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Zajonz TS, Habicher M, Böning A, Heringlake M, Ender J, Markewitz A, Brenck F, Sander M. Survey on the Updated German S3 Guideline for Intensive Care in Cardiac Surgery Patients. Thorac Cardiovasc Surg 2024; 72:2-10. [PMID: 36893800 DOI: 10.1055/s-0043-1764230] [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: 03/11/2023]
Abstract
BACKGROUND The German guideline on intensive care treatment of cardiac surgical patients provides evidence-based recommendations on management and monitoring. It remains unclear if, respectively, to which degree the guidelines are implemented into the daily practice. Therefore, this study aims to characterize the implementation of guideline recommendations in German cardiac surgical intensive care units (ICUs). METHODS An internet-based online survey (42 questions, 9 topics) was sent to 158 German head physicians of cardiac surgical ICUs. To compare the effect over time, most questions were based on a previously performed survey (2013) after introduction of the last guideline update in 2008. RESULTS A total of n = 65 (41.1%) questionnaires were included. Monitoring changed to increased provision of available transesophageal echocardiography specialists in 86% (2013: 72.6%), SvO2 measurement in 93.8% (2013: 55.1%), and electroencephalography in 58.5% (2013: 2.6%). The use of hydroxyethyl starch declined (9.4% vs. 2013: 38.7%), gelatin 4% presented the most administered colloid with 23.4% (2013: 17.4%). Low cardiac output syndrome was primarily treated with levosimendan (30.8%) and epinephrine (23.1%), while norepinephrine (44.6%) and dobutamine (16.9%) represented the most favored drug combination. The main way of distribution was web-based (50.9%), with increasing impact on therapy regimens (36.9% vs. 2013: 24%). CONCLUSION Changes were found in all questioned sectors compared with the preceding survey, with persisting variability between ICUs. Recommendations of the updated guideline have increasingly entered clinical practice, with participants valuing the updated publication as clinically relevant.
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Affiliation(s)
- Thomas Simon Zajonz
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Marit Habicher
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Andreas Böning
- Department of Cardiovascular Surgery, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
- Department of Adult and Pediatric Cardiovascular Surgery, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Matthias Heringlake
- Department of Anesthesiology and Intensive Care Medicine, Heart and Diabetes Center Mecklenburg, Western Pomerania, Karlsburg Hospital, Karlsburg, Germany
| | - Jörg Ender
- Department of Anaesthesiology and Intensive Care Medicine, Leipzig Heart Centre University Hospital, Heart Center Leipzig, Leipzig, Sachsen, Germany
| | - Andreas Markewitz
- Deutsche Gesellschaft für Thorax-, Herz- und Gefäßchirurgie, Berlin, Germany
| | - Florian Brenck
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care and Pain Medicine, Universitaetsklinikum Giessen und Marburg GmbH, Standort Giessen, Giessen, Hessen, Germany
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Wu H, Zhou C, Kong W, Zhang Y, Pan D. Prognostic nutrition index is associated with the all‐cause mortality in sepsis patients: A retrospective cohort study. J Clin Lab Anal 2022; 36:e24297. [PMID: 35187716 PMCID: PMC8993644 DOI: 10.1002/jcla.24297] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 02/04/2022] [Accepted: 02/08/2022] [Indexed: 12/18/2022] Open
Abstract
Background The study aimed at evaluating the prognostic utility of the prognostic nutritional index (PNI) for patients with sepsis. Methods Data in the present study were obtained from the Multiparameter Intelligent Monitoring in Intensive Care Database III. The calculation for PNI was as follows: serum albumin concentration (g/L) +0.005 × total lymphocyte count. 30‐day mortality was considered as the primary outcome, while 90‐day mortality and one‐year mortality were the secondary outcomes. Cox proportional risk models and propensity score matching (PSM) analyses were used to analyze the association between PNI and clinical outcomes in patients with sepsis. To assess the predictive value of PNI for 30‐day mortality, receiver operator characteristic (ROC) curve analysis was performed. Results A total of 2669 patients were in the study. After the confounding factors were adjusted, PNI ≥ 29.3 was identified as an independent predictive prognostic factor for the 30‐day all‐cause mortality (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.56–0.76; p < 0.00001). Moreover, PSM analysis further validated the prognostic predictive value of PNI for patients with sepsis. The AUC of the PNI was 0.6436 (95% CI: 0.6204–0.6625) which was significantly high than the AUC of NLR (0.5962, 95% CI: 0.5717–0.6206) (p = 0.0031), the RDW (0.5878, 95% CI: 0.5629–0.6127) (p < 0.0001), and PLR (0.4979, 95% CI: 0.4722–0.5235) (p < 0.0001). Conclusion The findings suggested that PNI was also a significant risk factor for sepsis.
