Impact of improving infection control and antibiotic stewardship practices on nosocomial infections and antimicrobial resistance in an oncology centre from India

Background: Improving basic infection control (IC) practices, diagnostics and anti-microbial stewardship (AMS) are key tools to handle antimicrobial resistance (AMR). Material(s) and Method(s): This is a retrospective study done over 6 years (2016-2021) in an oncology centre in North India with many on-going interventions to improve IC practices, diagnostics and AMS. This study looked into AMR patterns from clinical isolates, rates of hospital acquired infections (HAI) and clinical outcomes. Result(s): Over all, 98,915 samples were sent for culture from 158,191 admitted patients. Most commonly isolated organism was E. coli (n = 6951;30.1%) followed by Klebsiella pneumoniae (n = 5801;25.1%) and Pseudomonas aeroginosa (n = 3041;13.1%). VRE (Vancomycin resistant Enterococcus) rates fell down from 43.5% in Jan-June 2016 to 12.2% in July-Dec 2021, same was seen in CR (carbapenem resistant) Pseudomonas (23.0%-20.6%, CR Acinetobacter (66.6%-17.02%) and CR E. coli (21.6%-19.4%) over the same study period. Rate of isolation of Candida spp. from non-sterile sites also showed reduction (1.68 per 100 patients to 0.65 per 100 patients). Incidence of health care associated infections also fell from 2.3 to 1.19 per 1000 line days for CLABSI, 2.28 to 1.88 per 1000 catheter days for CAUTI. There was no change in overall mortality rates across the study period. Conclusion(s): This study emphasizes the point that improving compliance to standard IC recommendations and improving diagnostics can help in reducing the burden of antimicrobial resistance.Copyright © 2023 Indian Association of Medical Microbiologists

Tracheoesophageal Fistula Presenting With Gastrostomy Tube Pressurization

Introduction: Patients with COVID pneumonia who require intubation and prolonged mechanical ventilation are at risk for complications such as recurrent infection, tracheomalacia, tracheal stenosis, and the development of tracheoesophageal fistula (TEF). TEF is a devastating complication where the trachea and esophagus develop an abnormal connection in the lower airway that dramatically increases the mortality of critically ill patients by recurrent aspiration and pneumonias. Though commonly associated with neoplasms another risk is pressure induced ischemia of the common wall between the trachea and esophagus. This can occur due to overinflation of the endotracheal (ET) cuff, especially with concomitant use of a nasogastric tube (NGT). Definitive management requires surgical repair. Case Description/Methods: A 69-year-old male patient presented with acute hypoxemic respiratory failure secondary to COVID pneumonia requiring intubation and insertion of an NGT. On day 29 the patient underwent percutaneous enterogastrostomy (PEG) placement and tracheostomy;it was noted intraoperatively that the tracheal mucosa was inflamed and friable. On day 36 bronchoscopy was performed through the tracheostomy tube due to concerns for mucus plugging. Friable mucosa with granulation tissue was seen at the distal end of the tube, so an extra-long tracheostomy tube was exchanged to bypass the granulation tissue. Later that night the ventilator measured a 50% discrepancy between the delivered and exhaled tidal volumes, triggering an alarm. Exam noted distension of the PEG-bag with a fluid meniscus in the tubing moving in sync with each respiration. TEF was considered and bronchoscopic evaluation confirmed a 1-centimeter TEF. The patient underwent successful TEF repair and is slowly recovering (Figure). Discussion(s): Critically ill patients who require prolonged support are at high risk of complications and device related injury. With each device-day there is an increased risk of complications, such as infection, dislodgement, and pressure-related injuries. This case highlights the importance of serial physical examinations as well as understanding possible device related complications. An unexpected finding, such as a persistent air leak, air in a PEG bag, or a fluctuating meniscus should raise suspicion for the development of a serious complication and would warrant prompt confirmatory testing. Our literature review revealed no reports of a PEG tube abnormalities as a presenting finding for TEF.

2022 CAS Virtual Annual Meeting

The proceedings contain 63 papers. The topics discussed include: a retrospective study to optimize post-anesthetic recovery time after ambulatory lower limb orthopedic procedures at a tertiary care hospital in Canada;a virtual airway evaluation as good as the real thing?;airway management during in hospital cardiac arrest by a consultant led airway management team during the COVID-19 pandemic: a prospective and retrospective quality assurance project;prevention of cautery induced airway fire using saline filled endotracheal tube cuffs: a study in a trachea airway fire model;smart phone assisted retrograde illumination versus conventional laryngoscope illumination for orotracheal intubation: a prospective comparative trial;time to single lung isolation in massive pulmonary hemorrhage simulation using a novel bronchial blocker and traditional techniques;cannabinoid type 2 receptor activation ameliorates acute lung injury induced systemic inflammation;bleeding in patients with end-stage liver disease undergoing liver transplantation and fibrinogen level: a cohort study;endovascular Vena Cavae occlusion in right anterior mini-thoracoscopic approach for tricuspid valve in patients with previous cardiac surgery;and mesenchymal stem cell extracellular vesicles as a novel, regenerative nanotherapeutic for myocardial infarction: a preclinical systematic review.

Optimal Tracheostomy Timing Through Modeling Based on Severity of Vocal Cord Injury.

