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Jones TW, Hendrick T, Chase AM. Heterogeneity, Bayesian thinking, and phenotyping in critical care: A primer. Am J Health Syst Pharm 2024; 81:812-832. [PMID: 38742459 DOI: 10.1093/ajhp/zxae139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Indexed: 05/16/2024] Open
Abstract
PURPOSE To familiarize clinicians with the emerging concepts in critical care research of Bayesian thinking and personalized medicine through phenotyping and explain their clinical relevance by highlighting how they address the issues of frequent negative trials and heterogeneity of treatment effect. SUMMARY The past decades have seen many negative (effect-neutral) critical care trials of promising interventions, culminating in calls to improve the field's research through adopting Bayesian thinking and increasing personalization of critical care medicine through phenotyping. Bayesian analyses add interpretive power for clinicians as they summarize treatment effects based on probabilities of benefit or harm, contrasting with conventional frequentist statistics that either affirm or reject a null hypothesis. Critical care trials are beginning to include prospective Bayesian analyses, and many trials have undergone reanalysis with Bayesian methods. Phenotyping seeks to identify treatable traits to target interventions to patients expected to derive benefit. Phenotyping and subphenotyping have gained prominence in the most syndromic and heterogenous critical care disease states, acute respiratory distress syndrome and sepsis. Grouping of patients has been informative across a spectrum of clinically observable physiological parameters, biomarkers, and genomic data. Bayesian thinking and phenotyping are emerging as elements of adaptive clinical trials and predictive enrichment, paving the way for a new era of high-quality evidence. These concepts share a common goal, sifting through the noise of heterogeneity in critical care to increase the value of existing and future research. CONCLUSION The future of critical care medicine will inevitably involve modification of statistical methods through Bayesian analyses and targeted therapeutics via phenotyping. Clinicians must be familiar with these systems that support recommendations to improve decision-making in the gray areas of critical care practice.
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Affiliation(s)
- Timothy W Jones
- Department of Pharmacy, Piedmont Eastside Medical Center, Snellville, GA
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA, USA
| | - Tanner Hendrick
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Aaron M Chase
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, Athens, GA
- Department of Pharmacy, Augusta University Medical Center, Augusta, GA, USA
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Krutsinger DC, Maloney SI, Courtright KR, Bartels K. Barriers and Facilitators of Surrogates Providing Consent for Critically Ill Patients in Clinical Trials: A Qualitative Study. Chest 2024; 166:304-310. [PMID: 38387647 DOI: 10.1016/j.chest.2024.02.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Revised: 02/14/2024] [Accepted: 02/19/2024] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND Enrollment into critical care clinical trials is often hampered by the need to rely on surrogate decision-makers. To identify potential interventions facilitating enrollment into critical care clinical trials, a better understanding of surrogate decision-making for critical care clinical trial enrollment is needed. RESEARCH QUESTION What are the barriers and facilitators of critical care trial enrollment? What are surrogate decision-makers' perspectives on proposed interventions to facilitate trial enrollment? STUDY DESIGN AND METHODS We conducted semistructured interviews with 20 surrogate decision-makers of critically ill patients receiving mechanical ventilation. The interviews were recorded and transcribed verbatim, and analyzed for themes using an inductive approach. RESULTS Thematic analysis confirmed previous research showing that trust in the system, assessing the risks and benefits of trial participation, the desire to help others, and building medical knowledge as important motivating factors for trial enrollment. Two previously undescribed concerns among surrogate decision-makers of critically ill patients were identified, including the potential to interfere with clinical treatment decisions and negative sentiment about placebos. Surrogates viewed public recognition and charitable donations for participation as favorable potential interventions to encourage trial enrollment. However, participants viewed direct financial incentives and prioritizing research participants during medical rounds negatively. INTERPRETATION This study confirms and extends previous findings that health system trust, study risks and benefits, altruism, knowledge generation, interference with clinical care, and placebos are key concerns and barriers for surrogate decision-makers to enroll patients in critical care trials. Future studies are needed to evaluate if charitable giving on the patient's behalf and public recognition are effective strategies to promote enrollment into critical care trials.
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Affiliation(s)
- Dustin C Krutsinger
- Divisions of Pulmonary, Critical Care, and Sleep Medicine, University of Nebraska Medical Center, Omaha, NE; Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE.
| | - Shannon I Maloney
- Maurer College of Public Health, University of Nebraska Medical Center, Omaha, NE
| | - Katherine R Courtright
- Palliative and Advanced Illness Research (PAIR) Center, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Pulmonary, Allergy, and Critical Care Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karsten Bartels
- Department of Anesthesiology, University of Nebraska Medical Center, Omaha, NE
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Andreasen AS, Wetterslev M, Sigurdsson MI, Bove J, Kjaergaard J, Aslam TN, Järvelä K, Poulsen M, De Geer L, Agarwal A, Kjaer MBN, Møller MH. New-onset atrial fibrillation in critically ill adult patients-an SSAI clinical practice guideline. Acta Anaesthesiol Scand 2023; 67:1110-1117. [PMID: 37289426 DOI: 10.1111/aas.14262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 04/15/2023] [Indexed: 06/09/2023]
Abstract
BACKGROUND Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes. METHODS We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel. RESULTS The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197. CONCLUSIONS The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.
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Affiliation(s)
- Anne Sofie Andreasen
- Department of Intensive Care, Copenhagen University Hospital - Herlev, Herlev, Denmark
| | - Mik Wetterslev
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Martin Ingi Sigurdsson
- Division of Anesthesia and Intensive Care Medicine, Landspitali - The National University Hospital of Iceland, Reykjavik, Iceland
- Faculty of Medicine, University of Iceland, Reykjavik, Iceland
| | - Jeppe Bove
- Department of Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Tayyba Naz Aslam
- Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kati Järvelä
- Heart Hospital, Tampere University Hospital, Tampere, Finland
| | - Mette Poulsen
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lina De Geer
- Department of Anaesthesiology and Intensive Care, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Arnav Agarwal
- Division of General Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- MAGIC Evidence Ecosystem Foundation, Norway
| | | | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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4
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Ellekjaer KL, Perner A, Sivapalan P, Møller MH. Acetate- versus lactate-buffered crystalloid solutions: A systematic review with meta-analysis and trial sequential analysis. Acta Anaesthesiol Scand 2022; 66:782-794. [PMID: 35488485 PMCID: PMC9543208 DOI: 10.1111/aas.14076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 02/25/2022] [Accepted: 04/06/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE There is a widespread use of buffered crystalloid solutions in clinical practice. However, guidelines do not distinguish between specific types of buffered solutions and clinical equipoise exists. We aimed to assess the desirable and undesirable effects of acetate- versus lactate-buffered solutions in hospitalised patients. METHODS We conducted a systematic review with meta-analysis and trial sequential analysis of randomised clinical trials assessing the use of acetate- versus lactate-buffered solutions for intravenous administration in hospitalised adults and children. The primary outcome was all-cause short-term mortality. We adhered to our published protocol, the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement, the Cochrane Handbook and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology. RESULTS We included five RCTs enrolling 390 patients. We found no statistically significant difference in short-term mortality (random effects, risk ratio [RR] 0.29; 95% confidence interval [CI] 0.06-1.51, p = .14, I2 = 0%) or hospital length of stay (LOS) (random effects, mean difference [MD]-1.31, 95% CI -3.66 to 1.05, p = .28, I2 = 0%) between acetate- versus lactate-buffered solutions. The quality of evidence was very low. Data regarding intensive care unit LOS were reported by three trials and duration of vasopressor treatment by one trial; none of these data allowed for pooling in meta-analyses. No trials reported data on long-term mortality, health-related quality of life, adverse events, duration of mechanical ventilation or renal replacement therapy. CONCLUSION In this systematic review, we found very low quantity and quality of evidence on the use of acetate- versus lactate-buffered solutions in hospitalised patients.
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Affiliation(s)
- Karen Louise Ellekjaer
- Department of Intensive Care 4131Copenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Anders Perner
- Department of Intensive Care 4131Copenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Praleene Sivapalan
- Department of Intensive Care 4131Copenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - Morten Hylander Møller
- Department of Intensive Care 4131Copenhagen University Hospital RigshospitaletCopenhagenDenmark
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Morita Y, Williams B, Yamada Y, Kariya T. Effect of Anesthesia Machine Ventilator and ICU Ventilator on Intraoperative Oxygenation and Ventilation. J Cardiothorac Vasc Anesth 2022; 36:3175-3186. [PMID: 35624038 DOI: 10.1053/j.jvca.2022.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/21/2022] [Accepted: 03/17/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Yoshihisa Morita
- Department of Anesthesiology, University of Maryland, Baltimore, MD.
| | | | - Yoshitsugu Yamada
- Department of Anesthesiology, International University of Health and Welfare, Mita Hospital, Tokyo, Japan
| | - Taro Kariya
- Department of Anesthesiology, University of Tokyo, Tokyo, Japan
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6
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Bion J, Alderman JE. Peer review of quality of care: methods and metrics. BMJ Qual Saf 2022; 32:bmjqs-2022-014985. [PMID: 35863875 DOI: 10.1136/bmjqs-2022-014985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Julian Bion
- Intensive Care Medicine, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Joseph Edward Alderman
- Intensive Care Medicine, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
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Pallanch O, Ortalda A, Pelosi P, Latronico N, Sartini C, Lombardi G, Marchetti C, Maimeri N, Zangrillo A, Cabrini L. Effects on health-related quality of life of interventions affecting survival in critically ill patients: a systematic review. Crit Care 2022; 26:126. [PMID: 35524315 PMCID: PMC9075706 DOI: 10.1186/s13054-022-03993-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/24/2022] [Indexed: 12/12/2022] Open
Abstract
Survival has been considered the cornerstone for clinical outcome evaluation in critically ill patients admitted to intensive care unit (ICU). There is evidence that ICU survivors commonly show impairments in long-term outcomes such as quality of life (QoL) considering them as the most relevant ones. In the last years, the concept of patient-important outcomes has been introduced and increasingly reported in peer-reviewed publications. In the present systematic review, we evaluated how many randomized controlled trials (RCTs) were conducted on critically ill patients and reporting a benefit on survival reported also data on QoL. All RCTs investigating nonsurgical interventions that significantly reduced mortality in critically ill patients were searched on MEDLINE/PubMed, Scopus and Embase from inception until August 2021. In a second stage, for all the included studies, the outcome QoL was investigated. The primary outcome was to evaluate how many RCTs analyzing interventions reducing mortality reported also data on QoL. The secondary endpoint was to investigate if QoL resulted improved, worsened or not modified. Data on QoL were reported as evaluated outcome in 7 of the 239 studies (2.9%). The tools to evaluate QoL and QoL time points were heterogeneous. Four interventions showed a significant impact on QoL: Two interventions improved survival and QoL (pravastatin in subarachnoid hemorrhage, dexmedetomidine in elderly patients after noncardiac surgery), while two interventions reduced mortality but negatively influenced QoL (caloric restriction in patients with refeeding syndrome and systematic ICU admission in elderly patients). In conclusion, only a minority of RCTs in which an intervention demonstrated to affect mortality in critically ill patients reported also data on QoL. Future research in critical care should include patient-important outcomes like QoL besides mortality. Data on this topic should be collected in conformity with PROs statement and core outcome sets to guarantee quality and comparability of results.
