[Percutaneous dilatational tracheostomy. Critical considerations after one year's experience]

The authors discuss a series of 57 patients submitted to percutaneous dilational tracheostomy (PDT) in an Intensive Care Unit during a fifteen months periods. Patients were admitted for cardiac and/or respiratory failure in 27 cases (47%), sepsis in 13 cases (23%), shock in 12 cases (21%), coma in 5 cases (9%). Length of orotracheal intubation before PDT was 8.3 days +/- 3.9 without significant differences between Apache II and Saps scores at this time (17.4 +/- 6.3 and 20.4 +/- 4.3 respectively) and on admission day (19.3 +/- 6.25 and 20.8 +/- 3.6). The main complications we had to deal with during PDT were damage to previously inserted orotracheal tube, a pneumomediastinum, a small oozing of blood in three cases a serious bleeding in a septic patient with coagulation disorder. After these we performed PDT always coupled with fibrotrachoscopy in the aim to ameliorate PDT safety. On subsequent days the more frequent complication come up at the time of changing tracheal cannula and consisted in troubles ascribed to tracheal shreds (four cases) and one major bleeding after the maneuver always overcome. We also report one death due to impossibility cannula repositioning and subsequent failed intubation in a previously decannulated patient who developed trachobronchial obstruction. Although a supposed midline approach between second and third tracheal rings, was supposed autopsy (performed in three patients) revealed a lateralized cut in one case and an approach higher in another patient. The main advantages in our practice were the absence fo PDT related infections and an optimal and fast tracheal closure after cannula removal. In spite of some limits, this technique has quickly and totally replaced in our practice surgical tracheostomy.