Percutaneous dilatational tracheotomy in high-risk ICU patients

BACKGROUND Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT. METHODS PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed. RESULTS In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y12 receptor inhibitor) with iUFH (prophylactic or therapeutic dosage) except for triple therapy (n = 290) and (4) triple therapy (DAPT with iUFH in therapeutic dosage) (n = 149). Within the whole cohort, 74 (11%) bleedings were reported to be procedure-related. Bleeding occurrence during and after PDT was independently associated with low platelet count (OR 0.73, 95% CI 0.56, 0.92, p = 0.009), chronic kidney disease (OR 1.75, 95{\%} CI 1.01, 3.03, p = 0.047) and previous stroke (OR 2.13, 95{\%} CI 1.1, 3.97, p = 0.02). CONCLUSION In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy

Multimodal Evaluation of Long-Term Salivary Gland Alterations in Sarcoidosis

Background: Sarcoidosis is a systemic inflammatory disease characterized by non-caseating granulomas. In addition to the lungs as classical site of affection, extrapulmonary manifestations are common, for example in the cervical lymph nodes or the salivary glands. The aim of this investigation is the analysis of the long-term course of glandular symptoms and the sonographic evaluation of long-term salivary gland changes. Material and methods: All patients with a diagnosis of sarcoidosis over a period of 20 years in the departments of otorhinolaryngology, rheumatology, and pneumology were identified. In addition to clinical examinations and functional evaluation of the salivary glands, a sonographic examination of the salivary glands was carried out. The changes in the area of the salivary glands were assessed using B-mode sonography and different elastographic methods with appropriate scoring systems. Results: A total of 76 patients were included in the study (age 35.1 ± 21.6 years). Overall, 17 patients presented with salivary gland manifestation at the time of the initial diagnosis. Of these patients, 15 received steroid therapy, 6 were also treated with another drug, and 2 patients were not treated with drugs. The time span between initial diagnosis and follow-up was 88.2 months (±83.0). At the time of the initial diagnosis, 17/17 complained of swelling of the salivary glands, 9/17 of xerostomia, and 8/17 of pain in the area of the salivary glands. At the time of follow-up, 5/17 reported swelling of the salivary glands, 6/17 reported xerostomia, and 1/17 reported pain in the salivary gland area. Sonography showed sonomorphological abnormalities of the salivary glands only in individual cases, with only mild alterations on average. Conclusion: In summary, it can be observed that patients with initial symptoms in the area of the salivary glands, such as swelling or pain, also suffer more frequently from dry mouth and eyes. In all patients, however, these symptoms regressed over time. A previous diagnosis of sarcoidosis with involvement of the salivary glands only leads to permanent abnormalities in the area of the salivary glands in individual cases

Early Bronchoscopy Improves Extubation Rates after Out-of-Hospital Cardiac Arrest: A Retrospective Cohort Analysis

Background: Patients suffering from out-of-hospital cardiac arrest (OHCA) frequently receive a bronchoscopy after being admitted to the ICU. We investigated the optimal timing and the outcome in these patients. Methods: All patients who suffered from OHCA and were treated in our ICU from January 2013 to December 2018 were retrospectively analyzed. The data were collected from the patients’ medical files, and included duration of mechanical ventilation, antibiotics, microbiological test results and neurological outcome. The outcome was the effect of early bronchoscopy (≤48 h after administration) on the rate of intubated patients on day five and day seven. Results: From January 2013 to December 2018, 190 patients were admitted with OHCA. Bronchoscopy was performed in 111 patients out of the 164 patients who survived the first day. Late bronchoscopy >48 h was associated with higher rates of intubation on day five (OR 4.94; 95% CI 1.2–36.72, 86.7% vs. 55.0%, p = 0.036) and day seven (OR 4.96; 95% CI 1.38–24.69; 80.0% vs. 43.3%, p = 0.019). Conclusion: This study shows that patients who suffered from OHCA might have a better outcome if they receive a bronchoscopy early after hospital admission. Our data suggests an association of early bronchoscopy with a shorter intubation period

Percutaneous dilatational tracheotomy in high-risk ICU patients

Background!#!Percutaneous dilatational tracheotomy (PDT) has become an established procedure in intensive care units (ICU). However, the safety of this method has been under debate given the growing number of critically ill patients with high bleeding risk receiving anticoagulation, dual antiplatelet therapy (DAPT) or even a combination of both, i.e. triple therapy. Therefore, the purpose of this study, including such a high proportion of patients on antithrombotic therapy, was to investigate whether PDT in high-risk ICU patients is associated with elevated procedural complications and to analyse the risk factors for bleeding occurring during and after PDT.!##!Methods!#!PDT interventions conducted in ICUs at 12 European sites between January 2016 and October 2019 were retrospectively analysed for procedural complications. For subgroup analyses, patient stratification into clinically relevant risk groups based on anticoagulation and antiplatelet treatment regimens was performed and the predictors of bleeding occurrence were analysed.!##!Results!#!In total, 671 patients receiving PDT were included and stratified into four clinically relevant antithrombotic treatment groups: (1) intravenous unfractionated heparin (iUFH, prophylactic dosage) (n = 101); (2) iUFH (therapeutic dosage) (n = 131); (3) antiplatelet therapy (aspirin and/or P2Y!##!Conclusion!#!In this international, multicenter study bronchoscopy-guided PDT was a safe and low-complication airway management option, even in a cohort of high risk for bleeding on cardiovascular ICUs. Low platelet count, chronic kidney disease and previous stroke were identified as independent risk factors of bleeding during and after PDT but not triple therapy