Percutaneous dilatational tracheostomy (PDT) is one of the most frequent procedures performed in the intensive care unit (ICU). PDT may add potential benefit to clinical management of critically ill patients. Despite this, no clinical guidelines are available. We sought to characterize current practice in this international survey. An international survey, endorsed and peer reviewed by European Society of Intensive Care Medicine (ESICM), was carried out from May to October 2013. The questionnaire was accessible from the ESICM website in the ‘survey of the month’ section. 429 physicians from 59 countries responded to this survey. Single step dilatational tracheostomy was the most used PDT in ICU. Almost 75 % of PDT’s were performed by intensive care physicians. The main indication for PDT was prolonged mechanical ventilation. Tracheostomies were most frequently performed between 7–15 days after ICU admission. Volume control mechanical ventilation, and a combination of sedation, analgesia, neuromuscular blocking agents and fiberoptic bronchoscopy were used. Surgical tracheostomy was mainly performed in ICU by ENT specialists, and was generally chosen when for patients at increased risk for difficult PDT insertion. Bleeding controlled by compression and stoma infection/inflammation were the most common intra-procedural and late complications, respectively. Informed consent for PDT was obtained in only 60 % of cases. This first international picture of current practices in regard to tracheostomy insertion demonstrates considerable geographic variation in practice, suggesting a need for greater standardization of approaches to tracheostomy insertion.

/pdf/tracheostomy-procedures-in-the-intensive-care-unit-an-2nrkg4k26s.pdf

Tracheostomy procedures in the intensive care unit: an international survey

To evaluate the safety of percutaneous dilatational tracheostomy (PDT) in critically ill patients on an extracorporeal lung assist device requiring therapeutic anticoagulation. This was a retrospective, observational study on all patients undergoing tracheostomy while on pumpless extracorporeal lung assist or extracorporeal membrane oxygenation in intensive care units of two university hospitals in Germany between 2007 and 2013. During the study period PDT was performed on 118 patients. The median platelet count, international normalized ratio, and activated partial thromboplastin time before tracheostomy were 126 × 109/L (range 16–617 × 109/L), 1.1 (0.9–2.0) and 49 s (28–117 s), respectively. Seventeen patients (14.4 %) received a maximum of three bags of pooled platelets, and eight patients (6.8 %) received a maximum of four units of fresh frozen plasma before the procedure. In all patients the administration of intravenous heparin was briefly paused periprocedurally. No periprocedural clotting complication within the extracorporeal circuit was observed. Two patients (1.7 %) suffered from procedure-related major bleeding, with one patient requiring conversion to a surgical tracheostomy. Two pneumothoraces (1.7 %) were related to the PDT. One patient (0.8 %) had analgosedation-related hypotension with brief and successful cardiopulmonary resuscitation. Minor bleeding from the tracheostomy site occurred in 37 cases (31.4 %). No fatality was attributable to tracheostomy. The complication rates of PDT in the patients on extracorporeal lung support were low and comparable to those of other critically ill patients. Based on these results, we conclude that PDT performed by experienced operators with careful optimization of the coagulation state is a relatively safe procedure and not contraindicated for this patient group.

/pdf/safety-of-percutaneous-dilatational-tracheostomy-in-patients-5cshxdyiqz.pdf

Safety of percutaneous dilatational tracheostomy in patients on extracorporeal lung support.

Physiological and clinical outcomes associated with use of one-way speaking valves on tracheostomised patients: A systematic review.

Percutaneous dilatational tracheostomy with a double-lumen endotracheal tube: a comparison of feasibility, gas exchange, and airway pressures.

Introduction: Percutaneous tracheostomy (PCT) is being increasingly done by intensivists for critical care unit patients requiring either prolonged ventilation and/or for airway protection [1] Bronchoscopic guidance considered a gold standard, [2],[3] is not always possible due to logistic reasons and ventilation issues We share our experience of Griggs PCT technique without bronchoscopic guidance with simple modifications to ensure safe execution of the procedure Objective: The purpose of this study was to evaluate the safety issues and complications of PCT without bronchoscopic guidance in a multi-disciplinary tertiary Intensive Care Unit (ICU) Materials and Methods: A retrospective review of consecutive PCTs performed in our ICU between August 2010 and December 2013 by Griggs guide wire dilating forceps technique without bronchoscopic guidance is being presented It is done by withdrawing endotracheal tube with inflated cuff while monitoring expired tidal volume on ventilator and ensuring the free mobility of guide wire during each step of the procedure, thereby ensuring a safe placement of the tracheostomy tube (TT) in trachea Results: Analysis of 300 PCTs showed 26 patients (86%) had complications including 2 (06%) patients deteriorated neurologically and 2 (06%) deaths observed within 24 h following procedure The median operating time was 35 min (range, 25-8 min) There were no TT placement problems in any case Conclusion: Percutaneous tracheostomy can be safely performed without bronchoscopic guidance by adhering to simple steps as described

Griggs percutaneous tracheostomy without bronchoscopic guidance is a safe method: A case series of 300 patients in a tertiary care Intensive Care Unit.

Background The aim of the present study was to evaluate the frequency of different techniques, indications, timing, as well as procedural features, sedation and ventilation protocols, early and late complications of tracheostomy in Intensive Care Unit (ICU). Methods This was a retrospective survey on data collected in 2011. A questionnaire was mailed to all members of the Italian Society of Anesthesia, Analgesia and Intensive Care (SIAARTI). Results We included in the analysis 131 questionnaires. We found that: 1) Ciaglia Blue-Rhino® (CBR) was the most commonly used tracheostomy (32.8%; N.=1953) and the main indication was prolonged mechanical ventilation (58.8%; N.=77); 2) tracheostomy was performed between 7-15 days (71.8%; N.=94) from ICU admission by a dedicated team (62.6%; N.=82) involving more than one intensive care physician and a nurse; 3) tracheostomy was frequently guided by fiberoptic bronchoscope (93.1%, N.=122) while neck ultrasounds were used as a screening procedure to assess at-risk structure often in presence of pathological anatomical structures (68.7%; N.=90); 4) ventilation protocol and sedation-analgesia-neuromuscular blocking protocol were available in 83.2% and 58.8% of ICUs, respectively; 5) minor bleeding controlled by compression was the most common early and late complication. Conclusion Percutaneous tracheostomy is well established in Italian ICUs and CBR is the most popular technique performed in patients requiring prolonged mechanical ventilation. Tracheostomy is usually performed by a dedicated team using a specific sedation-analgesia-neuromuscular blocking and ventilation protocol, guided by fiberoptic bronchoscope and/or neck ultrasounds. Bleeding controlled by compression was the most common early and late complication.

Tracheostomy in Intensive Care Unit: a national survey in Italy.

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Tracheostomy in Intensive Care Unit: a national survey in Italy.