Ketamine sedation in mechanically ventilated patients: A systematic review and meta-analysis

PurposeKetamine use as a sedative agent in mechanically ventilated patients is increasing. This systematic review and meta-analysis collates existing literature and quantifies the impact of ketamine in mechanically ventilated patients.Materials and methodsEMBASE, MEDLINE, Scopus, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, conference proceedings, and reference lists were searched. Randomized and nonrandomized studies were included, and two reviewers independently screened abstracts of identified studies for eligibility.ResultsFifteen studies (n = 892 patients) were included. Random effects meta-analytic models revealed that ketamine was associated with a reduction in propofol infusion rate (mean difference in dose, −699 μg/min; 95% CI −1169 to −230, p = .003), but had no impact on fentanyl or midazolam. Ketamine was not associated with mortality, on-target sedation, vasopressor dependence, or hospital length of stay. Cardiovascular complications (e.g. tachycardia and hypertension) were most commonly reported, followed by neurocognitive events, such as agitation and delirium.ConclusionsThe data regarding ketamine use in mechanically ventilated patients is limited in terms of quantity, methodological quality, and demonstrated clinical benefit. Ketamine may play a role as a sedative-sparing agent, but may be associated with harm. High-quality studies are needed before widespread adoption of ketamine earlier in the sedation pathway.     

Utility and safety of draining pleural effusions in mechanically ventilated patients: a systematic review and meta-analysis

Introduction

Pleural effusions are frequently drained in mechanically ventilated patients but the benefits and risks of this procedure are not well established.

Methods

We performed a literature search of multiple databases (MEDLINE, EMBASE, HEALTHSTAR, CINAHL) up to April 2010 to identify studies reporting clinical or physiological outcomes of mechanically ventilated critically ill patients who underwent drainage of pleural effusions. Studies were adjudicated for inclusion independently and in duplicate. Data on duration of ventilation and other clinical outcomes, oxygenation and lung mechanics, and adverse events were abstracted in duplicate independently.

Results

Nineteen observational studies (N = 1,124) met selection criteria. The mean P_aO₂:F_iO₂ ratio improved by 18% (95% confidence interval (CI) 5% to 33%, I ² = 53.7%, five studies including 118 patients) after effusion drainage. Reported complication rates were low for pneumothorax (20 events in 14 studies including 965 patients; pooled mean 3.4%, 95% CI 1.7 to 6.5%, I ² = 52.5%) and hemothorax (4 events in 10 studies including 721 patients; pooled mean 1.6%, 95% CI 0.8 to 3.3%, I ² = 0%). The use of ultrasound guidance (either real-time or for site marking) was not associated with a statistically significant reduction in the risk of pneumothorax (OR = 0.32; 95% CI 0.08 to 1.19). Studies did not report duration of ventilation, length of stay in the intensive care unit or hospital, or mortality.

Conclusions

Drainage of pleural effusions in mechanically ventilated patients appears to improve oxygenation and is safe. We found no data to either support or refute claims of beneficial effects on clinically important outcomes such as duration of ventilation or length of stay.     

Accuracy of pleth variability index to predict fluid responsiveness in mechanically ventilated patients: a systematic review and meta-analysis

