Perfil de crianças e adolescentes dependentes de tecnologia em um hospital pediátrico do Sul do país / Perfil de niños e adolescentes dependientes de tecnología en un hospital pediátrico de referencia del sur del país / Profile of technology-dependent children and adolescents in a referral pediatric hospital in the south of the country

Resumo Objetivo identificar o perfil de crianças e adolescentes dependentes de tecnologia de um hospital de referência pediátrica do sul do país. Método estudo descritivo, com abordagem quantitativa. A coleta de dados ocorreu por meio da análise de prontuários, entre janeiro de 2016 e dezembro de 2019, armazenados em planilha Microsoft Excel para a análise estatística descritiva. Um projeto aprovado pelo Comitê de Ética sob o parecer 5.115.194. Resultados prevaleceu o sexo masculino (50,8%), em idade pré-escolar (30,8%), proveniente da Grande Florianópolis (60,1%). Os diagnósticos mais frequentes foram relacionados à prematuridade/período neonatal, anomalias congênitas/defeitos genéticos, doenças neurológicas e/ou neuromusculares, correspondendo a 37%, 33,2% e 18,5%. Os dispositivos tecnológicos mais utilizados foram gastrostomia (56,3%) e traqueostomia (36,6%). A utilização de medicamentos contínuos se deu em 93,4% e 49,2% utilizavam quatro ou mais medicamentos. As mães foram as principais cuidadoras (80,9%). Ocorreram 31 óbitos no período. Conclusão e implicação para a prática este grupo apresenta grande demanda de cuidados decorrentes do diagnóstico principal, dos dispositivos tecnológicos, das medicações e das possíveis complicações. A identificação do perfil das crianças e adolescentes dependentes de tecnologia contribuiu para ampliar a visibilidade de uma população que está em constante crescimento e, assim, prestar uma assistência integral, de acordo com suas especificidades e reais necessidades.

Resumen Objetivo identificar el perfil de niños y adolescentes dependientes de tecnología atendidos en un hospital de referência pediátrica del sur del país. Método estudio descriptivo con enfoque cuantitativo. La recolección de datos ocurrió através del análisis de las historias clínicas, desde enero de 2016 hasta diciembre de 2019, almacenadas en una hoja de cálculo de Microsoft Excel para el análisis estadístico descriptivo. El proyecto fue aprobado por el Comité de Ética bajo el parecer 5.115.194. Resultados predominaron varones (50,8%), en período de desarrollo preescolar (30,8%), la región más frecuentada de la Gran Florianópolis (60,1%). Los diagnósticos más frecuentes estuvieron relacionados con prematuridad/el período neonatal, anomalías congénitas/defectos genéticos, enfermedades neurológicas y/o neuromusculares, correspondiendo al 37%, 33,2% y 18,5%, respectivamente. Los dispositivos tecnológicos más utilizados fueron la gastrostomía (56,3%) y la traqueotomía (36,6%). El uso de medicación continua ocurrió en el 93,4% y el 49,2% utilizó cuatro o más medicamentos. Las madres fueron las principales cuidadoras en 80,9% de los casos, ocurriendo 31 óbitos en el período. Conclusión e implicación para la práctica este grupo tiene una alta demanda de atención debido al diagnóstico principal, dispositivos tecnológicos, medicamentos y posibles complicaciones. Identificar el perfil de niños y adolescentes dependientes de tecnología contribuye a aumentar la visibilidad de una población en constante crecimiento y, por lo tanto, calificar la asistencia, de acuerdo com sus especificidades y reales necesidades.

Abstract Objective to identify the profile of technology-dependent children and adolescents at a pediatric referral hospital in southern Brazil. Method a descriptive study with a quantitative approach. Data was collected by analyzing medical records between January 2016 and December 2019 and stored in a Microsoft Excel spreadsheet for descriptive statistical analysis. The project was approved by the Ethics Committee under protocol number 5.115.194. Results: The prevalence was male (50.8%), pre-school age (30.8%), from Greater Florianópolis (60.1%). The most frequent diagnoses were related to prematurity/neonatal period, congenital anomalies/genetic defects, and neurological and/or neuromuscular diseases, corresponding to 37%, 33.2%, and 18.5%. The most commonly used technological devices were gastrostomy (56.3%) and tracheostomy (36.6%). 93.4% used continuous medication and 49.2% used four or more medications. Mothers were the main caregivers (80.9%). There were 31 deaths during the period. Conclusion and implications for practice this group has a high demand for care due to the main diagnosis, technological devices, medications, and possible complications. Identifying the profile of technology-dependent children and adolescents has helped to increase the visibility of a population that is constantly growing and thus provides comprehensive care according to their specific needs.

Modified Early Warning Score como preditor de readmissão à unidade de terapia intensiva dentro de 48 horas: um estudo observacional retrospectivo / Modified Early Warning Score as a predictor of intensive care unit readmission within 48 hours: a retrospective observational study

RESUMO Objetivo: Avaliar a hipótese de que o Modified Early Warning Score (MEWS) por ocasião da alta da unidade de terapia intensiva associa-se com readmissão, e identificar o nível desse escore que prediz com maior confiabilidade a readmissão à unidade de terapia intensiva dentro de 48 horas após a alta. Métodos: Este foi um estudo observacional retrospectivo a respeito do MEWS de pacientes que receberam alta da unidade de terapia intensiva. Comparamos dados demográficos, escores de severidade, características da doença crítica e MEWS de pacientes readmitidos e não readmitidos. Identificamos os fatores associados com a readmissão em um modelo de regressão logística. Construímos uma curva Característica de Operação do Receptor para o MEWS na predição da probabilidade de readmissão. Por fim, apresentamos o critério ideal com maior sensibilidade e especificidade. Resultados: A taxa de readmissões foi de 2,6%, e o MEWS foi preditor significante de readmissão, juntamente do tempo de permanência na unidade de terapia intensiva acima de 10 dias e traqueostomia. A curva Característica de Operação do Receptor relativa ao MEWS para predizer a probabilidade de readmissão teve área sob a curva de 0,82, e MEWS acima de 6 teve sensibilidade de 0,78 (IC95% 0,66 - 0,9) e especificidade de 0,9 (IC95% 0,87 - 0,93). Conclusão: O MEWS associa-se com readmissão à unidade de terapia intensiva, e o escore acima de 6 teve excelente precisão como preditor prognóstico.

