Journal Feed Weekly Wrap-up

We always work hard, but we may not have time to read through a bunch of journals. It’s time to learn smarter. 

Originally published at JournalFeed, a site that provides daily or weekly literature updates. 

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#1: CRASH 3 – TXA for TBI

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TXA appears to have a slight 28-day mortality benefit in traumatic brain injury (TBI) patients with a GCS ≥9, especially when given early.

Why does this matter?
CRASH 2 found that TXA decreased mortality from bleeding in trauma patients. But it didn’t reduce transfusion requirement.

CRASH 3 – Heads Up!
This was a double blinded RCT with 9,127 included patients with TBI (GCS ≤12 or injury on CT) who received TXA or placebo within 3 hours. Included patients also could not have obvious extracranial bleeding. Patients were given TXA 1g over 10 minutes plus 1g over the next 8 hours. There were initially >12,000 patients, but only those who received it in <3 hours were included. Groups were well matched. In all patients given drug in under 3 hours, mortality at 28 days due to head injury was 18·5% TXA vs 19·8% placebo (risk ratio, RR 0·94, 95%CI 0·86–1·02). In the sensitivity analysis in which patients with GCS 3 or non-reactive pupils were excluded, 28-day mortality due to head injury was 12·5% TXA vs. 14·0% placebo (RR 0·89, 95%CI 0·80–1·00). In the subgroup with CGS 9-15, “mild to moderate head injury,” mortality was 166/2846 (5·8%) vs. 207/2769 (7·5%); RR 0·78, 95%CI 0·64–0·95. There was no mortality difference in the subgroup with more severe head injury, GCS 3-8. For less severe head injury cases, the earlier it was given, the greater the improvement in mortality. TXA was again safe to use, with no increase in clotting-related vascular events or other adverse outcomes. Among survivors, there was no improvement in TXA vs placebo in patient-centered disability, such as percentage confined to bed or who were unable to wash or dress themselves – each had about 12-13% with those bad outcomes. My take is that TXA appears to have a slight benefit in patients with a GCS ≥9, especially when given early. I think I would want it and would want my family to receive it. It is cheap, safe, and may help.

Another Spoonful

Effects of tranexamic acid on death, disability, vascular occlusive events and other morbidities in patients with acute traumatic brain injury (CRASH-3): a randomised, placebo-controlled trial. Lancet. October 14 2019.

#2: Be SMART – Balanced Fluid for Sepsis

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The use of balanced crystalloids for ICU patients with sepsis was associated with a lower 30-day in-hospital mortality (26.3% vs 31.2%, P=0.01) and a lower incidence of major adverse kidney events within 30 days (35.4% vs 40.1%, aOR 0.78) compared to normal saline.

Why does this matter?
Normal saline, the historical bastion of IV fluids, has supraphysiologic chloride concentration that may cause hyperchloremia, metabolic acidosis, renal vasoconstriction, hypotension, and altered immune function.  The recently published Isotonic Solutions and Major Adverse Renal Events Trial (SMART) compared balanced crystalloids to normal saline and found that balanced crystalloids decreased the composite outcome of death, new renal replacement therapy, or persistent renal dysfunction for critically ill adults. However, do patients with sepsis specifically benefit from balanced crystalloids?

Treating sepsis with a balanced approach…
This study was a secondary analysis of the 1,641 ICU patients with a diagnosis of sepsis from the original SMART trial. The use of balanced crystalloids was associated with a significantly lower 30-day in-hospital mortality (26.3% vs 31.2%, P=0.01). This corresponds to a 15.7% relative risk reduction and a 4.9% absolute risk reduction of death (NNT = 20) within 30 days. The effect on mortality was much more substantial for this subgroup of patients (i.e. sepsis) than the general ICU population in the SMART trial.

In addition, balanced crystalloids were associated with a lower incidence of major adverse kidney events within 30 days (35.4% vs 40.1%, aOR 0.78), a greater number of vasopressor-free days (20 ± 12 vs 19 ± 13; aOR 1.25; 95% CI 1.02 – 1.54), and more renal replacement therapy-free days (20 ± 12 vs 19 ± 13; aOR 1.35 [1.08 – 1.69]) compared to the normal saline group.

This study has several limitations including being a subgroup analysis, unblinded, using ICD-10 codes for identifying patients with sepsis, and having all patients enrolled from a single academic center (even if Vanderbilt is great…not biased at all – LOL). However, with little downside and a possible reduction in mortality and adverse renal events, why not be SMART and just use balanced fluids for patients with sepsis?

Balanced Crystalloids Versus Saline in Sepsis: A Secondary Analysis of the SMART Trial. Am J Respir Crit Care Med. 2019 Aug 27. doi: 10.1164/rccm.201903-0557OC. [Epub ahead of print]

#3: N95 vs Plain Mask for Flu Prevention

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This study found no difference in effectiveness between an N95 respiratory and common medical mask in preventing transmission of influenza or other viral respiratory illnesses in a healthcare workplace.

 Why does this matter?
When taking care of patients with viral respiratory illnesses, does it matter if you wear an N95 respiratory or a standard medical mask? Some of you may recall this was presented at ID Week a year ago, and we covered it. Now it’s officially published in JAMA.

Wear a mask, any mask!
This was a cluster randomized, pragmatic effectiveness trial performed in diverse outpatient settings of 7 large medical centers. During 4 consecutive flu seasons, healthcare personnel (HCP) at matched sites were randomized to N95 respirators or medical masks. In total, there were 2862 participants and 4689 HCP-seasons included in the analysis. In the N95 group, there were 207 laboratory-confirmed influenza infections, or 8.2% of HCP-seasons. In the mask group, there were 193 laboratory-confirmed influenza infections. or 7.2% of HCP-seasons. Researchers found no significant difference in incidence of laboratory-confirmed influenza between these two groups (difference of 1.0%, 95% CI of −0.5% to 2.5%; P=0.18). Additionally, the incidence of other laboratory detected respiratory infections, unspecified respiratory illnesses, and influenza-like illnesses were similar. Self-reported adherence (always or sometimes wearing the assigned device) was about 90% in both groups.

N95 Respirators vs Medical Masks for Preventing Influenza Among Health Care Personnel: A Randomized Clinical Trial. JAMA. 2019 Sep 3;322(9):824-833. doi: 10.1001/jama.2019.11645.

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