Critical Care Bulletin - Oct 2022

 

Renaissance of glucocorticoids in critical care in the era of COVID-19: ten urging questions

 

by Martin S. Winkler, Marcin F. Osuchowski, Didier Payen, Antoni Torres, Steffen Dickel and Tomasz Skirecki 

 

Critical Care volume 26, Article number: 308 (2022) 

 

The 40-year-old experience with glucocorticosteroids (GCs) in the context of severe infections is complex and troublesome. Recently, however, a clear indication for GCs in severe COVID-19 has been established. This may constitute a harbinger of a wider use of GCs in critical illnesses. A fundamental prerequisite of such an action is a better understanding of the heterogeneity of critical illness and GCs operationalization within the precision medicine approach. In this perspective, we formulate ten major questions regarding the use of GCs in critical illness. Answering them will likely facilitate a new era of effective and personalized GCs use in modern critical care.

 

Association between in-ICU red blood cells transfusion and 1-year mortality in ICU survivors

by Alice Blet, Joel B. McNeil, Julie Josse, Bernard Cholley, Raphaël Cinotti, Gad Cotter, Agnès Dauvergne, Beth Davison, Kévin Duarte, Jacques Duranteau, Marie-Céline Fournier, Etienne Gayat, Samir Jaber, Sigismond Lasocki, Thomas Merkling, Katell Peoc’h… 

 

Critical Care volume 26, Article number: 307 (2022) 

 

Background

Impact of in-ICU transfusion on long-term outcomes remains unknown. The purpose of this study was to assess in critical-care survivors the association between in-ICU red blood cells transfusion and 1-year mortality.

Methods

FROG-ICU, a multicenter European study enrolling all-comers critical care patients was analyzed (n = 1551). Association between red blood cells transfusion administered in intensive care unit and 1-year mortality in critical care survivors was analyzed using an augmented inverse probability of treatment weighting-augmented inverse probability of censoring weighting method to control confounders.

Results

Among the 1551 ICU-survivors, 42% received at least one unit of red blood cells while in intensive care unit. Patients in the transfusion group had greater severity scores than those in the no-transfusion group. According to unweighted analysis, 1-year post-critical care mortality was greater in the transfusion group compared to the no-transfusion group (hazard ratio (HR) 1.78, 95% CI 1.45–2.16). Weighted analyses including 40 confounders, showed that transfusion remained associated with a higher risk of long-term mortality (HR 1.21, 95% CI 1.06–1.46).

Conclusions

Our results suggest a high incidence of in-ICU RBC transfusion and that in-ICU transfusion is associated with a higher 1-year mortality among in-ICU survivors.

 

Optimized diagnosis-based comorbidity measures for all-cause mortality prediction in a national population-based ICU population

 

by Anna Aronsson Dannewitz, Bodil Svennblad, Karl Michaëlsson, Miklos Lipcsey and Rolf Gedeborg 

 

Critical Care volume 26, Article number: 306 (2022)

Background

We aimed to optimize prediction of long-term all-cause mortality of intensive care unit (ICU) patients, using quantitative register-based comorbidity information assessed from hospital discharge diagnoses prior to intensive care treatment.

Material and methods

Adult ICU admissions during 2006 to 2012 in the Swedish intensive care register were followed for at least 4 years. The performance of quantitative comorbidity measures based on the 5-year history of number of hospital admissions, length of stay, and time since latest admission in 36 comorbidity categories was compared in time-to-event analyses with the Charlson comorbidity index (CCI) and the Simplified Acute Physiology Score (SAPS3).

Results

During a 7-year period, there were 230,056 ICU admissions and 62,225 deaths among 188,965 unique individuals. The time interval from the most recent hospital stays and total length of stay within each comorbidity category optimized mortality prediction and provided clear separation of risk categories also within strata of age and CCI, with hazard ratios (HRs) comparing lowest to highest quartile ranging from 1.17 (95% CI: 0.52–2.64) to 6.41 (95% CI: 5.19–7.92). Risk separation was also observed within SAPS deciles with HR ranging from 1.07 (95% CI: 0.83–1.38) to 3.58 (95% CI: 2.12–6.03).

Conclusion

Baseline comorbidity measures that included the time interval from the most recent hospital stay in 36 different comorbidity categories substantially improved long-term mortality prediction after ICU admission compared to the Charlson index and the SAPS score.

