Deglución post extubación de pacientes críticos con y sin diagnóstico de COVID-19 durante la pandemia / Post extubation swallowing in critical patients with and without COVID-19 during the pandemic

Estudios previos han caracterizado la disfagia en pacientes críticos hospitalizados que requieren intubación y ventilación mecánica invasiva. A raíz de la pandemia COVID-19 es necesario conocer las características deglutorias de pacientes diagnosticados con la enfermedad para su manejo. El objetivo de este estudio es analizar las características deglutorias de pacientes críticos extubados con y sin diagnóstico de COVID-19. Se llevó a cabo un estudio de cohorte retrospectivo con una muestra a conveniencia de 43 sujetos mayores de 15 años, ingresados al Hospital San Juan de Dios (Santiago, Chile) entre el 01 de junio y el 31 de agosto de 2020, intubados con o sin diagnóstico de COVID-19. Del total de sujetos, 22 padecieron de COVID-19 quienes estuvieron significativamente más días intubados que aquellos sin la patología (p=0,002). Inmediatamente posterior a la extubación orotraqueal, más del 90% de la muestra presentó disfagia. No hubo diferencia significativa en el nivel FILS ni asociación significativa en el grado de severidad de la disfagia entre sujetos con y sin COVID-19. Tampoco hubo diferencia significativa en el nivel FILS entre los grupos a los 10 días post-extubación. El nivel FILS a los 10 días aumentó significativamente en aquellos sujetos con COVID-19 (p=0,016) y sin COVID-19 (p=0,004). En la muestra, el nivel FILS y grado de severidad de la disfagia de los pacientes con y sin COVID-19 no mostraron diferencias estadísticas, siendo alto el porcentaje de disfagia en ambos grupos, lo que se podría asociar a la intubación orotraqueal y al tubo orotraqueal. Es necesaria la incorporación del fonoaudiólogo dentro de los equipos de Unidades de Pacientes Críticos para el manejo de los pacientes con COVID-19 y disfagia. Además, se recomienda continuar con más estudios en el área.

Previous research have described the deglutition disorders in critical hospitalised patients who required intubation and mechanical ventilation. In the pandemic context, it is mandatory to study both level and grade of dysphagia in patients suffering from COVID-19. The aim of this study is to analyse the deglutition features of extubated critical patients with and without COVID-19. A retrospective cohort study was performed, considering a convenience sample of 43 patients from 15 years old hospitalised at 'Hospital San Juan de Dios' between June 1st and August 31th 2020, who were intubated, with and without the diagnosis of COVID-19. 22of out 43 patients were diagnosed with COVID-19 who were intubated for significantly more days in comparison with those without COVID-19 (p=.002). After the intratracheal extubation, 90% of the sample was diagnosed with dysphagia. There was no significant difference in the FILS score nor significant association in dysphagia severity between patients with and without COVID-19. After 10 days post extubation, there was no significant difference in the FILS score between both groups. The FILS score increased significantly in the COVID-19 (p=.016) and non-COVID-19 (p=.004) patients after 10 days post extubation. Post extubation, there are no statistical differences in the FILS score and dysphagia severity in critical ill patients with and without COVID-19, with a high percentage of dysphagia in both groups which could be associated with intratracheal intubation and endotracheal tubes. The incorporation of speech and language therapists in Critical Care Units is mandatory. Furthermore, it is recommended to perform extra research in the area.

The prophylactic effect of intravenous magnesium infusion on postoperative sore throat after thyroid surgery. A randomized clinical trial / Efecto profiláctico de la infusión de magnesio en dolor de garganta postoperatorio luego de una tiroidectomía. Un ensayo clínico aleatorizado

