Respiratory Compromise Research Articles

EGS SO22 - When What Is Left Is Not Right

Abstract Background Aims We present a case of small bowel obstruction in a massive inguinoscrotal hernia, with loss of abdominal domain, treated successfully by emergency surgery. The chronicity of the condition resulted in a large pendulous pelvic stomach, with the Duodeno jejunal flexure within the hernia and constricted by the hernial ring. Method The first contact with surgical team was as emergency, since initial referral to surgical outpatients was deferred by the patient, due to his embarrassment. After initial attempts to decompress the stomach through nasogastric tube and with nutritional support with parenteral nutrition, the patient was counselled for surgery. Informed consent was taken for right orchidectomy, possibility of open abdomen with delayed reconstruction, stoma, respiratory compromise, multiorgan failure and death.Prior to intervention, Intensive Therapy unit was consulted for admission following surgery, with plans to use Botox in the abdominal wall, to improve compliance, in case of abdominal compartment syndrome or respiratory failure. Results Through an inguinoscrotal incision, the inguinal canal was opened and the cord structures were transfixed and divided. The internal ring was divided laterally to allow gradual compression and replacement of the hernia intraabdominally. Over 8 litres of fluid was removed from Nasogastric aspirate. Lymphoedema in the scrotum made the laterality of the testis seen in the operative field ambiguous. The hernia was repaired with Bassini repair of the muscles, followed by polypropelene mesh. Following surgery, patient was discharged home with no immediate complications. Histology of the sac and Tunica Vaginalis revealed an atrophic right testis. Conclusion Distorted anatomy from chronicity of common surgical pathology may present challenge to even experienced surgeons. Unusual presentation of common pathology requires thinking outside the box. Since the lymphoedema in the scrotal hernial sac made the laterality of the testis unclear, an informed decision was taken not to remove the single testis seen in the operative field. The histology confirmed that this was the right decision, since the atrophic right testis was included in the operative specimen. Post operative imaging confirmed what was left, was the left testis.

Abstract 4122543: Can We Diagnose Ticagrelor-induced Dyspnea After Urgent Percutaneous Coronary Intervention with Cardiopulmonary Exercise Testing?

Background: Ticagrelor has been reported to cause shortness of breath (SOB) in 6 to 9 % of patients. Precise mechanisms are not enirely understood. We hypothesize that cardiopulmonary exercise testing (CPET) may be helpful in clinical assessment of patients reporting SOB on ticagrelor. Case presentation: 66-yo female with history of arterial hypertension, DM type 2 and prior MI presented with STEMI and successfully underwent urgent PCI of RCA and LAD. The patient received ticagrelor in loading dose followed by 90 mg b.i.d plus low-dose aspirin. Just after PCI she developed SOB with no evidence of acute cardiac or respiratory compromise. After discharge the patient continued to experience SOB impairing daily activities. In 6 months she was re-assessed. Clinical investigation (physical exam, blood tests, echo, CXR, spirometry) showed no abnormalities that could explain SOB. CPET despite good effort showed low VO 2 peak (7,8 ml*min/kg; 49% from predicted), undetectable anaerobic threshold (AT), severely impaired ventilatory efficacy (VE/VCO 2 =50,1) and marked hyperventilation (resting RER=1,0; PetCO 2 =18,0 mmHg at rest and 22,4 mmHg at peak load). Exercise EKG, blood pressure response, SpO 2 and breathing reserve were normal. Once the patient was switched from ticagrelor to clopidogrel she reported significant improvement. CPET one week after showed increase in VO 2 peak up to 12,5 ml/kg/min., AT of 11,1 ml*min/kg, better ventilatory efficacy (VE/VCO 2 =37,1) and less hyperventilation (PetCO 2 28,1 mmHg at rest and 28,8 mmHg at peak load). CPET performed one month later showed further improvement in VO 2 peak to 13,2 ml*min/kg, normal VE/VCO 2 and no signs of hyperventilation. Discussion: it is believed that ticagrelor-induced dyspnea can be driven by 2 potential mechanisms, first related to inhibition of adenosine reuptake, second - to sensory neuron P2Y12 inhibition. It occurs early after starting the medication and is not associated with structural cardiopulmonary abnormalities. Previous small data showed evidence of Cheyne-Stokes respiration during both night and day related to ticagrelor. Symptoms usually are dose-dependent and disappear after discontinuation of ticagrelor. In our case the patient demonstrated reversible hyperventilation and reduced exercise capacity associated with ticagrelor that was confirmed with CPET. Conclusion: CPET allows differentiating SOB in patients treated with ticagrelor. Further investigations are required to confirm this hypothesis.