ABSTRACT Objective: To evaluate the hypothesis that the Modified Early Warning Score (MEWS) at the time of intensive care unit discharge is associated with readmission and to identify the MEWS that most reliably predicts intensive care unit readmission within 48 hours of discharge. Methods: This was a retrospective observational study of the MEWSs of discharged patients from the intensive care unit. We compared the demographics, severity scores, critical illness characteristics, and MEWSs of readmitted and non-readmitted patients, identified factors associated with readmission in a logistic regression model, constructed a Receiver Operating Characteristic (ROC) curve of the MEWS in predicting the probability of readmission, and presented the optimum criterion with the highest sensitivity and specificity. Results: The readmission rate was 2.6%, and the MEWS was a significant predictor of readmission, along with intensive care unit length of stay > 10 days and tracheostomy. The ROC curve of the MEWS in predicting the readmission probability had an AUC of 0.82, and a MEWS > 6 carried a sensitivity of 0.78 (95%CI 0.66 - 0.9) and specificity of 0.9 (95%CI 0.87 - 0.93). Conclusion: The MEWS is associated with intensive care unit readmission, and a score > 6 has excellent accuracy as a prognostic predictor.

Cirugía transoral en cáncer de laringe estadificado T1-T2 / Transoral surgery in T1-T2 staged laryngeal cancer

Se realizó un estudio prospectivo y descriptivo, incluyendo 103 pacientes que fueron tratados por cáncer de laringe en etapa inicial (T1-T2) con cirugía transoral. De ellos, 55 se diagnosticaron en estadio T1, 16 en estadio T1-b y 32 en estadio T2. El control local inicial (CLI) en pacientes con tumores malignos de laringe estadificados T1 fue 91%, el control local con rescate (CLR) 96%, la preservación de la función de la laringe (PFL) 93% y la sobrevida específica 96%. En T1-b, el CLI fue 81%, el CLR 94%, la PFL 94% y la sobrevida específica 94%. En T2, el CLI fue 63%, el CLR 94%, la PFL 72% y la sobrevida específica 78%. La cirugía transoral en cáncer de laringe con T inicial tiene resultados oncológicos similares a otros tratamientos (cirugía externa o radioterapia), pero consideramos que es la mejor opción por su baja morbilidad, menor duración del tratamiento, y porque deja abiertas todas las posibilidades para tratar posibles recurrencias. (AU)

A prospective and descriptive study was conducted, including 103 patients who were treated for early stage laryngeal cancer (T1-T2) with transoral surgery. Of these, 55 were diagnosed in stage T1, 16 in stage T1-b and 32 in stage T2. The initial local control (CLI) in patients with malignant T1 laryngeal tumors was: 91%, local control with rescue (CLR) 96%, preservation of larynx function (PFL) 93% and specific survival 96%. In T1-b the CLI was 81%, the CLR 94%, the PFL 94% and the specific survival 94%. In T2 the CLI was 63%, the CLR 94%, the PFL 72% and the specific survival 78%. Transoral surgery in laryngeal cancer with initial T has oncological results similar to other treatments (external surgery or radiotherapy), but we consider that it is the best option because of its low morbidity, shorter duration of treatment, and because it leaves open all the possibilities to treat possible recurrences. (AU)

Predictores de éxito después de la decanulación en pacientes adultos críticamente enfermos: un estudio de cohorte retrospectivo / Success predictors after decannulation in critically ill adult patients: a retrospective cohort study

Introducción: la traqueostomía es una práctica frecuente dentro de las unidades de cuidados intensivos (UCI). El proceso de decanulación y el tiempo utilizado en ella resultan de interés clínico, mientras que los factores asociados al proceso y la dificultad en dicho proceso han sido poco estudiados. Objetivos: describir características clínicas y epidemiológicas de la población en estudio y su evolución desde el momento del ingreso en la UCI hasta el alta hospitalaria. Informar la incidencia de fallo de decanulación y analizar los factores de riesgo independientes asociados a la imposibilidad de esta. Materiales y métodos: estudio observacional de cohorte retrospectivo de pacientes internados en la UCI del Hospital Italiano de San Justo Agustín Rocca que requirieron traqueostomía durante su estadía. Utilizando la historia clínica informatizada se registraron variables epidemiológicas previas al ingreso en la UCI y datos evolutivos durante la internación. El período analizado fue desde el 5 de enero de 2016 hasta el 17 de diciembre de 2017. Se utilizaron modelos de regresión logística para la evaluación de potenciales predictores. Resultados: se reclutaron 50 pacientes, y todos fueron incluidos en el presente análisis. La edad promedio fue de 66 años (desvío estándar [DE] ± 15,5) y el 66% fueron hombres. El 42% fue decanulado durante el seguimiento. La incidencia en el fallo de decanulación fue del 4,77% (intervalo de confianza [IC] 95% 0,85-22,67). La mediana de tiempo hasta la decanulación desde la desvinculación de la asistencia ventilatoria fue de 17 días. En el análisis univariado hubo diferencias estadísticamente significativas en tipo de diagnóstico de ingreso en UCI y en el alta vivo hospitalaria al comparar pacientes decanulados versus no decanulados. En el análisis multivariado de regresión logística se halló el tipo de diagnóstico de ingreso en UCI como predictor independiente de imposibilidad de decanulación. Conclusiones: el motivo de ingreso clínico en UCI fue un factor predictor independiente asociado al fracaso de la decanulación y esto, posiblemente, está relacionado con la condición clínica y el estado general al ingreso, en comparación con los pacientes que ingresaron por causas quirúrgicas. No se hallaron comorbilidades ni antecedentes que se relacionen con el fracaso de la decanulación. (AU)

Introduction: the tracheostomy remains a very common surgical procedure done in the intensive care unit (ICU). The process of decannulation is of scientific interest with its associated factors not being sufficiently studied. Objectives: to describe the clinical and epidemiological characteristics of the population and their relationship to effective decanulation. To report the cumulative incidence of decannulation failure and success. To analyze independent risk factors associated with decannulation failure. Materials and methods: the present was a retrospective cohort of adult patients in the ICU at Hospital Italiano de San Justo who required tracheostomy during their in-hospital stay. Epidemiological variables were recorded before ICU admission and during their hospital stay using data from the electronic medical record. The inclusion period was 2 years long. We used descriptive statistics and logistic regression models to compare the proportion of patients who could be decannulated versus those who could not. Results: 50 patients were enrolled in the present study. Their mean age was 66 (±15.5) years and 66% of patients were male. 21 patients (42%) achieved to be decannulated. The cumulative incidence of decannulation failure was 4.77% (95% CI: 0.85-22.87). Median time from weaning to decannulation was 17 days. In univariate analysis, statistically significant differences were found in ICU admission diagnosis (p<0.001) and hospital discharge alive (p<0.001) when comparing decannulated versus not decannulated patients. In multivariate logistic regression analysis, ICU admission diagnosis was found to be an independent predictor of decannulation failure (p<0.01). Conclusions: clinical ICU admission diagnosis was an independent predictor associated with decannulation failure. This could be related to differences in baseline morbidity and clinical condition of these patients compared with surgical patients. However, no individual morbidities or clinical conditions were found to be associated in decannulation failure. (AU)

