Bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, pneumoretroperitoneum, and subcutaneous emphysema after percutaneous tracheostomy -A case report-

We report a rare case of a 72-year-old female who developed extensive subcutaneous emphysema, bilateral pneumothoraces, pneumomediastinum, pneumoperitoneum, and pneumoretroperitoneum after a percutaneous dilatational tracheostomy. The patient's T-cannula was accidentally connected to the oxygen line with a non-perforated connector. The patient rapidly developed respiratory insufficiency and subcutaneous emphysema in the neck and both shoulders. The bilateral pneumothoraces were managed using a chest tube. CT scans of the chest, abdomen, and pelvis revealed an extensive distribution of air throughout the chest and abdomen. The patient was treated successfully with supportive care. This case illustrates the rare occurrence of air passing into multiple body compartments, highlighting the potentially serious complications of a tracheostomy and the importance of intensive care during the recovery period

پنوموتوراکس و پنوموپريتوئن به‌دنبال تراکئوستومی

اهداف و زمينه: تراکئوستومی پرکوتانئوس، يک روش جراحی شايع در زمينه اعمال گوش وحلق و بينی است، که با عوارضی مثل خونريزی، عفونت، آمفيزم زيرپوستی، پنوموتوراکس، آسيب عصب راجعه حنجره‌ای و شکستگی حلقه تراشه همراه است. معرفی بيمار: خانم هفتاد ساله ای که قرار بود که تحت تراکئوستومی اورژانس بدليل انسداد ناکامل راه‌هوايی همراه با زجر تنفسی شديد و تنگی‌نفس بدنبال عود کانسر تيروييد مدولاری قرار بگيرد، که حدود دودقيقه پس از کار گذاری تراکئوستومی، فشارخون و اکسيژن شريانی بيمار، افت کرد اما فشار راه هوايی افزايش يافت. در معاينه فيزيکی، صداهای ريوی دوطرف، کاهش، و شکم به صورت ژنراليزه بزرگ شده بود. بلافاصله يک لوله تراشه تا ده سانتی متر وارد منفذ تراکئوستومی شده و به داخل تراشه هدايت شد. با شک به پنوموپريتوئن اقدام به پونکسيون شکم با سرنگ بيست سی سی شد که هوا خارج گرديد. بيمار پس از دو روز بستری در بخش مراقبتهای ويژه بدون عارضه جانبی مرخص شد. مکانيسم های احتمالی که باعث اين مشکل شدند عبارتند از: عدم جای گذاری درست تراکئوستومی به دليل محل تومور، جابه جايی لوله تراکئوستومی و باروتروما. در واقع پارگی ديواره آلوئول ها يا برونش ها موجب انتشار هوا به داخل فضای پلور و ايجاد پنوموتوراکس می شود و بااينکه فضای توراکس و پريتوئن از طريق ديافراگم جدا شده اند، ممکن است بدليل نقائص مادرزادی، ارتباط بين اين دو وجود داشته باشد. بنابراين انجام تراکئوستومی، به خصوص در بيماران دارای توده گردنی می تواند با عوارض جدی و تهديدکننده حيات همراه باشد. باتوجه به وجود چنين خطری، درمان به موقع می تواند باعث کاهش موربيديتی و مورتاليتی شود

Aiding Difficult and High-Stakes Medical Decision Making - Research on Parental Tracheostomy Decisions for Critically Ill Children

This dissertation illustrated the multiple approaches necessary to improving decision making in applied settings. It consists of three studies that aimed to understand high-stakes pediatric tracheostomy decisions and aid parents’ abilities to make these decisions. Chapter 1 involved an interview study of parents who had recently made a tracheostomy decision for their critically ill child. We found that parents were stressed and worried about future outcomes. They sought and desired information and emotional support for making this difficult decision. Despite these efforts, there seemed to exist opportunities to improve their understanding and forecasting of long-term challenges of a tracheostomy placement. Based on the literature of forecasting errors and narrative-form communication, Chapter 2 involved a survey experiment to test a possible intervention approach. It showed that narratives describing challenges that affect the child’s and/or the family’s quality of life from the point of view of parents who had already experienced them reduced parents’ tendency to choose tracheostomy. The effect was particularly strong when the narratives focused on challenges in the child’s quality of life. These narratives also led to less optimistic forecasting. Based on findings from Chapters 1 and 2, Chapter 3 presented a user-centered design process used to create education materials that were designed to help parents understand major challenges in life after a tracheostomy placement. This dissertation extends the literature on using narrative-form communication to help decision makers anticipate future experiences and reduce forecasting errors. It also demonstrates the multiple types of research needed to develop educational communication that is ready for implementation in clinical settings.PHDPsychologyUniversity of Michigan, Horace H. Rackham School of Graduate Studieshttp://deepblue.lib.umich.edu/bitstream/2027.42/162973/1/haoyangy_1.pd

Tracheostomy care and decannulation during the COVID-19 pandemic. A multidisciplinary clinical practice guideline.

