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Chen Z, Harhay MO, Fan E, Granholm A, McAuley DF, Urner M, Yarnell CJ, Goligher EC, Heath A. Statistical Power and Performance of Strategies to Analyze Composites of Survival and Duration of Ventilation in Clinical Trials. Crit Care Explor 2024; 6:e1152. [PMID: 39302988 PMCID: PMC11419436 DOI: 10.1097/cce.0000000000001152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/22/2024] Open
Abstract
BACKGROUND Patients with acute hypoxemic respiratory failure are at high risk of death and prolonged time on the ventilator. Interventions often aim to reduce both mortality and time on the ventilator. Many methods have been proposed for analyzing these endpoints as a single composite outcome (days alive and free of ventilation), but it is unclear which analytical method provides the best performance. Thus, we aimed to determine the analysis method with the highest statistical power for use in clinical trials. METHODS Using statistical simulation, we compared multiple methods for analyzing days alive and free of ventilation: the t, Wilcoxon rank-sum, and Kryger Jensen and Lange tests, as well as the proportional odds, hurdle-Poisson, and competing risk models. We compared 14 scenarios relating to: 1) varying baseline distributions of mortality and duration of ventilation, which were based on data from a registry of patients with acute hypoxemic respiratory failure and 2) the varying effects of treatment on mortality and duration of ventilation. RESULTS AND CONCLUSIONS All methods have good control of type 1 error rates (i.e., avoid false positive findings). When data are simulated using a proportional odds model, the t test and ordinal models have the highest relative power (92% and 90%, respectively), followed by competing risk models. When the data are simulated using survival models, the competing risk models have the highest power (100% and 92%), followed by the t test and a ten-category ordinal model. All models struggled to detect the effect of the intervention when the treatment only affected one of mortality and duration of ventilation. Overall, the best performing analytical strategy depends on the respective effects of treatment on survival and duration of ventilation and the underlying distribution of the outcomes. The evaluated models each provide a different interpretation for the treatment effect, which must be considered alongside the statistical power when selecting analysis models.
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Affiliation(s)
- Ziming Chen
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
| | - Michael O. Harhay
- Department of Biostatistics, Epidemiology and Informatics Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Eddy Fan
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital–Rigshospitalet, Copenhagen, Denmark
| | - Daniel F. McAuley
- School of Medicine, Dentistry and Biomedical Sciences, Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, United Kingdom
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Martin Urner
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Christopher J. Yarnell
- Department of Medicine, Division of Respirology, University Health Network, Toronto, ON, Canada
- Department of Critical Care Medicine, Scarborough Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Ewan C. Goligher
- Department of Biostatistics, Epidemiology and Informatics Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Toronto General Hospital Research Institute, Toronto, ON, Canada
| | - Anna Heath
- Child Health Evaluative Sciences, Peter Gilgan Centre for Research and Learning, The Hospital for Sick Children, Toronto, ON, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Department of Statistical Science, University College London, London, United Kingdom
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Zarbock A, Forni LG, Koyner JL, Bell S, Reis T, Meersch M, Bagshaw SM, Fuhmann DY, Liu KD, Pannu N, Arikan AA, Angus DC, Duquette D, Goldstein SL, Hoste E, Joannidis M, Jongs N, Legrand M, Mehta RL, Murray PT, Nadim MK, Ostermann M, Prowle J, See EJ, Selby NM, Shaw AD, Srisawat N, Ronco C, Kellum JA. Recommendations for clinical trial design in acute kidney injury from the 31st acute disease quality initiative consensus conference. A consensus statement. Intensive Care Med 2024; 50:1426-1437. [PMID: 39115567 PMCID: PMC11377501 DOI: 10.1007/s00134-024-07560-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Accepted: 07/10/2024] [Indexed: 09/06/2024]
Abstract
PURPOSE Novel interventions for the prevention or treatment of acute kidney injury (AKI) are currently lacking. To facilitate the evaluation and adoption of new treatments, the use of the most appropriate design and endpoints for clinical trials in AKI is critical and yet there is little consensus regarding these issues. We aimed to develop recommendations on endpoints and trial design for studies of AKI prevention and treatment interventions based on existing data and expert consensus. METHODS At the 31st Acute Disease Quality Initiative (ADQI) meeting, international experts in critical care, nephrology, involving adults and pediatrics, biostatistics and people with lived experience (PWLE) were assembled. We focused on four main areas: (1) patient enrichment strategies, (2) prevention and attenuation studies, (3) treatment studies, and (4) innovative trial designs of studies other than traditional (parallel arm or cluster) randomized controlled trials. Using a modified Delphi process, recommendations and consensus statements were developed based on existing data, with > 90% agreement among panel members required for final adoption. RESULTS The panel developed 12 consensus statements for clinical trial endpoints, application of enrichment strategies where appropriate, and inclusion of PWLE to inform trial designs. Innovative trial designs were also considered. CONCLUSION The current lack of specific therapy for prevention or treatment of AKI demands refinement of future clinical trial design. Here we report the consensus findings of the 31st ADQI group meeting which has attempted to address these issues including the use of predictive and prognostic enrichment strategies to enable appropriate patient selection.
