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Azari Jafari A, Mirmoeeni S, Momtaz D, Kotzur T, Murtha G, Garcia C, Moran M, Martinez P, Chen K, Krishnakumar H, Seifi A. Early Versus Late Tracheostomy in Patients with Traumatic Brain Injury: A US Nationwide Analysis. Neurocrit Care 2024; 40:551-561. [PMID: 37415023 DOI: 10.1007/s12028-023-01778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND One of the most critical issues in patients suffering from traumatic brain injury (TBI) is protecting the airway and attempting to keep a secure airway. It is evident that tracheostomy in patients with TBI after 7-14 days can have favorable outcomes if the patient cannot be extubated; however, some clinicians have recommended early tracheostomy before 7 days. METHODS A retrospective cohort of inpatient study participants was queried from the National Inpatient Sample to include patients with TBI between 2016 and 2020 undergoing tracheostomy and outcomes between the two groups of early tracheostomy (ET) (< 7 days from admission) and late tracheostomy (LT) (≥ 7 days from admission) were compared. RESULTS We reviewed 219,005 patients with TBI, out of whom 3.04% had a tracheostomy. Patients in the ET group were younger than those in the LT group (45.02 ± 19.38 years old vs. 48.68 ± 20.50 years old, respectively, p < 0.001), mainly men (76.64% vs. 73.73%, respectively, p = 0.01), and mainly White race (59.88% vs. 57.53%, respectively, p = 0.33). The patients in the ET group had a significantly shorter length of stay as compared with those in the LT group (27.78 ± 25.96 days vs. 36.32 ± 29.30 days, respectively, p < 0.001) and had a significantly lower hospital charge ($502,502.436 ± 427,060.81 vs. $642,739.302 ± 516,078.94 per patient, respectively, p < 0.001). The whole TBI cohort mortality was reported at 7.04%, which was higher within the ET group compared with the LT group (8.69% vs. 6.07%, respectively, p < 0.001). Patients in the LT had higher odds of developing any infection (odds ratio [OR] 1.43 [1.22-1.68], p < 0.001), emerging sepsis (OR 1.61 [1.39-1.87], p < 0.001), pneumonia (OR 1.52 [1.36-1.69], p < 0.001), and respiratory failure (OR 1.30 [1.09-1.55], p = 0.004). CONCLUSIONS This study shows that ET can provide notable and significant benefits for patients with TBI. Future high-quality prospective studies should be performed to investigate and shed more light on the ideal timing of tracheostomy in patients with TBI.
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Affiliation(s)
- Amirhossein Azari Jafari
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | | | - David Momtaz
- School of Medicine, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Travis Kotzur
- School of Medicine, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Gregory Murtha
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Carlos Garcia
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Maggie Moran
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Paola Martinez
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Kevin Chen
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Hari Krishnakumar
- School of Medicine, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Ali Seifi
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA.
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Gelormini C, Caricato A. Tracheostomy in traumatic brain injury: selection and stratification. Minerva Anestesiol 2023; 89:374-376. [PMID: 37140192 DOI: 10.23736/s0375-9393.23.17380-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Camilla Gelormini
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Anselmo Caricato
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Sacred HeartCatholic University, Rome, Italy
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3
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Mulima G, Lie SA, Charles A, Hanif AB, Varela CG, Banza LN, Young S. Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study. Malawi Med J 2022; 34:152-156. [PMID: 36406102 PMCID: PMC9641605 DOI: 10.4314/mmj.v34i3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.
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Affiliation(s)
- Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Stein Atle Lie
- The Norwegian Arthroplasty Registry, Haukeland University Hospital, Bergen, Norway
| | - Anthony Charles
- Department of Surgery, University of North Carolina, 4008 Burnett Womack Bldg, CB 7050, Chapel Hill, NC, 27599 USA
| | - Asma Bilal Hanif
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Carlos G Varela
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Leonard N Banza
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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Association between Traumatic Subarachnoid Hemorrhage and Acute Respiratory Failure in Moderate-to-Severe Traumatic Brain Injury Patients. J Clin Med 2022; 11:jcm11143995. [PMID: 35887760 PMCID: PMC9318973 DOI: 10.3390/jcm11143995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 01/25/2023] Open
Abstract
Acute respiratory failure (ARF) with a high incidence among moderate-to-severe traumatic brain injury (M-STBI) patients plays a pivotal role in worsening neurological outcomes. Traumatic subarachnoid hemorrhage (tSAH) is highly prevalent in M-STBI, which is associated with significant adverse outcomes. In this retrospective cohort study, we aimed to explore the association between the severity of the tSAH and ARF in the M-STBI population. A total of 771 subjects were reviewed. Clinical and neuroimaging data of M-STBI patients were retrospectively collected, and ARF was ascertained retrospectively based on their electronic medical record. The degree of tSAH was classified according to Fisher’s criteria, and the grade of tSAH was dichotomized to a low Fisher grade (Fisher grade 1–2) and a high Fisher grade (Fisher grade 3–4). After exclusion procedures, the data of 695 M-STBI patients were analyzed. A total of 284 (30.8%) had a high Fisher grade on admission. The overall rate of ARF within 48 h upon admission was 34.4% (239/695); it was 29.5% (142/481) and 46.3% (99/214) for the low and high Fisher groups, respectively. In a full cohort, a high Fisher grade was associated with ARF after adjusting for age, gender, GCS, smoking history, comorbidities, multiple injuries, characteristics of TBI, and pulmonary factors (OR 1.78; 95% CI, 1.11–2.85, p = 0.016). This result remained robust in the comparisons after PSM (71/132, 42.8% vs. 53/132, 31.9%; OR, 1.59; 95% CI, 1.02–2.49, p = 0.042). A high Fisher SAH grade exposure on admission is associated with ARF in M-STBI patients.
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Clark A, Zelmanovich R, Vo Q, Martinez M, Nwafor DC, Lucke-Wold B. Inflammation and the role of infection: Complications and treatment options following neurotrauma. J Clin Neurosci 2022; 100:23-32. [PMID: 35381478 DOI: 10.1016/j.jocn.2022.03.043] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 02/14/2022] [Accepted: 03/29/2022] [Indexed: 02/08/2023]
Abstract
Traumatic brain injury can have devastating consequences for patients and extended hospital stays and recovery course. Recent data indicate that the initial insult causes profound changes to the immune system and leads to a pro-inflammatory state. This alteration in homeostasis predisposes patients to an increased risk of infection and underlying autoimmune conditions. Increased emphasis has been placed on understanding this process both in the clinical and preclinical literature. This review highlights the intrinsic inflammatory conditions that can occur within the initial hospital stay, discusses long-term immune consequences, highlights emerging treatment options, and delves into important pathways currently being investigated with preclinical models.
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Affiliation(s)
- Alec Clark
- University of Central Florida, College of Medicine, Orlando, USA
| | | | - Quan Vo
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Melanie Martinez
- Department of Neurosurgery, University of Florida, Gainesville, USA
| | - Divine C Nwafor
- Department of Neurosurgery, West Virginia University, Morgantown, USA
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Bharti R, Sindhu S, Sundaram PK, Chauhan G. Prospective Observational Study of Early Tracheostomy Role in Operated Severe Head Injury Patients at A Level 1 Trauma Center. Bull Emerg Trauma 2021; 9:188-194. [PMID: 34692870 PMCID: PMC8525695 DOI: 10.30476/beat.2021.86725.1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 06/15/2021] [Accepted: 06/29/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: To evaluate the impact of the early tracheostomy on operated patients with severe head injury. Methods: This prospective observational study was conducted at a level 1 trauma center and medical college over one-year period. The study included all surgically managed severe head injury patients without any other life-threatening major injuries. Patients who underwent tracheostomy within 7 days were classified as early tracheostomy. Results: The patient’s mean age of this cohort study was 43.4±14.5 years. Motor-vehicle accidents were being the most common cause of severe head injury. Operated patients were undergoing early tracheostomy on an average of 2.9 days. We were observed that the patients spent on a mechanical ventilation on an average 3.67±2.26 days. This was significantly lower than previous four published studies (p<0.05) which had a range of mean 9.8-15.7 days. Conclusion: We have shown that it is possible to decrease mechanical ventilation (MV) time, intensive care unit (ICU) stay and total hospital stay by doing early tracheostomy in operated severe head injury patients.
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Affiliation(s)
- Rohit Bharti
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
| | | | | | - Ganesh Chauhan
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
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Liu C, Xie J, Xiao X, Li T, Li H, Bai X, Li Z, Wang W. Clinical predictors of prognosis in patients with traumatic brain injury combined with extracranial trauma. Int J Med Sci 2021; 18:1639-1647. [PMID: 33746580 PMCID: PMC7976565 DOI: 10.7150/ijms.54913] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Accepted: 01/04/2021] [Indexed: 12/20/2022] Open
Abstract
Objective: The purpose of this study was to investigate whether routine blood tests on admission and clinical characteristics can predict prognosis in patients with traumatic brain injury (TBI) combined with extracranial trauma. Methods: Clinical data of 182 patients with TBI combined with extracranial trauma from April 2018 to December 2019 were retrospectively collected and analyzed. Based on GOSE score one month after discharge, the patients were divided into a favorable group (GOSE 1-4) and unfavorable group (GOSE 5-8). Routine blood tests on admission and clinical characteristics were recorded. Results: Overall, there were 48 (26.4%) patients with unfavorable outcome and 134 (73.6%) patients with favorable outcome. Based on multivariate analysis, independent risk factors associated with unfavorable outcome were age (odds ratio [OR], 1.070; 95% confidence interval [CI], 1.018-1.124; p<0.01), admission Glasgow Coma Scale (GCS) score (OR, 0.807; 95% CI, 0.675-0.965; p<0.05), heart rate (OR, 1.035; 95% CI, 1.004-1.067; p<0.05), platelets count (OR, 0.982; 95% CI, 0.967-0.997; p<0.05), and tracheotomy (OR, 15.201; 95% CI, 4.121-56.078; p<0.001). Areas under the curve (AUC) of age, admission GCS, heart rate, tracheotomy, and platelets count were 0.678 (95% CI, 0.584-0.771), 0.799 (95% CI, 0.723-0.875), 0.652 (95% CI, 0.553-0.751), 0.776 (95% CI, 0.692-0.859), and 0.688 (95% CI, 0.606-0.770), respectively. Conclusions: Age, admission GCS score, heart rate, tracheotomy, and platelets count can be recognized as independent predictors of clinical prognosis in patients with severe TBI combined with extracranial trauma.
