-
Frontiers in Pharmacology 2019The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial.
BACKGROUND
The therapeutic role of neuromuscular blocking agents (NMBA) in patients with acute respiratory distress syndrome (ARDS) remains controversial.
METHODS
We systematically reviewed randomized controlled trials investigating the use of NMBA in ARDS patients from inception to July 2019. Relative risk (RR) was calculated for the incidence of barotrauma and mortality using the random-effect or fixed-effect model according to heterogeneity analysis.
RESULTS
Data were combined from five randomized controlled trials that included 1,461 patients (724 in the NMBA group and 737 in the control group). Pooled analysis showed that NMBA infusion did not reduce 28-day mortality (RR = 0.72, 95% confidence interval (CI) 0.44 to 1.17, =0.180, I-squared = 62.8%), but was associated with lower intensive care unit (ICU) mortality (RR = 0.60, 95% CI 0.41 to 0.88, = 0.009, I-squared = 9.2%). In addition, the incidence of barotrauma was significantly lower in patients treated with NMBA (RR = 0.53, 95% CI 0.33 to 0.84, = 0.007, I-squared = 0). However, infusion of NMBA might increase the risk of ICU-acquired weakness (RR = 1.34, 95% CI 0.97 to 1.84, = 0.066, I-squared = 0).
CONCLUSION
Infusion of NMBA could reduce ICU mortality and the incidence of barotrauma. The risk of ICU-acquired weakness was higher in moderate-to-severe ARDS patients treated with NMBA. The real effects of NMBA need to be further evaluated and confirmed by a study with a stricter design.
PubMed: 32063852
DOI: 10.3389/fphar.2019.01637 -
Journal of Intensive Care 2020Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits....
BACKGROUND
Neuromuscular blocking agent (NMBA) has been proposed by medical guidelines for early severe acute respiratory distress syndrome (ARDS) because of its survival benefits. However, new studies have provided evidence contradicting these results.
METHOD
A search was performed of the Pubmed, Scopus, Clinicaltrials.gov, and Virtual Health Library databases for randomized controlled trials (RCT) evaluating 28-day mortality in ARDS patients treated with NMBA within 48 h. An English language restriction was applied. Relevant data were extracted and pooled into risk ratios (RR), mean differences (MD), and corresponding 95% confidence intervals (CI) using random-effect model. Sensitivity and meta-regression analysis were performed.
RESULTS
From 2675 studies, we included five RCTs in the analysis, for a total of 1461 patients with a mean PaO/FIO of 104 ± 35 mmHg. The cisatracurium group had the same risk of death at 28 days (RR, 0.90; 95% CI, 0.78-1.03; = 50%, = 0.12) and 90 days (RR, 0.81; 95% CI, 0.62-1.06; = 56%, = 0.06) as the control group (no cisatracurium). The secondary outcomes of mechanical ventilation duration and ventilator-free days were not different between the two groups. Cisatracurium had a significantly lower risk of barotrauma than the control group with no difference in intensive care unit (ICU)-induced weakness. The PaO/FIO ratio was higher in the cisatracurium group but not until 48 h. Meta-regression analysis of the baseline PaO/FIO ratio, positive end-expiratory pressure (PEEP) revealed no heterogeneity. Subgroup analysis excluding the trial using high PEEP and light sedation strategy yielded an improvement in all mortality outcomes.
CONCLUSION
NMBA improves oxygenation only after 48 h in moderate, severe ARDS patients and has a lower barotrauma risk without affecting ICU weakness. However, NMBA does not reduce ventilator-free days, duration of mechanical ventilation or, most importantly, the mortality risk regardless of the severity of ARDS.
PubMed: 32015880
DOI: 10.1186/s40560-020-0431-z -
JAMA Network Open Jul 2019A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently... (Meta-Analysis)
Meta-Analysis
Assessment of Therapeutic Interventions and Lung Protective Ventilation in Patients With Moderate to Severe Acute Respiratory Distress Syndrome: A Systematic Review and Network Meta-analysis.
IMPORTANCE
A number of interventions are available to manage patients with moderate to severe acute respiratory distress syndrome (ARDS). However, the associations of currently available ventilatory strategies and adjunctive therapies with mortality are uncertain.
