Exercise: Prophylactic administration of parenteral steroids

Tao Fan and colleagues reported a meta-analysis of prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults.

They identified trials as shown in the following table:

Characteristics of included randomised placebo controlled trials on parenteral steroids for preventing complications after extubation in adults
Study Location Study population Time constraint* Mean (SD) age (years) Sample size (% female) Intervention in steroid group
Steroids Placebo Steroids Placebo
Gaussorgues (France and multicentre) Pneumonia, haemodynamic instability, postoperative, neurological 48 hours 55 (26) 53 (23) 138 (33.3) 138 (36.2) 40 mg IV and 40 mg IM methylprednisolone 30 min before extubation
Darmon (France and multicentre) Haemodynamic instability, neurological, postoperative 24 hours 49 (18.8) intubated for <36 h; 55.4 (17.9) intubated for >36 h 47.7 (19.4) intubated for <36 h; 59.4 (19.8) intubated for >36 h 348 (39.7) 352 (44.6) 8 mg IV dexamethasone 1 h before extubation
Ho (Taiwan) Haemodynamic instability, neurological, postoperative, trauma 24 hours 61 (14) 64 (18) 39 (25.6) 38 (21.1) 100 mg IV hydrocortisone 1 h before extubation
Cheng (Taiwan) Medical, surgical 48 hours 1 injection: 63 (16); 4 injections: 67 (18) 68 (16) 85 (1 injection: n=43 (65.1); 4 injections: n=42 (54.8)) 43 (65.1) Over 24 h, 40 mg IV infusion methylprednisolone every 6 h (total 160 mg) in 4 injections group; one infusion of methylprednisolone followed by three injections of normal saline every 6 h (total 40 mg) in 1 injection group
Francois 2007w5 (France and multicentre) Medical, surgical, and trauma (time constraint 24 h*) 24 hours 65 (46-75) 66 (48-74) 380 (37.0) 381 (35.0) 20 mg methylprednisolone initiated 12 h before planned extubation and continued every 4 h with last injection removal (total 80 mg)
Lee (Taiwan) Pneumonia, sepsis, heart failure, acute respiratory distress syndrome, COPD (time constraint 48 h*) 48 hours 72.4 (14.7) 72.7 (13.8) 40 (85.0) 40 (88.0) 5 mg IV dexamethasone every 6 h, total of four doses with last injection 24 h before extubation
*Time constraints for investigation after extubation.

Question 1: Is there any evidence of clinical heterogeneity between these trials?

Check suggested answer 1.

Two complications of extubation were reported as adverse outcomes: the presence or absence of laryngeal oedema and whether there was the need for re-intubation.

Question 2: What kind of variable are the outcomes in these trials?

Check suggested answer 2.

Question 3: How could the results of these trials be combined in a meta-analysis?

Check suggested answer 3.

Continue with exercise.

Reference

Tao Fan, Gang Wang, Bing Mao, Zeyu Xiong, Yu Zhang, Xuemei Liu, Lei Wang, Sai Yang. Prophylactic administration of parenteral steroids for preventing airway complications after extubation in adults: meta-analysis of randomised placebo controlled trials. BMJ 2008; 337: a1841.)


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