La traqueotomía diez años después

[Randomised clinical trial to compare two tracheotomy care methods in an Intensive Care Unit]

INTRODUCTION

Tracheotomy is a common technique in Intensive Care Units (ICU). It is known that nursing care during and after that procedure is directly related to its success, by reducing the possible complications to a minimum, such as the stoma infection, and contributing to a favourable outcome in critical patients.

OBJECTIVES

To compare the use of polyhexanide (PLX) versus saline+povidone iodine (PY) as antiseptics and infection incidence in tracheostomies performed in Intensive Care Units.

MATERIAL AND METHOD

A 2-year, experimental, randomised, open-label trial carried out in a multidiscipline ICU with 32 beds. The study was approved by the Research Ethics Committee of Principality of Asturias.

RESULTS

The overall infection rate observed for every hundred patients was 1.34 (95% CI; 0.81-2.01), with 1.46 when using PLX and 1.21 for PY (P=.685).

CONCLUSIONS

In spite of the experimental treatment (PLX) was shown to be effective in other types of wounds in our study. No significant differences were found between this technique and the standard one. Since there is no national registry of tracheotomy- associated infections, it is not possible to know whether the rate observed is within the usual parameters.

[Percutaneous tracheostomy procedure: nursing service control and follow-up]

A significant number of patients in the Intensive Care Units require ventilator support over long periods of time. A tracheostomy is necessary in these cases so that the patients can breathe properly and to allow access to the airway. Percutaneous tracheostomy (PT) is an increasingly used and minimally invasive procedure in which the Seldinger method is used for access the trachea. In recent years, it has become the alternative to surgical tracheostomy. In fact, it is becoming the technique of first choice in critical patients since it has many advantages regarding the conventional tracheostomy. It is an easy-to-use and safe technique, but one that is not exempt from risks. The nursing staff that helps to perform this operation must know its procedures, advantages, disadvantages, indications, contraindications and complications in order to act correctly and in coordination with the rest of the team and to be able to satisfy the patient's needs at each moment. In this article, the characteristic interventions of the nursing staff before, during and after performing this technique are explained.

[Percutaneous tracheotomy and cricothyroidotomy in the critical patient]

OBJECTIVE

To review and compare the complications of percutaneous tracheotomy (TP) and cricothyroidotomy (CT) used to perform tracheal intubation in patients requiring prolonged mechanical ventilation.

DESIGN

A prospective, observational study performed from October 2004 to October 2006, and follow-up of course until May 2007.

SETTING

Intensive care service from a university-affiliated teaching hospital.

PATIENTS

A total of 82 patients in which CT or TP were necessary. Forty-three TP and 39 CT were performed.

MAIN MEASUREMENTS

Reason for TP or CT, demographic data, severity scores, ICU length of stay, orotracheal intubation (OTI) days, CT/TP early and late complications and in-hospital evolution were collected.

RESULTS

TP/CT were performed due to prolonged ventilation in 62 (76%) patients and because of impaired neurological status in the remaining patients. There were no differences between TP/CT in gender, APACHE II, ICU length of stay, previous OTI days. Patients in the CT group were older (68 +/- 9 vs 54 +/- 15 years, p < 0.001). There were 5 mild adverse events (3 guide angulations and 2 lateral tracheal punctions) after TP, and 1 severe adverse event (pulmonary ventilation problem) after CT. There were no fatal event related with TP/CT. Thirty-four patients were decanulated. Mild local injuries were seen in 8 patients (6 TP vs 2 CT). Only 1 subglottic granuloma was seen late in CT group.

CONCLUSIONS

In our experience CT constitutes a safety and feasible alternative to TP when TP is counter-indicated.

Traqueostomía percutánea en pacientes ventilados

INTRODUCTION

Percutaneous tracheostomy is an alternative to conventional surgical tracheostomy. It is associated to a more feasible procedure, that is less invasive and linked to a lower degree of complications. Herein, we review our experience since the implementation of this technique in our Department.

DESIGN

Retrospective observational.

SETTING

Nineteen-bed intensive care department, in a general reference teaching hospital.

PATIENTS AND METHOD

A total of 115 of 130 tracheostomies performed from 2001 to 2003 were retrospectively analyzed. Collected data include epidemiological information, reason for performing the procedure, maintenance time of artificial airway before the tracheostomy and type of ventilatory support or oxygen supplementation before and after the procedure. The modified PEEP (PEEP-mod = FiO2 x PEEP) was calculated, sedation level received before and 4-6 hours after the technique and also 24 hours later, were reviewed. Subsequent patient evolution was collected.

INTERVENTIONS

Observational study on the results of routine procedures.

VARIABLES OF INTEREST

Blood gases indicators of effectiveness in oxygen supply and the need of mechanical ventilation support.

RESULTS

Median age of the 115 reviewed patients was 65 years. The most common admission reasons were: brain vascular accident in 25 cases, head and neck injury in 21, cancer in 11 and sepsis in 10 patients. Tracheostomy was indicated because prolonged mechanical ventilation in 52 patients, coma in 28 and emergency or scheduled surgery in 10 cases. Median length of stay in the ICU before tracheostomy was 14 days. Ninety-two patients were discharged from the ICU, and 52 from the Hospital. The remaining patients died during their hospital stay. Serious complications appeared in 5 patients (4%); 3 of them were the development of fistulae and all of them occurred in patients in whom the tracheostomy was performed in the ICU at bedside. Before the procedure, 72 patients were under mechanical ventilation, but only 56 received ventilatory support 24 hours after tracheostomy. When PEEP-mod values were analyzed, first monitoring of median value was 1.6 (range 0 to 2), 4-6 hours time median value was 2 (1.4-2.45), and 24 hours later median value was 1.2 (0-2) (global variation, p < 0.001).

CONCLUSIONS

In our experience, percutaneous tracheostomy performed at bedside in the ICU is an adequate solution with a low complication rate and its makes it possible to reduce the level of ventilatory support.

[Acute parotiditis after tracheostomy in Intensive Care]

Post-anesthesic parotiditis is a little known entity related with anesthesic procedures but described in any situation that motivates manipulation of the oropharyngeal cavity. Its physiopathological mechanism is not well-defined, although it could have a multifactorial origin. A case of a male who was admitted for post-operative control of brain tumor exeresis and who had preauricular and submaxillary inflammation after a routinely performed tracheostomy is presented. Coincidence with the performing of a tracheostomy required us to propose the differential diagnosis with the complications associated to said surgical act. Post-anesthesic parotiditis, even though it is a rare complication and has no clinical significance, should be kept in mind when there is facial edema after any manipulation of the oropharyngeal cavity.