title: One thousand bedside percutaneous tracheostomies in the surgical intensive care unit: time to change the gold standard.
abstract: BACKGROUND
  Bedside percutaneous tracheostomy (BPT) is a cost-effective alternative to open tracheostomy. Small series have consistently documented minimal morbidity, but BPT has yet to be embraced as the standard of care. Because this has been our preferred technique in the surgical ICU for more than 20 years, we reviewed our experience to ascertain its safety. We hypothesize that BPT has acceptably minimal morbidity, even in high-risk patients.
  
  
  METHODS
  Patients undergoing BPT from January 1998 to June 2008 were reviewed. High-risk patients were defined as those with cervical collar or halo, cervical spine injuries, systemic heparinization, positive end-expiratory pressure >10 cm H(2)O or fraction of inspired oxygen > 50%.
  
  
  RESULTS
  During the study period, 1,000 patients underwent BPT (74% men; mean ± SEM age 46 ± 0.6 years; 70% trauma). BPT was performed 8.9 ± 0.2 days (mean ± SEM) after admission. Patients remained ventilator dependent for an additional 9.7 ± 0.4 days (mean ± SEM). There were 482 (48%) patients undergoing BPT who were considered high-risk: 1 risk category, 273 patients; 2 risk categories, 139 patients; 3 risk categories, 56 patients; 4 risk categories, 12 patients; 5 risk categories, 2 patients. Complications occurred in 14 (1.4%) patients. Early complications included tracheostomy tube misplacement requiring revision (n = 4), bleeding requiring intervention (n = 2), infection (n = 1), and procedure failure requiring cricothyroidotomy (n = 1). Late complications included persistent stoma requiring operative closure (n = 4) and subglottic stenosis (n = 2). There were 6 complications (1.2%) in normal risk and 8 complications (1.7%) in high-risk patients. There were no deaths related to BPT.
  
  
  CONCLUSIONS
  BPT in the surgical intensive care unit is a safe procedure, even in high-risk patients. We believe BPT is the new gold standard for patients requiring tracheostomy for mechanical ventilation.
authors.affiliation: Department of Surgery, Denver Health Medical Center and theUniversity of Colorado, Denver, CO, USA.
authors.forename: Lucy Z
authors.initials: LZ
authors.lastname: Kornblith
authors.forename: Clay Cothren
authors.initials: CC
authors.lastname: Burlew
authors.forename: Ernest E
authors.initials: EE
authors.lastname: Moore
authors.forename: James B
authors.initials: JB
authors.lastname: Haenel
authors.forename: Jeffry L
authors.initials: JL
authors.lastname: Kashuk
authors.forename: Walter L
authors.initials: WL
authors.lastname: Biffl
authors.forename: Carlton C
authors.initials: CC
authors.lastname: Barnett
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Johnson
mesh_terms: D000328:Adult; D003362:Cost-Benefit Analysis; D003422:Critical Care / Q000191:economics / Q000379:methods* / Q000592:standards*; D005260:Female; D006801:Humans; D007362:Intensive Care Units / Q000191:economics / Q000706:statistics & numerical data; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011175:Positive-Pressure Respiration; D018570:Risk Assessment; D012307:Risk Factors; D012449:Safety; D059039:Standard of Care; D014139:Tracheostomy / Q000009:adverse effects* / Q000191:economics / Q000379:methods* / Q000401:mortality; D014481:United States