what’s cool & what’s new in critical care research. ccanni talk april 1st 2014
DESCRIPTION
A presentation given by Rob Mac Sweeney to the Northern Ireland Critical Care Network Conference on April 1st 2014TRANSCRIPT
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What’s Cool & What’s NewRecent Critical Care Research
Rob Mac Sweeney
CCaNNI Conference 2014
@critcarereviews
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Critical Care Literature
• >300 Journals
• Major Studies
• Major Guidelines
• Relevant Review Articles
• Commentaries
• Editorials
• Supplements
• Free Material
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Conflict of Interest Statement
•Not for profit site
•Completely independent
• I make no money from it
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ISICEM Brussels Meeting – March 2014
• ALBIOS Study
• SEPSISPAM study
• ANZICS Study
• CIRC Trial
• ProCESS Study
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ALBIOS Study
• Randomized, open-label study
• 1,818 patients with severe sepsis
• 20% albumin & vs crystalloid alone crystalloid
• No difference in• 28 day mortality
• 31.8% vs 32% (RR 1.0, 95% CI 0.87 – 1.14)
• 90 day mortality• 41.1% vs 43.6% (RR 0.94, 95% CI 0.85 – 1.05)
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ALBIOS Study
• Randomized, open-label study
• 1,818 patients with severe sepsis
• 20% albumin & vs crystalloid crystalloid alone
• No difference in• 28 day mortality
• 31.8% vs 32% (RR 1.0, 95% CI 0.87 – 1.14)
• 90 day mortality• 41.1% vs 43.6% (RR 0.94, 95% CI 0.85 – 1.05)
![Page 9: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/9.jpg)
ALBIOS Study
• Randomized, open-label study
• 1,818 patients with severe sepsis
• 20% albumin & vs crystalloid alone crystalloid
• No difference in• 28 day mortality
• 31.8% vs 32% (RR 1.0, 95% CI 0.87 – 1.14)
• 90 day mortality• 41.1% vs 43.6% (RR 0.94, 95% CI 0.85 – 1.05)
![Page 10: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/10.jpg)
SEPSISPAM Study
• Randomized, open-label study
• 776 patients with septic shock
• MAP 80-85 mmHg vs 65-70 mmHg
• No difference in• 28 day mortality
• 36.6% vs 34% (HR 1.07, 95% CI 0.84 – 1.38)
• 90 day mortality• 43.8% vs 42.3% (RR 1.04, 95% CI 0.83 – 1.30)
• Less RRT in chronic hypertensives• 31.7% vs 42.2%
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SEPSISPAM Study
• Randomized, open-label study
• 776 patients with septic shock
• MAP 80-85 mmHg vs 65-70 mmHg
• No difference in• 28 day mortality
• 36.6% vs 34% (HR 1.07, 95% CI 0.84 – 1.38)
• 90 day mortality• 43.8% vs 42.3% (RR 1.04, 95% CI 0.83 – 1.30)
• Less RRT in chronic hypertensives• 31.7% vs 42.2%
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SEPSISPAM Study
• Randomized, open-label study
• 776 patients with septic shock
• MAP 80-85 mmHg vs 65-70 mmHg
• No difference in• 28 day mortality
• 36.6% vs 34% (HR 1.07, 95% CI 0.84 – 1.38)
• 90 day mortality• 43.8% vs 42.3% (RR 1.04, 95% CI 0.83 – 1.30)
• Less RRT in chronic hypertensives• 31.7% vs 42.2%
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ANZICS Sepsis Epidemiology Study
• Retrospective, observational study
• 101,064 patients with severe sepsis
• Temporal review 2000 to 2012
• Mortality decreased• 35.0% to 18.4%
• 1.3% per annum
• Relative risk reduction 47.5%
• Adjusted odds ratio 0.49%
• Mortality rate <5% if young & no comorbidities
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ANZICS Sepsis Epidemiology Study
• Retrospective, observational study
• 101,064 patients with severe sepsis
• Temporal review 2000 to 2012
• Mortality decreased• 35.0% to 18.4%
• 1.3% per annum
• Relative risk reduction 47.5%
• Adjusted odds ratio 0.49%
• Mortality rate <5% if young & no comorbidities
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CIRC Trial
• Randomized, unblinded, sequential study
• 4,231 patients with OOH cardiac arrest
• Mechanical CPR vs Manual CPR
• CPR Equivalent• ROSC at ED admission 28.6% vs 32.2%
• 24 hr survival 21.8% vs 25%
