Percutaneous tracheostomy in the intensive care unit

Percutaneous tracheostomy is now established in intensive care practice. However, discussion continues on many aspects of the procedure. This update reviews recent studies of bedside percutaneous tracheostomy, which suggest that the commonly used techniques are safe in terms of short and long-term complications. The introduction of percutaneous tracheostomy into an intensive care unit has training implications, particularly for surgeons. The timing of percutaneous tracheostomy in critically ill patients, and the use of the technique in children remain controversial.     

The impact of percutaneous tracheostomy on intensive care unit practice and training

We studied the impact of introducing percutaneous tracheostomy to our intensive care unit on the incidence and timing of tracheostomy and on the implications for surgical training. The proportion of patients receiving intensive care who underwent tracheostomy doubled from a median of 8.5% to 16.8% (p < 0.01) following the introduction of the percutaneous technique with the procedure being undertaken significantly earlier during the intensive care stay. The opportunity for surgical trainees to gain experience in open surgical tracheostomy has been virtually lost. The increase in tracheostomy rate may reflect a previous under-utilisation caused by the logistic problems of transferring a critically ill patient to theatre, or alternatively a relaxation of the indications for tracheostomy caused by a perceived benefit for the patient. An increased workload may also have contributed to the rise. Surgical trainees should be encouraged to learn percutaneous techniques and training opportunities in open surgical techniques should be maximised.     

Early tracheostomy versus late tracheostomy in the surgical intensive care unit

BACKGROUND: This study's purpose was to determine if early tracheostomy (ET) of severely injured patients reduces days of ventilatory support, the frequency of ventilator-associated pneumonia (VAP), and surgical intensive care unit (SICU) length of stay (LOS). METHODS: This 2-year retrospective review included 185 SICU patients with acute injuries requiring mechanical ventilation and tracheostomy. ET was defined as 7 days or less, and late tracheostomy (LT) as more than 7 days. RESULTS: The incidence of VAP was significantly higher in the LT group, relative to the ET group (42.3% vs. 27.2%, respectively; P <.05). Acute Physiology and Chronic Health Evaluation II scores, hospital and SICU LOS, and the number of ventilator days were significantly higher in the LT group. CONCLUSIONS: In patients who required prolonged mechanical ventilation, there was significant decreased incidence of VAP, less ventilator time, and lower ICU LOS when tracheostomy was performed within 7 days after admission to the SICU.     

Techniques of tracheostomy for intensive care unit patients

The author and his colleagues believe that the surgical technique used constructing a tracheostomy can have a profound effect on the safety and care of patients in the intensive care unit particularly in the first few days after the operation. The Bj?rk procedure is commended to the surgeons.     

Use and safety of percutaneous tracheostomy in intensive care. Report of a postal survey of ICU practice

A brief questionnaire was sent to 231 clinical directors of intensive care units in England and Wales to investigate the use of percutaneous tracheostomy. There was a 76% response rate. Percutaneous tracheostomies were in use in 78.4% of units. The Ciaglia technique was the most commonly used, with 31.3% routinely using fibreoscopy as part of their technique. Only 12% of units routinely provided long-term follow up of their percutaneous tracheostomies. Overall, 78.4% thought that percutaneous tracheostomy was safe and 66.7% considered percutaneous tracheostomy to be the technique of choice for Intensive Care patients. Percutaneous tracheostomy is now a well-established technique. However, the limited use of fibreoscopy and the lack of long-term follow-up are areas of concern.     

The effect of tracheostomy on outcome in intensive care unit patients

BACKGROUND: Percutaneous dilatation tracheostomy (PDT) is increasingly being used in the intensive care unit (ICU), and has probably increased the number of procedures performed. The primary aim of this study was to document the short- and long-term outcome of patients with a tracheostomy performed during an ICU stay. METHODS: Patients in our ICU who underwent an unplanned tracheostomy between 1997 and 2003 were included in this analysis. The type of tracheostomy (PDT or surgical tracheostomy) and time of the procedure were registered prospectively in our ICU database. Survival was followed using the People's Registry of Norway and morbidity data from the individual hospital record. These patients were also compared with a group of ICU patients ventilated for more than 24 h, but managed without a tracheostomy. We also compared patients who had early tracheostomy (less than median time to procedure) with those who had late tracheostomy. RESULTS: Of the 2844 admissions (2581 patients), unplanned tracheostomy was performed during 461 admissions (16.2%) on 454 patients (17.6%). The median time to tracheostomy was 6 days. The ICU, hospital and 1-year mortality rates were 10.8, 27.1 and 37.2%, respectively, significantly less than those of the group ventilated without tracheostomy. The median time to decannulation was 14 days. Patients who had early tracheostomy had a more favourable long-term survival than those who had late tracheostomy. No procedure-related mortality was registered. CONCLUSIONS: In our ICU, having a tracheostomy performed was associated with a favourable long-term outcome with regard to survival, and early tracheostomy improved survival in addition to consuming less ICU resources.     

