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Buitinck SH, Koopmans M, Determann RM, Jansen RR, van der Voort PHJ. Enteral Vancomycin to Eliminate MRSA Carriership of the Digestive Tract in Critically Ill Patients. Antibiotics (Basel) 2022; 11:antibiotics11020263. [PMID: 35203865 PMCID: PMC8868137 DOI: 10.3390/antibiotics11020263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 02/13/2022] [Accepted: 02/16/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Carriership with methicillin resistant Staphylococcus aureus (MRSA) is a risk for the development of secondary infections in critically ill patients. Previous studies suggest that enteral vancomycin is able to eliminate enteral carriership with MRSA. Data on individual effects of this treatment are lacking. Methods: Retrospective analysis of a database containing 15 year data of consecutive patients from a mixed medical-(cardio)surgical 18 bedded intensive care unit was conducted. All consecutive critically ill patients with enteral MRSA carriership detected in throat and/or rectal samples were collected. We analyzed those with follow-up cultures to determine the success rate of enteral vancomycin. Topical application of 2% vancomycin in a sticky oral paste was performed combined with a vancomycin solution of 500 mg four times daily in the nasogastric tube. This treatment was added to a regimen of selective digestive tract decontamination (SDD) to prevent ICU acquired infection. Results: Thirteen patients were included. The mean age was 65 years and the median APACHE II score was 21. MRSA was present in the throat in 8 patients and in both throat and rectum in 5 patients. In all patients MRSA was successfully eliminated from both throat and rectum, which took 2–11 days with a median duration until decontamination of 4 days. Secondary infections with MRSA did not occur. Conclusions: Topical treatment with vancomycin in a 2% sticky oral paste four times daily in the nasogastric tube was effective in all patients in the elimination of MRSA and prevented secondary MRSA infections.
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Affiliation(s)
- Sophie H. Buitinck
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands; (S.H.B.); (M.K.); (R.M.D.)
| | - Matty Koopmans
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands; (S.H.B.); (M.K.); (R.M.D.)
| | - Rogier M. Determann
- Department of Intensive Care, OLVG Hospital, P.O. Box 95500, 1090 HM Amsterdam, The Netherlands; (S.H.B.); (M.K.); (R.M.D.)
| | - Rogier R. Jansen
- Department of Medical Microbiology, OLVG Hospital, Oosterpark 9, 1091 AC Amsterdam, The Netherlands;
| | - Peter H. J. van der Voort
- Department of Critical Care Medicine, University Medical Center Groningen, University of Groningen, P.O. Box 30001, 9700 RB Groningen, The Netherlands
- Correspondence: ; Tel.: +31-50-3610874
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Silvestri L, van Saene HKF, Sarginson RE, Gullo A. Selective Decontamination of the Digestive Tract and Ventilator-Associated Pneumonia: We Cannot Let Misinformation Go Uncorrected. J Intensive Care Med 2016; 22:181-2; author reply 183. [PMID: 17562740 DOI: 10.1177/0885066607299773] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Hurley JC. Topical antibiotics as a major contextual hazard toward bacteremia within selective digestive decontamination studies: a meta-analysis. BMC Infect Dis 2014; 14:714. [PMID: 25551776 PMCID: PMC4300056 DOI: 10.1186/s12879-014-0714-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Accepted: 12/11/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Among methods for preventing pneumonia and possibly also bacteremia in intensive care unit (ICU) patients, Selective Digestive Decontamination (SDD) appears most effective within randomized concurrent controlled trials (RCCT's) although more recent trials have been cluster randomized. However, of the SDD components, whether protocolized parenteral antibiotic prophylaxis (PPAP) is required, and whether the topical antibiotic actually presents a contextual hazard, remain unresolved. The objective here is to compare the bacteremia rates and patterns of isolates in SDD-RCCT's versus the broader evidence base. METHODS Bacteremia incidence proportion data were extracted from component (control and intervention) groups decanted from studies investigating antibiotic (SDD) or non-antibiotic methods of VAP prevention and summarized using random effects meta-analysis of study and group level data. A reference category of groups derived from purely observational studies without any prevention method under study provided a benchmark incidence. RESULTS Within SDD RCCTs, the mean bacteremia incidence among concurrent component groups not exposed to PPAP (27 control; 17.1%; 13.1-22.1% and 12 intervention groups; 16.2%; 9.1-27.3%) is double that of the benchmark bacteremia incidence derived from 39 benchmark groups (8.3; 6.8-10.2%) and also 20 control groups from studies of non-antibiotic methods (7.1%; 4.8 - 10.5). There is a selective increase in coagulase negative staphylococci (CNS) but not in Pseudomonas aeruginosa among bacteremia isolates within control groups of SDD-RCCT's versus benchmark groups with data available. CONCLUSIONS The topical antibiotic component of SDD presents a major contextual hazard toward bacteremia against which the PPAP component partially mitigates.
