Bernard G. Fikkers

Tracheostomy for long-term ventilated patients: a postal survey of ICU practice in The Netherlands

ObjectiveTo assess the frequency, timing, technique, and follow-up of tracheostomy for long-term ventilated patients in different intensive care units (ICUs) in The Netherlands.Design and settingPostal questionnaire, survey on retrospective data. A questionnaire was sent to all (n=63) ICUs with six or more beds suitable for mechanical ventilation and officially recognized by The Netherlands Intensive Care Society. Pediatric ICUs were excluded.Measurements and resultsThere was an 87% (n=55) response rate of contacted ICUs. The number of tracheostomies per year per unit varied widely (range 1–75), most ICUs (42%) performing between 11 and 25 tracheostomies per year. In 44% of ICUs (n=24) tracheostomy was not performed on a routine basis. In 25% of ICUs (n=14) tracheostomies were performed during the second week of ventilation. Surgical tracheostomy and percutaneous procedures were technique of first choice in 38% and 62% of ICUs, respectively. In only 7% of units were late follow-up protocols in use. Thirty-two units (58%) reported a total of 56 major complications.ConclusionsTiming and technique of tracheostomy varies widely in Dutch ICUs. The percutaneous technique is the procedure of choice for tracheostomy in most of these units. Late follow-up protocols are rarely in use.

Comparison of two percutaneous tracheostomy techniques, guide wire dilating forceps and Ciaglia Blue Rhino: a sequential cohort study

IntroductionTo evaluate and compare the peri-operative and postoperative complications of the two most frequently used percutaneous tracheostomy techniques, namely guide wire dilating forceps (GWDF) and Ciaglia Blue Rhino (CBR).MethodsA sequential cohort study with comparison of short-term and long-term peri-operative and postoperative complications was performed in the intensive care unit of the University Medical Centre in Nijmegen, The Netherlands. In the period 1997–2000, 171 patients underwent a tracheostomy with the GWDF technique and, in the period 2000–2003, a further 171 patients with the CBR technique. All complications were prospectively registered on a standard form.ResultsThere was no significant difference in major complications, either peri-operative or postoperative. We found a significant difference in minor peri-operative complications (P < 0.01) and minor late complications (P < 0.05).ConclusionDespite a difference in minor complications between GWDF and CBR, both techniques seem equally reliable.

Percutaneous tracheostomy with the guide wire dilating forceps technique: Presentation of 171 consecutive patients

Evaluation of percutaneous tracheostomy (PT) with the guide wire dilating forceps (GWDF) technique.

Incidence of cardiac arrests and unexpected deaths in surgical patients before and after implementation of a rapid response system

BackgroundRapid response systems (RRSs) are considered an important tool for improving patient safety. We studied the effect of an RRS on the incidence of cardiac arrests and unexpected deaths.MethodsRetrospective before- after study in a university medical centre. We included 1376 surgical patients before (period 1) and 2410 patients after introduction of the RRS (period 2). Outcome measures were corrected for the baseline covariates age, gender and ASA.ResultsThe number of patients who experienced a cardiac arrest and/or who died unexpectedly decreased non significantly from 0.50% (7/1376) in period 1 to 0.25% (6/2410) in period 2 (odds ratio (OR) 0.43, CI 0.14-1.30). The individual number of cardiac arrests decreased non-significantly from 0.29% (4/1367) to 0.12% (3/2410) (OR 0.38, CI 0.09-1.73) and the number of unexpected deaths decreased non-significantly from 0.36% (5/1376) to 0.17% (4/2410) (OR 0.42, CI 0.11-1.59). In contrast, the number of unplanned ICU admissions increased from 2.47% (34/1376) in period 1 to 4.15% (100/2400) in period 2 (OR 1.66, CI 1.07-2.55). Median APACHE ll score at unplanned ICU admissions was 16 in period 1 versus 16 in period 2 (NS). Adherence to RRS procedures. Observed abnormal early warning scores ≤72 h preceding a cardiac arrest, unexpected death or an unplanned ICU admission increased from 65% (24/37 events) in period 1 to 91% (91/101 events) in period 2 (p < 0.001). Related ward physician interventions increased from 38% (9/24 events) to 89% (81/91 events) (p < 0.001). In period 2, ward physicians activated the medical emergency team in 65% of the events (59/91), although in 16% (15/91 events) activation was delayed for one or two days. The overall medical emergency team dose was 56/1000 admissions.ConclusionsIntroduction of an RRS resulted in a 50% reduction in cardiac arrest rates and/or unexpected death. However, this decrease was not statistically significant partly due to the low base-line incidence. Moreover, delayed activation due to the two-tiered medical emergency team activation procedure and suboptimal adherence of the ward staff to the RRS procedures may have further abated the positive results.

Effects of a rapid response system on quality of life: a prospective cohort study in surgical patients before and after implementing a rapid response system

BackgroundThe aim of a rapid response system (RRS) is to improve the timely recognition and treatment of ward patients with deteriorating vital signs The system is based on a set of clinical criteria that are used to assess patient’s vital signs on a general ward. Once a patient is evaluated as critical, a medical emergency team is activated to more thoroughly assess the patient’s physical condition and to initiate treatment. The medical emergency team included a critical care physician and a critical care nurse.AimTo assess the effect of an RRS on health-related quality of life (HRQOL).MethodsProspective cohort study in surgical patients before and after implementing an RRS. HRQOL was measured using the EuroQol-5 dimensions (EQ-5D) and the EQ visual analogue scale (VAS) at pre surgery and at 3 and 6 months following surgery.ResultsNo statistical significant effects of RRS implementation on the EQ-5D index and EQ-VAS were found. This was also true for the subpopulation of patients with an unplanned intensive care unit admission. Regarding the EQ-5D dimensions, deterioration in the ‘mobility’ and ‘usual activities’ dimensions in the post-implementation group was significantly less compared to the pre-implementation group with a respective mean difference of 0.08 (p = 0.03) and 0.09 (p = 0.04) on a three-point scale at 6 months. Lower pre-surgery EQ-5D index and higher American Society of Anesthesiologists physical status (ASA-PS) scores were significantly associated with lower EQ-5D index scores at 3 and 6 months following surgery.ConclusionsImplementation of an RRS did not convincingly affect HRQOL following major surgery. We question if HRQOL is an adequate measure to assess the influence of an RRS. Pre-surgery HRQOL- and ASA-PS scores were strongly associated with HRQOL outcomes and may have abated the influence of the RRS implementation.