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therefore&#44; is now used in both acute and chronic patients discharged with some kind of home respiratory support&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The complication rate associated with this technique is considered to be higher in children than in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#8211;8</span></a> However&#44; both the frequency and type of complication&#44; above all mortality&#44; vary considerably between studies&#46; Mahadevan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> describe a global complications rate in these patients of 51&#37;&#44; with 2&#46;5&#37; of accidental decannulations&#44; percentages that are similar to those found in other publications&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#8211;12</span></a> Mortality directly attributable to MV ranges from 0&#46;5&#37; to 3&#37; in different series&#44; the most frequent causes being accidental decannulation and obstruction of the cannula&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#44;12&#8211;14</span></a> Global mortality of tracheotomised patients ranges from 7&#37; to 40&#37;&#44; depending on the study&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;9&#44;14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of this review is to analyse the tracheotomies performed in our unit in order to gain insight into the complications derived from the technique&#44; the mortality attributable to it and the global mortality of tracheotomised patients&#46; The purpose is also to compare our findings with those published in the most recent literature&#46; The study was approved by the institutional review board of the Cruces University Hospital &#40;Bilbao&#44; Spain&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a retrospective chart review of patients admitted to the Paediatric Intensive Care Unit &#40;PICU&#41; of the Cruces University Hospital that underwent tracheotomy in the unit in the period between January 2003 and December 2014&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patients were chosen after reviewing the records of patients discharged from the unit&#44; selecting those whose diagnosis and&#47;or techniques performed during admission showed a tracheotomy within the period covered by the study&#46; In total&#44; 26 patients were identified&#46; One patient was excluded because his medical history was not available&#46; The patients were included in the review&#44; regardless of whether the procedure was urgent or elective and of the surgical technique used for placing and fixing the cannula&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following variables were analysed &#8211; indication for tracheotomy&#44; age&#44; MV days prior to the tracheotomy&#44; length of stay in the PICU&#44; types of cannula &#40;cuffed or simple&#41; postoperative day for the first scheduled cannula replacement&#44; and complications directly related to this procedure&#44; mortality related to the technique and global mortality&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We also analysed a subgroup of patients with an episode of accidental removal of the tracheotomy cannula &#40;accidental decannulation&#41; with the purpose of finding possible differential factors in this subgroup with respect to the total&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Being a retrospective&#44; non-interventionist study&#44; informed consent was not requested from the parents&#47;guardians&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For the statistical study&#44; the Mann&#8211;Whitney eliminar test was used for independent samples&#46; Data were analysed using IBM SPSS statistics &#40;version 22&#46;0&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and indications</span><p id="par0050" class="elsevierStylePara elsevierViewall">During the 10-year study period&#44; near 6000 patients have been admitted to the Unit&#44; of which 30&#37; received MV&#46; Approximately 1500 were intubated and 25 of those underwent tracheotomy&#44; which constitutes 1&#46;5&#37; of the intubated patients&#46; Out of the 25 patients included in our series&#44; 13 were boys &#40;52&#37;&#41; and 12 girls &#40;48&#37;&#41;&#46; The mean age was 31&#46;3 months &#40;median&#58; 14 months&#44; range&#58; 0&#8211;12 years&#41;&#44; 44&#37; them were under the age of 1 year and 76&#37; under the age of 3 years&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Airway obstruction was the most frequent indication for tracheotomy&#44; 14 &#40;56&#37;&#41; of the patients&#44; while prolonged MV was the indication for tracheotomy in the remaining patients&#44; 11 &#40;44&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The different causes&#44; divided in subgroups&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Among the cases of airway obstruction&#44; 4 &#40;16&#37;&#41; were due to congenital factors &#40;Pierre&#8211;Robin sequence&#44; CHARGE syndrome&#44; congenital microretrognathia without identification&#44; Proteus syndrome&#41;&#44; 3 due to post-MV subglottic stenosis&#44; 2 presented severe tracheobronchomalacia uncontrolled with medical &#40;continuous positive pressure in the airway&#41; or surgical &#40;aortopexy&#41; treatment&#44; 2 presented vocal cord paresis &#40;one congenital&#44; one post-MV&#41;&#44; 1 base tongue tumour&#44; one facial trauma&#44; and 1 case secondary to obstruction due to infectious inflammation of the airway &#40;laryngitis&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Among the cases of prolonged MV&#44; 4 were secondary to medullary injury &#40;1 poly-trauma&#44; 1 intramedullary tumour&#44; 1 posterior fossa decompressive post-neurosurgery ischaemic injury and 1 transversal myelitis&#41;&#44; 3 cases of bronchopulmonary dysplasia&#44; 1 cardiopathy with recurrent failures in extubation&#44; 1 case of congenital hypotonia with respiratory failure&#44; 1 case of Ondine&#39;s syndrome and 1 patient with tuberculous meningitis and MV-dependent severe brain injury&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As to the characteristics of the tracheotomy cannulas&#44; 20&#37; of them were cuffed&#46; The first scheduled replacement was performed on the seventh postoperative day in most cases &#40;92&#37;&#41;&#44; and the reason why the procedure was not performed on the seventh day in the other episodes is unspecified&#46; In all cases&#44; the first replacement was performed by an otolaryngologist&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean stay at the PICU for these patients was prolonged &#40;53 days&#44; median&#58; 37&#44; range&#58; 1&#8211;338&#41;&#44; given their chronic condition&#46; Mean days on MV prior to ostomy was 48 days &#40;range&#58; 0&#8211;270&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Twenty-four tracheotomies were performed electively in the operating theatre&#59; 1 was an emergency procedure in an otherwise healthy girl with symptoms of infectious laryngitis&#44; due to intubation failure in the hospital of origin&#46; None of the tracheotomies were performed percutaneously&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Complications</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ten patients &#40;40&#37;&#41; presented complications related to the tracheotomy procedure during their stay in the PICU &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; 2 of them presenting more than 1 complication&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">As for mild complications&#44; 3 patients showed local infections resolved with treatment&#44; and 1 presented stoma granuloma&#46; No bleeding or significant neck wound from tube attachments were observed&#46; Among the severe complications&#44; 5 patients presented an episode of accidental decannulation&#44; 3 presented air leak syndrome &#40;pneumothorax&#47;pneumomediastinum&#41;&#44; 1 presented obstruction of the cannula and 1 died&#46; The deceased patient died in the immediate postoperative period as a result of accidental decannulation with impossibility of recannulation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Mortality