Program of Uncontrolled Donation After Circulatory Death as Potential Solution to the Shortage of Organs: A Canadian Single-Center Retrospective Cohort Study

Purpose

Worldwide, the number of patients waiting for organ transplantation exceeds the number of organs available. Program for uncontrolled donation after circulatory death (uDCD) implemented in Europe has resulted in a 10–15% expansion of the donor pool. We aimed to describe the number of patients eligible for an uDCD program in a regional tertiary care center.

Methods

We conducted a retrospective cohort study in a Canadian tertiary academic center located in a rural area including all adults who received cardiopulmonary resuscitation in 2016 and died in the emergency department (ED) or during their hospitalization. The primary outcome was the number of patients eligible for uDCD defined as aged between 18 and 60 years old whose collapse was witnessed and where the time between cardiac arrest to cardiopulmonary resuscitation and ED arrival was, respectively, less than 30 and 120 minutes. As a secondary outcome, we determined the number of patients eligible for controlled donation after circulatory death.

Results

Of the 130 patients included, 84 did not return to spontaneous circulation. We identified 15 potential uDCD candidates, with a mean age of 46.6 (95% Confidence Interval [CI] 41.3 to 52) years. Twelve had an out-of-hospital cardiac arrest with a mean time between collapse and arrival to the ED of 43.2 (29.8 to 56.6) minutes. Among the 46 patients who died after a return of spontaneous circulation, 10 (21.7%) were eligible for organ donation after circulatory death.

Conclusion

Implementing an uDCD program in a tertiary hospital covering a rural area could increase the number of donors.

Effect of Probiotics on Incident Ventilator-Associated Pneumonia in Critically Ill Patients: A Randomized Clinical Trial

IMPORTANCE

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 of Lactobacillus rhamnosus GG 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

Enteral L rhamnosus GG (1 × 1010 colony-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 including Clostridioides difficile infection, 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 of L rhamnosus in 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 probiotic L rhamnosus GG compared with placebo, resulted in no significant difference in the development of ventilator-associated pneumonia. These findings do not support the use of L rhamnosus GG in critically ill patients.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02462590.

Evaluating probiotics for the prevention of ventilator-associated pneumonia: a randomised placebo-controlled multicentre trial protocol and statistical analysis plan for PROSPECT

INTRODUCTION

Ventilator-associated pneumonia (VAP) is the most common healthcare-associated infection in critically ill patients. Prior studies suggest that probiotics may reduce VAP and other infections in critically ill patients; however, most previous randomised trials were small, single centre studies. The Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial (PROSPECT) aims to determine the impact of the probiotic Lactobacillus rhamnosus GG on VAP and other clinically important outcomes in critically ill adults.

METHODS

PROSPECT is a multicentre, concealed, randomised, stratified, blinded, controlled trial in patients ≥18 years old, anticipated to be mechanically ventilated ≥72 hours, in intensive care units (ICUs) in Canada, the USA and Saudi Arabia. Patients receive either 1×10¹⁰ colony forming units of L. rhamnosus GG twice daily or an identical appearing placebo. Those at increased risk of probiotic infection are excluded. The primary outcome is VAP. Secondary outcomes are other ICU-acquired infections including Clostridioides difficile infection, diarrhoea (including antibiotic-associated diarrhoea), antimicrobial use, ICU and hospital length of stay and mortality. The planned sample size of 2650 patients is based on an estimated 15% VAP rate and will provide 80% power to detect a 25% relative risk reduction.

ETHICS AND DISSEMINATION

This protocol and statistical analysis plan outlines the methodology, primary and secondary analyses, sensitivity analyses and subgroup analyses. PROSPECT is approved by Health Canada (#9427-M1133-45C), the research ethics boards of all participating hospitals and Public Health Ontario. Results will be disseminated via academic channels (peer reviewed journal publications, professional healthcare fora including international conferences) and conventional and social media. The results of PROSPECT will inform practice guidelines worldwide.

TRIALREGISTRATION NUMBER

NCT02462590; Pre-results.

Probiotics: Prevention of Severe Pneumonia and Endotracheal Colonization Trial-PROSPECT: a pilot trial

BACKGROUND

Probiotics are live microorganisms that may confer health benefits when ingested. Randomized trials suggest that probiotics significantly decrease the incidence of ventilator-associated pneumonia (VAP) and the overall incidence of infection in critically ill patients. However, these studies are small, largely single-center, and at risk of bias. The aim of the PROSPECT pilot trial was to determine the feasibility of conducting a larger trial of probiotics to prevent VAP in mechanically ventilated patients in the intensive care unit (ICU).