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Affiliation(s)
- Ottavia Pallanch
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostic (DISC), University of Genoa, Viale Benedetto XV 6, Genoa, Italy. .,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy.
| | - Nicola Latronico
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy.,Department of Anesthesia, Intensive Care and Emergency, ASST Spedali Civili University Hospital, Piazzale Ospedali Civili, 1, Brescia, Italy.,"Alessandra Bono" University Research Center for LOng-Term Outcome (LOTO) in Survivors of Critical Illness, University of Brescia, Brescia, Italy
| | - Chiara Sartini
- ASST Sette Laghi, Ospedale di Circolo Fondazione Macchi, Varese, Italy
| | - Gaetano Lombardi
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Cristiano Marchetti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nicolò Maimeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Luca Cabrini
- ASST Sette Laghi, Ospedale di Circolo Fondazione Macchi, Varese, Italy.,Dipartimento di Biotecnologie e Scienze della Vita, Università degli Studi dell'insubria, Varese, Italy
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8
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Levy B, Girerd N, Amour J, Besnier E, Nesseler N, Helms J, Delmas C, Sonneville R, Guidon C, Rozec B, David H, Bougon D, Chaouch O, Walid O, Hervé D, Belin N, Gaide-Chevronnay L, Rossignol P, Kimmoun A, Duarte K, Slutsky AS, Brodie D, Fellahi JL, Ouattara A, Combes A. Effect of Moderate Hypothermia vs Normothermia on 30-Day Mortality in Patients With Cardiogenic Shock Receiving Venoarterial Extracorporeal Membrane Oxygenation: A Randomized Clinical Trial. JAMA 2022; 327:442-453. [PMID: 35103766 PMCID: PMC8808325 DOI: 10.1001/jama.2021.24776] [Citation(s) in RCA: 37] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 12/22/2021] [Indexed: 12/12/2022]
Abstract
IMPORTANCE The optimal approach to the use of venoarterial extracorporeal membrane oxygenation (ECMO) during cardiogenic shock is uncertain. OBJECTIVE To determine whether early use of moderate hypothermia (33-34 °C) compared with strict normothermia (36-37 °C) improves mortality in patients with cardiogenic shock receiving venoarterial ECMO. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial of patients (who were eligible if they had been endotracheally intubated and were receiving venoarterial ECMO for cardiogenic shock for <6 hours) conducted in the intensive care units at 20 French cardiac shock care centers between October 2016 and July 2019. Of 786 eligible patients, 374 were randomized. Final follow-up occurred in November 2019. INTERVENTIONS Early moderate hypothermia (33-34 °C; n = 168) for 24 hours or strict normothermia (36-37 °C; n = 166). MAIN OUTCOMES AND MEASURES The primary outcome was mortality at 30 days. There were 31 secondary outcomes including mortality at days 7, 60, and 180; a composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at days 30, 60, and 180; and days without requiring a ventilator or kidney replacement therapy at days 30, 60, and 180. Adverse events included rates of severe bleeding, sepsis, and number of units of packed red blood cells transfused during venoarterial ECMO. RESULTS Among the 374 patients who were randomized, 334 completed the trial (mean age, 58 [SD, 12] years; 24% women) and were included in the primary analysis. At 30 days, 71 patients (42%) in the moderate hypothermia group had died vs 84 patients (51%) in the normothermia group (adjusted odds ratio, 0.71 [95% CI, 0.45 to 1.13], P = .15; risk difference, -8.3% [95% CI, -16.3% to -0.3%]). For the composite outcome of death, heart transplant, escalation to left ventricular assist device implantation, or stroke at day 30, the adjusted odds ratio was 0.61 (95% CI, 0.39 to 0.96; P = .03) for the moderate hypothermia group compared with the normothermia group and the risk difference was -11.5% (95% CI, -23.2% to 0.2%). Of the 31 secondary outcomes, 30 were inconclusive. The incidence of moderate or severe bleeding was 41% in the moderate hypothermia group vs 42% in the normothermia group. The incidence of infections was 52% in both groups. The incidence of bacteremia was 20% in the moderate hypothermia group vs 30% in the normothermia group. CONCLUSIONS AND RELEVANCE In this randomized clinical trial involving patients with refractory cardiogenic shock treated with venoarterial ECMO, early application of moderate hypothermia for 24 hours did not significantly increase survival compared with normothermia. However, because the 95% CI was wide and included a potentially important effect size, these findings should be considered inconclusive. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02754193.
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Affiliation(s)
- Bruno Levy
- Médecine Intensive et Réanimation, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France
- INSERM U1116, Faculté de Médecine, Vandoeuvre-les-Nancy, France
- Université de Lorraine, Nancy, France
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d’Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, Frances
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation et d’Anesthésie de Chirurgie Cardiaque Paris Sud, Hôpital Privé Jacques Cartier, Massy, France
| | - Emmanuel Besnier
- Department of Anaesthesiology and Critical Care, Rouen University Hospital, Rouen, France
- Normandie University, UNIROUEN, INSERM U1096, EnVi, Rouen, France
| | - Nicolas Nesseler
- Department of Anesthesia and Critical Care, Pontchaillou, University Hospital of Rennes, Rennes, France
- University Rennes, CHU de Rennes, Inra, INSERM, Institut NUMECAN – UMR_A 1341, UMR_S 1241, CIC 1414 (Centre d’Investigation Clinique de Rennes), Rennes, France
| | - Julie Helms
- Université de Strasbourg, Faculté de Médecine, Hôpitaux Universitaires de Strasbourg, Service de Médecine Intensive-Réanimation, Nouvel Hôpital Civil, Strasbourg, France
| | - Clément Delmas
- Intensive Cardiac Care Unit, Rangueil University Hospital, Toulouse, France
| | - Romain Sonneville
- AP-HP, Bichat Hospital, Medical and infectious diseases ICU, Paris, France
| | | | - Bertrand Rozec
- Service d’Anesthésie-Réanimation, Hôpital G&R Laennec CHU de Nantes, Nantes, France
- L’institut du Thorax INSERM, CNRS, CHU Nantes, UNIV Nantes, Nantes, France
| | - Helène David
- Department of Anesthesiology and Critical Care Medicine, Arnaud de Villeneuve Hospital, CHU Montpellier, Montpellier, France
- Montpellier University, INSERM, CNRS, PhyMedExp, Montpellier, France
| | - David Bougon
- Service de Réanimation, Centre Hospitalier Annecy, Genevois, France
| | - Oussama Chaouch
- Hôpital Européen Georges Pompidou, AP-HP, Department of Anesthesiology and Critical Care Medicine, Université Paris Descartes, Paris, France
| | - Oulehri Walid
- Service d’Anesthésie-Réanimation et Médecine péri-Opératoire, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Dupont Hervé
- Réanimation Médico-Chirurgicale Cardio-Thoracique, Vasculaire et Respiratoire, CHU Amiens Picardie, Amiens, France
| | - Nicolas Belin
- Service de Réanimation Médicale, CHU Besançon, Besançon, France
| | - Lucie Gaide-Chevronnay
- Unité de Réanimation Cardiovasculaire et Thoracique, Pôle Anesthésie Réanimation, CHU de Grenoble Alpes, Grenoble, France
| | | | - Antoine Kimmoun
- Médecine Intensive et Réanimation, CHRU Nancy, Pôle Cardio-Médico-Chirurgical, Vandoeuvre-les-Nancy, France
| | - Kevin Duarte
- Université de Lorraine, Centre d’Investigations Cliniques Plurithématique, INSERM 1433, CHRU de Nancy, Institut Lorrain du Coeur et des Vaisseaux, Nancy, France
| | - Arthur S. Slutsky
- Keenan Research Center, Li Ka Shing Knowledge Institute, St Michael’s Hospital, Unity Health Toronto, Toronto, Ontario, Canada
- Department of Medicine, Surgery, and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Daniel Brodie
- Department of Medicine, College of Physicians and Surgeons, Columbia University, and the Center for Acute Respiratory Failure, New York-Presbyterian Hospital/Columbia University Medical Center, New York, New York
| | - Jean-Luc Fellahi
- Service d’Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
- Laboratoire CarMeN, INSERM 1060, Université Lyon 1 Claude Bernard, Lyon, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, Bordeaux, France
- University Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, Pessac, France
| | - Alain Combes
- Sorbonne Université, INSERM, UMRS_1166-ICAN, Institute of Cardiometabolism and Nutrition, Paris, France
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université Hôpital Pitié–Salpêtrière, Paris, France
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Notz Q, Lee ZY, Menger J, Elke G, Hill A, Kranke P, Roeder D, Lotz C, Meybohm P, Heyland DK, Stoppe C. Omega-6 sparing effects of parenteral lipid emulsions-an updated systematic review and meta-analysis on clinical outcomes in critically ill patients. Crit Care 2022; 26:23. [PMID: 35045885 PMCID: PMC8767697 DOI: 10.1186/s13054-022-03896-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/11/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Parenteral lipid emulsions in critical care are traditionally based on soybean oil (SO) and rich in pro-inflammatory omega-6 fatty acids (FAs). Parenteral nutrition (PN) strategies with the aim of reducing omega-6 FAs may potentially decrease the morbidity and mortality in critically ill patients. METHODS A systematic search of MEDLINE, EMBASE, CINAHL and CENTRAL was conducted to identify all randomized controlled trials in critically ill patients published from inception to June 2021, which investigated clinical omega-6 sparing effects. Two independent reviewers extracted bias risk, treatment details, patient characteristics and clinical outcomes. Random effect meta-analysis was performed. RESULTS 1054 studies were identified in our electronic search, 136 trials were assessed for eligibility and 26 trials with 1733 critically ill patients were included. The median methodologic score was 9 out of 14 points (95% confidence interval [CI] 7, 10). Omega-6 FA sparing PN in comparison with traditional lipid emulsions did not decrease overall mortality (20 studies; risk ratio [RR] 0.91; 95% CI 0.76, 1.10; p = 0.34) but hospital length of stay was substantially reduced (6 studies; weighted mean difference [WMD] - 6.88; 95% CI - 11.27, - 2.49; p = 0.002). Among the different lipid emulsions, fish oil (FO) containing PN reduced the length of intensive care (8 studies; WMD - 3.53; 95% CI - 6.16, - 0.90; p = 0.009) and rate of infectious complications (4 studies; RR 0.65; 95% CI 0.44, 0.95; p = 0.03). When FO was administered as a stand-alone medication outside PN, potential mortality benefits were observed compared to standard care. CONCLUSION Overall, these findings highlight distinctive omega-6 sparing effects attributed to PN. Among the different lipid emulsions, FO in combination with PN or as a stand-alone treatment may have the greatest clinical impact. Trial registration PROSPERO international prospective database of systematic reviews (CRD42021259238).
