Morfine bij acute decompensatio cordis Zoekvraag 9 juli 2013 Marieke Romijn

Introductie

Richtlijnen acute decompensatio cordis  Acute boekje 2009  Harrison’s 2008  European Society of Cardiology 2012

Zoekvraag  P: acute decompensatio cordis  I: morfine  C: geen morfine  O: overlijden, IC opname, kliniek  Doel:

Zoekstrategie Pubmed  Mesh  Morphine AND Heart failure AND acute  Limits  Meta analyses, (systematic) review, RCT, guidelines

Uitkomst zoekstrategie  Artikelen11  Bruikbaar en beschikbaar2  Zonder limits89  Bruikbaar en beschikbaar2  Totaal4

 Retrospectief 2004  Mortaliteit en invasieve beademing  patiënten  Mortaliteit adjusted OR 4.84

 Conclusie:  ↑ Invasieve beademing  ↑ Hospitalisatie  ↑ IC opname  ↑ Mortaliteit

 Conclusie:  Geen bewijs voor effect  Wel slechtere uitkomsten  ↓ kwaliteit onderzoek

Richtlijnen  Avoid morphine!

Samenvatting uitkomsten  Morfine bij acute decompensatio cordis  Onvoldoende bewijs  ↑ risico mortaliteit, IC opname en mortaliteit  Terughoudendheid Echter!

Discussie  Slechte kwaliteit onderzoeken  RCT  ADHERE = retrospectief

Conclusie  Morfine bij acute decompensatio cordis … … wel geven

Vragen?

Referenties en zoekterm  Zoekterm 1:  ((("Morphine"[Mesh] OR morphin*[tiab]) AND ("Heart Failure"[Mesh] OR heart failure[tiab] OR cardiac failure[tiab])) AND acute[tw]) AND (systematic[sb] OR "Meta-Analysis"[Publication Type] OR "Randomized Controlled Trial"[Publication Type] OR "Controlled Clinical Trial"[Publication Type] OR "Clinical Trial"[Publication Type] OR "Practice Guideline"[Publication Type] OR "Guideline"[Publication Type])  Zoekterm 2:  ((("Morphine"[Mesh] OR morphin*[tiab]) AND ("Heart Failure"[Mesh] OR heart failure[tiab] OR cardiac failure[tiab])) AND acute[tw]) NOT (((("Morphine"[Mesh] OR morphin*[tiab]) AND ("Heart Failure"[Mesh] OR heart failure[tiab] OR cardiac failure[tiab])) AND acute[tw]) AND (systematic[sb] OR "Meta-Analysis"[Publication Type] OR "Randomized Controlled Trial"[Publication Type] OR "Controlled Clinical Trial"[Publication Type] OR "Clinical Trial"[Publication Type] OR "Practice Guideline"[Publication Type] OR "Guideline"[Publication Type]))

title/abstract gescreend 11 Exclusie: -1 Niet toegankelijk -1 Alleen abstract articles were not full text available articles included  Related articles’/ ‘citated by’ in Web of Science  ‘Related articles’ in Pubmed  ‘Reference Lists’ in golden hits Result: no missed articles articles included 2 Articles Full text not relevant on Domain, Determinant or Outcome according to exclusion criteria Gevonden artikelen 11 trials, guidelines

Referenties en zoekterm Grading of edema GradeDefinition "Absent"Absent or unilateral Grade +Mild: Both feet / ankles Grade ++ Moderate: Both feet, plus lower legs, hands or lower arms Grade +++ Severe: Generalised bilateral pitting edema, including both feet, legs, arms and face

Uitkomst zoekstrategie ArtikelenAantal Zoekstrategie11 Bruikbaar2 Zonder limits89 Bruikbaar2 Totaal4

Uitkomst Table 1. StudyValidityApplic ability Results Level of Evidence 10 Results Study design 1 Number of patients Inception cohort 2 Loss to follow-up 3 Follow-up duration 4 Standardizationintervention Group comparability 5 Correction forconfounders 6 Blinding External validity 7 Effect measure 8 Precision 9 Sacchetti et al. 1999RS-C181-0%?-?+-+ ORp, 95% CI 2bICU admissionETIICU-LOS OROR p95% CI OROR p daysp < (1.84) 0.46 Peacock et al. 2008RS-C %?-++-+ ORp, 95% CI 2b Morph ine No Morph ine Unadj OR (95% CI) Adj OR (95% CI) p ICU-LOS 3.0d2.2d <0.001 Mech vent 15.4%2.8% <0.001 ICU adm rate 38,7%14.4% <0.001 Mortality 13%2.4% 6.08 ( ) 4.84 ( ) < ) RS-C: retrospective cohort; PS-C: prospective cohort 2) clear inclusion- and exclusion criteria next to a clear description of patient cohort: + present; - absent 3) Loss to follow-up of > 20% is considered bias 4) Duration of follow-up: d: days 5) +: groups were similar for all prognostic important issues at the start of the experiment 6) +: stratification or logistic regression is performed 7) applicability of domain, determinant and outcome in clinical practice: + applicable, ± partially applicable 8) OR: odds ratio; r: correlation coefficient 9) 95% CI: 95% confidence interval; p: p-value 10) Level of Evidence, based on Oxford Centre for Evidence-based Medicine (May 2001) ETI: Endotracheal intubation ICU-LOS: ICU length of stay Adj OR: adjusted Odds Ratio Unadj OR: unadjusted Odds Ratio p: p-value ICU adm rate: ICU admission rate 95% CI: 95% Confidence interval