To systemically evaluate the accuracy of pleth variability index to predict fluid responsiveness in mechanically ventilated patients. A literature search of PUBMED, OVID, CBM, CNKI and Wanfang Data for clinical studies in which the accuracy of pleth variability index to predict fluid responsiveness was performed (last update 5 April 2015). Related journals were also searched manually. Two reviewers independently assessed trial quality according to the modified QUADAS items. Heterogeneous studies and meta-analysis were conducted by Meta-Disc 1.4 software. A subgroup analysis in the operating room (OR) and in intensive care unit (ICU) was also performed. Differences between subgroups were analyzed using the interaction test. A total of 18 studies involving 665 subjects were included. The pooled area under the receiver operating characteristic curve (AUC) to predict fluid responsiveness in mechanically ventilated patients was 0.88 [95 % confidence interval (CI) 0.84–0.91]. The pooled sensitivity and specificity were 0.73 (95 % CI 0.68–0.78) and 0.82 (95 % CI 0.77–0.86), respectively. No heterogeneity was found within studies nor between studies. And there was no significant heterogeneity within each subgroup. No statistical differences were found between OR subgroup and ICU subgroup in the AUC [0.89 (95 % CI 0.85–0.92) versus 0.90 (95 % CI 0.82–0.94); P = 0.97], and in the specificity [0.84 (95 % CI 0.75–0.86) vs. 0.84 (95 % CI 0.75–0.91); P = 1.00]. Sensitivity was higher in the OR subgroup than the ICU subgroup [0.84 (95 % CI 0.78–0.88) vs. 0.56 (95 % CI 0.47–0.64); P = 0.00004]. The pleth variability index has a reasonable ability to predict fluid responsiveness.     

Nursing interventions to prevent corneal injury in critically ill sedated and mechanically ventilated patients: A systematic review of interventions

ObjectiveTo identify the effectiveness of interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients.Research methodologyA systematic review of intervention studies was conducted in the following electronic databases: Cumulative Index to Nursing and Allied Health Literature, Cochrane Central Register of Controlled Trials, Embase, Latin American and Caribbean Literature in Health Sciences, LIVIVO, PubMed, Scopus and Web of Science, and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. Study selection and data extraction were performed by two independent reviewers. Quality assessment of the randomized and non-randomized studies was performed using the Risk of Bias (RoB 2.0) and ROBINS-I Cochrane tools, respectively, and the Newcastle-Ottawa Scale for cohort studies. The certainty of the evidence was assessed according to the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.Results15 studies were included. Meta-analysis showed that the risk of corneal injury in the lubricants group was 66% lower (RR = 0.34; 95 %CI: 0.13–0.92) than in the eye-taping group. The risk of corneal injury in the polyethylene chamber was 68% lower than in the eye ointment group (RR = 0.32; 95 %CI 0.07–1.44). The risk of bias was low in most of the studies included and the certainty of the evidence was evaluated.ConclusionsThe most effective interventions to prevent corneal injury in critically ill sedated mechanically ventilated, who have compromised blinking and eyelid closing mechanisms, are ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber.Implications for clinical practiceCritically ill, sedated, and mechanically ventilated patients who have compromised blinking and eyelid closing mechanisms must receive interventions to prevent corneal injury. Ocular lubrication, preferably gel or ointment, and protection of the corneas with a polyethylene chamber were the most effective interventions to prevent corneal injury in critically ill, sedated, and mechanically ventilated patients. A polyethylene chamber must be made commercially available for critically ill, sedated, and mechanically ventilated patients.     

Diagnostic value of the blind brush in mechanically ventilated patients with nosocomial pneumonia

Objectives: To check on the accuracy of a new protected blind brush (BB) inserted through an endotracheal tube to collect respiratory secretions to be used in the diagnosis of nosocomial pneumonia (NP) in ventilated patients.Design: Prospective study of patients who had undergone both BB and plugged telescoping catheter via fiberoptic bronchoscopy (PTC-FB) sample collection sessions.Setting: Intensive Care Unit of a referral-based University HospitalPatients: All patients (n=37) mechanically ventilated for more than 3 days with clinical and radiological criteria of NP between July 1990 and March 1991.Interventions: Randomized BB and PTC-FB sample collection sessions carried out less than 30 min apart.Measurements and main results: The two sampling procedures resulted in similar findings with both cultures either negative or positive and identified the same organism and colonies in 31 patients (83.7%). Agreement was 90% when the patients with right or bilateral pulmonary infiltrates were grouped together and 100% when only the right field was considered. Complications arising from BB sampling were much lower than those from the conventional PTC-FB technique.Conclusions: Our results, pending confirmation by other prospective studies, indicate that BB sampling is useful in the diagnosis of NP in ventilated patients with radiological evidence of either right or bilateral pulmonary infiltrates and that it could stand in for PTC-FB in ICU settings where this procedure is not available.     

