Illinois Masonic Medical Center Research Articles

Invited Symposium 1: Traumatic Brain Injury: Highlighting the Contributions of Dr. Harvey S. Levin Ph.D., ABPP-CN, FACSM 1946 - 2022

Invited Symposium 1: Traumatic Brain Injury: Highlighting the Contributions of Dr. Harvey S. Levin Ph.D., ABPP-CN, FACSM 1946 - 2022

Corrigendum.

Correspondence: Jan P. Kaminski, M.D., M.B.A., Advocate Illinois Masonic Medical Center, 900 W Nelson St, Suite First Floor, Chicago, IL 60657. E-mail: [email protected]

What are the cure rates for the most effective treatments for chronic hepatitis C genotype 1 infections?

Advocate Illinois Masonic Medical Center, Chicago, IL The authors declare no conflicts of interest.

How does the efficacy and safety of saw palmetto compare to alpha-1 blockers for the treatment of BPH?

Advocate Illinois Masonic Medical Center, Chicago, IL The authors declare no conflicts of interest.

Etiology and Determinants of In-Hospital Survival in Patients Resuscitated After Out-of-Hospital Cardiac Arrest in an Urban Medical Center

Out-of-hospital cardiac arrest (OHCA) is a leading cause of mortality globally. The goals of this study were to describe common causes of OHCA in an urban US medical center, identify predictive factors for survival, and to assess whether neurological status upon return of spontaneous circulation might be predictive of outcomes: 124 consecutive patients aged 18 years and older with OHCA admitted at Advocate Illinois Masonic Medical Center were studied. All patients resuscitated in the field with return of spontaneous circulation then transferred to the emergency department were included. The Glasgow Coma Score (GCS) was evaluated immediately on hospital arrival. In the total group, 34% (42 of 124) were discharged alive. In patients with coronary artery disease (CAD), 51% (20 of 39) were discharged alive versus 26% (22 of 85) of non-CAD patients (p <0.01). Initial GCS ≥ 9 was highly predictive of survival: 94% (34 of 36) of patients with GCS ≥ 9 survived versus 9% (8 of 88) with GCS ≤ 8 (p <0.0001). Defibrillation in the field was predictive of survival (chi-square = 7.81, p = 0.005). In the CAD group, all 16 patients with GCS ≥ 9 on presentation to the Emergency Department survived whereas all 13 with GCS ≤ 5 died (both p <0.0001). In the non-CAD group, 18 of 20 patients with GCS ≥ 9 survived, whereas only 2 of 52 with GCS ≤ 5 survived (both p <0.0001). Multivariate analysis by logistic regression showed that the strongest predictor of survival in the non-CAD subgroup was GCS (OR 0.27, CI 0.19 to 0.55, p <0.001). In conclusion, the etiology of the OHCA, immediate neurologic status, and defibrillation in the field (suggesting presenting arrhythmia) were predictive of survival. Immediate neurological recovery (GCS ≥ 9) regardless of etiology was a strong predictor of survival to discharge. Additional predictive factors depend on the etiology of the OHCA event. These data suggest that these straightforward factors can be helpful in predicting outcome in patients resuscitated after OHCA.

In pregnant women, are there any risks associated with HPV vaccination?

Advocate Illinois Masonic Medical Center, Residency In Family Medicine, Chicago, IL The authors declare no conflicts of interest.

Nonopioid analgesics as effective as opioids for acute pain?

Department of Family Medicine, Advocate Illinois Masonic Medical Center, Chicago, IL The authors declare no conflicts of interest.

Implementation of an EMR System for a Comprehensive Dental Service within a Large Regional Hospital Network: Challenges and Opportunities Presented by the Introduction of new Technology.

The development of new information technology has significant effects on the health care system, and its implementation and the associated change management process can bring some positive changes and gains in understanding, but there are challenges with making the transition. These benefits and challenges are explored in the context of a hospital based dental department. Additionally, the concept of the integration of oral health to overall systemic health is explored in context with an Electronic Medical Records system implementation, and the American Dental Association's recent recognition of dental anesthesiology as a clinical subspecialty. Qualitative survey of attending dental faculty members of the department, who represent a broad range of dental specialties and experience in private practice, hospital based practice, teaching, and public health practice. The faculty survey yielded some consistent themes, ranging from enhanced information to make better diagnoses, to challenges in transitioning to EMR, as well as concerns about data security and too much time and effort in front of a computer screen. A brief summary of the history of the stand-alone development of dentistry is given, which contributed to the separate development of dental EMRs from hospital EMRs. The various modalities of clinical care provided by the Department of Dentistry at Advocate Illinois Masonic Medical Center, Chicago, IL are presented to give a scope of the areas of need a successful EMR solution must meet in a hospital based dental setting. Public health aspects are included in the discussion. Macro level health data sets (ie NHANES, state level datasets) have the potential to be expanded to include more thorough data, combining medical health data and oral health data in the same datasets.

