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Percutaneous dilatational tracheostomy in patients with mechanical circulatory support: Is the procedure safe?

ABSTRACT: Background:We aimed to investigate the efficacy and safety of percutaneous dilatational tracheostomy procedure following cardiac surgery in patients receiving extracorporeal membrane oxygenation and/or left ventricular assist device. Methods:A total of 42 patients (10 males, 32 females; mean age 51±14.6 years; range, 18 to 77 years) who underwent percutaneous dilatational tracheostomy procedure under extracorporeal membrane oxygenation and/or left ventricular assist device support between January 2017 and January 2019 were retrospectively analyzed. Laboratory data, Simplified Acute Physiology Score-II and Sequential Organ Failure Assessment scores, and major and minor complications were recorded. The 30-day and one-year follow-up outcomes of the patients were reviewed. Results:Of 42 patients, 17 (42.5%), 14 (33.3%), and 11 (26.2%) received left ventricular assist device, extracorporeal membrane oxygenation, and extracorporeal membrane oxygenation + left ventricular assist device, respectively. During percutaneous dilatational tracheostomy, the laboratory values of the patients were as follows: international normalized ratio, 2.3±0.9; partial thromboplastin time, 59.4±19.5 sec; platelet count, 139.2±65.8×109/L, hemoglobin, 8.8±1.0 g/dL, and creatinine, 1.6±1.0 mg/dL. No peri-procedural mortality, major complication, or bleeding was observed. We observed minor complications including localized stomal ooze in four patients (8.3%) and local stomal infection in three patients (6.2%). Conclusion:Our study results suggest that percutaneous dilatational tracheostomy is an effective and safe technique in this patient population.

SUBMITTER: Bektas S

PROVIDER: S-EPMC7493610 | biostudies-literature | 2020 Jul

REPOSITORIES: biostudies-literature

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Percutaneous dilatational tracheostomy in patients with mechanical circulatory support: Is the procedure safe?

Bektaş Şerife Ş Çavuş Mine M Turan Sema S

Turk gogus kalp damar cerrahisi dergisi 20200728 3

<h4>Background</h4>We aimed to investigate the efficacy and safety of percutaneous dilatational tracheostomy procedure following cardiac surgery in patients receiving extracorporeal membrane oxygenation and/or left ventricular assist device.<h4>Methods</h4>A total of 42 patients (10 males, 32 females; mean age 51±14.6 years; range, 18 to 77 years) who underwent percutaneous dilatational tracheostomy procedure under extracorporeal membrane oxygenation and/or left ventricular assist device support ...[more]

PMID: 32953205

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Project description:INTRODUCTION: Tracheostomy is one of the more commonly performed procedures in critically ill patients yet the optimal method of performing tracheostomies in this population remains to be established. The aim of this study was to systematically review and quantitatively synthesize all randomized clinical trials (RCTs), comparing elective percutaneous dilatational tracheostomy (PDT) and surgical tracheostomy (ST) in adult critically ill patients with regards to major short and long term outcomes. METHODS: MEDLINE, EMBASE, CINAHL and the Cochrane Controlled Clinical Trials Register databases were searched to identify relevant studies. Additionally, bibliographies and selected conference proceedings were reviewed, and experts in the field and manufacturers of two PDT kits were contacted. Randomized clinical trials comparing any method of elective PDT to ST that included critically ill adults and reported at least one clinically relevant outcome were included. Data extracted included trial characteristics, measures of study validity, and clinically relevant outcomes. RESULTS: Seventeen RCTs involving 1,212 patients were included. Most PDTs used a multiple dilator technique and were performed in the intensive care unit (ICU). The pooled odds ratio (OR) for wound infection was 0.28 (95% confidence interval (CI), 0.16 to 0.49, p < 0.0005), indicating a significant reduction with PDT compared to ST. Overall, PDT was equivalent to ST for bleeding, major peri-procedural and long-term complications; however, subgroup analysis suggested PDT resulted in a lower incidence of bleeding (OR = 0.29 (95% CI 0.12 to 0.75, p = 0.01)) and death (OR = 0.71 (95% CI 0.50 to 1.0, p = 0.05)) when the STs were performed in the operating theatre. CONCLUSION: PDT reduces the overall incidence of wound infection and may further reduce clinical relevant bleeding and mortality when compared with ST performed in the operating theatre. PDT, performed in the ICU, should be considered the procedure of choice for performing elective tracheostomies in critically ill adult patients.

