Correspondence
Intraoperative variations in blood pressure and heart rate are known to occur7 but the haemodynamic changes were much more pronounced in our patient during tumour manipulation and excision compared with phaeochromocytoma. We also suggest that total thyroidectomy and radical neck dissection for cancer is likely to be prolonged and the surgery should be staggered for minimizing haemodynamic changes and the use of an EMG reinforced endotracheal tube for intraoperative recurrent laryngeal nerve monitoring may be helpful.
Acknowledgements
Declaration of interest None declared.
References 1. Bordi C. Multiple endocrine neoplasia (MEN)-associated tumours. Dig Liver Dis 2004; 36: S31–4 2. Thakker RV. Multiple endocrine neoplasia. Home Res 2001; 56: 67–72 3. Tauzin-Fin P, Sesay M, Gosse P, Ballanger P. Effects of perioperative alpha1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth 2004; 92: 512–17 4. Ulmer C, Koch KP, Seimer A, et al. Real-time monitoring of the recurrent laryngeal nerve: an observational clinical trial. Surgery 2008; 143: 359–65 5. Grant F. Anesthetic considerations in the multiple endocrine neoplasia syndromes. Curr Opin Anaesthesiol 2005; 18: 345–52 6. Maciel RT, Fernandes FC, Pereira Ldos S. Anesthesia in a patient with multiple endocrine abnormalities. Case Report. Rev Bras Anestesiol 2008; 58: 172–8 7. Atallah F, Bastide-Heulin T, Soulie M, et al. Haemodynamic changes during retroperitoneoscopic adrenalectomy for phaeochromocytoma. Br J Anaesth 2001; 86: 731–33 doi:10.1093/bja/aev059
Elevated serum concentrations of erythropoietin after xenon anaesthesia in cardiac surgery: secondary analysis of a randomized controlled trial C. Stoppe*, M. Coburn, A. Fahlenkamp, J. Ney, S. Kraemer, R. Rossaint, and A. Goetzenich Aachen, Germany *E-mail: [email protected]
Editor—Recently, the World Anti-Doping Agency officially added xenon to its list of banned substances, brought on by reports indicating that some athletes used xenon, beginning at Olympic Games at Athens in 2004 until Sochi in 2014. Accumulating evidence indicates that xenon has various beneficial biological effects on the human body. In particular, its capability to improve myocardial contractility and to activate hypoxia-inducible factor-1α (HIF-1α),1 2 resulting in an increase of circulating erythropoietin concentrations,3 renders xenon an attractive option to enhance the performance of elite athletes. Researchers and clinicians started a discussion about the clinical benefit in support of humans exposed to high demand for oxygen. In particular, patients after cardiac surgery frequently exerience haemodilution, blood loss, and an inflammatory response that may result in myocardial funciton and organ dysfunction. Given the promising properties of xenon, 1 we supposed it to represent an attractive option as an anaesthetic during cardiac surgery and evaluated its safety and feasibility.4 Apart from the favourable effects of xenon on blood flow, metabolism, and haemodynamics, little is known about its effects mediated at the molecular level. Ma and colleagues2 and Goetzenich and colleagues5 supposed the preconditioning effects to be mediated by an activation of HIF-1α and its
downstream effectors. While the measurement of HIF-1α is restricted to tissue samples, no study has investigated the effect of xenon on the downstream targets of HIF-1α, including erythropoietin, which provides various anti-inflammatory and protective effects.6 Using a database and serum samples from a recent randomized controlled trial that demonstrated the safety and feasibility of xenon anaesthesia in patients undergoing coronary artery bypass grafting surgery, we performed a secondary analysis and evaluated the effect of xenon anaesthesia on circulating concentrations of erythropoietin. 4 In brief, 30 patients undergoing elective coronary artery bypass grafting surgery were enrolled in this prospective, randomized, controlled trial and allocated to receive either balanced xenon or sevoflurane anaesthesia. 4 Blood samples were collected before surgery, at admission to the intensive care unit, and 24 h thereafter for the measurement of erythropoietin concentrations by the automatic IMMULITE®/IMMULITE 1000 Epo procedure (Siemens, Llanberies, UK). The measured erythropoietin concentrations after xenon anaesthesia demonstrated a significant increase on the first postoperative day [8.7 ( 4.3) vs 12.9 ( 7.4); P=0.017; Fig. 1]. Given that androgens, including testosterone, are known to
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan Flint on May 18, 2015
The authors are grateful to Assistant Professor R Singaporewalla, Consultant Surgeon and the patient for consenting to report this case. We declare that we do not have financial gain or any other interest in drugs and equipment mentioned in managing the case.
