Purpose
Central venous pressure (CVP) has been shown to have poor predictive value for fluid responsiveness in critically ill patients. We aimed to re-evaluate this in a larger sample subgrouped by ...baseline CVP values.
Methods
In April 2015, we systematically searched and included all clinical studies evaluating the value of CVP in predicting fluid responsiveness. We contacted investigators for patient data sets. We subgrouped data as lower (<8 mmHg), intermediate (8–12 mmHg) and higher (>12 mmHg) baseline CVP.
Results
We included 51 studies; in the majority, mean/median CVP values were in the intermediate range (8–12 mmHg) in both fluid responders and non-responders. In an analysis of patient data sets (
n
= 1148) from 22 studies, the area under the receiver operating curve was above 0.50 in the <8 mmHg CVP group 0.57 (95 % CI 0.52–0.62) in contrast to the 8–12 mmHg and >12 mmHg CVP groups in which the lower 95 % CI crossed 0.50. We identified some positive and negative predictive value for fluid responsiveness for specific low and high values of CVP, respectively, but none of the predictive values were above 66 % for any CVPs from 0 to 20 mmHg. There were less data on higher CVPs, in particular >15 mmHg, making the estimates on predictive values less precise for higher CVP.
Conclusions
Most studies evaluating fluid responsiveness reported mean/median CVP values in the intermediate range of 8–12 mmHg both in responders and non-responders. In a re-analysis of 1148 patient data sets, specific lower and higher CVP values had some positive and negative predictive value for fluid responsiveness, respectively, but predictive values were low for all specific CVP values assessed.
Because primary immunodeficiencies (PID) are rare diseases, transnational studies are essential to maximize the scientific outcome and lead to improved diagnosis and therapy. Immunologists in Europe ...have united to determine the prevalence of PID in Europe and to establish and evaluate harmonized guidelines for the diagnosis and treatment of PID as well as to improve the awareness of PID in Europe. In order to achieve this aim we have developed an internet-based database for clinical and research data on patients with PID. This database forms the platform for studies of demographics, the development of new diagnostic and therapeutic strategies and the identification of novel disease-associated genes. The database is completely secure, while providing access to researchers via a standard browser using password and encrypted log-in sessions and conforms to all European and national ethics and data protection guidelines. So far 2386 patients have been documented by 35 documenting centres in 20 countries. Common variable immunodeficiency (CVID) is the most common entity, accounting for almost 30% of all entries. First statistical analyses on the quality of life of patients show the advantages of immunoglobulin replacement therapy, at the same time revealing a mean diagnostic delay of over 4 years. First studies on specific questions on selected PID are now under way. The platform of this database can be used for any type of medical condition.
Background
In recent years, large trials have increased the level of evidence for intravenous (IV) fluid therapy, at least in the intensive care setting. It is less clear whether this change in the ...evidence base has been associated with changes in IV fluid use in different hospital departments.
Methods
We obtained details from the regional pharmacy regarding IV fluids issued to hospital departments in the Danish Capitol Region from January 2012 to May 2015. We used paired Wilcoxon's signed‐rank test to analyse changes in the issuing in different departments.
Results
Total regional issuing of IV fluids showed increase in crystalloid solutions (9%; P = 0.001) and decrease in colloid solutions (59%; P = 0.005). Subtype analysis showed increased issuing of buffered crystalloids (36%; P = 0.001), human albumin (30%; P < 0.0001) and decreased issuing in synthetic colloid solutions (82%; P < 0.0001) from Q1 2012 to Q2 2015. At the departmental level, the issuing of synthetic colloid solutions decreased markedly to all settings. The issuing of buffered crystalloids increased to orthopaedic (226%; P = 0.03) and to general surgery departments (686%; P = 0.002). Albumin solutions were increasingly issued to anaesthesia departments (63%; P = 0.005) and was rarely issued to general surgery and orthopaedic departments.
Conclusions
The issuing of IV fluid solutions to hospital departments has changed markedly over the last years to less colloid, in particular the synthetic solutions, and relatively more issuing of crystalloids, in particular the buffered solutions.
Background
Stress ulcer prophylaxis (SUP) may decrease the incidence of gastrointestinal bleeding in patients in the intensive care unit (ICU), but the risk of infection may be increased. In this ...study, we aimed to describe SUP practices in adult ICUs. We hypothesised that patient selection for SUP varies both within and between countries.
