Mathieu Hylands

CCCS-SSAI WikiRecs Clinical Practice Guideline: vasopressor blood pressure targets in critically ill adults with hypotension

Recommendation: We suggest against the use of a higher blood pressure (BP) target (MAP 75-85) when compared with a lower BP target (MAP 60-70) in adult critically ill patients with hypotension and requiring vasopressors. (Conditional recommendation) This is a recommendation developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCS-SSAI) according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort by a network of expert clinicians andmethodologists whose aim is to produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identifying potentially practice-changing evidence. See www. magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats—available on all digital devices. The electronic supplemental material also contains similar information expanding on the WikiRecs methods and processes. This is a recommendation developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. An abridged version of the guideline is published in Intensive Care Medicine (10.1007/s00134-016-4539-5).

CCCS-SSAI WikiRecs Clinical Practice Guideline: vasopressors in early traumatic shock

This is a recommendation developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (CCCSSSAI) according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort by a network of expert clinicians and methodologists whose aim is to produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identifying potentially practice-changing evidence. See www. magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats—available on all digital devices. The electronic supplemental material also contains similar information expanding on the WikiRecs methods and processes.

A systematic review of vasopressor blood pressure targets in critically ill adults with hypotension

PurposeClinicians must balance the risks from hypotension with the potential adverse effects of vasopressors. Experts have recommended a mean arterial pressure (MAP) target of at least 65 mmHg, and higher in older patients and in patients with chronic hypertension or atherosclerosis. We conducted a systematic review of randomized-controlled trials comparing higher vs lower blood pressure targets for vasopressor therapy administered to hypotensive critically ill patients.MethodsWe searched MEDLINE®, EMBASE™, and the Cochrane Central Register of Controlled Trials for studies of higher vs lower blood pressure targets for vasopressor therapy in critically ill hypotensive adult patients. Two reviewers independently assessed trial eligibility based on titles and abstracts, and they then selected full-text reports. Outcomes, subgroups, and analyses were prespecified. We used GRADE (Grading of Recommendations Assessment, Development and Evaluation) to rate the overall confidence in the estimates of intervention effects.ResultsOf 8001 citations, we retrieved 57 full-text articles and ultimately included two randomized-controlled trials (894 patients). Higher blood pressure targets were not associated with lower mortality (relative risk [RR], 1.05; 95% confidence interval [CI], 0.90 to 1.23; P = 0.54), and neither age (P = 0.17) nor chronic hypertension (P = 0.32) modified the overall effect. Nevertheless, higher blood pressure targets were associated with a greater risk of new-onset supraventricular cardiac arrhythmia (RR, 2.08; 95% CI, 1.28 to 3.38; P < 0.01).ConclusionCurrent evidence does not support a MAP target > 70 mmHg in hypotensive critically ill adult patients requiring vasopressor therapy.RésuméObjectifLes cliniciens doivent équilibrer les risques liés à l’hypotension aux complications potentielles des vasopresseurs. Des experts ont recommandé de cibler une tension artérielle moyenne (TAM) d’au moins 65 mmHg, et une TAM plus élevée chez les patients atteints d’hypertension chronique, d’athérosclérose ou plus âgés. Nous avons réalisé une revue systématique des études randomisées contrôlées comparant des cibles de tension artérielle plus élevées à plus basses chez des patients hypotendus en état critique recevant un traitement vasopresseur.MéthodeNous avons fait des recherches dans les bases de données Medline, EMBASE et dans le registre central des études contrôlées Cochrane afin d’en extraire les études comparant des cibles de tension artérielle plus élevées ou plus basses chez des patients adultes hypotendus et en état critique recevant un traitement vasopresseur. Deux examinateurs ont évalué de façon indépendante l’éligibilité des études selon leur titre et leur résumé, puis sélectionné les articles intégraux. Les critères d’évaluation, sous-groupes et analyses étaient spécifiés au préalable. Nous avons utilisé le système GRADE (Grading of Recommendations Assessment, Development and Evaluation) afin d’évaluer la confiance globale dans les estimations des effets de l’intervention.RésultatsParmi les 8001 citations, nous avons extrait 57 articles intégraux et finalement inclus deux études randomisées contrôlées (894 patients). Les cibles de tension artérielle plus élevées n’étaient pas associées à une mortalité plus basse (risque relatif [RR] 1,05; intervalle de confiance [IC] 95 %, 0,90 à 1,23; P = 0,54), et ni l’âge (P = 0,17) ni l’hypertension chronique (P = 0,32) n’ont modifié l’effet global. Cependant, les cibles de tension artérielle plus élevées étaient associées à un risque plus élevé de nouvelle apparition d’une arythmie cardiaque supraventriculaire (RR, 2,08; IC 95 %, 1,28 à 3,38; P < 0,01).ConclusionLes données probantes actuelles n’appuient pas une cible de TAM supérieure à 70 mmHg chez les patients adultes hypotendus et gravement malades nécessitant un traitement vasopresseur.

