Post-Covid tracheal resection – first case in India

Prolonged intubations result in tracheal damage and stenosis, the treatment for severe cases is resection and anastomosis. With the progress of the Covid-19 pandemic, this incidence kept rising but the timing and precautions for such aerosolising surgeries remained unclear. To report the first case of tracheal resection and anastomosis in India done during the Covid-19 pandemic along with its rationale. We report a case of 30/male with prolonged intubation and tracheostomy done for Covid-19 pneumonia and ARDS with failure to decannulate and complete loss of voice. After thorough preoperative work-up, he underwent tracheal resection of 4 rings with cricotracheal anastomosis during the covid-19 pandemic in October 2020. He was extubated on table and was asymptomatic after 3 months of follow-up with excellent voice. With good team effort and appropriate precautions, aerosolising airway surgeries resection anastomosis can be safely performed.

Airway Management and Anesthesia for Tracheal Resection in a 68-Year-Old: 3 Airways for the Price of 1

Subglottic tracheal stenosis can occur after prolonged intubation or tracheostomy. This stenosis can become severe and causes symptoms refractory to endoscopic interventions that require tracheal resection. This surgery presents unique anesthetic issues due to the airway anatomy, physiology, and shared airway management with the surgical team. We present the case of a 68-year-old patient who underwent cervical tracheal resection and reconstruction due to persistent symptoms despite balloon dilation and medical management with oxygen and heliox. Our anesthesia management involved several techniques that allowed the safe completion of this procedure. Firstly, we started the airway management with a combined size 4 Ambu® AuraStraight™ (Denmark) supraglottic airway device and flexible bronchoscopy to allow localization of the stenosis and dilation before endotracheal tube (ETT) placement. The conventional approach for this endoscopic evaluation phase is to use rigid bronchoscopy. Secondly, we used prior CT images to help guide our ETT tube size selection. Thirdly, we used total intravenous anesthesia during most of the procedure because of the intermittent apnea necessary to complete the tracheal resection. Lastly, extubation had to be done very carefully to minimize excessive patient neck movement and avoid any reintubation. Both could lead to a catastrophe with the newly reconstructed trachea.

Complications Associated With Removal of Airway Devices Under Deep Anesthesia In Children: An Analysis of The Wake Up Safe Database

Background: Previous studies examining removal of endotracheal tubes and supraglottic devices under deep anesthesia were underpowered to identify rare complications. This study sought to report all adverse events associated with this practice found in a large national database of pediatric anesthesia adverse events.Methods: An extract of an adverse events database created by the Wake Up Safe database, a multi-institutional pediatric anesthesia quality improvement initiative, was performed for this study. It was screened to identify anesthetics with variables indicating removal of airway devices under deep anesthesia. Three anesthesiologists screened the data to identify events where this practice possibly contributed to the event. Event data was extracted and collated. Results: 102 events met screening criteria and 66 met inclusion criteria. Two cardiac etiology events were identified, one of which resulted in the patient’s demise. The remaining 97% of events were respiratory in nature (64 events), including airway obstruction, laryngospasm, bronchospasm and aspiration. Some respiratory events consisted of multiple distinct events in series. Nineteen respiratory events resulted in cardiac arrest (29.7%) of which 15 (78.9%) were deemed preventable by local anesthesiologists performing independent review. Respiratory events resulted in intensive care unit admission (37.5%), prolonged intubation and temporary neurologic injury but no permanent harm. Provider and patient factors were root causes in most events. Upon investigation, areas for improvement identified included improving patient selection, ensuring monitoring, availability of intravenous access, and access to emergency drugs and equipment until emergence.Conclusions: Serious adverse events have been associated with this practice, but no respiratory events were associated with long-term harm.

Conservative Management of Large Tracheal Perforation due to Traumatic Intubation

Tracheal perforation is a rare complication of intubation and is associated with high mortality. Here we describe a case of large, full-thickness tracheal perforation from traumatic intubation after an elective procedure. The injury was managed with prolonged intubation that bypassed the site of injury, and the patient was successfully extubated after 11 days. Conservative management of tracheal perforation after traumatic intubation is an option in select patients that avoids need for surgery.

