Showing papers by "Deborah J. Cook published in 2008"
TL;DR: Low-dose vasopressin did not reduce mortality rates as compared with norepinephrine among patients with septic shock who were being treated with conventional (catecholamine) vasopressesors, and a test for heterogeneity between these two study strata was not significant.
Abstract: Background Vasopressin is commonly used as an adjunct to catecholamines to support blood pressure in refractory septic shock, but its effect on mortality is unknown. We hypothesized that low-dose vasopressin as compared with norepinephrine would decrease mortality among patients with septic shock who were being treated with conventional (catecholamine) vasopressors. Methods In this multicenter, randomized, double-blind trial, we assigned patients who had septic shock and were receiving a minimum of 5 μg of norepinephrine per minute to receive either low-dose vasopressin (0.01 to 0.03 U per minute) or norepinephrine (5 to 15 μg per minute) in addition to open-label vasopressors. All vasopressor infusions were titrated and tapered according to protocols to maintain a target blood pressure. The primary end point was the mortality rate 28 days after the start of infusions. Results A total of 778 patients underwent randomization, were infused with the study drug (396 patients received vasopressin, and 382 norepinephrine), and were included in the analysis. There was no significant difference between the vasopressin and norepinephrine groups in the 28-day mortality rate (35.4% and 39.3%, respectively; P = 0.26) or in 90-day mortality (43.9% and 49.6%, respectively; P = 0.11). There were no significant differences in the overall rates of serious adverse events (10.3% and 10.5%, respectively; P = 1.00). In the prospectively defined stratum of less severe septic shock, the mortality rate was lower in the vasopressin group than in the norepinephrine group at 28 days (26.5% vs. 35.7%, P = 0.05); in the stratum of more severe septic shock, there was no significant difference in 28-day mortality (44.0% and 42.5%, respectively; P = 0.76). A test for heterogeneity between these two study strata was not significant (P = 0.10). Conclusions Low-dose vasopressin did not reduce mortality rates as compared with norepinephrine among patients with septic shock who were treated with catecholamine vasopressors. (Current Controlled Trials number, ISRCTN94845869.)
1,385 citations
TL;DR: For patients with acute lung injury and acute respiratory distress syndrome, a multifaceted protocolized ventilation strategy designed to recruit and open the lung resulted in no significant difference in all-cause hospital mortality or barotrauma compared with an established low-tidal-volume protocolized breathing strategy.
Abstract: Context Low-tidal-volume ventilation reduces mortality in critically ill patients with acute lung injury and acute respiratory distress syndrome. Instituting additional strategies to open collapsed lung tissue may further reduce mortality. Objective To compare an established low-tidal-volume ventilation strategy with an experimental strategy based on the original “open-lung approach,” combining low tidal volume, lung recruitment maneuvers,
and high positive-end–expiratory pressure. Design and Setting Randomized controlled trial with concealed allocation and blinded data analysis conducted between August 2000 and March 2006 in 30 intensive care units in Canada, Australia, and Saudi Arabia. Patients Nine hundred eighty-three consecutive patients with acute lung injury and a ratio of arterial oxygen tension to inspired oxygen fraction not exceeding 250. Interventions The control strategy included target tidal volumes of 6 mL/kg of predicted body weight, plateau airway pressures not exceeding 30
cm H 2 O, and conventional levels of positive end-expiratory pressure (n = 508). The experimental strategy included target tidal volumes of 6 mL/kg of predicted body weight, plateau pressures not exceeding 40 cm H 2 O, recruitment maneuvers, and higher positive end-expiratory pressures (n = 475). Main Outcome Measure All-cause hospital mortality. Results Eighty-five percent of the 983 study patients met criteria for acute respiratory distress syndrome at enrollment. Tidal volumes remained similar in the 2 groups, and mean positive end-expiratory pressures were 14.6 (SD, 3.4) cm H 2 O in the experimental group vs 9.8 (SD, 2.7) cm H 2 O among controls during the first 72
hours (P < .001). All-cause hospital mortality rates were 36.4% and 40.4%, respectively (relative risk [RR], 0.90; 95% confidence interval [CI], 0.77-1.05; P = .19). Barotrauma rates were 11.2%
and 9.1% (RR, 1.21; 95% CI, 0.83-1.75; P = .33).
