Evidence-based critical care – Update 2006 Joel Peerless MD 3 January 2006
Intensivist shortage <ul><li>Experts predict that as the US population ages, the shortage of intensivists will become incr...
The old way… <ul><li>Intern/junior resident (Dr. X) was taught </li></ul><ul><li>a concept by his/her: </li></ul><ul><li>S...
The old way… <ul><li>Dr. X went on to become: </li></ul><ul><li>A senior resident </li></ul><ul><li>A chief resident </li>...
The old way…”Why do you do it that way??” <ul><li>“Well, I learned this from Dr. X” </li></ul><ul><li>“We’ve always done i...
The old way… dopamine <ul><li>Dopamine in low doses activates dopamine receptors in the kidney </li></ul><ul><li>Renal blo...
The old way… dopamine <ul><li>Dopamine is indicated for: </li></ul><ul><li>Preventing renal failure </li></ul><ul><li>Trea...
Evidence-based critical care <ul><li>THERE NOW EXISTS A MORE “SCIENTIFIC” METHOD TO PROVIDE CARE… </li></ul>
The new way… <ul><li>Try to adapt practice based on the quality of clinical studies that support the test or intervention ...
Evidence-based concepts <ul><li>The best study is: </li></ul><ul><li>Prospective </li></ul><ul><li>Randomized </li></ul><u...
Evidence-based concepts <ul><li>Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock ...
Grading system <ul><li>Grade A: At least 2 large, randomized trials with clearcut results </li></ul><ul><li>Grade B: At le...
Grading system <ul><li>Grade D: Nonrandomized, contemporaneous controls </li></ul><ul><li>Grade E: Nonrandomized, historic...
Evidence-based critical care <ul><li>VENTILATOR MANAGEMENT OF ARDS </li></ul><ul><li>Vt settings </li></ul><ul><li>Level o...
Low tidal volume strategy <ul><li>Barotrauma </li></ul><ul><ul><li>High pressure generated with flow of air into lungs </l...
Low tidal volume strategy <ul><li>Classic practice: Vt 10-15 cc/kg </li></ul><ul><li>Hypothesis: lower Vt is protective of...
Low tidal volume strategy <ul><li>When ARDS diagnosed, adjust Vt for ideal body weight </li></ul><ul><ul><li>60 kg x .6 cc...
PEEP levels in ARDS <ul><li>ARDS-net, NEJM, 2004 </li></ul><ul><li>Comparison of low and high PEEP in ARDS </li></ul><ul><...
Steroids for “late” ARDS <ul><li>Fibroproliferation can occur after 5-7 days of ARDS </li></ul><ul><li>This inflammatory p...
Steroids for “late” ARDS <ul><li>ARDS-net randomized placebo-controlled trial </li></ul><ul><li>Goal 200 patients over 6-8...
Other ARDS modalities <ul><li>We no longer consider: </li></ul><ul><li>Prone position </li></ul><ul><li>Inhaled nitric oxi...
Evidence-based critical care <ul><li>Glucose control in critically ill patients </li></ul>
Intensive insulin therapy <ul><li>NEJM, 2001, single center study </li></ul><ul><li>1,548 surgical patients </li></ul><ul>...
Intensive insulin therapy <ul><li>50% decrease in BSI, ARF requiring RRT, critical illness polyneuropathy and transfusion ...
Intensive insulin therapy <ul><li>Mayo Clin Proc, 2004 </li></ul><ul><li>800 critically ill medical-surgical patients in a...
Intensive insulin therapy <ul><li>GRADE D based on original study, (randomized but single center, mainly surgical patients...
Evidence-based critical care <ul><li>Activated protein-C in sepsis (Xigris) </li></ul>
 
 
RH Activated Protein C <ul><li>Prowess Study </li></ul><ul><ul><li>Recombinant human activated  pro tein C  w orldwide  e ...
RH Activated Protein C <ul><li>Prowess study </li></ul><ul><ul><li>1690 patients (840 placebo; 850 APC) </li></ul></ul><ul...
RH Activated Protein C <ul><li>Prowess study </li></ul><ul><ul><li>The difference in outcome was greatest in patients with...
RH Activated Protein C <ul><li>Contraindications </li></ul><ul><ul><li>Internal bleeding, hemorrhagic CVA, CHI, neurosurgi...
RH Activated Protein C <ul><li>GRADE B for patients with severe sepsis, multiple organ dysfunction, with APACHE >25 </li><...
Evidence-based critical care <ul><li>CORTICOSTEROIDS AND SEPTIC SHOCK </li></ul>
Corticosteroids and sepsis <ul><li>Old teaching: don’t give septic patients high dose steroids </li></ul><ul><li>New thoug...
Corticosteroids and sepsis <ul><li>Incidence of adrenal insufficiency </li></ul><ul><ul><li>30-50% in critically ill patie...
