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Which critical care treatments are supported by the latest evidence?

OCTOBER 23, 2018
Clinical Congress Daily Highlights, Tuesday First Edition


Care for the most seriously ill and injured patients is not always straightforward. A wide-ranging panel discussion on Tuesday considered the evidence — or lack thereof — for various treatments that are commonly deployed in critical care. Topics covered by the panel included the use of various drug regimens, when to consider life support, cutting-edge genomic techniques for identifying bacterial pathogens, and making evidence-based decisions on when and what to feed a critical care patient.

Robert Sawyer, MD, FACS, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, began with a discussion of whether current research supports giving patients corticosteroids, beta-blockers, vitamin C, or the antiviral ganciclovir, and he touched on the state of microbial diagnostics.

The latest research finds that steroids generally reduce mortality by about 6 percent, while the jury is still out on beta-blockers. Vitamin C is “the new shiny kid on the block,” said Dr. Sawyer. Because vitamin C has many helpful qualities — it scavenges reactive oxygen species, for example, and inhibits cell death — and is very inexpensive, it’s generally considered a good tool to use in conjunction with other therapies. Less evidence supports the use of ganciclovir — a recent study in JAMA, for example, found that patients given the antiviral fared no better than patients on placebo.

As for using cutting-edge genomic technologies to identify microbes — progress is being made, but they still don’t offer the sensitivity of good old plating techniques.

David Zonies, MD, FACS, MPH, Oregon Health & Science University, Portland, then tackled when and whether Extracorporeal Membrane Oxygenation (ECMO), which circulates blood through an “artificial lung”, can benefit patients. ECMO has had fits and starts — it was first successfully used for critical care on a motorcycle accident patient 1972, but for a mix of reasons — including poor study design — the technology was shelved, revived and shelved again in the 1980s and 1990s. Then when H1N1 influenza hit the Southern Hemisphere in 2009, there was a decided uptick in survival for critical care patients given ECMO.

The issue to consider today, said Dr. Zonies, is what ECMO serves as a bridge for. If a cardiac or respiratory patient is en route to a better outcome, ECMO may offer valuable temporary support. But in a case without an exit strategy, such as a terminal malignancy or end-stage organ dysfunction, there is little potential for benefit.

Wendy Greene, MD, FACS, director of the Acute and Critical Care Surgery Service of Emory University Hospital, Atlanta, GA, offered a detailed look at the evidence supporting when and what to feed critical care patients. “I am an advocate for my patients being able to eat,” said Dr. Greene. “We eat every day and they should too.” Despite fears that feeding patients enteral nutrition (EN) will complicate their intestinal surgery, evidence doesn’t support that feeding such patients increases leaks. While withholding EN is sound in some instances, such as in patients with very low blood pressure, generally we should try to get critical care patients eating sooner rather than later, Dr. Greene said. Benefits include improved oxygen delivery, less bacterial translocation, and better circulation within the gastrointestinal tract. The latest research finds little support for traditional nutritional surrogates like albumin and retinol binding protein, and instead supports things like fish-based sources of protein, fiber, and getting patients to solid foods as soon as possible.

Toan Huynh, MD, FACS, Charlotte, NC, rounded out the discussion with a look at strategies for treating patients who have lost significant blood volume. “Is there such a thing as an ideal fluid [for resuscitation]?” asked Dr. Huynh. Broadly speaking, the answer seems to be no. While there are many crystalloids and colloids on the market for replacing fluid in cases of greatly reduced blood volume, a suite of recent studies suggests the two often yield similar outcomes. As far as a general resuscitation strategy, one should be judicious in the amount of volume administered, and consider the type, dose, toxicity, and cost. Use physiology-based decision-making, Dr. Huynh advised: Consider what the best replacement is for the type of fluid that was lost. And consider the urgency and specificity of the situation.

The Panel Session, Cutting Edge Critical Care Review, was held October 23 at the 2018 Clinical Congress of the American College of Surgeons in Boston, MA. Program, webcast and audio information is available online at facs.org/clincon2018.

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