scholarly journals Gastrointestinal bleeding prophylaxis for critically ill patients: a clinical practice guideline

BMJ ◽  
2020 ◽  
pp. l6722 ◽  
Author(s):  
Zhikang Ye ◽  
Annika Reintam Blaser ◽  
Lyubov Lytvyn ◽  
Ying Wang ◽  
Gordon H Guyatt ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Gastrointestinal Bleeding ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Risk Of Bleeding ◽  
Weak Recommendation ◽  
Guideline Panel ◽  
Bleeding Prophylaxis

AbstractClinical questionWhat is the role of gastrointestinal bleeding prophylaxis (stress ulcer prophylaxis) in critically ill patients? This guideline was prompted by the publication of a new large randomised controlled trial.Current practiceGastric acid suppression with proton pump inhibitors (PPIs) or histamine-2 receptor antagonists (H2RAs) is commonly done to prevent gastrointestinal bleeding in critically ill patients. Existing guidelines vary in their recommendations of which population to treat and which agent to use.RecommendationsThis guideline panel makes a weak recommendation for using gastrointestinal bleeding prophylaxis in critically ill patients at high risk (>4%) of clinically important gastrointestinal bleeding, and a weak recommendation for not using prophylaxis in patients at lower risk of clinically important bleeding (≤4%). The panel identified risk categories based on evidence, with variable certainty regarding risk factors. The panel suggests using a PPI rather than a H2RA (weak recommendation) and recommends against using sucralfate (strong recommendation).How this guideline was createdA guideline panel including patients, clinicians, and methodologists produced these recommendations using standards for trustworthy guidelines and the GRADE approach. The recommendations are based on a linked systematic review and network meta-analysis. A weak recommendation means that both options are reasonable.The evidenceThe linked systematic review and network meta-analysis estimated the benefit and harm of these medications in 12 660 critically ill patients in 72 trials. Both PPIs and H2RAs reduce the risk of clinically important bleeding. The effect is larger in patients at higher bleeding risk (those with a coagulopathy, chronic liver disease, or receiving mechanical ventilation but not enteral nutrition or two or more of mechanical ventilation with enteral nutrition, acute kidney injury, sepsis, and shock) (moderate certainty). PPIs and H2RAs might increase the risk of pneumonia (low certainty). They probably do not have an effect on mortality (moderate certainty), length of hospital stay, or any other important outcomes. PPIs probably reduce the risk of bleeding more than H2RAs (moderate certainty).Understanding the recommendationIn most critically ill patients, the reduction in clinically important gastrointestinal bleeding from gastric acid suppressants is closely balanced with the possibility of pneumonia. Clinicians should consider individual patient values, risk of bleeding, and other factors such as medication availability when deciding whether to use gastrointestinal bleeding prophylaxis. Visual overviews provide the relative and absolute benefits and harms of the options in multilayered evidence summaries and decision aids available on MAGICapp.

scholarly journals Efficacy and safety of gastrointestinal bleeding prophylaxis in critically ill patients: systematic review and network meta-analysis

BMJ ◽  
2020 ◽  
pp. l6744 ◽  
Author(s):  
Ying Wang ◽  
Zhikang Ye ◽  
Long Ge ◽  
Reed A C Siemieniuk ◽  
Xin Wang ◽  
...  
Keyword(s):  
Systematic Review ◽  
High Risk ◽  
Gastrointestinal Bleeding ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Odds Ratio ◽  
Meta Analysis ◽  
Risk Of Bias ◽  
Bleeding Prophylaxis ◽  
Risk Patients