Corticosteroids and sepsis <ul><li>JAMA, 2002; multicenter, RCT, 300 patients </li></ul><ul><li>Septic shock, vasopressor ...
Corticosteroids and sepsis <ul><li>Nonresponders randomized to placebo vs hydrocortisone 50 mg IV every 6 hours + fludroco...
Corticosteroids and sepsis <ul><li>Should low doses of corticosteroids be used in the treatment of septic shock? </li></ul...
Evidence-based critical care <ul><li>PULMONARY ARTERY CATHETER USE IN THE ICU </li></ul>
PA catheter use in the ICU <ul><li>Old practice: any unstable patient who didn’t respond to fluids or who had possible car...
PA catheter use in the ICU <ul><li>JAMA, 2005 </li></ul><ul><li>Meta-analysis, 13 RCTs, 5051 patients </li></ul><ul><li>Us...
PA catheter use in the ICU <ul><li>RCT in progress </li></ul><ul><li>ARDS-net, 1000 patient goal </li></ul><ul><li>FACTT S...
Evidence-based critical care <ul><li>EARLY GOAL-DIRECTED THERAPY IN SEPSIS </li></ul>
Early goal-directed therapy <ul><li>“Standard” goals for sepsis (resuscitation) </li></ul><ul><ul><li>MAP  > 65 </li></ul>...
Early goal-directed therapy <ul><li>DO 2  = Hgb (SaO 2 ) x 1.34 x CI x 10 </li></ul><ul><li>“ Supranormal” goals for PAC (...
Early goal-directed therapy <ul><li>Supranormal goals disproven in  established  sepsis (NEJM x2) </li></ul><ul><li>Will t...
Early goal-directed therapy <ul><li>NEJM, 2001, Henry Ford Hospital </li></ul><ul><li>263 ED patients </li></ul><ul><li>Co...
Early goal-directed therapy <ul><li>There IS value to optimizing cardiac output, oxygen delivery and SVO 2  if you interve...
Evidence-based critical care <ul><li>ANTIBIOTICS and INFECTION CONTROL </li></ul><ul><li>WHO NEEDS TREATMENT AND FOR HOW L...
Who needs antibiotics? <ul><li>Systemic inflammatory response syndrome (SIRS) </li></ul><ul><li>Fever means  inflammation ...
Duration of antibiotic coverage <ul><li>Minimal data over duration of antibiotic usage for most infections </li></ul><ul><...
SICU antibiotic usage <ul><li>Perioperative coverage – single dose or 24 hours of coverage </li></ul><ul><li>UTI – 5 days ...
Evidence-based critical care <ul><li>VENTILATOR-ASSOCIATED PNEUMONIA </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>TREATME...
Ventilator-associated pneumonia - diagnosis <ul><li>Classic teaching: Fever, WBC, purulent sputum, + culture, infiltrate <...
Ventilator-associated pneumonia - diagnosis <ul><li>Fever/WBC, + culture without purulent sputum or CXR – NO ANTIBIOTICS <...
Ventilator-associated pneumonia treatment <ul><li>JAMA, 2003 </li></ul><ul><li>PRCDBT, 51 French ICUs, 401 patients </li><...
Ventilator-associated pneumonia prevention <ul><li>Subglottic suctioning of secretions </li></ul><ul><ul><li>Additional su...
Ventilator-associated pneumonia <ul><li>What is known </li></ul><ul><ul><li>More likely from mouth contents than from regu...
Catheter-related BSI <ul><li>Prevention – what doesn’t work </li></ul><ul><ul><li>Changing lines every three days </li></u...
Catheter-related BSI <ul><li>Prevention – what DOES work </li></ul><ul><ul><li>Subclavian site </li></ul></ul><ul><ul><li>...
 
C-difficile colitis <ul><li>Related to indiscriminate antibiotic usage </li></ul><ul><li>May occur with only a single dose...
Infection control techniques <ul><li>We  all  have the power to limit the occurrence of hospital acquired infections </li>...
Infection control techniques <ul><li>Soap and water </li></ul><ul><li>Hand disinfectant solutions : Steris product, Purell...
EBM in perspective
EBM in perspective <ul><li>We have very good data (A) </li></ul><ul><ul><li>DVT prophylaxis </li></ul></ul><ul><ul><li>Str...
EBM in perspective <ul><li>We have good data (B), but these studies can likely never be repeated </li></ul><ul><ul><li>Ear...
EBM in perspective <ul><li>We have good data (B) that will probably never get better despite further studies </li></ul><ul...
EBM in perspective <ul><li>We practice with lots of E’s – these probably can’t ethically be studied </li></ul><ul><ul><li>...
EBM in perspective – the good <ul><li>We know the quality of the data </li></ul><ul><li>Development of consensus statement...
EBM in perspective – the bad <ul><li>Extending data to non-studied or non-proven conditions: </li></ul><ul><li>Low tidal v...
