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Bini G, Russo E, Antonini MV, Pirini E, Brunelli V, Zumbo F, Pronti G, Rasi A, Agnoletti V. Impact of early percutaneous dilatative tracheostomy in patients with subarachnoid hemorrhage on main cerebral, hemodynamic, and respiratory variables: A prospective observational study. Front Neurol 2023; 14:1105568. [PMID: 37051061 PMCID: PMC10083491 DOI: 10.3389/fneur.2023.1105568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/02/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction Patients with poor-grade subarachnoid hemorrhage (SAH) admitted to the intensive care unit (ICU) often require prolonged invasive mechanical ventilation due to prolonged time to obtain neurological recovery. Impairment of consciousness and airway protective mechanisms usually require tracheostomy during the ICU stay to facilitate weaning from sedation, promote neurological assessment, and reduce mechanical ventilation (MV) duration and associated complications. Percutaneous dilatational tracheostomy (PDT) is the technique of choice for performing a tracheostomy. However, it could be associated with particular risks in neurocritical care patients, potentially increasing the risk of secondary brain damage. Methods We conducted a single-center, prospective, observational study aimed to assess PDT-associated variations in main cerebral, hemodynamic, and respiratory variables, the occurrence of tracheostomy-related complications, and their relationship with outcomes in adult patients with SAH admitted to the ICU of a neurosurgery/neurocritical care hub center after aneurysm control through clipping or coiling and undergoing early PDT. Results We observed a temporary increase in ICP during early PDT; this increase was statistically significant in patients presenting with higher therapy intensity level (TIL) at the time of the procedural. The episodes of intracranial hypertension were brief, and appeared mainly due to the activation of cerebral autoregulatory mechanisms in patients with impaired compensatory mechanisms and compliance. Discussion The low number of observed complications might be related to our organizational strategy, all based on a dedicated "tracheo-team" implementing both PDT following a strictly defined protocol and accurate follow-up.
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Affiliation(s)
- Giovanni Bini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Emanuele Russo
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Marta Velia Antonini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Emilia-Romagna, Italy
| | - Erika Pirini
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Valentina Brunelli
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
| | - Fabrizio Zumbo
- Neurointensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giorgia Pronti
- Department of Anesthesia and Intensive Care, Osspedale degli Infermi, Rimini, Italy
| | - Alice Rasi
- Department of Pediatrics, Ospedale Bufalini, Cesena (FC), Italy
| | - Vanni Agnoletti
- Department of Emergency Surgery and Trauma, Anesthesia and Intensive Care Unit, M Bufalini Hospital, Azienda Unità Sanitaria Locale (AUSL) della Romagna, Cesena, Italy
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Formisano R, D'Ippolito M, Giustini M, Della Vedova C, Laurenza L, Matteis M, Menna C, Rendina EA. The impact of early surgical treatment of tracheal stenosis on neurorehabilitation outcome in patients with severe acquired brain injury. Brain Inj 2023; 37:74-82. [PMID: 36346363 DOI: 10.1080/02699052.2022.2143899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Acquired tracheal stenosis (TS) is a potentially life-threatening condition following prolonged intubation and/or tracheostomy in adult patients with severe Acquired Brain Injury (sABI), requiring a tracheal resection and reconstruction. METHODS We included 38 sABI adult patients with TS, admitted at a post-acute Neurorehabilitation Hospital. Disability Rating Scale (DRS) and other functional assessment measures were recorded at admission (t1), before TS surgical treatment (t2), and at discharge (t3). Patients were defined as 'improved' when they changed from a more severe to a less severe disability, between time t2 and time t3, and as "not improved" when they did not show any further improvement between t2 and t3, or they already exhibited a disability improvement since time interval t1-t2. RESULTS Time interval between the injury onset and TS surgical treatment (t2-t0) was associated with the patient's disability improvement, suggesting the t2-t0 time interval ≤ 115 days as a cutoff value for a possible functional recovery. A t2-t0 time interval ≤ 170 days is also associated to absence of persistent dysphagia. CONCLUSIONS Early TS surgical treatment within 115 days from the injury onset contributes to the improvement of the disability level in patients with sABI, optimizing their functional outcomes and recovery potential.
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Affiliation(s)
- R Formisano
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - M D'Ippolito
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - M Giustini
- Environmental and Social Epidemiology Unit, National Institute of Health, Rome, Italy
| | - C Della Vedova
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - L Laurenza
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - M Matteis
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - C Menna
- Thoracic Surgery Department, Sant'Andrea Hospital, Rome, Italy
| | - E A Rendina
- Thoracic Surgery Department, Sant'Andrea Hospital, Rome, Italy
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Salik I, Das A, Naftchi AF, Vazquez S, Spirollari E, Dominguez JF, Sukul V, Stewart D, Moscatello A. Effect of tracheostomy timing in pediatric patients with traumatic brain injury. Int J Pediatr Otorhinolaryngol 2023; 164:111414. [PMID: 36527981 DOI: 10.1016/j.ijporl.2022.111414] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 11/07/2022] [Accepted: 12/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Traumatic brain injury (TBI) is a prevalent cause of disability and death in the pediatric population, often requiring prolonged mechanical ventilation. Patients with significant TBI or intracranial hemorrhage require advanced airway management to protect against aspiration, hypoxia, and hypercarbia, eventually necessitating tracheostomy. While tracheostomy is much less common in children compared to adults, its prevalence among pediatric populations has been steadily increasing. Although early tracheostomy has demonstrated improved outcomes in adult patients, optimal tracheostomy timing in the pediatric population with TBI remains to be definitively established. OBJECTIVE This retrospective cohort analysis aims to evaluate pediatric TBI patients who undergo tracheostomy and to investigate the impact of tracheostomy timing on outcomes. DESIGN/METHODS The Healthcare Cost and Utilization Project (HCUP) Kids' Inpatient Database (KID), collected between in 2016 and 2019, was queried using International Classification of Disease 10th edition (ICD10) codes for patients with traumatic brain injury who had received a tracheostomy. Baseline demographics, insurance status, and procedural day data were analyzed with univariate and multivariate regression analyses. Propensity score matching was performed to estimate the incidence of medical complications and mortality related to early versus late tracheostomy timing (as defined by median = 9 days). RESULTS Of the 68,793 patients (mean age = 14, IQR 4-18) who suffered a TBI, 1,956 (2.8%) received a tracheostomy during their hospital stay. TBI patients who were tracheostomized were older (mean age = 16.5 vs 11.4 years), more likely to have injuries classified as severe TBIs and more likely to have accumulated more than one indicator of parenchymal injury as measured by the Composite Stroke Severity Scale (CSSS >1) than non-tracheostomized TBI patients. TBI patients with a tracheostomy were more likely to encounter serious complications such as sepsis, acute kidney injury (AKI), meningitis, or acute respiratory distress syndrome (ARDS). They were also more likely to necessitate an external ventricular drain (EVD) or decompressive hemicraniectomy (DHC) than TBI patients without a tracheostomy. Tracheostomy was also negatively associated with routine discharge. Procedural timing was assessed in 1,867 patients; older children (age >15 years) were more likely to undergo earlier placements (p < 0.001). Propensity score matching (PSM) comparing early versus late placement was completed by controlling for age, gender, and TBI severity. Those who were subjected to late tracheostomy (>9 days) were more likely to face complications such as AKI or deep vein thrombosis (DVT) as well as a host of respiratory conditions such as pulmonary embolism, aspiration pneumonitis, pneumonia, or ARDS. While the timing did not significantly impact mortality across the PSM cohorts, late tracheostomy was associated with increased length of stay (LOS) and ventilator dependence. CONCLUSIONS Tracheostomy, while necessary for some patients who have sustained a TBI, is itself associated with several risks that should be assessed in context of each individual patient's overall condition. Additionally, the timing of the intervention may significantly impact the trajectory of the patient's recovery. Early intervention may reduce the incidence of serious complications as well as length of stay and dependence on a ventilator and facilitate a timelier recovery.