AbstractObjectiveTo determine, in critically ill patients, the relative impact of proton pump inhibitors (PPIs), histamine-2 receptor antagonists (H2RAs), sucralfate, or no gastrointestinal bleeding prophylaxis (or stress ulcer prophylaxis) on outcomes important to patients.DesignSystematic review and network meta-analysis.Data sourcesMedline, PubMed, Embase, Cochrane Central Register of Controlled Trials, trial registers, and grey literature up to March 2019.Eligibility criteria for selecting studies and methodsWe included randomised controlled trials that compared gastrointestinal bleeding prophylaxis with PPIs, H2RAs, or sucralfate versus one another or placebo or no prophylaxis in adult critically ill patients. Two reviewers independently screened studies for eligibility, extracted data, and assessed risk of bias. A parallel guideline committee (BMJ Rapid Recommendation) provided critical oversight of the systematic review, including identifying outcomes important to patients. We performed random-effects pairwise and network meta-analyses and used GRADE to assess certainty of evidence for each outcome. When results differed between low risk and high risk of bias studies, we used the former as best estimates.ResultsSeventy two trials including 12 660 patients proved eligible. For patients at highest risk (>8%) or high risk (4-8%) of bleeding, both PPIs and H2RAs probably reduce clinically important gastrointestinal bleeding compared with placebo or no prophylaxis (odds ratio for PPIs 0.61 (95% confidence interval 0.42 to 0.89), 3.3% fewer for highest risk and 2.3% fewer for high risk patients, moderate certainty; odds ratio for H2RAs 0.46 (0.27 to 0.79), 4.6% fewer for highest risk and 3.1% fewer for high risk patients, moderate certainty). Both may increase the risk of pneumonia compared with no prophylaxis (odds ratio for PPIs 1.39 (0.98 to 2.10), 5.0% more, low certainty; odds ratio for H2RAs 1.26 (0.89 to 1.85), 3.4% more, low certainty). It is likely that neither affect mortality (PPIs 1.06 (0.90 to 1.28), 1.3% more, moderate certainty; H2RAs 0.96 (0.79 to 1.19), 0.9% fewer, moderate certainty). Otherwise, results provided no support for any affect on mortality, Clostridium difficile infection, length of intensive care stay, length of hospital stay, or duration of mechanical ventilation (varying certainty of evidence).ConclusionsFor higher risk critically ill patients, PPIs and H2RAs likely result in important reductions in gastrointestinal bleeding compared with no prophylaxis; for patients at low risk, the reduction in bleeding may be unimportant. Both PPIs and H2RAs may result in important increases in pneumonia. Variable quality evidence suggested no important effects of interventions on mortality or other in-hospital morbidity outcomes.Systematic review registrationPROSPERO CRD42019126656.

scholarly journals Effect of timing of intubation on clinical outcomes of critically ill patients with COVID-19: a systematic review and meta-analysis of non-randomized cohort studies

Critical Care ◽  
2021 ◽  
Vol 25 (1) ◽  
Author(s):  
Eleni Papoutsi ◽  
Vassilis G. Giannakoulis ◽  
Eleni Xourgia ◽  
Christina Routsi ◽  
Anastasia Kotanidou ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Clinical Outcomes ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Mortality And Morbidity ◽  
Icu Admission ◽  
All Cause Mortality ◽  
Detectable Difference

Abstract Background Although several international guidelines recommend early over late intubation of patients with severe coronavirus disease 2019 (COVID-19), this issue is still controversial. We aimed to investigate the effect (if any) of timing of intubation on clinical outcomes of critically ill patients with COVID-19 by carrying out a systematic review and meta-analysis. Methods PubMed and Scopus were systematically searched, while references and preprint servers were explored, for relevant articles up to December 26, 2020, to identify studies which reported on mortality and/or morbidity of patients with COVID-19 undergoing early versus late intubation. “Early” was defined as intubation within 24 h from intensive care unit (ICU) admission, while “late” as intubation at any time after 24 h of ICU admission. All-cause mortality and duration of mechanical ventilation (MV) were the primary outcomes of the meta-analysis. Pooled risk ratio (RR), pooled mean difference (MD) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42020222147). Results A total of 12 studies, involving 8944 critically ill patients with COVID-19, were included. There was no statistically detectable difference on all-cause mortality between patients undergoing early versus late intubation (3981 deaths; 45.4% versus 39.1%; RR 1.07, 95% CI 0.99–1.15, p = 0.08). This was also the case for duration of MV (1892 patients; MD − 0.58 days, 95% CI − 3.06 to 1.89 days, p = 0.65). In a sensitivity analysis using an alternate definition of early/late intubation, intubation without versus with a prior trial of high-flow nasal cannula or noninvasive mechanical ventilation was still not associated with a statistically detectable difference on all-cause mortality (1128 deaths; 48.9% versus 42.5%; RR 1.11, 95% CI 0.99–1.25, p = 0.08). Conclusions The synthesized evidence suggests that timing of intubation may have no effect on mortality and morbidity of critically ill patients with COVID-19. These results might justify a wait-and-see approach, which may lead to fewer intubations. Relevant guidelines may therefore need to be updated.