The experimental group had lower rates of refractory hypoxemia (4.6%
vs 10.2%; RR, 0.54; 95% CI, 0.34-0.86; P = .01),
death with refractory hypoxemia (4.2% vs 8.9%; RR, 0.56; 95% CI, 0.34-0.93; P = .03), and previously defined eligible use of rescue therapies (5.1% vs 9.3%; RR, 0.61; 95% CI, 0.38-0.99; P = .045). Conclusions For patients with acute lung injury and acute respiratory distress syndrome, a multifaceted protocolized ventilation strategy designed to recruit and open the lung resulted in no significant difference in all-cause hospital mortality or barotrauma compared with an established low-tidal-volume protocolized ventilation strategy. This “open-lung”
strategy did appear to improve secondary end points related to hypoxemia and use of rescue therapies. Trial Registration clinicaltrials.gov Identifier: NCT00182195
1,243 citations
TL;DR: The aim of a survey is to gather reliable and unbiased data from a representative sample of respondents to help investigators administer questionnaires to clinicians about clinical practice.
Abstract: Survey research is an important form of scientific inquiry[1][1] that merits rigorous design and analysis.[2][2] The aim of a survey is to gather reliable and unbiased data from a representative sample of respondents.[3][3] Increasingly, investigators administer questionnaires to clinicians about
1,024 citations
TL;DR: There are a growing number of evidence-based strategies for VAP prevention, which, if applied in practice, may reduce the incidence of this serious nosocomial infection.
281 citations
TL;DR: This chapter describes the system used by the American College of Chest Physicians to grade recommendations for antithrombotic and thrombolytic therapy as part of the AntithromBotic and Thromboleytic Therapy: Evidence-Based Clinical Practice Guidelines (8th Edition).
192 citations
TL;DR: For critically ill patients who have suspected late ventilator-associated pneumonia and who are at low risk for difficult-to-treat Gram-negative bacteria, monotherapy is associated with similar outcomes compared with combination therapy and combination therapy is safe and may be associated with better microbiological and clinical outcomes.
Abstract: Objective:To compare a strategy of combination therapy with a strategy of monotherapy with broad-spectrum antibiotics for suspected late ventilator-associated pneumonia.Design:Randomized trial.Setting:Twenty-eight intensive care units in Canada and the United States.Patients:The study included 740 m
188 citations
TL;DR: In critically ill patients with severe renal insufficiency, DVT prophylaxis with dalteparin sodium, 5000 IU once daily, is not associated with an excessive anticoagulant effect due to drug bioaccumulation and is unlikely to contribute to bleeding.
Abstract: Background Use of low-molecular-weight heparins is avoided in patients with renal insufficiency because of concerns about an excessive anticoagulant effect and increased bleeding risk. To challenge this premise, we evaluated if deep vein thrombosis (DVT) prophylaxis with dalteparin sodium confers an excessive anticoagulant effect in critically ill patients with severe renal insufficiency. Methods We conducted a multicenter, single-arm clinical trial of DVT prophylaxis with dalteparin sodium, 5000 IU once daily in critically ill patients with a creatinine clearance lower than 30 mL/min (to convert to milliliters per second, multiply by 0.0167). Bioaccumulation was defined by a trough anti-Xa level higher than 0.40 IU/mL, measured twice weekly. The pharmacodynamic properties of dalteparin were assessed by serial anti-Xa levels measured on days 3, 10, and 17. Results We enrolled 156 patients with a mean (SD) creatinine clearance of 18.9 (6.5) mL/min; 18 were excluded because they died or were discharged before testing (n = 3) or had prevalent DVT (n = 15). Of 138 patients included, the median (interquartile range [IQR]) duration of dalteparin exposure was 7 (4-12) days. In 120 patients who had at least 1 trough anti-Xa level (427 total measurements), no patient had bioaccumulation (0%; 95% confidence interval [CI]: 0%-3.0%); the median (IQR) trough anti-Xa level was undetectable ( Conclusion In critically ill patients with severe renal insufficiency, DVT prophylaxis with dalteparin sodium, 5000 IU once daily, is not associated with an excessive anticoagulant effect due to drug bioaccumulation and is unlikely to contribute to bleeding. Trial Registration clinicaltrials.gov Identifier:NCT00138099
153 citations
TL;DR: Evidence-based recommendations for the diagnosis and treatment of Ventilator-associated pneumonia are presented and implementation of these recommendations into clinical practice may lessen the morbidity and mortality of patients who develop VAP.
