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Tekin P, Bulut A. Tracheostomy Timing in Unselected Critically Ill Patients with Prolonged Intubation: A Prospective Cohort Study. J Clin Med 2024; 13:2729. [PMID: 38792271 PMCID: PMC11121849 DOI: 10.3390/jcm13102729] [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: 04/07/2024] [Revised: 04/24/2024] [Accepted: 05/04/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Tracheostomy procedures are performed in the intensive care unit (ICU) for prolonged intubation, unsuccessful weaning and infection prevention through either percutaneous or surgical techniques. This study aimed to outline the impact of tracheostomy timing in the ICU on mortality, need for mechanical ventilation, and complications. Methods: Patients were included in the study on the day of tracheostomy. Demographic information, tracheostomy timing, technique, complications, sedation requirement and need for mechanical ventilation at discharge were recorded by an anesthesiologist, including the pre-tracheostomy period. Results: Tracheostomy was performed on 33 patients during the first 14 days of intubation and on 54 patients on the 15th day and beyond. There was no significant difference between the tracheostomy timing and mortality, sedation requirement, or weaning from the ventilator. We observed that patients who underwent tracheostomy with the surgical technique experienced more complications, but there was no significant difference. Tracheostomy performed after the 14th day was shown to be associated with prolonged hospital stay. Conclusions: Early tracheostomy does not have any influence on the need for mechanical ventilation, sedation and mortality. The optimal timing for tracheostomy is still controversial. We are of the opinion that randomized controlled trials involving patient groups with similar survival expectations are needed.
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Affiliation(s)
| | - Azime Bulut
- Department of Anesthesiology and Reanimation, Faculty of Medicine, Giresun University, 28100 Giresun, Türkiye;
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Yan A, Torpey A, Morrisroe E, Andraous W, Costa A, Bergese S. Clinical Management in Traumatic Brain Injury. Biomedicines 2024; 12:781. [PMID: 38672137 PMCID: PMC11048642 DOI: 10.3390/biomedicines12040781] [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: 01/31/2024] [Revised: 03/06/2024] [Accepted: 03/14/2024] [Indexed: 04/28/2024] Open
Abstract
Traumatic brain injury is one of the leading causes of morbidity and mortality worldwide and is one of the major public healthcare burdens in the US, with millions of patients suffering from the traumatic brain injury itself (approximately 1.6 million/year) or its repercussions (2-6 million patients with disabilities). The severity of traumatic brain injury can range from mild transient neurological dysfunction or impairment to severe profound disability that leaves patients completely non-functional. Indications for treatment differ based on the injury's severity, but one of the goals of early treatment is to prevent secondary brain injury. Hemodynamic stability, monitoring and treatment of intracranial pressure, maintenance of cerebral perfusion pressure, support of adequate oxygenation and ventilation, administration of hyperosmolar agents and/or sedatives, nutritional support, and seizure prophylaxis are the mainstays of medical treatment for severe traumatic brain injury. Surgical management options include decompressive craniectomy or cerebrospinal fluid drainage via the insertion of an external ventricular drain. Several emerging treatment modalities are being investigated, such as anti-excitotoxic agents, anti-ischemic and cerebral dysregulation agents, S100B protein, erythropoietin, endogenous neuroprotectors, anti-inflammatory agents, and stem cell and neuronal restoration agents, among others.
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Affiliation(s)
- Amy Yan
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Andrew Torpey
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Erin Morrisroe
- Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA;
| | - Wesam Andraous
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Ana Costa
- Department of Anesthesiology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA; (A.Y.); (A.T.); (W.A.); (A.C.)
