Association between use of lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis.

CONTEXT: Lung-protective mechanical ventilation with the use of lower tidal volumes has been found to improve outcomes of patients with acute respiratory distress syndrome (ARDS). It has been suggested that use of lower tidal volumes also benefits patients who do not have ARDS. OBJECTIVE: To determine whether use of lower tidal volumes is associated with improved outcomes of patients receiving ventilation who do not have ARDS. DATA SOURCES: MEDLINE, CINAHL, Web of Science, and Cochrane Central Register of Controlled Trials up to August 2012. STUDY SELECTION: Eligible studies evaluated use of lower vs higher tidal volumes in patients without ARDS at onset of mechanical ventilation and reported lung injury development, overall mortality, pulmonary infection, atelectasis, and biochemical alterations. DATA EXTRACTION: Three reviewers extracted data on study characteristics, methods, and outcomes. Disagreement was resolved by consensus. DATA SYNTHESIS: Twenty articles (2822 participants) were included. Meta-analysis using a fixed-effects model showed a decrease in lung injury development (risk ratio [RR], 0.33; 95% CI, 0.23 to 0.47; I2, 0%; number needed to treat [NNT], 11), and mortality (RR, 0.64; 95% CI, 0.46 to 0.89; I2, 0%; NNT, 23) in patients receiving ventilation with lower tidal volumes. The results of lung injury development were similar when stratified by the type of study (randomized vs nonrandomized) and were significant only in randomized trials for pulmonary infection and only in nonrandomized trials for mortality. Meta-analysis using a random-effects model showed, in protective ventilation groups, a lower incidence of pulmonary infection (RR, 0.45; 95% CI, 0.22 to 0.92; I2, 32%; NNT, 26), lower mean (SD) hospital length of stay (6.91 [2.36] vs 8.87 [2.93] days, respectively; standardized mean difference [SMD], 0.51; 95% CI, 0.20 to 0.82; I2, 75%), higher mean (SD) PaCO2 levels (41.05 [3.79] vs 37.90 [4.19] mm Hg, respectively; SMD, -0.51; 95% CI, -0.70 to -0.32; I2, 54%), and lower mean (SD) pH values (7.37 [0.03] vs 7.40 [0.04], respectively; SMD, 1.16; 95% CI, 0.31 to 2.02; I2, 96%) but similar mean (SD) ratios of PaO2 to fraction of inspired oxygen (304.40 [65.7] vs 312.97 [68.13], respectively; SMD, 0.11; 95% CI, -0.06 to 0.27; I2, 60%). Tidal volume gradients between the 2 groups did not influence significantly the final results. CONCLUSIONS: Among patients without ARDS, protective ventilation with lower tidal volumes was associated with better clinical outcomes. Some of the limitations of the meta-analysis were the mixed setting of mechanical ventilation (intensive care unit or operating room) and the duration of mechanical ventilation.

Association between static and dynamic thenar near-infrared spectroscopy and mortality in patients with sepsis: a systematic review and meta-analysis.

BACKGROUND: Oxygen delivery and consumption disturbances are frequently seen with critically illness, potentially leading to pathologic changes in tissue oxygenation (StO2). Near-infrared spectroscopy (NIRS) is a potentially useful method to monitor StO2, but the role of NIRS in prognostication of septic patients is uncertain. The aim of this study was to systematically review the literature and evaluate static and dynamic NIRS in patients with sepsis. METHODS: This is a systematic review and meta-analysis of publications between 1966 and 2013. The MEDLINE and EMBASE databases were searched for studies on StO2 in patients with severe sepsis or septic shock. Meta-analysis was limited to studies about static and dynamic variables derived from NIRS in patients with sepsis. The association between StO2, reperfusion slope (Rres), occlusion slope, and maximum StO2 minus basal StO2 (ΔStO2) and prognosis in septic patients was evaluated. RESULTS: The search identified 20 articles (962 participants; 717 with severe sepsis or septic shock, and 245 healthy controls). Compared with healthy controls, septic patients had lower levels of StO2 (78.27% [4.91%] vs. 82.02% [3.57%], p = 0.012), Rres (2.75% [0.63%] vs. 5.19% [2.86%] per second, p = 0.003), and ΔStO2 (7.86% [0.11%] vs. 12.53% [2.65%], p = 0.011). Survivors from sepsis presents higher levels of StO2 (81.68% [4.68%] vs. 74.54% [5.31%], p = 0.02) and Rres (3.37% [0.44%] vs. 2.16% [0.51%] per second, p = 0.016). CONCLUSION: Septic patients have lower levels of StO2, Rres and ΔStO2, and survivors from sepsis present higher levels of StO2 and Rres compared with nonsurvivors. LEVEL OF EVIDENCE: Systematic review/meta-analysis, level III.

Should we treat fever in critically ill patients? A summary of the current evidence from three randomized controlled trials.