attributable to tracheotomy complications was 4&#37; &#40;1 patient died due to accidental decannulation&#41;&#44; while global mortality during hospital stay was 20&#37; &#40;4 patients&#44; 16&#37;&#44; attributable to other causes unrelated to tracheotomy&#41;&#46; During follow-up and to date&#44; global mortality increased to 28&#37; &#40;7 patients&#41; and 2 patients were lost to follow-up due to treatment in another centre&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No technique-related problems in scheduled cannula replacements&#44; or infections described in other series&#44; such as mediastinitis or sepsis were observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Analysis of the accidental decannulations subgroup</span><p id="par0110" class="elsevierStylePara elsevierViewall">A comparative statistical analysis was performed between the group of patients that presented an episode of accidental decannulation &#40;5 patients&#41; and the rest of the patients &#40;20 patients&#41; to identify possible differential factors&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The mean age of the 5 patients that presented an episode of accidental decannulation was lower than that of the general group &#40;22&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;06 v&#46; 33&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>44&#46;11 months&#41;&#46; The mean length of stay in the PICU was similar in both groups &#40;41&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&#46;07 v&#46; 54&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>74&#46;1 days&#41;&#46; The analysis shows that the average number of MV days prior to tracheotomy is clearly higher in the accidental decannulations group &#40;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>118 v&#46; 33&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38 days&#41;&#44; a difference due to the prolonged time on MV of one patient compared to the rest of the group &#40;270 days&#41;&#46; However&#44; there was no difference between groups in terms of median MV days &#40;30 v&#46; 30 days&#41;&#46; The most frequent indication for tracheotomy in the subgroup of patients that presented an accidental decannulation was tracheobronchomalacia &#40;2 patients&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Among the variables analysed&#44; no statistically significant differences were observed between both groups with regard to mean age&#44; average number of MV days prior to performance of tracheotomy&#44; or mean stay days in the PICU&#46; In spite of the remarkable difference in the use of cuffed cannulas in the accidental decannulations group &#40;0&#37; v&#46; 20&#37; in the rest of the patients&#41;&#44; this difference does not reach statistical significance&#44; probably due to the insufficient sample size in the decannulations group&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In total&#44; 80&#37; of the patients who presented an accidental decannulation suffered cardiac arrest as a consequence&#44; and 1 of them died&#46; All of the accidental decannulation episodes occurred within the first 48<span class="elsevierStyleHsp" style=""></span>h of the postoperative period&#44; and 80&#37; within the first 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Tracheotomy in the paediatric patient is still an uncommon procedure<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> &#40;0&#46;5&#37;&#8211;2&#37; of patients on MV&#41; that is performed late in ventilated children&#44; usually in the operating theatre&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> In our series&#44; tracheotomised patients constituted approximately 1&#46;5&#37; of all intubated patients&#46; The time when the tracheotomy is performed is still under debate in paediatrics&#46; In adults&#44; where there is a theoretical barrier of 7&#8211;10 days of MV&#44; we found that current practice also varies&#44; with rates that range between 5&#37; and 24&#37; of tracheotomies in intubated patients<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;16&#44;17</span></a> and with a mean of 9 and 12 ventilation days&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> Griffiths et al&#46;&#44; in a meta-analysis that included 406 patients&#44; observed that an early tracheotomy significantly reduced the duration of MV and the stay in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The duration of intubation in children is not predicative of the need for a tracheotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> We now know that children can be on MV for months without important complications&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">A survey conducted among paediatric intensive care specialists showed that there is no consensus regarding the time at which a tracheotomy should be performed&#58; 81&#37; of respondents did not agree on indications and time&#46; However&#44; nearly 50&#37; of doctors considered that the procedure was underutilised&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> In the Al-Samri et al&#46; study<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> on 70 paediatric tracheotomies&#44; the mean duration &#40;range&#41; of MV before tracheotomy was 20 &#40;0&#8211;140&#41; days&#46; In our series&#44; mean MV days prior to tracheotomy was 48 &#40;0&#8211;270&#41; days&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Indications for tracheotomy have changed over the years&#46; In the 1970s&#44; inflammatory airway obstruction<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3&#44;5</span></a> &#40;epiglottitis and laryngotracheobronchitis&#41; was the most frequent indication&#46; Today&#44; the main indications are airway stenosis&#44; usually at subglottic level &#40;70&#37;&#41;&#44; and prolonged MV &#40;30&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">9&#44;11</span></a> In our series&#44; 52&#37; of patients had an airway obstruction&#44; either congenital &#40;24&#37;&#41; or subglottic stenosis &#40;12&#37;&#41;&#44; and 44&#37; were MV dependent&#46; Only 1 patient required tracheotomy due to an acute infectious process&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">To conclude&#44; current indications could be reduced to fixed airway obstruction&#44; airway toilet in ventilator-dependent patients&#44; and predicted long-term use of MV<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a>&#59; although&#44; as indicated by some authors&#44; indications should be case-dependent&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Non-invasive ventilation&#44; together assisted coughing&#44; is a recent alternative that is reducing the number of tracheotomies in ventilator-dependent patients&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Tracheotomy is an invasive procedure associated with multiple complications&#44; such as bleeding&#44; infection&#44; subcutaneous emphysema&#44; pneumothorax and tracheal stenosis&#46; Evidence has shown that technique-related morbidity and mortality in paediatric patients are 2&#8211;3 times higher than in the adult population&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#8211;8</span></a> In our series&#44; as well as in some others<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;9&#44;10</span></a> &#40;22&#8211;77&#37;&#41;&#44; we observed a high number of complications &#40;56&#37;&#41;&#44; with some patients presenting more than 1 complication&#46; Accidental decannulation stands out due to its high incidence and severity&#46; This occurred in 5 patients &#40;20&#37;&#41;&#46; This figure is higher than that reported by Mahadevan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> where 2&#46;5&#37; of decannulations were observed&#46; Out of the 5 decannulations&#44; 1 patient died due to impossibility of intubation due to presentation of a false passage&#46; This implies a mortality of 4&#37; in this group&#44; which is consistent with the rates reproted by Fraga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> in the literature &#40;0&#8211;6&#37;&#41;&#46; Interestingly&#44; this was the only case of emergency tracheotomy&#44; and was performed in a patient with acute