Ipct tracheo roma 2001

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Grigg’s Percutaneous tracheostomic technique :why?

How?C.Melloni

Servizio di Anestesia e Rianimazione

Ospedale di Faenza(RA)


Indications for PCt’s� Upper airway obstruction

» trauma» burns & corrosive chemicals» laryngeal dysfunction» foreign bodies» infections» inflammatory conditions» neoplasms» postoperative» obstructive sleep apnea

� access for pulmonary toilet � prolonged ventilatory support� airway protection� head injured or comatos epatient� postoperative neurosurgical procedure


Contraindications for PCT

� Coagulopathy� copious secretions….� Unstable ARDS� elevated ICP� deep trachea/difficult neck….


Advantages of PC vs surgical tracheostomy

� Smaller skin incision� less dissection and tissue trauma� less hemorrhage� fewer infection� fewer tracheal problems� fewer cosmetic deformities� procedure performed at the bedside

» decreasing the risk and cost of patient transportation to OR.» Faster procedure

» easier to perform

» requires less personnnel» requires less equipment» lower cost…..» Fewer operative KO

» fewer long term KO


Cervical spine & PCT

� Mayberry et al. Cervical spine clearance and neck estension during percutaneous tracheostomy in trama patients. CCM.2000;28:3436-3440

� “cleared(60) and non cleared(28)”� stabilized(collar.halo.operative fixation)� simult.FBS


Lesioni della trachea

� Ciaglia� Kaiser et al.Ann

Fr.Anesth.Reanin.1997;16:925-6

� Rx immediato ok� 3 ore dopo pnx bilat

� Griggs� Bourlon et al.Ann

Fr.nesth.Reanim. 1998;17:1156-9

� Rx immediato;cannula disassata a sn

� 10 ore dopo pneumomediast ed emfis cut.


Complications of tracheostomy

� Early:periprocedural…» paratracheal insertion,false

passage,tube misplacement

» pneumothorax

» subcutaneus emphysema

» aspiration

» bleeding» loss of airway» transient

hypoxia/hypercapnia» death

� late complications» tracheal

erosion:tracheoesophageal or trcaheoinnominatae fistula

» laringeal or subglottic stenosis

» voice changes

» deglutition problems


Genesi delle lesioni tracheali

� Pneumomediastino� La forma ovoidale dell’orifizio

tracheale non si adatta a quella della cannula;aria attorno alla cannula……

� Lesione della parete tracheale:

� Da parte di:� ago� guida metallica� della pinza

dilatatrice(Schachner…)� leader della cannula� scambiatore del tubo� sondini di aspirazione


Malposizionamento della tracheostomia

� Dexter A cadaver study appraising accurarcy of blind placement of percutaneous tracheostomy.Anaesthesia 1995;;50:863-4….solo 4 posizionamenti corretti!!!

� Sun KO.Barotrauna during percutaneous dilational tracheostomy.Anaesthesia 1996;51:1076-7

� Crofts et al.A comparison of percutaneous and operative tracheostomies in intensive care patients.Can.J.Anaesth. 1995;42:775-9.

� Caldicott et al.An evaluation of a new percutaneous tracheostomy kit.Anaesthesia 1995;50:49-51.

� Incidenza globale 6%� Citata una frequenza del 18% dopo Ciaglia(Winkler,71

paz,ICM 1994;20:476-9)� Evitabile con visione diretta FBS!!!


Emorragia

� rottura della vena tiroidea inferiore:� Buguet-Brown et al.Hemorrhagie aigue

cataclysmique par lesion de la veine thyroidienne inferiure au cours d’une tracheostomie percutane.Ann.Fr Anesth.Reanim.2001;20:304-305. griggs,paz,cirrotico con bil.coag alterato….


� Ciaglia P.Percutaneous tracheostomy is really better –if done correctly.Chest 1999;116:1138-9.

� No comments??


Per evitare la puntura del tubo endotracheale….

