Critical Care Medicine 2015


1. Ventura AM, Shieh HH, Bousso A et al. Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock. Crit Care Med. 2015 Nov;43(11):2292-302. doi: 10.1097/CCM.0000000000001260.

CONCLUSIONS: Dopamine was associated with an increased risk of death and healthcare-associated infection. Early administration of peripheral or intraosseous epinephrine was associated with increased survival in this population. Limitations should be observed while interpreting these results. PMID: 26323041

Comments: I'm not sure this is a fair comparison.  This was a low-dose of dopamine.  Not that I'm advocating for dopamine.  I think epinephrine is a better vasopressor in pediatric sepsis.  But the difference may not have been so pronounced had dopamine been dosed appropriately for more alpha stimulation.


2. Crit Care Med. 2015 Jul;43(7):1498-507. doi: 10.1097/CCM.0000000000000973.

Ultrasound-Guided Subclavian Vein Catheterization: A Systematic Review and

Lalu MM(1), Fayad A, Ahmed O, Bryson GL, Fergusson DA, Barron CC, Sullivan P,
Thompson C; Canadian Perioperative Anesthesia Clinical Trials Group.

Author information: 
(1)1Department of Anesthesiology, The Ottawa Hospital, University of Ottawa,
Ottawa, ON, Canada. 2The Ottawa Hospital Research Institute, Ottawa, ON, Canada. 
3Faculty of Medicine, The University of Ottawa, Ottawa, ON, Canada. 4Department
of Medicine, The University of Ottawa, Ottawa, ON, Canada. 5Department of
Surgery, The University of Ottawa, Ottawa, ON, Canada. 6Department of
Epidemiology and Community Medicine, The University of Ottawa, Ottawa, ON,

OBJECTIVE: Although ultrasound guidance for subclavian vein catheterization has
been well described, evidence for its use has not been comprehensively appraised.
Thus, we conducted a systematic review and meta-analysis to determine whether
ultrasound guidance of subclavian vein catheterization reduces catheterization
failures and adverse events compared to the traditional "blind" landmark method. 
All forms of ultrasound were included (dynamic 2D ultrasound, static 2D
ultrasound, and Doppler).
DATA SOURCES: Medline, Embase, Cochrane Central Register of Controlled Trials,
Cochrane Database of Systematic Reviews, and CINAHL (from inception to September
STUDY SELECTION: Randomized controlled trials of ultrasound compared to landmark
technique for subclavian catheterization in adult populations were considered.
Outcomes of interest included safety and failure of catheterization.
DATA EXTRACTION: Adverse event data were analyzed according to Peto's method and
expressed as odd ratios and 95% CIs. Failure of catheterization was analyzed with
inverse variance random effects modeling and expressed as risk ratios and 95% CI.
DATA SYNTHESIS: Six hundred and one studies were reviewed and 10 met inclusion
criteria (n = 2,168 participants). Six used dynamic 2D ultrasound (n = 719), one
used static 2D ultrasound (n = 821), and three used Doppler-guided insertion
techniques (n = 628). Overall complication rates were reduced with ultrasound use
compared to the landmark group (odd ratio, 0.53; 95% CI, 0.41-0.69). Subgroup
analysis demonstrated that dynamic 2D ultrasound reduced inadvertent arterial
puncture, pneumothorax, and hematoma formation. No difference in failure of
catheterization was noted between the ultrasound group and the landmark method
(risk ratio, 0.85; 95% CI, 0.48-1.51). Subgroup analysis of dynamic 2D ultrasound
demonstrated a significant decrease in failed catheterization (risk ratio, 0.24; 
95% CI, 0.06-0.92).
CONCLUSIONS: Ultrasound-guided subclavian catheterization reduced the frequency
of adverse events compared with the landmark technique. Our findings support the
use of dynamic 2D ultrasound for subclavian catheterization to reduce adverse
events and failed catheterization.

PMID: 25803646  [PubMed - indexed for MEDLINE]

3. Crit Care Med. 2015 Feb;43(2):439-44. doi: 10.1097/CCM.0000000000000707.

Comparison of the Full Outline of UnResponsiveness score and the Glasgow Coma
Scale in predicting mortality in critically ill patients*.

Wijdicks EF(1), Kramer AA, Rohs T Jr, Hanna S, Sadaka F, O'Brien J, Bible S,
Dickess SM, Foss M.

Author information: 
(1)1Division of Critical Care Neurology, Department of Neurology, Mayo Clinic,
Rochester, MN. 2Cerner Corporation, Vienna, VA. 3Department of Trauma and
Emergency Surgery, Borgess Medical Center, Kalamazoo, MI. 4Department of Critical
Care, Borgess Medical Center, Kalamazoo, MI. 5Department of Critical Care
Medicine, Mercy Hospital, St. Louis, MO. 6Project Management/Quality, Spartanburg
Regional Medical Center, Spartanburg, SC. 7Performance Improvement Department,
St. Mary's Medical Center, Huntington, WV. 8Intensive Care Unit, Shawnee Mission
Medical Center, Shawnee Mission, KS.

Comment in
    Crit Care Med. 2015 Feb;43(2):505-6.

OBJECTIVE: Impaired consciousness has been incorporated in prediction models that
are used in the ICU. The Glasgow Coma Scale has value but is incomplete and
cannot be assessed in intubated patients accurately. The Full Outline of
UnResponsiveness score may be a better predictor of mortality in critically ill
SETTING: Thirteen ICUs at five U.S. hospitals.
SUBJECTS: One thousand six hundred ninety-five consecutive unselected ICU
admissions during a six-month period in 2012.
DESIGN: Glasgow Coma Scale and Full Outline of UnResponsiveness score were
recorded within 1 hour of admission. Baseline characteristics and physiologic
components of the Acute Physiology and Chronic Health Evaluation system, as well
as mortality were linked to Glasgow Coma Scale/Full Outline of UnResponsiveness
score information.
MEASUREMENTS AND RESULTS: We recruited 1,695 critically ill patients, of which
1,645 with complete data could be linked to data in the Acute Physiology and
Chronic Health Evaluation system. The area under the receiver operating
characteristic curve of predicting ICU mortality using the Glasgow Coma Scale was
0.715 (95% CI, 0.663-0.768) and using the Full Outline of UnResponsiveness score
was 0.742 (95% CI, 0.694-0.790), statistically different (p = 0.001). A similar
but nonsignificant difference was found for predicting hospital mortality (p =
0.078). The respiratory and brainstem reflex components of the Full Outline of
UnResponsiveness score showed a much wider range of mortality than the verbal
component of Glasgow Coma Scale. In multivariable models, the Full Outline of
UnResponsiveness score was more useful than the Glasgow Coma Scale for predicting

CONCLUSIONS: The Full Outline of UnResponsiveness score might be a better prognostic tool of ICU mortality than the Glasgow Coma Scale in critically ill patients, most likely a result of incorporating brainstem reflexes and respiration into the Full Outline of UnResponsiveness score. PMID: 25393699

Comments: The FOUR score better assesses the brainstem than GCS, which explains why it performed better.