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01-12-2019 | Nutrition | Less is more in Intensive Care

Less is more in critical care is supported by evidence-based medicine

Authors: Catherine L. Auriemma, Greet Van den Berghe, Scott D. Halpern

Published in: Intensive Care Medicine | Issue 12/2019

Excerpt

The notion that “less is (or may be) more” in intensive care medicine has been contemplated by experts for decades. However, not until Kox and Pickkers’ review in 2013 had there been careful consideration of the evidence supporting this theory [1]. Their thought-provoking article focused specifically on sepsis, but the intervening years have yielded expanded evidence supporting this notion across many critical conditions. As healthcare systems seek to incentivize high-value care, transparency, and adherence to evidence-based practice guidelines, we must assess the strength of the evidence base regarding less is more. Here, we discuss recent randomized clinical trials (RCTs) that support the notion that even in intensive care units (ICUs), less intensive interventions may prove superior. …

Kox M, Pickkers P (2013) “Less is more” in critically ill patients not too intensive. JAMA Intern Med 173:1369–1372. https://doi.org/10.1001/jamainternmed.2013.6702 CrossRefPubMed

Rivers E, Nguyen B, Havstad S et al (2001) Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med 345:1368–1377. https://doi.org/10.1056/NEJMoa010307 CrossRefPubMed

ARISE Investigators and the ANZICS Clinical Trials Group (2014) Goal-directed resuscitation for patients with early septic shock. N Engl J Med 371:1496–1506. https://doi.org/10.1056/nejmoa1404380 CrossRef

Mouncey PR, Power GS, Harrison DA et al (2015) Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 372:1301–1311. https://doi.org/10.1056/NEJMoa1500896 CrossRef

Quinlan M (2014) A randomized trial of protocol-based care for early septic shock. J Emerg Med 47:256–257. https://doi.org/10.1016/j.jemermed.2014.06.009 CrossRef

Mehta S, Burry L, Cook D et al (2012) Daily sedation interruption in mechanically ventilated critically ill patients cared for with a sedation protocol: a randomized controlled trial. JAMA 308:1985–1992. https://doi.org/10.1001/jama.2012.13872 CrossRefPubMed

The Acute Respiratory Distress Syndrome Network (2000) Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury. N Engl J Med 342:1301–1308. https://doi.org/10.1056/NEJM200009143431113 CrossRef

Cavalcanti AB, Suzumura ÉA, Laranjeira LN et al (2017) Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) vs low PEEP on mortality in patients with acute respiratory distress syndrome—a randomized clinical trial. JAMA 318:1335–1345. https://doi.org/10.1001/jama.2017.14171 CrossRefPubMedPubMedCentral

Perner A, Haase N, Guttormsen AB, Tenhunen J, Klemenzson G, Åneman A et al (2012) Hydroxyethyl starch 130/0.42 versus Ringer’s acetate in severe sepsis. N Engl J Med 367:124–134. https://doi.org/10.1177/175114371301400116 CrossRefPubMed

10.

Myburgh JA, Finfer S, Bellomo R et al (2012) Hydroxyethyl starch or saline for fluid resuscitation in intensive care. N Engl J Med 367:1901–1911. https://doi.org/10.1056/nejmoa1209759 CrossRefPubMed

11.

Hébert PC, Wells G, Blajchman MA et al (1999) A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med 340:409–417CrossRef

12.

Lacroix J, Hébert PC, Hutchison JS et al (2007) Transfusion strategies for patients in pediatric intensive care units. N Engl J Med 356:1609–1619CrossRef

13.

Villanueva C, Colomo A, Bosch A et al (2013) Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med 368:11–21. https://doi.org/10.1056/NEJMoa1211801 CrossRefPubMed

14.

Mazer CD, Whitlock RP, Fergusson DA et al (2017) Restrictive or liberal red-cell transfusion for cardiac surgery. N Engl J Med 377:2133–2144. https://doi.org/10.1056/nejmoa1711818 CrossRefPubMed

15.

Gaudry S, Hajage D, Schortgen F et al (2016) Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med 375:122–133. https://doi.org/10.1056/nejmoa1603017 CrossRefPubMed

16.

Asfar P, Meziani F, Hamel J-F et al (2014) High versus low blood-pressure target in patients with septic shock. N Engl J Med 370:1583–1593. https://doi.org/10.1056/NEJMoa1312173 CrossRef

17.

Casaer MP, Mesotten D, Hermans G et al (2011) Early versus late parenteral nutrition in critically ill adults. N Engl J Med 365:506–517. https://doi.org/10.1056/NEJMoa1102662 CrossRefPubMed

18.

Fivez T, Kerklaan D, Mesotten D et al (2016) Early versus late parenteral nutrition in critically ill children. N Engl J Med 374:1111–1122. https://doi.org/10.1056/NEJMoa1514762 CrossRefPubMed

19.

TARGET Investigators for the ANZICS Clinical Trials Group, Chapman M, Peake SL et al (2018) Energy-dense versus routine enteral nutrition in the critically ill. N Engl J Med 379:1823–1834. https://doi.org/10.1056/NEJMoa1811687 CrossRef

20.

National Heart Lung and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Rice TW, Wheeler AP et al (2012) Initial trophic vs full enteral feeding in patients with acute lung injury: the EDEN randomized trial. JAMA 307:795–803. https://doi.org/10.1001/jama.2012.137 CrossRef

21.

Harhay MO, Wagner J, Ratcliffe SJ et al (2014) Outcomes and statistical power in adult critical care randomized trials. Am J Respir Crit Care Med 189:1469–1478. https://doi.org/10.1164/rccm.201401-0056CP CrossRefPubMedPubMedCentral

22.

Prescott HC, Calfee CS, Taylor Thompson B et al (2016) Toward smarter lumping and smarter splitting: rethinking strategies for sepsis and acute respiratory distress syndrome clinical trial design. Am J Respir Crit Care Med 194:147–155. https://doi.org/10.1164/rccm.201512-2544CP CrossRefPubMedPubMedCentral

23.

Laffey JG, Kavanagh BP (2018) Negative trials in critical care: why most research is probably wrong. Lancet Respir Med 6:659–660CrossRef

Title: Less is more in critical care is supported by evidence-based medicine
Authors: Catherine L. Auriemma
Greet Van den Berghe
Scott D. Halpern
Publication date: 01-12-2019
Publisher: Springer Berlin Heidelberg
Keywords: Nutrition
Care
Published in: Intensive Care Medicine / Issue 12/2019
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI: https://doi.org/10.1007/s00134-019-05771-2

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