| 701
702
Erythropoietin (mU ml–1)
A
| Correspondence
*
40
Xenon
30
Sevoflurane 20
10
n m ad af te r
U
h
IC
24
Testosterone (nmol l–1)
B
30
Xenon Sevoflurane
20
10
Acknowledgements on is
si 24
h
af
IC
te
U
ra
ad
m
dm
is
ra t pe eo Pr
C 130 Hemoglobin (g dl–1)
120
Assistance with this work: we are indebted to the patients who participated in the trial.
si
on
ive
0
Xenon Sevoflurane
Declaration of interest M.C., C.S., and R.R. received lecture and consultant fees from Air Liquide Santé International, a company interested in developing clinical applications for medical gases, including xenon. The remaining authors have not disclosed any potential conflicts of interest.
110 100 90
Funding Deutsche Forschungsgemeinschaft (DFG, Bonn, Deutschland; CO 799/3-1 to M.C.).
80
Su
rg e D ry ay D 1 ay D 2 ay D 3 ay D 4 ay D 5 ay D 6 ay D 7 ay D 8 D ay 9 ay D 10 ay D 11 ay D 12 ay D 13 ay 14
70
Fig 1 Perioperative serum concentrations of erythropoietin (), testosterone (), and haemoglobin (). () There was a significant increase (*) of serum erythropoietin concentrations after xenon anaesthesia from the preoperative value to the first postoperative day (24 h later), whereas no significant change was observed in the sevoflurane group. Serum concentrations of erythropoietin showed a trend towards difference between both groups on the first postoperative day (P=0.051). () No significant change or difference between groups was observed with respect to the measured testosterone concentrations. () Circulating concentrations of haemoglobin trended to be higher in the xenon group throughout the postoperative course. All data were analysed by two-way or Student’s unpaired t-test where appropriate (Prism-6, GraphPad Software Inc., La Jolla, CA, USA; SPSS-21, IBM Corporation, Armonk, NY, USA) to compare differences at distinct time points.
References 1. Dickinson R, Franks NP. Bench-to-bedside review: Molecular pharmacology and clinical use of inert gases in anesthesia and neuroprotection. Crit Care 2010; 14: 229 2. Ma D, Lim T, Xu J, et al. Xenon preconditioning protects against renal ischemic-reperfusion injury via HIF-1α activation. J Am Soc Nephrol 2009; 20: 713–20 3. Semenza GL. Involvement of oxygen-sensing pathways in physiologic and pathologic erythropoiesis. Blood 2009; 114: 2015–9 4. Stoppe C, Fahlenkamp AV, Rex S, et al. Feasibility and safety of xenon compared with sevoflurane anaesthesia in coronary surgical patients: a randomized controlled pilot study. Br J Anaesth 2013; 111: 406–16 5. Goetzenich A, Hatam N, Preuss S, et al. The role of hypoxia-inducible factor-1α and vascular endothelial growth factor in late-phase preconditioning with xenon, isoflurane and
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan Flint on May 18, 2015
Pr e
ad
op
m
is si o
is si o
er at ive
n
0
stimulate the production of erythropoietin,7 we investigated the circulating serum concentrations of testosterone at different time points, but did not observe significant differences (Fig. 1). To probe for an effect of erythropoietin on serum concentrations of haemoglobin, we compared haemoglobin between patients from both groups. Although no difference was observed with respect to administered packages of red blood cells or blood loss,4 the measured haemoglobin concentrations trended towards higher values in the xenon group (Fig. 1). However, we have to concede that the observed association between the increase of erythropoietin and haemoglobin remains speculative, and causes might be multifactorial. The present results may be judged within the limits of a preliminary analysis and considered as purely hypothesis generating. Apart from its effect on haemoglobin concentrations, an impressive body of evidence indicates that erythropoietin has cytoprotective properties and pleiotropic effects on the brain, kidney, and cardiovascular system.5 Erythropoietin modulates a broad array of cellular processes, such as progenitor stem cell development, cellular integrity, and angiogenesis, and it inhibits the apoptotic mechanisms of injury. We conclude that these findings are of particular interest in patients exposed to myocardial ischaemia–reperfusion and may stimulate new approaches for therapeutic use of xenon in the vulnerable patient.
