Feng Shi Nan, Diaz-Cruz Camilo, Cinotti Raphael, Asehnoune Karim, Schultz Marcus J, Shrestha Gentle S, Sanches Paula R, Robba Chiara, Cho Sung-Min
Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
Department of Neurology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
Neurocrit Care. 2025 Jan 7. doi: 10.1007/s12028-024-02198-6.
Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI.
A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings.
Of 1512 patients (median age = 54 years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59 days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30).
In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.
在中等收入国家（MICs），有创机械通气对急性脑损伤（ABI）患者可能带来复杂挑战。我们描述了国家收入水平对ABI患者撤机策略和预后的影响。
对2018年至2020年期间在18个国家的73个重症监护病房（ICU）收治的重症ABI患者登记数据进行二次分析。患者被分为高收入国家（HIC）或中等收入国家。主要结局是ICU死亡率。次要结局包括首次拔管天数、气管切开术、拔管失败、ICU住院时间和医院死亡率。多变量分析针对临床预先选定的协变量进行了调整，如年龄、性别、体重指数、神经严重程度、合并症和ICU管理。拔管和气管切开术结局还针对动脉血气值和通气设置进行了调整。
在1512例患者（中位年龄=54岁，66%为男性）中，1170例（77%）来自高收入国家，342例（23%）来自中等收入国家。中等收入国家的中位年龄显著更低[分别为35岁（范围26 - 52岁）和高收入国家的58岁（范围45 - 68岁）]。神经外科手术（47.7%对38.2%）和去骨瓣减压术（30.7%对15.9%）在中等收入国家更常见，而颅内压监测（12.0%对51.5%）和脑室外引流（7.6%对35.6%）则较少见。与高收入国家相比，中等收入国家的患者发生ICU死亡的几率高2.27倍[p = 0.009，95%置信区间（CI）1.22 - 4.21]。中等收入国家的拔管失败频率较低，但调整后无显著差异。中等收入国家的患者接受气管切开术的几率高3.38倍（p≤0.001，95% CI 2.28 - 5.01），平均ICU住院时间短5.59天（p < 0.001，95% CI - 7.82至 - 3.36），医院死亡几率高1.96倍（p = 0.011，95% CI 1.17 - 3.30）。
在一个需要有创机械通气的ABI患者国际登记研究中，与高收入国家相比中等收入国家的患者发生ICU死亡、气管切开术和医院死亡的几率更高，这可能是由于神经重症监护资源和管理的差异。
