Bedside Percutaneous Dilatational Tracheostomy Research Articles

Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients.

Anterior cervical spine fixation (ACSF) is a common mode of stabilization of cervical spine injuries. These patients usually need a prolonged mechanical ventilation, so an early tracheostomy is beneficial for them. However, it is often delayed due to the close proximity to the surgical site, due to the concerns of infection, and increased bleeding. Percutaneous dilatational tracheostomy (PDT) is also considered a relative contraindication due to the inability to achieve adequate neck extension. The objectives of our study are to assess the:Feasibility of performing a very early percutaneous dilatational tracheostomy in cervical spine injury patients, post-anterior cervical spine fixation.Safety in doing so with regard to surgical-site infection, early, and late complications.Benefits with regard to outcome measures like ventilator days and length of stay (LOS) in the intensive care unit (ICU) and hospital. We performed a retrospective review of all patients who underwent anterior cervical spine fixation and bedside percutaneous dilatational tracheostomy in our ICU from 1st January 2015 to 31st March 2021. Out of the 269 patients admitted to our ICU with cervical spine pathology, 84 were included in the study. About 40.4% patients had injury above C5 level (n-34) and 59.5% had below C5 level. About 86.9% patients had ASIA-A neurology. In our study, percutaneous tracheostomy was done at an average of 2.8 days from the cervical spine fixation. Average length of ventilator days post-tracheostomy was 8.32 days, ICU stay was 10.5 days, and hospital stay was 28.6 days. One patient developed anterior surgical-site infection. We conclude from our study that a very early percutaneous dilatational tracheostomy can be done in post-anterior cervical spine fixation patients as early as within 3 days without significant complications. Paul AL, Varaham R, Balaraman K, Rajasekaran S, Balasubramani VM. Safety and Feasibility of Very Early Bronchoscopy-assisted Percutaneous Dilatational Tracheostomy in Anterior Cervical Spine Fixation Patients. Indian J Crit Care Med 2022;26(10):1086-1090.

Safety of Prophylactic Anticoagulation During Bedside Procedures: A Prospective Multicenter Observational Study.

Bedside percutaneous dilatational tracheostomy (PDT) and percutaneous endoscopic gastrostomy (PEG) are common procedures performed in the intensive care unit (ICU). Venous thromboembolism (VTE) prophylaxis is frequently prescribed to ICU patients and it remains unclear whether pre-procedure discontinuation is necessary. This multi-center prospective observational study aimed to describe bleeding rates in patients undergoing bedside PEG or PDT who did or did not have VTE prophylaxis held. Decision to hold prophylaxis was made by the operating physician. The primary endpoint was the rate of peri-procedural bleeding complications. Secondary endpoints included quantification of held doses in the peri-procedural period, rate of venous thromboembolism, and characteristics associated with having prophylaxis held. 91 patients were included over a 2-year period. Patients were on average aged 54years, 40% female, mostly admitted to the trauma service (59%), and most commonly underwent bedside PDT (59%). Overall, 21% of patients had doses of pre-procedure prophylaxis held. Bleeding events occurred in 1 patient (1.4%) who had prophylaxis continued and in 1 patient (5.0%) who had prophylaxis held, a rate difference of 3.6% (95% CI-9.5%, 16.7%). One bleeding event was managed with bedside surgical repair and one with blood transfusion. There were 10 VTE events, all of whom had prophylaxis continued during the pre-procedure period but 3 had prophylaxis held after the procedure. Bleeding complications were rare and did not significantly differ depending on whether prophylaxis was held or not. Future research is required to confirm the lack of risk with continuing prophylaxis through bedside procedures.

Open Bedside Tracheostomy: Safe and Cost Saving but Underutilized Nationally.

