Rudas M, Seppelt I, Herkes R, Hislop R, Rajbhandari D, Weisbrodt L.; Crit Care. 2014 Sep 18;18(5):514. [Epub ahead of print]
Introduction: Long-term ventilated intensive care patients frequently require tracheostomy. Although overall risks are low, serious immediate and late complications still arise. Real-time ultrasound guidance has been proposed to decrease complications and improve accuracy of the tracheal puncture. We aimed to compare procedural safety and efficacy of real-time ultrasound guidance with the traditional landmark approach during percutaneous dilatational tracheostomy (PDT).
Methods: A total of 50 patients receiving PDT for clinical indications were randomly assigned, after informed consent, to have the tracheal puncture carried out using either traditional anatomical landmarks or real-time ultrasound guidance. Puncture position was recorded via bronchoscopy. Blinded assessors determined in a standardised fashion the deviation of the puncture off midline and whether appropriate longitudinal position between the first and fourth tracheal rings has been achieved. Procedural safety and efficacy data, including complications and number of puncture attempts required, were collected.
Results: In total 47 datasets were evaluable. Real-time ultrasound guidance resulted in significantly more accurate tracheal puncture. Mean deviation from midline was 15¿±¿3 versus 35¿±¿5 degrees (P¿=¿0.001). The proportion of appropriate punctures, defined a priori as 0¿±¿30 degrees from midline was significantly higher, 20/23 (87%) versus 12/24 (50%) (RR¿=¿1.74; 95% CI¿=¿1.13 to 2.67; P¿=¿0.006). First pass success rate was 20/23 (87%) in the ultrasound and 14/24 (58%) in the landmark group (RR¿=¿1.49, 95% CI¿=¿1.03 to 2.17; P¿=¿0.028). The observed decrease in procedural complications was not statistically significant 5/23 (22%) versus 9/24 (37%) (RR¿=¿0.58; 95% CI¿=¿0.23 to 1.47; P¿=¿0.24).
Conclusions: Ultrasound guidance significantly improved the rate of first-pass puncture and puncture accuracy. Fewer procedural complications were observed however this did not reach statistical significance. These results support wider general use of real-time ultrasound guidance as an additional tool to improve PDT.
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