gms | German Medical Science

Objective: Percutaneous tracheotomy is a relatively common procedure on critical care units worldwide. A reversible periprocedural ICP-increase above the widely considered upper limit of 20mmHg is often observed in patients with acute cerebral diseases. It is unclear, which factors determine this ICP-increase.

Method: We prospectively gathered data for all percutaneous tracheotomies (PT) performed on our neurological-neurosurgical intensive care unit starting in December 2010. A continuous minute-to-minute monitoring of intracranial pressure (ICP), cerebral perfusion pressure (CPP), mean arterial pressure (MAP), peripheral oxygen saturation (SpO₂) and heart rate was carried out from 60 minutes before the tracheotomy, during the procedure and for 60 minutes after the procedure. The following factors were evaluated by the means of logistic regression analysis: BMI, age, gender, tracheotomy technique (PercuTwist^® vs. Blue Rhino^®), physician performing the procedure (neurologist vs. neurosurgeon), duration of the procedure, underlying disease, duration of mechanical ventilation and baseline ICP value before the procedure. A periprocedural ICP increase above 20mmHg was evaluated as pathological.

Results: A total of 175 PTs were performed during the observation period between December 2010 and August 2013 – from these, 58 were carried out with ICP monitoring. The mean initial ICP value was 9mmHg and rose significantly to a mean periprocedural ICP value of 18mmHg (p<0.05). In a comparison between patients with and without a pathological ICP increase, a significant difference between the two groups was observed for patients with an increased initial ICP above 15mmHg (p<0.01). The other observed factors did not have any significant influence on the development of a pathological ICP during the PT.

Conclusions: Tracheotomies in patients with cerebral injury should be performed with ICP monitoring – regardless of the point in time when the procedure is carried out. We recommend delaying the procedure in cases with an initially increased ICP (above 15mmHg) due to the significantly increased periprocedural risk of developing a pathological ICP value.