Introduction
Tracheostomy is a surgical airway management procedure that involves making an incision on the anterior neck and opening a direct airway through an incision in the trachea.
Aim
We report ...a case of a difficult tracheostomy complicated by massive immediate bleeding from the innominate artery that required a median sternotomy for vascular access and control.
Case study
A 26-year-old lady with a short neck underwent a tracheostomy in a semi-emergency setting in view of prolonged intubation and frequent intubation prior. The tracheal incision was performed in between the 3rd and 4th tracheal rings and was complicated by massive bleeding from the innominate artery tear that was located below the sternum and necessitated a midline sternotomy procedure to access the artery. The artery was then repaired primarily and covered with a strap muscle that was swung over to the right and sutured to the periosteum of the right clavicle. She lost 6 L of blood, prompting a massive blood transfusion. Postoperatively, there was no bleeding from the wound, but she had an infected sternotomy wound that was managed with antibiotics and dressings. The tracheostomy tube care was uneventful.
Results and discussion
The short-neck hyperextension during trachea exposure can cause major thoracic vessels and tracheal rings to move upward, leading to tracheal incisions being made lower than intended and risking major vessel injury.
Conclusions
Imaging before surgery is recommended to delineate the anatomy and detect any major vessels present in the case of anticipated difficult tracheostomy.
Objective
This study was undertaken to determine whether a low residual quantity of dystrophin protein is associated with delayed clinical milestones in patients with DMD mutations.
Methods
We ...performed a retrospective multicentric cohort study by using molecular and clinical data from patients with DMD mutations registered in the Universal Mutation Database–DMD France database. Patients with intronic, splice site, or nonsense DMD mutations, with available muscle biopsy Western blot data, were included irrespective of whether they presented with severe Duchenne muscular dystrophy (DMD) or milder Becker muscular dystrophy (BMD). Patients were separated into 3 groups based on dystrophin protein levels. Clinical outcomes were ages at appearance of first symptoms; loss of ambulation; fall in vital capacity and left ventricular ejection fraction; interventions such as spinal fusion, tracheostomy, and noninvasive ventilation; and death.
Results
Of 3,880 patients with DMD mutations, 90 with mutations of interest were included. Forty‐two patients expressed no dystrophin (group A), and 31 of 42 (74%) developed DMD. Thirty‐four patients had dystrophin quantities < 5% (group B), and 21 of 34 (61%) developed BMD. Fourteen patients had dystrophin quantities ≥ 5% (group C), and all but 4 who lost ambulation beyond 24 years of age were ambulant. Dystrophin quantities of <5%, as low as <0.5%, were associated with milder phenotype for most of the evaluated clinical outcomes, including age at loss of ambulation (p < 0.001).
Interpretation
Very low residual dystrophin protein quantity can cause a shift in disease phenotype from DMD toward BMD. ANN NEUROL 2021;89:280–292
Warfarin ought to be utilized for an extended duration in individuals with a predisposition to thromboembolism, such as those with atrial fibrillation or aortic valve replacement. While the primary ...complication of long-term warfarin usage is the potential for bleeding, there are also infrequent complications like vascular and tracheal calcification. We present a case of a patient who experienced diffuse tracheal calcification as a result of long-term warfarin usage. A 74-year-old female patient, who had been receiving chronic warfarin treatment for atrial fibrillation, required intubation and was admitted to the intensive care unit due to aspiration pneumonia. As the patient was unable to be extubated during the hospital stay, she became a candidate for Percutaneous dilution tracheostomy (PDT). It was discovered during the PDT procedure that all available spaces of the trachea above the sternum were calcified, preventing the passage of the trach needle. The presence of tracheal calcification was confirmed by both a radiologist and ultrasound examination. Currently, individuals are compelled to employ oral anticoagulants, like warfarin, in order to avert thromboembolic diseases. Nevertheless, the protracted utilization of warfarin is linked with infrequent adverse outcomes, such as disseminated calcification. Consequently, meticulous scrutiny of these side effects is requisite for patients with enduring warfarin consumption.
