fficm hot topics feb 26th 2014
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Hot Topics.
FFICM Preparation Day London February 26th 2014
Rob Mac Sweeney
Critical Care Literature
• >300 Journals• Major Studies• Major Guidelines• Relevant Review Articles• Commentaries• Editorials• Supplements
• Free Material
Conflict of Interest Statement
•Not for profit site•Completely independent• I make no money from it
Hot Topics
• 2013 • 2012
• Major Research• Major Guidelines• Resources
Major Research Studies2013
TTM Study
• Randomized, parallel group study• 950 unconscious adults• 33°C (n=473) with 36°C (n=466)• No difference in• All cause mortality
• 33°C (50%) with 36°C (48%)• poor neurological function
• 33°C (54%) with 36°C (52%)
Kim Study
• Randomized, parallel group study• Prehospital cooling vs. standard care• 1,359 OOHCA patients• Cooling effective (reduced temp)• No difference• Survival to hospital discharge
• VF 63% vs 64% • nonVF 19% vs 16%
• Good neurological recovery• VF 57% vs 62% • nonVF 14% vs 13%
CATIS Study
• Randomized, parallel group study• 4,071 patients • Within 48 hrs ischemic stroke • nonthrombolysed and ↑SBP• Hypertension therapy vs no BP Rx• BP control effective• No difference• death and major disability
• 14 days / hospital discharge• 3 months
INTERACT2
• Randomized, controlled parallel group study• 2,839 pts with early spontaneous
intracerebral haemorrhage & ↑SBP• Compared SBP <140 mmHg vs <180• Aggressive BP control associated with• Trend for less adverse events (p=0.06)• Lower modified Rankin scores
• No difference in mortality
CRISTAL Study
• Randomized, stratified, open label, assessment blinded study• Any crystalloid vs any colloid• All fluid interventions other than fluid
maintenance in ICU• No difference• 28 day mortality (Col: 27% vs Cry: 25.4%)
• Colloids associated with improved• 90 day mortality• Days alive without mechanical ventilation• Days alive without vasopressor support
TracMan
• Randomized, parallel group study• 909 intubated patients • Respiratory failure• < 4 days• Predicted to need MV for further 7 days
• Tracheostomy timing• Early (≤ 4 days) vs late (after 10 days)• No difference in • Mortality / ICU LOS / Complications
• Only 45% late group received trache
β Blockade in Septic Shock
• Randomised, open-label, phase 2 study• 154 septic patients• Tachycardic & requiring high dose NA• Esmolol (HR 80 – 94) vs standard Rx• Esmolol effective at HR control• Esmolol associated with improved:• HR / SVI / LVSWI / lactate• NA requirement• Fluid requirement• 28 day mortality (49% vs 80%)
STATIN-VAP Study
• Randomized, controlled, blinded, parallel-group, multi-center trial• 300 patients with suspected VAP • Simvastatin 60 mg vs placebo• Study stopped early for futility• No difference in • 28 mortality• Duration mechanical ventilation• Δ SOFA
• Increased mortality in statin naïve• 21.5% vs 13.8%; p=0.054
VSE Study
• Randomized, double-blind, placebo-controlled, parallel-group trial• 268 pts with in-hospital cardiac arrest• Adrenaline/Vasopressin/
Methylprednisolone acutely & hydrocortisone later• VSE associated with improved
• ROSC (84% vs 66%)• Survival with good neurological recovery
(14% vs 5%)• Survival with good neurological recovery in
those with post resuscitation shock (21% vs 8%)
PROSEVA
• Randomised, multi-centre, parallel group study• 466 patients with severe ARDS• Prone position vs supine position• Prone position was associated with• Improved mortality
• 28 day: 16% vs 33%• 90 day: 23.6% vs 41.0
• Less cardiac arrests• No difference in complications
VILLANEAU
• Randomised, parallel group study• 921 pts with severe upper GI bleeding• Compared restrictive (Hb <7g/dL) vs
liberal transfusion strategy (Hb<9g/dL)• Restrictive strategy associated with• Reduced number of pts receiving
transfusion (15% vs 51%)• Increased probability survival (HR 0.55)• Less rebleeding (10% vs 16%)• Less adverse events (40% vs 48%)
REDOXS
• Randomised, blinded, 2x2 factorial study• 1,223 critically ill pts with MOF• Glutamine, antioxidants & placebo• Glutamine associated with harm
