This study was designed to examine prospectively the incidence of perioperative complications associated with elective tracheostomy in critically ill patients. An experienced surgeon and anesthesiologist participated in every tracheostomy procedure. In 81 procedures, there was no loss of airway control for greater than 20 sec, no airway obstruction, no blood loss exceeding 50 ml, and no aspiration. One patient (1.2%) had cardiovascular instability. During the next 48 h, two patients (2.4%) required wound packing to control hemorrhage but did not require blood transfusion and two patients (2.4%) had evidence of supraclavicular subcutaneous emphysema that was physiologically inconsequential. There was no perioperative mortality or major morbidity associated with the tracheostomy procedure. We conclude that, under controlled conditions, elective tracheostomy can be performed safely in critically ill patients.