Monitoring and auditing protocol adherence, data integrity and ethical conduct of a randomized clinical trial: A case study

PURPOSE

To categorize, quantify and interpret findings documented in feedback letters of monitoring or auditing visits for an investigator-initiated, peer-review funded multicenter randomized trial testing probiotics for critically ill patients.

MATERIALS & METHODS

In 37 Canadian centers, monitoring and auditing visits were performed by 3 trained individuals; findings were reported in feedback letters. At trial termination, we performed duplicate content analysis on letters, categorizing observations first into unique findings, followed by 10 pre-determined trial quality management domains. We further classified each observation into a) missing operational records, b) errors in process, and potential threats to c) data integrity, d) patient privacy or e) safety.

RESULTS

Across 37 monitoring or auditing visits, 75 unique findings were categorized into 10 domains. Most frequently, observations were in domains of training documentation (180/566 [32%]) and the informed consent process (133/566 [23%]). Most observations were missing operational records (438/566 [77%]) rather than errors in process (128/566 [23%]). Of 75 findings, 13 (62/566 observations [11%]) posed a potential threat to data integrity, 1 (1/566 observation [0.18%]) to patient privacy, and 9 (49/566 observations [8.7%]) to patient safety.

CONCLUSIONS

Monitoring and auditing findings predominantly concerned missing documentation with minimal threats to data integrity, patient privacy or safety.

TRIAL REGISTRATION

PROSPECT (Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial): NCT02462590.

The evolution of mean arterial pressure in critically ill patients on vasopressors before and during a trial comparing a specific mean arterial pressure target to usual care

Background

In randomized clinical controlled trials, the choice of usual care as the comparator may be associated with better clinician uptake of the study protocol and lead to more generalizable results. However, if care processes evolve to resemble the intervention during the course of a trial, differences between the intervention group and usual care control group may narrow. We evaluated the effect on mean arterial pressure of an unblinded trial comparing a lower mean arterial pressure target to reduce vasopressor exposure, vs. a clinician-selected mean arterial pressure target, in critically ill patients at least 65 years old.

Methods

For this multicenter observational study using data collected both prospectively and retrospectively, patients were recruited from five of the seven trial sites. We compared the mean arterial pressure of patients receiving vasopressors, who met or would have met trial eligibility criteria, from two periods: [1] at least 1 month before the trial started, and [2] during the trial period and randomized to usual care, or not enrolled in the trial.

Results

We included 200 patients treated before and 229 after trial initiation. There were no differences in age (mean 74.5 vs. 75.2 years; p = 0.28), baseline Acute Physiology and Chronic Health Evaluation II score (median 26 vs. 26; p = 0.47) or history of chronic hypertension (n = 126 [63.0%] vs. n = 153 [66.8%]; p = 0.41). Mean of the mean arterial pressure was similar between the two periods (72.5 vs. 72.4 mmHg; p = 0.76).

Conclusions

The initiation of a trial of a prescribed lower mean arterial pressure target, compared to a usual clinician-selected target, was not associated with a change in mean arterial pressure, reflecting stability in the net effect of usual clinician practices over time. Comparing prior and concurrent control groups may alleviate concerns regarding drift in usual practices over the course of a trial or permit quantification of any change.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01529-w.

Acute plastic bronchitis after Ross procedure treated with veno-venous extracorporeal membrane oxygenation

PURPOSE

Plastic bronchitis is a rare condition characterized by the formation of airway casts occluding the lower respiratory tract. It is described more commonly in children, especially following correction of congenital heart disease. It involves lymphatic abnormalities leading to endobronchial lymph precipitating airway cast formation. When it presents acutely, it can lead to acute airway obstruction, which can be life-threatening. Plastic bronchitis has been rarely described in adults and is potentially underdiagnosed. The purpose of this case report is to emphasize, for the adult anesthesiologist and adult critical care physician, the importance of prompt diagnosis and respiratory support in a case of plastic bronchitis.

CLINICAL FEATURES

A 40-yr-old female with severe aortic stenosis underwent a Ross procedure. The surgery was uneventful, but within two hours of arrival in the intensive care unit, the patient developed severe hypoxemia. Despite attempts to optimize her respiratory status, the patient remained severely hypoxemic, and veno-venous extracorporeal membrane oxygenation (ECMO) was initiated using a percutaneous femoro-femoral cannulation. A bronchoscopy showed bronchial secretions casting the proximal bronchus, suggestive of plastic bronchitis. After numerous bronchoscopies, we were able to clean the airways and wean the ECMO support on postoperative day 3.

