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 European Society of Intensive Care Medicine 2013 Meeting Update / October 9th 2013

Welcome

 

Hello

Welcome to a supplementary Critical Care Reviews Newsletter, bringing you the major research presented this afternoon at the Hot Topics Session at the European Society of Intensive Care Medicine 2013 Meeting in Paris. Six studies were presented, four of which have been simultaneously published in the Journal of the American Medical Association today. Unfortunately, I missed most of the session, and only caught the last talk on steroids in severe community-acquired pneumonia, meaning I'm missing data on one study, OPTIMISE, presented by Rupert Pearse. This has not been otherwise reported on the ESICM website, or any other that I'm aware of, so I don't have results for this at present.

While these presentations were streamed live online, the audiovisual files are not yet available for download. However, keynote talks from Greet van den Berghe, Luciano Gattinoni and John Marshall (a guest speaker at the Critical Care Reviews Meeting in January) are available online for free.

 

Published Results

Journal of the American Medical Association:     Fluids

Annane and colleagues performed a multicenter, randomized, open label, assessment blinded, clinical trial, stratified by case mix (sepsis, trauma, or hypovolemic shock without sepsis or trauma), comparing colloids (n = 1,414; gelatins, dextrans, hydroxyethyl starches, or 4% or 20% of albumin) with crystalloids (n = 1,443; isotonic or hypertonic saline or Ringer's lactate solution) for all fluid interventions other than fluid maintenance throughout the ICU stay, and found:

  1. no difference in
    • 28 day mortality (colloids 25.4% versus crystalloids 27.0%, RR 0.96, 95% CI 0.88 - 1.04, P=0.26)
    • renal replacement therapy use (colloids 11.0% versus crystalloids 12.5%, RR 0.93, 95% CI 0.83 to 1.03, P=0.19)
  2. improved outcomes with colloid therapy
    • reduced 90 day mortality (30.7% versus 34.2%; RR 0.92, 95% CI 0.86 - 0.99; P=0.03)
    • more days alive without mechanical ventilation
      • by day 7 (mean: 2.1 versus 1.8 days; mean difference 0.30, 95% CI 0.09 to 0.48 days, P=0.01)
      • by day 28 (mean: 14.6 versus 13.5 days; mean difference, 1.10, 95% CI 0.14 to 2.06 days; P=0.01)
    • more days alive without vasopressor therapy
      • by day 7 (mean: 5.0 vs 4.7 days; mean difference 0.30, 95% CI −0.03 to 0.50 days; P=0.04) 
      • by day 28 day (mean: 16.2 vs 15.2 days; mean difference 1.04, 95% CI −0.04 to 2.10 days; P=0.03)

Full Text:  Annane. Effects of Fluid Resuscitation With Colloids vs Crystalloids on Mortality in Critically Ill Patients Presenting With Hypovolemic Shock. The CRISTAL Randomized Trial. JAMA 2013;epublished October 9th

 

Journal of the American Medical Association:     Skeletal Muscle Wasting

Puthucheary and colleagues completed an observational study characterizing skeletal muscle wasting in 63 critically ill patients anticipated to be intubated for longer than 48 hours, to spend more than 7 days in critical care, and to survive ICU stay, and found:

  1. mean APACHE II score was 23.5 (95% CI 21.9-25.2)
  2. significant reductions in the rectus femoris cross-sectional area (CSA) at day 10 (−17.7%, 95% CI −25.9% to 8.1%, P<0.001)
  3. in 28 patients assessed by 3 skeletal muscle assessment methods on days 1 and 7
    • rectus femoris CSA decreased by 10.3% (95% CI 6.1% to 14.5%) 
    • muscle fiber CSA decreased by 17.5% (95% CI, 5.8% to 29.3%)
    • ratio of protein to DNA decreased by 29.5% (95% CI 13.4% to 45.6%)
  4. rectus femoris CSA decrease was greater in patients who experienced multi-organ failure, compared with single-organ failure, at
    • day 3 (−8.7% versus −1.8%, P=0 .03)
    • day 7 (−15.7% versus  −3.0% P <0 .001) 
  5. myofiber necrosis occurred in 20 of 37 patients (54.1%).
  6. the pattern of intracellular signaling supported
    • increased protein breakdown (n = 9, r = −0.83, P= 0.005)
    • decreased protein synthesis (n = 9, r = −0.69, P= 0.04)

