17 Agosto 2001
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Am J Respir Crit Care Med 2001 Jun;163(7):1524-7
PMID: 11401867, UI: 21294687
Anaesthesist 2001 May;50(5):323-8
Klinik fur Anaesthesiologie und Intensivmedizin der Universitatskliniken des Saarlandes, 66421 Homburg/Saar. aissol@med-rz.uni-sb.de
OBJECTIVE: In this phase 2 study gammahydroxybutyric acid-ethanolamide (GHB-ethanolamide) was compared with midazolam for sedation of patients in the intensive care unit (ICU). GHB-ethanolamide is a new derivative of gammahydroxybutyric acid, a drug commonly used for sedation in intensive care patients. METHODS: A total of 29 non-intubated, spontaneously breathing patients following major surgery, were randomly assigned to 2 groups: group A (n = 14) received 150 mg/kg GHB-ethanolamide i.v. followed by 150 mg/kg/h. Group B (n = 15) received 0.025 mg/kg midazolam i.v. followed by 0.025 mg/kg/h. The degree of sedation was assessed over a 3-5 h period both clinically by the Ramsay Score and by the spectral frequency index (SFx), derived by continuous computerized EEG recording (CATEEM). RESULTS: EEG: the SFx showed a significantly deeper sedation compared to baseline values, 10, 60 and 120 min after start of sedation in the GHB-ethanolamide group. By contrast, no difference could be observed compared to baseline values in the midazolam group. A comparison between both groups showed a deeper sedation in the GHB group 60 and 120 min after start of sedation. The Ramsay Score increased from baseline values of 2.0 (2.0/2.0) to 3.0 (2.0/3.0) during sedation (Median (25th/75th percentile) and no significant differences could be observed between groups. In the Midazolam group the sedation of two patients had to be terminated because of side effects (Ramsay Score 6 and paradoxical, agitated reaction). CONCLUSIONS: GHB-ethanolamide produces adequate sedation for extubated and spontaneously breathing ICU patients. The drug might be safer than midazolam with regards to side effects such as respiratory depression.
Publication Types:
PMID: 11417267, UI: 21310940
Chest 2001 Aug;120(2):538-42
Division of Anesthesia, Intensive Care and Pain Management, John Hunter Hospital, Newcastle, Australia.
[Medline record in process]
INTRODUCTION: Reports on reintubation have focused on patients in whom planned extubation has been unsuccessful or those who have been accidentally extubated. However, reintubation is often required in events not related to accidental extubation. These cases have not been well described previously. OBJECTIVES: To examine the causes, outcomes, and contributing factors associated with patients who required reintubation for events not including accidental extubation. METHODS: Appropriate reintubation incidents were extracted from the Australian Incident Monitoring Study in Intensive Care database and analyzed using descriptive methodology. RESULTS: One hundred forty-three incidents were identified with prominent precipitating events, including tube malposition (17%), securing/taping problems (17%), pilot tube/cuff problem (16%), blocked/kinked airway (14%), failed extubation (14%), and poor planning for extubation (6%). Narrative description of morbidity included hypoxia in 25% of reports, hypercarbic respiratory failure in 12%, aspiration in 7%, sputum retention in 7%, and cardiac arrhythmias in 6%. The reporter selected "major physiologic complications" and "prolonged hospital stay" as prominent adverse outcomes in 52% and 16% of patients, respectively. Major factors contributing to reintubation involved "error of judgement/problem recognition" (identified in 62% of reports), "high unit activity" (20%), "difficult patient habitus" (26%), and "lack of patient cooperation" (14%). Rechecking patient and equipment, and skilled assistance were prominent factors in limiting the adverse consequences of the incident. CONCLUSION: This study indicated that reintubation not related to accidental extubation resulted in major physiologic complications and potentially contributed to increased length of stay. Its findings suggest that the adequate provision of highly qualified, intensive-care-trained staff is essential for the avoidance or minimization of these incidents.
PMID: 11502655, UI: 21393820
Crit Care Med 2001 Aug;29(8):1640-8
PMID: 11505152, UI: 21396014
Crit Care Med 2001 Aug;29(8):1638-9
PMID: 11505148, UI: 21396010
Crit Care Med 2001 Feb;29(2 Suppl):N1
Brown University, Rhode Island Hospital, Providence, RI.
[Record supplied by publisher]
PMID: 11505088
Crit Care Med 2001 Aug;29(8 Suppl):166-176
Department of Pediatrics, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, WI (CGMW); the Departments of Pediatrics and Anesthesiology, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, MO (BPM); and the Department of Pediatrics, Cornell University-Weill Medical College, New York, NY (SP).
