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Telemedicine is a modality which utilizes technology to provide and support health care across large distances. It has redefined the practices of medicine in many specialties and continues to be a boon for clinicians on many frontiers. Its role in the branch of anesthesia remains largely unexplored but has shown to be beneficial in all the three phases: pre-operative, intra-operative, and post-operative. Now time has come that anesthesiologists across the globe reassess their strategies and utilize the telemedicine facilities in the field of anesthesia.Copyright © 2021 EDP Sciences. All rights reserved.
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Background: The indications for Long Term Ventilation (LTV) are expanding. Pneumonia is common in these patients and transmission of bacterial infections, and more recently COVID-19 infection, between users of ventilators is a concern. UK national standards recommend bacterial/viral filters for use with acute Non-Invasive Ventilation (NIV) to protect the ventilator from contamination. However, there are no recommendations made for LTV. UK National guidance also explicitly states that there is no airflow from the patient to the ventilator.1 Aims and objectives: To investigate whether exhaled gas reaches the ventilator outlet. Method(s): We conducted experiments on three ventilators with different circuits during NIV delivered to a member of the study team using standard clinical settings. We used a side-stream end tidal CO2 (EtCO2) analyser attached to the tubing adjacent to the ventilator outlet as shown in the figure. Result(s): Regardless of ventilator and circuit used we demonstrated that exhaled gas reaches the ventilator outlet during NIV. EtCO2 values were 1.6-3.7kPa. Conclusion(s): Exhaled gas reaches the ventilator outlet during NIV. This raises an urgent requirement within the LTV community to test ventilators for bacterial and viral colonisation, consider the use of bacterial/viral filters, and discuss routine decontamination of these devices between individual patient uses. (Figure Presented).
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SESSION TITLE: COVID-19 Case Report Posters 2 SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Malignant hyperthermia (MH) is a hypermetabolic crisis where an increase in carbon dioxide is seen despite an increased minute ventilation with a proposed mechanism as a disturbance in calcium homeostasis. Commonly seen in volatile anesthetic agents and depolarizing neuromuscular blockers, rarely with nondepolarizing agents. There has been one reported case of cisatracurium-induced MH in the setting of ARDS. There have been two cases reported of nondepolarizing neuromuscular agents causing MH in the setting of COVID-19. CASE PRESENTATION: A 34-year-old man with severe COVID-19 complicated by ARDS on ventilator day 16, due to refractory fevers, ventilatory dyssynchrony, high minute ventilation and auto-PEEP phenomena, the decision was made to attempt neuromuscular paralysis. After one dose of cisatracurium, the patient became hyperthermic and end-tidal carbon-dioxide increased from 58-98 with inability to oxygenate. The patient developed high peak pressures, bedside ultrasound revealed no evidence of pneumothorax also confirmed with chest x-ray. The patient then received a dose of dantrolene with end-tidal improving to 60 and tachycardia also resolved. A creatinine kinase level drawn was elevated at 571. DISCUSSION: A proposed mechanism of MH is calcium release from sarcoplasmic reticulum, a mutation in skeletal muscle ryanodine receptor calcium release channels that can release IL-6 when activated leading to excessive muscular contraction. Proinflammatory cytokine IL-6, dantrolene may block IL-6 release which results in its therapeutic effect in the treatment of MH. IL-6 has been used to predict deterioration from COVID-19. Dantrolene in this sense has been proposed as a potential therapeutic agent against COVID-19, inhibiting intracellular calcium influx thus preventing the pathological feedback of viral entry into cells via endocytosis, as this is a calcium dependent process. Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of MH, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. CONCLUSIONS: Given the possible link between IL-6 release, calcium and MH, SARS-CoV-2 viral entry into cells may place patients at higher risk of MH. Patients with COVID-19 may be at higher risk of malignant hyperthermia, even in rare agents such as non-depolarizing agents as seen in this case. Awareness of this potentially increased complication from these agents in those patients with COVID-19 is key as we continue in the ongoing global pandemic. Reference #1: Sathyanarayanan SP, Hamza M, Hamid K, Groskreutz D. Cisatracurium-Associated Malignant Hyperthermia During Severe Sars-CoV-2 Infection. Am J Ther. 2021 Aug 10;28(5):e590-e591. doi: 10.1097/MJT.0000000000001437. PMID: 34387563;PMCID: PMC8415506. Reference #2: Chiba N, Matsuzaki M, Mawatari T, Mizuochi M, Sakurai A, Kinoshita K. Beneficial effects of dantrolene in the treatment of rhabdomyolysis as a potential late complication associated with COVID-19: a case report. Eur J Med Res. 2021 Feb 8;26(1):18. doi: 10.1186/s40001-021-00489-8. PMID: 33557936;PMCID: PMC7868892. Reference #3: Han H, Ma Q, Li C, Liu R, Zhao L, Wang W, Zhang P, Liu X, Gao G, Liu F, Jiang Y, Cheng X, Zhu C, Xia Y. Profiling serum cytokines in COVID-19 patients reveals IL-6 and IL-10 are disease severity predictors. Emerg Microbes Infect. 2020 Dec;9(1):1123-1130. doi: 10.1080/22221751.2020.1770129. PMID: 32475230;PMCID: PMC7473317. DISCLOSURES: No relevant relationships by Hira Bakhtiar No relevant relationships by Timothy DAmico no disclosure on file for Sarah Margolskee;No relevant relationships by Carlos Merino No relevant relationships by Joanna Moore
