Effects of Preoperative Glucocorticoid Use on Patients Undergoing Single-Level Lumbar Fusions: A Retrospective Propensity Score-Matched Registry Study

Objective Spinal fusions are gaining popularity as a means of treating spinal deformity and instability from a range of pathologies. The prevalence of glucocorticoid use has also increased in recent decades, and their systemic effects are well-documented. Although commonly used in the preoperative period, the effects of steroids on outcomes among patients undergoing spinal fusions are inadequately described. This study compares the odds of developing complications among patients who underwent single-level lumbar fusions with and without preoperative glucocorticoid use in hopes of establishing more evidence-based parameters for guiding preoperative steroid use. Methods The TriNetX multi-institutional electronic health record database was used to perform a retrospective, propensity score-matched analysis of clinical outcomes of two cohorts of patients who underwent posterior or posterolateral single-level lumbar fusions with and without interbody fusion, those who used glucocorticoids for at least one week within a year of fusion and those who did not. The outcomes of interest were examined within 30 days of the operation and included death, reoperation, deep or superficial surgical site infection (SSI), pneumonia, reintubation, ventilator dependence, tracheostomy, acute kidney injury (AKI), renal insufficiency, pulmonary embolism (PE) or deep venous thrombosis (DVT), urinary tract infection (UTI), emergency department (ED) visit, sepsis, and myocardial infarction (MI). Results The odds of developing pneumonia within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.67 (p≤0.001, 95% CI: 0.59-0.69). The odds of requiring a tracheostomy within 30 days of spinal fusion in the cohort that used glucocorticoids within one year of operation compared to the cohort without glucocorticoid use was 0.39 (p≤0.001, 95% CI: 0.26-0.60). The odds of reoperation, deep and superficial SSI, and ED visits within 30 days of operation were significantly higher for the same glucocorticoid-receiving cohort, with odds ratios of 1.4 (p=0.003, 95% CI: 1.11-1.65), 1.86 (p≤0.001, 95% CI: 1.31-2.63), 2.28 (p≤0.001, 95% CI: 1.57-3.31), and 1.25 (p≤0.001, 95% CI: 1.17-1.33), respectively. After propensity score-matching, there was no significant difference between the odds of death, DVT, PE, MI, UTI, AKI, sepsis, reintubation, and ventilator dependence between the two cohorts. Conclusion In support of much of the current literature regarding preoperative glucocorticoid use and rates of complications, patients who underwent a single-level lumbar fusion and have used glucocorticoids for at least a week within a year of operation experienced significantly higher odds of reoperation, deep and superficial SSI, and ED visits. However, these patients using glucocorticoids were also found to have lower odds of developing pneumonia, renal insufficiency, and tracheostomy requirement than those who did not use steroids within a year of surgery.

Tracheal Stenosis in Open Versus Percutaneous Tracheostomy

OBJECTIVE

This study aims to investigate if there is an increased risk of developing tracheal stenosis after tracheostomy with an open versus percutaneous tracheostomy.

METHODS

The patient cohort included patients receiving open or percutaneous tracheostomies at Catholic Health Initiatives Midwest facilities from January 2017 to June 2023. The primary aim was to compare the differences in the risk of developing tracheal stenosis between open and percutaneous tracheostomy techniques. Between-technique differences in the risk of developing tracheal stenosis were assessed via a Cox proportional hazard model. To account for death precluding patients from developing tracheal stenosis, death was considered a competing risk.

RESULTS

A total of 828 patients met inclusion criteria (61.7% open, 38.3% percutaneous); 2.5% (N = 21) developed tracheal stenosis. The median number of days to develop tracheal stenosis was 84 (interquartile range: 60 to 243, range: 6 to 739). Tracheal stenosis was more frequent in patients who received a percutaneous tracheostomy (percutaneous: 3.5% vs. open: 2.0%); however, the risk of developing tracheal stenosis was statistically similar between open and percutaneous techniques (HR: 2.05, 95% CI: 0.86-4.94, p = 0.108).

CONCLUSIONS

This study demonstrates no significant difference in the development of tracheal stenosis when performing an open versus a percutaneous tracheostomy. Tracheal stenosis is a long-term complication of tracheostomy and should not influence the decision about the surgical technique used.

