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O'Shea TF, Franko LR, Paneitz DC, Shelton KT, Osho AA, Auchincloss HG. Tracheostomy is associated with decreased vasoactive-inotropic score in postoperative cardiac surgery patients on prolonged mechanical ventilation. JTCVS OPEN 2024; 18:138-144. [PMID: 38690409 PMCID: PMC11056458 DOI: 10.1016/j.xjon.2024.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 01/24/2024] [Accepted: 02/02/2024] [Indexed: 05/02/2024]
Abstract
Objective We sought to quantify the influence that tracheostomy placement has on the hemodynamic stability of postoperative cardiac surgery patients with persistent ventilatory requirements. Methods A retrospective, single-center, and observational analysis of postoperative cardiac surgery patients with prolonged mechanical ventilation who underwent tracheostomy placement from 2018 to 2022 was conducted. Patients were excluded if receiving mechanical circulatory support or if they had an unrelated significant complication 3 days surrounding tracheostomy placement. Vasoactive and inotropic requirements were quantified using the Vasoactive-Inotrope Score. Results Sixty-one patients were identified, of whom 58 met inclusion criteria. The median vasoactive-inotrope score over the 3 days before tracheostomy compared with 3 days after decreased from 3.35 days (interquartile range, 0-8.79) to 0 days (interquartile range, 0-7.79 days) (P = .027). Graphic representation of this trend demonstrates a clear inflection point at the time of tracheostomy. Also, after tracheostomy placement, fewer patients were on vasoactive/inotropic infusions (67.2% [n = 39] pre vs 24.1% [n = 14] post; P < .001) and sedative infusions (62.1% [n = 36] pre vs 27.6% [n = 16] post; P < .001). The percent of patients on active mechanical ventilation did not differ. Conclusions The median vasoactive-inotrope score in cardiac surgery patients with prolonged mechanical ventilation was significantly reduced after tracheostomy placement. There was also a significant reduction in the number of patients on vasoactive/inotropic and sedative infusions 3 days after tracheostomy. These data suggest that tracheostomy has a positive effect on the hemodynamic stability of patients after cardiac surgery and should be considered to facilitate postoperative recovery.
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Affiliation(s)
| | - Lynze R. Franko
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
| | - Dane C. Paneitz
- Boston University School of Medicine, Boston, Mass
- Department of Surgery, Johns Hopkins Hospital, Baltimore, Md
| | - Kenneth T. Shelton
- Division of Critical Care, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Mass
| | - Asishana A. Osho
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
- Division of Cardiac Surgery, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Mass
| | - Hugh G. Auchincloss
- Department of Surgery, Massachusetts General Hospital, Boston, Mass
- Division of Thoracic Surgery, Massachusetts General Hospital, Boston, Mass
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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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Peng C, Peng L, Yang F, Yu H, Wang P, Cheng C, Zuo W, Li W, Jin Z. Impact of Early Tracheostomy on Clinical Outcomes in Trauma Patients Admitted to the Intensive Care Unit: A Retrospective Causal Analysis. J Cardiothorac Vasc Anesth 2023; 37:2584-2591. [PMID: 36631378 DOI: 10.1053/j.jvca.2022.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 12/14/2022] [Accepted: 12/22/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVES To assess the indications, timing, and clinical outcomes that result from the early tracheostomy (ET) administration, by causal inference models. DESIGN A retrospective observational study. SETTING Multiinstitutional intensive care unit in the United States PARTICIPANTS: The study comprised 626 trauma patients. INTERVENTIONS An ET versus late tracheostomy (LT). MEASUREMENTS AND MAIN RESULTS Trauma patients with tracheostomy were identified from 2 public databases named Medical Information Mart for the Intensive Care-IV and eICU Collaborative Research Database. Tracheostomy was defined as early (≤7 days) or late (>7 days) from intensive care unit admission. A marginal structural Cox model (MSCM) with inverse probability weighting was employed. For comparison, the authors also used time-dependent propensity-score matching (PSM) to account for differences in the probability of receiving an ET or LT. A total of 626 eligible patients were enrolled in the study, of whom 321 (51%) received a ET. The MSCM and time-dependent PSM indicated that the ET group was associated with reduced ventilation-associated pneumonia (VAP) and a shorter mechanical ventilation (MV) duration than the LT group. Yet, mortality did not show any difference between the two groups. CONCLUSIONS The authors' study observed that ET was not associated with reduced mortality in trauma patients, but it was associated with reduced VAP risk and MV duration. The results warrant further validation in randomized controlled trials.
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Affiliation(s)
- Chi Peng
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Liwei Peng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Fan Yang
- Institute of Pathology and Southwest Cancer Center, Southwest Hospital, Third Military Medical University (Army Medical University) and Key Laboratory of Tumor Immunopathology, Ministry of Education of China, Chongqing, China
| | - Hang Yu
- Emergency Department, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Peng Wang
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Chao Cheng
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Wei Zuo
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Weixin Li
- Department of Neurosurgery, Tangdu Hospital, Air Force Medical University, Xi'an, China.
| | - Zhichao Jin
- Department of Health Statistics, Naval Medical University, Shanghai, China.
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Keizman E, Frogel JK, Ram E, Volvovitch D, Jamal T, Levin S, Raanani E, Sternik L, Kogan A. Early tracheostomy after cardiac surgery improves intermediate- and long-term survival. Med Intensiva 2023; 47:516-525. [PMID: 36868962 DOI: 10.1016/j.medine.2023.02.003] [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: 09/02/2022] [Accepted: 02/05/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVE Complicated post-cardiac surgery course, can lead to both prolonged ICU stay and ventilation, and may require a tracheostomy. This study represents the single-center experience with post-cardiac surgery tracheostomy. The aim of this study was to assess the timing of tracheostomy as a risk factor for early, intermediate, and late mortality. The study's second aim was to assess the incidence of both superficial and deep sternal wound infections. DESIGN Retrospective study of prospectively collected data. SETTING Tertiary hospital. PATIENTS Patients were divided into 3 groups, according to the timing of tracheostomy; early (4-10 days); intermediate (11-20 days) and late (≥21 days). INTERVENTIONS None. MAIN VARIABLES OF INTEREST The primary outcomes were early, intermediate, and long-term mortality. The secondary outcome was the incidence of sternal wound infection. RESULTS During the 17-year study period, 12,782 patients underwent cardiac surgery, of whom 407 (3.18%) required postoperative tracheostomy. 147 (36.1%) had early, 195 (47.9%) intermediate, and 65 (16%) had a late tracheostomy. Early, 30-day, and in-hospital mortality was similar for all groups. However, patients, who underwent early- and intermediate tracheostomy, demonstrated statistically significant lower mortality after 1- and 5-year (42.8%; 57.4%; 64.6%; and 55.8%; 68.7%; 75.4%, respectively; P < .001). Cox model demonstrated age [1.025 (1.014-1.036)] and timing of tracheostomy [0.315 (0.159-0.757)] had significant impacts on mortality. CONCLUSIONS This study demonstrates a relationship between the timing of tracheostomy after cardiac surgery and mortality: early tracheostomy (within 4-10 days of mechanical ventilation) is associated with better intermediate- and long-term survival.
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Affiliation(s)
- Eitan Keizman
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Jonathan K Frogel
- Department of Anaesthesiology, Sheba Medical Centre, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Eilon Ram
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - David Volvovitch
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Tamer Jamal
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Shany Levin
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel
| | - Alexander Kogan
- Department of Cardiac Surgery, Leviev Cardiothoracic and Vascular Centre, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel; Cardiac Surgery ICU, Sheba Medical Centre, affiliated to the Sackler School of Medicine, Tel Aviv University, Israel.
