Find care now
If you are experiencing a medical emergency, please call 911 or seek care at an emergency room.
This article was written by Rajiv Sonti, MD.
Research in the critical care setting is challenging. An insightful new study published in the New England Journal of Medicine shows how we can examine long-held beliefs with well-supported research.
In the medical intensive care unit (MICU), the pace of care is measured in minutes. When a patient has a severe infection or a life-threatening drop in blood pressure, we respond immediately.
In this high-stakes environment, we often default to the way things have always been done. As a researcher, this creates an opportunity to assess and improve these understudied “baked-in-beliefs.”
One such practice is the placement of an invasive arterial line. This is a thin tube inserted into an artery in the wrist to monitor blood pressure in critically ill patients continuously. I recently reviewed a major study for ACP Hospitalist, the EVERDAC trial. The study, published in the New England Journal of Medicine, found that a noninvasive blood pressure cuff can provide accurate measurements without the downsides of an invasive line.
One of the foundations of clinical research is to challenge longstanding practices that could potentially be improved. MedStar Health Research Institute supports clinician-researchers to improve care for all our patients, including intense clinical settings such as the ICU.
Questioning the gold standards.
For decades, medical education has taught that when patients have shock, an arterial line is the most accurate way to measure blood pressure. We assumed that we could gather more information with this method, and that more information was better.
Researchers in EVERDAC, a multicenter, open label, noninferiority trial, randomly assigned more than 1,000 patients who were in shock in the ICU to either receive an arterial line or be monitored with an automated blood pressure cuff. They found that for many patients, a standard, noninvasive blood pressure cuff was just as effective as an arterial line.
This is a significant finding because invasive lines carry real risks. Moving away from default arterial lines offers several clear benefits for patients:
-
Lower risk of infection: Arterial lines provide bacteria with a route into the body, increasing the risk of infection.
-
Increased mobility: An arterial line requires the patient’s wrist to be extended and fixed in position. Without a line, patients can move more freely.
-
Greater comfort: Fewer invasive lines mean less pain for patients.
The uniquely high-stakes environment in the ICU makes it challenging to answer even basic questions using tried-and-true study methods, so researchers need to be creative to provide insightful answers.
The challenge of research in critical care.
In fields such as cancer care, researchers design and implement studies over weeks, months or even years. Cancers tend to progress slowly, giving them time to explore how patients respond to new treatments.
In the ICU, the fast tempo of our care makes this kind of research nearly impossible. The clinical need to keep patients stable always overrides research protocols, and many patients are unconscious and unable to sign clinical study consent forms.
Data gathering in this environment can result in a firehose of time-sensitive information. This can introduce significant “noise” that obscures the clear signals we need for precise statistical analysis.
That is why the EVERDAC trial is about more than blood pressure. It is the next chapter in a longer story about how we can adapt research methods to help improve patient care at the bedside in the critical care setting.
My ongoing research focuses on another part of the ICU journey: the patient’s transition of an assisted breathing device (ventilator). There is plenty of high-quality research about how to care for patients when they first develop respiratory failure; there has been much less focus on the best way to reduce breathing support when their condition improves.
Our research is advancing patient care and developing solutions for clinicians at MedStar Health and beyond.
Related: Read “Research: Earlier Palliative Care Improves Patient Outcomes in the Cardiac ICU.”
How MHRI supports researchers.
No investigator or study succeeds in a vacuum. MedStar Health Research Institute actively invests in researchers, including those early in our careers.
Through programs such as the MHRI New Investigator Charitable Fund, Internal “K-award” Research Development Awards, and many other opportunities, MHRI enables me to find protected time in an otherwise full clinical schedule. Without this support, research is impossible.
But it’s about more than funding: MHRI breaks down compartmentalization to build bridges among colleagues who are interested in answering related questions. This provides early-career researchers access to mentorship opportunities. In my case, Nathan Cobb, MD, helped me bridge the gap between clinical medicine and data science.
As the ICU moves ever closer to a precision medicine approach, we’re asking important questions about long-held assumptions, enabling us to expand our understanding of the best ways to help critically ill patients regain their health.
By investing in researchers like me, MHRI helps ensure we’re solving the problems MedStar Health patients face, leading to better care for everyone in our communities.
