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Li Z, Zhu W, Zhang B, Zhang Y, Li H, Lv B, Zhen Q, Liu L, Liu L, Wu Y, Li S. A novel minimally invasive fixation method for flail chest management in a Canine model: an animal research. J Cardiothorac Surg 2023; 18:359. [PMID: 38098070 PMCID: PMC10722814 DOI: 10.1186/s13019-023-02445-5] [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: 01/16/2023] [Accepted: 11/04/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Multiple rib fractures can lead to flail chest with up to 35% mortality rate due to severe pulmonary complications. Current treatments of flail chest remain controversial. Studies have shown that surgical treatments can improve outcomes and reduce mortality, comparing to non-operative treatments. Current surgical fixation methods focus on stabilization of ribs on the outward facing side, and they require division of intercostal muscles. Damages to surrounding nerves and vessels may lead to chronic pain. This study tests a novel interior fixation method that minimizes neurovascular injuries. METHODS Twelve healthy canines were divided in two surgical operation groups for exterior and interior fixation using titanium metal plates. Osteotomy with oblique fractures was prepared under general anesthesia. Exterior fixation was performed in open surgery. Interior fixation was minimally invasive using custom made tools including a flexible shaft extension screwdriver, solid plate stand, guiding wire loop and metal plates with threaded holes. RESULTS Respiratory and cardiovascular functions (RR, PO2, PCO2, SpO2, and HR) together with body temperature were measured before anesthesia and within 48 h after surgery. The difference in measurements was not statistically significant between the two groups before surgery with P values greater than 0.05. However, the interior group canines had better RR and PO2 values starting from the 24th hour, and better PCO2, SpO2, and HR values starting from the 48th hour. It took longer operation time to complete the minimally invasive interior fixation surgery (P value less than 0.001), but the total blood loss was less than the exterior fixation group (P value less than 0.001). Results also showed that interior group canines suffered less pain, and they had quicker recovery in gastrointestinal and physical mobility. CONCLUSIONS The investigative interior fixation method was safe and effective in rib stabilization on a canine rib fracture model, comparing to the exterior fixation method. The interior fixation was minimally invasive, with less damages to tissues and nerves surrounding the ribs, leading to better postoperative outcomes.
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Affiliation(s)
- Zhe Li
- Department of Thoracic Surgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang City, Hebei, 050000, China
- Department of Thoracic Surgery, Shijiazhuang People's Hospital, No. 365 Jianhua South Street, Shijiazhuang City, Hebei, 050031, China
| | - Weiwei Zhu
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Bing Zhang
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Yaxiao Zhang
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Huixian Li
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Baolei Lv
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Qiang Zhen
- Department of Thoracic Surgery, The First Hospital of Shijiazhuang, No. 36, Fanxi Road, Shijiazhuang City, Hebei, 050011, China
| | - Lin Liu
- Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Lijun Liu
- Department of Thoracic Surgery, Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Yanxin Wu
- Hebei General Hospital, No.348 Heping West Road, Shijiazhuang City, Hebei, 050051, China
| | - Shujun Li
- Department of Thoracic Surgery, The Second Hospital of Hebei Medical University, No. 215 Heping West Road, Shijiazhuang City, Hebei, 050000, China.
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Peng C, Peng L, Yang F, Yu H, Wang P, Cheng C, Zuo W, Li W, Jin Z. Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis. J Cardiothorac Vasc Anesth 2023; 37:2584-2591. [PMID: 36631378 DOI: 10.1053/j.jvca.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models. DESIGN A retrospective observational study. SETTING Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients. INTERVENTIONS An ET versus late tracheostomy (LT). MEASUREMENTS AND MAIN RESULTS Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups. CONCLUSIONS The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Hang Yu
- Emergency Department, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China.
