膈肌起搏在急性颈段脊髓损伤中的应用。
Use of diaphragm pacing in the management of acute cervical spinal cord injury.
机构信息
From the University of Florida College of Medicine-Jacksonville, Jacksonville, Florida.
出版信息
J Trauma Acute Care Surg. 2018 Nov;85(5):928-931. doi: 10.1097/TA.0000000000002023.
BACKGROUND
Cervical spinal cord injury (CSCI) is devastating. Respiratory failure, ventilator-associated pneumonia (VAP), sepsis, and death frequently occur. Case reports of diaphragm pacing system (DPS) have suggested earlier liberation from mechanical ventilation in acute CSCI patients. We hypothesized DPS implantation would decrease VAP and facilitate liberation from ventilation.
METHODS
We performed a retrospective review of patients with acute CSCI managed at a single Level 1 trauma center between January 2005 and May 2017. Routine demographics were collected. Patients underwent propensity matching based on age, injury severity score, ventilator days, hospital length of stay, and need for tracheostomy. Outcome measures included hospital length of stay, intensive care unit length of stay, ventilator days (vent days), incidence of VAP, and mortality. Bivariate and multivariate logistic and linear regression statistics were performed using STATA Version 10.
RESULTS
Between July 2011 and May 2017, all patients with acute CSCI were evaluated for DPS implantation. Forty patients who had laparoscopic DPS implantation (DPS) were matched to 61 who did not (NO DPS). Median time to liberation after DPS implantation was 7 days. Hospital length of stay and mortality were significantly lower on bivariate analysis in DPS patients. Diaphragm pacing system placement was not found to be associated with statistically significant differences in these outcomes on risk-adjusted multivariate models that included admission year.
CONCLUSIONS
Diaphragm pacing system implantation in patients with acute CSCI can be one part of a comprehensive critical care program to improve outcomes. However, the association of DPS with the marked improved mortality seen on bivariate analysis may be due solely to improvements in critical care throughout the study period. Further studies to define the benefits of DPS implantation are needed.
LEVEL OF EVIDENCE
Therapeutic, level IV.
背景
颈椎脊髓损伤（CSCI）是毁灭性的。呼吸衰竭、呼吸机相关性肺炎（VAP）、败血症和死亡经常发生。膈肌起搏系统（DPS）的病例报告表明，急性 CSCI 患者可更早地脱离机械通气。我们假设 DPS 植入可减少 VAP 并促进通气撤离。
方法
我们对 2005 年 1 月至 2017 年 5 月期间在一家一级创伤中心接受治疗的急性 CSCI 患者进行了回顾性研究。收集了常规人口统计学资料。根据年龄、损伤严重程度评分、呼吸机使用天数、住院时间和气管切开术的需要，对患者进行倾向匹配。观察指标包括住院时间、重症监护病房时间、呼吸机使用天数（通气天数）、VAP 发生率和死亡率。使用 STATA 版本 10 进行双变量和多变量逻辑和线性回归统计分析。
结果
在 2011 年 7 月至 2017 年 5 月期间，所有急性 CSCI 患者均接受了 DPS 植入评估。40 例行腹腔镜 DPS 植入术（DPS）的患者与 61 例未行 DPS 植入术（NO DPS）的患者进行了匹配。DPS 植入后，平均 7 天即可实现撤离呼吸机。在 DPS 患者中，呼吸机撤离后住院时间和死亡率在双变量分析中显著降低。在包括入院年份的风险调整后的多变量模型中，DPS 放置与这些结果的统计学显著差异无关。
结论
在急性 CSCI 患者中植入膈肌起搏系统可以作为改善预后的综合重症监护计划的一部分。然而，DPS 与双变量分析中观察到的死亡率显著改善的关联可能仅归因于整个研究期间重症监护的改善。需要进一步的研究来确定 DPS 植入的益处。
证据等级
治疗性，IV 级。
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