27 Mar 07
Posted in ALI/ARDS at 18:53 by Laci
By N K J Adhikari, K E A Burns, J O Friedrich, J T Granton, D J Cook, M O Meade
BMJ, doi:10.1136/bmj.39139.716794.55
Objective
To review the literature on the use of inhaled nitric oxide to treat acute lung injury/acute respiratory distress syndrome (ALI/ARDS) and to summarise the effects of nitric oxide, compared with placebo or usual care without nitric oxide, in adults and children with ALI or ARDS.
Design
Systematic review and meta-analysis.
Data sources
Medline, CINAHL, Embase, and CENTRAL (to October 2006), proceedings from four conferences, and additional information from authors of 10 trials.
Review methods
Two reviewers independently selected parallel group randomised controlled trials comparing nitric oxide with control and extracted data related to study methods, clinical and physiological outcomes, and adverse events.
Main outcome measures
Mortality, duration of ventilation, oxygenation, pulmonary arterial pressure, adverse events.
Results
12 trials randomly assigning 1237 patients met inclusion criteria. Overall methodological quality was good. Using random effects models, we found no significant effect of nitric oxide on hospital mortality (risk ratio 1.10, 95% confidence interval 0.94 to 1.30), duration of ventilation, or ventilator-free days. On day one of treatment, nitric oxide increased the ratio of partial pressure of oxygen to fraction of inspired oxygen (PaO2/FiO2 ratio) (13%, 4% to 23%) and decreased the oxygenation index (14%, 2% to 25%). Some evidence suggested that improvements in oxygenation persisted until day four. There was no effect on mean pulmonary arterial pressure. Patients receiving nitric oxide had an increased risk of developing renal dysfunction (1.50, 1.11 to 2.02).
Conclusions
Nitric oxide is associated with limited improvement in oxygenation in patients with ALI or ARDS but confers no mortality benefit and may cause harm. We do not recommend its routine use in these severely ill patients
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Posted in Coronary artery disease at 18:51 by Laci
By D P Taggart
BMJ 2007;334:593-594
Surgery is effective on clinical and economic grounds, but stenting does not seem to be cost effective
This week, the BMJ publishes three studies dealing with revascularisation in ischaemic heart disease. Two of the studies compare the clinical effectiveness and cost effectiveness of revascularisation of isolated left anterior descending coronary disease by stenting or surgery, while the third examines the cost effectiveness of medical treatment, stenting, and surgery in multivessel disease. The studies raise key issues not only about the decision making process for intervention in the individual patient but also how to obtain maximum value from limited health service resources.
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Posted in Mechanical ventilation, Obesity at 18:50 by Laci
By A G Duarte, E BS Justino, T MS Bigler, J Grady
Critical Care Medicine. 2007;35:732-737
Objective
To examine the outcomes of morbidly obese patients with acute respiratory failure treated with mechanical ventilation.
Design
Retrospective study.
Setting
A 14-bed medical intensive care unit in an 800-bed university-based hospital.
Patients
A total of 50 morbidly obese subjects with acute respiratory failure requiring ventilatory assistance.
Measurements
Arterial blood gas measurements, intubation rate, days of mechanical ventilation, intensive care unit length of stay, hospital length of stay, and mortality.
Results
From January 1997 to December 2004, 50 morbidly obese patients with acute respiratory failure were treated with mechanical ventilation. Invasive mechanical ventilation was implemented in 17 patients with a mean body mass index of 53.2 +/- 12.2 kg/m2. A total of 33 patients were treated with noninvasive ventilation (NIV), of which 21 avoided intubation (NIV success) and 12 required intubation (NIV failure). Mean body mass index for the NIV success group was significantly less than for the NIV failure group (46.9 +/- 8.9 and 62.5 +/- 16.1 kg/m2, respectively, p = .001). Acute Physiology and Chronic Health Evaluation II scores were similar for patients treated with invasive and noninvasive ventilation. Significant improvements in pH and Paco2 were noted for the invasive mechanical ventilation and NIV success groups. No improvements in gas exchange were noted in the NIV failure group. Of patients treated with NIV, 36% required intubation. Hospital mortality for the invasive ventilation and NIV failure groups was increased.
Conclusion
The type of ventilatory assistance may influence clinical outcomes in morbidly obese patients with acute respiratory failure.
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Posted in Sepsis at 18:47 by Laci
By C G Durbin
Critical Care Medicine 2007; 35: 689-691
Improvements in clinical care require change in both clinicians’ behavior and the systems in which they practice. Information published in peer-reviewed journals and continuing medical education have been the primary methods available to inform physicians and other caregivers of advances in medical practice. The impact of these educational activities is limited, however. In 1999, the Institute of Medicine published a landmark report, To Err Is Human: Building a Safer Health System. The report identified, in part, a widening gap between what research has demonstrated will improve patient outcomes and clinicians’ actual practice. To improve care and reduce unnecessary variation in clinical practice, professional societies have developed and disseminated evidence-based practice guidelines.
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