Direct access screening colonoscopy as a safe and effective approach to increasing colorectal cancer screening.

540 Background: This year 135,000 patients will be diagnosed with colorectal cancer (CRC) and it is the second leading cause of cancer deaths in the US. CRC is largely preventable when screening is conducted. Nearly 60% of patients over 50 report never receiving any form of CRC screening. Colonoscopy remains the gold standard for CRC screening. Unfortunately, several barriers exist to obtaining this life-saving screening option (i.e. access to gastroenterologists, patient anxiety and lack of knowledge about the procedure). Our Direct Access Screening Colonoscopy program (DASC) has provided a successful solution to address many of these deterrents. Methods: In July 2015, the DASC program was launched at Advocate Illinois Masonic Medical Center. A nurse navigator telephonically completes health questionnaires and if patients were determined to be without significant comorbidities, they would be enrolled in the program. Prior to the procedure, the nurse would address all questions, instructions and bowel preparations. Patients that were not eligible for the program were navigated to a gastroenterologist for a formal evaluation. A retrospective review of all patients that underwent screening colonoscopy from July 2015 to July 2016 was conducted. Data collected included patient demographics, quality of preparation, Adenoma Detection Rate (ADR), patient satisfaction, and complications. Results: A total of 644 patients were referred for DASC. 373 patients (58%) were eligible for inclusion within the program. At the time of submission, 289 completed their colonoscopy. 201 patients (70%) had a normal colonoscopy. 88 patients were found to have at least one adenoma (ADR- 30%). No patients experienced any complications following DASC. Patient satisfaction scores were significantly higher for those who underwent DASC. The overall screening rate nearly doubled after implementation of the DASC program (30% vs 59%). Conclusions: Direct Access Screening Colonoscopy is a novel method to that increased the overall screening rate for CRC by almost 100%. It is a safe and effective alternative to the conventional process of obtaining a colonoscopy and can positively impact patient satisfaction and outcomes.

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Introduction: Atrial fibrillation is the most common arrhythmia and is associated with increased morbidity and mortality. Radiofrequency of AF is known to be an effectively treatment option. Ablation failures are related to the presence of persistent AF, left atrial enlargement, hypertension, diabetes, age, obstructive sleep apnea (OSA)1–7.The aim of this study was to examine the relationship betweenhigh right ventricular systolic pressure (RVSP >30 mmHg) and other prognostic factors as predictors of repeat radiofrequency ablation in atrial fibrillation patients. Methods: In this cross-sectional study, 147 patients withreported history of radiofrequency ablation at Advocate Illinois Masonic Medical Center between Jan 2005-Jan2012 were included. Clinical and echocardiography parameters were collected.Patients were categorized bywhether they had history of ablation in the past before the index ablation. The parameters were compared between groups. Appropriate statistical analyses were performed. Results: The population with mean age of 61 ± 10 years consisted of 20.4% (30 of 147)female. Baseline characteristics were similar between groups. Patients with repeated atrial fibrillation ablation had higher prevalence of flecainide use (p0.019), pulmonary hypertension (p0.006), RVSP (p<0.001), concomitant atrial flutter (p<0.001) and COPD (p0.019). Multivariable regression analysis showed Flecainide use (95%CI;1.150,9.328), RVP (95%CI;1.223,11.900) and concomitant atrial flutter (95%CI;1.786,18.447) are independently associated with repeat atrial fibrillation ablation Conclusions: This pilot study demonstrated the recurrence rate of AFwhich required repeat radiofrequency ablation in those with flecainideuse,pulmonary hypertension, high RVSP, concomitant atrial flutter,and COPD. However,persistent AF, left atrial enlargement, hypertension, diabetes, age which found to have the association with the repeat ablation were not identified as predictors for a repeat ablation in this study

