Presentation and outcome of Middle East respiratory syndrome in Saudi intensive care unit patients.

BACKGROUND: Middle East respiratory syndrome coronavirus infection is associated with high mortality rates but limited clinical data have been reported. We describe the clinical features and outcomes of patients admitted to an intensive care unit (ICU) with Middle East respiratory syndrome coronavirus (MERS-CoV) infection. METHODS: Retrospective analysis of data from all adult (>18 years old) patients admitted to our 20-bed mixed ICU with Middle East respiratory syndrome coronavirus infection between October 1, 2012 and May 31, 2014. Diagnosis was confirmed in all patients using real-time reverse transcription polymerase chain reaction on respiratory samples. RESULTS: During the observation period, 31 patients were admitted with MERS-CoV infection (mean age 59 ± 20 years, 22 [71 %] males). Cough and tachypnea were reported in all patients; 22 (77.4 %) patients had bilateral pulmonary infiltrates. Invasive mechanical ventilation was applied in 27 (87.1 %) and vasopressor therapy in 25 (80.6 %) patients during the intensive care unit stay. Twenty-three (74.2 %) patients died in the ICU. Nonsurvivors were older, had greater APACHE II and SOFA scores on admission, and were more likely to have received invasive mechanical ventilation and vasopressor therapy. After adjustment for the severity of illness and the degree of organ dysfunction, the need for vasopressors was an independent risk factor for death in the ICU (odds ratio = 18.33, 95 % confidence interval: 1.11-302.1, P = 0.04). CONCLUSIONS: MERS-CoV infection requiring admission to the ICU is associated with high morbidity and mortality. The need for vasopressor therapy is the main risk factor for death in these patients.

Fluid resuscitation in sepsis: a systematic review and network meta-analysis.

BACKGROUND: Fluid resuscitation is the cornerstone of sepsis treatment. However, whether balanced or unbalanced crystalloids or natural or synthetic colloids confer a survival advantage is unclear. PURPOSE: To examine the effect of different resuscitative fluids on mortality in patients with sepsis. DATA SOURCES: MEDLINE, EMBASE, ACP Journal Club, CINAHL, HealthSTAR, the Allied and Complementary Medicine Database, and the Cochrane Central Register of Controlled Trials through March 2014. STUDY SELECTION: Randomized trials that evaluated different resuscitative fluids in adult patients with sepsis or septic shock and death. No language restrictions were applied. DATA EXTRACTION: Two reviewers extracted data on study characteristics, methods, and outcomes. Risk of bias for individual studies and quality of evidence were assessed. DATA SYNTHESIS: 14 studies (18916 patients) were included with 15 direct comparisons. Network meta-analysis at the 4-node level showed higher mortality with starches than with crystalloids (high confidence) and lower mortality with albumin than with crystalloids (moderate confidence) or starches (moderate confidence). Network meta-analysis at the 6-node level showed lower mortality with albumin than with saline (moderate confidence) and low-molecular-weight starch (low confidence) and with balanced crystalloids than with saline (low confidence) and low- and high-molecular-weight starches (moderate confidence). LIMITATIONS: These trials were heterogeneous in case mix, fluids evaluated, duration of fluid exposure, and risk of bias. Imprecise estimates for several comparisons in this network meta-analysis contribute to low confidence in most estimates of effect. CONCLUSION: Among patients with sepsis, resuscitation with balanced crystalloids or albumin compared with other fluids seems to be associated with reduced mortality. PRIMARY FUNDING SOURCE: The Hamilton Chapter of the Canadian Intensive Care Foundation and the Critical Care Medicine Residency Program and Critical Care Division Alternate Funding Plan at McMaster University.

Small bowel feeding and risk of pneumonia in adult critically ill patients: a systematic review and meta-analysis of randomized trials.

INTRODUCTION: This systematic review and meta-analysis aimed to evaluate the effect of small bowel feeding compared with gastric feeding on the frequency of pneumonia and other patient-important outcomes in critically ill patients. METHODS: We searched EMBASE, MEDLINE, clinicaltrials.gov and personal files from 1980 to Dec 2012, and conferences and proceedings from 1993 to Dec 2012 for randomized trials of adult critically ill patients in the intensive care unit (ICU) comparing small bowel feeding to gastric feeding, and evaluating risk of pneumonia, mortality, length of ICU stay, achievement of caloric requirements, duration of mechanical ventilation, vomiting, and aspiration. Independently, in duplicate, we abstracted trial characteristics, outcomes and risk of bias. RESULTS: We included 19 trials with 1394 patients. Small bowel feeding compared to gastric feeding was associated with reduced risk of pneumonia (risk ratio [RR] 0.70; 95% CI, 0.55, 0.90; P = 0.004; I2 = 0%) and ventilator-associated pneumonia (RR 0.68; 95% CI 0.53, 0.89; P = 0.005; I2 = 0%), with no difference in mortality (RR 1.08; 95% CI 0.90, 1.29; P = 0.43; I2 = 0%), length of ICU stay (WMD -0.57; 95%CI -1.79, 0.66; P = 0.37; I2 = 0%), duration of mechanical ventilation (WMD -1.01; 95%CI -3.37, 1.35; P = 0.40; I2 = 17%), gastrointestinal bleeding (RR 0.89; 95% CI 0.56, 1.42; P = 0.64; I2 = 0%), aspiration (RR 0.92; 95% CI 0.52, 1.65; P = 0.79; I2 = 0%), and vomiting (RR 0.91; 95% CI 0.53, 1.54; P = 0.72; I2 = 57%). The overall quality of evidence was low for pneumonia outcome. CONCLUSIONS: Small bowel feeding, in comparison with gastric feeding, reduces the risk of pneumonia in critically ill patients without affecting mortality, length of ICU stay or duration of mechanical ventilation. These observations are limited by variation in pneumonia definition, imprecision, risk of bias and small sample size of individual trials.

