Endotracheal Research Articles

Non-invasive high-frequency ventilation in newborn infants with respiratory distress.

Non-invasive high-frequency ventilation in newborn infants with respiratory distress.

Impact of BioFire FilmArray Multiplex PCR in the Detection of Microbial Agents causing Severe Acute Respiratory Infection in the COVID-19 Era: A Cross-sectional Study from a Tertiary Care Hospital in Central India

Introduction: Many viral and bacterial respiratory tract infections can present with respiratory signs and progress to complicated pneumonia. In the recent Coronavirus Disease2019 (COVID-19) pandemic, it is crucial to test all Severe Acute Respiratory Infection (SARI) patients for other microbial infections in addition to COVID-19, enabling timely diagnosis and treatment to reduce morbidity and mortality. The automated system, BioFire FilmArray, utilises multiplex Polymerase Chain Reaction (PCR) to rapidly detect and identify multiple respiratory pathogens, including selected Antimicrobial Resistance (AMR) genes, within an hour. Aim: To detect bacterial and/or viral pathogens associated with hospitalised COVID-19-negative SARI patients using the BioFire FilmArray Pneumonia Panel (BFPP). Materials and Methods: This laboratory-based cross-sectional study was conducted at All India Institute of Medical Sciences (AIIMS), Nagpur, Maharashtra, India, from June 2020 to February 2021. Respiratory samples, such as sputum, tracheal aspirate, Endotracheal (ET) secretions, and Bronchoalveolar Lavage (BAL), were collected from COVID-19-negative hospitalised SARI cases. A total of 81 patients were included in the study. The samples were tested using the BFPP (multiplex PCR) system and processed using conventional culture techniques. Patient characteristics, clinical and laboratory investigation data, and findings of respiratory viral and bacterial agents, as well as antibiotic resistance genes detected by BioFire FilmArray, were recorded using paper case reports. The data were collected and analysed using Statistical Package for Social Sciences (SPSS) software. Results: Out of the 81 clinical samples processed, the BFPP detected 168 bacterial and 18 viral pathogens. Bacterial-viral codetection was observed in 13 (16%) samples. Atypical bacteria were detected in 3% of cases. Among the bacterial pathogens, the AMR gene for New Delhi Metallo-beta-lactamases (NDM) was detected in 42 (25.9%) cases, followed by CTX-M betalactamases, VIM, and the oxacillinase group of β-lactamases. Conclusion: The BFPP test is a valuable tool for the rapid detection of a wide range of pathogens, including associated AMR genes, with high sensitivity and specificity. This can greatly aid in treatment decisions.

Submental intubation in patients with maxillofacial fractures: case report and literature review

Background: Conventional orotracheal and nasotracheal intubation can be challenging in patients requiring fixation of fractures of the maxillofacial skeleton. The proximity of the surgical site for maxillofacial procedures to the airway predisposes patients with maxillofacial pathologies to anaesthetic complications like dislodged endotracheal (ET) tubes and inadvertent extubation. The need for maxillomandibular fixation (MMF) as part of fracture management precludes the use of orotracheal intubation. In patients with nasal bone fractures, nasotracheal intubation may not be feasible, and the complications associated with tracheostomy make it a last resort for securing access to the airway. The purpose of this article is to highlight the usefulness of submental intubation in the management of patients with maxillofacial fractures.Case presentation: We present our initial experience with the submental route of intubation and illustrate the procedure with a case of a patient with midface fractures successfully managed using submental intubation. A literature review of alternative airway routes to conventional orotracheal and nasotracheal intubation is also included.Discussion: Edentulous spaces, retromolar intubation, submental intubation, submandibular intubation, and tracheostomy have been used as alternatives to conventional endotracheal intubation. Each route has its associated advantages, disadvantages, and limitations.The submental approach is fast, easy to learn, and associated with minimal complications.Conclusion:Submental intubation is a safe option for airway management in patients with maxillofacial fractures.

Effect of operation table height on ease of mask ventilation, laryngeal view, and endotracheal intubation success.

