search strategy The search was conducted across published and unpublished databases. A search was conducted in JBI Library of Systematic Reviews, The Cochrane Library, CINAHL, MEDLINE, Scopus, ScienceDirect, Wiley InterScience, SpringerLink, PsycINFO (ovid), Web of science, ProQuest Dissertations and Theses, and MedNar. Methodological Quality Papers selected for retrieval were assessed by two independent reviewers for methodological validity prior to inclusion in the review, using the standardised critical appraisal instruments developed by the Joanna Briggs Institute. Data Collection/ Extraction Quantitative data were extracted from papers included in the review using a standardised data extraction tool developed by the JBI. Data Synthesis Findings were presented in narrative summary due to heterogeneity of the study designs. Results Six descriptive studies were included in this review. Nurses' use of the technology can be influenced by a combination of complex and inter-related factors, such as organisational factors, and user and system characteristics. Conclusions In order to successfully implement medication administration technology, system, user and organisational factors have to be collaborated concurrently. Implications for practice Users' needs should be accommodated when designing the system features. Prior to system implementation, institutions should consider the users' demographical characteristics and provide adequate preparations and training. A supportive culture from the institution and colleagues is also important. Implications for research There is a significant need for further research in this field. Further research to discover potential factors in different settings, locations and countries are suggested. Studies to evaluate nurses' use of the technology at regular

intervals are also required. Publication type: Journal: Article Source: EMBASE 16.Title: Hydroxyethyl starch versus other fluids for non-septic patients in the intensive care unit: A meta-analysis of randomized controlled trials Citation: Critical Care, March 2015, vol./is. 19/1, 1364-8535;1466-609X (March 19, 2015) Author(s): He B., Xu X., Li L., Ren R., Chen Z., Xiao J., Wang Y., Xu B. Language: English Abstract: Introduction: Use of hydroxyethyl starch (HES) in septic patients is reported to increase the mortality and incidence of renal replacement therapy (RRT). However, whether or not use of HES would induce the same result in non-septic patients in the intensive care unit (ICU) remains unclear. The objective of this meta-analysis was to evaluate 6% HES versus other fluids for non-septic ICU patients. Methods: Randomized controlled trials (RCTs) were searched from Pubmed, OvidSP, Embase database and Cochrane Library, published before November, 2013. A meta-analysis was made on the effect of 6% HES versus other fluids for non-septic ICU patients, including mortality, RRT incidence, bleeding volume, red blood cell (RBC) transfusion and fluid application for non-septic patients in ICU. Results: Twenty-two RCTs were included, involving 6,064 non-septic ICU patients. Compared with the other fluids, 6% HES was not associated with decreased overall mortality (RR = 1.03, 95%CI: 0.09 to 1.17; P = 0.67; I² = 0). There was no significant difference in RRT incidence, bleeding volume and red blood cell transfusion between 6% HES group and the other fluid groups. However, patients in HES group received less total intravenous fluids than those receiving crystalloids during the first day in ICU (SMD = -0.84; 95%CI: -1.39 to -0.30; P = 0.003, I ² = 74%). Conclusions: This meta-analysis found no increased mortality, RRT incidence, bleeding volumes or RBC transfusion in non-septic ICU patients, but the sample sizes were small and the studies generally were of poor quality. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at Critical Care 17.Title: Impact of daily bathing with chlorhexidine gluconate on ventilator associated pneumonia in intensive care units: A meta-analysis Citation: Journal of Thoracic Disease, 2015, vol./is. 7/4(746-753), 2072-1439;2077-6624 (2015) Author(s): Chen W., Cao Q., Li S., Li H., Zhang W. Language: English Abstract: Objective: Ventilator associated pneumonia (VAP) is the most important nosocomial infection in intensive care units (ICUs). Our objective was to assess whether daily bathing with chlorhexidine gluconate (CHG) would significantly result in the reduction of VAP. Materials and methods: Meta-analysis of randomized controlled trials (RCTs) and quasi-experimental studies were conducted. The setting are medical, surgical, trauma, and combined medical-surgical ICUs. The patients are adult. We searched electronic search engine (PubMed), Embase and the Cochrane Central Register database for all published studies related to the application of daily CHG bathing with VAP risk. Results: In all, six articles reporting a total of 27,638 ventilator-days met the inclusion criteria; 132 patients in the CHG arm developed a VAP (13,349 ventilator-days), compared with 188 patients in the control arm (14,289 ventilator-days). Daily bathing with CHG was significantly associated with decreased incidence risk of VAP [relative risk (RR): 0.73, 95% confidence interval (CI): 0.57-0.92, I²=0%]. In the subgroup analysis, we found that daily bathing with 2% CHG impregnated cloths or wipes would reduce the incidence risk of VAP among before-and-after studies (pooled RR: 0.73, 95% CI: 0.57-0.93). Conclusions: The application of daily bathing with CHG would decrease incidence risk of VAP, which would be an important complementary intervention to barrier precautions. Publication type: Journal: Article Source: EMBASE 18.Title: Impact of follow-up consultations for ICU survivors on post-ICU syndrome: a systematic review and meta-analysis. Citation: Intensive care medicine, May 2015, vol. 41, no. 5, p. 763-775 (May 2015) Author(s): Jensen, J F, Thomsen, T, Overgaard, D, Bestle, M H, Christensen, D, Egerod, I Abstract: To evaluate the impact of routine follow-up consultations versus standard of care for intensive care unit (ICU)

