Kwok M. Ho

Prevalence and factors of intensive care unit conflicts: the conflicus study.

RATIONALE Many sources of conflict exist in intensive care units (ICUs). Few studies recorded the prevalence, characteristics, and risk factors for conflicts in ICUs. OBJECTIVES To record the prevalence, characteristics, and risk factors for conflicts in ICUs. METHODS One-day cross-sectional survey of ICU clinicians. Data on perceived conflicts in the week before the survey day were obtained from 7,498 ICU staff members (323 ICUs in 24 countries). MEASUREMENTS AND MAIN RESULTS Conflicts were perceived by 5,268 (71.6%) respondents. Nurse-physician conflicts were the most common (32.6%), followed by conflicts among nurses (27.3%) and staff-relative conflicts (26.6%). The most common conflict-causing behaviors were personal animosity, mistrust, and communication gaps. During end-of-life care, the main sources of perceived conflict were lack of psychological support, absence of staff meetings, and problems with the decision-making process. Conflicts perceived as severe were reported by 3,974 (53%) respondents. Job strain was significantly associated with perceiving conflicts and with greater severity of perceived conflicts. Multivariate analysis identified 15 factors associated with perceived conflicts, of which 6 were potential targets for future intervention: staff working more than 40 h/wk, more than 15 ICU beds, caring for dying patients or providing pre- and postmortem care within the last week, symptom control not ensured jointly by physicians and nurses, and no routine unit-level meetings. CONCLUSIONS Over 70% of ICU workers reported perceived conflicts, which were often considered severe and were significantly associated with job strain. Workload, inadequate communication, and end-of-life care emerged as important potential targets for improvement.

Perioperative fluid management strategies in major surgery: a stratified meta-analysis

BACKGROUND: Both “liberal” and “goal-directed” (GD) therapy use a large amount of perioperative fluid, but they appear to have very different effects on perioperative outcomes. We sought to determine whether one fluid management strategy was superior to the others. METHODS: We selected randomized controlled trials (RCTs) on the use of GD or restrictive versus liberal fluid therapy (LVR) in major adult surgery from MEDLINE, EMBASE, PubMed (1951 to April 2011), and Cochrane controlled trials register without language restrictions. Indirect comparison between the GD and LVR strata was performed. RESULTS: A total of 3861 patients from 23 GD RCTs (median sample size = 90, interquartile range [IQR] 57 to 109) and 1160 patients from 12 LVR RCTs (median sample size = 80, IQR36 to 151) were considered. Both liberal and GD therapy used more fluid compared to their respective comparative arm, but their effects on outcomes were very different. Patients in the liberal group of the LVR stratum had a higher risk of pneumonia (risk ratio [RR] 2.2, 95% confidence interval [CI] 1.0 to 4.5), pulmonary edema (RR 3.8, 95% CI 1.1 to 13), and a longer hospital stay than those in the restrictive group (mean difference [MD] 2 days, 95% CI 0.5 to 3.4). Using GD therapy also resulted in a lower risk of pneumonia (RR 0.7, 95% CI 0.6 to 0.9) and renal complications (0.7, 95% CI 0.5 to 0.9), and a shorter length of hospital stay (MD 2 days, 95% CI 1 to 3) compared to not using GD therapy. Liberal fluid therapy was associated with an increased length of hospital stay (4 days, 95% CI 3.4 to 4.4), time to first bowel movement (2 days, 95% CI 1.3 to 2.3), and risk of pneumonia (RR ratio 3, 95% CI 1.8 to 4.8) compared to GD therapy. CONCLUSION: Perioperative outcomes favored a GD therapy rather than liberal fluid therapy without hemodynamic goals. Whether GD therapy is superior to a restrictive fluid strategy remains uncertain.

