Papers by Anthony Delaney
Critical Care Medicine, 2006
As healthcare professionals and institutions strive to improve patient safety, the treatment of d... more As healthcare professionals and institutions strive to improve patient safety, the treatment of deteriorating patients in non-critical care areas of our hospitals has come under great scrutiny. As there is evidence that deteriorating patients receive delayed and substandard ...
Critical Care Medicine, 2007
Objective: To independently appraise the methodological quality of a sample of reports of meta-an... more Objective: To independently appraise the methodological quality of a sample of reports of meta-analyses that address critical care topics in the Cochrane Database of Systematic Reviews compared with the quality of reports published in regular journals, using a validated assessment instrument, the Overview Quality Assessment Questionnaire (OQAQ).
Critical Care Medicine, 2007
To systematically review the literature to assess whether adjunctive therapy with polyclonal intr... more To systematically review the literature to assess whether adjunctive therapy with polyclonal intravenous immunoglobulin (ivIg) reduces mortality among critically ill adults with severe sepsis and septic shock. MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases; the meta-register of controlled trials; and the Medical Editors Trial Amnesty register. Prospective randomized clinical trials (RCTs) evaluating ivIg treatment in critically ill adults with severe sepsis or septic shock were included. Two reviewers conducted assessment of suitability for inclusion. Two authors independently determined the validity of included studies and extracted data. The effect of ivIg on all-cause mortality was quantified using a fixed-effect meta-analysis. Fourteen RCTs published between 1988 and 2006 were included. Most were small, used relatively low doses of ivIg, and included predominantly surgical patients with Gram-negative infections. There was a significant reduction in mortality associated with use of ivIg treatment with a pooled odds ratio of 0.66 (95% confidence interval 0.53-0.83; p < .0005). In general, a greater treatment effect was seen among studies of lower methodological quality, studies using higher doses of ivIg, and studies that did not use albumin as a control. There was evidence of between-study heterogeneity (chi-square p = .009), and this was at least moderate as measured by the I2 value (I2 = 53.8%). When only high-quality studies were pooled, the odds ratio for mortality was 0.96 (95% confidence interval 0.71-1.3; p = .78). This meta-analysis demonstrates an overall reduction in mortality with the use of ivIg for the adjunctive treatment of severe sepsis and septic shock in adults, although significant heterogeneity exists among the included trials and this result was not confirmed when only high-quality studies were analyzed. These data warrant a well-designed, adequately powered, and transparently reported clinical trial.
Critical Care, 2006
Introduction Nosocomial pneumonia is the most important infectious complication in patients admit... more Introduction Nosocomial pneumonia is the most important infectious complication in patients admitted to intensive care units. Kinetic bed therapy may reduce the incidence of nosocomial pneumonia in mechanically ventilated patients. The objective of this study was to investigate whether kinetic bed therapy reduces the incidence of nosocomial pneumonia and improves outcomes in critically ill mechanically ventilated patients.
Canadian Journal of Anaesthesia-journal Canadien D Anesthesie, 2008
Background: The efficacy of corticosteroids for reducing the incidence of post-extubation larynge... more Background: The efficacy of corticosteroids for reducing the incidence of post-extubation laryngeal edema remains controversial.
