Intubation Research Articles

Unplanned Extubation in the Burn Unit: A Retrospective Review

Abstract Unplanned extubation rates in burn patients were previously reported at 27% (3 cases per 100 ventilator days). As facial burns pose a unique challenge to tube securement, patients in our unit have surgically placed bite blocks to secure the endotracheal tube at the provider’s discretion. Herein, we assessed unplanned extubation rates at our burn center. We performed a retrospective cohort study including burn patients who required mechanical ventilation from 7/01/2015 to 6/30/2023. Demographics, comorbidities, injuries, and hospital course information were collected and compared between patients who had an unplanned extubation and those who did not. Binary logistic regression analyses were performed to identify factors associated with unplanned extubation and ventilator-associated pneumonia (VAP) complication. P < 0.05 was considered significant. Of 360 patients, 17 (4.7%) had unplanned extubations, representing 0.7 cases per 100 ventilator days. There were no significant differences in demographics, comorbidities, or burn injury characteristics between groups. Patients with unplanned extubation were more likely to have an inhalation injury (70.6% vs. 42.6%, p=0.001), paCO2 ≥50 (70.6% vs. 39.1%, p=0.031), more ventilator days (6 [2-15] vs. 2 [1-4] days, p<0.001), and more hospital days (14 [8.5-25.5] vs. 8 [2-20], p=0.020). VAP rate tended to be higher in the unplanned extubation group (17.6% vs. 5.5%, p=0.077. On multivariate analysis, inhalation injury was associated with increased risk of unplanned extubation (Odds ratio (OR) = 4.68 [1.59-13.81], p=0.005). No patients with bite blocks had an unplanned extubation. Further study on the utility of advanced securement devices is recommended.

Implementation of a Volume-Based Technique for Endotracheal Tube Cuff Inflation: A Quality Improvement Project

Background:The goal of endotracheal tube (ETT) cuff inflation is to produce a pressure within the range of 20–30 cm H2O to ensure a proper seal against the trachea without compromising mucosal perfusion. The gold standard for the assessment of ETT cuff pressure is a handheld manometer; however, due to a lack of availability, this is rarely performed. Using a 10-mL syringe for cuff inflation is a common practice but can lead to overinflation and higher-than-recommended pressures.Objective:The purpose of this quality improvement project was to evaluate the incidence of ETT cuff overinflation and determine if an educational intervention advocating for lower volumes would reduce the occurrence.Method:The authors evaluated 50 ETT cuff pressures before and 50 after an educational intervention proposing the use of a 5-mL syringe for cuff inflation rather than a 10-mL syringe.Results:Median cuff pressure significantly decreased from 60 cm H2O in the preintervention phase to 30 cm H2O in the postintervention phase using 5-mL syringes, a 50% decrease (p< .001).Conclusion:This project demonstrated that an educational presentation recommending a 5-mL syringe for ETT cuff inflation resulted in a significant reduction of cuff pressures.Implications for Nursing:Nurse anesthetists should be aware of the risk of overinflation of endotracheal tube cuffs. Implementing a volume-based inflation method into current practice will decrease this incidence and the harmful sequelae associated with high cuff pressure.

Effects of Endotracheal Weight-Based Epinephrine on Pharmacokinetics and Survival in Swine With a Cardiac Arrest.

The aims of this study were to compare concentration maximum (Cmax), time to Cmax, area under the curve, mean concentration over 4 minutes, and frequency and time to return of spontaneous circulation (ROSC) by group. This was a prospective, experimental study using swine. In total, 40 pigs (n = 8 per group) were assigned as follows: 0.1 mg/kg endotracheal (ET) tube, 1 mg intravenous (IV), 2 mg ET, Cardio Pulmonary Resuscitation (CPR) + defibrillation (CPR + defib), and CPR-Only. Pigs were placed in arrest for 2 minutes, CPR was then initiated for 2 minutes, and epinephrine was then administered and repeated every 4 minutes or until ROSC. Blood samples were collected over 4 minutes. Defibrillation was initiated at 3 minutes and continued every 2 minutes for 30 minutes or until ROSC. CPR + defib and CPR-Only Groups served as controls. The CPR + defib Group had defibrillations but did not receive epinephrine. The CPR-Only Group did not receive defibrillations or epinephrine. The Cmax and area under the curve were significantly higher in the IV Group compared to the 0.1 mg/kg ET Group (P < .05). The time to Cmax was significantly longer in the 0.1 mg/kg Group than the 1 mg IV Group (P = .03). The mean concentration of the 1 mg IV Group was higher than the 0.1 mg/kg ET Group until 180 and 240 seconds. There was no significant difference between the groups relative to time to ROSC (P > .05). Return of spontaneous circulation frequencies were: 0.1 mg/kg ET Group (7 of 8); 1 mg IV Group (5 of 8); and 2 mg ET Group (1 of 8), and both CPR + defib and CPR-Only (0 out of 8). This study challenges the current guidelines relative to ET epinephrine administration. Based on our ROSC data, the 0.1 mg/kg dose of epinephrine by ET should be used as a first-line intervention.