survivors. Systematic literature review from five databases (Cochrane CENTRAL, MEDLINE, EMBASE, PsycINFO, CINAHL), reference lists, citation tracking, and ongoing/unpublished trials. Randomized controlled trials investigating post-ICU consultations in adults with outcomes such as quality of life (QOL), anxiety, depression, posttraumatic stress disorder (PTSD), physical ability, cognitive function, and return to work were included. Two reviewers extracted data and assessed quality independently. The mean differences, risk ratios, and 95 % confidence intervals were calculated depending on outcome measures. From 1544 citations, five trials were included (855 patients). The overall risk of bias was low in two trials, unclear in two trials, and high in one trial. The overall quality of evidence was low. The trials assessed follow-up interventions defined as consultations informing survivors about their ICU stay. One trial found no effect on QOL. Pooling data from two trials (n = 374) showed a protective effect on risk of new onset PTSD at 3-6 months after ICU (risk ratio 0.49, 95 % CI 0.26-0.95). There was no effect on other outcomes. The evidence indicates that follow-up consultations might reduce symptoms of PTSD at 3-6 months after ICU discharge in ICU survivors, but without affecting QOL and other outcomes investigated. This review highlights that planning of future RCTs should aim to standardize interventions and outcome measures to allow for comparisons across studies. Source: Medline 19.Title: Impact of obesity on sepsis mortality: A systematic review Citation: Journal of Critical Care, June 2015, vol./is. 30/3(518-524), 0883-9441;1557-8615 (01 Jun 2015) Author(s): Trivedi V., Bavishi C., Jean R. Language: English Abstract: Purpose: Sepsis and severe sepsis are the most common cause of death among critically ill patients admitted in medical intensive care units. As more than one-third of the adult population of the United States is obese; we undertook a systematic review of the association between obesity and mortality among patients admitted with sepsis, severe sepsis, or septic shock. Materials and methods: A systematic review was conducted to identify pertinent studies using a comprehensive search strategy. Studies reporting mortality in obese patients admitted with sepsis were identified. Results: Our initial search identified 183 studies of which 7 studies met our inclusion criteria. Three studies reported no significant association between obesity and mortality, 1 study observed increased mortality among obese patients, whereas 3 studies found lower mortality among obese patients. Conclusion: Our review of the current clinical evidence of association of obesity with sepsis mortality revealed mixed results. Clinicians are faced with a number of challenges while managing obese patients with sepsis and should be mindful of the impact of obesity on antibiotics administration, fluid resuscitation, and ventilator management. Further studies are needed to elicit the impact of obesity on mortality in patients with sepsis. Publication type: Journal: Review Source: EMBASE 20.Title: Intravenous lipid emulsion in the emergency department: A systematic review of recent literature Citation: Journal of Emergency Medicine, March 2015, vol./is. 48/3(387-397), 0736-4679 (01 Mar 2015) Author(s): Cao D., Heard K., Foran M., Koyfman A. Language: English Abstract: Background Intravenous lipid emulsion (ILE) has been broadly attempted in the resuscitation of neurologic and cardiac toxic drug overdoses, however, the role of ILE in the emergency department is poorly defined. Objective This review aims to identify recent literature on the use of ILE in humans as an antidote and to familiarize emergency providers with the indications, availability, dosing recommendations, and adverse reactions associated with ILE use. Methods A systemic literature search of MEDLINE, EMBASE, and major toxicology conference abstracts was performed for human cases using ILE as an antidote with documented clinical outcomes through January 2014. Results Ninety-four published articles and 40 conference abstracts were identified, 85% of which had positive outcomes. The most common indication for ILE was for local anesthetic systemic toxicity (LAST). The most common nonlocal anesthetic xenobiotics were tricyclic-antidepressants and verapamil. Discussion No standard of care is defined for the use of ILE, although the American Heart Association recommends use in LAST, and the American College of Medical Toxicology recommends consideration for circumstances of hemodynamic instability resultant from lipid-soluble xenobiotics. ILE should be administered per American Society of Regional Anesthesia and Pain Medicine dosing recommendations. Laboratory interference, pancreatitis, respiratory distress syndrome, and interference with vasopressors should be considered as risks but are uncommon. Conclusions In the setting of severe hemodynamic compromise by lipid-soluble xenobiotics, ILE may be considered for resuscitation by emergency physicians. As such, ILE may be stocked in emergency departments in

close proximity to resuscitation rooms and areas where local nerve blocks are performed. Publication type: Journal: Review Source: EMBASE 21.Title: Management of critically ill patients with type 2 diabetes: The need for personalised therapy. Citation: World journal of diabetes, Jun 2015, vol. 6, no. 5, p. 693-706 (June 10, 2015) Author(s): Kar, Palash, Jones, Karen L, Horowitz, Michael, Deane, Adam M Abstract: Critical illness in patients with pre-existing diabetes frequently causes deterioration in glycaemic control. Despite the prevalence of diabetes in patients admitted to hospital and intensive care units, the ideal management of hyperglycaemia in these groups is uncertain. There are data that suggest that acute hyperglycaemia in critically ill patients without diabetes is associated with increased mortality and morbidity. Exogenous insulin to keep blood glucose concentrations < 10 mmol/L is accepted as standard of care in this group. However, preliminary data have recently been reported that suggest that chronic hyperglycaemia may result in conditioning, which protects these patients against damage mediated by acute hyperglycaemia. Furthermore, acute glucose-lowering to < 10 mmol/L in patients with diabetes with inadequate glycaemic control prior to their critical illness appears to have the capacity to cause harm. This review focuses on glycaemic control in critically ill patients with type 2 diabetes, the potential for harm from glucose-lowering and the rationale for personalised therapy. Source: Medline 22.Title: Mechanical versus manual chest compression for out-of-hospital cardiac arrest (PARAMEDIC): a pragmatic, cluster randomised controlled trial Citation: Lancet, Mar 2015, vol. 385, no. 9972, p. 947-955, 0140-6736 (March 14, 2015) Author(s): Perkins, Gavin D, Lall, Ranjit, Quinn, Tom, Deakin, Charles D, Cooke, Matthew W, Horton, Jessica, Lamb, Sarah E, Slowther, Anne-Marie, Woollard, Malcolm, Carson, Andy, Smyth, Mike, Whitfield, Richard, Williams, Amanda, Pocock, Helen, Black, John J M, Wright, John, Han, Kyee, Gates, Simon Abstract: Mechanical chest compression devices have the potential to help maintain high-quality cardiopulmonary resuscitation (CPR), but despite their increasing use, little evidence exists for their effectiveness. We aimed to study whether the introduction of LUCAS-2 mechanical CPR into front-line emergency response vehicles would improve survival from out-of-hospital cardiac arrest. Methods: The pre-hospital randomised assessment of a mechanical compression device in cardiac arrest (PARAMEDIC) trial was a pragmatic, cluster-randomised open-label trial including adults with non-traumatic, out-of-hospital cardiac arrest from four UK Ambulance Services (West Midlands, North East England, Wales, South Central). 