Gotta read V


 

 

It’s scary to see what “standard care” means for some specialties. Areej El-Jawahri and colleagues published in JAMA a randomized trial evaluating the effect of inpatient palliative care on quality of life after hematopoietic stem cell transplantation (HCT) [1]. A nonblinded study, with a moderate sample size ( N=160), assigning patients with hematologic malignancies undergoing autologous/allogeneic HCT and their caregivers to either intervention or standard care. The intervention patients met with palliative care team ate least twice a week during the hospitalization, the intervention was focused on management of physical and psychological symptoms, while in the “standard care” group the supportive care measures were instituted by the transplant team, and palliative care consultations were permitted, if requested. Well, the intervention group had better QOL at week two along with: less depression, lower anxiety, and less increase in symptom burden. At 3 months (secondary endpoint) intervention group had better QOL and less depression. I never had doubt that a specialized team addressing our patients’ physical and psychological needs would be beneficial. Patient centered care! Always! Only 2 patients in the standard care group received a palliative care consultation! T-W-O! Why is that? Why hematologists are so resistant to palliative care? Maybe they think they can handle all patients’ needs? Maybe they see palliative care as a failure? Ok, we need further research, but there is a singn here we can’t dismiss.

 

Last year we saw a meta-analysis showing possible mortality benefits of steroids for community-acquired pneumonia (CAP) [2]. This moth, another meta-analysis was published [3], also showing mortality benefits (RR = 0.46, 95%CI: 0.28 to 0.77, p = 0.003) and safety of adjunctive steroid therapy for severe CAP. Unfortunately, most of the studies had a small sample size and different dose regimens were used. However, the idea that steroids might decrease pulmonary inflammation and prevent the development of associated BOOP, and therefore, decrease mortality, really might be true. A multicenter trial is expected for next year (link). This might be a game changer. Let’s wait.

 

The VANCS trial [4] was published. An RCT comparing vasopressin vs norepinephrine in patients with vasoplegic shock after cardiac surgery. Single-center trial, with composite endpoint which was changed after the trial had enrolled some patients. So, it’s hard to make any strong recommendations. The study showed a difference in the primary outcome, 32% vs 49% favoring vasopressin (unadjusted hazard ratio, 0.55; 95% ci, 0.38 to 0.80; P = 0.0014), mostly driven by acute renal failure (defined as: new requirement for dialysis, increase in serum Cr >2mg/dl or double the most recent preoperative Cr level). Also, vasopressin group had less atrial fibrillation and ICU LOS. Josh Farkas discussed this article on PulmCrit (link), worth reading.

 

A viewpoint published on Critical Care Medicine, Early Liberal Fluids for Sepsis Patients Are Harmful [5], reinforce the recent beliefs that fluid resuscitation should be tailored to the patient’s needs, and arbitrary fluid boluses might be harmful. They made some recommendations in the end, which I don’t completely agree, but here they are: 1- Assess fluid-responsiveness using PLR maneuver before initial fluid resuscitation, coupled with real time or intermittent monitoring of cardiac output. 2- Careful early fluid resuscitation with modest fluid challenges (200–500mL) and titrate according to clinical findings, echocardiography, and noninvasive cardiac output. 3- Start with crystalloids and consider albumin. 4- New treatments to mitigate endothelial injury could be important.

When you think you have seen everything you bump into a 1913 book named: Flatulence and Shock [6]. Of course I didn’t read it, but if anyone has any interest on the mater and somehow have time to read the book, please, send me an email with the summary. Thanks.

 

1. El-Jawahri A, LeBlanc T, VanDusen H, et al. Effect of Inpatient Palliative Care on Quality of Life 2 Weeks After Hematopoietic Stem Cell Transplantation: A Randomized Clinical Trial. JAMA. 2016;316(20):2094-2103.

2. Siemieniuk RA, Meade MO, Alonso-Coello P, et al. Corticosteroid Therapy for Patients Hospitalized With Community-Acquired Pneumonia: A Systematic Review and Meta-analysis. Ann Intern Med. 2015;163(7):519-528.

3. Bi J, Yang J, Wang Y, et al. Efficacy and Safety of Adjunctive Corticosteroids Therapy for Severe Community-Acquired Pneumonia in Adults: An Updated Systematic Review and Meta-Analysis. PLoS One. 2016;11(11):e0165942.

4. Hajjar LA, Vincent JL, Gomes Galas FR, et al. Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock After Cardiac Surgery: The VANCS Randomized Controlled Trial. Anesthesiology. 2016.

5. Genga K, Russell JA. Early Liberal Fluids for Sepsis Patients Are Harmful. Crit Care Med. 2016;44(12):2258-2262.

6. Crookshank, F. G. Flatulence and Shock. London: Lewis, 1912. Print.

 

Photo Credit

Timo Schmid


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