Effect of Paediatric Rehabilitation in Infantile Systemic Hyalinosis: A Case Report.

Infantile systemic hyalinosis (ISH) is a very rare autosomal recessive disorder, which is characterized by a systemic build-up of hyaline material that causes extensive tissue destruction and functional impairment. The signs of this debilitating illness, which can involve organs, skin anomalies, and joint contractures, frequently appear in infancy. The paucity of available research on ISH emphasizes the need for all-encompassing management approaches to address the wide range of symptoms and enhance the overall quality of life for impacted babies. The interdisciplinary approach to ISH highlights the need for physiotherapy as a crucial element, with an emphasis on addressing the motor and developmental problems linked to the illness. Improving mobility and functional independence in newborns with ISH is facilitated by therapeutic exercises designed specifically for their needs. Here, we present a case of a six-month-old male child who visited a tertiary care center with complaints of minimal movements of all four limbs since birth with the inability to hold the neck. On examination, it was found that there were low-set ears with popular rashes and contractures over distal joints. Electromyography (EMG) and nerve conduction velocity (NCV) were done, which had abnormal findings suggestive of myopathy. On skin biopsy, it was confirmed that the child was suffering from ISH. Thus, the patient was referred to a physiotherapist. After six weeks of physiotherapy sessions, it was found that early and consistent physiotherapy interventions have been linked to a decrease in joint stiffness-related pain and discomfort, improving the affected infants' general comfort. Furthermore, physiotherapy interventions have a crucial role in supporting adaptive methods to get around physical restrictions, making it easier for infants with ISH to reach developmental milestones that could otherwise be difficult. Although there is little research on the effects of physical therapy on infants with ISH, new data indicate that a proactive, tailored physical therapy program can greatly enhance the functional ability of impacted children, improve their overall quality of life, and avert further problems. It is crucial to incorporate physiotherapy into the comprehensive care of infants diagnosed with ISH. This highlights the significance of timely diagnosis, interdisciplinary cooperation, and continuous research aimed at improving and optimizing physiotherapeutic therapies for this uncommon and crippling genetic illness.

Curosurf surfactant application on preterm babies with respiratory complications-health-economic benefits.

Background: The implementation of surfactant for respiratory syndrome approbates the therapy as a revolutionary method in intensive neonatal therapy and respiratory resuscitation. It is important to investigate the costs of this treatment. Objective: The aim of the study is to analyze the data by the application of the surfactant Curosurf to preterm babies with respiratory complications and describe the treatment costs, healthcare resource utilization and evaluate economic benefits of surfactant use in the treatment of neonates with respiratory distress syndrome (RDS) and hyaline-membrane disease (HDM). Methods: A retrospective survey was performed covering 167 babies based on respiratory complications due to preterm birth and the necessity to apply a surfactant therapy. A documentary method was implemented and for each patient, an individual research protocol was filled out - a questionnaire created specifically for the purposes of the study. Results and discussion: An analysis of the data from the application of CUROSURF was made and the obtained therapeutic results were compared to expenditures for the therapy, short-term therapeutic effect, benefits and consequences of the therapy of preterm newborns with respiratory complications. The application of CUROSURF to babies with RDS resulted in the realization of net savings due to the elimination of the necessity of conducting several diagnostic and therapeutic procedures as well as their duration reduction of hospital stay, thus defining its health-economic benefits. Conclusions: The models of evaluation of cost effectiveness reveal that the medicinal product is expensive but effective from the aspect of short-term therapeutic results.

Preoperative three-dimensional lung volumetry predicts respiratory complications in patients undergoing major liver resection for colorectal metastases.

