Pneumoperitoneum Secondary to Pneumothorax Post-Intubation in a Patient with Difficult Airway

The use of mechanical ventilation can be performed in situations where patients need ventilatory support to maintain adequate oxygenation. Its inappropriate use can cause some complications, among them: pneumothorax and pneumoperitoneum. Our report describes a 28-year-old man admitted to the ICU with a diagnosis of Covid-19 requiring mechanical ventilation with orotracheal intubation due to acute respiratory failure. During the patient’s clinical evolution he presented bilateral pneumothorax with evolution and progression to secondary pneumoperitoneum, where we sought to understand the relationship between the two conditions.

Lung Abscess with a Refractory Bronchopleural Fistula Saved from Potentially Fatal Sepsis by Omentoplasty and Extracorporeal Membrane Oxygenation

Controlling air leaks during thoracic drainage in patients with lung abscesses caused by bronchopleural fistulas is challenging. To reduce the occurrence of air leaks, positive pressure ventilation should be avoided whenever possible. A 69-year-old man presented with a 10-day history of gradually worsening chest pain. He had lost consciousness and was brought to the emergency room. His SpO2 was approximately 70%, and his systolic blood pressure was approximately 60 mmHg. Chest radiography and computed tomography revealed findings suggestive of a right pyothorax. Therefore, thoracic drainage was performed. However, the patient’s respiratory status did not improve, and his circulatory status could not be maintained. Therefore, extracorporeal membrane oxygenation was introduced after the improvement in circulation by noradrenaline and fluid resuscitation, resulting in adequate oxygenation and ventilation without the use of high-pressure ventilator settings. Subsequently, omentoplasty for a refractory bronchopleural fistula was successfully performed, and the air leak was cured without recurrence of the lung abscess.

HIGH FLOW NASAL OXYGEN- ALL YOU SHOULD KNOW

Respiratory support is applied to maintain adequate oxygenation and ventilation and hence supplemental oxygenation is the first line of treatment for hypoxemic respiratory failure. There are multiple conventional oxygen support devices. However, in majority of these, oxygen provided is not humidified and maximum flow rate is 15l/min. However, high flow nasal oxygen (HFNO) is an alternative to conventional oxygen therapy. It is a technique that delivers heated and humidified oxygen with a controlled fraction of inspired oxygen(FiO2) at a maximum flow rate of 60L/min via (1) a specialized nasal cannula

Early Extracorporeal Membrane Oxygenation in COVID-19 with Bullous Lung Disease on Mechanical Ventilation: A Case Report

Introduction: Extracorporeal membrane oxygenation (ECMO) has been well described as a viable option for patients in need of temporary supplemental oxygenation when ventilator capabilities have failed to augment a patient’s condition. Less described is the potential use of ECMO for lung protection in the setting of gigantic bullae despite initially adequate oxygenation. Case Report: We describe how the early incorporation of ECMO in a patient with coronavirus disease 2019 and necrotizing pneumonia complicated by multiple large and gigantic bullae led to a favorable outcome. Conclusion: The decision to start ECMO early, despite room for ventilator oxygenation adjustments, may have helped to prevent potential, significant complications such as tension pneumothorax while on positive pressure, thus potentially optimizing the outcome in this patient.

Fifteen-minute consultation: Intubation of the critically ill child presenting to the emergency department

Intubation of critically ill children presenting to the emergency department is a high-risk procedure. Our article aims to offer a step-by-step guide as to how to plan and execute a rapid, successful intubation in a way that minimises risk of adverse events and patient harm. We address considerations such as the need for adequate resuscitation before intubation and selection of equipment and personnel. We also discuss drug choice for induction and peri-intubation instability, difficult airway considerations as well as postintubation care. Focus is also given on the value of preintubation checklists, both in terms of equipment selection and in the context of staff role designation and intubation plan clarity. Finally, in cases of failed intubation, we recommend the application of the Vortex approach, highlighting, thus, the importance of avoiding task fixation and maintaining our focus on what matters most: adequate oxygenation.

Management and Prevention of COVID-19 in Pregnancy and Pandemic Obstetric Care: A Review of Current Practices

Constant accumulation of data results in continuous updates of guidelines and recommendations on the proper management of pregnant women with COVID-19. This study aims to summarize the up-to-date information about the prevention and management of suspected/confirmed SARS-CoV-2 infection in obstetric patients and obstetric care during prenatal, intrapartum, and postpartum periods. We conducted a comprehensive literature search in PubMed for relevant English-written full-text reviews. We also included relevant guidelines and recommendations. In women with a low risk for infection and uncomplicated pregnancy, elective and non-urgent appointments should be postponed or completed through telehealth. Vaccination should be discussed and distance and personal hygiene preventive measures should be recommended. Routine ultrasound examinations should be adjusted in order to minimize exposure to the virus. Standardized criteria should evaluate the need for admission. Women with moderate/high-risk for infection should be isolated and tested with RT-PCR. The mode and timing of delivery should follow routine obstetric indications. In case of infection, glucocorticoids are recommended in critically ill pregnant women, after individualized evaluation. During labor and concomitant infection, the duration of the first two stages should be reduced as possible to decrease aerosolization, while minimization of hemorrhage is essential during the third stage. Close maternal monitoring and adequate oxygenation when necessary always remain a prerequisite. Discharge should be considered on the first or second day postpartum, also depending on delivery mode. Breastfeeding with protective equipment is recommended, as its benefits outweigh the risks of neonatal infection. Recommendations are currently based on limited available data. More original studies on infected pregnant women are needed to establish totally evidence-based protocols of care for these patients.

Surgical Site Infections and Perioperative Optimization of Host Immunity by Selection of Anesthetics

Surgical site infections are significant health care issues, and efforts to mitigate their occurrence have been ongoing worldwide, mainly focusing to reduce the spillage of microbes to the otherwise sterile tissues. Optimization of host immunity has been also recognized including temperature regulation (normothermia), adequate oxygenation, and glucose management. A number of papers have described the role of anesthetics in host immunity. The role of anesthetics in postoperative outcomes including surgical site infections has been also studied. We will review the current literature and propose the importance of anesthetic selection to potentially mitigate surgical site infections.

Respiratory

Respiratory is the first system-based chapter because adequate oxygenation and ventilation support are critical for stabilizing unwell or at-risk newborns. Respiratory distress is an early, common sign that stabilization is needed. Stabilization includes identifying infants who require intervention; applying the Respiratory Sequence; using a scoring tool to differentiate mild, moderate, or severe respiratory distress and organizing care accordingly; initiating stabilization measures; and monitoring. Related procedures (e.g., intubation), supportive technologies (e.g., continuous positive airway pressure and mechanical ventilation), and monitoring tools (e.g., pulse oximetry) are described. Respiratory conditions include transient tachypnea of the newborn, respiratory distress syndrome, aspiration syndromes, pneumonia, persistent pulmonary hypertension of the newborn, pneumothorax, and pulmonary hypoplasia. Specific diagnosis and management for each condition round out the chapter, with blood gas and chest radiograph interpretations as needed. Two case scenarios show different care pathways for mild, moderate, and severe respiratory distress.