Sema TURAN, Bülent YAMAK, Soner YAVAŞ, Elif DİLBER, İhsan AYIK, Özcan ERDEMLİ

Does early tracheostomy decrease the nosocomial pneumonia incidence in cardiovascular surgery patients?

Amaç: Bu çalışmada kardiyovasküler yoğun bakım ünite (YBÜ)’mizde nozokomiyal pnömoni insidansı ile trakeostomi zamanlaması arasındaki korelasyon incelendi. Çalışma planı: Bu retrospektif çalışmaya Ocak 2008 - Aralık 2009 tarihleri arasında kardiyovasküler cerrahi YBÜ’de takip edilen ve trakeostomi açılan 64 hasta dahil edildi. Hastalar trakeostomi öncesi klinik pulmoner enfeksiyon skoru (KPİS) ve trakeostomi zamanlamasına göre dört gruba ayrıldı. Grup 1E (n=11): KPİS ≤5 olan endotrakeal entübasyonun ilk yedi günü içinde trakeostomi açılan hastalar. Grup 1L (n=9): KPİS ≤5 olan endotrakeal entübasyonun 7. gününden sonra trakeostomi açılan hastalar. Grup 2E (n=13): KPİS ≥6 olan endotrakeal entübasyonun ilk yedi günü içinde trakeostomi açılan hastalar. Grup 2L (n=31): KPİS ≥6 olan endotrakeal entübasyonun 7. gününden sonra trakeostomi açılan hastalar. Bulgular: Trakeostomi sonrası hastaların nozokomiyal pnömoni insidansları karşılaştırıldığında, grup 1E ile grup 1L arasında istatistiksel olarak anlamlı bir fark saptanmadı. Bununla birlikte, trakeostomi sonrası hastaların süperenfeksiyon oranları açısından da, grup 2E ve grup 2L arasında anlamlı bir farklılık gözlenmedi. Ancak grup 1E (24.9±4.3) ve grup 1L (30.4±4.4) arasında APACHE II skorları açısından anlamlı bir farklılık gözlendi (p=0.012). Grup 1E’de, grup 1L’ye kıyasla, anlamlı düzeyde düşük mortalite oranları gözlendi (p=0.043); ancak grup 2E ve grup 2L arasında bu fark gözlenmedi. Sonuç: Erken trakeostominin trakeostomi sonrası nozokomiyal pnömoni ve süperenfeksiyon insidansını azaltmadığı sonucuna vardık.

Kalp ve damar cerrahisi olgularında erken trakeostomi nozokomiyal pnömoni insidansını azaltıyor mu?

Background: This study aims to examine the correlation between the incidence of nosocomial pneumonia and the timing of tracheostomy in our cardiovascular intensive care unit (ICU). Methods: Between January 2008 and December 2009, 64 patients who were monitored in the cardiovascular surgery ICU and underwent tracheostomy were included in this retrospective study. The patients were divided into four groups according to their clinical pulmonary infection scores (CPIS) and the timing of tracheostomy. Group 1E (n=11): Patients with CPIS ≤5 who underwent tracheostomy within seven days of endotracheal intubation. Group 1L (n=9): Patients with CPIS ≤5 who underwent tracheostomy after seven days from endotracheal intubation. Group 2E (n=13): Patients with CPIS ≥6 who underwent tracheostomy within seven days of endotracheal intubation. Group 2L (n=31): Patients with CPIS ≥6 who underwent tracheostomy after seven days from endotracheal intubation. Results: Comparison of the incidence of nosocomial pneumonia of the patients following tracheostomy showed no statistically significant difference between group 1E and 1L. Also, there was no significant difference between group 2E and 2L in terms of superinfection rates of the patients following tracheostomy. However, a significant difference was observed between group 1E (24.9±4.3) and group 1L (30.4±4.4) (p=0.012) in terms of APACHE II scores. Significantly lower mortality rates were observed in group 1E, compared to group 1L (p=0.043), but not between group 2E and 2L. Conclusion: We concluded that early tracheostomy does not decrease the incidence of nosocomial pneumonia and superinfection following tracheostomy.

PDF

___

1. Hsu CL, Chen KY, Chang CH, Jerng JS, Yu CJ, Yang PC. Timing of tracheostomy as a determinant of weaning success in critically ill patients: a retrospective study. Crit Care 2005;9:R46-52.
2. Plummer AL, Gracey DR. Consensus conference on artificial airways in patients receiving mechanical ventilation. Chest 1989;96:178-80.
3. Yavas S, Yagar S, Mavioglu L, Cetin E, Iscan HZ, Ulus AT, et al. Tracheostomy: how and when should it be done in cardiovascular surgery ICU? J Card Surg 2009;24:11-8.
4. Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med 2004;32:1689-94.
5. Kollef MH. Prevention of hospital-associated pneumonia and ventilator-associated pneumonia. Crit Care Med 2004;32:1396-405.
6. Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery 1990;108:655-9.
7. Sugerman HJ, Wolfe L, Pasquale MD, Rogers FB, O'Malley KF, Knudson M, et al. Multicenter, randomized, prospective trial of early tracheostomy. J Trauma 1997;43:741-7.
8. Saffle JR, Morris SE, Edelman L. Early tracheostomy does not improve outcome in burn patients. J Burn Care Rehabil 2002;23:431-8.
9. Bouderka MA, Fakhir B, Bouaggad A, Hmamouchi B, Hamoudi D, Harti A. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma 2004;57:251-4.
10. Rello J, Diaz E. Ventilator-associated pneumonia, percutaneous tracheostomy, and antimicrobial prophylaxis. Chest 2004;126:1382-3.
11. Rello J, Lorente C, Diaz E, Bodi M, Boque C, Sandiumenge A, et al. Incidence, etiology, and outcome of nosocomial pneumonia in ICU patients requiring percutaneous tracheotomy for mechanical ventilation. Chest 2003;124:2239-43.
12. Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ 2005;330:1243.
13. Dunham CM, Ransom KJ. Assessment of early tracheostomy in trauma patients: a systematic review and meta-analysis. Am Surg 2006;72:276-81.
14. Terragni PP, Antonelli M, Fumagalli R, Faggiano C, Berardino M, Pallavicini FB, et al. Early vs late tracheotomy for prevention of pneumonia in mechanically ventilated adult ICU patients: a randomized controlled trial. JAMA 2010;303:1483-9.
15. Barquist ES, Amortegui J, Hallal A, Giannotti G, Whinney R, Alzamel H, et al. Tracheostomy in ventilator dependent trauma patients: a prospective, randomized intention-to-treat study. J Trauma 2006;60:91-7.
16. Möller MG, Slaikeu JD, Bonelli P, Davis AT, Hoogeboom JE, Bonnell BW. Early tracheostomy versus late tracheostomy in the surgical intensive care unit. Am J Surg 2005;189:293-6.