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Clinical Nutrition ESPEN Jun 2022The term enteral feeding intolerance (FI) is frequently used in clinical practice and the literature, yet there is no standardised definition. FI is often quoted as a... (Meta-Analysis)
Meta-Analysis
BACKGROUND & AIMS
The term enteral feeding intolerance (FI) is frequently used in clinical practice and the literature, yet there is no standardised definition. FI is often quoted as a reason for failure to meet enteral nutrition (EN) targets but the lack of a consensus definition precludes accurate estimates of prevalence, predictors and clinical outcomes associated with FI. A systematic review was performed of studies in adult critical care patients to evaluate the definitions, relative risk, predictors and clinical outcomes of FI and to propose a uniform definition.
METHODS
Database searches were completed in MEDLINE Ovid, Embase, CINAHL, PsycINFO, Google Scholar, NHS Evidence, Scopus and Web of Science. The search was performed in January and February 2021. Studies were included if they had an interventional, observational cohort or case-control study design and contained a definition of FI in critically ill adults. The following data were extracted from each included article: 1) study design; 2) study objective; 3) inclusion criteria; 4) population and setting; 5) sample size; 6) definition of FI; 7) prevalence of FI; 8) predictors of FI; 9) clinical outcome measures associated with FI. Studies were grouped based on the symptoms used to define FI with random effects meta-analysis.
RESULTS
89 unique studies containing a definition of FI were identified. Studies were categorised according to definition of FI into 3 groups: 1) Gastric residual volume (GRV) and/or gastrointestinal (GI) symptoms (n = 74); 2) Ability to achieve EN target (n = 5); 3) Composite definitions (n = 10). Meta-analysis showed a relative risk of FI of 0.55 [95% CI 0.45, 0.68] (p < 0.00001). The most frequently reported predictors of FI were use of vasoactive drugs, sedation or use of muscle relaxants, intra-abdominal pressure and APACHE II score.
CONCLUSIONS
FI is inconsistently defined in the literature but is reportedly common amongst critically ill adults. FI is most frequently defined by the presence of raised GRV and GI symptoms. However, studies show GRV to correlate poorly with delayed gastric emptying and this review demonstrated no correlation between GRV threshold and prevalence of FI. A standardised definition of FI is essential for future research and clinical practice. We propose a definition of FI including a failure to reach EN targets in addition to presence of GI symptoms.
PROTOCOL REGISTRATION
PROSPERO number CRD42020211879. Registered 29th September 2020.
Topics: Adult; Case-Control Studies; Critical Care; Critical Illness; Enteral Nutrition; Gastrointestinal Diseases; Humans; Infant, Newborn; Prevalence
PubMed: 35623881
DOI: 10.1016/j.clnesp.2022.04.014 -
Medicine Nov 2023Severe community-acquired pneumonia (sCAP) is characterized by severe symptoms and a poor prognosis, especially with the recent global impact of novel coronavirus in... (Meta-Analysis)
Meta-Analysis
BACKGROUND
Severe community-acquired pneumonia (sCAP) is characterized by severe symptoms and a poor prognosis, especially with the recent global impact of novel coronavirus in recent years. The use of glucocorticoids in sCAP is currently a subject of debate. To evaluate the clinical efficacy and safety of glucocorticoids and provide guidance for their rational use in clinical practice, we conducted this study.
METHODS
We searched PubMed, Web of Science, and China National Knowledge Infrastructure using the following search terms: "pneumonia", "pneumonias", "Pulmonary Inflammation", "Pulmonary Inflammations", "Lung Inflammation", and "Lung Inflammations". The primary outcomes included mortality and the length of hospital stay. The secondary outcomes included the duration of mechanical ventilation, duration of vasoactive drug use, gastrointestinal bleeding, and multiple infections. The Cochrane Collaboration was used to assess the risk of bias of the included studies. Stata/MP14 was used for meta-analysis.
RESULTS
These studies contained information on 1252 patients who received glucocorticoids and 1280 patients who did not. Meta-analysis showed that there was no difference in terms of mortality [risk ratio (RR) = 0.93, 95% confidence interval (CI): 0.81-1.07, P > .05], gastrointestinal bleeding (RR = 1.38, 95% CI: 0.83-2.30, P < .05), multiple infections (RR = 1.17, 95% CI: 0.90-1.53, P > .05) and length of hospital stay (mean difference [MD] = -0.87, 95% CI: -2.35 to 0.61, P > .05) between the hormonal and nonhormonal groups. However, there was a significant difference in the duration of mechanical ventilation (MD = -1.54; 95% CI, -1.89 to -1.12, P < .05) and the duration of use of vasoactive drugs (MD = -14.09, 95% CI: -15.72 to -12.46, P < .05).