BACKGROUND: The reported incidence of postoperative sore throat (POST) varies widely from 14.4 to 100% with maximum severity at 4th to 6th postoperative hour. Nonetheless, it has increasingly become a common clinical problem particularly in thyroid surgery. Although POST usually resolves spontaneously in few days, it is likely to be the most common complaint. OBJECTIVES: Driven by the increased number of patients with post-intubation sore throat following thyroid surgery, the aim of the present study was to evaluate the effectiveness of perioperative magnesium infusion in attenuating POST after thyroidectomy. METHODS AND MATERIAL: 80 female patients undergoing thyroid surgery, were preoperatively randomized into one of 2 groups. The magnesium group received magnesium sulfate (30 mg/kg) in 100 ml of isotonic saline over 15 min before induction of anesthesia, followed by a continuous magnesium sulfate infusion (10 mg/kg/h) for the duration of the operation. The control group received the same volume and rate of isotonic saline. RESULTS: This study showed that perioperative magnesium infusion had significantly reduced the overall incidence and severity of POST. The incidence of POST at rest (patients who recorded non-zero POST score after thyroid surgery) in the control group was 75% while the incidence of POST in magnesium group was 37.5% which is lower and that was highly significance. Higher sedation scores were encoun tered on arrival to PACU in Magnesium group when compared to controls. CONCLUSIONS: We concluded that perioperative magnesium sulphate infusion effectively decreased overall POST incidence and severity after thyroidectomy with better hemodynamic stability, albeit higher risk of post operative sedation.

La incidencia reportada de dolor de garganta postoperatorio (POST) varía ampliamente de 14,4 a 100% con severidad máxima en la 4ta a 6ta hora postoperatoria. Sin embargo, se ha convertido cada vez más en un problema clínico común, particularmente en la cirugía de tiroides. Aunque la POST generalmente se resuelve espontáneamente en pocos días, es probable que sea la queja más común. OBJETIVOS: Impulsado por el mayor número de pacientes con dolor de garganta después de la intubación después de la cirugía de tiroides, el objetivo del presente estudio fue evaluar la efectividad de la infusión perioperatoria de magnesio para atenuar la POST después de la tiroidectomía. MÉTODOS Y METERIAL: 80 pacientes mujeres sometidas a cirugía de tiroides, fueron asignadas al azar preoperatoriamente en uno de los 2 grupos. El grupo de magnesio recibió sulfato de magnesio (30 mg/kg) en 100 ml de solución salina isotónica durante 15 minutos antes de la inducción de la anestesia, seguido de una infusión continua de sulfato de magnesio (10 mg/kg/h) durante la operación. El grupo control recibió el mismo volumen y tasa de solución salina isotónica. RESULTADOS: Este estudio mostró que la infusión perioperatoria de magnesio había reducido significativamente la incidencia general y la gravedad de la POST. La incidencia de POST en reposo (pacientes que registraron una puntuación POST distinta de cero después de la cirugía de tiroides) en el grupo de control fue del 75%, mientras que la incidencia de POST en el grupo de magnesio fue del 37,5%, que es menor y de gran importancia. Se encontraron puntajes de sedación más altos al llegar a la UCPA en el grupo Magnesio en comparación con los controles. CONCLUSIONES: Llegamos a la conclusión de que la infusión perioperatoria de sulfato de magnesio disminuyó efectivamente la incidencia general de POST y la gravedad después de la tiroidectomía con una mejor estabilidad hemodinámica, aunque un mayor riesgo de sedación postoperatoria.

Treatment of Laryngeal Granulomas

Abstract Introduction Laryngeal granulomas are benign, recurrent lesions of many causes (reflux, voice abuse, intubation, and idiopathic), which renders its treatment difficult. Objective To describe our experience in the treatment of laryngeal granulomas. Methods From 16 medical records of the patients with laryngeal granulomas seen between 2010 and 2017 in a university hospital, the following data were analyzed: age, gender, vocal and gastroesophageal symptoms, vocal overuse, intubation, treatments, videolaryngoscopy before and after the treatment. Results Gender: female, 10; male, 6. Age: between 20 and 60 years old (11%). Etiology of the granulomas: intubation (9), reflux (4), idiopathic (3). The initial treatments adopted in all cases were: inhaled beclomethasone dipropionate 100 μg 12/12 hours (1month), proton pump inhibitor, omeprazole 40 mg/day (2months), and dietary and voice education. After this period, 10 patients (7 postintubation, 3 idiopathic) were submitted to surgery, since no improvements in the symptoms or in the lesions were seen. Of these, two recurred, requiring a second surgery, one of which recurred six times and received botulinum toxin A. Only one patient with granulomas due to laryngopharyngeal reflux presented no improvement in the symptoms nor in the lesion after the pharmacological treatment and had been submitted to microsurgery. All of the other patients with reflux granulomas were successfully treated with the drug treatment, and the longest treatment time for complete remission of the symptoms and of the lesions was 9 months. Conclusions In laryngeal granulomas caused by reflux, treatment with inhaled steroids and proton pump inhibitors proved to be effective, although prolonged. In postintubation and idiopathic granulomas, surgery was the best treatment.