Correspondence
levosimendan in rat cardiomyocytes. Interact Cardiovasc Thorac Surg 2014; 18: 321–8 6. Maiese K, Li F, Chong ZZ. New avenues of exploration for erythropoietin. JAMA 2005; 293: 90–5
| 703
7. Rishpon-Meyerstein N, Kilbridge T, Simone J, Fried W. The effect of testosterone on erythropoietin levels in anemic patients. Blood 1968; 31: 453–60
doi:10.1093/bja/aev060
Usefulness of ultrasound in percutaneous tracheotomy A. Fernández-Trujillo†, L. Santos-Sánchez*†, O. Farré-Lladó, A. Centeno-Álvarez, B. Nicolau-Miralles, I. Aguirre-Allende, J. L. López-Negre, and E. Bragulat-Baur Barcelona, Spain †
Both authors contributed equally to this work.
Editor—Percutaneous tracheotomy is a commonly performed procedure in patients requiring prolonged mechanical ventilation.1 2 Although it is a procedure with few complications, these may be serious, so it would be useful to optimize safety with ultrasound-guided techniques.3 4 It is known that ultrasound increases the safety of procedures such as central venous catheterization5 or thoracocentesis.6 This prospective observational study was performed on 16 donated fresh cadavers at the Department of Anatomy, Medical University, University of Barcelona. A total of 16 percutaneous tracheotomies were performed; these were randomized to two groups, namely ultrasound guided (UG) and Seldinger technique (ST), with eight cadavers in each group.7 Material from the Ciaglia Blue Dolphin® (Cook España S.A, Barcelona, Spain) was reused.8 An orotracheal intubation was performed. In the UG group, a portable Mindray DP-50® (Mindray Medical España S.L, Madrid, Spain) ultrasound machine with 5–10 MHz linear transducer was used. With the neck in hyperextension, transverse plane ultrasonography was performed to identify the tracheal midline. After the dilation of the trachea was done, members of the Department of Anatomy performed the anatomical neck dissection. In the ST group, palpation of the anterior part of the neck was done to identify the puncture point, and the same dilation technique and anatomical dissection as in the UG group were performed. We defined a sternomental distance (Savva test) lower than 13.5 cm ( positive predictive value 82%) and a Cormack and Lehane Classification grade 3 and 4 as the predictors of difficult airway management.9 10
The primary outcome was a successful wire insertion in the tracheal midline, defined as between 11 and 1 o’clock at the first attempt. The secondary outcome was dilation of the trachea between the first and second or the second and third tracheal rings. Another outcome was an evaluation of the possible complications, namely vascular injury, thyroid gland injury (isthmus or lobes), posterior tracheal wall puncture, oesophageal canalization, or subcutaneous tissue canalization. The results are shown in Table 1. Kleine-Brueggeney and colleagues11 performed a study in which nine punctures were performed on cadavers with the use of a guidewire, with a successful puncture at the first attempt in eight cadavers. The only one that was not achieved had difficult airway criteria. The conclusion was that ultrasound-guided puncture facilitates successful puncture of the trachea, as in our study; we had a first-attempt success rate of 87.5% in the UG group and 62.5% in ST group. Kleine-Brueggeney and colleagues11 also concluded that the use of ultrasound in transverse and longitudinal planes cannot prevent soft tissue puncture. Using tomography, they detected thyroid isthmus puncture in eight of nine cadavers. In our study, the tracheotomy was done with neck hyperextension; the puncture site was changed twice because of the position of the thyroid isthmus, and thyroid isthmus puncture occurred in only one of the 16 tracheotomies performed, and it was in the ST group. We conclude that ultrasound has potential to facilitate puncture and correct guide insertion during percutaneous tracheotomy even in subjects with difficult airway criteria. It can provide information on possible anatomical variations, increasing the safety of the procedure.