This article details how computers have changed life for those of us in pediatric intensive care. A week of clinical activity is described, with a focus on the interactions with computer systems that have become an integral part of patient-care activities for many of us. It becomes clear that the boundaries between personal computers, hospital systems, and the Internet are often not sharply defined. Resources that are used every week may include those residing on a personal digital assistant, on the hospital's electronic medical record, or on a distant site on the World Wide Web. Key resources on the Internet (World Wide Web and e-mail) are identified. The technical underpinnings, particularly the network that provides the infrastructure for various resources, are described.
PMID: 11496039
Crit Care Med 2001 Aug;29(8 Suppl):151-8
Sandia National Laboratories, Albuquerque, NM.
As advanced as today's critical care units are, changes in networks, computing platforms, instrumentation, human-machine interfaces, and software infrastructures and work being done in interoperability, process automation, and decision support all promise to alter both the structure and the operation of future critical unit settings. Although, as Yogi Berra said, "It's tough to make predictions, especially about the future," we can gain of a sense of the possibilities by studying emerging trends in each of these information technology-related areas. After describing notional physical and functional architectures for today's critical care units, this article provides a high-level overview of a number of trends in the areas listed above and provides the reader with starting points for further study. Although each of these trends may be fairly unremarkable when taken in isolation, when considered as a whole, the implications for critical care are profound. To that end, a final section of the article speculates on specific ways that these trends are likely to play themselves out in the context of tomorrow's critical care environments.
PMID: 11496037, UI: 21387184
Crit Care Med 2001 Jul;29(7 Suppl):S1-137
PMID: 11445750, UI: 21338377
Crit Care Med 2001 Jul;29(7 Suppl):S136-7
Department of Intensive Care, Erasme University Hospital, Free University of Brussels, Belgium.
PMID: 11445749, UI: 21338376
Crit Care Med 2001 Jul;29(7 Suppl):S109-16
Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh, PA, USA.
OBJECTIVE: We review the case definition, occurrence, and outcome of sepsis. We discuss whether the epidemiology of sepsis has changed over time and discuss issues important to our understanding of sepsis. DATA SOURCES: Literature review. DATA SUMMARY: Our understanding of the epidemiology of sepsis is hampered by the lack of a reliable case definition. Inconsistent application of sepsis definition criteria contributes to confusion and variability in the literature. Variability in the time course of sepsis also introduces difficulty. The Centers for Disease Control estimated an incidence of 73.6 per 100,000 population in 1979, rising to 175.9 per 100,000 in 1989. However, this study was of septicemia, not severe sepsis. There are several hospital-based studies of the occurrence of severe sepsis, defined using the American College of Chest Physicians/Society of Critical Care Medicine consensus criteria. These studies reported variable hospital and intensive care unit (ICU) occurrence rates, ranging from 2% to 11% of all hospital or ICU admissions. Most of these data are from academic, tertiary care centers, which limits generalizability. More population-based studies are required to better delineate the incidence and risk factors of sepsis in the general population. Hospital mortality from sepsis has ranged from 25% to 80% over the last few decades. Although mortality may be lower in recent years, sepsis is clearly still a very serious condition. Achieving a better understanding of whether the mortality rate for sepsis is falling, however, is confounded by the lack of a uniform definition. Risk factors for adverse outcome include the degree of physiologic derangement, organ dysfunction, underlying illness, site of infection, and microbiological etiology. We do not know, however, the factors that predict response to new therapies. This dilemma has led researchers to explore whether markers of the inflammatory cascade might be more specific for sepsis, more accurate for risk prediction, or more useful for predicting response to therapy. However, there as yet is no equivalent of the CPK-MB for acute myocardial infarction. Whether we will find such a marker as we develop a greater understanding of the genetic control of the inflammatory cascade is uncertain but promising. One might assume intuitively that the epidemiology of sepsis is changing. For example, the number of patients being treated in ICUs has increased over time, the technologies used in the ICU have changed, and the choice and the use of antibiotics have changed. Predisposing factors, such as chemotherapeutic regimens, have also changed, and there have been marked changes in antibiotic resistance. Furthermore, there have been wide changes in the microbiological etiologies of diseases such as pneumonia and acute exacerbations of chronic bronchitis. However, lacking good case definitions and true incidence studies, we can only make inferences about whether the epidemiology of sepsis is truly changing. CONCLUSION: Many studies have documented many aspects of the epidemiology of sepsis. However, the composite picture they provide, although rich in many aspects, remains incomplete and emphasizes the heterogeneity of the condition. Unfortunately, few population-based prospective cohort studies exist that allow us to accurately delineate the risk factors for sepsis, its course, and its outcome. To place new information, such as the role of genetic predisposition, in the correct context, it is essential that such studies be conducted.