Impact of Pharmacologic Patent Ductus Arteriosus Treatment on Acute Respiratory and Oxygenation Metrics in Very Low Birth Weight Infants.

Hypoxemia and respiratory compromise occur in very low birth weight (VLBW, <1,500 g) infants and may be associated with shunting across patent ductus arteriosus (PDA). The impact of pharmacologic PDA treatment on acute hypoxemia and respiratory metrics is unclear. This study aimed to determine whether pharmacologic PDA treatment is associated with acute improvement in hypoxemia and respiratory metrics in VLBW infants. At a single center (2012-2022), all VLBW infants with echocardiographic evidence of PDA and without exclusions were classified as having received or not received pharmacologic PDA treatment (PDA-T and PDA-NT). Mean daily fraction of inspired oxygen (FIO2) and Respiratory Acuity Score (RAS, PMID 30374050) were compared at baseline (day 0) and 3 days after the start of treatment. For PDA-T infants with archived 0.5 Hz (every 2-second) oxygen saturation (SpO2) data, mean daily SpO2 and the percentage of time with severe hypoxemia (SpO2 <80%) were compared before and after treatment. Severe hypoxemia was further analyzed after stratification by clinical variables (sex, medication, gestational age, and postnatal age). We analyzed 125 VLBW infants with PDA, of whom 66 received pharmacologic PDA treatment. We analyzed a subgroup of 43 PDA-T infants with every 2-second SpO2 data available. PDA-T infants had higher baseline FiO2 and RAS and lower SpO2 than PDA-NT infants (p < 0.05). Compared to baseline, RAS decreased from a median of 258 (interquartile range [IQR]: 171, 348) to 254 (IQR: 174, 419), 3 days after the start of treatment (p = 0.012), but median FiO2 increased from 37% (IQR: 28, 46) to 40% (IQR: 29, 52; p = 0.008). SpO2 and the percent time with severe hypoxemia were unchanged. In this 10-year, retrospective, single-center analysis, pharmacologic PDA treatment in VLBW infants was not associated with a major improvement in acute measures of oxygenation or level of respiratory support. · Infants with pharmacologically treated PDA had worse baseline respiratory and oxygenation metrics.. · RAS decreased but FiO2 increased 3 days after pharmacologic PDA treatment.. · Pharmacologic PDA treatment did not acutely improve SpO2 or severe hypoxemia..

Early detection and management of congenital pulmonary airway malformation in a newborn with stable clinical course

Introduction: Congenital pulmonary airway malformation (CPAM) is a rare developmental lung anomaly characterized by cystic lung lesions, constituting about 25% of congenital pulmonary anomalies. It typically occurs sporadically and is not significantly associated with race, age, or other maternal factors. The prenatal course of CPAM can vary based on factors such as lesion size, mediastinal shift, and associated anomalies. While the overall prognosis is generally favorable in the absence of severe complications like hydrops fetalis, which can adversely affect outcomes, management strategies include corticosteroids, thoracoamniotic shunt (TAS), and, in severe cases, open fetal surgery or the EXIT procedure. Postnatal surgical excision usually offers a curative outcome with an excellent prognosis. Without surgical intervention, there are risks of recurrent infections and, rarely, malignant transformation. Effective prenatal detection significantly impacts clinical decision-making and neonatal outcomes, and the necessity and timing of surgery for asymptomatic infants remain subjects of ongoing debate, underscoring the need for personalized, multidisciplinary care. Case Report: A female infant, delivered at 38 weeks via Cesarean section, was diagnosed with CPAM following routine prenatal ultrasound. Presence of extensive cystic regions in the right lung confirmed the diagnosis and a CPAM volume ratio (CVR) of 0.37 indicated a low risk of severe complications. The pregnancy was largely uneventful, with maternal chronic hypertension managed by Nifedipine and mild intermittent asthma. Postnatal chest radiography corroborated the CPAM diagnosis, while an abdominal ultrasound investigated intrahepatic calcifications. Maternal screening for cytomegalovirus and toxoplasmosis yielded negative results, and postnatally, the infant also tested negative for both infections. The neonate, though asymptomatic and stable, required close monitoring in the neonatal intensive care unit to prevent potential respiratory compromise. Conclusion: Advances in prenatal imaging have greatly improved the early detection and management of CPAM, allowing for targeted neonatal care and strategic planning. This case highlights the importance of a multidisciplinary approach involving obstetricians, maternal-fetal medicine specialists, neonatologists, and pediatric thoracic surgeons in the effective management of CPAM. Early identification and diligent postnatal monitoring are essential for ensuring optimal outcomes and minimizing the risk of complications. The coordinated care and strategic decision-making exemplified in this case underscore the potential for enhanced neonatal health and long-term well-being through comprehensive management of congenital anomalies.