� Ritrarlo prima di iniziare la procedura,in visione laringoscopica diretta,con cuffia subito sotto/tra le corde vocali:

� Muoverlo in alto e in basso dopo puntura della trachea con ago per vedere che l’ago non abbia penetrato il tubo e quindi non sia solidale con esso….

� Visione diretta FBS:ago oltre il lume del tubo…


Dulguerov et al.Percutaneous or surgical tracheostomy:a meta analysis.Crit.Care

Med 1999;27:1617-25.

� All publications(Medline)� english language� human studies� addressing complications� 65 papers� heterogeneity………..


Perioperatuve mortality of pct vs surgical techniques

0%10%20%30%40%50%60%70%80%90%

100%

periop postop tot

pctsurg 85-96surg 60-85


Serious perioperative complications of

tracheostomies.

0

20

40

60

80

100

120

per 10.000d

eath

card

iop

ulm

arre

st pn

x

pn

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edia

st

surg 60-85surg 85-96pct


Intermediate perioperative complications of tracheostomies

0

10

20

30

40

50

60

70

80

90


Desat/hypotens

Post trach.wall lesion

Cannula displac

aspiration. Switch tosurg.techn.


Minor perioperative complications of tracheostomies

050

100150200250300350

per 10.000h

aem

orrh

age

dif

ficu

lt tu

be

pla

cem

ent

fals

e p

assa

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Serious postoperative complications

0

50

100

150

200

250

300

per 10.000

dea

th

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esop

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Postoperative intermediate complications of tracheostomies

0

100

200

300

400

500

600

700

per 10.000

pneumonia atelectasis aspiration trachealcartil.lesion

surg 60-84surg 85-96Pct


Postoperative minor complications of tracheostomies

0

500

1000

1500

2000

2500

3000

3500

per 10.000

ext

hem

orrh

wou

nd

infe

ctio

n

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surg 60-84surg 85-96Pct


Comparison of surgical vs pct techniques:I

� Overall Ko rate lower with Pct’s,but � periop KO higher with Pct’s(

» tracheostomy tube placement(false passage,operative difficulty)

» subcut emphysema» post trach wall lesions» TEF» mortality» cardioresp arrest


Comparison of surgical vs pct techniques:II

� Postop KO lower with Pct’s:» less hemorrhage» less wound infection


Freeman BD, Isabella K, Cobb JP, Boyle WA 3rd, Schmieg RE Jr, Kolleff MH, Lin N, Saak T, Thompson

EC, Buchman TG. A prospective, randomized study comparing percutaneous with surgical tracheostomy

in critically ill patients.Crit Care Med 2001 May;29(5):926-30

� OBJECTIVE: To determine the relative cost-effectiveness of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) in critically ill patients. DESIGN: Prospective randomized study.

� SETTING: Medical, surgical, and coronary intensive care units at Barnes-Jewish Hospital, a tertiary care medical center.

� PATIENTS: Eighty critically ill mechanically ventilated patients requiring elective tracheostomy.

� INTERVENTIONS: Randomization to either PDT performed in the intensive care unit or ST performed in the operating room.


Freeman et al. A prospective, randomized study comparing

percutaneous with surgical tracheostomy in critically ill patients.

Crit Care Med 2001 May;29(5):926-30

� MEASUREMENTS AND MAIN RESULTS: Treatment groups were well matched with respect to age (PDT, 65.44 +/- 2.82 [mean +/- se] years; ST, 61.4 +/- 2.89 years, p = Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute Physiology and Chronic Health Evaluation II score: PDT, 16.87 +/- 0.84; ST, 17.88 +/- 0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1 +/- 2.0 mins; ST, 41.7 +/- 3.9 mins, p < .0001) and was associated with lower patient charges than ST (total patient charges: PDT, 1,569 dollars +/- 157 dollars vs. ST, 3,172 dollars +/- 114 dollars; equipment/supply charges: PDT, 688 dollars +/- 103 dollars vs. ST, 1,526 dollars +/- 87 dollars; professional charges: PDT, 880 dollars +/- 54 dollars vs. ST, 1,647 dollars +/- 50 dollars; p < .0001 for all). There were no differences in days intubated before tracheostomy (PDT, 12.7 +/- 1.1 days; ST, 15.6 +/- 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 +/- 2.5 days; ST, 28.5 +/- 3.1 days, p = .33), or hospital length of stay (PDT 49.7 +/- 4.2 days; ST, 43.7 +/- 3.5 days, p = .28) when we compared these two techniques. CONCLUSIONS: PDT is a cost-effective alternative to ST. The reduction in patient charges associated with PDT in this study resulted from the procedure being performed in the intensive care unit, thus eliminating the need for operating room facilities and personnel. PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation.