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Affiliation(s)
- Quirin Notz
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Zheng-Yii Lee
- Department of Anesthesiology, University of Malaya, Kuala Lumpur, Malaysia
| | - Johannes Menger
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Gunnar Elke
- Department of Anesthesiology and Intensive Care Medicine, University Medical Center Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - Aileen Hill
- Department of Anesthesiology and Intensive Care Medicine, University Hospital RWTH Aachen, Aachen, Germany
| | - Peter Kranke
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Daniel Roeder
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Christopher Lotz
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Patrick Meybohm
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, Canada
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Canada
| | - Christian Stoppe
- Department of Anesthesiology, Intensive Care, Emergency and Pain Medicine, University Hospital Wuerzburg, Wuerzburg, Germany.
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10
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Munch MW, Myatra SN, Vijayaraghavan BKT, Saseedharan S, Benfield T, Wahlin RR, Rasmussen BS, Andreasen AS, Poulsen LM, Cioccari L, Khan MS, Kapadia F, Divatia JV, Brøchner AC, Bestle MH, Helleberg M, Michelsen J, Padmanaban A, Bose N, Møller A, Borawake K, Kristiansen KT, Shukla U, Chew MS, Dixit S, Ulrik CS, Amin PR, Chawla R, Wamberg CA, Shah MS, Darfelt IS, Jørgensen VL, Smitt M, Granholm A, Kjær MBN, Møller MH, Meyhoff TS, Vesterlund GK, Hammond NE, Micallef S, Bassi A, John O, Jha A, Cronhjort M, Jakob SM, Gluud C, Lange T, Kadam V, Marcussen KV, Hollenberg J, Hedman A, Nielsen H, Schjørring OL, Jensen MQ, Leistner JW, Jonassen TB, Kristensen CM, Clapp EC, Hjortsø CJS, Jensen TS, Halstad LS, Bak ERB, Zaabalawi R, Metcalf-Clausen M, Abdi S, Hatley EV, Aksnes TS, Gleipner-Andersen E, Alarcón AF, Yamin G, Heymowski A, Berggren A, La Cour K, Weihe S, Pind AH, Engstrøm J, Jha V, Venkatesh B, Perner A. Effect of 12 mg vs 6 mg of Dexamethasone on the Number of Days Alive Without Life Support in Adults With COVID-19 and Severe Hypoxemia: The COVID STEROID 2 Randomized Trial. JAMA 2021; 326:1807-1817. [PMID: 34673895 PMCID: PMC8532039 DOI: 10.1001/jama.2021.18295] [Citation(s) in RCA: 147] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
IMPORTANCE A daily dose with 6 mg of dexamethasone is recommended for up to 10 days in patients with severe and critical COVID-19, but a higher dose may benefit those with more severe disease. OBJECTIVE To assess the effects of 12 mg/d vs 6 mg/d of dexamethasone in patients with COVID-19 and severe hypoxemia. DESIGN, SETTING, AND PARTICIPANTS A multicenter, randomized clinical trial was conducted between August 2020 and May 2021 at 26 hospitals in Europe and India and included 1000 adults with confirmed COVID-19 requiring at least 10 L/min of oxygen or mechanical ventilation. End of 90-day follow-up was on August 19, 2021. INTERVENTIONS Patients were randomized 1:1 to 12 mg/d of intravenous dexamethasone (n = 503) or 6 mg/d of intravenous dexamethasone (n = 497) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was the number of days alive without life support (invasive mechanical ventilation, circulatory support, or kidney replacement therapy) at 28 days and was adjusted for stratification variables. Of the 8 prespecified secondary outcomes, 5 are included in this analysis (the number of days alive without life support at 90 days, the number of days alive out of the hospital at 90 days, mortality at 28 days and at 90 days, and ≥1 serious adverse reactions at 28 days). RESULTS Of the 1000 randomized patients, 982 were included (median age, 65 [IQR, 55-73] years; 305 [31%] women) and primary outcome data were available for 971 (491 in the 12 mg of dexamethasone group and 480 in the 6 mg of dexamethasone group). The median number of days alive without life support was 22.0 days (IQR, 6.0-28.0 days) in the 12 mg of dexamethasone group and 20.5 days (IQR, 4.0-28.0 days) in the 6 mg of dexamethasone group (adjusted mean difference, 1.3 days [95% CI, 0-2.6 days]; P = .07). Mortality at 28 days was 27.1% in the 12 mg of dexamethasone group vs 32.3% in the 6 mg of dexamethasone group (adjusted relative risk, 0.86 [99% CI, 0.68-1.08]). Mortality at 90 days was 32.0% in the 12 mg of dexamethasone group vs 37.7% in the 6 mg of dexamethasone group (adjusted relative risk, 0.87 [99% CI, 0.70-1.07]). Serious adverse reactions, including septic shock and invasive fungal infections, occurred in 11.3% in the 12 mg of dexamethasone group vs 13.4% in the 6 mg of dexamethasone group (adjusted relative risk, 0.83 [99% CI, 0.54-1.29]). CONCLUSIONS AND RELEVANCE Among patients with COVID-19 and severe hypoxemia, 12 mg/d of dexamethasone compared with 6 mg/d of dexamethasone did not result in statistically significantly more days alive without life support at 28 days. However, the trial may have been underpowered to identify a significant difference. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04509973 and ctri.nic.in Identifier: CTRI/2020/10/028731.
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Affiliation(s)
| | - Marie W Munch
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Sheila N Myatra
- Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | | | | | - Thomas Benfield
- Department of Infectious Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Rebecka R Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | | | - Anne Sofie Andreasen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Herlev-Gentofte Hospital, Herlev, Denmark
| | - Lone M Poulsen
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Luca Cioccari
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mohd S Khan
- Rajendra Institute of Medical Sciences, Ranchi, India
| | | | | | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, Kolding Hospital, Kolding, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Hilleroed, Denmark
| | - Marie Helleberg
- Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens Michelsen
- Department of Anaesthesia and Intensive Care, Odense University Hospital, Odense, Denmark
| | | | | | - Anders Møller
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | | | - Klaus T Kristiansen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Urvi Shukla
- Symbiosis University Hospital and Research Centre, Lavale, India
| | - Michelle S Chew
- Department of Anaesthesia and Intensive Care Medicine, Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | | | - Charlotte S Ulrik
- Department of Respiratory Diseases, Copenhagen University Hospital-Amager and Hvidovre, Hvidovre, Denmark
| | - Pravin R Amin
- Bombay Hospital Institute of Medical Sciences, Mumbai, India
| | | | - Christian A Wamberg
- Department of Anaesthesia and Intensive Care, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Mehul S Shah
- Sir H. N. Reliance Foundation Hospital and Research Centre, Mumbai, India
| | - Iben S Darfelt
- Department of Anaesthesia and Intensive Care, Herning Hospital, Herning, Denmark
| | - Vibeke L Jørgensen
- Department of Thoracic Anaesthesia, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Margit Smitt
- Department of Neurointensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Maj-Brit N Kjær
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten H Møller
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tine S Meyhoff
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Gitte K Vesterlund
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Naomi E Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, Australia
| | - Sharon Micallef
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
| | - Abhinav Bassi
- The George Institute for Global Health, New Delhi, India
| | - Oommen John
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Medical Sciences, Manipal, India
| | - Anubhuti Jha
- The George Institute for Global Health, New Delhi, India
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Stephan M Jakob
- Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense
| | - Theis Lange
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Klaus V Marcussen
- Department of Anaesthesia and Intensive Care, Slagelse Hospital, Slagelse, Denmark
| | - Jacob Hollenberg
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anders Hedman
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Henrik Nielsen
- Aalborg University Hospital, Aalborg University, Aalborg, Denmark
| | | | - Marie Q Jensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jens W Leistner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Trine B Jonassen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Camilla M Kristensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Esben C Clapp
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Carl J S Hjortsø
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Thomas S Jensen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Liv S Halstad
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emilie R B Bak
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Reem Zaabalawi
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Matias Metcalf-Clausen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Suhayb Abdi
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emma V Hatley
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Tobias S Aksnes
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emil Gleipner-Andersen
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Arif F Alarcón
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Gabriel Yamin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Adam Heymowski
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anton Berggren
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Kirstine La Cour
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Sarah Weihe
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Alison H Pind
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Janus Engstrøm
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Capital Region, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Vivekanand Jha
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- The George Institute for Global Health, New Delhi, India
- Prasanna School of Public Health, Manipal Academy of Medical Sciences, Manipal, India
- School of Public Health, Imperial College, London, England
| | - Balasubramanian Venkatesh
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
- Department of Intensive Care, Wesley Hospital, Brisbane, Australia
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- The George Institute for Global Health, University of New South Wales, Sydney, Australia
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11
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Maves RC. Making sense of contradictory evidence in Covid-19 trials. Clin Infect Dis 2021:ciab012. [PMID: 33493302 PMCID: PMC7929038 DOI: 10.1093/cid/ciab012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Indexed: 11/22/2022] Open
Affiliation(s)
- Ryan C Maves
- Infectious Diseases and Critical Care Medicine Services, Naval Medical Center, San Diego, California, USA
- Department of Medicine, Uniformed Services University, Bethesda, Maryland, USA
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12
