Top 10 Critical Care Articles

Arbitrarily Chosen!

 

  1. ARDSnet: Low stretch ventilation in ARDS
    • RCT of 861 patients with ARDS, mechanical ventilation with a tidal volume of 6 ml/kg and plateau pressure ≤ 30 cmH20, in comparison with tidal volume of 12 ml/kg and plateau pressure ≤ 50cm H20, was associated with a 9% absolute mortality decrease (31% vs 40%, P=0.007; NNT=11) and a 2 day increase in ventilator-free days (12±11 vs. 10±11; P=0.007).
  2. TRICC: Restrictive transfusion thresholds in Critical Care
    • RCT of 838 critically ill patients transfused to 7 or 10 g/dl hemoglobin, there was no difference in either total 30 day mortality (18.7% vs 23.3%, P=0.11, respectively) or mortality in those with clinically significant cardiac disease (20.5% vs 22.9%; P=0.69). The restrictive transfusion policy was superior for mortality outcome in patients with APACHE II scores of <20 (8.7% vs 16.1%;P=0.03), in patients < 55 years of age (5.7% vs 13.0%; P=0.02), and during hospitalization (22.2% vs 28.1%;P=0.05).
  3. SAT: Daily interruption of sedation
    • RCT of 128 critically ill mechanically ventilated adults, given either a daily interruption of sedation or continued infusion, a sedation hold decreased the median durations of mechanical ventilation (4.9 days versus 7.3, p=0.004) and ICU length of stay (6.4 days versus 9.9 days, p = 0.02) as well as the requirement for diagnostic testing for changes in mental status (9% versus 27%, p = 0.02). There were no significant differences in adverse events, including self extubation (intervention group 4% versus control group 7 %, p = 0.88).
  4. NICE-SUGAR: Glucose control in the ICU
    • RCT of 6,104 medical and surgical ICU patients comparing intensive glucose control (81-108 mg/dL) with conventional glucose control (≤180 mg/dL). Intensive glucose control increased mortality (27.5% vs 24.9%; P=0.02). There was no significant difference between medical and surgical patients. Severe hypoglycaemic episodes (blood glucose level ≤40mg/dL) were more common in the intensive glucose control group (6.8% vs 0.5%; P<0.001). There were no significant differences in the median number of days of mechanical ventilation (P=0.56) or renal-replacement therapy (P=0.39), or days in ICU (P=0.84) or hospital (P=0.86).
  5. CORTICUS: Hydrocortisone in septic shock
    • RCT of 499 patients with septic shock to either hydrocortisone or placebo. There was no significant difference in 28-day mortality (hydrocortisone group 34.3% vs placebo group 31.5%; P=0.51). In the hydrocortisone group, shock was reversed more quickly than in the placebo group. 
  6. PROSEVA: Prone positioning in ARDS
    • RCT of 466 patients with moderate to severe ARDS (P:F ratio <150). Prone positioning was associated with reduced 28 day mortality (16% versus 32.8%, P<0.001), reduced 90 day mortality (23.6% versus 41%, P<0.001), and less cardiac arrests (31 patients versus 16 patients, P=0.02), with no difference in other complications.
  7. ProCESS: Early Goal Directed therapy vs Standard of care
    • RCT of 1341 patients with septic shock to EGDT, protocolized care, or usual care. Main differences were monitoring of central venous pressure and oxygen, and the use of intravenous fluids, vasopressors, inotropes, and blood transfusions. By 60 days, there were 92 deaths in the protocol-based EGDT group (21.0%), 81 in the protocol-based standard-therapy group (18.2%), and 86 in the usual-care group (18.9%) (relative risk with protocol-based therapy vs. usual care, 1.04; 95% confidence interval [CI], 0.82 to 1.31; P=0.83; relative risk with protocol-based EGDT vs. protocol-based standard therapy, 1.15; 95% CI, 0.88 to 1.51; P=0.31). There were no significant differences in 90-day mortality, 1-year mortality, or the need for organ support.
  8. PAC-Man: Pulmonary Arterial Catheter management in the ICU
    • Multicenter RCT comparing critical care management with a pulmonary artery catheter to management without a pulmonary artery catheter in 1,014 general ICU patients, there was no difference in hospital mortality (68% versus 66%, hazard ratio 1.09, 95% CI 0.94 to 1.27, P=0.39) or complications. Non-fatal complications secondary to PAC occurred in 9.5%
  9. EOLIA: ECMO for severe ARDS
    • RCT of 240 patients with Very Severe ARDS (P:F<80 for 6 hours) stopped early due to statistical likelyhood of no significant difference between groups. At 60 days, 44 of 124 patients (35%) in the ECMO group and 57 of 125 (46%) in the control group had died (relative risk, 0.76; 95% confidence interval [CI], 0.55 to 1.04; P=0.09). Crossover to ECMO occurred a mean (±SD) of 6.5±9.7 days after randomization in 35 patients (28%) in the control group, with 20 of these patients (57%) dying. The frequency of complications did not differ significantly between groups, except that there were more bleeding events leading to transfusion in the ECMO group than in the control group
  10. Early PT/OT in ventilated critically ill patients
    • RCT of 104 patients to intensive or standard pt/ot. Return to independent functional status at hospital discharge occurred in 29 (59%) patients in the intervention group compared with 19 (35%) patients in the control group (p=0.02; odds ratio 2.7 [95% CI 1.2-6.1]). Patients in the intervention group had shorter duration of delirium (median 2.0 days, IQR 0.0-6.0 vs 4.0 days, 2.0-8.0; p=0.02), and more ventilator-free days (23.5 days, 7.4-25.6 vs 21.1 days, 0.0-23.8; p=0.05) during the 28-day follow-up period than did controls. There was one serious adverse event in 498 therapy sessions (desaturation less than 80%). Discontinuation of therapy as a result of patient instability occurred in 19 (4%) of all sessions, most commonly for perceived patient-ventilator asynchrony.