Expert presenters provided an overview of recent impactful papers highlighting advances in neurocritical care, nonpulmonary critical care, and mechanical ventilation and respiratory support in the Sunday morning session Critical Care Year in Review – I.
Neha Dangayach, MD, MSCR, FCCP, Associate Professor of Neurosurgery and Neurology, and Director of Research for Neurocritical Care and Recovery, Icahn School of Medicine at Mount Sinai, presented an array of neurocritical care topics, including recently published data from the AcT trial demonstrating the efficacy of a novel agent for the treatment of acute ischemic stroke (AIS).
Tenecteplase, which has not been approved by the US Food and Drug Administration for use in AIS, has shown promise in this space, with similar clinical outcomes to the tissue plasminogen activator alteplase.
“[Tenecteplase] is a modified version of alteplase—a larger molecule, slightly longer half-life, and can be given only as a bolus,” Dr. Dangayach said. “So, there are definitely advantages to using tenecteplase.”
Several recent studies have compared the efficacy of tenecteplase and alteplase, and researchers have repeatedly proven the noninferiority of the former to the latter. As with alteplase, Dr. Dangayach said, the faster tenecteplase is administered, the better the outcomes.
She also highlighted recent research focusing on therapeutic targets for intracerebral hemorrhage (ICH).
“ICH is no longer a disease process that means poor outcomes,” said Dr. Dangayach, who predicts more minimally invasive surgical evacuation for ICH is on the horizon.
Findings from the ENRICH trial, which are not yet published but were presented at the American Association of Neurological Surgeons annual meeting earlier this year, demonstrated that minimally invasive parafascicular surgery to remove the hematoma results in an improvement in functional outcomes, Dr. Dangayach explained.
Nonpulmonary critical care
Akram Khan, MD, MBBS, FCCP, Associate Professor of Medicine, Oregon Health & Science University, discussed recent literature in nonpulmonary critical care, including bleeding and line placement, nutrition, pancreatitis, and delirium and long-term outcomes.
The current standard of care calls for nutritional support for critical care patients within 48 hours of ICU admission, using an enteral route for administration unless contraindicated, he explained. The American Society for Parenteral and Enteral Nutrition and European Society for Clinical Nutrition and Metabolism target for daily protein intake in the ICU is 1.2 to 2 g/kg. The daily caloric intake target is 20 to 25 kcal/kg.
EFFORT Protein, an international multicenter, pragmatic, registry-based randomized trial, has shown that giving these patients high-protein diets may not improve outcomes.
The NUTRIREA-3 study compared caloric intake among ventilated patients across 61 French ICUs in a randomized, controlled, multicenter, open-label, parallel-group, superiority trial.
“Using for the first 7 days, a low-calorie, low-protein diet did not lead to any significant increase in mortality,” Dr. Khan said. “And what I was surprised to see was that you actually got discharged 1 day earlier from the ICU if you used a low-calorie, low-protein diet compared to a standard-calorie, standard-protein diet.”
Gastrointestinal side effects were more common in patients who received the standard caloric intake, he added.
Mechanical ventilation and respiratory support
Robert C. Hyzy, MD, FCCP, Professor of Medicine, Division of Pulmonary and Critical Care Medicine, Michigan Medicine, shared recent findings in mechanical ventilation and respiratory support, including criteria for weaning patients off a ventilator.
The observational study WEAN SAFE included more than 5,000 patients who were on a ventilator for at least 2 days, 77% of whom experienced at least one separation event, Dr. Hyzy explained. About two-thirds of these individuals were weaned within a day. Another 10% had a 4- to 6-day wean, and nearly 10% had a prolonged wean of more than a week. Nearly 16% experienced weaning failure, and 20% had a tracheostomy at some point.
The median time for the first weaning attempt after meeting weaning criteria was 1 day; however, more than 22% of patients had a delay of at least 5 days due to such factors as frailty, trauma, a nontraumatic neurological event, level of consciousness/sedation, and ICU-written protocols for weaning.
The latter may seem counterintuitive, but Dr. Hyzy suggested, “If the only time you’re going consider a spontaneous trial [off the ventilator] is when [the ICU] protocol kicks into gear, maybe you’re not pushing hard enough.”
Dr. Hyzy also provided context for recent research on personalized, noninvasive support for acute hypoxemic respiratory failure, oxygen targets for intermittent mandatory ventilation, nutrition prior to extubation, and noninvasive ventilation vs high-flow nasal cannula post extubation for very high-risk patients.
Other recent advances
Dr. Hyzy also discussed recent papers on developments in acute respiratory distress syndrome during a continuation of the session, Critical Care Year in Review – II. In addition to Dr. Hyzy’s presentation, Angel Coz Yataco, MD, FCCP, discussed recent advances in the diagnosis and treatment of sepsis, and Mary Jane Reed, MD, FCCP, described new findings in surgical critical care. An audio recording of both sessions will be available following CHEST 2023 to attendees who purchased an On Demand Pass as part of their meeting registration.