CCR-Newsletter-Banner

 

 

European Society of Intensive Care Medicine Congress Update / October 1st 2014

 

Welcome

Welcome to a supplemental Critical Care Reviews Newsletter, bringing you the major research studies presented at the 2014 European Society of Intensive Care Medicine Annual Congress. These studies were presented yesterday and today, and mostly simultaneously co-published in the New England Journal of Medicine and the Journal of the American Medical Association. These papers are likely to be open access for a short period, before being placed behind a paywall for 6 months, so best to download them now. Summaries are included for two studies which have not yet been published - these data are provisional, as I was writing them down during the presentation. I'll add the remaining summaries over the next day or two. Please access the journal publications, or watch the available presentations, for further details of the other studies.

 

ARISE

The ARISE study Investigators completed a large, international, multi-centre, parallel group, randomized controlled trial, comparing early goal-directed therapy (n=796) with usual care (n=804) in 1600 patients presenting to the emergency department with early septic shock, and found:

  1. groups were similar at baseline
  2. no significant differences in
    • 90 day mortality
      • EGDT 18.6% vs UC 18.8%
      • absolute risk difference with EGDT vs UC, −0.3%; 95% CI -4.1 to 3.6; P = 0.90
    • survival time
    • mortality
      • ICU
        • 10.9 vs 12.9; RR 0.85, 95% CI 0.64 to 1.13; P=0.28
      • hospital
        • 14.5 vs 15.7; RR 0.92, 95% CI 0.73 to 1.17; 0.53
      • day 28 
        • 14.8 vs 15.9; RR 0.93 95% CI 0.73 to 1.17; P=0.53
    • duration of organ support
    • length of
      • ICU stay
        • 2.8 vs 2.8 days; p=0.81
      • hospital stay
        • 8.2 vs 8.5 days; p=0.89
  3. EGDT was associated with
    • greater fluid administration in the first 6 hours
      • 1964±1415 ml vs 1713±1401 ml
    • increased liklihood of receiving
      • vasopressors
        • 66.6% vs. 57.8%; P<0.001
      • red-cell transfusions
        • 13.6% vs. 7.0%; P<0.001
      • dobutamine
        • 15.4% vs. 2.6%; P<0.001

Back to Top ↑

 

SDD vs SOD

Full Text:  Oostdijk. Effects of Decontamination of the Oropharynx and Intestinal Tract on Antibiotic Resistance in ICUsA Randomized Clinical Trial. JAMA 2014;epublished October 1st

Editorial:  Kollef. Rational Use of Antibiotics in the ICU. Balancing Stewardship and Clinical Outcomes. JAMA 2014;epublished October 1st

Vodcast:  Presentation and Interview with Chieft Investigator Evelien Oostdijk

Back to Top ↑

 

TRISS

Holst and colleagues completed a Scandanavian multicenter, randomized, parallel-group trial in 1,005 patients (998 analyzed) with shock and a haemoglobin concentration ≤ 9g/dL, comparing a red cell transfusion trigger of ≤ 7g/dL with ≤ 9g/dL and found

  1. both groups were similar at baseline (≤ 7 g/d vs <9 g/dL)
    • SOFA median 10 vs 10; SAPS II median 51 vs 52
  2. the more restrictive transfusion trigger was associated with
    • less units of transfused red cells (median/IQR)
      • 1 (0-3) vs 4 (2-4)
  3. there was no statistically significant difference in (≤ 7 g/d vs <9 g/dL)
    • 90 day mortality
      • 43% vs 45%; RR 0.94; 95% CI 0.78 to 1.09; P = 0.44
    • ischemic events 
      • 7.2% vs 8%, RR 0.90, 95% CI 0.58 to 1.39, P=0.64
    • severe adverse reactions
      • 0 vs 0.2%, P≈1.0
    • requiring life support
      • at day 5: 64.4% vs 62.2%, RR 1.04, 95% 0.93 to 1.14; P=0.47
      • at day 14: 36.8% vs 36.8%, RR 0.99, 95% 0.81 to 1.19; P=0.95
      • at day 28: 7.2% vs 8.0%, RR 0.90, 95% CI 0.58 to 1.39; P=0.64
    • alive without vasopressor or inotropic therapy (mean % of days)
      • 73% vs 75%; P=0.93
    • alive without mechanical ventilation (mean % of days)
      • 65% vs 67%; P=0.49
    • alive without renal-replacement therapy (mean % of days)
      • 85% vs 83%; P=0.54
    • alive and out of the hospital (mean % of days)
      • 30% vs 31%; P=0.89

Full Text:  Holst. Lower versus Higher Hemoglobin Threshold for Transfusion in Septic Shock. TRISS Trial Group and the Scandinavian Critical Care Trials Group. New Engl J Med 2014;epublished October 1st

Editorial:  Hebert. Transfusion Threshold of 7 g per Deciliter — The New Normal. New Engl J Med 2014;epublished October 1st