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5
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Elsayed AA, Mousa MR, Beshey BN. Impact of early versus late tracheotomy on diaphragmatic function assessed by ultrasonography in mechanically ventilated stroke patients. EGYPTIAN JOURNAL OF ANAESTHESIA 2022. [DOI: 10.1080/11101849.2022.2067679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Affiliation(s)
- Amr Abdalla Elsayed
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Mohammed Refaat Mousa
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Bassem Nashaat Beshey
- Critical Care Medicine Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
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Chen JR, Gao HR, Yang YL, Wang Y, Zhou YM, Chen GQ, Li HL, Zhang L, Zhou JX. A U-shaped association of tracheostomy timing with all-cause mortality in mechanically ventilated patients admitted to the intensive care unit: A retrospective cohort study. Front Med (Lausanne) 2022; 9:1068569. [PMID: 36590960 PMCID: PMC9794610 DOI: 10.3389/fmed.2022.1068569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
Objectives To evaluate the association of tracheostomy timing with all-cause mortality in patients with mechanical ventilation (MV). Method It's a retrospective cohort study. Adult patients undergoing invasive MV who received tracheostomy during the same hospitalization based on the Medical Information Mart for Intensive Care-III (MIMIC-III) database, were selected. The primary outcome was the relationship between tracheostomy timing and 90-day all-cause mortality. A restricted cubic spline was used to analyze the potential non-linear correlation between tracheostomy timing and 90-day all-cause mortality. The secondary outcomes included free days of MV, incidence of ventilator-associated pneumonia (VAP), free days of analgesia/sedation in the intensive care unit (ICU), length of stay (LOS) in the ICU, LOS in hospital, in-ICU mortality, and 30-day all-cause mortality. Results A total of 1,209 patients were included in this study, of these, 163 (13.5%) patients underwent tracheostomy within 4 days after intubation, while 647 (53.5%) patients underwent tracheostomy more than 11 days after intubation. The tracheotomy timing showed a U-shaped relationship with all-cause mortality, patients who underwent tracheostomy between 5 and 10 days had the lowest 90-day mortality rate compared with patients who underwent tracheostomy within 4 days and after 11 days [84 (21.1%) vs. 40 (24.5%) and 206 (31.8%), P < 0.001]. Conclusion The tracheotomy timing showed a U-shaped relationship with all-cause mortality, and the risk of mortality was lowest on day 8, but a causal relationship has not been demonstrated.
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Affiliation(s)
- Jing-Ran Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hao-Ran Gao
- Department of Critical Care Medicine, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yan-Lin Yang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yan Wang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi-Min Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Guang-Qiang Chen
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Hong-Liang Li
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Linlin Zhang
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jian-Xin Zhou
- Department of Critical Care Medicine, Beijing Tiantan Hospital, Capital Medical University, Beijing, China,Department of Critical Care Medicine, Beijing Shijitan Hospital, Capital Medical University, Beijing, China,*Correspondence: Jian-Xin Zhou,
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7
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Predictors and outcomes of postoperative tracheostomy in patients undergoing acute type A aortic dissection surgery. BMC Cardiovasc Disord 2022; 22:94. [PMID: 35264113 PMCID: PMC8908588 DOI: 10.1186/s12872-022-02538-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 03/03/2022] [Indexed: 11/21/2022] Open
Abstract
Background Despite surgical advances, acute type A aortic dissection remains a life-threatening disease with high mortality and morbidity. Tracheostomy is usually used for patients who need prolonged mechanical ventilation in the intensive care unit (ICU). However, data on the risk factors for requiring tracheostomy and the impact of tracheostomy on outcomes in patients after Stanford type A acute aortic dissection surgery (AADS) are limited. Methods A retrospective single-institutional study including consecutive patients who underwent AADS between January 2016 and December 2019 was conducted. Patients who died intraoperatively were excluded. Univariate analysis and multivariate logistic regression analysis were used to identify independent risk factors for postoperative tracheostomy (POT). A nomogram to predict the probability of POT was constructed based on independent predictors and their beta-coefficients. The area under the receiver operating characteristic curve (AUC) was performed to assess the discrimination of the model. Calibration plots and the Hosmer–Lemeshow test were used to evaluate calibration. Clinical usefulness of the nomogram was assessed by decision curve analysis. Propensity score matching analysis was used to analyze the correlation between requiring tracheostomy and clinical prognosis. Results There were 492 patients included in this study for analysis, including 55 patients (11.2%) requiring tracheostomy after AADS. Compared with patients without POT, patients with POT experienced longer ICU and hospital stay and higher mortality. Age, cerebrovascular disease history, preoperative white blood cell (WBC) count and renal insufficiency, intraoperative amount of red blood cell (RBC) transfusion and platelet transfusion were identified as independent risk factors for POT. Our constructed nomogram had good discrimination with an AUC = 0.793 (0.729–0.856). Good calibration and clinical utility were observed through the calibration and decision curves, respectively. For better clinical application, we defined four intervals that stratified patients from very low to high risk for occurrence of POT. Conclusions Our study identified preoperative and intraoperative risk factors for POT and found that requiring tracheostomy was related to the poor outcomes in patients undergoing AADS. The established prediction model was validated with well predictive performance and clinical utility, and it may be useful for individual risk assessment and early clinical decision-making to reduce the incidence of tracheostomy.
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8
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Wang D, Wang S, Du Y, Song Y, Le S, Wang H, Zhang A, Huang X, Wu L, Du X. A Predictive Scoring Model for Postoperative Tracheostomy in Patients Who Underwent Cardiac Surgery. Front Cardiovasc Med 2022; 8:799605. [PMID: 35155610 PMCID: PMC8831542 DOI: 10.3389/fcvm.2021.799605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 12/28/2021] [Indexed: 12/26/2022] Open
Abstract
BackgroundA subset of patients require a tracheostomy as respiratory support in a severe state after cardiac surgery. There are limited data to assess the predictors for requiring postoperative tracheostomy (POT) in cardiac surgical patients.MethodsThe records of adult patients who underwent cardiac surgery from 2016 to 2019 at our institution were reviewed. Univariable analysis was used to assess the possible risk factors for POT. Then multivariable logistic regression analysis was performed to identify independent predictors. A predictive scoring model was established with predictor assigned scores derived from each regression coefficient divided by the smallest one. The area under the receiver operating characteristic curve and the Hosmer-Lemeshow goodness-of-fit test were used to evaluate the discrimination and calibration of the risk score, respectively.ResultsA total of 5,323 cardiac surgical patients were included, with 128 (2.4%) patients treated with tracheostomy after cardiac surgery. Patients with POT had a higher frequency of readmission to the intensive care unit (ICU), longer stay, and higher mortality (p < 0.001). Mixed valve surgery and coronary artery bypass grafting (CABG), aortic surgery, renal insufficiency, diabetes mellitus, chronic obstructive pulmonary disease (COPD), pulmonary edema, age >60 years, and emergent surgery were independent predictors. A 9-point risk score was generated based on the multivariable model, showing good discrimination [the concordance index (c-index): 0.837] and was well-calibrated.ConclusionsWe established and verified a predictive scoring model for POT in patients who underwent cardiac surgery. The scoring model was conducive to risk stratification and may provide meaningful information for clinical decision-making.
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Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Su Wang
- Department of Emergency Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yifan Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Song
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Anchen Zhang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Anchen Zhang
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Xiaofan Huang
| | - Long Wu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Long Wu
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Xinling Du
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Cote CL, Melong J, Tremblay P, Fagan A, Cooper M, Mullins G, Vician M, Brown T, Herman CR. Long-term laryngotracheal complications following cardiac surgery. J Card Surg 2021; 36:4597-4603. [PMID: 34647349 DOI: 10.1111/jocs.16066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Revised: 08/23/2021] [Accepted: 10/05/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Long-term laryngotracheal complications have not been described in adult patients undergoing cardiac surgery. The purpose of this study was to determine the incidence of and risk factors for laryngotracheal complications following cardiac surgery. METHODS A retrospective chart review of patients at high risk for laryngotracheal complications following cardiac surgery between 2006 and 2016 was performed. High-risk patients were reviewed to determine the presence of laryngotracheal complications including laryngotracheal stenosis, keyhole deformity, or vocal cord immobility. Logistic regression was used to identify predictors of long-term laryngotracheal complications. RESULTS Of 11,417 patients who underwent cardiac surgery, 1099 were identified as at high risk. Of these, 24 (2.2%) developed laryngotracheal complications following their surgery and intensive care unit (ICU) stay. Laryngotracheal stenosis and keyhole deformity were present in 13 (1.2%) and 6 (0.5%) patients, respectively. Logistic regression demonstrated older age (age ≥ 70 odds ratio [OR] 0.31, 95% confidence interval [CI] 0.12-0.83) was protective, while readmission to ICU for ventilation (OR 3.11, 95% CI 1.17-8.25) and receiving a tracheostomy (OR 7.83, 95% CI 2.22-27.6) were associated with laryngotracheal complications. CONCLUSIONS The incidence of long-term laryngotracheal complications following cardiac surgery was 2.2%. Readmission to ICU for ventilation and having a tracheostomy performed were associated with laryngotracheal complications.
