Goettler Claudia E, Fugo Jonathan R, Bard Michael R, Newell Mark A, Sagraves Scott G, Toschlog Eric A, Schenarts Paul J, Rotondo Michael F
Department of Surgery, East Carolina University, Greenville, North Carolina, USA.
J Trauma. 2006 May;60(5):991-6. doi: 10.1097/01.ta.0000217270.16860.32.
Tracheostomy has few, severe risks, while prolonged endotracheal intubation causes morbidity. The need for tracheostomy was assessed, based on early clinical parameters.
Adult trauma patients (January 1994-August 2004), intubated for resuscitation, ventilated >24 hours, were retrospectively evaluated for demographics, physiology, brain, and pulmonary injury. Tracheostomy patients were compared with those without. Chi-square, Mann-Whitney, and multivariate logistic regression were used with statistical significance at p < 0.05.*
Of 992 patients, 430 (43%) underwent tracheostomy at 9.22 +/- 5.7 days. Risk factors were age (45.6* +/- 18.8 vs. 36.7 +/- 15.9, OR: 2.1 (18 years increments), ISS (30.3* +/- 12.5 vs. 22.0 +/- 10.3, OR: 2.1 (12u increments), damage control (DC) [68%(n = 51) vs. 32%(n = 51), OR: 3.8], craniotomy [70%(n = 21) versus 30%(n = 9), OR: 2.6], and intracranial pressure monitor (ICP) [65.4%(n = 87) vs. 34.6%(n = 46), OR: 2.1]. A 100% tracheostomy rate (n = 30, 3.0%) occurred with ISS (injury severity score) = 75, ISS >or=50, and age >or=55, admit/24 hour GCS (Glasgow Coma Scale) = 3 and age >or=70, AIS abdomen, chest or extremities >or=5 and age >or=60, bilateral pulmonary contusions (BPC) and >or=8 rib fractures, craniotomy and age >or=50, craniotomy with intracranial pressure (ICP) and age >or=40, or craniotomy and GCS <or=4 at 24 hour.A tracheostomy rate of >or=90% (n = 105, 10.6%) was found with ISS >or=54, ISS >or=40, and age >or=40, admit/24 hour GCS = 3 and age >or=55, paralysis and age >or=40, BPC and age >or=55.A tracheostomy rate >or=80% (n = 248, 25.0%) occurred with ISS >or=38, age >or=80, admit/24 hour GCS = 3 and age >or=45, DC and age >or=50, BPC and age >or=50, aspiration and age >or=55, craniotomy with ICP, craniotomy with GCS <or=9 at 24 hour.
Discrete risk factors predict the need for tracheostomy for trauma patients. We recommend that patients with >or=90% risk undergo early tracheostomy and that it is considered in the >or=80% risk group to potentially decreased morbidity, increased patient comfort, and optimize resource utilization.
气管切开术风险少且严重程度低，而长时间气管插管会引发并发症。基于早期临床参数对气管切开术的必要性进行了评估。
对1994年1月至2004年8月因复苏而行气管插管、机械通气超过24小时的成年创伤患者的人口统计学、生理学、脑和肺损伤情况进行回顾性评估。将行气管切开术的患者与未行气管切开术的患者进行比较。采用卡方检验、曼-惠特尼检验和多因素逻辑回归分析，p<0.05为具有统计学意义。
992例患者中，430例（43%）在9.22±5.7天接受了气管切开术。危险因素包括年龄（45.6±18.8岁对36.7±15.9岁，比值比：2.1（每增加18岁））、损伤严重度评分（ISS）（30.3±12.5对22.0±10.3，比值比：2.1（每增加12分））、损害控制（DC）[68%（n = 51）对32%（n = 51），比值比：3.8]、开颅手术[70%（n = 21）对30%（n = 9），比值比：2.6]以及颅内压监测（ICP）[65.4%（n = 87）对34.6%（n = 46），比值比：2.1]。当ISS=75、ISS≥50且年龄≥55岁、入院/24小时格拉斯哥昏迷量表（GCS）=3且年龄≥70岁、简明损伤定级（AIS）腹部、胸部或四肢≥5且年龄≥60岁、双侧肺挫伤（BPC）且肋骨骨折≥8根、开颅手术且年龄≥50岁、开颅手术伴颅内压（ICP）且年龄≥40岁或开颅手术且24小时GCS≤4时，气管切开率为100%（n = 30，3.0%）。当ISS≥54、ISS≥40且年龄≥40岁、入院/24小时GCS = 3且年龄≥55岁、瘫痪且年龄≥40岁、BPC且年龄≥55岁时，气管切开率≥90%（n = 105，10.6%）。当ISS≥38、年龄≥80岁、入院/24小时GCS = 3且年龄≥45岁、DC且年龄≥50岁、BPC且年龄≥50岁、误吸且年龄≥55岁、开颅手术伴ICP、开颅手术且24小时GCS≤9时，气管切开率≥80%（n = 248，25.0%）。
特定危险因素可预测创伤患者对气管切开术的需求。我们建议，风险≥90%的患者应尽早行气管切开术，对于风险≥80%的患者也应考虑行气管切开术，以潜在降低并发症发生率、提高患者舒适度并优化资源利用。
