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NCS Currents June 2016

JOURNAL WATCH Journal Watch By Chitra Venkatasubramanian MBBS, MSc and Aimee Aysenne MD, MPH The past six months has been an exciting time for NEWS – New Science in Neurocritical Care. We have included key neurocritical care topics such as subarachnoid hemorrhage, ICH, subdural hematoma, status epilepticus, TBI, brain death and prognostication and have expanded to include CPR in the pediatric ICU, the new sepsis definitions, long term outcomes from CREST, hepatic encephalopathy, and ICU physician strain. Thank you for your comments. Please, keep them coming. We also want to thank the NCS Executive Office for upgrading the website for easier access and layout of articles and commentaries. In this edition of Currents, we highlight two landmark articles. The first is the 10-year follow up results of CREST that showed equivalency between stenting and carotid endarterectomy for carotid stenosis. The second is a commentary on the updated definitions of sepsis and septic shock. Chitra Venkata- subramanian MBBS, MSc No difference in 10-year outcomes between stenting and carotid endarterectomy Brott TG, Howard G, Roubin GS, et al. NEJM 2016;374:1021-1031. CREST was a multicenter randomized controlled trial, enrolling patients with symptomatic or asymptomatic carotid stenosis of ≥70% between 2000-2008. Stenting was preceded by dual antiplatelets and continued for four weeks post-stenting. Carotid endarterectomy (CEA) patients had aspirin 325 mg prior to and 80-325 mg daily for four weeks after. Both groups received standard medical therapy for vascular risk factors. Primary endpoint was a composite of stroke, myocardial infarction, or death in the periprocedural period (i.e., from randomization to 36 days post-procedure). Long term endpoint was the 10- year composite outcome. Time-to-restenosis was time from procedure to ipsilateral revascularization or ultrasound detection of 70-99% stenosis. 2,502 patients were randomized; about half were symptomatic. Median follow-up was 7.4 years. There were 161 composite periprocedural endpoints (5.2% in the stenting group and 4. 5% in the CEA group). The stenting group had almost twice as many strokes (4.1% versus 2.3 %, p=0.01), half as many MIs (1.1% versus 2.3%, p=0.03), and a 37% higher risk of periprocedural stroke, death, and subsequent ipsilateral stroke (p=0.04). The 10-year composite endpoint (n=1,607) did not differ between groups (11.8% for stenting versus 9.9% for CEA, p=0.51) without any temporal changes from year 1 to 9. There was no difference based on symptomatic status and no significant interaction for age, gender, or degree of stenosis. Post-procedural stroke rate was also similar: 42 in the stenting group (6.9%, 0.7%/year) and 41 in the CEA group (5.6%, 0.6%/year). Major stroke (i.e., NIHSS ≥ 9) occurred twice as often (12 versus 6) in the stenting group, but the difference was non-significant. Restenosis and revascularization rates were similarly low in both groups. CREST is a large landmark study that demonstrates equivalency between stenting and CEA for average risk asymptomatic and symptomatic carotid stenosis with respect to a primary composite endpoint of stroke, MI, or death in the peri-procedural period and at 10 years, with no additional difference in post-procedural ipsilateral strokes. CREST attests to the durability of stenting. What remains to be addressed is the superiority of either procedure over medical therapy for asymptomatic patients. Caution should be adopted while extrapolating the results of CREST to general practice, as the replication and generalizability is questionable particularly for low volume centers and where expertise cannot be verified. Revised definitions of sepsis and septic shock Singer M, Deutschmann CS, Seymour CW, et al. JAMA 2016;315:801-810. Sepsis and septic shock are ubiquitous in the ICU. The European Society of Intensive Care Medicine and the Society of Critical Care Medicine convened a taskforce to update the definitions of sepsis and septic shock. Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, and septic shock implies underlying circulatory and cellular metabolism abnormalities associated with increased mortality. SIRS criteria are non-specific and physiologic in some situations. The Sequential Organ Failure Assessment (SOFA) score – consisting of PaO2/FIO2 ratio, platelet count, bilirubin, MAP and/ or vasopressor requirements, GCS, creatinine, and urine output – was chosen to quantify the pathological response. A change in the baseline SOFA score of >2 points is associated with a mortality risk of approximately 10%. The term “severe sepsis” is now considered redundant. Septic shock was identified by hypotension, lactate >2, and vasopressor use, and is associated with >40% in-hospital mortality. The quick SOFA (qSOFA) score consists of two of the three variables: RR >22, GCS ≤13, or SBP ≤ 100. Outside of the ICU, the qSOFA’s predictive validity was similar to that of the SOFA score and faster to use. In the ICU, the SOFA score was superior to qSOFA. Validation of the definitions included 148,907 patients with suspected infection. Hospital mortality, ICU stay of ≥3 days, or both were used to assess SIRS criteria, SOFA score, and Logistic Organ Dysfunction System. In ICU patients, discrimination for hospital mortality with the SOFA score was greater than for SIRS criteria. In patients outside the ICU, discrimination of hospital mortality with the SOFA score was similar to that of the SIRS criteria. The suggested diagnostic algorithm for a patient with a suspected infection involves assessing qSOFA and, if positive, assess for organ dysfunction with the full SOFA score. The new definitions of sepsis and septic shock emphasize the life-threatening organ dysfunction. The validation study showed that the SOFA and qSOFA scores are indicators of patients with infection who may have a higher risk of mortality. These scores may be useful for measuring severity and as research tools for sepsis. While SIRS criteria were criticized for being nonspecific, it may remain a screening tool to identify patients with a potential infection. Further refinement of these definitions will be needed as sepsis becomes better understood. Aimee Aysenne MD, MPH 26


NCS Currents June 2016
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