Tracheotomie precoce chez les malades neutropeniques ventiles. Une etude retrospective

The prognosis of ventilated neutropenic patients in Intensive Care Unit (ICU) remains grim, particularly when mechanical ventilation (MV) is necessary. Tracheotomy, performed early after the onset of MV, could allows to improve the prognosis of such patients. The objective of our study was to evaluate the safety of tracheotomy in neutropenic ventilated cancer patients, in terms of infectious and haemorrhagic complications, and the benefit of tracheotomy in terms of in-ICU mortality and nosocomial pneumonias. For the study of safety of tracheotomy, the charts of twenty-six consecutive neutropenic patients undergoing a tracheotomy in our medical-surgical intensive care during a 4-year period, have been retrospectively reviewed. In all patients, the characteristics and duration of both neutropenia and mechanical ventilation have been recorded. Stomal bleeding and infection, and infectious pneumonias and alveolar haemorrhage have been carefully reviewed. Platelets were transfused in 23 of the 26 patients at the time of the procedure; no local haemorrhage was observed. Neither stomal nor pulmonary infections secondary to tracheotomy were noted. No respiratory worsening was attributable to the tracheotomy. Nineteen patients (73%) died in ICU, without a direct link between tracheotomy and death. For the study of the benefit of tracheotomy, the charts of fifty-three consecutive, ventilated, neutropenic or destined to become promptly neutropenic patients have been retrospectively reviewed. To avoid bias, patients who had just undergone surgery, and those who died within 48 hours of starting MV were excluded. Twenty patients underwent tracheotomy within 48 hours of mechanical ventilation (ET group), while 33 were tracheotomized later or remained intubated (INT group). The two groups were comparable wit regard to the underlying disease, respiratory failure, mechanical ventilation patterns and severity scores, but neutropenia was more profound in the ET group. In-ICU mortality was similar (ET: 70%; INT: 78.8%). However, the survival curves showed a trend towards longer survival in the ICU in the ET group, even after adjustment for the degree of neutropenia (Log-Rank test: p = 0.07). The incidence of pneumonias was similar in both groups. These findings suggest that a tracheotomy can be safely performed in neutropenic patients requiring mechanical ventilation, and that a tracheotomy could be proposed to such patients in order to prolong the survival, waiting for the end of the neutropenic period.