• Hospital discharge 9.4% vs 11%• Adjusted odds ratio 1.06 (95% CI 0.83–1.37)
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ProCESS Trial
• Randomized, parallel groups study
• 1,341 patients with early septic shock
• Compared 3 management strategies• Protocolized EGDT (River’s protocol)
• Protocolized standard care
• Usual care
• No difference in• 60 day mortality
• 21% vs 18.2% vs 18.9%
• 90 day mortality / 1 year mortality / need for organ support
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ProCESS Trial
• Randomized, parallel groups study
• 1,341 patients with early septic shock
• Compared 3 management strategies• Protocolized EGDT (River’s protocol)
• Protocolized standard care
• Usual care
• No difference in• 60 day mortality
• 21% vs 18.2% vs 18.9%
• 90 day mortality / 1 year mortality / need for organ support
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AHA Dallas Meeting – November 2013
• TTM study
• Kim OOHCA Hypothermia study
• CATIS Study
• LINC Study
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TTM Study
• Randomized, parallel group study
• 950 unconscious adults
• 33°C (n=473) with 36°C (n=466)
• No difference in• All cause mortality
• 33°C (50%) with 36°C (48%)
• poor neurological function• 33°C (54%) with 36°C (52%)
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TTM Study
• Randomized, parallel group study
• 950 unconscious adults
• 33°C (n=473) with 36°C (n=466)
• No difference in• All cause mortality
• 33°C (50%) with 36°C (48%)
• poor neurological function• 33°C (54%) with 36°C (52%)
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TTM Study
• Randomized, parallel group study
• 950 unconscious adults
• 33°C (n=473) with 36°C (n=466)
• No difference in• All cause mortality
• 33°C (50%) with 36°C (48%)
• poor neurological function• 33°C (54%) with 36°C (52%)
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Kim OOHCA Hypothermia Study
• Randomized, parallel group study
• Prehospital cooling vs. standard care
• 1,359 OOHCA patients
• Cooling effective (reduced temp)
• No difference• Survival to hospital discharge
• VF 63% vs 64% • nonVF 19% vs 16%
• Good neurological recovery• VF 57% vs 62% • nonVF 14% vs 13%
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Kim OOHCA Hypothermia Study
• Randomized, parallel group study
• Prehospital cooling vs. standard care
• 1,359 OOHCA patients
• Cooling effective (reduced temp)
• No difference• Survival to hospital discharge
• VF 63% vs 64% • nonVF 19% vs 16%
• Good neurological recovery• VF 57% vs 62% • nonVF 14% vs 13%
![Page 24: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/24.jpg)
Kim OOHCA Hypothermia Study
• Randomized, parallel group study
• Prehospital cooling vs. standard care
• 1,359 OOHCA patients
• Cooling effective (reduced temp)
• No difference• Survival to hospital discharge
• VF 63% vs 64% • nonVF 19% vs 16%
• Good neurological recovery• VF 57% vs 62% • nonVF 14% vs 13%
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CATIS Study
• Randomized, parallel group study
• 4,071 patients • Within 48 hrs ischemic stroke
• Nonthrombolysed and ↑SBP
• Hypertension therapy vs no BP Rx
• BP control effective
• No difference• death and major disability
• 14 days / hospital discharge
• 3 months
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CATIS Study
• Randomized, parallel group study
• 4,071 patients • Within 48 hrs ischemic stroke
• Nonthrombolysed and ↑SBP
• Hypertension therapy vs no BP Rx
• BP control effective
• No difference• death and major disability
• 14 days / hospital discharge
• 3 months
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LINC Study
• Randomized, parallel group study
• 2,589 patients with OOHCA
• Mechanical chest Manual chest compression with vs compression defibrillation per guidelines
• No difference in • 4 hour survival
• 23.6% vs 23.7%
• Neurologically favourable outcome• At ICU or Hospital discharge
• At 1 and 6 months
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ESICM Meeting – October 2013