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Timing of Tracheostomy in Critically Ill Infants and Children With Respiratory Failure: A Pediatric Health Information System Study. Pediatr Crit Care Med 2023; 24:e66-e75. [PMID: 36508241 DOI: 10.1097/pcc.0000000000003120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVES Tracheostomy placement in infants and children with respiratory failure has steadily increased over time, yet there is no consensus for optimal timing. We sought to: 1) describe tracheostomy timing and associated demographic and clinical characteristics in a large ICU cohort and 2) compare clinical outcomes between subgroups based on tracheostomy timing. DESIGN Retrospective observational study using the Pediatric Health Information System (PHIS). SETTING Neonatal ICUs and PICUs in the United States. PATIENTS PHIS was queried for patients less than 18 years who underwent tracheostomy from 2010 to 2020. Patients were included if admitted to an ICU with need for mechanical ventilation (MV) prior to tracheostomy in the same hospitalization. Patients were categorized as early tracheostomy (ET) (placement at MV day ≤ 14), late tracheostomy (LT) (MV days 15-60), and extended tracheostomy (ExT) (MV day > 60). Primary endpoints included demographic and clinical characteristics. Secondary endpoints included patient outcomes: in-hospital mortality, length of stay (LOS), hospital-acquired pneumonia (HAP), and hospital costs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Sixteen thousand one hundred twenty-one patients underwent tracheostomy at 52 children's hospitals. Ten thousand two hundred ninety-five had complete data and were included in the analysis. Thirty-nine percent (4,006/10,295) underwent ET, 40% (4,159/10,295) underwent LT, and 21% (2,130/10,295) underwent ExT. Majority of patients in all subgroups had complex chronic conditions. Median age was significantly different between subgroups with ET being the oldest ( p < 0.001). A multivariable regression analysis showed that ET was associated with lower in-hospital mortality ( p < 0.001), shorter hospital LOS ( p < 0.001), shorter ICU LOS ( p < 0.001), shorter post-tracheostomy LOS ( p < 0.001), decreased HAP ( p < 0.001), and lower hospital costs ( p < 0.001) compared with those who underwent LT or ExT. CONCLUSIONS In a large cohort of pediatric patients with respiratory failure, tracheostomy placement within 14 days of MV was associated with improved in-hospital outcomes. ET was independently associated with decreased mortality, LOS, HAP, and hospital costs.
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"Fighting the Minotaur" a Complex Blunt Chest Trauma Due to a Bull Attack: A Case Report. Rom J Anaesth Intensive Care 2022; 28:36-39. [PMID: 36846540 PMCID: PMC9949006 DOI: 10.2478/rjaic-2021-0006] [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: 03/01/2023] Open
Abstract
Bull-related injury continues to contribute to an unacceptable number of serious injuries and deaths, and bullfighting continues to be a popular, deeply traditional celebration of the culture of many Iberic-American countries. Most accidents due to bull attacks are horn-related penetrating traumas. Blunt chest trauma can cause a wide range of clinical presentations and injuries, making the diagnostics and therapies extremely challenging. Consequently, it is vital to quickly identify major life-threatening chest wall and intrathoracic injuries. In this case report, we aimed to describe the complexity of the management and the treatment of a blunt trauma patient hit by a bull.
