Hot Articles

The following articles have been chosen as the most noteworthy publications in critical care since December 2011.


Randomised Controlled Trials

ESICM Trials

Non-ESICM Trials

Guidelines & Position Statements

Randomised Controlled Trials

Guidelines & Position Statements

Randomised Controlled Trials

Observational Studies

Guidelines & Position Statements

Randomised Controlled Trials

Guidelines & Position Statements


Randomised Controlled Trials

Guidelines & Position Statements

Laptook. Effect of Therapeutic Hypothermia Initiated After 6 Hours of Age on Death or Disability Among Newborns With Hypoxic-Ischemic Encephalopathy. A Randomized Clinical Trial. JAMA 2017;318(16):1550-1560

Stöckl. Continuous versus intermittent neuromuscular blockade in patients during targeted temperature management after resuscitation from cardiac arrest—A randomized, double blinded, double dummy clinical trial. Resuscitation 2017;120:14-19

Koster. Safety of mechanical chest compression devices AutoPulse and LUCAS in cardiac arrest: a randomized clinical trial for non-inferiority. European Heart Journal 2017;38(40):3006–3013

The Implementation of Targeted Temperature Management: An Evidence-Based Guideline from the Neurocritical Care Society. Neurocrit Care 2017;epublished October 16th

Right heart dysfunction and failure in heart failure with preserved ejection fraction: mechanisms and management. Position statement on behalf of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2017;epublished October 16th

Koch. A Randomized Clinical Trial of Red Blood Cell Transfusion Triggers in Cardiac Surgery. Ann Thorac Surg 2017;104(4):1243-1250

Jaillette. Impact of tapered-cuff tracheal tube on microaspiration of gastric contents in intubated critically ill patients: a multicenter cluster-randomized cross-over controlled trial. Intensive Care Med 2017;43(11):1562–1571

Guidelines for the diagnosis and management of critical illness-related corticosteroid insufficiency (CIRCI) in critically ill patients (Part II): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017. Intnsive Care Med 2017;epublished October 31st

Treatment and Outcome of Hemorrhagic Transformation After Intravenous Alteplase in Acute Ischemic Stroke: A Scientific Statement for Healthcare Professionals From the American Heart Association / American Stroke Association. Stroke 2017;epublished November 2nd

Thiele. PCI Strategies in Patients with Acute Myocardial Infarction and Cardiogenic Shock (CULPRIT-SHOCK). N Engl J Med 2017;epublished October 30th

van Brunschot. Endoscopic or surgical step-up approach for infected necrotising pancreatitis: a multicentre randomised trial. Lancet 2017;epublished November 3rd

European Stroke Organization guideline for the diagnosis and treatment of cerebral venous thrombosis – endorsed by the European Academy of Neurology. Eur J Neurol 2017;24:1203–1213

30th Annual ESICM Congress (LIVES2017, Vienna) 

New Engl J Med - Age of Transfused Red Cells

JAMA - Alveolar Recruitment in ARDS

JAMA - Intra-Operative Blood Pressure Management

JAMA - Systematic ICU Admission for Elderly Sick Patients

JAMA - Early Goal-Directed Sepsis Care in Zambia

Intensive Care Medicine - Early Goal-Directed Nutrition

Intensive Care Medicine - Airway Pressure Release Ventilation

Intensive Care Medicine - Spontaneous Breathing Trials

Intensive Care Medicine - Biomarker-Guided Strategy for Discontinuing Antifungal Therapy

Kneyber. Recommendations for mechanical ventilation of critically ill children from the Paediatric Mechanical Ventilation Consensus Conference (PEMVECC). Intensive Care Med 2017;epublished September 22nd

