1
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Nielsen FM, Klitgaard TL, Bruun NH, Møller MH, Schjørring OL, Rasmussen BS. Lower or higher oxygenation targets in the intensive care unit: an individual patient data meta-analysis. Intensive Care Med 2024:10.1007/s00134-024-07523-3. [PMID: 38990335 DOI: 10.1007/s00134-024-07523-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 06/11/2024] [Indexed: 07/12/2024]
Abstract
PURPOSE Optimal oxygenation targets for patients with acute hypoxemic respiratory failure in the intensive care unit (ICU) are not clearly defined due to substantial variability in design of previous trials. This study aimed to perform a pre-specified individual patient data meta-analysis of the Handling Oxygenation Targets in the ICU (HOT-ICU) and the Handling Oxygenation Targets in coronavirus disease 2019 (COVID-19) (HOT-COVID) trials to compare targeting a partial pressure of arterial oxygen (PaO2) of 8-12 kPa in adult ICU patients, assessing both benefits and harms. METHODS We assessed 90-day all-cause mortality and days alive without life support in 90 days using a generalised mixed model. Heterogeneity of treatment effects (HTE) was evaluated in 14 subgroups, and results graded using the Instrument to assess the Credibility of Effect Modification Analyses (ICEMAN). RESULTS At 90 days, mortality was 40.4% (724/1792) in the 8 kPa group and 40.9% (733/1793) in the 12 kPa group (risk ratio, 0.99; 95% confidence interval [CI] 0.92-1.07; P = 0.80). No difference was observed in number of days alive without life support. Subgroup analyses indicated more days alive without life support in COVID-19 patients targeting 8 kPa (P = 0.04) (moderate credibility), and lower mortality (P = 0.03) and more days alive without life support (P = 0.02) in cancer-patients targeting 12 kPa (low credibility). CONCLUSION This study reported no overall differences comparing a PaO2 target of 8-12 kPa on mortality or days alive without life support in 90 days. Subgroup analyses suggested HTE in patients with COVID-19 (moderate credibility) and cancer (low credibility).
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Affiliation(s)
- Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark.
| | - Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Hobrovej 18-21, 9000, Aalborg, Denmark
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2
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de Grooth HJ, Parienti JJ. Heterogeneity between studies can be explained more reliably with individual patient data. Intensive Care Med 2023; 49:1238-1241. [PMID: 37466672 PMCID: PMC10556177 DOI: 10.1007/s00134-023-07163-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 07/06/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Harm-Jan de Grooth
- Department of Intensive Care, Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
- Laboratory for Critical Care Computational Intelligence (LCCCI), Amsterdam UMC Location VUmc, Amsterdam, The Netherlands.
| | - Jean-Jacques Parienti
- Department of Clinical Research and Biostatistics, Caen University Hospital and Caen Normandy University, Caen, France
- INSERM U1311 DYNAMICURE, Caen Normandy University, Caen, France
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3
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Nielsen FM, Klitgaard TL, Bruun NH, Møller MH, Schjørring OL, Rasmussen BS. Lower or higher oxygenation targets for acute Hypoxaemic respiratory failure: Protocol for an individual patient data meta-analysis. Acta Anaesthesiol Scand 2023; 67:811-819. [PMID: 36807011 DOI: 10.1111/aas.14220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 01/29/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Supplemental oxygen therapy is central to the treatment of acute hypoxaemic respiratory failure, a condition which remains a major driver for morbidity and mortality in intensive care. Despite several large randomised clinical trials comparing a higher versus a lower oxygenation target for these patients, significant differences in study design impede analysis of aggregate data and final clinical recommendations. METHODS This paper presents the protocol for conducting an individual patient data meta-analysis where full individual patient data according to the intention-to-treat principle will be pooled from the HOT-ICU and HOT-COVID trials in a one-step procedure. The two trials are near-identical in design. We plan to use a hierarchical general linear mixed model that accounts for data clustering at a trial and site level. The primary outcome will be 90-day all-cause mortality while the secondary outcome will be days alive without life-support at 90 days. Further, we outline 14 clinically relevant predefined subgroups which we will analyse for heterogeneity in the intervention effects and interactions, and we present a plan for assessing the credibility of the subgroup analyses. CONCLUSION The presented individual patient data meta-analysis will synthesise individual level patient data from two of the largest randomised clinical trials on targeted oxygen therapy in intensive care. The results will provide a re-analysis of the intervention effects on the pooled intention-to-treat populations and facilitate subgroup analyses with an increased power to detect clinically important effect modifications.
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Affiliation(s)
- Frederik Mølgaard Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Thomas Lass Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Niels Henrik Bruun
- Unit of Clinical Biostatistics, Aalborg University Hospital, Aalborg, Denmark
| | - Morten Hylander Møller
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Olav Lilleholt Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Bodil Steen Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
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4
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McNicholas BA. Is It Time to Re-Imagine Clinical Trials in Nephrology? J Am Soc Nephrol 2023; 34:366-368. [PMID: 36735335 PMCID: PMC10103358 DOI: 10.1681/asn.0000000000000070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/15/2022] [Indexed: 01/26/2023] Open
Affiliation(s)
- Bairbre A. McNicholas
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospital, Saolta Hospital Group, Galway, Ireland
- School of Medicine, University of Galway, Galway, Ireland
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5
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Hannon DM, Mistry S, Das A, Saffaran S, Laffey JG, Brook BS, Hardman JG, Bates DG. Modeling Mechanical Ventilation In Silico-Potential and Pitfalls. Semin Respir Crit Care Med 2022; 43:335-345. [PMID: 35451046 DOI: 10.1055/s-0042-1744446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Computer simulation offers a fresh approach to traditional medical research that is particularly well suited to investigating issues related to mechanical ventilation. Patients receiving mechanical ventilation are routinely monitored in great detail, providing extensive high-quality data-streams for model design and configuration. Models based on such data can incorporate very complex system dynamics that can be validated against patient responses for use as investigational surrogates. Crucially, simulation offers the potential to "look inside" the patient, allowing unimpeded access to all variables of interest. In contrast to trials on both animal models and human patients, in silico models are completely configurable and reproducible; for example, different ventilator settings can be applied to an identical virtual patient, or the same settings applied to different patients, to understand their mode of action and quantitatively compare their effectiveness. Here, we review progress on the mathematical modeling and computer simulation of human anatomy, physiology, and pathophysiology in the context of mechanical ventilation, with an emphasis on the clinical applications of this approach in various disease states. We present new results highlighting the link between model complexity and predictive capability, using data on the responses of individual patients with acute respiratory distress syndrome to changes in multiple ventilator settings. The current limitations and potential of in silico modeling are discussed from a clinical perspective, and future challenges and research directions highlighted.