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Affiliation(s)
- Claudia L Cote
- Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Jonathan Melong
- Division of Otolaryngology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Philippe Tremblay
- Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Andrew Fagan
- Department of Critical Care, Western University, London, Ontario, Canada
| | - Matthew Cooper
- Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Graeme Mullins
- Department of Family Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael Vician
- Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Tim Brown
- Division of Otolaryngology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Christine R Herman
- Division of Cardiac Surgery, Dalhousie University, Halifax, Nova Scotia, Canada
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Okada M, Watanuki H, Masato T, Sugiyama K, Futamura Y, Matsuyama K. Impact of Tracheostomy Timing on Outcomes After Cardiovascular Surgery. J Cardiothorac Vasc Anesth 2021; 36:2335-2338. [PMID: 34756803 DOI: 10.1053/j.jvca.2021.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 09/11/2021] [Accepted: 10/01/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aimed to investigate whether tracheostomy timing in patients undergoing cardiac surgery had an impact on outcomes. DESIGN Retrospective, observational study. SETTING Single-center university hospital. PARTICIPANTS Patients requiring tracheostomy among a total of 961 patients who underwent cardiovascular surgery via a median sternotomy from January 2014 to March 2021. INTERVENTIONS Early versus late tracheostomy. MEASUREMENTS AND MAIN RESULTS During the study period, tracheostomy was performed in 28 patients (2.9%). According to tracheostomy timing, postoperative day seven was chosen as the cutoff to define early (≤seven days) and late (>seven days) tracheostomy. Patients in the early-tracheostomy group had a significantly shorter ventilation time after tracheostomy compared with the late-tracheostomy group (p = 0.039), and early tracheostomy resulted in a reduction in total ventilation time (p = 0.001). The incidence of pressure ulcers was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group. There was a higher tracheal tube removal rate in the early-tracheostomy group compared with the late-tracheostomy group (p = 0.0007). The one-year survival rate in the early- and late-tracheostomy groups was 65% and 31%, respectively. The long-term mortality rate was significantly lower in the early-tracheostomy group compared with the late- tracheostomy group (p = 0.04). CONCLUSIONS Early tracheostomy (<seven days) may provide better clinical outcomes, with lower mortality and morbidity rates, when patients are judged to require at least seven days of ventilation after cardiovascular surgery.
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Affiliation(s)
- Masaho Okada
- Department of Cardiac Surgery, Aichi Medical University Hospital, Aichi, Japan
| | - Hirotaka Watanuki
- Department of Cardiac Surgery, Aichi Medical University Hospital, Aichi, Japan
| | - Tochii Masato
- Department of Cardiac Surgery, Aichi Medical University Hospital, Aichi, Japan
| | - Kayo Sugiyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Aichi, Japan
| | - Yasuhiro Futamura
- Department of Cardiac Surgery, Aichi Medical University Hospital, Aichi, Japan
| | - Katsuhiko Matsuyama
- Department of Cardiac Surgery, Aichi Medical University Hospital, Aichi, Japan.
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Bipin C, Sahu MK, Singh SP, Devagourou V, Rajashekar P, Hote MP, Talwar S, Choudhary SK. Tracheostomy in Postoperative Pediatric Cardiac Surgical Patients—The Earlier, the Better. JOURNAL OF CARDIAC CRITICAL CARE TSS 2021. [DOI: 10.1055/s-0041-1723749] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
Abstract
Abstract
Objectives This study was aimed to assess the benefits of early tracheostomy (ET) compared with late tracheostomy (LT) on postoperative outcomes in pediatric cardiac surgical patients.
Design Present one is a prospective, observational study.
Setting The study was conducted at a cardiac surgical intensive care unit (ICU) of a tertiary care hospital.
Participants All pediatric patients below 10 years of age, who underwent tracheostomy after cardiac surgery from January2019 to december2019, were subdivided into two groups according to the timing of tracheostomy: “early” if done before 7 days or “late” if done after 7 days postcardiac surgery.
Interventions ET versus LT was measured in the study.
Results Out of all 1,084 pediatric patients who underwent cardiac surgery over the study period, 41 (3.7%) received tracheostomy. Sixteen (39%) patients underwent ET and 25 (61%) underwent LT. ET had advantages by having reduced risk associations with the following variables: preoperative hospital stay (p = 0.0016), sepsis (p = 0.03), high risk surgery (p = 0.04), postoperative sepsis (p = 0.001), C-reactive protein (p = 0.04), ventilator-associated pneumonia (VAP; p = 0.006), antibiotic escalation (p = 0.006), and antifungal therapy (p = 0.01) requirement. Furthermore, ET was associated with lesser duration of mechanical ventilation (p = 0.0027), length of ICU stay (LOICUS; p = 0.01), length of hospital stay (LOHS; p = 0.001), lesser days of feed interruption (p = 0.0017), and tracheostomy tube change (p = 0.02). ET group of children, who had higher total ventilation-free days (p = 0.02), were decannulated earlier (p = 0.03) and discharged earlier (p = 0.0089).
Conclusion ET had significant benefits in reduction of postoperative morbidities with overall shorter mechanical ventilation, LOICUS, and LOHS, better nutrition supplementation, lesser infection, etc. These benefits may promote faster patient convalescence and rehabilitation with reduced hospital costs.
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Affiliation(s)
- Chalattil Bipin
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Manoj K. Sahu
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sarvesh P. Singh
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Velayoudam Devagourou
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Palleti Rajashekar
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Milind P. Hote
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Sachin Talwar
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
| | - Shiv K. Choudhary
- Intensive Care for Cardio Thoracic Vascular Surgery, Cardio Neuro Center, All India Institute of Medical Sciences, New Delhi, India
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Sareh S, Toppen W, Ugarte R, Sanaiha Y, Hadaya J, Seo YJ, Aguayo E, Shemin R, Benharash P. Impact of Early Tracheostomy on Outcomes After Cardiac Surgery: A National Analysis. Ann Thorac Surg 2020; 111:1537-1544. [PMID: 32979372 DOI: 10.1016/j.athoracsur.2020.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/03/2020] [Accepted: 07/20/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Despite evidence supporting its early use in respiratory failure, tracheostomy is often delayed in cardiac surgical patients given concerns for sternal infection. This study assessed national trends in tracheostomy creation among cardiac patients and evaluated the impact of timing to tracheostomy on postoperative outcomes. METHODS We used the 2005 to 2015 National Inpatient Sample to identify adults undergoing coronary revascularization or valve operations and categorized them based on timing of tracheostomy: early tracheostomy (ET) (postoperative days 1-14) and delayed tracheostomy (DT) (postoperative days 15-30). Temporal trends in the timing of tracheostomy were analyzed, and multivariable models were created to compare outcomes. RESULTS An estimated 33,765 patients (1.4%) required a tracheostomy after cardiac operations. Time to tracheostomy decreased from 14.8 days in 2005 to 13.9 days in 2015, sternal infections decreased from 10.2% to 2.9%, and in-hospital death also decreased from 23.3% to 15.9% over the study period (all P for trend <.005). On univariate analysis, the ET cohort had a lower rate of sternal infection (5.2% vs 7.8%, P < .001), in-hospital death (16.7% vs 22.9%, P < .001), and length of stay (33.7 vs 43.6 days, P < .001). On multivariable regression, DT remained an independent predictor of sternal infection (adjusted odds ratio, 1.35; P < .05), in-hospital death (odds ratio, 1.36; P < .001), and length of stay (9.1 days, P < .001), with no difference in time from tracheostomy to discharge between the 2 cohorts (P = .40). CONCLUSIONS In cardiac surgical patients, ET yielded similar postoperative outcomes, including sternal infection and in-hospital death. Our findings should reassure surgeons considering ET in poststernotomy patients with respiratory failure.
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Affiliation(s)
- Sohail Sareh
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California; Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, California
| | - William Toppen
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Ramsey Ugarte
- Department of Surgery, Los Angeles County Harbor-UCLA Medical Center, Torrance, California
| | - Yas Sanaiha
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Joseph Hadaya
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Young Ji Seo
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Esteban Aguayo
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Richard Shemin
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California
| | - Peyman Benharash
- Cardiovascular Outcomes Research Laboratories, Division of Cardiac Surgery, University of California, Los Angeles, Los Angeles, California.