EBM in perspective – the bad <ul><li>Blanket referrals to EBM: </li></ul><ul><li>PAC usage in critically ill patients : A ...
EBM in perspective: the bad <ul><li>There  are  patients with low urine output or impending renal failure secondary to  lo...
EBM in perspective – the scary <ul><li>OUTCOMES RELATED TO EVIDENCE-BASED CARE WILL BE MONITORED AND WILL BECOME A MEASURE...
EBM in perspective – keep reading <ul><li>The data may change !! </li></ul><ul><li>JAMA, July 13, 2005  </li></ul><ul><li>...
EBM in perspective – keep reading <ul><li>Studies with initially stronger effects (16%) </li></ul><ul><ul><li>Zidovudine i...
EBM in perspective – reading the literature <ul><li>Cautious use of “the literature”, “landmark” articles </li></ul><ul><u...
Summary <ul><li>We should use EBM consensus statements to keep our knowledge current </li></ul><ul><li>Reaching the highes...
Summary <ul><li>Realize that the public is watching our adherence to practice guidelines </li></ul><ul><li>Accept the fact...
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Evidence basedcritcare06

  1. 1. Evidence-based critical care – Update 2006 Joel Peerless MD 3 January 2006
  2. 2. Intensivist shortage <ul><li>Experts predict that as the US population ages, the shortage of intensivists will become increasingly acute </li></ul><ul><li>By 2020, the supply of intensivists will meet only 22% of the demand for their services </li></ul>
  3. 3. The old way… <ul><li>Intern/junior resident (Dr. X) was taught </li></ul><ul><li>a concept by his/her: </li></ul><ul><li>Senior resident </li></ul><ul><li>Chief resident </li></ul><ul><li>Fellow </li></ul><ul><li>Attending </li></ul><ul><li>Dr. X practiced what he was taught… </li></ul>
  4. 4. The old way… <ul><li>Dr. X went on to become: </li></ul><ul><li>A senior resident </li></ul><ul><li>A chief resident </li></ul><ul><li>A fellow </li></ul><ul><li>An attending </li></ul><ul><li>And taught the same concept to his/her junior resident, and so on and so on…. </li></ul>
  5. 5. The old way…”Why do you do it that way??” <ul><li>“Well, I learned this from Dr. X” </li></ul><ul><li>“We’ve always done it this way” </li></ul><ul><li>“We have good outcomes” </li></ul><ul><li>“I have an article to prove it” (more on this later…) </li></ul>
  6. 6. The old way… dopamine <ul><li>Dopamine in low doses activates dopamine receptors in the kidney </li></ul><ul><li>Renal blood flow is increased </li></ul><ul><li>Urine output is increased (sometimes) </li></ul><ul><li>The assumption, and teaching, became… </li></ul>
  7. 7. The old way… dopamine <ul><li>Dopamine is indicated for: </li></ul><ul><li>Preventing renal failure </li></ul><ul><li>Treating renal failure </li></ul><ul><li>Reversing renal vasoconstriction when vasopressors are used </li></ul><ul><li>Preventing renal failure during aortic and renal cross-clamping </li></ul><ul><li>Dopamine flowed like water (often better than urine) in ICUs worldwide </li></ul>
  8. 8. Evidence-based critical care <ul><li>THERE NOW EXISTS A MORE “SCIENTIFIC” METHOD TO PROVIDE CARE… </li></ul>
  9. 9. The new way… <ul><li>Try to adapt practice based on the quality of clinical studies that support the test or intervention – “Evidence-based” </li></ul><ul><li>A careful evaluation of existing studies </li></ul><ul><ul><li>Type of trial </li></ul></ul><ul><ul><li>Number of centers </li></ul></ul><ul><ul><li>Number of patients </li></ul></ul><ul><ul><li>Quality of the study </li></ul></ul>
  10. 10. Evidence-based concepts <ul><li>The best study is: </li></ul><ul><li>Prospective </li></ul><ul><li>Randomized </li></ul><ul><li>Double Blinded – not always possible </li></ul><ul><li>Multicenter </li></ul><ul><li>Meta-analyses evaluate a number of similar studies </li></ul>
  11. 11. Evidence-based concepts <ul><li>Surviving Sepsis Campaign Guidelines for the Management of Severe Sepsis and Septic Shock </li></ul><ul><li>11 critical care societies - international </li></ul><ul><li>Initial document: CCM March, 2004 </li></ul><ul><li>Evidence-based review: CCM supplement November, 2004 </li></ul>
