Top 10 Critical Care Papers of 2020
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Top 10 Critical Care Papers of 2020
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Healthcare
In this podcast, Ed Litton summarises 10 clinical trials in 10 minutes. Ed invites you to choose, based on the title alone, whether the findings were consistent with, or contrary to, the study hypothesis. Ed discusses 10 non-covid clinical trials, all published in 2020. Notably, all of these were published in the New England Journal, JAMA or Lancet and had important findings. The following hypothesises are discussed: 10. Firstly, the impact of resident physician schedules and the affect on patient safety. 9. Early initiation of renal replacement therapy and whether this improved outcomes for Acute Kidney Injury. 8. Does the implementation of early ECMO improve outcomes for patients with refractory VF and out of hospital cardiac arrest? 7. Then, can a machine learning algorithm reduce hypotensive severity? 6. In mechanically ventilated patients, is an approach of non sedation superior to light sedation? 5. Moreover, in patients who are ready for decannulation, does timing based on the suctioning frequency improve outcomes? 4. Does administering high dose tranexamic acid in patients with upper or lower GI bleeds decrease mortality? 3. Next, does a decreased exposure to vasopressors improve outcomes in older critically ill patients? 2. Will starting Dexmedetomidine at the time of cardiac surgery reduce AF and delirium in patients? 1. Also, will being conservative with oxygen in patients with ARDS improve outcomes? Tune in to a talk by Ed Litton as he shares the top 10 papers of 2020 in 10 minutes.
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Top 10 Critical Care Papers of 2020
- 10 in 10 Ed Litton CODA ZERO 17/2/21
- CONTRARY TO HYPOTHESIS CONSISTENT WITH HYPOTHESIS
- Landrigan et al NEJM 2020;382:2514-12
- Landrigan et al NEJM 2020;382:2514-12 CONTRARY TO HYPOTHESIS
- Landrigan et al NEJM 2020;382:2514-12 Cluster crossover RCT in 6 US PICUs Control: Extended duration (>24h) Intervention: Limited duration (<16h) 38,821 patient days DESIGN
- Landrigan et al NEJM 2020;382:2514-12 Cluster crossover RCT in 6 US PICUs Control: Extended duration (>24h) Intervention: Limited duration (<16h) ↑ Serious medical errors 97 vs 79 per 1000 patient days Intervention group Sleep & neurobehavioural performance 38,821 patient days DESIGN ↑ OUTCOMES Unintended consequences – increased workload
- Bagshaw et al NEJM 2020 383 240-51
- Bagshaw et al NEJM 2020 383 240-51 CONTRARY TO HYPOTHESIS
- 168 ICUs, 15 countries, 3019 AKI Control: Standard strategy Intervention: Accelerated RRT 97% vs 62% received RRT DESIGN Bagshaw et al NEJM 2020 383 240-51
- 168 ICUs, 15 countries, 3019 AKI Control: Standard strategy Intervention: Accelerated RRT 97% vs 62% received RRT DESIGN Bagshaw et al NEJM 2020 383 240-51 Intervention group Day 90 Mortality 44% v 44% Continued RRT dependence 10% vs 6% ↑ ↑Hypotension and adverse events Nudge towards deferring initiation OUTCOMES
- Yannopoulos et al Lancet 2020 396 1807-16
- Yannopoulos et al Lancet 2020 396 1807-16 CONSISTENT WITH HYPOTHESIS
- DESIGN Yannopoulos et al Lancet 2020 396 1807-16 1 US centre, 30 ‘refractory’ VF Intervention: EARLY ECMO Control: Standard ACLS Ceased at 1st interim analysis
- DESIGN OUTCOMES Yannopoulos et al Lancet 2020 396 1807-16 1 US centre, 30 ‘refractory’ VF Intervention: EARLY ECMO Control: Standard ACLS Ceased at 1st interim analysis Intervention group Hospital mortality 57% v 93% Exciting,…. but… Highly invested centre. Replicable? mRankin 0-3 (n=6) 77% required RRT
- Wijberge et al JAMA 2020 3923(11) 1052-60
- Wijberge et al JAMA 2020 3923(11) 1052-60 CONSISTENT WITH HYPOTHESIS
- DESIGN 1 centre RCT 68 elective non-cardiac Wijberge et al JAMA 2020 3923(11) 1052-60 Intervention: ML-derived algorithm Control: Standard care (monitor off) Hypotension prediction index coupled to guidance
- DESIGN OUTCOMES 1 centre RCT 68 elective non-cardiac Wijberge et al JAMA 2020 3923(11) 1052-60 Intervention: LM-derived algorithm Control: Standard care (monitor off) Hypotension prediction index coupled to guidance Intervention group TWA hypotension ↓ 16min ↓ Time to intervention ↓ But is the juice worth the squeeze?
