| Abstract | Ciljevi istraživanja: 1.) usporediti učestalost peri- i poslijeoperacijskih komplikacija, temakropatološke nalaze na autopsijskom materijalu bolesnika intenzivnog liječenja nakonprovedene „slijepe" perkutane dilatacijske traheotomije (SPDT) ili ultrazvukom vođene perkutane dilatacijske traheotomije (UTZPDT), 2.) odrediti osobitosti kirurške traheotomije (KT) i UTZPDT, te učestalost peri- i poslijeoperacijskih komplikacija navedenih postupaka u bolesnika s prijelomom vratne kralježnice i ozljedom vratnog dijela kralježnične moždine, akirurški liječenih prednjom fiksacijom vratne kralježnice (prema engl. Anterior Cervical Spine Fixation, ACSF), te 3. istražiti kliničke pokazatelje sigurnosti i učinkovitosti rano provedene UTZPDT u bolesnika s teškom ozljedom glave i mozga (prema engl. Severe Head Injury, SHI).
Ispitanici i metode: Istraživanje je učinjeno u 131 odraslog bolesnika, koji su liječeni u jedinici intenzivnog liječenja (JIL-u) Klinike za anesteziologiju i intenzivno liječenja KBC-a Rijeka, u razdoblju od travnja 1998. godine do srpnja 2005. godine, a podijeljena je u tri uzajamno neovisne studije. U opservacijskom, prvom dijelu istraživanja analizirana je 40 neselektirani bolesnika JIL-a, u kojih je provedena SPDT ili UTZPDT, a koji su kasnije, u razdoblju intenzivnog liječenja, preminuli zbog uzroka neovisnih o provedenom postupku perkutane dilatacijske traheotomije. U prospektivnom, drugom dijelu istraživanja analizirana je 29 produženo strojno ventiliranih bolesnika s ozljedom vratnog dijela kralježnične moždine i ACSFom, u kojih je primijenjena KT ili UTZPDT. U treći dio istraživanja uključena su 62 bolesnika s izoliranom SHI, koji su u prijamu bili komatozni, sa stanjem svijesti sukladno Glasgow koma ljestvic <= 8, te s CT-om potvrđenim ozljedama mozga prema klasifikaciji po Marschall-u 2>= II. U navedenih bolesnika učinjena je rana (5. do 7. dana) ili kasna (10. do 21. dana) UTZPDT. U pacijenata svih istraživanih skupina analizirane su opće demografske osobitosti, različiti klinički pokazatelji, poglavito učestalost pen- i poslijeoperacijskih komplikacija korištenih metoda perkutane kanulacije dušnika, a u prvoj studiji i patoanatomski nalazi dušnika i grkljana.
Rezultati: U bolesnika intenzivnog liječenja u kojih je provedena UTZPDT pronađen je značajno manji broj subkrikoidnih položaja kanile dušnika u odnosu na pacijente sa SPDT (0% vs. 32%: p< 0,05), a nije pronađena razlika u učestalosti prijeloma hrskavica dušnika neposredno uz stomu (28% vs. 36%:p=NS). U navedenih skupina pacijenata nije pronađena statistički značajna razlika u učestalosti ostalih proučavanih peri- i poslijeoperacijskih komplikacija. U bolesnika s ACSFom nisu zabilježene klinički značajne perioperacijske komplikacije povezane s postupkom KT ili UTZPDT. Nije utvrđena niti razlika u učestalosti manje klinički važnih perioperacijskih
komplikacija proučavanih postupaka kanulacije dušnika. Gnojna infekcija stome bila je značajno rjeđa nakon UTZPDT u odnosu na KT (0% vs. 27%: p< 0,05), a trajanje postupka UTZPDT bilo je statistički značajno kraće (8 vs. 24 minute:p< 0,05). U bolesnika sa SHI trajanje strojne ventilacije i dužina intenzivnog liječenja bili su statistički značajno kraći nakon rane u odnosu na kasnu UTZPDT (11 vs. 22 dana i 19 vs. 36 dana:p< 0,05). Nije pronađena statistički značajna razlika u smrtnosti u razdoblju intenzivnog liječenja, te u učestalosti peri- i poslijeoperacijskih komplikacija povezanih s postupcima rane odnosno kasne UTZPDT.