152 citations
TL;DR: In this patient population, the incidence of high-risk organisms newly acquired during an ICU stay is low, however, the presence of high risk pathogens is associated with worse clinical outcomes.
131 citations
TL;DR: This pilot trial comparing PS vs. PS + DI confirmed the safety and acceptability of the sedation protocol and DI, and guided important modifications to the protocol, thus enhancing the feasibility of a future multicenter trial.
Abstract: Objective:Protocolized sedation (PS) and daily sedative interruption (DI) in critically ill patients have both been shown to shorten the durations of mechanical ventilation (MV) and intensive care unit (ICU) stay. Our objective was to determine the safety and feasibility of a randomized trial to det
115 citations
TL;DR: The meta-analysis found no differences in mortality in patients with cancer receiving perioperative thromboprophylaxis with LMWH vs UFH, and further trials are needed to more carefully evaluate the benefits and harms of different heparin thromBopophylaxis strategies in this population.
Abstract: Background The relative benefits and harms of low-molecular-weight heparin (LMWH) and unfractionated heparin (UFH) are required for judgments regarding the appropriate perioperative thromboprophylaxis in patients with cancer. We systematically reviewed the literature to quantify these effects. Methods The comprehensive searches included (1) an electronic search of MEDLINE, EMBASE, ISI the Web of Science, and CENTRAL (The Cochrane Central Register of Controlled Trials); (2) a hand search of relevant conference proceedings; (3) a reference check of included trials; and (4) use of the PubMed “Related Articles” feature. Outcomes of interest included mortality, deep venous thrombosis, pulmonary embolism, bleeding complications, and thrombocytopenia. Results Of 3986 identified citations, we included 14 randomized clinical trials in the meta-analysis (all using preoperative prophylactic anticoagulation). The overall methodological quality was moderate. The meta-analysis showed no differences in mortality in patients receiving LMWH compared with UFH (relative risk [RR], 0.89; 95% confidence interval [CI], 0.61-1.28) or in clinically suspected deep venous thrombosis (RR, 0.73; 95% CI, 0.23-2.28). In a post hoc analysis including all studies assessing deep venous thrombosis, irrespective of the diagnostic strategy used, LMWH was superior to UFH (RR, 0.72; 95% CI, 0.55-0.94). There were no differences in rates of pulmonary embolism (RR, 0.60; 95% CI, 0.22-1.64), minor bleeding (RR, 0.88; 95% CI, 0.47-1.66), or major bleeding (RR, 0.95; 95% CI, 0.51-1.77). Conclusions We found no differences in mortality in patients with cancer receiving perioperative thromboprophylaxis with LMWH vs UFH. Further trials are needed to more carefully evaluate the benefits and harms of different heparin thromboprophylaxis strategies in this population.
TL;DR: The objective of this systematic review was to determine the efficacy and safety of anticoagulation in reducing mortality and thromboembolic events in cancer patients with a CVC.
Abstract: BACKGROUND.
Central venous catheter (CVC) placement increases the risk of thrombosis and subsequent death in patients with cancer. The objective of this systematic review was to determine the efficacy and safety of anticoagulation in reducing mortality and thromboembolic events in cancer patients with a CVC.
METHODS.
