Read the full Concise Critical Appraisal here. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

The EOLIA trial (Combes A, et al. N Engl J Med. 2018;378:1965-1975) was a multicenter, international RCT that randomized patients with severe ARDS as defined by one of three criteria: P/F ratio < 50 mm Hg for > 3 hours, P/F ratio < 80 mm Hg for > 6 hours, or pH < 7.25 coupled with Paco₂ ≥ 60 mm Hg for > 6 hours (with respiratory rate < 35 beats/min and plateau pressure ≤ 32 cm H₂O). Physicians were encouraged, but not required, to use paralysis and prone positioning before randomization. Exclusion criteria were vast and, most importantly, limited the study to salvageable, non-obese adult patients on mechanical ventilation for < 7 days with no contraindications for heparin use or vascular access. Randomization was stratified by the center, with the primary end point being 60-day mortality. A key secondary end point was treatment failure, which included crossover from conventional treatment to ECMO and overall death rates.

In order to properly power the study to detect a 20% mortality difference, a maximum of 331 patients were expected under an intention-to-treat protocol. However, after recruitment of 240 patients, an interim analysis failed to demonstrate a significant difference in 60-day mortality and led to early trial termination. A total of 1,015 patients were screened, with 124 assigned to receive ECMO and 125 assigned to the control group. Patient characteristics were similar between the two groups, with a majority of patients having bacterial (45%) or viral (18%) pneumonia. The key development for this study was that patients in both groups had access to similar rescue techniques and received low-pressure, low-volume ventilation according to current standard of care. Of significance, 35 patients in the control group (28%) crossed over to the ECMO group due to refractory hypoxemia at 6.5 ± 9.7 days.

At 60 days, 44 patients in the ECMO group (35%) and 57 in the control group (46%) had died (RR, 0.76; CI, 0.55–1.04; p = 0.09) with a hazard ratio in the ECMO group of 0.70 at 60 days (CI, 0.47–1.04; p = 0.07). The study also showed that the relative risk of treatment failure (death at day 60 on ECMO, crossover to ECMO, or death in the control group) was 0.62 (CI, 0.47–0.82; p = 0.001). At 60 days, patients on ECMO required less prone positioning, experienced less ischemic stroke, and had less need for renal replacement therapy. However patents receiving ECMO had a higher rate of bleeding requiring red blood cell transfusion (46% vs. 28%) and severe thrombocytopenia (27% vs. 16%).

When compared to previous RCTs, the EOLIA trial corrected many previous deficits: The authors standardized the mechanical ventilation settings for all subjects, all patients were offered similar rescue modalities (neuromuscular blockade, inhaled vasodilators, and prone positioning), subjects randomized to ECMO were nearly universally cannulated (98%, with 1 patient improving before ECMO use and 2 dying immediately after randomization), and finally, all patients randomized to ECMO were started on ECMO before transport to a specialty center. Additionally, the authors were methodical about creating succinct definitions of respiratory failure that met criteria for ECMO use.

Interpretation of results is difficult because many patients in the control group were transitioned to ECMO (28%) due to refractory hypoxemia but were analyzed as control group subjects due to the intention-to-treat principle. If solely examining treatment failure (as defined previously), there was a statistically significant benefit in favor of ECMO use. The authors admit that this exhibits bias toward the control group but note that the decision to transition to ECMO therapy was made only after every other rescue modality had been tried. Furthermore, the study did demonstrate a trend toward mortality benefit with the use of ECMO, although this was not statistically significant.

The most important criticism to surface on final assessment is the underpowering of the study to detect an absolute between-group mortality difference of 20%. This severely limited the primary analysis and led to early termination.

Coauthors of this installment of Concise Critical Appraisal:

Kevin M. Jones, MD, MPH, FACEP, is an assistant professor of emergency medicine with the Program for Trauma at the R. Adams Cowley Shock Trauma Center at the University of Maryland Medical Center, Baltimore, Maryland, USA.

