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Critical Care Journal Club Blog

The goal of this blog is to inform and briefly discuss new papers in Adult and Pediatric Critical Care and Hospital Medicine.
  • Trial randomized pts with hypoxemic resp insufficiency defined as paO2/FiO2 <300 to high-flow NC, standard NC or NIPPV. Primary endpoint of intubation was nonsig but perhaps underpowered and favored high-flow NC. Significant difference in vent-free days and 90-day mortality favoring high-flow NC. http://www.nejm.org/doi/full/10.1056/NEJMoa1503326#t=article

  • Permissive underfeeding of ICU patients at 60% caloric target vs. standard feedings. Controls received 1826 mean kcal/day, intervention group on average received 1036 kcal/day equivalent to a 1.5 kcal/mL TF at 29 cc/hr. No change in mortality, more insulin use in controls, less incident RRT for intervention group in post-hoc analysis. Supports the idea that permissive underfeeding with protein supp. is safe and possibly effective, while allowing us to conserve the global Jevity supply.

  • I think this paper on the use of arterial lines from JAMA Internal Medicine is worthy of discussion. Two quotes from the paper: "In the cohort of patients receiving vasopressors, arterial catheter use was associated with an increased odds of death” "In this propensity-matched cohort analysis, arterial catheters were not associated with improvements in hospital mortality in medical ICU patients requiring mechanical ventilation.” http://archinte.jamanetwork.com/article.aspx?articleid=1901115

  • In an article completely not relevant to critical care, multivariate regression demonstrates that confounders which associate with apple ingestion explain the reduction in doctor visits such that after adjustment for these, there is no independent association of the apple. Whatever- they stay taste good! JAMA Intern Med. 2015;175(5):777-783

  • JAMA. 2015;313(17):1719-1727 Infection of patients treated for C. diff with antibiotics using spores of NON-TOXIN PRODUCING C diff resulted in reduced recurrence. This builds on the concept of lactobacillus and fecal enemas by outcomepeting the toxic strains, who require more energy, with the wild type which can thrive. An innovative and apparently safe idea in the setting of increasing problems from C. diff superinfections.

  • Intriguing systematic review/meta-analysis by one of our previous research fellows and several Pitt faculty on whether there is a volume-outcome relationship for critical care in general. Data support a relationship, with implications for regionalization of critical care services. Online First http://journal.publications.chestnet.org/article.aspx?articleID=2289063

  • JAMA. 2015;313(16):1627-1635. Finally an RCT of anticoagulation + filter vs. anticoagulation alone. Not even a trend to support the filter most of which were successfully removed. If you can anticoagulate- DO IT. Still open is the question of whether these work when anticoagulation is contraindicated...

  • Neurologic function and health-related quality of life in patients following targeted temperature management at 33°c vs 36°c after out-of-hospital cardiac arrest: A randomized clinical trial. JAMA Neurol [Internet] 2015 http://dx.doi.org/10.1001/jamaneurol.2015.0169 Long term cognitive and health-related QOL outcomes data for patients with cardiac arrest randomized to hypothermia of 33C or 36C in the TTM trial.

  • Kerlin MP, Harhay MO, Kahn JM, Halpern SD. Nighttime intensivist staffing, mortality, and limits on life support: A retrospective cohort study. Chest 2015;147(4):951–8. Retrospective study using the IMPACT database showing no change in hospital mortality provided by nighttime attending intensivist staffing vs. nonintensivist or trainee staffing. Consistent with other studies in area and interesting subanalyses, probably worthy of discussion.

  • N Engl J Med 2015; 372:1419-1429 Patients getting complex heart surgery were randomized to (mean) 7d vs 28d old blood with outcomes of increase in multiple organ dysfunction (MODS) and other clinical endpoints. Patients received a median 4 u pRBC (ie a decent dose). No differences resulted despite the large differences in banked times.

  • From conclusion: "Among patients with AMI undergoing primary PCI, the use of bivalirudin with a median 3-hour postprocedure PCI-dose infusion resulted in a decrease in net adverse clinical events compared with both heparin alone and heparin plus tirofiban. This finding was primarily due to a reduction in bleeding events with bivalirudin, without significant differences in major adverse cardiac or cerebral events or stent thrombosis." At the very least this is an option in patients with HIT.

  • New paper release online in JAMA Int Med that examines the adoption of tight glycemic control after Leuven I but the failure to DE-adopt this disproven practice after NICE-SUGAR. It provides an interesting perspective on our tendency to pick up positive trials but not change management on the basis of negative ones.

  • A recent NEJM article (New England Journal of Medicine. 2015;372:747-755) finds the delta-P (ie driving pressure) best stratifies survival vs. death even in the setting of protetive Vt. So perhaps one should question whether a Vt is "protective" if the pressure required to acheive it is high.

  • Two important articles for CCM in this week's NEJM. EGDT did not change outcomes in the Australian study (similar to PROCESS) and TPN vs. enteral nutrition yields similar outcomes. Harvey, S. E., et al. "Trial of the Route of Early Nutritional Support in Critically Ill Adults." (http://www.nejm.org/doi/full/10.1056/NEJMoa1409860) ARISE investigators/ANZICS. "Goal-Directed Resuscitation for Patients with Early Septic Shock." (http://www.nejm.org/doi/full/10.1056/NEJMoa1404380)

  • JAMA Intern Med. doi:10.1001/jamainternmed.2014.3297 Propensity matched observational study using IMPACT database to examine the hypothesis "arterial lines do (or do not) improve outcomes". Did I miss it? - the prop score variables aren't actually given! Even if they were the only variables available that are all at all relevant are HR>150, SBP<90 and receipt of CPR in the first 24h. PS with variables not used in clinical decision making is an abuse. The results- meaningless.