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Hemoglobin Transfusion Threshold Not Associated with Differences in Morbidity, Mortality Among Patients with Septic Shock
Clinical question: Is there a difference in 90-day mortality and other outcomes when a lower versus higher hemoglobin threshold is used for blood transfusions in ICU patients with septic shock?
Background: Patients with septic shock frequently receive blood transfusions. This often occurs in the setting of active bleeding but has also been observed in non-bleeding patients for variable hemoglobin levels. Concrete data regarding the efficacy and safety of such transfusions based on hemoglobin thresholds is lacking.
Study design: International, multi-center, stratified, parallel group randomized trial.
Setting: General ICUs in Denmark, Norway, Sweden, and Finland.
Synopsis: Researchers analyzed data from 998 ICU patients in the Transfusion Requirements in Septic Shock (TRISS) trial. Primary outcome was 90-day mortality rate. Hemoglobin levels less than 7 gm/dL and 9 gm/dL were used for lower and higher hemoglobin thresholds, respectively. The mortality rates were 43% and 45%, respectively (RR 0.94; 95% CI 0.78 -1.09; P=0.44); when adjusted for risk factors, the results were similar. Additionally, there were no differences in secondary outcomes (i.e., use of life support, development of ischemic events, and severe adverse reactions).
Hospitalists involved in managing patients with septic shock should be mindful of similar 90-day mortality and several other secondary outcomes regardless of hemoglobin threshold.
Bottom line: Ninety-day mortality and other outcomes were not affected by transfusion thresholds in ICU patients with septic shock.
Clinical question: Is there a difference in 90-day mortality and other outcomes when a lower versus higher hemoglobin threshold is used for blood transfusions in ICU patients with septic shock?
Background: Patients with septic shock frequently receive blood transfusions. This often occurs in the setting of active bleeding but has also been observed in non-bleeding patients for variable hemoglobin levels. Concrete data regarding the efficacy and safety of such transfusions based on hemoglobin thresholds is lacking.
Study design: International, multi-center, stratified, parallel group randomized trial.
Setting: General ICUs in Denmark, Norway, Sweden, and Finland.
Synopsis: Researchers analyzed data from 998 ICU patients in the Transfusion Requirements in Septic Shock (TRISS) trial. Primary outcome was 90-day mortality rate. Hemoglobin levels less than 7 gm/dL and 9 gm/dL were used for lower and higher hemoglobin thresholds, respectively. The mortality rates were 43% and 45%, respectively (RR 0.94; 95% CI 0.78 -1.09; P=0.44); when adjusted for risk factors, the results were similar. Additionally, there were no differences in secondary outcomes (i.e., use of life support, development of ischemic events, and severe adverse reactions).
Hospitalists involved in managing patients with septic shock should be mindful of similar 90-day mortality and several other secondary outcomes regardless of hemoglobin threshold.
Bottom line: Ninety-day mortality and other outcomes were not affected by transfusion thresholds in ICU patients with septic shock.
Clinical question: Is there a difference in 90-day mortality and other outcomes when a lower versus higher hemoglobin threshold is used for blood transfusions in ICU patients with septic shock?
Background: Patients with septic shock frequently receive blood transfusions. This often occurs in the setting of active bleeding but has also been observed in non-bleeding patients for variable hemoglobin levels. Concrete data regarding the efficacy and safety of such transfusions based on hemoglobin thresholds is lacking.
Study design: International, multi-center, stratified, parallel group randomized trial.
Setting: General ICUs in Denmark, Norway, Sweden, and Finland.
Synopsis: Researchers analyzed data from 998 ICU patients in the Transfusion Requirements in Septic Shock (TRISS) trial. Primary outcome was 90-day mortality rate. Hemoglobin levels less than 7 gm/dL and 9 gm/dL were used for lower and higher hemoglobin thresholds, respectively. The mortality rates were 43% and 45%, respectively (RR 0.94; 95% CI 0.78 -1.09; P=0.44); when adjusted for risk factors, the results were similar. Additionally, there were no differences in secondary outcomes (i.e., use of life support, development of ischemic events, and severe adverse reactions).
