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Rosa RG, Walsh TS. Navigating complex interventions in post-ICU care: insights from a randomized clinical trial of post-intensive care multidisciplinary consultations. Intensive Care Med 2024; 50:725-727. [PMID: 38598126 DOI: 10.1007/s00134-024-07414-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Accepted: 03/24/2024] [Indexed: 04/11/2024]
Affiliation(s)
- Regis G Rosa
- Internal Medicine Department, Hospital Moinhos de Vento, Rua Ramiro Barcelos, 630, 10° Andar, Sala 1007, Porto Alegre, RS, 90660-020, Brazil.
- Brazilian Research in Intensive Care Network, São Paulo, RS, Brazil.
| | - Timothy S Walsh
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland
- Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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Aitken LM, Emerson LM, Kydonaki K, Blackwood B, Creagh-Brown B, Lone NI, McKenzie CA, Reade MC, Weir CJ, Wise MP, Walsh TS. Alpha 2 agonists for sedation to produce better outcomes from critical illness (A2B trial): protocol for a mixed-methods process evaluation of a randomised controlled trial. BMJ Open 2024; 14:e081637. [PMID: 38580355 PMCID: PMC11002363 DOI: 10.1136/bmjopen-2023-081637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/16/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION An association between deep sedation and adverse short-term outcomes has been demonstrated although this evidence has been inconsistent. The A2B (alpha-2 agonists for sedation in critical care) sedation trial is designed to determine whether the alpha-2 agonists clonidine and dexmedetomidine, compared with usual care, are clinically and cost-effective. The A2B intervention is a complex intervention conducted in 39 intensive care units (ICUs) in the UK. Multicentre organisational factors, variable cultures, perceptions and practices and the involvement of multiple members of the healthcare team add to the complexity of the A2B trial. From our pretrial contextual exploration it was apparent that routine practices such as type and frequency of pain, agitation and delirium assessment, as well as the common sedative agents used, varied widely across the UK. Anticipated challenges in implementing A2B focused on the impact of usual practice, perceptions of risk, ICU culture, structure and the presence of equipoise. Given this complexity, a process evaluation has been embedded in the A2B trial to uncover factors that could impact successful delivery and explore their impact on intervention delivery and interpretation of outcomes. METHODS AND ANALYSIS This is a mixed-methods process evaluation guided by the A2B intervention logic model. It includes two phases of data collection conducted during and at the end of trial. Data will be collected using a combination of questionnaires, stakeholder interviews and routinely collected trial data. A framework approach will be used to analyse qualitative data with synthesis of data within and across the phases. The nature of the relationship between delivery of the A2B intervention and the trial primary and secondary outcomes will be explored. ETHICS AND DISSEMINATION All elements of the A2B trial, including the process evaluation, are approved by Scotland A Research Ethics Committee (Ref. 18/SS/0085). Dissemination will be via publications, presentations and media engagement. TRIAL REGISTRATION NUMBER NCT03653832.
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Affiliation(s)
- Leanne M Aitken
- School of Health & Psychological Sciences, City, University of London, London, UK
| | - Lydia M Emerson
- School of Health & Psychological Sciences, City University of London, London, UK
| | - Kalliopi Kydonaki
- Department of Nursing, Midwifery & Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Bronagh Blackwood
- Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
| | | | - Nazir I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
| | - Cathrine A McKenzie
- Department of Pharmacy and Critical Care, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michael C Reade
- The University of Queensland - Saint Lucia Campus, Brisbane, Queensland, Australia
| | - Christopher J Weir
- Division of Clinical and Surgical Sciences, University of Edinburgh, Edinburgh, UK
| | - Matt P Wise
- Department of Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh Division of Clinical and Surgical Sciences, Edinburgh, UK
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Pauley E, Drake TM, Griffith DM, Sigfrid L, Lone NI, Harrison EM, Baillie JK, Scott JT, Walsh TS, Semple MG, Docherty AB. Recovery from Covid-19 critical illness: A secondary analysis of the ISARIC4C CCP-UK cohort study and the RECOVER trial. J Intensive Care Soc 2023; 24:162-169. [PMID: 37255989 PMCID: PMC10225805 DOI: 10.1177/17511437211052226] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023] Open
Abstract
Background We aimed to compare the prevalence and severity of fatigue in survivors of Covid-19 versus non-Covid-19 critical illness, and to explore potential associations between baseline characteristics and worse recovery. Methods We conducted a secondary analysis of two prospectively collected datasets. The population included was 92 patients who received invasive mechanical ventilation (IMV) with Covid-19, and 240 patients who received IMV with non-Covid-19 illness before the pandemic. Follow-up data were collected post-hospital discharge using self-reported questionnaires. The main outcome measures were self-reported fatigue severity and the prevalence of severe fatigue (severity >7/10) 3 and 12-months post-hospital discharge. Results Covid-19 IMV-patients were significantly younger with less prior comorbidity, and more males, than pre-pandemic IMV-patients. At 3-months, the prevalence (38.9% [7/18] vs. 27.1% [51/188]) and severity (median 5.5/10 vs 5.0/10) of fatigue were similar between the Covid-19 and pre-pandemic populations, respectively. At 6-months, the prevalence (10.3% [3/29] vs. 32.5% [54/166]) and severity (median 2.0/10 vs. 5.7/10) of fatigue were less in the Covid-19 cohort. In the total sample of IMV-patients included (i.e. all Covid-19 and pre-pandemic patients), having Covid-19 was significantly associated with less severe fatigue (severity <7/10) after adjusting for age, sex and prior comorbidity (adjusted OR 0.35 (95%CI 0.15-0.76, p=0.01). Conclusion Fatigue may be less severe after Covid-19 than after other critical illness.
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Affiliation(s)
- Ellen Pauley
- , Edinburgh, UKUniversity of Edinburgh Medical School
| | - Thomas M Drake
- Centre for Medical Informatics, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
| | - David M Griffith
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
| | - Louise Sigfrid
- Centre for Tropical Medicine and Global Health, , Oxford, UKUniversity of Oxford
| | - Nazir I Lone
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
- Centre for Population Health Sciences, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
| | - Ewen M Harrison
- Centre for Medical Informatics, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
| | - J Kenneth Baillie
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
- Roslin Institute, , Edinburgh, UKUniversity of Edinburgh
| | - Janet T Scott
- , Glasgow, UKMRC-University of Glasgow Centre for Virus Research
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
| | - Malcolm G Semple
- NIHR Health Protection Unit in Emerging Infectious Diseases, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, , Liverpool, UKUniversity of Liverpool
| | - Annemarie B Docherty
- Centre for Medical Informatics, The Usher Institute, , Edinburgh, UKUniversity of Edinburgh
- Anaesthesia, Critical Care and Pain Medicine, , Edinburgh, UKUniversity of Edinburgh
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Gaughan EE, Quinn TM, Mills A, Bruce AM, Antonelli J, MacKinnon AC, Aslanis V, Li F, O’Connor R, Boz C, Mills R, Emanuel P, Burgess M, Rinaldi G, Valanciute A, Mills B, Scholefield E, Hardisty G, Findlay EG, Parker RA, Norrie J, Dear JW, Akram AR, Koch O, Templeton K, Dockrell DH, Walsh TS, Partridge S, Humphries D, Wang-Jairaj J, Slack RJ, Schambye H, Phung D, Gravelle L, Lindmark B, Shankar-Hari M, Hirani N, Sethi T, Dhaliwal K. An Inhaled Galectin-3 Inhibitor in COVID-19 Pneumonitis: A Phase Ib/IIa Randomized Controlled Clinical Trial (DEFINE). Am J Respir Crit Care Med 2023; 207:138-149. [PMID: 35972987 PMCID: PMC9893334 DOI: 10.1164/rccm.202203-0477oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/16/2022] [Indexed: 02/02/2023] Open
Abstract
Rationale: High circulating galectin-3 is associated with poor outcomes in patients with coronavirus disease (COVID-19). We hypothesized that GB0139, a potent inhaled thiodigalactoside galectin-3 inhibitor with antiinflammatory and antifibrotic actions, would be safely and effectively delivered in COVID-19 pneumonitis. Objectives: Primary outcomes were safety and tolerability of inhaled GB0139 as an add-on therapy for patients hospitalized with COVID-19 pneumonitis. Methods: We present the findings of two arms of a phase Ib/IIa randomized controlled platform trial in hospitalized patients with confirmed COVID-19 pneumonitis. Patients received standard of care (SoC) or SoC plus 10 mg inhaled GB0139 twice daily for 48 hours, then once daily for up to 14 days or discharge. Measurements and Main Results: Data are reported from 41 patients, 20 of which were assigned randomly to receive GB0139. Primary outcomes: the GB0139 group experienced no treatment-related serious adverse events. Incidences of adverse events were similar between treatment arms (40 with GB0139 + SoC vs. 35 with SoC). Secondary outcomes: plasma GB0139 was measurable in all patients after inhaled exposure and demonstrated target engagement with decreased circulating galectin (overall treatment effect post-hoc analysis of covariance [ANCOVA] over days 2-7; P = 0.0099 vs. SoC). Plasma biomarkers associated with inflammation, fibrosis, coagulopathy, and major organ function were evaluated. Conclusions: In COVID-19 pneumonitis, inhaled GB0139 was well-tolerated and achieved clinically relevant plasma concentrations with target engagement. The data support larger clinical trials to determine clinical efficacy. Clinical trial registered with ClinicalTrials.gov (NCT04473053) and EudraCT (2020-002230-32).
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Affiliation(s)
- Erin E. Gaughan
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | - Tom M. Quinn
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | | | | | | | | | | | - Feng Li
- Centre for Inflammation Research, Edinburgh BioQuarter
| | | | - Cecilia Boz
- Centre for Inflammation Research, Edinburgh BioQuarter
| | - Ross Mills
- Centre for Inflammation Research, Edinburgh BioQuarter
| | | | | | | | | | - Bethany Mills
- Centre for Inflammation Research, Edinburgh BioQuarter
| | | | | | | | | | - John Norrie
- Edinburgh Clinical Trials Unit, Usher Institute, and
| | - James W. Dear
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, United Kingdom
| | - Ahsan R. Akram
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | - Oliver Koch
- Centre for Inflammation Research, Edinburgh BioQuarter
- Infectious Diseases Department, Western General Hospital, Edinburgh, United Kingdom
| | | | - David H. Dockrell
- Centre for Inflammation Research, Edinburgh BioQuarter
- Infectious Diseases Department, Western General Hospital, Edinburgh, United Kingdom
| | - Timothy S. Walsh
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Critical Care, New Royal Infirmary of Edinburgh, Edinburgh BioQuarter, Edinburgh, United Kingdom
| | | | | | | | | | | | - De Phung
- Galecto Inc., Copenhagen, Denmark; and
| | | | | | - Manu Shankar-Hari
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Critical Care, New Royal Infirmary of Edinburgh, Edinburgh BioQuarter, Edinburgh, United Kingdom
| | - Nikhil Hirani
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
| | | | - Kevin Dhaliwal
- Centre for Inflammation Research, Edinburgh BioQuarter
- Department of Respiratory Medicine
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Griffith DM, Walsh TS. Outcomes from COVID-19 Clinical Trials in Hospitalized Patients: Seeking the Truth That Matters. Am J Respir Crit Care Med 2022; 206:659-660. [PMID: 35608532 PMCID: PMC9799102 DOI: 10.1164/rccm.202205-0907ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Affiliation(s)
- David M Griffith
- Usher Institute University of Edinburgh Edinburgh, United Kingdom
| | - Timothy S Walsh
- Usher Institute University of Edinburgh Edinburgh, United Kingdom
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Blackwood B, Morris KP, Jordan J, McIlmurray L, Agus A, Boyle R, Clarke M, Easter C, Feltbower RG, Hemming K, Macrae D, McDowell C, Murray M, Parslow R, Peters MJ, Phair G, Tume LN, Walsh TS, McAuley DF. Co-ordinated multidisciplinary intervention to reduce time to successful extubation for children on mechanical ventilation: the SANDWICH cluster stepped-wedge RCT. Health Technol Assess 2022; 26:1-114. [PMID: 35289741 DOI: 10.3310/tcfx3817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Daily assessment of patient readiness for liberation from invasive mechanical ventilation can reduce the duration of ventilation. However, there is uncertainty about the effectiveness of this in a paediatric population. OBJECTIVES To determine the effect of a ventilation liberation intervention in critically ill children who are anticipated to have a prolonged duration of mechanical ventilation (primary objective) and in all children (secondary objective). DESIGN A pragmatic, stepped-wedge, cluster randomised trial with economic and process evaluations. SETTING Paediatric intensive care units in the UK. PARTICIPANTS Invasively mechanically ventilated children (aged < 16 years). INTERVENTIONS The intervention incorporated co-ordinated multidisciplinary care, patient-relevant sedation plans linked to sedation assessment, assessment of ventilation parameters with a higher than usual trigger for undertaking an extubation readiness test and a spontaneous breathing trial on low levels of respiratory support to test extubation readiness. The comparator was usual care. Hospital sites were randomised sequentially to transition from control to intervention and were non-blinded. MAIN OUTCOME MEASURES The primary outcome measure was the duration of invasive mechanical ventilation until the first successful extubation. The secondary outcome measures were successful extubation, unplanned extubation and reintubation, post-extubation use of non-invasive ventilation, tracheostomy, post-extubation stridor, adverse events, length of intensive care and hospital stay, mortality and cost per respiratory complication avoided at 28 days. RESULTS The trial included 10,495 patient admissions from 18 paediatric intensive care units from 5 February 2018 to 14 October 2019. In children with anticipated prolonged ventilation (n = 8843 admissions: control, n = 4155; intervention, n = 4688), the intervention resulted in a significantly shorter time to successful extubation [cluster and time-adjusted median difference -6.1 hours (interquartile range -8.2 to -5.3 hours); adjusted hazard ratio 1.11, 95% confidence interval 1.02 to 1.20; p = 0.02] and a higher incidence of successful extubation (adjusted relative risk 1.01, 95% confidence interval 1.00 to 1.02; p = 0.03) and unplanned extubation (adjusted relative risk 1.62, 95% confidence interval 1.05 to 2.51; p = 0.03), but not reintubation (adjusted relative risk 1.10, 95% confidence interval 0.89 to 1.36; p = 0.38). In the intervention period, the use of post-extubation non-invasive ventilation was significantly higher (adjusted relative risk 1.22, 95% confidence interval 1.01 to 1.49; p = 0.04), with no evidence of a difference in intensive care length of stay or other harms, but hospital length of stay was longer (adjusted hazard ratio 0.89, 95% confidence interval 0.81 to 0.97; p = 0.01). Findings for all children were broadly similar. The control period was associated with lower, but not statistically significantly lower, total costs (cost difference, mean £929.05, 95% confidence interval -£516.54 to £2374.64) and significantly fewer respiratory complications avoided (mean difference -0.10, 95% confidence interval -0.16 to -0.03). LIMITATIONS The unblinded intervention assignment may have resulted in performance or detection bias. It was not possible to determine which components were primarily responsible for the observed effect. Treatment effect in a more homogeneous group remains to be determined. CONCLUSIONS The intervention resulted in a statistically significant small reduction in time to first successful extubation; thus, the clinical importance of the effect size is uncertain. FUTURE WORK Future work should explore intervention sustainability and effects of the intervention in other paediatric populations. TRIAL REGISTRATION This trial is registered as ISRCTN16998143. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 18. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, Birmingham Children's Hospital, Birmingham, UK
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Roisin Boyle
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Mike Clarke
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Christina Easter
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Richard G Feltbower
- School of Medicine, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Karla Hemming
- Institute of Applied Health, University of Birmingham, Birmingham, UK
| | - Duncan Macrae
- Paediatric Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Margaret Murray
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Roger Parslow
- School of Medicine, Leeds Institute for Data Analytics, University of Leeds, Leeds, UK
| | - Mark J Peters
- Paediatric Intensive Care Unit, Great Ormond Street Hospital, London, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast Health and Social Care Trust, Belfast, UK
| | - Lyvonne N Tume
- School of Health and Society, University of Salford, Salford, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Daniel F McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, UK
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Shah A, Chester-Jones M, Dutton SJ, Marian IR, Barber VS, Griffith DM, Singleton J, Wray K, James T, Drakesmith H, Robbins PA, Frise MC, Young JD, Walsh TS, McKechnie SR, Stanworth SJ. Intravenous iron to treat anaemia following critical care: a multicentre feasibility randomised trial. Br J Anaesth 2021; 128:272-282. [PMID: 34872717 DOI: 10.1016/j.bja.2021.11.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 10/12/2021] [Accepted: 11/01/2021] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Anaemia is common and associated with poor outcomes in survivors of critical illness. However, the optimal treatment strategy is unclear. METHODS We conducted a multicentre, feasibility RCT to compare either a single dose of ferric carboxymaltose 1000 mg i.v. or usual care in patients being discharged from the ICU with moderate or severe anaemia (haemoglobin ≤100 g L-1). We collected data on feasibility (recruitment, randomisation, follow-up), biological efficacy, and clinical outcomes. RESULTS Ninety-eight participants were randomly allocated (49 in each arm). The overall recruitment rate was 34% with 6.5 participants recruited on average per month. Forty-seven of 49 (96%) participants received the intervention. Patient-reported outcome measures were available for 79/93 (85%) survivors at 90 days. Intravenous iron resulted in a higher mean (standard deviation [sd]) haemoglobin at 28 days (119.8 [13.3] vs 106.7 [14.9] g L-1) and 90 days (130.5 [15.1] vs 122.7 [17.3] g L-1), adjusted mean difference (10.98 g L-1; 95% confidence interval [CI], 4.96-17.01; P<0.001) over 90 days after randomisation. Infection rates were similar in both groups. Hospital readmissions at 90 days post-ICU discharge were lower in the i.v. iron group (7/40 vs 15/39; risk ratio=0.46; 95% CI, 0.21-0.99; P=0.037). The median (inter-quartile range) post-ICU hospital stay was shorter in the i.v. iron group but did not reach statistical significance (5.0 [3.0-13.0] vs 9.0 [5.0-16.0] days, P=0.15). CONCLUSION A large, multicentre RCT of i.v. iron to treat anaemia in survivors of critical illness appears feasible and is necessary to determine the effects on patient-centred outcomes. CLINICAL TRIAL REGISTRATION ISRCTN13721808 (www.isrctn.com).