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McNally JD, O'Hearn K, Fergusson DA, Lougheed J, Doherty DR, Maharajh G, Weiler H, Jones G, Khamessan A, Redpath S, Geier P, McIntyre L, Lawson ML, Girolamo T, Menon K. Prevention of post-cardiac surgery vitamin D deficiency in children with congenital heart disease: a pilot feasibility dose evaluation randomized controlled trial. Pilot Feasibility Stud 2020; 6:159. [PMID: 33110622 PMCID: PMC7583219 DOI: 10.1186/s40814-020-00700-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 09/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background The vast majority of children undergoing cardiac surgery have low vitamin D levels post-operative, which may contribute to greater illness severity and worse clinical outcomes. Prior to the initiation of a large phase III clinical trial focused on clinical outcomes, studies are required to evaluate the feasibility of the study protocol, including whether the proposed dosing regimen can safely prevent post-operative vitamin D deficiency in this high-risk population. Methods We conducted a two-arm, double-blind dose evaluation randomized controlled trial in children requiring cardiopulmonary bypass for congenital heart disease. Pre-operatively, participants were randomized to receive cholecalciferol representing usual care (< 1 year = 400 IU/day, > 1 year = 600 IU/day) or a higher dose approximating the Institute of Medicine tolerable upper intake level (< 1 year = 1600 IU/day, > 1 year = 2400 IU/day). The feasibility outcomes were post-operative vitamin D status (primary), vitamin D-related adverse events, accrual rate, study withdrawal rate, blinding, and protocol non-adherence. Results Forty-six children were randomized, and five withdrew prior to surgery, leaving 41 children (21 high dose, 20 usual care) in the final analysis. The high dose group had higher 25-hydroxyvitamin D concentrations both intraoperatively (mean difference + 25.9 nmol/L; 95% CI 8.3–43.5) and post-operatively (mean difference + 17.2 nmol/L; 95% CI 5.5–29.0). Fewer participants receiving high-dose supplementation had post-operative serum 25-hydroxyvitamin D concentrations under 50 nmol/L, compared with usual care (RR 0.31, 95% CI 0.11–0.87). Post-operative vitamin D status was associated with the treatment arm and the number of doses received. There were no cases of hypercalcemia, and no significant adverse events related to vitamin D. While only 75% of the target sample size was recruited (limited funding), the consent rate (83%), accrual rate (1.5 per site month), number of withdrawals (11%), and ability to maintain blinding support feasibility of a larger trial. Conclusions Pre-operative daily high-dose supplementation improved vitamin D status pre-operatively and at time of pediatric ICU admission. The protocol for a more definitive trial should limit enrollment of children with at least 30 days between randomization and surgery to allow adequate duration of supplementation or consider a loading dose. Trial registration ClinicalTrials.gov, NCT01838447. Registered on April 24, 2013
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Affiliation(s)
- James Dayre McNally
- Department of Pediatrics, Division of Critical Care, University of Ottawa, Ottawa, Canada.,CHEO, 401 Smyth Road, Ottawa, ON K1H 8L1 Canada
| | - Katie O'Hearn
- Children's Hospital of Eastern Ontario Research Institute, Ottawa, Canada
| | - Dean A Fergusson
- Department of Medicine, University of Ottawa, Ottawa, Canada.,Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Canada
| | - Jane Lougheed
- Department of Pediatrics, Division of Cardiology, University of Ottawa, Ottawa, Canada
| | | | - Gyaandeo Maharajh
- Department of Pediatric Surgery, Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Hope Weiler
- School of Human Nutrition, Faculty of Agricultural and Environmental Sciences, McGill University, Montreal, Canada
| | - Glenville Jones
- School of Medicine, Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Canada
| | - Ali Khamessan
- Euro-Pharm International Canada Inc., Montreal, Canada
| | - Stephanie Redpath
- Department of Pediatrics, Division of Neonatology, University of Ottawa, Ottawa, Canada
| | - Pavel Geier
- Department of Pediatrics, Division of Nephrology, University of Ottawa, Ottawa, Canada
| | - Lauralyn McIntyre
- Department of Medicine (Division of Critical Care), Ottawa Hospital Research Institute (OHRI), University of Ottawa, Ottawa, Canada
| | - Margaret L Lawson
- Department of Pediatrics, Division of Endocrinology, University of Ottawa, Ottawa, Canada
| | - Tara Girolamo
- Department of Pediatric Surgery, Division of Cardiovascular Surgery, University of Ottawa, Ottawa, Canada
| | - Kusum Menon
- Department of Pediatrics, Division of Critical Care, University of Ottawa, Ottawa, Canada
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13
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Møller MH, Derde LPG, Sweeney RM. Focus on clinical trial interpretation. Intensive Care Med 2020; 46:790-792. [PMID: 32166347 DOI: 10.1007/s00134-020-06000-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 03/03/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark. .,Centre for Research in Intensive Care, Copenhagen, Denmark.
| | - Lennie P G Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands.,Intensive Care Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rob Mac Sweeney
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, Northern Ireland
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14
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Girbes ARJ, de Grooth HJ. Time to stop randomized and large pragmatic trials for intensive care medicine syndromes: the case of sepsis and acute respiratory distress syndrome. J Thorac Dis 2020; 12:S101-S109. [PMID: 32148932 DOI: 10.21037/jtd.2019.10.36] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
In this paper we discuss the limitations of large randomized controlled trials with mortality endpoints in patients with critical illness associated diagnoses such as sepsis. When patients with the same syndrome diagnosis do not share the pathways that lead to death (the attributable risk), any therapy can only lead to small effects in these populations. Using Monte Carlo simulations, we show how the syndrome-attributable risks of critical illness-associated diagnoses are likely overestimated using common statistical methods. This overestimation of syndrome-attributable risks leads to a corresponding overestimation of attainable treatment effects and an underestimation of required sample sizes. We demonstrate that larger and more 'pragmatic' randomized trials are not the solution because they decrease therapeutic and diagnostic precision, the therapeutic effect size and the probability of finding a beneficial effect. Finally, we argue that the most logical solution is a renewed focus on mechanistic research into the complexities of critical illness syndromes.
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Affiliation(s)
- Armand R J Girbes
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
| | - Harm-Jan de Grooth
- Department of Intensive Care Medicine, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands.,Department of Anesthesiology, Amsterdam University Medical Centers, location VUmc, Amsterdam, The Netherlands
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15
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Afshari A, De Hert S. Pitfalls of clinical practice guidelines in the era of broken science: Let's raise the standards. Eur J Anaesthesiol 2019; 35:903-906. [PMID: 30376487 DOI: 10.1097/eja.0000000000000892] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Affiliation(s)
- Arash Afshari
- From the Department of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark (AA) and Department of Anaesthesiology and Perioperative Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium (SDH)
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16
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Sartini C, Lomivorotov V, Pieri M, Lopez-Delgado JC, Baiardo Redaelli M, Hajjar L, Pisano A, Likhvantsev V, Fominskiy E, Bradic N, Cabrini L, Novikov M, Avancini D, Riha H, Lembo R, Gazivoda G, Paternoster G, Wang C, Tamà S, Alvaro G, Wang CY, Roasio A, Ruggeri L, Yong CY, Pasero D, Severi L, Pasin L, Mancino G, Mura P, Musu M, Spadaro S, Conte M, Lobreglio R, Silvetti S, Votta CD, Belletti A, Di Fraja D, Corradi F, Brusasco C, Saporito E, D'Amico A, Sardo S, Ortalda A, Riefolo C, Fabrizio M, Zangrillo A, Bellomo R, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Reducing Mortality. J Cardiothorac Vasc Anesth 2019; 33:1430-1439. [DOI: 10.1053/j.jvca.2018.11.026] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Indexed: 12/15/2022]
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17
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Møller MH, Laake JH, Myburgh JA, Alhazzani W, Perner A. The Magic Bullet in Sepsis or the Inflation of Chance Findings? Chest 2019; 152:222-223. [PMID: 28693775 DOI: 10.1016/j.chest.2017.04.181] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 04/11/2017] [Indexed: 12/16/2022] Open
Affiliation(s)
- Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark.
| | - Jon H Laake
- Department of Anaesthesiology, National Hospital (Rikshospitalet), Oslo, Norway
| | - John A Myburgh
- Department of Intensive Care Medicine, St. George Clinical School, University of New South Wales, and The George Institute for Global Health, Sydney, Australia
| | - Waleed Alhazzani
- Department of Medicine, and Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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18
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Bertaggia L, Baiardo Redaelli M, Lembo R, Sartini C, Cuffaro R, Corrao F, Zangrillo A, Landoni G, Bellomo R. The Fragility Index in peri‐operative randomised trials that reported significant mortality effects in adults. Anaesthesia 2019; 74:1057-1060. [DOI: 10.1111/anae.14656] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2019] [Indexed: 12/01/2022]
Affiliation(s)
- L. Bertaggia
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
| | - M. Baiardo Redaelli
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
| | - R. Lembo
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
| | - C. Sartini
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
| | - R. Cuffaro
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
| | - F. Corrao
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
| | - A. Zangrillo
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
- Vita‐Salute San Raffaele University MilanItaly
| | - G. Landoni
- Department of Anaesthesia and Intensive Care IRCCS San Raffaele Scientific Institute MilanItaly
- Vita‐Salute San Raffaele University MilanItaly
| | - R. Bellomo
- Faculty of Medicine University of Melbourne Melbourne Vic. Australia
- Australian and Intensive Care Research Centre School of Public Health and Preventive Medicine Monash University Melbourne Vic. Australia
- Department of Intensive Care Austin Hospital Melbourne Vic. Australia
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19
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Sartini C, Lomivorotov V, Pisano A, Riha H, Baiardo Redaelli M, Lopez-Delgado JC, Pieri M, Hajjar L, Fominskiy E, Likhvantsev V, Cabrini L, Bradic N, Avancini D, Wang CY, Lembo R, Novikov M, Paternoster G, Gazivoda G, Alvaro G, Roasio A, Wang C, Severi L, Pasin L, Mura P, Musu M, Silvetti S, Votta CD, Belletti A, Corradi F, Brusasco C, Tamà S, Ruggeri L, Yong CY, Pasero D, Mancino G, Spadaro S, Conte M, Lobreglio R, Di Fraja D, Saporito E, D'Amico A, Sardo S, Ortalda A, Yavorovskiy A, Riefolo C, Monaco F, Bellomo R, Zangrillo A, Landoni G. A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Increasing Mortality. J Cardiothorac Vasc Anesth 2019; 33:2685-2694. [PMID: 31064730 DOI: 10.1053/j.jvca.2019.03.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 03/10/2019] [Accepted: 03/11/2019] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings. DESIGN A systematic review of the literature followed by a consensus-based voting process. SETTING A web-based international consensus conference. PARTICIPANTS Two hundred fifty-one physicians from 46 countries. INTERVENTIONS The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines. MEASUREMENTS AND MAIN RESULTS The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. CONCLUSION The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.
