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Unnithan AKA. An Audit of Tracheostomy in Traumatic Brain Injury. Indian J Otolaryngol Head Neck Surg 2023; 75:1750-1754. [PMID: 37636789 PMCID: PMC10447322 DOI: 10.1007/s12070-023-03732-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 03/23/2023] [Indexed: 08/29/2023] Open
Abstract
INTRODUCTION The timing of tracheostomy in traumatic brain injury is controversial. The benefits of early tracheostomy are early weaning from ventilation, and reduction in pneumonia. But some studies demonstrated increase in intracranial pressure during tracheostomy. AIM AND METHODS The aims of the audit are to analyse the timing, benefits, complications, and the results of tracheostomy in patients with traumatic brain injury in the hospital in the period of 2012-2021. RESULTS The number of patients was 34. The maximum number of tracheostomies(24) were between 6th to 14th days of admission. The complications were: worsening of Glasgow coma scale score - 3 (in the early group), bleeding - 2, subglottic stenosis-1, tracheocutaneous fistula-1. The main benefits obtained form tracheostomy were the easiness of weaning and tracheobronchial toilet. Twelve patients had pneumonia. Nine patients survived out of twelve. Six patients had acute respiratory distress syndrome. Five of them succumbed. The weaning time corresponded to the severity of injury and pulmonary status. The mortality according to the timing of tracheostomy were: 1/6(16.67%) in the group of first week, 9/19(47%) in the group of second week, and 3/8(37.5%) in the group of the third and fourth week. The mortality was less in the group of first week. CONCLUSIONS The timing of tracheostomy in traumatic brain injury should be at the earliest after the control of raised intracranial tension. There was reversible worsening of Glasgow coma scale score for 2 points in 3 cases after early tracheostomy. Mortality was less in the group of early tracheostomy.
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Mulima G, Lie SA, Charles A, Hanif AB, Varela CG, Banza LN, Young S. Tracheostomy without mechanical ventilation in patients with traumatic brain injury at a tertiary referral hospital in Malawi: a cross sectional study. Malawi Med J 2022; 34:152-156. [PMID: 36406102 PMCID: PMC9641605 DOI: 10.4314/mmj.v34i3.2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Background Tracheostomy alone, without mechanical ventilation, has been advocated to maintain a free airway in patients with traumatic brain injury in low-income settings with minimal critical care capacity. However, no reports exist on the outcomes of this strategy. We examine the results of this practice at a central hospital in Malawi. Methods This is a retrospective review of medical records and prospectively gathered trauma surveillance data of patients admitted to Kamuzu Central Hospital, with traumatic brain injury from January 2010 to December 2015. In-hospital mortality rates were examined according to registered traumatic brain injury severity and airway management. Results In our analysis, 1875 of 2051 registered traumatic brain injury patients were included; 83.3% were male, mean age 32.6 (SD 12.9) years. 14.2% (n=267) of the patients had invasive airway management (endotracheal tube or tracheostomy) with or without mechanical ventilation. Mortality in severe traumatic brain injury treated with tracheostomy without mechanical ventilation was 42% (10/24) compared to 21% (14/68) in patients treated without intubation or tracheostomy (p= 0.043). Tracheostomies had an overall complication rate of 11%. Conclusion Tracheostomy without mechanical ventilation in severe traumatic brain injury did not improve survival outcomes in our setting. Tracheostomy for severe traumatic brain injury cannot be recommended when mechanical ventilation is not available unless there are sufficient specialized human resources for follow up in the ward. Efforts to improve critical care facilities and human resource capacity to allow proper use of mechanical ventilation in severe traumatic brain injury should be a high priority in low-income countries where the burden of trauma is high.
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Affiliation(s)
- Gift Mulima
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Stein Atle Lie
- The Norwegian Arthroplasty Registry, Haukeland University Hospital, Bergen, Norway
| | - Anthony Charles
- Department of Surgery, University of North Carolina, 4008 Burnett Womack Bldg, CB 7050, Chapel Hill, NC, 27599 USA
| | - Asma Bilal Hanif
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Carlos G Varela
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Leonard N Banza
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi
| | - Sven Young
- Department of Surgery, Kamuzu Central Hospital, P.O. Box 149, Lilongwe, Malawi, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
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Mubashir T, Lai H, Oduguwa E, Chaudhry R, Balogh J, Williams GW, Maroufy V. Effect of tracheostomy timing on outcomes in patients with traumatic brain injury. Proc AMIA Symp 2022; 35:621-628. [DOI: 10.1080/08998280.2022.2084780] [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)
- Talha Mubashir
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Hongyin Lai
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Emmanuella Oduguwa
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Rabail Chaudhry
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Julius Balogh
- Department of Anesthesiology and Critical Care, University of Arkansas Medical Center, Little Rock, Arkansas
| | - George W. Williams
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Vahed Maroufy
- Department of Biostatistics and Data Science, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
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Goo ZQ, Muthusamy KA. Early versus standard tracheostomy in ventilated patients in neurosurgical intensive care unit: A randomized controlled trial. J Clin Neurosci 2022; 98:162-167. [PMID: 35182846 DOI: 10.1016/j.jocn.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 02/05/2022] [Accepted: 02/09/2022] [Indexed: 12/19/2022]
Abstract
INTRODUCTION Tracheostomy is performed in patients with prolonged mechanical ventilation, who suffered catastrophic neurologic insult or upper airway obstruction. Thus far, there is no consensus on the optimal timing in performing a tracheostomy. This study aims to test whether early tracheostomy in mechanically ventilated patients in a neurosurgical setting would be associated with a shorter time of mechanical ventilation as compared to standard tracheostomy. METHODS This single-center prospective randomized controlled trial was conducted at University Malaya Medical Centre from July 2019 to July 2021. The likelihood of prolonged ventilation was determined objectively using the TRACH score and the patient's clinical presentation. The outcomes measured were days of mechanical ventilation post-tracheostomy, days of neuro-intensive care unit stay, and days of hospital stay. Tracheostomy-related complications were collected. The data collected were analyzed using Statistical Package for the Social Sciences version 25 for Windows (SPSS Inc., Chicago, IL, USA). RESULTS In all, 39 patients were randomly assigned. Of these, 20 were allocated to the early tracheostomy group (ET) and 19 were allocated to the standard tracheostomy group (ST). The demographic characteristics were similar between the groups. The primary outcome, mean (SD) days of mechanical ventilation post-tracheostomy, was statistically different in the 2 groups- early 11.9 (9.3) days, standard 18.9 (32.5) days; p = 0.014. There were comparable tracheostomy-related complications in both groups. CONCLUSION Early tracheostomy is associated with a shorter duration of mechanical ventilation in a neurosurgical intensive care unit setting.
