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Sterr F, Bauernfeind L, Knop M, Rester C, Metzing S, Palm R. Weaning-associated interventions for ventilated intensive care patients: A scoping review. Nurs Crit Care 2024. [PMID: 39155350 DOI: 10.1111/nicc.13143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Revised: 07/22/2024] [Accepted: 07/25/2024] [Indexed: 08/20/2024]
Abstract
BACKGROUND Mechanical ventilation is a core intervention in critical care, but may also lead to negative consequences. Therefore, ventilator weaning is crucial for patient recovery. Numerous weaning interventions have been investigated, but an overview of interventions to evaluate different foci on weaning research is still missing. AIM To provide an overview of interventions associated with ventilator weaning. STUDY DESIGN We conducted a scoping review. A systematic search of the Medline, CINAHL and Cochrane Library databases was carried out in May 2023. Interventions from studies or reviews that aimed to extubate or decannulate mechanically ventilated patients in intensive care units were included. Studies concerning children, outpatients or non-invasive ventilation were excluded. Screening and data extraction were conducted independently by three reviewers. Identified interventions were thematically analysed and clustered. RESULTS Of the 7175 records identified, 193 studies were included. A total of six clusters were formed: entitled enteral nutrition (three studies), tracheostomy (17 studies), physical treatment (13 studies), ventilation modes and settings (47 studies), intervention bundles (42 studies), and pharmacological interventions including analgesic agents (8 studies), sedative agents (53 studies) and other agents (15 studies). CONCLUSIONS Ventilator weaning is widely researched with a special focus on ventilation modes and pharmacological agents. Some aspects remain poorly researched or unaddressed (e.g. nutrition, delirium treatment, sleep promotion). RELEVANCE TO CLINICAL PRACTICE This review compiles studies on ventilator weaning interventions in thematic clusters, highlighting the need for multidisciplinary care and consideration of various interventions. Future research should combine different interventions and investigate their interconnection.
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Affiliation(s)
- Fritz Sterr
- Faculty of Health, School of Nursing Sciences, Witten/Herdecke University, Witten, Germany
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Lydia Bauernfeind
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
- Institute of Nursing Science and Practice, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Michael Knop
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Christian Rester
- Faculty of Applied Healthcare Sciences, Deggendorf Institute of Technology, Deggendorf, Germany
| | - Sabine Metzing
- Faculty of Health, School of Nursing Sciences, Witten/Herdecke University, Witten, Germany
| | - Rebecca Palm
- Faculty of Health, School of Nursing Sciences, Witten/Herdecke University, Witten, Germany
- School VI Medicine and Health Sciences, Department of Health Services Research, Carl von Ossietzky Universität Oldenburg, Oldenburg, Germany
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Gallice T, Cugy E, Germain C, Barthélemy C, Laimay J, Gaube J, Engelhardt M, Branchard O, Maloizel E, Frison E, Dehail P, Cuny E. A Pluridisciplinary Tracheostomy Weaning Protocol for Brain-Injured Patients, Outside of the Intensive Care Unit and Without Instrumental Assessment: Results of Pilot Study. Dysphagia 2024; 39:608-622. [PMID: 38062168 PMCID: PMC11239749 DOI: 10.1007/s00455-023-10641-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/06/2023] [Indexed: 07/12/2024]
Abstract
Concurrently to the recent development of percutaneous tracheostomy techniques in the intensive care unit (ICU), the amount of tracheostomized brain-injured patients has increased. Despites its advantages, tracheostomy may represent an obstacle to their orientation towards conventional hospitalization or rehabilitation services. To date, there is no recommendation for tracheostomy weaning outside of the ICU. We created a pluridisciplinary tracheostomy weaning protocol relying on standardized criteria but adapted to each patient's characteristics and that does not require instrumental assessment. It was tested in a prospective, single-centre, non-randomized cohort study. Inclusion criteria were age > 18 years, hospitalized for an acquired brain injury (ABI), tracheostomized during an ICU stay, and weaned from mechanical ventilation. The exclusion criterion was severe malnutrition. Decannulation failure was defined as recannulation within 96 h after decannulation. Thirty tracheostomized ABI patients from our neurosurgery department were successively and exhaustively included after ICU discharge. Twenty-six patients were decannulated (decannulation rate, 90%). None of them were recannulated (success rate, 100%). Two patients never reached the decannulation stage. Two patients died during the procedure. Mean tracheostomy weaning duration (inclusion to decannulation) was 7.6 (standard deviation [SD]: 4.6) days and mean total tracheostomy time (insertion to decannulation) was 42.5 (SD: 24.8) days. Our results demonstrate that our protocol might be able to determine without instrumental assessment which patient can be successfully decannulated. Therefore, it may be used safely outside ICU or a specialized unit. Moreover, our tracheostomy weaning duration is very short as compared to the current literature.
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Affiliation(s)
- Thomas Gallice
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France.
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France.
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
| | - Emmanuelle Cugy
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Arcachon Hospital, Physical and Rehabilitation Medicine Unit, 33260, La Teste de Buch, France
| | - Christine Germain
- Medical Information Unit, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Clément Barthélemy
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Julie Laimay
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Julie Gaube
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Mélanie Engelhardt
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Cognition and Language Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Neuro-Vascular Unit, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Olivier Branchard
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Elodie Maloizel
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Eric Frison
- Medical Information Unit, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Patrick Dehail
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
| | - Emmanuel Cuny
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
- Neurodegenerative Diseases Institute, CNRS, UMR 5293, 33000, Bordeaux, France
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Gallice T, Cugy E, Branchard O, Dehail P, Moucheboeuf G. Predictive Factors for Successful Decannulation in Patients with Tracheostomies and Brain Injuries: A Systematic Review. Dysphagia 2024; 39:552-572. [PMID: 38189928 PMCID: PMC11239766 DOI: 10.1007/s00455-023-10646-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Accepted: 11/14/2023] [Indexed: 01/09/2024]
Abstract
Neurological patients frequently have disorders of consciousness, swallowing disorders, or neurological states that are incompatible with extubation. Therefore, they frequently require tracheostomies during their stay in an intensive care unit. After the acute phase, tracheostomy weaning and decannulation are generally expected to promote rehabilitation. However, few reliable predictive factors (PFs) for decannulation have been identified in this patient population. We sought to identify PFs that may be used during tracheostomy weaning and decannulation in patients with brain injuries. We conducted a systematic review of the literature regarding potential PFs for decannulation; searches were performed on 16 March 2021 and 1 June 2022. The following databases were searched: MEDLINE, EMBASE, CINAHL, Scopus, Web of Science, PEDro, OPENGREY, OPENSIGLE, Science Direct, CLINICAL TRIALS and CENTRAL. We searched for all article types, except systematic reviews, meta-analyses, abstracts, and position articles. Retrieved articles were published in English or French, with no date restriction. In total, 1433 articles were identified; 26 of these were eligible for inclusion in the review. PFs for successful decannulation in patients with acquired brain injuries (ABIs) included high neurological status, traumatic brain injuries rather than stroke or anoxic brain lesions, younger age, effective swallowing, an effective cough, and the absence of pulmonary infections. Secondary PFs included early tracheostomy, supratentorial lesions, the absence of critical illness polyneuropathy/myopathy, and the absence of tracheal lesions. To our knowledge, this is the first systematic review to identify PFs for decannulation in patients with ABIs. These PFs may be used by clinicians during tracheostomy weaning.