Methods
Adult ICUs were invited to participate in the survey. We registered country, type of hospital, type and size of ICU, preferred SUP agent, presence of local guideline, reported indications for SUP, criteria for discontinuing SUP, and concerns about adverse effects. Fisher's exact test was used to assess differences between groups.
Results
Ninety‐seven adult ICUs in 11 countries participated (eight European). All but one ICU used SUP, and 64% (62/97) reported having a guideline for the use of SUP. Proton pump inhibitors were the most common SUP agent, used in 66% of ICUs (64/97), and H2‐receptor antagonists were used 31% (30/97) of the units. Twenty‐three different indications for SUP were reported, the most frequent being mechanical ventilation. All patients were prescribed SUP in 26% (25/97) of the ICUs. Adequate enteral feeding was the most frequent reason for discontinuing SUP, but 19% (18/97) continued SUP upon ICU discharge. The majority expressed concern about nosocomial pneumonia and Clostridium difficile infection with the use of SUP.
Conclusions
In this international survey, most participating ICUs reported using SUP, primarily proton pump inhibitors, but many did not have a guideline; indications varied considerably and concern existed about infectious complications.
Changes in colloid solution sales in Nordic countries Kongsgaard, U. E.; Holtan, A.; Perner, A.
Acta anaesthesiologica Scandinavica,
April 2018, 2018-Apr, 2018-04-00, 20180401, Letnik:
62, Številka:
4
Journal Article
Recenzirano
Background
Administration of resuscitation fluid is a common intervention in the treatment of critically ill patients, but the right choice of fluid is still a matter of debate. Changes in medical ...practice are based on new evidence and guidelines as well as traditions and personal preferences. Official warnings against the use of hydroxyl‐ethyl‐starch (HES) solutions have been issued. Nordic guidelines have issued several strong recommendations favouring crystalloids over colloids in all patient groups. Our objective was to describe the patterns of colloid use in Nordic countries from 2012 to 2016.
Methods
The data were obtained from companies that provide pharmaceutical statistics in different countries. The data are sales figures from pharmaceutical companies to pharmacies and health institutions.
Results
We found a 56% reduction in the total sales of all colloids in Nordic countries over a 5‐year period. These findings were mainly related to a 92% reduction in the sales of HES solutions. A reduction in sales of other synthetic colloids has also occurred. During the same period, we found a 46% increase in albumin sales, but these numbers varied between Nordic countries.
Conclusion
The general reduction in colloid sales likely reflects the recommendation that colloids should be used only in special circumstances. The dramatic reduction in the sales of HES solutions was expected given evidence of harm and the official warnings. The steady increase in albumin sales and the notable differences between the five Nordic countries cannot be explained.
Background
Intensive care unit (ICU) mortality prediction scores deteriorate over time, and their complexity decreases clinical applicability and commonly causes problems with missing data. We aimed ...to develop and internally validate a new and simple score that predicts 90‐day mortality in adults upon acute admission to the ICU: the Simplified Mortality Score for the Intensive Care Unit (SMS‐ICU).
Methods
We used data from an international cohort of 2139 patients acutely admitted to the ICU and 1947 ICU patients with severe sepsis/septic shock from 2009 to 2016. We performed multiple imputations for missing data and used binary logistic regression analysis with variable selection by backward elimination, followed by conversion to a simple point‐based score. We assessed the apparent performance and validated the score internally using bootstrapping to present optimism‐corrected performance estimates.
Results
The SMS‐ICU comprises seven variables available in 99.5% of the patients: two numeric variables: age and lowest systolic blood pressure, and five dichotomous variables: haematologic malignancy/metastatic cancer, acute surgical admission and use of vasopressors/inotropes, respiratory support and renal replacement therapy. Discrimination (area under the receiver operating characteristic curve) was 0.72 (95% CI: 0.71–0.74), overall performance (Nagelkerke's R2) was 0.19 and calibration (intercept and slope) was 0.00 and 0.99, respectively. Optimism‐corrected performance was similar to apparent performance.
Conclusions
The SMS‐ICU predicted 90‐day mortality with reasonable and stable performance. If performance remains adequate after external validation, the SMS‐ICU could prove a valuable tool for ICU clinicians and researchers because of its simplicity and expected very low number of missing values.
