Year in Review 2013 Intensive Care. J.G. van der Hoeven Radboud University Medical Centre Nijmegen

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1 Year in Review 2013 Intensive Care J.G. van der Hoeven Radboud University Medical Centre Nijmegen

2 Contents ARDS Ventilator associated pneumonia Tracheostomy and endotracheal intubation General ICU care

3 Prone position in severe ARDS MC (27) RCT Severe ARDS and MV < 36 hrs with PF < 150 mmhg, FiO2 0.6 and PEEP 5 Tv 6 ml/kg PBW After inclusion stabilization period of hrs Guérin C. N Engl J Med 2013

4 Prone position in severe ARDS Prone for at least 16 consecutive hrs PEEP and FiO2 from table: Pplat < 30 and ph Clear criteria for stopping prone position Strategy followed for up to 28 days Proning as rescue in the supine group strictly controlled Guérin C. N Engl J Med 2013

5 Prone position in severe ARDS Supine (N = 229) Prone (N = 237) 90 P < P < P < , ,5 0 Mortality D28 Mortality D90 Extubation D90 Better oxygenation and less rescue therapy in prone group Main cause pneumonia - 4 ± 4 prone sessions Guérin C. N Engl J Med 2013

6 Prone position improves hemodynamics ARDS (N = 18) Protective ventilation Hemodynamic-, respiratory- and abdominal pressures + echocardiography before and 20 minutes after prone positioning Preload reserve tested by PLR test Jozwiak M. Am J Respir Crit Care Med 2013;188:

7

8 Very low TV ventilation MC (10) RCT Tv 3 ml/kg + ECCO2R (ila) versus Tv 6 ml/kg ARDS < 1 week AND Pplat > 25 using 6 ml/kg 24 h stabilization period with PEEP 12 before final inclusion Target PaO2 60 and ph 7.20 Bein T. Intensive Care Med 2013

9 No differences in ph en PaCO2 Bein T. Intensive Care Med 2013

10 Higher PEEP levels with 3mL/kg Bein T. Intensive Care Med 2013

11 Very low TV ventilation N = Tv 3 ml/kg 50 37,5 Tv 6 ml/kg P = P = P/F subgroup < ,5 0 VFD (D28) VFD (D60) 0 VFD (D28) VFD (D60) Mean duration of ila treatment 7.4 ± 4 D No differences in other outcome measures Lower IL-6 levels in first 48 hours Bein T. Intensive Care Med 2013

12 H1N1 and ECLS 123 H1N1 patients in France treated with ECLS - ICU mortality 44 (36%) Propensity score matched comparison with non-ecls treated H1N1 patients 52 unique pairs: mortality 40% conventional vs 50% ECLS (P = 0.32) Independent factors for mortality: higher Pplat, age and lactate under ECLS Pham T. Am J Respir Crit Care Med 2013;187:

13 Statin therapy and VAP MC, placebo controlled RCT to determine statin therapy (60 mg) on outcome of VAP MV > 2 days and suspected VAP (CPIS 5) Planned enrollment 1002 patients (8% in 28 D mortality Stopping rule - absolute increase in mortapity of 2.7% in simvastatin group Papazian L. JAMA 2013;310:

14 Statin therapy and VAP Stopped for futility after 300 patients - 6% increase in mortality (p = 0.1) No other significant differences Papazian L. JAMA 2013;310:

15 Antibiotic resistance Aminoglycosides During SDD Polymyxin E/B Daneman N. Lancet Infect Dis 2013

16 Antibiotic resistance During SDD Fluoroquinolones Cephalosporins -3 d generation Median duration SDD 16 months Daneman N. Lancet Infect Dis 2013

17 Attributable mortality VAP Meta-analysis of individual patient data from randomised prevention studies Attributable mortality mainly results from longer stay in the ICU Melsen WG. Lancet 2013

18 Early vs late tracheostomy TracMan trial - MC (N = 72) RCT Patients on MV 4 D and expected to be ventilated at least another 7 D Tracheostomy 4 D versus 10 D Primary outcome 30 D mortality Young D. JAMA 2013

19 Early vs late tracheostomy N = Days > 10 Days 75 % Received tracheostomy Mortality 30 D Mortality 2 Y ICU LOS not significantly different between groups Young D. JAMA 2013