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Affiliation(s)
- Irim Salik
- Department of Anesthesiology, Westchester Medical Center, Valhalla, NY, 10595, USA.
| | - Ankita Das
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | | | - Sima Vazquez
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Eris Spirollari
- New York Medical College School of Medicine, Valhalla, NY, 10595, USA
| | - Jose F Dominguez
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Vishad Sukul
- Department of Neurosurgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Dylan Stewart
- Department of Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
| | - Augustine Moscatello
- Department of Otolaryngology/Head and Neck Surgery, Westchester Medical Center, Valhalla, NY, 10595, USA
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Selvakumar S, Chan K, Ngatuvai M, Newsome K, Ang D, Bilski T, Elkbuli A. Timing of tracheostomy in patients with severe traumatic brain injuries: The need for tailored practice management guidelines. Injury 2022; 53:2717-2724. [PMID: 35768327 DOI: 10.1016/j.injury.2022.06.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2022] [Revised: 06/01/2022] [Accepted: 06/20/2022] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Traumatic brain injury (TBI) is one of the leading causes of fatal trauma, and patients often require prolonged ventilation and tracheostomy. There are currently no standardized guidelines regarding the optimal timing of tracheostomy placement for mechanically ventilated patients with severe TBI. This review aims to investigate the impact of tracheostomy timing on the clinical outcomes in patients with severe TBI. METHODS A literature search was conducted according to PRISMA 2020 guidelines. PubMed, Google Scholar, EMBASE, MedLine, Web of Science, Cochrane, and CINAHL were searched for studies evaluating the impact of early versus late tracheostomy on TBI patient outcomes. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Newcastle-Ottawa Scale (NOS) were used for quality of evidence and risk of bias assessment, respectively. RESULTS A total of nine studies met eligibility criteria. All nine studies investigated tracheostomy timing in severe TBI patients and demonstrated that early tracheostomy is associated with decreased ICU length-of-stay (LOS) and increased ventilator free-days compared to late tracheostomy. CONCLUSION Current evidence suggests that patients with severe TBI following traumatic injury may benefit from an early tracheostomy due to improved clinical outcomes, including decreased MV duration and ICU-LOS, compared to late tracheostomy. Further multi-institutional studies are needed to develop evidence-based guidelines.
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Affiliation(s)
| | - Kelvin Chan
- NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Micah Ngatuvai
- NSU NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Kevin Newsome
- Florida International University, Herbert Wertheim College of Medicine, Miami, FL, USA
| | - Darwin Ang
- Department of Surgery, Ocala Regional Medical Center, Ocala, FL, USA
| | - Tracy Bilski
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA; Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA.
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Sachdev A, Gupta N, Singh BP, Choudhari ND, Sharma N, Gupta S, Gupta D, Chugh P. Indication-based timing of tracheostomy and its effects on outcome in the pediatric intensive care unit. Pediatr Pulmonol 2022; 57:1684-1692. [PMID: 35506424 DOI: 10.1002/ppul.25952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 04/24/2022] [Accepted: 05/01/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of study was to find an association between the timing of tracheostomy with duration of mechanical ventilation (MV) and length of stay (LOS) in pediatric intensive care unit (PICU) and hospital. METHODS The data were collected prospectively from 2000 to 2018 and were analyzed retrospectively. Data included clinical diagnosis, indication, and duration (days) of MV, LOS in PICU and hospital before and after tracheostomy. Patients who did not receive MV or underwent MV for <24 h were excluded. According to the indication of tracheostomy enrolled patients were divided into four groups-airways anomalies (AA), central neurological impairment (CNI), cardiopulmonary insufficiency (CPI), and neuromuscular disorders (NMD). Patients in each group were divided into early (ET) and late tracheostomy (LT) category based on the median (interquartile range interquartile range [IQR]) days of pretracheostomy MV. RESULTS Two hundred and fifty six patients were analyzed. The frequency and median [IQR] days of pretracheostomy MV were -AA 54 [7(3,16)], CNI 120 [12(9,16)], CPI 51 [25(16.5,30.5)], and NMD 31[12(8,16.5)]. In AA patients, median (IQR) durations of posttracheostomy MV [2(1,5.2) versus 3.5(2,12); p = 0.032], PICU [7(5,8.2) versus11(7,18); p = 0.004] and hospital [12(9.7,21) versus 21.5(12,28); p = 0.027] stays were lower in ET as compared with LT group. Posttracheostomy MV duration was significantly short in ET patients with CNI and NMD (p < 0.005). The total days of MV, PICU and hospital stay were significantly lower in ET as compared with LT patients in all four groups (p < 0.01). CONCLUSION As compared with LT, ET patient had shorter durations of total MV and PICU and hospital stay.