Hospitalists involved in managing patients with septic shock should be mindful of similar 90-day mortality and several other secondary outcomes regardless of hemoglobin threshold.
Bottom line: Ninety-day mortality and other outcomes were not affected by transfusion thresholds in ICU patients with septic shock.
Early, Goal-Directed Therapy Doesn’t Improve Mortality in Patients with Early Septic Shock
Clinical question: Does early goal-directed therapy (EGDT) improve mortality in patients presenting to the ED with early septic shock?
Background: EGDT (achieving central venous pressure of 8-12 mmHg, superior vena oxygen saturation (ScvO2) of > 70%, mean arterial pressure ≥ 65mmHg, and urine output ≥ 0.5 mL/kg/h) has been endorsed by the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients with septic shock, but its effectiveness is uncertain and has been questioned by a recent randomized trial.
Study design: Prospective, randomized, parallel group trial.
Setting: Fifty-one tertiary and non-tertiary care metropolitan and rural hospitals, mainly in Australia and New Zealand.
Synopsis: Researchers randomized 1,600 patients who presented to the ED with early septic shock (evidence of refractory hypotension or hypoperfusion) to receive EGDT or usual care for six hours. All patients received antimicrobials and fluid resuscitation (approximately 2.5 liters) before randomization. There was no significant difference between the groups for the primary outcome (all-cause mortality at 90 days), but the EGDT group was more likely to receive vasopressor support and red blood cell transfusions and to have invasive monitoring.
Analysis for the whole group and various patient subgroups (location, age, APACHE II score, and others) did not show any benefit from using EGDT for any outcomes (including length of stay in ICU and hospital, invasive mechanical ventilation, and use of renal replacement therapy).
This study confirms that early diagnosis and aggressive treatment of sepsis is crucial. EGDT might be less important when fluid resuscitation and antimicrobials are started early after sepsis is suspected. With continuous improvement in these areas, monitoring of certain parameters as required in EGDT (like ScvO2, which requires a special catheter) might not be as important.
Bottom line: Early-goal directed therapy is not associated with improved mortality in sepsis in patients treated early with antimicrobials and aggressive fluid resuscitation.
Clinical question: Does early goal-directed therapy (EGDT) improve mortality in patients presenting to the ED with early septic shock?
Background: EGDT (achieving central venous pressure of 8-12 mmHg, superior vena oxygen saturation (ScvO2) of > 70%, mean arterial pressure ≥ 65mmHg, and urine output ≥ 0.5 mL/kg/h) has been endorsed by the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients with septic shock, but its effectiveness is uncertain and has been questioned by a recent randomized trial.
Study design: Prospective, randomized, parallel group trial.
Setting: Fifty-one tertiary and non-tertiary care metropolitan and rural hospitals, mainly in Australia and New Zealand.
Synopsis: Researchers randomized 1,600 patients who presented to the ED with early septic shock (evidence of refractory hypotension or hypoperfusion) to receive EGDT or usual care for six hours. All patients received antimicrobials and fluid resuscitation (approximately 2.5 liters) before randomization. There was no significant difference between the groups for the primary outcome (all-cause mortality at 90 days), but the EGDT group was more likely to receive vasopressor support and red blood cell transfusions and to have invasive monitoring.
Analysis for the whole group and various patient subgroups (location, age, APACHE II score, and others) did not show any benefit from using EGDT for any outcomes (including length of stay in ICU and hospital, invasive mechanical ventilation, and use of renal replacement therapy).
This study confirms that early diagnosis and aggressive treatment of sepsis is crucial. EGDT might be less important when fluid resuscitation and antimicrobials are started early after sepsis is suspected. With continuous improvement in these areas, monitoring of certain parameters as required in EGDT (like ScvO2, which requires a special catheter) might not be as important.
Bottom line: Early-goal directed therapy is not associated with improved mortality in sepsis in patients treated early with antimicrobials and aggressive fluid resuscitation.