CONCLUSION
Glucocorticoids reduced the duration of mechanical ventilation duration and vasoactive drug use in sCAP patients without increasing the risk of adverse events including hyperglycemia and multiple infections. However, there was no significant difference in mortality or length of hospital stay in sCAP patients between glucocorticoid and non-glucocorticoid groups. Glucocorticoids could be recommended for patients with sCAP with respiratory failure or hemodynamic instability.
Topics: Humans; Glucocorticoids; Randomized Controlled Trials as Topic; Pneumonia; Community-Acquired Infections; Gastrointestinal Hemorrhage; Inflammation
PubMed: 37986401
DOI: 10.1097/MD.0000000000036047 -
Journal of Clinical Nursing Feb 2020To investigate how intensive care nurses prepare, initiate, administer, titrate, and wean vasoactive medications.
AIM AND OBJECTIVE
To investigate how intensive care nurses prepare, initiate, administer, titrate, and wean vasoactive medications.
BACKGROUND
The management of vasoactive medications is core business for intensive care nurses, but little is known on how nurses manage these ubiquitous and potentially harmful medications.
DESIGN
A systematic review of the literature with narrative synthesis of data.
METHODS
The databases CINAHL Complete, Medline Complete and EMBASE were searched from 1965 to January 2019 with keywords under five concept headings and in a variety of configurations. This systematic review was conducted according to the PRISMA guidelines. Studies were assessed for quality and bias, and a modified narrative synthesis was used to analyse data, investigate findings and explore relationships within and between studies.
RESULTS
The review identified 13 studies: two observational studies, two pre and post intervention studies, four survey studies, two quasi-experimental studies, one longitudinal time series, one prospective controlled trial, and one interview incorporating content analysis. Four studies on preparing and initiating vasoactive medications described a lack of standardisation in infusion preparation and inconsistencies in dosing units and patient weights. Five of six studies on vasoactive medication administration examined nurses' use of syringe changeovers to reduce patient haemodynamic compromise and there were three studies on titration and weaning.
CONCLUSION
Further research on nurse management of vasoactive medications is needed to develop an evidence base for specialist education and standardised practices aimed at reducing risk for patient harm.
RELEVANCE TO CLINICAL PRACTICE
Nurses working in intensive care units in many parts of the world are responsible for the management of vasoactive medications. There is great variation in practices that include preparation, initiation, administration, titration and weaning of vasoactive medications, which increases the risk for medication errors and adverse events in a vulnerable population of critically ill patients.
Topics: Critical Care Nursing; Humans; Intensive Care Units; Medication Errors; Vasoconstrictor Agents
PubMed: 31715043
DOI: 10.1111/jocn.15093 -
British Journal of Anaesthesia May 2020The perioperative use of vasoactive drugs is ubiquitous in clinical anaesthesia; yet, the drugs, doses, and haemodynamic targets used are highly variable. Our objectives... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The perioperative use of vasoactive drugs is ubiquitous in clinical anaesthesia; yet, the drugs, doses, and haemodynamic targets used are highly variable. Our objectives were to determine whether the perioperative administration of vasoactive drugs reduces mortality, morbidity, and length of stay in adult patients (aged 16 yr or older) undergoing major abdominal surgery.
METHODS
MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials were searched for peer-reviewed RCTs with no language or date restrictions. Studies that assessed the intraoperative use of vasoactive drugs were included. Title, abstract, and full-text screening was performed. Risk of bias for each outcome measure was conducted. We calculated the risk ratio (RR) using the Mantel-Haenszel random-effects model with corresponding 95% confidence interval (CI) for dichotomous outcomes, and mean difference using the inverse variance random-effects model with corresponding 95% CI for continuous outcomes.
RESULTS
Twenty-six studies (5561 participants) were included. There was no difference in mortality at the longest follow-up with an RR of 0.84 (95% CI: 0.63-1.12; P=0.23). The intervention significantly reduced the number of patients with one or more postoperative complications; RR: 0.76 (95% CI: 0.66-0.88; P=0.0002). Hospital length of stay was reduced by 0.91 days in the intervention group.
CONCLUSIONS
This review is limited by the quality and sample size of individual studies, and the heterogeneity of the settings, interventions, and outcome measures. Perioperative administration of vasoactive drugs may reduce postoperative complications and hospital length of stay in adult patients having major abdominal surgery.
