Check out our journal watch, which is updated daily, to stay up-to-date with the latest critical care literature. The weekly newsletter contains a summary of the papers highlighted over the previous 7 days and is emailed to registered users every Sunday night.
Image: Shutterstock
Convalescent Plasma
Meta Analyses
In a systematic review of 4 published trials including 1060 patients with confirmed or treated COVID-19 in any treatment setting, the use of convalescent plasma was not associated with a significant reduction in all-cause mortality; risk ration 0.93 (95% CI, 0.63 to 1.38).
Added February 27th
Image: Shutterstock
Organ Donation
Position Statement
This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation.
Added February 27th
Image: Shutterstock
RECOVERY - Dexamethasone arm
RCT
Originally published in provisional format last Summer, the full paper of the RECOVERY trial - dexamethasone arm, is now out. In 6425 hospitalised patients with COVID-19, treatment with 10 mg IV dexamethasone for up to 10 days resulted in a lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone.
Added February 25rd
Image: Shutterstock
The BACLOREA Trial
RCT
The BACLOREA trial, initial presented at eCCR21, reported a decrease in agitation-related events with baclofen in 314 mechanically ventilated patients with alcohol misuse disorder (19.7% vs. 29.7% with placebo), but a longer length of mechanical ventilation (9 vs 8 days) and stay in the ICU (14 vs 11 days.
Added February 23rd
Image: Shutterstock
The VICTAS Trial
RCT
The VICTAS trial, comparing treatment with vitamin C, thiamine, and hydrocortisone with placebo in 501 patients with septic shock, reported no significant difference in ventilator- and vasopressor-free days (25 vs 26 , respectively) at 30 days. Funding was withdrawn after just 501 out of a planned 2000 patients were recruited.
Added February 23rd
Image: Digital Storm | Shutterstock
Editorial
Image: Kiryl Lis | Shutterstock
Narrative Review
Il-6 RA Antagonists
The REMAP-CAP trial investigators will present the results of their interleukin-6 receptor anatgonist domain, examining tocilizumab & sarilumab, in critically ill patients with COVID-19, on Thursday February 25th/26th. The preprint, published January 7th, reported a mortality benefit with this intervention.
Anticoagulation in COVID-19
The ACTIV4-a, ATTACC, & REMAP-CAP investigators will present the results of this multi-platform trial examining therapeutic & prophylactic anti- coagulation in patients with COVID-19. We hope to host this result over the next couple of months. The interim analysis was released January 28th.
TTM post Cardiac Arrest
Originally planned for CCR21, which became eCCR21, but delayed into the Spring, the long awaited results of the follow-up trial to the landmark targeted temperature management after out-of-hospital cardiac arrest is out soon. Is the avoidance of fever the critical aspect of TTM?
Balanced IV Fluid Solutions
This massive 11,000 patient trial from Brazil was also scheduled for CCR21, but was unavoidably delayed due to the pandemic. Comparing Plasma-Lyte 148 with 0.9% saline, it's almost ready for release now and we're delighted to be hosting this major trial result later this Spring.
Latest Major RCTs
Vitamin D for COVID-19
In a Brazilian two-centre, blinded RCT in 240 patients with moderate or severe COVID-19, Murai and colleagues reported that a single oral dose of 200 000 IU vitamin D3 did not significantly change the median (IQR) length of hospitalisation; vitamin D3 group, 7.0 (4.0-10.0) days, vs. placebo group, 7.0 (5.0-13.0) days; log-rank, P = 0.59; unadjusted HR, 1.07; 95% CI, 0.82-1.39; P = 0.62.
JAMA 2021;epublished February 17th
Image: Dimitri Karastelev | Unsplash
REALITY Trial
In 668 patients with acute myocardial infarction and a hemoglobin level between 7 and 10 g/dL, a red cell transfusion threshold of ≤8 g/dL was found to be non-inferior to a threshold of ≤10 g/dL, with the composite MACE outcome (all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization) at 30 days occurring in 11% vs 14%, respectively.
Fluids After Bypass Study
In 715 patients undergoing cardiopulmonary bypass and randomised to a protocol-guided strategy, using stroke volume variation to guide the administration of bolus fluids, or to usual care fluid administration, until desedation or up to 24 hours, there was no difference in the primary outcome of ICU length of stay; (median/IQR) intervention group; 27.9 hr (21.8–53.5 hr) vs control, 25.6 hr (21.9–64.6 hr); p = 0.95.
Crit Care Med 2021;epublished January 28th
Image: MAD.vertise | Shutterstock
MENDS2 Trial
In 432 ventilated adults with sepsis, randomised to receive IV sedation with either dexmedetomidine (0.2 to 1.5 μg/kg/hr) or propofol (5 to 50 μg/kg/min), there was no difference between groups in the primary outcome of days alive without delirium or coma during the 14-day intervention period; 10.7 vs. 10.8 days; OR, 0.96; 95% CI, 0.74 to 1.26; respectively. There were also no differences in secondary outcomes, including mortality.
