Episodes Of Aspiration Research Articles

Pulmonologist-Performed Ultrasound-Guided Fine-Needle Aspiration of Lung Lesions

Background and objective: Lung cancer is increasingly common, and accurate diagnosis is important for personalized treatment. Ultrasound-guided percutaneous fine-needle aspiration (FNA) is a useful method to obtain a specimen for a histological diagnosis of peripheral lung lesions. The aim of this study is to evaluate the diagnostic accuracy and complication rate of the procedure performed by pulmonologists. The result is compared with that of ultrasound-guided core needle biopsy performed by radiologists. Methods: We retrospectively evaluated the diagnostic accuracy and complication rates of pulmonologist-performed ultrasound-guided FNAs of lung lesions in the period of 1 August 2019 to 30 June 2021 (pulmonologist group) and radiologist-performed ultrasound-guided core needle biopsies (CNBs) of lung lesions in the period of 1 January 2010 to 31 December 2014 (radiologist group). A logistic regression analysis was used to identify independent influence factors associated with diagnostic accuracy in the pulmonologist group and in the combination of both groups. Results: In a 23-month period, pulmonologists in a tertiary center performed 113 episodes of ultrasound-guided fine-needle aspiration for peripheral lung lesions. The diagnostic accuracy and complication rates were 80.4% and 5.3%, respectively, compared to 86.8% and 7.4% in a historical cohort consisting of 68 episodes of ultrasound-guided core needle biopsies performed by radiologists in the same hospital. Lung lesions located in the upper lobe were predictive of successful diagnoses. Conclusions: An ultrasound-guided fine-needle aspiration by a pulmonologist is an easily accessible and reliable method to obtain specimens for histological diagnoses.

A Mixed Methods Study Exploring Patient Perspectives and Outcome Measures From Not Fasting Before Cardiac Catheterisation

This study aimed to describe the patient experience and incidence of adverse events in unfasted patients undergoing coronary angiography and angioplasty. In addition, to identify any association between duration of fasting and adverse events. Historically, patients were fasted before elective cardiac catheterisation. Routine fasting was not evidence-based, and many centres, including our unit, have discontinued the practice. Patients undergoing cardiac catheterisation at a large urban teaching hospital were invited to participate in a prospective observational cohort study documenting the duration of fasting and incidence of adverse events (n=508). Of these participants, 257 also completed a survey that captured perspectives and opinions regarding not fasting. The mean time since last fluid was 1.9±2.2 hours and for food was 3.9±3.7 hours. The most common adverse event was hypotension (10.0%). Rates of nausea (3.9%) and vomiting (0.6%) were low, and there were no episodes of aspiration. No associations were identified between the time since the last food or fluid and any adverse events. Thematic analysis of survey data yielded three themes: (1) in most, not fasting is preferable to fasting; (2) being able to eat and drink before the procedure positively affected well-being, and (3) one-fifth of the cohort expressed no preference between fasting and non-fasting. Not fasting before cardiac catheterisation is viewed favourably by patients. While this study provides additional evidence that not fasting is safe, event rates are low, and larger multicentre studies are needed for confirmation.

A typical presentation of a laryngeal foreign body in an infant

Background: A 1-year-old boy presented with a one-day history of fever and cough, potentially linked to an episode of aspiration during homemade rice feeding. Following the incident, he refused to feed, displaying irritability. The detection of neutrophil leucocytosis and dehydration prompted IV antibiotics and fluid. Persistent symptoms led to a lateral neck x-ray, revealing a radiopaque material near the epiglottis. Fibre optic laryngoscopy identified a metallic wire lodged in the right arytenoid cartilage and posterior pharyngeal wall, possibly a fragment from a rice polishing machine. Extraction under general anaesthesia resulted in minimal mucosal injury, and the child quickly recovered postoperatively.Conclusion: This report serves as a reminder to consider foreign body ingestion in the differential diagnosis, particularly in cases with subtle or unrelated symptoms in the paediatric age group. The multidisciplinary approach emphasises prompt intervention to prevent life-threatening complications in paediatric patients. Furthermore, employing awake fibre-optic laryngoscopy in the context of a suspected respiratory tract infection to confirm the presence of a foreign body is considered a clinically safer approach than immediately resorting to examination under anaesthesia.

Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

BackgroundThe utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain.MethodsWe systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models.ResultsOur meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04–1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24–0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41–0.96; p = 0.03; I2 = 0%) compared to DL.ConclusionVL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients.Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685. Registered 6 July 2023.

Development of organized pleural empyema as a result of occult foreign body aspiration.

Foreign body (FB) aspiration is a rare incident in adults. Many patients cannot recall the episode of aspiration and are hospitalized with complications of an endobronchial FB.

Surgical revision of the postesophagectomy gastric conduit to address poor emptying

IntroductionThe configuration of the gastric conduit after esophagectomy can lead to chronic gastrointestinal and respiratory issues. Surgical revision of the gastric conduit has been described in small series but appears to be infrequently used. We investigated outcomes of revising dilated or redundant conduit in patients with severe quality-of-life issues. MethodsWe identified all patients from 2016 to 2022 at our institution who underwent gastric conduit revision after previous esophagectomy either at our or another institution. Chart review was performed to assess prerevision course and perioperative outcomes. Pre- and postrevision imaging was compared for all patients to assess the impact of surgery on anatomic configuration. Patient-reported gastrointestinal and respiratory issues before and after surgery were examined. ResultsThe use of right thoracotomy combined with laparotomy to reduce redundancy and improve gastric emptying was performed in 8 patients. The symptoms necessitating reoperation included intolerance to oral intake and poor gastric emptying associated with both acute and chronic aspiration episodes. The median length of stay was 8 [4, 25] days, and there were no perioperative mortalities. Seven (87.5%) patients were tolerating oral intake at discharge. All patients had improvement in their prerevision symptoms on follow-up. ConclusionsGastric conduit revision can improve severe postesophagectomy gastrointestinal and respiratory symptoms in patients with dilated/redundant conduits with limited perioperative morbidity.

An Unusual Disease With a Common Presentation: Cricopharyngeal Dysfunction in Inclusion Body Myositis

ABSTRACT Cricopharyngeal (CP) dysfunction is a frequent cause of dysphagia among patients with inclusion body myositis. Early identification and prompt treatment is necessary because aspiration pneumonia is a leading cause of mortality among these patients. We present a case of a 57-year-old woman with a history of inclusion body myositis who presented with progressive dysphagia and aspiration pneumonia found to have CP dysfunction treated with endoscopic CP myotomy. Postoperatively, patient's dysphagia improved with no further episodes of aspiration at 2-year follow-up.

Airway Injury Caused by Aspiration of Iron Sulfate Pills: A Series of 11 Cases

It is not widely recognized that iron (ferrous sulfate) pill aspiration causes airway damage. Clinical diagnosis is challenging because patients are often unaware that they have aspirated a pill. The literature on this entity consists mainly of case reports. The aim of this study is to describe the clinical and pathologic features of iron pill aspiration in a series of 11 patients. A retrospective review of our pathology archives was performed to identify cases of iron pill aspiration (2013-2023). All available histologic and cytologic material was rereviewed. Clinical information was collected from the electronic medical record, and imaging studies were rereviewed. Eighteen endobronchial biopsies were identified from 11 patients (7 women and 4 men; mean age, 70 years; range, 44-82 years). Eight patients had corresponding cytology (20 specimens). Medication history was available in 9 of 11 patients, all of whom were taking iron sulfate pills. Two patients reported possible aspiration episodes; 4 had risk factors for aspiration. The diagnosis of iron pill aspiration was suspected prior to biopsy in only 1 case. Histologically, iron pill particles were yellow, golden brown, or gray, were elongated and crystal or fiber like, and stained strongly with an iron stain. Common histologic findings included mucosal ulceration, acute and/or chronic inflammation, fibrosis, and squamous metaplasia. Iron pill particles were also identified in 11 cytology specimens from 6 patients. On Papanicolaou staining, iron pill particles were yellow to golden, fiber like, refractile, and crystalline. Reactive epithelial cells, squamous metaplasia, and acute inflammation were common. The combination of iron pill intake and discolored mucosa on bronchoscopy is a potential clue to the diagnosis of iron pill aspiration. Pathologists should familiarize themselves with the appearance of iron pill particles in endobronchial biopsies and cytology specimens from the respiratory tract as this diagnosis is seldom suspected on clinical grounds, and most patients lack a history of aspiration.

