Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genoa, Italy.
School of Medicine and Surgery, University of Milano - Bicocca, Monza, Italy.
Intensive Care Med. 2020 May;46(5):983-994. doi: 10.1007/s00134-020-05935-5. Epub 2020 Feb 5.
Indications and optimal timing for tracheostomy in traumatic brain-injured (TBI) patients are uncertain. This study aims to describe the patients' characteristics, timing, and factors related to the decision to perform a tracheostomy and differences in strategies among different countries and assess the effect of the timing of tracheostomy on patients' outcomes.
We selected TBI patients from CENTER-TBI, a prospective observational longitudinal cohort study, with an intensive care unit stay ≥ 72 h. Tracheostomy was defined as early (≤ 7 days from admission) or late (> 7 days). We used a Cox regression model to identify critical factors that affected the timing of tracheostomy. The outcome was assessed at 6 months using the extended Glasgow Outcome Score.
Of the 1358 included patients, 433 (31.8%) had a tracheostomy. Age (hazard rate, HR = 1.04, 95% CI = 1.01-1.07, p = 0.003), Glasgow coma scale ≤ 8 (HR = 1.70, 95% CI = 1.22-2.36 at 7; p < 0.001), thoracic trauma (HR = 1.24, 95% CI = 1.01-1.52, p = 0.020), hypoxemia (HR = 1.37, 95% CI = 1.05-1.79, p = 0.048), unreactive pupil (HR = 1.76, 95% CI = 1.27-2.45 at 7; p < 0.001) were predictors for tracheostomy. Considerable heterogeneity among countries was found in tracheostomy frequency (7.9-50.2%) and timing (early 0-17.6%). Patients with a late tracheostomy were more likely to have a worse neurological outcome, i.e., mortality and poor neurological sequels (OR = 1.69, 95% CI = 1.07-2.67, p = 0.018), and longer length of stay (LOS) (38.5 vs. 49.4 days, p = 0.003).
Tracheostomy after TBI is routinely performed in severe neurological damaged patients. Early tracheostomy is associated with a better neurological outcome and reduced LOS, but the causality of this relationship remains unproven.
颅脑损伤（TBI）患者行气管切开术的适应证和最佳时机仍不明确。本研究旨在描述患者的特征、气管切开术的时机以及与决策相关的因素，探讨不同国家间策略的差异，并评估气管切开术时机对患者结局的影响。
我们从CENTER-TBI 前瞻性观察性纵向队列研究中选择 ICU 入住时间≥72 小时的 TBI 患者。气管切开术定义为早期（入院后≤7 天）或晚期（＞7 天）。我们使用 Cox 回归模型确定影响气管切开术时机的关键因素。采用扩展格拉斯哥预后评分（GOS）于 6 个月时评估结局。
在纳入的 1358 例患者中，433 例（31.8%）行气管切开术。年龄（危险比[HR] = 1.04，95%可信区间[CI] = 1.01-1.07，p = 0.003）、格拉斯哥昏迷评分≤8 分（HR = 1.70，95%CI=1.22-2.36，p＜0.001）、胸部创伤（HR = 1.24，95%CI = 1.01-1.52，p = 0.020）、低氧血症（HR = 1.37，95%CI = 1.05-1.79，p = 0.048）、无反应性瞳孔（HR = 1.76，95%CI = 1.27-2.45，p＜0.001）是气管切开术的预测因素。不同国家气管切开术的频率（7.9%-50.2%）和时机（早期 0-17.6%）存在显著差异。行晚期气管切开术的患者更可能出现不良神经结局，即死亡率和严重神经后遗症（OR = 1.69，95%CI = 1.07-2.67，p = 0.018），且住院时间（LOS）更长（38.5 天 vs. 49.4 天，p = 0.003）。
TBI 后常规行气管切开术治疗严重神经损伤患者。早期气管切开术与较好的神经结局和缩短 LOS 相关，但两者之间的因果关系尚未得到证实。
