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…
[az_accordion_section] [accordion title=”NICE SUGAR 2009″ id=”acc-1″]
Intensive versus Conventional Glucose Control in Critically Ill Patients
N Engl J Med. 2009 Mar 26;360(13):1283-97
The lowdown
– 6104 medical and surgical patients in intensive care
– Randomised to intensive glucose control (4.5-6mmol/L) or conventional control (less than 10mmol/L)
– Primary outcome was 90 day mortality: intensive control 27.5% vs 24.9% conventional control (p=0.02)
– Severe hypoglycaemia occurred more with intensive control
– There was no difference in morbidity outcomes (length of stay, duration of mechanical ventilation, infections)
Take Home Message
Intensive glucose control increased 90 day mortality, and increased the risk of severe hypoglycaemia in intensive care patients
[/accordion] [accordion title=”Isenman 2004″ id=”acc-2″]
Prophylactic antibiotic treatment in patients with predicted severe acute pancreatitis: a placebo-controlled, double-blind trial.
Gastroenterology. 2004 Apr;126(4):997-1004.
The Lowdown
– 114 patients with acute pancreatitis, plus CRP greater than 150 +/- pancreatic necrosis on CT
– Randomised to prophylactic antibiotics (ciprofloxacin and metronidazole) or placebo
– If signs of sepsis/ SIRS, treatment medication stopped and converted to open label antibiotics
– 12% of the antibiotic group and 9% in the placebo group developed infected pancreatic necrosis (P = 0.585).
– there was no difference in the rate of infected pancreatic necrosis, systemic complications, or mortality between groups
Take Home Message
In patients with acute, severe pancreatitis, antibiotic prophylaxis did not reduce the risk of developing infected pancreatic necrosis or mortality
[/accordion] [accordion title=”Leuven 1 2001″ id=”acc-3″]
Intensive insulin therapy in critically ill patients
N Eng J Med. 2001; 345(19): 1359-67
The Low down
– 1548 surgical ICU patients (predominantly cardiac) receiving mechanical ventilation
– randomised to intensive (blood glucose 80-110mg/dL) or conventional (less than 215mg/dL) glucose control
– Primary outcome (ICU mortality) higher in the conventional therapy group (8% vs 4.6%, p < 0.04)
– Intensive therapy associated with less renal impairment, infections, and RBC transfusions
– Hypoglycaemia (blood glucose less than 40mg/dL) more frequent with intensive insulin (5% vs 0.8%)
Take Home Message
In surgical patients requiring mechanical ventilation, intensive insulin therapy decreased ICU mortality but increased the risk of hypoglycaemia
[/accordion] [accordion title=”Leuven 2 2006″ id=”acc-4″]
Intensive insulin therapy in the Medical ICU
N Engl J Med. 2006; 354(5): 449-61
The Lowdown
– 1200 medical ICU patients, expected to be in ICU for at least 3 days
– Exclusions: surgical patients, able to tolerate oral nutrition
– Randomised to intensive (BSL target 80-110mg/dL) or conventional insulin (BSL less than 215mg/dL)
– Primary outcome: hospital mortality, not different between groups. ICU, 28-day and 90-day mortality not different between groups
– Secondary outcomes: days to wean from mechanical ventilation, length of ICU stay, risk of new kidney injury better with intensive insulin
– Hypoglycaemia more common in intensive insulin group (18.7% vs 3.1%)
Take Home Message
In medical ICU patients, intensive insulin therapy did not improve mortality. It improved length of ICU stay and duration of mechanical ventilation, but increased the risk of hypoglycaemia.
[/accordion] [accordion title=”Lau 2000″ id=”acc-5″]
Effect of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers
N Eng J Med. 2000; 343(5): 310-6
The Lowdown
– 240 patients with upper GI bleed and endoscopic treatment of an ulcer
– Randomised to IV omeprazole or placebo for 72 hours after endoscopy. All patients then received oral omeprazole
– Primary endpoint: 30 day recurrent bleeding lower in treatment group (6.7% vs 22.5% p < 0.001)
– no difference in 30 day mortality
Take Home Message
In patients following endoscopy for treatment of upper GI bleed, IV omeprazole infusion resulted in lower rates of recurrent bleeding than placebo
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