Clinical question: Does early goal-directed therapy (EGDT) improve mortality in patients presenting to the ED with early septic shock?
Background: EGDT (achieving central venous pressure of 8-12 mmHg, superior vena oxygen saturation (ScvO2) of > 70%, mean arterial pressure ≥ 65mmHg, and urine output ≥ 0.5 mL/kg/h) has been endorsed by the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients with septic shock, but its effectiveness is uncertain and has been questioned by a recent randomized trial.
Study design: Prospective, randomized, parallel group trial.
Setting: Fifty-one tertiary and non-tertiary care metropolitan and rural hospitals, mainly in Australia and New Zealand.
Synopsis: Researchers randomized 1,600 patients who presented to the ED with early septic shock (evidence of refractory hypotension or hypoperfusion) to receive EGDT or usual care for six hours. All patients received antimicrobials and fluid resuscitation (approximately 2.5 liters) before randomization. There was no significant difference between the groups for the primary outcome (all-cause mortality at 90 days), but the EGDT group was more likely to receive vasopressor support and red blood cell transfusions and to have invasive monitoring.
Analysis for the whole group and various patient subgroups (location, age, APACHE II score, and others) did not show any benefit from using EGDT for any outcomes (including length of stay in ICU and hospital, invasive mechanical ventilation, and use of renal replacement therapy).
This study confirms that early diagnosis and aggressive treatment of sepsis is crucial. EGDT might be less important when fluid resuscitation and antimicrobials are started early after sepsis is suspected. With continuous improvement in these areas, monitoring of certain parameters as required in EGDT (like ScvO2, which requires a special catheter) might not be as important.
Bottom line: Early-goal directed therapy is not associated with improved mortality in sepsis in patients treated early with antimicrobials and aggressive fluid resuscitation.
Arterial Catheter Use in ICU Doesn’t Improve Hospital Mortality
Clinical question: Does the use of arterial catheters (AC) improve hospital mortality in ICU patients requiring mechanical ventilation?
Background: AC are used in 40% of ICU patients, mostly to facilitate diagnostic phlebotomy (including arterial blood gases) and improve hemodynamic monitoring. Despite known risks (limb ischemia, pseudoaneurysms, infections) and costs necessary for insertion and maintenance, data regarding their impact on outcomes are limited.
Study design: Propensity-matched cohort analysis of data in the Project IMPACT database.
Setting: 139 ICUs in the U.S., with larger and urban hospitals providing the majority of the data.
Synopsis: Of 60,975 medical patients who required mechanical ventilation, 24,126 (39.6%) patients had an AC. Propensity score matching yielded 13,603 pairs of patients who did not have an AC with patients who did have an AC. For many variables that could influence mortality in such patients, there were no significant differences between the two groups. No association between AC use and hospital mortality in medical ICU patients who required mechanical ventilation was noted. This was confirmed in analyses of eight of nine secondary cohorts. In one cohort (patients requiring vasopressors), AC use was associated with an 8% increase in the odds of death. More blood transfusions were administered in the AC group, although this finding did not reach statistical significance.
Despite the rigorous and complex statistical analysis used in this study, residual confounders remained. It is still possible, but unlikely, that patients with an AC could have had a higher expected mortality, which the use of the AC ameliorated. This study raises an important question that should ideally be addressed by randomized trials.
Bottom line: Arterial catheters used in mechanically ventilated patients in the ICU are not associated with lower mortality and should therefore be used with caution, weighing the risks and benefits, until more studies are performed.
Clinical question: Does the use of arterial catheters (AC) improve hospital mortality in ICU patients requiring mechanical ventilation?
Background: AC are used in 40% of ICU patients, mostly to facilitate diagnostic phlebotomy (including arterial blood gases) and improve hemodynamic monitoring. Despite known risks (limb ischemia, pseudoaneurysms, infections) and costs necessary for insertion and maintenance, data regarding their impact on outcomes are limited.
Study design: Propensity-matched cohort analysis of data in the Project IMPACT database.