scholarly journals Association Between Cytomegalovirus Reactivation and Clinical Outcomes in Immunocompetent Critically Ill Patients: A Systematic Review and Meta-Analysis

2017 ◽  
Vol 4 (2) ◽  
Author(s):  
Philippe Lachance ◽  
Justin Chen ◽  
Robin Featherstone ◽  
Wendy I Sligl
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Critically Ill ◽  
Resource Utilization ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Health Resource ◽  
Health Resource Utilization ◽  
Cytomegalovirus Reactivation ◽  
Cmv Reactivation

Abstract Background The aim of our systematic review was to investigate the association between cytomegalovirus (CMV) reactivation and outcomes in immunocompetent critically ill patients. Methods We searched electronic databases and gray literature for original studies and abstracts published between 1990 and October 2016. The review was limited to studies including critically ill immunocompetent patients. Cytomegalovirus reactivation was defined as positive polymerase chain reaction, pp65 antigenemia, or viral culture from blood or bronchoalveolar lavage. Selected patient-centered outcomes included mortality, duration of mechanical ventilation, need for renal replacement therapy (RRT), and nosocomial infections. Health resource utilization outcomes included intensive care unit and hospital lengths of stay. Results Twenty-two studies were included. In our primary analysis, CMV reactivation was associated with increased ICU mortality (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.87–3.47), overall mortality (OR, 2.02; 95% CI, 1.60–2.56), duration of mechanical ventilation (mean difference 6.60 days; 95% CI, 3.09–10.12), nosocomial infections (OR, 3.20; 95% CI, 2.05–4.98), need for RRT (OR, 2.37; 95% CI, 1.31–4.31), and ICU length of stay (mean difference 8.18 days; 95% CI, 6.14–10.22). In addition, numerous sensitivity analyses were performed. Conclusions In this meta-analysis, CMV reactivation was associated with worse clinical outcomes and greater health resource utilization in critically ill patients. However, it remains unclear whether CMV reactivation plays a causal role or if it is a surrogate for more severe illness.

scholarly journals Brain Natriuretic Peptide to Predict Successful Liberation from Mechanical Ventilation in Critically Ill Patients: a Systematic Review and Meta-Analysis

2020 ◽  
Author(s):  
Jean Deschamps ◽  
Sarah K. Andersen ◽  
Jordan Webber ◽  
Robin Featherstone ◽  
Meghan Sebastianski ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Brain Natriuretic Peptide ◽  
Critically Ill ◽  
Natriuretic Peptide ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Spontaneous Breathing Trial ◽  
Clinical Criteria ◽  
Alternate Test

Abstract Background: Predicting successful liberation from mechanical ventilation (MV) in critically ill patients is challenging. Brain natriuretic peptide (BNP) has been proposed to help guide decision-making for readiness to liberate from MV following a spontaneous breathing trial (SBT). Methods : We performed a systematic review and meta-analysis of randomized and prospective observational studies that measured BNP levels at the time of SBT in patients receiving MV. The primary endpoint was successful liberation from MV (absence of re-intubation or non-invasive ventilation at 48h). Statistical analyses included bi-variate and Moses-Littenberg models, and DerSimonian-Laird pooling of areas under ROC curve (AUROC). Results: A total of 731 articles were screened. Eighteen adult and 2 pediatric studies were fulfilled pre-specified eligibility. The measure of the relative variation of BNP during SBT (DBNP%) after exclusion of SBT failure by clinical criteria in adults yielded a sensitivity and specificity of 0.889 [0.831-0.929] and 0.828 [0.730-0.896] for successful liberation from MV respectively, with a pooled AUROC of 0.92 [0.88-0.97]. The pooled AUROC for any method of analysis for absolute variation of BNP (DBNP), pre-SBT BNP and post-SBT BNP were 0.89 [0.83-0.95], 0.77 [0.63-0.91], and 0.85 [0.80-0.90], respectively.Conclusion: The relative change in BNP during a SBT has potential value as an incremental tool after successful SBT to predict successful liberation from MV in adults. There is insufficient data to support the use of BNP in children or as an alternate test to clinical indices of SBT or the use of DBNP, BNP-pre and BNP-post as an alternate or incremental test.Trial registration number: PROSPERO CRD42018087474 (2018-02-06)

