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.

Analysis of combined non-invasive respiratory support in the first six waves of the COVID-19 pandemic. Outcome according to the first respiratory support

Introduction: COVID-19 can lead to acute respiratory failure (ARF) requiring admission to intensive care unit (ICU). This study analyzes COVID-19 patients admitted to the ICU, according to the initial respiratory support. Its main aim is to determine if the use of combination therapy: high-flow oxygen system with nasal cannula (HFNC) and non-invasive ventilation (NIV), is effective and safe in the treatment of these patients. Methods: Retrospective observational study with a prospective database. All COVID-19 patients, admitted to the ICU, between March 11, 2020, and February 12, 2022, and who required HFNC, NIV, or endotracheal intubation with invasive mechanical ventilation (ETI-IMV) were analyzed. HFNC failure was defined as therapeutic escalation to NIV, and NIV failure as the need for ETI-IMV or death in the ICU. The management of patients with non-invasive respiratory support included the use of combined therapy with different devices. The study period included the first six waves of the pandemic in Spain. Results: 424 patients were analyzed, of whom 12 (2.8%) received HFNC, 397 (93.7%) NIV and 15 (3.5%) ETI-IMV as first respiratory support. PaO2/FiO2 was 145 ± 30, 119 ± 26 and 117 ± 29 mmHg, respectively (p = 0.003). HFNC failed in 11 patients (91.7%), who then received NIV. Of the 408 patients treated with NIV, 353 (86.5%) received combination therapy with HFNC. In patients treated with NIV, there were 114 failures (27.9%). Only the value of SAPS II index (p = 0.001) and PaO2/FiO2 (p < 0.001) differed between the six analyzed waves, being the most altered values in the 3rd and 6th waves. Hospital mortality was 18.7%, not differing between the different waves (p = 0.713). Conclusions: Severe COVID-19 ARF can be effectively and safely treated with NIV combined with HFNC. The clinical characteristics of the patients did not change between the different waves, only showing a slight increase in severity in the 3rd and 6th waves, with no difference in the outcome. © 2022 Elsevier Ltd

Investigations into the efficacy of a novel extubation-aerosol shield: a cough model study.

BACKGROUND: Physicians have had to perform numerous extubation procedures during the prolonged coronavirus disease 2019 (COVID 19) pandemic. Future pandemics caused by unknown pathogen may also present a risk of exposure to infectious droplets and aerosols. AIM: This study evaluated the ability of a newly developed aerosol barrier, "Extubation-Aerosol (EA)-Shield" to provide maximum protection from aerosol exposure during extubation via an aerosolised particle count and high-quality visualisation assessments. METHODS: We employed a cough model having parameters similar to humans and used micron oil aerosol as well as titanium dioxide as aerosol tracers. Aerosol barrier techniques employing a face mask (group M) and EA-Shield (group H) were compared. FINDINGS: The primary outcome was the difference in the number of particles contacting the physician's face before and after extubation. The maximum distances of aerosol dispersal after extubation were measured as the secondary outcomes. All aerosolised particles of the two tracers were significantly smaller in group H than in group M (p < 0.05). In addition, the sagittal and axial maximum distances and sagittal areas of aerosol dispersal for 3, 5, and 10 s after extubation were significantly smaller in group H than in group M (p < 0.05). CONCLUSION: This model indicates that EA-Shield could be highly effective in reducing aerosol exposure during extubation. Therefore, we recommend using it as an aerosol barrier when an infectious aerosol risk is suspected.

Difficult tracheal extubation due to endotracheal tube malfunction: A challenge during the COVID-19 pandemic.

Tracheal extubation is an aerosol-generating medical procedure. Difficult tracheal extubation is a serious complication that increases the risk of respiratory aerosol and pathogen spread, especially during the COVID-19 pandemic. The management of difficult extubation is potentially even more challenging during the pandemic. We report two cases of difficult extubation due to endotracheal tube cuff malfunction during the COVID-19 pandemic. Special airway maneuvers and infection control measures were employed to successfully manage the unexpected dilemma. This case series highlights the risk of COVID-19 virus transmission during difficult extubation. This report describes the preventive and reactive management of difficult extubation.

Safe Extubation of Patients with COVID-19 for Minimizing Aerosolized Droplets.

BACKGROUND: Healthcare workers must be protected during extubation of patients with coronavirus disease 2019 (COVID-19) owing to the presence of aerosolized droplets. Herein, we report a technique for extubating a patient with COVID-19 while minimizing aerosol dispersion. CASE REPORT: We retrospectively identified a total of 79 patients admitted to our hospital from February 2020 to January 2021. Six of these patients were intubated for mechanical ventilation, 2 of whom had to be extubated. We prepared a clear vinyl sheet in the shape of a tent to place over the patient, and 2 staff members, both well experienced in airway management, stood outside the tent on either side of the patient. Before extubation, we confirmed that the patient's consciousness level was good and the patient had no distress by adjusting the dose of sedative drugs. After extubation, a surgical mask was placed on the patient's face. CONCLUSION: Our experience indicates that this method of extubation in a patient with COVID-19 could be safely implemented to protect healthcare workers.