Clinically defined aspiration pneumonia is an independent risk factor associated with long-term hospital stay: a prospective cohort study

BackgroundLong-term hospital stay is associated with functional decline in patients with pneumonia, especially in the elderly. Among elderly patients with pneumonia, aspiration pneumonia is a major category. Clinical definition is usually used because it can occur without apparent aspiration episodes. It is still not clear whether a long-term hospital stay is due to aspiration pneumonia itself caused by underlying oropharyngeal dysfunction or simply due to functional decline in elderly patients with multiple comorbidities during acute infection. The aim of this study is to identify whether clinically defined aspiration pneumonia itself was associated with a long-term hospital stay.MethodsA prospective observational study on community-acquired (CAP) or healthcare-associated pneumonia (HCAP) was conducted from January 2012 through January 2014. Aspiration pneumonia was clinically defined as pneumonia not only occurring in patients after documented aspiration episodes, but also occurring in those with underlying oropharyngeal dysfunction: chronic disturbances of consciousness and/or chronic neuromuscular diseases. We defined thirty-day hospital stay as a long-term hospital stay and compared it with logistic regression analysis. Potential confounders included age, sex, HCAP, body mass index (BMI), long-term bed-ridden state, heart failure, cerebrovascular disorders, dementia, antipsychotics use, hypnotics use, and CURB score which is a clinical prediction tool used to assess the severity, standing for; C (presence of Confusion), U (high blood Urea nitrogen level), R (high Respiratory rate), and B (low Blood pressure). In a sub-analysis, we also explored factors associated with long-term hospital stay in patients with aspiration pneumonia.ResultsOf 2,795 patients, 878 (31.4%) had aspiration pneumonia. After adjusting potential confounders, the aspiration pneumonia itself was significantly associated with long-term hospital stay (adjusted odds ratio 1.44; 95% confidence interval 1.09—1.89, p < 0.01), as were higher age, male sex, high CURB score, HCAP, low BMI, heart failure, cerebrovascular disease, and antipsychotics use. Sub-analysis revealed factors associated with long-term hospital stay in the aspiration pneumonia, which included male sex, and multi-lobar chest X-ray involvement.ConclusionsClinically defined aspiration pneumonia itself was independently associated with long-term hospital stay. This result could potentially lead to specific rehabilitation strategies for pneumonia patients with underlying oropharyngeal dysfunction.

Evaluation of feeding difficulties using videofluoroscopic swallow study and swallowing therapy in infants and children.

Infants and children with feeding difficulties have swallowing dysfunction and high risk of aspiration, which could be silent without choking, resulting in recurrent pneumonia and long-term respiratory morbidity. Videofluoroscopic swallow study (VFSS) is a useful tool for real-time visualization of the swallowing process and airway aspiration. This study reported a single-institutional 10-year experience of VFSS in pediatric patients with feeding difficulties and the efficacy of swallowing therapy. From 2011 to 2020, 30 infants and children with feeding difficulties received VFSS examinations in a medical center at a median age of 19 months (range 7 days-8 years). The images of the swallowing process (oral phase, triggering of pharyngeal swallowing, and pharyngeal phase) under videofluoroscopy were analyzed by a radiologist and a speech-language pathologist. Aspiration severity was assessed from VFSS observations and rated by an eight-point Penetration-Aspiration-Scale (PAS), with higher scores indicating increased severity. Swallowing therapy was performed by experienced speech-language therapists, and follow-up of oral feeding tolerance and risk of aspiration pneumonia was done. Of the 30 patients, 24 (80%) had neurological deficits. High PAS scores (6-8) were observed in 25 (83.4%) patients, and 22 had a PAS score of 8, indicating silent aspiration. Of the 25 patients with high PAS scores, 19 (76%) had neurological deficits, and 18 (72%) depended on tube feeding at a median age of 20 months. Swallowing problems occurred most frequently during the pharyngeal phase in the patients with high PAS scores. VFSS-based swallowing therapy improved oral feeding ability and reduced aspiration episodes. Infants and children with swallowing dysfunction and neurological deficits had high risk of severe aspiration. Swallowing problems in the pharyngeal phase were the most common VFSS findings in patients with severe aspiration. VFSS may help guide problem-oriented swallowing therapy to reduce the risk of recurrent aspiration.

