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van Erp IA, van Essen T, Kompanje EJ, van der Jagt M, Moojen WA, Peul WC, van Dijck JT. Treatment-limiting decisions in patients with severe traumatic brain injury in the Netherlands. BRAIN & SPINE 2024; 4:102746. [PMID: 38510637 PMCID: PMC10951765 DOI: 10.1016/j.bas.2024.102746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/28/2023] [Accepted: 01/03/2024] [Indexed: 03/22/2024]
Abstract
Introduction Treatment-limiting decisions (TLDs) can be inevitable severe traumatic brain injury (s-TBI) patients, but data on their use remain scarce. Research question To investigate the prevalence, timing and considerations of TLDs in s-TBI patients. Material and methods s-TBI patients between 2008 and 2017 were analysed retrospecively. Patient data, timing, location, involvement of proxies, and reasons for TLDs were collected. Baseline characteristics and in-hospital outcomes were compared between s-TBI patients with and without TLDs. Results TLDs were reported in 117 of 270 s-TBI patients (43.3%) and 95.9% of deaths after s-TBI were preceded by a TLD. The majority of TLDs (68.4%) were categorized as withdrawal of therapy, of which withdrawal of organ-support in 64.1%. Neurosurgical intervention was withheld in 29.9%. The median time from admission to TLD was 2 days [IQR, 0-8] and 50.4% of TLDs were made within 3 days of admission. The main reason for a TLD was that the patients were perceived as unsalvageable (66.7%). Nearly all decisions were made multidisciplinary (99.1%) with proxies involvement (75.2%). The predicted mortality (CRASH-score) between patients with and without TLDs were 72.6 vs. 70.6%. The percentage of TLDs in s-TBI patients increased from 20.0% in 2008 to 42.9% in 2012 and 64.3% in 2017. Discussion and conclusion TLDs occurred in almost half of s-TBI patients and were instituted more frequently over time. Half of TLDs were made within 3 days of admission in spite of baseline prognosis between groups being similar. Future research should address whether prognostic nihilism contributes to self-fulfilling prophecies.
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Affiliation(s)
- Inge A.M. van Erp
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - T.A. van Essen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge and Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Erwin J.O. Kompanje
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
- Department of Ethics and Philosophy of Medicine, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Mathieu van der Jagt
- Department of Intensive Care Adults, Erasmus MC – University Medical Center, Rotterdam, the Netherlands
| | - Wouter A. Moojen
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Wilco C. Peul
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
| | - Jeroen T.J.M. van Dijck
- University Neurosurgical Center Holland, Leiden University Medical Center, Haaglanden Medical Center and HaGa Hospital, Leiden and The Hague, the Netherlands
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Leblanc G, Boutin A, Shemilt M, Lauzier F, Moore L, Potvin V, Zarychanski R, Archambault P, Lamontagne F, Léger C, Turgeon AF. Incidence and impact of withdrawal of life-sustaining therapies in clinical trials of severe traumatic brain injury: A systematic review. Clin Trials 2018; 15:398-412. [PMID: 29865897 DOI: 10.1177/1740774518771233] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background Most deaths following severe traumatic brain injury follow decisions to withdraw life-sustaining therapies. However, the incidence of the withdrawal of life-sustaining therapies and its potential impact on research data interpretation have been poorly characterized. The aim of this systematic review was to assess the reporting and the impact of withdrawal of life-sustaining therapies in randomized clinical trials of patients with severe traumatic brain injury. Methods We searched Medline, Embase, Cochrane Central, BIOSIS, and CINAHL databases and references of included trials. All randomized controlled trials published between January 2002 and August 2015 in the six highest impact journals in general medicine, critical care medicine, and neurocritical care (total of 18 journals) were considered for eligibility. Randomized controlled trials were included if they enrolled adult patients with severe traumatic brain injury (Glasgow Coma Scale ≤ 8) and reported data on mortality. Our primary objective was to assess the proportion of trials reporting the withdrawal of life-sustaining therapies in a publication. Our secondary objectives were to describe the overall mortality rate, the proportion of deaths following the withdrawal of life-sustaining therapies, and to assess the impact of the withdrawal of life-sustaining therapies on trial results. Results From 5987 citations retrieved, we included 41 randomized trials (n = 16,364, ranging from 11 to 10,008 patients). Overall mortality was 23% (range = 3%-57%). Withdrawal of life-sustaining therapies was reported in 20% of trials (8/41, 932 patients in trials) and the crude number of deaths due to the withdrawal of life-sustaining therapies was reported in 17% of trials (7/41, 884 patients in trials). In these trials, 63% of deaths were associated with the withdrawal of life-sustaining therapies (105/168). An analysis carried out by imputing a 4% differential rate in instances of withdrawal of life-sustaining therapies between study groups yielded different results and conclusions in one third of the trials. Conclusion Data on the withdrawal of life-sustaining therapies are incompletely reported in randomized controlled trials of patients with severe traumatic brain injury. Given the high proportion of deaths due to the withdrawal of life-sustaining therapies in severe traumatic brain injury patients, and the potential of this medical decision to influence the results of clinical trials, instances of withdrawal of life-sustaining therapies should be systematically reported in clinical trials in this group of patients.