OBJECTIVES
To compare and rank different therapeutic strategies to identify the best intervention associated with a reduction in mortality in adult patients with moderate to severe ARDS.
DATA SOURCES
An electronic search of MEDLINE, MEDLINE In-Process/ePubs Ahead of Print, Embase, Cochrane Controlled Clinical Trial Register (Central), PubMed, and CINAHL was conducted, from database inception to May 29, 2019.
STUDY SELECTION
Randomized clinical trials of interventions for adults with moderate to severe ARDS that used lung protective ventilation. No language restrictions were applied.
DATA EXTRACTION AND SYNTHESIS
Data were independently extracted by 2 reviewers and synthesized with Bayesian random-effects network meta-analyses.
MAIN OUTCOMES AND MEASURES
The primary outcome was 28-day mortality. Barotrauma was a secondary outcome.
RESULTS
Among 25 randomized clinical trials evaluating 9 interventions, 2686 of 7743 patients (34.6%) died within 28 days. Compared with lung protective ventilation alone, prone positioning and venovenous extracorporeal membrane oxygenation were associated with significantly lower 28-day mortality (prone positioning: risk ratio, 0.69; 95% credible interval, 0.48-0.99; low quality of evidence; venovenous extracorporeal membrane oxygenation: risk ratio, 0.60; 95% credible interval, 0.38-0.93; moderate quality of evidence). These 2 interventions had the highest ranking probabilities, although they were not significantly different from each other. Among 18 trials reporting on barotrauma, 448 of 6258 patients (7.2%) experienced this secondary outcome. No intervention was superior to any other in reducing barotrauma, and each represented low to very low quality of evidence.
CONCLUSIONS AND RELEVANCE
This network meta-analysis supports the use of prone positioning and venovenous extracorporeal membrane oxygenation in addition to lung protective ventilation in patients with ARDS. Moreover, venovenous extracorporeal membrane oxygenation may be considered as an early strategy for adults with severe ARDS receiving lung protective ventilation.
Topics: Adult; Aged; Bayes Theorem; Extracorporeal Membrane Oxygenation; Female; Humans; Male; Middle Aged; Network Meta-Analysis; Patient Positioning; Respiration, Artificial; Respiratory Distress Syndrome
PubMed: 31365111
DOI: 10.1001/jamanetworkopen.2019.8116 -
Therapeutic Advances in Respiratory... 2019Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great... (Comparative Study)
Comparative Study Meta-Analysis
Effect of lung recruitment and titrated positive end-expiratory pressure (PEEP) low PEEP on patients with moderate-severe acute respiratory distress syndrome: a systematic review and meta-analysis of randomized controlled trials.
BACKGROUND
Setting a positive end-expiratory pressure (PEEP) on patients with acute respiratory distress syndrome (ARDS) receiving mechanical ventilation has been an issue of great contention. Therefore, we aimed to determine effects of lung recruitment maneuver (RM) and titrated PEEP low PEEP on adult patients with moderate-severe ARDS.
METHODS
Data sources and study selection proceeded as follows: PubMed, Ovid, EBSCO, and Cochrane Library databases were searched from 2003 to May 2018. Original clinical randomized controlled trials which met the eligibility criteria were included. To compare the prognosis between the titrated PEEP and low PEEP groups on patients with moderate-severe ARDS (PaO/FiO < 200 mmHg). Heterogeneity was quantified through the statistic. Egger's test and funnel plots were used to assess publication bias.
RESULTS
No difference was found in 28-day mortality and ICU mortality (OR = 0.97, 95% CI (0.61-1.52), = 0.88; OR = 1.14, 95% CI (0.91-1.43), = 0.26, respectively). Only ventilator-free days, length of stay in the ICU, length of stay in hospital, and incidence of barotrauma could be systematically reviewed owing to bias and extensive heterogeneity.
CONCLUSION
No difference was observed in the RM between the titrated PEEP and the low PEEP in 28-day mortality and ICU mortality on patients with moderate-severe ARDS.
Topics: Adult; Hospitalization; Humans; Intensive Care Units; Positive-Pressure Respiration; Randomized Controlled Trials as Topic; Respiratory Distress Syndrome; Severity of Illness Index; Treatment Outcome
PubMed: 31269867
DOI: 10.1177/1753466619858228 -
Diving and Hyperbaric Medicine Jun 2019Physiological changes are induced by immersion, swimming and using diving equipment. Divers must be fit to dive. Using medication may impact the capacity to adapt to...
