Top Papers in Cri-cal Care Janna Landsperger, ACNP- BC

Transcription

1 Top Papers in Cri-cal Care 2015 Janna Landsperger, ACNP- BC

2 Objec-ves Review journal articles regarding delivery of critical care published over the past twelve months Provide evidence in support of current treatment guidelines

3 Acute Ischemic Stroke Background: - Reperfusion therapy proven efficacy in pa-ent with acute ischemic stroke - Treatment has limita-ons - Intraarterial treatment with locally delivered thromboly-c agents and clot removal or thrombectomy shown to be beneficial Basic Approach: Phase 3, mul-center clinical trial, randomized treatment- group assignments 16 centers Netherlands

4 Acute Ischemic Stroke Treatment Group (233) Control (267) Intraarterial treatment VS Usual Care Usual Care

5 Acute Ischemic Stroke

6 Acute Ischemic Stroke Results: Treatment group: Intrarterial therapy performed in 84.1% 90% of pa-ents received IV alteplase Median modified Rankin at 90 days was 3 in the interven-on and 4 in control Secondary outcome measures including NIHSS score, intracranial occlusion on follow- up CT favor treatment group Conclusion: Ly-cs save lives Intrarterial treament is safe and leads to increase in func-onal independence if obtained during first 6 hours

7 Acute Ischemic Stroke

8 Update

9 Trauma Resuscita-on Background: Clinical prac-ce guidelines since 2004: 1:1:1 transfusion ra-o No RCT with primary end point of survival supports op-mal trauma resuscita-on Study designed to address effec-veness and safety of 1:1:1 compared to 1:1:2 Basic Approach: Phase 3, mul-site, randomized trial 1:1:2: 3 U plasma, 0 dose platelets, 6 u PRBC or 3 U plasma, 1 dose platelets, 6 u PRBC

10 Trauma Resuscita-on Primary Outcome: absolute percentage group differences for 24h and 30d mortality Sample Size: 338 (1:1:1) 342 (1:1:2) Results 1:1:1 Group 1:1:2 Group P Value 24- h mortality No (%) 43 (12.7) 58 (17.0) d mortality No (%) 75 (22.4) 89 (26.1).26

11 Trauma Resuscita-on

12 Rivers E et al. N Engl J Med 2001;345: Sep-c Shock

13 Sep-c Shock

14 Background: Sep-c Shock EGDT incorporated into Surviving Sepsis Guidelines Does EGDT save lives over usual care? Basic Approach: Pragma-c, open, mul-center, RCT Assigned 1:1 ra-o to EGDT or usual care Total interven-on period 6 hrs

15

16 Results IntervenQon EGDT Usual Care Supplemental O2 89.6% 89.1% CVC 92.1% 50.9% A- Line 74.2% 62.2% Median IVF 2.0 L 1.8 L Vasopressor 53.3% 46.6% PRBC 8.8% 3.3% Primary outcome EGDT 184/623 (29.5%) Usual Care 181/620 (29.2%)

17 Age of Blood The new england journal of medicine original article Age of Transfused Blood in Critically Ill Adults Jacques Lacroix, M.D., Paul C. Hébert, M.D., Dean A. Fergusson, Ph.D., Alan Tinmouth, M.D., Deborah J. Cook, M.D., John C. Marshall, M.D., Lucy Clayton, M.Sc., Lauralyn McIntyre, M.D., Jeannie Callum, M.D., Alexis F. Turgeon, M.D., Morris A. Blajchman, M.D., Timothy S. Walsh, M.D., Simon J. Stanworth, F.R.C.P., Helen Campbell, D.Phil., Gilles Capellier, M.D., Pierre Tiberghien, M.D., Laurent Bardiaux, M.D., Leo van de Watering, M.D., Nardo J. van der Meer, M.D., Elham Sabri, M.Sc., and Dong Vo, B.Eng., for the ABLE Investigators and the Canadian Critical Care Trials Group* taire Background: Current regula-ons for RBC storage is 42 days Prior RCT suggested transfusion of older RBC associated with 16% increase in risk of death Basic Approach: Mul-- center, randomized blinded trial Compared RBC stored for less than 8 days with standard- issue RBC Cri-cally ill pa-ents assigned 1:1 ra-o

18 Age of Blood: Results

19 Age of Blood Conclusion: Fresher blood afforded no advantage Does older blood present addi-onal risks? 1:20 units donated blood wasted

20 Afib Background: 25% of pt with sepsis also have atrial fibrila-on Increased risk of stroke, heart failure, death Effec-veness between treatment strategies unknown Basic Approach: Restrospec-ve cohort study Used billing data from 20% of American hospitals

21 Afib

22 Results: Afib CB were the most commonly administered intravenous AF Selec-on of medica-on varied widely Hospital mortality lower for BB vs CCB BB were associated with superior survival in all subgroups analyzed Digoxin use was associated with worse outcomes in all subgroups analyzed Conclusion: RCT needed to compare mgmt AF during sepsis

23 References Berkhemer, O, et al. A randomized trial of intraarterial treatment for acute ischemic stroke N Engl J Med Jan 1;372(1): Goyal, M, et al. Randomized assessment of rapid endovascular treatment of ischemic stroke N Engl J Med Mar 12;372(11): Campbell, BC, et al. Endovascular therapy for ischemic stroke with perfusion- imaging selec-on N Engl J Med Mar 12;372(11): Powers, WJ, et al AHA/ASA Focused Update of the 2013 Guidelines for the Early Management of Pa-ents With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Associa-on/American Stroke Associa-on. Stroke Jun 29. Jauch, EC. Guidelines for the early management of pa-ents with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Associa-on/American Stroke Associa-on. Stroke Mar;44(3): Holcomb, JB. Transfusion of plasma, platelets, and red blood cells in a 1:1:1 vs a 1:1:2 ra-o and mortality in pa-ents with severe trauma: the PROPPR randomized clinical trial. JAMA Feb 3;313(5): Rivers, E. Early goal- directed therapy in the treatment of severe sepsis and sep-c shock. N Engl J Med Nov 8;345(19):

24 References ARISE Inves-gators. Goal- directed resuscita-on for pa-ents with early sep-c shock. N Engl J Med Oct 16;371(16): Mouncey, PR. Trial of early, goal- directed resuscita-on for sep-c shock. N Engl J Med Apr 2;372(14): Lacroix, J. Age of transfused blood in cri-cally ill adults. N Engl J Med Apr 9;372(15): Walkey, A. Prac-ce paherns and outcomes of treatments for aria lfibrilla-on during sepsis: A propensity- matched cohort study. Chest doi: /chest