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.
| | - Mae Chester-Jones
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Ioana R Marian
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Vicki S Barber
- Oxford Clinical Trials Research Unit (OCTRU), Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - David M Griffith
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK; Deanery of Molecular, Genetic and Population Health Sciences and University of Edinburgh, Edinburgh, UK
| | - Jo Singleton
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Katherine Wray
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, Oxford, UK
| | - Tim James
- Department of Clinical Biochemistry, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, MRC Weatherall Institute of Molecular Medicine, Oxford, UK; Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Peter A Robbins
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK
| | - Matthew C Frise
- Department of Physiology, Anatomy and Genetics, University of Oxford, Oxford, UK; Intensive Care Unit, Royal Berkshire Hospitals NHS Foundation Trust, Reading, UK
| | - J Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK; Usher Institute for Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Stuart R McKechnie
- Adult Intensive Care Unit, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK; Haematology Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK; Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Estcourt LJ, Turgeon AF, McQuilten ZK, McVerry BJ, Al-Beidh F, Annane D, Arabi YM, Arnold DM, Beane A, Bégin P, van Bentum-Puijk W, Berry LR, Bhimani Z, Birchall JE, Bonten MJM, Bradbury CA, Brunkhorst FM, Buxton M, Callum JL, Chassé M, Cheng AC, Cove ME, Daly J, Derde L, Detry MA, De Jong M, Evans A, Fergusson DA, Fish M, Fitzgerald M, Foley C, Goossens H, Gordon AC, Gosbell IB, Green C, Haniffa R, Harvala H, Higgins AM, Hills TE, Hoad VC, Horvat C, Huang DT, Hudson CL, Ichihara N, Laing E, Lamikanra AA, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, MacLennan S, Marshall J, McAuley DF, McDyer JF, McGlothlin A, McGuinness S, Miflin G, Montgomery S, Mouncey PR, Murthy S, Nichol A, Parke R, Parker JC, Priddee N, Purcell DFJ, Reyes LF, Richardson P, Robitaille N, Rowan KM, Rynne J, Saito H, Santos M, Saunders CT, Serpa Neto A, Seymour CW, Silversides JA, Tinmouth AA, Triulzi DJ, Turner AM, van de Veerdonk F, Walsh TS, Wood EM, Berry S, Lewis RJ, Menon DK, McArthur C, Zarychanski R, Angus DC, Webb SA, Roberts DJ, Shankar-Hari M. Effect of Convalescent Plasma on Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2021. [PMID: 34606578 DOI: 10.1101/2021.06.11.21258760] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
IMPORTANCE The evidence for benefit of convalescent plasma for critically ill patients with COVID-19 is inconclusive. OBJECTIVE To determine whether convalescent plasma would improve outcomes for critically ill adults with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The ongoing Randomized, Embedded, Multifactorial, Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP) enrolled and randomized 4763 adults with suspected or confirmed COVID-19 between March 9, 2020, and January 18, 2021, within at least 1 domain; 2011 critically ill adults were randomized to open-label interventions in the immunoglobulin domain at 129 sites in 4 countries. Follow-up ended on April 19, 2021. INTERVENTIONS The immunoglobulin domain randomized participants to receive 2 units of high-titer, ABO-compatible convalescent plasma (total volume of 550 mL ± 150 mL) within 48 hours of randomization (n = 1084) or no convalescent plasma (n = 916). MAIN OUTCOMES AND MEASURES The primary ordinal end point was organ support-free days (days alive and free of intensive care unit-based organ support) up to day 21 (range, -1 to 21 days; patients who died were assigned -1 day). The primary analysis was an adjusted bayesian cumulative logistic model. Superiority was defined as the posterior probability of an odds ratio (OR) greater than 1 (threshold for trial conclusion of superiority >99%). Futility was defined as the posterior probability of an OR less than 1.2 (threshold for trial conclusion of futility >95%). An OR greater than 1 represented improved survival, more organ support-free days, or both. The prespecified secondary outcomes included in-hospital survival; 28-day survival; 90-day survival; respiratory support-free days; cardiovascular support-free days; progression to invasive mechanical ventilation, extracorporeal mechanical oxygenation, or death; intensive care unit length of stay; hospital length of stay; World Health Organization ordinal scale score at day 14; venous thromboembolic events at 90 days; and serious adverse events. RESULTS Among the 2011 participants who were randomized (median age, 61 [IQR, 52 to 70] years and 645/1998 [32.3%] women), 1990 (99%) completed the trial. The convalescent plasma intervention was stopped after the prespecified criterion for futility was met. The median number of organ support-free days was 0 (IQR, -1 to 16) in the convalescent plasma group and 3 (IQR, -1 to 16) in the no convalescent plasma group. The in-hospital mortality rate was 37.3% (401/1075) for the convalescent plasma group and 38.4% (347/904) for the no convalescent plasma group and the median number of days alive and free of organ support was 14 (IQR, 3 to 18) and 14 (IQR, 7 to 18), respectively. The median-adjusted OR was 0.97 (95% credible interval, 0.83 to 1.15) and the posterior probability of futility (OR <1.2) was 99.4% for the convalescent plasma group compared with the no convalescent plasma group. The treatment effects were consistent across the primary outcome and the 11 secondary outcomes. Serious adverse events were reported in 3.0% (32/1075) of participants in the convalescent plasma group and in 1.3% (12/905) of participants in the no convalescent plasma group. CONCLUSIONS AND RELEVANCE Among critically ill adults with confirmed COVID-19, treatment with 2 units of high-titer, ABO-compatible convalescent plasma had a low likelihood of providing improvement in the number of organ support-free days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | - Bryan J McVerry
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Farah Al-Beidh
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital, Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | | | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Charlotte A Bradbury
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
- Faculty of Health Sciences, University of Bristol, Bristol, England
| | - Frank M Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Jeannie L Callum
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queens University, Kingston, Ontario, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Daly
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Menno De Jong
- Department of Medical Microbiology, University of Amsterdam Medical Center, University of Amsterdam, the Netherlands
| | - Amy Evans
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Dean A Fergusson
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Matthew Fish
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | | | - Claire Foley
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony C Gordon
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Iain B Gosbell
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
- Western Sydney University, Sydney, Australia
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - David T Huang
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Emma Laing
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | | | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley
| | | | | | - John Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - John F McDyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
| | | | - Stephanie Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Srinivas Murthy
- School of Medicine, University of British Columbia, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nicole Priddee
- Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Damian F J Purcell
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | | | - Nancy Robitaille
- Héma-Québec, Montreal, Quebec, Canada
- Division of Hematology and Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Jennifer Rynne
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Marlene Santos
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Jon A Silversides
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - Alan A Tinmouth
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Darrell J Triulzi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David K Menon
- University Division of Anesthesia, Addenbrooke's Hospital Cambridge, Cambridge, England
| | - Colin McArthur
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Canada
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
| | - David J Roberts
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, Kings College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
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9
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Estcourt LJ, Turgeon AF, McQuilten ZK, McVerry BJ, Al-Beidh F, Annane D, Arabi YM, Arnold DM, Beane A, Bégin P, van Bentum-Puijk W, Berry LR, Bhimani Z, Birchall JE, Bonten MJM, Bradbury CA, Brunkhorst FM, Buxton M, Callum JL, Chassé M, Cheng AC, Cove ME, Daly J, Derde L, Detry MA, De Jong M, Evans A, Fergusson DA, Fish M, Fitzgerald M, Foley C, Goossens H, Gordon AC, Gosbell IB, Green C, Haniffa R, Harvala H, Higgins AM, Hills TE, Hoad VC, Horvat C, Huang DT, Hudson CL, Ichihara N, Laing E, Lamikanra AA, Lamontagne F, Lawler PR, Linstrum K, Litton E, Lorenzi E, MacLennan S, Marshall J, McAuley DF, McDyer JF, McGlothlin A, McGuinness S, Miflin G, Montgomery S, Mouncey PR, Murthy S, Nichol A, Parke R, Parker JC, Priddee N, Purcell DFJ, Reyes LF, Richardson P, Robitaille N, Rowan KM, Rynne J, Saito H, Santos M, Saunders CT, Serpa Neto A, Seymour CW, Silversides JA, Tinmouth AA, Triulzi DJ, Turner AM, van de Veerdonk F, Walsh TS, Wood EM, Berry S, Lewis RJ, Menon DK, McArthur C, Zarychanski R, Angus DC, Webb SA, Roberts DJ, Shankar-Hari M. Effect of Convalescent Plasma on Organ Support-Free Days in Critically Ill Patients With COVID-19: A Randomized Clinical Trial. JAMA 2021; 326:1690-1702. [PMID: 34606578 PMCID: PMC8491132 DOI: 10.1001/jama.2021.18178] [Citation(s) in RCA: 132] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/24/2021] [Indexed: 02/06/2023]
Abstract
IMPORTANCE The evidence for benefit of convalescent plasma for critically ill patients with COVID-19 is inconclusive. OBJECTIVE To determine whether convalescent plasma would improve outcomes for critically ill adults with COVID-19. DESIGN, SETTING, AND PARTICIPANTS The ongoing Randomized, Embedded, Multifactorial, Adaptive Platform Trial for Community-Acquired Pneumonia (REMAP-CAP) enrolled and randomized 4763 adults with suspected or confirmed COVID-19 between March 9, 2020, and January 18, 2021, within at least 1 domain; 2011 critically ill adults were randomized to open-label interventions in the immunoglobulin domain at 129 sites in 4 countries. Follow-up ended on April 19, 2021. INTERVENTIONS The immunoglobulin domain randomized participants to receive 2 units of high-titer, ABO-compatible convalescent plasma (total volume of 550 mL ± 150 mL) within 48 hours of randomization (n = 1084) or no convalescent plasma (n = 916). MAIN OUTCOMES AND MEASURES The primary ordinal end point was organ support-free days (days alive and free of intensive care unit-based organ support) up to day 21 (range, -1 to 21 days; patients who died were assigned -1 day). The primary analysis was an adjusted bayesian cumulative logistic model. Superiority was defined as the posterior probability of an odds ratio (OR) greater than 1 (threshold for trial conclusion of superiority >99%). Futility was defined as the posterior probability of an OR less than 1.2 (threshold for trial conclusion of futility >95%). An OR greater than 1 represented improved survival, more organ support-free days, or both. The prespecified secondary outcomes included in-hospital survival; 28-day survival; 90-day survival; respiratory support-free days; cardiovascular support-free days; progression to invasive mechanical ventilation, extracorporeal mechanical oxygenation, or death; intensive care unit length of stay; hospital length of stay; World Health Organization ordinal scale score at day 14; venous thromboembolic events at 90 days; and serious adverse events. RESULTS Among the 2011 participants who were randomized (median age, 61 [IQR, 52 to 70] years and 645/1998 [32.3%] women), 1990 (99%) completed the trial. The convalescent plasma intervention was stopped after the prespecified criterion for futility was met. The median number of organ support-free days was 0 (IQR, -1 to 16) in the convalescent plasma group and 3 (IQR, -1 to 16) in the no convalescent plasma group. The in-hospital mortality rate was 37.3% (401/1075) for the convalescent plasma group and 38.4% (347/904) for the no convalescent plasma group and the median number of days alive and free of organ support was 14 (IQR, 3 to 18) and 14 (IQR, 7 to 18), respectively. The median-adjusted OR was 0.97 (95% credible interval, 0.83 to 1.15) and the posterior probability of futility (OR <1.2) was 99.4% for the convalescent plasma group compared with the no convalescent plasma group. The treatment effects were consistent across the primary outcome and the 11 secondary outcomes. Serious adverse events were reported in 3.0% (32/1075) of participants in the convalescent plasma group and in 1.3% (12/905) of participants in the no convalescent plasma group. CONCLUSIONS AND RELEVANCE Among critically ill adults with confirmed COVID-19, treatment with 2 units of high-titer, ABO-compatible convalescent plasma had a low likelihood of providing improvement in the number of organ support-free days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02735707.
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Affiliation(s)
- Lise J Estcourt
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Alexis F Turgeon
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, Quebec, Canada
- CHU de Québec-Université Laval Research Center, Population Health and Optimal Health Practices Unit, Trauma-Emergency-Critical Care Medicine, CHU de Québec-Université Laval, Quebec City, Quebec, Canada
| | - Zoe K McQuilten
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | - Bryan J McVerry
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Farah Al-Beidh
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Djillali Annane
- Intensive Care Unit, Raymond Poincaré Hospital, Paris, France
- Simone Veil School of Medicine, University of Versailles, Versailles, France
- University Paris Saclay, Garches, France
| | - Yaseen M Arabi
- Intensive Care Department, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Ministry of National Guard Health Affairs, Riyadh, Saudi Arabia
| | | | - Abigail Beane
- Nuffield Department of Clinical Medicine, University of Oxford, Oxford, England
| | | | - Wilma van Bentum-Puijk
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Zahra Bhimani
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Marc J M Bonten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Department of Medical Microbiology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Charlotte A Bradbury
- University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, England
- Faculty of Health Sciences, University of Bristol, Bristol, England
| | - Frank M Brunkhorst
- Center for Clinical Studies and Center for Sepsis Control and Care, Department of Anesthesiology and Intensive Care Medicine, Jena University Hospital, Jena, Germany
| | - Meredith Buxton
- Global Coalition for Adaptive Research, San Francisco, California
| | - Jeannie L Callum
- Canadian Blood Services, Ottawa, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre and Queens University, Kingston, Ontario, Canada
- Department of Laboratory Medicine and Molecular Diagnostics, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Allen C Cheng
- Infection Prevention and Healthcare Epidemiology Unit, Alfred Health, Melbourne, Australia
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Matthew E Cove
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - James Daly
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
| | - Lennie Derde
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Intensive Care Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | | | - Menno De Jong
- Department of Medical Microbiology, University of Amsterdam Medical Center, University of Amsterdam, the Netherlands
| | - Amy Evans
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Dean A Fergusson
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Matthew Fish
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | | | - Claire Foley
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | - Herman Goossens
- Department of Microbiology, Antwerp University Hospital, Antwerp, Belgium
| | - Anthony C Gordon
- Division of Anesthetics, Pain Medicine, and Intensive Care Medicine, Department of Surgery and Cancer, Imperial College London and Imperial College Healthcare NHS Trust, London, England
| | - Iain B Gosbell
- Australian Red Cross Lifeblood, Sydney and Perth, Australia
- Western Sydney University, Sydney, Australia
| | - Cameron Green
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rashan Haniffa
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | | | - Alisa M Higgins
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | | | | | | | - David T Huang
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Nao Ichihara
- Department of Healthcare Quality Assessment, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Emma Laing
- NHSBT Clinical Trials Unit, NHS Blood and Transplant, Cambridge, England
| | | | | | - Patrick R Lawler
- Cardiac Intensive Care Unit, Peter Munk Cardiac Centre, University Health Network, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kelsey Linstrum
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Edward Litton
- School of Medicine and Pharmacology, University of Western Australia, Crawley
| | | | | | - John Marshall
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ontario, Canada
| | - Daniel F McAuley
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - John F McDyer
- Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Shay McGuinness
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
| | | | - Stephanie Montgomery
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Paul R Mouncey
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Srinivas Murthy
- School of Medicine, University of British Columbia, Vancouver, Canada
| | - Alistair Nichol
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Anesthesia and Intensive Care, St Vincent's University Hospital, Dublin, Ireland
- School of Medicine and Medical Sciences, University College Dublin, Dublin, Ireland
- Department of Intensive Care, Alfred Health, Melbourne, Australia
| | - Rachael Parke
- Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland, New Zealand
- Medical Research Institute of New Zealand, Wellington
- School of Nursing, University of Auckland, Auckland, New Zealand
| | - Jane C Parker
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Nicole Priddee
- Scottish National Blood Transfusion Service, Edinburgh, Scotland
| | - Damian F J Purcell
- Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, Australia
| | - Luis F Reyes
- Universidad de La Sabana, Chia, Colombia
- Clinica Universidad de La Sabana, Chia, Colombia
| | | | - Nancy Robitaille
- Héma-Québec, Montreal, Quebec, Canada
- Division of Hematology and Oncology, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montreal, Quebec, Canada
| | - Kathryn M Rowan
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
| | - Jennifer Rynne
- School of Immunology and Microbial Sciences, Kings College London, London, England
| | - Hiroki Saito
- Department of Emergency and Critical Care Medicine, St Marianna University School of Medicine, Yokohama City Seibu Hospital, Yokohama, Japan
| | - Marlene Santos
- Li Ka Shing Knowledge Institute, Unity Health Toronto, St Michael's Hospital, Toronto, Ontario, Canada
| | | | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Christopher W Seymour
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Jon A Silversides
- Centre for Experimental Medicine, School of Medicine, Dentistry, and Biomedical Sciences, Queen's University Belfast, Belfast, Ireland
| | - Alan A Tinmouth
- Ottawa Hospital Research Institute, Clinical Epidemiology Unit, Ottawa, Ontario, Canada
| | - Darrell J Triulzi
- Department of Pathology, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Anne M Turner
- Medical Research Institute of New Zealand, Wellington
| | - Frank van de Veerdonk
- Radboud Institute for Molecular Life Sciences, Radboud University Medical Center, Nijmegen, the Netherlands
| | | | - Erica M Wood
- Transfusion Research Unit, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- Department of Clinical Hematology, Monash Health, Melbourne, Australia
| | | | - Roger J Lewis
- Berry Consultants LLC, Austin, Texas
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
- Department of Emergency Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - David K Menon
- University Division of Anesthesia, Addenbrooke's Hospital Cambridge, Cambridge, England
| | - Colin McArthur
- Clinical Trials Unit, Intensive Care National Audit and Research Centre, London, England
- Department of Critical Care Medicine, Auckland City Hospital, Auckland, New Zealand
| | - Ryan Zarychanski
- Department of Medicine, Critical Care and Hematology/Medical Oncology, University of Manitoba, Winnipeg, Canada
| | - Derek C Angus
- Clinical Research Investigation and Systems Modeling of Acute Illness Center, Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- UPMC Health System Office of Healthcare Innovation, Pittsburgh, Pennsylvania
| | - Steve A Webb
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
- St John of God Hospital, Subiaco, Australia
| | - David J Roberts
- NHS Blood and Transplant, Oxford, England
- Radcliffe Department of Medicine and BRC Hematology Theme, University of Oxford, Oxford, England
| | - Manu Shankar-Hari
- School of Immunology and Microbial Sciences, Kings College London, London, England
- Guy's and St Thomas' NHS Foundation Trust, ICU Support Offices, St Thomas' Hospital, London, England
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10
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Hurst EA, Mellanby RJ, Handel I, Griffith DM, Rossi AG, Walsh TS, Shankar-Hari M, Dunning J, Homer NZ, Denham SG, Devine K, Holloway PA, Moore SC, Thwaites RS, Samanta RJ, Summers C, Hardwick HE, Oosthuyzen W, Turtle L, Semple MG, Openshaw PJM, Baillie JK, Russell CD. Vitamin D insufficiency in COVID-19 and influenza A, and critical illness survivors: a cross-sectional study. BMJ Open 2021; 11:e055435. [PMID: 34686560 PMCID: PMC8728359 DOI: 10.1136/bmjopen-2021-055435] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 09/30/2021] [Indexed: 12/19/2022] Open
Abstract
OBJECTIVES The steroid hormone vitamin D has roles in immunomodulation and bone health. Insufficiency is associated with susceptibility to respiratory infections. We report 25-hydroxy vitamin D (25(OH)D) measurements in hospitalised people with COVID-19 and influenza A and in survivors of critical illness to test the hypotheses that vitamin D insufficiency scales with illness severity and persists in survivors. DESIGN Cross-sectional study. SETTING AND PARTICIPANTS Plasma was obtained from 295 hospitalised people with COVID-19 (International Severe Acute Respiratory and emerging Infections Consortium (ISARIC)/WHO Clinical Characterization Protocol for Severe Emerging Infections UK study), 93 with influenza A (Mechanisms of Severe Acute Influenza Consortium (MOSAIC) study, during the 2009-2010 H1N1 pandemic) and 139 survivors of non-selected critical illness (prior to the COVID-19 pandemic). Total 25(OH)D was measured by liquid chromatography-tandem mass spectrometry. Free 25(OH)D was measured by ELISA in COVID-19 samples. OUTCOME MEASURES Receipt of invasive mechanical ventilation (IMV) and in-hospital mortality. RESULTS Vitamin D insufficiency (total 25(OH)D 25-50 nmol/L) and deficiency (<25 nmol/L) were prevalent in COVID-19 (29.3% and 44.4%, respectively), influenza A (47.3% and 37.6%) and critical illness survivors (30.2% and 56.8%). In COVID-19 and influenza A, total 25(OH)D measured early in illness was lower in patients who received IMV (19.6 vs 31.9 nmol/L (p<0.0001) and 22.9 vs 31.1 nmol/L (p=0.0009), respectively). In COVID-19, biologically active free 25(OH)D correlated with total 25(OH)D and was lower in patients who received IMV, but was not associated with selected circulating inflammatory mediators. CONCLUSIONS Vitamin D deficiency/insufficiency was present in majority of hospitalised patients with COVID-19 or influenza A and correlated with severity and persisted in critical illness survivors at concentrations expected to disrupt bone metabolism. These findings support early supplementation trials to determine if insufficiency is causal in progression to severe disease, and investigation of longer-term bone health outcomes.
