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Critical Care Reviews Meeting 2022


June 15th to 17th

Titanic Belfast






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eCCR21 videos are now being released

RADAR2 Trial Result Presentation

Dr Jon Silversides (Belfast) presents the results of the phase II RADAR2 trial, investigating active deresuscitation after resuscitation, at the Critical Care Reviews Meeting 2021.

Prof Marlies Ostermann (London) delivers an editorial on this trial, with a panel discussion following, including Dr Tine Sylvest Myhoff (Copenhagen), Dr Fernando Zampieri (Sao Paulo), Dr Andrew Althouse (Pittsburgh) and co-investigator, Prof John Marshall (Toronto)

Session Timings

  • 2:15 - Jon Silversides- RADAR2 Trial Results Presentation

  • 31:00 - Marlies Ostermann - Editorial

  • 44:55 - Jon Silversides - Reply to the Editorial

  • 49:00 - Phil Gillen - Questions from Viewers

  • 55:56 - Rob Mac Sweeney chairs the Panel Discussion

Published Paper

The trial is presently unpublished.

Image:  Shutterstock | ChaNaWiT

Professors Vincenzo Russotto and Sheila Myatra discuss the INTUBE study, published March 23rd in JAMA, investigating global practice in performing tracheal intubation in critically ill patients.

Paper:  Russotto. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA 2021;325(12):1164-1172


REMAP-CAP IL-6 Receptor Antagonist Domain Results Livestream

This is the REMAP-CAP IL-6 receptor antagonist domain results presentation, recorded February 25th. The presentation was accompanied by a simultaneous publication in the New England Journal of Medicine.

Prof Derek Angus (Pittsburgh, USA) & Dr Liz Lorenzi (Berry Consultants, Austin, USA), set the scene with talks on the adaptive platform design of REMAP-CAP, and its underlying Bayesian framework, respectively. Next, Dr Lennie Derde (Utrecht, The Netherlands) presents the full results of the IL-6 receptor antagonist domain, followed by an independent editorial by Prof Tim Walsh (Edinburgh, Scotland). Lennie and her co-investigators reply to the editorial and questions from viewers. The session ends with a panel discussion, including external experts Dr David Harrison (Chief Statistician, ICNARC, London), Prof Anders Perner (Copenhagen, Denmark), and Prof Anthony Gordon (London, England), the lead investigator for the IL-6 RA domain at REMAP-CAP.

Session Timings

  • 1:37 - Derek Angus - The Beauty of Adaptive Designs

  • 19:22 - Liz Lorenzi -.The Statistical Framework of REMAP-CAP

  • 42:50 - Lennie Derde - The Results

  • 1:09:05 - Tim Walsh - The Editorial

  • 1:35:40 - Lennie Derde et al - Reply to the Editorial

  • 1:43:52 - Questions va Chris Nutt

  • 1:54:10 - Panel Discussion

Published Paper

Editorial


Journal Watch

Check out our journal watch, which is updated daily, to stay up-to-date with the latest critical care literature. The weekly newsletter contains a summary of the papers highlighted over the previous 7 days and is emailed to registered users every Sunday night.

Image:  Orrathai Poolsawat | Shutterstock

Trauma-Induced Hypercoagulopathy

Guideline

Image:  Heather | Wikimedia

Vaccine-Induced Thrombotic Thrombocytopaenia

Case Series

Image:  samunella | Shutterstock

Vaccine-Induced Thrombotic Thrombocytopaenia

Case Series

Image:  Kiryl Lis | Shutterstock

Liberation from Mechanical Ventilation

Randomised Controlled Trial

Image: Tho-Ge | Pixabay

International Intubation Practice

Observational Study

Image:  tungtaechit | Shutterstock

International Weaning Practice

Observational Study

Image: Shutterstock | KILO LUX

Albumin in Cirrhosis

RCT

In 777 patients, albumin infusions to increase the albumin level to a target of 30 g per liter or more did not improve the composite primary outcome of new infection, kidney dysfunction, or death between days 3 and 15, but resulted in increased adverse events

Added March 4th

Image: Shutterstock | Casa nayafana

Hepatorenal Syndrome

RCT

In 300 adults with cirrhosis and HRS-1, terlipressin was more effective in improving renal function but resulted in less liver transplantation (23% vs 29%) a higher 90-day mortality (51% vs 45%).

Added March 4th

Image: Shutterstock

Recovery of Consciousness

Observational Study

In 17,470 patients in the Traumatic Brain Injury Model Systems National Database, 7,547 (57%) suffered an initial loss of consciousness, which persisted to rehabilitation in 2,058 patients (12%). Of this group of 2,058 comatose patients, 82% (n = 1674) subsequently recovered consciousness during inpatient rehabilitation.

Added March 1st

Image: Shutterstock

Convalescent Plasma

Meta Analyses

In a systematic review of 4 published trials including 1060 patients with confirmed or treated COVID-19 in any treatment setting, the use of convalescent plasma  was not associated with a significant reduction in all-cause mortality; risk ration 0.93 (95% CI, 0.63 to 1.38).

Added February 27th

Image: Shutterstock

Organ Donation

Position Statement

This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation.