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Affiliation(s)
- Anil Sachdev
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Neeraj Gupta
- Department of Pediatrics, Sir Ganga Ram Hospital, New Delhi, India
| | - Bhanu P Singh
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Nilay D Choudhari
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Nikhil Sharma
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Suresh Gupta
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Dhiren Gupta
- Department of Pediatrics, Institute of Child Health, Sir Ganga Ram Hospital, New Delhi, India
| | - Parul Chugh
- Department of Research, Sir Ganga Ram Hospital, New Delhi, India
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Mubashir T, Lai H, Oduguwa E, Chaudhry R, Balogh J, Williams GW, Maroufy V. Effect of tracheostomy timing on outcomes in patients with traumatic brain injury. Proc AMIA Symp 2022; 35:621-628. [DOI: 10.1080/08998280.2022.2084780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Talha Mubashir
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Hongyin Lai
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Emmanuella Oduguwa
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Rabail Chaudhry
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Julius Balogh
- Department of Anesthesiology and Critical Care, University of Arkansas Medical Center, Little Rock, Arkansas
| | - George W. Williams
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Vahed Maroufy
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
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Hallan DR, Simion C, Rizk E. Early Versus Late Tracheostomy in Spontaneous Intracerebral Hemorrhage. Cureus 2022; 14:e24059. [PMID: 35573583 PMCID: PMC9097938 DOI: 10.7759/cureus.24059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2022] [Accepted: 04/12/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Recent literature supports early tracheostomy (<=7 days) over delayed tracheostomy (>7 days-3 months) to improve overall clinical outcomes for patients admitted with an acute head injury. There is conflicting evidence for the same in hemorrhagic stroke. Using a multi-institutional database, we explored this question in nontraumatic spontaneous intracerebral hemorrhage (sICH) patients. METHODS We used a de-identified database network (TriNetX's Research Network) to gather information on early tracheostomy (<=7 days) and late tracheostomy (>7d-3 months) in sICH patients. After accounting for the most common comorbidities, we explored the impact of this intervention on multiple patient outcomes including intensive care unit (ICU) length of stay, pneumonia, and mortality at 30, 90, and 365 days. RESULTS After propensity score matching, a total of 1210 patients were identified for both early tracheostomy (cohort 1) and late tracheostomy (cohort 2) cohorts. The 30-day survival rate was 0.9287 in cohort 1 vs 0.9536 in cohort 2, with a risk difference of 2.39% (95% confidence interval (CI) 0.557%-4.23%; relative risk (RR) 1.54, 95% CI (1.10-2.15); OR 1.577, 95% CI (1.11-2.24); p = 0.006). The 90-day and 365-day end-point survival rates were not statistically different between cohorts. ICU level of care codes were billed an average of 9.76 (SD 8.964) times in cohort 1 vs 14.618 (SD 11.851) in cohort 2 (p<0.0001). At 365 days, there were no differences between the two groups for pulmonary embolism, myocardial infarction, deep venous thrombosis, palliative care consultation, and percutaneous endoscopic gastrostomy tube placement. Cohort 1 had decreased incidence of pneumonia with 665 (54.95%) patients compared to cohort 2 with 725 (59.91%) (RR 0.917, 95% CI (0.856-0.983), OR 0.816, 95% CI (0.695-0.95), p = 0.013). CONCLUSION Early tracheostomy in sICH patients was associated with decreased pneumonia risk, decreased length of ICU care, and no difference in mortality at 90 and 365 days.
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Affiliation(s)
- David R Hallan
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Christopher Simion
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
| | - Elias Rizk
- Neurosurgery, Penn State Health Milton S. Hershey Medical Center, Hershey, USA
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Neurosurgical intensive care medicine : Intensive medical care studies from 2020/2021]. Anaesthesist 2021; 70:789-794. [PMID: 34378066 DOI: 10.1007/s00101-021-00978-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- C Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland.
| | - M Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - T Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - M Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - C J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - D Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - C Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Marra A, Vargas M, Buonanno P, Iacovazzo C, Coviello A, Servillo G. Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis. J Clin Med 2021; 10:jcm10153319. [PMID: 34362103 PMCID: PMC8348593 DOI: 10.3390/jcm10153319] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Revised: 07/23/2021] [Accepted: 07/26/2021] [Indexed: 12/17/2022] Open
Abstract
Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle–Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality.
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Butler EK, Killien EY, Groner JI, Arbabi S, Vavilala MS, Rivara FP. Optimal Timing of Tracheostomy in Injured Adolescents. Pediatr Crit Care Med 2021; 22:629-641. [PMID: 34192728 PMCID: PMC8259766 DOI: 10.1097/pcc.0000000000002681] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To evaluate the optimal timing of tracheostomy for injured adolescents. DESIGN Retrospective cohort study. SETTING Trauma facilities in the United States. PATIENTS Adolescents (age 12-17 yr) in the National Trauma Data Bank (2007-2016) who were ventilated for greater than 24 hours and survived to discharge. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS After stratifying by traumatic brain injury diagnosis, we compared ICU and hospital length of stay, pneumonia, and discharge disposition of patients with tracheostomy prior to three cut points (3, 7, and 14 d after admission) to 1) patients intubated at least as long as each cut point and 2) patients with tracheostomy on or after each cut point. Of 11,045 patients, 1,391 (12.6%) underwent tracheostomy. Median time to tracheostomy was 9 days (interquartile range, 6-13 d) for traumatic brain injury and 7 days (interquartile range, 3-12 d) for nontraumatic brain injury patients. Nontraumatic brain injury patients with tracheostomy prior to 7 days had 5.6 fewer ICU days (-7.8 to -3.5 d) and 5.7 fewer hospital days (-8.8 to -2.7 d) than patients intubated greater than or equal to 7 days and had 14.8 fewer ICU days (-19.6 to -10.0 d) and 15.3 fewer hospital days (-21.7 to -8.9 d) than patients with tracheostomy greater than or equal to 7 days. Similar differences were observed at 14 days but not at 3 days for both traumatic brain injury and nontraumatic brain injury patients. At the 3- and 7-day cut points, both traumatic brain injury and nontraumatic brain injury patients with tracheostomy prior to the cut point had lower risk of pneumonia and risk of discharge to a facility than those with tracheostomy after the cut point. CONCLUSIONS For injured adolescents, tracheostomy less than 7 days after admission was associated with improved in-hospital outcomes compared with those who remained intubated greater than or equal to 7 days and with those with tracheostomy greater than or equal to 7 days. Tracheostomy between 3 and 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated; however, unmeasured consequences of tracheostomy such as long-term complications and care needs must also be considered.
