CRITICAL APPRAISAL

ON SYSTEMATIC REVIEWS

Effectiveness & Safety of Procalcitonin evaluation for reducing

mortality in adults sepsis, severe sepsis or septic shock
 OBJECTIVES

GENERAL OBJECTIVES
To be able to appraise a journal on systematic review

SPECIFIC OBJECTIVES
To appraise directness, validity, & results of the chosen
journal
To address applicability of the study
To provide conclusions based on the appraisal of the journal
 CLINICAL SCENARIO

A 53 year old, Male, admitted at the ICU, came in at the ER

hypotensive, with 2-month history of hypogastric pain, dysuria &
intermittent febrile episodes. Patient was managed as a case of
Septic Shock probably secondary to Urosepsis vs. Intrabdominal
Infection.

Procalcitonin (ng/dl) was requested during the course of

admission.
Day 1: 12.54
Day 2: 50.18
Day 3: 2.65
 PROCALCITONIN
The procalcitonin test may be used, along with other tests and
examinations, to help detect or rule out sepsis in a seriously ill person. It
has primarily been used in people who seek care at emergency
departments or who are admitted to intensive care units (ICUs) with
signs and symptoms that may be due to sepsis. It may be used to help:

• Determine the risk that a critically ill person will progress to severe
sepsis, septic shock, or the risk of the person dying
• Distinguish between bacterial & non-bacterial causes of infection
• Diagnose kidney infections in children with UTI
• Detect the development of a secondary bacterial infection in a person
who has tissue damage
• Guide antibiotic treatment and/or monitor effectiveness
DIRECTNESS

CLINICAL QUESTION RESEARCH QUESTION

POPULATION Adult patients >18 years old Adult patients >18 years old
admitted in the ICU for Septic admitted in the ICU for Sepsis,
Shock Severe Sepsis & Septic Shock

EXPOSURES Procalcitonin Evaluation Procalcitonin Evaluation

 CLINICAL QUESTION

Among adult patients admitted in the ICU for septic shock, what
is the role of Procalcitonin in changing the course of treatment
to reduce mortality?
OBJECTIVES & ENDPOINTS

Primary outcomes:
1. Mortality at up to 28 days, in the ICU, in hospital (from
sepsis or all causes) and at longest follow-up.
2. Time receiving anti-microbial therapy (in days) or quantity
(volume) of antimicrobial agents received.
3. Change in antimicrobial regimen from a broad to a narrower
spectrum.
OBJECTIVES & ENDPOINTS

Secondary outcomes:
1. Hospital length of stays (days).
2. ICU length of stays (days).
3. Clinical severity of participant’s condition, assessed by
validated instruments such as APACHE II AND SOFA.
4. New infection.
5. Duration of mechanical ventilation (days).
VALIDITY
1. Were the criteria for
inclusion of the slides
appropriate?
2. Was the search for eligible
studies thorough?
3. Was the validity of the
included studies assessed?
4. Were the assessment of the
studies reproducible?
Yes Randomized control trial were included, come
with the least bias.
Electronic searches: CENTRAL, MEDLINE,
CINAHL, EMBASE, & ISRCTN.
Yes Tried to include published & unpublished. Asked
experts in the field for ongoing studies. Tried to
avoid publication bias. No language restriction
Yes Assessment of the methodological quality of the
included study. Reference standards were
acceptable.
Reference standards were interpreted
independently from the test in question.
Yes Authors decide on:
• Which studies to include
• How valid these studies are
RESULTS
1. What are the overall
results of the review?
2. Were the results similar
from the study to study?
3. How precise were the
results?
See results Quantitative summary of the results is
usually presented in a forest plot.
Outcomes can be reported as
dichotonomous or continuous variable.
Yes Visual inspection of forest plot.
Chi-squared test was used. p<0.01)
I2 statitic was used
Provide us point estimates and 95% CIs
for individual studies, and an overall
estimate.
APPLICABILITY
1. Can the results be
applied to our own patient?
Yes Criteria for determining whether the findings
from the subgroup analysis are credible
1. The subgroup analysis should be pre-
planned.
2. There shouldn’t be too many subgroup
analyses.
3. Subgroup differences, if found, should be
seen consistently in different studies.
4. Subgroup differences, if found, should be
biologically plausible.
 INDIVIDUALIZING THE RESULTS

1. Individualize the Procalcitonin evaluation lowers the hospitalization costs.

benefit, risks & costs to (page 7)
your patient?
 GRADE working
group grades of Remarks
evidence
High quality We are very confident that the true effect lies close to the estimate
of effect.

Moderate quality We are moderately confident in the effect estimate: The true effect
is likely to be close to the estimate of effect but may be
substantially different.

Low quality Our confidence in the effect estimate is limited: The true effect
may be substantially different from the estimate of the effect.

Very low quality We have very little confidence in the effect estimate: The true
effect is likely to be substantially different from the estimate of
effect.
RISK OF BIAS GRAPH
RISK OF BIAS SUMMARY
FUNNEL PLOT OF COMPARISON
CONCLUSION
THANK YOU!