The authors searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and ISI the Web of Science databases. They included randomized controlled trials in patients with cancer comparing unfractionated heparin (UFH), low-molecular-weight heparin (LMWH), vitamin K antagonists, fondaparinux, or ximelagatran with no intervention, placebo, or each other. The standard methods of the Cochrane Collaboration were used for the analyses.
RESULTS.
Of 3986 identified citations we included 9 randomized clinical trials, none of which evaluated fondaparinux or ximelagatran. Heparin therapy (UFH or LMWH) was associated with a trend toward a reduction in symptomatic deep venous thrombosis (DVT) (relative risk (RR), 0.43; 95% confidence interval (95% CI), 0.18–1.06), but there was no statistically significant effect on mortality (RR, 0.74; 95% CI, 0.40–1.36), infection (RR, 0.91; 95% CI, 0.36–2.28), major bleeding (RR, 0.68; 95% CI, 0.10–4.78), or thrombocytopenia (RR, 0.85; 95% CI, 0.49–1.46). The effect of warfarin on symptomatic DVT also was not statistically significant (RR, 0.62; 95% CI, 0.30–1.27).
CONCLUSIONS.
The balance of benefits and downsides of thromboprophylaxis in cancer patients with CVC are uncertain. Clinicians together with their patients must weigh these factors carefully when making decisions regarding thromboprophylaxis. Cancer 2008. © 2008 American Cancer Society.
TL;DR: In ICU patients with renal insufficiency, the incidence of DVT and major bleeding are considerable but appear related to patient comorbidities rather than to an inadequate or excessive anticoagulant from thromboprophylaxis with dalteparin.
Abstract: Background
Critically ill patients with renal insufficiency are predisposed to both deep vein thrombosis (DVT) and bleeding. The objective of the present study was to evaluate the prevalence, incidence and predictors of DVT and the incidence of bleeding in intensive care unit (ICU) patients with estimated creatinine clearance <30 ml/min.
Journal Article•
TL;DR: The results do not support the addition of scheduled RMs to usual treatment for ALI or ARDS and the findings precluded analyses about predictors of response or consistency of response.
Abstract: OBJECTIVE: To determine the magnitude, duration, and consistency of the effects of lung recruitment maneuvers (RMs) on oxygenation, lung mechanics, and comfort in patients with acute lung injury (ALI) and acute respiratory distress syndrome (ARDS).
METHODS: We conducted a prospective physiologic study at 3 tertiary-care hospitals. We enrolled 28 consecutive eligible patients with ARDS or ALI and a ratio of PaO2 to fraction of inspired oxygen (PaO2/FIO2) ≤ 250 mm Hg while receiving FIO2 ≥ 0.50. We performed RMs twice daily for 3 days. The first RM was at 35 cm H2O for 20 s. If initial response was equivocal, the clinician immediately administered another RM at a higher pressure (40 cm H2O, then 45 cm H2O) or for longer period (30 s, then 40 s), in a randomized order. Each patient had up to 6 sets of up to 3 RMs.
RESULTS: Twenty-seven patients met the criteria for ARDS at baseline; 1 had ALI. There was no net effect on oxygenation or pulmonary mechanics following the first or subsequent RMs. The largest rise in PaO2 was from 61 mm Hg to 71 mm Hg, and the largest decrease was 6 mm Hg following the first RM. Augmenting the inflation pressure or duration had no significant effect. These findings precluded analyses about predictors of response or consistency of response. Over the entire study of 122 RMs, 5 patients developed ventilator asynchrony, 3 appeared uncomfortable, 2 experienced transient hypotension, and 4 developed barotrauma that required intervention.
CONCLUSIONS: These results do not support the addition of scheduled RMs to usual treatment for ALI or ARDS.
TL;DR: The American College of Chest Physicians (ACCP) as mentioned in this paper developed the eighth edition of ACCP evidence-based guidelines on antithrombotic and thrombolytic therapy.
TL;DR: Although it might be ideal to have a single system for defining and reporting serious adverse events that would be applicable to both academic trials investigating established drugs and industry-sponsored trials of novel pharmaceutical agents, such a system would be unlikely to satisfy all.
