The Effects of Etomidate Anesthesia on Adrenal Insufficiency and Relative Risk of Mortality Associated with Severity of Critical Illness. A Meta-Analysis

Abstract Background: Adrenal insufficiency may put a person at higher risk with infections due to a lack of normal stress response by the body. Limited data has been available in pediatric adrenal insufficiency with Covid-19 Methods: We used TriNetX, with a large COVID-19 database, collecting real-time electronic medical records data. We compared children (0-18 years) who were diagnosed with Covid-19 with and without Adrenal insufficiency. This database collected information from 54 health care organizations Results: Mortality rate in children with Covid-19 and Adrenal insufficiency was 2.246% (19/846). Mortality rate in children with Covid-19 without adrenal insufficiency was 0.097 % (244/252211). Relative risk of mortality for children with Covid-19 and Adrenal insufficiency was 23.2 with a p value of < 0.0001. Endotracheal intubation rate in children with Covid-19 and Adrenal insufficiency was 1.418% (12/846). Endotracheal intubation rate in children with Covid-19 without Adrenal insufficiency was 0.065% (165/252211). Relative risk of endotracheal intubation for children with Covid-19 and Adrenal insufficiency was 21.68 with a p value of < 0.0001. Sepsis rate in children with Covid-19 and Adrenal insufficiency was 6.974% (59/846). Sepsis rate in children with Covid-19 without Adrenal insufficiency was 0.274% (691/252211). Relative risk of sepsis for children with Covid-19 and Adrenal insufficiency was 25.45 with a p value of < 0.00001. Conclusion: Mortality rate, endotracheal and sepsis showed increased association in children with Adrenal insufficiency and Covid-19 versus children with Covid-19 and no Adrenal insufficiency. Further studies with larger sample size are needed to study complication rates of Covid-19 and Adrenal insufficiency.

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Etomidate, Adrenal Insufficiency and Mortality Associated With Severity of Illness: A Meta-Analysis

Journal of Intensive Care Medicine ◽

10.1177/0885066620957596 ◽

2020 ◽

pp. 088506662095759

Author(s):

Stewart G. Albert ◽

Sujata Sitaula

Keyword(s):

Critical Illness ◽

Mortality Rate ◽

Adrenal Insufficiency ◽

Absolute Risk ◽

Meta Analysis ◽

Severity Of Illness ◽

Mortality Rates ◽

Secondary Outcome ◽

Relative Mortality ◽

Cochrane Reviews

Purpose: Etomidate causes adrenal insufficiency. Yet in critically ill patients, it is controversial whether it increases mortality rates above that of comparator anesthetic induction agents. We postulated that etomidate would increase relative mortality rates correspondingly to the severity of illness as defined by SAPS or APACHE scores. Materials and Methods: A literature search was performed on Pub Med, SCOPUS, and Cochrane Reviews for human studies, regardless of language, between 1983 and February 2020. The search strategy used keywords, “etomidate,” “adrenal insufficiency,” “glucocorticoid,” and “intensive care.” Both authors reviewed electronic data search titles, abstracts and extracted data, which were checked by the other reviewer. Primary outcome was 28-day survival. Secondary outcome was adrenal insufficiency. Results: There were 29 trials of etomidate versus comparators in 8584 patients. Etomidate was associated with adrenal insufficiency (risk ratio (rr) = 1·54, 95% CI; 1·42, 1·67, p < 0.001) and increased overall relative mortality rates (rr = 1.09, CI;1.04,1.16, p = 0.001). Meta-regression showed that with etomidate there was a continuous progressive relative risk of mortality associated with increasing severity of illness (predefined in each article by standard critical illness scores). In those patients who had a predicted mortality rate > the median for this analysis (predicted mortality 44%) the relative mortality rate (rr) = 1.20, Ci;1.12,1.29, p < 0.001, the absolute risk difference (rd) = 0.08, CI;0.05,0.11, p < 0.0001 and the number needed to harm (1/rd) was 12.5. In those with a calculated predicted mortality <44% there was no increase in relative mortality rate. Conclusions: Whereas etomidate causes adrenal insufficiency, it was not shown to increase mortality in many analyzed here in ICU settings. However, etomidate associated relative mortality rates increased progressively and correlated with the severity of critical illness scores. Intensivists should anticipate the need for glucocorticoid supplementation after etomidate in those with severe critical illness and in those with acute deterioration of vital signs.

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Association of hypertension and antihypertensive treatment with COVID-19 mortality: a retrospective observational study

European Heart Journal ◽

10.1093/eurheartj/ehaa433 ◽

2020 ◽

Vol 41 (22) ◽

pp. 2058-2066 ◽

Cited By ~ 76

Author(s):

Chao Gao ◽

Yue Cai ◽

Kan Zhang ◽

Lei Zhou ◽

Yao Zhang ◽

...