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Affiliation(s)
- He Wu
- Emergency Department The Second Affiliated Hospital and Yuying Children’s Hospital Wenzhou Medical University Wenzhou Zhejiang China
| | - Chongjun Zhou
- Department of Anus and Intestine Surgery The Second Affiliated Hospital and Yuying Children’s Hospital Wenzhou Medical University Wenzhou Zhejiang China
| | - Wanquan Kong
- Emergency Department The Second Affiliated Hospital and Yuying Children’s Hospital Wenzhou Medical University Wenzhou Zhejiang China
| | - Yi Zhang
- Emergency Department The Second Affiliated Hospital and Yuying Children’s Hospital Wenzhou Medical University Wenzhou Zhejiang China
| | - Da Pan
- Emergency Department The Second Affiliated Hospital and Yuying Children’s Hospital Wenzhou Medical University Wenzhou Zhejiang China
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Kong L, Wu Q, Liu B. The impact of selenium administration on severe sepsis or septic shock: a meta-analysis of randomized controlled trials. Afr Health Sci 2021; 21:277-285. [PMID: 34394308 PMCID: PMC8356584 DOI: 10.4314/ahs.v21i1.36] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Introduction The efficacy of selenium administration to treat severe sepsis or septic shock remains controversial. We conduct a systematic review and meta-analysis to explore the impact of selenium administration on severe sepsis or septic shock. Methods We search PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through May 2020 for randomized controlled trials (RCTs) assessing the effect of selenium administration on severe sepsis or septic shock. Meta-analysis is performed using the random-effect model. Results Five RCTs involving 1482 patients are included in the meta-analysis. Overall, compared with control group in septic patients, selenium administration is not associated with reduced 28-day mortality (RR=0.93; 95% CI=0.73 to 1.19; P=0.58), but results in substantially decreased all-cause mortality (RR=0.78; 95% CI=0.63 to 0.98; P=0.03) and length of hospital stay (MD=-3.09; 95% CI=-5.68 to -0.50; P=0.02). Conclusion Selenium administration results in notable decrease in all-cause mortality and length of hospital stay, but shows no substantial influence on the 28-day mortality, length of ICU stay, duration of vasopressor therapy, the incidence of acute renal failure, adverse events, and serious adverse events for septic patients.
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Affiliation(s)
- Lin Kong
- Department of Clinical Nutrition, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University Chongqing 400014, China
| | - Qing Wu
- Department of Pharmacy, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University Chongqing 400014, China
| | - Bo Liu
- Department of Gastroenterology, Children's Hospital of Chongqing Medical University, Chongqing 400014, China
- Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China International Science and Technology Cooperation base of Child development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Children's Hospital of Chongqing Medical University Chongqing 400014, China
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Llópez-Espinós P, Palazón-Bru A, Beneyto-Ripoll C, Martínez-Díaz AM, Gil-Guillén VF, Carbonell-Torregrosa MDLÁ. Quality assessment of meta-analyses evaluating randomized clinical trials to improve the prognosis of septic shock: an overview of systematic reviews. Curr Med Res Opin 2020; 36:929-939. [PMID: 32267785 DOI: 10.1080/03007995.2020.1754188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Objective: Clinical guidelines for the treatment of septic shock are based on the studies with the best scientific evidence, which are meta-analyses of clinical trials. However, these meta-analyses may have methodological limitations that prevent their conclusions from being extrapolated to routine clinical practice. Therefore, the objective of this study is to determine the quality of these meta-analyses through a systematic review.Methods: In this systematic review, we searched MEDLINE, Scopus and EMBASE from inception to May 2019. We selected meta-analyses from clinical trials that determined the effectiveness of an intervention in reducing the incidence of mortality in patients with septic shock. All items were extracted from the Overview Quality Assessment Questionnaire (OQAQ), which collects information from both systematic reviews and meta-analyses.Results: A total of 34 studies were included. Most elements of the OQAQ were conducted satisfactorily, although 35.3% of meta-analyses did not use a quality assessment of the studies included in other analyses. In 52.9% of meta-analyses, the quality of the studies was high or very high.Conclusions: The methods used to obtain the results should be taken into account when recommending an intervention to treat septic shock if the evidence comes from a meta-analysis of the analyzed characteristics.