BACKGROUND: Endotracheal intubation is a routinely performed procedure in the ICU. Whereas it is recognized that endotracheal intubation can result in laryngeal and tracheal injury, this study evaluated factors that may affect the incidence of posterior vocal cord ulcers (PVCUs). METHODS: One thousand three hundred fifty-five patients were retrospectively screened from 2002-2018 that received a tracheostomy with routine bronchoscopy at a single institution. Post tracheostomy operative notes were reviewed and included only if proper visualization of the vocal cords was documented. Primary outcome measures included presence of PVCU, length of time on a ventilator until a tracheostomy, hospital length of stay, and mortality. Stratification of the data focused on the severity of the ulcer (mild, moderate, and severe) and was analyzed using analysis of variance, multivariate analysis, and Kaplan-Meier modeling of PVCU incidence over time. RESULTS: We enrolled 192 subjects with documentation of vocal cord visualization. Thirty-nine subjects did not have a PVCU, whereas 153 subjects did. A median duration of 9 (interquartile range [IQR] 5-13) d was associated with developing a mild PVCU, whereas individuals intubated for a median of 6 (IQR 4-7) d were ulcer free. Statistical difference between length of time on a ventilator before tracheostomy and the severity of the PVCU seen was significant (P < .001). The Kaplan-Meier model showed that beyond 2 weeks of endotracheal intubation subjects will have > 80% chance of developing a moderate vocal cord ulcer. Whereas by day 7, there is only a 20% chance of developing a moderate ulcer. CONCLUSIONS: Earlier tracheostomy placement was associated with reduced severity of vocal cord ulcer formation. The Kaplan-Meier model suggests that waiting for 14 d is likely too long and earlier placement of a tracheostomy, within a week, may decrease the morbidity of posterior vocal cord injury.

Clinical Features and Risk Factors for Mortality in Patients with Stenotrophomonas maltophilia Infection

Introduction: It is important to know the risk factors for death in reducing mortality in patients with Stenotrophomonas maltophilia infections. The purpose of this study was to examine the risk factors associated with mortality in hospitalized patients with S. maltophilia infections. Material(s) and Method(s): Patients with S. maltophilia infections aged 18 years and older who were hospitalized in Haseki Research and Training between January 1, 2017, and April 30, 2022, were included in the study. The patients were divided into two groups, non-survivors and survivors, and the clinical features and laboratory parameters of the groups were compared. Mortality risk factors were analyzed by logistic and Cox regression analyses. Result(s): A total of 75 patients with S. maltophilia infections were included. The mortality rate was 38.6% (n= 29). Advanced age (OR= 1.05, 95% CI= 1.012-1.085, p= 0.009), COVID-19 pneumonia (OR= 9.52, 95% CI= 1.255-72.223, p= 0.029), and presence of central venous catheter (CVC) (OR= 18.25, 95% CI= 2.187-152.323, p= 0.007) were risk factors for death. Conclusion(s): Physicians should be aware of the potential risk of S. maltophilia infections for mortality, particularly in patients with predefined risk factors such as advanced age, the presence of CVC, and COVID-19. Performing CVC care in accordance with infection prevention and control measures and timely removal of CVC may be beneficial in reducing deaths due to S. maltophilia infection.Copyright © 2023 Bilimsel Tip Yayinevi. All rights reserved.

Anesthetic management of toxic epidermal necrolysis: a report of two cases

Toxic epidermal necrolysis (TEN), is an acute, life-threatening emergent disease involving the skin and mucous membranes with serious systemic complications. It is characterized by widespread epidermal sloughing. Drugs are the most common triggers of TEN, but infection, vaccination, radiation therapy and malignant neoplasms can all induce it in susceptible patients. We report two cases in whom a hair dye and a COVID-19 vaccine (BioNTech, Pfizer) were believed to be the causative agents. These patients have to undergo repeated debridements of the necrotic tissue. In this manuscript the anesthetic management of TEN patients is discussed. Detailed preoperative evaluation, aggressive fluid and electrolyte replacement, avoidance of hypothermia during debridement, minimizing anesthetic agents and limiting traumatic procedures are key points in the management.Copyright © 2023 Faculty of Anaesthesia, Pain and Intensive Care, AFMS. All rights reserved.

Biogenic nanosilver-fabricated endotracheal tube to prevent microbial colonization in a veterinary hospital.

COVID-19 patients have often required prolonged endotracheal intubation, increasing the risk of developing ventilator-associated pneumonia (VAP). A preventive strategy is proposed based on an endotracheal tube (ETT) modified by the in situ deposition of eucalyptus-mediated synthesized silver nanoparticles (AgNPs). The surfaces of the modified ETT were embedded with AgNPs of approximately 28 nm and presented a nanoscale roughness. Energy dispersive X-ray spectroscopy confirmed the presence of silver on and inside the coated ETT, which exhibited excellent antimicrobial activity against Gram-positive and Gram-negative bacteria, and fungi, including multidrug-resistant clinical isolates. Inhibition of planktonic growth and microbial adhesion ranged from 99 to 99.999% without cytotoxic effects on mammalian cells. Kinetic studies showed that microbial adhesion to the coated surface was inhibited within 2 h. Cell viability in biofilms supplemented with human tracheal mucus was reduced by up to 95%. In a porcine VAP model, the AgNPs-coated ETT prevented adhesion of Pseudomonas aeruginosa and completely inhibited bacterial invasion of lung tissue. The potential antimicrobial efficacy and safety of the coated ETT were established in a randomized control trial involving 47 veterinary patients. The microbial burden was significantly lower on the surface of the AgNPs-coated ETT than on the uncoated ETT (p < 0.05). KEY POINTS: • Endotracheal tube surfaces were modified by coating with green-synthesized AgNPs • P. aeruginosa burden of endotracheal tube and lung was reduced in a porcine model • Effective antimicrobial activity and safety was demonstrated in a clinical trial.