Colorectal liver metastases (CRLM) are the predominant factor limiting survival in patients with colorectal cancer and liver resection with complete tumor removal is the best treatment option for these patients. This study examines the predictive ability of three-dimensional lung volumetry (3DLV) based on preoperative computerized tomography (CT), to predict postoperative pulmonary complications in patients undergoing major liver resection for CRLM. Patients undergoing major curative liver resection for CRLM between 2010 and 2021 with a preoperative CT scan of the thorax within 6 weeks of surgery, were included. Total lung volume (TLV) was calculated using volumetry software 3D-Slicer version 4.11.20210226 including Chest Imaging Platform extension ( http://www.slicer.org ). The area under the curve (AUC) of a receiver-operating characteristic analysis was used to define a cut-off value of TLV, for predicting the occurrence of postoperative respiratory complications. Differences between patients with TLV below and above the cut-off were examined with Chi-square or Fisher's exact test and Mann-Whitney U tests and logistic regression was used to determine independent risk factors for the development of respiratory complications. A total of 123 patients were included, of which 35 (29%) developed respiratory complications. A predictive ability of TLV regarding respiratory complications was shown (AUC 0.62, p = 0.036) and a cut-off value of 4500 cm3 was defined. Patients with TLV < 4500 cm3 were shown to suffer from significantly higher rates of respiratory complications (44% vs. 21%, p = 0.007) compared to the rest. Logistic regression analysis identified TLV < 4500 cm3 as an independent predictor for the occurrence of respiratory complications (odds ratio 3.777, 95% confidence intervals 1.488-9.588, p = 0.005). Preoperative 3DLV is a viable technique for prediction of postoperative pulmonary complications in patients undergoing major liver resection for CRLM. More studies in larger cohorts are necessary to further evaluate this technique.

Intraoperative dexamethasone is associated with a lower risk of respiratory failure in thoracic surgery: Observational cohort study (SURTHODEX).

BACKGROUND: Postoperative complications, particularly respiratory complications, are of significant clinical concern in patients undergoing elective thoracic surgery. Dexamethasone (DXM), commonly administered to prevent postoperative nausea and vomiting (PONV), has potential anti-inflammatory effects that might be beneficial in reducing these complications. We aimed to investigate whether intraoperative DXM administration could mitigate the occurrence of respiratory complications following elective thoracic surgery. METHODS: We conducted a single-center observational study, including patients who underwent elective thoracic surgery from 2012 to 2020. The primary outcome was the onset of acute respiratory failure within 7 days post-surgery. Secondary outcomes encompassed other postoperative complications, duration of hospital stay, and mortality within 30 days post-surgery. An overlap propensity score analysis was employed to estimate the treatment effect. RESULTS: We included 1,247 adult patients, 897 who received dexamethasone (DXM) and 350 who served as controls. Intraoperative dexamethasone administration was associated with a significant reduction in respiratory complications with an adjusted relative risk (RR) of 0.65 (95% CI: 0.43-0.97). There was also a significant decline in composite infectious criteria with an adjusted RR of 0.76 (95% CI: 0.63-0.93). Cardiac complications were also assessed as a composite criterion, and a significant reduction was observed (adjusted RR, 0.68; 95% CI, 0.51-0.9). However, there were no association with mechanical complications, mortality within 30 days (adjusted RR of 0.43, 95% CI: 0.17-1.09) or in the length of hospital stay (adjusted RR of 0.85, 95% CI: 0.71-1.02). CONCLUSIONS: Dexamethasone administration was associated with a reduction in postoperative respiratory complications. Further prospective studies are needed to confirm these findings.

Effectiveness of implementing a standardized perioperative pain management protocol in children undergoing tonsillectomy: A quality improvement project.

