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Critical Care (London, England) Jun 2022Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge... (Review)
Review
INTRODUCTION
Fluid challenges are widely adopted in critically ill patients to reverse haemodynamic instability. We reviewed the literature to appraise fluid challenge characteristics in intensive care unit (ICU) patients receiving haemodynamic monitoring and considered two decades: 2000-2010 and 2011-2021.
METHODS
We assessed research studies and collected data regarding study setting, patient population, fluid challenge characteristics, and monitoring. MEDLINE, Embase, and Cochrane search engines were used. A fluid challenge was defined as an infusion of a definite quantity of fluid (expressed as a volume in mL or ml/kg) in a fixed time (expressed in minutes), whose outcome was defined as a change in predefined haemodynamic variables above a predetermined threshold.
RESULTS
We included 124 studies, 32 (25.8%) published in 2000-2010 and 92 (74.2%) in 2011-2021, overall enrolling 6,086 patients, who presented sepsis/septic shock in 50.6% of cases. The fluid challenge usually consisted of 500 mL (76.6%) of crystalloids (56.6%) infused with a rate of 25 mL/min. Fluid responsiveness was usually defined by a cardiac output/index (CO/CI) increase ≥ 15% (70.9%). The infusion time was quicker (15 min vs 30 min), and crystalloids were more frequent in the 2011-2021 compared to the 2000-2010 period.
CONCLUSIONS
In the literature, fluid challenges are usually performed by infusing 500 mL of crystalloids bolus in less than 20 min. A positive fluid challenge response, reported in 52% of ICU patients, is generally defined by a CO/CI increase ≥ 15%. Compared to the 2000-2010 decade, in 2011-2021 the infusion time of the fluid challenge was shorter, and crystalloids were more frequently used.
Topics: Critical Illness; Crystalloid Solutions; Fluid Therapy; Hemodynamic Monitoring; Hemodynamics; Humans; Shock, Septic
PubMed: 35729632
DOI: 10.1186/s13054-022-04056-3 -
Intensive Care Medicine Jan 2022We aimed to compare the effects of vitamin C, glucocorticoids, vitamin B1, combinations of these drugs, and placebo or usual care on longer-term mortality in adults with... (Meta-Analysis)
Meta-Analysis
Effect of adjunctive vitamin C, glucocorticoids, and vitamin B1 on longer-term mortality in adults with sepsis or septic shock: a systematic review and a component network meta-analysis.
We aimed to compare the effects of vitamin C, glucocorticoids, vitamin B1, combinations of these drugs, and placebo or usual care on longer-term mortality in adults with sepsis or septic shock. MEDLINE, Embase, CENTRAL, ClinicalTrials.gov and WHO-ICTRP were searched. The final search was carried out on September 3rd, 2021. Multiple reviewers independently selected randomized controlled trials (RCTs) comparing very-high-dose vitamin C (≥ 12 g/day), high-dose vitamin C (< 12, ≥ 6 g/day), vitamin C (< 6 g/day), glucocorticoid (< 400 mg/day of hydrocortisone), vitamin B1, combinations of these drugs, and placebo/usual care. We performed random-effects network meta-analysis and, where applicable, a random-effects component network meta-analysis. We used the Confidence in Network Meta-Analysis framework to assess the degree of treatment effect certainty. The primary outcome was longer-term mortality (90-days to 1-year). Secondary outcomes were severity of organ dysfunction over 72 h, time to cessation of vasopressor therapy, and length of stay in intensive care unit (ICU). Forty-three RCTs (10,257 patients) were eligible. There were no significant differences in longer-term mortality between treatments and placebo/usual care or between treatments (10 RCTs, 7,096 patients, moderate to very-low-certainty). We did not find any evidence that vitamin C or B1 affect organ dysfunction or ICU length of stay. Adding glucocorticoid to other treatments shortened duration of vasopressor therapy (incremental mean difference, - 29.8 h [95% CI - 44.1 to - 15.5]) and ICU stay (incremental mean difference, - 1.3 days [95% CI - 2.2 to - 0.3]). Metabolic resuscitation with vitamin C, glucocorticoids, vitamin B1, or combinations of these drugs was not significantly associated with a decrease in longer-term mortality.