Effect Of Different MAC Values On Bispectral Index In Isoflurane Anaesthesia

Introduction: The bispectral index monitors the unawareness component of balanced anaesthesia and gives us the depth of Anesthesia.It reflects the response of the brain to a variety of hypnotic and inhaled anaesthesia agents. The aim of this study was to see the effect of different MAC values of isoflurane on the bispectral index and hemodynamic variations at different MAC values. Material(s) and Method(s): This prospective study was conducted on 20 patients at tertiary care center for 6 months. After induction of Anesthesia, following parameters were recorded: noninvasive blood pressure measurement, heart rate, oxygen saturation, ETCo2 and BIS values. The BIS was continuously monitored and when the MAC values of isoflurane were 0.5, 0.7, 1, 1.2 and 1.5 corresponding BIS values and all the other haemodynamic parameters were noted. Result(s): In 11 patients out of 20 patients satisfactory BIS of 40-60 was achieved at MAC 0.5. In 16 out of 20 patients satisfactory BIS 40-60 was achieved at 0.7 MAC. In all the 20 patients satisfactory BIS was achieved at 1 MAC.In 2 out of 20 patients we couldn't proceed beyond 1.0 MAC because of the fall in MAP to <65mm of Hg. In 4 out of 20 patients we couldn't proceed beyond 1.2MAC because of the fall in MAP to <65mm of Hg. Conclusion(s): Isoflurane produced satisfactory BIS of 40-60 in 16 patients at 0.7 MAC and in all the 20 patients at 1 MAC.Use of BIS in our study helped in better titration of Isoflurane according to patient's individual needs thereby we avoided light plane of anaesthesia or deep hypnosis and the adverse effects associated with it. Copyright © 2022 Wolters Kluwer Medknow Publications. All rights reserved.

The Effects of Endotracheal Tube Size During Bronchoscopy in Simulated Models of Intubated Patients.

OBJECTIVE: The aim is to use a simulation lung model to assess the possibility of performing bronchoscopy through endotracheal tubes (ETT) less than 8.0-mm while appropriately ventilating patients with normal and ARDS lungs in the setting of SARS-CoV-2. METHODS: Five SHERIDAN® ETTs were used to ventilate SimMan® 3G under respiratory compliance levels representing normal and severe ARDS lungs. Baseline measurements of peak pressure, plateau pressure, and auto-positive end expiratory pressure (auto-PEEP) were recorded at four different inspiratory times (Ti). Three different-sized disposable bronchoscopes were inserted, and all measurements were repeated. RESULTS: Normal lung model: Slim bronchoscopes in 6.0-mm ETTs resulted in plateau pressures <30 cm H2 O, and increasing Ti to minimize peak pressure resulted in low auto-PEEP. Regular bronchoscopes in 7.0-mm ETTs had similar results. Large bronchoscopes in 7.5-mm ETTs generated plateau pressures ranging from 28 to 35 cm H2 O with modest auto-PEEP. Severe ARDS lung model: Slim bronchoscopes in 6.0-mm ETTs resulted in plateau pressures of 46 and an auto-PEEP of 5 cm H2 O. Regular bronchoscopes in 7.0-mm ETTs generated similar results. Large bronchoscopes in 8.0-mm ETTs displayed plateau pressures of 44 and an auto-PEEP of 2 cm H2 O. CONCLUSION: To mitigate risk of laryngeal injury, larger ETTs during bronchoscopy should be avoided. Our data show bronchoscopy with any ETT causes auto-PEEP and high plateau pressures, especially in lungs with poor compliance; however, ETT less than 7.5 mm can be used when considering several factors. Our data also suggest similar studies in patients with varying degrees of ARDS would be informative. LEVEL OF EVIDENCE: NA Laryngoscope, 2022.

Pulmonary Hemorrhage Due to Granulomatosis with Polyangiitis in a Pediatric Patient

INTRODUCTION: Granulomatosis with polyangiitis (GPA) is a rare rheumatologic disease in pediatric patients but with a similar presentation and organ involvement as an adult patient. We present a case of a patient with pulmonary hemorrhage due to GPA who was managed without extracorporeal life support. DESCRIPTION: A 14 year-old female with no medical history presented with migratory polyarthritis, sore throat, chest tightness, fatigue, and positive rheumatoid factor. Found to be hypoxic on presentation. Her respiratory failure progressed, requiring intubation and inhaled nitric oxide, with minimal improvement. A chest CT showed nonspecific bilateral multifocal, patchy airspace opacification. Her C-ANCA and proteinase 3 antibody were positive, making GPA the most likely diagnosis for which she was started on methylprednisolone and rituximab. Her hypoxemia continued to worsen despite maximal mechanical ventilator support and neuromuscular blockade infusion. She had bloody secretions from her endotracheal tube, concerning for pulmonary hemorrhage, despite high positive end-expiratory pressure. A chest radiograph at that time was consistent with worsening bilateral infiltrates. Echocardiogram showed normal biventricular function, pulmonary hypertension, and a 1.8 cm by 1.5 cm thrombus at the cavoatrial junction. A multidisciplinary team determined that the location of the clot precluded placement of ECMO cannulas without risking clot mobilization. Plasmapheresis was emergently initiated followed by further rituximab and cyclophosphamide. Her respiratory status stabilized after being placed in the prone position. She was ultimately discharged home after a prolonged period of intubation and hospitalization, on a steroid taper, oral anticoagulation for her cavoatrial thrombus, and maintenance rituximab therapy. DISCUSSION: This case highlights a rare case of GPA with multiorgan involvement in a pediatric patient resulting in refractory hypoxemia treated with aggressive rheumatologic therapy and proning. There is limited evidence for the efficacy of plasmapheresis in patients with GPA, although this patient may have benefited from it since she was not safe for extracorporeal life support. Furthermore, as highlighted through the COVID-19 pandemic, proning proved crucial in managing her severe hypoxemia.

Effect of head position changes on the depth of tracheal intubation in pediatric patients: A prospective, observational study.

Purpose: The purpose of this study was to investigate the effect of changing head position on the endotracheal tube (ETT) depth and to assess the risk of inadvertent extubation and bronchial intubation in pediatric patients. Methods: Subjects aged 4-12 years old with orotracheal intubation undergoing elective surgeries were enrolled. After induction, the distances between "the ETT tip and the trachea carina" (T-C) were measured using a Disposcope flexible endoscope in head neutral position, 45° extension and flexion, 60° right and left rotation. The distance of the ETT tip movement relative to the neutral position (ΔT-C) was calculated after changing the head positions. The direction of the ETT tip displacement and the adverse events including endobronchial intubation, accidental tracheal extubation, hoarseness and sore throat were recorded. Results: The ETT tip moved toward the carina by 0.5 ± 0.4 cm (P < 0.001) when the head was flexed. After extending the head, the ETT tip moved toward the vocal cord by 0.9 ± 0.4 cm (P < 0.001). Right rotation resulted that the ETT tip moved toward the vocal cord direction by 0.6 ± 0.4 cm (P < 0.001). Moreover, there was no displacement with the head on left rotation (P = 0.126). Subjects with the reinforced ETT had less ETT displacement after changing head position than the taper guard ETT. Conclusion: The changes of head position can influence the depth of the ETT especially in head extension. We recommend using the reinforced ETT to reduce the ETT displacement in pediatrics to avoid intubation complications. Clinical trial registration: [www.ClinicalTrials.gov], identifier, [ChiCTR2100042648].