Table 1 Results and complications [expressed as n (%)]. CTM, cricothyroid membrane puncture; first–third, puncture between first and third tracheal rings; OES, oesophageal canalization; ST, Seldinger technique group; SUB, subcutaneous tissue damage; >third, puncture lower than third tracheal ring; THYR, thyroid injury (isthmus or lobes); UG, ultrasound-guided group; VAS, vascular injury; WALL, posterior wall trachea damage
UG ST
First attempt
Midline
First–third
>Third
CTM
VAS
THYR
WALL
OES
SUB
7 (87.5%) 5 (62.5%)
8 (100%) 8 (100%)
6 (75%) 7 (87.5%)
2 (25%) 0
0 1 (12.5%)
1 (12.5%) 0
0 1 (12.5%)
0 0
0 0
0 0
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan Flint on May 18, 2015
*E-mail: [email protected]
Intraoperative variations in blood pressure and heart rate are known to occur7 but the haemodynamic changes were much more pronounced in our patient during tumour manipulation and excision compared with phaeochromocytoma. We also suggest that total thyroidectomy and radical neck dissection for cancer is likely to be prolonged and the surgery should be staggered for minimizing haemodynamic changes and the use of an EMG reinforced endotracheal tube for intraoperative recurrent laryngeal nerve monitoring may be helpful.
Acknowledgements
Declaration of interest None declared.
References 1. Bordi C. Multiple endocrine neoplasia (MEN)-associated tumours. Dig Liver Dis 2004; 36: S31–4 2. Thakker RV. Multiple endocrine neoplasia. Home Res 2001; 56: 67–72 3. Tauzin-Fin P, Sesay M, Gosse P, Ballanger P. Effects of perioperative alpha1 block on haemodynamic control during laparoscopic surgery for phaeochromocytoma. Br J Anaesth 2004; 92: 512–17 4. Ulmer C, Koch KP, Seimer A, et al. Real-time monitoring of the recurrent laryngeal nerve: an observational clinical trial. Surgery 2008; 143: 359–65 5. Grant F. Anesthetic considerations in the multiple endocrine neoplasia syndromes. Curr Opin Anaesthesiol 2005; 18: 345–52 6. Maciel RT, Fernandes FC, Pereira Ldos S. Anesthesia in a patient with multiple endocrine abnormalities. Case Report. Rev Bras Anestesiol 2008; 58: 172–8 7. Atallah F, Bastide-Heulin T, Soulie M, et al. Haemodynamic changes during retroperitoneoscopic adrenalectomy for phaeochromocytoma. Br J Anaesth 2001; 86: 731–33 doi:10.1093/bja/aev059
Elevated serum concentrations of erythropoietin after xenon anaesthesia in cardiac surgery: secondary analysis of a randomized controlled trial C. Stoppe*, M. Coburn, A. Fahlenkamp, J. Ney, S. Kraemer, R. Rossaint, and A. Goetzenich Aachen, Germany *E-mail: [email protected]
Editor—Recently, the World Anti-Doping Agency officially added xenon to its list of banned substances, brought on by reports indicating that some athletes used xenon, beginning at Olympic Games at Athens in 2004 until Sochi in 2014. Accumulating evidence indicates that xenon has various beneficial biological effects on the human body. In particular, its capability to improve myocardial contractility and to activate hypoxia-inducible factor-1α (HIF-1α),1 2 resulting in an increase of circulating erythropoietin concentrations,3 renders xenon an attractive option to enhance the performance of elite athletes. Researchers