A Meta-Analysis of the Influencing Factors for Tracheostomy after Cervical Spinal Cord Injury

Sex disparities in adverse outcomes after surgically managed isolated traumatic spinal injury

BACKGROUND

Traumatic spinal injury (TSI) encompasses a wide range of injuries affecting the spinal cord, nerve roots, bones, and soft tissues that result in pain, impaired mobility, paralysis, and death. There is some evidence suggesting that women may have different physiological responses to traumatic injury compared to men; therefore, this study aimed to investigate if there are any associations between sex and adverse outcomes following surgically managed isolated TSI.

METHODS

Using the 2013-2019 TQIP database, all adult patients with isolated TSI, defined as a spine AIS ≥ 2 with an AIS ≤ 1 in all other body regions, resulting from blunt force trauma requiring spinal surgery, were eligible for inclusion in the study. The association between the sex and in-hospital mortality as well as cardiopulmonary and venothromboembolic complications was determined by calculating the risk ratio (RR) after adjusting for potential confounding using inverse probability weighting.

RESULTS

A total of 43,756 patients were included. After adjusting for potential confounders, female sex was associated with a 37% lower risk of in-hospital mortality [adjusted RR (95% CI): 0.63 (0.57-0.69), p < 0.001], a 27% lower risk of myocardial infarction [adjusted RR (95% CI): 0.73 (0.56-0.95), p = 0.021], a 37% lower risk of cardiac arrest [adjusted RR (95% CI): 0.63 (0.55-0.72), p < 0.001], a 34% lower risk of deep vein thrombosis [adjusted RR (95% CI): 0.66 (0.59-0.74), p < 0.001], a 45% lower risk of pulmonary embolism [adjusted RR (95% CI): 0.55 (0.46-0.65), p < 0.001], a 36% lower risk of acute respiratory distress syndrome [adjusted RR (95% CI): 0.64 (0.54-0.76), p < 0.001], a 34% lower risk of pneumonia [adjusted RR (95% CI): 0.66 (0.60-0.72), p < 0.001], and a 22% lower risk of surgical site infection [adjusted RR (95% CI): 0.78 (0.62-0.98), p < 0.032], compared to male sex.

CONCLUSION

Female sex is associated with a significantly decreased risk of in-hospital mortality as well as cardiopulmonary and venothromboembolic complications following surgical management of traumatic spinal injuries. Further studies are needed to elucidate the cause of these differences.

Predicting extubation in patients with traumatic cervical spinal cord injury using the diaphragm electrical activity during a single maximal maneuver

BACKGROUND

The unsuccessful extubation in patients with traumatic cervical spinal cord injuries (CSCI) may result from impairment diaphragm function and monitoring of diaphragm electrical activity (EAdi) can be informative in guiding extubation. We aimed to evaluate whether the change of EAdi during a single maximal maneuver can predict extubation outcomes in CSCI patients.

METHODS

This is a retrospective study of CSCI patients requiring mechanical ventilation in the ICU of a tertiary hospital. A single maximal maneuver was performed by asking each patient to inhale with maximum strength during the first spontaneous breathing trial (SBT). The baseline (during SBT before maximal maneuver), maximum (during the single maximal maneuver), and the increase of EAdi (ΔEAdi, equal to the difference between baseline and maximal) were measured. The primary outcome was extubation success, defined as no reintubation after the first extubation and no tracheostomy before any extubation during the ICU stay.

RESULTS

Among 107 patients enrolled, 50 (46.7%) were extubated successfully at the first SBT. Baseline EAdi, maximum EAdi, and ΔEAdi were significantly higher, and the rapid shallow breathing index was lower in patients who were extubated successfully than in those who failed. By multivariable logistic analysis, ΔEAdi was independently associated with successful extubation (OR 2.03, 95% CI 1.52-3.17). ΔEAdi demonstrated high diagnostic accuracy in predicting extubation success with an AUROC 0.978 (95% CI 0.941-0.995), and the cut-off value was 7.0 μV.

CONCLUSIONS

The increase of EAdi from baseline SBT during a single maximal maneuver is associated with successful extubation and can help guide extubation in CSCI patients.

One-stage tracheostomy during surgery reduced early pulmonary infection and mechanical ventilation length in complete CSCI patients

Objective

Complete cervical spinal cord injury (CSCI) is a devastating injury that usually requires surgical treatment. Tracheostomy is an important supportive therapy for these patients. To evaluate the effectiveness of early one-stage tracheostomy during surgery compared with necessary tracheostomy after surgery, and to identify clinical factors for one-stage tracheostomy during surgery in complete cervical spinal cord injury.

Design

Data from 41 patients with complete CSCI treated with surgery were retrospectively analyzed.

