Top Papers in Critical Care2013

Janna Landsperger RN, MSN, ACNP-BC

Cardiac Endocrine Function

• Background: Epi reduces cerebral blood flow. Vasopressin avoids the negative effects on cerebral blood flow. Steroids in CA may decrease cerebral edema and systemic inflammation

• Basic Approach: 3 center, randomized, double-blind, placebo-controlled trial. Does combined vasopressine-epi during CPR + steroids improve survival and cerebral performance category as compared to epinephrine alone?

Mentzelopoulos S, JAMA 2013

Cardiac Endocrine Function• Results: 268 patients enrolled and completed trial over a

2 y period in 3 centers in Greece• Patients in VSE group had a higher probability for ROSC

for 20 minutes or longer• VSE patients received less epi and had shorter ACLS • Duration of MV and hospital LOS was similar • Patients receiving combination of VSE had improved

survival to hospital discharge (13.9% vs 5.1%) and favorable neurological status compared to control

• Conclusion: Improved survival to hospital d/c with favorable neurological status. Should ACLS change?

Cardiac Endocrine Function

Septic Shock

• Background: Septic shock, tachycardia and vasoconstriction occur to compensate for systemic vasodilation. Tachycardia is persistent after treatment of pain, hypovolemia, and fever and is associated with AE. Basic Approach: Present prospective observational clinical study examined the effects of reducing HR in septic shock patients by using esmolol to see if cardiovascular performance is impoved

Morelli A, CCM 2013

Septic Shock• Results: 25 patients requiring norepi to maintain MAP >

65 and a HR > 95 were treated with a continuous infusion of esmolol for goal HR 80-94

• Compared with baseline, HR and CI were significantly decreased after 24 h esmolol therapy

• Norepi requirements were significantly reduced (0.53 vs 0.41µg/kg/min) after 24 h of esmolol therapy

• Esmolol, arterial pH and Pao2 were higher and PaCo2 lower

• Microvascular flow index significantly increased from median 2.8 to 3.0

• Conclusion: Controlling HR may decrease myocardial demand. More patients needed.

Septic Shock

Trauma Resuscitation

• Background: Hemorrhage is the leading cause of death in trauma patients. ATLS recommends starting resuscitation with crystalloids, followed by PRBC. Don’t give FFP until labs are completed confirming coagulopathy or 4 PRBC are administered.

• Basic Approach: Observational prospective cohort study. Examined database of patients who required MT within 24 h of admission.

Kutcher, JAMA Surg 2013

Trauma Resuscitation• Results: Data collected from 174 critically injured trauma

patients over a 6 y study period in a single center• Patients received a median of 6.1L of crystalloid, 13u of

RBCs, 10u of FFP, and 1u of plt in 24 h• Mean 24 h crystalloid volume and number of blood

product given in the first 24 h decreased significantly• The RBC:FFP ratio decreased from a peak of 1.84:1 in

2007 to 1.55:1 in 2011• Decrease of 0.1 achieved in the MT protocol was

associated with a 5.6% reduction in mortality• Conclusion: Best practice elusive? RCT challenging.

Restricted crystalloid, more FFP

Trauma Resuscitation

Traumatic Brain Injury

• Background: ICP monitoring is currently standard of care for patients with severe TBI however there is inadequate evidence of efficacy.

• Basic Approach: Multi-center, parallel-group trial, with randomized assignment to ICP monitoring or imaging + clinical examination

Chesnut, R NEJM 2012

Traumatic Brain Injury• Results: 298 patients were randomized and followed for

6 m at 6 centers in 2 South American Countries over a 3 y study period

• No significant difference in the primary outcome (composite measure based on 21 measure of functional and cognitive status)

• 6 m mortality was 41% in the control group and 39% in the pressure monitoring group

• Median ICU LOS similar, number of AE similar• Conclusion: Similar primary outcome and mortality. If it

is not proven to be superior, do we need to keep doing it?

Traumatic Brain Injury

ReferencesMentzelopoulos, S et al. Vasopressin, epinephrine, and steroids and neurologically favorable survival after in-hospital cardiac arrest. JAMA. 2013;310(3):270-279

Morelli, A et al. Microvascular Effects of Heart Rate Control With Esmolol in Patients With Septic Shock: A Pilot Study. Critical Care Medicine. 2013 41(9)

Kutcher, M et al. A paradigm shift in trauma resuscitation: evaluation of evolving massive transfusion practices. JAMA Surgery 2013.

Chesnut, R, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. NEJM. 2012. 367(26).