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The Cochrane Database of Systematic... Mar 2016Proximal femoral fracture (PFF) is a common orthopaedic emergency that affects mainly elderly people at high risk of complications. Advanced methods for managing fluid... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Proximal femoral fracture (PFF) is a common orthopaedic emergency that affects mainly elderly people at high risk of complications. Advanced methods for managing fluid therapy during treatment for PFF are available, but their role in reducing risk is unclear.
OBJECTIVES
To compare the safety and effectiveness of the following methods of perioperative fluid optimization in adult participants undergoing surgical repair of hip fracture: advanced invasive haemodynamic monitoring, such as transoesophageal Doppler and pulse contour analysis; a protocol using standard measures, such as blood pressure, urine output and central venous pressure; and usual care.Comparisons of fluid types (e.g. crystalloid vs colloid) and other methods of optimizing oxygen delivery, such as blood product therapies and pharmacological treatment with inotropes and vasoactive drugs, are considered in other reviews.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2015, Issue 9); MEDLINE (October 2012 to September 2015); and EMBASE (October 2012 to September 2015) without language restrictions. We ran forward and backward citation searches on identified trials. We searched ClinicalTrials.gov and the World Health Organization (WHO) International Clinical Trials Registry Platform for unpublished trials. This is an updated version of a review published originally in 2004 and updated first in 2013 and again in 2015. Original searches were performed in October 2003 and October 2012.
SELECTION CRITERIA
We included randomized controlled trials (RCTs) in adult participants undergoing surgical treatment for PFF that compared any two of advanced haemodynamic monitoring, protocols using standard measures or usual care, irrespective of blinding, language or publication status.
DATA COLLECTION AND ANALYSIS
Two review authors assessed the impact of fluid optimization interventions on outcomes of mortality, length of hospital stay, time to medical fitness, whether participants were able to return to pre-fracture accommodation at six months, participant mobility at six months and adverse events in-hospital. We pooled data using risk ratio (RR) or mean difference (MD) for dichotomous or continuous data, respectively, on the basis of random-effects models.
MAIN RESULTS
We included in this updated review five RCTs with a total of 403 participants, and we added two new trials identified during the 2015 search. One of the included studies was found to have a high risk of bias; no trial featured all pre-specified outcomes. We found two trials for which data are awaited for classification and one ongoing trial.Three studies compared advanced haemodynamic monitoring with a protocol using standard measures; three compared advanced haemodynamic monitoring with usual care; and one compared a protocol using standard measures with usual care. Meta-analyses for the two advanced haemodynamic monitoring comparisons are consistent with both increased and decreased risk of mortality (RR Mantel-Haenszel (M-H) random-effects 0.41, 95% confidence interval (CI) 0.14 to 1.20; 280 participants; RR M-H random-effects 0.45, 95% CI 0.07 to 2.95; 213 participants, respectively). The study comparing a protocol with usual care found no difference between groups for this outcome.Three studies comparing advanced haemodynamic monitoring with usual care reported data for length of stay and time to medical fitness. There was no statistically significant difference between groups for these outcomes in the two studies that we were able to combine (MD IV fixed 0.63, 95% CI -1.70 to 2.96); MD IV fixed 0.01, 95% CI -1.74 to 1.71, respectively) and no statistically significant difference in the third study. One study reported reduced time to medical fitness when comparing advanced haemodynamic monitoring with a protocol, and when comparing protocol monitoring with usual care.The number of participants with one or more complications showed no statistically significant differences in each of the two advanced haemodynamic monitoring comparisons (RR M-H random-effects 0.83, 95% CI 0.59 to 1.17; 280 participants; RR M-H random-effects 0.72, 95% CI 0.40 to 1.31; 173 participants, respectively), nor any differences in the protocol and usual care comparison.Only one study reported the number of participants able to return to normal accommodation after discharge with no statistically significant difference between groups.There were few studies with a small number of participants, and by using the GRADE (Grades of Recommendation, Assessment, Development and Evaluation Working Group) approach, we judged the quality of the outcome evidence as low. We had included one study with a high risk of bias, but upon applying GRADE, we downgraded the quality of this outcome evidence to very low.
