Manejo clínico y complicaciones de pacientes traqueotomizados en cuidados intensivos / Clinical management and complications in tracheotomy patients at the Intensive Care Unit

OBJETIVO: analizar las pautas de actuación y manejo en la práctica clínica de los pacientes ingresados en una Unidad de Cuidados Intensivos (UCI) a los que se les realizó una traqueotomía, conocer las complicaciones y su evolución. MÉTODO: estudio de observaciones retrospectivo de todos los pacientes ingresados en una UCI polivalente del 15 de marzo de 2017 al 15 de marzo de 2018 a los que se les hizo una traqueotomía. Los datos se extrajeron de la historia clínica informatizada. Variables estudiadas: demográficas y clínicas del paciente y relacionadas con la traqueotomía. Se utilizó la analítica descriptiva e inferencial. Se consideró significativo p < 0,05. RESULTADOS: 48 pacientes incluidos cuya edad media (desviación estándar) fue 61,7 (14,9) años. 34 (71%) varones. Diagnóstico al ingreso mayoritario neurológico 27(56%). Nueve (19%) fallecieron en la UCI. Se realizaron 49 traqueotomías, 35 (71%) quirúrgicas. Se emplearon 105 cánulas. Se registraron 27 vomplicaciones, siendo las más habituales las de aparición tardía (44%) y por tipología la infección del estoma (26%). La decanulación se relacionó significativamente con la deglución (p = 0,005) y el sellado de la cánula (p= 0,001). Solamente el manejo neumotaponamiento tuvo relación significativa con la existencia de complicaciones (p = 0,029). CONCLUSIONES: la traqueotomía puede considerarse una práctica segura. Hay escasa evidencia y variabilidad en la práctica clínica en la asistencia al paciente traqueotomizado. El uso de protocolos que incluyan aspectos como el manejo del neumotaponamiento, la deglución o la fonación entre otros, podrían aumentar la calidad y seguridad asistencial en la atención a estos pacientes

OBJECTIVE: to analyze the guidelines for action and management in clinical practice for patients admitted at an Intensive Care Unit (ICU), who have undergone tracheotomy, to understand their complications and evolution. METHOD: a retrospective observational study on all patients admitted at a multipurpose ICU from March, 15 th, 2017 to March, 15th, 2018, who underwent a tracheotomy. Data were extracted from the computerized clinical record. The demographical and clinical variables of the patient were studied, as well as those associated with tracheotomy. Descriptive and inferential analysis was used. A value of p < 0.05 was considered significant. RESULTS: forty-eight (48) patients were included, with a mean age (standard deviation) of 61.7 (14.9) years; 34 (71%) were male. At admission, the primary diagnosis was neurological: 27 (56%). Nine (19%) patients died at the ICU. Forty-nine (49) tracheotomies were conducted, 35 (71%) were surgical; 105 trach tubes were used. Twenty-seven (27) complications were recorded; the most usual were of late onset (44%), and by type, stoma infection (26%). Decannulation was significantly associated with swallowing (p = 0.005) and trach tube sealing (p = 0.001). Only the management of the endotracheal tube cuff was significantly associated with the development of complications (p= 0.029). CONCLUSIONS: tracheotomy can be considered a safe practice. There is limited evidence and variability in clinical practice in terms of care for patients with tracheotomy. The use of protocols including aspects such as the management of the endotracheal tube cuff, swallowing or phonation, among others, could increase the quality and safety of care for these patients

Ensayo clínico aleatorizado para la comparación de dos métodos de cura de traqueotomía en una Unidad de Cuidados Intensivos / Randomised clinical trial to compare two tracheotomy care methods in an Intensive Care Unit

