| Abstract |
Introduction Retrospective comparative study of classical percutaneous and modified combined tracheostomy (combination of open and percutaneous tracheostomy) in hospitalized patients in Intensive Care Unit. Percutaneous dilatational tracheostomy is a method that is widely applied to Intensive Care Units (ICUs), relatively safe, rapid and practical, even by non-specialists with a low rate of complications compared to conventional tracheostomy. The comparison of the efficacy of this method from the existing literature was made among many different techniques of percutaneous tracheostomy (such as Griggs, Ciaglia, Percutwist, etc.) with conventional open tracheostomy. So it makes sense to have different results when comparing each different percutaneous technique with the basic technique of open tracheostomy. Method In recent years, a new surgical technique has been used in the Intensive Unit of the Venizelion General Hospital of Heraklion (VGNH) which combines the method of open and percutaneous tracheostomy, and was termed "modified or combined" Purpose The purpose of this postgraduate thesis is the retrospective study of comparison of conventional percutaneous versus combined tracheostomy in hospitalized patients in Intensive Care Unit the last eight years. Method and material In the percutaneous tracheostomy, which was applied in the present study, we only used one kind of technique, the single dilator technique, which is performed in the Intensive unit by the existing medical and nursing staff. In this method, based on the patient's anatomy, the point of the puncture is found, and after the trachea has been entered, a wire guide is inserted, followed by a single dilator expansion (Ciaglia type) and insertion of the final tracheostomy tube into the trachea. During the first four years, we observed a number of complications, of which the most important were extra-tracheal tube placement, pneumothorax and intraoperative hemorrhage. In the case of a serious complication, the operation was transformed into open tracheostomy, in the operating room, where the anatomical elements of the area were revealed and intra-tracheal tubular positioning of the tube or ligation of the blood vessels was made under direct vision. Thus, the idea was born to combine the positive characteristics of both methods, namely the simplicity and speed of percutaneous tracheostomy with the safety and accuracy of open tracheostomy. After studying the relevant literature, a part of the open tracheostomy procedure was adopted at the initial stage . In the final stage of the procedure, anterior wall of the trachea is punctured and the tracheostomy tube inserted, as it is performed in the conventional percutaneous technique, only in this case not the skin but the front wall of the trachea is dilated. In this minimally invasive technique using as little as possible the diathermy, bypassing the vessels as much as possible and avoiding the injury of the thyroid isthmus in front of the trachea, the interval between the second and third tracheal ring is palpated. The spot is punctured under direct vision and then the wire guide, the single dilator and finally the tracheostomy tube are inserted. Each technique was used for a four years period and results were compared in a retrospective study. The clinical results, the intraoperative complications of both methods as well as the postoperative outcome of the patients were studied. The study is retrospective and concerns patients who have been hospitalized and tracheostomy was performed in ICU in the last 8 years (2010-2018). Patients were divided into two groups depending on the technique of tracheostomy. In the years 2010-2014, in a total of 182 patients, percutaneous tracheostomy was performed, and in the years 2014-2018 a total of 185 patients were undergoing the combined tracheostomy method. Demographic and clinical characteristics of patients, ventilation of the patient preoperatively and postoperatively, duration of surgery, intraoperative events, later complications, monitoring and outcome 6 months after surgery were recorded. From the statistical analysis of the two groups, we found that with the combination method we had less intraoperative time, lower rate of intraoperative bleeding, pneumothorax, extratracheal tube placement, and reduced need for conversion into an open procedure (p value<0,001). In addition, we had a lower rate of post-operative bleeding and similar rates of surgical wound infections (p value<0,001). Therefore, the combined method seemed to have less complications compared to classical percutaneous tracheostomy. In addition, the correlation of quantitative variables was analyzed over the eight-year study period, and the main finding was that time to release from mechanical breathing is vital to reducing infections, has a negative correlation with survival and positive correlation with hospitalization time.
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