Setting: 139 ICUs in the U.S., with larger and urban hospitals providing the majority of the data.
Synopsis: Of 60,975 medical patients who required mechanical ventilation, 24,126 (39.6%) patients had an AC. Propensity score matching yielded 13,603 pairs of patients who did not have an AC with patients who did have an AC. For many variables that could influence mortality in such patients, there were no significant differences between the two groups. No association between AC use and hospital mortality in medical ICU patients who required mechanical ventilation was noted. This was confirmed in analyses of eight of nine secondary cohorts. In one cohort (patients requiring vasopressors), AC use was associated with an 8% increase in the odds of death. More blood transfusions were administered in the AC group, although this finding did not reach statistical significance.
Despite the rigorous and complex statistical analysis used in this study, residual confounders remained. It is still possible, but unlikely, that patients with an AC could have had a higher expected mortality, which the use of the AC ameliorated. This study raises an important question that should ideally be addressed by randomized trials.
Bottom line: Arterial catheters used in mechanically ventilated patients in the ICU are not associated with lower mortality and should therefore be used with caution, weighing the risks and benefits, until more studies are performed.
Clinical question: Does the use of arterial catheters (AC) improve hospital mortality in ICU patients requiring mechanical ventilation?
Background: AC are used in 40% of ICU patients, mostly to facilitate diagnostic phlebotomy (including arterial blood gases) and improve hemodynamic monitoring. Despite known risks (limb ischemia, pseudoaneurysms, infections) and costs necessary for insertion and maintenance, data regarding their impact on outcomes are limited.
Study design: Propensity-matched cohort analysis of data in the Project IMPACT database.
Setting: 139 ICUs in the U.S., with larger and urban hospitals providing the majority of the data.
Synopsis: Of 60,975 medical patients who required mechanical ventilation, 24,126 (39.6%) patients had an AC. Propensity score matching yielded 13,603 pairs of patients who did not have an AC with patients who did have an AC. For many variables that could influence mortality in such patients, there were no significant differences between the two groups. No association between AC use and hospital mortality in medical ICU patients who required mechanical ventilation was noted. This was confirmed in analyses of eight of nine secondary cohorts. In one cohort (patients requiring vasopressors), AC use was associated with an 8% increase in the odds of death. More blood transfusions were administered in the AC group, although this finding did not reach statistical significance.
Despite the rigorous and complex statistical analysis used in this study, residual confounders remained. It is still possible, but unlikely, that patients with an AC could have had a higher expected mortality, which the use of the AC ameliorated. This study raises an important question that should ideally be addressed by randomized trials.
Bottom line: Arterial catheters used in mechanically ventilated patients in the ICU are not associated with lower mortality and should therefore be used with caution, weighing the risks and benefits, until more studies are performed.
Bedside Attention Tests May Be Useful in Detecting Delirium
Clinical question: Are simple bedside attention tests a reliable way to routinely screen for delirium?
Background: Early diagnosis of delirium decreases adverse outcomes, but it often goes unrecognized, in part because clinicians do not routinely screen for it. Patients at high risk of delirium should be assessed regularly, although the best brief screening method is unknown. For example, the Confusion Assessment Method (CAM) requires training and is time-consuming to administer.
Study design: Cross-sectional portion of a larger point prevalence study.
Setting: Adult inpatients in a large university hospital in Ireland.
Synopsis: The study population (265 adult inpatients) was screened for inattention using months of the year backwards (MOTYB) and Spatial Span Forwards (SSF), a visual pattern recognition test. In addition, subjective/objective reports of confusion were gathered by interviewing patients and nurses and by reviewing physician documentation. Any patient who failed at least one of the screening tests or had reports of confusion was administered the CAM and then evaluated by a team of psychiatrists experienced in delirium detection.
Combining MOTYB with assessment of objective/subjective reports of delirium was the most accurate way to screen for delirium (sensitivity 93.8%, specificity 84.7%). In older patients (>69 years), MOTYB by itself was the most accurate. Addition of the CAM as a second-line screening test increased specificity but led to an unacceptable drop in sensitivity.