Introducción: La traqueotomía es una técnica habitual en las Unidades de Cuidados Intensivos (UCI). Es sabido que los cuidados enfermeros durante y posteriores al procedimiento están directamente relacionados con el éxito del mismo, minimizando el riesgo de aparición de complicaciones como la infección del estoma y favoreciendo la adecuada evolución del paciente crítico. Objetivos: Comparar la incidencia de infección en las traqueotomías realizadas en UCI según el antiséptico empleado: cura con polihexanida (PLX) y cura con suero fisiológico + povidona yodada (PY). Material y método: Ensayo experimental, aleatorizado y abierto, realizado en una UCI polivalente de 32 camas durante 2 años. El estudio fue aprobado por el Comité Ético de Investigación del Principado de Asturias. Resultados: La tasa observada de infecciones por 100 pacientes-día de traqueotomía fue de 1,34 (IC del 95%, 0,81-2,01): 1,46 en PLX y 1,21 PY (p valor 0,685). Conclusiones: A pesar de que el tratamiento experimental (PLX) ha mostrado su eficacia en otro tipo de heridas, en nuestro estudio no se encontraron diferencias significativas entre esta técnica y la estándar. Dado que no existe un registro nacional de incidencia de infección asociada a traqueotomías, no se puede saber si la observada está dentro de los parámetros habituales

Introduction: Tracheotomy is a common technique in Intensive Care Units (ICU). It is known that nursing care during and after that procedure is directly related to its success, by reducing the possible complications to a minimum, such as the stoma infection, and contributing to a favourable outcome in critical patients. Objectives: To compare the use of polyhexanide (PLX) versus saline + povidone iodine (PY) as antiseptics and infection incidence in tracheostomies performed in Intensive Care Units. Material and method: A 2-year, experimental, randomised, open-label trial carried out in a multidiscipline ICU with 32 beds. The study was approved by the Research Ethics Committee of Principality of Asturias. Results: The overall infection rate observed for every hundred patients was 1.34 (95% CI; 0.81-2.01), with 1.46 when using PLX and 1.21 for PY (P=.685). Conclusions: In spite of the experimental treatment (PLX) was shown to be effective in other types of wounds in our study. No significant differences were found between this technique and the standard one. Since there is no national registry of tracheotomy- associated infections, it is not possible to know whether the rate observed is within the usual parameters

[Nursing care for tracheotomy and tracheostomy patients]. / Les soins infirmiers aux patients trachéotomisés et trachéostomisés.

Nursing care is specific in otorhinolaryngology, particularly in oncology. The three dimensions of the care, technical, relational and educational, are essential and reflect the quality of the patient management which must be multi-disciplinary.

Plastia de estoma traqueal estenótico en un paciente Laringectomizado / Surgical revision of stenotic tracheal stoma in a post laryngectomy patient

La estenosis del traqueostoma después de laringectomía es una complicación frecuente, con una incidencia entre 4-44%, que implica un reto terapéutico. Puede ocurrir en el posoperatorio temprano o tardío, como consecuencia de disección inadecuada de la piel y grasa periostomal al momento de la creación del estoma, tensión en la piel, dehiscencia de sutura y cierre por segunda intención, infección, cicatriz hipertrófica, radioterapia, uso de esteroides, entre otros. La estenosis estomal puede provocar disminución del flujo de aire, turbulencia e inhabilidad para aclarar secreciones; en todos los casos requiere revisión quirúrgica para aumentar el diámetro del traqueostoma, ya que el uso permanente de una cánula representa grandes desventajas para el paciente. Se han descrito múltiples técnicas de cirugía. Presentamos la técnica quirúrgica aplicada a un paciente con estenosis tardía del traqueostoma, que ha tenido resultados óptimos...

Stenosis of the postlaryngectomy tracheal stoma remains a therapeutic challenge with major impact on patient rehabilitation as consequence of reduced flow of air, turbulence, and inability to clear secretions. Its incidence ranges between 4-44%; it may occur in the early or late postoperative and the most important predisposing factors are the inadequate dissection of the skin and periostomal fat at the time of the creation of the stoma, as well as tension in the skin, dehiscence of sutures with healing by second intention, hypertrophic scars, infection, radiation therapy, and use of steroids, among others. Tracheostomal stenosis can be managed in multiple ways nevertheless in all cases the goal is a widely patent stoma. There have been described many surgical techniques; here, we present a surgical revision technique used in a patient with late stenosis of the tracheostoma who has had optimal results...

