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Top Papers in Critical Care 2013

Top Papers in Critical Care 2013. Janna Landsperger, RN, MSN, ACNP-BC. Delirium. Background : Sedation for MV has AE including delirium, prolonged MV, PTSD. Dex may enhance patient safety, lead to earlier extubation, and reduce delirium

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Top Papers in Critical Care 2013

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  1. Top Papers in Critical Care2013 Janna Landsperger, RN, MSN, ACNP-BC

  2. Delirium • Background: Sedation for MV has AE including delirium, prolonged MV, PTSD. Dex may enhance patient safety, lead to earlier extubation, and reduce delirium • Basic Approach: Phase 3 multi-center randomized, double-blind study compared midazolam with dex (MIDEX) and propofol with dex (PRODEX) Jakob SM, JAMA 2012

  3. Delirium • Results: 500 patient randomized to each arm of the trial • Dex was not inferior to midazolam and propofol in maintaining target RASS • Dex reduced duration of MV compared with midazolam (123 h vs 164 h) but not with dex vs proporfol • Dex improved patients’ ability to communicate pain compared to midazolam and propofol • More AE including hypotension and bradycardia were associated with dex • Conclusion: Continuous benzo infusions are probably not the best; find out what works for each for individual patient and use it

  4. Delirium

  5. Seizure • Background: HOS lead to increased intensity of medical care and prolonged hospitalizations. No guidelines currently available for mgmt of HOS • Basic Approach: Retrospective medical record review designed to describe demographic and clinical characteristics of patients with HOS and explore current practices in mgmt Fields MC, JAMA NEURO 2013

  6. Seizure • Results: 3345 charts, 218 patients identified within study period (1 y) • Of patients with HOS, 64% had no history of seizure. • Seizures recurrent in 61% of patients during same stay • Stroke, metabolic derangement, and brain tumor most common etiologies • Phenytoin was the most common AED used • Mortality rate 14% • 34% of those discharged did not receive an AED at d/c • Conclusion: HOS are common, are typically recurrent, and are associated with a high mortality.

  7. Seizure

  8. Ischemic Stroke • Background: IV t-PA is the only reperfusion tx for acute ischemic stroke. Endovascular therapy recanulizes occlusions in large arteries more rapidly than IV t-PA and is being used with increasing frequency • Basic Approach: Phase 3, randomized, open-label clinical trial with a blinded outcome to test approach of IV t-PA followed by endovascular treatment compared with standard IV t-PA Broderick JP, NEJM 2013

  9. Ischemic Stroke • Results: Plan to enroll 900 at 58 centers. Stopped for futility after 656 participants • No significant difference in modified Rankin score (primary end point) at 90 d according to treatment • Findings between both groups were similar for mortality at 90 d • Safety profiles similar in the two treatment groups • Future trials of endovascular therapy should consider time to initiation of endovascular therapy • Conclusion: Endovascular therapy is not going away because some patients are not eligible to receive t-PA

  10. Ischemic Stroke

  11. Therapeutic Hypothermia • Background: Use of TH improves survival and neurological outcomes after CA. Neurological prognostication and mortality prediction remain a challenge • Basic approach: Retrospective analysis of post CA patients over a 6 y period Starodub R, Resuscitation 2013

  12. Therapeutic Hypothermia • Hypothesis: greater serum lactate clearance would be positively associated with survival to discharge • Results: 199 patients included in study; 3 centers • No association between initial serum lactate and survival to hospital discharge • Univariate analysis showed lactate levels at 12 h and 24 h predictive of survival to hospital discharge • For every unit increase in lactate at 12 h and 24 h, odds of survival decreased by 19% and 23% respectively • Conclusion: Further investigation of lactate and other biomarkers may improve ability to prognosticate outcomes in post CA patients. Or not.

  13. Therapeutic Hypothermia

  14. ARDS • Background: In HFOV patients’ lungs are held inflated to maintain oxygenation. Minimizes the process of opening and collapsing the alveoli and is often used in patients who have hypoxemia despite standard approach of MV • Basic Approach: Randomized, controlled trial of HFOV as compared with conventional MV Ferguson, N NEJM 2013

  15. ARDS • Results: 548 patients randomized in 39 centers in 5 countries over 1 y. Planned for 1200 • HFOV group underwent HFOV for a median of 3 d • 47% of patient in the HFOV group, as compared with 35% in the control group died in the hospital • HFOV group received higher doses of midazolam than the control (199 mg/d vs 142 mg/d) and more patients in HFOV group received neuromuscular blockers (83% vs 68%) • More patients in HFOV group received vasoactive drugs than the control (91% vs 84%) • Conclusion: Increased risk, no proven benefit

  16. ARDS

  17. GI Bleed • Background: Acute UGIB is common. Transfusion may be lifesaving; however the safest and most effective transfusion strategy is controversial • Basic Approach: Randomized, controlled trial assessing whether a restrictive threshold for RBC transfusion in patients with acute UGIB was safer and more effective than a liberal transfusion strategy Villanueva, C NEJM 2013

  18. GI Bleed • Results: 889 patients underwent randomization and completed study in 1 center over 7 y • Further bleeding complications occurred in 10% of pts in restrictive group vs 16% in liberal group • Hgb at 45 d was similar (11.6 vs 11.7) • 51% of pts in restrictive group compared to 14% of patients in the liberal group received no transfusion • Mortality at 45 d and probability of mortality was significantly lower in the restrictive group than the liberal (5% vs 9%) • Conclusion: Less blood is probably better

  19. GI Bleed

  20. References Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation. Jakob, SM, et al. JAMA. 2012 Mar 21;307(11):1151-60. Hospital-onset seizures: an inpatient study. Fields MC, Labovitz DL, French JA. JAMA Neurol. 2013 Mar 1;70(3):360-4. Endovascular therapy after intravenous t-PA versus t-PA alone for stroke. Broderick, J, et al. New England Journal of Medicine 2013. March 368(10). Association of serum lactate and survival outcomes in patients undergoing therapeutic hypothermia after cardiac arrest. Starodub, R et al. Resuscitation. 84 (2013) 1078–1082 High-frequency oscillation in early acute respiratory distress syndrome. Ferguson, N et al. The New England Journal of Medicine. 2013 Jan 22 Transfusion strategies for acute upper gastrointestinal bleeding.Villanueva, C. et al. The New England Journal of Medicine. 2013. January 3, 368(1)

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