Quality Evaluation of Guidelines for the Diagnosis and Treatment of Liver Failure

 

by Wang, Xia; Zheng, Meng-Yao; He, Hai-Yu; Zhu, Hui-Ling; Zhao, Ya-Fang; Chen, Yu-Hang; Xu, Zhi-Yuan; Yang, Jin-Hui; Sun, Da-Li 

 

Critical Care Medicine:  June 04, 2024.

 

Objectives: 

This study aimed to systematically assess the methodological quality and key recommendations of the guidelines for the diagnosis and treatment of liver failure (LF), furnishing constructive insights for guideline developers and equipping clinicians with evidence-based information to facilitate informed decision-making.

Data Sources: 

Electronic databases and manual searches from January 2011 to August 2023.

Study Selection: 

Two reviewers independently screened titles and abstracts, then full texts for eligibility. Fourteen guidelines were included.

Data Extraction and Synthesis: 

Two reviewers extracted data and checked by two others. Methodological quality of the guidelines was appraised using the Appraisal of Guidelines for Research and Evaluation II tool. Of the 14 guidelines, only the guidelines established by the Society of Critical Care Medicine and the American College of Gastroenterology (2023) achieved an aggregate quality score exceeding 60%, thereby meriting clinical recommendations. It emerged that there remains ample room for enhancement in the quality of the guidelines, particularly within the domains of stakeholder engagement, rigor, and applicability. Furthermore, an in-depth scrutiny of common recommendations and supporting evidence drawn from the 10 adult LF guidelines unveiled several key issues: controversy exists in the recommendation, the absence of supporting evidence and confusing use of evidence for recommendations, and a preference in evidence selection.

Conclusions: 

There are high differences in methodological quality and recommendations among LF guidelines. Improving these existing problems and controversies will benefit existing clinical practice and will be an effective way for developers to upgrade the guidelines.

 

Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock 2021

Critical Care Medicine: November 2021 - Volume 49 - Issue 11 - p e1063-e1143

Sepsis is life-threatening organ dysfunction caused by a dysregulated host response to infection (1). Sepsis and septic shock are major healthcare problems, impacting millions of people around the world each year and killing between one in three and one in six of those it affects (2–4). Early identification and appropriate management in the initial hours after the development of sepsis improve outcomes.

The recommendations in this document are intended to provide guidance for the clinician caring for adult patients with sepsis or septic shock in the hospital setting. Recommendations from these guidelines cannot replace the clinician’s decision-making capability when presented with a unique patient’s clinical variables. These guidelines are intended to reflect best practice…

Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update

 

Surviving Sepsis Campaign Guidelines on the Management of Adults With Coronavirus Disease 2019 (COVID-19) in the ICU: First Update

Critical Care Medicine: March 2021 - Volume 49 - Issue 3 - p e219-e234

 

BACKGROUND:

 The coronavirus disease 2019 pandemic continues to affect millions worldwide. Given the rapidly growing evidence base, we implemented a living guideline model to provide guidance on the management of patients with severe or critical coronavirus disease 2019 in the ICU.

METHODS:

The Surviving Sepsis Campaign Coronavirus Disease 2019 panel has expanded to include 43 experts from 14 countries; all panel members completed an electronic conflict-of-interest disclosure form. In this update, the panel addressed nine questions relevant to managing severe or critical coronavirus disease 2019 in the ICU. We used the World Health Organization’s definition of severe and critical coronavirus disease 2019. The systematic reviews team searched the literature for relevant evidence, aiming to identify systematic reviews and clinical trials. When appropriate, we performed a random-effects meta-analysis to summarize treatment effects. We assessed the quality of the evidence using the Grading of Recommendations, Assessment, Development, and Evaluation approach, then used the evidence-to-decision framework to generate recommendations based on the balance between benefit and harm, resource and cost implications, equity, and feasibility.