Added February 27th

Image: Shutterstock

RECOVERY - Dexamethasone arm

RCT

Originally published in provisional format last Summer, the full paper of the RECOVERY trial - dexamethasone arm, is now out. In 6425 hospitalised patients with COVID-19, treatment with 10 mg IV dexamethasone for up to 10 days resulted in a lower 28-day mortality among those who were receiving either invasive mechanical ventilation or oxygen alone.

Added February 25rd

Image: Shutterstock

The BACLOREA Trial

RCT

The BACLOREA trial, initial presented at eCCR21, reported a decrease in agitation-related events with baclofen in 314 mechanically ventilated patients with alcohol misuse disorder (19.7% vs. 29.7% with placebo), but a  longer  length of mechanical ventilation (9 vs 8 days) and stay in the ICU (14 vs 11 days.

Added February 23rd

Image: Shutterstock

The VICTAS Trial

RCT

The VICTAS trial, comparing treatment with vitamin C, thiamine, and hydrocortisone with placebo in 501 patients with septic shock, reported no significant difference in ventilator- and vasopressor-free days (25 vs 26 , respectively) at 30 days. Funding was withdrawn after just 501 out of a planned 2000 patients were recruited.

Added February 23rd


Upcoming CCR Hosted Major Trial Results

We'll bring these important results to you live and free

Anticoagulation in COVID-19

The ACTIV4-a, ATTACC, & REMAP-CAP investigators will present the results of this multi-platform trial examining therapeutic & prophylactic anti- coagulation in patients with COVID-19. The interim analysis was released January 28th and is available via the link below.

TTM post Cardiac Arrest

Originally planned for CCR21, which became eCCR21, but delayed into the Spring, the long awaited results of the follow-up trial to the landmark targeted temperature management after out-of-hospital cardiac arrest is out soon. Is the avoidance of fever the critical aspect of TTM? The results are due very soon.

Balanced IV Fluid Solutions

This massive 11,000 patient trial from Brazil was also scheduled for CCR21, but was unavoidably delayed due to the pandemic. Comparing Plasma-Lyte 148 with 0.9% saline, it's almost ready for release now and we're delighted to be hosting this major trial result later this Spring.

Latest Major RCTs

Vitamin D for COVID-19

COVID-19

In a Brazilian two-centre, blinded RCT in 240 patients with moderate or severe COVID-19, Murai and colleagues reported that a single oral dose of 200 000 IU vitamin D3 did not significantly change the median (IQR) length of hospitalisation; vitamin D3 group, 7.0 (4.0-10.0) days, vs. placebo group, 7.0 (5.0-13.0) days; log-rank, P = 0.59; unadjusted HR, 1.07; 95% CI, 0.82-1.39; P = 0.62.

JAMA 2021;epublished February 17th

Image: Dimitri Karastelev | Unsplash

REALITY Trial

Transfusion Thresholds in Myocardial Infarction

In 668 patients with acute myocardial infarction and a hemoglobin level between 7 and 10 g/dL, a red cell transfusion threshold of ≤8 g/dL was found to be non-inferior to a threshold of  ≤10 g/dL, with the composite MACE outcome (all-cause death, stroke, recurrent myocardial infarction, or emergency revascularization) at 30 days occurring in 11% vs 14%, respectively.

JAMA 2021;325(6):552-560. Published February 9th

Image:  Katsiuba Volha | Shutterstock

 

Fluids After Bypass Study

Fluid Optimisation

In 715 patients undergoing cardiopulmonary bypass and randomised to a protocol-guided strategy, using stroke volume variation to guide the administration of bolus fluids, or to usual care fluid administration, until desedation or up to 24 hours, there was no difference in the primary outcome of ICU length of stay; (median/IQR) intervention group; 27.9 hr (21.8–53.5 hr) vs control, 25.6 hr (21.9–64.6 hr); p = 0.95.

Crit Care Med 2021;epublished January 28th

Image:  MAD.vertise  |  Shutterstock

MENDS2 Trial

ICU Sedation

In 432 ventilated adults with sepsis, randomised to receive IV sedation with either dexmedetomidine (0.2 to 1.5 μg/kg/hr) or propofol (5 to 50 μg/kg/min), there was no difference between groups in the primary outcome of days alive without delirium or coma during the 14-day intervention period; 10.7 vs. 10.8 days; OR, 0.96; 95% CI, 0.74 to 1.26; respectively. There were also no differences in secondary outcomes, including mortality.

N Engl J Med 2021;epublished February 2nd

Image:  Shutterstock

Hypothermia for TBI with refractory intracranial hypertension

Neurosurgery

In adult patients suffering a traumatic brain injury, with a GCS score of 4 to 8, and initial ICP ≥ 25 mm Hg, the implementation of long-term mild hypothermia group (34–35 °C for 5 days), in comparison with normothermia group at 37 °C, did not improve the proportion with a favorable outcome (OR 1·55, 95%CI 0·91–2·64; P = 0·105) or mortality (P = 0·111) at 6 months.