Intensive Care Medicine - Positioning for VAP

Intensive Care Medicine - Adrenal Insufficiency Guideline

Circulation - Cardiogenic Shock Guideline

Lancet Respiratory Medicine - Sedation Interruption

Chest - Checklists for ICU Intubation

Critical Care Medicine - Nebulized Versus IV Amikacin in VAP

European Respiratory Journal - HAP / VAP Guideline

Annals of Surgery - Transfusion Thresholds in Burns

Critical Care - Loxapine for Agitation

Critical Care - Recombinant ACE 2 in ARDS

J Crit Care - Enteral Nutrition as Stress Prophylaxis

Am J Respir Crit Care Med - Coping Skills in ICU Survivors

European Respiratory Journal - NIV Guideline

NEJM - Oxygen in Acute Myocardial Infarction

Crit Care Resusc - Earplugs for Sleep Quality

Resuscitation - Intermittent vs Continuous Neuromuscular Blockade during Temperature Management post Cardiac Arrest

JAMA - Ganciclovir in CMV-Positive Critically Ill Patients

Critical Care - Serlipressin in Septic Shock

Critical Care Medicine - Simulation for ECMO Emergencies

Critical Care Medicine - Exposure Keratopathy

Critical Care - Software-Guided Glycaemic Control

Thorax - Rehabilitation in the ICU

JAMA - 24 vs 48 Hours of Hypothermia post Cardiac Arrest

JPEN - Paediatric Nutritional Support Guideline

Journal of Intensive Care - Japanese ARDS Guideline

Chinese Medical Journal - EEG Monitoring Guideline

Lancet respiratory Medicine - Simvastatin for Prevention & Treatment of ICU Delirium

Journal of Critical Care - Furosemide in Early Acute Kidney Injury

Lancet - Procalcitonin-Guided Antibiotics in Early Sepsis

Minerva Pneumologica - NIV vs IMV in Hypoxaemic Respiratory Failure

JAMA Cardiology - Spironolactone in Acute Heart Failure

Anaesth Crit Care Pain - French TTM Guideline

World Jounal of Emergency Surgery - Intra-Abdominal Infections Guideline

Critical Care Medicine - Blood flow & CRRT Circuit Lifespan

European Heart Journal - Safety of Mechanical Chest Compression Devices

Journal of Korean medical Science - Mild Hypothermia for Poor Grade Subarachnoid Haemorrhage

Critical Care Medicine - Shenfu Injection post Cardiac Arrest

JAMA - Cooling post Neonatal Hypoxic-Ischaemic Encephalopathy

Circulation - N-Acetylcysteine & Nitrate Therapy in STEMI

Thorax - Post ICU Rehabilitation

McDowell. Effectiveness of an exercise programme on physical function in patients discharged from hospital following critical illness: a randomised controlled trial (the REVIVE trial) Thorax 2017;72:594-595

JAMA - FAST Scan in Paediatric Trauma

J Allergy Clin Immunol Pract - Icatibant for ACE Inhibitor-Induced Angioedema

Ann Emerg Med - High Flow Nasal Oxygen in Cardiogenic Pulmonary Oedema

Critical Care - Supplementary Parenteral Nutrition

JAMA Surgery - Intraoperative Dexmedetomidine & Post-Op Cognitive Dysfunction

Intensive Care Med - AKI Guideline

American Thoracic Society Conference

NEJM - Angiotensin II for Septic Shock

NEJM - Time to Treatment in Sepsis

JAMA - Outcome Prediction ICU

Thorax - BTS Oxygen Use Guideline

Crit Care Medicine - Paediatric & Neonatal Septic Shock Guideline

Neurology - Brain Injury after CPR Guideline

Chest - Positioning for Endotracheal Intubation

Resuscitation - Video versus Direct Laryngoscopy for Paramedic Endotracheal Intubation

European Journal of Anaesthesiology - Severe Perioperative Bleeding Guideline

Annals of Intensive Care - Post Extubation High Flow Nasal Oxygen

Crit Care Medicine - Stress Ulcer Prophylaxis

American Heart Journal - Nitric Oxide in Acute PE

N Eng J Med - Bystander Efforts in Out-of-Hospital Cardiac Arrest

Lancet - Tranexamic Acid for Post Partum Haemorrhage

Lancet Haematology - FFP vs Coagulation Factor Concentrates for Traumatic Coagulopathy

