From the Sunnybrook Research Institute (A.S.A., D.C.S., R.A.F., A.K., C.D.M., A.B.N.), Department of Critical Care (D.C.S., R.A.F.), Division of Neurosurgery (T.G.M.), Department of Research Design and Biostatistics (A.K.), and Department of Surgery (A.B.N.), Sunnybrook Health Sciences Center; Clinical Epidemiology Program (A.S.A., D.C.S., R.A.F., J.G.R., A.K., A.B.N.), Institute of Health Policy, Management and Evaluation, Interdepartmental Division of Critical Care (D.C.S., R.A.F.), and Keenan Research Centre of the Li Ka Shing Knowledge Institute (J.G.R, A.B.N) and Department of Medicine (J.G.R.), St. Michael's Hospital, University of Toronto, Toronto; and Division of Neurosurgery (A.S.A.), University of Ottawa, Ottawa, Ontario, Canada.
J Trauma Acute Care Surg. 2014 Jan;76(1):70-6; discussion 76-8. doi: 10.1097/TA.0b013e3182a8fd6a.
The optimal timing of tracheostomy in patients with severe traumatic brain injury (TBI) is controversial; observational studies have been challenged through confounding by indication, and interventional studies have rarely enrolled patients with isolated TBI.
We included a cohort of adults with isolated TBI who underwent tracheostomy within 1 of 135 participating centers in the American College of Surgeons' Trauma Quality Improvement Program, during 2009 to 2011. Patients were classified as having undergone early tracheostomy (ET, ≤8 days) versus late tracheostomy (>8 days). Outcomes were compared between propensity score-matched groups to reduce confounding by indication. In sensitivity analyses, we used time-dependent proportional hazard regression to address immortal time bias and assessed the association between hospital ET rate and patients' outcome at the hospital level.
From 1,811 patients, a well-balanced propensity-matched cohort of 1,154 patients was defined. After matching, ET was associated with fewer mechanical ventilation days (median, 10 days vs. 16 days; rate ratio [RR], 0.70; 95% confidence interval [CI], 0.66-0.75), shorter intensive care unit stay (median, 13 days vs. 19 days; RR, 0.70; 95% CI, 0.66-0.75), shorter hospital length of stay (median, 20 days vs. 27 days; RR, 0.80; 95% CI, 0.74-0.86), and lower odds of pneumonia (41.7% vs. 52.7%; odds ratio [OR], 0.64; 95% CI, 0.51-0.80), deep venous thrombosis (8.2% vs. 14.4%; OR, 0.53; 95% CI, 0.37-0.78), and decubitus ulcer (4.0% vs. 8.9%; OR, 0.43; 95% CI, 0.26-0.71) but no significant difference in pulmonary embolism (1.8% vs. 3.3%; OR, 0.52; 95% CI, 0.24-1.10). Hospital mortality was similar between both groups (8.4% vs. 6.8%; OR, 1.25; 95% CI, 0.80-1.96). Results were consistent using several alternate analytic methods.
In this observational study, ET was associated with a shorter duration of mechanical ventilation, intensive care unit stay, and hospital stay but not hospital mortality. ET may represent a mechanism to reduce in-hospital morbidity for patients with TBI.
Therapeutic study, level II.
对于严重创伤性脑损伤（TBI）患者，气管切开术的最佳时机存在争议；观察性研究受到指示性混杂的挑战，而干预性研究很少纳入单纯 TBI 患者。
我们纳入了在 2009 年至 2011 年期间，在美国外科医师学会创伤质量改进计划的 135 个参与中心中的 1 个中心接受气管切开术的成年单纯 TBI 患者队列。患者分为早期气管切开术（ET，≤8 天）和晚期气管切开术（>8 天）。为了减少指示性混杂，通过倾向评分匹配组比较了结局。在敏感性分析中，我们使用时间依赖性比例风险回归来解决不朽时间偏倚，并评估了医院 ET 率与患者在医院水平的结局之间的关联。
在 1811 名患者中，确定了一个平衡良好的 1154 名患者的倾向评分匹配队列。匹配后，ET 与机械通气天数减少相关（中位数，10 天比 16 天；比值比[RR]，0.70；95%置信区间[CI]，0.66-0.75）、重症监护病房入住时间缩短（中位数，13 天比 19 天；RR，0.70；95%CI，0.66-0.75）、住院时间缩短（中位数，20 天比 27 天；RR，0.80；95%CI，0.74-0.86），肺炎发生率降低（41.7%比 52.7%；比值比[OR]，0.64；95%CI，0.51-0.80）、深静脉血栓形成（8.2%比 14.4%；OR，0.53；95%CI，0.37-0.78）和褥疮（4.0%比 8.9%；OR，0.43；95%CI，0.26-0.71），但肺栓塞发生率无显著差异（1.8%比 3.3%；OR，0.52；95%CI，0.24-1.10）。两组间的医院死亡率相似（8.4%比 6.8%；OR，1.25；95%CI，0.80-1.96）。使用几种替代分析方法的结果一致。
在这项观察性研究中，ET 与机械通气、重症监护病房入住时间和住院时间缩短相关，但与医院死亡率无关。ET 可能代表了降低 TBI 患者住院发病率的一种机制。
治疗性研究，II 级。
