Early, Goal-Directed Therapy for Septic Shock – A Patient-Level Meta-Analysis.

This paper by the PRISM investigators led by Kathryn Rowan was published in the New England Journal of Medicine in June 2017 Volume 376 number 23.  The full text of the article is available to subscribers to this journal via this link.  The Library and Knowledge Service can obtain the full text of the article for registered members by requesting it via the library website document request form.

BACKGROUND:  After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT.

METHODS:  We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics.

RESULTS:  We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation.

CONCLUSIONS:  In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics.

Latest issue of Critical Care Reviews Newsletter 287 11th June 2017

The 287th issue of the Critical Care Reviews Newsletter includes the latest research from across the medical literature from the previous week.  Highlights include “the pilot TOP-UP and SPIRIT randomised controlled trials, a worrying study on data fabrication in anaesthetic and general medical journals, a guideline on acute kidney injury reviews on fluid responsiveness, clinical examination in circulatory shock, continuous renal replacement therapy forty year anniversary and an interesting discussion on the management of septic shock”.
The full text of the newsletter can be accessed via this link.

Current issue of Critical Care Reviews Newsletter 284 21st May 2017

The 286th issue of the Critical Care Reviews Newsletter contains the latest research fromcritcal care reviews across the medical literature of the last seven days.

These include a randomised clinical trial on “Intraoperative ketamine for prevention of postoperative delirium or pain after major surgery in older adults”, a meta analysis on “Effort to breathe with various spontaneous breathing trial techniques”, a cohort study on “Short course adjunctive gentamicin as empirical therapy in patients with severe sepsis and septic shock” and a Cochrane Review on “High flow nasal cannulae for respiratory support in adult intensive care patients”

The full text of the newsletter can be accessed via this link.

Current issue of Critical Care Reviews Newsletter 284 21st May 2017

On Sunday the 284th Critical Care Reviews Newsletter was published provides the best critical care research from across the medical literature over the past week.critcal care reviews

The highlights of this week’s newsletter are the KARE randomised controlled trial, investigating keratinocyte growth factor in ARDS; guidelines on oxygen use, hemodynamic support of paediatric and neonatal septic shock, & management of the potential organ donor, as well as narrative reviews on the ICM research agenda on extracorporeal life support, high protein intake and central venous access device–related upper extremity deep vein thrombosis.

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Latest issue of “Journal of Critical Care” Volume 39 June 2017

This issue includes articles on the “Effect of ulinastatin combined with thymosin alpha 1 on sepsis: a systematic review and meta-analysis of Chinese and Indian patients”, “The accuracy of the bedside swallowing evaluation for detecting aspiratiojournal of critical care.pngn in survivors of acute respiratory failure” and “Acute kidney injury is an independent risk factor for myocardial injury after non cardiac surgery in critical patients”.

The contents page of this latest issue can be accessed via this link

To access the full text of these articles direct from the journal’s homepage you require 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.

Latest issue of Critical Care Reviews Newsletter 283 14th May 2017

The 283rd Critical Care Reviews Newsletter includes randomised controlled trials on poscritcal care reviewsitioning for endotracheal intubation of critically ill adults and video versus direct laryngoscopy for paramedic endotracheal intubation.  Also included is an observational study reporting patterns of intravenous fluid resuscitation use in adult intensive care patients, a worldwide perspective on decision-making on withholding or withdrawing life-support in the ICU. There is a guideline from the American Academy of Neurology on reducing brain injury following cardiopulmonary resuscitation and a review article on albumin administration in sepsis.
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Current issue of Critical Care Reviews Newsletter 282 7th May 2017

The Critical Care Newsletter 282nd issue provides the best critical care research from the literature in the last week.  Highlights include the latest HFNO trial and RCTs on stress ulcer prophylaxis, inhaled nitric oxide to treat acute pulmonary embolism and an education intervention for anti-infectious measures.  There are also observational studies on bystander efforts in out of hospital cardiac arrest and emergency transfusion of patients with unknown blood type with O positive red blood cells as well as guidelines on severe perioperative bleeding and the prevention of surgical site infection.

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