PMID: 11445744, UI: 21338371
Crit Care Med 2001 Jul;29(7 Suppl):S99-106
Department of Surgery, University Health Network, University of Toronto, Ontario, Canada. john.marshall@uhn.on.ca
OBJECTIVE: An improved understanding of the mechanisms through which infecting pathogens harm the host is leading to new formulations of the concept of sepsis. We review the roles of inflammation and coagulation in the pathogenesis of the multiple organ dysfunction syndrome, and explore the potential of new therapies to restore the fine biological balance between procoagulant and anticoagulant mechanisms that are disrupted during the life-threatening processes that lead to organ dysfunction. DATA SOURCES: Narrative review of published primary sources in the basic and clinical literature. DATA SUMMARY: Traditional models of host-pathogen interactions ascribe the morbidity of infection to the direct cytotoxic effects of micro-organisms on host tissues. However, abundant experimental and clinical evidence has revealed that it is the response of the host, rather than the trigger that elicited it, that is the more potent determinant of outcome. The elucidation of a complex network of host-derived inflammatory mediators raised the possibility that targeting these individually could improve patient outcomes, and some modest successes with this approach have been achieved. More recently, it is becoming evident that the inflammatory response, in turn, mediates its deleterious effects by inducing tissue hypoxia, and cellular injury, either through tissue necrosis or through the induction of programmed cell death or apoptosis. Thus, treatment strategies that target the downstream consequences of the activation of inflammation, for example, microvascular coagulation or acute adrenal insufficiency, represent the latest, and some of the most promising approaches to attenuation of the septic response to improve survival, and minimize organ dysfunction. The maladaptive sequelae of systemic inflammation, embodied in the concept of the multiple organ dysfunction syndrome, comprise the leading obstacle to survival for patients admitted to a contemporary intensive care unit. Further insights into this intimidatingly complex process will not only provide potent new therapeutic options, but promise to transform critical illness from a biological standoff, during which the clinician merely supports failing organs, to a disease that can be successfully treated.
PMID: 11445742, UI: 21338369
Crit Care Med 2001 Jul;29(7):1299-302
PMID: 11445673, UI: 21338300
Intensive Care Med 2001 Jun;27(6):999-1004
Unidade de Cuidados Intensivos Polivalente, Hospital de St Antonio dos Capuchos, Lisbon, Portugal. r.moreno@mail.telepac.pt
OBJECTIVES: Mortality after ICU discharge accounts for approx. 20-30% of deaths. We examined whether post-ICU discharge mortality is associated with the presence and severity of organ dysfunction/failure just before ICU discharge. PATIENTS AND METHODS: The study used the database of the EURICUS-II study, with a total of 4,621 patients, including 2,958 discharged alive to the general wards (post-ICU mortality 8.6%). Over a 4-month period we collected clinical and demographic characteristics, including the Simplified Acute Physiology Score (SAPS II), Nine Equivalents of Nursing Manpower Use Score, and Sequential Organ Failure Assessment (SOFA) score. RESULTS: Those who died in the hospital after ICU discharge had a higher SAPS II score, were more frequently nonoperative, admitted from the ward, and had stayed longer in the ICU. Their degree of organ dysfunction/failure was higher (admission, maximum, and delta SOFA scores). They required more nursing workload resources while in the ICU. Both the amount of organ dysfunction/failure (especially cardiovascular, neurological, renal, and respiratory) and the amount of nursing workload that they required on the day before discharge were higher. The presence of residual CNS and renal dysfunction/failure were especially prognostic factors at ICU discharge. Multivariate analysis showed only predischarge organ dysfunction/failure to be important; thus the increased use of nursing workload resources before discharge probably reflects only the underlying organ dysfunction/failure. CONCLUSIONS: It is better to delay the discharge of a patient with organ dysfunction/failure from the ICU, unless adequate monitoring and therapeutic resources are available in the ward.
