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|LITERATURE REVIEW ARTICLE
|Year : 2004 | Volume
| Issue : 3 | Page : 182-184
Fluids, CPR, sedation, MET, pyrexia and mobile phones
Samir Suri1, Michael Parr2
1 Intensive Care Unit, University of New South Wales, Liverpool Hospital, Sydney, Australia
2 Intensive Care Unit, Liverpool and Campbelltown Hospitals, University of New South Wales, Sydney, Australia and President, International Trauma Care (ITACCS), Australia
University of New South Wales, Liverpool Hospital, Sydney
|How to cite this article:|
Suri S, Parr M. Fluids, CPR, sedation, MET, pyrexia and mobile phones. Indian J Crit Care Med 2004;8:182-4
The landmark publication of the recent SAFE study provides some answers on fluid resuscitation and demonstrates large pragmatic studies are possible in Intensive Care. The search for effective drug therapy that influences outcome from cardiac arrest continues with a vasopressin versus epinephrine study from Europe. Daily interruption of sedation in Intensive Care is shown to reduce the incidence of complications. Should we be aggressive with temperature control in patients with neurological injury and is that ventilator malfunctioning because you are wearing a mobile phone?
| » The SAFE study|| |
The Australian and New Zealand Intensive Care Society Clinical Trails Group (ANZICS CTG) have published the Saline versus Albumin Fluid Evaluation (SAFE) study. The study involved nearly 7000 critically ill patients and in the words of Deborah Cooks accompanying editorial, "The SAFE Study is not only a landmark trial; it is also a milestone for the discipline of critical care medicine." The debate on colloids as opposed to crystalloids has continued for decades, and culminated in a series of meta-analyses that variably suggested that albumin was associated with increased mortality or did not alter outcome. The lack of adequacy of evidence on which to base practice was addressed by the ANZICS CTG.
The effect of administration of 4% albumin versus 0.9% sodium chloride on 28-day mortality in a heterogeneous population of critically ill patients who require fluid resuscitation was studied in a large simple randomized trial. Randomization was concealed and blinding of patients, clinicians and researchers were insured with identical fluid bottles and administration sets. A formal study confirming the effectiveness of the blinding was conducted. Random error was minimized by the recruitment of sufficient patients to allow the detection of a 3% absolute reduction in mortality from a baseline of 15 percent, with 90 percent power. The compliance rate was 97% for patients receiving the assigned fluid and concurrent interventions were similar in both groups.
The results of the study showed that mortality did not differ significantly between the groups. There were 726 deaths in the albumin group, as compared with 729 deaths in the saline group (relative risk of death, 0.99; 95 percent confidence interval, 0.91 to 1.09; P=0.87). There were also no significant differences between the groups in the mean numbers of days spent in the ICU, days spent in the hospital, days of mechanical ventilation, or days of renal-replacement therapy.
A subgroup analysis of 1186 patients with trauma, suggested albumin was associated with a trend toward increased mortality (relative risk of death in the albumin group, 1.36; 95% CI 0.99 to 1.86), possibly explained by trauma associated with brain injury (relative risk of death, 1.62; 95% CI 1.12 to 2.34). Another subgroup of 1218 patients with severe sepsis, suggested albumin was associated with a trend toward reduced mortality (relative risk of death, 0.87; 95% CI, 0.74 to 1.02). While these subgroup analyses clearly need to be interpreted with caution they identify areas of possible future investigation.
It is now clear from the success of the SAFE study that similar large pragmatic Intensive Care studies are a reality.
| » Vasopressin versus Epinephrine for Cardiopulmonary Resuscitation|| |
Wenzel's multicentre, prospective, randomized, double-blind, controlled clinical trial published in NEJM in January randomly assigned a total of 1219 patients who had out-of-hospital cardiac arrest. The study involved physician-staffed emergency medical service units in Austria, Germany, and Switzerland. Eligible adult patients were randomized to receive either adrenaline 1 mg or vasopressin 40 international units (IU) for each of the first two loops of the universal resuscitation algorithm. Patients remaining without a spontaneous circulation were then given repeated doses of adrenaline 1 mg as indicated by the universal algorithm. The primary end point for the study was survival to hospital, and the secondary end point was survival to hospital discharge. The two treatment groups had similar clinical profiles and there were no significant differences in the rate of hospital admission between the vasopressin and the epinephrine group either among patients with ventricular fibrillation or among those with pulse less electrical activity. However in the asystole patients, vasopressin use was associated with significantly higher rates of hospital admission (29.0%, vs. 20.3%, P=0.02) and hospital discharge (4.7% vs. 1.5%, P=0.04). The editorial by McIntyre called for "these advances to be translated into a new standard of care without delay".
