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Introduction: Lactulose is a non-absorbable disaccharide which acts in the large bowel, and is commonly used in the treatment of hepatic encephalopathy. We present an interesting case of altered mental status due to hepatic encephalopathy successfully managed with lactulose in a patient with history of total colectomy. Case Description/Methods: A 67-year-old male with non-alcoholic cirrhosis and inflammatory bowel disease (IBD) post total proctocolectomy with a continent ileostomy known as a Kock-pouch (K-pouch) presented to the hospital with flu like symptoms and altered mental status. He was subsequently found to be positive for COVID-19. At the time of initial evaluation, the patient was obtunded with an elevated ammonia level of 91 umol/L. Colorectal surgery was consulted as the patient was not able to empty his K-pouch. Recently, he complained of inability to catheterize and with bleeding from the stoma. Initial catheterization with a Water's tube yielded 400 cc of effluent. Nasogastric tube was placed through which he was receiving lactulose 30 mg q8 hours. The patient's mental status improved within 24 hours. The patient ultimately underwent flexible pouchoscopy with endoscopic dilation and placement of a 22 French mushroom catheter for decompression of the K-pouch. Discussion(s): Lactulose is a non-absorbable disaccharide composed of galactose and fructose. The small intestine does not have the enzymes required to breakdown lactulose so it reaches the large bowel in its original form. In the large bowel, it is metabolized by colonic bacteria into monosaccharides and then to volatile fatty acids, hydrogen and methane. Lactulose decreases both the production and absorption of ammonia mainly through the presence of gut bacteria. The question arises as to how lactulose decreased ammonia levels in this patient without a large bowel. One proposed mechanism is the translocation of bacteria normally found in the large bowel to the small intestine. Small Intestinal Bacterial Overgrowth (SIBO), is a condition causing an increased number of bacteria in the small intestine. Patients with IBD and structural abnormalities are at increased risk of developing SIBO. Lactulose is commonly used in the diagnosis through the administration of lactulose and subsequent measurements of hydrogen and methane gas in expired air. This condition, in our patient with history of ulcerative colitis and colectomy, is a proposed mechanism of the efficacy of lactulose in the treatment of hepatic encephalopathy.
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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.
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Introduction: Critically ill COVID-19-patients are at high risk of developing ICU-related malnutrition. This study aimed to examine the impact of proning on providing nutritional therapy for mechanically ventilated COVID-19-patients by comparing the achievement of nutritional goals and possible complications in patients who were proned vs. those who were not. Method(s): This is a single-center retrospective cohort study. We included all adult COVID-19 patients admitted to the ICU from 01/03/2020 until 31/05/2020 who required invasive mechanical ventilation (IMV), excluding those referred for ECMO. Data were extracted from electronic patient files. Weight-based nutrition targets were set in agreement with ESPEN guidelines [1]. Result(s): 32 patients were included (prone n = 16). Both groups were comparable in age, sex, comorbidities, biochemical markers and Nutrition Risk Screening on admission. Time on IMV was longer in the prone group (p = 0.032). The total time in prone position ranged from 19.5 h to 13.16 d. All patients received a NG tube, 1 proned patient received a jejunal tube. 6 received TPN (p = 0.654). Metoclopramide was used more often in the prone group (p = 0.028). The prevalence of vomiting (n = 4 vs. n = 5), large gastric residuals (n = 0 vs. n = 3) and VAP (n = 11 vs. n = 10) were comparable for the non-prone vs. prone group, resp. Table 1 shows the percentage of targets reached. These were lower in the prone group, though not statistically significant. However, when correcting for SAPS III-score, the impact of proning declined. Conclusion(s): These limited data suggest there is no significant difference in feeding COVID-19 patients on IMV that need proning vs. those who do not, except for metoclopramide use. Overall, reaching nutrition targets in these patients is challenging. This model suggests that disease impact is a greater influence on reaching nutritional goals than proning itself.
