Early versus late tracheostomy in cardiovascular intensive care patients

Abstract

Background: Benefits of tracheostomy have been well established. Most of the literature, refers these benefits to general intensive care population, excluding cardiac surgery or including only small number of these patients. On the other hand, there is no clear definition describing the proper time to perform the procedure and defining what are potential benefits of early compared to late tracheostomy. This retrospective cohort aims to assess the potential benefits of early tracheostomy on post-operative outcomes, length of stay and post-tracheostomy complications within cardiac surgical population. Methods: After obtaining REB approval, we conducted a retrospective chart review in a single, tertiary care institution, identifying patients who underwent tracheostomy after cardiac surgery from 1999 to 2006. Time-to-tracheostomy was defined as "early" if < 7 days or "late" if ≥ 7 days post-cardiac surgery). Results: 14,101 patients underwent cardiac surgery over the 7-year study period; from those, 147 (1.36%) received tracheostomy. 32 (22%) patients underwent early tracheostomy and 115 (78%) late tracheostomy. Incidence of atrial fibrillation (31.2% vs 61.7%; P = 0.003), kidney dysfunction (6.3% vs 27.2%; P = 0.015) and kidney failure 18.8% vs 43.5%; P = 0.013) were lower in the early tracheostomy group. There were no differences on post tracheostomy infection or presence of acute respiratory distress syndrome. Both the ICU and hospital length of stay were significantly shorter in early tracheostomy group, 21.5 (ET) vs 36.9 (LT) days and 37.5 (ET) vs 57.6 (LT) days respectively. There were no differences in mortality between groups. Conclusions: There are significant benefits in reduction of postoperative morbidities with overall shorter ICU and hospital stay. These benefits may promote faster patient rehabilitation with reduced healthcare costs.

Does Tracheostomy Affect the Mortality and Morbidity Rate After Cardiac Surgery?

“…Puentes et al advocated that tracheostomy reduces the post-operative atrial fibrillation and reduces the renal failure and does not increase the rate of deep sternal wound infection. In addition, they stated that reduced atrial fibrillation and renal failure could be associated with short cardiopulmonary bypass time and the need of less sedation [2]. In contrast, tracheostomy did not change the post-operative atrial fibrillation rate, renal dysfunction/failure incidence in patients who died in our study.…”

“…For this reason, tracheostomy is an alternative technique for prolonged mechanical ventilation to facilitate adequate airway management and ventilatory weaning [1]. Up to 20% of patients who required prolonged mechanical ventilation needs a tracheostomy [2]. Tracheostomy provides several potential advantages such as reducing the airway resistance, facilitating to wean from mechanical ventilation, providing early oral nutrition, reducing trauma to the oropharynx and larynx, reducing dead space, decreasing the delirium, improving overall patient's comfort, providing efficient tracheal aspiration, decreasing the need for sedation, reducing ventilator-associated complications, improving mobilisation, reducing infection risk and reducing the risk of extubation [2,3].…”

“…The treatment and timing strategy for tracheostomy has been evolved in past decades. The timing of tracheostomy is varying between two days and three weeks, however, there is no consensus regarding optimal timing for performing a tracheostomy [1][2][3]. The decision of tracheostomy should depend on clinical conditions and the physician's judgment [1,2].…”

“…The timing of tracheostomy is varying between two days and three weeks, however, there is no consensus regarding optimal timing for performing a tracheostomy [1][2][3]. The decision of tracheostomy should depend on clinical conditions and the physician's judgment [1,2]. The American 2001 consensus advocates the use of early tracheostomy in patients who require prolonged mechanical ventilatory assistance [4].…”

The effect of nebulized salbutamol on atrial electrical properties in mechanically ventilated critically ill patients — a randomized, double-blind study

“…It is characterised by uncoordinated atrial activation with consequent deterioration of atrial mechanical function. Its frequency varies from 5.8 [1] to 15% [2] or even 61.7% [3] depending on the ICU profile: medical or surgical which is many times higher than general population where the frequency is 2% [4]. The reason for that is the difference between general popu-lation and the population of critically ill.…”