  12. 12. Grading system <ul><li>Grade A: At least 2 large, randomized trials with clearcut results </li></ul><ul><li>Grade B: At least 1 large, randomized trial with clearcut results </li></ul><ul><li>Grade C: Small, randomized trials, uncertain results </li></ul>
  13. 13. Grading system <ul><li>Grade D: Nonrandomized, contemporaneous controls </li></ul><ul><li>Grade E: Nonrandomized, historical controls; case series; uncontrolled studies; expert opinion </li></ul>
  14. 14. Evidence-based critical care <ul><li>VENTILATOR MANAGEMENT OF ARDS </li></ul><ul><li>Vt settings </li></ul><ul><li>Level of PEEP </li></ul><ul><li>Use of steroids in “late” ARDS </li></ul>
  15. 15. Low tidal volume strategy <ul><li>Barotrauma </li></ul><ul><ul><li>High pressure generated with flow of air into lungs </li></ul></ul><ul><li>Volume trauma (volutrauma) </li></ul><ul><ul><li>Overdistention of alveoli can lead to further lung damage </li></ul></ul>
  16. 16. Low tidal volume strategy <ul><li>Classic practice: Vt 10-15 cc/kg </li></ul><ul><li>Hypothesis: lower Vt is protective of alveolar damage and outcome in ARDS </li></ul><ul><li>ARDS-net trial, NEJM, 2000 </li></ul><ul><li>Comparison of 6 ml/kg vs 12 ml/kg </li></ul><ul><li>861/1000 patients </li></ul><ul><li>Mortality 31% vs 39.8% </li></ul><ul><li>Reduction in mortality of 22% </li></ul>
  17. 17. Low tidal volume strategy <ul><li>When ARDS diagnosed, adjust Vt for ideal body weight </li></ul><ul><ul><li>60 kg x .6 cc/kg = 360 cc </li></ul></ul><ul><li>pCO 2 will likely increase – permissive hypercapnea </li></ul><ul><li>GRADE B </li></ul>
  18. 18. PEEP levels in ARDS <ul><li>ARDS-net, NEJM, 2004 </li></ul><ul><li>Comparison of low and high PEEP in ARDS </li></ul><ul><li>549 patients </li></ul><ul><li>Low versus high PEEP algorithm </li></ul><ul><li>All patients had low Vt </li></ul><ul><li>No difference in ventilator free days or mortality </li></ul>
  19. 19. Steroids for “late” ARDS <ul><li>Fibroproliferation can occur after 5-7 days of ARDS </li></ul><ul><li>This inflammatory process may present with worsening oxygenation, fever and leukocytosis (infection may present with same signs) </li></ul><ul><li>Case series of steroids to minimize the late inflammatory fibroproliferation </li></ul>
  20. 20. Steroids for “late” ARDS <ul><li>ARDS-net randomized placebo-controlled trial </li></ul><ul><li>Goal 200 patients over 6-8 years </li></ul><ul><li>No value in use of steroids in “late” ARDS </li></ul>
  21. 21. Other ARDS modalities <ul><li>We no longer consider: </li></ul><ul><li>Prone position </li></ul><ul><li>Inhaled nitric oxide </li></ul><ul><li>Surfactant </li></ul><ul><li>Liquid ventilation </li></ul>
  22. 22. Evidence-based critical care <ul><li>Glucose control in critically ill patients </li></ul>
  23. 23. Intensive insulin therapy <ul><li>NEJM, 2001, single center study </li></ul><ul><li>1,548 surgical patients </li></ul><ul><li>Randomized to tight vs non tight control </li></ul><ul><li>80-120 mg/dl vs 150 mg/dl </li></ul><ul><li>ICU mortality 4.6% vs 8.0% </li></ul><ul><li>43% risk reduction </li></ul>
  24. 24. Intensive insulin therapy <ul><li>50% decrease in BSI, ARF requiring RRT, critical illness polyneuropathy and transfusion requirement </li></ul><ul><li>Shorter duration of mechanical ventilation and ICU care </li></ul><ul><li>Less multiple organ failure </li></ul>
  25. 25. Intensive insulin therapy <ul><li>Mayo Clin Proc, 2004 </li></ul><ul><li>800 critically ill medical-surgical patients in a community ICU </li></ul><ul><li>Hospital mortality decreased </li></ul><ul><li>Decreased ICU LOS, ARF, transfusion requirement </li></ul><ul><li>Most benefit in septic patients </li></ul>
  26. 26. Intensive insulin therapy <ul><li>GRADE D based on original study, (randomized but single center, mainly surgical patients), likely upgrade to C </li></ul><ul><li>German study (600 patients) – negative </li></ul><ul><li>Two large scale randomized trials underway </li></ul><ul><ul><li>European study – 3500 medical/surgical patients </li></ul></ul><ul><ul><li>Australia/NZ – 4500 medical/surgical patients </li></ul></ul>
  27. 27. Evidence-based critical care <ul><li>Activated protein-C in sepsis (Xigris) </li></ul>