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Affiliation(s)
| | - Antonio Palazón-Bru
- Department of Clinical Medicine, Miguel Hernández University, San Juan de Alicante, Spain
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Higgins AM, Brooker JE, Mackie M, Cooper DJ, Harris AH. Health economic evaluations of sepsis interventions in critically ill adult patients: a systematic review. J Intensive Care 2020; 8:5. [PMID: 31934338 PMCID: PMC6950865 DOI: 10.1186/s40560-019-0412-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 10/31/2019] [Indexed: 12/12/2022] Open
Abstract
Background Sepsis is a global health priority. Interventions to reduce the burden of sepsis need to be both effective and cost-effective. We performed a systematic review of the literature on health economic evaluations of sepsis treatments in critically ill adult patients and summarised the evidence for cost-effectiveness. Methods We systematically searched MEDLINE, Embase, and the Cochrane Library using thesaurus (e.g. MeSH) and free-text terms related to sepsis and economic evaluations. We included all articles that reported, in any language, an economic evaluation of an intervention for the management of sepsis in critically ill adult patients. Data extracted included study details, intervention details, economic evaluation methodology, and outcomes. Included studies were appraised for reporting quality using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) checklist. Results We identified 50 records representing 46 economic evaluations for a variety of interventions including antibiotics (n = 5), fluid therapy (n = 2), early goal-directed therapy and other resuscitation protocols (n = 8), immunoglobulins (n = 2), and interventions no longer in clinical use such as monoclonal antibodies (n = 7) and drotrecogin alfa (n = 13). Twelve (26%) evaluations were of excellent reporting quality. Incremental cost-effectiveness ratios (ICERs) ranged from dominant (lower costs and higher effectiveness) for early goal-directed therapy, albumin, and a multifaceted sepsis education program to dominated (higher costs and lower effectiveness) for polymerase chain reaction assays (LightCycler SeptiFast testing MGRADE®, SepsiTest™, and IRIDICA BAC BSI assay). ICERs varied widely across evaluations, particularly in subgroup analyses. Conclusions There is wide variation in the cost-effectiveness of sepsis interventions. There remain important gaps in the literature, with no economic evaluations identified for several interventions routinely used in sepsis. Given the high economic and social burden of sepsis, high-quality economic evaluations are needed to increase our understanding of the cost-effectiveness of these interventions in routine clinical practice and to inform decision makers. Trial registration PROSPERO CRD42018095980
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Affiliation(s)
- Alisa M Higgins
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Joanne E Brooker
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - Michael Mackie
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia
| | - D Jamie Cooper
- 1Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, 553 St Kilda Rd, Melbourne, Victoria 3004 Australia.,2Department of Intensive Care and Hyperbaric Medicine, The Alfred, Melbourne, Victoria Australia
| | - Anthony H Harris
- 3Centre for Health Economics, Monash University, Melbourne, Victoria Australia
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Delay Within the 3-Hour Surviving Sepsis Campaign Guideline on Mortality for Patients With Severe Sepsis and Septic Shock. Crit Care Med 2019; 46:500-505. [PMID: 29298189 DOI: 10.1097/ccm.0000000000002949] [Citation(s) in RCA: 109] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
OBJECTIVES To specify when delays of specific 3-hour bundle Surviving Sepsis Campaign guideline recommendations applied to severe sepsis or septic shock become harmful and impact mortality. DESIGN Retrospective cohort study. SETTING One health system composed of six hospitals and 45 clinics in a Midwest state from January 01, 2011, to July 31, 2015. PATIENTS All adult patients hospitalized with billing diagnosis of severe sepsis or septic shock. INTERVENTIONS Four 3-hour Surviving Sepsis Campaign guideline recommendations: 1) obtain blood culture before antibiotics, 2) obtain lactate level, 3) administer broad-spectrum antibiotics, and 4) administer 30 mL/kg of crystalloid fluid for hypotension (defined as "mean arterial pressure" < 65) or lactate (> 4). MEASUREMENTS AND MAIN RESULTS To determine the effect of t minutes of delay in carrying out each intervention, propensity score matching of "baseline" characteristics compensated for differences in health status. The average treatment effect in the treated computed as the average difference in outcomes between those treated after shorter versus longer delay. To estimate the uncertainty associated with the average treatment effect in the treated metric and to construct 95% CIs, bootstrap estimation with 1,000 replications was performed. From 5,072 patients with severe sepsis or septic shock, 1,412 (27.8%) had in-hospital mortality. The majority of patients had the four 3-hour bundle recommendations initiated within 3 hours. The statistically significant time in minutes after which a delay increased the risk of death for each recommendation was as follows: lactate, 20.0 minutes; blood culture, 50.0 minutes; crystalloids, 100.0 minutes; and antibiotic therapy, 125.0 minutes. CONCLUSIONS The guideline recommendations showed that shorter delays indicates better outcomes. There was no evidence that 3 hours is safe; even very short delays adversely impact outcomes. Findings demonstrated a new approach to incorporate time t when analyzing the impact on outcomes and provide new evidence for clinical practice and research.