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Luo B, Chen HX, Song XD, Wang L, Zhao L, Tang XP. Timing of Tracheostomy in Patients with Intracerebral Haemorrhage: A Propensity-Matched Analysis. Curr Neurovasc Res 2022; 19:367-377. [PMID: 36125838 DOI: 10.2174/1567202619666220920122935] [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: 07/17/2022] [Revised: 08/05/2022] [Accepted: 08/12/2022] [Indexed: 11/22/2022]
Abstract
AIMS Although early tracheostomy (ET) is recommended for patients with severe stroke, the optimal timing of tracheostomy for patients with intracerebral haemorrhage (ICH) remains controversial. This study aimed to explore the clinical characteristics, risk factors and timing of tracheostomy in patients after tracheal intubation using a propensity-matched analysis. METHODS We conducted a retrospective database search and assessed 267 consecutive patients who underwent endotracheal intubation (175 of whom underwent tracheostomy) and ICH between July 2017 and June 2021. A logistic regression model was applied to identify the critical factors influencing the decision for tracheostomy by comparing factors in a tracheostomy group and a nontracheostomy group. Patients were divided into an early (≤5 days) or a late (>5 days) group according to the median time of tracheostomy. Propensity score matching was performed to adjust for possible confounders and investigate differences in outcomes between ET and late tracheostomy (LT). RESULTS Among the 267 enrolled patients with ICH and endotracheal intubation, 65.5% received tracheostomy during hospitalisation, and 52.6% received ET. The independent risk factors for tracheostomy included National Institute of Health Stroke Scale (NIHSS) (odds ratio [OR]: 1.179; 95% confidence interval [CI]: 1.028-1.351; P = 0.018), aspiration (OR: 2.171; 95% CI: 1.054-4.471; P = 0.035) and infiltrates (OR: 2.149; 95% CI: 1.088-4.242; P = 0.028). Using propensity matching, we found that ET was associated with fewer antibiotic-using days (15 vs. 18; P < 0.001) and sedativeusing days (6 vs. 8; P < 0.001), shorter intensive care unit (ICU) Length of Study (LOS) (9 vs. 12; P < 0.05) and reduced in-ICU costs (3.59 vs. 7.4; P < 0.001) and total hospital costs (8.26 vs. 11.28, respectively; P < 0.001). Muscle relaxants (31.8% vs. 60.6%) were used less frequently in patients with ET (P = 0.001). However, there were no differences between the ET and LT groups in terms of modified Rankin Scale (mRS) (4 vs. 4; P = 0.932), in-general-ward costs (4.74 vs. 4.37; P = 0.052), mechanical ventilation days (6 vs. 6; P = 0.961) and hospital LOS (23 vs. 23; P = 0.735) as well as the incidences of ventilator-associated pneumonia (28.8% vs. 37.9%; P = 0.268), tracheostomyrelated complications (16.7% vs. 19.7%; P = 0.652), respiratory failure (24.2% vs. 31.8%; P = 0.333), all-cause deaths (15.2% vs. 16.7%; P = 0.812) and pneumonia (77.3% vs. 87.9%; P = 0.108). CONCLUSION We recommend ET for high-risk patients with ICH. Although ET cannot reduce inhospital mortality or improve patient prognosis, it may help reduce hospital costs and ICU LOS as well as the use of antibiotics, sedatives and muscle relaxants.
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Affiliation(s)
- Bo Luo
- Department of Neurosurgery, Nanchong Central Hospital, No. 97 Renmin South Road, 637000, Nanchong, Sichuan Province, China
| | - Hua-Xuan Chen
- Department of Neurosurgery, Nanchong Central Hospital, No. 97 Renmin South Road, 637000, Nanchong, Sichuan Province, China
| | - Xu-Dong Song
- Department of Neurosurgery, Nanchong Central Hospital, No. 97 Renmin South Road, 637000, Nanchong, Sichuan Province, China
| | - Lin Wang
- Department of Neurosurgery, Nanchong Central Hospital, No. 97 Renmin South Road, 637000, Nanchong, Sichuan Province, China
| | - Long Zhao
- Department of Neurosurgery, The Affiliated Hospital of North Sichuan Medical College, No. 1, Maoyuan South Road, 637000, Nanchong, Sichuan Province, China
| | - Xiao-Ping Tang
- Department of Neurosurgery, The Affiliated Hospital of North Sichuan Medical College, No. 1, Maoyuan South Road, 637000, Nanchong, Sichuan Province, China
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Ji Y, Fang Y, Cheng B, Li L, Fang X. Tracheostomy timing and clinical outcomes in ventilated COVID-19 patients: a systematic review and meta-analysis. Crit Care 2022; 26:40. [PMID: 35135597 PMCID: PMC8822732 DOI: 10.1186/s13054-022-03904-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 01/26/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The association of tracheostomy timing and clinical outcomes in ventilated COVID-19 patients remains controversial. We performed a meta-analysis to evaluate the impact of early tracheostomy compared to late tracheostomy on COVID-19 patients' outcomes. METHODS We searched Medline, Embase, Cochrane, and Scopus database, along with medRxiv, bioRxiv, and Research Square, from December 1, 2019, to August 24, 2021. Early tracheostomy was defined as a tracheostomy conducted 14 days or less after initiation of invasive mechanical ventilation (IMV). Late tracheostomy was any time thereafter. Duration of IMV, duration of ICU stay, and overall mortality were the primary outcomes of the meta-analysis. Pooled odds ratios (OR) or the mean differences (MD) with 95%CIs were calculated using a random-effects model. RESULTS Fourteen studies with a cumulative 2371 tracheostomized COVID-19 patients were included in this review. Early tracheostomy was associated with significant reductions in duration of IMV (2098 patients; MD - 9.08 days, 95% CI - 10.91 to - 7.26 days, p < 0.01) and duration of ICU stay (1224 patients; MD - 9.41 days, 95% CI - 12.36 to - 6.46 days, p < 0.01). Mortality was reported for 2343 patients and was comparable between groups (OR 1.09, 95% CI 0.79-1.51, p = 0.59). CONCLUSIONS The results of this meta-analysis suggest that, compared with late tracheostomy, early tracheostomy in COVID-19 patients was associated with shorter duration of IMV and ICU stay without modifying the mortality rate. These findings may have important implications to improve ICU availability during the COVID-19 pandemic. Trial registration The protocol was registered at INPLASY (INPLASY202180088).
