A literature review in crit care reminds me of how ICU percutaneous tracheostomies are potentially dangerous and is associated with significant mortality. This mortality needs to be weighed in when deciding wether to make the hole in the neck or wait.
With the introduction of percutaneous kits, the number of patients getting a tracheostomy is increasing dramatically. As the number of ventilated patients in ICUs is going to increase, the number of tracehostomies is going to increase even more. Tracheostomies seem beneficial in terms of patient comfort, mobility and reduced requirement for sedation.
However, there is no evidence for tracheostomies improving the important end-points, such as duration of mechanical ventilation, duration of ICU stay or mortality. Recently, the tracman study got a lot of attention. It could not prove any statistically significant reduction in mortality, length of stay or infection rate. Importantly, percutaneous tracheostomy is associated with major complications. It is not as safe as we tend to think. In the US, each year 500 patients die or are permanently disabled because of tracheostomies.
The authors of the study in Crit Care wanted to look closer at the incidence of death caused by tracheostomies and why these patients died. Their study is a PRISMA literature review covering all papers, from case series to randomised trials, describing deaths related to percutaneous dilatational tracheostomies (PTD). After selection they identified 71 cases of PTD-related death to include in their study
71 cases of PTD-related death were identified. In 31% of cases fatal complications happened during the procedure. In 49% of cases it happened within 7 days of the procedure.
Bleeding was the major cause of death being responsible for 38% of PTD-related deaths. Usually this was bleeding from the innominate artery through a tracheovascular fistula into the airway.
This one is a bit scary as bleeding normally happens a few days after the procedure, the time it takes for the cannula or cuff to erode through the trachea into the artery. It can be preceded by sentinel hemoptysis but other than that it can be hard to spot. More about that here.
Risk factors, identified by the Crit Care authors were low tracheostomy site, not using fibrescope guidance, coagulopathy, previous surgery or radiotherapy to the neck, obesity or abnormal anatomy, malpositioned cannula and high cuff pressure.
Airway complications accounted for 29,6% of PTD deaths. Causes of death in this group were cannula dislocation, lost airway during the procedure and paratracheal cannula placement. Risk factors were not using bronchoscope guidance, inexperienced team, obese patients, difficult airway, not securing the cannula with sutures and post-procedural care by inexperienced nurses.
Less common causes of PTD-death were tracheal perforation (15,5%), pneumothorax (5,6%), bronchospasm (4,4%), cardiac arrest (4,4%) and sepsis (1,5%).
The authors calculate incidence of PTD attributable death to 0,17% from the studies included in their review. 1 in 600 patients who has a percutaneous tracheostomy will have a lethal complication related to his tracheostomy.
Study lives here:
Crit Care. 2013 Oct 29;17(5):R258. [Epub ahead of print] Death after percutaneous dilatational tracheostomy: a systematic review and analysis of risk factors. Simon M, Metschke M, Braune SA, Püschel K, Kluge S.