Talk Evidence - Sepsis, talc and blindsided by blinding
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Welcome back to Talk Evidence, your monthly roundup of the world of EBM. I'm Doug Jovis, multimedia editor here at the BMJ, and I'm joined in the studio by Helen MacDonald. Helen, can I get you to introduce yourself?
I'm Helen MacDonald, UK editor at the BMJ and resting GP.
And we are joined on the phone by Carl Hennigan, who is currently in quarantine in Oxford. Carl, can I get you to introduce yourself?
Yeah, I'm going to describe myself as an active GP because I've been working over Christmas, doing some urgent care work, and that's given me the lurgy. Thank you very much, Christmas. And I'm also editor-in-chief of BMJ Evidence-Based Medicine.
Well, I hope you get better soon, and I'm sure everyone listening does as well. Maybe it'll keep him a little bit more quiet this week, Helen.
I'll try.
We can mute him more easily.
Yeah, we can. Saying that, we are about to go straight over to Carl to do our first start and stop. Carl, you've been looking at corticosteroids for treating sepsis in children and adults.
Yeah, no, that was interesting. There's a Cochrane review update that was first published in 2004 and last updated in 2015 that examined the effects of corticosteroids on deaf and children and adults with sepsis. And what's interesting about this update is it included 61 trials and the new search revealed 25 additional trials. So this is quite some update. And so obviously this is an area of interest. And what's interesting about this update, what it found evidence for was a indicates that steroids reduced 28-day and hospital mortality among patients with sepsis, and they resulted in particularly large reductions in intensive care unit stays and hospital length of stay. And I think, you know, this is a really interesting issue because the paper itself says amongst clinicians and surveys shows that in sepsis, as opposed to septic shock, many clinicians don't use steroids.
And also in many guidelines, and I checked the NICE guidelines as well that were last updated in 2017, that they don't include steroids as actual treatment for sepsis. And my point is, and I think this is interesting, is how do we then translate this evidence into clinical practice and into guidelines, as opposed to now have to wait two or three years to implement this sort of intervention?
So you think it's strong enough to potentially start doing that already, the evidence?
Well, I think, look, it has a number of strengths in the outcomes. I think first is there are not just one or two trials. There are, like I said, 61 trials, including over 12,000 participants. What it did is it reduced 28-day mortality, not by much, but enough to make it of importance. Among 1,000 patients, about 24 more will be alive at 28 days. But particularly, it reduced the length of intensive care unit stay by a day and large reductions in length of hospital stay over a day of the mean difference. And one of the most crucial things about this is that what you worry about steroids is, do they actually increase your risk of what they call super infection? And there was no increase in the risk of such infections because what people worry about steroids is they have an effect on your immune system, so you're more likely to get an infection.
The answer is no, and that was backed up by 25 studies and moderate certainty evidence.
So we should wait to hear from our emergency care and acute care colleagues about whether they're convinced by Carl's find.
Absolutely. And as you said there, Carl, these are the kind of things that we need to get into practice. And that's exactly what our next article, Helen, is all about.
Yes, what you really need, Carl, is to commission a rapid recommendation.
On the steroids?
Yeah.
Yeah, no, I totally agree. And I think this is an important point because our structures at the moment are sort of set up to move very slow. But what we see is a move from the systematic review community into these living reviews to make them more up-to-date and more relevant. And I think we need a policy sort of living approach, particularly for these important questions that go, here's a rapid recommendation into a policy that changes practice.
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