Institutional analysis of intra- and post-operative tracheostomy management for risk reduction.

Objectives: Determine variability in intra- and post-operative management of tracheostomies (trachs) at our institution as existing literature suggests that trachs are a frequent trigger for airway-related emergencies. Catalyze the development of an institution-wide protocols for trach care. Methods: A 39-question online survey was sent to 55 providers who perform open and percutaneous trachs at three of the hospitals within our large, urban, academic medical center. These providers were identified by surveillance of the operating room schedules for 1 year. Results: The survey was completed by 40 of the 53 eligible providers (75.5%). Response rate by question varied. Respondents included members of all departments that perform trachs at our institution (Otorhinolaryngology, Trauma Surgery, Thoracic Surgery, General Surgery, Cardiovascular Surgery and Interventional Pulmonology).While most responses demonstrated uniformity in practice, notable variations included the following: 80% of percutaneous trach providers stated that morbid obesity was not a contraindication to performing a trach outside of the operating room (n = 20) while 58% of open trach providers stated that morbid obesity was a contraindication; only 35% of open trach providers perform a Bjork flap (n = 350). The survey also identified significant variability in practice with regards to timing of trach suture removal. Discussion: Lack of uniformity was identified in several practices related to intra- and post-operative tracheostomy care. Results did, however, trend toward consensus in many areas. The results are being used to establish a more consistent approach to tracheostomy management across our institution to ensure standardization of practice amidst the rapidly evolving practices of trach placement. Implications for practice: With ongoing evolution in the methods of trach placement and its management, the concepts put forth here will be a resource for health care providers at other institutions to consider intra-institutional analysis and establishment of practice standardization.

Nuances and Management of Hilar Submandibular Sialoliths With Combined Transoral Robotic Surgery-Assisted Sialolithotomy and Sialendoscopy.

OBJECTIVE: To describe the management, technical nuances, and success rates of transoral robotic surgery (TORS)-assisted sialolithotomy. STUDY DESIGN: Retrospective database review. SETTING: Quaternary academic medical center. METHODS: Between the months of January 2015 and May 2019, patients with hilar submandibular gland stones underwent 2 main variations of TORS-assisted sialolithotomy and sialendoscopy: (1) TORS followed by sialendoscopy for patients with palpable predominantly single stones and (2) either sialendoscopy followed by TORS and sialendoscopy or sialendoscopy followed by TORS only for patients with nonpalpable or multiple stones. Clinical charts were reviewed to collect data, including stone size (imaging review, intraoperative measurement), palpability, duration of operation, TORS variation, operative challenges, symptom improvement, gland preservation rate, and complications. RESULTS: Thirty-seven patients were identified. Patients were 26 to 80 years old (mean, 57.2 years), and 40.5% were female. Twenty-four patients (64.9%) underwent TORS followed by sialendoscopy; 10 (27.0%), sialendoscopy followed by TORS and sialendoscopy; and 3 (8.1%), sialendoscopy followed by TORS only. The mean stone size was 12.4 mm (range, 4-28 mm). Eleven patients had multiple stones with a mean 4 stones per patient (range, 2-9). Procedural success was 91.9% (34/37) at a mean follow-up of 34.2 weeks (range, 1.4-262.1), and the gland preservation rate was 97.3% (36/37). No patients reported symptoms of lingual nerve injury at 3-month follow-up. CONCLUSION: TORS combined with sialendoscopy for hilar submandibular gland sialolithiasis allows for improved visualization of critical anatomy, tissue manipulation, and operative flexibility. In our experience, the operative success rate is high, and duration of surgery compares favorably with conventional combined hilar approaches.

Outcomes After Tracheostomy in COVID-19 Patients.