PMID: 11497159, UI: 21388099
Intensive Care Med 2001 Jun;27(6):962-4
PMID: 11497153, UI: 21388093
Intensive Care Med 2001 Jun;27(6):1058-63
Service d'Anesthesie-Reanimation, Hjpital Beaujon, Clichy, France. franck.lagneau@bjn.ap-hop-paris.fr
OBJECTIVES: To investigate the effect of current intensity and choice of the stimulated muscle group on train-of-four (TOF) interpretation in the intensive care unit (ICU). DESIGN AND SETTING: Intervention study in a surgical intensive care unit. PATIENTS: 13 ventilated patients requiring prolonged muscle relaxation. MEASUREMENTS AND RESULTS: Prior to blockade TOF responses of left and right orbicularis oculi, adductor pollicis, and plantar flexors were recorded by setting the current intensity at 20, 40, 60, and 80 mA. The minimal current intensity (MCI) providing a supramaximal response was then identified for each muscle. Cisatracurium was then infused aiming to continuously observe a TOF at 2/4 on the left orbicularis oculi at 40 mA. The responses to TOF on all the muscle sites were further recorded at 40, 60, and 80 mA when the endpoint was reached for the first time, and after a 48-h infusion. After cessation of infusion the delay to observe 4/4 responses at TOF was recorded at each site at 40 mA or at MCI if MCI was above 40 mA. MCI did not differ between muscle groups. When the fixed endpoint was reached for the first time on left orbicularis oculi, the TOF response at 40 mA on right orbicularis oculi differed significantly. In contrast, no difference was observed between left and right sides at 40 mA at the other sites, nor at any sites at 60 and 80 mA. The TOF response on orbicularis oculi (left and right sides together) was different at 40 mA, compared to 60 and 80 mA. TOF responses at orbicularis oculi at 60 or 80 mA significantly differed from responses on adductor pollicis or plantar flexor, orbicularis oculi being less sensitive to cisatracurium than adductor pollicis or plantar flexor. After a 48-h infusion the same differences in sensitivities were observed between the muscle groups. At any current intensity the recovery was slower at adductor pollicis than at orbicularis oculi or plantar flexor. CONCLUSIONS: For a good TOF interpretation in the ICU the current intensity should be tested before onset of blockade. The orbicularis oculi is less sensitive to cisatracurium than adductor pollicis and plantar flexor both at onset and after a prolonged infusion. The recovery from relaxation is faster on orbicularis oculi and plantar flexor than on adductor pollicis.
PMID: 11497139, UI: 21388107
Intensive Care Med 2001 Jun;27(6):1029-36
Department of Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21287-5842, USA. sberenho@jhmi.edu
OBJECTIVES: To evaluate the effectiveness of procedure-specific surgical critical pathways on reducing resource utilization in a university surgical intensive care unit (ICU). DESIGN AND SETTING: Prospective cohort study in a university surgical ICU. PATIENTS: 194 patients, accounting for 255 patient days, sampled on randomly selected days over a 12-month period of time. MEASUREMENTS AND RESULTS: The primary outcomes of this study were pathway eligibility and laboratory utilization. Patients were eligible for a procedure-specific pathway in 34% of patient days identified, and the patient's clinical course was "on" pathway in 22% of patient days. Of those "on" the pathway, 54% had a pathway present in the chart and 32% of these included documentation of the patient's clinical course. Thus in 78% of the patient days the patient was either not eligible for a critical pathway or the patient's clinical course was "off" pathway. In those patients "on" the pathway 46 % did not have a pathway present in the chart. Being on a critical pathway did not reduce laboratory utilization. Laboratory utilization did not vary between patients "on" and "off" the pathway (19.1 +/- 11.3 laboratory tests/patient day versus 20.4 +/- 5.7 laboratory tests/patient day). Predicted laboratory utilization by the pathway was 5.6 laboratory tests/patient day. By reducing actual laboratory utilization to that predicted by the critical pathway we would reduce laboratory utilization at our institution by $1.2 million per year. CONCLUSIONS: Procedure-specific surgical critical pathways are not an effective tool for reducing resource utilization in our ICU. Most of our patients were not eligible for an available pathway, and those who were eligible and were "on" the pathway did not appear to have laboratory utilization guided by the pathway. Future initiatives need to explore other means such as ICU-specific care processes to reduce resource utilization in the ICU.
