Early tracheostomy in intensive care trauma patients improves resource utilization: a cohort study and literature review

Abstract

Introduction: Despite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients.

Methods: The following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay.

Results: Of 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean +/- standard error: 9.6 +/- 1.2 days versus 18.7 +/- 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 +/- 1.2 days versus 21.0 +/- 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 +/- 1.2 days versus 4.9 +/- 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days).

Conclusion: Early tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization.

Figure 1

Distribution of patients by timing of tracheostomy and corresponding intensive care unit (ICU) length of stay (LOS). There was a direct correlation between timing of tracheostomy and mean ICU LOS (r = 0.91; P < 0.001).

Figure 2

Kaplan–Meier curves of the duration of mechanical ventilation in early and late tracheostomy groups. Early tracheostomy was associated with a significantly shorter duration of mechanical ventilation.

Figure 3

Kaplan–Meier curves of intensive care unit (ICU) length of stay (LOS) in early and late tracheostomy groups. Early tracheostomy was associated with a significantly shorter ICU LOS.