Congenital adult tracheoesophageal fistula repair with transthoracic ventilation: a case report.

PURPOSE: To describe our experience using transthoracic ventilation to facilitate oral endotracheal tube (ETT) exchange after accidental ETT cuff rupture during a case of congenital tracheoesophageal fistula (TEF) repair. CLINICAL FEATURES: A 53-yr-old male underwent a congenital H-type TEF repair via right-sided thoracotomy with a single-lumen ETT and a bronchial blocker. A large air leak developed after ETT cuff rupture during fistula closure. Transthoracic intubation via tracheotomy was performed to continue ventilation during an oral ETT exchange in the lateral position. No hypoxia or hemodynamic compromise occurred. CONCLUSIONS: Airway device choice for TEF repair must be carefully considered in conjunction with the surgical team. In the present case of accidental ETT cuff rupture, rescue transthoracic ventilation safely facilitated oral ETT exchange.

RéSUMé: OBJECTIF: Décrire notre expérience avec la ventilation transthoracique pour faciliter l'échange de sonde endotrachéale (SET) orale après la rupture accidentelle du ballonnet de la SET lors d'un cas de réparation d'une fistule trachéo-oesophagienne (FTO) congénitale. CARACTéRISTIQUES CLINIQUES: Un homme de 53 ans a bénéficié d'une réparation de FTO congénitale de type H via une thoracotomie du côté droit avec une SET à simple lumière et un bloqueur bronchique. Une importante fuite d'air est apparue après la rupture du ballonnet de la SET lors de la fermeture de la fistule. Une intubation transthoracique par trachéotomie a été réalisée pour poursuivre la ventilation pendant un échange de SET orale en position latérale. Aucune hypoxie ou trouble hémodynamique ne s'est produit. CONCLUSION: Le choix du dispositif pour voies aériennes pour une réparation de FTO doit être soigneusement examiné en collaboration avec l'équipe chirurgicale. Dans le cas présent d'une rupture accidentelle du ballonnet de la SET, la ventilation transthoracique de secours a facilité un échange de SET orale en toute sécurité.

Implementation and evaluation of a novel, unofficial, trainee-organized hospital addiction medicine consultation service.

Background: To evaluate a novel, unofficial, trainee-organized, hospital addiction medicine consultation service (AMCS), we aimed to assess whether it was (1) acceptable to hospital providers and patients, (2) feasible to organize and deliver, and (3) impacted patient care. Methods: We performed a retrospective descriptive study of all AMCS consultations over the first 16 months. We determined acceptability via the number of referrals received from admitting services, and the proportion of referred patients who consented to consultation. We evaluated feasibility via continuation/growth of the service over time, and the proportion of referrals successfully completed before hospital discharge. As most referrals related to opioid use disorder, we determined impact through the proportion of eligible patients offered and initiated on opioid agonist therapy (OAT) in hospital, and the proportion of patients who filled their outpatient prescription or attended their first visit with their outpatient OAT prescriber. Results: The unofficial AMCS grew to involve six hospital-based residents and five supervising community-based addiction physicians. The service received 59 referrals, primarily related to injection opioid use, for 50 unique patients from 12 different admitting services. 90% of patients were seen before discharge, and 98% agreed to addiction medicine consultation. Among 34 patients with active moderate-severe opioid use disorder who were not already on OAT, 82% initiated OAT in hospital and 89% of these patients continued after discharge. Conclusions: Established in response to identified gaps in patient care and learning opportunities, a novel, unofficial, trainee-organized AMCS was acceptable, feasible, and positively impacted patient care over the first 16 months. This trainee-organized, unofficial AMCS could be used as a model for other hospitals that do not yet have an official AMCS.

Benefit of stereoscopic volume rendering for the identification of pediatric pulmonary vein stenosis from CT angiography.

The use of three-dimensional (3D) technologies in medical practice is increasing; however, its use is largely untested. One 3D technology, stereoscopic volume-rendered 3D display, can improve depth perception. Pulmonary vein stenosis (PVS) is a rare cardiovascular pathology, often diagnosed by computed tomography (CT), where volume rendering may be useful. Depth cues may be lost when volume rendered CT is displayed on regular screens instead of 3D displays. The objective of this study was to determine whether the 3D stereoscopic display of volume-rendered CT improved perception compared to standard monoscopic display, as measured by PVS diagnosis. CT angiograms (CTAs) from 18 pediatric patients aged 3 weeks to 2 years were volume rendered and displayed with and without stereoscopic display. Patients had 0 to 4 pulmonary vein stenoses. Participants viewed the CTAs in 2 groups with half on monoscopic and half on stereoscopic display and the converse a minimum of 2 weeks later, and their diagnoses were recorded. A total of 24 study participants, comprised of experienced staff cardiologists, cardiovascular surgeons and radiologists, and their trainees viewed the CTAs and assessed the presence and location of PVS. Cases were classified as simple (2 or fewer lesions) or complex (3 or more lesions). Overall, there were fewer type 2 errors in diagnosis for stereoscopic display than standard display, an insignificant difference (p = 0.095). There was a significant decrease in type 2 errors for complex multiple lesion cases (≥3) vs simpler cases (p = 0.027) and improvement in localization of pulmonary veins (p = 0.011). Subjectively, 70% of participants stated that stereoscopy was helpful in the identification of PVS. The stereoscopic display did not result in significantly decreased errors in PVS diagnosis but was helpful for more complex cases.

Uptake of slow-release oral morphine as opioid agonist treatment among hospitalised patients with opioid use disorder.

INTRODUCTION: Buprenorphine and methadone are highly effective first-line medications for opioid agonist treatment (OAT) but are not acceptable to all patients. We aimed to assess the uptake of slow-release oral morphine (SROM) as second-line OAT among medically ill, hospitalised patients with opioid use disorder who declined buprenorphine and methadone. METHODS: This study included consecutive hospitalised patients with untreated moderate-to-severe opioid use disorder referred to an inpatient addiction medicine consultation service, between June 2018 and September 2019, in Nova Scotia, Canada. We assessed the proportion of patients initiating first-line OAT (buprenorphine or methadone) in-hospital, and the proportion initiating SROM after declining first-line OAT. We compared rates of outpatient OAT continuation (i.e., filling outpatient OAT prescription or attending first outpatient OAT clinic visit) by medication type, and compared OAT selection between patients with and without chronic pain, using χ2 tests. RESULTS: Thirty-four patients were offered OAT initiation in-hospital; six patients (18%) also had chronic pain. Twenty-one patients (62%) initiated first-line OAT with buprenorphine or methadone. Of the 13 patients who declined first-line OAT, seven (54%) initiated second-line OAT with SROM in-hospital. Rates of outpatient OAT continuation after hospital discharge were high (>80%) and did not differ between medications (P = 0.4). Patients with co-existing chronic pain were more likely to choose SROM over buprenorphine or methadone (P = 0.005). DISCUSSION AND CONCLUSIONS: The ability to offer SROM (in addition to buprenorphine or methadone) increased rates of OAT initiation among hospitalised patients. Increasing access to SROM would help narrow the opioid use disorder treatment gap of unmet need.