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Affiliation(s)
- Chengli Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Xinshuang Xiao
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Tianyu Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Hui Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Xiangjun Bai
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Zhanfei Li
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
| | - Wei Wang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, P.R. China
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8
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Taveira I, Neto R, Salvador P, Costa R, Fernandes P, Castelões P. Determinants of the Need for Tracheostomy in Neurocritical Patients. Cureus 2020; 12:e11654. [PMID: 33391893 PMCID: PMC7769499 DOI: 10.7759/cureus.11654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Background: Given the difficulties in predicting the need for prolonged intubation and the timing of tracheostomy, the stroke-related early tracheostomy score (SETscore) was developed, and this tool has demonstrated moderate accuracy in predicting intensive care unit (ICU) length of stay (LoS), ventilation duration, and need for tracheostomy. We aim to assess the usefulness of SETscore in a more heterogeneous population that includes trauma patients to whom this score has not yet been applied. Material and Methods: A retrospective consecutive analysis of all neurocritical patients who were admitted to our medical-surgical ICU between 2016 and 2018 and who required endotracheal intubation within 48 h of admission was performed in this study. Clinicodemographic data, as well as tracheostomy timing, imaging results, and SETscore were evaluated. Results: The medical records of 732 neurocritical patients were reviewed, but only 493 patients were included, 68 of whom were tracheostomized (TR). These TR patients presented longer LoS and ventilation and antibiotic duration, lower Glasgow Coma Scale (GCS) score at admission, and more respiratory comorbidities. Severity scores, including SETscore, were higher in the TR group. A SETscore of >10 demonstrated 92.6% sensitivity and 79.1% specificity in predicting the need for tracheostomy. The majority of patients were tracheostomized after the seventh day of ICU admission. No significant differences in SETscore as well as in severity scores, age, and gender were observed between the early and late TR groups. However, the need for tracheostomy was significantly associated with lower ICU death rate even after controlling for GCS at admission, gender, age, and duration of invasive mechanical ventilation. Conclusion: SETscore can be applied to a heterogeneous population. However, more data and prospective analyses are needed to validate their clinical usefulness on a daily basis. Nevertheless, the present data are expected to contribute to the management of neurocritical patients, particularly in the setting of ICUs managing a broad spectrum of critically ill patients.
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Affiliation(s)
- Isabel Taveira
- Internal Medicine, Hospital do Litoral Alentejano, Santiago do Cacém, PRT
| | - Raul Neto
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, PRT
| | - Pedro Salvador
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, PRT
| | - Rita Costa
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, PRT
| | - Paula Fernandes
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, PRT
| | - Paula Castelões
- Internal Medicine, Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, PRT
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Wahlster S, Sharma M, Chu F, Granstein JH, Johnson NJ, Longstreth WT, Creutzfeldt CJ. Outcomes After Tracheostomy in Patients with Severe Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2020; 34:956-967. [PMID: 33033959 PMCID: PMC8363498 DOI: 10.1007/s12028-020-01109-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/09/2020] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To synthesize reported long-term outcomes in patients undergoing tracheostomy after severe acute brain injury (SABI). METHODS We systematically searched PubMed, EMBASE, and Cochrane Library for studies in English, German, and Spanish between 1990 and 2019, reporting outcomes in patients with SABI who underwent tracheostomy. We adhered to the preferred reporting items for systematic reviews and meta-analyses guidelines and the meta-analyses of observational studies in epidemiology guidelines. We excluded studies reporting on less than 10 patients, mixed populations with other neurological diseases, or studies assessing highly select subgroups defined by age or procedures. Data were extracted independently by two investigators. Results were pooled using random effects modeling. The primary outcome was long-term functional outcome (mRS or GOS) at 6-12 months. Secondary outcomes included hospital and long-term mortality, decannulation rates, and discharge home rates. RESULTS Of 1405 studies identified, 61 underwent full manuscript review and 19 studies comprising 35,362 patients from 10 countries were included in the meta-analysis. The primary outcome was available from five studies with 451 patients. At 6-12 months, about one-third of patients (30%; 95% confidence interval [CI] 17-48) achieved independence, and about one-third survived in a dependent state (36%, 95% CI 28-46%). The pooled short-term mortality for 19,048 patients was 12%, (95% CI 9-17%) with no significant difference between stroke (10%) and TBI patients (13%), and the pooled long-term mortality was 21% (95% CI 11-36). Decannulation occurred in 79% (95% CI 51-93%) of survivors. Heterogeneity was high for most outcome assessments (I2 > 75%). CONCLUSIONS Our findings suggest that about one in three patients with SABI who undergo tracheostomy may eventually achieve independence. Future research is needed to understand the reasons for the heterogeneity between studies and to identify those patients with promising outcomes as well as factors influencing outcome.
