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Background: Tracheotomy is a common technique; however, microbiological contamination of the surgical site can increase morbimortality. Up to 90% of patients present a positive culture of the airway. Among the most important related factors is the lack of tracheal cannula replacement and lower airway infections. It is convenient to identify microbiological contamination of surgical site in tracheal secretions samples and the specific microorganism associated. Objective: To determine the factors related to microbiological contamination of surgical site. Material and methods: A prospective cohort study which included patients undergoing tracheotomy was carried out. Tracheal secretion was sampled by direct swabbing for culture during surgery and from the surgical site 5 days after. Results: The initial report showed contamination of samples in 58.3%, and 5 days after in 80.6%, with an incidence of contamination of 22.3%. Initially the main agents identified were Pseudomonas aeruginosa in 13.9% of the cultures, Klebsiella pneumoniae in 11.1% and Enterobacter spp. in 11%. On day 5, the most common agents were Klebsiella pneumoniae in 25% of the cases, Acinetobacter baumannii in 11.1% and Pseudomonas aeruginosa in 11.1. Conclusions: The frequency of microbiological contamination is high. The main agents were Staphylococcus aureus, Klebsiella pneumoniae and Pseudomonas aeruginosa. No risk factors for the presence of post-tracheotomy contamination were identified.
Introducción: la traqueotomía es un procedimiento común; sin embargo, la contaminación microbiológica del sitio quirúrgico puede aumentar la morbimortalidad. Hasta el 90% de los pacientes presentan un cultivo positivo de la vía respiratoria. Como factores relacionados, resaltan la falta de recambio de cánulas traqueales y las infecciones de vías aéreas bajas. Es conveniente identificar la contaminación microbiológica de secreción traqueal del sitio quirúrgico y el microorganismo asociado. Objetivo: determinar los factores relacionados con la contaminación microbiológica del sitio quirúrgico. Material y métodos: se hizo un estudio de cohorte prospectiva que incluyó a pacientes sometidos a traqueotomía. Se tomó cultivo por hisopado directo de secreción traqueal durante la cirugía y del sitio quirúrgico 5 días después. Resultados: la muestra inicial mostró contaminación en 58.3% de los pacientes y a los 5 días postquirúrgicos en 80.6%, con incidencia de contaminación de 22.3%. Inicialmente se aisló Pseudomonas aeruginosa en 13.9% de los casos, Klebsiella pneumoniae en 11.1% y Enterobacter spp. en 11%. Al quinto día se aisló Klebsiella pneumoniae en 25% de los casos, Acinetobacter baumannii en 11.1% y Pseudomonas aeruginosa en 11.1%. Conclusiones: la frecuencia de contaminación microbiológica es alta y se encontraron principalmente Staphylococcus aureus, Klebsiella pneumoniae y Pseudomonas aeruginosa. No se identificaron factores de riesgo para la contaminación postquirúrgica.
Asunto(s)
Staphylococcus aureus , Traqueotomía , Humanos , Estudios Prospectivos , Antibacterianos , Pseudomonas aeruginosaRESUMEN
RESUMEN Objetivo. Describir las principales características demográficas, clínicas, laboratoriales y terapéuticas e identificar si están asociados con la mortalidad en pacientes traqueostomizados. Material y métodos. Estudio de cohorte retrospectiva en pacientes adultos con diagnóstico de COVID-19, ingresados a UCI (Unidad de Cuidados Intensivos) y que requirieron traqueostomía. Se extrajeron datos demográficos, clínicos, laboratoriales y de tratamiento de las historias clínicas de pacientes que ingresaron al Hospital III Daniel Alcides Carrión de Tacna. Para el análisis de supervivencia se empleó el modelo de riesgos proporcionales de Cox y se calcularon los cocientes de riesgo instantáneos (HR) con sus intervalos de confianza al 95% (IC95%). Resultados. Se evaluaron 73 pacientes, el 72,6% eran hombres, las comorbilidades más comunes fueron obesidad (68,5%), diabetes mellitus tipo 2 (35,6%) e hipertensión arterial (34,2%). El 37% de los participantes fallecieron durante la estancia en UCI. La mediana de tiempo desde la intubación hasta la traqueostomía y la duración de esta fue 17 (RIC: 15−21) y 21 (RIC: 3−39) días, respectivamente. El análisis multivariado mostró que los factores asociados a mortalidad, fueron presentar un valor de procalcitonina > 0,50 ng/dL en el momento de la traqueostomía (HRa: 2,40 IC95%: 1,03−5,59) y el nivel de PaO2/FiO2 menor o igual a 150 mmHg, (HRa: 4,44 IC95%: 1,56−12,60). Conclusiones. Los factores asociados a mortalidad al momento de realizar la traqueostomía fueron presentar un valor de procalcitonina > 0,50 ng/dL y un cociente PaO2/FiO2 menor o igual a 150 mmHg.