Meta-analysis of frusemide to prevent or treat acute renal failure

Abstract Objective To investigate the potential beneficial and adverse effects of frusemide to prevent or treat acute renal failure in adults. Design Meta-analysis of randomised controlled trials. Data sources Cochrane controlled trials register (2005 issue 4), Embase, and Medline (1966 to 1 February 2006), without language restrictions. Review methods Two reviewers checked the quality of the studies and independently extracted data. Results Nine randomised controlled trials totalling 849 patients with or at risk of acute renal failure were included. Outcome measures not significantly different after frusemide treatment were in-hospital mortality (relative risk 1.11, 95% confidence interval 0.92 to 1.33), risk for requiring renal replacement therapy or dialysis (0.99, 0.80 to 1.22), number of dialysis sessions required (weight mean difference - 0.48 sessions, - 1.45 to 0.50), and proportion of patients with persistent oliguria (urine output < 500 ml/day: 0.54, 0.18 to 1.61). Stratifying studies that used frusemide to prevent or treat acute renal failure did not change the results on mortality (relative risk ratio 2.10, 95% confidence interval 0.67 to 6.63) and the risk for requiring dialysis (4.12, 0.46 to 37.2). Evidence suggested an increased risk of temporary deafness and tinnitus in patients treated with high doses of frusemide (relative risk 3.97, 95% confidence interval 1.00 to 15.78). Conclusions Frusemide is not associated with any significant clinical benefits in the prevention and treatment of acute renal failure in adults. High doses may be associated with an increased risk of ototoxicity.

A systematic review on clinical benefits of continuous administration of β-lactam antibiotics

Objective:The clinical benefits of extended infusion or continuous infusion of &bgr;-lactam antibiotics remain controversial. We systematically reviewed the literature to determine whether any clinical benefits exist for administration of &bgr;-lactam antibiotics by extended or continuous infusion. Data Source:PubMed (January 1950 to November 2007), EMBASE (1966 to November 2007), and the Cochrane Controlled Trial Register were searched (updated November 2007). Study Selections:Randomized controlled trials (RCTs) were meta-analyzed, and observational studies were described by two unblinded reviewers. Data Extraction:A total of 846 patients from eligible prospective randomized controlled studies were included in the meta-analysis. Two observational studies were deemed appropriate for description. Data Synthesis:A meta-analysis of prospective RCTs was undertaken using Review Manager. Among a total of 59 potentially relevant studies, 14 RCTs involving a total of 846 patients from nine countries were deemed appropriate for meta-analysis. The use of continuous infusion of a &bgr;-lactam antibiotic was not associated with an improvement in clinical cure (n = 755 patients; odds ratio: 1.04, 95% confidence interval: 0.74-1.46, p = 0.83, I2 = 0%) or mortality (n = 541 patients; odds ratio: 1.00, 95% confidence interval: 0.48-2.06, p = 1.00, I2 = 14.8%). All RCTs except one used a higher antibiotic dose in the bolus administration group. Two observational studies, not pooled because they did not meet the a priori criteria for meta-analysis, showed that &bgr;-lactam administration by extended or continuous infusion was associated with an improvement in clinical cure. The difference in the results between the meta-analysis results and the observational studies could be explained by the bias created by a higher dose of antibiotic in the bolus group in the RCTs and because many of the RCTs only recruited patients with a low acuity of illness. Conclusions:The limited data available suggest that continuous infusion of &bgr;-lactam antibiotics leads to the same clinical results as higher dosed bolus administration in hospitalized patients.

Safety and efficacy of intravenous iron therapy in reducing requirement for allogeneic blood transfusion: systematic review and meta-analysis of randomised clinical trials

Objectives To evaluate the efficacy and safety of intravenous iron, focusing primarily on its effects on haemoglobin, requirement for transfusion, and risk of infection. Design Systematic review and meta-analysis of randomised controlled trials investigating the safety and efficacy of intravenous iron therapy. Data sources Randomised controlled trials from Medline, Embase, and the Cochrane Central Register of Controlled Trials from 1966 to June 2013, with no language restrictions. Eligibility criteria for selecting studies Eligible trials were randomised controlled trials of intravenous iron compared with either no iron or oral iron. Crossover and observational studies were excluded. Main outcome measures Change in haemoglobin concentration and risk of allogeneic red blood cell transfusion (efficacy) and risk of infection (safety). Results Of the 75 trials meeting the inclusion criteria, 72 studies including 10 605 patients provided quantitative outcome data for meta-analysis. Intravenous iron was associated with an increase in haemoglobin concentration (standardised mean difference 6.5 g/L, 95% confidence interval 5.1 g/L to 7.9 g/L) and a reduced risk of requirement for red blood cell transfusion (risk ratio 0.74, 95% confidence interval 0.62 to 0.88), especially when intravenous iron was used with erythroid stimulating agents (ESAs) or in patients with a lower baseline plasma ferritin concentration. There were no significant interactions between the efficacy of intravenous iron and type or dose administered. Intravenous iron was, however, associated with a significant increase in risk of infection (relative risk 1.33, 95% confidence interval 1.10 to 1.64) compared with oral or no iron supplementation. The results remained similar when only high quality trials were analysed. Conclusions Intravenous iron therapy is effective in increasing haemoglobin concentration and reducing the risk of allogeneic red blood cell transfusion and could have broad applicability to a range of acute care settings. This potential benefit is counterbalanced by a potential increased risk of infection.

