Nasotracheal vs. Orotracheal Intubation and Post-extubation Airway Obstruction in Critically Ill Children: An Open-Label Randomized Controlled Trial

Background: The data on long-term nasotracheal intubation among mechanically ventilated critically ill children is limited. The purpose of this study was to compare the rate of post-extubation airway obstruction (PEAO) with nasotracheal and orotracheal intubation.Methods: This open-label randomized controlled trial was conducted in PICU of a tertiary care and teaching hospital in North India from January-December 2020 involving intubated children aged 3 months−12 years. After written informed consent, children were randomized into nasotracheal and orotracheal intubation groups. Post-extubation, modified Westley's croup score (mWCS) was used at 10-timepoints (0-min, 30 min, 1, 2, 3, 6, 12, 24, 36, and 48-h after extubation) to monitor for PEAO. The primary outcome was the rate of PEAO; and secondary outcomes were time taken for intubation, number of intubation attempts, complications during intubation, unplanned extubation, repeated intubations, tube malposition/displacement, endotracheal tube blockade, ventilator associated pneumonia, skin trauma, extubation failure/re-intubation, duration of PICU stay, and mortality.Results: Seventy children were randomized into nasotracheal (n = 30) and orotracheal (n = 40) groups. Both the groups were similar in baseline characteristics. The rate of PEAO was similar between nasotracheal and orotracheal groups (10 vs. 20%, p = 0.14). The maximum mWCS and mWCS at 10-timepoints were similar in two groups. The time taken for intubation was significantly longer (85 vs. 48 s, p < 0.001) in nasotracheal group, whereas other secondary outcomes were similar in two groups.Conclusion: The rate of PEAO was not different between nasotracheal and orotracheal groups.Clinical Trial Registration:http://ctri.nic.in, Identifier: CTRI/2020/01/022988.

Suspected Sugammadex Hypersensitivity following Repeated Administration in the Setting of Multiple Flap Takebacks in a Brief Timespan

Sugammadex hypersensitivity is an uncommon event that typically occurs at higher doses. We report a case of suspected sugammadex hypersensitivity in a patient who developed hypoxia and bronchospasm following three administrations of the standard 2 mg/kg doses of sugammadex within 26 hours due to flap takebacks. Hypersensitivity to sugammadex was not initially suspected given that the patient had previous exposures. Diagnoses of pneumothorax, hemothorax, mucus plug, and tracheal tube malposition were immediately ruled out. Furthermore, the onset of hypoxia with sudden loss of tidal volume, development of high peak airway pressures, and temporal correlation with sugammadex administration all supported bronchospasm secondary to a hypersensitivity reaction. Sugammadex is a useful agent for neuromuscular blockade reversal; however, it is critical to carefully examine all adverse reactions. This case report highlights the importance of considering hypersensitivity reactions in the setting of repeat sugammadex administrations in a limited timeframe, such as in free flap reconstruction requiring multiple takebacks to the operating room in the setting of flap compromise.

Endoscopy-guided diode laser-assisted transcaruncular StopLoss Jones tube implantation for canalicular obstructions in primary surgery

Purpose To introduce and evaluate a minimally-invasive endoscopy-guided transcaruncular laser-assisted StopLoss Jones tube (SLJT) implantation technique for severe canalicular obstructions in primary surgeries. Methods We retrospectively identified 12 adult patients (12 eyes) with severe epiphora secondary to long-segment canalicular obstructions. All the 12 eyes underwent an endoscopy-guided transcaruncular SLJT implantation with an 810-nm diode laser’s assistance as the primary surgical approach. Surgical and functional success rates, intraoperative and postoperative complications, as well as the need for secondary surgery, are evaluated. Results Primary surgical success was achieved in 11 of the 12 cases (92%); one patient (8%) required secondary surgery to replace an SLJT with a shorter one. Ultimately, all cases showed well-placed functioning tubes. Three of the 12 cases (25%) presented conjunctival scarring, conjunctival granulation tissue, with or without tube-associated irritation of the ocular surface. We observed no sink-in, extrusion, nor crack of the tube. Complete functional success was achieved in 83%, and moderate functional success in 17% of all patients. The functionally unsuccessful outcome was not present in this study. Conclusion Endoscopy-guided transcaruncular diode laser-assisted SLJT implantation seems to be a promising minimally invasive approach for primary treatment of severe canalicular dacryostenosis. This novel technique shows high functional success rates. It seems to avoid the risk of tube malposition and extrusion, septal and turbinate injury, nasal adhesion, drainage failure, ethmoiditis, postoperative bleeding, and cutaneous scars.

A Comparison of Prehospital Nonphysician and Hospital Physician Placed Tube Thoracostomy

Background Prehospital chest decompression can be a lifesaving procedure in severe chest trauma. Studies investigating prehospital chest decompression are mostly European where physicians are assigned to prehospital care units. This report is one of the first to compare demographics and outcomes in patients undergoing prehospital chest decompression by trained aeromedical nonphysician personnel to hospital chest decompression by physicians. Methods Prehospital tube thoracostomy (PTT) patients were identified from January 2014 to January 2019 and were matched in a 1:2 ratio based on age, Injury Severity Score (ISS), and chest Abbreviated Injury Score (AIS) to patients who underwent hospital tube thoracostomy (HTT) within 24 hours of admission. Results Forty-nine PTT patients were matched to 98 HTT patients. PTT patients had lower admission Glasgow Coma Scale (GCS), a higher rate of pre-chest tube needle decompression, and higher level 1 trauma activation. PTT were placed sooner (21.9 vs 157.0 minutes, P < .001). Rates of tube malposition, organ injury, tube dislodgement, empyema, and hospital-acquired pneumonia over the course of hospital admission were not significantly different between the 2 groups. PTT patients had longer intensive care unit length of stay (LOS), but similar hospital LOS, and overall mortality. Discussion This report demonstrates that PTT is performed sooner than hospital placed tubes. Complication rates associated with tube thoracostomy and patient outcomes were not statistically different between PTT and HTT groups.