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British Journal of Anaesthesia May 2024Postoperative pulmonary complications (PPCs) are associated with postoperative mortality and prolonged hospital stay. Although intraoperative mechanical ventilation (MV)... (Review)
Review
BACKGROUND
Postoperative pulmonary complications (PPCs) are associated with postoperative mortality and prolonged hospital stay. Although intraoperative mechanical ventilation (MV) is a risk factor for PPCs, strategies addressing weaning from MV are understudied. In this systematic review, we evaluated weaning strategies and their effects on postoperative pulmonary outcomes.
METHODS
Our protocol was registered on PROSPERO (CRD42022379145). Eligible studies included randomised controlled trials and observational studies of adults weaned from MV in the operating room. Primary outcomes included atelectasis and oxygenation; secondary outcomes included lung volume changes and PPCs. Risk of bias was assessed using the Cochrane Risk of Bias (RoB2) tool, and quality of evidence with the GRADE framework.
RESULTS
Screening identified 14 randomised controlled trials including 1719 patients; seven studies were limited to the weaning phase and seven included interventions not restricted to the weaning phase. Strategies combining pressure support ventilation (PSV) with positive end-expiratory pressure (PEEP) and low fraction of inspired oxygen (FiO) improved atelectasis, oxygenation, and lung volumes. Low FiO improved atelectasis and oxygenation but might not improve lung volumes. A fixed-PEEP strategy led to no improvement in oxygenation or atelectasis; however, individualised PEEP with low FiO improved oxygenation and might be associated with reduced PPCs. Half of included studies are of moderate or high risk of bias; the overall quality of evidence is low.
CONCLUSIONS
There is limited research evaluating weaning from intraoperative MV. Based on low-quality evidence, PSV, individualised PEEP, and low FiO may be associated with reduced postoperative pulmonary outcomes.
SYSTEMATIC REVIEW PROTOCOL
PROSPERO (CRD42022379145).
PubMed: 38816331
DOI: 10.1016/j.bja.2024.03.043 -
BMC Musculoskeletal Disorders May 2024This review aims to study the clinical characteristics, diagnostic results, treatments, and outcomes in patients with heterotopic ossification following COVID-19...
BACKGROUND
This review aims to study the clinical characteristics, diagnostic results, treatments, and outcomes in patients with heterotopic ossification following COVID-19 infection.
METHODS
A literature search for eligible articles was conducted using MEDLINE/Pubmed, Global Health, and Scopus databases (January 12th, 2023), including all case reports and case series from any country and language. The criteria for inclusion in this review were cases of COVID-19 infection subsequently developing heterotopic ossification.
RESULTS
This systematic review analysed 15 reports (n = 20 patients) documenting cases of heterotopic ossification following COVID-19 infection. 80% of the patients were male, with a median age of 59 years. All patients required intensive care unit stay with an average duration of 48.5 days. Mechanical ventilation was necessary for all patients and 30% of them underwent tracheostomy. Common symptoms included stiffness and pain, most frequently affecting multiple locations (70%), with the hips and shoulders being predominantly involved. X-rays were the most commonly used imaging modality, followed by computed tomography. Although treatment was given, some of the patients continued to experience symptoms, particularly stiffness.
CONCLUSION
20 patients who developed heterotopic ossification after COVID-19 have been reported, the majority of which had at least two independent risk factors for this condition. The link between those two clinical entities is therefore uncertain, requiring further investigation. It is nonetheless important to suspect heterotopic ossification in patients with severe COVID-19 infection, prolonged immobilisation, mechanical ventilation, who develop joint pain and stiffness, as this condition can significantly impact patients' quality of life.
PROTOCOL REGISTRATION
CRD42023393516.
Topics: Humans; Ossification, Heterotopic; COVID-19; Male; Middle Aged; Female; Respiration, Artificial; Aged; SARS-CoV-2; Adult
PubMed: 38811925
DOI: 10.1186/s12891-024-07537-4 -
PeerJ 2024The optimal range of protein dosage and effect of high-dose protein on critically ill patients remain controversial. We conducted a meta-analysis to compare higher and... (Meta-Analysis)
Meta-Analysis
PURPOSE
The optimal range of protein dosage and effect of high-dose protein on critically ill patients remain controversial. We conducted a meta-analysis to compare higher and lower doses of protein supplementation for nutritional support in critically ill patients.
METHODS
We searched the PubMed, Embase, Scopus, and Cochrane Library databases for randomized controlled trials that compared higher (≥1.2 g/kg per day) lower (<1.2 g/kg per day) doses of protein supplementation among critically ill adult patients. This search spanned from the inception of relevant databases to November 20, 2023. Our primary endpoint of interest was overall mortality, while secondary endpoints included length of stay in the intensive care unit, length of hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury.
