What’s Cool & What’s NewRecent Critical Care Research

Rob Mac Sweeney

CCaNNI Conference 2014

rob@criticalcarereviews.com

@critcarereviews

Critical Care Literature

• >300 Journals

• Major Studies

• Major Guidelines

• Relevant Review Articles

• Commentaries

• Editorials

• Supplements

• Free Material

Conflict of Interest Statement

•Not for profit site

•Completely independent

• I make no money from it

ISICEM Brussels Meeting – March 2014

• ALBIOS Study

• SEPSISPAM study

• ANZICS Study

• CIRC Trial

• ProCESS Study

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)

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)

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)

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%

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%

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%

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

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

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)

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

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

AHA Dallas Meeting – November 2013

• TTM study

• Kim OOHCA Hypothermia study

• CATIS Study

• LINC Study

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%)

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%)

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%)

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%

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%

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%

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

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

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

ESICM Meeting – October 2013

• STATIN-VAP Study

• Beta Blockade in Sepsis Study

• CRISTAL Study

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

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

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%)

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%)

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%)

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%)

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%)

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

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

Podcasts

FFICM Course Presentation

Critical Care Reviews Meeting 2015