Wound care management: tracheostomy and gastrostomy

Disparities in Medication Prescriptions and Post-Tracheostomy Outcomes in Pediatric Patients

BACKGROUND

Granulation tissue formation and tracheitis are common pediatric tracheostomy complications. Ciprofloxacin/dexamethasone is frequently prescribed, but the influence of social determinants on this topic is unexplored.

METHODS

This study extends a prior cohort study of pediatric tracheostomy patients at a single academic institution from 2016 to 2020. Social determinants of health, including race, insurance status, and residence characteristics, including Area Deprivation Index (ADI), were evaluated. Logistic regression, Wilcoxon rank-sum, and log-rank tests (α = .05) analyzed relationships between these determinants and prescriptions and post-tracheostomy outcomes.

RESULTS

This cohort included 182 patients; 98/182 (53.9%) were male, and 140/182 (76.9%) were White, non-Hispanic. Non-White race was associated with increased odds of receiving nebulized ciprofloxacin/dexamethasone (OR = 2.80, 95% CI = 1.25-6.29). In those with tracheal culture results available (n = 63), Staphylococcus aureus was more common with public insurance (29/47, 7 with MRSA, 61.7%) compared with private (5/16, 3 with MRSA, 31.3%; OR = 3.54, 95% CI = 1.05-11.9). ADI was greater in the 7 patients with Streptococcus pneumoniae (median = 95, IQR = 88-99) compared to without (median = 77, IQR = 65-81, P = .003). Patients with tracheitis lived further from our center (median = 44.7 miles, IQR = 27.7-91.4 miles) compared with those who did not develop tracheitis (median = 33.4 miles, IQR = 12.0-85.2 miles, P = .02). Antibiotic resistance was more prevalent in children discharged home (14/35, 40.0%) than to transitional care (3/28, 10.7%; OR = 5.56, 95% CI = 1.40-22.0) and was associated with longer hospital stays (median = 70 days, range = 34-152 vs median = 35 days, range = 15-75 days, P = .02). Non-White patients experience increased odds of decannulation over time compared with White patients (HR = 2.85, 95% CI = 1.21-6.70). Discharge locations and ADI were associated with dressing choice post-tracheostomy.

DISCUSSION

This study revealed racial disparities in ciprofloxacin/dexamethasone usage, residence-related differences in tracheal culture results, and ADI-related dressing choices, which highlight the need for tailored, equitable care to optimize outcomes.

LEVEL OF EVIDENCE

4.

Novel Nanozyme-Based Multicomponent in situ Hydrogels with Antibacterial, Hypoxia-Relieving and Proliferative Properties for Promoting Gastrostomy Tube Tract Maturation

Purpose

Gastrostomy is the commonly used enteral feeding technology. The clinical risks caused by tube dislodgement and peristomal site infection are the common complications before complete tract maturation after gastrostomy. However, there is currently no relevant research to promote gastrostomy wound treatment and tract maturation.

Methods

Herein, a nanozyme loaded bioactive hydrogels (MO-HPA) was developed to accelerate tract maturation and inhibit bacteria. Nano-manganese dioxide (n-MO) and polylysine modified hyaluronic acid (HP) were synthesized and characterized. In situ hydrogels were prepared by mixing the HP/ alginate solution, and the n-MO solution containing Ca2+. The structure, physicochemical and mechanical properties of MO-HPA were evaluated. Furthermore, the antibacterial activity, and the In vitro and intracellular oxygen production efficacy were determined. The cell migration, wound healing and tube tract maturation promotion effect were assessed in cell experiments and in skin defect mouse model, as well as rabbit gastrostomy model.

Results

The n-MO has a uniform particle size with oxygen producing activities. The MO-HPA demonstrated a homogeneous and porous microstructure. Additionally, the gelation time, swelling ratio, rheological behavior, and mechanical properties of hydrogels could be tuned by adjusting the HP content. The antibacterial efficiency of the MO-HPA1.0 group on E. coli and S. aureus increased by about 40.1% and 55.6% respectively, compared to the MO-HPA0.5 group. Additionally, MO-HPA1.0 hydrogel demonstrated effective oxygen-producing and cell migration-promoting functions in both in vitro and cellular experiments. The MO-HPA1.0 group significantly accelerated wound healing in both of mouse skin defect model and rabbit gastrostomy model. The hydrogel group exhibited a significant promotion in collagen content and reduction in HIF-1α, which effectively hastened tract maturation.

Conclusion

Therefore, our study provides new and critical insights into a strategy to design bioactive hydrogels with multiple functions, which can open up a new avenue for accelerated wound healing after gastrostomy.