pathology &#40;laryngitis&#41;&#46; This circumstance may have had&#44; in part&#44; a negative effect on the performance of the technique or the fixing of the cannula&#46; It is important to mention the impact that the underlying disease &#40;airway obstruction above the cannula&#41; may have had in the severity of the respiratory failure at the time of the accidental decannulation&#44; and the additional difficulty for orotracheal reintubation following the incident&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">When analysing the surgical technique&#44; tracheotomy performed with a vertical skin incision and a horizontal intercartilaginous incision does not seem to differ from the conventional procedure&#44; in which a longitudinal skin incision and a vertical intercartilaginous incision are performed&#44; in terms of mortality and complications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> However&#44; the surgical technique&#44; as well as the material used to attach the cannula or the suture technique used&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> could be related to decannulations&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> The suture of the trachea to the skin is an important factor to facilitate recannulation in case of accidental decannulation&#46; In our series&#44; our surgical technique did not include this suture&#44; a fact that facilitates recannulation&#46; The deceased patient did not have a cuffed cannula&#44; and neither did the other 4 patients with decannulations&#46; Indications for cuffed cannulas are very limited in paediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> Cuffed cannulas were not indicated in any of our study patients with accidental decannulation&#44; and we could find no studies where this was found to be a contributing factor to decannulation&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Continuing with the analysis of the accidental decannulations group&#44; we observed that decannulated children are smaller&#44; although the difference was not statistically significant&#46; The age barrier regarding the number of complications&#44; according to different references&#44; is 1 year of age&#46; According to Parrilla et al&#46;&#44; complications in children under the age of 1 year are more frequent &#40;48&#37;&#41; than in older patients &#40;27&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> The higher complication rate in younger children seems to be related to the internal radius of the trachea&#44; which is smaller and more flexible&#46; In fact&#44; airflow through a tube is inversely proportional to the ratio raised to the fourth power&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> As a consequence&#44; a slight reduction of the endotracheal diameter may cause a severe obstruction to airflow in the airway&#44; which is why the airway obstruction complication is more frequent at this age&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">This complication may occur at any time&#44; particularly in older children and in children with respiratory assistance&#44; partly influenced by the weight of the ventilator circuit&#46; This may be avoided by using a cannula of adequate size and model&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> as well as the use of secure tracheotomy tube holders&#46; Every new tracheotomy tube should be equipped with an active humidification device until the first change of cannula to prevent obstruction due to plugs secretions&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> Shinkwin et al&#46; recommend that&#44; if decannulation occurs within the first postoperative week&#44; patients should be intubated and then the tracheotomy replaced in more stable conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> All carers of tracheotomised children should be trained to face correctly with accidental decannulation&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> According to Berry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> being under the age of 1&#44; together with the association of congenital cardiopathies and prematurity are associated with a higher mortality in children with tracheotomy&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">All the decannulations in our series occurred within the first 48<span class="elsevierStyleHsp" style=""></span>h&#46; This could be due to the degree of stoma maturation&#44; healing and tunnelling&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> During this period&#44; since the stoma is not organised the possibility of creating a false passage is higher than in more developed tracheotomies&#46; Due to the foregoing&#44; we consider that the critical period for decannulations lasts from the performance of the tracheotomy until the first cannula replacement&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> Many authors highlight the importance of postoperative care&#44; the training level of nursing staff in charge of the patient at the time of decannulation<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> and the need for an agreed protocol&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;23</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The duration of hospital stay of these patients will depend on several factors&#44; including the status of the patient&#44; the availability of home care&#44; financial resources&#44; and the ability of parents and other carers to perform this complex task at home&#46; Our patients were hospitalised for a median &#40;range&#41; duration of 37 &#40;1&#8211;388&#41; days&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">To conclude&#44; tracheotomy in childhood is related to a high rate of morbidity and mortality&#46; The complication rate is considerable&#44; with a technique-related mortality between 0 and 6&#37;&#46; Tracheotomy control&#44; particularly within the first 48<span class="elsevierStyleHsp" style=""></span>h&#44; is essential&#46; There is no clear consensus regarding indications for and multidisciplinary care of the tracheotomy&#46; Multicentre co-operative studies are required to reach a consensus on the care of tracheotomised paediatric patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tracheotomy in paediatric patients is a rare procedure&#46; In this paediatric series&#44; perioperative complications&#44; mortality related to surgical procedure and overall mortality are analysed&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective study conducted from January 2003 to December 2013&#46; Data were retrieved from patients who were tracheotomized and admitted to our PICU in the postoperative period&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data were collected from 25 tracheotomized patients admitted during the study period&#46; The mean age was 31&#46;3 months &#40;median 14 months&#44; range 1&#8211;144 months&#41;&#44; and PICU length of stay was 53 days &#40;median 37 days&#44; range 1&#8211;338 days&#41;&#46; Most patients &#40;68&#37;&#41; had comorbidities prior to admission&#44; with a higher prevalence of craniofacial anomalies&#47;polymalformative syndromes &#40;32&#37;&#41; and prematurity related disorders &#40;12&#37;&#41; being observed&#46; The most common aetiologies related to the procedure were congenital airway obstruction &#40;16&#37;&#41; and several types of spinal cord injury &#40;16&#37;&#41;&#44; followed by tracheobronchomalacia &#40;12&#37;&#41; and subglottic stenosis &#40;12&#37;&#41;&#46; Complications were detected in 40&#37; of patients&#44; with accidental decannulation being the most frequent&#46; Accidental or unexpected decannulation occurred was present in as many as 20&#37; of our patients&#44; mainly in the first 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; One patient died as a result&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The postoperative course of a tracheotomy is associated with a high rate of complications&#44; some of them related to life-threatening events&#46;</p></span>"