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Affiliation(s)
- Sarah Wahlster
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA.
| | - Monisha Sharma
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Frances Chu
- Health Science Library, University of Washington, Seattle, WA, USA
| | - Justin H Granstein
- Department of Neurological Surgery, Mount Sinai Hospital, New York, NY, USA
| | - Nicholas J Johnson
- Department of Emergency Medicine, University of Washington, Seattle, WA, USA
| | - W T Longstreth
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Claire J Creutzfeldt
- Department of Neurology, Harborview Medical Center, University of Washington, 325 9th Ave, Box 359775, Seattle, WA, 98104, USA
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10
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Jenkins R, Badjatia N, Haac B, Van Besien R, Biedlingmaier JF, Stein DM, Chang WT, Schwartzbauer G, Parikh G, Morris NA. Factors associated with tracheostomy decannulation in patients with severe traumatic brain injury. Brain Inj 2020; 34:1106-1111. [DOI: 10.1080/02699052.2020.1786601] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Affiliation(s)
- Ryne Jenkins
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Neeraj Badjatia
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bryce Haac
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Richard Van Besien
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
| | - John F. Biedlingmaier
- Department of Otolaryngology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Deborah M. Stein
- R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, Baltimore, MD, USA
- Zuckerberg San Francisco General Hospital and Trauma Center, Program in Trauma, University of California San Francisco School of Medicine, San Francisco, CA, USA
| | - Wan-Tsu Chang
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gary Schwartzbauer
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Gunjan Parikh
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas A. Morris
- Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
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11
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Maiden MJ, Cameron PA, Rosenfeld JV, Cooper DJ, McLellan S, Gabbe BJ. Long-Term Outcomes after Severe Traumatic Brain Injury in Older Adults. A Registry-based Cohort Study. Am J Respir Crit Care Med 2020; 201:167-177. [PMID: 31657946 DOI: 10.1164/rccm.201903-0673oc] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Rationale: Older adults (≥65 yr old) account for an increasing proportion of patients with severe traumatic brain injury (TBI), yet clinical trials and outcome studies contain relatively few of these patients.Objectives: To determine functional status 6 months after severe TBI in older adults, changes in this status over 2 years, and outcome covariates.Methods: This was a registry-based cohort study of older adults who were admitted to hospitals in Victoria, Australia, between 2007 and 2016 with severe TBI. Functional status was assessed with Glasgow Outcome Scale Extended (GOSE) 6, 12, and 24 months after injury. Cohort subgroups were defined by admission to an ICU. Features associated with functional outcome were assessed from the ICU subgroup.Measurements and Main Results: The study included 540 older adults who had been hospitalized with severe TBI over the 10-year period; 428 (79%) patients died in hospital, and 456 (84%) died 6 months after injury. There were 277 patients who had not been admitted to an ICU; at 6 months, 268 (97%) had died, 8 (3%) were dependent (GOSE 2-4), and 1 (0.4%) was functionally independent (GOSE 5-8). There were 263 patients who had been admitted to an ICU; at 6 months, 188 (73%) had died, 39 (15%) were dependent, and 32 (12%) were functionally independent. These proportions did not change over longer follow-up. The only clinical features associated with a lower rate of functional independence were Injury Severity Score ≥25 (adjusted odds ratio, 0.24 [95% confidence interval, 0.09-0.67]; P = 0.007) and older age groups (P = 0.017).Conclusions: Severe TBI in older adults is a condition with very high mortality, and few recover to functional independence.
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Affiliation(s)
- Matthew J Maiden
- Intensive Care Unit, Barwon Health, Geelong, Australia.,Intensive Care Unit, Royal Adelaide Hospital, Adelaide, Australia.,Discipline of Acute Care Medicine, University of Adelaide, Adelaide, Australia
| | - Peter A Cameron
- Emergency and Trauma Centre.,School of Public Health and Preventive Medicine and
| | - Jeffrey V Rosenfeld
- Department of Neurosurgery, and.,Department of Surgery, Monash University, Melbourne, Australia.,Department of Surgery, F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, Maryland; and
| | - D James Cooper
- Intensive Care Unit, The Alfred Hospital, Prahran, Australia.,School of Public Health and Preventive Medicine and
| | | | - Belinda J Gabbe
- School of Public Health and Preventive Medicine and.,Health Data Research UK, Swansea University Medical School, Swansea University, Singleton Park, United Kingdom
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12
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Inpatient Complications Predict Tracheostomy Better than Admission Variables After Traumatic Brain Injury. Neurocrit Care 2020; 30:387-393. [PMID: 30334232 DOI: 10.1007/s12028-018-0624-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy. METHODS We performed an observational study of adult traumatic brain injury (TBI) patients requiring intensive care unit (ICU) admission for ≥ 72 h and mechanical ventilation for ≥ 24 h between January 2014 and December 2014 at a level 1 trauma center. Patients who had life-sustaining measures withdrawn were excluded. Multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop predictive models. Inpatient complications prior to day 7 were used to standardize data collection for patients with and without tracheostomy. Patients who received tracheostomy prior to day 7 were excluded from analysis. RESULTS In total, 209 patients (78% men, mean 48 years old, median Glasgow Coma Scale score (GCS) 8) met study criteria with tracheostomy performed in 94 (45%). Admission predictors of tracheostomy included GCS, chest tube, Injury Severity Score, and Marshall score. Inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (EVD), number of operations, inpatient dialysis, aspiration, GCS on day 5, and reintubation. Multiple logistic regression analysis demonstrated that the number of operation room trips (adjusted odds ratio [AOR], 1.75; 95% CI, 1.04-2.97; P = 0.036), reintubation (AOR, 8.45; 95% CI, 1.91-37.44; P = .005), and placement of an EVD (AOR, 3.48; 95% CI, 1.27-9.58; P = .016) were independently associated with patients undergoing tracheostomy. Higher GCS on hospital day 5 (AOR, 0.52; 95% CI, 0.40-0.68; P < 0.001) was protective against tracheostomy. A model of inpatient variables only had a stronger association with tracheostomy than one with admission variables only (ROC AUC 0.93 vs 0.72, P < 0.001) and did not benefit from the addition of admission variables (ROC AUC 0.93 vs 0.92, P = 0.78). CONCLUSION Potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. Multicenter studies are needed to validate the results.
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Tignanelli CJ, Gipson J, Nguyen A, Martinez R, Yang S, Reicks PL, Sybrant C, Roach R, Thorson M, West MA. Implementation of a Prophylactic Anticoagulation Guideline for Patients with Traumatic Brain Injury. Jt Comm J Qual Patient Saf 2020; 46:185-191. [PMID: 31899154 DOI: 10.1016/j.jcjq.2019.11.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Revised: 11/20/2019] [Accepted: 11/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) are at an increased risk of developing complications from venous thromboembolisms (VTEs [blood clots]). Benchmarking by the American College of Surgeons Trauma Quality Improvement Program identified suboptimal use of prophylactic anticoagulation in patients with TBI. We hypothesized that institutional implementation of an anticoagulation protocol would improve clinical outcomes in such patients. METHODS A new prophylactic anticoagulation protocol that incorporated education, weekly audits, and real-time adherence feedback was implemented in July 2015. The trauma registry identified patients with TBI before (PRE) and after (POST) implementation. Multivariable regression analysis with risk adjustment was used to compare use of prophylactic anticoagulation, VTE events, and mortality. RESULTS A total of 681 patients with TBI (368 PRE, 313 POST) were identified. After implementation of the VTE protocol, more patients received anticoagulation (PRE: 39.4%, POST: 80.5%, p < 0.001), time to initiation was shorter (PRE: 140 hours, POST: 59 hours, p < 0.001), and there were fewer VTE events (PRE: 19 [5.2%], POST: 7 [2.2%], p = 0.047). Multivariable analysis showed that POST patients were more likely to receive anticoagulation (odds ratio [OR] = 10.8, 95% confidence interval [CI] = 6.9-16.7, p < 0.001) and less likely to develop VTE (OR = 0.33, 95% CI = 0.1-1.0, p = 0.05). CONCLUSION Benchmarking can assist institutions to identity potential clinically relevant areas for quality improvement in real time. Combining education and multifaceted protocol implementation can help organizations to better focus limited quality resources and counteract barriers that have hindered adoption of best practices.