ABSTRACT Objective: We aimed to describe the main demographic, clinical, laboratory and therapeutic characteristics and to identify whether they are associated with mortality in tracheostomized patients. Material and methods. Retrospective cohort study in adult patients diagnosed with COVID-19, admitted to ICU (Intensive Care Unit) and requiring tracheostomy. Demographic, clinical, laboratory and treatment data were obtained from the medical records of patients admitted to Hospital III Daniel Alcides Carrión in Tacna. The Cox proportional hazards model was used for survival analysis and hazard ratios (HR) with their 95% confidence intervals (95%CI) were calculated. Results. We evaluated 73 patients, 72.6% were men, the most common comorbidities were obesity (68.5%), type 2 diabetes mellitus (35.6%), and arterial hypertension (34.2%). Thirty-seven percent of the participants died during their stay at the ICU. The median time from intubation to tracheostomy and the duration of tracheostomy was 17 (RIC: 15-21) and 21 (RIC: 3-39) days, respectively. Multivariate analysis showed that the factors associated with mortality were procalcitonin > 0.50 ng/dL at the time of tracheostomy (HRa: 2.40 95%CI: 1.03-5.59) and a PaO2/FiO2 ratio less than or equal to 150 mmHg (HRa: 4.44 95%CI: 1.56-12.60). Conclusions. The factors associated with mortality at the time of tracheostomy were procalcitonin > 0.50 ng/dL and a PaO2/FiO2 ratio less than or equal to 150 mmHg.
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Humanos , Masculino , Femenino , TraqueotomíaRESUMEN
OBJECTIVE: To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning. METHODS: A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2µgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O. RESULTS: Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality. CONCLUSION: Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group.ClinicalTrials.gov Registry: NCT03128086.
Asunto(s)
Respiración Artificial , Desconexión del Ventilador , Humanos , Respiración con Presión Positiva , Grupos Control , Unidades de Cuidados IntensivosRESUMEN
de la deglución, los cuales representan todas las alteraciones del proceso fisiológico encargado de llevar el alimento desde la boca al esófago y después al estómago, salvaguardando siempre la protección de las vías respiratorias. OBJETIVO. Definir el manejo óptimo, de la disfagia en pacientes con antecedente de infección severa por COVID-19. METODOLOGÍA. Se realizó una revisión de la literatura científica en las bases de datos PubMed y Elsevier que relacionan el manejo de la disfagia y pacientes con antecedente de infección severa por SARS-CoV-2. Se obtuvo un universo de 134 artículos que cumplieron los criterios de búsqueda. Se seleccionaron 24 documentos, para ser considerados en este estudio. RESULTADOS. La incidencia de disfagia posterior a infección severa por SARS-CoV-2 fue del 23,14%, siendo la disfagia leve la más frecuente 48,0%. Los tratamientos clínicos más empleados en el manejo de la disfagia fueron rehabilitación oral y cambio de textura en la dieta en el 77,23% de los casos, mientras que el único tratamiento quirúrgico empleado fue la traqueotomía 37,31%. Un 12,68% de pacientes recuperó su función deglutoria sin un tratamiento específico. La eficacia de los tratamientos clínicos y quirúrgicos en los pacientes sobrevivientes de la infección severa por SARS-CoV-2 fue del 80,68%, con una media en el tiempo de resolución de 58 días. CONCLUSIÓN. La anamnesis es clave para el diagnóstico de disfagia post COVID-19. El tratamiento puede variar, desde un manejo conservador como cambios en la textura de la dieta hasta tratamientos más invasivos como traqueotomía para mejorar la función deglutoria.
INTRODUCTION. The difficulty to swallow or dysphagia is included within the problems of swallowing, which represent all the alterations of the physiological process in charge of carrying the food from the mouth to the esophagus, and then to the stomach, always taking into account the protection of the airways. OBJECTIVE. To define the optimal management, both clinical and surgical, for the adequate treatment of dysphagia produced as a consequence of severe SARS-CoV-2 infection. METHODOLOGY. A review of the scientific literature was carried out using both PubMed and Elsevier databases, which relate the management of dysphagia and patients with a history of severe SARS-CoV-2 infection. RESULTS. The incidence of dysphagia following severe SARS-CoV-2 infection was of 23,14%, with mild dysphagia being the most frequent 48,00%. The most frequently used clinical treatments for dysphagia management were oral rehabilitation and change in dietary texture in 77,23% of cases, while tracheotomy was the only surgical treatment used 37,31%. A total of 12,68% of patients recovered their swallowing function without specific treatment. The efficacy of clinical and surgical treatments in survivors of severe SARS-CoV-2 infection was 80,68%, with a mean resolution time of 58 days. CONCLUSION. An adequate medical history is key to the diagnosis of post-COVID-19 dysphagia. Treatment can range from conservative management such as changes in diet texture to more invasive treatments such as tracheotomy to improve swallowing function.
Asunto(s)
Rehabilitación , Respiración Artificial , Traqueotomía , Trastornos de Deglución/terapia , Deglución/fisiología , COVID-19 , Otolaringología , Rehabilitación de los Trastornos del Habla y del Lenguaje , Enfermedades Respiratorias , Habla , Atención Terciaria de Salud , Neumología , Trastornos de Deglución , Mecánica Respiratoria , Nutrición Enteral , Aerofagia , Disgeusia , Ecuador , Terapia por Ejercicio , Patólogos , Gastroenterología , Anosmia , Nervio Glosofaríngeo , Unidades de Cuidados Intensivos , Intubación IntratraquealRESUMEN
El carcinoma papilar tiroideo es el tipo de cáncer más común de esta glándula, y su tratamiento de elección es la tiroidectomía. Entre las complicaciones asociadas resalta la parálisis de las cuerdas vocales, la cual ocurre por una lesión directa del nervio laríngeo recurrente durante la cirugía. Se presenta una paciente de 22 años de edad con este diagnóstico, a la cual se le realizó una tiroidectomía total; en el postoperatorio inmediato la paciente comenzó con estridor laríngeo intenso que requirió una traqueotomía de urgencia. En el examen físico se constató una parálisis bilateral de las cuerdas vocales y se decidió comenzar un tratamiento de rehabilitación del nervio recurrente laríngeo con laserterapia y HIVAMAT-200 como modalidades combinadas. Los resultados alcanzados con la fisioterapia fueron satisfactorios y la paciente se reintegró rápidamente a su ámbito familiar, escolar y social.
