La trachéotomie en réanimation adulte: utile ou futile ?

While tracheostomy is commonly performed in critically ill adult patients requiring prolonged mechanical ventilation, no consensual recommendations exist regarding its use. The aim of this article is to provide a synthesis of the contemporary literature on tracheostomy. The currently most debated questions are addressed: What are the expected benefits of tracheostomy? In which patients should tracheostomy be performed? Should tracheostomy be performed early in the course of mechanical ventilation? Is percutaneous dilatational tracheostomy (PDT) preferable to surgical tracheostomy? How should patients be managed following tracheostomy placement? Due to the relatively low level of evidence of available studies, no definitive recommendations for tracheostomy can be made. However, these studies highlight several important issues. Firstly, early tracheostomy has failed to demonstrate any beneficial impact over prolonged translaryngeal intubation on mortality, infectious complications and duration of mechanical ventilation; however, it may reduce the need for sedative drugs, improve patients’ comfort and lead to earlier mobilisation and autonomy. Secondly, no specific subgroup of patients likely to draw the maximum benefit from tracheostomy has been identified so far. Thirdly, PDT seems to be preferable to surgical tracheostomy with respect to complications and costs. Finally, the optimal management of tracheostomized patients is far from being standardized. Further investigations are thus warranted to identify the best candidates for tracheostomy and delineate optimal care following tracheostomy placement. Until then, tracheostomy practices will remain largely influenced by physicians and patients’ preferences and preconceived opinions on tracheostomy.     

Automated versus non-automated weaning for reducing the duration of mechanical ventilation for critically ill adults and children: a cochrane systematic review and meta-analysis

IntroductionAutomated weaning systems may improve adaptation of mechanical support for a patient’s ventilatory needs and facilitate systematic and early recognition of their ability to breathe spontaneously and the potential for discontinuation of ventilation. Our objective was to compare mechanical ventilator weaning duration for critically ill adults and children when managed with automated systems versus non-automated strategies. Secondary objectives were to determine differences in duration of ventilation, intensive care unit (ICU) and hospital length of stay (LOS), mortality, and adverse events.MethodsElectronic databases were searched to 30 September 2013 without language restrictions. We also searched conference proceedings; trial registration websites; and article reference lists. Two authors independently extracted data and assessed risk of bias. We combined data using random-effects modelling.ResultsWe identified 21 eligible trials totalling 1,676 participants. Pooled data from 16 trials indicated that automated systems reduced the geometric mean weaning duration by 30% (95% confidence interval (CI) 13% to 45%), with substantial heterogeneity (I² = 87%, P <0.00001). Reduced weaning duration was found with mixed or medical ICU populations (42%, 95% CI 10% to 63%) and Smartcare/PS™ (28%, 95% CI 7% to 49%) but not with surgical populations or using other systems. Automated systems reduced ventilation duration with no heterogeneity (10%, 95% CI 3% to 16%) and ICU LOS (8%, 95% CI 0% to 15%). There was no strong evidence of effect on mortality, hospital LOS, reintubation, self-extubation and non-invasive ventilation following extubation. Automated systems reduced prolonged mechanical ventilation and tracheostomy. Overall quality of evidence was high.ConclusionsAutomated systems may reduce weaning and ventilation duration and ICU stay. Due to substantial trial heterogeneity an adequately powered, high quality, multi-centre randomized controlled trial is needed.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0755-6) contains supplementary material, which is available to authorized users.     

Impact of real-time ultrasound guidance on complications of percutaneous dilatational tracheostomy: a propensity score analysis