RESULTS
Seventeen studies including 2,965 critically ill patients were included in our meta-analysis. The pooled analyses showed no significant difference in overall mortality (RR 1.03, 95%CI [0.92-1.15], = 0.65, I = 0%), length of intensive care unit stay (MD 0.19, 95%CI [-0.67 to 1.04], = 0.66, I = 25%), length of hospital stay (MD 0.73, 95%CI [-1.59 to 3.04], = 0.54, I = 27%), duration of mechanical ventilation (MD -0.14, 95%CI [-0.83 to 0.54], = 0.68, I = 8%), and incidence of acute kidney injury (RR 1.11, 95%CI [0.87-1.41], = 0.38, I = 0%) between critically ill patients receiving higher or lower doses of protein supplementation.
CONCLUSIONS
For critically ill patients, the protein supplementation dose had no significant effect on clinical outcomes, including overall mortality, length of intensive care unit and hospital stay, duration of mechanical ventilation, and incidence of acute kidney injury.
Topics: Humans; Critical Illness; Randomized Controlled Trials as Topic; Length of Stay; Respiration, Artificial; Acute Kidney Injury; Intensive Care Units; Dietary Proteins; Dietary Supplements; Nutritional Support; Dose-Response Relationship, Drug
PubMed: 38799065
DOI: 10.7717/peerj.17433 -
Nutrients May 2024The utility of using indirect calorimetry (IC) to estimate energy needs and methods for its application to this purpose remain unclear. This systematic review... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The utility of using indirect calorimetry (IC) to estimate energy needs and methods for its application to this purpose remain unclear. This systematic review investigated whether using IC to estimate energy expenditure in critically ill patients is more meaningful for improving survival than other estimation methods.
METHODS
Comprehensive searches were conducted in MEDLINE using PubMed, Cochrane Central Register of Controlled Trials, and Igaku-Chuo-Zasshi up to March 2023.
RESULTS
Nine RCTs involving 1178 patients were included in the meta-analysis. The evidence obtained suggested that energy delivery by IC improved short-term mortality (risk ratio, 0.86; 95% confidence interval [CI], 0.70 to 1.06). However, the use of IC did not appear to affect the length of ICU stay (mean difference [MD], 0.86; 95% CI, -0.98 to 2.70) or the duration of mechanical ventilation (MD, 0.66; 95% CI, -0.39 to 1.72). Post hoc analyses using short-term mortality as the outcome found no significant difference by target calories in resting energy expenditure, whereas more frequent IC estimates were associated with lower short-term mortality and were more effective in mechanically ventilated patients.
CONCLUSIONS
This updated meta-analysis revealed that the use of IC may improve short-term mortality in patients with critical illness and did not increase adverse events.
Topics: Critical Illness; Humans; Calorimetry, Indirect; Energy Metabolism; Respiration, Artificial; Energy Intake; Length of Stay; Intensive Care Units; Randomized Controlled Trials as Topic; Nutritional Support
PubMed: 38794690
DOI: 10.3390/nu16101452 -
Journal of Clinical Medicine May 2024Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac... (Review)
Review
Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.
PubMed: 38792445
DOI: 10.3390/jcm13102903 -
Critical Care Explorations Jun 2024We planned to synthesize evidence examining the potential efficacy and safety of performing physical rehabilitation and/or mobilization (PR&M) in adult patients...
OBJECTIVES
We planned to synthesize evidence examining the potential efficacy and safety of performing physical rehabilitation and/or mobilization (PR&M) in adult patients receiving extracorporeal life support (ECLS).
DATA SOURCES
We included any study that compared PR&M to no PR&M or among different PR&M strategies in adult patients receiving any ECLS for any indication and any cannulation. We searched seven electronic databases with no language limitations.
STUDY SELECTION AND DATA EXTRACTION
Two reviewers, independently and in duplicate, screened all citations for eligibility. We used the Cochrane Risk of Bias 2 and Cochrane Risk Of Bias In Non-randomized Studies of Interventions tools to assess individual study risk of bias. Although we had planned for meta-analysis, this was not possible due to insufficient data, so we used narrative and tabular data summaries for presenting results. We assessed the overall certainty of the evidence for each outcome using the Grading of Recommendations Assessment, Development, and Evaluation framework.