• Increased mortality• Trend at 28 days (34% vs 27%; p=0.05)• Increased at 90 days (44% vs 37%; p=0.02)
• Antioxidants ineffective• Mortality• Other endoints
OSCILLATE
• Multi-centre, randomised, controlled, parallel group, trial• 548 pts with new-onset, moderate-
to-severe ARDS• Trial terminated early• Excess mortality 47% vs 35%; RR 1.33• HFOV associated with• Higher sedation requirements• More neuromuscular blockade• Higher vasopressor support
OSCAR
• Multi-centre, randomised, controlled, parallel group, trial• 795 pts moderate-to-severe ARDS• No difference in• Mortality 41% vs 41%• Duration antimicrobial agents• Duration pharmacological vasoactive
support• ICU LOS• Hospital LOS
CRICS
• Randomized, noninferiority, open-label, multicenter study• 452 pts receiving
• Mechanical ventilation > 2 days• Enteral nutrition within 36 hours of MV
• Monitoring gastric volume or not• No difference in
• VAP (15.8% vs 16.7%)• Other ICU-acquired infections• Duration MV / ICU LOS / Hospital LOS
• Higher proportion reached calorific goal (OR 1.77)
SUNSET-ICU
• Single-centre, block, randomised trial• Resident nighttime intensivist vs non-
resident nighttime intensivist• Resident nighttime intensivist not
associated with improvements in• ICU LOS• Mortality• Other endpoints
Early Parenteral Nutrition
• Randomised, single-blinded, parallel group study• Early PN in patients with relative
contraindications to early EN versus early starvation• 1,372 patients• Standard group: 40 % unfed• Nutritional delivery difference until D7• No difference in • 60 day mortality • LOS – ICU or Hospital
• PN - Shorter duration ventilation
Prasad – Medical Reversal
• Retrospective observational study• Looked at 10 years of NEJM
publications• Medical reversals – current practice
inferior to a prior standard• 146/363 studies• 40%
Neurological
• Shehabi. Sedation depth and long-term mortality in mechanically ventilated critically ill adults: a prospective longitudinal multicentre cohort study (SPICE study). Intensive Care Med 2013;39(5):910-918• Page. Effect of intravenous haloperidol on the duration of delirium
and coma in critically ill patients (Hope-ICU): a randomised, double-blind, placebo-controlled trial. Lancet Respiratory Medicine 2013;epublished August 21st• Mourvillier. Induced Hypothermia in Severe Bacterial Meningitis: A
Randomized Clinical Trial. JAMA 2013;epublished October 8th
Circulatory
• Mylotte. Primary Percutaneous Coronary Intervention in Patients With Acute Myocardial Infarction, Resuscitated Cardiac Arrest, and Cardiogenic Shock. The Role of Primary Multivessel Revascularization. J Am Coll Cardiol Intv 2013;6(2):115-125• Mahjoub. Evaluation of pulse pressure variation validity criteria in
critically ill patients: a prospective observational multicentre point-prevalence study. Br J Anaesth 2013;epublished December 29th
Respiratory
• Goodacre. Intravenous or nebulised magnesium sulphate versus standard therapy for severe acute asthma (3Mg trial): a double-blind, randomised controlled trial. Lancet Respiratory Medicine 2013;epublished May 17th• Hernandez. The effects of increasing effective airway diameter on weaning from
mechanical ventilation in tracheostomized patients: a randomized controlled trial. Intensive Care Med 2013;epublished March 8th• Figueroa-Casas. Accuracy of the chest radiograph to identify bilateral pulmonary
infiltrates consistent with the diagnosis of acute respiratory distress syndrome using computed tomography as reference standard. J Crit Care 2013; epublished April 5th• Thille. Comparison of the Berlin Definition for Acute Respiratory Distress Syndrome
with Autopsy. Am J Respir Crit Care Med 2013;epublished January 31st
Infection Control
• Harris. Universal Glove and Gown Use and Acquisition of Antibiotic-Resistant Bacteria in the ICU: A Randomized Trial. JAMA 2013;epublished October 4th• Huang. Targeted versus Universal Decolonization to Prevent ICU Infection.
