Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy

European Journal of Cardio-thoracic Surgery 25 (2004) 541–547 www.elsevier.com/locate/ejcts Weaning from ventilator after cardiac operation using the Ciaglia percutaneous tracheostomy Department of Cardiac Surgery, Villa Torri Hospital, viale Filopanti 12, 40126 Bologna, Italy Received 5 October 2003; received in revised form 2 December 2003; accepted 15 December 2003 Abstract Objective: To determine the predictors of weaning from mechanical ventilation after cardiac operation with the Ciaglia percutaneous dilatational tracheostomy (PDT) in our preliminary experience in the use of this technique. Methods: We prospectively analysed 33 consecutive patients (mean age 70.9 ^ 12.7 years) who underwent PDT in our intensive care unit after cardiac operation. The investigation involved preoperative and postoperative clinical status, operative procedure, indication and timing for PDT. Results: PDT was performed after a mean time of 7.7 ^ 5.0 consecutive days of translaryngeal intubation. Twenty-four (73%) patients were weaned from ventilator after a mean time of mechanical ventilation of 15.8 ^ 9.1 days. Time point of PDT was the only predictor of ventilator weaning ðP ¼ 0:0029Þ: there was significant association between PDT performed before the seventh consecutive day of translaryngeal intubation (early PDT) and successful weaning from ventilator (P ¼ 0:01; odds ratio ¼ 11.2, 95% confidence interval ¼ 1.2 – 104.3). Among the patients weaned from ventilator, those who underwent early PDT had significantly shorter times of mechanical ventilation, and intensive care unit and hospital stays than patients with later PDT (P ¼ 0:035; 0.011 and 0.0073, respectively). Nine (27%) patients died of their underlying disease while still being mechanically ventilated; another six (18%) spontaneously breathing but still incannulated patients died afterward. No major PDTrelated complications were observed. Two minor peristomal bleedings and one self-resolving subcutaneous emphysema were recorded. Conclusions: Early PDT was a safe and effective method to wean from mechanical ventilation the cardiosurgical patients of this series. q 2003 Elsevier B.V. All rights reserved. Keywords: Cardiac operation; Intensive care unit; Respiratory failure; Tracheostomy; Ventilator 1. Introduction Some patients occasionally require prolonged airway control after cardiac operations. In order to avoid complications and disadvantages of long-term translaryngeal intubation, elective tracheostomy technique, open or percutaneous, is considered the treatment of choice for this demanding kind of critically ill patients requiring prolonged mechanical ventilation [1]. However, the conventional open tracheostomy performed with the Jackson’s technique [2] is not a complications-free surgical procedure [3]. Therefore, percutaneous tracheostomy has gained increasing acceptance in intensive care units (ICUs) as an excellent alternative to the surgical tracheostomy: in * Corresponding author. Address: via Pignolini 5, Peschiera d/G, 37019 Verona, Italy. Tel.: þ 39-348-340-2078; fax: þ 39-51-253-854. E-mail address: (G. Gatti). 1010-7940/$ - see front matter q 2003 Elsevier B.V. All rights reserved. doi:10.1016/j.ejcts.2003.12.015 experienced hands, and with proper patient selection, it is feasible at the patient’s bedside, safe, easy, quick, and costeffective [4,5]. Out of all percutaneous tracheostomies, the Ciaglia percutaneous dilatational tracheostomy (PDT) [6] is nowadays the most widely used in ICUs [4]. So far, much has been written about superiority of percutaneous versus open tracheostomy [5,7], as well as on different types of percutaneous tracheostomy [6,8 – 10], but only a limited number of small studies concerning percutaneous tracheostomy in cardiosurgical patients [11 –13]. The purposes of this prospective study were both to analyse our preliminary experience in the use of PDT after cardiac operations and to outline the portrait (if possible) of the cardiosurgical patient who could get greater benefit by PDT for weaning from mechanical ventilation. Giuseppe Gatti*, Gabriele Cardu, Corrado Bentini, Pasqua Pacilli, Peppino Pugliese 542 G. Gatti et al. / European Journal of Cardio-thoracic Surgery 25 (2004) 541–547 2. Materials and methods 2.1. Study patients 2.2. Technique of percutaneous dilatational tracheostomy After informed consent was obtained from the patient and/or her/his relatives, a team composed of one anaesthesiologist and one cardiac surgeon performed PDT according to the Ciaglia and Graniero’s method [18], at the patient’s bedside in ICU. The Ciaglia Percutaneous Tracheostomy Introducer Set (Cook Critical Care, Bjaeverskov, Denmark) was used. Indications for PDT could be all clinical conditions requiring prolonged mechanical ventilation and airway protection. PDT may be also used to facilitate the weaning from ventilator and to obtain optimal pulmonary toilette. Contraindications include refused consent, age , 15 years, airway emergencies, uncontrolled coagulopathy, inability to palpate a deeply underlying trachea, infection of the neck, previous neck surgery or trauma, any other conditions causing deformity of the trachea, and need for a positive end-expiratory pressure . 15 cmH2O [5]. The Ethical Committee of our Institution approves these indications and contraindications for using PDT also in the cardiosurgical patient management. Therefore, we perform immediately an elective PDT in likely long-term ICU patients, providing that a period of translaryngeal intubation and mechanical ventilation longer than 10 days can be reasonably predicted. This prediction is made according to the patient’s preexisting cardiac disease and comorbidities, postoperative complications, current clinical status, as well as the simultaneous fulfillment of two conditions: the new simplified acute physiology score II (SAPS II) [14] $ 30 and the Murray lung injury score (LIS) [15] $ 1 [16]. Between March 2000 and June 2003 (40 months), 1492 patients were admitted or readmitted (3%) to our cardiosurgical ICU. Prediction as to the length of mechanical ventilation was made daily from the second postoperative day for the patients coming out from operation, and from the first day after endotracheal reintubation for the patients taken back to ICU. Above-mentioned contraindications for PDT were never found. Finally, PDT was tried and carried out in 33 (2.2%) cardiosurgical patients, i.e. the population of this study. The reason for ICU-admission of these patients was postoperative management of coronary artery bypass grafting (CABG) (n ¼ 11; 33%), valve procedure (n ¼ 6; 18%), combined CABG and valve procedure (n ¼ 10; 30%), surgery of the thoracic aorta (n ¼ 4; 12%), closure of postinfarction ventricular septal defect (n ¼ 1; 3%), or pericardectomy (n ¼ 1; 3%). Among the 10 (30%) patients who had been readmitted to ICU, the cause of readmission was respiratory failure ðn ¼ 6Þ; low cardiac output ðn ¼ 2Þ; or pneu (...truncated)