and clinicians started a discussion about the clinical benefit in support of humans exposed to high demand for oxygen. In particular, patients after cardiac surgery frequently exerience haemodilution, blood loss, and an inflammatory response that may result in myocardial funciton and organ dysfunction. Given the promising properties of xenon, 1 we supposed it to represent an attractive option as an anaesthetic during cardiac surgery and evaluated its safety and feasibility.4 Apart from the favourable effects of xenon on blood flow, metabolism, and haemodynamics, little is known about its effects mediated at the molecular level. Ma and colleagues2 and Goetzenich and colleagues5 supposed the preconditioning effects to be mediated by an activation of HIF-1α and its
downstream effectors. While the measurement of HIF-1α is restricted to tissue samples, no study has investigated the effect of xenon on the downstream targets of HIF-1α, including erythropoietin, which provides various anti-inflammatory and protective effects.6 Using a database and serum samples from a recent randomized controlled trial that demonstrated the safety and feasibility of xenon anaesthesia in patients undergoing coronary artery bypass grafting surgery, we performed a secondary analysis and evaluated the effect of xenon anaesthesia on circulating concentrations of erythropoietin. 4 In brief, 30 patients undergoing elective coronary artery bypass grafting surgery were enrolled in this prospective, randomized, controlled trial and allocated to receive either balanced xenon or sevoflurane anaesthesia. 4 Blood samples were collected before surgery, at admission to the intensive care unit, and 24 h thereafter for the measurement of erythropoietin concentrations by the automatic IMMULITE®/IMMULITE 1000 Epo procedure (Siemens, Llanberies, UK). The measured erythropoietin concentrations after xenon anaesthesia demonstrated a significant increase on the first postoperative day [8.7 ( 4.3) vs 12.9 ( 7.4); P=0.017; Fig. 1]. Given that androgens, including testosterone, are known to
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan Flint on May 18, 2015
The authors are grateful to Assistant Professor R Singaporewalla, Consultant Surgeon and the patient for consenting to report this case. We declare that we do not have financial gain or any other interest in drugs and equipment mentioned in managing the case.
| 701
702
Erythropoietin (mU ml–1)
A
| Correspondence
*
40
Xenon
30
Sevoflurane 20
10
n m ad af te r
U
h
IC
24
Testosterone (nmol l–1)
B
30
Xenon Sevoflurane
20
10
Acknowledgements on is
si 24
h
af
IC
te
U
ra
ad
m
dm
is
ra t pe eo Pr
C 130 Hemoglobin (g dl–1)
120
Assistance with this work: we are indebted to the patients who participated in the trial.
si
on
ive
0
Xenon Sevoflurane
Declaration of interest M.C., C.S., and R.R. received lecture and consultant fees from Air Liquide Santé International, a company interested in developing clinical applications for medical gases, including xenon. The remaining authors have not disclosed any potential conflicts of interest.
110 100 90
Funding Deutsche Forschungsgemeinschaft (DFG, Bonn, Deutschland; CO 799/3-1 to M.C.).
