Top Papers in Critical Care 2013
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Top Papers in Critical Care2013
Janna Landsperger RN, MSN, ACNP-BC
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Cardiac Endocrine Function
• Background: Epi reduces cerebral blood flow. Vasopressin avoids the negative effects on cerebral blood flow. Steroids in CA may decrease cerebral edema and systemic inflammation
• Basic Approach: 3 center, randomized, double-blind, placebo-controlled trial. Does combined vasopressine-epi during CPR + steroids improve survival and cerebral performance category as compared to epinephrine alone?
Mentzelopoulos S, JAMA 2013
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Cardiac Endocrine Function• Results: 268 patients enrolled and completed trial over a
2 y period in 3 centers in Greece• Patients in VSE group had a higher probability for ROSC
for 20 minutes or longer• VSE patients received less epi and had shorter ACLS • Duration of MV and hospital LOS was similar • Patients receiving combination of VSE had improved
survival to hospital discharge (13.9% vs 5.1%) and favorable neurological status compared to control
• Conclusion: Improved survival to hospital d/c with favorable neurological status. Should ACLS change?
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Cardiac Endocrine Function
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Septic Shock
• Background: Septic shock, tachycardia and vasoconstriction occur to compensate for systemic vasodilation. Tachycardia is persistent after treatment of pain, hypovolemia, and fever and is associated with AE. Basic Approach: Present prospective observational clinical study examined the effects of reducing HR in septic shock patients by using esmolol to see if cardiovascular performance is impoved
Morelli A, CCM 2013
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Septic Shock• Results: 25 patients requiring norepi to maintain MAP >
65 and a HR > 95 were treated with a continuous infusion of esmolol for goal HR 80-94
• Compared with baseline, HR and CI were significantly decreased after 24 h esmolol therapy
• Norepi requirements were significantly reduced (0.53 vs 0.41µg/kg/min) after 24 h of esmolol therapy
• Esmolol, arterial pH and Pao2 were higher and PaCo2 lower
• Microvascular flow index significantly increased from median 2.8 to 3.0
• Conclusion: Controlling HR may decrease myocardial demand. More patients needed.
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Septic Shock
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Trauma Resuscitation
• Background: Hemorrhage is the leading cause of death in trauma patients. ATLS recommends starting resuscitation with crystalloids, followed by PRBC. Don’t give FFP until labs are completed confirming coagulopathy or 4 PRBC are administered.
• Basic Approach: Observational prospective cohort study. Examined database of patients who required MT within 24 h of admission.
Kutcher, JAMA Surg 2013
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Trauma Resuscitation• Results: Data collected from 174 critically injured trauma
patients over a 6 y study period in a single center• Patients received a median of 6.1L of crystalloid, 13u of
RBCs, 10u of FFP, and 1u of plt in 24 h• Mean 24 h crystalloid volume and number of blood
product given in the first 24 h decreased significantly• The RBC:FFP ratio decreased from a peak of 1.84:1 in
2007 to 1.55:1 in 2011• Decrease of 0.1 achieved in the MT protocol was
associated with a 5.6% reduction in mortality• Conclusion: Best practice elusive? RCT challenging.
Restricted crystalloid, more FFP
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Trauma Resuscitation
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Traumatic Brain Injury
• Background: ICP monitoring is currently standard of care for patients with severe TBI however there is inadequate evidence of efficacy.
• Basic Approach: Multi-center, parallel-group trial, with randomized assignment to ICP monitoring or imaging + clinical examination
Chesnut, R NEJM 2012
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Traumatic Brain Injury• Results: 298 patients were randomized and followed for
6 m at 6 centers in 2 South American Countries over a 3 y study period
• No significant difference in the primary outcome (composite measure based on 21 measure of functional and cognitive status)
• 6 m mortality was 41% in the control group and 39% in the pressure monitoring group
• Median ICU LOS similar, number of AE similar• Conclusion: Similar primary outcome and mortality. If it
is not proven to be superior, do we need to keep doing it?
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Traumatic Brain Injury
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ReferencesMentzelopoulos, S et al. Vasopressin, epinephrine, and steroids and neurologically favorable survival after in-hospital cardiac arrest. JAMA. 2013;310(3):270-279
Morelli, A et al. Microvascular Effects of Heart Rate Control With Esmolol in Patients With Septic Shock: A Pilot Study. Critical Care Medicine. 2013 41(9)
Kutcher, M et al. A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices. JAMA Surgery 2013.
Chesnut, R, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. NEJM. 2012. 367(26).