Optimal patient positioning and operating table height are essential for an ergonomic posture of an anesthesiologist in which there is minimal or no strain on thewrist during mask ventilation. It also avoids flexion of the neck, lower back, and knee bending at the time of laryngoscopy and intubation. One hundred eighty patients were randomly allocated to three groups based on different table heights. The height of the table is kept at the mid-sternum level of an anesthesiologist in group 1, at the xiphoid process in group 2, and at the level of umbilicus in group 3. Laryngoscopic view with or without postural changes (exertion at wrist joint, flexion of the neck, lower back, or knee bending) was graded as per Cormack Lehane's (CL) grading. The degree of discomfort experienced by the anesthesiologist during mask ventilation or tracheal intubation was graded subjectively (1 = no discomfort, 2 = mild discomfort, 3 = moderate discomfort, and 4 = severe discomfort) at different table heights. Postural changes required to obtain the best glottic view and quality of endotracheal (ET) intubation (intubation time and attempts required) were also noted. For analysis, quantitative variables were expressed as mean ± SD and compared using unpaired t or analysis of variance test. Qualitative variables were expressed as frequencies/percentages and compared using the Chi-square test. Results with P value <0.05 were considered significant statistically. Moderate discomfort (strain at wrist joint) during bag-mask ventilation was experienced by the anesthesiologist in a maximum number of patients in group 1 (81.7%). Significant improvement was seen in CL grade after the use of postural modifications in groups 1 and 2 (P value ≤0.05). Greater postural modifications were required during ET intubation at lower table heights (group 3). It is advisable to adopt higher table positioning in relation to anesthesiologist performing the laryngoscopy for smooth and single-attempt ET intubation since the best laryngoscopic view and intubation with minimal postural modifications was seen at higher table heights (at the mid-sternum level of an anesthesiologist).

Antibiotic Susceptibility Pattern of the Potential Pathogens of Ventilator Associated Pneumonia in the Endotracheal Tubes of Critically Ill Patients

An endotracheal (ET) tube offers surface for potential pathogens to attach and produce biofilm. These potential pathogens are typically hospital flora with a broad range of antibiotic resistance. The study aimed to characterize the biofilm-producing flora in ET tube of critically ill patients. Following extubation, ET tubes were retrieved aseptically from 100 different patients and promptly transported in a sterile ziplock bag. Each ET tube was cut into three different sections; inner lumen was scraped out and inoculated on Blood agar, MacConkey agar, and Chocolate agar. Colonies produced on media were tested for antibiotic susceptibility testing by applying disc diffusion and Colistin minimum inhibitory concentration (MIC). Out of 100 ET tubes, monomicrobial growth was observed in 62, polymicrobial growth in 14, and no growth in 24 specimens. A total of 93 potential pathogens were isolated including 25 (26.89%) Acinetobacter species, 23 (24.73%) Klebsiella species, 15(16.12%) Pseudomonas species, 13 (13.98%) E. coli, 6 (6.45%), Staphylococcus aureus, 4 (4.3%) Coagulase Negative Staphylococcus species (CoNS), 2 (2.15%) Proteus species, 1 (1.07%) Enterobacter species and 4 (4.3%) Candida species. Imipenem and Colistin proved to be among the most successful antibiotics against gram negative isolates. Only 1 out of 25 Acinetobacter species was resistant to Colistin. Methicillin resistance emerged in two S. aureus and three CoNS strains. Microorganisms usually adhere themselves to the surface of ET tubes. They may act as potential pathogens for the onset of Ventilator Associated Pneumonia (VAP) and are resistant to commonly administered antibiotics in hospitals. A technique to reduce or prevent the risk of biofilm development is crucial.

A retrospective study on bacteriological profile and antibiotics prescription practice in a tertiary level intensive care unit

