hot topics - fficm preparation course 230215
TRANSCRIPT
Hot Topics.
FFICM Preparation Day London February 23rd 2015
Rob Mac Sweeney
Hot Topics
•2015
•2014
•2013
•2012
•Major Research
•Major Guidelines
Major Research Studies
2015
Amato Study● Post hoc review of 9 RCTs
● Multilevel Mediation Analysis
● Functional Lung Size
● ΔP = (Pplt – PEEP) = (Vt /CRS
)
● Vt / Pplat / PEEP →ΔP
● ΔP 7 cmH20 = ↑41% mortality
● Requires validation
PROPPR● Pragmatic multicentre RCT
● 680 severely ill trauma patients
● 1:1:1 with 1:1:2 FFP / Plt / RC
● ↔ mortality:
● Day 1
● Day 30
● Reduced exsanguination deaths
● 1:1:2 group “caught up”
Chlorhexidine Bathing● Pragmatic, Cluster Randomized
Crossover study
● 9340 patients
● Once daily 2% chlorhexidine
● 2 x 10 week periods each
● ↔ in infections
● 55 vs 60
● 2.86 vs 2.90 / 1000 pt days
Major Guidelines
2015
SSAI - Fluid Resuscitation
Ascites Club
Major Research Studies
2014
ALBIOS● Multicentre Open Label RCT
● 1795 patients with sepsis / shock
● 20% albumin + crystal vs crystal
● Target serum albumin > 30g/l
● ↔ 28 day mortality
● Albumin: 31.8% vs 32%
● ↔90 day mortality
● Albumin: 41.1% vs 43.6%
ARISE ● Australian / NZ RCT
● EGDT vs Usual Care
● Rivers algorithm
● 1600 patients with septic shock
● ↔90 mortality
● EGDT 18.6% vs 18.8%
● EGDT - more fluids,
vasopressors, RC, dobutamine
ProCESS● American multicentre RCT
● Testing Rivers EGDT protocol
● EDGT vs Standard vs Usual care
● 1341 patients with septic shock
● ↔ day 60 mortality
● 21% vs 18.2% vs 18.9%
● ↔ day 90 or 1 year mortality
CALORIES ● Pragmatic, open label RCT
● Enteral vs Parenteral nutrition
● Could be fed by either route
● 2400 emergency ICU pts
● ↔ Day 30 mortality
● PN: 33.1% vs EN: 34.2%
● PN – less hypos or vomiting
- no effect on infection
CIRC ● Mechanical CPR vs Manual CPR
● USA / European - OOHCA
● 4753 randomized, 522 excluded
● ↔ROSC: 28.6% v 32.3%
● ↔24 hour survival: 21.8% v 25%
● ↔ Hosp discharge: 9.4% vs 11%
LINC ● European open label RCT
● Mechanical CPR & defibrillation
● 2589 OOHCA patients
● ↔ 4 hr survival: 23.6% vs 23.7%
● ↔ CPC 1-2 survival
● At ICU / Hospital discharge
● At 1 or 6 month
HARP-2 ● Multicentre, UK/Ireland RCT
● Simvastatin vs Placebo
● 540 patients with ARDS
● ↔ Ventilator-free days
● ↔ Non-pulmonary organ
failure -free days
● ↔28 day mortality
METAPLUS ● European multi-centre RCT
● 301 pts expected ventilated >3/7
● Immune enhancing nutrients
● High protein diet both groups
● ↔new infections (53% vs 52%)
● ↑ 6/12 mortality with IMN
● 54% vs 35%
PEITHO ● European Multi-centre RCT
● 1,006 pts intermediate risk PE
● Tenecteplase & heparin vs
placebo & heparin
● ↓ Death / CVS decompensation
2.6% vs 5.6%
● ↔Deaths: 1.2% vs 1.8%; P=0.42
● ↑Stroke: 2.4% v 0.2%; ↑ Bleeding
SEPSISPAM● Multi-centre open label RCT
● 776 pts with septic shock
● MAP 80 - 85 vs 65 – 70
● ↔D28 mortality 36.6% vs 34%
● ↔D90 mortality 43.8% vs 42.3%
● ↔ serious adverse event
● ↑ AF with higher BP
● ↑ RRT with lower BP chronic HTN
TRISS● European multi-centre RCT
● 1005 pts septic shock & anaemia
● Transfuse Hb <9 g/dl vs <7 g/dl
● Less blood given (median 4 vs 1)
● ↔D90 mortality (45% vs 43%)
● ↔ischaemia / adverse events
VITdAL-ICU● Austrian single centre RCT
● 492 white ICU pts Vit D deficient
● Vit D vs Placebo
● ↔Hosp LOS 20 vs 19 days
● ↔ Hosp / 6/12 mortality