Papillary thyroid carcinoma is the most common type of cancer of this gland, and its treatment of choice is thyroidectomy. Vocal cord paralysis stands out among the associated complications, in which a direct injury to the recurrent laryngeal nerve occurs during surgery. We present a 22-year-old female patient with this diagnosis, who underwent a total thyroidectomy; in the immediate postoperative period the patient began with intense laryngeal stridor requiring an emergency tracheotomy. Physical examination revealed bilateral vocal cord paralysis and it was decided to begin rehabilitation treatment of the recurrent laryngeal nerve with laser therapy and HIVAMAT-200 as combined modalities. The results achieved with physiotherapy were satisfactory and the patient was quickly reintegrated into her family, school and social environment.
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Tiroidectomía , Traqueotomía , Parálisis de los Pliegues Vocales , Cáncer Papilar TiroideoRESUMEN
La policondritis recidivante es una enfermedad autoinmune, de etiología desconocida, infrecuente, caracterizada por lesiones inflamatorias recidivantes, afecta las estructuras cartilaginosas, el sistema cardiovascular y los órganos de los sentidos. Se presenta una paciente femenina de 31 años de edad, con antecedentes de trastornos menstruales, hipertensión arterial, diabetes mellitus, y colagenopatía en la familia. Que presenta un cuadro clínico que evoluciona desde dolores articulares hasta condritis nasal, auricular y traqueal, además de alteraciones vestibulococleares, lo que conllevan al diagnóstico de policondritis recidivante. Actualmente presenta una traqueotomía permanente y responde favorablemente al tratamiento.
Relapsing polychondritis is a rare autoimmune disease of unknown etiology, characterized by recurrent inflammatory lesions, which affects cartilaginous structures, the cardiovascular system and the sense organs. A 31-year-old female patient is presented, with a history of menstrual disorders, arterial hypertension, diabetes mellitus, and collagenosis in the family. Which presents a clinical picture that evolves from joint pain to nasal, auricular and tracheal chondritis, as well as vestibulocochlear alterations, which lead to the diagnosis of relapsing polychondritis. Nowadays has a permanent tracheostomy and is responding favorably to treatment.
RESUMEN
ABSTRACT Objective: To investigate whether protocol-directed weaning in neurocritical patients would reduce the rate of extubation failure (as a primary outcome) and the associated complications (as a secondary outcome) compared with conventional weaning. Methods: A quasi-experimental study was conducted in a medical-surgical intensive care unit from January 2016 to December 2018. Patients aged 18 years or older with an acute neurological disease who were on mechanical ventilation > 24 hours were included. All patients included in the study were ready to wean, with no or minimal sedation, Glasgow coma score ≥ 9, spontaneous ventilatory stimulus, noradrenaline ≤ 0.2μgr/kg/ minute, fraction of inspired oxygen ≤ 0.5, positive end-expiratory pressure ≤ 5cmH2O, maximal inspiratory pressure < -20cmH2O, and occlusion pressure < 6cmH2O. Results: Ninety-four of 314 patients admitted to the intensive care unit were included (50 in the Intervention Group and 44 in the Control Group). There was no significant difference in spontaneous breathing trial failure (18% in the Intervention Group versus 34% in the Control Group, p = 0.12). More patients in the Intervention Group were extubated than in the Control Group (100% versus 79%, p = 0.01). The rate of extubation failure was not signifiantly diffrent between the groups (18% in the Intervention Group versus 17% in the Control Group; relative risk 1.02; 95%CI 0.64 - 1.61; p = 1.00). The reintubation rate was lower in the Control Group (16% in the Intervention Group versus 11% in the Control Group; relative risk 1.15; 95%CI 0.74 - 1.82; p = 0.75). The need for tracheotomy was lower in the Intervention Group [4 (8%) versus 11 (25%) in the Control Group; relative risk 0.32; 95%CI 0.11 - 0.93; p = 0.04]. At Day 28, the patients in the Intervention Group had more ventilator-free days than those in the Control Group [28 (26 - 28) days versus 26 (19 - 28) days; p = 0.01]. The total duration of mechanical ventilation was shorter in the Intervention Group than in the Control Group [5 (2 - 13) days versus 9 (3 - 22) days; p = 0.01]. There were no diffrences in the length of intensive care unit stay, 28-day free from mechanical ventilation, hospital stay or 90-day mortality. Conclusion: Considering the limitations of our study, the application of a weaning protocol for neurocritical patients led to a high percentage of extubation, a reduced need for tracheotomy and a shortened duration of mechanical ventilation. However, there was no reduction in extubation failure or the 28-day free of from mechanical ventilation compared with the Control Group. ClinicalTrials.gov Registry:NCT03128086
