Critical Care

Question 1

POISE-3

Answer 1

TXA at beginning & end of surgery improved bleeding, but had no mortality benefit. Did cause a little clotting/cardiac AEs.

Question 2

Yang-Tobin study

Answer 2

RSBI predicts extubation failure. NEJM 1991.

Question 3

IABP-SHOCK II

Answer 3

In MI and cardiogenic shock, IABP did not reduce 30-day mortality. There were no differences in process-of-care outcomes, including ICU LOS, duration of catecholamines, or time to hemodynamic stability. NEJM 2012.

Question 4

SHOCK

Answer 4

Early PCI for MI with cardiogenic shock improves long-term mortality. Benefit seen in follow up long-term studies at 1 and 6 years. Only subgroup <75yo showed 30-day mortality benefit, but was under-powered for whole population. NEJM 1999.

Question 5

SALT-ED

Answer 5

LR did not decrease IP LoS for non-ICU patients, compared to NS. Did show improvement in MAKE (Major Adverse Kidney Events = composite of death, HD, AKI). Dose-dependent NAGMA for NS. Big criticism is that intervention was done in ER, not continued on floor.

Question 6

SMART-MED and SMART-SURG

Answer 6

LR decreased MAKE (Major Adverse Kidney Events = composite of death, HD, AKI) for ICU patients. Dose-dependent NAGMA for NS. Most significant subgroups are medical patients, sepsis, and prior RRT.

Question 7

IDEAL-ICU

Answer 7

In ICU patients and severe AKI without urgent indication for HD, delayed (opposed to early) RRT had no mortality difference, and 1/3 of the patients in the delayed RRT arm avoided RRT. Stopped early for futility at 488/864 patients enrolled. It’s a resolution of two earlier conflicting trials, ELAIN (for early RRT) and AKIKI (against early RRT). NEJM 2018.

Question 8

ROSE

Answer 8

Early NMB in ARDS does not improve mortality, and causes weakness & CV AEs. It is re-examining prior ACURASYS 20-center RCT from France showing 90-day mortality benefit, but was under-powered & older, incorporating outdated ARDS techniques. NEJM 2019

Question 9

PROSEVA

Answer 9

For ARDS with PF<150, prone positioning improves 28-day mortality. NEJM 2013.

Question 10

FACTT

Answer 10

In ALI & ARDS patients, targeting CVP < 4 (opposed to 10-14) resulted in shorter MV & ICU time. No mortality benefit. Also, CVC vs Swan didn’t matter. NEJM 2006.

Question 11

PAC-MAN

Answer 11

No clear benefit or harm to routine Pulmonary Artery Catherization in ICU patients. 10% complication rate in placement, none of which were fatal. Lancet 2005

Question 12

ESCAPE

Answer 12

Routine placement of Swan in Acute Heart Failure did not improve mortality. Can still be considered for failure of conservative therapy. JAMA 2005

Question 13

ARDSNet

Answer 13

In ARDS, TV of 6cc/kg IBW (vs 10-14) had lower mortality & MV time. NNT=9. NEJM 2000.

Question 14

TTM2

Answer 14

Therapeutic Hypothermia (33C) for OHCA did not have better mortality, functional outcome, or QoL, but did have more arrhythmias. NEJM 2021.

Question 15

3SITES

Answer 15

Subclavian CVC placement had fewer CLABSIs or DVTs, but more mechanical complications (improved with US guidance) compared to either IJ or Fem. US wasn’t randomized. NEJM 2015.

Question 16

65 trial

Answer 16

Investigated MAP goal 60 vs 65 found no difference. Permissive hypotension may improve mortality in those with chronic hypertension (counter-intuitive). JAMA 2020.

Question 17

SAFE

Answer 17

Albumin (vs NS) had no mortality benefit for ICU patients, and had worse outcomes in TBI. Severe sepsis trended had p=0.09 toward benefit. NEJM 2004.

Question 18

ALBIOS

Answer 18

Albumin 20% to keep level >3 had no effect on mortality, but did improve vasopressor requirements & SOFA scores. Septic ICU patients. Subgroup analysis showed survival benefit for septic shock at enrollment. NEJM 2014.

Question 19

PRORATA

Answer 19

In septic ICU patients, using procalcitonin reduced antibiotic time by 25% without worsening mortality by more than 10%. Major issues are that half of the procalcitonin arm deviated from protocol (but on-treatment analysis is unchanged); and that if 5% mortality target were used, it would have worsened. Lancet 2010.

Question 20

BICAR-ICU

Answer 20

Using bicarb to treat ICU patients with HCO3<20 or pH<7.2 did not improve mortality or SOFA scores. It did do both of those things for patients with AKI. 24% of control group received bicarb, underestimating treatment effect. Lancet 2018.

Question 21

NICE SUGAR

Answer 21

In ICU patients, strict glucose control (<108) had worse mortality than liberal target (<180). NEJM 2009.

Question 22

EOLIA

Answer 22

In severe ARDS, transfer to ECMO facility had a trend toward survival (p=0.09). Stopped early for futility, likely a mistake. Large crossover from control group, with 48% of those patients surviving. NEJM 2018.

Question 23

CESAR

Answer 23

In severe ARDS, transfer to ECMO facility improves survival, NNT=6. After transfer, more patients received lung-protective ventilation. Lancet 2009.

Question 24

VANCS

Answer 24

In post cardiac surgery patients with vasoplegic shock, vasopressin (vs levo) was better for mortality or major complications. Less AF, no difference in digital ischemia, mesenteric ischemia, hyponatremia or myocardial infarction.

Question 25

ADRENAL

Answer 25

In septic shock, hydrocortisone 200mg/d did not change mortality, but decreased vasopressor time. NEJM 2018.

Question 26

VITAMINS

Answer 26

Rebutted the Rivera trial about hydrocortisone, vitamin C, thiamine in septic shock. VITAMINS trial showed no difference in hydrocortisone +/- vitamin C & thiamine. JAMA 2020.

Question 27

ATHOS-3

Answer 27

Proof-of-concept for angiotensin-II as a vasopressor, in addition to levophed 0.2 (or equivalent). AT-II increased MAP more than placebo. NEJM 2017.

Question 28

APROCCHSS

Answer 28

Hydrocortisone + Fludricortisone in septic shock improved mortality. Steroids were given EARLIER than other trials. Weak signal (p=0.03, fragility index of 3, no extended mortality benefit at 28 days). NEJM 2018.

Question 29

ProCESS

Answer 29

In sepsis, EGDT does not confer a mortality difference. NEJM 2014.

Question 30

EmShockNet

Answer 30

Targeting LA clearance is no different than targeting ScVO2 in sepsis. JAMA 2010.

Question 31

LOVIT Trial.

Answer 31

IV Vitamin C worsened composite outcome of death / major organ dysfunction in septic shock, but after all statistics were done, it likely had no effect. NEJM 2022.

Question 32

HALT-IT

Answer 32

In GIB, empiric TXA did not decrease hemorrhage, death from hemorrhage, death from any cause, or arterial thrombus. Did increase VTE. In general, do not use. Lancet 2020.

Question 33

PROPPR

Answer 33

In trauma, MTP in 1:1:1 or 2:1:1 was studied. Primary endpoints failed (30 day mortality), but 24-hour mortality and death from hemorrhage were better in 1:1:1. JAMA 2015.

Question 34

PRESERVE

Answer 34

IV Bicarb does not prevent contrast-induced nephropathy. NEJM 2018.

Question 35

EPaNIC

Answer 35

Early TPN has worse ICU LoS, infections, MV days. More calories (esp protein) in first few days has worse short-term mortality. NEJM 2011.