Rare Diffuse Idiopathic Pulmonary Neuroendocrine Cell Hyperplasia (DIPNECH) Finding in a 9/11 World Trade Center Survivor: A Case Report.

Bronchial carcinoid tumors represent a relatively uncommon category within lung neoplasms, originating from neuroendocrine cells. The exact cause of these pulmonary tumors remains not fully understood. Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is characterized by widespread hyperplasia of these neuroendocrine cells, essential for regulating air and blood flow in response to stimuli such as hypoxia, dyspnea, and chronic obstructive pulmonary disease (COPD). The prognosis for bronchial carcinoid tumors hinges on factors such as grade and stage, with lung resection being the preferred treatment. A chest computed tomography (CT) scan unveiled diffuse bilateral pulmonary nodules with ground-glass opacities, leading to a right video-assisted thoracoscopic surgery (VATS) wedge resection. Immunohistochemical examination confirmed neuroendocrine differentiation, describing a lung wedge measuring 9 × 4 × 1.5 cm with spongy parenchyma and scattered white nodules.

Massive Hemorrhage Following Spontaneous Mediastinal Inflammatory Myofibroblastic Tumor Rupture: A Case Report.

A 45-year-old male in a hypertensive emergency was admitted with complaints of frontal headache, progressive chest discomfort, shortness of breath, dysphagia, and right upper quadrant abdominal pain radiating across the epigastrium and to the back that increases in intensity with deep inspiration. He denied any history of abdominal pain, vomiting, dyspnea, nausea, and weight loss. A computed tomography (CT) scan of the chest showed a posterior mediastinal mass between the esophagus and descending aorta. A magnetic resonance imaging (MRI) scan revealed a non-enhancing posterior mediastinal mass possibly compressing both the esophagus and the airway. A 30-degree thoracoscope was inserted in the chest cavity revealing a large hemothorax from a possibly ruptured inflammatory myofibroblastic tumor (IMT) encompassing nearly the entire pleural space with both fresh and clotted blood. Two liters of fresh blood was removed via a right thoracotomy procedure. Once removed, a large fibrinous clot-filled mass was resected entirely and sent to pathology. Postoperative recovery was uneventful; dysphagia and shortness of breath resolved. The patient gradually resumed his regular diet.

A Novel Approach to Repair of Tracheal Occlusion Secondary to Percutaneous Tracheostomy Creation.

The number of endotracheal intubations increased in the United States during the COVID-19 pandemic with an associated rise in laryngotracheal injury. Our patient had a complete laryngeal occlusion just proximal to the first tracheal ring. The Neodymium-doped Yttrium Aluminum Garnet (Nd-YAG) laser is often used to resolve sub-laryngeal occlusions, and without access to the Nd-YAG laser, we had to find an alternative solution. Few centers have the access to an Nd-YAG laser, the optimal choice for sub-laryngeal occlusion and our novel approach allowed us to reestablish tracheal continuity and the patient's ability to speak.

Histologic evidence of tracheal stenosis directly resulting from SARS-CoV-2 tissue infiltration, a case series.

BACKGROUND: There has been an anecdotal increase in the incidence of tracheal stenosis that has coincided with the SARS-CoV-2 pandemic. CASE PRESENTATION: This is a case series in which we report clinical and pathologic findings of two patients who subsequently developed subglottic tracheal stenosis after having been hospitalized with COVID-19 pneumonia. Histopathologic analysis of tissue from these patients shows features consistent with tissue infiltrated with SARS-CoV-2 virus, namely multinucleated syncytial cells with prominent nucleoli. CONCLUSION: Our findings directly implicate SARS-CoV-2 in the pathogenesis of tracheal stenosis.

Esophageal Pulmonary-splenopancreatic Fistula: A Serious Complication of Sleeve Gastrectomy.

Esophagopulmonary fistulas are exceedingly rare and require surgical debridement and repair or diversion to prevent overwhelming sepsis. Fistulas that cross the diaphragm are even rarer. This report describes the case of a patient with an iatrogenic esophageal perforation after sleeve gastrectomy that was never managed definitively and in whom an esophagopulmonary-splenopancreatic fistula developed. The patient underwent an esophagectomy with esophagojejunostomy and distal pancreaticosplenectomy for management of the fistula. This case presents a rare complication of sleeve gastrectomy and highlights the need for early definitive management of esophageal perforations.

Enhanced Recovery After Thoracic Surgery (ERATS).