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Affiliation(s)
- Zhen Qiang Goo
- Division of General Surgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
| | - Kalai Arasu Muthusamy
- Division of Neurosurgery, Department of Surgery, University Malaya Medical Centre, Kuala Lumpur, Malaysia.
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Bharti R, Sindhu S, Sundaram PK, Chauhan G. Prospective Observational Study of Early Tracheostomy Role in Operated Severe Head Injury Patients at A Level 1 Trauma Center. Bull Emerg Trauma 2021; 9:188-194. [PMID: 34692870 PMCID: PMC8525695 DOI: 10.30476/beat.2021.86725.1198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 06/15/2021] [Accepted: 06/29/2021] [Indexed: 11/19/2022] Open
Abstract
Objective: To evaluate the impact of the early tracheostomy on operated patients with severe head injury. Methods: This prospective observational study was conducted at a level 1 trauma center and medical college over one-year period. The study included all surgically managed severe head injury patients without any other life-threatening major injuries. Patients who underwent tracheostomy within 7 days were classified as early tracheostomy. Results: The patient’s mean age of this cohort study was 43.4±14.5 years. Motor-vehicle accidents were being the most common cause of severe head injury. Operated patients were undergoing early tracheostomy on an average of 2.9 days. We were observed that the patients spent on a mechanical ventilation on an average 3.67±2.26 days. This was significantly lower than previous four published studies (p<0.05) which had a range of mean 9.8-15.7 days. Conclusion: We have shown that it is possible to decrease mechanical ventilation (MV) time, intensive care unit (ICU) stay and total hospital stay by doing early tracheostomy in operated severe head injury patients.
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Affiliation(s)
- Rohit Bharti
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
| | | | | | - Ganesh Chauhan
- Department of Neurosurgery, Rajendra Institute of Medical Sciences, Ranchi, India
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Mubashir T, Arif AA, Ernest P, Maroufy V, Chaudhry R, Balogh J, Suen C, Reskallah A, Williams GW. Early Versus Late Tracheostomy in Patients With Acute Traumatic Spinal Cord Injury: A Systematic Review and Meta-analysis. Anesth Analg 2021; 132:384-394. [PMID: 33009136 DOI: 10.1213/ane.0000000000005212] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Acute traumatic spinal cord injuries (SCIs) often result in impairments in respiration that may lead to a sequelae of pulmonary dysfunction, increased risk of infection, and death. The optimal timing for tracheostomy in patients with acute SCI is currently unknown. This systematic review and meta-analysis aims to assess the optimal timing of tracheostomy in SCI patients and evaluate the potential benefits of early versus late tracheostomy. METHODS We searched Medline, PubMed, Embase, Cochrane Central, Cochrane Database of Systematic Reviews, and PsycINFO for published studies. We included studies on adults with SCI who underwent early or late tracheostomy and compared outcomes. In addition, studies that reported a concomitant traumatic brain injury were excluded. Data were extracted independently by 2 reviewers and copied into R software for analysis. A random-effects meta-analysis was performed to estimate the pooled odds ratio (OR) or mean difference (MD). RESULTS Eight studies with a total of 1220 patients met our inclusion criteria. The mean age and gender between early and late tracheostomy groups were similar. The majority of the studies performed an early tracheostomy within 7 days from either time of injury or tracheal intubation. Patients with a cervical SCI were twice as likely to undergo an early tracheostomy (OR = 2.13; 95% confidence interval [CI], 1.24-3.64; P = .006) compared to patients with a thoracic SCI. Early tracheostomy reduced the mean intensive care unit (ICU) length of stay by 13 days (95% CI, -19.18 to -7.00; P = .001) and the mean duration of mechanical ventilation by 18.30 days (95% CI, -24.33 to -12.28; P = .001). Although the pooled risk of in-hospital mortality was lower with early tracheostomy compared to late tracheostomy, the results were not significant (OR = 0.56; 95% CI, 0.32-1.01; P = .054). In the subgroup analysis, mortality was significantly lower in the early tracheostomy group (OR = 0.27; P = .006). Finally, no differences in pneumonia between early and late tracheostomy groups were noted. CONCLUSIONS Based on the available data, patients with early tracheostomy within the first 7 days of injury or tracheal intubation had higher cervical SCI, shorter ICU length of stay, and shorter duration of mechanical ventilation compared to late tracheostomy. The risk of in-hospital mortality may be lower following an early tracheostomy. However, due to the quality of studies and insufficient clinical data available, it is challenging to make conclusive interpretations. Future prospective trials with a larger patient population are needed to fully assess short- and long-term outcomes of tracheostomy timing following acute SCI.
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Affiliation(s)
- Talha Mubashir
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Abdul A Arif
- Department of Life Science, University of Toronto, Toronto, Ontario, Canada
| | - Prince Ernest
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Vahed Maroufy
- Department of Biostatistics, School of Public Health, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Rabail Chaudhry
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Julius Balogh
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - Colin Suen
- Department of Anesthesiology, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Alexander Reskallah
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
| | - George W Williams
- From the Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston (UT Health), Houston, Texas
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Can FK, Anıl AB, Anıl M, Gümüşsoy M, Çitlenbik H, Kandoğan T, Zengin N. The outcomes of children with tracheostomy in a tertiary care pediatric intensive care unit in Turkey. Turk Arch Pediatr 2018; 53:177-184. [PMID: 30459517 DOI: 10.5152/turkpediatriars.2018.6586] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2017] [Accepted: 03/14/2018] [Indexed: 11/22/2022]
Abstract
Aim We aimed to describe which clinical characteristics were associated with the outcome of tracheostomy in our tertiary care pediatric intensive care unit. Material and Methods This was a retrospective review of medical records of pediatric patients who underwent tracheostomy in our Pediatric Intensive Care unit from 2008 to 2014 in Turkey. Results Sixty-three patients were included the study. The median age of patients was 11 (range, 1-195) months. Twenty-five (39.7%) patients were female. The tracheostomy rate was 8.5% over a six-year period. Forty-nine (77.7%) patients were able to be discharged and sent home. The decannulation rate was 12.6% (n=8). The indications for tracheostomy were upper airway obstruction (n=9) and prolonged mechanical ventilation (n=54). The median intubation period before tracheostomy was 32 (range, 1-122) days and the median duration of pediatric intensive care unit stay after tracheostomy was 37 days. A total of 21 (52.5%) patients were weaned off mechanical ventilation. The rate of successful weaning from mechanical ventilation was higher in patients with upper airway obstruction than in those in the prolonged mechanical ventilation group (p=0.021). The complication rate was 25.3% in the pediatric intensive care unit and 11.1% at home. Conclusions Tracheostomy seems safe and improves pediatric patients' outcomes. The most important factor that affects the prognosis of children who underwent tracheostomy is the indication for tracheostomy. The outcomes are always better if the tracheostomy has been performed because of upper airway obstruction. Performing tracheostomy helps weaning from and off ventilator support and finally the discharge of patients with prolonged mechanical ventilation from the pediatric intensive care unit setting.
