Intracranial pressure monitoring during percutaneous tracheostomy "percutwist" in critically ill neurosurgery patients.

BACKGROUND: Tracheostomy is commonly required as part of the management of patients with severe brain damage. Percutaneous dilation tracheostomy is increasingly used in intensive care unit as an alternative to standard surgical tracheostomy. However, this procedure carries the risk of neurological complications, particularly in patients with intracranial hypertension. In this study, we sought to quantify the effects of Percutwist(R) tracheostomy (Rusch-Teleflex Medical) on intracranial pressure (ICP), cerebral perfusion pressure (CPP), arterial CO(2) tension (Paco(2)), and arterial O(2) tension (Pao(2)), in 65 consecutive critically ill patients admitted to the neurosurgical intensive care unit, undergoing bedside percutaneous tracheostomy.

METHODS: Sixty-five patients (29 men, 36 women, mean age 43 yr, 7 +/- 10.6) Glasgow Coma Scale <or=8, requiring long-term ventilatory support with a stable ICP <or=20 mm Hg were included. Elective percutaneous tracheostomies were performed at the bedside under endoscopic fiberoptic control. Intraoperative monitoring included continuous: electrocardiogram, Spo(2), invasive arterial blood pressure, ICP, CPP = mean arterial blood pressure-ICP). Episodes of ICP increment above 20 mm Hg or CPP decrease below 60 mm Hg (lasting more than 3 min) were recorded; hypoxia was defined as Pao(2) below 90 mm Hg, hypercarbia as Paco(2) more than 40 mm Hg.

RESULTS: Eighteen episodes of intracranial hypertension were recorded in 11 patients. No statistically significant modification of monitored variables was recorded, although the transient ICP increase was very close to statistical significance (P = 0.051). No episodes of CPP reduction below 60 mm Hg occurred. Six percent of patients developed hypercarbia.

CONCLUSIONS: Percutwist tracheostomy is a single-step method which allows for effective ventilation during the procedure, thus reducing the risk of hypercarbia and development of intracranial hypertension. The technique did not cause secondary pathophysiological insult and could be considered safe in a selected population of brain-injured patients.