Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review

Re October2004 Vol8sNo5 earch Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review Yaseen Arabi1, Samir Haddad2, Nehad Shirawi3 and Abdullah Al Shimemeri4 Corresponding author: Yaseen Arabi 0 ICU Pulmonary Fellow, Intensive Care Department (MC 1425), King Abdulaziz Medical City , Riyadh, Kingdom of Saudi Arabia 1 Associate Consultant, Intensive Care Department (MC 1425), King Abdulaziz Medical City , Riyadh, Kingdom of Saudi Arabia 2 Deputy Chairman, Intensive Care Department (MC 1425), King Abdulaziz Medical City , Riyadh, Kingdom of Saudi Arabia 3 Chairman, Intensive Care Department (MC 1425), King Abdulaziz Medical City , Riyadh, Kingdom of Saudi Arabia Introduction Despite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients. Methods The following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay. Results Of 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean standard error: 9.6 1.2 days versus 18.7 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 1.2 days versus 21.0 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 1.2 days versus 4.9 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days). Conclusion Early tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization. intensive care; mechanical ventilation; resource utilization; Saudi Arabia; trauma; tracheostomy; weaning - APACHE = Acute Physiology and Chronic Health Evaluation; CI = confidence interval; ICU = intensive care unit; ISS = Injury Severity Score; GCS = Glasgow Coma Score; LOS = length of stay; OR = odds ratio. Introduction Patients with multiple trauma often require mechanical ventilation for prolonged periods because of their inability to protect their airways, persistence of excessive secretions, and inadequacy of spontaneous ventilation [1]. Tracheostomy plays an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation [2]. The decision to proceed to tracheostomy is often made only if the patient could not be extubated within 1014 days or more [3]. In 1989, the American College of Chest Physicians Consensus Statement on Artificial Airways in Patients Receiving Mechanical Ventilation considered translaryngeal intubation to be the preferred technique for patients requiring up to 10 days of mechanical ventilation [4]. For those with anticipated need for artificial airway for more than 21 days, tracheostomy was recommended. For all other patients, the decision regarding the timing of tracheostomy was left to daily assessment and physician preference. Such practice was based on earlier reports showing high tracheal stenosis rates with tracheostomy as compared with endotracheal intubation [5,6]. For example, one study reported in 1981 [6] found an incidence of tracheal stenosis after tracheostomy of 65%, as compared with 19% after endotracheal intubation. The authors of that study concluded that tracheostomy for patients requiring an artificial airway for periods as long as 3 weeks could not be recommended. However, the incidence of tracheal stenosis has decreased substantially with recognition of its aetiology and improvements in tracheostomy materials, design and management [7], particularly with the use of high-volume, lowpressure cuffs. Also, the complications associated with prolonged endotracheal intubation are increasingly being recognized, including injury to the larynx and trachea, and patient discomfort. In addition, endotracheal intubation often requires the administration of systemic sedation, with attendant complications. Finally, the incidence of ventilator-associated pneumonia is related directly to the duration of mechanical ventilation [8] a complication that carries significant morbidity and mortality [9]. One of the under-appreciated consequences of delaying tracheostomy is prolonged mechanical ventilation and intensive care unit (ICU) stay. Notably, the large body of literature addressing local complications of tracheostomy contrasts with the paucity of reports on the advantages of this procedure, especially its impact on resource utilization. This contrast may have encouraged practitioners to consider alternatives to tracheostomy. The aim of the present study is to examine the impact of early tracheostomy on resource utilization in ICU trauma patients. This examination is followed by a review of the existing literature in this area. medical/surgical ICU staffed by full-time, on-site intensivists 24 hours a day and 7 days a week. Our department has nine consultant intensivists, all of whom are certified in critical care. The hospital has a designated trauma service, including a consultant surgeon, available 24 hours a day. Medical care in the ICU is provided by the ICU team, with the trauma team being responsible for surgical aspects of care. Ventilatory management, and decisions regarding extubation or tracheostomy and discharge from the ICU are made primarily by the ICU team. All percutaneous tracheostomies are performed at the bedside by the ICU tea (...truncated)