Giacomo Monti

Percutaneous tracheostomy, a systematic review.

Percutaneous dilatational tracheostomy (PDT) is a common procedure in intensive care units and the identification of the best technique is very important. We performed a systematic review and meta‐analysis of randomized studies comparing different PDT techniques in critically ill adult patients to investigate if one technique is superior to the others with regard to major and minor intraprocedural complications.

Spinal Analgesia in Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

OBJECTIVE Controversial results exist on the effects of spinal analgesia in cardiac surgery. The authors conducted a review of randomized studies to show whether there are any advantages in clinically relevant outcomes using spinal analgesia in patients undergoing cardiac surgery. DESIGN Meta-analysis. SETTING Multiple hospitals. PARTICIPANTS A total of 1,106 patients from 25 randomized trials. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULT PubMed, BioMedCentral, CENTRAL, EMBASE, Cochrane Central Register of Controlled Trials, and conference proceedings were searched (updated January 2009) for randomized trials that compared general anesthesia with an anesthetic plan including spinal analgesia in cardiac surgery. Four independent reviewers performed data extraction, with divergences resolved by consensus. A total of 1,106 patients from 25 randomized studies were included in the analysis. Overall analysis showed that there were no differences in terms of mortality (2/562 [0.4%] in the spinal group v 2/514 [0.4%] in the control arm [risk difference (RD) = 0.00 [-0.02, +0.02], p = 1.0), perioperative myocardial infarction (9/421 [2.1%] in the spinal group v 11/407 [2.7%] in the control arm [RD = 0.00, -(0.03, +0.02), p = 0.77), and the length of hospital stay (WMD = -0.28 days [-0.68, -0.13], p = 0.18, with 419 included patients). CONCLUSIONS This analysis indicated that spinal analgesia does not improve clinically relevant outcomes in patients undergoing cardiac surgery, discouraging further randomized controlled trials on this topic even if changes in techniques, devices, and drugs could modify the outlook of the comparison between spinal and standard anesthesia in this setting.

Vitamin D and outcomes in adult critically ill patients. A systematic review and meta-analysis of randomized trials

Purpose: Low vitamin D blood levels are associated with high mortality in critically ill patients. There is controversy about vitamin D supplementation in this population. The objective of this meta‐analysis was to evaluate if vitamin D administration reduces mortality in critically ill patients. Materials and methods: Online databases were searched up to September 1st, 2016 for randomized placebo‐controlled trials on the use of vitamin D in adult patients with critical illness. The primary end point was mortality among trials with low risk of bias. The secondary end points were length of hospital stay, length of intensive care unit stay, length of mechanical ventilation, and adverse events. Results: Seven studies published between 2011 and 2016, for a total of 716 patients, were included in the analysis. Vitamin D administration was associated with significantly lower mortality compared with placebo (101/320 [32%] in the vitamin D group vs 123/307 [40%] in the placebo group; odds ratio, 0.70 [95% confidence interval, 0.50 to 0.98]; P = .04; I2 = 0%). No differences in adverse events and other secondary end points were found. Conclusions: In critically ill patients, vitamin D administration might be associated with a reduction in mortality without significant adverse events. A large multicenter randomized trial should conclusively confirm these findings.

Single dilator vs. guide wire dilating forceps tracheostomy: a meta-analysis of randomised trials

Single dilator technique (SDT) and guide wire dilating forceps (GWDF) are the two most commonly used techniques of percutaneous dilatational tracheostomy (PDT) in critically ill adult patients. We performed a meta‐analysis of randomised, controlled trials comparing intraoperative, mid‐term and late complications of these two techniques.

Propofol and survival: A meta-analysis of randomized clinical trials

One of the most commonly used hypnotics is propofol. Several studies performed in cardiac surgery suggested an increased mortality in patients receiving a propofol‐based total intravenous anaesthesia. Furthermore, the possibility of infections and the ‘propofol syndrome’ have suggested that propofol might be dangerous. Nonetheless, propofol is widely used in different settings because of its characteristics: fast induction, rapid elimination, short duration of action, smooth recovery from anaesthesia, few adverse effects, no teratogenic effects, characteristics that have undoubtedly contributed to its popularity. The effect of propofol on survival is unknown. We decided to carry out a meta‐analysis of all randomized controlled studies ever performed on propofol vs. any comparator in any clinical setting.

Human protein C concentrates in adult septic patients

Some case reports and case series suggest that protein C concentrates may improve the outcome in patients with congenital or acquired protein C deficiency (not only in those with sepsis induced purpura fulminans). We reviewed the published literature on the use of protein C concentrates in adult septic patients and found that it is limited to less than 70 patients reported in observational studies with a 70% survival, and added our personal experience (two adult patients with sepsis and contraindications to recombinant activated protein C).

Continuous infusion versus bolus injection of furosemide in pediatric patients after cardiac surgery: A meta-analysis of randomized studies

Introduction. Acute renal failure and fluid retention are common problems in pediatric patients after cardiac surgery. Furosemide, a loop diuretic drug, is frequently administered to increase urinary output. The aim of the present study was to compare efficacy and complications of continuous infusion of furosemide vs bolus injection among pediatric patients after cardiac surgery. Methods. A systematic review and meta-analysis was performed in compliance with The Cochrane Collaboration and the Quality of Reporting of Meta-Analysis (QUORUM) guidelines. The following inclusion criteria were employed for potentially relevant studies: a) random treatment allocation, b) comparison of furosemide bolus vs continuous infusion, c) surgical or intensive care pediatric patients. Non-parallel design randomized trials (e.g. cross-over), duplicate publications and non-human experimental studies were excluded. Results. Up to August 2008, only three studies were found, with 92 patients randomized (50 to continuous infusion and 42 to bolus treatment). Overall analysis showed that continuous infusion and bolus administration were equally effective in achieving the predefined urinary output, and were associated with a similar amount of administered furosemide (WMD=- 1.71 mg/kg/day (-5.20; +1.78), p for effect=0.34, p for heterogeneity<0.001, I2=99.0). However, in the continuous infu- sion group, patients had a significantly reduced urinary output (WMD=-0.48 ml/kg/day (-0.88; -0.08), p for effect=0.02, p for heterogeneity <0.70, I2=0%). Conclusions. Existing data comparing furosemide bolus injection with a continuous infusion are insufficient to confidently assess the best way to administer furosemide to pediatric patients after cardiac surgery. Larger studies are needed before any recommendations can be made.

