International Symposium on Intensive Care and Emergency Medicine Update / March 18th 2014
Welcome
Hello
Welcome to a supplemental Critical Care Reviews Newsletter, bringing you the major resarch studies being presented at the 2014 Brussels meeting this week, and simultaneously published in JAMA and NEJM today, plus Resuscitation a few days earlier.
The ProCESS investigators completed an American multi-centre, randomized controlled trial in 1,341 patients with early septic shock, comparing three management strategies:
- protocol-based early goal-directed therapy (n=439, based on the Rivers GDT protocol)
- protocol-based standard therapy (not requiring the placement of a central venous catheter, administration of inotropes, or blood transfusions, n=446)
- usual care (n=456)
and found:
- significant inter-group differences with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids, vasopressors, inotropes, and blood transfusions.
- 60 day mortality rates:
- protocol-based EGDT group: 21.0%
- protocol-based standard-therapy group 18.2%
- usual-care group 18.9%
- relative risk with protocol-based therapy vs. usual care, 1.04; 95% CI 0.82 to 1.31; P=0.83
- relative risk with protocol-based EGDT vs. protocol-based standard therapy, 1.15; 95% CI 0.88 to 1.51; P=0.31
- There were no significant differences in
- 90-day mortality
- 1-year mortality
- need for organ support
Asfar and colleagues completed a multicenter, randomized, open-label trial in 776 patients with septic shock comparing resuscitation with a mean arterial pressure target of 80 to 85 mm Hg (high target group) with 65 to 70 mmHg (low target group), and found:
- no significant difference in
- 28 day mortality
- high target group 36.6% versus low target group 34.0%
- hazard ratio in the high target group 1.07, 95% CI 0.84 to 1.38; p=0.57
- high target group 36.6% versus low target group 34.0%
- 90 day mortality
- high target group 43.8% versus low target group 42.3%
- hazard ratio in the high-target group 1.04, 95% CI 0.83 to 1.30; p=0.74
- high target group 43.8% versus low target group 42.3%
- serious adverse events
- high target group 19.1% versus low target group 17.8%; p=0.64
- an increased incidence of atrial fibrillation with high-target therapy
- 28 day mortality
Caironi and colleagues completed a multicenter, randomized, controlled, open-label trial in 1,818 patients with severe sepsis, comparing 20% albumin and crystalloid solution (targeting a serum albumin level of 30 g/L), with crystalloid solution alone, and found:
- no difference in
- 28 day mortality (primary outcome)
- albumin group 31.8% versus crystalloid group 32.0%
- relative risk in the albumin group, 1.00; 95% CI 0.87 to 1.14; P=0.94
- albumin group 31.8% versus crystalloid group 32.0%
- 90 day mortality
- albumin group 41.1% versus crystalloid group 43.6%
- relative risk 0.94; 95% CI 0.85 to 1.05; P=0.29
- albumin group 41.1% versus crystalloid group 43.6%
- 28 day mortality (primary outcome)
- no significant differences in other secondary outcomes
- organ dysfunction:
- number of patients
- degree of dysfunction
- length of stay
- ICU
- hospital
- organ dysfunction:
- during the first 7 days, albumin therapy was associated with
- higher mean arterial pressure (P=0.03)
- lower net fluid balance (P<0.001)
- no significant difference in total daily administered fluid (P=0.10)
Kaukonen et al performed a retrospective, observational study from 2000 to 2012, in 101,064 patients with severe sepsis in Australia and New Zealand, and found:
- a decrease in absolute mortality:
- from 35.0% in 2000 (95% CI 33.2% to 36.8%) to 18.4% in 2012 (95% CI 17.8% to 19.0%), P < 0.001
- overall mortality decrease of 16.7% (95% CI 14.8% to 18.6%)
- an annual rate of absolute decrease of 1.3%
- relative risk reduction of 47.5% (95% CI 44.1% to 50.8%)
- adjusted mortality decreased throughout the study period
- odds ratio 0.49 (95% CI 0.46 to 0.52) in 2012, using the year 2000 as the reference (P < 0.001)
- no difference in annual mortality decline between patients with severe sepsis and those with all other diagnoses
- OR 0.94 (95% CI 0.94 to 0.95) vs 0.94 (95% CI 0.94 to 0.94) P = 0.37
- a greater annual increase in rates of discharge to home in patients with severe sepsis compared with all other diagnoses
- OR 1.03 (95% CI 1.02 to 1.03) vs 1.01 (95% CI 1.01 to 1.01) P <0.001
- a smaller annual increase in the rate of patients discharged to rehabilitation facilities in patients with severe sepsis compared with all other diagnoses
- OR 1.08 (95% CI 1.07 to 1.09) vs 1.09 (95% CI 1.09 to 1.10) P < 0.001
- in the absence of comorbidities and older age, mortality was less than 5%
Wik and colleagues performed a multi-centre, unblinded, randomized controlled trial in 4,753 patients (11% met post enrollment exclusion criteria) with out-of-hospital cardiac arrest, comparing integrated automated load distributing band CPR (iA-CPR, n=2,099) with high-quality manual CPR (M-CPR, n=2,132), and found:
- no difference in primary outcome, survival to hospital discharge
- adjusted odds ratio for iA-CPR compared to M-CPR: 1.06, 95% CI 0.83 to 1.37
- demonstrating therapeutic equivalence
- for iA-CPR compared to M-CPR
- sustained ROSC (emergency department admittance)
- 28.6% vs 32.3%
- 24 hour survival
- 21.8% vs 25.0%
- hospital discharge
- 9.4% vs 11.0%
- sustained ROSC (emergency department admittance)
- 20 minutes CPR fraction
- iA-CPR 80.4% vs M-CPR: 80.2%
I hope you find these brief summaries and links useful.
Until the weekend
Rob