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Affiliation(s)
- Fulya Kamit Can
- Unit of Pediatric Intensive Care, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Ayşe Berna Anıl
- Unit of Pediatric Intensive Care, Katip Çelebi Univercity School of Medicine, İzmir, Turkey
| | - Murat Anıl
- Clinic of Child Emergency Service, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Murat Gümüşsoy
- Department of Otorhinolaryngology, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Hale Çitlenbik
- Unit of Pediatric Intensive Care, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Tolga Kandoğan
- Department of Otorhinolaryngology, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
| | - Neslihan Zengin
- Unit of Pediatric Intensive Care, İzmir Tepecik Training and Research and Hospital, İzmir, Turkey
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Cai SQ, Hu JW, Liu D, Bai XJ, Xie J, Chen JJ, Yang F, Liu T. The influence of tracheostomy timing on outcomes in trauma patients: A meta-analysis. Injury 2017; 48:866-873. [PMID: 28284468 DOI: 10.1016/j.injury.2017.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2016] [Revised: 02/21/2017] [Accepted: 02/22/2017] [Indexed: 02/02/2023]
Abstract
OBJECTIVE This study aims to assess the influence of tracheostomy timing on outcomes among trauma patients, including mortality, medical resource utility and incidence of pneumonia. METHOD A systematic review of the literature was conducted by internet search. Data were extracted from selected studies and analyzed using Stata to compare outcomes in trauma patients with early tracheostomy (ET) or late tracheostomy (LT)/prolonged intubation (PI). RESULT 20 studies met our inclusion criteria with 3305 patients in ET group and 4446 patients in LT/PI group. Pooled data revealed that mortality was not lower in trauma patients with ET compared to those with LT/IP. However, ET was found to be associated with a significantly reduced length of ICU and hospital stay, shorter MV duration and lower risk of pneumonia. CONCLUSION Evidence of this meta-analysis supports the dimorphism in some clinical outcomes of trauma patients with different tracheostomy timing. Additional well-designed randomized controlled trials (RCTs) are needed to confirm it in future.
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Affiliation(s)
- Shi-Qi Cai
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jun-Wu Hu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Dong Liu
- Department of Radiology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Xiang-Jun Bai
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jie Xie
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Jia-Jun Chen
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Fan Yang
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China
| | - Tao Liu
- Department of Traumatic Surgery, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, China.
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Khalili H, Paydar S, Safari R, Arasteh P, Niakan A, Abolhasani Foroughi A. Experience with Traumatic Brain Injury: Is Early Tracheostomy Associated with Better Prognosis? World Neurosurg 2017; 103:88-93. [PMID: 28254541 DOI: 10.1016/j.wneu.2017.02.060] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 02/10/2017] [Accepted: 02/11/2017] [Indexed: 12/19/2022]
Abstract
OBJECTIVE In this study we compared the effects of early tracheostomy (ET) versus late tracheostomy on traumatic brain injury (TBI)-related outcomes and prognosis. PATIENTS AND METHODS Data on 152 TBI patients with a Glasgow Coma Scale (GCS) score of ≤8, admitted to Rajaee Hospital between March 1, 2014 and August 23, 2015, were collected. Rajaee Hospital is the main referral trauma center in southern Iran and is affiliated with Shiraz University of Medical Sciences. Patients who had tracheostomy before or at the sixth day of their admission were considered as ET, and those who had tracheostomy after the sixth day of admission were considered as late tracheostomy. RESULTS Patients with ET had a significantly lower hospital stay (46.4 vs. 38.6 days; P = 0.048) and intensive care unit stay (34.9 vs. 26.7 days; P = 0.003). Mortality rates were not significantly different between the 2 groups (P > 0.99). Although not statistically significant, favorable outcomes (Glasgow Outcome Scale >4) were higher and ventilator-associated pneumonia rates were lower among the ET group (P = 0.346 and P = 492, respectively). Multivariate analysis showed that ET significantly improves 6-month prognosis (Glasgow Outcome Scale >4) (odds ratio = 2.535; 95% confidence interval: 1.030-6.237). Higher age was inversely associated with favorable prognosis (odds ratio = -0.958; confidence interval: 0.936-0.981). Glasgow Coma Scale and Rotterdam score did not show any effect on 6-month prognosis. CONCLUSION Despite previous concern regarding increased mortality rates among patients who undergo ET, performing a tracheostomy for patients with severe TBI <6 days after their hospital admission, in addition to decreasing hospital and intensive care unit stays, will improve patient prognosis.
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Affiliation(s)
- Hosseinali Khalili
- Shiraz Trauma Research Center, Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shahram Paydar
- Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Rasool Safari
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Peyman Arasteh
- Trauma Research Center, Shahid Rajaee Trauma Hospital, Shiraz University of Medical Sciences, Shiraz, Iran; Non-communicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran.