Outcomes of heliox use in children with respiratory compromise: A 10-year single institution experience.

Heliox, a mixture of helium and oxygen, has been shown to improve laminar airflow and decrease airway resistance in children. This study aims to describe the outcomes of heliox use in children with respiratory compromise and to identify variables associated with a need for airway surgical intervention. A retrospective cohort study of patients who received heliox between 2012 and 2022 at a tertiary care children's hospital. A hundred and thirty-eight heliox treatments were recorded in 119 children. Twelve patients were excluded. Most (n = 100, 84%) patients had significant comorbidities. On average, patients spent a cumulative mean of 94 ± 187 h on heliox therapy per hospital admission. Patients with croup or asthma without known airway pathology presented at an older age than patients with other indications for heliox therapy (4.0 ± 4.7 vs. 2.2 ± 3.6 years, p = 0.04) and were significantly less likely to have background diseases (n = 14, 52% vs. n = 74, 93%, p < 0.0001). Overall, 51 (47.7%) patients were recommended tracheostomy placement, airway reconstruction, or palliative care. Cumulative use of heliox for more than 47 h was associated with an increased risk of needing tracheostomy or airway reconstruction (odds ratio 6.2, 95% confidence intervals 2.56-14.13, p < 0.0001). In multivariable regression analysis, neuromuscular disease, intracranial neuropathology, and cumulative time of heliox were associated with a need for definitive airway intervention. Heliox may be used as a temporizing agent in children with upper airway obstruction. The effectiveness of heliox use for more than 47 h in children, especially in the presence of neuromuscular disease and intracranial neuropathology should be reconsidered.Level of evidence: 4.

A retrospective review of intramuscular olanzapine and parenteral benzodiazepine coadministration in the emergency department.

Acute agitation is a common presenting symptom in medical and mental health emergencies that may require pharmacologic intervention. There is a manufacturer recommendation against intramuscular coadministration of olanzapine with parenteral (intramuscular or intravenous) benzodiazepines despite a deficiency of high-quality evidence. The purpose of this study was to contribute to available literature regarding intramuscular olanzapine and parenteral benzodiazepine use in acutely agitated patients in the emergency department (ED). This was a single-center retrospective chart review of adult ED patients who received intramuscular olanzapine and a parenteral benzodiazepine within 2 hours. The composite primary endpoint evaluated the occurrence of cardiac or respiratory compromise within 2 hours of medication administration. Secondary endpoints mirrored the primary endpoint within 30 minutes and evaluated the occurrence of cardiac arrest or desaturation in the ED outside the 2-hour window. One hundred eleven patients were included in the analysis, 64 (57.7%) of whom had documented vitals or oxygen status within 2 hours of medication administration. The composite primary endpoint occurred in 8 patients (12.5%), with only 1 patient requiring intervention with intravenous fluids. The secondary composite endpoint occurred in 2 (9.5%) of 21 patients with documented vitals or oxygen status within 30 minutes of treatment, neither of which required intervention. There were no identified events of intubation or significant cardiac events. Until better evidence is available, this combination therapy should, at minimum, include appropriate patient monitoring. Future studies should investigate risk factors for serious adverse effects.