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Affiliation(s)
- David M Hannon
- Anesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Ireland
| | - Sonal Mistry
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Anup Das
- School of Engineering, University of Warwick, Coventry, United Kingdom
| | - Sina Saffaran
- Faculty of Engineering Science, University College London, London, United Kingdom
| | - John G Laffey
- Anesthesia and Intensive Care Medicine, School of Medicine, NUI Galway, Ireland
| | - Bindi S Brook
- School of Mathematical Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Jonathan G Hardman
- Anesthesia and Critical Care, Injury Inflammation and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, United Kingdom.,Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Declan G Bates
- School of Engineering, University of Warwick, Coventry, United Kingdom
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6
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Randomised clinical trials in critical care: past, present and future. Intensive Care Med 2021; 48:164-178. [PMID: 34853905 PMCID: PMC8636283 DOI: 10.1007/s00134-021-06587-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 11/17/2021] [Indexed: 12/15/2022]
Abstract
Randomised clinical trials (RCTs) are the gold standard for providing unbiased evidence of intervention effects. Here, we provide an overview of the history of RCTs and discuss the major challenges and limitations of current critical care RCTs, including overly optimistic effect sizes; unnuanced conclusions based on dichotomization of results; limited focus on patient-centred outcomes other than mortality; lack of flexibility and ability to adapt, increasing the risk of inconclusive results and limiting knowledge gains before trial completion; and inefficiency due to lack of re-use of trial infrastructure. We discuss recent developments in critical care RCTs and novel methods that may provide solutions to some of these challenges, including a research programme approach (consecutive, complementary studies of multiple types rather than individual, independent studies), and novel design and analysis methods. These include standardization of trial protocols; alternative outcome choices and use of core outcome sets; increased acceptance of uncertainty, probabilistic interpretations and use of Bayesian statistics; novel approaches to assessing heterogeneity of treatment effects; adaptation and platform trials; and increased integration between clinical trials and clinical practice. We outline the advantages and discuss the potential methodological and practical disadvantages with these approaches. With this review, we aim to inform clinicians and researchers about conventional and novel RCTs, including the rationale for choosing one or the other methodological approach based on a thorough discussion of pros and cons. Importantly, the most central feature remains the randomisation, which provides unparalleled restriction of confounding compared to non-randomised designs by reducing confounding to chance.
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7
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Saunders B, Inzlicht M. Pooling resources to enhance rigour in psychophysiological research: Insights from open science approaches to meta-analysis. Int J Psychophysiol 2021; 162:112-120. [PMID: 33529643 DOI: 10.1016/j.ijpsycho.2021.01.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/21/2021] [Accepted: 01/25/2021] [Indexed: 12/20/2022]
Abstract
Recent years have witnessed calls for increased rigour and credibility in the cognitive and behavioural sciences, including psychophysiology. Many procedures exist to increase rigour, and among the most important is the need to increase statistical power. Achieving sufficient statistical power, however, is a considerable challenge for resource intensive methodologies, particularly for between-subjects designs. Meta-analysis is one potential solution; yet, the validity of such quantitative review is limited by potential bias in both the primary literature and in meta-analysis itself. Here, we provide a non-technical overview and evaluation of open science methods that could be adopted to increase the transparency of novel meta-analyses. We also contrast post hoc statistical procedures that can be used to correct for publication bias in the primary literature. We suggest that traditional meta-analyses, as applied in ERP research, are exploratory in nature, providing a range of plausible effect sizes without necessarily having the ability to confirm (or disconfirm) existing hypotheses. To complement traditional approaches, we detail how prospective meta-analyses, combined with multisite collaboration, could be used to conduct statistically powerful, confirmatory ERP research.
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Affiliation(s)
| | - Michael Inzlicht
- Department of Psychology, University of Toronto; Rotman School of Management, Canada
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8
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Moskowitz A, Andersen LW, Huang DT, Berg KM, Grossestreuer AV, Marik PE, Sherwin RL, Hou PC, Becker LB, Cocchi MN, Doshi P, Gong J, Sen A, Donnino MW. Ascorbic acid, corticosteroids, and thiamine in sepsis: a review of the biologic rationale and the present state of clinical evaluation. Crit Care 2018; 22:283. [PMID: 30373647 PMCID: PMC6206928 DOI: 10.1186/s13054-018-2217-4] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/03/2018] [Indexed: 12/12/2022] Open
Abstract
The combination of thiamine, ascorbic acid, and hydrocortisone has recently emerged as a potential adjunctive therapy to antibiotics, infectious source control, and supportive care for patients with sepsis and septic shock. In the present manuscript, we provide a comprehensive review of the pathophysiologic basis and supporting research for each element of the thiamine, ascorbic acid, and hydrocortisone drug combination in sepsis. In addition, we describe potential areas of synergy between these therapies and discuss the strengths/weaknesses of the two studies to date which have evaluated the drug combination in patients with severe infection. Finally, we describe the current state of current clinical practice as it relates to the thiamine, ascorbic acid, and hydrocortisone combination and present an overview of the randomized, placebo-controlled, multi-center Ascorbic acid, Corticosteroids, and Thiamine in Sepsis (ACTS) trial and other planned/ongoing randomized clinical trials.
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Affiliation(s)
- Ari Moskowitz
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA USA
| | - Lars W. Andersen
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
- Research Center for Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
- Department of Anesthesiology, Aarhus University Hospital, Aarhus, Denmark
| | - David T. Huang
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA USA
- Department of Emergency Medicine, University of Pittsburgh, Pittsburgh, PA USA
| | - Katherine M. Berg
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA USA
| | - Anne V. Grossestreuer
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
| | - Paul E. Marik
- Department of Internal Medicine, Eastern Virginia Medical School, Norfolk, VA USA
| | - Robert L. Sherwin
- Department of Emergency Medicine, Wayne State University School of Medicine/Detroit Receiving Hospital, Detroit, MI USA
| | - Peter C. Hou
- Division of Emergency Critical Care Medicine, Department of Emergency Medicine, Brigham and Women’s Hospital, Boston, MA USA
| | - Lance B. Becker
- Department of Emergency Medicine, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY USA
- Feinstein Institute for Medical Research, Manhasset, NY USA
| | - Michael N. Cocchi
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
- Department of Anesthesia Critical Care, Division of Critical Care, Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Pratik Doshi
- Department of Emergency Medicine and Internal Medicine, University of Texas Health Science Center at Houston, Houston, TX USA
| | - Jonathan Gong
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health System, New Hyde Park, NY USA
| | - Ayan Sen
- Department of Critical Care Medicine, Mayo Clinic, Phoenix, AZ USA
| | - Michael W. Donnino
- Beth Israel Deaconess Medical Center, Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Boston, MA USA
- Beth Israel Deaconess Medical Center, Department of Emergency Medicine, Boston, MA USA
- Beth Israel Deaconess Medical Center, Emergency Medicine, One Deaconess Rd, W/CC 2, Boston, MA 02215 USA
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9
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Zhao BC, Shen P, Liu KX. Perioperative Statins Do Not Prevent Acute Kidney Injury After Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. J Cardiothorac Vasc Anesth 2017; 31:2086-2092. [DOI: 10.1053/j.jvca.2017.04.038] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2017] [Indexed: 11/11/2022]
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10
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Krinsley JS, Chase JG, Gunst J, Martensson J, Schultz MJ, Taccone FS, Wernerman J, Bohe J, De Block C, Desaive T, Kalfon P, Preiser JC. Continuous glucose monitoring in the ICU: clinical considerations and consensus. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:197. [PMID: 28756769 PMCID: PMC5535285 DOI: 10.1186/s13054-017-1784-0] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Glucose management in intensive care unit (ICU) patients has been a matter of debate for almost two decades. Compared to intermittent monitoring systems, continuous glucose monitoring (CGM) can offer benefit in the prevention of severe hyperglycemia and hypoglycemia by enabling insulin infusions to be adjusted more rapidly and potentially more accurately because trends in glucose concentrations can be more readily identified. Increasingly, it is apparent that a single glucose target/range may not be optimal for all patients at all times and, as with many other aspects of critical care patient management, a personalized approach to glucose control may be more appropriate. Here we consider some of the evidence supporting different glucose targets in various groups of patients, focusing on those with and without diabetes and neurological ICU patients. We also discuss some of the reasons why, despite evidence of benefit, CGM devices are still not widely employed in the ICU and propose areas of research needed to help move CGM from the research arena to routine clinical use.