BACKGROUND
Physiological changes are induced by immersion, swimming and using diving equipment. Divers must be fit to dive. Using medication may impact the capacity to adapt to hyperbaric conditions. The aim of this systematic review is to assess the interaction of diving/hyperbaric conditions and medication and to provide basic heuristics to support decision making regarding fitness to dive in medicated divers.
METHODS
This was a systematic review of human and animal studies of medications in the hyperbaric environment. Studies were subdivided into those describing a medication/hyperbaric environment interaction and those concerned with prevention of diving disorders. Studies without a relation to diving with compressed air, and those concerning oxygen toxicity, hyperbaric oxygen therapy or the treatment of decompression sickness were excluded.
RESULTS
Forty-four studies matched the inclusion criteria. Animal studies revealed that diazepam and valproate gave limited protection against the onset of the high-pressure neurological syndrome. Lithium had a protective effect against nitrogen-narcosis and losartan reduced cardiac changes in repetitive diving. Human studies showed no beneficial or dangerous pressure-related interactions. In prevention of diving disorders, pseudoephedrine reduced otic barotrauma, vitamins C and E reduced endothelial dysfunction after bounce diving and hepatic oxidative stress in saturation diving.
DISCUSSION AND CONCLUSIONS
Animal studies revealed that psycho-pharmaceuticals can limit the onset of neurologic symptoms and cardiovascular protective drugs might add a potential protective effect against decompression sickness. No evidence of significant risks due to changes in pharmacologic mechanisms were revealed and most medication is not a contraindication to diving. For improving decision making in prescribing medicine for recreational and occupational divers and to enhance safety by increasing our understanding of pharmacology in hyperbaric conditions, future research should focus on controlled human studies.
Topics: Animals; Decompression Sickness; Diving; Humans; Hyperbaric Oxygenation; Inert Gas Narcosis; Swimming
PubMed: 31177519
DOI: 10.28920/dhm49.2.127-136 -
Medicine May 2019Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime,...
BACKGROUND
Traumatic vascular injury is caused by explosions and projectiles (bullets and shrapnel); it may affect the arteries and veins of the limbs, and is common in wartime, triggering bleeding, and ischemia. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries.
METHODS
To summarize the current evidence of diagnosis and treatment for traumatic vascular injury of limbs, for saving limbs and lives, and put forward some new insights, we comprehensively consulted literatures and analyzed progress in injury diagnosis and wound treatment, summarized the advanced treatments now available, especially in wartime, and explored the principal factors in play in an effort to optimize clinical outcomes.
RESULTS
Extremity vascular trauma poses several difficult dilemmas in diagnosis and treatment. The increasing use of high-energy weapons in modern warfare is associated with severe vascular injuries. Any delay in treatment may lead to loss of limbs or death. The development of diagnose and treat vascular injury of extremities are the clinical significance to the tip of military medicine, such as the use of fast, cheap, low invasive diagnostic methods, repairing severe vascular injury as soon as possible, using related technologies actively (fasciotomy, etc).
CONCLUSION
We point out the frontier of the diagnosis and treatment of traumatic vascular injury, also with a new model of wartime injury treatment in American (forward surgical teams and combat support hospitals), French military surgeons regarding management of war-related vascular wounds and Chinese military ("3 districts and 7 grades" model). Many issues remain to be resolved by further experience and investigation.
Topics: Amputation, Surgical; Ankle Brachial Index; Blast Injuries; Blood Vessel Prosthesis; Decompression, Surgical; Emergency Medicine; Extremities; Fasciotomy; Fractures, Bone; Humans; Military Medicine; Military Personnel; Retrospective Studies; Skin Transplantation; Time Factors; Trauma Severity Indices; United States; Vascular Surgical Procedures; Vascular System Injuries
PubMed: 31045795
DOI: 10.1097/MD.0000000000015406 -
Annals of Intensive Care Apr 2019Airway pressure release ventilation (APRV) has been considered a tempting mode of ventilation during acute respiratory failure within the concept of open lung...
