Search

Systematic reviews (SRs) and meta-analyses of pooled data are believed to provide high-quality evidence and as such are often relied upon by clinicians for making important therapeutic decisions. However, previous pooled analyses of SRs have shown flaws in many of the studies – in registration, protocol, search methods and sources, data extraction, analysis, coverage of the reported data and funding disclosure. Poorly conducted SRs are not only a waste of research efforts but may also mislead clinicians, thwarting even the best of efforts to improve patient outcomes. Vasopressors and inotropes are commonly used in the ICU to increase blood pressure in patients suffering from septic shock. In the late 1990s, shortly after standardization of the definition of sepsis and septic shock, the first human trials on the use of vasopressors and inotropes for septic shock began to appear. The Surviving Sepsis Campaign initiative, first launched in 2002, included one of the first systematic reviews of the literature on this topic, and it revealed the paucity of medical literature on the relation between the use of these drugs and patient outcomes. This finding triggered a series of clinical trials, and these have recently been included in systematic reviews. We intend to systematically search the literature for SRs studying the effect of vasopressors and inotropes on the outcomes of adult patients with sepsis. We aim to assess the number of SRs on this topic in relation to the average number of publications they include, to map the PICO questions they have addressed, their quality and their findings in order to highlight gaps in knowledge and quality.

Systematic reviews (SRs) and meta-analyses of pooled data are believed to provide high-quality evidence and as such are often relied upon by clinicians for making important therapeutic decisions. However, previous pooled analyses of SRs have shown flaws in many of the studies – in registration, protocol, search methods and sources, data extraction, analysis, coverage of the reported data and funding disclosure. Poorly conducted SRs are not only a waste of research efforts but may also mislead clinicians, thwarting even the best of efforts to improve patient outcomes. Vasopressors and inotropes are commonly used in the ICU to increase blood pressure in patients suffering from septic shock. In the late 1990s, shortly after standardization of the definition of sepsis and septic shock, the first human trials on the use of vasopressors and inotropes for septic shock began to appear. The Surviving Sepsis Campaign initiative, first launched in 2002, included one of the first systematic reviews of the literature on this topic, and it revealed the paucity of medical literature on the relation between the use of these drugs and patient outcomes. This finding triggered a series of clinical trials, and these have recently been included in systematic reviews. We intend to systematically search the literature for SRs studying the effect of vasopressors and inotropes on the outcomes of adult patients with sepsis. We aimed to assess the number of SRs on this topic in relation to the average number of publications they include, to map the PICO questions they have addressed, their quality and their findings in order to highlight gaps in knowledge and quality.

International audience; Objectives: Reintubation after failed extubation is associated with increased mortality and longer hospital length of stay. Noninvasive oxygenation modalities may prevent reintubation. We conducted a systematic review and meta-analysis to determine the safety and efficacy of high-flow nasal cannula after extubation in critically ill adults.Data Sources: We searched MEDLINE, EMBASE, and Web of Science.Study Selection: We included randomized controlled trials comparing high-flow nasal cannula to other noninvasive methods of oxygen delivery after extubation in critically ill adults.Data Extraction: We included the following outcomes: reintubation, postextubation respiratory failure, mortality, use of noninvasive ventilation, ICU and hospital length of stay, complications, and comfort.Data Synthesis: We included eight randomized controlled trials (n = 1,594 patients). Compared with conventional oxygen therapy, high-flow nasal cannula decreased reintubation (relative risk, 0.46; 95% CI, 0.30–0.70; moderate certainty) and postextubation respiratory failure (relative risk, 0.52; 95% CI, 0.30–0.91; very low certainty), but had no effect on mortality (relative risk, 0.93; 95% CI, 0.57–1.52; moderate certainty), or ICU length of stay (mean difference, 0.05 d fewer; 95% CI, 0.83 d fewer to 0.73 d more; high certainty). High-flow nasal cannula may decrease use of noninvasive ventilation (relative risk, 0.64; 95% CI, 0.34–1.22; moderate certainty) and hospital length of stay (mean difference, 0.98 d fewer; 95% CI, 2.16 d fewer to 0.21 d more; moderate certainty) compared with conventional oxygen therapy, however, certainty was limited by imprecision. Compared with noninvasive ventilation, high-flow nasal cannula had no effect on reintubation (relative risk, 1.16; 95% CI, 0.86–1.57; low certainty), mortality (relative risk, 1.12; 95% CI, 0.82–1.53; moderate certainty), or postextubation respiratory failure (relative risk, 0.82; 95% CI, 0.48–1.41; very low certainty). High-flow nasal cannula may reduce ICU length of stay (moderate certainty) and hospital length of stay (moderate certainty) compared with noninvasive ventilation.Conclusions: High-flow nasal cannula reduces reintubation compared with conventional oxygen therapy, but not compared with noninvasive ventilation after extubation.

