Clonidine and cardiac surgery: haemodynamic and metabolic effects, myocardial ischaemia and recovery.

Clonidine may have beneficial effects in patients undergoing major surgery. We enrolled 156 patients having elective CABG surgery in a double-blind, randomized trial. Patients were randomized to receive either two doses of placebo (Group PP) or clonidine 5 micrograms/kg (Group CC). Perioperative measurements included haemodynamics, anaesthetic and analgesic drug usage, creatinine clearance, cortisol excretion, recovery times and quality of life (SF-36) after surgery. Overall, there was no significant difference with time to tracheal extubation (median [10-90 centile]): CC 7.1 (3.4-18) h vs PP 8.0 (4.3-17) h, P = 0.70; but there was a higher proportion of patients extubated within four hours: CC 20% vs. PP 8%, P = 0.038. Clonidine resulted in a number of significant (P < 0.05) haemodynamic changes, particularly pre-CPB: less tachycardia and hypertension, more bradycardia and hypotension. Clonidine was associated with a significant (P < 0.05) reduction in anaesthetic drug usage, higher creatinine clearance, lower cortisol excretion and improvement in some aspects of quality of life. This study lends support to consideration of clonidine therapy in patients undergoing CABG surgery.

Percutaneous dilatational tracheostomy versus conventional surgical tracheostomy. A clinical randomised study.

BACKGROUND: As no clinical randomised studies have previously been performed comparing complications with the Ciaglia Percutaneous Dilatational Tracheostomy Introducer Set (PDT) and conventional surgical tracheostomy (TR), we designed a study with the aim of comparing the efficacy and safety of the two techniques. METHODS: Sixty patients selected for elective tracheostomy were randomised for either PDT (30 patients) or TR (30 patients). All patients had general anaesthesia and were ventilated with 100% oxygen. Furthermore, lidocaine with epinephrine 1% (3-5 ml) was used for local analgesia and to minimise bleeding during the procedure. RESULTS: The median time for insertion of the tracheostomy tube was 11.5 min (range 7-24 min) in the PDT group and 15 min (range 5-47 min) in the TR group (P<0.01). Complications during the procedure were cuff puncture of the endotracheal tube in 5 cases in the PDT group. Minor bleeding was encountered in 6 cases in the PDT group as opposed to 24 cases in the TR group (P<0.01), major bleeding in none versus 2 cases, respectively. In 8 cases in the PDT group, increased resistance to insertion of the tracheostomy tube was met by further dilatation. During the post-tracheostomy period, complications occurred with minor bleeding in 2 cases in the PDT group as opposed to 9 cases in the TR group (P<0.05), and major bleeding was encountered in 1 case in each group. Minor infections were encountered in 3 cases in the PDT group as opposed to 11 cases in the TR group (P<0.01). Major infection was encountered in none versus 8 cases, respectively (P<0.01). CONCLUSION: Our results indicate that the percutaneous dilatational tracheostomy technique performed with the Ciaglia Introducer Set is effective, safe and superior to conventional surgical tracheostomy as immediate complications as well as complications with the tracheostomy tube in situ are fewer and of less severity.

[Percutaneous dilatation tracheostomy. A preliminary study]. / Perkutan dilatationstrakeostomi. En proeliminoer undersøgelse.

Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study. The median time for insertion of the tracheostomy tube was 13.1 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period complications included one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion. Our preliminary results indicate that the technique as performed with the Ciaglia Introducer Set is effective and safe with only minor complications. Furthermore, we now use it as a bed-side procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. A conclusion on the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies including more patients.

Percutaneous dilatational tracheostomy.