Not Fasting Before Cardiac Catheterisation: An Observational Cohort Study of Patient Experience and Adverse Events

To describe the patient experience and incidence of adverse events in unfasted patients undergoing coronary angiography and angioplasty. To identify any association between duration of fasting and adverse events. Patients have historically fasted before cardiac catheterisation. Routine fasting was not evidence-based and many centres, including ours, have discontinued the practice. Patients undergoing cardiac catheterisation at Auckland City Hospital were invited to participate in a prospective observational cohort study documenting the duration of fasting and incidence of adverse events (n=508). Of these participants, 257 also completed a survey that captured perspectives regarding not fasting. The mean time since last fluid was 1.9±2.2 hrs and for food was 3.9±3.7 hours. The most common adverse event was hypotension (10%). Rates of nausea (3.9%) and vomiting (0.6%) were low, and there were no episodes of aspiration. No associations were identified between the time since the last food or fluid and any adverse events. Thematic analysis of survey data yielded three themes: 1) not fasting was preferable to fasting for most; 2) being able to eat and drink before the procedure positively affected wellbeing; and 3) one-fifth of the cohort expressed no preference between fasting and non-fasting. Not fasting before cardiac catheterisation is favourably viewed by patients. While this study provides additional evidence that not fasting is safe and event rates are low, larger, multicentre studies are needed for confirmation.

Intensive Dysphagia Rehabilitation Program Post Covid-19: Case Series Report

Dysphagia often occurs in the most severe cases of Covid-19 infection and has an impact on clinical outcomes and patients’ quality of life. Objective: This study aimed to describe the effects of intensive speech rehabilitation in cases of post-Covid-19 dysphagia in a hospital environment. Methods: This is a series of five patients admitted to a medical ward between May and August 2021. They were dysphagic, underwent orotracheal intubation and were submitted to evaluation and intensive speech therapy for five consecutive days. The intervention involved myofunctional exercises and in three cases electrical stimulation were also associated. The outcomes were: evolution of the Functional Oral Intake Scale (FOIS) and Penetration-Aspiration Scale (PAS) - according to videofluoroscopy - degree of dysphagia according to the Dysphagia Outcome and Severity Scale (DOSS) and improvement in quality of life (SWAL-QOL). Results: After therapy, one patient remained with severe dysphagia, two evolved to mild dysphagia, and two to functional deglutition. In four cases, there was an evolution of the PAS to level 1, showing reduction of aspiration episodes and laryngotracheal penetration, FOIS level 6 and improvement in the quality-of-life questionnaire scores. Conclusion: The therapy promoted an increase in the levels of oral intake, a reduction in the degree of severity of dysphagia and episodes of penetration and laryngotracheal aspiration, in addition to an improvement in the quality of life index in four of the five patients in this series.

Abstract Number ‐ 113: A Lateral Medullary Infarct Complicated by Central Hypoventilation Syndrome

