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JAMA Internal Medicine May 2024Central venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization... (Meta-Analysis)
Meta-Analysis
IMPORTANCE
Central venous catheters (CVCs) are commonly used but are associated with complications. Quantifying complication rates is essential for guiding CVC utilization decisions.
OBJECTIVE
To summarize current rates of CVC-associated complications.
DATA SOURCES
MEDLINE, Embase, CINAHL, and CENTRAL databases were searched for observational studies and randomized clinical trials published between 2015 to 2023.
STUDY SELECTION
This study included English-language observational studies and randomized clinical trials of adult patients that reported complication rates of short-term centrally inserted CVCs and data for 1 or more outcomes of interest. Studies that evaluated long-term intravascular devices, focused on dialysis catheters not typically used for medication administration, or studied catheters placed by radiologists were excluded.
DATA EXTRACTION AND SYNTHESIS
Two reviewers independently extracted data and assessed risk of bias. Bayesian random-effects meta-analysis was applied to summarize event rates. Rates of placement complications (events/1000 catheters with 95% credible interval [CrI]) and use complications (events/1000 catheter-days with 95% CrI) were estimated.
MAIN OUTCOMES AND MEASURES
Ten prespecified complications associated with CVC placement (placement failure, arterial puncture, arterial cannulation, pneumothorax, bleeding events requiring action, nerve injury, arteriovenous fistula, cardiac tamponade, arrhythmia, and delay of ≥1 hour in vasopressor administration) and 5 prespecified complications associated with CVC use (malfunction, infection, deep vein thrombosis [DVT], thrombophlebitis, and venous stenosis) were assessed. The composite of 4 serious complications (arterial cannulation, pneumothorax, infection, or DVT) after CVC exposure for 3 days was also assessed.
RESULTS
Of 11 722 screened studies, 130 were included in the analyses. Seven of 15 prespecified complications were meta-analyzed. Placement failure occurred at 20.4 (95% CrI, 10.9-34.4) events per 1000 catheters placed. Other rates of CVC placement complications (per 1000 catheters) were arterial canulation (2.8; 95% CrI, 0.1-10), arterial puncture (16.2; 95% CrI, 11.5-22), and pneumothorax (4.4; 95% CrI, 2.7-6.5). Rates of CVC use complications (per 1000 catheter-days) were malfunction (5.5; 95% CrI, 0.6-38), infection (4.8; 95% CrI, 3.4-6.6), and DVT (2.7; 95% CrI, 1.0-6.2). It was estimated that 30.2 (95% CrI, 21.8-43.0) in 1000 patients with a CVC for 3 days would develop 1 or more serious complication (arterial cannulation, pneumothorax, infection, or DVT). Use of ultrasonography was associated with lower rates of arterial puncture (risk ratio [RR], 0.20; 95% CrI, 0.09-0.44; 13.5 events vs 68.8 events/1000 catheters) and pneumothorax (RR, 0.25; 95% CrI, 0.08-0.80; 2.4 events vs 9.9 events/1000 catheters).
CONCLUSIONS AND RELEVANCE
Approximately 3% of CVC placements were associated with major complications. Use of ultrasonography guidance may reduce specific risks including arterial puncture and pneumothorax.
Topics: Humans; Central Venous Catheters; Catheterization, Central Venous; Catheter-Related Infections
PubMed: 38436976
DOI: 10.1001/jamainternmed.2023.8232 -
Jornal de Pediatria 2024To compare LISA with INSURE technique for surfactant administration in preterm with gestational age (GA) < 36 weeks with RDS in respect to the incidence of pneumothorax,... (Meta-Analysis)
Meta-Analysis Review
Less invasive surfactant administration versus intubation-surfactant-extubation in the treatment of neonatal respiratory distress syndrome: a systematic review and meta-analyses.
OBJECTIVES
To compare LISA with INSURE technique for surfactant administration in preterm with gestational age (GA) < 36 weeks with RDS in respect to the incidence of pneumothorax, bronchopulmonary dysplasia (BPD), need for mechanical ventilation (MV), regional cerebral oxygen saturation (rSO2), peri‑intraventricular hemorrhage (PIVH) and mortality.