AUTHORS' CONCLUSIONS
Five studies including a total of 403 participants provided no evidence that fluid optimization strategies improve outcomes for participants undergoing surgery for PFF. Further research powered to test some of these outcomes is ongoing.
Topics: Adult; Femoral Fractures; Fluid Therapy; Hemodynamics; Hip Fractures; Humans; Hypovolemia; Length of Stay; Randomized Controlled Trials as Topic
PubMed: 26976366
DOI: 10.1002/14651858.CD003004.pub4 -
Endoscopic endonasal skull base surgery for vascular lesions: a systematic review of the literature.Journal of Neurosurgical Sciences Dec 2016Endoscopic endonasal skull base surgery for vascular lesions is a controversial topic in neurosurgical practice. Concerns regarding the ability to effectively work... (Review)
Review
INTRODUCTION
Endoscopic endonasal skull base surgery for vascular lesions is a controversial topic in neurosurgical practice. Concerns regarding the ability to effectively work through the relatively narrow and deep endonasal corridor and manage serious hemorrhagic complications such as inadvertent internal carotid artery (ICA) injury during endoscopic surgery (EES) are relevant sources of disagreement between neurosurgeons. Nevertheless, following careful preoperative evaluation, EES may be indicated for rare, well-selected cases, including medially-projecting paraclinoid aneurysms and cavernous malformations (CMs) located next to the ventral surface of the brainstem. To date, only small retrospective case series and case reports, attesting the safety, feasibility and technical aspects of the EES for aneurysm clipping, CM resection and arterio-venous malformations (AVMs), have been published in the literature.
EVIDENCE ACQUISITION
In this manuscript, we conducted a systematic review of the literature applying the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines on EES for treatment of intracranial vascular lesions. We discuss the indications, advantages, limitations and technical aspects of EES for vascular lesions.
EVIDENCE SYNTHESIS AND CONCLUSIONS
Although rarely indicated, EES may be considered as an alternative treatment and part of the armamentarium of cerebrovascular neurosurgeons dealing with these challenging lesions.
Topics: Carotid Artery Injuries; Endoscopy; Humans; Neurosurgical Procedures; Orthopedic Procedures; Skull Base; Treatment Outcome
PubMed: 27327518
DOI: No ID Found -
Foot and Ankle Surgery : Official... Feb 2018Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with... (Meta-Analysis)
Meta-Analysis Review
Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis.
BACKGROUND
Our aim was to determine the evidence for thromboprophylaxis for prevention of symptomatic venous thromboembolism (VTE) in adults with foot or ankle trauma treated with below knee cast or splint. Our secondary aim was to report major bleeding events.
METHODS
MEDLINE and EMBASE databases were searched for randomized controlled trials from inception to 1st June 2015.
RESULTS
Seven studies were included. All focused on low molecular weight heparin (LMWH). None found a statistically significant symptomatic DVT reduction individually. At meta-analysis LMWH was protective against symptomatic DVT (OR 0.29, 95% CI 0.09-0.95). Symptomatic pulmonary embolism affected 3/692 (0.43%). None were fatal. 86 patients required LMWH thromboprophylaxis to prevent one symptomatic DVT event. The overall incidence of major bleeding was 1 in 886 (0.11%).
CONCLUSIONS
Low molecular weight heparin reduces the incidence of symptomatic VTE in adult patients with foot or ankle trauma treated with below knee cast or splint.
Topics: Ankle Injuries; Anticoagulants; Casts, Surgical; Foot Injuries; Hemorrhage; Heparin, Low-Molecular-Weight; Humans; Primary Prevention; Splints; Venous Thromboembolism
PubMed: 29413769
DOI: 10.1016/j.fas.2016.06.005 -
World Journal of Emergency Surgery :... Apr 2022Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of... (Meta-Analysis)
Meta-Analysis
Timing of pharmacologic venous thromboembolism prophylaxis initiation for trauma patients with nonoperatively managed blunt abdominal solid organ injury: a systematic review and meta-analysis.
