Dashiell Gantner

Diagnostic accuracy of a questionnaire and simple home monitoring device in detecting obstructive sleep apnoea in a Chinese population at high cardiovascular risk

Background and objective:  OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnosed globally in part due to the limited availability and technical requirements of polysomnography (PSG). The aim of this study was to test the accuracy of two simple methods for diagnosing OSA.

Age of Red Cells for Transfusion and Outcomes in Critically Ill Adults

BACKGROUND It is uncertain whether the duration of red‐cell storage affects mortality after transfusion among critically ill adults. METHODS In an international, multicenter, randomized, double‐blind trial, we assigned critically ill adults to receive either the freshest available, compatible, allogeneic red cells (short‐term storage group) or standard‐issue (oldest available), compatible, allogeneic red cells (long‐term storage group). The primary outcome was 90‐day mortality. RESULTS From November 2012 through December 2016, at 59 centers in five countries, 4994 patients underwent randomization and 4919 (98.5%) were included in the primary analysis. Among the 2457 patients in the short‐term storage group, the mean storage duration was 11.8 days. Among the 2462 patients in the long‐term storage group, the mean storage duration was 22.4 days. At 90 days, there were 610 deaths (24.8%) in the short‐term storage group and 594 (24.1%) in the long‐term storage group (absolute risk difference, 0.7 percentage points; 95% confidence interval [CI], ‐1.7 to 3.1; P=0.57). At 180 days, the absolute risk difference was 0.4 percentage points (95% CI, ‐2.1 to 3.0; P=0.75). Most of the prespecified secondary measures showed no significant between‐group differences in outcome. CONCLUSIONS The age of transfused red cells did not affect 90‐day mortality among critically ill adults. (Funded by the Australian National Health and Medical Research Council and others; TRANSFUSE Australian and New Zealand Clinical Trials Registry number, ACTRN12612000453886; ClinicalTrials.gov number, NCT01638416.)

Diagnostic accuracy of a questionnaire and simple home monitoring device in detecting obstructive sleep apnea in a high cardiovascular risk Chinese population

Background and objective:  OSA is a common condition associated with cardiovascular (CV) morbidity. It remains underdiagnosed globally in part due to the limited availability and technical requirements of polysomnography (PSG). The aim of this study was to test the accuracy of two simple methods for diagnosing OSA.

Intravenous fluids in traumatic brain injury: what's the solution?

Purpose of reviewIntravenous fluid is a fundamental component of trauma care and fluid management influences patient outcomes. This narrative review appraises recent clinical studies of fluid therapy in patients with traumatic brain injury (TBI), with respect to its use in volume resuscitation and prevention of secondary injury. Recent findingsDespite the development of level 1 evidence in fluid resuscitation, in patients with TBI key questions concerning optimal composition and volume remain unanswered. In the absence of randomized trials demonstrating patient outcome differences, clinical practice is often based on physiological principles and surrogate endpoints. There is a physiological rationale why excessive fluid administration and positive fluid balance may increase brain swelling and intracranial pressure (ICP); in some patients, a lower cumulative fluid balance may improve outcomes, but limited human data exist. Resuscitation with 4% albumin in TBI patients in ICU worsens mortality, which may be mediated by increased ICP during the first week after injury. Hypertonic saline and mannitol decrease ICP, but may not improve survival or neurological outcomes. Sodium lactate may be a future therapy for treatment and prevention of secondary brain injury. SummaryIn patients with TBI, intravenous fluids are integral to management; they may be both a source of harm and a potential therapy to limit secondary brain injury. They should be prescribed in accordance with other pharmaceutical or therapeutic interventions. Refined usage may improve patient outcomes.

Nutrition therapy in critically ill patients- a review of current evidence for clinicians

The provision of nutrition to critically ill patients is internationally accepted as standard of care in intensive care units (ICU). Nutrition has the potential to positively impact patient outcomes, is relatively inexpensive compared to other commonly used treatments, and is increasingly identified as a marker of quality ICU care. Furthermore, we are beginning to understand its true potential, with positive and deleterious consequences when it is delivered inappropriately. As with many areas of medicine the evidence is rapidly changing and often conflicting, making interpretation and application difficult for the individual clinician. This narrative review aims to provide an overview of the major evidence base on nutrition therapy in critically ill patients and provide practical suggestions.

