Predictors and outcomes of postoperative tracheostomy in patients undergoing acute type A aortic dissection surgery

Abstract

Background Despite surgical advances, acute type A aortic dissection remains a life-threatening disease with high mortality and morbidity. Tracheostomy is usually used for patients who need prolonged mechanical ventilation in the intensive care unit (ICU). However, data on the risk factors for requiring tracheostomy and the impact of tracheostomy on outcomes in patients after Stanford type A acute aortic dissection surgery (AADS) are limited. Methods A retrospective single-institutional study including consecutive patients who underwent AADS between January 2016 and December 2019 was conducted. Patients who died intraoperatively were excluded. Univariate analysis and multivariate logistic regression analysis were used to identify independent risk factors for postoperative tracheostomy (POT). A nomogram to predict the probability of POT was constructed based on independent predictors and their beta-coefficients. The area under the receiver operating characteristic curve (AUC) was performed to assess the discrimination of the model. Calibration plots and the Hosmer–Lemeshow test were used to evaluate calibration. Clinical usefulness of the nomogram was assessed by decision curve analysis. Propensity score matching analysis was used to analyze the correlation between requiring tracheostomy and clinical prognosis. Results There were 492 patients included in this study for analysis, including 55 patients (11.2%) requiring tracheostomy after AADS. Compared with patients without POT, patients with POT experienced longer ICU and hospital stay and higher mortality. Age, cerebrovascular disease history, preoperative white blood cell (WBC) count and renal insufficiency, intraoperative amount of red blood cell (RBC) transfusion and platelet transfusion were identified as independent risk factors for POT. Our constructed nomogram had good discrimination with an AUC = 0.793 (0.729–0.856). Good calibration and clinical utility were observed through the calibration and decision curves, respectively. For better clinical application, we defined four intervals that stratified patients from very low to high risk for occurrence of POT. Conclusions Our study identified preoperative and intraoperative risk factors for POT and found that requiring tracheostomy was related to the poor outcomes in patients undergoing AADS. The established prediction model was validated with well predictive performance and clinical utility, and it may be useful for individual risk assessment and early clinical decision-making to reduce the incidence of tracheostomy.

Incidence, Risk Factors, and Outcomes of Severe Hypoxemia After Cardiac Surgery

“…The volume of intraoperative transfusion of RBCs was another independent risk factors for SH in our analysis results, which has also been reported previously (12,13,18). Although blood transfusion can be life-saving in cardiac surgery, increasing evidence suggests that massive transfusion of blood and blood products is associated with poorer clinical outcomes (25)(26)(27)(28)(29)(30)(31)(32)(33)(34). Nakajima et al found that the volume of transfused RBCs was positively associated with the risk of postoperative hypoxemia in patients undergoing surgery for acute type A aortic dissection, showing a dose-effect relationship (13).…”

Nomogram and Risk Calculator for Postoperative Tracheostomy after Heart Valve Surgery

“…Undergoing a tracheostomy is an important indicator of the increased risk of poor prognoses in patients undergoing cardiovascular surgeries [ 3 , 7 , 9 , 20 ], which was again confirmed in the current study. Due to the difference of surgical populations in different studies, the reported rates of POTs in the previous literature were quite different [ 3 , 7 , 8 , 9 , 10 , 11 ]. The overall incidence rate of POTs after HVS was 1.8% in our analysis, falling within the range of incidence rates reported in the previous literature [ 3 , 12 , 13 ].…”

“…As an important indicator of poor prognoses, POT operations often indicate a higher risk of mortality, prolonged hospital stay, increased medical burden, and declined quality of life [ 4 , 5 , 6 , 7 ]. The incidence of POTs varies widely in the previous literature due to the different surgical populations in different studies [ 3 , 7 , 8 , 9 , 10 , 11 ]. Compared to other surgical types, patients undergoing cardiovascular surgery have been reported to have a relatively higher POT rate, mostly in the range of 1.4–11.8% [ 3 , 12 , 13 ].…”

Difficult Respiratory Weaning after Cardiac Surgery: A Narrative Review

“…The aforementioned risk factors were used to identify patients at greater risk for difficult weaning. Many of these factors were also combined and different mathematical models were elaborated to predict the need for prolonged mechanical ventilation or tracheostomy after cardiac surgery but, to the best of our knowledge, none of them has been validated in prospective studies [ 1 , 13 , 15 , 19 ]. Table 1 resumes the most recent studies on risk factors for prolonged ventilation and difficult weaning after cardiac surgery.…”

“…Identification of patients that could benefit most from this intervention represents a major challenge in clinical practice. Some risk factors for tracheostomy after cardiac surgery have been identified, including heart failure, diastolic dysfunction, respiratory diseases, renal replacement therapy, emergency surgery, need for mechanical circulatory support, and re-doing surgery [ 19 , 70 ]. Moreover, independent predictors of mortality after tracheostomy in cardiac surgery patients were the duration of ventilation before tracheostomy and the presence of postoperative heart failure associated with respiratory failure, suggesting that careful evaluation of risks and benefits in these patients is of utmost importance [ 71 ].…”