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A prospective, randomized study comparing percutaneous with surgical tracheostomy in critically ill patients

Freeman, Bradley D. MD; Isabella, Karen RN; Perren Cobb, J. MD; Boyle, Walter A. III MD; Schmieg, Robert E. Jr MD; Kolleff, Marin H. MD; Lin, Natatia BS; Saak, Thomas MD; Thompson, Errington C. MD; Buchman, Timothy G. PhD, MD

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Objective To determine the relative cost-effectiveness of percutaneous dilational tracheostomy (PDT) and surgical tracheostomy (ST) in critically ill patients.

Design Prospective randomized study.

Setting Medical, surgical, and coronary intensive care units at Barnes-Jewish Hospital, a tertiary care medical center.

Patients Eighty critically ill mechanically ventilated patients requiring elective tracheostomy.

Interventions Randomization to either PDT performed in the intensive care unit or ST performed in the operating room.

Measurements and Main Results  Treatment groups were well matched with respect to age (PDT, 65.44 ± 2.82 [mean ± se] years; ST, 61.4 ± 2.89 years, p = Ns), gender (PDT, 45% males; ST, 47.5% males, p = NS), severity of illness (Acute Physiology and Chronic Health Evaluation II score: PDT, 16.87 ± 0.84; ST, 17.88 ± 0.92, p = NS), and principle diagnosis. PDT was performed more quickly (PDT, 20.1 ± 2.0 mins; ST, 41.7 ± 3.9 mins, p < .0001) and was associated with lower patient charges than ST (total patient charges: PDT, $1,569 ± $157 vs. ST, $3,172 ± $114; equipment/supply charges: PDT, $688 ± $103 vs. ST, $1,526 ± $87; professional charges: PDT, $880 ± $ 54 vs. ST, $1,647 ± $50;p < .0001 for all). There were no differences in days intubated before tracheostomy (PDT, 12.7 ± 1.1 days; ST, 15.6 ± 1.9, p = .20), intensive care unit length of stay (PDT, 24.5 ± 2.5 days; ST, 28.5 ± 3.1 days, p = .33), or hospital length of stay (PDT 49.7 ± 4.2 days; ST, 43.7 ± 3.5 days, p = .28) when we compared these two techniques.

Conclusions PDT is a cost-effective alternative to ST. The reduction in patient charges associated with PDT in this study resulted from the procedure being performed in the intensive care unit, thus eliminating the need for operating room facilities and personnel. PDT may become the procedure of choice for electively establishing tracheostomy in the appropriately selected patient who requires long-term mechanical ventilation.

From the Departments of Surgery (BDF, KI, JPC, RES, NL, ECT, TGB), Anesthesiology (WAB, TS), and Medicine (MHK), Washington University School of Medicine, St. Louis, MO.

Supported, in part, by a grant from the Barnes Jewish Hospital Innovations in Health Care Program and GM00691-01.

© 2001 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins