New papers you should know – Duke Medical Intensive Care Unit

I am so sorry that this is out of date. Looking for a fellow to help out? Anybody???

May 2020

Tobin MJ. Basing respiratory management of COVID-19 on physiological principles. Am J Resp Crit Care Med. 2020. in press before published. This is sort of awesome and great for the Housestaff and fellows to eyeball. Key quote: “The surest way to increase COVID-19 mortality is liberal use of intubation and mechanical ventilation.” Boom!

June 2019

Subirà C, et al. Effect of Pressure Support vs T-Piece Ventilation Strategies During Spontaneous Breathing Trials on Successful Extubation Among Patients Receiving Mechanical Ventilation: A Randomized Clinical Trial. JAMA. 2019;321(22):2175-2182. You may ask, “Wow, do people still do 2-hour T-piece trials?’ But there is some debate about which is worse/better: potentially under-loading people pre-extubation with PS to overcome ETT resistance properties (WOB higher after extubation) or delaying extubation possibly with a harsh T-piece trial (some failures likely to have been false negatives). Now you know: 30 min of PS 8 / PEEP 0 led to higher rates of successful extubation c/w T-piece for 2 hours (82% vs. 74%), though the groups didn’t differ on reintubation rates or ICU LOS. Higher hospital (10.4% vs. 14.9%) and 90-day (13.2% vs. 17.3%) mortality in the T-piece group.

March-May 2019 (sorry)

Seymour C, et al. Derivation, Validation, and Potential Treatment Implications of Novel Clinical Phenotypes for Sepsis. JAMA. 2019; 321(20):2003-2017. doi: 10.1001/jama.2019.5791. Interestingly, 4 novel sepsis phenotypes seen in this study based on nearly 64,000 patients and multiple databases. In words of authors, “Of the 4 derived phenotypes, the α phenotype was the most common (n = 6625; 33%) and included patients with the lowest administration of a vasopressor; in the β phenotype (n = 5512; 27%), patients were older and had more chronic illness and renal dysfunction; in the γ phenotype (n = 5385; 27%), patients had more inflammation and pulmonary dysfunction; and in the δ phenotype (n = 2667; 13%), patients had more liver dysfunction and septic shock.”

Shehabi Y, et al. Early Sedation with Dexmedetomidine in Critically Ill Patients. May 19, 2019. NEJM. DOI: 10.1056/NEJMoa1904710. C/w standard RASS-targeted (RASS -2 to +1) sedation protocols (used prop, etc), no advantage of using early dex. In dex group, 64% needed propofol. Well done and large; also addressed many past trials’ shortcomings in its design and methodology.

PETAL Network. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. N Engl J Med 2019; 380:1997-2008. DOI: 10.1056/NEJMoa1901686. Sigh. Among patients w/ mod-severe ARDS, NMB did not really improve things compared to a fairly standard management protocol that had lighter sedation than the ACURASYS trial from a few years back. So, routine NMB use not indicated.

February 2019:

Arabi YM, et al. Adjunctive Intermittent Pneumatic Compression for Venous Thromboprophylaxis. NEJM. Interesting. First, it doesn’t seem to help to add compression to pharmacologic thromboprophylaxis. But beyond that, note the incidence of proximal LE DVT was ~4% overall and the median ICU day on which DVT was detected was day 8.

Bettler JR, et al. Effect of Titrating Positive End-Expiratory Pressure (PEEP) With an Esophageal Pressure-Guided Strategy vs an Empirical High PEEP-Fio2 Strategy on Death and Days Free From Mechanical Ventilation Among Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. This RCT crushed my spirit. Sadly, a negative trial despite the intuitive / physiological basis for the intervention. Ugh.

Casey JD, et al. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. NEJM. In this RCT, providing bag mask ventilation during the interval between induction until the initiation of laryngoscopy vs. not led to a lower incidence of severe hypoxemia. There appeared to be no difference in aspiration events between the groups.

January 2019:

Martyn JAJ, et al. Opioid tolerance in critical illness. NEJM. This is a very cool paper with lots of insights…I learned a lot!

Cox CE, et al. Effects of a Personalized Web-Based Decision Aid for Surrogate Decision Makers of Patients With Prolonged Mechanical Ventilation: A Randomized Clinical Trial. Annals of Internal Medicine. Mentioned here not for vanity’s sake, but simply because it is a bit of a crazy story!

December 2018:

Girard T, et al. Haloperidol and Ziprasidone for Treatment of Delirium in Critical Illness. NEJM Very smart investigators deliver a well-done trial that also seeks to challenge common practices.

Krag M, et al. Pantoprazole in Patients at Risk for Gastrointestinal Bleeding in the ICU. NEJM Very thought-provoking paper that may really change clinical practice.

November 2018:

Azoulay E, et al. Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure: The HIGH Randomized Clinical Trial. JAMA A nice follow up to the high flow O2 vs. NIV trial among immunosuppressed patients.

Wittekamp BH, et al. Decontamination Strategies and Bloodstream Infections With Antibiotic-Resistant Microorganisms in Ventilated Patients: A Randomized Clinical Trial. JAMA And the negative hits keep coming…

October 2018:

Prevent Investigators. Effect of a Low vs Intermediate Tidal Volume Strategy on Ventilator-Free Days in Intensive Care Unit Patients Without ARDS: A Randomized Clinical Trial. JAMA A great topic: low Vt ventilation is less harmful than higher Vt ventilation, but does low Vt ventilation matter in non-ARDS?

Perkins GD, et al. Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial. JAMA Very cool idea that extends the concept first evaluated in COPD to more general populations.

TARGET Investigators / ANZICS. Energy-Dense versus Routine Enteral Nutrition in the Critically Ill. NEJM Keep it simple…

September 2018: in progress