Freeman et al. A prospective, randomized study comparing percutaneous with surgical tracheostomy

in critically ill patients.Crit Care Med 2001 May;29(5):926-30

0

10

20

30

40

50

60

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Ravat F, Pommier C, Dorne R Percutaneous tracheostomy Ann Fr Anesth Reanim 2001

Mar;20(3):260-81

� ..the learning curve for percutaneous dilational tracheostomy

� significant decrease of complication incidence with the operator's experience

� continuous endoscopic guidance seems to increase the safety of the percutaneous procedure.

� There is a trend to replace the surgical procedure by the percutaneous one. However, according to the potentially jeopardizing complications, percutaneous tracheostomy should be done by an experienced operator with the help of a continuous endoscopic guidance


Massick DD, Yao S, Powell DM, Griesen D, Hobgood T, Allen JN, Schuller DE. Bedside tracheostomy in the intensive

care unit: a prospective randomized trial comparing open surgical tracheostomy

with endoscopically guided percutaneous dilational tracheotomy.Laryngoscope 2001 Mar;111(3):494-500

» 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


Massick et al.. Bedside tracheostomy in the intensive care unit: a prospective

randomized trial comparing open surgical tracheostomy with

endoscopically guided percutaneous dilational tracheotomy.

Laryngoscope 2001 Mar;111(3):494-500

� “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%... 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.


Byhahn C, Wilke HJ, Lischke V, Rinne T, Westphal Bedside percutaneous tracheostomy:

clinical comparison of Griggs and Fantoni techniques World J Surg 2001 Mar;25(3):296-301

» 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 patient's 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


GWDF (Griggs) vs Fantoni(TLT)� operating times:� 4.8 +/- 3.7 vs 9.2 +/- 3.9� Perioperative complications � 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.


Van Heurn LW, Mastboom WB, Scheeren CI, Brink PR, Ramsay G. Comparative clinical trial of

progressive dilatational and forceps dilatational tracheostomy.

Intensive Care Med 2001 Jan;27(1):292-5

0

5

10

15

20

25

30

35

duration of proc. Ko

PDTFDT

progressive dilatational tracheostomy (PDT)vs forceps dilatational tracheostomy (FDT).

Difficult or false insertion of the cannula

in 8 patients after FDT the most common complication. (min) %


Bowen CP, Whitney LR, Truwit JD, Durbin CG,

Moore MM. Comparison of safety and cost of

percutaneous versus surgical tracheostomy.

