02 May 09

Use of corticosteroids in acute lung injury and acute respiratory distress syndrome

Posted in ALI/ARDS, Steroid at 1:08 by Laci

By B Tang, JC Craig, GD Eslick, I Seppelt, AS McLean

Crit Care Med  2009;37:1594-1603

Controversy remains as to whether low-dose corticosteroids can reduce the mortality and morbidity of acute lung injury (ALI) or the acute respiratory distress syndrome (ARDS) without increasing the risk of adverse reactions. We aimed to evaluate all studies investigating prolonged corticosteroids in low-to-moderate dose in ALI or ARDS.

Datasources
MEDLINE, EMBASE, Current Content, and Cochrane Central Register of Controlled Trials, and bibliographies of retrieved articles.

Study selection
Randomized controlled trials (RCTs) and observational studies reported in any language that used 0.5-2.5 mg.kg-1.d-1 of methylprednisolone or equivalent to treat ALI/ARDS.

Data extraction
Data were extracted independently by two reviewers and included study design, patient characteristics, interventions, and mortality and morbidity outcomes.

Data synthesis
Both cohort studies (five studies, n = 307) and RCTs (four trials, n = 341) showed a similar trend toward mortality reduction (RCTs relative risk 0.51, 95% CI 0.24-1.09; p = 0.08; cohort studies relative risk 0.66, 95% CI 0.43-1.02; p = 0.06). The overall relative risk was 0.62 (95% CI 0.43-0.91; p = 0.01). There was also improvement in length of ventilation-free days, length of intensive care unit stay, Multiple Organ Dysfunction Syndrome Score, Lung Injury Scores, and improvement in PaO2/FiO2. There was no increase in infection, neuromyopathy, or any major complications. There was significant heterogeneity in the pooled studies. Subgroup and meta-regression analyses showed that heterogeneity had minimal effect on treatment efficacy; however, these findings were limited by the small number of studies used in the analyses.

Conclusion
The use of low-dose corticosteroids was associated with improved mortality and morbidity outcomes without increased adverse reactions. The consistency of results in both study designs and all outcomes suggests that they are an effective treatment for ALI or ARDS. The mortality benefits in early ARDS should be confirmed by an adequately powered randomized trial.

14 Jan 09

Acute lung injury after ruptured abdominal aortic aneurysm repair: The effect of excluding donations from females from the production of fresh frozen plasma

Posted in ALI/ARDS, Transfusion medicine at 0:40 by Laci

By S Wright, C Snowden, S Athey, AA Leaver, J-M Clarkson et al

Crit Care Med 2008:36;1796-1802

Transfusion-related acute lung injury may contribute to the development of acute lung injury in the critically ill, due to plasma from female donors containing antileukocyte antibodies. In July 2003, the U.K. National Blood Service stopped using female donor plasma for the production of fresh frozen plasma. Patients undergoing repair of a ruptured abdominal aortic aneurysm receive large amounts of fresh frozen plasma and often develop acute lung injury. We investigated whether the change to male fresh frozen plasma was associated with a change in the frequency of acute lung injury in these patients.

Design
A retrospective, before and after, observational, single-center study.

Setting
Tertiary care center and a regional blood center.

Patients
The study included 211 patients undergoing open repair of a ruptured abdominal aortic aneurysm between 1998 and 2006.

Interventions
None.

Measurements and main results
Primary outcome was the development of acute lung injury in the first 6 hrs after surgery. Secondary outcomes were significant hypoxia (Pao2/Fio2 ratio <300), time to extubation, and survival at 30 days. Groups were well matched and received similar volumes of intravenous fluids and blood components. There was significantly less acute lung injury following the change to male fresh frozen plasma (36% before vs. 21% after, p = .04). At 6 hrs after surgery, fewer patients were hypoxic (87% before vs. 62% after, p < .01). In multivariate analysis, the change in donor policy was associated with a decreased risk of developing acute lung injury (odds ratio 0.39; 95% confidence interval, 0.16ñ0.90). Time to extubation and survival at 30 days were not statistically different between groups.

Conclusions
The policy to exclude female donors from the production of fresh frozen plasma was associated with a decrease in the frequency of acute lung injury in patients undergoing repair of a ruptured abdominal aortic aneurysm.

20 Dec 08

Prone positioning in acute respiratory distress syndrome

Posted in ALI/ARDS, Mechanical ventilation at 0:21 by Laci

By R Fernandez, X Trenchs, J Klamburg, J Castedo, J M Serrano et al

Intensive Care Med 2008:34;1487-1491

We examined the effect on survival of prone positioning as an early and continuous treatment in ARDS patients already treated with protective ventilation.

Design and setting
Open randomized controlled trial in 17 medical-surgical ICUs.

Patients
Forty mechanically ventilated patients with early and refractory ARDS despite protective ventilation in the supine position.
Interventions  Patients were randomized to remain supine or be moved to early (within 48h) and continuous (=20h/day) prone position until recovery or death. The trial was prematurely stopped due to a low patient recruitment rate.

Measurements and results
Clinical characteristics, oxygenation, lung pressures, and hemodynamics were monitored. Need for sedation, complications, length of MV, ICU, and hospital stays, and outcome were recorded. PaO2/FIO2 tended to be higher in prone than in supine patients after 6h (202±78 vs. 165±70mmHg); this difference reached statistical significance on day 3 (234±85 vs. 159±78). Prone-related side effects were minimal and reversible. Sixty-day survival reached the targeted 15% absolute increase in prone patients (62% vs. 47%) but failed to reach significance due to the small sample.

Conclusions
Our study adds data that reinforce the suggestion of a beneficial effect of early continuous prone positioning on survival in ARDS patients.

12 Nov 08

Acute lung injury following blood transfusion: Expanding the definition.

Posted in ALI/ARDS at 0:00 by Laci

By PE Marik, HL Corwin

Crit Care Med 2008;36:3080-3084

Acute lung injury (ALI) is a well known complication following the transfusion of blood products and is commonly referred to as transfusion-related acute lung injury (TRALI). The objectives of this review are to summarize current knowledge of TRALI with an emphasis on issues pertinent to the intensivist and to define the newly recognized “Delayed TRALI syndrome.”

Data synthesis
The classic TRALI syndrome is an uncommon condition characterized by the abrupt onset of respiratory failure within hours of the transfusion of a blood product. It is usually caused by anti-leukocyte antibodies, resolves rapidly, and has a low mortality. A single unit of packed cells or blood component product is usually implicated in initiating this syndrome. It has, however, recently been recognized that the transfusion of blood products in critically ill or injured patients increases the risk (odds ratio 2.13; 95% confidence interval 1.75-2.52) for the development of the ALI 6-72 hours after the transfusion. This “delayed TRALI syndrome” is common, occurring in up to 25% of critically ill patients receiving a blood transfusion, and is associated with a mortality of up to 40%. While the delayed TRALI syndrome can develop after the transfusion of a single unit, the risk increases as the number of transfused blood products increase. The management of both the classic and delayed TRALI syndromes is essentially supportive.

Conclusions
Both the classic and delayed TRALI syndromes are among the most important complications following the transfusion of blood products and are associated with significant morbidity and increased mortality. The risk and benefits of all blood products should be assessed before transfusion.

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