- Wijberge et al NEJM 2020 382;12 1103-11
- Wijberge et al NEJM 2020 382;12 1103-11 CONTRARY TO HYPOTHESIS
- DESIGN 8 centre RCT 710 MV<24h Intervention: No sedation Control: Light propofol sedation Wijberge et al NEJM 2020 382;12 1103-11
- DESIGN OUTCOMES Other perspectives - patients, nurses? 8 centre RCT 710 MV<24h Intervention: No sedation Control: Light propofol sedation Intervention group Accidental extubation Morphine and crossover Day 90 Mortality 5% (CI -2-12%) ↑ ↑ Wijberge et al NEJM 2020 382;12 1103-11
- Hernandez Martinez et al NEJM 2020 383; 1009-17
- Hernandez Martinez et al NEJM 2020 383; 1009-17 CONSISTENT WITH HYPOTHESIS
- DESIGN Hernandez Martinez et al NEJM 2020 383; 1009-17 5 centre RCT 330 trach & no MV>24h Intervention: suctioning assessment Control: 24h capping HFO when trach being used
- DESIGN OUTCOMES Hernandez Martinez et al NEJM 2020 383; 1009-17 5 centre RCT 330 trach & no MV>24h Intervention: suctioning assessment Control: 24h capping HFO when trach being used Intervention group 7 Days (5-9) faster to decanulate 14 Days (9-33) less in hospital ↓ Pneumonia, weaning failure, decannulation failure, EXTRAORDINARY! Should change practice
- Roberts et al Lancet 2020 383; 1009-17
- Roberts et al Lancet 2020 383; 1009-17 CONTRARY TO HYPOTHESIS
- DESIGN 12,009/164/15 RCT ‘Sig.’ GIB Intervention: TXA 1g bolus + 3g/24 Control: Matching placebo Roberts et al Lancet 2020 383; 1009-17
- DESIGN OUTCOMES Intervention group 12,009/164/15 RCT ‘Sig.’ GIB Intervention: TXA 1g bolus + 3g/24 Control: Matching placebo <5/7 Bleeding death 4% v 4% Similar arterial thrombosis, transfusion Venous thrombosis, seizures ↑ Roberts et al Lancet 2020 383; 1009-17 Smaller effects in subgroups?