Benefits and Risks of Corticosteroid Prophylaxis in Adult Cardiac Surgery A Dose-Response Meta-Analysis

Background— Cardiopulmonary bypass and cardiac surgery are associated with a significant systemic inflammatory response that may increase postoperative complications. This meta-analysis assessed whether the benefits and risks of corticosteroid use were dose dependent in adult cardiac surgery. Methods and Results— Randomized controlled trials of the use of corticosteroid prophylaxis in adult cardiac surgery (>18 years of age) requiring cardiopulmonary bypass were selected from MEDLINE (1966 to August 1, 2008), EMBASE (1988 to August 1, 2008), and the Cochrane controlled trials register without any language restrictions. A total of 3323 patients from 50 randomized controlled trials were identified and subject to meta-analysis. Corticosteroid prophylaxis reduced the risk of atrial fibrillation (25.1% versus 35.1%; number needed to treat, 10; relative risk, 0.74; 95% confidence interval [CI], 0.63 to 0.86; P<0.01) and length of stay in the intensive care unit (weighted mean difference, −0.37 days; 95% CI, −0.21 to −0.52; P<0.01) and hospital (weighted mean difference, −0.66 days; 95% CI, −0.77 to −1.25; P=0.03) compared with placebo. The use of corticosteroid was not associated with an increased risk of all-cause infection (relative risk, 0.93; 95% CI, 0.61 to 1.41; P=0.73), but hyperglycemia requiring insulin infusion after corticosteroid prophylaxis was common (28.2%; relative risk, 1.49; 95% CI, 1.11 to 2.01; P<0.01). No additional benefits were found on all outcomes beyond a total dose of 1000 mg hydrocortisone, and very high doses of corticosteroid were associated with prolonged mechanical ventilation. Conclusions— Evidence suggests that low-dose corticosteroid is as effective as high-dose corticosteroid in reducing the risk of atrial fibrillation and duration of mechanical ventilation but with fewer potential side effects in adult cardiac surgery.

Comment on: Use of chlorhexidine-impregnated dressing to prevent vascular and epidural catheter colonization and infection: a meta-analysis.

Objectives: Vascular and epidural catheter-related infections cause significant morbidities and mortality in hospitalized patients. This meta-analysis assessed the effect of chlorhexidine-impregnated dressing on the risk of vascular and epidural catheter bacterial colonization and infection. Methods: Literature search was based on MEDLINE (1966 to 1 November 2005), EMBASE and Cochrane Controlled Trials Register (2005 issue 3) databases. Only randomized controlled clinical trials comparing chlorhexidine-impregnated dressing with placebo or povidine-iodine dressing were included in this meta-analysis. Two reviewers reviewed and extracted the data independently. Results: Eight studies assessing a single type of chlorhexidine-impregnated dressing were identified and subjected to meta-analysis. The chlorhexidine-impregnated dressing reduced the risk of epidural [3.6% versus 35%, odds ratio (OR) 0.07, 95% CI: 0.02–0.31, P = 0.0005] and intravascular catheter or exit-site bacterial colonization (14.8% versus 26.9%, OR 0.47, 95% CI: 0.34–0.65, P < 0.00001) (overall 14.3% versus 27.2%, OR 0.40, 95% CI: 0.26–0.61; P < 0.0001). The use of chlorhexidine-impregnated dressing was associated with a trend towards reduction in catheter-related bloodstream or CNS infections (2.2% versus 3.8%, OR 0.58, 95% CI: 0.29–1.14, P = 0.11). Local cutaneous reactions to chlorhexidine-impregnated dressing were reported in 5.6% of the patients in three studies (OR 8.17, 95% CI: 1.19–56.14, P = 0.04), and 96% of these reactions occurred in neonatal patients. The number needed to prevent one episode of intravascular catheter-related bloodstream infection was 142 for an average period of catheter in situ of 10 days and a change of dressing every 5 days. The cost of preventing one vascular catheter-related bloodstream infection was estimated to be £298 (US