N Eng J Med 2013;epublished May 29th• Climo. Effect of Daily Chlorhexidine Bathing on Hospital-Acquired
Infection. N Engl J Med 2013;368:533-542
Sepsis
• Bernard. Evaluating the Efficacy and Safety of Two Doses of the Polyclonal Anti-Tumor Necrosis Factor-[alpha] Fragment Antibody AZD9773 in Adult Patients With Severe Sepsis and/or Septic Shock: Randomized, Double-Blind, Placebo-Controlled Phase IIb Study. Crit Care Med 2013;epublished December 11th
• Opal. Effect of Eritoran, an Antagonist of MD2-TLR4, on Mortality in Patients With Severe Sepsis: The ACCESS Randomized Trial. JAMA 2013;309(11):1154
• Annane. Recombinant Human Activated Protein C for Adults with Septic Shock: a Randomized Controlled Trial (APROCCHSS Trial). Am J Respir Crit Care Med 2013; epublished March 22nd
• Guntupalli. A Phase 2 Randomized, Double-Blind, Placebo–Controlled Study of the Safety and Efficacy of Talactoferrin in Patients With Severe Sepsis. Critical Care Medicine 2013;41(3):706-716
• Kruger. A Multicentre Randomised Trial of Atorvastatin Therapy in Intensive Care Patients with Severe Sepsis. Am J Respir Crit Care Med 2013;epublished ahead of print
Miscellaneous
• Marik. Does the Central Venous Pressure Predict Fluid Responsiveness? An Updated Meta-Analysis and a Plea for Some Common Sense. Critical Care Medicine 2013;41(7):1774-1781• Schnell. Renal Perfusion Assessment by Renal Doppler During Fluid
Challenge in Sepsis. Crit Care Med 2013;41(5):1214-1220• Cooper. Albumin Resuscitation for Traumatic Brain Injury: Is Intracranial
Hypertension the Cause of Increased Mortality? J Neurotrauma 2013; epublished March 21st• Casaer. Role of Disease and Macronutrient Dose in the Randomized
Controlled EPaNIC Trial. Am J Respir Crit Care Med 2013;187:247-255
Podcasts
Major Guidelines2013
Surviving Sepsis Campaign
Pain, Analgesia & Delirium
Trauma Haemorrhage
Difficult Airway
Difficult Airway
Difficult Airway
Acute Pancreatitis
Red Cell Transfusion
Red Cell Transfusion
Red Cell Transfusion
Canadian Nutrition Guideline
Major Research Studies2012
EN vs EN & PN
• Two-centre, randomized controlled, parallel group study• 305 critically ill patients • Day 3 & received <60% calorific goal• EN plus PN to achieve 100% calorific
target vs EN alone• EN plus PN was associated with• Greater calorific intake: 28 vs 20
kcal/kg• Less infection: 27% vs 38%
Best TRIP
• Randomised, controlled trial• 324 pts with severe traumatic brain
injury• ICP guided vs clinical and imaging
guided management• No difference in• Composite of functional & cognitive
measures• 6 month mortality (ICP 39% vs C&I: 41%)• Length of stay
• Imaging clinical group received more days of brain specific therapies
CARRESS
• Randomised, parallel group study• 188 pts with acute decompensated
heart failure• Stepped pharmacological therapy vs
ultrafiltration• Greater creatinine rise with UF• +20.3±61.9 μmol/l vs −3.5±46.9 μmol
• No difference in weight loss• - 5.5±5.1 kg vs - 5.7±3.9 kg
• More complications with UF• 72% vs. 57%
SLEAP Study
• Randomised, controlled, parallel group study• 423 mechanically ventilated pts• Protocolised sedation vs protocolised
sedation plus daily sedation break• No difference in• Time to extubation• ICU LOS / Hospital LOS• Delirium / Unintended extubations
• Daily break in sedation associated with• more sedation / nursing interventions
CHEST study
• Randomised, controlled, parallel group study• 7000 ICU pts• Fluid resuscitation with 6% HES