Adherence to Guidelines in Adult Patients with Traumatic Brain Injury: A Living Systematic Review

Guidelines aim to improve the quality of medical care and reduce treatment variation. The extent to which guidelines are adhered to in the field of traumatic brain injury (TBI) is unknown. The objectives of this systematic review were to (1) quantify adherence to guidelines in adult patients with TBI, (2) examine factors influencing adherence, and (3) study associations of adherence to clinical guidelines and outcome. We searched EMBASE, MEDLINE, Cochrane Central, PubMed, Web of Science, PsycINFO, SCOPUS, CINAHL, and grey literature in October 2014. We included studies of evidence-based (inter)national guidelines that examined the acute treatment of adult patients with TBI. Methodological quality was assessed using the Research Triangle Institute item bank and Quality in Prognostic Studies Risk of Bias Assessment Instrument. Twenty-two retrospective and prospective observational cohort studies, reported in 25 publications, were included, describing adherence to 13 guideline recommendations. Guideline adherence varied considerably between studies (range 18-100%) and was higher in guideline recommendations based on strong evidence compared with those based on lower evidence, and lower in recommendations of relatively more invasive procedures such as craniotomy. A number of patient-related factors, including age, Glasgow Coma Scale, and intracranial pathology, were associated with greater guideline adherence. Guideline adherence to Brain Trauma Foundation guidelines seemed to be associated with lower mortality. Guideline adherence in TBI is suboptimal, and wide variation exists between studies. Guideline adherence may be improved through the development of strong evidence for guidelines. Further research specifying hospital and management characteristics that explain variation in guideline adherence is warranted.

Erythropoiesis-stimulating Agents in Critically Ill Trauma Patients: A Systematic Review and Meta-analysis

Objective: To perform a meta-analysis of all relevant randomized controlled trials assessing the effect of erythropoiesis-stimulating agents (ESAs) in critically ill trauma patients. Background: ESAs have effects beyond erythropoiesis. The administration of the ESA epoetin alfa to critically ill trauma patients has been associated with a reduction in mortality. Methods: We performed a systematic review and meta-analysis with trial sequential analysis. We searched Medline, Medline in Process, and other nonindexed citations, EMBASE, and the Cochrane Database from inception until September 9, 2015, for randomized controlled trials comparing ESAs to placebo (or no ESA). Results: We identified 9 eligible studies that randomly assigned 2607 critically ill patients after trauma to an ESA or placebo (or no ESA). Compared with placebo (or no ESA), ESA therapy was associated with a substantial reduction in mortality [risk ratio (RR) 0.63, 95% confidence interval (CI) 0.49–0.79, P = 0.0001, I2 = 0%). In patients with traumatic brain injury, ESA therapy did not increase the number of patients surviving with moderate disability or good recovery (RR 1.00, 95% CI 0.88–1.15, P = 0.95, I2 = 0%). With the dosing regimens employed in the included studies, ESA therapy did not increase the risk of lower limb proximal deep venous thrombosis (RR 0.97, 95% CI 0.72–1.29, P = 0.78, I2 = 0%). Conclusions: The administration of ESAs to critically ill trauma patients is associated with a significant improvement in mortality without an increase in the rate of lower limb proximal deep venous thrombosis. Given the worldwide public health significance of these findings research to validate or refute them is required.

Erythropoietin to Reduce Mortality in Traumatic Brain Injury: A Post-hoc Dose-effect Analysis

Objective: We aimed to assess whether the dosing regimen of erythropoietin shows a relationship to mortality in critically ill patients with traumatic brain injury (TBI). Background: Erythropoietin may decrease mortality in patients with TBI; however, the optimal dosing regimen remains uncertain. Methods: We conducted a post-hoc analysis of a multicenter, randomized trial of weekly erythropoietin versus placebo in patients with moderate and severe TBI admitted to intensive care. We assessed whether the cumulative dosage of erythropoietin was differentially associated with all-cause patient mortality evaluated at 6 months after injury. Results: There was a nonlinear relationship between dose and mortality (P = 0.008) that remained after adjustment for site and severity of illness (P = 0.01). Six-month mortality was lower in randomized patients who received 1 [adjusted hazard ratio (HR) 0.58, 95% confidence interval (CI) 0.33–1.01; P = 0.06] or 2 doses of erythropoietin (HR 0.31, 95% CI 0.12–0.80; P = 0.02) compared with those who received no doses. No benefit was seen with 3 doses (HR 1.55, 95% CI 0.66–3.62; P = 0.33). There was no differential effect of dose on functional neurological outcomes. Results across subgroups and secondary intention to treat analyses were consistent with primary findings. Conclusions: This post-hoc, hypothesis-generating analysis found potential reductions in mortality following 1 or 2 weekly doses of 40,000 IU of erythropoietin in intensive care unit patients with moderate or severe TBI, but not with 3 doses. These findings will inform the design of future trials of erythropoietin in critically ill patients with TBI and trauma.

