Peri-operative complications during percutaneous tracheostomy in obese patients.

The safety of percutaneous tracheostomy in 73 obese patients (body mass index > or = 27.5 kg.m(-2)) in a cohort of 474 adults was studied. Four percutaneous techniques were employed (percutaneous dilational tracheostomy, n = 48; Ciaglia Blue Rhino, n = 157; guide wire dilating forceps, n = 62, translaryngeal tracheostomy, n = 207). The overall complication rate was 43.8% (n = 32) in the obese group compared to 18.2% (n = 73) in the control group (p < 0.001). Seven (9.6%) obese patients suffered life-threatening complications compared to three non-obese patients (0.7%, p < 0.001). Obese patients had a 2.7-fold increased risk for peri-operative complications, and a 4.9-fold increased risk for serious complications. The data suggest that percutaneous tracheostomy in obese patients is associated with a considerably increased risk for peri-operative complications, especially for serious adverse events.

Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy.

UNLABELLED: Percutaneous dilational tracheostomy (PDT), according to Ciaglia's technique described in 1985, has become the most popular technique for percutaneous tracheostomy and is demonstrably as safe as surgical tracheostomy. In 1999, an extensively modified technique of PDT was introduced, the Ciaglia Blue Rhino (CBR; Cook Critical Care, Bloomington, IL), that consists of one-step dilation by means of a curved dilator with hydrophilic coating. To compare CBR with the basic technique of PDT, we performed a prospective, randomized trial in 50 critically ill adults. Twenty-five of these patients had PDT, and 25 had CBR. Average operating times were <3 min for CBR (range: 50-360 s) and <7 min for PDT (range: 4-20 min; P<0.0001). Tracheostomy was successfully completed in all patients. When CBR was performed, 11 minor, nonlife-threatening complications were noted: nine fractures of tracheal cartilage and two short periods of intraoperative oxygen desaturation. During PDT, seven complications occurred, of which three were potentially life-threatening: two injuries to the posterior tracheal wall, one pneumothorax, two tracheal cartilage fractures (P< 0.05 vs CBR), one case of bleeding, and one short episode of intraoperative oxygen desaturation. Regardless of whether PDT or CBR was performed, oxygenation was not significantly affected, and there was no infection of the tracheostoma. Based on our data, we conclude that new CBR is more practicable than PDT. No life-threatening complications occurred during CBR. IMPLICATIONS: To assess practicability and safety of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IL)-an extensively modified technique of percutaneous dilatational tracheostomy-50 critically ill adults on long-term ventilation underwent either new Ciaglia Blue Rhino or percutaneous dilatational tracheostomy in a prospective, randomized clinical trial.

Early percutaneous tracheostomy after median sternotomy.

OBJECTIVE: Tracheostomy offers significant advantages over endotracheal intubation in patients requiring long-term assisted ventilation. However, in patients who have undergone median sternotomy, it is believed that the danger of microbial contamination and consecutive infection of the sternal wound with microbes from the tracheostomy is high when conventional tracheostomy is performed. In contrast, percutaneous techniques are less likely to result in tracheostomy infection and thus bacterial contamination of neighboring structures. Nonetheless, to date there has been no prospective study confirming or disproving this assumption. Our study evaluated outcome after percutaneous tracheostomy in patients with a median sternotomy. METHODS: A total of 144 cardiac surgical patients had elective percutaneous tracheostomy at the bedside until postoperative day 14, with 4 different techniques. Systematic microbiologic monitoring of the sternal and tracheal wounds was used. RESULTS: In 13 patients sternal wound infection was suspected, but was confirmed in only 4 (2.8%) patients who actually showed microbial contamination of the sternum. In 2 of these patients, the identified microbes were not identical to those cultured from the trachea. The other 2 patients had sternal and tracheal cultures positive for methicillin-resistant Staphylococcus aureus. Cross-contamination of the sternotomy with microbes from the patient's airways was therefore ruled out. No patient had clinical signs of tracheostomy infection. Likewise, there were no cases of mediastinitis. CONCLUSIONS: On the basis of our data, we conclude that cross-contamination of the sternal wound with microbes from the trachea is not a problem. Elective percutaneous tracheostomy is safe, even if performed during the first 14 days after median sternotomy.

