The jury is still out on whether steroids lower mortality in septic shock patients, but multiple trials now have shown that steroids shorten duration of septic shock. If this effect shortens the length of ICU stays (as it did in ADRENAL), steroid use might translate to cost savings and lesschallenging hospitalizations for some patients and their families — even if the mortality benefit is marginal. I will continue to use glucocorticoids for patients with refractory septic shock who require multiple vasopressors or rapidly escalating doses. The dose of fludrocortisone given in APROCCHSS was so low that some have questioned its physiological effect in the setting of such high glucocorticoid dosing. Nevertheless, fludrocortisone is inexpensive, and its addition likely imparts no harm, so using the treatment protocol from APROCCHSS makes sense to me.

— Patricia Kritek, MD

Antipsychotics did not prevent delirium or affect its clinical course!

Two randomized trials demonstrate that antipsychotics have no role in ICU delirium prophylaxis and should not be used to treat patients with hypoactive ICU delirium. Antipsychotics might still have a role in managing patients with hyperactive delirium who are at imminent risk for self-harm (e.g., pulling out their endotracheal tubes). However, antipsychotic use should be discontinued at first opportunity given their associated risk for harms, such as QT prolongation and aspiration pneumonia 

— Neil H. Winawer, MD, SFHM, NEJM Journal Watch Hospital Medicinechotics

It is widely accepted that if there are life-threatening complications of acute kidney injury, such as hyperkalemia or metabolic acidosis, renal-replacement therapy should be initiated immediately. However, in the absence of such complications, there is no convincing evidence that outcome might be better if renal-replacement therapy was initiated early.

 Article Source: N Engl J Med 2018; 379:1431-1442. DOI: 10.1056/NEJMoa1803213

GI prophylaxis (most comonly PPI) is routinely used in the ICU for all ventilated patients and in patients with coagulopathy, and hepatic or kidney failure. However, the quality of evidence supporting the prophylactic use of proton-pump inhibitors in the ICU is limited. There are also concerns that PPI may increase the risk of Clostridium difficile infection, pneumonia, and myocardial ischemia. In this European, multicenter, parallel-group, blinded trial, 3296 patients were randomized to receive pantoprazole versus placebo. The authors concluded that 90 day-mortality did not differ between the two groups. The number of clinically important events (gastrointestinal bleeding, pneumonia, Clostridium difficile infection, or myocardial ischemia) were similar in those assigned to pantoprazole and those assigned to placebo.

Clinically important gastrointestinal bleeding occurred in 2.5% of the patients in the pantoprazole group and in 4.2% of the patients in the placebo group and no P value was reported since there was no adjustment for multiple comparisons. Overall rate of GI bleed in low and it is probably secondary to early feeding in ICU. Therefore, we should continue to use GI prophylaxis to all patients in the ICU who are at risk of developing GI bleed and we cannot justify stopping this practice based on this study.

Article Source: NEJM October 24, 2018. DOI: 10.1056/NEJMoa1714919