IntroductionRecent studies have demonstrated the feasibility of real-time ultrasound guidance during percutaneous dilatational tracheostomy, including in patients with risk factors such as coagulopathy, cervical spine immobilization and morbid obesity. Use of real-time ultrasound guidance has been shown to improve the technical accuracy of percutaneous dilatational tracheostomy; however, it is unclear if there is an associated reduction in complications. Our objective was to determine whether the peri-procedural use of real-time ultrasound guidance is associated with a reduction in complications of percutaneous dilatational tracheostomy using a propensity score analysis.MethodsThis study reviewed all percutaneous dilatational tracheostomies performed in an 8-year period in a neurocritical care unit. Percutaneous dilatational tracheostomies were typically performed by trainees under guidance of the attending intensivist. Bronchoscopic guidance was used for all procedures with addition of real-time ultrasound guidance at the discretion of the attending physician. Real-time ultrasound guidance was used to guide endotracheal tube withdrawal, guide tracheal puncture, identify guidewire entry level and confirm bilateral lung sliding. The primary outcome was a composite of previously defined complications including (among others) bleeding, infection, loss of airway, inability to complete procedure, need for revision, granuloma and early dislodgement. Propensity score analysis was used to ensure that the relationship of not using real-time ultrasound guidance with the probability of an adverse outcome was examined within groups of patients having similar covariate profiles. Covariates included were age, gender, body mass index, diagnosis, Acute Physiology and Chronic Health Evaluation II score, timing of tracheostomy, positive end-expiratory pressure and presence of risk factors including coagulopathy, cervical spine immobilization and prior tracheostomy.ResultsA total of 200 patients underwent percutaneous dilatational tracheostomy during the specified period, and 107 received real-time ultrasound guidance. Risk factors for percutaneous dilatational tracheostomy were present in 63 (32%). There were nine complications in the group without real-time ultrasound guidance: bleeding (n = 4), need for revision related to inability to ventilate or dislodgement (n = 3) and symptomatic granuloma (n = 2). There was one complication in the real-time ultrasound guidance group (early dislodgement). The odds of having an adverse outcome for patients receiving real-time ultrasound guidance were significantly lower (odds ratio = 0.08; 95% confidence interval, 0.009 to 0.811; P = 0.032) than for those receiving a standard technique while holding the propensity score quartile fixed.ConclusionsThe use of real-time ultrasound guidance during percutaneous dilatational tracheostomy was associated with a significant reduction in procedure-related complications.     

Bacteraemia following single-stage percutaneous dilatational tracheostomy

Objective  

Surgical tracheostomy in critically ill adults has largely been replaced by physicians performing percutaneous dilatational tracheostomy (PDT) at the bedside. Complications associated with this technique include haemorrhage, wound infection, barotrauma, false passage, ruptured tracheal ring and bacteraemia. Prophylactic antibiotics are not generally used with this procedure, however the incidence of bacteraemia following PDT has not been extensively studied.     

Use of ultrasound guidance to improve the safety of percutaneous dilatational tracheostomy: a literature review

Patients in ICUs frequently require tracheostomy for long-term ventilator support, and the percutaneous dilatational tracheostomy (PDT) method is preferred over surgical tracheostomy. The use of ultrasound (US) imaging to guide ICU procedures and interventions has recently emerged as a simple and noninvasive tool. The current evidence regarding the applications of US in PDT is encouraging; however, the exact role of US-guided dilatational tracheostomy (US-PDT) remains poorly defined. In this review, we describe the best available evidence concerning the safety and efficacy of US-PDT and briefly delineate the general principles of US image generation for the airway and of US-PDT procedures.     

Comparative clinical trial of progressive dilatational and forceps dilatational tracheostomy

OBJECTIVE: To compare the safety and early complications of progressive dilatational tracheostomy (PDT) and forceps dilatational tracheostomy (FDT). DESIGN: Prospective randomized trial. SETTING: Three-centre university and public teaching hospitals. PATIENTS: One hundred and twenty-seven consecutive patients were randomized to undergo PDT or FDT. RESULTS: The duration of the procedure was 7.0 +/- 3.5 min in the PDT group and 6.4 +/- 4.9 min in the FDT group, which was not significantly different. Intraprocedural complications occurred in 14 % with PDT and 31% with FDT (p = 0.03), and were usually minor. Difficult or false insertion of the cannula in eight patients after FDTwas the most common complication. CONCLUSIONS: Both percutaneous tracheostomy techniques are safe. The early complication rate of PDT appeared to be lower than FDT, but the early complication rate of FDT may be decreased significantly with small modifications to the set.     

