V. Lischke

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.

DROPERIDOL CAUSES A DOSE-DEPENDENT PROLONGATION OF THE QT INTERVAL

To further investigate possible prolongation of the frequency-corrected QT interval (QTc interval) after administration of droperidol (DRO), we studied 40 surgical patients who were randomly assigned to one of three groups, receiving an intravenous (IV) injection of either 0.1 mg/kg (Group 1, n = 10), 0.175 mg/kg (Group 2, n = 10), or 0.25 mg/kg (Group 3, n = 20) of DRO at induction of anesthesia. The QTc interval, heart rate, and arterial pressure were registered before and 1, 2, 3, 4, 5, 7.5, and 10 min after the respective dose injection. Significant prolongations of the median QTc interval were found in patients from all groups, ranging from 37 ms (8.0%) in Group 1, to 44 ms (10.6%) in Group 2, to 59 ms (14.9%) in Group 3, when compared with control. The heart rate showed a significant increase in all groups. Mean arterial pressure (MAP) was slightly but significantly decreased in Groups 1 and 3. Prolongation of the QTc interval is a predictable and dose-dependent side effect after injection of high-dose DRO.

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.

Selective inhibition by barbiturates of the synthesis of endothelium-derived hyperpolarizing factor in the rabbit carotid artery.

1 Several lines of evidence suggest that both volatile and intravenous anaesthetics may interfere with the synthesis and release of endothelium‐derived vasoactive factors. We have investigated the effects of three different barbiturates on the release of nitric oxide (NO) and endothelium‐derived hyperpolarizing factor (EDHF) in phenylephrine (1 μm)‐preconstricted, endothelium‐intact ring segments of the rabbit carotid artery. The segments were pretreated with the cyclo‐oxygenase inhibitor, diclofenac (1 μm), to prevent the formation of vasoactive prostanoids, such as prostacyclin (PGI2). 2 Acetylcholine (ACh) elicited a concentration‐dependent relaxation (EC50 0.15 μm) in control segments which was not significantly different from the relaxant responses of segments pretreated with methohexitone (0.03‐0.3 mM), phenobarbitone (0.1–0.3 mM) or thiopentone (0.1‐0.3 mM). 3 Inhibition of NO synthesis with NG–nitro‐L‐arginine (0.1 mM) significantly reduced the maximum relaxant response to ACh from 96 to 40%. This NO/PGI2‐independent relaxation appeared to be mediated by the release of EDHF, since it was strongly diminished in the presence of the K+ca inhibitors, tetrabutylammonium (1–3 mM) and charybdotoxin (10 nM), following preconstriction with potassium calcium (40 mM) or removal of the endothelium. Thiopentone or methohexitone markedly attenuated the EDHF‐mediated relaxant response to ACh, while phenobarbitone had no effect. The endothelium‐independent relaxation elicited by sodium nitroprusside (0.01 −10 μm), on the other hand, was only marginally affected by these anaesthetics. 4 The cytochrome P450 inhibitor, clotrimazole (3–100 μm), mimicked the inhibitory effect of thiopentone and methohexitone on the NO/PGI2‐independent relaxant response to ACh. Moreover the cytochrome P450‐catalyzed O‐dealkylation of 7‐ethoxycoumarin by rabbit liver microsomes was inhibited in the presence of thiopentone or methohexitone (0.3‐1 mM), while phenobarbitone was without effect. 5 These findings suggest that thiopentone and methohexitone selectively attenuate the EDHF‐mediated relaxant response to ACh in the rabbit carotid artery, presumably by interfering with its synthesis from arachidonic acid via the cytochrome P450 epoxygenase pathway.

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 (

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

506) and TLT (

Bedside Percutaneous Tracheostomy: Clinical Comparison of Griggs and Fantoni Techniques

362) were both much cheaper than open tracheostomy (

Prolongation of the QT–interval during induction of anesthesia in patients with coronary artery disease

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.

PercuTwist: A New Single-Dilator Technique for Percutaneous Tracheostomy

UNLABELLED A number of percutaneous procedures for tracheostomy have been established within the last few years, among them a new technique by Fantoni using a translaryngeal approach for cannula placement. To compare the new translaryngeal tracheostomy (TLT) to the common percutaneous dilatational technique (PDT), we prospectively studied 90 patients who required elective tracheostomy. Tracheostomy was performed according to either the Ciaglia or the Fantoni technique in 45 patients at bedside. The overall complication rate was 11.1% (n = 5) in PDT, including aspiration of blood (n = 4) and severe bleeding requiring surgical intervention (n = 1). During TLT, there were technical difficulties involving guidewire placement in 31.1% (n = 14), and one patient required conversion to PDT. No other complications were noted in TLT. Regardless of the technique used, the postoperative PaO2/FIO2 ratio was slightly lower than preoperatively (P was not significant). When PDT and TLT were compared, the postoperative PaO2/FIO2 ratio was significantly lower in PDT than in TLT (P < 0.05), whereas the preoperative levels did not vary significantly between PDT and TLT. During TLT, the PaCO2 increased significantly, whereas it remained stable throughout PDT. No infection of the tracheostoma was noted in either the PDT or the TLT. We therefore consider both the PDT and the TLT equally safe and attractive techniques for establishing long-term airway access in critically ill patients. IMPLICATIONS Elective tracheostomy is a widely accepted procedure for gaining long-term airway access. Two techniques for percutaneous tracheostomy-the established Ciaglia method and the new translaryngeal Fantoni technique-were prospectively studied for perioperative complications and practicability in 90 critically ill-patients.

Inhalation anesthetics inhibit the release of endothelium-derived hyperpolarizing factor in the rabbit carotid artery

Abstract. Elective tracheostomy is widely considered the preferred airway management of patients on long-term ventilation. In addition to open tracheostomy, a number of percutaneous procedures have been introduced during the last two decades, among them techniques according to Griggs (guidewire dilating forceps, or GWDF) and to Fantoni (translaryngeal tracheostomy, or TLT). The aim of the study was to evaluate these two techniques in terms of perioperative complications, risks, and benefits in critically ill patients. A series of 100 critically ill adult patients on long-term ventilation underwent elective percutaneous tracheostomy, either according to the Griggs (n= 50) or Fantoni (n= 50) technique. Tracheostomy was performed under general anesthesia at the patients bedside. The mean (±SD) operating times were short, 9.2 ± 3.9 minutes (TLT) and 4.8 ± 3.7 minutes (GWDF) on average. Perioperative complications were noted in 4% of patients during either TLT or GWDF and included massive bleeding, mediastinal emphysema, posterior tracheal wall injury, and pretracheal placement of the tracheostomy tube. With regard to oxygenation, pre- and postoperative arterial oxygen tension divided by the fraction of inspired oxygen (PaO2/FiO2) ratios did not vary significantly, and no perioperative hypoxia was noted regardless of the technique used. We conclude that both TLT and GWDF represent attractive, safe alternatives to conventional tracheostomy or other percutaneous procedures if carefully performed by experienced physicians and under bronchoscopic control.