Nasal Intermittent Positive Pressure Ventilation During Neonatal Endotracheal Intubation: A Randomized Controlled Trial.

This prospective, multicenter, randomized controlled trial aimed to determine whether the use of nasal intermittent positive pressure ventilation (NIPPV) during neonatal endotracheal intubation increased the rate of successful intubation without physiological instability during all intubation attempts. In total, 150 infants were randomly assigned to either an NIPPV or standard care group (n = 75 each). The primary outcome was successful intubation without physiological instability (defined as ≥ 20% decline in the peripheral oxygen saturation [SpO2] from preintubation value or bradycardia with a heart rate < 100 beats/min) during all intubation attempts. The mean postmenstrual age of the infants was 32.5 weeks, with a median weight of 1552 g at the time of intubation. The incidence of successful intubation without physiological instability during all intubation attempts was significantly higher in the NIPPV group (64%) than that in the standard care group (42.7%) (p = 0.009). This difference was particularly significant when inexperienced practitioners were involved. In the NIPPV group, the rates of bradycardia (18.7% vs. 41.3%) and severe desaturation (30.7% vs. 49.3%) were significantly lower, whereas the lowest SpO2 (85% vs. 76%) and lowest heart rate (118 vs. 105 beats/min) were significantly higher. NIPPV during endotracheal intubation increased the incidence of successful intubation without physiological instability during intubation attempts in neonates while reducing the rate of hypoxia and bradycardia.

The determinants for death in hospital following moderate to severe traumatic brain injury in Australia.

To establish the determinants of death in hospital for patients with moderate to severe traumatic brain injury (TBI) in Australia. Retrospective analysis of Australia New Zealand Trauma Registry (ANZTR) data. Cases were included if they presented to a participating hospital between 1 July 2015 and 30 June 2020 and had an Abbreviated Injury Severity (AIS) score - head greater than 2. Death in hospital. There were 16 350 patients. Their mean age was 51 years and 71% were male. After adjusting for measures of injury severity, there was an increased odds of in-hospital death for patients whose injury occurred outside daylight hours or first mode of transport was road ambulance, who were not transferred from another hospital, had an endotracheal tube placed prior to definitive hospital arrival or received their definitive hospital care outside Victoria. Among people presenting to a major trauma hospital in Australia following moderate to severe TBI, there were multiple factors independently associated with death in hospital. The potentially modifiable determinants of in-hospital death included out-of-hours access to emergency care, mode of transfer from the scene of the injury, prior facility care and pre-definitive hospital endotracheal intubation.

Postural drainage and high flow nasal oxygen therapy in four cats with decompensated cardiogenic pulmonary oedema.

This case series describes four cats with decompensated congestive heart failure and fulminant cardiogenic pulmonary oedema (CPE) that did not respond to conventional treatment and oxygen therapy, and subsequently developed hypoxaemic respiratory failure. The cats were anaesthetised to enable endotracheal intubation, manually ventilated with 100% oxygen and postural drainage was performed immediately to evacuate pulmonary oedema. Afterwards, the cats were extubated and transitioned to high-flow nasal oxygen (HFNO). HFNO allowed significant improvement in the respiration parameters without causing clinical complications. In three of the cats, the procedure was successful; duration of HFNO ranged between 4 and 44 h, and they were successfully weaned off the HFNO therapy. One cat required re-intubation due to HFNO-response failure and was ultimately euthanased. Another cat was euthanased 5 days later due to the severity of its underlying disease. This is the first report describing the combined technique of postural drainage and HFNO in cats with decompensated CPE. This combined technique could be a life-saving option for cats that fail to respond to conventional therapies and for which positive pressure ventilation is not an option.

Prone Positioning in a Pregnant Woman With Severe Acute Respiratory Distress Syndrome: A Case Report.