Abstract: Although it might be ideal to have a single system for defining and reporting serious adverse events that would be applicable to both academic trials investigating established drugs and industry-sponsored trials of novel pharmaceutical agents, such a system would be unlikely to satisfy all
TL;DR: There remain large gaps in understanding of guideline implementation in the intensive care unit, specifically as it applies to guidelines for the prevention, diagnosis, and treatment of VAP.
TL;DR: For patients with do-not-resuscitate orders, many physicians use NIV, and many RTs are asked to initiate NIV; most often to treat chronic obstructive pulmonary disease and cardiogenic pulmonary edema.
Abstract: Rationale:For patients with acute respiratory failure who have declined intubation and resuscitation or have chosen comfort measures only, noninvasive ventilation (NIV) may help them achieve important health or personal goals, or merely prolong the dying process.Objective:To determine clinicians’ at
TL;DR: Strategies to increase capacity involve enhancing recruitment efficiencies, considering alternative study designs and expanding consent procedures, and thoughtfully implementing these strategies may advance the care of critically ill adults and children.
Abstract: Deborah J. Cook, David Blythe, Amanda Rischbieth, Paul C. Hebert, Nicole Zytaruk, Kusum Menon, Simon Erikson, Robert Fowler, Diane Heels-Ansdell, Maureen O. Meade
TL;DR: Methods to improve recruitment are required to enhance the feasibility of conducting a multicentre fluid resuscitation trial in early septic shock, and resuscitation algorithms were acceptable to most physicians.
Abstract: Background: It is unknown whether fluid resuscitation with colloid or crystalloid in patients with severe sepsis or septic shock is associated with an improvement in clinical outcome. This randomized controlled trial determined the feasibility of conducting a large trial testing resuscitation with pentastarchvs normal saline in early septic shock, powered for a difference in mortality.
TL;DR: Pretest probability and a modified CPIS, which excludes culture results, are of limited utility in the diagnosis of late-onset ventilator-associated pneumonia.
TL;DR: Systematic screening detected elevated cardiac troponin measurements and MI in more patients than were found in routine practice, and Elevated cTn was an independent predictor of hospital mortality.
Abstract: To use screening cardiac troponin (cTn) measurements and electrocardiograms (ECGs) to determine the incidence of elevated cTn and of myocardial infarction (MI) in patients admitted to the intensive care unit (ICU), and to assess whether these findings influence prognosis. This is a prospective screening study. We enrolled consecutive patients admitted to a general medical-surgical ICU over two months. All patients underwent systematic screening with cTn measurements and ECGs on ICU admission, then daily for the first week in ICU, alternate days for up to one month and weekly thereafter until ICU death or discharge, for a maximum of two months. Patients without these investigations ordered during routine clinical care underwent screening for study purposes but these results were unavailable to the ICU team. After the study, all ECGs were interpreted independently in duplicate for ischaemic changes meeting ESC/ACC criteria supporting a diagnosis of MI. Patients were classified as having MI (elevated cTn and ECG evidence supporting diagnosis of MI), elevated cTn only (no ECG evidence supporting diagnosis of MI), or no cTn elevation. One hundred and three patients were admitted to the ICU on 112 occasions. Overall, 37 patients (35.9 per cent) had an MI, 15 patients (14.6 per cent) had an elevated cTn only and 51 patients (49.5 per cent) had no cTn elevation. Patients with MI had longer duration of mechanical ventilation (p < 0.0001), longer ICU stay (p = 0.001), higher ICU mortality (p < 0.0001) and higher hospital mortality (p < 0.0001) compared with those with no cTn elevation. Patients with elevated cTn had higher hospital mortality (p = 0.001) than patients without cTn elevation. Elevated cTn was associated with increased hospital mortality (odds ratio 27.3, 95 per cent CI 1.7 – 449.4), after adjusting for APACHE II score, MI and advanced life support. The ICU team diagnosed 18 patients (17.5 per cent) as having MI on clinical grounds; four of these patients did not have MI by adjudication. Thus, screening detected an additional 23 MIs not diagnosed in practice, reflecting 62.2 per cent of MIs ultimately diagnosed. Patients with MI diagnosed by the ICU team had similar outcomes to patients with MI detected by screening alone. Systematic screening detected elevated cTn measurements and MI in more patients than were found in routine practice. Elevated cTn was an independent predictor of hospital mortality. Further research is needed to evaluate whether screening and subsequent treatment of these patients reduces mortality.