RESUMO Objetivo: Investigar se o desmame por protocolo em pacientes neurocríticos reduz a taxa de falha de extubação (desfecho primário) e as complicações associadas (desfecho secundário) em comparação com o desmame convencional. Métodos: Realizou-se um estudo quase experimental em uma unidade de terapia intensiva médico-cirúrgica de janeiro de 2016 a dezembro de 2018. Foram incluídos pacientes com 18 anos de idade ou mais, com doença neurológica aguda e em ventilação mecânica > 24 horas. Todos os pacientes incluídos no estudo estavam prontos para o desmame, com nenhuma ou mínima sedação, escala de coma de Glasgow ≥ 9, estímulo ventilatório espontâneo, noradrenalina ≤ 0,2μgr/kg/minuto, fração inspirada de oxigênio ≤ 0,5, pressão expiratória positiva final ≤ 5cmH2O, pressão inspiratória máxima < -20cmH2O e pressão de oclusão < 6cmH2O. Resultados: Foram incluídos 94 dos 314 pacientes admitidos à unidade de terapia intensiva, sendo 50 no Grupo Intervenção e 44 no Grupo Controle. Não houve diferença significativa na falha do ensaio respiratório espontâneo (18% no Grupo Intervenção versus 34% no Grupo Controle, p = 0,12). Foram extubados mais pacientes no Grupo Intervenção do que no Controle (100% versus 79%; p = 0,01). A taxa de falha de extubação não foi significativamente diferente entre os grupos (18% no Grupo Intervenção versus 17% no Grupo Controle, risco relativo de 1,02; IC95% 0,64 - 1,61; p = 1,00). A taxa de reintubação foi menor no Grupo Controle (16% no Grupo Intervenção versus 11% no Grupo Controle; risco relativo de 1,15; IC95% 0,74 -1,82; p = 0,75). A necessidade de traqueotomia foi menor no Grupo Intervenção [4 (8%) versus 11 (25%) no Grupo Controle; risco relativo de 0,32; IC95% 0,11 - 0,93; p = 0,04]. Aos 28 dias, os pacientes do Grupo Intervenção tinham mais dias sem ventilador do que os do Grupo Controle [28 (26 - 28) dias versus 26 (19 - 28) dias; p = 0,01]. A duração total da ventilação mecânica foi menor no Grupo Intervenção do que no Controle [5 (2 - 13) dias versus 9 (3 - 22) dias; p = 0,01]. Não houve diferenças no tempo de internação na unidade de terapia intensiva, 28 dias sem ventilação mecânica, internação hospitalar ou mortalidade em 90 dias. Conclusão: Considerando as limitações de nosso estudo, a aplicação de um protocolo de desmame em pacientes neurocríticos levou à maior proporção de extubação, à menor necessidade de traqueotomia e à menor duração da ventilação mecânica. Entretanto, não houve redução na falha de extubação ou 28 dias sem ventilação mecânica em comparação com o Grupo de Controle. Registro ClinicalTrials.gov:NCT03128086
RESUMEN
Resumen: El uso de equipo de protección personal, en especial protección ocular, limita la visión al momento de llevar a cabo procedimientos quirúrgicos en área COVID. Estas limitaciones nos obligan a hacer modificaciones en procedimientos habituales, en esta ocasión se realizó una modificación a la incisión habitual del procedimiento de traqueostomía abierta. Se hizo una modificación descrita en bibliografías previas en la orientación de la incisión, cambiando la orientación habitual de la incisión horizontal a una incisión vertical, conservando el resto de la técnica y disección de planos habituales así como colocación de cánula. La modificación de la técnica tiene como objetivo disminuir el riesgo de complicaciones ocasionadas por la poca visión por parte del equipo de protección personal. Dentro de estas complicaciones se incluyen disminuir el riesgo de lesión a grandes vasos que por anatomía se encuentran en sitio anatómico a procedimiento, mejorar las condiciones de visión al ser un único plano de disección muscular y aponeurótico, disminuir sangrado transoperatorio al incidir en línea media, con ello reducir el riesgo de complicaciones y mejorar las condiciones de visión del operador.
Abstract: The use of personal protective equipment, especially eye protection, limits vision when performing surgical procedures in the COVID area, these limitations force us to make modifications to usual procedures, on this occasion a modification is made to the usual incision of the procedure open tracheostomy. A modification described in previous bibliographies was made, modifying the orientation of the incision, changing the usual orientation of the horizontal incision to a vertical incision, preserving the rest of the technique and dissection of the usual planes as well as placement of the cannula. The modification of the technique aims to reduce the risk of complications caused by poor vision due to personal protective equipment, within these complications to reduce the risk of injury to large vessels that by anatomy are in the anatomical site of the procedure, improve the vision conditions as it is a single muscle and aponeurotic dissection plane, reduce transoperative bleeding by incising in the midline, thereby reducing the risk of complications, improving the operator's vision conditions and reducing the risk of infection of personal health.
Resumo: O uso de equipamentos de proteção individual, principalmente proteção ocular, limita a visão ao realizar procedimentos cirúrgicos na área COVID. Essas limitações nos obrigam a fazer modificações nos procedimentos usuais, nesta ocasião foi feita uma modificação na incisão usual do procedimento de traqueostomia aberta. Realizou-se uma modificação descrita em bibliografias anteriores modificando a orientação da incisão, mudando a orientação usual da incisão horizontal para uma incisão vertical, mantendo o resto da técnica e dissecção dos planos habituais, bem como a colocação da cânula. A modificação da técnica visa diminuir o risco de complicações causadas pela má visão por equipamentos de proteção individual, dentro dessas complicações diminuir o risco de lesão de grandes vasos que pela anatomia estão no local anatômico do procedimento, melhorar as condições de visão ao ser um único plano de dissecção muscular e aponeurótica, reduzindo o sangramento intraoperatório por incisão na linha média, diminuindo assim o risco de complicações, melhorando as condições de visão do operador.