A Comparison of Ketamine to Midazolam for the Management of Acute Behavioral Disturbance in the Out-of-Hospital Setting

ObjectiveAcute behavioral disturbance is characterized by altered mental status and psychomotor agitation. Pharmacological sedation may be required, risking potential respiratory compromise. We compared the need for emergent airway support following administration of midazolam or ketamine to treat acute behavioral disturbance in the prehospital setting. MethodsIn this retrospective cohort study of patients with acute behavioral disturbance in an urban Emergency Medical Service (EMS) system between 2017-2021, we compared the likelihood of prehospital advanced airway management following administration of midazolam or ketamine. Advanced airway management was defined as prehospital endotracheal intubation or supraglottic airway insertion. ResultsAmong 376 eligible patients, the median age was 35; and 78% were male. The most common etiologies of acute behavioral disturbance were substance use (51%), trauma (18%), and presumed postictal agitation (11%). In all, 162 patients (43%) initially received midazolam and 214 (57%) ketamine. The frequency of advanced airway management was similar between these respective groups (12% [n=19] vs 11% [n=24], difference 0.5%, 95% CI -6.0% to 7.0%). Adjusted for potential confounders, the odds of receiving advanced airway management did not differ between midazolam and ketamine (aOR 1.02, 95% CI 0.44 to 2.38), nor were differences observed in emergency department intubation rates (14% in midazolam recipients, 11% for ketamine) or overall mortality (2% in midazolam recipients, 1% for ketamine). ConclusionIn this cohort study of patients with acute behavioral disturbance, emergent airway support nor other outcomes differed following prehospital treatment with midazolam or ketamine.

Acute respiratory compromise in the NICU

Acute respiratory compromise (ARC) is a significant and frequent emergency in the Neonatal Intensive Care Unit (NICU), characterized by absent, agonal, or inadequate respiration that necessitates an immediate response. The primary etiologies of ARC in neonates can be categorized into upper and lower airway issues, disordered control of breathing, and lung tissue disease. ARC events are particularly dangerous as they compromise oxygen delivery and carbon dioxide removal, potentially leading to cardiopulmonary arrest. Approximately 1 % of NICU admissions experience cardiopulmonary arrest, and ARC is the primary cause of most events. This article provides a comprehensive review of the etiologies of ARC, including anatomical abnormalities, syndromic disorders, airway obstruction, and pulmonary diseases such as bronchopulmonary dysplasia and pneumonia. Management strategies include the use of continuous positive airway pressure, positive pressure ventilation, and advanced interventions like extracorporeal membrane oxygenation (ECMO) in cases of severe respiratory distress. Additionally, quality improvement initiatives aimed at reducing incidents such as unplanned extubations (UE) are discussed, along with emergency responses to ARC, which often require multidisciplinary collaboration and advanced airway management. The article emphasizes the importance of preparedness, training, and structured emergency protocols to ARC in the NICU to optimize patient care.

Preoperative neurologic comorbidity and unanticipated early postoperative reintubation: a multicentre cohort study

BackgroundThe risk of respiratory complications is highest in the first 72 h post-surgery. Postoperative respiratory events can exacerbate pre-existing respiratory compromise and lead to reintubation of the trachea, particularly in patients with neurologic disorders. This study examined the association between neurologic comorbidities and unanticipated early postoperative reintubation in children. MethodsThis multicentre, 1:1 propensity score-matched study included 420 096 children who underwent inpatient, elective, noncardiac surgery at National Surgical Quality Improvement Program reporting hospitals in 2012–22. The primary outcome was unanticipated early postoperative reintubation within 72 h after surgery. The secondary outcome was prolonged postoperative mechanical ventilation, defined as ventilator use >72 h. We also evaluated 30-day mortality in patients requiring reintubation. ResultsCerebral palsy was associated with the highest risk of early reintubation (adjusted relative risk [RRadj]: 1.97, 95% confidence interval [CI]: 1.44–2.69; P<0.01), followed by seizure disorders (RRadj: 1.87, 95% CI: 1.50–2.34; P<0.01), neuromuscular disorders (RRadj: 1.76, 95% CI: 1.41–2.19; P<0.01), and structural central nervous system abnormalities (RRadj: 1.35, 95% CI: 1.13–1.61; P<0.01). Unanticipated early postoperative reintubation was associated with an eight-times increased risk of 30-day mortality (adjusted hazard ratio: 8.1, 95% CI: 6.0–11.1; P<0.01). Risk of prolonged postoperative mechanical ventilation was also increased with neurologic comorbidities, particularly seizure disorders (RRadj: 1.73, 95% CI: 1.55–1.93; P<0.01). ConclusionsChildren with neurologic comorbidities have an increased risk of unanticipated early postoperative reintubation and prolonged mechanical ventilation. Given the high mortality risk associated with these outcomes, children with neurologic comorbidities require heightened monitoring and risk assessment.