| | - Amin Niakan
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amin Abolhasani Foroughi
- Medical Imaging Research Center, Department of Radiology, Nemazee Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
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Zirpe KG, Tambe DV, Deshmukh AM, Gurav SK. The Impact of Early Tracheostomy in Neurotrauma Patients: A Retrospective Study. Indian J Crit Care Med 2017; 21:6-10. [PMID: 28197044 PMCID: PMC5278595 DOI: 10.4103/0972-5229.198309] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Although majority of neurotrauma patients require long term ventilatory support but the timing of tracheostomy in such patients is controversial. METHOD This retrospective study was conducted at a Tertiary Care Hospital, Pune, India. Patients >18 years of age, who underwent percutaneous tracheostomy (PCT) from June 2010 to November 2014 at neurotrauma unit (NTU) of hospital, were included. Patients were divided in two groups according to the timing of tracheostomy, early tracheostomy (ET) group (≤5 days; N=100) and late tracheostomy (LT) group (>5 days; N=64). The nonparametric Mann-Whitney test, and Chi-square tests were used to compare these groups. RESULT There were no significant differences between the groups in terms of age, sex, APACHE II and GCS Score. Patients in the ET group had a significantly shorter stay in the NTU compared to patients in the LT group (mean, 18 vs. 21.2 days, p=0.005), fewer mechanical ventilation days (mean, 8.1 vs. 11.7 days, P=0.000) and shorter length of stay in hospital (mean, 28.8 vs. 34.37 days, P=0.019). There was no difference between ET and LT groups in post PCT ventilator free days (mean, 8.2 vs. 9.4 days; P=0.094). Mortality rates in ET vs. LT groups were also comparable (35% vs. 29.7%; P=0.480). CONCLUSION Results suggest that ET in neurotrauma patients might be associated with shorter length of stay in NTU and hospital, and shorter duration of mechanical ventilation however there was no mortality difference.
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Affiliation(s)
- Kapil G. Zirpe
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
| | | | | | - Sushma K. Gurav
- Neurotrauma Unit, Ruby Hall Clinic, Pune, Maharashtra, India
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Abstract
Neuropulmonology refers to the complex interconnection between the central nervous system and the respiratory system. Neurologic injury includes traumatic brain injury, hemorrhage, stroke, and seizures, and in each there are far-reaching effects that can result in pulmonary dysfunction. Systemic changes can induce impairment of pulmonary function due to changes in the core structure and function of the lung. The conditions and disorders that often occur in these patients include aspiration pneumonia, neurogenic pulmonary edema, and acute respiratory distress syndrome, but also several abnormal respiratory patterns and sleep-disordered breathing. Lung infections, pulmonary edema - neurogenic or cardiogenic - and pulmonary embolus all are a serious barrier to recovery and can have significant effects on outcomes such as hospital course, prognosis, and mortality. This review presents the spectrum of pulmonary abnormalities seen in neurocritical care.
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Pasqua F, Nardi I, Provenzano A, Mari A. Weaning from tracheostomy in subjects undergoing pulmonary rehabilitation. Multidiscip Respir Med 2015; 10:35. [PMID: 26629342 PMCID: PMC4666070 DOI: 10.1186/s40248-015-0032-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 10/20/2015] [Indexed: 11/17/2022] Open
Abstract
Background Weaning from tracheostomy has implications in management, quality of life, and costs of ventilated patients. Furthermore, endotracheal cannula removing needs further studies. Aim of this study was the validation of a protocol for weaning from tracheostomy and evaluation of predictor factors of decannulation. Methods Medical records of 48 patients were retrospectively evaluated. Patients were decannulated in agreement with a decannulation protocol based on the evaluation of clinical stability, expiratory muscle strength, presence of tracheal stenosis/granulomas, deglutition function, partial pressure of CO2, and PaO2/FiO2 ratio. These variables, together with underlying disease, blood gas analysis parameters, time elapsed with cannula, comordibity, Barthel index, and the condition of ventilation, were evaluated in a logistic model as predictors of decannulation. Results 63 % of patients were successfully decannulated in agreement with our protocol and no one needed to be re-cannulated. Three variables were significantly associated with the decannulation: no pulmonary underlying diseases (OR = 7.12; 95 % CI 1.2–42.2), no mechanical ventilation (OR = 9.55; 95 % CI 2.1–44.2) and period of tracheostomy ≤10 weeks (OR = 6.5; 95 % CI 1.6–27.5). Conclusions The positive course of decannulated patients supports the suitability of the weaning protocol we propose here. The strong predictive role of three clinical variables gives premise for new studies testing simpler decannulation protocols.
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Affiliation(s)
- Franco Pasqua
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy ; Pulmonary Rehabilitation, San Raffaele Hospital, Montecompatri, Rome Italy
| | - Ilaria Nardi
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
| | - Alessia Provenzano
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
| | - Alessia Mari
- Pulmonary Medicine and Rehabilitation, Villa Delle Querce Hospital, Nemi, Rome Italy
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Keenan JE, Gulack BC, Nussbaum DP, Green CL, Vaslef SN, Shapiro ML, Scarborough JE. Optimal timing of tracheostomy after trauma without associated head injury. J Surg Res 2015; 198:475-81. [PMID: 25976854 DOI: 10.1016/j.jss.2015.03.072] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 03/19/2015] [Accepted: 03/25/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Controversy exists over optimal timing of tracheostomy in patients with respiratory failure after blunt trauma. The study aimed to determine whether the timing of tracheostomy affects mortality in this population. METHODS The 2008-2011 National Trauma Data Bank was queried to identify blunt trauma patients without concomitant head injury who required tracheostomy for respiratory failure between hospital days 4 and 21. Restricted cubic spline analysis was performed to evaluate the relationship between tracheostomy timing and the odds of inhospital mortality. The cohort was stratified based on this analysis. Unadjusted characteristics and outcomes were compared. Multivariable logistic regression was used to evaluate the effect of tracheostomy timing on mortality after adjustment for age, gender, race, payor status, level of trauma center, injury severity score, presentation Glasgow coma scale, and thoracic and abdominal abbreviated injury score. RESULTS There were 9662 patients included in the study. Restricted cubic spline analysis demonstrated a nonlinear relationship between timing of tracheostomy and mortality, with higher odds of mortality occurring with tracheostomy placement within 10 d of admission compared with later time points. The cohort was therefore stratified into early and delayed tracheostomy groups relative to this time point. The resulting groups contained 5402 (55.9%) and 4260 (44.1%) patients, respectively. After multivariable adjustment, the delayed tracheostomy group continued to have significantly reduced odds of mortality (Adjusted odds ratio, 0.82, 95% confidence interval, 0.71-0.95, C-statistic, 0.700). CONCLUSIONS Among non-head injured blunt trauma patients with prolonged respiratory failure, tracheostomy placement within 10 d of admission may result in increased mortality compared with later time points.
