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Critical Care Journal Club Blog

The goal of this blog is to inform and briefly discuss new papers in Adult and Pediatric Critical Care and Hospital Medicine.
  • Rivoraxaban and Abixaban can result in substantial irreversible bleeding. In this NEJM article (http://www.nejm.org/doi/full/10.1056/NEJMoa1607887#t=article) Andexanet Alfa reversed major bleeing in ~80% of cases but resulted in thrombosis in 18%. Given the severity of the bleeds this still may be an important reversal agent.

  • This question is examined using the Project IMPACT database and asserts overnight intubation may result in more reintubations and more death but many important factors (some covered in the commentary) aren't accounted for. http://archinte.jamanetwork.com/article.aspx?articleid=2547203

  • A recently published RCT in JAMA has generated lots of controversy based on it's finding of little benefit and perhaps harm (PTSD) resulting from mandated meeting: http://jama.jamanetwork.com/article.aspx?articleid=2532011 http://www.geripal.org/2016/07/fast-food-style-palliative-care.html http://www.pallimed.org/2016/07/jama-got-it-wrong-giving-prognostic_11.h...

  • Patients with ARDS were randomized to a full helmet non-invasive ventilation vs standard full face with significantly less intubation and shorter time on a vent. A small study but a big difference which requires validation. JAMA. Published online May 15, 2016. doi:10.1001/jama.2016.6338

  • Early (at time of AKI diagnosis) vs. delayed (required "indication" like high K, BUN over volume overload) strategies were compared demonstrating less infections and better diuresis when RRT was delayed. A bit surprising- worth reviewing... Gaudry et al DOI: 10.1056/NEJMoa1603017

  • N Engl J Med 2015; 373:2215-2224 ICU patients with fever were randomized to acetaminophen 1g q6h or placebo. Their temperature dropped a whopping 0.3C. This didn't alter the outcomes. Earlier data for fever control appears more promising but other techniques (like surface cooling) were used. Is this an indictment of cooling- not necessarily but it shows acetaminophen doesn't do much and doesn't alter outcomes in critical illness.

  • Two recent large RCTs (RIPCHeart: N Engl J Med 2015; 373:1397-1407 and ERRICA: N Engl J Med 2015; 373:1408-1417) in the 10/8/2015 NEJM examined RIPC via upper arm BP cuff inflation within cardiac surgery patients. Both failed to show benefit even in the surrogate outcomes like AKI, delirium and troponin leak contradicting earlier smaller studies. The editorial concludes with an important issue- how do we dose this therapy?!?

  • A prior JAMA published study using historical control suggested that buffered solutions used in resuscitation reduce AKI. I must admit I became a big fan of LR and plasmalyte thereafter. But the recent very well done SPLIT trial, an RCT by the ANZICS group using blinding and crossover design shows no difference in any of the clinical outcomes including AKI or mortality. Young et al. JAMA 2015 - Online only at present. doi:10.1001/jama.2015.12334.

  • Required reading for all intensivists! This is a well done RCT where EXPERIENCED personnel placed central lines in each of the 3 major positions. Limitation: limited US use especially at the femoral site but little difference in insertion times or arterial injury. The results confirm what's long been suspected- subclavians have the least infections/clots but more pneumos. Link: http://www.nejm.org/doi/full/10.1056/NEJMoa1500964?query=TOC

  • http://www.nejm.org/doi/full/10.1056/NEJMoa1403612#t=articleTop UK trial randomized 2007 adults undergoing nonemergent cardiac surgery to restrictive (7.5 g/dL) vs. liberal (9.0 g/dL) postoperative PRBC transfusion thresholds. Similar rates of combined primary endpoint, but significant increase in mortality in restrictive group and comparable between-group costs. Results are perhaps contrary to prevailing wisdom regarding transfusion targets.

  • Having recognized that their "wonder drug anticoagulant" was resulting in numerous exsanguination issues in primarily elderly folks prone to fall, Boehringer found a new way to make money- drug reversal with a monoclonal. Good for them- as long as it keeps our patients alive. But remind me why we don't use the readily reversible warfarin more often... http://www.nejm.org/doi/full/10.1056/NEJMoa1502000

  • Pubmed ID (PMID): 26092673 (Circulation) Endovasular cooling is more accurate than primitive surface methods with trends to support better outcomes PMID: 26061835 (NEJM) Bystander CPR saves lives (first ever RCT) PMID: 26061836 (NEJM) cell phone use to dispatch bystanders to perform CPR increases the bystander rates. Combined with the above one would expect with adequate power this system would yield better results.

  • In a beautiful piece of translational work by Kellum and others, the mechanisms whereby Remote Ischemic Preconditioning (RIPC) signals protection and its concentration by renal filtration is elaborated paving the way for a better informed phase 3 future clinical trial. Zarbock A, et al. Effect of remote ischemic preconditioning on kidney injury among high-risk patients undergoing cardiac surgery: A randomized clinical trial. JAMA. 2015

  • The idea of culturing the urine repeatedly in catheterized patients who inevitably become colonized and hence culture positive without meaningful infection is common and results in overuse of antibiotics. An intervention aimed at reducing cultures reduced this overuse without hurting patients. http://archinte.jamanetwork.com/article.aspx?articleID=2296017&utm_sourc...

  • Subjects received postop antibiotics for either 4 days or until 2 days after clinical resolution, with the latter strategy resulting in 8 days of antibiotic exposure. No difference in re-infection rate, surgical site infection or mortality but presentation of recurrent infectious complications was delayed in the longer duration group. http://www.nejm.org/doi/full/10.1056/NEJMoa1411162#t=article