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Affiliation(s)
- Chiara Sartini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | - Hynek Riha
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | | | - Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Ludhmila Hajjar
- Instituto do Coracao do Hospital das Clinicas, Sao Paulo, Brazil
| | - Evgeny Fominskiy
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Valery Likhvantsev
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Nikola Bradic
- Department of Cardiovascular Anesthesiology and Cardiac Intensive Medicine, University Hospital Dubrava, Zagreb, Croatia
| | - Daniele Avancini
- San Raffaele Telethon Institute for Gene Therapy (SR-Tiget), IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chew Yin Wang
- Anaesthesia and Intensive Care, University of Malaya, Kuala Lumpur, Malaysia
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maxim Novikov
- Saint Petersburg State University, Saint Petersburg, Russia
| | | | - Gordana Gazivoda
- Institute of Cardiovascular Diseases "Dedinje", Belgrade, Serbia
| | | | - Agostino Roasio
- Department of Anaesthesia and Intensive Care, Ospedale Cardinal Massaia di Asti, Asti, Italy
| | - Chengbin Wang
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Luca Severi
- Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Rome, Italy
| | | | - Paolo Mura
- Department of Anesthesia and Intensive Care Unit, Policlinico Duilio Casula AOU, Cagliari, Italy
| | - Mario Musu
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Simona Silvetti
- IRCCS Istituto Giannina Gaslini, Ospedale Pediatrico, Genoa, Italy
| | - Carmine Domenico Votta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Corradi
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Claudia Brusasco
- E.O. Ospedali Galliera, Genova, Italy and Università degli Studi di Pisa, Italy
| | - Simona Tamà
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Chow-Yen Yong
- Anaesthesia and Intensive Care, Hospital Pulau Pinang, Georgetown, Malaysia
| | - Daniela Pasero
- Department of Anesthesia and Intensive Care, A.O.U. Cittàdella Salute e della Scienza, Turin, Italy
| | | | - Savino Spadaro
- Department Morphology, Surgery and Experimental Medicine, Intensive Care Unit, University of Ferrara, Italy
| | | | - Rosetta Lobreglio
- Anesthesia and Intensive Care A.O.U Città della salute e della Scienza, Turin, Italy
| | - Diana Di Fraja
- Division of Cardiac Anesthesia and Intensive Care Unit, AORN dei Colli - Monaldi Hospital, Naples, Italy
| | | | | | - Salvatore Sardo
- Department of Medical Sciences and Public Health, University of Cagliari, Monserrato, Italy
| | - Alessandro Ortalda
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Andrey Yavorovskiy
- Department of Anesthesiology and Intensive Care, Sechenov First Moscow State Medical University, and Moscow Regional Clinical and Research Institute, Moscow, Russian Federation
| | - Claudio Riefolo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre, Melbourne, Australia
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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Cabrini L, Brusasco C, Roasio A, Corradi F, Nardelli P, Filippini M, Cotticelli V, Belletti A, Ferrera L, Antonucci E, Baiardo Redaelli M, Lattuada M, Colombo S, Olper L, Ponzetta G, Ananiadou S, Monti G, Severi L, Maj G, Giardina G, Biondi-Zoccai G, Benedetto U, Gemma M, Cavallero SSM, Hajjar LA, Zangrillo A, Bellomo R, Landoni G. Non-invAsive VentIlation for early General wArd respiraTory failurE (NAVIGATE): A multicenter randomized controlled study. Protocol and statistical analysis plan. Contemp Clin Trials 2019; 78:126-132. [PMID: 30739002 DOI: 10.1016/j.cct.2019.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Revised: 01/31/2019] [Accepted: 02/06/2019] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Few randomized trials have evaluated the use of non-invasive ventilation (NIV) for early acute respiratory failure (ARF) in non-intensive care unit (ICU) wards. The aim of this study is to test the hypothesis that early NIV for mild-moderate ARF in non-ICU wards can prevent development of severe ARF. DESIGN Pragmatic, parallel group, randomized, controlled, multicenter trial. SETTING Non-intensive care wards of tertiary centers. PATIENTS Non-ICU ward patients with mild to moderate ARF without an established indication for NIV. INTERVENTIONS Patients will be randomized to receive or not receive NIV in addition to best available care. MEASUREMENTS AND MAIN RESULTS We will enroll 520 patients, 260 in each group. The primary endpoint of the study will be the development of severe ARF. Secondary endpoints will be 28-day mortality, length of hospital stay, safety of NIV in non-ICU environments, and a composite endpoint of all in-hospital respiratory complications. CONCLUSIONS This trial will help determine whether the early use of NIV in non-ICU wards can prevent progression from mild-moderate ARF to severe ARF.
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Affiliation(s)
- Luca Cabrini
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Claudia Brusasco
- Department of Anesthesia and Intensive Care, EO Ospedali Galliera, Genova, Italy
| | - Agostino Roasio
- Department of Anesthesia and Intensive Care, Ospedale Civile di Asti, Asti, Italy
| | - Francesco Corradi
- Department of Anesthesia and Intensive Care, EO Ospedali Galliera, Genova, Italy; Università degli Studi di Pisa, Pisa, Italy
| | - Pasquale Nardelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Matteo Filippini
- Department of Anesthesia and Critical Care Medicine, Spedali Civili, Brescia, Italy
| | | | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Lorenzo Ferrera
- Department of Pneumology, Ospedale Villa Scassi ASL 3 Genovese, Genova, Italy
| | - Elio Antonucci
- Department of Emergency-Urgency Medicine, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Martina Baiardo Redaelli
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Lattuada
- Department of Anesthesia and Intensive Care, EO Ospedali Galliera, Genova, Italy
| | - Sergio Colombo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luigi Olper
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Ponzetta
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Sofia Ananiadou
- Department of Anesthesia and Intensive Care, ASST Cremona, Cremona, Italy
| | - Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Luca Severi
- Department of Anesthesia and Intensive Care, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
| | - Giulia Maj
- Department of Anesthesia and Intensive Care, Sant'Antonio e Biagio e Cesare Arrigo Hospital, Alessandria, Italy
| | - Giuseppe Giardina
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; IRCCS NEUROMED, Pozzilli, IS, Italy
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, School of Clinical Sciences, Bristol, United Kingdom
| | - Marco Gemma
- Department of Anesthesia and Intensive Care - Ospedale Fatebenefratelli (ASST Fatebenefratelli-Sacco), Milan, Italy
| | | | - Ludhmila Abrahao Hajjar
- Department of Cardiopneumology, Heart Institute, Faculty of Medicine, University of Sao Paulo, Hospital Siriolibanes, Sao Paulo, Brazil
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University Milan, Italy
| | - Rinaldo Bellomo
- Intensive Care Unit, Austin Hospital, Heidelberg, Melbourne, Australia; Australian and New Zealand Intensive Care Research Center, Monash University, Melbourne, VIC, Australia; School of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University Milan, Italy.
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Landoni G, Pieri M, Young PJ, Bellomo R. Why do multicenter randomized controlled trials not confirm the positive findings of single center randomized controlled trials in acute care? Minerva Anestesiol 2019; 85. [DOI: 10.23736/s0375-9393.18.13070-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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22
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Is research from databases reliable? No. Intensive Care Med 2019; 45:115-117. [DOI: 10.1007/s00134-018-5073-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Accepted: 01/19/2018] [Indexed: 02/05/2023]
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23
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Innovation and safety in critical care: should we collaborate with the industry? Con. Intensive Care Med 2018; 44:2279-2281. [PMID: 30406807 DOI: 10.1007/s00134-018-5295-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 06/29/2018] [Indexed: 10/27/2022]
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Afshari A, Møller MH. Broken science and the failure of academics-resignation or reaction? Acta Anaesthesiol Scand 2018; 62:1038-1040. [PMID: 29943406 DOI: 10.1111/aas.13167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- A Afshari
- Department of Anesthesia, Mother and Children's Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - M H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
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26
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Do trials that report a neutral or negative treatment effect improve the care of critically ill patients? Yes. Intensive Care Med 2018; 44:1985-1988. [PMID: 29947880 DOI: 10.1007/s00134-018-5129-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 03/05/2018] [Indexed: 12/30/2022]
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Affiliation(s)
| | - Raj Nichani
- Anaesthetic Department, Blackpool Victoria Hospital, UK
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28
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Perner A, Cecconi M, Cronhjort M, Darmon M, Jakob SM, Pettilä V, van der Horst ICC. Expert statement for the management of hypovolemia in sepsis. Intensive Care Med 2018; 44:791-798. [PMID: 29696295 DOI: 10.1007/s00134-018-5177-x] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2018] [Accepted: 04/11/2018] [Indexed: 12/13/2022]
Abstract
Hypovolemia is frequent in patients with sepsis and may contribute to worse outcome. The management of these patients is impeded by the low quality of the evidence for many of the specific components of the care. In this paper, we discuss recent advances and controversies in this field and give expert statements for the management of hypovolemia in patients with sepsis including triggers and targets for fluid therapy and volumes and types of fluid to be given. Finally, we point to unanswered questions and suggest a roadmap for future research.
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Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Maurizio Cecconi
- Department Anaesthesia and Intensive Care Units, IRCCS Istituto Clinico Humanitas, Humanitas University, Milan, Italy
| | - Maria Cronhjort
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Michael Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
- Paris-7 Medical School, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Bern (Inselspital), University of Bern, Bern, Switzerland
| | - Ville Pettilä
- Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Iwan C C van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
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Møller MH, Granholm A, Junttila E, Haney M, Oscarsson-Tibblin A, Haavind A, Laake JH, Wilkman E, Sverrisson KÖ, Perner A. Scandinavian SSAI clinical practice guideline on choice of inotropic agent for patients with acute circulatory failure. Acta Anaesthesiol Scand 2018; 62:420-450. [PMID: 29479665 PMCID: PMC5888146 DOI: 10.1111/aas.13089] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 12/28/2017] [Accepted: 01/03/2018] [Indexed: 12/22/2022]
Abstract
Background Adult critically ill patients often suffer from acute circulatory failure and those with low cardiac output may be treated with inotropic agents. The aim of this Scandinavian Society of Anaesthesiology and Intensive Care Medicine guideline was to present patient‐important treatment recommendations on this topic. Methods This guideline was developed according to GRADE. We assessed the following subpopulations of patients with shock: (1) shock in general, (2) septic shock, (3) cardiogenic shock, (4) hypovolemic shock, (5) shock after cardiac surgery, and (6) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality and serious adverse reactions. Results For all patients, we suggest against the routine use of any inotropic agent, including dobutamine, as compared to placebo/no treatment (very low quality of evidence). For patients with shock in general, and in those with septic and other types of shock, we suggest using dobutamine rather than levosimendan or epinephrine (very low quality of evidence). For patients with cardiogenic shock and in those with shock after cardiac surgery, we suggest using dobutamine rather than milrinone (very low quality of evidence). For the other clinical questions, we refrained from giving any recommendations or suggestions. Conclusions We suggest against the routine use of any inotropic agent in adult patients with shock. If used, we suggest using dobutamine rather than other inotropic agents for the majority of patients, however, the quality of evidence was very low, implying high uncertainty on the balance between the benefits and harms of inotropic agents.