Topics: Abdomen; Cardiovascular Agents; Drug Administration Schedule; Hemodynamics; Humans; Kidney; Length of Stay; Perioperative Care; Postoperative Complications; Vasodilator Agents
PubMed: 32171547
DOI: 10.1016/j.bja.2020.01.021 -
Frontiers in Medicine 2024Methylene blue is an interesting approach in reducing fluid overload and vasoactive drug administration in vasodilatory shock. The inhibition of guanylate cyclase...
BACKGROUND
Methylene blue is an interesting approach in reducing fluid overload and vasoactive drug administration in vasodilatory shock. The inhibition of guanylate cyclase induced by methylene blue infusion reduces nitric oxide production and improves vasoconstriction. This systematic review and meta-analysis aimed to assess the effects of methylene blue administration compared to placebo on the hemodynamic status and clinical outcomes in patients with sepsis and septic shock.
METHODS
The authors specifically included randomized controlled trials that compared the use of methylene blue with placebo in adult patients with sepsis and septic shock. The outcomes were length of intensive care unit stay, hemodynamic parameters [vasopressor use], and days on mechanical ventilation. We also evaluated the abnormal levels of methemoglobinemia. This systematic review and meta-analysis were recorded in PROSPERO with the ID CRD42023423470.
RESULTS
During the initial search, a total of 1,014 records were identified, out of which 393 were duplicates. Fourteen citations were selected for detailed reading, and three were selected for inclusion. The studies enrolled 141 patients, with 70 of them in the methylene blue group and 71 of them in the control group. Methylene blue treatment was associated with a lower length of intensive care unit stay (MD -1.58; 95%CI -2.97, -0.20; = 25%; = 0.03), decreased days on mechanical ventilation (MD -0.72; 95%CI -1.26, -0.17; = 0%; = 0.010), and a shorter time to vasopressor discontinuation (MD -31.49; 95%CI -46.02, -16.96; = 0%; < 0.0001). No association was found with methemoglobinemia.
CONCLUSION
Administering methylene blue to patients with sepsis and septic shock leads to reduced time to vasopressor discontinuation, length of intensive care unit stay, and days on mechanical ventilation.
SYSTEMATIC REVIEW REGISTRATION
https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023423470, CRD42023423470.
PubMed: 38698779
DOI: 10.3389/fmed.2024.1366062 -
Annals of Medicine and Surgery (2012) Oct 2023Portal hypertension, a major complication of chronic liver disease, often leads to life-threatening variceal bleeding, managed effectively with vasoactive drugs like... (Review)
Review
BACKGROUND
Portal hypertension, a major complication of chronic liver disease, often leads to life-threatening variceal bleeding, managed effectively with vasoactive drugs like terlipressin. However, the most optimal method of terlipressin administration, continuous versus intermittent infusion, remains a subject of debate, necessitating this systematic review and meta-analysis for evidence-based decision-making in managing this critical condition.
METHODS
This systematic review and meta-analysis adhered to the PRISMA standards and explored multiple databases until 6 April 2023, such as MEDLINE through PubMed, Scopus, Web of Science, and CENTRAL. Independent reviewers selected randomized controlled trials (RCTs) that met specific inclusion criteria. After assessing study quality and extracting necessary data, statistical analysis was performed using Review Manager (RevMan), with results presented as risk ratios (RR) or mean differences.
RESULTS
Five RCTs (=395 patients) were included. The continuous terlipressin group had a significantly lower risk of rebleeding (RR=0.43, =0.0004) and treatment failure (RR=0.22, =0.02) and fewer total adverse effects (RR=0.52, <0.00001) compared to the intermittent group. However, there were no significant differences between the two groups in mean arterial pressure (=0.26), length of hospital stays (=0.78), and mortality rates (=0.65).
CONCLUSION
This study provides robust evidence suggesting that continuous terlipressin infusion may be superior to intermittent infusions in reducing the risk of rebleeding, treatment failure, and adverse effects in patients with portal hypertension. However, further large-scale, high-quality RCTs are required to confirm these findings and to investigate the potential benefits of continuous terlipressin infusion on mortality and hospital stays.
PubMed: 37811089
DOI: 10.1097/MS9.0000000000001261 -
BMJ Clinical Evidence Sep 2008Leg ulcers usually occur secondary to venous reflux or obstruction, but 20% of people with leg ulcers have arterial disease, with or without venous disorders. Between... (Review)
Review
INTRODUCTION
Leg ulcers usually occur secondary to venous reflux or obstruction, but 20% of people with leg ulcers have arterial disease, with or without venous disorders. Between 1.5 and 3.0/1000 people have active leg ulcers. Prevalence increases with age to about 20/1000 in people aged over 80 years.
