Society of Critical Care Medicine, Feb. 2-6, 2008

Society of Critical Care Medicine's 37th Critical Care Congress

The Society of Critical Care Medicine's 37th Critical Care Congress took place Feb. 2-6 in Honolulu, Hawaii, and attracted more than 4,500 attendees from around the world. Highlights included sessions on improving quality-of-care in the intensive care unit (ICU) and new research that could significantly affect clinical practice.

"Although there was no official theme, the most prevalent theme was a push toward improved quality of care on a number of fronts," said meeting co-chair Louis Brusco, M.D., of St. Luke's-Roosevelt Hospital in New York City. "Popular lectures addressed issues such as decreasing ventilator-associated pneumonia, early goal-directed therapy and the surviving sepsis guidelines. They also addressed intensive insulin therapy, which we've been doing now for a couple of years. It's time in the cycle to start taking a second look at it and ask if we're doing it right and if we should be doing it as much as we are."

Some of the most exciting research was presented at the late-breaking session, said Brusco. A prime example was the CESAR (Conventional Ventilatory Support Versus Extracorporeal Membrane Oxygenation for Severe Adult Respiratory Failure) trial. Giles Peek, M.D., of Glenfield Hospital in Leicester, England, and colleagues compared the two strategies in 190 patients aged 18 to 65 and found that extracorporeal membrane oxygenation treatment resulted in a 31 percent lower six-month incidence of the combined primary outcome: death or severe disability.

"This was a major study, and we were very happy to get the results presented here for the first time," Brusco said. "A lot of people thought these results would never be shown because the risks of extracorporeal membrane oxygenation are so great in adults. If it's as good as they say it is, it will save one life for every six patients treated. But it's going to be very difficult to put into practice because very few centers are set up to do extracorporeal membrane oxygenation."

Another important late-breaking study showed that long-term use of dexmedetomidine (Precedex) may be just as effective as benzodiazepines in sedating critically ill, intubated patients but may cause significantly less delirium, Brusco said. Presented by Richard R. Riker, M.D., of the Maine Medical Center in Portland, the Precedex ICU Long-Term Sedation Trial Results study randomly assigned 297 adult patients who required mechanical ventilation to receive either dexmedetomidine or midazolam until extubation or for 30 days.

Among patients who had delirium at baseline, the researchers found that the cumulative incidence of delirium was significantly lower with dexmedetomidine than with midazolam (69.7 percent versus 94.6 percent). They also found that dexmedetomidine-treated patients had a 33.2 percent reduction in time to successful extubation (93.8 hours versus 138.4 hours).

"While not as earth-shattering as the CESAR study, this study may have a potentially bigger impact even though it was an industry-sponsored study," Brusco said. "ICU delirium is a significant addition to the cost of caring for critically ill, intubated patients. I don't think that dexmedetomidine has caught on as a sedative in the ICU because it doesn't produce as deep a level of sedation as, say, lorazepam. But that may be its saving grace because it causes less delirium."

Current U.S. Food and Drug Administration prescribing information limits the usage of dexmedetomidine to only 24 hours.

Another highlight at the late-breaking session, "Funding Critical Care Research: The Expected Impact of the U.S. Critical Illness and Injury Trials Group (USCIITG)," was presented by J. Perren Cobb, M.D., of Washington University in St. Louis. "He presented the blueprint going forward on how large-scale sepsis research conducted by the National Heart, Lung and Blood Institute is going to be funded and set up," Brusco said. "It's a big effort on the part of the federal government to finally recognize that what we do in the ICU represents a big percentage of health care dollars and that more research needs to be put into it. This is going to result in a lot of good research coming out in future years."

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