Hospitalists can easily incorporate the MOTYB test into daily patient assessments to help identify delirious patients but should be mindful of this study’s limitations (involved patients at a single institution, included assessment of only two bedside tests for attention, and completed formal delirium testing only in patients who screened positive).
Bottom line: Simple attention tests, particularly MOTYB, could be useful in increasing recognition of delirium among adult inpatients.
Clinical question: Are simple bedside attention tests a reliable way to routinely screen for delirium?
Background: Early diagnosis of delirium decreases adverse outcomes, but it often goes unrecognized, in part because clinicians do not routinely screen for it. Patients at high risk of delirium should be assessed regularly, although the best brief screening method is unknown. For example, the Confusion Assessment Method (CAM) requires training and is time-consuming to administer.
Study design: Cross-sectional portion of a larger point prevalence study.
Setting: Adult inpatients in a large university hospital in Ireland.
Synopsis: The study population (265 adult inpatients) was screened for inattention using months of the year backwards (MOTYB) and Spatial Span Forwards (SSF), a visual pattern recognition test. In addition, subjective/objective reports of confusion were gathered by interviewing patients and nurses and by reviewing physician documentation. Any patient who failed at least one of the screening tests or had reports of confusion was administered the CAM and then evaluated by a team of psychiatrists experienced in delirium detection.
Combining MOTYB with assessment of objective/subjective reports of delirium was the most accurate way to screen for delirium (sensitivity 93.8%, specificity 84.7%). In older patients (>69 years), MOTYB by itself was the most accurate. Addition of the CAM as a second-line screening test increased specificity but led to an unacceptable drop in sensitivity.
Hospitalists can easily incorporate the MOTYB test into daily patient assessments to help identify delirious patients but should be mindful of this study’s limitations (involved patients at a single institution, included assessment of only two bedside tests for attention, and completed formal delirium testing only in patients who screened positive).
Bottom line: Simple attention tests, particularly MOTYB, could be useful in increasing recognition of delirium among adult inpatients.
Clinical question: Are simple bedside attention tests a reliable way to routinely screen for delirium?
Background: Early diagnosis of delirium decreases adverse outcomes, but it often goes unrecognized, in part because clinicians do not routinely screen for it. Patients at high risk of delirium should be assessed regularly, although the best brief screening method is unknown. For example, the Confusion Assessment Method (CAM) requires training and is time-consuming to administer.
Study design: Cross-sectional portion of a larger point prevalence study.
Setting: Adult inpatients in a large university hospital in Ireland.
Synopsis: The study population (265 adult inpatients) was screened for inattention using months of the year backwards (MOTYB) and Spatial Span Forwards (SSF), a visual pattern recognition test. In addition, subjective/objective reports of confusion were gathered by interviewing patients and nurses and by reviewing physician documentation. Any patient who failed at least one of the screening tests or had reports of confusion was administered the CAM and then evaluated by a team of psychiatrists experienced in delirium detection.
Combining MOTYB with assessment of objective/subjective reports of delirium was the most accurate way to screen for delirium (sensitivity 93.8%, specificity 84.7%). In older patients (>69 years), MOTYB by itself was the most accurate. Addition of the CAM as a second-line screening test increased specificity but led to an unacceptable drop in sensitivity.
Hospitalists can easily incorporate the MOTYB test into daily patient assessments to help identify delirious patients but should be mindful of this study’s limitations (involved patients at a single institution, included assessment of only two bedside tests for attention, and completed formal delirium testing only in patients who screened positive).
Bottom line: Simple attention tests, particularly MOTYB, could be useful in increasing recognition of delirium among adult inpatients.
Medical Consultants Provide Benefits for Hospitalized Surgical Patients
Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?
Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.
Study design: Observational, retrospective, cohort study.
Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.
Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).
Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.
Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.
Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.
Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.
Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?
Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.
Study design: Observational, retrospective, cohort study.
Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.
Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).
Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.
Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.
Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.
Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.