| | - Sergio Bergese
- Department of Anesthesiology and Neurological Surgery, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794, USA
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Azari Jafari A, Mirmoeeni S, Momtaz D, Kotzur T, Murtha G, Garcia C, Moran M, Martinez P, Chen K, Krishnakumar H, Seifi A. Early Versus Late Tracheostomy in Patients with Traumatic Brain Injury: A US Nationwide Analysis. Neurocrit Care 2024; 40:551-561. [PMID: 37415023 DOI: 10.1007/s12028-023-01778-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND One of the most critical issues in patients suffering from traumatic brain injury (TBI) is protecting the airway and attempting to keep a secure airway. It is evident that tracheostomy in patients with TBI after 7-14 days can have favorable outcomes if the patient cannot be extubated; however, some clinicians have recommended early tracheostomy before 7 days. METHODS A retrospective cohort of inpatient study participants was queried from the National Inpatient Sample to include patients with TBI between 2016 and 2020 undergoing tracheostomy and outcomes between the two groups of early tracheostomy (ET) (< 7 days from admission) and late tracheostomy (LT) (≥ 7 days from admission) were compared. RESULTS We reviewed 219,005 patients with TBI, out of whom 3.04% had a tracheostomy. Patients in the ET group were younger than those in the LT group (45.02 ± 19.38 years old vs. 48.68 ± 20.50 years old, respectively, p < 0.001), mainly men (76.64% vs. 73.73%, respectively, p = 0.01), and mainly White race (59.88% vs. 57.53%, respectively, p = 0.33). The patients in the ET group had a significantly shorter length of stay as compared with those in the LT group (27.78 ± 25.96 days vs. 36.32 ± 29.30 days, respectively, p < 0.001) and had a significantly lower hospital charge ($502,502.436 ± 427,060.81 vs. $642,739.302 ± 516,078.94 per patient, respectively, p < 0.001). The whole TBI cohort mortality was reported at 7.04%, which was higher within the ET group compared with the LT group (8.69% vs. 6.07%, respectively, p < 0.001). Patients in the LT had higher odds of developing any infection (odds ratio [OR] 1.43 [1.22-1.68], p < 0.001), emerging sepsis (OR 1.61 [1.39-1.87], p < 0.001), pneumonia (OR 1.52 [1.36-1.69], p < 0.001), and respiratory failure (OR 1.30 [1.09-1.55], p = 0.004). CONCLUSIONS This study shows that ET can provide notable and significant benefits for patients with TBI. Future high-quality prospective studies should be performed to investigate and shed more light on the ideal timing of tracheostomy in patients with TBI.
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Affiliation(s)
- Amirhossein Azari Jafari
- Student Research Committee, School of Medicine, Shahroud University of Medical Sciences, Shahroud, Iran
| | | | - David Momtaz
- School of Medicine, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Travis Kotzur
- School of Medicine, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Gregory Murtha
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Carlos Garcia
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Maggie Moran
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Paola Martinez
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Kevin Chen
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA
| | - Hari Krishnakumar
- School of Medicine, University of Texas Health Science Center at San Antonio School of Medicine, San Antonio, TX, USA
| | - Ali Seifi
- Department of Neurosurgery, Division of Neuro Critical Care, University of Texas Health Science Center at San Antonio School of Medicine, 7033 Floyd Curl Drive, Mail code 7843, San Antonio, TX, 78299, USA.
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Vargas M, Battaglini D, Antonelli M, Corso R, Frova G, Merli G, Petrini F, Ranieri MV, Sorbello M, Di Giacinto I, Terragni P, Brunetti I, Servillo G, Pelosi P. Follow-up short and long-term mortalities of tracheostomized critically ill patients in an Italian multi-center observational study. Sci Rep 2024; 14:2319. [PMID: 38281994 PMCID: PMC10822864 DOI: 10.1038/s41598-024-52785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 01/23/2024] [Indexed: 01/30/2024] Open
Abstract