BACKGROUND
Blunt abdominal solid organ injury is common and is often managed nonoperatively. Clinicians must balance risk of both hemorrhage and thrombosis. The optimal timing of pharmacologic venous thromboembolism prophylaxis (VTEp) initiation in this population is unclear. The objective was to evaluate early (< 48 h) compared to late initiation of VTEp in adult trauma patients with blunt abdominal solid organ injury managed nonoperatively.
METHODS
Embase, MEDLINE, and the Cochrane Central Register of Controlled Trials were searched from inception to March 2021. Studies comparing timeframes of VTEp initiation were considered. The primary outcome was failure of nonoperative management (NOM) after VTEp initiation. Secondary outcomes included risk of transfusion, other bleeding complications, risk of deep vein thrombosis (DVT) and pulmonary embolism, and mortality.
RESULTS
Ten cohort studies met inclusion criteria, with a total of 4642 patients. Meta-analysis revealed a statistically significant increase in the risk of failure of NOM among patients receiving early VTEp (OR 1.76, 95% CI 1.01-3.05, p = 0.05). There was no significant difference in risk of transfusion. Odds of DVT were significantly lower in the early group (OR 0.36, 95% CI 0.22-0.59, p < 0.0001). There was no difference in mortality (OR 1.50, 95% CI 0.82-2.75, p = 0.19). All studies were at serious risk of bias due to confounding.
CONCLUSIONS
Initiation of VTEp earlier than 48 h following hospitalization is associated with an increased risk of failure of NOM but a decreased risk of DVT. Absolute failure rates of NOM are low. Initiation of VTEp at 48 h may balance the risks of bleeding and VTE.
Topics: Abdominal Injuries; Adult; Anticoagulants; Blood Transfusion; Humans; Venous Thromboembolism; Wounds, Nonpenetrating
PubMed: 35468835
DOI: 10.1186/s13017-022-00423-1 -
Journal of Orthopaedics and... Dec 2015It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
It is uncertain whether external fixation or open reduction internal fixation (ORIF) is optimal for patients with bicondylar tibial plateau fractures.
MATERIALS AND METHODS
A systematic review using Ovid MEDLINE, Embase Classic, Embase, AMED, the Cochrane Library, Open Grey, Orthopaedic Proceedings, WHO International Clinical Trials Registry Platform, Current Controlled Trials, US National Institute for Health Trials Registry, and the Cochrane Central Register of Controlled Trials. The search was conducted on 3rd October 2014 and no language limits were applied. Inclusion criteria were all clinical study designs comparing external fixation with open reduction internal fixation of bicondylar tibial plateau fractures. Studies of only one treatment modality were excluded, as were those that included unicondylar tibial plateau fractures. Treatment effects from studies reporting dichotomous outcomes were summarised using odds ratios. Continuous outcomes were converted to standardized mean differences to assess the treatment effect, and inverse variance methods used to combine data. A fixed effect model was used for meta-analyses.
RESULTS
Patients undergoing external fixation were more likely to have returned to preinjury activities by six and twelve months (P = 0.030) but not at 24 months follow-up. However, external fixation was complicated by a greater number of infections (OR 2.59, 95 % CI 1.25-5.36, P = 0.01). There were no statistically significant differences in the rates of deep infection, venous thromboembolism, compartment syndrome, or need for re-operation between the two groups.
CONCLUSION
Although external fixation and ORIF are associated with different complication profiles, both are acceptable strategies for managing bicondylar tibial plateau fractures.
Topics: External Fixators; Fracture Fixation; Fracture Fixation, Internal; Humans; Tibial Fractures
PubMed: 26307153
DOI: 10.1007/s10195-015-0372-9 -
PloS One 2014Observational studies have reported higher mortality among older adults treated with first-generation antipsychotics (FGAs) versus second-generation antipsychotics... (Comparative Study)
Comparative Study Meta-Analysis Review
Quantifying the role of adverse events in the mortality difference between first and second-generation antipsychotics in older adults: systematic review and meta-synthesis.