Appropriate Endotracheal Tube Position for Percutaneous Dilatational Tracheostomy: A Single-Center Observational Study

Aim This study aimed to investigate the appropriate endotracheal tube (ETT) position during percutaneous dilatational tracheostomy (PDT). Methods This single-center observational study included hospitalized patients who underwent surgical tracheostomy (ST) between August 2021 and October 2022. During ST, the trachea was opened, and the ETT was pulled out visually. It stopped when the ETT was no longer visible, and the tracheostomy tube was placed in the trachea. The ETT position was measured by considering the ETT position during ST to be the appropriate position during PDT. The correlation between the measured ETT position and patient characteristics was evaluated. A prediction equation for the ETT position was derived from the derivation group, and validation of the prediction equation was evaluated by the validation group. Results Forty-six and 15 patients were in the derivation and validation groups, respectively. Weight, duration of intubation, and in-hospital mortality were significantly different between the two groups. The measured ETT position correlated with body height (r=0.60, p<0.001) and sex (r=0.45, p=0.002), while the ETT position before ST showed a weak correlation (r=0.34, p=0.020). The predicted and measured values in the validation group correlated with each other (r=0.58, p=0.024). Conclusion The appropriate ETT position for PDT correlates with body height, and the equation "body height×0.112-0.323 cm" was derived. This predictive equation may be useful as a guide for ETT positioning during PDT puncture.

Safety of tracheostomy during extracorporeal membrane oxygenation support: A single-center experience

BACKGROUND

Some patients on extracorporeal membrane oxygenation (ECMO) require prolonged mechanical ventilation. An early tracheostomy strategy while on ECMO has appeared to be beneficial for these patients. This study aims to explore the safety of tracheostomy in ECMO patients.

METHODS

This is a retrospective observational single-center study.

RESULTS

Hundred and nine patients underwent tracheostomy (76 percutaneous and 33 surgical) during V-V ECMO support over an 8-year period. Patients with a percutaneous tracheostomy showed a significantly shorter ECMO duration [25.5 (17.3-40.1) vs 37.2 (26.5-53.2) days, p = 0.013] and a shorter ECMO-to-tracheostomy time [13.3 (8.5-19.7) vs 27.8 (16.3-36.9) days, p < 0.001] compared to those who underwent a surgical approach. There was no difference between the two strategies regarding both major and minor/no bleeding (p = 0.756). There was no difference in survival rate between patients who underwent percutaneous or surgical tracheostomy (p = 0.173). Patients who underwent an early tracheostomy (within 10 days from ECMO insertion) showed a significantly shorter hospital stay (p < 0.001) and a shorter duration of V-V ECMO support (p < 0.001). Our series includes 24 patients affected by COVID-19, who did not show significantly higher rates of major bleeding when compared to non-COVID-19 patients (p = 0.297). Within the COVID-19 subgroup, there was no difference in major bleeding rates between surgical and percutaneous approach (p = 1.0).

CONCLUSIONS

Percutaneous and surgical tracheostomy during ECMO have a similar safety profile in terms of bleeding risk and mortality. Percutaneous tracheostomy may favor a shorter duration of ECMO support and hospital stay and can be considered a safe alternative to surgical tracheostomy, even in COVID-19 patients, if relevant clinical expertise is available.

Association between surgical tracheostomy and chronic tracheal stenosis: A retrospective, single-center study

Background

Tracheal stenosis is a major complication of tracheostomy. Accordingly, anesthesiologists tend to select a smaller endotracheal tube (ETT) than usual for patients with a prior tracheostomy history, regardless of the presence or absence of respiratory symptoms. However, it likely comes from our trial and error, not scientific evidence. Therefore, in this study, we retrospectively examined the association between traditional surgical tracheostomy and tracheal stenosis as assessed by transverse computed tomography (CT).

Methods

Patients who underwent surgery for head and neck cancer from January 2010 to December 2013, with a temporary tracheostomy closed within a couple of months, were included. Exclusion criteria were tracheostoma before surgery, permanent tracheostomy, or insufficient CT follow-up. Transverse CT slices were measured 2 cm above and below the tracheostomy site (0.5 cm/slice for a total of 9 slices). The minimum cross-sectional tracheal area and horizontal and vertical diameters in transverse CT slices were compared before (baseline: BL), 6 months (6M) and 12 months (12M) after tracheostomy. Tracheal stenosis was defined as a decrease in the minimum cross-sectional tracheal area compared to BL.