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Jenkins R, Morris NA, Haac B, Besien RV, Stein DM, Badjatia N, Medic A, Mester G, Tran QK. Outcome predictors for severely brain-injured patients directly admitted or transferred from emergency departments to a trauma center. World J Emerg Med 2020; 11:120-121. [PMID: 32076479 DOI: 10.5847/wjem.j.1920-8642.2020.02.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Ryne Jenkins
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Nicholas A Morris
- Section of Neurocritical Care and Emergency Neurology, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Bryce Haac
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | | | - Deborah M Stein
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Neeraj Badjatia
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Section of Neurocritical Care and Emergency Neurology, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Amir Medic
- University of Maryland at College Park, College Park, MD, USA
| | - Gaurika Mester
- University of Maryland at College Park, College Park, MD, USA
| | - Quincy K Tran
- Program in Trauma, The R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD, USA.,Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
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A Modified Translaryngeal Tracheostomy Technique in the Neurointensive Care Unit. Rationale and Single-center Experience on 199 Acute Brain-damaged Patients. J Neurosurg Anesthesiol 2019; 31:330-336. [PMID: 30161098 DOI: 10.1097/ana.0000000000000535] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Brain-injured patients frequently require tracheostomy, but no technique has been shown to be the gold standard for these patients. We developed and introduced into standard clinical practice an innovative bedside translaryngeal tracheostomy (TLT) technique aided by suspension laryngoscopy (modified TLT). During this procedure, the endotracheal tube is left in place until the airway is secured with the new tracheostomy. This study assessed the clinical impact of this technique in brain-injured patients. MATERIALS AND METHODS This is a retrospective analysis of prospectively collected data from adult brain-injured patients who had undergone modified TLT during the period spanning from January 2010 to December 2016 at the Neurointensive care unit, San Gerardo Hospital (Monza, Italy). The incidence of intraprocedural complications, including episodes of intracranial hypertension (intracranial pressure [ICP] >20 mm Hg), was documented. Neurological, ventilatory, and hemodynamic parameters were retrieved before, during, and after the procedure. Risk factors for complications and intracranial hypertension were assessed by univariate logistic analysis. Data are presented as n (%) and median (interquartile range) for categorical and continuous variables, respectively. RESULTS A total of 199 consecutive brain-injured patients receiving modified TLT were included. An overall 52% male individuals who were 66 (54 to 74) years old and who had an admission Glasgow Coma Scale of 7 (6 to 10) were included in the cohort. Intracerebral hemorrhage (30%) was the most frequent diagnosis. Neurointensivists performed 130 (65%) of the procedures. Patients underwent tracheostomy 10 (7 to 13) days after intensive care unit admission. Short (ie, <2 min) and clinically uneventful increases in ICP>20 mm Hg were observed in 11 cases. Overall, the procedure was associated with an increase in ICP from 7 (4 to 10) to 12 (7 to 18) mm Hg (P<0.001). Compared with baseline, cerebral perfusion pressure (CPP), respiratory variables, and hemodynamics were unchanged during the procedure (P-value, not significant). Higher baseline ICP and core temperature were associated with an increased risk of complications and intracranial hypertension. Complication rates were low: 1 procedure had to be converted to a surgical tracheostomy, and 1 (0.5%) episode of minor bleeding and 5 (2.5%) of minor non-neurological complications were recorded. Procedures performed by intensivists did not have a higher risk of complications compared with those performed by ear, nose, and throat specialists. CONCLUSIONS A modified TLT (by means of suspension laryngoscopy) performed by neurointensivists is feasible in brain-injured patients and does not adversely impact ICP and CPP.
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Carlson KA, Dhillon NK, Patel KA, Huang R, Ng P, Margulies DR, Ley EJ, Barmparas G. Utilization of tracheostomy among geriatric trauma patients and association with mortality. Eur J Trauma Emerg Surg 2019; 46:1375-1383. [PMID: 31396650 DOI: 10.1007/s00068-019-01199-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2018] [Accepted: 07/28/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The purpose of this study was to investigate trends in tracheostomy (TR) utilization among trauma patients over the last decade and explore its impact on mortality among elderly trauma patients. METHODS Patients 18 years or older with at least 72 h on the ventilator were selected from the National Trauma Databank research datasets 2007 to 2015. Patients were divided into three groups based on age: 18-60, 61-80, and > 80 years and proportions of patients undergoing a TR were depicted. Elderly (> 80 years) were divided into two groups, based on whether they underwent a TR. The primary outcome was mortality. A Cox regression model with a time-dependent variable was utilized to account for survival bias. RESULTS Over the 9-year study period 284,774 patients met inclusion criteria. Of those, 21,465 (7.5%) were older than 80 years. Elderly patients were significantly less likely to undergo a TR (13.1% vs. 21.5% in the 18-60 years and 20.4% in the 61-80 years group, p < 0.01) and this trend continued throughout the study period. Among the elderly patients, those who underwent TR were more likely to have a severe (AIS ≥ 3) thoracic, abdominal, and/or spinal injury, but not head injury and were less likely to have a history of cerebrovascular accident (5.9% vs. 7.7%, p < 0.01). The overall mortality was significantly higher in elderly patients who did not undergo a TR (46.9% vs. 17.6%, p < 0.01). The adjusted hazard ratio for elderly patients undergoing a TR was 0.36 (adjusted p < 0.01). CONCLUSION In ventilated trauma patients, tracheostomy is less likely to be utilized in the elderly population compared to younger age groups. Amongst the elderly patients, performance of tracheostomy was associated with a significantly higher overall survival. Delaying or avoiding this procedure in the elderly trauma patient predominantly based on age might not be justified. STUDY TYPE Prognostic/epidemiological. LEVEL OF EVIDENCE III or IV.
