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Category Archives: Critical Care
CENSER Trial 2019. Early Use of Norepinephrine in Septic Shock Resuscitation. Source: AJRCC
PreVent Trial Summary: Casey et al. randomized 401 adults (age, ≥18 years) undergoing induction and tracheal intubation to either bag-mask ventilation during the bridging process or no ventilation. The primary objective was to assess whether positive-pressure ventilation with a bag-mask device during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration. The results showed that patients who did not undergo ventilation have significant lowest oxygen saturation events between induction and 2 minutes after tracheal intubation. No additional risk of aspiration was noted. The authors of PreVent trial concluded that among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher O2 saturation and a lower incidence of severe hypoxemia than those receiving no ventilation.
HYPRESS Trial (2016): Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis
HYPRESS Trial Summary: Keh D, et al. randomized 380 patients with sepsis defined by ≥2 SIRS criteria, proven infection, and ≥1 organ with new dysfunction to either IV hydrocortisone or placebo. The objective was to assess if early hydrocortisone therapy reduces progression to septic shock compared to placebo in patients with severe sepsis. The results showed no difference in the development of septic shock in both groups P=0.70. The authors of HYPRESS trial concluded that among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days.
SEPSISPAM Trial Summary:
TRICC trial Summary: Hebert PC et al. randomized 838 critically ill patients with anemia Hb < 9.0 g/dL within 72 hours after the ICU admission to either restrictive transfusion strategy (Hb 7-9) or liberal strategy (Hb 10-12). The objective was to compare the effect of restrictive transfusion goal with a liberal transfusion goal on mortality in critically ill patients. The results showed no difference in
2009, Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients (RENAL), NEJM
The RENAL trial was one of the largest trials that addressed an important question of doing continuous renal replacement therapy (CRRT) in critically ill patients with renal impairment. Based on this trial, high intensity CRRT at flow rate of 40 ml/kg/hr was found to have no benefits when compared to conventional CRRT at 25 ml/kg/hr.
Prior to this trial, the ATN trial was done in 2008 and compared high intensity renal replacement therapy with conventional approach in similar critically ill population. Both trials showed no benefits in the high intensity approach. In ATN trial, the stable patients were randomized to intermittent hemodialysis (HD) and the CRRT was reserved for unstable patients only. In contrast, RENAL trial addressed the intensity of CRRT and didn’t involve HD.
IABP-SHOCK II Trial (2012): Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock
2012, Intraaortic Balloon Support for Myocardial Infarction with Cardiogenic Shock, NEJM
ATHOS-3 Trial Summary:
A total of 321 patients with vasodilatory shock on high dose catecholamines were randomized to angiotensin II or placebo. Within 3 hours, ~70% of in the angiotensin II group showed significant improvement in their mean arterial pressure as compared with 23.4% patients in
ATHOS-3 Trial 2017, Angiotensin II for the Treatment of Vasodilatory Shock, NEJM
2012, Activated protein C (DrotAA) in Sepsis, NEJM
2017, Lung Recruitment and Titrated PEEP vs Low PEEP in ARDS, JAMA
2013, Prone Positioning in ARDS, NEJM
2018, Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit, The Lancet
2018, Lactated Ringer’s or Plasma-Lyte vs normal saline in non-critically ill patients, NEJM
2016, Pantoprazole for reducing GI bleeding in intubated patients, Critical Care Medicine
2002, Mild Therapeutic Hypothermia to Improve the Neurologic Outcome after Cardiac Arrest, NEJM
The TRISS trial studied the role of transfusion thresholds in septic shock. 998 patients were divided into two transfusion groups. One group received Hb transfusion with goal Hb of > 7 while the other group received with the goal of Hb > 9. No difference in mortality or ischemic events were noted after a mean follow up period of 90 days. However, Patients with goal Hb > 7 received 50% less amount of transfusion compared to those with goal > 9.
