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Psychiatric long-term complications of intensive care unit survivors.

To the Editor: The comprehensive meta-analysis by Delaney et al (1) showed that albumin use is associated with a decrease in mortality in patients with sepsis. Because the metaanalysis included studies published as long ago as 1983, the influence of existing standards of care on outcome may have affected the study’s findings. For example, Rackow et al (2) initiated mechanical ventilation at 12 mL/kg and zero end-expiratory pressure. They also provided blood to maintain hemoglobin concentrations at 10 g/dL. Consequently, use of interventions that are now known to have deleterious effects may have limited any potential benefit of albumin. A comparison of albumin vs. control in the nine studies published before 2000 showed mortality rates of 40.3% in the albumin group and 37.8% in the control group (chi-square, p .62). Conversely, in the eight studies published after 2000, mortality rates in the albumin and control groups were 26.5% and 32.9%, respectively (p .0049). The limitation of conducting metaanalyses without accounting for timerelated improvements in medical care has been previously recognized. Minneci et al (3) conducted a meta-analysis that showed that low-dose steroids were associated with decreased mortality in patients with sepsis while high-dose steroids were associated with increased mortality. Recognizing that the highdose steroid studies were conducted before 1989 (initial study published in 1963), the authors acknowledged that advances in care, such as ventilator management, fluid therapy, and use of vasopressor agents, may have influenced their findings. In the case of albumin, as with other aspects of critical care, researchers need to remain cognizant of the fact that improvements in care are ongoing and that meta-analyses may need to account for differences attributable to epochs of care in their analyses. The authors have not disclosed any potential conflicts of interest. Cesar Alaniz, PharmD, University of Michigan Hospitals and Health Centers and College of Pharmacy, Ann Arbor, MI; Robert C. Hyzy, MD, Division of Pulmonary and Critical Care Medicine, University of Michigan Hospitals and Health Centers, Ann Arbor, MI