R&R In The FASTLANE 054

Welcome to the 54th edition of Research and Reviews in the Fastlane. R&R in the Fastlane is a free resource that harnesses the power of social media to allow some of the best and brightest emergency medicine and critical care clinicians from all over the world tell us what they think is worth reading from the published literature.

This edition contains 10 recommended reads. The R&R Editorial Team includes Jeremy Fried, Nudrat Rashid, Soren Rudolph, Anand Swaminathan and, of course, Chris Nickson. Find more R&R in the Fastlane reviews in the : Overview; Archives and Contributors

This Edition’s R&R Hall of Famer

Van Zanten AH, et al. High-Protein Enteral Nutrition Enriched With Immune-Modulating Nutrients vs Standard High-Protein Enteral Nutrition and Nosocomial Infections in the ICU: A Randomized Clinical Trial. JAMA2014; 312(5): 514-524. PMID:25096691

• The MetaPlus study compared high-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition in the critically ill. Results showed that the addition of immune modulating nutrients was not associated with a reduction in infectious complications or other assessed clinical end points. In addition to this there is a suggestion of harm from the increased adjusted mortality at 6 months.
• Recommended by: Nudrat Rashid

Ebrahim S, et al. Reanalyses of randomized clinical trial data. JAMA. 2014; 312(10): 1024-32. PMID: 25203082

• These authors looked at RCTs that were followed by a published re-analysis of the data. A whopping 35% of the studies had different findings about the type of patient who should be treated. Of note, compared with the number of RCTs in the literature, only a few re-analyses (n=36) were published; however most (n=31) were published by the same research group…meaning maybe these authors don’t agree with themselves? Either that or we should be wary of the way statistics are used to paint a selective picture…
• Recommended by: Lauren Westafer
• Read More: Are a Third of Research Conclusions Wrong? (emlitofnote)

Guyton AC. Regulation of cardiac output. Anesthesiology. 1968; 29(2): 314-26. PMID: 5635884

• The modern emphasis on echo might make you think that the heart determines cardiac output. This classic paper by Guyton shows that unless the heart is failing, it has a permissive role in determining cardiac output. The real determinants are (1) the degree of vasodilation of the peripheral vasculature, especially veins, and (2) the filling of the circulatory system, indicated by the mean systemic filling pressure. Gotta love those Guyton curves!
• Recommended by: Chris Nickson

Slaughter SR et al. FDA approval of doxylamine-pyridoxine therapy for use in pregnancy. NEJM 2014; 370(12): 1081-3. PMID: 24645939

• Great editorial on the history and politics of the re-introduction of doxylamine-pyridoxine for N/V of pregnancy in the U.S
• Recommended by: Jeremy Fried

Rodriguez L et al. Evidence-based protocol for prophylactic antibiotics in open fractures: Improved antibiotic stewardship with no increase in infection rates. J Trauma Acute Care Surg 2014; 77(3): 400-8. PMID: 25159242

• Standard treatment for open fractures with significant tissue damage is variable but typically involves a 1st generation cephalosporin and an aminoglycoside. This study looks at infection rates before and after implementation of an evidence based protocol for prophylactic antibiotics in open fractures. The authors show a decrease in aminoglycoside use without an increase in infection rate. Ceftriaxone was substituted so the impact to antibiotic resistance is questionable.
• Recommended by: Anand Swaminathan

Meaney PA et al. Cardiopulmonary resuscitation quality: improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. 2013; 128(4): 417-35. PMID:23801105

• Great overview on how to improve CPR performance both inside and outside the hospital.  This group has made excellent recommendations which are nicely summarised in a table as well as giving directions for the future to close existing gaps in knowledge.
• Recommended by: Søren Rudolph

Cavender M, Sabatine MS. Bivalirudin versus heparin in patients planned for percutaneous coronary intervention: a meta-analysis of randomised controlled trials. Lancet 2014; 384(9943): 599-606. PMID: 25131979

• Bivalirudin is a direct thrombin inhibitor that has been used as an alternate therapy to heparin in patients undergoing PCI. In this meta-analysis of randomized controlled trials, the authors found that a bivalirudin-based regimen increases the risk of myocardial infarction and stent thrombosis in comparison to heparin. Bleeding was lower but the included studies had variable use of clopidogrel (mainly given with heparin). More evidence that expensive therapies are not necessarily better ones.
• Recommended by: Anand Swaminathan

Hocker, SE et al. Indicators of Central Fever in the Neurologic Intensive Care Unit. JAMA Neurol. 2013;70(12):1499-1504. PMID: 24100963

• Fever is common in this subgroup of patients. The authors provide a reliable model to differentiate central from infectious fever thus helping clinicians in selecting those patients that would not be harmed from stopping antibiotics. Blood transfusion, absence of infiltrate on chest x-ray, diagnosis of subarachnoid haemorrhage, intraventricular haemorrhage or tumour; and onset of fever within 72 hours of hospital admission were independent predictors of central fever.
• Recommended by: Nudrat Rashid

Wang CH et al. The effect of hyperoxia on survival following adult cardiac arrest: A systematic review and meta-analysis of observational studies. Resuscitation. 2014. PMID: 24892265

• A review and meta analysis looking at the impact of hyperoxia in arrest patients after ROSC is achieved. Limited by the heterogeneity of the studies, an association was found between hyperoxia and increased in hospital mortality. While we will likely never have the RCT examining this issue, this hints at what we know from many other disease states…there can definitely be too much of a good thing.
• Recommended by: Jeremy Fried

Oostdijk EN, et al. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUs: A Randomized Clinical Trial. JAMA. 2014; 312(14): 1429-1437. PMID: 25271544

• The Dutch are at it again showing that application of Selective decontamination of the digestive tract (SDD) and selective oropharyngeal decontamination (SOD) throughout the intensive care unit was associated with low levels of antibiotic resistance but no differences in day-28 mortality.
• Recommended by: Nudrat Rashid