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Affiliation(s)
- Elissa K. Butler
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
- Department of Surgery, SUNY Upstate Medical University, 750 E Adams St, Syracuse, NY 13210 USA
| | - Elizabeth Y. Killien
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
| | - Jonathan I. Groner
- Center for Pediatric Trauma Research and Department of Pediatric Surgery, Nationwide Children’s Hospital, 700 Children’s Drive, Columbus, OH 43205 USA
| | - Saman Arbabi
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Surgery, University of Washington, 1959 NE Pacific Street, WA 98195 USA
| | - Monica S. Vavilala
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Department of Anesthesiology & Pain Medicine, University of Washington, 1959 NE Pacific St, Seattle, WA 98195 USA
| | - Frederick P. Rivara
- Harborview Injury Prevention & Research Center, University of Washington, 325 9 Ave Box 359960, Seattle, WA 98122 USA
- Division of General Pediatrics, Department of Pediatrics, University of Washington and Seattle Children’s Hospital, 4800 Sand Point Way NE, Seattle, WA 98105 USA
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Early Tracheostomy in Severe Traumatic Brain Injury Patients: A Meta-Analysis and Comparison With Late Tracheostomy. Crit Care Med 2021; 48:e325-e331. [PMID: 32205623 DOI: 10.1097/ccm.0000000000004239] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES To elucidate the impact of early tracheostomy on hospitalization outcomes in patients with traumatic brain injury. DATA SOURCES Lilacs, PubMed, and Cochrane databases were searched. The close-out date was August 8, 2018. STUDY SELECTION Studies written in English, French, Spanish, or Portuguese with traumatic brain injury as the base trauma, clearly formulated question, patient's admission assessment, minimum follow-up during hospital stay, and minimum of two in-hospital outcomes were selected. Retrospective studies, prospective analyses, and case series were included. Studies without full reports or abstract, commentaries, editorials, and reviews were excluded. DATA EXTRACTION The study design, year, patient's demographics, mean time between admission and tracheostomy, neurologic assessment at admission, confirmed ventilator-assisted pneumonia, median ICU stay, median hospital stay, mortality rates, and ICU and hospital costs were extracted. DATA SYNTHESIS A total of 4,219 studies were retrieved and screened. Eight studies were selected for the systematic review; of these, seven were eligible for the meta-analysis. Comparative analyses were performed between the early tracheostomy and late tracheostomy groups. Mean time for early tracheostomy and late tracheostomy procedures was 5.59 days (SD, 0.34 d) and 11.8 days (SD, 0.81 d), respectively. Meta-analysis revealed that early tracheostomy was associated with shorter mechanical ventilation duration (-4.15 [95% CI, -6.30 to -1.99]) as well as ICU (-5.87 d [95% CI, -8.74 to -3.00 d]) and hospital (-6.68 d [95% CI, -8.03 to -5.32 d]) stay durations when compared with late tracheostomy. Early tracheostomy presented less risk difference for ventilator-associated pneumonia (risk difference, 0.78; 95% CI, 0.70-0.88). No statistical difference in mortality was found between the groups. CONCLUSIONS The findings from this meta-analysis suggest that early tracheostomy in severe traumatic brain injury patients contributes to a lower exposure to secondary insults and nosocomial adverse events, increasing the opportunity of patient's early rehabilitation and discharge.
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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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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: 31] [Impact Index Per Article: 7.8] [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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Development of clinical tracheostomy score to identify cervical spinal cord injury patients requiring prolonged ventilator support. J Trauma Acute Care Surg 2020; 87:195-199. [PMID: 30939580 DOI: 10.1097/ta.0000000000002286] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Cervical spinal cord injuries often necessitate ventilator support (VS). Prolonged endotracheal tube use has conveyed substantial morbidity in prospective study. Tracheostomy is recommended if VS is anticipated to be 7 days or longer, which defines prolonged ventilation (PV). Identifying these patients on arrival and before tracheostomy need is readily evident could prevent morbidity while lowering hospital costs. We aimed to create a tracheostomy score (trach score) to identify patients requiring PV and who could benefit from immediate tracheostomy. METHODS A review of patients with cervical spine fractures and cervical spinal cord injuries from 2005 to 2017 from the Pennsylvania Trauma Outcome Study database was performed. Patients were excluded for missing data, no use of VS or death in less than 7 days. Patients were selected for a training set or validation set by state identification number. We used automated forward stepwise selection to select a logistic model. Significant continuous variables were dichotomized to create a simplified screening score (trach score) and this was applied to the validation set. RESULTS Needing ventilation for 7 or more days was positively associated with higher Injury Severity Scores having a complete or anterior injury, and having a motor cord injury from C1 to C4. Application of the logistic model to the validation data produced a receiver operating characteristic curve with area under the curve of 0.7712, with 95% confidence limit (CL) of 0.6943 to 0.8481. The validation receiver operating characteristic curve was statistically better than chance using a contrast test with χ with p value less than 0.01. In the validation set, a trach score of 0 correlated to 33% needing PV, a score of 1 with 67% needing PV, 2 with 85%, and 3 with 98%. CONCLUSION Use of the trach score identified the majority of patients requiring prolonged VS in our study. An early tracheostomy protocol using predictive modeling could aid in reduction of intensive care unit length of stay and improving ventilator weaning in these patients. External verification of this predictive tool and of an early tracheostomy protocol is needed. LEVEL OF EVIDENCE This work is a retrospective prognostic cohort study and meets evidence Level III criteria.
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15
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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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17
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Sheehan BM, Grigorian A, Gambhir S, Maithel S, Kuza CM, Dolich MO, Lekawa ME, Nahmias J. Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days. J Intensive Care Med 2019; 35:1346-1351. [PMID: 31455142 DOI: 10.1177/0885066619870153] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. DESIGN Retrospective cohort analysis. SETTING The Pediatric Trauma Quality Improvement Program (TQIP) database. PATIENTS One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. INTERVENTIONS Not applicable. MEASUREMENTS AND MAIN RESULTS The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. CONCLUSION Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. ARTICLE TWEET Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.
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Affiliation(s)
- Brian M Sheehan
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Areg Grigorian
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Sahil Gambhir
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Shelley Maithel
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Catherine M Kuza
- Department of Anesthesia, 5116University of Southern California, Los Angeles, CA, USA
| | - Matthew O Dolich
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Michael E Lekawa
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
| | - Jeffry Nahmias
- Division of Trauma, Burns and Surgical Critical Care, Department of Surgery, 8788University of California, Irvine, Orange, CA, USA
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Kieninger M, Windorfer M, Eissnert C, Zech N, Bele S, Zeman F, Bründl E, Graf B, Künzig H. Impact of bedside percutaneous dilational and open surgical tracheostomy on intracranial pressure, pulmonary gas exchange, and hemodynamics in neurocritical care patients. Medicine (Baltimore) 2019; 98:e17011. [PMID: 31464959 PMCID: PMC6736110 DOI: 10.1097/md.0000000000017011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aim was to compare the impact of bedside percutaneous dilational tracheostomy (PDT) and open surgical technique (ST) on intracranial pressure (ICP), pulmonary gas exchange and hemodynamics.We retrospectively analyzed data of 92 neurocritical care patients with invasive ICP monitoring during either PDT (43 patients) or ST (49 patients).Peak ICP levels were higher during PDT (22 [17-38] mm Hg vs 19 [13-27] mm Hg, P = .029). Mean oxygen saturation (SpO2) and end-tidal carbon dioxide partial pressure (etCO2) did not differ. Episodes with relevant desaturation (SpO2 < 90%) or hypercapnia (etCO2 > 50 mm Hg) occurred rarely (5/49 during ST vs 3/43 during PDT for SpO2 < 90%; 2/49 during ST vs 5/43 during PDT for hypercapnia). Drops in mean arterial pressure (MAP) below 60 mm Hg were seen more often during PDT (8/43 vs 2/49, P = .026). Mean infusion rate of norepinephrine did not differ (0.52 mg/h during ST vs 0.45 mg/h during PDT). No fatal complications were observed.Tracheostomy can be performed as ST and PDT safely in neurocritical care patients. The impact on ICP, pulmonary gas exchange and hemodynamics remains within an unproblematic range.