Probiotics' effects on the incidence of nosocomial pneumonia in critically ill patients: a systematic review and meta-analysis

Introduction

Transpulmonary thermodilution is used to measure cardiac output (CO), global end-diastolic volume (GEDV) and extravascular lung water (EVLW). A system has been introduced (VolumeView/EV1000? system, Edwards Lifesciences, Irvine CA, USA) that employs a novel algorithm for the mathematical analysis of the thermodilution curve. Our aim was to evaluate the agreement of this method with the established PiCCO? method (Pulsion Medical Systems SE, Munich, Germany, clinicaltrials.gov identifier: NCT01405040)

Methods

Seventy-two critically ill patients with clinical indication for advanced hemodynamic monitoring were included in this prospective, multicenter, observational study. During a 72-hour observation period, 443 sets of thermodilution measurements were performed with the new system. These measurements were electronically recorded, converted into an analog resistance signal and then re-analyzed by a PiCCO₂? device (Pulsion Medical Systems SE).

Results

For CO, GEDV, and EVLW, the systems showed a high correlation (r² = 0.981, 0.926 and 0.971, respectively), minimal bias (0.2 L/minute, 29.4 ml and 36.8 ml), and a low percentage error (9.7%, 11.5% and 12.2%). Changes in CO, GEDV and EVLW were tracked with a high concordance between the two systems, with a traditional concordance for CO, GEDV, and EVLW of 98.5%, 95.1%, and 97.7% and a polar plot concordance of 100%, 99.8% and 99.8% for CO, GEDV, and EVLW, respectively. Radial limits of agreement for CO, GEDV and EVLW were 0.31 ml/minute, 81 ml and 40 ml, respectively. The precision of GEDV measurements was significantly better using the VolumeView? algorithm compared to the PiCCO? algorithm (0.033 (0.03) versus 0.040 (0.03; median (interquartile range), P = 0.000049).

Conclusions

For CO, GEDV, and EVLW, the agreement of both the individual measurements as well as measurements of change showed the interchangeability of the two methods. For the VolumeView method, the higher precision may indicate a more robust GEDV algorithm.

Trial registration

clinicaltrials.gov NCT01405040.     

Probiotics' effects on the incidence of nosocomial pneumonia in critically ill patients: a systematic review and meta-analysis

ABSTRACT: INTRODUCTION: To evaluate the efficacy of probiotics in preventing nosocomial pneumonia in critically ill patients. METHODS: We searched PubMed, EMBASE, and the Web of Science for relevant studies. Two reviewers extracted data and reviewed the quality of the studies independently. The primary outcome was the incidence of nosocomial pneumonia. Study-level data were pooled using a random-effects model when I2 was > 50% or a fixed-effects model when I2 was < 50%. RESULTS: Twelve randomized controlled studies with a total of 1,546 patients were considered. Pooled analysis showed a statistically significant reduction in nosocomial pneumonia rates due to probiotics (odd ratio [OR]= 0.75, 95% CI 0.57 to 0.97, P = 0.03, I2 = 46%). However, no statistically significant difference was found between groups regarding in-hospital mortality (OR = 0.93, 95% CI 0.50 to 1.74, P = 0.82, I2 = 51%), intensive care unit mortality (OR = 0.84, 95% CI 0.55 to 1.29, P = 0.43, I2 = 0%), duration of stay in the hospital (mean difference [MD] in days = -0.13, 95% CI -0.93 to 0.67, P = 0.75, I2 = 46%), or duration of stay in the intensive care units (MD = -0.72, 95% CI -1.73 to 0.29, P = 0.16, I2 = 68%). CONCLUSIONS: The use of probiotics was associated with a statistically significant reduction in the incidence of nosocomial pneumonia in critically ill patients. However, large, well-designed, randomized, multi-center trials are needed to confirm any effects of probiotics clinical endpoints such as mortality and length of ICU and hospital stay.     

