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Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review.

ABSTRACT: Background: Acute mesenteric ischaemia (AMI) is a surgical emergency which has an associated high mortality. The mainstay of active treatment includes early surgical intervention, with resection of non-viable bowel, and revascularisation of the ischaemic bowel where possible. Due to the physiological insult of AMI however, perioperative care often involves critical care and the use of vasoactive agents to optimise end organ perfusion. A number of these vasoactive agents are currently available with varied mechanism of action and effects on splanchnic blood flow. However, specific guidance on which is the optimal vasoactive drug to use in these settings is limited. This systematic review aimed to evaluate the current evidence comparing vasoactive drugs in AMI. Methods: A systematic search of Ovid Medline, Ovid Embase, Cochrane CENTRAL and the Cochrane Database of Systematic Review was performed on the 5th of November 2020 to identify randomised clinical trials comparing different vasoactive agents in AMI on outcomes including mortality. The search was performed through the Royal College of Surgeons of England (RCSEng) search support library. Results were analysed using the Rayyan platform, and independently screened by four investigators. Results: 614 distinct papers were identified. After screening, there were no randomised clinical trials meeting the inclusion criteria. Conclusions: This review identifies a gap in literature, and therefore recommends an investigation into current practice and clinician preference in relation to vasoactive agents in AMI. Multicentre randomised controlled trials comparing these medications on clinical outcomes will therefore be required to address this question.

SUBMITTER: Brennan CA

PROVIDER: S-EPMC8459625 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:ObjectiveTo estimate the incidence of acute mesenteric ischaemia (AMI), proportions of its different forms and short-term and long-term mortality.DesignSystematic review and meta-analysis.Data sourcesMEDLINE (Ovid), Web of Science, Scopus and Cochrane Library were searched until 26 July 2022.Eligibility criteriaStudies reporting data on the incidence and outcomes of AMI in adult populations.Data extraction and synthesisData extraction and quality assessment with modified Newcastle-Ottawa scale were performed using predeveloped standard forms. The outcomes were the incidence of AMI and its different forms in the general population and in patients admitted to hospital, and the mortality of AMI in its different forms.ResultsFrom 3064 records, 335 full texts were reviewed and 163 included in the quantitative analysis. The mean incidence of AMI was 6.2 (95% CI 1.9 to 12.9) per 100 000 person years. On average 5.0 (95% CI 3.3 to 7.1) of 10 000 hospital admissions were due to AMI. Occlusive arterial AMI was the most common form constituting 68.6% (95% CI 63.7 to 73.2) of all AMI cases, with similar proportions of embolism and thrombosis.Overall short-term mortality (in-hospital or within 30 days) of AMI was 59.6% (95% CI 55.5 to 63.6), being 68.7% (95% CI 60.8 to 74.9) in patients treated before the year 2000 and 55.0% (95% CI 45.5 to 64.1) in patients treated from 2000 onwards (p<0.05). The mid/long-term mortality of AMI was 68.2% (95% CI 60.7 to 74.9). Mortality due to mesenteric venous thrombosis was 24.6% (95% CI 17.0 to 32.9) and of non-occlusive mesenteric ischaemia 58.4% (95% CI 48.6 to 67.7). The short-term mortality of revascularised occlusive arterial AMI was 33.9% (95% CI 30.7 to 37.4).ConclusionsIn adult patients, AMI is a rarely diagnosed condition with high mortality, although with improvement of treatment results over the last decades. Two thirds of AMI cases are of occlusive arterial origin with potential for better survival if revascularised.Prospero registration numberCRD42021247148.