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Affiliation(s)
| | | | | | | | | | - Florian Zeman
- Centre for Clinical Studies, University Hospital Regensburg, Germany
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19
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The Timing of Tracheostomy and Outcomes After Aneurysmal Subarachnoid Hemorrhage: A Nationwide Inpatient Sample Analysis. Neurocrit Care 2018; 29:326-335. [DOI: 10.1007/s12028-018-0619-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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20
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Adly A, Youssef TA, El-Begermy MM, Younis HM. Timing of tracheostomy in patients with prolonged endotracheal intubation: a systematic review. Eur Arch Otorhinolaryngol 2017; 275:679-690. [PMID: 29255970 DOI: 10.1007/s00405-017-4838-7] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 12/01/2017] [Indexed: 02/07/2023]
Abstract
The objective of this article is to evaluate the appropriate timing of tracheostomy in patients with prolonged intubationregarding the incidence of hospital-acquired pneumonia, mortality, length of stay in intensive care unit (ICU) and duration of artificial ventilation. The study included published articles yielded by a search concerning timing of tracheostomy in adult and pediatric patients with prolonged intubation. The search was limited to articles published in English language in the last 30 years (between 1987 and 2017). For the 690 relevant articles, we applied our inclusion and exclusion criteria and only 43 articles were included. 41 studies in the adult age group including 222,501 patients and 2 studies in pediatric age group including 140 patients met our criteria. Studies in adult age group were divided into three groups according to the methodology of determining the cut off timing for early tracheostomy, they were divided into studies that considered early tracheostomy within the first 7, 14 or 21 days of endotracheal intubation, while in pediatric age group the cut off timing for early tracheostomy was within the first 7 days of endotracheal intubation. There was a significant difference in favor of early tracheostomy in adults' three groups and pediatric age group as early tracheostomy was superior regarding reduced duration of mechanical ventilation, with less mortality rates and less duration of stay in ICU. Regarding hospital-acquired pneumonia, it was significantly less in adult groups but with no significant difference in pediatric age group (3 patients out of 72 pediatric patient with early tracheostomy had pneumonia compared to 11 patients out of 68 with late tracheostomy). Studies defining early tracheostomy as that done within 7 days of intubation had better results than those defining early tracheostomy as that done within 14 or 21 days of intubation. In conclusion, early tracheostomy within 7 days of intubation should be done for both adults and pediatric patients with prolonged intubation.
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Affiliation(s)
- Ahmed Adly
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
| | - Tamer Ali Youssef
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt.
| | - Marwa M El-Begermy
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
| | - Hussein M Younis
- Department of Otolaryngology, Ain Shams University, 36 Ismail Whaba Street, Naser City, District 9, Cairo, Egypt
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Cai SQ, Hu JW, Liu D, Bai XJ, Xie J, Chen JJ, Yang F, Liu T. The influence of tracheostomy timing on outcomes in trauma patients: A meta-analysis. Injury 2017; 48:866-873. [PMID: 28284468 DOI: 10.1016/j.injury.2017.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aims to assess the influence of tracheostomy timing on outcomes among trauma patients, including mortality, medical resource utility and incidence of pneumonia. METHOD A systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes in trauma patients with early tracheostomy (ET) or late tracheostomy (LT)/prolonged intubation (PI). RESULT 20 studies met our inclusion criteria with 3305 patients in ET group and 4446 patients in LT/PI group. Pooled data revealed that mortality was not lower in trauma patients with ET compared to those with LT/IP. However, ET was found to be associated with a significantly reduced length of ICU and hospital stay, shorter MV duration and lower risk of pneumonia. CONCLUSION Evidence of this meta-analysis supports the dimorphism in some clinical outcomes of trauma patients with different tracheostomy timing. Additional well-designed randomized controlled trials (RCTs) are needed to confirm it in future.
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Affiliation(s)
- Shi-Qi Cai
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jun-Wu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Dong Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Xiang-Jun Bai
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jia-Jun Chen
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Fan Yang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Tao Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
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Khalili H, Paydar S, Safari R, Arasteh P, Niakan A, Abolhasani Foroughi A. Experience with Traumatic Brain Injury: Is Early Tracheostomy Associated with Better Prognosis? World Neurosurg 2017; 103:88-93. [PMID: 28254541 DOI: 10.1016/j.wneu.2017.02.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE In this study we compared the effects of early tracheostomy (ET) versus late tracheostomy on traumatic brain injury (TBI)-related outcomes and prognosis. PATIENTS AND METHODS Data on 152 TBI patients with a Glasgow Coma Scale (GCS) score of ≤8, admitted to Rajaee Hospital between March 1, 2014 and August 23, 2015, were collected. Rajaee Hospital is the main referral trauma center in southern Iran and is affiliated with Shiraz University of Medical Sciences. Patients who had tracheostomy before or at the sixth day of their admission were considered as ET, and those who had tracheostomy after the sixth day of admission were considered as late tracheostomy. RESULTS Patients with ET had a significantly lower hospital stay (46.4 vs. 38.6 days; P = 0.048) and intensive care unit stay (34.9 vs. 26.7 days; P = 0.003). Mortality rates were not significantly different between the 2 groups (P > 0.99). Although not statistically significant, favorable outcomes (Glasgow Outcome Scale >4) were higher and ventilator-associated pneumonia rates were lower among the ET group (P = 0.346 and P = 492, respectively). Multivariate analysis showed that ET significantly improves 6-month prognosis (Glasgow Outcome Scale >4) (odds ratio = 2.535; 95% confidence interval: 1.030-6.237). Higher age was inversely associated with favorable prognosis (odds ratio = -0.958; confidence interval: 0.936-0.981). Glasgow Coma Scale and Rotterdam score did not show any effect on 6-month prognosis. CONCLUSION Despite previous concern regarding increased mortality rates among patients who undergo ET, performing a tracheostomy for patients with severe TBI <6 days after their hospital admission, in addition to decreasing hospital and intensive care unit stays, will improve patient prognosis.
