Research Spotlight

Ferrari, L. and Fichera, A. (2021). “Clostridioides Difficile Infection.” Dis Colon Rectum 64(2): 151-155.

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A 70-year-old smoker with history of chronic obstructive pulmonary disease was admitted with a diagnosis of community-acquired pneumonia. She was started on macrolide antibiotic, and after 6 days she developed diarrhea (5 episodes over the previous 24 hours). Her stool sample was positive for Clostridioides difficile by nucleic acid amplification test and toxin-enzyme immunoassay using a 2-step algorithm. Her antibiotics were switched to vancomycin. Despite that she developed abdominal pain, distension, and respiratory distress 2 days later.
Surgical consultation was requested to rule out toxic megacolon or colonic perforation. An abdomen-pelvis CT scan was performed, which showed severe colonic dilatation and edematous haustral folds (Fig. 1). The patient underwent an urgent subtotal colectomy with end ileostomy. Intraoperatively she was found to have fecal peritonitis with perforation at the splenic flexure. Eventually she recovered uneventfully and was discharged 7 days after the operation. [No abstract; excerpt from article].

Bell, K.R., Fogelberg, D., Barber, J., Nakase-Richardson, R., Zumsteg, J.M., Dubiel, R., Dams-O’Connor, K. and Hoffman, J.M. (2021). “The effect of phototherapy on sleep during acute rehabilitation after traumatic brain injury: a randomized controlled trial.” Brain Inj Jan 17;1-9. [Epub ahead of print].

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Objective: To examine the impact of bright white light (BWL) exposure on sleep quality in persons with recent traumatic brain injury (TBI). Design: Randomized, controlled device-sham study Setting: 3 TBI Model System inpatient rehabilitation units Participants: 131 participants (mean 40.9 years, 68% male) Intervention: Intervention group (N = 65) received BWL (1260 lux at 20 inches, 440-480 nanometers length) for 30 minutes each morning at 12-24 inches from the face. Control group (N = 66) received red light (<450 lux, no light between 440 and 480 nanometers) for the same period. Planned intervention was maximum of 10 treatments or until discharge. Main Outcome Measure: Sleep duration and quality using actigraphic recording. Results: There were no differences found between groups on the primary outcomes nor on the secondary outcomes (sleepiness, mood, cooperation with therapy). Conclusion: BWL treatment during acute rehabilitation hospitalization does not appear to impact sleep or measures commonly associated with sleep. While studies have indicated common complaints of sleep difficulties after TBI, we were unable to document an effect for phototherapy as a treatment. With growing evidence of the effect of sleep on neural repair and cognition, further study is needed to understand the nature and treatment of sleep disorders after TBI. Clinicaltrials.gov Identifier: NCT02214212.

Danesh, V., Hecht, J., Hao, R., Boehm, L., Jimenez, E.J., Arroliga, A.C., Sanghi, S. and Stevens, A. (2021). “Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS): Study protocol for peer mentor training.” J Adv Nurs Jan 11. [Epub ahead of print].

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AIMS: The primary aim of the Peer Support for Post Intensive Care Syndrome Self-Management (PS-PICS) peer mentor training trial is to determine the feasibility for peer mentor training to connect new ICU survivors with survivors who have made successful recoveries. Secondary aims are to also examine peer mentor eligibility, recruitment and retention rates and assess changes in participant knowledge of Post Intensive Care Syndrome (PICS), reported symptoms and health-related quality of life. DESIGN: Prospective clinical feasibility trial. METHODS: This study received funding from the National Institutes of Health funded P30 Center for Excellence (2014-2020). Up to 20 adult patients who have had an ICU stay of 3 days or longer more than 3 months ago will be enrolled into the study. Participants will undergo a 6-week peer mentor training program to learn how to promote healthy self-management behaviours, social connections, and well-being using motivational interviewing (MI). Participants will complete surveys about their recovery at 3 points during the study: prior to training, 6 weeks post-training and 3 months post-training. Survey questions will be used to assess trends in participant social isolation, depression, functional status, and self-management behaviours. DISCUSSION: Enrollment closes by December 2020. As a feasibility trial, power sufficient for hypothesis testing will not be available. However, study operations and intervention fidelity contribute to future research knowledge and participant characteristics and longitudinal outcomes will yield data on intervention feasibility. This study is the first use of embedding peer-led motivational interviewing training into a peer support intervention for ICU survivors. IMPACT: Current self-management interventions are limited for ICU survivors and do not sufficiently address barriers to promoting self-management behaviours or improving their health status, well-being and cost of health. This study will provide data to develop and implement interventions for the self-management of PICS-related symptoms and sequelae.