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Affiliation(s)
- M. H. Møller
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - A. Granholm
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - E. Junttila
- Department of Anaesthesiology; Tampere University Hospital; Tampere Finland
| | - M. Haney
- Anaesthesiology and Intensive Care Medicine; Umeå University; Umeå Sweden
| | - A. Oscarsson-Tibblin
- Department of Anaesthesiology and Intensive Care; Department of Medicine and Health; Linköping University; Linköping Sweden
| | - A. Haavind
- Department of Anaesthesiology and Intensive Care; University Hospital Northern Norway; Tromsø Norway
| | - J. H. Laake
- Division of Critical Care; Oslo University Hospital; Oslo Norway
| | - E. Wilkman
- Division of Intensive Care Medicine; Department of Perioperative, Intensive Care and Pain Medicine; Helsinki University Hospital; University of Helsinki; Helsinki Finland
| | - K. Ö. Sverrisson
- Department of Anesthesia & Critical Care; Landspitali University Hospital of Iceland; Reykjavik Iceland
| | - A. Perner
- Department of Intensive Care 4131; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
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Niven DJ, McCormick TJ, Straus SE, Hemmelgarn BR, Jeffs L, Barnes TRM, Stelfox HT. Reproducibility of clinical research in critical care: a scoping review. BMC Med 2018; 16:26. [PMID: 29463308 PMCID: PMC5820784 DOI: 10.1186/s12916-018-1018-6] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Accepted: 01/31/2018] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND The ability to reproduce experiments is a defining principle of science. Reproducibility of clinical research has received relatively little scientific attention. However, it is important as it may inform clinical practice, research agendas, and the design of future studies. METHODS We used scoping review methods to examine reproducibility within a cohort of randomized trials examining clinical critical care research and published in the top general medical and critical care journals. To identify relevant clinical practices, we searched the New England Journal of Medicine, The Lancet, and JAMA for randomized trials published up to April 2016. To identify a comprehensive set of studies for these practices, included articles informed secondary searches within other high-impact medical and specialty journals. We included late-phase randomized controlled trials examining therapeutic clinical practices in adults admitted to general medical-surgical or specialty intensive care units (ICUs). Included articles were classified using a reproducibility framework. An original study was the first to evaluate a clinical practice. A reproduction attempt re-evaluated that practice in a new set of participants. RESULTS Overall, 158 practices were examined in 275 included articles. A reproduction attempt was identified for 66 practices (42%, 95% CI 33-50%). Original studies reported larger effects than reproduction attempts (primary endpoint, risk difference 16.0%, 95% CI 11.6-20.5% vs. 8.4%, 95% CI 6.0-10.8%, P = 0.003). More than half of clinical practices with a reproduction attempt demonstrated effects that were inconsistent with the original study (56%, 95% CI 42-68%), among which a large number were reported to be efficacious in the original study and to lack efficacy in the reproduction attempt (34%, 95% CI 19-52%). Two practices reported to be efficacious in the original study were found to be harmful in the reproduction attempt. CONCLUSIONS A minority of critical care practices with research published in high-profile journals were evaluated for reproducibility; less than half had reproducible effects.
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Affiliation(s)
- Daniel J Niven
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada.
| | - T Jared McCormick
- Department of Anesthesiology and Pain Medicine, University of Ottawa, 1053 Carling Avenue, B302, Ottawa, ON, K1Y 4E9, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute of St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Brenda R Hemmelgarn
- Department of Community Health Sciences, University of Calgary, 3280 Hospital Drive NW, Calgary, AB, T2N 4Z6, Canada
| | - Lianne Jeffs
- St. Michael's Hospital Volunteer Association Chair in Nursing and Scientist with the Keenan Research Center, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Institute of Health Policy Management and Faculty of Nursing, University of Toronto, 30 Bond Street, Toronto, ON, M5B 1W8, Canada
| | - Tavish R M Barnes
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Henry T Stelfox
- Department of Critical Care Medicine, University of Calgary, 3134 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
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Cost Analysis of Noninvasive Helmet Ventilation Compared with Use of Noninvasive Face Mask in ARDS. Can Respir J 2018; 2018:6518572. [PMID: 29670676 PMCID: PMC5833880 DOI: 10.1155/2018/6518572] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/04/2018] [Indexed: 12/13/2022] Open
Abstract
Intensive care unit (ICU) costs have doubled since 2000, totalling 108 billion dollars per year. Acute respiratory distress syndrome (ARDS) has a prevalence of 10.4% and a 28-day mortality of 34.8%. Noninvasive ventilation (NIV) is used in up to 30% of cases. A recent randomized controlled trial by Patel et al. (2016) showed lower intubation rates and 90-day mortality when comparing helmet to face mask NIV in ARDS. The population in the Patel et al. trial was used for cost analysis in this study. Projections of cost savings showed a decrease in ICU costs by $2527 and hospital costs by $3103 per patient, along with a 43.3% absolute reduction in intubation rates. Sensitivity analysis showed consistent cost reductions. Projected annual cost savings, assuming the current prevalence of ARDS, were $237538 in ICU costs and $291682 in hospital costs. At a national level, using yearly incidence of ARDS cases in American ICUs, this represents $449 million in savings. Helmet NIV, compared to face mask NIV, in nonintubated patients with ARDS, reduces ICU and hospital direct-variable costs along with intubation rates, LOS, and mortality. A large-scale cost-effectiveness analysis is needed to validate the findings.
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Landoni G, Lomivorotov V, Silvetti S, Nigro Neto C, Pisano A, Alvaro G, Hajjar LA, Paternoster G, Riha H, Monaco F, Szekely A, Lembo R, Aslan NA, Affronti G, Likhvantsev V, Amarelli C, Fominskiy E, Baiardo Redaelli M, Putzu A, Baiocchi M, Ma J, Bono G, Camarda V, Covello RD, Di Tomasso N, Labonia M, Leggieri C, Lobreglio R, Monti G, Mura P, Scandroglio AM, Pasero D, Turi S, Roasio A, Votta CD, Saporito E, Riefolo C, Sartini C, Brazzi L, Bellomo R, Zangrillo A. Nonsurgical Strategies to Reduce Mortality in Patients Undergoing Cardiac Surgery: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2018; 32:225-235. [DOI: 10.1053/j.jvca.2017.06.017] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Indexed: 11/11/2022]
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Anthon CT, Granholm A, Perner A, Laake JH, Møller MH. The effect of blinding on estimates of mortality in randomised clinical trials of intensive care interventions: protocol for a systematic review and meta-analysis. BMJ Open 2017; 7:e016187. [PMID: 28701412 PMCID: PMC5541632 DOI: 10.1136/bmjopen-2017-016187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Evidence exists that unblinded randomised clinical trials (RCTs) overestimate intervention effects compared with blinded RCTs. It has been suggested that this is less pronounced for objective (ie, not subject to interpretation) outcome measures, including mortality. This may not apply in the intensive care unit (ICU), as most deaths are preceded by decisions to withhold or withdraw treatments. Lack of blinding of physicians in RCTs of ICU interventions may potentially influence the decision towards a higher threshold for discontinuing treatment in patients who receive the investigational treatment and/or a lower threshold for discontinuing treatment in patients who receive the comparator (control). This may have important implications for patients, caregivers, researchers and society. Accordingly, we aim to assess whether lack of blinding affects mortality effect estimates in RCTs of ICU interventions. METHODS AND ANALYSIS We will conduct a systematic review with meta-analyses and assess the effect of blinding versus no blinding on mortality effect estimates in RCTs of interventions used in adult ICU patients.We will systematically search the Cochrane Library for systematic reviews reporting mortality effect estimates of any intervention used in adult ICU patients which includes at least one RCT with 'low risk of bias' in the bias domains 'blinding of participants and personnel' and/or 'blinding of outcome assessment' and one RCT with 'unclear' or 'high risk of bias' in the same bias domain(s). For each intervention, we will compare summary mortality effect estimates in blinded versus unblinded trials. ETHICS AND DISSEMINATION This research does not require ethical approval as we will use summary data from trials already approved by relevant ethical institutions. We will report the results in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) statement and submit the final paper to an international peer-reviewed journal. TRIAL REGISTRATION NUMBER PROSPERO, registration number: CRD42017056212.
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Affiliation(s)
- Carl Thomas Anthon
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Jon Henrik Laake
- Department of Anaesthesiology, National Hospital (Rikshospitalet), Oslo, Norway
| | - Morten Hylander Møller
- Department of Intensive Care 4131, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre for Research in Intensive Care (CRIC), Copenhagen, Denmark
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Perner A, Gordon AC, Angus DC, Lamontagne F, Machado F, Russell JA, Timsit JF, Marshall JC, Myburgh J, Shankar-Hari M, Singer M. The intensive care medicine research agenda on septic shock. Intensive Care Med 2017; 43:1294-1305. [DOI: 10.1007/s00134-017-4821-1] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2016] [Accepted: 04/25/2017] [Indexed: 12/15/2022]
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Interventions affecting mortality in critically ill and perioperative patients: A systematic review of contemporary trials. J Crit Care 2017; 41:107-111. [PMID: 28505485 DOI: 10.1016/j.jcrc.2017.05.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 05/03/2017] [Indexed: 11/22/2022]
Abstract
PURPOSE Confounders in randomized controlled trials (RCTs) reporting significant effects on mortality in critically ill patients using non-surgical techniques have not been systematically explored. We aimed to identify factors unrelated to the reported intervention that might have affected the findings and robustness of such trials. METHODS We searched Pubmed/MEDLINE for all RCTs on any non-surgical interventions reporting an effect on unadjusted mortality in critically ill patients between 1/1/2000 and 1/12/2015. We assessed: the number needed to treat/harm (NNT or NNH), sample size, trial design (blinded/unblinded, single or multinational, single or multicenter (sRCT or mRCT)), intention to treat (ITT) analysis, and countries of origin. RESULTS Almost half of RCTs were sRCTs. Median sample size was small, and 1/3 were not analyzed according to ITT principle. Lack of ITT analysis was associated with greater effect size (p=0.0028). Harm was more likely in mRCTs (p=0.002) and/or in blinded RCTs (p=0.003). Blinded RCTs had double sample size (p=0.007) and an increased NNT/NNH (p=0.002). Finally, mRCTs had higher NNT (p=0.005) and NNH (p=0.02), and harm was only detected in studies from Western countries (p=0.007). CONCLUSIONS These observations imply that major systematic biases exist and affect trial findings irrespective of the intervention being studied.