● Severely deficient subgroup
● ↓Hosp mortality 28% vs 46%
● ↔ Hosp / 6/12 mo
Major Guidelines
2014
ESICM -Neuroprognostication
ESICM - Shock
ESC – Cardiac Tamponade
ESC – Pulmonary Embolism
ESC – Revascularization
JSICM – Sepsis
SSAI - ARDS Ventilation
ADQI – AKI Biomarkers
NICE – Acute Heart Failure
UK - CPR Guidance
CCCS - Ebola
Major Research Studies
2013
TTM Study● Multi-centre RCT
● 950 OOHCA Patients
● 33°C vs 36°C
● ↔All cause mortality
● 50% vs 48%
● ↔Poor neuro function
● 54% vs 52%
Kim Study● Prehospital cooling
● 1,359 OOHCA patients
● ↔ Survival to hosp discharge● VF 63% vs 64%
● nonVF 19% vs 16%
● ↔ Good neuro recovery● VF 57% vs 62%
● nonVF 14% vs 13%
CATIS Study● 4,071 patients
● Within 48 hrs ischemic stroke
● Nonthrombolysed and ↑SBP
● ↑ BP Rx vs no BP Rx
● BP control effective
● ↔ death and major disability
• 14 days / hosp discharge
• 3 months
INTERACT2● Early ICH & ↑SBP
● SBP <140 mmHg vs <180
● 2,839 pts
● Aggressive BP control lead to
● Trend for adverse events
● ↓modified Rankin scores
● ↔mortality
CRISTAL ● Stratified, open label RCT
● Any colloid vs any crystalloid
● 2857 pts with hypovolaemic shock
● ↔ 28 day mortality
● 25.4% vs 27%
● Less deaths with colloids at D90
● 30.7% vs 34.2%
● Less vasopressors / ventilation
TracMan
● 909 intubated patients
● Tracheostomy timing
● ≤ 4 days vs > 10 days
● ↔Mortality / ICU LOS
● ↔Complications
● Only 45% late group received trache
β Blockade in Septic Shock
● 154 septic pts with ↑HR & ↑dose NA
● Esmolol vs standard Rx
● Esmolol
● ↓ HR / lactate / Norad / Fluids
● ↑ SVI / LVSWI
● ↓ D28 mortality (49% vs 80%)
STATIN-VAP● 300 patients suspected VAP
● Simvastatin 60 mg vs placebo
● Study stopped early for futility
● ↔28 mortality
● ↔Duration MV
● ↔Δ SOFA
● ↑ mortality in statin naïve
● 21.5% vs 13.8%; p=0.054
VSE Study● 268 cardiac arrest pts● Adrenaline/Vasopressin/Methylpred
acutely & hydrocortisone later
● VSE associated with improved
● ROSC (84% vs 66%)
● Good neuro recovery
● 14% vs 5%
● 21% vs 8%
(post resuscitation shock)
PROSEVA
● 466 patients with severe ARDS
● Prone vs supine position
● Prone position associated with
● ↓ mortality D28: 16% vs 33%
● ↓ mortality D90: 24% vs 41%
● ↓ cardiac arrests
● ↔ complications
VILLANEAU• 921 pts with upper GI bleed
• Hb <7g/dL vs Hb<9g/dL transfusion
triggers
• Restrictive strategy:
• ↓ number of pts receiving
transfusion (15% vs 51%)
• ↑probability survival
• ↓ Less rebleeding / AEs
REDOXS● 1,223 pts with MOF
● Glutamine & antioxidants
● Glutamine:
● ↑ mortality
● D28 (34% vs 27%; p=0.05)
● D90 (44% vs 37%; p=0.02)
● Antioxidants ineffective
● ↔Mortality / Other endoints
OSCILLATE● 548 pts with moderate-to-severe
ARDS
● Trial terminated early
● ↑mortality 47% vs 35%
● HFOV associated with
● ↑ sedation requirements
● ↑ neuromuscular blockade
● ↑ vasopressor support
OSCAR● 795 pts with moderate-to-severe
ARDS
● ↔Mortality 41% vs 41%
● ↔Duration antimicrobials
● ↔Duration pharmacological
vasoactive support
● ↔ LOS ICU or Hospital
CRICS
● 452 ventilated pts
● Not monitoring gastric volume
•↔VAP (15.8% vs 16.7%)
•↔ ICU-acquired infections
•↔Duration MV / ICU
or Hospital LOS
• ↑calorific goal (OR 1.77)
SUNSET-ICU
● Single-centre, block, randomised trial
● Resident nighttime intensivist
● ↔ICU LOS
● ↔Mortality
● ↔Other endpoints
Early Parenteral Nutrition