The effects of tracheostomy on outcome as well as on intra or post-operative complications is yet to be defined. Admission of patients with tracheostomy to rehabilitation facility is at higher risk of suboptimal care and increased mortality. The aim of the study was to investigate ICU mortality, clinical outcome and quality of life up to 12 months after ICU discharge in tracheostomized critically ill patients. This is a prospective, multi-center, cohort study endorsed by Italian Society of Anesthesia, Analgesia, Reanimation, and Intensive Care (SIAARTI Prot. n° 643/13) registered in Clinicaltrial.gov (NCT01899352). Patients admitted to intensive care unit (ICU) and requiring elective tracheostomy according to physician in charge decision were included in the study. The primary outcome was ICU mortality. Secondary outcomes included risk factors for ICU mortality, prevalence of mortality at follow-up, rate of discharge from the hospital and rehabilitation, quality of life, performance status, and management of tracheostomy cannula at 3-, 6, 12-months from the day of tracheostomy. 694 critically ill patients who were tracheostomized in the ICU were included. ICU mortality was 15.8%. Age, SOFA score at the day of the tracheostomy, and days of endotracheal intubation before tracheostomy were risk factors for ICU mortality. The regression tree analysis showed that SOFA score at the day of tracheostomy and age had a preeminent role for the choice to perform the tracheostomy. Of the 694 ICU patients with tracheostomy, 469 completed the 12-months follow-up. Mortality was 33.51% at 3-months, 45.30% at 6-months, and 55.86% at 12-months. Patients with tracheostomy were less likely discharged at home but at hospital facilities or rehabilitative structures; and quality of life of patients with tracheostomy was severely compromised at 3-6 and 12 months when compared with patients without tracheostomy. In patients admitted to ICU, tracheostomy is associated with high mortality, difficult rehabilitation, and decreased quality of life. The choice to perform a tracheostomy should be carefully weighed on family burden and health-related quality of life.Clinical trial registration: Clinicaltrial.gov (NCT01899352).
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Affiliation(s)
- Maria Vargas
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Pansini, 80100, Naples, Italy.
| | | | - Massimo Antonelli
- Dip Scienze dell'Emergenza, Anestesiologiche e della Rianimazione, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Ruggero Corso
- Dipartimento delle Terapie Intensive, Anestesiologia e Terapia del Dolore, Ospedale "Guglielmo da Saliceto"-Piacenza, Piacenza, Italy
| | - Giulio Frova
- Università degli Studi di Milano and Dipartimento Anestesia e Rianimazione Spedai Civili si Brescia, Brescia, Italy
| | - Guido Merli
- U.O.C. Anestesia e Rianimazione Ospedale Maggiore di Crema, Asst Crema, Italy
| | - Flavia Petrini
- Coordinamento Strutturale Medicina Perioperatoria, Terapia Dolore, Emergenze Intraospedaliere, Terapia Intensiva - ASL2 Abruzzo, Università di Chieti-Pescara, Pescara, Italy
| | - Marco V Ranieri
- Alma Mater Studiorum-Università di Bologna, IRCCS Policlinico di Sant'Orsola, Anesthesia and Intensive Care Medicine, Bologna, Italy
| | | | - Ida Di Giacinto
- Anesthesia and Intensive Care, Mazzoni Hospital, Ascoli Piceno, Italy
| | - Pierpaolo Terragni
- Department of Medicine, Surgery and Pharmacy, University of Sassari, Sassari, Italy
| | - Iole Brunetti
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Giuseppe Servillo
- Department of Neurosciences, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Via Pansini, 80100, Naples, Italy
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Unnithan AKA. An Audit of Tracheostomy in Traumatic Brain Injury. Indian J Otolaryngol Head Neck Surg 2023; 75:1750-1754. [PMID: 37636789 PMCID: PMC10447322 DOI: 10.1007/s12070-023-03732-2] [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: 03/28/2022] [Accepted: 03/23/2023] [Indexed: 08/29/2023] Open
Abstract
INTRODUCTION The timing of tracheostomy in traumatic brain injury is controversial. The benefits of early tracheostomy are early weaning from ventilation, and reduction in pneumonia. But some studies demonstrated increase in intracranial pressure during tracheostomy. AIM AND METHODS The aims of the audit are to analyse the timing, benefits, complications, and the results of tracheostomy in patients with traumatic brain injury in the hospital in the period of 2012-2021. RESULTS The number of patients was 34. The maximum number of tracheostomies(24) were between 6th to 14th days of admission. The complications were: worsening of Glasgow coma scale score - 3 (in the early group), bleeding - 2, subglottic stenosis-1, tracheocutaneous fistula-1. The main benefits obtained form tracheostomy were the easiness of weaning and tracheobronchial toilet. Twelve patients had pneumonia. Nine patients survived out of twelve. Six patients had acute respiratory distress syndrome. Five of them succumbed. The weaning time corresponded to the severity of injury and pulmonary status. The mortality according to the timing of tracheostomy were: 1/6(16.67%) in the group of first week, 9/19(47%) in the group of second week, and 3/8(37.5%) in the group of the third and fourth week. The mortality was less in the group of first week. CONCLUSIONS The timing of tracheostomy in traumatic brain injury should be at the earliest after the control of raised intracranial tension. There was reversible worsening of Glasgow coma scale score for 2 points in 3 cases after early tracheostomy. Mortality was less in the group of early tracheostomy.