BACKGROUND AND PURPOSE: Tonsillectomy procedures are commonly performed worldwide. At our academic tertiary care facility, we perform approximately 1000 tonsillectomy procedures annually. We have found inconsistent pain management strategies in pediatric tonsillectomy patients have contributed to variability in postoperative complications and the number and types of postoperative pain medications required in the Post Anesthesia Care Unit (PACU). This project aimed to assess the impact of implementing a standardized perioperative pain management protocol on reducing postoperative complications in pediatric patients who underwent a tonsillectomy procedure. METHODS: A pre-post-intervention design was utilized, comparing characteristics and outcomes of pediatric patients for whom a standardized perioperative pain management protocol was implemented over a 12-week period compared to those who did not. The standardized perioperative pain management protocol was utilized intraoperatively by the anesthesiologists, nurse anesthetists, and residents. A Qualtrics survey was used by the Post Anesthesia Care Unit (PACU) nurses to gather data as they cared for patients who underwent tonsillectomy. Four outcomes were measured: (1) postoperative pain medication administration, (2) rate of postoperative respiratory complications, (3) rate of adherence, and (4) usability of a standardized pain management protocol. Data were compared between pre and post-implementation groups. RESULTS: During the quality improvement project, 180 children underwent tonsillectomy, with 81 in the control group and 99 in the intervention group. The median age did not differ between groups. The control group had higher postoperative opioid medication usage (93.8% vs. 54.5%) and a higher number of opioids administered in the recovery room. Postoperative IV fentanyl was reduced in the intervention group (49.4% vs. 28.3% in the intervention, p = .004). Respiratory interventions were more frequent in the control group (24.7% vs. 7.1%), with increased respiratory team activation. Respiratory team activation in the Post Anesthesia Care Unit (PACU) includes a 511 page for anesthesia provider assistance. Respiratory interventions included bag-mask ventilation, lidocaine, propofol or succinylcholine administration, and reintubation. The intervention group had 100% adherence to the pain management protocol, and providers found it easy to use. CONCLUSION: The quality improvement project highlighted notable improvements in the intervention group for whom a standardized perioperative pain management protocol was used, including reduced opioid medication administration, lower incidence of respiratory interventions, and high adherence to the pain management protocol. These findings underscore the effectiveness and feasibility of standardized protocols in enhancing patient outcomes.

Respiratory Complications after Cystectomy with Urinary Diversion: Avoidable Complications or Ineluctable Destiny?

Background: Cystectomy with urinary diversion (CUD) is a highly morbid surgery. Despite implementing an enhanced recovery after surgery (ERAS®) protocol, postoperative respiratory complications (PRC) within 30 days after surgery remain frequent. This study aims to identify patients at higher risk of developing PRC after CUD. Methods: We conducted a retrospective analysis of 242 patients who underwent CUD at Lausanne University Hospital from 2012 to 2022, adhering to ERAS® guidelines. Data on postoperative complications, including pneumonia, respiratory failure, pulmonary embolism, lobar atelectasis, and pleural effusion, were analyzed. Chi-square and Mann-Whitney U tests compared patients with and without PRC. A multivariable Cox model identified independent prognostic factors. Results: PRC occurred in 41 patients (17%). Those with PRC experienced longer hospital stays and higher 30-day mortality rates. Poor ERAS® compliance was a significant risk factor. Multivariable analysis showed pneumonia was associated with postoperative ileus, while pulmonary embolism correlated with infectious and cardiovascular complications. Conclusions: PRC result in extended hospitalization and decreased survival. Rigorous adherence to ERAS® protocols, including early mobilization, respiratory physiotherapy, and avoiding nasogastric tubes, is essential for preventing PRC.

The role of overnight pulse oximetry in risk stratification of paediatric sleep disordered breathing in a district general hospital.

OBJECTIVES: Adenoidectomy and tonsillectomy are common surgical interventions in paediatric patients with sleep disordered breathing. Post operative respiratory complications are a recognised risk, and pre-operative risk stratification of patients is important to enable safe delivery of peri-operative care. Due to easy accessibility, overnight pulse oximetry is commonly used for this purpose. However, its limitations have been widely reported and recent national guidance recommends limiting use to patients with significant risk factors. We reviewed the use of overnight pulse oximetry in our local unit to determine if local guidelines should be adapted in line with these national recommendations. METHODS: Retrospective analysis of all paediatric patients referred for overnight pulse oximetry over an eighteen month period between August 2020 to February 2022. Data collection included patient age, weight, and relevant co-morbidities. The McGill score was used to risk stratify patients and determine the need for an overnight bed. This was then correlated with the occurrence of post operative respiratory complications. RESULTS: 200 patients were referred for overnight pulse oximetry, with a mean age of 7.5 years. 7.5 % (15/200) had significant comorbidities. 64 % (128/200) of patients were subsequently listed for surgery. 20.3 % (26/128) were deemed at risk of post-operative complications due to McGill scores of 3 and 4 and planned for overnight ward observation. Of these, 15 % (4/26) were subsequently discharged the same day. None of our patients developed major respiratory complications in the post operative period. CONCLUSION: Our findings support national recommendations that overnight pulse oximetry is not an accurate predictor of post-operative respiratory complications and resulted in unnecessary inpatient stays. Following discussion with the trust paediatric anaesthetist lead, our local guidance was tightened, limiting overnight pulse oximetry to children with relevant identifiable co-morbidities.

Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty.

STUDY OBJECTIVES: Postoperative respiratory complications (PORCs) can occur following supraglottoplasty (SGP) for obstructive sleep apnea. However, there are very limited data on risk factors associated with these complications. This study aims to evaluate the occurrence of PORC in children undergoing SGP and to assess clinical factors and polysomnographic parameters predicting these complications. METHODS: A retrospective study was performed in children with laryngomalacia who underwent SGP with preoperative polysomnography. RESULTS: 400 children who underwent SGP met the criteria for entry into the analysis with a total of 416 surgeries with corresponding preoperative polysomnography. The median age (interquartile range) at the time of polysomnography was 0.4 (0.2, 1.5) years. A total of 96 (23.1%) PORCs were noted. Compared with those without complications, children with PORCs had a higher proportion of congenital heart disease (P < .05), higher median obstructive apnea-hypopnea index (obstructive AHI; median 16.0 vs 11.4 events/h; P < .01), and lower median oxygen saturation (SpO2) (P < .001). The unadjusted odd ratio indicated an increased risk of PORCs in children with congenital heart disease (odds ratio 1.66; P < .05) and those with an obstructive AHI > 10 events/h (odds ratio 2.06; P < .01). Multiple regression analysis demonstrated that an obstructive AHI > 10 events/h was the only independent risk factor for PORCs (P < .05). CONCLUSIONS: In our cohort of children with laryngomalacia undergoing SGP, those with underlying congenital heart disease, higher obstructive AHI, and lower SpO2 were more likely to develop PORCs. Only children with an obstructive AHI > 10 events/h were at significantly increased risk for PORCs following SGP. Preoperative polysomnography is useful in preoperative planning in children undergoing SGP. CITATION: Kanavitoon S, Ngamprasertwong P, Gurbani N, et al. Polysomnographic parameters and clinical risk factors predicting postoperative respiratory complications in children undergoing supraglottoplasty. J Clin Sleep Med. 2024;20(1):9-16.

Investigating immediate postoperative medical complication risks relative to in-hospital length of stay after total shoulder arthroplasty.