PURPOSE: Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. METHODS: This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. RESULTS: Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. CONCLUSION: COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit

Occupational Therapy in the Intensive Care Unit: A Quick Reference Guide

Purpose: The purpose of this project was to create a quick reference guide for occupational therapists treating clients in the intensive care unit (ICU) in order to increase quality of care, decrease medical errors, and improve confidence. Methods: A literature review was conducted to determine the needs of occupational therapists and other health professionals working in the ICU environment. It was discovered that occupational therapists do not receive specific education on treating clients in the ICU and that there are no specific resources for occupational therapists currently available. Rehabilitation is beginning sooner within the ICU in order to decrease client length of stay and hospital costs, which will in turn bring more occupational therapists to work in this area of practice. The increasing number of therapists working in this area, establishes a need for this product. Results: Through the literature review and consultation with the University of North Dakota Simulation Center, a quick reference guide to occupational therapy within the ICU was created to provide occupational therapists with technical information about the person, the environment, and occupations within the ICU. The quick reference guide was designed through the guidance of Person-Environment-Occupation model. Conclusions: In order to provide quality and client centered care within the ICU; it is pertinent for health professionals to have specialized knowledge and skills specific to this area of practice. Through research and personal experience, it was evident that occupational therapists and many health professionals do not feel confident treating clients in the ICU. The limitations of this project include: the quick reference guide has not been piloted, the equipment is constantly advancing requiring the update of equipment in the guide frequently, and that it is not comprehensive and only provides the most relevant pieces of equipment to occupational therapy. Further recommendations for the quick reference guide include: implementing it into the University of North Dakota Occupational Therapy curriculum, use by fieldwork students, utilization by other health care professionals, and the adaptation of the guide for use by families

Hyperfractionated radiotherapy and chemotherapy for chidhood ependymoma: final results of the first prospective AIEOP (Associazione Italiana di Ematologia-Oncologia pediatrica) study

Purpose: A postsurgical “stage-based” protocol for ependymoma was designed. Methods and Materials: Children were given: (1) focal hyperfractionated radiotherapy (HFRT) if with no evidence of disease (NED), or (2) 4 courses with VEC followed by HFRT for residual disease (ED). HFRT dose was 70.4 Gy (1.1 Gy/fraction b.i.d.); VEC consisted of VCR 1.5 mg/m2 1/w, VP16 100 mg/m2/day 3, CTX 3 g/m2 d 1. When feasible, second-look surgery was recommended. Results: Sixty-three consecutive children were enrolled: 46 NED, 17 ED; the tumor was infratentorial in 47 and supratentorial in 16, with spinal metastasis in 1. Of NED patients, 35 of 46 have been treated with HFRT; 8 received conventionally fractionated radiotherapy, and 3 received no treatment. Of the 17 ED patients, 9 received VEC HFRT; violations due to postsurgical morbidity were as follows: HFRT only (2), conventionally fractionated radiotherapy (3) VEC (2), and no therapy (1). Objective responses to VEC were seen in 54%; objective responses to RT were seen in 75%. Overall survival and progression-free survival at 5 years for all 63 children were 75% and 56%, respectively; for the NED subgroup, 82% and 65%; and for the ED subgroup, 61% and 35%, respectively. All histologies were centrally reviewed. At multivariate analysis, grading, age, and site proved significant for prognosis. Conclusions: HFRT, despite the high total dose adopted, did not change the prognosis of childhood ependymoma as compared to historical series: New radiotherapeutic approaches are needed to improve local control. Future ependymoma strategies should consider grading when stratifying treatment indications

The Hapless State of Amyotrophic Lateral Sclerosis in India: A comprehensive look at life and medical services for ALS patients in rural Himachal Pradesh

Amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease is a neurodegenerative disorder that leads to paralysis. The disease requires a high amount of medical intervention and interdisciplinary focus to achieve quality of life for patients. This study looks at ALS patient’s lifestyles, their access to these medical devices, Indian therapeutic approaches and policy that impacts patients in Shimla, Himachal Pradesh. As caretakers have a critical part in the care for this disease, their lives were also considered in the case studies. It was found that ALS patients are not experiencing access to medical devices necessary for life because of physical accessibility barriers, financial barriers and a lack of knowledge about the disease. Knowledge of government healthcare financial policy and awareness of services offered by Asha Ek Hope to improve the access to these devices for ALS patients was not found in the study. Access to one of two pharmaceuticals was found to be achieved across the study group, however, the treatment methods for edaravone were inaccessible because of physical barriers and finances. With no known cure for the disease, the focus switches towards the Indian perspective on life and offering a death with dignity and comfort. It was found that ALS patients and their caregroups do not support passive euthanasia as determined by a 2018 Supreme Court decision while palliative care was found to be inexistent despite a dire need for this supportive care for families and patients living with ALS. The findings of this study shed light on the dire need for support of these patients in accessing devices and political advocacy. This study also brings public health awareness to the rare disease community in India—breaking down the public health and rare disease oxymoron

The Evolution of Aortic Aneurysm Repair: Past Lessons and Future Directions

The history and evolution of aortic aneurysm repair demonstrates an important paradigm within surgery, namely the importance of surgical pioneers and innovators who have\ud strived to achieve technical excellence and improve patient care. It also highlights the wider evolution of surgery from traditional open operative techniques to the modern minimally invasive procedures. The following chapter discusses the surgical innovators and the techniques they have described that have enabled the repair of both thoracic aortic aneurysms (TAA) and abdominal aortic aneurysms (AAA).\ud Aortic aneurysms represent a significant health risk particularly for the elderly population. AAA is the 14th-leading cause of death for the 60- to 85-year–old age group in the United States (10.8 deaths per 100,000 population). TAA by contrast is less frequent with an incidence of 10.4 per 100,000. Both AAA and TAA are known to increase in prevalence with advancing age and have an increased prevalence in males. The risk of aneurysm rupture increases with increasing aneurysm diameter over 5.5-6.0 cm and is the primary indication for the repair of both TAA and AAA.Therefore surgery to repair both AAA and TAA is either pre-emptive to prevent rupture or emergent to repair a rupture. Repair of TAA and AAA by either open or minimally invasive techniques significantly reduces the risk of rupture and improves patient mortality. The establishment of these techniques has required the development of procedures from embryonic thoughts in the minds of the surgeons of antiquity through to the utilisation of ever increasing modern technologies