Prone ventilation is a standard treatment for acute respiratory distress syndrome, and its clinical benefits are well established. However, implementing prone positioning safely and effectively is challenging in patients who are pregnant, have intra-abdominal hypertension, or are in other high-risk groups. A patient in the third trimester of pregnancy (28 weeks and 6 days of gestation) developed a body temperature of 39 °C and severe respiratory distress. She was transferred to the intensive care unit, received noninvasive ventilation, and ultimately underwent endotracheal intubation. Because her oxygenation index remained below 100, she received a diagnosis of severe acute respiratory distress syndrome. The patient was safely placed in the prone position with a swim ring while receiving venovenous extracorporeal membrane oxygenation. During this period, her intra-abdominal pressure did not increase significantly. The fetus was delivered by cesarean birth, and the patient was transferred to the general ward after extubation. This case report describes the use of prone positioning in a pregnant patient. The report offers critical care nurses insights into the clinical management of patients who are pregnant or have intra-abdominal hypertension.

Severe Adult-Onset Non-Dystrophic Myotonia With Apnea and Laryngospasm Due to Digenic Inheritance of SCN4A and CLCN1 Variants: A Case Report.

To report a case of adult-onset non-dystrophic myotonia complicated by recurrent episodes of laryngospasm. The patient is a 35-year-old man who was admitted to our hospital for recurrent episodes of apnea requiring endotracheal intubation with mechanical ventilation. He underwent extensive evaluation, including EMG, laryngoscopy, muscle biopsy, and genetic testing, which revealed a diagnosis of non-dystrophic myotonia. His myotonic disorder was due to the synergistic effects of a pathogenic CLCN1 variant and a newly reported SCN4A variant. His muscle biopsy demonstrated myofibrillar disorganization with Z-band streaming, which may reflect the severity of his clinical and electrographic myotonia. Treatment with mexiletine resulted in resolution of his episodes of laryngospasm and symptoms of myotonia in the extremities. Our case adds to the literature on the potentiating effects of chloride channelopathies on sodium channel myotonia. This is the first reported case of an adult-onset sodium channelopathy manifesting with respiratory failure due to laryngospasm. In addition, we present muscle biopsy findings that have not been described in the recent literature. This case also highlights that a myotonic disorder should be considered in the differential diagnosis for recurrent episodes of mixed hypoxic and hypercarbic respiratory failure.

Endotracheal Tube Cuff Inflation Methods in School-Age Children: Flow-Volume Loop-Guided Versus Stethoscope-Guided

Endotracheal Tube Cuff Inflation Methods in School-Age Children: Flow-Volume Loop-Guided Versus Stethoscope-Guided

Comparative study on incidence of airway related complications while using PVC tubes with a strategic cuff release manoeuvre versus armoured FMT endotracheal tubes in neurosurgical patients undergoing surgery in lateral position

Comparative study on incidence of airway related complications while using PVC tubes with a strategic cuff release manoeuvre versus armoured FMT endotracheal tubes in neurosurgical patients undergoing surgery in lateral position

Renal Function Markers Predicts Extubation Failure in Critically Ill Patients: A Retrospective Study.

Several studies attempt to identify predictors for weaning and extubation from mechanical ventilation (MV) and none have been shown to be particularly accurate. Therefore, the objective of the study was to evaluate whether markers of renal function may be associated with extubation failure. This retrospective study collected data through electronic medical records for 2 consecutive years. The inclusion criteria were:≥18years old and requiring invasive MV for a period of≥48hours. Extubation failure was determined when subjects needed to return to invasive MV within 48hours of the tracheal tube withdrawal. Acute kidney injury (AKI) was assessed according to the KDIGO classification. From a total of 167 subjects, 15% evolved with extubation failure. Lower creatinine clearance and higher fluid balance was observed in the extubation failure group compared to the successful extubation group (42 mL/min vs 100 mL/min, P =0.01 and 739 mL vs-189 mL, P =0.01, respectively). Subjects with AKI are 51% more likely to evolve with extubation failures than those with normal renal function (OR=2.7; 95% CI: 1.6-4.7; P <0.01). Renal dysfunction was related to the rate of extubation failure. Fluid balance and serum creatinine may be aspects to be considered when making the extubation decision.

Changes in Neuropsychiatric Symptoms Among COVID-19-Convalescent Patients During Hospitalization at a Tertiary Care Center.