Percepção dos profissionais atuantes nas UTI's quanto à importância de condutas de saúde bucal / Perception of professionals working in ICUS on the importance of oral health conducts

Introdução: a cavidade bucal é constituída de inúmeros microrganismos que favorecem o desenvolvimento de doenças quando o paciente se encontra imunossuprimido. Considerando esse fato, surge o interesse em avaliar as condições bucais de pacientes hospitalizados em Unidades de Terapia Intensiva. Objetivo: este trabalho tem como objetivo avaliar a percepção dos profissionais atuantes nas UTIs dos principais hospitais da região do Cariri do Ceará, quanto à importância das condutas de saúde bucal, o conhecimento dos profissionais sobre a associação da condição bucal e geral dos pacientes internos, analisar a existência de protocolos de higiene bucal para o paciente internado na UTI e justificar se há importância do cirurgião-dentista neste ambiente. Materiais e método: para obtenção de dados, foi realizada uma pesquisa do tipo transversal, na qual o instrumento para avaliação dos entrevistados foi um questionário constituído por 8 questões de múltipla escolha e 7 discursivas, abordando conteúdos relacionados aos objetivos da pesquisa. Resultados: de acordo com a análise de dados, foi observado que: a higienização bucal é realizada com antissépticos, sendo a clorexidina, a substância mais utilizada. A frequência da descontaminação era realizada nos intervalos de 6 e 12 horas. A higienização da língua era realizada por meio do tracionamento e limpeza com gaze, a mucosa não era higienizada. Não foi relatado o uso de saliva artificial e a realização de cursos de capacitações. Considerações finais: foi concluído neste estudo que muitos dos profissionais deixam a desejar na higienização bucal, visando apenas ao quadro de internação do paciente e, que, o dentista ainda não está incluído nas equipes de saúde que atuam diretamente nessas unidades, sendo uma das causas de deficiências nesses cuidados.(AU)

Introduction: The oral cavity consists of several microorganisms that favor the development of diseases when patients are immunosuppressed. Therefore, there is an interest in assessing the oral conditions of patients hospitalized in intensive care units (ICU). Objective: This study aims to assess the perception of professionals working in ICUs of the main hospitals of Cariri (Ceará, Brazil) on the importance of oral health conducts and the knowledge of professionals about the association of oral and general conditions of inpatients. It also analyzed the existence of oral hygiene protocols for ICU patients and justified whether dentists are important in such environment. Materials and method: The data was obtained with a cross-sectional research in which the instrument for assessing the respondents was a questionnaire consisting of eight multiple choice and seven discursive questions addressing contents related to the objectives of the study. Results: The data analysis showed that oral hygiene is performed with antiseptics, and chlorhexidine is the most used substance. The frequency of decontamination was performed at intervals of 6 and 12 hours. The tongue was cleaned using traction and gauze, and mucosa was not cleaned. The use of artificial saliva and the performance of training courses were not reported. Final considerations: This study concluded that many professionals fall short in oral hygiene, only considering the hospitalization condition of patients. Additionally, dentists are not yet included in the health teams working directly in intensive care units, which is one of the causes of deficiencies in such service.(AU)

Effects of conventional vs high-dose rocuronium on the QTc interval during anesthesia induction and intubation in patients undergoing coronary artery surgery: a randomized, double-blind, parallel trial