20 Difficult ICU intubation Prospective observational MC study (42) development and (18) validation All consecutive ICU patients with exclusion of pregnancy Difficult intubation: 3 laryngoscopic attempts or lasting > 10 minutes 1000 intubations for development and 400 for validation De Jong A. Am J Respir Crit Care Med 2013

21 Difficult intubation No problem 11,3% Development 88,7% 8% Difficult Factors Macocha score Mallampati score III/IV Obstructive sleep apnea syndrome Reduced mobility of cervical spine Limited mouth opening < 3 cm! Coma Severe hypoxemia (< 80%)! Non-anaesthesiologist Score 3 Points ! 1 1! 1 Validation PPV 36%, NPV 98%, AUC % De Jong A. Am J Respir Crit Care Med 2013

22 Difficult intubation % Difficult Intubation Macocha score De Jong A. Am J Respir Crit Care Med 2013

23 Difficult intubation % At least one complication Severe complication Sever hypoxemia Sever collaps Cardiac arrest Death Moderate complication Cardiac arrhythmia Esophageal intubation Agitation Aspiration Dental injury De Jong A. Am J Respir Crit Care Med 2013

24 Glutamine supplement MC RCT (40) with 2 2 design (glutamine and antioxidant supplementation for 28 D) Mechanical ventilation + organ failures Glutamine 0.35 mg/kg IBW Antioxidants: selenium, zinc, beta carotene, Vitamins E and C Heyland D. N Engl J Med 2013

25 Glutamine supplement Glutamine No glutamine Antioxidants No antioxidants 40 P = 0.05 P = ,4 27, ,8 28,8 Secondary outcomes Glutamine No glutamine P-value % 20 % 20 In-hospital mortality 37.2% 31% M mortality 43,7% 37,2% Mortality 28 D 0 Mortality 28 D Urea 13,4% 4% < No interaction between glutamine and antioxidants N = 1218 Heyland D. N Engl J Med 2013

26 Subgroup analysis Heyland D. N Engl J Med 2013

27 Antioxidants Double edged sword Oxygen radicals essential for immune activation Jaine M. Am J Respir Crit Care Med 2013

28 CRISTAL trial MC, open label RCT colloids vs crystalloids in ICU patient with hypovolemic shock N = 2857 Stratification by case mix (sepsis, trauma and other hypovolemic shock) Primary outcome 28 D mortality Annane D. JAMA 2013;310:

29 CRISTAL trial Colloids Crystalloids! P-value 28 D mortality (%) D mortality (%)! RRT (%)! Statistically significant but clinically irrelevant decrease in MV and vasopressor days in colloids group Annane D. JAMA 2013;310:

30 CRISTAL trial Annane D. JAMA 2013;310:

31 Esmolol and septic shock Target heart rate bpm started 24 hrs after admission (hemodynamic stabilization) Esmolol group! Higher SVI Higher LVSWI Lower NE dose Less volume therapy Morelli A. JAMA 2013;310:

32 Cardiac arrest MC RCT comparing 33 0 versus 36 0 in OHCA (all rhythms) N = D follow-up Target temperature for 24 hours - in both groups temperature < C for 72 hrs Primary outcome: death at end of trial No baseline differences Nielsen N. N Engl J Med 2013

33 Nielsen N. N Engl J Med 2013

34 Outcome % Death at end of trial Death/CPC 3-5 Death/Modified Rankin 4-6 Death at 180 D Nielsen N. N Engl J Med 2013

35 Nielsen N. N Engl J Med 2013

36 Conclusions (1) Prone position in patients with severe ARDS reduces mortality Very low Tv ventilation may be indicated in patients with severe ARDS There is still no evidence that SDD induces antibiotic resistance while VAP is associated with increased mortality

37 Conclusions (2) No indication for early tracheostomy No indication for glutamine supplementation No reason to use hydroxyethylstarch products Normothermia also improves outcome after cardiac arrest

Year in Review 2012 Intensive Care. J.G. van der Hoeven j.vanderhoeven@ic.umcn.nl or hahoe@mac.com www.intensivistenopleiding.nl

Year in Review 2012 Intensive Care. J.G. van der Hoeven j.vanderhoeven@ic.umcn.nl or hahoe@mac.com www.intensivistenopleiding.nl Year in Review 2012 Intensive Care J.G. van der Hoeven j.vanderhoeven@ic.umcn.nl or hahoe@mac.com www.intensivistenopleiding.nl ARDS Difficult weaning Fluid therapy Sepsis Subjects Berlin definition Bilateral

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