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Affiliation(s)
- James S Krinsley
- Division of Critical Care, Department of Medicine, Stamford Hospital, Columbia University College of Physicians and Surgeons, Stamford, CT, 06902, USA
| | - J Geoffrey Chase
- Department of Mechanical Engineering, Centre for Bio-Engineering, University of Canterbury, Christchurch, 8140, New Zealand
| | - Jan Gunst
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, 3000, Leuven, Belgium
| | - Johan Martensson
- Department of Intensive Care, Austin Hospital, Heidelberg, 3084, VIC, Australia.,Department of Anesthesia and Intensive Care Medicine, Karolinska University Hospital, Department of Physiology and Pharmacology, Karolinska Institutet, 171 77, Stockholm, Sweden
| | - Marcus J Schultz
- Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.,Department of Intensive Care, Laboratory of Experimental Intensive Care and Anesthesia (L E I C A), Faculty of Tropical Medicine, Mahidol University, Mahidol-Oxford Research Unit (MORU), Bangkok, Thailand
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium
| | - Jan Wernerman
- Karolinska University Hospital Huddinge & Karolinska Institutet, K32 14186, Stockholm, Sweden
| | - Julien Bohe
- Medical Intensive Care Unit, University Hospital of Lyon, Lyon, France
| | - Christophe De Block
- Department of Endocrinology, Diabetology and Metabolism, Antwerp University Hospital, B-2650, Edegem, Belgium
| | - Thomas Desaive
- GIGA-In Silico Medicine, Université de Liège, B4000, Liège, Belgium
| | - Pierre Kalfon
- Service de Réanimation polyvalente, Hôpital Louis Pasteur, CH de Chartres, 28000, Chartres, France
| | - Jean-Charles Preiser
- Department of Intensive Care, Erasme Hospital, Université libre de Bruxelles, 1070, Brussels, Belgium.
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11
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Rowan KM, Angus DC, Bailey M, Barnato AE, Bellomo R, Canter RR, Coats TJ, Delaney A, Gimbel E, Grieve RD, Harrison DA, Higgins AM, Howe B, Huang DT, Kellum JA, Mouncey PR, Music E, Peake SL, Pike F, Reade MC, Sadique MZ, Singer M, Yealy DM. Early, Goal-Directed Therapy for Septic Shock - A Patient-Level Meta-Analysis. N Engl J Med 2017; 376:2223-2234. [PMID: 28320242 DOI: 10.1056/nejmoa1701380] [Citation(s) in RCA: 326] [Impact Index Per Article: 46.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND After a single-center trial and observational studies suggesting that early, goal-directed therapy (EGDT) reduced mortality from septic shock, three multicenter trials (ProCESS, ARISE, and ProMISe) showed no benefit. This meta-analysis of individual patient data from the three recent trials was designed prospectively to improve statistical power and explore heterogeneity of treatment effect of EGDT. METHODS We harmonized entry criteria, intervention protocols, outcomes, resource-use measures, and data collection across the trials and specified all analyses before unblinding. After completion of the trials, we pooled data, excluding the protocol-based standard-therapy group from the ProCESS trial, and resolved residual differences. The primary outcome was 90-day mortality. Secondary outcomes included 1-year survival, organ support, and hospitalization costs. We tested for treatment-by-subgroup interactions for 16 patient characteristics and 6 care-delivery characteristics. RESULTS We studied 3723 patients at 138 hospitals in seven countries. Mortality at 90 days was similar for EGDT (462 of 1852 patients [24.9%]) and usual care (475 of 1871 patients [25.4%]); the adjusted odds ratio was 0.97 (95% confidence interval, 0.82 to 1.14; P=0.68). EGDT was associated with greater mean (±SD) use of intensive care (5.3±7.1 vs. 4.9±7.0 days, P=0.04) and cardiovascular support (1.9±3.7 vs. 1.6±2.9 days, P=0.01) than was usual care; other outcomes did not differ significantly, although average costs were higher with EGDT. Subgroup analyses showed no benefit from EGDT for patients with worse shock (higher serum lactate level, combined hypotension and hyperlactatemia, or higher predicted risk of death) or for hospitals with a lower propensity to use vasopressors or fluids during usual resuscitation. CONCLUSIONS In this meta-analysis of individual patient data, EGDT did not result in better outcomes than usual care and was associated with higher hospitalization costs across a broad range of patient and hospital characteristics. (Funded by the National Institute of General Medical Sciences and others; PRISM ClinicalTrials.gov number, NCT02030158 .).