TL;DR: The overall quality of critical care professional society guidelines and consensus statements, as assessed by three published quality instruments, is low and there is room for improvement, which could help facilitate knowledge translation and improve patient care in the intensive care unit.
Abstract: Objective:To examine the quality of professional society critical care guidelines and consensus statements.Data Source:MEDLINE, EMBASE, Cochrane Library (to May 2007), conference proceedings (1990 to May 2007), and personal files.Study Selection:We considered documents focused on 1) mechanical venti
TL;DR: Clinical characteristics correlate with eventual outcomes in VAP and it is suggested that clinicians follow these measures and consider integrating them in their decisions as to when to reevaluate persons with VAP who are not improving.
TL;DR: Six specific challenges associated with randomized clinical trials in vulnerable populations are identified and several potential solutions to overcome these challenges are suggested.
Abstract: Many persons enrolled in clinical trials can be considered vulnerable, and such trials often raise concerns because of the diminished ability of vulnerable persons to consider and protect their own interests. However, this research is necessary to answer important questions, such as which interventions are effective, which have no impact, and which do more harm than good. In this article, we identified six specific challenges associated with randomized clinical trials in vulnerable populations and have suggested several potential solutions to overcome these challenges. First addressed were macro issues, such as the scope of the problem, and research capacity in terms of funding and investigators. Next, we have addressed research ethics review, informed consent, regulatory hurdles, and serious adverse event reporting. As clinical trials are expanding globally, all stakeholders (investigators, granting agencies, REBs, DSMBs, regulatory bodies, universities, hospitals, clinicians, patients, and family members) should be aware of the challenges we have outlined, and work collaboratively toward effective solutions that improve the quality, quantity, safety, and relevance of clinical trials for vulnerable persons around the world.
TL;DR: Multidisciplinary, multimethod approaches to improving hand hygiene are likely necessary to improve the modest adherence to hand hygiene that is observed in ICU clinicians.
Abstract: Introduction Adherence to hand hygiene recommendations in the intensive care unit (ICU) is variable and moderate, at best. Objectives To measure adherence to hand hygiene recommendations among ICU clinicians in a prospective observational study in 6 multidisciplinary ICUs among 4 hospitals. Patients and methods We observed 115 clinicians (64 nurses, 21 respiratory therapists, 18 residents and 12 physicians) during 1 patient encounter, each. Clinicians were unaware that they were under observation. We documented use of gloves, soap, and alcohol solution before and after patient encounters for purposes of physical examination or patient care. Results The rate of adherence to current recommendations was 20% (95% CI 13.7-28.2). All 23 clinicians adhering to recommendations used gloves followed by washing with soap or alcohol solution. 57.4% (95% CI 48.3-66.0) of clinicians used some form of hand hygiene without fully adhering to recommendations, whereas 42.6% did not appear to attend to hand hygiene at all during observation. By univariate analysis, with nurses as the reference group, we found trends suggesting lowest adherence rates among residents (odds ratio [OR] 0.32, 95% CI 0.11-0.96) and intensivists (OR 0.46, 95% CI, 0.13-1.60), and highest adherence among respiratory therapists (OR 2.05, 95% CI 0.67-6.30). We also observed a center effect (p = 0.04). However, multivariate analysis showed no relationship of hand hygiene to clinician group (p = 0.06) nor ICU (p = 0.05). Conclusions Multidisciplinary, multimethod approaches to improving hand hygiene are likely necessary to improve the modest adherence to hand hygiene that we observed.