OBJECTIVE: To determine the outcomes of patients undergoing tracheostomy for COVID-19 and of healthcare workers performing these procedures. BACKGROUND: Tracheostomy is often performed for prolonged endotracheal intubation in critically ill patients. However, in the context of COVID-19, tracheostomy placement pathways have been altered due to the poor prognosis of intubated patients and the risk of transmission to providers through this highly aerosolizing procedure. METHODS: A prospective single-system multi-center observational cohort study was performed on patients who underwent tracheostomy after acute respiratory failure secondary to COVID-19. RESULTS: Of the 53 patients who underwent tracheostomy, the average time from endotracheal intubation to tracheostomy was 19.7 days ±â€Š6.9 days. The most common indication for tracheostomy was acute respiratory distress syndrome, followed by failure to wean ventilation and post-extracorporeal membrane oxygenation decannulation. Thirty patients (56.6%) were liberated from the ventilator, 16 (30.2%) have been discharged alive, 7 (13.2%) have been decannulated, and 6 (11.3%) died. The average time from tracheostomy to ventilator liberation was 11.8 days ±â€Š6.9 days (range 2-32 days). Both open surgical and percutaneous dilational tracheostomy techniques were performed utilizing methods to mitigate aerosols. No healthcare worker transmissions resulted from performing the procedure. CONCLUSIONS: Alterations to tracheostomy practices and processes were successfully instituted. Following these steps, tracheostomy in COVID-19 intubated patients seems safe for both patients and healthcare workers performing the procedure.

Animal Welfare Policy: Implementation in the Context of Wildlife Research--Policy Review and Discussion of Fundamental Issues.

The use of vertebrate animals in research and education in the United States is subject to a number of regulations, policies, and guidelines under the immediate oversight of Institutional Animal Care and Use Committees (IACUCs), which are charged with ensuring the ethical and appropriate use of the animal subjects. In almost all instances, this regulatory and oversight landscape of animal use has been developed around domesticated animals in biomedical research environments. When the research activities involve wild species, especially in their natural habitat rather than a laboratory, oversight personnel and investigators alike struggle with determining what constitutes ethical and appropriate activities. These difficulties stem from fundamental differences in biology between wild and domesticated animals and from the differences in research objectives and methods in wildlife compared with biomedical research. Here we discuss the various policies, regulations, and guidance documents for animal use in the context of wildlife research. We compare the expectations of the various oversight agencies and how these expectations are met when working with wild vertebrates. We make recommendations for how IACUCs can use available resources to ensure that activities involving wild species are conducted in compliance with existing regulations and policies and in ways that are biologically appropriate for these nondomesticated species.

Fundamental differences between wildlife and biomedical research.

Non-human animals have starred in countless productions of biological research. Whether they play the lead or supporting role depends on the nature of the investigation. These differences in the roles of animals affect nearly every facet of animal involvement, including: the choice of species, the sample size, the source of individuals, and the settings in which the animals are used. These roles establish different baselines for animal use that require substantially different ethical considerations. Efficient and appropriate oversight of wildlife research benefits the animals and their investigators. Toward that end, Institutional Animal Care and Use Committee (IACUCs) must appreciate the profound differences between biomedical and wildlife research and recognize the value of the state and federal permitting processes required for wildlife studies. These processes assure us that potential impacts beyond the level of the individual are minimal or are justified. Most importantly, IACUCs must recognize that they, and their investigators, have an obligation to use appropriate guidelines for evaluating wildlife research.

Wildlife researchers running the permit maze.

The study of wildlife, whether in the field or in the lab, may start with a hypothesis, a literature search, or a grant proposal, but in many cases, the work will never happen unless the researcher successfully navigates a maze of permit requirements. A single project can involve multiple permits at the national and state levels, and it can take months to obtain any one permit. Therefore, permits may not have been issued at the time of protocol review, but Public Health Service Policy makes accommodations for this situation. Once in hand, however, the permits convey critical information to the Institutional Animal Care and Use Committee (IACUC): one or more government agencies have determined that the activity will not be detrimental to the population or that any detriment is justified by the scientific knowledge that will be generated. This paper assumes that IACUCs are reviewing all wildlife protocols involving live vertebrates, regardless of the current, albeit temporary, distinction made by Animal and Plant Health Inspection Service Animal Care with regard to birds.