Early versus late tracheostomy after decompressive craniectomy for stroke

Abstract

BackgroundStroke patients requiring decompressive craniectomy are at high risk of prolonged mechanical ventilation and ventilator-associated pneumonia (VAP). Tracheostomy placement may reduce the duration of mechanical ventilation. Predicting which patients will require tracheostomy and the optimal timing of tracheostomy remains a clinical challenge. In this study, the authors compare key outcomes after early versus late tracheostomy and develop a useful pre-operative decision-making tool to predict post-operative tracheostomy dependence.MethodsWe performed a retrospective analysis of prospectively collected registry data. We developed a propensity-weighted decision tree analysis to predict tracheostomy requirement using factors present prior to surgical decompression. In addition, outcomes include probability functions for intensive care unit length of stay, hospital length of stay, and mortality, based on data for early (≤ 10 days) versus late (> 10 days) tracheostomy.ResultsThere were 168 surgical decompressions performed on patients with acute ischemic or spontaneous hemorrhagic stroke between 2010 and 2015. Forty-eight patients (28.5%) required a tracheostomy, 35 (20.8%) developed VAP, and 126 (75%) survived hospitalization. Mean ICU and hospital length of stay were 15.1 and 25.8 days, respectively. Using GCS, SOFA score, and presence of hydrocephalus, our decision tree analysis had 63% sensitivity and 84% specificity for predicting tracheostomy requirement. The early group had fewer ventilator days (7.3 versus 15.2, p < 0.001) and shorter hospital length of stay (28.5 versus 44.4 days, p = 0.014). VAP rates and mortality were similar between the two groups. Withdrawal of treatment interventions shortly post-operatively confounded mortality outcomes.ConclusionEarly tracheostomy shortens duration of mechanical ventilation and length of stay after surgical decompression for stroke, but it did not impact mortality or VAP rates. A decision tree is a practical tool that may be helpful in guiding pre-operative decision-making with patients’ families.Electronic supplementary materialThe online version of this article (10.1186/s40560-017-0269-1) contains supplementary material, which is available to authorized users.

Prevalence and Temporal Distribution of Extrasystoles in Septic ICU Patients: The Feasibility of Predicting Fluid Responsiveness Using Extrasystoles

“…In the planning of the study, we considered this cohort size adequate for rough estimation of the coverage and focused further on the validation of our classifications (interrater analyses). Inspecting more ECG records would lead to a narrower CI on the extrasystolic coverage estimate, but the current CI is indicative in our opinion and resembles what we have observed in clinical validation studies [ 8 , 10 ].…”

“…In theory, the extrasystoles method has no requirements to the way patients breathe. However, since any breathing pattern induces some (cyclic) variations in blood pressure, it may be important for the extrasystoles method to take into account when in a respiratory cycle, the postectopic beat occurs, which has the potential to improve the method compared with existing classification results [ 8 , 10 ].…”

“…Analyzing the hemodynamic response at the postectopic beat, for example, how much systolic blood pressure changes compared with preceding sinus beats, may predict fluid responsiveness. Based on experimental data [ 9 ] as well as clinical data [ 8 , 10 ], this method appears promising. While clinical validation in different patient groups is essential for considering the method's use in clinical practice, another crucial question arises for this specific method: to what extent are extrasystoles available in the everyday ICU setting?…”

Speech and Swallowing Function Outcome Following Early Tracheostomy in Patients Who Underwent Neurosurgical Intervention

“… In the introduction section, the authors have mentioned that “mechanical ventilator leads to decrease in intracranial pressure.” However, changes in intracranial pressure will depend on the ventilatory mode, pCO 2 level, and hemodynamic status of the patients. [ 4 ] Tracheostomy decreases incidence of ventilator-associated pneumonia – this is also much debated[ 5 ] Speech-related complications may be related to other factors rather than tracheostomy itself. Duration of orotracheal intubation before tracheostomy, synchronization with ventilator, and preexisting speech status if mentioned could probably help to exclude those factors.…”

“…In the introduction section, the authors have mentioned that “mechanical ventilator leads to decrease in intracranial pressure.” However, changes in intracranial pressure will depend on the ventilatory mode, pCO 2 level, and hemodynamic status of the patients. [ 4 ] Tracheostomy decreases incidence of ventilator-associated pneumonia – this is also much debated[ 5 ]…”