  28. 30. RH Activated Protein C <ul><li>Prowess Study </li></ul><ul><ul><li>Recombinant human activated pro tein C w orldwide e valuation in s evere s epsis </li></ul></ul><ul><ul><li>Randomized, double blinded, placebo controlled </li></ul></ul><ul><ul><li>96 hour infusion of activated protein C (APC) </li></ul></ul><ul><ul><li>Endpoint: death at 28 days </li></ul></ul>
  29. 31. RH Activated Protein C <ul><li>Prowess study </li></ul><ul><ul><li>1690 patients (840 placebo; 850 APC) </li></ul></ul><ul><ul><li>Mortality 30% vs 24.7%, p=0.005 </li></ul></ul><ul><ul><li>6.1% reduction of death </li></ul></ul><ul><ul><li>Serious bleeding 2% vs 3.5%, p=0.06 </li></ul></ul><ul><ul><li>Similar number of blood transfusions </li></ul></ul>
  30. 32. RH Activated Protein C <ul><li>Prowess study </li></ul><ul><ul><li>The difference in outcome was greatest in patients with an APACHE score >25 </li></ul></ul><ul><li>Address study </li></ul><ul><ul><li>PRCT of RHAPC in patients with APACHE <25 </li></ul></ul><ul><ul><li>No improvement in outcome </li></ul></ul><ul><ul><li>May be worse outcome in SURGICAL patients with single organ dysfunction </li></ul></ul>
  31. 33. RH Activated Protein C <ul><li>Contraindications </li></ul><ul><ul><li>Internal bleeding, hemorrhagic CVA, CHI, neurosurgical procedures, surgery within 12 hours </li></ul></ul><ul><ul><li>Many patients with abdominal sepsis require repeat explorations </li></ul></ul><ul><li>The drug is expensive ($100/kg) </li></ul>
  32. 34. RH Activated Protein C <ul><li>GRADE B for patients with severe sepsis, multiple organ dysfunction, with APACHE >25 </li></ul><ul><li>“Dear doctor” letter from Eli Lilly re: surgical patients with single organ dysfunction </li></ul>
  33. 35. Evidence-based critical care <ul><li>CORTICOSTEROIDS AND SEPTIC SHOCK </li></ul>
  34. 36. Corticosteroids and sepsis <ul><li>Old teaching: don’t give septic patients high dose steroids </li></ul><ul><li>New thought: patients with septic shock who are unresponsive to pressor agents may have adrenal insufficiency </li></ul>
  35. 37. Corticosteroids and sepsis <ul><li>Incidence of adrenal insufficiency </li></ul><ul><ul><li>30-50% in critically ill patients </li></ul></ul><ul><ul><li>50-60% in patients with septic shock </li></ul></ul><ul><li>Clinical presentation </li></ul><ul><ul><li>resistant hypotension </li></ul></ul><ul><ul><li>hyponatremia, hyperkalemia </li></ul></ul><ul><li>Low or “normal” serum cortisol level </li></ul>
  36. 38. Corticosteroids and sepsis <ul><li>JAMA, 2002; multicenter, RCT, 300 patients </li></ul><ul><li>Septic shock, vasopressor therapy </li></ul><ul><li>A baseline cortisol level of <25 mcg/dl </li></ul><ul><li>Corticotropin stimulation test (cortrosyn) </li></ul><ul><li>An increase in serum cortisol of 9 mcg/dl after corticotropin – “responders” </li></ul><ul><li>Unable to increase serum cortisol 9 mcg/dl – “nonresponders” </li></ul>
  37. 39. Corticosteroids and sepsis <ul><li>Nonresponders randomized to placebo vs hydrocortisone 50 mg IV every 6 hours + fludrocortisone </li></ul><ul><li>Mortality improved in patients with adrenal insufficiency </li></ul><ul><li>Faster time to vasopressor withdrawal </li></ul><ul><li>No difference in patients with adequate corticotropin response </li></ul>
  38. 40. Corticosteroids and sepsis <ul><li>Should low doses of corticosteroids be used in the treatment of septic shock? </li></ul><ul><li>GRADE C </li></ul><ul><li>SSC guidelines suggest steroids in pressor-dependent patients with low serum cortisol (don’t even bother with the cortrosyn stimulation) </li></ul>
  39. 41. Evidence-based critical care <ul><li>PULMONARY ARTERY CATHETER USE IN THE ICU </li></ul>
  40. 42. PA catheter use in the ICU <ul><li>Old practice: any unstable patient who didn’t respond to fluids or who had possible cardiac dysfunction; “we didn’t know where we were…” </li></ul><ul><li>Preoperative “optimization” of high risk patients </li></ul><ul><li>Old practices questioned: Connors, et al, JAMA, 1996 </li></ul><ul><li>Editorial: “abandon PACs until PRCT” </li></ul>