Severe Pulmonary Hemorrhage in a 3 Weeks Old Neonate with Covid-19 Infection

Aims To describe a case of 3 weeks old neonate presenting with severe pulmonary hemorrhage due to COVID-19 infection and its outcome. Methods We report an interesting case of pulmonary hemorrhage presenting at a young age of 3 weeks, in a previously healthy neonate who was infected with COVID-19 virus;Literature review and investigation results are included. This is a 3-week-old female, a product of full-term pregnancy and an uneventful perinatal course. She was admitted from the emergency department initially as a case of late neonatal sepsis, where a full septic workup was done. Her presenting complaints were low-grade fever and a blocked nose for one day. She was hemodynamically stable in the emergency department except for tachycardia secondary to fever, which improved once the fever was controlled. Her initial blood workup, including blood gas and CSF study, was reassuring (table 1a). Her COVID PCR was positive with a CT value of 17.77. She was treated with IV antibiotics and supportive management. Later that day, the patient developed cardiopulmonary arrest, CPR was initiated, and the patient was intubated. The patient was found to have pulmonary hemorrhage as evident by the fresh blood coming out of the endotracheal tube and the chest X-Ray findings of ground-glass opacities and dense consolidation (figure 1). After initial brief stabilization, the patient started deteriorating requiring escalation of respiratory support to HFOV. The patient continued to deteriorate and developed bilateral pneumothorax requiring bilateral chest tube insertion. After chest tube insertion, there was a mild transient improvement in oxygenation. The patient was put on the maximum ventilatory settings, but she kept having frequent desaturation, requiring frequent manual bag to tube ventilation. Later, she started developing progressive hypotension, that required support with maximum doses of inotropes. Her urine output started decreasing, for which frusemide were started with no response. Blood investigations showed severe DIC picture (table 1b and 1c). She was empirically covered with Meropenem and Vancomycin along with Remdesivir and Dexamethasone for COVID 19 pneumonia. Eventually, the child developed progressive desaturation, hypotension, and poor perfusion. Shortly after that, she developed cardiac arrest and was declared dead. Results The clinical picture of COVID 19 infection is more indistinct in children than in adults, with the most common symptoms being fever, cough, dyspnea, and malaise. In the few published cases of COVID-19 in the neonate, the presentation was that of late neonatal sepsis;interestingly, the lung involvement was not described as frequently as in older age groups. Pulmonary hemorrhage has been reported in adults but rarely in children. Some reports in adults suggested that patients with COVID infection had an increased inflammatory state that led to the development of vasculitis and pulmonary hemorrhage. Up to our knowledge, this is the youngest age at which a patient with COVID-19 infection developed pulmonary hemorrhage with no other underlying cause of it. Conclusion While many of the cases of COVID infection in children are mild, fatal complications like pulmonary hemorrhage can be present. Adding new challenges to the management of this viral infection.

Anesthetic Considerations for Chiari I Malformation in a BMI 62 Patient

Patients with Chiari I malformations present with tonsillar herniation below the foramen magnum causing abnormal spinal anatomy. Anesthesia challenges in this population include difficult airway management, monitoring intraoperative autonomic dysfunction, avoiding increased intracranial pressure, and accommodating sensitivity to neuromuscular blockade. We present a case with an additional airway management challenge due to morbid obesity with a BMI of 62. A 23 year old female with a history of Covid pneumonia and morbid obesity who presented with syringomyelia and Chiari I malformation. She initially presented with bilateral numbness, tingling, weakness, and pain in her hands. Imaging with MRI at the time showed downward displacement of the cerebellar tonsils with the tips reaching the lower portion of C1 and overall 10-12 mm displacement below the level of the foramen magnum. Syrinx was also visualized from the level of C1-C2 extending down to the level of T5-T6. Repeat MRI a year later showed no significant changes. However, she has worsening symptoms of pain in her right arm preventing her from working. She is agreeable to surgical decompression of the posterior fossa through a suboccipital craniotomy with resection of the posterior arch of C1 with duraplasty. Significant findings on the physical exam include Mallampati III, shorter thyromental distance, and limited range of motion of her cervical spine due to pain in her arms. We chose awake fiberoptic intubation due to difficult airway from morbid obesity and limited cervical spine range of motion and the consideration of hypercapnia induced from brief apnea the patient may not tolerate. She was premedicated with versed, glycopyrrolate, and dexmedetomidine, and given a 5% lidocaine paste lollipop to topicalize oropharynx. She was also started on a low dose remifentanil infusion for sedation during the awake fiberoptic approach. Blood pressure, heart rate, respiratory rate with continuous end-tidal capnography, and pulse oximetry were monitored during the awake fiberoptic intubation. A 7.0 endotracheal tube was lubricated with viscous lidocaine and placed over a fiberoptic scope. Once there was visualization of the vocal cords, additional 2% lidocaine was administered directly at the vocal cords. She was intubated smoothly on the first attempt. She was then immediately induced to general anesthesia with propofol and non-depolarizing muscle relaxant to avoid using succinylcholine due to the possible hypersensitivity caused by denervation. Intraoperatively, a conventional air warmer was used to prevent hypothermia. Invasive arterial blood pressure monitoring was applied. Normotensive blood pressure and normocapnia were maintained throughout the surgery. Muscular blockade was reversed with sugammadex at the end of surgery to ensure adequate ventilation especially with the patient's body habitus. Upon extubation, the patient had acute hypertension which was managed by nicardipine infusion and hydralazine boluses. Patient was taken to a neurosurgical intensive unit and monitored for two days. She was discharged home without any complication. In conclusion, anesthetic considerations for patients with Chiari I malformation include airway management, monitoring for autonomic dysfunction, avoiding increase in ICP, and optimizing postoperative neurological status with balanced anesthetic management.

