Early or late tracheotomy in patients after polytrauma

Introduction: Prolonged mechanical ventilation in patients after multi-organ trauma is an indication for tracheotomy, as well as to ensure proper toilet of the patient's respiratory tract. Recommendations determining the optimal time for the procedure remain ambiguous. Performing the procedure before the 10th day after intubation is beneficial for the therapy and the patient's health. Aim: The main objective of the study was to analyze the relationship between the timing of tracheotomy and the duration of mechanical ventilation in patients with multiple trauma. The secondary objective was to evaluate the relationship between the timing of the tracheotomy, and the length of stay in the ICU, total length of hospitalization and the incidence of pneumonia and mortality. Material and methods: A retrospective analysis of 124 patients of the Clinical Intensive Care Unit of the Military Institute of Medicine in Warsaw, Poland, who underwent tracheotomy in the years 2015-2019. The patients were divided into 2 groups: (1) patients who underwent the “early tracheotomy” (before day 10 of hospitalization) and (2) patients who underwent “late tracheotomy” (on the 10th day or later) Results: In patients who underwent tracheotomy before the 10th day of hospitalization, the use of mechanical ventilation was shorter (on average by 20.3 days). The duration of stay in the Intensive Care Unit (on average by 39.4 days) and the total time of hospitalization (on average by 43.1 days) were also significantly shorter. The mortality rate among patients with early tracheotomy was lower (2%) compared to patients with late tracheotomy (9%). Complication in the form of pneumonia was more common in patients with tracheotomy performed on day 10 or later. Conclusions: Tracheotomy performed up to the 10th day of hospitalization significantly reduces the duration of mechanical ventilation, the patient's stay in the intensive care unit and the total hospitalization time, and reduces the risk of pneumonia. There is no correlation between the timing of the tracheotomy performed and mortality.

Deep neck infections with and without mediastinal involvement: treatment and outcome in 218 patients

Purpose Infections of the deep neck, although becoming scarcer due to the widespread use of antibiotics, still represent a dangerous and possibly deadly disease, especially when descending into the mediastinum. Due to the different specialities involved in the treatment and the heterogenous presentation of the disease, therapeutic standard is still controversial. This study analyzes treatment and outcome in these patients based on a large retrospective review and proposes a therapeutic algorithm. Methods The cases of 218 adult patients treated with deep neck abscesses over a 10-year period at a tertiary university hospital were analyzed retrospectively. Clinical, radiological, microbiological and laboratory findings were compared between patients with and without mediastinal involvement. Results Forty-five patients (20.64%) presented with abscess formation descending into the mediastinum. Those patients had significantly (all items p < 0.0001) higher rates of surgical interventions (4.27 vs. 1.11) and tracheotomies (82% vs. 3.4%), higher markers of inflammation (CRP 26.09 vs. 10.41 mg/dl), required more CT-scans (3.58 vs. 0.85), longer hospitalization (39.78 vs 9.79 days) and more frequently needed a change in antibiotic therapy (44.44% vs. 6.40%). Multi-resistant pathogens were found in 6.67% vs. 1.16%. Overall mortality rate was low with 1.83%. Conclusion Despite of the high percentage of mediastinal involvement in the present patient collective, the proposed therapeutic algorithm resulted in a low mortality rate. Frequent CT-scans, regular planned surgical revisions with local drainage and lavage, as well as an early tracheotomy seem to be most beneficial regarding the outcome.

Timing of elective tracheotomy and duration of mechanical ventilation amongst patients admitted to intensive care with severe COVID-19: a multicentre prospective cohort study

BackgroundThe COVID-19 pandemic has strained intensive care unit (ICU) resources. Tracheotomy is the most frequent surgery performed on ICU patients and can affect the duration of ICU care. We studied the association between when tracheotomy occurs and weaning from mechanical ventilation, mortality, and intraoperative and postoperative complications.MethodsMulticentre prospective cohort including all COVID-19 patients admitted to ICUs in 36 hospitals in Spain who received invasive mechanical ventilation and tracheotomy between 11 March and 20 July 2020. We used a target emulation trial framework to study the causal effects of early (7 to 10 days post-intubation) versus late (>10 days) tracheotomy on time from tracheotomy to weaning, postoperative mortality, and tracheotomy complications. Cause-specific Cox models were used for the first two outcomes and Poisson regression for the third, all adjusted for potential confounders.FindingsWe included 696 patients, of whom 142 (20·4%) received early tracheotomy. Using late tracheotomy as the reference group, multivariable cause-specific analysis showed that early tracheotomy was associated with faster post-tracheotomy weaning (fully adjusted hazard ratio (HR) [95% confidence interval (CI)]: 1·31 [1·02 to 1·81]) without differences in mortality (fully adjusted HR [95% CI]: 0·91 [0·56 to 1·47]) or intraoperative or postoperative complications (adjusted rate ratio [95% CI]: 0·21 [0·03 to 1·57] and 1·49 [0·99 to 2·24], respectively).InterpretationEarly tracheotomy reduced post-tracheotomy weaning time, resulting in fewer mechanical ventilation days and shorter ICU stays, without changing complication or mortality rates. These results support early tracheotomy for COVID-19 patients when clinically indicated.FundingSupported by the NIHR, FAME, and MRC.Research in contextEvidence before this studyThe optimal timing of tracheotomy for critically ill COVID-19 patients remains controversial. Existing guidelines and recommendations are based on limited experiences with SARS-CoV-1 and expert opinions derived from situations that differ from a pandemic outbreak. Most of the available guidance recommends late tracheotomy (>14 days), mainly due to the potential risk of infection for the surgical team and the high patient mortality rate observed early in the first wave of the COVID-19 pandemic.Recent publications have shown that surgical teams can safely perform tracheotomies for COVID-19 patients if they use adequate personal protective equipment. Early tracheotomy seems to reduce the length of invasive mechanical ventilation without increasing complications, which may release crucial intensive care unit (ICU) beds sooner.The current recommendations do not suggest an optimal time for tracheotomy for COVID-19 patients, and no study has provided conclusions based on objective clinical parameters.Added value of this studyThis is the first study aiming to establish the optimal timing for tracheotomy for critically ill COVID-19 patients requiring invasive mechanical ventilation (IMV). The study prospectively recruited a large multicentre cohort of 696 patients under IMV due to COVID-19 and collected data about the severity of respiratory failure, clinical and ventilatory parameters, and whether patients need to be laid flat during their ICU stay (proned). The analysis focused on the duration of IMV, mortality, and complication rates. We used a prospective cohort study design to compare the ‘exposures’ of early (performed at day 7 to 10 after starting IMV) versus late (performed after day 10) tracheotomy and set the treatment decision time on the 7th day after orotracheal intubation.Implications of all the available evidenceThe evidence suggests that tracheotomy within 10 days of starting COVID-19 patients on mechanical ventilation allows these patients to be removed from ventilation and discharged from ICU quicker than later tracheotomy, without added complications or increased mortality. This evidence may help to release ventilators and ICU beds more quickly during the pandemic.