91 urban and semi-urban ambulance stations were selected for participation. Clusters were ambulance service vehicles, which were randomly assigned (1:2) to LUCAS-2 or manual CPR. Patients received LUCAS-2 mechanical chest compression or manual chest compressions according to the first trial vehicle to arrive on scene. The primary outcome was survival at 30 days following cardiac arrest and was analysed by intention to treat. Ambulance dispatch staff and those collecting the primary outcome were masked to treatment allocation. Masking of the ambulance staff who delivered the interventions and reported initial response to treatment was not possible. The study is registered with Current Controlled Trials, number ISRCTN08233942. Findings: We enrolled 4471 eligible patients (1652 assigned to the LUCAS-2 group, 2819 assigned to the control group) between April 15, 2010 and June 10, 2013. 985 (60%) patients in the LUCAS-2 group received mechanical chest compression, and 11 (<1%) patients in the control group received LUCAS-2. In the intention-to-treat analysis, 30 day survival was similar in the LUCAS-2 group (104 [6%] of 1652 patients) and in the manual CPR group (193 [7%] of 2819 patients; adjusted odds ratio [OR] 0·86, 95% CI 0·64-1·15). No serious adverse events were noted. Seven clinical adverse events were reported in the LUCAS-2 group (three patients with chest bruising, two with chest lacerations, and two with blood in mouth). 15 device incidents occurred during operational use. No adverse or serious adverse events were reported in the manual group. Interpretation: We noted no evidence of improvement in 30 day survival with LUCAS-2 compared with manual compressions. On the basis of ours and other recent randomised trials, widespread adoption of mechanical CPR devices for routine use does not improve survival. [Publication] 26 references Source: BNI Full text: Available Lancet at Lancet, The 23.Title: Nebulized antibiotics for ventilator-associated pneumonia: A systematic review and meta-analysis Citation: Critical Care, April 2015, vol./is. 19/1, 1364-8535;1466-609X (April 07, 2015)

Author(s): Zampieri F.G., Nassar A.P., Gusmao-Flores D., Taniguchi L.U., Torres A., Ranzani O.T. Language: English Abstract: Introduction: Nebulized antibiotics are a promising new treatment option for ventilator-associated pneumonia. However, more evidence of the benefit of this therapy is required. Methods: The Medline, Scopus, EMBASE, Biological Abstracts, CAB Abstracts, Food Science and Technology Abstracts, CENTRAL, Scielo and Lilacs databases were searched to identify randomized controlled trials or matched observational studies that compared nebulized antibiotics with or without intravenous antibiotics to intravenous antibiotics alone for ventilator-associated pneumonia treatment. Two reviewers independently collected data and assessed outcomes and risk of bias. The primary outcome was clinical cure. Secondary outcomes were microbiological cure, ICU and hospital mortality, duration of mechanical ventilation, ICU length of stay and adverse events. A mixed-effect model meta-analysis was performed. Trial sequential analysis was used for the main outcome of interest. Results: Twelve studies were analyzed, including six randomized controlled trials. For the main outcome analysis, 812 patients were included. Nebulized antibiotics were associated with higher rates of clinical cure (risk ratio (RR) = 1.23; 95% confidence interval (CI), 1.05 to 1.43; I² = 34%; D² = 45%). Nebulized antibiotics were not associated with microbiological cure (RR = 1.24; 95% CI, 0.95 to 1.62; I² = 62.5), mortality (RR = 0.90; CI 95%, 0.76 to 1.08; I² = 0%), duration of mechanical ventilation (standardized mean difference = -0.10 days; 95% CI, -1.22 to 1.00; I² = 96.5%), ICU length of stay (standardized mean difference = 0.14 days; 95% CI, -0.46 to 0.73; I² = 89.2%) or renal toxicity (RR = 1.05; 95% CI, 0.70 to 1.57; I² = 15.6%). Regarding the primary outcome, the number of patients included was below the information size required for a definitive conclusion by trial sequential analysis; therefore, our results regarding this parameter are inconclusive. Conclusions: Nebulized antibiotics seem to be associated with higher rates of clinical cure in the treatment of ventilator-associated pneumonia. However, the apparent benefit in the clinical cure rate observed by traditional meta-analysis does not persist after trial sequential analysis. Additional high-quality studies on this subject are highly warranted. Trial registration number: CRD42014009116. Registered 29 March 2014. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at Critical Care 24.Title: Noninvasive continuous cardiac output monitoring in perioperative and intensive care medicine. Citation: British journal of anaesthesia, Apr 2015, vol. 114, no. 4, p. 562-575 (April 2015) Author(s): Saugel, B, Cecconi, M, Wagner, J Y, Reuter, D A Abstract: The determination of blood flow, i.e. cardiac output, is an integral part of haemodynamic monitoring. This is a review on noninvasive continuous cardiac output monitoring in perioperative and intensive care medicine. We present the underlying principles and validation data of the following technologies: thoracic electrical bioimpedance, thoracic bioreactance, vascular unloading technique, pulse wave transit time, and radial artery applanation tonometry. According to clinical studies, these technologies are capable of providing cardiac output readings noninvasively and continuously. They, therefore, might prove to be innovative tools for the assessment of advanced haemodynamic variables at the bedside. However, for most technologies there are conflicting data regarding the measurement performance in comparison with reference methods for cardiac output assessment. In addition, each of the reviewed technology has its own limitations regarding applicability in the clinical setting. In validation studies comparing cardiac output measurements using these noninvasive technologies in comparison with a criterion standard method, it is crucial to correctly apply statistical methods for the assessment of a technology's accuracy, precision, and trending capability. Uniform definitions for 'clinically acceptable agreement' between innovative noninvasive cardiac output monitoring systems and criterion standard methods are currently missing. Further research must aim to further develop the different technologies for noninvasive continuous cardiac output determination with regard to signal recording, signal processing, and clinical applicability. © The Author 2015. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com. Source: Medline 25.Title: Nontraumatic hypotension and shock in the emergency department and the prehospital setting, prevalence, etiology, and mortality: A systematic review Citation: PLoS ONE, March 2015, vol./is. 10/3, 1932-6203 (19 Mar 2015)

Author(s): Holler J.G., Bech C.N., Henriksen D.P., Mikkelsen S., Pedersen C., Lassen A.T. Language: English Abstract: Background: Acute patients presenting with hypotension in the prehospital or emergency department (ED) setting are in need of focused management and knowledge of the epidemiology characteristics might help the clinician. The aim of this review was to address prevalence, etiology and mortality of nontraumatic hypotension (SBP < 90 mmHg) with or without the presence of shock in the prehospital and ED setting. Methods: We performed a systematic literature search up to August 2013, using Medline, Embase, Cinahl, Dare and The Cochrane Library. The analysis and eligibility criteria were documented according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-guidelines) and The Cochrane Collaboration. No restrictions on language, publication date, or status were imposed. We used the Newcastle-Ottawa quality assessment scale (NOS-scale) and the Strengthening the Reporting of Observational studies in Epidemiology (STROBE-statement) to assess the quality. Results: Six observational studies were considered eligible for analysis based on the evaluation of 11,880 identified papers. Prehospital prevalence of hypotension was 19.5/1000 emergency medicine service (EMS) contacts, and the prevalence of hypotensive shock was 9.5-19/1000 EMS contacts with an inhospital mortality of shock between 33 to 52%. ED prevalence of hypotension was 4-13/1000 contacts with a mortality of 12%. Information on mortality, prevalence and etiology of shock in the ED was limited. A meta-analysis was not feasible due to substantial heterogeneity between studies. Conclusion: There is inadequate evidence to establish concise estimates of the characteristics of nontraumatic hypotension and shock in the ED or in the prehospital setting. The available studies suggest that 2% of EMS contacts present with nontraumatic hypotension while 1-2% present with shock. The inhospital mortality of prehospital shock is 33-52%. Prevalence of hypotension in the ED is 1% with an inhospital mortality of 12%. Prevalence, etiology and mortality of shock in the ED are not well described. Publication type: Journal: Review Source: EMBASE Full text: Available National Library of Medicine at PLoS ONE 26.Title: Pharmacologic prevention and treatment of delirium in intensive care patients: A systematic review. Citation: Journal of critical care, Aug 2015, vol. 30, no. 4, p. 799-807 (August 2015) Author(s): Serafim, Rodrigo B, Bozza, Fernando A, Soares, Marcio, do Brasil, Pedro Emanuel A A, Tura, Bernardo R, Ely, E Wesley, Salluh, Jorge I F Abstract: The purpose of the study is to determine if pharmacologic approaches are effective in prevention and treatment of delirium in critically ill patients. We performed a systematic search to identify publications (from January 1980 to September 2014) that evaluated the pharmacologic interventions to treat or prevent delirium in intensive care unit (ICU) patients. From 2646 citations, 15 studies on prevention (6729 patients) and 7 studies on treatment (1784 patients) were selected and analyzed. Among studies that evaluated surgical patients, the pharmacologic interventions were associated with a reduction in delirium prevalence, ICU length of stay, and duration of mechanical ventilation, but with high heterogeneity (respectively, I(2) = 81%, P = .0013; I(2) = 97%, P < .001; and I(2) = 97%). Considering treatment studies, only 1 demonstrated a significant decrease in ICU length of stay using dexmedetomidine compared to haloperidol (Relative Risk, 0.62 [1.29-0.06]; I(2) = 97%), and only 1 found a shorter time to resolution of delirium using quetiapine (1.0 [confidence interval, 0.5-3.0] vs 4.5 [confidence interval, 2.0-7.0] days; P = .001). The use of antipsychotics for surgical ICU patients and dexmedetomidine for mechanically ventilated patients as a preventive strategy may reduce the prevalence of delirium in the ICU. None of the studied agents that were used for delirium treatment improved major clinical outcome, including mortality. Copyright © 2015 Elsevier Inc. All rights reserved. Source: Medline 27.Title: Rapid detection of health-care-associated bloodstream infection in critical care using Multipathogen real-time polymerase chain reaction technology: A diagnostic accuracy study and systematic review Citation: Health Technology Assessment, May 2015, vol./is. 19/35(1-141), 1366-5278;2046-4924 (01 May 2015) Author(s): Warhurst G., Dunn G., Chadwick P., Blackwood B., McAuley D., Perkins G.D., McMullan R., Gates S., Bentley A., Young D., Carlson G.L., Dark P. Language: English Abstract: Background: There is growing interest in the potential utility of real-time polymerase chain reaction (PCR) in diagnosing bloodstream infection by detecting pathogen deoxyribonucleic acid (DNA) in blood samples within a few hours. SeptiFast (Roche Diagnostics GmBH, Mannheim, Germany) is a multipathogen probe-based system targeting

ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection. As background to this study, we report a systematic review of Phase III diagnostic accuracy studies of SeptiFast, which reveals uncertainty about its likely clinical utility based on widespread evidence of deficiencies in study design and reporting with a high risk of bias. Objective: Determine the accuracy of SeptiFast real-time PCR for the detection of health-care-associated bloodstream infection, against standard microbiological culture. Design: Prospective multicentre Phase III clinical diagnostic accuracy study using the standards for the reporting of diagnostic accuracy studies criteria. Setting: Critical care departments within NHS hospitals in the north-west of England. Participants: Adult patients requiring blood culture (BC) when developing new signs of systemic inflammation. Main outcome measures: SeptiFast real-time PCR results at species/genus level compared with microbiological culture in association with independent adjudication of infection. Metrics of diagnostic accuracy were derived including sensitivity, specificity, likelihood ratios and predictive values, with their 95% confidence intervals (CIs). Latent class analysis was used to explore the diagnostic performance of culture as a reference standard. Results: Of 1006 new patient episodes of systemic inflammation in 853 patients, 922 (92%) met the inclusion criteria and provided sufficient information for analysis. Index test assay failure occurred on 69 (7%) occasions. Adult patients had been exposed to a median of 8 days (interquartile range 4-16 days) of hospital care, had high levels of organ support activities and recent antibiotic exposure. SeptiFast real-time PCR, when compared with culture-proven bloodstream infection at species/genus level, had better specificity (85.8%, 95% CI 83.3% to 88.1%) than sensitivity (50%, 95% CI 39.1% to 60.8%). When compared with pooled diagnostic metrics derived from our systematic review, our clinical study revealed lower test accuracy of SeptiFast real-time PCR, mainly as a result of low diagnostic sensitivity. There was a low prevalence of BC-proven pathogens in these patients (9.2%, 95% CI 7.4% to 11.2%) such that the post-test probabilities of both a positive (26.3%, 95% CI 19.8% to 33.7%) and a negative SeptiFast test (5.6%, 95% CI 4.1% to 7.4%) indicate the potential limitations of this technology in the diagnosis of bloodstream infection. However, latent class analysis indicates that BC has a low sensitivity, questioning its relevance as a reference test in this setting. Using this analysis approach, the sensitivity of the SeptiFast test was low but also appeared significantly better than BC. Blood samples identified as positive by either culture or SeptiFast real-time PCR were associated with a high probability (> 95%) of infection, indicating higher diagnostic rule-in utility than was apparent using conventional analyses of diagnostic accuracy. Conclusion: SeptiFast real-time PCR on blood samples may have rapid rule-in utility for the diagnosis of health-care-associated bloodstream infection but the lack of sensitivity is a significant limiting factor. Innovations aimed at improved diagnostic sensitivity of real-time PCR in this setting are urgently required. Future work recommendations include technology developments to improve the efficiency of pathogen DNA extraction and the capacity to detect a much broader range of pathogens and drug resistance genes and the application of new statistical approaches able to more reliably assess test performance in situation where the reference standard (e.g. blood culture in the setting of high antimicrobial use) is prone to error. Publication type: Journal: Article Source: EMBASE 28.Title: Recent advances in the diagnosis and treatment of acute myocardial infarction. Citation: World journal of cardiology, May 2015, vol. 7, no. 5, p. 243-276 (May 26, 2015) Author(s): Reddy, Koushik, Khaliq, Asma, Henning, Robert J Abstract: The Third Universal Definition of Myocardial Infarction (MI) requires cardiac myocyte necrosis with an increase and/or a decrease in a patient's plasma of cardiac troponin (cTn) with at least one cTn measurement greater than the 99(th) percentile of the upper normal reference limit during: (1) symptoms of myocardial ischemia; (2) new significant electrocardiogram (ECG) ST-segment/T-wave changes or left bundle branch block; (3) the development of pathological ECG Q waves; (4) new loss of viable myocardium or regional wall motion abnormality identified by an imaging procedure; or (5) identification of intracoronary thrombus by angiography or autopsy. Myocardial infarction, when diagnosed, is now classified into five types. Detection of a rise and a fall of troponin are essential to the diagnosis of acute MI. However, high sensitivity troponin assays can increase the sensitivity but decrease the specificity of MI diagnosis. The ECG remains a cornerstone in the diagnosis of MI and should be frequently repeated, especially if the initial ECG is not diagnostic of MI. There have been significant advances in adjunctive pharmacotherapy, procedural techniques and stent technology in the treatment of patients with MIs. The routine use of antiplatelet agents such as clopidogrel, prasugrel or ticagrelor, in addition to aspirin, reduces patient morbidity and mortality. Percutaneous coronary intervention (PCI) in a timely manner is the primary treatment of patients with acute ST segment elevation MI. Drug eluting coronary stents are safe and beneficial with primary coronary intervention. Treatment with direct thrombin inhibitors during PCI is non-inferior to unfractionated heparin and glycoprotein IIb/IIIa receptor antagonists and is

associated with a significant reduction in bleeding. The intra-coronary use of a glycoprotein IIb/IIIa antagonist can reduce infarct size. Pre- and post-conditioning techniques can provide additional cardioprotection. However, the incidence and mortality due to MI continues to be high despite all these recent advances. The initial ten year experience with autologous human bone marrow mononuclear cells (BMCs) in patients with MI showed modest but significant increases in left ventricular (LV) ejection fraction, decreases in LV end-systolic volume and reductions in MI size. These studies established that the intramyocardial or intracoronary administration of stem cells is safe. However, many of these studies consisted of small numbers of patients who were not randomized to BMCs or placebo. The recent LateTime, Time, and Swiss Multicenter Trials in patients with MI did not demonstrate significant improvement in patient LV ejection fraction with BMCs in comparison with placebo. Possible explanations include the early use of PCI in these patients, heterogeneous BMC populations which died prematurely from patients