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Affiliation(s)
- Kathryn M Rowan
- Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Derek C Angus
- University of Pittsburgh School of Medicine, Pittsburgh
| | | | | | | | - Ruth R Canter
- Intensive Care National Audit and Research Centre, London, United Kingdom
| | | | | | | | - Richard D Grieve
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - David A Harrison
- Intensive Care National Audit and Research Centre, London, United Kingdom
| | | | | | - David T Huang
- University of Pittsburgh School of Medicine, Pittsburgh
| | - John A Kellum
- University of Pittsburgh School of Medicine, Pittsburgh
| | - Paul R Mouncey
- Intensive Care National Audit and Research Centre, London, United Kingdom
| | - Edvin Music
- University of Pittsburgh School of Medicine, Pittsburgh
| | - Sandra L Peake
- Monash University, Melbourne, VIC, Australia
- University of Adelaide, Adelaide, SA, Australia
- Queen Elizabeth Hospital, Adelaide, SA, Australia
| | | | | | - M Zia Sadique
- London School of Hygiene and Tropical Medicine, London, United Kingdom
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12
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Iorio A, Fischer K, Makris M. Large scale studies assessing anti-factor VIII antibody development in previously untreated haemophilia A: what has been learned, what to believe and how to learn more. Br J Haematol 2017; 178:20-31. [PMID: 28387451 DOI: 10.1111/bjh.14610] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2016] [Accepted: 01/02/2017] [Indexed: 01/13/2023]
Abstract
Minimizing the risk of inhibitor development by acting on modifiable risk factors remains a sensible goal for treatment optimization in haemophilia A. By critically appraising published studies assessing inhibitor development, this review addresses the role of studies in previously untreated patients (PUPs) for establishing the immunogenicity of new concentrates, suggest novel research design to be adopted in future studies and discuss clinical practice implications of the reported differential immunogenicity of Kogenate Bayer and Advate factor VIII concentrates. Three considerations are relevant here: (i) all of the existing concentrates, when tested following the International Society on Thrombosis and Haemostasis Scientific and Standardization Committee recommendation, were shown to be safe; as a consequence, (ii) when considering using any newly introduced product, one should be aware that it could, in future, turn out to be as immunogenic as Kogenate Bayer, and (iii) at the population level, it might be wiser not to use Kogenate Bayer in PUPs, if the choice is against Advate. When presenting the risk of developing inhibitors to the individual patient (or their family), the message remains that the risk can be as high as 40%, without any efficient instrument to predict individual inhibitor risk. Patients should be invited to enrol into a randomized registry trial, including random assignment to trials with new investigational products.
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Affiliation(s)
- Alfonso Iorio
- Department of Clinical Epidemiology and Biostatistics and Department of Medicine, McMaster University, Hamilton, Canada
| | - Kathelijn Fischer
- Van Creveldkliniek, University Medical Centre Utrecht, Utrecht, the Netherlands
| | - Michael Makris
- Sheffield Haemophilia and Thrombosis Centre, Royal Hallamshire Hospital, Sheffield, UK.,Department of Infection, Immunity and Cardiovascular Disease, University of Sheffield, Sheffield, UK
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13
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Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, Jahan R, Tan JCK, Harvey SE, Bell D, Bion JF, Coats TJ, Singer M, Young JD, Rowan KM. Protocolised Management In Sepsis (ProMISe): a multicentre randomised controlled trial of the clinical effectiveness and cost-effectiveness of early, goal-directed, protocolised resuscitation for emerging septic shock. Health Technol Assess 2016; 19:i-xxv, 1-150. [PMID: 26597979 DOI: 10.3310/hta19970] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Early goal-directed therapy (EGDT) is recommended in international guidance for the resuscitation of patients presenting with early septic shock. However, adoption has been limited and uncertainty remains over its clinical effectiveness and cost-effectiveness. OBJECTIVES The primary objective was to estimate the effect of EGDT compared with usual resuscitation on mortality at 90 days following randomisation and on incremental cost-effectiveness at 1 year. The secondary objectives were to compare EGDT with usual resuscitation for requirement for, and duration of, critical care unit organ support; length of stay in the emergency department (ED), critical care unit and acute hospital; health-related quality of life, resource use and costs at 90 days and at 1 year; all-cause mortality at 28 days, at acute hospital discharge and at 1 year; and estimated lifetime incremental cost-effectiveness. DESIGN A pragmatic, open, multicentre, parallel-group randomised controlled trial with an integrated economic evaluation. SETTING Fifty-six NHS hospitals in England. PARTICIPANTS A total of 1260 patients who presented at EDs with septic shock. INTERVENTIONS EGDT (n = 630) or usual resuscitation (n = 630). Patients were randomly allocated 1 : 1. MAIN OUTCOME MEASURES All-cause mortality at 90 days after randomisation and incremental net benefit (at £20,000 per quality-adjusted life-year) at 1 year. RESULTS Following withdrawals, data on 1243 (EGDT, n = 623; usual resuscitation, n = 620) patients were included in the analysis. By 90 days, 184 (29.5%) in the EGDT and 181 (29.2%) patients in the usual-resuscitation group had died [p = 0.90; absolute risk reduction -0.3%, 95% confidence interval (CI) -5.4 to 4.7; relative risk 1.01, 95% CI 0.85 to 1.20]. Treatment intensity was greater for the EGDT group, indicated by the increased use of intravenous fluids, vasoactive drugs and red blood cell transfusions. Increased treatment intensity was reflected by significantly higher Sequential Organ Failure Assessment scores and more advanced cardiovascular support days in critical care for the EGDT group. At 1 year, the incremental net benefit for EGDT versus usual resuscitation was negative at -£725 (95% CI -£3000 to £1550). The probability that EGDT was more cost-effective than usual resuscitation was below 30%. There were no significant differences in any other secondary outcomes, including health-related quality of life, or adverse events. LIMITATIONS Recruitment was lower at weekends and out of hours. The intervention could not be blinded. CONCLUSIONS There was no significant difference in all-cause mortality at 90 days for EGDT compared with usual resuscitation among adults identified with early septic shock presenting to EDs in England. On average, costs were higher in the EGDT group than in the usual-resuscitation group while quality-adjusted life-years were similar in both groups; the probability that it is cost-effective is < 30%. FUTURE WORK The ProMISe (Protocolised Management In Sepsis) trial completes the planned trio of evaluations of EGDT across the USA, Australasia and England; all have indicated that EGDT is not superior to usual resuscitation. Recognising that each of the three individual, large trials has limited power for evaluating potentially important subgroups, the harmonised approach adopted provides the opportunity to conduct an individual patient data meta-analysis, enhancing both knowledge and generalisability. TRIAL REGISTRATION Current Controlled Trials ISRCTN36307479. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 97. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Tiffany M Osborn
- Departments of Surgery and Emergency Medicine, Washington University, St Louis, MO, USA
| | - G Sarah Power
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - David A Harrison
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - M Zia Sadique
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Richard D Grieve
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Rahi Jahan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Jermaine C K Tan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Sheila E Harvey
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
| | - Derek Bell
- Faculty of Medicine, Imperial College London, London, UK.,Department of Acute Medicine, Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Julian F Bion
- Department of Intensive Care Medicine, University of Birmingham, Birmingham, UK
| | - Timothy J Coats
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Mervyn Singer
- Bloomsbury Institute of Intensive Care Medicine, University College London, London, UK
| | - J Duncan Young
- Nuffield Division of Anaesthetics, University of Oxford, Oxford, UK
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit & Research Centre, London, UK
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Confronting the frustrations of negative clinical trials in acute respiratory distress syndrome. Ann Am Thorac Soc 2015; 12 Suppl 1:S58-63. [PMID: 25830838 DOI: 10.1513/annalsats.201409-414mg] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Despite robust successes in trials of mechanical ventilation, pharmacologic interventions in acute respiratory distress syndrome have been disappointing. Although ineffective therapy remains the compelling explanation for these negative trials, other possible explanations exist. These negative trials, better termed "statistically negative trials" or "indeterminate trials," cannot prove that a therapy is ineffective. It is important for clinicians and investigators to appreciate the alternative explanations for negative trials of potentially effective therapies because these indicate options for improving clinical trials in acute respiratory distress syndrome. These options can be organized into strategies that increase sample size, increase the signal from the therapy, and reduce the noise or variation in the study. Each of the strategies to improve the likelihood of a positive clinical trial poses a potential tradeoff in generalizability, cost, sample size, signal, or noise.
