A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Reducing Mortality

Abstract Objective Reducing mortality is a key target in critical care and perioperative medicine. We aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials, to increase mortality in these clinical settings. Design A systematic review of the literature followed by a consensus-based voting process. Setting A web-based international consensus conference. Participants 251 physicians from 46 countries. Interventions We performed a systematic literature search and identifiedall randomized controlled trials (RCTs) showing significant increase in unadjusted landmark mortality among surgical or critically ill patients. We reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention into international guidelines. Measurements and Main Results We selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin cross linked hemoglobin (92% of agreement among web voters),overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement).Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed. Conclusions We identified 12 clinical interventions with randomized trials showing increased mortality, with non-conflicting, and widely agreed-upon clinicians agreement on a global scale.