BACKGROUND: Decreasing the length of stay after thoracic surgery provides both clinical and financial benefits to both the patient and the clinical system. Since 2017, our institution has seen advancements in the care of patients undergoing thoracic surgery after utilising our protocol Enhanced Recovery After Thoracic Surgery (ERATS). METHODS: The protocol we implemented is comprehensive, including the patient's pain management, thoracostomy tube drainage, physical therapy and rehabilitation, ventilator support and pulmonary care, as well as other features of preoperative, intraoperative, and postoperative care. In a retrospective review, we compared the overall length of stay prior to the protocol implementation to the length of stay after initiating the changes. RESULTS: We identified a median decrease of 2 days (from 6 days to 4 days) following the implementation of this protocol for all types of thoracic surgical procedures (p<0.01). CONCLUSIONS: Upon implementation of the ERATS protocol, we appreciated a decrease in the length of stay of thoracic surgery patients at our institution.

British Association of Critical Care Nurses: Evidence-based consensus paper for oral care within adult critical care units.

BACKGROUND: Patients who are critically ill are at increased risk of hospital acquired pneumonia and ventilator associated pneumonia. Effective evidence based oral care may reduce the incidence of such iatrogenic infection. AIM: To provide an evidence-based British Association of Critical Care Nurses endorsed consensus paper for best practice relating to implementing oral care, with the intention of promoting patient comfort and reducing hospital acquired pneumonia and ventilator associated pneumonia in critically ill patients. DESIGN: A nominal group technique was adopted. A consensus committee of adult critical care nursing experts from the United Kingdom met in 2018 to evaluate and review the literature relating to oral care, its application in reducing pneumonia in critically ill adults and to make recommendations for practice. An elected national board member for the British Association of Critical Care Nurses chaired the round table discussion. METHODS: The committee focused on 5 aspects of oral care practice relating to critically ill adult patients. The evidence was evaluated for each practice within the context of reducing pneumonia in the mechanically ventilated patient or pneumonia in the non-ventilated patient. The five practices included the frequency for oral care; tools for oral care; oral care technique; solutions used and oral care in the non-ventilated patient who is critically ill and is at risk of aspiration. The group searched the best available evidence and evaluated this using the Grading of Recommendations Assessment, Development, and Evaluation system to assess the quality of evidence from high to very low, and to formulate recommendations as strong, moderate, weak, or best practice consensus statement when applicable. RESULTS: The consensus group generated recommendations, delineating an approach to best practice for oral care in critically ill adult patients. Recommendations included guidance for frequency and procedure for oral assessment, toothbrushing, and moisturising the mouth. Evidence on the use of chlorhexidine is not consistent and caution is advised with its routine use. CONCLUSION: Oral care is an important part of the care of critically ill patients, both ventilated and non-ventilated. An effective oral care programme reduces the incidence of pneumonia and promotes patient comfort. RELEVANCE TO CLINICAL PRACTICE: Effective oral care is integral to safe patient care in critical care.

A novel reconstruction technique of a tracheal defect in the emergent setting using a thymus flap in a patient with tracheoinnominate artery fistula.

BACKGROUND: There is a very high mortality associated with a tracheoinnominate artery fistula; however, when patients survive, they often require reconstruction of the eroded tracheal defect after the bleeding has been controlled. CASE PRESENTATION: This is the case of an 83-year-old male with a tracheoinnominate artery fistula who was stabilized in the operating room and underwent repair of his trachea. A novel technique of using the thymus gland as a pedicled flap to repair a large tracheal defect was executed after achieving hemostasis. The patient's defect was repaired successfully following control of the fistula. CONCLUSIONS: We have shown that the thymus gland can be used successfully as a pedicled flap for repair of a tracheal defect in the setting of a tracheoinnominate artery fistula.

Recognising and managing community-acquired pneumonia.

Pneumonia remains a significant cause of morbidity and mortality in the UK and yet the seriousness of the disease is underestimated. Pneumonia can be life-threatening because the delicate tissues of the alveoli and pulmonary capillaries are susceptible to damage from the inflammatory response. This damage leads to consolidation that prevents the diffusion of oxygen and carbon dioxide, and this in turn can lead to respiratory failure. This article summarises guidance on the diagnosis and management of community-acquired pneumonia, and also includes information on the prevention of pneumonia. This information should be valuable to nurses working in a variety of clinical areas since patients with community-acquired pneumonia are encountered in primary, intermediate, secondary and critical care.

Are visitors beneficial to patients in adult ICUs?

Despite their benefits, visits are limited in critical or intensive care settings. The British Association of Critical Care Nurses commissioned a position statement using evidence-based literature on visiting practices in adult ICUs. This article Thexamines the evidence, the benefits and drawbacks of visiting.