RESUMEN
BACKGROUND: Percutaneous dilation tracheostomy is an aerosol-generating procedure carrying a documented infectious risk during respiratory virus pandemics. For this reason, during the COVID-19 outbreak, surgical tracheostomy was preferred to the percutaneous one, despite the technique related complications increased risk. METHODS: We describe a new sequence for percutaneous dilation tracheostomy procedure that could be considered safe both for patients and healthcare personnel. A fiberscope was connected to a video unit to allow bronchoscopy. Guidewire positioning was performed as usual. While the established standard procedure continues with the creation of the stoma without any change in mechanical ventilation, we retracted the bronchoscope until immediately after the access valve in the mount tube, allowing normal ventilation. After 3 minutes of ventilation with 100% oxygen, mechanical ventilation was stopped without disconnecting the circuit. During apnea, the stoma was created by dilating the trachea and the tracheostomy cannula was inserted. Ventilation was then resumed. We evaluated the safeness of the procedure by recording any severe desaturation and by performing serological tests to all personnel. RESULTS: Thirty-six patients (38%) of 96 underwent tracheostomy; 22 (23%) percutaneous dilation tracheostomies with the new approach were performed without any desaturation. All personnel (150 operators) were evaluated for serological testing: 9 (6%) had positive serology but none of them had participated in tracheostomy procedures. CONCLUSION: This newly described percutaneous dilation tracheostomy technique was not related to severe desaturation events and we did not observe any positive serological test in health workers who performed the tracheostomies.
Asunto(s)
COVID-19 , Traqueostomía , Apnea/etiología , Humanos , Pandemias , Respiración Artificial/métodos , Traqueostomía/efectos adversos , Traqueostomía/métodosRESUMEN
Introducción: existe aún una controversia sobre los efectos en los parámetros ventilatorios en pacientes sometidos a una traqueotomía, y los estudios en casos de pacientes con SARS-CoV-2 son escasos. Objetivo: describir los cambios en los parámetros ventilatorios en pacientes operados de traqueotomía por SARS-CoV-2 en la unidad de cuidados intensivos (UCI). Métodos: se realizó un estudio retrospectivo, descriptivo y longitudinal en el que se incluyeron las variables como edad, sexo, comorbilidades, tiempo de intubación, parámetros ventilatorios, gasométricos y el índice de Kirby. Se utilizó estadística descriptiva con medidas de tendencia central y medidas de dispersión. Resultados: se recibieron 493 casos con COVID-19, 133 (26,35 %) ingresaron, 21 fueron operados en la UCI; el género masculino fue 76 % y edad de 56 años; la obesidad y la hipertensión fueron las comorbilidades más comunes, todos con PCR positivo; los parámetros ventilatorios preoperatorios fueron presión positiva al final de la espiración (PEEP) de 7,61 y fracción inspirada de oxígeno (FiO2) de 41,42, la gasometría fue pH de 7,42, presión parcial de oxígeno (pO2) de 95,04, presión parcial de dióxido de carbono (pCO2) de 41,47, bicarbonato (HCO3) de 29,14, saturación de oxígeno (SatO2) de 94,7 %, el índice de Kirby x = 235; y los posoperatorios (PEEP de 7,19 y FiO2 de 40,6), la gasometría fue de pH de 7.44, pO2 de 43,7, pCO2 de 87,7, HCO3 de 27,4, SatO2 de 95,23 %. Fallecieron tres pacientes, dos pacientes complicados con sangrado y un caso con decanulación accidental. El tiempo promedio de ventilación mecánica de fue de 5,7 días. Conclusiones: la traqueotomía generó cambios muy sutiles en los parámetros ventilatorios y gasométricos; sin embargo, la liberación de la ventilación mecánica fue en promedio menor a una semana, desocupando espacio en la UCI.
Introduction: Controversy continues to exist regarding the effects on ventilatory parameters in patients undergoing tracheostomy, and studies in cases with SARS-CoV-2 are scarce. Objective: To describe changes in ventilatory parameters in patients undergoing tracheostomy for SARS-CoV-2 in the intensive care unit. Methods: A retrospective, descriptive, longitudinal study was carried out. Variables such as age, sex, comorbidities, time of IOT, ventilatory parameters, blood gases and the Kirby index were included. Descriptive statistics with measures of central tendency and measures of dispersion were used. Results: n = 493 COVID-19 cases were received, n = 133 (26.35%) were admitted, 21 were operated on in the ICU, male gender was 76%, age 56 years, obesity and hypertension were the most common comorbidities, all With CRP +, the preoperative ventilatory parameters x (PEEP 7.61) and (FiO2 41.42), the blood gas was (pH 7.42), (pO2 95.04), (pCO2 41.47), ( HCO3 29.14), (Saturation O2 94.7%) and the Kirby index x = 235 and postoperative x (PEEP 7.19) and (FiO2 40.6), the blood gas was (pH 7.44), (pO2 43.7), (pCO2 87.7), (HCO3 27.4), (Saturation O2 95.23%). n = 3 died, two patients with bleeding complications and one case with accidental decannulation. The mean time of mechanical ventilation was n = 5.7 days. Conclusions: The tracheostomy generated very subtle changes in the ventilatory and gasometric parameters, however, the release of mechanical ventilation was on average less than one week, emptying space in the ICU.