with chronic ischemic disease, red blood cell contamination which decreases BMC renewal, and heparin which decreases BMC migration. In contrast, cardiac stem cells from the right atrial appendage and ventricular septum and apex in the SCIPIO and CADUCEUS Trials appear to reduce patient MI size and increase viable myocardium. Additional clinical studies with cardiac stem cells are in progress. Source: Medline Full text: Available National Library of Medicine at World Journal of Cardiology 29.Title: Reducing Pressure Injuries in Critically Ill Patients by Using a Patient Skin Integrity Care Bundle (Inspire) Citation: American Journal of Critical Care, May 2015, vol. 24, no. 3, p. 199-209, 1062-3264 (May 2015) Author(s): Coyer, Fiona, Gardner, Anne, Doubrovsky, Anna, Cole, Rae, Ryan, Frances Mary, Allen, Craig, McNamara, Greg Abstract: Purpose To test an interventional patient skin integrity bundle, the InSPiRE protocol, for reducing pressure injuries in critically ill patients in an Australian adult intensive care unit. Methods Before and after design: patients receiving the intervention (InSPiRE protocol) were compared with a similar control group who received standard care. Data collected included demographic and clinical variables, skin assessment, presence and stage of pressure injuries, and score on the Sequential Organ Failure Assessment (SOFA). Results Overall, 207 patients were enrolled, 105 in the intervention group and 102 in the control group. Most patients were men (mean age, 55 years). The groups were similar on major demographic variables (age, SOFA scores, intensive care unit stay). Cumulative incidence of pressure injuries was significantly lower in the intervention group (18.1%) than in the control group (30.4%) for skin injuries ( Formula , P = .04) and mucous injuries (t = 3.27, P= .001). Significantly fewer pressure injuries developed over time in the intervention group (log rank = 11.842, df = 1, P= .001) and intervention patients had fewer skin injuries (> 3 pressure injuries/patient = 1/105) than did control patients (> 3 pressure injuries/patient = 10/102; P = .02). Conclusion The intervention group, receiving the InSPiRE protocol, had a lower cumulative incidence of pressure injuries, and fewer and less severe pressure injuries that developed over time. Systematic and ongoing assessment of the patient's skin and risk for pressure injuries as well as implementation of tailored prevention measures are central to preventing pressure injuries. [PUBLICATION] Source: BNI Full text: Available American journal of critical care : an official publication, American Association of Critical-Care Nurses at American Journal of Critical Care 30.Title: Sedation options for intubated intensive care unit patients. Citation: Critical care nursing clinics of North America, Mar 2015, vol. 27, no. 1, p. 131-145 (March 2015) Author(s): Lacoske, Jennifer Abstract: A common requirement for intubated patients in the intensive care unit (ICU) is sedation and pain management to facilitate patient safety and timely, atraumatic healing. The Society of Critical Care Medicine guidelines for management of pain, sedation, and delirium in adult ICU patients provide assessment scales for pain, sedation, and delirium; medications for sedation and pain management, and protocols for weaning sedation, are discussed. Proficient assessment skills, pharmacologic knowledge of medications administered to provide sedation, and an understanding of the importance of nonpharmacologic interventions can help the registered nurse provide patient advocacy, safety, and improved outcomes. Copyright © 2015 Elsevier Inc. All rights reserved. Source: Medline 31.Title: Should suspected cervical spinal cord injury be immobilised?: A systematic review

Citation: Injury, April 2015, vol./is. 46/4(528-535), 0020-1383;1879-0267 (01 Apr 2015) Author(s): Oteir A.O., Smith K., Stoelwinder J.U., Middleton J., Jennings P.A. Language: English Abstract: Background Spinal cord injuries occur worldwide; often being life-threatening with devastating long term impacts on functioning, independence, health, and quality of life. Objectives Systematic review of the literature to determine the efficacy of cervical spinal immobilisation (vs no immobilisation) in patients with suspected cervical spinal cord injury (CSCI); and to provide recommendations for prehospital spinal immobilisation. Methods Searches were conducted of the Cochrane library, CINAHL, EMBASE, Pubmed, Scopus, Web of science, Google scholar, and OvidSP (MEDLINE, PsycINFO, and DARE) databases. Studies were included if they were relevant to the research question, published in English, based in the prehospital setting, and included adult patients with traumatic injury. Results The search identified 1471 citations, of which eight observational studies of variable quality were included. Four studies were retrospective cohorts, three were case series and one a case report. Cervical collar application was reported in penetrating trauma to be associated with unadjusted increased risk of mortality in two studies [(OR, 8.82; 95% CI, 1.09-194; p = 0.038) & (OR, 2.06; 95% CI, 1.35-3.13)], concealment of neck injuries in one study and increased scene time in another study. While, in blunt trauma, one study indicated that immobilisation might be associated with worsened neurological outcome (OR, 2.03; 95% CI, 1.03-3.99; p = 0.04, unadjusted). We did not attempt to combine study results due to significant heterogeneity of study design and outcome measures. Conclusion There is a lack of high-level evidence on the effect of prehospital cervical spine immobilisation on patient outcomes. There is a clear need for large prospective studies to determine the clinical benefit of prehospital spinal immobilisation as well as to identify the subgroup of patients most likely to benefit. Publication type: Journal: Review Source: EMBASE 32.Title: The etiology and outcome of non-traumatic coma in critical care: A systematic review Citation: BMC Anesthesiology, April 2015, vol./is. 15/1, 1471-2253 (April 29, 2015) Author(s): Horsting M.W.B., Franken M.D., Meulenbelt J., van Klei W.A., de Lange D.W. Language: English Abstract: Background: Non-traumatic coma (NTC) is a serious condition requiring swift medical or surgical decision making upon arrival at the emergency department. Knowledge of the most frequent etiologies of NTC and associated mortality might improve the management of these patients. Here, we present the results of a systematic literature search on the etiologies