Resuscitation, 2009
Aim: Determine current resuscitation practices and outcomes in patients presenting to the emergen... more Aim: Determine current resuscitation practices and outcomes in patients presenting to the emergency department (ED) with sepsis and hypoperfusion or septic shock in Australia and New Zealand (ANZ). Methods: Three-month prospective, multi-centre, observational study of all adult patients with sepsis and hypoperfusion or septic shock in the ED of 32 ANZ tertiary-referral, metropolitan and rural hospitals. Results: 324 patients were enrolled (mean [SD] age 63.4 [19.2] years, APACHE II score 19.0 [8.2], 52.5% male). Pneumonia (n = 138/324, 42.6%) and urinary tract infection (n = 98/324, 30.2%) were the commonest sources of sepsis. Between ED presentation and 6 hours post-enrolment (T6hrs), 44.4% (n = 144/324) of patients received an intra-arterial catheter, 37% (n = 120/324) a central venous catheter and 0% (n = 0/324) a continuous central venous oxygen saturation (ScvO 2 ) catheter. Between enrolment and T6hrs, 32.1% (n = 104/324) received a vasopressor infusion, 7.4% (n = 24/324) a red blood cell transfusion, 2.5% (n = 8/324) a dobutamine infusion and 18.5% (n = 60/324) invasive mechanical ventilation. Twenty patients (6.2%) were transferred from ED directly to the operating theatre, 36.4% (n = 118/324) were admitted directly to ICU, 1.2% (n = 4/324) died in the ED and 56.2% (n = 182/324) were transferred to the hospital floor. Overall ICU admission rate was 52.4% (n = 170/324). ICU and overall in-hospital mortality were 18.8% (n = 32/170) and 23.1% (n = 75/324) respectively. In-hospital mortality was not different between patients admitted to ICU (24.7%, n = 42/170) and the hospital floor (21.4%, n = 33/154). Conclusions: Management of ANZ patients presenting to ED with sepsis does not routinely include protocolised, ScvO 2 -directed resuscitation. In-hospital mortality compares favourably with reported mortality in international sepsis trials and nationwide surveys of resuscitation practices.
Critical Care, 2008
Meta-analysis can be a powerful tool for demonstrating the applicability of a concept beyond the ... more Meta-analysis can be a powerful tool for demonstrating the applicability of a concept beyond the context of individual clinical trials and observational studies, including exploration of effects across different subgroups. Meta-analysis avoids Simpson's paradox, in which a consistent effect in constituent trials is reversed when results are simply pooled. Meta-analysis in critical care medicine is made more complicated, however, by the heterogeneous nature of critically ill patients and the contexts within which they are treated. Failure to properly adjust for this heterogeneity risks missing important subgroup effects in, for example, the interaction of treatment with varying levels of baseline risk. When subgroups are defined by characteristics that vary within constituent trials (such as age) rather than features constant within each trial (such as drug dose), there is the additional risk of incorrect conclusions due to the ecological fallacy. The present review explains these problems and the strategies by which they are overcome.
Critical Care, 2006
Introduction Tracheostomy is one of the more commonly performed procedures in critically ill pati... more Introduction Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients with regards to major short and long term outcomes.
Intensive Care Medicine, 2010
Meta-analysis is a technique for combining evidence from multiple trials. However, meta-analyses ... more Meta-analysis is a technique for combining evidence from multiple trials. However, meta-analyses of studies with substantial heterogeneity among patients within trials-common in intensive carecan lead to incorrect conclusions if performed using aggregate data. Use of individual patient data (IPD) can avoid this concern, increase the power of a meta-analysis, and is useful for exploring subgroup effects. Barriers exist to IPD meta-analysis, most of which are overcome if clinical trials are designed to prospectively facilitate the incorporation of their results with other trials. We review the features of prospective IPD meta-analysis and identify those of relevance to intensive care research. We identify three clinical questions, which are the subject of recent or planned randomised controlled trials where IPD MA offers advantages over approaches using aggregate data.
