I am an intensive care trainee wanting to get a better understanding of the literature in intensive care medicine.
This 6 part series is intended to identify and summarise landmark papers in various aspects of management in ICU.
It is in no way intended to be comprehensive or exhaustive.
It is also intended to promote discussion – please let me know if you think I have excluded anything.
Click on the studies to get the lowdown…
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Rapid blood-pressure lowering in patients with acute intracerebral hemorrhage
N Engl J Med. 2013 Jun 20;368(25):2355-65
The Lowdown
- 2832 patients with acute haemorrhagic stroke and SBP 150-220
- Randomly assigned to intensive BP lowering to SBP less than 140 or less than 180 for 7 days
- Exclusions: structural cause of bleed, GCS 3-5, early surgery
- Primary outcome: death or major disability not significantly different between groups
- Health related quality of life better in treatment group than routine group at 90 days
Take Home Message
In patients with acute haemorrhagic stroke, intensive blood pressure lowering did not affect mortality rates, but it did improve functional outcome
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A Trial of Intracranial-Pressure Monitoring in Traumatic Brain Injury
N Engl J Med 2012; 367:2471-2481
The Lowdown
- 324 patients with severe traumatic brain injury in Bolivia and Ecuador
- Exclusions: age less than 13, unsurvivable injury
- Randomised to either management based on monitoring intraparenchymal intracranial pressure to less than 20mmhg (pressure-monitoring group) or based on imaging and clinical examination
- Primary outcome: a composite of survival time, duration and level of impaired consciousness, functional and neuropsychological status at 6 months- there was no significant difference between groups
- 6-month mortality was 41% in the imaging-clinical examination group and 39% in the ICP monitoring group
- The time during which patients received brain-specific treatment was significantly longer in the imaging–clinical examination group
Take Home Message
In patients with severe traumatic brain injury in Bolivia and Equador, care focused on maintaining monitored intracranial pressure at 20 mm Hg or less was not shown to be superior to care based on imaging and clinical examination
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Decompressive cradiectomy in diffuse traumatic brain injury
N Engl J Med. 2011; 364(16):1493-502
The Lowdown
- 155 patients with severe diffuse TBI and raised ICP
- Exclusions: age>59, mass lesions, not suitable for active treatment
- Randomly assigned to early decompressive craniectomy vs standard care
- Primary endpoint 6-month functional outcome worse with craniectomy than standard care (3 vs 4 on Extended Glasgow Outcome Scale, p=0.03)
- Unfavourable outcome (death, severe disability) higher in craniectomy group (70% vs 51%)
- Patients undergoing craniectomy had lower ICPs and shorter ICU stay
Take Home Message
In patients with severe diffuse traumatic brain injury and increased intracranial pressure, the use of craniectomy, as compared with standard care, decreased the mean intracranial pressure and the duration of both ventilatory support and the ICU stay but was associated with a significantly worse neurological outcome at 6 months.
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Thrombolysis with alteplase 3 to 4.5 hours after acute ischemic stroke
N Engl J Med. 2008 Sep 25;359(13):1317-29
The Lowdown
- 821 patients presenting within 3 to 4.5 hours with ischaemic stroke
- Exclusions – ICH, age > 80, high stroke severity
- Randomly allocated to alteplase or placebo
- Primary endpoint: disability at day 90. More favourable outcomes in the alteplase group (52.4% vs 45.2%)
- Also looked at death, intracranial haemorrhage
- Symptomatic ICH greater in alteplase group (2.4% vs 0.3%)
Take Home Message
In patients with ischaemic stroke, < 80 without high stroke severity alteplase improved 90 day disability compared to placebo.
There was increased risk of symptomatic ICH with alteplase treatment, but overall mortality was not affected
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Effect of intravenous corticosteroids on death within 14 days in 10008 adults with clinically significant head injury
The Lancet 2004; 364 (9442): 1321-28
The Lowdown
- 10008 patients with head injury and GCS 14 or less within 8 hours or less of injury
- Very heterogenous patient group from all over the world and highly variable health care systems
- Randomly allocated to 48 hours of intravenous methylprednisone or placebo
- Primary outcome: All cause mortality at 2 weeks significantly higher in the steroids group (21.1% vs 17.9%, p=0.0001)
Take Home Message
In patients with traumatic brain injury, the risk of death of all causes within two weeks of injury was higher in those allocated to methylprednisone than placebo
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Randomised trial of plasma exchange, intravenous immunoglobulin, and combined treatments in Guillain-Barré syndrome. Plasma Exchange/Sandoglobulin Guillain-Barré Syndrome Trial Group.
Lancet. 1997 Jan 25; 349(9047): 225-30.
The Lowdown
- 383 patients with severe Guillain-Barre syndrome
- Randomly assigned to plasma exchange (5 exchanges over 5-13 days), IVIg (for 5 days), or both (plasma exchanged followed by IVIg
- Primary outcome: improvement on disability grade scale, not significantly different between groups
- No difference in secondary outcomes: time to recovery, duration of mechanical ventilation
Take Home Message
Plasma exchange and IVIg had equivalent efficacy in treatment of severe Guillain-Barre syndrome
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