2023 Critical Care Year in Review (Part 2)
Research in mechanical ventilation, intubation, trauma and hemorrhage, neurology, nutrition, intensive insulin therapy, post-ICU outcomes
Intubation and mechanical ventilation
Video laryngoscopy was superior to direct laryngoscopy in first-pass success among ED residents and CCM fellows intubating critically ill patients (DEVICE trial). Besides confirming video laryngoscopy’s shorter learning curve, this result may also in part represent the decay in direct laryngoscopy skills in the post-video era.
Intubated trauma patients receiving a larger extra breath (sigh) every six minutes had markedly lower mortality in a randomized trial. If replicated, the finding would be remarkable and practice-changing. (SiVent)
Intoxicated patients (mostly by alcohol) with GCS of 8 or less did better if intubation was delayed. (NICO trial)
Does oxygen target matter? In a large, complicated pragmatic cluster-crossover study at a single academic center, there was no difference in any meaningful outcome (death, ventilator-free days, or severe complications) between patients randomized to an oxygen saturation target of 90%, 94%, or 98%. (PILOT trial)
In the ICONIC trial, targeting paO2 55-80 mm Hg (low oxygenation) or 110-150 mm Hg (high oxygenation) in mechanically ventilated patients did not affect mortality, although the trial was cut short and possibly underpowered.
Is etomidate harmful? A meta-analysis of 11 randomized trials suggested etomidate increased the risk of death, with a number need to harm of 31. Adrenal suppression is the putative mechanism. Meta-analyses are prone to falsely amplifying small (or absent) effects, by compounding publication bias.
During spontaneous breathing trials, there was no apparent advantage to using more-cumbersome T-pieces over the usual practice of pressure support ventilation in achieving successful ventilator liberation. (TIP-EX trial)
Patients planned for extubation who were receiving tube feedings had equivalent rates of reintubation/extubation failure whether or not their tube feedings were stopped 6 hours prior, or continued through extubation. (REVA network)
An expert panel broadened the definition of acute respiratory distress syndrome (ARDS), to include patients on high-flow oxygen, and made other small tweaks.
Hematology and hemorrhages
Tranexamic acid’s short-term survival benefits in traumatic hemorrhage were confirmed, with most of the benefit still persisting after six months. (PATCH trial)
Direct oral anticoagulants (DOACs) were found to be appropriate alternatives to injected enoxaparin for secondary prevention of venous thromboembolism in patients with invasive solid cancers or blood cancers. (CANVAS trial)
Giving extra cryoprecipitate to trauma patients undergoing massive transfusion did not help. (CRYOSTAT-2)
Patients with severe thrombocytopenia who need central lines had a 5% rate of major bleeding if not transfused platelets (vs. 2% severe bleeding in those who were transfused), but most of that risk accrued to patients with blood cancers.
Aortic balloon occlusion as a method to slow massive traumatic hemorrhage (to enable damage-control surgery) failed to show a benefit in a multicenter UK trial, after initially showing promise in single-center RCTs. (UK-REBOA)
Neurology and neurosurgery
For subdural hematoma requiring surgical evacuation, either craniotomy (replacing the bone flap immediately) or decompressive craniectomy (leaving the flap off temporarily) led to similar outcomes. (RESCUE-ASDH)
Nutrition in critical illness, intensive insulin therapy
Intensive insulin therapy was convincingly shown to be unhelpful at improving any meaningful outcome in critically ill patients, in a massive trial in Belgium. Rather, the study suggested an even more permissive approach to hyperglycemia (glucose of 215 mg/dL rather than the common target of 180 mg/dL) might be reasonable. (TGC-FAST)
Another large trial showed no benefit of a high dose protein nutrition strategy in critically ill patients; there was possible harm among those with acute kidney injury who received high dose protein. (EFFORT Protein)
And another trial suggested there may be no benefit to the high-caloric targets advised in critical care guidelines. Patients on mechanical ventilation and high-dose vasopressors restricted to ~420 kcal/day for the first 7 days did as well as those provided ~1750 kcal/day. (NUTRIREA-3)
Functional outcomes after critical illness, especially ARDS with mechanical ventilation, are much worse than most physicians recognize. (Review)
Intensive early mobilization did not lead to improved functional outcomes after critical illness, although the control group received much more physical therapy than is typical in U.S. ICUs, in the multicenter TEAM study by ANZICS.
Patients receiving intensive early mobilization had better cognitive outcomes, but no greater rates of functional independence, in a single center study at University of Chicago.
Thanks again for helping to bring PulmCCM back this year with your readership and support.
Happy holidays, and see you in 2024!