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Affiliation(s)
- Kjirsten Ayn Carlson
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Navpreet Kaur Dhillon
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Kavita Anil Patel
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Raymond Huang
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Phillip Ng
- Division of General Internal Medicine, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Daniel Reed Margulies
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Eric Jude Ley
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA
| | - Galinos Barmparas
- Division of Acute Care Surgery and Surgical Critical Care, Department of Surgery, Cedars-Sinai Medical Center, 8635 W. 3rd Street, Suite 650W, Los Angeles, CA, 90048, USA.
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Kaushal A, Bindra A, Kumar A, Goyal K, Kumar N, Rath GP, Gupta D. Long Term Outcome in Survivors of Decompressive Craniectomy following Severe Traumatic Brain Injury. Asian J Neurosurg 2019; 14:52-57. [PMID: 30937008 PMCID: PMC6417309 DOI: 10.4103/ajns.ajns_147_17] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Decompressive craniectomy (DC) is done for the management of intracranial hypertension due to severe traumatic brain injury (sTBI). Despite DC, a number of patients die and others suffer from severe neurological disability. We conducted this observational study to assess functional outcome as measured by Glasgow outcome scale-extended (GOSE) in survivors of DC. The correlation between various factors at admission and hospital with functional outcome was also obtained. Materials and Methods: Patients (15–65 years) posted for cranioplasty following DC due to sTBI were prospectively enrolled. Demographic profile, clinical data, and GOSE were noted at the time of admission for cranioplasty from the patient or nearest relative or both. Retrospective data noted from hospital records included admission Marshalls grading, Glasgow coma score (GCS), motor response, mean arterial pressure (MAP), and timing of DC at the time of initial admission following sTBI. Results: A total of 85 patients (71 males and 14 females) were enrolled over a period of 2 years. The mean age of the patients was 33.42 ± 12.70 years. The median GCS at the time of admission due to head injury, at the time of discharge, and at the time of cranioplasty was 8 (interquartile range [IQR] 3–15), 10 (IQR 4–15), and 15 (IQR 7–15), respectively. Thirty-one patients (36%) had good functional outcome (GOSE 5–8) and 54 patients (64%) had poor functional outcome (GOSE 1–4). On univariate analysis tracheostomy (P = 0.00), duration of hospital stay (P = 0.002), MAP at admission (P = 0.01), and GCS at discharge (P = 0.01) correlated with outcome [Table 1]. On multivariate analysis MAP at admission (odds ratio [OR] [95% confidence interval {CI}]; 0.07 [0.01–0.40] and tracheostomy (OR [95% CI]; 15 [1.45–162.9]) were found to be the independent predictors of functional outcome. Conclusion: Significant disability is seen among the survivors of DC. Tracheostomy and MAP at admission were found to be independently associated with the patient outcome.
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Affiliation(s)
- Ashutosh Kaushal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Ashish Bindra
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Abhyuday Kumar
- Department of Anesthesiology, Critical Care and Pain Medicine, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Keshav Goyal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Niraj Kumar
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Girija Prasad Rath
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
| | - Deepak Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences and associated Jai Prakash Narain Apex Trauma Centre, New Delhi, India
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Pozzi M, Galbiati S, Locatelli F, Clementi E, Strazzer S. Performance of a tracheostomy removal protocol for pediatric patients in rehabilitation after acquired brain injury: Factors associated with timing and possibility of decannulation. Pediatr Pulmonol 2017; 52:1509-1517. [PMID: 28950420 DOI: 10.1002/ppul.23832] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 09/01/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVES We assessed the performance of a tracheostomy decannulation protocol privileging safety over quickness, in pediatric patients undergoing rehabilitation from severe acquired brain injury. We analyzed factors associated with decannulation timing and possibility and examined cases of failure. HYPOTHESIS A safe decannulation protocol should minimize failures. STUDY DESIGN Retrospective observational study. PATIENT SELECTION Patients aged 0-17 admitted to rehabilitation with tracheostomy in the last 15 years (n = 123). METHODOLOGY We collected data on clinical and respiratory conditions at admittance, during the first rehabilitation stay and following follow-up controls. We described the sample and tested associations of several factors with the possibility to decannulate patients during either the first stay or follow-up. We described failures, defined as the cases in which tracheostomy tube had to be placed back immediately or after less than 1 month from removal. RESULTS At admittance, 93.5% patients were dysphagic and 37.9% had respiratory complications (mainly accumulation of supraglottic secretions). At first discharge, dysphagia was reduced (62.1%) and respiratory complications increased (41.1%). Tracheostomy was removed during the first stay in 55.3% patients, during follow-up in 13%, without failures among the 80 patients who followed the protocol. Four decannulations performed against protocol recommendations resulted in three failures. Decannulation was mainly prevented by the persistence of respiratory complications and dysphagia that constituted a relevant risk of aspiration and suffocation; decannulation was mainly postponed because of respiratory complications and breath-holding spells in very young children. CONCLUSIONS By applying a decannulation protocol that privileges safety over quickness, we encountered no failure. Respiratory complications and dysphagia that lead to supraglottic stagnation, and breath-holding spells, are key elements to consider before performing decannulation in pediatric patients.