"Tool-in-Lesion" Accuracy of Galaxy System: Robotic-Assisted, Electromagnetic Navigation Bronchoscopy with Integrated Tool-in-Lesion-Tomosynthesis Technology: The Match Study

SESSION TITLE: Late Breaking Procedures Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/18/2022 01:30 pm - 02:30 pm PURPOSE: The Galaxy SystemTM (Noah Medical, San Carlos, CA) is a novel robotic endoluminal platform using electromagnetic navigation combined with integrated tomosynthesis technology and augmented fluoroscopy. It provides intraprocedural imaging to correct CT-to-body divergence and novel confirmation of tool-in-lesion. The primary aim of this study was to assess the tool-in-lesion accuracy of the robotic bronchoscope with integrated digital tomosynthesis and augmented fluoroscopy. METHOD(S): Over four separate days, four operators (the authors) conducted the experiment using four pigs. Each physician performed between 4 and 6 nodule biopsies for 20 lung nodule biopsies. A porcine model (S. s. domesticus) was utilized. Each pig was anesthetized with volatile gas and underwent tracheostomy with an 8.5 endotracheal tube and bilateral chest tube thoracostomy. Anesthesia was monitored by a veterinarian with invasive hemodynamic monitoring. Under CT fluoroscopic guidance, simulated lung nodules were created by percutaneous injection of a gelatinous agar solution containing purple dye and radiopaque material into the lung periphery. A CT was then performed for pre-procedure planning. Using Galaxy's "Tool in Lesion TOMO+" with augmented fluoroscopy, the physician navigated to the lung nodules and a tool (needle) was placed into the lesion. Tool in lesion was defined by the needle in or tangential to the lesion determined by CBCT. Center strike was defined as the needle in the middle third in three orthogonal angles (axial, sagittal, and coronal) on CBCT. RESULT(S): Lung nodules' average size was 16.3+/-0.97 mm and were predominantly in the lower lobes (65%). Only 15% (3/20) had a bronchus sign and the average distance to the pleura was 6.88+/-5.5 mm. All four operators successfully navigated to all (100%) of the lesions in an average of 3 minutes and 39 seconds. The median number of tomosynthesis sweeps was 3 and augmented fluoroscopy was utilized in most cases (17/20 or 85%). Tool in lesion after final tomography sweep was 100% (20/20). Biopsy yielding purple pigmentation on microscopic or gross examination was also 100% (20/20). Center strike rate was 60%. CONCLUSION(S): The Galaxy SystemTM demonstrated successful digital tomography confirmed tool in lesion success in 100% (20/20) of lesions as confirmed by CBCT. Successful biopsy was achieved in 100% of lesions as confirmed by intralesional pigment acquisition. CLINICAL IMPLICATIONS: The combination of robotic navigation, catheter maneuverability and real-time correction for CT body divergence capitalizes on the strengths of all three technologies to improve diagnosis. Additional clinical trials are warranted to see if high success rates can be reproduced in patients. DISCLOSURES: Consultant relationship with Medtronic ILS Please note: $20001 - $100000 by Krish Bhadra, value=Consulting fee Consultant relationship with Veractye Please note: $1-$1000 by Krish Bhadra, value=Consulting fee Consultant relationship with Bodyvision Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Merit Endotek Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Boston Scientific Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Human Factor Testing relationship with Auris Surgical Robotics Please note: $1001 - $5000 by Krish Bhadra, value=Consulting fee Consultant relationship with Intuitive Surgical Robotics Please note: $5001 - $20000 by Krish Bhadra, value=Consulting fee Consultant relationship with Biodesix Please note: $5001 - $20000 by Krish Bhadra, value=Consulting fee Consultant relationship with Noah Medical Please note: 5/2020 Added 06/01/2022 by Krish Bhadra, value=Consulting fee Speaker relationship with Body Vision Please note: 2015 - present Added 05/29/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Magnisity Please note: 2021 - present Added 05/29/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Auris (J&J Ethicon) Please note: 2014-present Added 05/29/2022 by Douglas Hogarth, value=Honoraria Consultant relationship with Boston Scientific Please note: 2008 - present Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Medtronic Please note: 2010-2019 Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Broncus Please note: 2017-2021 Added 05/29/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with PulmonX Please note: $5001 - $20000 by Douglas Hogarth, value=Consulting fee Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Spiration Please note: $5001 - $20000 by Douglas Hogarth, value=Consulting fee Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Eolo Please note: $20001 - $100000 by Douglas Hogarth, value=Ownership interest Removed 06/08/2022 by Douglas Hogarth Consultant relationship with Noah Please note: 2019 - present Added 06/08/2022 by Douglas Hogarth, value=Ownership interest Consultant relationship with Noah Please note: 2019 - present Added 06/08/2022 by Douglas Hogarth, value=Consulting fee Consultant relationship with Medtronic Corporation Please note: $5001 - $20000 by Amit Mahajan, value=Consulting fee Consultant relationship with Boston Scientific Corporation Please note: $1001 - $5000 by Amit Mahajan, value=Consulting fee Consultant relationship with Pulmonx Corporation Please note: $5001 - $20000 by Amit Mahajan, value=Consulting fee Consultant relationship with Ambu USA Please note: $1-$1000 by Amit Mahajan, value=Consulting fee Consultant relationship with Circulogene Please note: $1001 - $5000 by Amit Mahajan, value=Consulting fee Consultant relationship with Medtronic/Covidien Please note: $1001 - $5000 by Otis Rickman, value=Consulting fee Copyright © 2022 American College of Chest Physicians