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Maslove DM, Lamontagne F, Marshall JC, Heyland DK. A path to precision in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:79. [PMID: 28366166 PMCID: PMC5376689 DOI: 10.1186/s13054-017-1653-x] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Precision medicine is increasingly touted as a groundbreaking new paradigm in biomedicine. In the ICU, the complexity and ambiguity of critical illness syndromes have been identified as fundamental justifications for the adoption of a precision approach to research and practice. Inherently protean diseases states such as sepsis and acute respiratory distress syndrome have manifestations that are physiologically and anatomically diffuse, and that fluctuate over short periods of time. This leads to considerable heterogeneity among patients, and conditions in which a “one size fits all” approach to therapy can lead to widely divergent results. Current ICU therapy can thus be seen as imprecise, with the potential to realize substantial gains from the adoption of precision medicine approaches. A number of challenges still face the development and adoption of precision critical care, a transition that may occur incrementally rather than wholesale. This article describes a few concrete approaches to addressing these challenges. First, novel clinical trial designs, including registry randomized controlled trials and platform trials, suggest ways in which conventional trials can be adapted to better accommodate the physiologic heterogeneity of critical illness. Second, beyond the “omics” technologies already synonymous with precision medicine, the data-rich environment of the ICU can generate complex physiologic signatures that could fuel precision-minded research and practice. Third, the role of computing infrastructure and modern informatics methods will be central to the pursuit of precision medicine in the ICU, necessitating close collaboration with data scientists. As work toward precision critical care continues, small proof-of-concept studies may prove useful in highlighting the potential of this approach.
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Affiliation(s)
- David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada. .,Department of Medicine, Queen's University, Kingston, ON, Canada. .,Department of Critical Care Medicine, Kingston General Hospital, Davies 2, 76 Stuart St., Kingston, Ontario, K7L 2V7, Canada.
| | - Francois Lamontagne
- Department of Medicine, Université de Sherbrooke, Sherbrooke, QC, Canada.,Centre de Recherche du CHU de Sherbrooke, Sherbrooke, QC, Canada.,Centre Hospitalier Universitaire de Sherbrooke, Sherbrooke, QC, Canada
| | - John C Marshall
- Department of Surgery, University of Toronto, Toronto, ON, Canada.,Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada.,St. Michael's Hospital, Toronto, ON, Canada
| | - Daren K Heyland
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.,Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, ON, Canada
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The authors reply. Crit Care Med 2017; 45:e467-e468. [DOI: 10.1097/ccm.0000000000002273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Landoni G, Pisano A, Lomivorotov V, Alvaro G, Hajjar L, Paternoster G, Nigro Neto C, Latronico N, Fominskiy E, Pasin L, Finco G, Lobreglio R, Azzolini ML, Buscaglia G, Castella A, Comis M, Conte A, Conte M, Corradi F, Dal Checco E, De Vuono G, Ganzaroli M, Garofalo E, Gazivoda G, Lembo R, Marianello D, Baiardo Redaelli M, Monaco F, Tarzia V, Mucchetti M, Belletti A, Mura P, Musu M, Pala G, Paltenghi M, Pasyuga V, Piras D, Riefolo C, Roasio A, Ruggeri L, Santini F, Székely A, Verniero L, Vezzani A, Zangrillo A, Bellomo R. Randomized Evidence for Reduction of Perioperative Mortality: An Updated Consensus Process. J Cardiothorac Vasc Anesth 2017; 31:719-730. [DOI: 10.1053/j.jvca.2016.07.017] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2016] [Indexed: 11/11/2022]
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Fuller BM, Ferguson IT, Mohr NM, Drewry AM, Palmer C, Wessman BT, Ablordeppey E, Keeperman J, Stephens RJ, Briscoe CC, Kolomiets AA, Hotchkiss RS, Kollef MH. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med 2017; 70:406-418.e4. [PMID: 28259481 DOI: 10.1016/j.annemergmed.2017.01.013] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Revised: 01/06/2017] [Accepted: 01/10/2017] [Indexed: 01/31/2023]
Abstract
STUDY OBJECTIVE We evaluated the efficacy of an emergency department (ED)-based lung-protective mechanical ventilation protocol for the prevention of pulmonary complications. METHODS This was a quasi-experimental, before-after study that consisted of a preintervention period, a run-in period of approximately 6 months, and a prospective intervention period. The intervention was a multifaceted ED-based mechanical ventilator protocol targeting lung-protective tidal volume, appropriate setting of positive end-expiratory pressure, rapid oxygen weaning, and head-of-bed elevation. A propensity score-matched analysis was used to evaluate the primary outcome, which was the composite incidence of acute respiratory distress syndrome and ventilator-associated conditions. RESULTS A total of 1,192 patients in the preintervention group and 513 patients in the intervention group were included. Lung-protective ventilation increased by 48.4% in the intervention group. In the propensity score-matched analysis (n=490 in each group), the primary outcome occurred in 71 patients (14.5%) in the preintervention group compared with 36 patients (7.4%) in the intervention group (adjusted odds ratio 0.47; 95% confidence interval [CI] 0.31 to 0.71). There was an increase in ventilator-free days (mean difference 3.7; 95% CI 2.3 to 5.1), ICU-free days (mean difference 2.4; 95% CI 1.0 to 3.7), and hospital-free days (mean difference 2.4; 95% CI 1.2 to 3.6) associated with the intervention. The mortality rate was 34.1% in the preintervention group and 19.6% in the intervention group (adjusted odds ratio 0.47; 95% CI 0.35 to 0.63). CONCLUSION Implementing a mechanical ventilator protocol in the ED is feasible and is associated with significant improvements in the delivery of safe mechanical ventilation and clinical outcome.
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Affiliation(s)
- Brian M Fuller
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO.
| | - Ian T Ferguson
- School of Medicine and Medical Science, University College Dublin, Dublin, Ireland
| | - Nicholas M Mohr
- Departments of Emergency Medicine and Anesthesiology, Division of Critical Care, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City, IA
| | - Anne M Drewry
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Christopher Palmer
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Brian T Wessman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Enyo Ablordeppey
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Jacob Keeperman
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO; Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Robert J Stephens
- Washington University School of Medicine in St. Louis, St. Louis, MO
| | | | - Angelina A Kolomiets
- School of Public Health and Social Justice, Saint Louis University, St. Louis, MO
| | - Richard S Hotchkiss
- Department of Anesthesiology, Division of Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
| | - Marin H Kollef
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Washington University School of Medicine in St. Louis, St. Louis, MO
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Belletti A, Benedetto U, Biondi-Zoccai G, Leggieri C, Silvani P, Angelini GD, Zangrillo A, Landoni G. The effect of vasoactive drugs on mortality in patients with severe sepsis and septic shock. A network meta-analysis of randomized trials. J Crit Care 2017; 37:91-98. [PMID: 27660923 DOI: 10.1016/j.jcrc.2016.08.010] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Revised: 07/04/2016] [Accepted: 08/08/2016] [Indexed: 02/05/2023]
Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Umberto Benedetto
- University of Bristol, School of Clinical Sciences, Bristol Heart Institute, Bristol, United Kingdom.
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Latina, Italy; Department of AngioCardioNeurology, IRCCS Neuromed, Pozzilli, Italy.
| | - Carlo Leggieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Paolo Silvani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Gianni D Angelini
- University of Bristol, School of Clinical Sciences, Bristol Heart Institute, Bristol, United Kingdom.
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
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41
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Cabrini L, Landoni G, Bocchino S, Lembo R, Monti G, Greco M, Zambon M, Colombo S, Pasin L, Beretta L, Zangrillo A. Long-Term Survival Rate in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation in Ordinary Wards. Crit Care Med 2016; 44:2139-2144. [DOI: 10.1097/ccm.0000000000001866] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Møller MH, Claudius C, Junttila E, Haney M, Oscarsson‐Tibblin A, Haavind A, Perner A. Scandinavian SSAI clinical practice guideline on choice of first-line vasopressor for patients with acute circulatory failure. Acta Anaesthesiol Scand 2016; 60:1347-1366. [PMID: 27576362 PMCID: PMC5213738 DOI: 10.1111/aas.12780] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 06/02/2016] [Accepted: 07/26/2016] [Indexed: 12/27/2022]
Abstract
Background Adult critically ill patients often suffer from acute circulatory failure, necessitating use of vasopressor therapy. The aim of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force for Acute Circulatory Failure was to present clinically relevant, evidence‐based treatment recommendations on this topic. Methods This guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. We assessed the following subpopulations of patients with acute circulatory failure: 1) shock in general, 2) septic shock, 3) cardiogenic shock, 4) hypovolemic shock and 5) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality, serious adverse reactions and quality‐of‐life. Results For patients with shock in general and those with septic shock, we recommend using norepinephrine rather than dopamine, and we suggest using norepinephrine rather than epinephrine, vasopressin analogues, and phenylephrine. For patients with cardiogenic shock and those with hypovolemic shock, we suggest using norepinephrine rather than dopamine, and we provide no recommendations/suggestions of norepinephrine vs. epinephrine, vasopressin analogues, and phenylephrine. For patients with other types of shock, including vasodilatory shock, we suggest using norepinephrine rather than dopamine, epinephrine, vasopressin analogues, and phenylephrine. Conclusions We recommend using norepinephrine rather than other vasopressors as first‐line treatment for the majority of adult critically ill patients with acute circulatory failure.
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Affiliation(s)
- M. H. Møller
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | - C. Claudius
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
| | - E. Junttila
- Department of Anaesthesiology Tampere University Hospital Tampere Finland
| | - M. Haney
- Anaesthesiology and Intensive Care Medicine Umeå University Umeå Sweden
| | - A. Oscarsson‐Tibblin
- Department of Anaesthesiology and Intensive Care Department of Medicine and Health Linköping University Linköping Sweden
| | - A. Haavind
- Department of Anaesthesiology and Intensive Care University Hospital Northern Norway Tromsø Norway
| | - A. Perner
- Department of Intensive Care Copenhagen University Hospital Rigshospitalet Denmark
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Defining the characteristics and expectations of fluid bolus therapy: A worldwide perspective. J Crit Care 2016; 35:126-32. [DOI: 10.1016/j.jcrc.2016.05.017] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/06/2016] [Accepted: 05/15/2016] [Indexed: 12/24/2022]
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Bellomo R, Landoni G, Young P. Improved survival in critically ill patients: are large RCTs more useful than personalized medicine? Yes. Intensive Care Med 2016; 42:1775-1777. [PMID: 27620285 DOI: 10.1007/s00134-016-4491-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2016] [Accepted: 08/03/2016] [Indexed: 01/08/2023]
Affiliation(s)
- Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Parkville, Melbourne, VIC, Australia. .,Austin Hospital, Studley Rd, Heidelberg, VIC, 3084, Australia.
| | - Giovanni Landoni
- Department of Anesthesiology and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University, Milan, Italy
| | - Paul Young
- Intensive Care Unit, Wellington Hospital and the Medical Research Institute of New Zealand, Wellington, New Zealand
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Claesson J, Freundlich M, Gunnarsson I, Laake JH, Møller MH, Vandvik PO, Varpula T, Aasmundstad TA. Scandinavian clinical practice guideline on fluid and drug therapy in adults with acute respiratory distress syndrome. Acta Anaesthesiol Scand 2016; 60:697-709. [PMID: 26988416 PMCID: PMC6680148 DOI: 10.1111/aas.12713] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 01/06/2016] [Accepted: 02/13/2016] [Indexed: 12/13/2022]
Abstract
BACKGROUND The objective of the Scandinavian Society of Anaesthesiology and Intensive Care Medicine (SSAI) task force on fluid and drug therapy in adults with acute respiratory distress syndrome (ARDS) was to provide clinically relevant, evidence-based treatment recommendations according to standards for trustworthy guidelines. METHODS The guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. RESULTS A total of seven ARDS interventions were assessed. We suggest fluid restriction in patients with ARDS (weak recommendation, moderate quality evidence). Also, we suggest early use of neuromuscular blocking agents (NMBAs) in patients with severe ARDS (weak recommendation, moderate quality evidence). We recommend against the routine use of other drugs, including corticosteroids, beta2 agonists, statins, and inhaled nitric oxide (iNO) or prostanoids in adults with ARDS (strong recommendations: low- to high-quality evidence). These recommendations do not preclude the use of any drug or combination of drugs targeting underlying or co-existing disorders. CONCLUSION This guideline emphasizes the paucity of evidence of benefit - and potential for harm - of common interventions in adults with ARDS and highlights the need for prudence when considering use of non-licensed interventions in this patient population.