To evaluate open bedside tracheostomy (OBT) and compare it with open operating room (OR) tracheostomy and bedside percutaneous dilatational tracheostomy (PDT) in complications and cost. To determine the tracheostomy practice patterns of academic otolaryngology programs. Retrospective cohort study and cross-sectional study. Public hospital and tertiary care hospital. Otolaryngology program directors were surveyed to determine their institutions' tracheostomy practice patterns and the factors preventing the implementation of open bedside tracheostomies. A retrospective chart review was done of tracheostomies performed at our institutions from 2009 to 2019 for prolonged mechanical ventilation. Complications, length of intubation, comorbidities, body mass index, demographics, mortality rates, and decannulation rates were recorded. A cost analysis between OBT and PDT was conducted. Data from 802 patients were analyzed for 449 OBTs, 206 PDTs, and 147 open OR tracheostomies. Complication rates were low. PDTs were more likely to have perioperative tracheal bleeding (P = .028) and mucus plugging (P = .006). OBTs were performed on sicker patients with a higher Charlson Comorbidity Index than PDT and OR tracheostomies. The cost of OBT was less than that of PDT. The survey response rate of tracheostomy practice patterns was 46%. The otolaryngologists at the responding programs all conducted OR tracheostomies, while 52.7% did OBTs and 30.9% PDTs. OBT can be done safely in patients with multiple comorbidities and has a cost that can be less than PDT. Despite these benefits, only 50% of academic institutions routinely performed OBT.

The Comparison Between the Early Tracheostomy and Orotracheal Intubation in COVID-19 Patients Required Mechanical Ventilation

Background: Supportive respiratory care and airway management are very important in treating COVID-19 patients with respiratory failure. There are two techniques for supporting patients with respiratory failure. Objectives: The current study aims to evaluate the efficacy and quality of patient care with early tracheostomy in intensive care unit (ICU) and compare mortality, hospital stay, and outcome between intubation and early tracheostomy. Methods: This study is conducted on total patients with confirmed COVID-19 in the ICU centers of a tertiary hospital. At the beginning of the study, all patients were intubated and connected to a mechanical ventilator. Within three days, the intensivists randomly performed bedside percutaneous dilational tracheostomy (PDT) for half of the patients. Early tracheostomy was defined as conducting tracheostomy within three days from intubation. Results: The total number of 36 patients was included in the study and categorized into two groups, including 18 patients in the early tracheostomy and 18 in orotracheal intubation. Half of the patients (50%) in the tracheostomy group were recovered from COVID-19 respiratory failure and discharged from ICU and hospital. All patients in the intubation group were expired. The length of staying alive in ICU in patients with an early tracheostomy was 26.47±3.79 compared with 7.58±2.36 days in intubated patients. Conclusion: The early tracheostomy compared with orotracheal intubation in respiratory failure patients with COVID-19 can significantly decrease mortality. However, airway management with an early tracheostomy increases the hospitalization stay and can increase recovery. So, conducting the early tracheostomy is recommended in this study.

Percutaneous Dilational Tracheostomy for Coronavirus Disease 2019 Patients Requiring Mechanical Ventilation.

To assess the impact of percutaneous dilational tracheostomy in coronavirus disease 2019 patients requiring mechanical ventilation and the risk for healthcare providers. Prospective cohort study; patients were enrolled between March 11, and April 29, 2020. The date of final follow-up was July 30, 2020. We used a propensity score matching approach to compare outcomes. Study outcomes were formulated before data collection and analysis. Critical care units at two large metropolitan hospitals in New York City. Five-hundred forty-one patients with confirmed severe coronavirus disease 2019 respiratory failure requiring mechanical ventilation. Bedside percutaneous dilational tracheostomy with modified visualization and ventilation. Required time for discontinuation off mechanical ventilation, total length of hospitalization, and overall patient survival. Of the 541 patients, 394 patients were eligible for a tracheostomy. One-hundred sixteen were early percutaneous dilational tracheostomies with median time of 9 days after initiation of mechanical ventilation (interquartile range, 7-12 d), whereas 89 were late percutaneous dilational tracheostomies with a median time of 19 days after initiation of mechanical ventilation (interquartile range, 16-24 d). Compared with patients with no tracheostomy, patients with an early percutaneous dilational tracheostomy had a higher probability of discontinuation from mechanical ventilation (absolute difference, 30%; p < 0.001; hazard ratio for successful discontinuation, 2.8; 95% CI, 1.34-5.84; p = 0.006) and a lower mortality (absolute difference, 34%, p < 0.001; hazard ratio for death, 0.11; 95% CI, 0.06-0.22; p < 0.001). Compared with patients with late percutaneous dilational tracheostomy, patients with early percutaneous dilational tracheostomy had higher discontinuation rates from mechanical ventilation (absolute difference 7%; p < 0.35; hazard ratio for successful discontinuation, 1.53; 95% CI, 1.01-2.3; p = 0.04) and had a shorter median duration of mechanical ventilation in survivors (absolute difference, -15 d; p < 0.001). None of the healthcare providers who performed all the percutaneous dilational tracheostomies procedures had clinical symptoms or any positive laboratory test for severe acute respiratory syndrome coronavirus 2 infection. In coronavirus disease 2019 patients on mechanical ventilation, an early modified percutaneous dilational tracheostomy was safe for patients and healthcare providers and associated with improved clinical outcomes.

