Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
BMC Neurol. 2020 Jun 3;20(1):223. doi: 10.1186/s12883-020-01809-x.
We evaluated severe pain-related adverse events (SAE) during the percutaneous dilatational tracheostomy (PDT) procedure performed by a neurointensivist and compared the outcomes with that of conventional surgical tracheostomy in neurocritically ill patients.
This was a retrospective and observational study of adult patients who were admitted to the neurosurgical intensive care unit between January 2014 and March 2018 and underwent tracheostomy. In this study, primary endpoints were incidence of SAE: cardiac arrest, arrhythmias, hypertension, hypotension, desaturation, bradypnea, or ventilatory distress. The secondary endpoint was procedure-induced complications.
A total of 156 patients underwent tracheostomy during the study. Elective surgery of brain tumors (34.0%) and intracranial hemorrhage (20.5%) were the most common reasons for admission. The most common reasons for tracheostomy were difficult ventilator weaning or prolonged intubation (42.9%) and sedative reduction (23.7%). Tachycardia (30.1%) and hypertension (30.1%) were the most common SAE. Incidence of SAE was more common in conventional tracheostomy compared to PDT (67.1% vs. 42.3%, P = 0.002). The total duration of SAE (19.8 ± 23.0 min vs. 3.4 ± 5.3 min, P < 0.001) and procedural time (42.2 ± 21.8 min vs. 17.7 ± 9.2 min, P < 0.001) were longer in conventional tracheostomy compared to PDT. Multivariable adjustment revealed that only PDT by a neurointensivist significantly reduced the incidence of SAE by one third (adjusted odds ratio [OR]: 0.36, 95% confidence interval [CI]: 0.187-0.691). In addition, PDT by a neurointensivist deceased the duration of SAE by 8.64 min (β: -8.64, 95% CI: - 15.070 - -2.205, P = 0.009) and prolonging the procedure time by every one minute significantly increased the duration of SAE by 6.38 min (β: 6.38, 95% CI: 0.166-0.470, P < 0.001). Procedure-induced complications were more common in conventional tracheostomy compared to PDT (23.5% vs. 11.3%, P = 0.047).
This retrospective and exploratory study of our single-center limited cohort of tracheostomy patients revealed that decreased SAE may be associated with short procedural time during the PDT procedure performed by a neurointensivist. It is proposed that PDT by a neurointensivist may be safe and feasible in neurocritically ill patients.
我们评估了神经重症医师行经皮扩张气管切开术（PDT）时严重疼痛相关不良事件（SAE）的发生情况，并与神经危重症患者行传统手术性气管切开术的结果进行了比较。
这是一项回顾性观察性研究，纳入了 2014 年 1 月至 2018 年 3 月期间入住神经外科重症监护病房并接受气管切开术的成年患者。本研究的主要终点为 SAE 的发生率：心脏骤停、心律失常、高血压、低血压、低氧血症、呼吸过缓或通气窘迫。次要终点为手术相关并发症。
研究期间共有 156 例患者接受了气管切开术。脑肿瘤（34.0%）和颅内出血（20.5%）的择期手术是最常见的入院原因。气管切开术最常见的原因是呼吸机脱机困难或长时间插管（42.9%）和镇静剂减量（23.7%）。心动过速（30.1%）和高血压（30.1%）是最常见的 SAE。与 PDT 相比，传统气管切开术的 SAE 发生率更高（67.1% vs. 42.3%，P=0.002）。传统气管切开术的 SAE 总持续时间（19.8±23.0 分钟 vs. 3.4±5.3 分钟，P<0.001）和手术时间（42.2±21.8 分钟 vs. 17.7±9.2 分钟，P<0.001）均长于 PDT。多变量调整显示，只有神经重症医师行 PDT 可将 SAE 发生率降低三分之一（校正比值比[OR]：0.36，95%置信区间[CI]：0.187-0.691）。此外，神经重症医师行 PDT 可使 SAE 持续时间缩短 8.64 分钟（β：-8.64，95% CI：-15.070- -2.205，P=0.009），且手术时间每延长 1 分钟，SAE 持续时间将延长 6.38 分钟（β：6.38，95% CI：0.166-0.470，P<0.001）。与 PDT 相比，传统气管切开术的手术相关并发症更常见（23.5% vs. 11.3%，P=0.047）。
本研究对单中心有限队列的气管切开术患者进行了回顾性和探索性分析，结果表明，神经重症医师行 PDT 时，手术时间较短可能与 SAE 减少相关。这提示神经危重症患者行神经重症医师行 PDT 可能是安全可行的。