Background: The purpose of this study was to investigate the association between in-hospital length of stay (LOS) and postoperative complication rates within 30 days of total shoulder arthroplasty (TSA). Methods: All patients who underwent either anatomic or reverse TSA between 2015 and 2019 were queried from the American College of Surgeons National Surgical Quality Improvement database. The study population was stratified into three cohorts as follows: LOS 0 (same-day discharge), LOS 1 (next-day discharge), and LOS 2-3 (LOS of 2-3 days). Patient demographics and comorbidities were compared between cohorts using bivariate analysis. Multivariate logistic regression analysis was conducted to investigate the relationship between LOS and postoperative complications. Results: In comparison to the LOS 0 day cohort, LOS 2-3 day cohort had a greater likelihood of developing overall complication (OR, 2.598; P < .001), major complication (OR, 1.885; P < .001), minor complication (OR: 3.939; P < .001), respiratory complication (OR: 12.979; P = .011), postoperative anemia requiring transfusion (OR, 23.338; P < .001), non-home discharge (OR, 10.430; P < .001), and hospital readmission (OR, 1.700; P = .012). Similarly, in comparison to the LOS 1 cohort, LOS 2-3 cohort had a greater likelihood of developing overall complication (OR: 2.111; P < .001), major complication (OR, 1.423; P < .001), minor complication (OR, 3.626; P < .001), respiratory complication (OR, 2.057; P < .001), sepsis or septic shock (OR: 2.795; P = .008), urinary tract infection (OR, 1.524; P = .031), postoperative anemia requiring transfusion (OR, 10.792; P < .001), non-home discharge (OR: 10.179; P < .001), hospital readmission (OR, 1.395; P < .001), and return to the operating room (OR. 1.394; P = .014). There was no significant difference in the risk of developing postoperative complications between LOS 0 day and LOS 1 day cohort. On baseline, the LOS 1 and LOS 2-3 day cohort had a higher proportion of patients with the following demographics and comorbidities compared to LOS 0 day cohort: advanced age, higher body mass index, female gender, positive smoking status, insulin-dependent diabetes, noninsulin-dependent diabetes, dyspnea at rest and moderate exertion, partially dependent functional status, an American Society of Anesthesiologists classification of 3 or higher, a history of severe chronic obstructive pulmonary disease, a history of congestive heart failure, the use of hypertension medication, disseminated cancer, wound infection, the use of steroids, and a history of bleeding disorder. Conclusion: Patients who were discharged on the same and next day following TSA demonstrated a reduced probability of experiencing respiratory complications, infections, postoperative anemia requiring transfusion, non-home discharge, and readmission in comparison to those with a LOS of 2-3 days. There was no difference in postoperative complications between same and nextday discharged patients. Patients who underwent outpatient arthroplasty were healthier at baseline compared to those who underwent inpatient arthroplasty.

How Lung Volume Recruitment Maneuvers Enhance Respiratory Function in Multiple Sclerosis Patients: A Quasi-Randomized Pilot Study.

Background and Objectives: In patients with multiple sclerosis (MS), a decrease in muscle strength can lead to limitations in pulmonary functions, potentially causing respiratory complications. To address these challenges, the lung volume recruitment (LVR) maneuver has emerged as a potential intervention. This study sought to evaluate the impact of a four-week LVR protocol on respiratory function in secondary progressive MS patients. Materials and Methods: In a quasi-randomized pre/post-controlled trial, 24 patients with secondary progressive MS were recruited. Participants aged 20-70 years with an EDSS score of 2 to 9 were alternately allocated to intervention (n = 12) or control groups (n = 12). The intervention group underwent a 4-week respiratory rehabilitation training focused on LVR, using a standardized cough machine treatment protocol twice daily. The control group received no respiratory intervention. Outcomes measured included forced vital capacity (FVC), maximal insufflation capacity (MIC), and peak cough flow (PCF), using turbine spirometry and other associated equipment. All measurements were taken at baseline (T0) and after 4 weeks (T1) by a blinded assessor. Results: For the intervention group, the mean difference pre/post-treatment in MIC (mL) was 0.45 (SD 1.13) (p = 0.02), and in MIC (%), it was 0.13 (SD 0.24) (p = 0.03). Compared to the control group (n = 10), the between-group mean difference for MIC (mL) was 0.54 (p = 0.02), and for MIC (%), it was 0.15 (p = 0.02). Conclusions: The short-term daily LVR protocol notably improved passive lung capacity, despite minimal changes in active lung capacity or cough force. The LVR maneuver offers promise for enhancing respiratory function, especially passive lung capacity, in secondary progressive MS patients. Further research should explore optimal treatment durations and frequencies for more extensive respiratory gains.

Peri-partum respiratory management of pregnant women with neuro-muscular disorders: a prospective observational study (IT-NEUMA-Pregn study).

