Late complications of percutaneous tracheostomy using the balloon dilation technique. / Complicaciones tardías de la traqueotomía percutánea con la modalidad de dilatación con balón.

OBJECTIVE: The purpose of this study was to determine the late complications in critically ill patients requiring percutaneous tracheostomy (PT) using the balloon dilation technique. DESIGN: A prospective, observational cohort study was carried out. SCOPE: Two medical-surgical intensive care units (ICU). PATIENTS: All mechanically ventilated adult patients consecutively admitted to the ICU with an indication of tracheostomy. INTERVENTIONS: All patients underwent PT according to the Ciaglia Blue Dolphin® method, with endoscopic guidance. Survivors were interviewed and evaluated by fiberoptic laryngotracheoscopy and tracheal computed tomography at least 6 months after decannulation. VARIABLES: Intraoperative, postoperative and long-term complications and mortality (in-ICU, in-hospital) were recorded. RESULTS: A total of 114 patients were included. The most frequent perioperative complication was minor bleeding (n=20) and difficult cannula insertion (n=19). Two patients had severe perioperative complications (1.7%) (major bleeding and inability to complete de procedure in one case and false passage and desaturation in the other). All survivors (n=52) were evaluated 211±28 days after decannulation. None of the patients had symptoms. Fiberoptic laryngotracheoscopy and computed tomography showed severe tracheal stenosis (>50%) in 2patients (3.7%), both with a cannulation period of over 100 days. CONCLUSIONS: Percutaneous tracheostomy using the Ciaglia Blue Dolphin® technique with an endoscopic guide is a safe procedure. Severe tracheal stenosis is a late complication which although infrequent, must be taken into account due to its lack of clinical expressiveness. Evaluation should be considered in those tracheostomized critical patients who have been cannulated for a long time.

[Percutaneous tracheostomy through dilatation with the Ciaglia Blue Dolphin(®) method]. / Traqueotomía percutánea por dilatación con el método Ciaglia Blue Dolphin(®)

OBJECTIVE: To describe the perioperative and postoperative complications in critically ill patients requiring percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique. DESIGN: A prospective, observational, cohort study was carried out. SCOPE: Two medical-surgical Intensive Care Units. PATIENTS: Adult patients subjected to prolonged mechanical ventilation. INTERVENTION: Percutaneous tracheostomy using Ciaglia Blue Dolphin(®) with an endoscopic guide. VARIABLES: Demographic variables, intraoperative and postoperative complications, and Intensive Care Unit and ward mortality were recorded. RESULTS: Seventy patients were included. Age: 68.6 ± 12 years (68.6% males). APACHE II score: 23.5±8.7. Duration of mechanical ventilation prior to percutaneous tracheostomy: 14.3 ± 5.5 days. Perioperative complications were recorded in 25 patients. In 23 of them the complications were mild: difficulty inserting the tracheostomy cannula (n=10), mild bleeding (n=7), partial atelectasis (n=3), cuff leak (n=2), and technical inability to complete the procedure (switch to Ciaglia Blue Rhino(®)) (n=1). Severe complications were recorded in 2 patients: severe bleeding that forced completion of the procedure via surgical tracheostomy (n=1), and false passage with desaturation (n=1). None of the complications proved life-threatening. Eleven complications occurred in the learning curve. As postoperative complications, mild peri-cannula bleeding was seen in 2 patients. CONCLUSIONS: Percutaneous tracheostomy using the Ciaglia Blue Dolphin(®) technique with an endoscopic guide is a safe procedure. As with other procedures, the learning curve contributes to increase the incidence of complications. Potential benefits versus other percutaneous tracheostomy techniques should be explored by randomized trials.

[Prolonged mechanical ventilation probability model]. / Modelo de probabilidad de ventilación mecánica prolongada.

