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Neurocritical Care

, Volume 25, Issue 1, pp 94–104 | Cite as

The SETscore to Predict Tracheostomy Need in Cerebrovascular Neurocritical Care Patients

  • Silvia Schönenberger
  • Faisal Al-Suwaidan
  • Meinhard Kieser
  • Lorenz Uhlmann
  • Julian BöselEmail author
Original Article

Abstract

Background and Purpose

Patients with severe stroke who require mechanical ventilation and neurointensive care unit (NICU) management often require a tracheostomy (TT). The optimal time point for TT remains unclear and a controversy in everyday NICU life. Here, we prospectively evaluated a score for prediction of TT need in NICU patients with cerebrovascular disease.

Methods

Seventy-five consecutively ventilated stroke patients were prospectively included in the study and assessed by the stroke-related early tracheostomy score (SETscore) within the first 24 h of admission. Endpoints were TT need, NICU-length of stay (NICU-LOS), and ventilation time (VT). We examined the correlation of these variables with the SETscore using regression analysis and determined a cut-off by receiver operating characteristic (ROC) analysis.

Results

Twenty-six patients had to be tracheostomized. The mean VT was 8.7 ±8 days and the mean NICU-LOS was 11.6 ± 8 days. The SETscore predicted NICU-LOS with a positive predictive value of 0.748 (p < 0.001) and VT with a positive predictive value of 0.799 (p < 0.001). The ROC analysis demonstrated a SETscore value of 8 to be the optimal cut-off to predict prolonged NICU-LOS, VT, and TT need with a sensitivity of 64 % and a specificity of 86 %.

Conclusions

Based on this monocentric study, the SETscore seems to be a valid tool to indicate prolonged NICU-LOS and VT, as well as TT need in cerebrovascular NICU patients. Confirmation of these results in larger cohorts with various settings may help to develop the SETscore as a decisive tool on primary TT early in time to avoid extubation failure.

Keywords

Ischemic stroke Intracerebral hemorrhage Subarachnoid hemorrhage Tracheostomy Extubation failure 

Notes

Funding

This study was not funded.

Compliance with Ethical Standards

Conflict of Interest

Dr. Bösel received travel grants and speaker honoraria from Covidien and Sedana. Dr. Schönenberger, Dr. Al-Suwaidan, Dr. Kieser, and Mr. Uhlmann report no conflicts.