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Affiliation(s)
- Guillaume Leblanc
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Amélie Boutin
- 3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Michèle Shemilt
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - François Lauzier
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,4 Department of Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Lynne Moore
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,3 Department of Social and Preventive Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Véronique Potvin
- 2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - Ryan Zarychanski
- 5 Department of Internal Medicine, Sections of Critical Care Medicine, Haematology and Medical Oncology, Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Patrick Archambault
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada.,6 Department of Family and Emergency Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
| | - François Lamontagne
- 7 Department of Medicine, Faculty of Medicine, University of Sherbrooke, Sherbrooke, QC, Canada.,8 Centre de recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada
| | - Caroline Léger
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada
| | - Alexis F Turgeon
- 1 Population Health and Optimal Health Practices Research Unit, Trauma-Emergency-Critical Care Medicine, Centre de recherche du CHU de Québec-Université Laval, Québec, QC, Canada.,2 Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Université Laval, Québec, QC, Canada
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3
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Sinuff T, Cook DJ, Rocker GM, Griffith LE, Walter SD, Fisher MM, Dodek PM, Sjokvist P, McDonald E, Marshall JC, Kraus PA, Levy MM, Lazar NM, Guyatt GH. DNR directives are established early in mechanically ventilated intensive care unit patients. Can J Anaesth 2014; 51:1034-41. [PMID: 15574557 DOI: 10.1007/bf03018494] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
PURPOSE Setting treatment goals in the intensive care unit (ICU) often involves resuscitation decisions. Our objective was to study the rate of establishing do-not-resuscitate (DNR) directives, determinants, and outcomes of those directives for mechanically ventilated patients. METHODS In a multicentre observational study, we included consecutive adults with no DNR directives within 24 hr of ICU admission who were mechanically ventilated for at least 48 hr. We identified the rate with which DNR directives were established, and factors associated with these directives. RESULTS Among 765 patients, DNR directives were established for 231 (30.2%) patients; 143 (62.1%) of these were established within the first week. Factors independently associated with a DNR directive were: patient age [> or = 75 yr (hazard ratio [HR] 2.3, 95% confidence interval 1.5-3.4], 65 to 74 yr (HR 1.8, 1.2-2.7), 50 to 64 yr (HR 1.4, 1.0-2.2) relative to < 50 yr); medical rather than surgical diagnosis (HR 1.8, 1.3-2.5); multiple organ dysfunction score (HR 1.7 for each five-point increment, 1.4-2.0); physician prediction of ICU survival [< 10% (HR 15.0, 6.7-33.6)], 10 to 40% [(HR 5.0, 2.3-11.2), 41 to 60% (HR 4.0, 1.8-9.0) relative to > 90%]; and physician perception of patient preference to limit life support (no advanced life support [(HR 5.8, 3.6-9.4) or partial advanced life support (HR 3.2, 2.2-4.6) compared to full measures]. CONCLUSION One third of mechanically ventilated patients had DNR directives established early during their ICU stay after the first 24 hr of admission. The strongest predictors of DNR directives were physician prediction of low probability of survival, physician perception of patient preference to limit life support, organ dysfunction, medical diagnosis and age.