Zaključak: Sveukupni rezultati ove doktorske disertacije dokazali su kako je UTZPDT sigurna i učinkovita metoda kanulacije dušnika u bolesnika intenzivnog liječenja, posebice u skupina pacijenata s ozljedama središnjeg živčanog sustava. |
| Abstract (english) | OBJECTIVES: The aims of our study were: 1.) compare the incidence of peri- and postoperative complications and macropathological findings on the autopsy materials of critically ill patients who underwent originally «blind» percutaneous dilatational tracheostomy (BPDT) method or ultrasonographically guided percutaneous dilatational tracheostomy (USGPDT), 2.) evaluate the features of surgical tracheostomy (ST) and USGPDT as well as the incidence of peri- and postoperative complications of mentioned procedures in patients with cervical spine injury treated by anterior cervical spine fixation (ACSF), and 3.) examine the impact of early USGPDT on outcome in patients with isolated severe head injury (SHI).
PATIENTS AND METHODS: The study was carried out on 131 adult patients who were admitted in the lntensive Care Units (ICU) of the Department of Anesthesiology and Intensive Care of the Clinical Hospital Center Rijeka since April 1998 to July 2005. Investigation was devided in three mutualy independent clinical studies. A opservational part of study was carried out on 40 unselected critically ill patients who had undergone BPDT or USGPDT and who later died to causes unrelated to percutaneous dilatational tracheostomy during the ICU treatment.
Twenty nine patients with cervical spine injury and neurologic deficit, previously treated by ACSF who underwent ST or USGPDT, were prospectively included in the second part of the study. ln the thirth study, sixty two patients with isolated SHI, Glasgow coma scale score 8, structural signs of cerebral contusion on CT scan, according to Marschalls classification II, were prospectively included. These patients were randomly divided in two groups and early (fifth to seventh ICU day) or late (tenth to twenty first ICU day) USGPDT was performed. In the
patients of all investigated groups the demographic findings, different clinical signs as well as the incidence of peri- and postoperative complications related to mentioned procedures were analized. Additionally, in the first part of the study, at autopsy the intercartilaginous space of placement of tracheostomy tube as well as macroscopic findings of cricoid cartilage and tracheal rings were evaluated.
RESUL TS: The subcricoid placement of tracheostomy tube was significantly less frequent in critically ill patients who underwent USGPDT in correlation with the patients after BPDT (0% vs. 32%:p< 0,05). There was no significant difference between the patient groups in the incidence
of tracheal ring fractures arround stoma as well as in the incidence of any peri- and postoperative complications related to BPDT and USGPDT procedures. In patients with cervical spine injury, treated by ACSF, no major complications related to ST or USGPDT were found. There was no
difference in the incidence of minor perioperative complications between USGPDT and ST. USGPDT was associated with lower prevalence of stoma purulent infection (0% vs. 27%: p< 0,05). The mean time of this tracheostomy procedure was significantly shorter (8 vs. 24 minutes:p< 0,05) in comparison with ST in patients with ACSF following cervical spine injury. In patients with SHI and early USGPDT the mean times of mechanical ventilatory support and lenth of stay in ICU were significantly shorter in relation to patients with late USGPDT (11 vs. 22 days and 19 vs. 36 days:p< 0,05). There was no differences in the mortality during the ICU treatment and in the incidence of the tracheostomy related peri- and postoperative complications between early and late USGPDT in patients with SHI.
CONCLUSION: The results of our study clearly established USGPDT as a safe and effective bedside procedure of the trachea puncture, particulary in the intensive care patients with the severe injuries of the central nervous system. |
