1 of 4

UNIVERSITY OF COLORADO HOSPITAL

SYSTEMATIC REVIEW OR META-ANALYSIS CRITIQUE
Facilitator of Journal Club

Name: David Ornelas

Date: 6.13.2015

Systematic Review:
It is a summary of evidence on a particular topic, conducted using a rigorous process for identifying, appraising, and
synthesizing numerous studies to answer a clinical question.
Meta-analysis:
A systematic review is the quantitative synthesis of multiple studies. A meta-analysis produces a summary statistic that
represents the effect of the intervention across multiple studies.
Both systematic reviews and meta-analyses yield the strongest level of evidence (LOE I) to use when making practice
decisions.

Article Reviewed: (Author names, Title of article, Journal, Year, Volume, Page numbers)
F.A. Zeiler, J. Teitelbaum, L.M. Gillman, M. West; THAM for Control of ICP; Neurocit Care (2014) 21:332-344
(Facilitator Info: Before you being your critique, read the critique form to be aware of what questions you should answer after reading
the article. Then, read the article for a first overview or impression. Finally, read the article again, slowly. Stop and answer the
questions from the critique form. Highlight the answers in the article. Also, on the critique form, write page numbers of where answers
can be found to help you when you are leading the discussion at the Journal Club. As you plan for the journal club, refer to the
Research and Evidence-Based Practice Manual 2nd Edition. Chapter 7 titled Participating in a Journal Club provides step by step
advice for the process.)

Article Purpose:

What are the review questions? What is the effect of THAM on ICP in patients with neurological illness?

Are they clearly and explicitly stated? Yes. However, the authors do not indicate review question until the methods
section.

Evaluation of Validity of the Review:

How was the clinical question focused with regard to:

o The population? Focused on patients with neurological illness.

The intervention? Use of THAM and its effects on the above population.

The outcome measure? Primary outcome measure was documented effect on ICP post-THAM
administration. With secondary outcome measures being cerebral perfusion pressure, mean arterial blood
pressure, patient outcome, and adverse effects of THAM.

Was a systematic approach used for the literature search:

o What search terms were used? The search terms are available in an Appendix not included with this
online article.
o

What years were included? The below listed databases from inception to February 2014. Also, meeting
proceedings were utilized from 2004 to February 2014.

What databases were used? MEDLINE, BIOSIS, EMBASE, Global health, HealthStar, SCOPUS,
and Cochrane Library

Were all the relevant databases, and appropriate search terms used for the search? All
databases appear relevant, however, the search terms are available in an Appendix not included with this
online article.

Were other searches performed to enhance the database retrieval (i.e. reference lists, additional
bibliographies, or professional organizations)? Yes. Meeting proceedings for the last 10 years were

2 of 4

looked at. Also, reference lists of any review articles or systematic reviews on THAM usage or ICP
control were reviewed for relevant studies on THAM.

What criteria were used to select studies to be included in the review? All studies included human subjects
with neurological illness with 5 or more patients of any age, the use of THAM, and documentation of ICP response to
THAM administration. Both prospective and retrospective studies were included as well. Lastly, non-English studies
were included based on the above information as well.
o

Were the criteria established before the review began? Yes. Based on the use of extended search
engines, i.e. meeting proceedings and reference lists.

Were inclusion criteria based upon:

o Sample characteristics? Yes
o

Interventions studied? Yes

Research methods? Yes

Research Design? Systematic Review

Outcomes examined? Yes

Is there a table of the studies included in the review with a brief synopsis of each study? Yes. It can be
viewed starting on page 336 of the article.

Were the methods used to critique the studies described? Two reviewers were utilized to critique in a two-step
fashion. First, the reviewers independently screened all titles and abstracts of the returned articles to decide if they met
the inclusion criteria. Second, full text of the chosen articles was then assessed to confirm if they met the inclusion
criteria and that the primary outcome of ICP response was reported in the study.

Were the critiques carried out by more than one person? Yes. Two reviewers were utilized to critique in a twostep fashion.

Interpreting the Results:

Were the results consistent across studies? Yes. All but one study showed reductions in ICP with THAM.

What were the overall results of the review? The use of THAM showed reductions in ICP with only one of the
twelve studies describing no ICP reduction. The results were broken down in to THAM use as a continuous
infusion and THAM use as bolus dosing. Of the six studies looking at continuous infusion, all displayed ICP
reductions. Five out the six bolus dose studies revealed ICP reductions.

How large is the intervention or treatment effect (for meta-analysis only)?

Are the conclusions or summary supported by the reported data? Yes. There currently exists Oxford level 2b,
GRADE B evidence to support that THAM reduces ICP.

Applicability of Results to Practice

What are the clinical implications for my clinical practice? The patient population in the Neuro-Surgical ICU is
similar to those described in the article. We routinely deal with high ICPs and having another medication to assist
in treatment might be beneficial.

3 of 4

Are my patients similar to the patients included in the original studies? Yes.

Is the intervention feasible in my setting? Yes. The Neuro-Surgical ICU has started initiating THAM therapy for
high ICPs.
o

What other information would I need to assess this? None

Were all important outcomes considered? Yes. If we can prevent ischemia to the brain or herniation our patient
outcomes should benefit.
o

What important outcomes were not considered? None

Do the benefits outweigh the potential harm/risk? Yes, I believe benefits do outweigh potential risks identified.
One of the main risks noted in the article is respiratory distress. At the point we would be using THAM to treat
high ICPs, the patient would be intubated. If not, they are in a critical care setting with vigilant and frequent
monitoring.

What is my clinical assessment of the patient or practice setting and are there any contraindications or
circumstances that would inhibit me from implementing the treatment/intervention? None anticipated.
THAM is a medication and needs to be ordered by a licensed provider. Our physicians are implementing this
intervention after discussion about this article.

How do my patients (and family) preferences fit with the intervention being considered? There does not
appear to be any ethical or legal issues in prescribing THAM, however, these would be discussed with patients
and family on an individual basis..

What is the level of evidence for this study? 1

4 of 4

Strongest
Evidence

Level
1
2
4
5

Weakest
Evidence

6
7
8

Evidence
Systematic review & meta-analysis of randomized controlled trials; clinical
guidelines based on systematic reviews or meta-analyses
One or more randomized controlled trials
Controlled trial (no randomization); quasi-experimental
Case-control or cohort study
Systematic review of descriptive studies; systematic review of qualitative
studies (metasynthesis)
Single descriptive or qualitative study
Program evaluation, research utilization, quality improvement projects; case
reports (JC sentinel event); benchmarking studies (NDNQI data, UHC reports);
or research-based clinical practice guidelines
Expert opinion (authorities and/or reports of expert committees) textbooks,
clinical product guidelines; non-research based clinical practice guidelines

2015, University of Colorado Hospital Authority. All information contained on this form is copyright protected
and may only be downloaded and/or reprinted for personal use. Permission to use these materials in whole or
in part for any commercial use is expressly prohibited unless prior written consent is granted by the
Department of Professional Resources, University of Colorado Hospital, Mail Stop 901, 12401 E. 17th Ave.,
Aurora, CO.