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SESSION TITLE: Pulmonary Procedures: Creativity and Complications SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 10:15 am - 11:10 am INTRODUCTION: Recent advances in the management of airway disorders have provided additional therapeutic options for pathology, such as central airway obstruction (CAO). Symptomatic CAO has been managed by bronchoscopic interventions with a high risk of airway compromise and respiratory failure. Other alternatives such as mechanical and jet ventilation may not ensure adequate respiratory support during the procedure and cause delays in life-saving treatments. Venovenous extracorporeal membrane oxygenation (VV ECMO) has been used as an adjunct to preserve safety during these airway interventions [1,2]. We present a case of complete tracheal occlusion successfully intervened using VV ECMO support. CASE PRESENTATION: The patient is a 55-year-old male with a history of ventilator-dependent respiratory failure s/p tracheostomy, secondary to post COVID-19 fibrosis, who presented from a long-term acute care facility with worsening hypoxemia. The patient was transferred to the intensive care unit, where he underwent flexible bronchoscopy via the tracheostomy lumen, which did not reveal a patent airway. Orotracheal intubation was unsuccessful as there was complete occlusion of the airway below the vocal cords with abundant granulation tissue. Interventional pulmonology was consulted, and emergent recanalization of the airway with rigid bronchoscopy-mediated debulking was performed. Due to the severity of hypoxemia, cardiothoracic surgery was consulted, and the patient was placed on VV ECMO to support further intervention. The patient was intubated with EFER-DUMON 13 mm rigid bronchoscope. Complete recanalization was achieved using a rigid barrel and forceps with patency of both mainstems and all segmental bronchi. There were no postprocedural complications, and the patient returned to his baseline ventilator settings. DISCUSSION: VV ECMO has been used as an adjunct to preserve safety during high-risk bronchoscopic interventions, primarily in CAO. Acute respiratory decompensation remains a feared complication during these interventions in cases of CAO. Initiating ECMO before these interventions may reduce the incidence of respiratory failure and airway compromise. In a case series, ECMO has been described by Stokes et al. as a supportive measure facilitating such interventions [3]. Further guidelines are required to standardize ECMO initiation as procedural support during airway interventions. CONCLUSIONS: Planned preprocedural ECMO initiation can prevent respiratory emergencies and allow therapeutic high-risk airway interventions. The choices for this patient were stark- either airway recanalization without ECMO bridge with a risk of hypoxic brain injury vs. VV ECMO support and curative airway intervention. In the absence of large-scale data and based on local availability of excellent ECMO support and Interventional Pulmonology, the latter approach was used, leading to successful and safe airway recanalization. Reference #1: Zapol WM, Wilson R, Hales C, Fish D, Castorena G, Hilgenberg A et al.Venovenous bypass with a membrane lung to support bilateral lung lavage. JAMA 1984;251:3269–71. Reference #2: Fung R, Stellios J, Bannon PG, Ananda A, Forrest P. Elective use of venovenous extracorporeal membrane oxygenation and high-flow nasal oxygen for resection of subtotal malignant distal airway obstruction. Anaesth Intensive Care 2017;45:88–91. Reference #3: Stokes JW, Katsis JM, Gannon WD, Rice TW, Lentz RJ, Rickman OB, Avasarala SK, Benson C, Bacchetta M, Maldonado F. Venovenous extracorporeal membrane oxygenation during high-risk airway interventions. Interact Cardiovasc Thorac Surg. 2021 Nov 22;33(6):913-920. doi: 10.1093/icvts/ivab195. PMID: 34293146;PMCID: PMC8632782 DISCLOSURES: No relevant relationships by Vatsal Khanna No relevant relationships by Anurag Mehrotra No relevant relationships by Trishya Reddy No relevant relationships by Bernadette Schmidt
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Purpose - The recent COVID-19 pandemic has (triggered) lots of interest in work from home (WFH) practices. Many organizations in India are changing their work practices and adopting new models of getting the work done. The purpose of the study to look at the boundary-fit perspective (Ammons (2013) and two factors, namely, individual preferences (boundary control, family identity, work identity and technology stress) and environmental factors (job control, supervisor support and organizational policies). These dimensions are used and considered to create various clusters for employees working from home. Design/methodology/approach - K-mean clustering was used to do the cluster analysis. Statistical package for social sciences 23 was used to explore different clusters based on a pattern of characteristics unique to that cluster, but each cluster differed from other clusters. Further analysis of variance test was conducted to see how these clusters differ across three chosen outcomes, namely, work-family conflict, boundary management tactics used and positive family-to-work spillover effect. The post hoc test also provided insights on how each cluster differs from others on these outcomes. Findings - The results indicated four distinct clusters named boundary-fit family guardians, work warriors, boundary-fit fusion lovers and dividers consistent (with previous) research. These clusters also differ across at least two major outcomes like boundary management tactics and positive spillover. The high control cluster profiles like Cluster 3 (boundary-fit fusion lovers) and Cluster 4 (dividers) showed low technostress and higher use of boundary management tactics. Cluster 3 (boundary-fit fusion lovers) and Cluster 1 (boundary-fit family guardians) having high environmental influencers also showed higher positive family-to-work spillover. Research limitations/implications - Because this study is very specific to the Indian context, a broad generalization requires further exploration in other cultural contexts. The absence of this exploration is one of the limitations of this study. On the culture continuum, countries may vary from being individualistic on one extreme to being collectivistic on the other extreme. Interaction of these two cultural extremities with the individual and the environmental dimension, as espoused in this research, can be examined further in a different cultural setting. Originality/value - This study has extended the work of Ammons (2013) and added external influencers as a dimension to the individual preferences given by (Kossek 2016), and created the cluster for employees in the Indian context. This study has demonstrated the importance of reduced technostress, and the use of boundary management tactics (temporal and behavioral) leads to positive family-to-work spillover. It has also emphasized the relevance of organization policies and supervisor support for better outcomes in WFH.
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Introduction: Outcomes and characteristics of patients with severe aortic stenosis (AS) treated during the COVID-19 pandemic is unknown. Methods: This was a single-centre observational study of patients undergoing AS treatment with transcatheter (TAVI) or surgical (SAVR) therapy during the first-wave of the UK COVID-19 pandemic compared to a control cohort undergoing treatment in 2019. Demographics, baseline echocardiogram, CT, procedural characteristics and outcome data were collated. The primary outcome was 30-day allcause mortality. The secondary endpoint was duration of post-procedural hospitalisation. Results: 319 patients were recruited - 122 underwent intervention during the pandemic [73 TAVI;49 SAVR] and 197 in 2019 [127 TAVI;70 SAVR]. In 2020, TAVI patients had a higher Euroscore II (p<0.001) but there were no differences in procedural complications or mortality [p=0.16] compared to TAVI 2019 cases. Duration from TAVI to discharge was shorter in 2020 (p<0.001). SAVR 2020 patients had similar baseline profile [p=0.48], surgical characteristics, mortality (p=0.68) and duration from SAVR to discharge compared to those in 2019. During the pandemic, TAVI patients were older (p<0.001) and had a higher Euroscore II (p<0.001) than SAVR counterparts. TAVI patients had reduced 30-day mortality [0 (0%) vs 3 (6%);p=0.06] and were discharged more rapidly post-intervention than SAVR patients [median 1 [1] vs 7 [4] days;p<0.001) translating into shorter hospitalization (p<0.001). Conclusions: TAVI and SAVR can be safely delivered with predictable resource utilisation during a pandemic. Despite the TAVI cohort incorporating higher risk, older patients, outcomes were at least as good as SAVR with a shorter length of post-procedural hospitalisation.