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Abstract
BACKGROUND Acute hypoxaemia de novo or on a background of chronic hypoxaemia is a common reason for admission to intensive care and for provision of mechanical ventilation. Various refinements of mechanical ventilation or adjuncts are employed to improve patient outcomes. Mortality from acute respiratory distress syndrome, one of the main contributors to the need for mechanical ventilation for hypoxaemia, remains approximately 40%. Ventilation in the prone position may improve lung mechanics and gas exchange and could improve outcomes. OBJECTIVES The objectives of this review are (1) to ascertain whether prone ventilation offers a mortality advantage when compared with traditional supine or semi recumbent ventilation in patients with severe acute respiratory failure requiring conventional invasive artificial ventilation, and (2) to supplement previous systematic reviews on prone ventilation for hypoxaemic respiratory failure in an adult population. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 1), Ovid MEDLINE (1950 to 31 January 2014), EMBASE (1980 to 31 January 2014), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to 31 January 2014) and Latin American Caribbean Health Sciences Literature (LILACS) (1992 to 31 January 2014) in Ovid MEDLINE for eligible randomized controlled trials. We also searched for studies by handsearching reference lists of relevant articles, by contacting colleagues and by handsearching published proceedings of relevant journals. We applied no language constraints, and we reran the searches in CENTRAL, MEDLINE, EMBASE, CINAHL and LILACS in June 2015. We added five new studies of potential interest to the list of "Studies awaiting classification" and will incorporate them into formal review findings during the review update. SELECTION CRITERIA We included randomized controlled trials (RCTs) that examined the effects of prone position versus supine/semi recumbent position during conventional mechanical ventilation in adult participants with acute hypoxaemia. DATA COLLECTION AND ANALYSIS Two review authors independently reviewed all trials identified by the search and assessed them for suitability, methods and quality. Two review authors extracted data, and three review authors reviewed the data extracted. We analysed data using Review Manager software and pooled included studies to determine the risk ratio (RR) for mortality and the risk ratio or mean difference (MD) for secondary outcomes; we also performed subgroup analyses and sensitivity analyses. MAIN RESULTS We identified nine relevant RCTs, which enrolled a total of 2165 participants (10 publications). All recruited participants suffered from disorders of lung function causing moderate to severe hypoxaemia and requiring mechanical ventilation, so they were fairly comparable, given the heterogeneity of specific disease diagnoses in intensive care. Risk of bias, although acceptable in the view of the review authors, was inevitable: Blinding of participants and carers to treatment allocation was not possible (face-up vs face-down).Primary analyses of short- and longer-term mortality pooled from six trials demonstrated an RR of 0.84 to 0.86 in favour of the prone position (PP), but findings were not statistically significant: In the short term, mortality for those ventilated prone was 33.4% (363/1086) and supine 38.3% (395/1031). This resulted in an RR of 0.84 (95% confidence interval (CI) 0.69 to 1.02) marginally in favour of PP. For longer-term mortality, results showed 41.7% (462/1107) for prone and 47.1% (490/1041) for supine positions, with an RR of 0.86 (95% CI 0.72 to 1.03). The quality of the evidence for both outcomes was rated as low as a result of important potential bias and serious inconsistency.Subgroup analyses for mortality identified three groups consistently favouring PP: those recruited within 48 hours of meeting entry criteria (five trials; 1024 participants showed an RR of 0.75 (95% CI 0.59 to 94)); those treated in the PP for 16 or more hours per day (five trials; 1005 participants showed an RR of 0.77 (95% CI 0.61 to 0.99)); and participants with more severe hypoxaemia at trial entry (six trials; 1108 participants showed an RR of 0.77 (95% CI 0.65 to 0.92)). The quality of the evidence for these outcomes was rated as moderate as a result of potentially important bias.Prone positioning appeared to influence adverse effects: Pressure sores (three trials; 366 participants) with an RR of 1.37 (95% CI 1.05 to 1.79) and tracheal tube obstruction with an RR of 1.78 (95% CI 1.22 to 2.60) were increased with prone ventilation. Reporting of arrhythmias was reduced with PP, with an RR of 0.64 (95% CI 0.47 to 0.87). AUTHORS' CONCLUSIONS We found no convincing evidence of benefit nor harm from universal application of PP in adults with hypoxaemia mechanically ventilated in intensive care units (ICUs). Three subgroups (early implementation of PP, prolonged adoption of PP and severe hypoxaemia at study entry) suggested that prone positioning may confer a statistically significant mortality advantage. Additional adequately powered studies would be required to confirm or refute these possibilities of subgroup benefit but are unlikely, given results of the most recent study and recommendations derived from several published subgroup analyses. Meta-analysis of individual patient data could be useful for further data exploration in this regard. Complications such as tracheal obstruction are increased with use of prone ventilation. Long-term mortality data (12 months and beyond), as well as functional, neuro-psychological and quality of life data, are required if future studies are to better inform the role of PP in the management of hypoxaemic respiratory failure in the ICU.