Rotational bed therapy to prevent and treat respiratory complications: a review and meta-analysis.

BACKGROUND: Immobility is associated with complications involving many body systems. OBJECTIVE: To review the effect of rotational therapy (use of therapeutic surfaces that turn on their longitudinal axes) on prevention and/or treatment of respiratory complications in critically ill patients. METHODS: Published articles evaluating prophylaxis and/or treatment were reviewed. Prospective randomized controlled trials were assessed for quality and included in meta-analyses. RESULTS: A literature search yielded 15 nonrandomized, uncontrolled, or retrospective studies. Twenty prospective randomized controlled trials on rotational therapy were published between 1987 and 2004. Various types of beds were studied, but few details on the rotational parameters were reported. The usual control was manual turning of patients by nurses every 2 hours. One animal investigation and 12 clinical trials addressed the effectiveness of rotational therapy in preventing respiratory complications. Significant benefits were reported in the animal study and 4 of the trials. Significant benefits to patients were reported in 2 of another 4 studies focused on treatment of established complications. Researchers have examined the effects of rotational therapy on mucus transport, intrapulmonary shunt, hemodynamic effects, urine output, and intracranial pressure. Little convincing evidence is available, however, on the most effective rotation parameters (eg, degree, pause time, and amount of time per day). Meta-analysis suggests that rotational therapy decreases the incidence of pneumonia but has no effect on duration of mechanical ventilation, number of days in intensive care, or hospital mortality. CONCLUSIONS: Rotational therapy may be useful for preventing and treating respiratory complications in selected critically ill patients receiving mechanical ventilation.     

Diagnosis of nosocomial pneumonia in mechanically ventilated patients by the blind protected telescoping catheter

Objectives To demonstrate that blind insertion of the protected telescoping catheter (PTC-NB) through the orotracheal tube can provide reliable pulmonary samples for the diagnosis of nosocomial pneumonia (NP) in ventilated patients.Design We performed a random comparison between the protected telescoping catheter intoduced through a bronchofiberscope (PTC-B) and the PTC-NB to diagnose NP.Setting: A general intensive care unit of a University Hospital.Patients 40 consecutive patients on mechanical ventilation and with suspicion of NP. The diagnosis of NP was suspected by clinical and chest X-ray findings.Measurements and results NP was confirmed microbiologically in 26 (65%) patients and maintained in 8 patients by clinical and radiological criteria. PTC-NB confirmed the microbiological diagnosis of PN in 21 (80%) patients. The use of antibiotics prior taking respiratory samples reduced the sensitivity of PTC-NB and PTC-B from 100–74% and from 94–70% (p=0.001). Both techniques agreed in 24 of 33 (73%) patients but such agreement was better when PN was on the right lung. Two patients developed a self-limiting hemoptysis after the PTC-B procedure.Conclusions PTC-NB is as sensitive as specific as PTC-B for diagnosing PN in mechanically ventilated patients, being a much easier technique to use.     

Corticosteroids to prevent extubation failure: a systematic review and meta-analysis

Purpose  To determine whether corticosteroids reduce the rate of extubation failure in intensive care patients of all age groups. Methods  Medline, EMBASE, the Cochrane Central Register of Controlled Trials, bibliographies of relevant articles, selected conference abstracts and unpublished trial databases were searched. Randomised clinical trials (RCTs) evaluating corticosteroids for the purpose of preventing extubation failure in mechanically ventilated, critically ill patients of all ages were included. Two authors independently assessed the validity of included studies and extracted data regarding characteristics of the studies and the rates of reintubation and manifestations of laryngeal oedema. Results  Fourteen RCTs including 2,600 participants were included. The mean duration of ventilation prior to attempted extubation ranged from 3 to 21 days. There was a reduction in reintubation with the use of corticosteroids, with a pooled odds ratio (OR) of 0.56 (95% CI; 0.41–0.77, P < 0.0005). The effect of corticosteroids tended to be more pronounced in studies when used at least 12 h prior to attempted extubation (OR 0.41, 95% CI; 0.26–0.64). The results were consistent across neonatal, paediatric and adult populations. There was also a reduction in laryngeal oedema in participants receiving corticosteroids, with a pooled OR of 0.36 (95% CI 0.27–0.49, P < 0.0005). Conclusions  Corticosteroids reduce laryngeal oedema and importantly reduce the incidence of extubation failure in critically ill patients of all ages.     