scholarly journals Brain Natriuretic Peptide to Predict Successful Liberation from Mechanical Ventilation in Critically Ill Patients: a Systematic Review and Meta-Analysis.

2019 ◽  
Author(s):  
Jean Deschamps ◽  
Sarah K. Andersen ◽  
Jordan Webber ◽  
Robin Featherstone ◽  
Meghan Sebastianski ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Brain Natriuretic Peptide ◽  
Critically Ill ◽  
Natriuretic Peptide ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Spontaneous Breathing Trial ◽  
Clinical Criteria ◽  
Clinical Indices

Abstract Background Predicting successful liberation from mechanical ventilation (MV) in critically ill patients is challenging. Brain natriuretic peptide (BNP) has been proposed to help guide decision-making for readiness to liberate from MV following a spontaneous breathing trial (SBT).Methods We performed a systematic review and meta-analysis of randomized and prospective observational studies that measured BNP levels at the time of SBT in patients receiving MV. The primary endpoint was successful liberation from MV (absence of re-intubation or non-invasive ventilation at 48h). Statistical analyses include bi-variate and Moses-Littenberg models, and DerSimonian-Laird pooling of areas under ROC curve (AUROC).Results A total of 731 articles were screened. After pre-specified inclusion criteria, 18 adult and 2 pediatric studies were included. The measure of the relative variation of BNP during SBT (ΔBNP%) after exclusion of SBT failure by clinical criteria in adults yielded a sensitivity and specificity of 0.889 [0.831-0.929] and 0.828 [0.730-0.896] respectively, with a pooled AUROC of 0.92 [0.88-0.97] for successful liberation from MV. The pooled AUROC for any method of analysis for absolute variation of BNP (ΔBNP), pre-SBT BNP and post-SBT BNP were 0.89 [0.83-0.95], 0.77 [0.63-0.91], and 0.85 [0.80-0.90], respectively.Conclusion The ΔBNP during a SBT is an accurate incremental tool after SBT success by clinical indices to predict successful liberation from MV in adults. There is insufficient data to support its use as an alternate test to clinical indices of SBT or the use of ΔBNP, BNP-pre and BNP-post as an alternate or incremental test, or in pediatric patients.

P0625CONTINUOUS RENAL REPLACEMENT THERAPY WITHOUT ANTICOAGULATION IN CRITICALLY ILL PATIENTS AT HIGH RISK OF BLEEDING-A SYSTEMATIC REVIEW AND META-ANALYSIS

2020 ◽  
Vol 35 (Supplement_3) ◽  
Author(s):  
Shiren Sun ◽  
Wei Zhang ◽  
Ming Bai ◽  
Lijuan Zhao ◽  
Xiaolan Chen ◽  
...  
Keyword(s):  
Systematic Review ◽  
Renal Replacement Therapy ◽  
High Risk ◽  
Replacement Therapy ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Meta Analysis ◽  
Bleeding Risk ◽  
Cochrane Library ◽  
Risk Of Bleeding