References

  1. 1.
    Bushnell CD, Phillips-Bute BG, Laskowitz DT, Lynch JR, Chilukuri V, Borel CO. Survival and outcome after endotracheal intubation for acute stroke. Neurology. 1999;52:1374–81.CrossRefPubMedGoogle Scholar
  2. 2.
    Gujjar AR, Deibert E, Manno EM, Duff S, Diringer MN. Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indications, timing, and outcome. Neurology. 1998;51:447–51.CrossRefPubMedGoogle Scholar
  3. 3.
    Steiner T, Mendoza G, De Georgia M, Schellinger P, Holle R, Hacke W. Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit. Stroke. 1997;28:711–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Chevron V, Menard JF, Richard JC, Girault C, Leroy J, Bonmarchand G. Unplanned extubation: risk factors of development and predictive criteria for reintubation. Crit Care Med. 1998;26:1049–53.CrossRefPubMedGoogle Scholar
  5. 5.
    Coplin WM, Pierson DJ, Cooley KD, Newell DW, Rubenfeld GD. Implications of extubation delay in brain-injured patients meeting standard weaning criteria. Am J Respir Crit Care Med. 2000;161:1530–6.CrossRefPubMedGoogle Scholar
  6. 6.
    Ko R, Ramos L, Chalela JA. Conventional weaning parameters do not predict extubation failure in neurocritical care patients. Neurocrit Care. 2009;10:269–73.CrossRefPubMedGoogle Scholar
  7. 7.
    MacIntyre N. Discontinuing mechanical ventilatory support. Chest. 2007;132:1049–56.CrossRefPubMedGoogle Scholar
  8. 8.
    MacIntyre NR, Cook DJ, Ely EW Jr, et al. Evidence-based guidelines for weaning and discontinuing ventilatory support: a collective task force facilitated by the American College of Chest Physicians; the American Association for Respiratory Care; and the American College of Critical Care Medicine. Chest. 2001;120:375S–95S.CrossRefPubMedGoogle Scholar
  9. 9.
    Mallick A, Bodenham AR. Tracheostomy in critically ill patients. Eur J Anaesthesiol. 2010;27:676–82.PubMedGoogle Scholar
  10. 10.
    Seder DB, Lee K, Rahman C, et al. Safety and feasibility of percutaneous tracheostomy performed by neurointensivists. Neurocrit Care. 2009;10:264–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Delaney A, Bagshaw SM, Nalos M. Percutaneous dilatational tracheostomy versus surgical tracheostomy in critically ill patients: a systematic review and meta-analysis. Crit Care. 2006;10:R55.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Hoekema D. Percutaneous tracheostomy coming of age for the neurointensivist? Neurocrit Care. 2009;10:261–3.CrossRefPubMedGoogle Scholar
  13. 13.
    Villwock JA, Jones K. Outcomes of early versus late tracheostomy: 2008–2010. Laryngoscope. 2014;124:1801–6.CrossRefPubMedGoogle Scholar
  14. 14.
    Rumbak MJ, Newton M, Truncale T, Schwartz SW, Adams JW, Hazard PB. A prospective, randomized, study comparing early percutaneous dilational tracheotomy to prolonged translaryngeal intubation (delayed tracheotomy) in critically ill medical patients. Crit Care Med. 2004;32:1689–94.CrossRefPubMedGoogle Scholar
  15. 15.
    Nieszkowska A, Combes A, Luyt CE, et al. Impact of tracheotomy on sedative administration, sedation level, and comfort of mechanically ventilated intensive care unit patients. Crit Care Med. 2005;33:2527–33.CrossRefPubMedGoogle Scholar
  16. 16.
    Griffiths J, Barber VS, Morgan L, Young JD. Systematic review and meta-analysis of studies of the timing of tracheostomy in adult patients undergoing artificial ventilation. BMJ. 2005;330:1243.CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Young D, Harrison DA, Cuthbertson BH, Rowan K, TracMan C. Effect of early vs late tracheostomy placement on survival in patients receiving mechanical ventilation: the TracMan randomized trial. JAMA. 2013;309:2121–9.CrossRefPubMedGoogle Scholar
  18. 18.
    Siempos II, Ntaidou TK, Filippidis FT, Choi AM. Effect of early versus late or no tracheostomy on mortality and pneumonia of critically ill patients receiving mechanical ventilation: a systematic review and meta-analysis. Lancet Respir Med. 2015;3:150–8.CrossRefPubMedGoogle Scholar
  19. 19.
    Bösel J, Schiller P, Hook Y, et al. Stroke-related early tracheostomy versus prolonged orotracheal intubation in neurocritical care trial (SETPOINT): a randomized pilot trial. Stroke. 2013;44:21–8.CrossRefPubMedGoogle Scholar
  20. 20.
    Bösel J, Schiller P, Hacke W, Steiner T. Benefits of early tracheostomy in ventilated stroke patients? Current evidence and study protocol of the randomized pilot trial SETPOINT (stroke-related early tracheostomy vs. prolonged orotracheal intubation in neurocritical care trial). Int J Stroke. 2012;7:173–82.CrossRefPubMedGoogle Scholar
  21. 21.
    Kollef MH, Ahrens TS, Shannon W. Clinical predictors and outcomes for patients requiring tracheostomy in the intensive care unit. Crit Care Med. 1999;27:1714–20.CrossRefPubMedGoogle Scholar
  22. 22.