Clinical question: How are medical consultants used for hospitalized surgical patients, and how does this vary among regions and hospitals in the U.S.?
Background: Reimbursement for surgical procedures is moving toward bundled payments, making it increasingly important to understand the use of resources in order to improve efficiency and quality of care.
Study design: Observational, retrospective, cohort study.
Setting: Fee-for-service Medicare patients undergoing colectomy or total hip replacement (THR) at U.S. acute care hospitals.
Synopsis: Using the Medicare Provider Analysis and Review (MEDPAR) File, the Carrier File, and the 2007 American Hospital Association’s annual survey, researchers evaluated a sample of 91,684 colectomy patients at 930 hospitals and 339,319 THR patients at 1,589 hospitals between the ages of 65 and 99 who were enrolled in Medicare parts A and B between 2007 and 2010. Sixty-nine percent of colectomy patients saw a consultant (50% medicine and 56% specialists). Sixty-three percent of THR patients saw a consultant (53% medicine and 24% specialists).
Patient factors for consults included older age, comorbidities, and nonelective admission. Hospital factors for consults included Midwest location, nonteaching, for-profit status, and hospital size. Greater use of consultants was associated with higher rates of post-operative complications.
Additional research on the association between mortality after complications (including type and timing) and number of consultants may help to improve future efficiency and outcomes. Creating a consensus about the use of medical consultants in healthy patients would also be beneficial.
Limitations of the study include a lack of detail on consult indications, unknown effect of pre-operative outpatient medical consults, major differences in median visits by site and surgery type, and the sole use of administrative claims data.
Bottom line: With the procedural fee for service changing to bundled payments, guidelines may be necessary for appropriate use of consultants, to improve both efficiency and quality of care provided by hospitals.
Fluid Resuscitation in Sepsis: Systematic Review and Network Meta-Analysis
Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?
Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.
Study design: Systematic review, network meta-analysis (NMA).
Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).
Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.
In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).
These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.
These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.
Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.
Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?
Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.
Study design: Systematic review, network meta-analysis (NMA).
Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).
Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.
In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).
These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.
These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.
Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.
Clinical question: Is there any difference between different resuscitative fluids (crystalloids or colloids) on mortality in critically ill sepsis patients?
Background: Fluid resuscitation, in addition to antibiotics and source control, is a cornerstone of initial management of sepsis. Resuscitation with crystalloids compared with colloids for critically ill patients has been evaluated in large randomized, controlled trials and meta-analyses; however, whether any of these fluid properties translates into a survival advantage, particularly regarding the optimal fluid for resuscitation in critically ill sepsis patients, remains unclear.
Study design: Systematic review, network meta-analysis (NMA).
Setting: Database search in MEDLINE, Embase, ACP Journal Club, Cumulative Index to Nursing and Allied Health Literature (CINAHL), HealthSTAR, the Allied and Complementary Medicine Database (AMED), and the Cochrane Central Register of Controlled Trials (CENTRAL).
Synopsis: Of 9,875 records that involved adult (aged ≥16 years) critically ill patients with severe sepsis or septic shock who required fluid resuscitation, with no restrictions on language or publication date, 14 randomized controlled trials were considered eligible. Interventions studied included any fluid or fluid strategy used for resuscitation compared with another fluid or fluid strategy. The endpoint was 90-day mortality or, if not available, 30-day intensive care unit or hospital mortality, whichever was longest. The analysis classified fluids as crystalloids or colloids. The relevant analyses were a four-node NMA (crystalloids vs. albumin vs. HES [hydroxyethyl starch] vs. gelatin) and a six-node NMA (crystalloids vs. albumin vs. HES vs. gelatin, with crystalloids divided into balanced or unbalanced and HES divided into low or high molecular weight), and a conventional fixed-effects meta-analytic comparison of crystalloids vs. colloids.
In the four-node analysis, the results suggested higher mortality with starches (vs. crystalloids) and lower mortality with albumin (vs. crystalloids and starches). In the six-node analysis, the results suggested that albumin is superior to saline and low molecular weight starch, and balanced crystalloids are superior to saline and starch (both high and low molecular weight).