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Hepatitis A is a common viral infection worldwide that is transmitted via the fecal-oral route. Since the introduction of an efficient vaccine, the incidence of infection has decreased but the number of cases has risen due to widespread community outbreaks among unimmunized individuals. Classic symptoms include fever, malaise, dark urine, and jaundice, and are more common in older children and adults. People are often most infectious 14 days prior to and 7 days following the onset of jaundice. We will discuss the case of a young male patient, diagnosed with acute hepatitis A, leading to fulminant hepatitis refractory to conventional therapy and the development of subsequent kidney injury. The medical treatment through the course of hospitalization was challenging and included the use of L-ornithine-L-aspartate and prolonged intermittent hemodialysis, leading to a remarkable outcome. Hepatitis A is usually self-limited and vaccine-preventable;supportive care is often sufficient for treatment, and chronic infection or chronic liver disease rarely develops. However, fulminant hepatitis, although rare, can be very challenging to manage as in the case of our patient.Copyright © 2023 The Author(s).
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Introduction: The coronavirus disease 2019 (COVID-19) mainly causes pulmonary disease. However, extrapulmonary manifesta-tions, which affect the gastrointestinal tract and hepatobiliary system, have been reported. Case Presentation: Here we reported a 4-year-old boy with acute lymphoblastic leukemia and abdominal pain who had acute necrotic pancreatitis secondary to COVID-19. Conclusion(s): According to the COVID-19 epidemic, if drug-induced pancreatitis is ruled out, viral causes, especially COVID-19, should be considered.Copyright © 2023, Author(s).
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A 5-month-old, intact male, yellow Labrador retriever was presented with a 24-hour history of anorexia and vomiting. Abdominal imaging revealed the presence of a mechanical obstruction in the jejunum and peritoneal effusion. Cytologic evaluation and culture of the effusion prior to surgery identified a suppurative exudate with bacteria consistent with septic peritonitis and suspected to be related to the intestinal lesion. An exploratory laparotomy was performed, and a segment of jejunum was circumferentially severely constricted by an off-white, fibrous band of tissue. Resection and anastomosis of the strangulated segment of jejunum and excision of the constricting band provided resolution of the clinical signs. The dog made a complete recovery. Histologic evaluation revealed the band to be composed of fibrovascular and smooth muscle tissue, consistent with an idiopathic anomalous congenital band. No other gastrointestinal lesions were observed, either grossly at surgery or histologically in the resected segment of intestine. To our knowledge, a similar structure has not been reported in the veterinary literature.Copyright © 2022 Canadian Veterinary Medical Association. All rights reserved.
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Perinatal arterial ischemic stroke (PAIS) is a rare cause of neonatal seizures, with an incidence of 1 in 2500 to 4000 live births, globally. This is a case of a neonate with PAIS due to transpla-cental passage of COVID-19 IgG antibodies from the mother. A term, male neonate, born to a primigravida with an unevent-ful antenatal history was presented on the second day of life with multiple episodes of focal clonic seizures involving the right upper and lower limbs. Magnetic resonance imaging revealed an acute infarct in the left frontal lobe, extending into the parietal region, anterior limb, and genu of internal capsule suggestive of arterial ischemic stroke. The known causes of PAIS were evaluated and ruled out. The result of reverse transcription polymerase chain reaction analysis for SARS-CoV-2 antigen was negative for both the mother and the neonate. COVID-19 IgG antibodies in the mother and neonate were elevated. Seizures were controlled with antiepileptics. The neonate had no further seizure episodes and was discharged on oral levetiracetam. The infant was developmentally and neurologically normal at 3 months of age. PAIS is a rare cause of neonatal seizures, and maternal COVID-19 infection may be associated with neonatal stroke.Copyright © 2022, Himalaya Wellness Company. All rights reserved.
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An aberrant right subclavian artery (ARSA), also called as arteria lusoria, is one of the most common aortic arch anomalies. ARSA-esophageal fistula is a rare, life-threatening complication, with only 37 cases reported in literature. We describe a case of a young girl who developed acute episode of massive hematemesis after the recovery from novel coronavirus disease 2019 (COVID-19) pneumonia. Computed tomography (CT) angiography showed ARSA with retroesophageal course and active contrast leak in esophagus. Digital subtraction angiography confirmed the site of active contrast extravasation from the ARSA. However, the patient succumbed to hypovolemic shock even before the endovascular or surgical interventions could be done.