METHODS
A systematic search in PubMed, Embase, Lilacs, CINAHL, SciELO databases, Brazilian Registry of Randomized Clinical Trials (ReBEC), Clinicaltrials.gov, and Cochrane Central Register of Controlled Trials (CENTRAL) was performed. RCTs evaluating the effects of the LISA technique versus INSURE in preterm infants with gestational age < 36 weeks and that had as outcomes evaluation of the rates of pneumothorax, BPD, need for MV, rSO2, PIVH, and mortality were included in the meta-analysis. Random effects and hazard ratio models were used to combine all study results. Inter-study heterogeneity was assessed using Cochrane Q statistics and Higgin's I2 statistics.
RESULTS
Sixteen RCTs published between 2012 and 2020 met the inclusion criteria, a total of 1,944 preterms. Eleven studies showed a shorter duration of MV and CPAP in the LISA group than in INSURE group. Two studies evaluated rSO2 and suggested that LISA and INSURE transiently affect brain autoregulation during surfactant administration. INSURE group had a higher risk for MV in the first 72 h of life, pneumothorax, PIVH and mortality in comparison to the LISA group.
CONCLUSION
This systematic review and meta-analyses provided evidence for the benefits of the LISA technique in the treatment of RDS, decreasing CPAP time, need for MV, BPD, pneumothorax, PIVH, and mortality when compared to INSURE.
Topics: Infant; Infant, Newborn; Humans; Infant, Premature; Surface-Active Agents; Airway Extubation; Pneumothorax; Pulmonary Surfactants; Intubation; Respiratory Distress Syndrome, Newborn; Cerebral Hemorrhage
PubMed: 37353207
DOI: 10.1016/j.jped.2023.05.008 -
Annals of the American Thoracic Society Dec 2023Conventional electromagnetic navigation bronchoscopy and other guided bronchoscopic modalities have a very desirable safety profile, but their diagnostic yield is only... (Meta-Analysis)
Meta-Analysis
Conventional electromagnetic navigation bronchoscopy and other guided bronchoscopic modalities have a very desirable safety profile, but their diagnostic yield is only 60-70% for pulmonary lesions. Recently, robotic-assisted bronchoscopy (RAB) platforms have been introduced to improve the diagnostic performance of bronchoscopic modalities. To determine the diagnostic performance and safety profile of RAB (using shape-sensing and electromagnetic navigation-based platforms) by performing a systematic review and meta-analysis. The PubMed, Embase, and Google Scholar databases were searched to find studies that reported on the diagnostic performance and/or the safety profile of one of the RAB systems. The quality of included studies was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. Meta-analysis was performed using MedCalc version 20.118. Pooled diagnostic yield was calculated using a Freeman-Tukey transformation. We planned to use a random-effects model if the index was >40%. Twenty-five studies were included: 20 including diagnostic and safety analyses and 5 including only safety analyses. The pooled diagnostic yield of RAB (20 studies, 1,779 lesions) was 84.3% (95% confidence interval, 81.1-87.2%). The index was 65.6%. On the basis of our subgroup analyses, the heterogeneity was likely driven by differences in study designs (prospective vs. retrospective) and procedural protocols (such as different RAB systems). Lesion size > 2 cm, the presence of a computed tomography bronchus sign, and concentric radial endobronchial ultrasound view were associated with a statistically significant increase in the odds of diagnosis with RAB. The overall rates of pneumothorax, need for tube thoracostomy, and significant hemorrhage were 2.3%, 1.2%, and 0.5%, respectively. RAB systems have significantly increased the diagnostic yield of navigational bronchoscopy compared with conventional systems such as electromagnetic navigation bronchoscopy, but well-designed prospective studies are needed to better understand the impact of various factors, such as the use of three-dimensional imaging modalities, cryobiopsy, and specific ventilatory protocols, on the diagnostic yield of RAB.
Topics: Humans; Bronchoscopy; Lung Neoplasms; Robotic Surgical Procedures; Prospective Studies; Retrospective Studies
PubMed: 37769170
DOI: 10.1513/AnnalsATS.202301-075OC -
Journal of Pediatric Surgery Oct 2023Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes... (Meta-Analysis)
Meta-Analysis
Evaluation and Management of Primary Spontaneous Pneumothorax in Adolescents and Young Adults: A Systematic Review From the APSA Outcomes & Evidence-Based Practice Committee.