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13
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Nam IC, Shin YS, Jeong WJ, Park MW, Park SY, Song CM, Lee YC, Jeon JH, Lee J, Kang CH, Park IS, Kim K, Sun DI. Guidelines for Tracheostomy From the Korean Bronchoesophagological Society. Clin Exp Otorhinolaryngol 2020; 13:361-375. [PMID: 32717774 PMCID: PMC7669309 DOI: 10.21053/ceo.2020.00353] [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: 03/16/2020] [Accepted: 05/19/2020] [Indexed: 12/17/2022] Open
Abstract
The Korean Bronchoesophagological Society appointed a task force to develop a clinical practice guideline for tracheostomy. The task force conducted a systematic search of the Embase, Medline, Cochrane Library, and KoreaMed databases to identify relevant articles, using search terms selected according to key questions. Evidence-based recommendations for practice were ranked according to the American College of Physicians grading system. An external expert review and a Delphi questionnaire were conducted to reach a consensus regarding the recommendations. Accordingly, the committee developed 18 evidence-based recommendations, which are grouped into seven categories. These recommendations are intended to assist clinicians in performing tracheostomy and in the management of tracheostomized patients.
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Affiliation(s)
| | - Inn-Chul Nam
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Yoo Seob Shin
- Department of Otolaryngology-Head and Neck Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Woo-Jin Jeong
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Min Woo Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Seong Yong Park
- Department of Thoracic and Cardiovascular Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Chang Myeon Song
- Department of Otolaryngology-Head and Neck Surgery, Hanyang University College of Medicine, Seoul, Korea
| | - Young Chan Lee
- Department of Otolaryngology-Head and Neck Surgery, Kyung Hee University School of Medicine, Seoul, Korea
| | - Jae Hyun Jeon
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jongmin Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chang Hyun Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Il-Seok Park
- Department of Otorhinolaryngology-Head and Neck Surgery, Hallym University College of Medicine, Seoul, Korea
| | - Kwhanmien Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Dong Il Sun
- Department of Otolaryngology-Head and Neck Surgery, College of Medicine, The Catholic University of Korea, Seoul, Korea
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14
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Krebs ED, Chancellor WZ, Beller JP, Mehaffey JH, Hawkins RB, Sawyer RG, Yarboro LT, Ailawadi G, Teman NR. Long-term Implications of Tracheostomy in Cardiac Surgery Patients: Decannulation and Mortality. Ann Thorac Surg 2020; 111:594-599. [PMID: 32619618 DOI: 10.1016/j.athoracsur.2020.05.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/01/2020] [Accepted: 05/07/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND The long-term implications of tracheostomy in cardiac surgical patients are largely unknown. We sought to investigate outcomes including decannulation and long-term mortality in a population of post-cardiac surgery patients. METHODS All patients undergoing cardiac surgery at a single institution between 1997 and 2016 were evaluated for postoperative tracheostomy placement, time to decannulation, and mortality. Patients were stratified by tracheostomy placement, as well as by successful decannulation for comparison. Kaplan-Meier analysis identified time to decannulation and mortality and a Fine-Gray's competing risk regression, accounting for mortality, identified predictors of time to decannulation. RESULTS Of 14,600 total cardiac surgery patients, only 309 required tracheostomy. Patients with tracheostomy had high rates of perioperative comorbidities, including 60% with heart failure and 24% with postoperative stroke. Tracheostomy patients had high short-term and long-term mortality, with a median survival of 152 days, 1-year survival of 41%, and 5-year survival of 29.1%. Patients remained with tracheostomy in place for a median of 59 days, with a 1-year decannulation rate of 80% in living patients. Patients with older age (hazard ratio 0.98, P = .01), chronic lung disease (hazard ratio 0.66, P = .03), and preoperative or postoperative dialysis (hazard ratio 0.45, P < .01) were less likely to have their tracheostomy removed. CONCLUSIONS Tracheostomy is associated with poor long-term survival of cardiac surgery patients. However, patients who do survive have a short duration of tracheostomy with almost all surviving patients eventually decannulated. This finding provides valuable information for pre-procedural counseling for these high-risk patients and their families.
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Affiliation(s)
- Elizabeth D Krebs
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia.
| | - William Z Chancellor
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Jared P Beller
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - J Hunter Mehaffey
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert B Hawkins
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Robert G Sawyer
- Department of Surgery, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan
| | - Leora T Yarboro
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Gorav Ailawadi
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
| | - Nicholas R Teman
- Division of Thoracic and Cardiovascular Surgery, University of Virginia, Charlottesville, Virginia
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15
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Sutt AL, Tronstad O, Barnett AG, Kitchenman S, Fraser JF. Earlier tracheostomy is associated with an earlier return to walking, talking, and eating. Aust Crit Care 2020; 33:213-218. [PMID: 32299649 DOI: 10.1016/j.aucc.2020.02.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 02/25/2020] [Accepted: 02/28/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Conjecture remains regarding the optimal timing for tracheostomy. Most studies examine patient mortality, ventilation duration, intensive care unit (ICU) length of stay, and medical complications. Few studies examine patient-centric outcomes. The aim of this study was to determine whether timing of tracheostomy had an impact on length of stay, morbidity, mortality, and patient-centric outcomes towards their functional recovery. METHODS This prospective observational study included data for all tracheostomised patients over 4 y in a tertiary ICU. The study time period commenced with the insertion of an endotracheal tube. Data collected included patient and disease specifics; mortality up to 4 y; mobility scores; and time to oral intake, talking, and out-of-bed exercises. To assess differences between timing of tracheostomy, a survival analysis was conducted to dynamically compare patients on days before and after tracheostomy tube (TT) placement during their ICU admission. RESULTS TT was placed in 276 patients. After tracheostomy, the patients were able to (on average) verbally communicate 7.4 d earlier (confidence interval [CI] = -9.1 to -4.9), return to oral intake 7.0 d earlier (CI = -10 to -4.6), and perform out-of-bed exercises 6.2 d earlier (CI = -8.4 to -4) than those who did not yet have a TT. In patients with an endotracheal tube, none were able to talk or have oral intake, and the majority (99%) did not participate in out-of-bed exercises/active rehabilitation. After tracheostomy, patients subsequently received significantly less analgesic and sedative drugs and more antipsychotics. No clear differences in ICU and long-term mortality were associated with tracheostomy timing. CONCLUSIONS Earlier tracheostomy is associated with earlier achievement of patient-centric outcomes - patients returning to usual daily activities such as talking, out-of-bed mobility, and eating/drinking significantly earlier, whilst also receiving less sedatives and analgesics.
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Affiliation(s)
- Anna Liisa Sutt
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia.
| | - Oystein Tronstad
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia; Physiotherapy Department, The Prince Charles Hospital, Brisbane, Australia.
| | - Adrian G Barnett
- Institute of Health and Biomedical Innovation & School of Public Health and Social Work, Queensland University of Technology, Brisbane, Australia.
| | - Sarah Kitchenman
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia.
| | - John F Fraser
- Critical Care Research Group, Adult Intensive Care Services, The Prince Charles Hospital, Brisbane, Australia; Northside Medical School, University of Queensland, Brisbane, Australia.
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16
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Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Zirpe K, Srinivasan S, Mohamed Z, Gupta KV, Wanchoo J, Chakrabortty N, Gurav S. Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020; 24:S31-S42. [PMID: 32205955 PMCID: PMC7085814 DOI: 10.5005/jp-journals-10071-g23184] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND AIM Critically ill patients on mechanical ventilation undergo tracheostomy to facilitate weaning. The practice in India may be different from the rest of the world and therefore, in order to understand this, ISCCM conducted a multicentric observational study "DIlatational percutaneous vs Surgical tracheoStomy in intEnsive Care uniT: A practice pattern observational multicenter study (DISSECT Study)" followed by an ISCCM Expert Panel committee meeting to formulate Practice recommendations pertinent to Indian ICUs. MATERIALS AND METHODS All existing International guidelines on the topic, various randomized controlled trials, meta-analysis, systematic reviews, retrospective studies were taken into account to formulate the guidelines. Wherever Indian data was not available, international data was analysed. A modified Grade system was followed for grading the recommendation. RESULTS After analyzing the entire available data, the recommendations were made by the grading system agreed by the Expert Panel. The recommendations took into account the indications and contraindications of tracheostomy; effect of timing of tracheostomy on incidence of ventilator associated pneumonia, ICU length of stay, ventilator free days & Mortality; comparison of surgical and percutaneous dilatational tracheostomy (PDT) in terms of incidence of complications and cost to the patient; Comparison of various techniques of PDT; Use of fiberoptic bronchoscope and ultrasound in PDT; experience of the operator and qualification; certain special conditions like coagulopathy and morbid obesity. CONCLUSION This document presents the first Indian recommendations on tracheostomy in adult critically ill patients based on the practices of the country. These guidelines are expected to improve the safety and extend the indications of tracheostomy in critically ill patients. HOW TO CITE THIS ARTICLE Gupta S, Dixit S, Choudhry D, Govil D, Mishra RC, Samavedam S, Tracheostomy in Adult Intensive Care Unit: An ISCCM Expert Panel Practice Recommendations. Indian J Crit Care Med 2020;24(Suppl 1):S31-S42.
