Surgical tracheostomy versus percutaneous dilatational tracheostomy. A prospective-randomized study with long-term follow-up.

BACKGROUND: To compare surgical tracheostomy (ST) versus percutaneous dilatational tracheostomy (PDT) in terms of complication rates. In particular we specifically studied the late tracheal complications of both methods by means of endoscopic controls of patients up to 6 months after the procedures. DESIGN: prospective-randomized clinical study. SETTING: University-affiliated tertiary care referral hospital. PATIENTS: 50 consecutive translaryngeally intubated patients with respiratory failure were randomized to undergo either ST (25 patients) or endoscopic guided PDT (25 patients). RESULTS: ST was performed in 41+/-14 min versus 14+/-6 min for PDT (p<0.0001). There was no procedure-related death. In the ST group there were no intraoperative complications. In the PDT group 2 intraoperative complications (minor hemorrhages) were observed. In the ST group 9 early postoperative complications occurred: one minor bleeding, 7 stomal infections and one accidental decannulation. In the PDT group only one early postoperative complication (minor bleeding) occurred. Early postoperative complication rates were 36% for ST and 4% for PDT. In the ST group there were no late tracheal complications. In the PDT group 2 late tracheal complications (one segmental malacia and one stenosis at the level of the stoma) were observed. CONCLUSIONS: This study confirms that PDT is a simpler and quicker procedure than ST and that it has a lower rate of early postoperative complications. Late tracheal complications were more frequent, although the difference was not statistically-significant, in the PDT group. Further investigations of long-term outcome following PDT are therefore necessary.

Measured versus calculated energy expenditure in pressure support ventilated ICU patients.

OBJECTIVE: To evaluate the usefulness of the modified Harris-Benedict formula predicting Energy Expenditure (EE) in pressure support ventilated, critically ill patient. SETTING: The intensive care unit (ICU) of a teaching hospital. PATIENTS: Fiftyfive patients admitted to ICU for acute respiratory failure, requiring mechanical ventilation. MEASUREMENTS AND RESULTS: After 12 hours at rest, EE was measured using indirect calorimetry (Datex-Deltatrac, with method exclusions - ICEE), and calculated using modified Harris-Benedict formula (MHBEE) (with correction for "hospital activity" and "stress factor") to calculate the bias between calculated and measured EE. Patients were divided into three groups on the basis of nutritional stress: A) non surgical/non septic patients (n = 10), B) complicated surgical patients (n = 21), C) severe infectious/multiple trauma patients (n = 24). In each group, a good correlation between calculated and measured EE was found [A) r = 0.809, p = 0.0046; B) r = 0.753 p = 0.0001; C) r = 0.711, p = 0.0001]. The bias (+/- SEM) was: A 175.1 (+/- 82) kcal/day, B 324.5 (+/- 64.5) kcal/day, C 366.7 (+/- 62.9) kcal/day. The mean difference value seems to be increased in the more stressed patients but these differences did not reach statistical significance (p = 0.23). A single correction factor for the original Harris-Benedict formula (OHBEE) was also calculated (ICEE/OHBEE) on each studied group: A) 1.20 (+/- 0.04), B) 1.28 (+/- 0.03), C) 1.50 (+/- 0.04) (p = 0.0001). CONCLUSIONS: The use of both "stress" and "activity" correction factors seems to be excessive in pressure support ventilated ICU patients. A single correction factor, proportional to the intensity of the illness, should be used in mechanically ventilated patients. Compared to the original Harris-Benedict formula, we found an EE increment of about 20%, 30%, and 50% respectively in non-septic/non-complicated, surgical complicated, and multiple trauma/septic patients.

Rapid turnover proteins in critically ill ICU patients. Negative acute phase proteins or nutritional indicators?