Keyword(s):

Relative Risk ◽

Observational Study ◽

Antihypertensive Treatment ◽

Meta Analysis ◽

Fold Increase ◽

Retrospective Observational Study ◽

Risk Of Mortality ◽

Increased Risk ◽

History Of ◽

Antihypertensive Treatments

Abstract Aims It remains unknown whether the treatment of hypertension influences the mortality of patients diagnosed with coronavirus disease 2019 (COVID-19). Methods and results This is a retrospective observational study of all patients admitted with COVID-19 to Huo Shen Shan Hospital. The hospital was dedicated solely to the treatment of COVID-19 in Wuhan, China. Hypertension and the treatments were stratified according to the medical history or medications administrated prior to the infection. Among 2877 hospitalized patients, 29.5% (850/2877) had a history of hypertension. After adjustment for confounders, patients with hypertension had a two-fold increase in the relative risk of mortality as compared with patients without hypertension [4.0% vs. 1.1%, adjusted hazard ratio (HR) 2.12, 95% confidence interval (CI) 1.17–3.82, P = 0.013]. Patients with a history of hypertension but without antihypertensive treatment (n = 140) were associated with a significantly higher risk of mortality compared with those with antihypertensive treatments (n = 730) (7.9% vs. 3.2%, adjusted HR 2.17, 95% CI 1.03–4.57, P = 0.041). The mortality rates were similar between the renin–angiotensin–aldosterone system (RAAS) inhibitor (4/183) and non-RAAS inhibitor (19/527) cohorts (2.2% vs. 3.6%, adjusted HR 0.85, 95% CI 0.28–2.58, P = 0.774). However, in a study-level meta-analysis of four studies, the result showed that patients with RAAS inhibitor use tend to have a lower risk of mortality (relative risk 0.65, 95% CI 0.45–0.94, P = 0.20). Conclusion While hypertension and the discontinuation of antihypertensive treatment are suspected to be related to increased risk of mortality, in this retrospective observational analysis, we did not detect any harm of RAAS inhibitors in patients infected with COVID-19. However, the results should be considered as exploratory and interpreted cautiously.

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Effects of therapeutic hypothermia on death among asphyxiated neonates with hypoxic-ischemic encephalopathy: A systematic review and meta-analysis of randomized control trials

PLoS ONE ◽

10.1371/journal.pone.0247229 ◽

2021 ◽

Vol 16 (2) ◽

pp. e0247229

Author(s):

Biruk Beletew Abate ◽

Melaku Bimerew ◽

Bereket Gebremichael ◽

Ayelign Mengesha Kassie ◽

MesfinWudu Kassaw ◽

...

Keyword(s):

Systematic Review ◽

Relative Risk ◽

Therapeutic Hypothermia ◽

Meta Analysis ◽

Hypoxic Ischemic Encephalopathy ◽

Whole Body ◽

Randomized Control Trials ◽

Risk Of Mortality ◽

Randomized Control ◽

Ischemic Encephalopathy

Background Hypoxic perinatal brain injury is caused by lack of oxygen to baby’s brain and can lead to death or permanent brain damage. However, the effectiveness of therapeutic hypothermia in birth asphyxiated infants with encephalopathy is uncertain. This systematic review and meta-analysis was aimed to estimate the pooled relative risk of mortality among birth asphyxiated neonates with hypoxic-ischemic encephalopathy in a global context. Methods We used the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines to search randomized control trials from electronic databases (PubMed, Cochrane library, Google Scholar, MEDLINE, Embase, Scopus, Web of Science, Cochrane Central Register of Controlled Trials (CENTRAL), and meta register of Current Controlled Trials (mCRT)). The authors extracted the author’s name, year of publication, country, method of cooling, the severity of encephalopathy, the sample size in the hypothermic, and non-hypothermic groups, and the number of deaths in the intervention and control groups. A weighted inverse variance fixed-effects model was used to estimate the pooled relative risk of mortality. The subgroup analysis was done by economic classification of countries, methods of cooling, and cooling devices. Publication bias was assessed with a funnel plot and Eggers test. A sensitivity analysis was also done. Results A total of 28 randomized control trials with a total sample of 35, 92 (1832 hypothermic 1760 non-hypothermic) patients with hypoxic-ischemic encephalopathy were used for the analysis. The pooled relative risk of mortality after implementation of therapeutic hypothermia was found to be 0.74 (95%CI; 0.67, 0.80; I2 = 0.0%; p<0.996). The subgroup analysis revealed that the pooled relative risk of mortality in low, low middle, upper-middle and high income countries was 0.32 (95%CI; -0.95, 1.60; I2 = 0.0%; p<0.813), 0.5 (95%CI; 0.14, 0.86; I2 = 0.0%; p<0.998), 0.62 (95%CI; 0.41–0.83; I2 = 0.0%; p<0.634) and 0.76 (95%CI; 0.69–0.83; I2 = 0.0%; p<0.975) respectively. The relative risk of mortality was the same in selective head cooling and whole-body cooling method which was 0.74. Regarding the cooling device, the pooled relative risk of mortality is the same between the cooling cap and cooling blanket (0.74). However, it is slightly lower (0.73) in a cold gel pack. Conclusions Therapeutic hypothermia reduces the risk of death in neonates with moderate to severe hypoxic-ischemic encephalopathy. Both selective head cooling and whole-body cooling method are effective in reducing the mortality of infants with this condition. Moreover, low income countries benefit the most from the therapy. Therefore, health professionals should consider offering therapeutic hypothermia as part of routine clinical care to newborns with hypoxic-ischemic encephalopathy especially in low-income countries.