Asunto(s)
Humanos , Traqueotomía , Respiración Artificial , Síndrome de Dificultad Respiratoria del Recién Nacido , Infecciones por CoronavirusRESUMEN
RESUMEN La enfermedad de multiminicores es un trastorno neuromuscular hereditario caracterizado por la presencia de múltiples 'cores' en biopsia muscular y características clínicas de una miopatía congénita. El presente caso trata de una paciente de 10 años de edad, con diagnóstico de enfermedad neuromuscular multiminicores, traqueostomizada desde los 7 años de edad por destete fallido y debilidad muscular. La paciente fue derivada al Departamento de Rehabilitación Cardio-respiratoria del hospital de Clínicas de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción, presentando en su primera evaluación dependencia crónica de oxígeno (por más de 12 meses), tos débil y no funcional con flujo pico tosido e inferior a 160 L/m, insuficiencia respiratoria crónica e hipercapnia (53 mmHg de CO2ET). Durante su seguimiento en nuestro departamento fueron seguidas las pautas de Rehabilitación Respiratoria contempladas en el Proyecto de evaluación, tratamiento y seguimiento de pacientes con Enfermedades Neuromusculares, y aprobado por el Consejo Superior de la Facultad de Ciencias Médicas de la Universidad Nacional de Asunción, dichas pautas están fundamentadas en los estudios y publicaciones científicas del Dr. John Bach (Rudgers University, Newart, Nueva Jersey-EEUU) y su equipo colaborador del Grupo Iberoamericano de Cuidados Respiratorios en Enfermedades Neuromusculares. Como resultado final del tratamiento y seguimiento aplicado por más de un año la paciente fue decanulada exitosamente, en un consultorio para pacientes ambulatorios, sin descompensaciones hemodinámicas, con una excelente tolerancia y sin requerimiento de internaciones hospitalarias.
ABSTRACT Multiminicores disease is a hereditary neuromuscular disorder characterized by the presence of multiple 'nuclei' on muscle biopsy and clinical features of a congenital myopathy. The present case concerns a 10-year-old patient, diagnosed with multiminicores disease, tracheostomized since she was seven due to failed weaning and muscle weakness. The patient was referred to the Department of Cardio-respiratory Rehabilitation of the Clínicas Hospital from the National University of Asunción, presenting in her first evaluation chronic oxygen dependence (for more than 12 months), weak and non-functional cough with cough peak flow less than 160 L / m, chronic respiratory failure and hypercapnia (52 mmHg CO2ET). We did the follow-up in order to the Respiratory Rehabilitation guidelines contemplated in the Project for the evaluation, treatment and follow-up of patients with Neuromuscular Diseases, which was approved by the Superior Council of the Medical Sciences School from the National University of Asunción, these guidelines are based on scientific studies and publications done by Dr. John Bach (Rudgers University, Newart, New Jersey-USA) and his collaborating team from the Ibero-American Group for Respiratory Care in Neuromuscular Diseases. As a result, the patient was successfully decannulated, in an outpatient clinic, without hemodynamic decompensations, with excellent tolerance and without the requirement of hospital admissions.
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La decanulación es el proceso de retirar la cánula de traqueotomía de forma definitiva, una vez que la patología original que motivó la traqueotomía se haya resuelto o mejorado significativamente.La predicción del éxito de decanulación es difícil debido a la influencia de varios factores. No existe un protocolo universalmente aceptado. Existen diversos protocolos y la elección depende, en gran medida, de cada institución y de la situación individual de cada paciente. Sin embargo, para lograr la decanulación exitosa deben tenerse en cuenta varios criterios esenciales que deben cumplirse independientemente del protocolo elegido.Se señalan las características que debe reunir el paciente apto para la decanulación y se presentan recomendaciones sobre los pasos necesarios para lograr el retiro de la cánula de traqueotomía en el niño de manera segura y minimizando el riesgo de fracaso.
Decannulation is the process of removing the tracheotomy cannula permanently, once the original pathology that led to the tracheotomy has been resolved or significantly improved. The prediction of decannulation success is difficult due to the influence of several factors. There is no universally accepted decannulation protocol. There are several protocols and the choice depends, largely, on each institution and the individual situation of each patient. However, in order to achieve successful decannulation, several essential criteria must be taken into account, which must be fulfilled regardless of the chosen protocol.We indicate the characteristics that the patient must meet for decannulation, and we present recommendations on the necessary steps to achieve the removal of the tracheotomy cannula in a child safely and minimizing the risk of failure.
Asunto(s)
Humanos , Masculino , Femenino , Preescolar , Niño , Traqueotomía , Remoción de Dispositivos/métodos , Pediatría , CánulaRESUMEN
Decannulation is the process of removing the tracheotomy cannula permanently, once the original pathology that led to the tracheotomy has been resolved or significantly improved. The prediction of decannulation success is difficult due to the influence of several factors. There is no universally accepted decannulation protocol. There are several protocols and the choice depends, largely, on each institution and the individual situation of each patient. However, in order to achieve successful decannulation, several essential criteria must be taken into account, which must be fulfilled regardless of the chosen protocol. We indicate the characteristics that the patient must meet for decannulation, and we present recommendations on the necessary steps to achieve the removal of the tracheotomy cannula in a child safely and minimizing the risk of failure.
La decanulación es el proceso de retirar la cánula de traqueotomía de forma definitiva, una vez que la patología original que motivó la traqueotomía se haya resuelto o mejorado significativamente. La predicción del éxito de decanulación es difícil debido a la influencia de varios factores. No existe un protocolo universalmente aceptado. Existen diversos protocolos y la elección depende, en gran medida, de cada institución y de la situación individual de cada paciente. Sin embargo, para lograr la decanulación exitosa deben tenerse en cuenta varios criterios esenciales que deben cumplirse independientemente del protocolo elegido. Se señalan las características que debe reunir el paciente apto para la decanulación y se presentan recomendaciones sobre los pasos necesarios para lograr el retiro de la cánula de traqueotomía en el niño de manera segura y minimizando el riesgo de fracaso.