[Ciaglia blue rhino: a modified technique for percutaneous dilatation tracheostomy. Technique and early clinical results]. / Ciaglia Blue Rhino: Ein weiterentwickeltes Verfahren der perkutanen Dilatationstracheotomie. Technik und erste klinische Ergebnisse.

OBJECTIVE: Elective tracheostomy has become an established treatment modality in modern intensive care medicine, and the number of percutaneously performed tracheostomies is steadily increasing. The Ciaglia Blue Rhino (CBR) represents another percutaneous technique in which the tracheostoma is formed by one-step dilation. Our study presents the technique itself and the early clinical experiences. METHODS: In 20 adult patients on long-term ventilation, CBR was done. After puncture of the trachea in typical manner, dilation of the tracheostoma was achieved in one single step by means of a curved dilator with a special hydrophilic coating. Then, the tracheostomy tube was inserted over a curved loading dilator. Practicability and safety were determined as well as gas exchange during the procedure by means of arterial blood gas samples. RESULTS: As a result of the dilator's hydrophilic coating, dilation of the tracheostoma was rapidly achieved within 152 +/- 22 s, virtually free from resistance of the trachea or the cervical tissues. Complications such as bleeding, aspiration or postoperative infection of the stoma were not noted in any of our patients. Fractures of isolated tracheal cartilage rings were seen in 5 patients, however, no therapeutic intervention was necessary. In terms of perioperative gas exchange, pre- and postoperative levels of FiO2, PaO2, PaCO2 and the oxygenation index (PaO2/FiO2) did not change significantly. CONCLUSIONS: Based on our early clinical experience, Ciaglia Blue Rhino represents a new method that may combine the typical advantages of each of the other techniques for percutaneous tracheostomy (i.e. Ciaglia, Griggs, Fantoni) in one single technique. This method is distinguished by a high level of safety and practicability. However, further comparative trials need to be done before a definitive judgement can be made.

beta-agonistic bronchodilators: comparison of dose/response in working rat hearts.

STUDY OBJECTIVES: Different beta-agonists are compared with regard to their cardiodepressive side effects. DESIGN: The metaphenolic bronchodilators reproterol, salbutamol, fenoterol, and terbutaline were introduced at a dosage of 0.0005 micromol to a maximum of 10 micromol per gram of heart tissue into the isolated working rat heart under hypoxic conditions, and the response was observed during subsequent reoxygenation. As an index of external heart work, aortic flow was measured. Heart rate, coronary flow, and developed pressure were recorded. At the end of heart perfusion, mitochondria were isolated and analyzed for adenosine triphosphatase activity, adenosine triphosphate (ATP) synthesis, and membrane fluidity. Moreover, intact mitochondria and lipid peroxidation were investigated using a model system. MEASUREMENTS AND RESULTS: Compared to controls, reproterol gave the most favorable results, with an increase of 25 to 30% of aortic flow during reoxygenation at a concentration of 10 micromol/g heart tissue. In contrast, both fenoterol and salbutamol at a concentration of 1 micromol/g heart tissue decreased aortic flow during reoxygenation, whereas terbutaline had a negative influence on aortic flow at 0.01 to 0.1 micromol/g heart tissue. Mitochondria of these hearts were isolated at the end of the experiment. Mitochondrial ATP synthesis was increased above controls at nearly all concentrations of reproterol. ATP synthesis was decreased at 1 micromol and 10 micromol fenoterol. As little as 0.0005 micromol terbutaline decreased ATP synthesis by 50%. In intact mitochondria, adenosine diphosphate (ADP) to oxygen ratios were found to be increased with terbutaline and fenoterol, indicating ADP consumption by myokinase activation. Lipid peroxidation was increased in a model system between concentrations of 0.002 micromol/mg and 0.04 micromol/mg phosphatidylcholine by fenoterol and terbutaline, whereas a decrease was noted with reproterol. Membrane fluidity was found increased after addition of reproterol, which supports the evidence of efficient ATP synthesis by this compound. CONCLUSIONS: Cardiodepressive side effects and greater toxicity of fenoterol and terbutaline were found under the conditions of our experiment. Salbutamol and, in particular, reproterol appear much better tolerated. In addition to partial beta-adrenergic agonism, reproterol may exert an inhibitory influence on adenosine receptor sites and phosphodiesterase, which could result in membrane stabilization by saving cyclic adenosine monophosphate or ATP.