Outcomes of percutaneous tracheostomy.

AIM: Percutaneous dilatational tracheostomy (PDT) is one of the most commonly performed procedures in critically ill patients receiving mechanical ventilation. Although many papers have compared different PDT techniques, few records on the outcome of tracheostomized patients after intensive care unit (ICU) discharge are available. METHODS: Prospective observational study to evaluate efficacy, safety and long-term consequences of PDT performed over a 6-year period (January 2002-December 2007) in a combined medical/surgical ICU in Rho, Milan, Italy. A total of 181 patients were subjected to PDT, 26.5% with the Ciaglia technique and 73.5% with the Percu-twist technique. RESULTS: The main endpoints that were examined were complications related to PDT and the final outcome of tracheostomized patients. Early complications included minor bleeding in 4 patients, stomal infection in 8 patients, and the occurrence of hypoxic/desaturation events during the procedure in 3 cases. Late complications included: tracheal stenosis in a single case, recurrent stomal granuloma in 2 cases, and tracheal mucosa injury caused by the endotracheal tube cuff in 3 patients. All patients who were decannulated late underwent bronchoscopic follow-up at 3, 6 and 12 months. Hospital discharge: of the 137 patients alive at the time of discharge from the hospital, 115 were decannulated (40 early decannulation, 75 late decannulation). In total, 22 patients were never decannulated (14 breathed spontaneously whereas 8 needed ventilator support). In the group of patients that were decannulated late, the mortality rate at 1 year was 20.6%. CONCLUSIONS: PDT-related early complications without clinical consequences were observed. Conversely, late complications were infrequent but had significant clinical implications. Although late decannulation is the major risk for complications, in 83.9% of cases tracheostomy is only a temporary measure.

Short term analgesia based sedation in the Intensive Care Unit: morphine vs remifentanil + morphine.

AIM: The aim of the study was the evaluation of postoperative short term analgesia-based sedation provided by a continuous i.v. morphine vs morphine+remifentanil infusion in the ICU. METHODS: A prospective, randomized, controlled study was carried out. INCLUSION CRITERIA: patients aged > 18 years undergoing major surgery (abdominal, vascular, thoracic). A total of 100 patients undergoing balanced anaesthesia, were enrolled; at the end of surgery an i.v. loading morphine dose (0.1 mg/kg) was administered and a continuous ground i.v. infusion (0.24 microg/kg/min) was started. When the patient was admitted to the ICU, a second i.v. continuous infusion was started and patients were allocated into 2 groups with regard to the second opioid: MM = morphine + morphine, MR = morphine + remifentanil. The second continuous infusion (boluses allowed) was titrated to obtain a numerical rate score (NRS) < 3 and Ramsay Scale =or>2. If Ramsay =or< 2 rescue sedation was administered (diazepam). RESULTS: The groups were homogeneous with regard to gender, age, weight, duration of surgery, intraoperative opioids, SAPS II. The second infusion rate in the first 24 postoperative hours was 0.73+/-0.55 microg/kg/min morphine in MM and 0.06+/-0.05 microg/kg/min remifentanil in RM. Hemodynamic parameters and SpO(2) were similar. Hypnotic consumption and NRS were significantly lower in RM, while Ramsay Scale was higher. Postextubation respiratory rate and minute volume were lower in group MM, while PaCO(2), postoperative nausea and vomiting (PONV) incidence and frequency of diazepam administration were higher. In both groups more than 70% of the patients were very satisfied. CONCLUSION: The combination of morphine + remifentanil provided better analgesia and sedation than morphine alone, with a lower incidence of side effects and a similar hemodynamic profile and patient satisfaction. The adherence to a clear analgesia based sedation protocol probably represents the most important issue carrying out analgosedation; however, the continuous infusion of a short acting drug, although more expensive, allows better titration and adjustment of the desired level of analgesia and sedation, avoiding the risk of undersedation as well as oversedation with a potential reduction of otherwise unnecessary ICU stays and, consequently, a decrease in comprehensive costs.

Effect of different sterile barrier precautions and central venous catheter dressing on the skin colonization around the insertion site.

