K. Westphal

Percutaneous tracheostomy: ciaglia blue rhino versus the basic ciaglia technique of percutaneous dilational tracheostomy.

Percutaneous dilational tracheostomy (PDT), according to Ciaglia’s technique described in 1985, has become the most popular technique for percutaneous tracheostomy and is demonstrably as safe as surgical tracheostomy. In 1999, an extensively modified technique of PDT was introduced, the Ciaglia Blue Rhino (CBR; Cook Critical Care, Bloomington, IL), that consists of one-step dilation by means of a curved dilator with hydrophilic coating. To compare CBR with the basic technique of PDT, we performed a prospective, randomized trial in 50 critically ill adults. Twenty-five of these patients had PDT, and 25 had CBR. Average operating times were <3 min for CBR (range: 50–360 s) and <7 min for PDT (range: 4–20 min;P < 0.0001). Tracheostomy was successfully completed in all patients. When CBR was performed, 11 minor, nonlife-threatening complications were noted: nine fractures of tracheal cartilage and two short periods of intraoperative oxygen desaturation. During PDT, seven complications occurred, of which three were potentially life-threatening: two injuries to the posterior tracheal wall, one pneumothorax, two tracheal cartilage fractures (P < 0.05 vs CBR), one case of bleeding, and one short episode of intraoperative oxygen desaturation. Regardless of whether PDT or CBR was performed, oxygenation was not significantly affected, and there was no infection of the tracheostoma. Based on our data, we conclude that new CBR is more practicable than PDT. No life-threatening complications occurred during CBR. Implications To assess practicability and safety of the Ciaglia Blue Rhino (Cook Critical Care, Bloomington, IL)—an extensively modified technique of percutaneous dilatational tracheostomy—50 critically ill adults on long-term ventilation underwent either new Ciaglia Blue Rhino or percutaneous dilatational tracheostomy in a prospective, randomized clinical trial.

Peri-operative complications during percutaneous tracheostomy in obese patients

The safety of percutaneous tracheostomy in 73 obese patients (body mass index ≥ 27.5 kg.m−2) in a cohort of 474 adults was studied. Four percutaneous techniques were employed (percutaneous dilational tracheostomy, n = 48; Ciaglia Blue Rhino, n = 157; guide wire dilating forceps, n = 62, translaryngeal tracheostomy, n = 207). The overall complication rate was 43.8% (n = 32) in the obese group compared to 18.2% (n = 73) in the control group (p < 0.001). Seven (9.6%) obese patients suffered life‐threatening complications compared to three non‐obese patients (0.7%, p < 0.001). Obese patients had a 2.7‐fold increased risk for peri‐operative complications, and a 4.9‐fold increased risk for serious complications. The data suggest that percutaneous tracheostomy in obese patients is associated with a considerably increased risk for peri‐operative complications, especially for serious adverse events.

Positive end‐expiratory pressure improves arterial oxygenation during prolonged pneumoperitoneum

Background:  Laparoscopic surgery usually requires the use of a pneumoperitoneum by insufflating gas in the peritoneal space. The gas most commonly used for insufflation is carbon dioxide. Increased intra‐abdominal pressure causes cephalad displacement of the diaphragm resulting in compressed lung areas, which leads to formation of atelectasis, especially during mechanical ventilation. The aim of this prospective study was to investigate the effect of prolonged intraperitoneal gas insufflation on arterial oxygenation and hemodynamics during mechanical ventilation with and without positive end‐expiratory pressure (PEEP).

Occupational exposure to volatile anaesthetics: epidemiology and approaches to reducing the problem.

Long term occupational exposure to trace concentrations of volatile anaesthetics is thought to have adverse effects on the health of exposed personnel. In contrast with halothane — an agent likely to cause mutagenic effects and proven to be teratogenic — isoflurane and enflurane have not so far been proved to have adverse effects on the health of personnel exposed long term. Data on the newer agents sevoflurane and desflurane are limited. Since possible health hazards from long term exposure to inhalational anaesthetics cannot yet be definitively excluded, many Western countries have established limits for exposure. These usually range from 2 to 10 ppm as a time-weighted average over the time of exposure.A number of investigations have demonstrated that, in operating theatres with modern climate control and waste anaesthetic gas scavenging systems, occupational exposure is unlikely to exceed threshold limits. However, occupational exposure from the use of volatile agents in operating theatres with poor air control — especially during bronchoscopy procedures in paediatric patients — remains a source of concern. This also holds true for both postanaesthesia care units (PACU) and intensive care units (ICU) lacking proper air conditioning and waste gas scavengers.To minimise occupational exposure to volatile anaesthetics, all measures must be taken to provide climate control and properly working scavenging devices, and ensure sufficient personal skill of the anaesthetist, e.g. during inhalational mask induction. Furthermore, low-flow anaesthesia should be used whenever possible. The sole use of intravenous drugs such as propofol instead of volatile agents, were this possible, would eliminate occupational exposure, but may result in environmental pollution by toxic metabolites (e.g. phenol).

