Paper reports overview: Sepsis, insulin and noninvasive ventilation

This commentary reflects on the paper reports published in the Critical Care Forum between 6 November 2001 and 8 January 2002

The paper reports presented here reflect the current leading issues in the intensive care literature, the search for the 'magic bullet' in sepsis being an obvious example. Many of the trials in sepsis that are currently being reported were presented at recent conferences [1]. This is the case for the KyperSept Antithrombin III Study [2]. The summary of this paper highlights the disappointment of the study: "ATIII [antithrombin III] joins a long list of promising experimental agents for sepsis that failed to show a significant benefit in a multicentre, randomised phase III clinical trial."

Although some success has been reported with 'magic bullet' studies [3], the paper by Rivers and colleagues [4] puts these to shame by demonstrating a superlative outcome benefit with essentially good early resuscitative care in severe sepsis and septic shock. Goal-directed therapy in the emergency department for patients with severe sepsis and septic shock improved survival from 46.5% (control) to 30.5% (goal-directed therapy). This was achieved by targeting central venous saturation – an investigation that could easily be performed in most modern emergency departments – and the resultant treatment was by no means complicated or expensive: increased fluids and/or blood, and occasionally dobutamine for inotropic support. That study mirrors the already impressive and abundant evidence for goal-directed therapy in another patient population – the high-risk surgical patient [5]. It is incredible, yet disconcerting, that a relatively basic but successful and cheap treatment for the high risk or critically ill patient is not current practiced in many intensive care units. However, the expensive practice of magic bullets will no doubt be enthusiastically received, despite the fact that the results are far less impressive. The report of Rivers and colleagues [4] emphasizes the enormous benefits that may be achieved by early, good, basic critical care management.

The benefits of noninvasive ventilation once again feature prominently in our paper reports [6]. Patients with acute hypoxaemic respiratory failure following lung resection were randomized to standard care with or without nonintermittent positive pressure ventilation. Not surprisingly, the need for extubation was significantly higher in the control group, as was hospital and 120-day mortality. It would be interesting to know whether this mortality benefit remained significant if the randomization had been to nonintermittent positive pressure ventilation versus invasive ventilation.

Hormone therapy has always been popular in the critically ill, and one report [7] investigated intensive insulin therapy in nondiabetic surgical and critically ill patients. Crude hospital mortality was 7.2% in the intensive therapy group versus 10.9% in the control group (P = 0.01), and this benefit was associated with a 46% reduction in bloodstream infections.

Finally a Canadian study [8] derived the 'Canadian C-spine rule' in order to allow more selective and specific ordering of C-spine X-rays in trauma patients who are alert and stable. The derived rule had a sensitivity of 100% and specificity of 42.5%.

As was highlighted in the first paper report overview published back in November 1999 [9], there has been an exponential growth in the amount of literature specific to intensive care and related fields. "This is set against the background of an ever-increasing service commitment and so time is at a premium to reflect on important breakthroughs in the literature," it said. Our paper reporters, who are few in number as compared with the amount of evidence based literature out there, are not immune to these time constraints. If you, the reader, would like more papers critiqued, or even to join our 'merry band of reporters', contact us on http://editorial@ccforum.com.