Relación entre el momento de la realización de la traqueotomía y la incidencia de neumonía asociada a ventilador, y la mortalidad en adultos en la Unidad de Cuidados Intensivos / Relationship between the tracheostomy and the incidence of ventilator-associated pneumonia and mortality in adults admitted to the Intensive Care Unit

Objetivos: Determinar la asociación entre la traqueotomía precoz (TP) (< 7 días) y la incidencia de neumonía asociada al ventilador (NAV). Materiales y métodos: Estudio observacional analítico de una cohorte retrospectiva de una población de pacientes que requirieron traqueotomía durante su ingreso en la Unidad de Cuidados Intensivos (UCI). Se compararon dos grupos de pacientes: a) traqueotomía precoz (TP) en los primeros siete días; b) traqueotomía tardía (TT) a partir del octavo día. Variables estudiadas: edad, género, compromiso, momento y duración de la intubación orotraqueal (IOT), microorganismos aislados en cultivos de secreción traqueal, incidencia de neumonía asociada a ventilación mecánica (NAV), duración de la estancia en la UCI y mortalidad. Se realizó un modelo de regresión logística multivariado, para determinar los factores asociados al desarrollo de neumonía. Resultados: Se estudiaron 85 pacientes. La media +/– desviación estándar de edad fue de 61,5 +/– 2 años. Los microorganismos aislados con mayor frecuencia fueron Klebsiella pneumoniae (10%), Enterobacter cloacae (6,6%) y Pseudomonas aeruginosa (6,6%). La mediana (rango intercuartílico) del momento (día) de realización de la traqueotomía (p 0,0000) y de la duración de la estancia (días) en la UCI (p 0,0010) fue estadísticamente mayor en el grupo sometido a traqueotomía tardía. La incidencia de NAV fue del 10,5% (9) y la mortalidad en adultos en la UCI fue del 27,3% (23). Conclusiones: La traqueotomía precoz no se asoció significativamente con la incidencia de NAV y la mortalidad, tanto en el análisis crudo como en el ajustado...

Objectives: To determine the association between early tracheostomy (TP) (< 7 days) and incidence of ventilator-associated pneumonia (VAP). Materials and Methods: Observational study of a retrospective cohort of a population of patients who required tracheostomy for admission to Intensive Care Unit (ICU). Data were compared in two groups of patients: a) early tracheostomy (PT) in the first 7 days, b) late tracheostomy (TT) from the 8th day. Variables studied: age, gender, commitment, time and duration of intubation (OTI), microorganisms isolated from tracheal secretion cultures, incidence of ventilator-associated pneumonia (VAP), duration of stay and ICU mortality. We performed a multivariate logistic regression model to determine factors associated with the development of pneumonia. Results: We studied 85 patients, the mean +/– SD age was 61.5 +/– 2.02 years. The most frequently isolated microorganisms were Klebsiella pneumoniae (10%), Enterobacter cloacae (6.6%) and Pseudomonas aeruginosa (6.6%). The median (interquartile range) of time (day) of performing tracheotomy (p 0.0000) and length of stay (days) in the ICU (p 0.0010) was statistically higher in the group receiving late tracheostomy. The incidence of VAP was 10.5% (9) and Adult Mortality in ICU was 27.3% (23). Conclusions: Early tracheotomy was not significantly associated with the incidence of VAP and mortality is crude analysis as the ajusted analysis...

[Care of the tracheostomy in brain injury patients]. / Prise charge des trachéotomies chez les cérébrolésés.

The evolution of a patient suffering from a serious head injury can require the placement of a tracheotomy. This helps with respirator weaning and usually enables the patient to be moved from the neurosurgical intensive care ward to the neurosurgery ward. Patients fitted with a tracheotomy will therefore be cared for by post-intensive care neurological rehabilitation departments.

[Nursing care in the patient with an artificial airway in the intensive care unit]. / Paciente con vía aérea artificial. Atención de enfermería en cuidados intensivos.

