Vasopressin versus Norepinephrine in Patients with Vasoplegic Shock After Cardiac Surgery: The VANCS Randomized Controlled Trial

This article was published in the Critical Care Medicine journal’s website in November 2017.  The full text of the article can be accessed by subscribers via this link.

Background:  Vasoplegic syndrome is a common complication after cardiac surgery and impacts negatively on patient outcomes. The objective of this study was to evaluate whether vasopressin is superior to norepinephrine in reducing postoperative complications in patients with vasoplegic syndrome.

Methods:  This prospective, randomized, double-blind trial was conducted at the Heart Institute, University of Sao Paulo, Brazil, between January 2012 and March 2014. Patients with vasoplegic shock (defined as mean arterial pressure less than 65 mmHg resistant to fluid challenge and cardiac index greater than 2.2 l · min−2 · m−2) after cardiac surgery were randomized to receive vasopressin (0.01 to 0.06 U/min) or norepinephrine (10 to 60 μg/min) to maintain arterial pressure. The primary endpoint was a composite of mortality or severe complications (stroke, requirement for mechanical ventilation for longer than 48 h, deep sternal wound infection, reoperation, or acute renal failure) within 30 days.

Results:  A total of 330 patients were randomized, and 300 were infused with one of the study drugs (vasopressin, 149; norepinephrine, 151). The primary outcome occurred in 32% of the vasopressin patients and in 49% of the norepinephrine patients (unadjusted hazard ratio, 0.55; 95% CI, 0.38 to 0.80; P = 0.0014). Regarding adverse events, the authors found a lower occurrence of atrial fibrillation in the vasopressin group (63.8% vs. 82.1%; P = 0.0004) and no difference between groups in the rates of digital ischemia, mesenteric ischemia, hyponatremia, and myocardial infarction.

Conclusions:  The authors’ results suggest that vasopressin can be used as a first-line vasopressor agent in postcardiac surgery vasoplegic shock and improves clinical outcomes.

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Family Stress in Pediatric Critical Care

Hagstrom, S. Journal of Pediatric Nursing. Published online: 21 November 2016

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Highlights

  • Separation was a primary source of stress for mothers with children at home.
  • The child’s illness and its potential effect on the future added to family stress.
  • Despite being told what to expect, families did not feel prepared for changes.
  • Parents reported a relationship between stress and uncertainty about the outcome.
  • Family context must be considered when assessing the stress of PICU hospitalization.

Read the full abstract here

Current Issue of “Intensive Care Medicine” Volume 42 Number 12

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To access Intensive Care Medicine’s latest issue’s contents page follow this link.

Articles in this issue include “Effect of early postexubation high flow nasal cannula vs conventional oxygen therapy on hypoxaemia in patients after major abdominal surgery a French multicentre randomised controlled trial (OPERA)”, “Diagnosis and management of skin and soft tissue infections in the intensive care unit: a review” and “Control groups in recent septic shock trials a systematic review”.

To access the full text of these articles from the journal’s homepage requires a personal subscription to the journal.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link.

The full text of articles from issues older than one year ago is available via this link to an archive of issues of Intensive Care Medicine.   A Rotherham NHS Athens password is required.  Eligible staff can register for an Athens password via this link.  Please speak to the library staff for more details.

Impella CP Versus Intra-Aortic Balloon Pump in Acute Myocardial Infarction Complicated by Cardiogenic Shock: The IMPRESS trial.

This article by Ouweneel et al was published in the Journal of the American College of Cardiology.  Subscribers to the journal can access the full text of the article via this link.  The full text is available to those with an NHS Athens password via the Proquest website sixty days after publication.  Individual articles can be ordered via the Rotherham NHS Foundation Trust Library and Knowledge Service.  Registered members of the library can make article requests online via this link

Background: Despite advances in treatment, mortality in acute myocardial infarction complicated by cardiogenic shock remains high. Short-term mechanical circulatory support devices acutely improve hemodynamic conditions. The Impella CP is a new percutaneous circulatory support device that provides more hemodynamic support than the intra-aortic balloon pump (IABP).