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Villemure-Poliquin N, Costerousse O, Lessard Bonaventure P, Audet N, Lauzier F, Moore L, Zarychanski R, Turgeon AF. Tracheostomy versus prolonged intubation in moderate to severe traumatic brain injury: a multicentre retrospective cohort study. Can J Anaesth 2023; 70:1516-1526. [PMID: 37505417 PMCID: PMC10447593 DOI: 10.1007/s12630-023-02539-7] [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: 08/09/2022] [Revised: 01/29/2023] [Accepted: 02/16/2023] [Indexed: 07/29/2023] Open
Abstract
PURPOSE Tracheostomy is a surgical procedure that is commonly performed in patients admitted to the intensive care unit (ICU). It is frequently required in patients with moderate to severe traumatic brain injury (TBI), a subset of patients with prolonged altered state of consciousness that may require a long period of mechanical respiratory assistance. While many clinicians favour the use of early tracheostomy in TBI patients, the evidence in favour of this practice remains scarce. The aims of our study were to evaluate the potential clinical benefits of tracheostomy versus prolonged endotracheal intubation, as well as whether the timing of the procedure may influence outcome in patients with moderate to severe TBI. METHODS We conducted a retrospective multicentre cohort study based on data from the provincial integrated trauma system of Quebec (Québec Trauma Registry). The study population was selected from adult trauma patients hospitalized between 2013 and 2019. We included patients 16 yr and older with moderate to severe TBI (Glasgow Coma Scale score < 13) who required mechanical ventilation for 96 hr or longer. Our primary outcome was 30-day mortality. Secondary outcomes included hospital and ICU mortality, six-month mortality, duration of mechanical ventilation, ventilator-associated pneumonia, ICU and hospital length of stay as well as orientation of patients upon discharge from the hospital. We used propensity score covariate adjustment. To overcome the effect of immortal time bias, an extended Cox shared frailty model was used to compare mortality between groups. RESULTS From 2013 to 2019, 26,923 patients with TBI were registered in the Québec Trauma Registry. A total of 983 patients who required prolonged endotracheal intubation for 96 hr or more were included in the study, 374 of whom underwent a tracheostomy and 609 of whom remained intubated. We observed a reduction in 30-day mortality (adjusted hazard ratio, 0.33; 95% confidence interval, 0.21 to 0.53) associated with tracheostomy compared with prolonged endotracheal intubation. This effect was also seen in the ICU as well as at six months. Tracheostomy, when compared with prolonged endotracheal intubation, was associated with an increase in the duration of mechanical respiratory assistance without any increase in the length of stay. No effect on mortality was observed when comparing early vs late tracheostomy procedures. An early procedure was associated with a reduction in the duration of mechanical respiratory support as well as hospital and ICU length of stay. CONCLUSION In this multicentre cohort study, tracheostomy was associated with decreased mortality when compared with prolonged endotracheal intubation in patients with moderate to severe TBI. This effect does not appear to be modified by the timing of the procedure. Nevertheless, the generalization and application of these results remains limited by potential residual time-dependent indication bias.