Participants and interventions

Ten patients (24.4%) underwent one-stage tracheostomy during surgery, thirteen (31.7%) underwent tracheostomy when necessary after surgery, and eighteen (43.9%) did not have a tracheostomy.

Main results

One-stage tracheostomy during surgery significantly reduced the development of pneumonia at 7 days after tracheostomy (p = 0.025), increased the PaO2 (p &lt; 0.05), and decreased the length of mechanical ventilation (p = 0.005), length of stay (LOS) in the intensive care unit (ICU) (p = 0.002), hospital LOS (p = 0.01) and hospitalization expenses compared with necessary tracheostomy after surgery (p = 0.037). A high neurological level of injury (NLI) (NLI C5 and above), a high PaCO2 in the blood gas analysis before tracheostomy, severe breathing difficulty, and excessive pulmonary secretions were the statistically significant factors for one-stage tracheostomy during surgery in the complete CSCI patients, but no independent clinical factor was found.

Conclusions

In conclusion, one-stage tracheostomy during surgery reduced the number of early pulmonary infections and the length of mechanical ventilation, ICU LOS, hospital LOS and hospitalization expenses, and one-stage tracheostomy should be considered when managing complete CSCI patients by surgical treatment.

The shoulder abductor strength is a novel predictor of tracheostomy in patients with traumatic cervical spinal cord injury

BACKGROUND

Early prediction of tracheostomy in traumatic cervical spinal cord injury (TCSCI) patients is often difficult. This study aims to clarify the association between shoulder abductor strength (SAS) and tracheostomy in patients with TCSCI.

METHODS

We retrospectively analyzed 513 TCSCI patients who were treated in our hospital. All patients were divided into a tracheostomy group and a non-tracheostomy group. The SAS was assessed using the Medical Research Council (MRC) Scale for Muscle Strength grading. Potential predictors were assessed for their association with tracheostomy in patients. A nomogram was developed based on multivariable logistic regression analysis (MLRA) to visualize the predictive ability of the SAS. Validation of the nomogram was performed to judge whether the nomogram was reliable for visual analysis of the SAS. Receiver operating characteristics curve, specificity, and sensitivity were also performed to assess the predictive ability of the SAS.

RESULTS

The proportion of patients with the SAS grade 0-2 was significantly higher in the tracheostomy group than in the non-tracheostomy group (88.1% vs. 54.8%, p = 0.001). The SAS grade 0-2 was identified as a significant predictor of the tracheostomy (OR: 4.505; 95% CI: 2.080-9.758; p = 0.001). Points corresponding to both the SAS grade 0-2 and the neurological level of injury at C2-C4 were between 60 and 70 in the nomogram. The area under the curve for the SAS grade 0-2 was 0.692. The sensitivity of SAS grade 0-2 was 0.239. The specificity of SAS grade 0-2 was 0.951.

CONCLUSIONS

SAS is a novel predictor of tracheostomy in patients after TCSCI. The SAS grade 0-2 had a good predictive ability of tracheostomy.

Classification and regression tree (CART) model to assist clinical prediction for tracheostomy in patients with traumatic cervical spinal cord injury: a 7-year study of 340 patients

OBJECTIVE

To develop a classification and regression tree (CART) model to predict the need of tracheostomy in patients with traumatic cervical spinal cord injury (TCSCI) and to quantify scores of risk factors to make individualized clinical assessments.

METHODS

The clinical characteristics of patients with TCSCI admitted to our hospital from January 2014 to December 2020 were retrospectively analyzed. The demographic characteristics (gender, age, smoking history), mechanism of injury, injury characteristics (ASIA impairment grades, neurological level of impairment, injury severity score), preexisting lung disease and preexisting medical conditions were statistically analyzed. The risk factors of tracheostomy were analyzed by univariate logistic regression analysis (ULRA) and multiple logistic regression analysis (MLRA). The CART model was established to predict tracheostomy.

RESULTS

Three hundred and forty patients with TCSCI met the inclusion criteria, in which 41 patients underwent the tracheostomy. ULRA and MLRA showed that age > 50, ISS > 16, NLI > C5 and AIS A were significantly associated with tracheostomy. The CART model showed that AIS A and NLI > C5 were at the first and second decision node, which had a significant influence on the decision of tracheostomy. The final scores for tracheostomy from CART algorithm, composed of age, ISS, NLI and AIS A with a sensitivity of 0.78 and a specificity of 0.96, could also predict tracheostomy.

CONCLUSION

The establishment of CART model provided a certain clinical guidance for the prediction of tracheostomy in TCSCI. Quantifications of risk factors enable accurate prediction of individual patient risk of need for tracheostomy.