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Affiliation(s)
- Jeffrey E Keenan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Daniel P Nussbaum
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Cindy L Green
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Steven N Vaslef
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mark L Shapiro
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John E Scarborough
- Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Dunham CM, Cutrona AF, Gruber BS, Calderon JE, Ransom KJ, Flowers LL. Early tracheostomy in severe traumatic brain injury: evidence for decreased mechanical ventilation and increased hospital mortality. INTERNATIONAL JOURNAL OF BURNS AND TRAUMA 2014; 4:14-24. [PMID: 24624310 PMCID: PMC3945824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 12/28/2013] [Indexed: 06/03/2023]
Abstract
OBJECTIVE In the past, the authors performed a comprehensive literature review to identify all randomized controlled trials assessing the impact of early tracheostomy on severe brain injury outcomes. The search produced only two trials, one by Sugerman and another by Bouderka. SUBJECTS AND METHODS The current authors initiated an Institutional Review Board-approved severe brain injury randomized trial to evaluate the impact of early tracheostomy on ventilator-associated pneumonia rates, intensive care unit (ICU)/ventilator days, and hospital mortality. Current study results were compared with the other randomized trials and a meta-analysis was performed. RESULTS Early tracheostomy pneumonia rates were Sugerman-48.6%, Bouderka-58.1%, and current study-46.7%. No early tracheostomy pneumonia rates were Sugerman-53.1%, Bouderka-61.3%, and current study-44.4%. Pneumonia rate meta-analysis showed no difference for early tracheostomy and no early tracheostomy (OR 0.89; p = 0.71). Early tracheostomy ICU/ventilator days were Sugerman-16 ± 5.9, Bouderka-14.5 ± 7.3, and current study-14.1 ± 5.7. No early tracheostomy ICU/ventilator days were Sugerman-19 ± 11.3, Bouderka-17.5 ± 10.6, and current study-17 ± 5.4. ICU/ventilator day meta-analysis showed 2.9 fewer days with early tracheostomy (p = 0.02). Early tracheostomy mortality rates were Sugerman-14.3%, Bouderka-38.7%, and current study-0%. No early tracheostomy mortality rates were Sugerman-3.2%, Bouderka-22.6%, and current study-0%. Randomized trial mortality rate meta-analysis showed a higher rate for early tracheostomy (OR 2.68; p = 0.05). Because the randomized trials were small, a literature assessment was undertaken to find all retrospective studies describing the association of early tracheostomy on severe brain injury hospital mortality. The review produced five retrospective studies, with a total of 3,356 patients. Retrospective study mortality rate meta-analysis demonstrated a larger mortality for early tracheostomy (OR 1.97; p < 0.0001). CONCLUSION For severe brain injury, analyses indicate that ventilator-associated pneumonia rates are not decreased with early tracheostomy. Further, this study implies that mechanical ventilation is reduced with early tracheostomy. Both the randomized trial and retrospective meta-analysis indicate that risk for hospital death increases with early tracheostomy. Findings imply that early tracheostomy for severe brain injury is not a prudent routine policy.
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Affiliation(s)
- C Michael Dunham
- Trauma/Critical Care Services, St. Elizabeth Health Center1044 Belmont Avenue, Youngstown, OH, 44501, USA
| | - Anthony F Cutrona
- Infection Control Services, St. Elizabeth Health Center1044 Belmont Avenue, Youngstown, OH, 44501, USA
| | - Brian S Gruber
- Trauma/Critical Care Services, St. Elizabeth Health Center1044 Belmont Avenue, Youngstown, OH, 44501, USA
| | - Javier E Calderon
- Infection Control Services, St. Elizabeth Health Center1044 Belmont Avenue, Youngstown, OH, 44501, USA
| | - Kenneth J Ransom
- Trauma/Critical Care Services, St. Elizabeth Health Center1044 Belmont Avenue, Youngstown, OH, 44501, USA
| | - Laurie L Flowers
- Trauma/Critical Care Services, St. Elizabeth Health Center1044 Belmont Avenue, Youngstown, OH, 44501, USA
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Huang YH, Lee TC, Liao CC, Deng YH, Kwan AL. Tracheostomy in craniectomised survivors after traumatic brain injury: a cross-sectional analytical study. Injury 2013; 44:1226-31. [PMID: 23347766 DOI: 10.1016/j.injury.2012.12.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2012] [Revised: 12/17/2012] [Accepted: 12/28/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Decompressive craniectomy (DC) is a life-saving measure for traumatic brain injury (TBI). However, survivors may remain in a vegetative or minimally conscious state and require tracheostomy to facilitate airway management. In this cross-sectional analytical study, we investigated the predictors for tracheostomy requirement and influence of tracheostomy timing on outcomes in craniectomised survivors after TBI. METHODS We enrolled 160 patients undergoing DC and surviving >7 days after TBI in this 3-year retrospective study. The patients were subdivided into 2 groups based on whether tracheostomy was (N=38) or was not (N=122) performed. We identified intergroup differences in early clinical parameters. Multivariable logistic regression was used to adjust for independent predictors of the need for tracheostomy. Early tracheostomy was defined as the performance of the procedure within the first 10 days after DC. Intensive care unit (ICU) stay, hospital stay, mortality, and Glasgow outcome scale (GOS) were analysed according to the timing of the tracheostomy procedure. RESULTS After TBI, 24% of craniectomised survivors required tracheostomy. In the multivariate logistic regression mode, the significant factors related to the need for tracheostomy were age (odds ratio=1.041; p=0.002), the Glasgow coma score (GCS) at admission (odds ratio=0.733; p=0.005), and normal status of basal cisterns (odds ratio=0.000; p=0.008). The ICU stay was shorter for patients with early tracheostomy than for those undergoing late tracheostomy (p=0.004). The timing of tracheostomy had no influence on the hospital stay, mortality, or GOS. CONCLUSION Age and admission GCS were independent predictors of the need for tracheostomy in craniectomised survivors after TBI. If tracheostomy is necessary, an earlier procedure may assist in patient care.
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Affiliation(s)
- Yu-Hua Huang
- Department of Neurosurgery, Kaohsiung Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Kaohsiung, Taiwan.