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Affiliation(s)
- Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Sara Galbiati
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | | | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy.,Unit of Clinical Pharmacology, Department of Biomedical and Clinical Sciences L. Sacco, CNR Institute of Neuroscience, "Luigi Sacco" University Hospital, Università di Milano, Milan, Italy
| | - Sandra Strazzer
- Scientific Institute IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
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Varghese R, Chakrabarty J, Menon G. Nursing Management of Adults with Severe Traumatic Brain Injury: A Narrative Review. Indian J Crit Care Med 2017; 21:684-697. [PMID: 29142381 PMCID: PMC5672675 DOI: 10.4103/ijccm.ijccm_233_17] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Effective nursing management strategies for adults with severe traumatic brain injury (STBI) are still a remarkable issue and a difficult task for neurologists, neurosurgeons, and neuronurses. A list of justified indications and scientific rationale for nursing management of these patients are continuously evolving. The objectives of the study are to analyze the pertinently available research and clinical studies that demonstrate the nursing management strategies for adults with STBI and to synthesize the available evidence based on the review. A comprehensive literature search was made in following databases such as Google Scholar, Cochrane, J-Gate, ProQuest, and ScienceDirect for retrieving the related studies. In the included studies, data were extracted and evaluated according to the objective. Narrative analysis was adopted to write this review. Patients with STBI have poor prognosis and require quality care for maximizing patients' survival. With a thorough knowledge and discernment of care of such patients, nurses can improve these patients' neurological outcomes.
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Affiliation(s)
| | - Jyothi Chakrabarty
- Department of Medical Surgical Nursing, Manipal College of Nursing, Manipal, Karnataka, India
| | - Girish Menon
- Department of Neurosurgery, Kasturba Hospital, Manipal, Karnataka, India
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Jeong YH, Kim SH, Choi EH, Whang K. Biomarkers of Physiological Disturbances for Predicting Mortality in Decompressive Craniectomy. Korean J Neurotrauma 2016; 12:77-83. [PMID: 27857912 PMCID: PMC5110923 DOI: 10.13004/kjnt.2016.12.2.77] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 10/23/2016] [Accepted: 10/25/2016] [Indexed: 11/29/2022] Open
Abstract
Objective Of many critical care regimens, the management of physiological disturbances in serum is particularly drawing an attention in conjunction with patient outcome. The aim of this study was to assess the association of serum biochemical markers with mortality in head trauma patients with decompressive craniotomy. Methods Ninety six patients with acute subdural hematoma underwent decompressive craniectomy between January 2014 and December 2015. The clinical data and laboratory variables of these patients were recorded and analyzed retrospectively. The pre-operative and post-operative day (POD) 0, day 1 and day 2 serum variables were measured. These were compared between the survivors and non-survivors. Results The factors of a large amount of intra-operative blood loss, shorter length of intensive care unit stays, and the needs for mechanical ventilation were related with mortality in the patients with decompressive craniectomy. These clinical factors were associated with the physiological derangements of sera. The average difference in serum chloride concentration between the pre-operative and POD 2 measurements (p=0.0192) showed a statistical significance in distinguishing between survivors and non-survivors. The average differences in albumin (p=0.0011) and platelet count (p=0.0004) between the pre-operative and POD 0 measurements suggested to be strong predictors of mortality in decompressive craniectomy. Conclusion Isolated values of physiological biomarkers are not sufficient enough to predict in-hospital mortality. This study emphasizes the importance of a combined prognostic model of the differences in the pre-operative and post-operative hyperchloremia, thrombocytopenia, and hypoalbuminemia to identify the risk of mortality in decompressive craniecomy.
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Affiliation(s)
- Young Ha Jeong
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea
| | - So Hyun Kim
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea
| | - Eun Hee Choi
- Institute of Lifestyle Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea
| | - Kum Whang
- Department of Neurosurgery, Wonju Severance Christian Hospital, Yonsei University, Wonju, Korea
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