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Affiliation(s)
- Emma A Hurst
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queen's Medical Research Institute, Edinburgh, UK
| | - Richard J Mellanby
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - Ian Handel
- The Roslin Institute and Royal (Dick) School of Veterinary Studies, University of Edinburgh, Edinburgh, UK
| | - David M Griffith
- Molecular, Genetic and Population Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Adriano G Rossi
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh, UK
| | - Timothy S Walsh
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh, UK
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, UK
- Peter Gorer Department of Immunobiology, School of Immunology & Microbial Sciences, Kings College London, London, UK
| | - Jake Dunning
- Centre for Tropical Medicine and Global Health, University of Oxford, Oxford, UK
| | - Natalie Z Homer
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queen's Medical Research Institute, Edinburgh, UK
| | - Scott G Denham
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queen's Medical Research Institute, Edinburgh, UK
| | - Kerri Devine
- Mass Spectrometry Core, Edinburgh Clinical Research Facility, Queen's Medical Research Institute, Edinburgh, UK
| | - Paul A Holloway
- Faculty of Medicine, Department of Metabolism, Digestion and Reproduction, Imperial College London, London, UK
| | - Shona C Moore
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Ryan S Thwaites
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Romit J Samanta
- Department of Medicine, University of Cambridge, Cambridge, UK
| | | | - Hayley E Hardwick
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Wilna Oosthuyzen
- Division of Genetics and Genomics, Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Lance Turtle
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Tropical and Infectious Disease Unit, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Malcolm G Semple
- NIHR Health Protection Research Unit in Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences, Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
- Respiratory Medicine, Alder Hey Children's Hospital, Liverpool, UK
| | | | - J Kenneth Baillie
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
- Division of Genetics and Genomics, Roslin Institute, University of Edinburgh, Edinburgh, UK
| | - Clark D Russell
- University of Edinburgh Centre for Inflammation Research, The Queen's Medical Research Institute, Edinburgh, UK
- Division of Genetics and Genomics, Roslin Institute, University of Edinburgh, Edinburgh, UK
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11
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Blackwood B, Tume LN, Morris KP, Clarke M, McDowell C, Hemming K, Peters MJ, McIlmurray L, Jordan J, Agus A, Murray M, Parslow R, Walsh TS, Macrae D, Easter C, Feltbower RG, McAuley DF. Effect of a Sedation and Ventilator Liberation Protocol vs Usual Care on Duration of Invasive Mechanical Ventilation in Pediatric Intensive Care Units: A Randomized Clinical Trial. JAMA 2021; 326:401-410. [PMID: 34342620 PMCID: PMC8335576 DOI: 10.1001/jama.2021.10296] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is limited evidence on the optimal strategy for liberating infants and children from invasive mechanical ventilation in the pediatric intensive care unit. OBJECTIVE To determine if a sedation and ventilator liberation protocol intervention reduces the duration of invasive mechanical ventilation in infants and children anticipated to require prolonged mechanical ventilation. DESIGN, SETTING, AND PARTICIPANTS A pragmatic multicenter, stepped-wedge, cluster randomized clinical trial was conducted that included 17 hospital sites (18 pediatric intensive care units) in the UK sequentially randomized from usual care to the protocol intervention. From February 2018 to October 2019, 8843 critically ill infants and children anticipated to require prolonged mechanical ventilation were recruited. The last date of follow-up was November 11, 2019. INTERVENTIONS Pediatric intensive care units provided usual care (n = 4155 infants and children) or a sedation and ventilator liberation protocol intervention (n = 4688 infants and children) that consisted of assessment of sedation level, daily screening for readiness to undertake a spontaneous breathing trial, a spontaneous breathing trial to test ventilator liberation potential, and daily rounds to review sedation and readiness screening and set patient-relevant targets. MAIN OUTCOMES AND MEASURES The primary outcome was the duration of invasive mechanical ventilation from initiation of ventilation until the first successful extubation. The primary estimate of the treatment effect was a hazard ratio (with a 95% CI) adjusted for calendar time and cluster (hospital site) for infants and children anticipated to require prolonged mechanical ventilation. RESULTS There were a total of 8843 infants and children (median age, 8 months [interquartile range, 1 to 46 months]; 42% were female) who completed the trial. There was a significantly shorter median time to successful extubation for the protocol intervention compared with usual care (64.8 hours vs 66.2 hours, respectively; adjusted median difference, -6.1 hours [interquartile range, -8.2 to -5.3 hours]; adjusted hazard ratio, 1.11 [95% CI, 1.02 to 1.20], P = .02). The serious adverse event of hypoxia occurred in 9 (0.2%) infants and children for the protocol intervention vs 11 (0.3%) for usual care; nonvascular device dislodgement occurred in 2 (0.04%) vs 7 (0.1%), respectively. CONCLUSIONS AND RELEVANCE Among infants and children anticipated to require prolonged mechanical ventilation, a sedation and ventilator liberation protocol intervention compared with usual care resulted in a statistically significant reduction in time to first successful extubation. However, the clinical importance of the effect size is uncertain. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN16998143.
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Affiliation(s)
- Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Lyvonne N. Tume
- School of Health and Society, University of Salford, Manchester, England
- Alder Hey Children’s NHS Trust, Liverpool, England
| | - Kevin P. Morris
- Birmingham Women’s and Children’s NHS Foundation Trust, Birmingham, England
- Institute of Applied Health Research, University of Birmingham, Birmingham, England
| | - Mike Clarke
- Centre for Public Health, School of Medicine, Dentistry and Biomedical Sciences, Queen’s University Belfast, Belfast, Ireland
| | - Clíona McDowell
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | | | - Mark J. Peters
- Great Ormond Street Hospital, London, England
- University College London, Great Ormond Street Institute of Child Health, NIHR Biomedical Research Centre, London, England
| | - Lisa McIlmurray
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Joanne Jordan
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | - Margaret Murray
- Northern Ireland Clinical Trials Unit, Royal Hospitals, Belfast, Ireland
| | - Roger Parslow
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Timothy S. Walsh
- Usher Institute of Population Health Sciences, University of Edinburgh, Edinburgh, Scotland
| | | | | | - Richard G. Feltbower
- Leeds Institute for Data Analytics, School of Medicine, University of Leeds, Leeds, England
| | - Daniel F. McAuley
- Wellcome-Wolfson Institute for Experimental Medicine, Queen’s University Belfast, Belfast, Ireland
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12
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Pauley E, Walsh TS. Resilience in survivors of critical illness: A scoping review of the published literature in relation to definitions, prevalence, and relationship to clinical outcomes. J Intensive Care Soc 2021; 23:345-358. [DOI: 10.1177/17511437211034701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Survivors of critical illness face substantial challenges in their recovery, including physical and cognitive dysfunction. Resilience is the ability to adapt and maintain one’s mental health after facing such challenges. Higher resilience levels have been found to be beneficial throughout the illness trajectory in cancer patients, but resilience has not been widely researched in critical care patients. We undertook a scoping review to identify published studies on resilience following critical illness and describe: how resilience has been measured; the prevalence of low resilience in critical care patients; and what associations (if any) exist between resilience and clinical outcomes. We searched: PubMed, Medline, PsychINFO, CINAHL, Web of Science, Cochrane Library, to identify relevant studies. We found 882 unique titles: 17 were selected for full text review, 10 were considered relevant. These included ICU inpatients and survivors, and trauma and sepsis survivors. A broad critical appraisal of each study was undertaken. The overall quality of published studies was low: there was wide variation in resilience-assessment tools across the studies, including the timing of measurement; only one used a validated tool. Estimates of low resilience ranged from 28%-67%, but with varying populations, high risk of inclusion bias, and small samples. Higher resilience levels were significantly associated with lower depression, anxiety, post-traumatic stress, pain, anger, executive dysfunction, and difficulty with self-care in critical care patients and survivors. Future studies should use validated resilience assessment, determine the optimum timing, and explore prevalence, associations with outcomes, and resilience-promoting interventions in non-selected or clearly defined populations.
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Affiliation(s)
- Ellen Pauley
- Royal Infirmary Edinburgh, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Royal Infirmary Edinburgh, University of Edinburgh, Edinburgh, UK
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13
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Al-Omari B, McMeekin P, Allen AJ, Akram AR, Graziadio S, Suklan J, Jones WS, Lendrem BC, Winter A, Cullinan M, Gray J, Dhaliwal K, Walsh TS, Craven TH. Systematic review of studies investigating ventilator associated pneumonia diagnostics in intensive care. BMC Pulm Med 2021; 21:196. [PMID: 34107929 PMCID: PMC8189711 DOI: 10.1186/s12890-021-01560-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 06/02/2021] [Indexed: 02/06/2023] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is an important diagnosis in critical care. VAP research is complicated by the lack of agreed diagnostic criteria and reference standard test criteria. Our aim was to review which reference standard tests are used to evaluate novel index tests for suspected VAP. Methods We conducted a comprehensive search using electronic databases and hand reference checks. The Cochrane Library, MEDLINE, CINHAL, EMBASE, and web of science were searched from 2008 until November 2018. All terms related to VAP diagnostics in the intensive treatment unit were used to conduct the search. We adopted a checklist from the critical appraisal skills programme checklist for diagnostic studies to assess the quality of the included studies. Results We identified 2441 records, of which 178 were selected for full-text review. Following methodological examination and quality assessment, 44 studies were included in narrative data synthesis. Thirty-two (72.7%) studies utilised a sole microbiological reference standard; the remaining 12 studies utilised a composite reference standard, nine of which included a mandatory microbiological criterion. Histopathological criteria were optional in four studies but mandatory in none. Conclusions Nearly all reference standards for VAP used in diagnostic test research required some microbiological confirmation of infection, with BAL culture being the most common reference standard used. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01560-0.
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Affiliation(s)
- Basem Al-Omari
- College of Medicine and Health Sciences, Khalifa University, PO Box 127788, Abu Dhabi, UAE. .,Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.
| | - Peter McMeekin
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - A Joy Allen
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ahsan R Akram
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Sara Graziadio
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK.,York Health Economics Consortium, Enterprise House, Innovation Way, University of York, York, UK
| | - Jana Suklan
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - William S Jones
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - B Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Co-operative, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amanda Winter
- NIHR Newcastle In Vitro Diagnostics Co-operative, The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Milo Cullinan
- Laboratory Medicine, Newcastle-Upon-Tyne Hospitals Foundation Trust, Newcastle upon Tyne, UK
| | - Joanne Gray
- School of Health and Life Science, University of Northumbria, Newcastle upon Tyne, UK
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Thomas H Craven
- Translational Healthcare Technologies Group, Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
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14
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Aitken LM, Kydonaki K, Blackwood B, Trahair LG, Purssell E, Sekhon M, Walsh TS. Inconsistent relationship between depth of sedation and intensive care outcome: systematic review and meta-analysis. Thorax 2021; 76:1089-1098. [PMID: 33859048 DOI: 10.1136/thoraxjnl-2020-216098] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 01/08/2021] [Accepted: 03/16/2021] [Indexed: 12/29/2022]
Abstract
PURPOSE To determine the effect of depth of sedation on intensive care mortality, duration of mechanical ventilation, and other clinically important outcomes. METHODS We searched MEDLINE, Embase, Cochrane Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature, PsycINFO from 2000 to 2020. Randomised controlled trials (RCTs) and cohort studies that examined the effect of sedation depth were included. Two reviewers independently screened, selected articles, extracted data and appraised quality. Data on study design, population, setting, patient characteristics, study interventions, depth of sedation and relevant outcomes were extracted. Quality was assessed using Critical Appraisal Skills Programme tools. RESULTS We included data from 26 studies (n=7865 patients): 8 RCTs and 18 cohort studies. Heterogeneity of studies was substantial. There was no significant effect of lighter sedation on intensive care mortality. Lighter sedation did not affect duration of mechanical ventilation in RCTs (mean difference (MD): -1.44 days (95% CI -3.79 to 0.91)) but did in cohort studies (MD: -1.52 days (95% CI -2.71 to -0.34)). No statistically significant benefit of lighter sedation was identified in RCTs. In cohort studies, lighter sedation improved time to extubation, intensive care and hospital length of stay and ventilator-associated pneumonia. We found no significant effects for hospital mortality, delirium or adverse events. CONCLUSION Evidence of benefit from lighter sedation is limited, with inconsistency between observational and randomised studies. Positive effects were mainly limited to low quality evidence from observational studies, which could be attributable to bias and confounding factors.
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Affiliation(s)
- Leanne M Aitken
- School of Health Sciences, City, University of London, London, UK
| | - Kalliopi Kydonaki
- School of Health and Social Care, Edinburgh Napier University, Edinburgh, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast Faculty of Medicine Health and Life Sciences, Belfast, UK
| | - Laurence G Trahair
- Adelaide Medical School, The University of Adelaide, Adelaide, South Australia, Australia
| | - Edward Purssell
- School of Health Sciences, City, University of London, London, UK
| | - Mandeep Sekhon
- School of Population Health & Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care & Pain Medicine and Usher Institute, The University of Edinburgh, Edinburgh, UK
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15
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Craven TH, Walton T, Akram AR, Scholefield E, McDonald N, Marshall ADL, Humphries DC, Mills B, Campbell TA, Bruce A, Mair J, Dear JW, Newby DE, Hill AT, Walsh TS, Haslett C, Dhaliwal K. Activated neutrophil fluorescent imaging technique for human lungs. Sci Rep 2021; 11:976. [PMID: 33441792 PMCID: PMC7806726 DOI: 10.1038/s41598-020-80083-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 12/15/2020] [Indexed: 12/12/2022] Open
Abstract
Neutrophil activation is an integral process to acute inflammation and is associated with adverse clinical sequelae. Identification of neutrophil activation in real time in the lungs of patients may permit biological stratification of patients in otherwise heterogenous cohorts typically defined by clinical criteria. No methods for identifying neutrophil activation in real time in the lungs of patients currently exist. We developed a bespoke molecular imaging probe targeting three characteristic signatures of neutrophil activation: pinocytosis, phagosomal alkalinisation, and human neutrophil elastase (HNE) activity. The probe functioned as designed in vitro and ex vivo. We evaluated optical endomicroscopy imaging of neutrophil activity using the probe in real-time at the bedside of healthy volunteers, patients with bronchiectasis, and critically unwell mechanically ventilated patients. We detected a range of imaging responses in vivo reflecting heterogeneity of condition and severity. We corroborated optical signal was due to probe function and neutrophil activation.