OV09 ROBOTIC REPAIR OF SUBXIPHOID INCISIONAL HERNIA POST CABG

Aim A median sternotomy that extends toward the epigastric area can weaken the upper abdominal wall and result in the development of subxiphoid incisional hernia. We aim to assess the efficacy and the feasibility of repair of subxiphoid incisional hernia post CABG robotically. In this video; we will also review the surgical technique and the steps for robotic repair of subxiphoid incisional hernia Material and Methods 57-year-old female presented with subxiphoid swelling post CABG in 2019. Her surgery was complicated with sternotomy wound infection with VAC dressing application and ARDS with prolonged intubation. She had 5x7 cm hernia defect that showed on the CT thorax along with sternal wound dehiscence. She underwent robotic repair of her hernia with phasix mesh and recovered well after surgery. Results The subxiphoid hernia is known for its repair complexities and high recurrence rate because the subxiphoid area is a complex structure consisting of boney structures, the rectus abdominis muscles, linea alba, and the diaphragm. The Da Vinci platform allows for accessing hard-to reach area with enhanced precision in dissection and superior dexterity compared to laparoscopy. The Robotic platform allows for manipulation of the camera to assess and operate on the abdominal wall with ease as compared to laparoscopy. Conclusions robotic repair of subxiphoid incisional hernia with mesh is safe and effective method of repair. There are no short-term or long- term side effects of the procedure with no recurrence at 6 months follow up.

Is Tracheostomy Safe?: Common Indications and Early Complications Among Ugandan Patients In A Pre-Covid-19 Era.

Background: Tracheostomy is a life-saving procedure whose outcomes may vary between hospitals based on disparities in their existing expertise. We aimed at establishing the indications, early tracheostomy-related complications and their associated factors in Uganda. Methods: In a prospective cohort study, we consecutively enrolled one-hundred patients, both adults and children 2 hours post-tracheostomy procedure. At baseline, information on patients’ socio-demographics, tracheostomy indications, pre- and post-procedural characteristics was collected through researcher administered questionnaires and from medical records. Clinical examination was performed at baseline but also at either day 7 or whenever a tracheostomy-related complication was suspected during the 7days follow-up. Comparison of patients’ baseline characteristics, tracheostomy indications and complications across two hospitals was done using Pearson’s chi-square. For predictors of early tracheostomy complications, bivariate and multivariate analysis models were fitted using binomial regression in STATA 13.0 software. Results: Majority of patients were adults (84%) and males (70%). The commonest tracheostomy indications were; pulmonary toilet (58%) and anticipated prolonged intubation (42%). Overall, 53% (95% CI: 43.0 – 62.7) had early complications with the commonest being tube obstruction (52.6%). Independent predictors of early tracheostomy-related complications were; anticipated having prolonged intubation as an indication (RR=1.8, 95%CI: 1.19 – 2.76), Bjork flap tracheal incision (RR=1.6, 95%CI: 1.09 – 2.43), vertical tracheal incision (RR=1.53, 95%CI: 1.02 – 2.27), and age below 18 years (RR=1.22, 95%CI: 1.00 – 1.47).Conclusion: Within a pre-COVID-19 context, pulmonary toilet is the commonest tracheostomy indication at major hospitals in Uganda. The incidence of early tracheostomy complications is high and majorly related to post-procedure tracheostomy tube management. Having anticipated prolonged intubation as an indication for tracheostomy, a Bjork flap or vertical tracheal incisions and being a child increases the risk of complications. Emphasis on surgical training and post-procedural management for both clinicians and nurses should be made. New data will be needed within the COVID-19 era.

