Recent preclinical and observational research has demonstrated adverse effects when using isotonic saline versus balanced fluids (i.e., lactated Ringer’s solution or Plasmalyte) for intravenous resuscitation. Raghunathan and colleagues conducted a retrospective cohort study to assess the association between choice of crystalloids and in-hospital mortality during the resuscitation of critically ill adults with sepsis.
They found that resuscitation with balanced fluids was associated with a lower risk of in-hospital mortality. However, generalizing this result could prove difficult since the study excluded pediatric and surgical patients. In addition, some degree of residual confounding is possible due to the observational nature of this work. Additional clinical trials are required to confirm this finding.
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Early protocolized care has become the standard since the 2001 trial by Rivers et al, which demonstrated 16% greater survival when patients with severe sepsis or septic shock were treated with a six-hour protocol of early, aggressive goal-directed therapy (EGDT). However, it is unclear which elements of the Rivers protocol are most beneficial. The Protocolized Care for Early Septic Shock (ProCESS) investigators, led by Derek Angus from the University of Pittsburgh, performed a multicenter trial comparing alternative resuscitation strategies for patients with septic shock.
Observational and qualitative studies have suggested positive benefits associated with family presence during cardiopulmonary resuscitation (CPR). Family presence may help alleviate the emotional burden and improve the bereavement process. Concerns about interference with resuscitative efforts and medicolegal ramifications have yet to be answered in rigorously designed studies. Patricia Jabre and colleagues in France conducted a multicenter, randomized controlled trial to determine if family presence during CPR was associated with a reduction in the likelihood of posttraumatic stress disorder (PTSD)-related symptoms. Results were published in the March 14 issue of The New England Journal of Medicine.
The primary end point was the proportion of relatives with PTSD-related symptoms, while secondary end points included the effect of family presence on medical efforts at resuscitation, the well-being of the healthcare team, and the filing of medicolegal claims. Of the 570 family members enrolled in an intention-to-treat analysis, 79% of the experimental group witnessed resuscitation versus 43% in the control group. Seventeen percent (n=95) of family members did not complete the 90-day post-event psychological assessment. There were no significant differences between the two groups in the characteristics of the resuscitation procedure, survival or characteristics of patients or enrolled family members. One significant limitation to this work was the prehospital environment; the results from this trial deserve replication in an intensive care unit. Read the full Concise Critical Appraisal.