Project description:BackgroundAcute mesenteric ischaemia (AMI) is a disease with different pathophysiological mechanisms, leading to a life-threatening condition that is difficult to diagnose based solely on clinical signs. Despite widely acknowledged need for biomarkers in diagnosis of AMI, a broad systematic review on all studied biomarkers in different types of AMI is currently lacking. The aim of this study was to estimate the diagnostic accuracy of all potential biomarkers of AMI studied in humans.MethodsA systematic literature search in PubMed, The Cochrane Library, Web of Science and Scopus was conducted in December 2022. Studies assessing potential biomarkers of AMI in (at least 10) adult patients and reporting their diagnostic accuracy were included. Meta-analyses of biomarkers' sensitivity, specificity, and positive and negative likelihood ratios were conducted. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the study quality was assessed with the QUADAS-2 tool.ResultsSeventy-five studies including a total of 9914 patients assessed 18 different biomarkers in serum/plasma and one in urine (each reported in at least two studies), which were included in meta-analyses. None of the biomarkers reached a conclusive level for accurate prediction. The best predictive value overall (all studies with any type and stage of AMI pooled) was observed for Ischaemia-modified albumin (2 studies, sensitivity 94.7 and specificity 90.5), interleukin-6 (n = 4, 96.3 and 82.6), procalcitonin (n = 6, 80.1 and 86.7), and intestinal fatty acid-binding protein (I-FABP) measured in serum (n = 16, 73.9 and 90.5) or in urine (n = 4, 87.9 and 78.9). In assessment of transmural mesenteric ischaemia, urinary I-FABP (n = 2, 92.3 and 85.2) and D-dimer (n = 3, 87.6 and 83.6) showed moderate predictive value. Overall risk of bias was high, mainly because of selected study populations and unclear timings of the biomarker measurements after onset of symptoms. Combinations of biomarkers were rarely studied, not allowing meta-analyses.ConclusionsNone of the studied biomarkers had sufficient sensitivity and specificity to diagnose AMI, although some biomarkers showed moderate predictive accuracy. Future studies should focus on timing of measurements of biomarkers, distinguishing between early stage and transmural necrosis, and between different types of AMI. Additionally, studies on combinations of biomarkers are warranted. PROSPERO registration: CRD42022379341.

Project description:ObjectivePrevious studies have demonstrated amputation and mortality rates to be 14.3% - 30% and 11.4% - 28.9%, respectively, for all patients presenting with acute limb ischaemia (ALI). Rates of ALI are higher in patients with malignancy than in those without. Despite this, there remains uncertainty with regards to the most appropriate management for patients with cancer presenting with ALI. This is because of previously published high rates of associated morbidity and mortality in this population. The aim of this review was to summarise the available evidence reporting on outcomes of ALI in patients with underlying malignancy.MethodA systematic review was performed in August 2020 in accordance with the PRISMA guidelines. The Medline, Scopus, Cochrane, and Embase databases were searched with the following search string ((acute limb ischaemia) OR (acute limb ischemia)) AND ((cancer) OR (malignancy)). A total of 849 papers were identified and reviewed; six studies were included. Studies were assessed for bias using the National Institute of Health/National Heart, Lung and Blood Institute Quality Assessment Tool. Data including demographics, Rutherford classification, baseline performance scores, method of revascularisation, and peri-procedural outcomes were extracted and analysed. Data were pooled based on outcomes of interest and pooled prevalence was reported with 95% confidence intervals (CI).ResultsSix studies with 284 patients with cancer were included for analysis. The pooled overall risk of amputation was 15% (95% CI 5.9 - 26.9). The pooled 30 day mortality rate was 24% (95% CI 14.7 - 34.6).ConclusionDespite limitations of interstudy selection bias and some clinical heterogeneity, the included studies demonstrated acceptable short and medium term outcomes for patients with cancer undergoing revascularisation for acute limb ischaemia. This is in line with current recommendations that patients with underlying malignancy should be considered strongly for revascularisation.

Project description:BackgroundThe recent focus on the critical setting, especially with the COVID-19 pandemic, has highlighted the need for minimizing contact-based care and increasing robotic use. Robotics is a rising field in the context of health care, and we sought to evaluate the use of robots in critical care settings.ObjectiveAlthough robotic presence is prevalent in the surgical setting, its role in critical care has not been well established. We aimed to examine the uses and limitations of robots for patients who are critically ill.MethodsThis systematic review was performed according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. MEDLINE, Embase, IEEE Xplore, and ACM Library were searched from their inception to December 23, 2021. Included studies involved patients requiring critical care, both in intensive care units or high-dependency units, or settings that required critical care procedures (eg, intubation and cardiopulmonary resuscitation). Randomized trials and observational studies were included.ResultsA total of 33 studies were included. The greatest application of robots in the intensive care unit was in the field of telepresence, whereby robots proved advantageous in providing a reduced response time, earlier intervention, and lower mortality rates. Challenges of telepresence included regulatory and financial barriers. In therapy and stroke rehabilitation, robots achieved superior clinical outcomes safely. Robotic use in patient evaluation and assessment was mainly through ultrasound evaluation, obtaining satisfactory to superior results with the added benefits of remote assessment, time savings, and increased efficiency. Robots in drug dispensing and delivery increased efficiency and generated cost savings. All the robots had technological limitations and hidden costs.ConclusionsOverall, our results show that robotic use in critical care settings is a beneficial, effective, and well-received intervention that delivers significant benefits to patients, staff, and hospitals. Looking ahead, it is necessary to form strong ethical and legislative frameworks and overcome various regulatory and financial barriers.Trial registrationPROSPERO International Prospective Register of Systematic Reviews CRD42021234162; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=234162.