EP465 - Transfusion Associated Circulatory Overload (TACO) Audit - A prospective analysis of adherence to standards ensuring safe transfusions

Abstract Aims TACO is defined as acute or worsening respiratory compromise during or up to 12 hours of transfusion, with additional features including cardiovascular system changes not explained by the patient’s underlying medical condition. In the UK, TACO remains a major cause of Morbidity in surgical post operative patients. The aim of this audit was to assess whether the current trust transfusion practices are synchronous with the NICE guidelines and SHOT recommendations. Methods We reviewed 27 incidences of transfusion during the whole month in acute general surgical ward. Patient’s notes, trust intranet and EPMA were used for data collection. The adherence to Ng24 as well as latest SHOT recommendations was checked. Following standards were taken into account: A formal pre-transfusion risk assessment for transfusion-associated circulatory overload (TACO) should be undertaken for all patients receiving blood transfusion and mitigating actions taken. (Serious hazards of transfusion SHOT recommendation) Patients who develop respiratory distress during or up to 24 hours following transfusion where transfusion is suspected to be the cause must be reported to SHOT. A structured incident review should be undertaken for every case of TACO. Weight-adjusted red cell dosing should be used. (NICE Guidelines Ng24) Result TACO assessment checklist was only completed for 15% of transfusions (compared to 35% nationally) while mitigation actions were only considered for 4% of patients. There appeared discordance among junior doctors regarding TACO Management. Conclusions Interventions like teaching sessions, information leaflets and posters, presentation for induction pack and liaison with Transfusion practitioner team to modify transfusion pathway significantly reduced inconsistencies regarding safe transfusions and immensely improved patient management.

Diagnostic Strategy in Idiopathic Diaphragmatic Paralysis

Unilateral diaphragmatic paralysis is a medical condition characterized by the impairment of either the right or left hemidiaphragm, resulting in an inability to contract effectively during inspiration. This condition may arise due to intrinsic diaphragmatic muscle dysfunction or a disruption in the neural input from the phrenic nerve to the affected hemidiaphragm. The etiology is diverse, with clinical manifestations varying from an absence of symptoms to severe respiratory compromise. This case study aims to review the assessment and management of unilateral diaphragmatic paralysis, highlighting the role of dynamic imaging techniques, such as diaphragmatic ultrasound, in the diagnosis, evaluation, and ongoing monitoring of patients with this condition.

Performing Esophageal Biopsies Is Safe During Upper Endoscopy for Food Impaction but Are Underperformed in Certain Populations.

Despite recommendations to perform esophageal biopsies during esophagogastroduodenoscopy (EGD) for esophageal food impaction to evaluate for eosinophilic esophagitis (EoE), endoscopists often forgo biopsies. There are minimal data on the risks of biopsies in this setting. To determine the safety of performing biopsies during EGD for food impaction. We conducted a retrospective cohort study of patients who presented to University of North Carolina Hospitals from 2014 to 2021 with endoscopically confirmed food impaction. Data were abstracted from the medical records. Baseline clinical characteristics, procedural details, and adverse events were compared between patients who did and did not undergo biopsy. Adverse events were classified as esophageal (mucosal tear, bleeding, perforation) or extra-esophageal (aspiration, respiratory compromise, hypotension, arrhythmia). Of 188 patients who underwent EGD for food impaction, 73 (39%) had biopsies taken. Older and non-White patients were less likely to be biopsied. None of the Black patients had biopsies taken. Only 2 (2.7%) of the 73 biopsied patients had an adverse event, and neither was related to the biopsies. Patients who were biopsied were less likely to experience adverse events. There were no differences in re-admission, ICU admission, or 30-day mortality between patients who were and were not biopsied. Esophageal biopsies remain underperformed during EGD for food impaction, especially in certain patient populations. Esophageal biopsies at the time of food impaction are unlikely to cause adverse events. Safety concerns should not preclude biopsies, and biopsies should be performed in the absence of extenuating circumstances.