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Affiliation(s)
- Thomas H Craven
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK.
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK.
| | - Tashfeen Walton
- School of Chemistry, EaStCHEM, University of Edinburgh, Edinburgh, UK
| | - Ahsan R Akram
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Emma Scholefield
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Neil McDonald
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Adam D L Marshall
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Duncan C Humphries
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Bethany Mills
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Thane A Campbell
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Annya Bruce
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Joanne Mair
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - James W Dear
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Adam T Hill
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Timothy S Walsh
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Chris Haslett
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
| | - Kevin Dhaliwal
- Translational Healthcare Technologies Group, Queen's Medical Research Institute, University of Edinburgh, 47 Little France Crescent, Edinburgh, EH16 4TJ, UK
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16
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Gillies MA, Ghaffar S, Moppett IK, Docherty AB, Clarke S, Rea N, Stephen J, Keerie C, Ray DC, White TO, MacLullich AMJ, Mills NM, Rowley MR, Murthy K, Pearse RM, Stanworth SJ, Walsh TS. A restrictive versus liberal transfusion strategy to prevent myocardial injury in patients undergoing surgery for fractured neck of femur: a feasibility randomised trial (RESULT-NOF). Br J Anaesth 2021; 126:77-86. [PMID: 32703548 DOI: 10.1016/j.bja.2020.06.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Revised: 04/30/2020] [Accepted: 06/26/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The optimum transfusion strategy in patients with fractured neck of femur is uncertain, particularly if there is coexisting cardiovascular disease. METHODS We conducted a prospective, single-centre, randomised feasibility trial of two transfusion strategies. We randomly assigned patients undergoing surgery for fractured neck of femur to a restrictive (haemoglobin, 70-90 g L-1) or liberal (haemoglobin, 90-110 g L-1) transfusion strategy throughout their hospitalisation. Feasibility outcomes included: enrolment rate, protocol compliance, difference in haemoglobin, and blood exposure. The primary clinical outcome was myocardial injury using troponin estimations. Secondary outcomes included major adverse cardiac events, postoperative complications, duration of hospitalisation, mortality, and quality of life. RESULTS We enrolled 200 (22%) of 907 eligible patients, and 62 (31%) showed decreased haemoglobin (to 90 g L-1 or less) and were thus exposed to the intervention. The overall protocol compliance was 81% in the liberal group and 64% in the restrictive group. Haemoglobin concentrations were similar preoperatively and at postoperative day 1 but lower in the restrictive group on day 2 (mean difference [MD], 7.0 g L-1; 95% confidence interval [CI], 1.6-12.4). Lowest haemoglobin within 30 days/before discharge was lower in the restrictive group (MD, 5.3 g L-1; 95% CI, 1.7-9.0). Overall, 58% of patients in the restrictive group received no transfusion compared with 4% in the liberal group (difference in proportion, 54.5%; 95% CI, 36.8-72.2). The proportion with the primary clinical outcome was 14/26 (54%, liberal) vs 24/34 (71%, restrictive), and the difference in proportion was -16.7% (95% CI, -41.3 to 7.8; P=0.18). CONCLUSION A clinical trial of two transfusion strategies in hip fracture with a clinically relevant cardiac outcome is feasible. CLINICAL TRIAL REGISTRATION NCT03407573.
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Affiliation(s)
- Michael A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK.
| | - Sadia Ghaffar
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Iain K Moppett
- Anaesthesia and Critical Care Section, Division of Clinical Neuroscience, Queen's Medical Centre, University of Nottingham, Nottingham, UK
| | - Annemarie B Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Sarah Clarke
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Nicola Rea
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Catriona Keerie
- Edinburgh Clinical Trials Unit, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - David C Ray
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Timothy O White
- Department of Trauma and Orthopaedics, Royal Infirmary Edinburgh, Edinburgh, UK
| | | | - Nicholas M Mills
- BHF Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Megan R Rowley
- Scottish National Blood Transfusion Service, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Krishna Murthy
- Department of Emergency Medicine, Royal Infirmary Edinburgh, Edinburgh, UK
| | - Rupert M Pearse
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Simon J Stanworth
- Department of Haematology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK; Radcliffe Department of Medicine, University of Oxford, Oxford BRC Haematology Theme, Oxford, UK; Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary Edinburgh, Edinburgh, UK; Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
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Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, Dark P, Roy AI, Perkins GD, McMullan R, Emerson LM, Blackwood B, Wright SE, Kefala K, O'Kane CM, Baudouin SV, Paterson RL, Rostron AJ, Agus A, Bannard-Smith J, Robin NM, Welters ID, Bassford C, Yates B, Spencer C, Laha SK, Hulme J, Bonner S, Linnett V, Sonksen J, Van Den Broeck T, Boschman G, Keenan DWJ, Scott J, Allen AJ, Phair G, Parker J, Bowett SA, Simpson AJ. More research is required to understand factors influencing antibiotic prescribing in complex conditions like suspected ventilator-associated pneumonia. Ann Transl Med 2020; 8:840. [PMID: 32794522 PMCID: PMC7396250 DOI: 10.21037/atm-20-3701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Thomas P Hellyer
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Daniel F McAuley
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Timothy S Walsh
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | - Niall Anderson
- College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh, UK
| | | | - Suveer Singh
- Department of Cancer and Surgery, Imperial College, London, UK
| | - Paul Dark
- Manchester National Institute for Health Research Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | | | - Ronan McMullan
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Lydia M Emerson
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Stephen E Wright
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cecilia M O'Kane
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University, Belfast, UK
| | - Simon V Baudouin
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Ross L Paterson
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
| | | | - Ashley Agus
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | | | - Nicole M Robin
- Countess of Chester Hospital NHS Foundation Trust, Chester, UK
| | - Ingeborg D Welters
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | | | - Bryan Yates
- Intensive Care Unit, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Craig Spencer
- Intensive Care Unit, Cardiff and Vale University Health Board, Cardiff, UK
| | | | - Jonathan Hulme
- Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
| | - Stephen Bonner
- Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK
| | - Vanessa Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead, UK
| | | | | | - Gert Boschman
- Becton Dickinson Life Sciences, Erembodegem, Belgium
| | | | - Jonathan Scott
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - A Joy Allen
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, Belfast, UK
| | - Jennie Parker
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - Susan A Bowett
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
| | - A John Simpson
- Faculty of Medical Sciences, Newcastle University, Newcastle, UK
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Mikola A, Sarkela MO, Walsh TS, Lipping T. Power Spectrum and Cross Power Spectral Density Based EEG Correlates of Intensive Care Delirium. Annu Int Conf IEEE Eng Med Biol Soc 2020; 2019:4562-4565. [PMID: 31946880 DOI: 10.1109/embc.2019.8857254] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Full montage EEG recordings of 15 ICU patients (altogether 23 recordings) were analysed to find EEG correlates of delirium. CAM-ICU assessment results were used as the reference. Time period from 7 to 30 minutes at the beginning of the recordings was analysed in 10 sec segments with 5 sec overlap. Relative power in the conventional frequency bands of the EEG signal at 20 electrode locations with common reference was calculated. In the state of delirium the relative power of frequencies above 8 Hz was lower; this effect was predominantly observed at central and parietal lobes. Also, the absolute cross power spectral density of 20 - 30 Hz was significantly lower in delirium between almost any two electrode locations.
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19
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Vlaar AP, Oczkowski S, de Bruin S, Wijnberge M, Antonelli M, Aubron C, Aries P, Duranteau J, Juffermans NP, Meier J, Murphy GJ, Abbasciano R, Muller M, Shah A, Perner A, Rygaard S, Walsh TS, Guyatt G, Dionne JC, Cecconi M. Transfusion strategies in non-bleeding critically ill adults: a clinical practice guideline from the European Society of Intensive Care Medicine. Intensive Care Med 2020; 46:673-696. [PMID: 31912207 PMCID: PMC7223433 DOI: 10.1007/s00134-019-05884-8] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 11/26/2019] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To develop evidence-based clinical practice recommendations regarding transfusion practices in non-bleeding, critically ill adults. DESIGN A task force involving 13 international experts and three methodologists used the GRADE approach for guideline development. METHODS The task force identified four main topics: red blood cell transfusion thresholds, red blood cell transfusion avoidance strategies, platelet transfusion, and plasma transfusion. The panel developed structured guideline questions using population, intervention, comparison, and outcomes (PICO) format. RESULTS The task force generated 16 clinical practice recommendations (3 strong recommendations, 13 conditional recommendations), and identified five PICOs with insufficient evidence to make any recommendation. CONCLUSIONS This clinical practice guideline provides evidence-based recommendations and identifies areas where further research is needed regarding transfusion practices and transfusion avoidance in non-bleeding, critically ill adults.
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Affiliation(s)
- Alexander P Vlaar
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands.
- Department of Intensive Care Medicine, University of Amsterdam, Room, C3-430, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - Simon Oczkowski
- Department of Medicine, McMaster University, Hamilton, Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Sanne de Bruin
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Marije Wijnberge
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
- Department of Anaesthesiology, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Massimo Antonelli
- Department of Anaesthesiology and Intensive Care Medicine, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
- Istituto di Anaesthesiology e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Cecile Aubron
- Department of Intensive Care Medicine, Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, Site La Cavale Blanche, Brest, France
| | - Philippe Aries
- Department of Intensive Care Medicine, Centre Hospitalier Régional et Universitaire de Brest, Université de Bretagne Occidentale, Site La Cavale Blanche, Brest, France
| | - Jacques Duranteau
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires Paris Sud (HUPS), Orsay, France
| | - Nicole P Juffermans
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Jens Meier
- Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine, Kepler University, Linz, Austria
| | - Gavin J Murphy
- Cardiovascular, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, College of Life Sciences, University of Leicester, Leicester, LE3 9QP, UK
| | - Riccardo Abbasciano
- Cardiovascular, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, College of Life Sciences, University of Leicester, Leicester, LE3 9QP, UK
| | - Marcella Muller
- Department of Intensive Care Medicine, Amsterdam UMC, Location AMC, Amsterdam, The Netherlands
| | - Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Sofie Rygaard
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Timothy S Walsh
- Anaesthetics, Critical Care, and Pain Medicine, University of Edinburgh, Edinburgh, Scotland
| | - Gordon Guyatt
- Department of Medicine, McMaster University, Hamilton, Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - J C Dionne
- Department of Medicine, McMaster University, Hamilton, Canada
- Guidelines in Intensive Care, Development and Evaluation (GUIDE) Group, Hamilton, Canada
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada
| | - Maurizio Cecconi
- Department of Anaesthesia and Intensive Care Medicine, Humanitas Clinical and Research Centre-IRCCS, Rozzano, Milan, Italy
- Humanitas University, Via Rita Levi Montalcini, Pieve Emanuele, Milan, Italy
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20
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Tominey S, Timmins A, Lee R, Walsh TS, Lone NI. Community prescribing of potentially nephrotoxic drugs and risk of acute kidney injury requiring renal replacement therapy in critically ill adults: A national cohort study. J Intensive Care Soc 2020; 22:102-110. [PMID: 34025749 DOI: 10.1177/1751143719900099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background Acute kidney injury demonstrates a high incidence in critically ill populations, with many requiring renal replacement therapy. Patients may be at increased risk of acute kidney injury if prescribed certain potentially nephrotoxic medications. We aimed to evaluate this association in ICU survivors. Methods Study design - secondary analysis of national cohort of ICU survivors to hospital discharge linked to Scottish healthcare datasets. Outcomes: primary - renal replacement therapy in ICU; secondary - early acute kidney injury (calculated using urine output and relative change from estimated baseline serum creatinine within first 24 h of ICU admission using modified-RIFLE criteria). Primary exposure: pre-admission community prescribing of at least one potential nephrotoxin: angiotensin-converting-enzyme inhibitors/angiotensin-receptor blockers, diuretics or nonsteroidal anti-inflammatory drugs. Statistical analyses: unadjusted associations - univariable logistic regression; confounder adjusted: multivariable logistic regression. Results During 2011-2013, 12,838 of 23,116 patients (55.5%) were prescribed at least one community prescription of at least one nephrotoxin; 1330 (5.8%) patients received renal replacement therapy; 3061 (15.7%) had acute kidney injury. Patients exposed to at least one examined nephrotoxin experienced higher incidence of renal replacement therapy (6.8% vs 4.5%; adjOR 1.46, 95%CI 1.24, 1.72, p < 0.001) and acute kidney injury (19.8% vs 10.9%; adjOR 1.61, 1.44, 1.80, p < 0.001). Increased risk of RRT was also found for angiotensin-converting-enzyme inhibitors/angiotensin-receptor blockers (adjOR 1.65, 1.40, 1.94), non-steroidal anti-inflammatory drugs (adjOR 1.12, 1.02, 1.44) and diuretics (adjOR 1.35, 1.14, 1.59). Conclusions Community prescribing of potential nephrotoxins increases the risk of renal replacement therapy/early acute kidney injury in ICU populations. Analyses were limited by the survivor dataset and potential residual confounding. Findings add consistency to previous research improving understanding of the harmful potential of these important medications and their timely cessation in acute illness.
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Affiliation(s)
- Steven Tominey
- Edinburgh Medical School, Edinburgh BioQuarter, Edinburgh, UK
| | - Alan Timmins
- Pharmacy Department, Victoria Hospital, Kirkcaldy, UK
| | - Robert Lee
- Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Nazir I Lone
- Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK
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21
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Hellyer TP, McAuley DF, Walsh TS, Anderson N, Conway Morris A, Singh S, Dark P, Roy AI, Perkins GD, McMullan R, Emerson LM, Blackwood B, Wright SE, Kefala K, O'Kane CM, Baudouin SV, Paterson RL, Rostron AJ, Agus A, Bannard-Smith J, Robin NM, Welters ID, Bassford C, Yates B, Spencer C, Laha SK, Hulme J, Bonner S, Linnett V, Sonksen J, Van Den Broeck T, Boschman G, Keenan DJ, Scott J, Allen AJ, Phair G, Parker J, Bowett SA, Simpson AJ. Biomarker-guided antibiotic stewardship in suspected ventilator-associated pneumonia (VAPrapid2): a randomised controlled trial and process evaluation. Lancet Respir Med 2020; 8:182-191. [PMID: 31810865 PMCID: PMC7599318 DOI: 10.1016/s2213-2600(19)30367-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Revised: 08/05/2019] [Accepted: 08/06/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND Ventilator-associated pneumonia is the most common intensive care unit (ICU)-acquired infection, yet accurate diagnosis remains difficult, leading to overuse of antibiotics. Low concentrations of IL-1β and IL-8 in bronchoalveolar lavage fluid have been validated as effective markers for exclusion of ventilator-associated pneumonia. The VAPrapid2 trial aimed to determine whether measurement of bronchoalveolar lavage fluid IL-1β and IL-8 could effectively and safely improve antibiotic stewardship in patients with clinically suspected ventilator-associated pneumonia. METHODS VAPrapid2 was a multicentre, randomised controlled trial in patients admitted to 24 ICUs from 17 National Health Service hospital trusts across England, Scotland, and Northern Ireland. Patients were screened for eligibility and included if they were 18 years or older, intubated and mechanically ventilated for at least 48 h, and had suspected ventilator-associated pneumonia. Patients were randomly assigned (1:1) to biomarker-guided recommendation on antibiotics (intervention group) or routine use of antibiotics (control group) using a web-based randomisation service hosted by Newcastle Clinical Trials Unit. Patients were randomised using randomly permuted blocks of size four and six and stratified by site, with allocation concealment. Clinicians were masked to patient assignment for an initial period until biomarker results were reported. Bronchoalveolar lavage was done in all patients, with concentrations of IL-1β and IL-8 rapidly determined in bronchoalveolar lavage fluid from patients randomised to the biomarker-based antibiotic recommendation group. If concentrations were below a previously validated cutoff, clinicians were advised that ventilator-associated pneumonia was unlikely and to consider discontinuing antibiotics. Patients in the routine use of antibiotics group received antibiotics according to usual practice at sites. Microbiology was done on bronchoalveolar lavage fluid from all patients and ventilator-associated pneumonia was confirmed by at least 104 colony forming units per mL of bronchoalveolar lavage fluid. The primary outcome was the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage. Data were analysed on an intention-to-treat basis, with an additional per-protocol analysis that excluded patients randomly assigned to the intervention group who defaulted to routine use of antibiotics because of failure to return an adequate biomarker result. An embedded process evaluation assessed factors influencing trial adoption, recruitment, and decision making. This study is registered with ISRCTN, ISRCTN65937227, and ClinicalTrials.gov, NCT01972425. FINDINGS Between Nov 6, 2013, and Sept 13, 2016, 360 patients were screened for inclusion in the study. 146 patients were ineligible, leaving 214 who were recruited to the study. Four patients were excluded before randomisation, meaning that 210 patients were randomly assigned to biomarker-guided recommendation on antibiotics (n=104) or routine use of antibiotics (n=106). One patient in the biomarker-guided recommendation group was withdrawn by the clinical team before bronchoscopy and so was excluded from the intention-to-treat analysis. We found no significant difference in the primary outcome of the distribution of antibiotic-free days in the 7 days following bronchoalveolar lavage in the intention-to-treat analysis (p=0·58). Bronchoalveolar lavage was associated with a small and transient increase in oxygen requirements. Established prescribing practices, reluctance for bronchoalveolar lavage, and dependence on a chain of trial-related procedures emerged as factors that impaired trial processes. INTERPRETATION Antibiotic use remains high in patients with suspected ventilator-associated pneumonia. Antibiotic stewardship was not improved by a rapid, highly sensitive rule-out test. Prescribing culture, rather than poor test performance, might explain this absence of effect. FUNDING UK Department of Health and the Wellcome Trust.
