Study Of Tracheotomy In Critically Ill Patients

Background and purpose:Tracheotomy is one of the oldest described surgical procedures, with a more than 3500-year history. Both surgical and percutaneous techniques involved in tracheotomy are widely used in current emergent medicine for patients in critical conditions. Tracheotomy is usually performed in patients after long-term use of mechanical ventilation with an endotracheal tube through the mouth, for making patients comfortable and easier for the care of the mouth and airway; avoiding potential laryngeal and airway stenosis; and reducing the use of sedation drugs. In the context of lacking guidelines for indications and timing of tracheotomy, we retrospectively analyzed the clinical data of 133 critically ill patients from the First Affiliated Hospital, College of Medicine, Zhejiang University, to explore indications, timing of tracheotomy and prophylaxis and treatment of procedure-related complications. Materials:The data of 133 patients who admitted in intensive care unit in the First Affiliated Hospital, College of Medicine, Zhejiang University from 2008 to 2010 were retrospectively analyzed, including 100 male and 33 female patients, aging from 7 year to 96 year old with a median age of 64.7±17.26 year. Primary diseases included severe pulmonary, multiple trauma,cerebrovascular accidents,cancer of the digestive system. All patients undergone tracheotomy with ventilator on.Methods:All of the patients were undergone tracheotomy under local anesthesia. Baseline data, mortality, and cause of death were analyzed. Oxygenation index, APACHEⅡscores, lactate concentration, and 6 hour lactate clearance rate were compared before and after the surgery respectively. Intraoperative and postoperative complications were recorded.Results:The mortality after tracheotomy was 88.72%(118/113). These patients all died from their primary disease progress. The survival time after the surgery was from 0(1 patient) to 179 days, with a mean time of 21.19±28.49 days. Other 15 patients (11.28%) were cured and discharged from hospital.After tracheotomy, oxygenation index, APACHEⅡscores and lactate level were no better than that before, but 6 h lactate clearance rate was markedly reduced with a significant difference. This indicated that tracheotomy had no good to improve physical signs and that the procedures may temporarily worsen the condition of critically ill patients.Statistical analysis shown that patients with preoperative oxygenation index<200, APACHEⅡscores> 20, lactate concentration>5 mmol/L, and 6 h lactate clearance rate <10% were at high risk of dying in a short time after tracheotomy. This indicated that there was no need to perform tracheotomy on patients in critical situations, especially with the above abnormal index.Physical signs and 6 hour lactate clearance rate in those 15 patients survived were dramatically better before and after the surgery. The mean time of ventilation assistance in these patients was 7.33 days with the longest 19 days in one patient, indicating that the optimal time for tracheotomy was one week after ventilation.The main cause of death was severe pulmonary accompanied by respiratory failure, acute multiple organ failure, septic shock, and pulmonary accompanied by fungal infection.66 dead patients (55.93%) out of 118 dead patients died within half of a month postoperation, including 39(33.0%) within 7 days and 27(22.88%) within 8 to 14 days. This indicated that tracheotomy failed to reduce the mortality of critically ill patients.A total of 14 patients experienced complications. There complications included cardiac arrest, difficult incubation, incision seepage, and subcutaneous emphysema. Incision seepage occurred in 8 patients,3 of which achieved hemostasis by reopening the incision and other 5 achieved hemostasis by compression (1 patient had cardiac arrest during compression and it was successfully reversed after immediate treatment). No complication-related death was found. Conclusions:a) The benefit of tracheotomy in critically ill patients may be limited and the mortality could not be reduced by such procedures.b) Patients with preoperative oxygenation index<200, APACHEⅡscores> 20, lactate concentration>5 mmol/L, and 6 h lactate clearance rate<10% were at high risk of dying shortly after tracheotomy. Tracheotomy failed to reverse multiple organ failure and bad perfusion and oxygen utilization in tissues in these patients.c) Patients with multiple trauma may benefit from tracheotomy due to acute injuries are easier to reverse. These patients usually need ventilation for a while and tracheotomy may good for their recovery.d) Some complications after tracheotomy may be severe and need us to pay attention. Mild complications such as incision seepage may also lead to unexpected outcomes. Surgical techniques to achieve incision without bleeding are necessary.e) The optimal time of tracheotomy is about one week after oral intubation, because at that time the patient's condition may be improved with ventilator assistance.f) The purpose of tracheotomy is to reduce inefficacious breath, decease airway resistance, and make it easier to suction and care the mouth, which then results in decreasing the use of sedation drugs and comforting patients.