Vasopressor use following traumatic injury: protocol for a systematic review

Introduction Worldwide, traumatic casualties are projected to exceed 8 million by year 2020. Haemorrhagic shock and brain injury are the leading causes of death following trauma. While intravenous fluids have traditionally been used to support organ perfusion in the setting of haemorrhage, recent investigations have suggested that restricting fluid therapy by tolerating more severe hypotension may improve survival. However, the safety of permissive hypotension remains uncertain, particularly among patients who have suffered a traumatic brain injury. Vasopressors preferentially vasoconstrict blood vessels that supply non-vital organs and capacitance vessels, thereby mobilising the unstressed blood volume. Used as fluid-sparing adjuncts, these drugs can complement resuscitative measures by correcting hypotension without diluting clotting factors or increasing the risk for tissue oedema. Methods and analysis We will identify randomised control trials comparing early resuscitation with vasopressors versus placebo or standard care in adults following traumatic injury. Data sources will include MEDLINE, EMBASE, CENTRAL, clinical trial registries and conference proceedings. Two reviewers will independently determine trial eligibility. For each included trial, we will conduct duplicate independent data extraction and risk of bias assessment. We will assess the overall quality of the data for each individual outcome using the GRADE approach. Ethics and dissemination We will report this review in accordance with the PRISMA statement. We will disseminate our findings at critical care and trauma conferences and through a publication in a peer-reviewed journal. We will also use this systematic review to create clinical guidelines (http://www.magicapp.org), which will be disseminated in a standalone publication. Trial registration number CRD42016033437.

CCCS-SSAI WikiRecs clinical practice guideline: vasopressor blood pressure targets in critically ill adults with hypotension and vasopressor use in early traumatic shock

These recommendations were developed by the Canadian Critical Care Society and the Scandinavian Society of Anaesthesiology and Intensive Care Medicine according to standards for trustworthy guidelines in collaboration with the MAGIC WikiRecs project. The WikiRecs project is an ongoing collaborative effort from a network of expert clinicians and methodologists aiming to rapidly produce trustworthy evidence summaries and clinical practice recommendations within 90 days of identification of potentially practice-changing evidence. See www.magicapp.org/public/guideline/OLwWKL for more details about methods and processes, full evidence summary (GRADE SoF-table), and practical information presented in multilayered formats, available on all devices.