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Affiliation(s)
- Thomas P Hellyer
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - Daniel F McAuley
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK; Regional Intensive Care Unit, The Royal Hospitals, Belfast, UK
| | - Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Queen's Medical Research Institute, Edinburgh, UK; Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Suveer Singh
- Department of Cancer and Surgery, Imperial College London, London, UK
| | - Paul Dark
- Division of Infection Immunity and Respiratory Medicine, Manchester National Institute for Health Research Biomedical Research Centre, University of Manchester, Manchester, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Gavin D Perkins
- Warwick Medical School, University of Warwick, Coventry, UK; Intensive Care Unit, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Ronan McMullan
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Lydia M Emerson
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Bronagh Blackwood
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Stephen E Wright
- Integrated Critical Care Unit, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Kallirroi Kefala
- Intensive Care Unit, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Cecilia M O'Kane
- The Wellcome-Wolfson Centre for Experimental Medicine, Queen's University Belfast, Belfast, UK
| | - Simon V Baudouin
- Intensive Care Unit, Royal Victoria Infirmary, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | - Ross L Paterson
- Intensive Care Unit, Western General Hospital, Edinburgh, UK
| | - Anthony J Rostron
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK; Integrated Critical Care Unit, Sunderland Royal Hospital, City Hospitals Sunderland NHS Foundation Trust, Sunderland, UK
| | - Ashley Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Jonathan Bannard-Smith
- Intensive Care Unit, Manchester Royal Infirmary, Manchester University NHS Foundation Trust, Manchester, UK
| | - Nicole M Robin
- Intensive Care Unit, Countess of Chester NHS Foundation Trust, Chester, UK
| | - Ingeborg D Welters
- Institute of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK
| | - Christopher Bassford
- Intensive Care Unit, University Hospital Coventry, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Bryan Yates
- Intensive Care Unit, Northumbria Specialist Emergency Care Hospital, Cramlington, UK
| | - Craig Spencer
- Intensive Care Unit, Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Shondipon K Laha
- Intensive Care Unit, Preston Royal Hospital, Lancashire Teaching Hospitals NHS Foundation Trust, Preston, UK
| | - Jonathan Hulme
- Intensive Care Unit, Sandwell General Hospital, Sandwell and West Birmingham Hospitals NHS Trust, West Bromwich, UK
| | - Stephen Bonner
- Intensive Care Unit, James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - Vanessa Linnett
- Intensive Care Unit, Queen Elizabeth Hospital, Gateshead NHS Foundation Trust, Gateshead, UK
| | - Julian Sonksen
- Intensive Care Unit, Russells Hall Hospital, Dudley Group NHS Foundation Trust, Dudley, UK
| | | | - Gert Boschman
- Becton Dickinson Biosciences Europe, Erembodegem, Belgium
| | | | - Jonathan Scott
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK
| | - A Joy Allen
- National Institute for Health Research Newcastle In Vitro Diagnostics Cooperative, Newcastle University, Newcastle, UK
| | - Glenn Phair
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - Jennie Parker
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - Susan A Bowett
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle, UK
| | - A John Simpson
- Translational and Clinical Research Institute, Newcastle University, Newcastle, UK; National Institute for Health Research Newcastle In Vitro Diagnostics Cooperative, Newcastle University, Newcastle, UK.
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Flanders CA, Rocke AS, Edwardson SA, Baillie JK, Walsh TS. The effect of dexmedetomidine and clonidine on the inflammatory response in critical illness: a systematic review of animal and human studies. Crit Care 2019; 23:402. [PMID: 31829277 PMCID: PMC6907244 DOI: 10.1186/s13054-019-2690-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Accepted: 11/28/2019] [Indexed: 02/08/2023]
Abstract
Background The α2 agonists, dexmedetomidine and clonidine, are used as sedative drugs during critical illness. These drugs may have anti-inflammatory effects, which might be relevant to critical illness, but a systematic review of published literature has not been published. We reviewed animal and human studies relevant to critical illness to summarise the evidence for an anti-inflammatory effect from α2 agonists. Methods We searched PubMed, the Cochrane library, and Medline. Animal and human studies published in English were included. Broad search terms were used: dexmedetomidine or clonidine, sepsis, and inflammation. Reference lists were screened for additional publications. Titles and abstracts were screened independently by two reviewers and full-text articles obtained for potentially eligible studies. Data extraction used a bespoke template given study diversity, and quality assessment was qualitative. Results Study diversity meant meta-analysis was not feasible so descriptive synthesis was undertaken. We identified 30 animal studies (caecal ligation/puncture (9), lipopolysaccharide (14), acute lung injury (5), and ischaemia-reperfusion syndrome (5)), and 9 human studies. Most animal (26 dexmedetomidine, 4 clonidine) and all human studies used dexmedetomidine. In animal studies, α2 agonists reduced serum and/or tissue TNFα (20 studies), IL-6 (17 studies), IL-1β (7 studies), NFκB (6 studies), TLR4 (6 studies), and a range of other mediators. Timing and doses varied widely, but in many cases were not directly relevant to human sedation use. In human studies, dexmedetomidine reduced CRP (4 studies), TNFα (5 studies), IL-6 (6 studies), IL-1β (3 studies), and altered several other mediators. Most studies were small and low quality. No studies related effects to clinical outcomes. Conclusion Evidence supports potential anti-inflammatory effects from α2 agonists, but the relevance to clinically important outcomes is uncertain. Further work should explore whether dose relationships with inflammation and clinical outcomes are present which might be separate from sedation-mediated effects.
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Affiliation(s)
| | - Alistair S Rocke
- Critical Care Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Stuart A Edwardson
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - J Kenneth Baillie
- Critical Care Department, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Critical Care Department, Royal Infirmary of Edinburgh, Edinburgh, UK. .,Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK. .,The Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK.
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Train S, Kydonaki K, Rattray J, Stephen J, Weir CJ, Walsh TS. Frightening and Traumatic Memories Early after Intensive Care Discharge. Am J Respir Crit Care Med 2019; 199:120-123. [PMID: 30312550 DOI: 10.1164/rccm.201804-0699le] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Sarah Train
- 1 University of Edinburgh Edinburgh, Scotland
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Shah A, Marian I, Dutton SJ, Barber VS, Griffith DM, McKechnie SR, Chapman G, Robbins PA, Young D, Walsh TS, Stanworth SJ. INtravenous Iron to Treat Anaemia following CriTical care (INTACT): A protocol for a feasibility randomised controlled trial. J Intensive Care Soc 2019. [DOI: 10.1177/1751143719870080] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background Anaemia is common in patients who survive critical illness and is associated with high levels of fatigue and poor quality of life. In non-critically ill patients, treating anaemia with intravenous iron has resulted in meaningful improvements in quality of life, but uncertainties regarding the benefits, risks, timing and optimal route of iron therapy in survivors of critical illness remain. Methods / Design INtravenous Iron to Treat Anaemia following CriTical care (INTACT) is an open-label, feasibility, parallel group, randomised controlled trial with 1:1 randomisation to either intravenous iron (1000 mg ferric carboxymaltose) or usual medical care. The primary objective is to assess the feasibility of a future, multicentre randomised controlled trial. Participants will be followed up for up to 90 days post-randomisation. The primary outcome measures, which will be used to determine feasibility, are recruitment and randomisation rates, protocol adherence and completeness of follow-up. Secondary outcome measures include collecting clinical, laboratory, health-related quality of life and safety data to inform the power calculations of a future definitive trial. Conclusion Improving recovery from critical illness is a recognised research priority. Whether or not correcting anaemia, with intravenous iron, improves health-related quality of life and recovery requires further investigation. If so, it has the potential to become a rapidly translatable intervention. Prior to embarking on a phase III multicentre trial, a carefully designed and implemented feasibility trial is essential.
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Affiliation(s)
- Akshay Shah
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Ioana Marian
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Susan J Dutton
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - Vicki S Barber
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
- Oxford Clinical Trials Research Unit, University of Oxford, Oxford, UK
| | - David M Griffith
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
- Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | | | - George Chapman
- Adult Intensive Care Unit, John Radcliffe Hospital, Oxford, UK
| | - Peter A Robbins
- Department of Physiology, Anatomy & Genetics, University of Oxford, Oxford, UK
| | - Duncan Young
- Nuffield Department of Clinical Neurosciences, University of Oxford, Oxford, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
- Centre for Population Health Sciences, Usher Institute, The University of Edinburgh, Edinburgh, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- NHS Blood & Transplant, Oxford, UK
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Affiliation(s)
- Timothy S Walsh
- Chair of Critical Care, Edinburgh University, Edinburgh, UK. .,Head, Anaesthetics, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK. .,Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - Ruth Endacott
- Plymouth University Clinical School, Plymouth, UK.,University of Plymouth, Drake Circus, Plymouth, Devon, PL4 8AA, UK
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26
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Gillies MA, Ghaffar S, Harrison E, Haddow C, Smyth L, Walsh TS, Pearse RM, Lone NI. The association between ICU admission and emergency hospital readmission following emergency general surgery. J Intensive Care Soc 2019; 20:316-326. [PMID: 31695736 DOI: 10.1177/1751143719843416] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background The relationship between postoperative intensive care (ICU) admission following emergency general surgery (EGS) and emergency hospital readmission has not been widely investigated. Methods Retrospective analysis of registry data for patients undergoing EGS in Scotland, 2005-2007. Exposure of interest was ICU admission status (direct from theatre; indirect after initial care on ward; no ICU admission). The primary outcome was emergency hospital readmission within 30 days of discharge. Results Thirty-seven thousand one hundred seventy-three patients were included in the analysis. Overall emergency readmission rate was 8% (n = 2983): 2756 (7.8%) in patients without postoperative ICU admission; 155 (12.1%) with direct ICU admission and 65 (14.7%) with indirect ICU admission. Indirect ICU admission was associated with increased hospital readmission rates (HR 1.24 [1.03, 1.49]; p = 0.024) compared with direct ICU admission. ICU admission was associated with increased three-year readmission rates (p = 0.006) and costs (p < 0.001) compared with initial ward care. Conclusion Indirect ICU admission is associated with increased emergency hospital readmission and healthcare costs for patients undergoing EGS.
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Affiliation(s)
- Michael A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Sadia Ghaffar
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ewen Harrison
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Catriona Haddow
- Information Services Division, NHS Services Scotland, Edinburgh, UK
| | - Lorraine Smyth
- Information Services Division, NHS Services Scotland, Edinburgh, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rupert M Pearse
- Barts and the London School of Medicine and Dentistry, Queen Mary University London, London, UK
| | - Nazir I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
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27
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Shah A, Wray K, James T, Shine B, Morovat R, Stanworth S, McKechnie S, Kirkbride R, Griffith DM, Walsh TS, Drakesmith H, Roy N. Serum hepcidin potentially identifies iron deficiency in survivors of critical illness at the time of hospital discharge. Br J Haematol 2019; 184:279-281. [PMID: 29363744 DOI: 10.1111/bjh.15067] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Akshay Shah
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Katherine Wray
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
| | - Timothy James
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Brian Shine
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Reza Morovat
- Department of Clinical Biochemistry, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Simon Stanworth
- NHS Blood and Transplant, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Stuart McKechnie
- Nuffield Department of Anaesthetics, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Rachael Kirkbride
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - David M Griffith
- MRC Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- MRC Centre for Inflammation Research, The Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Hal Drakesmith
- MRC Human Immunology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
- Biomedical Research Centre Blood Theme, NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Noémi Roy
- MRC Molecular Haematology Unit, Weatherall Institute of Molecular Medicine, University of Oxford, Oxford, UK
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28
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Gillies MA, Harrison EM, Pearse RM, Garrioch S, Haddow C, Smyth L, Parks R, Walsh TS, Lone NI. Intensive care utilization and outcomes after high-risk surgery in Scotland: a population-based cohort study. Br J Anaesth 2018; 118:123-131. [PMID: 28039249 DOI: 10.1093/bja/aew396] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The optimal perioperative use of intensive care unit (ICU) resources is not yet defined. We sought to determine the effect of ICU admission on perioperative (30 day) and long-term mortality. METHODS This was an observational study of all surgical patients in Scotland during 2005-7 followed up until 2012. Patient, operative, and care process factors were extracted. The primary outcome was perioperative mortality; secondary outcomes were 1 and 4 yr mortality. Multivariable regression was used to construct a risk prediction model to allow standard-risk and high-risk groups to be defined based on deciles of predicted perioperative mortality risk, and to determine the effect of ICU admission (direct from theatre; indirect after initial care on ward; no ICU admission) on outcome adjusted for confounders. RESULTS There were 572 598 patients included. The risk model performed well (c-index 0.92). Perioperative mortality occurred in 1125 (0.2%) in the standard-risk group (n=510 979) and in 3636 (6.4%) in the high-risk group (n=56 785). Patients with no ICU admission within 7 days of surgery had the lowest perioperative mortality (whole cohort 0.7%; high-risk cohort 5.3%). Indirect ICU admission was associated with a higher risk of perioperative mortality when compared with direct admission for the whole cohort (20.9 vs 12.1%; adjusted odds ratio 2.39, 95% confidence interval 2.01-2.84; P<0.01) and for high-risk patients (26.2 vs 17.8%; adjusted odds ratio 1.64, 95% confidence interval 1.37-1.96; P<0.01). Compared with direct ICU admission, indirectly admitted patients had higher severity of illness on admission, required more organ support, and had an increased duration of ICU stay. CONCLUSIONS Indirect ICU admission was associated with increased mortality and increased requirement for organ support. TRIAL REGISTRATION UKCRN registry no. 15761.
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Affiliation(s)
- M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine
| | - E M Harrison
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - R M Pearse
- Faculty of Medicine and Dentistry, Queen Mary University London, London, UK
| | - S Garrioch
- Department of Anaesthesia, Critical Care and Pain Medicine
| | - C Haddow
- NHS Services Scotland, Information Services Division, South Gyle, Edinburgh, UK
| | - L Smyth
- NHS Services Scotland, Information Services Division, South Gyle, Edinburgh, UK
| | - R Parks
- Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - T S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine
| | - N I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Perkins GD, Mistry D, Gates S, Gao F, Snelson C, Hart N, Camporota L, Varley J, Carle C, Paramasivam E, Hoddell B, McAuley DF, Walsh TS, Blackwood B, Rose L, Lamb SE, Petrou S, Young D, Lall R. Effect of Protocolized Weaning With Early Extubation to Noninvasive Ventilation vs Invasive Weaning on Time to Liberation From Mechanical Ventilation Among Patients With Respiratory Failure: The Breathe Randomized Clinical Trial. JAMA 2018; 320:1881-1888. [PMID: 30347090 PMCID: PMC6248131 DOI: 10.1001/jama.2018.13763] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE In adults in whom weaning from invasive mechanical ventilation is difficult, noninvasive ventilation may facilitate early liberation, but there is uncertainty about its effectiveness in a general intensive care patient population. OBJECTIVE To investigate among patients with difficulty weaning the effects of protocolized weaning with early extubation to noninvasive ventilation on time to liberation from ventilation compared with protocolized invasive weaning. DESIGN, SETTING, AND PARTICIPANTS Randomized, allocation-concealed, open-label, multicenter clinical trial enrolling patients between March 2013 and October 2016 from 41 intensive care units in the UK National Health Service. Follow-up continued until April 2017. Adults who received invasive mechanical ventilation for more than 48 hours and in whom a spontaneous breathing trial failed were enrolled. INTERVENTIONS Patients were randomized to receive either protocolized weaning via early extubation to noninvasive ventilation (n = 182) or protocolized standard weaning (continued invasive ventilation until successful spontaneous breathing trial, followed by extubation) (n = 182). MAIN OUTCOMES AND MEASURES Primary outcome was time from randomization to successful liberation from all forms of mechanical ventilation among survivors, measured in days, with the minimal clinically important difference defined as 1 day. Secondary outcomes were duration of invasive and total ventilation (days), reintubation or tracheostomy rates, and survival. RESULTS Among 364 randomized patients (mean age, 63.1 [SD, 14.8] years; 50.5% male), 319 were evaluable for the primary effectiveness outcome (41 died before liberation, 2 withdrew, and 2 were discharged with ongoing ventilation). The median time to liberation was 4.3 days in the noninvasive group vs 4.5 days in the invasive group (adjusted hazard ratio, 1.1; 95% CI, 0.89-1.40). Competing risk analysis accounting for deaths had a similar result (adjusted hazard ratio, 1.1; 95% CI, 0.86-1.34). The noninvasive group received less invasive ventilation (median, 1 day vs 4 days; incidence rate ratio, 0.6; 95% CI, 0.47-0.87) and fewer total ventilator days (median, 3 days vs 4 days; incidence rate ratio, 0.8; 95% CI, 0.62-1.0). There was no significant difference in reintubation, tracheostomy rates, or survival. Adverse events occurred in 45 patients (24.7%) in the noninvasive group compared with 47 (25.8%) in the invasive group. CONCLUSIONS AND RELEVANCE Among patients requiring mechanical ventilation in whom a spontaneous breathing trial had failed, early extubation to noninvasive ventilation did not shorten time to liberation from any ventilation. TRIAL REGISTRATION ISRCTN Identifier: ISRCTN15635197.