Results

Of 112 patients, 77 were included. The minimum tracheal area was significantly decreased at 6M and 12M compared to BL (BL: mean 285 [SD 68] mm², 6M: 267 [70] mm², P < 0.01 vs. BL, 12M: 269 [68] mm², P < 0.01 vs. BL), and the localization was predominantly at or above the tracheostomy site at 6M and 12M. Tracheal stenosis was identified in 55 patients at 6M and in 49 patients at 12M without any respiratory symptoms. With regard to horizontal and vertical diameter, only horizontal diameter was significantly decreased at 6M and 12M compared to BL (BL: 16.8 [2.4] mm, 6M: 15.4 [2.7] mm, P < 0.01 vs. BL, 12M: 15.6 [2.8] mm, P < 0.01 vs. BL).

Conclusion

Conventional surgical tracheostomy was associated with a decreased horizontal diameter of the trachea. It resulted in a decreased cross-sectional tracheal area in more than one-half of the patients; however, no patient complained of any respiratory symptoms. Therefore, even without respiratory symptoms, prior tracheostomy causes an increased risk of tracheal stenosis, and using a smaller ETT than usual could be reasonable.

Outcomes of Surgical Tracheostomy on Mechanically Ventilated COVID-19 Patients Admitted to a Private Tertiary Hospital in Tanzania

OBJECTIVES

 The coronavirus disease 2019 (COVID-19) pandemic has resulted in an increase in the number of patients necessitating prolonged mechanical ventilation. Data on patients with COVID-19 undergoing tracheostomy indicating timing and outcomes are very limited. Our study illustrates--- outcomes for surgical tracheotomies performed on COVID-19 patients in Tanzania.

METHODS

 This was a retrospective observational study conducted at the Aga Khan Hospital in Dar es Salaam, Tanzania.

RESULTS

 Nineteen patients with COVID-19 underwent surgical tracheotomy between 16^th March and 31^st December 2021. All surgical tracheostomies were performed in the operating theatre. The average duration of intubation prior to tracheotomy and tracheostomy to ventilator liberation was 16 days and 27 days respectively. Only five patients were successfully liberated from the ventilator, decannulated, and discharged successfully.

CONCLUSIONS

 This is the first and largest study describing tracheotomy outcomes in COVID-19 patients in Tanzania. Our results revealed a high mortality rate. Multicenter studies in the private and public sectors are needed in Tanzania to determine optimal timing, identification of patients, and risk factors predictive of improved outcomes.

Safety of surgical tracheostomy under continued antithrombotic therapy: A retrospective cohort study

OBJECTIVE

Although various guidelines have been established for the management of antithrombotic therapy during surgical treatments, surgical tracheostomy (ST) under continued antithrombotic therapy (CAT) remains challenging. Here, we investigated the risk factors for complications after ST by focusing on the application of CAT during ST.

DESIGN

A retrospective cohort study with medical records from 2009 to 2020.

SETTING

A single-center study.

PARTICIPANTS

This study included patients who had undergone ST at the Department of Otolaryngology of our hospital MAIN OUTCOME MEASURES: The primary outcomes were the incidence of complications and blood test results. Secondary outcomes were risk factors for postoperative complications.

RESULTS

We identified 288 patients (median age: 64 years; 184 men [64%]), among whom 40 (median age: 67 years; 29 men [73%]) underwent CAT. Although the patients undergoing CAT had significantly longer activated partial thromboplastin time (p=0.002) and a higher prothrombin time-international normalized ratio (p=0.006) compared to antithrombotic naïve patients, no statistically significant intergroup differences were observed for the risk of bleeding, infection, or subcutaneous emphysema. Instead, ST under local anesthesia (p=0.01) and ST for airway emergency (p=0.02) significantly increased the risk of early postoperative complications.

CONCLUSION

These results suggest that ST under CAT can be safely performed without any increased risk of postoperative complications. Nevertheless, surgeons should be extra cautious about early complications after ST under local anesthesia without intubation or ST for airway emergencies.

