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Klitgaard TL, Schjørring OL, Nielsen FM, Meyhoff CS, Perner A, Wetterslev J, Rasmussen BS, Barbateskovic M. Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2023; 9:CD012631. [PMID: 37700687 PMCID: PMC10498149 DOI: 10.1002/14651858.cd012631.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Abstract
BACKGROUND This is an updated review concerning 'Higher versus lower fractions of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit'. Supplementary oxygen is provided to most patients in intensive care units (ICUs) to prevent global and organ hypoxia (inadequate oxygen levels). Oxygen has been administered liberally, resulting in high proportions of patients with hyperoxemia (exposure of tissues to abnormally high concentrations of oxygen). This has been associated with increased mortality and morbidity in some settings, but not in others. Thus far, only limited data have been available to inform clinical practice guidelines, and the optimum oxygenation target for ICU patients is uncertain. Because of the publication of new trial evidence, we have updated this review. OBJECTIVES To update the assessment of benefits and harms of higher versus lower fractions of inspired oxygen (FiO2) or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, and LILACS. We searched for ongoing or unpublished trials in clinical trial registers and scanned the reference lists and citations of included trials. Literature searches for this updated review were conducted in November 2022. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared higher versus lower FiO2 or targets of arterial oxygenation (partial pressure of oxygen (PaO2), peripheral or arterial oxygen saturation (SpO2 or SaO2)) for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We excluded trials randomising participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, or PaO2 below 6 kPa) or to hyperbaric oxygen, and cross-over trials and quasi-randomised trials. DATA COLLECTION AND ANALYSIS Four review authors independently, and in pairs, screened the references identified in the literature searches and extracted the data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events (SAEs), and quality of life. We analysed all outcomes at maximum follow-up. Only three trials reported the proportion of participants with one or more SAEs as a composite outcome. However, most trials reported on events categorised as SAEs according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single SAE with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with an SAE in each trial. Two trials reported on quality of life. Secondary outcomes were lung injury, myocardial infarction, stroke, and sepsis. No trial reported on lung injury as a composite outcome, but four trials reported on the occurrence of acute respiratory distress syndrome (ARDS) and five on pneumonia. We, therefore, conducted two analyses of the effect of higher versus lower oxygenation strategies using 1) the single lung injury event with the highest reported proportion in each trial, and 2) the cumulated proportion of participants with ARDS or pneumonia in each trial. We assessed the risk of systematic errors by evaluating the risk of bias in the included trials using the Risk of Bias 2 tool. We used the GRADEpro tool to assess the overall certainty of the evidence. We also evaluated the risk of publication bias for outcomes reported by 10b or more trials. MAIN RESULTS We included 19 RCTs (10,385 participants), of which 17 reported relevant outcomes for this review (10,248 participants). For all-cause mortality, 10 trials were judged to be at overall low risk of bias, and six at overall high risk of bias. For the reported SAEs, 10 trials were judged to be at overall low risk of bias, and seven at overall high risk of bias. Two trials reported on quality of life, of which one was judged to be at overall low risk of bias and one at high risk of bias for this outcome. Meta-analysis of all trials, regardless of risk of bias, indicated no significant difference from higher or lower oxygenation strategies at maximum follow-up with regard to mortality (risk ratio (RR) 1.01, 95% confidence interval (C)I 0.96 to 1.06; I2 = 14%; 16 trials; 9408 participants; very low-certainty evidence); occurrence of SAEs: the highest proportion of any specific SAE in each trial RR 1.01 (95% CI 0.96 to 1.06; I2 = 36%; 9466 participants; 17 trials; very low-certainty evidence), or quality of life (mean difference (MD) 0.5 points in participants assigned to higher oxygenation strategies (95% CI -2.75 to 1.75; I2 = 34%, 1649 participants; 2 trials; very low-certainty evidence)). Meta-analysis of the cumulated number of SAEs suggested benefit of a lower oxygenation strategy (RR 1.04 (95% CI 1.02 to 1.07; I2 = 74%; 9489 participants; 17 trials; very low certainty evidence)). However, trial sequential analyses, with correction for sparse data and repetitive testing, could reject a relative risk increase or reduction of 10% for mortality and the highest proportion of SAEs, and 20% for both the cumulated number of SAEs and quality of life. Given the very low-certainty of evidence, it is necessary to interpret these findings with caution. Meta-analysis of all trials indicated no statistically significant evidence of a difference between higher or lower oxygenation strategies on the occurrence of lung injuries at maximum follow-up (the highest reported proportion of lung injury RR 1.08, 95% CI 0.85 to 1.38; I2 = 0%; 2048 participants; 8 trials; very low-certainty evidence). Meta-analysis of all trials indicated harm from higher oxygenation strategies as compared with lower on the occurrence of sepsis at maximum follow-up (RR 1.85, 95% CI 1.17 to 2.93; I2 = 0%; 752 participants; 3 trials; very low-certainty evidence). Meta-analysis indicated no differences regarding the occurrences of myocardial infarction or stroke. AUTHORS' CONCLUSIONS In adult ICU patients, it is still not possible to draw clear conclusions about the effects of higher versus lower oxygenation strategies on all-cause mortality, SAEs, quality of life, lung injuries, myocardial infarction, stroke, and sepsis at maximum follow-up. This is due to low or very low-certainty evidence.