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Affiliation(s)
- Noémie Villemure-Poliquin
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Ophthalmology and Otolaryngology - Head and Neck Surgery, Université Laval, Quebec City, QC, Canada
| | - Olivier Costerousse
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
| | - Paule Lessard Bonaventure
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Division of Neurosurgery, Department of Surgery, CHU de Québec -Université Laval, Quebec City, QC, Canada
| | - Nathalie Audet
- Department of Ophthalmology and Otolaryngology - Head and Neck Surgery, Université Laval, Quebec City, QC, Canada
| | - François Lauzier
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Medicine, Université Laval, Quebec City, QC, Canada
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada
| | - Lynne Moore
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada
- Department of Preventive and Social Medicine, Université Laval, Quebec City, QC, Canada
| | - Ryan Zarychanski
- Department of Internal Medicine, Sections of Critical Care Medicine, of Hematology and of Medical Oncology, Rady Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Research Institute of Oncology and Hematology, CancerCare Manitoba, Winnipeg, MB, Canada
| | - Alexis F Turgeon
- CHU de Québec - Université Laval Research Center, Population Health and Optimal Health Practices Research Unit (Trauma-Emergency-Critical Care Medicine), Quebec City, QC, Canada.
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care Medicine, Université Laval, Quebec City, QC, Canada.
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Cotoia A, Paradiso R, Ferrara G, Borriello G, Santoro F, Spina I, Mirabella L, Mariano K, Fusco G, Cinnella G, Singer P. Modifications of lung microbiota structure in traumatic brain injury ventilated patients according to time and enteral feeding formulas: a prospective randomized study. Crit Care 2023; 27:244. [PMID: 37344845 PMCID: PMC10283314 DOI: 10.1186/s13054-023-04531-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 06/14/2023] [Indexed: 06/23/2023] Open
Abstract
BACKGROUND Specialized diets enriched with immune nutrients could be an important supplement in patients (pts) with acute traumatic brain injury (TBI). Omega-3 and arginine may interact with immune response and microbiota. No data are available about the role of the specialized diets in modulating the lung microbiota, and little is known about the influence of lung microbiota structure in development of ventilator-associated pneumonia (VAP) in TBI pts. The aims of this study are to evaluate the impact of specific nutrients on the lung microbiota and the variation of lung microbiota in TBI pts developing VAP. METHODS A cohort of 31 TBI pts requiring mechanical ventilation in ICU was randomized for treatment with specialized (16pts) or standard nutrition (15pts). Alpha and beta diversity of lung microbiota were analyzed from bronco Alveolar Lavage (BAL) samples collected at admission and 7 days post-ICU admission in both groups. A further analysis was carried out on the same samples retrospectively grouped in VAP or no VAP pts. RESULTS None developed VAP in the first week. Thereafter, ten out of thirty-one pts developed VAP. The BAL microbiota on VAP group showed significant differences in beta diversity and Staphylococcus and Acinetobacter Genera were high. The specialized nutrition had influence on beta diversity that reached statistical significance only in Bray-Curtis distance. CONCLUSION Our data suggest that TBI patients who developed VAP during ICU stay have different structures of BAL microbiota either at admission and at 7 days post-ICU admission, while no correlation has been observed between different enteral formulas and microbiota composition in terms of richness and evenness. These findings suggest that targeting the lung microbiota may be a promising approach for preventing infections in critically ill patients.
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Affiliation(s)
- A. Cotoia
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - R. Paradiso
- Department of Animal Health, Istituto Zooprofilattico Sperimentale del Mezzogiorno, Naples, Italy
| | - G. Ferrara
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - G. Borriello
- Department of Animal Health, Istituto Zooprofilattico Sperimentale del Mezzogiorno, Naples, Italy
| | - F. Santoro
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - I. Spina
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - L. Mirabella
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - K. Mariano
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - G. Fusco
- Department of Animal Health, Istituto Zooprofilattico Sperimentale del Mezzogiorno, Naples, Italy
| | - G. Cinnella
- Department of Intensive Care, University Hospital of Foggia, Foggia, Italy
| | - P. Singer
- Intensive Care Unit Herzlia Médical Center, Herzliya, Israel
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Gelormini C, Caricato A. Tracheostomy in traumatic brain injury: selection and stratification. Minerva Anestesiol 2023; 89:374-376. [PMID: 37140192 DOI: 10.23736/s0375-9393.23.17380-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Affiliation(s)
- Camilla Gelormini
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Anselmo Caricato
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
- Sacred HeartCatholic University, Rome, Italy
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Rabinstein AA, Cinotti R, Bösel J. Liberation from Mechanical Ventilation and Tracheostomy Practice in Traumatic Brain Injury. Neurocrit Care 2023; 38:439-446. [PMID: 36859490 DOI: 10.1007/s12028-023-01693-6] [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: 08/11/2022] [Accepted: 02/06/2023] [Indexed: 03/03/2023]
Abstract
Liberating patients with severe traumatic brain injury (TBI) from mechanical ventilation is often a challenging task. These patients frequently require prolonged ventilation and have persistent alterations in the level and content of consciousness. Questions about their ability to protect their airway are common. Pulmonary complications and copious respiratory secretions are also very prevalent. Thus, it is hardly surprising that rates of extubation failure are high. This is a major problem because extubation failure is associated with a host of poor outcome measures. When the safety of an extubation attempt is uncertain, direct tracheostomy is favored by some, but there is no evidence that this practice leads to better outcomes. Current knowledge is insufficient to reliably predict extubation outcomes in TBI, and practices vary substantially across trauma centers. Yet observational studies provide relevant information that must be weighted when considering the decision to attempt extubation in patients with head injury. This review discusses available evidence on liberation from mechanical ventilation in TBI, proposes priorities for future research, and offers practical advice to guide decisions at the bedside.