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            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La traqueotom&#237;a es un procedimiento poco frecuente en la Unidad de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41;&#46; Analizamos las complicaciones derivadas de la t&#233;cnica&#44; la mortalidad atribuible a la misma y la mortalidad global de los pacientes traqueotomizados&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo descriptivo durante el periodo comprendido entre enero del 2003 y diciembre del 2013 de los pacientes ingresados en la UCIP a los que se realiza una traqueotom&#237;a a lo largo de su ingreso&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante el periodo analizado se recoge a 25 pacientes&#46; La media de edad es de 31&#44;3 meses &#40;rango 1-144&#44; mediana 14 meses&#41; y la media de estancia en UCIP es de 53 d&#237;as &#40;rango 1-338 d&#237;as&#44; mediana 37 d&#237;as&#41;&#46; En su mayor&#237;a &#40;68&#37;&#41; son pacientes con comorbilidades previas a su ingreso&#44; destacando en frecuencia las anomal&#237;as craneofaciales&#47;s&#237;ndromes polimalformativos &#40;32&#37;&#41; y problemas asociados a la prematuridad &#40;12&#37;&#41;&#46; Las patolog&#237;as m&#225;s frecuentes que motivaron la realizaci&#243;n del procedimiento fueron la obstrucci&#243;n cong&#233;nita de la v&#237;a a&#233;rea y diversas causas de lesi&#243;n medular&#44; seguido de traqueobroncomalacia y estenosis subgl&#243;tica&#46; Se detectaron complicaciones en el 40&#37; de los pacientes&#44; siendo la m&#225;s frecuente la decanulaci&#243;n accidental&#46; Presentaron durante el curso evolutivo una decanulaci&#243;n accidental el 20&#37; de los pacientes&#44; principalmente en las primeras 24<span class="elsevierStyleHsp" style=""></span>h del postoperatorio&#44; motivo por el que falleci&#243; uno de los pacientes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La realizaci&#243;n de la traqueotom&#237;a es un procedimiento poco frecuente en la UCIP&#44; aunque no exento de complicaciones&#44; algunas de ellas de riesgo vital&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Urabayen D&#44; L&#243;pez-Fern&#225;ndez YM&#44; Pilar-Orive J&#44; Nieto-Faza M&#44; Gil-Ant&#243;n J&#44; L&#243;pez-Bay&#243;n J&#44; et al&#46; An&#225;lisis de las traqueotom&#237;as en cuidados intensivos pedi&#225;tricos durante el periodo 2003&#8211;2013&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;84&#58;18&#8211;23&#46;</p>"
      ]
    ]
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BPD&#58; bronchopulmonary dysplasia&#59; TB&#58; tuberculosis&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#176; of patients &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Airway obstruction</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Congenital airway obstruction&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Subglottic stenosis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tracheobronchomalacia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Vocal cord paresis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2 &#40;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tumour &#40;base of tongue&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Facial trauma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infectious laryngitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Mechanic ventilation-dependent</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medullary injury&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Prematurity &#40;BPD&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3 &#40;12&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Extubation failure&#58; cardiopathy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Congenital hypotonia&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Central hypoventilation &#40;Ondine&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>TB Meningoencephalitis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1 &#40;4&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Indications of tracheotomy&#46;</p>"
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        "mostrarFloat" => true
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tracheotomy complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#176; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Mild</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infectious &#40;stoma area&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Stoma granuloma&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Severe</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Accidental decannulation&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Air leak &#40;pneumothorax&#44; pneumomediastinum&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Obstruction of the cannula&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Death &#40;tracheotomy related&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Accidental decannulation &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>5&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">General group &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>20&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">p</span> value&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">33&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>44&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;668&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mean MV days prior to tracheotomy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>118&#46;1&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;243&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Mean days admission PICU&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&#46;07&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">54<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>74&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;921&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top">Cuffed cannulas&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0 &#40;0&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">4 &#40;20&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&#46;275&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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        "descripcion" => array:1 [
          "en" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Analysis of the accidental decannulations subgroup&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0005"
          "bibliografiaReferencia" => array:27 [
            0 => array:3 [
              "identificador" => "bib0140"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Indications for tracheotomy in the Pediatric Intensive Care Population&#58; a pilot study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "W&#46; Lee"
                            1 => "P&#46; Koltai"
                            2 => "A&#46;N&#46; Harrison"
                            3 => "E&#46; Appachi"
                            4 => "D&#46; Bourdakos"
                            5 => "S&#46; Davis"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Otolaryngol Head Neck Surg"
                        "fecha" => "2002"
                        "volumen" => "128"
                        "paginaInicial" => "1249"
                        "paginaFinal" => "1252"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12431164"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0145"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Prevalence of tracheostomy in ICU patients&#58; a nation-wide survey in Switzerland"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:4 [
                            0 => "L&#46; Fischler"
                            1 => "S&#46; Erhart"
                            2 => "G&#46;R&#46; Kleger"
                            3 => "A&#46; Frutiger"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Intensive Care Med"
                        "fecha" => "2000"
                        "volumen" => "26"
                        "paginaInicial" => "1420"
                        "paginaFinal" => "1433"
                        "itemHostRev" => array:3 [
                          "pii" => "S0967586812004511"
                          "estado" => "S300"
                          "issn" => "09675868"