and prognosis of NTC. Methods: Two reviewers independently performed a systematic literature search in the Pubmed, Embase and Cochrane databases with subsequent reference and citation checking. Inclusion criteria were retrospective or prospective observational studies on NTC, which reported on etiologies and prognostic information of patients admitted to the emergency department or intensive care unit. Results: Eventually, 14 studies with enough data on NTC, were selected for this systematic literature review. The most common causes of NTC were stroke (6-54%), post-anoxic coma (3-42%), poisoning (<1-39%) and metabolic causes (1-29%). NTC was also often caused by infections, especially in African studies affecting 10-51% of patients. The NTC mortality rate ranged from 25 to 87% and the mortality rate continued to increase long after the event had occurred. Also, 5-25% of patients remained moderately-severely disabled or in permanent vegetative state. The mortality was highest for stroke (60-95%) and post-anoxic coma (54-89%) and lowest for poisoning (0-39%) and epilepsy (0-10%). Conclusion: NTC represents a challenge to the emergency and the critical care physicians with an important mortality and moderate-severe disability rate. Even though, included studies were very heterogeneous, the most common causes of NTC are stroke, post anoxic, poisoning and various metabolic etiologies. The best outcome is achieved for patients with poisoning and epilepsy, while the worst outcome was seen in patients with stroke and post-anoxic coma. Adequate knowledge of the most common causes of NTC and prioritizing the causes by mortality ensures a swift and adequate work-up in diagnosis of NTC and may improve outcome. Publication type: Journal: Article Source: EMBASE Full text: Available National Library of Medicine at BMC Anesthesiology 33.Title: The role of colonoscopy within 24 hours of presentation for acute lower gastrointestinal bleeding (Algib) - A systematic review Citation: Gastrointestinal Endoscopy, May 2015, vol./is. 81/5 SUPPL. 1(AB369), 0016-5107 (May 2015)

Author(s): Afshar I.R., Sadr M.S., Martel M., Barkun A.N. Language: English Abstract: Introduction: ALGIB is a common and potentially lethal disorder that often requires hospitalization. The role and benefits of urgent colonoscopy in the management of ALGIB remain controversial. Objective: The present study is a meta-analysis of published studies assessing the role of early colonoscopy (within 24 hours of presentation) in the management of ALGIB. Methods: Multiple search engines were queried on studies spanning 1980 to March 2014 using the terms related to gastrointestinal hemorrhage and urgent (emergency, early) colonoscopy. We included randomized controlled trials (RCTs) and observational studies assessing the role of early colonoscopy in patients with ALGIB. Two independent reviewers identified and evaluated the relevant studies. The primary outcome was 30 day-rebleeding. Descriptive statistics were generated as were risk ratios and weighted mean differences to characterize the utility of early colonoscopy. Results: Amongst 748 citations, 9 studies (1 abstract) included only an early colonoscopy population and 2 additional were RCTs (total n=1166, including n= 102 in the 2 RCT intervention early colonoscopy arms, mean age range 45-78 yrs, 47.7% females, 38.5% hemodynamic instability, 6.4u packed RBCs in first 24 hrs). Of the two RCT control groups (colonoscopy after 24 hours, n=102; mean age 65 yrs, 37.2% females, 68.0% hemodynamic instability, mean 1.5u pRBCs in first 24 hrs), one included randomization to angioembolization. Endoscopic findings classified as definitive cause of bleeding amongst all early colonoscopies (excluding four studies that solely assessed diverticular bleeding) were diverticula (27.1%), angiodysplasia (7.5%), ulcers (5.2%), cancer (8.5%), colitis (19.0%) and other findings (29.2%). A probable or definite cause of bleeding was found more often in patients undergoing early colonoscopy in the 2 RCTs (26.7% vs 12.8%; p-value=0.02). 85.4% of patients in all studies had endoscopic therapy (injection 9.8%, ligation 2.2%, thermal 15.5%, other 1.3%); other approaches included surgery (5.0%) or radiological therapy (16.9%). The rebleeding rate after 24 hours was (38/311) 12.2%, while all cause 30-day mortality was (14/778) 1.8%; one study reported mean days in ICU of 1.8 (50 patients). Amongst the 2 RCTs there were no significant attributable differences in rebleeding rates compared to controls RR=0.71 (0.45; 1.12) or mortality RR=0.50 (0.09; 2.66). Conclusion: Early colonoscopy with appropriate endoscopic hemostasis can be carried out in patients with ALGIB within the first 24 hours of presentation, with rebleeding noted in 12.2%. An early colonoscopy approach identifies more patients with a definitive cause of bleeding but does not result in decreased rebleeding or mortality. Publication type: Journal: Conference Abstract Source: EMBASE Full text: Available GASTROINTESTINAL ENDOSCOPY at Salisbury District Hospital Healthcare Library 34.Title: The use, prevalence and potential benefits of a diary as a therapeutic intervention/tool to aid recovery following critical illness in intensive care: a literature review Citation: Journal of Clinical Nursing, May 2015, vol. 24, no. 9-10, p. 1406-1425, 0962-1067 (May 2015) Author(s): Ewens, Beverley A, Hendricks, Joyce M, Sundin, Deb Abstract: To critically appraise the available literature and summarise the evidence related to the use, prevalence, purpose and potential therapeutic benefits of intensive care unit diaries following survivors' discharge from hospital and identify areas for future exploration. Intensive care unit survivorship is increasing as are associated physical and psychological complications. These complications can impact on the quality of life of survivors and their families. Rehabilitation services for survivors have been sporadically implemented and lack an evidence base. Patient diaries in intensive care have been implemented in Scandinavia and Europe with the intention of filling memory gaps, enable survivors to set realistic recovery goals and cement their experiences in reality. A review of original research articles. The review used key terms and Boolean operators across a 34-year time frame in: CIHAHL, Medline, Scopus, Proquest, Informit and Google Scholar for research reports pertaining to the area of enquiry. Twenty-two original research articles met the inclusion criteria for this review. The review concluded that diaries are prevalent in Scandinavia and parts of Europe but not elsewhere. The implementation and ongoing use of diaries is disparate and international guidelines to clarify this have been proposed. Evidence which demonstrates the potential of diaries in the reduction of the psychological complications following intensive care has recently emerged. Results from this review will inform future research in this area. Further investigation is warranted to explore the potential benefits of diaries for survivors and improve the evidence base which is currently insufficient to inform practice. The exploration of prospective diarising in the recovery period for survivors is also justified. Intensive care diaries are a cost effective intervention which may yield significant benefits to survivors. [PUBLICATION] 54 references Source: BNI