Predictors of difficulty in bedside percutaneous dilatational tracheostomy: pilot study.

percutaneous dilatational tracheostomy is currently one of the main procedures performed in an intensive care unit (ICU). However, there are no well-defined indicators of technical difficulty in performing the procedure. to define predictors of difficulty in performing bedside percutaneous dilatational tracheostomy. prospective cohort study encompassing 21 patients who underwent bedside percutaneous dilatational tracheostomy in the ICU at a single center. Sternohyoid (SH) distance shorter than 7 cm is associated with a 50% increase in the risk of technical difficulty (OR 0.44 and p <0.03). the reduction in (SH) distance is related to an increased risk of difficulty in performing percutaneous dilatational tracheostomy in the ICU bed.

Antiplatelet agents and anticoagulants increased the bleeding risk of bedside percutaneous dilational tracheostomy in critically ill patients

The main objective of this study was to investigate the safety of bedside percutaneous dilational tracheostomy (PDT) by pulmonologists in critically ill patients, and the factors associated with complications resulting from PDT. We retrospectively enrolled critically ill patients who had undergone bedside PDT in the intensive care units (ICUs) and respiratory care center from February 2016 to December 2018. A total of 312 patients were included for analysis, with a mean age of 69.6±17.7 years. Two hundred and eight of the patients were male (66.7%). The mean acute physiology and chronic health evaluation II score was 25.3±6.3, and the mean body mass index was 22.4±4.2. Most of the patients were intubated due to respiratory disorders (51.3%). Fifty-six patients (17.9%) received antiplatelet agents or an anticoagulant regularly prior to PDT. All enrolled patients were undergone bedside PDT successfully. The total complication rate of PDT was 14.4%. Patients who took antiplatelet agents or anticoagulants regularly before PDT had a higher risk of bleeding than patients who went without (26.8% versus 7.0%, adjusted odds ratio 4.93 [95% f 2.16-11.25], p<0.001). Finally, a longer length of intubation resulted in a higher probability in the length of ICU stay being ≧28 days (adjusted odds ratio 1.11 [95% CI 1.08-1.14], p<0.001). Our study demonstrated that it was feasible for pulmonologists to perform bedside PDT in critically ill patients. However, antiplatelet agents and anticoagulants use increased the risk of bleeding in PDT patients.

Impact of bedside percutaneous dilational and open surgical tracheostomy on intracranial pressure, pulmonary gas exchange, and hemodynamics in neurocritical care patients.

Aim was to compare the impact of bedside percutaneous dilational tracheostomy (PDT) and open surgical technique (ST) on intracranial pressure (ICP), pulmonary gas exchange and hemodynamics.We retrospectively analyzed data of 92 neurocritical care patients with invasive ICP monitoring during either PDT (43 patients) or ST (49 patients).Peak ICP levels were higher during PDT (22 [17-38] mm Hg vs 19 [13-27] mm Hg, P = .029). Mean oxygen saturation (SpO2) and end-tidal carbon dioxide partial pressure (etCO2) did not differ. Episodes with relevant desaturation (SpO2 < 90%) or hypercapnia (etCO2 > 50 mm Hg) occurred rarely (5/49 during ST vs 3/43 during PDT for SpO2 < 90%; 2/49 during ST vs 5/43 during PDT for hypercapnia). Drops in mean arterial pressure (MAP) below 60 mm Hg were seen more often during PDT (8/43 vs 2/49, P = .026). Mean infusion rate of norepinephrine did not differ (0.52 mg/h during ST vs 0.45 mg/h during PDT). No fatal complications were observed.Tracheostomy can be performed as ST and PDT safely in neurocritical care patients. The impact on ICP, pulmonary gas exchange and hemodynamics remains within an unproblematic range.