 

 

Prophylactic Postoperative Noninvasive Ventilation in Adults Undergoing Upper Abdominal Surgery: A Systematic Review and Meta-Analysis

 

by Lockstone, Jane; Denehy, Linda; Truong, Dominic; Whish-Wilson, Georgina A.; Boden, Ianthe; Abo, Shaza; Parry, Selina M. 

 

Critical Care Medicine: October 2022 - Volume 50 - Issue 10 - p 1522-1532

 

OBJECTIVES: 

Postoperative pulmonary complications (PPCs) are a leading cause of morbidity and mortality following upper abdominal surgery. Applying either noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) in the early postoperative period is suggested to prevent PPC. We aimed to assess whether postoperative NIV or CPAP or both prevent PPCs compared with standard care in adults undergoing upper abdominal surgery, including in those identified at higher PPC risk. Additionally, the different interventions used were evaluated to assess whether there is a superior approach.

DATA SOURCES: 

We searched PubMed, Embase‚ CINAHL, CENTRAL, and Scopus from inception to May 17, 2021.

STUDY SELECTION: 

We performed a systematic search of the literature for randomized controlled trials evaluating prophylactic NIV and/or CPAP in the postoperative period.

DATA EXTRACTION: 

Two authors independently performed study selection and data extraction. Individual study risk of bias was assessed using the PEDro scale, and certainty in outcomes was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework.

DATA SYNTHESIS: 

We included 17 studies enrolling 6,108 patients. No significant benefit was demonstrated for postoperative NIV/CPAP to reduce PPC (risk ratio [RR], 0.89; 95% CI, 0.78–1.01; very low certainty), including in adults identified at higher PPC risk (RR, 0.91; 95% CI, 0.77–1.07; very low certainty). No intervention approach was identified as superior, and no significant benefit was demonstrated when comparing: 1) CPAP (RR, 0.90; 95% CI, 0.79–1.04; very low certainty), 2) NIV (RR, 0.68; 95% CI, 0.41–1.13; very low certainty), 3) continuous NIV/CPAP (RR, 0.90; 95% CI, 0.77–1.05; very low certainty), or 4) intermittent NIV/CPAP (RR, 0.66; 95% CI, 0.39–1.10; very low certainty) to standard care.

CONCLUSIONS: 

These findings suggest routine provision of either prophylactic NIV or CPAP following upper abdominal surgery may not be effective to reduce PPCs‚ including in those identified at higher risk.

 

 

 

Extracorporeal membrane oxygenation for cardiogenic shock: a meta-analysis of mortality and complications

 

By Sasa Rajsic, Benedikt Treml, Dragana Jadzic, Robert Breitkopf, Christoph Oberleitner, Marina Popovic Krneta and Zoran Bukumiric 

 

Annals of Intensive Care volume 12, Article number: 93 (2022) 

 

Background

Venoarterial extracorporeal membrane oxygenation (va-ECMO) is an advanced life support for critically ill patients with refractory cardiogenic shock. This temporary support bridges time for recovery, permanent assist, or transplantation in patients with high risk of mortality. However, the benefit of this modality is still subject of discussion and despite the continuous development of critical care medicine, severe cardiogenic shock remains associated with high mortality. Therefore, this work aims to analyze the current literature regarding in-hospital mortality and complication rates of va-ECMO in patients with cardiogenic shock.

Methods

We conducted a systematic review and meta-analysis of the most recent literature to analyze the outcomes of va-ECMO support. Using the PRISMA guidelines, Medline (PubMed) and Scopus (Elsevier) databases were systematically searched up to May 2022. Meta-analytic pooled estimation of publications variables was performed using a weighted random effects model for study size.

Results

Thirty-two studies comprising 12756 patients were included in the final analysis. Between 1994 and 2019, 62% (pooled estimate, 8493/12756) of patients died in the hospital. More than one-third of patients died during ECMO support. The most frequent complications were renal failure (51%, 693/1351) with the need for renal replacement therapy (44%, 4879/11186) and bleeding (49%, 1971/4523), bearing the potential for permanent injury or death. Univariate meta-regression analyses identified age over 60 years, shorter ECMO duration and presence of infection as variables associated with in-hospital mortality, while the studies reporting a higher incidence of cannulation site bleeding were unexpectedly associated with a reduced in-hospital mortality.

