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International Symposium on Intensive Care and Emergency Medicine Update / March 18th 2014

Welcome

 

Hello

Welcome to a supplemental Critical Care Reviews Newsletter, bringing you the major resarch studies being presented at the 2014 Brussels meeting this week, and simultaneously published in JAMA and NEJM today, plus Resuscitation a few days earlier.

 


The ProCESS investigators completed an American multi-centre, randomized controlled trial in 1,341 patients with early septic shock, comparing three management strategies:

  1. protocol-based early goal-directed therapy (n=439, based on the Rivers GDT protocol)
  2. protocol-based standard therapy (not requiring the placement of a central venous catheter, administration of inotropes, or blood transfusions, n=446)
  3. usual care (n=456)

and found:

  1. significant inter-group differences with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids, vasopressors, inotropes, and blood transfusions.
  2. 60 day mortality rates:
    • protocol-based EGDT group: 21.0%
    • protocol-based standard-therapy group 18.2%
    • usual-care group 18.9%
      • relative risk with protocol-based therapy vs. usual care, 1.04; 95% 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
  3. There were no significant differences in
    • 90-day mortality
    • 1-year mortality
    • need for organ support

Asfar and colleagues completed a multicenter, randomized, open-label trial in 776 patients with septic shock comparing resuscitation with a mean arterial pressure target of 80 to 85 mm Hg (high target group) with 65 to 70 mmHg (low target group), and found:

  1. no significant difference in
    • 28 day mortality
      • high target group 36.6% versus low target group 34.0%
        • hazard ratio in the high target group 1.07, 95% CI 0.84 to 1.38; p=0.57
    • 90 day mortality
      • high target group 43.8% versus low target group 42.3%
        • hazard ratio in the high-target group 1.04, 95% CI 0.83 to 1.30; p=0.74
    • serious adverse events
      • high target group 19.1% versus low target group 17.8%; p=0.64
    • an increased incidence of atrial fibrillation with high-target therapy

Caironi and colleagues completed a multicenter, randomized, controlled, open-label trial in 1,818 patients with severe sepsis, comparing 20% albumin and crystalloid solution (targeting a serum albumin level of 30 g/L), with crystalloid solution alone, and found:

  1. no difference in
    • 28 day mortality (primary outcome)
      • albumin group 31.8% versus crystalloid group 32.0%
        • relative risk in the albumin group, 1.00; 95% CI 0.87 to 1.14; P=0.94
    • 90 day mortality
      • albumin group 41.1% versus crystalloid group 43.6%
        • relative risk 0.94; 95% CI 0.85 to 1.05; P=0.29
  2. no significant differences in other secondary outcomes
    • organ dysfunction:
      • number of patients
      • degree of dysfunction
    • length of stay
      • ICU 
      • hospital
  3. during the first 7 days, albumin therapy was associated with
    • higher mean arterial pressure (P=0.03)
    • lower net fluid balance (P<0.001)
  4. no significant difference in total daily administered fluid  (P=0.10)

Kaukonen et al performed a retrospective, observational study from 2000 to 2012, in 101,064 patients with severe sepsis in Australia and New Zealand, and found:

  1. a decrease in absolute mortality:
    • from 35.0% in 2000 (95% CI  33.2% to 36.8%) to 18.4% in 2012 (95% CI 17.8% to 19.0%), P  < 0.001
  2. overall mortality decrease of 16.7% (95% CI 14.8% to 18.6%)
  3. an annual rate of absolute decrease of 1.3%
    • relative risk reduction of 47.5% (95% CI  44.1% to 50.8%)
  4. adjusted mortality decreased throughout the study period
    • odds ratio 0.49 (95% CI 0.46 to 0.52) in 2012, using the year 2000 as the reference (P < 0.001)
  5. no difference in annual mortality decline between patients with severe sepsis and those with all other diagnoses
    • OR 0.94 (95% CI 0.94 to 0.95) vs 0.94 (95% CI  0.94 to 0.94) P = 0.37
  6. a greater annual increase in rates of discharge to home in patients with severe sepsis compared with all other diagnoses
    • OR  1.03 (95% CI 1.02 to 1.03) vs 1.01 (95% CI 1.01 to 1.01) P <0.001
  7. a smaller annual increase in the rate of patients discharged to rehabilitation facilities in patients with severe sepsis compared with all other diagnoses
    • OR 1.08 (95% CI 1.07 to 1.09) vs 1.09 (95% CI 1.09 to 1.10) P < 0.001
  8. in the absence of comorbidities and older age, mortality was less than 5%

Wik and colleagues performed a multi-centre, unblinded, randomized controlled trial in 4,753 patients (11% met post enrollment exclusion criteria) with out-of-hospital cardiac arrest, comparing integrated automated load distributing band CPR (iA-CPR, n=2,099) with high-quality manual CPR (M-CPR, n=2,132), and found:

  1. no difference in primary outcome, survival to hospital discharge
    • adjusted odds ratio for iA-CPR compared to M-CPR: 1.06, 95% CI 0.83 to 1.37
    • demonstrating therapeutic equivalence
  2. for iA-CPR compared to M-CPR
    • sustained ROSC (emergency department admittance)
      • 28.6% vs 32.3%
    • 24 hour survival
      • 21.8% vs 25.0%
    • hospital discharge
      • 9.4% vs 11.0%
  3. 20 minutes CPR fraction
    • iA-CPR 80.4% vs M-CPR: 80.2%

 

I hope you find these brief summaries and links useful.

 


Until the weekend

Rob

 

 

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