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This site has been built to create a compendium of all the landmark papers which are shaping the way we manage our critically ill patients. Each paper has been summarised and critiqued using a standard template and ends with a ‘bottom line’ conclusion to allow a quick reminder of the key points.
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In adult patients in ICU with septic shock, does a restrictive approach to fluid therapy compared to a standard care result in fewer deaths at day 90?
Fluid therapy in the critically unwell has been widely studied across many patient populationsHigher volumes of fluid in patients with sepsis and septic shock has been associated with harm, although a meta-analysisshowed that the quality of evidence was very lowThe ANDROMEDA SHOCKtrial demonstrated in those with septic shock, that by 2 hours only ~25% of patients were deemed to still be fluid responsiveThe CLASSIC pilot study showed that a restrictive fluid strategy was feasible and showed significantly less fluid was used in the first 5 ICU days in the restrictive groupStratified, parallel-group, open-label, international, randomised controlled trialRandomised 1:1 using a central web based systemTreatment group assignments not masked for clinicians, patients or investigatorsReceived assigned intervention from randomisation until ICU discharge (for a maximum of 90 days)31 ICUs in EuropeNovember 2018 to November 2021Inclusion:Exclusion:2223 screened –> 1554 randomisedComparing baseline characteristics of restrictive vs. standard groupRestrictive GroupFluids could be given for:Primary outcome:Death by day 90Secondary outcomes:In adult ICU patients with septic shock, IV fluid restriction did not result in fewer deaths at 90 days compared to standard IV fluid therapy
RandomisedMulti-centre trial involving 31 ICUs across 8 European countries increases external validityPre-published statistical analysis planIntention to treat analysisUnblindedThe most common infection source was GI – this may have necessitated large volumes of replacement fluid if diarrhoea or vomiting were prominent featuresPowered for a 7% reduction in mortalityLarge volumes of fluid given outside of the trial protocolJan 21, 2022 · The SMART trial involving 15000 adult ICU patients in 2018 showed a reduction in a composite outcome of death, new renal replacement therapy and persistent renal dysfunction at 30 days, with balanced crystalloid use. The SPLIT trial in 2015 compared Plasmalyte to 0.9% Sodium Chloride in 2278 critically ill patients.
Mar 10, 2023 · The CLOVERS Trial. nejmoa2212663. The Bottom Line Review. CLOVERS. Multicenter, randomized, unblinded superiority trial. Inclusion. Patients over 18 years old with either a suspected or confirmed infection and sepsis-induced hypotension (SBP<100 after 1 liter fluid) Pertinent Exclusion. More than 3L of IVF prior to enrollment (including EMS fluids)
Each paper has been summarised and critiqued using a standard template and ends with a 'bottom line' paragraph to allow a quick reminder of the key points. The papers are reviewed and cross checked by the editorial group.
Dec 9, 2020 · We contend that the Bayesian approach is ideal because it (a) directly answers the questions of interest (probabilities of clinically relevant benefit, harm, or futility), thereby reducing the risk of a false “positive” or false “negative” conclusion; and (b) the continuously updated posterior permits maximally efficient trial adaptations in sam...
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Jun 15, 2006 · Résumé. Background. Optimal fluid management in patients with acute lung injury is unknown. Diuresis or fluid restriction may improve lung function but could jeopardize extrapulmonary-organ...