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Affiliation(s)
- Thomas L Klitgaard
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Olav L Schjørring
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Frederik M Nielsen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian S Meyhoff
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Private Office, Hellerup, Denmark
| | - Bodil S Rasmussen
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Barbateskovic M, Schjørring OL, Russo Krauss S, Jakobsen JC, Meyhoff CS, Dahl RM, Rasmussen BS, Perner A, Wetterslev J. Higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the intensive care unit. Cochrane Database Syst Rev 2019; 2019. [PMID: 31773728 PMCID: PMC6880382 DOI: 10.1002/14651858.cd012631.pub2] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND The mainstay treatment for hypoxaemia is oxygen therapy, which is given to the vast majority of adults admitted to the intensive care unit (ICU). The practice of oxygen administration has been liberal, which may result in hyperoxaemia. Some studies have indicated an association between hyperoxaemia and mortality, whilst other studies have not. The ideal target for supplemental oxygen for adults admitted to the ICU is uncertain. Despite a lack of robust evidence of effectiveness, oxygen administration is widely recommended in international clinical practice guidelines. The potential benefit of supplemental oxygen must be weighed against the potentially harmful effects of hyperoxaemia. OBJECTIVES To assess the benefits and harms of higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU. SEARCH METHODS We identified trials through electronic searches of CENTRAL, MEDLINE, Embase, Science Citation Index Expanded, BIOSIS Previews, CINAHL, and LILACS. We searched for ongoing or unpublished trials in clinical trials registers. We also scanned the reference lists of included studies. We ran the searches in December 2018. SELECTION CRITERIA We included randomized controlled trials (RCTs) that compared higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU. We included trials irrespective of publication type, publication status, and language. We included trials with a difference between the intervention and control groups of a minimum 1 kPa in partial pressure of arterial oxygen (PaO2), minimum 10% in fraction of inspired oxygen (FiO2), or minimum 2% in arterial oxygen saturation of haemoglobin/non-invasive peripheral oxygen saturation (SaO2/SpO2). We excluded trials randomizing participants to hypoxaemia (FiO2 below 0.21, SaO2/SpO2 below 80%, and PaO2 below 6 kPa) and to hyperbaric oxygen. DATA COLLECTION AND ANALYSIS Three review authors independently, and in pairs, screened the references retrieved in the literature searches and extracted data. Our primary outcomes were all-cause mortality, the proportion of participants with one or more serious adverse events, and quality of life. None of the trials reported the proportion of participants with one or more serious adverse events according to the International Conference on Harmonisation Good Clinical Practice (ICH-GCP) criteria. Nonetheless, most trials reported several serious adverse events. We therefore included an analysis of the effect of higher versus lower fraction of inspired oxygen, or targets using the highest reported proportion of participants with a serious adverse event in each trial. Our secondary outcomes were lung injury, acute myocardial infarction, stroke, and sepsis. None of the trials reported on lung injury as a composite outcome, however some trials reported on acute respiratory distress syndrome (ARDS) and pneumonia. We included an analysis of the effect of higher versus lower fraction of inspired oxygen or targets using the highest reported proportion of participants with ARDS or pneumonia in each trial. To assess the risk of systematic errors, we evaluated the risk of bias of the included trials. We used GRADE to assess the overall certainty of the evidence. MAIN RESULTS We included 10 RCTs (1458 participants), seven of which reported relevant outcomes for this review (1285 participants). All included trials had an overall high risk of bias, whilst two trials had a low risk of bias for all domains except blinding of participants and personnel. Meta-analysis indicated harm from higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation regarding mortality at the time point closest to three months (risk ratio (RR) 1.18, 95% confidence interval (CI) 1.01 to 1.37; I2 = 0%; 4 trials; 1135 participants; very low-certainty evidence). Meta-analysis indicated harm from higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation regarding serious adverse events at the time point closest to three months (estimated highest proportion of specific serious adverse events in each trial RR 1.13, 95% CI 1.04 to 1.23; I2 = 0%; 1234 participants; 6 trials; very low-certainty evidence). These findings should be interpreted with caution given that they are based on very low-certainty evidence. None of the included trials reported any data on quality of life at any time point. Meta-analysis indicated no evidence of a difference between higher fraction of inspired oxygen or targets as compared with lower fraction or targets of arterial oxygenation on lung injury at the time point closest to three months (estimated highest reported proportion of lung injury RR 1.03, 95% CI 0.78 to 1.36; I2 = 0%; 1167 participants; 5 trials; very low-certainty evidence). None of the included trials reported any data on acute myocardial infarction or stroke, and only one trial reported data on the effects on sepsis. AUTHORS' CONCLUSIONS We are very uncertain about the effects of higher versus lower fraction of inspired oxygen or targets of arterial oxygenation for adults admitted to the ICU on all-cause mortality, serious adverse events, and lung injuries at the time point closest to three months due to very low-certainty evidence. Our results indicate that oxygen supplementation with higher versus lower fractions or oxygenation targets may increase mortality. None of the trials reported the proportion of participants with one or more serious adverse events according to the ICH-GCP criteria, however we found that the trials reported an increase in the number of serious adverse events with higher fractions or oxygenation targets. The effects on quality of life, acute myocardial infarction, stroke, and sepsis are unknown due to insufficient data.
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Affiliation(s)
- Marija Barbateskovic
- Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital, Centre for Research in Intensive Care, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
| | - Olav L Schjørring
- Department 7831, Rigshospitalet, Copenhagen University Hospital, Centre for Research in Intensive Care, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
- Aalborg University Hospital, Department of Anaesthesia and Intensive Care Medicine, Hobrovej 18-22, Aalborg, Denmark, 9000
| | - Sara Russo Krauss
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, 2100, Denmark, Ø
| | - Janus C Jakobsen
- Department 7831, Rigshospitalet, Copenhagen University Hospital, Centre for Research in Intensive Care, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital, Cochrane Hepato-Biliary Group, Blegdamsvej 9, Copenhagen, Sjælland, Denmark, DK-2100
- Holbaek Hospital, Department of Cardiology, Holbaek, Denmark, 4300
| | - Christian S Meyhoff
- Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Department of Anaesthesia and Intensive Care, Bispebjerg Bakke 23, Copenhagen, Denmark, DK-2400
| | - Rikke M Dahl
- Herlev Hospital, University of Copenhagen, Department of Anaesthesiology, Herlev Ringvej 75, Pavillon 10, I65F10, Herlev, Denmark, 2730
| | - Bodil S Rasmussen
- Department 7831, Rigshospitalet, Copenhagen University Hospital, Centre for Research in Intensive Care, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
- Aalborg University Hospital, Department of Anaesthesia and Intensive Care Medicine, Hobrovej 18-22, Aalborg, Denmark, 9000
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital, Centre for Research in Intensive Care, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University Hospital, Copenhagen Trial Unit, Centre for Clinical Intervention Research, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital, Centre for Research in Intensive Care, Blegdamsvej 9, Copenhagen, Denmark, DK-2100
