Update from Critical Care Congress

Many late breaking trials/studies were announced in this year’s critical care Congress. Here is the summary of few important ones.

  1. ANDROMEDA-SHOCK trial compared 424 adults with early septic shock were randomized to 2 alternative 8-hour resuscitation strategies: one based on serial measurements of serum lactate levels and the other on peripheral perfusion, assessed by serial capillary refill time (CRT) examinations. The trial was conducted among patients in the intensive care unit with early septic shock, defined as patients with suspected or confirmed infection who were recognized within 4 hours to have elevated serum lactate level (>2 mmol/L) and require vasopressors to maintain blood pressure despite a bolus of 20 mL/kg of intravenous crystalloids. The peripheral perfusion–targeted strategy represented an experimental approach in which resuscitation was guided by a standardized assessment of CRT, applying a microscope slide to the finger pulp for 10 seconds of blanching and then counting via a chronometer the time to reperfusion. The CRT test was assessed every 30 minutes and resuscitation was judged adequate if CRT was less than 3 seconds. The 30-minute frequency was chosen because physiologic compensation occurs more quickly than lactate clearance.  serum lactate and CRT perhaps improved faster in the CRT-guided group, as evidenced by better values at some but not all points over the first 72 hours, whereas the lactate level–guided group received more fluid at 8 hours (mean difference, −408 mL [95% CI, −705 to −110]; P = .01). At 28 days, the mortality rates were 43.4% in the lactate level–guided group and 34.9% in the CRT-guided group, with a hazard ratio of 0.75 (95% CI, 0.55 to 1.02) in favor of the CRT-guided group, which was not statistically significant (P = .06). There was less organ dysfunction at 72 hours in the CRT-guided group, as evidenced by a mean 72-hour Sequential Organ Failure Assessment (SOFA) score of 5.6 vs 6.6 (mean difference, −1.00 [95% CI, −1.97 to −0.02]; P = .045), but none of the other secondary outcomes showed a significant difference.
  2. Early norepinephrine in septic shock- this trial was published just prior to the critical Congress. In this doubleblind randomized controlled trial that enrolled 310 adults sepsis with hypotension, early norepinephrine(compared with placebo) administration resulted in significant higher shock control rate than standard treatment (76.1% vs 48.4%, respectively).  The findings of this study support the benefit of early administration of norepinephrine at the initiation of sepsis with hypotension resuscitation, together with fluid therapy.
  3.  EPVent-2, a multicenter randomized clinical trial comparing esophageal pressure–guided PEEP with PEEP guided by a high PEEP-Fio2 table in patients with moderate to severe ARDS. Mechanical ventilation with esophageal pressure–guided PEEP (102 patients) compared with the use of a high PEEP-Fio2 table (98 patients) did not improve the primary outcome, a ranked composite score that incorporated death and ventilator-free days within 28 days.
  4. Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation (PreVent) trial reported that Critically ill patients who underwent tracheal intubation had higher oxygen saturations and a lower incidence of severe hypoxemia with bag-mask ventilation. In a sample of about 400 critically ill patients, those who received bag-mask ventilation in the interval between induction and laryngoscopy had a lower incidence of severe hypoxemia (oxygen saturation <80%) compared with patients who did not receive ventilation (10.9% vs 22.8%, relative risk 0.48, 95% CI 0.30-0.77), and the bag-mask ventilation group had a nadir oxygen saturation 3.9 percentage points higher. Operator-reported aspiration during intubation was more likely in the control arm than in the bag-mask ventilation group (4% vs 2.5%, P=0.41).
  5. An EHR program implemented in Cleveland Clinic,  which only allows clinicians to order daily CXR for patients with either cardiac support devices or to have undergone cardiothoracic surgery reduced daily chest x-rays by by 23.5% overall, and average overnight CXRs by 36.6%.
  6. CDCs eSOFA Sepsis criteria optimized for electronic health record review could be a practical tool for epidemiologic surveillance of sepsis, a retrospective study found. In a sample of nearly 1 million patients, the 6.1% flagged as having sepsis through the current Sepsis-3 Sequential Organ Failure Assessment (SOFA) criteria had lower in-hospital mortality rates than the 4.4% flagged with the CDC’s newer Adult Sepsis Events simplified (ASE) eSOFA criteria (14.4% vs 17.1%, respectively).
  7.  Intermittent pneumatic compression did not reduce the incidence of lower-limb deep vein thrombosis (DVT) for critically ill patients, a randomized clinical trial showed.In a cohort of nearly 2,000 patients, DVT occurred in 3.9% of those receiving pneumatic compression, compared with 4.2% in a control group receiving only pharmacologic thromboprophylaxis (RR 0.93, P=0.74). Nor did the adjunctive intervention significantly lower incidence of pulmonary embolism (0.8% vs 1%) or 28-day mortality (14.6% vs 16.5%).
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