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Optimal Timing Of Tracheostomy In Injured Children
*Elissa K Butler1, Elizabeth Y Killien1, *Jonathan I Groner2, Saman Arbabi1, *Monica S Vavilala1, *Frederick P Rivara1
1University of Washington, Seattle, WA;2Nationwide Children's Hospital, Columbus, OH

Background: The optimal timing of tracheostomy in injured children is unknown. Our objective was to evaluate if patients with tracheostomy have improved outcomes compared to those with prolonged intubation.
Methods: All patients 0-18 years in the NTDB from 2007-2016 and ventilated for >24h who survived to discharge were included. After stratifying by traumatic brain injury (TBI) diagnosis, multivariable linear and Poisson regression analyses were used to determine if tracheostomy vs. prolonged intubation was associated with ventilator days, hospital and ICU length of stay, pneumonia, and need for post-discharge care. Timepoints of 7 and 14 days were assessed.
Findings: Of 26,274 patients, 2,420 (9.2%) underwent tracheostomy. Median time to tracheostomy was 10 (IQR:6-16) days for TBI and 8 (IQR: 3-14) days for non-TBI patients. Both TBI and non-TBI patients with tracheostomy prior to 7 and 14 days had fewer ventilator and ICU days compared to patients intubated ≥7 and ≥14 days (Table). Non-TBI patients with tracheostomy had shorter hospital length of stay and lower risk of pneumonia. There was no difference in need for post-discharge care.
Conclusions: Injured children with tracheostomy <7 days have improved in-hospital outcomes compared to those who remained intubated. Tracheostomy prior to 7 days may be the optimal time point when prolonged need for mechanical ventilation is anticipated.
Table. Outcomes of tracheostomy <7 and <14 days vs. intubation ≥7 and ≥14 days.

OutcomesTBI (n=18,818)Non-TBI (n=7,461)
Trach <7 vs Intubation ≥7 dTrach <14 vs Intubation ≥14 dTrach <7 vs Intubation ≥7 dTrach <14 vs Intubation ≥14 d
Mean ventilator days-2.1 (-2.7 to 1.3)-5.7 (-6.5 to -5.0)-3.6 (-5.0 to -2.3)-7.1 (-9.3 to -4.9)
Mean ICU days-1.9 (-2.7 to -1.1)-5.6 (-6.5 to -4.7)-4.7 (-6.5 to -2.8)-8.6 (-11.2 to -5.9)
Mean hospital length of stay (days)-1.3 (-2.9 to 0.2)-5.3 (-6.9 to -3.6)-3.8 (-6.6 to -1.1)-9.0 (-12.8 to -5.3)
Risk of pneumonia0.8 (0.7 to 1.0)0.9 (0.8 to 1.0)0.5 (0.3 to 0.8)0.6 (0.5 to 0.9)
Risk of post-discharge care0.9 (0.8 to 1.0)0.9 (0.9 to 1.0)0.9 (0.7 to 1.2)0.9 (0.8 to 1.2)

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