35.Title: Trial of early, goal-directed resuscitation for septic shock Citation: New England Journal of Medicine, April 2015, vol./is. 372/14(1301-1311), 0028-4793;1533-4406 (02 Apr 2015) Author(s): Mouncey P.R., Osborn T.M., Power G.S., Harrison D.A., Sadique M.Z., Grieve R.D., Jahan R., Harvey S.E., Bell D., Bion J.F., Coats T.J., Singer M., Young J.D., Rowan K.M. Language: English Abstract: Background: Early, goal-directed therapy (EGDT) is recommended in international guidelines for the resuscitation of patients presenting with early septic shock. However, adoption has been limited, and uncertainty about its effectiveness remains. Methods: We conducted a pragmatic randomized trial with an integrated cost-effectiveness analysis in 56 hospitals in England. Patients were randomly assigned to receive either EGDT (a 6-hour resuscitation protocol) or usual care. The primary clinical outcome was all-cause mortality at 90 days. Results: We enrolled 1260 patients, with 630 assigned to EGDT and 630 to usual care. By 90 days, 184 of 623 patients (29.5%) in the EGDT group and 181 of 620 patients (29.2%) in the usual-care group had died (relative risk in the EGDT group, 1.01; 95% confidence interval [CI], 0.85 to 1.20; P = 0.90), for an absolute risk reduction in the EGDT group of -0.3 percentage points (95% CI, -5.4 to 4.7). Increased treatment intensity in the EGDT group was indicated by increased use of intravenous fluids, vasoactive drugs, and red-cell transfusions and reflected by significantly worse organ-failure scores, more days receiving advanced cardiovascular support, and longer stays in the intensive care unit. There were no significant differences in any other secondary outcomes, including health-related quality of life, or in rates of serious adverse events. On average, EGDT increased costs, and the probability that it was cost-effective was below 20%. Conclusions: In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome. Publication type: Journal: Article Source: EMBASE Full text: Available The New England journal of medicine at New England Journal of Medicine 36.Title: Ventilator-associated events prevention, learning lessons from the past: A systematic review Citation: Heart & Lung, May 2015, vol. 44, no. 3, p. 251-259, 0147-9563 (May-Jun 2015) Author(s): Chahoud, Jad, Semaan, Adele, Almoosa, Khalid F Abstract: Preventing Ventilator-associated events (VAE) is a major challenge. Strictly monitoring for ventilator-associated pneumonia (VAP) is not sufficient to ensure positive outcomes. Therefore, the surveillance definition was updated and a change to the broader VAE was advocated. This paper summarizes the scientific efforts assessing VAP preventive bundles and the recent transition in surveillance methods. We conducted a systematic review to identify lessons from past clinical studies assessing VAP prevention bundles. We then performed a thorough literature review on the recent VAE surveillance algorithm, highlighting its advantages and limitations. VAP prevention bundles have historically proven their efficacy and the introduction of the new VAE definition aimed at refining and objectivizing surveillance methods. Randomized controlled trials remain vital to determine the effect of VAE prevention on patient outcomes. We recommend expanding beyond limited VAP prevention strategies towards VAE prevention bundles. [PUBLICATION] 52 references Source: BNI 37.Title: Why Are We Prolonging QT Interval Monitoring? Citation: Dimensions of Critical Care Nursing, May 2015, vol. 34, no. 3, p. 130-133, 0730-4625 (May 2015) Author(s): Barrett, Trina Abstract: Background: At present, monitoring of the QT interval (QTI) is not a standard practice in the medical intensive care unit setting, where many drugs that prolong the QTI are administered. This literature review looked at the current research for evidence-based standards to support QTI monitoring of patients with risk factors for QTI prolongation, which can result in life-threatening arrhythmias such as torsade de pointes. Objective/Aim: The objective of this article is to establish the existence of evidence-based standards for monitoring of the QTI and to raise awareness in the nursing profession of the need for such monitoring among patients who are at high risk for prolonged QTI. Method: To determine whether published standards for QTI monitoring exist, a search was conducted of the bibliographic databases CINAHL, EBSCOhost, Medline, PubMed, Google Scholar, and the Cochrane Library for the years 2013 and 2014. Also, a survey was conducted to determine whether practice standards for QTI monitoring are being implemented at 4 major hospitals in the Memphis area, including a level 1 trauma center. Results: The database search established the existence of published guidelines that support the need for QTI monitoring. Results of the hospital survey indicated that direct

care nurses were not aware of the need to identify high-risk patients, drugs with the potential to prolong QTI that were being administered to their patients, or evidence-based standards for QTI monitoring. Discussion: Review of the research literature underscored the need for QTI monitoring among high-risk patients, that is, those with genetic conditions that predispose them to QTI prolongation, those with existing cardiac conditions being treated with antiarrhythmic medications, or those who are prescribed any new medication classified as high risk on the basis of clinical research. This need is especially crucial in intensive care unit settings, where many antiarrhythmic medications are administered. [PUBLICATION] 10 references Source: BNI NHS Evidence |

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