Step-by-Step tutorial of bedside percutaneous dilatational tracheostomy

Bedside percutaneous dilatational tracheostomy has become one of the most commonly used interventions in ICU medicine. Different techniques have been developed, but guidance of percutaneous dilatational tracheostomy by video bronchoscope has been suggested to be clinically reasonable for direct visualization. The current Step-by-Step tutorial gives a detailed instruction of the procedure with visualization of every single step offering tips and pitfalls of the procedure.

Bedside percutaneous dilatational tracheostomy in patients outside the ICU: a single-center experience

PurposeTo assess the safety of medical-ward bedside percutaneous dilatational tracheostomy (GWB-PDT). Materials and methodsA retrospective study of all patients who underwent elective GWB-PDT between 2009 and 2015. A joint otolaryngology–ICU team performed all GWB-PDTs. The patients were followed until decannulation, discharge or death. Complications were divided into early (within 24 h) and late, and into minor and major. ResultsTwo hundred and fifty six patients were included in the study. The mean age was 77.7 ± 11.8 Medical history included cardiac comorbidities (42.6%) and cerebrovascular accidents (34.4%). Overall, 48 patients (18.9%) had 60 complications, of which 70% (42/60) were minor (13 early; 29 late complications). Fifteen patients (5.9%) had major complications. Eight patients had early major complications (loss of airway – two patients [0.8%], pneumothorax – two patients [0.8%], resuscitation - one patient [0.4%], and a single patient (0.4%) died within 24 h following PDT). Two additional patients (0.8%) underwent conversion to an open tracheostomy. Seven patients had late complications (airway complications in six patients [2.3%] and major bleeding in a single patient [0.4%]). Of the seven patients with late major complications, three had two major complications. Half of the complications occurred by POD 3. ConclusionGWB-PDT is a feasible and safe solution for tracheostomies in general-ward ventilated patients.

A service evaluation of surgical tracheostomies in the emergency theatre at University Hospital, Coventry: time for a dedicated tracheostomy team?

Introduction/aims: The routine practice of surgical tracheostomy has been challenged by bedside percutaneous dilatational tracheostomy (PDT). Whilst PDT is cost-effective and time-efficient, there is still a place for the open technique in patients with unfavourable anatomy, unstable cervical spine injuries and/or coagulopathies. Complication rates of the open technique are often lower, but booking such cases into busy emergency theatres may prove difficult.

Bedside Percutaneous Dilatational Tracheostomy by Griggs Technique: A Single-Center Experience.

BackgroundThe study evaluated reliability and outcomes of percutaneous dilatational tracheostomy (PDT) performed via Griggs’ method in the intensive care unit.Material/MethodsWe examined 78 patients who underwent bedside PDT in the intensive care unit (ICU). Demographic characteristics were recorded. In addition, ventilator-related pneumonia, duration of performing PDT, and rates of complications, mortality, and morbidity were assessed.ResultsThe mean age of patients was 68.7 years, and 56.4% were females (n=44). The most common indication for ICU was pneumonia (44.9%, n=35), followed by trauma (24.8%, n=13). Mean opening of PDT was 21 minutes. Mean duration of intubation prior to PDT was 21±6 days. Mean FiO2 before and after PDT was 58.7% and 49.1%, respectively. PEEP ratios before and after PDT were 5 and 3, respectively. Seventy-one patients (91%) needed no sedation after PDT. Mechanical ventilator-induced pneumonia was observed in 32.1% (n=25) of patients. The overall complication rate after PDT was 37.1%, most of which were minor. The most common and early complication of PDT was bleeding (28.2%, n=22). Other minor complications included hypotension (3.8%, n=3), desaturation (3.8%, n=3), and subcutaneous emphysema (1.3%, n=1).ConclusionsTracheostomy offers advantages in terms of improving patient comfort, facilitating weaning of patients from the respirator, and providing clearance of pulmonary secretions by reducing pulmonary dead-spaces. PDT is a simple and reliable procedure with lower complication rates. Its advantages include implementation at bedside, with a shortened procedure duration and accelerated wound healing.