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Affiliation(s)
- Tasnim Sinuff
- Department of Medicine, McMaster University Health Sciences Center, Room 2C11, 1200 Main Street West, Hamilton, Ontario L8N 3Z5, Canada
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Hall TC, Bilku DK, Al-Leswas D, Horst C, Dennison AR. The difficulties of clinical trials evaluating therapeutic agents in patients with severe sepsis. Ir J Med Sci 2011; 181:1-6. [DOI: 10.1007/s11845-011-0778-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2011] [Accepted: 10/15/2011] [Indexed: 12/27/2022]
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Tidswell M, LaRosa SP. Toll-like receptor-4 antagonist eritoran tetrasodium for severe sepsis. Expert Rev Anti Infect Ther 2011; 9:507-20. [PMID: 21609262 DOI: 10.1586/eri.11.27] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
The human innate immune system initiates inflammation in response to bacterial molecules, particularly Gram-negative bacterial endotoxin. The steps by which endotoxin exposure leads to systemic inflammation include binding to Toll-like receptor-4 that specifically recognizes endotoxin and subsequently triggers cellular and molecular inflammatory responses. Severe sepsis is a systemic inflammatory response to infection that induces organ dysfunction and threatens a person's survival. Severe sepsis is frequently associated with increased blood levels of endotoxin. It is a significant medical problem that effects approximately 700,000 patients every year in the USA, resulting in 250,000 deaths. Eritoran tetrasodium is a nonpathogenic analog of bacterial endotoxin that antagonizes inflammatory signaling by the immune receptor Toll-like receptor-4. Eritoran is being evaluated for the treatment of patients with severe sepsis.
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Affiliation(s)
- Mark Tidswell
- Adult Critical Care Division, Baystate Medical Center, 759 Chestnut Street, Springfield, MA 01199, USA.
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Abstract
OBJECTIVES Although the mortality of severe sepsis is easily quantified, the actual cause and timing of death from severe sepsis are less defined. We used the INDEPTH (International Integrated Database for the Evaluation of Severe Sepsis and Drotrecogin alfa activated) database to investigate the reported cause of death in patients with severe sepsis. DESIGN Retrospective database analysis. PATIENTS Data from 4459 patients with severe sepsis (drotrecogin alfa activated, n = 3228; placebo, n = 1231) included in five clinical trials conducted in tertiary care institutions in 28 countries. MEASUREMENTS AND MAIN RESULTS We examined the cause of death and the pattern of Sequential Organ Failure Assessment scores near the time of death. We also evaluated the time course of biomarker levels at this late stage. A total of 1201 (27.0%) patients died during the 28-day study period. The main causes of death were as follows: sepsis-associated multiple organ failure (43.1%), refractory septic shock (22.6%), and respiratory failure (13.0%). There were no significant differences in the distributions of cause of death between drotrecogin alfa activated and placebo patients, so that all patients were combined for analysis. The mean cardiovascular Sequential Organ Failure Assessment score increased from 2.4, 4 days before death, to 2.9, 1 day before death, and the mean respiratory Sequential Organ Failure Assessment score increased from 2.6, 4 days before death, to 2.9, 1 day before death. The increase in these individual Sequential Organ Failure Assessment scores was more prominent in patients who died early (day 0-5). Protein C levels decreased and interleukin-6 levels increased in the days before death. CONCLUSION Patients with severe sepsis typically die of multiple organ failure, refractory shock, or respiratory failure. Persistent, more than worsening, organ failure is the more common pattern before death.