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Affiliation(s)
- Yun Ji
- Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Yumin Fang
- Department of Intensive Care Unit, Suichang People's Hospital, Lishui, Zhejiang, China
| | - Baoli Cheng
- Department of Anesthesiology and Intensive Care, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
| | - Libin Li
- Department of Surgical Intensive Care Unit, the Second Affiliated Hospital, School of Medicine, Zhejiang University, 88 Jiefang Road, Hangzhou, Zhejiang, China
| | - Xiangming Fang
- Department of Anesthesiology and Intensive Care, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China.
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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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Schönhofer B, Geiseler J, Dellweg D, Fuchs H, Moerer O, Weber-Carstens S, Westhoff M, Windisch W. Prolonged Weaning: S2k Guideline Published by the German Respiratory Society. Respiration 2020; 99:1-102. [PMID: 33302267 DOI: 10.1159/000510085] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 07/09/2020] [Indexed: 01/28/2023] Open
Abstract
Mechanical ventilation (MV) is an essential part of modern intensive care medicine. MV is performed in patients with severe respiratory failure caused by respiratory muscle insufficiency and/or lung parenchymal disease; that is, when other treatments such as medication, oxygen administration, secretion management, continuous positive airway pressure (CPAP), or nasal high-flow therapy have failed. MV is required for maintaining gas exchange and allows more time to curatively treat the underlying cause of respiratory failure. In the majority of ventilated patients, liberation or "weaning" from MV is routine, without the occurrence of any major problems. However, approximately 20% of patients require ongoing MV, despite amelioration of the conditions that precipitated the need for it in the first place. Approximately 40-50% of the time spent on MV is required to liberate the patient from the ventilator, a process called "weaning". In addition to acute respiratory failure, numerous factors can influence the duration and success rate of the weaning process; these include age, comorbidities, and conditions and complications acquired during the ICU stay. According to international consensus, "prolonged weaning" is defined as the weaning process in patients who have failed at least 3 weaning attempts, or require more than 7 days of weaning after the first spontaneous breathing trial (SBT). Given that prolonged weaning is a complex process, an interdisciplinary approach is essential for it to be successful. In specialised weaning centres, approximately 50% of patients with initial weaning failure can be liberated from MV after prolonged weaning. However, the heterogeneity of patients undergoing prolonged weaning precludes the direct comparison of individual centres. Patients with persistent weaning failure either die during the weaning process, or are discharged back to their home or to a long-term care facility with ongoing MV. Urged by the growing importance of prolonged weaning, this Sk2 Guideline was first published in 2014 as an initiative of the German Respiratory Society (DGP), in conjunction with other scientific societies involved in prolonged weaning. The emergence of new research, clinical study findings and registry data, as well as the accumulation of experience in daily practice, have made the revision of this guideline necessary. The following topics are dealt with in the present guideline: Definitions, epidemiology, weaning categories, underlying pathophysiology, prevention of prolonged weaning, treatment strategies in prolonged weaning, the weaning unit, discharge from hospital on MV, and recommendations for end-of-life decisions. Special emphasis was placed on the following themes: (1) A new classification of patient sub-groups in prolonged weaning. (2) Important aspects of pulmonary rehabilitation and neurorehabilitation in prolonged weaning. (3) Infrastructure and process organisation in the care of patients in prolonged weaning based on a continuous treatment concept. (4) Changes in therapeutic goals and communication with relatives. Aspects of paediatric weaning are addressed separately within individual chapters. The main aim of the revised guideline was to summarize both current evidence and expert-based knowledge on the topic of "prolonged weaning", and to use this information as a foundation for formulating recommendations related to "prolonged weaning", not only in acute medicine but also in the field of chronic intensive care medicine. The following professionals served as important addressees for this guideline: intensivists, pulmonary medicine specialists, anaesthesiologists, internists, cardiologists, surgeons, neurologists, paediatricians, geriatricians, palliative care clinicians, rehabilitation physicians, intensive/chronic care nurses, physiotherapists, respiratory therapists, speech therapists, medical service of health insurance, and associated ventilator manufacturers.