PMID: 11497135, UI: 21388103
Intensive Care Med 2001 Jun;27(6):1022-8
Department of Intensive Care, University of Amsterdam, The Netherlands. j.m.binnekade@amc.uva.nl
OBJECTIVE: The assessment of critical nursing situations can be a valuable tool in the detection of weak elements in the safety of patients and the quality of care in the ICU. A critical nursing situation can be defined as any observable situation, which deviates from good clinical practice and which may potentially lead to an adverse event. The aim of our study was to establish the feasibility, reliability and validity of the Critical Nursing Situation Index (CNSI) as a tool for assessing the safety and the quality of nursing in the ICU. DESIGN: We described the deviations from standards and protocols in daily ICU nursing care, selected those with an implicit, clear risk for the patients and translated them into explicitly observable items. If an item was applicable during observation of the ICU practice, a critical nursing situation could be recorded as either true or false. The reliability of the CNSI was defined in terms of inter-observer agreement. The validity was assessed by exploring the relationship between the nursing time available (more or less than 30 min per patient per hour) and the incidence of critical nursing situations. SETTING: The study was performed in the ICU of a teaching hospital (30 IC beds) in which all disciplines, including cardiothoracic surgery and neurosurgery, were represented. PATIENTS: The CNSI was randomly applied to 83 ICU patients over a period of 3 months (200 times). MEASUREMENTS AND RESULTS: The reliability of the index was substantial (Kappa values in the range > or =0.70 to > 0.80). In terms of validity, less nursing time resulted in more critical situations (pooled relative risk (RR) 1.36; 95% confidence limits 1.11/1.67). CONCLUSION: The CNSI is simple to use and has encouraging metric properties, whereas the assessments are closely related to direct patient care. Moreover, the CNSI provides a tool for safety assessment by monitoring potentially dangerous situations that are generally regarded as needing to be avoided.
PMID: 11497134, UI: 21388102
J Trauma 2001 Jul;51(1):17-21
Department of Surgery, The Milton S. Hershey Medical Center, Penn State College of Medicine, Hershey, Pennsylvania 17033, USA.
BACKGROUND: Computerized human patient simulators (HPSs) have been used to improve diagnostic and therapeutic decision making. The goal of this study was to investigate the impact of HPSs and Advanced Trauma Life Support (ATLS) on the development of trauma management skills and self-confidence in surgical interns. METHODS: Three teams of interns completed two ATLS-like trauma scenarios on the HPS (pre-ATLS). They then took the ATLS provider course. After ATLS, the interns were evaluated on two different HPS trauma scenarios (post-ATLS). Two teams of senior residents, experienced in trauma care, completed the same HPS scenarios and were used as controls. Trauma management skills were scored in three areas--critical treatment decisions, potential for adverse outcomes, and team behavior--by staff trauma surgeons. After participating in the HPS trauma scenarios, the interns completed self-confidence questionnaires and a course evaluation survey. RESULTS: Trauma management skill scores increased 23% in critical treatment decisions, 25% in potential for adverse outcomes, and 47% in team behavior after ATLS/HPS (p < 0.002). Senior residents' performance on HPS trauma scenarios was better than the interns (p < 0.05) in all three areas evaluated. The interns' self-confidence scores rose significantly after the course. (p < 0.01) The HPS course evaluation survey averaged 8.3 out of a maximum 10. CONCLUSION: Use of HPSs in conjunction with ATLS appears to enhance the development of trauma management skills. The surgical interns participating in the study deemed the HPS to be a worthwhile experience and a confidence-building tool. In particular, trauma team behavior improved significantly after ATLS/HPS.
PMID: 11468460, UI: 21361518
J Trauma 2001 Jul;51(1):1-8, discussion 8-9
Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington 98104, USA. larrygen@u.washington.edu
BACKGROUND: Compartmental syndrome (CS) is difficult to diagnose in intensive care unit patients. Compartment perfusion pressure (CPP) is an invasive, indirect measure of ischemia. Near-infrared spectroscopy is noninvasive, and directly measures ischemia by transmitting light through tissues at wavelengths that react with hemoglobin to provide percent tissue oxygen saturation (Sto(2)). Animal studies demonstrate that Sto(2) is superior to CPP for detecting CS. However, there are no studies in humans comparing Sto(2) with CPP. We hypothesized that Sto(2) can reliably detect CS, and is superior to CPP. METHODS: CS was induced in 15 human volunteers using a standard calf compression model. At 30-minute intervals, compression was increased to reduce Sto(2) from baseline (86% +/- 4%) to 60%, 40%, 20%, and < 10%, with simultaneous recording of CPP. Outcome variables included deep peroneal nerve conduction assessed by electromyography, cutaneous peroneal nerve sensitivity using Semmes-Weinstein monofilaments, and pain (visual analog scale). RESULTS: Both Sto(2) and CPP significantly correlated with all ischemia outcome variables (p < 0.001). Receiver operating characteristic curves of deep peroneal nerve conduction demonstrated that Sto(2) had higher sensitivity than CPP for detecting > 50% block. For example, when specificity was 83% for Sto(2) and 84% for CPP, sensitivity was 85% versus 56%, respectively (p = 0.02). When specificity for both was 72%, sensitivity was 94% for Sto(2) versus 76% for CPP (p = 0.04). CONCLUSION: In intensive care unit patients who cannot alert physicians to symptoms, near-infrared spectroscopy may help clinicians to avoid delayed or unnecessary prophylactic fasciotomy, and provides the benefits of a continuous, noninvasive monitoring technique.