Bedside open tracheostomy at intensive care unit-our experiences of 1000 cases at a tertiary care teaching hospital of eastern India

IntroductionTracheostomy is usually done on critically ill patients those requiring prolonged mechanical ventilation at the intensive care unit (ICU). Bedside tracheostomy is often helpful for avoiding transferring the unstable patients to operation theater and also minimizing the cost. AimAssessing the safety, cost and procedure time, complications of bedside open tracheostomy at intensive care unit considering comparison to open tracheostomy at operation theater and bedside percutaneous dilatational tracheostomy (PDT) with its complications, cost and its simplicity. Materials and methodsThis descriptive retrospective study was carried out at a tertiary care teaching hospital during December 2006 to January 2016. It included 1000 patients, undergone open bedside tracheostomy along with 152 undergone open tracheostomy at operating room(OR) and 112 bedside PDT. All these patients were undergone bedside tracheostomy, followed up for next 3months. Complications occurring during and after tracheostomy were documented. Results and discussionThis study group comprised patients with age group of 8years to 82years. The complications among open bed side tracheostomy within 30days were 10 minor bleeding, 1 major bleeding, 2 cardiac arrest, 1 pneumothorax, 6 stomal sepsis, 5 cervical emphysema. Late complications like 2 laryngotracheal stenosis (LTS) were seen where as other complication like tracheocutaneous fistula and tracheoinominate fistula were not observed. The complications rate is less in bedside open tracheostomy than open tracheostomy at OR and bedside PDT in our study. ConclusionBedside elective open tracheostomy is safe, effective, cost effective and allowing timely tracheostomy with low morbidity.

Tracheostomy in Stroke Patients

Patients with severe ischemic and hemorrhagic stroke may require tracheostomy in the course of their disease. This may apply to stroke unit patients whose deficits include a severe dysphagia posing such risk of aspiration as it cannot be sufficiently counteracted by tube feeding and swallowing therapy alone. More often, however, tracheostomy is performed in stroke patients so severely afflicted that they require intensive care unit treatment and mechanical ventilation. In these, long-term ventilation and prolonged insufficient airway protection are the main indications for tracheostomy. Accepted advantages are less pharyngeal and laryngeal lesions than with prolonged orotracheal intubation, better oral hygiene and nursing care, and higher patient comfort. Optimal timing of tracheostomy is unclear, in general, as in stroke intensive care unit patients. Potential benefits of early tracheostomy concerning ventilation duration and length of stay, respirator weaning, airway safety, rate of pneumonia, and other complications, outcome and mortality have been suggested in studies on non-neurologic subgroups of critical care patients. Stroke patients have hardly been investigated with regard to these aspects, and mainly retrospectively. A single randomized pilot trial on early tracheostomy in 60 ventilated patients with severe hemorrhagic and ischemic stroke demonstrated feasibility, safety, and less need of sedation. Regarding the technique, bedside percutaneous dilational tracheostomy should be preferred over surgical tracheostomy because of several reported advantages. As the procedural risk is low and early tracheostomy does not seem to worsen the clinical course of the ventilated stroke patient, it is reasonable to assess the need of further ventilation at the end of the first week of intensive care and proceed to tracheostomy if extubation is not feasible. Reliable prediction of prolonged ventilation need and outcome benefits of early tracheostomy, however, await further clarification. Decannulation of stroke patients after discontinued ventilation has to follow reliable confirmation of swallowing ability, as by endoscopy.

Safety of Bedside Percutaneous Tracheostomy in the Critically Ill: Evaluation of More than 3,000 Procedures

Bedside percutaneous dilational tracheostomy has been demonstrated to be equivalent to open tracheostomy. At our institution, percutaneous dilational tracheostomy without routine bronchoscopy is our preferred method. My colleagues and I hypothesized that our 10-year percutaneous dilational tracheostomy experience would demonstrate that the technique is safe with low complication rates, even in obese patient populations. We conducted a retrospective review of all bedside percutaneous dilational tracheostomy performed by the Division of Trauma and Surgical Critical Care faculty from 2001 to 2011, excluding patients younger than 18 years of age. All major airway complications and procedure-related deaths were evaluated during the early (≤48 hours postprocedure), intermediate (in hospital), and late (after discharge) periods. Incidence of post-tracheostomy stenosis was also evaluated. There were 3,162 percutaneous dilational tracheostomies performed during the study period. Mean body mass index was 28 (16% with body mass index ≥35), mean Injury Severity Score was 32, and mean APACHE II score was 19. Major airway complications occurred in 12 (0.38%) patients, accounting for 5 (0.16%) deaths. Early major complications included 3 airway losses and 1 bleeding event requiring formal exploration with procedure-related deaths occurring in 3 patients. Intermediate major complications included 2 tube occlusion/dislodgement events with 2 related deaths. Late complications included 5 (0.16%) cases of tracheal stenosis requiring intervention without associated deaths. Bedside percutaneous dilational tracheostomy is safe across a broad critically ill patient population. The safety of this technique, even in the obese population, is demonstrated by its low complication rate. Routine bronchoscopic guidance is not necessary. Specially trained procedure nurse and process improvement programs contribute to the safety and efficacy of this procedure.

