Management of Percutaneous Coronary Intervention Complications: Algorithms From the 2018 and 2019 Seattle Percutaneous Coronary Intervention Complications Conference.

Complications of percutaneous coronary intervention (PCI) may have significant impact on patient survival and healthcare costs. PCI procedural complexity and patient risk are increasing, and operators must be prepared to recognize and treat complications, such as perforations, dissections, hemodynamic collapse, no-reflow, and entrapped equipment. Unfortunately, few resources exist to train operators in PCI complication management. Uncertainty regarding complication management could contribute to the undertreatment of patients with high-complexity coronary disease. We, therefore, coordinated the Learning From Complications: How to Be a Better Interventionalist courses to disseminate the collective experience of high-volume PCI operators with extensive experience in chronic total occlusion and high-risk PCI. From these conferences in 2018 and 2019, we developed algorithms that emphasize early recognition, effective treatment, and team-based care of PCI complications. We think that an algorithmic approach will result in a logical and systematic response to life-threatening complications. This construct may be useful for operators who plan to perform complex PCI procedures.

Pediatric button battery ingestion: Publication trends in the literature.

OBJECTIVE: Examine literature for evidence of changes in button battery (BB) research over time including: amount and rate of literature output, levels of evidence, and the location of the research. METHODS: Literature review of all peer-reviewed button battery literature available online through Pubmed and Embase was performed. Inclusion criteria were applied to ensure relevance. Publications were grouped into 4 time periods. Various study characteristics were compared between groups. RESULTS: A total of 255 original research studies were reviewed. A significant increase in study number was found with a 664% increase comparing 2009-2018 and 1977-1988 (p < 0.001) and a 187% increase comparing 2009-2018 and all previous years. Average author number significantly increased over the study period (range: 2.8 to 4.4; p < 0.001). Case report or case series were consistently the most common type of study design (range: 56.5% to 84.0%). Level of evidence has remained at 4-5 for the majority of studies (range: 87% to 92.1%). First author specialty remained stable over time, with non-otolaryngologist surgeons being the most common authors, followed by pediatricians and otolaryngologists (28.8%, 18.9%, 18.5%, respectively). Location of research has diversified, with US publications falling from 50% to 29.5% of all studies when comparing 1977-1988 to 2009-2018 time periods. CONCLUSIONS: Button battery ingestion in the pediatric population has been an important topic of discussion among various medical specialties due to a rise in morbidity and mortality surrounding these ingestions. Despite the increase in number of studies and authors, the strength of these studies has remained largely unchanged.

Time to perforation for button batteries lodged in the esophagus.

INTRODUCTION: New strategies recently proposed to mitigate injury caused by lithium coin cell batteries lodged in the esophagus include prehospital administration of honey to coat the battery and prevent local hydroxide generation and in-hospital administration of sucralfate suspension (or honey). This study was undertaken to define the safe interval for administering coating agents by identifying the timing of onset of esophageal perforations. METHODS: A retrospective study of 290 fatal or severe battery ingestions with esophageal lodgment was undertaken to identify cases with esophageal perforations. RESULTS: Esophageal perforations were identified in 189 cases (53 fatal, 136 severe; 95.2% in children ≤4 years). Implicated batteries were predominantly lithium (91.0%) and 92.0% were ≥20 mm diameter. Only 2% of perforations occurred in <24 h following ingestion, including 3 severe cases with perforations evident at 11-17 h, 12 h, and 18 h. Another 7.4% of perforations (11 cases) became evident 24 to 47 h post ingestion and 10.1% of perforations (15 cases) became evident 48 to 71 h post ingestion. By 3 days post ingestion, 26.8% of perforations were evident, 36.9% by 4 days, 46.3% by 5 days, and 66.4% by 9 days. CONCLUSION: Esophageal perforation is unlikely in the 12 h after battery ingestion, therefore the administration of honey or sucralfate carries a low risk of extravasation from the esophagus. This first 12 h includes the period of peak electrolysis activity and battery damage, thus the risk of honey or sucralfate is low while the benefit is likely high.