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0150"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
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Original Article
Analysis of tracheostomies in a Paediatric Intensive Care Unit during the period 2003–2013
Análisis de las traqueotomías en cuidados intensivos pediátricos durante el periodo 2003–2013
D. García-Urabayen, Y.M. López-Fernández, J. Pilar-Orive
Corresponding author
, M. Nieto-Faza, J. Gil-Antón, J. López-Bayón, S. Redondo-Blázquez
Unidad de Cuidados Intensivos Pediatricos, Hospital Universitario de Cruces, Baracaldo, Vizcaya, Spain
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    "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
    "titulo" => "Analysis of tracheostomies in a Paediatric Intensive Care Unit during the period 2003&#8211;2013"
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        "autoresLista" => "D&#46; Garc&#237;a-Urabayen, Y&#46;M&#46; L&#243;pez-Fern&#225;ndez, J&#46; Pilar-Orive, M&#46; Nieto-Faza, J&#46; Gil-Ant&#243;n, J&#46; L&#243;pez-Bay&#243;n, S&#46; Redondo-Bl&#225;zquez"
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      "es" => array:1 [
        "titulo" => "An&#225;lisis de las traqueotom&#237;as en cuidados intensivos pedi&#225;tricos durante el periodo 2003&#8211;2013"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Tracheotomies are rarely performed in the Paediatric Intensive Care Unit&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> This technique is performed in the paediatric patient noticeably less frequently than in adults&#44; where up to 10&#37; of all patients who receive mechanical ventilation &#40;MV&#41; are tracheotomised&#46;<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">2</span></a> Over time&#44; common indications for MV&#44; such as the infectious acute inflammation of the airway&#44; have now been replaced with others&#44; such as MV dependency in chronic patients&#44; severe airway obstruction due to congenital malformations&#44; and thoracic wall weakness in neuromuscular patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3&#8211;5</span></a> MV&#44; therefore&#44; is now used in both acute and chronic patients discharged with some kind of home respiratory support&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The complication rate associated with this technique is considered to be higher in children than in adults&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#8211;8</span></a> However&#44; both the frequency and type of complication&#44; above all mortality&#44; vary considerably between studies&#46; Mahadevan et al&#46;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> describe a global complications rate in these patients of 51&#37;&#44; with 2&#46;5&#37; of accidental decannulations&#44; percentages that are similar to those found in other publications&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#8211;12</span></a> Mortality directly attributable to MV ranges from 0&#46;5&#37; to 3&#37; in different series&#44; the most frequent causes being accidental decannulation and obstruction of the cannula&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">10&#44;12&#8211;14</span></a> Global mortality of tracheotomised patients ranges from 7&#37; to 40&#37;&#44; depending on the study&#46;<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;9&#44;14</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">The purpose of this review is to analyse the tracheotomies performed in our unit in order to gain insight into the complications derived from the technique&#44; the mortality attributable to it and the global mortality of tracheotomised patients&#46; The purpose is also to compare our findings with those published in the most recent literature&#46; The study was approved by the institutional review board of the Cruces University Hospital &#40;Bilbao&#44; Spain&#41;&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a retrospective chart review of patients admitted to the Paediatric Intensive Care Unit &#40;PICU&#41; of the Cruces University Hospital that underwent tracheotomy in the unit in the period between January 2003 and December 2014&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">The patients were chosen after reviewing the records of patients discharged from the unit&#44; selecting those whose diagnosis and&#47;or techniques performed during admission showed a tracheotomy within the period covered by the study&#46; In total&#44; 26 patients were identified&#46; One patient was excluded because his medical history was not available&#46; The patients were included in the review&#44; regardless of whether the procedure was urgent or elective and of the surgical technique used for placing and fixing the cannula&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The following variables were analysed &#8211; indication for tracheotomy&#44; age&#44; MV days prior to the tracheotomy&#44; length of stay in the PICU&#44; types of cannula &#40;cuffed or simple&#41; postoperative day for the first scheduled cannula replacement&#44; and complications directly related to this procedure&#44; mortality related to the technique and global mortality&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We also analysed a subgroup of patients with an episode of accidental removal of the tracheotomy cannula &#40;accidental decannulation&#41; with the purpose of finding possible differential factors in this subgroup with respect to the total&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Being a retrospective&#44; non-interventionist study&#44; informed consent was not requested from the parents&#47;guardians&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">For the statistical study&#44; the Mann&#8211;Whitney eliminar test was used for independent samples&#46; Data were analysed using IBM SPSS statistics &#40;version 22&#46;0&#41;&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Patients and indications</span><p id="par0050" class="elsevierStylePara elsevierViewall">During the 10-year study period&#44; near 6000 patients have been admitted to the Unit&#44; of which 30&#37; received MV&#46; Approximately 1500 were intubated and 25 of those underwent tracheotomy&#44; which constitutes 1&#46;5&#37; of the intubated patients&#46; Out of the 25 patients included in our series&#44; 13 were boys &#40;52&#37;&#41; and 12 girls &#40;48&#37;&#41;&#46; The mean age was 31&#46;3 months &#40;median&#58; 14 months&#44; range&#58; 0&#8211;12 years&#41;&#44; 44&#37; them were under the age of 1 year and 76&#37; under the age of 3 years&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Airway obstruction was the most frequent indication for tracheotomy&#44; 14 &#40;56&#37;&#41; of the patients&#44; while prolonged MV was the indication for tracheotomy in the remaining patients&#44; 11 &#40;44&#37;&#41;&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The different causes&#44; divided in subgroups&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">Among the cases of airway obstruction&#44; 4 &#40;16&#37;&#41; were due to congenital factors &#40;Pierre&#8211;Robin sequence&#44; CHARGE syndrome&#44; congenital microretrognathia without identification&#44; Proteus syndrome&#41;&#44; 3 due to post-MV subglottic stenosis&#44; 2 presented severe tracheobronchomalacia uncontrolled with medical &#40;continuous positive pressure in the airway&#41; or surgical &#40;aortopexy&#41; treatment&#44; 2 presented vocal cord paresis &#40;one congenital&#44; one post-MV&#41;&#44; 1 base tongue tumour&#44; one facial trauma&#44; and 1 case secondary to obstruction due to infectious inflammation of the airway &#40;laryngitis&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">Among the cases of prolonged MV&#44; 4 were secondary to medullary injury &#40;1 poly-trauma&#44; 1 intramedullary tumour&#44; 1 posterior fossa decompressive post-neurosurgery ischaemic injury and 1 transversal myelitis&#41;&#44; 3 cases of bronchopulmonary dysplasia&#44; 1 cardiopathy with recurrent failures in extubation&#44; 1 case of congenital hypotonia with respiratory failure&#44; 1 case of Ondine&#39;s syndrome and 1 patient with