In the Literature

The Hospitalist. 2008 June;2008(06):

June 1, 2008 | The Hospitalist

Sunil Kripalani, MD, MSc ; Elizabeth Rice, MD ; Shelley Ellis, MD, MPH ; Kellysopko, MD ; Andrew Lenneman, MD ; Rita Paschal, MD ; Leaanne Smith, APRN, FNP-Bc

Study design: Unblinded, randomized controlled trial. Patients were randomized to standard low tidal volume ventilation with low PEEP or low tidal volume ventilation with higher PEEP (intervention group). PEEP was increased in the intervention group to attain a plateau pressure of 28-30 cm H2O

Setting: 37 intensive care units in France.

Synopsis: Though PEEP, total PEEP, and plateau pressure were considerably higher in the experimental group, there was no difference in 28-day mortality compared with the control group, 27.8% vs. 31.2% (95% CI 0.90-1.40, p=0.31). There was, however, an increase in the number of ventilator-free days (seven vs. three, p=0.04) and organ-failure-free days (six vs. two, p=0.04) in the experimental group compared with the control group. Criteria were used to evaluate patients for readiness for extubation, but the differential application of PEEP between arms may have altered the timing of these evaluations in the two arms and may be at least partly responsible for the difference in ventilator-free days.

Throughout patient recruitment, the primary end point was monitored, resulting in 18 interim analyses of the data. No statistical adjustments were made for these frequent examinations of the data.

Bottom line: The use of higher PEEP and maximum plateau pressure to increase alveolar recruitment while limiting hyperinflation results in more ventilator-free and organ failure-free days in patients with acute lung injury and ARDS. These maneuvers do not, however, alter mortality.

Citation: Mercat A, Richard JCM, Vielle B, et al. Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome. A randomized controlled trial. JAMA 2008;299(6):646-655.

CLINICAL SHORTS

Serial CRP Measures Predict Poor Outcomes in Left-sided Native Valve Endocarditis

Prospective cohort study showed the CRP level after one week of antibiotic treatment and the percentage decline in CRP level during the first week of treatment are useful predictors of serious infectious complications or death.

Citation: Verhagen DW, Hermanides J, Korevaar JC, et al. Prognostic value of serial C-reactive protein measurements in left-sided native valve endocarditis. Arch Intern Med. 2008;168(3):302-307.

Lipid-rich Inflammatory Plaque is Associated with Lower Restenosis Risk After Carotid Endarterectomy

Patients whose plaques had marked macrophage infiltration or a large lipid core had lower risk of restenosis at one year.

Citation: Hellings WE, Moll FL, De Vries JP, et al. Atherosclerotic plaque composition and occurrence of restenosis after carotid endarterectomy. JAMA 2008;299(5):547-554.

Cardiac Catheterization USE is Suboptimal in Patients with Non-ST Segment Elevation ACS

Observational study revealed about one-third of patients were not referred for catheterization, most often because their physicians felt they were “not at high enough risk,” despite TIMI score indicating intermediate to high risk.

Citation: Lee CH, Tan M, Yan AT, et al. Use of cardiac catheterization for non-ST-segment elevation acute coronary syndromes according to initial risk: reasons why physicians choose not to refer their patients. Arch Intern Med. 2008;168(3):291-296.

Utilization of ICUs, Hospice Rises Among Elders with Advanced Lung Cancer

This retrospective analysis showed an increase in ICU use in the last six months of life, from 17.5% in 1993 to 24.7% in 2002; hospice use increased from 28.8% to 49.9%.

Citation: Sharma G, Freeman J, Zhang D, Goodwin JS. Trends in end-of-life ICU use among older adults with advanced lung cancer. Chest 2008;133(1):72-78.

LMWH Prophylaxis Reduces VTE Following Ischemic Stroke

This meta-analysis of three randomized trials showed a lower risk of DVT and PE with LMWH, compared with unfractionated heparin, without an increase in bleeding events.

Citation: Shorr AF, Jackson WL, Sherner JH, Moores LK. Differences between low-molecular-weight and unfractionated heparin for venous thromboembolism prevention following ischemic stroke. Chest 2008;133(1):149-155.

No Difference in Risk for Thrombocytopenia with LMWH, Unfractionated Heparin

This meta-analysis of randomized trials showed no statistically significant difference in the incidence of heparin associated thrombocytopenia with low-molecular-weight heparin and unfractionated heparin when used in the treatment of DVT and PE.

Citation: Morris TA, Castrejon S, Devendra G, Gamst AC. No difference in risk for thrombocytopenia during treatment of pulmonary embolism and deep venous thrombosis with either low-molecular-weight heparin or unfractionated heparin. Chest 2007;132(4):1131-1139.