Effect of Antibiotic Discontinuation Strategies on Mortality and Infectious Complications in Critically Ill Septic Patients: A Meta-Analysis and Trial Sequential Analysis.

OBJECTIVE: To investigate methods of antibiotic duration minimization and their effect on mortality and infectious complications in critically ill patients. DATA SOURCES: A systematic search of PubMed, Embase (via Ovid), clinicaltrials.gov, and the Cochrane Central Register of Controlled Trials (via Wiley) (CENTRAL, Issue 2, 2015). STUDY SELECTION: Randomized clinical trials comparing strategies to minimize antibiotic duration (days) for patients with infections or sepsis in intensive care. DATA EXTRACTION: A systematic review with meta-analyses and trial sequential analyses of randomized clinical trials. Dichotomous data are presented as relative risk (95% CIs) and p value, and continuous data are presented as mean difference (CI) and p value. DATA SYNTHESIS: We included 22 randomized clinical trials (6,046 patients). Strategies to minimize antibiotic use included procalcitonin (14 randomized clinical trials), clinical algorithms (two randomized clinical trials), and fixed-antibiotic duration (six randomized clinical trials). Procalcitonin (-1.23 [-1.61 to -0.85]; p < 0.001), but not clinical algorithm-guided antibiotic therapy (-7.41 [-18.18 to 3.37]; p = 0.18), was associated with shorter duration of antibiotic therapy. The intended reduction in antibiotic duration ranged from 3 to 7 days in fixed-duration antibiotic therapy randomized clinical trials. Neither procalcitonin-guided antibiotic treatment (0.91 [0.82-1.01]; p = 0.09), clinical algorithm-guided antibiotic treatment (0.67 [0.30-1.54]; p = 0.35), nor fixed-duration antibiotics (1.21 [0.90-1.63]; p = 0.20) were associated with reduction in mortality. Z-curve for trial sequential analyses of mortality associated with procalcitonin-guided therapy did not reach the trial sequential monitoring boundaries for benefit, harm, or futility (adjusted CI, 0.72-1.10). Trial sequential analyses for mortality associated with clinical algorithm and fixed-duration treatment accumulated less than 5% of the required information size. Despite shorter antibiotic duration, neither procalcitonin-guided therapy (0.93 [0.84-1.03]; p = 0.15) nor fixed-duration antibiotic therapy (1.06 [0.74-1.53]; p = 0.75) was associated with treatment failure. CONCLUSIONS: Although the duration of antibiotic therapy is reduced with procalcitonin-guided therapy or prespecified limited duration, meta-analysis and trial sequential analyses are inconclusive for mortality benefit. Data on clinical algorithms to guide antibiotic cessation are limited.

Local anesthetic delivery via surgical drain provides improved pain control versus direct skin infiltration following axillary node dissection for breast cancer.

BACKGROUND: Axillary node dissection has a central role in the surgical management of breast cancer; however, it is associated with a significant risk of lymphoedema and chronic pain. Peri-operative administration of local anesthesia reduces acute and persistent post-surgical pain, but there is currently no consensus on the optimal method of local anesthetic delivery. METHODS: Patients undergoing axillary dissection for breast cancer were randomly assigned to receive a one-off dose of levobupivacaine 0.5% (up to 2 mg/kg) following surgery, either via the surgical drain or by direct skin infiltration. Post-operative pain control at rest and on shoulder abduction was assessed using a numerical rating scale. Total analgesia consumption 48 h after surgery was also recorded. RESULTS: Pain scores were significantly lower when local anesthesia was administered via surgical drain at both 3 and 12 h after surgery; this trend extended to 24 h post-operatively. However, pain scores on shoulder abduction did not differ at the 12 or 24 h time points. No differences were found in the total analgesia consumption or length of hospital stay between treatment groups. DISCUSSION: This study demonstrates that local anesthetic delivery via a surgical drain provides improved pain control compared to direct skin infiltration following axillary node dissection. This is likely to be important for the management of acute pain in the immediate post-operative period; however, further studies may be required to validate this in specific patient subgroups, e.g., breast-conserving surgery versus mastectomy.

Cardiac arrest: a missed learning opportunity.

AIM: The Resuscitation Council advocates debriefing after cardiac arrests, as both a training tool and to improve patient outcomes. There is, however, a large variation between hospitals in their implementation of debriefing. This potentially disadvantages trainees, as they are unable to use the presented opportunity to improve their skills and knowledge. The primary aim of this survey was to investigate the utility and perception of debriefing postcardiac arrest among staff at a district general hospital. The secondary aim was to evaluate our specifically designed postcardiac arrest debrief tool. METHOD: A confidential, qualitative survey was distributed to 100 cardiac arrest team members at Lister Hospital, Stevenage, during February 2016. RESULTS: 72% of the participants reported never having debriefed postcardiac arrest at Lister Hospital. 93% believed that debriefing would improve individual performance, 95% felt it would benefit team performance and 88% felt it would improve patient safety. Our postcardiac arrest debrief tool was well received, with 93% stating that they would find the tool useful. CONCLUSIONS: Debriefing postcardiac arrest has been associated with improved return of spontaneous circulation (ROSC) neurological outcomes, hands-off compression times as well as reduced time delay to first compression. Despite the benefits, this survey has shown a lack of debriefing at our hospital. We have developed a concise debriefing tool aimed at providing much-needed training for those involved. The tool allows identification of key concerns in leadership, and teamwork and encourages open discussions around areas of concern. We believe that its implementation may improve resuscitation outcomes, and therefore, recommend its use postcardiac arrests.