DATA SYNTHESIS
We included 17 studies that enrolled 996 patients. Most studies examined venovenous extracorporeal membrane oxygenation (ECMO) and/or venoarterial ECMO as a bridge to recovery in the ICU. We found an uncertain effect of high-intensity/active PR&M on mortality, duration of mechanical ventilation, ICU length of stay, hospital length of stay, or quality of life compared with low-intensity/passive PR&M in patients receiving ECLS (very low certainty due to very serious imprecision). There was similarly an uncertain effect on safety events including clinically important bleeding, spontaneous intracerebral hemorrhage, limb ischemia, accidental decannulation, or ECLS circuit dysfunction (very low certainty due to very serious risk of bias and imprecision).
CONCLUSIONS
Based on the currently available summary of evidence, there is an uncertain effect of high-intensity/active PR&M on patient important outcomes or safety in patients receiving ECLS. Despite indirect data from other populations suggesting potential benefit of high-intensity PR&M in the ICU; further high-quality randomized trials evaluating the benefits and risks of physical therapy and/or mobilization in this population are needed.
Topics: Humans; Extracorporeal Membrane Oxygenation; Physical Therapy Modalities; Early Ambulation; Length of Stay
PubMed: 38787294
DOI: 10.1097/CCE.0000000000001095 -
Scientific Reports May 2024Community-acquired pneumonia (CAP) poses a significant global health challenge, prompting exploration of innovative treatments. This systematic review and meta-analysis... (Meta-Analysis)
Meta-Analysis
Community-acquired pneumonia (CAP) poses a significant global health challenge, prompting exploration of innovative treatments. This systematic review and meta-analysis aimed to evaluate the efficacy and safety of vitamin C supplementation in adults undergoing treatment for CAP. A comprehensive search of the MEDLINE, Embase, CINAHL, the Cochrane Central Register of Controlled Trials, and Clinical Trials.gov databases from inception to 17 November 2023 identified six randomized-controlled-trials (RCTs) meeting inclusion criteria. The primary outcome analysis revealed a non-significant trend towards reduced overall mortality in the vitamin C group compared to controls (RR 0.51; 95% CI 0.24 to 1.09; p = 0.052; I = 0; p = 0.65). Sensitivity analysis, excluding corona-virus-disease 2019 (COVID-19) studies and considering the route of vitamin C administration, confirmed this trend. Secondary outcomes, including hospital length-of-stay (LOS), intensive-care-unit (ICU) LOS, and mechanical ventilation, exhibited mixed results. Notably, heterogeneity and publication bias were observed in hospital LOS analysis, necessitating cautious interpretation. Adverse effects were minimal, with isolated incidents of nausea, vomiting, hypotension, and tachycardia reported. This meta-analysis suggests potential benefits of vitamin C supplementation in CAP treatment. However, inconclusive findings and methodological limitations warrants cautious interpretation, emphasising the urgency for high-quality trials to elucidate the true impact of vitamin C supplementation in CAP management.
Topics: Humans; Ascorbic Acid; Community-Acquired Infections; Dietary Supplements; Pneumonia; Treatment Outcome; Randomized Controlled Trials as Topic; Length of Stay; COVID-19; Respiration, Artificial
PubMed: 38783029
DOI: 10.1038/s41598-024-62571-5 -
Journal of the Pediatric Infectious... May 2024Risk stratification is a cornerstone of the Pediatric Infectious Diseases Society COVID-19 treatment guidance. This systematic review and meta-analysis aimed to define...
BACKGROUND
Risk stratification is a cornerstone of the Pediatric Infectious Diseases Society COVID-19 treatment guidance. This systematic review and meta-analysis aimed to define the clinical characteristics and comorbidities associated with critical COVID-19 in children and adolescents.
METHODS
Two independent reviewers screened the literature (Medline and EMBASE) for studies published through August 31, 2023, that reported outcome data on patients aged ≤21 years with COVID-19. Critical disease was defined as an invasive mechanical ventilation requirement, intensive care unit admission, or death. Random effects models were used to estimate pooled odds ratios (OR) with 95% confidence intervals (CI), and heterogeneity was explored through subgroup analyses.
RESULTS
Among 10,178 articles, 136 studies met the inclusion criteria for review. Data from 70 studies, which collectively examined 172,165 children and adolescents with COVID-19, were pooled for meta-analysis. In previously healthy children, the absolute risk of critical disease from COVID-19 was 4% (95% CI, 1%-10%). Compared with no comorbidities, the pooled OR for critical disease was 3.95 (95% CI, 2.78-5.63) for the presence of one comorbidity and 9.51 (95% CI, 5.62-16.06) for ≥2 comorbidities. Key risk factors included cardiovascular and neurological disorders, chronic pulmonary conditions (excluding asthma), diabetes, obesity, and immunocompromise, all with statistically significant ORs >2.00.