Airway Management and Risk Factors for Prolonged Intubation in Patients with Severe Croup

Croup is a common respiratory illness in children with a substantial variation in the severity of symptoms. Most of the patients present with mild symptoms, but patients with severe croup require intensive care unit (ICU) management. The aim of this study was to investigate the airway management of patients with severe croup who required intubation and determine the risk factors for prolonged intubation. We performed an 18-year retrospective observational cohort study at the pediatric ICU of a tertiary children's hospital in Japan. A total of 16 patients with croup who were intubated for upper airway obstruction were included in the study. Most patients (13of 16, 81%) were intubated with an endotracheal tube (ETT) smaller than their age-appropriate size. The median difference in the internal diameter (ID) between the selected ETT and the age-appropriate size was 1.0 mm (interquartile range: 0.5–1.0). Multivariate analysis performed on factors affecting the cumulative incidence of extubation revealed that the difference in ID between the selected ETT and age-appropriate size (mm) significantly reduced the duration of intubation (hazard ratio: 0.092, p = 0.03). A downsized ETT without a cuff may be recommended for intubation of patients with croup.

Impact of Bedside Re-Explorations in a Cardiovascular Surgery Intensive Care Unit Led by Surgeons

Surgical re-explorations represent 3–5% of all cardiac surgery. Concerns regarding mortality and major morbidity of re-explorations in the intensive care unit (ICU) setting exist. We sought to investigate whether they may have different outcomes compared with those performed in the operating room (OR). Single center retrospective review of patients who underwent mediastinal re-exploration in the ICU or in the OR after cardiac surgery. Mediastinal re-explorations were also classified as: “planned” and “unplanned”. Primary outcome was 30-day mortality, secondary outcomes include deep sternal wound infection (DSWI), sepsis, ICU and hospital length of stay, prolonged intubation (>72 h), tracheostomy, pneumonia, acute kidney injury requiring dialysis and stroke. Between 2010 and 2019, 195 of 7263 patients (2.7%) underwent mediastinal re-exploration after cardiac surgery. More patients in the ICU group experienced two or more re-explorations (30.3% vs 2.3%, p < 0.001), a higher incidence of postoperative pneumonia (22% vs 7%, p = 0.004), prolonged intubation (46.8% vs 19.8%, p < 0.001) and longer hospital stay (30.3 ± 34.2 vs. 20.8 ± 18.3 days, p = 0.014). There were no differences in mortality between ICU and OR (16.5% vs. 13.9%, p = 0.24) nor in sepsis (14.7% vs 7%, p = 0.91) and DSWI rates (1.8% vs 1.2%, p = 0.14). Re-explorations in the ICU were not associated with increased mortality, sepsis and mediastinitis rate.

Clinical characteristics and outcomes of neonates with polymicrobial ventilator-associated pneumonia in the intensive care unit

Background Ventilator associated pneumonia (VAP) caused by more than one microorganisms is not uncommon and may be potentially challenging, but the relevant data is scarce in ventilated neonates. We aimed to investigate the clinical characteristics and outcomes of polymicrobial VAP in the neonatal intensive care unit (NICU). Methods All neonates with definite diagnosis of VAP from a tertiary level neonatal intensive care unit (NICU) in Taiwan between October 2017 and September 2020 were prospectively observed and enrolled for analyses. All clinical features, therapeutic interventions and outcomes were compared between the polymicrobial VAP and monomicrobial VAP episodes. Multivariate regression analyses were used to find the independent risk factors for treatment failure. Results Among 236 episodes of neonatal VAP, 60 (25.4%) were caused by more than one microorganisms. Polymicrobial VAP episodes were more likely to be associated with multidrug-resistant pathogens (53.3% versus 34.7%, P = 0.014), more often occurred in later days of life and in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. Otherwise most clinical characteristics of polymicrobial VAP were similar to those of monomicrobial VAP. The therapeutic responses and treatment outcomes were also comparable between these two groups, although modification of therapeutic antibiotics were significantly more common in polymicrobial VAP episodes than monomicrobial VAP episodes (63.3% versus 46.2%; P < 0.001). None of any specific pathogens was significantly associated with worse outcomes. Instead, it is the severity of illness, including presence of concurrent bacteremia, septic shock, and requirement of high-frequency oscillatory ventilator and underlying neurological sequelae that are independently associated with treatment failure. Conclusions Polymicrobial VAP accounted for 25.4% of all neonatal VAP in the NICU, and frequently occurred in neonates with prolonged intubation and underlying bronchopulmonary dysplasia. In our cohort, most clinical features, therapeutic responses and final outcomes of neonates with monomicrobial and polymicrobial VAP did not differ significantly.