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Barbateskovic M, Schjørring OL, Jakobsen JC, Meyhoff CS, Rasmussen BS, Perner A, Wetterslev J. Oxygen supplementation for critically ill patients-A protocol for a systematic review. Acta Anaesthesiol Scand 2018; 62:1020-1030. [PMID: 29708586 DOI: 10.1111/aas.13127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/13/2018] [Accepted: 03/14/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND In critically ill patients, hypoxaemia is a common clinical manifestation of inadequate gas exchange in the lungs. Supplemental oxygen is therefore given to all critically ill patients. This can result in hyperoxaemia, and some observational studies have identified harms with hyperoxia. The objective of this systematic review is to critically assess the evidence of randomised clinical trials on the effects of higher versus lower inspiratory oxygen fractions or targets of arterial oxygenation in critically ill adult patients. METHODS We will search for randomised clinical trials in major international databases. Two authors will independently screen and select references for inclusion using Covidence, extract data and assess the methodological quality of the included randomised clinical trials using the Cochrane risk of bias tool. Any disagreement will be resolved by consensus. We will analyse the extracted data using Review Manager and Trial Sequential Analysis. To assess the quality of the evidence, we will create a 'Summary of Findings' table containing our primary and secondary outcomes using the GRADE assessment. DISCUSSION Supplemental oxygen administration is widely recommended in international guidelines despite lack of robust evidence of its effectiveness. To our knowledge, no systematic review of randomised clinical trials has investigated the effects of oxygen supplementation in critically ill patients. This systematic review will provide reliable evidence to better inform future trialists and decision-makers on clinical practice on supplemental oxygen administration in critically ill patients.
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Affiliation(s)
- M. Barbateskovic
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
| | - O. L. Schjørring
- Centre for Research in Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Medicine; Aalborg University Hospital; Aalborg Denmark
| | - J. C. Jakobsen
- Centre for Research in Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
- The Cochrane Hepato-Biliary Group; Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Copenhagen Denmark
- Department of Cardiology; Holbaek Hospital; Holbaek Denmark
| | - C. S. Meyhoff
- Department of Anaesthesia and Intensive Care; Bispebjerg and Frederiksberg Hospital; Copenhagen University Hospital; Copenhagen Denmark
| | - B. S. Rasmussen
- Centre for Research in Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
- Department of Anaesthesia and Intensive Care Medicine; Aalborg University Hospital; Aalborg Denmark
| | - A. Perner
- Centre for Research in Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
- Department of Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
| | - J. Wetterslev
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Copenhagen Denmark
- Centre for Research in Intensive Care; Copenhagen University Hospital; Copenhagen Denmark
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Hansen BA, Bruserud Ø. Hypomagnesemia in critically ill patients. J Intensive Care 2018; 6:21. [PMID: 29610664 PMCID: PMC5872533 DOI: 10.1186/s40560-018-0291-y] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Magnesium (Mg) is essential for life and plays a crucial role in several biochemical and physiological processes in the human body. Hypomagnesemia is common in all hospitalized patients, especially in critically ill patients with coexisting electrolyte abnormalities. Hypomagnesemia may cause severe and potential fatal complications if not timely diagnosed and properly treated, and associate with increased mortality. MAIN BODY Mg deficiency in critically ill patients is mainly caused by gastrointestinal and/or renal disorders and may lead to secondary hypokalemia and hypocalcemia, and severe neuromuscular and cardiovascular clinical manifestations. Because of the physical distribution of Mg, there are no readily or easy methods to assess Mg status. However, serum Mg and the Mg tolerance test are most widely used. There are limited studies to guide intermittent therapy of Mg deficiency in critically ill patients, but some empirical guidelines exist. Further clinical trials and critical evaluation of empiric Mg replacement strategies is needed. CONCLUSION Patients at risk of Mg deficiency, with typical biochemical findings or clinical symptoms of hypomagnesemia, should be considered for treatment even with serum Mg within the normal range.
