2016’s MVAs (Most Valuable Articles)


 

I wish I could make an incredible video like Google does every year, but I think a small retrospective of the MVAs (most valuable articles) of 2016 will do the job! For us, the ICU Revisited Team, the year was a glass half full, it was a year of enlightenment and knowledge, beers, SMACC DUB, the blog was born, Fabio is gonna be a father, Daniel became a beer brewer, Rodolpho is one step closer to finishing his residency, and I, well, I think I can make good jokes. However, for some, 2016 was a glass half empty. Lot of good guys died, and as a friend of mine said, after Carrie Fisher’s death: “it appears 2016 will die shooting”. Anyhow, here are the 2016 MVAs, in our opinion, of course. Enjoy.

 

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit, by Gaudry et al [1].

The AKIKI trial compared two strategies regarding the timing of RRT in critically ill patients. Inclusion criteria was: acute kidney injury that was compatible with a diagnosis of acute tubular necrosis (really? people still think this way?) and to undergo randomization patients were required to have KDIGO stage 3 AKI. Patients in the early strategy group received RRT within 6 hours of randomization, while patients in the delayed strategy group would receive RRT if any of the criteria were met: severe hyperkalemia, metabolic acidosis, pulmonary edema, blood urea nitrogen level higher than 112 mg per deciliter, or oliguria for more than 72 hours. The primary outcome was mortality at 60 days. No difference. The most interesting finding in my opinion, was that 98% of the patients in the early strategy received RRT, while only 51% in the delayed strategy did. Well, if you adopt the strategy of early dialysis, you will unnecessarily dialyze ~47% of the patients. Doesn’t seem safe and cost effective, does it?

 

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) [2].

The new ASPEN guidelines deserve a full post for itself, a good blend of low and high quality evidence. But like any other guidelines, if you’re up to date with your readings, it won’t add much. But it fulfill its purpose.

 

Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage, by Qureshi et al [3].

The ATACH-2 trial evaluated blood pressure targets in patients with intracerebral hemorrhage. The targets were: a SBP in the range of 140-179mmHg (control group) vs 110-139 (intervention group), throughout the period of 24 hours after randomization. No difference in the primary outcome of death or disability. Well, the only thing that changed is that I won’t start any vasopressor if my patient has a SBP of 120mmHg, the same way I won’t start a nitroprusside drip if the SBP is 178mmHg.

 

Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients A Randomized Clinical Trial, for the CHECKLIST-ICU investigators [4].

CHECKLIST-ICU trial deserves a place in our list because it was the bigger trial already designed and conducted in Brazilian ICUs, and I really hope it was the embryo of an amazing research future for us. Also, it showed that implementation of checklists did not reduce the in-hospital mortality, which might be true for the participant ICUs, which might be in another level of care just for the fact they accepted/were invited to participate in the study. However, the use of checklists might help in if we consider we still have ICUs around the globe living in the Dark Ages.

 

Restricting volumes of resuscitation uid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial, by Hjortrup et al [5].

The CLASSIC trial is not gonna change the world, yet. It was a feasibility trial evaluating the effects of a protocol restricting resuscitation fluid vs a standard care protocol after initial resuscitation in ICU patients with septic shock. Well, a more restricting protocol was safe. Job done. The study also pointed to some interesting benefits in patient-centered outcomes, like AKI and death, all pointing towards the benefit of restricted strategy. I think future holds better days for us, and for our patients.

 

The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), by Singer at al [6].

Well…I’m gonna confess one thing:, I’m a big fan of Sepsis 3.0. And we can spend the rest of the year here discussing the pros and cons, but not today. Read it. Think about it. Worth it.

 

Guidelines for the Management of Severe Traumatic Brain Injury 4th Edition [7].

It was about time, the new BTF guidelines for TBI. It was already discussed here, take a look (link).

 

Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit The Oxygen-ICU Randomized Clinical Trial, by Girardis at al [8].

Another trial already discussed here in the blog (link), and, despite the misfortunes of fate, it was a good trial.

 

One-Year Outcomes in Caregivers of Critically Ill Patients, by Cameron et al [9].

