Early vs' Late Tracheostomy in Neurotrauma Patients

1
Early vs. Late Tracheostomy in Neurotrauma
Patients

• Meghan Blair, Lacey Penrod, Victoria Pierce,
  Gabriel Speth

2
PICO QUESTION

• In neurotrauma patients, do early tracheotomies
  performed within seven days versus 28 days result
  in earlier weaning from the ventilator, decreased
  rates of pneumonia and shorter length of stay in
  the intensive care unit?

3
Identification of the Problem

• Lack of sufficient research.
• Practice based upon physician discretion.
• Discrepancy among healthcare providers regarding
  how timing of tracheotomy affects patient
  outcomes.

4
Extent of the Problem

• According to the CDC 235,000 people sustaining
  traumatic brain injury (TBI) are hospitalized
  annually in the U.S.
• The mean incremental cost of mechanical
  ventilation is 1,522 per day (Dasta, McLaughlin,
  Mody, Piech, 2005).

5
Extent of the Problem

• ICU average daily cost with mechanical
  ventilation is 3,968 (Dasta, McLaughlin, Mody,
  Piech, 2005).
• On average, Ventilator-Acquired Pneumonia (VAP)
  costs a total of 10,000 per patient (Vincent,
  2007).

6
Review of the Literature

• Systematic Reviews
• Prospective Randomized Studies
• Randomized Controlled Trials
• Retrospective Studies
• Meta-Analyses

7
Early Tracheotomy

• Pros

• Cons

• Shorter stay in ICU
• Fewer days on mechanical ventilation

• No significant difference in rates of pneumonia
  or mortality
• Psychosocial issues

8
Critique of the Literature

• Pros

• Cons

• Peer-reviewed data
• Randomized-controlled trials
• Homogenous populations
• Clearly defined criteria for timing of
  tracheotomies

• Lack of consideration of external variables
• Nursing care
• Small sample size
• Lack of differentiation between types of trauma
• Mainly retrospective studies

9
Pneumonia Statistics

• Early Tracheotomy

• Late Tracheotomy

• Rodriguez (51)
• 78
• Armstrong (62)
• 76
• Kluger (55)
• 14
• Lesnik (32)
• 19

• Rodriquez (55)
• 96
• Armstrong (95)
• 84
• Kluger (65)
• 37
• Lesnik (69)
• 59

10
Ventilator Days Statistics

• Early Tracheotomy

• Late Tracheotomy

• Rodriguez (51)
• 12 7.1 days
• Armstrong (62)
• 15 12 days
• Lesnik (32)
• 6 3 days
• Bouderka (31)
• 14.5 7.3 days

• Rodriguez (55)
• 32 22.2 days
• Armstrong (95)
• 29 26 days
• Lesnik (69)
• 21 12 days
• Bouderka (31)
• 17.5 10.6 days

11
ICU Days Statistics

• Early Tracheotomy

• Late Tracheotomy

• DAmelio (21)
• 13 6 days
• Sugerman brain injury (35)
• 16 5.9 days
• Sugerman nonbrain injury (13)
• 30 18 days

• DAmelio (10)
• 26 13 days
• Sugerman brain injury (13)
• 19 11.3 days
• Sugerman nonbrain injury (20)
• 30 22 days

12
Recommendation

• For patients with severe head trauma,
  tracheotomies should be implemented within seven
  days if the need for artificial ventilation is
  anticipated to exceed 21 days.
• Organizational protocol should be established to
  determine timing of tracheotomies.

13
Evaluation

• Monitor patient outcomes after implementation and
  compare with data prior to early tracheotomies.
• This would include analysis of
• VAP rates
• Length of ICU stay
• Days on the ventilator

14
Suggestions for Further Study

• Additional research studies should consider
• Effects of external variables such as nursing
  care
• Including larger sample sizes
• Performing randomized controlled trials as
  opposed to retrospective studies

15
New Research Questions

• What effects does nursing care of ventilated
  patients have on outcomes?
• What other dependent variables should be
  considered when implementing early tracheotomy?
• Physiological factors
• Psychosocial aspects
• Cost

16
References

• Ahmed, N., Kuo, Y. (2007). Early versus late
  tracheostomy in patients with severe traumatic
  brain injury. Surgical Infections, 8(3), 343-347.
• Augustyn, B. (2007). Ventilator-associated
  pneumonia Risk factors and prevention. Critical
  Care Nurse, 27(4), 32-39.
• Barquist, E.S., Amortegui, J., Hallal, A.,
  Giannotti, G., Whinney, R., Alzamel, H.,
  MacLeod, J. (2006). Tracheostomy in ventilator
  dependent trauma patients a prospective,
  randomized intention-to-treat study. The Journal
  of Trauma Injury, Infection and Critical Care,
  60(1), 91-97.
• Bouderka, M., Fakhir, B., Bouaggad, A.,
  Hmamouchi, B., Hamoudi, D., Harti, A. (2004).
  Early tracheostomy versus prolonged endotracheal
  intubation in severe head injury. Journal of
  Trauma Injur,y Infection and Critical Care,
  57(2), 251-254.

17
References

• Center for Disease Control and Prevention.
  (2009). What is Traumatic Brain Injury? Retrieved
  April 17, 2009, from http//www.cdc.gov/ncipc/tbi/
  TBI.htm.
• Dasta, J., McLaughlin, T., Mody, S., Piech, C.
  (2005). Daily cost of an intensive care unit day
  The contribution of mechanical ventilation.
  Critical Care Medicine, 33(6), 1266-1271.
• Dunham, C., Ransom, K. (2006). Assessment of
  early tracheostomy in trauma patients a
  systematic review and meta-analysis. The American
  Surgeon, (57)3, 276-281.
• Gilony, D., Gilboa, D., Blumstein, T., Murad, H.
  Talmi, Y., Kronenberg, J. Wolf, M. (2005).
  Effects of tracheostomy on well-being and
  body-image perceptions. American Academy of
  Otolaryngology-Head and Neck Surgery, 133(3),
  366-371.

18
References

• Griffiths, J., Barber, V.S., Morgan, L., Young,
  D.J. (2005). Systematic review and meta-analysis
  of studies of the timing of tracheostomy in adult
  patients undergoing artificial ventilation. BMJ,
  330. doi 10.1136/bmj.38467.485671.E0.
• Lindgren, V.A., Ames, N.J. (2005). Caring for
  patients on mechanical ventilation. American
  Journal of Nursing, 105(5), 50-60.
• Vincent, J.L. (2007). Intensive care medicine
  Annual update 2007. Berlin Springer.