The Role of the β-Adrenergic Receptors in Cerebral Vasodilation During Hemodilution

To the Editor In a recent paper investigating the dose-dependent effects of nebivolol (1.25 and 2.5 mg/kg) on the changes in regional cerebral blood flow (rCBF) after an isovolemic exchange of blood for 10% pentastarch in isoflurane-anesthetized rats (hemoglobin reduced to approximately 60 g/L), Hu et al.1 found that hemodilution caused marked increases in rCBF, which were not affected by pretreatment with low-dose nebivolol, but were completely abolished with high-dose nebivolol. The authors theorized that high-dose nebivolol abolished the increase in rCBF during hemodilution because the plasma drug levels were sufficient to block the cerebral β2-adrenergic receptors. This theory is based on the assumption that the β2-adrenergic receptors mediate cerebral vasodilation during hemodilution. In support of this mechanism, Hu et al. cited results from a previous study in their laboratory using the same rat model, which demonstrated that the selective β2-adrenergic antagonist, ICI 118,551, caused marked attenuation of the increases in rCBF during hemodilution.2 We have demonstrated in pentobarbital-anesthetized dogs that hemodilution of a similar degree to that studied by Hu et al.1 caused increases in blood flow to regions of the brain (cerebral cortex, cerebellum, pons, medulla, and spinal cord), as evaluated with the radioactive microsphere technique, which were well preserved after high-grade, nonselective β-adrenergic blockade with propranolol (1 mg/kg IV).3 The completeness of the β-adrenergic blockade was confirmed by its ability to completely abolish the inotropic and depressor responses to isoproterenol (5 µg, IV), and to cause pronounced decreases in heart rate (−27%), dP/dtmax (−40%), and aortic blood flow (−28%). Since propranolol has been demonstrated to freely cross the blood–brain barrier,4 our findings suggest that neither the β1- nor the β2-adrenergic receptors play an important role in mediating vasodilation in the regional circulations of the brain during hemodilution. In addition to vasomotor tone, arterial blood pressure and blood viscosity are determinants of cerebral blood flow during hemodilution.5 β-Adrenergic blockade markedly attenuated the increase in cardiac output accompanying hemodilution in our study and that of Hu et al.,1 but, in both studies, arterial blood pressure was well maintained (>90% of control value), reflecting an increase in systemic vascular resistance presumably via the arterial baroreceptor reflex.6 Thus, a difference in arterial blood pressure cannot explain the different cerebral blood flow findings in the 2 studies. Furthermore, the decrease in hematocrit, and therefore in blood viscosity, was similar in the absence and presence of β-adrenergic blockade in both studies, which also excludes this factor. Possible explanations for the discrepancy in the cerebral blood flow findings in our study and that of Hu et al.1 include differences in species, method used to measure cerebral blood flow, and anesthetic technique. In any case, a balanced review of the literature indicates that the role of the β-adrenergic receptors in the increased cerebral blood flow during hemodilution remains a matter of debate. Further studies are required to resolve this issue. George J. Crystal, PhD, FAHA M. Ramez Salem, MD Department of Anesthesiology Advocate Illinois Masonic Medical Center Chicago, Illinois [email protected]

