Brief Updates on Hypothermia, Hyperglycemia, Cholesterol, Blood Pressure Lowering in Stroke and Testosterone

I've read a lot of interesting articles recently, but none that are sufficient fodder for a dedicated post.  So here I will update some themes from previous blog posts with recent articles from NEJM and JAMA that relate to them.

Prehospital Induction of Hypothermia After Cardiac Arrest
In this article in the January 1st issue of JAMA, investigators from King County Washington report the results of a trial which tested the hypothesis that earlier (prehospital) induction of hypothermia, by infusing cold saline, would augment the assumed benefit of hypothermia that is usually initiated in the hospital for patients with ventricular fibrillation.  Please guess what was the effect of this intervention on survival to hospital discharge and neurological outcomes.

You were right.  There was not even a signal, not a trend towards benefit, even though body temperature was lower by 1 degree Celcius and time to target hypothermia temperature in the hospital was one hour shorter.  However, the intervention group experienced re-arrest in the field significantly more often than the control group and had more pulmonary edema and diuretic use.  Readers interested in exploring this topic further are referred to this post on Homeopathic Hypothermia.

Hyperglycemic Control in Pediatric Intensive Care
In this article in the January 9th issue of NEJM, we are visited yet again by the zombie topic that refuses to die.  We keep looking for subgroups or populations that will benefit, and if we find one that appears to, it will be a Type I error, thinks the blogger with Bayesian inclinations.  In this trial, 1369 pediatric patients at 13 centers in England were randomized to tight versus conventional glycemic control.  Consistent with other trials in other populations, there was no benefit in the primary outcome, but tightly "controlled" children had much more and severe hypoglycemia.  The "cost effectiveness" analysis they report is irrelevant.  You can't have "cost effectiveness" of an ineffective therapy.  My, my, how we continue to grope.

More is Not Less, It Just Costs More: Early Tracheostomy, Early Parenteral Nutrition, and Rapid Blood Pressure Lowering in ICH

The past 2 weeks have provided me with some interesting reading of new data that deserve to be integrated with several other studies and themes discussed in this blog.  The three trials below share the goal of intervening early and aggressively so I thought it may be interesting to briefly consider them together.

Firstly, Young et al (May 22/29, 2013 issue of JAMA) report the results of the TracMan multicenter trial of early tracheostomy in ICUs in the UK.  These data seal the deal on an already evolving shift in my views on early tracheostomy that were based on anecdotal experience and earlier data from Rumbak and Terragni.  Briefly, the authors enrolled 899 patients expected to receive at least 7 more days of mechanical ventilation (that prediction was no more reliable in the current trial than it had been in previous trials) and randomized them to receive a trach on day 4 (early) versus on day 10 (late).    The early patients did end up receiving less sedatives and  had a trend toward shorter duration of respiratory support.  But their KM curves are basically superimposable and the mortality rates virtually identical at 30 days.  These data, combined with other available studies, leave little room for subjective interpretation.  Early tracheostomy, it is very likely, does not favorably affect outcomes enough to justify its costs and risks.