RESULTS:

The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued nine statements (three new and six updated) related to ICU patients with severe or critical coronavirus disease 2019. For severe or critical coronavirus disease 2019, the panel strongly recommends using systemic corticosteroids and venous thromboprophylaxis but strongly recommends against using hydroxychloroquine. In addition, the panel suggests using dexamethasone (compared with other corticosteroids) and suggests against using convalescent plasma and therapeutic anticoagulation outside clinical trials. The Surviving Sepsis Campaign Coronavirus Diease 2019 panel suggests using remdesivir in nonventilated patients with severe coronavirus disease 2019 and suggests against starting remdesivir in patients with critical coronavirus disease 2019 outside clinical trials. Because of insufficient evidence, the panel did not issue a recommendation on the use of awake prone positioning.

CONCLUSION:

The Surviving Sepsis Campaign Coronavirus Diease 2019 panel issued several recommendations to guide healthcare professionals caring for adults with critical or severe coronavirus disease 2019 in the ICU. Based on a living guideline model the recommendations will be updated as new evidence becomes available.

Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation

Facing COVID-19 in the ICU: vascular dysfunction, thrombosis, and dysregulated inflammation

Daniel E. Leisman, Clifford S. Deutschman & Matthieu Legrand 

Intensive Care Medicine (2020)Cite this article Published: 28 April 2020

 Current management guidelines for COVID-19 reflect the assumption that critically ill patients infected with SARS-CoV-2 develop acute respiratory distress syndrome (ARDS). However, emerging data and clinical reports increasingly suggest an alternative view that severe COVID-19 reflects a confluence of vascular dysfunction, thrombosis, and dysregulated inflammation…

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations

Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Cardiovascular, Endocrine, Hematologic, Pulmonary, and Renal Considerations

Critical Care Medicine: March 2020 - Volume 48 - Issue 3 - p e173-e191

Objectives: 

To develop evidence-based recommendations for clinicians caring for adults with acute or acute on chronic liver failure in the ICU.

Design: 

The guideline panel comprised 29 members with expertise in aspects of care of the critically ill patient with liver failure and/or methodology. The Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy were followed throughout. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development.

Setting: 

The panel was divided into nine subgroups: cardiovascular, hematology, pulmonary, renal, endocrine and nutrition, gastrointestinal, infection, perioperative, and neurology.

Interventions: 

We developed and selected population, intervention, comparison, and outcomes questions according to importance to patients and practicing clinicians. For each population, intervention, comparison, and outcomes question, we conducted a systematic review aiming to identify the best available evidence, statistically summarized the evidence whenever applicable, and assessed the quality of evidence using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements.

Measurements and Main Results: 

In this article, we report 29 recommendations (from 30 population, intervention, comparison, and outcomes questions) on the management acute or acute on chronic liver failure in the ICU, related to five groups (cardiovascular, hematology, pulmonary, renal, and endocrine). Overall, six were strong recommendations, 19 were conditional recommendations, four were best-practice statements, and in two instances, the panel did not issue a recommendation due to insufficient evidence.

Conclusions: 

Multidisciplinary international experts were able to formulate evidence-based recommendations for the management acute or acute on chronic liver failure in the ICU, acknowledging that most recommendations were based on low-quality indirect evidence.

The exsecutive summary can be found here: https://journals.lww.com/ccmjournal/Fulltext/2020/03000/Guidelines_for_the_Management_of_Adult_Acute_and.17.aspx

2019 IDSA Guidelines for Community Acquired Pneumonia in Adults: To HCAP, we just say fare thee well

2019 IDSA Guidelines for Community Acquired Pneumonia in Adults: To HCAP, we just say fare thee well

by Jon-Emile S. Kenny 

New guidelines from the American Thoracic Society/Infectious Disease Society of America

Background 

The last American Thoracic Society/Infectious Disease Society of America [ATS/IDSA] guidelines on community acquired pneumonia [CAP] were published in 2007; it seems hard to remember the world at that time – free from the tweeting of medical information, free from the tweeting of world leaders.  Is 2019 better for everyone?  Worse?  For some?

The 2019 inception of the ATS/IDSA guidelines for CAP reserves a more pragmatic approach than its screed-like predecessor – clearly defining 16 high-yield clinical questions and answering them under the direction of the PICO framework.  Critically, the current recommendations make clear that:

“This guideline focuses on patients in the United States who have not recently completed foreign travel…. on adults who do not have an immunocompromising condition, such as inherited or acquired immune deficiency or drug-induced neutropenia, including patients actively receiving cancer chemotherapy, patients infected with HIV with suppressed CD4 counts, and solid organ or bone marrow transplant recipients.”