BACKGROUND: Pregnant women with neuromuscular diseases (NMDs) often display respiratory muscle impairment which increases the risk for pulmonary complications (PCs). The aim of this study was to identify pregnant NMDs patients with pulmonary risk factors and to apply in these women non-invasive ventilation (NIV) combined with mechanical insufflation-exsufflation (MI-E) in the peri-partum period. METHODS: We conducted a multicenter observational study on women with NMDs undergoing cesarean section or spontaneous labor in a network of 7 national hospitals. In these subjects we applied a protocol for screening and preventing PCs, and we evaluated PCs rate, maternal and neonatal outcome. RESULTS: Twenty-four patients out of the 94 enrolled pregnant women were at risk for PCs and were trained or retrained to use NIV and/or MI-E before delivery. After delivery, 17 patients required NIV with or without MI-E. Despite nine out of the 24 women at pulmonary risk developed postpartum PCs, none of them needed reintubation nor tracheostomy. In addition, the average birth weight and Apgar score were normal. Only one patient without pulmonary risk factors developed postpartum PCs. CONCLUSION: This study showed the feasibility of applying a protocol for screening and treating pregnant NMDs women with pulmonary risk. Despite a PCs rate of 37% was observed in these patients, maternal and neonatal outcome were favorable.

Monitoring and Management of Respiratory Function in Pompe Disease: Current Perspectives.

Pompe disease (PD) is a neuromuscular disorder caused by a deficiency of acid alpha-glucosidase (GAA) - a lysosomal enzyme responsible for hydrolyzing glycogen. GAA deficiency leads to accumulation of glycogen in lysosomes, causing cellular disruption. The severity of PD is directly related to the extent of GAA deficiency - if no or minimal GAA is produced, symptoms are severe and manifest in infancy, known as infantile onset PD (IOPD). If left untreated, infants with IOPD experience muscle hypotonia and cardio-respiratory failure leading to significant morbidity and mortality in the first year of life. In contrast, late-onset PD (LOPD) patients have more GAA activity and present later in life, but also have significant respiratory function decline. Despite FDA-approved enzyme replacement therapy, respiratory insufficiency remains a major cause of morbidity and mortality, emphasizing the importance of early detection and management of respiratory complications. These complications include impaired cough and airway clearance, respiratory muscle weakness, sleep-related breathing issues, and pulmonary infections. This review aims to provide an overview of the respiratory pathology, monitoring, and management of PD patients. In addition, we discuss the impact of novel approaches and therapies on respiratory function in PD.

Bronchopleural fistula associated persistent pneumothorax in a patient recovering from COVID-19 pneumonia: A case report.

Key Clinical Message: Pneumothorax and bronchopleural fistula (BPF) are potentially fatal complications that can occur in patients with COVID-19 pneumonia. Early detection, appropriate treatment, and consideration of surgical intervention are necessary for optimum outcomes. Introduction: Healthcare professionals face complex challenges as a result of the rare emergence of pneumothorax among the variety of COVID-19 complications, including severe viral pneumonia. Case History: A 57-year-old male with multiple comorbidities diagnosed with COVID-19 pneumonia was admitted to our center and exhibited bilateral crepitations. During hospitalization, the patient developed right-sided pneumothorax that persisted despite chest tube insertion was linked to the presence of BPF. Discussion: The occurrence of pneumothorax in COVID-19 patients is relatively rare risk factors for which are not yet fully understood, although smoking history may play a role. Conservative management is recommended for asymptomatic cases, while intercostal drainage is necessary for symptomatic patients. Surgical intervention may be required to manage the BPF in some instances. Conclusion: Pneumothorax and BPF are rare but potentially life-threatening complications in patients recovering from COVID-19 pneumonia. Early recognition, appropriate treatment, and consideration of surgical intervention are crucial for optimizing patient outcomes.

Esophageal cancer operation in the COVID-19 era: are the outcomes different from its past in an observational cohort study?

COVID-19 spread rapidly and potentially affected every medical profession, including surgery. This study aims to compare the postoperative outcomes of oesophageal cancer surgeries in COVID-19 age and a year before. Methods: This retrospective cohort study was performed as a single-centred study from March 2019 to March 2022 at Cancer institute, Tehran, Iran. Demographic data, cancer type, surgical procedures, and postoperative outcomes and complications were compared between the two groups pre-COVID-19 and during the COVID-19 pandemic. Results: Totally, 120 patients enroled in the study, of which 57 underwent surgery before the COVID-19 pandemic, and 63 during the COVID-19 pandemic. The mean age in these groups was 56.9 (±12.49) and 58.11 (±11.43), respectively. Females included 50.9% and 43.5% of individuals who underwent surgery before and during the COVID-19 pandemic. The interval between admission and surgery was significantly shorter in patients underwent surgery during the COVID-19 pandemic (5.17 vs. 7.05; P=0.013). However, there was no significant difference between time interval between surgery and discharge [11.68 (7.81) vs. 12 (6.92); P=0.689]. Aspiration pneumonia was the most common complication in both groups. There was no significant difference between postoperative complications in both groups. Conclusion: Outcomes of oesophageal cancer surgeries in COVID-19 age in our institution were comparable with the year before the pandemic. The decrease in the time interval between surgery and discharge did not lead to an increase in postoperative complications and could be noted for post-COVID-19 era policymaking, too. This study suggests not postponing any of the surgical treatments for oesophageal cancer in the COVID-19 era.

