A Case of Nasal Mucosa Cautery With Reintubation Under Pharyngeal Suction for Massive Epistaxis After Extubation

We describe a case of massive epistaxis that occurred after removal of a nasal endotracheal tube, prompting emergent reintubation. Mask ventilation could not be performed because the nasal cavity was packed with gauze and the airway was being evacuated with a suction catheter. Therefore, instead of inhalational anesthetics and muscle relaxants, boluses of midazolam and remifentanil were administered, and reintubation was promptly performed. Sedation was maintained with dexmedetomidine infusion and midazolam. Nasal cautery was performed near the left sphenopalatine foramen. The patient was extubated without agitation or additional hemorrhage. Immediate recognition of the potential for airway loss, sufficient control of active bleeding, and drug selection in accordance with the emergent circumstances enabled prompt resecuring of the airway without pulmonary aspiration of blood.

Management of post-operative pancreatic fistulas following Longmire–Traverso pylorus-preserving pancreatoduodenectomy by endoscopic vacuum-assisted closure therapy

Background Pylorus-preserving pancreatoduodenectomy (PPPD) with pancreatogastrostomy is a standard surgical procedure for pancreatic head tumors, duodenal tumors and distal cholangiocarcinomas. Post-operative pancreatic fistulas (POPF) are a major complication causing relevant morbidity and mortality. Endoscopic vacuum therapy (EVT) has become a widely used method for the treatment of intestinal perforations and leakages. Here we report on a pilot single center series of 8 POPF cases specifically caused by dehiscences of the pancreatogastric anastomosis (PGD), successfully managed by EVT. Methods We included all patients with PGD after PPPD, who were treated with EVT between 07/2017 and 08/2020. For EVT a vacuum drainage film (EVT film) or open-pore polyurethane foam sponge (EVT sponge) was fixed to a 14Fr or 16Fr suction catheter and placed endoscopically within the PGD for intracavitary EVT with continuous suction between − 100 and − 150 mmHg. The EVT film/sponge was exchanged twice per week. EVT was discontinued when the PGD was sufficiently healed. Results PGD closure was achieved in 7 of 8 patients after a mean EVT time of 16 days (range 8–38) and 3 EVT film/sponge exchanges (range 1–9). One patient died on day 18 after PPPD from acute hemorrhagic shock, unlikely related to EVT, before effectiveness of EVT could be fully achieved. There were no adverse events directly attributable to EVT. Conclusions EVT could be an effective and safe addition to our therapeutic armamentarium in the management of POPF with PGD. Unless prospective comparative studies are available, EVT as minimally invasive therapeutic alternative should be considered individually by an interdisciplinary team involving endoscopists, surgeons and radiologists.

Shock Due to an Obstructed Endotracheal Tube

Endotracheal tube obstruction by a mucus plug causing a ball-valve effect is a rare but significant complication. The inability to pass a suction catheter through the endotracheal tube with high peak and plateau pressure differences are classical features of an endotracheal tube obstruction. A case is described of endotracheal tube obstruction from a mucus plug that compounded severe respiratory acidosis and hypotension in a patient who simultaneously had abdominal compartment syndrome. The mucus plug was not identified until a bronchoscopic assessment of the airway was performed. Due to the absence of classical signs, the delayed identification of the obstructing mucus plug exacerbated diagnostic confusion. It resulted in various treatments being trialed whilst the patient continued to deteriorate from the evasive offending culprit. We suggest that earlier and more routine use of bronchoscopy should be employed in an intensive care unit, especially as a definitive way to rule out endotracheal obstruction.

