Stress ulcer prophylaxis in the critically ill: a meta-analysis.

PURPOSE: To examine the differential effect of stress ulcer prophylaxis on overt bleeding, clinically important bleeding, and mortality in critically ill patients. DATA IDENTIFICATION: Computerized bibliographic search of published and unpublished research. STUDY SELECTION: Independent review of 168 articles identified 42 relevant randomized trials for inclusion. DATA ABSTRACTION: The validity, population, intervention, and outcomes of each trial were evaluated. RESULTS: Stress ulcer prophylaxis with antacids (odds ratio 0.40 [95% confidence interval (CI) 0.20 to 0.79]) or histamine-2-receptor antagonists (odds ratio 0.29 [95% CI 0.17 to 0.45]) decreases the incidence of overt gastrointestinal bleeding. Histamine-2-receptor antagonists are more effective than antacids at reducing overt hemorrhage (odds ratio 0.56 [95% CI 0.33 to 0.97]). A significant reduction in clinically important gastrointestinal hemorrhage is evident only with histamine-2-receptor antagonist therapy. There is a trend favoring antacids over sucralfate in the outcome of clinically important bleeding (odds ratio 0.65 [95% CI 0.16 to 2.49]); however, there are insufficient data to evaluate histamine-2-receptor antagonists versus sucralfate. No difference in mortality between treated and untreated patients was found. CONCLUSIONS: Overt gastrointestinal bleeding in critically ill patients is reduced by prophylaxis with antacids or histamine-2-receptor antagonists. Histamine-2-receptor antagonists are more effective than antacids at decreasing overt bleeding and are more effective than no treatment at reducing the incidence of clinically important bleeding. Mortality rates in the intensive care unit are not decreased by stress ulcer prophylaxis.     

Dexmedetomidine dosage in critically ill patients undergoing intraoperative wake-up test: A randomized controlled trial

Objective:The aim of this study was to find the optimum dosage of dexmedetomidine in Spinal Orthopedic Scoliosis Correction Surgery when used in combination with propofol and remifentanil in American Society of Anesthesiologists (ASA) III patients with severe scoliosis undergoing intraoperative wake-up test.Materials and methods:We selected a total of 60 ASA III ≤40 years old patients who underwent Spinal Orthopedic Scoliosis Correction Surgery (SOSCS) and randomized them into groups A, B, and C. Group A was administered 0.2 μg/(kg·h) of dexmedetomidine, group B 0.3 μg/(kg·h), and group C 0.4 μg/(kg·h). The main parameters monitored were: wake-up time; wake-up quality; adverse effects that occur while the patient is awake; postoperative awareness of intraoperative wake-up test; heart rate (HR); mean arterial pressure (MAP); and oxygen saturation (SpO₂). Values of these parameters were monitored at 7 timestamps separated by 5 minutes >30 minutes.Results:Group B had a higher MAP at 10 minutes before wake-up (P = .03) and at the moment of wake-up (P = .04) than group A. The Wake-up time of group A was 14.95 ± 7.42 minutes, group B was 14.7 ± 6.52 minutes, which was significantly shorter than that of group C 21.3 ± 10.02 minutes (P = .02). The wake-up quality was excellent. All other parameters had no significant statistical differences.Conclusion:Doses of 0.2 to 0.3 μg/(kg·h) have shorter wake-up time and fewer hemodynamic fluctuations compared to 0.4 μg/(kg·h).     

Stress ulcer prophylaxis in non-critically ill patients: less may be more

Significant upper gastrointestinal bleeding resulting from stress ulceration is a serious life-threatening complication. However, it occurs relatively rarely even in the sickest patients. Therefore, guidelines suggest that prophylaxis (e.g., with acid-suppressive therapy) should be reserved for highly selected patients. Despite these recommendations, numerous studies suggest that many hospitalized patients are inappropriately placed on acid-suppressive therapy (AST) for the sole purpose of preventing stress ulceration. Moreover, it appears that once AST is started, medications are continued even after discharge, resulting in further unnecessary expenditure of resources. National and local efforts are needed to curtail this practice that places patients at risk for drug side effects while affording them little or no benefit.     