Project description:BackgroundThe aim of this multicentre prospective observational study was to identify the incidence, patient characteristics, diagnostic pathway, management and outcome of acute mesenteric ischaemia (AMI).MethodsAll adult patients with clinical suspicion of AMI admitted or transferred to 32 participating hospitals from 06.06.2022 to 05.04.2023 were included. Participants who were subsequently shown not to have AMI or had localized intestinal gangrene due to strangulating bowel obstruction had only baseline and outcome data collected.ResultsAMI occurred in 0.038% of adult admissions in participating acute care hospitals worldwide. From a total of 705 included patients, 418 patients had confirmed AMI. In 69% AMI was the primary reason for admission, while in 31% AMI occurred after having been admitted with another diagnosis. Median time from onset of symptoms to hospital admission in patients admitted due to AMI was 24 h (interquartile range 9-48h) and time from admission to diagnosis was 6h (1-12 h). Occlusive arterial AMI was diagnosed in 231 (55.3%), venous in 73 (17.5%), non-occlusive (NOMI) in 55 (13.2%), other type in 11 (2.6%) and the subtype could not be classified in 48 (11.5%) patients. Surgery was the initial management in 242 (58%) patients, of which 59 (24.4%) underwent revascularization. Endovascular revascularization alone was carried out in 54 (13%), conservative treatment in 76 (18%) and palliative care in 46 (11%) patients. From patients with occlusive arterial AMI, revascularization was undertaken in 104 (45%), with 40 (38%) of them in one site admitting selected patients. Overall in-hospital and 90-day mortality of AMI was 49% and 53.3%, respectively, and among subtypes was lowest for venous AMI (13.7% and 16.4%) and highest for NOMI (72.7% and 74.5%). There was a high variability between participating sites for most variables studied.ConclusionsThe overall incidence of AMI and AMI subtypes varies worldwide, and case ascertainment is challenging. Pre-hospital delay in presentation was greater than delays after arriving at hospital. Surgery without revascularization was the most common management approach. Nearly half of the patients with AMI died during their index hospitalization. Together, these findings suggest a need for greater awareness of AMI, and better guidance in diagnosis and management.Trial registrationNCT05218863 (registered 19.01.2022).

Project description:Diagnostic uncertainty is one of the largest contributory factors to the occurrence of diagnostic errors across most specialties in medicine and arguably uncertainty is greatest in primary care due to the undifferentiated symptoms primary care physicians are often presented with. Physicians can respond to diagnostic uncertainty in various ways through the interplay of a series of cognitive, emotional and ethical reactions. The consequences of such uncertainty however can impact negatively upon the primary care practitioner, their patients and the wider healthcare system. Understanding the nature of the existing empirical literature in relation to managing diagnostic uncertainty in primary medical care is a logical and necessary first step in order to understand what solutions are already available and/or to aid the development of any training or feedback aimed at better managing this uncertainty. This review is the first to characterize the existing empirical literature on managing diagnostic uncertainty in primary care.Sixteen databases were systematically searched from inception to present with no restrictions. Hand searches of relevant websites and reference lists of included studies were also conducted. Two authors conducted abstract/article screening and data extraction. PRISMA guidelines were adhered to.Ten studies met the inclusion criteria. A narrative and conceptual synthesis was undertaken under the premises of critical reviews. Results suggest that studies have focused on internal factors (traits, skills and strategies) associated with managing diagnostic uncertainty with only one external intervention identified. Cognitive factors ranged from the influences of epistemological viewpoints to practical approaches such as greater knowledge of the patient, utilizing resources to hand and using appropriate safety netting techniques. Emotional aspects of uncertainty management included clinicians embracing uncertainty and working with provisional diagnoses. Ethical aspects of uncertainty management centered on communicating diagnostic uncertainties with patients. Personality traits and characteristics influenced each of the three domains.There is little empirical evidence on how uncertainty is managed in general practice. However we highlight how the extant literature can be conceptualised into cognitive, emotional and ethical aspects of uncertainty which may help clinicians be more aware of their own biases as well as provide a platform for future research.PROSPERO registration: CRD42015027555.