INTRODUCTION
Controversy exists in the optimal management of adolescent and young adult primary spontaneous pneumothorax. The American Pediatric Surgical Association (APSA) Outcomes and Evidence-Based Practice Committee performed a systematic review of the literature to develop evidence-based recommendations.
METHODS
Ovid MEDLINE, Elsevier Embase, EBSCOhost CINAHL, Elsevier Scopus, and Wiley Cochrane Central Register of Controlled Trials databases were queried for literature related to spontaneous pneumothorax between January 1, 1990, and December 31, 2020, addressing (1) initial management, (2) advanced imaging, (3) timing of surgery, (4) operative technique, (5) management of contralateral side, and (6) management of recurrence. The Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines were followed.
RESULTS
Seventy-nine manuscripts were included. Initial management of adolescent and young adult primary spontaneous pneumothorax should be guided by symptoms and can include observation, aspiration, or tube thoracostomy. There is no evidence of benefit for cross-sectional imaging. Patients with ongoing air leak may benefit from early operative intervention within 24-48 h. A video-assisted thoracoscopic surgery (VATS) approach with stapled blebectomy and pleural procedure should be considered. There is no evidence to support prophylactic management of the contralateral side. Recurrence after VATS can be treated with repeat VATS with intensification of pleural treatment.
CONCLUSIONS
The management of adolescent and young adult primary spontaneous pneumothorax is varied. Best practices exist to optimize some aspects of care. Further prospective studies are needed to better determine optimal timing of operative intervention, the most effective operation, and management of recurrence after observation, tube thoracostomy, or operative intervention.
LEVEL OF EVIDENCE
Level 4.
TYPE OF STUDY
Systematic Review of Level 1-4 studies.
Topics: Child; Humans; Adolescent; Young Adult; Pneumothorax; Chest Tubes; Thoracic Surgery, Video-Assisted; Thoracotomy; Evidence-Based Practice; Retrospective Studies; Recurrence; Treatment Outcome
PubMed: 37130765
DOI: 10.1016/j.jpedsurg.2023.03.018 -
Chest Oct 2023Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled...
BACKGROUND
Primary spontaneous pneumothorax (PSP) has several commonly used management strategies: observation, aspiration, and chest tube placement. Economic modelling of pooled data comparing techniques has not been performed.
RESEARCH QUESTION
Based on studies from the past 20 years, which approach to management of PSP delivers the highest utility?
STUDY DESIGN AND METHODS
A systematic review of PSP management strategies (observation, aspiration, or chest tube placement) included in the Medline and EMBASE databases from January 1, 2000, through April 10, 2020, was conducted. Text screening, bias assessment, and data extraction were performed by two authors (G. E. and C. A. P.). Inclusion and exclusion criteria were defined a priori. The primary outcome was PSP resolution after the initial intervention. Secondary outcomes were PSP recurrence, length of stay, rate of surgical management, and complications. The meta-analysis compared treatment arms; dichotomous outcomes were reported as relative risk (RRs) and continuous outcomes were reported as mean differences. A cost-utility analysis within the Canadian health care system context with deterministic and probabilistic sensitivity analyses was performed.
RESULTS
Five thousand one hundred seventy-nine articles were identified; after screening, 22 articles were included. Most trials showed a high risk of bias, but randomized trials showed a lower risk. Compared with chest tube placement, observation (mean difference, 5.17; 95% CI, 3.75-6.59; P < .01; I = 62%) and aspiration (mean difference, 2.72; 95% CI, 2.39-3.04; P < .01; I = 0%) showed a shorter length of stay. Compared with observation, chest tube placement (RR, 0.81; 95% CI, 0.71-0.91; P < .01; I = 62%) and aspiration (RR, 0.73; 95% CI, 0.61-0.88; P < .01; I = 67%) showed higher resolution without additional intervention. Two-year recurrence rates did not differ between management strategies. Observation showed the best utility (0.82) and lowest cost; observation was the optimal strategy in 98.2% of Monte Carlo simulations.
