Early Tracheostomy for Severe Pediatric Traumatic Brain Injury is Associated with Reduced Intensive Care Unit Length of Stay and Total Ventilator Days

Abstract

Objectives: To determine whether, similar to adults, early tracheostomy in pediatric patients with severe traumatic brain injury (TBI) improves inhospital outcomes including ventilator days, intensive care unit (ICU) length of stay (LOS), and total hospital LOS when compared to late tracheostomy. Design: Retrospective cohort analysis. Setting: The Pediatric Trauma Quality Improvement Program (TQIP) database Patients: One hundred twenty-seven pediatric patients <16 years old with severe (>3) abbreviated injury scale TBI who underwent early (days 1-6) or late (day ≥7) tracheostomy between 2014 and 2016. Interventions: Not applicable. Measurements and Main Results: The Pediatric TQIP database was queried for patients <16 years old with severe TBI, who underwent tracheostomy. Patient demographics and outcomes of early versus late tracheostomy were compared using Student t test, Mann-Whitney U test, and χ2 analysis. Sixteen patients underwent early tracheostomy while 111 underwent late tracheostomy. The groups had similar distributions of age, gender, mechanism of injury, and mean injury severity scores (P > .05). Early tracheostomy was associated with decreased ICU LOS (early: 17 vs late: 32 days, P < .05) and ventilator days (early: 9.7 vs late: 27.1 days, P < .05). There was no difference in total LOS (early: 26.7 vs late: 41.3 days, P = .06), the incidence of acute respiratory distress syndrome (early: 6.3% vs late: 2.7%, P = .45), pneumonia (early: 12.5% vs late: 29.7%, P = .15), or mortality (early: 0% vs late: 2%, P = .588) between the 2 groups. Conclusion: Similar to adults, early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days. Future prospective trials are needed to confirm these findings. Article Tweet: Early tracheostomy in pediatric patients with severe TBI is associated with decreased ICU LOS and ventilator days.

Tracheostomy practices in children on mechanical ventilation: a systematic review and meta-analysis

“…The search did not return any randomized trials. The authors found eight studies 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 that compared the prognoses of patients undergoing “early” or “late” tracheostomy: in five, “early tracheostomy” was defined as being performed before 14 days of mechanical ventilation, and “late,” after this period. In two studies, “early” was defined as before seven days post-trauma injury, and, in one, as before ten days of ventilation ( Table 2 ).…”

“…– 18 y. < 7 days post-trauma 43/48 Death in hospital 14 (9.7) 21 (10.3) 7 Sheehan et al, 2019 64 Retrospective cohort Traumatic brain injury patients, <16 y. < 7 days post-trauma 16/111 Death in hospital 9.7 (6.5) 27.1 (28.9) 7 McLaughlin et al, 2019 65 Retrospective, propensity score matching Children with severe traumatic brain injury, <15 years ≤ 14 days of MV 121/121 Death in hospital 14 (7.4) 26 (11.8) 9 Pizza et al, 2017 66 Retrospective cohort General PICU Age range: 0 y.…”

“… 66 , 67 Early tracheostomy was associated with higher probabilities of discharge to home in McLaughlin (29.8% versus 14.9%), and Sheehan (50% versus 9.2%, p < 0.001). 64 , 65 F. Other effects and complications related to early or late tracheostomy …”

“…Deep vein thromboses were reported by Sheehan (6.3% in the early, 8.1% in the late groups) and McLaughlin (2.7% and 12.9%): the meta-analysis showed a risk ratio of 0.31, non-significant ( p = 0.06). 64 , 65 The Sheehan's and McLaughlin cohorts were composed of children with traumatic brain injury; different times were used to define “early tracheostomy” ( Table 2 ). 64 , 65 The authors did not find other comparable cohorts of brain trauma patients.…”

“… 64 , 65 The Sheehan's and McLaughlin cohorts were composed of children with traumatic brain injury; different times were used to define “early tracheostomy” ( Table 2 ). 64 , 65 The authors did not find other comparable cohorts of brain trauma patients.…”