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Affiliation(s)
- Roxanna Bloomfield
- Intensive Care Unit and Department of Anaesthesia, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, Scotland, UK, AB25 2ZN
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Prolonged glucocorticoid treatment is associated with improved ARDS outcomes: analysis of individual patients’ data from four randomized trials and trial-level meta-analysis of the updated literature. Intensive Care Med 2015; 42:829-840. [DOI: 10.1007/s00134-015-4095-4] [Citation(s) in RCA: 171] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2015] [Accepted: 10/08/2015] [Indexed: 12/13/2022]
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Mouncey PR, Osborn TM, Power GS, Harrison DA, Sadique MZ, Grieve RD, Jahan R, Harvey SE, Bell D, Bion JF, Coats TJ, Singer M, Young JD, Rowan KM. Trial of early, goal-directed resuscitation for septic shock. N Engl J Med 2015; 372:1301-11. [PMID: 25776532 DOI: 10.1056/nejmoa1500896] [Citation(s) in RCA: 1029] [Impact Index Per Article: 114.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Early, goal-directed therapy (EGDT) is recommended in international guidelines for the resuscitation of patients presenting with early septic shock. However, adoption has been limited, and uncertainty about its effectiveness remains. METHODS We conducted a pragmatic randomized trial with an integrated cost-effectiveness analysis in 56 hospitals in England. Patients were randomly assigned to receive either EGDT (a 6-hour resuscitation protocol) or usual care. The primary clinical outcome was all-cause mortality at 90 days. RESULTS We enrolled 1260 patients, with 630 assigned to EGDT and 630 to usual care. By 90 days, 184 of 623 patients (29.5%) in the EGDT group and 181 of 620 patients (29.2%) in the usual-care group had died (relative risk in the EGDT group, 1.01; 95% confidence interval [CI], 0.85 to 1.20; P=0.90), for an absolute risk reduction in the EGDT group of -0.3 percentage points (95% CI, -5.4 to 4.7). Increased treatment intensity in the EGDT group was indicated by increased use of intravenous fluids, vasoactive drugs, and red-cell transfusions and reflected by significantly worse organ-failure scores, more days receiving advanced cardiovascular support, and longer stays in the intensive care unit. There were no significant differences in any other secondary outcomes, including health-related quality of life, or in rates of serious adverse events. On average, EGDT increased costs, and the probability that it was cost-effective was below 20%. CONCLUSIONS In patients with septic shock who were identified early and received intravenous antibiotics and adequate fluid resuscitation, hemodynamic management according to a strict EGDT protocol did not lead to an improvement in outcome. (Funded by the United Kingdom National Institute for Health Research Health Technology Assessment Programme; ProMISe Current Controlled Trials number, ISRCTN36307479.).
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Affiliation(s)
- Paul R Mouncey
- From the Clinical Trials Unit, Intensive Care National Audit and Research Centre (P.R.M., G.S.P., D.A.H., R.J., S.E.H., K.M.R.), Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine (M.Z.S., R.D.G.), and Faculty of Medicine, Imperial College London (D.B.), Department of Acute Medicine, Chelsea and Westminster Hospital NHS Foundation Trust (D.B.), and Bloomsbury Institute of Intensive Care Medicine, University College London (M.S.), London, the Department of Intensive Care Medicine, University of Birmingham, Birmingham (J.F.B.), Department of Cardiovascular Sciences, University of Leicester, Leicester (T.J.C.), and Nuffield Division of Anaesthetics, University of Oxford, Oxford (J.D.Y.) - all in the United Kingdom; and the Departments of Surgery and Emergency Medicine, Washington University at St. Louis, St. Louis (T.M.O.)
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19
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Abstract
Abstract
Background:
The effect of urinary alkalinization in cardiac surgery patients at risk of acute kidney injury (AKI) is controversial and trial findings conflicting. Accordingly, the authors performed a prospectively planned individual patient data meta-analysis of the double-blind randomized trials in this field.
Methods:
The authors studied 877 patients from three double-blind, randomized controlled trials enrolled to receive either 24 h of intravenous infusion of sodium bicarbonate or sodium chloride. The primary outcome measure was a postoperative increase in serum creatinine concentration of greater than 25% or 0.5 mg/dl (> 44 μm/L) within the first five postoperative days. Secondary outcomes included the raw change in serum creatinine, greater than 50% and greater than 100% rises in serum creatinine, developing AKI (Acute Kidney Injury Network criteria), initiation of renal replacement therapy, morbidity, and mortality.
Results:
Patients were similar in demographics, comorbidities, and cardiac procedures. Sodium bicarbonate increased plasma bicarbonate (P < 0.001) and urine pH (P < 0.001). There were no differences in the development of the primary outcome (Bicarbonate 45% [39–51%] vs. Saline 42% [36–48%], P = 0.29). This result remained unchanged when controlling for study and covariates (odds ratio [OR], 99% confidence interval [CI]: Bicarbonate vs. Control, 1.11 [0.77–1.60], P = 0.45). There was, however, a significant study-adjusted benefit in elective coronary artery bypass surgery patients in terms of renal replacement therapy (Bicarbonate vs. Control, OR: 0.38 [99% CI: 0.25–0.58], P < 0.0001) and the development of an Acute Kidney Injury Network grade = 3 (Bicarbonate vs. Control, OR: 0.45 [99% CI: 0.43–0.48], P < 0.0001).
Conclusions:
Urinary alkalinization using sodium bicarbonate infusion is not associated with an overall lower incidence of AKI; however, it reduces severe AKI and need for renal replacement therapy in elective coronary artery bypass patients.
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Abbenbroek B, Duffield CM, Elliott D. The intensive care unit volume–mortality relationship, is bigger better? An integrative literature review. Aust Crit Care 2014; 27:157-64; quiz 165. [DOI: 10.1016/j.aucc.2014.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 01/27/2014] [Accepted: 02/11/2014] [Indexed: 10/25/2022] Open
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Yealy DM, Kellum JA, Huang DT, Barnato AE, Weissfeld LA, Pike F, Terndrup T, Wang HE, Hou PC, LoVecchio F, Filbin MR, Shapiro NI, Angus DC. A randomized trial of protocol-based care for early septic shock. N Engl J Med 2014; 370:1683-93. [PMID: 24635773 PMCID: PMC4101700 DOI: 10.1056/nejmoa1401602] [Citation(s) in RCA: 1621] [Impact Index Per Article: 162.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND In a single-center study published more than a decade ago involving patients presenting to the emergency department with severe sepsis and septic shock, mortality was markedly lower among those who were treated according to a 6-hour protocol of early goal-directed therapy (EGDT), in which intravenous fluids, vasopressors, inotropes, and blood transfusions were adjusted to reach central hemodynamic targets, than among those receiving usual care. We conducted a trial to determine whether these findings were generalizable and whether all aspects of the protocol were necessary. METHODS In 31 emergency departments in the United States, we randomly assigned patients with septic shock to one of three groups for 6 hours of resuscitation: protocol-based EGDT; protocol-based standard therapy that did not require the placement of a central venous catheter, administration of inotropes, or blood transfusions; or usual care. The primary end point was 60-day in-hospital mortality. We tested sequentially whether protocol-based care (EGDT and standard-therapy groups combined) was superior to usual care and whether protocol-based EGDT was superior to protocol-based standard therapy. Secondary outcomes included longer-term mortality and the need for organ support. RESULTS We enrolled 1341 patients, of whom 439 were randomly assigned to protocol-based EGDT, 446 to protocol-based standard therapy, and 456 to usual care. Resuscitation strategies differed significantly with respect to the monitoring of central venous pressure and oxygen and the use of intravenous fluids, vasopressors, inotropes, and blood transfusions. By 60 days, there were 92 deaths in the protocol-based EGDT group (21.0%), 81 in the protocol-based standard-therapy group (18.2%), and 86 in the usual-care group (18.9%) (relative risk with protocol-based therapy vs. usual care, 1.04; 95% confidence interval [CI], 0.82 to 1.31; P=0.83; relative risk with protocol-based EGDT vs. protocol-based standard therapy, 1.15; 95% CI, 0.88 to 1.51; P=0.31). There were no significant differences in 90-day mortality, 1-year mortality, or the need for organ support. CONCLUSIONS In a multicenter trial conducted in the tertiary care setting, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes. (Funded by the National Institute of General Medical Sciences; ProCESS ClinicalTrials.gov number, NCT00510835.).