Clinical Significance of Respiratory Involvement in Cryptosporidiosis: Cross-Sectional Study of Children with Diarrhea and Respiratory Symptoms in Uganda.

Respiratory cryptosporidiosis is considered an occasional, late-stage complication of HIV/AIDS. This study aimed to assess the clinical importance of respiratory cryptosporidiosis in children with diarrhea and respiratory symptoms at Mulago Hospital, Kampala, Uganda. Children aged 9 to 36 months presenting with diarrhea and cough or unexplained tachypnea (N = 1,918) were screened for fecal Cryptosporidium using polymerase chain reaction (PCR). Children with positive stool samples were eligible for further diagnostic tests, including sputum induction. Sputum samples were subjected to PCR for Cryptosporidium, as well as routine microbiology (culture and gram stain) and auramine stain for tuberculosis. Regression analyses were used to investigate 1) factors associated with respiratory cryptosporidiosis and 2) whether respiratory cryptosporidiosis was independently associated with hospitalization. Prevalence of enteric cryptosporidiosis was 260/1,918 (13.6%) (>80% Cryptosporidium hominis). Of the 236 children who had sputum available for analysis, 62 (26.3%) had Cryptosporidium in the sputum, only two of whom had HIV infection. Children with Cryptosporidium in the sputum were more likely to have abnormal oxygen saturation at presentation (SpO2 <96%; P = 0.053); no other differences in frequency or severity of respiratory signs were noted. No alternative bacterial cause of respiratory symptoms was identified in 37.7% of children with respiratory cryptosporidiosis, compared with 23.6% of children without (P = 0.04). Sputum-positive children had twice the odds of hospitalization compared with children without Cryptosporidium infection at this site (adjusted odds ratio = 2.08, 95% confidence interval: 1.02-4.22; P = 0.043). Respiratory tract involvement is common in children with intestinal cryptosporidiosis who are experiencing respiratory symptoms. Such children may experience some degree of respiratory compromise and may be at increased risk for hospitalization.

Morbidity in giant omphaloceles: Predictive factors and management strategies.

To identify predictors of morbidity in GO through an analysis of associated anomalies, defect characteristics and management strategies. PubMed and Ovid EMBASE databases were searched from 2013 to 2023. Primary end points assessed correlation of morbidity with gestational age (GA), birth weight (BW), eviscerated organs, defect size, associated anomalies and management strategy. Twenty articles were included for analysis with a total of 1009 GO. Median GA was 37 weeks (27-41), with a median BW of 2700 g (900-6000). 143 cardiovascular anomalies, 238 pulmonary anomalies, 98 musculoskeletal anomalies, 53 urogenital anomalies, 94 gastrointestinal anomalies, 11 neurological anomalies and 43 chromosomal anomalies were identified. 82 had unspecified additional anomalies, of which 20 and 17 were defined as major and minor, respectively. 123 neonates were managed with primary closure, 206 neonates with staged closure and 312 neonates with conservative treatment. Complications included sepsis, respiratory compromise, feeding dysfunction and closure-related adverse events. Long-term morbidity included home ventilation (n = 72), long-term parental nutrition (n = 36), and delayed motor neurodevelopment (n = 21). Main predictors of morbidity were pulmonary hypertension/hypoplasia, major congenital anomalies, greater defect size and liver herniation. Key predictors of poor outcomes include the presence of additional congenital anomalies, defect size, liver herniation and pulmonary hypertension/hypoplasia.

Community-Acquired Candida albicans Empyema Leading to Tension Physiology: A Case Report.

A tension empyema, in which purulent material accumulates in the chest cavity and leads to cardiopulmonary dysfunction, is a rare complication of empyemas. Moreover, fungal empyemas that grow Candida albicans and cause tension physiology have not yet been previously described. In this report, we present an immunocompetent 30-year-old male who presented to the emergency department with worsening shortness of breath and was found to have a left-sided fungal empyema causing tension physiology. Left chest thoracostomy yielded approximately 4 liters of purulent fluid. Pleural cultures eventually grew C albicans, and after antifungal therapy, surgical decortication of the lung, and a prolonged intensive care unit stay, the patient was discharged home in stable condition. While mortality from C albicans empyemas that cause respiratory compromise is exceedingly high, our case highlights that aggressive management with rapid chest thoracostomy and antifungal therapy can lead to a favorable outcome.