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Affiliation(s)
- Thomas Gallice
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France.
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France.
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France.
| | - Emmanuelle Cugy
- Physical and Rehabilitation Medicine Unit, Swallowing Evaluation Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Arcachon Hospital, 33260, La Teste de Buch, France
| | - Olivier Branchard
- Neurosurgery Unit B, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
| | - Patrick Dehail
- Bordeaux Research Center for Population Health (BPH), Team: ACTIVE, University Bordeaux Segalen, UMR_S 1219, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
| | - Geoffroy Moucheboeuf
- Neurological ICU, Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
- Physical and Rehabilitation Medicine Unit, Bordeaux University Hospital, Tastet-Girard Hospital, 33000, Bordeaux, France
- Traumatic and Surgical ICU, , Bordeaux University Hospital, Pellegrin Hospital, 33000, Bordeaux, France
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Zhao J, Zheng W, Xuan NX, Zhou QC, Wu WB, Cui W, Tian BP. The impact of delayed tracheostomy on critically ill patients receiving mechanical ventilation: a retrospective cohort study in a chinese tertiary hospital. BMC Anesthesiol 2024; 24:39. [PMID: 38262946 PMCID: PMC10804499 DOI: 10.1186/s12871-024-02411-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
OBJECTIVES The timing of tracheostomy for critically ill patients on mechanical ventilation (MV) is a topic of controversy. Our objective was to determine the most suitable timing for tracheostomy in patients undergoing MV. DESIGN Retrospective cohort study. SETTING AND PARTICIPANTS One thousand eight hundred eighty-four hospitalisations received tracheostomy from January 2011 to December 2020 in a Chinese tertiary hospital. METHODS Tracheostomy timing was divided into three groups: early tracheostomy (ET), intermediate tracheostomy (IMT), and late tracheostomy (LT), based on the duration from tracheal intubation to tracheostomy. We established two criteria to classify the timing of tracheostomy for data analysis: Criteria I (ET ≤ 5 days, 5 days < IMT ≤ 10 days, LT > 10 days) and Criteria II (ET ≤ 7 days, 7 days < IMT ≤ 14 days, LT > 14 days). Parameters such as length of ICU stay, length of hospital stay, and duration of MV were used to evaluate outcomes. Additionally, the outcomes were categorized as good prognosis, poor prognosis, and death based on the manner of hospital discharge. Student's t-test, analysis of variance (ANOVA), Mann-Whitney U test, Kruskal-Wallis test, Chi-square test, and Fisher's exact test were employed as appropriate to assess differences in demographic data and individual characteristics among the ET, IMT, and LT groups. Univariate Cox regression model and multivariable Cox proportional hazards regression model were utilized to determine whether delaying tracheostomy would increase the risk of death. RESULTS In both of two criterion, patients with delayed tracheostomies had longer hospital stays (p < 0.001), ICU stays (p < 0.001), total time receiving MV (p < 0.001), time receiving MV before tracheostomy (p < 0.001), time receiving MV after tracheostomy (p < 0.001), and sedation durations. Similar results were also found in sub-population diagnosed as trauma, neurogenic or digestive disorders. Multinomial Logistic regression identified LT was independently associated with poor prognosis, whereas ET conferred no clinical benefits compared with IMT. CONCLUSIONS In a mixed ICU population, delayed tracheostomy prolonged ICU and hospital stays, sedation durations, and time receiving MV. Multinomial logistic regression analysis identified delayed tracheostomies as independently correlated with worse outcomes. TRIAL REGISTRATION ChiCTR2100043905. Registered 05 March 2021. http://www.chictr.org.cn/listbycreater.aspx.
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Affiliation(s)
- Jie Zhao
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
- Department of Critical Care Medicine, The First Affiliated Hospital, Ningbo University, Ningbo, Zhejiang, China
| | - Wei Zheng
- Department of Critical Care Medicine, Zhejiang Daishan First People's Hospital, The Second Affiliated Hospital Daishan Branch, Zhejiang University School of Medicine, Zhoushan, China
| | - Nan-Xian Xuan
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Qi-Chao Zhou
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Wei-Bing Wu
- Department of Critical Care Medicine, Zhejiang Qingyuan People's Hospital, The Second Affiliated Hospital Qingyuan Branch, Zhejiang University School of Medicine, Lishui, China
| | - Wei Cui
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China
| | - Bao-Ping Tian
- Department of Critical Care Medicine, The Second Affiliated Hospital, Zhejiang University School of Medicine, 88 Jiefang Rd, Hangzhou, 310009, China.