BACKGROUND Antibiotics are the most commonly prescribed medicines in intensive care units (ICU). The irrational use of antibiotics leads to the development of multidrug-resistant organisms (MDR). The aim of the study is to determine the bacteriological profile of infections in our ICU and antibiotic prescription practice, before and after the culture results. METHODOLOGY This is a retrospective study conducted in a tertiary-level, 33-bedded ICU in Nepal to evaluate the bacteriological profile and antibiotic prescription practice. The patients who were admitted between a period of 3 months (January 2023 to March 2023) were enrolled. The data variables collected were; patients' details, culture samples sent (blood, urine, endotracheal (ET) aspirate, sputum, cerebrospinal fluid (CSF), wound swab, pleural fluid, ascitic fluid, tissue culture, and peritoneal fluid), gram stain results, culture sensitivity results, empirical antibiotics used, and change in antibiotics following culture results. RESULTS A total of 378 culture samples were obtained from 230 patients. A positive culture report was obtained for 165 (43.65%) of the 378 samples sent. Urine was the most common sample sent for microbiology (28%), followed by blood (25.3%) and sputum (22.75%). The percentage occurrence of gram-negative bacteria was 84%, while that of gram-positive bacteria was 16%. Methicillin- resistant coagulase-negative staphylococcus (MRCONS) was the most common gram-positive organism isolated (46.15%), and Klebsiella pneumoniae was the most common gram-negative organism (38.84%). Cephalosporin was the commonest group of empirical antibiotics used in our ICU, followed by carbapenem. Empirical antibiotic treatment was continued in 108 patients (47%), changed following the culture results in 92 patients (40%), and discontinued in 30 patients (13%). Escalation of antibiotics was done in 78 patients (85%) and de-escalation in 14 patients (15%). CONCLUSION Antimicrobial resistance and the irrational prescription of antibiotics can lead to a global economic burden. Hence, antibiotic stewardship programs are required to reduce the irrational prescribing patterns of antibiotics.

Impact of the route of adrenaline administration in patients suffering from out-of-hospital cardiac arrest on 30-day survival with good neurological outcome (ETIVIO study)

BackgroundOver the past decades, international guidelines for cardiopulmonary resuscitation (CPR) have changed the recommendation for alternative routes for drug administration. Until now, evidence for the substantial superiority of one route with respect to treatment outcome after CPR has been lacking. The present study compares the effects of intravenous (IV), intraosseous (IO) and endotracheal (ET) adrenaline application during CPR in out-of-hospital cardiac arrest (OHCA) on clinical outcomes within the database of the German Resuscitation Registry (GRR).MethodsThis registry analysis was based on the GRR cohort of 212,228 OHCA patients between 1989 and 2020. Inclusion criteria were: OHCA, application of adrenaline, and out-of-hospital CPR. Excluded from the study were patients younger than 18 years, those who had trauma or bleeding as suspected causes of cardiac arrest, and incomplete data sets. The clinical endpoint was hospital discharge with good neurological outcome [cerebral performance category (CPC) 1/2]. Four routes of adrenaline administration were compared: IV, IO, IO + IV, ET + IV. Group comparisons were done using matched-pair analysis and binary logistic regression.ResultsIn matched-pair group comparisons of the primary clinical outcome hospital discharge with CPC 1/2, the IV group (n = 2416) showed better results compared to IO (n = 1208), [odds ratio (OR): 2.43, 95% confidence interval (CI): 1.54–3.84, p < 0.01] and when comparing IV (n = 8706) to IO + IV (n = 4353), [OR: 1.33, 95% CI: 1.12–1.59, p < 0.01]. In contrast, no significant difference was found between IV (n = 532) and ET + IV (n = 266), [OR: 1.26, 95% CI: 0.55–2.90, p = 0.59]. Concurrently, binary logistic regression yielded a highly significant effect of vascular access type (χ² = 67.744(3), p < 0.001) on hospital discharge with CPC1/2, with negative effects for IO (regression coefficient (r.c.) = − 0.766, p = 0.001) and IO + IV (r.c. = − 0.201, p = 0,028) and no significant effect for ET + IV (r.c. = 0.117, p = 0.770) compared to IV.ConclusionsThe GRR data, collected over a period of 31 years, seem to emphasize the relevance of an IV access during out-of-hospital CPR, in the event that adrenaline had to be administered. IO administration of adrenaline might be less effective. ET application, though removed in 2010 from international guidelines, could gain importance as an alternative route again.

CODE BLUE in a patient with tracheal stent: Are we fully equipped?

