Long term outcomes following percutaneous dilatational tracheostomy in the critically ill

Background: Percutaneous procedures are now the predominant tracheostomy technique within the critical care setting. Complication rates for various techniques appear to be equivalent to those achieved with surgical tracheostomy. There is a paucity of data when comparing percutaneous procedures, particularly when considering late complications (tracheo-innominate artery fistulae (TIF), tracheooesophageal fistulae (TOF) and tracheal stenosis (TS). Given the severity of illness and associated mortality in many of these patients the incidence of these complications remains difficult to define. Confounding factors present in survivors of critical illness may present difficulties in diagnosis such that underlying tracheal pathology may go undiagnosed. Aims: To determine: The incidence of common early and late complications of percutaneous dilatational tracheostomy (PDT) in relation to surgical tracheostomy (ST). The role of peri-operative events that may contribute to the aetiology of late complications of TS, TIF and TOF. The incidence of early and late complications in relation to percutaneous tracheostomy to define the safest percutaneous technique. The utility of adjunctive techniques (bronchoscopy & ultrasound scanning) in reducing complications of PDT. The prevalence of sub-clinical TS following PDT using the single tapered dilator technique (STD). Aetiological factors for sub-clinical TS. Whether sub-clinical TS may present atypically in critical illness survivors. Methods: We have conducted a systematic review of all prospective studies reporting late complications after tracheostomy performed in the critically ill. We have also extracted data to assess the role of peri-operative events and monitoring in causing or preventing late complications. We have undertaken an eleven-year review of all PDTs performed within our unit to define the incidence of complications arising within our own population. Finally, a prospective study to identify the prevalence of sub-clinical TS and identify atypical presenting features in survivors of critical illness has been performed. Results: All surgical and percutaneous techniques are broadly similar in terms of early and late complications. There is a higher incidence of wound infection when comparing ST to the multiple dilator PDT. There are few studies assessing late complications between percutaneous techniques. The TS rate varies from 2.8 to 0.6% for ST and the STD technique respectively. Due to limited data we were unable to identify peri-operative events that may lead to late complications. There is a very low rate of complications attributed to the STD technique with only 9 significant late adverse events. The rate of sub-clinical TS is low with doubtful clinical significance. Conclusions: We have not found a significant difference in the incidence of TS between PDT and ST. Our pooled proportions meta-analysis may indicate a tendency toward a higher rate of stenosis for ST. The reported complication rates presented within our cohort study may indicate that the STD PDT is one of the safer techniques available. The rate of sub-clinical stenoses following STD PDT is low and of doubtful clinical significance. Further work is required to define the role for percutaneous tracheostomy outside the critical care setting and to gather qualitative data to assess the patient’s perception of tracheostomy in the critical care setting

Hyperoxemia and excess oxygen use in early acute respiratory distress syndrome: insights from the LUNG SAFE study

Contains fulltext : 218568.pdf (publisher's version ) (Open Access)BACKGROUND: Concerns exist regarding the prevalence and impact of unnecessary oxygen use in patients with acute respiratory distress syndrome (ARDS). We examined this issue in patients with ARDS enrolled in the Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) study. METHODS: In this secondary analysis of the LUNG SAFE study, we wished to determine the prevalence and the outcomes associated with hyperoxemia on day 1, sustained hyperoxemia, and excessive oxygen use in patients with early ARDS. Patients who fulfilled criteria of ARDS on day 1 and day 2 of acute hypoxemic respiratory failure were categorized based on the presence of hyperoxemia (PaO2 > 100 mmHg) on day 1, sustained (i.e., present on day 1 and day 2) hyperoxemia, or excessive oxygen use (FIO2 >/= 0.60 during hyperoxemia). RESULTS: Of 2005 patients that met the inclusion criteria, 131 (6.5%) were hypoxemic (PaO2 < 55 mmHg), 607 (30%) had hyperoxemia on day 1, and 250 (12%) had sustained hyperoxemia. Excess FIO2 use occurred in 400 (66%) out of 607 patients with hyperoxemia. Excess FIO2 use decreased from day 1 to day 2 of ARDS, with most hyperoxemic patients on day 2 receiving relatively low FIO2. Multivariate analyses found no independent relationship between day 1 hyperoxemia, sustained hyperoxemia, or excess FIO2 use and adverse clinical outcomes. Mortality was 42% in patients with excess FIO2 use, compared to 39% in a propensity-matched sample of normoxemic (PaO2 55-100 mmHg) patients (P = 0.47). CONCLUSIONS: Hyperoxemia and excess oxygen use are both prevalent in early ARDS but are most often non-sustained. No relationship was found between hyperoxemia or excessive oxygen use and patient outcome in this cohort. TRIAL REGISTRATION: LUNG-SAFE is registered with ClinicalTrials.gov, NCT02010073