Perioperative management of spinal cord injury: the anesthesiologist's point of view

BACKGROUND

Traumatic spinal cord injury (SCI) is one of the most devastating events a person can experience. It may be life-threatening or result in long-term disability. This narrative review aims to delineate a systematic step-wise airways, breathing, circulation and disability (ABCD) approach to perioperative patient management during spinal cord surgery in order to fill some of the gaps in our current knowledge.

METHODS

We performed a comprehensive review of the literature regarding the perioperative management of traumatic spinal injuries from May 15, 2020, to December 13, 2020. We consulted the PubMed and Embase database libraries.

RESULTS

Videolaryngoscopy supplements the armamentarium available for airway management. Optical fiberscope use should be evaluated when intubating awake patients. Respiratory complications are frequent in the acute phase of traumatic spinal injury, with an estimated incidence of 36-83%. Early tracheostomy can be considered for expected difficult weaning from mechanical ventilation. Careful intraoperative management of administered fluids should be pursued to avoid complications from volume overload. Neuromonitoring requires investments in staff training and cooperation, but better outcomes have been obtained in centers where it is routinely applied. The prone position can cause rare but devastating complications, such as ischemic optic neuropathy; thus, the anesthetist should take the utmost care in positioning the patient.

CONCLUSIONS

A one-size fit all approach to spinal surgery patients is not applicable due to patient heterogeneity and the complexity of the procedures involved. The neurologic outcome of spinal surgery can be improved, and the incidence of complications reduced with better knowledge of patient-specific aspects and individualized perioperative management.

Early vs. Late Tracheostomy in Patients with Traumatic Brain Injury: Systematic Review and Meta-Analysis

Introduction. Tracheostomy can help weaning in long-term ventilated patients, reducing the duration of mechanical ventilation and intensive care unit length of stay, and decreasing complications from prolonged tracheal intubation. In traumatic brain injury (TBI), ideal timing for tracheostomy is still debated. We performed a systematic review and meta-analysis to evaluate the effects of timing (early vs. late) of tracheostomy on mortality and incidence of VAP in traumatic brain-injured patients. Methods. This study was conducted in conformity with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. We performed a search in PubMed, using an association between heading terms: early, tracheostomy, TBI, prognosis, recovery, impact, mortality, morbidity, and brain trauma OR brain injury. Two reviewers independently assessed the methodological quality of eligible studies using the Newcastle–Ottawa Scale (NOS). Comparative analyses were made among Early Tracheostomy (ET) and late tracheostomy (LT) groups. Our primary outcome was the odds ratio of mortality and incidence of VAP between the ET and LT groups in acute brain injury patients. Secondary outcomes included the standardized mean difference (MD) of the duration of mechanical ventilation, ICU length of stay (LOS), and hospital LOS. Results. We included two randomized controlled trials, three observational trials, one cross-sectional study, and three retrospective cohort studies. The total number of participants in the ET group was 2509, while in the LT group it was 2597. Early tracheostomy reduced risk for incidence of pneumonia, ICU length of stay, hospital length of stay and duration of mechanical ventilation, but not mortality. Conclusions. In TBI patients, early tracheostomy compared with late tracheostomy might reduce risk for VAP, ICU and hospital LOS, and duration of mechanical ventilation, but increase the risk of mortality.

Tracheostomy practice and timing in traumatic brain-injured patients: a CENTER-TBI study

Purpose

Indications and optimal timing for tracheostomy in traumatic brain-injured (TBI) patients are uncertain. This study aims to describe the patients’ characteristics, timing, and factors related to the decision to perform a tracheostomy and differences in strategies among different countries and assess the effect of the timing of tracheostomy on patients’ outcomes.

Methods

We selected TBI patients from CENTER-TBI, a prospective observational longitudinal cohort study, with an intensive care unit stay ≥ 72 h. Tracheostomy was defined as early (≤ 7 days from admission) or late (> 7 days). We used a Cox regression model to identify critical factors that affected the timing of tracheostomy. The outcome was assessed at 6 months using the extended Glasgow Outcome Score.

Results

Of the 1358 included patients, 433 (31.8%) had a tracheostomy. Age (hazard rate, HR = 1.04, 95% CI = 1.01–1.07, p = 0.003), Glasgow coma scale ≤ 8 (HR = 1.70, 95% CI = 1.22–2.36 at 7; p < 0.001), thoracic trauma (HR = 1.24, 95% CI = 1.01–1.52, p = 0.020), hypoxemia (HR = 1.37, 95% CI = 1.05–1.79, p = 0.048), unreactive pupil (HR = 1.76, 95% CI = 1.27–2.45 at 7; p < 0.001) were predictors for tracheostomy. Considerable heterogeneity among countries was found in tracheostomy frequency (7.9–50.2%) and timing (early 0–17.6%). Patients with a late tracheostomy were more likely to have a worse neurological outcome, i.e., mortality and poor neurological sequels (OR = 1.69, 95% CI = 1.07–2.67, p = 0.018), and longer length of stay (LOS) (38.5 vs. 49.4 days, p = 0.003).