Criticality: the experience of developing an interactive educational tool based on board games.

Critical care services have seen many changes over recent years prompted by the seminal paper by the Department of Health (2000) Comprehensive critical care: A review of adult critical care services. This led to the expansion of critical care services with the resultant recruitment of large numbers of nurses new to critical care. Northumbria and other Universities within the UK were commissioned to provide formal education to critical care nurses and developed Foundations in Acute and Critical Care Module to provide nurses new to critical care, or from other acute clinical settings, with the knowledge and skills to manage this complex group of patients. The aim of this paper is to share the authors' experience of developing "Criticality" a board game designed to formatively assess learning amongst critical care nurses following a formal taught module in a Higher Education Institution (HEI) and prior to the summative assessment. Author experience suggests that Criticality is a useful revision tool and also fun and interactive which helped the students to identify strengths and weaknesses in their knowledge base and thus direct their revision prior to summative assessment.

Panoramic ECG display versus conventional ECG: ischaemia detection by critical care nurses.

AIM: To compare accuracy and certainty of diagnosis of cardiac ischaemia using the Panoramic ECG display tool plus conventional 12-lead electrocardiogram (ECG) versus 12-lead ECG alone by UK critical care nurses who were members of the British Association of Critical Care Nurses (BACCN). BACKGROUND: Critically ill patients are prone to myocardial ischaemia. Symptoms may be masked by sedation or analgesia, and ECG changes may be the only sign. Critical care nurses have an essential role in detecting ECG changes promptly. Despite this, critical care nurses may lack expertise in interpreting ECGs and myocardial ischaemia often goes undetected by critical care staff. METHOD: British Association of Critical Care Nurses (BACCN) members were invited to complete an online survey to evaluate the analysis of two sets of eight ECGs displayed alone and with the new display device. RESULTS: Data from 82 participants showed diagnostic accuracy improved from 67·1% reading ECG traces alone, to 96·0% reading ECG plus Panoramic ECG display tool (P < 0·01, significance level α = 0·05). Participants' diagnostic certainty score rose from 41·7% reading ECG alone to 66·8% reading ECG plus Panoramic ECG display tool (P < 0·01, α = 0·05). CONCLUSION: The Panoramic ECG display tool improves both accuracy and certainty of detecting ST segment changes among critical care nurses, when compared to conventional 12-lead ECG alone. This benefit was greatest with early ischaemic changes. Critical care nurses who are least confident in reading conventional ECGs benefit the most from the new display. RELEVANCE TO CLINICAL PRACTICE: Critical care nurses have an essential role in the monitoring of critically ill patients. However, nurses do not always have the expertise to detect subtle ischaemic ECG changes promptly. Introduction of the Panoramic ECG display tool into clinical practice could lead to patients receiving treatment for myocardial ischaemia sooner with the potential for reduction in morbidity and mortality.

Position statement on visiting in adult critical care units in the UK.

To provide nurses with an evidence-based Position Statement on the standards patients and visitors should expect when visiting an adult critical care unit in the 21st century in the UK. The British Association of Critical Care Nurses (BACCN) is a leading organization for critical care nursing in the UK and regularly receives enquiries about best practice regarding visiting policies. Therefore, in keeping with the BACCN's commitment to provide evidence-based guidance for nurses, a Position Statement on visiting practices in adult critical care units was commissioned. This brought together experts from the field of critical care nursing and representatives from patient and relatives' groups to review visiting practices and the literature and produce a Position Statement. An extensive search of the literature was undertaken using the following databases: Blackwell Synergy, CINAHL, Medline, Swetswise, Cochrane Data Base of Systematic Reviews, National Electronic Library for Health, Institute for Healthcare Improvement and Google Scholar. After obtaining selected articles, the references from these articles were then evaluated for their relevance to this Position Statement and were retrieved. The evidence suggests a disparity between what nurses believe is best practice and what patients and visitors actually want. Historically, visitors have been perceived as being responsible for increasing noise, taking up space, taking up nursing time, hindering nursing care and spreading infection. The evidence reviewed for this Position Statement suggests there are many benefits to patients and nurses from visitors. There was no evidence to suggest that visitors pose a direct infection risk to patients. Clear visiting policies based on evidence will negate arbitrary decisions by nurses regarding who can visit and will lessen confusion and dispel myths which can only bring benefits to patients, staff and organizations. To make nurses aware of the physical and psychological benefits of visiting to patients. Visitors bring a positive energy to patients and can act as advocates. They can supply nurses with vital information about patients which will enable the nurse to provide more individualized care. Being cognizant of the evidence will help nurses develop policies on visiting which are up to date for the 21st century.