Full Text:  Puthucheary. Acute Skeletal Muscle Wasting in Critical Illness. JAMA 2013;epublished October 9th

 

Journal of the American Medical Association:     Beta Blockade in Sepsis

Morelli and colleagues undertook an open-label, randomized phase 2 study in 154 critically ill patients with septic shock and a heart rate of 95/min or higher, requiring high-dose norepinephrine to maintain a mean arterial pressure of 65 mm Hg or higher, and compared a continuous infusion of esmolol titrated to maintain heart rate between 80/min and 94/min for their ICU stay (n=77) with standard treatment (n=77), and found:

  1. targeted heart rates were achieved in all patients in the esmolol group compared with those in the control group
  2. esmolol was associated with (median AUC):
    • a greater reduction in heart rate in the first 96 hours:  −28/min (IQR −37 to −21) versus −6/min (95% CI −14 to 0)
    • increased stroke volume index: 4 mL/m2: (IQR −1 to 10) vs 1 mL/m2 (IQR −3 to 5; P = 0.02)
    • increased left ventricular stroke work index: 3 mL/m2 (IQR 0 to 8) versus 1 mL/m2 (IQR −2 to 5; P = 0.03)
    • decreased arterial lactataemia:,  −0.1 mmol/L (IQR −0.6 to 0.2) versus 0.1 mmol/L (IQR −0.3 for 0.6; P = 0.007)
    • decreased norepinephrine dose: −0.11 μg/kg/min (IQR −0.46 to 0.02) versus −0.01 μg/kg/min (IQR −0.2 to 0.44) (P = 0.003)
    • reduced fluid requirements:  3975 mL/24 h (IQR 3663 to 4200) versus 4425 mL/24 h (IQR 4038 to 4775) (P < 0.001)
    • reduced 28 day mortality (49.4% versus 80.5%; adjusted hazard ratio 0.39; 95% CI 0.26 to 0.59; P < 0.001)

Full Text:  Morelli. Effect of Heart Rate Control With Esmolol on Hemodynamic and Clinical Outcomes in Patients With Septic Shock. A Randomized Clinical Trial. JAMA 2013;epublished October 9th

 

Journal of the American Medical Association:     Statins in VAP

Papazian and colleagues completed a randomized, placebo-controlled, double-blind, parallel-group, multi-center trial in 300 critically ill patients receiving invasive mechanical ventilation for more than 2 days and with suspected ventilator-associated pneumonia, comparing simvastatin 60 mg with placebo,and found:
  1. the study was stopped for futility at the first scheduled interim analysis
  2. no difference in 28 day mortality (simvastatin 21.2% versus placebo 15.2% P = 0.10; hazard ratio 1.45, 95% CI 0.83 to 2.51; between-group difference 6.0%, 95% CI −3.0% to 14.9%)
  3. 93% in the simvastatin group and 89% in the placebo group were naive to statin therapy at ICU admission
    • in statin-naive patients, a trend for worsened 28 day mortality with statins 21.5% versus 13.8% (P = 0.054) (between-group difference 7.7%, 95% CI −1.8% to 16.8%)
  4. no significant differences regarding
    • mortality: 14 day, ICU, or hospital
    • duration of mechanical ventilation
    • changes in SOFA score

Full Text:  Papazian. Effect of Statin Therapy on Mortality in Patients With Ventilator-Associated PneumoniaA Randomized Clinical Trial.   JAMA 2013;epublished October 9th

 

Unpublished Results

Torres. Corticosteroids for Severe Community-Acquired Pneumonia.

In a parallel group, randomized controlled trial Torres and colleagues compared methylprednisolone 0.5 mg/kg 12 hourly (n=31) with matching placebo (n=29) for five days in 60 patients, and found:

  1. steroid therapy was associated with
    • reduced rates of treatment failure (primary outcome) 13% versus 31% (p=0.021), (crude odds ratio 0.34, 95% CI 0.14 - 0.87, p=0.024) (adjusted OR 0.34, 95% CI 0.12 - 0.96, p=0.04)
    • reduced mortality 10% versus 15%
    • reduced inflammatory cytokine levels
    • no reduction in length of stay (10.5 days versus 11 days)
  2. treatment failure was largely due to worsening of the chest radiograph

(these results are provisional as I was taking notes during the presentation)

 

Unpublished Study

Pearse. OPTIMISE Trial: Haemodynamic therapy for high-risk surgical patients.

I hope you find these brief summaries and links useful.

 


Until Sunday.

Rob

 

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