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Affiliation(s)
- J. Claesson
- Anaesthesiology and Intensive Care MedicineUmeå University and the University Hospital of UmeåUmeåSweden
| | - M. Freundlich
- AnaesthesiologyAalborg University HospitalAalborgDenmark
| | - I. Gunnarsson
- Anaesthesiology and Intensive Care MedicineLandspitali University HospitalReykjavikIceland
| | - J. H. Laake
- AnaesthesiologyDivision of Critical CareOslo University HospitalOsloNorway
| | - M. H. Møller
- Intensive Care 4131Copenhagen University Hospital RigshospitaletCopenhagenDenmark
| | - P. O. Vandvik
- MedicineInnlandet Hospital Trust‐Division GjøvikNorway and Norwegian Knowledge Centre for the Health ServicesOsloNorway
| | - T. Varpula
- Intensive Care MedicineHelsinki University HospitalHelsinkiFinland
| | - T. A. Aasmundstad
- AnaesthesiologyDivision of Critical CareOslo University HospitalOsloNorway
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Ridgeon EE, Young PJ, Bellomo R, Mucchetti M, Lembo R, Landoni G. The Fragility Index in Multicenter Randomized Controlled Critical Care Trials*. Crit Care Med 2016; 44:1278-84. [DOI: 10.1097/ccm.0000000000001670] [Citation(s) in RCA: 158] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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47
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Pisano A, Landoni G, Lomivorotov V, Comis M, Gazivoda G, Conte M, Hajjar L, Finco G, Jovic M, Mucchetti M, Kunstýř J, Paternoster G, Likhvantsev V, Ruggeri L, Ma J, Alvaro G, Bukamal N, Borghi G, Pasyuga V, Cabrini L, Greco M, Guarracino F, Lembo R, Lobreglio R, Monaco F, Montisci A, Pala G, Pasin L, Pieri M, Santini F, Silvetti S, Zambon M, Baiardo Redaelli M, Castella A, De Vuono G, Lucchetta L, Zangrillo A, Bellomo R. Worldwide Opinion on Multicenter Randomized Interventions Showing Mortality Reduction in Critically Ill Patients: A Democracy-Based Medicine Approach. J Cardiothorac Vasc Anesth 2016; 30:1386-95. [PMID: 27499346 DOI: 10.1053/j.jvca.2016.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Democracy-based medicine is a combination of evidence-based medicine (systematic review), expert assessment, and worldwide voting by physicians to express their opinions and self-reported practice via the Internet. The authors applied democracy-based medicine to key trials in critical care medicine. DESIGN AND SETTING A systematic review of literature followed by web-based voting on findings of a consensus conference. PARTICIPANTS A total of 555 clinicians from 61 countries. INTERVENTIONS The authors performed a systematic literature review (via searching MEDLINE/PubMed, Scopus, and Embase) and selected all multicenter randomized clinical trials in critical care that reported a significant effect on survival and were endorsed by expert clinicians. Then they solicited voting and self-reported practice on such evidence via an interactive Internet questionnaire. Relationships among trial sample size, design, and respondents' agreement were investigated. The gap between agreement and use/avoidance and the influence of country origin on physicians' approach to interventions also were investigated. MEASUREMENTS AND MAIN RESULTS According to 24 multicenter randomized controlled trials, 15 interventions affecting mortality were identified. Wide variabilities in both the level of agreement and reported practice among different interventions and countries were found. Moreover, agreement and reported practice often did not coincide. Finally, a positive correlation among agreement, trial sample size, and number of included centers was found. On the contrary, trial design did not influence clinicians' agreement. CONCLUSIONS Physicians' clinical practice and agreement with the literature vary among different interventions and countries. The role of these interventions in affecting survival should be further investigated to reduce both the gap between evidence and clinical practice and transnational differences.
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Affiliation(s)
- Antonio Pisano
- Division of Cardiac Anesthesia and Intensive Care, AORN "Dei Colli", Monaldi Hospital, Naples, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy.
| | | | - Marco Comis
- Cardiac and Vascular Department, Mauriziano Hospital, Turin, Italy
| | - Gordana Gazivoda
- Institute of Cardiovascular Diseases ׳Dedinje׳, Belgrade, Serbia
| | - Massimiliano Conte
- Department of Anesthesia and Intensive Care, Mater Dei Hospital, Bari, Italy
| | - Ludhmila Hajjar
- Intensive Care Unit, Universidade de Sao Paulo, Sao Paulo, Brazil
| | - Gabriele Finco
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Miomir Jovic
- Institute of Cardiovascular Diseases ׳Dedinje׳, Belgrade, Serbia
| | - Marta Mucchetti
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Jan Kunstýř
- Department of Anesthesiology and Intensive Care, First Faculty of Medicine, Charles University in Prague, and General University Hospital in Prague, Prague, Czech Republic
| | - Gianluca Paternoster
- Cardiovascular Anaesthesia and Intensive Care, San Carlo Hospital, Potenza, Italy
| | | | - Laura Ruggeri
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Jun Ma
- Center for Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Gabriele Alvaro
- Department of Anesthesia and Intensive Care, Azienda Ospedaliero-Universitaria "Mater Domini", Catanzaro, Italy
| | - Nazar Bukamal
- Mohammed Bin Khalifa Bin Sulman Al-Khalifa Cardiac Center, West Riffa, Bahrain
| | - Giovanni Borghi
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Vadim Pasyuga
- Cardiac Anesthesia and Intensive Care, Federal Centre for Cardiac Surgery, Astrakhan, Russia
| | - Luca Cabrini
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Massimiliano Greco
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Fabio Guarracino
- Cardiothoracic Department, University Hospital of Pisa, Pisa, Italy
| | - Rosalba Lembo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Rosetta Lobreglio
- Cardiac Anesthesia and Intensive Care, San Giovanni Battista Hospital, University of Turin, Turin, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Montisci
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni Pala
- Cardioanaesthesia and Intensive Care, Civil Hospital "SS Annunziata", Sassari, Italy
| | - Laura Pasin
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Marina Pieri
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Francesco Santini
- Division of Cardiac Surgery, IRCCS S Martino, University Hospital, Genova, Italy
| | - Simona Silvetti
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Zambon
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | | | - Alberto Castella
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Giovanni De Vuono
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Luca Lucchetta
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Rinaldo Bellomo
- Faculty of Medicine, University of Melbourne, Melbourne, Australia
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Amrein K, Perl S, Dimai HP. Letter to the Editor: Preadmission Bisphosphonate and Mortality in Critically Ill Patients. J Clin Endocrinol Metab 2016; 101:L60-1. [PMID: 27163474 DOI: 10.1210/jc.2016-1362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Karin Amrein
- Department of Internal Medicine (K.A., H.P.D.), Division of Endocrinology and Diabetology, and Department of Internal Medicine (S.P.), Division of Cardiology, Medical University of Graz, 8036 Graz, Austria
| | - Sabine Perl
- Department of Internal Medicine (K.A., H.P.D.), Division of Endocrinology and Diabetology, and Department of Internal Medicine (S.P.), Division of Cardiology, Medical University of Graz, 8036 Graz, Austria
| | - Hans Peter Dimai
- Department of Internal Medicine (K.A., H.P.D.), Division of Endocrinology and Diabetology, and Department of Internal Medicine (S.P.), Division of Cardiology, Medical University of Graz, 8036 Graz, Austria
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Landoni G, Pasin L, Cabrini L, Scandroglio AM, Baiardo Redaelli M, Votta CD, Bellandi M, Borghi G, Zangrillo A. Volatile Agents in Medical and Surgical Intensive Care Units: A Meta-Analysis of Randomized Clinical Trials. J Cardiothorac Vasc Anesth 2016; 30:1005-14. [PMID: 27238433 DOI: 10.1053/j.jvca.2016.02.021] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To comprehensively assess published randomized peer-reviewed studies related to volatile agents used for sedation in intensive care unit (ICU) settings, with the hypothesis that volatile agents could reduce time to extubation in adult patients. DESIGN Systematic review and meta-analysis of randomized trials. SETTING Intensive care units. PARTICIPANTS Critically ill patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The BioMedCentral, PubMed, Embase, and Cochrane Central Register databases of clinical trials were searched systematically for studies on volatile agents used in the ICU setting. Articles were assessed by trained investigators, and divergences were resolved by consensus. Inclusion criteria included random allocation to treatment (volatile agents versus any intravenous comparator, with no restriction on dose or time of administration) in patients requiring mechanical ventilation in the ICU. Twelve studies with 934 patients were included in the meta-analysis. The use of halogenated agents reduced the time to extubation (standardized mean difference = -0.78 [-1.01 to -0.55] hours; p for effect<0.00001; p for heterogeneity = 0.18; I(2) = 32% in 7 studies with 503 patients). Results for time to extubation were confirmed in all subanalyses (eg, medical and surgical patients) and sensitivity analyses. No differences in length of hospital stay, ICU stay, and mortality were recorded. CONCLUSIONS In this meta-analysis of randomized trials, volatile anesthetics reduced time to extubation in medical and surgical ICU patients. The results of this study should be confirmed by large and high-quality randomized controlled studies.
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Affiliation(s)
- Giovanni Landoni
- IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy.
| | | | | | | | | | | | | | | | - Alberto Zangrillo
- IRCCS San Raffaele Scientific Institute; Vita-Salute San Raffaele University, Milan, Italy
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