A Comprehensive study of Tracheostomy in ICU Patients and Correlation of Timing of the Procedure with Complications

INTRODUCTION: Tracheostomy is known to be one of the oldest surgical procedures. There are references to the creation of a surgical airway in many ancient texts. Until towards the end of the nineteenth century and before the introduction of asepsis along with the development of safe anaesthetic techniques, the procedure was considered to be extremely dangerous and risk of fatality due to the procedure was high. Tracheostomy was considered as a last resort in hopeless cases and was the cause of great anxiety for the patient and surgeon alike. Chevalier Jackson established the principles of the operation at the beginning of the twentieth century and these remain in place today. AIMS AND OBJECTIVES: 1. To define optimum time to carry out an elective tracheostomy. 2. To assess the incidence, indications, timing of the procedure and the outcome of tracheostomy on patients in the intensive care units (ICU). 3. To study the effectiveness of tracheostomy in reducing the duration of mechanical ventilation and hospital stay. 4. To study the complications (early and late) associated with tracheostomy. MATERIAL: Case details of patients admitted in Intensive care units undergoing tracheostomy and Medical records department in RGGGH AND MMC from January 2020 to October 2021. METHODOLOGY It is a prospective observational study of patients admitted in intensive care unit patients requiring mechanical ventilation and undergoing tracheostomy in the intensive care units. After getting approval from the ethical committee, this study was conducted. It was carried out in our tertiary care hospital affiliated to a teaching Institute. The period of the study is from January 2020 to October 2021. The total number of patients included in our study are 100, above 12 years age of patients of which includes male , female and transgenders. Case details of patients undergoing tracheostomy in Intensive care units with a thorough history taking, detailed clinical examination and with appropriate Radiological investigations and Videolaryngoscopic evaluation for a Prospective observational study methodology was done. SUMMARY & CONCLUSION The study population was split into early tracheostomy group and late tracheostomy groups. Tracheostomy is one of the most common surgical procedure done in intensive care units. From our study we conclude that ❖ GCS of less than or equal 7 was observed to be an indicator for patients requiring endotracheal intubation and prolonged mechanical ventilation. ❖ Reintubation attempts was observed to be common among those patients who were on prolonged endotracheal intubation and had undergone late tracheostomy i.e., after 7 days of intubation and it was least among the early tracheostomy group. Sudden desaturation, tube block excessive tracheal secretions and a deteriorating GCS level were found to be the common causes for repeated reintubation with endotracheal tubes. This in turn provokes airway injury like supraglottic laryngeal mucosal injury resulting mucosal congestion, supraglottic stenosis, mucosal ulceration and oedema of epiglottis, glottic injury resulting in intubation granuloma, ulceration, subglottic stenosis and tracheal stenosis. Hence, the reason for endotracheal tube reintubation should be individualized and staff nurses should be enlightened about the need of frequent tracheobronchial toileting and maintaining a proper position of the endotracheal tube and tracheostomy tube by properly securing it. ❖ In the event of Immediate complications intraoperative bleeding has been the single most common complication noted. Tracheostomy tube block, tube displacement and stomal bleeding have been noted in the post-operative period. This can be avoided by imparting adequate knowledge and skill about the management of the complications. Adequate tube suctioning and proper tracheostomy stoma care with regular dressing plays a vital role in the prevention of these complications. ❖ Patients on prolonged intubation who had underwent late tracheostomy i.e., after 7 days of intubation were more prone for airway injuries such as supraglottic mucosal congestion and edema and Intubation granuloma (glottic injury) as a consequence of reintubation attempts. They also ended up in long term complications like tracheal stenosis and subglottic stenosis. Cuffed tubes should be of appropriate size and the cuff pressure to be maintained within or at 20 mmHg. There are cuff pressure monitors available (Cuff manometer), which can be suggested to be used routinely in order to avoid these complications. ❖ From our study it has been analysed that tracheostomy performed within 7 days after intubation was associated with shortened duration of mechanical ventilation, reduced duration of ICU admission and hospital stay than those among the late tracheostomy group. ❖ Early Tracheostomy (≤ 7 days) is observed to have resulted in earlier weaning off from the Mechanical Ventilation, a finding suggested by more number of ventilator-free days. The possibility of earlier weaning off from Mechanical ventilation, thereby decreasing the exposure of patients to its associated risks, can be attributed as a prime factor responsible for the lesser complications and long-term survival among the patients undergoing early tracheostomy. ❖ Tracheostomy can be carried out as soon as the need for a prolonged Mechanical ventilatory support is anticipated. ❖ Hence by day 6 to 7 if the patient could not be weaned off from the mechanical ventilatory support and extubated, based on the daily weaning assessment and patient‟s clinical diagnosis an early elective surgical tracheostomy for the purpose of Mechanical ventilator support can be planned which will result in a better clinical outcome of the patient undergoing intensive care treatment