Percutaneous versus open tracheostomy: comparison of procedures and surgical site infections

Effect of open surgical and percutaneous dilatational tracheostomy on postoperative wound complications in patients: A meta-analysis

Tracheostomy is one of the most common operations. The two main methods of tracheostomy are open surgical tracheostomy (OST) and percutaneous dilatational tracheostomy (PDT). In critical cases, the combination of these two approaches is especially crucial, with the possibility of successful outcomes and low complications. Thus, the purpose of this system is to analyse the effects of both methods on the outcome of postoperative wound. In this research, we performed a systematic review of Cochrane Library, PubMed, Web of Science and Embase, to determine all randomized controlled trials (RCTs) that are comparable in terms of postoperative injury outcomes. Eleven RCTs were found after screening. This study will take the necessary data from the selected trials and evaluate the documentation for RCTs. PDT was associated with a lower incidence of infection at the wound site than OST (OR, 4.46; 95% CI: 2.84-7.02 p < 0.0001), and PDT decreased blood loss (OR, 2.88; 95% CI: 1.62-5.12 p = 0.0003). But the operation time did not differ significantly in both PDT to OST (MD, 4.65; 95% CI: -1.19-10.48 p = 0.12). The meta-analyses will assist physicians in selecting the best operative procedure for critical cases of tracheostomy. These data can serve as guidelines for clinical management and in the design of future randomized, controlled studies.

Open and percutaneous pediatric tracheostomy: comorbidities and in-hospital mortality

Background

Tracheostomy procedures are used to establish a surgical airway in patients when non-invasive methods fail to offer adequate support. In pediatric patients, this procedure is relatively rare, and data on patients is scarce, limiting the ability of physicians to contextualize patient outcomes and identify those most at risk. This can be crucial, as research has shown that early tracheostomy in pediatric patients may improve clinical outcomes. The objective of this study is to characterize the comorbidities of pediatric patients undergoing open and percutaneous tracheostomies and examine their association with in-hospital mortality, as well as to compare patient demographics and comorbidity frequency between the two approaches. The 2016 Kids’ Inpatient Database was used to identify patients younger than 21 with ICD-CM-10 codes for open or percutaneous tracheostomies to determine demographic characteristics and identify the most frequent comorbidities in these patient cohorts.

Results

A weighted total of 5229 cases were analyzed. Congenital cardiopulmonary defects, newborn respiratory diseases, and traumatic lung or brain injury were the most common comorbidities for tracheostomy patients. In open tracheostomies, there was an increased likelihood of in-hospital mortality in patients aged less than one (OR = 2.2; 95% CI, 1.6–3.0) and in patients with atrial septal defects (OR = 1.9; 95% CI, 1.5–2.5), patent ductus arteriosus (OR = 2.5, 95% CI, 2.0–3.3), bronchopulmonary dysplasia (OR = 2.1; 95% CI, 1.6–2.8), and acute kidney injury (OR = 5.6, 95% CI, 4.3–7.2). Trauma-related comorbidities were more common in patients who underwent percutaneous procedures and were not associated with an increased likelihood of mortality. Patient age < 1 was associated with an increased risk of in-hospital mortality in both the open (OR = 2.2; 95% CI, 1.6–3.0) and percutaneous (OR = 2.3, 95% CI (1.3–3.9) approaches.

Conclusion

There are many indications for pediatric tracheostomy, and patients often present with complicated disease profiles and complicated courses of care. Broadly, we found that congenital cardiopulmonary defects were associated with a higher likelihood of in-hospital patient mortality, especially in younger patients undergoing an open-approach procedure. Patients undergoing a percutaneous-approach procedure were more likely to have trauma-related comorbidities such as pneumothorax or brain hemorrhage that were not associated with in-hospital mortality.

Surgical Tracheostomies in COVID-19 Patients: Indications, Technique, and Results in a Second-Level Spanish Hospital

OBJECTIVE

The main purpose of this work is to describe the sociodemographic and clinical characteristics of intensive care unit (ICU) patients in a second-level hospital in Madrid, Spain, focusing in those who underwent surgical tracheostomy during the coronavirus disease 2019 (COVID-19) pandemic. The surgical technique and associated complications are also detailed.

STUDY DESIGN

Observational and historical cohort.

SETTING

Single center.

METHODS

Eighty-three intubated COVID-19 patients were analyzed. Thirty bedside surgical tracheostomies had been performed following our safety protocol.

RESULTS

Data from 83 patients admitted to the ICU in Infanta Leonor University Hospital were collected; 74.7% were male. The average age was 59.7 years. The main comorbidities found were hypertension in 51.8%, diabetes mellitus in 25.3%, asthma in 7.2%, and chronic obstructive pulmonary disease in 3.6%. A surgical tracheostomy was carried out in 36.1% of patients who needed a prolonged intubation. The most frequent complication of the surgical procedure, bleeding, occurred in 30%, but the majority were mild and ceased with compression only. The most relevant complication was local infection, which occurred in 26.7% of patients. There were statistically significant differences in the time from the beginning of mechanical ventilation until weaning between tracheostomized and nontracheostomized patients. The mortality rate of patients who underwent tracheostomy was 56.7%. Despite severe acute respiratory syndrome coronavirus 2 being highly contagious and tracheostomy being considered a high-risk procedure, our rate of infected ear, nose, and throat specialists was only 11.8%.

CONCLUSION

In our experience, bedside surgical tracheostomy is a safe procedure in COVID-19 patients when safety protocols are followed.

Does percutaneous dilatational tracheostomy increase the incidence of sternal wound infection - a single center retrospective of 4100 cases

BACKGROUND

The impact of percutaneous dilatational tracheostomy (PDT) on the development of post-median sternotomy wound infection (SWI) and mediastinitis is still controversial. We aimed to investigate the frequency of cross-infection and incidence of SWI after PDT.

