الفهرس 
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Abstract
Tracheostomy is becoming a very common procedure in the ICU , with improvements in critical care medicine over the past 30 years, more patients are surviving initial episodes of acute respiratory failure, trauma, and extensive surgeries and are requiring prolonged periods of mechanical ventilation. It is now common practice to expeditiously convert these patients from translaryngeal intubation to tracheostomy.
Most surgeons prefer the operating room (OR) for the performing of tracheostomy. Unfortunately, the risks of transporting critically ill patients from the ICU may result in increased morbidity. Moreover, the dependency on surgeons, inability to get (OR) time, and other emergencies may delay elective tracheostomy in patients requiring intensive care. Tracheostomy as a surgical procedure reputedly dates back in Egypt some 3500 yr ago. The standard tracheostomy technique was described in 1909 by Jackson .
Percutaneous tracheostomy had largely replaced surgical tracheostomy in the intensive care unit setting. Although it seems logical that surgeons continue to do tracheostomies, anesthesiologists and intensive care specialists are familiar with airway control and guide wire techniques and could replace surgeons in the performance of PDT.
PDT might reduce the number of complications in Egyptian patients. Thus, this study aims to compare to compare the standard surgical tracheostomy technique and the percutaneous dilational tracheostomy technique (PDT) using the Ciaglia technique as regard the complications, and the outcome in critically ill patients.
This is a nonrandamised study was prospectively conducted on sixty critically ill patients who underwent tracheostomy at the Critical Care Medicine Dept., at Cairo University Hospitals, Egypt in the period from January 2010 to January 2011.
Informed written consents had been obtained from the next of kin and the study was approved by the hospital’s ethical committee. Patients with the following indications were included in the study : Prolonged ventilatory support, airway control, pulmonary toilet and airway obstruction.
Patients with the following criteria were excluded from the study: Infection of tracheostomy site, known or expected difficult endotracheal intubation, distorted anatomy with unidentifiable anatomic land marks, previous surgery at the site, bleeding diathesis and those with unstable cervical spine.
Patients were classified into two groups: Group A: 30 patients who underwent surgical tracheostomy in the operating room. Group B: 30 patients who underwent bedside percutaneous tracheostomy in The ICU who were subdivided into two groups B1 which included 15 patients who underwent percutaneous tracheostomy using the multiple dilator technique and group B2 which included 15 patients who underwent percutaneous tracheostomy using the guidewire dilating forcepes.
All patients were evaluated during and after the operation and the following data were recorded: The intra and post operative complications (bleeding, hypoxia, hypotension, pneumothorax, surgical emphysema, false passage, inability to complete the procedure, proceural mortality, wound infection and atelectasis. ABG, Chest x ray, Hb level, mean arterial blood pressure (before and after tracheostomy), duration of the procedure, of ICU stay, of mechanical ventilation, the number of patients who were successfully weaned from mechanical ventilation after tracheostomy and the outcome( death, discharge)
In our study, the baseline demographic characteristics, diagnosis on Intensive Care Unit ( ICU) admission, indications of tracheostomy and co-morbidities were homogenous between both groups without statistical significant difference .In our study, there was no mortality related to either procedure. The PDT was not associated with clinically important hemorrhage (blood loss requiring blood transfusion or surgical intervention), purulent infection at the stoma, or any lethal complication.
The ST group had the following complications after return from the operating room; 3 patients had clinically significant bleeding and required blood transfusion, 5 patients had a minimal bleeding , 5 patients had surgical emphysema which resolved spontaneously, 2 patients with pneumothorax which had been resolved following chest tube drainage,3 patients had atalectasis of one or both lungs, 5 patients were hypoxic and 7 patients were hypotensive which may be due to problems attributed to the transport and 7 patients with stomal infection ( within 1 week) which may had been potentiated by the wide spread tissue dissection required for the surgical technique
The PDT was not associated with clinically significant hemorrhage, purulent infection at the stoma, or any lethal complication. The ST group had 3 patients with stomal infection but no patient suffered pneumothorax, surgical emphysema, hypotension , hypoxia and clinically significant bleeding.
An important finding in our study, which is at variance with many reports, is that the mean duration of translaryngeal intubation before tracheostomy in the percutaneous group i.e (timing of tracheostomy) ( 9.3 ± 2 ) was significally shorter than that in the surgical group ( 20.7 ± 4 ) . This could be explained by the fact that the waiting period between making the decision to perform a tracheostomy and its actual performance is considerably shorter for PDT than ST because operating room availability is not a factor. In addition PDT does not require transfer of potentially unstable patients from the ICU to the operating room.
This early versus late tracheostomy in our study could explain the favorable impact on the outcome in critically ill patients in terms of reduction of mechanical ventilation days , length ICU stay, and mortality in the percutaneous group compared to the surgical group.
In our study, the mean duration of mechanical ventilation in the PCT group (12 ± 3) was significantly shorter than that of the surgical group (25± 5) this could be attributed to earlier application of the tracheostomy in the former group . This was comparable to many reports. the mean duration of ICU stay in the PCT group (20 ± 5) was significantly shorter than that of the surgical group ( 30 ± 5) this could be attributed to earlier application of the tracheostomy in the former group . This was comparable to many reports.In our study, The mean duration of the procedure was significally shorter in the PCT group compared to the ST group ( 8± 4 vs 36 ± 10)
In the present study, the mortality in the PCT group( 16 patients) (54%) was lower than the ST group (25 patients) (83%). This could be attributed to: (a) earlier application of tracheostomy in the PCT group and thus avoiding complications of prolonged intubation.
In our study , the number of patients who were successfully weaned from mechanical ventilation (MV) was significantly higher in the PCT group compared to the ST group ( 12 vs 3 ). On the other hand there was no statistically significant difference between both groups regarding the effect of tracheostomy on arterial blood gases, haemoglobin level, before and after tracheostomy, and coagulation profile before tracheostomy .