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Affiliation(s)
- Gavin D. Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, England
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Dipesh Mistry
- Warwick Clinical Trials Unit, University of Warwick, Coventry, England
| | - Simon Gates
- Warwick Clinical Trials Unit, University of Warwick, Coventry, England
- Cancer Research United Kingdom Clinical Trials Unit, University of Birmingham, Birmingham, England
| | - Fang Gao
- Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
- Cancer Research United Kingdom Clinical Trials Unit, University of Birmingham, Birmingham, England
| | - Catherine Snelson
- Queen Elizabeth Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, England
| | - Nicholas Hart
- Guy’s and St Thomas’ NHS Foundation Trust, London, England
| | | | | | - Coralie Carle
- Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough, England
| | | | - Beverley Hoddell
- Warwick Clinical Trials Unit, University of Warwick, Coventry, England
| | | | | | | | - Louise Rose
- University of Toronto, Toronto, Ontario, Canada
- Kings College London, London, England
| | | | - Stavros Petrou
- Warwick Clinical Trials Unit, University of Warwick, Coventry, England
| | | | - Ranjit Lall
- Warwick Clinical Trials Unit, University of Warwick, Coventry, England
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30
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Docherty AB, Alam S, Shah AS, Moss A, Newby DE, Mills NL, Stanworth SJ, Lone NI, Walsh TS. Unrecognised myocardial infarction and its relationship to outcome in critically ill patients with cardiovascular disease. Intensive Care Med 2018; 44:2059-2069. [PMID: 30374693 DOI: 10.1007/s00134-018-5425-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Accepted: 10/17/2018] [Indexed: 12/19/2022]
Abstract
PURPOSE To establish the incidence of myocardial infarction (MI) in ICU patients with co-existing cardiovascular disease (CVD), and explore its association with long-term survival. METHODS In a multi-centre prospective cohort study in 11 UK ICUs, we enrolled 273 critically ill patients with co-existing CVD. We measured troponin I (cTnI) with a high sensitivity assay for 10 days; ECGs were carried out daily for 5 days and analysed by blinded cardiologists for dynamic changes. Data were combined to diagnose myocardial 'infarction', 'injury' or 'no injury' according to the third universal definition of MI. Patients were followed-up for 6 months. Regression and mediation analyses were used to explore relationships between acute physiological derangements, MI, and mortality. RESULTS cTnI was detected in all patients, with a rise/fall pattern consistent with an acute hit. In 73% of patients, this peaked on days 1-3 [median 114 ng/l (first, third quartiles: 27, 393)]. Serial ECGs indicated 24.2% (n = 66) of patients experienced MI, but > 95% were unrecognized by clinical teams. Type 2 MI was the most likely aetiology in all cases. A further 46.1% (n = 126) experienced injury (no ECG changes). Injury and MI were both associated with 6-month mortality (reference: no injury): OR injury 2.28 (95% CI 1.06-4.92, p = 0.035), OR MI 2.70 (95% CI 1.11-6.55, p = 0.028). Mediation analysis suggested MI partially mediated the relationship between acute physiological derangement and 6-month mortality (p = 0.002), suggesting a possible causal association. CONCLUSIONS Undiagnosed MI occurs in around a quarter of critically ill patients with co-existing CVD and is associated with lower long-term survival.
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Affiliation(s)
- Annemarie B Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, 2nd Floor Anaesthetics Corridor, Royal Infirmary Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, UK. .,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK. .,The Usher Institute, University of Edinburgh, Edinburgh, UK.
| | - Shirjel Alam
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Anoop S Shah
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Alastair Moss
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - David E Newby
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Nicholas L Mills
- Centre for Cardiovascular Sciences, University of Edinburgh, Edinburgh, UK
| | - Simon J Stanworth
- Radcliffe Department of Medicine, University of Oxford, Oxford, UK.,Transfusion Medicine, NHS Blood and Transplant, Oxford, UK
| | - Nazir I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, 2nd Floor Anaesthetics Corridor, Royal Infirmary Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.,The Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, 2nd Floor Anaesthetics Corridor, Royal Infirmary Edinburgh, Old Dalkeith Road, Edinburgh, EH16 4SA, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Shankar-Hari M, Datta D, Wilson J, Assi V, Stephen J, Weir CJ, Rennie J, Antonelli J, Bateman A, Felton JM, Warner N, Judge K, Keenan J, Wang A, Burpee T, Brown AK, Lewis SM, Mare T, Roy AI, Wright J, Hulme G, Dimmick I, Gray A, Rossi AG, Simpson AJ, Conway Morris A, Walsh TS. Early PREdiction of sepsis using leukocyte surface biomarkers: the ExPRES-sepsis cohort study. Intensive Care Med 2018; 44:1836-1848. [PMID: 30291379 DOI: 10.1007/s00134-018-5389-0] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2018] [Accepted: 09/24/2018] [Indexed: 12/11/2022]
Abstract
PURPOSE Reliable biomarkers for predicting subsequent sepsis among patients with suspected acute infection are lacking. In patients presenting to emergency departments (EDs) with suspected acute infection, we aimed to evaluate the reliability and discriminant ability of 47 leukocyte biomarkers as predictors of sepsis (Sequential Organ Failure Assessment score ≥ 2 at 24 h and/or 72 h following ED presentation). METHODS In a multi-centre cohort study in four EDs and intensive care units (ICUs), we standardised flow-cytometric leukocyte biomarker measurement and compared patients with suspected acute infection (cohort-1) with two comparator cohorts: ICU patients with established sepsis (cohort-2), and ED patients without infection or systemic inflammation but requiring hospitalization (cohort-3). RESULTS Between January 2014 and February 2016, we recruited 272, 59 and 75 patients to cohorts 1, 2, and 3, respectively. Of 47 leukocyte biomarkers, 14 were non-reliable, and 17 did not discriminate between the three cohorts. Discriminant analyses for predicting sepsis within cohort-1 were undertaken for eight neutrophil (cluster of differentiation antigens (CD) CD15; CD24; CD35; CD64; CD312; CD11b; CD274; CD279), seven monocyte (CD35; CD64; CD312; CD11b; HLA-DR; CD274; CD279) and a CD8 T-lymphocyte biomarker (CD279). Individually, only higher neutrophil CD279 [OR 1.78 (95% CI 1.23-2.57); P = 0.002], higher monocyte CD279 [1.32 (1.03-1.70); P = 0.03], and lower monocyte HLA-DR [0.73 (0.55-0.97); P = 0.03] expression were associated with subsequent sepsis. With logistic regression the optimum biomarker combination was increased neutrophil CD24 and neutrophil CD279, and reduced monocyte HLA-DR expression, but no combination had clinically relevant predictive validity. CONCLUSIONS From a large panel of leukocyte biomarkers, immunosuppression biomarkers were associated with subsequent sepsis in ED patients with suspected acute infection. CLINICAL TRIAL REGISTRATION NCT02188992.
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Affiliation(s)
- Manu Shankar-Hari
- School of Immunology & Microbial Sciences, Kings College, London, UK. .,Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK.
| | - Deepankar Datta
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - Julie Wilson
- School of Immunology & Microbial Sciences, Kings College, London, UK.,Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Valentina Assi
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | | | - Christopher J Weir
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Jillian Rennie
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - Jean Antonelli
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK
| | - Anthony Bateman
- Department of Anaesthesia, Critical Care & Pain Medicine, University of Edinburgh, Edinburgh, UK
| | - Jennifer M Felton
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - Noel Warner
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Kevin Judge
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Jim Keenan
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Alice Wang
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Tony Burpee
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - Alun K Brown
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Sion M Lewis
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Tracey Mare
- Guy's and St Thomas' NHS Foundation Trust, London, SE17EH, UK
| | - Alistair I Roy
- Becton-Dickinson Bioscience, Franklin Lakes, NJ, USA.,Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, UK
| | - John Wright
- Emergency Department, Royal Victoria Infirmary, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gillian Hulme
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Ian Dimmick
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle upon Tyne, UK
| | - Alasdair Gray
- Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Department of Emergency Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adriano G Rossi
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Conway Morris
- University Division of Anesthesia, Department of Medicine, Addenbrooke's Hospital, Hills Road, Cambridge, UK
| | - Timothy S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, UK.,Centre for Population Health Sciences, Usher Institute, University of Edinburgh, Edinburgh, UK.,Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
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32
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Hodgson CL, Walsh TS, Lone N. The long road home: are outcomes different for patients with sepsis? Intensive Care Med 2018; 44:1556-1557. [PMID: 30022235 DOI: 10.1007/s00134-018-5301-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 07/02/2018] [Indexed: 10/28/2022]
Affiliation(s)
- C L Hodgson
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia.
| | - T S Walsh
- University of Edinburgh, Edinburgh, UK
| | - N Lone
- University of Edinburgh, Edinburgh, UK
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Walsh TS, Stanworth S, Boyd J, Hope D, Hemmatapour S, Burrows H, Campbell H, Pizzo E, Swart N, Morris S. The Age of BLood Evaluation (ABLE) randomised controlled trial: description of the UK-funded arm of the international trial, the UK cost-utility analysis and secondary analyses exploring factors associated with health-related quality of life and health-care costs during the 12-month follow-up. Health Technol Assess 2018; 21:1-118. [PMID: 29067906 DOI: 10.3310/hta21620] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND At present, red blood cells (RBCs) are stored for up to 42 days prior to transfusion. The relative effectiveness and safety of different RBC storage times prior to transfusion is uncertain. OBJECTIVE To assess the clinical effectiveness and cost-effectiveness of transfusing fresher RBCs (stored for ≤ 7 days) compared with current standard-aged RBCs in critically ill patients requiring blood transfusions. DESIGN The international Age of BLood Evaluation (ABLE) trial was a multicentre, randomised, blinded trial undertaken in Canada, the UK, the Netherlands and France. The UK trial was funded to contribute patients to the international trial and undertake a UK-specific health economic evaluation. SETTING Twenty intensive care units (ICUs) in the UK, as part of 64 international centres. PARTICIPANTS Critically ill patients aged ≥ 18 years (≥ 16 years in Scotland) expected to require mechanical ventilation for ≥ 48 hours and requiring a first RBC transfusion during the first 7 days in the ICU. INTERVENTIONS All decisions to transfuse RBCs were made by clinicians. One patient group received exclusively fresh RBCs stored for ≤ 7 days whenever transfusion was required from randomisation until hospital discharge. The other group received standard-issue RBCs throughout their hospital stay. MAIN OUTCOME MEASURES The primary outcome was 90-day mortality. Secondary outcomes included development of organ dysfunction, new thrombosis, infections and transfusion reactions. The primary economic evaluation was a cost-utility analysis. RESULTS The international trial took place between March 2009 and October 2014 (UK recruitment took place between January 2012 and October 2014). In total, 1211 patients were assigned to receive fresh blood and 1219 patients to receive standard-aged blood. RBCs were stored for a mean of 6.1 days [standard deviation (SD) ± 4.9 days] in the group allocated to receive fresh blood and 22.0 days (SD ± 8.4 days) in the group allocated to receive standard-aged blood. Patients received a mean of 4.3 RBC units (SD ± 5.2 RBC units) and 4.3 RBC units (SD ± 5.5 RBC units) in the groups receiving fresh blood and standard-aged blood, respectively. At 90 days, 37.0% of patients in the group allocated to receive fresh blood and 35.3% of patients in the group allocated to receive standard-aged blood had died {absolute risk difference 1.7% [95% confidence interval (CI) -2.1% to 5.5%]}. There were no between-group differences in any secondary outcomes. The UK cohort comprised 359 patients randomised and followed up for 12 months for the cost-utility analysis. UK patients had similar characteristics and outcomes to the international cohort. Mean total costs per patient were £32,346 (95% CI £29,306 to £35,385) in the group allocated to receive fresh blood and £33,353 (95% CI £29,729 to £36,978) in the group allocated to receive standard-aged blood. Approximately 85% of the total costs were incurred during the index hospital admission. There were no significant cost differences between the two groups [mean incremental costs for those receiving fresh vs. standard-aged blood: -£231 (95% CI -£4876 to £4415)], nor were there significant differences in outcomes (mean difference in quality-adjusted life-years -0.010, 95% CI -0.078 to 0.057). LIMITATIONS Adverse effects from the exclusive use of older RBCs compared with standard or fresh RBCs cannot be excluded. CONCLUSIONS The use of RBCs aged ≤ 7 days confers no clinical or economic benefit in critically ill patients compared with standard-aged RBCs. FUTURE WORK Future studies should address the safety of RBCs near the end of the current permitted storage age. TRIAL REGISTRATION Current Controlled Trials ISRCTN44878718. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 62. See the NIHR Journals Library website for further project information. The international ABLE trial was also supported by peer-reviewed grants from the Canadian Institutes of Health Research (177453), Fonds de Recherche du Québec - Santé (24460), the French Ministry of Health Programme Hospitalier de Recherche Clinique (12.07, 2011) and by funding from Établissement Français du Sang and Sanquin Blood Supply.
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Affiliation(s)
- Timothy S Walsh
- Anaesthesia, Critical Care and Pain Medicine, Division of Health Sciences, University of Edinburgh, Edinburgh, UK
| | - Simon Stanworth
- Department of Haematology, Oxford University Hospitals, Oxford, UK.,NHS Blood and Transplant, John Radcliffe Hospital, Oxford, UK.,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Julia Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - David Hope
- Edinburgh Critical Care Research Group, Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Sue Hemmatapour
- Department of Haematology and Blood Transfusion, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Burrows
- Department of Haematology and Blood Transfusion, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Helen Campbell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, UK
| | - Nicholas Swart
- Department of Applied Health Research, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
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Conway Morris A, Datta D, Shankar-Hari M, Stephen J, Weir CJ, Rennie J, Antonelli J, Bateman A, Warner N, Judge K, Keenan J, Wang A, Burpee T, Brown KA, Lewis SM, Mare T, Roy AI, Hulme G, Dimmick I, Rossi AG, Simpson AJ, Walsh TS. Cell-surface signatures of immune dysfunction risk-stratify critically ill patients: INFECT study. Intensive Care Med 2018; 44:627-635. [PMID: 29915941 PMCID: PMC6006236 DOI: 10.1007/s00134-018-5247-0] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 04/16/2018] [Indexed: 01/13/2023]
Abstract
PURPOSE Cellular immune dysfunctions, which are common in intensive care patients, predict a number of significant complications. In order to effectively target treatments, clinically applicable measures need to be developed to detect dysfunction. The objective was to confirm the ability of cellular markers associated with immune dysfunction to stratify risk of secondary infection in critically ill patients. METHODS Multi-centre, prospective observational cohort study of critically ill patients in four UK intensive care units. Serial blood samples were taken, and three cell surface markers associated with immune cell dysfunction [neutrophil CD88, monocyte human leucocyte antigen-DR (HLA-DR) and percentage of regulatory T cells (Tregs)] were assayed on-site using standardized flow cytometric measures. Patients were followed up for the development of secondary infections. RESULTS A total of 148 patients were recruited, with data available from 138. Reduced neutrophil CD88, reduced monocyte HLA-DR and elevated proportions of Tregs were all associated with subsequent development of infection with odds ratios (95% CI) of 2.18 (1.00-4.74), 3.44 (1.58-7.47) and 2.41 (1.14-5.11), respectively. Burden of immune dysfunction predicted a progressive increase in risk of infection, from 14% for patients with no dysfunction to 59% for patients with dysfunction of all three markers. The tests failed to risk stratify patients shortly after ICU admission but were effective between days 3 and 9. CONCLUSIONS This study confirms our previous findings that three cell surface markers can predict risk of subsequent secondary infection, demonstrates the feasibility of standardized multisite flow cytometry and presents a tool which can be used to target future immunomodulatory therapies. TRIAL REGISTRATION The study was registered with clinicaltrials.gov (NCT02186522).
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Affiliation(s)
- Andrew Conway Morris
- University Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Box 93, Hills Road, Cambridge, CB2 0QQ, England, UK.
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, UK.
| | - Deepankar Datta
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, UK
- Edinburgh Critical Care Research Group, University of Edinburgh School of Clinical Sciences, Edinburgh, Scotland, UK
| | - Manu Shankar-Hari
- Intensive Care Unit, Guy's and St Thomas' Hospital NHS Foundation Trust, London, England, UK
| | - Jacqueline Stephen
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | - Christopher J Weir
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | - Jillian Rennie
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, UK
| | - Jean Antonelli
- Edinburgh Clinical Trials Unit, Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, Scotland, UK
| | - Anthony Bateman
- Intensive Care Unit, Western General Hospital, Crewe Road South, Edinburgh, Scotland, UK
| | | | | | | | - Alice Wang
- BD Biosciences, San Jose, CA, USA
- IncellDx, Menlo Park, CA, USA
| | | | - K Alun Brown
- Vascular Immunology Research Laboratory, Rayne Institute (King's College London), St Thomas' Hospital, London, England, UK
| | - Sion M Lewis
- Vascular Immunology Research Laboratory, Rayne Institute (King's College London), St Thomas' Hospital, London, England, UK
| | - Tracey Mare
- Vascular Immunology Research Laboratory, Rayne Institute (King's College London), St Thomas' Hospital, London, England, UK
| | - Alistair I Roy
- Integrated Critical Care Unit, Sunderland Royal Hospital, Sunderland, England, UK
| | - Gillian Hulme
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle, England, UK
| | - Ian Dimmick
- Flow Cytometry Core Facility Laboratory, Faculty of Medical Sciences, Centre for Life, Newcastle University, Newcastle, England, UK
| | - Adriano G Rossi
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, England, UK
| | - Timothy S Walsh
- MRC Centre for Inflammation Research, University of Edinburgh, 47 Little France Crescent, Edinburgh, Scotland, UK
- Edinburgh Critical Care Research Group, University of Edinburgh School of Clinical Sciences, Edinburgh, Scotland, UK
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Tsang STJ, McHugh MP, Guerendiain D, Gwynne P, Boyd J, Laurenson IF, Templeton KE, Lewis S, Simpson AHRW, Walsh TS. Evaluation of Staphylococcus aureus eradication therapy in orthopaedic surgery. J Med Microbiol 2018; 67:893-901. [PMID: 29671723 DOI: 10.1099/jmm.0.000731] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Despite WHO recommendations, there is currently no national screening and eradication policy for the detection of methicillin-sensitive Staphylococcus aureus (MSSA) in the UK prior to elective orthopaedic surgery. This study aimed to evaluate the effectiveness of current standard methicillin-resistant S. aureus (MRSA) eradication therapies in the context of S. aureus (both MRSA and MSSA) decolonization in an elective orthopaedic population. METHODOLOGY A total of 100 patients awaiting joint replacement surgery who were positive for S. aureus on PCR nasal screening underwent the current standard MRSA pre-operative decolonization regimen for 5 days. Prior to commencement of the eradication therapy, swabs of the anterior nares, throat and perineum were taken for culture. Further culture swabs were taken at 48-96 h following treatment, at hospital admission for surgery and at hospital discharge. Following the completion of treatment, patients were asked to provide feedback on their experience using Likert rating scales. The primary outcome of this study was S. aureus clearance 48-96 h following eradication treatment.Results/Key Findings. Clearance of S. aureus 48-96 h following treatment was 94 % anterior nares, 66 % throat and 88 % groin. Mean completion with nasal mupirocin was 98 %. There was no statistically significant recolonization effect between the end of the eradication treatment period and the day of surgery (P>0.05) at a median time of 10 days. CONCLUSION Current MRSA decolonisation regimens are well tolerated and effective for MSSA decolonization for the anterior nares and groin. The decolonization effect is preserved for at least 10 days following treatment.