Acute epiglottitis after COVID-19 infection

In patients with acute epiglottitis, the possibility of COVID-19 should be ruled out. Repeated nasofiberoscopy examinations or a tracheostomy, which may produce infectious aerosols, may be required.

Surgical Tracheostomy Outcomes in COVID-19-Positive Patients

Objective

The aim of this case series was to demonstrate that surgical tracheostomy can be undertaken safely in critically ill mechanically ventilated patients with coronavirus disease 2019 (COVID-19) and that it is an effective weaning tool.

Study Design

Retrospective case series.

Setting

Single academic teaching hospital in London.

Methods

All adult patients admitted to the adult intensive care unit (AICU), diagnosed with severe COVID-19 infection and requiring surgical tracheostomy between the March 10, 2020, and May 1, 2020, were included. Data collection focused upon patient demographics, AICU admission data, tracheostomy-specific data, and clinical outcomes.

Results

Twenty patients with COVID-19 underwent surgical tracheostomy. The main indication for tracheostomy was to assist in respiratory weaning. Patients had undergone mechanical ventilation for a median of 16.5 days prior to surgical tracheostomy. Tracheostomy remained in situ for a median of 12.5 days. Sixty percent of patients were decannulated at the end of the data collection period. There were no serious immediate or short-term complications. Surgical tracheostomy facilitated significant reduction in intravenous sedation at 48 hours after tracheostomy formation. There was no confirmed COVID-19 infection or reported sickness in the operating surgical or anesthetic teams.

Conclusion

Surgical tracheostomy has been demonstrated to be an effective weaning tool in patients with severe COVID-19 infection.

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.

Comparison of the efficacy of surgical tracheostomy and percutaneous dilatational tracheostomy with flexible lightwand and ultrasonography in geriatric intensive care patients

AIM

To compare the applicability, technical difficulties and postoperative complications of surgical tracheostomy and percutaneous dilatational tracheostomy with the flexible lightwand + ultrasonography method applied because of prolonged intubation to geriatric patients in the intensive care unit.

METHODS

A retrospective evaluation was made of 76 patients who received surgical tracheostomy (group 1) and 78 patients who received percutaneous dilatational tracheostomy (group 2). The patients were evaluated in respect of demographic data, duration of intubation, length of stay in the intensive care unit and discharge status, and after the intervention, the development of tube-related complications, early stage local complications and late-stage complications.

RESULTS

The time from intubation to tracheostomy was determined as 22.73 ± 15.23 days in group 1 and 12.65 ± 7.64 days in group 2. The mortality rate of patients in group 1 was determined to be statistically significantly higher than that of group 2 (P = 0.048). When evaluated in respect to early and late complications, nine early- and seven late-stage complications developed in group 1, and three early- and three late-stage complications developed in group 2 (P = 0.05). In the evaluation of factors related to mortality, the time from intubation to tracheostomy (r = 0.249, P = 0.01) and the presence of a comorbidity (r = 0.325, P = 0.004) were determined to have a positive correlation with the development of mortality.

CONCLUSION

Percutaneous dilatational tracheostomy with the flexible lightwand + ultrasonography technique is a safe, rapid and effective method with the advantage of management in respect to early complications, such as bleeding, and can be used safely in the geriatric patient population in intensive care conditions. Geriatr Gerontol Int 2020; ••: ••-••.

Healthcare costs and outcomes for patients undergoing tracheostomy in an Australian tertiary level referral hospital

OBJECTIVE

Patients undergoing tracheostomy represent a unique cohort, as often they have prolonged hospital stay, require multi-disciplinary, resource-intensive care, and may have poor outcomes. Currently, there is a lack of data around overall healthcare cost for these patients and their outcomes in terms of morbidity and mortality. The objective of the study was to estimate healthcare costs and outcomes associated in tracheostomy patients at a tertiary level hospital in South Australia.

DESIGN

Retrospective review of prospectively collected data in patients who underwent tracheostomy between July 2009 and May 2015.

METHODS

Overall healthcare-associated costs, length of mechanical ventilation, length of intensive care unit stay, and mortality rates were assessed.