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Zandstra D, Abecasis F, Taylor N, Damjanovic V, Silvestri L, van Saene HKF. For control of colonisation with extended-spectrum β-lactamase-producing bacteria, SDD does work. Intensive Care Med 2013; 39:539. [PMID: 23287872 DOI: 10.1007/s00134-012-2780-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/09/2012] [Indexed: 10/27/2022]
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Petros A, Silvestri L, Booth R, Taylor N, van Saene H. Selective decontamination of the digestive tract in critically ill children: systematic review and meta-analysis. Pediatr Crit Care Med 2013; 14:89-97. [PMID: 22805154 DOI: 10.1097/PCC.0b013e3182417871] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We examined the impact of selective decontamination of the digestive tract on morbidity and mortality in critically ill children. DATA SOURCES We searched MEDLINE, EMBASE, the Cochrane Register of Controlled Trials, and previous meta-analyses. STUDY SELECTION We included all randomized controlled trials comparing administration of enteral antimicrobials in selective decontamination of the digestive tract with or without a parenteral component with placebo or standard therapy used in the controls. DATA EXTRACTION The primary end point was the number of acquired pneumonias. Secondary end points were number of infections and overall mortality. Odds ratios were pooled with the random effect model. DATA SYNTHESIS Four randomized controlled trials including 335 patients were identified. Pneumonia was diagnosed in five of 170 patients (2.9%) for selective decontamination of the digestive tract and 16 of 165 patients (9.7%) for controls (odds ratio 0.31; 95% confidence interval 0.11-0.87; p = .027). Overall mortality for selective decontamination of the digestive tract was 13 of 170 (7.6%) vs. control, 11 of 165 (6.7%) (odds ratio 1.18; 95% confidence interval 0.50-2.76; p = .70). In three studies (n = 109), infection occurred in ten of 54 (18.5%) patients on selective decontamination of the digestive tract and 24 of 55 (43.6%) in the controls (odds ratio 0.34; 95% confidence interval 0.05-2.18; p = .25). CONCLUSIONS In the four available pediatric randomized controlled trials, selective decontamination of the digestive tract significantly reduced the number of children who developed pneumonia.
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Abstract
INTRODUCTION Selective decontamination of the digestive tract (SDD) has been proposed to prevent endogenous and exogenous infections and to reduce mortality in critically ill patients. Although the efficacy of SDD has been confirmed by randomized controlled trials (RCTs) and systematic reviews, SDD has been the subject of intense controversy, based mainly on an insufficient evidence of efficacy and on concerns about resistance. AREAS COVERED This article reviews the philosophy, the current evidence on the efficacy of SDD and the issue of emergence of resistance. All SDD RCTs were searched using Embase and Medline, with no restriction of language, gender or age. Personal archives were also explored, including abstracts from major scientific meetings; references in papers and published meta-analyses on SDD were crosschecked. Up-to-date evidence of the impact of SDD on carriage, infections and mortality is presented, and the efficacy of SDD in selected patient groups was investigated, along with the problem of the emergence of resistance. EXPERT OPINION SDD significantly reduces the number of infections of the lower respiratory tract and bloodstream, multiple organ failure and mortality. It also controls resistance, particularly when the full protocol of parenteral and enteral antimicrobials is used.
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Affiliation(s)
- Luciano Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Via Fatebenefratelli 34, 34170 Gorizia, Italy.
