scholarly journals Alpha-2 agonists for sedation of mechanically ventilated adults in intensive care units: a systematic review

2016 ◽  
Vol 20 (25) ◽  
pp. 1-118 ◽  
Author(s):  
Moira Cruickshank ◽  
Lorna Henderson ◽  
Graeme MacLennan ◽  
Cynthia Fraser ◽  
Marion Campbell ◽  
...  
Keyword(s):  
Systematic Review ◽  
Intensive Care ◽  
Critically Ill ◽  
Outcome Measures ◽  
Risk Of Bias ◽  
Controlled Trials ◽  
Mechanically Ventilated ◽  
Length Of Icu Stay ◽  
Sedative Agents

BackgroundCare of critically ill patients in intensive care units (ICUs) often requires potentially invasive or uncomfortable procedures, such as mechanical ventilation (MV). Sedation can alleviate pain and discomfort, provide protection from stressful or harmful events, prevent anxiety and promote sleep. Various sedative agents are available for use in ICUs. In the UK, the most commonly used sedatives are propofol (Diprivan®, AstraZeneca), benzodiazepines [e.g. midazolam (Hypnovel®, Roche) and lorazepam (Ativan®, Pfizer)] and alpha-2 adrenergic receptor agonists [e.g. dexmedetomidine (Dexdor®, Orion Corporation) and clonidine (Catapres®, Boehringer Ingelheim)]. Sedative agents vary in onset/duration of effects and in their side effects. The pattern of sedation of alpha-2 agonists is quite different from that of other sedatives in that patients can be aroused readily and their cognitive performance on psychometric tests is usually preserved. Moreover, respiratory depression is less frequent after alpha-2 agonists than after other sedative agents.ObjectivesTo conduct a systematic review to evaluate the comparative effects of alpha-2 agonists (dexmedetomidine and clonidine) and propofol or benzodiazepines (midazolam and lorazepam) in mechanically ventilated adults admitted to ICUs.Data sourcesWe searched major electronic databases (e.g. MEDLINE without revisions, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE and Cochrane Central Register of Controlled Trials) from 1999 to 2014.MethodsEvidence was considered from randomised controlled trials (RCTs) comparing dexmedetomidine with clonidine or dexmedetomidine or clonidine with propofol or benzodiazepines such as midazolam, lorazepam and diazepam (Diazemuls®, Actavis UK Limited). Primary outcomes included mortality, duration of MV, length of ICU stay and adverse events. One reviewer extracted data and assessed the risk of bias of included trials. A second reviewer cross-checked all the data extracted. Random-effects meta-analyses were used for data synthesis.ResultsEighteen RCTs (2489 adult patients) were included. One trial at unclear risk of bias compared dexmedetomidine with clonidine and found that target sedation was achieved in a higher number of patients treated with dexmedetomidine with lesser need for additional sedation. The remaining 17 trials compared dexmedetomidine with propofol or benzodiazepines (midazolam or lorazepam). Trials varied considerably with regard to clinical population, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded outcome assessors. Compared with propofol or benzodiazepines (midazolam or lorazepam), dexmedetomidine had no significant effects on mortality [risk ratio (RR) 1.03, 95% confidence interval (CI) 0.85 to 1.24,I2 = 0%;p = 0.78]. Length of ICU stay (mean difference –1.26 days, 95% CI –1.96 to –0.55 days,I2 = 31%;p = 0.0004) and time to extubation (mean difference –1.85 days, 95% CI –2.61 to –1.09 days,I2 = 0%;p < 0.00001) were significantly shorter among patients who received dexmedetomidine. No difference in time to target sedation range was observed between sedative interventions (I2 = 0%;p = 0.14). Dexmedetomidine was associated with a higher risk of bradycardia (RR 1.88, 95% CI 1.28 to 2.77,I2 = 46%;p = 0.001).LimitationsTrials varied considerably with regard to participants, type of comparators, dose of sedative agents, outcome measures and length of follow-up. Overall, risk of bias was generally high or unclear. In particular, few trials blinded assessors.ConclusionsEvidence on the use of clonidine in ICUs is very limited. Dexmedetomidine may be effective in reducing ICU length of stay and time to extubation in critically ill ICU patients. Risk of bradycardia but not of overall mortality is higher among patients treated with dexmedetomidine. Well-designed RCTs are needed to assess the use of clonidine in ICUs and identify subgroups of patients that are more likely to benefit from the use of dexmedetomidine.Study registrationThis study is registered as PROSPERO CRD42014014101.FundingThe National Institute for Health Research Health Technology Assessment programme. The Health Services Research Unit is core funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorates.