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Eating disorders have the highest mortality rate of any psychiatric condition. Since the COVID-19 pandemic, the number of patients who have required medical stabilisation on paediatric wards has increased significantly. Likewise, the number of patients who have required medical stabilisation against their will as a lifesaving intervention has increased. This paper highlights a fictional case study aiming to explore the legal, ethical and practical considerations a trainee should be aware of. By the end of this article, readers will be more aware of this complex issue and how it might be managed, as well as the impact it can have on the patient, their family and ward staff.
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Background: A proportion of patients with COVID-19 become critically ill, but few studies describe the functional outcomes and rehabilitation process of these patients. Objective(s): To describe the complications encountered and functional outcomes of critically ill COVID-19 patients requiring intubation and subsequent intensive care unit (ICU) management and rehabilitation. Method(s): Retrospective case note review was conducted on all patients requiring intubation and ICU admission and subsequently discharged from our hospital from February 15, 2020 to May 1, 2020. Demographics, preexisting medical conditions, complications encountered in ICU, ICU and General Ward Length of Stay, number of therapy sessions delivered, nutritional data, and functional outcomes on discharge were collected from electronic medical records and entered in a deidentified database. Result(s): Most patients developed significant breathlessness affecting post-ICU rehabilitation, a few patients developed ICU associated delirium while no patient developed ICU-associated weakness. All patients survived and could walk 20 m within 12 days post-extubation. Conclusion(s): Early ICU and sustained post-ICU rehabilitation of critically ill, intubated COVID-19 patients is feasible. Further studies could look into the outcomes of this group of patients, in particular the effect of nutrition and pulmonary training on functional outcomes. We strongly recommend an interdisciplinary rehabilitation team approach in managing critically ill COVID-19 patients. Copyright © The Author(s) 2022.
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Introduction: In the beginning of March 2020 with first case of COVID-19 reported in Turkey, measures that were assumed to decrease the spread of SARS-CoV-2 were taken quickly. Use of personel protective equipments and limiting number of people contacting with the patients were some of the most important precautions. Although these precautions protected medical student from risk of infection, they limited their practical learning oportunities and probably negatively effected their education. Aim of our study was to measure the effect of pandemic on medical education of grade 6 medical students. Material(s) and Method(s): We had 6th grade medical students that finished their education between July 2020 and June 2021 fill out a questionnaire that measures their self-esteem on evaluation and procedural practice in pediatric patients and presents their subjective opinions on this period and their solution suggestions with closed and open ended questions. Result(s): Forty nine grade 6 student was included in the study. Their self-esteem was average (general competency in pediatric patients was 2.31+/-0.94 and general self reported competency in clinical practices was 2.65+/-1.42). The practice they feel most confident was hand washing (4.44+/-1.16), and the practice the feel least confident was establishment of vascular access (1.94+/-1.09). When they were asked to evaluate their self-competency in pediatric patients from 1 to 5,the procedure they most frequently observed was establishment of vascular access (74%) and least frequently observed was lumbar puncture (12%). Most frequently performed procedure was urinary catheterization (20%). 80.9% them stated that they felt unlucky to be 6th grade in COVID-19 pandemic and they would like to have more opportunities to contact with the patients with personal protective equipment (PPE). Conclusion(s): Education of 6th grade medical students affected negatively with decreasing number and diversity of patients and limited opportunity to evaluate patients and observe and perform procedures. Improvements should be made in pediatric departments to increase possibility of student to encounter patients and continue hands on learning with the right precautions. Copyright © 2022, Galenos Publishing House. All rights reserved.
