Daily Anesthesiology Research Analysis

BACKGROUND: For critically ill adults undergoing tracheal intubation, observational studies suggest that the use of etomidate to induce anesthesia may increase the risk of death. Whether the use of ketamine rather than etomidate decreases the risk of death is uncertain. METHODS: In a randomized trial conducted in 14 emergency departments and intensive care units in the United States, we randomly assigned critically ill adults who were undergoing tracheal intubation to receive ketamine or etomidate for the induction of anesthesia. The primary outcome was in-hospital death from any cause by day 28. The secondary outcome was cardiovascular collapse during intubation, defined by the occurrence of a systolic blood pressure below 65 mm Hg, receipt of a new or increased dose of vasopressors, or cardiac arrest. RESULTS: A total of 2365 patients underwent randomization and were included in the trial population; 1176 were assigned to the ketamine group and 1189 to the etomidate group. In-hospital death by day 28 occurred in 330 of 1173 patients (28.1%) in the ketamine group and in 345 of 1186 patients (29.1%) in the etomidate group (risk difference adjusted for trial site, -0.8 percentage points; 95% confidence interval [CI], -4.5 to 2.9; P = 0.65). Cardiovascular collapse during intubation occurred in 260 of 1176 patients (22.1%) in the ketamine group and in 202 of 1189 patients (17.0%) in the etomidate group (risk difference, 5.1 percentage points; 95% CI, 1.9 to 8.3). Prespecified safety outcomes were similar in the two groups. CONCLUSIONS: Among critically ill adults undergoing tracheal intubation, the use of ketamine to induce anesthesia did not result in a significantly lower incidence of in-hospital death by day 28 than etomidate. (Funded by the Patient-Centered Outcomes Research Institute and others; RSI ClinicalTrials.gov number, NCT05277896.).

IMPORTANCE: Awake prone positioning (APP) has shown inconstant associations with improved clinical outcomes in nonintubated patients with COVID-19 developing severe pneumonia. OBJECTIVE: To evaluate the effects of APP on the need for intubation or incidence of death among patients with COVID-19-related hypoxemic respiratory failure. DESIGN, SETTING, AND PARTICIPANTS: This randomized clinical trial was conducted at 20 hospitals in France and 1 hospital in Mexico between July 2020 and August 2021. The study included patients from wards and intensive care units. Adult patients (18 years or older) who were not intubated and required at least 3 L/min of oxygen flow due to COVID-19 infection were included and randomly assigned in a 1:1 ratio to either APP or standard care. Intention-to-treat statistical analysis was performed from September to December 2024. INTERVENTION: Patients randomly assigned to the APP group were offered the intervention lasting at least 6 hours a day. Patients randomly assigned to standard care had no positioning constraint, including no contraindication to spontaneous APP. MAIN OUTCOMES AND MEASURES: The primary outcome was a composite criterion of intubation and/or death in the first 28 days of randomization. Prespecified secondary outcomes at 28 days of enrollment were days alive outside the intensive care unit (ICU), days alive outside the hospital, proportion of patients admitted to ICU (for patients not in ICU at baseline), and days alive and free from mechanical ventilation. A bayesian approach was used to provide insights into the complete distribution of the effect estimates. RESULTS: A total of 445 patients were included in the final analysis (mean [SD] age, 60 [11] years; 329 males [74%]; median [IQR] SpO2 to FIO2 [peripheral oxygen saturation to fraction of inspired oxygen] ratio, 150 [114-194] and 155 [109-221] in the standard care and APP groups, respectively). With a noninformative prior distribution, the posterior probability that APP decreased intubation and/or death compared with standard care was 93.8% (mean odds ratio [OR], 0.74; 95% credible interval [CrI], 0.48-1.09). For secondary outcomes, between the APP and standard care groups, the mean difference in the number of days alive and free from mechanical ventilation was 0.33 (95% CrI, -1.37 to 2.03) days; in the number of days alive outside the ICU was 1.28 (95% CrI, -0.78 to 3.34) days; and in the number of days alive outside the hospital was 1.55 (95% CrI, -0.22 to 3.32) days. CONCLUSIONS AND RELEVANCE: In this randomized clinical trial of nonintubated patients with COVID-19 and hypoxemic respiratory failure, daily APP of 6 hours showed a high probability of reduced endotracheal intubation and/or death over a wide range of prior distributions. These results support APP's use in patients with hypoxemic pneumonia due to COVID-19 infection. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04366856.

BACKGROUND: Intravenous iron improves haemoglobin recovery after surgery and in critical illness. However, the impact on longitudinal markers of iron status and inflammation are unknown. Further, it is unknown if iron studies obtained early in acute illness may moderate i.v. iron treatment responses. METHODS: This is a planned analysis from a randomised clinical trial of critically ill adults with haemoglobin levels <10 g dl RESULTS: A total of 100 patients were included: 49 intervention and 51 standard care. The intervention group achieved higher haemoglobin (adjusted mean difference, 0.69 [95% confidence interval, 0.13-1.25] g dl CONCLUSIONS: Intravenous iron increases haemoglobin and ferritin concentrations through 3 months following critical illness. Traditional iron assays are influenced by inflammation, impeding utility in iron deficiency detection. The soluble transferrin receptor-log ferritin index measured early in critical illness has potential to identify differential i.v. iron treatment responses.