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Affiliation(s)
- Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany.
- Outcomes Research Consortium, Cleveland, OH, USA.
| | - Lui G Forni
- Depatment of Critical Care, Royal Surrey Hospital Foundation Trust, Guildford, Surrey, UK
- School of Medicine, Kate Granger Building, University of Surrey, Guildford, Surrey, UK
| | - Jay L Koyner
- Section of Nephrology, University of Chicago, Chicago, IL, USA
| | - Samira Bell
- Division of Population Health and Genomics, University of Dundee, Dundee, UK
| | - Thiago Reis
- Hospital Sírio-Libanês, São Paulo, Brazil
- Fenix Nephrology, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
| | - Melanie Meersch
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital of Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada
| | - Dana Y Fuhmann
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 2000, Pittsburgh, PA, 15224, USA
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Kathleen D Liu
- Departments of Medicine and Anesthesia, University of California, San Francisco, San Francisco, CA, USA
| | - Neesh Pannu
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Ayse Akcan Arikan
- Division of Nephrology and Critical Care Medicine, Department of Pediatric, Baylor College of Medicine, Houston, TX, USA
| | - Derek C Angus
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - D'Arcy Duquette
- Critical Care Strategic Clinical Network, Alberta Health Services, Calgary, Canada
| | - Stuart L Goldstein
- Division of Nephrology and Hypertension, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Eric Hoste
- Intensive Care Unit, Ghent University Hospital, Ghent University, Ghent, Belgium
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Matthieu Legrand
- Department of Anesthesia and Perioperative Care, Division of Critical Care Medicine, UCSF, San Francisco, CA, USA
| | - Ravindra L Mehta
- Department of Medicine, University of California San Diego, La Jolla, San Diego, CA, USA
| | | | - Mitra K Nadim
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Thomas' Hospital, Guy's & St, London, UK
| | - John Prowle
- Faculty of Medicine and Dentistry, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Emily J See
- Department of Critical Care, University of Melbourne, Parkville, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Nephrology, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Nicholas M Selby
- Centre for Kidney Research and Innovation, University of Nottingham, Nottingham, UK
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, The Cleveland Clinic, Cleveland, OH, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, and Center of Excellence in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Claudio Ronco
- Department of Medicine, University of Padova, Padua, Italy
- International Renal Research Institute of Vicenza (IRRV), Vicenza, Italy
- Department of Nephrology, San Bortolo Hospital, Vicenza, Italy
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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Granholm A, Munch MW, Meier N, Sjövall F, Helleberg M, Hertz FB, Kaas-Hansen BS, Thorsen-Meyer HC, Andersen LW, Rasmussen BS, Andersen JS, Albertsen TL, Kjær MBN, Jensen AKG, Lange T, Perner A, Møller MH. Empirical meropenem versus piperacillin/tazobactam for adult patients with sepsis (EMPRESS) trial: Protocol. Acta Anaesthesiol Scand 2024; 68:1107-1119. [PMID: 38769040 DOI: 10.1111/aas.14441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 04/30/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Piperacillin/tazobactam may be associated with less favourable outcomes than carbapenems in patients with severe bacterial infections, but the certainty of evidence is low. METHODS The Empirical Meropenem versus Piperacillin/Tazobactam for Adult Patients with Sepsis (EMPRESS) trial is an investigator-initiated, international, parallel-group, randomised, open-label, adaptive clinical trial with an integrated feasibility phase. We will randomise adult, critically ill patients with sepsis to empirical treatment with meropenem or piperacillin/tazobactam for up to 30 days. The primary outcome is 30-day all-cause mortality. The secondary outcomes are serious adverse reactions within 30 days; isolation precautions due to resistant bacteria within 30 days; days alive without life support and days alive and out of hospital within 30 and 90 days; 90- and 180-day all-cause mortality and 180-day health-related quality of life. EMPRESS will use Bayesian statistical models with weak to somewhat