Effect of Early Sustained Prophylactic Hypothermia on Neurologic Outcomes Among Patients With Severe Traumatic Brain Injury: The POLAR Randomized Clinical Trial

Importance After severe traumatic brain injury, induction of prophylactic hypothermia has been suggested to be neuroprotective and improve long-term neurologic outcomes. Objective To determine the effectiveness of early prophylactic hypothermia compared with normothermic management of patients after severe traumatic brain injury. Design, Setting, and Participants The Prophylactic Hypothermia Trial to Lessen Traumatic Brain Injury–Randomized Clinical Trial (POLAR-RCT) was a multicenter randomized trial in 6 countries that recruited 511 patients both out-of-hospital and in emergency departments after severe traumatic brain injury. The first patient was enrolled on December 5, 2010, and the last on November 10, 2017. The final date of follow-up was May 15, 2018. Interventions There were 266 patients randomized to the prophylactic hypothermia group and 245 to normothermic management. Prophylactic hypothermia targeted the early induction of hypothermia (33°C-35°C) for at least 72 hours and up to 7 days if intracranial pressures were elevated, followed by gradual rewarming. Normothermia targeted 37°C, using surface-cooling wraps when required. Temperature was managed in both groups for 7 days. All other care was at the discretion of the treating physician. Main Outcomes and Measures The primary outcome was favorable neurologic outcomes or independent living (Glasgow Outcome Scale–Extended score, 5-8 [scale range, 1-8]) obtained by blinded assessors 6 months after injury. Results Among 511 patients who were randomized, 500 provided ongoing consent (mean age, 34.5 years [SD, 13.4]; 402 men [80.2%]) and 466 completed the primary outcome evaluation. Hypothermia was initiated rapidly after injury (median, 1.8 hours [IQR, 1.0-2.7 hours]) and rewarming occurred slowly (median, 22.5 hours [IQR, 16-27 hours]). Favorable outcomes (Glasgow Outcome Scale–Extended score, 5-8) at 6 months occurred in 117 patients (48.8%) in the hypothermia group and 111 (49.1%) in the normothermia group (risk difference, 0.4% [95% CI, –9.4% to 8.7%]; relative risk with hypothermia, 0.99 [95% CI, 0.82-1.19]; P = .94). In the hypothermia and normothermia groups, the rates of pneumonia were 55.0% vs 51.3%, respectively, and rates of increased intracranial bleeding were 18.1% vs 15.4%, respectively. Conclusions and Relevance Among patients with severe traumatic brain injury, early prophylactic hypothermia compared with normothermia did not improve neurologic outcomes at 6 months. These findings do not support the use of early prophylactic hypothermia for patients with severe traumatic brain injury. Trial Registration clinicaltrials.gov Identifier: NCT00987688; Anzctr.org.au Identifier: ACTRN12609000764235

Variables associated with pulmonary thromboembolism in injured patients: A systematic review

BACKGROUND Pulmonary thromboembolism (PTE) is a dangerous complication of traumatic injury, with varied risk profiles and treatment options. This review aims to describe reported incidence and variables associated with PTE among severely injured patients. METHODS Searches were conducted using PubMed, Cochrane and MEDLINE. Relevant studies were identified by two independent reviewers based on predetermined inclusion criteria. Incidence of PTE was the primary outcome measure. Variables associated with PTE was the secondary outcome measure. The Newcastle-Ottawa Scale was used to assess quality of included studies. RESULTS There were eight studies that satisfied inclusion criteria. The diagnosed incidence of PTE in these populations ranged from 0.35 to 24%. The most common variables associated with PTE were pelvic or lower limb injury, chest injury, higher total Injury Severity Score, male sex and age. Variables that were less commonly associated with PTE were previous warfarin use, head injury, high serum lactate, soft tissue injury, more than one operation, more than three days on a ventilator, presence of a subclavian central venous catheter, need for a blood transfusion, systolic blood pressure <90mmHg, abdominal injury, presence of a deep venous thrombosis, inferior vena cava filter placement and isolated liver spleen or spinal injuries. CONCLUSIONS The reported incidence of PTE after major trauma is variable and dependent on inclusion criteria, diagnostic criteria and study design. Identified variables differed to those reported for venous thromboembolism in other populations. It is difficult to predict populations at risk of clinically significant PTE following injury using available evidence. Further studies linked to patient-specific variables will assist in more precise risk-stratification and interventions.