Clinical practice guidelines in the intensive care unit: a survey of Canadian clinicians’ attitudes

PURPOSE: To understand clinicians' perceptions regarding practice guidelines in Canadian intensive care units (ICUs) to inform guideline development and implementation strategies. METHODS: We developed a self-administered survey instrument and assessed its clinical sensibility and reliability. The survey was mailed to ICU physicians and nurses in Canada to determine local ICU guideline development and use, and to compare physicians' and nurses' attitudes and preferences towards guidelines. RESULTS: The survey was completed by 51.6% (565/1095) of potential respondents. Although less than half reported a formal guideline development committee in their ICU, 81.0% reported that guidelines were developed at their institutions. Of clinicians who used guidelines in the ICU, 70.2% of nurses and 42.6% of physicians reported using them frequently or always. Professional society guidelines (with or without local modification) were reportedly used in most ICUs, but physicians were more confident than nurses of their validity (P<0.001). Physicians considered endorsement of guidelines by a colleague more relevant for enhancing guideline use than did nurses (P<0.001). Nurses considered low risk of the guideline and whether the guideline is consistent with their practice (P<0.001) to be more relevant to guideline uptake than did physicians (P<0.001). Lack of agreement with recommendations was a more important barrier to use of guidelines for physicians than for nurses (P<0.001). CONCLUSIONS: Many Canadian institutions locally develop guidelines, and many ICU physicians and nurses report using them. Planning implementation strategies according to clinician preferences may increase guideline use. The nature of the differences in attitudes towards guidelines between nurses and physicians, and their impact on clinician adherence to guidelines requires further exploration.     

Family satisfaction in intensive care unit: a prospective survey

Background

To assess family satisfaction in the intensive care unit (ICU) and to identify parameters for improvement.

Study design

Prospective observational monocentric study.

Patients and methods

One hundred and twenty families were given a questionnaire of twenty-four items covering: satisfaction with reception and waiting areas, satisfaction with care and satisfaction with information/decision-making. Each item was evaluated by families according to three levels: high, intermediate, and poor satisfaction. Opinions concerning accessibility time, information notice and visitor limitations were also gathered.

Results

Several factors, such as waiting time, respect of family's wishes, visiting hours, lack of social support, and examination's results communication were associated with poor level of satisfaction. Twenty-three percent of families felt restricted by visitation policy for children and 17 % by visitor's number limitation.

Discussion

Quality of family reception in the ICU needs to be improved concerning waiting time, visiting hours, social and emotional support.     

The economic benefit of organizational restructuring of the cardiothoracic intensive care unit

OBJECTIVES: Compare cost/benefits of organizational restructuring of the cardiac intensive care unit (CICU). DESIGN: Prospective, with a retrospective control period. SETTING: Academic medical center. Participants: Sixty-six CICU patients (prospective) and 57 patients who received care before restructuring (retrospective) were compared. Entrance criteria were constant for both study periods. INTERVENTIONS: The CICU was restructured from a level III ICU to a level I ICU with the initiation of a consultant CICU service. The CICU service provided an attending physician dedicated to ICU care daily. All cardiac patients admitted into the CICU received consultation by the CICU service. MEASUREMENTS AND MAIN RESULTS: The average postoperative intubation time decreased during the intervention period (61% extubated within 6 hours v 12%, p = 0.004). Pharmacy, radiology, laboratory, and ICU costs decreased 279 US dollars (p = 0.004), 196 US dollars (p = 0.003), 190 US dollars (p = 0.15), and 470 US dollars (p = 0.12), respectively. The ICU length of stay (0.28 days shorter) as well as the overall postsurgery stay (0.54 days shorter) were reduced in the intervention period (p = 0.11 and 0.10, respectively). CONCLUSIONS: The CICU service significantly reduced both total ICU-related costs ($1,173/patient) and overall costs (2,285 US dollars/patient) during the intervention period. Professional fees only reduced overall savings by 8%. These results indicate that organizational restructuring of the CICU to newer models can reduce costs associated with cardiac surgery.     

Acquisition, spread, and control of Pseudomonas aeruginosa in a cardiothoracic intensive care unit.

The isolation rate and spread of infection and colonisation with Pseudomonas aeruginosa in a cardiothoracic intensive care unit was studied over two and a half years. The overall acquisition rate was low (2.68%) and was concentrated in the group of patients undergoing prolonged intensive care (over seven days). Although some cross-infection from long-stay to short-stay patients occurred in 1978 and 1979, when cubicle isolation was inadequate, acquisition of Ps aeruginosa was confined to the long-stay group when isolation facilities became sufficient. Further study of the long-stay patients disclosed two factors--use of broad-spectrum antibiotics and tracheostomy--significantly associated with acquisition of Ps aeruginosa. The possible uses of the results obtained and the particular relevance of a policy of narrow-spectrum chemoprophylaxis for open-heart surgery are discussed.     

A survey of infection in an intensive care unit ''Forewarned is forearmed''

The infection (36%) and mortality rates (28%) were investigated in 433 patients admitted to a Respiratory Intensive Care Unit. It was found that the mortality rate was higher (45%) in the infected group than in the non-infected group (19%) and particularly so in patients who had had intra-abdominal surgery or who remained in the unit for longer than a week.     

A survey of intensive care unit visiting policies in the United Kingdom

Admission to an intensive care unit is a highly stressful event for both patients and their relatives. Feelings of anxiety, pain, fear and a sense of isolation are often reported by survivors of a critical illness, whilst the majority of relatives report symptoms of anxiety or depression while their relative was in the intensive care unit. Traditionally, infection control concerns and a belief that liberal visiting by patients’ relatives interferes with the provision of patient care have led many units to impose restricted visiting policies. However, recent studies suggest that an open visiting policy with unrestricted visiting hours improve visitors’ satisfaction and reduces anxiety. In order to determine current visiting practice and provision for relatives within intensive care units, a questionnaire was sent to the principal nurse in all units within the United Kingdom. A total of 206 hospitals out of 271 completed the survey (76%). We found that 165 (80.1%) of responding units still impose restricted visiting policies, with wide variations in the facilities available to patients’ relatives.