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2019 Abstract Award Recipients

2/16/2019
A highlight of the Critical Care Congress is the Star Research and Research Snapshot Theater presentations—which focus on original investigative research and case reports.
 
A highlight of the Critical Care Congress is the Star Research and Research Snapshot Theater presentations, which focus on original investigative research and case reports. This year, SCCM received over 2,000 abstract submissions. Those accepted are published in the January 2019 supplement of Critical Care Medicine, and selected abstracts will be presented and will receive awards at the 48th Critical Congress.

Learn more about the 2019 Star Research Award recipients below:

In Training Award
Star Research: Pediatric Shock Circulation
Effect of Epinephrine Versus Vasopressin Rescue on Cerebral Blood Flow During CPR
Slovis et al (Crit Care Med. 2019;47:7)

How would you summarize your research?
Vasopressin alone or in combination with epinephrine is not currently recommended by either pediatric or adult American Heart Association guidelines for cardiac arrest. However, clinical and translational data on vasopressin’s benefits during cardiopulmonary resuscitation (CPR) are mixed. We hypothesize that vasopressin serves a role as a rescue medication when epinephrine is ineffective in achieving its physiologic goal of raising coronary perfusion pressure (CoPP). To study this, we utilized an existing laboratory model of hemodynamic-directed CPR (HD-CPR), in which vasopressor administration is titrated to CoPP, with vasopressin administered if epinephrine fails to meet CoPP goals. We performed an analysis of 67 swine experiments (10 and 30 kg), all with invasive hemodynamic and neurologic monitoring systems in place. Animals received HD-CPR for 1 of 3 models of in-hospital cardiac arrest (IHCA): 1) primary ventricular fibrillation IHCA; 2) asphyxia-associated IHCA; or 3) lipopolysaccharide-induced shock-associated IHCA.

What were some interesting findings?
Of the 67 animals, 19 failed to respond to either of 2 initial doses of epinephrine, as evidenced by CoPP remaining below the a priori goal of 20 mm Hg. Nine (47%) of these achieved the CoPP goal after the first dose of vasopressin. Of the 19 epinephrine nonresponders, the majority (11/19, 68%) had shock-associated IHCA; 5/9 (56%) responded to vasopressin. When comparing CoPP, mean arterial pressure, cerebral blood flow, and brain tissue oxygenation after each vasopressor, the greatest net effect is from the first dose of epinephrine, likely due to low baseline values of these physiologic markers at the onset of CPR. However, the effect wanes after the second dose of epinephrine, both in the overall population and in the 19 epinephrine nonresponders. Cerebral blood flow is significantly greater with vasopressin as compared to the second dose of epinephrine, both in the overall population of 67 animals (p = 0.002) and in the 19 epinephrine nonresponders (p = 0.01). This suggests that, after 2 doses of epinephrine, especially in a population that has not yet achieved response in CoPP, a subsequent dose of vasopressin can be an effective physiologic rescue for systemic and coronary hemodynamics as well as cerebral blood flow.

Why is this research important to the critical care community?
These data from high-fidelity models of IHCA with extensive physiologic monitoring in place demonstrate that vasopressin may have a role during CPR as a rescue medication after epinephrine fails to achieve CoPP goals. This suggests that, while vasopressin is not superior to epinephrine as the primary vasopressor for cardiac arrest, there are likely populations of patients who could benefit from it. These findings further support the use of real-time physiology to guide resuscitation efforts.
 

Young Investigator Award
Star Research: Pediatric Pulmonary
Acute Respiratory Distress Syndrome Following Pediatric Trauma: Application of PALICC Criteria
Killien et al (Crit Care Med. 2019; 47:5)

How would you summarize your research?
While acute respiratory distress syndrome (ARDS) is a known complication of both adult and pediatric trauma, most studies of pediatric ARDS have included very few trauma patients. Until this year, there were no studies evaluating the incidence, risk factors, or outcomes of ARDS development after pediatric trauma. Our study team published several studies this year on the epidemiology of ARDS following pediatric trauma, using the National Trauma Data Bank (NTDB), but this database relies on documentation of ARDS by data registrars with no way of confirming the ARDS diagnoses. We thus conducted this study to apply the 2015 Pediatric Acute Lung Injury Consensus Conference (PALICC) pediatric ARDS criteria to a cohort of pediatric trauma patients to better understand the true incidence of ARDS among critically injured children and the outcomes among patients who developed ARDS.