Unintentionally Retained Foreign Objects: A Descriptive Study of 308 Sentinel Events and Contributing Factors.

OBJECTIVE: Unintentionally retained foreign objects (URFOs) remain the sentinel events most frequently reported to The Joint Commission. The objective of this study was to describe reports of URFOs, including the types of objects, anatomic locations, contributing factors, and harm, in order to make recommendations to improve perioperative safety. METHODS: A retrospective review was undertaken of events involving URFOs reported to The Joint Commission from October 2012 through March 2018. Inclusion criteria were events meeting Joint Commission definitions of URFO and sentinel event. Exclusion criteria were sponges used intraoperatively and guidewires. Event reports included patients undergoing surgery, child birth, wound care, and other invasive procedures. RESULTS: A total of 308 events involving URFOs were reported: instruments (102), catheters and drains (52), needles and blades (33), packing (30), implants (14), specimens (6), and other items (71). Many of the instruments were used in minimally invasive or orthopedic surgery. Items were most frequently retained in the abdomen or the vagina. Most URFOs occurred in the operating room. A total of 1,156 contributing factors were identified, most frequently in the categories human factors, leadership, and communication. In the majority of reports, the harm was categorized as unexpected additional care/extended stay. Five patients died as a result of the URFO. CONCLUSION: We describe events involving URFOs voluntarily reported to The Joint Commission. The variety of retained items, the departments involved, and the large number of contributing factors demonstrate the complexity of patient care and the need for a multifaceted plan for prevention. We make recommendations based on these findings.

Pathologic findings and causes of death of stranded cetaceans in the Canary Islands (2006-2012).

This study describes the pathologic findings and most probable causes of death (CD) of 224 cetaceans stranded along the coastline of the Canary Islands (Spain) over a 7-year period, 2006-2012. Most probable CD, grouped as pathologic categories (PCs), was identified in 208/224 (92.8%) examined animals. Within natural PCs, those associated with good nutritional status represented 70/208 (33.6%), whereas, those associated with significant loss of nutritional status represented 49/208 (23.5%). Fatal intra- and interspecific traumatic interactions were 37/208 (17.8%). Vessel collisions included 24/208 (11.5%). Neonatal/perinatal pathology involved 13/208 (6.2%). Fatal interaction with fishing activities comprised 10/208 (4.8%). Within anthropogenic PCs, foreign body-associated pathology represented 5/208 (2.4%). A CD could not be determined in 16/208 (7.7%) cases. Natural PCs were dominated by infectious and parasitic disease processes. Herein, our results suggest that between 2006 and 2012, in the Canary Islands, direct human activity appeared responsible for 19% of cetaceans deaths, while natural pathologies accounted for 81%. These results, integrating novel findings and published reports, aid in delineating baseline knowledge on cetacean pathology and may be of value to rehabilitators, caregivers, diagnosticians and future conservation policies.

Death as a Consequence of Foreign Body Aspiration in Children.

AIM: To analyze the rate of mortality in children with foreign body aspiration (FBA). METHODS: We outlined a retrospective review of hospital data of patients between 1971 and 2013. FBA occurring in children 0 year to 14 years was considered for inclusion (patient ages ranged from 0.6 to 15 years, with a median age of 2.2 years). The gender structure within the investigated cases was 75.8% males and 24.2% females. During the study period, 772 patients undergoing rigid bronchoscopy with the diagnosis of FBA were included. Deaths on arrival were excluded. RESULTS: Total rate of mortality (for whole investigated period) was 0.785. For last fifteen years of the investigated period the rate of mortality was zero. CONCLUSION: For prevention of foreign body aspiration in children and its mortality should be taken two strategies: non-medical (alterations in product design and public education campaigns) and medical (education of medical staff and improvement of equipment).

Lithium batteries: A technological advance with unintended injury consequences.