Vodcast:  Interview with Chief Investigator Lars Holst

Back to Top ↑

 

CALORIES

Full Text:  Harvey. Trial of the Route of Early Nutritional Support in Critically Ill Adults (CALORIES Study). New Engl J Med 2014;epublished October 1st

Editorial:  Cook. The Route of Early Nutrition in Critical Illness. New Engl J Med 2014;epublished October 1st

Vodcast:  Presentation and Interview with Chief Investigator Kathy Rowan

Back to Top ↑

 

FENO HSR

Full Text:  Bove. Effect of Fenoldopam on Use of Renal Replacement Therapy Among Patients With Acute Kidney Injury After Cardiac Surgery: A Randomized Clinical Trial. JAMA 2014;epublished September 29th 

Back to Top ↑

 
 

HARP 2

Full Text:  McAuley. Simvastatin in ARDS. New Engl J Med 2014;epublished September 30th 

 
 

VITdAL ICU

Amrein and colleagues performed a randomized double-blind, placebo-controlled, single-center study in 492 critically ill patients with vitamin D deficiency (≤20 ng/mL), comparing vitamin D3 administration (PO or NG, 540,000 IU followed by monthly maintenance doses of 90,000 IU for 5 months; n=249) with placebo (n=243), and found:

  1. 475 patients were included in the final analysis (vit D n=237; placebo n=238)
  2. there were no significant differences in (median / IQR)
    • length of hospital stay
      • vit D: 20.1 days [11.1-33.3] vs placebo 19.3 days [11.1-34.9]; P = 0.98
    • mortality
      • hospital
        • vit D 28.3% [95% CI 22.6%-34.5%] vs placebo 35.3% [95% CI 29.2%-41.7%]; HR 0.81 [95% CI 0.58-1.11]; P=0.18
      • 6-month
        • vit D 35.0% [95% CI 29.0%-41.5%] vs placebo 42.9% [95% CI 36.5%-49.4%]; HR 0.78 [95% CI 0.58-1.04]; P = 0.09
  3. in the most severe vitamin D deficiency subgroup (n = 200)
    • no significant differences in
      • length of hospital stay
        • vit D 20.1 days (12.9-39.1) vs placebo 19.0 days (11.6-33.8)
      • 6-month mortality
        • vit D 34.7% [95% CI 25.4%-45.0%] vs placebo 50.0% [95% CI 39.9%-60.1%]; HR 0.60 [95% CI 0.39-0.93], P for interaction = 0.12
    • vit D was associated with significantly lower
      • hospital mortality
        • 28.6% [95% CI 19.9%-38.6%] vs 46.1% [95% CI 36.2%-56.2%]; HR 0.56 [95% CI 0.35-0.90], P for interaction = 0.04

Back to Top ↑ 

 

FLORALI

In 310 patients with acute hypoxaemic respiratory failure (PaO2 /FiO2 < 300 mmHg), standard oxygen therapy (n=94) was compared with high flow nasal oxygen (n=106) and with a combination of noninvasive ventilation (minimum 8 hours per day) and HFNO (n=110). The authors found:

  1. most patients had either community-acquired pneumonia (≈60%) or hospital-acquired pneumonia (≈10%)
  2. 77% had a PaO2 /FiO2 < 200 mmHg
  3. no difference in the requirement for invasive mechanical ventilation (1° outcome)
    • SOT 46.8 % vs HFNO 37.7% vs NIV/HFNO 50%; p=0.17
      • reduced requirement for invasive mechanical ventilation in those with a PaO2 /FiO2 < 200 mmHg (n=238)
      • SOT 52.7 % vs HFNO 34.9% vs NIV/HFNO 58%; p=0.009
  4. reduced 
    • ICU mortality
      • SOT 19.1 % vs HFNO 11.3 % vs NIV/HFNO 24.5 %; p<0.05
    • 90 day mortality
      • SOT 23.4 % vs HFNO 12.3 % vs NIV/HFNO 28.2 %; p<0.05

Back to Top ↑

 

EPO ACR 02

Cariou and colleagues completed a French, multi-centre, parallel group, randomised controlled trial, comparing early, high-dose erythropoietin (40,000 IU immediately after ROSC and 12 hourly for 48 hours, n=234) with placebo (n=242) in 476 patients with return of spontaneous circulation after out-of-hospital cardiac arrest, and found:

  1. groups were similar at baseline
  2. there was no difference in
    • neurological recovery
    • cerebral performance category 1 (best outcome) - 32% each
    • mortality (missed the figure)
    • duration mechanical ventilation
      • Epo 5.6 days vs placebo 6.0 days; p=0.61
  3. erythropoietin was associated with increased rates of
    • thrombosis
      • 12.4% vs 5.8%; p=0.01
    • acute stent thrombosis
      • 8 (3.4%) vs 1 (0.4%); p=0.02
 
 

 

I hope you find these links useful.


Until next week

Rob

 

 

Search