Long-Term Complications of Decompressive Craniectomy for Head Injury

532.5). Conclusions: Chlorhexidine-impregnated dressing is effective in reducing vascular and epidural catheter bacterial colonization and is also associated with a trend towards reduction in catheter-related bloodstream or CNS infections. A large randomized controlled trial is needed to confirm whether chlorhexidine-impregnated dressing is cost-effective in preventing bacterial infection related to vascular and epidural catheters.

A comparison of continuous and bi-level positive airway pressure non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis.

There is currently much interest in the use of decompressive craniectomy for intracranial hypertension. Though technically straightforward, the procedure is not without significant complications. A retrospective analysis was undertaken of 164 patients who had had a decompressive craniectomy for severe head injury in the years 2004 to 2009 at the two major hospitals in Western Australia. Eighty-six patients had a bifrontal decompression and seventy-eight had a unilateral decompression. Two patients died due to post-operative care issues. Complications attributable to the decompressive surgery were: herniation of the cortex through the bone defect (42 patients, 25.6%), subdural effusion (81 patients, 49.4%), seizures (36 patients, 22%), hydrocephalus (23 patients, 14%), and syndrome of the trephined (2 patients, 1.2%). Complications attributable to the subsequent cranioplasty included: sudden death due to massive cerebral swelling in 3 patients (2.2%), infection requiring removal of the bone flap in 16 patients (11.6%), and bone flap resorption requiring augmentation in 10 patients (7.2%). After excluding simple complications such as subdural effusion and brain herniation through the skull defect and some patients who died as a direct consequence of traumatic brain or extracranial injury, 81 patients (55.5%) had at least one complication after decompressive craniectomy. The occurrence of at least one complication after decompressive craniectomy was significantly associated with an increased risk of prolonged stay in the hospital or rehabilitation facility (odds ratio 2.54, 95%confidence interval 1.22,5.24, p=0.013), after adjusting for predicted risk of unfavorable outcome.

Determinants of Procedural Pain Intensity in the Intensive Care Unit. The Europain® Study

IntroductionWe conducted the present study to investigate the potential beneficial and adverse effects of continuous positive airway pressure (CPAP) compared with bi-level positive airway pressure (BiPAP) noninvasive ventilation in patients with cardiogenic pulmonary oedema.MethodWe included randomized controlled studies comparing CPAP and BiPAP treatment in patients with cardiogenic pulmonary oedema from the Cochrane Controlled Trials Register (2005 issue 3), and EMBASE and MEDLINE databases (1966 to 1 December 2005), without language restriction. Two reviewers reviewed the quality of the studies and independently performed data extraction.ResultsSeven randomized controlled studies, including a total of 290 patients with cardiogenic pulmonary oedema, were considered. The hospital mortality (relative risk [RR] 0.76, 95% confidence interval [CI] 0.32–1.78; P = 0.52; I2 = 0%) and risk for requiring invasive ventilation (RR 0.80, 95% CI 0.33–1.94; P = 0.62; I2 = 0%) were not significantly different between patients treated with CPAP and those treated with BiPAP. Stratifying studies that used either fixed or titrated pressure during BiPAP treatment and studies involving patients with or without hypercapnia did not change the results. The duration of noninvasive ventilation required until the pulmonary oedema resolved (weighted mean difference [WMD] in hours = 3.65, 95% CI -12.12 to +19.43; P = 0.65, I2 = 0%) and length of hospital stay (WMD in days = -0.04, 95% CI -2.57 to +2.48; P = 0.97, I2 = 0%) were also not significantly different between the two groups. Based on the limited data available, there was an insignificant trend toward an increase in new onset acute myocardial infarction in patients treated with BiPAP (RR 2.10, 95% CI 0.91–4.84; P = 0.08; I2 = 25.3%).ConclusionBiPAP does not offer any significant clinical benefits over CPAP in patients with acute cardiogenic pulmonary oedema. Until a large randomized controlled trial shows significant clinical benefit and cost-effectiveness of BiPAP versus CPAP in patients with acute cardiogenic pulmonary oedema, the choice of modality will depend mainly on the equipment available.