Lithium-ion (Li-ion) batteries have been powering portable electronic equipment since the mid-1990s. Today, they are ubiquitous in portable electronics, with more than four billion manufactured each year. However, Li-ion batteries are also associated with a spectrum of injuries related to the type of device as well as the person using the device. These injuries range from cutaneous injuries due to flame burns and explosions to corrosion injuries from ingestion. This article describes how the composition of Li-ion batteries can cause injury, the types and extent of Li-ion battery-related injuries, and suggests strategies for prevention.

Serious complications after button battery ingestion in children.

Serious and fatal complications after button battery ingestion are increasing worldwide. The aim of this study is to describe serious complications after battery ingestion in children in the Netherlands.All pediatric gastroenterologists in the Netherlands performing upper endoscopies were asked to report all serious complications after battery ingestion in children (0-18 years) between 2008 and 2016 retrospectively.Sixteen serious complications were reported: death after massive bleeding through esophageal-aortal fistula (n = 1), esophageal-tracheal fistula (n = 5), stenosis after (suspected) perforation and mediastinitis (n = 5), (suspected) perforation and mediastinitis (n = 3), vocal cord paralysis (n = 1), and required reintubation for dyspnea and stridor (n = 1). The median time interval between ingestion and presentation was 5 (IQR 2-258) h. All children were ≤ 5 (median 1.4; IQR 0.9-2.1) years. Vomiting (31.3%), swallowing/feeding problems (31.3%), and fever (31.3%) were the most common presenting symptoms; however, 18.8% of the patients were asymptomatic (n = 1 missing). All batteries were button batteries (75% ≥ 20 mm; 18.8% < 20 mm; n = 1 missing). The batteries were removed by esophagogastroduodenoscopy (50%) and rigid endoscopy (37.5%) or surgically (12.5%). CONCLUSION: Sixteen serious complications occurred after small and large button batteries ingestion between 2008 and 2016 in both symptomatic and asymptomatic children in the Netherlands. Therefore, immediate intervention after (suspected) button battery ingestion is required. What is Known: • Button battery ingestion may result in serious and fatal complications. • Serious and fatal complications after button battery ingestion are increasing worldwide. What is New: • Sixteen serious complications after button battery ingestion occurred during 2008-2016 in children in the Netherlands. • Serious complications were also caused by small batteries (< 20 mm) in the Netherlands and also occurred in asymptomatic Dutch children.

Analysis of Complications After Button Battery Ingestion in Children.

AIM: Button battery ingestion (BBI) in children may cause severe complications. This analysis is a literature review of complications after pediatric BBI. METHODS: Literature was searched on PubMed (1995-2015) using the terms "button battery," "ingestion," and "children." End points were age, type and diameter of battery, complications, affected organ, and fatality. RESULTS: A total of 31 publications were analyzed. Patients from 4 months to 19 years old were included (n = 136,191, with n = 102,143 or 75% aged <6 y). In 6262, the diameter of the battery was documented. Batteries of 20 mm or greater in size were more prone to complications (n = 226). With regard to the anatomy, BBI caused complications mainly in the esophagus (n = 88, 38.94%). Sixty-one fatal outcomes were reported. CONCLUSIONS: Children younger than 6 years are the most prone to BBI, with lithium batteries of 20 mm or greater in size associated with complications. Complications have been estimated at 0.165%, with lethality of 0.04%. The esophagus is the most affected organ, but vascular involvement is often fatal.

Morbidity and mortality in children undergoing bronchoscopy for foreign body removal.