PMID: 11468459, UI: 21361517
J Trauma 2001 Jul;51(1):10-6
Trauma Department, Hannover Medical School, Hannover, Germany. richter.martinus@mh-hannove.de
BACKGROUND: The crash mechanisms and clinical course of car occupants with thoracic injury were analyzed to determine prognostic factors and to create a basis for injury prophylaxis. METHODS: A technical and medical investigation of car occupants with a thoracic injury (Abbreviated Injury Scale-thorax [AIS(THORAX)] > or = 1) at the scene of the crash and the primary admitting hospital was performed. RESULTS: Between 1985 and 1998, 581 car occupants sustained a thoracic injury. Mean parameter values were as follows: AIS(THORAX), 2.5; Hannover Polytrauma Score (PTS), 21.4; Injury Severity Score (ISS), 24.2; Delta-v, 49.6 km/h (30.8 mph); and extent of passenger compartment deformation (DEF) (scale, 1--9), 4.0. In 19% (n = 112) of patients involved, the clinical course was evaluated: AIS(THORAX), 2.5; PTS, 20.0; ISS, 19.3; Delta-v, 50.1 km/h (31.1 mph); DEF, 3.9; intensive care unit time, 8.3 days; ventilation time, 5.7 days; and hospital stay, 15.3 days. In the groups with higher AIS(THORAX), ISS, PTS, and intensive care unit and ventilation time, higher Delta-v and DEF occurred. In patients with longer hospital stay, higher Delta-v, but no difference in DEF occurred. CONCLUSION: The injury severity and the clinical course demonstrated a positive correlation with the crash severity. Therefore, our technical accident analysis allows prediction of the severity of injury and the clinical course. It may consequently serve as a tool for development of more sophisticated injury prevention strategies and may improve passive car safety.
PMID: 11468457, UI: 21361514
JAMA 2001 Jul 18;286(3):335-40
Department of Internal Medicine, Division of Infectious Diseases and AIDS, University Hospital, Heidelberglaan 100, 3584 CX Utrecht, the Netherlands. m.bonten@wxs.nl
CONTEXT: Although meta-analyses of randomized trials have shown that selective digestive decontamination (SDD) prevents nosocomial pneumonia in critically ill patients, the influence of trial quality on the effectiveness of SDD has not been rigorously evaluated. OBJECTIVE: To assess the methodological quality of individual studies of SDD and its relation to the reported effects on pneumonia and mortality. DESIGN: Thirty-two studies were identified in a MEDLINE and reference list search and their methodological quality was assessed using a scoring system (range, 0-13 points) based on allocation and concealment, patient selection, patient characteristics, blinding of the intervention, and the definition of pneumonia. MAIN OUTCOME MEASURE: Methodological quality of the primary trials and its effect on the relative risk reductions (RRRs) of SDD on pneumonia and mortality. RESULTS: The mean (SD) methodological quality score was 7.8 (2.9) (range, 1-11). The RRRs ranged from -0.1 to 1.0 for pneumonia and from -0.1 to 0.6 for mortality. The methodological quality score was associated with the RRR for pneumonia so that for each quality-point added, the RRR decreased by 5.8% (95% confidence interval, 2.4%-9.3%). No association between trial quality and the impact of SDD was found on mortality. Of the individual trial quality characteristics, patient selection, allocation of intervention, and blinding most strongly influenced the treatment effect. CONCLUSIONS: The inverse relationship between methodological quality score and the benefit of SDD on the incidence of pneumonia may have resulted in overly optimistic estimates of SDD in prior meta-analyses. This emphasizes the importance of rigorous trial design in evaluating preventive interventions in the intensive care unit.
PMID: 11466100, UI: 21359752
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