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Qiu Y, Yin Z, Wang Z, Xie M, Chen Z, Wu J, Wang Z. Early versus late tracheostomy in stroke-related patients: A systematic review and meta-analysis. J Clin Neurosci 2023; 114:48-54. [PMID: 37302372 DOI: 10.1016/j.jocn.2023.06.004] [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: 01/21/2023] [Revised: 06/02/2023] [Accepted: 06/05/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Tracheostomy is an operative intervention for patients who require ventilator assistance while in the intensive care unit (ICU). This study aimed to compare efficacy and safety between early tracheostomy (ET) and late tracheostomy (LT) in stroke patients. METHODS Embase, PubMed, and the Cochrane Library were searched for available studies. Stroke-related patients were categorized into ET and LT groups using seven days as the cutoff timepoint. The primary efficacy outcome was mortality; secondary efficacy outcomes were modified Rankin Scores (mRS) obtained at follow up, as well as durations of hospital stay, ICU stay, and ventilator use. Safety outcomes were total complication and ventilator associated pneumonia (VAP) incidence. RESULTS Nine studies with 3,789 patients were included in the current analysis. No statistical difference in mortality was observed. ET was associated with shorter hospital stay (MD -5.72, 95% CI -9.76 to -1.67), shorter ICU stay (MD -4.77, 95% CI -6.82 to -2.72), and shorter ventilator duration (MD -4.65, 95% CI -8.39 to -0.90); however, no statistically significant difference was found in follow-up mRS scores. Examination of safety measures found the ET group exhibited a lower rate of VAP compared with LT (OR 0.80, 95 % CI 0.68 to 0.93), while no statistical difference was found in total complications. CONCLUSION Our meta-analysis concluded that ET was associated with shorter hospital stay, less time on a ventilator, and lower incidence of VAP. Future studies are warranted to investigate the functional outcomes and the occurrence of complications of ET in stroke patients.
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Affiliation(s)
- Youjia Qiu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Ziqian Yin
- Suzhou Medical College of Soochow University, Suzhou, Jiangsu Province 215002, China
| | - Zilan Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China.
| | - Minjia Xie
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Zhouqing Chen
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Jiang Wu
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China
| | - Zhong Wang
- Department of Neurosurgery & Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu Province 215006, China.
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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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Early prediction of hospital outcomes in patients tracheostomized for complex mechanical ventilation weaning. Ann Intensive Care 2022; 12:73. [PMID: 35934745 PMCID: PMC9357593 DOI: 10.1186/s13613-022-01047-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Accepted: 07/14/2022] [Indexed: 11/10/2022] Open
Abstract
Background Tracheostomy is often performed in the intensive care unit (ICU) when mechanical ventilation (MV) weaning is prolonged to facilitate daily care. Tracheostomized patients require important healthcare resources and have poor long-term prognosis after the ICU. However, data lacks regarding prediction of outcomes at hospital discharge. We looked for patients’ characteristics, ventilation parameters, sedation and analgesia use (pre-tracheostomy) that are associated with favorable and poor outcomes (post-tracheostomy) using univariate and multivariate logistic regressions. Results Eighty tracheostomized patients were included (28.8% women, 60 [52–71] years). Twenty-three (28.8%) patients were intubated for neurological reasons. Time from intubation to tracheostomy was 14.7 [10–20] days. Thirty patients (37.5%) had poor outcome (19 patients deceased and 11 still tracheostomized at hospital discharge). All patients discharged with tracheostomy (n = 11) were initially intubated for a neurological reason. In univariate logistic regressions, older age and higher body-mass index (BMI) were associated with poor outcome (OR 1.18 [1.07–1.32] and 1.04 [1.01–1.08], p < 0.001 and p = 0.025). No MV parameters were associated with poor outcome. In the multiple logistic regression model higher BMI and older age were also associated with poor outcome (OR 1.21 [1.09–1.36] and 1.04 [1.00–1.09], p < 0.001 and p = 0.046). Conclusions Hospital mortality of patients tracheostomized because of complex MV weaning was high. Patients intubated for neurological reasons were frequently discharged from the acute care hospital with tracheostomy in place. Both in univariate and multivariate logistic regressions, only BMI and older age were associated with poor outcome after tracheostomy for patients undergoing prolonged MV weaning. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01047-z.
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Wang R, Zhang J, He M, Xu J. A novel risk score for predicting hospital acquired pneumonia in aneurysmal subarachnoid hemorrhage patients. Int Immunopharmacol 2022; 108:108845. [DOI: 10.1016/j.intimp.2022.108845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/05/2022]
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Huang CH, Ni SY, Lu HY, Huang APH, Kuo LT. Predictors of Prolonged Mechanical Ventilation Among Patients with Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping. Neurol Ther 2022; 11:697-709. [PMID: 35184263 PMCID: PMC9095775 DOI: 10.1007/s40120-022-00336-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 02/07/2022] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Aneurysmal subarachnoid hemorrhage (aSAH) is a fatal event with high mortality and morbidity rates. Survivors may require prolonged intubation with mechanical ventilation (MV). However, the risk factors for prolonged intubation in these patients remain unclear. The aim of this study was to determine the predictors of prolonged MV in aSAH patients who underwent surgical clipping. METHODS In total, 108 adult patients with a primary diagnosis of aSAH who were on MV > 48 h and survived > 14 days after surgery were included. Clinicodemographic and radiological characteristics, laboratory tests on admission, and initial Glasgow Coma Scale (GCS) and its components were analyzed. RESULTS The average age of the patients included in the analysis was 59.1 ± 12.5 years. Overall, 32 patients (29.6%) had prolonged MV. The group with prolonged MV showed a higher prevalence of diabetes mellitus and hypertension, lower initial GCS and its components, higher World Federation of Neurosurgeons (WFNS) and Hunt and Hess grades, and higher initial white cell counts. The independent factors associated with prolonged MV were a history of diabetes mellitus (odds ratio [OR] 5.799, 95% confidence interval [CI] 1.109-30.334; P = 0.037) and Hunt and Hess grade 3-5 (OR 7.217, 95% CI 1.090-47.770; P = 0.040). CONCLUSION A history of diabetes mellitus and Hunt and Hess grade 3-5 independently predict prolonged MV after microsurgical clipping in patients with aSAH. Thus, knowledge of potential predictors for prolonged MV is essential to improve the early initiation of adequate treatment in the early stages of treatment and provide useful information for communication between caregivers and families.
