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Safety of Early Tracheostomy Performed by Intensivists in Acute Brain-injured Patients: A 1-Year Observational Study.

To the Editor: Tracheostomy is frequently performed in acute brain injury (ABI) patients and can be associated with several complications.1 Early tracheostomy (< 7 d from admission) is reported to be associated with better neurological outcome and lower duration of hospitalization in headinjured patients.2 We present a single-center study reporting postprocedural complications of intensivist-performed surgical and percutaneous tracheostomies in the intensive care unit (ICU) of the Parma University Hospital, Italy. After Institutional Review Board approval with waiver of consent, we conducted a retrospective analysis of prospectively collected data in 104 consecutive ABI patients requiring tracheostomy between January 2017 and December 2017. Details of the tracheostomy techniques are available in the Supplementary Material (Supplemental Digital Content 1, http://links.lww.com/ JNA/A295). We compared cardiorespiratory variables before, during, and after tracheostomy, and reported procedure-related complications; full details of the study methodology and analysis are shown in the Supplementary Material (Supplemental Digital Content 2: Data collection and analysis, http://links.lww.com/JNA/A296). Patient characteristics and tracheostomy indications, type, and complications are summarized in the Supplementary Material (Supplementary Digital Content 3: Tables S1 and S2, http://links.lww.com/JNA/A297). The mean (±SD) time to tracheostomy after ICU admission was 5.1 (± 2.8) days, and the duration of mechanical ventilation was 17 (± 8.7) days. Almost 85% of tracheostomies were performed using the Parma technique3 (an open surgical approach routinely performed by intensivists in our ICU), and 15% using a standard percutaneous technique.4 Procedure duration was 24.4 (±5.7) minutes and 9.1 (±9.5) minutes for the Parma and percutaneous techniques, respectively. The flat bed position was tolerated by a minority of patients (38.5%); the antiTrendelenburg position (mean head elevation 16.6± 7.4 degrees) was adopted in the others. Monitored hemodynamic variables before and after tracheostomy are shown in Table 1. Only heart rate showed significant differences before and after tracheostomy in the averaged 24-hour data. Ventilation and respiratory variables are reported in the Supplementary Material (Supplemental Digital Content 3: Table S3, http://links.lww.com/JNA/A297). The only significant differences between 1 hour before and 1 hour after tracheostomy, respectively, were as follows: inspired oxygen fraction (FiO2) (40%±7.9% vs. 43.9%±8.3%; P<0.001), arterial partial pressure of oxygen/FiO2 ratio (298.3±90.8 vs. 269.5±92.2; P<0.001), and lactate (1.0±0.5 vs. 0.9±0.7mmol/L; P=0.009). Procedure-related complications are summarized in the Supplementary Material (Supplemental Digital Content 3: Table S2, http://links.lww.com/JNA/A297). Arterial hypertension was the most common medical complication (68%), and successfully treated with intravenous drugs in all cases. Among the 62 patients with ICP monitoring, 19 (30.1%) had increases in ICP during the procedure, but this was adequately controlled by increased sedation (84.2%) or opening the ventricular drain (15.8%); no procedure had to be abandoned because of intracranial hypertension. The most common surgical complications were tracheal ring(s) fracture in 3 patients and bleeding requiring maxillofacial surgeon consultation in one. Postoperative complications were stoma bleeding (8%, none needing surgery), stoma infection (8%), and cannula obstruction (1%). Ninety-eight patients (94%) were discharged alive from the ICU, and median length of ICU stay was 21.5 ( ± 10.8) days. The tracheostomy remained in situ at discharge in 89 of 94 (86%) patients. In summary, we found that (a) tracheostomies are performed early in ABI patients in our ICU; (b) tracheostomies can be performed by an intensivist at the bedside (without the need for surgical consultation and/ or transportation of the patient in the operating room), and (c) tracheostomy-related complications (mainly Received for publication May 2, 2020; accepted May 15, 2020. From the *Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy; and †Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium. T.T. and E.P. contributed equally. The authors have no funding or conflicts of interest to disclose. Address correspondence to: Edoardo Picetti, MD, E-mail: edoardopicetti @hotmail.com. Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website, www.jnsa. com. Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved. DOI: 10.1097/ANA.0000000000000707 RESEARCH LETTER