A bstract Introduction Tracheostomy is among the common procedures performed in the intensive care unit (ICU), with percutaneous dilatational tracheostomy (PDT) being the preferred technique. We sought to understand the current practice of tracheostomy in Indian ICUs. Materials and methods A pan-India multicenter prospective observational study, endorsed and peer-reviewed by the Indian Society of Critical Care Medicine (ISCCM), on various aspects of tracheostomy performed in critically ill patients was conducted between September 1, 2019 and December 31, 2019. The SPSS software was used for the statistical analysis. Cross tables were generated and the chi-square test was used for testing of association. The p value < 0.05 was considered statistically significant. Results Out of 67 ICUs that participated, 88.1% were from private sector hospitals. A total of 923 tracheostomies were performed during the study period; out of which, 666 were PDT and 257 were surgical tracheostomy (ST). Coagulopathic patients received more platelet transfusion [ p = 0.037 with platelet count (PC) < 50 × 10 9 , p = 0.021 with PC 50–100 × 10 9 ] and fresh frozen plasma transfusion in the ST group ( p = 0.0001). The performance of PDT vs ST by day 7 of admission was 28.4% vs 21% ( p = 0.023). The single dilator technique (60.4%) was the preferred technique for PDT followed by the Grigg's forceps and then the multiple dilator technique. Fiberoptic bronchoscope (FOB) and ultrasonography (USG) were used in 29.3% and 16.8%, respectively, for guidance during tracheostomy. Most of the PDTs were performed by a trained intensivist (74.2%), whereas ST was mostly done by an ENT surgeon (56.8%). Percutaneous dilatational tracheostomy resulted in less hemorrhagic (2.6% vs 7%, p = 0.002) and desaturation complications (2.3% vs 6.6%, p = 0.001) as compared to ST. The duration of procedure was shorter in the PDT group (average shortening by 9.2 minutes) and the ventilator-free days (VFD) were higher in the PDT group. The cost was less in PDT by approximately Rs. 13,104. Conclusion Percutaneous dilatational tracheostomy, especially the single dilator technique, is preferred by clinicians in Indian ICUs. The incidence of minor complications like hemorrhagic episodes is lower with PDT. Percutaneous dilatational tracheostomy was found to be cheaper on cost per patient basis as compared to ST (with or without complications). How to cite this article Gupta S, Tomar DS, Dixit S, Zirpe K, Choudhry D, Govil D, et al . Dilatational Percutaneous vs Surgical TracheoStomy in IntEnsive Care UniT: A Practice Pattern Observational Multicenter Study ...
Introduction: Patients with sepsis have a higher incidence of multiorgan failure, higher ICU stay and higher mortality. The cytokines, both pro and anti-inflammatory are released during an inflammatory insult and they play an important role in the pathogenesis of multiorgan failure and septic shock. The blood purification techniques have been used for few years but the co-relation of reduced cytokine levels with decreased mortality has not been studied. Purpose of study: Retrospective data collection of 10 critically ill septic patients who underwent oXiris TM membrane based Continuous Renal Replacement Therapy (CRRT) and the co-relation of changes in cytokine levels measured during the therapy with the outcome of the patient. Method: We collected the retrospective data on critically ill septic patients who underwent oXiris TM membrane based CRRT. Cytokine levels were measured for all patients who underwent blood purification therapies and every 12 hourly for next 72 hours. We noted the trend in need for vasopressors, oxygenation index, urine output and outcome of the patient. Result: The IL-6 and IL-10 levels were very high in all patients who underwent oXiris TM CRRT. The cytokines levels showed a downward trend by an average of 36% in six patients at the first measurement during the therapy. The rest four patients did not show any appreciable change. The reduction in cytokine levels also co-related with reduction in vasopressor (22%) in the first 12 hours and an increase in urine output (17%). At the end of 72 hours, six patients had almost 70% reduction in cytokine levels and the need for vasopressor reduced by 58% whereas four patients had an unmeasurable change in cytokine levels. All these four patients died within next 2 days whereas only one patient died from the remaining six patients. The PaO2/FiO2 ratio improved in the patients which showed decrease in cytokine levels post oXiris TM therapy. Conclusion: Cytokine reduction co-related strongly with response of the blood purification therapies and also can predict a favorable outcome of the patient.
Objective: To examine the safety and complications associated with percutaneous tracheostomy (PT) in critically ill coagulopathic patients under real-time ultrasound guidance. Materials and methods: Coagulopathy was defined as international normalized ratio (INR) ≥1.5 or thrombocytopenia (platelet count ≤50,000/mm 3 ). Neck anatomy was assessed for all patients before the procedure and was characterized as excellent, good, satisfactory, and unsatisfactory based on the number of vessels in the path of needle. Percutaneous tracheostomy was performed under real-time ultrasound (USG) guidance, with certain modifications to the technique, and patients in both groups were assessed for immediate complications including bleeding. Results: Six hundred and fifty-two patients underwent USG-guided PT. Three hundred and forty-five (52.9%) were coagulopathic before the procedure. Ninety-nine patients (15.2%) had an excellent neck anatomy on USG scan, and 112 patients (62 in coagulopathy group vs 50 in noncoagulopathy group, p value 0.386) had an unsatisfactory neck anatomy for tracheostomy. A total of 42 events of immediate complications were noted in 37 patients (5.7%). No difference was seen in the rate of immediate complications in both groups (5.8% in coagulopathy group vs 5.5% in noncoagulopathy group, p value 0.886). The incidence of minor bleeding in coagulopathic patients was 14 patients (4.1%) and 7 (2.3%) in those without coagulopathy, and this difference was not statistically different (p value-0.199). In the subgroup analysis of patients with significant coagulopathy and unsatisfactory anatomy, no difference was observed in the incidence of immediate complications. Conclusion: This study shows the efficacy and safety of real-time ultrasound-guided PT, even in patients with coagulopathy. Development of thrombocytopenia leads to an increased risk of iatrogenic and unprovoked bleeding and is also associated with increased mortality. 9,11 The use of real-time ultrasound during PT in such patients may increase the safety and decrease the unnecessary use of blood products and their related side effects.
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