Prevention of catheter-related bloodstream infection in critically ill patients using a disinfectable, needle-free connector: a randomized controlled trial

OBJECTIVE: The aim of this study was to assess the efficacy of a disinfectable, needle-free connector in the prophylaxis of catheter-related bloodstream infection. METHODS: A randomized controlled trial was performed in a polyvalent intensive care unit. Patients who needed multilumen central venous catheters were randomly assigned to a study or a control group. All catheters were inserted and manipulated according to the Centers for Disease Control and Prevention (CDC) recommendations. Study group patients were equipped with catheters with disinfectable, needle-free connectors whereas control group patients were equipped with catheters with 3-way stopcocks. Two peripheral blood cultures and a semiquantitative culture of the catheter tip were performed on removal of the catheter. RESULTS: The study included 243 patients, with a total of 278 central venous catheters. The catheters' mean insertion duration was 9.9 days. Both groups were comparable regarding patient and catheter characteristics. Incidence rate of catheter-related bloodstream infection was 0.7 per 1000 days of catheter use in the study group, compared with 5.0 per 1000 days of catheter use in the control group (P=.03). CONCLUSIONS: To add a disinfectable, needle-free connector to the CDC recommendations reduces the incidence of catheter-related bloodstream infection in critically ill patients with central venous catheters.     

Insulin therapy for critically ill hospitalized patients: a meta-analysis of randomized controlled trials

BACKGROUND: Hyperglycemia is common in critically ill hospitalized patients, and it is associated with adverse outcomes, including increased mortality. The objective of this meta-analysis was to determine the effect of insulin therapy initiated during hospitalization on mortality in adult patients with a critical illness. METHODS: An electronic search in the English-language articles of MEDLINE and the Cochrane Controlled Clinical Trials Register and a hand search of key journals and relevant review articles were performed. Randomized controlled trials that reported mortality data on critically ill hospitalized adult patients who were treated with insulin were selected. Data on patient demographics, hospital setting, intervention (formulation and dosage of insulin, delivery method, and duration of therapy), mortality outcomes, adverse events, and methodological quality were extracted. RESULTS: Thirty-five trials met the inclusion criteria. Combining data from all trials using a random-effects model showed that insulin therapy decreases short-term mortality by 15% (relative risk [RR], 0.85; 95% confidence interval [CI], 0.75-0.97). In subgroup analyses, insulin therapy decreased mortality in the surgical intensive care unit (RR, 0.58; 95% CI, 0.22-0.62), when the aim of therapy was glucose control (RR, 0.71; 95% CI, 0.54-0.93), and in patients with diabetes mellitus (RR, 0.73; 95% CI, 0.58-0.90). A near-significant trend toward decreasing mortality was seen in patients with acute myocardial infarction who did not receive reperfusion therapy (RR, 0.84; 95% CI, 0.71-1.00). No randomized trials of insulin in the medical intensive care unit were identified. CONCLUSION: Insulin therapy initiated in the hospital in critically ill patients has a beneficial effect on short-term mortality in different clinical settings.     

Stress ulceration: a serious complication in critically ill patients

The incidence of gastrointestinal bleeding in critically ill patients appears to have declined over the past decade; however, it has not been shown that the incidence of stress ulceration has declined as well. The pathophysiology of stress ulceration is not totally understood, although various factors have been implicated: mucosal barrier breakdown, decreased mucosal blood flow, increased intraluminal acid, decreased epithelial regeneration, and lowered intramural pH. It is widely accepted that prevention is the cornerstone of management for stress ulceration. The critical care nurse must be aware of the importance of monitoring and maintaining a gastric pH greater than 3.5. Antacids, histamine receptor antagonists, sucralfate, and prostaglandins have all been shown to play a role in the treatment of stress ulcerations.     

Adherence to isoniazid prophylaxis in the homeless: a randomized controlled trial

OBJECTIVES: To test 2 interventions to improve adherence to isoniazid preventive therapy for tuberculosis in homeless adults. We compared (1) biweekly directly observed preventive therapy using a $5 monetary incentive and (2) biweekly directly observed preventive therapy using a peer health adviser, with (3) usual care at the tuberculosis clinic. METHODS: Randomized controlled trial in tuberculosis-infected homeless adults. Outcomes were completion of 6 months of isoniazid treatment and number of months of isoniazid dispensed. RESULTS: A total of 118 subjects were randomized to the 3 arms of the study. Completion in the monetary incentive arm was significantly better than in the peer health adviser arm (P = .01) and the usual care arm (P = .04), by log-rank test. Overall, 19 subjects (44%) in the monetary incentive arm completed preventive therapy compared with 7 (19%) in the peer health adviser arm (P = .02) and 10 (26%) in the usual care arm (P = .11). The median number of months of isoniazid dispensed was 5 in the monetary incentive arm vs 2 months in the peer health adviser arm (P = .005) and 2 months in the usual care arm (P = .04). In multivariate analysis, independent predictors of completion were being in the monetary incentive arm (odds ratio, 2.57; 95% CI, 1.11-5.94) and residence in a hotel or other stable housing at entry into the study vs residence on the street or in a shelter at entry (odds ratio, 2.33; 95% CI, 1.00-5.47). CONCLUSIONS: A $5 biweekly cash incentive improved adherence to tuberculosis preventive therapy compared with a peer intervention or usual care. Living in a hotel or apartment at the start of treatment also predicted the completion of therapy.     