In Response

We agree with Mahajan et al.1 that keeping a vial of Depo-Medrol® (Pharmacia & Upjohn Company, Kalamazoo, MI) inverted for 2 hours as we described2 is not the only way to separate 2 phases from a methylprednisolone acetate (MPA) suspension. Besides aspirating the entire contents into a 1-mL syringe and keeping the syringe “suspended” vertically for more than 2 hours as Mahajan et al.1 describe, there is the possibility of separating these 2 phases by centrifugation as Rijsdijk et al. have shown in a recent publication.3 The question is, “Which one of these three methods is more suitable for use in a busy clinical practice?” The advantage of centrifugation is that it is the quickest method but requires the centrifuge and a laminar flow hood for processing samples with sterile precautions. The method suggested by Mahajan et al.1 requires the use of a sterile (autoclaved) metallic test tube stand in the regional anesthesia tray. We are not aware of any commercial manufacturers who include a sterile test tube stand in their standardized kits, which begs the question of the clinical feasibility of Mahajan et al.'s suggestion. The 2 methods proposed by Mahajan et al.1 and by us2 require at least 2 hours of separation and the awareness that the upcoming patient may be a candidate for intrathecal injection using methylprednisolone with a reduced concentration of preservatives. We agree with Mahajan et al.1 that our method requires very careful insertion of the needle and aspiration from the small vial containing a total of 1 mL of contents. However, if practitioners choose the proposed method of Mahajan et al.1 and if either their prediction is not correct that the patient is a suitable candidate for intrathecal injection of corticosteroids, or if the patient does not agree to proceed with such an injection, they cannot sterilely reinject the contents back into the vial for subsequent use at a later time. However, by using our method2 in the case of someone not being a candidate for intrathecal MPA, one can always mix these 2 phases again by merely reverting the vial back upright. However, before using intrathecal MPA for managing postherpetic neuralgia-related pain, we should consider the recently published study of Rijsdijk et al.,3 performed on 12 dogs showing a dose-dependent intrathecal inflammation after MPA and recommending that MPA not be administered intrathecally to patients. These findings do not necessarily nullify the clinical work of Kotani et al.4 in 277 humans who underwent MPA intrathecal injections. Those authors observed no clinical complications, no abnormal findings on repeated lumbar magnetic resonance imaging scans taken postinjection, and no pleocytosis or proteinosis (which typically occurs as a prelude to arachnoiditis).5,6 Therefore, further clinical study is decidedly warranted concerning intrathecal MPA before either embracing or discarding this therapy for patients with postherpetic neuralgia. Kenneth D. Candido, MD Nebojsa Nick Knezevic, MD, PhD Department of Anesthesiology Advocate Illinois Masonic Medical Center Chicago, IL Department of Anesthesiology University of Illinois Chicago, IL [email protected]

Tracheal Wall Collapse Produced by Esophageal Detector Devices in a Porcine Cardiac Arrest Model

To the Editor Schuh et al.1 compared 3 esophageal detector devices (EDDs) for detecting tracheal and esophageal intubation in pigs, before and after inducing cardiac arrest. They concluded that false-negative results (no reinflation of the bulb with the tracheal tube in the trachea) with one of the devices were caused by decreased tone of the posterior tracheal wall during cardiac arrest. We have 2 issues regarding their interpretation of these results. First, among the factors affecting the performance of EDDs are (a) whether the self-inflating bulb (SIB) is compressed before or after being attached to the tracheal tube, and (b) a decreased functional residual capacity.2 Schuh et al. did not specify whether the bulb was compressed before or after being attached to the tracheal tube.1 In our investigation of the efficacy of the EDD in confirming tracheal intubation in morbidly obese patients, we found that compressing the SIB after connection to the tracheal tube decreased the occurrence of false-negative results (from 24% to 4%).3 Second, an altered functional residual capacity/closing capacity relationship after anesthetic induction in supine patients results in decreased caliber of airways. In addition, excessive negative pressure generated by an SIB (more negative than −36.7 mm Hg) can result in collapse of large airways, invagination of the posterior tracheal wall, and consequently no reinflation of the SIB.3 SIBs used clinically in prior studies generate negative pressures between −55 and −68 mm Hg,4,5 whereas the SIBs used by Schuh et al.1 generate greater negative pressures in excess of −100 mm Hg. The authors' findings do not support their proposed mechanism for the false-negative results. If decreased tone was an important factor, then there should have been more false-negative results as the postarrest phase progressed. We propose that their false-negative results were caused by the excessive negative pressure generated by Bulb #2 (−110.2 mm Hg). David J. Lang, DO M. Ramez Salem, MD Department of Anesthesiology Advocate Illinois Masonic Medical Center University of Illinois College of Medicine Chicago, Illinois [email protected]

Sellick Maneuver

*Department of Anesthesia and Critical Care, University of Chicago †Department of Anesthesiology, Advocate Illinois Masonic Medical Center, University of Illinois College of Medicine, Chicago, IL