Subcutaneous emphysema and pneumothorax during percutaneous tracheostomy without any evidence of tracheal wall injury on repeated bronchoscopy

Percutaneous dilatational tracheostomy (PDT) is fast becoming the method of choice for securing an airway in chronic ventilated patients in intensive care units worldwide. It has been advocated as a safe and efficient bedside alternative for open surgical tracheostomy [1,2]. Most of the complications reported with different PDT techniques are mild and easy to overcome, but some major, life-threatening complications like pneumotho rax, pneumomediastinum, subcutaneous emphysema, cardiovascular compromise have been reported as well. Our patient was 50 years old female, weighing 84 kg, with diagnosis of right hand marjolin’s ulcer with emphysema and respiratory failure. Bedside PDT with ULTRAperc (Smith Medical, Hythe, Kent, UK) single stage dilator technique was planned, as she was on ventilator support for 11 days and was a difficult case to wean. After all aseptic precautions and local anesthetic infiltration, procedure was started under fiberoptic bronchoscope (FOB) guidance. Standard technique for PDT was followed; FOB was inserted through a special T connector up to the level of carina. After dilatation of the tracheal stoma, when the tracheostomy tube was inserted, end-tidal carbon dioxide trace was detected in the beginning but soon thereafter no vis ible chest rise was observed and on auscultation of the chest, no breath sounds were heard. The patient was immediately connected to the endotracheal tube, which was still lying in the oral cavity just below the vocal cords, still there was no visible chest rise and compliance of the chest was very poor. Patient also developed desaturation upto SPO2 of 88%, bradycardia and hypotension. Cardiopulmonary resuscitation was started. Possibility of pneumothorax was thought upon and 16 gauge intravenous cannula with three way assembly leading to water seal was inserted in the left second intercostal space as decrease in breath sounds were more predominant on left side. There was a sudden gush of air. There was also air crepitus on palpation in the neck and chest wall on palpation. Intercostal drain was put on left side in fifth intercostal space along the midclavicular line. Then, tracheostomy was completed under bronchoscopic visu alisation and 7 mm internal diameter tracheostomy tube was put into the stoma. Position was confirmed using, capnography, chest auscultation and fiberoptic bronchoscopy. The patient was also started on inotropic support and vitals improved gradually. No evidence of tracheal wall injury was found even on repeated bronchoscopy. The pneumothorax that occurred in this case could have been caused either by a false passage formation or by rupture of emphysematous bullae as a result of an increase in peak airway pressure and/ or air trapping. The dynamic hyper inflation of lungs and air trapped in the thorax and mediastinum could be implicated in decreasing the venous return and thereby causing hemodynamic compromise in the form of hypotension, bradycardia and near cardiac arrest.

Safety and Efficiency of Interventional Pulmonologists Performing Percutaneous Tracheostomy