sceptical neutral priors. Adaptive analyses will be conducted after follow-up of the primary outcome for the first 400 participants concludes and after every 300 subsequent participants, with adaptive stopping for superiority/inferiority and practical equivalence (absolute risk difference <2.5%-points) and response-adaptive randomisation. The expected sample sizes in scenarios with no, small or large differences are 5189, 5859 and 2570 participants, with maximum 14,000 participants and ≥99% probability of conclusiveness across all scenarios. CONCLUSIONS EMPRESS will compare the effects of empirical meropenem against piperacillin/tazobactam in adult, critically ill patients with sepsis. Due to the pragmatic, adaptive design with high probability of conclusiveness, the trial results are expected to directly inform clinical practice.
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Affiliation(s)
- Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Nick Meier
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Fredrik Sjövall
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Marie Helleberg
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Frederik Boëtius Hertz
- Department of Clinical Microbiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Benjamin Skov Kaas-Hansen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Hans-Christian Thorsen-Meyer
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Lars Wiuff Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
- Prehospital Emergency Medical Services, Aarhus, Denmark
| | - Bodil Steen Rasmussen
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Anaesthesia and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Jakob Steen Andersen
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | | | - Maj-Brit Nørregaard Kjær
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Aksel Karl Georg Jensen
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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4
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Meier N, Munch MW, Granholm A, Perner A, Hertz FB, Venkatesh B, Hammond NE, Li Q, De Bus L, De Waele J, Kauzonas E, Sjövall F, Møller MH, Helleberg M. Empirical carbapenems or piperacillin/tazobactam for infections in intensive care: An international retrospective cohort study. Acta Anaesthesiol Scand 2024; 68:821-829. [PMID: 38549422 DOI: 10.1111/aas.14419] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 03/14/2024] [Accepted: 03/14/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Critically ill patients in intensive care units (ICU) are frequently administered broad-spectrum antibiotics (e.g., carbapenems or piperacillin/tazobactam) for suspected or confirmed infections. This retrospective cohort study aimed to describe the use of carbapenems and piperacillin/tazobactam in two international, prospectively collected datasets. METHODS We conducted a post hoc analysis of data from the "Adjunctive Glucocorticoid Therapy in Patients with Septic Shock" (ADRENAL) trial (n = 3713) and the "Antimicrobial de-escalation in the critically ill patient and assessment of clinical cure" (DIANA) study (n = 1488). The primary outcome was the proportion of patients receiving initial antibiotic treatment with carbapenems and piperacillin/tazobactam. Secondary outcomes included mortality, days alive and out of ICU and ICU length of stay at 28 days. RESULTS In the ADRENAL trial, carbapenems were used in 648 out of 3713 (17%), whereas piperacillin/tazobactam was used in 1804 out of 3713 (49%) participants. In the DIANA study, carbapenems were used in 380 out of 1480 (26%), while piperacillin/tazobactam was used in 433 out of 1488 (29%) participants. Mortality at 28 days was 23% for patients receiving carbapenems and 24% for those receiving piperacillin/tazobactam in ADRENAL and 23% and 19%, respectively, in DIANA. We noted variations in secondary outcomes; in DIANA, patients receiving carbapenems had a median of 13 days alive and out of ICU compared with 18 days among those receiving piperacillin/tazobactam. In ADRENAL, the median hospital length of stay was 27 days for patients receiving carbapenems and 21 days for those receiving piperacillin/tazobactam. CONCLUSIONS In this post hoc analysis of ICU patients with infections, we found widespread initial use of carbapenems and piperacillin/tazobactam in international ICUs, with the latter being more frequently used. Randomized clinical trials are needed to assess if the observed variations in outcomes may be drug-related effects or due to confounders.