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Affiliation(s)
- Ching-Hua Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
| | - Shih-Ying Ni
- Department of Psychiatry, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsueh-Yi Lu
- Department of Industrial Engineering and Management, National Yunlin University of Science and Technology, Yunlin, Taiwan
| | - Abel Po-Hao Huang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
| | - Lu-Ting Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, 100 Taiwan
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Panther EJ, Lucke-Wold B. Subarachnoid hemorrhage: management considerations for COVID-19. EXPLORATION OF NEUROPROTECTIVE THERAPY 2022; 2:65-73. [PMID: 35340712 PMCID: PMC8951071 DOI: 10.37349/ent.2022.00018] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 02/18/2022] [Indexed: 02/05/2023]
Abstract
Subarachnoid hemorrhage (SAH) has deleterious outcomes for patients, and during the hospital stay, patients are susceptible to vasospasm and delayed cerebral ischemia. Coronavirus disease 2019 (COVID-19) has been shown to worsen hypertension through angiotensin-converting enzyme 2 (ACE2) activity, therefore, predisposing to aneurysm rupture. The classic renin-angiotensin pathway activation also predisposes to vasospasm and subsequent delayed cerebral ischemia. Matrix metalloproteinase 9 upregulation can lead to an inflammatory surge, which worsens outcomes for patients. SAH patients with COVID-19 are more susceptible to ventilator-associated pneumonia, reversible cerebral vasoconstriction syndrome, and respiratory distress. Emerging treatments are warranted to target key components of the anti-inflammatory cascade. The aim of this review is to explore how the COVID-19 virus and the intensive care unit (ICU) treatment of severe COVID can contribute to SAH.
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Affiliation(s)
- Eric J. Panther
- College of Medicine, University of Florida, Gainesville, Florida 32610, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, Florida 32610, USA
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11
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The RAISE Score: A Possible Tool to Better Identify Subarachnoid Hemorrhage Patients Who Might Benefit From Early Tracheostomy? Crit Care Med 2022; 50:e329-e330. [PMID: 35191885 DOI: 10.1097/ccm.0000000000005367] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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12
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Shen Y, Cao Q, Zhuo H, Hu M, Chen S. Early Versus Late Tracheostomy in Stroke Patients: A Retrospective Analysis. Neuropsychiatr Dis Treat 2022; 18:2713-2723. [PMID: 36419859 PMCID: PMC9677992 DOI: 10.2147/ndt.s388062] [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: 08/30/2022] [Accepted: 11/04/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The timing of tracheostomy (TR) in severe stroke patients receiving mechanical ventilation has not been determined. In this study, we compared some prognostic indicators of early tracheostomy (ET) and late tracheostomy (LT). A meta-analysis was performed to obtain a higher level of evidence of the timing of TR in patients with severe stroke receiving mechanical ventilation. METHODS The study was a retrospective single-center study. We divided the severe stroke patients who received TR from June 2020 to June 2022 into the ET group and LT group. The demographic characteristics, clinical characteristics and prognostic indices were compared. For this meta-analysis, we systematically searched PubMed and other databases. The compared prognostic indicators included mechanical ventilation time, ICU length of stay (LOS), total LOS, ventilator-related pneumonia (VAP) incidence, and mortality. RESULTS A total of 61 patients were included in our study, including 32 patients in the ET group and 29 patients in the LT group. Univariate and multivariate analyses showed that the NIHSS score in the ET group was higher than that in the LT group (P < 0.05). In terms of outcome indicators, compared with the LT group, the median mechanical ventilation time in the ET group was shortened by 5.5 days (P = 0.034). The ICU LOS and total LOS in the ET group were significantly lower than those in the LT group (median 14.5 days vs 22 days, P = 0.004; 21 days vs 27 days, P = 0.019). The meta-analysis showed that ET could significantly shorten the ICU LOS (MD -3.89 [95% CI: -6.86, -0.92]) and the total LOS (MD -7.70 [95% CI: -8.57, -6.83]) and significantly reduce the occurrence of VAP (OR 0.75 [95% CI: 0.64, 0.87]). CONCLUSION The results of our retrospective study and meta-analysis support that ET can shorten the ICU LOS and total LOS and reduce the occurrence of VAP. Therefore, it has a positive effect on the prognosis of patients with severe stroke who need mechanical ventilation support.
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Affiliation(s)
- Yu Shen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Department of Neurology, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Qian Cao
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Hou Zhuo
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Mengyao Hu
- The Medical Imaging Center, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Shenjian Chen
- Department of Neurology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.,Neurology Intensive Care Unit, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
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13
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Maas MB. Why Predict What Time Will Tell? A Strategic Rationale for Predicting Prolonged Mechanical Ventilation After Subarachnoid Hemorrhage. Crit Care Med 2022; 50:160-162. [PMID: 34914648 DOI: 10.1097/ccm.0000000000005250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Matthew B Maas
- Department of Neurology, Northwestern University, Chicago, IL.,Department of Anesthesiology, Northwestern University, Chicago, IL
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14
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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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15
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Towner JE, Rahmani R, Zammit CG, Khan IR, Paul DA, Bhalla T, Roberts DE. Mechanical ventilation in aneurysmal subarachnoid hemorrhage: systematic review and recommendations. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:575. [PMID: 32972406 PMCID: PMC7512211 DOI: 10.1186/s13054-020-03269-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 09/02/2020] [Indexed: 02/04/2023]
Abstract
Objective Mechanical ventilation (MV) has a complex interplay with the pathophysiology of aneurysmal subarachnoid hemorrhage (aSAH). We aim to provide a review of the physiology of MV in patients with aSAH, give recommendations based on a systematic review of the literature, and highlight areas that still need investigation. Data sources PubMed was queried for publications with the Medical Subject Headings (MeSH) terms “mechanical ventilation” and “aneurysmal subarachnoid hemorrhage” published between January 1, 1990, and March 1, 2020. Bibliographies of returned articles were reviewed for additional publications of interest. Study selection Study inclusion criteria included English language manuscripts with the study population being aSAH patients and the exposure being MV. Eligible studies included randomized controlled trials, observational trials, retrospective trials, case-control studies, case reports, or physiologic studies. Topics and articles excluded included review articles, pediatric populations, non-aneurysmal etiologies of subarachnoid hemorrhage, mycotic and traumatic subarachnoid hemorrhage, and articles regarding tracheostomies. Data extraction Articles were reviewed by one team member, and interpretation was verified by a second team member. Data synthesis Thirty-one articles met the inclusion criteria for this review. Conclusions We make recommendations on oxygenation, hypercapnia, PEEP, APRV, ARDS, and intracranial pressure monitoring.
