Department of Clinical Research, Children's Health - Children's Medical Center Dallas, 1935 Medical District Drive, Dallas, TX, 75235, USA.
Department of Advanced Practice Services, Critical Care Services, Children's Health - Children's Medical Center Dallas, 1935 Medical District Drive, Dallas, TX, 75235, USA.
Neurocrit Care. 2018 Feb;28(1):83-92. doi: 10.1007/s12028-017-0429-0.
There is a lack of data describing the risk factors for extubation failure (EF) or tracheostomy placement in pediatric neurocritical care (NCC) patients.
A retrospective chart review of children admitted to the pediatric intensive care unit who were intubated for >24 h with an acute neurocritical illness and had an extubation attempt. Bivariate and multivariate statistical analysis was performed to determine significant associations of demographic, neurologic, pulmonary, and clinical variables with EF and tracheostomy placement. Analysis of predictive factors for EF (within 48 h) and tracheostomy placement during the hospitalization was conducted on a first extubation attempt group (n = 193) and a second attempt group (n = 23) who experienced either EF or a "late re-intubation" (>48 h-7 days).
Traumatic brain injury (37.3%) and seizures/status epilepticus (31.4%) were the most common diagnoses with neuromuscular weakness patients having the highest risk for EF and tracheostomy placement. EF occurred in 20/193 (10.4%) patients after their first attempt and 6/23 (26.1%) after a second attempt. Compared to those with a fair/strong cough, patients with a weak/absent cough had a relative risk (RR) of 9.4 for EF (95% CI, 4.9-17.9, p < 0.001) and 6.7 (95% CI, 2.3-18.9, p = 0.01) for tracheostomy placement on the first and second attempts, respectively. Glasgow Coma Score (GCS), endotracheal tube (ETT) secretion characteristics, and pulmonary variables were not associated with EF or tracheostomy placement.
A weak/absent cough reflex is associated with an increased risk of failing extubation and placement of a tracheostomy in intubated pediatric NCC patients.
目前缺乏描述儿科神经危重症患者（NCC）拔管失败（EF）或气管切开术风险因素的数据。
对因急性神经危重症而接受>24 小时气管插管且尝试拔管的儿童重症监护病房患儿进行回顾性图表审查。对人口统计学、神经学、肺部和临床变量与 EF 和气管切开术放置的显著相关性进行了双变量和多变量统计分析。对首次拔管尝试组（n=193）和第二次尝试组（n=23）的 EF（48 小时内）和住院期间气管切开术放置的预测因素进行了分析，第二次尝试组的患者出现 EF 或“迟发性再插管”（>48 小时-7 天）。
创伤性脑损伤（37.3%）和癫痫发作/癫痫持续状态（31.4%）是最常见的诊断，神经肌肉无力患者的 EF 和气管切开术放置风险最高。193 名患者中有 20 名（10.4%）在首次尝试后出现 EF，23 名患者中有 6 名（26.1%）在第二次尝试后出现 EF。与咳嗽有力/强烈的患者相比，咳嗽无力/无咳嗽的患者 EF 的相对风险（RR）为 9.4（95%CI，4.9-17.9，p<0.001），在首次和第二次尝试时气管切开术放置的 RR 分别为 6.7（95%CI，2.3-18.9，p=0.01）。格拉斯哥昏迷评分（GCS）、气管内导管（ETT）分泌物特征和肺部变量与 EF 或气管切开术放置无关。
在接受气管插管的儿科 NCC 患者中，咳嗽无力/无反射与拔管失败和气管切开术放置风险增加相关。