Worth the Wait? The Impact of Timing of Repair of Esophageal Atresia With Tracheoesophageal Fistula on Outcomes

IntroductionInfants with esophageal atresia and tracheoesophageal fistula (EA/TEF) are at increased risk for respiratory compromise and gastric perforation until fistula ligation. We sought to describe current practice regarding the timing of EA/TEF repair and hypothesized that age at repair is a predictor of adverse outcomes. MethodsThe Pediatric Health Information System (PHIS) database was used to identify patients with EA/TEF who underwent fistula ligation and esophago-esophagostomy at US children's hospitals from July 2016–June 2021. Patients with a repair >10 days of age, a long-gap atresia, or H-type fistula were excluded. Comorbidities including prematurity and operative congenital heart disease were noted. Outcomes including anastomotic leak, gastric perforation, and post-operative respiratory failure were assessed for association with age and day of the week of operation. ResultsAmong 863 patients that were evaluated, the plurality of operations was on DOL 2 (36%) and 83% were on a weekday (random rate = 71%). Later operations had shorter LOS (p = 0.04) and more recurrent nerve injuries (p = 0.01). Weekend repairs were associated with equivalent outcomes. Gastric perforations occurred in 18 (2.0%) patients; 11 (61%) of these occurred after DOL 2. ConclusionsWe found no significant differences in outcomes other than more recurrent nerve injury and decreased LOS with EA/TEF repair at older ages. Although repair beyond DOL 2 was safe from a respiratory standpoint, most gastric perforations occurred after this point. In the absence of contraindications or significantly reduced weekend capabilities, we recommend repair of EA/TEF by DOL 2. Level of EvidenceIII.

Is NEWS of value for patients with acute stroke?

Patients with acute stroke are at risk of respiratory or circulatory compromise resulting in vital instability, which can be captured through the widely used aggregated National Early Warning Score (NEWS). We aimed to assess the relation between vital instability (defined as NEWS of five or higher) and death or dependency at 90 days after stroke. In this observational cohort study we studied 763 patients with ischaemic stroke (n = 400), intracerebral haemorrhage (ICH) (n = 146) or subarachnoid haemorrhage (SAH) (n = 217), hospitalized to a Dutch tertiary referral hospital from 1 January 2017 to 31 December 2018. We calculated NEWS for each 8 h time span during the first 72 h after hospitalization. We also decomposed NEWS into its three components respiration, circulation and consciousness. The primary outcome was death or dependency (modified Rankin Scale score ⩾3) at 90 days after stroke. The association of vital instability with functional dependency was examined using Poisson regression. Two hundred and twenty-seven (58%) patients with ischaemic stroke, 101 (69%) with ICH and 142 (65%) with SAH had at least one episode of vital instability. In patients with ischaemic stroke or SAH, vital instability was associated after adjustment for confounders with death or dependency (adjusted relative risk 1.55 ((95% CI) 1.25-1.93 and 2.13 (1.35-3.36), respectively)). This was mainly driven by impaired consciousness, which was associated with death or dependency in all types of stroke. Respiratory insufficiency and circulatory instability were associated with death or dependency only in SAH. Vital instability in the first 72 h of hospitalization for ischaemic stroke or SAH is associated with death or dependency at 90 days. Impaired consciousness was the main driver of this relationship. NEWS may not be appropriate for patients with acute stroke, mainly due to the dichotomous manner in which the level of consciousness is classified, and modification of NEWS should be considered for these patients.

