TRACMAN

The TracMan trial was recently published in JAMA. TracMan is a randomised trial comparing early vs late tracheostomy in ICU patients. Which just happens to be one of the big current controversies in intensive care.

Background
Since the introduction of bedside percutaneous tracheostomy kits in the 80s tracheostomy use in the ICUs has boomed. Today one third of all patients recieve a tracheostomy. It´s merits are said to be reduced sedative drug use, earlier weaning from ventilators, patient convenience, a reduced incidence of nosocomial airway infections and, as a consequence of all this, reduced mortality and hospital stay.

While those benefits are not very controversial, the timing of tracheostomy is. It is natural to assume that these benefits would be amplified if the patient has her/his tracheostomy really early, as in within days rather than within a week or two.  It makes perfect sense but has been hard to prove. As a result, early vs late tracheostomy is one the big controversies in intensive care.

I have worked in ICUs representing the extremes. One ICU was ridiculously conscious about early tracheotomies and incredibly aggressive. It seemed almost all patients ended up with a hole in the neck and preferably within a day or two. My seniors ecstatically told me how this would dramatically improve patient treatment and transit time through the ICU.

Then later national data came out and I could compare our ICU- and hospital stays with ICUs in the rest of the country. We scored on par with the rest of them. Our ICU- and hospital stays were as long as in the other ICUs, including those I knew had adopted a considerably more conservative and ´slow´ approach to tracheostomy. That made me question at least the part about reduced hospital stays.

The study
TracMan was a british study that ran from 2004 to 2008. Patients where eligible if they were likely to require at least 7 or more days on ventilatory support. Patient´s were randomised into either early tracheostomy or late tracheostomy, with some weighting to get rid of bias (location, age, sex, diagnosis). The early group had their tracheostomies within four days of ICU admission while the late group had theirs on day 10 or later.

Primary outcomes were all-cause mortality at 30 days. Secondary outcomes were mortality in the ICU and at 1 and 2 years, hospital discharge, length of stayin the ICU, hospital stay  finally antimicrobial-free days (as a proxy for infections).

Results
909 patients were randomised. After some withdrawals, 451 received early tracheostomies while 448 ended up in the late group. Groups had similar baseline characteristics.

All cause mortality at 30 days was not statistically different between the two groups.
ICU, hospital and 1- and 2-year survival was not statistically different.
ICU admission time was 13,1 days in the early groups vs 13,0 days in the late group.
Hospital stay in those who survived to discharge was 33 days in the early group vs 34 days in the late group.
Antibiotic use 30 days after randomisations was the same in both groups.

Take-home message
The TracMan study could not prove any statistically significant reduction in mortality, length of stay or infection rate. It would seem one can safely wait an additional 7 days before performing the tracheostomy. If it is still needed by then?

TracMan lives here (free):

JAMA. 2013 May 22;309(20):2121-9. doi: 10.1001/jama.2013.5154. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. Young D, Harrison DA, Cuthbertson BH, Rowan K; TracMan Collaborators.

Interesting editorial from JAMA ed lives here:

JAMA. 2013 May 22;309(20):2163-4. doi: 10.1001/jama.2013.6014. When should a mechanically ventilated patient undergo tracheostomy? Angus DC.

 

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