Accordingly, and as mentioned in the 2016 update on hospital-acquired and ventilator-associated pneumonia, guidelines remain guidelines.  They are not sacrosanct; they needn’t be followed without falter in all patients, always; clinical judgement and individual patient characteristics are also guiding principles.  In my humble opinion, the only deontological imperative is that you are informed and the current IDSA CAP guidelines are an excellent fund of rational, practical information.

Major asthma guideline update: ICS-LABA as-needed replaces albuterol

Major asthma guideline update: ICS-LABA as-needed replaces albuterol

In their first major update in 30 years, newly published asthma guidelines recommend significant changes to the way physicians treat millions of patients diagnosed with asthma. The Global Initiative for Asthma (GINA) now advises that, in general:  Most people with asthma can now be prescribed just one inhaler: an inhaled corticosteroid-and-long-acting beta agonist (ICS-LABA) combination [... read more]

Formal guidelines: management of acute respiratory distress syndrome

Formal guidelines: management of acute respiratory distress syndrome

by Laurent Papazian, Cécile Aubron, Laurent Brochard, Jean-Daniel Chiche, Alain Combes, Didier Dreyfuss, Jean-Marie Forel, Claude Guérin, Samir Jaber, Armand Mekontso-Dessap, Alain Mercat, Jean-Christophe Richard, Damien Roux, Antoine Vieillard-Baron and Henri Faure

Abstract

Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −); four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven (surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious effect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure, early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were approved by the experts with strong agreement.

Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients

Improved Guideline Adherence and Reduced Brain Dysfunction After a Multicenter Multifaceted Implementation of ICU Delirium Guidelines in 3,930 Patients

by Trogrlic, Zoran; van der Jagt, Mathieu; Lingsma, Hester; Gommers, Diederik; Ponssen, Huibert H.; Schoonderbeek, Jeannette F. J.; Schreiner, Frodo; Verbrugge, Serge J.; Duran, Servet; Bakker, Jan; Ista, Erwin  

Critical Care Medicine: March 2019 - Volume 47 - Issue 3 - p 419–427

Objectives: Implementation of delirium guidelines at ICUs is suboptimal. The aim was to evaluate the impact of a tailored multifaceted implementation program of ICU delirium guidelines on processes of care and clinical outcomes and draw lessons regarding guideline implementation. Design: A prospective multicenter, pre-post, intervention study.

Setting: ICUs in one university hospital and five community hospitals.

Patients: Consecutive medical and surgical critically ill patients were enrolled between April 1, 2012, and February 1, 2015. Interventions: Multifaceted, three-phase (baseline, delirium screening, and guideline) implementation program of delirium guidelines in adult ICUs. Measurements and Main Results: The primary outcome was adherence changes to delirium guidelines recommendations, based on the Pain, Agitation and Delirium guidelines. Secondary outcomes were brain dysfunction (delirium or coma), length of ICU stay, and hospital mortality. A total of 3,930 patients were included. Improvements after the implementation pertained to delirium screening (from 35% to 96%; p < 0.001), use of benzodiazepines for continuous sedation (from 36% to 17%; p < 0.001), light sedation of ventilated patients (from 55% to 61%; p < 0.001), physiotherapy (from 21% to 48%; p < 0.001), and early mobilization (from 10% to 19%; p < 0.001). Brain dysfunction improved: the mean delirium duration decreased from 5.6 to 3.3 days (–2.2 d; 95% CI, –3.2 to –1.3; p < 0.001), and coma days decreased from 14% to 9% (risk ratio, 0.5; 95% CI, 0.4–0.6; p < 0.001). Other clinical outcome measures, such as length of mechanical ventilation, length of ICU stay, and hospital mortality, did not change.

Conclusions: This large pre-post implementation study of delirium-oriented measures based on the 2013 Pain, Agitation, and Delirium guidelines showed improved health professionals’ adherence to delirium guidelines and reduced brain dysfunction. Our findings provide empirical support for the differential efficacy of the guideline bundle elements in a real-life setting and provide lessons for optimization of guideline implementation programs.