Research Spotlight

Shih, E., DiMaio, J.M., Squiers, J.J., Krueger, A.R., Schwartz, G.S., Herd, J. and Bleich, A.T. (2021). “Treatment of acute respiratory distress syndrome from COVID-19 with extracorporeal membrane oxygenation in obstetrical patients.” Am J Obstet Gynecol MFM 4(2): 100537.

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BACKGROUND: Extracorporeal membrane oxygenation therapy has been used as a rescue therapy for patients with severe acute respiratory distress syndrome from COVID-19 who have failed conventional ventilatory strategies. Little is known about the outcome of pregnant and postpartum patients on extracorporeal membrane oxygenation therapy. OBJECTIVE: To describe the medical and surgical outcomes of pregnant and postpartum patients who were placed on extracorporeal membrane oxygenation therapy for severe acute respiratory distress syndrome from COVID-19. STUDY DESIGN: A case series reviewing pregnant or postpartum patients with laboratory-confirmed COVID-19 who were placed on extracorporeal membrane oxygenation therapy was conducted within the Baylor Scott & White Healthcare system. The demographics and the medical and surgical outcomes were collected and reviewed. RESULTS: Between March 2020 and October 2021, 5 pregnant and 5 postpartum women were supported with venovenous extracorporeal membrane oxygenation therapy. The median age was 30 years (interquartile range, 26-33.5) and the median body mass index was 36.6 kg/m(2) (interquartile range, 29.5-42.0). There was a median of 4.5 days (interquartile range, 1.5-6.8) from admission to any hospital to intubation and 9 days (interquartile range, 7-13) to extracorporeal membrane oxygenation therapy cannulation. One patient had an ischemic stroke, 1 patient had a presumed hemorrhagic stroke, and 9 patients developed bleeding while on extracorporeal membrane oxygenation therapy. Of the 5 pregnant women, 2 patients had intrauterine fetal demise and 3 underwent delivery for maternal hemodynamic instability. The 5 postpartum women were initiated on extracorporeal membrane oxygenation therapy a median of 10 days (interquartile range, 3-11) after delivery. The median length of time on extracorporeal membrane oxygenation therapy was 22 days (interquartile range, 11-31). At the time of the study, there were 2 inpatient mortalities, 6 patients survived to discharge from the extracorporeal membrane oxygenation therapy hospital, and 2 patients were still admitted. CONCLUSION: There is limited information regarding the use of extracorporeal membrane oxygenation therapy for COVID-19 acute respiratory distress syndrome in obstetrical patients. This case series describes the use of extracorporeal membrane oxygenation therapy and survival in pregnant and postpartum patients with COVID-19.

Gaudino, M., Sanna, T., Ballman, K.V., Robinson, N.B., Hameed, I., Audisio, K., Rahouma, M., Di Franco, A., Soletti, G.J., Lau, C., Rong, L.Q., Massetti, M., Gillinov, M., Ad, N., Voisine, P., DiMaio, J.M., Chikwe, J., Fremes, S.E., Crea, F., Puskas, J.D. and Girardi, L. (2021). “Posterior left pericardiotomy for the prevention of atrial fibrillation after cardiac surgery: an adaptive, single-centre, single-blind, randomised, controlled trial.” Lancet 398(10316): 2075-2083.

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BACKGROUND: Atrial fibrillation is the most common complication after cardiac surgery and is associated with extended in-hospital stay and increased adverse outcomes, including death and stroke. Pericardial effusion is common after cardiac surgery and can trigger atrial fibrillation. We tested the hypothesis that posterior left pericardiotomy, a surgical manoeuvre that drains the pericardial space into the left pleural cavity, might reduce the incidence of atrial fibrillation after cardiac surgery. METHODS: In this adaptive, randomised, controlled trial, we recruited adult patients (aged ≥18 years) undergoing elective interventions on the coronary arteries, aortic valve, or ascending aorta, or a combination of these, performed by members of the Department of Cardiothoracic Surgery from Weill Cornell Medicine at the New York Presbyterian Hospital in New York, NY, USA. Patients were eligible if they had no history of atrial fibrillation or other arrhythmias or contraindications to the experimental intervention. Eligible patients were randomly assigned (1:1), stratified by CHA(2)DS(2)-VASc score and using a mixed-block randomisation approach (block sizes of 4, 6, and 8), to posterior left pericardiotomy or no intervention. Patients and assessors were blinded to treatment assignment. Patients were followed up until 30 days after hospital discharge. The primary outcome was the incidence of atrial fibrillation during postoperative in-hospital stay, which was assessed in the intention-to-treat (ITT) population. Safety was assessed in the as-treated population. This study is registered with ClinicalTrials.gov, NCT02875405, and is now complete. FINDINGS: Between Sept 18, 2017, and Aug 2, 2021, 3601 patients were screened and 420 were included and randomly assigned to the posterior left pericardiotomy group (n=212) or the no intervention group (n=208; ITT population). The median age was 61·0 years (IQR 53·0-70·0), 102 (24%) patients were female, and 318 (76%) were male, with a median CHA(2)DS(2)-VASc score of 2·0 (IQR 1·0-3·0). The two groups were balanced with respect to clinical and surgical characteristics. No patients were lost to follow-up and data completeness was 100%. Three patients in the posterior left pericardiotomy group did not receive the intervention. In the ITT population, the incidence of postoperative atrial fibrillation was significantly lower in the posterior left pericardiotomy group than in the no intervention group (37 [17%] of 212 vs 66 [32%] of 208 [p=0·0007]; odds ratio adjusted for the stratification variable 0·44 [95% CI 0·27-0·70; p=0·0005]). Two (1%) of 209 patients in the posterior left pericardiotomy group and one (<1%) of 211 in the no intervention group died within 30 days after hospital discharge. The incidence of postoperative pericardial effusion was lower in the posterior left pericardiotomy group than in the no intervention group (26 [12%] of 209 vs 45 [21%] of 211; relative risk 0·58 [95% CI 0·37-0·91]). Postoperative major adverse events occurred in six (3%) patients in the posterior left pericardiotomy group and in four (2%) in the no intervention group. No posterior left pericardiotomy related complications were seen. INTERPRETATION: Posterior left pericardiotomy is highly effective in reducing the incidence of atrial fibrillation after surgery on the coronary arteries, aortic valve, or ascending aorta, or a combination of these without additional risk of postoperative complications. FUNDING: None.