Evaluación del proceso de decanulación en pacientes traqueostomizados en el Hospital Carlos van Buren: una cohorte retrospectiva / Evaluation of decannulation process in tracheotomized patients at Carlos van Buren Hospital: a retrospective cohort

RESUMEN Introducción: El proceso de decanulación consiste en la evaluación de las competencias de la vía aérea superior que conlleva al retiro definitivo de una cánula de traqueostomía. La predicción de su éxito resulta dificultosa debido al alto número de variables que la afectan. Para conseguir este objetivo, es fundamental contar con un protocolo adecuado a la institución de salud, que se sume a un manejo multidisciplinario. Objetivo: El objetivo propuesto fue evaluar el éxito de decanulación en los pacientes adultos del Hospital Carlos van Buren que siguieron el protocolo institucional. Material y método: Estudio de cohorte retrospectivo que se desarrolló durante el primer semestre del año 2016. Se evaluó el éxito de decanulación en pacientes adultos traqueostomizados que cumplieron con los criterios de inclusión. La muestra final fue de 18 pacientes, de los cuales se obtuvieron datos de interés desde las historias clínicas y registros del servicio de medicina y rehabilitación. Resultados: De los 18 pacientes incluidos en el estudio ninguno cumplió con los criterios de ingreso al protocolo de decanulación institucional al momento de la evaluación inicial por el Servicio de Medicina Física y Rehabilitación, requiriendo todos entrenamiento para aplicar dicho protocolo. Finalmente, un total de 15 pacientes lograron decanulación exitosa, requiriendo una mediana de 22 días de entrenamiento fonoaudiológico y kinesiológico. Conclusiones: Tras el entrenamiento terapéutico se logró 83% de éxito en la decanulación, lo que requirió un trabajo coordinado entre las diferentes disciplinas del servicio de medicina física y rehabilitación y del apoyo del servicio de otorrinolaringología. Se deberá revaluar el protocolo institucional para ajustarlo a la realidad local.

ABSTRACT Introduction: The decannulation process consist in the evaluation of the upper airways competences which carry the definite extraction of the traqueostomy cannula. The prediction of its success is difficult due to the high number of variables that affect it. In order to reach this goal, is fundamental to count with an adequate protocol of the health institution, which assumes the multidisciplinary management. Aim: The proposed goal was to evaluate the success of decannulation in adult patients of Carlos van Buren hospital who followed the institutional protocol. Material and method: The cohort retrospective study that developed during the first semester of 2016. The decannulation success was evaluated in adult patients tracheostomized who fulfilled the inclusion criteria. The final sample was of 18 patients, of which were obtained data of interest from the clinical histories and register of the Medicine and Rehabilitation Service. Results: Of the 18 patients in this study none of them met the entry criteria of the institutional decannulation protocol at the time of the initial evaluation by the Physical Medicine and Rehabilitation Service, requiring all training in order to apply the protocol. Finally, a total of 15 patients achieved a successful decannulation requiring a median of 22 days of phonoaudiological and kinesiological training. Conclusions: After the therapeutic training it was achieved a 83% of success in decannulation, which required a coordinated work between the different disciplines of the Physical Medicine and Rehabilitation Service and the support of the Otorhinolaryngology Service. The institutional protocol should be evaluated to adjust it to the local reality.

Tracheostomy in children: a ten-year experience from a tertiary center in southern Brazil / Traqueostomia em crianças: uma experiência de dez anos em um centro terciário do sul do Brasil

Abstract Introduction: Children may require tracheostomy due to many different health conditions. Over the last 40 years, indications of tracheostomy have endorsed substantial modifications. Objective: To evaluate pediatric patients warranted tracheostomy at our Hospital, in regard to their indications, associated comorbidities, complications and decannulation rates. Methods: Retrospective study concerning patients under 18 years of age undergoing tracheostomy in a tertiary health care center, from January 2006 to November 2015. Results: 123 children required a tracheostomy after ENT evaluation during the study period. A proportion of 63% was male, and 56% was under one year of age. Glossoptosis was the most common indication (30%), followed by subglottic stenosis (16%) and pharyngomalacia (11%). The mortality rate was 31%. By the end of this review, 35 children (28.4%) had been decannulated, and the fewer the number of comorbidities, the greater the decannulation rate (0.77 ± 0.84 vs. 1.7 ± 1.00 comorbidities; p < 0.001). Conclusion: Tracheostomy in children is a relatively frequent procedure at our hospital. The most common indications are glossoptosis and subglottic stenosis. A high mortality rate was found, potentially substantiated by the high number of critical care patients with chronic neurological conditions in this cohort. Our decannulation rate is slightly below other series, probably because of the greater amount of patients with comorbidities.

Resumo Introdução: As crianças podem necessitar de traqueostomia devido a diferentes problemas de saúde. Ao longo dos últimos 40 anos, as indicações de traqueostomia passaram por mudanças substanciais. Objetivo: Avaliar pacientes pediátricos com traqueostomia no nosso hospital, no que diz respeito às suas indicações, comorbidades associadas, complicações e taxas de decanulação. Método: Estudo retrospectivo de pacientes com menos de 18 anos submetidos a traqueostomia em um centro de saúde terciário, de janeiro de 2006 a novembro de 2015. Resultados: 123 crianças precisaram de uma traqueostomia após avaliação otorrinolaringológica durante o período do estudo. Do total, 63% eram do sexo masculino e 56% menores de um ano. Glossoptose foi a indicação mais comum (30%), seguida por estenose subglótica (16%) e faringomalácia (11%). A taxa de mortalidade foi de 31%. Até o fim deste artigo, 35 crianças (28,4%) haviam sido decanuladas e quanto menor o número de comorbidades, maior foi a taxa de decanulação (0,77 ± 0,84 vs. 1,7 ± 1,00 comorbidades; p < 0,001). Conclusão: A traqueostomia em crianças é um procedimento relativamente frequente em nosso hospital. As indicações mais comuns são glossoptose e estenose subglótica. Uma alta taxa de mortalidade foi encontrada, potencialmente comprovada pelo elevado número de pacientes críticos com condições neurológicas crônicas nessa coorte. Nossa taxa de decanulação está ligeiramente abaixo de outras séries, provavelmente por causa da maior quantidade de pacientes com comorbidades.

