An audit of perioperative staffing and complications during percutaneous and surgical tracheostomy insertion

Introduction

Percutaneous tracheostomy (PDT) has been established as a safe technique in the critically ill, with an equivalent complication rate to surgical tracheostomy (ST). However, PDT insertion may result in unrecognised hypercarbia, and has been associated with an increased perioperative complication rate. We therefore decided to audit current practice within our ICU.

Methods

Over a 3-month period, prospective data were collected on 25 patients within a 14-bed regional ICU. A single observer collected data on staff present, cardiovascular recordings and end-tidal carbon dioxide.

Results

PDT was performed on 15 patients within the ICU, and ST was performed on 10 patients. Indication for tracheostomy was prolonged mechanical ventilation in 16 patients, poor neurological status in eight patients and sputum retention in one patient. Cardiovascular instability, defined as a greater than 20% deviation from normal blood pressure, occurred in nine (60%) patients during PDT. For ST, eight (80%) patients were cardiovascularly unstable. Hypercarbia, as detected by an end-tidal CO₂ rise of more than 20%, occurred in six (40%) patients during PDT and in one (10%) patient during ST. See Table 1.

Table 1 Staff involved in PDT and ST

Conclusion

This audit has shown that assistance for PDT is inferior to that provided in the operating theatre, and this has potential safety implications particularly when junior staff are anaesthetising. Perioperative complication rates were similar overall, confirming the safety of PDT as a technique. Hypercarbia occurred relatively frequently during PDT, however, which may have deleterious effects in the brain-injured patient. From this audit, we would recommend that within our ICU more attention be focused on adequate staffing during the performance of this operative procedure on critically ill patients. Also, end-tidal carbon dioxide should be monitored carefully and treated if elevated.