TBCK syndrome: a rare multi-organ neurodegenerative disease.

TBCK syndrome is an autosomal recessive disorder primarily characterized by global developmental delay, hypotonia, abnormal magnetic resonance imaging (MRI), and distinctive craniofacial phenotypes. High variability is observed among affected individuals and their corresponding variants, making clinical diagnosis challenging. Here, we discuss recent breakthroughs in clinical considerations, TBCK function, and therapeutic development.

Documentation of Assessments and Interventions Using a Pediatric Preoperative Risk Assessment Checklist in the Postanesthesia Care Unit: A Quality Improvement Initiative.

PURPOSE: Describe the impact of the implementation of an evidence-based pediatric preoperative risk assessment (PPRA) checklist on the frequency of postanesthesia care unit (PACU) nursing assessments and interventions in children at risk for respiratory complications during emergence from anesthesia. DESIGN: Prospective pre-/postdesign. METHODS: Pediatric perianesthesia nurses assessed 100 children preintervention according to current standard. After nurses received pediatric preoperative risk factor (PPRF) education, another 100 children were assessed postintervention using the PPRA checklist. Pre-/postpatients were unmatched for statistical purposes due to two different groups. Frequency of PACU nursing respiratory assessments/interventions was evaluated. FINDINGS: Demographic variables, risk factors, frequency of nursing assessments/interventions were summarized in pre-/postinterventions. Significant differences (P < .001) were noted between pre-/postintervention groups with increased frequency of postnursing assessments/interventions that correlated with increased risk factors and weighted risk factors. CONCLUSIONS: By identifying total PPRFs, PACU nurses used their plan of care to frequently assess and pre-emptively intervene with children who had increased risk factors to prevent or mitigate respiratory complications on emergence from anesthesia.

Post-COVID-19 syndrome and diabetes mellitus: a propensity-matched analysis of the International HOPE-II COVID-19 Registry.

Background: Diabetes mellitus (DM) is one of the most frequent comorbidities in patients suffering from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) with a higher rate of severe course of coronavirus disease (COVID-19). However, data about post-COVID-19 syndrome (PCS) in patients with DM are limited. Methods: This multicenter, propensity score-matched study compared long-term follow-up data about cardiovascular, neuropsychiatric, respiratory, gastrointestinal, and other symptoms in 8,719 patients with DM to those without DM. The 1:1 propensity score matching (PSM) according to age and sex resulted in 1,548 matched pairs. Results: Diabetics and nondiabetics had a mean age of 72.6 ± 12.7 years old. At follow-up, cardiovascular symptoms such as dyspnea and increased resting heart rate occurred less in patients with DM (13.2% vs. 16.4%; p = 0.01) than those without DM (2.8% vs. 5.6%; p = 0.05), respectively. The incidence of newly diagnosed arterial hypertension was slightly lower in DM patients as compared to non-DM patients (0.5% vs. 1.6%; p = 0.18). Abnormal spirometry was observed more in patients with DM than those without DM (18.8% vs. 13; p = 0.24). Paranoia was diagnosed more frequently in patients with DM than in non-DM patients at follow-up time (4% vs. 1.2%; p = 0.009). The incidence of newly diagnosed renal insufficiency was higher in patients suffering from DM as compared to patients without DM (4.8% vs. 2.6%; p = 0.09). The rate of readmission was comparable in patients with and without DM (19.7% vs. 18.3%; p = 0.61). The reinfection rate with COVID-19 was comparable in both groups (2.9% in diabetics vs. 2.3% in nondiabetics; p = 0.55). Long-term mortality was higher in DM patients than in non-DM patients (33.9% vs. 29.1%; p = 0.005). Conclusions: The mortality rate was higher in patients with DM type II as compared to those without DM. Readmission and reinfection rates with COVID-19 were comparable in both groups. The incidence of cardiovascular symptoms was higher in patients without DM.