Conclusions

Extracorporeal membrane oxygenation is an invasive life support with a high risk of complications. We identified a pooled in-hospital mortality of 62% with patient age, infection and ECMO support duration being associated with a higher mortality. Protocols and techniques must be developed to reduce the rate of adverse events. Finally, randomized trials are necessary to demonstrate the effectiveness of va-ECMO in cardiogenic shock.

 

Doppler study of portal vein and renal venous velocity predict the appropriate fluid response to diuretic in ICU: a prospective observational echocardiographic evaluation

 

by Pierre-Grégoire Guinot, Pierre-Alain Bahr, Stefan Andrei, Bogdan A. Popescu, Vincenza Caruso, Paul-Michel Mertes, Vivien Berthoud, Maxime Nguyen and Belaid Bouhemad 

 

Critical Care volume 26, Article number: 305 (2022) 

 

Background

Fluid overload and venous congestion are associated with morbi-mortality in the ICU (intensive care unit). Administration of diuretics to correct the fluid balance is common, although there is no strong relationship between the consequent fluid loss and clinical improvement. The aim of the study was to evaluate the ability of the portal pulsatility index, the renal venous impedance index, and the VEXUS score (venous ultrasound congestion score) to predict appropriate diuretic-induced fluid depletion.

Methods

The study had a prospective, observational, single-center observational design and was conducted in a university-affiliated medico-surgical ICU. Adult patients for whom the clinician decided to introduce loop diuretic treatment were included. Hemodynamic and ultrasound measurements (including the portal pulsatility index, renal venous impedance index and VEXUS score) were performed at inclusion and 2 hours after the initiation of the diuretics. The patients’ characteristics were noted at inclusion, 24 h later, and at ICU discharge. The appropriate diuretic-induced fluid depletion was defined by a congestive score lower than 3 after diuretic fluid depletion. The congestive score included clinical and biological parameters of congestion.

Results

Eighty-one patients were included, and 43 (53%) patients presented with clinically significant congestion score at inclusion. Thirty-four patients (42%) had an appropriate response to diuretic-induced fluid depletion. None of the left- and right-sided echocardiographic parameters differed between the two groups. The baseline portal pulsatility index was the best predictor of appropriate response to diuretic-induced fluid depletion (AUC = 0.80, CI95%:0.70–0.92, p = 0.001), followed by the renal venous impedance index (AUC = 0.72, CI95% 0.61–0.84, p = 0.001). The baseline VEXUS score (AUC of 0.66 CI95% 0.53–0.79, p = 0.012) was poorly predictive of appropriate response to diuretic-induced fluid depletion.

Conclusion

The portal pulsatility index and the renal venous impedance index were predictive of the appropriate response to diuretic-induced fluid depletion in ICU patients. The portal pulsatility index should be evaluated in future randomized studies.

 

 

 

 

Right ventricular strain measurements in critically ill patients: an observational SICS sub-study

 

by Madelon E. Vos, Eline G. M. Cox, Maaike R. Schagen, Bart Hiemstra, Adrian Wong, Jacqueline Koeze, Iwan C. C. van der Horst and Renske Wiersema 

 

Annals of Intensive Care volume 12, Article number: 92 (2022) 

 

Background

Right ventricular (RV) dysfunction is common in critically ill patients and is associated with poor outcomes. RV function is usually evaluated by Tricuspid Annular Plane Systolic Excursion (TAPSE) which can be obtained using critical care echocardiography (CCE). Myocardial deformation imaging, measuring strain, is suitable for advanced RV function assessment and has widely been studied in cardiology. However, it is relatively new for the Intensive Care Unit (ICU) and little is known about RV strain in critically ill patients. Therefore, the objectives of this study were to evaluate the feasibility of RV strain in critically ill patients using tissue-Doppler imaging (TDI) and explore the association between RV strain and conventional CCE measurements representing RV function.

Methods

This is a single-center sub-study of two prospective observational cohorts (Simple Intensive Care Studies (SICS)-I and SICS-II). All acutely admitted adults with an expected ICU stay over 24 h were included. CCE was performed within 24 h of ICU admission. In patients in which CCE was performed, TAPSE, peak systolic velocity at the tricuspid annulus (RV s’) and TDI images were obtained. RV free wall longitudinal strain (RVFWSL) and RV global four-chamber longitudinal strain (RV4CSL) were measured during offline analysis.

