Top Papers in Critical Care 2013
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Transcript of Top Papers in Critical Care 2013
Top Papers in Critical Care2013
Janna Landsperger, RN, MSN, ACNP-BC
Delirium
• Background: Sedation for MV has AE including delirium, prolonged MV, PTSD. Dex may enhance patient safety, lead to earlier extubation, and reduce delirium
• Basic Approach: Phase 3 multi-center randomized, double-blind study compared midazolam with dex (MIDEX) and propofol with dex (PRODEX)
Jakob SM, JAMA 2012
Delirium • Results: 500 patient randomized to each arm of the trial• Dex was not inferior to midazolam and propofol in
maintaining target RASS• Dex reduced duration of MV compared with midazolam
(123 h vs 164 h) but not with dex vs proporfol• Dex improved patients’ ability to communicate pain
compared to midazolam and propofol• More AE including hypotension and bradycardia were
associated with dex• Conclusion: Continuous benzo infusions are probably
not the best; find out what works for each for individual patient and use it
Delirium
Seizure
• Background: HOS lead to increased intensity of medical care and prolonged hospitalizations. No guidelines currently available for mgmt of HOS
• Basic Approach: Retrospective medical record review designed to describe demographic and clinical characteristics of patients with HOS and explore current practices in mgmt
Fields MC, JAMA NEURO 2013
Seizure• Results: 3345 charts, 218 patients identified within study
period (1 y)• Of patients with HOS, 64% had no history of seizure.• Seizures recurrent in 61% of patients during same stay• Stroke, metabolic derangement, and brain tumor most
common etiologies• Phenytoin was the most common AED used• Mortality rate 14%• 34% of those discharged did not receive an AED at d/c• Conclusion: HOS are common, are typically recurrent,
and are associated with a high mortality.
Seizure
Ischemic Stroke
• Background: IV t-PA is the only reperfusion tx for acute ischemic stroke. Endovascular therapy recanulizes occlusions in large arteries more rapidly than IV t-PA and is being used with increasing frequency
• Basic Approach: Phase 3, randomized, open-label clinical trial with a blinded outcome to test approach of IV t-PA followed by endovascular treatment compared with standard IV t-PA Broderick JP, NEJM 2013
Ischemic Stroke• Results: Plan to enroll 900 at 58 centers. Stopped for
futility after 656 participants• No significant difference in modified Rankin score
(primary end point) at 90 d according to treatment• Findings between both groups were similar for mortality
at 90 d• Safety profiles similar in the two treatment groups• Future trials of endovascular therapy should consider
time to initiation of endovascular therapy• Conclusion: Endovascular therapy is not going away
because some patients are not eligible to receive t-PA
Ischemic Stroke
Therapeutic Hypothermia
• Background: Use of TH improves survival and neurological outcomes after CA. Neurological prognostication and mortality prediction remain a challenge
• Basic approach: Retrospective analysis of post CA patients over a 6 y period
Starodub R, Resuscitation 2013
Therapeutic Hypothermia• Hypothesis: greater serum lactate clearance would be
positively associated with survival to discharge• Results: 199 patients included in study; 3 centers• No association between initial serum lactate and survival to
hospital discharge• Univariate analysis showed lactate levels at 12 h and 24
h predictive of survival to hospital discharge• For every unit increase in lactate at 12 h and 24 h, odds of
survival decreased by 19% and 23% respectively • Conclusion: Further investigation of lactate and other
biomarkers may improve ability to prognosticate outcomes in post CA patients. Or not.
Therapeutic Hypothermia
ARDS
• Background: In HFOV patients’ lungs are held inflated to maintain oxygenation. Minimizes the process of opening and collapsing the alveoli and is often used in patients who have hypoxemia despite standard approach of MV
• Basic Approach: Randomized, controlled trial of HFOV as compared with conventional MV
Ferguson, N NEJM 2013
ARDS• Results: 548 patients randomized in 39 centers in 5
countries over 1 y. Planned for 1200• HFOV group underwent HFOV for a median of 3 d• 47% of patient in the HFOV group, as compared with
35% in the control group died in the hospital • HFOV group received higher doses of midazolam than
the control (199 mg/d vs 142 mg/d) and more patients in HFOV group received neuromuscular blockers (83% vs 68%)
• More patients in HFOV group received vasoactive drugs than the control (91% vs 84%)
• Conclusion: Increased risk, no proven benefit
ARDS
GI Bleed
• Background: Acute UGIB is common. Transfusion may be lifesaving; however the safest and most effective transfusion strategy is controversial
• Basic Approach: Randomized, controlled trial assessing whether a restrictive threshold for RBC transfusion in patients with acute UGIB was safer and more effective than a liberal transfusion strategy
Villanueva, C NEJM 2013
GI Bleed• Results: 889 patients underwent randomization and
completed study in 1 center over 7 y• Further bleeding complications occurred in 10% of pts in
restrictive group vs 16% in liberal group• Hgb at 45 d was similar (11.6 vs 11.7)• 51% of pts in restrictive group compared to 14% of
patients in the liberal group received no transfusion• Mortality at 45 d and probability of mortality was
significantly lower in the restrictive group than the liberal (5% vs 9%)
• Conclusion: Less blood is probably better
GI Bleed
ReferencesDexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation. Jakob, SM, et al. JAMA. 2012 Mar 21;307(11):1151-60.
Hospital-onset seizures: an inpatient study. Fields MC, Labovitz DL, French JA. JAMA Neurol. 2013 Mar 1;70(3):360-4.
Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. Broderick, J, et al. New England Journal of Medicine 2013. March 368(10).
Association of serum lactate and survival outcomes in patients undergoing therapeutic hypothermia after cardiac arrest. Starodub, R et al. Resuscitation. 84 (2013) 1078–1082
High-frequency oscillation in early acute respiratory distress syndrome. Ferguson, N et al. The New England Journal of Medicine. 2013 Jan 22
Transfusion strategies for acute upper gastrointestinal bleeding. Villanueva, C. et al. The New England Journal of Medicine. 2013. January 3, 368(1)