James Lantry III, MD, is an assistant professor of emergency and critical care medicine and the associate program director of the Critical Care Fellowship at the University of Maryland Medical Center in Baltimore, Maryland, USA. Dr. Lantry is an editor of Concise Critical Appraisal.

Practitioners will need to assess their knowledge on a more frequent basis in order maintain certification requirements. The Review and Assessment product line, developed by the Society of Critical Care Medicine, offers a complete spectrum of critical care review solutions to assist with the recent trend of periodic examinations. Many of these resources available have flexible, effective self-study options.

• Assess your knowledge and mimic the open-book format with Self-Assessment: Adult and Self-Assessment: Pediatric. These valuable reviews each contain a collection of multiple-choice, case-based questions and answers, with corresponding rationales, from the top critical care focus areas.
• Evaluate your critical care knowledge while earning continuing medical education and MOC credit with Advanced Knowledge Assessment: Adult and Advanced Knowledge Assessment: Pediatric question sets. These self-study tools are composed of questions, answers, rationales, and study materials.
• Receive 4.5 days of extensive coverage of core critical care topics with the live Multiprofessional Critical Care Review Course (MCCRC): Adult and MCCRC: Pediatric, which will each be held August 5 through 9, 2018, in Rosemont, Illinois, USA.

View the complete list of product details and live event registrations online.

Receive 4.5 days of expert guidance on the core areas of critical care medicine led by expert faculty. Whether you need to certify, recertify, or simply review, these courses provide an excellent update and thorough overview of the field.

Both the adult and pediatric board review courses include interactive board preparation sessions using audience response technology and feature practice questions, answers, and rationales.

As a registered participant, you will benefit from:

• Online access to practice questions
• Comprehensive course syllabus
• Post-course online access to MCCRC On Demand, which features videos containing the slide presentations and synchronized speaker audio from all sessions of the live course
• Fulfilling continuing medical education requirements and gaining assessments of knowledge in critical care

Both courses will be held August 5 through 9, 2018, at the Loews Chicago O’Hare Hotel in Rosemont, Illinois, USA. Hotel reservations made after July 11, 2018, may not receive the discounted rate. Visit the adult or pediatric course online for details, including agenda, faculty, and registration information.

The two-day courses, Critical Care Ultrasound: Pediatric and Neonatal and Critical Care Ultrasound: Adult, will take place on August 5 and 6, 2018.

These courses provide the ability to:

• Immediately integrate learned skills into your clinical practice
• Increase your diagnostic skills and scanning proficiency
• Learn from field experts the latest strategies in ultrasound image interpretation and diagnostic challenges, as well as new innovations and procedures
• Experience high-quality education from prominent faculty, including nurse practitioners, physician assistants, and others
• Receive a significant hands-on experience, ensured by a five-to-one learner-to-faculty ratio

Following these courses on August 7, 2018, is the one-day Advanced Critical Care Ultrasound: Adult course, which provides an opportunity to expand your echocardiographic skills and knowledge. Attendees should be experienced in ultrasound use and looking for advanced practice.

Registration for the ultrasound courses includes a complimentary copy of SCCM’s Comprehensive Critical Care Ultrasound eBook. Register today, or contact SCCM Customer Service at +1 847 827-6888.

SCCM Pod-363 Hemodynamic Support of Pediatric and Neonatal Septic Shock

SCCM Pod-362 Time of Admission to the PICU and Mortality

SCCM Pod-361 Antibiotic Therapy in Comatose Mechanically Ventilated Patients Following Aspiration

SCCM Pod-360 Alarm and Alert Fatigue in Critical Care

This unique conference is focused on peer-to-peer learning led by expert faculty and is ideal for both individuals and intensive care unit teams. Attendees will experience an environment of learning and sharing with like-minded critical care professionals to improve bedside care as well as:

• Discuss the updated pain, agitation, delirium, immobility, and sleep interruption (PAD-IS) guidelines
• Assess ethical considerations for end-of-life planning
• Debate how critical care quality and safety will change the future of bedside care
• Identify 2019 SCCM collaborative opportunities
• Assess findings from the Critical Care Societies Collaborative National Summit on Clinician Burnout
• Earn continuing medical education credit

Accepted abstracts will be featured as poster presentations at the conference, with the top abstracts receiving awards.

