Weinberg Jordan A, Stevens Lily R, Goslar Pamela W, Thompson Terrell M, Sanford Jessica L, Petersen Scott R
Department of Surgery, Dignity Health-St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
Trauma Surg Acute Care Open. 2016 Dec 19;1(1):e000052. doi: 10.1136/tsaco-2016-000052. eCollection 2016.
Extubation failure in critically ill patients is associated with higher morbidity and mortality. Although predictors of failed extubation have been previously determined in intensive care unit (ICU) cohorts, relatively less attention has been directed toward this issue in patients with trauma. The aim of this study was to identify predictors of extubation failure among patients with trauma in a multidisciplinary ICU setting.
A prospective observational study of extubation failures (EF) was conducted at an American College of Surgeons level I trauma center over 3 years (2011-2013). Case-control patients (CC) were then compared with the study group (EF) with respect to demographic/clinical characteristics and outcomes. Failure of extubation was defined as reintubation within 72 hours following planned extubation.
7830 patients were admitted to the trauma service and 1098 (14%) underwent mechanical ventilation. 63 patients met inclusion criteria for the EF group and 63 comprised the CC group. The overall rate of extubation failure was 5.7% and mean time to reintubation was 13.0 hours. Groups (EF vs CC) were similar for Injury Severity Score (21 vs 21), Glasgow Coma Scale at extubation (11 vs 10), number of comorbidities (1.5 vs 1.7), injury mechanism (blunt 79% vs 74%), and body mass index (27.9 vs 27.2). In addition, groups were similar with respect to weaning protocol compliance (84% vs 89%, p=0.57). EF group had significantly increased ICU length of stay (LOS) (15.7 vs 7.4 days, p<0.001), ventilator days (13.3 vs 4.8, p<0.001), and mortality (9.5% vs 0%, p=0.03). Multiple regression analysis identified that EF was associated with increased odds of: (1) temperature >38°C at time of extubation (OR 5.9, 95% CI 1.7 to 20.8), and (2) non-surgeon intensivist consultation (OR 24.2, 95% CI 5.5 to 105.9).
Extubation failure is associated with increased LOS, ventilator days, and mortality in patients with trauma. Fever at time of extubation is associated with extubation failure, and the presence of such should give pause in the decision to extubate. Non-surgeon intensivist involvement increases risk of extubation failure, and a surgical critical care service may be most appropriate for the management of ventilated patients with trauma.
III, Prognostic and epidemiological.
重症患者拔管失败与更高的发病率和死亡率相关。尽管此前已在重症监护病房（ICU）队列中确定了拔管失败的预测因素，但创伤患者在这一问题上受到的关注相对较少。本研究的目的是确定多学科ICU环境中创伤患者拔管失败的预测因素。
在美国外科医师学会一级创伤中心进行了一项为期3年（2011 - 2013年）的拔管失败（EF）前瞻性观察研究。然后将病例对照患者（CC）与研究组（EF）在人口统计学/临床特征及结果方面进行比较。拔管失败定义为计划拔管后72小时内再次插管。
7830例患者入住创伤科，1098例（14%）接受了机械通气。63例患者符合EF组纳入标准，63例组成CC组。拔管失败的总体发生率为5.7%，再次插管的平均时间为13.0小时。两组（EF组与CC组）在损伤严重程度评分（21 vs 21）、拔管时格拉斯哥昏迷量表评分（11 vs 10）、合并症数量（1.5 vs 1.7）、损伤机制（钝性伤79% vs 74%）和体重指数（27.9 vs 27.2）方面相似。此外，两组在撤机方案依从性方面也相似（84% vs 89%，p = 0.57）。EF组的ICU住院时间（LOS）显著延长（15.7天 vs 7.4天，p < 0.001）、呼吸机使用天数（13.3天 vs 4.8天，p < 0.001）和死亡率（9.5% vs 0%，p = 0.03）。多元回归分析确定，EF与以下因素的几率增加相关：（1）拔管时体温>38°C（比值比5.9，95%置信区间1.7至20.8），以及（2）非外科重症医学专家会诊（比值比24.2，95%置信区间5.5至105.9）。
拔管失败与创伤患者的住院时间延长、呼吸机使用天数增加和死亡率升高相关。拔管时发热与拔管失败相关，出现这种情况应在拔管决策时予以考虑。非外科重症医学专家参与会增加拔管失败风险，手术重症监护服务可能最适合管理创伤通气患者。
III，预后和流行病学。