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Phase 2 trial of eritoran tetrasodium (E5564), a toll-like receptor 4 antagonist, in patients with severe sepsis. Crit Care Med 2010; 38:72-83. [PMID: 19661804 DOI: 10.1097/ccm.0b013e3181b07b78] [Citation(s) in RCA: 166] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Endotoxin is a potent stimulus of proinflammatory response and systemic coagulation in patients with severe sepsis. Endotoxin is a component of Gram-negative bacteria that triggers an innate immune response through Toll-like receptor 4 signaling pathways in myeloid cells. We evaluated safety and tolerability of two dose regimens of eritoran tetrasodium (E5564), a synthetic Toll-like receptor 4 antagonist, and explored whether it decreases 28-day mortality rate in subjects with severe sepsis. DESIGN Prospective, randomized, double-blind, placebo-controlled, multicenter, ascending-dose phase II trial. SETTING Adult intensive care units in the United States and Canada. PATIENTS Three hundred adults within 12 hrs of recognition of severe sepsis, with Acute Physiology and Chronic Health Evaluation (APACHE) II-predicted risk of mortality between 20% and 80%. INTERVENTIONS Intravenous eritoran tetrasodium (total dose of either 45 mg or 105 mg) or placebo administered every 12 hrs for 6 days. MEASUREMENTS AND MAIN RESULTS Prevalence of adverse events was similar among subjects treated with 45 mg or 105 mg of eritoran tetrasodium or with placebo. For modified intent-to-treat subjects, 28-day all-cause mortality rates were 26.6% (eritoran tetrasodium 105 mg), 32.0% (eritoran tetrasodium 45 mg), and 33.3% in the placebo group. Mortality rate in the eritoran tetrasodium 105-mg group was not significantly different from placebo (p = .335). In prespecified subgroups, subjects at highest risk of mortality by APACHE II score quartile had a trend toward lower mortality rate in the eritoran tetrasodium 105-mg group (33.3% vs. 56.3% placebo group, p = .105). A trend toward a higher mortality rate was observed in subjects in the lowest APACHE II score quartile for the eritoran 105-mg group (12.0% vs. 0.0% placebo group, p = .083). CONCLUSIONS Eritoran tetrasodium treatment appears well tolerated. The observed trend toward a lower mortality rate at the 105-mg dose, in subjects with severe sepsis and high predicted risk of mortality, should be further investigated.
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Abstract
While antibiotics address the root cause of sepsis--that of pathogen infection--they fail to provide an adequate cure for the condition. Currently, 30% to 50% of septic patients die, and this figure is likely to increase in line with the proliferation of multi-drug resistant bacteria. With an increased understanding of the immune response, it has been proposed that modulation of this defence mechanism offers the best hope of cure. Many entry-points in the immune system have been identified and targeted therapies have been developed,but why are these not in routine clinical practice? This review examines the latest evidence for the use of immuno-modulating drugs, obtained from human clinical trials. We discuss cytokine-based therapies, steroids and anti-coagulants. Finally, consideration is given as to why successful therapies in the laboratory, and in vivo models, do not automatically translate into clinical benefit
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Affiliation(s)
- A O'Callaghan
- Department of Surgery, Cork University Hospital, Cork, Ireland.
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9
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Moselli NM, Debernardi F, Piovano F. Forgoing life sustaining treatments: differences and similarities between North America and Europe. Acta Anaesthesiol Scand 2006; 50:1177-86. [PMID: 17067320 DOI: 10.1111/j.1399-6576.2006.01150.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND As evidence exist that severe neurological damage or prolonged death after inappropriate CPR could occur, restraints and indications for CPR were perceived as necessary. The objective of this review is to examine policies and attitudes towards end-of-life decisions in Europe and North America and to outline differences and similarities. METHODS A bibliographic database search from 1990 to 2006 was performed using the following terms: do-not-resuscitate orders, end-of-life decisions, withholding/withdrawal of life-sustaining treatments, medical futility and advanced directives. Eighty-eight articles, out of 305 examined, were analyzed and their data systematically reported and compared where possible. They consisted of studies, questionnaires and surveys answering the following questions: percentage of deaths of critical patients preceded by do-not-resuscitate orders, factors affecting the decision for do-not-resuscitate orders, people involved in this decision (patient, surrogates and medical staff) and how it was performed. RESULTS There is an evident gap between the North American use of standard and formal procedures compared with Europe. Second, they diverge in the role acknowledged to surrogates in the decisional process, as in Europe, restraints and reserves to accept surrogates as decision makers seem still strong and a paternalistic approach at the end-of-life is still present. CONCLUSION Incidentally, despite the predictable differences between Europe and North America, concerns do exist about the actual extent of autonomy wished by patients and surrogates. It is important to highlight these findings, as the paternalistic attitude, too often negatively depicted, could be, according to the best medical practice, justified and more welcomed in some instances.
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Affiliation(s)
- N M Moselli
- Unit of Anaesthesiology, Intensive Care and Pain Therapy, Institute for Cancer Research and Treatment (IRCC), Candiolo (Torino), Italy.
