Hot topics lecture given by Rob Mac Sweeney at the FFICM Preparation Course in London on March 9th 2016

1. Hot Topics
.
FFICM Preparation Day
London March 9th 2016
Rob Mac Sweeney

4. http://bit.do/CCR-FFICM16

6. Paul Young | Wellington
Saline or Plasmalyte
Is SPLIT the Solution

7. Hot Topics
•2016
•2015
•2014
•2013
•2012
•Major Research
•Major Guidelines

9. Major Research Studies
2016

10. Sepsis 3
Definitions
Process
Delphi Process
Database validation
Screening with qSOAF
Identify with SOAF
? Advance

11. DIABOLO
French multi-centre RCT
Early metabolic alkalosis
382 patients
No separation MV | pH | PaCO2
↔ duration ventilation
↔ duration weaning
↓ bicarb & days with alkalosis

12. Major Research Studies
2015

13. HEAT
Paracetamol is harmful ?
1g IV Paracetamol 6° or placebo
700 pts
Groups well balanced
↔ temperature (0.2°C)
↔ ICU free days (23 v 22)
Immunomodulatory effect ?

14. 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

15. SPLIT
Cluster, crossover RCT
0.9% Saline vs Plasmalyte
2,278 pts
All fluid administrative
purposes
2000 ml each
↔ AKI 9.2% v 9.6%
Pilot study

16. EUROTHERM
> 20 mmHg for > 5 minutes
32°C – 35°C vs standard mgt
Stage 2
387 patients
∆ 2.14°C | ↓ stage 2 failure
acOR 1.53 poor outcome GOS-
E
Timing of intervention ?

17. ABLE
Is fresh blood better than old ?
Young RBCs vs standard
RBCs
2430 patients
RBCs: 6 days vs 22 days
90 day mortality: 37% vs 35%
No 2° outcome differences
TRIGGER | RECESS

18. EPO-TBI
EPO pleotropic effects
40,000 IU EPO x 3 or placebo
Withholding criteria
606 patients
↔ GOS-E 1 - 4: 44% vs 45%
↔ 6/12 mortality 11% vs 16%
↔ DVT 16% vs 18%

19. ProMISe
Open label, pragmatic RCT
Early septic shock
EGDT: SpO2
| ScvO2
| CVP |
MAP | Hb
1,260 patients
Some separation
↔ 90 day mortality: 29% vs
29%

20. FLORALI
Open label, multi-centre RCT
FM vs HFNO vs NIV
SpO2 > 92%
310 patients
↔D28 reintubation 47 v 38 v
50%
↓ ICU mortality 19 v 11 v 25%
↓ D90 mortality 23 v 12 v 28%

21. 3Sites
Open label, RCT 10 French
ICUs
Subclavian v I Jugular v
Femoral
CRBSI & symptomatic DVT
Experienced clinicians
3,471 catheters in 3,027
patients

22. 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

23. Chlorhexidine Bathing
Pragmatic, Cluster Randomized
Crossover study
9340 patients
Once daily 2% chlorhexidine
2 x 10 week periods each
↔ infections
55 vs 60
2.86 vs 2.90 / 1000 pt days

24. Major Research Studies
2014

25. 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

26. ARISE
Australian / NZ RCT
EGDT vs Usual Care
Rivers algorithm
1600 patients with septic shock
↔ 90 mortality
EGDT 18.6% vs 18.8%
EGDT - ↑ fluids, vasopressors,
RC, dobutamine

27. 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

28. 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

29. 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%

30. 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

31. 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

32. 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%

33. 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

34. 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

35. 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

36. 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%
↔ mortality at 6 months

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
No gastric volume monitoring
• ↔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 Research Studies
2012

57. 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%

58. 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

59. CARRESS

60. 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

61. 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

62. 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)

63. 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

64. 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

65. Berlin Definition of ARDS

66. 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%

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

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

69. 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

70. 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

71. 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%)

72. 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

73. Good Luck
.
@critcarereviews
http://bit.do/CCR-FFICM16