This enthusiasm for urgent change in resuscitation protocols is premature on closer inspection of the data. There was no significant difference overall between the groups in the rate of survival to hospital admission and survival to hospital discharge. In the post hoc subgroup analysis of patients with asystole; 12 patients who received vasopressin, as compared with 4 who received epinephrine, survived to hospital discharge (P=0.04) but the numbers are small, and the confidence interval includes unity. Ten of the 20 survivors in the subgroup that received vasopressin and epinephrine were in comatose or vegetative state or had severe cerebral disability, as compared with 1 of 5 in the epinephrine group. Many would prefer to use 'neurologically intact" independent living as a primary endpoint for resuscitation studies and when analyzed from this perspective, the overall result favors the adrenaline group. We need good evidence before changing existing practice, ineffective as it may be, and perhaps more answers will come with recommendations from the next International Consensus on CPR and Emergency Cardiovascular Care (ECC) Science Conference in January 2005.
| » Daily scheduled interruption of sedation reduces ICU complications|| |
An increasing body of evidence supports the safety and efficacy of strategies that allow scheduled interruption of sedation during mechanical ventilation. In the June edition of Critical Care Medicine an article addressed the technique of 'daily awakening' involving the elective interruption of sedation and analgesia until the patient is awake, able to understand simple commands, or agitated or uncomfortable. Sedation is then restarted at half the previous dose. In an analysis of 126 patients prospectively enrolled into a randomized controlled trial of daily sedation interruption vs. conventional management, investigators found a significant reduction in the incidence of seven ICU complications in the daily interruption cohort. Kaplan-Meier analysis shows no difference between groups in the time to the first complication, suggesting reduction in complications is due to shorter duration of mechanical ventilation. Indeed the percent of patients that underwent diagnostic tests to assess unexplained altered mental status decreased from 27% to 9%. The process also presents an early opportunity for assessment for extubation criteria. Daily interruption of sedation was also associated with fewer symptoms of posttraumatic stress syndrome. The lack of increased rate of inadvertent removal of central lines and tubes was reassuring.
| » Critical care outreach to floor patients|| |
Acute clinical deterioration is usually preceded by a period of physiologic instability, which if recognized and treated early and aggressively, may reduce incidence of unanticipated ICU admissions, cardiac arrests and deaths. Recognition of patients at risk also provides the opportunity to involve ICU teams in early care of critically ill patients needing inevitable ICU admission. An ICU based Medical Emergency Team (MET) has a key role in these issues and may provide continuity of care following ICU admission and reduce post-ICU complications and ICU readmission rate. In the April issue of Critical Care Medicine, Bellomo and colleagues assessed the impact of a MET on post-operative morbidity and mortality. The introduction of the MET was associated with a 36.6% reduction in postoperative hospital mortality (23 lives/1000 surgical admissions) and 50% reduction in adverse events. Duration of hospital stay after major surgery decreased from a mean of 23 days to 18 days. Emergency intensive care admissions fell by relative 44%. Thus the MET is associated with major cost savings and increased efficiency of hospital care. This paper adds weight to the evidence base in support of the MET system concept.
| » Elevated body temperature predicts longer length of stay in a neurological ICU|| |
In the July issue of Critical Care Medicine a study reported that an elevated body temperature is an independent predictor of a longer length of stay for patients in a neurological intensive care unit. In 4,295 adult patients admitted to a neurology/neurosurgery ICU with a stay of longer than 1 day, the association between body temperature and outcome was analyzed. An elevated temperature was defined as one greater than 38o C. The analysis, which controlled for age, diagnosis, severity of illness and complications, showed there was a graded association between body temperature and lengths of both ICU stay and hospital stay. In addition, body temperature was associated in a dose-dependent manner with a higher mortality rate and a reduced probability of being discharged home. The number of complications was the stronger predictor of ICU length of stay ( = 0.68), whereas body temperature was the second strongest ( = 0.14). Also in a matched, weighted group, when compared to patients without an elevated body temperature, patients with an elevated body temperature had ICU and hospital lengths of stay that were 3.2 and 4.3 days longer, respectively. Whether this reflects the severity of the initial injury and whether aggressive temperature control will impact on these outcomes will require future studies.
| » Could your mobile phone cause a ventilator to malfunction?|| |
A study from Boston in the April issue of Critical Care Medicine showed that six of 14 ventilators tested malfunctioned when a cell phone at maximum power output was placed within 15 cm of the ventilator. One ventilator doubled the ventilator rate and another increased the displayed tidal volume. In one of the infant ventilators displayed tidal volume increased from 21 to 100 ml.One ventilator, stopped ventilating when a cell phone at maximum power output was placed at 30 cm from the ventilator. Interestingly the researchers concluded that it is reasonably safe to permit cell phones in ICU's as long as they are kept at a distance of 3 feet from all mechanical devices. With the increased availability and use of mobile phones there will be continued need to demonstrate their safety in many healthcare environments.