Accuracy of plethysmographic indices as predictors of fluid responsiveness in mechanically ventilated adults: a systematic review and meta-analysis

Purpose

To systematically review the accuracy of the variation in pulse oxymetry plethysmographic waveform amplitude (?POP) and the Pleth Variability Index (PVI) as predictors of fluid responsiveness in mechanically ventilated adults.

Methods

MEDLINE, Scopus and the Cochrane Database of Systematic Reviews were screened for clinical studies in which the accuracy of ?POP/PVI in predicting the hemodynamic response to a subsequent fluid bolus had been investigated. Random-effects meta-analysis was used to summarize the results. Data were stratified according to the amount of fluid bolus (large vs. small) and to the study index (?POP vs. PVI).

Results

Ten studies in 233 patients were included in this meta-analysis. All patients were in normal sinus rhythm. The pooled area under the receiver operating characteristic curve (AUC) for identification of fluid responders was 0.85 [95?% confidence interval (CI) 0.79–0.92]. Pooled sensitivity and specificity were 0.80 (95 % CI 0.74–0.85) and 0.76 (0.68–0.82), respectively. No heterogeneity was found within studies with the same amount of fluid bolus, nor between studies on ?POP and those on PVI. The AUC was significantly larger in studies with a large bolus amount than in those with a small bolus [0.92 (95 % CI 0.87–0.96) vs. 0.70 (0.62–0.79); p?p?=?0.08 and 0.86 (95 % CI 0.75–0.93) vs. 0.68 (0.56–0.77) (small bolus), p?=?0.02], respectively.

Conclusions

Based on our meta-analysis, we conclude that ?POP and PVI are equally effective for predicting fluid responsiveness in ventilated adult patients in sinus rhythm. Prediction is more accurate when a large fluid bolus is administered.     

Effects of nurse-led sedation protocols on mechanically ventilated intensive care adults: A systematic review and meta-analysis

ObjectivesThe objective of the study was to compare nurse-led sedation protocols with physician-led usual care in intensive care units (ICUs) in treating mechanically ventilated adult patients.Review method usedThis is a systematic review and meta-analysis.Data sourcesPubMed, Cochrane Library, EMBASE, CINAHL, China National Knowledge Infrastructure, and China Wanfang databases were interrogated for articles published before May 2020.Review methodAs per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, eight randomised controlled trials (RCTs) and six preintervention and postintervention studies published in English and Chinese met the inclusion criteria for the meta-analysis. Two reviewers independently extracted data into a tabular format using predefined data fields. Disagreements were resolved by consensus. The quality of the included RCTs and preintervention and postintervention studies was assessed using the Cochrane Quality Assessment Tool and Risk Of Bias In Non-randomised Studies of Interventions assessment tool.ResultsEight RCTs were of intermediate methodological quality, and six preintervention and postintervention studies exhibited a low to moderate risk of bias. Compared with usual care, nurse-led sedation protocols resulted in significantly decreased durations of mechanical ventilation (days) (standardised mean difference = ?1.765; 95% confidence interval [CI] = ?2.461, ?1.068); P < 0.001; I² = 97.7%); decreased length of ICU stay (days) (standardised mean difference = ?1.463; 95% CI = -2.181, ?0.745; P < 0.001; I² = 97.3%); reduced ICU mortality (relative risk [RR] = 0.854; 95% CI = 0.747, 0.983; P = 0.027), I² = 0%); and decreased incidence of ventilator-associated pneumonia (RR = 0.438; 95% CI = 0.292, 0.657; P < 0.001; I² = 41.4%), delirium (RR = 0.522; 95% CI = 0.338, 0.807; P = 0.003; I² = 26.6%), and extubation failure (RR = 0.498; 95% CI = 0.266, 0.932; P = 0.029; I² = 45.1%).ConclusionsAlthough pre–post intervention study design cannot establish causality, the present findings raise the considerable possibility that a sedation protocol can be safely implemented by nurses to reduce mortality in ICUs and sedation-related adverse events in patients on mechanical ventilation compared with physician-led usual care.     

