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1.
Lung India ; 39(SUPPL 1):S154, 2022.
Article in English | EMBASE | ID: covidwho-1856979

ABSTRACT

Background: Tracheoesophageal fistula (TEF) is a rare condition that can be congenital or acquired. Patients of COVID-19 remain intubated for prolonged periods that can give rise to a multitude of complications. We came across a case where patient develop TEF after 7 days of tracheostomy. Case Study: 34 years female admitted with Covid pneumonia. Patient required ICU care for respiratory distress, required intubation. Patient was treated with standard treatment and kept on controlled ventilation. Patient underwent tracheostomy on day 12 of intubation. On day 17 of patient had an episode of sudden severe respiratory distress, desaturation, hypotension tachycardia not generating tidal volumes and rising peak pressures on ventilator. Patient developed bilateral tension pneumothorax immediately bilateral intercostal drainage tubes insertion done and patient settled. On day 19 patient had persistent cough with RT feeds coming through tracheostomy tube and site. Suspecting TEF CT neck with thorax was done. A rent is seen in the tracheal and esophageal walls close to the bulb of tracheostomy tube. with a TEF. Long tracheostomy tube was inserted as conservative management. Discussion: COVID-19 patients with severe pneumonia may require and remain on prolonged mechanical ventilation. The sudden deterioration of respiratory status, gastric distension and food particles in intubated tube are suspicious to TEF. Conclusion: Early tracheostomy can prevent some complications of prolonged intubation. If a patient develops sudden desaturation, gastric distension and food particles in tracheostomy tube then TEF should always be in the differential diagnosis.

2.
Journal of Investigative Medicine ; 70(2):470, 2022.
Article in English | EMBASE | ID: covidwho-1705422

ABSTRACT

Case Report Transverse myelitis is the segmental inflammation of the spinal cord with motor and sensory abnormalities at and below the level of the lesion. Often, the etiology is unknown but may be attributed to autoimmune conditions or viruses. Here we describe a rare case of transverse myelitis secondary to severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]/coronavirus disease (COVID-19). Case A 5-year-old male with a history of asthma presented for vomiting and altered mental status. The patient was noted to be altered, lethargic, and in respiratory distress. Intubation was performed. After family collateral was obtained, it was revealed that patient possibly ingested Sertraline and/or Risperidone at an unknown time prior to arrival. History also revealed that he had slurred speech, ataxia, and a fall with trauma to forehead 1 day prior to arrival. He tested positive for COVID-19 via PCR and chest x-ray revealed RLL consolidation. Dexamethasone was started. When sedation was weaned in hopes of extubation, patient was noted to be alert, but not moving extremities and had minimal gag and cough reflex. MRI of Brain and Spine were conducted and revealed findings suggestive of long segment transverse myelitis involving C2 to C3. LP was performed with unremarkable CSF studies and IV Solumedrol was started. In light of active COVID-19 infection, and worsening respiratory status, patient started on 5 days Remdesivir. Further, patient underwent ten sessions of plasmapheresis. Repeat MRI was consistent with previous. Physical and occupational therapy initiated at the onset of illness in hopes of achieving musculoskeletal improvement. Patient had some minimal musculoskeletal improvement, however, given his condition, decision was made for patient to undergo placement of gastrostomy and tracheostomy tubes. Patient was weaned off of sedatives and withdrawal was treated with a clonidine taper. Once stabilized, patient was transferred to neurological inpatient rehabilitation center. Discussion Neurological manifestations in children affected by SARS-CoV-2 are relatively common but are often non-specific. Worldwide data reports only 1% of children with COVID-19 present with severe symptoms of encephalopathy, seizures, and meningeal signs. Pathophysiology is multifactorial, including direct invasion of the CNS, vascular insufficiency, immune dysregulation and autoimmunity. Imaging is paramount in the diagnosis of transverse myelitis. Treatments are emerging and may include steroids, immunoglobulin, plasmapheresis, and monoclonal antibodies. Conclusion Much is unknown about COVID-19. Information is emerging and evolving daily. Cases of transverse myelitis in COVID-19 have been reported in few adult patients and minimal pediatric patients. Practitioners should keep transverse myelitis on their list of differentials for neurological complications of SARS-CoV-2 infections and initiate aggressive treatment with a multidisciplinary approach.