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SESSION TITLE: Rare Cases of Nervous System and Thrombotic Complication Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Rivaroxaban is a dose-dependent inhibitor of factor Xa. It is approved by the FDA to help reduce the risk of blood clots. Although bioavailability is not significantly affected at lower doses (80-100%), bioavailability at higher doses (≥15 mg) is as low as 66% when given without food [1] [3]. Here, we present a patient with poor oral intake who developed deep vein thrombosis (DVT) while on high dose Xarelto. CASE PRESENTATION: Our patient was a 48-year-old male with a history of pulmonary embolism diagnosed two months prior to admission (on 20 mg rivaroxaban daily at home) and morbid obesity who presented with dyspnea, fever, and decreased appetite. His viral PCR was positive for COVID-19, and CT angiogram showed multifocal ground glass opacities but was negative for pulmonary embolism. He was severely hypoxic on room air and required noninvasive ventilatory support in the intensive care unit. He was treated with remdesivir, dexamethasone, and baricitinib. His food intake was extremely poor due to near continuous use of noninvasive ventilation and decreased appetite. A nasogastric (NG) tube was offered, but the patient declined and elected to continue diminished oral feedings. He was able to take all of his home medications including rivaroxaban during this time. On day four, clinical nutrition was consulted because he had 3% loss of body weight. On day seven, the patient developed a fever of 101.6° F. Ultrasound of his lower extremities revealed acute DVTs in his left popliteal vein, posterior tibial vein, and peroneal vein. His anticoagulation was switched to full-dose enoxaparin and a NG tube was placed. On day ten, he was intubated due to worsening hypoxia. Unfortunately, the patient deteriorated into multiorgan failure and died on day seventeen. DISCUSSION: The latest expert guidelines suggest that direct oral anticoagulants (DOAC) should be used over vitamin K antagonists (VKA) in patients with acute venous thromboembolism (VTE) due to lower rates of major bleeding and recurrent VTE as well as convenience. Although VKAs are preferred in situations with extreme weight and renal impairment, DOACs have been proven to be effective for the large majority of patients [2]. Unlike rivaroxaban, the bioavailabilities of other DOACs like apixaban, edoxaban, and dabigatran are all unaffected by food and should be preferred in patients with tenuous oral intake [3]. It is well known that COVID-19 can produce a hypercoagulable state. This factor, combined with our patient's predisposition to blood clots and poor appetite, ended up precipitating new onset VTEs in his left leg despite rivaroxaban therapy. CONCLUSIONS: In patients with decreased oral intake, DOACs other than rivaroxaban should be considered. Patients should be briefed on the importance of taking high dose rivaroxaban with food. Our goal is to bring awareness to providers about this significant pharmacodynamic property of rivaroxaban. Reference #1: Mueck W, Stampfuss J, Kubitza D, Becka M. Clinical pharmacokinetic and pharmacodynamic profile of rivaroxaban. Clin Pharmacokinet. 2014 Jan;53(1):1-16. doi: 10.1007/s40262-013-0100-7. PMID: 23999929;PMCID: PMC3889701. Reference #2: Stevens SM, Woller SC, Baumann Kreuziger L, Bounameaux H, Doerschug K, Geersing GJ, Huisman MV, Kearon C, King CS, Knighton AJ, Lake E, Murin S, Vintch JRE, Wells PS, Moores LK. Executive Summary: Antithrombotic Therapy for VTE Disease: Second Update of the CHEST Guideline and Expert Panel Report. Chest. 2021 Dec;160(6):2247-2259. doi: 10.1016/j.chest.2021.07.056. Epub 2021 Aug 2. PMID: 34352279. Reference #3: Lexicomp Online. Copyright © 1978-2022 Lexicomp, Inc. DISCLOSURES: No relevant relationships by Rishika Bajaj No relevant relationships by Ann Hylton No relevant relationships by Roger McSharry No relevant relationships by Krupa Solanki
