Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study

Abstract

Introduction: Patients with poor-grade subarachnoid hemorrhage (SAH) admitted to the intensive care unit (ICU) often require prolonged invasive mechanical ventilation due to prolonged time to obtain neurological recovery. Impairment of consciousness and airway protective mechanisms usually require tracheostomy during the ICU stay to facilitate weaning from sedation, promote neurological assessment, and reduce mechanical ventilation (MV) duration and associated complications. Percutaneous dilatational tracheostomy (PDT) is the technique of choice for performing a tracheostomy. However, it could be associated with particular risks in neurocritical care patients, potentially increasing the risk of secondary brain damage.

Methods: We conducted a single-center, prospective, observational study aimed to assess PDT-associated variations in main cerebral, hemodynamic, and respiratory variables, the occurrence of tracheostomy-related complications, and their relationship with outcomes in adult patients with SAH admitted to the ICU of a neurosurgery/neurocritical care hub center after aneurysm control through clipping or coiling and undergoing early PDT.

Results: We observed a temporary increase in ICP during early PDT; this increase was statistically significant in patients presenting with higher therapy intensity level (TIL) at the time of the procedural. The episodes of intracranial hypertension were brief, and appeared mainly due to the activation of cerebral autoregulatory mechanisms in patients with impaired compensatory mechanisms and compliance.

Discussion: The low number of observed complications might be related to our organizational strategy, all based on a dedicated "tracheo-team" implementing both PDT following a strictly defined protocol and accurate follow-up.

Keywords: critical care; intracranial pressure; neurocritical care; percutaneous tracheostomy; subarachanoid hemorrhage.

Figure 1

Flow chart of study population selection; in the gray boxes, the subjects were excluded from the main analysis (see methods). ICU, intensive care unit; SAH, subarachnoid hemorrhage; WLST, withdrawal of life-sustaining treatments; PDT, percutaneous dilational tracheostomy; ICP, intracranial pressure.

Figure 2

Box plots illustrating the distribution of ICP (A), CPP (B), MAP (C) and PaCO2 (D) values (minimum value, first quartile, median, third quartile, and maximum value) at the five time points in the whole group. ICP, intracranial pressure; CPP, cerebral perfusion pressure; MAP, mean arterial pressure; PaCO₂, partial pressure of carbon dioxide in the arterial blood.

Figure 3

Box plots illustrating the distribution of ICP values (minimum value, first quartile, median, third quartile, and maximum value) at the five time points in patients presenting with N-ICP (light gray boxes) and H-ICP (dark gray boxes). ICP, intracranial pressure; N-ICP, normal intracranial pressure; H-ICP, high intracranial pressure.

Figure 4

Box plots illustrating the distribution of CPP values (minimum value, first quartile, median, third quartile, and maximum value) at the five time points in patients presenting with N-ICP (light gray boxes) and H-ICP (dark boxes). CPP, cerebral perfusion pressure; N-ICP, normal intracranial pressure; H-ICP, high intracranial pressure.

Figure 5

Box plots illustrating the distribution of PaCO2 values (minimum value, first quartile, median, third quartile, and maximum value) at the five time points in patients presenting with N-ICP (light gray boxes) and H-ICP (dark gray boxes). PaCO₂, partial pressure of carbon dioxide in the arterial blood; N-ICP, normal intracranial pressure; H-ICP, high intracranial pressure.