EClinicalMedicine 2021;epublished January 28th

Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures

End-of-Life

In a prospective study in 20 ICUs in 3 countries, amongst 631 patients who underwent continued monitoring after planned withdrawal of life-sustaining support, 14% of patients had a resumption of cardiac activity after a period of pulselessness. Just 1 percent were observed clinically. The longest period to resumption of cardaic activity was 4 minutes 20 seconds.

N Engl J Med 2021; 384:345-352  |  January 28th, 2021

Image: SURIYO CINNABUT  |  Shutterstock

HOT-ICU Trial Results

Respiratory

In a Danish led, international, multi-centre, randomised controlled trial trial in 2928 adults with acute hypoxaemic respiratory failure, targetting a PaO2 of 8 kPa, in comparison with 12 kPa, did not improve the primary outcome of 90-day mortality (42.9% vs 42.4%; adjusted risk ratio, 1.02; 95% CI, 0.94 to 1.11; P=0.64).

Presented at eCCR21. Video available at eCCR21 webpage

N Engl J Med 2021;epublished January 20th

Image:  AndaPhoto  |  Shutterstock

Tocilizumab in patients with severe or critical COVID-19

COVID-19 Tocilizumab

In a Brazilian randomised controlled trial involving 9 hospitals, the use of tocilizumab as a single intravenous infusion of 8 mg/kg plus standard care (n=65) versus standard care alone (n=64), resulted in suimilar levels of mechanical ventilation at day 15 (28% vs. 20; (odds ratio 1.54, 95% CI0.66 to 3.66; P=0.32).), respectively, and increased mortality (17% vs. 3%; odds ratio 6.42, 95% CI,1.59 to 43.2).

BMJ 2021;372:n84, published January 20th

Image: M Morea | Shutterstock



Featured

Methylprednisolone for COVID-19

Methylprednisolone pulse for hospitalised severe COVID-19 patients

Plasma Therapy for Covid-19

The Prevention of Severe Covid-19 in Older Adults

RELAx Trial

PEEP Levels in Non-ARDS

Sodium Nitrite for OOHCA

Effect of Out-of-Hospital Sodium Nitrite on Survival to Hospital Admission After Cardiac Arrest

COVID-19

Tocilizumab & sarilumab reduce mortality in severe COVID-19

January 8th

In a pre-print paper, the REMAP-CAP trial investigators have reported efficacy with interleukin 6 receptor anatgonists in critically ill patients with COVID-19. Hospital mortality was 28.0% (98/350) for tocilizumab, 22.2% (10/45) for sarilumab and 35.8% (142/397) for control.

Preprint January 7th

RECOVERY Trial Halts Convalescent Plasma Arm

January 15th 21:00

In 10,406 randomised patients, with 1873 reported deaths, there was no significant difference in the primary endpoint of 28-day mortality -18% convalescent plasma vs. 18% usual care alone; risk ratio 1.04 [95% confidence interval 0.95-1.14]; p=0.34.

Prof Peter Horby, Tweet, Jan 15th

Therapeutic Anticoagualtion halted across 3 COVID-19 Trials

December 22nd

Three large randomised controlled trials, ATTACC, @ACTIV4a, and REMAP-CAP, have, for futility, halted recruitment to their therapeutic anticoagulation arms in critically ill patients with COVID-19.


Other Recent RCTS of Note

Inhaled Heparin for ARDS

In this multi-centre, blinded Australian trial, 25 000 IU of nebulised heparin administered 6 hourly while invasively ventilated, did not significantly alter the primary outcome of functional outcomes (SF-36) at 60 days; survivors in the heparin group (n=97) mean 53·6 vs control 48·7; difference 4·9 [95% CI –4·8 to 14·5]; p=0·32).

Procalcitonin to Reduce Long-Term Infection-associated Adverse Events in Sepsis

In this trial PCT-guided antimicrobial treatment in sepsis was effective in reducing infection-associated adverse events like infections by multidrug-resistant organisms and Clostridioides difficile, as well as in-hospital and 28-day mortality.

Am J Respir Crit Care Med 2021;202(3):202–210

January 17th 2021

Infant Intubation

First-attempt success rate of video laryngoscopy in small infants

Lancet 2020;396(10266):1905-1913

Neonatology

Higher or Lower Hemoglobin Transfusion Thresholds for Preterm Infants

In 1824 infants born prematurely between 22 and 26 weeks and weighing less than 1000 g, a higher hemoglobin threshold for red-cell transfusion did not improve survival without neurodevelopmental impairment at 22 to 26 months of age, corrected for prematurity

N Engl J Med 2020;383:2639-2651


Latest Guidelines

Surviving Sepsis Campaign COVID-19 Update

Crit Care Med 2021;epublished January 28th

Image:  AHMETOZER35 | Shutterstock

Recommended

  • In
    • Systemic corticosteroids
    • Venous thromboprophylaxis
  • Out
    • Hydroxychloroquine

Suggested

  • In
    • Dexamethasone as perferred steroid
    • Remdesevir in non-ventilated critically ill
  • Out
    • Convalescent plasma   (outside clinical trials)
    • Therapeutic anticoagulation  (outside clinical trials)
    • Remdesevir in ventilated critically ill
  • No recommendation
    • Awake prone positioning.


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