The impact of tracheostomy timing on clinical outcomes and adverse events in intubated patients with infratentorial lesions: early versus late tracheostomy

Abstract

We evaluated the association between the timing of tracheostomy and clinical outcomes in patients with infratentorial lesions. We performed a retrospective observational cohort study in a neurosurgical intensive care unit (ICU) at a tertiary academic medical center from January 2014 to December 2018. Consecutive adult patients admitted to the ICU who underwent resection of infratentorial lesions as well as tracheostomy were included for analysis. Early tracheostomy was defined as performed on postoperative days 1-10 and late tracheostomy on days 10-20 after operation. Univariate and multivariate analyses were used to compare the characteristics and outcomes between both cohorts. A total of 143 patients were identified, and 96 patients received early tracheostomy. Multivariable analysis identified early tracheostomy as an independent variable associated with lower occurrence of pneumonia (odds ratio, 0.25; 95% CI, 0.09-0.73; p = 0.011), shorter stays in ICUs (hazard ratio, 0.4; 95% CI, 0.3-0.6; p = 0.03), and earlier decannulation (hazard ratio, 0.5; 95% CI, 0.4-0.8; p = 0.003). However, no significant differences were observed between the early and late tracheostomy groups regarding hospital mortality (p > 0.999) and the modified Rankin scale after 6 months (p = 0.543). We also identified postoperative brainstem deficits, including cough, swallowing attempts, and extended tongue as well as GCS < 8 at ICU admission as the risk factors independently associated with patients underwent tracheostomy. There is a significant association between early tracheostomy and beneficial clinical outcomes or reduced adverse event occurrence in patients with infratentorial lesions.

Clinical Indications for Extubation in Coma Patients with Severe Neurological Craniocerebral Injury with Meta-Analysis

“…Severe traumatic brain injury (STBI) is a common acute and critical condition in neurosurgery [2,3]. Severe traumatic brain injury accounts for 13%-21% of craniocerebral injuries and is characterized by critical and dangerous conditions, complexity, high mortal-ity rate, and poor prognosis [4][5][6]. Patients with severe craniocerebral injury all have different degrees of coma, cannot eat on their own, and have a significant metabolic response to systemic stress, resulting in impaired nutritional intake, metabolic disorders, and depletion of the body's original nutritional reserves, leading to varying degrees of malnutrition soon after admission to the hospital [7].…”

Traqueostomía Temprana vs Tardía en Pacientes Neuroquirúrgicos Internados en Una Unidad De Cuidados Intensivos.

“…En la actualidad la traqueostomía sigue siendo una alternativa de manejo importante en las distintas UCI, si bien su uso no se circunscribe a cierto tipo de pacientes, es necesario mencionar que algunos grupos entre los que se encuentran los neurocríticos, por sus características clínicas son sometidos a esta intervención con mayor frecuencia. Los efectos clínicos atribuibles a la traqueostomía han sido ampliamente descritos, sin embargo, aún no se logra dilucidar o establecer un consenso sobre el momento oportuno para su realización, razón fundamental por la que se adelantó este estudio (16,17). Con relación al momento de la traqueostomía, en esta serie de casos se consideró traqueostomía temprana aquella realizada en un tiempo menor o igual a 9 días y traqueostomía tardía en un tiempo superior a ese término; es importante resaltar que la clasificación aquí realizada no obedece a una definición estandarizada, si bien algunos estudios lo proponen no existe un consenso establecido sobre el significado de estos dos términos (TQT temprana y TQT tardía), estando con frecuencia sujetos a la visión del grupo multidisciplinario que realiza el seguimiento a cada caso; lo anterior ha contribuido a que la agrupación de estudios al respecto resulte difícil y genere mucha más controversia (18,19).…”

Early tracheostomy: on the cutting edge, some benefit more than others

“…The primary cause is the need to provide both long and short-term care for affected patients. The approximate cost per stroke can vary widely based on the need for ICU level of care, long-term acute care and poststroke outpatient care [10,19]. Recent estimates show that poststroke care is approximately $4850 [19] in the USA,…”

“…Studies have defined early tracheostomy from as soon as 3 days to as late as 10 days. Those studies have similarly defined late tracheostomy from over 3 days, to as late as 14 days [10,15]. Regardless of the definition, many of the results have been consistent.…”

“…At the core of the debate over early versus late tracheostomy is the desire to improve clinical outcomes. Early studies showed mixed benefits from early tracheostomy [1,[10][11][12], so it is not surprising that there has been historical controversy. Understandably, there can also be hesitancy amongst providers, as the procedure is not risk-free: resulting in visible scarring, tracheal stenosis, tracheomalacia, tracheal-oesophageal fistula, infection, and of course bleeding into the airway [13].…”