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Bebarta VS, Garrett N, Maddry JK, Arana A, Boudreau S, Castaneda M, Dixon P, Tanen DA. A prospective, randomized trial of intravenous hydroxocobalamin versus noradrenaline or saline for treatment of lipopolysaccharide-induced hypotension in a swine model. Clin Exp Pharmacol Physiol 2019; 46:216-225. [DOI: 10.1111/1440-1681.13060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Revised: 12/11/2018] [Accepted: 12/15/2018] [Indexed: 01/10/2023]
Affiliation(s)
- Vikhyat S. Bebarta
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora Colorado
| | - Normalynn Garrett
- Clinical Research Division; 59th Medical Wing; JBSA-Lackland AFB Texas
| | - Joseph K. Maddry
- Clinical Research Division; 59th Medical Wing; JBSA-Lackland AFB Texas
| | - Allyson Arana
- Clinical Research Division; 59th Medical Wing; JBSA-Lackland AFB Texas
| | - Susan Boudreau
- Clinical Research Division; 59th Medical Wing; JBSA-Lackland AFB Texas
| | - Maria Castaneda
- Clinical Research Division; 59th Medical Wing; JBSA-Lackland AFB Texas
| | - Patricia Dixon
- Clinical Research Division; 59th Medical Wing; JBSA-Lackland AFB Texas
| | - David A. Tanen
- Department of Emergency Medicine; Harbor-UCLA; Torrance California
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Ghabra H, White W, Townsend M, Boysen P, Nossaman B. Use of biomarkers in the prediction of culture-proven infection in the surgical intensive care unit. J Crit Care 2018; 49:149-154. [PMID: 30439629 DOI: 10.1016/j.jcrc.2018.10.023] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2018] [Revised: 09/19/2018] [Accepted: 10/28/2018] [Indexed: 01/10/2023]
Abstract
PURPOSE The purpose of this study was to prospectively analyze the predictive role of classic predictors for suspected infection (temperature, WBC and derivatives) with two biomarkers, procalcitonin and lactate, on the incidence of culture-proven infection in the surgical intensive care unit (SICU). MATERIALS AND METHODS One hundred forty-six consecutive patients admitted for suspected infection had admission and 12-h procalcitonin values, admission and every 6-h lactate values for 24 h, and admission temperature, leukocyte count, lymphocyte count and percentage measured and analyzed in this study. RESULTS Peak (highest measured value ≤24-h of admission) procalcitonin values were not predictive for culture-proven infection. However, a culture-negative subset was identified when peak procalcitonin values were < 2.9 ng/mL and when peak lactate values were < 1.3 mmol/L with a probability of 98.3% (P < .001). No other admission predictor was statistically associated with culture-proven infection. Following boosted-tree partitioning, a C-index of 0.85 was calculated with a misclassification rate of 23.3%. CONCLUSIONS The ability to utilize procalcitonin values in the diagnosis of culture-proven infection was not realized in this study. However, the association of admission peak procalcitonin values with admission peak lactate values identified a group of patients who were culture-negative for suspected infection. No other admission predictor was associated with culture-proven infection.
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Affiliation(s)
- Hussam Ghabra
- Department of Anesthesiology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA; King Abdulaziz University, Department of Anesthesia and Critical Care, Jeddah, Saudi Arabia
| | - William White
- Department of Anesthesiology, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
| | - Michael Townsend
- Department of Surgery, Section Acute Care Surgery, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
| | - Philip Boysen
- Department of Anesthesiology, Section Critical Care Medicine, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
| | - Bobby Nossaman
- Department of Anesthesiology, Section Critical Care Medicine, Ochsner Medical Center, 1514 Jefferson Hwy, New Orleans, LA 70121, USA.