OBJECTIVES/HYPOTHESIS: Analyze morbidity and mortality among children undergoing bronchoscopy for foreign body removal. STUDY DESIGN: Multicenter retrospective review using the American College of Surgeons Pediatric National Surgical Quality Improvement Program from 2014 and 2015. METHODS: Patients were identified using Current Procedural Terminology code 31635. Demographics, time to surgery, operative times, hospitalization time, and complications were collected. Multivariate logistic regression was used to identify predictive factors for major adverse events. RESULTS: Three hundred thirty-four patients were included (mean age 3.7 years, 59.0% male). Preoperative sepsis syndrome was present in 5.7% of patients and 8.1% had asthma. Of the patients, 5.1% percent of patients had a tracheostomy. Bronchoscopy was performed by an otolaryngologist (65.4%) or a pediatric surgeon (33.1%). Mean operative time was 27.4 minutes, whereas mean total operating room time was 54.6 minutes. Airway foreign bodies were located in 269 patients (80.5%), with 62.5% being located in the mainstem bronchus. Operative time was longer when foreign bodies were in the mainstem bronchus or distal to it. Mean time to surgery from admission was 0 days, and mean duration of hospitalization was 1 day. One patient (0.3%) required reoperation for respiratory reasons, and three (0.9%) required readmission for related reasons. No patients remained hospitalized at 30 days. Two (0.6%) had a postoperative pneumonia, and two (0.6%) required reintubation. One patient death (0.3%) occurred within 2 weeks of bronchoscopy. No significant differences were identified in operative time, time to surgery, or hospitalization time based on age, gender, presence of a tracheostomy, or surgical specialty. CONCLUSIONS: Bronchoscopy for identification and removal of airway foreign bodies had minimal morbidity in this group. LEVEL OF EVIDENCE: 2b. Laryngoscope, 128:1226-1229, 2018.

Risk Factors for Death in Dogs Treated for Esophageal Foreign Body Obstruction: A Retrospective Cohort Study of 222 Cases (1998-2017).

BACKGROUND: Limited data exist describing risk factors for death, and long-term outcomes in dogs with esophageal foreign body (EFB) obstruction. HYPOTHESIS/OBJECTIVES: To evaluate short- and long-term outcomes, and analyze risk factors for death in dogs with EFB obstruction. We hypothesized duration of entrapment and treatment type would affect outcome. ANIMALS: A total of 222 dogs were treated for EFB obstruction at an emergency and referral hospital between March 1998 and March 2017. METHODS: Medical records for dogs with EFB were retrospectively evaluated. RESULTS: Foreign material most frequently was osseous (180/222 [81%]), with distal esophagus the most common location (110/222 [49.5%]). Duration of clinical signs was not associated with risk of death (OR = 1.08, 95% CI 0.99-1.17; P = 0.2). Entrapment was treated by endoscopy (204/222 [91.8%]), surgery after endoscopic attempt (13/222 [5.9%]), and repeat endoscopy after surgery was recommended but declined (5/222 [2.3%]). In-hospital case fatality rate was 11/222 (5%). Risk of death was significantly higher with surgery (OR = 20.1, 95% CI 3.59-112.44; P = 0.001), and 5/5 (100%) of dogs died if undergoing endoscopy after surgery was recommended but declined. Increasing numbers of postprocedural complications (OR = 3.44, CI 2.01-5.91; P < 0.001), esophageal perforation (OR = 65.47, CI 4.27-1004.15; P = 0.003), and postprocedure esophageal hemorrhage (OR = 11.81, CI 1.19-116.77; P = 0.04) increased in-hospital risk of death. Esophageal strictures were reported in 4/189 (2.1%) of survivors available for follow-up. CONCLUSIONS AND CLINICAL IMPORTANCE: Death is uncommon in canine EFB; however, treatment type affects outcome, and these data should be used to guide decision-making in dogs with EFB.

Foreign body aspiration in children: A study of children who lived or died following aspiration.

Foreign body aspiration (FBA) is a preventable cause of mortality and morbidity in children. We conducted a chart review of children who presented to a university hospital due to FBA in the period 1999-2014. Children were either managed with bronchoscopy for removal of the foreign body or died due to FBA. A total of 103 children were seen due to FBA including 27 deaths. The majority of children were boys and were less than 3 years old. Most aspirated foreign bodies were food-related, mainly peanuts. The majority of children presented with acute choking incidents, a smaller number presented with recurrent chest infections, and few children's choking incidents were unwitnessed. X-ray had a high rate of false negatives and bronchoscopy was the gold standard technique for assessment and management. Aspiration of foreign bodies is a preventable, life-threatening condition that calls for increased parent education and awareness.