Acute Postoperative Negative-pressure Pulmonary Edema

We read with interest the case scenario regarding acute postoperative negative-pressure pulmonary edema (NPPE).1The authors elegantly discussed the diagnosis, differential diagnosis, epidemiological features, pathogenesis, and clinical management of NPPE. We are concerned that anesthetic management may have inadvertently contributed to the cause of this complication. The patient described was given opioid doses equivalent to 27.5 mg iv morphine (0.25 mg fentanyl = 25 mg + 0.5 mg hydromorphone = 2.5 mg)2and a nondepolarizing muscle relaxant. The fact that the patient (with a normal airway) developed laryngospasm after extubation suggests that the patient was not ready for extubation. In addition, it is possible that reduced pharyngeal muscle tone due to residual neuromuscular blockade resulted in upper airway obstruction.3,4A patient with a “train-of-four” ratio of 0.9 or greater may still develop postoperative hypoxemia5and may require the administration of reversal drugs.The initial difficulty in mask ventilation after extubation implies that the inspiratory stridor had progressed to a ball–valve obstruction.6Applying positive airway pressure under these circumstances may actually worsen ball–valve closure.6Inflation of the pharynx distends the piriform fossae, pressing the aryepiglottic folds more firmly against each other and reinforcing the closure.6We suggest that the complication presented could have been prevented by delaying extubation.*Advocate Illinois Masonic Medical Center, Chicago, Illinois. mrsalem@sbcglobal.net

Management of the Difficult and Failed Airway.

Management of the Difficult and Failed Airway. Edited by Orlando R. Hung, M.D., and Michael F. Murphy, M.D., F.R.C.P.C. New York, McGraw-Hill, 2008. Pages: 510. Price: $129.00.Few scenarios in the practice of medicine stoke the fires of immediate concern quite like encountering a difficult and failed airway. Unfortunately, adequate prediction of potentially challenging anatomy remains far from a perfect science despite having been the cornerstone of modern anesthetic practice for decades. The ever present possibility for disaster fuels continuing discourse not only throughout anesthesia but also across many other disciplines over methods and techniques with which to approach such problematic cases. The magnitude of this problem is reflected in the seemingly endless supply of novel and innovative airway devices and the sheer quantity of ongoing research ventures aimed at improved understanding of the complex interplay between anatomy, pharmacology, and airway manipulation. Indeed, the absolute increases in the volume of both our knowledge and technology are exceeded only by the rate at which they are escalating.Whether the discipline is anesthesiology, emergency medicine, intensive care, or first response, securing the difficult and challenging airway in virtually any situation is the focus of this extremely useful book. Edited by two of Canada’s well-regarded airway management experts, the text offers a number of additions to existing difficult airway manuals in both its content and its formulation of the difficult airway approach.Starting with a well-written and informative introduction to emergency airway algorithms and their similarities to and discrepancies from the American Society of Anesthesiologists Difficult Airway Algorithm, the book delves into a thoroughly informative discussion on how the editors’ Canadian twist on established practice results in improvements to airway management that can be applied to virtually any emergent situation. The text continues with a comprehensive background discussion of devices in and techniques for the difficult airway that serve as the basis of the aforementioned algorithmic progressions. These initial chapters build the foundation for the true value of this text.The book includes topics that vary from airway management in the intensive care unit setting to the management of a motorcyclist with a full face helmet. Each chapter tackles a new airway management dilemma with an informal question and discussion style that permits both straightforward reading and rapid browsing and referral. Through analysis of the pitfalls and caveats associated with unique situations encountered at every step in the process of securing the airway, the authors manage not only to elucidate the fundamental principles inherent to emergent airway control but also to foster an objective approach to the control of the airway in any potential scenario. Each chapter even concludes with a small set of self-evaluation questions that are certainly beneficial to readers, especially those still in training.It is difficult to edit the perfect text, and this book is no exception. It is not as comprehensive as some of the other available references on the market, and a subset of readers may not embrace the novel approaches inherent to the presented algorithms. In addition, it is surprising to note that the discussion on “the best way to confirm placement of an endotracheal tube in the trachea,” included in the chapter entitled “Airway Devices and Techniques,” is too casual and possesses a reference list that ignores a number of rather important citations. The same complaints could be carried over to the discussions on “how do prehospital providers confirm and maintain intratracheal placement of the ETT” in chapter 13 and the chapter on “Aspiration: Risks and Prevention.” Both sections certainly lack depth and, yet again, an appropriate selection of references.These criticisms, however, should not overshadow the text’s value to both junior trainees and veteran anesthesiologists alike. Well written, functionally organized, and implementing algorithms that may be complementary to the established knowledge base of the majority of readers, Management of the Difficult and Failed Airway receives our highest recommendation for any practitioner interested in improving his or her knowledge of airway management.*Advocate Illinois Masonic Medical Center, Chicago, Illinois.ramez.salem-md@advocatehealth.com