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Affiliation(s)
- James E Towner
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Redi Rahmani
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.
| | - Christopher G Zammit
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,TriHealth Critical Care, 10506 Montgomery Road, Suite 301, Cincinnatir, OH, 45242, USA
| | - Imad R Khan
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - David A Paul
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Department of Imaging Sciences, University of Rochester Medical Center, 601 Elmwood Ave, Box 670, Rochester, NY, 14642, USA.,Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
| | - Debra E Roberts
- Department of Neurosurgery, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Neurocritical Care, Department of Neurology, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Division of Pulmonary Diseases and Critical Care, Department of Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA.,Department of Anesthesiology and Perioperative Medicine, University of Rochester Medical Center, 601 Elmwood Ave, Rochester, NY, 14642, USA
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16
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Behmanesh B, Gessler F, Quick-Weller J, Dubinski D, Konczalla J, Seifert V, Setzer M, Weise L. Early versus Delayed Surgery for Spinal Epidural Abscess : Clinical Outcome and Health-Related Quality of Life. J Korean Neurosurg Soc 2020; 63:757-766. [PMID: 32759625 PMCID: PMC7671776 DOI: 10.3340/jkns.2019.0230] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 03/08/2020] [Indexed: 01/27/2023] Open
Abstract
Objective Spinal epidural abscess (SEA) is a severe and life-threatening disease. Although commonly performed, the effect of timing in surgical treatment on patient outcome is still unclear. With this study, we aim to provide evidence for early surgical treatment in patients with SEA.
Methods Patients treated for SEA in the authors’ department between 2007 and 2016 were included for analysis and retrospectively analyzed for basic clinical parameters and outcome. Pre- and postoperative neurological status were assessed using the American Spinal Injury Association Impairment Scale (AIS). The self-reported quality of life (QOL) based on the Short-Form Health Survey 36 (SF-36) was assessed prospectively. Surgery was defined as “early”, when performed within 12 hours after admission and “late” when performed thereafter. Conservative therapy was preferred and recommend in patients without neurological deficits and in patients denying surgical intervention.
Results One hundred and twenty-three patients were included in this study. Forty-nine patients (39.8%) underwent early, 47 patients (38.2%) delayed surgery and 27 (21.9%) conservative therapy. No significant differences were observed regarding mean age, sex, diabetes, prior history of spinal infection, and bony destruction. Patients undergoing early surgery revealed a significant better clinical outcome before discharge than patients undergoing late surgery (p=0.001) and conservative therapy. QOL based on SF-36 were significantly better in the early surgery cohort in two of four physical items (physical functioning and bodily pain) and in one of four psychological items (role limitation) after a mean follow-up period of 58 months. Readmission to the hospital and failure of conservative therapy were observed more often in patients undergoing conservative therapy.
Conclusion Our data on both clinical outcome and QOL provide evidence for early surgery within 12 hours after admission in patients with SEA.
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Affiliation(s)
- Bedjan Behmanesh
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Florian Gessler
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | | | - Daniel Dubinski
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Juergen Konczalla
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Matthias Setzer
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
| | - Lutz Weise
- Department of Neurosurgery, Goethe University, Frankfurt am Main, Germany
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17
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The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy. Neurosurg Rev 2020; 44:1513-1522. [PMID: 32583308 PMCID: PMC7314615 DOI: 10.1007/s10143-020-01339-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 05/18/2020] [Accepted: 06/17/2020] [Indexed: 12/19/2022]
Abstract
We evaluated the association between the timing of tracheostomy and clinical outcomes in patients with infratentorial lesions. We performed a retrospective observational cohort study in a neurosurgical intensive care unit (ICU) at a tertiary academic medical center from January 2014 to December 2018. Consecutive adult patients admitted to the ICU who underwent resection of infratentorial lesions as well as tracheostomy were included for analysis. Early tracheostomy was defined as performed on postoperative days 1-10 and late tracheostomy on days 10-20 after operation. Univariate and multivariate analyses were used to compare the characteristics and outcomes between both cohorts. A total of 143 patients were identified, and 96 patients received early tracheostomy. Multivariable analysis identified early tracheostomy as an independent variable associated with lower occurrence of pneumonia (odds ratio, 0.25; 95% CI, 0.09-0.73; p = 0.011), shorter stays in ICUs (hazard ratio, 0.4; 95% CI, 0.3-0.6; p = 0.03), and earlier decannulation (hazard ratio, 0.5; 95% CI, 0.4-0.8; p = 0.003). However, no significant differences were observed between the early and late tracheostomy groups regarding hospital mortality (p > 0.999) and the modified Rankin scale after 6 months (p = 0.543). We also identified postoperative brainstem deficits, including cough, swallowing attempts, and extended tongue as well as GCS < 8 at ICU admission as the risk factors independently associated with patients underwent tracheostomy. There is a significant association between early tracheostomy and beneficial clinical outcomes or reduced adverse event occurrence in patients with infratentorial lesions.
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18
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Kleffmann J, Pahl R, Ferbert A, Roth C. Factors influencing intracranial pressure (ICP) during percutaneous tracheostomy. Clin Neurol Neurosurg 2020; 195:105869. [PMID: 32353664 DOI: 10.1016/j.clineuro.2020.105869] [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: 06/30/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Percutaneous tracheostomy (PT) is common on ICUs. An increase of intracranial pressure (ICP) can be observed in patients with acute cerebral diseases. Factors determining ICP increase remain unclear. PATIENTS AND METHODS Data for all PTs were collected prospectively. ICP, cerebral perfusion pressure (CPP), mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), and heart rate (HR) were monitored continuously every minute. Primary outcome parameter was an increase of ICP during PT (ICP > 20 mmHg). Influencing factors were evaluated by the means of logistic regression analysis: Body mass index (BMI), age, gender, physician performing the procedure (neurologist vs. neurosurgeon), duration of the procedure, underlying disease, duration of mechanical ventilation, and baseline ICP value before the procedure. RESULTS A total of 175 PTs were performed during the observation period between 2010 and 2013. Of these, 54 received ICP monitoring and were included into this study. Median initial ICP value was 10.4 mmHg and rose significantly to a median value of 18.4 mmHg (p < 0.05). In 21 patients (38,9%) an increase of median ICP above 20 mmHg was seen during at least one interval. Comparing patients with and without pathological ICP increase a significant difference between the two groups was only observed for patients with an increased baseline ICP above 15 mmHg. All other factors had no significant influence on the development of a pathological ICP peaks during PT. CONCLUSION Percutaneous tracheostomies in patients with cerebral injury leads to a significant increase of ICP during the procedure. Patients with a baseline ICP > 15 mmHg are at risk to develop harmful ICP crises.