• STATIN-VAP Study
• Beta Blockade in Sepsis Study
• CRISTAL Study
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STATIN-VAP Study
• Randomized, controlled, blinded, parallel-group study
• 300 patients with suspected VAP
• Simvastatin 60 mg vs placebo
• Study stopped early for futility
• No difference in • 28 mortality
• Duration mechanical ventilation
• Δ SOFA
• Increased mortality in statin naïve• 21.5% vs 13.8%; p=0.054
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STATIN-VAP Study
• Randomized, controlled, blinded, parallel-group, multi-center trial
• 300 patients with suspected VAP
• Simvastatin 60 mg vs placebo
• Study stopped early for futility
• No difference in • 28 mortality
• Duration mechanical ventilation
• Δ SOFA
• Increased mortality in statin naïve• 21.5% vs 13.8%; p=0.054
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β Blockade in Septic Shock
• Randomised, open-label, phase 2 study
• 154 septic patients
• Tachycardic & requiring high dose NA
• Esmolol (HR 80 – 94) vs standard Rx
• Esmolol effective at HR control
• Esmolol associated with improved:• HR / SVI / LVSWI / lactate
• NA requirement
• Fluid requirement
• 28 day mortality (49% vs 80%)
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β Blockade in Septic Shock
• Randomised, open-label, phase 2 study
• 154 septic patients
• Tachycardic & requiring high dose NA
• Esmolol (HR 80 – 94) vs standard Rx
• Esmolol effective at HR control
• Esmolol associated with improved:• HR / SVI / LVSWI / lactate
• NA requirement
• Fluid requirement
• 28 day mortality (49% vs 80%)
![Page 33: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/33.jpg)
β Blockade in Septic Shock
• Randomised, open-label, phase 2 study
• 154 septic patients
• Tachycardic & requiring high dose NA
• Esmolol (HR 80 – 94) vs standard Rx
• Esmolol effective at HR control
• Esmolol associated with improved:• SVI / LVSWI / lactate
• NA requirement
• Fluid requirement
• 28 day mortality (49% vs 80%)
![Page 34: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/34.jpg)
β Blockade in Septic Shock
• Randomised, open-label, phase 2 study
• 154 septic patients
• Tachycardic & requiring high dose NA
• Esmolol (HR 80 – 94) vs standard Rx
• Esmolol effective at HR control
• Esmolol associated with improved:• SVI / LVSWI / lactate
• NA requirement
• Fluid requirement
• 28 day mortality (49% vs 80%)
![Page 35: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/35.jpg)
β Blockade in Septic Shock
• Randomised, open-label, phase 2 study
• 154 septic patients
• Tachycardic & requiring high dose NA
• Esmolol (HR 80 – 94) vs standard Rx
• Esmolol effective at HR control
• Esmolol associated with improved:• SVI / LVSWI / lactate
• NA requirement
• Fluid requirement
• 28 day mortality (49% vs 80%)
![Page 36: What’s Cool & What’s New in Critical Care Research. CCaNNI talk April 1st 2014](https://reader035.vdocuments.us/reader035/viewer/2022062406/559620b31a28ab045f8b45c4/html5/thumbnails/36.jpg)
CRISTAL Study
• Randomized, stratified, open label, assessment blinded study
• Any crystalloid vs any colloid
• All fluid interventions other than fluid maintenance in ICU
• No difference• 28 day mortality (Col: 27% vs Cry: 25.4%)
• Colloids associated with improved• 90 day mortality• Days alive without mechanical ventilation• Days alive without vasopressor support
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CRISTAL Study
• Randomized, stratified, open label, assessment blinded study
• Any crystalloid vs any colloid
• All fluid interventions other than fluid maintenance in ICU
• No difference• 28 day mortality (Col: 27% vs Cry: 25.4%)
• Colloids associated with improved• 90 day mortality• Days alive without mechanical ventilation• Days alive without vasopressor support
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Podcasts
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FFICM Course Presentation
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Critical Care Reviews Meeting 2015