Background: Stroke volume variation (SVV) – as measured by the pulse contour cardiac output (PiCCO®) system – predicts the cardiac output response to a fluid challenge in patients on controlled ...ventilation. Whether this applies to patients on pressure support ventilation is unknown.
Methods: Thirty consecutive patients with septic shock were included. All were on pressure support ventilation, monitored using the PiCCO® system and receiving 500 ml of colloid on clinical indications. Arterial pulse contour SVV and the transpulmonary thermodilution cardiac index were measured before and after fluid challenge.
Results: Forty‐seven per cent of the patients were defined as fluid responders by an observed increase of > 10% in the cardiac index after fluid. Prior to fluid challenge, the cardiac index was lower in responders compared with non‐responders (mean ± SD, 3.0 ± 0.6 vs. 4.0 ± 1.2 l/min/m2, P < 0.01). In contrast, pre‐infusion values of SVV were similar between subsequent responders and non‐responders (13 ± 5 vs. 16 ± 6%, P =0.26). The mean areas under the ROC curves were 0.77 (95% confidence interval, 0.60–0.94) and 0.52 (0.30–0.73) for pre‐fluid cardiac index and SVV, respectively, indicating a predictive power of only the cardiac index.
Conclusions: SVV did not predict the response in cardiac output to fluid challenge in patients with septic shock on pressure support ventilation.
Background
Adult critically ill patients often suffer from acute circulatory failure, necessitating use of vasopressor therapy. The aim of the Scandinavian Society of Anaesthesiology and Intensive ...Care Medicine (SSAI) task force for Acute Circulatory Failure was to present clinically relevant, evidence‐based treatment recommendations on this topic.
Methods
This guideline was developed according to standards for trustworthy guidelines, including a systematic review of the literature and use of the GRADE methodology for assessment of the quality of evidence and for moving from evidence to recommendations. We assessed the following subpopulations of patients with acute circulatory failure: 1) shock in general, 2) septic shock, 3) cardiogenic shock, 4) hypovolemic shock and 5) other types of shock, including vasodilatory shock. We assessed patient‐important outcome measures, including mortality, serious adverse reactions and quality‐of‐life.
Results
For patients with shock in general and those with septic shock, we recommend using norepinephrine rather than dopamine, and we suggest using norepinephrine rather than epinephrine, vasopressin analogues, and phenylephrine. For patients with cardiogenic shock and those with hypovolemic shock, we suggest using norepinephrine rather than dopamine, and we provide no recommendations/suggestions of norepinephrine vs. epinephrine, vasopressin analogues, and phenylephrine. For patients with other types of shock, including vasodilatory shock, we suggest using norepinephrine rather than dopamine, epinephrine, vasopressin analogues, and phenylephrine.
Conclusions
We recommend using norepinephrine rather than other vasopressors as first‐line treatment for the majority of adult critically ill patients with acute circulatory failure.
Stress ulcer prophylaxis (SUP) is regarded as standard of care in the intensive care unit (ICU). However, recent randomized, clinical trials (RCTs) and meta‐analyses have questioned the rationale and ...level of evidence for this recommendation. The aim of the present systematic review was to evaluate if SUP in the critically ill patients is indicated. Data sources: MEDLINE including MeSH, EMBASE, and the Cochrane Library. Participants: patients in the ICU. Interventions: pharmacological and non‐pharmacological SUP. Study appraisal and synthesis methods: Risk of bias was assessed according to Grading of Recommendations Assessment, Development, and Evaluation, and risk of random errors in cumulative meta‐analyses was assessed with trial sequential analysis. A total of 57 studies were included in the review. The literature on SUP in the ICU includes limited trial data and methodological weak studies. The reported incidence of gastrointestinal (GI) bleeding varies considerably. Data on the incidence and severity of GI bleeding in general ICUs in the developed world as of today are lacking. The best intervention for SUP is yet to be settled by balancing efficacy and harm. In essence, it is unresolved if intensive care patients benefit overall from SUP. The following clinically research questions are unanswered: (1) What is the incidence of GI bleeding, and which interventions are used for SUP in general ICUs today?; (2) Which criteria are used to prescribe SUP?; (3) What is the best SUP intervention?; (4) Do intensive care patients benefit from SUP with proton pump inhibitors as compared with other SUP interventions? Systematic reviews of possible interventions and well‐powered observational studies and RCTs are needed.
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