    Seneff MG, Zimmerman JE, Knaus WA, Wagner DP, Draper EA. Predicting the duration of mechanical ventilation. The importance of disease and patient characteristics. Chest. 1996;110:469–79.CrossRefPubMedGoogle Scholar
  23. 23.
    Huttner HB, Kohrmann M, Berger C, Georgiadis D, Schwab S. Predictive factors for tracheostomy in neurocritical care patients with spontaneous supratentorial hemorrhage. Cerebrovasc Dis. 2006;21:159–65.CrossRefPubMedGoogle Scholar
  24. 24.
    Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013;39:165–228.CrossRefPubMedGoogle Scholar
  25. 25.
    Riker RR, Picard JT, Fraser GL. Prospective evaluation of the Sedation–Agitation scale for adult critically ill patients. Crit Care Med. 1999;27:1325–9.CrossRefPubMedGoogle Scholar
  26. 26.
    Simmons LE, Riker RR, Prato BS, Fraser GL. Assessing sedation during intensive care unit mechanical ventilation with the Bispectral Index and the Sedation–Agitation Scale. Crit Care Med. 1999;27:1499–504.CrossRefPubMedGoogle Scholar
  27. 27.
    Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation–Sedation Scale: validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166:1338–44.CrossRefPubMedGoogle Scholar
  28. 28.
    Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation–Sedation Scale (RASS). JAMA. 2003;289:2983–91.CrossRefPubMedGoogle Scholar
  29. 29.
    Barry R, James MT. Guidelines for classification of acute kidney diseases and disorders. Nephron. 2015;131:221–6.CrossRefPubMedGoogle Scholar
  30. 30.
    Walcott BP, Kamel H, Castro B, Kimberly WT, Sheth KN. Tracheostomy after severe ischemic stroke: a population-based study. J Stroke Cerebrovasc Dis. 2014;23:1024–9.CrossRefPubMedGoogle Scholar
  31. 31.
    Pinheiro Bdo V, Tostes Rde O, Brum CI, Carvalho EV, Pinto SP, Oliveira JC. Early versus late tracheostomy in patients with acute severe brain injury. J Bras Pneumol. 2010;36:84–91.CrossRefPubMedGoogle Scholar
  32. 32.
    Jüttler E, Unterberg A, Hacke W. Hemicraniectomy for middle-cerebral-artery stroke. N Engl J Med. 2014;370:2347–8.CrossRefPubMedGoogle Scholar
  33. 33.
    R Core Team. R Foundation for Statistical Computing V, Austria. https://www.R-project.org/. R: A language and environment for statistical computing. R Foundation for Statistical Computing, Vienna, Austria. 2015. https://www.R-project.org/.
  34. 34.
    Sing T, Sander O, Beerenwinkel N, Lengauer T. ROCR: visualizing classifier performance in R. Bioinformatics. 2005;21:3940–1.CrossRefPubMedGoogle Scholar
  35. 35.
    Warnes GR, Bolker B, Bonebakker L, Gentleman R, Huber W, Liaw A, Lumley T, Maechler M, Magnusson A, Moeller S, Schwartz M, Venables B. gplots: various R programming tools for plotting data. R package version 2.17.0. 2015. http://CRAN.R-project.org/package=gplots.
  36. 36.
    Dahl DB. xtable: export tables to LaTeX or HTML. R package version 1.7-4. 2014.Google Scholar
  37. 37.
    Qureshi AI, Suarez JI, Parekh PD, Bhardwaj A. Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support. Crit Care Med. 2000;28:1383–7.CrossRefPubMedGoogle Scholar
  38. 38.
    Szeder V, Ortega-Gutierrez S, Ziai W, Torbey MT. The TRACH score: clinical and radiological predictors of tracheostomy in supratentorial spontaneous intracerebral hemorrhage. Neurocrit Care. 2010;13:40–6.CrossRefPubMedGoogle Scholar
  39. 39.
    Rodriguez JL, Steinberg SM, Luchetti FA, Gibbons KJ, Taheri PA, Flint LM. Early tracheostomy for primary airway management in the surgical critical care setting. Surgery. 1990;108:655–9.PubMedGoogle Scholar
  40. 40.
    Bouderka MA, Fakhir B, Bouaggad A, Hmamouchi B, Hamoudi D, Harti A. Early tracheostomy versus prolonged endotracheal intubation in severe head injury. J Trauma. 2004;57:251–4.CrossRefPubMedGoogle Scholar
  41. 41.
    Dunham CM, LaMonica C. Prolonged tracheal intubation in the trauma patient. J Trauma. 1984;24:120–4.CrossRefPubMedGoogle Scholar
  42. 42.
    Rabinstein AA, Wijdicks EF. Outcome of survivors of acute stroke who require prolonged ventilatory assistance and tracheostomy. Cerebrovasc Dis. 2004;18:325–31.CrossRefPubMedGoogle Scholar
  43. 43.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818–29.CrossRefPubMedGoogle Scholar
  44. 44.
    Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis. 1988;138:720–3.CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2016

Authors and Affiliations

  • Silvia Schönenberger
    • 1
  • Faisal Al-Suwaidan
    • 2
    • 3
  • Meinhard Kieser
    • 4
  • Lorenz Uhlmann
    • 4
  • Julian Bösel
    • 1
    Email author
  1. 1.Department of NeurologyUniversity of HeidelbergHeidelbergGermany
  2. 2.Neurocritical Care Department, National Neuroscience InstituteKing Fahad Medical CityRiyadhSaudi Arabia
  3. 3.King Saud Bin Abdulaziz University for Health SciencesRiyadhSaudi Arabia
  4. 4.Institute of Medical Biometry and InformaticsUniversity of HeidelbergHeidelbergGermany

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