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A Systematic Review and Meta-Analysis of Inpatient Mortality Associated With Nosocomial and Community COVID-19 Exposes the Vulnerability of Immunosuppressed Adults

Frontiers in Immunology ◽

10.3389/fimmu.2021.744696 ◽

2021 ◽

Vol 12 ◽

Author(s):

Mark J. Ponsford ◽

Tom J. C. Ward ◽

Simon M. Stoneham ◽

Clare M. Dallimore ◽

Davina Sham ◽

...

Keyword(s):

Systematic Review ◽

Critical Care ◽

Relative Risk ◽

Meta Analysis ◽

Case Definition ◽

Risk Of Death ◽

Risk Of Mortality ◽

Increased Risk ◽

Critical Care Admission ◽

Community Acquired Infection

BackgroundLittle is known about the mortality of hospital-acquired (nosocomial) COVID-19 infection globally. We investigated the risk of mortality and critical care admission in hospitalised adults with nosocomial COVID-19, relative to adults requiring hospitalisation due to community-acquired infection.MethodsWe systematically reviewed the peer-reviewed and pre-print literature from 1/1/2020 to 9/2/2021 without language restriction for studies reporting outcomes of nosocomial and community-acquired COVID-19. We performed a random effects meta-analysis (MA) to estimate the 1) relative risk of death and 2) critical care admission, stratifying studies by patient cohort characteristics and nosocomial case definition.Results21 studies were included in the primary MA, describing 8,251 admissions across 8 countries during the first wave, comprising 1513 probable or definite nosocomial COVID-19, and 6738 community-acquired cases. Across all studies, the risk of mortality was 1.3 times greater in patients with nosocomial infection, compared to community-acquired (95% CI: 1.005 to 1.683). Rates of critical care admission were similar between groups (Relative Risk, RR=0.74, 95% CI: 0.50 to 1.08). Immunosuppressed patients diagnosed with nosocomial COVID-19 were twice as likely to die in hospital as those admitted with community-acquired infection (RR=2.14, 95% CI: 1.76 to 2.61).ConclusionsAdults who acquire SARS-CoV-2 whilst already hospitalised are at greater risk of mortality compared to patients admitted following community-acquired infection; this finding is largely driven by a substantially increased risk of death in individuals with malignancy or who had undergone transplantation. These findings inform public health and infection control policy and argue for individualised clinical interventions to combat the threat of nosocomial COVID-19, particularly for immunosuppressed groups.Systematic Review RegistrationPROSPERO CRD42021249023

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A systematic review and meta-analysis of inpatient mortality associated with nosocomial and community COVID-19 exposes the vulnerability of immunosuppressed adults

10.1101/2021.07.10.21260306 ◽

2021 ◽

Author(s):

Mark J Ponsfonrd ◽

Tom JC Ward ◽

Simon Stoneham ◽

Clare M Dallimore ◽

Davina Sham ◽

...

Keyword(s):

Systematic Review ◽

Critical Care ◽

Relative Risk ◽

Meta Analysis ◽

Case Definition ◽

Risk Of Death ◽

Risk Of Mortality ◽

Increased Risk ◽

Critical Care Admission ◽

Community Acquired Infection

Background: Little is known about the mortality of hospital-acquired (nosocomial) COVID-19 infection globally. We investigated the risk of mortality and critical care admission in hospitalised adults with nosocomial COVID-19, relative to adults requiring hospitalisation due to community-acquired infection. Methods: We systematically reviewed the peer-reviewed and pre-print literature from 1/1/2020 to 9/2/2021 without language restriction for studies reporting outcomes of nosocomial and community-acquired COVID-19. We performed a random effects meta-analysis (MA) to estimate the 1) relative risk of death and 2) critical care admission, stratifying studies by patient cohort characteristics and nosocomial case definition. Results: 21 studies were included in the primary MA, describing 8,246 admissions across 8 countries during the first wave, comprising 1517 probable or definite nosocomial COVID-19, and 6729 community-acquired cases. Across all studies, the risk of mortality was 1.31 times greater in patients with nosocomial infection, compared to community-acquired (95% CI: 1.01 to 1.70). Rates of critical care admission were similar between groups (Relative Risk, RR=0.74, 95% CI: 0.50 to 1.08). Immunosuppressed patients diagnosed with nosocomial COVID-19 were twice as likely to die in hospital as those admitted with community-acquired infection (RR=2.14, 95% CI: 1.76 to 2.61). Conclusions: Adults who acquire SARS-CoV-2 whilst already hospitalised are at greater risk of mortality compared to patients admitted following community-acquired infection; this finding is largely driven by a substantially increased risk of death in individuals with malignancy or who had undergone transplantation. These findings inform public health and infection control policy, and argue for individualised clinical interventions to combat the threat of nosocomial COVID-19, particularly for immunosuppressed groups. Systematic review registration: PROSPERO CRD42021249023

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