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Affiliation(s)
| | - Raphael Cinotti
- Department of Anesthesia and Critical Care, CHU Nantes, Nantes Université, Hôtel Dieu, 44000, Nantes, France.,Methods in Patient-Centered Outcomes and Health Research, University of Nantes, University of Tours, INSERM, 22 Boulevard Benoni Goulin, 44200, Nantes, France
| | - Julian Bösel
- Department of Neurology, Kassel General Hospital, Kassel, Germany.,Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Formisano R, D'Ippolito M, Giustini M, Della Vedova C, Laurenza L, Matteis M, Menna C, Rendina EA. The impact of early surgical treatment of tracheal stenosis on neurorehabilitation outcome in patients with severe acquired brain injury. Brain Inj 2023; 37:74-82. [PMID: 36346363 DOI: 10.1080/02699052.2022.2143899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Acquired tracheal stenosis (TS) is a potentially life-threatening condition following prolonged intubation and/or tracheostomy in adult patients with severe Acquired Brain Injury (sABI), requiring a tracheal resection and reconstruction. METHODS We included 38 sABI adult patients with TS, admitted at a post-acute Neurorehabilitation Hospital. Disability Rating Scale (DRS) and other functional assessment measures were recorded at admission (t1), before TS surgical treatment (t2), and at discharge (t3). Patients were defined as 'improved' when they changed from a more severe to a less severe disability, between time t2 and time t3, and as "not improved" when they did not show any further improvement between t2 and t3, or they already exhibited a disability improvement since time interval t1-t2. RESULTS Time interval between the injury onset and TS surgical treatment (t2-t0) was associated with the patient's disability improvement, suggesting the t2-t0 time interval ≤ 115 days as a cutoff value for a possible functional recovery. A t2-t0 time interval ≤ 170 days is also associated to absence of persistent dysphagia. CONCLUSIONS Early TS surgical treatment within 115 days from the injury onset contributes to the improvement of the disability level in patients with sABI, optimizing their functional outcomes and recovery potential.