Tratamiento de la inmovilidad cordal bilateral / Bilateral vocal fold immobility treatment

La inmovilidad bilateral de las cuerdas vocales en aducción puede ser provocada por diversas etiologías y pone en riesgo la vida de los pacientes por la disnea grave que puede ocasionar. Existen diversas técnicas quirúrgicas para aumentar el espacio glótico, entre las que prevalecen las cirugías transorales que resecan tejido. El objetivo del presente trabajo es determinar la tasa de resolución de la disnea inspiratoria o decanulación, en pacientes con inmovilidad cordal bilateral en aducción, tratados mediante cordotomía posterior y aritenoidectomía parcial. Fueron tratados en este estudio 17 enfermos por inmovilidad bilateral de las cuerdas vocales en aducción, mediante cordotomía posterior y aritenoidectomía parcial medial por vía transoral con láser de CO2 , cauterio y radiofrecuencia. Ocho pacientes tuvieron traqueostomía. El 75% fueron decanulados. El 100% de los pacientes sin traqueostomía mejoraron la disnea inspiratoria y no tuvieron limitación para las actividades de su vida cotidiana. Como conclusión del trabajo, se determinó que la cordotomía posterior y la aritenoidectomía parcial por vía transoral fueron muy eficaces para mejorar el calibre de la vía aérea superior, con baja morbilidad y sin complicaciones. (AU)

Bilateral medial vocal fold immobility, can be caused by various etiologies and can lead to severe dyspnea that may risk patients life. There are several surgical techniques for increasing the glottic space, prevailing transoral surgeries that remove tissue. The objective of this study is to determine the rate of resolution of inspiratory dyspnea and decanulation in patients with bilateral vocal cord immobility in adduction. In this study 17 patients diagnosed with bilateral vocal fold immobility in adduction were treated with posterior cordotomy and partial medial arytenoidectomy with transoral approach, using CO2 laser, radiofrequency or electrocautery. Eight of our patients were tracheostomized. Six of the tracheostomized patients had their tracheostomies removed (6 out of 8, 75%). Nine without tracheostomy showed improvement of inspiratory dyspnea and had no limitation on their daily lives activities. (9 out of 9, 100%). As a conclussion, we can say that transoral cordotomy and partial arytenoidectomy were very effective in improving the caliber of the upper airway, with low morbidity and no complications. (AU)

Traqueostomía quirúrgica clásica en la unidad de cuidados intensivos / Open tracheotomy in the intensive care unit

Introducción: Los pacientes de la Unidad de Cuidados Intensivos (UCI) que requieren una traqueostomía (TQT) pueden ser intervenidos mediante una técnica percutánea o quirúrgica clásica en pabellón o directamente en la cama de la UCI. No hay consenso en la literatura sobre cuál procedimiento tiene menos complicaciones. Objetivo: Caracterizar las traqueostomías quirúrgicas clásicas realizadas en el Hospital Barros Luco-Trudeau en el año 2007y comparar las complicaciones de las traqueostomías quirúrgicas clásicas en UCI versus en pabellón entre los años 2006 a mayo de 2008. Material y método: Estudio retrospectivo, descriptivo de la revisión de fichas clínicas de 93 pacientes que se les realizó una traqueostomía en el año 2007. Otro analítico, desde el año 2006 a mayo de 2008, con una muestra del procedimiento realizado en UCI y en pabellón con un "n" de 50 por cada grupo. Resultados: En 2007, 98,8% de las TQT fueron realizadas por otorrinolaringólogos. 30,11% se realizaron en la UCI, y 86,40% el primer cirujano fue un residente bajo supervisión. En los grupos comparados no hubo complicaciones intraoperatorias y no encontramos diferencias estadísticamente significativas en las complicaciones posoperatorias. Conclusiones: No hubo diferencias estadísticamente significativas en la frecuencia de complicaciones entre los grupos estudiados. La traqueostomía abierta en UCI es un procedimiento vigente y seguro.

Introduction: Patients in the Intensive Care Unit (ICU) requiring tracheotomy (TQT) can be operated by a percutaneous technique, or open in operating room or directly in the ICU bed. There is no consensus in the literature on which procedure has fewer complications. Aim: Describe open tracheotomy performed in the Barros Luco Hospital in 2007 and complications of open tracheostomy in the ICU is compared with those in the operating room from 2006 to May 2008. Material and method: Retrospective, descriptive study of the review of medical records of 93 patients who an open tracheostomy was performed in 2007. Another analytical from 2006 to May 2008 with a sample of the procedure performed in the ICU and the operating room with "n" of 50 per group. Results: In 2007, 98.8% of the TQT were performed by otolaryngologists. 30.11% were performed in the ICU, and 86.40% the first surgeon was a resident under supervision. In the comparison group there were no intraoperative complications, and no statistically significant differences in postoperative complications Conclusions: No statistically significant differences in the frequency of complications between groups. The open tracheostomy in the ICU is a valid and safe procedure.

Traqueostomía percutánea con técnica Ciaglia Blue Rhino: experiencia en Hospital Clínico FUSAT de Rancagua / Percutaneous tracheostomy Ciaglia Blue Rhino technique: revision 2 years of experience

Introducción: La traqueostomía descrita ya hacia el 1500 AC, en las últimas décadas ha evolucionado al desarrollo de sistemas de abordaje mínimamente invasivos o percutáneos, de los cuales la técnica de Ciaglia Blue Rhino (dilatador único), es la más utilizada en la actualidad. Objetivo: Se realizó un estudio retrospectivo descriptivo de las traqueostomías realizadas en el Hospital Clínico FUSAT de Rancagua, entre los años 2006 y 2012, con el fin de evaluar ventajas, desventajas e incidencia de complicaciones de la técnica abierta versus la técnica percutánea en nuestras manos. Material y método: Se incluyeron 64 traqueostomías consecutivas de las cuales 42 fueron percutáneas con técnica de Ciaglia Blue Rhino y el resto con técnica abierta clásica. Resultados: Al analizar los resultados encontramos ventajas de la técnica percutánea como un importante acortamiento del tiempo quirúrgico (de 45,27 minutos en la técnica clásica a 15,28 minutos promedio en la técnica percutánea), una menor incidencia de complicaciones (14% en procedimiento percutáneo versus 27% en procedimiento abierto) y una curva de aprendizaje relativamente rápida que permitió que la indicación para el procedimiento percutáneo pasara desde 68% en la primera mitad de la serie al 92% en la segunda mitad de ésta. Conclusión: Creemos que la técnica es segura en manos de otorrinolaringólogos y debería incorporarse como una herramienta más al arsenal quirúrgico de la especialidad.