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Affiliation(s)
- Bernd Schönhofer
- Klinikum Agnes Karll Krankenhaus, Klinikum Region Hannover, Laatzen, Germany,
| | - Jens Geiseler
- Klinikum Vest, Medizinische Klinik IV: Pneumologie, Beatmungs- und Schlafmedizin, Marl, Germany
| | - Dominic Dellweg
- Fachkrankenhaus Kloster Grafschaft GmbH, Abteilung Pneumologie II, Schmallenberg, Germany
| | - Hans Fuchs
- Universitätsklinikum Freiburg, Zentrum für Kinder- und Jugendmedizin, Neonatologie und Pädiatrische Intensivmedizin, Freiburg, Germany
| | - Onnen Moerer
- Universitätsmedizin Göttingen, Klinik für Anästhesiologie, Göttingen, Germany
| | - Steffen Weber-Carstens
- Charité, Universitätsmedizin Berlin, Klinik für Anästhesiologie mit Schwerpunkt operative Intensivmedizin, Campus Virchow-Klinikum und Campus Mitte, Berlin, Germany
| | - Michael Westhoff
- Lungenklinik Hemer, Hemer, Germany
- Universität Witten/Herdecke, Herdecke, Germany
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Universität Witten/Herdecke, Herdecke, Germany
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Sutt AL, Tronstad O, Barnett AG, Kitchenman S, Fraser JF. Earlier tracheostomy is associated with an earlier return to walking, talking, and eating. Aust Crit Care 2020; 33:213-218. [PMID: 32299649 DOI: 10.1016/j.aucc.2020.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Conjecture remains regarding the optimal timing for tracheostomy. Most studies examine patient mortality, ventilation duration, intensive care unit (ICU) length of stay, and medical complications. Few studies examine patient-centric outcomes. The aim of this study was to determine whether timing of tracheostomy had an impact on length of stay, morbidity, mortality, and patient-centric outcomes towards their functional recovery. METHODS This prospective observational study included data for all tracheostomised patients over 4 y in a tertiary ICU. The study time period commenced with the insertion of an endotracheal tube. Data collected included patient and disease specifics; mortality up to 4 y; mobility scores; and time to oral intake, talking, and out-of-bed exercises. To assess differences between timing of tracheostomy, a survival analysis was conducted to dynamically compare patients on days before and after tracheostomy tube (TT) placement during their ICU admission. RESULTS TT was placed in 276 patients. After tracheostomy, the patients were able to (on average) verbally communicate 7.4 d earlier (confidence interval [CI] = -9.1 to -4.9), return to oral intake 7.0 d earlier (CI = -10 to -4.6), and perform out-of-bed exercises 6.2 d earlier (CI = -8.4 to -4) than those who did not yet have a TT. In patients with an endotracheal tube, none were able to talk or have oral intake, and the majority (99%) did not participate in out-of-bed exercises/active rehabilitation. After tracheostomy, patients subsequently received significantly less analgesic and sedative drugs and more antipsychotics. No clear differences in ICU and long-term mortality were associated with tracheostomy timing. CONCLUSIONS Earlier tracheostomy is associated with earlier achievement of patient-centric outcomes - patients returning to usual daily activities such as talking, out-of-bed mobility, and eating/drinking significantly earlier, whilst also receiving less sedatives and analgesics.
