In this edition of the series, Dr. Molinar provides an excellent review of the different types of hetastarches available along with associated pharmacokinetic and pharmacodynamic profiles.
CLICK HERE TO VIEW THE RECORDED JOURNAL CLUB WEBINAR
This is followed by Dr. Ahn’s review and discussion of the Schortgen et al. study in Lancet 2001. This was thew first “larger” study to evaluate hetastarch and its possible deleterious effect on the kidneys when compared to Gelatin in a multi-center randomized trial in France.
Finally, not until 2008 did we have a large multi-center German study called the VISEP trial published in NEJM which looked at severe sepsis and septic shock patients and compared Hetastarch to Lactated ringers (along with evaluation of intensive vs conventional glucose control). This too as a secondary endpoint ealuated the effects of therapy on renal failure and need for RRT. Although this trial was stopped prematurely because of severe hypoglycemic episodes in the intensive insulin therapy group, it is still the single largest multicenter trial to date looking at the outcomes of septic patients receiving Hetastarch.
These two trials really are the basis of what I have termed the “anti-hextend” movement in the critical care community however they are marked by a myriad of SIGNIFICANT design and statistical FLAWS which have also led to widespread criticism. This journal club webinar aims to dig deep into the analysis of these two trials and was a very engaging and though provoking session. Please FEEL free to comment below and let the discussion continue!!
In keeping with the spirit of ICU 2.0-3.0, I am proud to announce the introduction of the Critical Care Journal Club Series. The series will feature weekly or bi-weekly online, live, real time broadcasts of journal club conferences in the Surgical Intensive Care. The presenters will be residents and fellows rotating through the Surgical ICU and will be moderated by an attending physician. These discussions, much like the anesthesia ones are lively, educational and usually lead to animated conversations on controversial critical care topics facing us today.
Subscribe to the site via twitter or rss to get regular updates and find out how you can attend the next session LIVE online. In the mean time:
CLICK HERE
to get to the list of recordings of the sessions. As always, comments, suggestions and lively discussion is heavily encouraged!!
Now featuring live online journal clubs on exciting topics in Anesthesia primarily focused on the ambulatory setting. Follow the link to the Journal Club Series to explore the site and register for the next event. Theses live journal clubs are moderated, live events that lead to lively discussions and feature some of the experts in the field. After the event, you can find a link to the recording of the event where you can review the conference and continue the conversation online …. click on the link and enjoy …
The Endocrine Society is an multi-national, multidiscipline organization with ~14,000 members from over 100 countries. It was founded in 1916 and publishes 4 peer-reviewed journals. On March 26th, 2009 immediately after the NICE SUGAR study was published they released a statement which supports loosening glycemic control in ICU patients may now be more prudent. They state that we should be targeting glucose values between 144-180 mg/dl “until we better understand the reasons for these somewhat counterintuitive findings.”
Below is an excerpt from the statement which can be viewed in its entirety here –>
The Endocrine Society commends the NICE-SUGAR investigators for producing an important and provocative addition to the medical literature and draws the following conclusions and recommendations from their data. First, near-normalization of blood sugar does not clearly improve outcomes in all critically ill hyperglycemic ICU patients, and there is even a suggestion that such an approach may worsen outcomes. Second, looser control of hyperglycemia, i.e., target blood glucose of 144-180 mg/dl, is a reasonable, and perhaps preferable, option in this particular group of very sick patients. Third, it is essential to assess clinically meaningful outcomes, such as mortality, as well as surrogate or intermediate endpoints, such as blood sugar level, in studies of diabetes treatment as the NICE-SUGAR study has done; improvement of blood sugar control may not always translate to better clinical results.
This week’s issue of NEJM features another in a long debated series of trials that investigates the benefits of “tight” vs “conventional” glycemic control in the ICU. Is this the one that finally gives us the answer? Let’s find out…
The NICE-SUGAR Study Investigators are a multinational, multicenter and multidisciplinary collaboration. The primary objective of this trial was to find the optimal glycemic level for critically ill patients. Patients expected to stay in the ICU for >3 days were enrolled within 24 hours of admission to the ICU. They were randomized to either recive INTENSIVE (81-108 mg/dl) or CONVENTIONAL (<180 mg/dl) therapy. The primary endpoint was 90 day mortality (any cause / after randomization).
After enrolling 6104 patients, 3054 received intensive rx and 3050 received conventional rx. Groups were relatively well matched at baseline. The major difference in primary outcome was a RRR of ~ 9% in the conventional group (24.5% vs 27.5%). This corresponded to an odds ratio of 1.14 (95% CI 1.02-1.28), p=0.02. There was no differernce in the treatment effect when looking at medical vs. surgical patients. Of note, severe hypoglycemia (<40) occured ~13x more often in the intensive group (0.5% vs 6.8% p<0.001). No other significant differences upon subgroup analysis or secondary outcomes were found.
Read more…
Wander over to the Evidence Based Medicine section of the website which has recently been opened!
Here you will have an opportunity to review an excellent series from the BMJ by senior lecturer Trisha Greenhalgh entitled “How to read a paper.” This series goes through the basics of a systematic approach on reading, analyzing and critiquing a scientific paper. The BMJ has consistently been a reliable resource for evidence based medical practice sticking to their motto “Helping doctors make better decisions.” Enjoy!
This should at least provide a starting point for our young medical colleagues as well as a good review for the more experienced ones in the art of scientific investigation and evidence based medical decision making. As always please feel free to leave comments and suggestions. Remember, this is an open forum, become part of it!