Intensive versus conventional glucose control in critically ill patients: A meta-analysis of randomized controlled trials

BackgroundCritically ill patients commonly develop hyperglycemia. It remains unclear, however, to what extent correcting hyperglycemia will benefit these patients. We performed this meta-analysis to evaluate the benefits and risks of intensive glucose control versus conventional glucose control in critically ill adult patients.MethodsA systematic literature search of MEDLINE, PubMed, and Cochrane databases (until June 2011) was conducted using specific search terms. Randomized controlled trials that compared intensive glucose control with a target glucose goal < 6.1 mmol/l (110 mg/dl) to conventional glucose control in adult intensive care patients were included. The random-effect model was used to estimate the pooled risk ratio of the two treatment arms.ResultsTwenty two studies that randomized 13,978 participants were included in the meta-analysis. Overall, intensive glucose control did not reduce the short-term mortality (RR = 1.02, 95% CI: 0.95–1.10, p = 0.51), 90 day or 180 day mortality (RR = 1.06, 95% CI: 0.99–1.13, p = 0.08), sepsis (RR = 0.96, 95% CI: 0.83–1.12, p = 0.59) or new need for dialysis (RR = 0.96, 95% CI: 0.83–1.11, p = 0.57). The incidence of hypoglycemia was significantly higher in intensive glucose control group compared with conventional glucose control group (RR = 5.01, 95% CI: 3.45–7.28, p < 0.00001).ConclusionsThis meta-analysis found that intensive glucose control in critically ill adults did not reduce mortality but is associated with a significantly increased risk of hypoglycemia.     

The effect of early enteral nutrition supplemented with synbiotics on lipid and glucose homeostasis in critically ill patients: A randomized controlled trial

Background and aimsThe aim of the present study was to investigate the effects of gut microbiota modulation through synbiotic supplementation on lipid and glucose homeostasis in tube-fed critically-ill adult patients.MethodsThis study is placebo-controlled, parallel, single-center, double-blind clinical trial. 42 patients were randomly distributed in placebo and synbiotic groups to receive intervention for a maximum of 14 days. Serum levels of fasting glucose, total cholesterol, and triglycerides, insulin, and free fatty acids were obtained from blood sampling at baseline and the end of the study. Also, insulin resistance was determined by homeostasis model assessment of insulin resistance (HOMA-IR).ResultFasting glucose level (Day0 = 87.84 ± 15.51, Day14 = 83.76 ± 8.71 mg/dl, P = 0.51), fasting insulin level (Day0 = 9.46 ± 7.31, Day14 = 7.97 ± 5.19 mIU/L, P = 1.00), and HOMA index (Day0 = 1.89 ± 1.48, Day14 = 1.72 ± 1.17, P = 0.75) during the study were decreasing in both groups, but the decreases were not significant. Serum levels of total cholesterol, triglyceride, and free fatty acidsat the beginning of the study were 114.18 ± 43.43 mg/dl, 146.59 ± 53.99 mg/dl, 0.83 ± 0.57 mmol/L, and at the end of the study were 129.10 ± 39.05 mg/dl, 127.40 ± 91.88 mg/dl, 0.88 ± 0.77 mmol/L, respectively. None of these changes were significant either (P = 0.99, P = 0.38, P = 0.90, respectively).ConclusionsAccording to our findings, synbiotics supplementation in critically ill patients has no significant effect on lipid and glucose profile.     

Fansimef for prophylaxis of malaria: a double-blind randomized placebo controlled trial.