Conclusions

Tracheostomy after TBI is routinely performed in severe neurological damaged patients. Early tracheostomy is associated with a better neurological outcome and reduced LOS, but the causality of this relationship remains unproven.

Electronic supplementary material

The online version of this article (10.1007/s00134-020-05935-5) contains supplementary material, which is available to authorized users.

Sex-related discrepancies in the epidemiology, injury characteristics and outcomes after acute spine trauma: A retrospective cohort study

Context/Objective: The potential effects of sex on injury severity and outcomes after acute spine trauma (AST) have been reported in pre-clinical and clinical studies, even though the data are conflicting. This study compared females and males regarding the epidemiology, injury characteristics, and clinical outcomes of AST. Design: Retrospective cohort study. Setting: Acute spine care quaternary center. Participants: All consecutive cases of AST admitted from January/1996 to December/2007 were included. Interventions: None. Outcome Measures: The potential effects of sex on the epidemiology, injury characteristics, and clinical outcomes of AST were studied. Results: There were 504 individuals with AST (161 females, 343 males; mean age of 49.44 ± 0.92 years). Sex was not associated with age or pre-existing co-morbidities as assessed using the Charlson Co-morbidity Index, however, females had a greater number of International Classifications of Diseases (ICD) codes at admission and higher Cumulative Illness Rating Scale (CIRS) than males. Over the 12-year period, the male-to-female ratio has not significantly changed. Although there were significant sex-related discrepancies regarding injury etiology, level and severity of AST, males and females had similar lengths of stay in the acute spine center, in-hospital survival post-AST, and need for mechanical ventilation and tracheostomy. Conclusion: This study suggests that females with AST present with a greater number of pre-existing co-morbidities, a higher frequency of thoraco-lumbar trauma, less severe neurological impairment and a greater proportion of MVA-related injuries. However, females and males have a similar length of stay in the acute spine center, and comparable in-hospital survival, need for mechanical ventilation, and tracheostomy after AST.

Critical Care Management of Acute Spinal Cord Injury-Part II: Intensive Care to Rehabilitation

Spinal cord injury is devastating to those affected due to the loss of motor and sensory function, and, in some cases, cardiovascular collapse, ventilatory failure, and bowel and bladder dysfunction. Primary trauma to the spinal cord is exacerbated by secondary insult from the inflammatory response to injury. Specialized intensive care of patients with acute spinal cord injury involves the management of multiple systems and incorporates evidence-based practices to reduce secondary injury to the spinal cord. Patients greatly benefit from early multidisciplinary rehabilitation for neurologic and functional recovery. Treatment of acute spinal cord injury may soon incorporate novel molecular agents currently undergoing clinical investigation to assist in neuroprotection and neuroregeneration.

Analysis of the risk factors for tracheostomy and decannulation after traumatic cervical spinal cord injury in an aging population

STUDY DESIGN

Retrospective study.

OBJECTIVES

To investigate the risk factors associated with tracheostomy after traumatic cervical spinal cord injury (CSCI) and to identify factors associated with decannulation in an aging population.

SETTING

Advanced critical care and emergency center in Yokohama, Japan.

METHODS

Sixty-five patients over 60 years with traumatic CSCI treated between January 2010 and June 2017 were enrolled. The parameters analyzed were age, sex, American Spinal Injury Association impairment scale score (AIS) at admission and one year after injury, neurological level of injury (NLI), injury mechanism, Charlson's comorbidity index (CCI), smoking history, radiological findings, intubation at arrival, treatment choice, length of intensive care unit (ICU) stay, tracheostomy rate, improvement of AIS, decannulation rate, and mortality after one year.

RESULTS

The study included 48 men (74%; mean age 72.8 ± 8.3 years). Twenty-two (34%), 10 (15%), 24 (37%), and 9 (14%) patients were classified as AIS A, B, C, and D, respectively. The tracheostomy group showed significantly more severe degree of paralysis, more patients with major fractures or dislocations, more operative treatment, longer ICU stay, poorer improvement in AIS score after one year and higher rate of intubation at arrival. AIS A at injury was the most significant risk factor for tracheostomy. The non-decannulation group had a significantly higher mortality. The risk factor for failure of decannulation was CCI.

CONCLUSIONS

Risk factors for tracheostomy after traumatic CSCI were AIS A, operative treatment, major fracture/dislocation, and intubation at arrival. The only factor for failure of decannulation was CCI.