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Affiliation(s)
- Hosseinali Khalili
- Shiraz Trauma Research Center, Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Rasool Safari
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Arasteh
- Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Non-communicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran.
| | - Amin Niakan
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Abolhasani Foroughi
- Medical Imaging Research Center, Department of Radiology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Zirpe KG, Tambe DV, Deshmukh AM, Gurav SK. The Impact of Early Tracheostomy in Neurotrauma Patients: A Retrospective Study. Indian J Crit Care Med 2017; 21:6-10. [PMID: 28197044 PMCID: PMC5278595 DOI: 10.4103/0972-5229.198309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Although majority of neurotrauma patients require long term ventilatory support but the timing of tracheostomy in such patients is controversial. METHOD This retrospective study was conducted at a Tertiary Care Hospital, Pune, India. Patients >18 years of age, who underwent percutaneous tracheostomy (PCT) from June 2010 to November 2014 at neurotrauma unit (NTU) of hospital, were included. Patients were divided in two groups according to the timing of tracheostomy, early tracheostomy (ET) group (≤5 days; N=100) and late tracheostomy (LT) group (>5 days; N=64). The nonparametric Mann-Whitney test, and Chi-square tests were used to compare these groups. RESULT There were no significant differences between the groups in terms of age, sex, APACHE II and GCS Score. Patients in the ET group had a significantly shorter stay in the NTU compared to patients in the LT group (mean, 18 vs. 21.2 days, p=0.005), fewer mechanical ventilation days (mean, 8.1 vs. 11.7 days, P=0.000) and shorter length of stay in hospital (mean, 28.8 vs. 34.37 days, P=0.019). There was no difference between ET and LT groups in post PCT ventilator free days (mean, 8.2 vs. 9.4 days; P=0.094). Mortality rates in ET vs. LT groups were also comparable (35% vs. 29.7%; P=0.480). CONCLUSION Results suggest that ET in neurotrauma patients might be associated with shorter length of stay in NTU and hospital, and shorter duration of mechanical ventilation however there was no mortality difference.
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Affiliation(s)
- Kapil G. Zirpe
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
| | | | | | - Sushma K. Gurav
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
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Abstract
Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system. Neurologic injury includes traumatic brain injury, hemorrhage, stroke, and seizures, and in each there are far-reaching effects that can result in pulmonary dysfunction. Systemic changes can induce impairment of pulmonary function due to changes in the core structure and function of the lung. The conditions and disorders that often occur in these patients include aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome, but also several abnormal respiratory patterns and sleep-disordered breathing. Lung infections, pulmonary edema - neurogenic or cardiogenic - and pulmonary embolus all are a serious barrier to recovery and can have significant effects on outcomes such as hospital course, prognosis, and mortality. This review presents the spectrum of pulmonary abnormalities seen in neurocritical care.
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Humble SS, Wilson LD, McKenna JW, Leath TC, Song Y, Davidson MA, Ehrenfeld JM, Guillamondegui OD, Pandharipande PP, Patel MB. Tracheostomy risk factors and outcomes after severe traumatic brain injury. Brain Inj 2016; 30:1642-1647. [PMID: 27740854 DOI: 10.1080/02699052.2016.1199915] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE To determine risk factors associated with tracheostomy placement after severe traumatic brain injury (TBI) and subsequent outcomes among those who did and did not receive a tracheostomy. METHODS This retrospective cohort study compared adult trauma patients with severe TBI (n = 583) who did and did not receive tracheostomy. A multivariable logistic regression model assessed the associations between age, sex, race, insurance status, admission GCS, AIS (Head, Face, Chest) and tracheostomy placement. Ordinal logistic regression models assessed tracheostomy's influence on ventilator days and ICU LOS. To limit immortal time bias, Cox proportional hazards models assessed mortality at 1, 3 and 12-months. RESULTS In this multivariable model, younger age and private insurance were associated with increased probability of tracheostomy. AIS, ISS, GCS, race and sex were not risk factors for tracheostomy placement. Age showed a non-linear relationship with tracheostomy placement; likelihood peaked in the fourth decade and declined with age. Compared to uninsured patients, privately insured patients had an increased probability of receiving a tracheostomy (OR = 1.89 [95% CI = 1.09-3.23]). Mortality was higher in those without tracheostomy placement (HR = 4.92 [95% CI = 3.49-6.93]). Abbreviated injury scale-Head was an independent factor for time to death (HR = 2.53 [95% CI = 2.00-3.19]), but age, gender and insurance were not. CONCLUSIONS Age and insurance status are independently associated with tracheostomy placement, but not with mortality after severe TBI. Tracheostomy placement is associated with increased survival after severe TBI.
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Affiliation(s)
- Stephen S Humble
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Laura D Wilson
- b Department of Hearing and Speech Sciences , Vanderbilt University School of Medicine , Nashville , TN , USA.,c Department of Communication Sciences and Disorders , University of Tulsa , Tulsa , OK , USA
| | - John W McKenna
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Taylor C Leath
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | | | | | - Jesse M Ehrenfeld
- e Departments of Anesthesiology , Surgery, and Biomedical Informatics, Vanderbilt University School of Medicine , Nashville , TN , USA
| | - Oscar D Guillamondegui
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA
| | - Pratik P Pandharipande
- e Departments of Anesthesiology , Surgery, and Biomedical Informatics, Vanderbilt University School of Medicine , Nashville , TN , USA.,f Veterans Affairs (VA) Tennessee Valley Healthcare System , Nashville VA Medical Center , Nashville , TN , USA
| | - Mayur B Patel
- a Departments of Surgery and Neurosurgery, Division of Trauma & Surgical Critical Care , Vanderbilt University Medical Center , Nashville , TN , USA.,b Department of Hearing and Speech Sciences , Vanderbilt University School of Medicine , Nashville , TN , USA.,f Veterans Affairs (VA) Tennessee Valley Healthcare System , Nashville VA Medical Center , Nashville , TN , USA
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Effect of Early Versus Late Tracheostomy or Prolonged Intubation in Critically Ill Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2016; 26:14-25. [DOI: 10.1007/s12028-016-0297-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Tracheostomy is associated with decreased hospital mortality after moderate or severe isolated traumatic brain injury. Wien Klin Wochenschr 2016; 128:397-403. [PMID: 27220338 PMCID: PMC4916187 DOI: 10.1007/s00508-016-1004-y] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Accepted: 03/22/2016] [Indexed: 12/18/2022]
Abstract
Background Data regarding the impact and timing of tracheostomy in patients with isolated traumatic brain injury (TBI) are ambiguous. Our goal was to evaluate the impact of tracheostomy on hospital mortality in patients with moderate or severe isolated TBI. Materials and Methods We performed a retrospective cohort analysis of data prospectively collected at 87 Austrian intensive care units (ICUs). All patients continuously admitted between 1998 and 2010 were evaluated for the study. In total, 4,735 patients were admitted to ICUs with isolated TBI. Of these patients, 2,156 had a moderate or severe TBI (1,603 patients were endotracheally intubated only, 553 patients underwent tracheostomy). Epidemiological data (trauma severity, treatment, and outcome) of the two groups were compared. Results Patients with moderate or severe isolated TBI undergoing tracheostomy had a similar Glasgow Coma Scale score, median (interquartile range): 6 (3–8) vs 6 (3–8); p = 0.90, and Simplified Acute Physiology Score II, 45 (37–54) vs 45 (35–56); p = 0.86, compared with intubated patients not undergoing tracheostomy. Furthermore, patients undergoing tracheostomy exhibited higher Abbreviated Injury Scale Head scores and had a longer ICU stay for survivors, 30 (22–42) vs 9 (3–17) days; p < 0.0001). In contrast, risk-adjusted mortality was lower in patients undergoing tracheostomy compared with patients who remained intubated, observed-to-expected mortality ratio (95 % confidence interval): 0.62 (0.53–0.72) vs 1.00 (0.95–1.05) respectively. Conclusions Despite the greater severity of head injury, patients with isolated TBI who underwent tracheostomy had a lower risk-adjusted mortality than patients who remained intubated. Reasons for this difference in outcome may be multifactorial and require further investigation.