Interventions affecting mortality in critically ill and perioperative patients: A systematic review of contemporary trials

Purpose: Confounders in randomized controlled trials (RCTs) reporting significant effects on mortality in critically ill patients using non‐surgical techniques have not been systematically explored. We aimed to identify factors unrelated to the reported intervention that might have affected the findings and robustness of such trials. Methods: We searched Pubmed/MEDLINE for all RCTs on any non‐surgical interventions reporting an effect on unadjusted mortality in critically ill patients between 1/1/2000 and 1/12/2015. We assessed: the number needed to treat/harm (NNT or NNH), sample size, trial design (blinded/unblinded, single or multinational, single or multicenter (sRCT or mRCT)), intention to treat (ITT) analysis, and countries of origin. Results: Almost half of RCTs were sRCTs. Median sample size was small, and 1/3 were not analyzed according to ITT principle. Lack of ITT analysis was associated with greater effect size (p = 0.0028). Harm was more likely in mRCTs (p = 0.002) and/or in blinded RCTs (p = 0.003). Blinded RCTs had double sample size (p = 0.007) and an increased NNT/NNH (p = 0.002). Finally, mRCTs had higher NNT (p = 0.005) and NNH (p = 0.02), and harm was only detected in studies from Western countries (p = 0.007). Conclusions: These observations imply that major systematic biases exist and affect trial findings irrespective of the intervention being studied. HIGHLIGHTSNo systematic exploration of confounders in RCTs reporting a significant effect on mortality has been performed.47% of these trials were single centre, 31% were not analysed according to the intention to treat principle.Blinded and/or multicentre design was associated with an increased number needed to treat/harm.Major systematic biases exist and affect trial findings irrespective of the intervention being studied.

Continuous infusion versus bolus injection of furosemide in critically ill patients. A systematic review and meta-analysis

Introduction. Fluid overload and a positive fluid balance are common in the intensive care unit (ICU). Furosemide is frequently administered to increase urine output. A bolus injection is the traditional mode of administration, but many concerns have been raised about possible intravascular volume fluctuations, toxicity and enhanced tolerance. Furosemide related adverse effects can be enhanced in critically ill patients. Continuous infusion should allow better hemodynamic stability, less side effects and an easier achievement of the desired diuretic effect. We performed a systematic review and meta-analysis to compare the effects and complications of continuous furosemide infusion with those of bolus injections in critically ill patients in the ICU. Methods. Studies were searched in PubMed (updated January 2009). Backward snowballing of included papers was performed. International experts were contacted for further studies. The inclusion criteria were: random allocation to treatment, comparison of furosemide bolus vs continuous infusion, performed in surgical or intensive care patients. The exclusion criteria were: non-parallel design randomized trials, duplicate publications, non-human experimental studies, no outcome data. Results. Four eligible randomized clinical trials were identified, including 129 patients (64 to continuous infusion and 65 to bolus treatment). Continuous perfusion was not associated with a significant reduction in risk of mortality as compared to bolus injection Conclusions. Furosemide in continuous perfusion was not associated with a significant reduction in risk of hospital mortality as compared to bolus administration in critically ill patients in ICU, but existing data are insufficient to confidently assess the best way to administer furosemide . Applying a protocol to drive furosemide therapy could be more relevant than the chosen mode of administration.

Long-Term Survival Rate in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation in Ordinary Wards.

Objective:Noninvasive ventilation is a life-saving technique increasingly used to treat acute respiratory failure. Noninvasive ventilation has been applied mostly in ICUs, but several reasons brought to an increasing application of noninvasive ventilation in ordinary wards. Few articles evaluated the outcomes of patients receiving noninvasive ventilation including long-term follow-up. The aim of the present study was to assess 1-year survival rate of patients treated with noninvasive ventilation outside the ICU for acute respiratory failure of heterogeneous causes and to identify the predictors of long-term mortality. Design:Prospective, observational, pragmatic study. Setting:Ordinary wards of a teaching hospital. Patients:Consecutive patients treated with noninvasive ventilation for acute respiratory failure. Interventions:None. Measurements and Main Results:Two-hundred and twenty-patients were enrolled. Mortality rates at 30-day, 90-days, and 1-year follow-up were 20%, 26%, and 34%. When excluding patients with “do-not-resuscitate” status, mortality rates were 13%, 19%, and 28%. The multivariate analyses identified solid cancer, pneumonia in hematologic patients, and do-not-resuscitate status as independent predictors of mortality with postoperative acute respiratory failure associated with improved survival. The same predictors were confirmed when excluding do-not-resuscitate patients from the analyses. Conclusions:Noninvasive ventilation applied in ordinary wards was effective, with long-term outcomes not different from those reported for ICU settings. Solid cancer, pneumonia in hematologic malignancies, and do-not-resuscitate status predicted mortality, whereas patients with postoperative acute respiratory failure had the best survival rate. Additional studies are required to evaluate noninvasive ventilation efficacy in the wards compared with ICU.