METHODS

In a randomized blinded trial, patients expected to be mechanically ventilated for ≥72 hours were allocated to receive either 1 × 10(10) colony-forming units of Lactobacillus rhamnosus GG or placebo, twice daily. Patients were excluded if they were at increased risk of L. rhamnosus GG infection or had contraindications to enteral medication. Feasibility objectives were: (1) timely recruitment; (2) maximal protocol adherence; (3) minimal contamination; and (4) estimated VAP rate ≥10 %. We also measured other infections, diarrhea, ICU and hospital length of stay, and mortality.

RESULTS

Overall, in 14 centers in Canada and the USA, all feasibility goals were met: (1) 150 patients were randomized in 1 year; (2) protocol adherence was 97 %; (3) no patients received open-label probiotics; and (4) the VAP rate was 19 %. Other infections included: bloodstream infection (19.3 %), urinary tract infections (12.7 %), and skin and soft tissue infections (4.0 %). Diarrhea, defined as Bristol type 6 or 7 stools, occurred in 133 (88.7 %) of patients, the median length of stay in ICU was 12 days (quartile 1 to quartile 3, 7-18 days), and in hospital was 26 days (quartile 1 to quartile 3, 14-44 days); 23 patients (15.3 %) died in the ICU.

CONCLUSIONS

The PROSPECT pilot trial supports the feasibility of a larger trial to investigate the effect of L. rhamnosus GG on VAP and other nosocomial infections in critically ill patients.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01782755 . Registered on 29 January 2013.

The preparation of patients for cardiac surgery

This study examines the impact of a preadmission telephone intervention on anxiety, knowledge, and readiness for discharge for patients attending a preadmission teaching program prior to cardiac surgery. The primary goal of the telephone intervention was to provide support by giving additional information about individual concerns. The telephone intervention did not have an effect on anxiety and knowledge. A significantly higher level of anxiety was found in the experimental group on admission, but this difference became nonsignificant when baseline level and length of waiting time were entered as covariates. The more anxious group rated their perceived knowledge level lower, despite the fact that both groups had similar scores in actual knowledge. Given the potential barrier that anxiety can pose for patient learning, nurses need to adapt their interventions to deal with the patients' feelings of anxiety that accompany cardiac surgery to make the learning process effective.

Detection of group B Streptococcus by immunoassay following enrichment in LIM-selective broth medium

Rapid immunoassays have been developed to decrease the time to detection of Group B Streptococcus (GBS) carriage in pregnant women. In this study, a total of 162 pregnant women, considered to be high-risk obstetric patients, were seen in the Family Care Center at Memorial Hospital of Rhode Island, a 300-bed teaching hospital associated with Brown University Medical School. Vaginal and rectal specimens were taken and tested for GBS by using two rapid enzyme immunoassays (EIAs) that were compared with culture. Quidel and Hybritech ICON Group B strep tests were run following 4 h incubation in the selective enrichment LIM Group B strep broth; cultures were done both directly and after enrichment. Results with both EIAs were identical, with overall sensitivity, specificity, and positive and negative predictive values of 38%, 98%, 88%, and 84% respectively. However, when women having positive cultures were separated into moderately to heavily colonized (> or = 3 +) and lightly colonized (< or = 2 +) populations, the sensitivities were 82% and 19%, respectively. Although GBS assays are useful in the rapid diagnosis of heavily colonized women, culture following enrichment remains the most sensitive method for a lightly colonized population.

[Preoperative structured patient education]

This article describes the factors that motivated the nursing staff of the cardiac surgery unit at the Royal Victoria Hospital in Montreal, to revise their preoperative teaching program. The motivating factors described are the length of the preoperative waiting period; the level of preoperative anxiety; the decreased length of hospital stay; the dissatisfaction of the nursing staff with current patient teaching practices; and the lack of available resources. The reorganization of the teaching program was based upon the previously described factors combined with a review of the literature that demonstrated the impact of preoperative anxiety, emotional support and psycho-educational interventions upon the client's recovery. The goals of the new teaching program are to provide the client and the family with cognitive and sensory information about the client's impending hospitalization, chronic illness and necessary lifestyle modifications. The program consists of a system of telephone calls during the preoperative waiting period; a videotape viewing; a tour of the cardiac surgery unit; informal discussion groups; and the availability of nursing consultation to decrease preoperative anxiety. The end result of these interventions is more time for client support and integration of necessary information by the client and family. This kind of program has the potential to provide satisfaction at many levels by identifying client's at risk; increasing client knowledge; increasing support; decreasing anxiety during the preoperative waiting period; and decreasing the length of hospital stay. The nursing staff gained a heightened sense of accomplishment because the program was developed according to the nursing department's philosophy, which includes primary nursing.(ABSTRACT TRUNCATED AT 250 WORDS)