Safety and Efficacy of Rigid Bronchoscopy-guided Percutaneous Dilational Tracheostomy: A Single-center Experience

BACKGROUND

Percutaneous dilational tracheostomy (PDT) is commonly performed by a broad spectrum of practitioners. Aside from relative contraindications such as morbid obesity, coagulopathy, and complex airway anatomy, it is preferred over surgical tracheostomy in the critically ill. Rigid bronchoscopy-guided (RBG) PDT provides a secure airway, allows for unobstructed ventilation, protects the posterior membrane from puncture, and increases suction capacity.

METHODS

This is a retrospective case series of patients who underwent RBG-PDT from 2008 to 2023 at Beth Israel Deaconess Medical Center. Electronic medical records were reviewed for preprocedural demographic data, procedural events, and postprocedural outcomes.

RESULTS

A total of 104 patients underwent RBG-PDT over a 15-year period. Median patient age was 61.95 (95% CI: 59.00-64.90), median BMI was 30.25 kg/m2 (IQR, 23.6 to 37.2) with 41.9% (32.5% to 51.3%) of patients included having a BMI over 30 kg/m2. PDT placement occurred in a mean of 13.7 days after intubation, with 70% due to prolonged mechanical ventilation resulting from ongoing respiratory failure. In all, 51.0% of patients had at least one increased bleeding risk factor, with an increased aPTT >36 seconds being the most common (36.5%). In all, 26.9% of patients underwent tracheostomy with ongoing therapeutic anticoagulation with heparin. In total, 60.6% of patients received concomitant percutaneous endoscopic gastrostomy (PEG) tube placement. No cases of pneumothorax or loss of the airway at the time of exchange of the endotracheal tube for rigid tracheoscopy were reported.

CONCLUSION

RBG-PDT is a safe and effective procedure extending the patient population appropriate for PDT when performed by an experienced Interventional Pulmonology team.

[PEG Tube Placement - Step by Step]

When critically ill patients require long-term enteral nutrition, insertion of a feeding tube is indicated. The method of choice is percutaneous endoscopic gastrostomy (PEG) tube placement, known in everyday clinical practice as a PEG tube or simply PEG. When performed in a standardized manner and with consideration of contraindications, PEG placement is a less invasive and well-established standard of care in the ICU.

Synchronous tracheostomy and gastrostomy placement results in shorter length of stay in traumatic brain injury patients

BACKGROUND

American Society for Parenteral and Enteral Nutrition (ASPEN) guidelines recommend gastrostomy for patients suspected to require enteral access device for 4-6 weeks. Our hypothesis was that traumatic brain injury (TBI) patients undergoing synchronous tracheostomy/gastrostomy (SYNC) compared to tracheostomy first (DELAY) have shorter length of stay (LOS) but higher rates of unnecessary gastrostomy.

METHODS

Retrospective review of TBI patients requiring tracheostomy in 2017-2022 ​at a Level 1 trauma center was conducted. SYNC and DELAY patients were compared, and CoxPH analysis was performed for LOS.

RESULTS

394 patients were included [mean age: 42 (SD:18); mortality: 9 ​%]. The DELAY group had longer LOS (39 vs 32 days, p ​< ​0.001). There was no significant difference in unnecessary gastrostomy rate between groups (p ​= ​0.1331). In adjusted hazard analysis, SYNC predicted shorter LOS (HR:1.54; 95 ​% CI:1.20-1.98, p ​< ​0.001).

CONCLUSIONS

Synchronous gastrostomy was associated with shorter length of stay and similar rates of unnecessary gastrostomy in TBI patients.

A Novel Dressing Method to Achieve Early Natural Tracheostoma Closure

Tracheotomy is a routine surgical procedure in oral and maxillofacial surgery. After decannulation, spontaneous tracheostoma closure is usually expected. However, wound healing is often delayed, requiring 1 to 2 weeks for healing and resulting in the need for surgical closure. Although many reports have described the surgical closure of a tracheostoma, few reports have focused on the dressing methods for closure of tracheal openings after decannulation. Herein, the authors report a new tracheostoma closure method that does not rely on surgical closure or the adhesive strength of the tape. The authors' conventional dressing method was to place gauze over the tracheostoma after decannulation and apply pressure through elastic tape or with a film dressing to seal the tracheostoma and achieve natural closure by reducing the leakage of air and tracheal secretions. However, the conventional method cannot completely prevent the leakage of air and tracheal secretions. We developed a novel method to achieve early closure by markedly reducing the leakage by partially inserting the gauze into the tracheostoma.

Educational Quality of YouTube Videos for Patients Undergoing Elective Procedures

INTRODUCTION

YouTube has become a main resource used by patients for self-education on medicine. It is important for surgeons to understand the quality and reliability of videos that patients are likely to view about elective procedures.

METHODS

Videos were categorized by view count and content creators. The top 20 videos for each term, sorted by relevance, were evaluated using DISCERN criteria, a question set externally validated to assess the quality of information regarding health treatment choices. DISCERN score (DS) closer to 5 indicate higher quality information and 1 indicates the opposite. Total scores were given: 15-26 (very poor), 27-38 (poor), 39-50 (fair), 51-62 (very good), and 63-75 (excellent). Search terms included "Wound Care", "Skin Grafting", "Tracheostomy", and "percutaneous endoscopic gastrostomy tube placement".

