Bedside tracheostomy in the intensive care unit: a prospective randomized trial comparing open surgical tracheostomy with endoscopically guided percutaneous dilational tracheotomy.

OBJECTIVES: Objectives of the study were 1) to analyze the complication incidence and resource utilization of two methods of bedside tracheostomy and 2) to define selection criteria for bedside tracheostomy. STUDY DESIGN: Prospective randomized trial in the setting of a tertiary care center at a university hospital. METHODS: One hundred sixty-four consecutive intubated patients selected for elective tracheostomy were enrolled. One hundred patients met selection criteria for bedside tracheostomy and were randomly assigned to either open surgical tracheostomy (50) or endoscopically guided percutaneous dilational tracheotomy(50). The remaining 64 patients received open surgical tracheostomies in the operating room. Main outcome measures were 1) perioperative and postoperative complication incidence and 2) resource utilization. RESULTS: Patients meeting our selection criteria for bedside tracheostomy had a significantly reduced perioperative complication rate compared with those who failed to meet these criteria, and subsequently underwent tracheostomy placement in the operating room (5% vs. 20%, P less than or equal to.01). No statistically significant difference was found in the perioperative complication incidence between the two methods of bedside tracheostomy. However, percutaneous tracheostomy placement at the bedside resulted in a significant increase in postoperative complication incidence (16% vs. 2%, P <.05) and incurred an additional patient charge of $436 per bedside procedure. CONCLUSIONS: This investigation prospectively confirms the safety of bedside tracheostomy placement in properly selected patients. Complication incidence and resource utilization are defined for two methods of bedside tracheostomy. The results of this study confirm that open surgical tracheostomy represents the standard of care in bedside tracheostomy placement by providing a more secure airway at a markedly reduced patient charge. These findings will aid in the development of protocols and pathways for surgical airway management in critically ill patients to maximize cost-effective, high-quality care.

Tumor growth and audiometric change in vestibular schwannomas managed conservatively.

OBJECTIVE: To prospectively define the correlation between changes in tumor volume and audiometric function in vestibular schwannomas managed conservatively. STUDY DESIGN: Prospective longitudinal study. METHODS: Twenty-one patients (age range, 15-84 y; mean age, 63.3 y) with newly diagnosed vestibular schwannomas were enrolled between 1994 and 1999 in a protocol at The Ohio State University Hospital (Columbus, OH) to evaluate the correlation between tumor volume and audiometric change during a period of observation. Patients were evaluated yearly by clinical examination, a standardized internal auditory canal magnetic resonance imaging scan with gadolinium contrast for volumetric analysis, and audiometric function testing. Demographic data, historical features, neurofibromatosis type 2 (NF2) status, initial testing results, and serial testing results were recorded. RESULTS: An increase in tumor volume occurred in 14 of the 21 patients (66%). The pattern of volumetric change was found to be extremely variable. Multiple regression analysis revealed significant correlations of changes in tumor volume with changes in pure-tone average and speech discrimination score (P < .0001 and P = .0021, respectively). Change in tumor volume had greater effect on pure-tone average and speech discrimination score in patients initially with class D audiometric function when compared with those initially in class A (P = .0083 and P = .0245, respectively). The presence of NF2 had an independent protective effect against deterioration of the pure-tone average when compared with patients without NF2 (P = .0125). CONCLUSIONS: This study demonstrated a significant correlation between a change in volume and auditory deterioration in vestibular schwannomas being managed with a trial of observation. A given change in tumor volume appeared to have a greater effect on pure-tone average and speech discrimination score as initial auditory classification declined.

Quantification of the learning curve for percutaneous dilatational tracheotomy.

OBJECTIVES/HYPOTHESIS: Although numerous investigators have reported a bedside percutaneous dilatational tracheotomy (PDT) complication incidence similar to that of standard operative tracheostomy, others have proposed a "learning curve" for PDT resulting in increased complications early in individual or institutional experience with this procedure. The objective of this investigation is to characterize and quantify the proposed learning curve for PDT. STUDY DESIGN: Prospective analysis of complication incidence for the first 100 PDT procedures performed in a local community hospital Department of General Surgery. METHODS: Demographic data, patient disease variables, and patient anatomic features, as well as perioperative, postoperative, and late complications, were recorded prospectively. Patients were divided into sequential cohorts of 20 and were evaluated for complications at regular intervals. RESULTS: Perioperative and late complication incidence was significantly higher in the first 20 patients who underwent PDT. However, postoperative complication incidence did not significantly vary with operator or institutional experience. In addition, patients with suboptimal anatomy were found to have a significantly increased complication incidence, independent of operator and institutional experience. CONCLUSIONS: Percutaneous dilational tracheotomy has an identifiable learning curve that is most prominent in the first 20 patients treated. Early experience with PDT should be obtained under controlled circumstances, ideally the operating suite. Although most complications occur during acquisition of early experience with PDT, certain life-threatening complications such as tube dislodgment or inability to complete procedure may occur even after extensive experience is obtained. Bedside PDT has an acceptable complication incidence, but any surgeon employing this technique must be prepared to perform immediate standard open tracheotomy to minimize potentially lethal complications of this elective procedure.

Revised technique for retrieving small polyps from the colon and rectum after snare polypectomy.

Use of a nylon tissue biopsy bag at the suction port during snare colonoscopic polypectomy refines our previously reported technique in which we used a 4-inch x 4-inch gauze pad. The nylon tissue biopsy bag results in superior pathologic specimens, maintains simplicity of the technique, and is cost effective.