Self-Transcendence and Depression Among AIDS Memorial Quilt Panel Makers

Self-transcendence is a process that can help individuals reestablish well-being after experiencing a significant, life-altering event. In this study, we sought to identify the relationship between self-transcendence and depression in individuals who lost loved ones to HIV/AIDS and to describe and compare self-transcendence, self-transcendence variables of acceptance and spirituality, and depression among bereaved individuals who created AIDS Memorial Quilt panels with those who did not. The findings support Reed's self-transcendence theory, with inverse correlations between self-transcendence and depression obtained from both the total group and the panel makers. Significant differences were also found between certain self-transcendence variables and depression among the study participants related to gender and ethnicity. In addition, thematic analysis of panel maker interviews revealed five themes: Quilt panel making provides validation, Quilt panel making creates a living memory, liberating acceptance of loss, community of survivors, and connection to a higher power. These findings assist in understanding the complexities of the grief process and support the usefulness of Quilt panel making as an intervention for coping with grief related to HIV/AIDS.

An Unusual Cause of Leak in a Silicone Endotracheal Tube Secured by the SecureEasy® Endotracheal Tube Holder in the Trauma Intensive Care Unit

The LMA-Fastrach ™ (LMA North America, San Diego, CA) has been used in patients with a difficult airway, including those with an unstable cervical spine.1,2We report a case of a successful intubation via the LMA-Fastrach ™ in a patient with severe ankylosing spondylitis and an unstable C5–C6 fracture dislocation with subsequent leak around the silicone, dedicated endotracheal tube (ETT), resulting in desaturation.The 40-yr-old male patient was awake, alert, and spontaneously breathing at the time of admission. During the course of his evaluation, his breathing became progressively laborious, and tracheal intubation was requested by the trauma team. After multiple failed attempts at awake nasal and oral fiberoptic intubation and awake direct laryngoscopy, tracheal intubation was performed blindly via a size 4 LMA-Fastrach ™ after intravenous administration of 17 mg etomidate by the trauma team. The patient was transferred to the trauma intensive care unit, where the 7.0-mm-ID, silicone, dedicated ETT was secured at 26 cm at the lips with a SecureEasy® ETT holder (Smiths Medical, Dublin, OH). Four hours after the initial intubation, mechanical tidal volumes were noted to decrease slowly (200–300 ml/breath). The presumed diagnosis was a cuff leak; deflation and reinflation of the pilot balloon with 3–5 ml air attested to the integrity of the cuff. The breathing circuit was also checked and found to be intact. The leak eventually resolved. However, the problem recurred and persisted the following days in an inconsistent pattern and at variable intervals. ETT exchange was contemplated but not attempted in light of the initial difficult intubation. The patient subsequently underwent both anterior and posterior fusions of the cervical spine with halo traction placement; no intraoperative leaks were noted. On admission day 9, however, increasing leakage and episodes of desaturation led to the decision to perform a tracheostomy. In the operating room, careful listening determined the leak to be at the level of the 15-mm male connector. Application of electrical tape to the proximal end of the ETT corrected the problem.After insertion of a No. 8 Shiley® tracheostomy tube (Tyco Healthcare, Mansfield, MA), the ETT was removed, and close examination revealed several holes at the proximal end of the ETT that lined up with the metal prongs of the SecureEasy® device (fig. 1). The ETT cuff was found to be intact. It was also noted that the 15-mm connector was from a 6.5-mm-ID ETT.The LMA-Fastrach ™ manufacturer was contacted and informed of the events. After reviewing all relevant information and photographs, the manufacturer of the LMA-Fastrach ™ stated that the problem we encountered had never been previously reported to LMA North America (as of October 2005). Several factors seem to have contributed to the leak in the ETT. The soft medical grade silicone of the dedicated ETT supplied with the LMA-Fastrach ™ can be torn or perforated by prolonged contact with sharp or pointed objects. The respiratory care department at our institution has used the SecureEasy® for some time without incident. We assume that the metal prongs do not perforate or otherwise damage the standard polyvinylchloride ETT. Moreover, tension exerted on the soft silicone ETT by inadequately supported ventilator tubing could have stretched open the small perforations and may have accounted for the inconsistent nature of the leak. Finally, the leak was further compounded by the inadvertent use of an incorrectly sized 15-mm male ETT connector.In conclusion, our unique case raises concerns about the long-term use of the silicone ETT packaged with the LMA-Fastrach ™ in the critical care unit in conjunction with the SecureEasy® ETT holder.*Advocate Illinois Masonic Medical Center, Chicago, Illinois. ninos-j.joseph@advocatehealth.com