Am Surg 2001 Jan;67(1):54-60

» Tracheostomy continues to be a standard procedure for the management of long-term ventilator-dependent patients. Traditionally the procedure has been performed by surgeons in the operating theater using an open technique. This routine practice has recently been challenged by the introduction of bedside percutaneous dilatational tracheostomy (PDT), which has been reported to be a cost-effective alternative. The purpose of this study is to evaluate and compare the safety, procedure time, cost, and utilization of percutaneous and surgical tracheostomies at a university hospital. A retrospective medical chart review was performed on all ventilator-dependent intensive care unit patients at the University of Virginia Medical Center undergoing tracheostomy during a 23-month period beginning December 26, 1996. Of the 213 patients identified for review, 74 and 139 patients received percutaneous and surgical tracheostomies, respectively. Of 74 percutaneous tracheostomies, 73 reviewed were performed by general surgeons, pulmonary physicians, or anesthesiologists in the intensive care unit; all open tracheostomies were performed by surgeons in the operating room, and one percutaneous procedure was performed in the operating room. Perioperative complications occurred in five of 74 patients (6.76%) during PDT; of these, three patients (4.1%) experienced major complications requiring emergent operative exploration of the neck. Three patients (2.2%) experienced perioperative complications during surgical tracheostomy. The mean procedure time was significantly shorter for the percutaneous procedure. Average charges per patient in an uncomplicated case including professional fees, inventory, bronchoscopy (if performed), and operating room charges were $1753.01 and $2604.00 for percutaneous and standard tracheostomies, respectively. These charges do not include the charges associated with surgical intervention after PDT complications. In contrast to previously published reports showing complications clustered during a physician's first 30 percutaneous cases, our study demonstrated no relationship between complication occurrence and physician experience. That is, no learning curve associated with performing PDT was evident. In addition there was no association seen between physician specialty and complication rate. PDT in the intensive care unit costs less than surgical tracheostomy performed in the operating room and can be performed in less time. Several other studies have recommended that bronchoscopy during PDT provides additional safety; however, in our series all three major complications took place during bronchoscopy-assisted percutaneous procedures. Our series suggests that PDT carries an appreciable risk of major complications. Careful patient selection and additional experience with the procedure may decrease complication rates to an acceptable level.


Comparison of safety and cost of percutaneous versus

surgical tracheostomy.

Bowen CP, Whitney LR, Truwit JD, Durbin CG,

Moore MM.Am Surg 2001 Jan;67(1):54-60

0

1

2

3

4

5

6

7

KO major Ko

PDTSURG

requiring emergent operative exploration of the neck


Stocchetti N, Parma A.Neurophysiological

consequences of three tracheostomy techniques: a

randomized study in neurosurgical patients J

Neurosurg Anesthesiol 2000 Oct;12(4):307-13

� effects of different tracheostomy techniques on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and cerebral extraction of

oxygen. We attempted to identify the main mechanisms affecting intracranial pressure during tracheostomy. To do so we conducted a

prospective, block-randomized, clinical study which took place in a neurosurgical intensive care unit in a teaching hospital. The patients

studied consisted of thirty comatose patients admitted to the intensive care unit because of head injury, subarachnoid hemorrhage, or brain

tumor. Ten patients per group were submitted to standard surgical tracheostomy, percutaneous dilatational tracheostomy or translaryngeal tracheostomy. In every technique a significant increase of ICP (P < .05)

was observed at the time of cannula placement. Intracranial hypertension (ICP > 20 mm Hg) was more frequent in the percutaneous

dilatational tracheostomy group (P < .05). Cerebral perfusion pressure dropped below 60 mm Hg in eleven cases, more frequently during

surgical tracheostomy. Arterial tension of CO2 significantly increased in all three groups during cannula placement. No other major

complications were recorded during the procedures. At follow-up no severe anatomic or functional damage was detected. We conclude that

the three tracheostomy techniques, performed in selected patients where the risk of intracranial hypertension was reduced to the minimum,

were reasonably tolerated but caused an intracranial pressure rise and cerebral perfusion pressure reduction in some cases.


Prevalence of tracheostomy in ICU patients. A nation-wide

survey in Switzerland.Fischler L, Erhart S, Kleger

GR, Frutiger A.Intensive Care Med 2000

Oct;26(10):1428-33♥ Open questionnaire,48 ICUs (70 %),1995 & 1996:90,412 patients

for a total of 243,921 ICU days.

♥ prevalence of tracheostomy: 10% in the long-term ventilated patients (defined as > 24 h), or 1.3 % of all patients.

♥ Most tracheostomies were performed during the 2nd week of ventilation.

♥ frequency of tracheostomy varied widely (0-60 %) slightly associated with the different language regions of our country and with the policy of hospitals to accept or refuse intubated patients on their normal wards.

♥ Most units offered either conventional surgical tracheostomy (69 %) and/or percutaneous procedures (57 %).

♥ The decision to perform a tracheostomy was made mostly by the intensivist and the procedure was more often performed in the ICU (65 %) than in the operating theatre (35 %).

