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Metrics details. The original article was published in Critical Care 20 In this observational study, adrenaline was independently associated with mortality in cardiogenic shock CS.
The data presented are the odds ratio OR of a multivariable propensity score-adjusted analysis, where patients that used adrenaline had an adjusted OR of 3. The main concern with the article is precisely the choice of the OR as its measure of effect.
Applying this equation, Jussa Joikaa Pallaksella - Various - Tie Musiikkiin RR for day mortality would be 1. Although this number still shows a statistically significant increase in mortality, one must remember that this information comes from an observational study. The GRADE working group proposal for rating the quality of evidence for interventions ranks the conclusions from observational studies as low quality evidence [ 4 ].
This quality of evidence can be rated up if a large magnitude of effect is present. However, the suggestion in the GRADE guidelines is that this rating up should be done when the RR as at least equal to All Of You - Miles Davis - Classic Ballads, which Jussa Joikaa Pallaksella - Various - Tie Musiikkiin not the case in this study [ 5 ].
In conclusion, the evidence suggesting an increased mortality risk associated with adrenaline use in CS is low quality at best, Play It Again Sam - Hans Theessink - Titanic one could rate it down to very low quality if we consider that there is imprecision in the estimate and, therefore, an adequately designed and powered clinical trial is imperative to provide a reliable answer to this question.
We thank Ribeiro and Restelatto for their comments on our article about assessing the concurrent use of vasoactive medications in cardiogenic shock [ 1 ]. They raise two potential issues regarding our main finding, the association between adrenaline use and day mortality: the use of the odds ratio OR instead of relative risk RR and that the evidence is from an observational study. While we agree that the OR might not always accurately describe the RR, logistic regression analysis is a gold standard statistical technique for binary responses, so it was an obvious choice also in our study.
Moreover, after conversion from ORs, both the univariate and adjusted multivariable RR for adrenaline use were over 2 2. As we were curious about the association between adrenaline use and increased mortality, we performed and reported further analyses using additional propensity score adjustments in the subgroup of vasopressor-treated patients as described in our article.
The effect size diminished a bit but remained statistically significant OR 3. We also reported analyses using propensity score matching, Kaplan—Meier curves and log-rank tests, as well as an adjusted Cox regression model and the association was statistically significant regardless of the analysis technique. As suggested by Ribeiro and Restelatto, we performed an additional analysis using Poisson regression with robust variance: for adrenaline use in a multivariable model with propensity score adjustment within the subgroup of vasopressor-treated patients, the RR for day mortality was 1.
So, the main finding is supported by several sensitivity analyses and we can be confident that there is a clearly statistically significant association Jussa Joikaa Pallaksella - Various - Tie Musiikkiin adrenaline use and day mortality in our data. Albeit being a result from an observational study, we argue that this is still a clinically significant finding, especially considering the very high frequency of poor outcome also emphasized by Ribeiro and Restelatto.
This warrants attention because it raises justified questions about the safety of this treatment. And we fully agree, as we conclude in our article, that there is a need for randomized controlled trial to confirm this detected association. Current real-life use of vasopressors and inotropes in cardiogenic shock - adrenaline use is associated with excess organ injury and mortality.
Crit Care. Zou G. A modified poisson regression approach to prospective studies with binary data. Am J Epidemiol. Zhang J, Yu KF.
A method of correcting the odds ratio in cohort studies of common outcomes. J Clin Epidemiol. GRADE guidelines: 9. Rating up the quality of evidence. Download references. Both authors wrote the manuscript and conducted the Decay Of Gods Creation - Blaze Of Perdition - Reincarnations re-analysis.
Both authors read and approved the final manuscript. Correspondence to Rodrigo Antonini Ribeiro. Reprints and Gratitude - Earth, Wind & Fire - Gratitude. Ribeiro, R. Increased mortality with the use of adrenaline in shock: the evidence is still limited. Crit Care 20, doi Download citation. Search all BMC articles Search.
References 1. Article PubMed Google Scholar 3. Article PubMed Google Scholar 5. Competing interests The authors declare that they have no competing interests regarding this manuscript. About this article.
Cite this article Ribeiro, R.
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