Reducing Mortality in Critically Ill Patients

135 Pages·2015·3.166 MB·English

by  Giovanni Landoni, Marta Mucchetti, Alberto Zangrillo, Rinaldo Bellomo (eds.)

Reducing Mortality
in Critically
Patients
Giovanni Landoni
Marta Mucchetti
Alberto Zangrillo
Rinaldo Bellomo
Editors
123
Reducing Mortality in Critically Ill Patients

Giovanni Landoni (cid:129) Marta Mucchetti
Alberto Zangrillo (cid:129) Rinaldo Bellomo
Editors
Reducing Mortality
in Critically Ill Patients
Editors
Giovanni Landoni Alberto Zangrillo
Department of Anesthesia Department of Anesthesia
and Intensive care and Intensive Care
IRCCS San Raffaele Scientifi c Institute IRCCS San Raffaele Scientifi c Institute
and Vita-Salute San Raffaele University and Vita-Salute San Raffaele University
Milan , Milan Milan
Italy Italy
Marta Mucchetti Rinaldo Bellomo
Department of Anesthesia Department of Intensive Care
and Intensive Care Austin Hospital
IRCCS San Raffaele Scientifi c Institute Heidelberg, Vic. 3084
Milan Australia
Italy
ISBN 978-3-319-17514-0 ISBN 978-3-319-17515-7 (eBook)
DOI 10.1007/978-3-319-17515-7
Library of Congress Control Number: 2015941426
Springer Cham Heidelberg New York Dordrecht London
© Springer International Publishing Switzerland 2015
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Contents
1 Decision Making in the Democracy-based Medicine Era:
The Consensus Conference Process . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Massimiliano Greco , Marialuisa Azzolini , and Giacomo Monti
Part I Interventions that Reduce Mortality
2 Noninvasive Ventilation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Luca Cabrini , Margherita Pintaudi , Nicola Villari ,
and Dario Winterton
3 Lung-Protective Ventilation and Mortality in Acute
Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
Antonio Pisano , Teresa P. Iovino , and Roberta Maj
4 Prone Positioning to Reduce Mortality in Acute
Respiratory Distress Syndrome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
Antonio Pisano , Luigi Verniero , and Federico Masserini
5 Tranexamic Acid in Trauma Patients . . . . . . . . . . . . . . . . . . . . . . . . . 39
Annalisa Volpi , Silvia Grossi , and Roberta Mazzani
6 Albumin Use in Liver Cirrhosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Łukasz J. Krzych
7 Daily Interruption of Sedatives to Improve Outcomes
in Critically Ill Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Christopher G. Hughes , Pratik P. Pandharipande ,
and Timothy D. Girard
Part II Interventions that Increase Mortality
8 Tight Glycemic Control. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Cosimo Chelazzi , Zaccaria Ricci , and Stefano Romagnoli
9 Hydroxyethyl Starch in Critically Ill Patients. . . . . . . . . . . . . . . . . . . 73
Rasmus B. Müller , Nicolai Haase , and Anders Perner
v
vi Contents
10 Growth Hormone in the Critically Ill . . . . . . . . . . . . . . . . . . . . . . . . . 79
Nigel R. Webster
11 Diaspirin Cross-Linked Hemoglobin and Blood Substitutes. . . . . . . 83
Stefano Romagnoli , Giovanni Zagli , and Zaccaria Ricci
12 Supranormal Elevation of Systemic Oxygen Delivery
in Critically Ill Patients. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Kate C. Tatham , C. Stephanie Cattlin , and Michelle A. Hayes
13 Does β -Agonist Use Improve Survival in Critically
2
Ill Patients with Acute Respiratory Distress Syndrome?. . . . . . . . . . 103
Vasileios Zochios
14 High-Frequency Oscillatory Ventilation . . . . . . . . . . . . . . . . . . . . . . . 111
Laura Pasin , Pasquale Nardelli , and Alessandro Belletti
15 Glutamine Supplementation in Critically Ill Patients . . . . . . . . . . . . 117
Laura Pasin , Pasquale Nardelli , and Desiderio Piras
Part III Updates
16 Reducing Mortality in Critically Ill Patients:
A Systematic Update . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 125
Marta Mucchetti , Livia Manfredini , and Evgeny Fominskiy
17 Is Therapeutic Hypothermia Benefi cial
for Out-of-Hospital Cardiac Arrest? . . . . . . . . . . . . . . . . . . . . . . . . . . 133
Hesham R. Omar , Devanand Mangar ,
and Enrico M. Camporesi
1
Decision Making in the Democracy-based