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Background: Enteral tubes, including nasogastric (NG) tubes, are an important tool in managing multiple medical conditions in which oral feeding cannot be successfully accomplished due to feeding ability or safety, and these devices are commonly employed at children's hospitals worldwide. While these devices are life-saving, they can develop are a significant burden on families and the healthcare system. There is relatively little published data on the practices of pediatric enteral tube outpatient management, including whether primary outpatient management is undertaken by pediatric gastroenterologists or other medical practitioners (e.g. primary care providers and other pediatric subspecialists), and if a primary management team would affect overall clinical outcomes. In the late fall of 2019, at the American Family Children's Hospital (AFCH), a tertiary care children's hospital, pediatric outpatient enteral tube management, with the exception of tubes in patients under the primary care of Pediatric Hematology/Oncology (PHO), was fully assumed by the Pediatric Gastroenterology (PGI) division, with previous management divided or shared among the PGI division, primary care providers, and other pediatric subspecialists. Due to the division having subspecialty nurses, nurse practitioners, and physicians who had expertise managing enteral tubes on an inpatient and outpatient basis, we hypothesized that primary outpatient management by Pediatric GI would reduce ED utilization for nasogastric tube evaluation. Method(s): We performed a retrospective chart review of all patients discharged from AFCH with a nasogastric tube in place from March 1 2018 to October 31 2019 and June 1 2020 to January 31 2022. The study was reviewed by the University of Wisconsin-Madison Minimal Risk Research Institutional Review Board and met criteria for exempt human subjects. We left a 7-month temporal gap to allow for complete implementation of the policy of pediatric GI management to be uniformly practiced within the hospital, and to account for the beginning of the COVID-19 pandemic, when outpatient clinics were closed and ED evaluation was required for all hands-on non-inpatient medical care at our institution. Patients were grouped and analyzed according to being pre-intervention or post-intervention, and they were followed until either their NG tube was permanently removed, or until their NG tube was replaced with a gastrostomy tube. Patients were excluded if they were primarily managed by PHO, lost to followup, still had NG tube in place at time of data analysis, died during the study period, or had their tube converted to a postpyloric tube. Our primary outcome was the incidence rate of ED visits for nasogastric tube evaluation per patient-weeks between the pre- and post-intervention groups. Patient demographics and diagnoses were also recorded and analyzed. Statistical analysis was conducted. Result(s): There were 130 patients identified after applying inclusion and exclusion criteria, with 56 in the pre-intervention group and 74 in the post-intervention group. The median chronological age of patients in the pre-intervention group was 5 months, and it was 6 months for the post-intervention group. The mean time from initial hospital discharge to either NG tube removal or conversion to gastrostomy tube was 6.2 weeks in the pre-intervention group and 8.8 weeks in the post-intervention group. In the pre-intervention group, the incidence rate of ED visits for NG tube evaluation was 15.6 visits per 100 patient-weeks (95% Confidence Intervals (CI): 11.7-20.3), and in the post-intervention group, the rate was 9.7 visits per 100 patient-weeks (95% CI: 7.4-12.4). Discussion(s): This study demonstrated that at our institution, there appeared to be a decrease in ED utilization for nasogastric tube evaluation after outpatient tube management was assumed by the PGI division, but this decrease was not quite enough to reach statistical significance. This study is limited by multiple factors including the retrospective nature of the study, modest sample size limiting statistical power, and, potentially, lingering effects of the COVID-19 pandemic affecting patient care decisions. Identifying balancing measures from this intervention, as well as identifying alternative changes that could further decrease ED evaluation rates, can be explored in future quality improvement initiatives.
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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.