Protected specimen brush or bronchoalveolar lavage to diagnose bacterial nosocomial pneumonia in ventilated adults: a meta-analysis

OBJECTIVE: We conducted a meta-analysis by using summary receiver operating characteristic curves to compare the diagnostic value for bacterial nosocomial pneumonia of the following: a) quantitative culture (colony-forming units per milliliter or CFU/mL) of respiratory secretions collected with a bronchoscopic protected specimen brush (PSB); b) quantitative culture of a bronchoscopic bronchoalveolar lavage (BAL); and c) the percentage of infected cells (IC) in BAL. DATA SOURCES: All studies published in the English or the French language, through January 1, 1995, on the evaluation of PSB or BAL for the diagnosis of pneumonia were considered for analysis. The relevant literature was identified through computer and reference searching and by experts in the field. STUDY SELECTION: A study was included if at least two of three independent readers regarded its purpose as the evaluation of CFU-PSB, CFU-BAL, or IC-BAL for the diagnosis in human beings of bacterial nosocomial pneumonia in ventilated adults and if the study was prospective and published in a peer-reviewed journal. DATA EXTRACTION: Three readers reviewed all published articles and decided whether to include each study; consensus was defined as agreement by at least two readers. The authors of each original article included in the meta-analysis were asked to complete a questionnaire in which they were asked to check and to correct the data extracted by one of the independent readers. DATA SYNTHESIS: Summary receiver operating characteristic curves were used to compare the efficacy of three diagnostic tests. Eighteen studies on CFU-PSB (795 patients) were included, as well as 11 studies on CFU-BAL (435 patients) and 11 on IC-BAL (766 patients). The accuracy of these tests was not different. However, it seems that administration of previous antibiotics markedly decreased accuracy of CFU-PSB (p = .0002) but not the accuracy of CFU-BAL and that of IC-BAL. CONCLUSION: Both PSB and BAL are reliable to diagnose bacterial nosocomial pneumonia. Because CFU-BAL and IC-BAL seemed more resistant to the effects of antibiotics, we recommend BAL rather than PSB if the patient is already receiving antibiotics.     

Music therapy effectiveness to decrease anxiety in mechanically ventilated patients

The aim of this review is to find out whether or not music therapy is an effective nursing intervention to decrease anxiety and promote relaxation in ventilator-dependent patients. For the purpose of this review, relaxation has been considered as a reduction in state anxiety and physiologic signs (heart rate, blood pressure or respiratory rate). A comprehensive search has been conducted in electronic databases (Cochrane Library, Medline, CINHAL, Embase and PsycLit) in order to identify systematic reviews on music therapy effectiveness or randomised control trials that compare the effectiveness of music therapy versus no music or other relaxation techniques in patients receiving ventilatory assistance. Three studies, two randomised control trials and a systematic review accomplished the inclusion criteria of this review. All studies found a significant difference between groups on the mean post-test state anxiety, concluding that there was a greater reduction in state anxiety in the experimental condition due to the intervention. Findings in terms of physiologic measures have been contradictory from study to study, reaching different conclusions. None of the three studies have accomplished the quality criteria established for this review. Some methodological limitations make their results be not fully reliable and therefore, it has not been possible to reach a satisfactory answer. Further and more rigorous research is needed on this area, as there is not enough valid research to conclude that music therapy is an effective nursing intervention for decreasing patients' anxiety. As it causes no harm and is a relatively inexpensive intervention, it would be worth exploring its effects on different kind of outcomes and settings.     