Results

A total of 171 patients were included. Feasibility of RVFWSL and RV4CSL was, respectively, 62% and 56% in our population; however, when measurements were performed, intra- and inter-rater reliability based on the intraclass correlation coefficient were good to excellent. RV dysfunction based on TAPSE or RV s’ was found in 56 patients (33%) and 24 patients (14%) had RV dysfunction based on RVFWSL or RV4CSL. In 14 patients (8%), RVFWSL, RV4CSL, or both were reduced, despite conventional RV function measurements being preserved. These patients had significantly higher severity of illness scores. Sensitivity analysis with fractional area change showed similar results.

Conclusions

TDI RV strain imaging in critically ill patients is challenging; however, good-to-excellent reproducibility was shown when measurements were adequately obtained. Future studies are needed to elucidate the diagnostic and prognostic value of RV strain in critically ill patients, especially to outweigh the difficulty and effort of imaging against the clinical value.

 

Evaluation of inhaled nitric oxide (iNO) treatment for moderate-to-severe ARDS in critically ill patients with COVID-19: a multicenter cohort study

 

by Khalid Al Sulaiman, Ghazwa B. Korayem, Ali F. Altebainawi, Shmeylan Al Harbi, Abdulrahman Alissa, Abdullah Alharthi, Raed Kensara, Amjaad Alfahed, Ramesh Vishwakarma, Hussain Al Haji, Naif Almohaimid, Omar Al Zumai, Fahad Alrubayan, Abdulmajid Asiri, Nasser Alkahtani, Abdulaziz Alolayan… 

 

Critical Care volume 26, Article number: 304 (2022) 

 

Background

Inhaled nitric oxide (iNO) is used as rescue therapy in patients with refractory hypoxemia due to severe COVID-19 acute respiratory distress syndrome (ARDS) despite the recommendation against the use of this treatment. To date, the effect of iNO on the clinical outcomes of critically ill COVID-19 patients with moderate-to-severe ARDS remains arguable. Therefore, this study aimed to evaluate the use of iNO in critically ill COVID-19 patients with moderate-to-severe ARDS.

Methods

This multicenter, retrospective cohort study included critically ill adult patients with confirmed COVID-19 treated from March 01, 2020, until July 31, 2021. Eligible patients with moderate-to-severe ARDS were subsequently categorized into two groups based on inhaled nitric oxide (iNO) use throughout their ICU stay. The primary endpoint was the improvement in oxygenation parameters 24 h after iNO use. Other outcomes were considered secondary. Propensity score matching (1:2) was used based on the predefined criteria.

Results

A total of 1598 patients were screened, and 815 were included based on the eligibility criteria. Among them, 210 patients were matched based on predefined criteria. Oxygenation parameters (PaO2, FiO2 requirement, P/F ratio, oxygenation index) were significantly improved 24 h after iNO administration within a median of six days of ICU admission. However, the risk of 30-day and in-hospital mortality were found to be similar between the two groups (HR: 1.18; 95% CI: 0.77, 1.82; p = 0.45 and HR: 1.40; 95% CI: 0.94, 2.11; p= 0.10, respectively). On the other hand, ventilator-free days (VFDs) were significantly fewer, and  ICU and hospital LOS were significantly longer in the iNO group. In addition, patients who received iNO had higher odds of acute kidney injury (AKI) (OR (95% CI): 2.35 (1.30, 4.26), p value = 0.005) and hospital/ventilator-acquired pneumonia (OR (95% CI): 3.2 (1.76, 5.83), p value = 0.001).

Conclusion

In critically ill COVID-19 patients with moderate-to-severe ARDS, iNO rescue therapy is associated with improved oxygenation parameters but no mortality benefits. Moreover, iNO use is associated with higher odds of AKI, pneumonia, longer LOS, and fewer VFDs.

 

 

 

Trends in mortality in septic patients according to the different organ failure during 15 years

 

by Carolina Lorencio Cárdenas, Juan Carlos Yébenes, Emili Vela, Montserrat Clèries, Josep Mª Sirvent, Cristina Fuster-Bertolín, Clara Reina, Alejandro Rodríguez, Juan Carlos Ruiz-Rodríguez, Josep Trenado and Elisabeth Esteban Torné 

 

Critical Care volume 26, Article number: 302 (2022) 

Background

The incidence of sepsis can be estimated between 250 and 500 cases/100.000 people per year and is responsible for up to 6% of total hospital admissions. Identified as one of the most relevant global health problems, sepsis is the condition that generates the highest costs in the healthcare system. Important changes in the management of septic patients have been included in recent years; however, there is no information about how changes in the management of sepsis-associated organ failure have contributed to reduce mortality.