METHODS

In a retrospective design, out of a total of 4100 procedures, all patients who had undergone median sternotomy and postoperative PDT were included from January 2010 to May 2013. For comparison of the pathogens isolated from SWIs, data from all patients who developed an SWI without a PDT during the aforementioned period were also analyzed. Demographical, pre-, peri- and post-operative data were compared. Microbiologic analysis from cultures of sternal and tracheal wounds was performed. Day and duration of tracheostomy were correlated to SWI occurrence.

RESULTS

Of the 265 patients who underwent a PDT, 25 (9.4 %) developed an SWI. In this cohort, identical pathogens were isolated from the tracheostomy and SWI in 36 % (9/25) of the patients. Of the pathogens isolated from the SWIs from the PDT + SWI group, 60 % were gram-positive bacteria, 20 % gram-negative bacteria and 20 % Candida spp. In the cross-infection group, the patients developed the following types of SWIs: 11.1 % CDC I, 55.6 % CDC II and 33.3 % mediastinitis (CDC III). The incidence of SWI in the group SWI + PDT was 9.4 % (9.4 % vs. 3.4 %, PDT + SWI and SWI w/oPDT , respectively, p = 0.0001). In group SWI w/oPDT , only 1.5 % (2/131 vs. 5/25; p = 0.001) Candida spp were isolated from SWI. The infection-related in-hospital mortality was high in groups PDT + SWI vs. SWI w/oPDT (20 % vs. 0 %, respectively; p = 0.0001). The statistical analysis did not demonstrate any correlation between time of performing PDT and occurrence of SWI.

CONCLUSIONS

There was a high incidence of microbial cross-infection from the PDTs to the sternal wounds in our study. We did not detect any correlation between the time of performing PDT and occurrence of SWI. According to our data, PDT seems to increase the incidence of SWI, especially caused by Candida spp., after cardiac surgery, which results in a prolonged hospital stay. Therefore, early antifungal prophylaxis after a PDT might be reasonable in high-risk patients on long-term mechanical ventilation if there is an impending SWI.

Bedside Tracheostomy and Percutaneous Endoscopic Gastrostomy on the Patient's Television

Bedside surgical procedures such as percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) placement in ICU settings are widely accepted; however, these procedures often require the addition of bulky equipment into the patient's room, which consumes valuable space and restrict workflow. A practice modification was developed in our trauma program, which reduces clutter in the patient's room, streamlines workflow, and results in better patient care and teaching. Simple and cost-effective, this has become the standard in our trauma center and could be of benefit to other institutions as well.

Utility of percutaneous dilatational tracheostomy in the inmediate postoperative period of liver transplant

OBJECTIVE

To determinate the safety of percutaneous dilatational tracheostomy (PDT) on hepatic allograft recipients.

PATIENTS AND METHODS

We reviewed the records of patients who underwent liver transplantation between October 2007 and April 2013, followed by PDT. In this time period, 25 liver recipients underwent PDT in our intensive care unit. We recorded severity index scores such as APACHE II and SAPS II, number of days since intubation, ratios of PaO2/FiO2 (arterial oxygen pressure to fraction of inspired oxygen), coagulation study findings, complications, and procedure-related mortality rates. We compared these records with the general ICU population and literature reports.

RESULTS

The median age was 58 (IC range 47-65) and 64% were men. The median time since intubation to PDT was 11 days (IC range 6.5-15.5) and from transplant to PDT 12 days. The median ratio of PaO2/FiO2 was 212 (IC range 177-259). The median platelet count was 89 (IC range 37-149), significantly lower than the general ICU population (272 (IC range 186-381) P=.001). Complications were infrequent and included clinically remarkable major bleeding 8% (vs. 0,3% in general ICU population; P=.005), peristomal infection (4%) and ventilator-associated pneumonia 16% (vs. 2,8% in general ICU population; P=.007). There were no deaths associated with the procedures.

CONCLUSION

PDT was tolerated well in recipients of liver allografts and had a relatively low risk of major complications and a low procedure-related mortality rate.

Burn intensive care

As a result of continuous development in the treatment of burns, the LD50 (the burn size lethal to 50% of the population) for thermal injuries has risen from 42% total body surface area (TBSA) during the 1940s and 1950s to more than 90% TBSA for young thermally injured patients. This vast improvement in survival is due to simultaneous developments in critical care, advancements in resuscitation, control of infection through early excision, and pharmacologic support of the hypermetabolic response to burns. This article reviews these recent advances and how they influence modern intensive care of burns.

Open Tracheostomy after Aborted Percutaneous Approach due to Tracheoscopy Revealing Occult Tracheal Wall Ulcer

Tracheostomy is a common procedure for intensive care patients requiring prolonged mechanical ventilation. In this case report, we describe a 78-year-old female patient admitted for an aneurysm of the cerebral anterior communicating artery. Following immediate endovascular coiling, she remained ventilated and was transferred to the neurological intensive care unit. On postoperative day ten, a percutaneous tracheostomy (PCT) was requested; however, a large ulcer or possible tracheoesophageal fistula was identified on the posterior tracheal wall following bronchoscopic assessment of the trachea. Therefore, the requested PCT procedure was aborted. An open tracheostomy in the operating room was completed; however, due to the position and depth of the ulcer, a reinforced endotracheal tube (ETT) was placed via the tracheostomy. Four days later, the reinforced ETT was replaced with a Shiley distal extended tracheostomy tube to bypass the ulceration. Careful inspection and evaluation of the tracheostomy site before PCT prevented a potentially life-threatening issue in our patient.