- Lamontagne et al JAMA 2020 323(10: 938-49
- Lamontagne et al JAMA 2020 323(10: 938-49 CONSISTENT(ish) WITH HYPOTHESIS
- DESIGN 65 UK sites, 2600 >65 YRs, <6h vaso Lamontagne et al JAMA 2020 323(10: 938-49 Intervention: MAP 60-65 Control: Clinical preference Registry embedded, completed <2yrs
- DESIGN OUTCOMES Intervention group 65 UK sites, 2600 >65 YRs, <6h vaso Lamontagne et al JAMA 2020 323(10: 938-49 Day 90 Mortality -2.9% (-6.8-1.1) Intervention: MAP 60-65 Control: Clinical preference Age as an ‘enricher’ Dose, duration, MAP ↓ Similar RRT, SAEs, cognitive scores… Registry embedded, completed <2yrs
- Lamontagne et al JAMA 2020 323(10: 938-49
- Lamontagne et al JAMA 2020 323(10: 938-49 CONTRARY TO HYPOTHESIS
- DESIGN Lamontagne et al JAMA 2020 323(10: 938-49 6 US sites, 798 pre CTS + CPB Intervention: 24h periop DEX Control: 24h periop PLACEBO Stopped early ‘futility’, Wildtype Sedation/analgesia
- DESIGN OUTCOMES Lamontagne et al JAMA 2020 323(10: 938-49 Intervention group 6 US sites, 798 pre CTS + CPB Intervention: 24h periop DEX Control: 24h periop PLACEBO Stopped early ‘futility’, Wildtype Sedation/analgesia Delirium RR 1.5 (0.99-2.2) AF RR 0.9 (0.7-1.2) Clinically significant hypotension ↑ Don’t routinely start
- Barrot et al NEJM 2020 382(11): 999-1008
- Barrot et al NEJM 2020 382(11): 999-1008 CONTRARY TO HYPOTHESIS
- DESIGN Barrot et al NEJM 2020 382(11): 999-1008 13 French ICUs, <12h MV ARDS Intervention: PaO2 55-70, (88-92%) Control: PaO2 80-105, (at least 96%) Enrolled 205 of planned 850
- DESIGN OUTCOMES Barrot et al NEJM 2020 382(11): 999-1008 13 French ICUs, <12h MV ARDS Intervention: PaO2 55-70, (88-92%) Control: PaO2 80-105, (at least 96%) Enrolled 205 of planned 850 Intervention group Day 28 Mortality 34% v 27% HR, mesenteric ischaemia, D90 mortality ↑ ? Target upper end of range
- Thank You ed_litton@hotmail.com
Editor's Notes
- Consistent with or contrary to hypothesis ALL RCTS ALL NEJM, JAMA, LANCET NO COVID
- Medical errors highly prevalent – stay humble
- Medical errors highly prevalent – stay humble
- Medical errors highly prevalent – stay humble
- Medical errors highly prevalent – stay humble
- Refractory no ROSC after 3 shocks Unanimous decision of DSMB as crossed prespecified monitoring boundary 0.986 Open label, activation of ECMO team within 20min of 911 call through changes to prehospital care
- Refractory no ROSC after 3 shocks Unanimous decision of DSMB as crossed prespecified monitoring boundary 0.986 Open label, activation of ECMO team within 20min of 911 call through changes to prehospital care
- Refractory no ROSC after 3 shocks Unanimous decision of DSMB as crossed prespecified monitoring boundary 0.986 Open label, activation of ECMO team within 20min of 911 call through changes to prehospital care
- Refractory no ROSC after 3 shocks Unanimous decision of DSMB as crossed prespecified monitoring boundary 0.986 Open label, activation of ECMO team within 20min of 911 call through changes to prehospital care
- Algorithm art line waveform based predictive rather than reactive – fixed not dynamic, training set of 1300 patients 23 variables extracted from the arterial waveform
- Algorithm art line waveform based predictive rather than reactive – fixed not dynamic, training set of 1300 patients 23 variables extracted from the arterial waveform
- Algorithm art line waveform based predictive rather than reactive – fixed not dynamic, training set of 1300 patients 23 variables extracted from the arterial waveform
- Algorithm art line waveform based predictive rather than reactive – fixed not dynamic, training set of 1300 patients 23 variables extracted from the arterial waveform
- 27% crossover from no sedation in first 24h Minimal rass separation of 1
- 27% crossover from no sedation in first 24h Minimal rass separation of 1
- 27% crossover from no sedation in first 24h Minimal rass separation of 1
- 27% crossover from no sedation in first 24h Minimal rass separation of 1
- Spain Differential NHFO and open label
- Spain Differential NHFO and open label
- Spain Differential NHFO and open label
- Spain Differential NHFO and open label
- All cause death outcomes similar Subgroups all similar including income status and illness severity Half patients variceal
- All cause death outcomes similar Subgroups all similar including income status and illness severity Half patients variceal
- All cause death outcomes similar Subgroups all similar including income status and illness severity Half patients variceal
- All cause death outcomes similar Subgroups all similar including income status and illness severity Half patients variceal
- France Planned 850 enrolled
- France Planned 850 enrolled
- France Planned 850 enrolled
- France Planned 850 enrolled