Abstract Background and Aims Continuous renal replacement therapy (CRRT) has been widely used in the critical care setting and anticoagulation is usually necessitated. However, critically ill patients are commonly at incremental risk of bleeding, which contributed to the hesitation of anticoagulant use for CRRT in clinical practice. The current guideline recommended CRRT proceed without anticoagulation in patients with contraindication to citrate and increased bleeding risk. Nevertheless, the efficacy of anticoagulation-free CRRT remains inconsistent. Therefore, the purpose of our present systematic review is to evaluate the efficacy and safety of anticoagulant-free CRRT based on the current literatures. Method We conducted a comprehensive search of PubMed (US National Library of Medicine, Bethesda, MD, USA), Cochrane Library databases and EMBASE from database inception to January 12, 2019 for potential candidate studies. Studies included adult critically ill (age > 18 years) patients with increased bleeding risk, and underwent CRRT without anticoagulation were considered for the inclusion. Results Finally, 17 observational studies and 3 randomized controlled trials with 1615 patients were included in our present meta-analysis. There was no significant difference in filter lifespan between the anticoagulation-free and systemic heparin group. The filter lifespan was significantly prolonged in the citrate (WMD -23.01, 95%CI [-28.62, -17.39], P < 0.001; I2 = 0%, P = 0.53) and nafamostat (WMD -8.4, 95%CI [-9.9, -6.9], P < 0.001; I2 = 33.7%, P = 0.21) groups, compared with anticoagulation-free group. The averaged filter lifespan of the anticoagulation-free CRRT ranged from 10.2 to 52.5 hours. Conclusion The filter lifespan in anticoagulation-free patients with increased bleeding risk was comparable to that in patients without increased bleeding risk underwent systemic heparin anticoagulation CRRT. Nafamostat was not recommended for CRRT anticoagulation due to its drawbacks. Currently, the optimal choice of anticoagulation strategy for critically ill patients without citrate contraindications at high risk of bleeding should be regional citrate anticoagulation. Further studies should focus on the special cut-off value of activated partial thromboplastin time (APTT), international normalized ratio (INR) and platelet (PLT) count, at which the anticoagulation-free CRRT would be beneficial.

scholarly journals Mucoactive agents for acute respiratory failure in the critically ill: a systematic review and meta-analysis

Thorax ◽  
2020 ◽  
Vol 75 (8) ◽  
pp. 623-631 ◽  
Author(s):  
Rohan Anand ◽  
Daniel F McAuley ◽  
Bronagh Blackwood ◽  
Chee Yap ◽  
Brenda ONeill ◽  
...  
Keyword(s):  
Systematic Review ◽  
Mechanical Ventilation ◽  
Respiratory Failure ◽  
Acute Respiratory Failure ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Controlled Trials ◽  
Randomised Controlled

PurposeAcute respiratory failure (ARF) is a common cause of admission to intensive care units (ICUs). Mucoactive agents are medications that promote mucus clearance and are frequently administered in patients with ARF, despite a lack of evidence to underpin clinical decision making. The aim of this systematic review was to determine if the use of mucoactive agents in patients with ARF improves clinical outcomes.MethodsWe searched electronic and grey literature (January 2020). Two reviewers independently screened, selected, extracted data and quality assessed studies. We included trials of adults receiving ventilatory support for ARF and involving at least one mucoactive agent compared with placebo or standard care. Outcomes included duration of mechanical ventilation. Meta-analysis was undertaken using random-effects modelling and certainty of the evidence was assessed using Grades of Recommendation, Assessment, Development and Evaluation.ResultsThirteen randomised controlled trials were included (1712 patients), investigating four different mucoactive agents. Mucoactive agents showed no effect on duration of mechanical ventilation (seven trials, mean difference (MD) −1.34, 95% CI −2.97 to 0.29, I2=82%, very low certainty) or mortality, hospital stay and ventilator-free days. There was an effect on reducing ICU length of stay in the mucoactive agent groups (10 trials, MD −3.22, 95% CI −5.49 to −0.96, I2=89%, very low certainty).ConclusionOur findings do not support the use of mucoactive agents in critically ill patients with ARF. The existing evidence is of low quality. High-quality randomised controlled trials are needed to determine the role of specific mucoactive agents in critically ill patients with ARF.PROSPERO registration numberCRD42018095408.

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