Fever is a nonspecific response to various types of infectious or non-infectious insult and its significance in disease remains an enigma. Our aim was to summarize the current evidence for the use of antipyretic therapy in critically ill patients. We performed systematic review and meta-analysis of publications from 1966 to 2013. The MEDLINE and CENTRAL databases were searched for studies on antipyresis in critically ill patients. The meta-analysis was limited to: randomized controlled trials; adult human critically ill patients; treatment with antipyretics in one arm versus placebo or non-treatment in another arm; and report of mortality data. The outcomes assessed were overall intensive care unit mortality, changes in temperature, intensive care unit length of stay, and hospital length of stay. Three randomized controlled trials, covering 320 participants, were included. Patients treated with antipyretic agents showed similar intensive care unit mortality (risk ratio 0.91, with 95% confidence interval 0.65-1.28) when compared with controls. The only difference observed was a greater decrease in temperature after 24 hours in patients treated with antipyretics (-1.70±0.40 versus - 0.56±0.25ºC; p=0.014). There is no difference in treating or not the fever in critically ill patients.

Neuromuscular blocking agents in patients with acute respiratory distress syndrome: a summary of the current evidence from three randomized controlled trials.

BACKGROUND: Acute respiratory distress syndrome (ARDS) is a potentially fatal disease with high mortality. Our aim was to summarize the current evidence for use of neuromuscular blocking agents (NMBA) in the early phase of ARDS. METHODS: Systematic review and meta-analysis of publications between 1966 and 2012. The Medline and CENTRAL databases were searched for studies on NMBA in patients with ARDS. The meta-analysis was limited to: 1) randomized controlled trials; 02) adult human patients with ARDS or acute lung injury; and 03) use of any NMBA in one arm of the study compared with another arm without NMBA. The outcomes assessed were: overall mortality, ventilator-free days, time of mechanical ventilation, adverse events, changes in gas exchange, in ventilator settings, and in respiratory mechanics. RESULTS: Three randomized controlled trials covering 431 participants were included. Patients treated with NMBA showed less mortality (Risk ratio, 0.71 [95 % CI, 0.55 - 0.90]; number needed to treat, 1 - 7), more ventilator free days at day 28 (p = 0.020), higher PaO2 to FiO2 ratios (p = 0.004), and less barotraumas (p = 0.030). The incidence of critical illness neuromyopathy was similar (p = 0.540). CONCLUSIONS: The use of NMBA in the early phase of ARDS improves outcome.

Devemos tratar febre em doentes graves? Resumo da evidência atual de três ensaios clínicos randomizados / Should we treat fever in critically ill patients? A summary of the current evidence from three randomized controlled trials

A febre é uma resposta não específica a vários tipos de insultos, de origem infecciosa ou não, e sua importância em doenças continua a ser um enigma. Nosso objetivo foi resumir a evidência atual para o uso de antipiréticos em pacientes graves. Foram realizadas revisão sistemática e meta-análise de publicações entre 1966 e 2013. As bases de dados MEDLINE e CENTRAL foram pesquisadas para estudos sobre antipirese em pacientes graves. A meta-análise restringiu-se a ensaios clínicos randomizados em humanos adultos; pacientes graves; tratamento com antipiréticos em um braço contra placebo ou não tratamento no outro; e dados sobre mortalidade. Os desfechos avaliados foram: mortalidade geral na unidade de terapia intensiva, mudança de temperatura e tempo de internação na unidade de terapia intensiva e no hospital. Três ensaios clínicos randomizados com 320 participantes foram incluídos. Os pacientes tratados com antipiréticos tiveram mortalidade na unidade de terapia intensiva semelhante aos controles (razão de risco de 0,91, com intervalo de confiança de 95% de 0,65-1,28). A única diferença observada foi uma diminuição na temperatura após 24 horas em pacientes tratados com antipiréticos (-1,70±0,40 x - 0,56±0,25ºC; p=0,014). Não houve diferença entre tratar ou não a febre em pacientes graves.

Fever is a nonspecific response to various types of infectious or non-infectious insult and its significance in disease remains an enigma. Our aim was to summarize the current evidence for the use of antipyretic therapy in critically ill patients. We performed systematic review and meta-analysis of publications from 1966 to 2013. The MEDLINE and CENTRAL databases were searched for studies on antipyresis in critically ill patients. The meta-analysis was limited to: randomized controlled trials; adult human critically ill patients; treatment with antipyretics in one arm versus placebo or non-treatment in another arm; and report of mortality data. The outcomes assessed were overall intensive care unit mortality, changes in temperature, intensive care unit length of stay, and hospital length of stay. Three randomized controlled trials, covering 320 participants, were included. Patients treated with antipyretic agents showed similar intensive care unit mortality (risk ratio 0.91, with 95% confidence interval 0.65-1.28) when compared with controls. The only difference observed was a greater decrease in temperature after 24 hours in patients treated with antipyretics (-1.70±0.40 versus - 0.56±0.25ºC; p=0.014). There is no difference in treating or not the fever in critically ill patients.