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Affiliation(s)
- Anna Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia.
| | - Oystein Tronstad
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia; Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation & School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Sarah Kitchenman
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia.
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10
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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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11
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Krishnamoorthy V, Hough CL, Vavilala MS, Komisarow J, Chaikittisilpa N, Lele AV, Raghunathan K, Creutzfeldt CJ. Tracheostomy After Severe Acute Brain Injury: Trends and Variability in the USA. Neurocrit Care 2020; 30:546-554. [PMID: 30919303 DOI: 10.1007/s12028-019-00697-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND/OBJECTIVE Severe acute brain injury (SABI) is responsible for 12 million deaths annually, prolonged disability in survivors, and substantial resource utilization. Little guidance exists regarding indication or optimal timing of tracheostomy after SABI. Our aims were to determine national trends in tracheostomy utilization among mechanically ventilated patients with SABI in the USA, as well as to examine factors associated with tracheostomy utilization following SABI. METHODS We conducted a population-based retrospective cohort study using the National Inpatient Sample from 2002 to 2011. We identified adult patients with SABI, defined as a primary diagnosis of stroke, traumatic brain injury or post-cardiac arrest who received mechanical ventilation for greater than 96 h. We analyzed trends in tracheostomy utilization over time and used multilevel mixed-effects logistic regression to analyze factors associated with tracheostomy utilization. RESULTS There were 94,082 hospitalizations for SABI during the study period, with 30,455 (32%) resulting in tracheostomy utilization. The proportion of patients with SABI who received a tracheostomy increased during the study period, from 28.0% in 2002 to 32.1% in 2011 (p < 0.001). Variation in tracheostomy utilization was noted based on patient and facility characteristics, including higher odds of tracheostomy in large hospitals (OR 1.34, 95% CI 1.18-1.53, p < 0.001, compared to small hospitals), teaching hospitals (OR 1.15, 95% CI 1.06-1.25, p = 0.001, compared to non-teaching hospitals), and urban hospitals (OR 1.60, 95% CI 1.33-1.92, p < 0.001, compared to rural hospitals). CONCLUSIONS Tracheostomy utilization has increased in the USA among patients with SABI, with wide variation by patient and facility-level factors.
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Affiliation(s)
- Vijay Krishnamoorthy
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA. .,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA.
| | - Catherine L Hough
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | | | | | - Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, USA.,Harborview Injury Prevention and Research Center, University of Washington, Seattle, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University, 2301 Erwin Rd., Durham, NC, 27710, USA
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12
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Duration of Respiratory Failure After Trauma Is Not Associated With Increased Long-Term Mortality. Crit Care Med 2019; 46:1263-1268. [PMID: 29742591 DOI: 10.1097/ccm.0000000000003202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although 1-year survival in medically critically ill patients with prolonged mechanical ventilation is less than 50%, the relationship between respiratory failure after trauma and 1-year mortality is unknown. We hypothesize that respiratory failure duration in trauma patients is associated with decreased 1-year survival. DESIGN Retrospective cohort of trauma patients. SETTING Single center, level 1 trauma center. PATIENTS Trauma patients admitted from 2011 to 2014; respiratory failure is defined as mechanical ventilation greater than or equal to 48 hours, excluded head Abbreviated Injury Score greater than or equal to 4. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Mortality was calculated from the Washington state death registry. Cohort was divided into short (≤ 14 d) and long (> 14 d) ventilation groups. We compared survival with a Cox proportional hazard model and generated a receiver operator characteristic to describe the respiratory failure and mortality relationship. Data are presented as medians with interquartile ranges and hazard ratios with 95% CIs. We identified 1,503 patients with respiratory failure; median age was 51 years (33-65 yr) and Injury Severity Score was 19 (11-29). Median respiratory failure duration was 3 days (2-6 d) with 10% of patients in the long respiratory failure group. Cohort mortality at 1 year was 16%, and there was no difference in mortality between short and long duration of respiratory failure. Predictions for 1-year mortality based on respiratory failure duration demonstrated an area under the receiver operator characteristic curve of 0.57. We determined that respiratory failure patients greater than or equal to 75 years had an increased hazard of death at 1 year, hazard ratio, 6.7 (4.9-9.1), but that within age cohorts, respiratory failure duration did not influence 1-year mortality. CONCLUSIONS Duration of mechanical ventilation in the critically injured is not associated with 1-year mortality. Duration of ventilation following injury should not be used to predict long-term survival.
