Hot Topics talk given by Rob Mac Sweeney at the National FFICM Exam Preparation Course, London, February 23rd 2015

1. Hot Topics
.
FFICM Preparation Day
London February 23rd 2015
Rob Mac Sweeney

3. Hot Topics
•2015
•2014
•2013
•2012
•Major Research
•Major Guidelines

5. Major Research Studies
2015

6. 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 cmH2
0 = ↑41% mortality
● Requires validation

7. 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”

8. 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

9. Major Guidelines
2015

10. SSAI - Fluid Resuscitation

11. Ascites Club

12. Major Research Studies
2014

13. 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%

14. 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

15. 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

16. 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

17. 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%

18. 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

19. 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

20. 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%

21. 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

22. 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

23. 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

24. 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

25. Major Guidelines
2014

26. ESICM -Neuroprognostication

27. ESICM - Shock

28. ESC – Cardiac Tamponade

29. ESC – Pulmonary Embolism

30. ESC – Revascularization

31. JSICM – Sepsis

32. SSAI - ARDS Ventilation

33. ADQI – AKI Biomarkers

34. NICE – Acute Heart Failure

35. UK - CPR Guidance

36. CCCS - Ebola

37. Major Research Studies
2013

38. 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%

39. 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%

40. 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

41. 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

42. 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

43. TracMan
●
909 intubated patients
●
Tracheostomy timing
●
≤ 4 days vs > 10 days
●
↔Mortality / ICU LOS
●
↔Complications
●
Only 45% late group received trache

44. 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%)

45. 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

46. 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)

47. 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

48. 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

49. 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

50. OSCILLATE ●
548 pts with moderate-to-severe
ARDS
●
Trial terminated early
●
↑mortality 47% vs 35%
●
HFOV associated with
●
↑ sedation requirements
●
↑ neuromuscular blockade
●
↑ vasopressor support

51. OSCAR
●
795 pts with moderate-to-severe
ARDS
●
↔Mortality 41% vs 41%
●
↔Duration antimicrobials
●
↔Duration pharmacological
vasoactive support
●
↔ LOS ICU or Hospital

52. 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)

53. SUNSET-ICU
●
Single-centre, block, randomised trial
●
Resident nighttime intensivist
●
↔ICU LOS
●
↔Mortality
●
↔Other endpoints

54. Early Parenteral Nutrition
●
Early PN versus starvation
●
1,372 patients
●
Standard group: 40 % unfed
●
↔ 60 day mortality
●
↔LOS – ICU or Hospital
●
PN: ↓ duration ventilation

55. Reversal
●
Retrospective observational
●
Looked at 10 years of NEJM
publications
●
Medical reversals – current practice
inferior to a prior standard
●
146/363 studies
●
40%

56. Major Guidelines
2013

57. Surviving Sepsis Campaign

58. Pain, Analgesia & Delirium

59. Trauma Haemorrhage

60. Difficult Airway

61. Difficult Airway

62. Difficult Airway

63. Acute Pancreatitis

64. Red Cell Transfusion

65. Red Cell Transfusion

66. Red Cell Transfusion

67. Canadian Nutrition Guideline

68. Major Research Studies
2012

69. 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%

70. 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

71. 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

72. 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

73. 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

74. 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)

75. 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

76. 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

77. Berlin Definition of ARDS

78. 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%

79. PRODEX / MIDEX
●
MIDEX (n=500)
●
Dexmedetomidine v Midaz
●
Dexmedetomidine:
●
↓duration ventilation
●
↑patient interaction
●
↑hypotension / bradycardia
●
↔ time at target sedation
●
↔ ICU / Hosp LOS / death

80. PRODEX / MIDEX
●
PRODEX (n=437)
●
Dexmedetomidine v Propofol
●
Dexmedetomidine:
●
↑patient interaction
●
↔time at target sedation
●
↔Duration ventilation
●
↔ICU / Hosp LOS // Death

81. 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

82. 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

83. 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%)

84. 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

85. Major Guidelines
2012

86. KDIGO AKI Guideline

87. ESICM Colloids Guideline

88. STEMI Guideline

89. STEMI Guideline

90. Heart Failure Guideline

91. Good Luck
.
rob@criticalcarereviews.com
@critcarereviews