Citations

Abstract Background CERTAIN (Checklist for Early Recognition and Treatment of Acute Illness and iNjury) has been shown to improve critical care process and patient outcomes in international ICUs with variable resources. Methods CERTAIN education program derived from this approach is designed, promoted, and implemented following the Logic model. Through the roadmap of the Logic model, we presented a dynamic, longitudinal implementation framework that had sufficient rigor yet offers flexibility to reach the need of the existing and emerging diversified medical education projects. Results Using the Logic model, the delivery of the CERTAIN education program is optimized to deliver relevant education content in various environments. During the COVID-19 outbreak, the implementational framework demonstrated that it could serve as an excellent template for effective response to global pandemics. Conclusions The Logical model is useful as a facilitation tool for planning and evaluating innovative education delivery and dissemination. The CERTAIN program provided an example for other continuous professional education projects.

OBJECTIVES: To evaluate the efficacy of the simultaneous hypertonic saline solution and IV furosemide (HSS+Fx) for patients with fluid overload compared with IV furosemide alone (Fx). DATA SOURCES: Electronic databases (MEDLINE, EMBASE, CENTRAL, Cochrane Database of Systematic Reviews, PsycINFO, Scopus, and WOS) were searched from inception to March 2020. STUDY SELECTION: Randomized controlled trials on the use of HSS+Fx in adult patients with fluid overload versus Fx were included. DATA EXTRACTION: Data were collected on all-cause mortality, hospital length of stay, heart failure–related readmission, along with inpatient weight loss, change of daily diuresis, serum creatinine, and 24-hour urine sodium excretion from prior to post intervention. Pooled analysis with random effects models yielded relative risk or mean difference with 95% CIs. DATA SYNTHESIS: Eleven randomized controlled trials comprising 2,987 acute decompensated heart failure patients were included. Meta-analysis demonstrated that HSS+Fx was associated with lower all-cause mortality (relative risk, 0.55; 95% CI, 0.46–0.67; p < 0.05; I2 = 12%) and heart failure–related readmissions (relative risk, 0.50; 95% CI, 0.33–0.76; p < 0.05; I2 = 61%), shorter hospital length of stay (mean difference, –3.28 d; 95% CI, –4.14 to –2.43; p < 0.05; I2 = 93%), increased daily diuresis (mean difference, 583.87 mL; 95% CI, 504.92–662.81; p < 0.05; I2 = 76%), weight loss (mean difference, –1.76 kg; 95% CI, –2.52 to –1.00; p < 0.05; I2 = 57%), serum sodium change (mean difference, 6.89 mEq/L; 95% CI, 4.98–8.79; p < 0.05; I2 = 95%), and higher 24-hour urine sodium excretion (mean difference, 61.10 mEq; 95% CI, 51.47–70.73; p < 0.05; I2 = 95%), along with decreased serum creatinine (mean difference, –0.46 mg/dL; 95% CI, –0.51 to –0.41; p < 0.05; I2 = 89%) when compared with Fx. The Grading of Recommendation, Assessment, Development, and Evaluation certainty of evidence ranged from low to moderate. CONCLUSIONS: Benefits of the HSS+Fx over Fx were observed across all examined outcomes in acute decompensated heart failure patients with fluid overload. There is at least moderate certainty that HSS+Fx is associated with a reduction in mortality in patients with acute decompensated heart failure. Factors associated with a successful HSS+Fx utilization are still unknown. Current evidence cannot be extrapolated to other than fluid overload states in acute decompensated heart failure.

Patients with congenital heart disease who have a morphological right ventricle (RV) serving as a systemic ventricle have an increased incidence of RV dysfunction. A different structural response of micro‐vessels to increased stress in the RV wall is a possible mechanism for this dysfunction. We examined this possibility by measuring the volume of myocardium perfused by arteries less than 200μm in lumen diameter (V) 7 weeks after a 5mg/kg IV injection of monocrotaline in three 2‐week old and three 18‐week old pigs. This information was obtained by use of 3D micro‐CT of transmural segments (~ 2cm 3 ) of the RV wall. The table provides the average values of V (mm 3 /mm 2 ± SD). Pulmonary artery pressures in the mature, treated pigs were 35±6 mmHg and in the juvenile were 25±2 mmHg. V did not differ from control in the treated 2.5‐month old pigs but trended down in the 6‐month old pigs. We conclude that the volume of myocardium perfused by an arteriole in the RV wall may be an indicator of the perfusion reserve available to the microcirculation in response to increased wall stress. A more definitive answer would require delayed study of the early onset treatment group at the age of 6 months. (Supported in part by NIH grant EB000305)

IMPORTANCE: Propofol, ketamine, and etomidate are common anesthetic agents for induction of anesthesia in the ICU. The choice between these agents is complex and may not depend solely upon severity of illness. OBJECTIVES: To evaluate the association between the administration of propofol, ketamine, and etomidate and ICU, hospital mortality, and length of stay. DESIGN, SETTING, AND PARTICIPANTS: Retrospective single-center cohort study. ICUs in a tertiary medical center, between January 01, 2012, and December 31, 2017. Critically ill adult patients given a single IV anesthetic for intubation. MAIN OUTCOME AND MEASURES: Primary outcomes were ICU and hospital mortality. Secondary outcomes were ICU- and hospital-free days through 28 days. An inverse probability of treatment weighed approach was used. The propensity score was estimated using a generalized logit model as a function of patient characteristics, admission source, ICU type, readmission status, length of ICU stays prior to intubation, and acute physiology score. Mortality outcomes were assessed with weighted logistic regression and -free days assessed by weighted linear regression with Bonferroni correction for pairwise comparisons. RESULTS: Of 2,673 patients, 36% received propofol, 30% ketamine and 34% etomidate. Overall ICU and hospital mortality were 19% and 29%, respectively. Patients given ketamine had higher odds of ICU mortality (1.45; [95% CI, 1.07–1.94]; p = 0.015) and patients given etomidate had higher odds of ICU mortality (1.87; 1.40–2.49; p < 0.001), hospital mortality (1.43; 1.09–1.86; p = 0.009), and less ICU-free days (–2.10; –3.21 to –1.00; p < 0.001) than those given propofol. Patients given ketamine and etomidate had similar odds of hospital mortality (1.06; 0.80–1.42; p = 0.761) and similar hospital-free days (0.30; –0.81 to 1.40; p = 0.600). CONCLUSIONS AND RELEVANCE: Compared with ketamine and etomidate, propofol was associated with better outcome in critically ill patients undergoing anesthesia for intubation. Even after adjusting for severity of illness prior to intubation, residual confounders cannot be excluded.