These results highlight potentially important differences in mortality among solutions; it suggests an advantage of balanced crystalloids versus saline and low or high molecular weight starch, with similar mortality results for balanced crystalloids and albumin. These differences were not detectable using a standard meta-analytic approach directly comparing “any crystalloids vs. any colloids.” Biological rationale is consistent with the findings of lower mortality with balanced crystalloid solutions than with saline, as it mimics the homeostatic composition of body fluids to a greater extent than unbalanced fluids.
These results raise concerns about using unbalanced crystalloids in the acute resuscitation of patients with sepsis.
Bottom line: Among patients with sepsis, resuscitation with balanced crystalloids or albumin is associated with reduced mortality compared to other fluids.
Hip Fracture Adverse Outcomes Among Nursing Home Residents
Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?
Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.
Study design: Retrospective cohort study.
Setting: Fee-for-service Medicare beneficiaries.
Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.
Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.
The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.
Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.
Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?
Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.
Study design: Retrospective cohort study.
Setting: Fee-for-service Medicare beneficiaries.
Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.
Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.
The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.
Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.
Clinical question: What are the risk factors for mortality and functional decline following hip fracture among nursing home residents?
Background: Little is known about the survival and functional outcomes of nursing home residents who sustain hip fracture. Previous studies on hip fracture have either excluded nursing home residents or have been limited by small sample size.
Study design: Retrospective cohort study.
Setting: Fee-for-service Medicare beneficiaries.
Synopsis: This retrospective study of 60,111 patients residing in nursing homes who were hospitalized for hip fracture between 2005 and 2010 found that 36.2% died within six months. Within this cohort, 53.5% of the patients who did not have total dependence prior to the hip fracture either died or became totally disabled within six months.
Specifically, patients older than 90 years (vs. those younger than 75 years: RR 1.42; P<0.001), with severe cognitive impairment (vs. intact cognition: RR 1.66, P<0.001), and receiving nonoperative management (vs. internal fixation: RR 1.48, P<0.001) had a higher combined risk of death or new total dependence in locomotion within six months of the hip fracture.
The findings suggest there is substantial mortality and functional decline following hip fracture among residents in nursing homes. A profound decrease in activities of daily living across the spectrum was observed. Interestingly, patients who underwent nonoperative treatment, even after risk adjustment, were more likely to have adverse outcomes, suggesting surgery should be considered, if consistent with the patient’s overall goal of care.
Bottom line: Significant mortality and functional decline occurs following hip fracture among nursing home patients. Patients with severe cognitive impairment, older age (more than 90 years), and receiving nonoperative treatment are more likely to die or develop complete dependence in locomotion.
Post-Operative Pneumonia Reduced by Standardization in Noncritical Surgical Patients
Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?
Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.
Study design: Retrospective, cohort study.
Setting: University-affiliated VA hospital involving all noncardiac surgical patients.
Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).
It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.
Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.
Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?
Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.
Study design: Retrospective, cohort study.
Setting: University-affiliated VA hospital involving all noncardiac surgical patients.
Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).
It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.
Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.
Clinical question: What is the long-term effectiveness of a standardized pneumonia prevention program among surgical noncritical inpatients?
Background: Few studies have focused on the prevention of post-operative pneumonia in non-mechanically ventilated patients. The current study describes the effectiveness of an intervention designed to reduce post-operative pneumonia among noncritical patients who did not require mechanical ventilation.
Study design: Retrospective, cohort study.
Setting: University-affiliated VA hospital involving all noncardiac surgical patients.
Synopsis: A standardized pneumonia prevention program was implemented in 2007 in noncritical care settings for noncardiac surgery patients. Post-operative pneumonia rates were compared to pre-intervention and to American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) benchmarks. Rates of post-operative pneumonia following the intervention dropped from 0.78% to 0.44%, a 43% decrease (P=0.01). Both pre- and post-intervention rates were significantly better than those reported in the ACS-NSQIP database (2.56%).
It was proposed that widespread implementation of the program could lead to a 43% reduction of pneumonia cases in the ACS-NSQIP population, which would translate into a cost savings of more than $280 million.