RESULTS

A total of 454 patients with tracheostomies were examined. Majority of the tracheostomies (n = 386 (85%)) were performed in intensive care unit patients, predominantly using bedside percutaneous approach (85%). The median length of hospital stay was 44 (29-63) days and the in-hospital mortality rate was 20%. Overall total cost of managing a patient with tracheostomy was median $192,184 (inter-quartile range $122560-$295553); mean 225,200 (range $5942-$1046675) Australian dollars. There were no statistically significant differences in any of the measured outcomes, including costs, between patients who underwent percutaneous versus surgical tracheostomy and patients who underwent early versus late tracheostomy in their intensive care unit stay. Factors that predicted (adjusted R 2 = 0.53) the cost per patient were intensive care unit length of stay and hospital length of stay.

CONCLUSION

Hospitalised patients undergoing tracheostomy experience high morbidity and mortality and typically experience highly resource-intensive and costly healthcare.

Adverse outcomes after percutaneous dilatational tracheostomy versus surgical tracheostomy in intensive care patients: case series and literature review

Tracheostomy is a routinely done procedure in the setting of intensive care unit (ICU) in patients requiring prolonged mechanical ventilation. There are two ways of making a tracheostomy: an open surgical tracheostomy and percutaneous dilatational tracheostomy. Percutaneous dilatational tracheostomy is associated with fewer complications than open tracheostomy. In this study, we would like to compare both techniques of performing a tracheostomy in ICU patients and to present possible complications, methods of diagnosing and treating and minimizing their risk.

Tracheostomy in special groups of critically ill patients: Who, when, and where?

Tracheostomy is one of the most common procedures undertaken in critically ill patients. It offers many theoretical advantages over translaryngeal intubation. Recent evidence in a heterogeneous group of critically ill patients, however, has not demonstrated a benefit for tracheostomy, in terms of mortality, length of stay in Intensive Care Unit (ICU), or incidence of ventilator-associated pneumonia. It may be a beneficial intervention in articular subsets of ICU patients. In this article, we will focus on the evidence for the timing of tracheostomy and its effect on various subgroups of patients in critical care.

Percutaneous versus surgical strategy for tracheostomy: protocol for a systematic review and meta-analysis of perioperative and postoperative complications

BACKGROUND

Tracheostomy is one of the most frequently performed procedures in intensive care medicine. The two main approaches to form a tracheostoma are the open surgical tracheotomy (ST) and the interventional strategy of percutaneous dilatational tracheotomy (PDT). It is particularly important to the critically ill patients that both procedures are performed with high success rates and low complication frequencies. Therefore, the aim of this systematic review is to summarize and analyze existing and relevant evidence for peri- and postoperative parameters of safety.

METHODS/DESIGN

A systematic literature search will be conducted in The Cochrane Library, MEDLINE, LILACS, and Embase to identify all randomized controlled trials (RCTs) comparing peri- and postoperative complications between the two strategies and to define the strategy with the lower risk of potentially life-threatening events. A priori defined data will be extracted from included studies, and methodological quality will be assessed according to the recommendations of the Cochrane Collaboration.

DISCUSSION

The findings of this systematic review with proportional meta-analysis will help to identify the strategy with the lowest frequency of potentially life-threatening events. This may influence daily practice, and the data may be implemented in treatment guidelines or serve as the basis for planning further randomized controlled trials. Considering the critical health of these patients, they will particularly benefit from evidence-based treatment.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42015021967.

Percutaneous tracheostomy

BACKGROUND: Percutaneous tracheostomy (PT) has gained an increasing acceptance as an alternative to the conventional surgical tracheostomy (ST). In experienced hands, and with proper patient selection, it is safe, easy and quick. COMPLICATIONS: Perioperative complications are comparable with those of ST and these are mostly minor. An important advantage of PT over ST is that there is no need to move a critically ill patient to the operating room and the rate of stomal infection is very low. Although data on late complications of PT are not yet sufficient, available reports show a favourable result. TECHNIQUES: Ciaglia's method is the most commonly applied, but no study has shown superiority of any of the percutaneous techniques described. The decision on which method to use should solely be made depending on the clinical situation and the experience of the operator. The learning curve demands caution, attention to detail and adequate experience on the part of the intensive care physician. Although PT is unfortunately declared 'easy', it must be left in the hands of experienced physicians to avoid unnecessary complications, and the risk of overimplementation should be kept in mind.