In patients with severe acute kidney injury (AKI) but no urgent indication for renal replacement therapy (RRT), the optimal time to initiate RRT remains controversial. While starting RRT preemptively ...may have benefits, this may expose patients to unnecessary RRT. To study this, we conducted a 12-center open-label pilot trial of critically ill adults with volume replete severe AKI. Patients were randomized to accelerated (12 h or less from eligibility) or standard RRT initiation. Outcomes were adherence to protocol-defined time windows for RRT initiation (primary), proportion of eligible patients enrolled, follow-up to 90 days, and safety in 101 fully eligible patients (57 with sepsis) with a mean age of 63 years. Median serum creatinine and urine output at enrollment were 268 micromoles/l and 356 ml per 24 h, respectively. In the accelerated arm, all patients commenced RRT and 45/48 did so within 12 h from eligibility (median 7.4 h). In the standard arm, 33 patients started RRT at a median of 31.6 h from eligibility, of which 19 did not receive RRT (6 died and 13 recovered kidney function). Clinical outcomes were available for all patients at 90 days following enrollment, with mortality 38% in the accelerated and 37% in the standard arm. Two surviving patients, both randomized to standard RRT initiation, were still RRT dependent at day 90. No safety signal was evident in either arm. Our findings can inform the design of a large-scale effectiveness randomized control trial.
Purpose
Oral chlorhexidine is used widely for mechanically ventilated patients to prevent pneumonia, but recent studies show an association with excess mortality. We examined whether de-adoption of ...chlorhexidine and parallel implementation of a standardized oral care bundle reduces intensive care unit (ICU) mortality in mechanically ventilated patients.
Methods
A stepped wedge cluster-randomized controlled trial with concurrent process evaluation in 6 ICUs in Toronto, Canada. Clusters were randomized to de-adopt chlorhexidine and implement a standardized oral care bundle at 2-month intervals. The primary outcome was ICU mortality. Secondary outcomes were time to infection-related ventilator-associated complications (IVACs), oral procedural pain and oral health dysfunction. An exploratory post hoc analysis examined time to extubation in survivors.
Results
A total of 3260 patients were enrolled; 1560 control, 1700 intervention. ICU mortality for the intervention and control periods were 399 (23.5%) and 330 (21.2%), respectively (adjusted odds ratio aOR, 1.13; 95% confidence interval CI 0.82 to 1.54;
P
= 0.46). Time to IVACs (adjusted hazard ratio aHR, 1.06; 95% CI 0.44 to 2.57;
P
= 0.90), time to extubation (aHR 1.03; 95% CI 0.85 to 1.23;
P
= 0.79) (survivors) and oral procedural pain (aOR, 0.62; 95% CI 0.34 to 1.10;
P
= 0.10) were similar between control and intervention periods. However, oral health dysfunction scores (− 0.96; 95% CI − 1.75 to − 0.17;
P
= 0.02) improved in the intervention period.
Conclusion
Among mechanically ventilated ICU patients, no benefit was observed for de-adoption of chlorhexidine and implementation of an oral care bundle on ICU mortality, IVACs, oral procedural pain, or time to extubation. The intervention may improve oral health.
LAMP shines a light on Zika virus Smith, Orla M
Science (American Association for the Advancement of Science),
2017-May-05, 2017-05-05, 20170505, Letnik:
356, Številka:
6337
Journal Article
An antimalarial to add to the armamentarium Smith, Orla M
Science (American Association for the Advancement of Science),
2017-Apr-28, 2017-04-28, 20170428, Letnik:
356, Številka:
6336
Journal Article
Mapping a path to HIV elimination Smith, Orla M
Science (American Association for the Advancement of Science),
2017-Mar-31, 2017-03-31, 20170331, Letnik:
355, Številka:
6332
Journal Article
Wonder Smith, Orla M.
Science,
12/2015, Letnik:
350, Številka:
6267
Book Review, Journal Article
Recenzirano
Wonder is a new, environmentally themed exhibition that heralds the opening of the elegantly refurbished Renwick gallery. Wonder Renwick Gallery of the Smithsonian American Art Museum, Washington, ...D.C. Through 10 July 2016.
A patient's progress Smith, Orla M.
Science,
12/2015, Letnik:
350, Številka:
6267
Book Review, Journal Article
Recenzirano
They say that each event that happens to you prepares you for the next step on life's journey. The award-winning journalist Jon Palfreman, best known for his 1982 Nova documentary, The Case of the ...Frozen Addict, is likely to agree with this. As he meticulously researched the story of six young heroin addicts who suddenly developed severe Parkinson's disease after ingesting a bad batch of heroin, little did he know that several decades later he, too, would be diagnosed with this disease. Brain Storms is Jon Palfreman's frank autobiography about life after his diagnosis and his quest to learn everything possible about this incurable neurodegenerative disorder. Brain Storms The Race to Unlock the Mysteries of Parkinson's DiseaseJon Palfreman Scientific American/Farrar, Straus and Giroux, 2015. 283 pp.