Introduction A 43‐year‐old male with no known past medical history presented to a primary stroke center for sudden onset headache, nausea, vomiting, and dizziness while driving. A computed tomography angiogram of the head and neck revealed a left vertebral artery occlusion, and the patient was transferred to our comprehensive stroke center for further evaluation and treatment. Upon arrival at our facility, the patient was noted to have a national institute of health stroke scale score of 7 with left facial droop, dysarthria, and right upper extremity dysmetria. A cerebral angiogram revealed a tortuous left vertebral artery with dissection in the V4 segment. Subsequent brain diffusion weighted imaging revealed an acute infarct in the right lateral medulla measuring 1.4cm and several acute cerebellar infarcts. (fig. 1) In the postangiography period, the patient had dysphagia, sialorrhea, multiple aspiration episodes, and oral secretions requiring early tracheostomy and percutaneous endoscopic gastrostomy on hospital day (HD) #6. The subsequent hospital course was complicated by prolonged singultus lasting until HD #23 and repetitive vomiting requiring a transition from a gastric to a gastro‐jejunal feeding tube. Methods A central hypoventilation syndrome (CHS) prolonged ventilator weaning. Despite preserved ability to take large‐volume voluntary breaths, the patient experienced multiple episodes of sleep‐associated apnea and rapid shallow breathing pattern during daily spontaneous breathing trials (SBT). The apnea episodes were registered with ventilator apnea alarms set at 20 seconds. This pattern continued when attempting an SBT utilizing a T‐piece adaptor. The ability to maintain adequate minute ventilation in an asleep state subsequently improved, and the patient was able to tolerate 48 hours of spontaneous breathing with no apnea on HD #35. Results Few cases of CHS secondary to lateral medullary infarction (LMI) have been documented in the literature.(1‐3) As the respiratory drive originates from neurons in the latero‐rostro‐ventral medulla, infarcts in this brainstem region may lead to respiratory failure. More specifically to our patient, ataxic breathing may result from lesions in the rostro‐ventral medulla with yawning and hiccups being seen in lesions to the posterolateral medulla.(4) As our patient presented with a sizable 1.4cm lesion, likely impairing these brainstem centers, it is expected that his symptoms would account for multiple respiratory symptoms. The unique feature of the acquired CHS in the setting of LMI is its unilateral location implying lateralization of the respiratory control. In addition to the aforementioned symptoms, his lesion likely led to prolonged weaning from the ventilator as has been described previously.(5) Conclusions This case raises awareness regarding potentially disastrous complications of the lateral medullary syndrome like central hypoventilation syndrome. We urge caution and careful evaluation of patients with lateral medullary infarctions for disorders of the respiratory control system.

Supreme laryngeal mask airway for cesarean section under general anesthesia: a 10-year retrospective cohort study.

Previous research showed the use of supraglottic airways in obstetric anesthesia. The relevant evidence of laryngeal mask airway (LMA) on maternal and neonatal outcomes is still limited. We aimed to assess the maternal and neonatal outcomes when the LMA Supreme was used for cesarean section under general anesthesia. We included all patients who underwent general anesthesia for cesarean section between January 2010 and December 2019. Propensity score matching was used to reduce potential bias from non-random selection of airway intervention. The primary outcome was adverse maternal and neonatal outcomes defined as maternal regurgitation, aspiration, hypoxemia, and low neonatal Apgar scores. Secondary outcomes included patient admission to the intensive care unit, neonate required tracheal intubation, external cardiac massage, and admission to the neonatal intensive care unit. A total of 723 patients were included in the analysis; of whom, 221 received Supreme laryngeal mask airway (LMA group) and 502 were intubated with an endotracheal tube (ETT group). After propensity score matching, 189 patients remained in each group. No episode of regurgitation and aspiration occurred in both groups. There was no difference in the rates of Apgar score below 7 at 1 min (14.3% LMA group vs. 15.3% ETT group, OR 0.931, 95% CI 0.574 to 1.510, P = 0.772) and 5 min (3.7% vs. 4.2%, OR 0.875, 95% CI 0.324 to 2.365, P = 0.792). No difference was observed in the secondary outcomes between the two groups. The LMA Supreme was not associated with higher adverse maternal and neonatal outcomes when compared to an endotracheal tube for cesarean section under general anesthesia. It might be considered an alternative to tracheal intubation in obstetric practice.

Initial Outcomes of Endoscopic CO2 Laser Posterior Cordectomy and Partial Arytenoidectomy Among Patients with Bilateral Vocal Cord Paralysis: A Case Series

&#x0D; &#x0D; &#x0D; &#x0D; ABSTRACTObjective: To describe the initial outcomes of endoscopic CO2 laser posterior cordectomy and partial arytenoidectomy among patients with bilateral vocal cord paralysis in our institution.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Methods: &#x0D; Design: Case Series&#x0D; Setting: Tertiary National University Hospital&#x0D; Participants: 17 Patients&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Results: Seventeen (17) patients who underwent transoral posterior cordectomy and partial arytenoidectomy using carbon dioxide laser were included in the study consisting of 14 females and 3 males. Iatrogenic injury was the most common cause of bilateral vocal cord paralysis in this subset of patients. Five patients who tolerated decannulation and another six who had no preoperative tracheostomy all reported subjective improvement in breathing. All of them were also observed to have resolution of stridor and increased respiratory comfort compared to their preoperative condition. The most common postoperative complication was granuloma formation at the medial arytenoidectomy site occurring only in 4 patients. None of the patients complained of aspiration episodes or dysphagia during the postoperative period.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; Conclusion: Our initial experience with transoral endoscopic posterior cordectomy and partial arytenoidectomy using carbon dioxide laser has good postoperative outcomes among patients with bilateral vocal cord paralysis.&#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D; &#x0D;