INTERPRETATION
Observation is the dominant choice compared with aspiration and chest tube placement for PSP. It should be considered as the first-line therapy in appropriately selected patients.
PubMed: 37209773
DOI: 10.1016/j.chest.2023.05.017 -
The Cochrane Database of Systematic... Jul 2023Nasal continuous positive airway pressure (NCPAP) is a strategy to maintain positive airway pressure throughout the respiratory cycle through the application of a bias... (Review)
Review
BACKGROUND
Nasal continuous positive airway pressure (NCPAP) is a strategy to maintain positive airway pressure throughout the respiratory cycle through the application of a bias flow of respiratory gas to an apparatus attached to the nose. Early treatment with NCPAP is associated with decreased risk of mechanical ventilation exposure and might reduce chronic lung disease. Nasal intermittent positive pressure ventilation (NIPPV) is a form of noninvasive ventilation delivered through the same nasal interface during which patients are exposed to short inflations, along with background end-expiratory pressure.
OBJECTIVES
To examine the risks and benefits of early (within the first six hours after birth) NIPPV versus early NCPAP for preterm infants at risk of or with respiratory distress syndrome (RDS). Primary endpoints are respiratory failure and the need for intubated ventilatory support during the first week of life. Secondary endpoints include the incidence of mortality, chronic lung disease (CLD) (oxygen therapy at 36 weeks' postmenstrual age), pneumothorax, duration of respiratory support, duration of oxygen therapy, and intraventricular hemorrhage (IVH).
SEARCH METHODS
Searches were conducted in January 2023 in CENTRAL, MEDLINE, Embase, Web of Science, and Dissertation Abstracts. The reference lists of related systematic reviews and of studies selected for inclusion were also searched.
SELECTION CRITERIA
We considered all randomized and quasi-randomized controlled trials. Eligible studies compared NIPPV versus NCPAP treatment, starting within six hours after birth in preterm infants (< 37 weeks' gestational age (GA)).
DATA COLLECTION AND ANALYSIS
We collected and analyzed data using the recommendations of the Cochrane Neonatal Review Group.
MAIN RESULTS
We included 17 trials, enrolling 1958 infants in this review. NIPPV likely reduces the rate of respiratory failure (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.54 to 0.78; risk difference (RD) -0.08, 95% CI -0.12 to -0.05; 17 RCTs, 1958 infants; moderate-certainty evidence) and needing endotracheal tube ventilation (RR 0.67, 95% CI 0.56 to 0.81; RD -0.07, 95% CI -0.11 to -0.04; 16 RCTs; 1848 infants; moderate-certainty evidence) amongst infants treated with early NIPPV compared with early NCPAP. The meta-analysis demonstrated that NIPPV may reduce the risk of developing CLD compared to CPAP (RR 0.70, 95% CI 0.52 to 0.92; 12 RCTs, 1284 infants; low-certainty evidence) slightly. NIPPV may result in little to no difference in mortality (RR 0.82, 95% CI 0.62 to 1.10; 17 RCTs; 1958 infants; I of 0%; low-certainty evidence), the incidence of pneumothorax (RR 0.92, 95% CI 0.60 to 1.41; 16 RCTs; 1674 infants; I of 0%; low-certainty evidence), and rates of severe IVH (RR 0.98, 95% CI 0.53 to 1.79; 8 RCTs; 977 infants; I of 0%; low-certainty evidence).
AUTHORS' CONCLUSIONS
When applied within six hours after birth, NIPPV likely reduces the risk of respiratory failure and the need for intubation and endotracheal tube ventilation in very preterm infants (GA 28 weeks and above) with respiratory distress syndrome or at risk for RDS. It may also decrease the rate of CLD slightly. However, most trials enrolled infants with a gestational age of approximately 28 to 32 weeks with an overall mean gestational age of around 30 weeks. As such, the results of this review may not apply to extremely preterm infants that are most at risk of needing mechanical ventilation or developing CLD. Additional studies are needed to confirm these results and to assess the safety of NIPPV compared with NCPAP alone in a larger patient population.