TL;DR: Opportunities to improve conference abstract reporting exist and this scale could guide future conference abstract submissions and aid individuals considering conference abstract data to inform clinical practice, systematic reviews, guidelines, or policy.
TL;DR: Much more methodologically rigorous data are required in the form of large, well designed randomized trials before firm recommendations about prophylaxis can be provided to this highly vulnerable population of critically ill patients.
Abstract: PURPOSE OF REVIEW Although critically ill patients are at high risk of venous thromboembolism and bleeding, and thromboprophlyaxis is of proven effectivity in other settings, there remain relatively few data to assist clinicians in providing evidence-based care for medical-surgical patients in the intensive care unit. RECENT FINDINGS Deep vein thrombosis occurs in 5-10% of critically ill patients even if they receive unfractionated heparin for prophylaxis. Both heparin and low molecular weight heparin can be safely administered to the majority of critically ill patients and the low molecular weight heparin dalteparin does not appear to bioaccumulate even when administered to patients with severe renal dysfunction. Further research is currently underway to better define how these conditions can be optimally treated. SUMMARY Despite the high morbidity and mortality because of critical illness, the risk of venous thromboembolism in these patients, and adverse outcomes due to venous thromboembolism, much more methodologically rigorous data are required in the form of large, well designed randomized trials before firm recommendations about prophylaxis can be provided to this highly vulnerable population.
TL;DR: The use of HES for volume resuscitation in critically ill patients is associated with increased use of renal replacement therapy and may result in increased mortality.
Abstract: Objectives: To evaluate the impact of HES solutions on adverse renal outcomes and mortality in critically ill patients requiring acute volume resuscitation.
Design: Systematic review and meta-analysis of randomized controlled trials.
Data Sources: We searched electronic databases from 1950 to 2007 (MEDLINE, EMBASE, the Cochrane Central Registry of Controlled Trials, and the SCOPUS database). Conference proceedings and grey literature sources were also searched from 2002-2007.
Review Methods: We included all randomised controlled trials of patients requiring acute volume resuscitation who received HES compared to an alternative resuscitation fluid. No restrictions were considered regarding language or publication type. Data were independently extracted in duplicate.
Results:Of 2381 citations reviewed, we included 22 trials (n=1866) in the analysis. Patients receiving HES were more likely to receive renal replacement therapy [odds ratio [OR] 1.91 (95% confidence interval [CI] 1.22-2.99, I^210.5%)]. This was also true for patients with severe sepsis or septic shock [OR 1.82 (95% CI 1.27-2.62, I^20%)]. In high quality trials, multicentre trials, and in reports indicating adequate allocation concealment, there was a trend toward increased risk of death associated with HES. Other adverse events were not systematically evaluated and were poorly reported.
Limitations: Considerable clinical and methodologic heterogeneity exists among these trials.
Conclusions: The use of HES for volume resuscitation in critically ill patients is associated with increased use of renal replacement therapy and may result in increased mortality. We caution against the routine use of HES for volume resuscitation in critically ill patients.
TL;DR: This narrative review article presents the rate, clinical consequences, and optimal strategies to prevent VTE in critically ill patients, focusing primarily on medical-surgical intensive care unit (ICU) patients, but also addressing other specific subgroups of critically ill Patients.
Abstract: Critically ill patients in the medical-surgical intensive care unit are at high risk of both venous thromboembolism (VTE) and bleeding. Although thromboprophylaxis is of proven effectiveness in other settings, relatively little data exist to inform "best practice" for the prevention of VTE for these patients. This narrative review article presents the rate, clinical consequences, and optimal strategies to prevent VTE in critically ill patients, focusing primarily on medical-surgical intensive care unit (ICU) patients, but also addressing other specific subgroups of critically ill patients. Despite the large number of medical-surgical ICU patients, their moderately high risk of VTE, and the morbidity and mortality likely to be associated with the development of VTE, relatively little methodologically rigorous data are available to guide practice. Large, well-designed randomized trials, powered to detect differences in clinically relevant end points, are required to advance the care of this highly vulnerable patient population.