Intensive Care Medicine 2015


1. Intensive Care Med. 2015 Sep;41(9):1549-60. doi: 10.1007/s00134-015-3822-1. Epub
2015 May 8.

A systematic review and meta-analysis of early goal-directed therapy for septic
shock: the ARISE, ProCESS and ProMISe Investigators.

Angus DC(1), Barnato AE, Bell D, Bellomo R, Chong CR, Coats TJ, Davies A, Delaney
A, Harrison DA, Holdgate A, Howe B, Huang DT, Iwashyna T, Kellum JA, Peake SL,
Pike F, Reade MC, Rowan KM, Singer M, Webb SA, Weissfeld LA, Yealy DM, Young JD.

Author information: 
(1)Department of Critical Care Medicine, University of Pittsburgh School of
Medicine, Pittsburgh, USA.

Comment in
    Intensive Care Med. 2015 Sep;41(9):1723-4.
    Intensive Care Med. 2015 Sep;41(9):1727-8.
    Intensive Care Med. 2015 Sep;41(9):1725-6.
    Intensive Care Med. 2015 Sep;41(9):1676-8.
    Intensive Care Med. 2015 Sep;41(9):1729-30.

PURPOSE: To determine whether early goal-directed therapy (EGDT) reduces
mortality compared with other resuscitation strategies for patients presenting to
the emergency department (ED) with septic shock.
METHODS: Using a search strategy of PubMed, EmBase and CENTRAL, we selected all
relevant randomised clinical trials published from January 2000 to January 2015. 
We translated non-English papers and contacted authors as necessary. Our primary
analysis generated a pooled odds ratio (OR) from a fixed-effect model.
Sensitivity analyses explored the effect of including non-ED studies, adjusting
for study quality, and conducting a random-effects model. Secondary outcomes
included organ support and hospital and ICU length of stay.
RESULTS: From 2395 initially eligible abstracts, five randomised clinical trials
(n = 4735 patients) met all criteria and generally scored high for quality except
for lack of blinding. There was no effect on the primary mortality outcome (EGDT:
23.2% [495/2134] versus control: 22.4% [582/2601]; pooled OR 1.01 [95% CI
0.88-1.16], P = 0.9, with heterogeneity [I(2) = 57%; P = 0.055]). The pooled
estimate of 90-day mortality from the three recent multicentre studies (n = 4063)
also showed no difference [pooled OR 0.99 (95% CI 0.86-1.15), P = 0.93] with no
heterogeneity (I(2) = 0.0%; P = 0.97). EGDT increased vasopressor use (OR 1.25
[95% CI 1.10-1.41]; P < 0.001) and ICU admission [OR 2.19 (95% CI 1.82-2.65); P <
0.001]. Including six non-ED randomised trials increased heterogeneity (I(2) =
71%; P < 0.001) but did not change overall results [pooled OR 0.94 (95% CI 0.82
to 1.07); P = 0.33].
CONCLUSION: EGDT is not superior to usual care for ED patients with septic shock
but is associated with increased utilisation of ICU resources.

PMID: 25952825  [PubMed - in process]

2. Intensive Care Med. 2015 Sep;41(9):1538-48. doi: 10.1007/s00134-015-3796-z. Epub
2015 Apr 14.

High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic
patients: a randomized controlled clinical trial.

Vourc'h M(1), Asfar P, Volteau C, Bachoumas K, Clavieras N, Egreteau PY,
Asehnoune K, Mercat A, Reignier J, Jaber S, Prat G, Roquilly A, Brule N, Villers
D, Bretonniere C, Guitton C.

Author information: 
(1)Medical Intensive Care Unit, Hôtel-Dieu, University Hospital of Nantes, 30 bd
Jean Monnet, 44093, Nantes, France.

Comment in
    Intensive Care Med. 2015 Sep;41(9):1673-5.

