Objective: To determine the impact of point-of-care ultrasound (POCUS)-guided resuscitation on clinical outcomes in adult patients with shock. Data Source: We searched MEDLINE, Embase, and unpublished sources from inception to December 2023. Study Selection: We included randomized controlled trials (RCTs) that examined the use of POCUS to guide resuscitation in patients with shock. Data Extraction: We collected data regarding study and patient characteristics, POCUS protocol, control group interventions, and outcomes. Data Synthesis: We identified 18 eligible RCTs. POCUS slightly influences physicians’ plans for IV fluid (IVF) and vasoactive medication prescription (moderate certainty), but results in little to no changes in the administration of IVF (low to high certainty) or inotropes (high certainty). POCUS may result in no change in the number of CT scans performed (low certainty) but probably reduces the number of diagnostic echocardiograms performed (moderate certainty). POCUS-guided resuscitation probably reduces 28-day mortality (relative risk [RR] 0.88; 95% CI, 0.78–0.99), the duration of vasoactive medication (mean difference –0.73 d; 95% CI, –1.16 to –0.30), and the need for renal replacement therapy (RRT) (RR 0.80; 95% CI, 0.63–1.02) (low to moderate certainty evidence), and lactate clearance (high certainty evidence). POCUS-guided resuscitation may results in little to no difference in ICU or hospital admissions, ICU and hospital length of stay, and the need for mechanical ventilation (MV) (low to moderate certainty evidence). There is an uncertain effect on the risk of acute kidney injury and the duration of MV or RRT (very low certainty evidence). Conclusions: POCUS-guided resuscitation in shock may yield important patient and health system benefits. Due to lack of sufficient evidence, we were unable to explore how the thresholds of operator competency, frequency, and timing of POCUS scans impact patient outcomes.
Growing interest in microbial dysbiosis during critical illness has raised questions about the therapeutic potential of microbiome modification with probiotics. Prior randomized trials in this population suggest that probiotics reduce infection, particularly ventilator-associated pneumonia (VAP), although probiotic-associated infections have also been reported.
Objective
To evaluate the effect ofLactobacillus rhamnosusGG on preventing VAP, additional infections, and other clinically important outcomes in the intensive care unit (ICU).
Design, Setting, and Participants
Randomized placebo-controlled trial in 44 ICUs in Canada, the United States, and Saudi Arabia enrolling adults predicted to require mechanical ventilation for at least 72 hours. A total of 2653 patients were enrolled from October 2013 to March 2019 (final follow-up, October 2020).
Interventions
EnteralL rhamnosusGG (1 × 1010colony-forming units) (n = 1321) or placebo (n = 1332) twice daily in the ICU.
Main Outcomes and Measures
The primary outcome was VAP determined by duplicate blinded central adjudication. Secondary outcomes were other ICU-acquired infections includingClostridioides difficileinfection, diarrhea, antimicrobial use, ICU and hospital length of stay, and mortality.
Results
Among 2653 randomized patients (mean age, 59.8 years [SD], 16.5 years), 2650 (99.9%) completed the trial (mean age, 59.8 years [SD], 16.5 years; 1063 women [40.1%.] with a mean Acute Physiology and Chronic Health Evaluation II score of 22.0 (SD, 7.8) and received the study product for a median of 9 days (IQR, 5-15 days). VAP developed among 289 of 1318 patients (21.9%) receiving probiotics vs 284 of 1332 controls (21.3%; hazard ratio [HR], 1.03 (95% CI, 0.87-1.22;P = .73, absolute difference, 0.6%, 95% CI, –2.5% to 3.7%). None of the 20 prespecified secondary outcomes, including other ICU-acquired infections, diarrhea, antimicrobial use, mortality, or length of stay showed a significant difference. Fifteen patients (1.1%) receiving probiotics vs 1 (0.1%) in the control group experienced the adverse event ofL rhamnosusin a sterile site or the sole or predominant organism in a nonsterile site (odds ratio, 14.02; 95% CI, 1.79-109.58;P < .001).
Conclusions and Relevance
Among critically ill patients requiring mechanical ventilation, administration of the probioticL rhamnosusGG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use ofL rhamnosusGG in critically ill patients.
KEY POINTS Demand for organs continues to exceed their availability, both in Canada and around the world.[1][1] Optimizing the medical management of potential organ donors is an important strategy for enhancing organ supply. The explicit goals for management of deceased organ donors in the intensive
This chapter has two objectives. First, using a highly simplified, imaginary week in the life of a small country, we illustrate some of the critical differences between cash and accrual accounting. We see that accrual accounting paints a more realistic picture of the government's fiscal performance and position. The second objective is to show how accrual-based information can reframe decisions, when that information underpins the whole financial management system. We also explain why it is important that the key components of the financial management system—budgeting, appropriating, and reporting—are integrated.
This chapter looks at a government's balance sheet, showing the various types of assets and liabilities it contains. It defines net worth as the difference between total assets and total liabilities and explains why net worth is a better, more comprehensive, measure of fiscal position than the more common measure, debt. It introduces the importance of good asset management and highlights that debt is but one of a government's liabilities and may not be the largest. It describes some of the complexities of measuring the value of many liabilities.
