Randomized Controlled Trials

Jul 192018
 
Prophylactic haloperidol did not prevent delirium in the ICU: REDUCE trial

Delirium occurs in a large proportion of critically ill patients, and ICU patients who get delirious tend to have longer hospital stays and higher mortality. However, it has never been shown that delirium independently increases the risk for poor outcomes, or is just a fellow traveler with severe illness, i.e., a signal of more severe [… read more]

Jul 152018
 
Should antibiotics for sepsis be given in the ambulance?

Observational studies of patients in sepsis strongly suggest that outcomes are improved by giving antibiotics as soon as possible after recognition of sepsis. The Surviving Sepsis Campaign recently decided everyone with suspected sepsis should receive antibiotics within one hour of emergency department arrival. So why not give antibiotics before the patient even arrives to the [… read more]

Jun 242018
 
DVT-PE in cancer: Oral anticoagulant edoxaban non-inferior to enoxaparin

Most patients with cancer-associated deep venous thrombosis (DVT) or pulmonary embolism (PE) in the U.S. are treated indefinitely with subcutaneous injections of low-molecular weight heparin (LMWH), like enoxaparin. LMWH has been shown to be better than warfarin at preventing DVT/PE in cancer patients, with similar rates of bleeding. A new generation of oral anticoagulants have [… read more]

Jun 142018
 
Vitamin C cocktail for sepsis: randomized trials to test efficacy

Since Marik et al announced exceptional survival rates among patients with septic shock given a cocktail of vitamin C, thiamine, and hydrocortisone, physicians taking care of septic patients have expressed both enthusiasm and skepticism about the cocktail’s reported lifesaving effects. Soon, more rigorous testing from randomized, double-blind placebo-controlled trials should provide harder data about the [… read more]

Jun 132018
 
Bougies for all intubations led to high success rates, even on difficult airways

Bougies are long, stiff plastic wands inserted into the trachea through the glottis during direct laryngoscopy (DL), providing a “guidewire” over which an endotracheal (ET) tube can then be more easily advanced into the trachea. Bougies have traditionally been used after one or more failed intubation attempts with direct laryngoscopy, at which point the airway [… read more]

Jun 072018
 
Prolonged infusions of beta-lactam antibiotics save lives in sepsis: meta-analysis

Infusing antipseudomonal beta-lactam antibiotics over longer periods could save lives in sepsis over intermittent bolus dosing, according to a systematic review and meta-analysis of randomized trials. Vardakas et al aggregated data from studies of patients with sepsis receiving infusions of carbapenems, cephalosporins, and penicillins with antipseudomonal activity. Studies included compared prolonged infusion (over at least three [… read more]

May 012018
 
Catheter-Directed Lysis Adds Risk, Not Benefit, for Proximal DVT

by Crystal Phend, Senior Associate Editor, MedPage Today Thrombolytics delivered to acute proximal deep-vein thrombus (DVT) with clot removal did not reduce the risk of post-thrombotic syndrome but did raise major bleeding risk over anticoagulant treatment alone in the Acute Venous Thrombosis: Thrombus Removal with Adjunctive Catheter-Directed Thrombolysis (ATTRACT) clinical trial. The proportion of patients with post-thrombotic [… read more]

Apr 192018
 
Checking procalcitonin in the ICU saves lives? Maybe

Procalcitonin (PCT) levels can be useful (although limited) in deciding whether and when to start, de-escalate, and stop antibiotic therapy in patients with suspected infection. Physicians’ use of procalcitonin in antibiotic decisions has exploded since the FDA approval of a PCT assay whose manufacturer provides specific (albeit oversimplified) cut-off values at which to consider infection [… read more]

Apr 042018
 
Are balanced crystalloids better than saline? SMART Talk with Dr. Michael Pinsky

Jon-Emile S. Kenny MD [@heart_lung] with illustrations by Carla M Canepa MD “Each time new experiments are observed to agree with the predictions, the theory survives and our confidence in it is increased; but if ever new observation is found to disagree, we have to abandon or modify the theory.” — Stephen Hawking A 47 [… read more]

Mar 022018
 
Corticosteroids do help in sepsis: ADRENAL trial

Stress-dose corticosteroids appear safe and generally beneficial in patients with septic shock undergoing mechanical ventilation, without improving survival. That’s the takeaway from the ADRENAL trial recently published in the New England Journal of Medicine. Investigators (led by the famed ANZICS collaborative) randomized 3,800 patients with septic shock requiring mechanical ventilation in 69 medical-surgical ICUs around the [… read more]

