Update in Critical Care Medicine: Evidence Published in 2016

U PDATE Update in Critical Care Medicine: Evidence Published in 2016 Mark Hepokoski, MD, and Atul Malhotra, MD W e summarize key articles in critical care medicine published in 2016. We used an informal survey of academic and community intensivists to identify novel articles from high-impact journals that had important effects on clinical practice. In addition, we searched the most accessed journals from the American College of Physicians' JournalWise database to ﬁnd articles that were particularly relevant to internal medicine clinicians. We included 2 studies on acute respiratory distress syndrome (ARDS) that solidiﬁed the need to better un- derstand the epidemiology of this disorder by demon- strating high rates of underrecognition and disparities in care. A novel noninvasive ventilation (NIV) device that may beneﬁt patients with early ARDS was also identiﬁed, and lower oxygen targets may be appropri- ate. Studies of patients with severe sepsis showed no beneﬁt of adjunctive steroid therapy; however, contin- uous infusion of antibiotics may signiﬁcantly reduce mortality. Intensive blood pressure control does not seem to improve neurologic outcome in patients with acute intracerebral hemorrhage (ICH), and length of hospital stay may predict poor neurologic outcome and mortality in patients with in-hospital cardiac arrest. Progress was made in our understanding of the man- agement of critically ill patients with acute kidney injury (AKI), as a randomized trial suggested that earlier initi- ation of renal replacement therapy (RRT) decreases mortality. Finally, depressive symptoms were shown to be highly prevalent in caregivers of critically ill patients, and strategies that provide social support to these per- sons should be identiﬁed. ARDS and Acute Respiratory Failure ARDS Often Goes Unrecognized or Underappreciated, Even in ICUs Bellani G, Laffey JG, Pham T, et al; LUNG SAFE Investigators. Epidemiology, patterns of care, and mortality for patients with acute respiratory distress syndrome in intensive care units in 50 countries. JAMA. 2016;315:788-800. [PMID: 26903337] doi:10.1001/jama.2016.0291 Background: Acute respiratory distress syndrome is de- ﬁned by acute onset of bilateral alveolar or interstitial inﬁltrates, with impaired gas exchange in the absence of congestive heart failure (1). In patients with known ARDS, lung protective ventilation has proven beneﬁt (2, 3), but evidence suggests that many patients for which this therapy would be appropriate are not receiv- Ann Intern Med. 2017;166:W20-W26. doi:10.7326/M17-0138 For author afﬁliations, see end of text. This article was published at Annals.org on 30 March 2017. ing it (4, 5). Whether a diagnosis of ARDS affects what therapies the patient receives is also unclear, emphasiz- ing the need for further epidemiologic data on this condition. Findings: This multinational cohort included more than 29 000 patients admitted to participating intensive care units (ICUs). Of these patients, 10.4% fulﬁlled the crite- ria for ARDS, and most episodes occurred within 48 hours. Clinical recognition of ARDS varied from 51.3% in mild ARDS to 78.5% in severe ARDS. However, fewer than two thirds of patients with ARDS received a tidal volume of 8 mL per kg of ideal body weight or less, and plateau pressure was recorded in only 40.1%. Hospital mortality was 34.9% among patients with mild ARDS, 40.3% among those with moderate ARDS, and 46.1% among those with severe ARDS. The use of some ad- junctive therapies that are recommended by some ex- perts, such as neuromuscular blockade and prone po- sitioning, increased with clinical recognition. Cautions: The observational nature of this study pre- cludes conclusions regarding the appropriateness of the interventions that patients received. In addition, an emerging literature suggests that individualized ther- apy for mechanical ventilation in ARDS may be reason- able (3, 6). Thus, analyses of large cohorts using a one-size-ﬁts-all approach may result in inappropriate assumptions, because the therapeutic decisions that treating clinicians make on the basis of bedside obser- vations and individual patient characteristics may be justiﬁable and reasonable. Implications: Acute respiratory distress syndrome re- mains common and underrecognized, with substantial associated mortality. Treating clinicians should be aware of the epidemiology of ARDS so that proven therapies (lung protective ventilation) may be instituted promptly with early disease recognition and other ther- apies considered. Future ARDS trials will also depend on accurate and timely diagnosis. ARDS-Related Mortality Is Decreasing, on the Basis of National Death Certiﬁcate Data Cochi SE, Kempker JA, Annangi S, et al. Mortality trends of acute respiratory distress syndrome in the United States from 1999 to 2013. Ann Am Thorac Soc. 2016;13:1742-51. [PMID: Background: Substantial advances have been made in the treatment and understanding of ARDS over the past 2 decades (7–9). However, recent assessments of mor- bidity and mortality trends have been mostly limited to single-center studies in speciﬁc geographic regions (10, 11). Temporal and demographic trends in ARDS are also underinvestigated. Annals of Internal Medicine W20 © 2017 American College of Physicians Downloaded From: http://annals.org/pdfaccess.ashx?url=/data/journals/aim/936156/ by a University of California San Diego User on 06/20/2017