The abstract submission period ends June 29, 2018, at 12:00 a.m. midnight Central Time.

If you have any questions, please contact SCCM Customer Service at +1 847 827-6888.

Faculty will describe the planning process of creating a database, review accurate and efficient data acquisition options, and provide an overview of a basic approach to data cleaning. Whether designing a clinical trial or retrospective cohort study, building an effective database is a critical skill in conducting research involving the critically ill patient.

This is a grant-sponsored webcast; it is complimentary for attendees.

The paper describes how training local PFCCS instructors within an international environment proved an effective method for establishing a uniform, reproducible, and sustainable approach to educating health-care providers in the fundamentals of pediatric critical care.

Check out the full online article!

Choose between holding a live, traditional licensed course or a hybrid online licensed course. The traditional licensed course is an instructor-led, two-day, live course with all lectures and skill stations conducted onsite. The online licensed course gives participants the pretest and lectures via SCCM’s learning management system four weeks before the scheduled onsite skill stations.

In addition to the FCCS course, consider hosting one of these other two Fundamentals courses:

• FCCS: Obstetrics is designed for intensivists and nonintensivists who may provide maternal/fetal critical care and for clinicians in obstetrics seeking additional education on critical care.
• FCCS: Tropical Diseases prepares healthcare professionals to care for patients infected with tropical diseases.

Both FCCS: Obstetrics and FCCS: Tropical Diseases are available only as live, traditional licensed courses.

To learn more about how to host an FCCS course, please contact the Fundamentals team at +1 847 827-6869 or fccs@sccm.org.

Rosemont, Illinois, USA has the convenience and amenities of downtown Chicago but at a lower price and is just minutes from O’Hare International Airport. A free shuttle is offered between the airport and Loews Chicago O’Hare Hotel, and there is easy access to the CTA Blue Line, which will take you into downtown Chicago.

Reservations must be guaranteed with a major credit card at the time of booking. Cancellations must be made at least 24 hours before the scheduled check-in time of 4:00 p.m. in order to avoid a charge of one night’s room and tax. An early departure fee may apply. For any questions or assistance with booking, please contact SCCM Customer Service.

Sessions will explore hot topics in critical care patient safety and quality such as burnout; care implementation strategies; the pain, agitation, delirium, immobility, and sleep interruption guidelines; and end-of-life planning.

Attendees will:

• Assess findings from the Critical Care Societies Collaborative National Summit on Clinician Burnout
• Debate how critical care quality and safety will change the future of bedside care
• Discuss the updated pain, agitation, delirium, immobility, and sleep interruption (PAD-IS) guidelines and how they relate to ICU patient quality and safety measures and outcomes
• Examine implementation strategies for patient- and family-centered care to improve both quality and safety in the ICU
• Assess ethical considerations for end-of-life planning and potential quality and safety factors
• Review patient safety and quality abstracts
• Identify 2019 SCCM collaborative opportunities

The top abstracts will be featured in poster presentations. Abstract submission is currently open and will close June 29, 2018.

Intensive care unit teams as well as individuals are encouraged to attend this multiprofessional critical care event!

In addition to attending the Critical Care Quality Summit, take a trip to the Centers for Disease Control and Prevention (CDC) and visit the David J. Sencer CDC Museum, which showcases the CDC’s history and work on both the national and global level.

To learn more and to register, please visit the Critical Care Quality Summit website or contact SCCM Customer Service at +1 847 827-6869.