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Affiliation(s)
- Nick Meier
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Marie Warrer Munch
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Frederik Boëtius Hertz
- Department of Clinical Microbiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Immunology & Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Balasubramanian Venkatesh
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Naomi E Hammond
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Qiang Li
- Critical Care Program, The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Liesbet De Bus
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jan De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Evaldas Kauzonas
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Fredrik Sjövall
- Department of Intensive and Perioperative Care, Skåne University Hospital, Malmö, Sweden
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Marie Helleberg
- Department of Clinical Medicine, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Infectious Diseases, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Centre of Excellence for Health, Immunity and Infections, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Wieruszewski PM, Leone M, Kaas-Hansen BS, Dugar S, Legrand M, McKenzie CA, Bissell Turpin BD, Messina A, Nasa P, Schorr CA, De Waele JJ, Khanna AK. Position Paper on the Reporting of Norepinephrine Formulations in Critical Care from the Society of Critical Care Medicine and European Society of Intensive Care Medicine Joint Task Force. Crit Care Med 2024; 52:521-530. [PMID: 38240498 DOI: 10.1097/ccm.0000000000006176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2024]
Abstract
OBJECTIVES To provide guidance on the reporting of norepinephrine formulation labeling, reporting in publications, and use in clinical practice. DESIGN Review and task force position statements with necessary guidance. SETTING A series of group conference calls were conducted from August 2023 to October 2023, along with a review of the available evidence and scope of the problem. SUBJECTS A task force of multinational and multidisciplinary critical care experts assembled by the Society of Critical Care Medicine and the European Society of Intensive Care Medicine. INTERVENTIONS The implications of a variation in norepinephrine labeled as conjugated salt (i.e., bitartrate or tartrate) or base drug in terms of effective concentration of norepinephrine were examined, and guidance was provided. MEASUREMENTS AND MAIN RESULTS There were significant implications for clinical care, dose calculations for enrollment in clinical trials, and results of datasets reporting maximal norepinephrine equivalents. These differences were especially important in the setting of collaborative efforts across countries with reported differences. CONCLUSIONS A joint task force position statement was created outlining the scope of norepinephrine-dose formulation variations, and implications for research, patient safety, and clinical care. The task force advocated for a uniform norepinephrine-base formulation for global use, and offered advice aimed at appropriate stakeholders.
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Affiliation(s)
- Patrick M Wieruszewski
- Department of Pharmacy, Mayo Clinic, Rochester, MN
- Department of Anesthesiology, Mayo Clinic, Rochester, MN
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Medicine, Nord Hospital, Assistance Publique Hôpitaux Universitaires de Marseille, Aix Marseille University, Marseille, France
| | | | - Siddharth Dugar
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH
| | - Matthieu Legrand
- Division of Critical Care Medicine, Department of Anesthesiology and Perioperative Care, University of California San Francisco, San Francisco, CA
| | - Cathrine A McKenzie
- Department of Clinical and Experimental Medicine, School of Medicine, University of Southampton, National Institute of Health and Care Research (NIHR), Southampton Biomedical Research Centre, Perioperative and Critical Care Theme, and NIHR Wessex Applied Research Collaborative, Southampton, United Kingdom
| | - Brittany D Bissell Turpin
- Ephraim McDowell Regional Medical Center, Danville, KY
- Department of Pharmacy, University of Kentucky, Lexington, KY
| | - Antonio Messina
- Department of Anesthesia and Intensive Care, IRCCS Humanitas Research Hospital, Rozzano (MI), Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (MI), Italy
| | - Prashant Nasa
- Department of Critical Care Medicine, NMC Specialty Hospital, Dhabi, United Arab Emirates
| | - Christa A Schorr
- Cooper Department of Medicine, Cooper Research Institute, Cooper University Hospital, Camden, NJ
- Cooper Medical School at Rowan University, Camden, NJ