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22
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Huang DT, Angus DC, Barnato A, Gunn SR, Kellum JA, Stapleton DK, Weissfeld LA, Yealy DM, Peake SL, Delaney A, Bellomo R, Cameron P, Higgins A, Holdgate A, Howe B, Webb SA, Williams P, Osborn TM, Mouncey PR, Harrison DA, Harvey SE, Rowan KM. Harmonizing international trials of early goal-directed resuscitation for severe sepsis and septic shock: methodology of ProCESS, ARISE, and ProMISe. Intensive Care Med 2013; 39:1760-75. [PMID: 23958738 PMCID: PMC3864363 DOI: 10.1007/s00134-013-3024-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Accepted: 07/09/2013] [Indexed: 01/20/2023]
Abstract
PURPOSE To describe and compare the design of three independent but collaborating multicenter trials of early goal-directed resuscitation for severe sepsis and septic shock. METHODS We reviewed the three current trials, one each in the USA (ProCESS: protocolized care for early septic shock), Australasia (ARISE: Australasian resuscitation in sepsis evaluation), and the UK (ProMISe: protocolised management in sepsis). We used the 2010 CONSORT (consolidated standards of reporting trials) statement and the 2008 CONSORT extension for trials assessing non-pharmacologic treatments to describe and compare the underlying rationale, commonalities, and differences. RESULTS All three trials conform to CONSORT guidelines, address the same fundamental questions, and share key design elements. Each trial is a patient-level, equal-randomized, parallel-group superiority trial that seeks to enroll emergency department patients with inclusion criteria that are consistent with the original early goal-directed therapy (EGDT) trial (suspected or confirmed infection, two or more systemic inflammatory response syndrome criteria, and refractory hypotension or elevated lactate), is powered to detect a 6–8 % absolute mortality reduction (hospital or 90-day), and uses trained teams to deliver EGDT. Design differences appear to primarily be driven by between-country variation in health care context. The main difference between the trials is the inclusion of a third, alternative resuscitation strategy arm in ProCESS. CONCLUSIONS Harmonization of study design and methods between severe sepsis trials is feasible and may facilitate pooling of data on completion of the trials.
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Lei J, Gao G, Jiang J. Acute traumatic brain injury: is current management evidence based? An empirical analysis of systematic reviews. J Neurotrauma 2013; 30:529-37. [PMID: 23151044 DOI: 10.1089/neu.2012.2548] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Traumatic brain injury (TBI) is a major health and socioeconomic problem worldwide with a high rate of death and long-term disability. Previous studies have summarized evidence from large-scale randomized trials, finding no intervention showing convincing efficacy for acute TBI management. The present empirical study set out to assess another crucial component of evidence base-systematic review, which contributes a lot to evidence-based health care, in terms of clinical issues, methodological aspects, and implication for practice and research. A total of 44 systematic reviews pertaining to therapeutic interventions for acute TBI were identified through electronic database searching, clinical guideline retrieval, and expert consultation, of which 21 were published in Cochrane Library and 23 in peer-reviewed journals. Their methodological quality was generally satisfactory, with the median Overview Quality Assessment Questionnaire score of 5.5 (interquartile range 2-7). Cochrane reviews are of better quality than regular journal reviews. Twenty-nine high-quality reviews provided no conclusive evidence for the investigated 22 interventions except for an adverse effect of corticosteroids. Less than one-third of the component trials were reported with adequate allocation concealment. Additionally other methodological flaws in design-for example, ignoring heterogeneity among the TBI population-also contributed to the failure of past clinical research. Based on the above findings, evidence from both systematic reviews and clinical trials does not fully support current management of acute TBI. Translating from laboratory success to clinical effect remains an unique challenge. Accordingly it may be the time to rethink the way in future practice and clinical research in TBI.
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Affiliation(s)
- Jin Lei
- Department of Neurosurgery, Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
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Schneider AG, Lipcsey M, Bailey M, Pilcher DV, Bellomo R. Simple translational equations to compare illness severity scores in intensive care trials. J Crit Care 2013; 28:885.e1-8. [PMID: 23566728 DOI: 10.1016/j.jcrc.2013.02.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 01/20/2013] [Accepted: 02/04/2013] [Indexed: 12/22/2022]
Abstract
PURPOSE Comparison of illness severity for intensive care unit populations assessed according to different scoring systems should increase our ability to compare and meta-analyze past and future trials but is currently not possible. Accordingly, we aimed to establish a methodology to translate illness severity scores obtained from one system into another. MATERIALS AND METHODS Using the Australian and New-Zealand intensive care adult patient database, we obtained simultaneous admission Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores and Simplified Acute Physiology Score (SAPS) II in 634428 patients admitted to 153 units between 2001 and 2010. We applied linear regression analyses to create models enabling translation of one score into another. Sensitivity analyses were performed after removal of diagnostic categories excluded from the original APACHE database, after matching for similar risk of death, after splitting data according to country of origin (Australia or New Zealand) and after splitting admissions occurring before or after 2006. RESULTS The translational models were APACHE III=3.08×APACHE II+5.75; APACHE III=1.47×SAPS II+8.6; and APACHE II=0.36×SAPS II+4.4. The area under the receiver operating curve for mortality prediction was 0.853 (95% confidence interval, 0.851-0.855) for the "APACHE II derived APACHE III" score and 0.854 (0.852-0.855) for the "SAPS II derived APACHE III" vs 0.854 (0.852-0.855) for the original APACHE III score. Similarly, it was 0.841 (0.839-0.843) for the "SAPS II derived APACHE II score" vs 0.842 (0.840-0.843) for the original APACHE II score. Correlation coefficients as well as intercepts remained very similar in all subgroups analyses. CONCLUSIONS Simple and robust translational formulas can be developed to allow clinicians to compare illness severity between studies involving critically ill patients. Further studies in other countries and health care systems are needed to confirm the generalizability of these results.
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Affiliation(s)
- Antoine G Schneider
- Department of Intensive Care, Austin Health, Intensive Care Unit, Heidelberg, Australia; Department of Epidemiology and Preventive Medicine, The Alfred Center, Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
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25
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Affiliation(s)
- Roger F Soll
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Fletcher Allen Health Care, University of Vermont, College of Medicine, Burlington, Vermont 05401, USA.