OBJECTIVE: To design a probability model for prolonged mechanical ventilation (PMV) using variables obtained during the first 24 hours of the start of MV. DESIGN: An observational, prospective, multicenter cohort study. SCOPE: Thirteen Spanish medical-surgical intensive care units. PATIENTS: Adult patients requiring mechanical ventilation for more than 24 hours. INTERVENTIONS: None. STUDY VARIABLES: APACHE II, SOFA, demographic data, clinical data, reason for mechanical ventilation, comorbidity, and functional condition. A multivariate risk model was constructed. The model contemplated a dependent variable with three possible conditions: 1. Early mortality; 2. Early extubation; and 3. PMV. RESULTS: Of the 1661 included patients, 67.9% (n=1127) were men. Age: 62.1±16.2 years. APACHE II: 20.3±7.5. Total SOFA: 8.4±3.5. The APACHE II and SOFA scores were higher in patients ventilated for 7 or more days (p=0.04 and p=0.0001, respectively). Noninvasive ventilation failure was related to PMV (p=0.005). A multivariate model for the three above exposed outcomes was generated. The overall accuracy of the model in the training and validation sample was 0.763 (95%IC: 0.729-0.804) and 0.751 (95%IC: 0.672-0.816), respectively. The likelihood ratios (LRs) for early extubation, involving a cutoff point of 0.65, in the training sample were LR (+): 2.37 (95%CI: 1.77-3.19) and LR (-): 0.47 (95%CI: 0.41-0.55). The LRs for the early mortality model, for a cutoff point of 0.73, in the training sample, were LR (+): 2.64 (95%CI: 2.01-3.4) and LR (-): 0.39 (95%CI: 0.30-0.51). CONCLUSIONS: The proposed model could be a helpful tool in decision making. However, because of its moderate accuracy, it should be considered as a first approach, and the results should be corroborated by further studies involving larger samples and the use of standardized criteria.

[Economics and equity in urgency and emergency care]. / Economía y equidad en urgencias y emergencias.

The financial sustainability of public health systems (PHS) is currently threatened by population growth, increased prevalence of chronic conditions and disabilities, inequality in access and use of resources, zero cost delivery and global economic crisis. The emergency department (ED) is one for which demand is highest--without relation to the health model--because disease becomes established in disadvantaged socio-demographic areas and inequalities, hyperconsumption and decision making more closely linked to the user are maintained. The medical device of ED is a multiple one and its diverse product lines make it difficult to measure. This review discusses the need to deploy measurement tools in ED, where there are high direct costs--primarily structural--and other variables related to the activity, where the marginal cost is higher than the average and there is no economy of scale in such interventions. The possible mechanisms of private copayment in financing the supply of EDs are also studied, showing their advantages and disadvantages, with the conclusion that they are not recommendable--due to their scarce fund raising and deterrent capacity, which is why fundamental strategic changes in the management of these resources are needed.

Economía y equidad en urgencias y emergencias / Economics and equity in urgency and emergency care

públicos (SSP) está amenazada por el crecimientopoblacional, la mayor prevalencia de procesos crónicosy discapacidades, la inequidad residual en el acceso yutilización de los recursos, el coste nulo en la prestacióny la crisis económica mundial.Los servicios de Urgencias y Emergencias (SUE)son uno de los más demandados –sin relación con elmodelo de salud– porque la enfermedad asienta enáreas sociodemográficas menos favorecidas, se mantieneninequidad, hiperconsumo y capacidad de decisiónmás ligada al usuario. El producto sanitario de los SUEes múltiple y con líneas de producción diversas quedificultan su medición. En esta revisión se analiza lanecesidad de implantar herramientas de medida en losSUE, donde existen altos costes directos –fundamentalmenteestructurales– y otros variables relacionadoscon la actividad, donde el coste marginal es superior almedio y sin economía de escala en estas intervenciones.Se estudian, asimismo, los posibles mecanismos decoparticipación privada en la financiación de la ofertade los SUE, se muestran sus ventajas e inconvenientesy se concluye que no son recomendables –por su escasacapacidad recaudadora y disuasoria– por lo queson necesarios cambios estratégicos fundamentales enla gestión de estos recursos(AU)

The financial sustainability of public health systems(PHS) is currently threatened by populationgrowth, increased prevalence of chronic conditions anddisabilities, inequality in access and use of resources,zero cost delivery and global economic crisis.The emergency department (ED) is one for whichdemand is highest – without relation to the health model– because disease becomes established in disadvantagedsocio-demographic areas and inequalities, hyperconsumptionand decision making more closely linkedto the user are maintained. The medical device of EDis a multiple one and its diverse product lines make itdifficult to measure.This review discusses the need to deploy measurementtools in ED, where there are high direct costs– primarily structural – and other variables related tothe activity, where the marginal cost is higher than theaverage and there is no economy of scale in such interventions.The possible mechanisms of private copaymentin financing the supply of EDs are also studied,showing their advantages and disadvantages, with theconclusion that they are not recommendable – due totheir scarce fund raising and deterrent capacity, whichis why fundamental strategic changes in the managementof these resources are needed(AU)