Call Mariah S, Kutcher Matthew E, Izenberg Robert A, Singh Tanya, Cohen Mitchell J
Department of Surgery at San Francisco General Hospital, University of California, San Francisco, California 94110, USA.
J Trauma. 2011 Dec;71(6):1673-9. doi: 10.1097/TA.0b013e31821e87c2.
Spinal cord injury (SCI) carries potentially devastating respiratory implications depending on injury level. Optimal strategies for mechanical ventilation in this setting remain poorly described. We reviewed our experience of ventilatory weaning and extubation outcomes in this patient population.
Eighty mechanically ventilated SCI patients over a 5-year period at a major Level I trauma center were assessed. Injury, clinical, and outcome data were extracted using our ICU database, chart, and registry data.
We identified 80 patients with SCI, classified by anatomic injury and motor functional level. There were no differences in injury severity between patients who were successfully extubated and those who failed (all p = NS). Seventy-four percent were extubated at the time of discharge; successful extubation was associated with lower level of cord injury (p = 0.001) and higher arrival Glasgow Coma Scale score (13.7 ± 2.6 vs. 10.8 ± 5.0, p = 0.021). Of extubation failures, 80% were due to pulmonary mechanical insufficiency, 22% inadequate pulmonary toilet, and 5% sedation or neurologic issues. Patients with weaning or extubation failures had longer ICU (29.9 days ± 24.5 days vs. 8.5 days ± 9.3 days; p < 0.001) and hospital stays (45.8 days ± 45.8 days vs. 26.6 days ± 23.9 days; p = 0.009), and higher rates of ventilator-associated pneumonia (83% vs. 15%, p < 0.001).
Higher level of SCI correlates strongly with failure to wean and extubate; despite this, a subset of patients with high cord injury who can be safely weaned and extubated exists. A multicenter study is warranted to specifically identify patients with high SCI who merit weaning and extubation trials.
脊髓损伤（SCI）根据损伤平面会对呼吸产生潜在的严重影响。在这种情况下，机械通气的最佳策略仍描述甚少。我们回顾了我们在这一患者群体中进行通气撤机和拔管结果的经验。
对一家一级创伤中心5年内80例接受机械通气的SCI患者进行了评估。使用我们的重症监护病房数据库、病历和登记数据提取损伤、临床和结果数据。
我们确定了80例SCI患者，并根据解剖损伤和运动功能水平进行了分类。成功拔管和未成功拔管的患者在损伤严重程度上没有差异（所有p=无显著性差异）。74%的患者在出院时拔管；成功拔管与较低的脊髓损伤平面相关（p=0.001），且入院时格拉斯哥昏迷量表评分较高（13.7±2.6对10.8±5.0，p=0.021）。在拔管失败的患者中，80%是由于肺部机械功能不全，22%是由于肺部清洁不足，5%是由于镇静或神经问题。撤机或拔管失败的患者在重症监护病房的住院时间更长（29.9天±24.5天对8.5天±9.3天；p<0.001），住院时间也更长（45.8天±45.8天对26.6天±23.9天；p=0.009），呼吸机相关性肺炎的发生率更高（83%对15%，p<0.001）。
较高平面的SCI与撤机和拔管失败密切相关；尽管如此，仍有一部分高位脊髓损伤患者能够安全地撤机并拔管。有必要进行一项多中心研究，以明确哪些高位SCI患者值得进行撤机和拔管试验。