Topics: Humans; Infant; Infant, Newborn; Continuous Positive Airway Pressure; Infant, Extremely Premature; Intermittent Positive-Pressure Ventilation; Oxygen; Pneumothorax; Respiratory Distress Syndrome, Newborn; Respiratory Insufficiency
PubMed: 37466143
DOI: 10.1002/14651858.CD005384.pub3 -
The American Journal of Emergency... Jun 2024Spontaneous pneumothorax (SP) is a widespread clinical entity, and methods of managing adult SP remain controversial. The aim of this meta-analysis was to further... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Spontaneous pneumothorax (SP) is a widespread clinical entity, and methods of managing adult SP remain controversial. The aim of this meta-analysis was to further determine the clinical efficacy and safety of simple aspiration (SA) in comparison to intercostal tube drainage (ITD) during the management of adult SP.
METHODS
EMBASE, Medline and the Cochrane Central Register of Controlled Trials via Ovid SP were searched (to June 2023) to identify randomized controlled trials (RCT) that reported outcomes of interest after comparing SA with ITD for the management of adult SP.
RESULTS
The search strategy yielded 1447 citations, of which 10 RCTs enrolling 1044 subjects were included. Compared with the ITD group, the SA group had a significantly lower the initial success rate of the procedure for the management of SP (OR 0.63, 95% CI [0.47-0.86]; P = 0.004). Moreover, SA was associated with a decreased duration of hospitalization (mean difference-2.05 days, 95% CI [-2.66 - -1.44]; P < 0.001) and a decreased need for operation (P = 0.03). For frequently reported adverse events such as subcutaneous emphysema (P = 0.32), bleeding (P = 0.0.26) and wound infection (P = 0.07), no significant difference between the SA and ITD groups was found. There was no significant difference for other outcomes. Subgroup analysis found that there was no significant difference between SA and ITD in terms of the initial success rate, 1-week success rate or any type of adverse event for PSP patients.
CONCLUSIONS
In the management of adult SP, the use of SA decreased the initial success rate but also decreased the duration of hospitalization and the need for operation compared with ITD. The incidence of adverse events did not differ between the two approaches. The research plan was registered at PROSPERO, and the registration number was CRD42023436770.
Topics: Pneumothorax; Humans; Randomized Controlled Trials as Topic; Adult; Drainage; Chest Tubes; Suction; Length of Stay
PubMed: 38537340
DOI: 10.1016/j.ajem.2024.03.020 -
Acta Radiologica (Stockholm, Sweden :... Dec 2023An accurate diagnosis of peripheral lung and pleural lesions using image-guided transthoracic biopsy procedure becomes a good diagnostic performance protocol. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
An accurate diagnosis of peripheral lung and pleural lesions using image-guided transthoracic biopsy procedure becomes a good diagnostic performance protocol.
PURPOSE
To examine the difference between ultrasonography (USG)-guided versus computed tomography (CT)-guided transthoracic biopsy for pleural and peripheral lung lesions by pooling data from published studies.
MATERIAL AND METHODS
PubMed, CENTRAL, Scopus, Web of Science, and Embase were searched for comparative studies up to 20 February 2023 irrespective of the language of publication. The outcomes were adequacy of the sample and complications (pneumothorax and hemothorax).
RESULTS
Two randomized controlled trials (RCTs) and eight non-RCTs were eligible. The total sample size was 1618. Meta-analysis showed that there was no difference in the adequacy of the sample obtained by USG- or CT-guided biopsies; however, an analysis of only non-RCTs indicated better adequacy with USG. On pooled analysis of any pneumothorax, there was a lower risk associated with USG-guided biopsies, but the risk of pneumothorax requiring interventional treatment was not different in the two groups. Similarly, the pooled analysis also demonstrated a reduced risk of hemothorax with USG-guided biopsies.
CONCLUSION
While there seems to be no difference in the adequacy of the sample obtained with either imaging modality, retrospective data show that USG guidance offers better diagnostic yield compared to CT guidance for peripheral lung and pleural biopsies. The risk of pneumothorax and hemothorax is also significantly lower with USG-guided biopsies. Results should be interpreted with caution owing to selection bias among studies. There is a need for large-scale RCTs to enhance current evidence.
