[show abstract][hide abstract] ABSTRACT: To review the literature on goal directed fluid therapy and evaluate the quality of evidence for each combination of goal and monitoring method.
A search of major digital databases and hand search of references was conducted. All studies assessing the clinical utility of a specific fluid therapy goal or set of goals using any monitoring method were included. Data was extracted using a pre-determined pro forma and papers were evaluated using GRADE principles to assess evidence quality.
Eighty-one papers met the inclusion criteria, investigating 31 goals and 22 methods for monitoring fluid therapy in 13052 patients. In total there were 118 different goal/method combinations. Goals with high evidence quality were central venous lactate and stroke volume index. Goals with moderate quality evidence were sublingual microcirculation flow, the oxygen extraction ratio, cardiac index, cardiac output, and SVC collapsibility index.
This review has highlighted the plethora of goals and methods for monitoring fluid therapy. Strikingly, there is scant high quality evidence, in particular for non-invasive G/M combinations in non-operative and non-intensive care settings. There is an urgent need to address this research gap, which will be helped by methodologies to compare utility of G/M combinations.
Journal of critical care 10/2013; · 2.13 Impact Factor
[show abstract][hide abstract] ABSTRACT: OBJECTIVE:: The aim of this study was to systematically review and evaluate the quality of current evidence about fluid therapy (FT) in acute pancreatitis (AP). BACKGROUND:: Intravenous FT is thought to be important in the early management of patients with AP. Clinically relevant questions remain regarding the type of fluid, the rate of administration, and the goal of FT. METHODS:: A comprehensive literature search for human studies was performed using online databases (MEDLINE, EMBASE, PubMed, and the Cochrane Library). The quality of the entire body of evidence was then graded according to the Grading of Recommendations Assessment, Development and Evaluation Working Group guidelines in relation to 3 key areas: type of fluid, rate of fluid administration, and goal-directed FT. RESULTS:: The initial search yielded 410 studies, of which 15 met the inclusion criteria. Only 2 randomized studies compared types of fluids. Nine studies looked at aggressive versus nonaggressive resuscitation protocols, of which 4 concluded that an aggressive approach yielded better outcomes and 5 concluded that a nonaggressive approach was better. Two studies investigated goal-directed FT, using different goals; one demonstrating benefit and the other none. Analysis of the body of evidence as per the Grading of Recommendations Assessment, Development and Evaluation Working Group revealed that the majority of evidence was of low or very low quality. CONCLUSIONS:: FT is considered a cornerstone of the early management of patients with AP and yet the evidence on which it is based remains paltry and of poor quality. This systematic review has demonstrated the equipoise necessary for the design of randomized controlled trials to answer pressing questions relating to the type of fluid, the rate of administration, and how FT should be guided.
[show abstract][hide abstract] ABSTRACT: To evaluate police and autopsy reports in sudden unexplained deaths in 0-40 year olds. A structured, blind review of police and autopsy reports send to a cardiac genetic service from before (February 2006-December 2007) and after (January-December 2009) new best practice guidelines were introduced in Australia and New Zealand was performed. The reviews focused on reporting on: (1) presentation and clinical history, (2) cardiac autopsy, (3) histological tests and toxicology, and (4) detailed examination of coronary arteries. 110 reports were evaluated against the guidelines. 100 % reported location, 95 % activity at time of death, and 84 % some clinical history. Less than 25 % reported on family history, presence/absence of illicit drugs or alcohol, recorded a possible arrhythmic trigger, or history of fits/faints or collapses. Over 95 % listed heart weight, valvular examinations, pulmonary and some myocardial histology. Less than 50 % commented on septal, LV (left ventricle) and RV (right ventricle) wall thickness. Less than 50 % mentioned site of histology samples, or gave specific description of LV or RV histology or conduction system. Toxicology was not mentioned in a third. Histology of coronary arteries was described in only 18 %. Post guidelines reporting increased in some areas, e.g. in 1-40 year olds: antecedent symptoms (22-61 %), number and location of histology samples (0-47 %), and histology of coronary arteries (6-50 %). Most police and autopsy reports fall short of best practice guidelines. They have improved somewhat after the new guidelines were introduced, but need to be more consistent and particularly need to include significant negative findings.
Forensic Science Medicine and Pathology 05/2012; 8(4):380-9. · 2.44 Impact Factor