Beth Israel Deaconess Medical Center

Critical Care Research

Many department members in the critical care division are engaged in extensive research in respiratory physiology and lung mechanics, with the goal of improving care for patients with acute respiratory failure in the ICU. In a recent investigation researchers at BIDMC evaluated the role of prone positioning on transpulmonary pressures and lung volumes in patients with healthy lungs. In this study they identified that end-expiratory esophageal pressure decreases, whereas end-expiratory transpulmonary pressure and expiratory reserve volume increases when patients are moved from supine to prone position. Additional measures including mean respiratory system driving pressure increase in the prone position due to increased chest wall elastance. Investigators noted that these increases in end-expiratory transpulmonary pressure and expiratory reserve volume may be one mechanism for the observed clinical benefit with prone positioning.

In a Letter to the Editor members of the department addressed an important aspect of lung mechanics in patients with acute respiratory distress syndrome. Specifically, expiratory muscle activity can cause patients to push their lungs below the relaxation volume expected if they were passively breathing. Investigators noted that this expiratory effort appeared to counteract the expected benefit of PEEP in maintaining lung volume and recruitment. They further found that the removal of these expiratory efforts with deep sedation and paralysis with neuromuscular blockers allowed for the restoration of lung volumes and transpulmonary pressures, as demonstrated using Campbell diagrams depicting the pressure-volume loop of the chest wall.

Selected Publications:

Several members of the critical care division are engaged in conducting research into patient and staff experiences in the intensive care unit. As part of this researchers have looked to identify methods to reduce moral distress in providers, and to quantify which outcomes are most highly valued by patients. In a multicenter investigation of 68 ICUs in Europe and the USA data was collected on perceptions of excessive care among clinicians working in the unit over a one month period. Additional work within the department has focused on the willingness of patients and their families to speak up about care concerns. Patients and families were surveyed in several cohorts, including internet surveys, as well real-time surveys of patient/families that were currently in the intensive care unit. Results of the survey identified areas where speaking up may be a challenge for participants, with barriers to effective communication stemming from their concern that raising issues may cause discordance. Strategies to ameliorate these barriers are currently being investigated in ongoing studies.

Selected Publications:

Observational Research

Dr. Matthias Eikermann joined the BIDMC Department of Anesthesia, bringing with his a wealth of knowledge and expertise in database driven research. As such, much work has been done recently to characterize the association between various disease states and outcomes using data from the electronic medical record. In a recent investigation investigators found an increased risk of perioperative ischemic stroke among patients with a preoperatively diagnosed patent foramen ovale (PFO). Further, PFO was associated with an increased risk of large vessel territory stroke and more severe stroke-related neurologic deficits. These observations were extended in another study in which the long-term risk of ischemic stroke after surgery was evaluated. Investigators noted that in this investigation of more than 140,000 patients who underwent non-cardiac surgery, the PFO-attributable ischemic stroke risk was significantly mitigated among patients who received a postoperative prescription of combined antithrombotic therapy, and was not present among patients that underwent PFO closure before surgery.

In addition to these investigations, observational work within the anesthesia department has focused on identify strategies to minimize postoperative respiratory complications and hospital readmissions.

Selected Publications:

Cardiac Anesthesia Research

Many of the trials in the cardiac anesthesia division are currently ongoing. Several investigators have been working on prospective randomized controlled trials that focus on postoperative delirium prevention in elderly cardiac surgery patients, given its multifactorial nature and potentially modifiable risk factors. One currently ongoing randomized controlled trial evaluates the effectiveness of decreasing the incidence of delirium while using a factorial combination of two different sedatives in conjunction with intravenous acetaminophen. In this study investigators complete rigorous postoperative delirium assessments while patients are in the hospital, as well as at one year postoperatively. Another ongoing randomized controlled trial is investigating the link between the deleterious effects of hyperoxia following ischemic-reperfusion injury after cardiopulmonary bypass and postoperative cognitive dysfunction. The study is using a protocolized management strategy aimed towards the maintenance of an intraoperative normoxic level of oxygen as opposed to hyperoxia to determine whether this reduces the incidence of delirium in this population of patients.

Additional work within the cardiac division has centered on optimal intraoperative management strategies for patients undergoing cardiac surgery. This includes a strong focus on intraoperative blood pressure management. As such investigators undertook a retrospective database project to evaluate the relationship between the blood pressure coefficient of variation and incidence of a composite score for postoperative adverse events. Investigators found that increased systolic blood pressure variability was associated with 30 day mortality and development of renal failure.

Selected Publications:

Perioperative Ultrasound Training

Perioperative ultrasound, including the topics of transesophageal echocardiography (TEE), transthoracic echocardiography (TTE), ultrasound guided regional anesthesia, vascular access, and lung exams, represents a critical part of the modern practice of anesthesiology and requires a complex combination of technical and cognitive skills. Our ultimate goal is to define the most efficient ways to educate residents in these and other complex tasks related to consultancy in anesthesiology. We have developed and tested curricula to teach both TEE and TTE to trainees in Anesthesiology, Emergency Medicine, Cardiology, Critical Care, Surgery and Internal Medicine. The courses utilize high fidelity echocardiography simulators in conjunction with lectures and web-based modules. Our work has presented both the educational rationales and the positive outcomes for both cognitive, manual skills, and workflow as the result of our integrative approach. We share this curriculum with many programs internationally and have also contributed basic TEE lecture videos to OpenAnesthesia.org and the Anesthesia Toolbox Project for free access. We have created and implemented a curriculum for all of perioperative ultrasound, including lung exams, abdominal exams, ultrasound for regional anesthesia and ultrasound for vascular access.

Non-technical Development of Trainees

Provision of feedback, development of non-technical skills such as professionalism and interpersonal communication, and support for resident wellness are essential to the development of trainees. We are pursuing several initiatives aimed at improving feedback quantity, quality, and utility. After conducting a national survey on feedback quality and faculty development in providing feedback, we developed and launched a system of daily feedback provision and an associated educational program for staff on how to provide feedback to trainees. We conducted a multicenter funded project exploring whether a series of teaching sessions on providing challenging feedback to trainees resulted in any improvement in quantity, quality, or utility of feedback. We developed an ambulatory surgical patient survey that allowed assessment of residents’ professionalism and communication skills. We used the data from this tool to construct a curriculum for trainees that resulted in improved performance on the survey. Based on this project, we explored whether providing residents individualized feedback from ambulatory surgical patients and performing targeted reflective work can improve resident performance on the survey.