Purpose As the COVID-19 pandemic has unfolded, there has been growing recognition of risks to frontline health care workers. When caring for patients with tracheostomy, speech-language pathologists ...have significant exposure to mucosal surfaces, secretions, and aerosols that may harbor the SARS-CoV-2 virus. This tutorial provides guidance on practices for safely performing patient evaluation and procedures, thereby reducing risk of infection. Method Data were collated through review of literature, guidelines, and consensus statements relating to COVID-19 and similar high-consequent infections, with a focus on mitigating risk of transmission to health care workers. Particular emphasis was placed on speech-language pathologists, nurses, and other allied health professionals. A multinational interdisciplinary team then analyzed findings, arriving at recommendations through consensus via electronic communications and video conference. Results Reports of transmission of infection to health care workers in the current COVID-19 pandemic and previous outbreaks substantiate the need for safe practices. Many procedures routinely performed by speech-language pathologists have a significant risk of infection due to aerosol generation. COVID-19 testing can inform level of protective equipment, and meticulous hygiene can stem spread of nosocomial infection. Modifications to standard clinical practice in tracheostomy are often required. Personal protective equipment, including either powered air-purifying respirator or N95 mask, gloves, goggles, and gown, are needed when performing aerosol-generating procedures in patients with known or suspected COVID-19 infection. Conclusions Speech-language pathologists are often called on to assist in the care of patients with tracheostomy and known or suspected COVID-19 infection. Appropriate care of these patients is predicated on maintaining the health and safety of the health care team. Careful adherence to best practices can significantly reduce risk of infectious transmission.
The COVID-19 pandemic is unprecedented. Amongst those who contracted COVID-19, a number required intubation and prolonged ventilation. This increased the number of ventilated patients in the hospital ...and increased the requirement for tracheostomy of severe COVID-19 patients. Our objective is to study the outcome of patients with COVID-19 who underwent tracheostomy.
This study is a novel retrospective study in a tertiary centre in Malaysia. Case notes of COVID- 19 patients who underwent tracheostomy in Hospital Ampang were collected using the electronic Hospital Information System. Data were analysed using the SPSS system.
From a total of 30 patients, 15 patients survived. All patients underwent either open or percutaneous tracheostomy. The median age is 53 (range: 28-69) with a significant p-value of 0.02. Amongst comorbidities, it was noted that diabetes mellitus was significant with a p-value of 0.014. The median time from the onset of COVID-19 to tracheostomy is 30 days. The median duration of intensive care unit (ICU) stay is 30.5 days, with the median duration of hospital length of stay of 44 days (p = 0.009 and <0.001, respectively). No complications that contributed to patient death were found. Survivors had a median of 29.5 days from tracheostomy to oxygen liberation.
Tracheostomy in COVID-19 patients that requires prolonged ventilation is unavoidable. It is a safe procedure and mortality is not related to the procedure. Mortality is primarily associated with COVID-19.
Suprastomal collapse and granulation are common sequelae of pediatric tracheostomy. We present the first measure of suprastomal obstructive pathology, the Seattle Suprastomal Safety Score (5S), an ...instrument with 2 domains: collapse and granulation.
Cross-sectional repeated testing survey.
Electronic survey.
A library of images was assembled from still pictures of the suprastomal area in 50 patients who previously underwent trachea-bronchoscopy at a quaternary children's hospital. Five pediatric otolaryngologists and 2 pediatric pulmonologists reviewed the images in random, blinded fashion and provided 5S scores. Participants repeated this process 2 to 4 weeks later. Interrater agreement was calculated with an intraclass correlation coefficient (ICC) with a 2-way random-effects model and Fleiss's κ. Intrarater agreement was measured with an ICC using a 2-way mixed-effects model as well as with test-retest correlations using Spearman rank coefficient. All measures were performed separately on collapse and granulation domains.