Intraaortic balloon pump in patients with cardiogenic shock complicating myocardial infarction: a systematic review and meta-analysis of randomized trials.

INTRODUCTION: Cardiogenic shock is associated with significant mortality, particularly when caused by myocardial infarction. Intraaortic balloon pump (IABP) is the primary hemodynamic adjunct in patients with cardiogenic shock; however, evidence suggests that IABP may not improve mortality in this population. METHODS: We conducted an electronic search of the Medline, EMBASE, and Cochrane trial registry databases. Two reviewers independently screened citations and identified eligible trials. The same reviewers abstracted data independently. We pooled the data using a fixed effect model and reported dichotomous outcomes as risk ratios (RRs) with 95% confidence intervals (CIs). Subsequently, we used the GRADE approach to judge the quality of evidence. RESULTS: We included 4 randomized trials with 735 patients. The use of IABP did not reduce the risk of death in patients with cardiogenic shock secondary to cardiac ischemia when compared with usual care (RR, 0.94; 95% CI, 0.79-1.13; P = 0.52; I² = 0%; moderate confidence). The use of IABP was not associated with an increased risk of stroke (RR, 0.77; 95% CI 0.22-2.69; P = 0.68; I² = 48%; very low confidence), limb ischemia (RR, 1.24; 95% CI, 0.59-2.59; P = 0.58; I² = 0%; low confidence), or major bleeding (RR, 0.76; 95% CI, 0.34-1.72; P = 0.52; I² = 0%; low confidence). CONCLUSIONS: The use of IABP in patients with cardiogenic shock complicating myocardial ischemia does not reduce mortality (moderate confidence) and is not associated with a higher risk of complications (very low to low confidence). The results should be interpreted with caution owing to limitations such as imprecision, risk of bias, and clinical heterogeneity.

Intra-aortic balloon pump in patients with cardiogenic shock complicating myocardial infarction: a systematic review and meta-analysis of randomized trials (protocol).

BACKGROUND: Cardiogenic shock is the leading cause of death in patients with acute myocardial infarction. Despite significant advancements in health technology and research, hospital mortality approaches 50%. The intra-aortic balloon pump is a mechanical hemodynamic assist device that has been used for over 40 years in the management of patients with cardiogenic shock. A recent randomized trial suggests that the use of intra-aortic balloon pumps does not reduce mortality in patients with ischemic cardiogenic shock. METHODS: We plan to search MEDLINE, EMBASE, and the Cochrane Trial Registry for potentially eligible randomized trials that compare the use of intra-aortic balloon pump with no mechanical device support in patients with cardiogenic shock. No date, language or journal limitations will be applied. Two reviewers will independently screen and identify eligible studies using predefined eligibility criteria. Data abstraction will be done independently and in duplicate. We plan to use RevMan software to generate pooled estimates across included studies, using the previously published method of DerSimonian and Laird. We will report pooled estimates as risk ratios with 95% confidence intervals for binary outcomes, and as mean differences with 95% confidence intervals for continuous outcomes. We will assess the quality of evidence using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. DISCUSSION: The aim of this systematic review and meta-analysis is to summarize the available evidence on the efficacy of the intra-aortic balloon pump in cardiogenic shock. Systematic review registration: PROSPERO CRD42014007056.

Fluid resuscitation in severe sepsis and septic shock: systematic description of fluids used in randomized trials.

INTRODUCTION:  Fluid therapy is one of the cornerstones of initial management of sepsis, but the choice of fluids used for resuscitation is controversial.  OBJECTIVES:  While trying to determine the effects of alternative fluids used in sepsis resuscitation randomized controlled trials (RCTs), we found that the precise description of those fluids was frequently not available. This report presents the result of our efforts to provide the characteristics of those fluids to both researchers and clinicians. METHODS:  We searched the following electronic databases: CENTRAL, MEDLINE, EMBASE, CINAHL, and ACPJC, and examined the reference lists of recently published meta­analyses of fluid therapies in critically ill patients. These databases were searched from inception until August 2013. The data abstraction stage included determination of fluid composition, pH, chloride concentration, and presence or absence of buffers. We relied on the original articles as well as on manufacturers' websites, contact with authors, and contact with experts in the field.  RESULTS:  Our original search yielded 7002 articles. In consecutive stages, we reduced it to 20. The types of fluids varied widely, including chloride content (110-154 mmol/l) and presence or absence of buffering substances in colloid solutions. Those characteristics were frequently not presented and rarely emphasized in the original articles.  CONCLUSIONS:  The basic characteristics of fluids used in fluid therapy trials are often not easily available, yet of increasingly recognized clinical importance. We provide the information concerning composition of fluids used in RCTs, which will be useful not only to future investigators and systematic reviewers but also to clinicians using those fluids in regular clinical practice.