Sir, Airway stents have long been used to maintain luminal integrity of compromised airway in case of obstruction and malignancy.[1] The complications associated with airway stent placement are malposition, haemorrhage, airway rupture during placement, migration, impaction, formation of granulation tissue, and stent fracture.[2] We present here a challenging case of an airway emergency in a patient with a tracheal stent inserted for a malignancy. A 29-year-old woman diagnosed with adenoid cystic carcinoma of trachea 2 years back had undergone debulking of tumor, tracheal stenting with a metallic stent, and chemo-radiotherapy elsewhere. On the second day of admission, CODE BLUE was activated in view of acute onset biphasic stridor, with air hunger and low oxygen saturation. Despite resuscitation measures, the patient had persistent tachycardia, tachypnea, and hypoxia with non-rebreathing mask (15 L/min of O2). A review of Computed Tomography (CT) neck revealed a tracheal narrowing 1.7 cm distal to vocal cords with narrowest diameter of 6 mm [Figure 1a], complicating an imminent intubation for the patient. She was pre-oxygenated with a non-invasive ventilation mask. Intravenous boluses of fentanyl 75 mcg, muscle relaxant (suxamethonium 100 mg) was given and intubated with a 5.0 mm ID cuffed endotracheal (ET) tube through direct laryngoscopy. A chest x-ray confirmed the position of the ET tube but it fell short of bypassing the tracheal stent, which was reflected in decreased tidal volumes and increased peak pressure. As the length of the 5.0 mm ET tube (23 cm) was not enough to bypass the stent, we had to increase the length by rail roading another 6.5 mm ID tube at the distal end, after removing the connector [Figure 1b]. This step significantly improved the tidal volumes (350-400 ml) without much rise in peak pressure with marked improvement in the oxygenation of patient in the blood gas analysis. Patient underwent bronchoscopic biopsy and excision of mass around the stent after putting on veno-venous extracorporeal membrane oxygenation for oxygenation. Post-procedure ET tube was removed after suctioning and intubated with 7.0 mm ID ET tube for postoperative ventilation and eventually extubated.Figure 1: (a) image showing CECT neck with tracheal stent in situ. (b) image showing the proximal end of 6.5 mm ID tube is cut and railroaded over 5.0 mm ID tube to increase the lengthSecuring airway in an in-hospital CODE blue needs quick thinking and swift action. This case highlights a unique situation where a tracheal stent precluded a “conventional intubation.” A tracheostomy could damage the stent and a supraglottic airway device risked aspiration.[3] A fibre-optic bronchoscope is essential and the best available option to ensure correct position of the tube within the stent or just above the stent. It can also avoid stent-related complications but is not readily available everywhere.[4] No formal guidelines are available in terms of airway management with tracheal stents in situ. A literature search also revealed paucity of data with regard to management in similar case scenarios. Microlaryngeal surgery (MLS) tubes can be made available in the CODE BLUE kits anticipating such scenarios, as they are longer than conventional ET tubes with same internal diameter.[5] This case though uncommon highlights the need to incorporate airway management in cases of tracheal stents as part of our teaching curriculum. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Less Invasive Surfactant Administration (LISA) in Premature Neonates, using 5F feeding tube versus 2 mm Endotracheal tube – An Innovative, Pilot study

Introduction: Administration of LISA using thin and soft catheters like 5 F orogastric tube, though less invasive, is technically challenging and needs expertise. We hypothesized, use of a 2 mm Endotracheal (ET) tube for administration of LISA could be an easy and convenient alternative. Methods: This is a prospective, single-centric, quasi-random, pilot trial conducted in the inborn unit of a tertiary care hospital from May 2020 - December 2020. All the inborn preterm (28 - 34 weeks) neonates with respiratory distress requiring surfactant were alternately allocated to receive LISA using a 5 F infant feeding tube or an uncuffed 2.0 size ET tube. The primary outcome was successful administration of surfactant defined as a procedure without any need for positive pressure ventilation. Results: In our study, 25 neonates were enrolled in each arm. Administration of LISA using 2 mm ET tube was associated with better success of surfactant administration with lesser incidence of PPV (20 vs 11, p &lt; 0.05), desaturation (5 vs 12, p &lt; 0.05), and bradycardia (3 vs 10, p &lt; 0.05) compared to LISAOG. Conclusions: Administration of LISA using a 2 mm ET is an easily adaptable and convenient alternative that is well tolerated by the neonates without any adverse effects.

Antibiotic Susceptibility Pattern of Aerobic Bacterial Pathogen Isolated from Endotracheal Aspirate.