BACKGROUND
Observational studies have reported higher mortality among older adults treated with first-generation antipsychotics (FGAs) versus second-generation antipsychotics (SGAs). A few studies examined risk for medical events, including stroke, ventricular arrhythmia, venous thromboembolism, myocardial infarction, pneumonia, and hip fracture.
OBJECTIVES
1) Review robust epidemiologic evidence comparing mortality and medical event risk between FGAs and SGAs in older adults; 2) Quantify how much these medical events explain the observed mortality difference between FGAs and SGAs.
DATA SOURCES
Pubmed and Science Citation Index.
STUDY ELIGIBILITY CRITERIA, PARTICIPANTS, AND INTERVENTIONS
Studies of antipsychotic users that: 1) evaluated mortality or medical events specified above; 2) restricted to populations with a mean age of 65 years or older 3) compared FGAs to SGAs, or both to a non-user group; (4) employed a "new user" design; (5) adjusted for confounders assessed prior to antipsychotic initiation; (6) and did not require survival after antipsychotic initiation. A separate search was performed for mortality estimates associated with the specified medical events.
STUDY APPRAISAL AND SYNTHESIS METHODS
For each medical event, we used a non-parametric model to estimate lower and upper bounds for the proportion of the mortality difference-comparing FGAs to SGAs-mediated by their difference in risk for the medical event.
RESULTS
We provide a brief, updated summary of the included studies and the biological plausibility of these mechanisms. Of the 1122 unique citations retrieved, we reviewed 20 observational cohort studies that reported 28 associations. We identified hip fracture, stroke, myocardial infarction, and ventricular arrhythmias as potential intermediaries on the causal pathway from antipsychotic type to death. However, these events did not appear to explain the entire mortality difference.
CONCLUSIONS
The current literature suggests that hip fracture, stroke, myocardial infarction, and ventricular arrhythmias partially explain the mortality difference between SGAs and FGAs.
Topics: Antipsychotic Agents; Cardiovascular Diseases; Dementia; Hip Fractures; Humans; Pneumonia
PubMed: 25140533
DOI: 10.1371/journal.pone.0105376 -
Critical Care Explorations May 2021To compare different modalities of renal replacement therapy in critically ill adults with acute kidney injury. (Review)
Review
OBJECTIVES
To compare different modalities of renal replacement therapy in critically ill adults with acute kidney injury.
DATA SOURCES
We searched Medline, PubMed, Embase, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov from inception to 25 May, 2020. We included randomized controlled trials comparing the efficacy and safety of different renal replacement therapy modalities in critically ill patients with acute kidney injury.
STUDY SELECTION
Ten reviewers (working in pairs) independently screened studies for eligibility, extracted data, and assessed risk of bias.
DATA EXTRACTION
We performed random-effects frequentist network meta-analyses and used the Grading of Recommendations, Assessment, Development, and Evaluation approach to assess certainty of evidence. The primary analysis was a four-node analysis: continuous renal replacement therapy, intermittent hemodialysis, slow efficiency extended dialysis, and peritoneal dialysis. The secondary analysis subdivided these four nodes into nine nodes including continuous veno-venous hemofiltration, continuous veno-venous hemodialysis, continuous veno-venous hemodiafiltration, continuous arterio-venous hemodiafiltration, intermittent hemodialysis, intermittent hemodialysis with hemofiltration, slow efficiency extended dialysis, slow efficiency extended dialysis with hemofiltration, and peritoneal dialysis. We set the minimal important difference threshold for mortality as 2.5% (relative difference, 0.04).