ROLE OF DEBULKING FOR BENIGN ENDOBRONCHIAL LESIONS: A CASE OF CHRONICALLY ASPIRATED FOREIGN BODY PRESENTING AS NECROTIZING PNEUMONIA

SESSION TITLE: Case Reports of Procedure Treatments Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Foreign body aspiration can affect ventilation-oxygenation dynamics causing significant morbidity and mortality in children and adults. Patient presentation can range from asymptomatic to life-threatening hypoxia. A thorough history and physical examination helps in narrowing differential diagnosis and provision of timely management. A myriad of complications can occur from aspirated Foreign body including recurrent pneumonia, lung abscess, obstructive emphysema, and death. Here we present a case of a patient with recurrent pneumonia from a chronically aspirated foreign body. CASE PRESENTATION: 37-year-old male with past medical history of a recent COVID-19 infection and bronchus intermedius endobronchial mass (squamous metaplasia on biopsy 2009) who presented with fever, chest pain, worsening dyspnea. Initial workup was consistent with severe sepsis. A CT chest showed complete collapse, cavitation in right lower lobe and presence of right bronchus stent. Patient was treated with IV fluids and antibiotics during the hospitalization. He underwent bronchoscopy for airway examination and bronchoalveolar lavage. Airway exam showed a large endobronchial mass in the bronchus intermedius. Endobronchial biopsies were taken, followed by tissue debulking using flexible forceps and cryoprobe. A yellow plastic foreign object was then visualized dislodged in the right lower lobe. This was successfully removed with grasping forceps. Patient had to be extubated and be reintubated to remove foreign object in one piece as it did not fit the endotracheal tube. Post debulking, bronchus intermedius and right lower lobe were patent and procedure was completed. Our patient responded well to treatment he was ultimately transitioned to oral antibiotics and discharged home with outpatient follow up. Repeat bronchoscopy 6 weeks later showed normal airways. DISCUSSION: Our case illustrated the importance of thorough investigation while treating patients with recurrent pneumonia, and this sometimes should include bronchoscopy with airway exam. In our case a bronchoscopy was done several years ago, however the foreign body was not identified as the cause of the endobronchial lesion. A lingering foreign body in the long run has significant morbidity as seen in our case despite appropriate treatment with antibiotics patient continued to have recurrent post obstructive pneumonias. Bronchoscopy remains the gold standard in definitive diagnosis and management of foreign body. Since the refinement of bronchoscopy and debulking, the rate of mortality from foreign body aspiration has been remarkably reduced. CONCLUSIONS: In summary patients with history suggestive of potential foreign body aspiration presenting with recurrent pneumonias at a particular anatomical location should prompt physicians to perform diagnostic bronchoscopy, which remains the gold standard for diagnosing of foreign body aspiration Reference #1: Foreign Body Aspiration Natan Cramer;Noel Jabbour;Melissa M. Tavarez;Roger S. Taylor. DISCLOSURES: No relevant relationships by Maria Abril No relevant relationships by Bilal Bangash No relevant relationships by Imran Tarrar

DON'T CUT THE NECK: A NOVEL OPTION FOR DEFINITIVE RESCUE AIRWAY

SESSION TITLE: Close Critical Care Calls SESSION TYPE: Case Reports PRESENTED ON: 10/18/2022 11:15 am - 12:15 pm INTRODUCTION: COVID-19 has resulted in many patients presenting in severe hypoxemic respiratory failure without the ability to achieve adequate oxygenation despite non-invasive positive pressure ventilation prior to attempting endotracheal intubation. Recently, the American Academy of Anesthesiology (AAOA) released an updated 2022 guideline addressing difficult airway management. Though evidence is limited, the use of a combination maneuvers with a supraglottic airway and lighted stylet yielded a greater than 75% intubation success rate after failed direct laryngoscopy [1]. The following case emphasizes a novel definitive airway rescue option for an anatomically and physiologically difficult airway, complicated by an inability to ventilate and oxygenate in the setting of severe hypoxemic respiratory failure. CASE PRESENTATION: The patient is a 58 year old, morbidly obese (BMI-58) female with severe COVID-19 pneumonia and severe refractory hypoxemia on Bi-Level non-invasive ventilation (inspiratory pressure 20, expiratory pressure 15, 100% fraction inspired oxygen) complicated by an acute complete opacification of the left hemi-thorax and right pneumothorax with oxygen saturation (SpO2) of 80%. Rapid sequence induction was attempted, however failed despite multiple maneuvers. Due to continued deterioration of the patient's oxygenation, a laryngeal mask airway (LMA) was placed with improvement of the patient's oxygen saturation. A single-use disposable bronchoscope was then placed through the LMA with successful navigation through the vocal cords and direct visualization of the tip within the right main-stem bronchus. Using trauma shears, the handle of the bronchoscope was cut away from the insertion tube. The LMA was then retracted (Fig. 1) and forceps were utilized to maintain position of the insertion tube (Fig. 2) during this maneuver. The video laryngoscope blade was then reinserted into the oropharynx for visualization of the insertion tube coursing through the vocal cords. Using the insertion tube from the single-use bronchoscope as a stylet, intubation was successfully accomplished by inserting a 7.5mm ETT over the insertion tube under direct visualization with the video laryngoscope (Fig. 3). DISCUSSION: Single use bronchoscope devices have been successfully used for planned awake intubations [2] as well as confirmation of endotracheal tube placement [3] after emergent intubation. The novel technique described above can be a useful measure to facilitate intubation under direct visualization in complicated airway scenarios without the need for a surgical airway. CONCLUSIONS: This technique offers a number of advantages to include direct visualization of the airway, navigational capability of bronchoscopy and confirmation of placement with video laryngoscopy. The combination of these techniques can be considered as an alternative prior to pursuing an invasive surgical option. Reference #1: Jeffrey L. Apfelbaum, Carin A. Hagberg, Richard T. Connis, Basem B. Abdelmalak, Madhulika Agarkar, Richard P. Dutton, John E. Fiadjoe, Robert Greif, P. Allan Klock, David Mercier, Sheila N. Myatra, Ellen P. O'Sullivan, William H. Rosenblatt, Massimiliano Sorbello, Avery Tung;2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway. Anesthesiology 2022;136:31–81 doi: https://doi.org/10.1097/ALN.0000000000004002 Reference #2: Kristensen MS, Fredensborg BB. The disposable Ambu aScope vs. a conventional flexible videoscope for awake intubation – a randomised study. Acta Anaesthesiol Scand. 2013 Aug;57(7):888-95. doi: 10.1111/aas.12094. Epub 2013 Mar 15. PMID: 23495767 Reference #3: Mitra A, Gave A, Coolahan K, Nguyen T. Confirmation of endotracheal tube placement using disposable fiberoptic bronchoscopy in the emergent setting. World J Emerg Med. 2019;10(4):210-214. doi: 10.5847/wjem.j.1920-8642.2019.04.003. PMID: 31534594;PMCID: PMC6732169 DISCLOSURES: No relevant r lationships by John Levasseur No relevant relationships by Lauren Sattler No relevant relationships by Tyson Sjulin