Myocardial ischemia, as well as the induction agents used in anesthesia, may cause corrected QT interval (QTc) prolongation. The objective of this randomized, double-blind trial was to determine the effects of high- vs conventional-dose bolus rocuronium on QTc duration and the incidence of dysrhythmias following anesthesia induction and intubation. Fifty patients about to undergo coronary artery surgery were randomly allocated to receive conventional-dose (0.6 mg/kg, group C, n=25) or high-dose (1.2 mg/kg, group H, n=25) rocuronium after induction with etomidate and fentanyl. QTc, heart rate, and mean arterial pressure were recorded before induction (T0), after induction (T1), after rocuronium (just before laryngoscopy; T2), 2 min after intubation (T3), and 5 min after intubation (T4). The occurrence of dysrhythmias was recorded. In both groups, QTc was significantly longer at T3 than at baseline [475 vs 429 ms in group C (P=0.001), and 459 vs 434 ms in group H (P=0.005)]. The incidence of dysrhythmias in group C (28%) and in group H (24%) was similar. The QTc after high-dose rocuronium was not significantly longer than after conventional-dose rocuronium in patients about to undergo coronary artery surgery who were induced with etomidate and fentanyl. In both groups, compared with baseline, QTc was most prolonged at 2 min after intubation, suggesting that QTc prolongation may be due to the nociceptive stimulus of intubation.

Mortalidade neonatal precoce relacionada a intervenções clínicas / Early neonatal mortality related to clinical interventions / Mortalidad neonatal precoz vinculada a intervenciones clínicas

Estudo descritivo, transversal, que objetivou identificar a influência das intervenções clínicas realizadas na sala de parto e UTI Neonatal no óbito neonatal precoce em Cuiabá-MT, no ano de 2010. A coleta de dados foi feita em janeiro-fevereiro/2011, com base nos dados contidos nas declarações de nascidos vivos, declarações de óbito e prontuário hospitalares, sendo arquivados e tratados no programa SPSS versão 15.0. Dos 77 óbitos analisados, 94,7% dos bebês nasceram no hospital e mais de 70% morreram precocemente. As intervenções em sala de parto que se associaram ao risco de óbito precoce foram a reanimação cardiopulmonar e intubação; durante a internação, o cateter central de inserção periférica e a hemotransfusão associaram-se como fator de proteção para o óbito precoce. O conhecimento de práticas clínicas benéficas ou maléficas para a saúde do neonato é imprescindível para alcançar a qualidade do cuidado e, consequentemente, reduzir os óbitos neonatais, especialmente os precoces.

Descriptive cross-sectional study that aimed at verifying the influence of clinical interventions carried out in the delivery room and in the Neonatal ICU in the early neonatal death, in Cuiabá-MT, 2010. The data collection was performed in January-February 2011, based on the data found in the live birth certificates, death certificates and hospital records, filed and examined in the SPSS program version 15.0. Of the 77 deaths analyzed, 94.7% of the babies were born in a hospital and more than 70% died early. The interventions in the delivery room that were associated to the risk of early death were cardiopulmonary resuscitation and intubation; during the hospital stay, the central catheter of peripheral insertion and the blood transfusion were associated as protection factors for early death. Knowing about which of these clinical practices are beneficial or harmful to the neonate´s health is essential to reach the quality of care and, consequently, to reduce the neonatal deaths, mainly the early ones.

Estudio descriptivo transverso que objetivó verificar la influencia de las intervenciones clínicas realizadas en la sala de partos y UTI Neonatal en la muerte neonatal precoz, en Cuiabá-MT, 2010. La recolección de datos se llevó a cabo en enero-febrero de 2011, basado en los datos de las declaraciones de nacidos vivos, certificados de defunción y archivos del hospital, que fueron archivados y procesados en el programa SPSS versión 15.0. De las 77 muertes analizadas, 94,7% de los bebés nacieron en el hospital y más de 70% murieron temprano. Las intervenciones en la sala de partos que se asociaron al riesgo de muerte precoz fueron la reanimación cardiopulmonar y intubación; durante la hospitalización, el catéter central de inserción periférica y la transfusión de sangre se asociaron como factor protector de la muerte prematura. El conocimiento de las prácticas clínicas que son benéficas o perjudiciales para la salud del recién nacido es esencial para lograr la calidad de la atención y, en consecuencia, reducir las muertes neonatales, especialmente las tempranas.

