Dr Lily LL Chang, ICU, Pamela Youde Nethersole Eastern Hospital, Hong Kong
Background:
Tracheostomy is a common procedure performed in patients requiring prolonged mechanical ventilation in the critical care setting.
Objective:
The primary objective is to describe the short-term and long-term outcomes of tracheostomized Intensive Care Unit (ICU) patients. The secondary objective is to identify any predictors of complications during and after the tracheostomy procedure.
Design:
Retrospective and prospective, observational case series performed in a general medical-surgical adult ICU in a local tertiary centre.
Patients:
The inclusion criteria were adult patients older than 18 years old admitted to the ICU of Pamela Youde Nethersole Eastern Hospital (PYNEH) with subsequent tracheostomy done during the observational period and those immediate post-operative cases. Exclusion criterion was patients already had a tracheostomy before current ICU admission.
Methods:
Medical records from July 2008 to December 2009 were reviewed in the retrospective part. Data were collected prospectively from July 2010 to June 2011. Intra-procedural complications of tracheostomy were recorded during the prospective period. Short-term complications were recorded in both periods, while long-term complications were retrieved from retrospective period. Functional outcome of tracheostomized and survived patients in the retrospective period were assessed in the form of Barthel Index (BI) via telephone contacts. Short Form-36 (SF-36) questionnaires were sent to survived patients to study their physical and mental function.
Results:
A total of 153 patients were recruited. Among them, 99 were recruited retrospectively while 54 were recruited prospectively, which respectively represented 5.5% and 4.5% of total ICU admissions during the two study periods. The most common indication for tracheostomy was prolonged mechanical ventilation (72.6%), followed by failure of extubation (15%). The mean duration of intubation was 9.05 ± 6.48 days. Surgical tracheostomy was the predominant method used (73.9%). There were no statistically significant differences between surgical and percutaneous tracheostomy on the complication rate. Duration of percutaneous tracheostomy (8.33 ± 5.51 minutes) was significantly shorter than the duration of surgical tracheostomy (42.36 ± 20.33 minutes, p= 0.011). Minor bleeding was the most common short-term complication (10.5%) and tracheal stenosis was the most common long-term complication (5.1%). Multivariate analysis using logistic regression showed that hypertension (adjusted odds ratio 5.28, 95% CI 1.05-26.51, p= 0.044) and chronic renal failure (CRF) (adjusted odds ratio 17.56, 95% CI 2.87-107.42, p= 0.002) were independent risk factors for minor bleeding; while the need to reintubate within 48 hours after extubation (adjusted odds ratio 10.5, 95% CI 1.30-84.88, p= 0.027) was an independent risk factor for tracheal stenosis. CRF was independently associated with composite complications (minor bleeding and tracheal stenosis; odds ratio 13.63, 95% CI of 2.47-75.16, p= 0.003). Mental health score at 1 year or more was generally better than physical health score in this cohort of patients.
Conclusion:
This observational case series described the short-term and long-term outcomes of tracheostomized patients from ICU. Minor bleeding occurred in 10.5% of patients and tracheal stenosis occurred in 5.1% of patients. Their long-term outcome was relatively poor, with mental health slightly better than physical health; they required various degrees of assistance in the activity of daily living, and most of them required rehabilitation upon hospital discharge. CRF was found to be associated with increased risk for composite complications compared with those without CRF. However due to the small number of patients suffering from CRF in this study, further investigations should be conducted to verify this finding.