Ventilator-associated pneumonia (VAP) is one of the major hospital-acquired infections and the emergence of bacterial resistance is common among patients in the intensive care units (ICUs). The aim of the study is to identify the common bacterial pathogen isolated from an endotracheal (ET) aspirate and its antibiotic susceptibility pattern. A prospective analytical study was carried out in a tertiary care hospital for a period of 1 year. All ET aspirate sample sent to the microbiology laboratory was processed and identified by standard biochemical tests and antibiotic sensitivity was by disk diffusion method as per Clinical and Laboratory Standards Institute (CLSI) guidelines. Of the total 217 samples studied, 85 (39.17.1%) were culture sterile and 132 (60.82%) showed culture positive. Among 132 isolates, the predominant organism was Acinetobacter baumannii (36.36%) followed by Klebsiella pneumoniae (24.24%) and Pseudomonas aeruginosa (20.45%). We have reported a higher percentage of resistance among the isolated gram-negative bacilli to carbapenems, aminoglycosides, and third-generation cephalosporins, with increased sensitivity to piperacillin-tazobactam and cefoperazone-sulbactam. In our study, A. baumannii was the predominantly isolated gram-negative bacilli followed by K. pneumoniae and P. aeruginosa. One of the rising concerns to hospital-acquired respiratory pathogens is the surge of multidrug resistance patterns. Hence, strict adherence to antibiotic policy and appropriate use according to the guidelines will save the use of drugs in the future in life-threatening conditions.

TEMPOROMANDIBULAR JOINT DISLOCATION DUE TO NEAR SELF-EXTUBATION

TEMPOROMANDIBULAR JOINT DISLOCATION DUE TO NEAR SELF-EXTUBATION

Lateral flow test performance in children for SARS-CoV-2 using anterior nasal and buccal swabbing: sensitivity, specificity, negative and positive predictive values

ObjectiveTo determine if the sensitivity of the lateral flow test is dependent on the viral load and on the location of swabbing in the respiratory tract in children.DesignPhase 1: Routinely...

Clinicoradiological correlation of Endotracheal secretion culture in each case of suspected VAP: a need of the present to combat drug-resistance

Background: Ventilator-associated pneumonia (VAP) in intensive care unit (ICU)-admitted patients is a life-threatening event, caused by a diverse range of microbes having varied susceptibility to different classes of antibiotics. Materials and Methods: We enrolled patients admitted in trauma ICU on mechanical ventilation for &gt;48 h. Modified clinical pulmonary infection score (≥6) having a significant bacterial count (≥105 cfu/ml) in endotracheal (ET) secretions was used to diagnose VAP. Subsequently, we did antibiotic susceptibility testing by the modified Kirby–Bauer method, and the results were interpreted per Clinical and Laboratory Standards Institute guidelines. Results: We enrolled 389 patients in this study. Amongst these, we noted VAP events in 87 patients with an incidence of 15.62/1000 days of ventilators. Gram-negative rods were the predominant microbes causing VAP. Acinetobacter baumannii-calcoaceticus complex (n = 30) followed by Klebsiella pneumoniae (n = 27) and Pseudomonas aeruginosa (n = 19) was the predominant isolate. All nine isolated Staphylococcus aureus strains were methicillin-resistant S. aureus (MRSA). About 48.72% (38/78) of the Gram-negative microbes were meropenem sensitive. All strains of A. baumanii and P. aeruginosa were sensitive to polymyxin B, whereas all isolated MRSA strains were sensitive to vancomycin and linezolid. In addition, drug-resistant epidemiological important bacterial pathogens were also isolated from ET secretions. Conclusion: VAP is caused by a diverse group of multidrug-resistant microorganisms; however, drug-resistant microbes also colonise the in situ ET tubes. Therefore, accurate diagnosis of VAP and its differentiation from ET tube colonisation is a need of present times as appropriate treatment of actual VAP cases will reduce the burden of drug-resistant microbes in ICU settings.

RT-PCR Ct values combined with age predicts invasive mechanical ventilation and mortality in hospitalized COVID-19 patients in a MERS-CoV-endemic country