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Affiliation(s)
- Sachin Gupta
- Department of Critical Care Medicine, Narayana Superspeciality Hospital, Gurugram, Haryana, India, , e-mail:
| | - Subhal Dixit
- Department of Critical Care Medicine, Sanjeevan & MJM Hospital, Pune, Maharashtra, India, , e-mail:
| | - Dhruva Choudhry
- Department of Pulmonary & Critical Care Medicine, University of Health Sciences Rohtak, Haryana, India, , e-mail:
| | - Deepak Govil
- Department of Critical Care, Institute of Critical Care & Anesthesiology, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | | | - Srinivas Samavedam
- Department of Critical Care, Virinchi Hospital, Hyderabad, Telangana, India, , e-mail:
| | - Kapil Zirpe
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
| | - Shrikanth Srinivasan
- Department of Critical Care Medicine, Manipal Hospitals, New Delhi, India, , e-mail:
| | - Zubair Mohamed
- Department of Organ Transplant Anaesthesia and Critical Care, Amrita Institute of Medical Sciences and Research Centre, Kochi, Kerala, India, , e-mail:
| | - Kv Venkatesha Gupta
- Department of Critical Care Medicine, Manipal Hospitals, Bengaluru, Karnataka, India, , e-mail:
| | - Jaya Wanchoo
- Department of Neuroanaesthesia and Critical Care, Institute of Neurosciences, Medanta The Medicity, Gurugram, Haryana, India, , e-mail:
| | - Nilanchal Chakrabortty
- Department of Neurointensive Care, Institute of Neurosciences, Kolkata, West Bengal, India, , e-mail:
| | - Sushma Gurav
- Department of Neurocritical Care, Ruby Hall Clinic, Grant Medical Foundation, Pune, Maharashtra, India, , e-mail:
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17
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Huddleston SJ, Brown R, Rudser K, Goswami U, Tomic R, Lemke NT, Shaffer AW, Soule M, Hertz M, Shumway S, Kelly R, Loor G. Need for tracheostomy after lung transplant predicts decreased mid- and long-term survival. Clin Transplant 2019; 34:e13766. [PMID: 31815320 DOI: 10.1111/ctr.13766] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 11/30/2019] [Accepted: 12/05/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND Tracheostomy is an important adjunct for lung transplant patients requiring prolonged ventilation. We explored the effects of post-transplant tracheostomy on survival and bronchiolitis obliterans syndrome after lung transplant. METHODS A retrospective, single center analysis was performed on all lung transplant recipients during the Lung Allocation Score (LAS) era. Risk factors for post-transplant tracheostomy or death within 30 days were assessed. Kaplan-Meier estimates and Cox proportional hazards models were used to examine the association between tracheostomy within 30 days after transplant and survival at 1 and 3 years. A total of 403 patients underwent single or bilateral lung transplant between May 2005 and February 2016 with complete data for 352 cases, and 35 patients (9.9%) underwent tracheostomy or died (N = 10, 2.8%) within 30 days. RESULTS In adjusted analyses, primary graft dysfunction grade 3 (PGD3) was associated with a composite end point of tracheostomy or death within 30 days (HR 3.11 (1.69, 5.71), P-value < .001). Tracheostomy within 30 days was associated with decreased survival at 1(HR 4.25 [1.75, 10.35] P-value = .001) and 3 years (HR 2.74 [1.30, 5.76], P-value = .008), as well as decreased bronchiolitis obliterans (BOS)-free survival at 1 (HR 1.87 [1.02, 3.41] P-value = .042) and 3 years (HR 2.15 [1.33, 3.5], P-value = .002). CONCLUSION Post-transplant tracheostomy is a marker for advanced lung allograft dysfunction with significant reduction in long-term overall and BOS-free survival.
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Affiliation(s)
- Stephen J Huddleston
- Division of Cardiothoracic Surgery, Department of a Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Roland Brown
- Divison of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Kyle Rudser
- Divison of Biostatistics, University of Minnesota School of Public Health, Minneapolis, MN, USA
| | - Umesh Goswami
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Rade Tomic
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Nicholas T Lemke
- Division of Cardiothoracic Surgery, Department of a Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Andrew W Shaffer
- Division of Cardiothoracic Surgery, Department of a Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Matthew Soule
- Division of Cardiothoracic Surgery, Department of a Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Marshall Hertz
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Department of Medicine, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Sara Shumway
- Division of Cardiothoracic Surgery, Department of a Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Rose Kelly
- Division of Cardiothoracic Surgery, Department of a Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Texas Heart Institute, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX, USA
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Jacob B, Stock D, Chan V, Colantonio A, Cullen N. Predictors of in-hospital mortality following hypoxic-ischemic brain injury: a population-based study. Brain Inj 2019; 34:178-186. [PMID: 31674215 DOI: 10.1080/02699052.2019.1683897] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To identify predictors of in-hospital mortality following Hypoxic-Ischemic Brain Injury (HIBI) using the Anderson Behavioral Model.Design and Setting: Population based retrospective cohort study in Ontario, Canada with data collected between 1 April 2002 and 31 March 2017.Patients: Adult patients aged 20 years and older with HIBI-related acute care admission were identified in the health administrative data. Multivariable cox proportional hazard regression models were used to identify predisposing, need and enabling factors that predict in-hospital mortality.Results: Of the 7492 patients admitted to acute care with HIBI, the in-hospital mortality rate was 71%. The predisposing factors associated with mortality were female sex (HR, 1.16; 95% CI, 1.10-1.23) and older age (65-79 vs. 20-34: HR, 1.17; 95% CI, 1.02-1.35). The need factors associated with mortality were the presence of COPD (HR, 1.10; 95% CI, 1.02-1.17), psychiatric illness (HR, 1.13; 95% CI, 1.05-1.20) injury due to cardiac illness (HR, 1.19; 95% CI, 1.12-1.26) and longer emergency department length of stay. Having spending any time in an alternate level of care and the application of tracheotomy procedures were found to reduce mortality.Conclusions: The acute/critical care centers need to consider these findings to adopt prevention strategies targeting reduced in-hospital mortality.
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Affiliation(s)
- Binu Jacob
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - David Stock
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Clinical Health and Epidemiology, Dalhousie University, Halifax, Canada
| | - Vincy Chan
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada
| | - Angela Colantonio
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,Institute for Clinical Evaluative Sciences, Toronto, Canada.,Department of Occupational Science & Occupational Therapy, University of Toronto, Toronto, Canada
| | - Nora Cullen
- Toronto Rehabilitation Institute, University Health Network, Toronto, Canada.,Rehabilitation Sciences Institute, University of Toronto, Toronto, Canada.,West Park Healthcare Centre, Toronto, Canada
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19
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Deser SB. Does Tracheostomy Affect the Mortality and Morbidity Rate After Cardiac Surgery? JOURNAL OF CLINICAL AND EXPERIMENTAL INVESTIGATIONS 2018. [DOI: 10.5799/jcei.433810] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
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20
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Affronti A, Casali F, Eusebi P, Todisco C, Volpi F, Beato V, Manini EV, Scopetani G, Ragni T. Early Versus Late Tracheostomy in Cardiac Surgical Patients: A 12-Year Single Center Experience. J Cardiothorac Vasc Anesth 2018; 33:82-90. [PMID: 30049523 DOI: 10.1053/j.jvca.2018.05.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Indexed: 02/07/2023]
Abstract
OBJECTIVES To evaluate whether early tracheostomy is associated with better outcomes in mechanical ventilation-dependent patients after cardiac surgery compared with a late tracheostomy. DESIGN Retrospective, observational study. SETTING Cardiac surgical intensive care unit (ICU) of a tertiary care center. PARTICIPANTS All patients who underwent tracheostomy after cardiac surgery between 2004 and 2015 were subdivided into the following 2 groups according to the timing of tracheostomy: "early" if the tracheostomy was performed before the 14th postoperative day and "late" from the 14th postoperative day onward. INTERVENTIONS Early versus late tracheostomy. MEASUREMENTS AND MAIN RESULTS During the study period, 112 of 5,148 patients (2.2%) underwent tracheostomy after cardiac surgery. Early tracheostomy was performed in 62 patients, and 50 patients underwent late tracheostomy. Both groups of patients were similar in terms of preoperative and intraoperative characteristics, perioperative risk, and postoperative complications. Patients in the early group had a significantly shorter ventilation time (31.3 ± 23.6 v 39.4 ± 22.4 d; p = 0.034), shorter ICU stay (37.7 ± 21.7 v 46.4 ± 25 d; p = 0.025), and a shorter hospital stay (53.4 ± 29.3 v 66.8 ± 38.5 d; p = 0.020). There were no intergroup differences in weaning rates and in-hospital, 3-month, and 1- and 2-year mortality. CONCLUSIONS In this study, early tracheostomy after cardiac surgery in patients requiring prolonged mechanical ventilation was associated with a shorter ventilation time and ICU and hospital stay, but did not result in a lower in-hospital and long-term mortality rate.