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Dhainaut JF, Claessens YE, Janes J, Nelson DR. Underlying Disorders and Their Impact on the Host Response to Infection. Clin Infect Dis 2005; 41 Suppl 7:S481-9. [PMID: 16237651 DOI: 10.1086/432001] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Underlying disorders, especially those that chronically impair immune host response (e.g., cancers and hematologic malignancies) but also those that acutely impair this response (e.g., major surgery and multiple trauma), increase the incidence of infection and alter the outcome of patients with sepsis. As a part of innate immunity, inflammatory and coagulation responses are lower in patients with underlying disorders than in patients without such disorders, whereas the need for vasopressors and mechanical ventilation is more frequent. Although these patients are older, age-related defects do not appear to be responsible for this lower response, because innate immunity is usually up-regulated in the elderly. Innate immunity seems to be negligibly affected by the direct consequences of underlying disorders, but underlying disorder-related chronic organ insufficiency certainly participates in the observed organ dysfunction, overestimating the infectious insult by itself. Although innate immunity seems not to be actually blunted in patients with underlying disorders, the underlying disorder itself contributes to the severity of the physiological response to sepsis, thereby resulting in a worse outcome.
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Affiliation(s)
- Jean-Francois Dhainaut
- Intensive Care and Emergency Department, Cochin University Hospital, Rene Descartes University, Paris, France.
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11
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Dhainaut JF, Laterre PF, LaRosa SP, Levy H, Garber GE, Heiselman D, Kinasewitz GT, Light RB, Morris P, Schein R, Sollet JP, Bates BM, Utterback BG, Maki D. The clinical evaluation committee in a large multicenter phase 3 trial of drotrecogin alfa (activated) in patients with severe sepsis (PROWESS): role, methodology, and results. Crit Care Med 2003; 31:2291-301. [PMID: 14501959 DOI: 10.1097/01.ccm.0000085089.88077.af] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE In the multinational PROWESS trial, drotrecogin alfa (activated) significantly reduced mortality rate in patients with severe sepsis compared with placebo. The use of large multiple-center trials can potentially complicate interpretation of results in severe sepsis populations because of variability in medical attitudes and practices and the frequency of confounding events such as protocol violations. The objective of this study was to perform a blinded, critical, integrated review of data from the 1,690 severe sepsis patients from 164 medical centers enrolled in the PROWESS trial using a Clinical Evaluation Committee. DESIGN Blinded, critical, integrated review of data. SETTING Participating sites. PATIENTS The 1,690 severe sepsis patients from 164 medical centers enrolled in the PROWESS trial. INTERVENTIONS We performed analyses of the optimal cohort, defined as patients who had full compliance with the protocol, had evidence of an infection, and received adequate anti-infective therapy. We also performed other analyses, including significant underlying disorders, life support measures, and causes of death. MEASUREMENTS AND MAIN RESULTS The optimal cohort of 81.4% of the intention-to-treat population [drotrecogin alfa (activated), n = 695; placebo, n = 680] had similar baseline severity of illness between the two groups, a similar pharmacodynamic effect, and a relative risk of death estimate consistent with that observed in the overall PROWESS trial (0.83, 95% confidence interval 0.69-0.99 vs. 0.806, 95% confidence interval 0.69-0.94). A beneficial effect of drotrecogin alfa (activated) similarly was observed in patients with significant underlying disorders (0.73, 95% confidence interval 0.57-0.93) who were more severely ill and had a higher percentage of patients forgoing life-sustaining therapy. In contrast with the original investigator determinations, a benefit associated with drotrecogin alfa (activated) treatment in urinary tract infection adjudicated by the Clinical Evaluation Committee was observed. CONCLUSIONS The survival benefit associated with drotrecogin alfa (activated) use was consistent with the results of the overall trial regardless of whether patients met criteria of the optimal cohort or had a significant underlying disorder.
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Affiliation(s)
- Jean-François Dhainaut
- Department of Intensive Care, Cochin Hospital, Cochin Institute, Cochin Port-Royal Medical School, Paris V University, France.