BACKGROUND: Rapid turnover proteins are often used as metabolic indicators in patients receiving nutritional therapy. However, their plasmatic concentration can be influenced by activation of acute phase reaction due to stress. The aim of this prospective, observational study was to evaluate changes of positive and negative acute phase proteins in mechanically ventilated ICU patients with acute stress. METHODS: Plasmatic concentrations of prealbumin (PRA), retinol-binding protein (RBP), c-reactive protein (CRP) as well as resting energy expenditure (REE) and nitrogen balance were measured in thirty ICU patients before starting nutritional support (Baseline) and then after 3 and 8 days of parenteral nutrition (TPN). RESULTS: Plasmatic concentrations of CRP were high at baseline and did not change (p = 0.47), while RBP and PRA were low and progressively increased during the study (p = 0.0001 and p = 0.004). Percentage changes from baseline of both PRA and RBP were significantly correlated with nitrogen balance (p = 0.01 and p = 0.009); while no significant correlation was observed between changes of rapid turnover proteins and CRP (p = 0.72 and p = 0.10). CONCLUSIONS: All the variables involved in the study are known to be influenced by both metabolic state and resolution of inflammation. However, the observed changes of rapid turnover proteins significantly correlate with nitrogen balance in the face of a persistent inflammation, as documented by CRP plasmatic concentrations. This suggests that RBP and PRA monitoring may be used as complement clinical evaluation of nutritional therapy also in ICU patients with ongoing inflammation.

Hyperacute pneumonitis in a patient with overwhelming Strongyloides stercoralis infection.

The case of a 64-year-old man who was admitted to hospital with fever, general deterioration and anorexia is reported. For the past 4 years, the patient had been receiving corticosteroid therapy for a chronic inflammatory demyelinating polyradiculoneuropathy. Soon after admission the patient developed respiratory insufficiency as a result of a massive pneumonitis, with severe hypoxia, acute anaemia, acute renal failure and a systemic inflammatory response syndrome (SIRS) requiring admission to the Intensive Care Unit (ICU). All faecal, bronchial, duodenal and urine samples showed Strongyloides stercoralis larvae. Despite antihelmintic therapy and cardiorespiratory support, the patient died from the consequences of irreversible shock. Strongyloidiasis is present worldwide and can be a chronic, essentially asymptomatic infection. This nematode can produce an overwhelming hyperinfection syndrome, especially in patients showing deficient cell-mediated immunity. Strongyloides hyperinfection syndrome is frequently fatal but is potentially a treatable clinical condition. Patients undergoing immunosuppressive therapy or with suspected immunity deficiency (HIV infection, malnutrition, lymphomas, leukaemias or other neoplasia treated with systemic radiotherapy or chemotherapy) must be also monitored for opportunistic Strongyloides stercoralis infection, because clinical manifestation of the systemic hyperinfection syndrome can be rather non-specific.

[Percutaneous or surgical trachetomy. Prospective, randomized comparison of the incidence of early and late complications]. / Tracheotomia percutanea e chirurgica. Confronto prospettico, randomizzato dell'incidenza di complicanze precoci e tardive.

BACKGROUND: To compare early and late complications after either conventional surgical or percutaneous dilatational tracheostomy. DESIGN: Prospective, randomized study. SETTING: General intensive care unit and neuro-surgical intensive care unit in a university hospital. PATIENTS: 50 consecutive patients, requiring tracheostomy for prolonged mechanical ventilation. INTERVENTIONS AND MEASUREMENTS: Patients were randomly allocated to receive either surgical (surgical group, n = 25) or percutaneous dilatational tracheostomy (percutaneous group, n = 25). Occurrence of perioperative complication were carefully evaluated during ICU stay. Late complications were evaluated with both physical and endoscopic examination at 1, 3 to 6 months after tracheostomy. RESULTS: All surgical and percutaneous tracheostomies were successfully completed and no deaths directly related to the tracheostomy procedures were reported. Completion of the procedure required 41 +/- 14 min in the surgical group and 14 +/- 6 min in the percutaneous one (p < 0.0001). The incidence of early perioperative complications was higher in the surgical group (36%) than in percutaneous one (12%), (p < 0.05). The endoscopic follow-up demonstrated one segmental malacia and one stenosis of the trachea in the percutaneous group only (p = n.s.). Skin repair was better after percutaneous tracheostomy than in the surgical group (p < 0.01). CONCLUSIONS: In experienced hands, percutaneous dilatational tracheostomy is as safe and effective as the conventional surgical tracheostomy. The percutaneous technique is less time-consuming and has a lower rate of early infectious complications with better cosmetic results than the surgical technique.