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

Transcription

1 Top Papers in Cri-cal Care 2016 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 Sepsis Background: Give acetaminophen to lower temperature in sepsis No high- level evidence on its benefit Basic Approach: Prospec-ve, parallel- group, blinded, RCT Randomly assigned 1:1 ra-o acetaminophen vs placebo Primary outcome: ICU- free days to day 28

4 Sepsis Interven-ons 1:1 ra-o Randomiza-on Study Drug Acetaminophen Placebo 100ml 1 gm IV q 6 hours D5 q 6 hours Con-nue un-l fever resolved Con-nue un-l fever resolved

5 Sepsis Results N= 700 No significant difference in ICU- free days to day 28 No significant difference in mortality at day 28 or 90 No significant difference in length of ICU stay, or hospital LOS Adverse Events: liver dysfunc-on in 8.1% of pa-ent assigned to acetamionophen Markedly elevated temp associated with death in 1 pa-ent assigned to placebo

6 Kaplan Meier Estimates of the Probability of Survival to Day 90. Young P et al. N Engl J Med 2015;373:

7 Sep-c Shock Background: Con-nua-on of IV vasopressors for hypotension increases ICU LOS Can midodrine be used to replace IV vasopressors? Basic Approach: Retrospec-ve, one year study period MICU Included pa-ents with sep-c shock, > 24 hours pressors Primary outcome: dura-on of IV vasopressor and ICU LOS

8 Sep-c Shock Study Design IV Vasopressors Only N = 140 IV vasopressors + midodrine N= 135 Norepinephrine N = mg q 8 hours Phenylephrine N = 38 Increased un-l IV pressor not required

9 Results

10 Respiratory Failure Background: Allows constant FiO2 during peak inspiratory flow Decreased intuba-on rates in respiratory failure Basic Approach: Mul-center RCT Randomized to conven-onal versus high flow prior to extuba-on Primary outcome: reintuba-on within 72 hours

11 Respiratory Failure Interven-ons Target SpO2 >92% 10 L/min High- Flow Con-nue 24 hours Nasal cannula Non- rebreather Target SpO2 > 92% Conven-onal oxygen

12 Respiratory Failure Results: N= 527 Reintuba-on rate within 72 hours (basal rate 13%) High- flow 13 pa-ents (4.9%) Conven-onal 32 pa-ents (12.2%) P = Need to treat 14 to prevent 1 reintuba-on No significant difference in median -me to reintuba-on Difference in median ICU length of stay was not significant

13 Nutri-on Background: Correct electrolyte imbalances + thiamine supplementa-on No evidence regarding restricted versus standard caloric intake during electrolyte replacement Basic Approach: Randomized, parallel- group, mul-center, single blind clinical trial Restricted versus no caloric restric-on Primary outcome: number of days alive ajer d/c from ICU

14 Nutri-on Interven-on Phosphate and thiamine monitoring and replacement implemented in both groups Phosphate replacement dose not different between groups Restricted n= kcal/ hr 2 days 40 kcal/ hr 1 day 60 kcal/h 1 day Day 4 100% Standard n= 170 Con-nue nutri-onal support as planned

15 Nutri-on Results Standard Care Caloric Mgmt p Value Vital status (% alive) ICU D/C status 150/165 (91%) 157/166 (95%) 0.20 Hospital D/C status 135/165 (82%) 151/166 (91% Day 60 status 128/163 (79% 149/164 (91%) Day 90 status 128/163 (79%) 143/164 (87%) LOS (days) ICU Hospital

16 Renal Failure Background: AKI common in ICU, associated with high M&M When to ini-ate therapy is up for debate Basic Approach: Unblinded, prospec-ve, mul-center randomized trial Primary outcome: survival un-l death or day 60

17 Early Strategy n= 311 Renal Failure Interven-on RRT started within 6 hours of stage 3 AKI RRT d/c for UOP > 500/24h Delayed Strategy n=308 RRT started for oliguria /anuria > 72 hours RRT d/c for UOP > 500/24h Criteria mandated RRT in delayed group: BUN > 112 K+ > 6 ph < 7.15 Pulmonary edema from volume overload

18 Renal Failure Results

19 APPs in ICU Background: APPs used in ICUs for decades Long- term outcomes of pa-ents cared for con-nuously by APPs unknown Basic Approach: Prospec-ve cohort study of all admission MICU 3 years Primary Outcome: 90 day survival of pa-ents cared for by NPs vs resident team

20 APPs in ICU Medical Director Aoending A Aoending B Aoending C Fellow A Fellow B Fellow A/ B Day Resident Intern Resident Intern NP Night Intern Intern NP

21 APPs in ICU Results

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23 References Young P, et al. Acetaminophen for Fever in Cri-cally Ill Pa-ents with Suspected Infec-on. N Engl J Med Dec 3;373(23): Whitson, M, et al. Feasibility, U-lity, and Safety of Midodrine During Recovery Phase From Sep-c Shock. Chest Jun;149(6): Hernández G,et al. Effect of Postextuba-on High- Flow Nasal Cannula vs Conven-onal Oxygen Therapy on Reintuba-on in Low- Risk Pa-ents: A Randomized Clinical Trial. JAMA Apr 5;315(13): Doig GS, Simpson F, Heighes PT, et al. Restricted versus con-nued standard caloric intake during the management of refeeding syndrome in cri-cally ill adults: a randomised, parallel- group, mul-centre, single- blind controlled trial Lancet Respir Med Dec;3(12): Gaundry et al. Ini-a-on Strategies for Renal- Replacement Therapy in the Intensive Care Unit. N Engl J Med Jul 14;375(2): Landsperger JS, Semler MW, Wang L, Byrne D, Wheeler AP. Outcomes of Nurse- Praci-oner Delivered Cri-cal Care. Chest. 2016;149(5):

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