scholarly journals Gastric Residual Volumes in the Adult Intensive Care Patient: a Systematic Review

2021 ◽  
Author(s):  
◽  
Rebecca Jane Jarden
Keyword(s):  
Systematic Review ◽  
At Risk ◽  
Intensive Care ◽  
Enteral Nutrition ◽  
Outcome Measures ◽  
Full Text ◽  
Primary Outcome ◽  
Risk Of Bias ◽  
Randomised Controlled ◽  
Patient At Risk

<p>Background: Enteral nutrition is one method of delivering nutrition to intubated patients. There are several issues that prevent optimal delivery of the prescribed enteral nutrition goal rates. The measurement of the patient's gastric residual volume (GRV) may demonstrate tolerability, or intolerability, of enteral nutrition. Identifying a safe GRV, at which to accept and continue enteral nutrition delivery, is essential to ensure the delivery of enteral nutrition adequately achieves the nutritional requirements of patients, and to mitigate the risks associated with the delivery of enteral nutrition. Objectives: This systematic review sought to answer the research question: what is the maximum GRV to accept in order to continue the delivery of enteral nutrition in the Intensive Care Unit (ICU) adult patient? This is specifically related to the primary outcome measures indicative of accepting a specified GRV that is too high or too low. Accepting a GRV that is too high would put the patient at risk of vomiting, regurgitation, aspiration of gastric contents and potentially aspiration pneumonia. Conversely, accepting a GRV that is too low would put the patient at risk of not achieving caloric needs, potentially placing the patient at risk of malnutrition and increased morbidity. Search methods: Databases searched included: CCTR, CLCMR, CLTA, CLEED, OVID MEDLINE (R) (Ovid SP), EMBASE, CINAHL Plus with Full Text (EBSCO host via helicon), AMED, Ovid Nursing Full Text plus, CDSR, ACP Journal Club, DARE, Proquest via helicon (advanced search), Pubmed via helicon (limits "all adult", "humans", "abstract", "title"), all EBM reviews, and the reference lists of articles. Selection criteria: The types of studies eligible for inclusion were published randomised controlled trials, case controlled studies, cohort studies and observational studies. Interventions considered were a comparison of two or more GRV measures. The participants eligible were adult ICU or critical care patients receiving enteral nutrition. The primary outcome measures for study inclusion were caloric requirement met, and specified potential adverse events including vomiting, regurgitation, or aspiration. Data collection and analysis: Data was extracted using a data extraction tool created by the researcher. Risk of bias was assessed by the author using two risk of bias assessment tools. Main results: Three studies met the inclusion criteria for the systematic review (McClave et al., 2005; Metheny, Schallom, Oliver, & Clouse, 2008; Pinilla, Samphire, Arnold, Liu, & Thiessen, 2001). Each of these studies contained methodological risks of bias and limitations related to their study designs. McClave et al.'s study was a prospective study (n = 40), Metheny et al.'s study was a prospective descriptive study (n = 206), and Pinilla et al.'s study was a randomised controlled trial (n = 80). No one study, or a combination of studies, provided conclusive evidence to support the use of one particular GRV over another. Author's conclusion: No recommendation for a definitive GRV was made in this systematic review due to the lack of strong evidentiary support for one GRV over another. There remain opportunities for enhancing practice through developing a consistent, multidisciplinary approach to managing GRVs. There are future research opportunities related to improving the management of GRVs in the enterally fed ICU patient, and achieving optimal volumes of nutrition delivered.</p>

scholarly journals Which treatment is most effective for patients with Achilles tendinopathy? A living systematic review with network meta-analysis of 29 randomised controlled trials