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Agrawal A, Baisakhiya N, Kakani A, Nagrale M. Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from a rural set-up of a developing country. Int J Crit Illn Inj Sci 2013; 1:13-6. [PMID: 22096768 PMCID: PMC3209989 DOI: 10.4103/2229-5151.79276] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background: Neurosurgical patients including patients with severe head injury are at risk of developing respiratory complications. These can adversely affect the outcome and can result in poor survival. Many studies confirm that tracheostomy is a safe, effective method of airway management for patients with severe head, facial and multisystem organ trauma. Aims: To know the indications for performing early tracheostomy and its outcome. Settings and Design: Retrospective data analysis. Materials and Methods: The present study is a retrospective analysis of all patients who were admitted with the diagnosis of head injury between January 2007 and December 2009 and underwent tracheostomy at a rural tertiary care trauma center of Central India. Results: During the study period, a total of 40 patients with head injury underwent tracheostomy. All the patients sustained head injury in road traffic accidents. The mean age of the patients was 37.6 years (range 14–75 years, standard deviation 14 ± 14.9 years). Maximum number of patients were in their third decade of life, followed by those in the fifth and fourth decades. There were 36 males and 4 females. Tracheostomy was performed in 30 patients with severe head injury, 9 patients with moderate head injury and in only one case of mild head injury as the patient had multiple facial injuries compromising the airway. Conclusions: Neurocritical care is a relatively new field in India, and the facilities for critical neurosurgical patients are available only in a very few tertiary care centers mainly serving the urban areas. In the present study, we discuss our limited experience with tracheostomy in patients with head injury while facing the challenge of limited resources.
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Affiliation(s)
- Amit Agrawal
- Department of Neurosurgery, MM Institute of Medical Sciences & Research, Maharishi Markandeshwar University, Mullana- Ambala, 133203 (Haryana), India
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The impact of tracheostomy timing in patients with severe head injury: an observational cohort study. Injury 2012; 43:1432-6. [PMID: 21536285 DOI: 10.1016/j.injury.2011.03.059] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2011] [Accepted: 03/29/2011] [Indexed: 02/02/2023]
Abstract
STUDY DESIGN A retrospective analysis of 66 adults with severe head injury admitted to the neurosurgical intensive care unit (ICU) who required tracheostomy. OBJECTIVE The purpose of this cohort study was to examine the impact of the tracheostomy timing in patients with severe head injury. METHODS Patients were included in this study if they were admitted to the neurosurgical ICU because of severe head injury and if tracheostomy was performed. The patients were classified into 2 groups: early tracheostomy (ET) and late tracheostomy (LT). The timing of tracheostomy was considered early if it was performed by day 10 of mechanical ventilation and late if it was performed after day 10. We compared the duration of mechanical ventilation, length of stay (LOS) at ICU, hospital LOS, incidence of pneumonia, duration of antibiotics use, and mortality between the ET and LT groups. RESULTS Of the 2481 patients with severe head injury admitted to the neurosurgical ICU, 66 (2.7%) required tracheostomy; 16 of whom were in the ET group and 50 were in the LT group. The ICU LOS was significantly shorter in the ET group (p<0.001). The incidence of nosocomial pneumonia was lower in the ET group (p=0.04) and the duration of antibiotic use was significantly shorter in the ET group (p<0.001). The patients in the ET group had a lower incidence of pneumonia caused by gram-negative microorganisms (p=0.001). CONCLUSIONS ET in patients with severe head injury might contribute to a shorter duration of ICU LOS, lower incidence of gram-negative microorganism-related nosocomial pneumonia, and shorter duration of antibiotic use.
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Agrawal A, Gode D, Kakani A, Nagrale M, Quazi SZ, Gaidhane A, Shaikh P. Resource utilization in the management of traumatic brain injury patients in a critical care unit: An audit from rural setup of a developing country. Int J Crit Illn Inj Sci 2012; 1:110-3. [PMID: 22229133 PMCID: PMC3249841 DOI: 10.4103/2229-5151.84794] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction: Traumatic brain injuries (TBI) are steadily increasing and are a major cause of mortality and morbidity, particularly in the young population, leading to the loss of life and productivity in the developing countries. Providing critical care to these patients with TBI is a challenge even in well-advanced centers in major cities of India. In the present study, we describe our experience of resource utilization in the management of TBI in a critical care unit (CCU) from a rural setup. Materials and Methods: All consecutive patients who were admitted from January 2007 to December 2009 in the CCU for the management of traumatic brain injury were included in the study. The case records of the patients were reviewed retrospectively, and data were collected on age, gender, severity of head injury, associated injuries, total CCU stay, total hospital stay, and outcome. Results: The total duration (days) of hospital stay was 8.96±6.16 days and a median of 8 days, and CCU stay was 3.77±6.34 days with a median of 2 days. No deaths occurred with mild head injury. A total of 73 (19.16%) deaths occurred in 381 admitted subjects in CCU. The risk of death among both the sexes is not significantly different, that is, odds ratio (OR) 1.032 [95% confidence interval (CI) 0.351–3.03], so also the risk of death among the different age groups is also not significant having OR, 0.978 (95% CI, 0.954–1.00). The severity of head injury (mild, moderate, and severe) and CCU stay parameters had significant difference with risk of death [OR, 3.22 (95% CI, 2.49–4.16) and OR, 2.50 (95% CI, 1.9–3.2)]. Conclusions: Apparently it seems possible to use the existing health care structures in rural areas to improve trauma care. It becomes particularly relevant in poor resource, developing countries, where health care facilities and access to specialized care units are still far below the acceptable standard, there is a need to compare with the reference group to further support the evidence.
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Affiliation(s)
- Amit Agrawal
- Department of Neurosurgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India
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Yaghi S, Moore P, Ray B, Keyrouz SG. Predictors of tracheostomy in patients with spontaneous intracerebral hemorrhage. Clin Neurol Neurosurg 2012; 115:695-8. [PMID: 22910395 DOI: 10.1016/j.clineuro.2012.08.010] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2011] [Revised: 07/30/2012] [Accepted: 08/03/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND One third of patients with intracerebral hemorrhage (ICH) require mechanical ventilation; in most, tracheostomy may be necessary. Limited data exist about predictors of tracheostomy in ICH. The aim of our study is to identify predictors of tracheostomy in ICH. METHODS We reviewed medical records of patients seen in our institution between 2005 and 2009, using ICD-9 codes for ICH, for admission clinical and radiological parameters. A stepwise logistic regression model was used to identify tracheostomy predictors. RESULTS Ninety patients with ICH were included in the analysis, eleven of which required tracheostomy. Patients requiring a tracheostomy were more likely to have a large hematoma volume (≥30mL) (63.4% vs. 29.1%, p=0.037), intraventricular hemorrhage (81.8% vs. 27.8%, p<0.0001), hydrocephalus (81.8% vs. 8.8%, p<0.0001), admission GCS<8 (81.8% vs. 5.1%, p<0.0001), intubation≥14 days (54.5% vs. 1.27%, p<0.0001) and pneumonia (63.6% vs. 17.7%, p=0.003). Stepwise logistic regression yielded admission GCS (OR=80.55, p=0.0003) and intubation days (OR=87.49, p<0.006) as most important predictors. CONCLUSION We could potentially predict the need for tracheostomy early in the course of ICH based on the admission GCS score; duration of intubation is another predictor for tracheostomy. Early tracheostomy could decrease the time, and therefore risks of prolonged endotracheal intubation and length of hospital stay.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, University of Arkansas for Medical Sciences, Little Rock, AR, United States.