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Affiliation(s)
- S T J Tsang
- School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK.,Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France, Crescent Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - M P McHugh
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - D Guerendiain
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - P Gwynne
- School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - J Boyd
- Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent , Old Dalkeith Road, Edinburgh EH16 4SB, Scotland
| | - I F Laurenson
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - K E Templeton
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - S Lewis
- Edinburgh Clinical Trials Unit, University of Edinburgh, Usher Institute, Old Medical School, Teviot Place, Edinburgh EH8 9AG, UK
| | - A H R W Simpson
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France, Crescent Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - T S Walsh
- Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent , Old Dalkeith Road, Edinburgh EH16 4SB, Scotland
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Lone NI, Lee R, Salisbury L, Donaghy E, Ramsay P, Rattray J, Walsh TS. Predicting risk of unplanned hospital readmission in survivors of critical illness: a population-level cohort study. Thorax 2018; 74:1046-1054. [PMID: 29622692 DOI: 10.1136/thoraxjnl-2017-210822] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Revised: 03/07/2018] [Accepted: 03/19/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Intensive care unit (ICU) survivors experience high levels of morbidity after hospital discharge and are at high risk of unplanned hospital readmission. Identifying those at highest risk before hospital discharge may allow targeting of novel risk reduction strategies. We aimed to identify risk factors for unplanned 90-day readmission, develop a risk prediction model and assess its performance to screen for ICU survivors at highest readmission risk. METHODS Population cohort study linking registry data for patients discharged from general ICUs in Scotland (2005-2013). Independent risk factors for 90-day readmission and discriminant ability (c-index) of groups of variables were identified using multivariable logistic regression. Derivation and validation risk prediction models were constructed using a time-based split. RESULTS Of 55 975 ICU survivors, 24.1% (95%CI 23.7% to 24.4%) had unplanned 90-day readmission. Pre-existing health factors were fair discriminators of readmission (c-index 0.63, 95% CI 0.63 to 0.64) but better than acute illness factors (0.60) or demographics (0.54). In a subgroup of those with no comorbidity, acute illness factors (0.62) were better discriminators than pre-existing health factors (0.56). Overall model performance and calibration in the validation cohort was fair (0.65, 95% CI 0.64 to 0.66) but did not perform sufficiently well as a screening tool, demonstrating high false-positive/false-negative rates at clinically relevant thresholds. CONCLUSIONS Unplanned 90-day hospital readmission is common. Pre-existing illness indices are better predictors of readmission than acute illness factors. Identifying additional patient-centred drivers of readmission may improve risk prediction models. Improved understanding of risk factors that are amenable to intervention could improve the clinical and cost-effectiveness of post-ICU care and rehabilitation.
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Affiliation(s)
- Nazir I Lone
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Robert Lee
- Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - Lisa Salisbury
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Queen Margaret Drive, Queen Margaret University Edinburgh, Musselburgh, UK
| | - Eddie Donaghy
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Pamela Ramsay
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Edinburgh Napier University, Edinburgh, UK
| | - Janice Rattray
- School of Nursing and Health Sciences, University of Dundee, Dundee, UK
| | - Timothy S Walsh
- University Department of Anaesthesia, Critical Care, and Pain Medicine, School of Clinical Sciences, University of Edinburgh, Edinburgh, UK.,Usher Institute for Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,MRC Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Walsh TS, Juffermans NP. New blood for old? High quality evidence that fresh red blood cells confer no benefit for critically ill patients. Intensive Care Med 2018. [PMID: 29541789 DOI: 10.1007/s00134-018-5106-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary of Edinburgh, Room S8208, 2nd Floor, 51 Little France Crescent, Edinburgh, EH16 4SA, Scotland
| | - Nicole P Juffermans
- Department of Intensive Care and Laboratory of Experimental Intensive Care and Anesthesiology, Academic Medical Center, Room G3-206, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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Tsang STJ, McHugh MP, Guerendiain D, Gwynne PJ, Boyd J, Simpson AHRW, Walsh TS, Laurenson IF, Templeton KE. Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques: One third of carriers missed. Bone Joint Res 2018; 7:79-84. [PMID: 29330346 PMCID: PMC5805824 DOI: 10.1302/2046-3758.71.bjr-2017-0175.r1] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVES Nasal carriers of Staphylococcus (S.) aureus (MRSA and MSSA) have an increased risk for healthcare-associated infections. There are currently limited national screening policies for the detection of S. aureus despite the World Health Organization's recommendations. This study aimed to evaluate the diagnostic performance of molecular and culture techniques in S. aureus screening, determine the cause of any discrepancy between the diagnostic techniques, and model the potential effect of different diagnostic techniques on S. aureus detection in orthopaedic patients. METHODS Paired nasal swabs for polymerase chain reaction (PCR) assay and culture of S. aureus were collected from a study population of 273 orthopaedic outpatients due to undergo joint arthroplasty surgery. RESULTS The prevalence of MSSA nasal colonization was found to be between 22.4% to 35.6%. The current standard direct culturing methods for detecting S. aureus significantly underestimated the prevalence (p = 0.005), failing to identify its presence in approximately one-third of patients undergoing joint arthroplasty surgery. CONCLUSION Modelling these results to national surveillance data, it was estimated that approximately 5000 to 8000 S. aureus surgical site infections could be prevented, and approximately $140 million to $950 million (approximately £110 million to £760 million) saved in treatment costs annually in the United States and United Kingdom combined, by using alternative diagnostic methods to direct culture in preoperative S. aureus screening and eradication programmes.Cite this article: S. T. J. Tsang, M. P. McHugh, D. Guerendiain, P. J. Gwynne, J. Boyd, A. H. R. W. Simpson, T. S. Walsh, I. F. Laurenson, K. E. Templeton. Underestimation of Staphylococcus aureus (MRSA and MSSA) carriage associated with standard culturing techniques: One third of carriers missed. Bone Joint Res 2018;7:79-84. DOI: 10.1302/2046-3758.71.BJR-2017-0175.R1.
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Affiliation(s)
- S T J Tsang
- Department of Orthopaedic Surgery, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK and School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - M P McHugh
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - D Guerendiain
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - P J Gwynne
- School of Biological Sciences, University of Edinburgh, King's Buildings, Mayfield Road, Edinburgh EH9 3JR, UK
| | - J Boyd
- Edinburgh Clinical Trials Unit, University of Edinburgh (Usher Institute), Nine Bioquarter, 9 Little France Road, Edinburgh, EH16 4UX
| | - A H R W Simpson
- Department of Orthopaedic Surgery, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - T S Walsh
- Critical care and Pain Medicine, Department of Anaesthesia, Critical care and Pain Medicine, University of Edinburgh, Chancellor's Building, 49 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SB, UK
| | - I F Laurenson
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
| | - K E Templeton
- Department of Medical Microbiology, Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
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Craven TH, Wojcik G, McCoubrey J, Brooks O, Grant E, Reilly J, Laurenson IF, Kefala K, Walsh TS. Lack of concordance between ECDC and CDC systems for surveillance of ventilator associated pneumonia. Intensive Care Med 2017; 44:265-266. [PMID: 29159563 DOI: 10.1007/s00134-017-4993-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2017] [Indexed: 11/27/2022]
Affiliation(s)
- Thomas H Craven
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK.
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK.
- Royal Infirmary of Edinburgh, Edinburgh, UK.
| | - Gosha Wojcik
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
| | | | | | | | | | | | - Kallirroi Kefala
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
- Edinburgh Critical Care Research Group, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, Edinburgh, UK
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Docherty AB, Sim M, Oliveira J, Adlam M, Ostermann M, Walsh TS, Kinsella J, Lone NI. Early troponin I in critical illness and its association with hospital mortality: a cohort study. Crit Care 2017; 21:216. [PMID: 28814347 PMCID: PMC5559840 DOI: 10.1186/s13054-017-1800-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Accepted: 07/20/2017] [Indexed: 12/21/2022]
Abstract
Background Troponin I (TnI) is frequently elevated in critical illness, but its interpretation is unclear. Our primary objectives in this study were to evaluate whether TnI is associated with hospital mortality and if this association persists after adjusting for potential confounders. We also aimed to ascertain whether addition of TnI to the Acute Physiological and Chronic Health Evaluation II (APACHE II) risk prediction model improves its performance in general intensive care unit (ICU) populations. Methods We performed an observational cohort study with independent derivation and validation cohorts in two general level 3 ICU departments in the United Kingdom. The derivation cohort was a 4.5-year cohort (2010–2014) of general ICU index admissions (n = 1349). The validation cohort was used for secondary analysis of a prospective study dataset (2010) (n = 145). The primary exposure was plasma TnI concentration taken within 24 h of ICU admission. The primary outcome was hospital mortality. We performed multivariate regression, adjusting for components of the APACHE II model. We derived the risk prediction score from the multivariable model with TnI. Results Hospital mortality was 37.3% (n = 242) for patients with detectable TnI, compared with 14.6% (n = 102) for patients without detectable TnI. There was a significant univariate association between TnI and hospital mortality (OR per doubling TnI 1.16, 95% CI 1.13–1.20, p < 0.001). This persisted after adjustment for APACHE II model components (TnI OR 1.05, 95% CI 1.01–1.09, p = 0.003). TnI correlated most strongly with the acute physiology score (APS) component of APACHE II (r = 0.39). Addition of TnI to the APACHE II model did not improve discrimination (APACHE II concordance statistic [c-index] 0.835, 95% CI 0.811–0.858; APACHE II + TnI c-index 0.837, 95% CI 0.813–0.860; p = 0.330) or other measures of model performance. Conclusions TnI is an independent predictor of hospital mortality and correlates most highly with the APS component of APACHE II. It does not improve risk prediction. We would not advocate the adoption of routine troponin analysis on admission to ICU, and we recommend that troponin be measured only if clinically indicated. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1800-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Annemarie B Docherty
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary Edinburgh, 2nd Floor Anaesthetics Corridor, Edinburgh, EH16 4SA, UK. .,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK.
| | - Malcolm Sim
- Academic Unit of Anaesthesia, Pain & Critical Care, University of Glasgow, Glasgow, UK
| | - Joao Oliveira
- Department of Critical Care, King's College London, Guys and St Thomas' Hospital, London, UK.,Internal Medicine Department, Hospital Jose Joaquim Fernandes, Beja, Portugal
| | - Michael Adlam
- Department of Critical Care, King's College London, Guys and St Thomas' Hospital, London, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guys and St Thomas' Hospital, London, UK
| | - Timothy S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary Edinburgh, 2nd Floor Anaesthetics Corridor, Edinburgh, EH16 4SA, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
| | - John Kinsella
- Academic Unit of Anaesthesia, Pain & Critical Care, University of Glasgow, Glasgow, UK
| | - Nazir I Lone
- Department of Anaesthesia, Critical Care and Pain Medicine, University of Edinburgh, Royal Infirmary Edinburgh, 2nd Floor Anaesthetics Corridor, Edinburgh, EH16 4SA, UK.,Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK
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Lone NI, Gillies MA, Haddow C, Dobbie R, Rowan KM, Wild SH, Murray GD, Walsh TS. Five-Year Mortality and Hospital Costs Associated with Surviving Intensive Care. Am J Respir Crit Care Med 2017; 194:198-208. [PMID: 26815887 DOI: 10.1164/rccm.201511-2234oc] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Survivors of critical illness experience significant morbidity, but the impact of surviving the intensive care unit (ICU) has not been quantified comprehensively at a population level. OBJECTIVES To identify factors associated with increased hospital resource use and to ascertain whether ICU admission was associated with increased mortality and resource use. METHODS Matched cohort study and pre/post-analysis using national linked data registries with complete population coverage. The population consisted of patients admitted to all adult general ICUs during 2005 and surviving to hospital discharge, identified from the Scottish Intensive Care Society Audit Group registry, matched (1:1) with similar hospital control subjects. Five-year outcomes included mortality and hospital resource use. Confounder adjustment was based on multivariable regression and pre/post within-individual analyses. MEASUREMENTS AND MAIN RESULTS Of 7,656 ICU patients, 5,259 survived to hospital discharge (5,215 [99.2%] matched to hospital control subjects). Factors present before ICU admission (comorbidities/pre-ICU hospitalizations) were stronger predictors of hospital resource use than acute illness factors. In the 5 years after the initial hospital discharge, compared with hospital control subjects, the ICU cohort had higher mortality (32.3% vs. 22.7%; hazard ratio, 1.33; 95% confidence interval, 1.22-1.46; P < 0.001), used more hospital resources (mean hospital admission rate, 4.8 vs. 3.3/person/5 yr), and had 51% higher mean 5-year hospital costs ($25,608 vs. $16,913/patient). Increased resource use persisted after confounder adjustment (P < 0.001) and using pre/post-analyses (P < 0.001). Excess resource use and mortality were greatest for younger patients without significant comorbidity. CONCLUSIONS This complete, national study demonstrates that ICU survivorship is associated with higher 5-year mortality and hospital resource use than hospital control subjects, representing a substantial burden on individuals, caregivers, and society.
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Affiliation(s)
- Nazir I Lone
- 1 Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom.,2 Department of Anaesthesia, Critical Care and Pain, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Michael A Gillies
- 2 Department of Anaesthesia, Critical Care and Pain, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Catriona Haddow
- 3 Information Services Division, NHS Scotland, Edinburgh, United Kingdom; and
| | - Richard Dobbie
- 3 Information Services Division, NHS Scotland, Edinburgh, United Kingdom; and
| | - Kathryn M Rowan
- 4 Intensive Care National Audit & Research Centre, London, United Kingdom
| | - Sarah H Wild
- 1 Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Gordon D Murray
- 1 Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Timothy S Walsh
- 2 Department of Anaesthesia, Critical Care and Pain, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2017. Other selected articles can be found online at http://ccforum.com/series/annualupdate2017 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .
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Affiliation(s)
- Annemarie B. Docherty
- Department of Anaesthesia, Critical Care, Pain Medicine, and Intensive Care Medicine, University of Edinburgh, Edinburgh, UK
- University of Edinburgh, Centre for Inflammation Research, Edinburgh, UK
| | - Timothy S. Walsh
- Department of Anaesthesia, Critical Care, Pain Medicine, and Intensive Care Medicine, University of Edinburgh, Edinburgh, UK
- University of Edinburgh, Centre for Inflammation Research, Edinburgh, UK
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Gillies MA, Lone NI, Pearse RM, Haddow C, Smyth L, Parks RW, Walsh TS, Harrison EM. Effect of day of the week on short- and long-term mortality after emergency general surgery. Br J Surg 2017; 104:936-945. [PMID: 28326535 DOI: 10.1002/bjs.10507] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Revised: 11/14/2016] [Accepted: 01/11/2017] [Indexed: 11/08/2022]
Abstract
BACKGROUND The effect of day of the week on outcome after surgery is the subject of debate. The aim was to determine whether day of the week of emergency general surgery alters short- and long-term mortality. METHODS This was an observational study of all patients undergoing emergency general surgery in Scotland between 1 January 2005 and 31 December 2007, followed to 2012. Multilevel logistic and Cox proportional hazards regression were used to assess the effect of day of the week of surgery on outcome after adjustment for case mix and risk factors. The primary outcome was perioperative mortality; the secondary outcome was overall survival. RESULTS A total of 50 844 patients were identified, of whom 31 499 had an emergency procedure on Monday to Thursday and 19 345 on Friday to Sunday. Patients undergoing surgery at the weekend were younger (mean 45·9 versus 47·5 years; P < 0·001) and had fewer co-morbidities, but underwent riskier and/or more complex procedures (P < 0·001). Patients who had surgery at the weekend were more likely to have been operated on sooner than those who had weekday surgery (mean time from admission to operation 1·2 versus 1·6 days; P < 0·001). No difference in perioperative mortality (odds ratio 1·00, 95 per cent c.i. 0·89 to 1·13; P = 0·989) or overall survival (hazard ratio 1·01, 0·97 to 1·06; P = 0·583) was observed when surgery was performed at the weekend. There was no difference in overall survival after surgery undertaken on any particular day compared with Wednesday; a borderline reduction in perioperative mortality was seen on Tuesday. CONCLUSION There was no difference in short- or long-term mortality following emergency general surgery at the weekend, compared with mid-week.