Both courses will be held August 5-9, 2018, at the Loews Chicago O’Hare Hotel in Rosemont, Illinois, USA. Each will provide the most comprehensive review and update of the diagnosis, monitoring, and management of critically ill patients. Course highlights include:

• Modular course content, allowing for single or multiday registration to meet comprehensive or specific learning needs
• Accurate assessments of attendees’ critical care knowledge
• Interactive sessions that utilize audience response technology and practice questions, answers, and rationales
• World-class faculty who provide the most up-to-date information in critical care across all healthcare professions
• Cutting-edge topics such as extracorporeal membrane oxygenation, choice of vasopressor in shock states, renal replacement therapy techniques, environmental injuries, emerging infections, and delirium
• Online access to practice questions and post-course audio recordings of the lectures

All courses offer continuing medical education and Maintenance of Certification (MOC) credit hours to physicians, nurses, and physician assistants. Register online for the Adult or Pediatric course using your Customer ID and password, or contact SCCM Customer Service at +1 847 827-6888.

Critical Care Ultrasound: Adult and Critical Care Ultrasound: Pediatric and Neonatal are comprehensive, two-day courses that will take place on August 5 and 6, 2018. These courses provide the ability to:

• Immediately integrate learned skills into your clinical practice
• Increase your diagnostic skills and scanning proficiency
• Learn from field experts on the latest strategies in ultrasound image interpretation and diagnostic challenges, as well as new innovations and procedures
• Experience high-quality education from prominent, multiprofessional faculty
• Receive a significant hands-on experience, ensured by a five-to-one learner-to-faculty ratio

Expand your echocardiographic skills and knowledge with the one-day Advanced Critical Care Ultrasound: Adult course. This course will be held on August 7, 2018. The advanced course provides attendees with an opportunity to:

• Focus on the specialty-specific use of echocardiography in the management of the critically ill patient
• Gain hands-on experience with faculty-assisted skill stations including transesophageal echocardiography
• Learn important cardiovascular information for the noninvasive management of the hemodynamically unstable patient

All courses offer continuing medical education and Maintenance of Certification (MOC) credit hours to physicians, nurses, and physician assistants. Register online today for Critical Care Ultrasound: Adult, Critical Care Ultrasound: Pediatric and Neonatal, and Advanced Critical Care Ultrasound: Adult, using your Customer ID and password, or contact SCCM Customer Service at +1 847 827-6888.

The report, which is being released as the U.S. Department of Health and Human Services Pain Management Best Practices Inter-Agency Task Force meets for the first time, found a decrease in opioid prescribing and increases in the use of state prescription drug monitoring programs (PDMPs), number of physicians trained and certified to treat patients with an opioid use disorder, and in access to naloxone.

“While this progress report shows physician leadership and action to help reverse the epidemic, such progress is tempered by the fact that every day, more than 115 people in the United States die from an opioid-related overdose,” said Patrice A. Harris, MD, MA, Chair AMA Opioid Task Force. “What is needed now is a concerted effort to greatly expand access to high quality care for pain and for substance use disorders. Unless and until we do that, this epidemic will not end.”

To further address the opioid epidemic, the AMA urges policymakers and insurers to remove barriers to care for pain and substance use disorders. Visit the AMA opioid website for more information.

Read the full Concise Critical Appraisal here. Concise Critical Appraisal is a regular feature aimed at highlighting the best and most relevant literature from a variety of academic journals and encouraging discussion around recent studies and research.

For this prospective, observational cohort study, the authors used physiologic data obtained using tissue spectrometry and laser Doppler flowmetry from 58 infants who underwent surgery. These infants were divided into 3 groups based on the type of surgery—infants who underwent major noncardiac surgery (group 1), infants with congenital heart disease who underwent primary biventricular repair (group 2), and infants with functionally univentricular hearts who underwent palliative procedures (group 3). The authors then measured physiologic variables, including cerebral oxygen saturation (cSO₂) and relative cerebral blood flow (rcFlow), in order to calculate cerebral fractional tissue oxygen extraction (cFTOE), arteriocerebral difference in oxygen content (acDO₂) and cerebral metabolic rate of oxygen metabolism (CMRO₂), before and after transfusion.