Single-dilator percutaneous tracheostomy: a comparison of PercuTwist and Ciaglia Blue Rhino techniques

AbstractObjective. To compare two single-dilator percutaneous tracheostomy techniques, Ciaglia Blue Rhino and the new PercuTwist technique. Design and setting. Randomized, observational clinical trial in patients undergoing elective percutaneous tracheostomy in the intensive care units of a university hospital. Patients. Seventy consecutive, adult patients undergoing either Blue Rhino (n=35) or PercuTwist tracheostomy (n=35). Interventions. Performance of percutaneous tracheostomy with a novel screwlike dilating device (PercuTwist) or conically shaped, flexible rubber dilator (Blue Rhino). Results. Stoma dilation was successful with the respective device in all patients. While subsequent tracheostomy cannula insertion was uneventful in all but one patients undergoing the Blue Rhino technique, it was difficult or even impossible in eight patients who underwent PercuTwist tracheostomy. Regarding serious and intermediate procedural-related complications, two cases of posterior tracheal wall injury occurred with the PercuTwist technique. No serious or intermediate complications were noted during Blue Rhino tracheostomy. There was no statistical significance between the two techniques in terms of minor and overall complications. Conclusions. So far the new PercuTwist technique represents an alternative to the established Blue Rhino technique. Nonetheless, the two cases of posterior tracheal wall injury should not be underestimated, on the one hand, but, on the other, may be attributed to a learning curve with a new technique. The new PercuTwist technique should be performed by various teams and in a considerably larger numbers of patients before an ultimate rating can be made.

Tracheostomy in cardiosurgical patients: surgical tracheostomy versus Ciaglia and Fantoni methods

BACKGROUND Patients requiring prolonged mechanical ventilation are not uncommon in a cardiosurgical intensive care unit. Elective tracheostomy is considered the airway treatment of choice in these patients. METHODS To evaluate different techniques for tracheostomy, we prospectively investigated 120 patients who had conventional open (n = 40), minimally invasive percutaneous dilatational (n = 40), or translaryngeal (n = 40) tracheostomy techniques. The main areas of investigation included oxygenation index (partial pressure of arterial oxygen divided by fraction of inspired oxygen), complications, infection, and cost. RESULTS The oxygenation index decreased in almost every patient, regardless of the technique used, but the extent of decrease was significantly lower in both minimally invasive techniques compared with the conventional method. Overall complication rate was 12.5% both in open tracheostomy and in percutaneous dilatational tracheostomy, whereas no complications occurred in translaryngeal tracheostomy procedures. Bacterial contamination of the tracheostomy site was found in 35% of the open tracheostomies, whereas no infection was seen in percutaneous dilatational or translaryngeal tracheostomies. In terms of costs, PDT (

Incidence of gastrointestinal complications in cardiopulmonary bypass patients

506) and TLT (

Totally endoscopic Nissen fundoplication with a robotic system in a child.

362) were both much cheaper than open tracheostomy (

Percutaneous Tracheostomy: A Clinical Comparison of Dilatational (Ciaglia) and Translaryngeal (Fantoni) Techniques

699). CONCLUSIONS Percutaneous dilatational and translaryngeal tracheostomies are safe and cost-effective procedures that can be done easily at the patients bedside and thus are attractive alternatives to conventional surgical tracheostomy in long-term airway access in a cardiosurgical intensive care unit.

Effects of prolonged pneumoperitoneum on hemodynamics and acid-base balance during totally endoscopic robot-assisted radical prostatectomies.