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Guan XD, Tong L. Critical Care Medicine 2017: Bigger Picture, Better Future. Chin Med J (Engl) 2018; 130:1135-1136. [PMID: 28485310 PMCID: PMC5443016 DOI: 10.4103/0366-6999.205866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Xiang-Dong Guan
- Department of Critical Care Medicine,The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
| | - Li Tong
- Department of Critical Care Medicine,The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, Guangdong 510080, China
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Could resuscitation be based on microcirculation data? No. Intensive Care Med 2018; 44:947-949. [PMID: 29736788 DOI: 10.1007/s00134-018-5095-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Accepted: 02/11/2018] [Indexed: 12/28/2022]
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Early outcome of early-goal directed therapy for patients with sepsis or septic shock: a systematic review and meta-analysis of randomized controlled trials. Oncotarget 2018; 8:27510-27519. [PMID: 28460438 PMCID: PMC5432353 DOI: 10.18632/oncotarget.15550] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Accepted: 02/13/2017] [Indexed: 02/05/2023] Open
Abstract
Various trials and meta-analyses have reported conflicting results concerning the application of early goal-directed therapy (EGDT) for sepsis and septic shock. The aim of this study was to update the evidence by performing a systematic review and meta-analysis. Multiple databases were searched from initial through August, 2016 for randomized controlled trials (RCTs) which investigated the associations between the use of EGDT and mortality in patients with sepsis or septic shock. Meta-analysis was performed using random-effects model and heterogeneity was examined through subgroup analyses. The primary outcome of interest was patient all-cause mortality including hospital or ICU mortality. Seventeen RCTs including 6207 participants with 3234 in the EGDT group and 2973 in the control group were eligible for this study. Meta-analysis showed that EGDT did not significantly reduce hospital or intensive care unit (ICU) mortality (relative risk [RR] 0.89, 95% CI 0.78 to 1.02) compared with control group for patients with sepsis or septic shock. The findings of subgroup analyses stratified by study region, number of research center, year of enrollment, clinical setting, sample size, timing of EGDT almost remained constant with that of the primary analysis. Our findings provide evidence that EGDT offers neutral survival effects for patients with sepsis or septic shock. Further meta-analyses based on larger well-designed RCTs or individual patient data meta-analysis are required to explore the survival benefits of EDGT in patients with sepsis or septic shock.
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Lan H, Zhou X, Xue J, Liu B, Chen G. The ability of left ventricular end-diastolic volume variations measured by TEE to monitor fluid responsiveness in high-risk surgical patients during craniotomy: a prospective cohort study. BMC Anesthesiol 2017; 17:165. [PMID: 29202703 PMCID: PMC5716247 DOI: 10.1186/s12871-017-0456-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/24/2017] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND This study was aimed to evaluate the ability of left ventricular end-diastolic volume variations (LVEDVV) measured by transesophageal echocardiography (TEE) compared with stroke volume variation (SVV) obtained by the FloTrac/Vigileo monitor to predict fluid responsiveness, in patients undergoing craniotomy with goal direct therapy. METHODS We used SVV obtained by the FloTrac/Vigileo monitor to manage intraoperative hypotension in adult patients undergoing craniotomy (ASA III - IV) after obtaining IRB approval and informed consent. The LVEDVV were measured by TEE through the changes of left ventricular short diameter of axle simultaneously. When cardiac index (CI) ≤ 2.5 and SVV ≥ 15%, comparisons were made between the two devices before and after volume expansion. RESULTS We enrolled twenty-six patients referred for craniotomy in this study and 145 pairs of data were obtained. Mean Vigileo-SVV and TEE-LVEDVV were 17.8 ± 2.78% and 22.1 ± 7.25% before volume expansion respectively, and were 10.95 ± 2.8% and 13.58 ± 3.78% after volume expansion respectively (P < 0.001). The relationship between Vigileo-SVV and TEE-LVEDVV was significant (r2 = 0.55; p < 0.001). Agreement between Vigileo-SVV and TEE-LVEDVV was 3.3% ± 3.9% (mean bias ± SD, Bland-Altman). CONCLUSIONS For fluid responsiveness of patients during craniotomy in ASA III-IV, LVEDVV measured by left ventricular short diameter of axle using M type echocaidiographic measurement seems an acceptable monitoring indicator. This accessible method has promising clinical applications in situations where volume and cardiac function monitoring is of great importance during surgery. TRIAL REGISTRATION Chinese Clinical Trial Registry, ChiCTR-TRC-13003583 , August 20, 2013.