JAMA Internal Medicine - Antiviral Therapy for CMV Reactivation

Annals of Thoracic Surgery - Corticosteroids in Neonatal Cardiac Operations

JAMA - Postoperative Troponin Elevation in Noncardiac Surgery

Intensive Care Medicine - Immunoglobulin for Necrotising Soft Tissue Infection

New England Journal of Medicine - Ularitide in Acute Heart Failure

Intensive Care Medicine - NIV Post Extubation in Chronic Respiratory Disorders

Intensive Care Medicine - IV Chloride Restriction in Cardiac Surgery

Critical Care Medicine - Transfusion in Critically Ill Oncology Patients

J Trauma - Damage Control Resuscitation Guideline

J Crit Care - Tracheostomy Guideline

Intensive Care Med - Condolence Letter

JPEN J Parenter Enteral Nutr - Parenteral Nutrition Guideline

Intensive Care Medicine - Early Enteral Nutrition Guideline

Critical Care Medicine - Contrast-Induced Nephropathy

Critical Care - Pseudomonas Vaccine

Society of Critical Care Medicine Annual Congress

JAMA - Video vs Direct Laryngoscopy for Intubation in ICU

N Engl J Med - Therapeutic Hypothermia for Paediatric Cardiac Arrest

N Engl J Med - Paediatric Glycaemic Control

JAMA - Intubation during Cardiac Arrest

Crit Care Med - Surviving Sepsis Campaign Guidelines

Crit Care Med - Family-Centred Care Guidelines

Chest - Liberation from Mechanical Ventilation Guidelines


NEJM - Age of Transfused Blood

NEJM - Tranexamic Acid for Coronary Artery Surgery

Intensive Care Medicine - High Flow Nasal Oxygen post Abdominal Surgery

Intensive Care Medicine - Balanced versus Unbalanced Crystalloids

Intensive Care Medicine - HFNO vs NIV for Pre-Oxygenation in Hypoxic ICU patients

Critical Care - Steroids in Early Sepsis-Associated ARDS

Am J Respir Crit Care Med - Helium / Oxygen in Exacerbations of COPD

Intensive Care Medicine - Intravascular Catheter Dressings

J Crit Care - Intensity of Feeding

ESICM 2016

NEJM - Levosimendan in Sepsis




JAMA - Intubation during Paediatric Cardiac Arrest

Therapeutic Hypothermia & Cardiac Arrest

JAMA - Steroids in Sepsis

Intensive Care Medicine - Fluid Resuscitation in Sepsis

Intensive Care Medicine - Nitric Oxide during Cardiopulmonary Bypass

Intensive Care Medicine - NAVA

Intensive Care Medicine - IV Iron for Anaemia

Intensive Care Medicine - Recovery Programme

Lancet - Early, Goal-Directed Mobilisation

Critical Care Medicine - Dopamine vs Adrenaline in Septic Shock

 Neurosurgery - 4th Brain Trauma Foundation TBI Guideline

NEJM - High Flow Nasal Oxygen for Preterm Infants

Crit Care Med - Stress Ulcer Prophylaxis

Liver International - Vasopressor Support for Cirrhosis & Septic Shock

NEJM - Decompressive Craniotomy

Am J Respir Crit Care Med - Sevoflurane for Sedation ARDS

Chinese Medical Journal - Evaluation of Coma after Cardiac Arrest

N Engl J Med - Factor Xa Inhibitor Related Bleeding

Lancet Respiratory Medicine - Sedation & Analgesia

JAMA Cardiology - Nonshockable Out-of-Hospital Cardiac Arrest

Shock - Hydrocortisone in Septic Shock

JAMA Internal Medicine - Sodium Selenite & Procalcitonin in Sepsis

Journal of Critical Care - Heparin for Pneumonia in Ventilated Patients

European Heart Journal - Acute Heart Failure Guideline

Clinical Infectious Diseases - HAP & VAP Guideline

Am J Respir & Crit Care Med - Burnout Syndrome in Critical Care Professionals

JAMA - Palliative Care-Led Meetings

Lancet - Platelet Transfusion in Haemorrhagic Stroke

JAMA - Timing of Renal Replacement Therapy in AKI

American Thoracic Society Meeting

New England Journal of Medicine:     Timing of Renal Replacement Therapy in AKI

JAMA:     Aspirin for the Prevention of ARDS

JAMA:     Helmet NIV for ARDS

American Journal of Kidney Disease:     Renal Replacement Therapy Dose

Journal of the American College of Cardiology:     Early Aldosterone Blockade in Acute MI

