Adult patients, tight glucose control is not associated with significantly

Reduced hospital mortality but is associated with an increased risk of

Hypoglycemia.

Antithrombin III for critically ill patients.

Cochrane Database Syst Rev. 2008 Jul 16;(3):CD005370.

BACKGROUND: Critical illness is associated with uncontrolled inflammation and

vascular damage which can result in multiple organ failure and death.

Antithrombin III (AT III) is an anticoagulant with anti-inflammatory properties

but the efficacy and any harmful effects of AT III supplementation in critically

ill patients are unknown. OBJECTIVES: To assess the benefits and harms of AT III

in critically ill patients. SEARCH STRATEGY: We searched the Cochrane Central

Register of Controlled Trials (CENTRAL) (The Cochrane Library); MEDLINE; EMBASE;

Science Citation Index Expanded; International Web of Science; CINAHL; LILACS;

and the Chinese Biomedical Literature Database (up to November 2006). We

contacted authors and manufacturers in the field. SELECTION CRITERIA: We included

all randomized clinical trials, irrespective of blinding or language, that

compared AT III with no intervention or placebo in critically ill patients. DATA

COLLECTION AND ANALYSIS: Our primary outcome measure was mortality. We each

independently abstracted data and resolved any disagreements by discussion. We

presented pooled estimates of the intervention effects on dichotomous outcomes as

relative risks (RR) with 95% confidence intervals (CI). We performed subgroup

analyses to assess risk of bias, the effect of AT III in different populations

(sepsis, trauma, obstetric, and paediatric patients), and the effect of AT III in

patients with or without the use of concomitant heparin. We assessed the adequacy

of the available number of participants and performed a trial sequential analysis

to establish the implications for further research. MAIN RESULTS: We included 20

randomized trials with a total of 3458 participants; 13 of these trials had high

risk of bias. When we combined all trials, AT III did not statistically

significantly reduce overall mortality compared with the control group (RR 0.96,

95% CI 0.89 to 1.03; no heterogeneity between trials). A total of 32 subgroup and

sensitivity analyses were carried out. Analyses based on risk of bias, different

populations, and the role of adjuvant heparin gave insignificant differences. AT

III reduced the multiorgan failure score among survivors in an analysis involving

very few patients. AT III increased bleeding events (RR 1.52, 95% CI 1.30 to

1.78). AUTHORS' CONCLUSIONS: AT III cannot be recommended for critically ill

patients based on the available evidence. A randomized controlled trial of AT

III, without adjuvant heparin, with prespecified inclusion criteria and good bias

protection is needed.

Empirical fluconazole versus placebo for intensive care unit patients: a

Randomized trial.

Ann Intern Med. 2008 Jul 15;149(2):83-90.

Schuster MG, Edwards JE Jr, Sobel JD, Darouiche RO, Karchmer AW, Hadley S,

Slotman G, Panzer H, Biswas P, Rex JH.

BACKGROUND: Invasive infection with Candida species is an important cause of

morbidity and mortality in intensive care unit (ICU) patients. Optimal preventive

strategies have not been clearly defined. OBJECTIVE: To see whether empirical

fluconazole improves clinical outcomes more than placebo in adult ICU patients at

high risk for invasive candidiasis. DESIGN: Double-blind, placebo-controlled,

randomized trial conducted from 1995 to 2000. SETTING: 26 ICUs in the United

States. PATIENTS: 270 adult ICU patients with fever despite administration of

broad-spectrum antibiotics. All had central venous catheters and an Acute

Physiology and Chronic Health Evaluation II score greater than 16. INTERVENTION:

Patients were randomly assigned to either intravenous fluconazole, 800 mg daily,

or placebo for 2 weeks and were followed for 4 weeks thereafter. Two hundred

forty-nine participants were available for outcome assessment. MEASUREMENTS: A

composite primary outcome that defined success as all 4 of the following:

resolution of fever; absence of invasive fungal infection; no discontinuation

because of toxicity; and no need for a nonstudy, systemic antifungal medication

(as assessed by a blinded oversight committee). RESULTS: Only 44 of 122 (36%)

fluconazole recipients and 48 of 127 (38%) placebo recipients had a successful

outcome (relative risk, 0.95 [95% CI, 0.69 to 1.32; P = 0.78]). The main reason

for failure was lack of resolution of fever (51% for fluconazole and 57% for

placebo). Documented invasive candidiasis occurred in 5% of fluconazole

recipients and 9% of placebo recipients (relative risk, 0.57 [CI, 0.22 to 1.49]).

Seven (5%) fluconazole recipients and 10 (7%) placebo recipients had adverse

events resulting in discontinuation of the study drug. Discontinuation because of

abnormal liver test results occurred in 3 (2%) fluconazole recipients and 5 (4%)

placebo recipients. Limitations: Twenty-one randomly assigned patients were not

included in the analysis because they either did not meet entry criteria or did

not have postbaseline assessments. Fewer fungal infections than anticipated

occurred in the control group. Confidence bounds were wide and did not exclude

potentially important differences in outcomes between groups. CONCLUSION: In

Date: 2016-01-05; view: 769