METHODS AND OUTCOMES
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of standard treatments, adjuvant treatments, and organisational interventions for venous leg ulcers? What are the effects of interventions to prevent recurrence of venous leg ulcers? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2007 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
RESULTS
We found 80 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
CONCLUSIONS
In this systematic review we present information relating to the effectiveness and safety of the following interventions: compression bandages and stockings, cultured allogenic (single or bilayer) skin replacement, debriding agents, dressings (cellulose, collagen, film, foam, hyaluronic acid-derived, semi-occlusive alginate), hydrocolloid (occlusive) dressings in the presence of compression, intermittent pneumatic compression, intravenous prostaglandin E1, larval therapy, laser treatment (low-level), leg ulcer clinics, multilayer elastic system, multilayer elastomeric (or non-elastomeric) high-compression regimens or bandages, oral treatments (aspirin, flavonoids, pentoxifylline, rutosides, stanozolol, sulodexide, thromboxane alpha(2) antagonists, zinc), peri-ulcer injection of granulocyte-macrophage colony-stimulating factor, short-stretch bandages, single-layer non-elastic system, skin grafting, superficial vein surgery, systemic mesoglycan, therapeutic ultrasound, self-help (advice to elevate leg, advice to keep leg active, advice to modify diet, advice to stop smoking, advice to reduce weight), and topical treatments (antimicrobial agents, autologous platelet lysate, calcitonin gene-related peptide plus vasoactive intestinal polypeptide, freeze-dried keratinocyte lysate, mesoglycan, negative-pressure recombinant keratinocyte growth factor, platelet-derived growth factor).
Topics: Bandages; Debridement; Humans; Leg Ulcer; Occlusive Dressings; Ultrasonic Therapy; Varicose Ulcer; Wound Healing
PubMed: 19445798
DOI: No ID Found -
Alimentary Pharmacology & Therapeutics Mar 2017Hepatorenal syndrome type 1 (HRS1) is a functional, rapidly progressive, potentially reversible form of acute kidney injury occurring in patients with cirrhosis.... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Hepatorenal syndrome type 1 (HRS1) is a functional, rapidly progressive, potentially reversible form of acute kidney injury occurring in patients with cirrhosis. Characterised by intense renal arterial vasoconstriction, it carries a very poor prognosis. There is a significant unmet need for a widely approved, safe and effective pharmacological treatment.
AIM
To re-evaluate efficacy and safety of pharmacological treatments for HRS1, in the light of recently published randomised controlled trials (RCTs).
METHODS
MEDLINE (OvidSP), EMBASE, PubMed and Cochrane registers were searched for RCTs reporting efficacy and adverse events related to pharmacological treatment of HRS1. Search terms included: 'hepatorenal syndrome', 'terlipressin', 'noradrenaline', 'octreotide', 'midodrine', 'vasopressin', 'dopamine', 'albumin' and synonyms. Comparison of vasoactive drugs vs. placebo/no treatment, and two active drugs were included. Meta-analysis was performed for HRS1 reversal, creatinine improvement, mortality and adverse events.
RESULTS
Twelve RCTs enrolling 700 HRS1 patients were included. Treatment with terlipressin and albumin led to HRS1 reversal more frequently than albumin alone or placebo (RR: 2.54, 95% CI: 1.51-4.26). Noradrenaline was effective in reversing HRS1, but trials were small and nonblinded. Overall, there was mortality benefit with terlipressin (RR: 0.79, 95% CI: 0.63-1.01), but sensitivity analysis including only trials with low risk of selection bias weakened this relationship (RR: 0.87, 95% CI: 0.71-1.06). Notably, there was a significant risk of adverse events with terlipressin therapy (RR: 4.32, 95% CI: 0.75-24.86).
CONCLUSIONS
Terlipressin treatment is superior to placebo for achieving HRS1 reversal, but mortality benefit is less clear. Terlipressin is associated with significant adverse events, but infusion regimens may be better tolerated. There is continued need for safe and effective treatment options for hepatorenal syndrome.