Critical care capacity in Canada: results of a national cross-sectional study

IntroductionIntensive Care Units (ICUs) provide life-supporting treatment; however, resources are limited, so demand may exceed supply in the event of pandemics, environmental disasters, or in the context of an aging population. We hypothesized that comprehensive national data on ICU resources would permit a better understanding of regional differences in system capacity.MethodsAfter the 2009–2010 Influenza A (H1N1) pandemic, the Canadian Critical Care Trials Group surveyed all acute care hospitals in Canada to assess ICU capacity. Using a structured survey tool administered to physicians, respiratory therapists and nurses, we determined the number of ICU beds, ventilators, and the ability to provide specialized support for respiratory failure.ResultsWe identified 286 hospitals with 3170 ICU beds and 4982 mechanical ventilators for critically ill patients. Twenty-two hospitals had an ICU that routinely cared for children; 15 had dedicated pediatric ICUs. Per 100,000 population, there was substantial variability in provincial capacity, with a mean of 0.9 hospitals with ICUs (provincial range 0.4-2.8), 10 ICU beds capable of providing mechanical ventilation (provincial range 6–19), and 15 invasive mechanical ventilators (provincial range 10–24). There was only moderate correlation between ventilation capacity and population size (coefficient of determination (R²) = 0.771).ConclusionICU resources vary widely across Canadian provinces, and during times of increased demand, may result in geographic differences in the ability to care for critically ill patients. These results highlight the need to evolve inter-jurisdictional resource sharing during periods of substantial increase in demand, and provide background data for the development of appropriate critical care capacity benchmarks.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0852-6) contains supplementary material, which is available to authorized users.     

Percutaneous dilatational tracheostomy — early results and long-term outcome of 326 critically ill patients

Objective: To analyze perioperative and postoperative complications and long-term sequelae following percutaneous dilatational tracheostomy (PDT). Design: A prospective clinical study of patients undergoing PDT. Setting: Seven intensive care units at a University hospital Patients: 326 intensive care patients (202 male, 124 female; age: 11–95 years) with indications for tracheostomy. Interventions: Using tracheoscopic guidance, 337 PDTs were performed according to Ciaglias' method. In 106 decannulated patients, tracheal narrowing was assessed by plain tracheal radiography. Results: Two procedure-related deaths were seen (0.6 %). Perioperative and postoperative complications occurred with 9.5 % of the PDTs. One of 106 patients, who were followed-up for at least 6 months, showed a clinically relevant tracheal stenosis. Subclinical tracheal stenosis of at least 10 % of the cross-sectioned area was recognized in 46 of 106 patients (43.4 %). In the univariate analysis, the degree of stenosis was influenced by the age of the patient (p = 0.044), the duration of intubation prior to PDT (p = 0.042) and by the duration of cannulation (p = 0.006). These parameters had no statistical significance in a multiple regression model. Conclusion: When performed by experienced physicians, percutaneous dilatational tracheostomy under fiberoptic guidance is a safe method. The risks of early complications and of clinically relevant tracheal stenoses are low. Subclinical tracheal stenoses are found in about 40 % of patients following PDT. Received: 25 July 1997 Accepted: 7 April 1998     

Exposure and confidence across critical airway procedures in pediatric emergency medicine: An international survey study

BackgroundAirway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described.ObjectivesOur aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children.MethodsA web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience performing or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or ≥ 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to “not confident” or “confident.” Multivariate regression models were used to assess relevant associations.Results1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting “confidence” in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures.ConclusionBMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist.     

Percutaneous tracheostomy: comparison of Ciaglia and Griggs techniques

Background  

Although the standard tracheostomy described in 1909 by Jacksonhas been extensively used in critical patients, a more simple procedure thatcan be performed at the bedside is needed. Since 1957 several different typesof percutaneous tracheostomy technique have been described. The purpose of thepresent study was to compare two bedside percutaneous tracheostomy techniques:percutaneous dilatational tracheostomy (PDT) and the guidewire dilating forceps(GWDF).     

Ultrasound-guided percutaneous dilatational tracheostomy: a safe method to avoid cranial misplacement of the tracheostomy tube

The aim of this investigation was to evaluate the role of ultrasonography in avoiding cranial misplacement of the tracheostomy tube and tracheal ring fractures during percutaneous dilatational tracheostomy (PDT). The tracheas of 26 consecutive ICU patients who had undergone PDT but who later died were removed en bloc at autopsy. The tracheas were opened along the membranous portion and the condition of tracheal rings and the site of tracheostomy macroscopically evaluated. The patients were divided in two groups: group A with 15 patients who underwent "blind" PDT and group B with 11 patients who underwent ultrasound-guided PDT. In five (33%) patients from group A, autopsy revealed that the tracheostomy tube was placed between the cricoid cartilage and the first tracheal ring (cranial misplacement) and in six (43%) patients a fracture of one tracheal ring was found. Cranial misplacement of the tracheostomy tube in patients from group B was not found (P < 0.05) and four (36%) patients had a broken tracheal ring (P = NS). The authors maintain that by using ultrasound-guided PDT cranial misplacement of the tracheostomy tube may be entirely avoided.     