BackgroundSeveral risk factors have been used to predict severity of coronavirus disease 2019 (COVID-19), real-time reverse transcriptase polymerase chain reaction (RT-PCR) cycle threshold (Ct) values have not been included. MethodsA retrospective analysis of laboratory-confirmed COVID-19 patients who were hospitalized between March 2 and September 1, 2020, in an academic hospital in Riyadh that serves as a Middle East respiratory syndrome coronavirus (MERS-CoV) referral center was conducted. Nasopharyngeal (NP) and endotracheal (ET) samples were tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) by RT-PCR, and viral load (VL) was determined based on the Ct values of E genes. The Ct values were distributed into four groups, with group Ct1 (≤19) indicating the highest VL and Ct4 (≥31) indicating the lowest VL. Univariate logistic regression was used to analyze age, gender, and comorbidities in relation to Ct groups for a primary endpoint of either invasive mechanical ventilation (IMV) or mortality. Significant variables were further analyzed by multivariate logistic regression. ResultsThe analysis included 728 patients hospitalized with COVID-19 (38% female; median age = 53 years; 41.3% diabetic; 39.4% hypertensive). Overall, 13.6% of these patients required IMV, and the in-hospital mortality rate was 15.5%. The IMV rate was higher in the Ct1 and Ct2 groups (15.2% and 15.5%, respectively) than in the Ct4 group (6.4%; p = 0.01). The mortality rate was also higher in the Ct1 and Ct2 groups (19.4% and 18.9%, respectively) than in the Ct4 group (8.9%; p = 0.02). The univariate analysis showed that lower Ct values and increasing age were associated with an increased risk of IMV (OR: 1.03; 95% CI: 1.01, 1.04; P < 0.0001) and mortality (OR: 1.04; 95% CI: 1.03, 1.06; P < 0.0001). The multivariate analysis showed that Ct1 was associated with the highest risk of mortality (OR: 2.29; 95% CI: 1.16, 5.52; P = 0.016), while Ct2 was associated with the highest risk of IMV (OR: 3.1; 95% CI: 1.47, 6.53; P = 0.003). ConclusionThe SARS-CoV-2 RT-PCR Ct values of hospitalized COVID-19 patients can be used as predictors of IMV and mortality, and this effect increases when combined with age. Clinicians could use these predictors to triage older patients for risk stratification and allocate IMV.

Knowledge Regarding Ventilator-associated Pneumonia and its Prevention Among Nurses Working at Intensive Care Units of Two Teaching Hospitals in Sri Lanka

Introduction: Ventilator-associated Pneumonia (VAP) is the commonest hospital-acquired infection among mechanically ventilated patients in Intensive Care Units (ICUs). Previous studies on ICU nurses report poor practice on VAP and preventive measures. The study aimed to assess knowledge on VAP and its prevention among ICU nurses from two teaching hospitals in Sri Lanka. Methods: A descriptive cross-sectional study was conducted among 127 nurses from adult ICUs. Data were collected using a pre-tested self-administered questionnaire and analysed using SPSS version 20. Knowledge levels were categorized as good (above 75%), average (50-75%) and poor (below 50%). Results: Overall results showed that 62.2% had average, 33.1% had good, and 4.7% had poor knowledge on VAP and its prevention. The mean knowledge score was 70.15±10.5. Most participants had good knowledge on the meaning of VAP (68.5%), upper respiratory tract functions (84.3%), causative microorganisms (56.7%) and mode of transmission (78.7%). The majority had an average knowledge on standard precautions (48.8%) for VAP and poor knowledge on signs of VAP (52%). Regarding prevention of VAP, most of them had good knowledge on natural preventive mechanisms (92.1%), using of suction catheters (96.9%) and reducing microbial colonization in the oropharynx (93.7%). In contrast, poor knowledge was evident on minimum endotracheal (ET) suction pressure (69.3%), minimum ET cuff pressure (64.6%), early weaning from ventilator (72.4%), and disinfection of ventilator parts (53.5%). Conclusions: Overall knowledge of ICU nurses on VAP and its preventive measures was average. Knowledge deficiencies were identified in preventive strategies in maintaining airways and disinfection.&#x0D; Keywords: Nurses, Ventilator-associated pneumonia, Intensive care unit, Knowledge, Prevention

Adverse event using Medtronic NIM™ EMG endotracheal tube on a patient receiving anesthesia for hemithyroidectomy: a case report