Project description:ObjectivesTo summarize the literature on prevalence, impact, and contributing factors related to diagnostic error in the PICU.Data sourcesSearch of PubMed, EMBASE, and the Cochrane Library up to December 2019.Study selectionStudies on diagnostic error and the diagnostic process in pediatric critical care were included. Non-English studies with no translation, case reports/series, studies providing no information on diagnostic error, studies focused on non-PICU populations, and studies focused on a single condition/disease or a single diagnostic test/tool were excluded.Data extractionData on research design, objectives, study sample, and results pertaining to the prevalence, impact, and factors associated with diagnostic error were abstracted from each study.Data synthesisUsing independent tiered review, 396 abstracts were screened, and 17 studies (14 full-text, 3 abstracts) were ultimately included. Fifteen of 17 studies (88%) had an observational research design. Autopsy studies (autopsy rates were 20-47%) showed a 10-23% rate of missed major diagnoses; 5-16% of autopsy-discovered diagnostic errors had a potential adverse impact on survival and would have changed management. Retrospective record reviews reported varying rates of diagnostic error from 8% in a general PICU population to 12% among unexpected critical admissions and 21-25% of patients discussed at PICU morbidity and mortality conferences. Cardiovascular, infectious, congenital, and neurologic conditions were most commonly misdiagnosed. Systems factors (40-67%), cognitive factors (20-3%), and both systems and cognitive factors (40%) were associated with diagnostic error. Limited information was available on the impact of misdiagnosis.ConclusionsKnowledge of diagnostic errors in the PICU is limited. Future work to understand diagnostic errors should involve a balanced focus between studying the diagnosis of individual diseases and uncovering common system- and process-related determinants of diagnostic error.

Project description:BackgroundContinuous monitoring of patient vital signs may improve patient outcomes. Head-worn displays (HWDs) can provide hands-free access to continuous vital sign information of patients in critical and acute care contexts and thus may reduce instances of unrecognized patient deterioration.ObjectiveThe purpose of the study is to conduct a systematic review of the literature to evaluate clinical, surrogate, and process outcomes when clinicians use HWDs for continuous patient vital sign monitoring.MethodsThe review was registered with PROSPERO (CRD42019119875) and followed the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. A literature search was conducted for articles published between January 1995 and June 2020 using the following databases: PubMed, Embase, CINAHL, PsycINFO, and Web of Science. Overall, 2 reviewers independently screened titles and abstracts and then assessed the full text of the articles. Original research articles that evaluated the clinical, surrogate, or process outcomes of head-mounted displays for continuous vital sign monitoring in critical care or acute care contexts were included.ResultsOf the 214 records obtained, 15 (7%) articles met the predefined criteria and were included in this review. Of the 15 studies, 7 (47%) took place in a clinical context, whereas the remainder took place in a simulation environment. In 100% (7/7) of the studies that evaluated gaze behavior, changes were found in gaze direction with HWDs. Change detection improvements were found in 67% (2/3) of the studies evaluating changes in the participants' ability to detect changes in vital signs. Of the 10 studies assessing the ease of use of the HWD, most participants of 7 (70%) studies reported that the HWD was easy to use. In all 6 studies in which participants were asked if they would consider using the HWD in their practice, most participants responded positively, but they often suggested improvements on the HWD hardware or display design. Of the 7 studies conducted in clinical contexts, none reported any clinical outcomes.ConclusionsAlthough there is limited and sometimes conflicting evidence about the benefits of HWDs from certain surrogate and process outcomes, evidence for clinical outcomes is lacking. Recommendations are to employ user-centered design when developing HWDs, perform longitudinal studies, and seek clinical outcomes.Trial registrationPROSPERO International Prospective Register of Systematic Reviews CRD42019119875; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=119875.

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Vasoactive agents in acute mesenteric ischaemia in critical care. A systematic review.

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