Percutaneous dilational tracheostomy or conventional surgical tracheostomy?

OBJECTIVE: Percutaneous dilational tracheostomy (PDT) is increasingly used in intensive care units (ICU), and it has a low incidence of complications. The aim of this study was to compare the costs, complications, and time consumption of PDT with that of conventional surgical tracheostomy (ST) when both procedures were performed in the ICU. DESIGN: The study was a prospective, randomized trial. SETTING: The procedures were performed routinely in the ICU of Satakunta Central Hospital. PATIENTS: During a 23-month period from December 1995 to November 1997, 30 patients underwent PDT and 26 patients had ST. In one patient, PDT was converted to ST. All patients were receiving ventilation in the ICU, and all tracheostomies were performed at the patient's bedside in the ICU. The Portex percutaneous tracheostomy kit was used for all PDTs. RESULTS: The mean time to perform PDT was 11 mins (SD, 6; range, 2-40), and the mean time to perform ST was 14 mins (SD, 6; range, 3-39). In the PDT group, five patients had moderate bleeding during the procedure. In three patients, the bleeding was resolved with compression; in one patient, it was resolved with ligation of the vessel; and in one patient, it was resolved with electrocoagulation. Bleeding did not cause any complications afterward. In the PDT group, one patient had minimal oozing from the wound edge on the first postoperative day and it was resolved spontaneously. In the ST group, there were no intraprocedural complications. One patient had bleeding from the wound on first postoperative day. The sutures were removed, and the bleeding vessel was ligated. The mean cost (in U. S. dollars) of PDT was $161 (SD, 10.4; range, $159-$219), and the mean cost of ST was $357 (SD, $74; range, $239-$599). The cost of PDT was significantly lower than the cost of ST (p < .001). CONCLUSION: We found that PDT is a cost-effective procedure in critically ill ICU patients. Although we performed ST at the bedside in the ICU to avoid the risks associated with moving critically ill patients to the operating room, we found PDT to be a simple and safe procedure.     

经皮扩张气管切开术在ICU的应用和护理

目的探讨运用经皮气管扩张切开术（PDT）在重症监护病房（ICU）中的应用效果和护理。方法以气管切开术患者40例为研究对象,随机分为标准的开放性气管切开术（OT）组和经皮扩张气管切开术（PDT）组,每组20例,比较两组的手术时间、术中出血量及术后出血量,并总结分析行PDT患者的护理过程。结果 PDT组手术时间为（10.82±1.47）min、术中出血量及术后出血量分别为（5.86±0.18）mL、（3.21±0.13）mL,与OT组比较,P〈0.01。结论与标准的外科气管切开术组比,PDT手术时间短,出血量少,更加易于护理。     

Perceptions of the appropriateness of care in California adult intensive care units

IntroductionIncreased demand for expensive intensive care unit (ICU) services may contribute to rising health-care costs. A focus on appropriate use may offer a clinically meaningful way of finding the balance. We aimed to determine the extent and characteristics of perceived inappropriate treatment among ICU doctors and nurses, defined as an imbalance between the amount or intensity of treatments being provided and the patient’s expected prognosis or wishes.MethodsThis was a cross-sectional study of doctors and nurses providing care to patients in 56 adult ICUs in California between May and August 2013. In total, 1,363 doctors and nurses completed an anonymous electronic survey.ResultsThirty-eight percent of 1,169 respondents (95% confidence interval (CI) 35% to 41%, 51.1% of physicians and 35.8% of nurses) identified at least one patient as receiving inappropriate treatment. Respondents most commonly reported that the amount of treatment provided was disproportionate to the patient’s expected prognosis or wishes—325 out of 429 (76%, 95% CI 72% to 80%)—and that treatment was ‘too much’ in 93% of cases. Factors associated with perceived inappropriateness of treatment were the belief that death in their ICU is seen as a failure (odds ratio (OR) 5.75, 95% CI 2.28 to 14.53, P = 0.000), profession (doctors more than nurses) (OR 2.50, 95% CI 1.58 to 3.97, P = 0.000), lack of collaboration between doctors and nurses (OR 1.84, 95% CI 1.21 to 2.80, P = 0.004), intent to leave their job (OR 1.73, 95% CI 1.18 to 2.55, P = 0.005), and the perceived responsibility to control health-care costs (OR 1.57, 95% CI 1.05 to 2.33, P = 0.026). Providers supported formal communication training (90%, 95% CI 88% to 92%) and mandatory family meetings (89%, 95% CI 87% to 91%) as potential solutions to reduce the provision of inappropriate treatment.ConclusionsDoctors and nurses working in California ICUs frequently perceive treatment to be inappropriate. They also identified measures that could reduce the provision of inappropriate treatment.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0777-0) contains supplementary material, which is available to authorized users.     

Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis

Introduction  

Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients with regards to major short and long term outcomes.     

Percutaneous dilatational tracheostomy: mostly safe,but do benefits outweigh risks?

Percutaneous dilatational tracheostomies have become one of the most frequently performed surgical procedures in the ICU, and are believed to offer a variety of advantages over open tracheostomies, including increased convenience. Recent publications have established that the risk of fatal complications related to the procedure is low. However, clinicians must still weigh these risks against expected but largely unproven benefits. More research is needed to establish the indications for the procedure, including the optimal patient selection and timing during a course of mechanical ventilation. Such studies should also seek to improve our ability to accurately identify which patients will require prolonged mechanical ventilation, and to quantify the potential benefits of tracheostomy compared with prolonged translaryngeal intubation.In a previous issue of Critical Care, Simon and colleagues provide a contribution that helps clarify the safety of the percutaneous dilatational tracheostomy procedure [1]. Tracheostomy is one of the most common surgical procedures performed in the ICU [2], and percutaneous tracheostomies have now largely replaced the open tracheostomy technique [3,4]. The percutaneous approach allows the procedure to be performed in the ICU instead of in the operating room, making it more convenient to arrange and avoiding competition for limited operating room resources [5]. The percutaneous approach is also a skill that can be taught to intensivists, whereas surgeons largely performed open tracheostomies.Most evaluations of percutaneous tracheostomies have suggested that their safety profile is similar to that of the open procedure in unselected ICU patients [5]. However, there are several problems inherent to defining the safety of new procedures. For example, safety information derived from comptive randomised trials may fail to detect safety concerns because of limited sample size and restrictive inclusion and exclusion criteria. Adverse events that occur in routine practice are seldom captured by the medical literature, introducing a potential for publication and reporting bias [6]. Finally, the requirements for post-market surveillance that have been developed for pharmaceutical therapies seldom exist for new surgical techniques.Simon and colleagues systematically reviewed the peer-reviewed literature spanning a 28-year period to catalogue and describe the complications reported to be associated with the procedure [1]. In addition, they went to great lengths (including contacting all corresponding authors) to estimate the denominator for these published reports, a necessary step for estimating the incidence of associated complications. To corroborate these risk estimates, they also augmented the literature review with a thorough analysis of their own departmental records representing real-world data and an accurate local estimate of complications relative to total number of procedures. They concluded that the incidence of lethal complications is low: only 1.7 deaths per 1,000 procedures. Furthermore, the greatest risk of fatality occurred during the procedure (nearly one-third of deaths), suggesting that there still may be opportunities to improve the safety of the operative technique and reduce complications [7]. Finally, this study from Simon and colleagues suggests several potential risk factors for encountering complications, although their methodology precluded a systematic evaluation of these factors.Future research in this field should attempt to answer a number of remaining research questions. We need to identify the residual role for the open tracheostomy, especially since these procedures are becoming less common and are only being performed in the most technically challenging and highest risk patients. There is still a need for further research to inform the indications for all types of tracheostomy, including the optimal patient selection and timing during an episode of mechanical ventilation [8]. Although the risk of percutaneous tracheostomy may seem low, whether patients should be subjected to this risk without clear benefits to the procedure is debatable.With the publication of the TracMan trial, we know that there is no benefit of early (≤4 days) versus late (≥10 days) tracheostomy [9]. Future studies should therefore focus on the benefits and risks of avoiding tracheostomy in favour of prolonged translaryngeal intubation, as well as on the value of late versus later tracheostomies in general ICU patients. We also need to improve our ability to accurately identify which patients will require prolonged mechanical ventilation both to aid clinical decision-making and to improve study validity [9,10]. Finally, we believe that some patient populations – for example, those with chronic respiratory conditions or underlying neurological injury – may have risk–benefit profiles that differ from general ICU patients, and this should be further explored.