The investigators compared neuropsychiatric symptoms among COVID-19 patients at hospital admission and at discharge. Clinical data on neuropsychiatric syndromes were prospectively collected from 103 COVID-19 patients at admission and immediately before discharge. Clinical evaluations and serum biomarkers were analyzed to assess their relationship with neuropsychiatric symptoms and patient survival. Neuropsychiatric symptoms had improved by the time of hospital discharge (N=81) compared with admission. Depression scores decreased from 5.0 to 3.8 points on the Beck Depression Inventory (t=3.04); anxiety scores decreased from 12.3 to 10.0 points on the Beck Anxiety Inventory (t=2.75); and cognitive scores increased from 21.8 to 23.6 points on the Montreal Cognitive Assessment (t=-4.07). Delirium was present among 24% of patients upon admission but only among 12% before discharge. Markers of inflammation were correlated with neuropsychiatric symptoms. Longer hospital stays significantly predicted depression (R2=0.06), and gender and procalcitonin levels were significantly associated with anxiety (R2=0.05). Cognitive impairment was linked to depression and the need for endotracheal intubation. Both cognitive impairment and endotracheal intubation were associated with lower survival rates (R2=0.10 and 0.18, respectively). These findings reveal that a significant number of COVID-19 patients continued to exhibit affective symptoms, delirium, and cognitive deficits at discharge, with delirium and cognitive deficits being linked to lower survival rates and inflammation markers being significantly associated with these symptoms. Factors such as gender, hospital stay length, and mechanical ventilation predicted neuropsychiatric symptoms.

Current airway management practice among Swiss anesthesiologists : Results of anational survey.

While limited data on the impact of implementing guidelines in airway management on outcomes exist, there is aconsensus that the implementation and the adherence to guidelines enhance patient safety. Recently, the Swiss Society for Anesthesiology and Perioperative Medicine (SSAPM) endorsed the guidelines of The Fondation Latine des Voies Aériennes (FLAVA) as the official guidelines for airway management in Switzerland. This study aimed to determine current practice of airway management in Switzerland. To determine the available equipment, the differences between institutions and between specialists and residents in dealing with airway management. In collaboration with the SSAPM, acovering letter with asurvey link to the questionnaire used in the online airway management survey among German anesthesiologists was sent to all heads of departments of anesthesia and members of the SSAPM in August 2023. The participants (residents and specialists) were asked about their personal and institutional backgrounds, access to airway management devices, awareness of recognized airway management guidelines and the importance and application of airway management techniques. Overall, 555 anesthesiologists participated in the survey (response rate 21%). The main findings were: in general, Swiss anesthesia departments are well-equipped and adhere to airway management guidelines. The guidelines of FLAVA are only known by just over 50%. The vast majority used the traditional screening tests to identify an airway that might be potentially difficult to manage. Of the respondents, 25% still adhere to the myth that amask ventilation check is necessary before the administration of amuscle relaxant and 14% said that their institution used video laryngoscopy as the primary intubation device. More than 80% think that the expertise to perform awake fiberoptic intubation is important for their daily practice; however, 31% consider their expertise in this technique to be insufficient. In other words, there is abig safety gap. Swiss anesthesia departments are well-equipped and adhere to airway management guidelines. The need for regular training to gain and maintain expertise in managing difficult airways, especially to future specialists, still prevails. Thus, developing and establishing anationwide educational program in airway management and its continuous evaluation would be amilestone for patient safety.

P-849. Characteristics and Outcomes of Patients with Community-acquired and Nosocomial Klebsiella pneumoniae Bacteremia in a Tertiary Hospital in the Philippines