Airway Obstruction Caused by Sputa in Heat and Moisture Exchange Filter During Ventilation Using Supra-Laryngeal Mask Airway: A Case Report

Introduction: Supra-laryngeal mask airway (LMA) is widely accepted as an alternative to the tracheal tube. However, compared to the use of a tracheal tube, it may take longer to identify the many different causes of sudden respiratory distress. In particular, heat and moisture exchange filters are one of the most overlooked causes. Case presentation: The case was that of a 76-year-old male Japanese patient (161.9 cm, 66.5 kg) who underwent an open renal biopsy. He presented with chronic obstructive pulmonary disease, with a Hugh–Jones dyspnea score of 2. The patient did not discontinue smoking prior to the operation. Anesthesia was induced using propofol (100 mg), fentanyl (100 ?g), and remifentanil (0.3 ?g/kg/min). I-gel™ #4 was inserted following neuromuscular blockade with rocuronium (40 mg). Anesthesia was maintained with 3–6% desflurane under positive pressure ventilation. After induction in the left lateral and jackknife positions, the following ventilator settings were used: volume-controlled ventilation with tidal volumes of 450 mL, respiratory rate of 12 breaths per minute, an inspiratory: expiratory ratio of 1:2, and a positive end expiratory pressure of 5 cmH2O. With these settings, the peak inspiratory pressure was 16 cmH2O. Five minutes after initiating the operation, the peak inspiratory pressure steadily increased to 30 cmH2O. Although we administered rocuronium, the peak inspiratory pressure and end-tidal carbon dioxide concentration increased over time. When we disconnected the heat and moisture exchange filter and LMA, we noticed a large quantity of sputa. A suction catheter was passed down the LMA and the sputa was removed, but the LMA was not obstructed. The peak inspiratory pressure continued to increase with tidal volumes of only 20–30 mL. Despite a normal external appearance of the heat and moisture exchange filter, we replaced it with a new one. The ability to ventilate improved immediately and the SpO2 recovered from 92% to 100%. Conclusions

1244 The TAL Suction Retractor: A Simple Technique for Visualising the Transverse Acetabular Ligament (TAL) During Total Hip Replacement (THR) Surgery

Introduction The transverse acetabular ligament (TAL) is an anatomical landmark that is of particular use during primary total hip replacements (THR). Visualisation is important to aid the orientation of the acetabular cup and it is a structure that can be identified in virtually every primary hip replacement surgery. We introduce a simple technique to facilitate this. Method A thoracic suction catheter is taped to the distal end of a blunt Hohmann’s retractor with two steristrips wrapping around the catheter and retractor leaving approximately 1-1.5cm of retractor exposed. Our preference is for a thoracic suction catheter with side holes and a proximal end which allows direct connection with the tip of the Yankauer suction. The blunt Hohmann’s retractor is used as the inferior acetabular retractor in the usual way, placed inferior to the transverse acetabular ligament, resting on the posterior ischial surface. The catheter suction tip should lie just under the TAL, in the most dependant point of the wound. Results The TAL suction catheter can be used continuously or intermittently to facilitate visualisation of the TAL during reaming, trialling, and acetabular cup placement. The TAL suction retractor provides suction in the most dependant point of the surgical wound, preventing unnecessary movement and facilitates a clutter-free surgical field leading to more streamlined and efficient surgery with potential reduced operative times. Conclusions The transverse acetabular ligament (TAL) suction retractor is a simple improvised surgical tool that makes it easier to visualise the TAL during acetabular preparation in total hip replacements.

Esophageal Perforation and EVAC in Pediatric Patients: A Case Series of Four Children