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Turok DK, Espey E, Edelman AB, Lotke PS, Lathrop EH, Teal SB, Jacobson JC, Simonsen SE, Schulz KF. The methodology for developing a prospective meta-analysis in the family planning community. Trials 2011; 12:104. [PMID: 21527040 PMCID: PMC3103448 DOI: 10.1186/1745-6215-12-104] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 04/29/2011] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Prospective meta-analysis (PMA) is a collaborative research design in which individual sites perform randomized controlled trials (RCTs) and pool the data for meta-analysis. Members of the PMA collaboration agree upon specific research interventions and outcome measures, ideally before initiation but at least prior to any individual trial publishing results. This allows for uniform reporting of primary and secondary outcomes. With this approach, heterogeneity among trials contributing data for the final meta-analysis is minimized while each site maintains the freedom to design a specific trial. This paper describes the process of creating a PMA collaboration to evaluate the impact of misoprostol on ease of intrauterine device (IUD) insertion in nulliparous women. METHODS After the principal investigator developed a preliminary PMA protocol, he identified potential collaborating investigators at other sites. One site already had a trial underway and another site was in the planning stages of a trial meeting PMA requirements. Investigators at six sites joined the PMA collaborative. Each site committed to enroll subjects to meet a pre-determined total sample size. A final common research plan and site responsibilities were developed and agreed upon through email and face-to-face meetings. Each site committed to contribute individual patient data to the PMA collaboration, and these data will be analyzed and prepared as a multi-site publication. Individual sites retain the ability to analyze and publish their site's independent findings. RESULTS All six sites have obtained Institutional Review Board approval and each has obtained individual funding to meet the needs of that site's study. Sites have shared resources including study protocols and consents to decrease costs and improve study flow. This PMA protocol is registered with the Cochrane Collaboration and data will be analyzed according to Cochrane standards for meta-analysis. CONCLUSIONS PMA is a novel research method that improves meta-analysis by including several study sites, establishing uniform reporting of specific outcomes, and yet allowing some independence on the part of individual sites with respect to the conduct of research. The inclusion of several sites increases statistical power to address important clinical questions. Compared to multi-center trials, PMA methodology encourages collaboration, aids in the development of new investigators, decreases study costs, and decreases time to publication. TRIAL REGISTRATION ClinicalTrials.gov: NCT00613366, NCT00886834, NCT01001897, NCT01147497 and NCT01307111.
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Affiliation(s)
- David K Turok
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eve Espey
- Department of Obstetrics and Gynecology, University of New Mexico, Albuquerque, New Mexico, USA
| | - Alison B Edelman
- Department of Obstetrics and Gynecology, Oregon Health & Science University, Portland, Oregon, USA
| | - Pamela S Lotke
- Department of Obstetrics and Gynecology, University of Arizona, Tucson, Arizona, USA
| | - Eva H Lathrop
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Stephanie B Teal
- Department of Obstetrics and Gynecology, University of Colorado, Denver, Colorado, USA
| | - Janet C Jacobson
- Department of Obstetrics and Gynecology, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Sara E Simonsen
- Department of Family and Preventive Medicine, Division of Public Health, University of Utah, Salt Lake City, Utah, USA
| | - Kenneth F Schulz
- Quantitative Sciences, Family Health International, Research Triangle Park, North Carolina, USA
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Year in review in Intensive Care Medicine 2010: II. Pneumonia and infections, cardiovascular and haemodynamics, organization, education, haematology, nutrition, ethics and miscellanea. Intensive Care Med 2011; 37:196-213. [PMID: 21225240 PMCID: PMC3029678 DOI: 10.1007/s00134-010-2123-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2010] [Accepted: 12/27/2010] [Indexed: 12/14/2022]
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An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2011; 15:R6. [PMID: 21211010 PMCID: PMC3222033 DOI: 10.1186/cc9403] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2010] [Revised: 07/08/2010] [Accepted: 01/06/2011] [Indexed: 12/25/2022]
Abstract
INTRODUCTION In patients with acute lung injury (ALI) and/or acute respiratory distress syndrome (ARDS), recent randomised controlled trials (RCTs) showed a consistent trend of mortality reduction with prone ventilation. We updated a meta-analysis on this topic. METHODS RCTs that compared ventilation of adult patients with ALI/ARDS in prone versus supine position were included in this study-level meta-analysis. Analysis was made by a random-effects model. The effect size on intensive care unit (ICU) mortality was computed in the overall included studies and in two subgroups of studies: those that included all ALI or hypoxemic patients, and those that restricted inclusion to only ARDS patients. A relationship between studies' effect size and daily prone duration was sought with meta-regression. We also computed the effects of prone positioning on major adverse airway complications. RESULTS Seven RCTs (including 1,675 adult patients, of whom 862 were ventilated in the prone position) were included. The four most recent trials included only ARDS patients, and also applied the longest proning durations and used lung-protective ventilation. The effects of prone positioning differed according to the type of study. Overall, prone ventilation did not reduce ICU mortality (odds ratio = 0.91, 95% confidence interval = 0.75 to 1.2; P = 0.39), but it significantly reduced the ICU mortality in the four recent studies that enrolled only patients with ARDS (odds ratio = 0.71; 95% confidence interval = 0.5 to 0.99; P = 0.048; number needed to treat = 11). Meta-regression on all studies disclosed only a trend to explain effect variation by prone duration (P = 0.06). Prone positioning was not associated with a statistical increase in major airway complications. CONCLUSIONS Long duration of ventilation in prone position significantly reduces ICU mortality when only ARDS patients are considered.
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Procalcitonin-guided algorithms of antibiotic therapy in the intensive care unit: A systematic review and meta-analysis of randomized controlled trials. Crit Care Med 2010; 38:2229-41. [PMID: 20729729 DOI: 10.1097/ccm.0b013e3181f17bf9] [Citation(s) in RCA: 176] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Prowle JR, Bellomo R. Continuous renal replacement therapy: recent advances and future research. Nat Rev Nephrol 2010; 6:521-9. [DOI: 10.1038/nrneph.2010.100] [Citation(s) in RCA: 92] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Affiliation(s)
- Richard B Parad
- Department of Newborn Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA 02115, USA.
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Hurley JC. Individual patient data meta-analysis in intensive care medicine and contextual effects. Intensive Care Med 2010; 36:903-4; author reply 905. [PMID: 20232051 DOI: 10.1007/s00134-010-1812-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/04/2009] [Indexed: 11/29/2022]
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Wanted: early goal-directed therapy for septic shock--dead or alive, but not critically ill! Intensive Care Med 2009; 36:1-3. [PMID: 19760393 DOI: 10.1007/s00134-009-1655-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2009] [Accepted: 08/05/2009] [Indexed: 01/20/2023]
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