Percutaneous dilational tracheostomy in neurointensive care patients

Introduction

Neurointensive care patients often require elective tracheostomy for prolonged ventilatory support, control of intracranial pressure as sedation is weaned and for impaired pharyngeal and laryngeal reflexes. The possibility of raised intracranial pressure, worsened by patient positioning and intraprocedural occult hypercarbia, makes it a higher risk procedure [1]. There is little information on the timing of percutaneous dilational tracheostomy (PDT) or periprocedural complications in neurointensive care patients.

Methods

Out of 80 patients who underwent PDT over a period of 1 year, information was obtained and analysed on 52 patients. Baseline demographical information collected included the date of admission, date of PDT, level of the operator, supervision, and periprocedural complications. We also looked at the use of post-procedure chest radiography (CXR). Analysis was then carried out to determine the timing of PDT, the incidence of complications and the use of CXR.

Results

Fifty-two patients were included, median age 56 years (range 20 to 79 years). The procedure was carried out either by two trainees with a consultant supervising (40%) or by a consultant and a trainee (57%). Two patients who had a difficult anatomical approach had the procedure done by two consultants. The timing of PDT ranged from 1 day to 22 days with a mean of 7.69 days and SD of 4.29 days. There were only three reported complications (5%), none of them major or involving raised intracranial pressure. CXR was requested in 68% of cases; of the 35 patients who did have CXR, only 51% had recorded reports in the notes.

Conclusion

In spite of recommendations that CXR is not required following uncomplicated PDT, most operators still request one, a habit that leads to unnecessary patient and staff exposure to radiation. The majority of the PDTs was performed by trainees in our unit, and the low complication rate proves that the technique is safe and easy. PDT in neurointensive care patients carries a higher risk, but with proper patient selection and senior input the procedure is as safe as in general intensive care patients.