tuberculous meningitis and MV-dependent severe brain injury&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">As to the characteristics of the tracheotomy cannulas&#44; 20&#37; of them were cuffed&#46; The first scheduled replacement was performed on the seventh postoperative day in most cases &#40;92&#37;&#41;&#44; and the reason why the procedure was not performed on the seventh day in the other episodes is unspecified&#46; In all cases&#44; the first replacement was performed by an otolaryngologist&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The mean stay at the PICU for these patients was prolonged &#40;53 days&#44; median&#58; 37&#44; range&#58; 1&#8211;338&#41;&#44; given their chronic condition&#46; Mean days on MV prior to ostomy was 48 days &#40;range&#58; 0&#8211;270&#41;&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">Twenty-four tracheotomies were performed electively in the operating theatre&#59; 1 was an emergency procedure in an otherwise healthy girl with symptoms of infectious laryngitis&#44; due to intubation failure in the hospital of origin&#46; None of the tracheotomies were performed percutaneously&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Complications</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ten patients &#40;40&#37;&#41; presented complications related to the tracheotomy procedure during their stay in the PICU &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#44; 2 of them presenting more than 1 complication&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0095" class="elsevierStylePara elsevierViewall">As for mild complications&#44; 3 patients showed local infections resolved with treatment&#44; and 1 presented stoma granuloma&#46; No bleeding or significant neck wound from tube attachments were observed&#46; Among the severe complications&#44; 5 patients presented an episode of accidental decannulation&#44; 3 presented air leak syndrome &#40;pneumothorax&#47;pneumomediastinum&#41;&#44; 1 presented obstruction of the cannula and 1 died&#46; The deceased patient died in the immediate postoperative period as a result of accidental decannulation with impossibility of recannulation&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Mortality attributable to tracheotomy complications was 4&#37; &#40;1 patient died due to accidental decannulation&#41;&#44; while global mortality during hospital stay was 20&#37; &#40;4 patients&#44; 16&#37;&#44; attributable to other causes unrelated to tracheotomy&#41;&#46; During follow-up and to date&#44; global mortality increased to 28&#37; &#40;7 patients&#41; and 2 patients were lost to follow-up due to treatment in another centre&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">No technique-related problems in scheduled cannula replacements&#44; or infections described in other series&#44; such as mediastinitis or sepsis were observed &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Analysis of the accidental decannulations subgroup</span><p id="par0110" class="elsevierStylePara elsevierViewall">A comparative statistical analysis was performed between the group of patients that presented an episode of accidental decannulation &#40;5 patients&#41; and the rest of the patients &#40;20 patients&#41; to identify possible differential factors&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">The mean age of the 5 patients that presented an episode of accidental decannulation was lower than that of the general group &#40;22&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>21&#46;06 v&#46; 33&#46;6<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>44&#46;11 months&#41;&#46; The mean length of stay in the PICU was similar in both groups &#40;41&#46;8<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>39&#46;07 v&#46; 54&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>74&#46;1 days&#41;&#46; The analysis shows that the average number of MV days prior to tracheotomy is clearly higher in the accidental decannulations group &#40;60<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>118 v&#46; 33&#46;2<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>38 days&#41;&#44; a difference due to the prolonged time on MV of one patient compared to the rest of the group &#40;270 days&#41;&#46; However&#44; there was no difference between groups in terms of median MV days &#40;30 v&#46; 30 days&#41;&#46; The most frequent indication for tracheotomy in the subgroup of patients that presented an accidental decannulation was tracheobronchomalacia &#40;2 patients&#41;&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Among the variables analysed&#44; no statistically significant differences were observed between both groups with regard to mean age&#44; average number of MV days prior to performance of tracheotomy&#44; or mean stay days in the PICU&#46; In spite of the remarkable difference in the use of cuffed cannulas in the accidental decannulations group &#40;0&#37; v&#46; 20&#37; in the rest of the patients&#41;&#44; this difference does not reach statistical significance&#44; probably due to the insufficient sample size in the decannulations group&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">In total&#44; 80&#37; of the patients who presented an accidental decannulation suffered cardiac arrest as a consequence&#44; and 1 of them died&#46; All of the accidental decannulation episodes occurred within the first 48<span class="elsevierStyleHsp" style=""></span>h of the postoperative period&#44; and 80&#37; within the first 24<span class="elsevierStyleHsp" style=""></span>h&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Discussion</span><p id="par0130" class="elsevierStylePara elsevierViewall">Tracheotomy in the paediatric patient is still an uncommon procedure<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> &#40;0&#46;5&#37;&#8211;2&#37; of patients on MV&#41; that is performed late in ventilated children&#44; usually in the operating theatre&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">15</span></a> In our series&#44; tracheotomised patients constituted approximately 1&#46;5&#37; of all intubated patients&#46; The time when the tracheotomy is performed is still under debate in paediatrics&#46; In adults&#44; where there is a theoretical barrier of 7&#8211;10 days of MV&#44; we found that current practice also varies&#44; with rates that range between 5&#37; and 24&#37; of tracheotomies in intubated patients<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">2&#44;16&#44;17</span></a> and with a mean of 9 and 12 ventilation days&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">18</span></a> Griffiths et al&#46;&#44; in a meta-analysis that included 406 patients&#44; observed that an early tracheotomy significantly reduced the duration of MV and the stay in the ICU&#46;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">19</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">The duration of intubation in children is not predicative of the need for a tracheotomy&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> We now know that children can be on MV for months without important complications&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">12</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">A survey conducted among paediatric intensive care specialists showed that there is no consensus regarding the time at which a tracheotomy should be performed&#58; 81&#37; of respondents did not agree on indications and time&#46; However&#44; nearly 50&#37; of doctors considered that the procedure was underutilised&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">20</span></a> In the Al-Samri et al&#46; study<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a> on 70 paediatric tracheotomies&#44; the mean duration &#40;range&#41; of MV before tracheotomy was 20 &#40;0&#8211;140&#41; days&#46; In our series&#44; mean MV days prior to tracheotomy was 48 &#40;0&#8211;270&#41; days&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Indications for tracheotomy have changed over the years&#46; In the 1970s&#44; inflammatory airway obstruction<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">3&#44;5</span></a> &#40;epiglottitis