Resuscitation:     Video Laryngoscopy during CPR

Critical Care:     European Guideline on Bleeding & Coagulopathy post Trauma

JAMA:     Checklists

Resuscitation:     Hypercapnoea post Cardiac Arrest

NEJM:     Antiarrhythmics in Out-of-Hospital Cardiac Arrest

Critical Care:     Steroids for Refractory Shock post Cardiac Arrest

Intensive Care Medicine:     Probiotics for the Prevention of VAP

Brussel's International Symposium on Intensive Care & Emergency Medicine

JAMA:  Dexmedetomidine Sedation in ICU

JAMA: High-Flow Nasal Oxygen post Extubation

JAMA: Non-Invasive Ventilation post Extubation after Abdominal Surgery

JAMA: Secondary Infections post Sepsis

NEJM: Early TPN in Childern

Critical Care Medicine:  Fragility Index in Critical Care

Journal of Infection - UK Meningitis Guidelines

JAMA - Sepsis Definition

JAMA - Statins for AKI

JAMA - ARDS Epidemiology

Lancet Respiratory Medicine - Effect of Light on Delirium

Intensive Care Medicine - Blood Pressure Targets in Shock

NICE Trauma Guideline

JAMA - Acetazolamide for COPD

Intensive Care Medicine - Percutaneous Dilational Tracheostomy

Pediatric Crit Care Med - Aminophylline for Prevention of AKI

Blue Journal - End-of-Life Communication

JPEN J Parenter Enteral Nutr - Nutritional Support in the Critically Ill

Intensive Care Medicine - Continuous vs Intermittent Beta Lactam Infusion

Chest - Antithrombotic Therapy for VTE

Resuscitation - TTM post Cardiac Arrest

German Medical Society - Delirium, Analgesia & Sedation Guideline

Annals of Intensive Care - Renal Replacement Therapy Guideline

ANZICS - Acute Pain Management Scientific Evidence


Journal of Thrombosis and Haemostasis - Guideline on Antidotes for Direct Oral Anticoagulants

American Journal of Respiratory & Critical Care Medicine:     Physical Therapy for Respiratory Failure

NICE Guideline on Acute Heart Failure

NICE Guideline on IV Fluid Therapy in Young People

Journal of Trauma:  Western Trauma Guidelines

Critical Care Medicine:     SCCM Guideline on Ultrasound in Critical Care

Critical Care Medicine: SCCM Guideline on Organ Procurement

Critical Care Medicine:    SCCM Guideline on ICU Process & Structures

Lancet Infectious Diseases:     Body Surface Decolonization & UTIs

JAMA:     Transfusion in Anaemic Children with Elevated Lactate

Intensive Care Medicine:  Post-Resuscitation Care Guideline

American Heart Association:  ST-Elevation MI Guideline Update

American Heart Association:  Infective Endocarditis Guideline

2015 Cardiac Arrest Guidelines

  1. Part 1: Executive Summary: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S315-S367
  2. Part 2: Evidence Evaluation and Management of Conflicts of Interest: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S368-S382
  3. Part 3: Ethical Issues: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S383-S396
  4. Part 4: Systems of Care and Continuous Quality Improvement: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S397-S413
  5. Part 5: Adult Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S414-S435
  6. Part 6: Alternative Techniques and Ancillary Devices for Cardiopulmonary Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S436-S443
  7. Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S444-S464
  8. Part 8: Post–Cardiac Arrest Care: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S465-S482
  9. Part 9: Acute Coronary Syndromes: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S483-S500
  10. Part 10: Special Circumstances of Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S501-S518
  11. Part 11: Pediatric Basic Life Support and Cardiopulmonary Resuscitation Quality: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S519-S525
  12. Part 12: Pediatric Advanced Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care
  13. Circulation 2015;132:S526-S542
  14. Part 13: Neonatal Resuscitation: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S543-S560
  15. Part 14: Education: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2015;132:S561-S573