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12
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Morris PE, Hite RD, Ohl C. Relationship between the inflammation and coagulation pathways in patients with severe sepsis: implications for therapy with activated protein C. BioDrugs 2003; 16:403-17. [PMID: 12463764 DOI: 10.2165/00063030-200216060-00002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
In patients with severe sepsis, thrombin has been implicated in the interrelationship between the coagulation and inflammation pathways. Thrombin is responsible for conversion of fibrinogen to fibrin (thrombus formation). Thrombin also activates endothelial cells, white blood cells and platelets. Regulation of both the coagulation and inflammation pathways is in part through the interaction of thrombin and activated protein C. Activated protein C has particular attributes that may inhibit microvascular thrombi, promote fibrinolysis and directly dampen the pro-inflammatory aspect of infection. In patients with severe sepsis, many investigators have demonstrated an active coagulopathic state, with low protein C levels. A phase III clinical trial has now demonstrated reduced mortality in patients with severe sepsis receiving activated protein C.
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Affiliation(s)
- Peter E Morris
- Division of Pulmonary and Critical Care Medicine, Wake Forest University School of Medicine, Winston Salem, North Carolina 27104, USA.
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Oral HB, Ozakin C, Akdiş CA. Back to the future: antibody-based strategies for the treatment of infectious diseases. Mol Biotechnol 2002; 21:225-39. [PMID: 12102547 DOI: 10.1385/mb:21:3:225] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Before antibiotics, sera from immune animals and humans were used to treat a variety of infectious diseases, often with successful results. After the discovery of antimicrobial agents, serum therapy for bacterial infections was rapidly forsaken. In the last two decades, problems with treatment of newly emerged, re-emerged, or persistent infectious diseases necessitated researchers to develop new and/or improved antibody-based therapeutic approaches. This article reviews some information on the use of antibodies for the treatment of infectious diseases, with special reference to the most seminal discoveries and current advances as well as available treatment approaches in this field.
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Affiliation(s)
- H Barbaros Oral
- Department of Microbiology and Infectious Diseases, School of Medicine, Uludag University, Bursa, Turkey.
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14
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Abstract
OBJECTIVE To critically review the advantages and disadvantages of pediatric meningococcemia as a model for testing antisepsis therapies. DATA SOURCES Research and review articles on the pathogenesis and treatment of human meningococcemia, as well as editorial commentaries discussing the failure of clinical trials for adult sepsis or Systemic Inflammatory Response Syndrome. Data from these sources are presented in the context of the author's experience as principal investigator in a large, randomized trial on children with invasive meningococcal disease. STUDY SELECTION AND DATA EXTRACTION Studies were selected to include aspects of epidemiology, pathophysiology, outcome prediction, and therapeutic trials. DATA SYNTHESIS Compared with an adult sepsis population, meningococcemia is a single disease, diagnosed clinically with high reliability. Patients are previously healthy, without underlying medical or surgical conditions. In contrast to sepsis trials, nearly all patients with meningococcal disease receive effective antibiotics. Finally, meningococcemia most closely resembles animal models of endotoxin infusion, in which most antisepsis therapies have been highly effective. However, the meningococcal model carries major disadvantages, among them that meningococcemia is rare and rapidly progressive and patients are widely dispersed geographically. In addition, a wide range of experimental therapies is routinely provided in an attempt to preserve life or limbs. CONCLUSIONS Meningococcemia is an ideal model of a rapidly progressive bacterial infection associated with marked endotoxemia. Problems with the model can be overcome by extensive pretrial logistic planning, as well as close coordination and cooperation with national regulatory agencies.
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Affiliation(s)
- B P Giroir
- University of Texas Southwestern Medical Center, Dallas 75235-9063, USA.
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Abid O, Akça S, Haji-Michael P, Vincent JL. Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure. Crit Care Med 2000; 28:947-9. [PMID: 10809264 DOI: 10.1097/00003246-200004000-00006] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE The aim of the study was to determine the prognosis in patients who needed norepinephrine treatment in our institution in relation to the degree of organ failure and the evolution of the disease process. DESIGN Retrospective case note analysis of outcome of those patients who needed norepinephrine according to our institutional regimen. PATIENTS A total of 100 consecutive patients admitted to our 31-bed medical-surgical intensive care unit (ICU) who were treated with norepinephrine for severe hypotension and evidence of end-organ hypoperfusion unresponsive to both fluid resuscitation and dopamine treatment at 20 microg/kg/min. MEASUREMENTS The degree of organ dysfunction at the time of starting norepinephrine treatment was assessed by the sequential organ failure assessment (SOFA) score. The time before starting norepinephrine treatment was defined as the time elapsed between ICU admission and that of starting norepinephrine administration. The patients were defined as survivors or nonsurvivors according to their ICU outcome. RESULTS There were relationships between mortality and the degree of organ dysfunction and mortality and the duration of ICU stay before starting norepinephrine treatment. The mortality rate was 100% in the 30 patients with a total SOFA score of >12 and a delay before starting norepinephrine treatment of >1 day. The mortality rate of the other patients was 63%. The lowest mortality was seen in patients with lower SOFA scores and early norepinephrine administration after admission. CONCLUSIONS Both the time of starting norepinephrine treatment after admission to the ICU and the degree of organ dysfunction have an important bearing on subsequent outcome. Although norepinephrine may be a lifesaving catecholamine in some cases, its administration to patients who have already developed multiple organ failure during their stay in the ICU is associated with a poor outcome.