Topics: Humans; Pneumothorax; Hemothorax; Ultrasonography; Lung; Image-Guided Biopsy; Tomography, X-Ray Computed; Retrospective Studies
PubMed: 37822264
DOI: 10.1177/02841851231206349 -
Wideochirurgia I Inne Techniki... Dec 2023The diagnosis of pulmonary nodules (PNs) has traditionally relied on computed tomography (CT)-guided biopsy. To reduce radiation exposure, low-dose CT-guided PN biopsy...
INTRODUCTION
The diagnosis of pulmonary nodules (PNs) has traditionally relied on computed tomography (CT)-guided biopsy. To reduce radiation exposure, low-dose CT-guided PN biopsy has been employed.
AIM
This meta-analysis aimed at evaluating the efficacy and safety of low-dose CT-guided biopsy in the diagnosis of PNs.
MATERIAL AND METHODS
PubMed, Web of Science, and Wanfang were searched for relevant articles until June 2023. Comparing low-dose CT to normal-dose CT, we considered factors such as diagnostic yield, diagnostic accuracy, biopsy process time, dose-length product (DLP) value, the frequency of pneumothorax and pulmonary bleeding, and the frequency with which complications necessitated the placement of a chest tube.
RESULTS
This meta-analysis included data from a total of 6 investigations. There was a total of 459 patients who had a CT-guided PN biopsy performed at a low dosage, and 384 patients who had a normal-dose CT-guided PN biopsy. There were no statistically significant differences between the low-dose CT and normal-dose CT groups in terms of diagnostic accuracy (p = 0.08), diagnostic yield (p = 0.55), biopsy procedure duration (p = 0.30), pneumothorax (p = 0.61), pulmonary hemorrhage (p = 0.29), or complications requiring a chest tube (p = 0.48). Low-dose CT patients obtained a DLP that was 91% lower than those in the standard-dose CT group (p = 0.01). According to Egger's test, there is a significant possibility of publication bias in DLP (p = 0.034).
CONCLUSIONS
The diagnostic and safety results of low-dose CT-driven PN biopsy are equivalent to those of the standard one, although patients are much less exposed to radiation.
PubMed: 38239580
DOI: 10.5114/wiitm.2023.131563 -
Perfusion Dec 2023The Coronavirus Disease 2019 (COVID-19) pandemic has been ongoing for over 3 years, during which numerous clinical and experimental studies have been conducted. The... (Review)
Review
BACKGROUND
The Coronavirus Disease 2019 (COVID-19) pandemic has been ongoing for over 3 years, during which numerous clinical and experimental studies have been conducted. The objective of this systematic review and meta-analysis was to assess the survival probability and complications of COVID-19 patients receiving extracorporeal membrane oxygenation (ECMO).
METHODS
We searched the databases by using Population-Intervention-Comparison-Outcome-Study Design (PICOS). We conducted a search of the PubMed, Web of Science, and EMBASE databases to retrieve studies published until December 10, 2022. A random-effects meta-analysis, subgroup analysis, and assessed the studies using the Newcastle-Ottawa Scale score. The results were presented as pooled morbidity with 95% confidence intervals.
RESULTS
The study was conducted on 19 studies that enrolled a total of 1494 patients, and the results showed a pooled survival probability of 66.0%. The pooled morbidity for intracranial hemorrhage was 8.7%, intracranial thrombosis 7.0%, pneumothorax 9.0%, pulmonary embolism 11.0%, pulmonary hemorrhage 9.0%, heart failure 14.0%, liver failure 13.0%, renal injury 44.0%, gastrointestinal hemorrhage 6.0%, gastrointestinal ischemia 6.0% and venous thrombosis 31.0%.
CONCLUSION
This systematic review and meta-analysis of observational studies focused on the survival probability and complications of COVID-19 patients undergoing ECMO, which are significant in evaluating the use of ECMO in COVID-19 patients and provide a basis for further research.
TRIAL REGISTRATION
Our study was registered on PROSPERO with registration number CRD42022382555.
PubMed: 38158713
DOI: 10.1177/02676591231224645