| | - Jan J De Waele
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
- Department of Internal Medicine and Pediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, NC
- Outcomes Research Consortium, Cleveland, OH
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Zampieri FG, Singh G. Using Bayesian statistics to foster interpretation of small clinical trials in extracorporeal cardiopulmonary resuscitation after cardiac arrest. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:201-202. [PMID: 38243634 DOI: 10.1093/ehjacc/zuae010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 01/21/2024]
Affiliation(s)
- Fernando G Zampieri
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, 2-124E Clinical Sciences Building, 8440-112 ST NW Edmonton, T6G2B7 Alberta, Canada
| | - Gurmeet Singh
- Department of Critical Care Medicine, University of Alberta Faculty of Medicine & Dentistry, Edmonton, 2-124E Clinical Sciences Building, 8440-112 ST NW Edmonton, T6G2B7 Alberta, Canada
- Division of Cardiac Surgery, Department of Surgery, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
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7
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Renard Triché L, Futier E, De Carvalho M, Piñol-Domenech N, Bodet-Contentin L, Jabaudon M, Pereira B. Sample size estimation in clinical trials using ventilator-free days as the primary outcome: a systematic review. Crit Care 2023; 27:303. [PMID: 37528425 PMCID: PMC10394791 DOI: 10.1186/s13054-023-04562-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 07/04/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Ventilator-free days (VFDs) are a composite endpoint increasingly used as the primary outcome in critical care trials. However, because of the skewed distribution and competitive risk between components, sample size estimation remains challenging. This systematic review was conducted to systematically assess whether the sample size was congruent, as calculated to evaluate VFDs in trials, with VFDs' distribution and the impact of alternative methods on sample size estimation. METHODS A systematic literature search was conducted within the PubMed and Embase databases for randomized clinical trials in adults with VFDs as the primary outcome until December 2021. We focused on peer-reviewed journals with 2021 impact factors greater than five. After reviewing definitions of VFDs, we extracted the sample size and methods used for its estimation. The data were collected by two independent investigators and recorded in a standardized, pilot-tested forms tool. Sample sizes were calculated using alternative statistical approaches, and risks of bias were assessed with the Cochrane risk-of-bias tool. RESULTS Of the 26 clinical trials included, 19 (73%) raised "some concerns" when assessing risks of bias. Twenty-four (92%) trials were two-arm superiority trials, and 23 (89%) were conducted at multiple sites. Almost all the trials (96%) were unable to consider the unique distribution of VFDs and death as a competitive risk. Moreover, significant heterogeneity was found in the definitions of VFDs, especially regarding varying start time and type of respiratory support. Methods for sample size estimation were also heterogeneous, and simple models, such as the Mann-Whitney-Wilcoxon rank-sum test, were used in 14 (54%) trials. Finally, the sample sizes calculated varied by a factor of 1.6 to 17.4. CONCLUSIONS A standardized definition and methodology for VFDs, including the use of a core outcome set, seems to be required. Indeed, this could facilitate the interpretation of findings in clinical trials, as well as their construction, especially the sample size estimation which is a trade-off between cost, ethics, and statistical power. Systematic review registration PROSPERO ID: CRD42021282304. Registered 15 December 2021 ( https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021282304 ).
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Affiliation(s)
- Laurent Renard Triché
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France. lrenard--
| | - Emmanuel Futier
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | | | | | - Laëtitia Bodet-Contentin
- Medical Intensive Care Unit, CHRU de Tours, Tours, France
- INSERM, SPHERE, UMR1246, Université de Tours et Nantes, Tours et Nantes, France
| | - Matthieu Jabaudon
- Department of Perioperative Medicine, CHU Clermont-Ferrand, 58 Rue Montalembert, 63000, Clermont-Ferrand, France
- iGReD, CNRS, INSERM, Université Clermont Auvergne, Clermont-Ferrand, France
| | - Bruno Pereira
- Biostatistics Unit, Department of Clinical Research, and Innovation (DRCI), CHU Clermont-Ferrand, Clermont-Ferrand, France
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