Abstract Background Klebsiella pneumoniae (KPN) bacteremia is associated with higher morbidity and mortality, but there is paucity of local data. This study describes the clinical, microbiologic profile, capsular types, and outcomes of individuals with community-acquired and nosocomial KPN bacteremia. Methods This study prospectively enrolled patients in a private tertiary hospital from January 1, 2023 to December 31, 2023. Hospitalized patients &amp;gt;/= 18 years old with documented KPN bacteremia were included in the study and isolates subjected to capsular typing. The two-tailed t test was used for continuous variables reported as mean and standard deviation whereas chi-square test was used for categorical variables reported as frequencies and percentages. Descriptive statistics were used and univariate analysis using Medcalc Statistical software. Results A total of 25 patients developed KPN bacteremia during the study period; 18 were community-acquired (CA) and 7 were nosocomial. More than half of patients were female (16/25, 64%), with median age 70 (+/- 15) years old. The most common comorbidities were hypertension (15/25, 60%), diabetes mellitus 14/25 (56%), and solid tumor (9/25, 36%). The average intensive care unit stay of 3.4 (+/- 5.9) days for CA KPN bacteremia was significantly shorter than the 13.6 (+/- 16.1) days for those with nosocomial KPN bacteremia. There was no difference in the total length of hospital stay for CA KPN bacteremia (36.7 +/- 85 days) and nosocomial KPN bacteremia (38.6 +/- 23.3 days). Wild-type KPN isolates (15/25, 83.3%) were more commonly found in CA KPN bacteremia, whereas multi-drug resistant isolates were more common for nosocomial KPN. Patients with endotracheal intubation (OR=16, 95% CI 2.2 to 118.3), positive qSOFA (OR=6.42, 95% CI 1.1 to 37.7%), identification of rmpA (OR=9.33, 95% CI 1.5 to 59.5%), and K20 capsular serotype (OR=6.0, 95% CI 1.0 to 35.9%) were more likely to have higher mortality. Conclusion In this cohort, KPN bacteremia occurred more frequently among women, and in the older age group. CA-KPN was more common than nosocomial KPN bacteremia, but the latter was associated with multi-drug resistance. Endotracheal intubation, positive qSOFA, rmpA, and K20 capsular serotypes were associated with higher mortality. Disclosures All Authors: No reported disclosures

385. Sepsis-Associated Encephalopathy and Dementia Outcome: A Retrospective Cohort Study of 30,378 Adult Sepsis Inpatient Survivors at a Tertiary Medical Center in Taiwan

Abstract Background Sepsis-associated encephalopathy (SAE) is commonly observed in critically ill patients without identifiable causes, potentially leading to neurological sequelae. Prior studies have associated the long-term risk of dementia with sepsis or in-hospital infections, or the short-term risk of mortality with SAE, rather than the short-term dementia risk with SAE. We aimed to assess the association between SAE and the 1-year risk of dementia among sepsis survivors.Figure 1.Flowchart of the selection process of adult sepsis inpatient survivors (n = 30,378). Methods This cohort included inpatients aged ≥ 18 years with first-time sepsis during 2010-2019, no prior dementia or central nervous system (CNS) infections, Glasgow Coma Scale (GCS) measurements within 7 days of sepsis, and who survived the index hospitalization (Figure 1). Sepsis was identified using Sepsis-3 criteria. SAE was defined as having at least two GCS measurements of either &amp;lt; 7 for patients with endotracheal tubes, tracheostomies, or aphasia, or &amp;lt; 12 for the remaining patients within the 7 days of sepsis. Dementia at 3 months and 1 year was defined by the presence of ICD-9 and ICD-10 diagnosis codes from 7 days to 3 months, and from 3 months to 1 year post-sepsis onset, respectively. Multivariable Cox models were used, considering death as the competing risk. Demographic, clinical characteristics, and outcomes of adult sepsis inpatient survivors, stratified by SAE status. Results Of 30,378 eligible sepsis inpatient survivors, 6.4% developed SAE within 7 days of sepsis onset. Patients with SAE tended to be older, female, and have more comorbidities compared to those without SAE (Table 1). Dementia occurred more frequently in patients with SAE than those without (10.9% vs 3.9% within 3 months; 3.6% vs 2.1% within 1 year). Similar patterns were observed in mortality rate. SAE was significantly associated with an increased risk of dementia for 3-month (adjusted hazard ratio [aHR] 1.81; 95% confidence interval [CI] 1.55-2.12) and for 1-year (aHR 1.54; 95% CI 1.18-2.01), compared to patients without SAE (Table 2). This association was significantly stronger among patients without chronic pulmonary disease, stroke, and with a qSOFA &amp;lt; 2, regarding the 3-month dementia risk (Figure 2). Risk of dementia and all-cause mortality associated with SAE among adult sepsis inpatient survivors. Conclusion Determining whether SAE is a trigger for the disease itself or merely triggers more intensive dementia surveillance requires more studies with standardized SAE diagnostic criteria and post-sepsis follow-up strategies. Subgroup analyses of the risk of dementia and all-cause mortality associated with SAE. Disclosures All Authors: No reported disclosures

