Archive for September, 2008|Monthly archive page

Use of Polyclonal Ig as Adjuvant Therapy for Sepsis/Severe Sepsis K Georg. Kreymann et al CCM 2007 35(12) 2677-

This important paper is a meta analysis of all trials including the use of IVIG in patients (adult and Children-including neonates) with sepsis and severe sepsis. IVIG bind up toxins, allow oponisation and bind toxins and superantigens Previous papers from the Cochrane group have apparently not included all studies which this meta analysis has tried to do.
The search criteria was vigorous, including peer reviewed articles as well as personal communications, letters etc. They particularly included studies which used mortality as an end point. They graded papers on strict guidelines as there was a paucity of double blinded randomised placebo controlled trials (DBRPCT) to try and add some power to the meta analysis.

In all 27 trials were included. In 15 trials, including 1492 patients (adults and children) showed the use of IVIG created a RR of 0.79 (significant). When split into type of IVIG, the IVIGAM (immunoglobulins containing predominantly IVIG A and M) were used in 560 patients with a significant RR of 0.66. With just IVIG, including 932 patients, RR was 0.85 (significant). IVIG A and M showed further benefit over just IVIG. It is interesting to note many studies showed a positive trend but these trials were rated as significantly heterogeneous on tests. The largest trial showed no difference between those treated with IVIG and these not. 12 trials included neonates and are not discussed further here.

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Invasive ventilation for COPD patients

Implications of prognostic pessimism in patients with chronic obstructive pulmonary disease (COPD) or asthma admitted to intensive care in the UK within the COPD and asthma outcome study (CAOS): multicentre observational cohort study. Wildman et el. BMJ December 2007.

I think this paper has raised the profile of whether or not to invasively ventilate patients with an exacerbation of COPD. However the paper only includes the prognosis of patients actually admitted to critical care. This means that the pessimisim in these patients was not great enough for them not to be addmitted at all. Whilst a randomised trial including all patients with an exacerbation would be unethical this is a problem with the study.

Dr. Hina Pattani