ESICM Hot Topics and New Trials

N Engl J Med:     Plasmalyte vs Saline

JAMA:     Paracetamol for Fever in Critically ill with Suspected Infection

Lancet:     Erythropoietin for Traumatic Brain Injury

N Engl J Med:     Hypothermia for Intracranial Hypertension in Traumatic Brain Injury

Am J Respir Crit Care Med:     Apnoeic Oxygenation

JAMA:     ICU Admission for Older Adults with Pneumonia

JAMA:     Do-Not-Resuscitate Status


NEJM:     CVC Insertion Site

Clinical Drug Investigation:  Esmolol for Sepsis

Lancet:     Methylprednisolone for Cardiopulmonary Bypass

Lancet:     Sigmoid Diverticulitis

Lancet:  CVC Line Infection Prevention

American Journal of Respiratory & Crit Care Med:     End-of-Life Care

Critical Care:     Laxative Therapy

Lancet:  Oxyenation Target in Bronchiolitis

Lancet:  Bubble CPAP for Paediatric Pneumonia

European Journal of Anesthesiology:     Pre-Oxygenation

Critical Care Medicine:     Vasopressors for Paediatric Septic Shock

Blue Journal:     Oxygenation Targets in Mechanically Ventilated Patients

Journal of Hepatology:     Plasma Exchange for Acute Liver Failure

Circulation:     ESC Guidelines on Pulmonary Hypertension | Pericardial Disease | Non-Persistent ST Elevation Coronary Syndromes | Infective Endocarditis

British Journal of Haematology:     Guideline on Admission for Haematology Cancer Patients

Journal of Trauma:  Early Surgery in Traumatic Brain Injury

Annals of Surgery:     Cryopreserved Packed Red Cells

NEJM / Lancet:     Idarucizumab for Dabigatran

Lancet:     Bioprosthetic Total Artificial Heart Heart

New England Journal of Medicine:     Hypothermia for Deceased Kidney Donor Graft

JAMA:     Bystander CPR

Blue Journal:     β-Lactam Infusion in Severe Sepsis

Perioperative Medicine:     Stroke Volume Variation

Critical Care Medicine:    Critical Care Interventions

Blue Journal:     Haemofiltration for Postcardiac Surgery Shock

Annals of Surgery:     Abdominal Vacuum Therapy post Laparotomy

Annals of Intensive Care:     Guideline on Cardiogenic Shock

Journal of Trauma:     Guideline on ED Thoracotomy

Critical Care Medicine:     Hypothermia for Paediatric Traumatic Brain Injury

Circulation:     Targeted Temperature Management

New England Journal of Medicine:     Out-of-Hospital CPR

New England Journal of Medicine:     Stroke Thrombolysis

New England Journal of Medicine:     Stroke Thrombectomy

Blue Journal:     Guideline on Requests for Inappropriate ICU Therapy

Blue Journal:     Guideline on Managing Conscientious Objections in ICM

Journal of Cardiac Failure:     Statement on Percutaneous Mechanical Circulatory Support

European Heart Journal:     Guideline on Acute Heart Failure

Stroke:     Guideline on Spontaneous Intracerebral Haemorrhage

Critical Care Medicine:     Talactoferrin for Sepsis

New England Journal of Medicine:     Intra-Abdominal Infection

American Thoracic Society Meeting 2015

New England Journal of Medicine:     Underfeeding

New England Journal of Medicine:     High Flow Nasal Oxygen

Journal of the American Medical Association:     High Flow Nasal Oxygen

Lancet:     Red Cell Transfusion in Upper GI Haemorrhage

 British Medical Journal:     MRSA Therapy

AJRCCM:     GUIDELINE - Conscientious Objections in ICU

Intensive Care Society:     Provision of Intensive Care Servces

Neurocritical Care:     Hemispheric Infarction

Neurocritical Care:     Devastating Brain Injury

Swiss Medical Weekly:     Ethics in ICU

New England Journal of Medicine:     Paediatric Therapeutic Hypothermia post Cardiac Arrest