Development of massive pneumopericardium after intubation and positive pressure ventilation

Pneumopericardium is a rare complication of chest trauma, mechanical ventilation and cavitating pneumonia. We report a case of a 7-year-old patient with chronic myeloid leukemia who developed massive pneumopericardium immediately after being electively intubated for a diagnostic radiological procedure in the setting of ongoing Enterococcal pneumonia. As intensive care medicine becomes more prevalent in hospitals, we believe that clinicians need to be aware of this uncommon but potentially fatal condition

Length of exposure to the hospital environment is more important than antibiotic exposure in healthcare associated infections by methicillin-resistant Staphylococcus aureus: a comparative study

OBJECTIVES: Both total antimicrobial use and specific antimicrobials have been implicated as risk factors for healthcare-associated methicillin-resistant Staphylococcus aureus (HCA-MRSA) infection. The aims of this study were: (I) to explore predictors of a new HCA-MRSA infection in comparison with a new healthcare-associated methicillin-sensitive Staphylococcus aureus (HCA-MSSA); (II) to thoroughly assess the role of recent antibiotic use qualitatively and quantitatively. METHODS: The time-period for our study was from October 1997 through September 2001. Through applying strict criteria, we identified two groups of inpatients, one with a new HCA-MRSA infection and one with a new HCA-MSSA infection. We recorded demographic, clinical and antibiotic use-related data up to 30 days before the positive culture date. RESULTS: We identified 127 and 70 patients for each group, respectively. Two logistic regression models were carried out to assess the role of antimicrobial use (qualitatively and quantitatively). In model I, duration of hospital stay, presence of chronic wounds, aminoglycoside and fluoroquinolone use retained statistical significance. In model II, duration of hospital stay and history of intubation during the last month stood out as the only significant predictors of a subsequent HCA-MRSA infection. No significant differences in outcome were noted. CONCLUSIONS: The length of exposure to the hospital environment may be the best predictor of a new HCA-MRSA infection. Use of aminoglycosides and fluoroquinolones may also stand independently along with presence of chronic ulcers and surgical procedures. No independent association between quantitative antibiotic use and subsequent HCA-MRSA infection was documented.

Comparing two methods of LMA insertion; classic versus simplified [airway]

The aim of this study is to compare two methods of LMA insertion, "classic" versus "simplified" [AIRWAY], due to factors such as: time to insertion, number of attempts, blood stained LMA, air leak around LMA, and gastric inflation. The word "AIRWAY" refers to the similarity of this method to oropharyngeal airway insertion. One hundred ASA class I and II patients elected for lower limb orthopedic surgery but without any head and face injury or head and neck abnormality, having their tooth intact, were selected and divided to two groups of fifty; classic and simplified. In the classic group, the index finger used as a guide, pushes the back of LMA towards the hard palate, inserting it into the pharynx till a resistance is felt and the LMA is then fixed it its place. In the AIRWAY group, the deflated LMA is entered into the mouth in a 180 degree inside-out position compared to the classic method without using fingers and is proceeded until it enters the pharynx [sudden loss of resistance] and then returned 180 degree back to its normal position to be fixed in the right place. The attempt numbers, time to insertion, complications such as laryngospasm, blood stained LMA and gastric inflation is being investigated. Demographic data such as age, sex and ASA class, demonstrate no meaningful statistic difference between the two groups. Successful first attempt in AIRWAY group [86%] had no meaningful statistic difference with the classic group [80%] [p>0.05]. The overall success rate in LMA insertion [within two attempts] was 100% and 82% in AIRWAY and classic groups respectively [p>0.05] and 11 patients with failed insertion attempts, were excluded from the study. The time for successful insertion was meaningfully less in the AIRWAY group compared to the classic one [p<0.0001].In the classic group 32% of LMAs became blood stained compared to 16% in the AIRWAY group, which the difference was not meaningful. No other complications such as laryngospasm or oxygen desaturation occurred. Comparison of the whole advantages and disadvantages of both groups, mention that, by putting the LMA insertion time together with the low complication rates, the AIRWAY method can be assumed as a preferred simplified method with few complications for inserting LMA

Role of tracheostomy [early VS late] in intubated cases of neurosurgical patients in surgical intensive care unit [SICU] setting

