Top Papers in Critical Care Janna Landsperger, ACNP-BC

Transcription

1 Top Papers in Critical Care 2014 Janna Landsperger, ACNP-BC

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

3 Blood Transfusions Background: Blood management programs established to improve blood utilization Basic Approach: Analyzed blood utilization and clinical outcomes for adult inpatients in single center over a 6 year interval following implementation of EMR clinical decision support Goodnough, Transfusion epub July 2014

4 Blood Transfusions

5 Blood Transfusions Results: Trends in hospital-wide RBC utilization and outcomes analyzed for all patients at Stanford from Jan 2008 to Dec Alert implemented July 2010 Electronic alert and education significantly decreased RBC utilization Clinical outcomes (mortality, LOS) improved Conclusion: Aggressive transfusion practices do not improve clinical outcomes, expose patients to unnecessary risk, and are costly

6 Tachyarrhythmias Background: Traditional first line AF treatment is antiarrhythmic drug. Previous trials show conflicting results regarding use of ablation as first line therapy. Basic Approach: Multicenter trial of 127 treatment naïve patients with AF randomized to antiarrhythmic drugs or radiofrequency ablation. Morillo, JAMA 2014

7 Tachyarrhythmias

8 Tachyarrhythmias Results: Atrial tachyarrhythmias reccurred in 72% of drug group and 55% of the ablation group. Asymptomatic AF 18% in drug group vs 9% in ablation group Quality of life was significantly improved in the ablation group compared with the drug group Ablation group had a 9% rate of serious AEs Conclusion: Compared to drugs, ablation had a lower rate of recurrent tachyarrhythmias, however AF was documented in 50% of all patients after 2 yrs. Consider cost and risk analysis when choosing treatment

9 Therapeutic Hypothermia Background: Guidelines recommend hypothermia for unconscious patients admitted to ICU after out-of-hospital arrest, but optimal temperature is unknown. Basic Approach: RCT. After out-of hospital cardiac arrest, patients randomized to targeted temp of 33 or 36 C Nielsen, NEJM 2014

10 Therapeutic Hypothermia

11 Therapeutic Hypothermia Results: 939 patients in primary analysis 50% of patients in 33 C group died; 48% of patients in 36 C group died No significant difference between groups with respect to composite outcome of death or poor neurological function at 180 days SAE occurred with similar frequency between groups (93% vs 90%) Conclusion: Colder is not better. Prevention of fever is important

12 Delirium Background: Survivors of critical illness often have cognitive dysfunction; little is known about the epidemiology of long-term cognitive impairment after critical illness Basic Approach: Prospective cohort study. Enrolled adults with respiratory failure or shock in MICU or SICU. Evaluated for inhospital delirium and assessed global cognition and executive function after discharge. Pandharipande, NEJM 2014

13 Delirium

14 Delirium Results: 821 patients 74% developed delirium during hospital stay 3 months: 40% had global cognition scores 1.5 SD below population mean, 26% had scores 2 SD below population mean 12 months: 25% had cognitive impairment similar to mild Alzheimer's, 34% had impairment similar to moderate TBI Use of sedative or analgesic not associated with cognitive impairment at 3 and 12 months Conclusion: ICU patients are at high risk for cognitive dysfunction. Duration of delirium correlates with cognitive dysfunction.

15 Stroke Background: Early decompressive hemicraniectomy decreases mortality in patients <60 years with MCA infarction. Benefit in older patients is uncertain Basic Approach: Prospective unblinded multicenter RCT. Patients assigned in a 1:1 ratio, to medical therapy or early hemicraniectomy Juttler NEJM 2014

16 Stroke

17 Stroke Results: 112 patients randomized 38% in the hemicraniectomy group vs 18% in the control group survived without severe disability Lower mortality in surgery group (33% vs. 70%) 88 SAEs in surgery group vs 84 in control group Stopped for efficacy after 82 patients had 6 month followup Conclusion: Hemicraniectomy increased survival without severe disability among patients >60 years with MCA infarct

18 Palliative Care Concept of enhancing care as death approaches Requires understanding patients perspective Goal care for patients in a manner consistent with their values Cook NEJM 2014

19 Palliative Care Ensuring dignity Elicit values of patients Communicate clearly and compassionately Shared decision-making model Provide valid prognostic information Make recommendation Provide holistic care Orchestrate transition to comfort with grace

20 References Goodnough LT, Maggio P, Hadhazy E, et al. Restrictive blood transfusion practices are associated with improved patient outcomes. Transfusion Jul 4. Morillo C, Verma A, Connolly S, et al. Radiofrequency Ablation vs Antiarrhythmic Drugs as First-Line Treatment of Paroxysmal Atrial Fibrillation (RAAFT-2): A Randomized Trial. JAMA. 2014;311(7): Niklas N, Wettersley J, Cronberg T, et al. Targeted temperature management at 33C versus 36C after cardiac arrest. N Engl J Med 2013; 369: Pandharipande PP, Girard TD, Jackson JC, et al. Long-term cognitive impairment after critical illness. N Engl J Med Oct 3;369(14): Juttler E, Unterberg A, Woitzik J, et al. Hemicraniectomy in Older Patients with Extensive Middle-Cerebral-Artery Stroke. N Engl J Med Mar 20; 370(12): Cook D, Rocker G. Dying with dignity in the intensive care unit. N Engl J Med Jun 26;370(26):