Objectives: The aim of this study was to determine whether the Impella CP can decrease 30-day mortality when compared with IABP in patients with severe shock complicating acute myocardial infarction.

Methods:  In a randomized, prospective, open-label, multi-center trial, we assigned 48 patients with severe cardiogenic shock complicating acute myocardial infarction to Impella CP (n=24) or IABP (n=24). Severe cardiogenic shock was defined as systolic blood pressure lower than 90 mmHg or the need for inotropic or vasoactive medication and the requirement for mechanical ventilation. The primary endpoint was 30-day all-cause mortality.

Results:  At 30 days, mortality in patients treated with either IABP or Impella CP was similar (50% and 46%, respectively, hazard ratio (HR) with Impella CP, 0.96 (95% confidence interval (CI) 0.42 to 2.18; p=0.92). At 6 months, mortality rates for both Impella CP and IABP were 50% (HR 1.04 (95% CI; 0.47-2.32, p=0.923).

Conclusions:  In this explorative randomized controlled trial involving mechanically ventilated cardiogenic shock patients after acute myocardial infarction, routine treatment with Impella CP was not associated with reduced 30-day mortality compared with IABP.

Resting energy expenditure, calorie and protein consumption in critically ill patients

Zusman, O. et al. Critical Care. Published: 10 November 2016

Background: Intense debate exists regarding the optimal energy and protein intake for intensive care unit (ICU) patients. However, most studies use predictive equations, demonstrated to be inaccurate to target energy intake. We sought to examine the outcome of a large cohort of ICU patients in relation to the percent of administered calories divided by resting energy expenditure (% AdCal/REE) obtained by indirect calorimetry (IC) and to protein intake.

Methods: Included patients were hospitalized from 2003 to 2015 at a 16-bed ICU at a university affiliated, tertiary care hospital, and had IC measurement to assess caloric targets. Data were drawn from a computerized system and included the % AdCal/REE and protein intake and other variables. A Cox proportional hazards model for 60-day mortality was used, with the % AdCal/REE modeled to accommodate non-linearity. Length of stay (LOS) and length of ventilation (LOV) were also assessed.

Results: A total of 1171 patients were included. The % AdCal/REE had a significant non-linear (p < 0.01) association with mortality after adjusting for other variables (p < 0.01). Increasing the percentage from zero to 70 % resulted in a hazard ratio (HR) of 0.98 (CI 0.97–0.99) pointing to reduced mortality, while increases above 70 % suggested an increase in mortality with a HR of 1.01 (CI 1.01–1.02). Increasing protein intake was also associated with decreased mortality (HR 0.99, CI 0.98–0.99, p = 0.02). An AdCal/REE >70 % was associated with an increased LOS and LOV.

Conclusions: The findings of this study suggest that both underfeeding and overfeeding appear to be harmful to critically ill patients, such that achieving an Adcal/REE of 70 % had a survival advantage. A higher caloric intake may also be associated with harm in the form of increased LOS and LOV. The optimal way to define caloric goals therefore requires an exact estimate, which is ideally performed using indirect calorimetry. These findings may provide a basis for future randomized controlled trials comparing specific nutritional regimens based on indirect calorimetry measurements.

Read the full article here

Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial


This randomised controlled trial by Keh et al for SepNet–Critical Care Trials Group was published in JAMA in November 2016 (JAMA. 2016;316(17):1775-1785).  The full text of the article is available to subscribers via this link.  Registered members of the library can request the full text online via this link.

Importance:  Adjunctive hydrocortisone therapy is suggested by the Surviving Sepsis Campaign in refractory septic shock only. The efficacy of hydrocortisone in patients with severe sepsis without shock remains controversial.