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Shaw JJ, Santry HP. Who Gets Early Tracheostomy?: Evidence of Unequal Treatment at 185 Academic Medical Centers. Chest 2016; 148:1242-1250. [PMID: 26313324 DOI: 10.1378/chest.15-0576] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Although the benefits of early tracheostomy in patients dependent on ventilators are well established, the reasons for variation in time from intubation to tracheostomy remain unclear. We identified clinical and demographic disparities in time to tracheostomy. METHODS We performed a level 3 retrospective prognostic study by querying the University HealthSystem Consortium (2007-2010) for adult patients receiving a tracheostomy after initial intubation. Time to tracheostomy was designated early (< 7 days) or late (> 10 days). Cohorts were stratified by time to tracheostomy and compared using univariate tests of association and multivariable adjusted models. RESULTS A total of 49,191 patients underwent tracheostomy after initial intubation: 42% early (n = 21,029) and 58% late (n = 28,162). On both univariate and multivariable analyses, women, blacks, Hispanics, and patients receiving Medicaid were less likely to receive an early tracheostomy. Patients in the early group also experienced lower rates of mortality (OR, 0.84; 95% CI, 0.79-0.88). CONCLUSIONS Early tracheostomy was associated with increased survival. Yet, there were still significant disparities in time to tracheostomy according to sex, race, and type of insurance. Application of evidence-based algorithms for tracheostomy may reduce unequal treatment and improve overall mortality rates. Additional research into this apparent bias in referral/rendering of tracheostomy is needed.
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Affiliation(s)
- Joshua J Shaw
- Department of Surgery and the Center for Outcomes Research-Surgical Research Scholars Program, University of Massachusetts Medical School, Worcester, MA
| | - Heena P Santry
- Department of Surgery and the Center for Outcomes Research-Surgical Research Scholars Program, University of Massachusetts Medical School, Worcester, MA; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA.
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The Impact of Tracheostomy Timing on Clinical Outcome and Adverse Events in Poor-Grade Subarachnoid Hemorrhage. Crit Care Med 2016; 43:2429-38. [PMID: 26308429 DOI: 10.1097/ccm.0000000000001195] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE The value of optimal timing of tracheostomy in patients with subarachnoid hemorrhage is controversially debated. This study investigates whether early or late tracheostomy is associated with beneficial outcome or reduced rates of adverse events. DESIGN Retrospective observational multicentric on patients prospectively inserted into a database. SETTING Neurologic ICUs of one academic hospital and two secondary hospitals in Germany. PATIENTS Data of all patients admitted to the Goethe University Hospital between 2006 and 2011 with poor-grade subarachnoid hemorrhage were prospectively entered into a database. All patients who underwent tracheostomy were included for analysis. Follow-up was maintained in primary and secondary ICUs. INTERVENTIONS Patients underwent tracheostomy upon expected long-term ventilation. Early tracheostomy was defined as performed on days 1-7 and late tracheostomy on days 8-20 after admission. MEASUREMENT AND MAIN RESULTS We compared 148 consecutive patients admitted with poor-grade (World Federation of Neurosurgical Societies, 3-5) subarachnoid hemorrhage. Early tracheostomy was performed in 39 patients and late tracheostomy in 109 patients. In early versus late tracheostomy groups, no significant differences were observed with regard to ICU mortality (7.7% vs 7.3%; p=0.93) and median modified Rankin Scale after 6 months (3 vs 3; p=0.94). Of the early group, pneumonia developed in 19 patients, whereas in the late group, pneumonia developed in 75 patients (48.7% vs 68.8%; p=0.03; odds ratio, 2.32; 95% CI, 1.1-4.9). Six patients of the early group (15.4%) and 36 patients of the late group (33%) suffered from respiratory adverse event (p=0.04; odds ratio, 2.71; 95% CI, 1.04-7.06). Mechanical ventilation was shorter (17.4 vs 22.3 d; p<0.05) and decannulation occurred earlier (42 vs 54 d; p=0.039) in the early tracheostomy group. CONCLUSIONS Tracheostomy within 7 days of critical care admission is a feasible and safe procedure for patients with poor-grade subarachnoid hemorrhage. Early tracheostomy was not associated with an improvement in mortality or neurologic outcome but associated with fewer respiratory adverse events.
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Abstract
PURPOSE OF REVIEW In recent years, we have begun to better understand how to monitor the injured brain, look for less common complications and importantly, reduce unnecessary and potentially harmful intervention. However, the lack of consensus regarding triggers for intervention, best neuromonitoring techniques and standardization of therapeutic approach is in need of more careful study. This review covers the most recent evidence within this exciting and dynamic field. RECENT FINDINGS The role of intracranial pressure monitoring has been challenged; however, it still remains a cornerstone in the management of the severely brain-injured patient and should be used to compliment other techniques, such as clinical examination and serial imaging.The use of multimodal monitoring continues to be refined and it may be possible to use them to guide novel brain resuscitation techniques, such as the use of exogenous lactate supplementation in the future. SUMMARY Neurocritical care management of traumatic brain injury continues to evolve. However, it is important not to use a 'one-treatment-fits-all' approach, and perhaps look to use targeted therapies to individualize treatment.
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Holscher CM, Stewart CL, Peltz ED, Burlew CC, Moulton SL, Haenel JB, Bensard DD. Early tracheostomy improves outcomes in severely injured children and adolescents. J Pediatr Surg 2014; 49:590-2. [PMID: 24726119 DOI: 10.1016/j.jpedsurg.2013.09.002] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2013] [Revised: 08/03/2013] [Accepted: 09/01/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND Early tracheostomy has been advocated for adult trauma patients to improve outcomes and resource utilization. We hypothesized that timing of tracheostomy for severely injured children would similarly impact outcomes. METHODS Injured children undergoing tracheostomy over a 10-year period (2002-2012) were reviewed. Early tracheostomy was defined as post-injury day ≤ 7. Data were compared using Student's t test, Pearson chi-squared test and Fisher exact test. Statistical significance was set at p<0.05 with 95% confidence intervals. RESULTS During the 10-year study period, 91 patients underwent tracheostomy following injury. Twenty-nine (32%) patients were < 12 years old; of these, 38% received early tracheostomy. Sixty-two (68%) patients were age 13 to 18; of these, 52% underwent early tracheostomy. Patients undergoing early tracheostomy had fewer ventilator days (p=0.003), ICU days (p=0.003), hospital days (p=0.046), and tracheal complications (p=0.03) compared to late tracheostomy. There was no difference in pneumonia (p=0.48) between early and late tracheostomy. CONCLUSION Children undergoing early tracheostomy had improved outcomes compared to those who underwent late tracheostomy. Early tracheostomy should be considered for the severely injured child. SUMMARY Early tracheostomy is advocated for adult trauma patients to improve patient comfort and resource utilization. In a review of 91 pediatric trauma patients undergoing tracheostomy, those undergoing tracheostomy on post-injury day ≤ 7 had fewer ventilator days, ICU days, hospital days, and tracheal complications compared to those undergoing tracheostomy after post-injury day 7.