Project description:OBJECTIVES:To review temporary percutaneous mechanical circulatory support devices for the treatment of cardiogenic shock, including current evidence, contraindications, complications, and future directions. DATA SOURCES:A MEDLINE search was conducted with MeSH terms: cardiogenic shock, percutaneous mechanical circulatory support, extracorporeal membrane oxygenation, Impella, and TandemHeart. STUDY SELECTION:Selected publications included randomized controlled trial data and observational studies describing experience with percutaneous mechanical circulatory support in cardiogenic shock. DATA EXTRACTION:Studies were chosen based on strength of association with and relevance to cardiogenic shock. DATA SYNTHESIS:Until recently, there were few options if cardiogenic shock was refractory to vasopressors or intra-aortic balloon pump counterpulsation. Now, several percutaneous mechanical circulatory support devices, including Impella (Abiomed, Danvers, MA), TandemHeart (CardiacAssist, Pittsburgh, PA), and extracorporeal membrane oxygenation, are more accessible. Compared with intra-aortic balloon pump, Impella provides greater hemodynamic support but no reduction in mortality. Similarly, TandemHeart improves hemodynamic variables but not survival. Comparative studies have been underpowered for mortality because of small sample size. Veno-arterial extracorporeal membrane oxygenation offers the advantage of biventricular circulatory support and oxygenation, but there are significant vascular complications. Comparative studies with extracorporeal membrane oxygenation have not been completed. Despite lack of randomized controlled data, there has been a substantial increase in use of percutaneous mechanical circulatory support. Several ongoing prospective studies with larger sample sizes may provide answers, and newer devices may become smaller, easier to insert, and more effective. CONCLUSIONS:Mortality from cardiogenic shock remains unacceptably high despite early coronary revascularization or other therapies. Although evidence is lacking and complications rates are high, improvements and experience with percutaneous mechanical circulatory support may offer the prospect of better outcomes.

Project description:BackgroundBoth single-use and reusable bronchoscopes are suitable for percutaneous dilatational tracheostomy (PDT) to visualise the trachea during the insertion process. To determine the least costly option, the price of single-use bronchoscopes must be weighed against the estimated average cost of a bronchoscopy with reusable equipment. In the latter case, the acquisition cost must be spread over the equipment's useful life and other relevant costs, such as reprocessing and repair, must be included.ObjectiveThis study aimed to calculate the cost of using single-use or reusable bronchoscopes per PDT procedure.MethodsA systematic literature search was conducted to identify studies comparing the costs of reusable and single-use bronchoscopes for PDT. Inclusion criteria were articles assessing the cost of single-use or reusable bronchoscopes, and where costs were divided into acquisition, reprocessing, and repair costs. A questionnaire regarding repair rates and costs for reusable bronchoscopes was sent to 366 hospitals in the US, UK, and Germany to supplement the identified literature.ResultsEleven studies met the inclusion criteria. Ninety-nine completed responses were received, of which 31 hospitals used reusable equipment for PDT. Literature research revealed an average acquisition cost of $US135 (SD 152) and reprocessing cost of $US123 (SD 128). Additionally, a combination of data from the literature and the questionnaires gave a repair cost per use of $US148 (SD 242), resulting in a total average cost of $US406 for reusable bronchoscopes and $US249 (SD 36) for single-use bronchoscopes per PDT procedure. Thus, the incremental cost per use of a reusable bronchoscope compared with a single-use bronchoscope was $US157.ConclusionsWe conclude that significant savings can be made by using single-use bronchoscopes to guide PDT in preference to reusable bronchoscopes. Results depend on hospital setting, the reprocessing procedures, annual bronchoscope procedures, individual repair cost, and repair rates.

Project description:BACKGROUND:We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients. METHODS:This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications. RESULTS:A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P?=?0.002). The total duration of SAE (19.8?±?23.0?min vs. 3.4?±?5.3?min, P?<?0.001) and procedural time (42.2?±?21.8?min vs. 17.7?±?9.2?min, P?<?0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187-0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64?min (?: -8.64, 95% CI: -?15.070 - -2.205, P?=?0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38?min (?: 6.38, 95% CI: 0.166-0.470, P?<?0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P?=?0.047). CONCLUSIONS:This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.

