神经重症监护病房同期与延迟行经皮内镜下胃造瘘术行气管切开术的结局。
Outcomes of Tracheostomy With Concomitant and Delayed Percutaneous Endoscopic Gastrostomy in the Neuroscience Critical Care Unit.
机构信息
1 Department of Neurology, University of Mississippi Medical Center, Jackson, MS, USA.
2 Department of Acute and Chronic Care, Johns Hopkins University School of Nursing, Baltimore, MD, USA.
出版信息
J Intensive Care Med. 2019 Oct;34(10):835-843. doi: 10.1177/0885066617718492. Epub 2017 Jul 4.
BACKGROUND
In patients with severe neurologic conditions, percutaneous endoscopic gastrostomy (PEG) is typically performed either alone or with a tracheostomy. The characteristics and outcomes of patients receiving PEG concomitantly with a tracheostomy (CTPEG) and those receiving delayed PEG (DPEG) after a tracheostomy were compared.
METHODS
Retrospective cohort study in a 24-bed neuroscience critical care unit (NCCU) at a tertiary care hospital. Consecutive patients admitted to the NCCU from April 2007 to July 2013 who underwent percutaneous tracheostomy and gastrostomy by the percutaneous tracheostomy team were included and grouped according to the timing of PEG placement: CTPEG versus DPEG.
RESULTS
Of the 290 patients, 234 (81%) received CTPEG. Demographic and clinical characteristics were similar among the 2 groups except for a lower median (interquartile range [IQR]) body mass index (BMI; 27 [22.67-31.60] versus 30.8 [24.55-40.06], = .017) and lower rate of acute respiratory distress syndrome (3.85% vs 10.71%, = .048) in the CTPEG cohort. Furthermore, 59% of CTPEG cohort were neurology patients while 63% of DPEG were neurosurgery patients, = .004. Primary outcomes showed shorter mean NCCU length of stay (LOS; 25 [12] vs 33 [17] days, < .001) and median hospital LOS (32 [25-43] vs 37 [31-56] days, = .002) for the CTPEG cohort. Secondary outcomes showed higher predischarge prealbumin levels (15.6 [7.75] vs 11.58 [5.41], = .021) and lower median overall hospital cost (US$123 860.20 [US$99 024-US$168 713.40] vs US$159 633.50 [US$121 312-US$240 213.10], = .0003) in the CTPEG group. Anatomic contraindications were the most common reason for DPEG (30%).
CONCLUSIONS
Among institutions with a tracheostomy team, the practice of tracheostomy with concomitant PEG placement may be considered as feasible as delayed PEG in carefully selected neurocritically ill patients with possible advantages of overall shorter NCCU and hospital LOS, higher predischarge prealbumin, and lower hospital costs. These findings may aid in decisions regarding the timing of PEG placement in the NCCU. Further prospective studies are warranted.
背景
在患有严重神经疾病的患者中，经皮内镜下胃造口术（PEG）通常单独进行或与气管造口术同时进行。比较了同时接受 PEG 联合气管造口术（CTPEG）和接受气管造口术后延迟 PEG（DPEG）的患者的特征和结局。
方法
这是一项在一家三级医院的 24 张床位神经科学重症监护病房（NCCU）进行的回顾性队列研究。纳入 2007 年 4 月至 2013 年 7 月期间经 NCCU 接受经皮气管造口术和胃造口术的连续患者，并根据 PEG 放置时间进行分组：CTPEG 与 DPEG。
结果
在 290 名患者中，234 名（81%）接受了 CTPEG。两组的人口统计学和临床特征相似，但 CTPEG 组的中位数（四分位距 [IQR]）体质量指数（BMI；27 [22.67-31.60] 与 30.8 [24.55-40.06]，.017）和急性呼吸窘迫综合征（ARDS）发生率（3.85% vs 10.71%，.048）较低。此外，CTPEG 组中 59%为神经科患者，而 DPEG 组中 63%为神经外科患者，.004。主要结局显示 CTPEG 组的 NCCU 住院时间（25 [12] 天与 33 [17] 天， <.001）和中位住院时间（32 [25-43] 天与 37 [31-56] 天， =.002）更短。次要结局显示 CTPEG 组出院前前白蛋白水平较高（15.6 [7.75] 与 11.58 [5.41]， =.021）和总住院费用中位数较低（US$123860.20 [US$99024-US$168713.40] 与 US$159633.50 [US$121312-US$240213.10]， =.0003）。解剖学禁忌是 DPEG 的最常见原因（30%）。
结论
在有气管造口术团队的机构中，气管造口术联合同时进行 PEG 可能与在精心挑选的神经危重症患者中延迟进行 PEG 一样可行，可能具有较短的 NCCU 和住院 LOS、更高的出院前前白蛋白和更低的住院费用等优势。这些发现可能有助于决策 NCCU 中 PEG 放置的时机。需要进一步的前瞻性研究。
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