New England Journal of Medicine:     Alcoholic Hepatitis

Intensive Care Medicine:     High Flow Nasal Cannulae Oxygen for Intubation

JAMA Internal Medicine:     Post ICU Rehabilitation

Intensive Care Medicine:     Polymyxin B Hemoperfusion

Chest:     Surfactant in ARDS

Intensive Care Medicine:    Early Rehabilitation

Critical Care Medicine:     Regional Citrate Anticoagulation for RRT

NEJM:     Age of Transfused Red Cells

NEJM:     ARDS Driving Pressure

JAMA:     Steroids for Community-Acquired Pneumonia

Acta Anaesthesiologica Scandinavica:     Fluid Resuscitation Guideline

NEJM:     Endovascular Stroke Therapy

Journal of Trauma:     EAST Guideline on Clearing the Cervical Spine in the Obtunded Patient

NEJM:     Stroke Neuroprotection

JAMA:     Trauma Transfusion Ratios


Lancet Respiratory Medicine:     Perioperative Goal-Directed Oxygen Delivery

JAMA:     Hypoxaemic Ischaemic Encephalopathy

New England Journal of Medicine:     Endovascular Stroke Therapy

New England Journal of Medicine:     Traumatic Brain Injury

Stroke:     Statins for Subarachnoid Haemorrhage

Lancet:     Red Cell Transfusion Triggers

 Lancet:     IV Fluid Therapy

Intensive Care Medicine:     Therapeutic Hypothermia for Cardiac Arrest

Intensive Care Medicine:    Balanced Crystalloid Solutions

Cell Transplantation:     Spinal Cord Regeneration

Resuscitation:     Refractory Cardiac Arrest

Journal of Clinical Epidemiology:     Fragility Index

ESICM Congress Studies

New England Journal of Medicine:     ARISE Study

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

New England Journal of Medicine:     TRISS Study

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

Unpublished:     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

New England Journal of Medicine:     CALORIES

Journal of the American Medical Association:     SDD vs SOD

ESICM Congress Studies

Journal of the American Medical Association:     VITdAL-ICU Study

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

Unpublished:     FLORALI Study

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

New England Journal of Medicine:  Ebola Virus Disease

Critical Care Medicine:  Fatty Acid Supplementation

Anesthesiology:  Erythropoietin & Acute Kidney Injury

European Heart Journal:  STEMI

European Heart Journal:  Guidelines

European Journal of Anaesthesiology:  Cardiovascular Assessment & Management for Non-Cardiac Surgery

Canadian Medical Association Journal:  Melatonin for Delirium

ESC Congress Studies

ESC Congress Studies

European Heart Journal:     ESC Guidelines

Infection Control and Hospital Epidemiology:     Healthcare-Associated Infection Guidelines

Journal of the American Medical Association:     Immunonutrition

Abstract:  van Zanten. High-Protein Enteral Nutrition Enriched With Immune-Modulating Nutrients vs Standard High-Protein Enteral Nutrition and Nosocomial Infections in the ICU. A Randomized Clinical Trial (MetaPlus study). JAMA 2014;312(5):514-524

British Medical Journal:     Albumin in Sepsis

Full Text:  Patel. Randomised trials of human albumin for adults with sepsis: systematic review and meta-analysis with trial sequential analysis of all-cause mortality. BMJ 2014;349:g4561

Annals of Internal Medicine:     Fluid Resuscitation in Sepsis

Abstract:  Rochwerg. Fluid Resuscitation in Sepsis: A Systematic Review and Network Meta-analysis. Ann Intern Med 2014;epublished July 22nd