Introduction: In pediatric patients, esophageal perforation (EP) is rare but associated with significant morbidity and mortality rates of up to 20–30%. In addition to standard treatment options, endoscopic esophageal vacuum-assisted closure (EVAC) therapy has shown promising results, especially in adult patients. Thus far, the only data on technical success and effectiveness of EVAC in pediatric patients were published in 2018 by Manfredi et al. at Boston Children's Hospital. The sparse data on EVAC in children indicates that this promising technique has been barely utilized in pediatric patients. More data are needed to evaluate efficacy and outcomes of this technique in pediatric patients.Method: We reviewed five cases of therapy using EVAC, ArgyleTM Replogle Suction Catheter (RSC), or both on pediatric patients with EP in our institution between October 2018 and April 2020.Results: Five patients with EP (median 3.4 years; 2 males) were treated with EVAC, RSC, or a combination. Complete closure of EP was not achieved after EVAC alone, though patients' health stabilized and inflammation and size of EP decreased after EVAC. Four patients then were treated with RSC until the EP healed. One patient needed surgery as the recurrent fistula did not heal sufficiently after 3 weeks of EVAC therapy. Two patients developed stenosis and were successfully treated with dilatations. One patient treated with RSC alone showed persistent EP after 5 weeks.Conclusion: EVAC in pediatric patients is technically feasible and a promising method to treat EP, regardless of the underlying cause. EVAC therapy can be terminated as soon as local inflammation and C-reactive protein levels decrease, even if the mucosa is not healed completely at that time. A promising subsequent treatment is RSC. An earlier switch to RSC can substantially reduce the need of anesthesia during subsequent treatments. Our findings indicate that EVAC is more effective than RSC alone. In some cases, EVAC can be used to improve the tissues condition in preparation for a re-do surgery. At 1 year after therapy, all but one patient demonstrated sufficient weight gain. Further prospective studies with a larger cohort are required to confirm our observations from this small case series.

Closed Endotracheal Suctioning Impact on Ventilator-Related Parameters in Obstructive and Restrictive Respiratory Systems: A Bench Study

A closed suctioning system (CSS) in patients with coronavirus disease 2019 (COVID-19) prevents spraying respiratory secretions into the environment during suction. However, it is not clear whether ventilation is maintained during the suction procedure, especially in patients with compromised pulmonary mechanics. This paper determines the effects of endotracheal tube (ETT) size, suction catheter size, and two lung mechanics (resistance and compliance) on ventilator-related parameters measured during suction. Suction was performed on an adult training lung, ventilated with either volume-controlled (VC-CMV) or pressure-controlled mandatory ventilation (PC-CMV), using ETT sizes of 6.5–8.0 mm paired with suction catheter sizes of 8–14 French (Fr). Peak inspiratory pressure (PIP) increased by 50% when the ETT’s ventilation area was less than 25 mm2 in size, especially in patients with high airway resistance ventilated with VC-CMV. Positive end-expiratory pressure (PEEP) levels significantly decreased when using 14 Fr SC during VC-CMV and fewer effects during PC-CMV. Change of expiratory minute volume increased with higher outer diameter of suction catheters and decreased with severe lung compliance during PC-CMV. The change in ventilator-related parameters were intently monitored in the patient whose pulmonary mechanic was compromised through the CSS endotracheal tube suctioning procedures in clinical airway management.

Optimizing effects on airway pressure and minute volume during closed endotracheal suctioning: a simulated lung model

A closed suction system is used to remove endotracheal secretions without interrupting the patient’s ventilation. Closed suctioning may reduce adverse effects associated with suctioning with, for example, decreased clinical signs of hypoxemia and limited environmental, personnel, and patient contamination. However, it is not clear whether ventilation is maintained during the procedure. We aimed to determine the effects of endotracheal tube (ETT) size, suction catheter (SC) size, and SC length in the ETT on ventilation parameters measured during suction. Suction was performed on a test lung, ventilated with either volume-controlled continuous mandatory ventilation (VC-CMV) or pressure-controlled continuous mandatory ventilation (PC-CMV) using ETT sizes of 6.0–8.5 mm paired with SC sizes of 8–16 French gauge (Fr = 0.33 mm). Airway resistance ( Raw), peak inspiratory pressure (PIP), positive end-expiratory pressure (PEEP), and expiratory minute volume ( Vexp) were recorded for each ventilation episode by a HAMILTON-G5 ventilator. Here, Raw was considerably increased by insertion of the SC into the ETT. This Raw effect altered the PIP and Vexp. PIP was increased in VC-CMV because the ventilation area of the ETT was reduced, and Vexp was decreased in PC-CMV in relation to the size of the SC. PEEP decreased with application of the 16 Fr SC and 30 L/min flow rate in VC-CMV. We conclude that airway pressure and minute volume are not maintained during closed endotracheal suctioning with VC-CMV and PC-CMV, respectively. The degree of interference to ventilation is affected through selection of appropriate SC size and ventilation settings.