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Affiliation(s)
| | - Øyvind Bruserud
- Section for Endocrinology, Department of Clinical Science, University of Bergen, Bergen, Norway
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Rygård SL, Jonsson AB, Madsen MB, Perner A, Holst LB, Johansson PI, Wetterslev J. Effects of red blood cell storage time on transfused patients in the ICU-protocol for a systematic review. Acta Anaesthesiol Scand 2017; 61:1384-1397. [PMID: 28901549 DOI: 10.1111/aas.12991] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Accepted: 08/18/2017] [Indexed: 01/28/2023]
Abstract
BACKGROUND Patients in the intensive care unit (ICU) are often anaemic due to blood loss, impaired red blood cell (RBC) production and increased RBC destruction. In some studies, more than half of the patients were treated with RBC transfusion. During storage, the RBC and the storage medium undergo changes, which lead to impaired transportation and delivery of oxygen and may also promote an inflammatory response. Divergent results on the clinical consequences of storage have been reported in both observational studies and randomised trials. Therefore, we aim to gather and review the present evidence to assess the effects of shorter vs. longer storage time of transfused RBCs for ICU patients. METHODS We will conduct a systematic review with meta-analyses and trial sequential analyses of randomised clinical trials, and also include results of severe adverse events from large observational studies. Participants will be adult patients admitted to an ICU and treated with shorter vs. longer stored RBC units. We will systematically search the Cochrane Library, MEDLINE, Embase, BIOSIS, CINAHL and Science Citation Index for relevant literature, and we will follow the recommendation by the Cochrane Collaboration and the Preferred Reporting Items for Systemtic Review and Meta-Analysis (PRISMA)-statement. We will assess the risk of bias and random errors, and we will use the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach to evaluate the overall quality of evidence. CONCLUSION We need a high-quality systematic review to summarise the clinical consequences of RBC storage time among ICU patients.
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Affiliation(s)
- S. L. Rygård
- Department of Intensive Care, 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - A. B. Jonsson
- Department of Intensive Care, 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - M. B. Madsen
- Department of Intensive Care, 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - A. Perner
- Department of Intensive Care, 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
- Centre for Research in Intensive Care (CRIC); Copenhagen Denmark
| | - L. B. Holst
- Department of Intensive Care, 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - P. I. Johansson
- Department of Transfusion Medicine; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - J. Wetterslev
- Centre for Research in Intensive Care (CRIC); Copenhagen Denmark
- Copenhagen Trial Unit; Centre for Clinical Intervention Research; Copenhagen University Hospital; Rigshospitalet Copenhagen Denmark
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Barbateskovic M, Schjørring OLL, Jakobsen JC, Meyhoff CS, Dahl RM, Rasmussen BS, Perner A, Wetterslev J. Higher versus lower inspiratory oxygen fraction or targets of arterial oxygenation for adult intensive care patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2017. [DOI: 10.1002/14651858.cd012631] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Marija Barbateskovic
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Olav Lilleholt L Schjørring
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Aalborg University Hospital; Department of Anaesthesia and Intensive Care Medicine; Hobrovej 18-22 Aalborg Denmark 9000
| | - Janus C Jakobsen
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 7812, Rigshospitalet, Copenhagen University Hospital; Cochrane Hepato-Biliary Group; Blegdamsvej 9 Copenhagen Sjaelland Denmark DK-2100
- Holbaek Hospital; Department of Cardiology; Holbaek Denmark 4300
| | - Christian S Meyhoff
- Bispebjerg Hospital, University of Copenhagen; Department of Anaesthesiology; Copenhagen NV Denmark
| | - Rikke M Dahl
- Herlev Hospital, University of Copenhagen; Department of Anaesthesiology; Herlev Ringvej 75, Pavillon 10, I65F10 Herlev Denmark 2730
| | - Bodil S Rasmussen
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Aalborg University Hospital; Department of Anaesthesia and Intensive Care Medicine; Hobrovej 18-22 Aalborg Denmark 9000
| | - Anders Perner
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
| | - Jørn Wetterslev
- Department 7812, Rigshospitalet, Copenhagen University Hospital; Copenhagen Trial Unit, Centre for Clinical Intervention Research; Blegdamsvej 9 Copenhagen Denmark DK-2100
- Department 7831, Rigshospitalet, Copenhagen University Hospital; Centre for Research in Intensive Care; Blegdamsvej 9 Copenhagen Denmark DK-2100