Anesthesia & Analgesia:     Perioperative Goal-Directed Therapy

Pestaña and colleagues completed a pragmatic, multi-centre study in 142 patients undergoing general surgery, comparing a noninvasive cardiac output monitor guided hemodynamic protocol, including fluid administration and vasoactive drugs, with standard practice, and found:

  • the interventional protocol was associated with
    • an increase in the number of
      • colloid boluses (2.4 ± 1.8 vs 1.3 ± 1.4; P < 0.001)
      • packed red blood cell units (0.6 ± 1.3 vs 0.2 ± 0.6; P = 0.019)
      • dobutamine use (p < 0.001)
        • intraoperatively: 25% vs 1.4%
        • postoperatively: 19.4% vs 0%
    • reduced
      • reoperations (5.6% vs 15.7%; P = 0.049)
    • no statistically significant differences in
      • overall fluid administration
      • overall complications (40% vs 41%)
        • relative risk 0.99; 95% CI 0.67 to 1.44; P = 0.397
      • length of stay (11.5 [8-15] vs 10.5 [8-16]; P = 0.874)
      • time to first flatus (62 hours [40-76] vs 72 hours [48-96]; P = 0.180)
      • wound infection (7 vs 14; P = 0.085)
      • anastomotic leaks (2 vs 5; P = 0.23)
      • mortality (4.2% vs 5.7%; P = 0.67)

Conclusion: The use of a perioperative goal-directed haemodynamic protocol in major abdominal surgery was not associated with reductions in overall complications, length of hospital stay, or mortality.

Abstract:  Pestaña. Perioperative Goal-Directed Hemodynamic Optimization Using Noninvasive Cardiac Output Monitoring in Major Abdominal Surgery: A Prospective, Randomized, Multicenter, Pragmatic Trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). Anesth Analg 2014;epublished July 9th

JAMA: Red Cell Management in Traumatic Brain Injury

Robertson and colleagues, using a factorial design, compared intravenous erythropoietin (500 IU/kg per dose, n=102) with saline (n=98), plus red cell transfusion at a threshold of either 7 g/dL (n=99) or 10 g/dL (n=101), on Glasgow Outcome Scale score at 6 months postinjury, in 200 patients within 6 hours of closed head injury and unable to follow commands. Erythropoietin or placebo was initially dosed daily for 3 days and then weekly for 2  weeks (group 1, n = 74). The protocol was subsequently amended to (I think, it's remarkably poorly described) a single erythropoietin dose, possibly followed by further doses at 1 and 2 weeks if the patient was still in ICU (n=126). The authors found:

  1. no interaction between erythropoietin and hemoglobin transfusion threshold
  2. no statistical improvement on favorable outcome rate (dichotomized as favorable (good recovery and moderate disability) or unfavorable (severe disability, vegetative, or dead))
    • between placebo and erythropoietin
      • placebo: 38.2%; 95% CI 28.1% to 49.1%
      • erythropoietin
        • first dosing regimen:  48.6%; 95% CI 31.4% to 66.0%, P =0.13
        • second dosing regimen: 29.8%; 95% CI 18.4% to 43.4%; P  < 0.001
    • between haemoglobin transfusion thresholds
      • 7 g/dL:  42.5%
      • 10 g/dL: 33.0%
        • 95% CI for the difference −0.06 to 0.25, P = 0.28
  3. the 10 g/dL transfusion threshold was associated with a
    • higher incidence of thromboembolic events (21.8% vs 8.1%; odds ratio 0.32, 95% CI 0.12 to 0.79; P = 0.009)

Conclusion: In a two centre, factorial, randomized controlled trial, in patients with closed head injury, neither erythropoietin administration nor red blood cell transfusion maintaining a haemoglobin level of ≥10 g/dL versus ≥ 7 g/dL, were statistically associated with improved outcomes, with the higher haemoglobin level associated with more thrombotic events.

Abstract:  Robertson. Effect of Erythropoietin and Transfusion Threshold on Neurological Recovery After Traumatic Brain Injury:  A Randomized Clinical Trial. JAMA 2014;312(1):36