Introduction: The tracheostomy described as about 1500 BC, only in recent decades has seen the development of systems for minimally invasive or percutaneous, of which the Ciaglia Blue Rhino technique (single dilator), is most often used today. Aim: We performed a retrospective study of tracheostomies performed at the FUSAT Clinical Hospital from Rancagua, between 2006 and 2012, in order to evaluate advantages, disadvantages and incidence of complications of open surgery versus percutaneous technique in our hands. Material and methods: Included 64 tracheostomies of which 42 were percutaneous Ciaglia Blue Rhino technique. Results: In analyzing the results highlights shortening surgical time from 45.27 minutes for classical technique to 15.28 minutes for percutaneous (statistically significant) in relation to complications, they showed a lower incidence in the group with percutaneous technique, the learning curve of the procedure is quick, reaching its indication in our series more than 90% of cases once acquired experience. Conclusion: We believe that the technique is safe in the hands of Otolaryngologists and should be incorporated as another tool to the arsenal surgical specialty.

Traqueostomía pediátrica: análisis de diez años en la Unidad de Cuidados Intensivos del Hospital Pediátrico Docente de Sancti Spíritus José Martí / Pediatric tracheostomy: a ten-year analysis in the Intensive Care Unit of Sancti Spiritus José Martí Pediatric Teaching Hospital

Fundamento En los últimos 20 años ha habido un cambio considerable en el rol de la traqueostomía en la edad pediátrica. La obstrucción de la vía aérea superior secundaria a infecciones dejó de constituir la causa más común de traqueostomía en el niño. Asimismo, las alteraciones estructurales de la vía aérea superior y la necesidad de asistencia ventilatoria prolongada o crónica se han convertido en las indicaciones más frecuentes de traqueostomías pediátricas.Objetivo Determinar la incidencia de la traqueostomía en nuestro medio, sus principales indicaciones, complicaciones e influencia en la mortalidad. MetodologíaSe realizó un estudio descriptivo retrospectivo de los pacientes que requirieron traqueostomía en la unidad de cuidados intensivos pediátricos del Hospital Pediátrico Docente José Martí de Sancti Spíritus, Cuba, en un período de diez años, desde 1999 hasta 2008. Resultados Fue necesario practicar traqueostomía a 14 (0,5 por ciento) pacientes del total de ingresados durante ese período, de ellos 9 (64,2 por ciento) eran menores de un año. La indicación más frecuente fue la necesidad de ventilación mecánica prolongada asociada a patología neurológica con 10 (71,42 por ciento) casos. Las malformaciones e infecciones agudas de las vías aéreas superiores constituyeron indicaciones poco frecuentes. Las principales complicaciones que se presentaron fueron infección en 10 (71,4 por ciento) casos y la obstrucción en 4 (28,5 por ciento), siendo aislados más comúnmente la Pseudomonas aeruginosa en seis (60 por ciento), el Staphylococcus aureus en tres (30 por ciento), la Klebsiella pneumoniae en tres (30 por ciento) y el Enterobacter cloacae en tres (30 por ciento). Además, cuatro (28,5 por ciento) pacientes fueron decanulados exitosamente, fallecieron cinco (35,7 por ciento) y sólo en uno (7,14 por ciento) la causa se relacionó con la traqueostomía.

Introduction There has been a significant change in the role of pediatric tracheostomy over the last twenty years. Obstruction of the upper airway caused by infectious agents is no longer the leading cause of tracheostomy in children. Structural anomalies of the upper airway as well as the need for prolonged ventilator assistance have become the most frequent indication for pediatric tracheostomy. ObjectiveThe purpose of this paper is to assess the incidence, indications, complications, and role in mortality of tracheostomy in our pediatric population. MethodsA retrospective descriptive study of pediatric patients who underwent tracheostomy was conducted between 1999 and 2008 in the Pediatric Intensive Care Unit of the José Martí de Sancti Spiritus Pediatric Teaching Hospital in Cuba. Results Tracheostomy was performed in 14 patients during the period of the study (0.5 percent of admitted patients). Nine of them (64.2 percent) were younger than one year. The most frequent indication for the procedure was the need for prolonged mechanical ventilation in patients with neurologic disorders in 10 patients (71.42 percent). Upper airway malformations and acute infections were infrequent indications for tracheostomy. The most frequent complications were infectious in 10 patients (71.4 percent) and obstruction in four patients (28.5 percent). The following germs were found: Pseudomona aeruginosa in six patients (60 percent), Staphylococcus aureus in three patients (30 percent), and Enterobacter cloacae in three patients (30 percent). Furthermore, four patients were successfully decannulated (28.5 percent), five patients died (35.7 percent) but only in one (7.14 percent), death could be attributed to tracheostomy. Conclusion The need for prolonged mechanical ventilation in patients with neurologic disorders was the main indication for tracheostomy in our pediatric population; most of these children were younger than one year. The procedure had little.

Extubation failure influences clinical and functional outcomes in patients with traumatic brain injury / A falência da extubação influencia desfechos clínicos e funcionais em pacientes com traumatismo cranioencefálico

OBJECTIVE: To evaluate the association between extubation failure and outcomes (clinical and functional) in patients with traumatic brain injury (TBI). METHODS: A prospective cohort study involving 311 consecutive patients with TBI. The patients were divided into two groups according to extubation outcome: extubation success; and extubation failure (defined as reintubation within 48 h after extubation). A multivariate model was developed in order to determine whether extubation failure was an independent predictor of in-hospital mortality. RESULTS: The mean age was 35.7 ± 13.8 years. Males accounted for 92.3%. The incidence of extubation failure was 13.8%. In-hospital mortality was 4.5% and 20.9% in successfully extubated patients and in those with extubation failure, respectively (p = 0.001). Tracheostomy was more common in the extubation failure group (55.8% vs. 1.9%; p < 0.001). The median length of hospital stay was significantly greater in the extubation failure group than in the extubation success group (44 days vs. 27 days; p = 0.002). Functional status at discharge was worse among the patients in the extubation failure group. The multivariate analysis showed that extubation failure was an independent predictor of in-hospital mortality (OR = 4.96; 95% CI, 1.86-13.22). CONCLUSIONS: In patients with TBI, extubation failure appears to lengthen hospital stays; to increase the frequency of tracheostomy and of pulmonary complications; to worsen functional outcomes; and to increase mortality. .

