R. Adams Cowley Shock Trauma Center, Program in Trauma, University of Maryland School of Medicine, 22 S. Greene Street, Gudelsky Bldg., Room G7K18, Baltimore, MD, 21201, USA.
Section of Neurocritical Care and Emergency Neurology, Program in Trauma, Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA.
Neurocrit Care. 2019 Apr;30(2):387-393. doi: 10.1007/s12028-018-0624-7.
Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy.
We performed an observational study of adult traumatic brain injury (TBI) patients requiring intensive care unit (ICU) admission for ≥ 72 h and mechanical ventilation for ≥ 24 h between January 2014 and December 2014 at a level 1 trauma center. Patients who had life-sustaining measures withdrawn were excluded. Multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop predictive models. Inpatient complications prior to day 7 were used to standardize data collection for patients with and without tracheostomy. Patients who received tracheostomy prior to day 7 were excluded from analysis.
In total, 209 patients (78% men, mean 48 years old, median Glasgow Coma Scale score (GCS) 8) met study criteria with tracheostomy performed in 94 (45%). Admission predictors of tracheostomy included GCS, chest tube, Injury Severity Score, and Marshall score. Inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (EVD), number of operations, inpatient dialysis, aspiration, GCS on day 5, and reintubation. Multiple logistic regression analysis demonstrated that the number of operation room trips (adjusted odds ratio [AOR], 1.75; 95% CI, 1.04-2.97; P = 0.036), reintubation (AOR, 8.45; 95% CI, 1.91-37.44; P = .005), and placement of an EVD (AOR, 3.48; 95% CI, 1.27-9.58; P = .016) were independently associated with patients undergoing tracheostomy. Higher GCS on hospital day 5 (AOR, 0.52; 95% CI, 0.40-0.68; P < 0.001) was protective against tracheostomy. A model of inpatient variables only had a stronger association with tracheostomy than one with admission variables only (ROC AUC 0.93 vs 0.72, P < 0.001) and did not benefit from the addition of admission variables (ROC AUC 0.93 vs 0.92, P = 0.78).
Potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. Multicenter studies are needed to validate the results.
缺乏关于哪些患者需要行气管切开术的相关数据，这可能会限制对早期气管切开术治疗效果的研究。
我们对 2014 年 1 月至 2014 年 12 月期间在一家 1 级创伤中心接受重症监护病房（ICU）入住时间超过 72 小时和机械通气时间超过 24 小时的成年创伤性脑损伤（TBI）患者进行了一项观察性研究。排除了有生命支持措施撤出的患者。多变量逻辑回归分析用于评估与接受气管切开术相关的入院和住院期间因素，并建立预测模型。在第 7 天之前的住院期间并发症用于标准化有和无气管切开术患者的数据收集。在第 7 天之前接受气管切开术的患者不纳入分析。
共有 209 例患者（78%为男性，平均年龄为 48 岁，中位格拉斯哥昏迷评分（GCS）为 8）符合研究标准，其中 94 例（45%）接受了气管切开术。气管切开术的入院预测因素包括 GCS、胸腔引流管、损伤严重程度评分和 Marshall 评分。与气管切开术相关的住院期间因素包括需要使用外部脑室引流管（EVD）、手术次数、住院期间透析、吸入、第 5 天的 GCS 和再插管。多变量逻辑回归分析表明，手术室就诊次数（调整后的优势比[OR]，1.75；95%CI，1.04-2.97；P=0.036）、再插管（OR，8.45；95%CI，1.91-37.44；P=0.005）和 EVD 放置（OR，3.48；95%CI，1.27-9.58；P=0.016）与患者行气管切开术独立相关。第 5 天住院时 GCS 较高（OR，0.52；95%CI，0.40-0.68；P<0.001）可降低气管切开术的风险。仅基于住院期间变量的模型与仅基于入院变量的模型相比，与气管切开术的相关性更强（ROC 曲线下面积 0.93 比 0.72，P<0.001），并且并不受益于入院变量的增加（ROC 曲线下面积 0.93 比 0.92，P=0.78）。
与入院特征相比，潜在可改变的住院期间因素与气管切开术的相关性更强。需要多中心研究来验证这些结果。