International audience; Objective: The role of high-flow nasal cannula during and before intubation is unclear despite a number of randomized clinical trials. Our objective was to conduct a systematic review and meta-analysis examining the benefits of high-flow nasal cannula in the peri-intubation period.Data Sources: We performed a comprehensive search of relevant databases (MEDLINE, EMBASE, and Web of Science).Study Selection: We included randomized clinical trials that compared high-flow nasal cannula to other noninvasive oxygen delivery systems in the peri-intubation period.Data Extraction: Our primary outcome was severe desaturation (defined as peripheral oxygen saturation reading < 80% during intubation). Secondary outcomes included peri-intubation complications, apneic time, Pao2 before and after intubation, Paco2 after intubation, ICU length of stay, and short-term mortality.Data Synthesis: We included 10 randomized clinical trials (n = 1,017 patients). High-flow nasal cannula had no effect on the occurrence rate of peri-intubation hypoxemia (relative risk, 0.98; 95% CI, 0.68–1.42; 0.3% absolute risk reduction, moderate certainty), serious complications (relative risk, 0.87; 95% CI, 0.71–1.06), apneic time (mean difference, 10.3 s higher with high-flow nasal cannula; 95% CI, 11.0 s lower to 31.7 s higher), Pao2 measured after preoxygenation (mean difference, 3.6 mm Hg higher; 95% CI, 3.5 mm Hg lower to 10.7 mm Hg higher), or Pao2 measured after intubation (mean difference, 27.0 mm Hg higher; 95% CI, 13.2 mm Hg lower to 67.2 mm Hg higher), when compared with conventional oxygen therapy. There was also no effect on postintubation Paco2, ICU length of stay, or 28-day mortality.Conclusions: We found moderate-to-low certainty evidence that the use of high-flow nasal cannula likely has no effect on severe desaturation, serious complications, apneic time, oxygenation, ICU length of stay, or overall survival when used in the peri-intubation period when compared with conventional oxygen therapy.

List of included studies, search strategy, and risk of bias assessment. Detailed study methods, reference list of included studies, search strategy, risk of bias assessment. (DOCX 520 kb)

Purpose To review the characteristics, findings and quality of systematic reviews (SRs) on the effect of any vasopressor/inotrope on outcomes in adult patients with sepsis compared with either no treatment, another vasopressor or inotrope or fluids. Materials and methods We systematically searched Cochrane Central Register of Controlled Trials, PubMed and Embase (January 1993–March 2021). Descriptive statistics were used. Results Among the 28 SRs identified, mortality was the primary outcome in most (26/28) and mortality was usually (23/28) studied using randomised controlled trials (RCTs). Fifteen SRs focused exclusively on patients with sepsis or septic shock. Sepsis and septic shock were always grouped for the analysis. Publication bias was consistently low when studied. The most consistent findings were a survival advantage with norepinephrine versus dopamine, which disappeared in analyses restricted to 28-day mortality, and more arrhythmias with dopamine. However, these analyses were dominated by a single study. Only 2 SRs were judged to be of moderate-high quality. Lack of blinding and attrition bias may have affected the outcomes. Conclusions The quality of SRs on the effect of vasopressors/inotropes on the outcomes of adult patients with sepsis can be improved, but high-quality, multicenter, RCTs should be preferred to additional SRs on this topic.