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Gilaed A, Shorbaji N, Katzir O, Ankol S, Badarni K, Andrawus E, Roimi M, Katz A, Bar-Lavie Y, Raz A, Epstein D. Early risk factors for prolonged mechanical ventilation in patients with severe blunt thoracic trauma: A retrospective cohort study. Injury 2024; 55:111194. [PMID: 37978015 DOI: 10.1016/j.injury.2023.111194] [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: 05/04/2023] [Revised: 10/14/2023] [Accepted: 11/07/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND A significant proportion of patients with severe chest trauma require mechanical ventilation (MV). Early prediction of the duration of MV may influence clinical decisions. We aimed to determine early risk factors for prolonged MV among adults suffering from severe blunt thoracic trauma. METHODS This retrospective, single-center, cohort study included all patients admitted between January 2014 and December 2020 due to severe blunt chest trauma. The primary outcome was prolonged MV, defined as invasive MV lasting more than 14 days. Multivariable logistic regression was performed to identify independent risk factors for prolonged MV. RESULTS The final analysis included 378 patients. The median duration of MV was 9.7 (IQR 3.0-18.0) days. 221 (58.5 %) patients required MV for more than 7 days and 143 (37.8 %) for more than 14 days. Male gender (aOR 3.01, 95 % CI 1.63-5.58, p < 0.001), age (aOR 1.40, 95 % CI 1.21-1.63, p < 0.001, for each category above 30 years), presence of severe head trauma (aOR 3.77, 95 % CI 2.23-6.38, p < 0.001), and transfusion of >5 blood units on admission (aOR 2.85, 95 % CI 1.62-5.02, p < 0.001) were independently associated with prolonged MV. The number of fractured ribs and the extent of lung contusions were associated with MV for more than 7 days, but not for 14 days. In the subgroup of 134 patients without concomitant head trauma, age (aOR 1.63, 95 % CI 1.18-2.27, p = 0.004, for each category above 30 years), respiratory comorbidities (aOR 9.70, 95 % CI 1.49-63.01, p = 0.017), worse p/f ratio during the first 24 h (aOR 1.55, 95 % CI 1.15-2.09, p = 0.004), and transfusion of >5 blood units on admission (aOR 5.71 95 % CI 1.84-17.68, p = 0.003) were independently associated with MV for more than 14 days. CONCLUSIONS Several predictors have been identified as independently associated with prolonged MV. Patients who meet these criteria are at high risk for prolonged MV and should be considered for interventions that could potentially shorten MV duration and reduce associated complications. Hemodynamically stable, healthy young patients suffering from severe thoracic trauma but no head injury, including those with extensive lung contusions and rib fractures, have a low risk of prolonged MV.
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Affiliation(s)
- Aran Gilaed
- Department of General Thoracic Surgery, Rambam Health Care Campus, Israel
| | - Nadeem Shorbaji
- Department of Diagnostic Imaging, Rambam Health Care Center, Haifa, Israel
| | - Ori Katzir
- Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Shaked Ankol
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel
| | - Karawan Badarni
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Elias Andrawus
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Michael Roimi
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Amit Katz
- Department of General Thoracic Surgery, Rambam Health Care Campus, Israel
| | - Yaron Bar-Lavie
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Critical Care Division, Rambam Health Care Campus, Haifa, Israel
| | - Aeyal Raz
- Ruth and Bruce Rappaport Faculty of Medicine, Technion, Haifa, Israel; Department of Anesthesiology, Rambam Health Care Campus, Haifa, Israel
| | - Danny Epstein
- Critical Care Division, Rambam Health Care Campus, Haifa, Israel.