and laryngotracheobronchitis&#41; was the most frequent indication&#46; Today&#44; the main indications are airway stenosis&#44; usually at subglottic level &#40;70&#37;&#41;&#44; and prolonged MV &#40;30&#37;&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">9&#44;11</span></a> In our series&#44; 52&#37; of patients had an airway obstruction&#44; either congenital &#40;24&#37;&#41; or subglottic stenosis &#40;12&#37;&#41;&#44; and 44&#37; were MV dependent&#46; Only 1 patient required tracheotomy due to an acute infectious process&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">To conclude&#44; current indications could be reduced to fixed airway obstruction&#44; airway toilet in ventilator-dependent patients&#44; and predicted long-term use of MV<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a>&#59; although&#44; as indicated by some authors&#44; indications should be case-dependent&#46;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">1</span></a> Non-invasive ventilation&#44; together assisted coughing&#44; is a recent alternative that is reducing the number of tracheotomies in ventilator-dependent patients&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">6</span></a></p><p id="par0155" class="elsevierStylePara elsevierViewall">Tracheotomy is an invasive procedure associated with multiple complications&#44; such as bleeding&#44; infection&#44; subcutaneous emphysema&#44; pneumothorax and tracheal stenosis&#46; Evidence has shown that technique-related morbidity and mortality in paediatric patients are 2&#8211;3 times higher than in the adult population&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#8211;8</span></a> In our series&#44; as well as in some others<a class="elsevierStyleCrossRefs" href="#bib0155"><span class="elsevierStyleSup">4&#44;9&#44;10</span></a> &#40;22&#8211;77&#37;&#41;&#44; we observed a high number of complications &#40;56&#37;&#41;&#44; with some patients presenting more than 1 complication&#46; Accidental decannulation stands out due to its high incidence and severity&#46; This occurred in 5 patients &#40;20&#37;&#41;&#46; This figure is higher than that reported by Mahadevan et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0180"><span class="elsevierStyleSup">9</span></a> where 2&#46;5&#37; of decannulations were observed&#46; Out of the 5 decannulations&#44; 1 patient died due to impossibility of intubation due to presentation of a false passage&#46; This implies a mortality of 4&#37; in this group&#44; which is consistent with the rates reproted by Fraga et al&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">14</span></a> in the literature &#40;0&#8211;6&#37;&#41;&#46; Interestingly&#44; this was the only case of emergency tracheotomy&#44; and was performed in a patient with acute pathology &#40;laryngitis&#41;&#46; This circumstance may have had&#44; in part&#44; a negative effect on the performance of the technique or the fixing of the cannula&#46; It is important to mention the impact that the underlying disease &#40;airway obstruction above the cannula&#41; may have had in the severity of the respiratory failure at the time of the accidental decannulation&#44; and the additional difficulty for orotracheal reintubation following the incident&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">When analysing the surgical technique&#44; tracheotomy performed with a vertical skin incision and a horizontal intercartilaginous incision does not seem to differ from the conventional procedure&#44; in which a longitudinal skin incision and a vertical intercartilaginous incision are performed&#44; in terms of mortality and complications&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">7</span></a> However&#44; the surgical technique&#44; as well as the material used to attach the cannula or the suture technique used&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">21</span></a> could be related to decannulations&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> The suture of the trachea to the skin is an important factor to facilitate recannulation in case of accidental decannulation&#46; In our series&#44; our surgical technique did not include this suture&#44; a fact that facilitates recannulation&#46; The deceased patient did not have a cuffed cannula&#44; and neither did the other 4 patients with decannulations&#46; Indications for cuffed cannulas are very limited in paediatrics&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">22</span></a> Cuffed cannulas were not indicated in any of our study patients with accidental decannulation&#44; and we could find no studies where this was found to be a contributing factor to decannulation&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">Continuing with the analysis of the accidental decannulations group&#44; we observed that decannulated children are smaller&#44; although the difference was not statistically significant&#46; The age barrier regarding the number of complications&#44; according to different references&#44; is 1 year of age&#46; According to Parrilla et al&#46;&#44; complications in children under the age of 1 year are more frequent &#40;48&#37;&#41; than in older patients &#40;27&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> The higher complication rate in younger children seems to be related to the internal radius of the trachea&#44; which is smaller and more flexible&#46; In fact&#44; airflow through a tube is inversely proportional to the ratio raised to the fourth power&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">4</span></a> As a consequence&#44; a slight reduction of the endotracheal diameter may cause a severe obstruction to airflow in the airway&#44; which is why the airway obstruction complication is more frequent at this age&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">This complication may occur at any time&#44; particularly in older children and in children with respiratory assistance&#44; partly influenced by the weight of the ventilator circuit&#46; This may be avoided by using a cannula of adequate size and model&#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> as well as the use of secure tracheotomy tube holders&#46; Every new tracheotomy tube should be equipped with an active humidification device until the first change of cannula to prevent obstruction due to plugs secretions&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">13</span></a> Shinkwin et al&#46; recommend that&#44; if decannulation occurs within the first postoperative week&#44; patients should be intubated and then the tracheotomy replaced in more stable conditions&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> All carers of tracheotomised children should be trained to face correctly with accidental decannulation&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">23</span></a> According to Berry et al&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">24</span></a> being under the age of 1&#44; together with the association of congenital cardiopathies and prematurity are associated with a higher mortality in children with tracheotomy&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">All the decannulations in our series occurred within the first 48<span class="elsevierStyleHsp" style=""></span>h&#46; This could be due to the degree of stoma maturation&#44; healing and tunnelling&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">25</span></a> During this period&#44; since the stoma is not organised the possibility of creating a false passage is higher than in more developed tracheotomies&#46; Due to the foregoing&#44; we consider that the critical period for decannulations lasts from the performance of the tracheotomy until the first cannula replacement&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">26</span></a> Many authors highlight the importance of postoperative care&#44; the training level of nursing staff in charge of the patient at the time of decannulation<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">27</span></a> and the need for an agreed protocol&#46;<a class="elsevierStyleCrossRefs" href="#bib0165"><span class="elsevierStyleSup">6&#44;23</span></a></p><p