DATA SYNTHESIS
Thirty randomized controlled trials ( = 3,774 patients) proved eligible. There may be no difference in mortality between continuous renal replacement therapy and intermittent hemodialysis (relative risk, 1.04; 95% CI, 0.93-1.18; low certainty), whereas continuous renal replacement therapy demonstrated a possible increase in mortality compared with slow efficiency extended dialysis (relative risk, 1.06; 95% CI, 0.85-1.33; low certainty) and peritoneal dialysis (relative risk, 1.16; 95% CI, 0.92-1.49; low certainty). Continuous renal replacement therapy may increase renal recovery compared with intermittent hemodialysis (relative risk, 1.15; 95% CI, 0.91-1.45; low certainty), whereas both continuous renal replacement therapy and intermittent hemodialysis may be worse for renal recovery compared with slow efficiency extended dialysis and peritoneal dialysis (low certainty). Peritoneal dialysis was probably associated with the shortest duration of renal support and length of ICU stay compared with other interventions (low certainty for most comparisons). Slow efficiency extended dialysis may be associated with shortest length of hospital stay (low or moderate certainty for all comparisons) and days of mechanical ventilation (low certainty for all comparisons) compared with other interventions. There was no difference between continuous renal replacement therapy and intermittent hemodialysis in terms of hypotension (relative risk, 0.92; 95% CI, 0.72-1.16; moderate certainty) or other complications of therapy, but an increased risk of hypotension and bleeding was seen with both modalities compared with peritoneal dialysis (low or moderate certainty). Complications of slow efficiency extended dialysis were not sufficiently reported to inform comparisons.
CONCLUSIONS
The results of this network meta-analysis suggest there is no difference in mortality between continuous renal replacement therapy and intermittent hemodialysis although continuous renal replacement therapy may increases renal recovery compared with intermittent hemodialysis. Slow efficiency extended dialysis with hemofiltration may be the most effective intervention at reducing mortality. Peritoneal dialysis is associated with good efficacy, and the least number of complications however may not be practical in all settings. Importantly, all conclusions are based on very low to moderate certainty evidence, limited by imprecision. At the very least, ICU clinicians should feel comfortable that the differences between continuous renal replacement therapy, intermittent hemodialysis, slow efficiency extended dialysis, and, where clinically appropriate, peritoneal dialysis are likely small, and any of these modalities is a reasonable option to employ in critically ill patients.
PubMed: 34079944
DOI: 10.1097/CCE.0000000000000399 -
Journal of Tissue Viability Feb 2023To systematically summarize and review the existing literature to determine the difference between wound cleansing techniques, irrigation and swabbing, in relation to... (Review)
Review
Wound irrigation versus swabbing technique for cleansing noninfected chronic wounds: A systematic review of differences in bleeding, pain, infection, exudate, and necrotic tissue.
PURPOSE
To systematically summarize and review the existing literature to determine the difference between wound cleansing techniques, irrigation and swabbing, in relation to bleeding, pain, infection, necrotic tissue and exudate in non-infected chronic wounds including pressure injuries, venous and arterial leg ulcers and diabetic foot ulcers.
METHODS
A systematic search of the electronic databases Ovid Medline, Cochrane Database of Systematic Reviews, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and EMBASE was performed to identify all relevant literature in English. The search also included systematic reviews as a method to obtain additional potential citations by manually searching the reference lists. Included studies were assessed for methodological quality using the Cochrane Risk of Bias Tool.
RESULTS
One study met eligibility criteria. Two hundred fifty six patients with wounds healing via secondary intention (n = 256) were included. Wound cleansing via swabbing technique was associated with increased perception of pain and increased rates of infection when compared to the irrigation group (93.4% versus 84.2% p = 0.02 and 5.2% versus 3.3% p = 0.44, respectively). Only a small proportion of this sample met the inclusion criteria, so the results are not considered externally valid.
CONCLUSION
Wound cleansing remains a controversial topic. Despite calls for further research, there continues to remain a large gap in evidence to guide practice. Irrigation continues to replace swabbing in the management of chronic wounds, although evidence of improved outcomes is virtually nonexistent. Although the one study identified was of sound methodological quality, chronic wounds accounted for only a small percentage of the sample. Therefore, results are not generalizable to those with chronic wounds. Further research is needed to determine the effectiveness of basic wound cleansing techniques before considering more costly products.
Topics: Humans; Exudates and Transudates; Pain; Surgical Wound Infection; Therapeutic Irrigation
PubMed: 36462962
DOI: 10.1016/j.jtv.2022.11.002 -
International Journal of Surgery... May 2022Pulmonary cement embolism (PCE) was a rare but fatal complication for percutaneous vertebral augmentation (PVA). Thus we did a systematic review and meta-analysis of... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Pulmonary cement embolism (PCE) was a rare but fatal complication for percutaneous vertebral augmentation (PVA). Thus we did a systematic review and meta-analysis of cohort studies to investigate the risk factors for PCE after PVA.