CONCLUSIONS
While the absolute risk for critical COVID-19 in children and adolescents without underlying health conditions is relatively low, the presence of one or more comorbidities was associated with markedly increased risk. These findings support the importance of risk stratification in tailoring pediatric COVID-19 management.
PubMed: 38780125
DOI: 10.1093/jpids/piae052 -
The Clinical Respiratory Journal May 2024This systematic review aimed to summarize the available data on the treatment of pulmonary contusions with exogenous surfactants, determine whether this treatment... (Review)
Review
This systematic review aimed to summarize the available data on the treatment of pulmonary contusions with exogenous surfactants, determine whether this treatment benefits patients with severe pulmonary contusions, and evaluate the optimal type of surfactant, method of administration, and drug concentration. Three databases (MEDline, Scopus, and Web of Science) were searched using the following keywords: pulmonary surfactant, surface-active agents, exogenous surfactant, pulmonary contusion, and lung contusion for articles published between 1945 and February 2023, with no language restrictions. Four reviewers independently rated the studies for inclusion, and the other four reviewers resolved conflicts. Of the 100 articles screened, six articles were included in the review. Owing to the limited number of papers on this topic, various types of studies were included (two clinical studies, two experiments, and two case reports). In all the studies, surfactant administration improved the selected ventilation parameters. The most frequently used type of surfactant was Curosurf® in the concentration of 25 mg/kg of ideal body weight. In most studies, the administration of a surfactant by bronchoscopy into the segmental bronchi was the preferable way of administration. In both clinical studies, patients who received surfactants required shorter ventilation times. The administration of exogenous surfactants improved ventilatory parameters and, thus, reduced the need for less aggressive artificial lung ventilation and ventilation days. The animal-derived surfactant Curosurf® seems to be the most suitable substance; however, the ideal concentration remains unclear. The ideal route of administration involves a bronchoscope in the segmental bronchi.
Topics: Humans; Pulmonary Surfactants; Contusions; Lung Injury; Respiratory Distress Syndrome; Animals; Respiration, Artificial; Treatment Outcome; Bronchoscopy
PubMed: 38778673
DOI: 10.1111/crj.13776 -
Clinical Nutrition ESPEN Jun 2024International guidelines recommend a target protein intake of ≥1.2 g/kg/day to all critically ill patients for optimal outcomes. There are however various conflicting... (Review)
Review
International guidelines recommend a target protein intake of ≥1.2 g/kg/day to all critically ill patients for optimal outcomes. There are however various conflicting data related to this recommendation. The primary objective of this review was to compare a protein intake group (≥1.2 g/kg/day) with a lower protein intake group (<1.2 g/kg/day) in critically ill adult patients on mortality, length of intensive care unit (ICU) and hospital stay. Secondly, the effect of protein intake on length of mechanical ventilation, adverse nutrition-related events and muscle mass and strength parameters were investigated. Sixteen randomised controlled trials (RCTs) of adult patients admitted to an intensive or high care unit and receiving nutrition support in the form of enteral- and/or parenteral nutrition were selected against prespecified eligibility criteria. Two independent reviewers extracted relevant data and assessed the risk of bias of the included studies. Review Manager 5.4.1 was used to analyse data and GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) was used to evaluate the certainty of the evidence. The higher protein group, when compared to the lower protein group, probably results in little to no difference in mortality (risk ratio [RR] 1.01; 95% confidence interval [CI]: 0.89 to 1.14; moderate-certainty evidence); with a probable slight increase in length of ICU stay (mean difference [MD] 0.33; 95% CI -0.57 to 1.23; moderate-certainty) and length of hospital stay (MD 1.72; 95% CI -0.58 to 4.01; moderate-certainty evidence), on average. For secondary outcomes, it was found that the higher protein group probably does not reduce the length of mechanical ventilation (MD 0.08; 95% CI -0.38 to 0.53; moderate-certainty evidence). Higher protein group probably reduces the occurrence of diarrhoea and high gastric residual volume and may reduce the occurrence of constipation. It may also increase nitrogen balance (MD 3.66; 95% CI 1.81 to 5.51; low-certainty evidence). Importantly, there does not seem to be harm associated with the higher protein group, though it should be mentioned that for many of the adverse events in this study, the certainty of evidence was low or very low.
Topics: Humans; Critical Illness; Intensive Care Units; Dietary Proteins; Length of Stay; Respiration, Artificial; Adult; Randomized Controlled Trials as Topic; Practice Guidelines as Topic; Enteral Nutrition; Critical Care; Parenteral Nutrition; Hospital Mortality
PubMed: 38777455
DOI: 10.1016/j.clnesp.2024.04.003