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Introduction: Rapid sequence induction requires quick and single attempt intubation to secure airway without any untoward complications. As the number of attempts increase, risk of desaturation and aspiration increase which is potentially life threatening. In such circumstances, miscalculation may cost loss of time which may prove fatal. Various adjuncts and techniques have been devised to prevent such calamities. Aim: To compare ease of intubation with angulated stylet versus distally preloaded bougie for rapid sequence intubation in elective general anaesthesia procedures. Materials and Methods: This randomised trial was conducted in 100 patients belonging to 18-60 years of age from November 2019 to October 2020. Patients were intubated using rapid sequence including cricoid pressure by either styletted endotracheal tube (Group S) or distally preloaded bougie (Group B), for surgeries performed under general anaesthesia. The primary outcome was to determine mean time to intubation (TTI) and number of attempts, while secondary outcomes were haemodynamic responses to intubation and complications. Data comparison between independent groups in this normally distributed data was done using student -t test while intragroup analysis was done using chi-square test. Results: A total of hundred patients were randomized into two groups- group S (mean age: 41.12 years) and group B (mean age: 37.34 years), of 50 patients each. Number of intubation attempts with stylet were single in 82%, two in 18% cases while with preloaded bougie, it was 80% and 14%, respectively (p-value=0.196). Time to intubation was 22.16 seconds (group S) versus 33.78 seconds (group B) (p-value <0.05). The haemodynamic assessments revealed that tachycardia, hypertension and increased End tidal carbon dioxide (EtCO2) was seen for 10 minutes immediately post induction in both the groups, though the intergroup difference was non significant. The incidence of sore throat was higher with stylet than bougie, though non-significant (p-value=0.118). Conclusion: Stylet should be preferred for ease of intubation in rapid sequence inductions. However, the insertion and removal of stylet must be done cautiously to prevent postoperative sore throat.
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INTRODUCTION/HYPOTHESIS: As the world braces itself against new variants of SARS-CoV-2, less resource-rich facilities must consider what to do when the surge of critically ill COVID-19 patients requiring mechanical ventilation outnumbers the supply of ventilators. One solution is multiplex ventilation, where a single ventilator supports two patients. Previously proposed scenarios sacrifice volume control for pressure control in the name of safety. However, volume control ventilation, low tidal volumes, high positive endexpiratory pressure (PEEP) and high respiratory rate are key for Acute Respiratory Distress Syndrome (ARDS) ventilator management. We offer a proof of concept for an accessible multiplex ventilation model with volume protective settings. METHODS: Using one parent ventilator, two daughter circuits were improved with a 3D-printed splitter fitted with laser-cut mechanical flowmeters. Resistance valves connected to each flowmeter outflow port attach to the inspiratory limb of the daughter circuit. At the patient wye, a Luer lock attaches a dry arterial line transducer and an end-tidal CO2 monitor. A one-way check valve connects each daughter circuit expiratory limb to a T-piece at the expiratory port of the ventilator. Test lungs were used to assess whether lung-protective settings can be maintained and adjusted by measuring plateau and driving pressures with varying lung compliance. RESULTS: The improved sub-circuit flowmeters and valves allowed monitoring and manipulation of flow to correct tidal volume shifts with changes in patient lung compliance. Dry arterial line transducers reliably measured peak pressure, PEEP, stress index and plateau pressure on a GE monitor. One-way valves prevented expiratory gas rebreathing by the more compliant lungs. CONCLUSIONS: We concede that two patients on one ventilator is not a good idea, but as the COVID-19 pandemic rages on, resource-poor facilities will run out of good ideas quickly. With our solution, volume control ventilation can be employed, pressures measured, alarms set, and volumes calculated and adjusted for each patient. In the spirit of Roosevelt's call to “do what you can, with what you've got, where you are”, we submit that this is a relatively low-tech, inexpensive model that allows ARDS settings with just a few simple parts, anywhere in the world.