Topics: Albumins; Creatinine; Hepatorenal Syndrome; Humans; Liver Cirrhosis; Lypressin; Prognosis; Randomized Controlled Trials as Topic; Terlipressin; Treatment Outcome; Vasoconstrictor Agents
PubMed: 28052382
DOI: 10.1111/apt.13912 -
BMC Anesthesiology Feb 2017Oliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Oliguria is associated with a decreased kidney- and organ perfusion, leading to organ damage and increased mortality. While the effects of correcting oliguria on renal outcome have been investigated frequently, whether urine output is a modifiable risk factor for mortality or simply an epiphenomenon remains unclear. We investigated whether targeting urine output, defined as achieving and maintaining urine output above a predefined threshold, in hemodynamic management protocols affects 30-day mortality in perioperative and critical care.
METHODS
We performed a systematic review with a random-effects meta-analyses and meta-regression based on search strategy through MEDLINE, EMBASE and references in relevant articles. We included studies comparing conventional fluid management with goal-directed therapy and reporting whether urine output was used as target or not, and reporting 30-day mortality data in perioperative and critical care.
RESULTS
We found 36 studies in which goal-directed therapy reduced 30-day mortality (OR 0.825; 95% CI 0.684-0.995; P = 0.045). Targeting urine output within goal-directed therapy increased 30-day mortality (OR 2.66; 95% CI 1.06-6.67; P = 0.037), but not in conventional fluid management (OR 1.77; 95% CI 0.59-5.34; P = 0.305). After adjusting for operative setting, hemodynamic monitoring device, underlying etiology, use of vasoactive medication and year of publication, we found insufficient evidence to associate targeting urine output with a change in 30-day mortality (goal-directed therapy: OR 1.17; 95% CI 0.54-2.56; P = 0.685; conventional fluid management: OR 0.74; 95% CI 0.39-1.38; P = 0.334).
CONCLUSIONS
The principal finding of this meta-analysis is that after adjusting for confounders, there is insufficient evidence to associate targeting urine output with an effect on 30-day mortality. The paucity of direct data illustrates the need for further research on whether permissive oliguria should be a key component of fluid management protocols.
Topics: Critical Care; Fluid Therapy; Humans; Oliguria; Regression Analysis
PubMed: 28187752
DOI: 10.1186/s12871-017-0316-4 -
The Heart Surgery Forum May 2022This meta-analysis aimed to compare the potential effects of local anesthesia (LA) and general anesthesia (GA) for transcatheter aortic valve implantation (TAVI). (Meta-Analysis)
Meta-Analysis
BACKGROUND
This meta-analysis aimed to compare the potential effects of local anesthesia (LA) and general anesthesia (GA) for transcatheter aortic valve implantation (TAVI).
MEASUREMENTS
All relevant studies were searched from Pubmed, EMbase, Web of Science, and the Cochrane Library (January 1, 2016, to June 1, 2021). The main outcomes of this literature meta-analysis were 30-day mortality, procedural time, new pacemaker implantation, total stay in the hospital, use of the vasoactive drug, and intra-and postoperative complications and emergencies, including conversion to open, myocardial infarction, pulmonary complication, vascular complication, renal injury/failure, stroke, transesophageal echocardiography, life-threatening/major bleeding, cardiac tamponade, and emergency PCI. Pooled risk ratio (RR) and mean difference (MD) together with a 95% confidence interval (CI) were calculated.
RESULTS
A total of 17 studies, including 20938 patients, in the final analysis, fulfilled the inclusion criteria. Intra-and postoperative complications (myocardial infarction, vascular complication, renal injury/failure, stroke, and cardiac tamponade) undergoing TAVI in severe AS patients under GA do not offer a significant difference compared with LA. No differences were observed between LA and GA for new pacemaker implantation, total stay in the hospital, transesophageal echocardiography, and emergency PCI. LA has lower mortality compared with GA (RR 0.69, P = 0.600), pulmonary complications (RR 0.54, P = 0.278), life-threatening/major bleeding (RR 0.85, P = 0.855), and lower times of conversion to open (RR 0.22, P = 0.746). LA has many advantages, including a shorter procedure duration (MD=-0.38, P = 0.000) and reduction of the use of the vasoactive drug (RR 0.57, P = 0.000).
CONCLUSIONS
For TAVI, both LA with or without sedation and GA are feasible and safe. LA appears a feasible alternative to GA for AS patients undergoing TAVI.
Topics: Anesthesia, General; Anesthesia, Local; Aortic Valve Stenosis; Cardiac Tamponade; Humans; Myocardial Infarction; Percutaneous Coronary Intervention; Postoperative Complications; Stroke; Transcatheter Aortic Valve Replacement
PubMed: 35787764
DOI: 10.1532/hsf.4631