BACKGROUND
Airway pressure release ventilation (APRV) has been considered a tempting mode of ventilation during acute respiratory failure within the concept of open lung ventilation. We performed a systematic review and meta-analysis to verify whether adult patients with hypoxemic respiratory failure have a higher number of ventilator-free days at day 28 when ventilated in APRV compared to conventional ventilation strategy. Secondary outcomes were difference in PaO/FiO at day 3, ICU length of stay (LOS), ICU and hospital mortality, mean arterial pressure (MAP), risk of barotrauma and level of sedation. We searched MEDLINE, Scopus and Cochrane Central Register of Controlled Trials database until December 2018.
RESULTS
We considered five RCTs for the analysis enrolling a total of 330 patients. For ventilatory-free day at day 28, the overall mean difference (MD) between APRV and conventional ventilation was 6.04 days (95%CI 2.12, 9.96, p = 0.003; I = 65%, p = 0.02). Patients treated with APRV had a lower ICU LOS than patients treated with conventional ventilation (MD 3.94 days [95%CI 1.44, 6.45, p = 0.002; I = 37%, p = 0.19]) and a lower hospital mortality (RD 0.16 [95%CI 0.02, 0.29, p = 0.03; I = 0, p = 0.5]). PaO/FiO at day 3 was not different between the two groups (MD 40.48 mmHg [95%CI - 25.78, 106.73, p = 0.23; I = 92%, p < 0.001]). MAP was significantly higher during APRV (MD 5 mmHg [95%CI 1.43, 8.58, p = 0.006; I = 0%, p = 0.92]). Then, there was no difference regarding the onset of pneumothorax under the two ventilation strategies (RR 1.94 [95%CI 0.54, 6.94, p = 0.31; I = 0%, p = 0.74]). ICU mortality and sedation level were not included into quantitative analysis.
CONCLUSION
This study showed a higher number of ventilator-free days at 28 day and a lower hospital mortality in acute hypoxemic patients treated with APRV than conventional ventilation, without any negative hemodynamic impact or higher risk of barotrauma. However, these results need to be interpreted with caution because of the low-quality evidence supporting them and the moderate heterogeneity found. Other well-designed RCTs need to be conducted to confirm our findings.
PubMed: 30949778
DOI: 10.1186/s13613-019-0518-7 -
International Angiology : a Journal of... Apr 2019Endovascular treatment below-the-knee is safe and effective but limited by poor patency. Coronary drug-eluting stents (DES) may play a role in providing mechanical... (Meta-Analysis)
Meta-Analysis
INTRODUCTION
Endovascular treatment below-the-knee is safe and effective but limited by poor patency. Coronary drug-eluting stents (DES) may play a role in providing mechanical scaffolding and deliver anti-proliferative drug to the site of vascular barotrauma to reduce the incidence of restenosis. Our aim was to evaluate and compare the use of contemporary DES with standard endovascular-therapies for atherosclerotic disease of infrapopliteal arteries.
EVIDENCE ACQUISITION
We performed a meta-analysis of randomized controlled trials comparing DES with conventional treatment for symptomatic peripheral artery disease (search date 30 August 2017). The primary endpoint was primary patency. Secondary endpoints were freedom from target lesion revascularization (TLR), major amputation, sustained Rutherford class improvement and mortality.
EVIDENCE SYNTHESIS
We identified 7 trials enrolling 801 randomly assigned patients (392 DES, 409 control). At the median follow-up of 12-months DES improved rates of primary patency (OR 3.49, 95%CI 2.38-5.12, I2=0%, P<0.00001), freedom from TLR (OR 2.19, 95%CI 1.30-3.69, I2=38%, P=0.003), major amputation (OR 0.56, 95%CI 0.31-0.99, I2=0%, P=0.049), and Rutherford class improvement (OR 1.62, 95%CI 1.01-2.59, I2=65%, P=0.046), but not mortality (OR 1.05, 95%CI 0.68-1.62; I2 =0%, P=0.91) compared to control. Subgroup analysis of primary patency favoured DES coated in sirolimus analogues compared to paclitaxel (Test for subgroup differences, Chi2=6.51, df=1, P=0.01, I2=84.6%).