♥ Units where the intensivist had exclusive control used only percutaneous techniques.

♥ An overall complication rate of 13 % was reported, bleeding and infections being at the top of the scale.

♥ Only 27 % of the units performed late follow-up protocols.


Percutaneous tracheostomy in critically ill patients: a

prospective, randomized comparison of two

techniques.

Nates NL, Cooper DJ, Myles PS, Scheinkestel CD, Tuxen

DVCrit Care Med 2000 Nov;28(11):3734-9

� : One hundred critically ill patients with an indication for PDT. INTERVENTIONS: PDT with the Ciaglia technique using the Ciaglia PDT introducer set and the Griggs technique using a Griggs PDT kit and guidewire dilating forceps. MEASUREMENTS AND MAIN RESULTS: Surgical time, difficulties, and surgical and anesthesia complications were measured at 0-2 hrs, 24 hrs, and 7 days postprocedure. Groups were well matched, and there were no differences between the two methods in surgical time or in anesthesia complications. Major bleeding complications were 4.4 times more frequent with the Griggs PDT kit. With the Ciaglia PDT kit, both intraoperative and at 2 and 24 hrs, surgical complications were less common (p = .023) and the procedure was more often completed without expert assistance (p = .013). Tracheostomy bleeding was not associated with either anticoagulant therapy or an abnormal clotting profile. Multivariate analysis identified the predictors of PDT complications as the Griggs PDT kit (p = .027) and the Acute Physiology and Chronic Health Evaluation (APACHE) II score (p = .041). The significant predictors of time required to complete PDT were the APACHE II score (p = .041), a less experienced operator (p = .0001), and a female patient (p = .013). CONCLUSIONS: Patients experiencing PDT with the Ciaglia PDT kit had a lower surgical complication rate (2% vs. 25%), less operative and postoperative bleeding, and less overall technical difficulties than did patients undergoing PDT with the Griggs PDT kit. Ciaglia PDT is, therefore, the preferred technique for percutaneous tracheostomy in critically ill patients


Crit Care 2000;4(3):143-6 Percutaneous tracheostomy: comparison of Ciaglia and

Griggs techniques. Kost KM.


Preparazione paziente:consenso,monitoraggio,O2,anest

esia…...


Anestesia

� (Midazolam 2-3 mg)� Fentanile 100-150 microgr� Propofol 1 mg/kg,poi 6 mg/kg/hr� atracurium 0.3-0.4 mg/kg� FiO2 0.80

� IPPV volumetric….� Slight hyperventilation…..






Preparazione campo chirurgico:strumenti & accessori...


Verifica del materiale,lubrificazione...



Anatomia topografica


Individuare punto di incisione:locale


Posizione del paziente...





Trucchi del mestiere di endoscopista….





Penetrazione della trachea,direzione caudale,perdita di resistenza….



Conferma aspirazione aria..




Rimuovere ago e siringa,lasciare in situ ago cannula e inserire il filo guida...


Rimuovere camicia del filo guida ,lasciare 25-30 cm esterni...




Il filo guida deve entrare liberamente……..






Pro e contro dell’allargamento della incisione...



Passare il dilatatore lungo il filo guida;avvitamento……..











Inserire la pinza di Griggs chiusa seguendo il filo guida con i rebbi

scanalati...



Far procedere la pinza fino alla parete anteriore...


Aprire la pinza con entrambe le mani...








Dilatazione dei tessuti tracheali



Introdurre nuovamente la pinza chiusa lungo il filo guida …..


Penetrare nuovamente in trachea,aprire la pinza a due mani ,dilatare le pareti

tracheali e retrarla aperta...


Inserire il mandrino lungo il filo guida ...



Avanzare la cannula in trachea..



Rimuovere otturatore e filo guida….


Cuffiare ,aspirare la trachea...





Collegare al mount,riprendere ventilazione,controllare….


Punti per eccesso stomico...



� Sedation with propofol 3 mg/kg/hr maintained at least until the return of a sufficient Spont.resp.

Health & Medicine

Ipct tracheo roma 2001