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Ochoa-ardila ME, García-cañas A, Gómez-mediavilla K, González-torralba A, Alía I, García-hierro P, Taylor N, van Saene HKF, de la Cal MA. Long-term use of selective decontamination of the digestive tract does not increase antibiotic resistance: a 5-year prospective cohort study. Intensive Care Med 2011; 37. [DOI: 10.1007/s00134-011-2307-0] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2010] [Accepted: 06/27/2011] [Indexed: 10/18/2022]
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Abecasis F, Sarginson RE, Kerr S, Taylor N, van Saene HK. Is Selective Digestive Decontamination Useful in Controlling Aerobic Gram-Negative Bacilli Producing Extended Spectrum Beta-Lactamases? Microb Drug Resist 2011; 17:17-23. [DOI: 10.1089/mdr.2010.0060] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Francisco Abecasis
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Richard E. Sarginson
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Steve Kerr
- Paediatric Intensive Care Unit, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Nia Taylor
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
| | - Hendrik K.F. van Saene
- Department of Medical Microbiology, University of Liverpool, Liverpool, United Kingdom
- Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
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Edgeworth JD. Has decolonization played a central role in the decline in UK methicillin-resistant Staphylococcus aureus transmission? A focus on evidence from intensive care. J Antimicrob Chemother 2010; 66 Suppl 2:ii41-7. [DOI: 10.1093/jac/dkq325] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Silvestri L, de la Cal MA, Taylor N, van Saene HK, Parodi PC. Selective decontamination of the digestive tract in burn patients: an evidence-based maneuver that reduces mortality. J Burn Care Res 2010; 31:372-3; author reply 374. [PMID: 20182385 DOI: 10.1097/BCR.0b013e3181d1b61f] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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García-Hierro P, de la Cal MA, van Saene HK, Silvestri L. Un nuevo ensayo clínico con descontaminación digestiva selectiva. Med Intensiva 2009; 33:297-300. [DOI: 10.1016/s0210-5691(09)72198-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2009] [Accepted: 04/20/2009] [Indexed: 10/20/2022]
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van Saene HKF, Petros AJ, Sarginson RE, Gordon AC, Bion JF. Is Selective Decontamination of the Digestive Tract a Solution to the Antimicrobial Resistance Problem in the UK? J Intensive Care Soc 2009. [DOI: 10.1177/175114370901000202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Hendrick KF van Saene
- Consultant/Reader Medical Microbiology, School of Clinical Sciences, University of Liverpool
| | - Andy J Petros
- Consultant Intensivist, Paediatric and Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children
| | - Richard E Sarginson
- Consultant Anaesthetist & Intensive Care Medicine, Intensive Care Unit, Royal Liverpool Children's NHS Trust
| | - Anthony C Gordon
- Consultant and Honorary Senior Lecturer, Critical Care Medicine, Charing Cross Hospital, Imperial College NHS Trust
| | - Julian F Bion
- Professor of Intensive Care Medicine, University Dept Anaesthesia and Intensive Care Medicine, Queen Elizabeth Hospital, Birmingham
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Batra R, Eziefula AC, Wyncoll D, Edgeworth J. Throat and rectal swabs may have an important role in MRSA screening of critically ill patients. Intensive Care Med 2008; 34:1703-6. [PMID: 18500421 DOI: 10.1007/s00134-008-1153-1] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2007] [Accepted: 05/03/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Methicillin-resistant Staphylococcus aureus (MRSA) is a major problem in intensive care units (ICU). International guidelines recommend screening patients for MRSA on admission, although consensus on sites required for optimum detection has not been reached. Our aim was to determine whether throat and rectal swabs identified a significant number of additional MRSA-colonised patients not captured by swabbing at keratinized skin carriage sites (anterior nares, perineum and axillae). DESIGN Prospective cohort study. SETTING 30-Bed medical and surgical ICU in a tertiary teaching hospital. PATIENTS One thousand four hundred and eighty adult patients consecutively admitted over 15 months. MEASUREMENTS AND RESULTS Swabs from carriage sites (anterior nares, perineum, axillae, throat and rectum), wounds and clinical samples taken within 48 h of ICU admission were analysed to identify patients admitted with MRSA. A complete set of carriage swabs were received from 1,470 patients. 105 (7%) patients were admitted with MRSA of which 63 (60%) were detected by a pooled keratinized skin swab (anterior nares, perineum, axillae). A further 36 (34%) patients were detected only by throat or rectal swabs. Indeed, throat and rectal swabs combined had a higher sensitivity than pooled keratinised skin swabs (76 vs. 60% P = 0.0247). Swabs from all carriage sites together detected 95% (100) of MRSA positive patients, with five patients being positive at wound sites only. CONCLUSIONS The throat and rectum are important and potentially hidden sites of MRSA carriage in critically ill patients. These findings prompt the need for larger studies to determine the most cost-effective screening strategy for MRSA detection. DESCRIPTOR Non-pulmonary nosocomial infections.