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Introduction: Unplanned removal of NGTs is common and associated with multiple complications.1 Methods used to secure these tubes may influence removal rates.2 Following national guidance,3 we confirmed tube placement by CXR. We used the text of CXR requests to estimate the rates of NGT placement and to see how these were influenced by changing how NGTs were secured. We also used similar methodology to review changes to CXR requests mentioning central lines (CVCs) and endotracheal tubes (ETT). Objectives: To see how CXR requests for NGT placement were influenced by changing the method used to secure these tubes. MethodsIn a 42 bedded mixed general and neurosurgical unit, in November 2019 we changed the method to secure NGTs from Hollister feeding tube attachment devices (Hollister, IL, USA)., to handcrafted slings made from Micropore (3M, MN, USA) 1.25cm Surgical Tape.4 The text of CXR requests between October 2017 and July 2021 were analysed for text associated with NGTs, CVCs and ETTs. The number of bed days was calculated for each month from October 2017 and CXR rates per 100 bed days were calculated. Mann-Whitney U tests were used to establish if CXR rates changed significantly after November 2019 and after admitting patients with COVID-19 in March 2020. Distributions are shown as medians with [IQR]. Results: There were 15239 CXRs, a median of 330 [IQR 303-357] CXRs requested a month. The fraction mentioning each device was: ETT: 8%, CVC: 13%, NGT: 38% (18% of these also mentioning another device). The rates per 100 patient days per month were: NGT pre-Nov 2019: 15.9 [15.0-16.4]. Post-Nov 2019 11.6 [10.1-12.7] (p<0.001), Nov 2019 to February 2020: 12.0 [8.0-13.3], vs Pre Nov 2019 p=0.008. For CVCs pre-March 2019: 4.1 (3.6-4.6) post March 2019: 5.2 (4.6-5.9) (p< 0.001) for ETTs pre-March 2019: 2.8 (2.0-3.3), post-March 2019: 3.1 (2.4-3.7). Changes in monthly rates are shown in the run chart in Figure 1. Conclusions: Changing the method of securing NGTs resulted in a reduction of CXR requests mentioning NGTs, reviewing CXR requests can be used to monitor NGT displacements. The rate of CVC requests increased following March 2020.
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Introduction: Admitting acutely unwell patients to the intensive care unit (ICU) can represent a busy and challenging time, particularly out of hours or in the context of surge into areas not usually utilised for delivery of intensive care. It is usual for the team to perform a number of procedures at the point of admission in order to stabilise the patient. Objectives: During the Covid-19 surge it was noted that efficiency and potentially patient safety were being compromised by the time taken to locate essential equipment required to carry out the frequent and specialist procedures that are often performed at admission. This quality improvement project set out to address this short fall by introducing mobile workstations that were fully stocked with the required equipment and provided a working surface. Four different stations were introduced a general station (Intravenous, central, and arterial access, blood cultures, nasogastric tube insertion, urinary catheter insertion) and 3 specialist procedure stations an intercostal chest drain station, airway station and a percutaneous tracheostomy/lumbar puncture station. A spare general station was kept stocked in a storeroom so that after use stations could be replaced immediately. Laminated contents lists with photographs of drawer layouts were attached to allow restocking. General stations were sealed before being positioned in designated positions, marked on the floor, in each of the different clinical areas. The stations were designed to be easily cleaned to conform to infection control protocols. Methods: Medical staff performed an electronic questionnaire before and after the introduction of the equipment stations. Results: The 12 responders reported performing, on average 4 procedure per admission. Pre-intervention the average reported time taken to find equipment need was reported to be 22.5 minutes, with a further average 18.5 minutes taken by a second member of staff, usually bedside nursing staff. Post intervention these reported times fell to 7.5 minutes and 7 minute respectively, at time saving of 40.7 minutes (65%). In 2018/2019 our unit admitted 788 patients, therefore over a year we could potential save up to 535 hours, with the financial implications being obvious. The post intervention questionnaire contained a significant number of positive comments regarding the stations from staff. Conclusion: This simple intervention is clearly able to improve patient safety, reduce frustration amongst staff as well as save time and money. The mobile nature of the stations allowed them to be used in other areas when required such as theatre, recovery and the emergency department, a feature which has been particularly beneficial during the Covid-19 surge. Other units may want to consider this set up as a way of improving safety and efficiency.