Topics: Adult; Ascorbic Acid; Glucocorticoids; Humans; Network Meta-Analysis; Sepsis; Shock, Septic; Thiamine
PubMed: 34750650
DOI: 10.1007/s00134-021-06558-0 -
Critical Care (London, England) Aug 2016The time course of blood lactate levels could be helpful to assess a patient's response to therapy. Although the focus of published studies has been largely on septic... (Review)
Review
BACKGROUND
The time course of blood lactate levels could be helpful to assess a patient's response to therapy. Although the focus of published studies has been largely on septic patients, many other studies have reported serial blood lactate levels in different groups of acutely ill patients.
METHODS
We performed a systematic search of PubMed, Science Direct, and Embase until the end of February 2016 plus reference lists of relevant publications. We selected all observational and interventional studies that evaluated the capacity of serial blood lactate concentrations to predict outcome. There was no restriction based on language. We excluded studies in pediatric populations, experimental studies, and studies that did not report changes in lactate values or all-cause mortality rates. We separated studies according to the type of patients included. We collected data on the number of patients, timing of lactate measurements, minimum lactate level needed for inclusion if present, and suggested time interval for predictive use.
RESULTS
A total of 96 studies met our criteria: 14 in general ICU populations, five in general surgical ICU populations, five in patients post cardiac surgery, 14 in trauma patients, 39 in patients with sepsis, four in patients with cardiogenic shock, eight in patients after cardiac arrest, three in patients with respiratory failure, and four in other conditions. A decrease in lactate levels over time was consistently associated with lower mortality rates in all subgroups of patients. Most studies reported changes over 6, 12 or 24 hrs, fewer used shorter time intervals. Lactate kinetics did not appear very different in patients with sepsis and other types of patients. A few studies suggested that therapy could be guided by these measurements.
CONCLUSIONS
The observation of a better outcome associated with decreasing blood lactate concentrations was consistent throughout the clinical studies, and was not limited to septic patients. In all groups, the changes are relatively slow, so that lactate measurements every 1-2 hrs are probably sufficient in most acute conditions. The value of lactate kinetics appears to be valid regardless of the initial value.
Topics: Critical Illness; Humans; Intensive Care Units; Lactic Acid; Sepsis
PubMed: 27520452
DOI: 10.1186/s13054-016-1403-5 -
Chest Jun 2021Historically, β-blockers have been considered to be relatively contraindicated for septic shock because they may cause cardiac suppression. On the other hand, there is... (Meta-Analysis)
Meta-Analysis
Effect of Ultrashort-Acting β-Blockers on Mortality in Patients With Sepsis With Persistent Tachycardia Despite Initial Resuscitation: A Systematic Review and Meta-analysis of Randomized Controlled Trials.
BACKGROUND
Historically, β-blockers have been considered to be relatively contraindicated for septic shock because they may cause cardiac suppression. On the other hand, there is an increasing interest in the use of β-blockers for treating patients with sepsis with persistent tachycardia despite initial resuscitation.
RESEARCH QUESTION
Do ultrashort-acting β-blockers such as esmolol and landiolol improve mortality in patients with sepsis with persistent tachycardia despite initial resuscitation?
STUDY DESIGN AND METHODS
This was a systematic review and meta-analysis. We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase for randomized controlled trials (RCTs) that compared the mortality of patients with sepsis and septic shock treated with esmolol or landiolol. We updated our search on April 20, 2020. Two independent reviewers assessed whether titles and abstracts met the following eligibility criteria: (1) RCT, (2) patients with sepsis and septic shock ≥ 18 years of age, and (3) treatment with either esmolol/landiolol or placebo/no interventions. Two authors independently extracted selected patient and study characteristics and outcomes. The results of all analyses are presented using random effect models.
RESULTS
Seven RCTs with a pooled sample size of 613 patients were included. Of these, six RCTs with 572 patients reported 28-day mortality. Esmolol or landiolol use in patients with sepsis and septic shock was significantly associated with lower 28-day mortality (risk ratio, 0.68; 95% CI, 0.54-0.85; P < .001). Unimportant heterogeneity was observed (I = 31%). The absolute risk reduction and number of patients to be treated to prevent one death were 18.2% and 5.5, respectively.