Objective:  To determine whether hydrocortisone therapy in patients with severe sepsis prevents the development of septic shock.  Design, Setting, and Participants: Double-blind, randomized clinical trial conducted from January 13, 2009, to August 27, 2013, with a follow-up of 180 days until February 23, 2014. The trial was performed in 34 intermediate or intensive care units of university and community hospitals in Germany, and it included 380 adult patients with severe sepsis who were not in septic shock.

Interventions:  Patients were randomly allocated 1:1 either to receive a continuous infusion of 200 mg of hydrocortisone for 5 days followed by dose tapering until day 11 (n = 190) or to receive placebo (n = 190).

Main Outcomes and Measures:  The primary outcome was development of septic shock within 14 days. Secondary outcomes were time until septic shock, mortality in the intensive care unit or hospital, survival up to 180 days, and assessment of secondary infections, weaning failure, muscle weakness, and hyperglycemia (blood glucose level >150 mg/dL [to convert to millimoles per liter, multiply by 0.0555]).

Results:  The intention-to-treat population consisted of 353 patients (64.9% male; mean [SD] age, 65.0 [14.4] years). Septic shock occurred in 36 of 170 patients (21.2%) in the hydrocortisone group and 39 of 170 patients (22.9%) in the placebo group (difference, −1.8%; 95% CI, −10.7% to 7.2%; P = .70). No significant differences were observed between the hydrocortisone and placebo groups for time until septic shock; mortality in the intensive care unit or in the hospital; or mortality at 28 days (15 of 171 patients [8.8%] vs 14 of 170 patients [8.2%], respectively; difference, 0.5%; 95% CI, −5.6% to 6.7%; P = .86), 90 days (34 of 171 patients [19.9%] vs 28 of 168 patients [16.7%]; difference, 3.2%; 95% CI, −5.1% to 11.4%; P = .44), and 180 days (45 of 168 patients [26.8%] vs 37 of 167 patients [22.2%], respectively; difference, 4.6%; 95% CI, −4.6% to 13.7%; P = .32). In the hydrocortisone vs placebo groups, 21.5% vs 16.9% had secondary infections, 8.6% vs 8.5% had weaning failure, 30.7% vs 23.8% had muscle weakness, and 90.9% vs 81.5% had hyperglycemia.

Conclusions and Relevance:  Among adults with severe sepsis not in septic shock, use of hydrocortisone compared with placebo did not reduce the risk of septic shock within 14 days. These findings do not support the use of hydrocortisone in these patients.

Clinical Review: Paracetamol in fever in critically ill patients – an update

Chiumello, D. et al. Journal of Critical Care. Published online: November 4, 2016

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Fever, that is arbitrary defined as an increase in body temperature above 38.3 °C, can affect up to 90% of patients admitted in intensive care unit. Induction of fever is mediated by the release of pyrogenic cytokines (tumor necrosis factor alfa, interleukin-1, interleukin-6 and interferons). Fever is associated with increased length of stay in intensive care unit and with a worse outcome in some subgroups of patients (mainly neurocritically ill patients).

Although fever can increase oxygen consumption in unstable patients on the contrary can activate physiologic systems that are involved in pathogens clearance. Treatments to reduce fever include the use of antipyretics. Thus the reduction of fever might reduce the ability to develop an efficient host response. This balance, between harms and benefits, has to be taken into account every time we decide to treat or not to treat fever in a given patient.

Treatments to reduce fever include the use of antipyretics. Among the antipyretics Paracetamol is one of the most common used. Paracetamol is a synthetic, nonopioid, centrally acting analgesic and antipyretic drug. Its antipyretic effect occurres because it inhibits cyclooxygenase-3 and the prostaglandin synthesis, within the central nervous system, resetting the hypothalamic heat-regulation center. In this clinical review we will summarize the use of Paracetamol as antipyretic in critically ill patients (sepsis, trauma, neurological and medical).

Read the abstract here