An Unusual Cause of a “Missing Tip” in An Arrow® Flextip Plus® Epidural Catheter

To the Editor: It is mandatory to inspect the distal tip of an epidural catheter after removing it, as the presence of the black mark on the tip signifies that the entire catheter has been retrieved. We report a case of a “missing tip” after catheter removal in a parturient. To initiate epidural analgesia, on our first attempt, we inserted a 19-gauge Arrow® Flextip Plus® catheter at the L3–4 interspace, aseptically, via a midline approach through a 17-guage Tuohy needle. After the procedure, we removed the catheter without resistance or procedural difficulty. However, the distal black marker band at the catheter’s tip was missing. Computed tomography imaging did not reveal any retained portion of the catheter. The patient remained asymptomatic and was discharged. We sent the catheter to the manufacturer for evaluation. Nondestructive testing of the catheter revealed the following: 1) no indication of catheter separation (Fig. 1); 2) an overall length identical to that of an unused catheter (80.2 cm); 3) no evidence of misuse or excessive stretching (Fig. 1); and 4) the markings of the returned catheter were shifted by approximately 2 mm.Figure 1.: A close-up view of the returned epidural catheter (bottom) next to a normal, unused catheter (top). The tip appears undamaged, with no evidence of misuse or excessive stretching of the catheter.The manufacturer concluded that our catheter was improperly imprinted. The manufacturer has no record of a similar report. We recommend inspection of the catheter tip before insertion. Kenneth Warzynski, MD Xuan Au-Truong, MD Ninos J. Joseph, BS Department of Anesthesiology Advocate Illinois Masonic Medical Center Chicago, IL [email protected]

Lessons Learned in Controlling an Acinetobacter Outbreak

BACKGROUND/OBJECTIVES: Acinetobacter baumannii has been associated with many outbreaks in hospitals. Lessons learned by a community teaching hospital that experienced two outbreaks of A. baumannii are presented. METHODS: Advocate Illinois Masonic Medical Center is a 551 bed trauma center in Chicago. An outbreak of multidrug-resistant (MDR) A. baumannii was first identified in August 2004 in the adult surgical intensive care unit (SICU), primarily among trauma patients on ventilators. Infection Control (IC) immediately stressed strict Contact Precautions for patients with MDR strains, increased handwashing awareness, and emphasized oral care every 2 hours, discarding Yankauers at the end of every nursing shift, and proper handling of ventilator circuits. When new cases continued to develop and were transferred to other units, all patients with Acinetobacter , regardless of the antibiotic susceptibility profile and location, were placed on Contact Precautions. Surveillance cultures (patients, environment, equipment, especially previously reported reservoirs) were taken in the SICU. Supplies stocked in patient rooms were minimized. IC reviewed routine procedures (housekeeping, handling of blood gases, cleaning of rented specialty beds, etc.) to identify breaks in infection control techniques. Since the Trauma residents rotated throughout the city and other regional trauma centers were experiencing similar outbreaks, the investigation widened to the Emergency Department and Wound Care Center. IC presented education programs, wrote guidelines, and monitored personnel practices. RESULTS: Surveillance cultures did not identify a reservoir. Positive environmental cultures taken from supposedly cleaned surfaces revealed inadequate housekeeping. Pulse field gel electrophoresis performed at another trauma center found the isolates to be unrelated. After these measures were taken, only sporadic unrelated cases of A. baumannii developed in the SICU. No outbreaks in other areas of the hospital. About a year later, a new outbreak of antibiotic susceptible Acinetobacter occurred. Rapid implementation of aggressive infection control techniques used during the previous outbreak helped to quickly suppress this one. Since September 2005, only two unrelated cases have occurred. CONCLUSIONS: The key to controlling the organism is strict adherence to isolation procedures (gowning and gloving before entering the room, removing the gown and gloves before exiting), careful handwashing, and thorough cleaning and disinfection of environmental surfaces and equipment. With increasing MDR Acinetobacter cases, vigilant surveillance for cases, monitoring of personnel practices, and meticulous adherence to basic infection control techniques is critical.