Airway foreign bodies in pediatric patients: anatomic location of foreign body affects complications and outcomes.

BACKGROUND: Airway foreign bodies (FB) are a common medical emergency within the pediatric population. While deaths are not uncommon, the in-hospital mortality rates and correlation with anatomic location of the airway foreign body have not been previously reported. METHODS: The KID database was reviewed for 2003, 2006, 2009, and 2012 for pediatric patients with a discharge diagnosis of airway foreign body using ICD-9 codes (933.1, 934.x). RESULTS: 11,793 patients, ages 0-17, were found to have an airway FB. Of patients admitted for airway FB 21.2 % required mechanical ventilation during their hospitalization, and the overall mortality rate was 2.5 %. Location of the airway FB was dependent on age (p < 0.01). Use of mechanical ventilation was dependent on the location of the airway FB (p < 0.01) and being transferred from another hospital (OR 2.59, p < 0.01). Univariate analysis demonstrated differences in in-hospital mortality based on location (p < 0.01), use of a ventilator during hospitalization (OR 24.4, p < 0.01), and transfer from another hospital (OR 2.11, p < 0.01). CONCLUSIONS: The in-hospital mortality rate for airway foreign bodies is 2.5 %. The anatomic location of airway FB in pediatric patients varies by age, and affects the need for mechanical ventilation and in-hospital mortality.

Button Battery Ingestion in Children: A Paradigm for Management of Severe Pediatric Foreign Body Ingestions.

Gastrointestinal injuries secondary to button battery ingestions in children have emerged as a dangerous and difficult management problem for pediatricians. Implementation of a multidisciplinary team approach, with rapid and coordinated care, is paramount to minimize the risk of negative outcomes. In addition to providing a comprehensive review of the topic, this article outlines the authors' referral center's experience with patients with severe battery ingestion, highlighting the complications, outcomes, and important lessons learned from their care. The authors also propose an algorithm for clinical care that may be useful for guiding best management of pediatric button battery ingestion.

Fibrous ingluvial foreign bodies in 33 cockatiels (Nymphicus hollandicus).

The presentation, treatment and outcomes of 33 ingluvial fibrous foreign bodies in cockatiels (Nymphicus hollandicus) are described. Vomiting, lethargy and weight loss were the most common presenting signs. Diagnosis was made on palpation of a mass in the crop (ingluvies). Both surgical and non-surgical treatment regimens were evaluated. The overall mortality rate was 33%, suggesting fibrous materials are not safe for cockatiels to groom or ingest and should not be offered as cage accessories.

Risk factors for complications associated with upper gastrointestinal foreign bodies.

AIM: To investigate predictive risk factors associated with complications in the endoscopic removal of foreign bodies from the upper gastrointestinal tract. METHODS: We retrospectively reviewed the medical records of 194 patients with a diagnosis of foreign body impaction in the upper gastrointestinal tract, confirmed by endoscopy, at two university hospital in South Korea. Patient demographic data, including age, gender, intention to ingestion, symptoms at admission, and comorbidities, were collected. Clinical features of the foreign bodies, such as type, size, sharpness of edges, number, and location, were analyzed. Endoscopic data those were analyzed included duration of foreign body impaction, duration of endoscopic performance, endoscopic device, days of hospitalization, complication rate, 30-d mortality rate, and the number of operations related to foreign body removal. RESULTS: The types of upper gastrointestinal foreign bodies included fish bones, drugs, shells, meat, metal, and animal bones. The locations of impacted foreign bodies were the upper esophagus (57.2%), mid esophagus (28.4%), stomach (10.8%), and lower esophagus (3.6%). The median size of the foreign bodies was 26.2 ± 16.7 mm. Among 194 patients, endoscopic removal was achieved in 189, and complications developed in 51 patients (26.9%). Significant complications associated with foreign body impaction and removal included deep lacerations with minor bleeding (n = 31, 16%), ulcer (n = 11, 5.7%), perforation (n = 3, 1.5%), and abscess (n = 1, 0.5%). Four patients underwent operations because of incomplete endoscopic foreign body extraction. In multivariate analyses, risk factors for endoscopic complications and failure were sharpness (HR = 2.48, 95%CI: 1.07-5.72; P = 0.034) and a greater than 12-h duration of impaction (HR = 2.42, 95%CI: 1.12-5.25, P = 0.025). CONCLUSION: In cases of longer than 12 h since foreign body ingestion or sharp-pointed objects, rapid endoscopic intervention should be provided in patients with ingested foreign bodies.