BackgroundThe neural integrity monitor (NIM) electromyogram (EMG) endotracheal (ET) tube is a widely used device to monitor neural response through muscle activity. It is helpful in surgical procedures with high risk of damaging delicate structures in the head and neck. This case provides a thorough analysis of an adverse event that was encountered in the operating room, which others can hopefully learn from.Case presentationWe are reporting a case in which a patient undergoing hemithyroidectomy had experienced an adverse event using the Medtronic NIM™ EMG endotracheal tube. After successful induction and intubation, confirming the proper positioning of the electrode wires was necessary before the incision could be made. Upon reexamination, the patient suddenly became difficult to ventilate with increased peak airway pressure, decreased tidal volume, and end tidal CO2. This episode lasted approximately 15 min and the patient’s condition remained stable despite low tidal volumes. The problem was unexpectedly resolved upon deflation of the cuff of the ET tube.ConclusionsThere are several similar reports of these endotracheal tubes causing obstruction, especially those in which overinflation of the cuff caused cuff herniation and blockage of the Murphy eye and the bevel. It is currently believed that the design of this tube allowed for the obstruction to occur. The patient’s short body habitus may have also been a small contributing factor. The distance that the electrodes must sit within the vocal cords to the tip of the bevel is longer in this type of ET tube compared with a standard ET tube. The distance from the true vocal cords to where the cuff sits in the trachea is also greater in this model NIM EMG tube. There was no confirmation of the exact obstructive process that took place, however, confirming the tube and cuff positioning would have been optimal.

Outcomes of Nonvigorous Neonates Born through Meconium-Stained Amniotic Fluid after a Practice Change to No Routine Endotracheal Suctioning from a Developing Country.

The International Liaison Committee on Resuscitation (ILCOR) 2015 gave a weak recommendation based on low certainty of evidence against routine endotracheal (ET) suctioning in non-vigorous (NV) neonates born through meconium-stained amniotic fluid (MSAF) and suggested for immediate resuscitation without direct laryngoscopy. A need for ongoing surveillance post policy change has been stressed upon. This study compared the outcomes of NV MSAF neonates before and after implementation of the ILCOR 2015 recommendation. This was a prospective cohort study of term NV MSAF neonates who underwent immediate resuscitation without ET suctioning (no ET group, July 2018 to June 2019, n = 276) compared with historical control who underwent routine ET suction (ET group, July 2015 to June 2016, n = 271). Baseline characteristics revealed statistically significant higher proportion of male gender and small for gestational age neonates in the prospective cohort. There was no significant difference in the incidence of primary outcome of meconium aspiration syndrome (MAS) between the groups (no ET group: 27.2% vs ET group: 25.1%; p = 0.57). NV MSAF neonates with hypoxic ischemic encephalopathy (HIE) was significantly lesser in the prospective cohort (no ET group: 19.2% vs ET group: 27.3%; p = 0.03). Incidence of air leaks and need for any respiratory support significantly increased after policy change. In NV MSAF neonates with MAS, need for mechanical ventilation (MV) (no ET group: 24% vs ET group: 39.7%; p = 0.04) and mortality (no ET group: 18.7% vs ET group: 33.8%; p = 0.04) were significantly lesser. Current study from a developing country indicates that immediate resuscitation and no routine ET suctioning of NV MSAF may not be associated with increased risk of MAS and may be associated with decreased risk of HIE. Increased requirement of any respiratory support and air leak post policy change needs further deliberation. Decreased risk of MV and mortality among those with MAS was observed. · Not performing ET suction in NV MSAF infants is not associated with increase in the incidence of MAS.. · Initiating immediate resuscitation without ET suctioning was associated with decreased risk of HIE but increased receipt of any respiratory support and air leak.. · Large multicentric trial is required to generate robust evidence..

Endotracheal bleed after intra cardiac repair in tetralogy of fallot patients: a diagnostic challenge

Background: Tetralogy of Fallot (TOF) is the most common congenital cyanotic heart disease (CCHD) in children. With the development and advancement of paediatric cardiac surgery and intensive care units, a large number of TOF are presenting for cardiac surgery. Operated TOF may suffer from endotracheal (ET) bleeding in postoperative period which results in delayed extubation of patients. ET bleeding is multifactorial with MAPCAs, coagulopathy residual VSD, and high LA pressure being usual causes. The objective of this study was to evaluate those children of TOF who suffered from ET bleeding, their causes and management after intracardiac repair.Methods: This was a single center retrospective study that included patients with a diagnosis of TOF. Total of 27 patients were operated at GB Pant Hospital, Department of CTVS from February 2021 to November 2021. After taking ethical approval we conducted a retrospective study to analyse the cause of endotracheal bleed. Statistical analyses were performed using STATA software version (16.0). Continuous variables were presented as mean±standard deviation (SD) or median (interquartile range [IQR]. Inclusion criteria was- all diagnosed case of tetralogy of fallot patient with age –1.5-8 years, both male and female. Exclusion criteria was- patients having co-morbidities, like juvenile diabetes, hypothyroidism, syndromic patients.Results: Endotracheal bleed noted in majority of patient in those MAPCAs were not coiled, not able to be ligated intaoperatively, they bleed in postoperative period which further delayed extubation of patients. Of the patients with Endotracheal bleed none had a residual cardiac defect. Post-operative mortality was 1/27.Conclusions: We hereby conclude that cause of endotracheal bleed after intracardiac repair of tetralogy of fallot patients can be due to left uncoiled, non- ligated major aorto-pulmonary collateral arteries (MAPCAs).