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Affiliation(s)
- Jens Kleffmann
- Neurocenter Kassel, Marburger Str. 85, 34127 Kassel, Germany; Department of Neurosurgery, Klinikum Kassel, Mönchebergstraße 41-43, 34125 Kassel, Germany
| | - Roman Pahl
- Institute of Medical Biometry and Epidemiology (IMBE), Philipps University Marburg, Bunsenstraße 3, 35037 Marburg, Germany
| | - Andreas Ferbert
- Department of Neurology, DRK-Kliniken Nordhessen, Hansteinstraße 29, 34121 Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Hansteinstraße 29, 34121 Kassel, Germany; Department of Neurology, Philipps University Marburg, Baldingerstraße, 35037 Marburg, Germany.
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19
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McCann MR, Hatton KW, Vsevolozhskaya OA, Fraser JF. Earlier tracheostomy and percutaneous endoscopic gastrostomy in patients with hemorrhagic stroke: associated factors and effects on hospitalization. J Neurosurg 2020; 132:87-93. [PMID: 30611136 DOI: 10.3171/2018.7.jns181345] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 07/31/2018] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Existing literature supports benefits of early tracheostomy and percutaneous endoscopic gastrostomy (PEG) in certain patient populations. The aim of this study was to review tracheostomy and PEG placement data in patients with hemorrhagic stroke in order to identify factors associated with earlier placement and to evaluate outcomes. METHODS The authors performed a retrospective review of consecutive patients treated for hemorrhagic stroke between June 1, 2011, and June 1, 2015. Data were analyzed by logistic and multiple linear regression. RESULTS Of 240 patients diagnosed with hemorrhagic stroke, 31.25% underwent tracheostomy and 35.83% underwent PEG tube placement. Factors significantly associated with tracheostomy and PEG included the presence of pneumonia on admission and subarachnoid hemorrhage. Earlier tracheostomy was significantly associated with shorter ICU length of stay; earlier tracheostomy and PEG placement were associated with shorter overall hospitalization. Timing of tracheostomy and PEG was not significantly associated with patient survival or the incidence of complications in this population. CONCLUSIONS This study identified patient risk factors associated with increased likelihood of tracheostomy and PEG in patients with hemorrhagic stroke who were critically ill. Additionally, we found that the timing of tracheostomy was associated with length of ICU stay and overall hospital stay, and that the timing of PEG was associated with overall length of hospitalization. Complication rates related to tracheostomy and PEG in this population were minimal. This retrospective data set supports some benefit to earlier tracheostomy and PEG placement in this population and justifies the need for further prospective study.
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Affiliation(s)
| | | | | | - Justin F Fraser
- 1Department of Neurological Surgery
- 2College of Medicine
- 5Department of Neurology
- 6Department of Radiology; and
- 7Department of Neuroscience, University of Kentucky, Lexington, Kentucky
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21
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Chen W, Liu F, Chen J, Ma L, Li G, You C. Timing and Outcomes of Tracheostomy in Patients with Hemorrhagic Stroke. World Neurosurg 2019; 131:e606-e613. [PMID: 31408751 DOI: 10.1016/j.wneu.2019.08.013] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Revised: 08/01/2019] [Accepted: 08/02/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE In the present study, we sought to evaluate the timing and outcomes in patients with hemorrhagic stroke who received tracheostomy. METHODS A retrospective database search was undertaken to identify patients with hemorrhagic stroke between January 2010 and December 2018. Clinical data on basic demographics, clinical features, and outcomes were extracted. The primary outcome was in-hospital mortality and secondary outcomes were hospital stays and hospital costs. Univariate and multivariate analyses were used to compare the characteristics and outcomes between patients with hemorrhagic stroke who underwent tracheostomy early (days 1-6) and late (days 7 or later). RESULTS A total of 425 patients were identified, 74.4% (n = 316) received an early tracheostomy during the hospitalization. Patients with hemorrhagic stroke who received early tracheostomy had a higher rate of neurosurgical operation (odds ratio, 2.77; 95% confidence interval, 1.54-4.99; P = 0.001) and different types of hemorrhagic stroke (P = 0.001) in comparison with the late tracheostomy patients. In addition, early tracheostomy was associated with shorter hospital stays (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P = 0.003) and reduced hospital costs (P < 0.001) than with late tracheostomy. However, no significant difference was observed with regard to in-hospital mortality between early and late tracheostomy groups (P = 0.744). CONCLUSIONS In our cohort, early tracheostomy in patients with hemorrhagic stroke may help reduce hospital stays and hospital costs, but not in-hospital mortality. Future prospective multicenter studies are warranted to validate these findings.
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Affiliation(s)
- Wei Chen
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Fujun Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Jing Chen
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Guoping Li
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, Chengdu, Sichuan Province, People's Republic of China.