CONCLUSION

Plastic bronchitis can present in adult patients and be life-threatening when associated with acute respiratory failure. We report an unusual case of an adult patient treated with veno-venous ECMO for plastic bronchitis following cardiac surgery. Use of ECMO support while providing airway cleaning can be lifesaving in patients with respiratory failure secondary to plastic bronchitis.

Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65): protocol and statistical analysis plan for a randomised clinical trial

INTRODUCTION

Vasodilatory hypotension is common among intensive care unit (ICU) patients; vasopressors are considered standard of care. However, optimal mean arterial pressure (MAP) targets for vasopressor titration are unknown. The objective of the Optimal VAsopressor TitraTION in patients 65 years and older (OVATION-65) trial is to ascertain the effect of permissive hypotension (vasopressor titration to achieve MAP 60-65 mm Hg) versus usual care on biomarkers of organ injury in hypotensive patients aged ≥65 years.

METHODS AND ANALYSIS

OVATION-65 is an allocation-concealed randomised trial in 7 Canadian hospitals. Eligible patients are ≥65 years of age, in an ICU with vasodilatory hypotension, receiving vasopressors for ≤12 hours to maintain MAP ≥65 mm Hg during or after adequate fluid resuscitation, and expected to receive vasopressors for ≥6 additional hours. Patients are excluded for any of the following: active treatment for spinal cord or acute brain injury; vasopressors given solely for bleeding, ventricular failure or postcardiopulmonary bypass vasoplegia; withdrawal of life-sustaining treatments expected within 48 hours; death perceived as imminent; previous enrolment in OVATION-65; organ transplant within the last year; receiving extracorporeal life support or lack of physician equipoise. Patients are randomised to permissive hypotension versus usual care for up to 28 days. The primary outcome is high-sensitivity troponin T, a biomarker of cardiac injury, on day 3. Secondary outcomes include biomarkers of injury to other organs (brain, liver, intestine, skeletal muscle); lactate (a biomarker of global tissue dysoxia); resource utilisation; adverse events; mortality (90 days and 6 months) and cognitive function (6 months). Assessors of biomarkers, mortality and cognitive function are blinded to allocation.

ETHICS AND DISSEMINATION

This protocol has been approved at all sites. Consent is obtained from the eligible patient, the substitute decision-maker if the patient is incapable, or in a deferred fashion where permitted. End-of-grant dissemination plans include presentations, publications and social media platforms and discussion forums.

TRIAL REGISTRATION NUMBER

NCT03431181.

Early Evidence of Sepsis-Associated Hyperperfusion-A Study of Cerebral Blood Flow Measured With MRI Arterial Spin Labeling in Critically Ill Septic Patients and Control Subjects

OBJECTIVES

Mechanisms underlying sepsis-associated encephalopathy remain unclear, but reduced cerebral blood flow, alone or in conjunction with altered autoregulation, is reported as a potential contributor. We compared cerebral blood flow of control subjects and vasopressor-dependent septic patients.

DESIGN

Randomized crossover study.

SETTING

MRI with arterial spin labeling.

PATIENTS

Ten sedated septic patients on mechanical ventilation (four with controlled chronic hypertension) and 12 control subjects (six with controlled chronic hypertension) were enrolled. Mean ± SD ages were 61.4 ± 10.2 and 44.2 ± 12.8 years, respectively (p = 0.003). Mean Acute Physiology and Chronic Health Evaluation II score of septic patients at ICU admission was 27.7 ± 6.6.

INTERVENTIONS

To assess the potential confounding effects of sedation and mean arterial pressure, we measured cerebral blood flow with and without sedation with propofol in control subjects and at a target mean arterial pressure of 65 mm Hg and greater than or equal to 75 mm Hg in septic patients. The sequence of sedation versus no sedation and mean arterial pressure targets were randomized.

MEASUREMENTS AND MAIN RESULTS

In septic patients, cerebral blood flow measured at a mean arterial pressure target of 65 mm Hg (40.4 ± 10.9 mL/100 g/min) was not different from cerebral blood flow measured at a mean arterial pressure target of greater than or equal to 75 mm Hg (41.3 ± 9.8 mL/100 g/min; p = 0.65). In control subjects, we observed no difference in cerebral blood flow measured without and with sedation (24.8 ± 4.2 vs 24.9 ± 5.9 mL/100 g/min; p = 0.93). We found no interaction between chronic hypertension and the effect of sedation or mean arterial pressure targets. Cerebral blood flow measured in sedated septic patients (mean arterial pressure target 65 mm Hg) was 62% higher than in sedated control subjects (p = 0.001).

