fficm hot topics feb 26th 2014
DESCRIPTION
FFICM Hot Topics 2014 talk given by Rob Mac Sweeney on Feb 26th 2014 at the National FFICM Preparation Day in LondonTRANSCRIPT
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.