The Latest In Critical Care: May 29, 2025
Anticoagulation for acute chest syndrome, CONSORT update, dex for delirium, IO vs IV
Therapeutic anticoagulation to prevent pulmonary thrombosis in sickle cell acute chest syndrome
Patients with acute chest syndrome due to sickle cell disease may appear as if they are having pneumonia, pulmonary edema, and pulmonary embolism, all at once.
In situ thrombosis of the pulmonary arteries is common during acute chest syndrome. Usually these manifest as small or “microthrombi” at the segmental or subsegmental levels. The role of anticoagulation in acute chest syndrome, either prophylactically or therapeutically, is still under investigation.
In a randomized trial of 172 patients at 12 French hospitals between 2016 and 2021, adult patients with acute chest syndrome receiving full-dose anticoagulation had a shorter time to illness resolution and lower opioid use, without any major bleeding. Control patients received prophylactic dose anticoagulation. Pulmonary thrombosis was not tested as an outcome, and chest CT angiography was not uniformly performed, so it’s unclear if the observed benefits were actually due to a reduction in generation of in situ thromboses.
(Dessap et al, AJRCCM, March 2025)
Dexmedetomidine to prevent postoperative delirium after cardiac surgery
As many as half of older adults undergoing cardiac surgery become delirious after their operation. Prophylactic dexmedetomidine has been tested repeatedly as a potential mitigator of delirium in these patients.
The European Society of Anaesthesiology and Intensive Care Medicine stopped just short of endorsing dexmedetomidine infusions (sold as Precedex) intraoperatively for the prevention of postoperative delirium (POD), in its 2024 update to guidelines on postoperative delirium in adults.
In a meta-analysis of 15 randomized trials (n=3,675) enrolling cardiac surgery patients, the pooled arms receiving dexmedetomidine had a 33% relative risk reduction in postoperative delirium (RR 0.67; 95% CI: 0.51 to 0.89; p = 0.01).
There were no statistically significant differences in mortality, hypotension, or acute kidney injury between the pooled treatment arms.
(Barbosa et al, Current Anesthesiology Reports 2025)
CONSORT 2025: keeping researchers honest since ‘96
“Biased results from poorly designed and poorly reported trials are wasteful and can mislead decision making in healthcare at all levels, from treatment decisions for the individual patient to formulation of national public health policies.” —Hopewell et al BMJ 2025
Not as exciting as a real-life consort update, but important nonetheless:
Since 1996, CONSORT (Consolidated Standards of Reporting Trials) has specified how randomized trials should be reported to maximize transparency and reduce the likelihood of waste and fraud.
For example, for many years, authors have been required to pre-register their protocols and to describe their blinding and randomization processes.
The latest updates require that in addition to the previous ~25 other checklist items:
Authors specify where and how de-identified individual participant data can be accessed. This will prevent situations in which contested patient data is not provided to outside parties for transparent review, as allegedly occurred in the early goal-directed therapy trial for sepsis.
How missing data were handled in the analysis: it’s easier to show an effect when a few patients’ data is “lost”
Intervention and comparator as they were actually administered: in multiple high-profile trials, and untold numbers of low-profile ones, adherence to the protocol has gone unreported.
Clear definitions and assessments of any harms or unintended effects of the intervention are provided.
Any important changes made to the trial after it starts are reported.
There is no randomized trial police force, but investigators who flout the CONSORT guidelines might invite criticism from peers, funders, policymakers, and PulmCCM.
Intraosseous vs. intravenous access in cardiac arrest: meta-analysis
Intraosseous lines have become much more widely used in recent years for fast access in cardiac arrest, especially in prehospital encounters.
A meta-analysis of four RCTs with 9,475 patients found no significant differences between the pooled IO and IV arms in survival (6.6% vs. 6.9%, OR 0.99, 95% CI 0.84–1.18) or favorable neurological outcome (4.7% vs. 4.6%, OR 1.07, 95% CI 0.88–1.30).
IOs were more often successfully placed on the first attempt (92.3% vs. 62.3%; OR 6.18, 95% CI 3.50–10.91), and access was obtained about 15 seconds faster with IOs.
However, there was a trend toward lower rates of ROSC in the IO arms (24.6% vs. 27.0%, OR 0.92, 95% CI 0.80–1.06).
The findings largely mirrored those of the two largest and most recent RCTs, which were heavily weighted in the meta-analysis. We reviewed those here:
Intraosseous vs intravenous access: which is better during resuscitation?
During cardiac arrest, every second matters (at least potentially). For out-of-hospital cardiac arrest in particular, intravenous access can be difficult to establish, delaying the administration of epinephrine and other drugs and possibly worsening outcomes.