INTERPRETATION
The use of ultrashort-acting β-blockers such as esmolol and landiolol in patients with sepsis with persistent tachycardia despite initial resuscitation was associated with significantly lower 28-day mortality.
TRIAL REGISTRY
UMIN Clinical Trials Registry; No.: UMIN000040174; URL: https://www.umin.ac.jp/ctr/index.htm.
Topics: Adrenergic beta-Antagonists; Humans; Randomized Controlled Trials as Topic; Resuscitation; Sepsis; Tachycardia
PubMed: 33434497
DOI: 10.1016/j.chest.2021.01.009 -
JAMA Internal Medicine Feb 2019Although corticosteroids are widely used for adults with sepsis, both the overall benefit and potential risks remain unclear. (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Although corticosteroids are widely used for adults with sepsis, both the overall benefit and potential risks remain unclear.
OBJECTIVE
To conduct a systematic review and meta-analysis of the efficacy and safety of corticosteroids in patients with sepsis.
DATA SOURCES AND STUDY SELECTION
MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were searched from inception until March 20, 2018, and updated on August 10, 2018. The terms corticosteroids, sepsis, septic shock, hydrocortisone, controlled trials, and randomized controlled trial were searched alone or in combination. Randomized clinical trials (RCTs) were included that compared administration of corticosteroids with placebo or standard supportive care in adults with sepsis.
DATA EXTRACTION AND SYNTHESIS
Meta-analyses were conducted using a random-effects model to calculate risk ratios (RRs) and mean differences (MDs) with corresponding 95% CIs. Two independent reviewers completed citation screening, data abstraction, and risk assessment.
MAIN OUTCOMES AND MEASURES
Twenty-eight-day mortality.
RESULTS
This meta-analysis included 37 RCTs (N = 9564 patients). Eleven trials were rated as low risk of bias. Corticosteroid use was associated with reduced 28-day mortality (RR, 0.90; 95% CI, 0.82-0.98; I2 = 27%) and intensive care unit (ICU) mortality (RR, 0.85; 95% CI, 0.77-0.94; I2 = 0%) and in-hospital mortality (RR, 0.88; 95% CI, 0.79-0.99; I2 = 38%). Corticosteroids were significantly associated with increased shock reversal at day 7 (MD, 1.95; 95% CI, 0.80-3.11) and vasopressor-free days (MD, 1.95; 95% CI, 0.80-3.11) and with ICU length of stay (MD, -1.16; 95% CI, -2.12 to -0.20), the sequential organ failure assessment score at day 7 (MD, -1.38; 95% CI, -1.87 to -0.89), and time to resolution of shock (MD, -1.35; 95% CI, -1.78 to -0.91). However, corticosteroid use was associated with increased risk of hyperglycemia (RR, 1.19; 95% CI, 1.08-1.30) and hypernatremia (RR, 1.57; 95% CI, 1.24-1.99).
CONCLUSIONS AND RELEVANCE
The findings suggest that administration of corticosteroids is associated with reduced 28-day mortality compared with placebo use or standard supportive care. More research is needed to associate personalized medicine with the corticosteroid treatment to select suitable patients who are more likely to show a benefit.
Topics: Adrenal Cortex Hormones; Adult; Glucocorticoids; Humans; Hydrocortisone; Intensive Care Units; Organ Dysfunction Scores; Prednisolone; Sepsis; Shock, Septic; Time Factors
PubMed: 30575845
DOI: 10.1001/jamainternmed.2018.5849 -
Nutrients Jul 2023The optimal timing of enteral nutrition (EN) in sepsis patients is controversial among societal guidelines. We aimed to evaluate the evidence of early EN's impact on... (Review)
Review
The optimal timing of enteral nutrition (EN) in sepsis patients is controversial among societal guidelines. We aimed to evaluate the evidence of early EN's impact on critically ill sepsis patients' clinical outcomes. We searched the MEDLINE, Embase, CINAHL, Cochrane Library, ClinicalTrials.gov, and ICTRP databases on 10 March 2023. We included studies published after 2004 that compared early EN versus delayed EN in sepsis patients. We included randomized controlled trials (RCTs), non-RCTs, cohort studies, and case-control studies. Forest plots were used to summarize risk ratios (RRs), including mortality and mean difference (MD) of continuous variables such as intensive care unit (ICU) length of stay and ventilator-free days. We identified 11 eligible studies with sample sizes ranging from 31 to 2410. The RR of short-term mortality from three RCTs was insignificant, and the MD of ICU length of stay from two RCTs was -2.91 and -1.00 days (95% confidence interval [CI], -5.53 to -0.29 and -1.68 to -0.32). Although the RR of intestinal-related complications from one RCT was 3.82 (95% CI, 1.43 to 10.19), indicating a significantly higher risk for the early EN group than the control group, intestinal-related complications of EN reported in five studies were inconclusive. This systematic review did not find significant benefits of early EN on mortality in sepsis patients. Evidence, however, is weak due to inconsistent definitions, heterogeneity, risk of bias, and poor methodology in the existing studies.