  41. 43. PA catheter use in the ICU <ul><li>JAMA, 2005 </li></ul><ul><li>Meta-analysis, 13 RCTs, 5051 patients </li></ul><ul><li>Use of PA catheter neither increased overall mortality or hospital days, nor conferred benefit </li></ul><ul><li>Use of the PA catheter was associated with a higher use of inotropes and vasodilators </li></ul>
  42. 44. PA catheter use in the ICU <ul><li>RCT in progress </li></ul><ul><li>ARDS-net, 1000 patient goal </li></ul><ul><li>FACTT Study: PRMCT of PAC vs CVP for management of ALI and ARDS </li></ul><ul><li>and </li></ul><ul><li>PRMCT of “fluid conservative” vs “fluid liberal” management of ALI and ARDS </li></ul>
  43. 45. Evidence-based critical care <ul><li>EARLY GOAL-DIRECTED THERAPY IN SEPSIS </li></ul>
  44. 46. Early goal-directed therapy <ul><li>“Standard” goals for sepsis (resuscitation) </li></ul><ul><ul><li>MAP > 65 </li></ul></ul><ul><ul><li>CVP 8-12 </li></ul></ul><ul><ul><li>Urine output >0.5 cc/hr </li></ul></ul>
  45. 47. Early goal-directed therapy <ul><li>DO 2 = Hgb (SaO 2 ) x 1.34 x CI x 10 </li></ul><ul><li>“ Supranormal” goals for PAC (1980s) </li></ul><ul><ul><li>CI > 4.5 L/min/m 2 </li></ul></ul><ul><ul><li>DO 2 I > 600 ml O 2 /min/m 2 </li></ul></ul><ul><ul><li>VO 2 I > 170 ml 0 2 /min/m 2 </li></ul></ul><ul><li>Fluids, blood, inotropes, pressors… </li></ul><ul><li>We could measure our progress with a calculator!! </li></ul>
  46. 48. Early goal-directed therapy <ul><li>Supranormal goals disproven in established sepsis (NEJM x2) </li></ul><ul><li>Will this theory work if we get to the patient earlier? </li></ul>
  47. 49. Early goal-directed therapy <ul><li>NEJM, 2001, Henry Ford Hospital </li></ul><ul><li>263 ED patients </li></ul><ul><li>Control group: MAP, CVP, UO </li></ul><ul><li>Protocol group: MAP, CVP, UO, SCVO 2 >70 </li></ul><ul><li>Mortality 46.5 vs 30.5%, p=.009 </li></ul>
  48. 50. Early goal-directed therapy <ul><li>There IS value to optimizing cardiac output, oxygen delivery and SVO 2 if you intervene early enough </li></ul><ul><li>(Is it really the SVO 2 that makes the difference, or is it resuscitation??) </li></ul>
  49. 51. Evidence-based critical care <ul><li>ANTIBIOTICS and INFECTION CONTROL </li></ul><ul><li>WHO NEEDS TREATMENT AND FOR HOW LONG </li></ul><ul><li>VENTILATOR ASSOCIATED PNEUMONIA </li></ul><ul><li>CATHETER-RELATED BACTERIAL STREAM INFECTION </li></ul><ul><li>C-DIFFICILE COLITIS </li></ul>
  50. 52. Who needs antibiotics? <ul><li>Systemic inflammatory response syndrome (SIRS) </li></ul><ul><li>Fever means inflammation , not necessarily infection </li></ul><ul><li>Emergence of multiresistant bacteria </li></ul><ul><li>Treating fever alone or fever + WBC without a source of infection is usually not in the best interest of the patient </li></ul>
  51. 53. Duration of antibiotic coverage <ul><li>Minimal data over duration of antibiotic usage for most infections </li></ul><ul><ul><li>Bacteremia – 2 weeks </li></ul></ul><ul><ul><li>Endocarditis – 6 weeks </li></ul></ul><ul><li>What about “double coverage” for pneumonia </li></ul><ul><ul><li>SPACE bugs: S erratia, P seudomonas, A cinetobacter, C itrobacter, E nterobacter </li></ul></ul><ul><ul><li>VAP coverage was always 2 weeks </li></ul></ul>
  52. 54. SICU antibiotic usage <ul><li>Perioperative coverage – single dose or 24 hours of coverage </li></ul><ul><li>UTI – 5 days </li></ul><ul><li>Sinusitis – 5-7 days </li></ul><ul><li>Bacteremia – 10 days </li></ul>
  53. 55. Evidence-based critical care <ul><li>VENTILATOR-ASSOCIATED PNEUMONIA </li></ul><ul><li>DIAGNOSIS </li></ul><ul><li>TREATMENT </li></ul><ul><li>PREVENTION </li></ul>
  54. 56. Ventilator-associated pneumonia - diagnosis <ul><li>Classic teaching: Fever, WBC, purulent sputum, + culture, infiltrate </li></ul><ul><li>75% of intubated patients are colonized with GNB after 3 days in the ICU </li></ul><ul><li>You could have bronchitis or sinusitis + atelectasis, or pulmonary edema </li></ul><ul><li>Endotracheal aspirate vs BAL </li></ul><ul><ul><li>BAL samples give quantitative cultures </li></ul></ul>
