Percutaneous dilatational tracheostomy (PDT) in trauma patients: a safe procedure

Purpose

Percutaneous dilatational tracheostomy (PDT) is a standard procedure routinely performed on intensive care units. While complication rates and long-term outcomes have been studied in different patient populations, there are few studies known to these authors involving PDT in trauma patients and the complications which may result.

Methods

Between March 2007 and August 2013, all instances and peri-procedural complications during PDT occurring on the trauma intensive care unit, a unit specialized in the care of injured patients and especially polytrauma patients, were documented. PDTs were performed by a surgeon with the assistance and supervision of another, using bronchoscopic guidance performed by the respiratory medicine department.

Results

289 patients were included in the study, 225 men and 64 women with a mean age of 49 ± 21 years. Complications occurred in 37.4 % of cases. The most common complication, bleeding, occurred in 26.3 % of patients ranging from little to severe bleeding. Fracture of tracheal cartilage occurred in 6 % of PDT cases. Additional complications such as dislocation of the guidewire, hypotension, and oxygen desaturation were observed. Most complications did not require treatment. The second tracheal intercartilaginous space was successfully intubated in 82 % of cases.

Conclusions

PDT is a safe procedure in trauma patients. When considering the severity of complications such as major blood loss, pneumothorax, or death, this evidence suggests that PDT is safer in trauma patients compared to other patient cohorts.

     

Percutaneous dilatational tracheostomy: still a surgical procedure.

Although percutaneous dilatational tracheostomy (PDT) has been shown to be a cost-effective bedside alternative to open tracheostomy (OT), prior reports of the complications of the procedure are contradictory. Reported complications range from minor events to fatal ones, in varying percentages. This prospective study was designed to identify the type and severity of complications accompanying the introduction of PDT to a tertiary medical center. Surgical and medical intensive care unit (ICU) patients requiring elective tracheostomy were identified as appropriate for PDT using approved institutional criteria. All procedures were performed at an ICU bedside in the presence of a surgeon privileged to perform OT. Demographic data, procedural information, and patient outcome (including minor and major complications, length of stay, and survival) were collected. PDT was performed in 96 ICU patients, with complete data available for 95 patients. PDT was performed in an average of 13.1+/-1.0 minutes. Twenty-three major and minor complications occurred, including two perioperative deaths, in 15 patients (15.8%). A total of 37 PDT patients (38.9%) died in the hospital, indicative of the severity of illness of patients requiring tracheostomy. Based on the experience to date, Cedars-Sinai Medical Center (Los Angeles, CA) continues to require a surgeon privileged to perform OT to participate in all PDT procedures.     

Percutaneous dilatational tracheostomy is as safe as open tracheostomy

Although percutaneous dilatational tracheostomy (PDT) has been advocated as an alternative to open tracheostomy (OT) its relative safety has been questioned repeatedly. This study prospectively compared the safety and complications of PDT and OT. Ninety-four patients underwent PDT and 252 patients underwent OT at this institution from December 1998 through April 2000 with the choice of procedure left to the operator. OT was performed in the operating room whereas PDT was performed in intensive care units (ICUs). PDT was performed by surgeons and medical intensivists under a strict institutional policy and procedure governing patient selection and conduct of the procedure. Complications were defined as bleeding, loss of airway, hypotension, hypoxia, tracheostomy tube malposition, subcutaneous emphysema, infection, and conversion of PDT to OT. All patients survived the operation. PDT and OT had similar complication rates: 2.1 per cent for PDT versus 2.8 per cent for OT (P = not significant). Postoperative bleeding, which was the most frequent complication, occurred in one PDT patient and four OT patients. One PDT patient required conversion to OT as a result of extensive tracheal fibrosis. Subcutaneous emphysema, soft-tissue infection, and a malpositioned tracheostomy tube were the remaining complications in the OT patients. We conclude that the complication rates of PDT and OT are comparable. The choice of PDT or OT should be dictated by the surgeon's training and experience, the patient's condition, neck anatomy, and stability for transfer to the operating room.     

Percutaneous endovascular aneurysm repair in morbidly obese patients

Objective

Endovascular aneurysm repair (EVAR) with percutaneous femoral access (PEVAR) has several potential advantages. Morbidly obese (MO) patients present unique anatomical challenges and have not been specifically studied. This study examines the trends in the use of PEVAR and its surgical outcomes compared with open femoral cutdown (CEVAR) in MO patients.

Transanal endoscopic microsurgery: safe for midrectal lesions in morbidly obese patients

BackgroundTransanal endoscopic microsurgery is a safe option for proximal rectal tumors in morbidly obese patients for whom transabdominal pelvic dissection often is fraught with morbidity.MethodsFrom a database of 318 patients who underwent transanal endoscopic microsurgery, we report a retrospective case-control study of 9 patients with a body mass index range of 35 to 66 with sessile rectal lesions 6 to 15 cm from the anal verge who underwent transanal endoscopic microsurgery. Case subjects were compared with 15 controls and matched for age, tumor type, and level of tumor. The average body mass index of controls was 30 (P < .001). By using t test analysis, perioperative outcomes (surgical time, blood loss, and hospital length of stay) and postoperative complications were compared.ResultsSessile tumors were located 7 to 11 cm from the anal verge with a diameter of 1 to 4 cm. Patient and tumor factors such as age, distal tumor margin from anal verge, and tumor diameter were not significantly different between case subjects and controls. Surgical blood loss, surgical time, and hospital length of stay were not significantly different between the 2 groups. One complication occurred among the cases. No complications occurred in the control group. All patients had complete surgical resections with negative margins.ConclusionsTransanal endoscopic microsurgery in morbidly obese patients is a safe, feasible, and a viable alternative to low anterior resection.     

Successful management of a morbidly obese patient for electroconvulsive therapy with elective tracheostomy

Electroconvulsive therapy (ECT) is a treatment for affective catatonia and requires multiple general anesthetics. Morbid obesity is an increasingly prevalent condition that may complicate the standard anesthetic management of a patient undergoing ECT. We report the successful airway management of a morbidly obese ECT patient via elective tracheostomy.     

Ultrasound-guided percutaneous dilatational tracheostomy with laryngeal mask airway control in a morbidly obese patient

Percutaneous dilatational tracheostomy (PDT) is a widely used and accepted method of long-term ventilation of critically ill patients in many intensive care units. However, it has certain contraindications that must be taken into account; for example, difficult anatomy and short, bull neck that are so often seen in morbidly obese persons. We present a case of a morbidly obese female patient in whom ultrasound-guided PDT was performed and in whom the airway was controlled by Laryngeal Mask Airway (LMA) during the procedure. Possible advantages of an ultrasonography-guided method and LMA control in morbidly obese patients also are discussed.     

Percutaneous tracheostomy in patients with cervical spine fractures--feasible and safe

The aim of this study is to evaluate the short and long-term results of percutaneous tracheostomy in patients with documented cervical spine fracture. Between June 2000 and September 2005, 38 consecutive percutaneous tracheostomy procedures were performed on multi-trauma patients with cervical spine fracture. Modified Griggs technique was employed at the bedside in the general intensive care department. Staff thoracic surgeons and anesthesiologists performed all procedures. Demographics, anatomical conditions, presence of co-morbidities and complication rates were recorded. The average operative time was 10 min (6-15). Two patients had minor complications. One patients had minor bleeding (50 cc) and one had mild cellulitis. Nine patients had severe paraparesis or paraplegia prior to the PCT procedure and 29 were without neurological damage. There was no PCT related neurological deterioration. Twenty-eight patients were discharged from the hospital, 21 were decannulated. The average follow-up period was 18 months (1-48). There was no delayed, procedure related, complication. These results demonstrate that percutaneous tracheostomy is feasible and safe in patients with cervical spine fracture with minimal short and long-term morbidity. We believe that percutaneous tracheostomy is the procedure of choice for patients with cervical spine fracture who need prolonged ventilatory support.