A leaking food pipe: Bronchoesophageal fistula secondary to lung cancer

A 58-year-old female with advanced lung cancer, hypertension, hyperlipidemia, pulmonary artery thrombosis, bilateral subclavian artery stenosis, and vocal cord dysfunction presented to the ER with cough, shortness of breath, dysphagia, and weight loss. HR 114 bpm, RR 24/min, SpO2 95% on 4L, Temperature 36.2o C. She was lethargic, chronically ill-looking, and had bronchial breath sounds and crackles in the right upper lobe. Chest x-ray revealed enlarging previously known right upper lobe mass and loculated right pleural effusion. Contrast CT of the chest showed unchanged necrotic right apical mass, increased consolidation inferior to a mass in the right middle lobe, and metastatic infiltration of the right lateral 6th rib. She also had purulent secretions in all airways on bronchoscopy. Shortly after bronchoscopy, she had an episode of aspiration and required Intensive Care Unit (ICU) admission.

716 Safety and benefits of intraoperative enteral nutrition in critically ill pediatric burn patients

IntroductionBurn injuries significantly increase a patient’s metabolic demand. Adequate nutrition is essential to aid in recovery and reduce morbidity and mortality. This is important for pediatric patients, who have limited reserves and are in a period of growth, in contrast to adults. Burn patients often need multiple surgeries, with standard perioperative fasting periods leading to multiple nutritional interruptions. Continuous intraoperative feeding has been a proposed solution, but there is no current consensus on its role and safety, particularly in the pediatric population. The goal of our study was therefore to examine the safety and benefits of intraoperative nutrition in critically ill pediatric burn injury patients.MethodsA systematic review of MEDLINE, PubMed, Scopus, and Google Scholar was conducted using the following terms: Feeding or enteral or nutrition or fasting and adolescent or youth or pediatric or child or teen and burn or thermal injury or fire. The primary outcome was incidence of aspiration. Secondary outcomes included patient nutritional status (caloric deficit, weight), wound healing, days spent in the intensive care unit, ventilator days, pneumonia, number of surgeries, length of hospital stay, and mortality. Pooled analyses of binary outcomes were computed.ResultsFour studies consisting of 496 patients, met inclusion criteria. All studies were level IV evidence, but had high methodological quality. The median burn total body surface area (TBSA) was 43.8% (IQR 33.4-58.8%), with a median of one-third of patients having an inhalational injury. Patients underwent a median of 4.2 surgeries (IQR 1.8-7.4). Intraoperative feeding was conducted through nasoduodenal tubes. There were no aspiration events. Pooled analysis demonstrated that there were no differences in rates of aspiration, pneumonia, or wound infection (p >0.05) between patients who were intraoperatively fed and those who were not. Those fed intraoperatively had significantly more surgeries, ventilator days, longer hospital stays, but lower mortality (p< 0.05). There was large heterogeneity in nutritional assessment methods. Intraoperatively fed patients had an average gain of 144.4 kcal/kg and 1.7 days of exclusive enteral nutrition (vs. loss of -119.1 kcal/kg and -1.4 days) and cumulative positive caloric balance of +2673kcal ±2147 (vs. loss of -7899kcal ±3123), compared to those with interrupted feeding.ConclusionsContinuous intraoperative duodenal feeding during burn surgery appears to be safe in the Pediatric burn population, with no reported episodes of aspiration. Uninterrupted feeding was also associated with weight maintenance and reduced caloric deficit. It may also have survival benefit, as continuously fed patients needed more surgeries and intensive/hospital care, but had decreased mortality.

Abstract No. : ABS3025: To study the safety and efficacy of preoperative oral carbohydrate loading in type 2 Diabetics undergoing elective off pump coronary artery bypass grafting.