  55. 57. Ventilator-associated pneumonia - diagnosis <ul><li>Fever/WBC, + culture without purulent sputum or CXR – NO ANTIBIOTICS </li></ul><ul><li>Fever/WBC, purulent sputum or changing CXR, + sputum culture -> empiric therapy </li></ul><ul><li>Fever/WBC, purulent sputum or changing CXR, + sputum culture -> BAL + empiric therapy </li></ul>
  56. 58. Ventilator-associated pneumonia treatment <ul><li>JAMA, 2003 </li></ul><ul><li>PRCDBT, 51 French ICUs, 401 patients </li></ul><ul><li>VAP treatment for 8 vs 15 days </li></ul><ul><li>No excess mortality, recurrent infections, ventilator days, ICU LOS with 8 day treatment </li></ul><ul><li>But, recurrence of VAP was higher with PSD </li></ul>
  57. 59. Ventilator-associated pneumonia prevention <ul><li>Subglottic suctioning of secretions </li></ul><ul><ul><li>Additional suction port above the ETT cuff </li></ul></ul><ul><ul><li>Some studies suggest decreased VAP </li></ul></ul><ul><ul><li>Who will get them, will you risk changing the tube?? </li></ul></ul><ul><li>Role of gastric contents </li></ul><ul><ul><li>Gastric residuals: not shown to correlate with VAP (a major cause of poor nutrition) </li></ul></ul>
  58. 60. Ventilator-associated pneumonia <ul><li>What is known </li></ul><ul><ul><li>More likely from mouth contents than from regurgitation of stomach contents </li></ul></ul><ul><ul><li>Head of bed 30 degrees up is the only proven preventive technique!! </li></ul></ul><ul><ul><li>Early effective antibiotic therapy is essential !! </li></ul></ul><ul><ul><li>Start with broad-spectrum coverage, then taper antibiotics based on EA/BAL results </li></ul></ul>
  59. 61. Catheter-related BSI <ul><li>Prevention – what doesn’t work </li></ul><ul><ul><li>Changing lines every three days </li></ul></ul><ul><ul><li>Performing wire changes </li></ul></ul><ul><ul><li>Putting antibiotic solutions (goop) on the site </li></ul></ul><ul><ul><li>Antibiotic lock solutions </li></ul></ul>
  60. 62. Catheter-related BSI <ul><li>Prevention – what DOES work </li></ul><ul><ul><li>Subclavian site </li></ul></ul><ul><ul><li>Prep: Chlorhexidine (not povidone) </li></ul></ul><ul><ul><li>Barrier precautions: Hat, mask, gown, gloves, FULL body drape </li></ul></ul><ul><ul><li>Antiseptic coated catheters ($$$; beware of hospital administrators) </li></ul></ul><ul><ul><li>Management of stopcocks: alcohol prior to injections, keep ports closed </li></ul></ul>
  61. 64. C-difficile colitis <ul><li>Related to indiscriminate antibiotic usage </li></ul><ul><li>May occur with only a single dose of antibiotics (even perioperative coverage) </li></ul><ul><li>May require colectomy </li></ul><ul><li>May be fatal </li></ul><ul><li>A huge topic in the lay press and certainly will be seized on by the legal community </li></ul>
  62. 65. Infection control techniques <ul><li>We all have the power to limit the occurrence of hospital acquired infections </li></ul><ul><li>Hand washing is the most effective method of limiting hospital acquired infections </li></ul>
  63. 66. Infection control techniques <ul><li>Soap and water </li></ul><ul><li>Hand disinfectant solutions : Steris product, Purell </li></ul><ul><li>Remember: C-difficile toxin spores are not killed by hand solutions; use soap and water </li></ul><ul><li>Wear protective gowns and mask when examining c-diff patients </li></ul>
  64. 67. EBM in perspective
  65. 68. EBM in perspective <ul><li>We have very good data (A) </li></ul><ul><ul><li>DVT prophylaxis </li></ul></ul><ul><ul><li>Stress ulcer prophylaxis </li></ul></ul><ul><ul><li>Spontaneous breathing trials </li></ul></ul><ul><ul><li>Preventive practices for CR-BSI </li></ul></ul>
  66. 69. EBM in perspective <ul><li>We have good data (B), but these studies can likely never be repeated </li></ul><ul><ul><li>Early goal-directed therapy in septic shock </li></ul></ul><ul><ul><li>Activated protein-C for severe sepsis </li></ul></ul><ul><ul><li>Low Vt in ARDS </li></ul></ul>
  67. 70. EBM in perspective <ul><li>We have good data (B) that will probably never get better despite further studies </li></ul><ul><ul><li>Crystalloids vs colloids, albumin </li></ul></ul><ul><ul><li>Bicarbonate in acidosis </li></ul></ul><ul><li>We are able to eliminate unproven or potentially unsafe practices </li></ul><ul><ul><li>NO for ARDS </li></ul></ul><ul><ul><li>Prone positioning for ARDS </li></ul></ul>
