Evidence in Intensive Care - Nervous system
Systematic reviews and meta-analyses in blue
Other high impact trials in red
Traumatic Brain Injury
Decompressive craniectomy in TBI
NEJM 2011;364:1493-1502
Decompression as rescue (compared to medical management with refractory raised ICP) reduced ICP and reduced LOV and LOS but resulted in worse outcomes.
Decompressive group had twice as many with non-reactive pupils which when accounted for made the outcomes non significantly worse.
Could be due to axonal stretch or reperfusion injury or upward herniation.
May be of benefit if applied early but no data to support it as yet.
Haemostatic drugs for TBI
Cochrane review 2010
No reliable data.
Since this review CRASH-2 published (20000 patient multicentre RCT Lancet 2010) which showed tranexamic acid in 1st 3h of injury after trauma reduced death due to bleeding. Subgroup analysis on GCS suggests likely to be effective in all groups. Crash 2 intracranial bleeding study ongoing.
NB I seem to remember further analysis of crash 2 showed worse outcomes if TXA given late – need to check this – see ICM monitor notes.
Routine ICP monitoring in coma
Cochrane 2010
No adequate studies so no evidence whether beneficial.
A trial of ICP monitoring in TBI.
Chesnut et al. NEJM 2012;367:2471-2481
No difference if used ICP monitoring or not.
Lots of problems with paper - see monitor 20.2
Stroke
Cooling post stroke
Cochrane review 2009
Aspirin within 48h of ischaemic stroke reduces death or disability by 1%.
IV and direct thrombolysis reduce risk by 10% but have to be within 3 and 6h respectively.
No outcome difference with either pharmalogical or physical cooling.
Interesting to note that temp only 0.2 degrees lower with pharmacological cooling (ie paracetamol or NSAIDS).
rt-PA for acute ischaemic stroke: updated systematic review and meta-analysis.
Wardlow et al. Lancet 2012;379:2364-2372.
Rt-PA increased the number of patients alive with favourable outcome and alive and independent (42 for every 1000 treated) including those >80. Benefit greatest the earlier given but benefit if in 1st 6h.
Increased 7 day mortality (ICH) but no increased mortality at 6 months (with better functional outcome).
Magnesium for aneurysmal subarachnoid haemorrhage (MASH-2): a randomized placebo-controlled trial.
Dorhout Mees SM et al. Lancet published online May 25, 2012.
No improvement in outcome.
2010 review
Thrombolysis in ischaemic stroke in 1st 3h
- Leads to better functional outcome at 3 months
- Increases risk of ICH
- No mortality benefit
Sedation
Dexmedetomidine vs midazolam or propofol for sedation during prolonged mechanical ventilation: two randomized controlled trials.
Jakob et al. JAMA 2012; 307: 1151–1160.
Dexmedetomidine has similar efficacy to propofol or midazolam.
Dex had shorter duration of MV than midazolam and a shorter time to extubation than both propofol and midazolam.
Patients ability to communicate was better with dex than p or m.
Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol. A randomized controlled trial.
Mehta et al. JAMA 2012;308(19)
Protocol targeting light sedation.
Addition of daily sedation holds did not reduced duration of MV or LOS. Did increased sedation use and nurse workload.
Preservative free propofol increases ICU infections and sepsis (no mortality difference)
Am J Infect Control 2011;39:141-147
Propofol comes as plain, with EDTA (retards bacterial growth) and with a sulphite preservative.
Propofol formulation and outcome:
Lower mortality in propofol with EDTA ICM 2000;26 Suppl 4:S452-462.
Neuroprotective effect enhanced with EDTA J Cereb Blood Flow Metab 2008;28:354-366.
EDTA propofol protective against lung injury (with sulphites increases IL6 and worsens gas exchange) Acta Anaesthesiol Scand 2009;53:176-182
Delerium
The effect of earplugs during the night on the onset of delirium and sleep perception: a randomized controlled trial in intensive care patients
Rompaey BV et al. Crit Care 2012, 16: R73
Randomised single blind. Given ear plugs if not sedated.
Improved quality of sleep, reduced risk of developing delirium, delayed onset of delirium.
Most benefit in 1st 48 h of admission.
Routine use of CAM ICU
Van Ejik et al. Am J RCCM 2011;184:340-344
Sensitivity 47%, specificity 98%.
So, fails to identify over half of patients with delerium in daily practice (much better in research context).
Deleriu is associated with worse outcomes. It is not known whether it is causative or an association.
Critical illness weakness
Critical illness weakness.
Cochrane review 2009.
Reduced incidence of CIPMN in intensive insulin therapy.
Did not include NICE-SUGAR (NEJM 2009) which clearly showed increased hypoglycaemic episodes and increased mortality.
Rehabilitation of critical illness polyneuropathy and myopathy patients: an observational study.
Novak et al. Int J Rehabilitation Res 2011;34:336–342.
Early admission to an inpatient rehabilitation programme following a long critical illness is associated with significant rapid function improvement in those with CIPNM.