Elderly ICU outcomes

Long-term outcomes of elderly patients admitted to ICU as an emergenc

Tracheocarotid artery fistula in a patient who had tracheostomy successfully treated with a saphenous vein graft

Tracheoarterial fistula is a complication of tracheostomy with a high associated mortality. A 25-year-old male patient with Duchenne’s muscular dystrophy underwent a percutaneous tracheostomy using the single tapered dilator (Blue Rhino) technique to facilitate weaning from mechanical ventilation. Nine weeks after the procedure, he developed significant upper airway bleeding, leading to haemodynamic instability. A CT angiogram of the neck and thorax did not reveal a source of the bleeding. The patient was subsequently transferred to the operating theatre where a 1 cm defect in the right common carotid artery was found and repaired with a graft from the left short saphenous vein. Clinicians who undertake tracheostomy formation should be aware of the possibility of tracheoarterial defect and may wish to discuss it at tracheostomy formation. It should be considered early in the event of a significant bleed. This case identifies deep tissue infection and misplacement of the tracheostomy tube as major contributing factors to fistula formation.</jats:p

The Sabadell score is an independent predictor of five-year outcome after critical care discharge

Abstract Background: Critical care survivors frequently suffer persistent morbidity and increased risk of mortality compared to the general population. However, there are no standardised tools to identify at-risk patients to target potential interventions. Our aim was to establish whether the “Sabadell score”, a simple tool applied upon critical care discharge, is an independent predictor of five-year mortality.Methods: Prospective observational cohort study of adults admitted to a mixed critical care unit at Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom. Sabadell score applied to all patients from September 2011 to December 2017. Primary outcome: five-year mortality assessed using a multivariable flexible parametric survival analysis adjusted for demographics, and clinically relevant covariates. Primary outcome: Adults discharged alive following critical care admission. Results: There were 5954 patients with a minimum of 18 months follow-up. Mean age was 59.5 (SD±17) and 57.1% were male. Patients were categorised into Sabadell scores, zero (38.4%), one (47.9%), two (10.5%) and three (3.1%). Adjusted hazard ratios for mortality were 2.09 (C.I. 1.85–2.36), 3.95 (C.I. 3.39–4.60) and 21.04 (C.I. 17.24–25.68) respectively. Sabadell score three predicted 99.9%, 99.5%, 98.5% and 87.4% mortality at five years for patients ³80 (aHR 3.37), 60-79 (aHR 2.52), 40-59 (aHR 2.03) and 16-39 respectively. A Sabadell score of two predicted 71.0%, 52.7%, 44.8% and 23.7% mortality at five years for these age categories.Conclusions : Sabadell score is an independent predictor of five-year survival after critical care discharge. These findings could be used to guide provision of increased support for patients after critical care discharge and/or informed discussions with patients and relatives about dying to ascertain their future wishes.</jats:p

The Sabadell score is an independent predictor of five-year outcome after critical care discharge

Background: Critical care survivors frequently suffer persistent morbidity and increased risk of mortality compared to the general population. However, there are no standardised tools to identify at-risk patients to target potential interventions. Our aim was to establish whether the “Sabadell score”, a simple tool applied upon critical care discharge, is an independent predictor of five-year mortality. Methods: Prospective observational cohort study of adults admitted to a mixed critical care unit at Aintree University Hospital NHS Foundation Trust, Liverpool, United Kingdom. Sabadell score applied to all patients from September 2011 to December 2017. Primary outcome: five-year mortality assessed using a multivariable flexible parametric survival analysis adjusted for demographics, and clinically relevant covariates. Primary outcome: Adults discharged alive following critical care admission. Results: There were 5954 patients with a minimum of 18 months follow-up. Mean age was 59.5 (SD±17) and 57.1% were male. Patients were categorised into Sabadell scores, zero (38.4%), one (47.9%), two (10.5%) and three (3.1%). Adjusted hazard ratios for mortality were 2.09 (C.I. 1.85–2.36), 3.95 (C.I. 3.39–4.60) and 21.04 (C.I. 17.24–25.68) respectively. Sabadell score three predicted 99.9%, 99.5%, 98.5% and 87.4% mortality at five years for patients ³80 (aHR 3.37), 60-79 (aHR 2.52), 40-59 (aHR 2.03) and 16-39 respectively. A Sabadell score of two predicted 71.0%, 52.7%, 44.8% and 23.7% mortality at five years for these age categories.Conclusions : Sabadell score is an independent predictor of five-year survival after critical care discharge. These findings could be used to guide provision of increased support for patients after critical care discharge and/or informed discussions with patients and relatives about dying to ascertain their future wishes