RESULTS

In total, 80 unique videos were evaluated with a total view of 8,848,796. The mean overall DS was 2.15 and a mean bias DS was 2.46. The median DISCERN total score for each key term was Tracheostomy: 35 (poor), Skin Grafting 26 (very poor), percutaneous endoscopic gastrostomy: 32 (poor), and Wound Care: 40 (fair).

CONCLUSIONS

YouTube videos surrounding elective procedures should be viewed cautiously in patient education despite wide availability. The videos in this study show high levels of bias and low DS. Healthcare providers should be aware of poor-quality consumer health information often disseminated in online media such as YouTube.

Nurse specialist and ostomy patient: Competence and skills in the care pathway. A scoping review

AIMS AND OBJECTIVES

To summarise the evidence published to date regarding nursing core competence in stoma care of any type of ostomy throughout the patient's ostomy surgery candidate care pathway from preoperative to follow-up.

BACKGROUND

Nurses should play a key role in all ostomy patient care pathways to help them to adapt to the new physics and psychological conditions from the preoperative phases to the prevention of tardive stomal complications.

DESIGN

Scoping review.

METHODS

This scoping review was conducted following the methodological framework proposed by Arskey and O'Malley, following the Preferred Reporting Item for Systematic Review and Meta-analysis for Scoping Review. PRISMA-ScR Checklist is included in the manuscript. The following databases were queried: PubMed, EMBASE and CINAHL, from August to October 2022.

RESULTS

The search strategy in the consulted databases identified 3144 studies. Different types of ostomies were found and investigated: tracheostomy, gastrostomy, jejunostomy, ileostomy, colostomy and urostomy. The results of the included studies helped address the objective that allowed the ostomatherapy skills to be broken down into the different periods of the care pathway.

CONCLUSION

Caring for an ostomy patient requires advanced skills and a trusting relationship. The skills outlined in this research suggest how essential the stoma care nurse specialist is in these patients' care.

Prevention of device-related infections in patients with cancer: Current practice and future horizons

Over the past several years, multifaceted advances in the management of cancer have led to a significant improvement in survival rates. Throughout patients' oncological journeys, they will likely receive one or more implantable devices for the administration of fluids and medications as well as management of various comorbidities and complications related to cancer therapy. Infections associated with these devices are frequent and complex, often necessitating device removal, increasing health care costs, negatively affecting quality of life, and complicating oncological care, usually leading to delays in further life-saving cancer therapy. Herein, the authors comprehensively review multiple evidence-based recommendations along with best practices, expert opinions, and novel approaches for the prevention of diverse device-related infections. The authors present many general principles for the prevention of these infections followed by specific device-related recommendations in a systematic manner. The continuous involvement and meaningful cooperation between regulatory entities, industry, specialty medical societies, hospitals, and infection control-targeted interventions, along with primary care and consulting health care providers, are all vital for the sustained reduction in the incidence of these preventable infections.

Zwitterion and N-halamine functionalized cotton wound dressing with enhanced antifouling, antibacterial, and hemostatic properties

With emerging needs of wound care management, a multi-functional wound dressing is needed. To prevent infection and reduce patient suffering, antibacterial efficacy against a broad-spectrum of bacteria plus robust antifouling are among the most preferred properties. In this study, a wound dressing was created with antibacterial and anti-fouling capabilities is presented. The approaches used a synthesized tri-functional copolymer comprised of an N-halamine precursor moiety, a marine-inspired surface binding dopamine moiety, and a zwitterionic anti-adhesion moiety bonded onto a commercial cotton gauze. The resulting HaloCare™ wound dressing demonstrated >99.99 % inactivation within 5 min against E. coli and a panel of ESKAPE pathogens plus achieved 98.77 % reduction of non-specific protein binding. HaloCare was also shown to be compatible with hemostatic agents without impacting hemostatic efficacy. HaloCare shows great potential particularly in traumatic injury events as an infection preventing and hemostatic wound management system.

Prevention and management of minor complications in percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) was developed by Ponsky-Gauderer in the early 1980s. These tubes are placed through the abdominal wall mainly to administer fluids, drugs and/or enteral nutrition but can also be used for drainage or decompression. The tubes consist of an internal and external retention device. It is a generally safe technique but major or minor complications may arise during and after tube placement.

METHOD

A narrative review of the literature investigating minor complications after PEG placement.

RESULTS

This review was written from a clinical viewpoint focusing on prevention and management of minor complications and documented with real cases from more than 21 years of clinical practice.

CONCLUSIONS

Depending on the literature the incidence of minor complications after gastrostomy placement can be high. To decrease associated morbidity, prevention, early recognition and popper management of these complications are important.