Recent Studies from InFACT Member Groups
The PREVENT trial (N Engl J Med 380:1305, 2019) undertaken by the Saudi Critical Care Trials Group with international collaborators from Canada, India, and Australia was recently published. In 2003 patients receiving pharmacologic DVT prophylaxis, they found no added benefit for the use of pneumatic compression devices – with respect to deep vein thrombosis, pulmonary embolism, or death. This well-conducted and adequately powered trial suggests strongly that physical methods are redundant in preventing DVT in critically ill patients who are receiving pharmacologic prophylaxis. Read more
Congratulations to the Latin America Intensive Care Network (LIVEN) on the publication of the ANDROMEDA trial (JAMA 321:654, 2019). ANDROMEDA evaluated the utility of a resuscitation strategy based on capillary refill in comparison with a lactate-guided resuscitation strategy. Recruiting 424 patients presenting with septic shock in five South American countries, they showed that titrating resuscitation to a simple clinical parameter – capillary refill – resulted in survival rates that were at least as good as those when resuscitation was guided by lactate levels. Moreover new onset organ dysfunction was significantly less in patients whose resuscitation was guided by perfusion. While the study was likely under-powered to show a mortality benefit, the work has important implications. First, it shows that resuscitation using a dynamic and simple clinical parameter is at least as efficacious as resuscitation guided by a biochemical variable. And even more importantly, the strategy is simple and readily applicable in the pre-hospital setting or in resource-limited areas. Read more
Minimizing the inadvertent harm of clinical intervention
Acute care is, by definition, an active discipline. Its implicit mandate is urgent intervention to sustain life and to prevent major complications. Increasingly, however, it is realized that these interventions can themselves cause further harm.
Two new trials from InFACT member groups exemplify this core principle, and underline the need for nuanced and continuous reevaluation of the processes of ICU supportive care. The ROSE (Reevaluation of Systemic Early Neuromuscular Blockade) trial led by the PETAL Network found no benefit to paralytic agents in the management of patients with severe ARDS, but rather an increased risk of major cardiovascular events in those patients routinely managed with neuromuscular blockade. And a 4000 patient trial led by the ANZICS Clinical Trials Group, the Sedation Practice in Intensive Care Evaluation (SPICE) III trial found no benefit to the routine use of dexmedetomidine for sedation, and an increased risk of bradycardia and hypo-tension.