130/0.4 (Voluven) or 0.9% saline• No differences in• Mortality (HES 18% vs 17%)• LOS – ICU / Hospital
• HES associated with increased• RRT (7% vs 5.8%; RR 1.21)• Pruritus / Rash / Hepatic failure
6S Study
• Randomised, controlled, multicentre, parallel group study• 804 ICU pts with severe sepsis• Compared fluid resuscitation • 130/0.4 hydroxyethyl starch (tetraspan)
vs Ringer's acetate
• HES associated with• Increased 90 day mortality (51% vs 43%)• Increased RRT requirement (22% vs
16%)• Trend for increased bleeding (10% vs
6%, p=0.09)
IABP-II Study
• Randomised, open-label, multicentre, parallel group study• 600 pts with acute MI & cardiogenic
shock• IABP vs no IABP• No difference in• 30 day mortality (IABP 40% vs 41%)• Time to haemodynamic stabilisation• ICU LOS• Catecholamine therapy• Bleeding or other comlications
PROWESS SHOCK Study
• Randomised, controlled, multicentre, parallel group study• 1,697 patients with septic shock• No difference in• 28 day mortality (APC 26.4% vs 24.2%)• 90 day mortality (34.1% vs 32.7%)
• No subgroup effect seen
Berlin Definition of ARDS
MASH-2
• Randomised, placebo-controlled, multicentre, parallel group study• 1,204 pts within 4 days of
aneurysmal SAH• MgSO4 (64 mmol/day) ve placebo• No difference in• Functional outcome• 90 day mortality (MgSO4 26% vs 25%)
PRODEX / MIDEX
• Two phase 3, non-inferiority RCTs• MIDEX (n=500)• Dexmedetomidine associated with
• Decreased duration of ventilation• Increased patient interaction• Increased hypotension & bradycardia
• No difference in• time at target sedation• ICU LOS / Hospital LOS / mortality
PRODEX / MIDEX
• PRODEX (n=437)• Dexmedetomidine associated with • Increased patient interaction
• No difference in• time at target sedation• Duration mechanical ventilation• ICU LOS / Hospital LOS / mortality
Fever Control in Sepsis
• Randomised, multi-centre, parallel group trial• 200 pts with septic shock requiring
vasopressors• External cooling (36.5 to 37°C) vs not• Cooling effective (36.8 C vs 38.4)• Cooling was associated with• Early 50% reduction in vasopressor
requirement (54% vs. 20%)• Greater ICU shock reversal (86 vs. 73%)• Improved 14 day mortality (19 vs. 34%)
EDEN
• Randomized, open-label, multi-centre, parallel group study• 1000 patients ≤ 48 hrs of ALI & MV• Initial trophic EN vs initial full EN• Trophic feeding Δ -900 kcal/day• No difference in
• Ventilator free days• 60 day mortality• Infectious complications
• Full EN associated with• More vomiting / greater residual gastric
volumes / prokinetic use / constipation
LIFENOX
• Randomised, placebo-controlled, parallel group study• 8,307 acutely ill medical patients with
graduated compression stockings• subcutaneous enoxaparin (40 mg
daily) vs. placebo• No difference• 30 day mortality (4.9% versus 4.8%)• Bleeding (0.4% versus 0.3%)
BALTI-2
• Randomised, placebo-controlled, parallel group study• 326 pts with ARDS• salbutamol (15 μg/kg/h) vs. placebo• Trial stopped early for safety• Increased mortality 34% vs 23%• Risk ratio 1.47
Major Guidelines2012
KDIGO AKI Guideline
ESICM Colloids Guideline
STEMI Guideline
STEMI Guideline
Heart Failure Guideline
Other Resources
Other Resources
• Podcasts• Vodcasts• Journals• Websites• Societies• Guidelines• Practice Questions
Tips
• ICS guidelines• Brainstem testing• Staffing levels
• NICE guidelines• AKI
• AAGBI• NAP • Airway• Tracheostomy care
Good Luck.
rob@criticalcarereviews.com
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