3.
J Intensive Care Med ; 37(2): 240-247, 2022 Feb.
Article in English | MEDLINE | ID: covidwho-1463146

ABSTRACT

INTRODUCTION: Patients with COVID-19 ARDS require significant amounts of sedation and analgesic medications which can lead to longer hospital/ICU length of stay, delirium, and has been associated with increased mortality. Tracheostomy has been shown to decrease the amount of sedative, anxiolytic and analgesic medications given to patients. The goal of this study was to assess whether tracheostomy decreased sedation and analgesic medication usage, improved markers of activity level and cognitive function, and clinical outcomes in patients with COVID-19 ARDS. STUDY DESIGN AND METHODS: A retrospective registry of patients with COVID-19 ARDS who underwent tracheostomy creation at the University of Pennsylvania Health System or the Johns Hopkins Hospital from 3/2020 to 12/2020. Patients were grouped into the early (≤14 days, n = 31) or late (15 + days, n = 97) tracheostomy groups and outcome data collected. RESULTS: 128 patients had tracheostomies performed at a mean of 19.4 days, with 66% performed percutaneously at bedside. Mean hourly dose of fentanyl, midazolam, and propofol were all significantly reduced 48-h after tracheostomy: fentanyl (48-h pre-tracheostomy: 94.0 mcg/h, 48-h post-tracheostomy: 64.9 mcg/h, P = .000), midazolam (1.9 mg/h pre vs. 1.2 mg/h post, P = .0012), and propofol (23.3 mcg/kg/h pre vs. 8.4 mcg/kg/h post, P = .0121). There was a significant improvement in mobility score and Glasgow Coma Scale in the 48-h pre- and post-tracheostomy. Comparing the early and late groups, the mean fentanyl dose in the 48-h pre-tracheostomy was significantly higher in the late group than the early group (116.1 mcg/h vs. 35.6 mcg/h, P = .03). ICU length of stay was also shorter in the early group (37.0 vs. 46.2 days, P = .012). INTERPRETATION: This data supports a reduction in sedative and analgesic medications administered and improvement in cognitive and physical activity in the 48-h period post-tracheostomy in COVID-19 ARDS. Further, early tracheostomy may lead to significant reductions in intravenous opiate medication administration, and ICU LOS.


Subject(s)
Analgesia , COVID-19 , Humans , Registries , Retrospective Studies , SARS-CoV-2 , Tracheostomy
4.
J Intensive Care Med ; 36(11): 1340-1346, 2021 Nov.
Article in English | MEDLINE | ID: covidwho-1367648

ABSTRACT

Background: A significant number of patients with severe respiratory failure related to COVID-19 require prolonged mechanical ventilation. Minimal data exists regarding the timing, safety, and efficacy of combined bedside percutaneous tracheostomy and endoscopy gastrostomy tube placement in these patients. The safety for healthcare providers is also in question. This study's objective was to evaluate the effectiveness and safety of combined bedside tracheostomy and gastrostomy tube placement in COVID-19 patients. Design and Methods: This is a single arm, prospective cohort study in patients with COVID-19 and acute respiratory failure requiring prolonged mechanical ventilation who underwent bedside tracheostomy and percutaneous endoscopic gastrostomy placement. Detailed clinical and procedural data were collected. Descriptive statistics were employed and time to event curves were estimated and plotted using the Kaplan Meier method for clinically relevant prespecified endpoints. Results: Among 58 patients, the median total intensive care unit (ICU) length of stay was 29 days (24.7-33.3) with a median of 10 days (6.3-13.7) postprocedure. Nearly 88% of patients were weaned from mechanical ventilation postprocedure at a median of 9 days (6-12); 94% of these were decannulated. Sixty-day mortality was 10.3%. Almost 90% of patients were discharged alive from the hospital. All procedures were done at bedside with no patient transfer required out of the ICU. A median of 3.0 healthcare personnel total were present in the room per procedure. Conclusion: This study shows that survival of critically ill COVID-19 patients after tracheostomy and gastrostomy was nearly 90%. The time-to-event curves are encouraging regarding time to weaning, downsizing, decannulation, and discharge. A combined procedure minimizes the risk of virus transmission to healthcare providers in addition to decreasing the number of anesthetic episodes, transfusions, and transfers patients must undergo. This approach should be considered in critically ill COVID-19 patients requiring prolonged mechanical ventilation.