At a time when Fansimef, the fixed combination of mefloquine, sulfadoxine and pyrimethamine was considered for prophylaxis of falciparum malaria, a randomized double-blind study comparing the efficacy and tolerability of Fansimef with that of Lariam (mefloquine), Fansidar, chloroquine and placebo in malaria prophylaxis was performed in Thailand from July 1987 to January 1988. The study population of 602 adult males was recruited in Pak Tongchai District, some 360 km North-East of Bangkok, where multiresistant P. falciparum is endemic. All active treatments and placebo were given once weekly for 24 weeks with doses as follows: Fansimef: 125 mg mefloquine + 250 mg sulfadoxine + 12.5 mg pyrimethamine (1 half-strength tablet); Lariam: 125 mg mefloquine (1 half-strength tablet); Fansidar: 500 mg sulfadoxine + 25 mg pyrimethamine; chloroquine; 300 mg. A loading dose of 2 half-strength tablets was given in the Fansimef group in weeks 1 and 2 and in the Lariam group in weeks 1 to 4. The incidence of acute episodes of P. falciparum per 100 person months of prophylaxis was 0.17 each in the Fansimef and the Lariam groups, 1.18 in the Fansidar group, 0.69 in the chloroquine group and 0.64 in the placebo group (differences statistically not significant). Clinically adverse events were reported by 170 subjects (Fansimef 28, Lariam 29, Fansidar 41, choroquine 43, placebo 29; differences statistically not significant). The most frequent adverse events in all groups were headache, sleepiness, dizziness and weakness.(ABSTRACT TRUNCATED AT 250 WORDS)     

Effect of high-fat,low-carbohydrate enteral formula versus standard enteral formula in hyperglycemic critically ill patients: a randomized clinical trial

International Journal of Diabetes in Developing Countries - High-fat, low-carbohydrate diets may attenuate the hyperglycemia in critically ill patients. This study was performed to compare the...     

Pilates in heart failure patients: a randomized controlled pilot trial

Background: Conventional cardiac rehabilitation program consist of 15 min of warm-up, 30 min of aerobic exercise and followed by 15 min calisthenics exercise. The Pilates method has been increasingly applied for its therapeutic benefits, however little scientific evidence supports or rebukes its use as a treatment in patients with heart failure (HF). Purpose: Investigate the effects of Pilates on exercise capacity variables in HF. Methods: Sixteen pts with HF, left ventricular ejection fraction 27 ± 14%, NYHA class I-II were randomly assigned to conventional cardiac rehabilitation program (n = 8) or mat Pilates training (n = 8) for 16 weeks of 30 min of aerobic exercise followed by 20 min of the specific program. Results: At 16 weeks, pts in the mat Pilates group and conventional group showed significantly increase on exercise time 11.9 ± 2.5 to 17.8 ± 4 and 11.7 ± 3.9 to 14.2 ± 4 min, respectively. However, only the Pilates group increased significantly the ventilation (from 56 ± 20 to 69 ± 17 L/min, P= 0.02), peak VO(2) (from 20.9 ± 6 to 24.8 ± 6 mL/kg/min, P= 0.01), and O(2) pulse (from 11.9 ± 2 to 13.8 ± 3 mL/bpm, P= 0.003). The Pilates group showed significantly increase in peak VO(2) when compared with conventional group (24.8 ± 6 vs. 18.3 ± 4, P= 0.02). Conclusions: The result suggests that the Pilates method may be a beneficial adjunctive treatment that enhances functional capacity in patients with HF who are already receiving standard medical therapy.     

Effect of antibiotic prophylaxis on acute necrotizing pancreatitis: Results of a randomized controlled trial

Background and Aims: This study addresses whether antibiotic prophylaxis is beneficial for acute necrotizing pancreatitis. Methods: This randomized, controlled trial enrolled 276 patients with severe acute pancreatitis. There were 56 patients with 30% or more necrosis proved by contrast‐enhanced computerized tomography who were eligible for randomization: 29 in the study group and 27 in the control group, who received i.v. imipenem–cilastatin (3 × 500 mg/day) within 72 h of the onset of symptoms for 7–14 days, and no antibiotic prophylaxis, respectively. The primary end‐point was the incidence of infectious complication. The secondary end‐points were mortality, the incidence of necrosectomy for infected necrosis, the incidence of organ complication and hospital courses. Results: Characteristics of baseline data were similar in the two groups. No significant differences were found in the incidence of infected pancreatic necrosis (37% vs 27.6%), mortality (10.3% vs 14.8%) and the incidence of operative necrosectomy (29.6% vs 34.6%) between the study group and the control group (P > 0.05). The incidence of extrapancreatic infections, organ complications and hospital courses between the groups were also not significantly different. However, a significantly increased incidence of fungal infection was observed in the study group versus the control group (36.1% vs 14.2%, P < 0.05). Conclusion: There was no benefit in the outcomes when antibiotic prophylaxis was routinely used in patients with acute necrotizing pancreatitis.     

The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: A meta-analysis of randomized controlled clinical trials with trial sequential analysis

Background

The optimal timing of tracheotomy in critically ill ventilated patients remains controversial.