Competing interests

DCS holds a New Investigator Award from the Canadian Institutes for Health Research and a Fellowship in Translational Health Research from Physicians’ Services Incorporated Foundation. BHC declares that he has no competing interests.     

Safety of percutaneous dilatational tracheostomy in patients on extracorporeal lung support

Purpose

To evaluate the safety of percutaneous dilatational tracheostomy (PDT) in critically ill patients on an extracorporeal lung assist device requiring therapeutic anticoagulation.

Methods

This was a retrospective, observational study on all patients undergoing tracheostomy while on pumpless extracorporeal lung assist or extracorporeal membrane oxygenation in intensive care units of two university hospitals in Germany between 2007 and 2013.

Results

During the study period PDT was performed on 118 patients. The median platelet count, international normalized ratio, and activated partial thromboplastin time before tracheostomy were 126 × 10⁹/L (range 16–617 × 10⁹/L), 1.1 (0.9–2.0) and 49 s (28–117 s), respectively. Seventeen patients (14.4 %) received a maximum of three bags of pooled platelets, and eight patients (6.8 %) received a maximum of four units of fresh frozen plasma before the procedure. In all patients the administration of intravenous heparin was briefly paused periprocedurally. No periprocedural clotting complication within the extracorporeal circuit was observed. Two patients (1.7 %) suffered from procedure-related major bleeding, with one patient requiring conversion to a surgical tracheostomy. Two pneumothoraces (1.7 %) were related to the PDT. One patient (0.8 %) had analgosedation-related hypotension with brief and successful cardiopulmonary resuscitation. Minor bleeding from the tracheostomy site occurred in 37 cases (31.4 %). No fatality was attributable to tracheostomy.

Conclusions

The complication rates of PDT in the patients on extracorporeal lung support were low and comparable to those of other critically ill patients. Based on these results, we conclude that PDT performed by experienced operators with careful optimization of the coagulation state is a relatively safe procedure and not contraindicated for this patient group.     

Cathelicidin antimicrobial protein,vitamin D,and risk of death in critically ill patients

IntroductionDecreased production of cathelicidin antimicrobial protein-18 (hCAP18) has been proposed to be a key mechanism linking decreased 25-hydroxyvitamin D (25D) levels with adverse outcomes among critically ill patients. However, few studies in humans have directly assessed plasma hCAP18 levels, and no study has evaluated the association between hCAP18 levels and adverse outcomes among critically ill patients.MethodsWe performed a single-center, prospective cohort study among 121 critically ill patients admitted to intensive care units (ICUs) between 2008 and 2012. We measured plasma hCAP18, 25D, D-binding protein, and parathyroid hormone levels on ICU day 1. The primary endpoint was 90-day mortality. Secondary endpoints included hospital mortality, sepsis, acute kidney injury, duration of mechanical ventilation, and hospital length of stay.ResultsICU day 1 hCAP18 levels were directly correlated with 25D levels (Spearman’s rho (r_s) = 0.30, P = 0.001). In multivariate analyses adjusted for age and Acute Physiology and Chronic Health Evaluation II (APACHE II) score, patients with hCAP18 levels in the lowest compared to highest tertile on ICU day 1 had a 4.49 (1.08 to 18.67) greater odds of 90-day mortality, and also had greater odds of sepsis. ICU day 1 levels of other analytes were not associated with 90-day mortality.ConclusionsLower 25D levels on ICU day 1 are associated with lower hCAP18 levels, which are in turn associated with a greater risk of 90-day mortality. These findings provide a potential mechanistic basis for the frequently observed association between low 25D levels and poor outcomes in critically ill patients.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0812-1) contains supplementary material, which is available to authorized users.     

Clinical review: Percutaneous dilatational tracheostomy

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.     

Clinical review: Percutaneous dilatational tracheostomy

As the number of critically ill patients requiring tracheotomy for prolonged ventilation has increased, the demand for a procedural alternative to the surgical tracheostomy (ST) has also emerged. Since its introduction, percutaneous dilatational tracheostomies (PDT) have gained increasing popularity. The most commonly cited advantages are the ease of the familiar technique and the ability to perform the procedure at the bedside. It is now considered a viable alternative to (ST) in the intensive care unit. Evaluation of PDT procedural modifications will require evaluation in randomized clinical trials. Regardless of the PDT technique, meticulous preoperative and postoperative management are necessary to maintain the excellent safety record of PDT.