Early percutaneous tracheostomy after median sternotomy

Abstract

Objective: Tracheostomy offers significant advantages over endotracheal intubation in patients requiting long-term assisted ventilation. However, in patients who have undergone median sternotomy, it is believed that the danger of microbial contamination and consecutive infection of the sternal wound with microbes from the tracheostomy is high when conventional tracheostomy is performed. In contrast, percutaneous techniques are less likely to result in tracheostomy infection and thus bacterial contamination of neighboring structures. Nonetheless, to date there has been no prospective study confirming or disproving this assumption. Our study evaluated outcome after percutaneous tracheostomy in patients with a median sternotomy. Methods: A total of 144 cardiac surgical patients had elective percutaneous tracheostomy at the bedside until postoperative day 14, with 4 different techniques. Systematic microbiologic monitoring of the sternal and tracheal wounds was used. Results: In 13 patients sternal wound infection was suspected, but was confirmed in only 4 (2.8%) patients who actually showed microbial contamination of the sternum. In 2 of these patients, the identified microbes were not identical to those cultured from the trachea. The other 2 patients had sternal and tracheal cultures positive for methicillin-resistant Staphylococcus aureus. Cross-contamination of the sternotomy with microbes from the patient's airways was therefore ruled out. No patient had clinical signs of tracheostomy infection. Likewise, there were no cases of mediastinitis. Conclusions: On the basis of our data, we conclude that cross-contamination of the sternal wound with microbes from the trachea is not a problem. Elective percutaneous tracheostomy is safe, even if performed during the first 14 days after median sternotomy.