IntroductionDespite the integral role played by tracheostomy in the management of trauma patients admitted to intensive care units (ICUs), its timing remains subject to considerable practice variation. The purpose of this study is to examine the impact of early tracheostomy on the duration of mechanical ventilation, ICU length of stay, and outcomes in trauma ICU patients.MethodsThe following data were obtained from a prospective ICU database containing information on all trauma patients who received tracheostomy over a 5-year period: demographics, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II, Glasgow Coma Scale score, Injury Severity Score, type of injuries, ICU and hospital outcomes, ICU and hospital length of stay (LOS), and the type of tracheostomy procedure (percutaneous versus surgical). Tracheostomy was considered early if it was performed by day 7 of mechanical ventilation. We compared the duration of mechanical ventilation, ICU LOS and outcome between early and late tracheostomy patients. Multivariate analysis was performed to assess the impact of tracheostomy timing on ICU stay.ResultsOf 653 trauma ICU patients, 136 (21%) required tracheostomies, 29 of whom were early and 107 were late. Age, sex, Acute Physiology and Chronic Health Evaluation II score, Simplified Acute Physiology Score II and Injury Severity Score were not different between the two groups. Patients with early tracheostomy were more likely to have maxillofacial injuries and to have lower Glasgow Coma Scale score. Duration of mechanical ventilation was significantly shorter with early tracheostomy (mean ± standard error: 9.6 ± 1.2 days versus 18.7 ± 1.3 days; P < 0.0001). Similarly, ICU LOS was significantly shorter (10.9 ± 1.2 days versus 21.0 ± 1.3 days; P < 0.0001). Following tracheostomy, patients were discharged from the ICU after comparable periods in both groups (4.9 ± 1.2 days versus 4.9 ± 1.1 days; not significant). ICU and hospital mortality rates were similar. Using multivariate analysis, late tracheostomy was an independent predictor of prolonged ICU stay (>14 days).ConclusionEarly tracheostomy in trauma ICU patients is associated with shorter duration of mechanical ventilation and ICU LOS, without affecting ICU or hospital outcome. Adopting a standardized strategy of early tracheostomy in appropriately selected patients may help in reducing unnecessary resource utilization.
Intrathecal colistin (Polymxin E) is becoming an important option for the treatment of post-neurosurgical meningitis caused by multidrug resistant (MDR) Acinetobacter baumannii. We report a case of 28-year-old man who developed meningitis due to MDR A. baumannii associated with an external ventricular drain. The patient was cured using a 4-week course of intrathecal colistin 3.2 mg via external ventricular drain (EVD) daily without any serious side effects.
Severe sepsis and septic shock are major reasons for intensive care unit (ICU) admission and leading causes of mortality in noncoronary ICUs [1][2][3]. Apart from in the West, little is known about outcomes of patients admitted to the ICU with severe sepsis and septic shock, despite the seriousness of AbstractIntroduction We conducted the present study to assess the validity of mortality prediction systems in patients admitted to the intensive care unit (ICU) with severe sepsis and septic shock. We included Acute Physiology and Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Mortality Probability Model (MPM) II 0 and MPM II 24 in our evaluation. In addition, SAPS II and MPM II 24 were customized for septic patients in a previous study, and the customized versions were included in this evaluation. Materials and method This cohort, prospective, observational study was conducted in a tertiary care medical/surgical ICU. Consecutive patients meeting the diagnostic criteria for severe sepsis and septic shock during the first 24 hours of ICU admission between March 1999 and August 2001 were included. The data necessary for mortality prediction were collected prospectively as part of the ongoing ICU database. Predicted and actual mortality rates, and standardized mortality ratio were calculated. Calibration was assessed using Lemeshow-Hosmer goodness of fit C-statistic. Discrimination was assessed using receiver operating characteristic curves. Results The overall mortality prediction was adequate for all six systems because none of the standardized mortality ratios differed significantly from 1. Calibration was inadequate for APACHE II, SAPS II, MPM II 0 and MPM II 24 . However, the customized version of SAPS II exhibited significantly improved calibration (C-statistic for SAPS II 23.6 [P = 0.003] and for customized SAPS II 11.5 [P = 0.18]). Discrimination was best for customized MPM II 24 (area under the receiver operating characteristic curve 0.826), followed by MPM II 24 and customized SAPS II. Conclusion Although general ICU mortality system models had accurate overall mortality prediction, they had poor calibration. Customization of SAPS II and, to a lesser extent, MPM II 24 improved calibration. The customized model may be a useful tool when evaluating outcomes in patients with sepsis.
A significant proportion of trauma patients require tracheostomy during intensive care unit stay. The timing of this procedure remains a subject of debate. The decision for tracheostomy should take into consideration the risks and benefits of prolonged endotracheal intubation versus tracheostomy. Timing of tracheostomy is also influenced by the indications for the procedure, which include relief of upper airway obstruction, airway access in patients with cervical spine injury, management of retained airway secretions, maintenance of patent airway and airway access for prolonged mechanical ventilation. This review summarizes the potential advantages of tracheostomy versus endotracheal intubation, the different indications for tracheostomy in trauma patients and studies examining early versus late tracheostomy. It also reviews the predictors of prolonged mechanical ventilation, which may guide the decision regarding the timing of tracheostomy.
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