Impact of Early Non-Invasive Ventilation in Amyotrophic Lateral Sclerosis: A multicenter Randomized Controlled Trial.

BACKGROUND AND OBJECTIVE: Forced vital capacity (FVC) less than 50% of predicted is one of the main parameters used for Non-Invasive Ventilation (NIV) initiation in Amyotrophic Lateral Sclerosis (ALS). Recent studies suggest that higher values of FVC could be considered as a threshold. The aim of this study is to evaluate whether early use of NIV improves the prognosis of ALS patients compared with standard initiation. METHODS: This is a randomized, parallel, multicenter, open-label, controlled clinical trial, with recruitment at the ALS outpatient multidisciplinary units of six Spanish hospitals. Patients were included when their FVC reached the 75% threshold and were randomized by computer, stratifying by center in an allocation ratio of 1:1 to Early NIV (FVC below 75%) or Standard NIV (FVC below 50%) initiation. The primary outcome was time to death or tracheostomy.Trial registration number ClinicalTrials.gov: NCT01641965. RESULTS: Between May 2012 and June 2014, 42 patients were randomized to two groups, 20 to Early NIV and 22 to Standard NIV initiation. We found differences in survival in favor of the intervention group: an incidence of mortality (2.68 [1.87-5.50] vs. 3.33 [1.34-4.80] person-months) and a median survival (25.2 vs. 19.4 months), although without reaching statistical significance (p = 0.267). CONCLUSIONS: This trial did not reach the primary endpoint of survival; nevertheless, it is the first Randomized Controlled Trial (RCT) to demonstrate the benefits of early NIV in slowing the decline of respiratory muscle strength and reducing adverse events. Although not all the results reached statistical significance, all the analyzed data favor early NIV. In addition, this study demonstrates good tolerance and compliance with early NIV without quality of sleep impairment. These data reinforce the early respiratory evaluation of ALS patients and NIV initiation with an FVC of around 75%.

Impact of Preemptive Postoperative Pressure Support Ventilation and Physiotherapy on Postoperative Pulmonary Complications after Major Cervicofacial Cancer Surgery: A before and after Study.

Introduction: Complex cervicofacial cancer surgery with free flap reconstruction is known to have a high incidence of postoperative pulmonary complications (PPCs). We hypothesized that by implementing an optimized respiratory protocol, including preemptive postoperative pressure support ventilation, physiotherapy, and critical respiratory support and follow-up, we could decrease the incidence of PPCs. Patients and methods: We evaluated the incidence of PPCs over two periods in two groups of patients having a routine or optimized postoperative respiratory protocol: 156 adult patients undergoing major cervicofacial cancer surgery were assessed; 91 were in Group 1 (routine) and 65 were in Group 2 (optimized). In Group 1, no ventilatory support sessions were performed. The incidence of pulmonary complications in both groups was compared using a multivariate analysis. Mortality was also compared until one year postoperatively. Results: In Group 2 with an optimized protocol, the mean number of ventilatory support sessions was 3.7 ± 1 (minimum 2, maximum 6). The incidence of respiratory complications, which was 34% in Group 1 (routine), was reduced by 59% OR = 0.41 (0.16; 0.95), p = 0.043) to 21% for the optimized Group 2. No difference in mortality was found. Conclusions: The present retrospective study showed that using an optimized preemptive respiratory pressure support ventilation combined with physiotherapy after a major cervicofacial surgery could possibly help reduce the incidence of pulmonary complications. Prospective studies are needed to verify these findings.