PURPOSE: Intubation of hypoxemic patients is associated with life-threatening
adverse events. High-flow therapy by nasal cannula (HFNC) for preoxygenation
before intubation has never been assessed by randomized study. Our objective was
to evaluate the efficiency of HFNC for preoxygenation, compared to high
fraction-inspired oxygen facial mask (HFFM).
METHODS: Multicenter, randomized, open-labelled, controlled PREOXYFLOW trial (NCT
01747109) in six French intensive care units. Acute hypoxemic adults requiring
intubation were randomly allocated to HFNC or HFFM. Patients were eligible if
PaO2/FiO2 ratio was below 300 mmHg, respiratory rate at least 30/min and if they
required FiO2 50% or more to obtain at least 90% oxygen saturation. HFNC was
maintained throughout the procedure, whereas HFFM was removed at the end of
general anaesthesia induction. Primary outcome was the lowest saturation
throughout intubation procedure. Secondary outcomes included adverse events
related to intubation, duration of mechanical ventilation and death.
RESULTS: A total of 124 patients were randomized. In the intent-to-treat
analysis, including 119 patients (HFNC n = 62; HFFM n = 57), the median
(interquartile range) lowest saturation was 91.5% (80-96) for HFNC and 89.5%
(81-95) for the HFFM group (p = 0.44). There was no difference for difficult
intubation (p = 0.18), intubation difficulty scale, ventilation-free days (p =
0.09), intubation-related adverse events including desaturation <80% or mortality
(p = 0.46).
CONCLUSIONS: Compared to HFFM, HFNC as a preoxygenation device did not reduce the
lowest level of desaturation.

PMID: 25869405  [PubMed - in process]

3. Intensive Care Med. 2015 Apr;41(4):623-32. doi: 10.1007/s00134-015-3693-5. Epub
2015 Feb 18.

Failure of high-flow nasal cannula therapy may delay intubation and increase

Kang BJ(1), Koh Y, Lim CM, Huh JW, Baek S, Han M, Seo HS, Suh HJ, Seo GJ, Kim EY,
Hong SB.

Author information: 
(1)Division of Pulmonary and Critical Care Medicine, Department of Internal
Medicine, University of Ulsan College of Medicine, Ulsan University Hospital,
Ulsan, South Korea.

Comment in
    Intensive Care Med. 2015 Aug;41(8):1514-5.
    Intensive Care Med. 2015 Sep;41(9):1673-5.
    Intensive Care Med. 2015 Jun;41(6):1157-8.

PURPOSE: Intubation in patients with respiratory failure can be avoided by
high-flow nasal cannula (HFNC) use. However, it is unclear whether waiting until
HFNC fails, which would delay intubation, has adverse effects. The present
retrospective observational study assessed overall ICU mortality and other
hospital outcomes of patients who received HFNC therapy that failed.
METHODS: All consecutive patients in one tertiary hospital who received HFNC
therapy that failed and who then required intubation between January 2013 and
March 2014 were enrolled and classified according to whether intubation started
early (within 48 h) or late (at least 48 h) after commencing HFNC.
RESULTS: Of the 175 enrolled patients, 130 (74.3 %) and 45 (25.7 %) were
intubated before and after 48 h of HFNC, respectively. The groups were similar in
terms of most baseline characteristics. The early intubated patients had better
overall ICU mortality (39.2 vs. 66.7 %; P = 0.001) than late intubated patients. 
A similar pattern was seen with extubation success (37.7 vs. 15.6 %; P = 0.006), 
ventilator weaning (55.4 vs. 28.9 %; P = 0.002), and ventilator-free days
(8.6 ± 10.1 vs. 3.6 ± 7.5; P = 0.011). In propensity-adjusted and -matched
analysis, early intubation was also associated with better overall ICU mortality
[adjusted odds ratio (OR) = 0.317, P = 0.005; matched OR = 0.369, P = 0.046].
CONCLUSIONS: Failure of HFNC might cause delayed intubation and worse clinical
outcomes in patients with respiratory failure. Large prospective and randomized
controlled studies on HFNC failure are needed to draw a definitive conclusion.

PMID: 25691263  [PubMed - in process





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