Chip-Less Real-Time Wireless Sensing of Endotracheal Intubation Tubes by Printing and Mounting Conformable Antenna Tag

Endotrachealintubation is a common medical practice for patients requiring upper airway management. An important parameter while performing intubation is the depth of insertion of the tube. However, most current solutions rely on vision-based feedback for successfully performing remote intubation. We propose a novel application of chip-less RF sensing technology to identify the intubation tube from the exterior and serve as an additional feedback modality, independent of the visual aid. We used printable silver conductive ink to fabricate flexible RF antennas to be deployed on the Endotracheal (ET) intubation tubes. An interrogating antenna, connected to a network analyzer, placed on top of the neck can identify the RF antenna inside the trachea during intubation in real-time. A prototype design was developed and tested with various wireless channel mediums (air, water, phantom models, and duck neck). Seven human subjects were involved in another experiment that used human fingers as a wireless medium between the antennas. Experimental results show that the proposed method can identify the presence of ET tubes by registering a significant change in the return loss magnitude (2.21 dB in phantom model and an average of 1.16 dB in human experiments) across all the mediums. The proposed sensing solution can be used as a viable feedback parameter for robotic control systems that aim to automate intubation with or without visual feedback.

Lung targeted liposomes for treating ARDS.

Acute Respiratory Distress Syndrome (ARDS), associated with Covid-19 infections, is characterized by diffuse lung damage, inflammation and alveolar collapse that impairs gas exchange, leading to hypoxemia and patient’ mortality rates above 40%. Here, we describe the development and assessment of 100-nm liposomes that are tailored for pulmonary delivery for treating ARDS, as a model for lung diseases. The liposomal lipid composition (primarily DPPC) was optimized to mimic the lung surfactant composition, and the drug loading process of both methylprednisolone (MPS), a steroid, and N-acetyl cysteine (NAC), a mucolytic agent, reached an encapsulation efficiency of 98% and 92%, respectively. In vitro, treating lipopolysaccharide (LPS)-stimulated RAW 264.7 macrophages with the liposomes decreased TNFα and nitric oxide (NO) secretion, while NAC increased the penetration of nanoparticles through the mucus. In vivo, we used LPS-induced lung inflammation model to assess the accumulation and therapeutic efficacy of the liposomes in C57BL/6 mice, either by intravenous (IV), endotracheal (ET) or IV plus ET nanoparticles administrations.Using both administration methods, liposomes exhibited an increased accumulation profile in the inflamed lungs over 48 h. Interestingly, while IV-administrated liposomes distributed widely throughout the lung, ET liposomes were present in lungs parenchyma but were not detected at some distal regions of the lungs, possibly due to imperfect airflow regimes. Twenty hours after the different treatments, lungs were assessed for markers of inflammation. We found that the nanoparticle treatment had a superior therapeutic effect compared to free drugs in treating ARDS, reducing inflammation and TNFα, IL-6 and IL-1β cytokine secretion in bronchoalveolar lavage (BAL), and that the combined treatment, delivering nanoparticles IV and ET simultaneously, had the best outcome of all treatments. Interestingly, also the DPPC lipid component alone played a therapeutic role in reducing inflammatory markers in the lungs. Collectively, we show that therapeutic nanoparticles accumulate in inflamed lungs holding potential for treating lung disorders.SignificanceIn this study we compare intravenous versus intratracheal delivery of nanoparticles for treating lung disorders, specifically, acute respiratory distress syndrome (ARDS). By co-loading two medications into lipid nanoparticles, we were able to reduce both inflammation and mucus secretion in the inflamed lungs. Both modes of delivery resulted in high nanoparticle accumulation in the lungs, intravenously administered nanoparticles reached lung endothelial while endotracheal delivery reached lung epithelial. Combining both delivery approaches simultaneously provided the best ARDS treatment outcome.