Project description:BackgroundPercutaneous mechanical circulatory support devices (pMCSDs) are increasingly used on the assumption (but without solid proof) that their use will improve prognosis. A meta-analysis was undertaken according to the PRISMA guidelines to evaluate the benefits of pMCSDs in patients undergoing high-risk percutaneous coronary intervention (hr-PCI).MethodsWe searched PubMed, EMbase, Cochrane Library, Clinical Trial.gov, and other databases to identify eligible studies. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for 30-day and 6-month all-cause mortality rates, reinfarction, and other adverse events using a random effect model.ResultsSixteen randomized controlled trials (RCTs) were included in this study. In the pooled analysis, intra-aortic balloon pump (IABP) was not associated with a decrease in 30-day and 6-month all-cause mortality (RR 1.01 95% CI 0.61-1.66; RR 0.88 95% CI 0.66-1.17), reinfarction (RR 0.89 95% CI 0.69-1.14), stroke/transient ischemic attack (TIA) (RR 1.75 95% CI 0.47-6.42), heart failure (HF) (RR 0.54 95% CI 0.11-2.66), repeat revascularization (RR 0.73 95% CI 0.25-2.10), embolization (RR 3.00 95% CI 0.13-71.61), or arrhythmia (RR 2.81 95% CI 0.30-26.11). Compared with IABP, left ventricular assist devices (LVADs) were not associated with a decrease in 30-day and 6-month all-cause mortality (RR 0.96 95% CI 0.71-1.29; RR 1.23 95% CI 0.88-1.72), reinfarction (RR 0.98 95% CI 0.68-1.42), stroke/TIA (RR 0.45 95% CI 0.1-1.95), acute kidney injury (AKI) (RR 0.83 95% CI 0.38-1.80), or arrhythmia (RR 1.52 95% CI 0.71-3.27), but LVADs were associated with a decrease in repeat revascularization (RR 0.26 95% CI 0.08-0.83). However, LVADs significantly increased the risk of bleeding compared with IABP (RR 2.85 95% CI 1.72-4.73).ConclusionsNeither LVADs nor IABP improves short or long-term survival in hr-PCI patients. LVADs are more likely to reduce repeat revascularization after PCI, but to increase the risk of bleeding events than IABP.

Project description:BackgroundTeaching and assessing clinical procedures requires a clear delineation of the individual steps required to successfully complete the procedure. For decades, human reliability analysis (HRA) has been used to identify the steps required to complete technical procedures in higher risk industries. However, the use of HRA is uncommon in healthcare. HRA has great potential supporting simulation-based education (SBE) in two ways: (1) to support training through the identification of the steps required to complete a clinical procedure; and (2) to support assessment by providing a framework for evaluating performance of a clinical procedure. The goal of this study was to use HRA to identify the steps (and the risk associated with each of these steps) required to complete a bronchoscope-assisted percutaneous dilatational tracheostomy (BPDT). BPDT is a potentially high-risk minimally invasive procedure used to facilitate tracheostomy placement at the bedside or in the operating theatre.MethodsThe subgoals, or steps, required to complete the BPDT procedure were identified using hierarchical task analysis. The Systematic Human Error Reduction and Prediction Approach (SHERPA) was then used to identify potential human errors at each subgoal, the level of risk and how these potential errors could be prevented.ResultsThe BPDT procedure was broken down into 395 subgoals, of which 18% were determined to be of high-risk. The most commonly identified remediation strategies for reducing the risk of the procedure included: checklist implementation and audit, statutory and mandatory training modules, simulation training, consultant involvement in all procedures, and fostering a safety-focused hospital culture.ConclusionThis study provides an approach for how to systematically identify the steps required to complete a clinical procedure for both training and assessment. An understanding of these steps is the foundation of SBE. HRA can identify 'a correct way' for teaching learners how to complete a technical procedure, and support teachers to give systematic and structured feedback on performance.

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Percutaneous dilatational tracheostomy in patients with mechanical circulatory support: Is the procedure safe?

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Percutaneous dilatational tracheostomy in patients with mechanical circulatory support: Is the procedure safe?

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