颈椎脊髓损伤患者行气管切开术的时机影响整体预后。
Time to tracheostomy impacts overall outcomes in patients with cervical spinal cord injury.
机构信息
From the Division of Trauma, Critical Care, Emergency Surgery, and Burns, Department of Surgery, College of Medicine (T.A., K.H., N.K., M.Z., M.D., L.C., A.T., L.G., B.J.), University of Arizona, Tucson, Arizona.
出版信息
J Trauma Acute Care Surg. 2020 Aug;89(2):358-364. doi: 10.1097/TA.0000000000002758.
BACKGROUND
The morbidity associated with cervical spine injury increases in the setting of concomitant cervical spinal cord injury (CSCI). A significant proportion of these patients require placement of a tracheostomy. However, it remains unclear if timing to tracheostomy following traumatic CSCI can impact outcomes. The aim of our study was to characterize outcomes associated with tracheostomy timing following traumatic CSCI.
METHODS
We performed a 5-year (2010-2014) analysis of the American College of Surgeons Trauma Quality Improvement Program database and included all adult (age, ≥18 years) trauma patients who had traumatic CSCI and received tracheostomy. Patients were subdivided into two groups: early tracheostomy (ET) (≤4 days from initial intubation) and late tracheostomy (LT) (>4 days). Outcome measures included respiratory complications, ventilator-free days, intensive care unit-free days and hospital length of stay, and mortality. Multivariate logistic regression analysis was performed.
RESULTS
A total of 5,980 patients were included in the study, of which 1,010 (17%) patients received ET, while 4,970 (83%) patients received LT. Mean age was 46 years, and 73% were men. In terms of CSCI location, 48% of the patients had high CSCI (C1-C4), while 52% had low CSCI (C5-C7). Patients in the ET group had lower rates of respiratory complications (30% vs. 46%, p = 0.01), higher ventilator-free days (13 days vs. 9 days; p = 0.02), intensive care unit-free days (11 days vs. 8 days; p = 0.01), and a shorter hospital length of stay (22 days vs. 29 days; p = 0.01) compared with those in the LT group. On regression analysis, ET was associated with lower rates of respiratory complications in patients with high CSCI (odds ratio, 0.55 [0.41-0.81]) and low CSCI (odds ratio, 0.93 [0.72-0.95]). However, no association was found between time to tracheostomy and in-hospital mortality.
CONCLUSION
Early tracheostomy regardless of CSCI level may lead to improved outcomes. Quality improvement efforts should focus on defining the optimal time to tracheostomy and considering ET as a component of SCI management bundle.
LEVEL OF EVIDENCE
Therapeutic, level IV.
背景
颈椎损伤相关发病率在同时伴有颈脊髓损伤（CSCI）的情况下会增加。这些患者中有相当一部分需要进行气管切开术。然而，目前尚不清楚创伤性 CSCI 后行气管切开术的时机是否会影响结局。本研究的目的是描述创伤性 CSCI 后行气管切开术时机与结局之间的关系。
方法
我们对美国外科医师学会创伤质量改进计划数据库进行了 5 年（2010-2014 年）的分析，纳入了所有接受气管切开术的成年（年龄≥18 岁）创伤性 CSCI 患者。将患者分为两组：早期气管切开术（ET）（气管插管后≤4 天）和晚期气管切开术（LT）（气管插管后>4 天）。观察指标包括呼吸系统并发症、无呼吸机天数、无重症监护室天数和住院天数以及死亡率。采用多变量逻辑回归分析。
结果
本研究共纳入 5980 例患者，其中 1010 例（17%）患者接受 ET，4970 例（83%）患者接受 LT。患者平均年龄为 46 岁，73%为男性。根据 CSCI 部位，48%的患者为高位 CSCI（C1-C4），52%的患者为低位 CSCI（C5-C7）。与 LT 组相比，ET 组患者呼吸系统并发症发生率较低（30%比 46%，p=0.01）、无呼吸机天数较长（13 天比 9 天，p=0.02）、无重症监护室天数较长（11 天比 8 天，p=0.01）、住院时间较短（22 天比 29 天，p=0.01）。回归分析显示，无论 CSCI 水平如何，ET 与高位 CSCI（比值比，0.55[0.41-0.81]）和低位 CSCI（比值比，0.93[0.72-0.95]）患者的呼吸系统并发症发生率降低相关。然而，气管切开术时间与住院死亡率之间无相关性。
结论
无论 CSCI 水平如何，早期气管切开术均可改善结局。质量改进工作应集中于明确气管切开术的最佳时机，并考虑将 ET 作为 SCI 管理套餐的组成部分。
证据水平
治疗性，IV 级。
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