HSC Section 6 Nov2016 Green Book

W.W. Kettunen et al. Tracheostomy complications in trauma

Table 3 Comparison of demographics, injury severity, mechanism of injury, hospitalization details, disposition, and death for patients with tracheal stenosis versus patients without tracheal stenosis

Tracheal stenosis

No tracheal stenosis

Parameter

Value

Value

P value

No. of subjects Age (years) *

9 (1.5%)

607 (98.5%) 45.2 6 20.6 452 (74.5%)

29.8 6 11.8

.021 .701 .175 .659

Sex (male)

6 (66.7%)

Injury severity score †

30.0 (19.5, 37.0) 3.0 (3.0, 13.0)

25.0 (17.0, 33.0) 5.0 (3.0, 14.0)

Glasgow coma scale score †

Mechanism of injury

1.000

Blunt

9 (100.0%)

572 (94.2%)

Penetrating

0 (.0%) 0 (.0%) 0 (.0%)

31 (5.1%)

Drowning

2 (.3%) 2 (.3%)

Burn

9.3 6 7.9

7.0 6 4.9

Admission to tracheostomy interval (days)

.175 .036 .055 .127 .604

28.3 6 18.8 26.7 6 21.7 40.0 6 21.7

18.9 6 13.3 16.1 6 11.7 26.9 6 25.6

Intensive care unit days * Mechanical ventilation days * Hospital length of stay (days) *

Disposition

Home/home with home health care/jail/mental health facility Rehabilitation center/select specialty hospital acute care/ other acute hospitals

2 (22.2%) 7 (77.8%)

77 (12.7%) 42 (69.4%)

Skilled nursing unit/nursing home

0 (.0%) 0 (.0%) 0 (.0%)

28 (4.6%) 80 (13.2%) 75 (12.4%)

Hospice/death

Death

.610

*Mean 6 standard deviation. † Median (25th and 75th percentile).

open group were for surgical scar revision. The other major complications observed in our PT patients included loss of airway, bleeding, and tracheo-innominate artery fistula, all well-known risks of PT. As we did not find the route of tracheostomy formation to influence the incidence of tracheal stenosis, we attemp- ted to identify factors that may have contributed to stenosis formation. Numerous and variable risk factors for tracheal stenosis following intubation have been suggested in the literature and include trauma and inflammation at the endotracheal tube cuff site, excess granulation tissue around the tracheal stoma site or over a fractured cartilage, high tracheostomy site, prolonged intubation, traumatic intubation, or previous intubation or tracheostomy. 1 Both groups in this study received tracheostomy within 7 days of admission as per American College of Surgeons recom- mendations. Our study demonstrated that patients who developed tracheal stenosis tended to have longer mechan- ical ventilator requirements (26.7 vs 16.1 days, P 5 .055), with patients developing stenosis being on the ventilator on average 11 additional days. It could be hypothesized that additional ventilator days meant more time with an inflated tracheal cuff causing tracheal ischemia and stenosis. We did identify that younger age and longer length of ICU stay were associated with increased rate of tracheal stenosis; however, the reason for these findings is unclear and these findings were not observed in similar studies. There are several limitations to our study. It is retro- spective in nature with a relatively small sample size. Also,

the study time frame included the widespread introduction of the percutaneous technique at our institution. The associated learning curve for a new procedure may have influenced the results or influenced which technique was used to create the tracheostomy in specific patients. Also, the percentage of patients seen after dismissal from the hospital was unknown. Common shortcomings of other investigations into this topic are length and reliability of follow-up, thereby calling into question the accuracy of the reported inci- dence of tracheal stenosis. We have a unique practice environment in which there are 2 level-1 trauma centers serving the entire population center with extremely rural surroundings. This leads to an isolated trauma population for study. These centers inform each other of any complications or admissions from each other’s population. Additionally, the next closest trauma center for follow-up for tracheal symptoms is 200 miles away. Because of this, we do not believe that any patients were lost to follow-up or transferred to the other trauma center with a compli- cation of tracheal stenosis. Also, in our city, if a patient presented to one of the other large multispecialty groups, then that patient would be redirected to our clinic. Evidence for this rests in the fact that 5 of the 9 tracheal stenosis patients presented to our clinic in a delayed fashion well after hospital discharge. These factors help distinguish our follow-up results as compared with other studies. This said, there still exists the possibility that late occurring and/or subclinical tracheal stenoses may have

171