Purpose Traditional critical care dogma regarding the benefits of early tracheostomy during invasive ventilation has had to be revisited due to the risk of COVID-19 to patients and healthcare staff. Standard practises that have evolved to minimise the risks associated with tracheostomy must be comprehensively reviewed in light of the numerous potential episodes for aerosol generating procedures. We meet the urgent need for safe practise standards by presenting the experience of two major London teaching hospitals, and synthesise our findings into an evidence-based guideline for multidisciplinary care of the tracheostomy patient. Methods This is a narrative review presenting the extensive experience of over 120 patients with tracheostomy, with a pragmatic analysis of currently available evidence for safe tracheostomy care in COVID-19 patients. Results Tracheostomy care involves many potentially aerosol generating procedures which may pose a risk of viral transmission to staff and patients. We make a series of recommendations to ameliorate this risk through infection control strategies, equipment modification, and individualised decannulation protocols. In addition, we discuss the multidisciplinary collaboration that is absolutely fundamental to safe and effective practise. Conclusion COVID-19 requires a radical rethink of many tenets of tracheostomy care, and controversy continues to exist regarding the optimal techniques to minimise risk to patients and healthcare workers. Safe practise requires a coordinated multidisciplinary team approach to infection control, weaning and decannulation, with integrated processes for continuous prospective data collection and audit.

Our experience of this technique has been very positive, with excellent control of both obstructive and infective symptoms, and exceptionally low rates of complications. Further work will be required to allow conclusive demonstration of its advantages over extracapsular tonsillectomy.

No abstract

The advent of endoscopic retrograde cholangio-pancreatography (ERCP) has enabled physicians and surgeons to carry out a range of diagnostic and therapeutic procedures pertaining to various pathologies found within the hepato-biliary system. Despite being relatively less invasive when compared to traditional methods of surgery, ERCP still carries recognized complications that are a cause for morbidity amongst patients. Furthermore, rarer complications can occur in difficult circumstances that are potentially fatal. We report two cases whereby the patients sustained serious splenic injuries as a consequence of the procedure. Splenic lacerations were diagnosed on computer tomography scanning in both patients who subsequently underwent emergency splenectomy. The patients made an uneventful recovery and returned home after surgery.To date twelve cases have been reported in current medical literature regarding injury to the spleen following ERCP. These aforementioned injuries have arisen particularly when the endoscopist has encountered difficult or variations in anatomy whilst performing ERCP. In addition to presenting two cases, we review the literature and discuss the implications of these complications and how this may affect the way in which clinicians take informed consent from patients before conducting ERCP.