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Abstract
BACKGROUND The influence of tracheostomy timing on outcome after severe head injury remains controversial. METHODS The investigation was based on data prospectively collected by the Pennsylvania Trauma Society Foundation statewide trauma registry from January 1990 until December 2005. RESULTS 3,104 patients met criteria for inclusion in the study (GCS ≤ 8 and tracheostomy). Early Tracheostomy Group (ETG) patients, defined as tracheostomy performed during hospital days 1-7, were more likely to be functionally independent at discharge (adjusted odds ratio (OR) 1.45, 95% confidence interval (CI), 1.16-1.82, P = 0.001) and have a shorter length of stay (adjusted OR 0.23, 95% CI, 0.20-0.28, P < 0.0001). However, Late Tracheostomy Group (LTG) patients, defined as tracheostomy performed >7 days after admission, were approximately twice as likely to be discharged alive (adjusted OR 2.12, 95% CI, 1.60-2.82, P < 0.0001). Using a Composite Outcome Scale, which combined these three measures, there was a non-significant trend toward a higher likelihood of a poor outcome in LTG patients. When this analysis was repeated using only those patients in relatively good condition on admission, LTG patients were found to be approximately 50% less likely to have a good outcome (adjusted OR 0.46, 95% CI, 0.28-0.73, P = 0.001) when compared to ETG patients. CONCLUSIONS These results indicate a complex relationship between tracheostomy timing and outcome, but suggest that a strategy of early tracheostomy, particularly when performed on patients with a reasonable chance of survival, results in a better overall clinical outcome than when the tracheostomy is performed in a delayed manner.
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Shamim MS, Qadeer M, Murtaza G, Enam SA, Farooqi NB. Emergency department predictors of tracheostomy in patients with isolated traumatic brain injury requiring emergency cranial decompression. J Neurosurg 2011; 115:1007-12. [DOI: 10.3171/2011.7.jns101829] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Patients with severe traumatic brain injury (TBI) frequently require a tracheostomy for prolonged mechanical ventilation and/or pulmonary toilet. It is now proven that the earlier the procedure is done, the more beneficial it is to the patient. The present study was carried out to determine if the requirement of a tracheostomy can be predicted on arrival of a patient to the emergency department. The prediction can potentially aid in combining the procedure with cranial decompression. In this study, the authors' aim was to determine the emergency department predictors of tracheostomy in patients with isolated TBI requiring emergency cranial decompression.
Methods
The authors performed a retrospective chart review of all patients who underwent surgery for isolated TBI and required more than 4 days of mechanical ventilation. Multivariate logistic regression analysis was used for predictive indicators.
Results
In patients with isolated severe TBI, a patient age of 31–50 years, the presence of preexisting medical comorbid conditions, a delay in emergency department arrival exceeding 1.5 hours, an abnormal pupil response on arrival, and a preoperative neurological worsening during hospital stay were independent predictors of the requirement for tracheostomy. These findings were validated in a small cohort of patients and were found to be significant.
Conclusions
Requirement of a tracheostomy can be predicted in patients with severe TBI on arrival to the emergency department. These results were validated in a small cohort of patients, and it was found that the positive predictive value of requirement of tracheostomy was directly proportional to the number of predictors present. Larger prospective studies with appropriate control groups are further recommended to validate the authors' findings.
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Ganuza JR, Oliviero A. Tracheostomy in spinal cord injured patients. Transl Med UniSa 2011; 1:151-72. [PMID: 23905031 PMCID: PMC3728845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Patients with cervical spinal cord injury frequently need prolonged mechanical ventilation as a result of worsening pulmonary vital capacity due to paralysis of respiratory muscles, severe impairment of tracheobronchial secretions clearance and high incidence of respiratory complications like pneumonia or atelectasis. Patients with thoracic spinal cord injury may need mechanical ventilation due to associate injuries. For these reasons, tracheostomy is frequently performed in these patients, more frequently when the spinal cord injury is at cervical level. Percutaneous technique, performed in the ICU, should be considered the preferred procedure for performing elective tracheostomies in spinal cord injured patients. Tracheostomy should be implemented as soon as possible in SCI patients they require prolonged mechanical ventilation. Tracheostomy can be performed just after anterolateral cervical spine fixation surgery. Tracheostomy can be removed when no longer needed without major complications.
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Affiliation(s)
- Javier-Romero Ganuza
- Center: ICU and Neurology Unit, Internal Medicine Department, National Hospital for Paraplegics, Toledo, Spain
| | - Antonio Oliviero
- Center: ICU and Neurology Unit, Internal Medicine Department, National Hospital for Paraplegics, Toledo, Spain
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Abstract
OBJECTIVE To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients. DESIGN Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation. SETTING Three hundred forty-nine intensive care units from 23 countries. PATIENTS We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit. CONCLUSIONS In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality rate than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction.
