Overview
This podcast episode, hosted by JAMA Editor-in-Chief Dr. Kirsten Bibbins-Domingo with Drs. Christopher Seymour and Derek Angus, reviews four major clinical trials in critical care, focusing on sepsis alerts, oxygen strategies in trauma, respiratory support, and biomarker-guided antibiotic duration.
Electronic Sepsis Screening (SCREEN Trial)
- The SCREEN trial randomized hospital wards to activate or withhold electronic sepsis alerts based on QSOFA criteria.
- Alerts notified both nurses and physicians and were accompanied by quality improvement efforts.
- Over 60,000 patients participated across 45 wards over 1.5 years.
- The trial found a significant reduction in hospital mortality (risk ratio 0.85) with the alert system.
- Alerts led to more lactate tests and IV fluid orders, but not to increased antibiotic prescribing.
- No mortality change was seen among just those patients who triggered alerts.
- The intervention affected workflows and overall vigilance on wards.
Early Restrictive vs. Liberal Oxygen for Trauma (Traumox 2 Trial)
- This large, multi-center trial randomized trauma patients to restrictive or liberal oxygen strategies.
- No differences were observed in 30-day death or respiratory complications between the groups.
- Findings suggest that neither a strictly restrictive nor liberal approach offers a clear benefit.
- Current guidelines remain vague on optimal oxygen targets for trauma patients.
- More individualized approaches and further research are needed.
High Flow Nasal Oxygen vs. Non-Invasive Ventilation (RENOVATE Trial)
- The RENOVATE trial enrolled ≈1,800 patients in acute respiratory failure, randomizing to high flow nasal oxygen or non-invasive ventilation.
- High flow nasal oxygen was found largely non-inferior and as effective as non-invasive ventilation.
- High flow was more practical and easier to use, but some uncertainty remains for small subgroups (e.g., immunocompromised).
- Editorials explore implications for both emergency and ICU settings, noting persistent subgroup concerns.
Biomarker-Guided Antibiotic Duration (ADAPT Sepsis Trial)
- The ADAPT Sepsis trial tested whether antibiotic duration in sepsis could be safely reduced using procalcitonin, CRP, or standard care protocols.
- Procalcitonin guidance reduced antibiotic duration by about one day without compromising safety (non-inferior mortality).
- CRP guidance did not significantly affect antibiotic duration and nearly missed the non-inferiority threshold for mortality.
- The findings support daily procalcitonin for guiding antibiotic discontinuation but raise questions about the use of CRP.
Key Dates / Deadlines
- Morris Fishbine Fellowship application deadline: January 5th, 2025.
Recommendations / Advice
- Electronic sepsis alerts may improve hospital mortality on a population basis.
- No clear benefit for restrictive versus liberal oxygen in trauma; guideline recommendations should remain flexible.
- High flow nasal oxygen is a practical alternative to non-invasive ventilation for acute respiratory failure.
- Consider procalcitonin for safer reduction of antibiotic use in sepsis, but more evidence is needed for CRP guidance.
Questions / Follow-Ups
- What are the optimal alert criteria and implementation methods for electronic sepsis alerts?
- How should clinicians individualize oxygen therapy in trauma patients based on current evidence?
- Are there specific patient subgroups where high flow nasal oxygen may not be appropriate?
- What are the cost-effectiveness and logistical implications of routine procalcitonin testing in sepsis care?