Feb 162018
 
Ruling Out PE in the ED: Critical Analysis of the PROPER Trial

By Scott Aberegg, M.D., M.P.H. This post is going to be an in-depth “journal club” style analysis of the PROPER trial. In this week’s JAMA, Freund et al report the results of the PROPER randomized controlled trial of the PERC (pulmonary embolism rule -out criteria) rule for safely excluding pulmonary embolism (PE) in the emergency department (ED) [… read more]

Feb 152018
 
PERC Can Safely Rule Out Pulmonary Embolism in ED Setting

By Salynn Boyles, Contributing Writer, MedPage Today A clinical assessment protocol proved to be as effective as blood testing and CT imaging in the emergency department setting for ruling out pulmonary embolism in very low-risk patients in a newly reported French clinical trial. The crossover cluster-randomized PROPER study was conducted at 14 emergency departments (EDs) in France [… read more]

Jan 312018
 
Choose Wisely – Avoid Sildenafil for Pulmonary Hypertension in Corrected Left-Heart Valvular Disease (SIOVAC Trial)

Jon-Emile S. Kenny MD [@heart_lung] “It’s these expressions, I never give, That keep me searching for a heart of gold … And I’m gettin’ old.” -Neil Young An 86 year old woman is admitted with progressive dyspnea and lower extremity edema.  8 months ago she received a trans-catheter aortic valve replacement (TAVR) for severe aortic [… read more]

Jan 262018
 
FDA Approves First Nebulized LAMA for COPD

by Salynn Boyles, MedPage Today The FDA approved a nebulized formulation of glycopyrrolate (Lonhala Magnair) for long-term maintenance treatment of patients with moderate-to-severe COPD, said manufacturer Sunovion Pharmaceuticals. It’s the first long-acting muscarinic antagonist (LAMA) to be sold in this form. Recommended dosing is 25 mcg twice daily. The approval was made on the strength of data [… read more]

Jan 172018
 
Vitamin D improved asthma symptoms and reduced exacerbations

Multiple randomized trials have suggested that vitamin D supplementation might improve asthma control and reduce severity of asthma attacks. A new meta-analysis bolsters that hypothesis, and may encourage more physicians and people with asthma to consider vitamin D supplements for low vitamin D levels. In a study in Lancet Respiratory Medicine, authors analyzed the experience [… read more]

Jan 152018
 
N-acetylcysteine (NAC), sodium bicarbonate no help in preventing contrast nephropathy

N-acetylcysteine (NAC) and sodium bicarbonate are commonly provided to patients undergoing angiographic procedures with intravenous contrast. Small randomized trials had suggested NAC or bicarbonate or both could prevent kidney injury from so-called contrast nephropathy. That practice has no benefit, based on results of a large randomized trial showing neither NAC nor bicarb improved outcomes after [… read more]

Dec 182017
 
Esmolol in Sepsis: Microcirculatory Savior or Autoregulation Annihilator?

Jon-Emile S. Kenny MD [@heart_lung] Background If venous pressure were always the downstream pressure of an artery, then when flow is zero, the arterial pressure should equal the venous pressure.  For example, if one were to measure the coronary artery pressure and coronary sinus pressure at zero flow, their pressures should be equal.  Yet, this [… read more]

Dec 142017
 
Sedation interruptions were even more helpful in surgical patients

Most good medical intensive care units have incorporated interruptions in sedation (so-called ‘sedation vacations’) into standard care for patients receiving mechanical ventilation. Avoiding excessive sedation in general is believed to reduce prolonged mechanical ventilation in ICUs. However, there is surprisingly little data about effects of sedation (or over-sedation) on critically ill postoperative patients in the [… read more]

Dec 012017
 
Should patients watch videos of CPR before code status decisions?

Physicians and patients alike tend to avoid frank discussions about “code status” — whether a patient would want CPR or mechanical ventilation in the event of a cardiac or respiratory arrest. When doctors address code status at all, they tend to phrase the questions in such a way to cut off any thoughtful discussion: “If [… read more]

Nov 192017
 
Oral steroids don't improve cough due to colds (but are prescribed anyway)

Oral corticosteroids are frequently prescribed for persistent cough after the common cold in patients without respiratory disease. Like much of what physicians offer or advise, steroids for ordinary cough are traditionally provided not based on evidence, but on the premise that “it might help.” A new study in JAMA substantially undermines that premise. Authors randomized [… read more]