Ten years of asthma admissions to adult critical care units in England and Wales

OBJECTIVES: To describe the patient demographics, outcomes and trends of admissions with acute severe asthma admitted to adult critical care units in England and Wales. DESIGN: 10-year, retrospective analysis of a national audit database. SETTING: Secondary care: adult, general critical care units in the UK. PARTICIPANTS: 830 808 admissions to adult, general critical care units. PRIMARY AND SECONDARY OUTCOME MEASURES: Demographic data including age and sex, whether the patient was invasively ventilated or not, length of stay (LOS; both in the critical care unit and acute hospital), survival (both critical care unit and acute hospital) and time trends across the 10-year period. RESULTS: Over the 10-year period, there were 11 948 (1.4% of total) admissions with asthma to adult critical care units in England and Wales. Among them 67.5% were female and 32.5% were male (RR F:M 2.1; 95% CI 2.0 to 2.1). Median LOS in the critical care unit was 1.8 days (IQR 0.9–3.8). Median LOS in the acute hospital was 7 days (IQR 4–14). Critical care unit survival rate was 95.5%. Survival at discharge from hospital was 93.3%. There was an increase in admissions to adult critical care units by an average of 4.7% (95% CI 2.8 to 6.7)/year. CONCLUSIONS: Acute asthma represents a modest burden of work for adult critical care units in England and Wales. Demographic patterns for admission to critical care unit mirror those of severe asthma in the general adult community. The number of critical care admissions with asthma are rising, although we were unable to discern whether this represents a true increase in the incidence of acute asthma or asthma severity

Melatonin for the prevention of postoperative delirium in older adults:a protocol for a systematic review and meta-analysis

INTRODUCTION: Postoperative delirium (POD) is a major cause of morbidity, particularly in elderly patients. Melatonin has been suggested as a low-risk pharmacological intervention to help prevent POD. A previous systematic review found limited high-quality evidence to support the use of melatonin in the prevention of POD. Several further randomised studies have since been published. This systematic review aims to synthesise the evidence from randomised controlled trials (RCTs) examining the effect of melatonin on the prevention of POD in older adults. METHODS AND ANALYSIS: A systematic search of RCTs of melatonin (any dose and formulation) in POD will be run across Embase, Medline, CINAHL and PsychInfo. RCTs published from January 1990 until the end of February 2022 and reporting outcomes for melatonin use to prevent POD in patients will be included. Screening of search results and data extraction from included articles will be performed by two independent reviewers. The primary outcome will be incidence of POD in older adults undergoing surgery. Secondary outcomes are delirium duration and length of hospital stay. The review will also describe the dosage, timing and administration regimes of melatonin therapy and as well as the scales and definitions used to describe POD. A registry review of ongoing trials will be also be performed. For the meta-analysis, data will be pooled using a random effects model to generate a forest plot and obtain an odds ratio (OR) for the incidence of POD. Results will be reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. ETHICS AND DISSEMINATION: No ethical approval is required. This review will be disseminated via peer-reviewed manuscript and conferences. The results will be used as the basis of work to optimise this intervention for future trials in surgical populations. PROSPERO REGISTRATION NUMBER: This review is registered with PROSPERO (CRD42021285019)

Corticosteroids in septic shock:a systematic review and network meta-analysis

Abstract Background Multiple corticosteroids and treatment regimens have been used as adjuncts in the treatment of septic shock. Qualitative and quantitative differences exist at cellular and tissular levels between the different drugs and their patterns of delivery. The objective of this study was to elucidate any differences between the drugs and their treatment regimens regarding outcomes for corticosteroid use in adult patients with septic shock. Methods Network meta-analysis of the data used for the recently conducted Cochrane review was performed. Studies that included children and were designed to assess respiratory function in pneumonia and acute respiratory distress syndrome, as well as cross-over studies, were excluded. Network plots were created for each outcome, and all analyses were conducted using a frequentist approach assuming a random-effects model. Results Complete data from 22 studies and partial data from 1 study were included. Network meta-analysis provided no clear evidence that any intervention or treatment regimen is better than any other across the spectrum of outcomes. There was strong evidence of differential efficacy in only one area: shock reversal. Hydrocortisone boluses and infusions were more likely than methylprednisolone boluses and placebo to result in shock reversal. Conclusions There was no clear evidence that any one corticosteroid drug or treatment regimen is more likely to be effective in reducing mortality or reducing the incidence of gastrointestinal bleeding or superinfection in septic shock. Hydrocortisone delivered as a bolus or as an infusion was more likely than placebo and methylprednisolone to result in shock reversal

Response to Letter to the Editor from Richard Dorin:Dynamic pituitary-adrenal interactions in the critically ill after cardiac surgery

Diabetes mellitus: pathophysiological changes and therap