OBJETIVO: Avaliar a associação entre falência da extubação e desfechos clínicos e funcionais em pacientes com traumatismo cranioencefálico (TCE). MÉTODOS: Coorte prospectiva com 311 pacientes consecutivos com TCE. Os pacientes foram divididos em dois grupos de acordo com o resultado da extubação: sucesso ou falência (necessidade de reintubação dentro de 48 h após extubação). Um modelo multivariado foi desenvolvido para verificar se a falência de extubação era um preditor independente de mortalidade hospitalar. RESULTADOS: A média de idade foi de 35,7 ± 13,8 anos, e 92,3% dos pacientes eram do sexo masculino. A incidência de falência da extubação foi de 13,8%. A mortalidade hospitalar foi, respectivamente, de 20,9% e 4,5% nos pacientes com falência e com sucesso da extubação (p = 0,001). A realização de traqueostomia foi mais frequente no grupo falência da extubação (55,8% vs. 1,9%; p < 0,001). A mediana de tempo de permanência hospitalar foi significantemente maior nos pacientes com falência do que naqueles com sucesso da extubação (44 dias vs. 27 dias; p = 0,002). Os pacientes com falência da extubação apresentaram piores desfechos funcionais na alta hospitalar. A análise multivariada mostrou que a falência da extubação foi um preditor independente para a mortalidade hospitalar (OR = 4,96; IC95%, 1,86-13,22). CONCLUSÕES: A falência da extubação esteve associada a maior permanência hospitalar, maior frequência de traqueostomia e de complicações pulmonares, piores desfechos funcionais e maior mortalidade em pacientes com TCE. .

Traqueostomía percutánea en una unidad de cuidados intensivos / Percutaneous tracheostomy in an intensive care unit

Background: Prolonged mechanical ventilation (PMV) is a main factor in a long stay at Intensive Care Units (ICU) in our country. The correct and prompt tracheostomy (TQT) indication has shown significant reductions in ICU stay. The classic open technique has been progressively replaced by the percutaneous TQT. Aims: To describe the experience and the results of percutaneous TQT in a tertiary center ICU. Methods: Prospective study of patients in PMV who underwent a percutaneous tracheostomy in ICU at Hospital Doctor Sótero del Rio, since January 2009 to June 2010. We analyse patient characteristics, waiting time, duration of procedure and complications. Results: The series consist of 130 PMV patients, 101 men, median age 51 (17-22) years old, more frequent diagnoses were neurological disease, cerebrovascular disease and infectious disease. The mean waiting time for the procedure was 1 (0-3) day, the operative time was 11 (3-15) minutes, complications rate was 7.6 percent, and the most frequent was local hemorrhage. Discussion: Percutaneous TQT technique is a feasible and safe procedure in ICU at a Tertiary Hospital, with a short waiting time and a low complication rate.

Introducción: La ventilación mecánica (VM) prolongada es uno de los factores que prolongan la estadía en la Unidad de Pacientes Críticos, el aumento considerable de la realización de traqueostomías (TQT) ha logrado reducir significativamente la estadía en Unidad de Cuidados Intensivos (UCI). La técnica puede ser abierta (quirúrgica) o percutánea. Objetivos: Describir la experiencia y describir los resultados obtenidos de la realización de la TQT percutánea en UCI en nuestro centro. Métodos: Estudio prospectivo de todos los pacientes sometidos a VM en quienes se realizó una traqueostomía percutánea en la UCI en el Hospital Doctor Sótero del Río desde enero del año 2009 a junio de 2010. Se analizó características de los pacientes, tiempo de espera, duración del procedimiento y complicaciones. Resultados: La serie fue de 130 pacientes que requerían VM prolongada, 101 hombres, mediana de edad 51 (17-22) años, los diagnósticos más frecuentes fueron enfermedad neurológica, enfermedad cerebrovascular y patología infecciosa. El tiempo de espera para el procedimiento fue de 1 (0-3) días, la duración del procedimiento fue de 11 (3-15) minutos, complicaciones en 7,6 por ciento, siendo hemorragia local la más frecuente. Discusión: La TQT percutánea es una técnica posible de implementar en una UCI, con resultados óptimos, baja tasa de complicaciones y con una resolución oportuna.

Percutaneous tracheostomy versus surgical tracheostomy in ICU patients

Tracheostomy is one of the most commonly performed surgical procedures in the critically ill patient. This procedure has been performed using standard surgical principles. Percutaneous dilatational tracheostomy [PDT] was first described in 1957 5 and became increasingly popular after the release of a commercially available kit in 1985. The aim of this study is to compare percutaneous dilatational tracheostomy with surgical tracheostomy in regards to the overall mortality as well as major perioperative and postoperative complications. Fifty ICU patients indicated for tracheostomies were included in prospective randomized study. Our patients were divided into 2 equal groups; percutaneous tracheostomy and surgical tracheostomy group. The outcome measures were divided into perioperative, early postoperative and late postoperative complications. The perioperative designation was used to categorize complications that occur between initiation of the procedure and 24 hours postoperatively. Early postoperative evaluation was performed daily during the first week and then on the 14th day. Long-term evaluation was done 3 months after decannulation. The total incidence of perioperative complications was 28% and 24% in the surgical and percutaneous tracheostomy group respectively. Early postoperative complications were significantly more frequent after surgical tracheostomy [52%] than after percutaneous tracheostomy [20%]. Long-term evaluation was completed in 32 patients [18 SgT and 14 PDT]. Eighteen patients died of their underlying disease. 6 patients [2 SgT and 4PDT] still needed their tracheostomy. The cumulative incidence of long-term complication was 77% and 35% in the SgT and PDT groups respectively. Percutaneous tracheostomy and surgical tracheostomy are both safe when performed by experienced skilled practitioners. However, percutaneous dilatational tracheostomy is simpler and faster technique than surgical tracheostomy

Sequelas pós-intubação e traqueostomia cirúrgica aberta: devemos sempre fazer a istmectomia? / Postintubation injuries and open surgical tracheostomy: should we always perform isthmectomy?

