Locally developed guidelines reduce immediate complications from percutaneous dilatational tracheostomy using the Ciaglia Blue Rhino technique: a report on 200 procedures.

Ciaglia Blue Rhino percutaneous dilatational tracheostomy is used as an aid to ventilatory weaning. It carries an immediate complication rate previously reported in 100 consecutive patients by Fikkers et al at 6% for "major" complications and 30% for "minor" complications. Mortality has been associated with the procedure. Our institution has performed dilatational percutaneous tracheostomy since 1998 and used the Blue Rhino technique since 2002. Consensus guidelines were developed following initial experiences. They focus on preoperative risk assessment including levels of ventilatory support and anatomical considerations, seniority of staff use of bronchoscopy and capnography and correction of coagulopathies. Following introduction of the guidelines we conducted an audit of the first 200 Ciaglia Blue Rhino tracheostomies performed. There was an immediate major complication rate of 3% and minor complication rate of 18%. No deaths occurred within 24 hours of the procedure. We conclude that applying our consensus guidelines produced an immediate complication rate for Ciaglia Blue Rhino percutaneous dilatational tracheostomy below published audits.

Transient paralysis after administration of a single dose of cyclizine.

Two patients with underlying neuromuscular disorders developed varying degrees of paralysis after a single dose of cyclizine, one necessitating full mechanical ventilation. These cases appear to be unique in the literature and represent an increasing spectrum of adverse reactions seen with the greater use of cyclizine.

Nasopharyngeal airway continuous positive airway pressure: a method to wean from or avoid mechanical ventilation in adults.

A simple technique using a nasopharyngeal airway and a continuous positive airway pressure circuit has proved an effective alternative to a tight fitting nasal or face mask for delivery of continuous positive airway pressure. Nasal trauma, discomfort and mouth breathing are the main disadvantages.

An investigation of interface pressures in low air loss beds.

Prospective randomised trials indicate that the low air loss bed is a successful method of treatment for pressure sores. To study the properties of these beds interface pressures were measured in two different low air loss beds. Ten healthy volunteers had eight readings at six different body sites taken supine and sitting. Occipital and heel pressures for both products exceeded 4.7 kPa, the accepted capillary closing pressure, while pressures at other sites were below this. These findings suggest that pressure relief alone is not the sole reason for the clinical acceptance of low air loss beds in the treatment of pressure sores.

A prospective two-month audit of the lack of provision of a high-dependency unit and its impact on intensive care.

All admissions into a six-bedded intensive care unit were audited prospectively over a 2-month period. Data were collected daily and classified according to criteria for intensive care or high-dependency admission. There were 30 planned admissions (72 bed days) following elective major surgery, seven admissions following semi-elective surgery (41 bed days) and 47 emergency admissions (185 bed days). Overall bed occupancy was 89%. Of 366 possible intensive care days, 66 (23%) were occupied by high-dependency patients. Of the planned admissions all but five were discharged within 2 days. There were 39 major complications during the study period requiring life-saving interventions and 16 lesser but significant complications. In 12% of patients discharge was delayed because of the absence of a high-dependency unit. Four patients were transferred to an intensive care unit in another hospital and four patients were discharged prematurely because other patients required urgent admission. Seven patients were refused admission and three patients scheduled for elective operations had their surgery deferred. We estimate that over the study period 22 additional patients could have been cared for if a high-dependency unit existed.

The fluidised bed.

The process of fluidisation involves blowing warm air through small solid microspheres thus creating a liquid, without wetness. The warmth provides some important properties including reducing the metabolic rate in thermal injury which has a beneficial effect on mortality, modifying catabolism after surgery, providing gradual vasodilation in shock and core temperature stability in illness. The fluidisation ensures prevention and successful treatment of pressure sores, a comfortable and less stressful environment than conventional care, a reduction in pain, ease of wound care, discourages a bacterial persistence and reduces the work of the nurse. The importance of proper fluid balance, bacteriological care and limitations of posture must be appreciated in using the bed.

Nosocomial infection due to enterococci attributed to a fluidized microsphere bed. The value of pyrolysis mass spectrometry.

The potential of fluidised microsphere beds as sources of nosocomial Enterococcal infection was investigated with the help of pyrolysis mass spectrometry. Isolates from clinical specimens collected from two patients who were nursed sequentially on a fluidized microsphere bed were compared with similar isolates cultured from the microspheres before and after decontamination. Pyrolysis mass spectrometry confirmed that nosocomial spread had indeed occurred and that the existing decontamination process was inadequate. Recommendations for improvements to this decontamination process appear to have prevented further cases.

Measurements of interface pressure between body sites and the surfaces of four specialised air mattresses.

Four specialised air mattresses had interface pressure measured under six body sites prone to pressure sores in 10 subjects, supine and sitting. The mattresses were the Clinirest (SSI) and FirstStep (KCI) continuous airflow mattress overlays, and Airwave (Pegasus) and Nimbus (Huntleigh) alternating pressure air mattresses. On the mattress overlays, average supine interface pressures were 2.33 kPa (scapula), 4.15 kPa (elbow), 1.94 kPa (sacrum) and 2.79 kPa (buttock), although they were higher at the occiput (7.97 kPa) and heel (11.7 kPa). The alternating pressure air mattresses had an average minimum interface pressure close to zero for three sites, rising to 4.28 kPa under the heel. Average maximum interface pressures were 8.61 kPa (occiput), 5.21 kPa (scapula), 4.90 (elbow), 4.85 kPa (sacrum), 4.61 kPa (buttock) and 13.2 kPa (heel). No accepted scientific method exists for comparing the two types of mattress. Our data suggest a clinical benefit at the occiput and heel (supine) in using an alternating pressure air mattress and a benefit in using a continuous airflow mattress overlay at other sites.

Air-fluidized beds and their ability to distribute interface pressures generated between the subject and the bed surface.

Pressures were measured under five anatomical sites prone to pressures sores for ten subjects, supine and sitting on two different air-fluidized beds. The beds were the Clinitron (trademark, SSI) and the Fluidair Plus (trademark, KCI Mediscus). Mean supine pressures were less than 4 kPa under four sites. The average supine buttock pressure was 2.65 kPa. This increased to 3.71 kPa upon sitting up, though pressures did not rise above the accepted capillary closing pressure, on either bed. Low interface pressures at these sites were due to good moulding between subject and bed. Heel pressures averaging 7.08 kPa, were a factor of 2.67 times greater than buttock pressure, and were higher than expected considering the depth the heels sunk to in both beds. This exceeded the accepted capillary closing pressure and was attributed to covering sheets preventing true floatation at the heels.

Potential for bed sores due to high pressures: influence of body sites, body position, and mattress design.

Pressures were measured on 10 subjects, supine and sitting, under six anatomical sites prone to bed sores on three different mattresses. Studied were the Clinifloat and Therarest specialist replacement mattresses, and a standard hospital mattress. Mean supine pressures were less than 5 kPa under four sites. Average supine buttock pressure was 2.93 kPa. Occiput and heel pressures were much higher than under other sites, being on average 2.6 and 4.5 times greater respectively than the mean buttock pressure. On sitting up, buttock pressure increased by a factor of 1.7 on average, to a level higher than the accepted capillary closing pressure. Measurements were consistent with mattress design, specific features of which can significantly affect pressure under certain sites.