Year in Review: No disclosures Critical Care Medicine Eric J. - - PDF document

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Year in Review: No disclosures Critical Care Medicine Eric J. - - PDF document

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5/31/2013 Year in Review: No disclosures Critical Care Medicine Eric J. Seeley, M.D. Assistant Professor of Medicine Division of Pulmonary and Critical Care Medicine Why I Selected These Studies Question 1: High quality studies What

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5/31/2013 1

Year in Review: Critical Care Medicine

Eric J. Seeley, M.D. Assistant Professor of Medicine Division of Pulmonary and Critical Care Medicine

No disclosures Why I Selected These Studies…

  • High quality studies
  • They answer a commonly

encountered clinical question

  • They move care from anecdote to

evidence Question 1: What is the best way to ventilate patients with moderate to severe ARDS?

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5/31/2013 2

ARDS ARDSNet Ventilation Play with Vent Paralytics

Plan B APRV HFOV ECLS iNO

Prone Positioning

ARDS ARDSNet Ventilation Play with Vent Paralytics

Plan B APRV

HFOV

ECLS iNO

Prone Positioning

2 RCTS Evaluate High Frequency Oscillatory Ventilation in ARDS

  • OSCAR – NEJM Feb 2013, Young et al

– Multicenter RCT: 29 Centers, UK – Enrolled 795 patients, P/F < 200 for >2 days – Randomized to Low Tidal Volume vs. HFOV (R100)

  • OSCILLATE Trial - NEJM Feb 2013, Ferguson et al

– Multicenter RCT: 39 Centers, 5 Countries – Planned to enroll 1200 (stopped at 548) – Entry: new-onset ARDS with P/F < 200 – Randomized to Low Tidal Volume vs. HFOV (3100B)

No Benefit, Potential Harm with HFOV in Moderate-Severe ARDS

OSCILLATE OSCAR

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5/31/2013 3

ARDS ARDSNet Ventilation Play with Vent Paralytics

Plan B APRV HFOV ECLS iNO

Prone Positioning

Question 2: Should I use low-tidal volume ventilation for all patients?

Background

  • Strong evidence supports the use of lung-

protective ventilation for patients with ARDS (NEJM 2000)

  • HOWEVER, could patients benefit from lung

protective ventilation if they are at risk for ARDS? Might they benefit even if there is no clear risk factor for ARDS?

Neto et al JAMA Oct 24/31, 2012- Vol 308, No 165

  • Study Design

– Meta-Analysis

  • 20 studies with a total of 2822 patients
  • Studies performed in the OR, MICU, SICU, NICU
  • Primary reason for intubation was schedule surgery
  • Included 15 RCTs, 5 were cross-sectional or cohort studies
  • Average Tidal Volume

– Protective 6.45 ml/kg vs. Conventional 10.60 ml/kg (P<0.001)

  • Follow: 3hrs->10 days
  • Outcomes: Lung Injury, Mortality, Pulmonary Infection,

Atelectasis

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Neto et al JAMA Oct 24/31, 2012- Vol 308, No 165

Lung Injury Mortality Pulmonary Infection Atelectasis RR for low VT 0.33 0.64 0.52 0.62 p-value <0.001 0.007 0.005 0.03

Low VT better High VT better

Question 2: Should I use low-tidal volume ventilation for all patients? Answer: Yes, unless there is a compelling contraindication Question 3: Should I rush to start TPN on my patient who cannot tolerate enteral feeds?

