Evaluation of a new tracheostomy technique for morbidly obese patients on an intensive care unit

Abstract

IntroductionWe previously showed that erythropoietin (EPO) attenuates the morphological signs of spinal cord ischemia/reperfusion (I/R) injury in swine [1] without, however, improving neurological function. The clinical use of EPO has been cautioned most recently due to serious safety concerns arising from an increased mortality in acute stroke patients treated with EPO and simultaneously receiving systemic thrombolysis [2]. Carbamylated EPO (cEPO) is an EPO derivative without erythropoietic activity and devoid of the EPO side eff ects, but with apparently well maintained cytoprotective qualities [3]. We therefore tested the hypothesis whether cEPO may be equally effi cient as EPO in reducing morphological as well as functional aortic occlusion-induced spinal cord I/R injury. Methods In a randomized and blinded trial pigs received either vehicle (control, n = 9), EPO or cEPO, respectively (n = 9 each; 5,000 IU/kg over 30 minutes before and during the fi rst 4 hours of reperfusion). Animals underwent 30 minutes of thoracic aortic balloon occlusion with catheters placed immediately downstream of the A. subclavia and upstream of the aortic trifurcation. Spinal cord function was assessed by motor evoked potentials (MEP as percentage of the amplitude before aortic occlusion) and lower limb refl exes (assessed as the subjective strength of response) for a period of 10 hours after reperfusion. Tissue damage was evaluated using Nissl staining. Results Both EPO-treated and cEPO-treated animals presented with attenuated spinal cord injury in the Nissl staining (median (quartile) percentage of damaged neurons in the thoracic segments: control 27 (25,44), cEPO 8 (4,10), and EPO 5 (5,7), P <0.001 vs control group; in the lumbar segments: control 26 (19,32), cEPO 7 (5,13), EPO 8 (5,10), P <0.001 vs control group). However, while only cEPO treatment was associated with recovery of the MEP amplitude to pre-occlusion values when compared with the control group (P <0.05), lower limb refl ex response was comparably restored stronger in both treatment groups (P <0.05 vs control). Conclusions In a clinically relevant porcine model mimicking aortic crossclamping during vascular surgery repair of thoracic aortic aneurysm, cEPO protected spinal cord function and integrity as eff ective as EPO when applied at equipotent doses. Acknowledgements Supported by the Deutsche Forschungs gemeinschaft (SCHE 899/2-2). References Introduction Unfolded protein response (UPR)-mediated apoptosis plays a pivotal role in ischemia-reperfusion injury. Sodium 4-phenylbutyrate (PBA) has been reported to act as a chemical chaperone inhibiting UPR-mediated apoptosis triggered by ischemia in various organs other than the heart. Therefore we investigated whether PBA reduces UPR-mediated apoptosis and protects against myocardial ischemia-reperfusion injury in mice. Methods C57BL/6 mice were subjected to 30 minutes LAD ischemia followed by reperfusion. PBA (100 mg/kg) or PBS (control) was administrated intraperitoneally just before ischemia. Apoptosis, infarct ...

Complication Rate of Percutaneous Dilatational Tracheostomy in Critically Ill Adults With Obesity

“…Twelve studies included a comparison group without obesity, 4,10,[23][24][25][26][27][28][29][30][31][32] 1 study compared PDTs with OSTs in patients with obesity, 33 and the remaining 5 studies reported solely on PDT outcomes in patients with obesity. [34][35][36][37][38] Table 1 summarizes the study design, included patients, and surgical technique, while Table 2 presents the PDT-associated complication rates.…”

“…The mortality rate in the 15 included studies reporting mortality directly associated with the procedure in individuals with obesity was 0.3% (2 of 727 patients). 4,10,[23][24][25][26]28,29,31,[33][34][35][36][37][38] One patient had a cardiac arrest during a Griggs PDT after having recurrent episodes of ventricular fibrillation in the context of a coronary artery bypass graft requiring intraaortic balloon counterpulsation, while another died the day after PDT from massive hemorrhage secondary to an unidentified subcutaneous vessel. 24…”

“…The rate of serious intraoperative or direct postoperative (ie, within 48 hours of the procedure) life-threatening AEs in 16 studies reporting this outcome measure was 4.0% (30 of 750 patients). 4,10,[23][24][25][26][28][29][30][31][33][34][35][36][37][38] These consisted mainly of intraoperative hypoxemia, 24,30 accidental loss of airway, 4,24,25,33 bleeding requiring an additional surgical procedure, 24,33 and aerodigestive tract injury. 24,29 All reported life-threatening complications, including intraoperative, direct postoperative, or late AEs, are detailed in Table 3.…”

“…Intraoperative or direct postoperative non-life-threatening events were reported in 74 of 750 patients (9.9%) in 16 studies reporting this outcome. 4,10,[23][24][25][26][28][29][30][31][33][34][35][36][37][38] Late, life-threatening AEs were reported in 4 of 112 patients with obesity who underwent PDT (3.6%) from 2 studies reporting this outcome. 4,28 All 4 cases represented accidental decannulations (Table 3).…”

Intensive care management of morbidly obese patients

“…1). 4 Emergency cricothyrotomy in a 'cannot intubate, cannot ventilate' scenario is also potentially more difficult due to increased neck circumference and thickness of subcutaneous tissues, which distorts anatomical landmarks. Cannula cricothyrotomy is considered preferential to needle cricothyrotomy in this group of patients, although evidence supporting one technique over another is limited.…”