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Affiliation(s)
- O Abid
- Department of Intensive Care Medicine, Erasme University Hospital, Free University of Brussels, Belgium
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Vincent JL. Forgoing life support in western European intensive care units: the results of an ethical questionnaire. Crit Care Med 1999; 27:1626-33. [PMID: 10470775 DOI: 10.1097/00003246-199908000-00042] [Citation(s) in RCA: 253] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine current views of European intensive care physicians regarding end-of-life decisions. DESIGN A questionnaire was sent to all physician members of the European Society of Intensive Care Medicine. All questionnaires were anonymous. RESULTS A total of 504 completed questionnaires from 16 western European countries were analyzed. Eighty-seven percent of the respondents were male. Forty-six percent of respondents said that intensive care unit admissions were generally or commonly affected by bed shortages, particularly in the south. Nevertheless, 73% of units frequently admit patients with no hope of survival, although only 33% of respondents felt that such patients should be admitted. Eighty percent of respondents felt that written do-not-resuscitate orders should be applied, but only 58% did so, with a wide variation according to country (from 8% in Italy to 91% in The Netherlands). Ninety-three percent of physicians sometimes withhold treatment from patients with no hope of a meaningful life, but withdrawal of treatment is less common. Forty percent of respondents said that they would deliberately administer large doses of drugs to such patients until death ensued. Forty-nine percent of respondents involved staff, patients, and family in end-of-life decisions. Forty-five percent of respondents felt that an ethics consultation was useful in such situations. Physicians in the countries of southern Europe were less likely than those in the north to apply do-not-resuscitate orders, withhold treatment, and discuss such issues with the patients. However, they were more likely to value the opinion of an ethics consultant. CONCLUSIONS Intensive care unit admissions are frequently limited by the availability of beds across Europe, particularly in the south and in the United Kingdom, yet 73% of intensivists still admit patients with no hope of survival. When treating patients with no hope of survival, 40% of intensivists will deliberately administer large doses of drugs until death ensues. There are interesting differences between what a physician actually does and what he or she believes should be done with regard to various ethical questions. Important differences in attitudes also exist between European countries.
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Affiliation(s)
- J L Vincent
- Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium.
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Dhainaut JF, Tenaillon A, Hemmer M, Damas P, Le Tulzo Y, Radermacher P, Schaller MD, Sollet JP, Wolff M, Holzapfel L, Zeni F, Vedrinne JM, de Vathaire F, Gourlay ML, Guinot P, Mira JP. Confirmatory platelet-activating factor receptor antagonist trial in patients with severe gram-negative bacterial sepsis: a phase III, randomized, double-blind, placebo-controlled, multicenter trial. BN 52021 Sepsis Investigator Group. Crit Care Med 1998; 26:1963-71. [PMID: 9875905 DOI: 10.1097/00003246-199812000-00021] [Citation(s) in RCA: 125] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the efficacy and safety of using natural platelet-activating factor receptor antagonist (PAFra), BN 52021, to treat patients with severe Gram-negative bacterial sepsis. DESIGN A prospective, randomized, double-blind, placebo-controlled, multicenter clinical trial. SETTING Fifty-nine academic medical center intensive care units in Europe. PATIENTS Six hundred nine patients with severe sepsis, suspected to be related to Gram-negative bacterial infection, who received PAFra or placebo. INTERVENTIONS Patients were randomized to receive either a dose of PAFra (120 mg iv) every 12 hrs over a 4-day period or placebo over a 4-day period. MEASUREMENTS AND MAIN RESULTS The patients were well matched at study entry for severity of illness and for risk factors known to influence the outcome of sepsis. Among all randomized patients, the 28-day, all-cause mortality rate was 49% (152/308) in the placebo group, and 47% (140/300) in the PAFra group (p=.50). When analyzed on the basis of the previously defined target population, the 28-day, all-cause mortality rate was 50% (115/232) in the placebo group and 44% (94/212) in the PAFra group, yielding a 12% reduction in mortality rate (p=.29). In patients with documented infection involving other organisms, there was no difference between treated and placebo groups. When the outcomes of organ dysfunctions were examined in the overall population and in the documented Gram-negative bacterial infection population, the number of patients who resolved hepatic dysfunction tended to be higher in the treated group than in the placebo group (p=.06). The number of adverse events reported were not different between the two groups. CONCLUSIONS A 4-day administration of the studied PAFra (BN 52021) failed to demonstrate a statistically significant reduction in the mortality rate of patients with severe sepsis suspected to be related to Gram-negative bacterial infection. If PAFra treatment has any therapeutic activity in severe Gram-negative bacterial sepsis, the incremental benefits are small and will be difficult to demonstrate in a patient population as defined by this clinical trial.