CONCLUSIONS
At midterm follow-up DES significantly improved rates of primary patency, re-intervention, Rutherford class improvement and major amputation for the treatment of atherosclerotic disease of infrapopliteal arteries compared to control therapy, with no effect on patient survival. Stents coated in sirolimus analogues were more effective than paclitaxel.
Topics: Amputation, Surgical; Angioplasty, Balloon; Constriction, Pathologic; Drug-Eluting Stents; Humans; Limb Salvage; Peripheral Arterial Disease; Popliteal Artery; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 30650949
DOI: 10.23736/S0392-9590.19.04049-5 -
Vibration and bubbles: a systematic review of the effects of helicopter retrieval on injured divers.Diving and Hyperbaric Medicine Dec 2018Vibration from a helicopter during aeromedical retrieval of divers may increase venous gas emboli (VGE) production, evolution or distribution, potentially worsening the...
INTRODUCTION
Vibration from a helicopter during aeromedical retrieval of divers may increase venous gas emboli (VGE) production, evolution or distribution, potentially worsening the patient's condition.
AIM
To review the literature surrounding the helicopter transport of injured divers and establish if vibration contributes to increased VGE.
METHOD
A systematic literature search of key databases was conducted to identify articles investigating vibration and bubbles during helicopter retrieval of divers. Level of evidence was graded using the Oxford Centre for Evidence-Based Medicine guidelines. A modified quality assessment tool for studies with diverse designs (QATSDD) was used to assess the overall quality of evidence.
RESULTS
Seven studies were included in the review. An in vitro research paper provided some evidence of bubble formation with gas supersaturation and vibration. Only one prospective intervention study was identified which examined the effect of vibration on VGE formation. Bubble duration was used to quantify VGE load with no difference found between the vibration and non-vibration time periods. This study was published in 1980 and technological advances since that time suggest cautious interpretation of the results. The remaining studies were retrospective chart reviews of helicopter retrieval of divers. Mode of transport, altitude exposure, oxygen and intravenous fluids use were examined.
CONCLUSION
There is some physical evidence that vibration leads to bubble formation although there is a paucity of research on the specific effects of helicopter vibration and VGE in divers. Technological advances have led to improved assessment of VGE in divers and will aid in further research.
Topics: Air Ambulances; Decompression Sickness; Diving; Embolism, Air; Humans; Prospective Studies; Retrospective Studies; Vibration
PubMed: 30517957
DOI: 10.28920/dhm48.4.241-251 -
Journal of Critical Care Apr 2019To determine if recruitment manoeuvres (RMs) would decrease 28-day mortality of patients with acute respiratory distress syndrome (ARDS) compared with standard care. (Meta-Analysis)
Meta-Analysis
PURPOSE
To determine if recruitment manoeuvres (RMs) would decrease 28-day mortality of patients with acute respiratory distress syndrome (ARDS) compared with standard care.
MATERIALS AND METHODS
Relevant randomized controlled trials (RCTs) published prior to April 26, 2018 were systematically searched. The primary outcome was mortality. The secondary outcomes were oxygenation, barotrauma or pneumothorax, the need for rescue therapies. Data were pooled using the random effects model. And the quality of evidence was assessed by the GRADE system.
RESULTS
Of 3180 identified studies, 15 were eligibly included in our analysis (N = 2755 participants). In the primary outcome, RMs were not associated with reducing 28-day mortality (RR 0.90; 95% CI 0.74-1.09), ICU mortality (RR 0.92; 95% CI 0.74-1.1), and the in-hospital mortaliy (RR 1.02; 95% CI 0.93-1.12). In the secondary outcomes, RMs could improve oxygenation (MD 37.85; 95% CI 11.08-64.61), the rates of barotrauma (RR 1.42; 95% CI 0.83-2.42) and the need for rescue therapies (RR 0.69; 95% CI 0.42-1.12) did not show any difference in the ARDS patients with RMs.
CONCLUSIONS
Earlier meta-analyses found decreased mortality with RMs, in the contrary, our results indicate that RMs could improve oxygenation without detrimental effects, but it does not appear to reduce mortality.
Topics: Adult; Critical Care; Humans; Randomized Controlled Trials as Topic; Respiration, Artificial; Respiratory Distress Syndrome; Ventilator-Induced Lung Injury
PubMed: 30453220
DOI: 10.1016/j.jcrc.2018.10.033