Comparison of sedation strategies for critically ill patients:A protocol for a systematic review incorporating network meta-analyses

Abstract Background Sedatives and analgesics are administered to provide sedation and manage agitation and pain in most critically ill mechanically ventilated patients. Various sedation administration strategies including protocolized sedation and daily sedation interruption are used to mitigate drug pharmacokinetic limitations and minimize oversedation, thereby shortening the duration of mechanical ventilation. At present, it is unclear which strategy is most effective, as few have been directly compared. Our review will use network meta-analysis (NMA) to compare and rank sedation strategies to determine their efficacy and safety for mechanically ventilated patients. Methods We will search the following from 1980 to March 2016: Ovid MEDLINE, CINAHL, Embase, PsycINFO, and Web of Science. We will also search the Cochrane Library, gray literature, and the International Clinical Trials Registry Platform. We will use a validated randomized control trial search filter to identify studies evaluating any strategy to optimize sedation in mechanically ventilated adult patients. Authors will independently extract data from eligible studies in duplicate and complete the Cochrane Risk of Bias tool. Our outcomes of interest include duration of mechanical ventilation, time to first extubation, ICU and hospital length of stay, re-intubation, tracheostomy, mortality, total sedative and opioid exposure, health-related quality of life, and adverse events. To inform our NMA, we will first conduct conventional pair-wise meta-analyses using random-effects models. Where appropriate, we will perform Bayesian NMA using WinBUGS software. Discussion There are multiple strategies to optimize sedation for mechanically ventilated patients. Current ICU guidelines recommend protocolized sedation or daily sedation interruption. Our systematic review incorporating NMA will provide a unified analysis of all sedation strategies to determine the relative efficacy and safety of interventions that may not have been compared directly. We will provide knowledge users, decision makers, and professional societies with ranking of multiple sedation strategies to inform future sedation guidelines. Systematic review registration PROSPERO CRD4201603748

Delirium prediction in the intensive care unit: comparison of two delirium prediction models

Background: Accurate prediction of delirium in the intensive care unit (ICU) may facilitate efficient use of early preventive strategies and stratification of ICU patients by delirium risk in clinical research, but the optimal delirium prediction model to use is unclear. We compared the predictive performance and user convenience of the prediction model for delirium (PRE-DELIRIC) and early prediction model for delirium (E-PRE-DELIRIC) in ICU patients and determined the value of a two-stage calculation. Methods: This 7-country, 11-hospital, prospective cohort study evaluated consecutive adults admitted to the ICU who could be reliably assessed for delirium using the Confusion Assessment Method-ICU or the Intensive Care Delirium Screening Checklist. The predictive performance of the models was measured using the area under the receiver operating characteristic curve. Calibration was assessed graphically. A physician questionnaire evaluated user convenience. For the two-stage calculation we used E-PRE-DELIRIC immediately after ICU admission and updated the prediction using PRE-DELIRIC after 24 h. Results: In total 2178 patients were included. The area under the receiver operating characteristic curve was significantly greater for PRE-DELIRIC (0.74 (95% confidence interval 0.71-0.76)) compared to E-PRE-DELIRIC (0.68 (95% confidence interval 0.66-0.71)) (z score of -2.73 (p < 0.01)). Both models were well-calibrated. The sensitivity improved when using the two-stage calculation in low-risk patients. Compared to PRE-DELIRIC, ICU physicians (n = 68) rated the E-PRE-DELIRIC model more feasible. Conclusions: While both ICU delirium prediction models have moderate-to-good performance, the PRE-DELIRIC model predicts delirium better. However, ICU physicians rated the user convenience of E-PRE-DELIRIC superior to PRE-DELIRIC. In low-risk patients the delirium prediction further improves after an update with the PRE-DELIRIC model after 24 h

Colección José Arencibia [Material gráfico]

Copia digital. Madrid : Ministerio de Educación, Cultura y Deporte. Subdirección General de Coordinación Bibliotecaria, 201

Time to Administration of Antibiotics among Inpatients with Severe Sepsis or Septic Shock