80
Su
rg e D ry ay D 1 ay D 2 ay D 3 ay D 4 ay D 5 ay D 6 ay D 7 ay D 8 D ay 9 ay D 10 ay D 11 ay D 12 ay D 13 ay 14
70
Fig 1 Perioperative serum concentrations of erythropoietin (), testosterone (), and haemoglobin (). () There was a significant increase (*) of serum erythropoietin concentrations after xenon anaesthesia from the preoperative value to the first postoperative day (24 h later), whereas no significant change was observed in the sevoflurane group. Serum concentrations of erythropoietin showed a trend towards difference between both groups on the first postoperative day (P=0.051). () No significant change or difference between groups was observed with respect to the measured testosterone concentrations. () Circulating concentrations of haemoglobin trended to be higher in the xenon group throughout the postoperative course. All data were analysed by two-way or Student’s unpaired t-test where appropriate (Prism-6, GraphPad Software Inc., La Jolla, CA, USA; SPSS-21, IBM Corporation, Armonk, NY, USA) to compare differences at distinct time points.
References 1. Dickinson R, Franks NP. Bench-to-bedside review: Molecular pharmacology and clinical use of inert gases in anesthesia and neuroprotection. Crit Care 2010; 14: 229 2. Ma D, Lim T, Xu J, et al. Xenon preconditioning protects against renal ischemic-reperfusion injury via HIF-1α activation. J Am Soc Nephrol 2009; 20: 713–20 3. Semenza GL. Involvement of oxygen-sensing pathways in physiologic and pathologic erythropoiesis. Blood 2009; 114: 2015–9 4. Stoppe C, Fahlenkamp AV, Rex S, et al. Feasibility and safety of xenon compared with sevoflurane anaesthesia in coronary surgical patients: a randomized controlled pilot study. Br J Anaesth 2013; 111: 406–16 5. Goetzenich A, Hatam N, Preuss S, et al. The role of hypoxia-inducible factor-1α and vascular endothelial growth factor in late-phase preconditioning with xenon, isoflurane and
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan Flint on May 18, 2015
Pr e
ad
op
m
is si o
is si o
er at ive
n
0
stimulate the production of erythropoietin,7 we investigated the circulating serum concentrations of testosterone at different time points, but did not observe significant differences (Fig. 1). To probe for an effect of erythropoietin on serum concentrations of haemoglobin, we compared haemoglobin between patients from both groups. Although no difference was observed with respect to administered packages of red blood cells or blood loss,4 the measured haemoglobin concentrations trended towards higher values in the xenon group (Fig. 1). However, we have to concede that the observed association between the increase of erythropoietin and haemoglobin remains speculative, and causes might be multifactorial. The present results may be judged within the limits of a preliminary analysis and considered as purely hypothesis generating. Apart from its effect on haemoglobin concentrations, an impressive body of evidence indicates that erythropoietin has cytoprotective properties and pleiotropic effects on the brain, kidney, and cardiovascular system.5 Erythropoietin modulates a broad array of cellular processes, such as progenitor stem cell development, cellular integrity, and angiogenesis, and it inhibits the apoptotic mechanisms of injury. We conclude that these findings are of particular interest in patients exposed to myocardial ischaemia–reperfusion and may stimulate new approaches for therapeutic use of xenon in the vulnerable patient.
Correspondence
levosimendan in rat cardiomyocytes. Interact Cardiovasc Thorac Surg 2014; 18: 321–8 6. Maiese K, Li F, Chong ZZ. New avenues of exploration for erythropoietin. JAMA 2005; 293: 90–5
| 703
7. Rishpon-Meyerstein N, Kilbridge T, Simone J, Fried W. The effect of testosterone on erythropoietin levels in anemic patients. Blood 1968; 31: 453–60
doi:10.1093/bja/aev060
Usefulness of ultrasound in percutaneous tracheotomy A. Fernández-Trujillo†, L. Santos-Sánchez*†, O. Farré-Lladó, A. Centeno-Álvarez, B. Nicolau-Miralles, I. Aguirre-Allende, J. L. López-Negre, and E. Bragulat-Baur Barcelona, Spain †
Both authors contributed equally to this work.