Pham, V., Nguyen, L., Hedin, R.J., Shaver, C., Hammonds, K.A.P. and Culp, W.C., Jr. (2021). “COVID-19: Anesthesia Machine Circuit Pressure During Use As An Improvised ICU Ventilator.” Anesth Analg Jan 12. [Epub ahead of print].

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BACKGROUND: Use of anesthesia machines as improvised ICU ventilators may occur in locations where waste anesthesia gas suction(WAGS) is unavailable. Anecdotal reports suggest as much as 18 cmH2O positive end-expiratory pressure(PEEP) being inadvertently applied under these circumstances, accompanied by inaccurate pressure readings by the anesthesia machine. We hypothesized that resistance within closed anesthetic gas scavenging systems(AGSS) disconnected from WAGS may inadvertently increase circuit pressures. METHODS: An anesthesia machine was connected to an anesthesia breathing circuit, a reference manometer, and a standard bag reservoir to simulate a lung. Ventilation was initiated as follows: Volume Control, TV 500 mL, respiratory rate 12, I:E 1:1.9, FiO2 1.0, fresh gas flow(FGF) rate 2.0 liters per minute(LPM), and PEEP 0 cmH2O. After engaging the ventilator, PEEP and peak inspiratory pressure(PIP) were measured by the reference manometer and the anesthesia machine display simultaneously. The process was repeated using prescribed PEEP levels of 5, 10, 15, and 20 cmH2O. Measurements were repeated with the WAGS disconnected and then were performed again at FGF of 4, 6, 8, 10, and 15 LPM. This process was completed on three anesthesia machines: Dräger Perseus A500, Dräger Apollo, and the GE Avance CS2. Simple linear regression was used to assess differences. RESULTS: Utilizing non-parametric Bland-Altman analysis, the reference and machine manometer measurements of PIP demonstrated median differences of -0.40 cmH2O (95%LOA: -1.00,0.55) for the Dräger Apollo, -0.40 cmH2O (95%LOA: -1.10, 0.41) for the Dräger Perseus, and 1.70 cmH2O (95%LOA: 0.80,3.00) for the GE Avance CS2. At FGF 2 LPM and PEEP 0 cmH2O with the WAGS disconnected, the Dräger Apollo had a difference in PEEP of 0.02 cmH2O (95%CI: -0.04,0.08; p=0.53); the Dräger Perseus A500, <0.0001 cmH2O (95%CI: -0.11 0.11; p=1.00); and the GE Avance CS2, 8.62 cmH2O (95%CI: 8.55,8.69; p<0.0001). After removing the hose connected to the AGSS and the visual indicator bag on the GE Avance CS2, the PEEP difference was 0.12 cmH2O (95%CI: 0.059,0.181; p=0.0002). CONCLUSIONS: Displayed airway pressure measurements are clinically accurate in the setting of disconnected WAGS. The Dräger Perseus A500 and Apollo with open scavenging systems do not deliver inadvertent CPAP with WAGS disconnected, but the GE Avance CS2 with a closed AGSS does. This increase in airway pressure can be mitigated by the manufacturer's recommended alterations. Anesthesiologists should be aware of the potential clinically important increases in pressure that may be inadvertently delivered on some anesthesia machines, should the WAGS not be properly connected.

Karacsonyi, J., Stanberry, L., Alaswad, K., Krestyaninov, O., Choi, J.W., Rangan, B.V., Nikolakopoulos, I., Vemmou, E., Ungi, I. and Brilakis, E.S. (2021). “Predicting Technical Success of Chronic Total Occlusion Percutaneous Coronary Intervention: Comparison of 3 Scores.” Circ Cardiovasc Interv 14(1): e009860.

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The success of chronic total occlusion (CTO) percutaneous coronary intervention (PCI) significantly increased from 77% between 2000 and 20111 to 85% to 90% currently at experienced centers and depends on center and operator experience and lesion characteristics. Several CTO PCI scoring systems have been developed to assess procedural difficulty. The first one was the Japan chronic total occlusion (J-CTO) score that estimates the likelihood of successful guidewire crossing within the first 30 minutes based on 5 variables: blunt stump, calcification, lesion tortuosity, prior failed attempt, and occlusion length ≥20 mm. Another widely used score is the Prospective Global Registry for the Study of Chronic Total Occlusion Intervention (PROGRESS-CTO) score that uses 4 angiographic characteristics: moderate/severe proximal vessel tortuosity, proximal cap ambiguity, circumflex coronary artery CTO, and absence of interventional collaterals to predict technical success.The EuroCTO CASTLE score utilizes 6 variables for assessing the likelihood of success: prior Coronary artery bypass graft surgery, age (≥70 years), stump anatomy (blunt or invisible), tortuosity degree (severe or unseen), length of occlusion (≥20 mm), and extent of calcification (>50% of the segment). [No abstract; excerpt from article].