Bottom line: A sustained reduction of post-operative pneumonia among noncritical surgical patients can be achieved by a standardized pneumonia prevention program, which may lead to improved outcomes and substantial cost savings.
Aspirin vs. Anticoagulation for VTE Prevention in Lower Extremity Orthopedic Surgery
Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?
Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.
Study design: Meta-analysis.
Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.
Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.
Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).
Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.
Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.
Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?
Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.
Study design: Meta-analysis.
Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.
Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.
Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).
Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.
Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.
Clinical question: What are rates of venous thromboembolism (VTE) and bleeding among adult patients receiving aspirin versus anticoagulants after major lower extremity orthopedic surgery?
Background: VTE is common after hip fracture surgery and elective total knee/hip arthroplasty. National guidelines recommend pharmacologic thromboprophylaxis but leave clinicians to select the specific agents. The efficiency and safety of aspirin in these patient populations, compared to other anticoagulants, has been a source of great controversy.
Study design: Meta-analysis.
Setting: Eight randomized trials in the U.S., Spain, Sweden, and Canada.
Synopsis: The trials included 1,408 subjects; aspirin was compared with other anticoagulants for VTE prevention and bleeding after major lower extremity orthopedic surgery. The primary outcome was the rate of proximal deep vein thrombosis (DVT). The different classes of anticoagulants included warfarin, heparin, low molecular weight heparin (LMWH), and danaparoid. Treatment duration was seven to 21 days with clinical follow-up extended up to six months.
Overall rates of DVT did not differ statistically between aspirin and anticoagulants (10.4% vs. 9.2%); however, the balance of risk versus benefit of aspirin compared to anticoagulation differed according to type of surgery; there was a nonsignificant trend favoring anticoagulation for VTE prevention following hip fracture repair, but no difference was found for knee/hip arthroplasty. The risk of bleeding was lower with aspirin than with anticoagulants following hip fracture repair (3.1% vs. 10%) and knee/hip arthroplasty (3.9% vs. 7.8%).
Rates of pulmonary embolism were too low in all the groups to provide reliable estimates.
Bottom line: Aspirin may be associated with higher risk of VTE following hip fracture repair compared to anticoagulants, although bleeding rates were substantially lower. Aspirin was similarly effective compared to anticoagulants for VTE prevention after knee/hip arthroplasty and may be associated with lower bleeding risk.
Depletive Fluid Management Strategy During Weaning from Mechanical Ventilation Can Lower VAP Rates
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.
Clinical question: What is the benefit associated with a depletive fluid management strategy on ventilator-associated complication (VAC) and ventilator-associated pneumonia (VAP) during weaning from mechanical ventilation?
Background: VAP is common in the ICU. Pulmonary edema predisposes patients to pneumonia by altering the alveolar microenvironment through enhancement of bacterial colonization and infectivity and a decrease in host bactericidal capacities. A fluid management strategy aimed at lowering lung fluid balance may prove useful in reducing both VAC and VAP.
Study design: Randomized controlled trial.
Setting: Nine ICUs in Europe and South America, between May 2007 and July 2009.
Synopsis: Data from the B-type Natriuretic Peptide for the Management of Weaning (BMW) trial was used to compare the cumulative incidence of VAC and VAP between the biomarker-driven, depletive fluid management group and the usual care group during the 14 days following randomization. The trial enrolled 304 randomized patients, 152 in each group.
Compared with usual care, the interventional strategy was associated with a higher proportion of patients receiving diuretics, in higher doses, resulting in a significantly more negative fluid balance during weaning and a shorter duration of mechanical ventilation. VAC (as defined by worsening oxygenation) occurred in 13.2% of patients during the 14 days following randomization: 17.8% in the usual care group and 8.6% in the interventional group. VAP occurred in 13.5% during the 14 days following randomization: 17.8% in the usual care group and 9.2% in the interventional group.
Bottom line: A biomarker-driven, depletive fluid strategy decreases the cumulative incidence of VAC and VAP.