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Introduction: Sodium zirconium cyclosilicate is a novel potassium binder developed by AstraZeneca and is sold under the brand name Lokelma (TM). It has been approved for use in England in 2020 for the treatment of non-lifethreatening hyperkalaemia, and stable hyperkalaemia in patients with chronic kidney disease.1 It is available as powder sachets (5 grams and 10 grams) and is designed to be mixed with water and administered enterally. The starting dose is recommended as 10 grams three times per day, and resolution of hyperkalaemia is usually seen within two days, after which a lower maintenence dose may be administered. The radiopaque properties of sodium zirconium cyclosilicate have previously been noted on computed tomography before in 2021,2 but, to our knowledge, this has not yet been described on plain radiography. Case presentation: We present the case of a critically unwell lady in her 50s with COVID-19 pneumonitis. As a feature of her critical illness syndrome, she developed acute renal failure, and required renal replacement therapy. Persistent problems with hyperkalaemia were noted, and sodium zirconium cyclosilicate was administered enterally via a nasogastric tube as directed in the product literature. For unrelated reasons, she also required a chest radiograph within the following hour. On reviewing the radiograph, a radiopaque material was noted in the stomach, and was seen to very clearly outline the major anatomical features of the organ, including the greater and lesser curve, and gastric rugae. After discussion with our local radiology colleagues and finding the material is opaque on computed tomography, we concluded this material must be the recently administered sodium zirconium cyclosilicate. Investigation: Image of radiograph showing radiopaque material in the stomach of a critically unwell patient. Discussion: To our knowledge, the radiopaque properties of sodium zirconium cyclosilicate have not been described before in the medical literature as relating to plain radiography. When interpreting plain radiographs, it is important to understand and exclude sources of artefact. As sodium zirconium cyclosilicate becomes widespread in critical care areas, we believe the above-described scenario will be commonly encountered. Moreover, we believe that sodium zirconium cyclosilicate may have additional utility as a well tolerated enteral contrast agent with the added benefit of lowering serum potassium concentration.
ABSTRACT
Introduction: Sufficient nutrition has been repeatedly demonstrated to be a vital part of recovery from critical illness.1 Nutrition is often delivered in the intensive care setting via a Nasoenteral (NE) tube if oral diet is impractical or inadequate;this is first line as per ESPEN guidance.2 It has been observed that patients in the intensive care unit (ICU), particularly those who have been intubated due to COVID-19, are at high risk of agitation and delirium which can lead to accidental NE displacement. Nasal Loop Bridles (NLB) are amedical device which can be placed at bedside and are used to reduce the risk of NE tube displacement. The usage of NLBs varies between Trusts. Insertion of a NLB is a medical procedure which should be consented for where possible and clearly documented. Objectives: To identify all patients who had a NLB placed during the second wave of the COVID-19 pandemic at Royal Surrey Hospital (RSH) ICU, ascertain their reason for insertion, and identify any nutritional deficits incurred prior to NLB insertion. Secondary objectives include assessing quality of documentation of NLB insertion. Methods: A literature review was undertaken regarding the safety and efficacy of NLBs. This was followed by a retrospective observation of patients admitted to RSH ICU between December 2020 and March 2021. Data was collected on patients who required a NLB, including accrued nutritional deficit prior to placement and adverse incidents. Documentation of NLB rationale and placement was also noted. Results: 10 patients met inclusion criteria. The most common indications for insertion were delirium and previous tube displacement. Two NLBs were placed prior to any NE displacements therefore resulted in no nutritional losses. In the remaining patients a range of 1-5 NE tubes were accidentally displaced prior to NLB insertion (mean 2.7 tubes). 6-117 hours of feeding were lost prior to NLB placement resulting in a deficit of 744-6843kcal. Two patients were unable to have a NLBwhen indicated due to stock shortages, resulting in a deficit of 4140 and 6480kcal. No standard documentation was utilised for NLB placement. No major incidents occurred in relation to NLBs. Conclusion: This study highlights the benefits of NLBs in respect to nutritional delivery in patients who have undergone emergency sedation and ventilation and are at risk of delirium. It has also highlighted the need for improved documentation of this medical procedure. Inferences made from this study, and work by other centres identified in the literature review, suggest that it may be beneficial to consider early or prophylactic NLB placement in this cohort. Further local research could test criteria for use of NLBs including hyperactive delirium, difficulty of initial NE tube insertion and number of previous displaced tubes, in order to elucidate the most effective timing and indication for their use.