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Affiliation(s)
- Alessandro Affronti
- Department of Cardiac Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy.
| | - Francesco Casali
- Department of Cardiac Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Paolo Eusebi
- Health Planning Service, Regional Health Authority of Umbria, Department of Epidemiology and Neurological Clinic, Department of Medicine, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Cristina Todisco
- Department of Anaesthesia and Intensive Care, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Francesca Volpi
- Department of Anaesthesia and Intensive Care, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Virginia Beato
- Department of Anaesthesia and Intensive Care, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Emilia Virginia Manini
- Department of Anaesthesia and Intensive Care, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Giulia Scopetani
- Department of Cardiac Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
| | - Temistocle Ragni
- Department of Cardiac Surgery, Santa Maria della Misericordia Hospital, Perugia, Italy
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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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Toeg H, French D, Gilbert S, Rubens F. Incidence of sternal wound infection after tracheostomy in patients undergoing cardiac surgery: A systematic review and meta-analysis. J Thorac Cardiovasc Surg 2017; 153:1394-1400.e7. [DOI: 10.1016/j.jtcvs.2016.11.040] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Revised: 10/27/2016] [Accepted: 11/04/2016] [Indexed: 12/17/2022]
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23
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Risk factors for ventilator-associated pneumonia among patients undergoing major oncological surgery for head and neck cancer. Front Med 2017; 11:239-246. [PMID: 28493197 DOI: 10.1007/s11684-017-0509-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 11/27/2016] [Indexed: 01/03/2023]
Abstract
Patients undergoing major oncological surgery for head and neck cancer (SHNC) have a particularly high risk of nosocomial infections. We aimed to identify risk factors for ventilator-associated pneumonia (VAP) in patients undergoing SHNC. The study included 465 patients who underwent SHNC between June 2011 and June 2014. The rate of VAP, risk factors for VAP, and biological aspects of VAP were retrospectively evaluated. The incidence of VAP was 19.6% (n = 95) in patients who required more than 48 h of mechanical ventilation. Staphylococcus (37.7%), Enterobacteriaceae (32.1%), Pseudomonas (20.8%), and Haemophilus (16.9%) were the major bacterial species that caused VAP. The independent risk factors for VAP were advanced age, current smoking status, chronic obstructive pulmonary disease, and a higher simplified acute physiology score system II upon admission. Tracheostomy was an independent protective factor for VAP. The median length of stay in the ICU for patients who did or did not develop VAP was 8.0 and 6.5 days, respectively (P = 0.006). Mortality among patients who did or did not develop VAP was 16.8% and 8.4%, respectively (P < 0.001). The potential economic impact of VAP was high because of the significantly extended duration of ventilation. A predictive regression model was developed with a sensitivity of 95.3% and a specificity of 69.4%. VAP is common in patients who are undergoing SHNC and who require more than 48 h of mechanical ventilation. Therefore, innovative preventive measures should be developed and applied in this high-risk population.
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24
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Patient Outcomes After Early Versus Late Tracheostomy in the Puerto Rico Trauma Hospital. J Patient Saf 2016; 16:216-222. [DOI: 10.1097/pts.0000000000000268] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Otero TMN, Yeh DD, Bajwa EK, Azocar RJ, Tsai AL, Belcher DM, Quraishi SA. Elevated Red Cell Distribution Width Is Associated With Decreased Ventilator-Free Days in Critically Ill Patients. J Intensive Care Med 2016; 33:241-247. [PMID: 27251107 DOI: 10.1177/0885066616652612] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Elevated red cell distribution width (RDW) is associated with mortality in a variety of respiratory conditions. Recent data also suggest that RDW is associated with mortality in intensive care unit (ICU) patients. Although respiratory failure is common in the ICU, the relationship between RDW and pulmonary outcomes in the ICU has not been previously explored. Therefore, our goal was to investigate the association of admission RDW with 30-day ventilator-free days (VFDs) in ICU patients. METHODS We performed a retrospective analysis from an ongoing prospective, observational study. Patients were recruited from medical and surgical ICUs of a large teaching hospital in Boston, Massachusetts. The RDW was assessed within 1 hour of ICU admission. Poisson regression analysis was used to investigate the association of RDW (normal: 11.5%-14.5% vs elevated: >14.5%) with 30-day VFD, while controlling for age, sex, race, body mass index, Nutrition Risk in the Critically Ill score, the presence of chronic lung disease, Pao2/Fio2 ratio, and admission levels of hemoglobin, mean corpuscular volume, phosphate, albumin, C-reactive protein, and creatinine. RESULTS A total of 637 patients comprised the analytic cohort. Mean RDW was 15 (standard deviation 4%), with 53% of patients in the normal range and 47% with elevated levels. Median VFD was 16 (interquartile range: 6-25) days. Poisson regression analysis demonstrated that ICU patients with elevated admission RDW were likely to have 32% lower 30-day VFDs compared to their counterparts with RDW in the normal range (incidence rate ratio: 0.68; 95% confidence interval: 0.55-0.83: P < .001). CONCLUSIONS We observed an inverse association of RDW and 30-day VFD, despite controlling for demographics, nutritional factors, and severity of illness. This supports the need for future studies to validate our findings, understand the physiologic processes that lead to elevated RDW in patients with respiratory failure, and determine whether changes in RDW may be used to support clinical decision-making.
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Affiliation(s)
- Tiffany M N Otero
- 1 Tufts University School of Medicine, Boston, MA, USA.,2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - D Dante Yeh
- 3 Department of Surgery, Massachusetts General Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
| | - Ednan K Bajwa
- 4 Harvard Medical School, Boston, MA, USA.,5 Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Ruben J Azocar
- 6 Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
| | - Andrea L Tsai
- 6 Department of Anesthesiology, Tufts Medical Center, Boston, MA, USA
| | - Donna M Belcher
- 7 Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, MA
| | - Sadeq A Quraishi
- 2 Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA.,4 Harvard Medical School, Boston, MA, USA
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Pilarczyk K, Marggraf G, Dudasova M, Demircioglu E, Scheer V, Jakob H, Dusse F. Tracheostomy After Cardiac Surgery With Median Sternotomy and Risk of Deep Sternal Wound Infections: Is It a Matter of Timing? J Cardiothorac Vasc Anesth 2015; 29:1573-81. [DOI: 10.1053/j.jvca.2015.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2015] [Indexed: 12/20/2022]
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Szakmany T, Russell P, Wilkes AR, Hall JE. Effect of early tracheostomy on resource utilization and clinical outcomes in critically ill patients: meta-analysis of randomized controlled trials. Br J Anaesth 2014; 114:396-405. [PMID: 25534400 DOI: 10.1093/bja/aeu440] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Early tracheostomy may decrease the duration of mechanical ventilation, sedation exposure, and intensive care stay, possibly resulting in improved clinical outcomes, but the evidence is conflicting. METHODS Systematic review and meta-analysis of randomized trials in patients allocated to tracheostomy within 10 days of start of mechanical ventilation was compared with placement of tracheostomy after 10 days if still required. Medline, EMBASE, the Cochrane Controlled Clinical Trials Register, and Google Scholar were searched for eligible trials. The co-primary outcomes were mortality within 60 days, and duration of mechanical ventilation, sedation, and intensive care unit stay. Secondary outcomes were the number of tracheostomy procedures performed, and incidence of ventilator-associated pneumonia (VAP). Outcomes are described as relative risk or weighted mean difference with 95% confidence intervals. RESULTS Of note, 4482 publications were identified and 14 trials enrolling 2406 patients were included. Tracheostomy within 10 days was not associated with any difference in mortality [risk ratio (RR): 0.93 (0.83-1.05)]. There were no differences in duration of mechanical ventilation [-0.19 days (-1.13-0.75)], intensive care stay [-0.83 days (-2.05-0.40)], or incidence of VAP. However, duration of sedation was reduced in the early tracheostomy groups [-2.78 days (-3.68 to -1.88)]. More tracheostomies were performed in patients randomly assigned to receive early tracheostomy [RR: 2.53 (1.18-5.40)]. CONCLUSION We found no evidence that early (within 10 days) tracheostomy reduced mortality, duration of mechanical ventilation, intensive care stay, or VAP. Early tracheostomy leads to more procedures and a shorter duration of sedation.