2020 ◽  
pp. bjsports-2019-101872 ◽  
Author(s):  
Arco C van der Vlist ◽  
Marinus Winters ◽  
Adam Weir ◽  
Clare L Ardern ◽  
Nicky J Welton ◽  
...  
Keyword(s):  
Systematic Review ◽  
Exercise Therapy ◽  
Randomised Controlled Trials ◽  
Meta Analysis ◽  
Achilles Tendinopathy ◽  
Risk Of Bias ◽  
Controlled Trials ◽  
Wait And See ◽  
Randomised Controlled

ObjectiveTo provide a consistently updated overview of the comparative effectiveness of treatments for Achilles tendinopathy.DesignLiving systematic review and network meta-analysis.Data sourcesMultiple databases including grey literature sources were searched up to February 2019.Study eligibility criteriaRandomised controlled trials examining the effectiveness of any treatment in patients with both insertional and/or midportion Achilles tendinopathy. We excluded trials with 10 or fewer participants per treatment arm or trials investigating tendon ruptures.Data extraction and synthesisReviewers independently extracted data and assessed the risk of bias. We used the Grading of Recommendations Assessment, Development and Evaluation to appraise the certainty of evidence.Primary outcome measureThe validated patient-reported Victorian Institute of Sport Assessment-Achilles questionnaire.Results29 trials investigating 42 different treatments were included. 22 trials (76%) were at high risk of bias and 7 (24%) had some concerns. Most trials included patients with midportion tendinopathy (86%). Any treatment class seemed superior to wait-and-see for midportion Achilles tendinopathy at 3 months (very low to low certainty of evidence). At 12 months, exercise therapy, exercise+injection therapy and exercise+night splint therapy were all comparable with injection therapy for midportion tendinopathy (very low to low certainty). No network meta-analysis could be performed for insertional Achilles tendinopathy.Summary/conclusionIn our living network meta-analysis no trials were at low risk of bias and there was large uncertainty in the comparative estimates. For midportion Achilles tendinopathy, wait-and-see is not recommended as all active treatments seemed superior at 3-month follow-up. There seems to be no clinically relevant difference in effectiveness between different active treatments at either 3-month or 12-month follow-up. As exercise therapy is easy to prescribe, can be of low cost and has few harms, clinicians could consider starting treatment with a calf-muscle exercise programme.PROSPERO registration numberCRD42018086467.

Physiotherapy as an Initial Treatment Option for Femoroacetabular Impingement: A Systematic Review of the Literature and Meta-analysis of 5 Randomized Controlled Trials

2019 ◽  
Vol 48 (8) ◽  
pp. 2042-2050 ◽  
Author(s):  
Graeme Hoit ◽  
Daniel B. Whelan ◽  
Tim Dwyer ◽  
Prabjit Ajrawat ◽  
Jaskarndip Chahal
Keyword(s):  
Systematic Review ◽  
Randomized Controlled Trials ◽  
Outcome Measures ◽  
Femoroacetabular Impingement ◽  
Meta Analysis ◽  
Hip Pain ◽  
Cochrane Library ◽  
Controlled Trials ◽  
Randomized Controlled

Background: Femoroacetabular impingement is a common and debilitating source of hip pain in young adults. Although physiotherapy is used as a mainstay of nonoperative care for femoroacetabular impingement, the evidence regarding different physiotherapy practices is poorly understood. Purpose: To collect and synthesize the best available evidence and arrive at a summary estimate of treatment effect for the utility of physiotherapy in the management of femoroacetabular impingement. Study Design: Meta-analysis. Methods: A systematic review was performed on February 2, 2019, of PubMed, EMBASE, and Cochrane Library databases using “femoroacetabular impingement OR hip pain” and “physiotherapy OR nonoperative management” and their synonyms as search terms. Central treatment themes were identified across protocols, and pooled analyses were conducted to assess for differences in patient-reported outcome measures across these themes. Results: A total of 5 randomized controlled trials met our inclusion criteria. The studies included 124 patients with a mean age of 35 years, of whom 24% were male. The average follow-up was 9.4 weeks (range, 6-12 weeks), and the follow-up rate across all participants was 86%. Among these 5 studies, 4 studies used a physiotherapy protocol that focused on core strengthening versus no core strengthening, 4 studies compared active strengthening versus passive modalities, and 3 studies compared supervised versus unsupervised physiotherapy. Pooled analysis across all studies demonstrated improved outcomes in the treatment groups compared with the controls (standardized mean difference [SMD], 0.76; 95% CI, 0.38-1.13; P < .0001). Core strengthening (SMD, 0.82; 95% CI, 0.39-1.26; P = .0002), active physiotherapy (SMD, 0.70; 95% CI, 0.29-1.10; P = .0008), and supervised physiotherapy (SMD, 0.58; 95% CI, 0.14-1.03; P = .01) were found to result in statistically significant improvements in functional outcomes compared with no core strengthening, passive modalities, and unsupervised care, respectively. Conclusion: Supervised physiotherapy programs focusing on active strengthening and core strengthening are more effective than unsupervised, passive, and non–core focused programs. Future studies with longer term follow-up and validated femoroacetabular impingement specific outcome measures are required to determine prognostic factors for success with nonoperative care as well as to determine the ideal patient profile and structured rehabilitation protocol.