OBJETIVO: Avaliar a influência da equipe cirúrgica (cirurgia geral ou cirurgia torácica) e da técnica operatória utilizada (com ou sem istmectomia) sobre a incidência de injúrias pós-intubação nas vias aéreas em pacientes traqueostomizados. MÉTODOS: Foram prospectivamente incluídos neste estudo 164 pacientes admitidos na unidade de terapia intensiva para adultos do Hospital Estadual Sumaré e que ficaram sob intubação traqueal por mais de 24 h, no período entre 1º de janeiro e 31 de agosto de 2007. Quando foi necessária a realização de traqueostomia, os pacientes foram aleatorizados para as equipes de cirurgia geral e torácica. Todos os pacientes foram submetidos à traqueoscopia flexível para a decanulação e/ou a avaliação tardia da via aérea. RESULTADOS: Dos 164 pacientes no estudo, 90 (54,88 por cento) faleceram (sem relação com o procedimento), 67 (40,85 por cento) completaram o seguimento e 7 (4,27 por cento) tiveram seguimento parcial. Dos 67 pacientes com seguimento completo, 32 foram traqueostomizados (21 pela equipe de cirurgia geral e 11 pela equipe de cirurgia torácica). A istmectomia foi realizada em 22 pacientes (11 pela equipe de cirurgia geral e 11 pela equipe de cirurgia torácica). Não houve diferença entre o índice de complicações estomais quando se comparou as equipes, mas sim quando se comparou as técnicas (com e sem istmectomia). CONCLUSÕES: A não realização da istmectomia paralelamente à traqueostomia faz com que o cirurgião realize o óstio traqueal mais distalmente do que supõe. Nestes casos, houve um maior índice de complicações do estoma traqueal.

OBJECTIVE: To evaluate the influence of the surgical team (general surgery or thoracic surgery) and the surgical technique (with or without isthmectomy) on the incidence of postintubation injuries in the airways of tracheostomized patients. METHODS: Between January 1st and August 31st, 2007, 164 patients admitted to the adult intensive care unit and tracheally intubated for more than 24 h were studied prospectively at the Sumaré State Hospital, located at the city of Sumare, Brazil. When tracheostomy was necessary, these patients were randomly assigned to thoracic or general surgery teams. All of the patients were submitted to fiberoptic tracheoscopy for decannulation or late evaluation of the airway. RESULTS: Of the 164 patients in the study, 90 (54.88 percent) died (due to causes unrelated to the procedure), 67 (40.85 percent) completed follow-up, and 7 (4.27 percent) were lost to follow-up. Of the 67 patients who completed follow-up, 32 had undergone tracheostomy (21 by the general surgery team and 11 by the thoracic surgery team), and 22 had been submitted to isthmectomy (11 by the general surgery team and 11 by the thoracic surgery team). There was no difference between the surgical teams in terms of the incidence of stomal complications. However, there was a significant difference when the surgical techniques (with or without isthmectomy) were compared. CONCLUSIONS: Not performing isthmectomy in parallel with tracheostomy leads the surgeon to open the tracheal stoma more distally than expected. In such cases, there were more stomal complications.

Traqueostomía abierta vs traqueostomía percutánea / Open vs percutaneous tracheostomy

Introducción: La traqueostomía está indicada para prevenir el daño laríngeo producido por intubaciones prolongadas, mejorar la higiene traqueal, disminuir el espacio muerto y minimizar la estadía en Unidades de Pacientes Críticos (UPC). La técnica más utilizada es la abierta, que permite un adecuado control de la anatomía y de la hemostasia. Actualmente, en las UPC es cada vez más habitual, la realización de la técnica percutánea. Varios trabajos indican que es una técnica rápida y con menos complicaciones, pero aún existe controversia. Objetivo: Comparar a través de un estudio prospectivo, ambas técnicas en cuanto a duración del procedimiento y complicaciones peri y postoperatorias. Material y método: De un total de 91 pacientes, se seleccionaron 50 que no tenían contraindicación para realizar técnica percutánea. En esos 50 pacientes se realizó en forma aleatoria, técnica abierta y técnica percutánea obteniendo 2 grupos de 25 pacientes (Grupos AyP). Todos los pacientes fueron intervenidos en pabellón y bajo anestesia general. Resultados: La duración total del procedimiento incluida la anestesia fue de 65,8 min y de 59,2 min y la duración de la cirugía fue de 40,4 min y 32,2 min, respectivamente. Las complicaciones perioperatorias fueron: grupo A 16 por ciento (desaturación y sangrado lo más frecuente) y Grupo P: 40 por ciento (desaturación y pérdida de vía aérea lo más frecuente) y las posoperatorias de 8 por ciento y 12 por ciento (sangrado e infección lo más frecuente en ambos grupos) en los grupos AyP, respectivamente. Conclusión: Al comparar ambas técnicas, no hubo en nuestras manos diferencias estadísticamente significativas en cuanto al número de complicaciones ni en cuanto a la duración del procedimiento.

Introduction: Tracheostomy is indicated to prevent laryngeal injury in cases of long-term translaryngeal intubation, to improve tracheal hygiene, decrease the dead space and reduce the time spent in intensive care units (ICU). The open technique is the most commonly used technique, which allows for an adequate control of anatomy and haemostasis. Currently, the percutaneous technique is increasingly used in CPUs, since it is a fast technique, with less perioperative complications. However, there is still controversy on this issue. Aim: This paper is a prospective study, designed to compare both techniques in terms of procedure duration and peri- and postoperative complications. Material and method: Out of a total of 91 patients, 50 were selected that did not have any counterindications for the percutaneous technique. These 50 patients were randomly assigned to either the open or the percutanous technique groups, obtaining 2 groups of 25 patients (Groups A andP). All patients had the surgery performed in the operating room, undergeneral anesthesia. Results: Total duration of the procedure (including anesthesia) was 65.8 and 59.2 min, and surgery duration was 40.4 and 32.2 min, respectively. Perioperative complications were: Group A, 16 percent (oxygen desaturation and bleeding were the more frequent problems), and Group P, 40 percent (oxygen desaturation and airway loss were the more frequent problems). Postoperative complications In Groups A and P were 8 and 12 percent (bleeding and infection being the more frequent problems in both groups), respectively. Conclusion: In our study, a comparison of both techniques did not show significant differences regarding either number of complications or duration of the procedure.