Head and Neck Symptoms as Predictors of Outcome in Tetanus Patients

ABSTRACT Objective: This study aims to investigate which, if any head and neck symptoms (trismus, dysphagia, alterations in speech or facial movements, and dyspnea) might be good predictors of outcomes (mortality, tracheostomy, discharged, decannulated) and prognosis of tetanus patients. Methods:Design: Retrospective Cohort StudySetting: Tertiary National University HospitalPatients: Seventy-three (73) pediatric and adult patients diagnosed with tetanus and admitted at the emergency room of the Philippine General Hospital between January 1, 2013 and December 31, 2017. Demographic characteristics, incubation periods, periods of onset, routes of entry, head and neck symptoms, stage, and outcomes were retrieved from medical records and analyzed. Results: Of the 73 patients included, 53 (73%) were adults, while the remaining 20 (27%) were pediatric. The three most common head and neck symptoms were trismus (48; 66%), neck pain/ rigidity (35; 48%), and dysphagia to solids (31; 42%). Results of multivariate logistic regression analysis showed that only trismus (OR = 3.742, p = .015) and neck pain/ rigidity (OR = 4.135, p = .015) were significant predictors of decannulation. No dependent variable/symptoms had a significant effect in predicting discharge and mortality. Conclusion: Clinically diagnosed tetanus can be easily recognized and immediately treated. Most of the early complaints are head and neck symptoms that can help in early diagnosis and treatment resulting in better prognosis. In particular, trismus and neck pain/rigidity may predict the outcome of decannulation after early tracheotomy, but not of discharge and mortality.

Clinical Observation of Early Tracheotomy in the Treatment of Craniocerebral Trauma

<p><strong>Objective: </strong>To investigate the clinical effect of early tracheotomy in treatment of severe craniocerebral trauma. <strong>Method: </strong>42 patients of 24 h with traumatic brain injury before tracheotomy were treated as early group, 39 patients with 24 h trauma after tracheotomy were treated as conventional group. Polyvinyl chloride (PVC) tracheotomy tubes were used on all the patients. <strong>Results</strong><strong>: </strong>The treatment time in the early group was significantly shorter than the conventional group. The mortality and the incidence of adverse reactions were significantly lower than that of the conventional group, and the difference was significant between the groups (<em>p </em>&lt; 0.05). <strong>Conclusion: </strong>The efficacy and prognosis of early tracheotomy in patients with severe traumatic brain injury, surgical treatment are good and it is worthy of clinical application.</p><div><div><p> </p></div></div>

Surgery for acute mediastinitis in oesophageal perforations and descending necrotising infection: complications, mortality and protective factors

Acute mediastinitis is a life-threatening situation that is associated with high rates of morbidity and mortality. The most common causes of mediastinitis are: oesophageal perforation, acute necrotising mediastinitis (ANM) and post-sternotomy mediastinitis. The aim of this study was to analyze prognostic factors and the differences between mediastinitis from various origins. A retrospective analysis was carried out on all patients operated on for acute mediastinitis between 2000 and 2009. Surgical interventions were performed on 33 patients (69.7% male), the majority as a consequence of oesophageal perforation (21 cases). The overall mortality rate was 30%. Better survival was seen in subjects less than 60 years of age, subjects with no comorbidities, and subjects who had undergone early tracheotomy. Patients with ANM were younger, had less comorbidities, diagnosed later and required more repeat interventions compared to those patients who had mediastinitis caused by oesophageal perforations. Mortality was lower in the ANM group, but this was not statistically significant. Protective factors in mediastinitis are: early diagnostic and treatment, age under 60 years, absence of major comorbidity and early tracheotomy.