From the Temerty Faculty of Medicine (S.J.F., J.S., V.M.), University of Toronto, Toronto, ON, Canada; Interdepartmental Division of Critical Care (S.T., J.S., V.M.), University of Toronto, Toronto, ON, Canada; Division of Critical Care Medicine, Department of Medicine (J.S., V.M.), University Health Network, Toronto, ON, Canada; Department of Critical Care Medicine, Faculty of Medicine and Dentistry (D.J.K.), University of Alberta, Edmonton, AB, Canada; Department of Critical Care Medicine (V.M.), Sunnybrook Health Sciences Centre, Toronto, ON, Canada; and Krembil Research Institute (V.M.), University Health Network, Toronto, ON, Canada.
J Trauma Acute Care Surg. 2022 Jan 1;92(1):223-231. doi: 10.1097/TA.0000000000003394.
Patients with acute traumatic cervical or high thoracic level spinal cord injury (SCI) typically require mechanical ventilation (MV) during their acute admission. Placement of a tracheostomy is preferred when prolonged weaning from MV is anticipated. However, the optimal timing of tracheostomy placement in patients with acute traumatic SCI remains uncertain. We systematically reviewed the literature to determine the effects of early versus late tracheostomy or prolonged intubation in patients with acute traumatic SCI on important clinical outcomes.
Six databases were searched from their inception to January 2020. Conference abstracts from relevant proceedings and the gray literature were searched to identify additional studies. Data were obtained by two independent reviewers to ensure accuracy and completeness. The quality of observational studies was evaluated using the Newcastle Ottawa Scale.
Seventeen studies (2,804 patients) met selection criteria, 14 of which were published after 2009. Meta-analysis showed that early tracheostomy was not associated with decreased short-term mortality (risk ratio [RR], 0.84; 95% confidence interval [CI], 0.39-1.79; p = 0.65; n = 2,072), but was associated with a reduction in MV duration (mean difference [MD], 13.1 days; 95% CI, -6.70 to -21.11; p = 0.0002; n = 855), intensive care unit length of stay (MD, -10.20 days; 95% CI, -4.66 to -15.74; p = 0.0003; n = 855), and hospital length of stay (MD, -7.39 days; 95% CI, -3.74 to -11.03; p < 0.0001; n = 423). Early tracheostomy was also associated with a decreased incidence of ventilator-associated pneumonia and tracheostomy-related complications (RR, 0.86; 95% CI, 0.75-0.98; p = 0.02; n = 2,043 and RR, 0.64; 95% CI, 0.48-0.84; p = 0.001; n = 812 respectively). The majority of studies ranked as good methodologic quality on the Newcastle Ottawa Scale.
Early tracheostomy in patients with acute traumatic SCI may reduce duration of mechanical entilation, length of intensive care unit stay, and length of hospital stay. Current studies highlight the lack of high-level evidence to guide the optimal timing of tracheostomy in acute traumatic SCI. Future research should seek to understand whether early tracheostomy improves patient comfort, decreases duration of sedation, and improves long-term outcomes.
Systematic Review, level III.
急性创伤性颈髓或高胸段脊髓损伤（SCI）患者在急性入院期间通常需要机械通气（MV）。当预计需要长时间脱机时，首选气管切开术。然而，急性创伤性 SCI 患者气管切开术的最佳时机仍不确定。我们系统地回顾了文献，以确定急性创伤性 SCI 患者中早期与晚期气管切开术或长时间插管对重要临床结局的影响。
从数据库建立到 2020 年 1 月，对 6 个数据库进行了检索。检索了相关会议摘要和灰色文献，以确定其他研究。由两名独立审查员获取数据，以确保准确性和完整性。使用纽卡斯尔-渥太华量表评估观察性研究的质量。
17 项研究（2804 例患者）符合入选标准，其中 14 项研究发表于 2009 年以后。Meta 分析显示，早期气管切开术与短期死亡率降低无关（风险比 [RR]，0.84；95%置信区间 [CI]，0.39-1.79；p = 0.65；n = 2072），但与 MV 持续时间缩短相关（平均差值 [MD]，13.1 天；95%CI，-6.70 至-21.11；p = 0.0002；n = 855）、重症监护病房住院时间（MD，-10.20 天；95%CI，-4.66 至-15.74；p = 0.0003；n = 855）和住院时间（MD，-7.39 天；95%CI，-3.74 至-11.03；p < 0.0001；n = 423）。早期气管切开术也与呼吸机相关性肺炎和气管切开相关并发症的发生率降低相关（RR，0.86；95%CI，0.75-0.98；p = 0.02；n = 2043 和 RR，0.64；95%CI，0.48-0.84；p = 0.001；n = 812）。大多数研究在纽卡斯尔-渥太华量表上的方法学质量评分较高。
急性创伤性 SCI 患者早期气管切开术可能会缩短机械通气时间、重症监护病房住院时间和住院时间。目前的研究强调缺乏高级别的证据来指导急性创伤性 SCI 中气管切开术的最佳时机。未来的研究应致力于了解早期气管切开术是否能提高患者舒适度、缩短镇静时间并改善长期预后。
系统评价，III 级。