P-296. Risk Factors and Treatment Outcome of Multidrug-Resistant Acinetobacter baumanii Pneumonia with or without COVID-19 Infection in an Infectious Diseases Hospital from January 2020 to December 2022: A Retrospective Cohort Study

Abstract Background Acinetobacter baumanii has become one of the most virulent pathogens for most hospitalized patients worldwide. Compared to the United States, Asia has a higher incidence and percentage of multidrug resistance (MDR). With the emergence of COVID-19 infection, patient's risk factors and outcomes are important to understand the correlation of the two disease entities. Methods Single-center, retrospective cohort study that utilized records to determine the risk factors and clinical outcome of adult patients with Multidrug-resistant Acinetobacter baumanii pneumonia admitted at San Lazaro Hospital for a 3 year period. Cox regression analysis was employed to determine predictors for mortality. Results A total of 70 patients were included and 9 (12.8%) of which were seen to have COVID-19. With regards to Acinetobacter baumanii resistance; 51.4% had Multidrug-resistance, 21.4% had Pandrug-resistance, and 27.1% had Extensively drug-resistance. In terms of treatment, most patients had Meropenem (31.4%) or Meropenem + other antibiotics (27.4%). The mean length of hospitalization did not differ significantly between non-COVID-19 (21.4 days) and COVID-19 patients (18.4 days) (p=0.711). Also, mortality rates did not differ significantly between non-COVID-19 (60.7%) and COVID-19 patients (55.6%) (p=0.771). Having Endotracheal tube was seen to be a significant predictor for mortality among patients with Multidrug-resistant Acinetobacter baumanii pneumonia (HR=5.0, 95%CI=1.4 to 16.4, p&amp;lt; 0.0001). On the other hand, Meropenem use was significantly associated with improved survival whether in single (HR=0.3, 95%CI=0.08 to 0.8, p=0.025), or in combination (HR=0.2, 95%CI=0.07 to 0.8, p=0.026). Conclusion Among patients with Multidrug-resistant Acinetobacter baumanii pneumonia, length of hospital stays, and mortality rates did not differ significantly between those with and without COVID-19. Being on an Endotracheal tube increases the risk of mortality compared to those without invasive procedures. Meropenem with or without combination was seen to be effective in reducing the risk of mortality in this study. Disclosures All Authors: No reported disclosures

P-1833. Acute Virulence Expression and Evolution of Artificial Airway Adapted Pseudomonas aeruginosa

Abstract Background Mechanical ventilation is life-saving and may be lifelong in medically complex children with tracheostomy tubes (TT). Ventilator-associated infections (VAI), a common complication of mechanical ventilation, result in an estimated $1.25 billion per year of healthcare costs. Pseudomonas aeruginosa (Pa) frequently colonizes TT and endotracheal tubes and is a leading cause of VAI. Despite the importance of VAI, little is known about how Pa establishes colonization, limiting our ability to improve management. We hypothesize that Pa adaptively evolves to reduce its potential for acute virulence to facilitate colonization. Methods Convenience samples of Pa isolates from patients requiring endotracheal tubes or TT were collected from the UPMC Children’s Hospital of Pittsburgh microbiology lab. Isolates were screened for virulence factors including proteases, rhamnolipids, twitching motility, lysis and sheen, amino acid auxotrophy, and mucoid colony morphology. Isolate infectivity was tested on a in vitro primary human cell epithelial model. DNA was extracted from longitudinal isolates for whole genome sequencing. Results One hundred thirty-five isolates from 124 unique patients were screened for acute and chronic virulence phenotypes in a cross-sectional study. Low protease production, rhamnolipid production, and reduced twitching motility were more frequently present in respiratory isolates compared to skin and soft tissue infection (SSTI) isolates. Lysis and sheen were present in approximately one-third of respiratory isolates, similar to SSTI isolates. In longitudinal specimens from 23 patients, 95% of patients maintained their Pa genotype over time and representation from all three clades (PAO1, PA14, and PA7) of Pa were detected, with the PAO1 clade containing most isolates. Whole genome sequencing revealed mutations in global virulence regulators. Respiratory isolates had reduced infectious capabilities in an epithelial cell infection model. Conclusion These data suggest that isolates from mechanically ventilated patients are diverse between patients, maintained within a given patient over time, and have lower virulence expression than Pa isolates from other sites. Disclosures All Authors: No reported disclosures

P-1127. Outcomes of Guideline Discordant Tracheal Aspirate Cultures in the Pediatric ICU