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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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Zhang B, Li GK, Wang YR, Wu F, Shi SQ, Hang X, Feng QL, Li Y, Wan XY. Prediction of factors influencing the timing and prognosis of early tracheostomy in patients with multiple rib fractures: A propensity score matching analysis. Front Surg 2022; 9:944971. [PMID: 36211272 PMCID: PMC9537817 DOI: 10.3389/fsurg.2022.944971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To investigate the factors affecting the timing and prognosis of early tracheostomy in multiple rib fracture patients. Methods A retrospective case-control study was used to analyze the clinical data of 222 patients with multiple rib fractures who underwent tracheotomy in the Affiliated Hospital of Yangzhou University from February 2015 to October 2021. According to the time from tracheal intubation to tracheostomy after admission, the patients were divided into two groups: the early tracheostomy group (within 7 days after tracheal intubation, ET) and late tracheostomy group (after the 7th day, LT). Propensity score matching (PSM) was used to eliminate the differences in baseline characteristics Logistic regression was used to predict the independent risk factors for early tracheostomy. Kaplan–Meier and Cox survival analyses were used to analyze the influencing factors of the 28-day survival. Results According to the propensity score matching analysis, a total of 174 patients were finally included in the study. Among them, there were 87 patients in the ET group and 87 patients in the LT group. After propensity score matching, Number of total rib fractures (NTRF) (P < 0.001), Acute respiratory distress syndrome (ARDS) (P < 0.001) and Volume of pulmonary contusion(VPC) (P < 0.000) in the ET group were higher than those in the LT group. Univariate analysis showed that the patients who underwent ET had a higher survival rate than those who underwent LT (P = 0.021). Pearson's analysis showed that there was a significant correlation between NTRF and VPC (r = 0.369, P = 0.001). A receiver operating characteristic(ROC)curve analysis showed that the areas under the curves were 0.832 and 0.804. The best cutoff-value values of the VPC and NTRF were 23.9 and 8.5, respectively. The Cox survival analysis showed that the timing of tracheostomy (HR = 2.51 95% CI, 1.12–5.57, P = 0.004) and age (HR = 1.53 95% CI, 1.00–2.05, P = 0.042) of the patients had a significant impact on the 28-day survival of patients with multiple rib fractures. In addition, The Kaplan–Meier survival analysis showed that the 28-day survival of patients in the ET group was significantly better than that of the LT group, P = 0.01. Conclusions NTRF, ADRS and VPC are independent risk factors for the timing and prognosis of early tracheotomy. A VPC ≥ 23.9% and/or an NTRF ≥ 8.5 could be used as predictors of ET in patients with multiple rib fractures. Predicting the timing of early tracheostomy also need prediction models in the future.
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Affiliation(s)
- Bing Zhang
- Department of Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Gong-Ke Li
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yu-Rong Wang
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Fei Wu
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Su-Qin Shi
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xin Hang
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Qin-Ling Feng
- Department of Emergency Intensive Care Medicine(EICU), affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Yong Li
- Department of Critical Care Medicine, affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Xian-Yao Wan
- Department of Critical Care Medicine, The First Affiliated Hospital of Dalian Medical University, Dalian, China
- Correspondence: Xian-Yao Wan Yong Li
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McShane EK, Sun BJ, Maggio PM, Spain DA, Forrester JD. Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ Open Qual 2022; 11:e001589. [PMID: 35551095 PMCID: PMC9109116 DOI: 10.1136/bmjoq-2021-001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU). LOCAL PROBLEM From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57). METHODS Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients. INTERVENTIONS In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app. RESULTS Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008). CONCLUSIONS We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.
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Affiliation(s)
- Erin K McShane
- Stanford University School of Medicine, Stanford, California, USA
| | - Beatrice J Sun
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Paul M Maggio
- Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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Joffe A, Barnes CR. Extubation of the potentially difficult airway in the intensive care unit. Curr Opin Anaesthesiol 2022; 35:122-129. [PMID: 35191402 DOI: 10.1097/aco.0000000000001119] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Extubation in the intensive care unit (ICU) is associated with a failure rate requiring reintubation in 10-20% patients further associated with significant morbidity and mortality. This review serves to highlight recent advancements and guidance on approaching extubation for patients at risk for difficult or failed extubation (DFE). RECENT FINDINGS Recent literature including closed claim analysis, meta-analyses, and national society guidelines demonstrate that extubation in the ICU remains an at-risk time for patients. Identifiable strategies aimed at optimizing respiratory mechanics, patient comorbidities, and airway protection, as well as preparing an extubation strategy have been described as potential methods to decrease occurrence of DFE. SUMMARY Extubation in the ICU remains an elective decision and patients found to be at risk should be further optimized and planning undertaken prior to proceeding. Extubation for the at-risk patient should be operationalized utilizing easily reproducible strategies, with airway experts present to guide decision making and assist in reintubation if needed.