INTRODUCTION: Complications related to the artificial airway (endotracheal tube and tracheotomy) in intensive care units are a major health problem that depends largely on the management and care applied to these devices. The daily challenge of nursing professionals is to minimize the incidence of these complications (among which highlights the pneumonia associated with mechanical ventilation). INTERVENTIONS: We analyzed 21 measures related to management of these devices in order to reflect the recommendations based on scientific evidence and provide quality care applied to the patient that need these devices. CONCLUSIONS: Compliance with the standards for care and management of patients with an artificial airways is vital in reducing the incidence of complications associated with these devices. Not all management rules are standardized.

Pediatric tracheotomy wound complications: incidence and significance.

OBJECTIVES: To determine the incidence and to describe wound complications and associated risk factors of pediatric tracheotomy. DESIGN: Retrospective case series. SETTING: Freestanding tertiary care academic pediatric hospital. PATIENTS: Sixty-five consecutive children undergoing tracheotomy over 15 months. MAIN OUTCOME MEASURES: Postoperative wound complications objectively and independently documented by an advanced practice nurse specializing in tracheotomy care. Secondary outcome measures included comorbidities, mortality rates, and wound status after subsequent examinations and management. RESULTS: The mean (SEM) patient age at tracheotomy was 45 (8.7) months (median age, 9.1 months). The most common indication for tracheotomy was pulmonary disease (36.9%), followed by neurologic impairment and laryngeal abnormalities. There were 19 patients (29%) with and 46 patients (71%) without wound complications. There were no significant differences between the 2 groups in age (P = .68) or weight (P = .55); however, infants younger than 12 months had an increased complication rate (39% vs. 17%, P = .04). The type of tracheotomy tube was predictive of postoperative wound complications (P = .02). All patients with wounds received aggressive local wound care. Five of 13 patients had complete resolution of stomal wounds, whereas 8 patients had persistent wound issues. There were 5 non-wound-related mortalities. CONCLUSIONS: With attempts to classify tracheotomy wound breakdowns as reportable events, including never events, increasing emphasis is being placed on posttracheotomy care. This study demonstrates that wound breakdown in pediatric tracheotomy patients is common. These complications can be mitigated, although not prevented completely, with aggressive wound surveillance and specialized wound care.

Cuidados enfermeros relacionados con la traqueotomía percutánea / Nursing care related with percutaneous tracheostomy

La traqueotomía es una técnica empleada para establecer comunicación entre la tráquea y el aire exterior. Frente a la Traqueotomía Quirúrgica(TQ), la Traqueotomía Percutánea (TP) proporciona un acceso traqueal mínimamente invasivo, reduciendo el riesgo de hemorragia e infección pero incrementando las posibilidades de decanulación accidental y la dificultad del cambio de cánula.El propósito de este trabajo es describir los cuidados enfermeros del paciente relacionados con la TP, empleando el lenguaje de las clasificaciones de intervenciones y resultados enfermeros NIC y NOC y exponer el procedimiento para el cambio de la cánula traqueal, por ser una técnica que realiza la enfermera o en la que colabora de forma activa con el médico y de la que se encuentran aportaciones recientes en la bibliografía. Encontramos diferencias de opiniones en cuanto a cuándo realizar el primer cambio de la cánula y a los cuidados del estoma (AU)

Tracheostomy is a technique that is used to establish communication between the trachea and the external air. When compared with Surgical Tracheostomy (ST), percutaneous tracheostomy (PT) provides minimally invasive tracheal access, reducing the risk of haemorrhaging and infection,but also increasing the chances of accidental decannulation and cannula change difficulties.The aim of this work is to describe the nursing care provided to the PT patient, using the language of the NIC and NOC nursing interventions and outcomes classifications and to explain the procedure to change the tracheal cannula, given that it is a technique performed by the nurse orin which the nurse actively collaborates side by side with the physician and for which recent contributions have been found in the literature. We found differences in terms of when to change the cannula for the first time and in terms of stoma care (AU)