To study the role of early vs. late tracheostomy, in neurosurgical intubated cases admitted in surgical intensive care unit, on recovery from pneumonia during ventilation, length of intensive care unit stay and duration of ventilatory support and weaning. The Study was conducted in the Department of Anaesthesia and Surgical Intensive Care Unit with collaboration of ENT Department, Abbasi Shaheed Hospital, Karachi from Jan 2007-Dec 2008. A retrospective analysis of the case file records of the intubated neurosurgical patients admitted in surgical intensive care unit for whom elective tracheostomy was performed, for prolonged ventilation, was made from 2007-2008 of 50 cases. Early tracheostomy was consider, when it was performed within 3 - 7 days of intubation and late was after that or 8- 14 days. Data collected include the information regarding the patient's name, age, sex, etiology and Glasgow coma score [GCS] on admission, time duration of patients' stay in surgical intensive care unit, time period of weaning from mechanical support and recovery from pneumonia during ventilation, along with chest x-ray's, culture and sensitivity reports. Depending on the time of tracheostomy performed two groups were made: Group- I in which tracheostomy was performed early within 3-7 days of intubation and Group- II in which tracheostomy were performed after an interval of more than 7 days or 8-14 days [late tracheostomy]. For group I the early tracheostomy was done at the median of 4th day vs. that of 10th day for the group II. The number of cases that developed pneumonia in group- I was 45.45% versus Group- II 54.54%, [odd ratio 0.27]. Duration of mechanical ventilation was significant with early tracheostomy [mean, standard deviation] 11.95 days +/- 3.14 versus late tracheostomy 21.79 days +/- 6.06. Intensive care unit stay was shorter in group- I [mean, standard deviation] 15.09 days +/- 3.49 versus in group- II 26.71days +/- 7.00. Recovery from pneumonia was shorter in group- I [mean, standard deviation] 9.0 days +/- 1.63 versus in group- II 14.23 days +/- 1.81. Our study shows that early tracheostomy has a positive role in reducing the risk of pneumonia, because of easier access to lower airway for clearance but not statistically significant, decreased the overall time period of surgical intensive unit stay and patients were weaned off earlier from mechanical support, in comparison to those in which tracheostomy was performed late. Therefore early tracheostomy in selected patients may help in reducing unnecessary resource utilization

Resultados e complicações da entubação bicanalicular em dacriocistorrinostomia externa / Results and complications of bicanalicular intubation in external dacryocystorhinostomy

OBJETIVO: Analisar a taxa de sucesso e complicações em pacientes com obstrução lacrimal, submetidos à entubação bicanalicular na cirurgia de dacriocistorrinostomia externa (DCR-Ex). MÉTODOS: Foram analisados os dados dos pacientes operados no Hospital do Servidor Público Estadual de São Paulo. A entubação lacrimal foi realizada com tubo de silicone, removido após oito semanas. O sucesso da cirurgia foi considerado nos casos de pacientes sem epífora ou secreção ocular no pós-operatório, com boa passagem de fluido para a narina ou orofaringe. As complicações relacionadas com o tubo de silicone foram agrupadas em uma tabela. RESULTADOS: Os pacientes foram operados no período de abril de 2002 a julho de 2006, com tempo de seguimento médio de três meses. Do total de 65 olhos obteve-se uma taxa de sucesso de 89,2 por cento. Sete pacientes apresentaram epífora no pós-operatório, dos quais 5 foram reoperados. Em 7 olhos houve extrusão do silicone com menos de 15 dias de pós-operatório, e neste grupo 1 paciente necessitou de reoperação. Seis olhos apresentaram complicações com o silicone: prolapso do tubo (4 casos), formação de granuloma na cavidade nasal (1 caso) e aderência dos pontos lacrimais (1 caso). COCLUSÕES: Este grupo de pacientes apresentou taxa elevada de sucesso (89,2 por cento) com a cirurgia de DCR-Ex associada à entubação bicanalicular. A entubação intra-operatória com tubo de silicone não é isenta de complicações.

PURPOSE: To analyze the success rate and complications in patients with lacrimal obstruction submitted to surgeries. METHODS: The data of patients operated in the "Hospital do Servidor Público Estadual of São Paulo" were analyzed. The lacrimal intubation was performed with a silicone tube, removed after 8 weeks. Surgeries were considered successful in those cases where patients had no postoperative epiphora or ocular secretion, and with a good passage of fluid to the nose or oropharynx. The complications related to the silicone tube were grouped in a table. RESULTS: The patients were operated from April 2002 to July 2006 with an average follow-up period of three months. In a total of 65 eyes, success was obtained in 89.2 percent of the cases. Seven patients presented postoperative epiphora, and 5 of them were reoperated. In 7 eyes there was an extrusion of the silicone in less than 15 days from surgery, and in this group one patient needed a reoperation. Six eyes presented complications with the silicone: tube prolapse (4 cases), granuloma formation in the nasal cavity (1 case) and lacrimal puncta adhesion (1 case). CONCLUSIONS: This group of patients presented a high success rate with Ex-DCR surgery associated with lacrimal intubation. The intraoperative intubation with silicone tube is not free of complications.