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Affiliation(s)
- M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Surgical and Perioperative Health Research (SPHeRe), University of Edinburgh, Edinburgh, UK
| | - N I Lone
- Centre for Population and Health Sciences, University of Edinburgh, Edinburgh, UK
| | - R M Pearse
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - C Haddow
- Information Services Division, NHS Services Scotland, South Gyle, Edinburgh, UK
| | - L Smyth
- Information Services Division, NHS Services Scotland, South Gyle, Edinburgh, UK
| | - R W Parks
- Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - T S Walsh
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - E M Harrison
- Surgical and Perioperative Health Research (SPHeRe), University of Edinburgh, Edinburgh, UK.,Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
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45
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Kean S, Salisbury LG, Rattray J, Walsh TS, Huby G, Ramsay P. ‘Intensive care unit survivorship’ - a constructivist grounded theory of surviving critical illness. J Clin Nurs 2017; 26:3111-3124. [DOI: 10.1111/jocn.13659] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2016] [Indexed: 12/23/2022]
Affiliation(s)
- Susanne Kean
- School of Health in Social Science; Nursing Studies; The University of Edinburgh; Edinburgh UK
| | - Lisa G Salisbury
- School of Health in Social Science; Nursing Studies; The University of Edinburgh; Edinburgh UK
| | - Janice Rattray
- School of Nursing & Midwifery; University of Dundee; Dundee UK
| | - Timothy S Walsh
- School of Clinical Science; Queens Medical Research Institute; The University of Edinburgh; Edinburgh UK
| | - Guro Huby
- Faculty of Health and Social Studies; Østfold University College; Halden Norway
| | - Pamela Ramsay
- School of Nursing; Midwifery & Social Care; Edinburgh Napier University; Edinburgh UK
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46
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McNamee JJ, Gillies MA, Barrett NA, Agus AM, Beale R, Bentley A, Bodenham A, Brett SJ, Brodie D, Finney SJ, Gordon AJ, Griffiths M, Harrison D, Jackson C, McDowell C, McNally C, Perkins GD, Tunnicliffe W, Vuylsteke A, Walsh TS, Wise MP, Young D, McAuley DF. pRotective vEntilation with veno-venouS lung assisT in respiratory failure: A protocol for a multicentre randomised controlled trial of extracorporeal carbon dioxide removal in patients with acute hypoxaemic respiratory failure. J Intensive Care Soc 2016; 18:159-169. [PMID: 28979565 DOI: 10.1177/1751143716681035] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
One of the few interventions to demonstrate improved outcomes for acute hypoxaemic respiratory failure is reducing tidal volumes when using mechanical ventilation, often termed lung protective ventilation. Veno-venous extracorporeal carbon dioxide removal (vv-ECCO2R) can facilitate reducing tidal volumes. pRotective vEntilation with veno-venouS lung assisT (REST) is a randomised, allocation concealed, controlled, open, multicentre pragmatic trial to determine the clinical and cost-effectiveness of lower tidal volume mechanical ventilation facilitated by vv-ECCO2R in patients with acute hypoxaemic respiratory failure. Patients requiring intubation and mechanical ventilation for acute hypoxaemic respiratory failure will be randomly allocated to receive either vv-ECCO2R and lower tidal volume mechanical ventilation or standard care with stratification by recruitment centre. There is a need for a large randomised controlled trial to establish whether vv-ECCO2R in acute hypoxaemic respiratory failure can allow the use of a more protective lung ventilation strategy and is associated with improved patient outcomes.
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Affiliation(s)
- J J McNamee
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
| | - M A Gillies
- Department of Anaesthesia, Critical Care and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK.,Chief Scientists Office NHS Research Scotland, Clydebank, UK
| | - N A Barrett
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.,King's Health Partners Academic Health Science Centre, London, UK
| | - A M Agus
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - R Beale
- Guy's and St Thomas' NHS Foundation Trust, King's College London, UK.,King's Health Partners Academic Health Science Centre, London, UK
| | - A Bentley
- Acute Intensive Care Unit, University Hospital of South Manchester NHS Foundation Trust, Manchester, UK.,Centre for Respiratory Medicine & Allergy, University of Manchester, UK
| | - A Bodenham
- Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, UK
| | - S J Brett
- Centre for Perioperative Medicine and Critical Care Research, Imperial College Healthcare NHS Trust, London, UK
| | - D Brodie
- Columbia College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, USA
| | - S J Finney
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - A J Gordon
- Section of Anaesthetics, Pain Medicine and Intensive Care, Imperial College London, Imperial College Healthcare NHS Trust, London, UK
| | - M Griffiths
- National Heart & Lung Institute, Imperial College, London, UK.,National Institute for Health Research Respiratory Biomedical Research Unit, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | - D Harrison
- Intensive Care National Audit and Research Centre, London, UK
| | - C Jackson
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - C McDowell
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - C McNally
- Northern Ireland Clinical Trials Unit, The Royal Hospitals, Belfast, UK
| | - G D Perkins
- Warwick Clinical Trials Unit, University of Warwick, Coventry, UK.,Heart of England NHS Foundation Trust, Birmingham, UK
| | - W Tunnicliffe
- University Hospitals Birmingham NHS Foundation Trust, UK
| | - A Vuylsteke
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - T S Walsh
- Anaesthetics, Critical Care and Pain Medicine, School of Clinical Sciences, College of Medicine, Edinburgh University, Edinburgh, UK
| | - M P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - D Young
- Kadoorie Centre for Critical Care Research and Education, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - D F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast Health and Social Care Trust, Belfast, UK.,Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Wellcome Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK
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47
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Conway Morris A, Gadsby N, McKenna JP, Hellyer TP, Dark P, Singh S, Walsh TS, McAuley DF, Templeton K, Simpson AJ, McMullan R. 16S pan-bacterial PCR can accurately identify patients with ventilator-associated pneumonia. Thorax 2016; 72:1046-1048. [PMID: 27974525 PMCID: PMC5738539 DOI: 10.1136/thoraxjnl-2016-209065] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2016] [Revised: 09/10/2016] [Accepted: 10/01/2016] [Indexed: 11/23/2022]
Abstract
Ventilator-associated pneumonia (VAP) remains a challenge to intensive care units, with secure diagnosis relying on microbiological cultures that take up to 72 hours to provide a result. We sought to derive and validate a novel, real-time 16S rRNA gene PCR for rapid exclusion of VAP. Bronchoalveolar lavage (BAL) was obtained from two independent cohorts of patients with suspected VAP. Patients were recruited in a 2-centre derivation cohort and a 12-centre confirmation cohort. Confirmed VAP was defined as growth of >104 colony forming units/ml on semiquantitative culture and compared with a 16S PCR assay. Samples were tested from 67 patients in the derivation cohort, 10 (15%) of whom had confirmed VAP. Using cycles to cross threshold (Ct) values as the result of the 16S PCR test, the area under the receiver operating characteristic (ROC) curve (AUROC) was 0.94 (95% CI 0.86 to 1.0, p<0.0001). Samples from 92 patients were available from the confirmation cohort, 26 (28%) of whom had confirmed VAP. The AUROC for Ct in this cohort was 0.89 (95% CI 0.83 to 0.95, p<0.0001). This study has derived and assessed the diagnostic accuracy of a novel application for 16S PCR. This suggests that 16S PCR in BAL could be used as a rapid test in suspected VAP and may allow better stewardship of antibiotics.
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Affiliation(s)
- Andrew Conway Morris
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK.,Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Naomi Gadsby
- Department of Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - James P McKenna
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK
| | - Thomas P Hellyer
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Paul Dark
- Institute of Inflammation and Repair, University of Manchester, Manchester Academic Health Sciences Centre, Manchester, UK.,Intensive Care Unit, Salford Royal NHS Foundation Trust, Greater Manchester, UK
| | - Suveer Singh
- Intensive Care Unit, Chelsea and Westminster Hospital, Imperial College London, London, UK
| | - Timothy S Walsh
- Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
| | - Danny F McAuley
- Centre for Infection and Immunity, Queen's University Belfast, UK.,Intensive Care Unit, Royal Victoria Infirmary, Belfast, UK
| | - Kate Templeton
- Department of Clinical Microbiology, NHS Lothian, Edinburgh, UK
| | - A John Simpson
- Institute of Cellular Medicine, Newcastle University, Newcastle, UK
| | - Ronan McMullan
- Department of Microbiology, Belfast Health & Social Care Trust, Belfast, UK.,Centre for Infection and Immunity, Queen's University Belfast, UK
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48
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Connolly B, Salisbury L, O'Neill B, Geneen L, Douiri A, Grocott MPW, Hart N, Walsh TS, Blackwood B. Exercise rehabilitation following intensive care unit discharge for recovery from critical illness: executive summary of a Cochrane Collaboration systematic review. J Cachexia Sarcopenia Muscle 2016; 7:520-526. [PMID: 27891297 PMCID: PMC5114628 DOI: 10.1002/jcsm.12146] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2016] [Accepted: 08/02/2016] [Indexed: 01/26/2023] Open
Abstract
Skeletal muscle wasting and weakness are major complications of critical illness and underlie the profound physical and functional impairments experienced by survivors after discharge from the intensive care unit (ICU). Exercise-based rehabilitation has been shown to be beneficial when delivered during ICU admission. This review aimed to determine the effectiveness of exercise rehabilitation initiated after ICU discharge on primary outcomes of functional exercise capacity and health-related quality of life. We sought randomized controlled trials, quasi-randomized controlled trials, and controlled clinical trials comparing an exercise intervention commenced after ICU discharge vs. any other intervention or a control or 'usual care' programme in adult survivors of critical illness. Cochrane Central Register of Controlled Trials, Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica Database, and Cumulative Index to Nursing and Allied Health Literature databases were searched up to February 2015. Dual, independent screening of results, data extraction, and quality appraisal were performed. We included six trials involving 483 patients. Overall quality of evidence for both outcomes was very low. All studies evaluated functional exercise capacity, with three reporting positive effects in favour of the intervention. Only two studies evaluated health-related quality of life and neither reported differences between intervention and control groups. Meta-analyses of data were precluded due to variation in study design, types of interventions, and selection and reporting of outcome measurements. We were unable to determine an overall effect on functional exercise capacity or health-related quality of life of interventions initiated after ICU discharge for survivors of critical illness. Findings from ongoing studies are awaited. Future studies need to address methodological aspects of study design and conduct to enhance rigour, quality, and synthesis.
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Affiliation(s)
- Bronwen Connolly
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | - Lisa Salisbury
- Edinburgh Critical Care Research Group MRC Centre for Inflammation ResearchUniversity of EdinburghEdinburghUK
| | - Brenda O'Neill
- Institute of Nursing and Health Research, School of Health SciencesUlster UniversityNewtownabbeyUK
| | - Louise Geneen
- School of Medicine, College of Medicine, Dentistry, and NursingUniversity of DundeeDundeeUK
| | - Abdel Douiri
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
- Department of Public Health Sciences, Division of Health and Social Care ResearchKing's College LondonLondonUK
| | - Michael P. W. Grocott
- Integrative Physiology and Critical Illness Group, Clinical and Experimental SciencesUniversity of SouthamptonSouthamptonUK
- Critical Care Research AreaSouthampton NIHR Respiratory Biomedical Research UnitSouthamptonUK
- Anaesthesia and Critical Care Research UnitUniversity Hospital Southampton NHS Foundation TrustSouthamptonUK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Research UnitGuy's and St Thomas' NHS Foundation TrustLondonUK
- Division of Asthma, Allergy, and Lung BiologyKing's College LondonLondonUK
- National Institute of Health Research Biomedical Research CentreGuy's and St Thomas' NHS Foundation Trust and King's College LondonLondonUK
| | | | - Bronagh Blackwood
- Health Sciences, School of Medicine, Dentistry, and Biomedical Sciences, Centre for Infection and ImmunityQueen's University BelfastBelfastUK
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49
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Dorward DA, Felton JM, Robb CT, Craven T, Kipari T, Walsh TS, Haslett C, Kefala K, Rossi AG, Lucas CD. The cyclin-dependent kinase inhibitor AT7519 accelerates neutrophil apoptosis in sepsis-related acute respiratory distress syndrome. Thorax 2016; 72:182-185. [PMID: 27965411 PMCID: PMC5284332 DOI: 10.1136/thoraxjnl-2016-209229] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2016] [Revised: 09/13/2016] [Accepted: 09/21/2016] [Indexed: 02/04/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is a neutrophil-dominant disorder with no effective pharmacological therapies. While the cyclin-dependent kinase inhibitor AT7519 induces neutrophil apoptosis to promote inflammation resolution in preclinical models of lung inflammation, its potential efficacy in ARDS has not been examined. Untreated peripheral blood sepsis-related ARDS neutrophils demonstrated prolonged survival after 20 hours in vitro culture. AT7519 was able to override this phenotype to induce apoptosis in ARDS neutrophils with reduced expression of the pro-survival protein Mcl-1. We demonstrate the first pharmacological compound to induce neutrophil apoptosis in sepsis-related ARDS, highlighting cyclin-dependent kinase inhibitors as potential novel therapeutic agents.
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Affiliation(s)
- David A Dorward
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Jennifer M Felton
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Calum T Robb
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Thomas Craven
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Tiina Kipari
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Timothy S Walsh
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK.,Department of Critical Care, Anaesthesia and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Christopher Haslett
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Kallirroi Kefala
- Department of Critical Care, Anaesthesia and Pain Medicine, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Adriano G Rossi
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
| | - Christopher D Lucas
- The MRC Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, UK
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50
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Hall DP, Estcourt LJ, Doree C, Hopewell S, Trivella M, Walsh TS. Plasma transfusions prior to insertion of central lines for people with abnormal coagulation. Cochrane Database Syst Rev 2016; 9:CD011756. [PMID: 27647489 PMCID: PMC5215106 DOI: 10.1002/14651858.cd011756.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
BACKGROUND The insertion of central venous catheters (CVCs) may be associated with peri- and post-procedural bleeding. People who require a central line often have disorders of coagulation as a result of their underlying illness, co-morbidities or the effects of treatment. Clinical practice in some institutions is to mitigate the risk of bleeding in these patients by prophylactically transfusing fresh frozen plasma (FFP) in order to correct clotting factor deficiencies prior to central line insertion. However, FFP transfusion is not without risk, and it remains unclear whether this intervention is associated with reduced rates of bleeding or other clinically-meaningful outcomes. OBJECTIVES To assess the effect of different prophylactic plasma transfusion regimens prior to central line insertion in people with abnormal coagulation. SEARCH METHODS We searched for randomised controlled trials (RCTs) in the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library 2016, Issue 3), PubMed (e-publications only), Ovid MEDLINE (from 1946), Ovid Embase (from 1974), the Transfusion Evidence Library (from 1950) and ongoing trial databases to 1 March 2016. SELECTION CRITERIA We included RCTs involving transfusions of plasma to prevent bleeding in people of any age with abnormal coagulation requiring insertion of a central venous catheter, published in English. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We identified four trials eligible for inclusion, of which three are ongoing. We did not exclude any studies because they were not published in English.The included study randomised 81 adults in intensive care whose INR (International Normalised Ratio) was greater than or equal to 1.5 to no FFP or to a single dose of 12 mL/kg FFP prior to undergoing central venous catheterisation (58 participants) or other invasive procedure (23 participants). It is the subgroup of 58 adults undergoing CVC insertion that were included in this review, the study authors provided unpublished data for this review's outcomes.The quality of the evidence was low or very low across different outcomes according to the GRADE methodology. The included study was at high risk of bias due to lack of blinding of participants and personnel and imbalance in the number of participants who had liver disease between study arms.There was insufficient evidence to determine a difference in major procedure-related bleeding within 24 hours (one RCT; 58 participants; no events in either study arm, very low-quality evidence). We are very uncertain whether FFP reduces minor procedure-related bleeding within 24 hours of the study (one RCT; 58 participants, RR 0.67, 95% CI 0.12 to 3.70, very low-quality evidence).No studies were found that looked at: all-cause mortality; the proportion of participants receiving plasma or red cell transfusions; serious adverse reactions (transfusion or line-related complications); number of days in hospital; change in INR; or quality of life.The three ongoing studies are still recruiting participants (expected recruitment: up to 355 participants in total). and are due to be completed by February 2018. AUTHORS' CONCLUSIONS There is only very limited evidence from one RCT to inform the decision whether or not to administer prophylactic plasma prior to central venous catheterisation for people with abnormal coagulation. It is not possible from the current RCT evidence to recommend whether or not prophylactic plasma transfusion is beneficial or harmful in this situation. The three ongoing RCTs will not be able to answer this review's questions, because they are small studies and do not address all of the comparisons included in this review (355 participants in total). To detect an increase in the proportion of participants who had major bleeding from 1 in 100 to 2 in 100 would require a study containing at least 4634 participants (80% power, 5% significance).
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Affiliation(s)
- David P Hall
- NHS LothianCritical Care and AnaestheticsRoyal Infirmary of EdinburghEdinburghUKEH16 4SA
| | - Lise J Estcourt
- NHS Blood and TransplantHaematology/Transfusion MedicineLevel 2, John Radcliffe HospitalHeadingtonOxfordUKOX3 9BQ
| | - Carolyn Doree
- NHS Blood and TransplantSystematic Review InitiativeJohn Radcliffe HospitalOxfordUKOX3 9BQ
| | - Sally Hopewell
- University of OxfordOxford Clinical Trials Research UnitNuffield Department of Orthopaedics, Rheumatology and Musculoskeletal SciencesWindmill RoadOxfordOxfordshireUKOX3 7LD
| | - Marialena Trivella
- University of OxfordCentre for Statistics in MedicineBotnar Research CentreWindmill RoadOxfordUKOX3 7LD
| | - Timothy S Walsh
- Edinburgh Royal InfirmaryLittle France CrescentEdinburghUKEH16 2SA
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