The route of early nutrition in critical illness. NEJM, October 2014 [online]
Cook, D. and Arabi, Y.
http://www.nejm.org/doi/full/10.1056/NEJMe1411474?af=R&rss=currentIssue
Randomized trials may be broadly categorized as explanatory or pragmatic. Explanatory trials address the question, “Can this intervention work under ideal conditions?” Pragmatic trials ask, “Does this intervention work under usual conditions?” Usual conditions, of course, are context-dependent. In the United Kingdom, the CALORIES trial by Harvey et al.,1 reported in the Journal,addresses the clinical effectiveness of early enteral nutrition, as compared with early parenteral nutrition, in critically ill patients without contraindications to either route of delivery. This trial, commissioned and sponsored by the Health Technology Assessment Program of the National Institute for Health Research, was pragmatic in design and conduct.
Monday 20 October 2014
Goal-directed resuscitation for patients with early septic shock
Goal-directed resuscitation for patients with early septic shock. NEJM, October 2014 [online]
The ARISE Investigators and the ANZICS Clinical Trials Group
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380?af=R&rss=currentIssue
The ARISE Investigators and the ANZICS Clinical Trials Group
http://www.nejm.org/doi/full/10.1056/NEJMoa1404380?af=R&rss=currentIssue
Early goal-directed therapy has been endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients presenting to the emergency department with septic shock. However, its effectiveness is uncertain.
Lower versus higher hemoglobin threshold for transfusion in septic shock
Lower versus higher hemoglobin threshold for transfusion in septic shock. NEJM, October 2014 [online]
Holst, L.B., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1406617?af=R&rss=currentIssue
Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization.
Holst, L.B., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1406617?af=R&rss=currentIssue
Blood transfusions are frequently given to patients with septic shock. However, the benefits and harms of different hemoglobin thresholds for transfusion have not been established. In this multicenter, parallel-group trial, we randomly assigned patients in the intensive care unit (ICU) who had septic shock and a hemoglobin concentration of 9 g per deciliter or less to receive 1 unit of leukoreduced red cells when the hemoglobin level was 7 g per deciliter or less (lower threshold) or when the level was 9 g per deciliter or less (higher threshold) during the ICU stay. The primary outcome measure was death by 90 days after randomization.
Trial of the route of early nutritional support in critically ill adults
Trial of the route of early nutritional support in critically ill adults. NEJM, October 2014 [online]
Harvey, S.E., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1409860?af=R&rss=currentIssue#t=articleTop
Nutritional support is standard for critically ill patients and requires a complex calculus of timing, route of delivery, and the amount and type of nutrients that are administered — all of which may affect patient outcomes. The interpretation of published meta-analyses of trials comparing nutritional support through the parenteral route versus the enteral route in critically ill patients is complicated by small sample sizes, variable quality, selection bias, lack of standardized definitions, and interventions that combine multiple elements of nutritional support (e.g., timing and route). Currently, the enteral route is the mainstay, largely on the grounds of physiological rationale and modest evidence suggesting an association with fewer infections, yet it can also be associated with gastrointestinal intolerance and underfeeding. The parenteral route, though more invasive, more often secures delivery of the intended nutrition but has been associated with greater risks and rates of complications. However, these studies have not considered improvements in delivery, formulation, and monitoring of parenteral nutrition.
Harvey, S.E., et al.
http://www.nejm.org/doi/full/10.1056/NEJMoa1409860?af=R&rss=currentIssue#t=articleTop
Nutritional support is standard for critically ill patients and requires a complex calculus of timing, route of delivery, and the amount and type of nutrients that are administered — all of which may affect patient outcomes. The interpretation of published meta-analyses of trials comparing nutritional support through the parenteral route versus the enteral route in critically ill patients is complicated by small sample sizes, variable quality, selection bias, lack of standardized definitions, and interventions that combine multiple elements of nutritional support (e.g., timing and route). Currently, the enteral route is the mainstay, largely on the grounds of physiological rationale and modest evidence suggesting an association with fewer infections, yet it can also be associated with gastrointestinal intolerance and underfeeding. The parenteral route, though more invasive, more often secures delivery of the intended nutrition but has been associated with greater risks and rates of complications. However, these studies have not considered improvements in delivery, formulation, and monitoring of parenteral nutrition.
The effect of goal-directed therapy on mortality in patients with sepsis
The effect of goal-directed therapy on mortality in patients with sepsis - earlier is better: a meta-analysis of randomized controlled trials. Critical Care 2014, 18:570
Gu, W-J., et al.
http://ccforum.com/content/pdf/s13054-014-0570-5.pdf
The Surviving Sepsis Campaign guidelines recommend goal-directed therapy (GDT) for the early resuscitation of patients with sepsis. However, the findings of the ProCESS (Protocolized Care for Early Septic Shock) trial show no benefit from GDT for reducing mortality rates in early septic shock. We performed a meta-analysis to integrate these findings with existing literature on this topic and evaluate the effect of GDT on mortality from sepsis. We searched the PubMed, EMBASE, CENTRAL, and reference lists of articles. Randomized controlled trials comparing GDT with standard therapy or usual care in patients with sepsis were included. The prespecified primary outcome was overall mortality.
Gu, W-J., et al.
http://ccforum.com/content/pdf/s13054-014-0570-5.pdf
The Surviving Sepsis Campaign guidelines recommend goal-directed therapy (GDT) for the early resuscitation of patients with sepsis. However, the findings of the ProCESS (Protocolized Care for Early Septic Shock) trial show no benefit from GDT for reducing mortality rates in early septic shock. We performed a meta-analysis to integrate these findings with existing literature on this topic and evaluate the effect of GDT on mortality from sepsis. We searched the PubMed, EMBASE, CENTRAL, and reference lists of articles. Randomized controlled trials comparing GDT with standard therapy or usual care in patients with sepsis were included. The prespecified primary outcome was overall mortality.