2014, Does albumin infusion helps in Septic shock?, NEJM
Mechanical ventilation is a complex topic to understand. With this infographic, I have tried to explain 4 most commonly used ventilator modes in intensive care units. The two broad categories are the volume limited and pressure limited ventilation while each of them have further sub-branches. In future posts, I’m going to create a basic flowchart of all ventilator modes with their benefits and disadvantages. Till then, use this infographic to understand the basic of mechanical ventilation and how pressure, flow and volumes are linked to each other.
Summarized by / Author: Usama bin Nasir, MD
Contribution To Literature:
WARFASA trial established role of aspirin for prevention of recurrent VTE in patients who have completed 6-18 months course of anticoagulation and were no longer on it.
According to ACCP (CHEST) Antithrombotic Therapy for VTE Disease 2016 guidelines, in patients with an unprovoked proximal DVT or PE who are stopping anticoagulant therapy and do not have a contraindication to aspirin, aspirin over no aspirin to prevent recurrent VTE (Grade 2B) is recommended.
It was a multicenter, randomized, double-blind, placebo-controlled that took place and involved enrollment from 2004 to 2010. 403 patients were enrolled and distributed among the study groups. Median follow up period was 2 years.
- Age ≥18 years
- Completed therapy with 6-18 months of vitamin K antagonist for first, symptomatic, unprovoked, objectively confirmed proximal DVT, PE, or both
Important exclusion criteria included
- Cancer or major thrombophilia
- Indication for long-term anticoagulation
- Atherosclerotic disease requiring antiplatelet therapy
- Active bleeding
- Recurrent VTE was significantly decreased in patients on aspirin compared to patients on placebo. (HR 0.58; 95% CI 0.36-0.93; P=0.02)
- Bleeding (4 events in each group) and death rates (HR 1.04; 95% CI 0.32-3.42; P=0.95) were similar in both groups.
The WARFASA trial successfully established role of aspirin in prevention of VTE recurrence. Another trial that was done during same time period was the ASPIRE trial. The ASPIRE trial results were non-significant but the important difference between the trials was that in WARFASA all patients completed minimum of 6 months oral anticoagulation. Recurrent rates of VTE after 3-6 months of OAC for unprovoked VTE can reach up to 11% (2) once the anticoagulation is stopped therefore starting aspirin is important and carries grade 2B recommendation per CHEST 2016 guidelines.
- Becattini C, Agnelli G, Schenone A, et al. Aspirin for preventing the recurrence of venous thromboembolism. N Engl J Med. 2012;366(21):1959-67. Source
- Prandoni P, et al. “The risk of recurrent venous thromboembolism after discontinuing anticoagulation in patients with acute proximal deep vein thrombosis or pulmonary embolism. A prospective cohort study in 1,626 patients.”Haematologica 2007. 92(2):199-205.
- Antithrombotic Therapy for VTE Disease: CHEST Guideline and Expert Panel Report. Chest 2016;149:315-352.
Procalcitonin has proven to be a great marker for guiding antibiotics treatment in patients with concern for lower respiratory tract infections. However, it’s not yet established how much does clinicians adhere to using the antibiotic therapy based on procalcitonin results. The ProACT trial recently got published in NEJM. It showed that despite it’s usefulness, clinicians still base their antibiotic use on clinical suspicion. Take a look at our visual abstract for the findings.
The APROCCHSS trial clinically analyze the combination of steroid therapy in patients with septic shock and shows significant mortality benefit.
Source: JAMA Internal Medicine
NICE-SUGAR Trial: 2009, Intensive versus Conventional Glucose Control in Critically Ill Patients | NEJM
The NICE trial tackled an important question of what should be the goal blood glucose levels in critically ill patients. The results of this trial were quiet significant and showed tighter or intensive blood glucose control was associated with highter 28 days and 90 days mortality. Additionally, it also led to an increase number of hypoglycemic episodes in these patients.
Guideline recommendations based on NICE-SUGAR Trial
The American Diabetes Association recommends starting insulin in patients with persistent hyperglycemia above 180 mg/dL in critically ill patients, and to maintain the glycemic range between 140-180 mg/dL.