METHODS: Fifteen patients electively selected for percutaneous dilatational tracheostomy as performed with the Ciaglia Percutaneous Tracheostomy Introducer Set are reported in this preliminary study. RESULTS: The median time for insertion of the tracheostomy tube was 13.9 min. Complications were cuff puncture of the translaryngeal tube at an early stage of the procedure in one case, and minor bleeding controllable by the compressible effect of the dilatational procedure in three cases. During the posttracheostomy period, complications were one case of minor bleeding controllable by digital compression and one case of minor infection, i.e. cellulitis in a few millimetres around the stoma without purulent secretion. CONCLUSIONS: Our preliminary results indicate the technique as performed with the Ciaglia Introducer Set to be effective and safe with only minor complications. Furthermore, we now use it as a bedside procedure in the ICU, thus avoiding the transportation of critically ill patients to the operating theatre. The conclusion of the superiority of percutaneous tracheostomy to dissectional tracheostomy has to await clinical randomized studies, including more patients.

[Complications and late sequelae after nasotracheal intubation]. / Komplikationer og senfølger efter nasotrakeal intubation.

A total of 379 patients admitted to the Intensive Care Unit (ICU) for mechanical ventilation were prospectively investigated for lesions of the nose, nasal cavity, ears and larynx during and after nasotracheal intubation. One to two years later, the surviving patients were questioned to investigate late persisting sequelae. During intubation and up to five days following extubation, inflammatory changes and ulceration of the nostrils or nasal septum were found in respectively 76 (20%) and 110 (29%) patients. There were bleedings from the nasal cavity in 67 (19%) and fractures of the conchae in 40 patients (11%). Hoarseness was noted in 135 patients (42%). Inflammatory changes and ulcerations of the nostril and nasal septum were correlated to the duration of intubation. Among the 281 patients included in the follow-up study, 100 (35%) had symptoms from the nose and nasal cavity. Sixty-five (24%) had symptoms related to the ears, 56 (20%) to the maxillary sinus, 81 (29%) to the voice and 90 (32%) to the throat. Increasing duration of intubation was found to be correlated to persisting symptoms from the larynx. Former ulcerations of the nose were associated with a tendency toward nasal bleeding. To avoid as many complications as possible from the nose and nasal cavity, we recommend orotracheal intubation. As late sequelae from the larynx increase with the duration of intubation, perhaps tracheostomy should be performed earlier than is general practice today, but that has to be proven in forthcoming studies.

Complications and late sequelae following nasotracheal intubation.

A total of 379 patients admitted to the ICU for mechanical ventilation were prospectively investigated for lesions on the nose, nasal cavity, ears and larynx during and after nasotracheal intubation. One to two years later, the surviving patients were questioned to investigate late persisting sequelae. During intubation and up to 5 days following extubation, inflammatory changes and ulceration of the nostrils or nasal septum were found in 76 (20%) and 110 patients (29%), respectively. There were bleedings from the nasal cavity in 67 (19%) and fractures of the conchae in 40 patients (11%). Hoarseness was noted in 135 patients (42%). Inflammatory changes and ulcerations of the nostril and nasal septum were correlated to the duration of intubation. Among the 281 patients included in the follow-up study, 100 (35%) had symptoms from the nose and nasal cavity. Sixty-five (24%) had symptoms related to the ears, 56 (20%) to the maxillary sinus, 81 (29%) to the voice and 90 (32%) to the throat. Increasing duration of intubation was found to be correlated to persisting symptoms from the larynx. Former ulcerations of the nose were associated with a tendency to nasal bleeding. To avoid as many complications as possible from the nose and nasal cavity, we recommend orotracheal intubation. As late sequelae from the larynx increase with the duration of intubation, perhaps tracheostomy should be performed earlier than is general practice today, but that has to be proven in forthcoming studies.

Intra-aortic balloon counterpulsation in Denmark 1988-1991. Early results and complications.

During the years 1988-1991 6319 patients underwent cardiac surgical procedures in Denmark. In 183 patients (2.9%) with left ventricular failure intra-aortic balloon counterpulsation (IABP) was used. Four percent of the IABP were placed preoperatively, 86% intraoperatively and 10% postoperatively. Severe complications occurred in 16 patients (8.7%) and were mainly vascular due to limb ischemia. The incidence of complications was independent of the duration of balloon pumping. Sixty percent of the patients were weaned from IABP. The 30-day mortality rate was 54%. During the observation period we found a gradual decrease in the use of IABP as well as a reduction in mortality.