  • Study Design

– Randomized Multicenter Trial in Belgium – 4600 patients at nutritional risk who were not chronically malnourished

  • (majority were surgical patients)

– Randomized to early (<48 h) vs. late ( 1 wk) TPN to meet nutritional needs in at risk patients – Compared guidelines in Europe (early) vs. N. America (late)

Early versus Late Parenteral Nutrition in Critically Ill Adults

Casaer, M.P. NEJM 365(6): Aug 2011

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5/31/2013 5 Early versus Late Parenteral Nutrition in Critically Ill Adults

Casaer, M.P. NEJM 365(6): Aug 2011 Days After Enrollment Late-Initiation Early-Initiation P Value

Death at 90 Days 11.2% 11.2% 1.00 Discharge Alive from ICU within 8 days 75.2 % 71.7 % 0.007 Duration of ICU Stay (days) 3 (2-7) 4 (2-9) 0.02 Duration of hospital stay (median) 14 (9-27) 16 (9-29) 0.004 New Infection 22.8 26.2 0.008 Median duration of RRT (days) 7 (3-6) 10 (5-23) 0.04 Mean total incremental health care cost 16,863 17,973 0.04

Early versus Late Parenteral Nutrition in Critically Ill Adults

Casaer, M.P. NEJM 365(6): Aug 2011 Doig et al JAMA May 2013

  • Multicenter RCT in Australia/New Zeland
  • Enrolled 1372 patients with relative

contraindications to early enteral nutrition who were expected to be in the ICU > 2days

  • Randomized to standard practice vs. TPN w/in

24 hours of ICU admission

  • Super Early TPN

Doig et al JAMA May 2013

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Doig et al JAMA May 2013 Early-PN Standard Care P Value

60 day mortality 21.5% 22.8% 0.60 Duration of ICU stay (d) 8.6 (8.2-9.0) 9.3 (8.9-9.7) 0.06 Duration of hospital stay (d) 25.4 (24.4-26.6) 24.7 (23.7-25.8) 0.5 New Infection 10.9% 11.4% .91

Question 3:

Should I start TPN on my patient who can’t tolerate enteral feeds? Answer: No need to provide super early or early TPN, but try to feed enterally as soon as possible Question 4: In actively bleeding patients, what is a reasonable transfusion threshold?

Background

  • 1999 NEJM TRICC trial

– Liberal Transfusion

  • Trigger Hb of 10 g/dl
  • Goal Hb 10-12 g/dl

– Restrictive Transfusion

  • Trigger Hb 7 g/dl
  • Goal Hb 7-9 g/dl
  • These patients were euvolemic
  • ACTIVELY BLEEDING PATIENTS WERE EXCLUDED
  • What do we do with actively bleeding patients?
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  • RCT single center in Spain
  • Enrolled 921 patients with UGIB
  • Randomized to:

– Transfusion trigger of Hb 7 g/dl vs. 9 g/dl – Stratified by presence of cirrhosis

  • Primary outcome was 45 day survival
  • Secondary outcomes: further bleeding

Villanueva C et al. NEJM, 2013;368:11-21

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Villanueva C et al. N Engl J Med 2013;368:11-21

Trigger = Hb <7 Trigger = Hb <9

Villanueva C et al. NEJM, 2013;368:11-21

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Villanueva C et al. N Engl J Med 2013;368:11-21

Villanueva C et al. NEJM, 2013;368:11-21

Transfusion Strategies for Acute Upper Gastrointestinal Bleeding

Restrictive Liberal P Value

Death at 45 Days 5% 9% 0.02 Further Bleeding 10% 16% 0.01 Number of days in hospital 9.6 11.5 0.01 Adverse events (any) 40% 48% 0.02 Transfusion associated cardiac overload <1 4 0.001 Cardiac Complications 11% 16% 0.04

Question 4: In actively bleeding patients, what is a reasonable transfusion threshold? Answer: FOR UPPER GIB Utilize a threshold of Hb < 7

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Based on these 6 papers…

  • HFOV should be eliminated from the

treatment algorithm for moderate-severe ARDS

  • Lung protective ventilation can be widely

employed in the ICU

  • Initiation of TPN in patients who are at

nutritional risk can be “delayed”

  • In actively bleeding patients with UGIB a

transfusion trigger of Hb < 7 can be used

Questions?