● Early PN versus starvation
● 1,372 patients
● Standard group: 40 % unfed
● ↔ 60 day mortality
● ↔LOS – ICU or Hospital
● PN: ↓ duration ventilation
Reversal● Retrospective observational
● Looked at 10 years of NEJM
publications
● Medical reversals – current practice
inferior to a prior standard
● 146/363 studies
● 40%
Major Guidelines
2013
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 Studies
2012
EN vs EN & PN
● 305 critically ill patients
● Day 3 & received <60% calorific goal
● EN plus PN to achieve 100% calorific
target vs EN alone
● EN plus PN associated with
● ↑Calories: 28 vs 20 kcal/kg
● ↓ Infection: 27% vs 38%
Best TRIP● 324 pts severe TBI
● ICP guided vs clinical and imaging
guided management
● ↔ Composite of functional &
cognitive measures
● ↔ 6 month mortality (ICP
39% vs C&I: 41%)
● ↔ Length of stay
CARRESS● 188 pts with acute decompensated
heart failure
● Stepped pharmacological therapy vs
ultrafiltration
● UF: ↑complications
↑creatinine
● +20.3 vs −3.5 μmol
● ↔weight loss
● - 5.5±5.1 vs - 5.7±3.9 kg
SLEAP Study● 423 pts
● Protocolised sedation vs PS plus daily
sedation break
● ↔ Time to extubation
● ↔ ICU LOS / Hospital LOS
● ↔ Delirium / Unintended
extubations
● PS & DSB: ↑sedation / nursing
CHEST study● 7000 ICU pts
● Fluid resuscitation with
● 6% HES 130/0.4 vs 0.9% saline
● ↔Mortality (HES 18% vs 17%)
● ↔LOS – ICU / Hospital
● HES associated with increased
● ↑RRT (7% vs 5.8%; RR 1.21)
● ↑Pruritus / Rash / Liver failure
6S Study
● 804 severe sepsis pts
● Fluid resuscitation
● 130/0.4 HES vs Ringer's acetate
● HES associated with
● ↑ D90 death (51% vs 43%)
● ↑ RRT (22% vs 16%)
● ↑ bleeding (10 v 6%,p=0.09)
IABP-II Study
● 600 pts with acute MI
& cardiogenic shock
● IABP vs no IABP
● ↔D30 death (IABP 40 v 41%)
● ↔Time to CVS stabilisation
● ↔ICU LOS
● ↔Catecholamines therapy
PROWESS SHOCK Study
● 1,697 pts with septic shock
● ↔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
● 1,204 pts within 4 days of
aneurysmal SAH
● MgSO4 (64 mmol/day) vs placebo
● ↔Functional outcome
● ↔90 day mortality
● MgSO4 26% vs 25%
PRODEX / MIDEX● MIDEX (n=500)
● Dexmedetomidine v Midaz
● Dexmedetomidine:
● ↓duration ventilation
● ↑patient interaction
● ↑hypotension / bradycardia
● ↔ time at target sedation
● ↔ ICU / Hosp LOS / death
PRODEX / MIDEX
● PRODEX (n=437)
● Dexmedetomidine v Propofol
● Dexmedetomidine:
● ↑patient interaction
● ↔time at target sedation
● ↔Duration ventilation
● ↔ICU / Hosp LOS // Death
Fever Control● 200 pts with septic shock requiring
vasopressors
● External cooling (36.5 to 37°C) vs not
● Cooling was associated with
● Early ↓ vasopressors
● ↑ ICU shock reversal
● ↓ 14 day mortality
EDEN• 1000 pts early ALI
• Initial trophic EN vs full EN
● Trophic feeding Δ -900 kcal/day
● ↔Ventilator free days
● ↔60 day mortality
● ↔Infectious complications
● Full EN: ↑ GI complications
LIFENOX
● 8,307 acutely ill medical patients with
graduated compression stockings
● subcutaneous enoxaparin (40 mg
daily) vs. placebo
● ↔D30 death (4.9% vs 4.8%)
● ↔Bleeding (0.4% versus 0.3%)
BALTI-2
• 326 pts with ARDS
• salbutamol (15 μg/kg/h) vs. placebo
• Trial stopped early for safety
• ↑Mortality 34% vs 23%
● Risk ratio 1.47
Major Guidelines
2012
KDIGO AKI Guideline
ESICM Colloids Guideline
STEMI Guideline
STEMI Guideline
Heart Failure Guideline