effect of intravenous nitroglycerine on blood pressure during intubation

Hypertension is one of the most frequent complication during laryngoscopy and intubation; thus in the premedication or induction stages, many drugs have been used to control this hypertension. Nitroglycerine is one of the drugs thought to be effective and the purpose of this study is to appraise this deliberation. 150 patients of 20-50 years of age were enrolled in this randomized double blind clinical trial. They were randomly divided into two group, one received 2 micro g/kg nitroglycerine while the other group did not received any drug. Blood pressure was checked in 3 different stages and compared. In both groups, pre and post intubation systolic pressure had a significant difference; whereas this relation could not be found for the diastolic pressure. These variables did not have a statistically significant relation prior to intubation; whilst after intubation, a significant relation was elicited. Injection of 2 micro g/kg nitroglycerine immediately after anesthetic induction is effective in preventing the unwanted increase in the blood pressure, and as a result, complications following this response in patients with ischemic heart disease would be reduced

Caffeine in children with obstructive sleep apnea

Children with obstructive sleep apnea [OSA] have a higher rate of adverse post-extubation respiratory events, such as laryngospasm, upper airway obstruction, apnea, desaturation and/or need for re-intubation. They are overly sensitive to sedatives and narcotics. Although the etiology of OSA is primarily obstruction [mechanical or neuromuscular], a central element may contribute to OSA. Caffeine citrate has been shown to be effective in treating apnea of prematurity. This study evaluated whether the administration of caffeine benzoate to children with OSA decreases the number of children who experience adverse post-extubation respiratory events. In a randomized, double-blind and placebo-controlled study, children with OSA scheduled for adenotonsillectomy [T and A] received either caffeine benzoate, 20 mg/kg IV, [caffeine group, n = 36] or saline [placebo group, n = 36]. The primary outcome evaluated the number of children who developed adverse post-extubation respiratory events, and the secondary outcome was the incidence of those events. The results demonstrated the two groups differed in the number of children who developed adverse post-extubation respiratory events [p = 0.032]. The overall incidence of adverse postoperative respiratory events was less in the caffeine group than the placebo group [p = 0.0196]. In children with OSA scheduled for T and A, administration of caffeine benzoate, 20 mg/kg IV, decreased the number of children who developed adverse post-extubation respiratory events and decreased the overall incidence of adverse post-extubation respiratory events. PACU duration, hospital discharge time and postoperative delirium did not differ between groups

Reintubation increases ventilator-associated pneumonia in pediatric intensive care unit

To determine the incidence, risk factors, mortality, and causative organisms of Nosocomial Pneumonia [NP] in patients with endotracheal [ET] tube, with or without mechanical ventilation. Patients admitted to the Pediatric Intensive Care Unit [PICU], over a period of 1 year who had ET intubations, were enrolled consecutively into the study. Diagnosis of NP was based on CDC criteria [1988]. Semiquantiative assay of endotracheal aspirate [ETA] with a colony count of > 105 cfu/mL was taken as evidence of infection. Colonization was defined as isolation of organism with < 105 cfu/mL. Age, nutritional status, number and duration of intubations, duration of mechanical ventilation, sedation, nasogastric feeding were the risk factors studied for development of NP. Intubation attempts of more than one were defined as reintubation. Risk factors found significant on univariate analysis, were subjected to multiple regression analysis to determine the most important predictors of NP. The study group comprised of 72 children with a median age of 3.7 years and boys: girls' ratio of 1.9:1.Twenty two of 72 [30.5%] developed NP; the predominant isolates from ETA were Pseudomonas aeruginosa [12], Acinetobacter anitratus [5], Klebsiella sp [3] and Staphylococcus aureus and E.coli [1] each. Additionally, 18[39%] had evidence of ET colonization, with Pseudomonas aeruginosa being the commonest 9[50%]. Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP. On multiple regression analysis, reintubation was the only independent risk factor for NP [OR 0.72, 95% CI 0.55-0.94]. Overall mortality was 21% [15/72];7[47%]of these deaths were secondary to NP. NP developed in nearly one third of the intubated patients; Gram negative organisms were the predominant etiological agents and associated with high mortality. Re-intubation, prolonged duration of intubation and mechanical ventilation were the significant risk factors on univariate analysis for development of NP. On multiple regression analysis, reintubation was the only independent risk factor for NP

Post intubation trauma: A prospective autopsy study.