Background & Aims:The aim was to study the safety and efficacy of oral carbohydrate loading in type 2 diabetics undergoing off-pump coronary artery bypass grafting (CABG).The primary objective was to evaluate the residual gastric volume and secondary objectives included evaluating insulin resistance and inotrope requirement.Group 1 (n=20)Group 2 (n=20) P MeanSDMeanSDPre op RBS135.945.1142.729.80.580Intraoperative RBS 1 (2 h)138.735.2156.527.60.084Intraoperative RBS 2 (4 h)142.626.8162.121.80.016Intraoperative RBS 3 (6 h)152.525.0169.719.60.020Post OP RBS 1 (0 h)198.531.4199.525.40.886Post OP RBS 2 (4 h)159.953.2195.217.30.008Post OP RBS 3 (8 h)168.135.5172.115.50.651Post OP RBS 4 (12 h)184.537.1157.211.50.003Post OP RBS 5 (16 h)199.542.4150.121.5<0.001Methods:This prospective, unicentric, non-blinded randomised controlled study was conducted on 40 American Society of Anesthesiologists grade III & IV subjects. The study population was randomly allocated into Control Group in which patients were given 800 ml of clear fluids on the night before surgery and 400 ml of clear fluids 2 hours before on the day of surgery and Study group in which patients were given carbohydrate drink (50 gm of two carbohydrate sachets mixed with 800 ml of water) night before surgeryand 50 gm of one carbohydrate sachet mixed with 400 ml of water 2 h before surgery.Results:Both the groups had comparable residual gastric volumes. The Carboload group had higher blood sugar levels in the preoperative and intraoperative periods. Blood sugar control was better in the Carboload group during the postoperativeperiod, and the mean total insulin requirement and lactate levels for the Carboload group were less than the clear fluid group.Patient wellbeing was significantly higher in the Carboload group. No episodes of regurgitation or aspiration were recordedin either group.Conclusion:In patients with type 2 diabetes, consuming a Carboload drink two hours before surgery was safe and didnot increase the risk of pulmonary aspiration. Although there was a slight increase in their preoperative blood glucose levels, the postoperative glucose levels were easier to control and required a lesser amount of insulin to achieve normoglycemia.Moreover, we found a remarkable improvement in the patient’s well being as the carbohydrate consumed group experiencedless thirst, and hunger. Patients with Type 2 diabetes may benefit from the physiologic benefits of this beverage, justas do patients without diabetes in enhanced recovery after surgery (ERAS) protocols. RBS levels during the perioperative period (mg/dl)

Percutaneous Endoscopic Gastrostomy Placement under NIV in Amyotrophic Lateral Sclerosis with Severe Ventilatory Dysfunction: A Safe and Effective Procedure

Introduction: Amyotrophic lateral sclerosis (ALS) is a neurodegenerative disorder with an inexorably progressive course which leads to a progressive neuromuscular weakness. Weight loss is one of the major bad prognostic factors in ALS. The placement of percutaneous endoscopic gastrostomy (PEG) is of paramount importance in patients with dysphagia to improve the disease outcomes, although some fear exists regarding the possible ventilatory complications during the procedure. The aim of this study was to evaluate the safety and effectiveness of PEG tube insertion under non-invasive ventilation (NIV) in patients with ALS and severe ventilatory impairment. Methods: A retrospective study of all consecutive PEGs placed in our department from May 2011 to January 2018 in patients with ALS was performed. The procedure was performed under non-invasive positive-pressure ventilation for ventilatory support. Results: We included 59 patients with ALS with severe ventilatory impairment, 58% were female, with a mean age of 67.2 ± 10.1 years and a median follow-up of 6 [2–15] months. The main indication for PEG placement was dysphagia (98%). The median time for PEG tube insertion since the established diagnosis of ALS was 12 [6–25] months and 4 [2–18] months since the beginning of bulbar symptoms. The majority of the patients had placed a 20-Fr PEG (63%) and under mild sedation with midazolam (80%), all under NIV. There were no immediate complications during and after the procedure (no episodes of aspiration or orotracheal intubation) and mortality. Conclusion: The placement of PEG is a very important procedure in patients with ALS and severe ventilatory impairment. The interdisciplinary department collaboration permitted the placement of PEG under NIV, in a safe and effective procedure in this special population.

Breathing-swallow dysfunction in COPD: How silent aspiration may be contributing to exacerbations.

Breathing-swallow dysfunction in COPD: How silent aspiration may be contributing to exacerbations.