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Affiliation(s)
- T Szakmany
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK Cwm Taf UHB, Royal Glamorgan Hospital, Llantrisant, UK
| | - P Russell
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK
| | - A R Wilkes
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK
| | - J E Hall
- Cardiff Institute of Infection and Immunity, Cardiff University, UHW Main Building, Heath Park, Cardiff CF14 4XN, UK
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Esteve F, Lopez-Delgado JC, Javierre C, Skaltsa K, Carrio ML, Rodríguez-Castro D, Torrado H, Farrero E, Diaz-Prieto A, Ventura JL, Mañez R. Evaluation of the PaO2/FiO2 ratio after cardiac surgery as a predictor of outcome during hospital stay. BMC Anesthesiol 2014; 14:83. [PMID: 25928646 PMCID: PMC4448284 DOI: 10.1186/1471-2253-14-83] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2014] [Accepted: 09/22/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The arterial partial pressure of O2 and the fraction of inspired oxygen (PaO2/FiO2) ratio is widely used in ICUs as an indicator of oxygenation status. Although cardiac surgery and ICU scores can predict mortality, during the first hours after cardiac surgery few instruments are available to assess outcome. The aim of this study was to evaluate the usefulness of PaO2/FIO2 ratio to predict mortality in patients immediately after cardiac surgery. METHODS We prospectively studied 2725 consecutive cardiac surgery patients between 2004 and 2009. PaO2/FiO2 ratio was measured on admission and at 3 h, 6 h, 12 h and 24 h after ICU admission, together with clinical data and outcomes. RESULTS All PaO2/FIO2 ratio measurements differed between survivors and non-survivors (p < 0.001). The PaO2/FIO2 at 3 h after ICU admission was the best predictor of mortality based on area under the curve (p < 0.001) and the optimum threshold estimation gave an optimal cut-off of 222 (95% Confidence interval (CI): 202-242), yielding three groups of patients: Group 1, with PaO2/FIO2 > 242; Group 2, with PaO2/FIO2 from 202 to 242; and Group 3, with PaO2/FIO2 < 202. Group 3 showed higher in-ICU mortality and ICU length of stay and Groups 2 and 3 also showed higher respiratory complication rates. The presence of a PaO2/FIO2 ratio < 202 at 3 h after admission was shown to be a predictor of in-ICU mortality (OR:1.364; 95% CI:1.212-1.625, p < 0.001) and of worse long-term survival (88.8% vs. 95.8%; Log rank p = 0.002. Adjusted Hazard ratio: 1.48; 95% CI:1.293-1.786; p = 0.004). CONCLUSIONS A simple determination of PaO2/FIO2 at 3 h after ICU admission may be useful to identify patients at risk immediately after cardiac surgery.
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Affiliation(s)
- Francisco Esteve
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Juan C Lopez-Delgado
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Casimiro Javierre
- Physiological Sciences II Department, Universitat de Barcelona, IDIBELL, Barcelona, Spain.
| | | | - Maria Ll Carrio
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - David Rodríguez-Castro
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Herminia Torrado
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Elisabet Farrero
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Antonio Diaz-Prieto
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Josep Ll Ventura
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
| | - Rafael Mañez
- Intensive Care Department, Hospital Universitari de Bellvitge, IDIBELL (Institut d'Investigació Biomèdica Bellvitge; Biomedical Investigation Institute of Bellvitge), L'Hospitalet de Llobregat, C/Feixa Llarga s/n., 08907, Barcelona, Spain.
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Costello JP, Emerson DA, Shu MK, Peer SM, Zurakowski D, Reilly BK, Klugman D, Jonas RA, Nath DS. Outcomes of tracheostomy following congenital heart surgery: a contemporary experience. CONGENIT HEART DIS 2014; 10:E25-9. [PMID: 24898170 DOI: 10.1111/chd.12192] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/24/2014] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Following congenital heart surgery, pediatric patients may experience persistent respiratory failure that requires tracheostomy placement. Currently, definitive knowledge of the optimal timing for tracheostomy placement in this patient population is lacking. METHODS An 8-year retrospective review of 17 pediatric patients who underwent congenital heart surgery and subsequently required tracheostomy placement was performed. Patients were evaluated with regard to the timing of tracheostomy and mortality. RESULTS The overall study mortality was 24%. The median duration of intubation prior to tracheostomy was 60 days (interquartile range: 19-90 days); there was no difference in the average time between intubation and tracheostomy for survivors compared with nonsurvivors (51 vs. 73 days, P = .37). No difference was observed in the overall duration of positive pressure ventilation when tracheostomy was performed within 30 days of intubation compared with greater than 30 days following intubation (481 vs. 451 days, P = .88). Overall, 18% of patients were successfully weaned from the ventilator after a median duration of positive pressure ventilation of 212 days. CONCLUSION The timing of tracheostomy placement may be an important factor in clinical outcomes for pediatric patients with persistent dependence on mechanical ventilatory support following congenital heart surgery. A larger, multi-institution study may help further elucidate our observed clinical findings in this patient population.
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Affiliation(s)
- John P Costello
- Division of Cardiovascular Surgery, Children's National Health System, Washington, DC, USA; The Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Health System, Washington, DC, USA
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Villwock JA, Jones K. Outcomes of early versus late tracheostomy: 2008-2010. Laryngoscope 2014; 124:1801-6. [PMID: 24706383 DOI: 10.1002/lary.24702] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2013] [Revised: 03/25/2014] [Accepted: 04/02/2014] [Indexed: 12/19/2022]
Abstract
OBJECTIVES/HYPOTHESIS The ideal timing of tracheostomy varies. This study sought to determine demographic, management, and outcome differences in patients undergoing early tracheostomy (ET) versus late tracheostomy (LT) (<10 days vs. >10 days postintubation, respectively). STUDY DESIGN Retrospective review of the 2008 to 2010 Nationwide Inpatient Sample for patients with extreme severity of illness who underwent tracheostomy. METHODS Patients were subdivided based on the timing of tracheostomy placement (days 1-5, 6-10, 11-15, 16-20, 21-25). ET and LT were defined using a 10-day cutoff. Descriptive statistics were obtained for hospital and patient demographics. Multivariate models analyzed the effect of tracheostomy timing on primary outcomes of in-hospital morbidity/mortality, length of stay (LOS), and charges. RESULTS A total of 124,990 tracheostomy cases met inclusion criteria. Of the total cases, 53,749 underwent ET, and 71,244 underwent LT. Significant predictors (P < .01) of ET included patient age <65 years (odds ratio [OR]: 1.136), admission to a Midwest hospital (OR: 1.430), neurologic disorder (OR: 1.196), paralysis (OR: 1.264), and admission to a government, nonfederal hospital (OR: 1.434). Significant predictors of LT included admission to a small hospital (OR: 1.150), acute respiratory failure (OR: 1.601), and acute chronic respiratory failure (OR: 1.349). The economic outcomes of hospital costs and LOS increased linearly and significantly with time to tracheostomy, as did mortality (P < .001). ET was associated with a significantly increased rate of discharge to home (P < .001) and decreased rate of sepsis (P < .001) and ventilator-associated pneumonia (P < .001). CONCLUSIONS Efficient and effective healthcare delivery is paramount in today's economic climate. Identification of patients likely to need prolonged ventilator support and ET may prove to be a cost- and morbidity-saving measure and deserves further prospective examination.