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Barbateskovic M, Larsen LK, Oxenbøll-Collet M, Jakobsen JC, Perner A, Wetterslev J. Pharmacological interventions for delirium in intensive care patients: a protocol for an overview of reviews. Syst Rev 2016; 5:211. [PMID: 27923397 PMCID: PMC5142129 DOI: 10.1186/s13643-016-0391-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2016] [Accepted: 11/26/2016] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND The prevalence of delirium in intensive care unit (ICU) patients is high. Delirium has been associated with morbidity and mortality including more ventilator days, longer ICU stay, increased long-term mortality and cognitive impairment. Thus, the burden of delirium for patients, relatives and societies is considerable. Today, reviews of randomised clinical trials are produced in large scales sometimes making it difficult to get an overview of the available evidence. A preliminary search identified several reviews investigating the effects of pharmacological interventions for the management and prevention of delirium in ICU patients. The conclusions of the reviews showed conflicting results. Despite this unclear evidence, antipsychotics, in particular, haloperidol is often the recommended pharmacological intervention for delirium in ICU patients. The objective of this overview of reviews is to critically assess the evidence of reviews of randomised clinical trials on the effect of pharmacological management and prevention of delirium in ICU patients. METHODS/DESIGN We will search for reviews in the following databases: Cochrane Library, MEDLINE, EMBASE, Science Citation Index, BIOSIS, Cumulative Index to Nursing and Allied Health Literature, Latin American and Caribbean Health Sciences Literature, and Allied and Complementary Medicine Database. Two authors will independently select references for inclusion using Covidence, extract data and assess the methodological quality of the included systematic reviews using the ROBIS tool. Any disagreement will be resolved by consensus. We will present the data as a narrative synthesis and summarise the main results of the included reviews. In addition, we will present an overview of the bias risk assessment of the systematic reviews. DISCUSSION Results of this overview may establish a way forward to find and update or to design a high quality systematic review assessing the effects of the most promising pharmacological intervention for delirium in ICU patients. SYSTEMATIC REVIEW REGISTRATION PROSPERO - CRD42016046628 .
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Affiliation(s)
- Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Laura Krone Larsen
- Department of neuroanaesthesiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Marie Oxenbøll-Collet
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Janus Christian Jakobsen
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Cardiology, Holbaek Hospital, Holbaek, Denmark
| | - Anders Perner
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Centre for Research in Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
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Wetterslev J, Thorlund K, Brok J, Gluud C. Trial sequential analysis may establish when firm evidence is reached in cumulative meta-analysis. J Clin Epidemiol 2007; 61:64-75. [PMID: 18083463 DOI: 10.1016/j.jclinepi.2007.03.013] [Citation(s) in RCA: 1338] [Impact Index Per Article: 78.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2005] [Revised: 03/08/2007] [Accepted: 03/20/2007] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND OBJECTIVE Cumulative meta-analyses are prone to produce spurious P<0.05 because of repeated testing of significance as trial data accumulate. Information size in a meta-analysis should at least equal the sample size of an adequately powered trial. Trial sequential analysis (TSA) corresponds to group sequential analysis of a single trial and may be applied to meta-analysis to evaluate the evidence. STUDY DESIGN AND SETTING Six randomly selected neonatal meta-analyses with at least five trials reporting a binary outcome were examined. Low-bias heterogeneity-adjusted information size and information size determined from an assumed intervention effect of 15% were calculated. These were used for constructing trial sequential monitoring boundaries. We assessed the cumulative z-curves' crossing of P=0.05 and the boundaries. RESULTS Five meta-analyses showed early potentially spurious P<0.05 values. In three significant meta-analyses the cumulative z-curves crossed both boundaries, establishing firm evidence of an intervention effect. In two nonsignificant meta-analyses the cumulative z-curves crossed P=0.05, but never the boundaries, demonstrating early potentially spurious P<0.05 values. In one nonsignificant meta-analysis the cumulative z-curves never crossed P=0.05 or the boundaries. CONCLUSION TSAs may establish when firm evidence is reached in meta-analysis.
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Affiliation(s)
- Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen, Denmark.
