Management of a patient with tracheomalacia and supraglottic obstruction after thyroid surgery.

PURPOSE: We describe an unusual combination of dynamic supraglottic, glottic, subglottic, and intrathoracic airway obstructions following a total thyroidectomy. These problems were anticipated, documented videographically, and managed preemptively. CLINICAL FEATURES: Following a total thyroidectomy, we replaced the endotracheal tube with a laryngeal mask airway, namely, the LMA-Classic™, in a patient with symptomatic tracheal compression and probable obstructive sleep apnea. Spontaneous ventilation was observed bronchoscopically through the LMA-Classic. Supraglottic swelling, extraglottic collapse on inspiration, and intrathoracic collapse on expiration were documented prior to recovery. These observations were of sufficient concern to warrant reinsertion of the endotracheal tube and subsequent tracheal extubation over a tube exchanger. Thereafter, we provided face-mask continuous positive airway pressure using a Boussignac mask with an endotracheal ventilation catheter in situ. CONCLUSIONS: Acute airway collapse following thyroid surgery is a rare and potentially serious complication. Diagnosis by conventional methods may be insensitive. Difficulties may not be apparent until the patient becomes distressed after tracheal extubation, and this circumstance will worsen airway compromise. In such a state, re-establishing the airway can become life-threatening. We describe the preemptive identification, physiologic manifestations, and management of the supraglottic and subglottic obstruction exemplified by this case.

Hospital administrative database underestimates delirium rate after cardiac surgery.

PURPOSE: Administrative electronic databases are highly specific for postoperative complications, but they lack sensitivity. The objective of this study was to determine the incidence of delirium after cardiac surgery using a targeted prospectively collected dataset and to compare the findings with the incidence of delirium in the same cohort of patients identified in a hospital administrative database. METHODS: Following Research Ethics Board approval, we compared delirium rates in a prospectively collected data research database with delirium rates in the same cohort of patients in an administrative hospital database where delirium was identified from codes entered by coding and abstracting staff. Every 12 hr postoperatively, delirium was assessed with a Confusion Assessment Method in the Intensive Care Unit. The administrative database contained the International Classification of Diseases version 10 (ICD-10) codes for patient diagnoses. The ICD-10 codes were extracted from the administrative database for each patient in the research database and were checked for the presence of the ICD-10 code for delirium. RESULTS: Data from a cohort of 1,528 patients were analyzed. Postoperative delirium was identified in 182 (11.9%) patients (95% confidence interval [CI], 10.3-13.5%) in the research dataset and 46 (3%) patients (95% CI, 2.2-3.8%) in the administrative dataset (P < 0.001). Thirteen (0.85%) patients who were coded for delirium in the administrative database were not identified in the research dataset. The median onset of postoperative delirium in these patients was significantly delayed (4 [3-9] days) compared with patients identified by both datasets (2 [1-9] days) and compared with patients from the research database only (1 [1-14] days) (P = 0.007). CONCLUSION: Postoperative delirium rates after cardiac surgery are underestimated by the hospital administrative database.