Classic PICU Articles

[DeadCactus]

---

Members do not see this ad.

What articles would you list as classic/cornerstone articles in the PICU literature?

 

[SurfingDoctor]

http://www.nejm.org/doi/full/10.1056/NEJM200005043421801
http://www.nejm.org/doi/full/10.1056/NEJMoa010307
http://jamanetwork.com/journals/jama/fullarticle/195197
http://www.nejm.org/doi/full/10.1056/NEJMoa1411480
http://www.nejm.org/doi/full/10.1056/NEJMoa0810625
http://www.nejm.org/doi/full/10.1056/NEJMoa071366
http://www.nejm.org/doi/full/10.1056/NEJMoa1401602
http://www.nejm.org/doi/full/10.1056/NEJMoa040232
http://www.nejm.org/doi/full/10.1056/NEJMoa011300

I have to be honest, while the list could go on and on, I have developed a healthy dose of skepticism when it comes to any article that drastically alters practice because it shows a huge large benefit. The problem is that maybe therapies used in the PICU have modern evidence to support they do nothing to change outcome (iNO, oscillator versus conventional ventilator, craniectomy for TBI). Furthermore (and this is a problem of all large, randomized clinical studies) is that studies try to recruit a large number of patients, which while matched, are heterogeneous by design and try to apply one therapy to show they work. Often they don't and how could they, you tried to take every sick patient and give them one treatment and change the mortality. Does that really make sense? Pathyphysiology for even one clinical entity is diverse. But sometimes, you do show a benefit with a single therapy and that's nowadays always make me pause. I remember being taught the E. Rivers, et al paper on septic shock was the paper that revolutionized septic shock. Fast forward 15 years and three independent studies each with 2-3x the power of the original study show protocolized, end goal directed therapy doesn't change outcomes. I don't know, others are welcome to disagree, but I overtime, I have come to appreciate how little we understand about pathophysiology and you can't hammer every square peg into a round hole.

 

[BigRedBeta]

It's an excellent list from @SurfingDoctor

I agree that so called "practice changing" papers need context to them. For example, while adults with cardiac arrest benefit from hypothermia the THAPCA trial did not show the same in kids...but what does that really mean? Does it mean that kids in no way benefit from cooling? Or just that they didn't get benefit from the way the THAPCA trial cooled them? Maybe they need to be cooled lower or longer, or warmed up slower.

The real benefit of the Rivers trial may not have been about pushing to specific physiologic parameters, but in early aggressive fluid therapy at all. Again, the context at the time of the study may change the real "answer" given by the paper. At the time in the early to mid 90's almost all the prior sepsis trials enrolled patients at anytime in their first 48-72 hours after admission and then started the study interventions. Rivers was unique for focusing on ED management and the first 6 hours of presentation - something that is mirrored in the ProCESS trial linked above.

 

[SurfingDoctor]

It's an excellent list from @SurfingDoctor

I agree that so called "practice changing" papers need context to them. For example, while adults with cardiac arrest benefit from hypothermia the THAPCA trial did not show the same in kids...but what does that really mean? Does it mean that kids in no way benefit from cooling? Or just that they didn't get benefit from the way the THAPCA trial cooled them? Maybe they need to be cooled lower or longer, or warmed up slower.

The real benefit of the Rivers trial may not have been about pushing to specific physiologic parameters, but in early aggressive fluid therapy at all. Again, the context at the time of the study may change the real "answer" given by the paper. At the time in the early to mid 90's almost all the prior sepsis trials enrolled patients at anytime in their first 48-72 hours after admission and then started the study interventions. Rivers was unique for focusing on ED management and the first 6 hours of presentation - something that is mirrored in the ProCESS trial linked above.

I agree with the assessment of Rivers and EGDT. Granted I didn't practice in the pre-EDGT era so I have no really perspective, but I do think EGDT and the Surviving Sespsis Campaign brought to light to doing something and doing it early was better than waiting till the patient was on deaths door. And since doing something as opposed to nothing is kinda the standard of care nowadays, and the ProCESS and subsequent trials were in academic centers as opposed to community hospital where protocols are more helpful for consistency, the newer trials didn't show a protective benefit. Unfortunately offering therapy earlier when people are sick only provides so much benefit when you don't actually understand the pathophysiology of the disease like sepsis. THAPCA (via global cerebral hypoperfusion) and ARDS fit into the same box of multiple pathways under one diagnosis. Anyway...