CONCLUSIONS

In septic patients, cerebral blood flow was higher than in sedated control subjects and did not vary with mean arterial pressure targets. Further research is required to understand the clinical significance of cerebral hyperperfusion in septic patients on vasopressors and to reassess the neurologic effects of current mean arterial pressure targets in sepsis.

Vasopressor Use for Severe Hypotension-A Multicentre Prospective Observational Study

BACKGROUND

The optimal approach to titrate vasopressor therapy is unclear. Recent sepsis guidelines recommend a mean arterial pressure (MAP) target of 65 mmHg and higher for chronic hypertensive patients. As data emerge from clinical trials comparing blood pressure targets for vasopressor therapy, an accurate description of usual care is required to interpret study results. Our aim was to measure MAP values during vasopressor therapy in Canadian intensive care units (ICUs) and to compare these with stated practices and guidelines.

METHOD

In a multicenter prospective cohort study of critically ill adults with severe hypotension, we recorded MAP and vasopressor doses hourly. We investigated variability across patients and centres using multivariable regression models and Analysis of variance (ANOVA), respectively.

RESULTS

We included data from 56 patients treated in 6 centers. The mean (standard deviation [SD]) age and Acute Physiology and Chronic Health Evaluation (APACHE) II score were 64 (14) and 25 (8). Half (28 of 56) of the patients were at least 65 years old, and half had chronic hypertension. The patient-averaged MAP while receiving vasopressors was 75 mm Hg (6) and the median (1st quartile, 3rd quartile) duration of vasopressor therapy was 43 hours (23, 84). MAP achieved was not associated with history of underlying hypertension (p = 0.46) but did vary by center (p<0.001).

CONCLUSIONS

In this multicenter, prospective observational study, the patient-level average MAP while receiving vasopressors for severe hypotension was 75 mmHg, approximately 10 mmHg above current recommendations and stated practices. Moreover, our results do not support the notion that clinicians tailor vasopressor therapy to individual patient characteristics such as underlying chronic hypertension but MAP achieved while receiving vasopressors varied by site.

Vasopressor stewardship: a case report and lesson shared

A case report, focused on vasopressor use and presented in this article, is likely to resonate with many critical care nurses. In this article the authors describe opportunities to enhance safety with vasopressor therapy. Specifically, the goal of improving communication among physicians, nurses, and pharmacists around desired endpoints for vasopressor therapy, triggers for reassessment of the therapeutic strategy and cause of the patient's shock was identified as an area for improvement. A form piloted within an organization for use during multidisciplinary rounds and key findings is shared. Vasopressors constitute the mainstay of therapy for nearly every hemodynamically unstable patient in critical care. It is hoped that the lessons and information shared help empower critical care nurses to facilitate vasopressor stewardship within their facilities and, ultimately, enhance patient safety.

Prescribed targets for titration of vasopressors in septic shock: a retrospective cohort study

BACKGROUND

Without robust clinical evidence to guide titration of vasopressors in septic shock, it is unclear how dosing of these potent medications occurs. We sought to measure the proportion of vasopressor prescriptions for septic shock that were missing explicit targets and to describe the targets that we identified.

METHODS

We conducted a multicentre, retrospective cohort study involving 9 intensive care units (ICUs) located at 3 academic hospitals in Canada and Australia. We reviewed charts of consecutive patients aged 18 years or older who were admitted to the ICU for a presumptive diagnosis of sepsis. Other inclusion criteria were hypotension (systolic arterial pressure ≤ 90 mm Hg or mean arterial pressure [MAP] ≤ 65 mm Hg) and continuous infusion of vasopressors for at least 1 hour within the initial 48 hours of ICU stay, the period of observation for this study.

RESULTS

We included data from 369 patient charts. At least 1 target was specified in 99% of charts. The most common targets were MAP measurements (73%). The median initial MAP target was 65 (range 55-90) mm Hg. In multivariable regression models, hospital site and older age of the patient, but not comorbidities of the patient, were associated with MAP targets. In 40% of patients, the treating team modified the initial target at least once.

INTERPRETATION

This study suggests that an explicit blood pressure target accompanies nearly every vasopressor prescription and that patient characteristics have little influence on its value. Identification of a titration strategy that will maximize benefit and minimize harm constitutes a research priority.

The role of the pharmacist in humanitarian aid in Bosnia-Herzegovina: the experience of Pharmaciens Sans Frontières

BACKGROUND

Founded in 1985, Pharmaciens Sans Frontières (PSF) is a nongovemmental organization of pharmacists involved in humanitarian aid. PSF relied on approximately 100 expatriates in 1998, which included 50 pharmacists distributed throughout 24 missions (i.e., 14 emergency, 7 development, 3 assessment). It is necessary to add 200-250 local staff to this group.