Retained weapon injuries: experience from a civilian metropolitan trauma service in South Africa.

INTRODUCTION: Retained weapon (RW) injuries are uncommon, but there is no current consensus on the best management approach. METHODS: We reviewed our experience of 102 consecutive patients with non-missile RWs in a high-volume metropolitan trauma service managed over a 10-year period. RESULTS: Of the 102 patients, 95 were males (93%), 7 were females (7%), and median age was 24 (21-28) years. Weapons: 73% (74/102) knives, 17% (17/102) screwdrivers, 5% spears, 6% (6/102) others [axe (1), glass fragment (1), stick (1), sickle blade (1), wire (1) and stone (1)]. LOCATION: 8% (8/102) head, 20% (20/102) in the face, 9% (9/102) neck, 14% (14/102) thorax, 25% (26/102) abdomen, 23% (23/102) upper limb, 2% (2/102) lower limb. Four per cent (4/102) were haemodynamically unstable and proceed immediately to the operating theatre for operative exploration and weapon extraction. Imagining: 88 (86%) plain radiographs, 65 (64%) non-contrast CT scans, 41 (40%) contrast CT angiography, 4 (4%) formal angiography. Seventy-two underwent simple extraction, and 29 underwent extract plus open operation. One patient absconded. Specialist surgeons involved in extraction: trauma surgeons (74), neurosurgeons (10), ophthalmic surgeons (11) and ENT surgeons (4). Overall, 92% (94/102) survived to discharge. CONCLUSIONS: The vast majority of patients with RWs will be admitted in a stable condition and haemodynamic instability was almost exclusively seen in the anterior thorax. The most common site was the posterior abdomen. Detailed imagining should be used liberally in stable patients and unplanned extraction in an uncontrolled environment should be strongly discouraged.

A comparative study of small intestinal perforation secondary to foreign body and other non-traumatic causes.

BACKGROUND: Little was known about gastrointestinal perforation secondary to foreign body in adults, which was only documented by several case series reports. The aim of this study was to characterize it with comparative methods. METHODS: A retrospective study was conducted on twenty patients with the diagnosis of gastrointestinal perforation secondary to foreign body between January 2003 and October 2013. The perforations were all located in the small intestine and compared to eighty-seven patients with non-traumatic small intestinal perforation. RESULTS: 35% of the patients in the foreign body group were over 65 years of age, which is much higher than the local elderly population ratio (p=0.002). In the foreign body group, more patients presented without diffuse abdominal physical signs (p=0.008) and preoperational CT scans had higher accuracy (p=0.027). Perforation repair was performed more often (p=0.024). Mean MPI was 19.9 and the morbidity rate was 35%, significantly lower than in the cases of other causes (p=0.001, 0.041). Mean duration of hospitalization was 11.5 days and was shorter compared to other causes (p=0.038). CONCLUSION: Clinical performance of small intestinal perforation secondary to foreign body is atypical, and preoperative diagnosis relies on CT scans. Primary perforation closure is safe and effective, and relatively better outcomes can be achieved.