Use of bronchoalveolar lavage to diagnose bacterial pneumonia in mechanically ventilated patients

We studied the efficacy and safety of bronchoscopy with bronchoalveolar lavage (BAL) in mechanically ventilated patients. Seventy-seven patients, 60 of whom underwent BAL, were analyzed. Of the patients undergoing BAL, 30 had clinical pneumonia, 24 had a diagnosis other than pneumonia by clinical criteria or autopsy, and six could not be classified but clinically improved without changing their antibiotic therapy. Of the 30 pneumonia patients, 18 had bacterial cultures felt to be diagnostic of bacterial pneumonia: two cases of Legionella pneumophila, and 16 cases with one or more organisms recovered at greater than 10(4) cfu/ml of BAL fluid. No patient without the clinical diagnosis of pneumonia had a positive bacterial culture greater than 10(4) cfu/ml of BAL fluid (chi-square = 18.2, p less than .001). Of the patients classified with pneumonia, Pneumocystis carinii was found in six and cytologic evidence of viral infection in three patients. Of the 30 patients undergoing BAL with pneumonia, 27 had one or more pathogens identified in the lavage specimen. Although no patient died as a result of lavage, significant hypoxemia was encountered in some patients undergoing lavage. In 35 patients with the same FIO2 before and after bronchoscopy, the median change in PO2 was -8.0 torr (range -63.0 to +29.0). We found that bacterial cultures of BAL fluid appeared useful in defining the presence and etiology of pneumonia.     

Gastroesophageal reflux in mechanically ventilated pediatric patients and its relation to ventilator-associated pneumonia

Introduction  

The objective was to determine the frequency of gastroesophageal reflux (GER) in mechanically ventilated pediatric patients and its role as a risk factor for ventilator-associated pneumonia (VAP), which may be enhanced among those patients.     

Anticoagulant prophylaxis to prevent asymptomatic deep vein thrombosis in hospitalized medical patients: a systematic review and meta-analysis

Summary.  Background:  The effect of anticoagulant prophylaxis on the prevention of deep vein thrombosis (DVT) should include an investigation of both clinical and subclinical DVT. We conducted a systematic review to determine whether anticoagulant prophylaxis reduces the risk of asymptomatic DVT compared to no prophylaxis in at-risk hospitalized medical patients. Methods:  MEDLINE, EMBASE, and the Cochrane Library were searched through March 2007 for randomized trials of anticoagulant prophylaxis for the prevention of asymptomatic DVT, assessed by venogram or ultrasound. We assessed four outcomes: all asymptomatic DVT, asymptomatic proximal DVT, major bleeding and mortality. Random effects meta-analyses were performed and results were expressed using relative risk (RR) and 95% confidence intervals (95% CIs). Results:  Four trials including 5516 patients were eligible. Our pooled analysis demonstrated that compared to placebo, anticoagulant prophylaxis was associated with a significantly lower risk of any asymptomatic DVT (RR 0.51; 95% CI 0.39–0.67) and asymptomatic proximal DVT (RR 0.45; 95% CI 0.31–0.65). Anticoagulant prophylaxis was associated with a significantly increased risk of major bleeding compared to placebo (RR 2.00; 95% CI 1.05–3.79). There was no significant difference in the pooled estimate for all-cause mortality. Anticoagulant prophylaxis conferred an absolute risk reduction of any DVT and proximal DVT of 2.6% and 1.8%, respectively, and was associated with a 0.5% absolute risk increase in major bleeding. Conclusions:  Anticoagulant prophylaxis is effective in preventing asymptomatic DVT in at-risk hospitalized medical patients but is associated with an increased bleeding risk. The therapeutic benefits of anticoagulant prophylaxis appear to outweigh the risks of bleeding.