This was a retrospective cohort study of all pediatric trauma patients (age 17 years and younger) admitted to the intensive care unit (ICU) at Seattle’s Harborview Medical Center over a 9-year period from 2009-2017. Harborview is the only level 1 pediatric trauma center for the entire 5-state northwest region of Washington, Wyoming, Alaska, Montana, and Idaho. We also included patients who had been transferred from the Harborview emergency department or ICU to the Seattle Children’s Hospital ICU for advanced respiratory care, including high-frequency oscillatory ventilation and extracorporeal life support, which were not available at Harborview for the entire duration of the study period. We used electronic health records to identify all patients who met PALICC oxygenation criteria sustained for at least 6 hours during the first 7 days after their injury. We then reviewed the charts of the patients who met oxygenation criteria to determine whether they met the remainder of the PALICC criteria, including chest imaging findings and origin of edema.

What were some interesting findings?
We found that, of 2470 pediatric trauma patients, 5.6% met oxygenation criteria and 4.4% met full pediatric ARDS criteria. This is a much higher incidence that what had been identified in our previous work using the NTDB, when we found an incidence of only 1.8% among pediatric trauma patients admitted to an ICU. To better understand the impact of the new pediatric ARDS definition on incidence, we also applied the Berlin ARDS criteria to the cohort and found a slightly lower incidence of 3.1%. Importantly, only 1.1% of the cohort had ARDS documented at any time by a physician. ARDS was most commonly a direct result of the trauma itself (87.2%), while the remainder of patients had an additional trigger (pneumonia, aspiration, or sepsis). We also found that patients with ARDS had a much higher risk of mortality compared to patients without ARDS; mortality was 33.0% among patients with ARDS and only 1.7% among patients without ARDS. After adjusting for age, injury mechanism, injury severity score, and the presence of severe brain injury or severe chest injury, there was still a relative risk of 4.97 for mortality among patients with ARDS versus those without ARDS. Mortality was also dependent on the severity of ARDS, with 46.2% mortality among patients with severe ARDS, 34.4% among patients with moderate ARDS, and 29.5% among patients with mild ARDS. Another key finding was that, of patients who survived to hospital discharge, 74.0% of those with ARDS required ongoing care in a rehabilitation, nursing, or other acute care facility compared to only 11.9% of patients without ARDS, and the risk of ongoing post-discharge care remained higher among patients with ARDS even after adjusting for the same factors (age, injury mechanism, injury severity score, severe brain injury, or severe chest injury).

Why is this research important to the critical care community?
The key takeaways for the critical care community are that ARDS development following severe traumatic injury in children is common and is associated with a very high risk of morbidity and mortality, and that ARDS may be under-recognized in this population. Because treatment strategies may differ for patients diagnosed with ARDS, it is important to be able to identify ARDS early. We hope that these findings raise awareness among providers caring for critically injured children about the frequency and poor outcomes associated with ARDS and help facilitate earlier implementation of treatment and ultimately prevention strategies.
 

Gold Medal Award
Star Research: Quality and Patient Safety
Five-Year Outcomes After Implementing a Pain, Agitation, and Delirium Guideline in a Mixed ICU
Fish et al (Crit Care Med. 2019; 47:18)

How would you summarize your research?
We updated our ICU sedation guidelines based on SCCM’s 2013 Pain, Agitation, and Delirium (PAD) guidelines. The major initiatives we implemented were to: 1) try to use more as-needed medication boluses instead of continuous infusions, 2) recommend the use of analgosedation, 3) update our sedation goal to light sedation (Richmond Agitation-Sedation Scale score of –1 to 1), 4) preferentially use propofol and dexmedetomidine infusions over midazolam infusions, 5) implement the Critical-Care Pain Observation Tool behavior pain scale. It has been 5 years since we updated the guidelines, so we looked at our outcomes for those 5 years compared to the 1 year prior to making the changes.

What were some interesting findings?
Over the 5 years, we cared for more intubated patients with higher average Acute Physiology and Chronic Health Evaluation IV scores. Despite these patients being sicker, we have decreased their mean time on the ventilator and their ICU and hospital lengths of stay. During this time, our ICU and hospital standardized mortality ratio remained constant. We conservatively estimate that our hospital saved more than $4.2 million dollars because of the decreased lengths of stay.

Why is this research important to the critical care community?
By implementing the concepts of the SCCM 2013 PAD guidelines, patients will potentially have better clinical outcomes with decreased overall healthcare costs. Decreased ventilator days and lengths of stay also free up critical resources, thus also increasing ICU capacity.
 
 
For more information on Critical Care Congress abstracts, visit sccm.org/abstracts.