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13
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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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14
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Fokin AA, Wycech J, Chin Shue K, Stalder R, Crawford M, Lozada J, Puente I. Early Versus Late Tracheostomy in Trauma Patients With Rib Fractures. J Surg Res 2019; 245:72-80. [PMID: 31401250 DOI: 10.1016/j.jss.2019.07.023] [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] [Received: 01/04/2019] [Revised: 06/19/2019] [Accepted: 07/11/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients with blunt chest trauma with multiple rib fractures (RF) may require tracheostomy. The goal was to compare early (≤7 d) versus late (>7 d) tracheostomy patients and to analyze clinical outcomes, to determine which timing is more beneficial. METHODS This retrospective review included 124 patients with RF admitted to trauma ICU at two level 1 trauma centers who underwent tracheostomy. Analyzed variables included age, gender, injury severity score, Glasgow Coma Scale, number of ribs fractured, total fractures of the ribs, prevalence of bilateral RF, flail chest, maxillofacial injuries, cervical vertebrae trauma, traumatic brain injuries (TBI), coinjuries, epidural analgesia, surgical stabilization of RF, failure to extubate, hospital LOS, intensive care unit LOS (ICULOS), duration of mechanical ventilation, mortality, and timing and type of tracheostomy. RESULTS Mean number of RF in all tracheostomized patients with blunt chest trauma was 5.2 and 85% of patients had pulmonary co-injuries. Mean tracheostomy timing was 9.9 d. Early tracheostomy (ET) was correlated with statistically significant reduction in ICULOS and duration of mechanical ventilation. The dominant cause of mortality in all groups was TBI and it was more pronounced in the ET patients. Most deaths were encountered between 3 and 5 wk after admission. ET was more often performed in the operating room with an open technique, whereas late tracheostomy was more often implemented with percutaneous technique at bedside. CONCLUSIONS ET could be beneficial in chest trauma patients with multiple RF as it reduces ICULOS and ventilation requirements. Mortality benefits are not correlated with tracheostomy timing.
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Affiliation(s)
- Alexander A Fokin
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida.
| | - Joanna Wycech
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Kyle Chin Shue
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida
| | - Ryan Stalder
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Wake Forest University, Winston-Salem, North Carolina
| | - Maggie Crawford
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida
| | - Jose Lozada
- Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida
| | - Ivan Puente
- Division of Trauma and Critical Care Services, Delray Medical Center, Delray Beach, Florida; Division of Trauma and Critical Care Services, Broward Health Medical Center, Fort Lauderdale, Florida; Department of Surgery, Florida Atlantic University, Charles E. Schmidt College of Medicine, Boca Raton, Florida; Department of Surgery, Florida International University, Herbert Wertheim College of Medicine, Miami, Florida
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15
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A Randomized Controlled Trial of Surgical Rib Fixation in Polytrauma Patients With Flail Chest. J Surg Res 2019; 242:223-230. [PMID: 31100568 DOI: 10.1016/j.jss.2019.04.005] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 02/19/2019] [Accepted: 04/03/2019] [Indexed: 12/28/2022]
Abstract
