Thyroid Storm: A Dreaded Complication of Percutaneous Tracheostomy

Background: Thyroid gland may be manipulated during tracheostomy. Although uncommon, this may result in potentially life-threatening thyroid storm especially in patients with underlying thyroidal illness. Plasmapheresis maybe used as a treatment modality for these patients. Clinical Case: A 65-year-old Hispanic male was admitted to the hospital for acute exacerbation of heart failure and pneumonia. Medical history was significant for atrial fibrillation. He had been on amiodarone for 2 years, which was discontinued 2 months ago when he was diagnosed with amiodarone indued thyrotoxicosis (AIT). He was never started on any treatment for AIT. Lab work on admission was significant for undetectable TSH, fT4 of 4.4 ng/ml (RR: 0.8-1.5 ng/ml) and fT3 of 4pg/ml (RR: 2.2- 4.0 pg/ml). TSH receptor antibody was negative. Thyroid ultrasound showed mildly atrophic gland with no nodules. Methimazole, cholestyramine and hydrocortisone were initiated, and TFTs were trending down. Hospital course was complicated by cardio-respiratory failure requiring mechanical ventilation. After a short-term improvement in his clinical status, patient underwent percutaneous tracheotomy due to failure to wean from mechanical ventilation. On POD1, he was found to be tachycardic and febrile with Burch-Wartofsky score of 55, which was highly suggestive of thyroid storm. fT4 was >8ng/ml and fT3 was 11.4pg/ml. He did not respond to maximal doses of thionamides, steroids and b-blocker. Thyroidectomy was considered, but patient was deemed to be high risk for any surgical intervention. Plasmapheresis was initiated for 5 days. TFT started trending down and patient improved clinically. On POD 14, fT4 was 2.1ng/ml, fT3 was 3.8 pg/ml. Conclusion: This case highlights a rare complication of tracheostomy in a patient with known history of AIT. Studies have shown that there can be a significant increase in serum thyroid hormone levels after tracheostomy, even in euthyroid patients. There may even be a role of performing tracheostomy with thyroidectomy in non-euthyroidal patients. Use of plasmapheresis for thyroid storm is recommended by American Society of Apheresis when first line medical therapy fails. It maybe particularly effective in AIT as amiodarone and its active metabolite are highly bound to plasma proteins. To our knowledge, this is the first case of thyroid storm with a history of AIT, which was precipitated by tracheostomy, and successfully treated with plasmapheresis. References: 1. Esen E, Karaman M, Deveci I, Tatlıpınar A, Tuncel A, Sheidaei S, Esen S. Analysis and comparison of changing in thyroid hormones after percutaneous and surgical tracheotomy. Auris Nasus Larynx. 2012 Dec;39(6):601-5.2. Muller C, Perrin P, Faller B, Richter S, Chantrel F. Role of plasma exchange in the thyroid storm. Ther Apher Dial. 2011 Dec;15(6):522-31.

Viral Infectivity in Patients Undergoing Tracheotomy With COVID-19: A Preliminary Study

Objective To establish the presence of live virus and its association with polymerase chain reaction (PCR) positivity and antibody status in patients with COVID-19 undergoing tracheotomy. Study Design Prospective observational study. Setting Single institution across 3 hospital sites during the first wave of the COVID-19 pandemic. Methods Patients who were intubated for respiratory wean tracheotomy underwent SARS-CoV-2 PCR nasal, throat, and endotracheal tube swabs at the time of the procedure. These were assessed via quantitative real-time reverse transcription PCR. The tracheal tissue excised during the tracheotomy was cultured for SARS-CoV-2 with Vero E6 and Caco2 cells. Serum was assessed for antibody titers against SARS-CoV-2 via neutralization assays. Results Thirty-seven patients were included in this study. The mean number of days intubated prior to undergoing surgical tracheotomy was 27.8. At the time of the surgical tracheotomy, PCR swab testing yielded 8 positive results, but none of the 35 individuals who underwent tissue culture were positive for SARS-CoV-2. All 18 patients who had serum sampling demonstrated neutralization antibodies, with a minimum titer of 1:80. Conclusion In our series, irrespective of positive PCR swab, the likelihood of infectivity during tracheotomy remains low given negative tracheal tissue cultures. While our results do not undermine national and international guidance on tracheotomy after day 10 of intubation, given the length of time to procedure in our data, infectivity at 10 days cannot be excluded. We do however suggest that a preoperative negative PCR swab not be a prerequisite and that antibody titer levels may serve as a useful adjunct for assessment of infectivity.

Successfully managed bilateral pneumothorax and subcutaneous emphysema after emergency open surgical tracheotomy

Background The most common complications we encountered in tracheotomies are hemorrhage, pneumothorax, and tube displacement. In this case report, we describe bilateral pneumothorax following an emergency tracheotomy. Case presentation A 57-year-old woman, who was diagnosed with laryngeal carcinoma, was developed sudden respiratory distress in the ear nose throat (ENT) ward before surgery. The patient was taken to the operating room for emergency tracheotomy. After surgery, at the 5th minute of the mechanical ventilator follow-up in ICU, she developed subcutaneous emphysema on her eyes, face, neck, and chest. She was taken to re-operation. On the postoperative follow-up, bilateral pneumothorax was detected on chest X-ray and bilateral thorax tube was applied by thoracic surgeon. She was externed to ENT ward on the 3rd postoperative day. The left thorax tube was removed on the 2nd and right thorax tube was removed on the 6th postoperative day. Conclusion Here, we presented a successfully managed bilateral pneumothorax and subcutaneous emphysema after emergency open surgical tracheotomy. If persistence reduction of SPO2 levels after tracheotomy, pneumothorax should be kept in the mind.

Emergency surgical tracheotomy in the era of COVID-19 pandemic

At the beginning of 2020 a novel variant of coronavirus, named SARS-CoV-2, was identified as responsible for the development of severe pneumonia and acute respiratory distress syndrome (ARDS) with very high mortality, exceeding 30%. The disease caused by SARS-CoV-2, called Coronavirus Disease 2019 (COVID-19), was declared a pandemic by WHO on March 11th, 2020. Patients affected by COVID-19 may present with subtle, specific symptoms, but the sudden onset of life-threatening acute respiratory failure is not uncommon. The peculiarities of the disease combined with the single patient’s comorbidities, e.g. advanced age and cardiovascular diseases, plus hypoxia and hypotension secondary to ARDS, and multiorgan failure, may lead to unexpected difficulties in the case of tracheal intubation. The occurrence of the ‘Cannot-Intubate-Cannot-Oxygenate’ (CICO) scenario in COVID-19 patients represents a hazard not only for the patients but also for the assisting healthcare workers due to the high risk of aerosol-generating infected particles during conventional rescue airway procedures. While international consensus guidelines on the management of CICO scenario in COVID-19 patients are still lacking, there is evidence that both scalpel cricothyrotomy (CT) and open surgical tracheotomy (OST) represent valid alternatives for the establishment of a front-of-neck emergency airway. Primary CT requires a staged conversion to formal tracheotomy; conversely, OST represents a definitive mastery of the airway in COVID-19 patients in case of prolonged mechanical ventilation dependency, avoiding a second procedure and further exposure to aerosols. Furthermore, in patients with facial trauma and/or head and neck tumors, OST allows obtaining safe airway control. In the context of the current pandemic, emergency OST procedure in SARS-CoV-2 positives (or with unknown status) requires adequate arrangements and the use of proper personal protective equipment to limit risks for clinicians.