2023 Critical Care Year in Review (Part 1)
Recaps of sepsis, Covid, cardiovascular care, cardiac arrest, physiology
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Sepsis, infectious disease
Managing septic shock with a restrictive-fluids approach (preferentially using vasopressors after a single liter crystalloid bolus) led to similar outcomes as the usual practice of bolusing large volumes of fluids first. Restrictive-fluids patients received less fluid but required longer durations of vasopressors. Despite the significant differences in fluids delivered, there was no difference in need for mechanical ventilation between groups. Either approach in severe sepsis with shock seems reasonable. (CLOVERS trial)
Piperacillin-tazobactam (marketed as Zosyn) did not cause more renal failure than cefepime, but cefepime did result in more delirium and coma than pip-tazo, in a randomized trial of critically ill patients receiving the antipseudomonal antibiotics. (ACORN)
Corticosteroids reduced mortality from severe community-acquired pneumonia by 50% (6% vs 12%) in the CAPE COD trial in French ICUs. Some experts have begun recommending steroids (e.g. hydrocortisone 200 mg daily) for CAP patients requiring mechanical ventilation.
Beta blockers (landiolol) given to patients receiving norepinephrine for septic shock led to worse outcomes; prior trials had suggested beta-blockade might be helpful, by blunting negative effects of vasopressor-induced tachycardia. (STRESS-L)
Inhaled amikacin reduced the incidence of ventilator-associated pneumonia, but whether it improves hard clinical outcomes like mortality remains unknown. (AMIKINHAL)
CDC issued a “toolkit” to pressure hospitals to devote resources to create and maintain systematic programs to identify, treat and track sepsis:
Vitamin C did not improve outcomes among patients hospitalized with Covid-19. Neither critically ill nor non-critically ill patients benefited. (LOVIT-COVID and REMAP-CAP)
Simvastatin seemed highly likely to have reduced ventilator-days and mortality in critically ill patients with Covid-19 between 2020 and 2022, compared to placebo (REMAP-CAP)
Inhaled corticosteroids did not improve outcomes from Covid-19 pneumonia in the Omicron era. (ACTIV-6 trial)
Pulse oximeters are less accurate in darker-skinned patients—often generating falsely high readings—and this led to delays of care in severely ill darker-skinned patients during the Covid-19 pandemic.
Cardiovascular care, strokes
Mechanical thrombectomy was shown to markedly improve functional independence after large ischemic strokes (SELECT2), heralding a new standard of care for the condition.
For ischemic strokes caused by thromboemboli from atrial fibrillation, starting a direct oral anticoagulant early (3-7 days) prevented more subsequent strokes, as compared to waiting longer. (ELAN trial)
Patients receiving ECMO for cardiogenic shock due to myocardial infarction had no improvement in survival, and more serious complications, compared to patients managed conventionally. (ECLS-SHOCK trial)
Semaglutide (Wegovy) improved heart failure symptoms along with weight reduction, further raising the sense of optimism for the costly drugs’ potential for mitigating the devastating public health consequences of obesity.
A Cochrane review did not find a benefit from cooling below 36° after cardiac arrest, but suggested that patients do better if they receive active (i.e., device-based) cooling to at least 36°.
Authors for the American College of Cardiology argued cooling patients below normothermia may no longer be necessary (dissenting from the American Heart Association guidelines advising it).
After cardiac arrest, a large trial found no benefit to maintaining temperature <37° for 72 hours as compared to 36 hours (after targeting 36° for the first 24 hours), using cooling devices. Read in NEJM
ECMO provided no detectable benefit when applied to patients failing resuscitations from out-of-hospital cardiac arrests due to ventricular arrhythmias. (INCEPTION trial)