Abstract Background Life-saving mechanical ventilation is associated with risk of ventilator-associated infections, though diagnosis of such infections can be difficult. Diagnostic respiratory cultures are often obtained via tracheal aspirate. These cultures can be misleading due to the non-sterile nature of the respiratory tract and the potential for chronic colonization of endotracheal and tracheostomy tubes by pathogenic bacteria which are not actively causing infection. Consequently, growth does not necessarily reflect infection. Misinterpretation of inappropriately collected cultures results in unintended consequences including unnecessary use of antibiotics, antibiotic resistance, and prolonged hospital stay. Methods We created a clinical decision support tool as part of the BrightStar2 initiative using signs of acute respiratory infection with the aim to safely minimize collection of cultures lacking diagnostic utility. We completed a retrospective study of tracheal aspirate cultures (TAC) collected in a 36-bed ICU at a pediatric tertiary care hospital from January to December 2022. We determined whether cultures met support tool criteria for collection, including signs of infection, respiratory change, and lack of previous TAC within 48 hours. We then investigated results of unsupported cultures to determine whether cultures provided clinically actionable information. Results Of 200 tracheal aspirate cultures, 133 cultures (67%) did not meet criteria for collection, most commonly due to lack of change in respiratory status. A total of 27 unsupported TACs grew new organisms (20%) of which only one organism had clinical significance, accounting for less than 1% of unsupported cultures. Conclusion This data suggests our clinical decision support tool is effective in identifying patients in whom a TAC will not yield useful clinical information. Disclosures All Authors: No reported disclosures

Case Report: Innovative anesthetic approaches for whole lung lavage in an infant with pulmonary alveolar proteinosis

IntroductionPulmonary alveolar proteinosis (PAP) is a rare disease in infancy characterized by the accumulation of lipoprotein material within the alveoli, leading to impaired gas exchange, ventilation-perfusion mismatch, and, in severe cases, respiratory failure that may result in death. Treatment options include medical therapy and whole lung lavage (WLL), typically requiring lung isolation techniques or extracorporeal membrane oxygenation. Previous studies have reported the application of several lung isolation techniques in pediatric WLL. However, the use of a bronchial blocker (BB) in infant WLL has not been previously reported.Case descriptionThis study reports the anesthesia management of a 12-month-old infant diagnosed with secondary PAP, complicated by severe pneumonia and patent ductus arteriosus. The child presented with respiratory failure requiring WLL. The anesthesia method employed was intravenous general anesthesia, and airway management involved using a BB placed outside the endotracheal tube to facilitate one-lung ventilation (OLV). The procedure successfully maintained blood oxygen levels above 90%, and the WLL was completed without any anesthetic complications.ConclusionThis case demonstrates that using endotracheal intubation combined with extraluminal placement of a BB for lung isolation is a viable and effective approach for performing WLL in infants.

Comparison of NoSAS score with STOP-Bang and Berlin scores in predicting difficult airway

BackgroundThis study aimed to compare the effectiveness of the NoSAS, STOP-Bang, and Berlin scoring systems, which are utilized to predict obstructive sleep apnea syndrome (OSAS), in forecasting difficult airway management. Additionally, the study sought to determine which of these scoring systems is the most practical and effective for this purpose.MethodsFollowing the ethics committee approval, preoperative NoSAS, STOP-Bang, and Berlin scores were calculated for 420 patients aged 18 years and older who were scheduled for tracheal intubation. Mask ventilation and intubation were performed by research assistant with a minimum of two years of experience. Detailed examinations and recordings were conducted, including demographic data, neck circumference, OSAS diagnosis, history of difficult intubation, comorbidities, ASA classification, Mallampati classification, and Cormack-Lehane grade. Subsequently, the predictive efficacy of these three scoring systems for difficult mask ventilation and difficult intubation was compared.ResultsIn our study, 83 patients (19.8%) were classified as having difficult mask ventilation, and 101 patients (24.0%) were classified as having difficult intubation. The NoSAS score demonstrated a higher predictive power compared to the other scoring systems for difficult mask ventilation and difficult intubation. The cut-off value for the NoSAS score was determined to be 6.5 for predicting difficult mask ventilation and 7.5 for predicting difficult intubation.ConclusionThe routine implementation of the NoSAS score, an easy-to-use, rapid and objective tool primarily developed for OSAS screening, is likely to be effective in preoperatively identifying difficult airways in patients undergoing general anesthesia.