MACROGLOSSIA IN THE SETTING OF COVID-19

SESSION TITLE: COVID-19 Case Report Posters 1 SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Macroglossia is a rare but life-threatening symptom that disrupts a person's ability to talk, swallow, and can also compromise their airway. Although not very well studied, there are several case reports describing a possible association between COVID-19 infection and macroglossia in people with African ancestry. We present an African American man who developed significant macroglossia several days after testing positive for COVID-19. CASE PRESENTATION: A 59 y/o African American male with a history of chronic bronchitis and tobacco use presented with 4 days of dyspnea. Sars-Cov-2 PCR was positive. Chest x-ray revealed bilateral, diffuse lung infiltrates. He had an elevated CRP of 295 and a d-dimer of 265. He became lethargic and hypercapnic requiring intubation which was nontraumatic. He was sedated, paralyzed, and proned. He received steroid therapy, broad spectrum antibiotics and a dose of Sarilumab. About a week later, he developed macroglossia that worsened over the course of days. Side effect profiles of each of his medications did not reveal any increased likelihood of macroglossia. C1Q complement cascade was mildly elevated and C1 esterase inhibitor level was normal. Diagnosis and treatment was necessary at this point as concerns for tongue central necrosis were raised and baseline tongue size would be required for proper evaluation and surgical intervention if necessary. He was given 4 units of FFP for possible angioedema with no improvement. CT Neck W/ contrast revealed edema and protrusion of the tongue without a discrete mass. Workup for acromegaly, sarcoidosis, amyloidosis, and hypothyroidism were negative. A pressure ulcer developed on his tongue due to the endotracheal tube and so he underwent tracheostomy. His tongue was draped in Chlorhexidine soaked gauze as well as Vashe wound solution. As he recovered from COVID-19 pneumonia, his respiratory status improved as well as his macroglossia. His tracheostomy was decannulated and his tongue returned to its baseline size. DISCUSSION: Macroglossia can lead to complications including airway compromise, dysphagia, or speech difficulties. It has been heavily proposed in the literature that COVID-19 infection can lead to postinfectious inflammatory peripheral nerve injury secondary to immune driven mechanisms. It was also previously proposed in literature based on immune-histochemical analysis of a tongue tissue sample taken from a COVID-19 patient that tongue muscle atrophy occurs as well as macrophage infiltration similar to that of nerve injury repair which can eventually lead to macroglossia. CONCLUSIONS: As the effects of COVID-19 are becoming better studied overtime, macroglossia, especially in those with African ancestry, is increasingly coming under the radar. This case report seeks to educate clinicians on this possible sequela and encourage supportive treatment in hopes that the tongue will recover. Reference #1: McCrossan S, Martin S, Hill C. Tongue Reduction for Macroglossia. J Craniofac Surg. 2021;32(5):1856-1859. doi:10.1097/SCS.0000000000007276 Reference #2: Colombo D, Del Nonno F, Nardacci R, Falasca L. May macroglossia in COVID-19 be related not only to angioedema?. J Infect Public Health. 2022;15(1):112-115. doi:10.1016/j.jiph.2021.10.026 Reference #3: Fernandez CE, Franz CK, Ko JH, et al. Imaging Review of Peripheral Nerve Injuries in Patients with COVID-19. Radiology. 2020;298 (3). https://doi.org/10.1148/radiol.2020203116 DISCLOSURES: No relevant relationships by Megan Devine No relevant relationships by Devin Haney No relevant relationships by Es-Haq Hassanin No relevant relationships by Nadim Islam No relevant relationships by Alyssa Weyer

Conservative Management of Acquired Tracheo-Esophageal Fistula after Lithium Button Battery Ingestion