Asunto(s)
Pediatría , Traqueotomía , Niño , Humanos , Estudios Retrospectivos , Tráquea , TraqueostomíaRESUMEN
Resumen Introducción: actualmente los profesionales de la salud se enfrentan al manejo de las vías aéreas artificiales en grupos pediátricos, esto requiere de cuidados delicados y mucha atención para detectar, establecer y manejar situaciones apremiantes; por esta razón, existe un mayor riesgo de aparición de infecciones bacterianas traqueopulmonares. El objetivo del estudio fue analizar la caracterización de las infecciones en pacientes pediátricos portadores de cánula de traqueotomía en las diferentes publicaciones científicas. Materiales y métodos: se realizó una revisión sistemática mediante la búsqueda de la literatura existente entre los años 2015-2020 en las bases de datos Elsevier, PubMed, Google Académico y SciELO, teniendo en cuenta los criterios de inclusión artículos en idioma inglés, español y población de edad entre los 0-15 años con infección de cánula de traqueotomía en los años 2015-2020. Resultados: de 258 artículos distribuidos en las bases de datos, se seleccionaron 21 artículos que cumplían con los criterios de inclusión. Conclusiones: a pesar de que en la actualidad existan criterios clínicos, factores de riesgo y pruebas de laboratorio asociados a infecciones de la cánula postraqueotomía en pacientes pediátricos, se requiere mayor investigación para definir las guías clínicas de manejo en la toma de decisiones médicas. Asimismo, se consideró como limitación importante la cantidad de literatura existente con respecto al tema.
Abstract Introduction: Currently, health professionals face the management of artificial airways in pediatric groups, this requires delicate care and a lot of attention to detect, establish and manage pressing situations, which is why there is a greater risk of tracheo-pulmonary bacterial infections. The objective was to analyze the characterization of infections in pediatric patients with tracheostomy tubes in the different scientific publications. Method: A systematic review of the literature was carried out between the years 2015-2020 in Elsevier, PubMed, Google Academic and SciELO databases, taking into account the inclusion criteria of the population aged 0-15 years in the years 2015-2020. The amount of existing literature on the subject was considered an important limitation. Results: From 258 articles distributed in the databases, 21 articles were selected that met the inclusion criteria. Conclusions: Although there are currently clinical criteria, risk factors and laboratory tests associated with infections of the post-tracheotomy tube in pediatric patients, further research is required to define clinical guidelines for management in medical decision-making.
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Humanos , Masculino , Femenino , Recién Nacido , Lactante , Preescolar , Niño , Adolescente , Infecciones Bacterianas/etiología , Traqueítis/microbiología , Traqueotomía/efectos adversos , Bronquitis/microbiología , Cánula/efectos adversos , Respiración Artificial/efectos adversos , Infecciones Bacterianas/diagnóstico , Infecciones Bacterianas/tratamiento farmacológico , Traqueítis/diagnóstico , Traqueítis/tratamiento farmacológico , Bronquitis/diagnóstico , Bronquitis/tratamiento farmacológicoRESUMEN
Los progresos en la ciencia y la tecnología en el ámbito de la salud y, en concreto, en la unidad de cuidados intensivos (UCI) hospitalarios han incrementado la supervivencia en la población que demanda atención médica; no obstante, también han generado una población que requiere cuidados y manejos específicos, en su mayoría de manera multidisciplinaria, entre ellos, los pacientes que requieren de atención a traqueotomía. La necesidad de estandarizar el proceso de decanulación es una carencia no cubierta. En esta revisión narrativa exponemos algunos criterios, protocolos o guías vertidas por los autores consultados, sin que hasta el momento exista una guía estandarizada.
Progress in science and technology in the health field, and specifically in the hospital intensive care unit, has increased survival in the population that requires medical care; however, it has also generated a population that requires specific care and management, mostly in a multidisciplinary way, including patients who require attention to a tracheostomy. The need to standardize the decannulation process is an unmet deficiency. In this narrative review, we expose some criteria, protocols or guidelines issued by the authors consulted, so far there is no standardized guide.good surgical and clinical results in the vast majority of cases.
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Humanos , Cánula , TraqueotomíaRESUMEN
RESUMEN Introducción: la COVID-19 causada por el SARS-CoV-2 constituye una amenaza para la salud pública mundial; con mayor efecto negativo en pacientes con comorbilidades y deterioro del estado de salud. Caso clínico: paciente femenina, de color de piel blanca, de 59 años de edad con antecedentes patológicos personales de hipertensión arterial, diabetes mellitus tipo II, enfermedad pulmonar obstructiva crónica y exfumadora con confirmación de COVID-19 por PCR-RT, presentó neumopatía aguda inflamatoria como complicación y evolución satisfactoria. Sin fuente de infección precisada, se aislaron todos los contactos, se estudiaron y fueron negativos a la COVID-19. Conclusiones: se concluye con la presentación de este caso que la pandemia actual significa un desafío para la comunidad científica porque no existe un tratamiento específico contra el SARSCoV-2. No obstante, Cuba utiliza en su protocolo diversos medicamentos que han demostrado efectividad en el control de la enfermedad al lograr la evolución clínica satisfactoria de varios casos críticos.
ABSTRACT Introduction: SARS-CoV-2 (COVID-19) is a threat to global public health; with the most negative effect on patients with comorbidities and weak health status. Clinical case: a 59-year-old, white skinned, female patient with personal pathological history of high blood pressure, diabetes mellitus type II, chronic obstructive pulmonary disease and ex-smoker with confirmed positive PCR-RT (COVID-19 carrier), presented acute inflammatory pneumopathy as a complication and satisfactory evolution. Without a precise source of infection, all contacts were isolated, they underwent to studies and resulted negative to COVID-19. Conclusions: with this case report it is concluded that this pandemic is a challenge for the scientific community because there is not a specific treatment against SARSCoV-2. Nevertheless, Cuba makes use of its protocols of treatment where diverse medicines are included; which have demonstrated effectiveness in the control of the disease, achieving a satisfactory clinical evolution of several critical patients.