Editor—Percutaneous tracheotomy is a commonly performed procedure in patients requiring prolonged mechanical ventilation.1 2 Although it is a procedure with few complications, these may be serious, so it would be useful to optimize safety with ultrasound-guided techniques.3 4 It is known that ultrasound increases the safety of procedures such as central venous catheterization5 or thoracocentesis.6 This prospective observational study was performed on 16 donated fresh cadavers at the Department of Anatomy, Medical University, University of Barcelona. A total of 16 percutaneous tracheotomies were performed; these were randomized to two groups, namely ultrasound guided (UG) and Seldinger technique (ST), with eight cadavers in each group.7 Material from the Ciaglia Blue Dolphin® (Cook España S.A, Barcelona, Spain) was reused.8 An orotracheal intubation was performed. In the UG group, a portable Mindray DP-50® (Mindray Medical España S.L, Madrid, Spain) ultrasound machine with 5–10 MHz linear transducer was used. With the neck in hyperextension, transverse plane ultrasonography was performed to identify the tracheal midline. After the dilation of the trachea was done, members of the Department of Anatomy performed the anatomical neck dissection. In the ST group, palpation of the anterior part of the neck was done to identify the puncture point, and the same dilation technique and anatomical dissection as in the UG group were performed. We defined a sternomental distance (Savva test) lower than 13.5 cm ( positive predictive value 82%) and a Cormack and Lehane Classification grade 3 and 4 as the predictors of difficult airway management.9 10
The primary outcome was a successful wire insertion in the tracheal midline, defined as between 11 and 1 o’clock at the first attempt. The secondary outcome was dilation of the trachea between the first and second or the second and third tracheal rings. Another outcome was an evaluation of the possible complications, namely vascular injury, thyroid gland injury (isthmus or lobes), posterior tracheal wall puncture, oesophageal canalization, or subcutaneous tissue canalization. The results are shown in Table 1. Kleine-Brueggeney and colleagues11 performed a study in which nine punctures were performed on cadavers with the use of a guidewire, with a successful puncture at the first attempt in eight cadavers. The only one that was not achieved had difficult airway criteria. The conclusion was that ultrasound-guided puncture facilitates successful puncture of the trachea, as in our study; we had a first-attempt success rate of 87.5% in the UG group and 62.5% in ST group. Kleine-Brueggeney and colleagues11 also concluded that the use of ultrasound in transverse and longitudinal planes cannot prevent soft tissue puncture. Using tomography, they detected thyroid isthmus puncture in eight of nine cadavers. In our study, the tracheotomy was done with neck hyperextension; the puncture site was changed twice because of the position of the thyroid isthmus, and thyroid isthmus puncture occurred in only one of the 16 tracheotomies performed, and it was in the ST group. We conclude that ultrasound has potential to facilitate puncture and correct guide insertion during percutaneous tracheotomy even in subjects with difficult airway criteria. It can provide information on possible anatomical variations, increasing the safety of the procedure.
Table 1 Results and complications [expressed as n (%)]. CTM, cricothyroid membrane puncture; first–third, puncture between first and third tracheal rings; OES, oesophageal canalization; ST, Seldinger technique group; SUB, subcutaneous tissue damage; >third, puncture lower than third tracheal ring; THYR, thyroid injury (isthmus or lobes); UG, ultrasound-guided group; VAS, vascular injury; WALL, posterior wall trachea damage
UG ST
First attempt
Midline
First–third
>Third
CTM
VAS
THYR
WALL
OES
SUB
7 (87.5%) 5 (62.5%)
8 (100%) 8 (100%)
6 (75%) 7 (87.5%)
2 (25%) 0
0 1 (12.5%)
1 (12.5%) 0
0 1 (12.5%)
0 0
0 0
0 0
Downloaded from http://bja.oxfordjournals.org/ at University of Michigan Flint on May 18, 2015
*E-mail: [email protected]