N Engl J Med 2021;epublished February 2nd
Image: Shutterstock
Hypothermia for TBI with refractory intracranial hypertension
In adult patients suffering a traumatic brain injury, with a GCS score of 4 to 8, and initial ICP ≥ 25 mm Hg, the implementation of long-term mild hypothermia group (34–35 °C for 5 days), in comparison with normothermia group at 37 °C, did not improve the proportion with a favorable outcome (OR 1·55, 95%CI 0·91–2·64; P = 0·105) or mortality (P = 0·111) at 6 months.
EClinicalMedicine 2021;epublished January 28th
Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures
In a prospective study in 20 ICUs in 3 countries, amongst 631 patients who underwent continued monitoring after planned withdrawal of life-sustaining support, 14% of patients had a resumption of cardiac activity after a period of pulselessness. Just 1 percent were observed clinically. The longest period to resumption of cardaic activity was 4 minutes 20 seconds.
N Engl J Med 2021; 384:345-352 | January 28th, 2021
Image: SURIYO CINNABUT | Shutterstock
HOT-ICU Trial Results
In a Danish led, international, multi-centre, randomised controlled trial trial in 2928 adults with acute hypoxaemic respiratory failure, targetting a PaO2 of 8 kPa, in comparison with 12 kPa, did not improve the primary outcome of 90-day mortality (42.9% vs 42.4%; adjusted risk ratio, 1.02; 95% CI, 0.94 to 1.11; P=0.64).
Presented at eCCR21. Video available at eCCR21 webpage
N Engl J Med 2021;epublished January 20th
Image: AndaPhoto | Shutterstock
Tocilizumab in patients with severe or critical COVID-19
In a Brazilian randomised controlled trial involving 9 hospitals, the use of tocilizumab as a single intravenous infusion of 8 mg/kg plus standard care (n=65) versus standard care alone (n=64), resulted in suimilar levels of mechanical ventilation at day 15 (28% vs. 20; (odds ratio 1.54, 95% CI0.66 to 3.66; P=0.32).), respectively, and increased mortality (17% vs. 3%; odds ratio 6.42, 95% CI,1.59 to 43.2).
BMJ 2021;372:n84, published January 20th
Image: M Morea | Shutterstock
Featured
COVID-19
Tocilizumab & sarilumab reduce mortality in severe COVID-19
In a pre-print paper, the REMAP-CAP trial investigators have reported efficacy with interleukin 6 receptor anatgonists in critically ill patients with COVID-19. Hospital mortality was 28.0% (98/350) for tocilizumab, 22.2% (10/45) for sarilumab and 35.8% (142/397) for control.
Preprint January 7th
RECOVERY Trial Halts Convalescent Plasma Arm
In 10,406 randomised patients, with 1873 reported deaths, there was no significant difference in the primary endpoint of 28-day mortality -18% convalescent plasma vs. 18% usual care alone; risk ratio 1.04 [95% confidence interval 0.95-1.14]; p=0.34.
Prof Peter Horby, Tweet, Jan 15th
Therapeutic Anticoagualtion halted across 3 COVID-19 Trials
Three large randomised controlled trials, ATTACC, @ACTIV4a, and REMAP-CAP, have, for futility, halted recruitment to their therapeutic anticoagulation arms in critically ill patients with COVID-19.
Other Recent RCTS of Note
Inhaled Heparin for ARDS
In this multi-centre, blinded Australian trial, 25 000 IU of nebulised heparin administered 6 hourly while invasively ventilated, did not significantly alter the primary outcome of functional outcomes (SF-36) at 60 days; survivors in the heparin group (n=97) mean 53·6 vs control 48·7; difference 4·9 [95% CI –4·8 to 14·5]; p=0·32).
Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis
In this trial PCT-guided antimicrobial treatment in sepsis was effective in reducing infection-associated adverse events like infections by multidrug-resistant organisms and Clostridioides difficile, as well as in-hospital and 28-day mortality.
Am J Respir Crit Care Med 2021;202(3):202–210
January 17th 2021
Ultra-early tranexamic acid after subarachnoid haemorrhage (ULTRA): a randomised controlled trial.
Lancet 2020;epublished December 21st
Risk of Overcorrection in Rapid Intermittent Bolus vs Slow Continuous Infusion Therapies of Hypertonic Saline for Patients With Symptomatic Hyponatremia
JAMA Intern Med 2020;epublished October 26th
Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants
In 1824 infants born prematurely between 22 and 26 weeks and weighing less than 1000 g, a higher hemoglobin threshold for red-cell transfusion did not improve survival without neurodevelopmental impairment at 22 to 26 months of age, corrected for prematurity
N Engl J Med 2020;383:2639-2651
Surviving Sepsis Campaign COVID-19 Update
Crit Care Med 2021;epublished January 28th
Image: AHMETOZER35 | Shutterstock
Recommended
- In
- Systemic corticosteroids
- Venous thromboprophylaxis
- Out
- Hydroxychloroquine
Suggested
- In
- Dexamethasone as perferred steroid
- Remdesevir in non-ventilated critically ill
- Out
- Convalescent plasma (outside clinical trials)
- Therapeutic anticoagulation (outside clinical trials)
- Remdesevir in ventilated critically ill
- No recommendation
- Awake prone positioning.