To determine whether catheter-associated urinary tract infections are associated with increased morbidity and mortality in critically ill patients.
MEDLINE, HealthStar, EMBASE, and CINAHL databases ...from inception to June 2010 and bibliographies of included studies without language restriction.
Studies reporting mortality or morbidity in adult intensive care unit patients with and without catheter-associated urinary tract infections.
Two authors independently selected studies and extracted data on study methodology, quality, and patient outcomes using a standardized form. Meta-analyses were performed using random-effects models.
Of 720 citations, 11 studies enrolling 2,745 patients with and 60,719 patients without catheter-associated urinary tract infections met inclusion criteria. Catheter-associated urinary tract infection was associated with a significant increase in mortality (odds ratio OR, 1.99; 95% confidence interval CI, 1.72-2.31; p < .00001; I2 = 54%; eight studies; 62,063 patients) and length of stay in the intensive care unit (weighted mean difference of + 12 days; 95% CI, 9-15; p < .00001; I2 = 96%; seven studies; 13,011 patients) and hospital (mean difference + 21 days; 95% CI, 11-32; p < .0001; I2 = 98%; five studies; 10,183 patients). Restricting the analysis only to the two studies that adjusted for other outcome predictors, catheter-associated urinary tract infections were not associated with an increase in mortality (OR, 0.97; 95% CI, 0.82-1.16; p = .77; I2 = 0%; two studies; 5,626 patients). Although both studies individually demonstrated significantly increased intensive care unit length of stay after adjustment, pooled data showed that catheter-associated urinary tract infections were associated with a significant increase in intensive care unit length of stay using only a fixed effects model (mean difference + 2.6 days; 95% CI, 2.3-3.0; p < .00001) and not a random effects model (mean difference + 8 days; 95% CI, -13 to +28 days; p = .46) due to the high degree of heterogeneity for this outcome between the two studies (I2 = 99.6%) which results in a larger CI.
Catheter-associated urinary tract infection is associated with significantly increased mortality and length of stay in unmatched studies. Increased mortality and possibly increased length of stay appear to be consequences of confounding by unmeasured variables. These findings highlight the importance of evaluating risks and benefits of commonly used treatments such as antibiotics to manage catheter-associated urinary tract infection.
Long-acting drug to treat resistant malaria Smith, Orla M.
Science (American Association for the Advancement of Science),
07/2015, Letnik:
349, Številka:
6245
Journal Article
Acute kidney injury is a common and devastating complication of critical illness, for which renal replacement therapy is frequently needed to manage severe cases. While a recent systematic review ...suggested that "earlier" initiation of renal replacement therapy improves survival, completed trials are limited due to small size, single-centre status, and use of variable definitions to define "early" renal replacement therapy initiation.
This is an open-label pilot randomized controlled trial. One hundred critically ill patients with severe acute kidney injury will be randomly allocated 1:1 to receive "accelerated" initiation of renal replacement therapy or "standard" initiation at 12 centers across Canada. In the accelerated arm, participants will have a venous catheter placed and renal replacement therapy will be initiated within 12 hours of fulfilling eligibility. In the standard initiation arm, participants will be monitored over 7 days to identify indications for renal replacement therapy. For participants in the standard arm with persistent acute kidney injury, defined as a serum creatinine not declining >50% from the value at the time of eligibility, the initiation of RRT will be discouraged unless one or more of the following criteria are fulfilled: serum potassium ≥6.0 mmol/L; serum bicarbonate ≤10 mmol/L; severe respiratory failure (PaO₂/FiO₂<200) or persisting acute kidney injury for ≥72 hours after fulfilling eligibility. The inclusion criteria are designed to identify a population of critically ill adults with severe acute kidney injury who are likely to need renal replacement therapy during their hospitalization, but not immediately. The primary outcome is protocol adherence (>90%). Secondary outcomes include measures of feasibility (proportion of eligible patients enrolled in the trial, proportion of enrolled patients followed to 90 days for assessment of vital status and the need for renal replacement therapy) and safety (occurrence of adverse events).
The optimal timing of renal replacement therapy initiation in patients with severe acute kidney injury remains uncertain, representing an important knowledge gap and a priority for high-quality research. This pilot trial is necessary to establish protocol feasibility, confirm the safety of participants and obtain estimated events rates for design of a large definitive trial.
NCT01557361.
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