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Affiliation(s)
| | | | | | - Clay Cothren Burlew
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health Medical Center, Denver, CO, USA
| | - Steven L Moulton
- University of Colorado School of Medicine, Aurora, CO, USA; Children's Hospital Colorado, Aurora, CO, USA
| | | | - Denis D Bensard
- University of Colorado School of Medicine, Aurora, CO, USA; Denver Health Medical Center, Denver, CO, USA.
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Tracheostomy timing in traumatic brain injury: a propensity-matched cohort study. J Trauma Acute Care Surg 2014; 76:70-6; discussion 76-8. [PMID: 24368359 DOI: 10.1097/ta.0b013e3182a8fd6a] [Citation(s) in RCA: 65] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and interventional studies have rarely enrolled patients with isolated TBI. METHODS We included a cohort of adults with isolated TBI who underwent tracheostomy within 1 of 135 participating centers in the American College of Surgeons' Trauma Quality Improvement Program, during 2009 to 2011. Patients were classified as having undergone early tracheostomy (ET, ≤8 days) versus late tracheostomy (>8 days). Outcomes were compared between propensity score-matched groups to reduce confounding by indication. In sensitivity analyses, we used time-dependent proportional hazard regression to address immortal time bias and assessed the association between hospital ET rate and patients' outcome at the hospital level. RESULTS From 1,811 patients, a well-balanced propensity-matched cohort of 1,154 patients was defined. After matching, ET was associated with fewer mechanical ventilation days (median, 10 days vs. 16 days; rate ratio [RR], 0.70; 95% confidence interval [CI], 0.66-0.75), shorter intensive care unit stay (median, 13 days vs. 19 days; RR, 0.70; 95% CI, 0.66-0.75), shorter hospital length of stay (median, 20 days vs. 27 days; RR, 0.80; 95% CI, 0.74-0.86), and lower odds of pneumonia (41.7% vs. 52.7%; odds ratio [OR], 0.64; 95% CI, 0.51-0.80), deep venous thrombosis (8.2% vs. 14.4%; OR, 0.53; 95% CI, 0.37-0.78), and decubitus ulcer (4.0% vs. 8.9%; OR, 0.43; 95% CI, 0.26-0.71) but no significant difference in pulmonary embolism (1.8% vs. 3.3%; OR, 0.52; 95% CI, 0.24-1.10). Hospital mortality was similar between both groups (8.4% vs. 6.8%; OR, 1.25; 95% CI, 0.80-1.96). Results were consistent using several alternate analytic methods. CONCLUSION In this observational study, ET was associated with a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay but not hospital mortality. ET may represent a mechanism to reduce in-hospital morbidity for patients with TBI. LEVEL OF EVIDENCE Therapeutic study, level II.
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Villwock JA, Villwock MR, Deshaies EM. Tracheostomy timing affects stroke recovery. J Stroke Cerebrovasc Dis 2014; 23:1069-72. [PMID: 24555919 DOI: 10.1016/j.jstrokecerebrovasdis.2013.09.008] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/05/2013] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The timing of tracheostomy in stroke patients unable to protect their airway has become a topic of debate. Proponents for early tracheostomy (ET) cite benefits including less ventilation-associated pneumonia, less sedative drug use, shorter length of stay, and reduced mortality in comparison with late tracheostomy (LT). METHODS We examined the timing of tracheostomy on stroke patient outcomes across the United States using the Nationwide Inpatient Sample (2008-2010). Independent samples t tests and chi-squared tests were used to make comparisons between early (≤10 days) and late (11-25 days) tracheostomy. Multivariable models, adjusted for confounding factors, investigated outcome measures. RESULTS In total, 13,165 stroke cases were included in the study (5591 in the ET group and 7574 in the LT group). Patients receiving an ET had a significant reduction in the odds of ventilator-associated pneumonia in comparison with the LT group (OR: .688, P = .026). The length of stay for patients receiving an ET was significantly lower in comparison with the LT group (P < .001) and was associated with an 18% reduction in total hospital costs (P < .001). CONCLUSIONS Early tracheostomy for stroke patients may reduce the incidence of ventilator-associated pneumonia, thereby shortening the hospital stay and lowering total hospital costs. These relationships warrant further investigation in a large prospective multicenter trial.
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Affiliation(s)
- Jennifer A Villwock
- Department of Otolaryngology, SUNY Upstate Medical University, Syracuse, New York
| | - Mark R Villwock
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York
| | - Eric M Deshaies
- Department of Neurosurgery, SUNY Upstate Medical University, Syracuse, New York.
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Abstract
BACKGROUND Patients with cervical spinal cord injury frequently undergo early anterior cervical spine fixation (ACSF) and tracheostomy procedures to reduce further deterioration, to reduce risk of pulmonary complications, and to improve patient mobilization. However, tracheostomy is often delayed because of the risk of cross contamination as a result of the proximity to the ACSF incision site. Currently, there is a paucity of studies evaluating this outcome to determine the safety of early tracheostomy after ACSF. In this study, we have evaluated the outcomes and complications associated with early tracheostomy placement. METHODS We performed a retrospective review of all patients who underwent tracheostomy placement and ACSF during the same hospitalization between 2005 and 2010. A variety of patient and procedural data were collected, including demographics, timing of ACSF and tracheostomy, length of hospitalization, indication for surgery, American Spinal Injuries Association and Glasgow Coma Scale scores on admission, reason for tracheostomy, method of tracheostomy, and complications. RESULTS Of the 1,184 patients who underwent an ACSF, 20 (1.7%) required a postfixation tracheostomy. Tracheostomy was performed at mean (SD) of 6.9 (4.2) days after ACSF, ranging from 0 to 17 days. Although nearly half of all patients underwent postfixation tracheostomy within 6 days, no wound or implant infection was seen to occur in any patient. Ten patients (50%) developed ventilator-associated pneumonia, with most cases occurring before tracheostomy (90% vs. 10%, p < 0.0001). Univariate analysis only revealed late tracheostomy to significantly increase the risk of complications (odds ratio, 9.33; 95% confidence interval, 1.19-73.0; p = 0.033). Analysis of all studies in the literature revealed a 1% cross-infection rate, with no cases involving implant contamination. CONCLUSION Our findings suggest that early tracheostomy can be performed safely after cervical spine fixation surgery, with no patients developing incisional or implant infections. As the risk of cross contamination is only 1%, early tracheostomy should be strongly considered because of its potential benefits. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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