Medicine Era: The Consensus
Conference Process
Massimiliano Greco , Marialuisa Azzolini ,
and Giacomo Monti
Randomized controlled trials (RCTs) are considered the gold standard in evidence-
based medicine. However, their effi cacy in producing reliable fi ndings has been
recently criticized in the fi eld of critical care medicine [1 ] . While an increasing
number of RCTs on critically ill patients have been published over the last few
years, a large part of these trials failed to fi nd signifi cant effects [2 ] . Moreover, when
an intervention produced an effect on mortality, it was frequently contradicted by
further trials that showed no effect for the same intervention or even opposite results
(“the pendulum effect”) [1 ]. Lack of reproducibility or external validity, underpow-
ered studies, or methodological fl aws created a blurred picture on the available evi-
dence in critical care medicine. Given these premises, the task of driving clinical
practice according to the updated literature has become a tough job for the
clinician.
Consensus conference and guidelines were designed to simplify this task [3 ].
However, their approach has been criticized, due to the priority given to experts’
opinion and the possibility of introducing expert-related bias [4 ].
A new method has been recently proposed and already employed in neighboring
fi elds to answer these drawbacks: democracy-based medicine [5 –8 ].
F ollowing this pathway, a new democratic consensus conference was conducted
to identify all the randomized controlled trial with a statistical signifi cant effect on
mortality ever published in the intensive care setting.
T he entire process of consensus building has been described elsewhere [ 5] and is
summarized in this chapter.
M. Greco , MD (*) (cid:129) M. Azzolini , MD (cid:129) G. Monti , MD
Department of Anesthesia and Intensive Care , IRCCS San Raffaele Scientifi c Institute ,
Via Olgettina 60 , Milan 20132 , Italy
e-mail: [email protected]
© Springer International Publishing Switzerland 2015 1
G. Landoni et al. (eds.), Reducing Mortality in Critically Ill Patients,
DOI 10.1007/978-3-319-17515-7_1
2 M. Greco et al.
1.1 Systematic Review
We performed a systematic review searching several scientifi c databases (MEDLINE/
PubMed, Scopus, and Embase) to identify all multicenter RCTs on any intervention
infl uencing mortality in critically ill patients (research updated to June 20, 2013).
Inclusion criteria were:
(cid:129) M ulticenter RCT published in a peer review journal reporting a statistical signifi -
cant difference on unadjusted mortality between cases and controls at any time
(cid:129) Focusing on critically ill patients, defi ned as all patients with acute failure of at
least one organ or need for intensive treatment or emergency treatment, regard-
less of where the admission ward is
(cid:129) A ssessing nonsurgical interventions (but including any other drugs, strategy, or
techniques)
The literature research identifi ed more than 36,000 papers that were screened at
title/abstract level, of these 200 were retrieved in full text and analyzed. Sixty-three
were fi nally identifi ed in this preliminary phase.
1.2 Reaching Consensus in Democracy-based Medicine
T he process of democray-based medicine was based on two distinct worldwide
s urveys and on an international meeting held between them. The fi rst survey
explored the opinions on the strength of the evidence on the articles identifi ed by the
systematic review and included a platform where colleagues could also propose
other articles allegedly missed by the systematic review.
The international meeting was held on June 20, 2013, at the Vita-Salute San
Raffaele University in Milan. The 63 earlier identifi ed articles were analyzed con-
sidering the results of the fi rst web survey. Several papers were then excluded
because of methodological fl aws or exclusion criteria. Nineteen interventions infl u-
encing mortality were fi nally identifi ed during the consensus meeting.
F or each of them, a statement was proposed by the consensus meeting to synthe-
tize the participants’ opinion on the available evidence on each topic. The external
validity of this process was explored by the second web survey, which collected the
vote of colleagues worldwide on each statement proposed by the consensus.
T he second web survey had the possibility to exclude other studies when there
was low agreement among voters.
1.3 The 15 Identified Topics and the Diffusion of the Results
to the International Community of Colleagues
F ifteen topics were thus fi nally identifi ed and reported in Table 1 .1 [9 – 32 ]. They are
extensively described, along with the evidence to support them, in this book, where
the reader will fi nd a chapter dedicated to each one of these 15 topics.
1 Decision Making in the Democracy-based Medicine Era 3
Table 1.1 The 15 interventions infl uencing mortality identifi ed by the consensus conference
Increasing survival Increasing mortality
Albumin in hepatorenal syndrome [9 ] Supranormal elevation of systemic oxygen delivery [2 5 ]
Daily interruption of sedatives [1 0 ] Diaspirin cross-linked hemoglobin [2 6 ]
Mild hypothermia [1 1 ] Growth hormone [2 7 ]
Noninvasive ventilation [1 2 – 19 ] Tight glucose control [2 8 ]
Prone position [2 0 ] IV salbutamol [2 9 ]
Protective ventilation [2 1 – 23 ] Hydroxyethyl starch [3 0 ]
Tranexamic acid [2 4 ] High-frequency oscillatory ventilation [3 1 ]
Glutamine supplementation [3 2 ]
They were identifi ed through a democratic process by a total of 555 physicians
from 61 countries that chose to participate in the fi rst democracy-based consensus
conference on randomized and multicenter evidence to reduce mortality in critically
ill patients.
G iven these premises and the large amount of information collected and generated
through the whole process, the authors had the ethical duty to disseminate consensus
results so as to reach the widest audience of peers. In addition to this book, the main
article regarding the consensus is published in Critical Care Medicine [ 33] , and further
articles will be published to describe other unpublished fi ndings of the consensus.
1.4 A Common Shell for a Flexible Process
The process above described in detail was the same with small difference among all
the four consensus conferences [6 – 8 , 3 3] . The fi rst three consensus conferences
focused on cardiac anesthesia and intensive care (6), on the perioperative period of
any surgery (7), and on patients with or at risk for acute kidney injury (8). The peri-
operative consensus process and results have already been described in details on a
Springer book [3 4 ].
The four consensus conferences included between 340 and 1,090 participants from
61 to 77 countries. All were based on a systematic review of literature, on two web-
based surveys that preceded and followed, respectively, an international meeting.
Each time we published a manuscript on the consensus results on an international
journal. There were only a small difference related to the systematic review (accord-
ing to the broadness and complexity of the subject) and some variance in the question
posed by the web survey [ 5 ]. However, the fi ve-step process for democratic consensus
building is now well tested and to our knowledge is the only method employed to
democratically share the decision process with a global audience and to allow to reach
an agreement among a population of colleagues in a worldwide horizon.
Conclusions
This consensus conference identifi ed the 15 interventions with the strongest evi-
dence of a positive or negative effect on mortality in the critical care setting. This
summary of evidence may serve as a fundamental guide for clinicians worldwide