Outcomes of percutaneous tracheostomy.

AIM: Percutaneous dilatational tracheostomy (PDT) is one of the most commonly performed procedures in critically ill patients receiving mechanical ventilation. Although many papers have compared different PDT techniques, few records on the outcome of tracheostomized patients after intensive care unit (ICU) discharge are available. METHODS: Prospective observational study to evaluate efficacy, safety and long-term consequences of PDT performed over a 6-year period (January 2002-December 2007) in a combined medical/surgical ICU in Rho, Milan, Italy. A total of 181 patients were subjected to PDT, 26.5% with the Ciaglia technique and 73.5% with the Percu-twist technique. RESULTS: The main endpoints that were examined were complications related to PDT and the final outcome of tracheostomized patients. Early complications included minor bleeding in 4 patients, stomal infection in 8 patients, and the occurrence of hypoxic/desaturation events during the procedure in 3 cases. Late complications included: tracheal stenosis in a single case, recurrent stomal granuloma in 2 cases, and tracheal mucosa injury caused by the endotracheal tube cuff in 3 patients. All patients who were decannulated late underwent bronchoscopic follow-up at 3, 6 and 12 months. Hospital discharge: of the 137 patients alive at the time of discharge from the hospital, 115 were decannulated (40 early decannulation, 75 late decannulation). In total, 22 patients were never decannulated (14 breathed spontaneously whereas 8 needed ventilator support). In the group of patients that were decannulated late, the mortality rate at 1 year was 20.6%. CONCLUSIONS: PDT-related early complications without clinical consequences were observed. Conversely, late complications were infrequent but had significant clinical implications. Although late decannulation is the major risk for complications, in 83.9% of cases tracheostomy is only a temporary measure.

Algodystrophy: pathophysiological considerations.

Algodystrophy can follow a wide variety of painful disorders and the Sympathetically Maintained Pain (SMP) syndromes form a chapter of medicine which is far more important than generally considered. The abnormal central sensitization of internucial pools of spinal neurones must be considered as the crucial element of these painful states. Treatment must be carried out in the first phase in order to minimize the state of spinal hypersensitivity.

[Total parenteral nutrition and dialysis. Complementary importance in the therapy of acute renal insufficiency in aortic surgery]. / Nutrizione parenterale total (N.P.T.) e dialisi. Momenti complementari della terapia della insufficienza renale acuta (I.R.A.) nella chirurgia dell'aorta.

The acute renal insufficiency (A.R.I.) consequent on surgical pathology of the aorta is in the Milan School, one of the most important postoperative complications and requires the use of total parenteral feeding (T.P.F.). Parenteral infusion of AAe and hypertonic glucose in patients with A.R.I. has given positive results, not only insofar as it improves the general nutritional state, but also because it facilitates recovery of renal function and improves survival. Reutilisation of endogenous nitrogen gives a synthesis of structural proteins to the benefit of metabolic homoeostasis and the patient's clinical condition. On the basis of recent nephrology studies on uraemic toxicity, the therapeutic problem of A.R.I. in surgical patients has been examined: early peritoneal dialysis associated with T.P.F. and the combination, in the postoperative stage, of parenteral feeding and periodic peritoneal dialysis. The average duration of this treatment has been personally found to be about 8-18 days. The example is given of a clinical case of A.R.I. in a patient operated by aneurysmectomy for rupture of an aneurysm of the abdominal aorta.