Tracheostomy management in patients with severe acute respiratory distress syndrome receiving extracorporeal membrane oxygenation: an International Multicenter Retrospective Study

Background Current practices regarding tracheostomy in patients treated with extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome are unknown. Our objectives were to assess the prevalence and the association between the timing of tracheostomy (during or after ECMO weaning) and related complications, sedative, and analgesic use. Methods International, multicenter, retrospective study in four large volume ECMO centers during a 9-year period. Results Of the 1,168 patients treated with ECMO for severe ARDS (age 48 ± 16 years, 76% male, SAPS II score 51 ± 18) during the enrollment period, 353 (30%) and 177 (15%) underwent tracheostomy placement during or after ECMO, respectively. Severe complications were uncommon in both groups. Local bleeding within 24 h of tracheostomy was four times more frequent during ECMO (25 vs 7% after ECMO, p < 0.01). Cumulative sedative consumption decreased more rapidly after the procedure with sedative doses almost negligible 48–72 h later, when tracheostomy was performed after ECMO decannulation (p < 0.01). A significantly increased level of consciousness was observed within 72 h after tracheostomy in the “after ECMO” group, whereas it was unchanged in the “during-ECMO” group. Conclusion In contrast to patients undergoing tracheostomy after ECMO decannulation, tracheostomy during ECMO was neither associated with a decrease in sedation and analgesia levels nor with an increase in the level of consciousness. This finding together with a higher risk of local bleeding in the days following the procedure reinforces the need for a case-by-case discussion on the balance between risks and benefits of tracheotomy when performed during ECMO.

Development of a Management Algorithm for Acute and Chronic Radiation Urethritis and Cystitis

<b><i>Objective:</i></b> The purpose of this review was to summarize the current literature on the assessment and treatment of radiation urethritis and cystitis (RUC) for the development of an evidenced-based management algorithm. <b><i>Material and Methods:</i></b> The PubMed/MEDLINE database was searched by a multidisciplinary group of experts in January 2021. <b><i>Results:</i></b> In total, 48 publications were identified. Three different types of RUC can be observed in clinical practice: inflammation-predominant, bleeding-predominant, and the combination of inflammation- and bleeding-RUC. There is no consensus on the optimal treatment of RUC. Inflammation-predominant RUC should be treated symptomatically based on the existence of bothersome storage or voiding lower urinary tract symptom as well as on pain. When bleeding-predominant RUC has occurred, hydration and hyperbaric oxygen therapy (HOT) should be used first and, if HOT is not available, oral drugs instead (sodium pentosane polysulfate, aminocaproic acid, immunokine WF 10, conjugated estrogene, or pentoxifylline + vitamin E). If local bleeding persists, focal therapy of bleeding vessels with a laser or electrocoagulation is indicated. In case of generalized bleeding, intravesical installation should be initiated (formalin, aluminium salts, and hyaluronic acid/chondroitin). Vessel embolization is a less invasive treatment with potentially less complications and good clinical outcomes. Open- or robot-assisted surgery is indicated in patients with permanent, life-threatening bleeding, or fistulae. <b><i>Conclusions:</i></b> Treatment of RUC, if not self-limiting, should be done according to the type of RUC and in a stepwise approach. Conservative/medical treatment (oral and topic agents) should primarily be used before invasive (transurethral) treatments.

Single center experience of pediatric percutaneous balloon pericardiotomy

Background: Percutaneous balloon pericardiotomy is a percutaneous procedure that creates a window in the parietal pericardium by balloon dilation. The use of percutaneous balloon pericardiotomy has not been reported well in children. Objectives: The objective of this study was to describe the single centre experience of percutaneous balloon pericardiotomy in children. Methods: This was a retrospective study to describe all the children aged <20 years undergoing percutaneous balloon pericardiotomy during an 18-year period (2001–2019). Patient characteristics, technical and ultimate procedural success, and repeat interventions were collected. Results: A total of 13 percutaneous balloon pericardiotomy’s were performed in 11 children at the median age of 12 years (range 1.8–19). The etiologies of pericardial effusion were post-pericardiotomy syndrome (n = 4), restrictive cardiomyopathy (n = 1), autoimmune diseases (n = 3), malignancy (n = 2), and idiopathic (n = 1). Two patients received two percutaneous balloon pericardiotomy. The technical success of percutaneous balloon pericardiotomy was 100% with no acute adverse events (balloon rupture or local bleeding). Five (45%) required re-intervention and ultimately three required a surgical pericardial window 6 to 35 days after the percutaneous balloon pericardiotomy. As a result, ultimate procedural success rate was 73% (8/11). Conclusion: Percutaneous balloon pericardiotomy was performed safely with high technical success in children. Percutaneous balloon pericardiotomy may be considered for recurrent and persistent pericardial effusion, before considering a surgical pericardial window.