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Abstract
Magnesium (Mg) deficiency commonly occurs in critical illness and correlates with a higher mortality and worse clinical outcome in the intensive care unit (ICU). Magnesium has been directly implicated in hypokalemia, hypocalcemia, tetany, and dysrhythmia. Moreover, Mg may play a role in acute coronary syndromes, acute cerebral ischemia, and asthma. Magnesium regulates hundreds of enzyme systems. By regulating enzymes controlling intracellular calcium, Mg affects smooth muscle vasoconstriction, important to the underlying pathophysiology of several critical illnesses. The principle causes of Mg deficiency are gastrointestinal and renal losses; however, the diagnosis is difficult to make because of the limitations of serum Mg levels, the most common assessment of Mg status. Magnesium tolerance testing and ionized Mg2+ are alternative laboratory assessments; however, each has its own difficulties in the ICU setting. The use of Mg therapy is supported by clinical trials in the treatment of symptomatic hypomagnesemia and preeclampsia and is recommended for torsade de pointes. Magnesium therapy is not supported in the treatment of acute myocardial infarction and is presently undergoing evaluation for the treatment of severe asthma exacerbation, for the prevention of post-coronary bypass grafting dysrhythmias, and as a neuroprotective agent in acute cerebral ischemia.
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Affiliation(s)
- Garrison M Tong
- University of Southern California, School of Medicine, Los Angeles, CA 90089-9317, USA
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Gowda RM, Khan IA. Magnesium in treatment of acute myocardial infarction. Int J Cardiol 2004; 96:467-9. [PMID: 15301901 DOI: 10.1016/j.ijcard.2003.04.067] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2003] [Accepted: 04/12/2003] [Indexed: 11/26/2022]
Abstract
Magnesium has properties of myocardial cytoprotection, the pathophysiological explanations of which in acute myocardial infarction include prevention of arrhythmia, antiplatelet effect, prevention of reperfusion injury, and coronary vasodilation. Although several studies have evaluated the role of magnesium administration in patients with acute myocardium infarction, the clinical impact of such a therapy in this condition has been controversial, largely as a result of conflicting data from randomized controlled trials. The data available to date do not favor the routine administration of intravenous magnesium in patients with myocardial infarction, but this should not preclude magnesium administration to replenish low serum magnesium concentrations or use of magnesium sulfate for treatment of torsade de pointes in patients with myocardial infarction.
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Early administration of intravenous magnesium to high-risk patients with acute myocardial infarction in the Magnesium in Coronaries (MAGIC) Trial: a randomised controlled trial. Lancet 2002; 360:1189-96. [PMID: 12401244 DOI: 10.1016/s0140-6736(02)11278-5] [Citation(s) in RCA: 122] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The benefits of supplemental administration of intravenous magnesium in patients with ST-elevation myocardial infarction (STEMI) are controversial. Despite promising results from work in animals and the ready availability of this simple, inexpensive treatment, conflicting results have been reported in clinical trials. Our aim was to compare short-term mortality in patients with STEMI who received either intravenous magnesium sulphate or placebo. METHODS We did a randomised, double-blind trial in 6213 patients with acute STEMI who were assigned a 2 g intravenous bolus of magnesium sulphate administered over 15 min, followed by a 17 g infusion of magnesium sulphate over 24 h (n=3113), or matching placebo (n=3100). Our primary endpoint was 30-day all-cause mortality. At randomisation, patients were stratified by their eligibility for reperfusion therapy. The first stratum included patients who were aged 65 years or older and eligible for reperfusion therapy, and the second stratum included patients of any age who were not eligible for reperfusion therapy. Analysis was by intention-to-treat. FINDINGS At 30 days, 475 (15.3%) patients in the magnesium group and 472 (15.2%) in the placebo group had died (odds ratio 1.0, 95% CI 0.9-1.2, p=0.96). No benefit or harm of magnesium was observed in eight prespecified subgroup analyses of patients and in 15 additional exploratory subgroup analyses. After adjustment for factors shown to effect mortality risk in a multivariate regression model, no benefit of magnesium was observed (1.0, 0.8-1.1, p=0.53). INTERPRETATION Early administration of magnesium in high-risk patients with STEMI has no effect on 30-day mortality. In view of the totality of the available evidence, in current coronary care practice there is no indication for the routine administration of intravenous magnesium in patients with STEMI.
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