Timing of Tracheostomy Placement among Children with Severe Traumatic Brain Injury: A Propensity-Matched Analysis
Cory McLaughlin, MD1; David Darcy, MD1; Caron Park, MS2; Christianne J. Lane, PhD2; Wendy J. Mack, PhD2; David Bliss, MD3; Anoopindar K. Bhalla, MD3; Jeffrey S. Upperman, MD4; Avery B. Nathens, MD MPH PhD5; Randall S. Burd, MD PhD6; Aaron R. Jensen, MD MEd3
1Children's Hospital Los Angeles, Los Angeles, CA; 2Southern California Clinical and Translational Science Institute, University of Southern California, Los Angeles, CA; 3Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA; 4Children's Hospital of Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA; 5University of Toronto, American College of Surgeons, Toronto, ON, Canada; 6Children's National Medical Center, Washington, DC
Purpose: Early tracheostomy has been associated with shorter hospital stay and fewer complications in adult trauma patients. The purpose of this study was to determine if early tracheostomy is also associated with shorter hospital stay and lower rate of complications for children with severe traumatic brain injury (TBI).
Methods: Records of children (<15 years) with severe TBI (head abbreviated injury severity, AIS ≭3) obtained from the National Trauma Data Bank (2007-2015) were analyzed. Outcomes after early (≤14 days) and late (≭15 days) tracheostomy placement were compared using propensity score matching. Propensity scores were calculated based on age, race, pulse, blood pressure, GCS-motor score, injury mechanism, associated injury AIS scores, TBI subtype, craniotomy, and ICP monitor placement.
Results: 6,101 mechanically ventilated (>48h) children with severe TBI were analyzed. 5,740 children (94%) were successfully extubated without tracheostomy, 95% of whom were extubated by 18 days. Tracheostomy was performed in 361 children (6%) at a median [IQR] of 15 [10,22] days. After matching, we compared 121 children with early and 121 with late tracheostomy. Early tracheostomy was associated with lower ventilator days (14 [9,19] versus 25 [19,35]), ICU days (19 [14,25] versus 31 [24,43]), and hospital days (26 [19,41] versus 39 [31,54], all p<0.05). Pneumonia (24% versus 41%), venous thromboembolism (3% versus 13%) and decubitus ulcer (4% versus 13%) occurred less frequently with early tracheostomy (all p<0.05).
Conclusions: Early tracheostomy is associated with shorter hospital stay and fewer complications among children with severe TBI. Children rarely successfully extubate without tracheostomy after 3 weeks.
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