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Agrawal A, Joharapurkar SR, Golhar KB, Shahapurkar VV. Early tracheostomy in severe head injuries at a rural center. J Emerg Trauma Shock 2011; 2:56. [PMID: 19561960 PMCID: PMC2700570 DOI: 10.4103/0974-2700.44687] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- Amit Agrawal
- Department of Surgery, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha, India
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Ganuza JR, Forcada AG, Gambarrutta C, De La Lastra Buigues ED, Gonzalez VEM, Fuentes FP, Luciani AA. Effect of technique and timing of tracheostomy in patients with acute traumatic spinal cord injury undergoing mechanical ventilation. J Spinal Cord Med 2011; 34:76-84. [PMID: 21528630 PMCID: PMC3066483 DOI: 10.1179/107902610x12886261091875] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE To assess the effect of timing and techniques of tracheostomy on morbidity, mortality, and the burden of resources in patients with acute traumatic spinal cord injuries (SCls) undergoing mechanical ventilation. DESIGN Review of a prospectively collected database. SETTING Intensive and intermediate care units of a monographic hospital for the treatment of SCI. PARTICIPANTS Consecutive patients admitted to the intensive care unit (ICU) during their first inpatient rehabilitation for cervical and thoracic traumatic SCI. A total of 323 patients were included: 297 required mechanical ventilation and 215 underwent tracheostomy. OUTCOME MEASURES Demographic data, data relevant to the patients' neurological injuries (level and grade of spinal cord damage), tracheostomy technique and timing, duration of mechanical ventilation, length of stay at ICU, incidence of pneumonia, incidence of perioperative and early postoperative complications, and mortality. RESULTS Early tracheostomy (<7 days after orotracheal intubation) tracheostomy was performed in 101 patients (47%) and late (> or = 7 days) in 114 (53%). Surgical tracheostomy was employed in 119 cases (55%) and percutaneous tracheostomy in 96 (45%). There were 61 complications in 53 patients related to all tracheostomy procedures. Two were qualified as serious (tracheoesophageal fistula and mediastinal abscess). Other complications were mild. Bleeding was moderate in one case (late, percutaneous tracheostomy). Postoperative infection rate was low. Mortality of all causes was also low. CONCLUSION Early tracheostomy may have favorable effects in patients with acute traumatic SC. Both techniques, percutaneous and surgical tracheostomy, can be performed safely in the ICU.
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Affiliation(s)
- Javier Romero Ganuza
- Intensive Care Unit and Internal Medicine Department, Paraplejics National Hospital, Toledo, Spain.
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Ahmadinegad M, Karamouzian S, Lashkarizadeh MR. Use of glasgow coma scale as an indicator for early tracheostomy in patients with severe head injury. TANAFFOS 2011; 10:26-30. [PMID: 25191347 PMCID: PMC4153128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/26/2010] [Accepted: 12/20/2010] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early tracheostomy can reduce the time required for mechanical ventilation, the duration of ICU stay, and treatment expenses. Choosing the optimal time for tracheostomy in patients with severe head injury is therefore important. The purpose of this study was to find the optimal time for tracheostomy according to Glasgow Coma Scale (GCS). MATERIALS AND METHODS In this prospective study, patients with severe head injury (GCS<8) admitted to the ICU of Kerman Shahid Bahonar Hospital were evaluated every day according to their GCS, and possible need for tracheostomy. RESULTS Seventy-four patients were enrolled. The GCS of 49 patients on day 5 following ICU admission was <9. Forty-two patients (85.7%) eventually needed tracheostomy, and tracheostomy was not required in the remainder (14.3%). The prevalence of tracheostomy in patients with GCS >9 was 50%, and this difference was statistically significant. CONCLUSION The present study showed that GCS of patients with severe head injury on day 5 following ICU admission may be used for decision-making regarding the time of tracheostomy. Tracheostomy should be carried out on day 5 following ICU admission if the GCS is ≤8, but it can be delayed if the GCS on the 5(th) day is >9.
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Does Acuity Matter?—Optimal Timing of Tracheostomy Stratified by Injury Severity. ACTA ACUST UNITED AC 2009; 66:220-5. [DOI: 10.1097/ta.0b013e31816073e3] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Aissaoui Y, Azendour H, Balkhi H, Haimeur C, Kamili Drissi N, Atmani M. [Timing of tracheostomy and outcome of patients requiring mechanical ventilation]. ACTA ACUST UNITED AC 2007; 26:496-501. [PMID: 17521853 DOI: 10.1016/j.annfar.2007.03.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2006] [Accepted: 03/26/2007] [Indexed: 11/22/2022]
Abstract
OBJECTIVES To assess the impact of tracheostomy timing on outcome of critically ill patients requiring mechanical ventilation (MV). STUDY DESIGN Retrospective clinical study in a twelve beds intensive care unit (ICU). PATIENTS AND METHODS From January 2001 to June 2005, patients under MV who received tracheostomy were divided into 2 groups: early tracheostomy group when tracheostomy was performed before or on day 7 and late tracheostomy group when it was performed thereafter. We compared prevalence of nosocomial pneumonia, length of sedation, lengths of MV, length of stay in ICU, weaning from MV and mortality rates between the 2 groups. RESULTS During this period of 4 years and half, 112 patients underwent tracheostomy, 62 of whom had early tracheostomy and 50 had late tracheostomy. Early tracheostomy was associated with significant reduction of length of sedation (10+/-3 vs 17+/-5 days, P<0.001), length of MV (21+/-19 vs 29+/-17 days, P=0.02) and length of stay in ICU (33+/-22 vs 42+/-18 days, P=0.042). There were no differences in prevalence of pneumonia (21% for early tracheostomy group vs 31% for late tracheostomy group, P=0, 13), weaning from MV (50 vs 36%, P=0.19), and mortality rates between the 2 groups (38 vs 54%, P=0.15). CONCLUSION This study demonstrated that early tracheostomy (< or =7 days), was associated with shorter length of sedation, shorter duration of MV and shorter ICU length of stay, without affecting weaning from MV, prevalence of nosocomial pneumonia or survival.
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Affiliation(s)
- Y Aissaoui
- Service de réanimation, département d'anesthésie-réanimation et urgences, hôpital militaire d'instruction des armées Mohammed-V, Rabat, Morocco
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Clum SR, Rumbak MJ. Mobilizing the patient in the intensive care unit: the role of early tracheotomy. Crit Care Clin 2007; 23:71-9. [PMID: 17307117 DOI: 10.1016/j.ccc.2006.11.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A large number of studies have evaluated the benefits of early tracheotomy. Heterogeneity in the various studies reviewed in this article is apparent, with early tracheotomy ranging from one to several days, and benefits regarding incidence of pneumonia and mortality are variable. An additional factor likely contributing to the differing results relates to the varied patient populations in the individual studies, which ranged from burn patients to medical ICU patients to trauma patients and head trauma patients. A close look at the studies with the least confounding variables suggests that early tracheotomy has some merit. Most studies suggest that time in the ICU, on mechanical ventilation, and in the hospital is reduced.
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Affiliation(s)
- Stephen R Clum
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Section of Interventional Pulmonology, University of South Florida College of Medicine, Tampa, FL 33612, USA
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