Subject(s)
COVID-19 , Tracheostomy , Gastrostomy , Humans , Prospective Studies , SARS-CoV-2
6.
J Intensive Care Med ; 36(5): 612-616, 2021 May.
Article in English | MEDLINE | ID: covidwho-978875

ABSTRACT

BACKGROUND: Covid-19 pandemic has resulted in the development of severe and persistent respiratory failure requiring long term ventilatory support. This necessitates the need for a reliable and easy to implement tracheostomy protocol given the concern for viral transmission risk to the involved healthcare personnel due to the aerosol generating nature of the procedure. We describe a protocol with unique and novel modifications to the Ciaglia dilatational percutaneous tracheostomy, effectively implemented during the Covid-19 pandemic at our institution. METHODS: We describe the baseline characteristics of our initial 11 patients who underwent the procedure. Outlined are the healthcare personnel involved and the steps which are organized into 4 phases: planning, pre-procedure, intra-procedure and post-procedure. We have tracked procedural duration, provider safety as well as the development of new complications. RESULTS: We describe use of this protocol for 11 bedside percutaneous tracheostomies performed on patients with COVID-19. The average total procedural duration as well as incision to tracheostomy tube placement times was 32.6 minutes and 5.8 minutes respectively. All 3 providers performing the tracheostomies remained asymptomatic with negative COVID-19 RT-PCR testing at 3 weeks. CONCLUSIONS: We report an efficacious and adaptable protocol for elective bedside percutaneous tracheostomies for patients with persistent ventilatory requirements due to COVID-19 with an intent to provide standardized and safe care for the patient and the involved healthcare personnel.


Subject(s)
COVID-19 , Critical Pathways , Occupational Exposure/prevention & control , Personal Protective Equipment/standards , Respiratory Insufficiency , Tracheostomy , COVID-19/complications , COVID-19/physiopathology , COVID-19/prevention & control , Critical Pathways/organization & administration , Critical Pathways/trends , Female , Health Personnel , Humans , Infection Control/methods , Male , Middle Aged , Patient Care Team/organization & administration , Proof of Concept Study , Respiratory Insufficiency/etiology , Respiratory Insufficiency/therapy , SARS-CoV-2/isolation & purification , Safety Management , Tracheostomy/methods , Tracheostomy/trends , United States
7.
Respir Care ; 65(11): 1773-1783, 2020 11.
Article in English | MEDLINE | ID: covidwho-695569

ABSTRACT

The COVID-19 pandemic has profoundly affected health care delivery worldwide. A small yet significant number of patients with respiratory failure will require prolonged mechanical ventilation while recovering from the viral-induced injury. The majority of reports thus far have focused on the epidemiology, clinical factors, and acute care of these patients, with less attention given to the recovery phase and care of those patients requiring extended time on mechanical ventilation. In this paper, we review the procedures and methods to safely care for patients with COVID-19 who require tracheostomy, gastrostomy, weaning from mechanical ventilation, and final decannulation. The guiding principles consist of modifications in the methods of airway care to safely prevent iatrogenesis and to promote safety in patients severely affected by COVID-19, including mitigation of aerosol generation to minimize risk for health care workers.