Gastrointestinal complications after cardiac surgery are associated with a high mortality rate. Because of the absence of early specific clinical signs, diagnosis is often delayed. The present study seeks to determine predictive risk factors for subsequent gastrointestinal complications after cardiosurgical procedures. Within a 1-year period, a total of 1116 patients who had undergone open heart surgery with cardiopulmonary bypass were prospectively studied for gastrointestinal complications. To determine predictive factors, all case histories of the patients were analyzed. Of the 1116 patients, 23 (2.1%) had gastrointestinal complications during the postoperative period, 10 of whom had to undergo subsequent abdominal surgery. Of these 23 patients, 20 died. Early gastrointestinal complications, which occurred mostly on postoperative days 6 or 7, consisted of bowel ischemia or hepatic failure. Late complications were gastrointestinal bleeding, pseudomembranous colitis, cholecystitis, and septic rupture of a spleen. The relative risk for abdominal complications after cardiopulmonary bypass was highly increased in association with (1) a cardiac index less than 2.0 l/min−1/(m2)−1, (2) postoperative onset of atrial fibrillation, (3) emergency surgery, (4) need for vasopressors, (5) need for intraaortic balloon counterpulsation, and (6) need for early redo thoracotomy due to surgical complications. All patients with necrotic bowel disease had elevated serum lactate levels. Furthermore, cardiopulmonary bypass and aortic clamping times were significantly prolonged in patients who developed gastrointestinal complications. A number of predictive factors contribute to the development of gastrointestinal complications after cardiopulmonary bypass surgery. Knowledge of these factors may lead to earlier identification of patients at increased risk and may allow more efficient and earlier interventions to reduce mortality.RésuméObjectifs: Les complications gastro-intestinales après chirurgie cardiaque sont associéesà un taux de mortalité élevé. Le diagnostic en est souvent retardé en raison de I’absence de signes cliniques spécifiques, précoces. Cette étude chercheà déterminer les facteurs de risque prédictifs de complications gastrointestinales après chirurgie cardio-vasculaire. Méthodes: Pendant une période d’un an, 1116 patients au total ayant eu une intervention chirurgicaleà coeur ouvert avec shunt cardiopulmonaire ont été étudiés prospectivement dans` la recherche de complications gas tro-intestinales. Afin de déterminer les facteurs prédictifs, tous les antécédents ont é té analysés. Résultats: 23 (2.1%) des 1116 patients ont eu des complications gastrointestinales pendant la période postopératoire, dont 10 qui ont nécessité un acte chirurgical abdominal. Parmi ces 23 patients, 20 sont décédés. Des complications gastro-intestinales précoces sont survenues aux jours postopératoires 6 ou 7, sous forme d’ischémie intestinale ou d’insuffisance hepatique. Les complications tardives ont été I’hémorragie gastro-intestinale, la colite pseudomembraneuse, la cholécystite et un cas de rupture septique de la rate. Le risque relatif de faire des complications abdominales après shunt cardio-pulmonaire était plus important lorsque le patient: (1) avait un indexe cardiaque inférieurà 2,0 l/min−1/ (m2)−1, (2) a prése nté une fibrillation auriculaire postopératoire, (3) a eu besoin d’une intervention en urgence, (4) a eu besoin de vasopresseurs, (5) a nécessité I’utilisation d’un ballonnetà contrepression, et (6) a eu une re-thoracotomie précoce en raison des complications. Tous les patients ayant une nécrose intestinale avaient des taux de lactates élevés dans le sérum. Les temps de shunt cardio-pulmonaire et de clampage aortique ont été prolongés de façon significative chez les patients qui ont développé des complications gastro-intestinales. Conclusions: II existe un certain nombre de facteurs prédictifs qui peuvent contribuer au développement des complications gastrointestinales après un shunt cardio-pulmonaire. La connaissance de ces facteurs pourrait aiderà identifier ces patientsà risque et pourrait permettre une intervention plus efficace et plus précoce, réduisant ainsi la mortalité.ResumenObjetivo: Las complicaciones gastrointestinales tras cirugía cardiaca conllevan una alta tasa de mortalidad. Debido a la ausencia de signos clinico precoces, el diagnóstico, con frecuenci à, se retrasa. El presente estudio pretende averiguar los factores que permitan predecir el riesgo de padecer complicaciones gastrointestinales tras cirugía cardiaca. Métodos: Durante un anõ se estudiaron prospectivamente las complicaciones gastrointestinales de 1,116 pacientes intervenidos a corazón abierto con derivación cardio-pulmonar. Se analizaron las historias clínicas de todos los pacientes con objeto de averiguar los factores predictivos. Resultados: En 23 (2.1%) de los 1,116 pacientes se produjeron complicaciones gastrointestinales en el periodo postoperatorio, requiriendo 10 de ellos tratamiento quirúrgico. De los 23 pacientes, 20 fallecieron. Las complicaciones gastrointestinales precoces aparecieron entre el 6, 7 dias del postoperatorio, tratándose de isquemia intestinal o fracaso hepático. Las complicaciones tardias fueron: hemorragia gastrointestinal, colitis pseudo-membranosa, colecistitis y ruptura séptica del bazo. El riesgo de desarrollar complicaciones abdominales, tras derivación cardio-pulmonar se incrementa cuando se producen: (1) índice cardiaco menor a 2.0 l/min−1/ (m2)−1, (2) crisis postoperatorias de fibrilación atrial, (3) cirug ía de urgencia, (4) utilización de vasopresores, (5) empleo del balón intraaórtico de contrapulsación y (6) retoracotomía precoz por complicaciones quirúrgicas. Todos los pacientes con afectación necrótica intestinal presentaron niveles altos de la concentración sérica de lactato. Además, en los pacientes que desarrollaron complicaciones gastrointestinales, tanto el tiempo de derivación cardio-pulmonar como el del clampado de aorta fueron significativamente más prolongados. Conclusiones: Se describen diversos factores predictivos que contribuyen al desarrollo de complicaciones gastrointestinales tras cirugía cardiaca con derivación cardio-pulmonar. El conocimiento de los mismos, permitirá la identificación precoz de los pacientes de mayor riesgo, pudiéndose así realizar intervenciones más precoces y eficaces que reduzcan la mortalidad.