From the Harborview Injury Prevention & Research Center (E.Y.K., E.K.B, S.J.M., M.S.V., F.P.R.), Division of Pediatric Critical Care Medicine, Department of Pediatrics (E.Y.K., R.S.W.), University of Washington, Seattle, Washington; Department of Pediatric Critical Care Medicine (K.L.G.), Cincinnati Children's Hospital, Cincinnati, Ohio; Department of Surgery (E.K.B.), University of Montreal, Montreal, Quebec, Canada; Department of Epidemiology, School of Public Health (S.J.M.), University of Washington; Center for Child Health, Behavior, and Development (R.S.W., F.P.R.), Seattle Children's Research Institute; Department of Anesthesiology and Pain Medicine (M.S.V.), and Division of General Pediatrics, Department of Pediatrics (F.P.R.), University of Washington, Seattle, Washington.
J Trauma Acute Care Surg. 2023 Apr 1;94(4):615-623. doi: 10.1097/TA.0000000000003848. Epub 2022 Nov 28.
Tracheostomy placement is much more common in adults than children following severe trauma. We evaluated whether tracheostomy rates and outcomes differ for pediatric patients treated at trauma centers that primarily care for children versus adults.
We conducted a retrospective cohort study of patients younger than 18 years in the National Trauma Data Bank from 2007 to 2016 treated at a Level I/II pediatric, adult, or combined adult/pediatric trauma center, ventilated >24 hours, and who survived to discharge. We used multivariable logistic regression adjusted for age, insurance, injury mechanism and body region, and Injury Severity Score to estimate the association between the three trauma center types and tracheostomy. We used augmented inverse probability weighting to model the likelihood of tracheostomy based on the propensity for treatment at a pediatric, adult, or combined trauma center, and estimated associations between trauma center type with length of stay and postdischarge care.
Among 33,602 children, tracheostomies were performed in 4.2% of children in pediatric centers, 7.8% in combined centers (adjusted odds ratio [aOR], 1.47; 95% confidence interval [CI], 1.20-1.81), and 11.2% in adult centers (aOR, 1.81; 95% CI, 1.48-2.22). After propensity matching, the estimated average tracheostomy rate would be 62.9% higher (95% CI, 37.7-88.1%) at combined centers and 85.3% higher (56.6-113.9%) at adult centers relative to pediatric centers. Tracheostomy patients had longer hospital stay in pediatric centers than combined (-4.4 days, -7.4 to -1.3 days) or adult (-4.0 days, -7.2 to -0.9 days) centers, but fewer children required postdischarge inpatient care (70.1% pediatric vs. 81.3% combined [aOR, 2.11; 95% CI, 1.03-4.31] and 82.4% adult centers [aOR, 2.51; 95% CI, 1.31-4.83]).
Children treated at pediatric trauma centers have lower likelihood of tracheostomy than children treated at combined adult/pediatric or adult centers independent of patient or injury characteristics. Better understanding of optimal indications for tracheostomy is necessary to improve processes of care for children treated throughout the pediatric trauma system.
Prognostic and Epidemiological; Level III.
与成人相比，严重创伤后的儿童更常进行气管切开术。我们评估了主要治疗儿童的创伤中心与主要治疗成人的创伤中心相比，儿科患者的气管切开率和结局是否存在差异。
我们对 2007 年至 2016 年国家创伤数据库中年龄小于 18 岁的患者进行了回顾性队列研究，这些患者在 1 级/2 级儿科、成人或成人/儿科联合创伤中心接受治疗，通气时间超过 24 小时，且存活至出院。我们使用多变量逻辑回归，根据年龄、保险、损伤机制和部位以及损伤严重程度评分，调整了与三种创伤中心类型与气管切开术的相关性。我们使用增强逆概率加权来模拟基于在儿科、成人或联合创伤中心接受治疗的倾向的气管切开术的可能性，并估计了创伤中心类型与住院时间和出院后护理之间的关联。
在 33602 名儿童中，4.2%的儿童在儿科中心接受了气管切开术，在联合中心为 7.8%（校正优势比[aOR]，1.47；95%置信区间[CI]，1.20-1.81），在成人中心为 11.2%（aOR，1.81；95% CI，1.48-2.22）。在倾向匹配后，联合中心的气管切开术估计平均发生率将高出 62.9%（95% CI，37.7-88.1%），成人中心的估计平均发生率将高出 85.3%（56.6-113.9%）。与儿科中心相比，气管切开术患者在联合中心（-4.4 天，-7.4 至-1.3 天）或成人中心（-4.0 天，-7.2 至-0.9 天）的住院时间更长，但需要出院后住院治疗的儿童更少（70.1%儿科 vs. 81.3%联合[校正优势比，2.11；95%CI，1.03-4.31]和 82.4%成人中心[aOR，2.51；95%CI，1.31-4.83]）。
与在成人/儿科联合或成人创伤中心接受治疗的儿童相比，在儿科创伤中心接受治疗的儿童进行气管切开术的可能性更低，而与患者或损伤特征无关。为了改善整个儿科创伤系统中接受治疗的儿童的护理流程，需要更好地了解气管切开术的最佳适应证。
预后和流行病学；III 级。