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RESUMEN Introducción: el manejo de la vía aérea y la ventilación artificial juega un papel indispensable para mantener las funciones vitales en el paciente crítico, en los infectados por la COVID-19 este manejo posee peculiaridades específicas. Objetivo: Describir el manejo de la vía aérea en el paciente crítico con la COVID-19 Métodos: se realizó una revisión de la literatura, mediante artículos recuperados en MEDLINE, Scopus, ClinicalKey y ScienceDirect publicados hasta mayo de 2020. Desarrollo: la oxigenoterapia resulta útil para mantener niveles de saturación de oxígeno superiores al 96 % en estadios poco avanzados; mediante los sistemas de oxigenación convencional, y la cánula nasal de alta frecuencia. La traqueostomía precoz se debe realizar en pacientes estables con baja demanda de oxígeno en los que se prevea ventilación mecánica prolongada; y en pacientes con la COVID-19 positivos 14 días posteriores al inicio de la intubación orotraqueal. La ventilación mecánica no invasiva mostró menor tasa de intubación con respecto a otras variantes de oxigenación. Se deben configurar parámetros óptimos, teniendo en cuenta las particularidades del paciente. Conclusiones: la intubación se debe realizar mediante una secuencia de inducción rápida, minimizando el tiempo de exposición, la realización de la traqueostomía es de preferencia tardía en el paciente infectado, y la ventilación mecánica no invasiva debe realizarse evitando al máximo la aerosolización. En la ventilación mecánica invasiva resultan útiles estrategias de protección pulmonar, disminución de volúmenes corrientes individualizada a las características y fenotipos del paciente; presión meseta y presión de distensión deseados y la utilización de la ventilación en decúbito prono.
ABSTRACT Introduction: airway management and artificial ventilation play an indispensable role in maintaining vital functions in the critically-ill patient, in those infected with the COVID-19 this management has specific particularities. Objective: to describe airway management in the critically-ill patient with the COVID -19 Methods: a medical literature review was conducted, using articles retrieved from MEDLINE, Scopus, ClinicalKey and ScienceDirect published up to May 2020. Development: oxygen therapy is useful for maintaining oxygen saturation levels above 96% in the less advanced stages; using conventional oxygenation systems and high frequency nasal cannula. Early tracheostomy should be performed in stable patients with low oxygen demand where prolonged mechanical ventilation is expected; and in patients with confirmed COVID-19, 14 days after the starting of orotracheal intubation. Non-invasive mechanical ventilation showed a lower intubation rate than other oxygenation variants. Optimal parameters should be set, taking into account the different characteristics of the patient. Conclusions: intubation should be performed through a rapid induction sequence, minimizing exposure time, tracheostomy is preferably performed late in the infected patient, and non-invasive mechanical ventilation should be performed avoiding aerosolization as much as possible. In invasive mechanical ventilation, strategies for lung protection, reduction of tidal volumes individualized to the characteristics and phenotypes of the patient, desired plateau pressure and distension pressure along with the use of prone ventilation are useful.
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Since the outbreak of novel coronavirus disease (COVID-19) in December 2019, it has spread to various regions and countries, forming a global pandemic. Reducing nosocomial infection is a new issue and challenge for all healthcare systems. Otolaryngology is a high-risk specialty as it close contact with upper respiratory tract mucous, secretions, droplets and aerosols during procedures and surgery. Therefore, infection prevention and control measures for this specialty are essential. Literatures on the epidemiology, clinical characteristics and infection control measures of COVID-19 were reviewed, practical knowledge from first-line otolaryngologists in China, the United States, and Brazil were reviewed and collated. It was recommended that otolaryngology professionals should improve screening in suspected patients with relevant nasal and pharyngeal symptoms and signs, suspend non-emergency consultations and examinations in clinics, and rearrange the working procedures in operating rooms. The guidelines of personal protective equipment for swab sampling, endoscopy and surgery were listed. Indications for tracheotomy during the pandemic should be carefully considered to avoid unnecessary airway opening and aerosol-generation; precautions during surgery to reduce the risk of exposure and infection were illustrated. This review aimed to provide recommendations for otolaryngologists to enhance personal protection against COVID-19 and reduce the risk of nosocomial infection.
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Betacoronavirus , Infecciones por Coronavirus/epidemiología , Control de Infecciones , Otolaringología , Neumonía Viral/epidemiología , Brasil , COVID-19 , China , Infecciones por Coronavirus/prevención & control , Infecciones por Coronavirus/transmisión , Humanos , Pandemias/prevención & control , Equipo de Protección Personal , Neumonía Viral/prevención & control , Neumonía Viral/transmisión , SARS-CoV-2 , Traqueotomía , Estados UnidosRESUMEN
The median thoracotomy is an access incision made longitudinally through the sternum and variants can be subdivided into total vertical and partial upper or partial lower vertical incisions. In surgical practice, using a partial median sternotomy is an alternative option that causes less surgical aggression. The brachiocephalic artery is one of the thoracic vessels most often affected in traumas and it can be accessed via a median sternotomy. This report describes use of an upper partial sternotomy to provide access in a case of traumatic iatrogenic injury of the brachiocephalic trunk.