Contraindications and complications

The major contraindication to tracheostomy in critically ill patients is local infection or inflammation at the proposed tracheostomy site. Patients with extensive burns or soft tissue infection involving the anterior neck should not undergo the procedure. Tracheostomy is relatively contraindicated in patients with cardiovascular or respiratory instability, such as those requiring high-dose vasopressor support or positive end-expiratory pressure at levels greater than 15 to 20 cmH 2O. Severe coagulopathy, uncorrectable by platelet or component transfusion, represents another relative contraindication.

Even in properly selected patients, a large number of complications have been reported with tracheostomy ( Stauffer ef a/ 19.8.1; Heffner ... 1988.; Hazard ei a/ !99!).

The incidence of these adverse events varies widely in different reports. Table.2 lists the most widely reported complications. Tracheostomy has been associated with a small but definite perioperative mortality, sometimes as high as 5 per cent, although usually much lower. Potentially lethal intraoperative crises include a variety of cardiac arrhythmias and sometimes striking falls in Pao2 or blood pressure. Perioperative pneumothorax or pneumomediastinum may occur and may be fatal. Hemorrhage may occur during the procedure, or may be delayed for hours or days, owing to venous or arterial disruption during the procedure or to delayed erosion into the innominate vein, a condition termed tracheo-innominate fistula which is rare but nearly always fatal. Misplacement of the tracheostomy tube into the anterior pretracheal space may lead to mediastinal emphysema, although mild subcutaneous emphysema may occur more frequently and be of much less importance. Tracheostomy tube misplacement may precipitate acute hypoxemia, cardiac arrhythmias, or shock, and may be a rare cause of mortality. Even in patients who endure the tracheostomy procedure without intraoperative misadventure, problems may develop later. Local infection at the site may be very troublesome to manage, and may lead to extensive necrosis of the anterior neck, sepsis, and, rarely, septic shock. After removal of the tracheostomy tube, healing of the stoma may be delayed, and considerable cosmetic deformity is a common result even when healing progresses well. Perhaps of greater concern, tracheostomy may result in tracheal narrowing with resulting respiratory impairment. Tracheal narrowing may occur at the stomal site, at the cuff site within the trachea, or in the subglottic region, although it is possible that this is partly the effect of antecedent endotracheal intubation.

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Table 2 Principal complications of tracheostomy

Table 2 Principal complications of tracheostomy

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