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Critical Care Reviews Newsletter - ATS Update

May 20th 2013



Welcome to a supplementary Critical Care Reviews Newsletter, bringing you the results of latest research presented at the Critical Care Clinical Trials session of the American Thoracic Society meeting held a few hours ago in Philadelphia. These studies have been simultaneously published online in JAMA and the NEJM.

New England Journal of Medicine:     Prone Ventilation

Guérin and colleagues performed a multicenter, prospective, randomized, controlled trial in 466 patients with severe ARDS comparing prone-positioning sessions of at least 16 hours duration (n=237) with the supine position (n=229). Severe ARDS was defined as a PaO2/Fi02 ratio less than 150 mm Hg, with an FiO2 of at least 0.6, a PEEP of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. 28-day mortality was markedly lower in the prone group (16% versus 32.8%; P<0.001; hazard ratio for death 0.39, 95% CI 0.25 to 0.63). Unadjusted 90-day mortality was also lower with prone positioning (23.6% versus 41.0%; P<0.001; hazard ratio 0.44, 95% CI 0.29 to 0.67). The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group.

Full Text:  Guérin. Prone Positioning in Severe Acute Respiratory Distress Syndrome (PROSEVA). New Engl J Med 2013;epublished May 20th

Editorial:  Soo Hoo. In Prone Ventilation, One Good Turn Deserves Another. New Engl J Med 2013;epublished May 20th 


Journal of the American Medical Association:     Parenteral Nutrition

Doig et al completed a multicenter, randomized, single-blind trial comparing early parenteral nutrition (PN) in critically ill adults with relative contraindications to early enteral nutrition (EN)(n=686) with standard care (n=686).  Of 682 patients receiving standard care, 199 patients (29.2%) initially commenced EN, 186 patients (27.3%) initially commenced PN, and 278 patients (40.8%) remained unfed. Time to EN or PN in patients receiving standard care was 2.8 days (95% CI, 2.3 to 3.4). Patients receiving early PN commenced PN a mean of 44 minutes after enrollment (95% CI 36 to 55). There was no difference in 60 day mortality (standard care 22.8% versus early PN 21.5%; risk difference −1.26%; 95% CI −6.6 to 4.1; P = 0.60). Early PN patients rated 60 day quality of life (RAND-36 General Health Status) statistically, but not clinically meaningfully, higher (45.5 for standard care versus 49.8 for early PN; mean difference 4.3; 95% CI 0.95 to 7.58; P = 0.01). Early PN patients required fewer days of invasive ventilation (7.73 vs 7.26 days per 10 patient × ICU days, risk difference −0.47; 95% CI, −0.82 to −0.11; P = 0.01) and, based on Subjective Global Assessment, experienced less muscle wasting (0.43 vs 0.27 score increase per week; mean difference −0.16; 95% CI −0.28 to −0.038; P = 0.01) and fat loss (0.44 vs 0.31 score increase per week; mean difference −0.13; 95% CI −0.25 to −0.01; P = 0.04).

Full Text: Doig. Early Parenteral Nutrition in Critically Ill Patients With Short-term Relative Contraindications to Early Enteral Nutrition: A Randomized Controlled Trial. JAMA 2013;epublished May 20th   

Editorial:  Ochoa Gautier. Early Nutrition in Critically Ill Patients: Feed Carefully and in Moderation. JAMA 2013;epublished May 20th 


Journal of the American Medical Association:     Music Therapy

Azoulay and colleagues performed a multi-centre randomized trial examining whether listening to self-initiated patient-directed music (PDM) reduced anxiety and sedative exposure during ventilatory support in 373 critically ill patients. Three groups were compared, self-initiated PDM (n = 126), with preferred selections tailored by a music therapist, self-initiated use of noise-canceling headphones (NCH; n = 122), or usual care (n = 125). 86% of patients were white, 52% were female, and the mean (SD) age was 59 (14) years. The patients had a mean (SD) Acute Physiology, Age and Chronic Health Evaluation III score of 63 (21.6) and a mean (SD) of 5.7 (6.4) study days. Patients in the PDM group listened to music for a mean (SD) of 79.8 (126) (median [range], 12 [0-796]) minutes/day. Patients in the NCH group wore the noise-abating headphones for a mean (SD) of 34.0 (89.6) (median [range], 0 [0-916]) minutes/day. The mixed-models analysis showed that at any time point, patients in the PDM group had an anxiety score that was 19.5 points lower (95% CI, −32.2 to −6.8) than patients in the usual care group (P = 0.003). By the fifth study day, anxiety was reduced by 36.5% in PDM patients. The treatment × time interaction showed that PDM significantly reduced both measures of sedative exposure. Compared with usual care, the PDM group had reduced sedation intensity by −0.18 (95% CI −0.36 to −0.004) points/day (P = 0.05) and had reduced frequency by −0.21 (95% CI −0.37 to −0.05) points/day (P = 0.01). The PDM group had reduced sedation frequency by −0.18 (95% CI −0.36 to −0.004) points/day versus the NCH group (P = 0.04). By the fifth study day, the PDM patients received 2 fewer sedative doses (reduction of 38%) and had a reduction of 36% in sedation intensity.

Full Text: Chlan. Effects of Patient-Directed Music Intervention on Anxiety and Sedative Exposure in Critically Ill Patients Receiving Mechanical Ventilatory Support: A Randomized Clinical Trial. JAMA 2013;epublished May 20th  


New England Journal of Medicine:     Nighttime ICU Staffing

Kerlin et al undertook a 1-year randomized trial in an academic medical ICU to assess the effects of nighttime staffing with in-hospital intensivists (intervention) as compared with nighttime coverage by daytime intensivists who were available for consultation by telephone (control). 1598 patients were included in the analyses. The median APACHE III score was 67 (interquartile range, 47 to 91), the median length of stay in the ICU was 52.7 hours (interquartile range, 29.0 to 113.4), and mortality in the ICU was 18%. Patients who were admitted on intervention days were exposed to nighttime intensivists on more nights than were patients admitted on control days (median, 100% of nights [interquartile range, 67 to 100] vs. median, 0% [interquartile range, 0 to 33]; P<0.001). Nonetheless, intensivist staffing on the night of admission did not have a significant effect on the length of stay in the ICU (rate ratio for the time to ICU discharge, 0.98; 95% CI 0.88 to 1.09; P=0.72), ICU mortality (relative risk 1.07; 95% CI 0.90 to 1.28), or any other end point. Analyses restricted to patients who were admitted at night showed similar results, as did sensitivity analyses that used different definitions of exposure and outcome.

Full Text:  Kerlin. A Randomized Trial of Nighttime Physician Staffing in an Intensive Care Unit. New Engl J Med 2013;epublished May 20th



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