Review on Effect of Hemorrhages in Rescuing Casualties from Fatalities

Introduction: High bleeding due to hypolemia may cause early death. If injured persons hospitalized due to trauma, they may more likely to die. Methods for bleeding control include mechanical, heat treatment, drug therapy, or topical hemostats. The purpose of this study was to evaluate the efficacy of hemorrhage and their usages in all emergency bleeding cases (in the years of 2008-2019). In this study, relevant articles were collected and reviewed using keywords, local bleeding, clotting, trauma, emergency, bleeding and systematic check. The relevant articles were collected and reviewed. Currently, hemostatic materials can be used to control and reduce bleeding using a variety of mechanisms, including integration coagulation factors at one point, adhesion to tissues, and activation of coagulation cascades and so on. Some of these dressings are approved by the US Food and Drug Administration. Conclusion: The use of hemorrhagic bandages is one of the most important recent developments. Mineral-based hemorrhages are better than other products in terms of mechanism of action. However, it is still not an ideal product. Research in this area should be given more attention.

Shark-related injuries in Hawai’i treated at a level 1 trauma center

BackgroundAlthough rare, human–shark interactions can result in a wide spectrum of injuries. This is the first study to characterize shark-related injuries (SRIs) in Hawai’i.MethodsThis is a retrospective review of the State of Hawai’i Division of Aquatic Resources Shark Incidents List between January 1, 2009 and December 31, 2019. Trauma registry data and medical records of patients treated for SRIs at the only level 1 trauma center in Hawai’i were reviewed.ResultsSixty-one patients sustained SRIs in the Hawaiian Islands: 25 in Maui, 16 in O’ahu, 12 in Hawai’i, and 8 in Kaua’i. In cases where the shark species could be identified, tiger sharks were the most frequent (25, 41%). Four cases were fatal—all died on scene in Maui with the shark species unknown. Forty-five survivors (79%) received definitive care at regional facilities. Twelve (21%) were treated at the level 1 trauma center, of which two were transferred in for higher level of care. Of the 12 patients, 11 (92%) had extremity injuries, with 3 lower extremity amputations (25%), 2 with vascular injuries (17%), and 5 with nerve injuries (42%). One had an injury to the abdomen. All patients had local bleeding control in the prehospital setting, with 9 (75%) tourniquets and 3 (25%) hemostatic/pressure dressings applied for truncal or proximal extremity injuries. The mean time from injury to emergency department arrival was 63 minutes.DiscussionMost SRIs are managed at regional facilities, rather than at a level 1 trauma center. Prehospital hemorrhage control is an important survival skill as time to definitive care may be prolonged. For cases treated at the level 1 trauma center, nerve injuries were common and should be suspected even in the absence of major vascular injury. Correlating shark behavior with observed injury patterns may help improve public awareness and ocean safety.Level of evidenceLevel V, epidemiological.

Reduction of bacterial colonization at the exit site of peripherally inserted central catheters: A comparison between chlorhexidine-releasing sponge dressings and cyano-acrylate

Introduction: A serious complication associated with Central Venous Access Device (CVAD) is infection because of bacterial contamination, either by the extra-luminal or by the intra-luminal route. We evaluated the efficacy, the safety, and the cost-effectiveness of two strategies for non-inferiority in controlling bacterial colonization of the exit-site of Peripherally-Inserted Central Catheters (PICC). Methods: After PICC placement, a skin swab of the exit site was taken and cultured. In group A the exit site was sealed with N-butyl-cyanoacrylate glue, while in group B a chlorhexidine-releasing sponge dressing was applied. A second skin culture was taken at day 7. Results: A total of 51 patients were enrolled in each group. In 42 patients the second skin culture was not performed because of 20 patients were lost at follow-up or deceased and in 22 patients the dressing needed to be changed early, because of local bleeding (13 cases, in group B) or because of dressing detachment (four in group A and five in group B). The microbiological study was completed in 36 patients in group A and 24 in group B. No microorganisms were isolated in any patient. Conclusions: Both strategies were effective in controlling bacterial colonization. Glue was effective in reducing local bleeding, and it was more cost-effective than sponge dressing. During the first week, when local bleeding and bacterial colonization must be prevented, glue might be more appropriate than chlorhexidine-releasing dressing; after the first week chlorhexidine-releasing dressing might be preferable, considering that the safety of glue application on the skin for prolonged periods is still questionable.

Bleeding Disorders in Bothrops atrox Envenomations in the Brazilian Amazon: Participation of Hemostatic Factors and the Impact of Tissue Factor

Bleeding is a common hemostatic disorder that occurs in Bothrops envenomations. We evaluated the changes in coagulation, fibrinolysis components, and platelets in Bothrops atrox envenomations with bleeding. This is an observational study with B. atrox snakebite patients (n = 100) treated in Manaus, Brazilian Amazon. Bleeding was recorded on admission and during hospitalization. We found that the platelet count in our patients presented a weak correlation to tissue factor, factor II, and plasminogen. Tissue factor presented weak correlation to factor V, II, D-dimer, plasminogen, alpha 2-antiplasmin, and moderate correlation to fibrinogen and fibrin/fibrinogen degradation product (FDP). Patients with systemic bleeding (n = 20) presented low levels of factor V, II, fibrinogen, plasminogen, and alpha 2-antiplasmin, and high levels of tissue factor and FDP compared to those without bleeding. Patients with only local bleeding (n = 41) and without bleeding showed similar levels of hemostatic factors. Thrombocytopenia was observed mainly in patients with systemic bleeding and increased levels of serum venom. No association was found between venom levels and systemic bleeding, or between venom levels and clinical severity of envenomation. This is the first report that shows the participation of the extrinsic coagulation pathway in the consumption coagulopathy of B. atrox envenomations with systemic bleeding due to tissue factor release.