Mortality and tracheotomy

Early Versus Late Tracheostomy in Trauma Patients With Rib Fractures

BACKGROUND

Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial.

METHODS

This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy.

RESULTS

Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside.

CONCLUSIONS

ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.

[Percutaneous tracheotomy and cricothyroidotomy in the critical patient]

OBJECTIVE

To review and compare the complications of percutaneous tracheotomy (TP) and cricothyroidotomy (CT) used to perform tracheal intubation in patients requiring prolonged mechanical ventilation.

DESIGN

A prospective, observational study performed from October 2004 to October 2006, and follow-up of course until May 2007.

SETTING

Intensive care service from a university-affiliated teaching hospital.

PATIENTS

A total of 82 patients in which CT or TP were necessary. Forty-three TP and 39 CT were performed.

MAIN MEASUREMENTS

Reason for TP or CT, demographic data, severity scores, ICU length of stay, orotracheal intubation (OTI) days, CT/TP early and late complications and in-hospital evolution were collected.

RESULTS

TP/CT were performed due to prolonged ventilation in 62 (76%) patients and because of impaired neurological status in the remaining patients. There were no differences between TP/CT in gender, APACHE II, ICU length of stay, previous OTI days. Patients in the CT group were older (68 +/- 9 vs 54 +/- 15 years, p < 0.001). There were 5 mild adverse events (3 guide angulations and 2 lateral tracheal punctions) after TP, and 1 severe adverse event (pulmonary ventilation problem) after CT. There were no fatal event related with TP/CT. Thirty-four patients were decanulated. Mild local injuries were seen in 8 patients (6 TP vs 2 CT). Only 1 subglottic granuloma was seen late in CT group.

CONCLUSIONS

In our experience CT constitutes a safety and feasible alternative to TP when TP is counter-indicated.