Prolonged intubation of the trachea in the treatment of acute respiratory failure has become common in intensive care units during last two decades. Although intubation of the trachea confers great advantage, lesions of the larynx and the trachea may result and are severe on occasions. Hence, it is important that, our knowledge regarding the effects of intubation on the respiratory tract needs to be expanded with all available means of study. This at times can be a challenging issue in routine medicolegal work, as they are of potential nature for misinterpretation and needs caution in interpreting.

The CobraPLA(TM) During Anesthesia with Controlled Ventilation: A Clinical Trial of Efficacy

The CobraPLA(TM) (CPLA) is a relatively new supraglottic airway device that has not been sufficiently investigated. Here, we performed a prospective observational study to evaluate the efficacy of the CPLA during controlled ventilation. In 50 anesthetized and paralyzed patients undergoing elective surgery a CPLA was inserted and inflated to an intracuff pressure of 60 cm H2O. The success rate of insertion upon the first attempt was 82% (41/50), with a mean insertion time of 16.3 +/- 4.5 seconds. The adequacy of ventilation was assessed by observing the end tidal CO2 waveform, movement of the chest wall, peak airway pressure (13.5 cm H2O), and leak fraction (4%). We documented the airway sealing pressure (22.5 cm H2O) and noted that the the site of gas leaks at that pressure were either at the neck (52%), the abdomen (46%), or both (2%). In 44 (88%) patients, the vocal cords were visible in the fiberoptic view through the CPLA. There was no gastric insufflation during the anesthesia. Respiratory and hemodynamic parameters remained stable during CPLA insertion. Postoperative blood staining of CPLA was minimal, occurring in 22% (11/50) of patients. Mild and moderate throat soreness was reported in 44% (22/50) and 4% (2/50) of patients, respectively. Lastly, mild dysphonia was observed in 6% (3/50) of patients and mild dysphagia in 10% (5/50) of patients. Our results indicated that the CPLA is both easy to place and allows adequate ventilation during controlled ventilation.

Pneumomediastinum and pneumopericardium--a clinical condition of multispeciality interest.

Pneumomediastinum with its usual associations like pneumopericardium has been described in detail including review of literature, aetiopathogenesis, symptoms and signs, complications, necessary investigations and management protocol by the authors in this article of multispeciality interest.

Relationship between the morphologic alterations of vocal cords from adult autopsies and the cause of death

OBJETIVO: O objetivo deste trabalho foi identificar as possíveis alterações na espessura da membrana basal das cordas vocais e relacionar estas com a causa de morte. MÉTODO: Foram utilizadas laringes coletadas de adultos autopsiados, no período de 1993 até 2001. Realizamos as colorações da Hematoxilina- Eosina e Ácido Periódico de Schiff, onde foi medido o diâmetro da membrana basal. RESULTADOS: Foram analisadas 66 cordas vocais, o espessamento foi identificado em 14 casos (21,2 por cento), sendo encontrado em proporções iguais entre os sexos, sendo freqüente em pacientes da cor branca (12 casos, 85,7 por cento). Foram encontradas alterações respiratórias em 10 (71,4 por cento) dos casos com espessamento. Entre os pacientes intubados, 7 (18,4 por cento) apresentaram espessamento. Entre os fumantes 9 (19,63 por cento) apresentavam espessamento. Não houve influência estatisticamente significativa do espessamento na doença que levou o indivíduo à morte. CONCLUSÃO: Em relação a causa de morte não há diferença estatisticamente significante entre os casos cuja causa de morte foi por doenças respiratórias ou por doenças não respiratórias e o diagnóstico de espessamento da membrana basal das cordas vocais. Sua etiopatogênese necessita de maiores estudos.