Topics: Humans; Enteral Nutrition; Critical Illness; Intensive Care Units; Sepsis; Case-Control Studies; Length of Stay
PubMed: 37513620
DOI: 10.3390/nu15143201 -
Journal of the American Medical... Jan 2022To determine the effects of using unstructured clinical text in machine learning (ML) for prediction, early detection, and identification of sepsis.
OBJECTIVE
To determine the effects of using unstructured clinical text in machine learning (ML) for prediction, early detection, and identification of sepsis.
MATERIALS AND METHODS
PubMed, Scopus, ACM DL, dblp, and IEEE Xplore databases were searched. Articles utilizing clinical text for ML or natural language processing (NLP) to detect, identify, recognize, diagnose, or predict the onset, development, progress, or prognosis of systemic inflammatory response syndrome, sepsis, severe sepsis, or septic shock were included. Sepsis definition, dataset, types of data, ML models, NLP techniques, and evaluation metrics were extracted.
RESULTS
The clinical text used in models include narrative notes written by nurses, physicians, and specialists in varying situations. This is often combined with common structured data such as demographics, vital signs, laboratory data, and medications. Area under the receiver operating characteristic curve (AUC) comparison of ML methods showed that utilizing both text and structured data predicts sepsis earlier and more accurately than structured data alone. No meta-analysis was performed because of incomparable measurements among the 9 included studies.
DISCUSSION
Studies focused on sepsis identification or early detection before onset; no studies used patient histories beyond the current episode of care to predict sepsis. Sepsis definition affects reporting methods, outcomes, and results. Many methods rely on continuous vital sign measurements in intensive care, making them not easily transferable to general ward units.
CONCLUSIONS
Approaches were heterogeneous, but studies showed that utilizing both unstructured text and structured data in ML can improve identification and early detection of sepsis.
Topics: Humans; Machine Learning; Natural Language Processing; Sepsis; Shock, Septic; Vital Signs
PubMed: 34897469
DOI: 10.1093/jamia/ocab236 -
Chest Oct 2023IV fluids are recommended for adults with sepsis. However, the optimal strategy for IV fluid management in sepsis is unknown, and clinical equipoise exists.
BACKGROUND
IV fluids are recommended for adults with sepsis. However, the optimal strategy for IV fluid management in sepsis is unknown, and clinical equipoise exists.
RESEARCH QUESTION
Do lower vs higher fluid volumes improve patient-important outcomes in adult patients with sepsis?
STUDY DESIGN AND METHODS
We updated a systematic review with meta-analysis and trial sequential analysis of randomized clinical trials assessing lower vs higher IV fluid volumes in adult patients with sepsis. The coprimary outcomes were all-cause mortality, serious adverse events, and health-related quality of life. We followed the recommendations from the Cochrane Handbook and used the Grading of Recommendations Assessment, Development and Evaluation approach. Primary conclusions were based on trials with low risk of bias if available.
RESULTS
We included 13 trials (N = 4,006) with four trials (n = 3,385) added to this update. The meta-analysis of all-cause mortality in eight trials with low risk of bias showed a relative risk of 0.99 (97% CI, 0.89-1.10; moderate certainty evidence). Six trials with predefined definitions of serious adverse events showed a relative risk of 0.95 (97% CI, 0.83-1.07; low certainty evidence). Health-related quality of life was not reported.