Methods

A retrospective analysis was conducted from hospital discharge records from the Minimum Basic Data Set Acute-Care Hospitals (CMBD-HA in Catalan language) for the Catalan Health System (CatSalut). CMBD-HA is a mandatory population-based register of admissions to all public and private acute-care hospitals in Catalonia. Sepsis was defined by the presence of infection and at least one organ dysfunction. Patients hospitalized with sepsis were detected, according ICD-9-CM (since 2005 to 2017) and ICD-10-CM (2018 and 2019) codes used to identify acute organ dysfunction and infectious processes.

Results

Of 11.916.974 discharges from all acute-care hospitals during the study period (2005–2019), 296.554 had sepsis (2.49%). The mean annual sepsis incidence in the population was 264.1 per 100.000 inhabitants/year, and it increased every year, going from 144.5 in 2005 to 410.1 in 2019. Multiorgan failure was present in 21.9% and bacteremia in 26.3% of cases. Renal was the most frequent organ failure (56.8%), followed by cardiovascular (24.2%). Hospital mortality during the study period was 19.5%, but decreases continuously from 25.7% in 2005 to 17.9% in 2019 (p < 0.0001). The most important reduction in mortality was observed in cases with cardiovascular failure (from 47.3% in 2005 to 31.2% in 2019) (p < 0.0001). In the same way, mean mortality related to renal and respiratory failure in sepsis was decreased in last years (p < 0.0001).

Conclusions

The incidence of sepsis has been increasing in recent years in our country. However, hospital mortality has been significantly reduced. In septic patients, all organ failures except liver have shown a statistically significant reduction on associated mortality, with cardiovascular failure as the most relevant.

 

Comparison of ultrasound-guided internal jugular vein and supraclavicular subclavian vein catheterization in critically ill patients: a prospective, randomized clinical trial

 

by Becem Trabelsi, Zied Hajjej, Dhouha Drira, Azza Yedes, Iheb Labbene, Mustapha Ferjani and Mechaal Ben Ali 

 

Annals of Intensive Care volume 12, Article number: 91 (2022) 

 

Background

The aim of this study was to compare the effectiveness and safety of ultrasound-guided out-of-plane internal jugular vein (OOP-IJV) and in-plane supraclavicular subclavian vein (IP-SSCV) catheterization in adult intensive care unit.

Methods

A total of 250 consecutive patients requiring central venous catheterization, were randomly assigned to undergo either ultrasound-guided OOP-IJV or IP-SSCV cannulation. All catheterizations were carried out by three physicians. The primary outcome was the first attempt success rate. Ultrasound scanning time, venous puncture time, insertion time, overall access time, number of puncture attempts, number of needle redirections, success rate, guidewire advancing difficulties, venous collapse and adverse events were also documented.

Results

The first attempt success rate was significantly higher in IP-SSCV group (83.2%) compared to OOP-IJV group (63.2%) (p = 0.001). The IP-SSCV group was associated with a longer ultrasound scanning time (16.54 ± 13.51 vs. 5.26 ± 4.05 s; p < 0.001) and a shorter insertion time (43.98 ± 26.77 vs. 53.12 ± 40.21 s; p = 0.038). In the IP-SCCV group, we recorded a fewer number of puncture attempts (1.16 ± 0.39 vs. 1.47 ± 0.71; p < 0.001), needle redirections (0.69 ± 0.58 vs. 1.17 ± 0.95; p < 0.001), difficulties in guidewire advancement (2.4% vs. 27.4%; p < 0.001), venous collapse (2.4%, vs. 18.4%; p < 0.001) and adverse events (8.8% vs. 13.6%; p = 0.22).

Conclusions

The IP-SSCV approach is an effective and a safe alternative to the classic OOP-IJV catheterization in critical adult patients.

 

 

 

Early administration of hydrocortisone, vitamin C, and thiamine in adult patients with septic shock: a randomized controlled clinical trial

 

by Qing-Quan Lyu, Rui-Qiang Zheng, Qi-Hong Chen, Jiang-Quan Yu, Jun Shao and Xiao-Hua Gu 

 

Critical Care volume 26, Article number: 295 (2022) 

 

Background

The combination therapy of hydrocortisone, vitamin C, and thiamine has been proposed as a potential treatment in patients with sepsis and septic shock. However, subsequent trials have reported conflicting results in relation to survival outcomes. Hence, we performed this randomized controlled trial (RCT) to evaluate the efficacy and safety of early combination therapy among adult patients with septic shock.