Introduction:Acquired tracheo-esophageal fistula (TEF) is a dreaded complication of lithium button battery (LBB) ingestion in the pediatric population. Traditionally acquired TEFs are managed with surgical interventions. Very few case reports have described successful closure of a TEF secondary to LBB with conservative management. There is no reported literature on the use fibrin glue or laser therapy to enhance closure. Here we describe successful conversative management of TEF secondary to LBB and for the first time, attempted trial of fibrin glue and argon laser therapy. Case presentation: 13-month-old female presented to the emergency department with a 3-day history of croupy cough. Neck X ray demonstrated a radio-opaque foreign body suggestive of a button battery. Patient urgently underwent rigid esophagoscopy and found to have a 20 mm lithium battery in the proximal esophagus. The negative pole was facing anteriorly. Battery was retrieved and inspection revealed a Zagar 2 B grade mucosal injury. Site was washed with 0.25% acetic acid. Direct laryngoscopy and bronchoscopy noted significant posterior tracheal wall edema. Patient was kept NPO overnight and an esophagram obtained next day was reassuring. Therefore, diet was advanced as tolerated and patient discharged next day with plan to repeat esophagram in 2 weeks and endoscopy in 4 weeks. Patient presented 3 days later with drooling, coughing, nasal congestion. She tested positive for SARS Covid 19 PCR on admission. Esophagram at admission noted irregularity and distension of the proximal esophagus with persistent focal outpouching. Patient was kept strict NPO and a repeat esophagram 24 hours later showed large volume aspiration associated with excessive coughing. A nasogastric tube was placed, and tube feedings initiated. Esophogastroduodenoscopy (EGD) was delayed by 1 week due to COVID positive status and upper respiratory symptoms. Initial EGD demonstrated purulent exudates in proximal esophagus and a 6 mm fistulous opening surrounded by ulcerated margins. Bronchoscopy confirmed tracheal end of fistula in addition to posterior tracheal wall ulceration. A fiber-optic scope was used to advance the endotracheal tube so that its distal end was positioned beyond the inflamed mucosa. Patient was kept intubated and sedated, on IV antibiotics and PPI, and on NG tube feeds in the ICU. Repeat scope 7 days post TEF diagnosis showed a 4 mm fistula with healing of the ulcerated mucosa. Fibrin glue was injected into the fistula from the tracheal side in an attempt to close the TEF, but this was unsuccessful and lead to dislodgment of fibrin glue into airway creating a foreign body which necessitated endoscopic retrieval. EGD, 14 days after diagnosis of TEF demonstrated a fistula now ~ 3 mm wide. Argon plasma coagulation (APC) probe (Beamer unit flow of 0.5 L/min,15 W) was directed at the mucosa lining the esophageal end of the fistula with an aim to promote healing by secondary intention. At 21 days post TEF diagnosis complete closure of the fistula was demonstrated on EGD and bronchoscopy and the per-operative esophogram was reported as normal. Patient was discharged 5 days later tolerating an age-appropriate diet. A follow-up esophogram 2 weeks later was reassuring. Patient was asymptomatic on clinical follow up visit 4 weeks from discharge. Discussion(s): Acquired TEF secondary to LBB ingestion is traditionally managened through endoscopic or open surgical repair. However, these procedures can be complicated by high rates of recurrent laryngeal nerve injury, tracheal stenosis, recurrent fistula, and mortality. Thus, experts have started to advocate the use of esophageal rest as conservative management of acquired TEF to permit closure by secondary intention. Five pediatric cases to date have reported sustained closure of TEF secondary to LBB with conservative management including strict NPO status and tube feeds/parenteral nutrition. The duration of healing has varied from 4 -11 weeks. We documented successful healing of acquired TEF within 21 days of initial diagnosis making it the shortest recovery period to date. We report the use of argon plasma coagulation at low settings to produce controlled heat coagulation at the fistula site in order to expose the submucosa and enhance healing by secondary intention. Successful closure of congenital TEF have been reported with injection of fibrin glue into the fistulous tract but this technique may not work for acquired TEF because of surrounding inflammation and a patulous tract. We opted to keep our patient sedated and intubated for 2 weeks to minimize movement, and promote healing of the TEF, but risk vs benefit needs to be weighed on a case-to-case basis. In conclusion, conservative management of acquired TEF is a feasible first step and may be considered before opting for surgical repair. Use of APC at low setting may reduce duration of closure of acquired TEF but high-powered, multi-center studies are needed.

Intra-oral kinking of a micro-cuff endotracheal tube: an unusual cause of difficult ventilation

Background: Intra-oral kinking of endotracheal tube is a rare but not unheard of complication. It could be lifethreatening if left unrecognised. Case presentation: A ten-year-old boy with developmental delay, scoliosis and recurrent chest infections was transferred to our paediatric intensive care (PIC) with SARS-CoV-2 pneumonia. The child was intubated with a size 5.5 micro-cuff endotracheal tube for critical hypoxic respiratory failure at his local hospital. The intubation was reported to be straightforward, with a grade 1 laryngoscopy view, but he was notably difficult to ventilate and oxygenate on the ventilator. He was transferred by road and was requiring a fraction of inspired oxygen of 0.8 and inhaled nitric oxide at 20 parts per million to maintain oxygen saturations of greater than 94%. The retrieval team also reported that he required a peak inspiratory pressure of as high as 49 cmH2O and positive end-expiratory pressure of 8 cmH2O with a 1:1 I: E ratio to maintain tidal volume of 6 ml/kg for his weight of 30kg. He was fully sedated and paralysed. The child was examined on arrival to PIC. His trachea was central and there was no wheeze or abdominal distension. The capnography waveforms were of normal appearance. A chest X-ray was also done to exclude endobronchial intubation and obvious pneumothorax. He was noted to be unusually difficult to bag ventilate, and the delivery of tidal volumes were hugely variable with any change in head positioning. He was best ventilated with head-tilt and chin-lift. Our concerns were escalated when the 'red-flag' of inability to pass the suction catheter was highlighted by the nursing team. The course of his tracheal tube was immediately palpated, and a twist was felt in the oropharynx. This finding was confirmed on laryngoscopy, which revealed a significant kink at letter C of this micro-cuff tube (Figure 1). The airway was swiftly exchanged, and immediate improvements of both ventilation and gas exchanged were observed. Conclusion: The polyvinyl polymers of endotracheal tubes are known to soften at body temperature and have a higher tendency to bent at acute angles,1 where the pilot tubing exists2;and when bending forces are applied away from the anatomical curvature, also known as the Magill curve (radius of approximately 140 millimetres), of most conventional tracheal tubes.2-5 Kinking of endotracheal tube at blind spots such as within the pharynx may happen more frequently in paediatrics than in adult critical care practice due to the use of straighter tracheal tubes with smaller wall thickness. We would like to raise awareness of this unusual case of difficult bag ventilation and high airway pressure ventilation. If a well-secured tracheal tube suddenly becomes problematic following, or in relation to positional changes, tube malfunction should be suspected. The integrity of the endotracheal tube must also be interrogated.