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Affiliation(s)
- Jennifer A Villwock
- Department of Otolaryngology, SUNY-Upstate Medical University, Syracuse, New York, U.S.A
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Duann CW, Hsieh MS, Chen PT, Chou HP, Huang CS. Successful percutaneous tracheostomy via puncture through the thyroid isthmus. Respirol Case Rep 2014; 2:57-60. [PMID: 25473567 PMCID: PMC4184506 DOI: 10.1002/rcr2.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2013] [Revised: 12/18/2013] [Accepted: 12/22/2013] [Indexed: 11/14/2022] Open
Abstract
Tracheostomy is one of the most frequently performed procedures in intensive care units. Bedside percutaneous tracheostomy has become an increasingly popular option to standard open tracheostomy. Several contraindications for percutaneous tracheostomy, including an enlarged thyroid isthmus, have been described. However, as experience with this technique has increased, most of the described contraindications appear to be relative rather than absolute, provided the procedure is performed by an experienced practitioner. Herein we present a case of an unavoidable direct puncture of the thyroid isthmus during a percutaneous tracheostomy. The procedure was performed smoothly, and no complications occurred.
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Affiliation(s)
- Chi-Wei Duann
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital Taipei, Taiwan
| | - Min-Shiau Hsieh
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital Taipei, Taiwan ; Department of Surgery, National Yang-Ming University Hospital Yilan, Taiwan
| | - Pin-Tarng Chen
- Department of Anesthesiology, Taipei Veterans General Hospital Taipei, Taiwan
| | - Hsiao-Ping Chou
- Department of Radiology, Taipei Veterans General Hospital Taipei, Taiwan
| | - Chien-Sheng Huang
- Division of Thoracic Surgery, Department of Surgery, Taipei Veterans General Hospital Taipei, Taiwan ; Institute of Clinical Medicine, School of Medicine, National Yang-Ming University Taipei, Taiwan
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Ben-Avi R, Ben-Nun A, Levin S, Simansky D, Zeitlin N, Sternik L, Raanani E, Kogan A. Tracheostomy after cardiac surgery: timing of tracheostomy as a risk factor for mortality. J Cardiothorac Vasc Anesth 2014; 28:493-6. [PMID: 24525162 DOI: 10.1053/j.jvca.2013.10.031] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Indexed: 12/29/2022]
Abstract
OBJECTIVES The optimal timing for tracheostomy after cardiac surgery in patients undergoing prolonged ventilation is controversial. The aim of this study was to assess the effect of tracheostomy timing on short- and long-term mortality of these patients. DESIGN Retrospective study of prospectively collected data. SETTING Cardiac surgical intensive care unit (ICU) in a tertiary-care, university-affiliated hospital. PARTICIPANTS All patients undergoing tracheostomy after cardiac surgery between September 2004 and March 2013 were included. INTERVENTIONS The authors compared the outcome in 2 groups of patients according to the timing of tracheostomy: Group I, early-intermediate tracheostomy (0-14 days) and Group II, late tracheostomy (≥15 days). MEASUREMENTS AND MAIN RESULTS During the study period, 6,069 patients underwent cardiac surgery; among them, 199 patients (3.26%) received a tracheostomy. There were 90 patients in Group I and 109 patients in Group II. There was no significant difference in the severity of the patients' illness between the groups. The mortality rate at 3 months, 6 months, 1 year, and 2 years was 37%, 48%, 56%, and 58% in Group I, respectively, and 58%, 70%, 74%, and 77% in Group II, respectively (p< 0.01). CONCLUSIONS Early-intermediate (0-14 days) tracheostomy after cardiac surgery in patients requiring prolonged mechanical ventilation was associated with reduced mortality compared with late tracheostomy (≥15 days).
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Affiliation(s)
- Ronny Ben-Avi
- Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alon Ben-Nun
- Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Shany Levin
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - David Simansky
- Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nonna Zeitlin
- Department of Thoracic Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Leonid Sternik
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Ehud Raanani
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Alexander Kogan
- Department of Cardiac Surgery, Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Hosseinian L, Chiang Y, Itagaki S, Polanco A, Rhee A, Chikwe J. Earlier versus later tracheostomy in patients with respiratory failure after cardiac surgery in the United States. J Cardiothorac Vasc Anesth 2013; 28:488-92. [PMID: 24295717 DOI: 10.1053/j.jvca.2013.07.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2013] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objective of this study was to evaluate the impact of timing of tracheostomy on outcomes of patients with respiratory failure after cardiac surgery. DESIGN Retrospective analysis of national database. SETTING United States hospitals. PARTICIPANTS A weighted estimate of 2,063,227 patients (475,773 case records) undergoing cardiac surgery identified from the Nationwide Inpatient Sample between 2002-2010 INTERVENTIONS: Early versus late tracheostomy. MEASUREMENTS AND MAIN RESULTS The incidence of postoperative respiratory failure was 7.8%. The strongest independent predictors of respiratory failure included female gender (odds ratio [OR] 1.3, 95% confidence interval [CI] 1.28-1.31), age (OR 1.13 for each decade, 95% CI 1.12-1.13), chronic obstructive airways disease (OR 2.16, 95% CI 2.13-2.19), chronic renal insufficiency (OR 2.28, 95% CI 2.25-2.31), and valve surgery (OR 1.62, 95% CI 1.6-1.64). Tracheostomy was performed in 22.9% of patients with respiratory failure; 13.6% of tracheostomies were performed within 5 days of surgery (or within 5 days of intubation in patients who underwent reintubation), and 20.5% were performed on postoperative day 21 or later. Compared with tracheostomy performed within 5 days of intubation, there was a near-stepwise increase in risk of mortality with delayed tracheostomy performed between days 11-15 (OR 1.29, 95% CI 1.16-1.43), days 16-20 (OR 1.25, 95% CI 1.11-1.41), and day 21 or later (OR 1.53, 95% CI 1.37-1.71). CONCLUSIONS In this analysis of outcomes of patients with respiratory failure after cardiac surgery in the United States, deferring tracheostomy did not appear to improve patient outcomes after cardiac surgery.
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Affiliation(s)
| | - Yuting Chiang
- Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York
| | - Shinobu Itagaki
- Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York
| | - Antonio Polanco
- Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York
| | | | - Joanna Chikwe
- Cardiothoracic Surgery, The Mount Sinai Medical Center, New York, New York.
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Papuzinski C, Durante M, Tobar C, Martinez F, Labarca E. Predicting the need of tracheostomy amongst patients admitted to an intensive care unit: a multivariate model. Am J Otolaryngol 2013; 34:517-22. [PMID: 23809275 DOI: 10.1016/j.amjoto.2013.05.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2013] [Revised: 05/15/2013] [Accepted: 05/19/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Patients requiring prolonged invasive mechanical ventilation are prone to complications, such as infections, tracheal stenosis and death. It has been proposed that early tracheostomy could have a role in preventing these outcomes, but the proper identification of patients at risk can be difficult. PURPOSE The aim of this study was to develop a multivariate model that allows the early detection of patients that will require prolonged ventilatory support. PATIENTS AND METHODS A retrospective cohort study was undertaken in the intensive care unit of the Hospital Naval Almirante Nef, Chile, between June 2011 and June 2012. The charts of all intubated patients were reviewed in search for early predictors of prolonged intubation (>7 days). Multivariate logistic regression analysis was used to detect statistically significant associations and to assess potential confounders. RESULTS A total of 349 patients were admitted to the intensive care unit during the study period and 142 (40.7%) required invasive mechanical ventilation. Most of them were male (60.5%), with a mean age of 65.8 ± 16.7 years. Thirty-five patients (24%) required to be ventilated for 7 days or more, and 16 (46%) were tracheostomized for this reason. The regression model showed that older age (p=0.026), a Pa/Fi ratio of less than 200 (p=0.046), and the presence of chronic pulmonary disease (p=0.035) or hypernatremia (p=0.012) on intubation day were significantly associated with the requirement of prolonged intubation. DISCUSSION Invasive mechanical ventilation is a common reason for admittance to the ICU. The abovementioned predictors can be of assistance when selecting patients that could benefit from early tracheostomies, and are in agreement with earlier reports. Although the model's discriminating capacity was good, it is necessary to formally validate it before recommending its widespread use.
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Challapudi G, Natarajan G, Aggarwal S. Single-center Experience of Outcomes of Tracheostomy in Children with Congenital Heart Disease. CONGENIT HEART DIS 2013; 8:556-60. [DOI: 10.1111/chd.12048] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/21/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Geetha Challapudi
- Division of Cardiology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Mich USA
| | - Girija Natarajan
- Division of Neonatology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Mich USA
| | - Sanjeev Aggarwal
- Division of Cardiology; Carman and Ann Adams Department of Pediatrics; Children's Hospital of Michigan; Wayne State University School of Medicine; Detroit Mich USA
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