ABSTRACT
Tubes and catheters are medical devices introduced into the human body to help ill patients in critical health conditions. However, several positioning errors occur during or after the placement of such devices (Endotracheal tubes mispositioned in 10 to 20% of intubations). In addition, the delay of X-ray diagnosis after surgery can cause serious complications. Such delays are caused by the hospitals' resourcelessness or due to workload in intensive care units. The X-rays images availability (Most used diagnosis modality in intensive care units, 40% to 50%) and the presence of tubes in those images (lines are present on 33% of X-ray images) present a fertile ground to feed DCNNs training on tube error detection tasks and reduce complications. However, training and tuning one DCNN learner to resolve tube detection is time-consuming. Therefore, we propose a custom stacked generalization framework to combine wake learners with a proposed meta learner neural network architecture to resolve tube error detection tasks. The proposed framework AUC (93.84%) outperforms other related work methods with the input size of (380pixel*380pixel). Furthermore, we demonstrated the sensibility of stacked generalization to the number of base learners. Moreover, we validated the utility of input cross-validation used to form level1-metadata for the stacked generalization. Our framework can be adapted to be integrated with a CAD (computer aid decision system) for tubes error detection. The CAD can detect errors immediately after patient screening and notify radiologists to prioritize diagnosis of cases with positioning errors to adjust tubes and reduce risks significantly.
ABSTRACT
Aim and objective: To find out whether the COVID-19 affected ARDS lungs are recruitable with the combined use of 1. Transpulmonary pressure monitoring (to limit the stress);2. End expiratory lung volume measurement (to limit strain);3. Electrical impedance tomography;4. Compliance (to diagnose overdistension) and the increase in the SpO2 as a marker of clinical recruitment. Materials and methods: Retrospective data from charts and progress sheets were collected from 27 patients admitted to the ICU (between February 2021 and June 2021) with PaO2/FiO2 ratio <150 with a diagnosis of acute respiratory distress syndrome. Data acquisition: As a protocol, the esophageal pressure was monitored using the polyfunctional nasogastric tube (Nutrivent). The end-expiratory volume was measured using the Carescape R860 (Carescape R860;GE Healthcare) by the nitrogen multiple breath wash-out/ wash-in (EELV) at a PEEP of 5. Electrical impedance tomography measurements were performed using the PulmoVista 500. We performed a recruitment maneuver using the staircase maneuver. Statistics: Categorical variables are presented as frequency and percentage (%) and continuous variables are presented as mean and standard deviation. Comparison between pre- and post-recruitable was tested using t-test, while repeated-measures ANOVA was used to test follow-ups like 2 hours and 4 hours. Statistical significance is assumed at a value of p < 0.05. Results: As per the results of our study we found that almost 2/3rd (66.7%) of the COVID ARDS lungs were recruitable safely. The average plateau pressure (cm of H2O), mean compliance, FRC, and SPO2 were noted before the attempt at recruitment and after recruitment. After conducting the staircase manoeuvre, the plateau pressure remained at 25.56 with a standard deviation of 3.641. However, the mean compliance rose to 31.926 with a standard deviation of 10.099. Post recruitment there was a marked rise of FRC to 1581.778 with a standard deviation of 311.049 mL. Pre recruitment means SPO2 was 83.6% with a standard deviation of 3.9%. Post recruitment at 2 hours the SPO2 had reached 91.1% with a standard deviation of 5.4% and remained the same at 91.9% with a standard deviation of 7.5%. Among the 27 patients' clinical recruitment was seen in 18 patients (66.7%). As per the results of our study, we found that almost 2/3rd (66.7% or 18/27 pts) of the COVID ARDS lungs were recruitable safely (rise in SPO2 maintained at 2 and 4 hours along with the absence of overdistension as seen on EIT with an increase in FRC and compliance). Conclusion: As per the results of our study almost 2/3rd of COVID-19 patients were recruitable. This is the first Indian study to comprehensively study recruitment in COVID-19. ARDS pts with the best available techniques. This study shows that majority of COVID-19 lungs may be recruitable in the earlier stage of the illness (within the first week of ARDS) and thus warrant a trial of a safe monitored recruitment strategy.