Open bedside tracheostomy: routine procedure for patients under prolonged mechanical ventilation

BACKGROUND: Tracheostomy is electively performed in critically ill patients requiring prolonged respiratory support. The risk of transporting, the increasing associated cost and operative room schedule are some of the obstacles for wider acceptance of this procedure. The use of rigid selection criteria exclude many patients who would benefit of this approach. OBJECTIVE: To determine the safety of open bedside tracheostomy (OBT) as a routine intensive care units (ICU) procedure without any selection criteria, considering its peri and postoperative complications. METHOD: Retrospective medical chart review of all patients that underwent elective tracheostomy between April 1999 and December 2005 at ICU of three private hospitals. RESULTS: The study group comprised 552 patients with a mean age of 69.6 ± 15.8 years. The incidence of significant complications (until 30 days after the procedure) was 4.34 percent (24 cases): 9 minor bleeding, 9 major bleeding, 2 subcutaneous emphysema, 4 stomal infections. Late complications were: laryngotracheal stenosis in 2 and tracheoinomminate fistula in 1 patient. CONCLUSIONS: OBT seems to be a safe and simple procedure, when performed by a team of experienced physicians under controlled circumstances, and should be considered as an option for ICU patients.

INTRODUÇÃO: A traqueostomia é um procedimento eletivo realizado em pacientes de unidades de terapia intensiva sob ventilação mecânica prolongada. O risco associado ao transporte, custos e dificuldades de agendamento cirúrgico são alguns obstáculos para uma maior aceitação da traqueostomia. O uso de rígidos critérios de seleção para a realização deste procedimento a beira do leito exclui muitos pacientes que se beneficiariam deste método. OBJETIVO: Determinar à segurança da traqueostomia convencional a beira do leito como procedimento de rotina (sem a utilização dos critérios de seleção) em unidades de terapia intensiva, considerando as complicações intra e pós-operatórias. MÉTODO: Revisão retrospectiva de prontuários de pacientes submetidos à traqueostomia eletiva nas unidades de terapia intensiva de três hospitais privados no período de abril de 1999 a dezembro de 2005. RESULTADOS: Foram incluídos 552 pacientes com idade media de 69.6 ± 15.8 anos. A incidência de complicações pós-operatórias (até o 30° pós-operatório) foi 4.34 por cento (24 casos): 9 sangramentos leves, 9 sangramentos importantes, 2 enfisemas subcutâneos, 4 infecções do estoma. As complicações tardias observadas foram: estenose laringotraqueal em 2 pacientes e fistula traqueo-inominada em 1 paciente. CONCLUSÃO: A traqueostomia convencional a beira do leito parece ser um procedimento simples e seguro quando realizado por equipe experiente em condições controladas, deve, portanto ser considerada como uma opção para pacientes em terapia intensiva sob ventilação prolongada.

Study of the need for tracheostomy in oral and maxillofacial surgery

Tracheostomy is one of the most common surgical procedures. It is considered as a life saving measure that should be performed immediately once a patient's airway shows obstruction. In Oral and Maxillofacial surgery [OMFS], it was found that tracheostomy is needed in various situations. A total number of 252 OMFS patients that were treated in two hospitals from the year 2001 to 2003 were reviewed for airway problems that needed tracheostomy. Out of that number, four cases had tracheostomy. Two of those four patients had emergency tracheostomy; one patient had pan-facial fracture, and the other one had a temporomandibular joint [TMJ] ankylosis. The other two patients had elective tracheostomy and both had TMJ ankylosis. The results of this study showed that there are certain situations in which tracheostomy should be considered as an elective surgical procedure that of a great value to some OMFS patients

Clinical outcomes of failed extubation in a postoperative intensive care unit.

The causes and consequences of failed extubation in postoperative intensive care unit (ICU) patients were prospectively collected by clinical observation study in the surgical ICU Siriraj Hospital from 1st October 2000 to 31st March 2001. The failure rate was 1.7 per cent (9/477). Patients underwent the following types of surgery: abdominal surgery 66.67 per cent, orthopedic 22.22 per cent, and head-neck surgery 11.11 per cent. Reasons for reintubation were respiratory failure 55.56 per cent (5/9), inadequate cough reflex 22.22 per cent (2/9), congestive heart failure 11.11 per cent (1/9), and acute myocardial infarction 11.11 per cent (1/9). The consequences of failed extubation were worse outcomes:- the average length of stay in these patients increased from 3.67 days to 9.3 days. The mortality rate was 33.33 per cent. Tracheostomy was required in 55.56 per cent. From these observations we conclude that extubation should be performed at the appropriate time for each patient. This will differ according to the patient and his/her circumstances.

Trauma de Cuello / Neck Trauma

El trauma de esta estructura representa del 5 al 10 por ciento de todos los traumas. La diversidad de lesiones en un área tan pequeña y sus diferentes manejos llevaron a una alta tasa de exploraciones en blanco creando controversia entre el manejo quirúrgico mandatoio y el manejo selectivo. La tendencia actual es que en paciente asintomáticos con heridas en la zona II, el examen físico es seguro para descartar lesiones graves, proponiéndose por esta razón el manejo individualizado. Al colocar en práctica la experiencia militar en la práctica civil se encontraon altos índices de exploraciones en blanco (69-84 por ciento), desarrollándose estudios de manejo selectivo que disminuyeron el número de exploraciones negativas y los costos sin variar la morbimortalidad. La clasificación de Monson y Saletta de las zonas de cuello tiene la importancia clínica de seleccionar a los paicentes según sus posibles lesiones y su estudio. Los mecanismos del trauma se clasifican en penetrante y no penetrante; el primero sucede cuando la lesión atraviesa el plano profundo del músculo cutáneo o platisma del cuello y el segundo mecanismo es producido por procesos de aceleración y desaceleración en accidentes de transito, contusiones, ahorcadura. El manejo del paciente comprende el manejo adecuado de la vía aérea, la inmovilización del cuello y el control por compresión del sangrado buscando disminuir el tiempo de traslado a un centro especializado dentro de los primeros 60 minutos siguientes al trauma; se debe evaluar el mecanismo de lesión, trayecto de la herida, estado general, pérdida de sangre y descartar o confirmar otras lesiones concomitantes realizando una adecuada evaluación de la vía aérea así como del compromiso vascular, neurológico y del tracto digestivo

Alargamiento mandibular mediante tracción en pacientes con síndrome de Pierre Robin / Treatment of Pierre Robin syndrome by gradual mandibular distraction

El alargamiento óseo mediante tracción gradual es una nueva herramienta para el tratamiento de las malformaciones óseas del esqueleto facial. Utilizamos esta técnica en dos pacientes con síndrome de Pierre Robin portadores de hipoplasia mandibular severa con obstrucción respiratoria crítica, logrando un alargamiento mandibular importante (entre 1,65 cm y 2,2 cm), suficiente para permitir el cierre de la traqueostomía en un paciente y retirar de asistencia respiratoria mecánica al segundo caso. Con este método relativamente sencillo se logran excelentes resultados estético y funcional con muy pocos inconvenientes