Methods

This single-center, double-blind RCT enrolled adult patients with diagnosis of septic shock within 12 h from Northern Jiangsu People's Hospital between February 2019 and June 2021. Recruited patients were randomized 1:1 to receive intervention (hydrocortisone 200 mg daily, vitamin C 2 g every 6 h, and thiamine 200 mg every 12 h) or placebo (0.9% saline) for 5 days or until ICU discharge. The primary endpoint was 90-day mortality. The secondary endpoints included mortality at day 28, ICU discharge, and hospital discharge; shock reversal; 72-h Delta SOFA score; ICU-free days, vasopressor-free days, and ventilator support -free days up to day 28; ICU length of stay (LOS) and hospital LOS.

Results

Among 426 patients randomized, a total of 408 patients with septic shock were included in the per-protocol (PP) analysis, of which 203 were assigned to the intervention group and 205 to the placebo group. In the PP population, the primary outcome of 90-day mortality was 39.9% (81/203) and 39.0% (80/205) in the intervention and the placebo groups, respectively, and was not significantly different (P = 0.86). There was no significant difference between two groups in 28-day mortality (36.5% vs. 36.1%, P = 0.94) or the ICU mortality (31.5% vs. 28.8%, P = 0.55) and hospital mortality (34.5% vs. 33.2%, P = 0.78). No other secondary outcomes showed significant differences between two groups, including shock reversal, vasopressor-free days, and ICU LOS. Intention-to-treat analysis included all the 426 patients and confirmed these results (all P > 0.05).

Conclusion

Among adult patients with septic shock, early use of hydrocortisone, vitamin C, and thiamine combination therapy compared with placebo did not confer survival benefits.

 

 

Effectiveness of Continuous Cuff Pressure Control in Preventing Ventilator-Associated Pneumonia: A Systematic Review and Meta-Analysis of Randomized Controlled Trials*

 

by Maertens, Bert; Lin, Frances; Chen, Yingyan; Rello, Jordi; Lathyris, Dimitrios; Blot, Stijn

 

Critical Care Medicine: October 2022 - Volume 50 - Issue 10 - p 1430-1439

 

OBJECTIVES: 

Microaspiration of subglottic secretions is the main pathogenic mechanism for ventilator-associated pneumonia (VAP). Adequate inflation of the endotracheal cuff is pivotal to providing an optimal seal of the extraluminal airway. However, cuff pressure substantially fluctuates due to patient or tube movements, which can induce microaspiration. Therefore, devices for continuous cuff pressure control (CCPC) have been developed in recent years. The purpose of this systematic review and meta-analysis is to assess the effectiveness of CCPC in VAP prevention.

DATA SOURCES: 

A systematic search of Embase, the Cochrane Central Register of Controlled Trials, and the International Clinical Trials Registry Platform was conducted up to February 2022.

STUDY SELECTION: 

Eligible studies were randomized controlled trials (RCTs) and quasi-RCTs comparing the impact of CCPC versus intermittent cuff pressure control on the occurrence of VAP.

DATA EXTRACTION: 

Random-effects meta-analysis was used to calculate odds ratio (OR) and 95% CI for VAP incidence between groups. Secondary outcome measures included mortality and duration of mechanical ventilation (MV) and ICU stay. The certainty of the evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach.

DATA SYNTHESIS: 

Eleven RCTs with 2,092 adult intubated patients were included. The use of CCPC was associated with a reduced risk of VAP (OR, 0.51). Meta-analyses of secondary endpoints showed no significant difference in mortality but significant differences in durations of MV (mean difference, –1.07 d) and ICU stay (mean difference, –3.41 d) in favor of CCPC. However, the risk of both reporting and individual study bias was considered important. The main issues were the lack of blinding, potential commercial conflicts of interest of study authors and high heterogeneity due to methodological differences between studies, differences in devices used for CCPC and in applied baseline preventive measures. Certainty of the evidence was considered “very low.”

CONCLUSIONS: 

The use of CCPC was associated with a reduction in VAP incidence; however, this was based on very low certainty of evidence due to concerns related to risk of bias and inconsistency.