Acute Respiratory Distress Syndrome in a Patient with Myasthenia Gravis and Septic Shock: A Case Report

Introduction: Myasthenia gravis (MG) is an autoimmune disorder characterized by muscle weakness, often affecting respiratory and oropharyngeal muscles. This predisposition to respiratory compromise, coupled with impaired swallowing and the potential need for immunosuppressive therapies, increases the risk of pneumonia and subsequent sepsis in MG patients. Sepsis, in turn, is a significant risk factor for acute respiratory distress syndrome (ARDS), a severe lung condition with high mortality. Case presentation: We present the case of a 47-year-old male with a 4-year history of MG who was admitted to our hospital with progressive dyspnea and dysphagia. His condition deteriorated rapidly, leading to septic shock and respiratory failure necessitating invasive mechanical ventilation. Blood cultures identified Klebsiella pneumoniae with extended-spectrum beta-lactamase (ESBL) production. Despite aggressive treatment, including therapeutic plasma exchange (TPE), the patient's hospital course was complicated. Conclusion: This case underscores the critical importance of vigilant monitoring and early intervention in MG patients presenting with respiratory symptoms or signs of infection. Prompt recognition and aggressive management of sepsis are crucial to mitigate the risk of ARDS and improve outcomes in this vulnerable patient population.

Congenital diaphragmatic hernia presenting as bowel obstruction in an infant: A case report

Congenital Diaphragmatic Hernia (CDH) is commonly diagnosed in antenatal scans or presents in the neonatal age group. Presentation of CDH in infants or older children with respiratory symptoms is less common. Similarly, the presentation of CDH with primarily gastrointestinal symptoms is also quite rare and poses a diagnostic and therapeutic challenge. An atypical case of CDH with later presentation with gastrointestinal symptoms is described. A failure to diagnose and correct it in a timely fashion could have a deleterious impact on the outcome. A case of a five-month-old child presenting with features of bowel obstruction is described. On evaluation, the child had rapidly progressive respiratory distress and gross abdominal distension, which was found to be due to left-sided CDH. A closed-loop obstruction with impending strangulation was managed with prompt surgery. The patient had a favorable outcome.Late presenting CDH may present with primarily gastrointestinal symptoms with impending respiratory compromise. A high index of suspicion is necessary to ensure early diagnosis and management.

Ultra-Sound Guided Quadratus Lamborum Block Using Dexamethasone and Bupivacaine versus Dexmedetomidine and Bupivacaine for Post-Operative Analgesia after Labaroscopic Cholecystectomy

Abstract Background The goal of postoperative pain management is provision of comfort, early mobilization and improved respiratory function without causing inadequate sedation and respiratory compromise, which can be achieved through using regional anethesia. Transversus abdominis plane (TAP) block has been increasedly used for postoperative pain relief after lower abdominal surgeries. The main advantage of quadratus lumborum block (QLB) compared to TAP block is the extension of local anesthetic agent beyond the transversus abdominis plane to the thoracic paravertebral space. The wider spread of the local anesthetic agents may produce extensive analgesia and prolonged action of the injected local anesthetic solution. Objective To assess the analgesic effect of addition dexamethasone or Dexmedetomidine with bupivacaine in ultrasound-guided QLB to prolong it’s duration in patients undergoing laparscopic abdominal surgeries in the early postoperative period regarding pain relief, provision of comfort, and improved respiratory functions. Patients and Methods After approval of anesthesiology department scientific and ethical committees in Ain Shams University Hospitals, patients undergoing laparscopic abdominal surgeries were included in the study, and were divided into two groups (n = 10; each); group A and B . Where in group A patients(n = 10) received 20 ml bupivacaine 0.5% plus 100 μg Dexmedetomidine diluted in 5ml 0.9% NaCl (the total volume injected in all patients is 25 ml), and group B patients (n = 10) received 20 ml bupivacaine 0.25% plus 8 mg dexamethasone (2 ml) plus 3 ml 0.9% NaCl . Results The thesis proved that the addition of either Dexmedetomidine or dexamethasone to bupivacaine 0.25% in ultrasound guided QLB for laparscopic abdominal (cholecystectomy) surgeries hastened the onset, prolonged the duration of sensory block, increased post-operative analgesia and decreased rescue analgesia needed without increasing the risk of adverse effects, with Dexmedetomidine showing better results. Conclusion The addition of either 100 μg Dexmedetomidine diluted in 5 ml 0.9% NaCl or 8 mg dexamethasone to 20 ml bupivacaine 0.25% in ultrasound guided quadratus lumborum block for laparscopic abdominal surgery prolonged the duration of analgesia significantly and decreased the postoperative analgesic requirement. Hence, our study suggests that either Dexmedetomidine or dexamethasone may be a useful alternative as an adjuvant to long-acting local anesthetics for quadratus lumborum nerve block with Dexmedetomidine showing better results.