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Management of tracheostomized patients after poor grade subarachnoid hemorrhage: Disease related and pulmonary risk factors for failed and delayed decannulation. Clin Neurol Neurosurg 2019; 184:105419. [PMID: 31306892 DOI: 10.1016/j.clineuro.2019.105419] [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: 05/02/2019] [Revised: 07/04/2019] [Accepted: 07/06/2019] [Indexed: 02/01/2023]
Abstract
OBJECTIVE Tracheostomy is often indicated in patients with spontaneous subarachnoid hemorrhage (sSAH). Decannulation is a major goal of neurorehabilitation, but cannot be achieved in all patients. The aim of this study was to describe the course of decannulation and to identify associated risk factors in a single-center collective. PATIENTS AND METHODS We retrospectively reviewed 87 sSAH patients with WFNS (World Federation of Neurosurgical Societies) grade III-IV, who received tracheostomy. Decannulation events and the time from tracheostomy to decannulation were recorded in a 200-days follow-up. Variables analyzed were: age, sex, WFNS grade, Fisher grade, the presence of intracerebral or intraventricular hematoma, acute hydrocephalus, aneurysm location, aneurysm obliteration (surgical vs. endovascular), treatment related complications, decompressive craniectomy, symptomatic cerebral vasospasm, vasospasm-related infarction and timing of tracheostomy. Further risk factors analyzed were preexisting chronic lung disease and pneumonia. Functional outcome was assessed by the modified Rankin Scale (mRS). RESULTS The rate of successful decannulation was 84% after a median of 47 days. A higher WFNS grade and pneumonia were associated with both a prolonged time to decannulation (TTD) and decannulation failure (DF). Older age (> 60 years) and necessity for decompressive craniectomy were only associated with prolonged TTD. Outcome analysis revealed that patients with DF show a significantly (p < 0.01) higher rate of unfavorable outcome (mRS 3-6). CONCLUSION Successful decannulation is possible in the majority of sSAH patients and particularly, in all patients with WFNS grade III. WFNS grading, age, the necessity for decompressive craniectomy and pneumonia are significantly associated with the TTD. WFNS grade and pneumonia are significantly associated with DF. The mean cannulation time of sSAH patients is shorter in relation to stroke patients.
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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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24
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Tracheostomy and mortality in patients with severe burns: A nationwide observational study. Burns 2018; 44:1954-1961. [PMID: 29980328 DOI: 10.1016/j.burns.2018.06.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2018] [Revised: 04/27/2018] [Accepted: 06/15/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Tracheostomy is often performed in patients with severe burns who are undergoing prolonged mechanical ventilation. However, the appropriate timing of tracheostomy and its effect on mortality remain unknown. The aim of this study was to determine whether tracheostomy can reduce mortality in patients with severe burns. METHODS Using the Japanese Diagnosis Procedure Combination database from April 2010 to March 2014, we extracted data on adult patients with severe burns (burn index score of ≥15) who started mechanical ventilation within 3days of admission. We estimated the hazard ratio for 28-day in-hospital mortality associated with tracheotomy performed from day 5 to 28. We adjusted for baseline and time-dependent confounders using inverse probability of treatment weighting methods and fitted a marginal structural Cox proportional hazard model. RESULTS We identified 680 eligible patients (94 in the tracheostomy group, 2289 person-days; 586 in the non-tracheostomy group, 11,197 person-days). Patients who underwent a tracheostomy had worse prognostic factors for mortality. After adjustment for these factors, the hazard ratio for 28-day mortality associated with tracheostomy compared with non-tracheostomy was 0.73 (95% confidence interval, 0.39-1.34). CONCLUSIONS There was no significant association between 28-day in-hospital mortality and early tracheostomy in adult patients with severe burns.
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Wojak JF, Ditz C, Abusamha A, Smith E, Gliemroth J, Tronnier V, Küchler J. The Impact of Extubation Failure in Patients with Good-Grade Subarachnoid Hemorrhage. World Neurosurg 2018; 117:e335-e340. [PMID: 29908380 DOI: 10.1016/j.wneu.2018.06.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 06/05/2018] [Indexed: 12/30/2022]
Abstract
OBJECTIVE To analyze the clinical impact of extubation failure (EF) in patients with good-grade subarachnoid hemorrhage (SAH), in whom a good clinical course usually is expected. PATIENTS AND METHODS We reviewed the clinical data from 141 patients with SAH and 1) initial Hunt & Hess grade 1-3; 2) induction of general anesthesia for intervention; and 3) the presence of data about the functional outcome. Patients were divided into 3 groups: 1) primary tracheotomized patients (PT); 2) patients with successful extubation (ES); and 3) patients with EF (reintubation within 48 hours). RESULTS EF occurred with a rate of 0.12. The leading cause of EF was respiratory insufficiency (n = 7), followed by impaired consciousness (n = 5). Multivariate logistic regression did not show any neurologic predictor of EF. Patients with ES showed an excellent outcome after 6 months (favorable outcome: 95.7%), whereas the outcome of patients with EF and PT was significantly (P < 0.05) poorer. The case fatality rate was nonsignificantly greater in the EF group (0.15 vs. 0.03). Hospitalization was significantly reduced for patients with ES, whereas the occurrence of symptomatic cerebral vasospasms and vasospastic cerebral infarction was similar between patients with EF, ES, or PT. CONCLUSIONS We showed that EF is a frequent condition in good grade-SAH but is not predictable using common neurologic parameters. Regarding the functional outcome, we were able to show that the result of an extubation trial clearly delineates the patients in 2 distinct groups, in which ES predicts an excellent outcome.
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Affiliation(s)
- Jann F Wojak
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | | | - Emma Smith
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Volker Tronnier
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany.