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Affiliation(s)
- Haidan Lan
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Xiaoshuang Zhou
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Jing Xue
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China
| | - Guo Chen
- Department of Anesthesiology, West China Hospital of Sichuan University, No.37, Guo Xue Xiang, Chengdu, 610041, Sichuan, People's Republic of China.
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The Lactate/Albumin Ratio: A Valuable Tool for Risk Stratification in Septic Patients Admitted to ICU. Int J Mol Sci 2017; 18:ijms18091893. [PMID: 28869492 PMCID: PMC5618542 DOI: 10.3390/ijms18091893] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Revised: 08/22/2017] [Accepted: 08/27/2017] [Indexed: 12/29/2022] Open
Abstract
The lactate/albumin ratio has been reported to be associated with mortality in pediatric patients with sepsis. We aimed to evaluate the lactate/albumin ratio for its prognostic relevance in a larger collective of critically ill (adult) patients admitted to an intensive care unit (ICU). A total of 348 medical patients admitted to a German ICU for sepsis between 2004 and 2009 were included. Follow-up of patients was performed retrospectively between May 2013 and November 2013. The association of the lactate/albumin ratio (cut-off 0.15) and both in-hospital and post-discharge mortality was investigated. An optimal cut-off was calculated by means of Youden’s index. The lactate/albumin ratio was elevated in non-survivors (p < 0.001). Patients with an increased lactate/albumin ratio were of similar age, but clinically in a poorer condition and had more pronounced laboratory signs of multi-organ failure. An increased lactate/albumin ratio was associated with adverse in-hospital mortality. An optimal cut-off of 0.15 was calculated and was associated with adverse long-term outcome even after correction for APACHE2 and SAPS2. We matched 99 patients with a lactate/albumin ratio >0.15 to case-controls with a lactate/albumin ratio <0.15 corrected for APACHE2 scores: The group with a lactate/albumin ratio >0.15 evidenced adverse in-hospital outcome in a paired analysis with a difference of 27% (95%CI 10–43%; p < 0.01). Regarding long-term mortality, again, patients in the group with a lactate/albumin ratio >0.15 showed adverse outcomes (p < 0.001). An increased lactate/albumin ratio was significantly associated with an adverse outcome in critically ill patients admitted to an ICU, even after correction for confounders. The lactate/albumin ratio might constitute an independent, readily available, and important parameter for risk stratification in the critically ill.
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Park SK, Shin SR, Hur M, Kim WH, Oh EA, Lee SH. The effect of early goal-directed therapy for treatment of severe sepsis or septic shock: A systemic review and meta-analysis. J Crit Care 2017; 38:115-122. [PMID: 27886576 DOI: 10.1016/j.jcrc.2016.10.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 10/24/2016] [Accepted: 10/24/2016] [Indexed: 01/18/2023]
Abstract
PURPOSE To assess the effects of early goal-directed therapy (EGDT) on reducing mortality compared with conventional management of severe sepsis or septic shock. MATERIALS AND METHODS We included a systemic review, using the Medline and EMBASE. Seventeen randomized trials with 5765 patients comparing EGDT with usual care were included. RESULTS There were no significant differences in mortality between EGDT and control groups (relative risk [RR], 0.89; 95% confidence interval [CI], 0.79-1.00), with moderate heterogeneity (I2=56%). The EGDT was associated with lower mortality rates when the mortality rate of the usual care group was greater than 30% (12 trials; RR, 0.83; 95% CI, 0.72-0.96), but not when the mortality rate in the usual care group was less than 30% (5 trials; RR, 1.03; 95% CI, 0.92-1.16). The mortality benefit was seen only in subgroup of population analyzed between publication of the 2004 and 2012 Surviving Sepsis Campaign guidelines, but not before and after these publications. CONCLUSION This meta-analysis was heavily influenced by the recent addition of the trio of trials published after 2014. The results of the recent trio of trials may be biased due to methodological issues. This includes lack of blinding by incorporating similar diagnostic and therapeutic interventions as the original EGDT trial.