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Silvestri L, Van Saene HKF, Casarin A, Berlot G, Gullo A. Impact of Selective Decontamination of the Digestive Tract on Carriage and Infection Due to Gram-Negative and Gram-Positive Bacteria: A Systematic Review of Randomised Controlled Trials. Anaesth Intensive Care 2008; 36:324-38. [PMID: 18564793 DOI: 10.1177/0310057x0803600304] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Meta-analyses of randomised controlled trials of selective digestive decontamination have clinical outcome measures, mainly pneumonia and mortality. This meta-analysis has a microbiological endpoint and explores the impact of selective digestive decontamination on Gram-negative and Gram-positive carriage and severe infections. We searched electronic databases, Cochrane Register of Controlled Trials, previous meta-analyses and conference proceedings with no language restrictions. We included randomised controlled trials which compared the selective digestive decontamination protocol with no treatment or placebo. Three reviewers independently applied selection criteria, performed the quality assessment and extracted the data. The outcome measures were carriage and severe infection due to Gram-negative and Gram-positive bacteria. Odds ratios were pooled with the random effect model. Fifty-four randomised controlled trials comprising 9473 patients were included; 4672 patients received selective digestive decontamination and 4801 were controls. Selective digestive decontamination significantly reduced oropharyngeal carriage (odds ratio [OR] 0.13, 95% confidence interval [CI] 0.07 to 0.23), rectal carriage (OR 0.15, 95% CI 0.07 to 0.31), overall infection (OR 0.17, 95% CI 0.10 to 0.28), lower respiratory tract infection (OR 0.11, 95% CI 0.06 to 0.20) and bloodstream infection (OR 0.35, 95% CI 0.21 to 0.67) due to Gram-negative bacteria. Reduction in Gram-positive carriage was not significant. Gram-positive lower airway infections were significantly reduced (OR 0.52, 95% CI 0.34 to 0.78). Gram-positive bloodstream infections were not significantly increased (OR 1.03, 95% CI 0.75 to 1.41). The association of parenteral and enteral antimicrobials was superior to enteral antimicrobials in reducing carriage and severe infections due to Gram-negative bacteria. This meta-analysis confirms that selective digestive decontamination mainly targets Gram-negative bacteria; it does not show a significant increase in Gram-positive infection.
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Affiliation(s)
- L. Silvestri
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
| | - H. K. F. Van Saene
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Medical Microbiology, University of Liverpool and Department of Clinical Microbiology and Infection Control, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - A. Casarin
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Department of Critical Care, St. Michael's Hospital, Toronto, Ontario, Canada
| | - G. Berlot
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anesthesia, Intensive Care and Pain Therapy, University Hospital, Trieste, Italy
| | - A. Gullo
- Department of Emergency, Unit of Anaesthesia and Intensive Care, Presidio Ospedaliero di Gorizia, Gorizia, Italy
- Head, Unit of Anaesthesia and Intensive Care, Policlinico University Hospital, Catania, Italy
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Spoelstra-de Man AM, Girbes AR. Comment on "Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shock: 2008" by Dellinger et al. Intensive Care Med 2008; 34:1160-2; author reply 1163-4. [PMID: 18415078 DOI: 10.1007/s00134-008-1089-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/27/2008] [Indexed: 01/04/2023]
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Silvestri L, van Saene HKF, Thomann C, Perić M. Selective decontamination of the digestive tract reduces pneumonia and mortality without resistance emerging. Am J Infect Control 2007; 35:354-7. [PMID: 17577486 DOI: 10.1016/j.ajic.2006.07.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2006] [Accepted: 07/05/2006] [Indexed: 11/29/2022]
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Stoutenbeek CP, van Saene HKF, Little RA, Whitehead A. The effect of selective decontamination of the digestive tract on mortality in multiple trauma patients: a multicenter randomized controlled trial. Intensive Care Med 2006; 33:261-70. [PMID: 17146635 DOI: 10.1007/s00134-006-0455-4] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 10/17/2006] [Indexed: 12/21/2022]
Abstract
OBJECTIVE Evaluation of selective decontamination of the digestive tract (SDD) on late mortality in ventilated trauma patients in an intensive care unit (ICU). METHODS A multicenter, randomized controlled trial was undertaken in 401 trauma patients with Hospital Trauma Index-Injury Severity Score of 16 or higher. Patients were randomized to control (n=200) or SDD (n=201), using polymyxin E, tobramycin, and amphotericin B in throat and gut throughout ICU treatment combined with cefotaxime for 4 days. Primary endpoint was late mortality excluding early death from hemorrhage or craniocerebral injury. Secondary endpoints were infection and organ dysfunction. RESULTS Mortality was 20.9% with SDD and 22.0% in controls. Overall late mortality was 15.3% (57/372) as 29 patients died from cerebral injury, 16 SDD and 13 control. The odds ratio (95% confidence intervals) of late mortality for SDD relative to control was 0.75 (0.40-1.37), corresponding to estimates of 13.4% SDD and 17.2% control. The overall infection rate was reduced in the test group (48.8% vs. 61.0%). SDD reduced lower airway infections (30.9% vs. 50.0%) and bloodstream infections due to aerobic Gram-negative bacilli (2.5% vs. 7.5%). No difference in organ dysfunction was found. CONCLUSION This study demonstrates that SDD significantly reduces infection in multiple trauma, although this RCT in 401 patients was underpowered to detect a mortality benefit.
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Affiliation(s)
- C P Stoutenbeek
- Department Intensive Care, Academic Medical Center, Amsterdam, The Netherlands
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Silvestri L, van Saene HKF. Selective decontamination of the digestive tract does not increase resistance in critically ill patients: Evidence from randomized controlled trials. Crit Care Med 2006; 34:2027-9; author reply 2029-30. [PMID: 16801879 DOI: 10.1097/01.ccm.0000226400.53640.99] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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