The RECOVER trial was a punch in my stomach. The disease process involves, not only the patients and doctors, but also the patients’ families and caregivers. Some of us already experienced in a more personal aspect what is to take care of a relative after hospital discharge. The conclusion that “most caregivers of critically ill patients reported high levels of depressive symptoms, which commonly persisted up to 1 year and did not decrease in some caregivers” was alarming.

 

Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension, by Hutchinson et al [10].

Same o’ same o’. Decompressive craniectomy decreases mortality at the cost of increased disability. Be advised: No DC for me.

 

Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock The VANISH Randomized Clinical Trial, by Gordon at al [11].

Finally! It was speculated that the early use of vasopressin could reduce the incidence of AKI in septic shock. Well, it doesn’t.

 

Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids?, by Bentzer at al [12].

Methods evaluating fluid responsiveness never gets old. A great review published in JAMA. (link)

 

Maybe you’re thinking: “well, this is a shitty list!”. Yeah, it might be, but after hours of discussion, fist fights, and gambling, we decided, for many reasons, not to include a few trials in this list. However, we’ll give them the almost-there medal. I know, maybe next year!

 

-Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis (LeoPARDS) [13]

-Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial [14]

– Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock After Cardiac Surgery (VANCS trial) (link) [15]

-Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure The EMPIRICUS Randomized Clinical Trial [16]

-Hypothermia for Neuroprotection in Convulsive Status Epilepticus [17]

 

See you in 2017!

 

1. Gaudry S, Hajage D, Schortgen F, et al. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med. 2016;375(2):122-133.

2. McClave SA, Taylor BE, Martindale RG, et al. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2016;40(2):159-211.

3. Qureshi AI, Palesch YY, Barsan WG, et al. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. N Engl J Med. 2016;375(11):1033-1043.

4. Cavalcanti AB, Bozza FA, Machado FR, et al. Effect of a Quality Improvement Intervention With Daily Round Checklists, Goal Setting, and Clinician Prompting on Mortality of Critically Ill Patients: A Randomized Clinical Trial. JAMA. 2016;315(14):1480-1490.

5. Hjortrup PB, Haase N, Bundgaard H, et al. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med. 2016;42(11):1695-1705.

6. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315(8):801-810.

7. Carney N, Totten AM, OʼReilly C, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2016.

8. Girardis M, Busani S, Damiani E, et al. Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. JAMA. 2016;316(15):1583-1589.

9. Cameron JI, Chu LM, Matte A, et al. One-Year Outcomes in Caregivers of Critically Ill Patients. N Engl J Med. 2016;374(19):1831-1841.

10. Hutchinson PJ, Kolias AG, Timofeev IS, et al. Trial of Decompressive Craniectomy for Traumatic Intracranial Hypertension. N Engl J Med. 2016;375(12):1119-1130.

11. Gordon AC, Mason AJ, Thirunavukkarasu N, et al. Effect of Early Vasopressin vs Norepinephrine on Kidney Failure in Patients With Septic Shock: The VANISH Randomized Clinical Trial. JAMA. 2016;316(5):509-518.

12. Bentzer P, Griesdale DE, Boyd J, MacLean K, Sirounis D, Ayas NT. Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids? JAMA. 2016;316(12):1298-1309.

13. Gordon AC, Perkins GD, Singer M, et al. Levosimendan for the Prevention of Acute Organ Dysfunction in Sepsis. N Engl J Med. 2016.

14. Zarbock A, Kellum JA, Schmidt C, et al. Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial. JAMA. 2016;315(20):2190-2199.

15. Hajjar LA, Vincent JL, Barbosa Gomes Galas FR, et al. Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock after Cardiac Surgery: The VANCS Randomized Controlled Trial. Anesthesiology. 2017;126(1):85-93.

16. Timsit JF, Azoulay E, Schwebel C, et al. Empirical Micafungin Treatment and Survival Without Invasive Fungal Infection in Adults With ICU-Acquired Sepsis, Candida Colonization, and Multiple Organ Failure: The EMPIRICUS Randomized Clinical Trial. JAMA. 2016;316(15):1555-1564.

17. Legriel S, Lemiale V, Schenck M, et al. Hypothermia for Neuroprotection in Convulsive Status Epilepticus. N Engl J Med. 2016;375(25):2457-2467.

 

 

Photo credit

Enon MVA


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2016’s MVAs (Most Valuable Articles)

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