Evaluating the impact of nurse independent prescribing in a weekend clinical nurse specialist service.

Nurse independent prescribing (NIP) is having a significant positive impact on patient care, yet little is written about NIP initiatives in the out-of-hours (OOH) period, which is a critical time for those with palliative care needs who wish to remain at home. This paper evaluates the impact of an NIP initiative in one weekend clinical nurse specialist (CNS) service in the UK. A 6-month audit of prescribing activity data is presented along with the results of a survey of local GPs. The paper concludes that NIP offers an effective way for the CNS working in the OOH period to offer timely and appropriate symptom control in a single, seamless consultation. Discussion surrounds the factors that affect the success of NIP initiatives and practical recommendations for other providers developing such a service.

Standards for nurse staffing in critical care units determined by: The British Association of Critical Care Nurses, The Critical Care Networks National Nurse Leads, Royal College of Nursing Critical Care and In-flight Forum.

BACKGROUND: Since 1967 the gold standard for nurse staffing levels in intensive care and subsequently critical care units has been one nurse for each patient. However, critical care has changed substantially since that time and in recent years this standard has been challenged. Previously individual nursing organisations such as the British Association of Critical Care Nurses (BACCN) and the Royal College of Nursing have produced guidance on staffing levels for critical care units. This paper represents the first time all three UK Professional Critical Care Associations have collaborated to produce standards for nurse staffing in critical care units. These standards have evolved from previous works and are endorsed by BACCN, Critical Care Networks National Nurse Leads Group (CC3N) and the Royal College of Nursing Critical Care and In-flight Forum. AIM: The aim of this paper is to provide an overview of the much more detailed document 'Standards for Nurse Staffing in Critical Care', which can be found on the BACCN web site at www.baccn.org.uk. The full paper has extensively reviewed the evidence, whereas this short paper provides essential detail and the 12 standard statements. METHODS: Representation was sort from each of the critical care associations. The authors extensively reviewed the literature using the terms: (1) critical care nursing, (2) nursing, (3) nurse staffing, (4) skill mix, (5) adverse events, (6) health care assistants and critical care, (7) length of stay, (8) critical care, (9) intensive care, (10) technology, (11) infection control. OUTCOMES: Comprehensive review of the evidence has culminated in 12 standard statements endorsed by BACCN, CC3N and the Royal College of Nursing Critical Care and In-flight Forum. The standards act as a reference for nursing staff, managers and commissioners associated with critical care to provide and support safe patient care. CONCLUSION: The review of the evidence has shown that the contribution of nursing can be difficult to measure and consequently support nurse staffing ratios. However, there is a growing body of evidence which associates higher number of registered nursing staff to patient ratio relates to improved safety and better outcomes for patients. The challenge for nurses is to produce accurate and meaningful outcome measures for nursing and collect data that accurately reflect the input of nursing on patient outcomes and safety.

British Association of Critical Care Nurses position statement on prescribing in critical care.

BACKGROUND: Nurses in the UK are now one group of non-medical staff who can prescribe. This practice is evolving for critical care nursing staff who care for critically ill patients during their stay in hospital through ward and outpatient follow-up after admission to critical care. AIM: The purposes of this paper were to present existing information regarding prescribing to support nurses in critical care currently prescribing and to inform those who are intending to prescribe. METHODS: To develop the position statement, a search of the literature was conducted using key databases. To ascertain the current level and type of prescribing in critical care, a short questionnaire was sent by email to British Association of Critical Care Nursing members, and the results of this are presented in Appendix A. OUTCOMES/RESULTS: Evidence was found in relation to the history, context in critical care, educational requirements and issues of consent related to non-medical prescribing. CONCLUSIONS: The position statement is based upon evidence from the literature, National Health Service policy and the Nursing and Midwifery Council regulations. It takes account of the critical care patient pathway before, during and after an admission to critical care.

Development of a critical care nursing research strategy: a tripartite approach.

The building of nursing research capacity is important, as it improves the quality of nurse education, the talent of nurses and the standard of patient care. A local critical care nursing research strategy was developed using a tripartite model applied to practice. This was a collaborative approach to critical care research as a model to direct, deliver, facilitate and support nursing research in practice through planned and protected investment in nursing research time. The tripartite model was evaluated and recommendations made with the aim of sharing findings so that other nurses can utilize these experiences to set up similar secondment opportunities for the promotion of nursing research.