  68. 71. EBM in perspective <ul><li>We practice with lots of E’s – these probably can’t ethically be studied </li></ul><ul><ul><li>Use of antibiotics early in sepsis </li></ul></ul><ul><ul><li>Draining abscesses </li></ul></ul><ul><ul><li>Giving fluids for hypovolemia </li></ul></ul><ul><ul><li>Vasopressors in septic shock </li></ul></ul><ul><ul><li>Mechanical ventilation in respiratory failure </li></ul></ul>
  69. 72. EBM in perspective – the good <ul><li>We know the quality of the data </li></ul><ul><li>Development of consensus statements </li></ul><ul><ul><li>ASA, SCCM, ACCP, EAST </li></ul></ul><ul><ul><li>www.guideline.gov </li></ul></ul><ul><li>Guidelines and protocols </li></ul><ul><ul><li>Keep us current and consistent in our care </li></ul></ul><ul><ul><li>Allows ongoing monitoring of practices </li></ul></ul><ul><ul><li>Educate our trainees </li></ul></ul>
  70. 73. EBM in perspective – the bad <ul><li>Extending data to non-studied or non-proven conditions: </li></ul><ul><li>Low tidal volumes for all : There is no data that patients who do not have ARDS should be ventilated with low tidal volumes </li></ul><ul><li>Daily breaks in sedation : It is not reasonable to break sedation in some patients: ARDS, elevated ICP, etc </li></ul>
  71. 74. EBM in perspective – the bad <ul><li>Blanket referrals to EBM: </li></ul><ul><li>PAC usage in critically ill patients : A PAC may still be useful in managing your patient </li></ul><ul><li>The anti-dopamine conspiracy : Lancet, 2000: 328 patients; 23 ICUs; no effect on renal dysfunction, LOS or mortality </li></ul>
  72. 75. EBM in perspective: the bad <ul><li>There are patients with low urine output or impending renal failure secondary to low cardiac output who may benefit from the use of low dose dopamine </li></ul>
  73. 76. EBM in perspective – the scary <ul><li>OUTCOMES RELATED TO EVIDENCE-BASED CARE WILL BE MONITORED AND WILL BECOME A MEASURE OF QUALITY AND POTENTIALLY A SOURCE OF MEDICOLEGAL LIABILITY </li></ul>
  74. 77. EBM in perspective – keep reading <ul><li>The data may change !! </li></ul><ul><li>JAMA, July 13, 2005 </li></ul><ul><li>Contradicted findings (16%) </li></ul><ul><ul><li>Hormone therapy and CAD risk </li></ul></ul><ul><ul><li>Vitamin E and CAD risk </li></ul></ul><ul><ul><li>Vit A and breast cancer </li></ul></ul><ul><ul><li>Monoclonal AB to endotoxin (HA1A) </li></ul></ul><ul><ul><li>Nitric oxide in ARDS </li></ul></ul>
  75. 78. EBM in perspective – keep reading <ul><li>Studies with initially stronger effects (16%) </li></ul><ul><ul><li>Zidovudine in HIV </li></ul></ul><ul><ul><li>Angioplasty vs TPA in AMI </li></ul></ul><ul><ul><li>TPA in CVA </li></ul></ul><ul><ul><li>CEA and risk reduction of CVA or death </li></ul></ul><ul><ul><li>Acetylcysteine preventing contrast nephropathy </li></ul></ul>
  76. 79. EBM in perspective – reading the literature <ul><li>Cautious use of “the literature”, “landmark” articles </li></ul><ul><ul><li>It’s easy to quote the last line of the abstract </li></ul></ul><ul><li>LOOK FOR THE EDITORIAL </li></ul><ul><ul><li>Comments on the quality and limitations of the study </li></ul></ul><ul><ul><li>“This study raises more questions than it answers” </li></ul></ul><ul><ul><li>“Large, randomized trials are needed” </li></ul></ul>
  77. 80. Summary <ul><li>We should use EBM consensus statements to keep our knowledge current </li></ul><ul><li>Reaching the highest rankings (grade A) may be limited by ethics, resource restrictions and marketing strategies </li></ul><ul><li>Be watchful for “new” data or negation of previously accepted data </li></ul>
  78. 81. Summary <ul><li>Realize that the public is watching our adherence to practice guidelines </li></ul><ul><li>Accept the fact that external monitoring of evidence-based practices and outcomes will be standard in the future </li></ul><ul><li>Be proactive in maintaining high standards of care </li></ul>
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