Using these noninvasive modalities, the authors demonstrated that transfusion resulted in no significant change in arterial carbon dioxide, heart rate, lactate, or pH, although groups 1 and 2 had increases in mean arterial pressure (MAP). In addition to this change in MAP, the authors demonstrated that posttransfusion cSO₂ values were statistically higher in all groups and that cFTOE decreased, although rcFlow, acDO₂, and aCMRO₂ remained unchanged. These latter measures suggest that, even though oxygen extraction decreased, the fact that cerebral blood flow remained the same as well as aCMRO₂, there did not appear to be a significant pretransfusion oxygen deficit in these patients. Even though oxygen extractions decreased, these latter measures demonstrate that there was no pretransfusion oxygen deficit since cerebral blood flow and CMRO₂ remained the same The authors comment on a possible role of altered cerebral autoregulation as well. They also found that infants with a cFTOE > 0.4 had a steep increase in cSO₂ and that this degree of extraction was seen more commonly among the two groups of infants with congenital heart disease.

The authors comment that elevated cFTOE had been previously associated with poor neurologic outcomes in preterm infants and that cFTOE could serve as a surrogate measure of the adequacy of oxygenation in their patient population as well. They also suggest that infants who had more profound (> 0.4) extraction, and subsequently a more profound rise in cSO₂, may be better candidates for transfusion than infants with the same hemoglobin value but lower extraction.

This study supports the use of physiologic variables, obtained noninvasively, to make the decision of whether to transfuse a critically ill infant who has undergone surgery. This may be an important place to start in making this decision, but more outcome data must be obtained. While anemia may be bad for these infants, the risks of transfusion may be worse.

Author of this installment of Concise Critical Appraisal:

Daniel E. Sloniewsky, MD, is an associate professor in the Division of Pediatric Critical Care Medicine in the Department of Pediatrics at Stony Brook Long Island Children’s Hospital. Dr. Sloniewsky is an editor of Concise Critical Appraisal.

Submit your proposal online today.

Accepted proposals will be presented at a 2018 Clinical Investigators Meeting, where investigators will receive:

• An opportunity to obtain written feedback on their proposal from the Discovery Steering Committee before they present at the meeting
• Peer feedback and discussion on the presented proposal
• Access to site expansion opportunities for their research
• Formal letter endorsing the proposal from Discovery, the Critical Research Network, which may aid in future funding requests

2018 Clinical Investigator Meetings

• October 1, 2018: This meeting will be held at the National Institutes of Health in Rockville, Maryland, USA.

The most important change in the revision of the SSC bundles is that there is now a single “Hour-1 Bundle” with the explicit intention of beginning resuscitation and management immediately.

This new sepsis “Hour-1 Bundle” should be introduced to staff in the emergency department (ED), wards, and intensive care unit as the next iteration of ever-improving tools in the care of patients with sepsis and septic shock as we all work to lessen the global burden of sepsis.

Reflecting the latest evidence, the Hour-1 Bundle highlights five steps that healthcare professionals should begin as soon as sepsis is recognized:

• Measure the blood lactate level. A high lactate level indicates that the tissues are not getting enough oxygen from the blood.
• Perform blood cultures to identify the cause of the infection. Blood samples should be taken before antibiotics are administered, if possible.
• Administer broad-spectrum antibiotics that are active against the causative organism.
• Start intravenous fluids. Fluid resuscitation is an essential step to stabilize the patient’s condition.
• Administer vasopressors to raise blood pressure. This is a critical resuscitation step in patients with septic shock.

“There is no reason to delay treatment for patients with sepsis and septic shock,” comments lead author Mitchell Levy, MD, MCCM. “Recognizing the urgent need to treatment, clinicians must (and many already do) begin treatment immediately, rather than waiting for 3 or 6 hours in these critically ill patients.” The authors point out that the new revision is based on the 2016 SSC guidelines update, which provides further discussion and evidence related to each step and to comprehensive management of sepsis. They also note some important gaps in current knowledge, including the need for further studies in important subgroups such as patients with burns and compromised immune function. Read the Statement from Surviving Sepsis Campaign Leadership on Time Zero in the Emergency Department.

Find the new SSC Hour-1 Bundle and related resources at survivingsepsis.org/Bundle.