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Affiliation(s)
- Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Su Rin Shin
- Department of Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Republic of Korea
| | - Min Hur
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Eun-Ah Oh
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Soo Hee Lee
- Department of Anesthesiology and Pain Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
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Suhaimi FM, Chase JG, Pretty CG, Shaw GM, Razak NN, Jamaludin UK. Insulin sensitivity and sepsis score: A correlation between model-based metric and sepsis scoring system in critically ill patients. Biomed Signal Process Control 2017. [DOI: 10.1016/j.bspc.2016.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Lu Y, Zhang H, Teng F, Xia WJ, Sun GX, Wen AQ. Early Goal-Directed Therapy in Severe Sepsis and Septic Shock: A Meta-Analysis and Trial Sequential Analysis of Randomized Controlled Trials. J Intensive Care Med 2016; 33:296-309. [PMID: 27756870 DOI: 10.1177/0885066616671710] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The Surviving Sepsis Campaign guidelines recommend early goal-directed therapy (EGDT) for the resuscitation of patients with sepsis; however, the recent evidences quickly evolve and convey conflicting results. We performed a meta-analysis to evaluate the effect of EGDT on mortality in adults with severe sepsis and septic shock. METHODS We searched electronic databases to identify randomized controlled trials that compared EGDT with usual care or lactate-guided therapy in adults with severe sepsis and septic shock. Predefined primary outcome was all-cause mortality at final follow-up. RESULTS We included 13 trials enrolling 5268 patients. Compared with usual care, EGDT was associated with decreased mortality (risk ratio [RR]: 0.87, 95% CI: 0.77-0.98; 4664 patients, 8 trials; Grading of Recommendations Assessment, Development, and Evaluation [GRADE] quality of evidence was moderate). Compared with lactate clearance-guided therapy, EGDT was associated with increased mortality (RR: 1.60, 95% CI: 1.24-2.06; 604 patients, 5 trials; GRADE quality of evidence was low). Patients assigned to EGDT received more intravenous fluid, red cell transfusion, vasopressor infusion, and dobutamine use within the first 6 hours than those assigned to usual care (all P values < .00001). CONCLUSION Adults with severe sepsis and septic shock who received EGDT had a lower mortality than those given usual care, the benefit may mainly be attributed to treatments administered within the first 6 hours. However, the underlying mechanisms by which lactate clearance-guided therapy benefits these patients are yet to be investigated.
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Affiliation(s)
- Yao Lu
- 1 Department of Blood Transfusion, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Han Zhang
- 1 Department of Blood Transfusion, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Fang Teng
- 1 Department of Blood Transfusion, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Wen-Jun Xia
- 1 Department of Blood Transfusion, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Gui-Xiang Sun
- 1 Department of Blood Transfusion, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ai-Qing Wen
- 1 Department of Blood Transfusion, Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
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Hutchinson KM, Shaw SP. A Review of Central Venous Pressure and Its Reliability as a Hemodynamic Monitoring Tool in Veterinary Medicine. Top Companion Anim Med 2016; 31:109-121. [PMID: 27968811 DOI: 10.1053/j.tcam.2016.08.009] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 08/04/2016] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To review the current literature regarding central venous pressure (CVP) in veterinary patients pertaining to placement (of central line), measurement, interpretation, use in veterinary medicine, limitations, and controversies in human medicine. ETIOLOGY CVP use in human medicine is a widely debated topic, as numerous sources have shown poor correlation of CVP measurements to the volume status of a patient. Owing to the ease of placement and monitoring in veterinary medicine, CVP remains a widely used modality for evaluating the hemodynamic status of a patient. A thorough evaluation of the veterinary and human literature should be performed to evaluate the role of CVP measurements in assessing volume status in veterinary patients. DIAGNOSIS Veterinary patients that benefit from accurate CVP readings include those suffering from hypovolemic or septic shock, heart disease, or renal disease or all of these. Other patients that may benefit from CVP monitoring include high-risk anesthetic patients undergoing major surgery, trending of fluid volume status in critically ill patients, patients with continued shock, and patients that require rapid or large amounts of fluids. THERAPY The goal of CVP use is to better understand a patient's intravascular volume status, which would allow early goal-directed therapy. PROGNOSIS CVP would most likely continue to play an important role in the hemodynamic monitoring of the critically ill veterinary patient; however, when available, cardiac output methods should be considered the first choice for hemodynamic monitoring.
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Affiliation(s)
| | - Scott P Shaw
- VCA, Specialty Regional Medical Director; Northeast Los Angeles, CA, USA
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