Recruitment maneuver in prevention of hypoxia during percutaneous dilational tracheostomy: Randomized trial

BACKGROUND: Percutaneous dilational tracheostomy (PDT) can potentially lead to hypoxia and alveolar derecruitment. The aim of this prospective study was to evaluate the efficacy of performing a recruitment maneuver (RM) before tracheostomy, in order to improve oxygenation. METHODS: We enrolled 29 eligible trauma patients with acute lung injury criteria requiring tracheostomy in a university ICU. Subjects were ventilated on volume controlled mechanical ventilation (tidal volume of 6 mL/kg) and FIO2set at 1.0. Subjects were randomized into 2 groups: RM group (subjects who underwent RM 10 min before PDT, 15 subjects) and no-RM group (subjects without application of RM before PDT, 14 subjects). RM was performed by imposition of continuous positive airway pressure of 40 cm H2O for 40 seconds. We collected gas exchange, respiratory, and hemodynamic data 5 times: 1 hour before RM, 5 min after RM, 5 min after PDT, 30 min after PDT, and 6 hours after PDT. RESULTS: Subjects who underwent RM had a significant increase in PaO2; 5 min after the maneuver, PaO2increased from 222.6 \uc2\ub1 33.4 mm Hg to 341.3 \uc2\ub1 33.1 mm Hg (P <.01) and was always significantly maintained throughout the following times of the study, compared to the no-RM group: in the RM and no-RM groups, respectively, 260.7 \uc2\ub1 35.4 mm Hg vs 108.5 \uc2\ub1 36.9 mm Hg 5 min after PDT; 285.6 \uc2\ub1 29.1 mm Hg vs 188.4 \uc2\ub1 21.4 mm Hg 30 min after PDT; and 226.3 \uc2\ub1 24.8 mm Hg vs 147.6 \uc2\ub1 42.8 mm Hg 6 h after PDT (P <.01). CONCLUSIONS: Our study suggests that application of RM before PDT could be useful to avoid hypoxemia following such procedure, by reducing fall in PaO2and preventing the decrease in oxygenation values below baseline at 6 hours. \uc2\ua9 2012 Daedalus Enterprises

Percutaneous vascular cannulation for extracorporeal life support (ECLS): A modified technique

Purpose: Vascular access and cannulation are crucial issues to maximize the efficiency of extracorporeal circulation techniques and to preserve patients' safety. Techniques of cannulation have changed over the years, from surgical cutdown to percutaneous approaches, which are now considered standard practice. We describe an original modified percutaneous cannulation technique developed in our Department and we report our clinical experience and complications observed. Methods: A Seldinger technique utilizing 3 guidewires with passage of a dilator over each guidewire was used. Two concentric pursestring sutures, prepared before cannulation, minimize procedureassociated bleeding. Cannulation is performed under direct fluoroscopic control. Results: From 1997 to 2009, 38 patients (31 VV-ECLS, 7 VA-ECLS) have been cannulated using our technique, resulting in a total of 69 venous cannulations. Average external caliber of venous cannulae was 23 Fr (15-29 Fr). Mean duration of the entire cannulation procedure was 40 minutes (20-60 min). Adverse events occurred in 3 patients. Conclusions: The technique described is safe and feasible and the incidence of procedure-related complications is very low, but it may require longer time to be performed. \uc2\ua9 2010 Wichtig Editore