OBJECTIVE

To describe PSF's mission in Bosnia-Herzegovina from 1992 to 1999 and to define the pharmacist's impact in the supply of medicines and the development of pharmaceutical care and services.

RESULTS

In April 1992, at the beginning of Sarajevo's siege, PSF sent a small team of three volunteer pharmacists to Bosnia-Herzegovina. The objective of the emergency phase (1992-1995) was to set up a massive supply program of essential medicines and medical and biologic materials and to implement a distribution system based on existing health centers. The signing of the Dayton peace agreement and a progressive return to peace and stability marked the beginning of the postemergency phase (1995-1997). This phase pursued previous objectives of establishing a distribution network and added the implementation of logistic centers. PSF widened its involvement to medical laboratory analysis, production of medicines, disposal of expired medications sent during the conflict, and the implementation of a national center for quality control. Currently, the development phase's (1998-1999) objective is to provide adequate support for the reorganization of pharmaceutical care and services by establishing pharmacy work groups and developing and maintaining good relationships with the international community and Bosnia-Herzegovina pharmacists.

CONCLUSIONS

Humanitarian aid is essential in major conflicts, as seen in the case of Bosnia-Herzegovina. Although it is difficult to evaluate the impact of the distribution network implemented by PSF, it allowed for a better provisioning of medications to the general population. PSF played an important role in such cases. In fact, PSF provides its pharmaceutical expertise to these embattled areas not only by offering financial support to the logistics or supplying of medications, but by offering professional support to the organization/reorganization of the pharmaceutical practice.

New methodology for specific inhalation challenges with occupational agents in powder form

Numerous agents in powder form (wood dust, flour, antibiotics, drugs, etc.) can cause occupational asthma. The diagnosis is generally confirmed by specific inhalation challenges in a special challenge room. There are several pitfalls to the procedure: 1) subjects may be exposed to high concentrations of particles; the concentrations of particles may be higher than the threshold limit value-short term exposure level (TLV-STEL), possibly resulting in severe or irritant reactions; 2) the exposure is erratic. To overcome these problems, a new device for aerosolization of powders has been developed. This apparatus consists of three parts: a particles generator, an aerosol delivery system connected to an orofacial mask, and monitors - a photometer and a cascade impactor. Information on the concentration and size distribution of inhaled particles can therefore be obtained. We performed specific inhalation challenges with this apparatus on 20 subjects suspected of having occupational asthma. The concentration of particles was generally below or close to the TLV-STEL and information was obtained on the proportion of particles with a diameter less than 10 mu. Falls in forced expiratory volume in one second (FEV1) were progressive with each increase in the duration of exposure. The five subjects who had negative reactions to exposure were asked to tip the relevant product from one tray to another in the traditional realistic way. All had negative responses. We conclude that this new procedure offers advantages over the traditional method as it gives information on the concentration and size distribution of inhaled particles and makes the drawing of a dose-response curve possible, both of which may improve the safety and accuracy of the test.

New methodology for specific inhalation challenges with occupational agents in powder form

Numerous agents in powder form (wood dust, flour, antibiotics, drugs, etc.) can cause occupational asthma. The diagnosis is generally confirmed by specific inhalation challenges in a special challenge room. There are several pitfalls to the procedure: 1) subjects may be exposed to high concentrations of particles; the concentrations of particles may be higher than the threshold limit value-short term exposure level (TLV-STEL), possibly resulting in severe or irritant reactions; 2) the exposure is erratic. To overcome these problems, a new device for aerosolization of powders has been developed. This apparatus consists of three parts: a particles generator, an aerosol delivery system connected to an orofacial mask, and monitors - a photometer and a cascade impactor. Information on the concentration and size distribution of inhaled particles can therefore be obtained. We performed specific inhalation challenges with this apparatus on 20 subjects suspected of having occupational asthma. The concentration of particles was generally below or close to the TLV-STEL and information was obtained on the proportion of particles with a diameter less than 10 mu. Falls in forced expiratory volume in one second (FEV1) were progressive with each increase in the duration of exposure. The five subjects who had negative reactions to exposure were asked to tip the relevant product from one tray to another in the traditional realistic way. All had negative responses. We conclude that this new procedure offers advantages over the traditional method as it gives information on the concentration and size distribution of inhaled particles and makes the drawing of a dose-response curve possible, both of which may improve the safety and accuracy of the test.