Subject(s)
Coronavirus Infections , Device Removal/methods , Gastrostomy , Infection Control , Pandemics , Pneumonia, Viral , Tracheostomy , Ventilator Weaning/methods , Betacoronavirus , COVID-19 , Coronavirus Infections/complications , Coronavirus Infections/surgery , Coronavirus Infections/therapy , Critical Care/methods , Critical Care/standards , Gastrostomy/instrumentation , Gastrostomy/methods , Humans , Infection Control/instrumentation , Infection Control/methods , Infection Control/standards , Pneumonia, Viral/complications , Pneumonia, Viral/surgery , Pneumonia, Viral/therapy , Respiration, Artificial/methods , Risk Adjustment , SARS-CoV-2 , Tracheostomy/instrumentation , Tracheostomy/methods
8.
Nurs Stand ; 35(8): 76-82, 2020 08 05.
Article in English | MEDLINE | ID: covidwho-644318

ABSTRACT

A tracheostomy is a surgical procedure that involves creating an opening and inserting a tube in the trachea to enable air transit from the external atmosphere to the lungs. The insertion of a tracheostomy is a common procedure used to wean patients from mechanical ventilation and to manage patients with upper respiratory tract complications. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has resulted in many patients requiring a tracheostomy as part of respiratory management. The two most commonly used tracheostomy insertion procedures are the open surgical tracheostomy and the percutaneous dilatation tracheostomy, both of which are associated with a range of complications. This article outlines the indications, benefits and complications of tracheostomy insertion, as well as the various types of tracheostomy tube that may be used. It also explains the role of the nurse in caring for patients before, during and after tracheostomy insertion, including the management of tracheostomy-related complications and emergencies.


Subject(s)
Nurse's Role , Respiration, Artificial , Tracheostomy , Betacoronavirus , COVID-19 , Coronavirus Infections , Humans , Intensive Care Units , Pandemics , Pneumonia, Viral , Respiration, Artificial/methods , SARS-CoV-2 , Tracheostomy/methods , United Kingdom
9.
HNO ; 68(11): 828-837, 2020 Nov.
Article in German | MEDLINE | ID: covidwho-591841

ABSTRACT

BACKGROUND: Since emergence of the new coronavirus in China in December 2019, many countries have been struggling to control skyrocketing numbers of infections, including among healthcare personnel. It has now been clearly demonstrated that SARS-CoV­2 resides in the upper airways and transmits easily via aerosols and droplets, which significantly increases the risk of infection when performing upper airway procedures. Ventilated COVID-19 patients in a critical condition in the intensive care unit may require tracheotomy for long-term ventilation and to improve weaning. However, the risk of secondary infection of medical personnel performing subsequent tracheostomy care remains unclear. OBJECTIVE: This study aimed to evaluate the risk of droplet dispersion during tracheostomy tube change and overview tracheostomy tube change in COVID-19 patients. MATERIALS AND METHODS: The current literature was reviewed, quantitative and qualitative analyses of droplet formation during tracheostomy tube change in n = 8 patients were performed, and an overview of and checklist for tracheostomy tube change were compiled. RESULTS: This study demonstrates that tracheostomy tube change, in particular insertion of the new tube, may cause significant droplet formation. The aerosolization of particles smaller than 5 µm was not analyzed. CONCLUSION: Our data, together with the current literature, clearly emphasize that tracheostomy care is associated with a high infection risk and should only be performed by a small group of well-trained, maximally protected healthcare personnel.


Subject(s)
Coronavirus Infections/therapy , Infectious Disease Transmission, Patient-to-Professional/prevention & control , Intubation, Intratracheal/adverse effects , Pneumonia, Viral/therapy , Tracheostomy , Aerosols , Betacoronavirus , COVID-19 , Humans , Pandemics , SARS-CoV-2
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