Inpatient Complications Predict Tracheostomy Better than Admission Variables After Traumatic Brain Injury
Data regarding who will require tracheostomy are lacking which may limit investigations into therapeutic effects of early tracheostomy.
We performed an observational study of adult traumatic brain injury (TBI) patients requiring intensive care unit (ICU) admission for ≥ 72 h and mechanical ventilation for ≥ 24 h between January 2014 and December 2014 at a level 1 trauma center. Patients who had life-sustaining measures withdrawn were excluded. Multivariable logistic regression analyses were used to assess admission and inpatient factors associated with receiving a tracheostomy and to develop predictive models. Inpatient complications prior to day 7 were used to standardize data collection for patients with and without tracheostomy. Patients who received tracheostomy prior to day 7 were excluded from analysis.
In total, 209 patients (78% men, mean 48 years old, median Glasgow Coma Scale score (GCS) 8) met study criteria with tracheostomy performed in 94 (45%). Admission predictors of tracheostomy included GCS, chest tube, Injury Severity Score, and Marshall score. Inpatient factors associated with tracheostomy included the requirement for an external ventricular drain (EVD), number of operations, inpatient dialysis, aspiration, GCS on day 5, and reintubation. Multiple logistic regression analysis demonstrated that the number of operation room trips (adjusted odds ratio [AOR], 1.75; 95% CI, 1.04–2.97; P = 0.036), reintubation (AOR, 8.45; 95% CI, 1.91–37.44; P = .005), and placement of an EVD (AOR, 3.48; 95% CI, 1.27–9.58; P = .016) were independently associated with patients undergoing tracheostomy. Higher GCS on hospital day 5 (AOR, 0.52; 95% CI, 0.40–0.68; P < 0.001) was protective against tracheostomy. A model of inpatient variables only had a stronger association with tracheostomy than one with admission variables only (ROC AUC 0.93 vs 0.72, P < 0.001) and did not benefit from the addition of admission variables (ROC AUC 0.93 vs 0.92, P = 0.78).
Potentially modifiable inpatient factors have a stronger association with tracheostomy than do admission characteristics. Multicenter studies are needed to validate the results.
KeywordsTracheostomy Traumatic brain injury Head injury Outcomes
N.B., N.M., and R.J. contributed to the conception and design of the research. B.H., D.S., G.P., G.S., N.B., N.M., R.J., R.V.B., and W.C. contributed to the acquisition and analysis of data. N.M. and R.J. drafted the article. B.H., D.S., G.P., G.S., N.B., N.M., R.J., R.V.B., and W.C. revised the article critically for important intellectual content. N.M. and R.J. contributed equally to the manuscript.
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Conflict of interest
The authors declare that they have no conflict of interest.
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Declaration of Helsinki and its later amendments or comparable ethical standards. For this type of study formal consent is not required.
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