ICC for interrater agreement was 0.88 (95% CI, 0.82-0.93) for collapse and 0.97 (95% CI, 0.96-0.98) for granulation, indicating almost perfect agreement. Fleiss's κ demonstrated moderate agreement for collapse and almost perfect agreement for granulation. ICC for intrarater agreement was 0.95 (95% CI, 0.93-0.97) and 0.99 (95% CI, 0.98-0.99) for collapse and granulation, respectively, indicating almost perfect agreement. Spearman rank correlation for test-retest demonstrated substantial agreement for collapse and almost perfect agreement for granulation.
The 5S demonstrates excellent interrater and intrarater agreement, making it highly reliable as a novel measure of suprastomal collapse and granulation in tracheostomy-dependent pediatric patients.
This study was performed to elucidate the current clinical features and outcomes of tetanus using a national inpatient database in Japan.
We used the Japanese Diagnosis Procedure Combination ...inpatient database to retrospectively investigate patients with tetanus from July 2010 to March 2016. We examined the patients' characteristics; the proportions of patients requiring tracheal intubation, mechanical ventilation, and tracheostomy; and the discharge status.
We identified 499 patients who were diagnosed with tetanus. No patient had a diagnosis of tetanus neonatorum or obstetric tetanus. The median age was 74years. Overall, 53.5% of the patients required intubation and mechanical ventilation. Among patients who required intubation and mechanical ventilation, 80.6% started it within 3days of admission, and 77.5% required tracheostomy during hospitalization. The median duration of mechanical ventilation was 23days. The median length of hospitalization was 35days. The proportions of patients who were discharged to home and to locations other than home were 58.1% and 35.1%, respectively. The in-hospital mortality was 6.8%.
The present study suggests that acute-care physicians should be ready to provide intensive care for patients with tetanus and cooperate with medical social workers and families for subsequent long-term nursing care.
•Approximately half of patients with tetanus needed mechanical ventilation.•Three-quarters of patients with mechanical ventilation required tracheostomy.•In-hospital mortality of tetanus patients in Japan was 6.8%.
The optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and ...interventional studies have rarely enrolled patients with isolated TBI.
We included a cohort of adults with isolated TBI who underwent tracheostomy within 1 of 135 participating centers in the American College of Surgeons' Trauma Quality Improvement Program, during 2009 to 2011. Patients were classified as having undergone early tracheostomy (ET, ≤8 days) versus late tracheostomy (>8 days). Outcomes were compared between propensity score-matched groups to reduce confounding by indication. In sensitivity analyses, we used time-dependent proportional hazard regression to address immortal time bias and assessed the association between hospital ET rate and patients' outcome at the hospital level.
From 1,811 patients, a well-balanced propensity-matched cohort of 1,154 patients was defined. After matching, ET was associated with fewer mechanical ventilation days (median, 10 days vs. 16 days; rate ratio RR, 0.70; 95% confidence interval CI, 0.66-0.75), shorter intensive care unit stay (median, 13 days vs. 19 days; RR, 0.70; 95% CI, 0.66-0.75), shorter hospital length of stay (median, 20 days vs. 27 days; RR, 0.80; 95% CI, 0.74-0.86), and lower odds of pneumonia (41.7% vs. 52.7%; odds ratio OR, 0.64; 95% CI, 0.51-0.80), deep venous thrombosis (8.2% vs. 14.4%; OR, 0.53; 95% CI, 0.37-0.78), and decubitus ulcer (4.0% vs. 8.9%; OR, 0.43; 95% CI, 0.26-0.71) but no significant difference in pulmonary embolism (1.8% vs. 3.3%; OR, 0.52; 95% CI, 0.24-1.10). Hospital mortality was similar between both groups (8.4% vs. 6.8%; OR, 1.25; 95% CI, 0.80-1.96). Results were consistent using several alternate analytic methods.
In this observational study, ET was associated with a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay but not hospital mortality. ET may represent a mechanism to reduce in-hospital morbidity for patients with TBI.
Therapeutic study, level II.
PDF