International Journal of Cardiology, 2010
Background: The objective of this study was to critically review the literature to evaluate wheth... more Background: The objective of this study was to critically review the literature to evaluate whether levosimendan compared to standard therapy, in patients with acute severe heart failure, is associated with improved clinical outcomes. Methods: Medline, EMBASE, and the Cochrane central register of clinical trials were searched. We also searched clinical trials registries, bibliographies of included studies and review articles and contacted the manufacturers of levosimendan to identify unpublished studies. Randomised clinical trials comparing levosimendan to standard therapy or placebo, in adult patients with acute severe heart failure, reporting at least one outcome of interest were included. Data were extracted regarding the characteristics, methodological quality and clinical outcomes, and combined using a fixed-effect meta-analysis. Results: We identified 19 RCTs enrolling 3650 patients, only two studies fulfilled all of the validity criteria. There was a non-significant reduction in mortality with levosimendan compared with placebo (OR 0.83, 95%CI, 0.62-1.10, p = 0.20). Levosimendan was associated with reduced mortality compared to dobutamine (OR 0.75, 95%CI, 0.61-0.92, p = 0.005). Levosimendan was associated with improvements in haemodynamic parameters when compared to either placebo or dobutamine. Conclusions: Levosimendan improved haemodynamic parameters when compared with placebo, without showing evidence of survival benefit. Levosimendan improved both haemodynamics and survival when compared with dobutamine. Crown
Critical Care, 2008
Complex interventions, such as the introduction of medical emergency teams or an early goal-direc... more Complex interventions, such as the introduction of medical emergency teams or an early goal-directed therapy protocol, are developed from a number of components that may act both independently and inter-dependently. There is an emerging body of literature advocating the use of integrated complex interventions to optimise the treatment of critically ill patients. As with any other treatment, complex interventions should undergo careful evaluation prior to widespread introduction into clinical practice. During the development of an international collaboration of researchers investigating protocol-based approaches to the resuscitation of patients with severe sepsis, we examined the specific issues related to the evaluation of complex interventions. This review outlines some of these issues. The issues specific to trials of complex interventions that require particular attention include determining an appropriate study population and defining current treatments and outcomes in that population, defining the study intervention and the treatment to be used in the control group, and deploying the intervention in a standardised manner. The context in which the research takes place, including existing staffing levels and existing protocols and procedures, is crucial. We also discuss specific details of trial execution, in particular randomization, blinded outcome adjudication and analysis of the results, which are key to avoiding bias in the design and interpretation of such trials.
Critical Care, 2009
Introduction Older age is associated with higher prevalence of chronic illness and functional imp... more Introduction Older age is associated with higher prevalence of chronic illness and functional impairment, contributing to an increased rate of hospitalization and admission to intensive care. The primary objective was to evaluate the rate, characteristics and outcomes of very old (age ≥ 80 years) patients admitted to intensive care units (ICUs). Methods Retrospective analysis of prospectively collected data from the Australian New Zealand Intensive Care Society Adult Patient Database. Data were obtained for 120,123 adult admissions for ≥ 24 hours across 57 ICUs from 1 January 2000 to 31 December 2005. Results A total of 15,640 very old patients (13.0%) were admitted during the study. These patients were more likely to be from a chronic care facility, had greater co-morbid illness, greater illness severity, and were less likely to receive mechanical ventilation. Crude ICU and hospital mortalities were higher (ICU: 12% vs. 8.2%, P P Conclusions The proportion of patients aged ≥ 80 years admitted to intensive care in Australia and New Zealand is rapidly increasing. Although these patients have more co-morbid illness, are less likely to be discharged home, and have a greater mortality than younger patients, approximately 80% survive to hospital discharge. These data also imply a potential major increase in demand for ICU bed-days for very old patients within a decade.
Critical Care Medicine, 2008
Severe sepsis is a common health problem with consequences for both patients and the healthcare s... more Severe sepsis is a common health problem with consequences for both patients and the healthcare system. Over the past 20 years, multiple immunomodulatory agents have been investigated in an unsuccessful attempt to decrease the morbidity and mortality of severe sepsis. Drotrecogin alfa (activated; Xigris) may represent a breakthrough in the treatment of sepsis. It has been demonstrated to have beneficial effects in decreasing biological markers of the severity of sepsis in preclinical and Phase II studies. A single, large Phase III trial has demonstrated the efficacy of drotrecogin alfa (activated) in a sample of patients with severe sepsis. This sample appears to be comparable with the general population of patients with severe sepsis. Three separate economic analyses have shown drotrecogin alfa (activated) to have a cost-utility ratio similar to other therapies that are currently funded, when used for the treatment of the most severely ill group of patients. This review provides an opinion that drotrecogin alfa (activated) is a cost-efficient therapy that should be considered as part of a standard of care in healthcare systems that can provide a modern critical care service.
Critical Care, 2005
Introduction Meta-analyses have been suggested to be the highest form of evidence available to cl... more Introduction Meta-analyses have been suggested to be the highest form of evidence available to clinicians to guide clinical practice in critical care. The purpose of this study was to systematically evaluate the quality of meta-analyses that address topics pertinent to critical care.
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Papers by Anthony Delaney