Evaluation of the description of active mobilisation protocols for mechanically ventilated patients in the intensive care unit: A systematic review of randomized controlled trials

Heart & Lung ◽  
2018 ◽  
Vol 47 (3) ◽  
pp. 253-260 ◽  
Author(s):  
Rodrigo Santos de Queiroz ◽  
Micheli Bernardone Saquetto ◽  
Bruno Prata Martinez ◽  
Edil Alves Andrade ◽  
Paula Aracoeli Miranda Pimentel da Silva ◽  
...  
Keyword(s):  
Systematic Review ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Randomized Controlled Trials ◽  
Controlled Trials ◽  
Mechanically Ventilated ◽  
Mechanically Ventilated Patients ◽  
Randomized Controlled ◽  
Ventilated Patients

Hypophosphataemia in Critically Ill Adults and Children – A Systematic Review

2020 ◽  
Author(s):  
Annika Reintam Blaser ◽  
Jan Gunst ◽  
Carole Ichai ◽  
Michael Casaer ◽  
Carina Benstoem ◽  
...  
Keyword(s):  
Systematic Review ◽  
Randomized Controlled Trials ◽  
Critically Ill ◽  
Risk Of Bias ◽  
Controlled Trials ◽  
Randomized Controlled ◽  
Adults And Children ◽  
Research Questions ◽  
Critically Ill Adults ◽  
Ill Adults

Abstract Background: Phosphate is the main intracellular anion essential for numerous biological processes. Symptoms of hypophosphataemia are non-specific, yet potentially life-threatening. This systematic review process was initiated to gain a global insight into hypophosphataemia, associated morbidity and treatments. Methods: A systematic review was conducted (PROSPERO CRD42020163191). Nine clinically relevant questions were generated, seven for adult and two for paediatric critically ill patients, and prevalence of hypophosphataemia was assessed in both of these groups. We identified trials through systematic searches of Medline, EMBASE, Scopus, Cochrane Central Register of Controlled Trials, CINAHL, and Web of Science. Quality assessment was performed using the Cochrane risk of bias tool for randomized controlled trials and the Newcastle-Ottawa Scale for observational studies.Results: For all research questions, we identified 2727 titles in total, assessed 399 full texts, and retained 82 full texts for evidence synthesis, with 20 of them identified for several research questions. Only 3 randomized controlled trials were identified with two of them published only in abstract form, as well as 28 prospective and 31 retrospective studies, and 20 case reports. Relevant risk of bias regarding selection and comparability was identified for most of the studies. No meta-analysis could be performed. The prevalence of hypophosphataemia varied substantially in critically ill adults and children, but no study assessed consecutive admissions to intensive care.In both critically ill adults and children, several studies report that hypophosphataemia is associated with worse outcome (prolonged length of stay and the need for respiratory support, and higher mortality). However, there was insufficient evidence regarding the optimal threshold upon which hypophosphataemia becomes critical and requires treatment. We found no studies regarding the optimal frequency of phosphate measurements, and regarding the time window to correct hypophosphataemia. In adults, nutrient restriction on top of phosphate repletion in patients with refeeding syndrome may improve survival, although evidence is weak. Conclusion: Evidence on the definition, outcome and treatment of clinically relevant hypophosphataemia in critically ill adults and children is scarce and does not allow answering clinically relevant questions. High quality clinical research is crucial for the development of respective guidelines.

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