Background: The steady rise in the number of critically ill patients in the USA has led to an increase in the need for tracheostomies in patients requiring chronic ventilatory support. There is a matched need for experienced operators to safely and efficiently perform these procedures. Objectives: We evaluated the effects on procedural outcomes and efficiency of percutaneous dilatational tracheostomy (PDT) placement in the medical intensive care unit (MICU) by the surgical team (ST) or interventional pulmonologists (IP). The IP team joined the PDT team in September 2007 and became primarily responsible for all PDT in the MICU. Methods: A retrospective analysis of prospectively collected data of patients who received PDT in the MICU by ST and IP from September 2007 to August 2010 was made. Outcomes including safety, efficacy, and procedural efficiency were compared. Results: One hundred seven patients underwent bedside PDT in the MICU during this period. Forty-three procedures (40.2%) were performed by the ST and 64 procedures (59.8%) were performed by IP. There was no statistical difference between the incidence of airway injury and infection between the two procedural groups. There were no deaths related to the performance of PDT in our series. PDT was completed within 48 h of request in 100% of IP patients and 95% of ST patients (p = 0.08). Conclusions: There were no statistical differences in PDT between the ST and IP groups when comparing complications. There was a trend towards an increased efficiency in time to PDT after consultation within the IP PDT group. Trained IP can safely and effectively perform PDT.

Anticoagulation management around percutaneous bedside procedures

Percutaneous endoscopic gastrostomy (PEG) and percutaneous dilatational tracheostomy (PDT) are frequently performed bedside in the intensive care unit. Critically ill patients frequently require anticoagulant (AC) and antiplatelet (AP) therapies for myriad indications. There are no societal guidelines proffering strategies to manage AC/AP therapies periprocedurally for bedside PEG or PDT. The aim of this study is to evaluate the management of AC/AP therapies around PEG/PDT, assess periprocedural bleeding complications, and identify risk factors associated with bleeding. A retrospective, observational study of all adult patients admitted from October 2004 to December 2009 receiving a bedside PEG or PDT was conducted. Patients were identified by procedure codes via an in-hospital database. A medical record review was performed for each included patient. Four hundred fifteen patients were included, with 187 PEGs and 352 PDTs being performed. Prophylactic anticoagulation was held for approximately one dose before and two doses or less after the procedure. There was wide variation in patterns of holding therapy in patients receiving anticoagulation via continuous infusion. There were 19 recorded minor bleeding events, 1 (0.5%) with PEG and 18 (5.1%) with PDT, with no hemorrhagic events. No association was found between international normalized ratio, prothrombin time, or activated partial thromboplastin time values and bleed risk (p = 0.853, 0.689, and 0.440, respectively). Platelet count was significantly lower in patients with a bleeding event (p = 0.006). We found that while practice patterns were quite consistent in regard to the management of prophylactic anticoagulation, it varied widely in patients receiving therapeutic anticoagulation. It seems that prophylactic anticoagulation use did not affect bleed risk with PEG/PDT.

Bronchoscope-guided percutaneous dilatational tracheostomy performed by an experienced intensivist: a 26-month experience at a tertiary care center in United Arab Emirates

Bedside percutaneous dilatational tracheostomy (PDT) is a safe procedure with an acute complication rate of 10 to 15%. Our hypothesis was that having an experienced person performing or supervising the procedure results in extremely low complications with PDT. We formed a tracheostomy team which always included at least a consultant or specialist experienced (at least 25 procedures) in performing the procedure.

Safety analysis of percutaneous dilational tracheostomies with bronchoscopy in the obese patient

Since originally described in 1985 by Ciaglia, percutaneous dilational tracheostomy (PDT) has grown in popularity, and today is widely used for critically ill patients requiring long-term mechanical ventilation. Since the inception of PDT, obesity has been considered a relative contraindication to its use. The purpose of this study is to evaluate the risks of PDT in obese patients. Retrospective review. A retrospective review was performed of prospectively collected data from 426 patients who underwent PDT at a single teaching institution from July 2003 to October 2009. The groups were separated into those who had a body mass index (BMI) of <30 or ≥30 kg/m(2) . The following variables were collected: blood loss at the time of procedure, difficulty in tracheotomy dilation and/or tracheostomy placement, presence of tracheal ring breaks, any bleeding episodes requiring treatment by surgery or blood transfusion, pre- and postprocedure pneumonia, and stoma infection requiring antibiotics. All tracheostomies were placed using the Ciaglia Blue Rhino Introducer Kit (Cook Medical Inc., Bloomington, IN). Statistical analysis was performed with nonparametric statistics using χ(2) testing with P < .05 as significant. No statistically significant difference was found between the obese and nonobese groups for any of the variables studied. Similar results were found when BMI of 40 was used for grouping. PDT can be performed safely in obese patients. There were no statistically significant differences in measured variables found between the two study groups. This study supports the use of intensive care unit bedside PDT in the obese population.