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Affiliation(s)
- J F Dhainaut
- Medical Intensive Care Unit of Cochin Port-Royal University Hospital, Paris, France
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Eidelman LA, Jakobson DJ, Pizov R, Geber D, Leibovitz L, Sprung CL. Foregoing life-sustaining treatment in an Israeli ICU. Intensive Care Med 1998; 24:162-6. [PMID: 9539075 DOI: 10.1007/s001340050539] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine whether physicians in Israel withhold and/or withdraw life-sustaining treatments. DESIGN A prospective, descriptive study of consecutively admitted patients. Patients were prospectively evaluated for diagnoses, types and reasons for foregoing life-sustaining treatment, mortality and times from foregoing therapy until mortality. SETTING A general intensive care unit of a university hospital in Israel. RESULTS Foregoing life-sustaining treatment occurred in 52 (13.5%) of 385 patients admitted and 5 (1%) had cardiopulmonary resuscitation. Withholding therapy occurred in 48 patients. Four patients with brain death had all treatments withdrawn. No patient had antibiotics, nutrition or fluids withheld or withdrawn. Time from foregoing therapy until death was 2.9 +/- 0.6 days. Thirty-one of 48 (65%) patients who had therapy withheld died within 48 h. CONCLUSIONS Withholding life-prolonging treatments is common in an Israeli intensive care unit whereas withdrawing therapy is limited to brain dead patients. Terminal patients die soon after withholding, even if the therapy is not withdrawn. Withholding treatments should be an option for patients and professionals who object to withdrawing therapies.
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Affiliation(s)
- L A Eidelman
- Department of Anesthesiology and Critical Care Medicine, Hadassah University Medical Center, Hebrew University of Jerusalem, Israel
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Cook DJ, Hébert PC, Heyland DK, Guyatt GH, Brun-Buisson C, Marshall JC, Russell J, Vincent JL, Sprung CL, Rutledge F. How to use an article on therapy or prevention: pneumonia prevention using subglottic secretion drainage. Crit Care Med 1997; 25:1502-13. [PMID: 9295824 DOI: 10.1097/00003246-199709000-00017] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Evidence based critical care medicine involves integrating clinical experience, expertise, and patient preferences with explicit, systematic, and judicious use of current best evidence in making medical decisions. Published evidence has many sources: research from the basic sciences of medicine, and from patient-centered clinical research on the accuracy of diagnostic tests, the power of prognostic markers, and the effectiveness and safety of preventive, therapeutic, rehabilitative, and palliative interventions. When critically appraising a clinical article for potential use in intensive care unit (ICU) practice, the first question we ask ourselves is: Is this study valid? If examination of the study methods reveals that the design is rigorous, we can turn to the two other key questions: What are the results? and, Will the results help me care for my patients? This approach may aid in the interpretation of an article on therapy or prevention; in it we discuss a strategy designed to prevent ventilator associated pneumonia in critically ill patients.
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Affiliation(s)
- D J Cook
- Department of Medicine, McMaster University, Hamilton, ON, Canada
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