id="par0180" class="elsevierStylePara elsevierViewall">The duration of hospital stay of these patients will depend on several factors&#44; including the status of the patient&#44; the availability of home care&#44; financial resources&#44; and the ability of parents and other carers to perform this complex task at home&#46; Our patients were hospitalised for a median &#40;range&#41; duration of 37 &#40;1&#8211;388&#41; days&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">To conclude&#44; tracheotomy in childhood is related to a high rate of morbidity and mortality&#46; The complication rate is considerable&#44; with a technique-related mortality between 0 and 6&#37;&#46; Tracheotomy control&#44; particularly within the first 48<span class="elsevierStyleHsp" style=""></span>h&#44; is essential&#46; There is no clear consensus regarding indications for and multidisciplinary care of the tracheotomy&#46; Multicentre co-operative studies are required to reach a consensus on the care of tracheotomised paediatric patients&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Conflict of interest</span><p id="par0190" class="elsevierStylePara elsevierViewall">The authors declare that there are no conflicts of interest&#46;</p></span></span>"
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          "titulo" => "Resumen"
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              "titulo" => "Introducci&#243;n"
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              "titulo" => "Patients and indications"
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              "titulo" => "Analysis of the accidental decannulations subgroup"
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    "fechaRecibido" => "2014-12-12"
    "fechaAceptado" => "2015-02-24"
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Tracheotomy"
            1 => "Paediatrics"
            2 => "Postoperative complications"
            3 => "Paediatric Intensive Care Units"
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          "clase" => "keyword"
          "titulo" => "Palabras clave"
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          "palabras" => array:4 [
            0 => "Traqueotom&#237;a"
            1 => "Pediatr&#237;a"
            2 => "Complicaciones postoperatorias"
            3 => "Unidades de Cuidado Intensivo Pedi&#225;trico"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Tracheotomy in paediatric patients is a rare procedure&#46; In this paediatric series&#44; perioperative complications&#44; mortality related to surgical procedure and overall mortality are analysed&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This is a retrospective study conducted from January 2003 to December 2013&#46; Data were retrieved from patients who were tracheotomized and admitted to our PICU in the postoperative period&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data were collected from 25 tracheotomized patients admitted during the study period&#46; The mean age was 31&#46;3 months &#40;median 14 months&#44; range 1&#8211;144 months&#41;&#44; and PICU length of stay was 53 days &#40;median 37 days&#44; range 1&#8211;338 days&#41;&#46; Most patients &#40;68&#37;&#41; had comorbidities prior to admission&#44; with a higher prevalence of craniofacial anomalies&#47;polymalformative syndromes &#40;32&#37;&#41; and prematurity related disorders &#40;12&#37;&#41; being observed&#46; The most common aetiologies related to the procedure were congenital airway obstruction &#40;16&#37;&#41; and several types of spinal cord injury &#40;16&#37;&#41;&#44; followed by tracheobronchomalacia &#40;12&#37;&#41; and subglottic stenosis &#40;12&#37;&#41;&#46; Complications were detected in 40&#37; of patients&#44; with accidental decannulation being the most frequent&#46; Accidental or unexpected decannulation occurred was present in as many as 20&#37; of our patients&#44; mainly in the first 24<span class="elsevierStyleHsp" style=""></span>h after surgery&#46; One patient died as a result&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The postoperative course of a tracheotomy is associated with a high rate of complications&#44; some of them related to life-threatening events&#46;</p></span>"
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            "titulo" => "Introduction"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
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        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La traqueotom&#237;a es un procedimiento poco frecuente en la Unidad de cuidados intensivos pedi&#225;tricos &#40;UCIP&#41;&#46; Analizamos las complicaciones derivadas de la t&#233;cnica&#44; la mortalidad atribuible a la misma y la mortalidad global de los pacientes traqueotomizados&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo descriptivo durante el periodo comprendido entre enero del 2003 y diciembre del 2013 de los pacientes ingresados en la UCIP a los que se realiza una traqueotom&#237;a a lo largo de su ingreso&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Durante el periodo analizado se recoge a 25 pacientes&#46; La media de edad es de 31&#44;3 meses &#40;rango 1-144&#44; mediana 14 meses&#41; y la media de estancia en UCIP es de 53 d&#237;as &#40;rango 1-338 d&#237;as&#44; mediana 37 d&#237;as&#41;&#46; En su mayor&#237;a &#40;68&#37;&#41; son pacientes con comorbilidades previas a su ingreso&#44; destacando en frecuencia las anomal&#237;as craneofaciales&#47;s&#237;ndromes polimalformativos &#40;32&#37;&#41; y problemas asociados a la prematuridad &#40;12&#37;&#41;&#46; Las patolog&#237;as m&#225;s frecuentes que motivaron la realizaci&#243;n del procedimiento fueron la obstrucci&#243;n cong&#233;nita de la v&#237;a a&#233;rea y diversas causas de lesi&#243;n medular&#44; seguido de traqueobroncomalacia y estenosis subgl&#243;tica&#46; Se detectaron complicaciones en el 40&#37; de los pacientes&#44; siendo la m&#225;s frecuente la decanulaci&#243;n accidental&#46; Presentaron durante el curso evolutivo una decanulaci&#243;n accidental el 20&#37; de los pacientes&#44; principalmente en las primeras 24<span class="elsevierStyleHsp" style=""></span>h del postoperatorio&#44; motivo por el que falleci&#243; uno de los pacientes&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La realizaci&#243;n de la traqueotom&#237;a es un procedimiento poco frecuente en la UCIP&#44; aunque no exento de complicaciones&#44; algunas de ellas de riesgo vital&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Garc&#237;a-Urabayen D&#44; L&#243;pez-Fern&#225;ndez YM&#44; Pilar-Orive J&#44; Nieto-Faza M&#44; Gil-Ant&#243;n J&#44; L&#243;pez-Bay&#243;n J&#44; et al&#46; An&#225;lisis de las traqueotom&#237;as en cuidados intensivos pedi&#225;tricos durante el periodo 2003&#8211;2013&#46; An Pediatr &#40;Barc&#41;&#46; 2016&#59;84&#58;18&#8211;23&#46;</p>"
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Indications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#176; of patients &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Airway obstruction</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Congenital airway obstruction&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Tracheobronchomalacia&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Mechanic ventilation-dependent</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Medullary injury&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Tracheotomy complications&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">N&#176; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " colspan="2" align="left" valign="top"><span class="elsevierStyleItalic">Mild</span></td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Infectious &#40;stoma area&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Stoma granuloma&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Air leak &#40;pneumothorax&#44; pneumomediastinum&#41;&nbsp;\t\t\t\t\t\t\n
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Idiomas
Anales de Pediatría (English Edition)
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¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?