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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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Outcome After Subarachnoid Hemorrhage from Blood Blister–Like Aneurysm Rupture Depends on Age and Aneurysm Morphology. World Neurosurg 2017; 105:944-951.e1. [DOI: 10.1016/j.wneu.2017.06.129] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 06/19/2017] [Accepted: 06/20/2017] [Indexed: 11/20/2022]
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Ditz C, Wojak JF, Smith E, Abusamha A, Tronnier VM, Gliemroth J, Küchler JN. Safety of Percutaneous Dilatational Tracheostomy in Patients with Acute Brain Injury and Reduced PaO 2/FiO 2 Ratio-Retrospective Analysis of 54 Patients. World Neurosurg 2017; 105:102-107. [PMID: 28578113 DOI: 10.1016/j.wneu.2017.05.127] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Revised: 05/19/2017] [Accepted: 05/22/2017] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Percutaneous dilatational tracheostomy (PDT) is a commonly performed method in neurocritical care, and its safety has been proven in numerous studies. Nevertheless, data regarding the application in patients with acute brain injury and poor respiratory function are poor. The purpose of this study was to evaluate the incidence of hypoxemia and hypercapnia during PDT in those patients. METHODS In a retrospective analysis, we acquired data from 54 patients with an acute brain injury (ABI) and a reduced PaO2/FiO2 ratio (PaO2/FiO2 < 300 mm Hg). In all cases, blood gas analyses before, during, and approximately 12 hours after PDT were available. We reviewed the patients' ventilator settings, results of gas exchange, and radiographic signs of acute respiratory distress syndrome (ARDS). Patients with ARDS were defined using the Berlin criteria. RESULTS We observed 2 cases (3.6%) of intraoperative hypoxemia (PaO2 < 60 mm Hg) and 4 cases (7.4%) of intraoperative hypercapnia (PaCO2 > 55 mm Hg). Twenty patients fulfilled the Berlin criteria for ARDS. While mean PaO2 did not differ significantly between ARDS and non-ARDS patients, intraoperative hypoxemia only occurred in the ARDS group (2/20). Mean PaCO2 was similar in the ARDS and non-ARDS groups, and cases of hypercapnia were apparent in both groups. The mean PaO2/FiO2 ratio of all patients improved from 229.1 mm Hg before PDT to 255.3 mm Hg. CONCLUSIONS Regarding the intraoperative gas exchange, indication of PDT in patients with ABI and ARDS should be considered carefully. However, PDT in ABI patients with reduced PaO2/FiO2 ratio alone appears to be a safe procedure.
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Affiliation(s)
- Claudia Ditz
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jann F Wojak
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Emma Smith
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | | | | | - Jan Gliemroth
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany
| | - Jan N Küchler
- Department of Neurosurgery, University of Lübeck, Lübeck, Germany.
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Abnormal Breathing Patterns Predict Extubation Failure in Neurocritically Ill Patients. Case Rep Crit Care 2017; 2017:9109054. [PMID: 28348899 PMCID: PMC5350289 DOI: 10.1155/2017/9109054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2016] [Revised: 02/03/2017] [Accepted: 02/07/2017] [Indexed: 02/05/2023] Open
Abstract
In neurologically injured patients, predictors for extubation success are not well defined. Abnormal breathing patterns may result from the underlying neurological injury. We present three patients with abnormal breathing patterns highlighting failure of successful extubation as a result of these neurologically driven breathing patterns. Recognizing abnormal breathing patterns may be predictive of extubation failure and thus need to be considered as part of extubation readiness.
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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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Postoperative Tracheotomie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Zhang Z, Akulian J, Hong Y, Liu N, Chen Y. How should this patient with repeated aspiration pneumonia be managed and treated?-a proposal of the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure. J Thorac Dis 2016; 8:3720-3727. [PMID: 28149569 PMCID: PMC5227226 DOI: 10.21037/jtd.2016.12.51] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Cerebrovascular accident (CVA) is commonly seen among the elderly with a substantial proportion of patients suffering from long-term dysphagia and/or an inability to protect their airway. This potentially imposes on them an increased risk of malnutrition and aspiration pneumonia. In this article, we present a patient with malnutrition and dysphagia secondary to CVA. We propose a procedure for which we will name the Percutaneous ENdoscopIc Gastrostomy and Tracheostomy (PENlIGhT) procedure for placement of percutaneous endoscopic gastrostomy (PEG) and tracheostomy tube (TT) at the same time. The medical literature was systematically reviewed for both PEG and tracheostomy, aiming to provide the state-of-the-art evidence for clinical use of the PENlIGhT procedure. In clinical practice, the PENlIGhT procedure is indicated for patients who are expected to have prolonged swallowing disturbance and mechanical ventilation. Some prediction tools and scores can be helpful to identify such groups of patients. Patients with poor neurological outcomes who require prolonged maintenance of life are also good candidates for the PENlIGhT procedure.
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Affiliation(s)
- Zhongheng Zhang
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Jason Akulian
- Section of Interventional Pulmonology, Division of Pulmonary and Critical Care, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Yucai Hong
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Ning Liu
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
| | - Yuhao Chen
- Department of Emergency Medicine, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou 310016, China
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Konczalla J, Brawanski N, Bruder M, Senft C, Platz J, Seifert V. Outcome of Patients with Long-Lasting Cerebral Vasospasm After Subarachnoid Hemorrhage: Is Prolonged Treatment for Cerebral Vasospasm Worthwhile? A Matched-Pair Analysis. World Neurosurg 2015; 88:488-496. [PMID: 26498398 DOI: 10.1016/j.wneu.2015.10.033] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Cerebral vasospasm (CVS) occurs regularly between days 3 and 12 after subarachnoid hemorrhage (SAH). Yet, some patients suffering from SAH have long-lasting cerebral vasospasm (LL-CVS, i.e., longer than 14 days). The outcome of these patients with a very long treatment is unknown. METHODS Patients with SAH were entered into a prospectively collected database. In unconscious patients, CVS was treated until a reversal of CVS was confirmed by imaging. Outcome was assessed with the modified Rankin Scale (mRS; favorable [mRS 0-2] and unfavorable [mRS 3-6]) 6 months after SAH. Data were compared by matched pair analysis. RESULTS Of 1126 patients, 106 had LL-CVS (9.4%). The mean of treatment was until day 20 (range, 15-42). Of these patients, more than 30% needed treatment longer than 21 days after SAH; 29% had a small intracerebral hematoma (ICH; <50 mL). Hydrocephalus that required external ventricular drainage was present in 81%. Outcomes were favorable in 60%, and 8% died. In the multivariate logistic regression analysis, risk factors for an unfavorable outcome were elderly patients, poor admission status, and the presence of small ICH. Compared with the matched control group, who had "regular-lasting" CVS, patients with LL-CVS had a significant better outcome (60% vs. 49%) and a significant lower mortality rate (8% vs. 27%). CONCLUSION Patients with LL-CVS had a significant better outcome than patients with "regular-lasting" CVS. Risk factors for worse outcome of patients with LL-CVS were a worse admission status, elderly age, and the presence of small ICH. We recommend using an objective method to validate the reversal of CVS in unconscious patients.
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Affiliation(s)
- Juergen Konczalla
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany.
| | - Nina Brawanski
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Markus Bruder
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Christian Senft
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
| | - Volker Seifert
- Department of Neurosurgery, Goethe-University Hospital, Frankfurt am Main, Germany
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