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Affiliation(s)
- Aaron Joffe
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, Seattle, Washington
- Banner MD Anderson Cancer Center, Gilbert, Arizona, USA
| | - Christopher R Barnes
- Department of Anesthesiology & Pain Medicine, Harborview Medical Center, Seattle, Washington
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Park C, Bahethi R, Yang A, Gray M, Wong K, Courey M. Effect of Patient Demographics and Tracheostomy Timing and Technique on Patient Survival. Laryngoscope 2020; 131:1468-1473. [PMID: 32996189 DOI: 10.1002/lary.29000] [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: 05/05/2020] [Revised: 07/06/2020] [Accepted: 07/19/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The ideal timing and technique of tracheostomy vary among patients and may impact outcomes. We aim to examine the association between tracheostomy timing, placement technique, and patient demographics on survival. STUDY DESIGN Retrospective cohort study. METHODS A retrospective review was performed for all patients who underwent tracheostomy in 2016 and 2017 at one urban academic tertiary-care hospital. Kaplan-Meier curves were created based on combinations of tracheostomy timing and technique (early percutaneous, early non-percutaneous, late percutaneous, and late non-percutaneous). Cox proportional hazard models were used to determine multivariable effects of timing, technique, and other demographic factors. Primary outcome measures were tracheostomy-related mortality and overall survival. Secondary outcomes were in-hospital, 30-day, and 90-day mortality. RESULTS Our study included 523 patients. There were six tracheostomy-related deaths, with hemorrhage and tracheoesophageal fistula being the most common causes. Tracheostomy timing and technique combinations were not associated with differences in all-cause mortality or survival following discharge. Cox proportional hazard models showed that Charlson Comorbidity Index (CCI) and unknown partner status were associated with a decrease in survival (P < .01 and P = .05, respectively). Additionally, patient age, gender, race, CCI, and body mass index were not independently associated with changes in survival. CONCLUSION Late and non-percutaneous tracheostomies were associated with more tracheostomy-related deaths, but timing and technique were not associated with differences in patient survival. Multiple regression analysis showed that increased patient comorbidities, measured via CCI, and unknown partner status were independently associated with decreased survival. Proceduralists should discuss timing, technique, and patient social factors together with the medical care team when constructing plans for postdischarge management. LEVEL OF EVIDENCE 4 Laryngoscope, 131:1468-1473, 2021.
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Affiliation(s)
| | | | - Anthony Yang
- Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mingyang Gray
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Kevin Wong
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Mark Courey
- Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, USA
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Pu H, Lei Y, Yuan D, Zhou Y. Tracheal Reconstruction Surgery Supported by Extracorporeal Membrane Oxygenation for Patients with Traumatic Post-Tracheotomy Tracheal Stenosis. Ann Thorac Cardiovasc Surg 2020; 26:327-331. [PMID: 32475889 PMCID: PMC7801178 DOI: 10.5761/atcs.oa.20-00005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
PURPOSES Patients who require surgeries for traumatic post-tracheotomy tracheal stenosis (PTTS) often cannot be supported using conventional airway management approaches. This study documents the use of extracorporeal membrane oxygenation (ECMO) in patients with PTTS. METHODS Patient characteristics, procedure, and outcome of patients who required tracheal reconstruction surgery for PTTS supported by ECMO were retrieved and analyzed. RESULTS Four patients (mean age 28 years; range 17-48 years) with traumatic PTTS underwent tracheal reconstruction surgery supported by ECMO. The mean time from removal of tracheotomy tube to admission was 3.2 months (range: 1-9 months). The mean diameter of the stenotic segment was 5 mm (range: 4-6 mm). One patient underwent tracheoplasty and semi-tracheostomy with venoarterial ECMO urgently. Three patients underwent tracheal resection and end-to-end anastomosis (TRE) with venovenous ECMO empirically. Intervention success was achieved in 100% (4/4) of patients. The mean duration of ECMO was 35.3 hours (range: 16-53 hours). The overall survival rate was 100% (4/4) within a mean follow-up of 26 months (range: 7-57 months). CONCLUSIONS ECMO is a safe and feasible method to support oxygenation for patients with critical traumatic PTTS during tracheal reconstruction surgery.
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Affiliation(s)
- Hong Pu
- Department of Critical Care Medicine, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
| | - Yu Lei
- Department of Critical Care Medicine, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, Chengdu, China
| | - Dongqiong Yuan
- Department of Critical Care Medicine, Chengdu Fifth People's Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, China
| | - Yan Zhou
- Department of Critical Care Medicine, West China Hospital, West China Medical School, Sichuan University, Chengdu, China
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