Cengiz, A., Yoder, L.H. and Danesh, V. (2021). “A concept analysis of role ambiguity experienced by hospital nurses providing bedside nursing care.” Nurs Health Sci 23(4): 807-817.

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The concept of role ambiguity, despite its wide application in nursing research, lacks a clear definition and conceptualization, resulting in inconsistencies about how it is defined, operationalized, and applied in research. The purpose of this paper was to analyze and define the concept of role ambiguity among hospital nurses providing nursing care, using the concept analysis method developed by Walker and Avant. The three defining attributes of role ambiguity were lack of information (information deficiency), lack of clarity, and unpredictability. Antecedents included lack of clear role definitions, lack of education/training, communication problems, supervisory behaviors and support, organizational culture, practice environment conditions, experience, group cohesiveness, and preferred work setting. The consequences of role ambiguity included increased stress, lack of organizational commitment, job dissatisfaction, burnout, and increased intent to leave. This concept analysis provides a clear conceptual definition to better understand role ambiguity among hospital nurses along with implications for nurse leaders, educators, clinicians, and researchers to support nurses and guide future research. This paper further emphasizes the importance of nurse-manager relationships in reducing the experience of role ambiguity among hospital nurses.

Culp, W.C., Jr. and Muse, K.W. (2021). “Preventing Operating Room Fires: Impact of Surgical Drapes on Oxygen Contamination of the Operative Field.” J Patient Saf 17(8): e1846-e1850.

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OBJECTIVE: The aim of the study was to measure underdrape oxygen pooling, surgical site oxygen contamination, and time to restoration of 21% oxygen concentration after cessation of oxygen delivery by measuring oxygen concentration under simulated clinical conditions with various drapes. METHODS: In a 2-part study, oxygen permeability of four differing surgical drapes was measured (Part A) and a mannequin was used to measure underdrape oxygen pooling and surgical site oxygen contamination (Part B). In Part A, a container of high concentration oxygen was sealed with a surgical drape. Oxygen concentrations on both sides of the drape were then measured over time to quantify drape oxygen permeability. Part B included a mannequin model draped for a hypothetical surgical site with oxygen administered by face mask. Oxygen concentration was measured at both the surgical site and under the drape nearest the surgical site. RESULTS: Oxygen permeability varied significantly between drapes tested. The surgical site oxygen concentration ranged from 20% to 58% (P = 0.0001). The commonly used woven 100% cotton operating room (OR) towel was highly permeable. The plastic occlusive drape created an impermeable barrier, which did not allow for any oxygen contamination but created the longest time to return to 21% oxygen concentration at the underdrape site after cessation of oxygen delivery. CONCLUSIONS: Surgical drapes have varying oxygen permeability and can lead to high concentration underdrape oxygen pooling. Oxygen contamination of the surgical site varies widely based on drape material and may reach dangerously high levels, especially with the cotton OR towel. Surgical drape selection may impact OR fire risk.

Scullin, M.K., Jones, W.E., Phenis, R., Beevers, S., Rosen, S., Dinh, K., Kiselica, A., Keefe, F.J. and Benge, J.F. (2021). “Using smartphone technology to improve prospective memory functioning: A randomized controlled trial.” J Am Geriatr Soc.

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BACKGROUND: A decline in the ability to perform daily intentions-known as prospective memory-is a key driver of everyday functional impairment in dementia. In the absence of effective pharmacological treatments, there is a need for developing, testing, and optimizing behavioral interventions that can bolster daily prospective memory functioning. We investigated the feasibility and efficacy of smartphone-based strategies for prospective memory in persons with cognitive impairment. METHODS: Fifty-two older adults (74.79 ± 7.20 years) meeting diagnostic criteria for mild cognitive impairment or mild dementia were enrolled in a 4-week randomized controlled trial. Participants were trained to use a digital voice recorder app or a reminder app to off-load prospective memory intentions. Prospective memory was assessed using experimenter-assigned tasks (e.g., call the laboratory on assigned days), standardized questionnaires, and structured interviews. Secondary dependent measures included days of phone and app usage, acceptability ratings, quality of life, and independent activities of daily living. RESULTS: Participant ratings indicated that the intervention was acceptable and feasible. Furthermore, after the four-week intervention, participants reported improvements in daily prospective memory functioning on standardized questionnaires (p < 0.001, η(p) (2) = 0.285) and the structured interview (p < 0.001, d = 1.75). Participants performed relatively well on experimenter-assigned prospective memory tasks (51.7% ± 27.8%), with performance levels favoring the reminder app in Week 1, but reversing to favor the digital recorder app in Week 4 (p = 0.010, η(p) (2) = 0.079). Correlational analyses indicated that greater usage of the digital recorder or reminder app was associated with better prospective memory performance and greater improvements in instrumental activities of daily living (completed by care partners), even when controlling for condition, age, baseline cognitive functioning, and baseline smartphone experience. CONCLUSIONS: Older adults with cognitive disorders can learn smartphone-based memory strategies and doing so benefits prospective memory functioning and independence.