AIM: The purpose of this prospective, randomized, controlled study was the comparison of maximal sterile barrier (consisting of mask, cap, sterile gloves, gown, large drape) vs control precautions (mask, cap, sterile gloves, small drape) and of transparent polyurethan film vs gauze dressing for use on central venous (CVC) nontunneled catheters, inserted via the jugular vein. Skin colonization at the insertion site (defined by quantitative skin cultures performed at the time of insertion and in days 2 and 5) was used as a primary endpoint. Catheter tip colonization was also assessed through qualitative culture and CVC related sepsis was defined by the isolation of the same organism from the catheter tip and the blood, with clinical sepsis of no other apparent source. METHODS: Eighty-two consecutive patients were enrolled, admitted to a mixed medical-surgical ICU, aged 72+/-12 years, 58% male, SAPS II 42+/-13. One-hundred and seven CVCs were studied (presenting 750 catheter in situ days); CVCs were in place for a mean period of 6.9+/-4.7 days and 5 episodes of central catheter-related bloodstream infection were detected (6.6 per 1000 catheter days). RESULTS: A multiple logistic regression detected an increased risk of skin colonization in male gender (OR=2.5) and control precautions (OR=3.4) and no difference with regard to age, dressing and diagnostic group. CONCLUSIONS: Maximal sterile barrier proved to be an effective and recommended practice. However surveillance skin cultures revealed the common and changing nature of colonization of skin at the insertion site.

Quality of life before intensive care admission: agreement between patient and relative assessment.

OBJECTIVE: To assess the agreement between patients and relatives concerning the formers' quality of life (QOL) before intensive care unit (ICU) admission. DESIGN: Prospective study involving direct interviews of patients and relatives during ICU stay. SETTING: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital. PATIENTS AND METHODS: A hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h, and their relatives were interviewed. The instruments used were two questionnaires suitable for ICU patients: QOL-IT and QOL-SP. Interobserver reproducibility was investigated in 36 patients. RESULTS: Interobserver reproducibility was nearly perfect (weighted Kappa 0.99 for QOL-IT and QOL-SP). Considering global scores, weighted Kappa was 0.78 for QOL-IT and 0.82 for QOL-SP, with the mean difference between patients and relatives lower than 0.3 for both scores but with limits of agreement wider than 4. Among the items, concordance was excellent in the areas of physical activity and social life for both questionnaires. Gender, living together with the patient and the degree of relationship of relatives did not influence the agreement. CONCLUSIONS: The relatives give global scores for both instruments which can be regarded as acceptable substitutes for those given by patients. However, the wide limits of agreement should make investigators cautious in analysing together scores generated by patients and by relatives. The emotional dimension seems to be assessed less accurately by relatives than the physical one.

Validation of two quality of life questionnaires suitable for intensive care patients.

OBJECTIVE: To validate two instruments measuring quality of life (QOL) suitable for patients admitted to the intensive care unit (ICU): QOL-IT and QOL-SP. DESIGN: Prospective study using patient interviews. SETTING: Two four-bed surgical-medical ICUs in a 960-bed teaching hospital. PATIENTS AND METHODS: One hundred seventy-two adult, co-operative patients consecutively admitted to ICU for more than 24 h were interviewed. One year after hospital discharge, 84 survivors were interviewed again. Inter-observer reproducibility was investigated in 36 patients. To validate the instruments, the QOL-IT and QOL-SP scores reported by patients were considered according to the functional limitation evaluated by the interviewer. Moreover, the theoretical prediction that patients with chronic diseases should have a worse QOL before ICU admission than patients with only acute illness was tested. QOL-IT and QOL-SP scores given 1 year after hospital discharge were compared with those recorded at the first interview. RESULTS: Inter-observer reproducibility was excellent. The possible range of QOL-IT is 0-20 and that of QOL-SP 0-29. According to the functional limitation (absent, mild or severe), the median QOL-IT score increased from 3 to 6 to 13 and QOL-SP from 2 to 6 to 12 (p< 0.0001). The patients with chronic diseases gave scores significantly higher than the patients with only acute illness (median QOL-IT 8 versus 3, p< 0.013; QOL-SP 8 versus 4, p< 0.004). The median QOL-IT score changed from 3 to 4 one year after hospital discharge, a difference which is statistically (p< 0.001), but not clinically, significant. The median QOL-SP score was 3 and did not change. CONCLUSIONS: QOL-IT and QOL-SP are instruments able to discriminate between different health states.