title: The effect of tracheotomy on drug consumption in patients with acute aneurysmal subarachnoid hemorrhage: an observational study.
abstract: BACKGROUND
  Patients with aneurysmal subarachnoid hemorrhage (aSAH) are common in intensive care units (ICU). In patients with aSAH, sedation is used as a neuroprotective measure in order to secure adequate cerebral perfusion pressure (CPP). Compared with the use of an endotracheal tube, a tracheotomy has the advantage of securing the airway at a much lower level of distress, and aSAH patients can often be awakened more rapidly. Little is known about the impact of tracheotomy on the consumption of sedative/analgesic and vasoactive drugs and the maintenance of CPP within defined limits in aSAH patients.
  
  
  METHODS
  We conducted an observational study of aSAH patients who underwent percutaneous tracheotomy. A prospective registry of patient data was supplemented with retrospective retrievals from medical records. Sedative, analgesic and vasoactive drug doses were registered for 3 days prior to and after percutaneous tracheotomy, respectively. Blood pressure, CPP, and the mode of mechanical ventilation were registered 24 h prior to and after tracheotomy.
  
  
  RESULTS
  Between January 2001 and June 2009, 902 aSAH patients were admitted to our hospital; 74 (8%) were deeply comatose/dying upon arrival. The ruptured aneurysm was repaired in 828 patients (surgical repair 50%) and percutaneous tracheotomy was performed 182 times in 178 patients (59 men and 119 women). This subpopulation (178 of 828 patients) was significantly older (56 vs. 53 years) and presented with a more severe Hunt & Hess grade (p < 0.001). Percutaneous tracheotomy caused a marked decline in mean daily consumption of the analgesics/sedatives fentanyl, midazolam, and propofol, as well as the vasoactive drugs noradrenaline and dopamine. These declines were statistically and clinically significant. The mean CPP was 76 mmHg (SD 8.6) the day before and 79 mmHg (SD 9.6) 24 h after percutaneous tracheotomy. After percutaneous tracheotomy, mechanical ventilatory support could be reduced to a patient-controlled ventilatory support mode in a significant number of patients (p < 0.001).
  
  
  CONCLUSIONS
  Percutaneous tracheotomy in aSAH patients is a swift procedure with low risk that is associated with a significant decline in the consumption of sedative/analgesic and vasoactive drugs while clinical surveillance parameters remain stable or improve.
authors.affiliation: Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, 0027 Norway ; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
authors.forename: Leiv Arne
authors.initials: LA
authors.lastname: Rosseland
authors.affiliation: Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, 0027 Norway.
authors.forename: Jon
authors.initials: J
authors.lastname: Narum
authors.affiliation: Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, 0027 Norway ; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
authors.forename: Audun
authors.initials: A
authors.lastname: Stubhaug
authors.affiliation: Department of Anesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital - Rikshospitalet, Oslo, 0027 Norway ; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.
authors.forename: Ulf
authors.initials: U
authors.lastname: Kongsgaard
authors.affiliation: Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
authors.forename: Wilhelm
authors.initials: W
authors.lastname: Sorteberg
authors.affiliation: Department of Neurosurgery, Oslo University Hospital - Rikshospitalet, Oslo, Norway.
authors.forename: Angelika
authors.initials: A
authors.lastname: Sorteberg
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000700:Analgesics / Q000627:therapeutic use*; D002560:Cerebrovascular Circulation / Q000502:physiology*; D002648:Child; D002675:Child, Preschool; D004298:Dopamine / Q000627:therapeutic use; D005260:Female; D005283:Fentanyl / Q000627:therapeutic use; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D007223:Infant; D008297:Male; D008874:Midazolam / Q000627:therapeutic use; D008875:Middle Aged; D009638:Norepinephrine / Q000627:therapeutic use; D061646:Operative Time; D015742:Propofol / Q000627:therapeutic use; D011446:Prospective Studies; D012121:Respiration, Artificial / Q000379:methods; D013345:Subarachnoid Hemorrhage / Q000601:surgery*; D014140:Tracheotomy / Q000379:methods*; D014662:Vasoconstrictor Agents / Q000627:therapeutic use*; D055815:Young Adult
chemical_list: D000700:Analgesics; D006993:Hypnotics and Sedatives; D014662:Vasoconstrictor Agents; D008874:Midazolam; D005283:Fentanyl; D004298:Dopamine; D009638:Norepinephrine; D015742:Propofol
keywords: Blood pressure; Critical care; Dopamine; Fentanyl; Midazolam; Noradrenaline; Stroke; Subarachnoid hemorrhage; Tracheotomy