Critical care telemedicine
Critical care telemedicine: evolution and state of the art. Critical Care Medicine, Nov 2014, Vol. 42(11), p.2429-36
Lilly, C., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/Critical_Care_Telemedicine___Evolution_and_State.14.aspx
To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda.
Lilly, C., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/Critical_Care_Telemedicine___Evolution_and_State.14.aspx
To review the growth and current penetration of ICU telemedicine programs, association with outcomes, studies of their impact on medical education, associations with medicolegal risks, identify program revenue sources and costs, regulatory aspects, and the ICU telemedicine research agenda.
Beyond the evidence: treating pulmonary hypertension in the intensive care unit
Beyond the evidence: treating pulmonary hypertension in the intensive care unit. Critical Care, 2014, 18: 542
Bauer, S.R. and Tonelli, A.R.
http://ccforum.com/content/18/5/524
Most patients with pulmonary arterial hypertension succumb to their disease in the ICU; however, limited evidence-based information exists to guide treatment in those that present with advanced right ventricular failure. Critical care physicians should be aware of the complexities of the treatment of patients with pulmonary arterial hypertension and should develop a strategy for their care. Current management is based on the pathophysiology of the disease and involves a multidisciplinary team supported by institutional polices directed at optimizing patient safety.
Bauer, S.R. and Tonelli, A.R.
http://ccforum.com/content/18/5/524
Most patients with pulmonary arterial hypertension succumb to their disease in the ICU; however, limited evidence-based information exists to guide treatment in those that present with advanced right ventricular failure. Critical care physicians should be aware of the complexities of the treatment of patients with pulmonary arterial hypertension and should develop a strategy for their care. Current management is based on the pathophysiology of the disease and involves a multidisciplinary team supported by institutional polices directed at optimizing patient safety.
Measuring pain in non-verbal critically ill patients
Measuring pain in non-verbal critically ill patients: which pain instrument? Critical Care, Oct 2014, 18: 554
Payen, J-F and Gelinas, C.
http://ccforum.com/content/18/5/554
Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.
Payen, J-F and Gelinas, C.
http://ccforum.com/content/18/5/554
Pain is experienced by many critically ill patients. Although the patient’s self-report represents the gold-standard measure for pain, many patients are unable to communicate in the ICU. In this commentary, we discuss the study findings comparing three objective scales for the assessment of pain in non-verbal patients and the importance of the tool selection process.
Three-year risk of cardiovascular disease among intensive care patients with acute kidney injury
Three-year risk of cardiovascular disease among intensive care patients with acute kidney injury: a population based cohort study. Critical Care, Oct 2014, 18: 492
Gammelager, H., et al.
http://ccforum.com/content/18/5/492
Acute kidney injury (AKI) is common among intensive care unit (ICU) patients, but follow-up data on subsequent risk of cardiovascular disease remain sparse. We examined the impact of AKI on three-year risk of first-time heart failure, myocardial infarction (MI), and stroke among ICU patients surviving to hospital discharge, and whether this risk is modified by renal recovery before hospital discharge.
Gammelager, H., et al.
http://ccforum.com/content/18/5/492
Acute kidney injury (AKI) is common among intensive care unit (ICU) patients, but follow-up data on subsequent risk of cardiovascular disease remain sparse. We examined the impact of AKI on three-year risk of first-time heart failure, myocardial infarction (MI), and stroke among ICU patients surviving to hospital discharge, and whether this risk is modified by renal recovery before hospital discharge.
Detecting acute distress and risk of future psychological morbidity in critically ill patients
Detecting acute distress and risk of future psychological morbidity in critically ill patients: validation of the intensive care psychological assessment tool. Critical Care, Sept 2014, 18: 519
Wade, D., et al.
http://ccforum.com/content/pdf/s13054-014-0519-8.pdf
The psychological impact of critical illness on a patient can be severe, and frequently results in acute distress as well as psychological morbidity after leaving hospital. A UK guideline states that patients should be assessed in critical care units, both for acute distress and risk of future psychological morbidity; but no suitable method for carrying out this assessment exists. The Intensive care psychological assessment tool (IPAT) was developed as a simple, quick screening tool to be used routinely to detect acute distress, and the risk of future psychological morbidity, in critical care units.
Wade, D., et al.
http://ccforum.com/content/pdf/s13054-014-0519-8.pdf
The psychological impact of critical illness on a patient can be severe, and frequently results in acute distress as well as psychological morbidity after leaving hospital. A UK guideline states that patients should be assessed in critical care units, both for acute distress and risk of future psychological morbidity; but no suitable method for carrying out this assessment exists. The Intensive care psychological assessment tool (IPAT) was developed as a simple, quick screening tool to be used routinely to detect acute distress, and the risk of future psychological morbidity, in critical care units.
The changing role of palliative care in the ICU
The changing role of palliative care in the ICU. Critical Care Medicine, Nov 2014, Vol. 42(11), p.2418-28.
Aslakson, R.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/The_Changing_Role_of_Palliative_Care_in_the_ICU.13.aspx
Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.
Aslakson, R.A., et al.
http://journals.lww.com/ccmjournal/Abstract/2014/11000/The_Changing_Role_of_Palliative_Care_in_the_ICU.13.aspx
Palliative care is an interprofessional specialty as well as an approach to care by all clinicians caring for patients with serious and complex illness. Unlike hospice, palliative care is based not on prognosis but on need and is an essential component of comprehensive care for critically ill patients from the time of ICU admission. In this clinically focused article, we review evidence of opportunities to improve palliative care for critically ill adults, summarize strategies for ICU palliative care improvement, and identify resources to support implementation.
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