INTERPRETATION
Among adult patients with sepsis, lower IV fluid volumes probably result in little to no difference in all-cause mortality compared with higher IV fluid volumes, but the interpretation is limited by imprecision in the estimate, which does not exclude potential benefit or harm. Similarly, the evidence suggests lower IV fluid volumes result in little to no difference in serious adverse events. No trials reported on health-related quality of life.
TRIAL REGISTRATION
PROSPERO; No.: CRD42022312572; URL: https://www.crd.york.ac.uk/prospero/.
PubMed: 37142091
DOI: 10.1016/j.chest.2023.04.036 -
Advances in Clinical and Experimental... Aug 2020The antibiotic meropenem is commonly administered to patients with sepsis and septic shock. The aim of this study was to conduct a meta-analysis to evaluate the clinical... (Meta-Analysis)
Meta-Analysis
The antibiotic meropenem is commonly administered to patients with sepsis and septic shock. The aim of this study was to conduct a meta-analysis to evaluate the clinical efficacy and safety of continuous compared to intermittent meropenem infusion for the treatment of sepsis. Electronic databases such as PubMed, EMBASE, Cochrane Library, and China National Knowledge Infrastructure (CNKI) were researched to collect clinical trials comparing continuous and intermittent infusion of meropenem in patients with sepsis. After data extraction and quality assessment of the included studies, Stata v. 12.0 software (Stata Corporation LLC, College Station, USA) was used for a meta-analysis of mortality, clinical cure, microbiological eradication, and safety. Seven studies with a total of 1,191 participants met the inclusion criteria and were included in the meta-analysis. The meta-analysis showed that continuous meropenem infusion was superior to intermittent infusion in terms of mortality (combined risk ratio (RR) = 0.66, 95% confidence interval (95% CI) = 0.46-0.98, p = 0.03), clinical cure rate (combined RR = 1.15, 95% CI = 1.02-1.30, p = 0.026) and microbiological eradication (combined RR = 1.20, 95% CI = 1.01-1.42, p = 0.04), although it may increase the incidence of some adverse events (AEs). Compared with intermittent dosing, administration of meropenem antibiotics through continuous infusion in patients with sepsis is associated with decreased hospital mortality, increased clinical cure rates and greater microbiological eradication. Further high-quality studies should be conducted to confirm our findings.
Topics: Anti-Bacterial Agents; China; Humans; Infusions, Intravenous; Meropenem; Sepsis
PubMed: 32783408
DOI: 10.17219/acem/121934 -
Journal of Intensive Care Medicine Sep 2023The prevalence and its impact on mortality of sepsis-induced cardiomyopathy (SICM) remain controversial. In this systematic review and meta-analysis, we investigated... (Meta-Analysis)
Meta-Analysis Review
The prevalence and its impact on mortality of sepsis-induced cardiomyopathy (SICM) remain controversial. In this systematic review and meta-analysis, we investigated the prevalence and prognosis of SICM. We searched MEDLINE, Cochrane Central Register of Controlled Trials, and Embase. Titles and abstracts were evaluated based on the following criteria: (1) published in English, (2) randomized controlled trials, cohort studies, or cross-sectional studies, (3) ≥ 18 years with sepsis, (4) reporting the prevalence and/or comparison of short-term mortality between those with and without SICM, defined as the new-onset reduction in left ventricular ejection fraction (LVEF) within 72 h on admission or from the diagnosis of sepsis. The random-effect model was used for all analyses. This meta-analysis was registered at PROSPERO (CDR42022332896). Sixteen studies reported the prevalence of SICM and the pooled prevalence of SICM was 20% (95% confidence interval [CI], 16-25%; = 89.9%, P < 0.01). Eleven studies reported short-term mortality and SICM was associated with significantly higher short-term mortality (The pooled odds ratio: 2.30, 95% CI, 1.43-3.69; = 0%, P = 0.001). The prevalence of SICM was 20% in patients with sepsis, and the occurrence of SICM was associated with significantly higher short-term mortality.
Topics: Humans; Stroke Volume; Ventricular Function, Left; Prevalence; Cross-Sectional Studies; Sepsis; Cardiomyopathies; Prognosis; Shock, Septic
PubMed: 37272081
DOI: 10.1177/08850666231180526