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Affiliation(s)
- R Formisano
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - M D'Ippolito
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - M Giustini
- Environmental and Social Epidemiology Unit, National Institute of Health, Rome, Italy
| | - C Della Vedova
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - L Laurenza
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - M Matteis
- Neurorehabilitation 2, Post-Coma Unit, IRCCS Fondazione Santa Lucia, Rome, Italy
| | - C Menna
- Thoracic Surgery Department, Sant'Andrea Hospital, Rome, Italy
| | - E A Rendina
- Thoracic Surgery Department, Sant'Andrea Hospital, Rome, Italy
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11
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Percutaneous tracheostomy in the ICU: a review of the literature and recent updates. Curr Opin Pulm Med 2023; 29:47-53. [PMID: 36378112 DOI: 10.1097/mcp.0000000000000928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE OF REVIEW The following article summarizes the current available knowledge regarding tracheostomy techniques, indications, contraindications, procedure timing, use of assisted technologies and tracheostomy feasibility and safety in high-risk populations. In light of the ongoing corona virus disease (COVID-19) pandemic, a focus was placed on tracheostomy in this unique patient group. RECENT FINDINGS Percutaneous dilatation tracheostomy (PDT) is commonly used in the ICU setting. It has been shown to be well tolerated and feasible in a diverse patient population including those regarded to be at high risk such as the obese, coagulopathic and acute respiratory failure patient. This patient profile presented itself frequently in the recent COVID-19 pandemic. Indeed studies showed that PDT is well tolerated in COVID-19 ICU patients leading to reduced ICU length of stay (LOS), decrease in ventilator-associated pneumonia rate (VAP) and reduced duration on invasive mechanical ventilation (IMV). Despite initial concerns, virus transmission from patient to healthcare provider (HCP) was shown to be negligible when proper precautions are taken. SUMMARY Bedside PDT in the ICU is a well tolerated procedure having the potential to benefit both the individual patient as well as to improve resource utilization of the healthcare system.
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Kumar R, Zenian MS, Maeng TY, Fadzil F, Mohd Azli AN. Patient Outcomes following Immediate Tracheostomy and Emergency Decompressive Craniectomy in the Same Setting. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:15746. [PMID: 36497820 PMCID: PMC9738754 DOI: 10.3390/ijerph192315746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 11/15/2022] [Accepted: 11/17/2022] [Indexed: 06/17/2023]
Abstract
Early tracheostomy is recommended for patients with severe traumatic brain injury or stroke. Tracheostomy in the same setting as emergency decompressive craniectomy, on the other hand, has never been investigated. Our goal was to compare the outcomes related to the duration of mechanical ventilation in patients who had immediate (IT) vs. early (ET) tracheostomy following an emergency decompressive craniectomy in a Neurosurgical centre in Sabah, Malaysia. We reviewed 135 patients who underwent emergency decompressive craniectomy for traumatic brain injury (TBI) and stroke patients between January 2013 and January 2018 in this retrospective cohort study. The cohort included 49 patients who received immediate tracheostomy (IT), while the control group included 86 patients who received a tracheostomy within 7 days of decompressive surgery (ET). The duration of mechanical ventilation, length of stay (LOS) in the critical-care unit, and intravenous sedation were significantly shorter in the IT group compared to the ET group, according to the study. There was no significant difference between the two groups in the incidence of ventilator-associated pneumonia (VAP), tracheostomy-related complications, or 30-day mortality rate. In conclusion, compared to early tracheostomy, immediate tracheostomy in the same setting as emergency decompressive craniectomy is associated with a shorter duration of mechanical ventilation and LOS in critical-care units with acceptable morbidity and mortality rates. This practise could be used in busy centres with limited resources, such as those where mechanical ventilators, critical-care unit beds, or OT wait times are an issue.
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Affiliation(s)
- Ramesh Kumar
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Mohd Sofan Zenian
- Department of Neurosurgery, Hospital Queen Elizabeth, Sabah 88300, Malaysia
| | - Tang Yiu Maeng
- Department of Surgery, Penang General Hospital, Penang 10990, Malaysia
| | - Farizal Fadzil
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
| | - Anis Nabillah Mohd Azli
- Department of Surgery, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur 56000, Malaysia
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13
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 198] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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14