Early vasopressor use following traumatic injury: a systematic review

Objectives Current guidelines suggest limiting the use of vasopressors following traumatic injury; however, wide variations in practice exist. Although excessive vasoconstriction may be harmful, these agents may help reduce administration of potentially harmful resuscitation fluids. This systematic review aims to compare early vasopressor use to standard resuscitation in adults with trauma-induced shock. Design Systematic review. Data sources We searched MEDLINE, EMBASE, ClinicalTrials.gov and the Central Register of Controlled Trials from inception until October 2016, as well as the proceedings of 10 relevant international conferences from 2005 to 2016. Eligibility criteria for selecting studies Randomised controlled trials and controlled observational studies that compared the early vasopressor use with standard resuscitation in adults with acute traumatic injury. Results Of 8001 citations, we retrieved 18 full-text articles and included 6 studies (1 randomised controlled trial and 5 observational studies), including 2 published exclusively in abstract form. Across observational studies, vasopressor use was associated with increased short-term mortality, with unadjusted risk ratios ranging from 2.31 to 7.39. However, the risk of bias was considered high in these observational studies because patients who received vasopressors were systematically sicker than patients treated without vasopressors. One clinical trial (n=78) was too imprecise to yield meaningful results. Two clinical trials are currently ongoing. No study measured long-term quality of life or cognitive function. Conclusions Existing data on the effects of vasopressors following traumatic injury are of very low quality according to the Grading of Recommendations, Assessment, Development and Evaluation methodology. With emerging evidence of harm associated with aggressive fluid resuscitation and, in selected subgroups of patients, with permissive hypotension, the alternatives to vasopressor therapy are limited. Observational data showing that vasopressors are part of usual care would provide a strong justification for high-quality clinical trials of early vasopressor use during trauma resuscitation. Trial registration number CRD42016033437.

1177: VASOPRESSOR USE FOLLOWING TRAUMATIC INJURY–A SINGLE-CENTER HISTORICAL COHORT STUDY

Crit Care Med 2015 • Volume 43 • Number 12 (Suppl.) electronic medical records of admissions to the STICU from November 2013 to October 2014. All patients whose length of stay in the STICU was less than 12 hr were included. We recorded demographic data, admission diagnosis, admitting service, documented reason for ICU admission, time of ICU stay, time interval to extubation, patient location prior to ICU admission, and time interval to death. Results: Of the 1244 admissions to the STICU, a total of 106 (8.5%) patients had a length of stay less than 12 hr. The most common documented indication for admission to the STICU was ventilator management accounting for 41.5% of all short-stay admissions. In this group, 23 (52%) patients were extubated within 4 hr of arrival and then transferred to the ward since they had no other indication for STICU admission. Over the course of the year, this represents a minimum increase of 0.5 full time equivalent (FTE) critical care nursing to provide care to these patients. Conclusions: Our review demonstrates that nearly 25% of short stay admissions in the Surgical/Trauma ICU only required a short period of ventilator management prior to extubation and subsequent transfer to the ward. Developing a mechanism to treat these patients that does not require STICU admission could result in better resource utilization by reducing required full-time equivalent nursing care.

Vasopressor use following traumatic injury – A single center retrospective study

Objectives Vasopressors are not recommended by current trauma guidelines, but recent reports indicate that they are commonly used. We aimed to describe the early hemodynamic management of trauma patients outside densely populated urban centers. Methods We conducted a single-center retrospective cohort study in a Canadian regional trauma center. All adult patients treated for traumatic injury in 2013 who died within 24 hours of admission or were transferred to the intensive care unit were included. A systolic blood pressure <90 mmHg, a mean arterial pressure <60 mmHg, the use of vasopressors or ≥2 L of intravenous fluids defined hemodynamic instability. Main outcome measures were use of intravenous fluids and vasopressors prior to surgical or endovascular management. Results Of 111 eligible patients, 63 met our criteria for hemodynamic instability. Of these, 60 (95%) had sustained blunt injury and 22 (35%) had concomitant severe traumatic brain injury. The subgroup of patients referred from a primary or secondary hospital (20 of 63, 32%) had significantly longer transport times (243 vs. 61 min, p<0.01). Vasopressors, used in 26 patients (41%), were independently associated with severe traumatic brain injury (odds ratio 10.2, 95% CI 2.7–38.5). Conclusions In this cohort, most trauma patients had suffered multiple blunt injuries. Patients were likely to receive vasopressors during the early phase of trauma care, particularly if they exhibited signs of neurologic injury. While these results may be context-specific, determining the risk-benefit trade-offs of fluid resuscitation, vasopressors and permissive hypotension in specific patients subgroups constitutes a priority for trauma research going forwards.