BACKGROUND Flail chest (FC) is known to account for high mortality and morbidity and is typically treated with conservative care. Operative fixation of FC has been advocated as an alternative treatment choice. This prospective randomized controlled trial aims to compare surgical and nonsurgical management of FC in patients with severe polytrauma. METHODS Severe polytrauma patients with FC admitted between January 2015 and July 2017 to our trauma center were investigated. The enrolled patients were randomly assigned to the surgical or nonsurgical group. Basic characteristics of injury and clinical outcomes were compared. RESULTS Fifty patients entered final analysis, with 25 patients in each group. Operative rib fixation was associated with shorter duration of mechanical ventilation (7 d [interquartile range {IQR} 6-10] versus 9 d [IQR 7-12], P = 0.012), shorter ICU stay (10 d [IQR 7-12] versus 12 d [IQR 9-15], P = 0.032), lower risk of adult respiratory distress syndrome (28% versus 60%, P = 0.045), pneumonia (48% versus 80%, P = 0.038), and thoracic deformity (8% versus 36%, P = 0.037) and less pain while coughing (pain score 6 [IQR 3-8] versus 8 [IQR 4-9], P = 0.029) and deep breathing (pain score 5 [IQR 3-9] versus 7 [IQR 3-9], P = 0.038). Subgroup analysis was conducted by presence of pulmonary contusion. Shorter time on the ventilator use and ICU stay associated with rib surgery was not observed in patients with pulmonary contusion. CONCLUSIONS This study reveals that surgical rib fixation may provide some critical care benefits for severe polytrauma patients with FC, including less medical resource use and lower risk of complications. Further studies should be designed to optimally identify patients who are most likely to benefit from this surgery.
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16
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Wang R, Pan C, Wang X, Xu F, Jiang S, Li M. The impact of tracheotomy timing in critically ill patients undergoing mechanical ventilation: A meta-analysis of randomized controlled clinical trials with trial sequential analysis. Heart Lung 2018; 48:46-54. [PMID: 30336945 DOI: 10.1016/j.hrtlng.2018.09.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 09/07/2018] [Accepted: 09/11/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND The optimal timing of tracheotomy in critically ill ventilated patients remains controversial. OBJECTIVES The objective of this meta-analysis was to assess tracheotomy timing for critically ill ventilated patients and determine the outcomes' reliability. METHODS We searched PubMed, Embase, and the Cochrane Library for randomized controlled trials. RESULTS Compared with late tracheotomy, early tracheotomy presented a lower incidence of ventilator-associated pneumonia (VAP), shorter duration of mechanical ventilation (MV), and shorter intensive care unit (ICU) stay. However, trial sequential analysis (TSA), a kind of cumulative meta-analysis, indicated that the evidence was unreliable and inconclusive. CONCLUSIONS The Findings suggest that early tracheotomy seems to be associated with a lower incidence of VAP, shorter duration of MV, shorter duration of sedation, and shorter ICU stay. However, the apparent benefits revealed in traditional meta-analysis contrast with the post-TSA results. More fully powered, randomized controlled trials focused on the outcomes of tracheotomy are highly warranted.
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Affiliation(s)
- Ruohui Wang
- Department of ICU, The First Affiliated Hospital, Heilongjiang University of Chinese Medicine, Harbin, China
| | - Changkun Pan
- Department of ICU, Jiamusi Tumour Hospital, Jiamusi, China
| | - Xiaokun Wang
- Department of neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Feng Xu
- Department of Respiratory and Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shuang Jiang
- Department of ICU, Jiamusi Hospital of Chinese Medicine, Jiamusi, China.
| | - Ming Li
- Department of ICU, The Second Affiliated Hospital of Harbin Medical University, Harbin, China.
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17
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Lu Q, Xie Y, Qi X, Li X, Yang S, Wang Y. Is Early Tracheostomy Better for Severe Traumatic Brain Injury? A Meta-Analysis. World Neurosurg 2018; 112:e324-e330. [DOI: 10.1016/j.wneu.2018.01.043] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 12/11/2022]
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18
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Kang BH, Cho J, Lee JCJ, Jung K. Early Versus Late Tracheostomy in Trauma Patients: A Propensity-Matched Cohort Study of 5 Years’ Data at a Single Institution in Korea. World J Surg 2018; 42:1742-1747. [DOI: 10.1007/s00268-018-4474-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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