ABSTRACTBackground: Current evidence suggests that administration of appropriate antibiotic therapy within 1 h after the onset of hypotension significantly improves mortality rates among patients with severe sepsis and septic shock.Objectives: To determine the interval from recognition of severe sepsis or septic shock in inpatients to initial administration of antibiotic and to assess institutional compliance with the Surviving Sepsis Campaign’s recommendation for early antibiotic therapy.Methods: A 6-month retrospective chart analysis was conducted to determine the interval from documented onset of hypotension to initial administration of antibiotic for patients with severe sepsis or septic shock. Patients who were admitted to a general medicine ward, a surgery ward, or the intensive care unit (ICU) of a 475-bed university-affiliated hospital and who met the criteria for severe sepsis or septic shock were eligible for inclusion. Patients who received antibiotics before meeting the criteria for severe sepsis or septic shock were excluded.Results: Charts for 100 patients with severe sepsis or septic shock were reviewed. The mean age was 69.0 years (standard deviation 18.7 years), and 56% were men. The median interval from onset of severe sepsis or septic shock to administration of antibiotic was 4.00 h (interquartile range [IQR] 1.80–6.45 h). The median interval from the time a physician ordered an antibiotic to administration of the drug was 1.28 h (IQR 0.57–3.05 h). The interval between ordering and administration differed significantly for patients on the wards (5.67 h), those with onset in the ICU (4.00 h), and those with onset in the emergency department (3.28 h) (p = 0.039). The overall survival rate was 56%.Conclusion: At the study hospital, the interval from onset of severe sepsis or septic shock to initial administration of antibiotic to inpatients exceeded the 1-h period recommended by the Surviving Sepsis Campaign. These results will be used as a baseline for future quality assurance and improvement initiatives aimed at minimizing the time to antibiotic administration for this group of patients, who are at high risk of death.RÉSUMÉContexte : D’après les données probantes actuelles, l’administration d'une antibiothérapie adéquate dans l’heure suivant la survenue d’hypotension aide grandement à réduire le taux de mortalité chez les patients atteints de sepsis sévère ou de choc septique.Objectifs : Déterminer quel est l’intervalle séparant le diagnostic du sepsis sévère ou du choc septique de l’administration initiale d’un antibiotique aux patients hospitalisés et évaluer le degré de conformité de l’établissement envers la recommandation de la campagne « Surviving Sepsis » (survivre au sepsis) qui préconise une antibiothérapie précoce.Méthodes : Une analyse rétrospective couvrant six mois de dossiers médicaux a été effectuée dans le but de déterminer l’intervalle entre la survenue consignée de l’hypotension et l’administration initiale d’un antibiotique chez des patients atteints de sepsis sévère ou de choc septique. Les patients qui étaient admis à un service de médecine générale ou de chirurgie ou à l’unité de soins intensifs (USI) d’un hôpital universitaire de 475 lits et qui répondaient aux critères d’un sepsis sévère ou d’un choc septique étaient admissibles à l’étude. Ceux qui ont reçu des antibiotiques avant de satisfaire aux critères d’un sepsis sévère ou d’un choc septique ont été exclus.Résultats : Les dossiers médicaux de 100 patients atteints de sepsis sévère ou de choc septique ont été étudiés. L’âge moyen était de 69,0 ans (écart-type de 18,7 ans) et 56 % des patients étaient des hommes. L’intervalle médian entre le moment du diagnostic d’un sepsis sévère ou d’un choc septique et celui de l’administration d’un antibiotique était de 4,0 h (écart interquartile [ÉIQ] de 1,80 à 6,45 h). L’intervalle médian entre le moment où le médecin prescrivait un antibiotique et l’administration de celui-ci était de 1,28 h (EIQ de 0,57 à 3,05 h). L’intervalle entre le moment de la prescription et celui de l’administration était beaucoup plus important pour les patients chez qui un sepsis sévère ou un choc septique apparaissait alors qu’ils se trouvaient au service de chirurgie ou de médecine générale (5,67 h) que pour les patients qui étaient à l’USI (4,00 h) ou au service des urgences (3,28 h) (p = 0,039). Le taux de survie global était de 56 %.Conclusion : À l’hôpital où s’est déroulée l’étude, l’intervalle entre les premières manifestations d’un sepsis sévère ou d’un choc septique et le moment où l’antibiotique était administré aux patients excédait la période d’une heure recommandée par la campagne « Surviving Sepsis » (survivre au sepsis). Ces résultats serviront de référence pour de futurs programmes d’amélioration et d’assurance de la qualité dont l’objectif sera de réduire au maximum la période de temps située entre le diagnostic et l’administration de l’antibiotique pour ce groupe de patients qui présente un risque élevé de mortalité.