METHODS
We systematically searched PubMed, EMBASE, Cochrane library, Google Scholar, web of science, and ClinicalTrial.gov from the establishment of the database to September 2021. All eligible studies assessing the risk factors for PCE after PVA were incorporated. Dichotomous data was calculated by risk difference (RD) from Mantel-Haenszel method (M - H method); continuous data was analyzed by mean difference (MD) from Inverse-Variance method (I-V method). All variables were taken as measure of effect by fixed effect model. Heterogeneity, sensitivity, and publication bias analyses were also performed.
RESULTS
This study totally included 13 studies. According to the Newcastle-Ottawa Scale (NOS), 7 studies were considered as low quality, with NOS< 6. The others were of relatively high quality, with NOS≥6. 144/6251 patients (2.3%) had PCE after PVA. percutaneous vertebroplasty (PVP) (RD = 0.02, 95%CI: [0.01, 0.04], Z = 3.70, P < 0.01), thoracic vertebra (RD = 0.03, 95%CI: [0.01, 0.05], Z = 3.53, P < 0.01), higher cement volume injected per level (MD = 0.23, 95%CI: [0.05, 0.42], Z = 2.44, P = 0.01), more than three vertebrae treated per session (MD = -0.05, 95%CI: [-0.08, -0.02], Z = 3.65, P < 0.01), venous cement leakage (RD = 0.07, 95%CI: [0.03, 0.11], Z = 3.79, P < 0.01) were more likely to cause PCE.
CONCLUSION
This study showed that risk factors for PCE included PVP, thoracic vertebra, higher cement volume injected per level, more than three vertebrae treated per session, venous cement leakage. As a serious complication, PCE should be paid attention and avoided.
Topics: Bone Cements; Fractures, Compression; Humans; Kyphoplasty; Osteoporotic Fractures; Pulmonary Embolism; Risk Factors; Spinal Fractures; Treatment Outcome; Vertebroplasty
PubMed: 35452848
DOI: 10.1016/j.ijsu.2022.106632 -
Critical Care (London, England) Mar 2020The association of central venous pressure (CVP) and mortality and acute kidney injury (AKI) in critically ill adult patients remains unclear. We performed a... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The association of central venous pressure (CVP) and mortality and acute kidney injury (AKI) in critically ill adult patients remains unclear. We performed a meta-analysis to determine whether elevated CVP is associated with increased mortality and AKI in critically ill adult patients.
METHODS
We searched PubMed and Embase through June 2019 to identify studies that investigated the association between CVP and mortality and/or AKI in critically ill adult patients admitted into the intensive care unit. We calculated the summary odds ratio (OR) and 95% CI using a random-effects model.
RESULTS
Fifteen cohort studies with a broad spectrum of critically ill patients (mainly sepsis) were included. On a dichotomous scale, elevated CVP was associated with an increased risk of mortality (3 studies; 969 participants; OR, 1.65; 95% CI, 1.19-2.29) and AKI (2 studies; 689 participants; OR, 2.09; 95% CI, 1.39-3.14). On a continuous scale, higher CVP was associated with greater risk of mortality (5 studies; 7837 participants; OR, 1.10; 95% CI, 1.03-1.17) and AKI (6 studies; 5446 participants; OR, 1.14; 95% CI, 1.06-1.23). Furthermore, per 1 mmHg increase in CVP increased the odds of AKI by 6% (4 studies; 5150 participants; OR, 1.06; 95% CI, 1.01-1.12). Further analyses restricted to patients with sepsis showed consistent results.
CONCLUSIONS
Elevated CVP is associated with an increased risk of mortality and AKI in critically ill adult patients admitted into the intensive care unit.
TRIAL REGISTRATION
PROSPERO, CRD42019126381.
Topics: Acute Kidney Injury; Central Venous Pressure; Critical Illness; Humans; Intensive Care Units; Mortality
PubMed: 32138764
DOI: 10.1186/s13054-020-2770-5