Audit of over 500 percutaneous dilational tracheostomies

To review immediate procedure-related complications of percutaneous dilational tracheostomy (PDT) in relation to patient characteristics, technique and seniority of operator.

Retrospective audit of all tracheostomies performed in our ICU over 10 years.

Data were derived from a prospectively maintained tracheostomy logbook and, when necessary, from patients' case notes. Data were compiled to determine demographic characteristics, diagnosis on admission, indication for tracheostomy, technique used, seniority of operator, and complications related to the procedure.

581 tracheostomies (501 PDT and 80 surgical) were performed between January 1995 and December 2004. A written protocol was followed with standardisation of indication, authorisation and supervision by consultant, antibiotic prophylaxis and anaesthetic technique. Mean patient age was 67.6 (SD, 15.7 years) (PDT group) and 52.1 (SD, 12.4) (surgical group). Mean Apache II score was 20.6 (SD, 7.9) (PDT) and 19.7 (SD, 6.8) (surgical). The PDT techniques used were Griggs' forceps dilatation (85%), Ciaglia's multiple sequential dilator technique (15%), and Ciaglia's Blue Rhino single dilator technique (0.2%). Prolonged respiratory weaning was the most common indication (42%), followed by head injury and other neurological causes (31%). The surgical group comprised patients with multiple trauma and those deemed to have difficult anatomy, with 11 PDTs being converted to surgical tracheostomies. In the PDT group, bleeding was the most common complication (4.3%), followed by desaturation (1.0%), bradycardia (1.0%) and hypotension (0.8%). Two patients in the PDT group needed surgical control of bleeding. There was one death, 11 days after PDT, caused by secondary haemorrhage. Complications were not related to operator seniority.

Our findings are comparable with those of other published case studies, with low complication rates for PDT. This audit supports our structured training program, policies on procedure, and quality audit process.