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Article 1
Effect of Chlorhexidine Bathing Every Other Day on Prevention of Hospital-Acquired Infections in the Surgical ICU: A Single-Center, Randomized Controlled Trial. Swan JT, Ashton CM, Bui LN, Pham VP, Shirkey BA, Blackshear JE, Bersamin JB, Pomer RM, Johnson ML, Magtoto AD, Butler MO, Tran SK, Sanchez LR, Patel JG, Ochoa RA Jr, Hai SA, Denison KI, Graviss E, Wray NP. Crit Care Med. 2016 Oct;44(10):1822-32.
In this study the authors describe a single-center, pragmatic, randomized trial to test the hypothesis comparing daily soap and water bathing versus 2% chlorhexidine gluconate bathing every other day for the prevention of four hospital acquired infections (HAIs) in SICU patients, namely catheter-associated urinary tract infection (CAUTI), ventilator-associated pneumonia (VAP), incisional surgical site infection (incisional SSI), and primary bloodstream infection (primary BSI). Patients and bedside clinicians were aware of treatment-group assignment, but investigators who determined efficacy and safety outcomes were blinded. The control arm consisted of soap and water bathing after randomization; the treatment arm consisted of bathing with chlorhexidine every other day alternating with soap and water. Patients were randomized within 48 hours of admission to the SICU to either treatment arm and bathed per protocol until SICU discharge, day 28, or death. Of 350 randomizations, 325 patients were included in the primary analysis. Treatment arms were balanced regarding age, race, prerandomization hospital course, and severity of illness (based on APACHE II scores). However, patients in the chlorhexidine arm were more likely to have kidney dysfunction, liver failure, subclavian bloodstream catheters, invasive airway at randomization, and a SICU admission status of unscheduled surgery. Patients received 83.4% of study baths and averaged six baths each (SD = 6.6; range, 0–28), which was similar (p = 0.8) between arms.
Fifty-three incident HAIs (35 with soap and water versus 18 with chlorhexidine) were detected. Compared with soap and water bathing alone, intermittent chlorhexidine bathing decreased the risk of acquiring HAIs (HR = 0.555; 95% CI, 0.309–0.997; p = 0.049) by 44% in an unadjusted primary analysis. The chlorhexidine group experienced fewer secondary outcome incidences of CAUTIs (14 vs 7), VAPs (13 vs 8), incisional SSIs (6 vs 3), primary BSIs (2 vs 0), and deaths during the study (23 vs 18), but these individual secondary outcomes were not powered and were not significantly different. Additionally, there were no differences in adverse skin occurrences between the groups.
This inexpensive, safe, and easy to implement intervention decreased the incidence HAIs in SICU patients who are expected to require at least 48 hours of ICU care.
Article 2
Pantoprazole or Placebo for Stress Ulcer Prophylaxis (POP-UP): Randomized Double-Blind Exploratory Study. Selvanderan SP, Summers MJ, Finnis ME, Plummer MP, Ali Abdelhamid Y, Anderson MB, Chapman MJ, Rayner CK, Deane AM. Crit Care Med. 2016 Oct;44(10):1842-50.
This study represents a prospective randomized double-blind parallel group study comparing patients they received pantoprazole or placebo in the Royal Adelaide Hospital ICU of South Australia, which is a referral center for trauma, neurological injuries, and burn patients. Patients who were enrolled were anticipated to be mechanically ventilated for greater than 24 hours and were receiving and enteral nutrition within 48 hours of admission. Multiple exclusion criteria were listed in the manuscript which primarily were exclusions that would make the patient at high risk for gastrointestinal bleeding. The intervention was administered as once daily dose (40mg pantoprazole or placebo) until the patient was no longer mechanically ventilated or for a maximum of 14 days.
The major outcomes of interest were clinically significant gastrointestinal bleeding, infective ventilator associated complications or pneumonia, and Clostridium difficile infection. A total of 214 patients were included in the intention to treat analysis. They were no episodes of clinically significant gastrointestinal bleeding and either group (placebo: 0/108 [upper 97.5% CIs, 3.36] vs pantoprazole: 0/106 [upper 97.5% CIs, 3.42]; overall: 0/214 [upper 97.5% CI, 1.71]). There was no difference in infective ventilator associated complications or pneumonia in the two groups as per the CDC criteria (placebo: 1/108 [0.9%; 95% CI, 0.02–5.1] vs pantoprazole: 2/106 [1.9%; 95% CI, 0.2–5.1]). Thirty patients assigned to pantoprazole and 40 patients assigned to placebo were tested for Clostridium difficile infection with one patient who received pantoprazole recording a positive sample (placebo: 0/108 [97.5% CI, 3.4] vs pantoprazole: 1/106 [0.9%; 95% CI, 0.02–5.1]).
Not a single episode of clinically significant gastrointestinal bleeding in either group was observed. Data from this study also suggest that administration of pantoprazole does not markedly increase the risk of infective ventilator-associated pneumonia or Clostridium difficile infection (a finding that contradicts previous observational studies). This study suggests when patients are receiving enteral nutrition, prophylactic pantoprazole is not beneficial nor harmful, thus challenging many institutions stress ulcer prophylaxis algorithms.
Article 3
Early initiation of extracorporeal membrane oxygenation improves survival in adult trauma patients with severe adult respiratory distress syndrome. J Trauma Acute Care Surg. 2016 Aug;81(2):236-43.
In this study, the authors describe their experience managing severe refractory hypoxic respiratory failure in trauma patients using ECMO. Severe ARDS was defined using the Berlin definition of PaO2/FIO2 of less than 100. The comparison group was made up of trauma patients treated in a one year period immediately preceding institution of ECMO for refractory hypoxia using conventional means. Namely, the initial use of both volume control and pressure control modes, maintaining lung-protective ventilation (tidal volume <= 6 mL/kg per ideal body weight [IBW]) and following ARDSNet protocol goals were used as a general guideline for oxygenation, ventilation, pH, and airway pressure management. Additional rescue maneuvers included chemical paralysis, inverse I/E ventilation, open lung ventilation, and inhaled nitric oxide. They note that prone positioning was not part of the algorithm for these patients and that the use of paralytics, inhaled nitric oxide, open lung ventilation was at the discretion of the treating intensivist and not protocolized. Despite the lack of protocol, there was no difference between these modalities used between the groups. There was also no difference in data related to age, Injury Severity Scores (ISSs), admission lactic acid levels, base deficit, the number of transfused red blood cell units within the first 24 hours, and presence of severe traumatic brain injury between the groups. Additionally, Murray Lung Injury (MLI), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores determined at the onset of severe ARDS were not different between the groups.
The major outcome of interest, which was hospital mortality, found the ECMO group had a significantly reduced mortality compared to patients managed using conventional means (ECMO 13.3% vs. CONV 64.3%, p = 0.01). Other outcomes of interest including median hospital length of stay, ICU-free days, ventilator-free days, and time from admission to the development of severe ARDS were not different between the two groups.
The authors point out that there was a short time from onset of severe ARDS to ECMO cannulation, with mean times of 1.9 days (± 1.4 days) once severe ARDS was diagnosed and maximal therapy instituted. They conclude their high ECMO survival compared to the conventionally managed group is partially dependent on this short interval, suggesting that the ability to significantly reduce high ventilator settings helped to reduce ongoing ventilator-associated lung injury and irreversible fibrosis that is normally encountered in this patient population. The authors also discuss the complications in the ECMO cohort of both hemorrhage and thrombosis which were common, but did not affect mortality.
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