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McShane EK, Sun BJ, Maggio PM, Spain DA, Forrester JD. Improving tracheostomy delivery for trauma and surgical critical care patients: timely trach initiative. BMJ Open Qual 2022; 11:e001589. [PMID: 35551095 PMCID: PMC9109116 DOI: 10.1136/bmjoq-2021-001589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 04/26/2022] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND Tracheostomy is recommended within 7 days of intubation for patients with severe traumatic brain injury (TBI) or requiring prolonged mechanical ventilation. A quality improvement project aimed to decrease time to tracheostomy to ≤7 days after intubation for eligible patients requiring tracheostomy in the surgical intensive care unit (SICU). LOCAL PROBLEM From January 2017 to June 2018, approximately 85% of tracheostomies were performed >7 days after intubation. The tracheostomy was placed a median of 10 days after intubation (range: 1-57). METHODS Quality improvement principles were applied at an American College of Surgeons-verified level I trauma centre to introduce and analyse interventions to improve tracheostomy timing. Using the electronic health record, we analysed changes in tracheostomy timing, hospital length of stay (LOS), ventilator-associated pneumonia and peristomal bleeding rates for three subgroups: patients with TBI, trauma patients and all SICU patients. INTERVENTIONS In July 2018, an educational roll-out for SICU residents and staff was launched to inform them of potential benefits of early tracheostomy and potential complications, which they should discuss when counselling patient decision-makers. In July 2019, an early tracheostomy workflow targeting patients with head injury was published in an institutional Trauma Guide app. RESULTS Median time from intubation to tracheostomy decreased for all patients from 14 days (range: 4-57) to 8 days (range: 1-32, p≤0.001), and median hospital LOS decreased from 38 days to 24 days (p<0.001, r=0.35). Median time to tracheostomy decreased significantly for trauma patients after publication of the algorithm (10 days (range: 3-21 days) to 6 days (range: 1-15 days), p=0.03). Among patients with TBI, family meetings were held earlier for patients who underwent early versus late tracheostomy (p=0.008). CONCLUSIONS We recommend regular educational meetings, enhanced by digitally published guidelines and strategic communication as effective ways to improve tracheostomy timing. These interventions standardised practice and may benefit other institutions.
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Affiliation(s)
- Erin K McShane
- Stanford University School of Medicine, Stanford, California, USA
| | - Beatrice J Sun
- Department of Surgery, Stanford University, Stanford, California, USA
| | - Paul M Maggio
- Department of Surgery, Stanford University, Stanford, California, USA
| | - David A Spain
- Department of Surgery, Stanford University, Stanford, California, USA
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15
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Goo ZQ, Muthusamy KA. Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial. J Clin Neurosci 2022; 98:162-167. [PMID: 35182846 DOI: 10.1016/j.jocn.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Tracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy. METHODS This single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient's clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS In all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups. CONCLUSION Early tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.
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Affiliation(s)
- Zhen Qiang Goo
- Division of General Surgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Kalai Arasu Muthusamy
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Singh R, Shekhar S, De R, Singh R, Akhileshwar, Kumar N. Early versus late tracheostomy in patients with acute brain injury: Importance of SET score. Anesth Essays Res 2022; 16:7-11. [PMID: 36249128 PMCID: PMC9558650 DOI: 10.4103/aer.aer_22_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 02/08/2022] [Accepted: 03/02/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction: Patients with acute brain injury presents are unique subset of neurocritical care patients with its long-term functional prognosis difficult to determine. They often have long intensive care unit (ICU) stay and presents as challenge to decide when to transfer out of ICU. This prospective study aims to assess the benefits of early tracheostomy in terms of ICU-length of stay (ICU-LOS), number of days on ventilator (ventilator days), incidence of ventilator-associated pneumonia (VAP), and mortality rates. Materials and Methods: After institutional ethical clearance, 80 patients were randomized into two groups: Group A, early tracheostomy group (tracheostomy within 3 days of intubation) and Group B, standard of care group (tracheostomy after 10 days of intubation: late tracheostomy). A cutoff of 10 in the SET score was used in predicting need of early tracheostomy; both groups were compared with respect to ICU-LOS, number of ventilator days (ventilation time), need of analgesia and sedation, incidence of VAP, and mortality data. Results: Both the groups were comparable in terms of demographic profile and various disease severity scores. ICU-LOS was 14.9 ± 3.6 days in Group A and 17.2 ± 4.6 in Group B. The number of days on ventilator and incidence of VAP was significantly lower in Group A as compared to Group B. There was significantly lower mortality in Group A subset of patients in ICU. Conclusion: SET score is a simple and reliable score with fair accuracy and high sensitivity and specificity in predicting need of tracheostomy in neurocritical patients. A cutoff of 10 in the score can be reliably used in predicting need of early tracheostomy as in few other studies. Early tracheostomy is clearly advantageous in neurocritical patients, but has no advantage in terms of long-term mortality rates.
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